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American Medicine
A WEEKLY JOURNAL
FOUNDED, OAVNED, AND CONTROLED BY
THE MEDICAL PROFESSION OF AMERICA
GEORGE M. GOULD, Editor
G. C. C. HOWARD, Managing Editor
Oinical Medicine
David Riesman
A. O. J. Kklly
J. Edwin Swekt
Helin Murphy
General Surgery
Maktin B. Tinkbk
A. B. Ceaio
Chables a. Obb
Orthopedic Surgery
H. ADOtJsics Wilson
CHARLES 8. DOLLEY,
MARTIN B. TINKER, Assittant EdUori
COLLABORATORS
Obstetrics and Gynecology
WiLHER Kbcsen
Frank C. Hammond
JVervous and Mental Diseases
J K Mitchell
F. Savaby Pkarce
Treatment
Solomon Solis Cohen
H, C. Wood, Je.
L. F. Appleman
Dermatology
M. B. Hartzell
Laryngology, k'le.
D. BSADEN Kyle
Ophchalinolof/y
Walter L. Pyle
Pathology
R. M. Pearce
VOLUME IV
JULY-DECEMBER, 1902
O
PIlILADELrHIA
AMERICAN-MKDrciNE PUBLISHING COMPANY
/
^^1
Entered According to Act of Congress
in the year 1902
BY THE AMERICAN-MEDICINE PUBLISHING COMPANY
In the office of the Librarian at Washington
ALL RIGHTS RESERVED
m
PKESS OF
A. H. 8ICKLEK COMPANY
PHILADELPHIA
American Medicine
GEOBGE M. GKJULD, EdiUyr
G. C. C. HOWARD, Halutging Editor
CHARLES 8. DOLLEY
MARTIN B. TINKER, AuUtarU Editort
Clinical Medicine
David Riesman
A. O. J. Kelly
h. h. cushisg
Helen Murphy
General /Surgery
Martin B. Tinker
A. B. Craig
Charles A. Orr
Orthopedic Surgery
H. Augustus Wilson
COLLiABORATORS
Obstetrics and Gynecology
WiLMEB Krusen
Frank C. Hammond
Nervous and Mental IHseases
3. K. Mitchell
F. Savary Pearce
Treatment
Solomon Solis Cohen
H. C. Wood, Jr.
L. F. Appleman
Dermatology
M. B. Hartzkll
PUBttaBKD WinCLr *T 1321 WaLWUT StRETT, PhILADILPBIA, BV THB AlfBRlCAN'MBDICIBB PrBLnSins COHPAMT
Vol. IV, No. 1.
JULY 5, 1902.
Laryngology, Ba.
D. Braden Kyl«
Ophthalmology
Walter L. Pylb
Pathology
R. M. Pearce
LOO Yeably.
A Discourtesy in Consultation Practice.— We
have been asked to take note of a too frequently occur-
ring instance of thoughtlessness on the part of consultants,
consisting in referring a patient to another specialist with-
out considering the wishes of the general physician or
colleague who first sent the patient. It is right and
courteous that the family physician who refers the
patient should know what disposition is made of the
case. He may have had in mind that the disease would
need the attention of still another specialist, may even
have spoken to such an one ; at least he has his rightful
preference as to all consultants. But if without advice
asked the patient is sent off to the consultant's /riend
unknown complications and even hard feelings may
arise. In some cases the reference back to the original
physician is difficult or even impossible, as e.g., when
the patient comes from a distance, in emergencies, etc.
But at least a frank notice of the facts in the case can be
sent at once, and further instructions asked for. Such
courtesy and consideration of the rights of the referer is
not only good ethics and manners, but is quite as good
policy.
The proper sections before which papers should
be read in the American Medical and other general
medical societies is a matter which may well engage
the attention of section officers and the writers of the
papers themselves. There can be no difference of opin-
ion as to the majority of papers, because their signifi-
cance and teachings are only appreciated by the special-
ists attending by preference the individual section
dealing each with his particular work. But if epilepsy
may bo due to eye-strain or to phimosis, if anemia may
be caused by nasal stenosis, or chorea by oral abnor-
mality, papers upon these subjects should not be read
before the respective ophthalmic, surgical, laryngologii;
or stomatological sections. The physician who first and
usually sees such patients is not the oculist, the surgeon,
the laryngologist or the dentist, but is the general or
family physician. The lesson chiefly concerns him.
The rigid differentiation of the sections tends to make
the spetdalist overlook tlie intimate or deferred relations
of diseases of on«^ organ with those of others. The gen-
eralist, indeed, is fast becoming a s[)ecialist, as one after
another of the specialists limits his field of work. At
the i)resent rate of progress his function will soon be
solely that of an adviser as to what specialists the pa-
tient should consult. If this process extends and con-
tinues there will some time be need of a section for pan-
specialists, in which shall be considered the interrela-
tions of the diseases of individual organs.
, King Edward's Progress Toward Kecovery. —
The steady progress toward recovery which has followed
the operation on King Edward performed by Sir Fred-
erick Treves and his eminent colleagues must be re-
garded as peculiarly gratifying, not only to his Majesty,
the members of the Royal family and those who bear
the vast responsibilities of state, but especially to the
surgeons concerned. The unusually trying position in
which the King's medical and surgical attendants were
placed owing to his Majesty's refusal to allow of earlier
operation should be borne in mind in commenting upon
the case. Adverse criticism of the operative procedure
finds its immediate and strongest rebuke in the success-
ful outcome. That in connection with this particular
case our British confreres should be accused of faulty
diagnosis and timidity, that they should be derided for
practising a dangerous conservatism and as being behind
the times in surgical technic is obviously unfair and
unseemly. It is perhaps the case that the English are
more prone than are the Amerlam surgeons to accept
the maxim of Sir Thomas Browne that "deliberating
delay may be wise cunctation ;" but in the case of King
Edward they seem to have met the emergency as
promptly as their Royal patient would j)ermit in his
anxiety to get through with the coronation ceremonies,
any interruption of which meant financial disaster to
thousands of his loyal subjects. To advise the ICing and
to restrain the King are vastly different propositions and
on his Msyesty undoul)tedly rests the responsibility for
delay in operating. In performing the simpler and
shorter operation Sir Frederick Treves followed his
ac<!ustomed practice in cases of acute appendicitis, and
there appears to be no ground for special criticism at
this time. It is rather a time for congratulation ; while
the announcement that Sir Joseph Lister and Sir Fred-
erick Treves were name<l for coronation honors seems
particularly appropriate and it will be but natunU to
look for some token of Royal favor in the near future for
their aasociates in the case, Sir Thomas IJarlow, Sir
Francis Laking and Sir Thomas Smith.
2 AXEBICAN MEDICINE!
EDITORIAL COMMENT
[July 5, 1903
Corouatioii Honors for Medical Men. — We note
with satisfaction the names of three members of the
medical profession in the announcement of honors
to be conferred by King Edward VII in connec-
tion with his coronation. Titles are usually re-
served for individuals who have gained distinction
rather by military prowess or . political achievements
than by merely intellectual or professional accomplish-
ments of any kind. Another important element has
entered into the question of conferring such honors
of late years. Very few are picked out for titles except
those who have amassed large fortunes and are able to
add the claims of wealth to other possible merits, or who
having inherited millions, have spent their money freely
for public purposes. Mr. Justin McCarthy, in a recent
number of the Independent (New York), pointed out that
authors have been very rarely considered suitable recip-
ients of honors on such occasions. When peerages have
been conferred on mere authors the reward has been given
because the authors have been members of the House of
Commons and, in that capacity, have rendered important
services to one or other of the great political parties.
Bulwer Lytton was honored by a peerage. But he
might have gone on writing novels throughout the
whole of his life without receiving a peerage, just as
Dickens and Thackeray did, who wrote far better novels
than his, if he had not been a member of the House of
Commons and held an important place in a conservative
government.
There is no doubt that military men and politicians
have generally absorbed too much of the world's atten-
tion and come to be considered as the proper subjects for
honors. The medical profession has been neglected
because as a rule its members are entirely out of politics.
The legal profession fares much better, because its mem-
bers as a rule are likely to be occupied with things
political. Some time it will come to be realized that the
profession which has labored unselfishly to reduce the
great sum of human suffering, although at the same time
it lessened its own opportunities for gain, have really
been doing the world's best work. It is not to be ex-
pected, perhaps, that this realization will come to an
aristocratic country like England, but one is rather sur-
prised to find in republican America how few were the
names of physicians mentioned as possible candidates
for the role of 100 great men whose names were to adorn
a hall of fame. The time does not seem so far off, how-
ever, in which a more discriminating appreciation will
lead to a more equitable distribution of the titles and dis-
tinctions that in themselves mean very little yet are
supposed to be the expression of a generation's sense of
merit in its contemporaries.
" His Ammons Dropped."— Dr. Emma Billstein,
of Highlands, N. C, writes as follows :
One moist, sultry day during midsummer, in Higlilands,
N. C, a man came to my door with vegetables to sell. He
seemed not to understand what I said and asking me to repeat
the question he apologized, saying, " I can't hear when my
ammons drop," and suiting the action to the word lie put his
hands to his ears. The gesture gave the clue to his moaning.
Questioning elicited the information that ho then had a "rushing
sound " in his ears and that whenever he becomes heated from
exertion, noticeably on warm, wet days, his " ammons always
drop" and make him " deaf." He had this day ridden far and
ascended about 1,000 feet— Highlands being approximately 4,000
feet above sea level. Like many of the mountaineers, this man
can neither read nor write, but his pronunciation of the strange
word at once suggei-ted the spelling I have used and it o<:curred
to me that it may be one of the not uncommon survivals of
Elizabethan Knglish in these mountains.
It is of exceptional interest to find words like this of
the mountaineer of South Carolina living on for hun-
dreds of years after they have as literature become
extinct. The special word almonds (pronounced arnmonds
or amnions) as applied to physiologic structures has a
strange etymologic history. The I is an inserted letter,
probably a blunder from confusion of the initial a with
the Arabic al. It is curious to note that in pronuncia-
tion this I was dropped, the habit of speech being
stronger than the stupid science of the foolish etymolo-
gist. The word comes from Greek, Ait»-)Aa?.n^ an almond.
Later forms are, Latin, amygdala, whence amygd'la,
amyhlla, amyndla, amynda, amende, amande. The
word was early applied to the tonsils. The almmidii of
the throat always meant the tonsils, but the almonds of
the ear (Ger., Ohrenmandel), sometimes meant the ton-
sils, and sometimes a lymphatic gland above the mas-
toid process, or below the external ear. The ignorant
man with aural tinnitus and deafness evidently sup-
posed these symptoms due to " dropping of his
ammons " (almonds), as swelling of the tonsils, parotid,
etc., sometimes produces such symptoms. The Southern
negro will tell his physician that his palate is down, and
he will tie up a bunch of hair on top of his head in
order to hold up the fallen palate.
Unsuspected Insanity. — The confession of the
insane nurse, Jane Toppan, that she had in her life '
killed 31 persons placed in her charge, is probably not to
be trusted, but her contention that she is not insane, and
her conviction of certain murders causes a shudder and
arouses in the mind a terrible question as to the possible
existence of mental aberration in those placed in authority
of any kind. This suspicion is intensified by the recog-
nition that the lines delimiting the sane mind are by no
means clear, since there are all grades of insanity each
springing from and based upon normality, and fading
into each other by imperceptible shades. One might
paraphrase an old proverb by saying that no mind is
absolutely normal or abnormal. There are a number o»
instances of army generals whose actions are hardly
explainable, except upon the assumption of mental
unsoundness. Wherever there is a striking illogicality
of action on the part of those in authority, insanity
should be suspected. Legislative halls are by no means
exempt from suspicion. Considering the numbers o^
physicians and their natural temptations and possibili-
ties, it is strange that there have not been more cases oi
insanity among them than are on record. The explana-
tion may be that under such circumstances they quickly
or immediately choose the profession of quackery. There
can be no reasonable doubt that there are today in our
country hundreds, one would more accurately say
thousands, of quacks who by all the laws of psychiatry
should be in asylums for the insane. The ignorant and
July 0, 1902]
EDITORIAL COMMENT
(Amebican Medicine 3
superstitious have for such lunatics an unaccountable
fascination, and there is just enough sanity in the
duper's mind to recognize the fact and profit by the false
sentiment. A recognition of this sad fact is decidedly
needed on the part of lawmakers in order to free the
community from the ruin and wretchedness caused by
medical delusions and lunatic deluders.
Vacation-time does not come to the majority of
physicians. Every one, however, should plan for it and
should manage so that he shall not miss it. It is difficult
because it is directly expensive, and may in the loss of
patients prove indirectly so. There is also the ever-
present duty of not neglecting our chief duty, the care
of those who are not yet recovered from their illness,
and of those whose time of confinement is approaching.
But the duty to patients is also a duty to keep one's
own health, to unbend and relax the mind, and by rest
and the healing of Nature to be all the better prepared to
meet the demands of practice. Burke warned us that
"they who always labor can have no true judgment."
There is no calling in which it is so dangerous to allow
habit to rule, the depressing influence of over-appli-
cation, and of continuous application as it is in medicine.
Of all men the physician should bring to every case
a spontaneity and a keen sensitiveness of mind, in order
that no subtle sign of disease or vague suggestion of cure
may be ignortd. Nothing better aids in securing this
mental attitude than an entire change of thought and
action, for a longer or shorter season, aqd at least once a
year. "Shop" should be shut up and left, and not
a word of it "talked" for at least one month of the
twelve. It is possible ; there is some colleague who
is trustworthy, and on the whole it is perhaps a real gain
instead of a loss even in money and patients. We
believe the nifyority of patients are pleased to know
their physician takes a summer vacation. Perhaps there
is a little human pride, not of the highest kind, in their
feeling ; and perhaps, too, they are glad to be rid of us for
awhile. Surely they come back when we come bac-k,
both better for the test.
The union of medical colleges in New York,
Cleveland and a numlier of others of our large cities
re(*ntly, give evidence that the teaching members of
the profession are appreciating the importance of unit-
ing their effort** in order to do better work and maintain
higher standards. A plan for the union of the Denver
College of Medicine and the Gross Medical College in
Denver is said to have been drawn up by the executive
committees of the two faculties recently and is prob-
ably iKlopted by this time. The Otlorado Medical
Journal, in discussing the question of consolidation,
says: "The city of Denver is sufficiently large to
supiwrt one medical college with benefit to itself and
the State in which it is l(K*ated, but there is no cry-
ing necessity for the existence of more than one medieval
college in a city with not over 150,000 inhabitantw, and
the sentiment of its medical profession should be so pro-
nounced that a union of the two already existing schools
would be an iinpt^rative necessity." With a limited
• leinand and more factories than are necessary to supply
the legit! mat« call for their protlucts the quality of pro-
duction is sure to deteriorate. The union of medical col-
leges gives evidence of a healthier spirit in the profes-
sion. It must be generally recognized now, with the
present re(}uirements in medical education for large clin-
ical facilities and extonsive laboratory courses, that a
small institution without endowment and with only a
limited staff is certain to be a fiulure so far as giving its
students adequate instruction is concerned. The example
set by medical colleges in the cities mentioned should be
followed in many other cities where not twice but many
times the number of medical schools that are neetledcan
be found. The medical schools of Denver and the other
cities mentioned are not to be compared with another
cla.ss of institutions which are scattered in considerable
numbers over the country and which need not union,
but extermination. These schools turn out many poorly
trained physicians to add to the numbers of an already
overcrowded medical profession, and since their sole
excuse for existence is the selfish interests of their socalled
professors the sentiment of the medical profession against
these "diploma mills" should be strong enough to force
them to close their doors.
Syphilis and Sin. — Those who are inclined to sneer
at any causal relation between the relationship of nudum
and morbus, between inethical conduct and the spread of
disease, should read the monograph of Dr. Bloch on the
origin of syphilis. Since the introduction of the disease
into Kurope in 1493 and its dissemination in a few years
over the entire European and Oriental world, the deaths,
sutfering and expense due to it are incomprehensible and
appalling. Centuries of crime, lasciviousness and cruelty
were needed to bring together such men as composed the
crews of Columbus, the army of Charles Ylll, and such
women as helped them to scatter the poison throughout
the world. Bloch shows that the disease among the
naked savages of the West Indies was comparatively
harmless, but to the whites of Spain, Italy and Europe
it was intensely virulent and fatal. Cncontrolled lust
both of the flesh and of power was plainly the sine >/iia
non of the terrible experience with syphilis, from which
the world has suffered for 400 years. Unnecessary war,
the receiving from ^avage or semicivilized peoples their
vices, or taking to them our own— these are things that
bring strange and unexpected punishments. Every i)hy-
sician has a voice in the affairs of his country, and every
physician who seeks to prevent disease must seek to
stop the crimes, national or personal, that scatter it
broadcast. By the degenerate Spanianl the (h^gt-nerate
American savage sent through Europe the rotting poison
which after four centuries returns to us and is working
ruin in every city_, village and hospital of the liuid,
creating still its inevitable impotence, sterility and
death, llow effective both the sin and the disease have
been in ending the Spanish power none can accurately,
perhaps none sufficiently, estimate. As we take the
reins from the nerveless hands of Spain, it behooves us
to lo(}k carefully into the relationship and rosultw of war,
colonization and venereal diseaw.
"The Mysteries of l>ife and IVIIn«l" is the title
of an article in the June number of th<; IhrtniolUI;/ liemew,
the publication of which must be a great thorn in the
4 AKBSICAN MEDIOIITE;
EDITORIAL COMMENT
[July 6, 1902
flesh of Professors Loeb and Matthews. It is a genuine
and literal contribution to the gaiety of nations. It is
full of quotation marks as if a real interview, but as the
things quoted and said to have been said are neither
good science, good sense, good nonsense, neither good
physics nor good metaphysics, the scientists named
could, therefore, not have authorized such foolishness,
and may well pray once more to be forever delivered
from their friends. This is especially true of men who
shrink from every approach of the interviewer and who
loathe the science of the newspaper and lay magazine.
"I very early came to the belief" the interviewer
makes Dr. Loeb say, " that the forces which rule in the
realm of living things are not other than those we know
in the inanimate world ; 20 years have been spent col-
lecting the facts to prove this theory — the theory never
changed." What misreporting and unscience ! No
man, with a glimpse of true scientific method, would 20
years in advance jump down upon his facts with a dog-
matic theory of their nature and origin cocked and primed,
and even shot off". "I wanted to go to the iwttom of
things. I wanted to take life in my hands and play
with it" ("a pair of hands, extended as if to clutch this
elusive phantom, suit the action to the words," adds the
interviewer). " I wanted to handle it in my laboratory,
etc.," says, or is said to have said, this new "Faust"
" whose dreams come true." What a pity the amateur
reporter had not allowed the traduced scientist to look
over his MS. Any one who had studied psychology or
logic for an hour would not talk of a bottle full of grav-
ity, literal physical weighing a thought, rolling a ball of
comparison down the floor, or "clutching in a pair of
hands " a sentiment, or a sensation. Only crazy men and
ignorant materialists talk that way.
" The myth of tiie instincts " is explained by " posi-
tive or negative heliotropism," and " naught is here but
the play of physical forces " to represent the "childish
ideas" of the old physiologists ; " wiseacredom rubs its
purblind eyes and stares." It certainly does stare at
the wonders of lay magazine science reporters.
Heteromorphosis ' explains so much of life origins.
"There is no complex structure ia germ-cells to explain
their forms, only a reaction between a specific kind of
protoplasm and the physical forces, etc." Of course Prof.
Loeb would tell the smart reportorial young man that
the origin of the specific kind of protoplasm is yet to be
explained ; also that if there were a complex structure
of the germ-cells it would be claimed by a class of dog-
matic pseudo-scientists as a still better proof of " no life
here." " The demonstration was complete," says the
entranced reporter, "and the tireless and restless inves-
tigator passed on." But "the new science of experi-
mental morphology was born." "The new chemistry,"
the contractions of pieces of jellyfish, and of excised
hearts, stopped or started by certain chemic solutions,
again "causes this daring physiologist to press on with
feverish haste, although lys restraint and caution became
admirable." He had to "press on " to show that the
> " The unoffending reader who wends his way through the serried
pages (jfie) wherein Dr. Loeb's work Is set down, will recoil before the
oriental prodigality of large names." This on one page of the article ■
a few pages larthcr on are these words : " Ohemists, with the old
glchemlst's love of high-sounding names, called this v dency or almn-
Kity.
heartbeat is " not due to the mysterious influence of still
more mysterious nerves, but is only due to the presence or
absence of a minute quantity of certain salts." Whence
the heart itself is no matter ; common salt probably pro-
duced it, at least the hearts of lay magazine scientists.
But the magazine scientist says that Dr. Loeb says
that electricity created it, both it and all nmscular action
and all life-processes. Dr. Loeb's smiles at this point must
be rapidly turning very grim and sour. But he has to be
" pressed on " to no less a divine act than the " manufac-
ture of living beings." "After the union of the two cells
the influence of either parent seems as slight as that of a
hen brooding over its nest of eggs. An incubator may
replace it, a fact whose wide significance seems a little to
have escaped the airy-headed folk who prattle of prenatal
influence." Airy-headed folk will certainly ask whence
the two cells, the hen, the brooding and even the incu-
bator. Solid scientific heads like Mr. Snyder need not be
troubled to explain these things. Then follows an account
of the sea-urchin egg parthenogenetic experiments at
which physiologists and bacteriologists are now quietly
and sadly smiling. Dr. Loeb was wretchedly misreported
as to the potassium cyanid experiments. These are
supposed by Mr. Snyder to prove— good heavens what
do they not prove — perhaps the secret of "eternal
life," the absurdity of food and the birth of a "third
science," which must re-form (note the hyphen ! ) " its
line of march from the reports sent back by this single
daring scout, working always beyond the farthest out-
posts of the accepted and the known." Such " science "
is more harmful to science than all the theology and
bigotry of the world. But the great presser-on is still
pressed on to the demonstration of the uselessness of the
supposed mysterious and elaborate structure of nerve-
cells and ganglions, that " simple mechanical conceptions
of the processes of sensation," are all that is needed,
that nerves "jell," and this explains their conductivity,
and all about ions, and all about the rest. Surely the
interviewer has too many ions in the fire ! " Slight
wonder if a young man of 30, keen to enter the front of
the lists, should sit up nights thinking about it, and
Professor Matthews did."
We sympathize with Professors Loeb and Matthews
and with the University of Chicago authorities ; would
that they might unite to stop the antics of the reporters
who travesty science, and especially the American
variety !
Genuine scientists, as we demonstrated in our issue
of April 19, 1902, page 624, do not believe a theory
before consulting facts ; by that method facts are made to
prove the theory tis easily as in Mr. Prattler Snyder's case.
It is not well to settle the question as to the mechanical
nature and origin of life 20 or any years before there
is a single proof of the theory. It is better done 20
years after. In his admirable address on the Evolution of
Biology in the Nineteenth Century, delivered before the
Sarnmlung deutscher Naturforsclier at Aachen, September
17, 1900, Oscar Hertwig says :
" The greatest triumph of the chemic and physical methods
was in demonstrating that physiologic processes are chemico-
physical rather than vital. But this conception has been carried
too far ; some physiologists look upon life, with all its complex
July 5, 1902]
EEVIEWS
[American Mbdicine 5
manifestations, as being entirely chemic and physical. This
is as far wrong as the old theory of vitalism. The relation of
the physicist to biologic questions is similar to tliat of the
chemist. Physiologic questions cannot be explained on purely
chemic and physical grounds. We cannot find out the role
played by albumin in vital processes by study of its chemistry,
but by direct study of the protoplasm in living cells. We must
return to an anatomico-biologic basis and let it be modified by
the chemico-physic conception. The material world must be
united by biologic studies with the manifestations of the imma-
terial world of life."
The difference between a working hypothesis
and dogmatism in .science is in a final analysis a,s
great as between .science and dogmatism. The working
iiypotiiesis is a tiieory wliich is so liglitly held that it
will not dictate investigation nor dominate it, and will
be renounced with perfect ease and willingness when
facts disprove it. It is formed and followed only to sug-
gest methods, not substantiate results. The scientific
dogma is a very different affair. It is not formed as the
result of a study of facts, nor does it seek facts to aid in
establishing the truth. In his heart the dogmatist does
not seek truth but the proof of a preconceived belief.
The working theory always leads to truth, although
sometimes that truth is only negative, the disproof of
itself. Dogmatism really never leads to truth except at
the discomfiture and even the disgrace of the dogmatist.
The socalled scientist who seeks by scientific investiga-
gation to prop up his dogma is not a scientist, and soon
or late he comes to grief. It is not a right nor a result-
ful method. Many lives are today being wasted in
coloring, misconceiving, or doing positive violence to
facts by men who work toward an end too firmly be-
lieved in advance, instead of by a lightly-held theory
which suggests but never intimidates. Dogma may be
likened to a selfish tyrant whose injustice leads to revo-
lution, the working hypothesis to a constitutional ruler
whose pleasure is the freedom and welfare of his people.
Statistics of the Boer War. — According to the
Hospital 5,776 officers and men were killed in action,
and 2,019 died of the wounds which they received. The
deaths from disease amounted to 13,272, and these fig-
ures, large as they are, compare favorably with those of
preceding wars. There was a high proportion of officers
killed and wounded, and a high deathrate from disease
among privates. In action one officer was killed to
every 10.15 men, and one officer was wounded to every
11.34 men. But of those who died from disease, only
one in every 38.5 men was an officer. This is partly
accounted for by the recklessness with which the men
drank polluted water. The number of invalids sent
home during the war was about 70,000, and of these
more than 6,000 died or left the service. The vast
majority, of course, were restored to health. The finan-
cial cost of the war will foot up about 11,100,000,000.
This, according to the Cobden Club, is sufficient to
establish fifty universities, while Oxford and Cambridge
are in desperate need of money. If one-tenth of this
amount were asked for the endowment of laboratories, etc. ,
to prevent death and disease and suffering, with what con-
tempt would the request be met by both government and
people ! So far is our " poor best " from true civilization.
BOOK REVIEWS
American Edition of Nothnagel's Encyclopedia : Typhoid
and Typhus Fevers.— By Dr. H. Curschmann, of Leip-
zig. Edited, with additions, by William Osier, M.D.,
Professor of the Principles and Practice of Medicine,
Johns Hopliins University. Octavo of 646 pages, illus-
trated, including a number of temperature charts and two
full-page colored plates. Philaxlelphia and London: W.
B. Saunders & Co., 1901. Cloth, «5.00 net; sheep or half
morocco, $6.00 net.
For a quarter of a century the famous Ziemssen Encyclo-
pedia of Medicine has held supreme place throughout the world
as a work of reference and a mine of information, but the mar-
velous progress of medicine in recent times has made a new
system necessary, and v. Ziemssen has found a worthy suc-
cessor in theNothuagel Encyclopedia. This monumental work,
the acme of German scholarship and knowledge, is now,
through the enterprise of the publishing house of Messrs. W. B.
Saunders A Co., being made accessible to those not conversant
with the German language. To issue an English translation of
this large system is an undertaking of no mean proportions,
and deserves encouragement and support. The English trans-
lation is under the competent editorial supervision of Dr. A.
Stengel, of Philadelphia; and each separate work is being pre-
pared for American and English readers by a recognized
specialist in his particular subject.
The volume before us, comprising Curschmann's article on
Typhoid and Typhus Fevers, has been edited by Dr. William
Osier, who has brought the subject matter up to date and has
added valuable data from his own vast and well-digested experi-
ence. The result is the most comprehensive work on typhoid
and typhus fevers in existence, and there is scarcely a question
that can be addressed to the book that it does not answer. The
only subject of importance to which the reviewer was unable to
find any reference is the role played by insects in the transmis-
sion of typhoid fever.
Dr. Osier's additions have been made to the chapters on
Pathology, the State of the Blood, Surgical Complications, the
Diagnosis by Bacteriologic Methods, Perforation and Perito-
nitis, and the Hepatic Complications of Typhoid Fever. The
chapter on bacteriology has been thoroughly revised, with par-
ticular reference to tiie distribution of the bacilli in the body.
It is shown that, much more often than has been generally be-
lieved, the bacilli are contained in the urine and in the blood,
and that, by proper methods, which are fully described, it is
possible to isolate them from both fluids.
The symptomatology is discussed, the subject being
minutely subdivided, so that data on any particular phase of it
can be readily found. Regarding the pulse, Curschmann very
properly emphasizes its disproportionate slowness, and con-
siders this to possess much diagnostic value. This opinion coin-
cides witli the experience of the reviewer, but the fact does not
seem to have been generally recognised. The Widal reaction
is described in detail. As to its value, the author holds that,
with due attention to proper proportions and with the lapse of
time necessary to produce the phenomenon, the reaction is of
great diagnostic importance. With regard to the significance
of the dlazo reaction in the urine, Curschmann is of the opinion
that a certain degree of diagnostic and prognostic value may be
attached to it, although it is not an infallible sign. It may occur
in acute miliary tuberculosis, in pneumonia, in certain acute
exanthems, in malaria, and in typhus fever. Only rarely is
it absent from the urine in typhoid fever.
The chapter on Typhoid Fever in Children is very interest-
ing and complete, which is not surprising, in view of the fact
that it is based upon the author's personal records of 613 cases.
The section upon the treatment begins with a brief discus-
sion of the socalled " specific treatment," viz., that based upon
bacteriologic methods. Not much has been accomplished in
this direction, but the data are sufficient to encourage a hopeful
spirit. The prophylactic inoculations, after the method of
Wright, with dead cultures of typhoid bacilli, have been quite
efficacious in preventing the disease, particularly in the British
army in South Africa ; and the method, at the present time at
least, is applicable to persons going into a district in which the
/
6 American Medicine)
AMEKICAN NEWS AND NOTES
[July 5, 1902
disease prevails ; and also to armies, or other large bodies of
people, lilcely to be attacked by an epidemic of typhoid fever.
The medical treatment recommended is that now employed by
the majority of progressive physicians. Curschmaun is decid-
edly skeptical with regard to the socalled " antiseptic treat-
ment," and Osier, with his well-known antipathy toward tlie
various specific treatments based upon the use of intestinal
antiseptics, naturally does not contradict the German author.
A liquid diet is recommended, milk being considered the most
suitable article of food. Tiie strained cereals— such as oatmeal,
tapioca and arrowroot — may be added to the milk ; and Icecream
is also approved. The mucilaginous broths may be given
alone, or with bouillon or proteids. Gelatin is permissible.
The use of eggs is not advised, or, at least, not urged. The yolk
may be given with bouillon or wine, but not with milk, as the
latter combination is not very digestible. Osier makes extensive
use of egg albumen, prepared by thoroughly shaking the white
of egg with ice and a small amount of water, straining and then
flavoring with lemon, sherry or brandy. Alcoholic beverages
are considered by Curschmaun as indispensable— a view not
entirely shared by all medical men. Solid food is not permitted
until the sixth or seventh day of convalescence ; and then only
in cautious amounts. The author has practically given up the
use of antipyretic drugs, and resorts to them only in hyper-
pyrexia. The treatment of complications is fully covered. It is
interesting to read that in meteorism Curschmann has had no
results from turpentine, and but little better success from the
use of the rectal tube. The treatment of hemorrhage consists
in the use of opium. Hemostatic and styptic remedies are of
very little value. In alarming cases the intravenous or subcu-
taneous use of salt solution, or even transfusion of blood, may
be practised. In the Johns Hopkins Hospital good results have
been obtained by the use of calcium chlorid, in 2-gram (;JO-graiu)
doses, every three or four hours ; and from subcutaneous injec-
tion of a 2% solution of gelatin. In the section on Intestinal
Perforation, Osier's well-known views are tersely set forth : "As
soon as perforation is believed to have occurred, immediate
surgical Intervention is demanded." The results of this pro-
cedure seem to warrant its application.
The section on Typhus Fever has the same excellent quali-
ties as are possessed by that on typhoid fever. Three very
good illustrations, two of the typhus, and one of the typhoid
eruption, increase the value of the article. The bacteriology of
typhus fever is considered to be still unsettled. There can be
no doubt that the contagium is a specific poison, but none of
the microorganisms brought forward, up to the present time,
has gained an unequivocal endorsement. The prevention of
the disease by careful quarantine measures is advised. Cursch-
mann is enthusiastic in praise of the open-air treatment of dis-
ease. Hydrotherapy holds the same place in typhus as in typhoid
fever ; the antipyretic remedies have given no marked result.
From a typographic point of view, this, the first volume of
the series to be issued, is extremely satisfactory. The transla-
tion is all that could be desired. Taking the booli all in all, we
can only repeat what we liave said above, that it is the most
comprehensive work on typhoid and typhus fevers in existence.
Practical Dietetics, with Special Reference to Diet in
Disease.— By W. Gilman Thompson, M.D., Professor of
Medicine in the Cornell University Medical College in
New York City, Visiting Physician to the Presbyterian
and Bellevue Hospitals. Second edition, enlarged and
thoroughly revised. New York: D. Appleton & Co.,
1902.
The first edition of this book was so well received that little
of criticism is at this time necessary. The author has thor-
oughly revised it and brought it up to date, and has availed
himself of the exceedingly valuable contributions to scientific
dietetics published by tlie United States Department of Agricul-
ture. The sections on diet in disease have also been enlarged,
and there are a number of excellent formulas and receipts em-
bodied under the different headings. The important subject to
which the work is devoted is properly receiving much more
attention from physicians every day, and the thoroughly scien-
tific and practical grasp of the subject shown by the author
ought to make this volume very popular.
AMERICAN NEWS AND NOTES.
OENERAXi.
X-Rays for Lieprosy.— The territorial board of health of
Hawaii is to begin a series of experiments to determine the
value of x-rays in the treatment of leprosy. Application has
been made for a physician from the U. S. Marine-Hospital Ser-
vice and also an expert from an eastern medical college.
Warning to Profession.- Several western physicians
unite in warning the profession against a man traveling under
the name of E. .T. Saunders and purporting to represent the
Saunders Medical Exchange, of New York City. He offers
shares in the agency, and books, instruments, etc., at cost. It
is said that the New York postoiHce and police departments
characterize him as a swindler.
EASTERN STATES.
Nurse Toppan Pronounced Insane.— Jane Toppan, the
Lowell, Mass., nurse, charged with poisoning patients, has been
committed to the Taunton Insane Asylum for life. She has
confessed to killing by poison 31 patients whom she had
nursed.
Insanity in Massachusetts.- According to the third
annual report of the board for the year ending September 30,
1901, tliere are altogether 7,642 patients in State institutions, and
in addition to these 519 in the Boston Insane Hospital, 1,123 in
city and town almshouses, 117 in private families and 80 in
private families under the care of overseers of tlie poor, .392 in
private institutions, and 8^37 in institutions for the feeble-
minded. This makes a grand total of 10,710 persons, with an
increase of 3.56 patients duringthe year.
NEW YORK.
Dr. William M. Leszynsky has been appointed consulting
neurologist to the Harlem Hospital.
Hospitals for Acute Insane. — The State Commission in
Lunacy has arranged to establish in Manhattan and Brooklyn
boros hospitals for the more active treatment of the acute
insane. They will be known as psychopathic hospitals, the
former providing for 200, the latter 100 patients.
Floating: Hospital Season Begun. — The initial trip of the
floating hospitals of St. John's Guild was made June 2ii. Daily
trips will be made during the summer by the two boats.
Health Commissioner Lederle, who was present on the fi rst trip,
expressed his satisfaction at tlie work accomplished.
Inspecting Ophthalmologists Appointed. — Following
their declaration of June 11 regarding ophthalmia in school
children, the Board of Health of New York City has appointed
a corps of 11 pliysicians to inspect school children daily until
the summer vacation. Their pay will be §100 per month.
PHIIiADEIiPHIA. PENN8YL.VANIA. ETC.
Altooiia Hospital. — It is reported that Charles M. Schwab
has made a donation of ^"),000 to this hospital.
St. Joseph's Hospital. — Dr. P. F. Moylau has been ap-
pointed a member of the visiting medical staff.
Camden Free ft-om Smallpox. — The last case of smallpox
was discharged from the Municipal Hospital June 27.
Philadelphia School for Nurses.— At the annual com-
mencement held June 24 a class of 105 received diplomas. The
course is about 10 weeks in length.
Medical Society of New Jersey.- Officers for the ensuing
year: President, E. L. B. Godfrey, Camden; vice-presidents
Henry Mitchell, A. W. Taylor, W. H. Johnson ; secretary, E.
W. Hedges, Plainfield; treasurer, Archibald Mercer, Newark.
Dr. Angney Appointed Police Surgeon.- Dr. William
M. Angney has been appointed chief surgeon of the Bureau of
Police to succeed Dr. T. H. Andrews. For the past eight years
Dr. Angney has been a medical inspector in the Bureau of
Health.
Suit Against State Hospital.— The State Hospital for the
Insane at Norristown has been sued for $11,454 by Dr. Susan J
Taber. The basis is alleged breach of a five-year contract by
relieving the plaintiff of her position February 1, 1901, without
reasonable cause.
Board of Health Resigns.— Dr. H. J. Edwards, president
and two other members, constituting a majority of the South
Bethlehem Board of Health, have resigned. This action is the
result of differences between the board and the town council
regarding the management of smallpox.
July 5, 1902]
FOEEIGN NEWS AND NOTES
iAmebican Medicike
Society of , Nurses Chartered. — Judge Ralston has
approved the charter of the Society of Nurses of the Hospital
of the Protestant Episcopal Churcli in Philadelphia. The cor-
poration was formed " for the maintenance of a high standard
in professional worlc among pupil and graduate nurses of the
Episcopal Hospital, mutual friendship and social intercourse
and the care of members when ill, irom dues, bequests and
voluntary contributions."
Wills Eye Hospital.— A benevolent citizen of Philadelphia
has offered to give $15,000 to a fund for the endowment of the
Wills Hospital, provided the sum of $100,000 shall be subscribed
by January 1, 1903. The impression among many people is that,
as the Wills Hospital is managed by the Board of City Trusts,
any shortage may be supplied from the resources of the Girard
Estate. This is erroneous, as not one dollar of the Girard
Income is available for the hospital.
SOUTHERN STATES.
Applicant's Right to Examine Papers. — The city solicitor
of Washington, D. C, has, in an opinion lianded down to the
Board of Medical Supervisors, decided that an unsuccessful
applicant for license to practise medicine has the right to inspect
his papers afterward. The decision was the result of the refusal
of the board to permit such inspection by a rejected candidate.
\rESTERN STATES.
The Eastern Oregon District Medical Society will hold
a meeting at Hot Lake July 16, 1902.
Dr. H. V. Wurdeman has been elected professor of ophthal-
mology in the Chicago Eye, Ear, Nose and Throat College.
Dr. Adolph Gehrman ha.s resigned his position as bacte-
riologist and director of tlie laboratory of the Chicago Depart-
ment of Health.
Women Control Directorate of Hospital. — The entire
control of the Kalamazoe Hospital has been jjlaced in a board of
directors consisting of five men and ten women, no one of
whom shall be a physician in active practice.
Chinese Physician Lands. — The Chinese Bureau at San
Francisco is abashed over the recent landing from the Gaelic of
the Chinese physician, Yeang Wing. He is 74 years old, a grad-
uate of Yale, and dresses in the garb of a European.
Chicago Hospitals Unsafe.— As a result of the St. Luke
Sanitarium fire, every hospital and sanitarium in Chicago will
be inspected by tlie city building department. It is said that
many of the hospitals have no fire-escape, only two or three are
fireproof and most of them have narrow stairways.
Centenary Hospital Opened at St. Louis.— The faculty
of Barnes Medical College has recently completed at a cost of
?115,000 the new centenary hospital, to be used in connection
with the college. The capacity is 150 patients, and the three
operating rooms are open to all pliysicians, who can treat
patients under the same terms accorded the regular staff.
Digestive Value of Foods.— The following are extracts
from a bulletin just given out by the State Agricultural Depart-
ment of Minnesota: The opinion entertained by a great many
people that whole wheat and graham bread is more nutritious
than that made from standard patent flour, tlie flour used in
everyday baking, is erroneous. When milk was used as a
ration with bread, butter, beans, eggs and potatoes all the pro-
tein of tlie milk was digested and, in addition, 4.91% more of the
Srotein of the other foods with which it was combined was
igested than when the milk was omitted. The highest degree
of digestibility was secured in a mixed ration. Experiments
made with butter showed that it has a high degree of digestibil-
ity, 98% of it being available to the body. Cheese should be
used in the diet regularly and in small quantities rather than at
irregular intervals and in large quantities, as is frequently the
case. Cheese ordinarily is one of the cheapest and most nutri-
tious foods that can be procured. It is possible to secure a
larger amount of digestible nutrients and available energy
from cheese, costing 15 cents a pound, than from meat, costing
10 cents a pound. Oatmeal, like cheese and beans, is slow of
digestion, requiring much intestinal work for the digestive
process ; but if well prepared and thoroughly cooked it is a
suitable food for persons of all habits.
CANADA.
The Tuberculin Test.— The Canadian Government has sent
Mr. A. G. Hopkins, veterinary quarantine officer for Canada,
to England to apply the tuberculin test to all cattle over six
months old intended for export or breeding purposes from the
United Kingdom t<j Canada.
Victorian Order of Nurses.- This organization, founded
l)y Lady Aberdeen, has now spread generally throughout Brit-
ish North America. Its work is nursing among those unable
to pay for proper care during sickness, or those at such a dis-
tance from the centers of civilization that trained nurses cannot
be secured. Lady Minto has added the Cottage Hospitals,
which have proved of the greatest value wherever placed.
These rural institutions in nearly every instance become self-
supporting and also have a very important educational value,
and become, in a measure, small training schools in the
districts.
FOREIGN NEWS AND NOTES
GENERAL.
New Medical College in China.— The Medical Missionary
Society in China has decided to establish a medical college for
men in connection with the society's hospital at Canton.
United States Consul McWade is chairman of the committee
on organization.
Fig Coffee.— A product called coffee of figs, manufactured
in Austria, is much used in Germany and Austro-Hungary. It
is obtained by drying fruits, especially figs, and mixing them
with coffee. It is said to correct the bitter taste of the coffee
and diminish its excitant quality, in addition to possessing con-
siderable nutritive power.
Smoking Carriages for Ladles.— On the continent smok-
ing is growing so rapidly in favor among the fair sex that on
some of the Belgian railroads smoking apartments are to be
provided exclusively for women. This result has been brought
about through a young lady finding herself the object of much
protest on her producing a cigaret in an ordinary compart-
ment reserved for ladies. The young lady has taken action to
compel all the Belgian companies to provide smoking accom-
modation for ladies. — lLondo7i Health^
Sanitation at the Dusseldorf Exliibition.— One of the
sections at this exhibition, organized under the direction of Dr.
A. Hoffmann, is devoted to " sanitary arrangements and social
institutions." Portable structures built on the Briimmer system
are shown. This is based on the principle that every separate
piece of the building is of the same size and joined together in
the same manner. In this way huts of any size can be con-
structed for temporary quarautine stations or isolation hos-
pitals. Model workmen's cottages, plans of hospitals, asylums,
sauatoriuins, etc., are also exhibited.
Medicine in Bombay.— A Swedish consul at Bombay
states that " because of their fear of sanitary inspection and
modern methods of preventing and curing disease the natives
of India in vast numbers are the victims of plague. In conse-
quence of the hatred and fear of hospitals and medical men the
population of Bombay has decreased 40,000 in the last ten years,
while the increase in the whole of India in the same time was
about 15%. Bom nay now has 760,000 people. The hospital and
general medical service in India are of the best and do much
good in the affected districts in spite of the prejudice which
prevails against such things. The plague is generally fatal
without the most skilful medical attention. The natives in
their ignorance seek only to be left to die in peace. The ancient
traditions of the country are extremely diflicult, almost impos-
sible, to eradicate."
Dangerous Substitutes for Sugar.- In the course of an
article on food adulteration, Dr. de Lavarenne, editor of Ln
Pres.se MHicale, refers to the manner in which the use of
saccharin is being extended. It is not only use<l to sweeten
beer but it is now also employed in the manufactureof syrups,
jams, lemonades, wines (especially chainpagne), cider, brandy,
pastry and chocolates. Special Hubstanccs of this nature are on
the market for sweetening cider and brandy. Among these
sucrainine may be mentioned, which is said to be seven hun-
dred times sweeter than cane sugar. Other products of the
same kind are sugar extract (made in Switzerland), cannabin,
etc All these names arc misleading, for tlie substances are
only sugars in name, being coal-tar derivations. They are not
foods Moreover, their long-continued use may gravely affect
the digestive functions. Dulcin, another sweetening body,
which has been used as a substitute for saccharin, was given to
a dog at the rate of one grain a day. The animal died in three
weeks
GREAT BRITAIN.
Vital Statistics of South African War.-The vital 8te-
tisties of the South African war, which are now i>ract cally
complete, show according to IlonpUal that 5,776 ofllcers and nien
were killed in action, and 2,019 died of the wounds which they
received The deaths from disease amounted to 1:1,272, and it is
said that these figures, large as they are, compare favorably
with those of preceding wars. One noticeable fact is the very
hieh proportion of officers killed and wounded, and another the
hitth (loath-rate, from disease, among privates. In action, one
olticer was killed to every 10.15 men, and one officer was
wounded to every ll.:J4 men. But of those who d l«l from <ll«-
ease only one in every 38.5 men was an officer. This is partly
8 American Medicine]
SOCIETY REPORTS
[July 6, 19a2
accounted for, doubtless, by the recklessness with which the
"Tommies" drank polluted water. The number of invalids
sent home during the war was about 70,000.
Liondon'8 Fire Traps.-We are sure that if a practical
Inquiry were generally made in the buildings of London for
protection against firean appalling conclusion would be reached.
Several lives have been lost recently in London fires because
there was no way of escape. London is undoubtedly swarming
on all sides with death-traps only ready to claim their victims
when a fire has broken out. Every one is aware of the difficul-
ties which have to be faced when the question of the efficient
protection of life shut up in buildings in a congested area is
approached. In probably the majority of buildings in London
It is impossible even to escape to the roof and thence to
f'ain a safe refuge on the adjoining premises. We know of at
east of one instance, that of well-known bank premises, m
which the boundaries of the property are marked on the root by
ugly spiked fences. While it is true that even this way of
escape is not easy, it is certain that in a greater number of
instances no such thing as a fire ladder is available.— [Z/anec<. J
Vivisection In England.— The annual report for the year
1901, by Mr. Thane, the Inspector for England and Scotland,
and by Sir Thornley Stoker, the Inspector for Ireland, on the
experiments on living animals performed during the year
under license from the Secretary of State for the Home Depart-
ment, has just been issued as a Parliamentary paper. In Eng-
land and Scotland there were 257 licensees, of whom 56 per-
formed no experiments ; and, in the words of the report, the
" tables show that licenses and certificates have been granted
and allowed only upon the recommendation of persons of high
scientific standing ; that the licensees are persons who, by their
training and education, are fitted to undertake experimental
work and to profit by it ; and that all experimental work has
been conducted in suitable places." It is also said that the
Inspectors have found the animals everywhere suitably lodged
and well cared for, and the licensees desirous of acting in every
way in accordance with the spirit of the act. Under what is
described as Table III (A), 2,049 experiments were performed
in England and Scotland, and the larger part of these are
unattended by pain, because the animal is kept under an
anesthetic during the whole of the experiment, and must, if
pain is likely to continue after the effect of the anesthetic had
ceased, or if any serious injury has been inflicted upon the
animal, be killed before it recovers from the influence of the
anesthetic. In experiments performed under Certificate B, or
B linked with EE, 69ft in number, the initial operations are
performed under anesthetics, from the effects of which the ani-
mals are allowed to recover. The experiments included in
Table III (B), 9,596 in number, were all performed without
anesthetics. They were mostly inoculations, but a few were
feeding experiments, or the administration of various sub-
stances by the mouth, or the abstraction of a minute quantity
of blood for examination. In no instance has a certificate dis-
pensing with the use of anesthetics been allowed for an experi-
ment involving a serious operation. Inoculations into deep
parts, requiring a preliminary incision in order to expose the
Eart into which the inoculation is to be made, are required to
e performed under an anesthetic, and are included in Table
III (A), In a very large number of the inoculation experi-
ments included in Table III (B), the results are negative, and
the animals suffer no inconvenience whatever : while in the
event of pain ensuing as the result of an inoculation, a condi-
tion attached to the license requires that the animal shall be
killed under anesthetics as soon as the main result of the
experiment has been attained. — London Times.
OBITUARIES.
Nicholas Nicholaivicli Dvorashln, in St. Petersburg, June 10. He
was the physician who flrst rendered aid to the wounded Czar Alex-
ander II. Formerly a brilliant man his mind became clouded, and
recently he was beaten by a mob who misunderstood his acts. He died
later in an asylum, charges of ill treatment by the hospital manage-
ment having been made.
George W. Ludwig, of Chambersburg, Pa., June 23, aged 48. Dr.
Ludwig was born in Chambersburg, but had been engaged as Jeweler
and oculist in other cities. He died in the University of Maryland
Hospital at Baltimore, where he was being treated for intestinal tuber-
culosis.
William N. Fisher, at Washington, D. C, June 25, aged 29. Death
was the result of falling down the elevator shaft at the Columbian
University Hospital where Dr. Fisher was visiting patients, his skull
being fractured in five places.
Alexander M. Mecray, at Maple Shade, N. J., June 26, aged 63. He
was one of the leading practitioners of Camden until three years ago,
when he was stricken with apoplexy.
Isaac Joslah Wetherbee, one of the oldest dentists in Massachu-
setts, at Dorchester, June 25, aged 85.
Jacob F. Meyer, of Buffalo, was shot and instantly killed June 20.
Ernest Potter Jenks, of New York, June 25, aged 36.
H. F. Prager, of Brooklyn, June 22, aged 52.
SOCIETY REPORTS
THE AMERICAN PROCTOLOGIC SOCIETY.
Fourth Annual Meeting, Held at Saratoga Springs, New
York, June lo and ii, 1902.
[Specially Reported for American Medicine.]
William Bodenhamer (New York) and Edmund Andrews
(Chicago) were elected honorary members. The following
were elected active members: A. Teirlinck, Ghent, Bel-
gium- William L. Dickinson, Saginaw, Mich.; J. M. Franken-
berger, Kansas City, Mo.; John T. Jelks, Memphis, Tenn.
Drs. Mathews and Beach were elected a Committee on Publica-
tion of Transactions. The following officers were elected to
serve the ensuing year: President, Samuel T. Earle, Balti-
more, Md.; vice-president, Floyd W. McRae, Atlanta, Ga.; sec-
retary and treasurer, William M. Beach, Pittsburg. Executive
Council— George J. Cook, chairman, Indianapolis, Ind.; Lewis
H. Adler, Philadelphia; Thomas Charles Martin, Cleveland,
Ohio. Adjourned to meet at the time and place of the American
Medical Association in 1903.
President's Address : The Relation of the Rectal Valve
to Obstipation, a Clinical Research.— Thomas Charles
Martin (Cleveland). A glance at this table discovers that of
the 40 cases operated prior to two years ago two were not
improved, one of these had no complications discoverable by
me, the other was subject to recurrent invagination of the sig-
moid to the rectum. Five patients were improved. Three of
these had complications, one had gonorrheal peritonitis and
malignant disease of the cervix uteri, another had been sub-
jected twice to laparotomy and had Meckel's diverticulum
removed and oophorectomy performed, and the third had mov-
able right kidney and an ovarian tumor; of the six patients
who suffered recurrence of obstipation three were those
whose condition after operation had been improved only;
of the remaining three recurrences one had been subjected
to hysterectomy, and the other two (cases 15 and 26) I. have not
been able to get report. In a total of 40 cases 5 were improved
and 33 cured.
Dietary tn the Treatment of Rectal Diseases.— A. P,
Buchman (Ft. Wayne, Ind.). Beginning with hemorrhoids
and ending with proctitis, catarrhal or otherwise, the whole
pathologic ensemble is primarily referable to what has been lefl
over a long time, and not to what is daily ingested in the food
supply. Indigestion even in its most elementary state is over-
looked and underestimated. Digestion is not fermentation. It
is a process of decomposition of molecular particles and s
recomposition of chemic elements by which toxins and toxic
substances are formed. Carbon dioxid in excess in living tissu«
for too long a time will produce paralysis of function anci
finally organic disintegration. Catarrhal proctitis is ofter
many feet away from the point treated. Give well regulated
diet for chronic constipation. Internal hemorrhoids disappeai
under palliative treatment and regulated diet. In a case cited
he used 30% protargol to mucous membrane, daily colon bath
witli open air and rest.
Discussion.—SAMVBi. T. Eakle (Baltimore) called attentioi
to the fact that we should reflect in these cases before resortinj
to operation. James P. Tuttlb (New York). This papei
justifies the position taken by Mathews and myself will
regard to taking other members into the society. It is th(
work of these men along other lines than operative ones
Buchman closes : I heard a lecture yesterday at the Postgrad
uate in New York concerning the stomach, in which thi
lecturer detailed the pathologic condition, and then the druf
treatment. Each member of the class took down carefull;
all he had said ; then he said " the most important thing ii
diet," and the books closed at once. He should have givei
the diet first.
Diagnosis and Treatment of ProctltlB. — Howard A
Kelly (Baltimore). The special importance of the subjec
alluded to lies in the fact that the affection is, for the most part
unrecognized, and so allowed to run a chronic course. Th^
local symptoms are often vague, and in women they give ris
to disease of the uterus or ovaries. Some of its symptom
are decidedly serious in character; such as the poisonou
character of the mucous secretion of the bowel. When asst
ciated with other pelvic diseases it is apt to be overlooked
Cause is generally obscure. The better recognition of thes
affections hinges on the diagnosis. If such a case is examine(
per vaginam the empty rectum feels like a flattened flbrillate<
cord easily rolled from side to side. Topical and dietary am
drug treatment and massage recommended. Excepting atrc
phic catarrh, almost all forms of proctitis are associated witl
diarrhea. Most types occur in tropical regions, and are due t
specific microorganisms. Treatment, prolonged rest in bei
and irrigations, with fluid extract of krameria in irrigatioi
solutions. Diet of milk and meat exclusively was followed b;
improvement. Trichomonas inteslinalis parasites disapp^earei
under irrigation of pure lime water. Ankylostoma intestinaHi
no medication attempted.
Discussion.— ii.T . Earle (Baltimore) spoke in defense of th
ground taken by bacteriologists that the role played by th
July 5, 1902]
SOCIETY REPORTS
iAUEKIOAN MeDICIKK 9
ameba is the production of dysentery as we find it in temperate
climates. Whiether otiier organisms pave the way for the
ameba, or whether they do it themselves, is a question.
Treatment of Hemorrhoids.— George J. Cook (Indian-
apolis). In 1876 Andrews, of Chicago, gave statistics which
were obtained directly from advertising specialists, showing
that in 3,200 cases of hemorrhoids treited by injection of caus-
tics there were 13 deaths due directly to the treatment, besides
8 cases of embolism of the liver, 10 cases of dangerous hemor-
rhage, numerous cases of severe pain, abscess, fistula and ulcer-
ation. Since that time there has been no evidence to indicate
that better results have been obtained. A report of six cases of
deaths due directly to this treatment Is given covering the past
18 months. All were treated by advertisers, but subsequently
came under the care of regular physicians, from whom reports
were received. In every case an abscess formed as the result of
the injection, and septic infection followed, resulting in death in
from six to ten days. In one case was pneumonia, in another
thrombus of the hepatic vessels. Many of the bad results fol-
lowing tills treatment is attributed to the method of injec-
tion. Having the piles protruding through the anus and then
Injected when tlie vessels are distended with blood is bad prac-
tice, because when the tumors are replaced much of the coagu-
lated blood is forced from the pile tissue into the surrounding
vessels and may cause abscess or sloughing. The better method
is to use a tul)e speculum, and after the blood is pressed out of
the tumor inject the caustic, thus avoiding the formation of
blood clots in the vessels. Many cases were treated in this way
with only two unpleasant results. In these two cases there
was secondary hemorrhage, which was easily controlled.
This method of treatment is advised only in cases when a gen-
eral anesthetic cannot be administered. The treatment of piles
by injection is the most dangerous method in use, as is shown
by statistics. The relief in the majority of cases is temporary,
averaging about four years.
Discussion. — J. N. Mathews (Louisville). The proctolo-
gist should either endorse this treatment or denounce it. In my
infirmary to-day are two ladies, one of them treated for three
weelis in New York by the injection plan. She does not seem
to have any hemorrhoids. On examination I found a hole in
the gut. Another lady had the same injection plan and the
same result. I have seen two cases of violent hemorrhage
endangering the lives of the patient. I have also seen much
injury done and do not believe it a rational treatment as it is so
easy to establish a dangerous condition and is not so radical
a cure and endorses quack treatment. We can very well see
that by injecting a tumor of this kind an artery may be injected
and a thrombus estaijlished. As the author says, he would only
use it where it was dangerous to give an anesthetic; I often
think cases are chimerical. We have given etlier or chloroform
where we have had heart murmurs. Geo. B. Evans (Day-
ton, O.). In 11 years I have never injected a single pile. It is
not radical. I was influenced to take this stand by Kelsey,
Tuttle, and Mathews in '91. Fully 50% of the cases have had
previously the carbolic acid treatment. These cases had some
kind of fistula or fissure and I prefer keeping; my hands off the
hypodermic. L. H. Adler (Philadelphia) is in favor of the
treatment. Some patients absolutely refuse to have an opera-
tion performed and thinks the profession entirely wrong in
condemning the matter in toto. J. Rawson Pennington
(Chicago) says that in his estimation there are too many "I
thinks " and " I guesses " in medicine. The quack discovers or
originates some method and the profession continues to con-
demn and then take it up. He has had little experience with
carbolic treatment, but on general principles does not like it.
Others may have had good results with it, but the clamp and
cautery and the ligature are wliat he gets the best results with.
George .1. Cook, in closing the discussion, said he used the
injection method as a last resort. When he does use it, he
injects only one pile at a time.
On the Causes and Treatment of Rectal Abscess.—
Wini.iAM M. Beach (Pittsburg). The location of an abscess is
usuUy definite and circumscribed about the rectum by the
limits of tlie pelvic fascia and integument. There are the mar-
ginal and deep-seated varieties. The ischiorectal is one of the
latter. Trauma, mechanical, chemic, thermic, secondary pro-
cesses, bacteriologic, such as gonorrliea, syphilis, tul)erculous,
Bac-illus coK eommunis, zymotic diseases and idiopathic, seem
to be the exciting causes, which vary according to the location
of the pus area. As soon as pus is determined, freely evacuate
it. Introduce intestinal antiseptics and apply cold. Never
poultice. ,,,,,, V „ ^
Z)i«cM«.s?on.— James P. Tuttle (New York) says that
prompt and radical treatment of this inflammatory condition
around the rectum is perhaps tlie means of preventing rectal
diseases. Four out of five fistulas can be avoided if the peri-
rectal inflammatory condition is treated in the beginning.
The Treatment of Rectal Fistulas by Complete Excis-
ion and Closure with Burled Catgut Sutures.- Fi,OYi) W.
MoRae (Atlanta). Some time ago he advised treating fistulas
by excision of the entire fistulous tract, bringing the raw sur-
faces together by sutures with a view to securing healing by
first intention. Many o^ses and authorities are cited. This
method of proctedure saves the victims of this disease enormous
amount of suffering. Has had very good success. Operation
described and two cases reported.
Discussion.— J . Rawson Pennington (Chicago) descrllMd
a modification of this operation. S. T. Earle (Baltimore)
thinks that Pennington's idea is very much more dilficult
than that of the author. When a fistulous tract is laid open it
is not difficult to find the openings of other tracts. L. H.
Adler (Philadelphia) has had unfortunate results with the
use of this method but he may be urged to take it up again
later on. George .T. Cook (Indianapolis) said that Morris,
of New York, always filled the fistulous tract with plaster-of-
paris and then dissected the whole thing out. Martin (Cleve-
land) does not select patients for this operation who are stout.
Patients who have a thick pelvic floor are not good patients for
this operation. When there is much induration he advises
taking baths for some time so that the induration will be les-
sened. Traction is made on the fistulous tract by means of a
forceps and over the ischiorectal space a broad adhesive band
or T bandage is placed. McRab thought Dr. Pennington's
method a great deal more diflicult. When there is more or less
retention of pus it is unfavorable for treatment. The real
points of merit in this method are the laying open of these
tracts and cleaning each one separately and a tnorough dissec-
tion of all the indurated tissue. J. Rawson Pennington pre-
sented a pathologic specimen showing various valves of the
rectum.
Excision of Cancer of the Rectum.- Lewis H. Apler
(Philadelphia). Tiiis paper will appear in a future number of
American Medicine.
Colostomy : Tumors Complicating It.- B. Merrill Rick-
ETTS (Cincinnati). Colostomy may be attended with many
complications, due to benign or malignant neoplasms. Reports
two or three complicating cases. Hernia may complicate,
hydrocele, aneurysm, adhesions, and cysts are frequently
found by the surgeon in colostomy.
Discussion.— 3 . Rawson Pennington (Chicago) described
a case of a malignant growth of the rectum on which a colostomy
was done and the x-ray later used. For a period of five months
no pus has been seen. The patient had had violent pains in the
legs and abdomen, which disappeared after the x-rays were
used. Martin (Cleveland) also reports a similar case. Tuttle
(New York) and McRae (Atlanta) also reported similar cases.
Adler said that all patients gained in weight, sometiines as
much as 25 pounds. He also called attention to the fact that
cancer was very prevalent in the sooty regions of our country.
Treatmentof Hemorrhoids by Enucleation. — George B.
Evans (Dayton). Therearetwoclassesof internal hemorrhoids,
the capillary and the venous. Tlie capillary is in reality a
rectal tumor. Case described. He does not believe in tampon
nor the Pennington plug. In this operation as in all others for
hemorrhoids we fail to find an ideal one. In its application it is
no doubt restricted. In cases in which the varicosities are
comparatively accessible when from any rea.son there is no
bowel paresis and the plug can be placed securely and securely
remain for a time thereby ensuring protection from hemorrhage
and likely from infection, it is no doubt a very agreeable and
satisfactory operation to both patient and operator; but to
be able to determine in every instance in which apparent weak-
ness of the operation may manifest itself, it seems to me it wil
be diflicult. He reported 11 successful cases.
/)j«CM.M)ore.— William L. Dickinson (Saginaw) expres.sed
surprise at the bad results of this operation. In all his cases iodo-
form gauze coated with sterilized vaselin is used as packing.
Pennington (Chicago). A hemorrhoid is an angioma, a dis-
eased condition in the submucosa. He expressed considerable
surprise at such unfortunate results with this operation. In 225
cases he had only two hemorrhages. Usually four days after
operation patient can get up. Evans said that in his case the
bleeding vessel could not be found ; it was behind the tampon.
He likes this operation very much better than the clamp and
cautery.
A Report on Ulcerations of the Rectum. — Samitkl T.
Earle ( Baltimore) gave a complete pathologic report, carefully
gone over in detail.
Some Interesting Cases of Rectal Diseases.— Louis J.
Krouse (Cincinnati) presented some very interesting cases of
rectal diseases— one of abscess, one of ulceration with cicatrices,
and one of ischiorectal abscess.
Handling Contagious Diseases.— The appropriation of
?1,025,WX) asked by the Health Department for better provisions
fordcaling with contagious diseases in New York City has been
cut to ^^M^OCX). In commenting on this as a disappointment,
the Times is not sure that the end sought would not have been
defeated if the full amount asked for had been appropriated.
Great reforms cannot be accomplished by single steps and a
complete system inaugurated at once would probablv meet
popular (>i)position so determined as to be a serious obstacle.
Alter inontioning the public drwidof a " pest house," the Times
says: "The solution of the problem will probably bo found in
the multiplication of reception hospitals scatUired through the
city, safe as to location, attractive as to appearance, and at least
suffliMontly accessible to permit parents aiui friends to see from
a safedistaiK^e where their children and those they care for are
taken and under what conditions ofenvironmeut they are estab-
lished. As these reception hospitals fill up, patients In con-
dition to be moved may be taken to North Brother Island
without shock to those interested in them."
10 American Medicine)
COREESPONDENCE
[JCLY 5, 19
CLINICAL NOTES and CORRESPONDENCE
[Communications are Invited for this Department. The Editor Is
not responsible for the views advanced by any contributor.!
MEDICAL LICENSURE RECIPROCITY.
BY
WILLIAM S. CHASP^, A.M., M.D.,
of Akron, Ohio.
I have been greatly interested in the articles which have
appeared in American Medicine advocating something like uni-
formity and reciprocity in State medical licensure. I hope that
the campaign will be kept up until much of the injustice and at
least a little of the arrogance which present laws make it pos-
sible for some State Boards to display have been eliminated.
I am better acquainted with the conditions in Ohio than
elsewhere, and it is to a few of them which I wish to call atten-
tion, hoping to illustrate by a concrete example some of the
evils caused by the existing order.
In substance the Ohio law requires every man who wishes
to practise medicine in this State to stand an examination, for
the privilege of which he pays §25. Two examinations are held
each year, six months apart. There is a clause in the law, how-
ever, which gives the examining board power, upon the pay-
ment of ?50, to admit to practice, without examination, a physi-
cian who holds a certificate issued by the examining board of
another State, provided the examining board of that State
extends a similar courtesy to physicians holding Ohio certificates.
The law also admits, without examination, for a specified num-
ber otyears, the graduates of Ohio medical schools.
It was my privilege to receive a degree last June from one
of the best medical schools in the country. There were about
12 others in the class who wished to practise in Ohio. The
State medical examinations came early in June, long before our
commencement, and for reasons which were fully explained to
the Ohio Board, we were unable to appear in Columbus at that
time. We tried to have the State Board give us a special
examination, agreeing to pay all additional expenses incurred.
This was refused, and we w ere told that if we wished to practise
medicine in Ohio, the only thing for us to do was to appear
before the board on the second Tuesday in December for exami-
nation. We explained that forced idleness for six months would
be a great hardship for all, and some of us endeavored to have
the board accept certificates signed by the Michigan Board of
Examiners, which we thought might be done under the clause
mentioned above that gave the board a right to admit certain
persons, upon the payment of a double fee, without examina-
tion. The reply was that there was no reciprocity between
Ohio and Michigan. I next made a personal trip to Columbus
to see whether the board would accept a certificate from >rew
York, stating that I had passed sviccessfully the medical exami-
nation required under the New York law. I was told that the
Ohio examiners recognized the certificate from no other State
in the Union, and that the only thing on earth for me and my
classmates to do was to appear at Columbus on December 10,
take our examinations, and wait another month for the board's
report. And that is what we were obliged to do.
It was in vain that we protested against the injustice done
us as citizens of Ohio, where the chief fault had been that we
left our State for a medical education because we thought it
possible to get a better one elsewhere. We were compelled to
remain out of practice for seven months while the law admitted
our neighbors, who had studied medicine in Ohio, without even
so much as an examination.
The hardest part of all, however, was to see the osteopath,
who had acquired his skill and diploma after six weeks of
arduous toil in a correspondence school begin the practice of
his "profession" under our very noses, without even a letter of
introduction or a certificate of moral character, and to note the
apparent prosperity of the clairvoyant and the psychic healer,
with no more claim to recognition than that obtained in a few
dollars' worth of buncombe in a paid newspaper advertisement.
I have not mentioned the injustice worked by such condi-
tions on well-equipped physicians of experience from other
States who might wish to change their residence. The pr(
visions of the law and the rulings of the board in our case wi
make that apparent. I believe in surrounding the practice <
medicine with all the safeguards possible ; but if our legisli
tures enact laws which place the faith curist and the disciplt
of a dozen different "opathies" on a plane several degree
above that occupied by honorable and capable practitionei
and at the same time foist upon us medical boards which, to a
outsider at least, seem to spend a goodly portion of their vaU
able time in nursing petty jealousies over the maintenance <
a more or less imaginary dignity— then, I say, the true spirit t
a medical law, which should be to protect the public at larg
and the profession from quacks and incompetents, is bein
violated and a remedy cannot be applied too soon.
RECIPROCITY IN MEDICAL LICENSURE.
BY
WM. M. CUMMINGS, M.D.,
of San Diego, Cal.
To the Editor of American Medicine: — Relating to rec
procity in medical licensure I want to say that the article b
Dr. Samuel A. Fisk, published in your issue of May 31, is, i
my opinion, timely and well covers the ground. It is worth;
of the careful perusal of all concerned. If I were to add anj
thing to what has been so well stated by Dr. Fisk, I would sa;
that in nearly, if not all the States when laws governing medics
practice were first enacted all practitioners of a certain numbe
of years' practice were licensed. So all those who are at th
present time licensed under the laws of any State should b
allowed to take a license and to practice in any other Stat
without examination. The number of such practitioners wh
might want to change their residence would be so small that :
would practically cut no figure. A good point made by Di
Fisk is that the possession of a diploma is a disadvantage
faith healers, etc., being exempted from operation of the law a
long as they do not pose as " M.D.s". But his article is so fu:
of good points, his recommendations are so sensible and man
festly the only feasible way out of the present difficulty, thf
the entire article should be carefully read by all concerned.
RECIPROCITY IN STATE EXAMINING BOARDS.
BY
H. D. MOORE, M.D.,
of Danbury, Conn.
To the Editor of American Medicine : — The discussion reh
tive to " reciprocity in State examining boards " has failed t
bring forward any champion of the present system. The adv(
cates of reciprocity seem to disregard the logical conclusion <
their argument, i. e., that reciprocity leads unerringly to redui
tio ad absurdum of the whole scheme of medical practice legii
lation. Within the past three years I have passed a number c
State examinations in the West, East and South, and iu th
light of the experience thus gained, cannot understand th
sympathy so persistently expressed for the forgetful " ol
practitioner" to whom medical technology seems such a buj
bear. The physician thinks, talks, and writes in medical feci
nology from the cradle to the grave of his professional caree;
It is safe to say that any practitioner who has been trained pro]
erly and has kept in touch with the advances constantly bein
made (and what physician will admit that he does not kee
abreast ol the times?) will have no difficulty in satisfying h:
colleagues in any State that he has a right to practise.
The conviction expressed by all successful candidates fc
State licenses is that tlie examinations are exceedingly fair an
impartial and designed only to demonstrate the applicant
fitness to practice. My personal experience warrants the asse
tion that the questions asked are of such a nature as to fav(
the practitioner of 10 years' standing. Did not the scheme <
" State Board of Medical Examiners " originate with repr
sentative practitioners as a relief against quackery and incomp
tency, nominally for public safety, but in reality for sel
July 5, 1902]
CXDRRESPONDENCE
;ahbrican Medicine 11
protection ? The " old practitioner " is now beginning to find
these laws a boomerang. If he does not or cannot keep up with
the procession, with all due respect to him he should not
grumble if the conditions for which he is responsible bring
him to a realization of his negligence or incompetency. There
is something queer in the case cited in A merican Medii-ine for
May 31 of the Yale A.M. and Harvard M.D., and is a reflection
which will be resented by men having the same or equivalent
degrees. There is no argument in it against the principle
involved. It hurts one's self-pride and may compromise a
false dignity somewhat to be " put through a course of sprouts "
by one's colleagues, but the worthy doctor who has grown gray
and honorable in a community will find worse shock to his
dignity than an examination when he pitches his tent among
strangers and begins poaching upon the preserves of other gray
and honorable doctors. The graduates of the past 10 years will
sustain the present system, and while the abolition of sectarian
boards of examiners and the establishment of one standard to
which all practitioners must conform would make the present
system more ideal. Still as it is it has considerable virtue.
NOTES UPON ELEVEN MISCELLANEOUS ARTICLES
ON ANIMAL PARASITES.'
BY
CH. WARDELL STILES, Ph.D.,
of Washington, D. C.
1. — Treatment for roundworms in sheep, goats and cattle (pp.
7-14), by Ch. Wardell Stiles. Experiments in Texas showed
that a single dose (60 to 960 cc, according to s^ze and species of the
animal) of a 1% solution of coal-tar creosote usually kills the free
strongyles in the stomach, but cannot be relied upon for worms
in the small intestine. For the worms below the fourth
stomach, powdered thymol was used. For stomacli worms,
gasolin has been the popular treatment heretofore, but with
the gasolin method 4 to 9 doses are necessary. The new treat-
ment, therefore, represents a large aggregate saving in material
and more particularly in labor. A series of experiments in
dosing ruminants in different positions (standing, on the back,
on the side, etc.) shows that the posture has an important bear-
ing on the success of the treatment, for if animal is standing,
the drench runs directly into the fourth stomach, but if on the
side or back it runs into the first stomach.
2.— The disinfection of kennels, pens, and yards by fire (pp.
15-17, fig. 1 and pis. 1-2), by C. W. Stiles. The author proposes
throwing a spray of oil with a cyclone nozzle and setting the
spray on fire.
S. — Eimeria SliedcB (Lindemann, 1865), correct name for the
hepatic coccidia of rabbits (p. 18), by C. W. Stiles. Historical
note, changing the name of Coccidium oviforme, a protozoan
parasite of man, rabbits, etc., according to the Law of Priority.
4. — Eimeriella, new genus of coccidia (pp. 18-19), by C. W.
Stiles. Type, -E7. wona (Schneider). The author overlooked the
fact that Mesnil's Legerella antedates Eimeriella, until too late
to change the proof, but he calls attention to this point in the
margin.
5.— Notes on parasites— 58 to 62 (pp. 19-24), by C. W. Stiles
and Albert Hassall. Technical notes on nomenclature of cer-
tain parasites, none of which occur in man.
6.— Two trematodes (Monostomulum lentis and Agamodisto-
mum ophthalmohium) parasitic in the human eye (pp. 24-36, figs.
2-4), by C. W. Stiles.
8.— An Egyptian and Japanese strongyle {Strongylus sub-
tilis) which may possibly occur in returning American troops
(pp. 41^2, figs. 14-21), by C. W. Stiles.
O.—An adult cestode {Diplogonoporus grandisy of man which
may possibly occur in returning American troops (pp. 43-47,
figs. 22-27), by C. W. Stiles and Louise Tayler.
10.— A larval cestode {Sparganum Mansoni) of man which
may possibly occur in returning American troops (pp. 47-56, figs.
30-36), by C. W. Stiles and Louise Tayler.
• Bull. No m. Bureau of Animal Industry, U. 8. Department of
AKriculture, Washington, D. C. May be onlcred from the Superintend-
ent of Public Documents, Union Building, Washington, D. C. Price,
10 ccnt«.
These four articles give complete . diagnoses, synonymy,
bibliographies, and general reviews of the present zoologic and
medical knowledge of the five parasites mentioned, none of
which have as yet been reported for this country and as a result
they are scarcely mentioned in American textbooks. Persons
who have followed the bureau work on parasites will have
noticed that in a number of cases the articles present complete
summaries of the entire literature of the world bearing upon
the species treated. If tliis policy is continued, the bureau pub-
lications will naturally form the basis of all future work in this
line for this country, since it will not be necessary for an author
to consult any papers prior to the one in which the bureau sum-
marizes the subject. As it is practically impossible for physi-
cians and zoologists, except in a few cities, to obtain even a
portion of the original European literature, this policy adopted
by the bureau will result in eventually furnishing to American
workers in all parts of the country a complete digest of the siib-
.ject of medical zoology.
7, — A case of vinegar eel (Anguillula aceli) infection in the
human bladder (pp. 35-40, figs. 6-13), by C. W. Stiles and W.
Ashby Frankland. The authors found the vinegar eel in sam-
ples of urine taken by catheter from the bladder of a young
married woman. As infection from the stomach to tlie bladde:
seems very improbable, the autliors suggest the possibility of
infection by means of vaginal douches, acidulated with vinegar,
to prevent pregnancy. There is added a key to the clinical
diagnosis of worms in the urine and in the vagina, arranged on
the plan of a dichotomous botanical key, which will be useful
to physicians engaged in clinical microscopic work.
11. — Spurious parasitism due to partially digested bananas
(pp. 56-57, figs. 37-38), by C. W. Stiles and Albert Hassall. On
several occasions, partially digested bananas have been sent to
the Bureau for determination, the physicians wlio liad tlie cases
mistaking these structures for tapeworms or other parasites.
MEDICAL EXAMINING BOARDS FOR MEDICAL
EXAMINERS.
BY
CHAS. A. WILSON, M.D.,
of San Antonio, Texas.
To the Editor of A merican Afedieine : — After a careful read-
ing, in your issue of May 24, of an editorial entitled " The hard-
ship of State limitation of license to practise," etc., permit me
to offer the following suggestion : I^et us have a medical exam-
ining board for medical examiners, /. e., the appointment of a
national examining board by the government, if you please,
and that each member of State Medical Examining Boards be
required to qualify before it and to show his fitness to be a
member of an examining l}oard. That such State board sliall
then be allowed to issue certificates and that such certificate
shall be recognized by the examining board of any other State.
I have passed my examination before the board and liold
my certificate, but when a man tells me that I am wrong in
stating the age of viability to be seven months, that I should
have said four and a half months, I lose confidence in liis being
eminently fitted for the position he holds.
THE EFFECT OF RONTGEN RAYS ON THE BLOOD.
Preliminary Note.
BY
SAMUEL H. FRIEND, M.D.,
of Milwaukee, Win.
While treating patients with the ROntgen rays I observed
in a case of inoperable cancer of the breast, and in a case of
intraabdominal sarcoma, as one of the effe<!ts of treatment a
great increase of erythrocytes and a great diminution of leuko-
cytes.
I intend to describe this condition in detail in a future com-
munication.
12 AMKKICAN MKDICINI.1
COERESPONDENCE
(July ;
1902
AN OVEN FOR THE RAPID FIXATION OF BLOOD
FILMS.
BY
JOHN C. Da COSTA, JR., M.D.,
of Philadelphia.
In staining blood fllms with Eiirllch's triaoid mixture fix-
ation at a higli degree of dry lieat is an absolute essential for
crisp, clear-cut differentiation of the histologic characteristics
of the different blood cells, since chemic flxative.s, however well
they may answer when other stains are employed, are at the
best but indifferent substitutes for heat when the " triple stain "
is used. Experience has convinced me that brief fixation at a
high and definite temperature is greatly preferable to the older
method of prolonged heating of the films on a copper plate at a
low degree of heat. Passing the film repeatedly through the
naked flame while it is sometimes useful for a hurried clinical
examination, is but a makeshift method which gives, as a rule,
uneven fixation, some areas of the specimen usually being
underfixed and others scorched. The use of a simple oven
such as is illustrated below obviates the objections to these
other procedures, and, aside
from its convenience as a time-
saver, ensures certain and con-
stant results, for the tempera-
ture being registered exactly
and easily controllable, acci-
dental underheating and over-
heating of the specimen may
be avoided.
The oven consists of a rec-
tangular copper box, 8x4x3J
inches, mounted upon a copper
plate J inch in thickness, and
provide'd with a hinged cover
and thermometer which regis-
ters as high as 200° C. The
thermometer, when the oven
is in use, is to be fixed up-
right in an adjustable screw
socket at one end of the
copper box, upon the floor of which the bulb rests, pro-
tected by a covering of tin-foil ; when the apparatus is not in
use the thermometer may be removed and placed in a wooden
case, to guard against breakage. The oven is riveted to a hori-
zontal rod which is attached to an ordinary iron buret stand
by a thumb-screw fitting, by means of which it may be raised
or lowered so as to obtain the desired degree of heat, supplied
by a small " baby " Bunsen gas flame, or alcohol lamp placed
upon the iron base of the stand.
The dried blood films are enclosed in the box, which should
be fixed at a point about 8 inches above the summit of the
burner, after which the gas is lighted and allowed to burn until
the thermometer registers 160° C. The gas is then turned off,
the cover of the oven is thrown back, and after the temperature
has fallen to 30° C. the films are removed, fixed and ready for
staining. The whole procedure, from the time the gas is
lighted until the films are properly fixed and cooled, takes
about 15 minutes. The apparatus described was made by
Messrs. Charles Lentz & Sons, after my design.
CORRECTION.
To the Editor of American Medicine .—Will you allow me
to call your attention to an inaccuracy in American Medicine
for May 31, 1902, page 924? F. C. H., in abstracting my article
on a case of " Severe Anemia with Enlargement of the Spleen
in an Infant " writes as follows : " The similarity in this case
to those described under the head 'Anemia Infantum Pseudo-
leukemia,' leads the author to believe that it belongs to the lat-
ter type." This statement is somewhat misleading. What I
say in my article is that : " the similarity of my own case to
those described under the head of 'Anemia Infantum Pseudo-
leukemia' is too obvious to need extended comment. . . ." The
anemia is secondary, and the case, so far as one case can, tends
to support the view of those authors who believe that von
Jaksch's disease, socalled, is not a disease sui generis ; is not a
primary but a secondary anemia, which may be dependent
upon a great variety of causes. In the case under discussion
the cause is rhachitis, and such I would consider the diagnosis.
I believe with Wentworth, from whose article I quoted
extensively, that there is no ground for considering anemia
infantum pseudoleukemia as a primary anemia, and would not
regard the cases which have been described as such as consti-
tuting a particular type.
Frank Spoonbr Churchill, M.D.
THE FREE LECTURE MOVEMENT.
BY
C. T>. SPIVAK, M.D.,
of Denver, Col.
To the Editor of American Medicine .—In your editorial
" The Free Lecture Movement," published May 10, 1902, you
suggest to the members of the medical profession that the sys-
tem should include hygiene and all matters pertaining to health,
that " this duty has not been appreciated." Permit me to state
a few facts which may be of interest from a historic stand-
point.
The movement for the dissemination of rational ideas
among the people concerning hygienic matters was launched in
Philadelphia by the Society for the Extension of University
Teaching, in 1893. They have added to their staff of lecturers
one on physiology and hygiene. I had the pleasure of serving
in the latter capacity from 1893 till 1896. The idea of utilizing
the public schools for the lectures on hygiene occurred to me
while lecturing before a down-town literary society in a build-
ing where a night school for foreigners was conducted on the
second floor. After the school was over the pupils used to
come into my room quietly and listen attentively to my lecture
and even take part in the discussion. I presented the plan to
the late Prof. William Pepper, then president of the University
of Pennsylvania, who was greatly interested in my work as
popularizer of hygiene. He at once warmly responded, and
gave me a letter of introduction to Dr. Thos. (i. Morton, then
member of the Board of Education. At the invitation of Dr.
Morton I appeared before the Board of Education at their regu-
lar meeting, November 23, 1894, and laid before them the plan,
that they permit the use of the public schools for one night a
week during four successive weeks for the purpose of delivering
popular lectures on physiology and hygiene. The members o)
the board showed considerable Interest in the plan, and granted
my request. On Thanksgiving evening I delivered the first
lecture on physiology and hygiene at the Mount Vernon School,
Controller Joseph D. Murphy presiding.
There were many reasons why the movement proved abor-
tive, but it was not due to lack of appreciation on the part ol
the members of the profession, before whom the plan was laid
nor to the Board of Education, for they cheerfully granted mj
request. Nor had the people looked with indifference at raj
feeble attempt at instruction; they filled the schoolroom and
listened attentively. Should such a movement be inaugurated
now it would meet with success. The Board of Educatior
would undoubtedly furnish the hall, light and janitor service
All that would be needed is a staff of lecturers. It seems to m(
that the Philadelphia County Medical Society ought to under
take this task and arrange a course of lectures on physiologj
and hygiene, to be given in the various public schools. I air
sure there could be found enough volunteers who would delivei
one or two lectures in one school and repeat the same in one oi
more other schools. Such a movement would do the medica
profession and the community at large more good than th(
enactment of restrictive laws.
Philadelphia should not be behind New York in the mattei
of free lectures, and should, besides, l)e the pioneer in the pop
ularization of the subjects pertaining to health.
JOLY 5, 1902]
CYSTIC DEGENERATION OF BOTH KIDNEYS
'American Medicinb 13
ORIGINAL ARTICLES
CASE OF CYSTIC
DEGENERATION OF
NEYS.'
BOTH KID-
BY
I. N. DAXFORTH, A.M., M.D.,
of Chicago.
Ou August 23, 1895, I was first consulted at my office by Mr.
W — -, a hale and hearty looking man, aged 36. He was 5 feet
S inches in height, weighed 150 pounds, and manifested every
outward sign of vigorous health. He was married and the
lather of two healthy children. He was manager of a large
manufacturing concern, a position involving large responsi-
bility and calling for the exercise of vigorous powers of body
and mind. His personal history was quite negative, having
had no illness of any account, no bodily injury, no specific
infection, no intemperance in the use of alcoholics, although he
admitted that he smoked pretty Irequentlv. Two years prior to
his first visit to me, a little albumin was discovered in his
urine but it disappeared in a short time, and he ceased visiting
his physician, as he had no symptoms or discomfort which
seemed to require treatment. In the winter of 1894 he had a
somewhat severe attack of la grippe and was two weeks in bed,
but I cannot learn that he had any unusual symptom or that any
examination of the urine was made at that time. My first
examination (August 23, 1895) was made. in a very hasty and
slovenly manner, as I was very much occupied, and a "snap
shot diagnosis of interstitial nephritis was made. A few days
later 1 saw him again under more favorable conditions, and
arrived at once at the conclusion that the case was one of cystic
disease involving both kidneys. He had considerable arterial
tension, a somewhat hypertrophic left ventricle, without valvu-
lar lesion ; admitted having occasional occipital headache, with
momentary attacks of vertigo, and sometimes slight blurring
of vision of very brief duration. His digestion seemed unim-
paired, and his general appearance was that of a vigorous, well-
nourished and able-bodied man.' I was particularly struck by
his quick, decisive manner, his prompt, ready and intelligent
answers, and other evidences of an active brain, unimpaired
and unembarrassed by toxemia. His urine was pale and clear,
slightly acid and with a specific gravity of 1,010, and albumin
to the amount of one-half gram to the liter, as determined by
bsbach's method. There was \% of urea, as shown by the hvpc>-
bromite test, and as he was passing about 3,000 cc. of urine in
the 24 hours, it followed that he was excreting about the normal
amount of solids. The microscope showed plenty of leuko-
cytes and epitheiia, both ovoid and polygonal, but no tube casts.
There was no crystalline sediment.
The patient's abdomen was noticeably protuberant, Avith
prominent lateral bulging on either side and a well-marked
sulcus in the median line, and these characteristics were espe-
cially noticeable when the patient stood erect. Examination of
the abdomen with the patient lying on his back disclosed the
presence of an enormous reniform tumor in each lumbar region,
extending above so as to occupy the entire' hypochondriac
region, and below so as to occupy the entire iliac region. They
also occupied the mid-region of the abdomen, so as to actually
come in contact with each other when the patient was in the
prone position, although they were easily separable and readily
outlined by palpation. Nodulations and protuberances could
be easily made out, as well as the fact that they were very
numerous and varied greatly as to size. It was easy enough to
determine that these protuberances contained a thin watery
fluid, as the fluctuations peculiar to a thin fluid were plainly
recognizable. The diagnosis of general cystic degeneration,
therefore, seemed warranted, and of course the questions of
prognosis and treatment were settled as soon as the diagnosis
was established.
The history of the case during the three years following my
first connection with it is interesting, although uneventful.
The urine was always abundant in quantity, rarely less than
2,000 cc, and frequently more than 3,000 in the 24 hours ; it was
usually clear, limpid and watery, but now and then it would
appear more or less cloudy with mucus ; it was generally odor-
less, and never offensive ; the albumin ranged from a mihimum
of one-tenth to a maximum of one-half grain to the liter
(Esbach) ; the specific gravity ranged from 1,004, the lowest, to
1,015 the highest point, but tlieso extremes only occurre<l at inter-
vals, the usual average being about 1,010; the urea sometimes
fell as low as0.4%,aiidoc('asionally rose to 1.75%, with a specific
gravity of 1,015 ; and on one occasion it reached 2'^, with the
same specific gravity. It generally ran from 0.59i, to 0.7%. These
(lata would give an average of from 45 to 60 grains of solids for
the 24 hours, as calculated by the coefficient of Hiiser, or about
the average for a healthy man. But the urea was nearly always
less than the quantity demanded by normal estimates, and this
was apparent also from the slight indications of cumulative
uremic poisoning already mentioned. The microscopic findings
were quite negative; leukocytes and epitheiia in varying, but
never large, numbers; occasionally a few shriveled red blood
globules; and now and then a few crystals of uric acid, sodic
urateor calcic oxalate made up the sum total. No tube casts
> Read before the AssoclHtlon of American PbyxlclanH, May, 1902.
were found, although they were, on one occasion, reported to
be present before I saw the patient.
The conditions— aii the conditions— which I have reported,
remained practically unchanged during the first three years of
my attendance. Occasional attacks of slight illness from colds
indigestion, headache, ete'., manifested themselves, but they
behaved precisely as they would in a man with two healthy
Kidneys. The patient attended to a large business all the time,
and suflered and surmounted the annoyances ooused by strikes
business reverses, bank failure, fires, and all things else inci-
dent to a large manufacturing business, with the fortitude of a
man of robust mind and body, and his quick motions, elastic
step, ruddy complexion and active mind, gave no hint of the
fact that both his kidneys were in a state of anatomic chaos.
I made frequent examinations of the kidneys, and in fact I
made some futile attempts at measuring them, for the purpose
of determining their rate of growth or enlargement. I soon
became satisfied that a very slow process of enlargement was
going on, with almost mathematic symmetry, so that the shape
or form of the growing tumors preserved acloseiesemblanceto
the kidney.
The treatment was practically nothing. The bowels were
kept free by the use of salines (usually Hunyadi water) and
the attempt was made to keep the patient on a non-nitrogenous
diet, but he rebelled and ate alx)ut what he pleased. When I
first saw him, I prescribed potassic citrate. The patient
imagined that he was materially aided in excreting urea by this
Right kidney (exterior). Weight, 6 Ibc.
remedy, and so I frequently prescribed it In doses of 10 to 20
grains, four times a day; ana it is quite true that on several
occasions I found a notable increase of urea, after he had taken
potassic citrate a few days. No other treatment was employed,
unless temporarily demanded for some temporary ailraeot
which did not directly implicate the kidneys.
Such in the history of the first thr«H» yearn of my con-
nection with this case, and such is practically the history
of an unknown number of years liefore I saw the patient.
About six months prior to the patient's death a change took
place. The urine lessened in quantity and became turl>id ; the
albumin increasetl gradually but progressively; slight hematuria
appeared occasionally ; the urea remained about the same, or
generally about .5%. At this time the microscope showpfl a
great increase of leukocytes, ejiithclia, amorphous granular
deT)osit, (•holostcrin crystals, and now and then blood globules.
The patient c^implained of abdominal dislontion and weight,
and ho also ha»l headache, vertigo and disturbed or uncertain
vision. Hut he rosolutely.kept about his busiiiess in spite of
all remonstrance or advice. No increase in the size or feeling
of the tumors could bo detected by palpation.
Ou April 6, 1899, he called at my olllco Inr the last time. Ho
had moderate hematuria, increased albuminuriif and was pass-
ing only a small (juantity of dark muddy urine; he was sent to
his home in a neighboring suburb, and advised to go to bed
] 4 Amrbican Mkdicimb]
CYSTIC DEGENERA.TION OF BOTH KIDNEYS
[Jni-Y 5, l(
and call his family physician. On April 10 I was called In con-
sultation. He was now having profuse hematuria, nausea,
vomitinijf, headache, with a temperature of 102°. April 12, I
was again called, and found the symptoms much the same.
The urine was scanty, and seemed to consist more of blood than
of urine; nausea and vomiting very troublesome ; temperature
100° to 102° ; no pain nor tenderness in either kidney. April 21,
I was again called in consultation, and found substantially the
same symptoms, which were uninfluenced by treatment. There
was at this time considerable mental dulness, tending toward
coma. April 21, the patient died, having been comatose for
several hours before death. It was only after considerable
diplomacy that we were able to get permission to examine and
remove the kidneys, but wo were forl)idden to do any more than
that. We were able, however, to determine that the liver,
spleen and pancreas were apparently healthy ; at least neither
of these organs gave any indications of cystic change to the
naked eye. The kidneys were enormously enlarged, the right
Left kidney (exterior). Weight, ay^ lbs.
one ^weighed 6 pounds, and the left one 5i pounds, several
hours after removal from the body, and after a considerable
quantity of fluid had escaped by leakage. At least 10 or 12
ounces should be added to each kidney to represent its true
weight during the lifetime of the patient. Both kidneys had
imdergone perfect and complete cystic degeneration, not a trace
of normal tissue being discernible in either organ. I feel
Eretty confident about this, as a careful examination was made
y several of us in the Pathologic I^aboratory of the North-
western University Women's Medical School. The cysts varied
in size from a small pea to a hen's egg, the walls were thin and
translucent; they wore generally filled with a clear watery
fluid, which was somewhat cloudy, but a few of the larger
cysts contained blood. A micros'copic examination of the
watery fluid from one of the larger cysts showed a few small
round cells like leukocytes, a few nucleated pavement epithe-
lial cells, crystals of cholesterin, and some amorphous granular
matter, probably derived from broken down disintegrated
cells. The fluid also contained a little urea and a little albumin.
The accompanying photographs give a fairly good
idea of the external and internal appearance of these
remarkable organs. So far as I have been able to learn,
no larger specimens of cystic kidneys have found their
way into any pathologic museum in thi.s country.
It is an interesting fact that the patient's sister, still
living, and in good health, ha.s also cystic disea.se of the
kidneys a.s was determined by exploratory operation by
the late Dr. Fenger, some years ago. The patient's
father died at the age of .59 of some acute attack, said to
have been la grippe, in 1892. His mother died at the
age of 40 of a " congestive chill," after a very brief and
swdden illness. Both parents were in perfect healtli,
apparently, up to their respective fatal attacks. One
sister died at the age of 30 of some gastric disease, whit
was diagnosticated cancer.
One brother is living, perfectly well at the age of 3
although I have not been able to verify this statemei
by a personal examination. One sLster has bilateri
cystic kidneys, but is apparently in perfect health, as
have already stated.
The patient left two sons, now aged 13 and 19 respe
tively, and apparently in vigorous health. I have trit
to get an opportunity to examine them for the purpos
of determining the possible presence of cystic kidney
but cannot induce them to allow me to do so.
There does not seem to be a strongly marked hered
tary tendency to polycystic kidney. M. Bar— quoted I:
Henry Morri-s — ^ " observed the polycystic lesion in tl
kidneys of three successive children born of the .san:
mother, each of whom presented the cystic degeneratio
in a different degree." Morris also relates one oth(
case in which tA'o children of a family of six had bila
eral cystic kidneys.
I have .seen only one other case of polycystic kidney
and this occurred in an unmarried woman aged 40, witl
out hereditary antecedents. It was a typical case (
bilateral disease. The enlargement was not extensivi
The right kidney weighed 23 ounces, the left 24J ounces
but the cystic change was complete.
In conclusion, I wish to emphasize three points <
special interest in the foregoing ca.se :
First. The enormous size of the kidneys. The tw
Right kidney (interior). Weight, « lbs.
organs during the life of the patient weighed more tha
13 pounds, or about 2.5 times the weight of the normn
kidneys. Yet these colossal ma.sses did not seem to pre
duce mucli suffering or inconvenience. The patien
frequently told me that he did not realize any incor
venience from weight, pain or distention. He frequentl
complained of constipation and a sense of oppressio
or fulness after eating heartily, but simple aperleni
were always competent for the relief of the former, an
no special treatment was ever required for the latter. S
gradually had thase giant kidneys acquired their dimer
sions that the patient scarcely realized their presence ; i
was a remarkable and very extreme case of toleration.
1 Sarglcal Diseases of the Kidney, tSS.
July 5, 1902]
PERNICIOUS ANEMIAS
[American Medicine 15
Second. The perfect, complete and absolute meta-
morphosis of the kidneys into a congeries of cysts is
also noteworthy. I could not detect in any portion of
either kidney, by the naked eye, or with an ordinary
hand lens, anything which indicated the presence of a
particle of true renal parenchyma. It is possible that a
prolonged and exhaustive search might have resulted in
the discovery of a few minute islets of renal tissue, but
I think not, as I feel confident that the examination
which I and my associates made was careful and minute
enough to determine this point. The process of cystic
degeneration was complete. It is, of course, impossible
to decide absolutely whether the cystic change was
congenital or postnatal ; whether it began during the
intrauterine life of the patient, and continued thereafter
in uninterrupted progress, or whether it was altogether
a postnatal pathologic process. But I venture the con-
jecture that it began during the intrauterine life as an
arrest or fault of development, and that it continued
Left kidney (interior). Weight, n]^ lbs.
luring life, at least to the extent of a progressive increase
in.: the size of the cysts.
Third. Another remarkable fact is the vigorous health
md great activity of the patient. He managed a large
business, requiring an active brain and a vigorous Ixxly.
EIis appearance was that of an unusually healthy man ; his
itep was quick and elastic, and he did not hesitate to
•un or jump when he found it expedient; he did not
mgage much in games like bowls or golf, because he
'ound it inconvenient to " stoop over " on account of
he presence of his abdominal impediment, but he
ihowed absolutely no lack of muscular development or
wdily nutrition. His mental outfit was perfect. He was
;heerful, witty, quick at repartee, animated and ready
n conversation, and the peer of any of his competitors
n comprehending a business proposition. In fact, when
he various branches of the industry in whlcli he was
■iigaged formed a "trust," he was chosen " manager "
>f the amalgamation.
I have already remarked that he was the father of
wo healthy children, who give no evidence of any
)hysical or mental defects, so far as I can determine
vithout a physical examination, which they declined.
PERNICIOUS ANEMIAS: THEIR DIAGNOSIS AND
TREATMENT.'
BY
GEORGE DOCK, M.D.,
of Ann Arbor, Mich.
Professor of Medicine in the University of Michigan. Ann Arbor, Mich.
When in accepting the flattering invitation of the
distinguished chairman of the Section in Medicine I
cast about for a topic worthy of your consideration, a
number of things conspired to make me .-select pernicious
anemia. Among these reasons I may mention in the
first place that this is a widespread condition, and though
relatively rare, occurs often enough to make it well for
the physician to have his mind turned toward it so that
no matter which one of its many aspects it presents he
may be prepared for it. Further, several of your mem-
bers have made most important contributions to our
knowledge of the subject, and in thus making us their
debtors have laid on us all the obligation of adding what
we can to the common fund. Finally, my own interest
was early attracted to the subject by some of its first
students in this country, such as Pepper, Osier and Musser,
and chance has thrown in my way a considerable amount
of clinical material.
Of the early history of pernicious anemia, absorbing
as it is, I shall say little. The differences of opinion of
Addison and his followers on the one side, and Biermer
and others on the opposite, have not yet been wholly
reconciled. In many of the early studies the efforts
made to elucidate the subject were verbal rather than
material. Such words as "essential," "idiopathic,"
" primary, " were used with a seeming confidence in
their potency that later readers can hardly understand.
A striking evidence of the early difftculties was the
belief that a positive disignosis was not possible during
life. Bristowe, as late as 1888, said: "It is impossible
to lay down any trustworthy distinction between the
chlorosis of young girls and pernicious anemia, except
such as depend on the age and sex of the patient, and in
the effects of treatment." Yet the postmortem features
relied upon to settle the diagnosis, sucli as fatty degener-
ation and hemorrhages, were by no means capable of
satisfying a critical investigator. Notwithstanding the
minuteness of the clinical examinations in many early
cases, there was a very important feature that was'imper-
fectly studied, viz., the blood. Many interesting facts
were early learnefl about the blood, but the importance
of stained preparations was di.scoverefl at a compara-
tively recent date. The other details received only
irregular and uncertain attention, bi'cau.s(> each in turn
exploited often as pathognomonic features fre<|uently
led to disappointment and consequently to neglect. It
was hard to realize that in the .study of the blood during
life we might have anatomic material quite as useful
in a diagnostic way, as the inuch-tjilke<l-of fiitty degener-
ation of organs. Even now the neglect of a complete
study of the blood too often happens, and some other-
wise valuable observations have thereby been rendered
almost worthless.
The work of a large number of observers since 1880,
when Ehrlich described the nucleated red blood-cor-
puscles more fully than had been done before, Iwuls
to the conclusion that the final diagnosis of per-
nicious anemia depends on the blood examination.
Although fatal cases of anemia may not corresi)on(l with
the blood conditions in i)ernicious anemia, and the
results of autopsy may not permit us to cla.Hs tliem posi-
tively with other definite di.seases, still we se«>ni war-
rant<'(l in holding to the statement just made. Two
other decidcKl gains have been made beside the recog-
nition of the blood changes. One of these is the knowl-
edge of the excess of iron in the liver cells, discovereil
> AddrcM before the general ReMlOD of the Illinoli l^tate Medical
(Society, (iulncy, 111., May Jl, 1902.
16 Ahebioan Medicine
PERNICIOUS ANEMIAS
[JtTLY 5, 1902
by Quincke and made the basis of Hunter's important
work.' The other Is the demonstration by 8chauman of
the similarity of the blood in bothriocephalus anemia to
that in pernicious anemia. While neither of these
advances is as yet complete, they help us to form a more
satisfactory idea of the condition than was possible
before. In common with the majority of those who
have studied pernicious anemia, I look on this not as a
distinct and specific disease, but as a symptom-complex.
However, as a matter of convenience, I shall often speak
of it as a disease. The complex includes a number of
features that can be made out by the anamnesis and the
ordinary methods of examination, and these features
occur in such frequent combinations, and so strongly
marked, that a diagnosis can sometimes be made by
them alone. But the exact diagnosis, the only useful
one very often, and the indispensable one if the case is
to be used to advance our knowledge, is based on the
condition of the blood. To this I shall return again.
From this point of view the term pernicious anemia is as
useful as any other that has been suggested, and since it
involves neither theory of cause nor unproved anatomic
seat, is preferable to any other name hitherto proposed.
The addition of Biermer's term "progressive" is
unnecessary, and has sometimes been misleading, as
Quincke early predicted it would be. The objection
urged by some that the word pernicious should not be
used because some patients have recovered, is not very
sound, because the exceptions are few, and moreover,
the term is after all only relative. (" Morbi animi perni-
ciosiores pluresque sunt, quam corporis." — Cicero.) The
alternative, favored by some, anemia gravis, might have
been conveniently adopted as a technical term had it
been introduced early, but as there are not a few
secondary anemias with very different clinical features
that fully deserve the epithet gravis, it is now more
equivocal than the term in common use.
What are the origins of pernicious anemias ? Regard-
ing this question our ideas have undergone considerable
change since Biermer attributed them to poverty,the puer-
peral state, unhygienic surroundings, discharges such as
diarrhea, and hemorrhages, and Gusserow about the same
time to pregnancy. Cases following hemorrhage and preg-
nancy seem not only relatively, but absolutely rarer than
was formerly thought, while poverty and unhygienic sur-
roundings can be excluded positively as factors in a fairly
large proportion of cases. Many of my own patients
were farmers or village dwellers, whose homes and food
material left nothing to be desired. On the other hand,
faulty preparation of the food and bad habits of eating
could often be discovered. Intestinal parasites are
important causes in many parts of the world, and in all
cases should be searched for by examination of the stools.
Common as pernicious anemia is in my field of observa-
tion, intestinal parasites are comparatively rare, and
though I have paid special attention to the point, I
have not found a case in which I could trace any connec-
tion. I have been struck by the large proportion of
patients with infectious processes in the mouth, such as
carious teeth, gingivitis, and pyorrhea alveolaris. Dys-
peptic and diarrheal conditions have often been noted
early, but in other cases similar symptoms seemed
rather to be the results of the anemia. Most valuable
work bearing on pernicious anemia can be done in cases
of gastrointestinal disease by careful studies of the blood.
Syphilis is an occasional cause of nernicious anemia that
should always be borne in mind. I have never been
able to prove malaria and typhoid fever as causes in my
cases. But it is unnecessary to enlarge on this phase of
the subject. Even with the clearest history of previous
disease we are still ignorant of the connection between
it and the peculiar changes in the blood. Whether this
is a specific poison, as some believe, or a toxic substance
that varies in ditferent cases, has yet to be proved.
We are but little better off when we come to discuss
the pathology, or, as some prefer to call it, the pathologic
physiology, of pernicious anemia. We can limit our-
selves to the blood and blood-forming organs, because
most of the other alterations can be ascribed to the
anemia itself, others to unknown poisons causing or
resulting from early or late complications.
In studying anemias it is necessary to recall some
facts, obvious but often forgotten, about the blood. This
substance, medium and tissue both, constantly changes
in the healthy body and constantly remains nearly the
same in chemic and histologic constitution. Red
corpuscles are ever being worn out and renewed, leuko-
cytes come and go, the plasma gives and takes its
organic and inorganic elements. An important feature
is that degeneration and regeneration do not show them-
selves in the healthy blood, though we know they are
present. Even a direct loss of a moderate quantity of
blood, as we see after menstruation, normal confinement,
and hemorrhage from small wounds, is replaced with-
out evidences of effort. With larger losses we do see
such evidences. Unusual corpuscles, young or unripe
cells, normoblasts appear, as if the demand for mature
cells could not be met. The same thing happens also in
simple anemias, due to disease, and we also find the
same sometimes in pernicious anemias, but in the latter
we see other forms, megaloblasts, such as rarely occur
in benign anemias, even when severe, and in fact do
not belong to the products of adult blood formation,
though they do to that of the fetus. Not only do we
find such cells as belong to the latter period of fetal life,
when the blood-forming organs are fully developed, but
also those belonging to the earliest stages, before there is
bone-marrow, and when the capillaries and the liver are
the seats of active blood formation. Why this abnormal
kind of blood formation should occur in disease is not
easy to understand. It might be supposed that it repre-
sents the final effort at compensation on the part of an
almost paralyzed blood-forming function. On the other
hand, it may be due to the kind of irritant in the dis-
ease. At all events clinical evidence indicates that
megaloblastic blood is not as useful as normoblastic
blood for the post-embryonic organism. It is the index
of the pernicious change.
In fatal cases we find, corresponding to the altera-
tions in the blood, not only evidences of abnormal
growth in the bone-marrow, a reversion to the late fetal
type, but even in the liver. But the changes in the bone-
marrow are not uniform. In some bones normal condi-
tions prevail, or there may be hyperplasia of normal
adult tissue. Such things help to explain the remittent
or prolonged course in some cases. In others there is no
attempt at normal regeneration. Is there still another
process, one that has been thought to be the chief
anatomic basis of pernicious anemia — a perversion of'
marrow to the megaloblastic type without preceding
increased destruction of blood? This question carries
the problem of pathogeny farther than one can profitably
follow it at this time. I confess to a leaning toward the
belief that pernicious anemia is due to excessive and
peculiar degeneration of blood-cells, especially in the
portal area, with the fetal type of blood- formation
secondary, perhaps as the result of the incompetence of
the ordinary tissue, as Eichhorst long ago supposed.
Those who have not yet read Schauman's fascinating
work on "Pernicious Anemia in the Light of the
Modern Toxic Hypothesis" (Volkmann's Sammlung,
No. 287, 1900), will find the whole matter discussed there
in a most suggestive manner. On the other hand, the
view of megaloblastic degeneration of the marrow,
or megaloblastic newgrowth of that tissue, with increased
blood destruction due to the presence of many vulnerable
cells in the circulating blood, cannot yet be entirely set
aside as impossible. It is not enough to find a megalo-
blastic newgrowth in bone-marrow, somewhere, and
megaloblasts in the blood. Given such a case we have
still to ascertain whether the fuller picture of pernicious
anemia has been present.
July 5, 1902]
PERNICIOUS ANEMIAS
[Akkrican Hbdicike 17
Regarding the practical diagnosis of pernicious
anemia, it is necessary to speak in some detail. It
is generally accepted that the diagnosis of an anemia,
using the word in a wide sense, cannot be positively
made by inspection only, but in pernicious anemia this
is sometimes less true than in other anemias, and one is
often struck at first glance by the marked pallor of the
skin and mucous membranes, the yellow tint of the skin
and the peculiar yellow sub-conjunctival fat; by the
slight edema, the shortness of breath on exertion, the
weakness and languor, the tiabby muscles with the sub-
cutaneous fat often well preserved. When in addition to
these we get a history of palpitation of the heart,
of fever, of anorexia, vomiting and diarrhea, of dizziness,
numbness or tingling, the suspicion increases almost to
certainty. But often the symptoms are not so marked,
the history ilot so full. Weakness, dyspnea, dyspeptic
symptoms and diarrhea may be the only complaints
in some cases ; pain in, and palpitation of the heart
in others ; general weakness in others ; dyspnea and
edema in others ; dull pains in the abdomen and weak-
ness in others. Most of the eases coming under my
observation with any other than the correct diagnosis are
called either heart disease or malignant disease. Many
have been treated a long time with digitalis. In none of
these cases have I found the simulation of severe valvular
disea.se, as we sometimes see in chlorosis. In not a few
cases the diagnosis of leukemia has been made and
given to the patient, without any blood examination.
Addison's disease is often suspected, on account of the
weakness. In one of my cases, with vitiligo and its
characteristic pigmented areas, the resemblance was
close, but the blood-picture very different. A combina-
tion of the two diseases is, of course, possible. One
patient, a candidate for matrimony, complained only of
impotence, though the pallor and yellow tint were
enough to suggest severe anemia.
Any of the symptoms mentioned indicates a com-
plete examination of the blood. The stomach symp-
toms may strongly suggest cancer. Examination of that
organ may reveal absent HCl, perhaps abnormal fermen-
tation, sometimes a tumor. The combination, in com-
parison with the total number of cancers of the stomach
is doubtless rare. Two well-marked cases occurred in
my series. Examination of the stools may show fermen-
tation diarrheas, catarrhal dysentery, or parasites.
There may be a distinct history of syphilis. In all of
my syphilitic cases (three), treatment for the specific
disease had been badly carried out or neglected. Some
cases of chronic malaria, with intense pallor, yellow
tint, dyspnea, and edema strongly resemble the external
appearance of pernicious anemia, but in several such
cases I have seen, the blood-picture was very different.
As regards the blood in pernicious anemia, the man-
ner of flow is rarely especially suggestive, being usually
scanty in my experience, but the drop is more watery,
the color darker, though also transparent, than in other
anemias of equal corpuscular strength. In the micro-
scopic examination of the fresh drop, a matter weshould
not neglect, we notice the great variation in size and
shape of the red cells — nearly alway more marked even
with high counts than in other anemic conditions — and
the deeper color of many individual corpuscles. The
scarcity of leukocytes and blood-plates, the sciinty fibrin,
and the tendency of the red cells to form heaps rather
than rolls, complete the picture.
The corpuscles should be counted. In a marked case
the poverty in red cells is diagnostic, for the alternatives
susi)ected rarely have so marked an oligocythemia. It
is instructive to allow observant students, as I have
sometimes teen able to do in my clinic, to compare
two patients outwardly alike, one with cancer with
3,000,000 re<l corpuscles and SOfc of hemoglobin, the
other with pernicious anemia, with 1,500,000 red cor-
puscles and 40 fo of hemoglobin, or with 900,000 corpuscles
and 2-5% of hemoglobin.
But not all cases have such low counts, and to limit
the diagnosis to those with less than 1,000,000 cor-
puscles leaves out some of the most important. One
may find very characteristic changes with 1,500,000,
2,000,000, or even more. Quite as important is the
determination of the color strength or hemoglobin.
Except in rare instances this will be as high as or often
higher than the proportion of red corpuscles.
Examination of the specific gravity of the blood and
of the cells and serum separately is also of value.
A special count of the leukocytes forms part of the
complete examination. The estimation of these cells
along with the reds admits too great an error. Capps
has emphasized the value of the hematokrit in the study
of pernicious anemia, showing, as it does, the increased
volume index of the red corpuscles.
Though this part of the examination, like the general
appearance of the patient, suftices to make the diagnosis
in many cases, the examination of stained preparations
is necessary for the final verdict and essential in the
less advanced cases. For this we need well made
spreads. As the staining is for the purpose of bringing
out fine details of nucleus and protoplasm we need
clear nuclear and protoplasm — rather hemoglobin — dyes,
and not such as are necessary for showing cell granules.
Hematoxylin and eosin are most satisfactory in general,
but eosin and basic anilin dyes can also be used. The
study of the preparation is best made by a systematic
search with a mechanic stage, noting the differential
count of the leukocytes, the number and special features
of nucleated red cells, the details as to shapes and sizes
of red cells, polychromatophilia, basophile granules.
The habit of sketching all noteworthy appearances will
make much fof accuracy and furnish useful records. In
the study of the nucleated red cells certain individuals
will give rise to difficulties that experience cannot
wholly remove. Typical normoblasts and typical megalo-
blasts are easy to recognize. It so happens that in practice
many nucleated red cells do not come under either cate-
gory. Ehrlich, in describing these cells, was not ignorant
of the difficulty, but his remarks in relation to it were
not satisfactory. The fact, as he then believed, that there
are differences in the fate of the nucleus in the two classes
of cells was obviously of little value in a stainetl and
mounted preparation. The other diagnostic feature, that
one kind of cell occurred in benign, the other in pernicious
anemia, amounted to begging the question. Ehrlich's
advice in such a predicament, to keep on looking and be
guided by other nucleated cells. Is not of much assist-
ance in cases such as he mentions, in which only one
nucleated but uncertain red cell can he found in several
preparations. Some observers have countetl only typical
cells, leaving others out of consideration. Most fre-
quently a prolonged examination will enable us to recog-
nize the preponderance of either normoblasts or megalo-
blasts, but at the same time I think it important to pay
more attention to the atypical nucleated red cells and to
carefully describe them. Many of them are, doubtless,
degenerating normoblasts or megaloblasts, others still
more closely resemble the cells found in the earliest
months of blood formation. They therefore carry the
apparent reversion back to a still earlier stage than do
megaloblasts. In practice these "metrocytes" may be
considered as of about the same value as megaloblasts,
but careful studies may throw much additional light
upon the conditions in which they occur.
Though megaloblasts are the most striking fejitures
of the blood in pernicious anemia, we must remember
that besides the difficulty of |)ositively rirognizing them
they sometimes occur in other conditions. It is true
that these other conditions— acute infections chiefly—
can he distinguished resulily from pernicious anomia,but
the fa<'t remains that no single feature of the blood is
characteristic of the latter diseaw, but that the whole
series of altemtlons must be carefully weiglunl.
Regarding the prognosis of pernicious anemia it is not
18 AUEHIOAII MkDICINX]
PERNICIOUS ANEMIAS
[July 5, 18«2
enough now to say that it is unfavorable. In the first place,
we must distinguish Wirtain cases of bothriocephalus
anemia, in which recovery may follow removal of the
parasites. Syphilitic cases are also relatively favorable,
but in these the tendency to relapse must not be forgot-
ten. In many other cases, cryptogenic after the most
thorough search, remarkable improvement may occur,
even without special treatment, but more certainly when
the most careful treatment has been carried out. A
complete recovery cannot be expected in the present
state of our knowledge, even in bothriocephalus cases,
unless the cause is removed before the megaloblastic
degeneration is ineradicably developed. I have not seen
a case of pernicious anemia that I thought had wholly
recovered. Several patients have attained a normal
blood count and remained well for one, two or three
years. The longest interval without treatment was
three years and five months, the patient working as a
railroad conductor for the time mentioned. He then
had an attack of what was called "grip," and after four
months of ill-health returned, complaining of shortness
of breath and weakness and with 1,644,000 red corpuscles,
3,700 leukocytes, 45 fc to oOjii hemoglobin. He recov-
ered enough to return to his work, but relapsed twice at
Intervals of about one year. One patient, whose illness
was apparently hopeless, with 702,250 red corpuscles, 25%
hemoglobin and many megaloblasts, is still alive after
more than five years, but I have not seen him nor
examined his blood recently. Often patients will insist
they are well enough to stop treatment, with not more
than 3,000,000 red corpuscles. Even with nearly 5,000,000
red corpuscles, 96'/c hemoglobin, occasional poikilocytes,
microcytes or macrocytes, show that the blood is not
yet normal. Even in the combination of pernicious
anemia and newgrowths, as of the stoniach, consider-
able improvement may occur.
Can the examination of the blood assist us in prog-
nosis? My own opinion is that it cannot assist us very
much. One need examine only a small series of cases to
learn that the blood changes have no constant relation
to the outcome. In general, cases with less than
1,000,000 red corpuscles are unfavorable ; those with
600,000 or less, very unfavorable. But even with less
than 500,000 great improvement is possible, and on the
other hand a patient first seen with 2,500,000 red cells,
but with megaloblasts and poikilocytes, may steadily
decline. So with all the other factors. A low color
index may be a good sign, likewise the normal propor-
tion of polynuclear cells and eosinophiles, the absence of
marked degeneration of the nuclei and protoplasm of
the red cells, normoblasts numerous and megaloblasts
few. But there are so many exceptions, and in some
cases contradictions, in the various elements, that
the prognosis can rarely be based on the blood. In all
cases the other symptoms, especially those on the part
of the alimentary canal, are of cardinal importance.
Practically, one should begin the treatment of a case of
pernicious anemia with the hope of improvement for at
least some time, and be guarded in the expression of a
prognosis as to duration. Even with apparent general
improvement, it is necessary to follow up the conditions
in the blood by frequent examinations, for unfavorable
changes are often first shown there.
The treatment of pernicious anemia is a large subject,
and I shall not attempt to do more than outline it. It
may seem trite to say that the patient is to be treated
and not the disease, but nowhere is the statement more
applicable. We often see patients who have improved
much under the simple administration of arsenic, and
we sometimes see improvement without any treatment,
but in most cases it is only by answering every indica-
tion that good results can be expected. Causal treat-
ment, in patients with parasites or syphilis, is under-
stood as a matter of course.
In the majority of cases the alimentary canal requires
treatment, and this often begins with careful work on
the part of the dentist, or by the use of the toothbrush
with antiseptic mouthwashes.
A test-meal, or rather a series of test-meals, should
be given early, and the anatomic and chemic conditions
in the stomach cleared up as much as possible. Hydro-
chloric acid is almost always indicated, and often lavage
is necessary.
The diet must be laid out in detail, with reference to
the conditions in stomach and intestine, and care taken
that the directions are followed. The bitter tonics can
often be used with advantage. Constipation or diarrhea
require appropriate treatment. Intestinal antiseptics
are sometimes of distinct benefit. In one of my cases
there was frequent and troublesome diarrhea. The
patient herself found that salol was useful for that symp-
tom, and took it in large quantities for five years, dur-
ing which she had three severe relapses. • Arsenic was
not well borne, and though various other things were
tried, the salol seemed most useful.
In many cases weakness is so marked that the patient
must be put to bed and massage given. Friction with
cod-liver oil or alcohol can often be used with benefit.
The patient must always be warned against the danger
of over-exertion. Belapses sometimes quickly follow
errors in that regard.
Bathing should be practised according to the strength.
Cold friction, or the cold spray or douche, should be used
whenever possible. Not the least important aid in my
opinion is fresh air. For several years I have kept ane-
mic patients in this open air, just as in the treatment of
tuberculftsis. Many of them spend the entire winter
day on open balconies with manifest advantage.
The relapses should be looked for, and not allowed to
go far without treatment. The patient must be im-
pressed with the necessity of having the blood examined
at intervals, even when he is apparently well. The re-
lapses may come on at any time, but especially after any
depressing incident or disease. They are more likely to
occur in winter and spring. I think lack of fresh air is
a more important factor than told in these cases, and
advise all my patients either to go to a warmer climate
and live out of doors or to take open-air treatment at
home at such times.
I purposely mention last, drugs that are supposed to
act on the blood-forming organs or the blood itself. As
long as we know so little of blood formation and the
action of drugs upon that function, it is impossible to
speak positively of the position of arsenic, which is so
widely used as a specific in pernicious anemia. That the
drug has a beneficial action on the blood I do not think
can be doubted. In many cases we see the blood get
worse in the beginning of its use. That has been ex-
plained, and with some reason, as due to increased break-
down of imperfect cells, but it may be due to an irritant
action on the hematopoietic organs, followed in favorable
cases by stimulation. In either ease the treatment is not
ideal, for it does not, so far as we know, reach the cause
of the disease. It may be useful, however, in tiding the
patient over a time during which the primary disease is
being dealt with by the recuperative power of the body.
It is important to remember that some patients cannot
take arsenic by the stomach in any form. In such cases
the hypodermic method may be tried, and will some-
times seem useful. According to any theory we can
form of the action of arsenic in pernicious anemia, it
must be given in such doses as have a distinct effect on
the body. Accordingly, the blood and the alimentary
canal must be carefully watched during its administra-
tion.
Iron is often said to be useless, sometimes even dan-
gerous, in pernicious anemia. Like arsenic, it some-
times seems to cause a temporary deterioration of the
blood, but I have often used it with apparent gain, alone
or with arsenic. The fact that there is an excess of iron
in the liver cells does not seem to me a good reason for
withholding that drug. We know that in other anemias
JVLX 5, 1902)
TUBERCULOSIS OF THE IRIS
lAKERICAN MKSXCXSE 19
iron often seems to do good when the natural sources of
iron show no fault.
I often use with satisfaction a drug rarely mentioned
in this connection, viz., mercury bichlorid, and not only
in syphilitic cases, but in others. It atiU, in my opinion,
much like arsenic, by irritating the blood-forming organs.
It can often be combined advantageously with arsenic
and iron, as well as hydrochloric acid, the dose of each
f being carefully adapted to the case.
Time is too short to speak of all the details in the
treatment of pernicious anemia, nor is that necessary.
If I have contributed at all to the closer study and more
thoughtful treatment of the conditions that go under
that name, I will have gratified my own hopes and
expectations.
TUBERCULOSIS OF THE IRIS.*
BY
HARRY FRIEDENWALD, A.B., M.U.,
of Baltimore, Md.
Three forms of tuberculosis of the iris have been
described, one characterized by a large solitary tubercle,
a second presenting small miliary tubercles, while in the
third the tubercles are visible only on microscopic exami-
nation.
A. The first is unilateral, unaccompanied by iritic
inflammation, and has the appearance of a neoplasm.
Miliary tubercles may be associated with it. It was for-
merly known as granuloma, a name given to it by Vir-
chow until Haab, in 1879, deflnitely proved its tubercu-
lous character.!
B. Miliary tuberculosis of the iris was first described
in 1870 by Gradenigo.' A young man aged 21 pre-
sented subacute inflammation, first in the iris of one eye
and then of the other, with six or seven round tubercles
of the size of half a millet seed. In three months he
succumbed to miliary tuberculosis. Tubercles were
found in the choroid, iris and on the back of the cornea.
Three years later Perls ^ corroborated these observations.
A number of cases have been published since then.
Small yellow, yellowish-gray or gray elevations are
observed on the surface of the iris, usually of both eyes.
They may be situated In any part of the iris, but' are
more frequently found in the lower portion or in the
angle of the anterior chamber. They slowly undergo
changes, some disappearing while others form. Tuber-
culous bulbi results frequently.
Cases have been observed which greatly resembled
this form but which terminated favorably, and this
raised doubt as to their true nature. By some it was
regarded as retrogressive tuberculosis (Haab), as lymph-
oma (Horner), as simple granuloma (Speron), and the
tuberculous chara<',ter was denied by many on the ground
of negative results in examinations for tubercle bacilli,
and of spontaneous disappearance. This question was
answered in 1891 by Leber.' He pointed out that the
spontaneous disai)pearance did not disprove the tubercu-
lous nature, basing the assertion on the observation of
similar occurrences in tuberculous lesions elsewhere. He
called attention to the fact that products of tuberculosis
frequently contain bacilli in such small numbers that it
is most difficult or impossible to find them and that even
implantation of the material in rabbits or guinoapigs
may fail to give positive results. His investigations
showed conclusively that these cjises are tuberculous.
He terms them '*attenuate<l tubercular iritis."
Later Leber ' explained that he meant by " attenu-
ated (abgeschwaecht) a mild, benign form often ending
in rfscovery. . . . It is not possible to state whether
this is due to weak btu;illi or to the small number of
bacilli, or to the great resistance of the organism."
• Read before the Baltimore Medical and SurKlcal Bm'lcty, January
27, 1902. DemODHt ration of Case II.
tKoster had previously discovered tuberclen In a perforating
granuloma.
SameIsohn» in 1893 gave additional testimony^ in
favor of the correctness t>f Leber's conclusions, but he
strongly objected to the term " attenuated," and pre-
ferred to regard the condition as " disseminated tubercu-
losis of the iris, which is on the whole more benign than
the solitary form."
In 1897 Ammann" reported a casein which there
were no bacilli and the cultures were negative, but posi-
tive results were obtained by implantation of the mate-
rial into rabbits and guineapig-'.
On the other hand, a ca.se of Haensel's and Lelier's ' had
shown that repeated implantation of bits of the disea.sed
iris produced but slight reaction, but the examination of
the eyeball after removal, as well as the death of the
patient from tuberculosis of the lungs and liver, jiroved
the tuberculous nature of the disease. And it may be
added that Schieck,* in a large number of observations on
experimental tuberculous iritis, found retrogression of
the tubercles to occur as well spontaneously as in conse-
quence of treatment with tuberculin.
C. The third form has been described by Michel,'
who states that in these cases " the tubercles are so small
and so deep in the tissue of the iris as not to be visible
to the naked eye." He found distinct tuberculous for-
mations microscopically in chronic iritis, without macro-
scopic nodules. The.se tubercles are situated under the
endothelium or along the bloodvessels, are similar
to those of the pia and in structure most resemble
the tubercles of bovine tuberculosis. Michel main-
tains that tuberculous iritis is as common as the
syphilitic. In tliis view he has few followers. Vel-
hagen'" did not find one case in 8,000 patients at the
clinic in Gottingen, though there were many syphilitic
cases.
Though commonly admitted that tuberculous iritis
of every form is usually secondary, many cases have
been reported in which no other manifestations of tuber-
culosis could be found. Thus Denig" found that in 86
published cases of tuberculosis of the iris and ciliary
body, n« other signs of tuberculosis could be discoveretl
in 07. But we must bear in mind that a primary lesion
may be difficult or impossible to find, as in a hidden gland.
It is not out of place to remind you that C'ohnheim in
1879 introduced the method of demonstrating the
infectious nature of tuberculous material by imi)lanting
it in the anterior chamber of rabbits and guineapigs,
where it produced characteristic tuberculosis t)f the iris,
I wish to report two cases of tulierculous iritis, the
description of which follows :
Cask I.— Bernard A., colored, ngeil 16, applied for treatment
in my service at the Haltiinoro Eye, Kar and Throat Charity
Hospital, April 23, 1898. He was much undersized, appoarinK
like a boy of 10 or 12 years. There was no history or sign of
sy])hilis. He complained of having had eye trouble for one
week. Both eyes presented intense iritis with synechiie, but
there was only .slight congestion of the eyeballs. In the right
iris there was one small white round elevation in the iris on the
nasal side, about midway between tlie pupillary edge and the
margin. The anterior chamber contained a small hypopyon.
On May .'! the eyeballs had become clearer and were almost
white, but the right iris now showed the same unbroken syno-
chiie (notwithstanding that atropin had been freely uso<l ; the
iris also showed three fresh whitish elevations at the lower
periphery of the iris ; the hypoiiyon had disappeared. There
was marked punctjite keratitis. The condition of the left eye
was similar, out there were no tubercles visible. The Ikiv was
examined for tuberculosis and he informed us that he had a
number of "sores" on his body His thorax wa.s found covcre<l
with old cicatrices and with discharging (Istulas which l<xl down
to carious Ijone. He was examintHl by surgeons, who concurretl
in tlie diagnosis of lul>ercuIous Ixme disease.
November 10, 1898, he returne<I. The punctat<> keratitis was
very marked. Both irides were bulging from iucreiiscMl pros-
sure in the posterior chamber (iris IximbO). Vision was
reduced in both eyes to counting of lingers (U. E. at 7 ft., \,. E.
at 4 ft.).
An iridectomy was therefore attempted on the left eye on
November 14. Great dilllculty was experienced. The for-
ceps pif^ked bit after bit of the soft iris but a largo plo»'e could
not be extracted. At this time no elevations were present. A
bit of the iris which was picked off was Introduced into the
anterior chamber of a rabbit, but the result was negative.
20 Amekican Mkdicinbi
TUBERCULOSIS OF THE IRIS
[July 5,-1902
When the hemorrhage in the anterior chamber, produced
by the oi)eration, had cleared it was found that the area where
the iris tissue had been removed was covered with a grayish
deposit. Vision was not improved. Much care was given the
boy and lie was seen at intervals for a period of over a year;
during this time the general condition improved greatly and
the coiulition of his eyes did not get worse ; no signs of fresh
intlammatiou appeared.
There ih no doubt as to the tuberculous character of
the iritis in the right eye. We may repeat here that
the tubercles disjippeared ; the condition left was that of
any severe plastic iritis with complete synechise and the
results following separation of the two chambers. Leber
would define it as " attenuated miliary tuberculosis of
the iris."
The inflammation of the left eye was likewise doubt-
lessly tuberculous, though as above stated, tubercles
were not visible. The condition of the right eye is that
of group B, the left that of group C. It is interesting to
see the two forms thus associated.
Case II.— This occurred In James S., a tall, very emaciated
negro, aged 22, who was admitted into the service of Dr. Cary
B. Gamble, Jr., at the Baltimore City Hospital, December 10,
1901. He had been feeling badly for three months, and had had
Irregular chills and a dry cough ; his feet and legs had begun
to swell three weeks before he entered the hospital and he was
unable to walk. About this time an eruption appeared on his
body and on the hands and face.
On admission, the patient was very weak, his general
expression heavy ; he was anemic ; the pulse was rapid l)ut of
good volume. There was an extensive eruption over the body.
OnEthe covered portions and between the fingers there were
numerous burrows of scabies ; in addition to this there was an
eruption over the face, legs and chest ; this was an elevated
eruption, pustular in places, but chiefly of the papulosquamous
Fig. 1.— R. E., Miliary Tubercles of the Iris.
type, with slightly elevated borders. The eruption had serpig-
inous outlines and was covered with small, fine scales. Dr.
Melvin S. Rosenthal, the dermatologist of the hospital, believed
it to be of specific origin, although the patient denied venereal
disease. He found on the penis a small, white cicatrix and
adenopathy of the inguinal glands as well as general adenitis.
Chest.— The chest is broad and deep ; expansion equal and
fairly good. Behind there was a slight dulness on percussion
at the lower part of the right lung. Sputum examination gave
a negative result.
Heart.— Sounds are clear, area of cardiac dulness not
increased ; no visible pulsation. The following was ordered :
Corrosive sublimate grains ij
Potassium iodld 5ss
Tincture of cinchona ) of each equal parts sufficient
Water ( to make siv
Mix. Sig.— A teaspoonful three times a day.
Sulfur ointment and baths were given for the scabies.
This, as well as the syphilitic eruption responded rapidly to
the treatment.
I was asked to examine the eyes about January 12. They
were apparently free from irritation, but the patient had com-
plained that his vision was failing. Iritis was diagnosed and
atropin instillations ordered.
January 15.— The vision is, R. E.,2;60 ; L. E., 4/30. The right
cornea presents a fine keratitis punctata, with two large gray
spots on the posterior surface, larger than the largest ordina-
rily seen. The iris is completely bound down and the pupil is
covered with a membrane, which forms a dense ring just inside
the pupillary margin. The dark brown iris presents on the
surface seven small gray Infiltrations scattered about. When
looked at with a magnifying glass they appear like minute
pearls. (See figure in which the largest corneal deposits, as
well as the iris tubercles, are shown.)
In the left eye the pupil is dilated almost ad maximum.
There is a deposit in this pupil, which, like that in the right eye,
has formed a denser ring, marking the previous position of the
pupil, and in this eye there is a fine keratitis punctata and one
larger deposit on the membrane of Descemet.
The ophthalmoscopic appearance is very interesting. In
the left eye the media are clear, so that a fairly sharp image of
the fundus can be seen. All the veins are enlarged. The
superior temporal vein, about one PD. from the papilla, is sud-
denly interrupted by a gray opacity (vasculitis). About three
PD. from the upper edge of the papilla there is a very exten-
sive vasculitis of the sufjerior.temporal vein, with a number of
small hemorrhages. This vasculitis extends a great distance
into the periphery. The inferior nasal vein is similar to the
superior temporal in being converted into a broad white streak
with irregular margins, apparently fresh vasculitis.
The right eye cannot be examined satisfactorily, for the
pupil is small, but the papilla appears to be normal. The fields
show great restriction, but cannot be accurately determined on
account of the patient's bad vision.
The appearance of the irides is unmistakably that of tuber-
culosis ; that of the retina is no less that of syphilitic vasculitis.
In the belief that tuberculous lesions would be found to account
for the disease of the iris, even though the sputum examina-
tions had been negative, the matter was brought to the atten-
tion of Dr. Gamble, with the following result.
The examinations made during the end of January and the
beginning of February are summarized in the following :
February 5, Heart. — Visible pulsation over the cardiac area
from the second interspace on the right of the sternum to the
fifth interspace on the left, just inside the nipple line. Cardiac
dulness begins above on left side at the lower border of the
second rib, and extends one inch to the right of the sternum.
Apex beat in fifth interspace one inch outside the nipple line.
Chest. — Flatness on both sides of chest ; posteriorly on the
right side it begins at the angle of the scapula and extends to
the lower limit; on the left, two inches below the angle of the
scapula and extends to the lower limit. There is an absence of
voice and breath sounds over these areas. On the right side
dulness extends in front to the level of the lower part of the
fourth rib ; on the left, to the axillary line. Skoda's resonance
at both apices in front. The eruptions noted above have prac-
tically cleared. There are still left some marks of the syphilid.
No tubercle bacilli have at any time been found in the sputum.
Medicae Diagnosis : Pleurisy, probably tuberculous.
Pericarditis, probably tuberculoiis. Syphilis. Scabies.
During his stay in the hospital the patient's general con-
dition improved greatly. The condition of the irides likewise
underwent a change, in that the tubercles became markedly
smaller so that some could not be found without difficulty and
without the help of a magnifying glass. His vision improved
greatly.
On February 15 the patient left the hospital without per-
mission and has not been seen since. He is reported to have
gone back to work as a laborer.
In conclusion, we may state that while the miliary
tubercles of the iris are usually described as yellowish-
gray or yellow, and when vascularized, reddish, in both
of the foregoing cases they were distinctly grayish and
pearl-like in appearance.
The deposits on the inner surface of the cornea dif-
fered from those ordinarily found in plastic or serous
iritis. Besides the fine deposits there were a few very
large, white, sharply circumscribed deposits in both
eyes, between 1 and 1.5 mm. in diameter. They were
not round, but irregular in form and had the appear-
ance of the tubercles in the iris. They were probably
tuberculous, as in the case of Gradenigo's, before men-
tioned.
BIBLIOGRAPHY.
' Annales d'oculist.. Vol. 64.
2 Arch, fur Ophth., Vol. xix, Part 1, p. 221.
'Transactions of the Ophth. Gesellschaft, Heidelberg, 1891, p. 44.
* Transactions of the Ophth. Gesellschaft, lieidelberg, 1893, p. 85.
'Transactions of the Ophth. Gtesellschaft, Heidelberg, 1893.
6 Klin. Monatsbl., 1897, p. 35.
' Arch, fttr Ophth., Vol. xxv. Part 4.
e Arch, fiir Ophth., Vol. i.
"Ijehrbueh d. Augenheilk., second edition, 1890, p. 318 ; also Arch. f.
Ophth., Vol. xxvii, Pan 2, p. 171.
i»Klin. Monatebl., 1894, p 121.
"Arch. f. Augenheilk., 1895. See Nagel's Jahresbericht for 1895,
p. 511.
Slate Pencil in the Brain.— Autopsy upon a boy of 16 in
London revealed a slate pencil three-fourths inch in length in
the left hemisphere of the brain, where it had caused an abscess.
The boy had suffered from pain in the head for five years. The
pencil is supposed to have been introduced through the nose.
Bg'yptian Medical Congress.— The Organizing Committee
of the Egyptian Medical Congress, to be held at Cairo in Decem-
ber, has arranged a series of excursions to places of interest for
the benefit of members of the congress. A series of tourist
steamers has also been arranged for, thus giving the choice of
various itineraries and lengths of time for the journey.
July
19021
EPILEPSY DUE TO AMETROPIC EYE-STRAIN
[Ambbican Medicime 21
SIX CASES OF EPILEPSY DUE TO AMETROPIC
EYE-STRAIN.
BY
GEORGE M. GOULD, M.D.,
of POilladelphia.
That epilepsy has been caused by imbalance of the
ocular muscles and cured by operation has been asserted,
but this cannot be true if, as I believe, the incoordina-
tion of the external ocular muscles is itself the result of
ametropia. That ametropia does occasionally cause epi-
lepsy is, I think, beyond question by those who have
studied the facts with a genuine scientific spirit. To the
large number of cases of this kind which have already
been reported, I wish to place on record the epitomized
histories of six others. I have selected from my records
only those instances in which cure has been immediate,
certain, and complete, and in which it ha.s persisted for
several years. I have had a large number of ca.ses in
which there has been more or less relief, and especially
when the previous conditions were variant phases of the
infinitely varying condition called petit mal.
Case No. 5,S49. — The patient was a man, aged 36, who came
to me in September, 1898. He had been refracted without a
mydriatic by others during the past 16 years, and of course had
never liad his ametropic error properly corrected. For 14 years
he had suffered from insomnia, which had of late grown worse.
There was also headache and pain in the eyes. During this
time he had been afflicted with frequent attacks of unconscious-
ness. Just how often these occurred was difficult to make out,
as he never iell or had convulsions ; he only knew they were
" frequent." I found his ametropia was :
R. + S. 2.25 + c. 0.62 ax. 90 = 20/40
L. 4S. 2.25 4- c. 0.50 ax. 90 = 20/40
with slight exophoria.
Since wearing the spectacles prescribed, coupled with
strengthening of the adduction-power, he has had but two or
three slight and short attacks of unconsciousness that he knows
of, he at once began to sleep better, his headache and exophoria
disappeared, and lie is now greatly improved in health.
Case 5,552.— The patient was a man of 25, who came to me in
September, 1898, and who on account of his symptoms had been
obliged to resign his position in a bank. He had also been
refracted without a mydriatic, and his glasses were the reverse
of correct. There was a family history of insanity and epilepsy.
He complained of occipital headache, jiain in the temples and
neck, and sick headache. During the past year he had been
much worried Vjy what were plainly attacks of the petit mal
type ; but the symptoms mo.st hard to bear were what he called
"thickening of the tongue," with loss of memory, and blurring
of the vision. After prescribing glasses for his low, compound,
hyperopic astigmatism against the rule, all of these symptoms
began at once to abate. He had but one slight attack of
"thickening of the tongue" during the three weeks following,
and in two months all nis symptoms had disappeared, he was
gaining in flesh, and he was happy. In two years he began to
be frightened at obscure symptoms which he feared might
finally become the same as those from which he formerly
suffered. I found his ametropia had changed, and since order-
ing new lenses I have not heard from him. He promised to
return in two years.
Case 6,27.y.— The patient, a woman of 45, came to me in Octo-
ber, 1900, in a bad state of health suffering with all the symp-
toms of eye-strain. There had also been chorea. Seven years
ago she had eclampsia, and since then, every two or three days,
except when under the influence of bromid, she had attacks ol
unconsciousness, in which she frequently Ifell to the floor.
Uromid medication served only to postpone these attacks for a
week. She had 4° of exophoria and 4° of hyperphoria with an
irritating degree of compound hyperopic astigmatism. I cor-
rected her ametro|)ia, her presbyopia, and her hyperphoria
with one pair of bifocal lenses, and from that time to May 1,
1902, she has had but one slight epileptic attack that her hus-
band knows of, and she is greatly improved in general health.
Case 5,097.— A man of 22 caine to me in February, 1898, with
optieians' gla.sses not correcting his astigmatism of 1.37 I).
ax. .90 in each eye. During the last six years he had had six or
seven epileptic convulsions, the aura being a trembling of the
left arm. Inthela.st two seizures he had bitten his under lip
badly. After he began wearing the cylinders I ordered, he at
onco gained flesh, was more healthy ; he has not had an epilep-
tic fit since.
Ca.'te ^,6.?*.— This is particularly of interest to mo because I
wa.s so convinced that tlie man's epilOTsy could not be due to
his small ametropic error that I at nrst refused to prescribe
glasses. He was sent to me in March, 1893, by a physician in
New York State, who was certain that his symptoms pointed to
severe eye-strain. He was 43 years of age, just the age, be it
noted, whenpresbyopla was beginning to make itself irrltatingly
manifest. For six mouths he had been " running down in
health." Whenever he attempted to read his eyes troubled
him (he called it " weakness of the eyes "), followed by occipi-
tal pain, and if he persisted tliere was objective vertigo and
great sleepiness. The chief complaint was of attacks of dizzi-
ness occurring often in the street, associated with nausea. He
would sink to the ground, and then would have to be carried to
a carriage and driven home, where he remained in bod in a
semiunconscious state (" as if drunk "), usually for the rest of
the day. These attacks had occurred two or three times a week.
Under a mydriatic I found his only ocular abnormality was
one-half a diopter of hyperopia in the right eye and one diopter
in the left eye. I told him I did not believe his epilepsy was
due to eye-strain. I had him examined by a competent aurist
and rhinologist with a negative result. As it was a matter of
awful seriousness with the poor man, I sent him to the most
distinguished diagnostician in Philadelphia, who after thor-
ough study thought all the symptoms indicated a tumor of the
cerebellum. Before sending the thoroughly disheartened man
home I finally said to him I would prescribe the glasses indi-
cated for his slight hyperopia, anisometropia and presbyopia.
I told him that he could lay aside the distance-glasses in two
months if his epileptic seizures continued as before. He
weighed 127 pounds at this time. I did not hear from him or
see him for about two years, and supposed that he had become
a confirmed epileptic or had died. He now came back for a
change of glasses, as he had had some disquieting signs of a pos-
sible return of his old trouble. From the day he left me he
gained one pound a day until he reached his normal weight, 172
pounds. He has never had a seizure or a very decided epileptic
symptom since. His static refraction remains the same; I have
changed his reading glasses several times. He was well and
healthy a year ago.
Case 5,?S8. — This patient, a man of 37, came to me October
14, 1899, with a liistory of typical grand mal attacks, biting the
tongue, etc., for 25 years. He had also excruciating headaches,
and much indigestion. As near as he could estimate, the
attacks had numbered about 12 a year. I found his error of
refraction was :
R. -f S. 0.75 -f- c. 0.62 ax. 75° = 20/20
L. +8. 0.50 -f-c. 0.62 ax. 75° =20,120
This especially with perfect acuteness of vision in both
eyes constitutes a defect infinitely more irritating to the nerv-
ous system than regular astigmatism of far higher degree. I
prescribed correcting lenses. I saw this man last on April 28,
1902. In the two and one-half years that have elapsed lie has
never had a fit nor a headache; there is now no complaint of
indigestion, and he has good health. One year and a half after
I first prescribed he read fine print long and late during one
evening, and this use of the eyes brought on a kind of a mild
epileptoid attack that so frightened him that he came to me the
next day to see if the glasses were still correct. I found a con-
siderable cliange in the refraction had taken place, and ordered
new lenses, now worn with entire satisfaction.
It may be said, as it has been said, that in the experi-
ence of others, eye-strain is not a causal agency in the
production of epilepsy. In reply one should not need to
remind : 1. That undoubtedly eye-strain is not the most
common, and perhaps it i.s a relatively uncommon cause
of the disease. 2. That however seldom it may be tlie
cause it should not be neglected, on awount of the terri-
ble mystery and Incurability of the dread affection.
3. That the relief of eye-strain is far from certain with
the prescription of glasses, even by the most reputable
of oculists, becjiuse there are a hundred ways in which
the prescription may not be correct, the gla.s,ses improp-
erly worn, or the ametropia quickly changed.
The Episcopal Eye. Ear and Throat Hosnital. of Wash-
ington, D. C, has recently received a donation of ?10,000 toward
the erection of a new hospital building. This institution was
organized five years ago, and has already outgrown its present
quarters. A lot 57 by 1161 feet, centrally situated, has been piir
cha.sed, and it is expected the new building (to cost about f75,-
000) will be erected during the coming year.
Insects and Disease.— The Department of Agriculture
has prepared in the form of a farmer's bulletin entitled
" How lns(jcts Affetrt Health in Hiiral Districts," a dear, direct
description of the manner in which insei-ts transmit dlsMse
and of the preventive measures whli^h lie within the reach of
every American agriculturist. Malaria and typhoid fever are
mentioned as diseases which are provenUble and which are
very largely "country diseases," neither being often found in
cities except through contamination from country districts or
suburbs Detaile<1 instructions for the avoidance of malaria
production by mosqultos is given. The bulletin Is expected t<)
prove one of the most practical and valuable publications of the
department.
AMBBioiu. medicik.) vesical hypebesthesia in the female
[Jdly 5, 1902
FURTHER NOTES ON VESICAL HYPERESTHESIA IN
THE FEMALE *
BY
FREDERIC lUERHOFP, M.D.,
of New York City.
Fellow of the New York Academy of Medicine; Corresponding Mem-
ber of the French Association of Genitourinary Surgery, etc.
It is only within recent years, and especially since
the Invention of the jjerfected cystoscope, that the diag-
nosis and treatment of bladder diseases have approached
exactitude. And of no other class of cases is this truer
than of that ill-deflned one known as the "irritable
bladder," so long considered a neurosis. But as in the
light of more exact study and investigation the hitherto
broad held of neuroses in general is being greatly nar-
rowed, so, too, this condition, upon careful investigation,
is shown to be due, in the large majority of cases, to
tangible and remediable causes. In a previous article '
I stilted that after a careful urologic, as well as gyneco-
logic, examination of 57 cases it was my opinion that
few if any of the cases presenting this complex of
symptoms could not be shown to rest upon some tangi-
ble abnormal condition of either urethra, bladder, or
neighboring pelvic organs. The examination of 119
additional cases has served only to strengthen this view.
By "irritable bladder," or, better, vesical hyper-
esthesia, is meant that condition in which, with perfectly
clear urine (or if turbidity be present, it is not due to
pus), there is found an abnormally frequent desire to
urinate, this desire being at times entirely unaccom-
panied by pain, at other times there being a varying
degree of tenesmus or pain, or both.
A review of the recent literature on this subject
reveals reports of isolated cases, and competent observers
are beginning to accept the fallacy of the neurosis
theory, and advise careful examination of genital and
urinary organs for tangible lesions before a nervous
cause of the pollakiuria is diagnosed. Notably is this
the case with Winter.'' So, also, Vergely ' advises that
in all cases of vesical trouble in women the uterus
should flrst be examined and existing lesions corrected.
On the other hand, however, some of the modern text-
books, notably those by American authors, still class
this condition among the neuroses. In general, how-
ever, it has not received the careful investigation and
study which its great frequency would warrant.
Uacheux ' found hyperemia present in a number of
cases ; Garceau ° found hyperemia of the vesical neck and
trigone in six cases. Desnos'' draws attention to the
fact that, after operations on the uterus and vagina, cys-
titis and also reflex bladder disturbances may occur, the
latter being more frequent, and especially after hysterec-
tomy. Knorr,' referring to cases he examined con-
jointly with me, states that in the greater number there
wa.s some local cause. Janet' speaks for the removal,
flrst of all, of the cause, and then for the treatment of
the bladder hyperesthesia by gradual distention. Chev-
alier '■' remarks upon the occurrence of vesical hyperes-
thesia through hyperacidity of urine containing large
quantities of urates. Gurwitsch" reports a case, in a
girl of 17, in which pollakiuria was present without
appreciable vesical changes. The urine contained a large
amount of urate and oxalate crystals, which he considers
to have been the cause of the condition. With the
views of Chevalier and Gurwitsch I cannot fully agree.
The examination of a number of ca.ses, in which an ab-
normal amount of phosphates, or urates, was present, has
led me to believe that these do not cause vesical hyper-
esthesia unless there is a coexisting, or preexisting
hyperemic or iniiammatory condition of the bladder-
neck. In other words, they act as accessory causes only.
Vineberg" describes only that class of cases which are
due to congestion of the trigone. Huldschiner " men-
* Read before the Section on Clinical Medicine and Surgery, Medi-
cal and Chirurgical Faculty, Baltimore, Md., March 7, itWi.
tions the presence of diverticula as being causes of
"irritable bladder." These, he states, may be congen-
ital (an assumption which, I believe, would be very
hard to prove), or accjuired, as a result of trauma in
childbirth ; or parametritis, or perimetritis with con-
traction. Here, again, we hav«} a confusion of cause and
effect. Reference to the list of causes, in the present
article, shows that in 75 of the 176 cases reported there
were present clear evidences of preceding perivesical
inflammatory processes, the exudate having gone on to
contraction. In some of these 75 cases, as also in others
of suppurative cystitis not included in this list, there
were present diverticula of gi^ater or less extent. In
none of them, however, could I make up my mind that
the pollakiuria was caused by the diverticula per se,
but rather that these, as well as the frequency of urina-
tion, were the results of the contraction of the perivesical
exudate. Of other observers, Knox " performed vaginal
cystotomy in two cases of long-standing vesical hyper-
esthesia, achieving a cure in both cases. It is to be
regretted, however, that a preliminary cystoscopy was
not done, in order to determine the exact cause of the
condition, before the adoption of such severe operative
measures. Michon '* reports a case in which, after the
menopause, a pedunculated myoma of the uterus caused
pollakiuria, through pressure. Removal of the growth,
by laparotomy, removed all the vesical symptoms.
MacNaughton Jones '■'^ relates a case in which an enlarged
and anteflexed uterus, pressing upon the neck of the
bladder, had led first to increased frequency, later to
incontinence of urine. Ventrofixation speedily and per-
manently removed the disability. Mirabeau '" relates
two cases in which, some time after celiotomy, disturb-
ance in the bladder-functions (irritability) occurred. The
cystoscope revealed only anemia and atrophy (?) of the
mucous membrane. He refers the changes to the insuf-
ficient establishment of collateral circulation following
the ligation of abdominal vessels during the operation.
A perusal of the above reftrences and also the table
of causes in my own 176 cases demonstrates that in all
there were tfftigible vesical or perivesical changes suffi-
cient to bring about the abnormal character of the
urination. In only nine of my cases were nervous
conditions present, which occurred only as accompani-
ments of the vesical or perivesical conditions. I believe,
therefore, that it is not claiming too much to say that if
cases of vesical hyperesthesia are studied carefully it will
be found that, in every instance, the condition is due to
some appreciable change in, or adjacent to, the bladder-
wall, and that in no case is it a pure neurosis.
The abnormal conditions, occurring alone or asso-
ciated, found in the two series of 176 cases (57 in the old,
119 in the new), were as follows :
Old
Series. New. Total.
Urethritis — S 3
Urethrocystitis (sphincteral Inflammation) — 5 .5
Sphincteral papiilomata — 15 15
V esical hyperemia 14. 57 71
Vesical varices 5 7 12
Catarrhal cystitis 27 23 50
Prolapse of anterior vaginal wall (not to the
extent of cystocele) — 3 3
Cystocele 4 2 6
Bact«riurla — 1 1
Vesical tuberculosis 1 — 1
Pericystitis 27 48 75
Carcinoma (extraveslcal) 3—3
Pregnancy 5 9 14
Malposltlonsof the uterus..... 10 43 53
Inflammatory conditions of the uterus, or
adnexa, or both — 23 | 23
Pelvic inttamnialions, acut« ^alone or as
accompanying conditions) — 2 2
Pelvic inflammations, chronic — 24 24
Tumor>i fut«rlne — 2 2
^"'"'"^^ jpelvic - 2 2
Movable kidney — 11
Nervous conditions (as accompanying
causes) 4 5 9
Many of the diagnostic features, as also the method
of cystoscopic examination, having been touched upon
previously,' I shall confine myself chiefly to the discus-
sion of the causes not fully described before, and refer
.TOLY 5, 1902]
VESICAL HYPERESTHESIA IN THE FEMALE
[AStKBICAN MeDICIKB 23
those sufficiently interested to ttie previous publication
for a fuller report.
Urethritis and Urethral Changes. — Any discharge
must be exainined, for decision as to its gonorrheal or non-
gonorrheal character, and the urethritis treated accord-
ingly. If there is no visible discharge, then a urethral
scraping should be made and exainined, as very often a
discharge may consist of the merest irace, which yet
bears gonococci. If neither is obtainable, then it is
advisable to employ the endoscope to locate areas of
inflammation, fissures, condylomata, etc., which may at
times alone cause all the symptoms. Treatment must
be applied with reference to the character of the ureth-
ral changes found on examination.
Urethrocystitis (catarrhal). — In this condition there
is usually a more marked degree of tenesmus than of
pollakiuria. The urine is clear and of normal composi-
tion. The cystoscope reveals redness and swelling of a
degree of severity, varying with the intensity of the pro-
cess. This change is, however, one which affects the
sphincteral margin exclusively, or chiefly. The mucous
membrane at the sphincter and just beyond, on both
the vesical and urethral sides, is found congested and
swollen, sometimes markedly so. The surface is angry-
red and irregular, especially over the lower, median por-
tion. The rest of the bladder is free of inflammation ;
the urethra, however, may also be the seat of a catarrhal
inflanmiatory change. A feature of this condition is the
excjuisite tenesmus it frequently calls forth. Treatmetit
consists of the application of nitrate of silver, in .5^ to
'Ifo solution, directly to the sphincteral margin and the
parts immediately adjacent to it, by means either of the
catheter or through tlie endoscopic tube.
Sphincteral Papillomata. — These are distinct, warty
excrescences directly upon, or immediately adjacent to,
the sphincteral margin. They may vary in size and char-
acter from tiny growths (consisting of a vascular loop and
a retaining membrane, the loop apparently being sepa-
ratetl from the membrane by a trans-parent medium) to
clearly defined and prominent small tumors with a
smooth or fimbriated surface. They may give rise to
very severe and continuous tenesmus, and may be
removed either by cauterization witli the actual cautery
or by strong caustic applications through the endoscopic
tube, or by means of the snare, if large enough.
Hyperemia. — This condition possesses certain points
which distinguish it fnmi true cystitis, viz., while in
cystitis of either the suppurative or catarrhal type we
see a surface somewhat roughened, and of an even, deep-
red color, all contours of the individual vessels being lost,
in hyperemia we can readily distinguish that the red-
ness is caused by an abnormality of the capillaries, which
ai)pear to be increa.sed in number and dilated. The
individual vessels are, however, still recognizable, whilst
between them are distinguisliable small areas, or islets of
normal, yellowish mucous membrane. Zuckerkandl"
considers local hyperemia a cause of vesical hyperes-
thesia and mentions"* the increased liability to cystitis
resulting therefrom. Kelly '" states that he finds it in
all those cases hitherto diagnosed as " irritable bladder."
The condition is due either to direct irritation of the
mucous membrane, to the extension to the bladder, of
urethral, congestive processes, or it is secondary to pelvic
congestions, or to pressure of other organs or tumor-
masses. Treatment consists first of the removal of any
extravesical pressure causes; subsequently, irrigations
of 1 'fc boric acid solution, alone, or followed by instilla-
tions of. 25ff to .o'/c nitrate-of-silver solution. The con-
dition is of importance because it may be a precursor of
vesical inflammation.
Vesical Vtirices.— These occur as the result of pressure
• xerted outside of the bladder by masses (either tumors,
or the enlarged uterus) upon the larger pelvic, venous
trunks. I have also observed them as an accompani-
ment of c-ardiac changes, or of varicosities of the veins of
the lower extremities. They vary in extent from what
is merely a marked increase in the number and develop-
ment of the normally -seen venous plexuses of the bladder-
wall, to distinct, tortuous, hemorrhoidal formations, the
affected vessels being seen to rise as tortuous, bluish-red
cords, above the level of the surrounding mucous mem-
brane. Zuckerkandl ''" speaks of having noticed this con-
dition in some of his cases. Kolischer-' says that at
times quite decided hemorrhage may result therefrom.
I have never seen this result, but can readily believe that
it might easily occur, especially upon careless or rough
instrumentation. He also states that contrary to the
statement of other authors, he has not observed them in
pregnant women. Possibly, then, I have been luckier
than he, for I have seen them very pronounced in
several such cases. Treatment consis'ts, first of all, of
the removal of the obstruction to the venous circulation,
if necessary. Should hemorrhage occur, the bladder
may be washed out, using a large catheter. I have
found that when there are coagula in the bladder, it
is a good plan to fill the bladder with fluid to the maxi-
nmm of tolerance, and then instruct the patient to
empty the bladder voluntarily. In this way large coagula
will often be expelled with ease. As a hemostatic,
solutions of antipyrin or ferripyrin may be employed.
The use of the actual cautery has been suggested to con-
trol severe bleeding from vesical hemorrhoids.
Cutarrhal Cystitis. — In this condition is found a condi-
tion of more or less difiuse reddening, with swelling and
roughening of the mucous membrane, most marked, as a
rule, about the lower portion of the sphincteral margin and
the trigone. The islets of normal, yellowish nmcous
membrane, such as occur in hyperemia are not present,
and the surface looks "satiny" (Nitze). At times the
inflammation may also be present over portions of the
bladder-wall outside of the trigone, in discrete, or con-
fluent patches. With all this the urine remains clear or,
if turbidity is present, it will be found to be due to phos-
phates, or bacteria only. The sediment contains epi-
thelium, mucous shreds, bacteria and only isolated leuko-
cytes. The cystoscopic conditions have been well
described by >ritze," Viertel '" and Rovzing." Among
our cases of this class there occurred a number presents
ing the condition described by me under the name
"cystitis papillomatosa." "■ '" Eecently, Zechmeister
and ]Matzenauer " have also described, under the name
"cystitis colli proliferans <cdematosa," a (onditioa
which I believe is identical with that which I had
described previously. When this is present, the rough-
ening is found, on close inspection, to be due to the for-
mation of minute papillary growths, of a rosy-red color,
not transparent, yet each showing distiiu-tly that it con-
tains a small, vascular loop. They always spring from a
broad area of inflammation, and I have seen them only
in the region of the trigone and sphincter.
There was also present, in some of the cases of catarrhal
cystitis, the phenomenon first described by Kolischer'"
under the title." <edemabuIlosum," and later by Casper,^
and myself.™ This condition is marke<J by the occurrence
of small, transparent blels, or vesicles, at diflert'iit part*
of the bladder-wall. It has also been ol)served as an ac-
companiment of pyosalpinx with parametritic exudate,
of cyst«cele, urethrocystitis, an<l of vesical carcinfima.
The treatment of catarrhal cystitis is usually simple :
Vesical irrigations with 1%, boric acid solution, followed
by the instillation or injection of .2r)^i to 2^ nitrate-of-
silver solution. If large numbers of bacteria are pri-sent
in this or any other vesical condition, excepting only
gonorrheal cystitis, the most reliable internal agent
which I have found is urotropin, in 0.5 gm. doses, tlirte
times daily, taken in water, during or after meals.
J'rolapseo/the Anttrior Vaginal Walt, Sol to the Eartent
o/a True Cystoeele.—TM>*, I IM-Iieve, acts only as an ac-
cessory caiise, a» cystocele does. In this condition we
find only a sharp des<-ent of the trigone, the floor of the
bladder, behind the sphincter, falling sharply away.
Cystocele.— To just how gieat a degree the uncompli-
24 AMXBIOAI? MEDieiHX]
VESICAL HYPERESTHESIA IN THE FEMALE
(July 5, 1902
cated cystoc«ele may prove a factor in the production of
vesical liyperestiiesia is very uncertain. It seems plausible
that, when the prolapse is at all marked, the continuous
traction upon the sphincter of a pocket distended with
urine may easily disturb the functions of this muscle.
Its presence, also, seems to favor the development of
cystitis. When cystocele occurs uncomplicated by in-
flammation, the cytoscope reveals changes in the floor of
the bladder, varying from the mere indication of pouch-
ing to decided pocket formation, or sacculation. In the
latter case, we look down into a partially-illuminated
cavity, through a more or less irregular opening, whose
margins are often plicated. If the cystcK-ele is replaced,
and retained in position, through the vagina, the site of
the prolapse will be found marked by folds and creases.
Treatment is gynecologic. In cases in which inflamma-
tion exists, the picture is that of a cystitis upon the
plicated, or prolapsed mucous membrane.
Bacteriuria. — When this causes symptoms we find it
occurring usually as an accompaniment of vesical hyper-
emia. Usually the presence of bacteria, when the vesical
mucous membrane is normal, causes no symptoms what-
ever, even though it may have existed for a considerable
time. In bacteriuria the urine is turbid, and upon ex-
amination the turbidity is found to be due entirely to
bacteria. Bacterium coli is most frequently the germ
found in this condition. The internal use of urotropin
alone, as described before, or alternated with salol, in
conjunction with the regulation of the bowels, and with
bladder-irrigation with Ifc boric acid solution, followed
by r^foio \fc nitrate-of-silver solution, usually gives the
best and speediest results.
Vesical Tuberculosis. — This is a cause of vesical hyper-
esthesia only in its earlier stages. Later in the course
of the disease there is regularly an acid, suppurative
cystitis. Typical of this condition are the tuberculous
nodule, the tuberculous ulceration, and ecchymoses
(Casper'' and AntaP^). Casper has also been able to
positively recognize miliary tubercles, and states that
in no case has he failed to find ecchymoses. Two cases
have come under my own observation, one presenting
the symptoms of only vesical hyperesthesia, the other of
a severe, suppurative cystitis. Both occurred in females.
In the former case, which also presented signs of ad-
vanced pulmonary tuberculosis, the cystoscope revealed
a normal bladder-wall, with the exception of a large
shallow ulceration, with clean-cut edges of somewhat
irregular outline, on the lower left posterior wall. It
rose from an apparentlj' normal base, was surrounded
by a narrow margin of inflammation, and its surface was
covered with a yellowish-gray coating. The second case
also occurred in a patient with pulmonary tuberculosis,
though not very advanced. The history of the acute
attack covered only a period of six to seven weeks,
although there had been slighter trouble with urination,
at intervals, over an indefinite period prior to this.
The cystoscope revealed a diffuse cystitis affecting the
trigone. At different points over the bladder-wall were
distinct ecchymoses, surrounded by apparently healthy
walls. Both ureteral orifices (notably the right) were
swollen and infiamed. On the upper left lateral wall
were three small superficial ulcerations, discrete, with
clean-cut edges, rising from an apparently healthy
mucous membrane, and surrounded by a narrow zone of
inflammation. They were covered with a yellowish-
gray coating. Catheterization of the ureters revealed a
considerable quantity of pus in the urine from the right
kidney, a small amount in that from the left. No
tubercle bacilli were found in the urine (both cases were
seen only once, in consultation), still I am forced to look
upon both as cases of vesical tuberculosis, the first case
primary, the second secondary to tuberculous renal dis-
ease. When it is a result of a descending process, pro-
ceeding from the kidneys, there is usually pronounced
cystitis, either general or localized to the trigone, and
especially to the parts surrounding the ureter of the
affected side, and the process does not properly come
under the heading of " vesical hyperesthesia." Treat-
ment should, first of all, be directed to the general con-
dition. Local treatment consists of measures varying
from injections of nitrate-of-silver solution to iodoform
emulsion, to curettage, cauterization or excision.
Pericystitis. — This condition, which I have before
fully described," is, I believe, one of the most frequent
of the accessory causes of frequent urination in the
female. Interfering as it does with the distensibility of
the bladder, smaller quantities of urine than normal call
forth the desire to urinate. When the exudate about
the bladder is recent the cystoscope may reveal nothing,
and the only sign of its presence be, that attempts to dis-
tend the bladder soon meet with a sense of resistance.
When it is old, however, we see through the cystoscope
that circumscribed portions of the bladder-wall (usually
the lower lateral and the upper posterior and postero-
lateral) are marked by sharp, scar-like yellowish-white
strands, which tend to have fimbriated extremities. In
a most excellent article, Senn ■'* describes, from an anu'
tomic point of view, what I had described from a cysto-
scopio standpoint. He says :
" In pericystitis the peritoneal coat of the bladder is the
seat of the inflammation, that is, in reality, a vesical peritoni-
tis. This anatomic form of cystitis follows usually in conse-
quence of the extension of an inflammation from one of the
adjacent organs ; in rare instances it is caused by intestinal
perforation. The inflammatory product is most abundant
around the base and at the sides of the bladder. In the female,
vesical peritonitis is usually secondary to pelvic peritonitis.
The immobilization of the bladder by adhesions, and the vascu-
lar disturbances caused by the pericystitis are often productive
of great vesical distress, and secondary pathologic changes often
reach the mucous membrane of the bladder."
Treatment consists of a gradual stretching of the peri-
vesical strands, by means of a gradual, progressive dis-
tention of the bladder with fluid. Tepid boric-acid solu-
tion is slowly and gently injected to the point of
tolerance, and allowed to remain a few minutes. The
procedure is repeated at daily intervals ; if possible, the
quantity of fluid being gradually increased. Knorr, as
well as I, has seen excellent results follow this pro-
cedure.
Carcinoma. — As this is rarely primary, but usually
due to the extension of the process from the uterus to
the parametrium, and thence to the bladder, we usually
find the trigone the part involved. During the earliest
stage, there ^ill be seen only a slight prominence in this
region. As the process begins t« involve the bladder-
wall, the floor becomes progressively raised and thrown
into folds, usually transverse, which, in the course of
time, extend anteroposteriorly to involve the parts from
the sphincter to and beyond the interureteral ligament,
and laterally beyond the ureteral orifices. The mucous
membrane is at first smooth and apparently normal.
Later it becomes reddened and irregular and, as the
process approaches the mucous membrane, it becomes
the seat of vesicles of oedema bullosum. The ureteral
orifices may be involved and may open upon one of
the folds, being visible as dark openings only during
the act of discharging urine, or they may be hidden in
the depths of a crease or a convoluted, trumpet-shaped
depression. Later, ulceration and destruction change
the aspect of the picture. Owing to the nature and
situation of the process, radical operation is rarelj' of
service, and treatment must be mainly palliative. Local
treatment if radical is apt only to increase the suffering.
Simple irrigations at times afford some relief.
Pregnancy. — This may cause vesical hyperesthesia,
either as a direct result of pressure upon the bladder by
the distended uterus, or as a result of the vesical hyper-
emia, varices, etc., which it may bring about through
interference with the pelvic circulation (Peyer,^'* Fritsch,'*
Zuckerkandl," Viertel,''* Casper''). These conditions
may occur in the earlier months of pregnancy, and
become more pronounced if the distensibility of the
JULY 5, 1902]
VESICAL HYPERESTHESIA IN THE FEMALE
[Amkbican Mkbicikx 26
bladder is interfered with by pericystitic strands, or
adhesions. The cystoscope reveals a rounded tumor,
covered with nonnal mucous membrane, protruding into
the bladder. Close inspection shows it to be marked
with rounded long irregularities, in all probability the
fiber bundles of the uterine muscle seen through the
bladder-wall. Another condition seen at times during
pregnancy is a decided prominence (both in depth
of coloration and in extent of development) of the
venous plexuses of the vesical wall. These may, at
times, especially if there is cardiac insufficiency, become
pronouncedly varicose. If no inflammatory reaction is
present, no treatment is needed. When it is present,
however, benefit is obtained from irrigations, followed
by the application of nitrate-of-silver solution, of ^^fc
to i^, through the endoscopic tube to the trigone and
sphincter. In cases in which there is a tendency to abort,
irrigations alone should be employed.
Malpositions of the Uterus. — These act, when they are
a cause at all, through direct pressure upon the bladder,
usually at or near the fundus, and by limiting the dis-
tensibility of the bladder. Usually the cause is the cer-
vix of an adherent, retroflexed uterus. The cystoscope
shows a protrusion at the lower posterior, or postero-
lateral part of the bladder. When the fundus is dis-
placed forward there is a protrusion higher up, on the
posterior wall, resembling somewhat the picture seen in
pregnancy, except that the striations, seen in the latter,
are missing. Treatment is gynecologic.
Infldmmatori/ Conditions of the Uterus, or Adnexa, of
Both.— These may exert an influence through the exten-
sion of inflammation to the bladder by bringing about
conge.stion affecting this viscus, or by limiting its dis-
tensibility. Treatment of the bladder is unnecessary ;
it should be directed toward the original condition, since
the vesical hyperesthesia usually disappears with the
subsidence of the inflammation.
Pelvic Inflammations (acute). — These act similarly to
the preceding.
Pelvic Inflammations (chronic). — These act, as does
pericystitis, chiefly mechanically, through limiting the
distensibility of the bladder.
Tumors (pelvic and uteritie). — These become factors in
the causation of vesical hyperesthesia either because of
their direct pressure upon the bladder or by bringing
about congestion of the vesical mucous membrane
through interference with the pelvic circulation. They
are only recognizable with the cystoscope when they
press directly upon the bladder. Then they present a
protrusion, of rounded contour, into the vesical cavity.
Movable Kifhieij.— The extent to which a movable
kidney may act as a factor in the production of pollaki-
uria has not been decided. Personally, I believe its
influence is slight.
Nervous Conditions. — The nervous conditions we have
met have been neurasthenia, hysteria, ataxia and epi-
lepsy. Of these, neurasthenia occurs most frequently
and'is of the greatest importance as a contributory cause.
It stands to reason that if the nervous system is weak-
ened, conditions which otherwise would perhaps pass
unnoticed may produce marked symptoms. Then,
again, allowance must also ije made for the natural ten-
dency to exaggerate symptoms or conditions which is
present in those suffering from nervous conditions.
Coincident with the treatment of whatever vesical or
extravesical changes may be present must be that of the
nervous disease.
The prognosis of vesical hy|)eresthesia is goo<l. It is
not, of itself, a serious condition, but may prove a very
favorable foundation for graver conditions of the urinary
organs. The cases due to local inflammatory changes
are most readily and ([uickly cured. In the prt^sence of
extravesicid causes, however, the course of the disea.se is
slower and more ti'dious, and may extend over months,
or even years ; if neglected, it may letid on to incurable
atrophy of the bliulder. Usually, however, appropriate
treatment is soon followed by a gratifying mitigation in
the severity of the symptoms. Unless the causative fac-
tors «in be entirely removetl the condition shows a ten-
dency to recur at times. Consetjuently these cases should
he treated, whenever possible, until all the causes, prin-
cipal and accessory, have been removed. If this is
impossible, as unfortunately is too often the case, then
we must be content to later treat the recurrences.
As a result of the investigation and study of the above
series of cases I have been the more firmly fixed in the
conclusions expressed in my former article, viz., that
1. The term " vesical hyperesthesia," or " irritable
bladder," is in almost every case, in the female, erro-
neously applied.
2. As a true neurosis vesical hyperesthesia occurs
rarely.
3. In cases in which vesical hyperesthesia exists it
does so only as a symptom ; in the majority of cases as a
direct result of some change in the vesical mucous mem-
brane, in the minority as an indirect result of changes in
other organs adjoining or near the bladder.
4. The dis^nosis of the causative factor must rest
upon a thorough examination not only of the bladder
but also of the urethra and the genital and pelvic organs
as well.
5. The treatment must be directed both against the
local changes and the causative fiictors of these.
1 desire in conclusion to express my sense of deep
obligation to my friend and colleague. Dr. Richard
Knorr, of Berlin, Cermany, for his valuable help in
assuming the gynecologic examination" of the cases stud-
ied for this article, for placing the material at my dis-
posal, and for the permission to report the same.
REFERENCES.
'Bierhoff: On the socalled "Irritable bladder" of the female.
Amer. Jour, of the Med Scleix^es, Vol. cxx. No. fl.
2 Winter: Ijehrbueh der Uynttkologlschen DIagnostlk.
3 Vergely : Quoted in Anicr. Journal of Obstetrics, 1000.
* Daebeux : Sur la vessle irritable, chcz la femme : These de Paris,
1894
sGarceau; Some atfectlons of the female bladder. Boston Med.
and Surg. Journal. Vol. 138.
"Dcsnos: Troubles do la vessle consOcullfs aux operations sur
I'ut^rus. See Le Progrfts Medical, IKfld, No. ;W.
'Knorr: Ueber - Irritable bladder," bei der Frau. Monatsschr. f.
Geburtsh. u. Oynftk., Vol. xl. No 6.
sjauct: Traltement dcs pollakluries nerveuses par la dilation
progressive de la vessle. Ann. des mal. des org. genlto-ur.. ItWi.
8 Chevalier: Ijes pollakluries urlques. Ann. des mal. des org.
genlto-ur.. Vol. xvil.
■"Gurwltsch: Zur Kasulstik der Pollaklurie. Q,uoted In Jahres-
beriehtderCieburtsh. u. Gyniik., Vol. xlll. ^. „ „ ^ , ,„„
I'Vlneberg: Bltulderatn-ctions In women. N.Y.Med Jour., ItflW.
"Huldschiner: Keizbare Blase und Blasen-Dlvertlkel. Centralbl
fttr die Kr. der Ham u. Sexual-Organc. Vol. x. . . , . , j .
"Knox: Vaginal cystotomy for the cure of irrllable bladder.
Amer. Jour, of Obstetr., Vol. xl. .. ., , , . . i,
i« Miction: FIbrome de I'uterus. Retention Incomplete, et polla-
klurie. Ann. des mal. des org. genlUvur , llftW.
li MacNaughtonJoncs : Complete Incontinence of urine cured by
ventrofixation of the uterus. Trans. Obstetr. Hoc. of London, Vol. xl.
"Mlrabeau: Ueljcr trophlsche Bla-senstfirungen nach gynhkolog-
Ischen Opera llonen. Ontmlbl. filr G.vn., 1«(9
II Zuckerkandl : I'eber cine Form der irrltnblen Blase bclm « elbc.
Wiener me<l. Presse. 18B4, Nos. 20 and 21. „ ,. , , , „
i> Zuckerkandl: Veriinderungcn des welbllchen OeniUtlcM abhAng-
igcn Formen von Cystitis. Wiener med. Presse, Oct. 14, 18M.
i» Kelly: Operative Gynecology.
»Zurkerkandl: Article quoted in No. 17. ^^
!iKollscher: Die Erkrankungen der welbllchen Hamrohre uno
fflNllzc: LehrbuchderKystoskople. .. «, . u.i...
23 vierU-1 : Physl kallsche U ntereuehungsmethodcn der BUwe. Velt »
"''24'Rovzl'nK:'Kilni8che und experimentelle lyntfirsuebungen Ubcr
dielnfektHisen Krankheltcn der Harnorgane, 1808
!'>Blcrlioff: Article quoted in No. 1. „.,,««
M BlerhofT: Cystitis papllloniatosa. Medical News, May 2t\, IHOO.
« Z.fhmel«ter und Niatzenauer: Cystitis colli prollfenuis ledema-
tosa. (;enlralbl. f. die Kr. der Ham und Scxual-OrKnne. > ol. xll, No. 1.
"Kollscher: Centralbl. f<lr Gyniik. und Oebnrt«h., Vol. xlx.
»Ca»i)er: Handbiich der CysUMicopU', 1898. „, ,ann
""Blerhoir: (Kdema bullosum veslcie. Medical News, Nov. 24, IflOO.
31 Casper: liOc clt.
M iilrrhofr* The intraveycai evidences of |>erive»lc»l Intlammalory
prfKCSses In the female .Medical News. March 1), IIIOI.
' »<Henn: Classillcatlon of cystitis. Amer. Jour of Obstetr., Vol. xll.
» Pever • Die Ueizblasf, o<Icr idlopathUcho BlBneiirel/.ungj 1888. ■
MFrltscii: Zur .Kilologle und Theraplc dtw BlaM.-n-Kalarrh».
W'lener med. Presse, 18W. . , , v, ,-
31 Zuckerkandl : Article quoted In No. D.
»" VIertel : Article quoted In No. tL
"•Casper: l/>c clt.
26 AUERICAir Medioink)
OVARIAN IRRITATION
I July 5, 1902
OVARIAN IRRITATION AS A FACTOR IN THE
ETIOLOGY OF PSEUDOCYESIS.'
BY
J. THOMPSON SCHELL, M.D.,
of Philadelphia, Pa
Demonstrator of Obstetrics, Medlco-Chirurglcal College; Gynecologist
to the Out-patient Department of the .Samaritan Hospital, etc
The pos.sibility of ovarian irritation being a factor in
the causation of pseudocyesis, or spurious pregnancy,
was suggested to me rather forcibly several years ago by
a series of three cases which came under my care at that
time, and of which I made a brief report.
After searching the literature on the subject, I could
not find at that time any suggestion that ovarian irrita-
tion had ever been considered as a causal factor in this
condition, and since then I have made a more careful
search with very little or no better results.
The literature consists mainly of reports of isolated
cases more or less marked, but the etiology is not con-
sidered, except very briefly. The etiology of pseudo-
cyesis is obscure, and if the report and study of this
small series of cases will help to throw any light on the
subject, I will feel amply repaid.
McArdle, in the New York Medical Journal of 1886, after
reporting several cases of phantom tumors says : " Hysteria In
an adult female is the predisposing cause of phantom tumors
and spurious pregnancy."
Dr. DaCosta, in a clinical lecture reported in the Philadel-
phia Medical Times of 1871, on "Phantom Tumors," sums up
the knowledge of the subject at that time in these words:
" These strange spurious swellings that have been called phan-
tom tumors, which require much care and some skill to
discriminate, and which, while they have perplexed more than
one observer, receive but very unwilling attention from the
most."
E. N. Chapman, in the American Medical Times of 1864,
reports 11 cases of spurious pregnancy, and while he says the
cause of this condition is not known, suggests the possible irri-
tation of the uterus and amenorrhea as a cause, and the study of
the cases which he reports could be interpreted to mean ovarian
irritation— at least in some instances.
In Case 2 of his series he gives this history : "Always had
irregular and painful periods with tender pelvic organs. Case
.3 on examination showed a retrotlexed and tender uterus with
evidence of pelvic cellulitis."
In another case, in a very stout married woman, the exam-
ination revealed a small virginal uterus witli no mention of
any other pelvic lesions.
A more suggestive case is the following: " History of
great tenderness in the lower part of the abdomen and pain in
the sacral region, much aggravated by walking or any ix>rm of
even light exercise; an examination showed a retrodisplace-
ment, with partial procidentia of the uterus."
It seems to me that these cases all suggest some form
of pelvic trouble, possibly ovarian.
After going over the medical journals and finding so
little on the etiology of this interesting condition, I con-
sulted textbooks with the following results :
Dr. S. Weir Mitchell, in Anomalies and Curiosities of
Medicine, page 73, says that a young woman, or maybe
one at or past the climacteric eagerly desires a child,
or is horribly afraid of becoming pregnant ; menses
become slightly irregular and finally cease; abdomen
and breasts enlarge owing to the rapid taking on of fat.
There comes with this excess of fat the most profound
conviction of the fact of pregnancy. By and by a child
is felt, the physician takes it for granted and this goes on
until time corrects the delusion.
The most noteworthy historic case of pseudocyesis is prob-
ably that which occurred in Queen Mary of England, who
wished to ensure the succession of a Catholic heir. She was
most desirous of having a son by her consort, Philip, and she
prayed for pregnancy. Finally the menses stopped, the breasts
began to enlarge and became discolored around the nipples ;
she had morning sickness of a violent nature and the abdomen
enlarged. On consultation with the ladies of her court her
opinion of pregnancy was strongly confirmed. Her favorite
amusement then was to make baby clothes and count on her
fingers the period of pregnancy. When the end of the
period of the ninth month approached the people were awak-
1 Read before the Philadelphia County Medical Society, March 13,
1902, and the Germantown Medical Society, .March 17, 1902.
ened one night by the joyous peals of the bells of London
announcing the new heir. An ambassador had been sent to
tell the Pope that Mary could feel the new life within her, and
the people rushed to St. Paul's Cathedral to listen to the vener-
able Archbishop of Canterbury describe the baby prince and
give thanks for her deliverance. The spurious labor pains
passed away, and after being assured that it was not real preg-
nancy Mary went into violent hysterics, and Philip, disgusted
with the whole affair, deserted her; then commenced the perse-
cution of the Protestants which blighted the reign.
The American Textbook of Obstetrics, under Diagnosis of
Pregnancy, says; "Pseudocyesis occurs oftenest towards the
menopause, and its false appearances are quickly unmasked by
the administration of an anesthetic." Also under Pathology of
Pregnancy, " Pseudopregnancy may result from a strong desire
for pregnancy in a patient suffering from ascites." Playfair's
Textbook makes this statement: "Ovarian irritation of the
menopause, mental influences, fright or desire to have children
all are factors In the causes of false pregnancy."
In Grandin and .larman's Practical Obstetrics, page 21, we
find this statement : " Neuropathic women at the menopause
and women very anxious to bear children are liable to false
pregnancy. This is usually the result of a desire to become a
mother, and the delusion is sometimes assisted by a few uncer-
tain symptoms."
I could go on multiplying quotations of this kind,
but as the few I have already quoted are fair samples of
what can be found in most of the textbooks on obstet-
rics, and as they do not throw any very definite light
upon the actual etiology of the disease, I will desist and
report my own cases :
Case I.— Mrs. P., white, aged 33, puberty at 12 years; her
menses were always regular and painless, intervals 28 days,
flow normal and lasting only four to five days. Married 11
years, had one child at full term during the second year of her
nfarried life; a miscarriage at six months two years after
the birth of the first child, and another miscarriage two
years later. For two years preceding the history of her sup-
posed pregnancy she complained of backache, more or less
severe, some leukorrhea, and pain in the lower part of the
abdomen, especially in tlie left iliac region. Menstruation
during this time became much more profuse, with consider-
able pain on the first day but not enough to require medi-
cation. The last regular period was November 15, 1898;
the December period failed to appear, and at that time she
became nauseated, wiih some vomiting, especially in the
morning. Coexisting with the amenorrhea and vomiting, she
complained of a feeling of weight in the pelvis, with frequent
urination. The nausea gradually diminished, and disappeared
about February 1. During this time the abdomen was gradu-
ally enlarging,' and on March 28, or about 20 weeks from the
time she had her last period, she felt what she Ijelieved to be
fetal movements, which persisted constantly and distinctly
until labor, August 13, 1899.
Up to this time she was under the care of a Neighboring
physician, who was called to deliver her ; after being in labor 40
hours, she became exhausted and discouraged, and discharged
her physician. She called in another, who sent her to the
Samaritan Hospital, where in the absence of Dr. Haehnlen,
through whose courtesy I report this case, I was called to de-
liver her. On questioning her, a part of the above history wa.s
elicited, and in addition she informed me that she had passed a
large quantity of water about 10 hours after she noticed her first
pain. Examination showed a stout, well-built woman, weigh-
ing about 190 pounds, with a tremendously enlarged abdomen,
strice and linea niger very faintly shown; the breasts con-
tained colostrum, and the primary and secondary areola were
present.
Bimanual examination showed a soft, club-shaped cervix,
lacerated Ijilaterally, and patulous to the internal os, wliich
was closed. No distinct uterine enlargement could Ije made
out. on account of the thick abdominal walls, nor could any
fetal movements be felt nor fetal heart sounds or uterine souffle
be heard. On examination under ether the uterus was felt en-
larged to about the size of a two months' pregnancy in a normal
position, the lett ovary was enlarged, and the whole left broad
ligament, including the tube, was tliickeued. There was a
mucopurulent discharge from the uterus, and a curettage was
done with no other results than the removal of some shreds of
endometrium, and a diagnosis of complete pseudocyesis was
made. Subsequent history: Patient wa,s discharged 12 days
later with abdomen as large as on admission. Periods have
been regular ever since, with some pain on the first and second
day, backache and soreness or tenderness in the left iliac
region. Tliis patient is at present complaining of various
symptoms suggestive of pelvic trouljle, l5Ut refuses to be ex-
amined.
Cask II.— Mrs. D., white, aged 29, puberty at 12 years. Men-
struated twice in six weeks and then missed for a year. Was
considered a very delicate child at that time. At about 13J years
she started to menstruate again, had an irregular menstruation,
and suffered great pain, which compelled her to stay in bed for
several days and required the use of opiates to relieve her.
This continued until she was married at the age of 23, and
July 5, 1902J
OVARIAN IRRITATION
[Ajtebican Medicink 27
though still irregular, she suffered less pain. A short time after
she was married she missed four months' periods and gained 35
pounds in weight, aud thinking she was pregnant made prepa-
rations tor the child's birth; liut after missing four periods,
while moving so'me heavy furniture she was taken with a severe
hemorrhage from the vagina which lasted for 12 hours, and
then had an apparently normal menstruation lasting for seven
more days. After this she was allowed to sit up and the physi-
cian in attendance was unable to say whether she had had a
miscarriage or not, as she had not passed anything resembling
even the smallest ovum. After this event she was still irregu-
lar but never missed over one period until about September,
1899, when the periods stopped again, although slie .says at times
she had a slight show ; February 22 she was sure that she felt life.
During this time the abdomen and breasts had steadily in-
creased in size. She suffered with nausea, especially in the
morning, which was quite marked up to March 10, when she
started to menstruate again. At that time I was called by her
physician. Dr. Klein Baker, to see her, and advised an exam-
ination under ether with the following results : Abdomen en-
larged to about the size of a five months' pregnancy, very fat
walls and marked distention of bowels, uterus normal as to
size and slightly displaced to the right side, the left ovarv and
tube were markedly enlarged and the right ovary was appar-
ently normal. As there was a mucopurulent discharge from the
uterus, I did a curettage aud the patient made a good recovery.
Subsequent history: Periods are still irregular and painful,
she has great backache, marked leukorrhea, and pains and ten-
derness in the left ovarian region. An examination made a
few days ago showed a very tender and prolapsed left ovary ;
the region of the right ovary was very tender but the ovary
could not be palpated.
Case III.— Mrs. H., a markedly neurotic patient, aged .33,
married 11 years, had two children, followed three years ago by
a miscarriage. Puberty occurred at about 13 years and has
since been irregular, but not painful. On October 1, 1899. 1 was
requested by her physician. Dr. W. H. Hornby, to meet him in
consultation to assist in making a diagnosis. The history is
briefly as follows: Had amenorrhea extending over January,
February and March with nausea and some vomiting in the
morning. The abdomen during these three months was noticed
to be steadily enlarging. She was examined at this time by
another physician, who pronounced her four months pregnant,
and he was engaged to deliver her, the nurse being also engaged
at this time. In April she began to menstruate again and bad
what were apparently normal periods in May and .Tune. The
abdomen, notwithstanding the menstruation, seemed to be get-
ting steadily larger, and in .Tuly nausea reappeared, but she
failed to menstruate at the time. Dr. Hornby was called and
'expressed doubts as to her being pregnant. The breasts at this
time were enlarged, veins were markedly distended and colo-
strum in abundance was present, with a distinct primary and
secondary areola. In August and September she had metror-
rhagia and menorrhagia. When I saw her on October 1,
1899, the abdomen was enlarged to about the size of a
full term pregnancy, but no fetal heart sounds or uterine
souflle could be heard. I suggested an examination
under ether with the following results : The uterus was
slightly enlarged and retrodisplaced. both ovaries pro-
lapsed, tubes apparently normal as to size and the right ovary
quite considerably enlarged. A curettage was done and the
patient made a good recovery. Subsequent history, which was
Kindly furnished by Dr. Hornby, is as follows: "Since the
recovery frQm the curettage Mrs. H. has bef-n under my care at
different times for her general nervous condition. She had some
nausea and backache. Her abdominal enlargement disap-
peared, her breasts regained their normal size and she lost con-
siderable in weight."
Case IV.— .Mrs. B., aged .38, .white, puberty at llj years.
Her menses were irregular and painful, especially on the first
day. When she was about 18 years old she suffered from
menorrhagia in addition to this condition. This continued
until she was married ; shortly after which she became
g regnant, and was delivered of a large child at full term,
he had considerable trouble, forceps having to lie used, apd
she was confined to bed for five weeks after delivery. Men-
struation did not reappear for two years, although the child
was at the breast only for six months. When the periods
returned they were very scanty and irregular. This con-
tinued up to the time of her present illness, which began
March 10, 1901, with amenorrhea, morning nausea, frequent
micturitiiHi and a gradually enlarging abdomen. About the
middle of July she felt wliat she thought were fetal movo-
metits; these symptoms continued until 1 saw her December 2,
1901. Mrs. 15. is a resident of a small coimtry village about T.'j
miles from Philadelphia, and with the remembrance of the
previous difficult labor and tedious convalescence in her mind,
she decided to come to Philadelphia to be confined. After being
examined by a local physician, who pronounced her seven
months pregnant, she came to Philadelphia and was examined
by me in the early part of December.
Examination. — White woman, brunet, well built, breasts
enlarged and primary pigments present. Breasts contained
milk ; abdomen enlarged to about the size of a seven months'
pregnancy, groat amount of tympany, the abdominal wall very
tat. No fetal heart sounds could be heard, nor fetal movements
felt, altbougb she persisted in her statement that she distinctly
felt the movements. Hicks' sign of pregnancy was absent. Upon
bimanual examination without ether, the uterus seemed some-
what enlarged, but on account of the large abdomen nothing
definite could be made out ; so an examination under ether was
made, and the uterus was found to l)e enlarged to about the size
of a two months' pregnancy, verv soft, botli ovaries enlarged, the
left one to the size of a lemon and the right one a little larger.
A foul-smelling bloody discharge was seen issuing from the
cervix. I did a curettage, removing a quantity of what seemed
to be diseased endometrium tissue, but no fetal or placental
tissue was found. The patient made an uninterrupted recovery
and has returned to her home with the expectation of coming
again to Philadelphia in the near future to have her diseased
pelvic organs removed.
In the study of the eases which I have just reported
the first thing to which I would call attention is
that all of these women were comparatively young, their
ages being respectively 33, 29, 33 and 28 years, therefore
they can hardly be classed as being at the menopause,
which condition seems to be considered by many authori-
ties the most frequent cause of pseudocyesis.
The mental attitude of all th&se women was indif-
ference as to the probability of pregnancy, and I could
not get them to express themselves as being either very
desirous of being pregnant or as having any serious
objection to or fear of,the same. No. Ill was a very
nervous and hysteric person, but she was entirely indif-
ferent as to whether she was pregnant or not, and since
the curettage, has been constantly under her physician's
care for various hysteric symptoms.
All these women, since their minds have been clarified
of delusional pregnancy, have l)een aimoyed by more or
less severe symptoms of ovarian di.sea.se. Case II has
been treated by her i)hysician, who has considered the
desirability of ovariotomy later, and Case IV has made
arrangements for an oj)eration in the hope of getting
relief from her symptoms.
I have always looked upon pseudocyesis as a mental
disease, and still think that it is probably a manifestation
of hysteria, but I would like to sugg&st that a pelvic irri-
tation is the possible cause of the hysteria in some ca.ses.
I have had other cases of pseudocyesis more or less
marked at the menopause, and in hysteric women in
whom no pelvic disea.se was found ; but I firmly believe
that there are some cases, and possibly a larger number
than we now have any idea of, in which the hysteric
condition is brought about by .some form of ovarian dis-
ease. In Grower's book on Nervous Diseases we find this
statement: "Charcot believed after careful investigation
that ' ovarian disease was very often the ciiu.se of
hysteria.'" Banney says: "Pul)erty is a cause, also
uterine displacements, cervical diseases, and, especially,
irregular menses and ovarian disease."
While I do not feel competent to go into a discussion
as to the etiologj' of hysteria, I would like to say that the
question is still an un.settled one, and the ctiu.sal factors
are probably manifold ; and I telieve that if
pseudocyesis is hysteria, then in .some instantws the
(;ause of this form of hysteria is ovarian disease, for
while I know that the few cases I have quotod are totall.v
inade<iuate to prove anything, they are suggestive, and
if the suggestion thrown out is taken up it might be the
means of throwing more light upon this very obscure
and very interesting subject.
Public School Placed in AHvluni.— An innovation in
Philadelphia will bo made this fall by establishing a public
school in the Philadelphia Orphanage, with two teachers. In
addition to the inmates of the institution children living in the
vicinity will also attend.
Maternity Service Collectloiis Slopped.— During the
))a.st ten months something like 20,000 l)oxe« bearing the legend
" rleivso give one cent to the Free Maternity Hospital .Service of
Pounsylvania " have been (lisj)laye<l in public places throughout
the State. The Master appointed by tiio Court when a charter
was applied for has rendered an adverse report, not because the
"service" is directly harmful but because the money handled
is out of proportion to the g(M)d accompllMhed. The purposes
of tiie organization are the relief of desiltuto women iu need of
medical care during parturition.
28 American Medicine]
WHAT IS PATHOLOGY ?
[Judy 5, 1902
SPECIAL ARTICLE
WHAT IS PATHOLOGY?
BY
JOHN BENJAMIN NICHOLS, M.D.,
of Washington, D. C.
Medicine may be defined as the science tliat relates to dis-
ease and the art that deals with the treatment of disease. In
accordance with this definition, medicine can be divided into
two great departments, sharply distinct from each other, viz.,
(a) pa^Aotoffj/, the pure science of disease, and (6) therapeutics,
or applied pathology, the art of treating disease.
Science is knowing, art is doing. Science is pure and
applied. Pure science relates exclusively and disinterestedly
to abstract knowledge without any thought or care as to any
use to which it may be put. Applied science considers and
arranges acquired knowledge with a view to its application to
useful purposes ; it is the basis of art, leads to art.
. Disease phenomena make up a well-defined class of the
phenomena of life, corresponding and coordinate with other
classes of vital phenomena. Diseasejs as susceptible of inde-
pendent investigation as other departments of biology, and
per se may be as fascinating and interesting a subject to the
student, entirely aside from any humanitarian, utilitarian or
therapeutic considerations and applications. In other words
there is &pure science of disease, not applied.
The pure science of disease is pathology, so named from the
Greek words -«%, disease, /dyor, discourse. The applied
science of disease, or applied pathology, is therapeutics, the
body of principles and methods of practice employed in the
actual treatment and management of disease.
Disease is a condition common to all forms of life, vegetable
as well as animal, from the highest to the lowest, and is not con-
fined to one genus or species alone, or to any circumscribed
groups. The science of pathology covers the subject of disease
in all its scientific aspects and throughout the animal and vege-
table orders of life. As disease forms one of the classes of vital
phenomena, so pathology is a department of biology, the
science of life in general. Pathology is an integral and essen-
tial part of biology, rooted and imbedded in that science, and is
coordinate with such departments of biology as anatomy, phys-
iology, taxonomy, etc. Pathology is base^ on and receives
important light frompther departments of biologic knowledge ;
in turn it throws light on other branches of biology, and con-
tributes its share and its special data to the elucidation of gen-
eral biologic problems, and of psychologic and sociologic ques-
tions as well.
A pure science of pathology in its largest aspects and its
general biologic bearings and relationships has yet to be elab-
orated. Practical reasons heretofore have directed and restricted
the investigation and the literary and educational treatment of
pathology to the confines of small generic groups, as man
(human medicine), the useful animals (veterinary medicine),
and cultivated plants (vegetable pathology), and with special
reference to and connection with therapeutic applications.
This leaves large gaps in the organic series in which pathologic
phenomena have not been systematically investigated, and has
resulted in a general lack of correllation and generalization of
the phenomena of disease in the various orders of life. Path-
ology is capable, however, of a broad treatment, taking into
account the disease phenomena occurring throughout the entire
organic world (comparative pathology), and establishing the
broadest inductions and generalizations as to the causes,
nature, and processes of disease. Such a development of path-
ology, besides its purely academic value and interest, could not
fail to throw light on some of the obscure problems of practical
medicine.
According to the character of the phenomena in question, or
the technical methods of Investigation employed, the subject of
pathology embraces several coordinate lines of investigation
such as etiology, the study of the causes of disease ; pathologic
anatomy, relating to the anatomic and histologic changes asso-
ciated with disease conditions; pathologic chemistry, or
chemic pathology, dealing with the special chemi(^ phenomena
of disease; physiologic pathology — symptomatology— covering
the aberrations and disturbances of the vital processes and
functions in disease. Like other sciences, pathology is elabor-
ated both from observation and experiment; from observation
of cases of disease spontaneously arising, and from study of
morbid conditions purposely and experimentally induced or
modified. All these departments or lines of study and investi-
gation are of equal and coordinate rank, and all alike go to
make up the total of pathologic science. The expression path-
ology cannot be rationally restricted to any one part of, or any
one class of methods of studying, disease phenomena, but
belongs to the entire subject, and covers alike all parts of the
subject. The designation pathologist rightfully belongs to any
one who systematically and scientifically studies any class of
morbid phenomena or by any method, whether it be by observa-
tion, experiment, or statistics ; whether it be the study of
anatomic changes, chemic phenomena, physiologic features or
clinical conditions and symptoms; or by microscopic, biologic,
bacteriologic or chemic methods, or the results of clinical and
physical methods of examination of patients. Therefore, the
scientific clinician who systematically studies the symptoms,
the aberrant functions, in fact the physiologic manifestations
of disease as observed at the bedside, is as much a pathologist
and as much entitled to be so called as is the pathologic anato-
mist or the microscopist.
While the fundamental and most general meaning of the
term "pathology" is the science of disease— " the sum of
scientific knowledge concerning disease, its origin, its various
physiologic and anatomic features, and its causative relations "
(Century Dictionary)— there are other subordinate senses in
which, with greater or less propriety, the term is frequently
employed.
One frequent use of the term is that in which we speak of
the " pathology " of some disease, as the " pathology of typhoid
fever," meaning thereby the essential nature of the disease, or
a succinct and comprehensive view of the causes and processes
of the disease, the chain of phenomena proceeding from the
initial cause to the final effects, or " totality of the morbid con-,
ditions and processes in a disease " (Century Dictionary). As
the use of the term pathology in this sense is general and com-
mon, there seems to be a need for it, and this use is perhaps
unobjectionable in that it is not likely to lead to ambiguity or
misconceptions.
Of late years there has arisen a tendency to confine or
degrade the meaning of the term pathology, which should cover
the entire science of disease, to a designation for the nar-
rower science of pathologic anatomy.' Numerous treatises are
current and courses are given in many medical schools pur-
porting to present the subject of pathology. Examination of
these manuals and courses shows that they present a large
amount of valuable information regarding the manifestations of
disease as observable in the dead, but very little about the pro-
cesses of disease in the living body. What these treatises and
courses really present is the subject of pathologic anatomy or
pathologic histology, not pathology as a whole. The anatomic
changes associated with morbid conditions are of course essen-
tial to an understanding of disease and of pathology; but the
physiologic or functional changes— the symptoms and clinical
phenomena— are equally essential. For instance, a knowledge
of the anatomic lesions of typhoid fever is necessary to any
understanding of that disease, but the symptomatology is of
equal importance; no matter how well we might know the
changes manifest postmortem, from them alone no conception
whatever could be obtained as to the symptoms and clinical
features of the disease during its course.
The ordinary work on " pathology " is, then, really a work
on pathologic anatomy, this particular branch of pathology
inclining to assume the name belonging to the entire science.
While there may be no deliberate intention to restrict the
>An exactly similar tendency has also unfortunately arisen to
restrict the meaning of the term biology to designate what Is reallv
comparative anatomy; thus, the ordinary textbook on "biology"
treats simply of the|dlssectlon and anatomy of various typical ani-
mals, which, however essentially a part of biology or however
Important in teaching that science. Is not all of biology
July 5, 19021
WHAT IS PATHOLOGY?
[AXKBICAN MkDIOINX 29
meaning of the term pathology to this particular branch of the
science, its common use in this sense, in effect, leads to miscon-
ception and a narrowing of its meaning. This use and narrow-
ing of the terra pathology is in every way unfortunate, since it
leads to ambiguity and error, and is tending to degrade the
significance of the term from its original and largest sense. It
is needless to say that a designation is needed for the science of
disease in general, and there is no better name than pathology ;
the present tendency is to destroy this significance without
providing a substitute name. This use, or misuse, of the term
in question is not only unfortunate, but entirely unnecessary,
as a proper and exactly fitting designation is already available,
viz., pathologic anatomy, or pathologic histology. Possibly the
shorter term has come into use from its brevity. If, however,
the expression " pathologic anatomy," or such a designation
as " pathologic anatomist," is too cumbrous and inconvenient,
a shorter term, accurately fitting and euphonious, could easily
be coined and introduced after the analogy of the word anatomy,
such as "pathotomy," with the related terms " pathotomist "
and " pathotomic."
In another sense the term pathology is frequently applied
to one of the departments of clinical or diagnostic work. The
data obtainable for diagnostic purposes and the methods of
clinical examination of patients fall into certain tolerably well-
marked classes: (a) the anamnesis, or history of the case;
(6) the subjective phenomena experienced by the patient and
communicable by him, but not otherwise discoverable; (c) the
objective characteristics exhibited by the patient's body and
ascertainable by direct examination of the patient's person, the
somatic or "physical" examination; and (d) the objective
characteristics manifested by fluid and solid materials, secre-
tions, ejeeta, bits of tissue, and the like, removed from the body
and subjected to chemie, microscopic, and bacteriologic
examination in the clinical laboratory — what might be called
the eesomatic examination.
The term pathology is usually applied, or misapplied, to the
class of work done in the clinical laboratory, and persons
engaged in that work are often called pathologists. The count-
ing of the pulse, the taking of temperatures, and the observation
of symptoms at the bedside are just as scientific and just as
much part of pathologic work as is the routine examination of
urine, sputum, and blood for diagnostic purposes, and it is irra-
tional and invidious to apply the term pathologic to eesomatic
clinical examinations and not to physical or somatic examina-
tions when both are alike devoted to the same object of clinical
diagnosis. Conversely, the laboratory work and findings are
just as much a part of clinical medicine as are the work and
results of physical examination ; and the ecsomatist may be as
much a clinician as the somatic diagnostician.
Apparently some more suitable term than " pathology "
is needed to designate the general field of work covered by the
clinical laboratory; the need of a new name is especially felt as
this is largely a new field of work. The methods of such a lab-
oratory are very diverse in their character, being partly micro-
scopic, partly biologic or bacteriologic, partly <;hemic. The
one common feature about the material dealt with in the clin-
ical laboratory is that it is all removed /»'Owi tlie body and exam-
ined elsewhere. Hence such a term as eesomatic (from 1%, out
of, away from, and ««/;«, the body) should be a satisfactory
designation for the department of medicine covered by clinical
laboratory methods, with the correlative terms ecsomatics and
ecsomatiKt. Eesomatic work thus stands in contrast with such
forms of clinical investigation as inspection, palpation, percus-
sion, auscultation, x-ray work, sphygmography, thermometry,
etc. — the direct somaWc examination of the subject. A clinical
laboratory would be an eesomatic laboratory. " Pathotomic "
or pathologic-anatomic work could also be included within the
scope of the term eesomatic, relating to the anatomic and histo-
logic examination of parts removed from the body. Autopsy
work would thus come equally with routine clinical laboratory
investigations within the province of the "ecsomatist" (not
"pathologist") of a hospital.
Owing to the rather misleading titles of certain works
of large circulation the expression "clinical diagnosis" has
with many come to mean the principles and practice of diagno-
sis from clinical laboratory findings, or what might be called
" eesomatic diagnosis." Clinical diagnosis properly covers the
whole field of diagnosis by any and all methods, those of physi-
cal examination as well as of laboratory examination, and the
restriction of its significance to one class of diagnostic methods
is irrational.
A clear line can be drawn between the scientific and the
practical aspects of medicine. The purely scientific side of
medicine is represented by the pure science of pathology, the
study of disease in the abstract. The practical side of medicine
is represented mainly by clinical medicine, the actual treat-
ment and management of concrete individual cases of disease.
Clinical medicine is applied pathology, an application of the
results of pathologic science to useful purposes. Clinical med-
icine presents a clear division into two distinct departments :
(a) Diagnosis, the determination and recognition of the disease
condition present, and (6) therapeutics, the treatment of that
condition. Both diagnosis and therapeutics are applications of
pathologic principles and considerations to useful ends.
The study of disease phenomena with a view to elucidating
their general nature and relations in a scientific way comes
within the domain of pure pathology. The study of individual
cases of disease, with a view simply to their diagnosis and
treatment, pertains to practical or clinical medicine. In this
sense pathology stands in contrast with clinical medicine ; one
is the study of disease for impersonal scientific purposes, the
other for practical, useful, individual, therapeutic purposes.
The general tendency has been, however, to regard pathology
as meaning the employment of laboratory methods in medical
investigations. To which it may be said, first, that the data of
pathology are elicited not only from laboratory findings, but
also from bedside observations and statistical studies by other
than laboratory methods ; and, second, that laboratory methods
are largely applicable for purely clinical purposes, in the diag-
nosis of clinical cases, as contrasted witli scientific purposes.
A distinction can thus be made betweeti a pathologic lab-
oratory and a clinical laboratory as to their aims, though not
so much as to their technical methods. The pathologic lab-
oratory is devoted to the scientific investigation of disease in
a general and impersonal manner, while the clinical labora-
tory is employed for the routine examination of material
for aid in the diagnosis of actual, individual, personal cases of
disease. The ordinary hospital laboratory is a clinical labora-
tory ; while contributions to pathologic science may emanate
from such a laboratory they may also emanate as well from
the ward and bedside, so that the ecsomatist or worker in the
clinical laboratory has no exclusive title to the designation
pathologist, if he has any at all.
The study of the phenomena of disease for the elucidation
of the subject in its scientific aspects properly pertains to path-
ology, and this applies alike to all departments of the subject,
physiologic and chemie as well as anatomic. Laboratory
methods, while an important part of the means by which
pathology is studied, are not its sole means of investigation ;
nor are they employed exclusively for purely scientific pur-
poses, but for routine diagnostic purposes as well ; so that lab-
oratory work in medicine is not necessarily Interchangeably
synonymous with pure pathologic Investigation. Nor are
laboratory methods the only "scientific" means of studying
disease; since bedside observation, with or without Instru-
ments of precision, may, it is to be hoped, be just as scientific
in spirit and methods as the operations of the laboratory.
l»uro Milk for Poor of Chicago.— The furnishing of pure
milk to the residents in the poorer ouarters of Chicago was
begun by the Northwestern University Settlemont .June 1(1.
Pasteurized milk Is sold at the same i)rice as ordinary milk.
Modified milk for infant feeding Is also furnlsheii on physi-
cians' prescriptions. Circulars announcing this fact have been
printed in various foreign languages and distrlbutetl.
To Save Paupers ft-oin DIsscctinK Room.— It Is reported
that the poor committee of city councils of Wllllamsport is to
make a test of the law requiring that the Ixxilos of pau]>er8
shall be turned over to the State Anatomic ]k>ard for dissection.
To that end a joint resolution Is to be passed by councils
instructing the poor lx)ard to bury all pauper dead. If the
anatomic board objects the city Is to stand the expense of a test
case. Members or the LegiHlature will bo asked to use their
influence In obulning the repeal or modifying of the law.
30 AMEBICAS iMEDICINEJ
THE WORLD'S LATEST LITERATURE
[Jdly 5, 1902
THE WORLD'S LATEST LITERATURE
Jonrnal of the American Medical Association.
Jane iS, 1901. [Vol. xxxvill. No. 26.]
1. A Contribution t« the Treatment of Pneumonia with Antlpneumo.
cocclc Serum. Bkice W Goldsborouoh.
2. On the Immunization Treatment of Hay-Fever. E. Flktchek
INOAI.S.
3. A New Method of Treating the Broad Ligament Stumps in Vaginal
Hystertwlomy. E. C. Dudley.
4. The Physician as a Social Economic Factor. Edgar J. Spbatlino.
1. — Pneumonia anil Antipneumococcic Serum. — Golds-
borough reports nine ca.ses in which tiiere was a marked change
within eight hours of the administration of the serum, and in
many tlie crisis was sucee.ssfully passed in 48 hours. As its use
does not interfere with that of other remedies there is no excuse
for not trying it. The dose, 20 ec, can be repeated in eight
hours if there is not a marked change for the better. Prom one
to three injections have been used. The percentage of deaths
after its use is 16.5 against 25% to 35% without it. That it is not
effectual against the toxin of certain pneumonias does not con-
traindicate its administration, as we never know with just
what exact type of toxin we are dealing, [h.m.]
2. — See American Medicine, Vol. Ill, No. 24, p. 1002.
3.— A New Method of Treating Broad Ligament
Stumps. — The ligaments are ligated en masse in such matmer
as to avoid sloughing of the stumps, and drawn down into the
vagina. Between them the anterior and posterior peritoneal
margins of the vaginal wound are united by a continuous cat^
gut suture which also secures by one or two stitches the broad
ligaments themselves so they cannot slip back into the pelvic
cavity. The ligaments are then brought together by end-to-end
approximation, or, if long, they may be folded one on the other
and fastened together. The anterior and posterior margins of
the vaginal mucosa are then united by continuous catgut
suture. The ligaments fixed in this manner hold the viscera
high up in the pelvis and prevent prolapse of the pelvic floor
(rectum, vagina and bladder), [h.m.]
Medical Record.
June 18, 190S. [Vol. 61, No. 26.]
1. The Differential Diagnosis of Typhoid and Malarial Fevers, with
Especial Reference to the Occurrence of Both Diseases In the Same
Patient : with Report of Cases. Isaac Ivan Lemann.
2. Combined Transverse and Longitudinal Incision In Median Lapar-
otomy, with the Object of Preventing Ventral Hernia. Lewis A.
Stimson.
X Empyema of the Antrum of Hlghmore with Ptosis and Diplopia.
Understudy of the Effect of Treatment on the Ocular Disturb-
ances. Heber Nelson Hoople.
4. A Word about American Mineral Waters and Mineral Spring Re-
sorts. James K. Crook.
5. The Characteristics and Tendencies of Modern Medical Progress in
America. Jonathan Wright.
1-— Typhoid and Malarial Fevers.— Lemann reports a
number of cases of malaria simulating typhoid and vice versa,
and cases in which repeated blood examinations finally showed
both diseases to be present. A person suffering from chronic
malarial infection may develop typhoid, or during convales-
cence from typhoid relapse from a preceding malarial attack
may occur; in some instances the two infections may be
coincident in time. A fresh malarial infection during typhoid
is rare. It is wisest to treat all doubtful cases as typhoid, [h.m.]
3.— Combined Transverse Liongitudinal and Median
Incision in Liaparotomy.— Stimson, acting upon the idea sug-
gested by McBurney of separating rather than dividing the
muscular fibers to prevent future hernia, has devised the
following operation which he has used successfully in more
than 50 cases : It consists of a curved transverse incision
through the skin, aponeurosis and sheath of the recti, followed by
the usual longitudinal separation of those muscles and division
of the peritoneum. The incision crosses the median line, about
4 centimeters above the upper margin of the symphysis pubis,
and extends on each side toward the anterior superior spine of
the ilium to a distance varying with the amount of the subcu-
taneous fat. It is then carried through the aponeurosis and
sheath of the rectus on each side, its outer portion following the
direction of the fibers of the aponeurosis, and the deeper por-
tion not extending beyond the outer edge of the rectus! and the
upper flap thus outlined is raised from the muscles by division
of its attachment to the septum constituting the linea alba. The
sheath below the incision is similarly freed toward the sym-
physis; a few vessels connecting the sheath and the recti will
need to be ligated. The recti are then separated and the perito-
neum divided in the median line in the usual manner. At the
termination of the operation tlie peritoneum is sutured, and the
flap replaced and secured by catgut sutures. The skin is sutured
with silk ; if drainage is necessary, the drain is placed at the
center of the incision in the median line, and if the wound has
been contaminated by contact with pus a small rubber tissue
drain is placed between the flap and the rectus on each side
emerging near the end of the incision, [a.b.c]
3.— Eye Disturbances Attending Empyema of Antrum
of Highmore.— Hoople reports the case of a previously healthy
young man of 21, who on account of confusion of lines and
blurring of images was almost disabled from following his
work as a draughtsman. Examination showed incoordination
of extrinsic eye muscles, diplopia, impaired vision, impaired
accommodation and double ptosis. He had suffered repeated
and severe hemorrhages from the nose. Operation which freed
the left middle turbinate from adhesion to outer wall of left
middle meatus was followed by free discharge of foul pus from
the left antrum, with recovery from all abnormal symptoms.
[a.b.c]
4. — American Mineral Waters. — Crook presents a number
of tables showing that in every class save the sulfated salines
the waters of our own country are richer in mineral ingredients
than those of Europe. Our spring resorts are not inferior
as regards climate, beauty of scenery, elegant hotels and all the
comforts of European watering places. The hegira abroad is
due to the neglect of balneotherapy by the medical profession
here. In Europe this and climatotherapy is embraced in the
curriculums of all the leading universities. Almost every State
here possesses valuable mineral spring resorts, but at most of
these no regime exists and therefore the results will not com-
pare with those abroad, [h.m.]
Neiv York Medical Journal.
June 21, 1902. [Vol. lxxv, No. 25.]
1. Difficulties in the Diagnosis of Certain Febrile Diseases. Glent-
woKTH R. Butler.
2. Gastroptosla the Cause of Symptoms Erroneously Attributed to
Nephroptosia. Achilles Rose.
3. Permanent Results, Failures and Relapse, following Bottini's Opera-
tion for the Relief from Prostatic Obstruction. F. Kriessel.
4. The Hygiene of Pregnancy Charles E. Paddock.
5. Cerebral Localization and Brain Function. L. Harrison Mettleb
1. — Difficulties in the Diagnosis of Certain Febrile Dis-
eases.—Butler gives in detail the notes of 10 cases in which
diagnosis was not made until late in the disease or until autopsy.
He divides them into four groups, the febrile symptoms being
due to (1) concealed suppuration; (2) tuberculous infection;
(3) irregular forms of typhoid fever ; (4) malignant endocar-
ditis. An interesting case in the first group was an undiagnosed
appendicitis in which the appendix, lying well back, had per-
forated with the resulting formation of a small retrocecal
abscess. This, in turn, ruptured into the cecum causing a
pylephlebitis, the liver containing 40 to 50 metastatic abscesses.
[a. O.K.]
3. — Gastroptosla and Nephroptosia. — Rose's article is
mainly a series of quotations from other writers regarding the
symptoms and treatment of fioating kidney. These symptoms
in a great majority of cases, he claims, are due to enteroptosia
and are relieved when that condition is relieved. Nephroptosia
is included in enteroptosia and to him it is impossible to see
how the displaced kidney can be accused of causing the symp-
toms attributed to it exclusively. Much of the confusion is
caused by the various understandings of the terms in use.
Atonia gistrica, gastroptosla and dilation of the stomach are
identical. Gastroptosla and nephroptosia form part of enterop-
tosia or splanchnoptosia. Tlie two former may need to be
spoken of independently of the latter, but it is doubtful if dis-
placement of stomach or kidney ever exists without the whole
splanchnon being relaxed, [a.o.e.]
3. — Results of the Bottini Operation. — Kreissel gives a
history of eight cases in which the performance of the Bottini
operation (or hypertrophied prostate were followed after vary-
Jdly 5, 1902]
THE WOELD'S LATEST LITERATUEE
(Ambbican Medicins 31
ing intervals by a return of symptoms. Many of the disap-
pointing results can be explained by the various structural
changes in the gland, by the variety in size, shape, arrange-
ment and localization of the protrusions, and by the mechanical
difficulties of the operation. Collar-shaped protrusions give
the most difficulty. An incision penetrating the entire lobe is
not necessary. If a case is suited to the Bottini operation, the
only necessary and effective incisions are those in the longitudi-
nal axis of the elongated portion of the posterior urethra. The
groove should be burned only deep enough to establish a lumen
of the approximate caliber of the normal urethra. Kreissel
places the patient on a small portable table which is placed on
the operating table, and sits on a high chair. An adjustable
arm rest aids greatly in manipulation of the instrument. A
close observation of cases leads to the conclusion that the
Bottini operation is but palliative, the number of cases of
relapse after having been apparently well for two years or over
being constantly increasing. A radical and permanent relief
from prostatic obstmction can only be expected from prostatec-
tomy, and as its technic becomes perfected it will be the opera-
tion of choice in cases permitting its employment, [a.g.e.]
Medical News.
June SS, 1901. [Vol. 80, No. 26.]
1. Medical Etiquette at the Dispensary Clinic. Thomas J. Hillis.
2. The Local Treatment of the Organs. Byron (Joakley.
3. The Causes and Manner of Death In Epilepsy. Wii^liam P. Sprat-
ling.
4. General Enteroptosls. Robert T. Morris.
3. — Local Treatment of the Organs. — Coakley presents
experimental evidence that various organs can be benefited by
intraorganic medication. In the treatment sepsis, air embolism,
hemorrhage, hematoma, pressure necrosis, paralysis and rup-
ture of the organ or its capsule, anemia of the organ and scle-
rosis from puncture can all be avoided by proper technic. CO2
in excess displaces the hemoglobin, staining the serum. XaCl
will not combine chemically with CO2, but holds it in solution,
allowing the red cells to take up the hemoglobin again. Greater
leukocytosis can be secured from intravenous than from intra-
intestinal and subcutaneous injections. Raising the solution
from 110° F. to 120° F. increases leukocytosis. Bleeding causes
leukocytosis, and when followed by decinormal salt solution
this is increased still further. Localization is necessary to com-
bat serious disease Intraorganic injections enormously increase
metabolism. The writer reports experiments showing greatly
increased venal activity and a higher red cell count in the
splenic vein after injections in the kidneys and spleen. Blood-
letting and local injection in pneumonia increases leukocytosis,
relieves the heart, causes the formation of red cells of higher
oxydizing power, aids toxic elimination, prevents hemoglobin
displacement and causes general stimulation. It does not cause
pulmonary edema. It acts favorably in pleuritic effusion and
on the spleen in typhoid and has been successfully used in
anemia, diphtheria, scarlatina and measles. He describes
instruments of precision — the organometer, the organotome
and the phlebotome— invented by him for the proper adminis-
tration of the solution, [h.m.]
3. — Causes and Manner of Death In Epilepsy. — Any
epileptic may die suddenly at any time as the result of a single
seizure, from a series of seizures ending in status epilepticus,
from an accident occurring in a fit, or from all other causes that
ordinarily produce it, with preponderance in favor of heart and
lung disease. A study of 220 deaths gives the following per-
centages : 4% from single fits, 24% from status epilepticus, 129i>
from accident, including suffocation in bed ; 24^0 from lung dis-
ease, chiefly tuberculosis ; lO^ii from organic heart disease, and
26% from all other causes. [u.M.]
4. — General Knteroptosls.— Robert Morris believes that
this condition is caused originally in women by the wearing of
the corset in early adult life. The closefitting corset refuses to
permit the liver to glide over the right kidney as in normal
respiration, but instead the liver, acting like the piston of a
pump, drives the kidney down, and thus we have movable kid-
ney. The abdominal muscles being " splinted " by the corset
liecome atrophic. Durinjj gestation the recti separate more or
less. After parturition the unsupportetl liver, kidney, trans-
verse colon and other viscera sag and the ligaments elongate
and produce enteroptosls. Massage, a closefitting corset, and
electricity can do much to relieve the semi-invalidism. Some
cases secure relief only by operation. The author makes a long
median incision, removes all tissue, including peritoneum, be-
tween recti ; shortens ligaments of liver, replaces kidney and
approximates recti, with good results, [a. B.C.]
Philadelphia Medical Journal.
June IS, 190i. [Vol. ix. No. 26.]
1. A Remarkable Case of Coma, Apparently Due to Acid Intoxication
bui Generis. D. L. Edsall.
2. Dysmenorrhea. J. J. Gubnky Williams.
3. Tinnitus Aurium. G. Griffin Lewis
4. A Oiseof Acute Articular Rheumatism with Pyemic Temperature.
treated with Antistreptococcic Serum. Ji. J. Chipman.
5. 1 wo Cases of Hydrocele Presenting Unusual Features. Frederic
Griffith.
1.— A Remarkable Case of Coma.— Edsall details a case
of coma apparently due to acid intoxication. The marked
clinical characteristics of this form of intoxication, whether the
primary disease be diabetes or some other condition, are
usually drowsiness, stupor or coma, at times preceded by
nervous excitement and even convulsions— peculiar deep res-
pirations, reduction of temperature, an odor of acetone, and
the presence of acetone, diaeetic acid and oxybutyric acid in
the urine. It is now recognized that this form of intoxication
is due to an excess of acids ; and those cases which show an
absence of a primary general disease of such a character as to
offer a fair explanation of the occurrence of intoxication are
classed under the term acid intoxication sui generic, or crypto-
genic acid intoxication. Acid intoxication has been shown to
be chiefly the result of the decomposition of the fats of either
the food or the tissues, or both ; though it can scarcely be
doubted that proteins play some part in its production. The
subject in general is fully discussed, with a review of the lit-
erature. The patient herein reported is a milkman, 63 years of
age, in apparently fairly good health, who was suddenly over-
come by vertigo followed by prolonged coma, which lasted
about 10 hours, during which time he was given alkaline trans-
fusions. He exhibited during this time the symptoms and the
urinary signs of acid intoxication ; then rapidly recovered and
subsequently remained perfectly well, the symptoms as well as
the urinary signs of the acid intoxication disappearing coinci-
dently with his improvement. The signs of diabetes were
absent at all times. The case is, in certain clinical features,
apparently unique, so far as the literature of the sut)jeet is con-
cerned. Edsall fails to find another recorded case in which
siprns of acid intoxication of great severity appeared with such
remarkable rapidity, and none other in which there was ab-
sence of prolonged gastrointestinal or other symptoms before
the appearance of the signs of acid intoxication. The final
course of the coma in this case was eijually remarkable. <'om-
plete recovery within a few hours, without any notable symp-
toms remaining behind, is without an analogue in the reported
cases of this condition. The treatment of this patient, original
with the author, consisted of the intravenous infusion of 75 gm.
of sodium bicarbonate. The urine which was tested with each
portion voided remained distinctly alkaline for about 70 hours
after the alkaline infusions wore given, [f.c.h.]
3.— Tinnitus Auriunj.— Ijcwis discusses this subject from
its various standpoints, the entire discourse being of marked
value to the general practitioner. The reader is referred to the
original article, [f.c.h.]
4. — A Case of Acat« Articular Rheumatism Treat«d
with Antistreptococcic Serum.— ('hipman details a case of
acute articular rheumatism with a pyemic temperature success-
fully treated with the antlstreptococjilo serum. This is the first
case, so far as he can ascertain, which has been treated by this
methmi. In reviewing the history of this case It seems possible
to ascribe the sudden remission of symptoms to mere coinci-
dence. The patient was greatly prostrated, physically and
mentally, and appeared to be rapidly progressing toward a
lethal ending. All the symptoms wore being intensified when
the serum was commenced, and the improvement was marked
from the first injection and her condition was practically nor-
mal from the third inje<!tioii. [p.c.h.]
32 Ambbioan Mbsicikk]
THE WORLD'S LATEST LITEEATUEE
(July B, 1902
CLINICAL. MEDICINE
David Ribsman A. O. J. Kellt
Alcoholic and Syphilitic Liver Cirrhosis.— One of
the most interesting and tlioroughly practical discussions
evoked at tiie meeting last week of the American Medi-
cal Association took place in the Section on the Practice
of Medicine with regard to Dr. Stockton's paper on
syphilis of the liver. It is evident that the impression
is gaining ground that many supposed cases of alcoholic
liver cirrhosis are really syphilitic cirrhosis maBquerad-
ing under the name of the cognate incurable ailment.
This error of diagnosis is especially lamentable, since the
most encouraging branch of therapeutics at the present
time is undoubtedly the employment of a specific treat-
ment for serious syphilitic conditions. It has unfortu-
nately become the custom to think that tertiary lesions
of syphilis are much rarer than they really are. Many
of the obscure ailments of middle life and later are due
to unrecognized visceral syphilitic lesions. As Professor
Osier insisted in the discussion, syphilis is a disease,
whose treatment is especially the province of the general
and family practitioner. It is only the family practi-
tioner who can keep patients under supervision for the
many years that are necessary in order to provide assur-
ance against the development of subsequent serious
pathologic conditions in the patient himself, or in his
family. The treatment of syphilis by the specialist only
too often leaves the patient open to the danger of suffer-
ing from unrecognized syphilitic lesions of the nervous
system or the abdominal viscera later in life. The
absence of a syphilitic history by no means justifies the
physician in attendance in assuming that syphilis is nec-
essarily without influence in the case. The custom of
the nervous specialist to assume the existence of syphilis
and administer specific treatment until at least a nega-
tive therapeutic test is obtained would seem to be the
most advisable course also for the general practitioner
when in the presence of obscure internal conditions
with even the remotest possibility of their being syphi-
litic.
The experience of Johns Hopkins Hospital, as pointed
out by Dr. Futcher, seems to indicate that at least 20 fo
of obscure febrile conditions are due to visceral syphilis.
This is a much larger proportion than even the medical
men of large cities where syphilis is at the present day so
common would be inclined to estimate. There seems
good reason, therefore, to suggest that every general
practitioner in the country should take to heart the sug-
gestive details of this discussion. The use of specific
treatment in properly selected cases brings more thera-
peutic satisfaction than it is the lot of the medical man
to be able to give in any other set of apparently so
serious conditions. The syphilitic suspicion, therefore,
should never be allowed to become dormant, and while
uncalled-for presumption in a particular case can do no
harm, it may be a source of the greatest possible good.
It would certainly be discouraging to think, as seems
not unlikely from some of the frank confessions of the
discussion, that there are a number of supposedly incur-
able alcoholic liver cirrhoses suffering without hope and
without improvement, though the administration of
antisyphilitic treatment faithfully pursued for a time
would not only relieve their symptoms but actually
restore them to health.
The Symptoms and Diagnosis of Carcinoma ot the
Hepatic Flexure of the Colon. — As stated by Maylard,' while
it is frequently the custom to speak of carcinoma of the colon
as a disease p«r «e, there is little doubt that much difficulty and
confusion would be removed, and greater accuracy in diagnosis
obtained, if the colon was looked upon not so much as an
anatomic and physiologic entity as a more or less complex part
of the organism, whereby disease at one part presents a train of
'Edinburgh Medical Journal, May, 1902.
symptoms peculiar to itself and different from that of another
part. He deprecates the tendency to refer in articles to carci-
noma of the " colon," whereas the part of the colon involved
should always be specified. At present it is impossible to make
a positive diagnosis of carcinoma of the hepatic flexure of the
colon, but the symptoms which may be regarded as fairly sug-
gestive of disease in this particular region are the prominence
of digestive derangements, in association with other symptoms
indicative of colon disease ; the order in which these symptoms
arise, first in connection with the bowel, and secondarily in
connection with the stomach ; the symptoms associated with
attacks of hepatic flexure obstruction are more acute than those
connected with obstruction more distally situated, and do not
usually occur until the patient has already shown signs of con-
stitutional disease ; pain is a commoner and more acutely felt
symptom in disease of the cecum, ascending colon, and hepatic
flexure, than when the growth attacks other segments of the
large bowel. The pain is usually felt over the seat of the
disease; while the symptoms may suggest disease of the colon,
up to and including the hepatic flexure, the absence of any
tangible growth in the right iliac and lumbar regions will point
to the implication of the flexure, [p.c.h.]
Effect of Ablation of the Spleen on Pancreatic
Digestion In Animals Deprived of Their Stomachs.— At
the meeting of the Society de Biologie, of Paris, on April 19,
1902, Frouin ' reports on the results following the ablation of
the spleen in animals in which the stomach had been seques-
tered or entirely removed. The animals remained in good
health, showing that the ablation of the spleen in no way modi-
fies pancreatic digestion in cases where there is no gastric diges-
tion of albuminoids. Gley points out, however, that we must
not conclude from this that the spleen exercises no influence
on the function of the pancreas, inasmuch as it has been
shown by Sohiff, Herzen and others that the spleen is capable
under certain conditions of provoking the intrapancreatic for-
mation of a proteolytic ferment. The two questions : duodenal
digestion and the role of the spleen in the elaboration of trypsin
are not necessarily related. [c.s.D.]
The Association of Movable Kidney on the Right
Side with Symptoms of Hepatic Disturbance.- Haber-
shon ' emphasizes the medical aspect of the condition known as
movable and floating kidney, and states that even without a
coincident ptosis of the liver, a displacement of the right kidney
is often responsible for profound symptoms of hepatic disturb-
ance. For every patient that applies to a surgeon for relief, at
least a dozen apply primarily to the physician, though the fre-
quency of the condition is by no means universally recog-
nized. According to Glenard 2.7% of men and 22% of women
suffering from dyspepsia and visceral troubles have a floating
or movable kidney. In a large majority of cases it occurs upon
the right side ; when the left kidney is displaced, it is more
common for both kidneys to be affected. The four common
causes of movable kidney are : Tight lacing in women, violent
falls or sudden muscular exertion, frequent child-bearing, any
cause which produces in a patient hitherto well nourished wast-
ing or absorption of fat in the mesentery, abdominal parietes, or
in the tissues around the kidney. The conditions which may be
confounded with floating kidney are given. The symptoms are
described as subjective and visceral. The hepatic symptoms
are general biliousness, attacks of colicky pain simulating
biliary colic and jaundice. The symptoms are exceedingly
intractable; all ordinary remedies, including mercurials, alka-
line mixtures, etc., seldom afford any relief to the patient.
This is so much the case that when a patient has severe hepatic
symptoms, short of jaundice, and the ailments do not yield to
ordinary treatment, one should at once suspect that the hepatic
condition is l)eing continued by the reflex disturbance of a
mobile and displaced kidney, and all efforts should be re-
doubled to detect it. Unless thelkidney is kept in position by a
belt, or (in condition of excessive mobility) by operation, the
attacks will recur. Several cases are detailed, [f.c.h.]
Lobular Pneumonia in Infants.— Herman B. Sheffield,'
having treated nearly 200 cases of this disease with only one
1 La Semaine Mfidicale, Aprir23, 1902.
2 Edinburgh Medical Journal, May, 1902.
s New York Post Graduatc.IAprll, 1902. .
J ULY 5, 1902)
THE WORLD'S LATEST LITERATURE
[AnERlCAit Medicine 33
death, maintains that very energetic treatment instituted early
is the best. When called to a case he immediately prescribes a
moderate dose both of spirit ol nitrous ether and solution ol
ammonium acetate, to be repeated every two to four hours
with strychnin sulfate in gradually increased doses. He then
applies a poultice of five parts each of flaxseed meal and
camphorated oil, one or two parts of mustard, and a sufficient
quantity of boiling water to make a thick paste by thorough
stirring. This mass is spread on thin gauze or paper and
applied to the chest and back. The child is then wrapped in an
oiled-silk jacket, lined with absorbent cotton, and in a blanket.
The poultice is renewed three or four times in 24 hours. Expec-
torants, stimulants, nerve-sedatives and alteratives are resorted
to if indications arise. The tent, made by bedsheets hung
around the bed and moistened with creosote, oil of eucalyptus,
etc., is highly recommended. Whisky may be given in the
very beginning or end of the disease, or may be given with
milk or eggs more as. a food. Milk, eggs, and beef juice form
the most suitable diet. Water should be given ad libitum.
About the sixth day of the disease sodium iodid in small doses
is administered, and if there are any signs of pleurisy with
effusion the following ointment is applied : one part each of
gaultheria oil, guaiacol and ichthyol, and four parts of iodin
ointment. [c.A.o.]
Degenerative Bulbar Paralysis. — Cotton • details the case
of an American schoolgirl, aged 11 years. The symptoms pre-
sent, the course of the disease and the onset, he considers suflfl-
cient to justify one in classifying the ease as a degenerative
bulbar paralysis, the extreme rareness of which in a female child
lends exceptional interest to the case, [f.c.h.]
The Influence of Phlorldzin Glycosuria and Pancre-
atic Glycosuria on the Elimination of Sodium Chlorid. —
Lepine and Maltet ^ report to the Society de Biologic, Paris,
the results of a series of experiments on the relation of
phloridzin on the excretion of sodium chlorid. Though phlor-
ldzin in certain doses renders the kidneys permeable to sugar,
they find that it does not augment the elimination of rosanilin
bisulfate, an inoflfenslve coloring matter, neither does it affect
the excretion of sodium chlorid directly, but only when the
dose of phloridzin has been sufficient to produce glycosuria is
the elimination of sodium chlorid increased. It is not the
phloridzin but the sugar that causes the hyperchloruria, as it
occurs in connection with the glycosuria which ensues after
ablation of the pancreas. The passage of a relatively large
molecule like that of sugar facilitates the passage of a smaller
molecule, [c.s.d.]
The Diagnosis of Smallpox. — Marsden' details the differ-
ential diagnosis between smallpox and scarlet fever, measles,
typhoid fever, urticaria, pneumonia, purpura, cerebrospinal
fever, ulcerative endocarditis, various forms of skin affections
as acne, macular syphilides, etc., all of which may be con-
founded in one of their stages with variola. It is important to
remember that by vaccination we may determine doubtful
cases, as in every case of genuine smallpox the attempt at vac-
cination will be followed by negative results, while in a .arge
proportion of the other diseases a typical reaction will be ob-
tained, the want of inoculability usually depending on the time
which has elapsed since it was previously performed. It is
also imperative to mention that in no case should doubt as to
the nature of a case be allowed to exist longer than two days, as
it is essential that before the end of the third day all persons
exposed to the infection should be efliciently protected by vac-
cination. As soon as doubt arises the patient should be
isolated pending the conclusive diagnosis, [f.c.h.]
The Effect of Certain Poisons on Inorganic Ferments.
— Harry C. Jones* calls attention to the continuation of the
work of Bredig and his pupils on inorganic ferments, and the
striking relations which have been established between them
and certain enzymes, from which it may be concluded that
there is a general agreement between the action of poisons on
organic and inorganic ferments, and that the colloidal solution
of the metals in many relations at least may be regarded as
' Pedlalrlca, June, ISOii.
2 La Hcmalne MCdlcjile, April 21, 10O2.
"The Medical Chronicle, February, 1(102.
* Bulletin of Johns Hopkins Hospital, May, 1902.
inorganic models of organic enzymes. The action of the col
loidal solutions of the metals, the enzymes and catalysis gener-
ally, may be referred to the surface energy possessed by these
substances. [c.s.D.]
Hepatic licsions in Infancy. — Wollstein,' at 370 necrop-
sies performed on infants under 4, found fatty infiltration of
the liver in 214 cases, 58%, including 45 cases in which it was
tuberculous as well as fatty. Of the remainder, 22 showed
tubercles without fatty infiltration, 2 were cirrhotic, 85 deeply
congested, and only 47 normal to the unaided eye. Details of
the associated conditions are given, [a.o.j.k.]
Concerning the Value of Precipitins as a Means of
Distinguishing Between Proteid Bodies.— Rostoski = finds
that precipitins are not of use in distinguishing between various
albuminous bodies, but answer only for differentiating between
native albumins. The blood of a rabbit treated with any one of
the albumins precipitated in the blood of the horse, not only
that particular albumin in the horse's blood, but all of the
albumins, and it was impossible to separate by this means
albumin from globulin. The serum of an animal treated with
Bence-Jones' body precipitated human blood-serum and albu-
min and globulin prepared from such serum ; but not the blood-
serum or the albumin and globulin of another animal. For the
action of the precipitins salts are indispensable, [d.r.]
The Spread of Lieprosy and an Examination of the
Fish Hypothesis.— Neve,' discussiug the spread of leprosy,
gives some observations on the hypothesis of its spread by
means of fish as applied to Kashmir. It is believed that fish
is not an actual cause <le novo of leprosy, but that it, as well as
other foodstuffs, may serve as a carrier of leprous virus with
which it may have been in accidental contact, [a.o.j.k.]
An Experimental Inquiry on the Disinfection of
Floors for Plague.— Leonard Rogers,* OflSciatiug Professor of
Pathology and Bacteriologist to the Medical College of Calcutta,
reports an investigation carried out under the orders of the
Government of Bengal on lines suggested by the Plague
Commission for the purpose of determining what strengths of
the different disinfectants are required to be used in order to
kill all the species of microorganisms known to have about the
same resistance as the plague bacillus Itself. The strengths of
various disinfectants requiretl to kill the plague bacillus in
from 10 to 15 minutes are summarized. Practical experiments
on the destruction of bacteria in tiie dirt floors of dwellings
result in the conclusion that neither the mineral acids nor
potassium permanganate are reliable disinfectants, even when
used in solutions which are many times as strong as are
required to destroy the plague bacillus in test tubes in 16
minutes. Of the disinfectants which are sufficiently cheap to
be employed on a large scale, phenol and mercury perchlorid
in acid solution give the best results. It appears that in order
to be sure of killing microorganisms of as little resisting power
as the plague bacillus on the surface of mud floors 15 times as
strong a solution of phenol and 40 times as strong a one of acid
perchlorid of mercury as are effective against the plague
bacillus in test tubes in 15 minutes must be used. [c.s.D.]
The Etiology of InfVintlle Paralysis.— Gossage' discusses
the clinical and pathologic features of infantile paralysis,
reviews the literature of its etiology, and reports several Illus-
trative cases. He believes that there are two, and probably
three or four definite diseases, including under the term anterior
poliomyelitis : (1) Those in which the paralysis comes on sud-
denly without previous ill-health ; (2) those in which the onset
of the paralysis is preceded by general symptoms, such as
fever, vomiting, pain in the back, eU;.; (3) epidemic cases; and
(4) adult cases. The last three may possibly be the same disease
which may sometimes occur sporadically, and at other times
epidemically. The disease is believed to be an Infection due \a
a spettiflc microorganism; indeed, since there are two or more
definite diseases included under the name of infantile palsy
there are believed to be two or more speciflo microorganisms.
[a.o.j.k.]
> American Journal of tbo Medical Bolenoes, Vol. cxxlll, p. 817, IWZ.
« MOnohcner niwl. \V(K-h , May B, 1902.
• Hrlllsli Mcdiiiil Journiil, May 3, 1902.
'Journal of HyKlcne, Aiirll 1, \9f)t.
'American Journal of ibe Medical Mclencos, Vol. cxxlll, p. 798, 1902.
84 American MEsioiNa]
THE WORLD'S LATEST LITEEATUEE
[July 5, 1902
A. B. Craio
GENERAL, SURGERY
Martin B. Tinker
C. A. Our
The Surgical Soctiou of the American Medical
Association.— The meeting at Saratoga was generally
considered, by those Interested, one of the most success-
ful in the history of the section. The attendance was
unusually large even to the end; the discussions were
active, many valuable points being brought out ; and,
most important of all, the papers read were most of them
distinct contributions to surgery. Indeed, in real value
the papers read compare very favorably with those of the
special surgical societies both in this country and abroad.
Because a communication is presented by some unknown
practitioner from a small city or town, it often does not
attract the attention it deserves. A prominent professor
from a metropolitan school presents his paper before the
learned members of the association of his specialty, and
his views are widely read and generally accepted. The
unknown doctor from a small town and the young man
at the beginning of his career have no such opportuni-
ties and their contributions are frequently overlooked,
though often as important as those of the member of the
learned society. Citizens of a republic should be spe-
cially ready to give all men a fair hearing. In arranging
the programs of the sections the otflcers have recognized
the necessity of admitting a sufficient number of papers
from men prominent in the profession to ensure the suc-
cess of the meeting, but meritorious articles have never
been denied a place, no matter what their source. In
this way many excellent papers have been brought
before the profession that would otherwise have passed
unnoticed, and the section has thus rendered an im-
portant service to surgery. It may be contended that
the best plan would be to fill the programs with papers
by men of recognized high standing, as would be per-
fectly possible, but it should be remembered that many
eminent surgeons, from the very fact of their reputation,
have less time for original thought and work than others
less widely known ; moreover, the experience of certain
men in the districts remote from the great medical
centers may be wider along some lines than that of
surgeons of metropolitan hospitals. Among those
Americans who have worked in small out of the way
towns, rendering most important contributions to sur-
gery, may be mentioned Marion Sims, who did his most
important early work in a small town in Alabama ;
Ephraim McDowell, who not only performed his first
ovariotomy, but always practised, in a small town in
Kentucky, and William Beaumont, who, at a remote
military post, made his famous studies on gastric diges-
tion. Examples of this kind might readily be multi-
plied. There are in our small towns, as well as in our
great medical centers, men of great originality and first-
rate ability, whose contributions will always be worthy
of attention. The Surgical Section of the American
Metlical Association is specially helpful in giving these
members of the profession an opportunity to present
their work. Many of our best-known surgeons, some of
whom have not been in the habit of attending the sec-
tion meetings regularly, expressed gratification at the
high character of the papers presented at the recent
meeting.
A Method of Treating Certain Conditions of the
Joints.— Swan 1 reports a number of cases of swelling of the
kneejoint from tuberculosis and other causes in which entire
cure with perfect use of the joint was effected by the application
of pure carbolic acid to the synovial membrane. Good access
to the joint may be obtained by an incision convex backward,
reaching from the inner edge of the ligamentum patellse to a
point, in the adult, about two inches above the base of the
patella. In closing the wound, three layers require adaptation
and suturing, the synovial membrane, a layer aponeurotic
1 Medical Press and Circular, January 29, 1902.
below and aponeurotic and muscular above, and the skin.
Tuberculous infiltration of the bursa beneath the ligamentum
patellw is often overlooked. This can be removed through an
incision along tlie inne margin of the ligament, freeing the
latter from its attachment, slipping it to the external side of the
growth and then using blunt knife and scissors. [ii.M.]
Preparation of Patients for and Their Treatment
After Laparotomy.— F. 11. Wiggin' describes at length the
usual methods of preparing patients before and after abdominal
operations. He deems it best in all cases requiring abdominal
section to keep the patient in bed at least one week prior to
operating. During this period massage may be employed to
advantage, and so far as compatible with a healthy mental con-
dition, visitors and friends should be excluded. In the prepa-
ration of the skin covering the abdomen, after tlioroughly
cleansing it, he advocates the application of a soap poultice for
four hours over the site of the proposed incision, then replacing
it by a compress moistened in a 1% formalin solution. This
compress is allowed to remain until the patient is placed on the
operating table, [f.c.h.]
A Contribution to the Study of Malignant Endocar-
ditis.—F. J. Poynton and Alexander Paine.^ The authors,
while investigating the pathogenesis of rlieumatic fever, were
led to the study of certain cases of malignant endocarditis asso-
ciated with a history of acute rheumatism, and in which, dur-
ing the course of the disease, there were often active manifesta-
tions of rheumatic fever. They collected .30 such cases from
postmortem records, all with a previous history of rheumatic
fever, and in no case was there abscess formation. Tlie present
research leads to the conclusion that there is a group of cases
of malignant endocarditis rheumatic in origin. The chief
reasons upon which they Ijase their assertion may be summar-
ized thus : First, the probability that some of these cases were
rheumatic was in accord \vith clinical experience. The cases
recorded in the paper bear out this statement. Second, the
probability that some of these cases were rheumatic was in
accord with pathologic experience. The minute investigation
of the morbid anatomy of the clinical cases recorded support
this; and, third, that some of these oases were rheumatic was
in their opinion in accord with bacteriologlc experience, for the
authors have shown that a diplococcus is a cause of rheumatic
fever, and a diplococcus can be isolated from these cases of
malignant endocarditis whlcli will reproduce the disease in
rabbits, and can be studied in pure culture. Tliese organisms
resemble one another so closely as to lead to the conclusion that
they are identical. Diplococcus rheumaticiis when passed
through a series of rabbits will produce malignant endocarditis
Indistinguishable from that produced by the diplococcus
Isolated from certain cases of malignant endocarditis in man.
By these diplocooci every grade of valvulitis, from simple to
malignant and vice versa, can be produced, as the microscopic
specimens bear witness. The clinical cases, six in number,
exemplify the characteristic type of the disease under consider-
ation, and also the gradations between this type and rheumatic
fever, [c.a.o.]
Removal of Prostatic Adenomas. — Thompson ' reports
a suprapubic removal of adenomatous growths which caused
an enlarged and obstructing prostate. The patient was 66
years old and had led a catheter life for several years, con-
stantly growing worse. Once wltliin the bladder the lateral
lobes of the prostate were found much enlarged, but there was
no " cross-bar." The mucous membrane over each lobe was
incised and with the finger peeled back. Then the finger
was able to enucleate the adenoma on each side. Hemorrhage
was controlled by hot solution and temporary pressure. The
wound was closed with tubular drainage, the patient being
allowed to sit up after four weeks. Recovery was complete,
though slow. The author quotes many opinions as to the pos-
sibility of removing the entire prostate. What is usually
removed and that which relieves the patient when removed
consists of an adenomatous growth in each lateral lobe, together
with the " cross-bar " when present, [a.b.c]
Congenital Displacement of the Hip-Joints. — Noble
■ The Vermont Medical Journal, May 25, 1902.
2 The Medical Press and Circular, May 7, 1902.
' British Medical Journal, May 81.
July 5, 1902]
THE WOELD'S LATEST LITERATURE
[AXEBICAK MkDIOINE 35
Smith' briefly discusses various operations, and recommends
extension by means of a long Liston splint. Tlie perineal
baud draws tlie pelvis upward, and tlie limb is drawn down
and fixed to the splint in the ordinary way. It may tal<e
several weeks before the bead of the bone reaches the natural
position. Later weights with a pulley may be substituted for
the splint, or used alternately. If the neck is so twisted that
the feet point upward when the head is in normal position
osteotomy of the femur must be done. Lateral pressure to the
hip by a metal band may be applied, but with great caution in
the case of girls, as the pelvic cavity may be compressed. If
reduction is iuipeded by contraction of muscles the latter may
have to be divided or stretched. In a few months the tendency
of the joint to rise is lessened. Kecumbency may be necessary
for six or eight months, with crutches and a raised sole on the
sound leg for 18 or 24 months. If both joints are affected a tri-
cycle may be used for getting about. A fold of capsule between
the head and acetabulum causes a tendency to relapse, but firm
lateral pressure will probably overcome this, [h.m.]
A Case of Perforated Gastric Ulcer. — Hamann ' reports
tlie case of a male of 22, who at first appeared to be suffering
from Reichinann's disease, or spasm of the pylorus, and a diag-
nosis of gastric ulcer had not been made. The patient had
steadily improved under treatment. During the course of what
appeared to be a marked amelioration of all symptoms there
was a sudden attack of severe pain in the epigastrium and in
the base of the chest anteriorly attended with faintness and
vomiting. The ejected material did not contain blood. The
pain came on 4J hours after the last meal, and did not immedi-
ately follow an injury, strain, or the ingestion of food or drink.
Perforation of a gastric ulcer was diagnosed, and operation was
performed 5J hours subsequent to rupture. The perforation
proved to be a round opening 1 of an inch in diameter on the
anterior wall of the stomach, about 1 inch from the pylorus.
Tlie edges of the opening were smooth, and the surrounding
tissue was dense and fibrous in character. There were no
recognizable gastric contents in the peritoneal cavity. The
patient made a good recovery, no doubt largely attributable
to the early diagnosis and prompt operation, and to the fact that
little, if anj', of the gastric contents had escaped Into the peri-
toneal cavity. Ff.c.h.]
Surgical Treatment of Arteriovenous Aneurysm. —
Treves ' states that this form of aneurysm is not now so fre-
quently found as in the days when lileeding was common and
the brachial artery was frequently wounded in bleeding from
the [median basilic vein, but with the advent of the modern
small bullet used in warfare it is becoming more common.
Prognosis in both this and varicose aneurysm is unfavorable
unless there is resort to surgical measures. Tlie only operative
measure which is to lie commended is ligature of the vessel or
vessels at the wounded spot— the ideal procedure is that in
which both artery and vein are ligatured above and below the
point of a1:)normal communication; this, however, cannot
always be done. The author reports four cases of arteriovenous
aneurysm. In each instance the wound was inflicted by a
bullet in the South African war. In one the superficial
femoral vessels were involved; in a second, the lesion was at
the bifurcation of the popliteal artery ; in a third, the bifurca-
tion of the common femoral was involved ; and in a fourth, a
branch of the internal carotid had been injured. Uecovery
followed in eacli case, [a.b.c]
Double Resection of the Intestine for Injury.— R.
I^ane Joynt ' reports the case of a boy, 10 years of age, who was
struck in the alidomen by the shaft of a wagon. He opened the
abdomen a few hours subsequently and found an enormous
quantity of blood and discolored liquid in theabdominal cavity.
A portion of the jejunum was torn away from its mesentery
for a distance of over 18 inches, the rent in the mesentery
extending to its root. Immediately above the rent was another
tear extending through both the bowel and mesentery, and the
upper torn end of the bowel had a hole jiunched through It
about one inch above its free end. Part of the mesentery between
> Medical Press and Circular, January Mi, 1(K)2.
« The CUveland .Medical .rmiriial. April, 1902.
"British Medical .loiirnal, May 10, 1908.
<The Medical I'ress, May 21, 11(02.
the two rents was removed, together w^ith the affected bowel, the
ends of the latter being united by means of a Murphy button.
The total length of bowel removed measured 24 inches, three
inches being transverse colon, the remainder the jejunal portion.
The Murphy button was passed on the seventeenth day, and
the patient made a steady recovery, [f.c.h.]
Perforated Gastric Ulcer.— R. F. Tobin ' refers to four
cases of perforated gastric ulcer in anemic girls between the
ages of 20 and 30. All had previously complained of gastric
trouble and three of the four were domestic servants. In all
the ulcer was situated an inch or two in front of the esophageal
opening, in all there was a similarity of symptoms, pain in the
left epigastric region and pain above the left clavicle, scanty
vomiting and retching, rigid abdomen, absence of abdominal
respiration, absence or diminution of liver dulness and shock.
In all there was not only recovery, but according to the author
a more rapid return to good condition than would probably have
been the case had that catastrophe been averted by rest and
medical treatment. Perforation in this locality is very frequent
and is explained as follows : It occurs in the area of tlie stom-
ach that extends forward from the esophagus underneath the
liver, an area that would be pressed upon by the liver were
that organ unduly depressed or the stomach unduly drawn up.
Owing to the laxity of tissue in the usual sufferers from this
disease and to the fact that they are on their feet all day long,
the liver is not well braced up. Moreover, the stomach, owing
to its fixity to the diaphragm, is being continually drawn
through a long range of movement as the anemic sufterer goes
about her work. The author calls attention to the very early
disappearance of liver dulness in the mesial line and to the
greatly increased shock by movement. The surgeon should
close the perforation at once. [c.A.o.]
Hypertrophy of the Prostate.— Smyth » reports the
removal of an enlarged prostate after the suprapubic method of
Preyer. The patient was a man of 60 years who had suffered
much obstruction of llio urine for some years. Once within
the bladder he buttoned-holed the mucous membrane over each
enlarged lobe and enucleated the growths. He cautions against
permitting the patient to leave the table until all hemorrhage is
controlled, [a.b.c]
Cancer of the Breast.— Thomas Bryant' grivesan analysis
of 46 cases which have been operated upon and survived
the operation from .'> to 32 years. His routine operation
is to remove the entire diseased gland with the skin and
fat over the affected area; when the axillary glands are en-
larged to dissect out the axilla and subpectoral spaces, and in
every case for examination purposes to cut into the axilla and
remove glands or lymphoid tissue which appears to be suspic-
ious, but otherwise not to dissect it out, the incision in the
axilla skirting the border of the pectoral muscle. The wound
is invariably drained through the axilla for the first two or
three days. The pectoral muscle is dissected clean, but not
removed, unless involved in the malignant infiltration. In
cases of recurrence unfavorable for operation, unless the
removal of the ovaries can bo shown in the future to be suc-
cessful, the x-rays should be employed, for the benefit which
has been derived by this treatment when judiciously applied
by men of understanding has been very great. In order to
make the rays effective the treatment must be continued for
several months after it has seemed to be beneficial ; a three-
months' course, with about three applications a week, appears to
be the shortest time from which any permanent good is to be
expected, and this treatment is full of hope, [f.o.h.]
Jjlnen Thread for lilgatures and Sutures.— Barker* has
used linen thread, such as is supplied for sewing machines, as a
material for sutures and ligatures for the past two years with
great satisfaction. The advantages of this material are that It
can be procured everywhere in the world where sewing
machines are sold. It Is specially spun so an to travel evenly
through the eye of the sewing machine needle, it Is very cheap,
can bo readily sterilized by boiling, is very strong, ties a good
knot and is entirely nonlrrltalive. [m.b.t.]
1 Medical Tn-HH and (Jlrculnr, May 7. W02.
'Britlsli .Medlrnl .Intirnnl, May .11.
»Tlie .Medical I'n'KN, May 21, IlKK.
< Lancet, .May it, mU.
Akkbioait Mestcikk]
THE WORLD'S LATEST LITERATURE
[July 5, 1902
GYNECOIiOGY AND OBSTETRICS
WiLMER KRU8EN FBANK C. HAHMOND
Adenoinyoiiia of the Uterus. — In this department
we have repeatedly called attention to the importance and
difficulty of early diagnosis of uterine carcinoma, and
emphasized the necessity for more careful clinical study of
the symptoms of this insidious disease. Hemorrhage
from the genital tract after the menopause is almost
invariably indicative of incipient malignant disease and
demands careful investigation. The recognition of
malignant disease of the body of the uterus presents
unusual difficulty ; it is only by a dilation and intra-
uterine exploration that we can be certain of our diag-
nosis, and often the clinical examination must be fol-
lowed by a microscopic test. We have frequently seen
advanced adenocarcinoma of the body of the uterus
without any change in the size or symmetry of the
organ, or any evidence apparent on the ordinary biman-
ual examination. And we have recently seen one case
in which the presence of a small adenomyoma presented
the same perplexing problem in differential diagnosis.
One of the most interesting additions to our gynecologic
pathology during the past year was a contribution to the
Philadelphia Obstetric Society by Dr. T. S. CuUen, of
Baltimore, who ranks preeminent as an authority upon
pathology of the female generative organs. In the
examination of over 700 cases of uterine myoma at the
Johns Hopkins Hospital, he found 19 specimens of
adenomyoma. Many of these were detected in the
early stages, and hence the very beginnings could be fol-
lowed. CuUen divides these growths into three main
groups: (1) Those in which the uterus preserves a
relatively normal contour; (2) subperitoneal or intra-
ligamentary adenomyomas ; (3) submucous adenomy-
omas. In discussing the origin of these neoplasms, he
observed that formerly the majority of writers thought
that they were due to remnants of the Wolffian duct,
but now the consensus of opinion is that the greater num-
ber at least are derived either from the uterine mucosa
or from a portion of Mueller's duct. In over half of his
cases the uterine mucosa could be seen extending by
continuity into the adenomyoma, demonstrating beyond
peradventure their origin from the mucosa. In the
second place, in no other part of the body, either in the
embryo or in the adult, do we find glands resembling
uterine glands and surrounded by characteristic stroma,
and furthermore, the Wolffian body contains no struct-
ures that can be mistaken for uterine glands. The
uterine mucosa is, as Sanger taught his students, a defi-
nite organ and has a well defined function to fulfil.
This function is seen in practically every case of adeno-
myoma.
Adenomyomas are usually detected during the child-
bearing period, and give rise to menstrual disturbance
varying from a few months to 10 years or more. The
periods are usually more profuse and painful, but
between periods there is, as a rule, little or no discharge.
In 15 cases reported by Cullen, the patients were married,
and of this number nine had had children. In the first
group the uterus may be normal in size, but as a rule is
two or three times as large as normal. It is globular in
form, and often slightly irregular in outline due to small
discrete myomas which are often present. The append-
ages show a peculiar tendency to become adherent, and
the uterus is often fixed by dense bands of inflammatory
tissue. A sound introduced into the uterus will give no
clue, and curettings will invariably yield nothing but
normal mucosa. We thus see that while we have
some clue from the slow increase in size of the organ and
the profuse menstrual period, yet no diagnosis can be
made untd the organ is removed. The subperitoneal
and intrahgamentary adenomyomas cannot possibly be
differentiated from ordinary myomas, sarcomas, or
obscure cysts until removal, and the submucous variety
offers no points of clinical variation from submucous
myomas. The prognosis in these cases is very favorable,
provided the uterus is removed before pressure symp-
toms have developed. A case of adenocarcinoma
developing in part from the glands of an adenomyoma
was reported and an illustration given of a squamous-
cell carcinoma of the cervix associated with an early
adenomyoma of the l>ody.
It is particularly between the first group of cases and
uterine carcinoma of the body of the uterus that there
will be difficulty in the diagnosis, and we use this contri-
bution as an additional argument in favor of more fre-
quent vaginal examinations during the fourth decade,
and a more rigid determination to know the cause for all
extraordinary bleeding or menstrual disturbance, even
if in doubtful cases it requires intrauterine and micro-
scopic investigation.
1. — Dysmenorrhea. — According to Herman ' there are two
kinds of dysmenorrhea— that produced by the physiologic con-
gestion of the pelvic organs which precedes menstruation and
the other caused by the contractions of the uterus which should
expel its contents. One morbid condition which produces
abnormal congestion of the uterus and consequent pain is ret-
roversion or retroflexion, but this is not true dysmenorrhea,
which is due to uterine contractions accompanying menstrua-
tion. These pains are spasmodic and sometimes ascribed to a
narrow os, or some obstruction in the canal ; but the disease is
usually a nervous one and its natural remedy is pregnancy.
The severity of the pain in dysmenorrhea depends not solely
on its local cause, but also on the sensitiveness of the patient.
The best drugs for the relief of uterine colic are antipyrin and
phenacetin. Sometimes guaiacum gives relief. The local treat-
ment of spasmodic dysmenorrhea is dilation of the cervix,
which is best done by the passage of bougies. If all other treat-
ment fails and the dysmenorrhea is so severe as to wreck the
patient's life, it can be cured by removing the ovaries, [w.k.]
Subperitoneal Hysterectomy. — Moullin 2 having secured
the ovarian arteries with a double ligature, cuts between them
and extends the incision as far down as need be through that
portion of the broad ligament which is free from vessels, and
then carries it across the face of the tumor to the opposite side
above the bladder, which is stripped down out of the way. The
uterine artery is ligated as close as possible to the cervix and a
clamp placed over the ligature. The amputation should be at
the lowest possible level, the artery being cut below the point
at which it divides. There is no necessity to strip the peri-
toneum from the back of the uterus in order to make a posterior
flap. After suturing the stump with chromicized catgut he
draws the anterior flap and the bladder well over its face and
fastens it with a continuous suture from one side of the pelvis
to the other. The strength of the parietes depends entirely on
the fascia. There must be accurate adaptation and firm union.
The aponeurosis splits to form the sheath of the rectus on each
side. In the lower two-thirds the strongest layer lies in front,
the upper third behind the muscle. The former is separated
from the peritoneum by cellular tissue and fat, the latter is
closely applied. In the lower part he sutures peritoneum,
fascia and skin separately ; above he makes only two layers of
sutures. In hernia the edges of the aponeurosis must be
sought by carrying the incision above and below, the scar tissue
removed and the edges approximated, [h.m.]
Wlaiev's Serum In Malignant Tumors.— Riohelot ' re-
ported at the Societe de Chirurgie, Paris, April 16, the surpris-
ingly favorable results which he had secured from the adminis-
tration of Wlaiev's serum in a case of vegetant tumor of the
ovary, which after a simple exploratory laparatomy performed ■
by Doyen had proved inoperable. Such improvement has
occurred that he hopes soon to operate. [c.s.D.]
The Avoidance of Childbed Fever.— Hofmeier * con-
cludes his careful consideration of this subject, reviews the
opinions of other authors, quotes hospital statistics and reports
some cases, from all of which it seems that the subject of puer-
> British Medical Journal, May 17, 1902. ^
2 Medical Press and Circular, January 29, 1902.
' La Semaine Mfidicale, April 23, 1902.
< Munchener medlclnische Wochenschrlft, May 13, 1902.
July 5, 1902]
THE WORLD'S LATEST LITERATURE
[AXERICAU HKDICINB 37
peral fever is still full of difficulties and the problem of its pre-
vention is by no means solved, [w.k.]
Analysis of Some Recent Gynecologic Methods.— Mo-
Naughton- Jones ' maintains that ideal asepsis may be secured
for operating and describes the technic. When septic complica-
tions are present he advocates resection of the abdominal wound
after free cauterization with Paquelin. The reaction against
drainage is perhaps too strong. In cases of retrodeviation he
prefers the Alexander-Adams operation when the uterus is
freely mobile, the Olshausen when there are adnexal complica-
tions. Of the operations which include the uterus he has most
frequently performed Kelly's ventrosuspension and it has
never interfered with pregnancy or delivery and the sutures
have caused no trouble. Ferrier's is the best operation after
the childbearing period, when the uterus is enlarged and
heavy. He emphasizes the need for complete hemostasis both
arterial and venous in the Alexander-Adams operation. With
some exceptions he prefers the abdominal to the vaginal route
in hysterectomy, myomectomy and adnexal disease. In con-
servative operations on the ovaries and tubes one of the greatest
advances in gynecology has been made, [h.m.]
A Case of Inversion of the Uterus.— Hoysted ' was
called in haste by a midwife to see a woman in a state of col-
lapse, and found on examination a complete inversion of the
uterus. The midwife stated that she was pressing hard upon
the abdomen to " push out the afterbirth, when it all came out."
He quickly peeled oflf the placenta from the fundus, then
administering chloroform and inserting the finger of the left
hand in theuninverted part of the vagina, by gentle pressure
upward and forward, at the same time compressing the mass
slightly with the right hand, he was able to tuck in a fold of its
posterior surface through the cervix. Continuing this process,
the whole slipped through his hands into the vulva, the feeling
being that of an indiarubber ball righting itself after being
turned inside out. On abdominal pressure the fundus uteri
was felt in the hypogastrium, and contraction took place almost
immediately ; after this there was little or no hemorrhage, and
the woman was restored from an apparently desperate condi-
tion by the usual methods and made a satisfactory recovery.
[W.K.]
TREATMENT
Solomon Solis Cohen
H. C. Wood, Jr. L. F. Applbman
Treatment of Chronic Pulmonary Paralysis (Vagus
Neurosis). — G. Zuelzer (Therapeutische Monntshefte, Vol. xvi.
No. 2, 1902, p. iXi) states that the theory that bronchial asthma
is dependent on spasm of the bronchial muscles, induced
by irritation of the vagus, has been confirmed experimentally,
and good results have been obtained by giving atropin in
this condition ; but acute emphysema occurs also as a., con-
comitant of the tachycardia accompanying socalled .stenocar-
diac attacks. In this condition the latter symptom is to be
attributed to irritation of the vagus, while the former is due to
paralysis of the nerve. As, however, some of the nerve fibers
may be irritated while others are paralyzed, it was argued that
emphysema and slowing of the pulse might also occur in con-
junction, a theory that Zuelzer was able to confirm by observa-
tion in a number of cases. He found a diminished area of car-
diacs dulness, retardation of the pulse, which was quite full, to
60 or 40 beats, and displacement of the pulmonary borders, to
the right and in front as far as the eighth rib, and to the left as
far as the fifth rib. The provisional diagnosis of vagus neurosis
fouud support in the tenderness of the nerve trunk, especially
on the left side, when the head was rotated, and in the good
eflects obtained with atropin. A course of dally injections of
0.001 gram of atropin, continued for from eight to ten days,
usually suffices to bring about permanent improvement in the
symptoms. Nervous subjects necessitate greater care in the
dosage, [r.m.o.]
Therapeutics of Asthma. — There are several varieties of
asthma, requiring different treatment, but they all agree in
' Medical Press and Circular, January 22, 1902.
« British Medical Journal, May 17, 19*2.
some features, so that they can be classed together therapeuti-
cally as well as clinically. Many cases depend on reflex irrita-
tion, often from the nose (polypi, swelling of the turbinates,
etc.); but it cannot be excluded that such reflexes may also arise
elsewhere, especially from the walls of the bronchioles them-
selves. They lead to spasmodic narrowing of the lumen of the
bronchioles by a hypersecretion of mucus, by congestion or
swelling of the mucous membrane, or by tonic spasm of the
bronchial musculature. Possibly all three of these factors may
concur.
Considering the condition as a reflex, we may attack it
therapeutically at the afferent or efferent end of the arch, or at
the center. The first— removal of the cause— is the most
rational method. When gross changes, especially of the nose
or pharynx, can be demonstrated, these should be removed.
When the condition is one of increased susceptibility to un-
avoidable irritants (as to pollen in hay-fever), this may be low-
ered by cocain, or mechanic protection afforded by ointment.
At the other end of the reflex arc a number of drugs meeting
different indications may be employed.
1. lodida act simply by rendering the secretion less tena-
cious, so that it may be expectorated. The same result could
be reached by any other salt, and especially by alkalies, could
they be brought to the site of the process; but with them this
cannot be done nearly as efficiently as with iodids, since the
latter are readily absorbed unchanged, and penetrate into all
parts of the organism. The dose for this purpose is 1 to 3 gm.
(20 to 40 grs.) per day.
2. Nitrites. — These, by lowering the general blood pres-
sure tend to diminish the congestion and secretion. Charlse
potassii nitratis act in the .same way, and the empyreu-
matic products contained in the smoke act like the next group.
3. Atropin (stramonium ; also lobelia, nicotin and empyreu-
matic products in smoke). These act in several ways, by : (a)
Relieving the muscular spasm through paralysis of the bron-
chial muscles ; (6) lessening the secretion; (c) heightening the
reflex activity of the respiratory center; (d) conceivably also
by diminishing the sensibility of the bronchial mucous mem-
brane, when the beginning of the afferent path is situated here.
The usefulness of the different members of the series is not the
same in all cases. This need scarcely cause surprise, consider-
ing the neurotic nature of the affection.
4. Morphin acts : (a) By lessening secretion ; (6) by lessen-
ing irritability of the center; (c) by diminishing the discom-
fort of the patient.
Centrally we may achieve good results by two diametrically
opposed sets of remedies :
1. By depressants, through (a) lowering the reflex excita-
bility of the centers concerned in the production of the attack ;
(6) by narcotics, through diminishing the discomfort of the
patient. The same remedies meet indications a and 6: Mor-
phin, codein, alcohol, chloroform, KBr, HCN.
2. By stimulants, through increa.sing the activity of the
respiratory center when it has become exhausted through the
violence of the attack. Among stimulants, caffoin, strychnin,
and atropin stand foremost for this purpose. The same
result may be achieved through counterirritation (ammonia,
sinapism).
Finally, much of the discomfort of the patient may be
removed symptomatically, by the inhalation of oxygen or
compressed air.— Torald SoUmann's " Pharmacology."
The Medical Treatment of Intestinal Putreftwjtion.—
Singer {Therapeutinche Monntshefte, Vol. xv. No. 0, 1901. p. 441)
reviews various methods of disinfecting the intestinal tract.
Enteroclysis materially diminishes the number of bacteria.
Chemic dlslnfectfiiits arc less satisfactory than careful regula-
tion of the diet, which should consist chiefly of milk and vege-
tables, with a minimum of nitrogenous food. The good reaulta
reported by many clinicians, especially In typhoidal affoctious.
are to he attributed more to the antipyretic moasureH employed
than to the intestinal .antiseptics. The physiologic means of com-
bating intestinal putrefaction Is that employed by nature,
namely, purgation ; here the olTlcacy of any ronio<ly doponds,
in addition to Its antiseptic properties, on Its power of influ-
encing peristalsis, and drugs, like opium, that Inhibit porlstalHlN
are accordingly countorindlcat6<l. Another Important factor is
38 AjiBSiOAir Meticinzi
THE WORLD'S LATEST LITERATURE
[JOLY 5, 1802
the flHshitiK of the lymph channels ; by this means the organic
and inorganic poiwons are H\yept into the laowel and their
absorption is prevented. Calomel acts entirely by virtue of its
laxative effect, as it is in no sense a direct antiseptic; it has,
however, the advantage of not overloading the digestive organs.
Lactic acid stimnlatos peristalsis and, as it Is the end product of
many bacteria, inhibits their growth; it also diminishes the
amount of indican and sulfates in the urine. Among intestinal
antiseptics that are mentioned favorably are saccharin, salol,
salicylic acid, resorcin and the antipyretic coal-tar derivatives.
[R.M.O.]
Treatment of Buccal Ijeukoplasla. — Paul Combalat
(Journal de.i Praticiens, .June 1.5, 1901) cautions against the use
of caustics in the treatment of leukoplasia. He has also seen in
syphilitic leukoplasia no appreciable result follow the use of
the iodids and mercury, and on the contrary, believes they may
hasten the formation of a cancer. He advises that all arthri-
tic manifestations should receive appropriate treatment.
Smoking should be absolutely prohibited, as tobacco smoke is
a most violent irritant to the diseased area. Alcohol, wines,
highly seasoned foods, and very hot or very cold substances
should be prohibited for the same reason. The condition of the
teeth should receive careful attention ; the patient should clean
them regularly after eich meal. Brocq directs that the mouth
be washed out frequently with a weak solution of boric acid.
Certain patients complain of considerable dryness of the mouth,
particularly in the morning or evening. This may be relieved
by the application of vaselin to which has been added boric
acid, ifo of balsam of Peru, or 1% of aristol. When leukoplasia
is torpid, salicylic acid is the best local application ; 40 drops of
a Wfc alcoholic solution of salicylic acid should be added to a
glass of water and the mouth bathed five or six times a day.
For fissures or excoriations, a weak solution of chromic acid
may be applied with an applicator, after which the patient
should rinse the mouth with plain water. If no change occurs
under this treatment, the diseased area should be removed
either with a sharp curet or with thegalvano or thermocautery.
Under these circumstances it is necessary that the tissues be
destroyed deeply and on one patch at a time, [l.f.a.]
Bedbaths.— KrSnig and Cramer (Therapeutische Monat-
shefle, Vol. xvi, No. 2, 1902, p. 97). In order to spare the typhoid
patient the distress of a cold balh, Kronig resorts to a cold wet
rub in bed and to sprinkling with 20 liters of water from a
watering pot, the bed being protected with a rubber sheet.
The temperature of the water is lowered within ten minutes
from 28° C. (83° F.) to 1.5° C. (56° F.). A similar procedure has
been proposed by Cramer for use in private practice. It
requires but 4 liters of water. In the bath proper, according to
his method, the abdomen is completely covered with water, and
it Is possible also to give a full bath or a permanent bath. [The
method of sprinkling in typhoid fever has been in use for some
time in the editor's hospital service. As an antipyretic
procedure it may be said to rival tubbing, while at the same ti me
It is better borne by most patients. It is particularly well adapted
for private practice, as it requires no bathtub and the patient
does not have to be lifted bodily from his bed. The method is
as follows : The head of the bed is raised about a foot from the
floor, three ordinary pine boards as long as the bed is wide are
Introduced crosswise under the mattress to keep it from sag-
ging and to insure a uniform flow toward the foot of the bed.
The mattress is covered with a large rubber sheet on which are
placed a pillow and a linen sheet. The patient is stripped as
for tubbing and sprinkled with water of the desired tempera-
ture either from a watering-pot or, more conveniently, from a
tube with a rose nozzle attached to an irrigating reservoir. The
water as it flows off is received in a pail placed at the foot of
the bed, and can be used again and again, the temperature being
maintained, if necessary, by the addition of ice. The water
should be poured from not too great a height and chiefly on the
abdomen and lower extremities, as the patient finds this less
distressing and the effect is equally good. After the sprinkling
the patient is wrapped in a dry sheet, covered with a blanket
and rubbed until reaction has set in.] [r.m.o.]
Treatment of Tracheobroiichltlc Adenopathy in Chil-
dren.—The Journal lies Pratieietis, August -3, 1902, states that the
treatment of adenopathy in children must be prophylactic,
pathogenic and symptomatic. The prophylactic treatment
should be the same as for tuberculosis. If adenopathy is estab-
lished, efforts must be matle to diminish it, or at least to hinder
its increase. Two means are employed for this purpose : revul-
sives and general treatment. The best revulsives are tincture
of iodin applied locally, flyblisters, and the actual cautery
applied to the interscapnlothoracic region. Comby prescribes
friction with —
Pota.ssium iodid, ] of each J dram
Extract of conium, J
Benzoinated lard 7J drams
and internally the following :
Potassium iodid 75 grains
Syrup of orange-peel 2 ounces
Distilled water 4 ounces
One tablespoonful in the morning,
or.
Potassium iodid 2J drams
Syrup of quinin 7 ounces
One teaspoonful morning and evening.
The usual remedies for tuberculosis may be given. In
attacks resembling whooping-cough or asthma, potassium
bromid is indicated as follows :
Potassium bromid 75 grains
Syrup of orange-peel 2 ounces
Distilled water 4 ounces
or,
Antipyrin 75 grains
Linden water 2 ounces
Syrup of belladonna, I , ^^ „ ounces
Syrup of maidenhair, | °' ^^'^ ^ ounces
Three teaspoonfuls daily,
or,
Tincture of belladonna, 1 of each 5 to 20 drops,
Tincture of conium, J according to age.
Tincture of aconite . . 1 to 10 drops, according to age.
Syrup of orange-flowers 2 ounces
Teaspoonful doses as needed.
Inhalations of ethyl iodid have also been employed. Weil
recommends inhalations of pyridin, allowing one dram in a
room for 20 or 30 minutes, three times a day. If threatened
suffocation should cause crises of laryngismus, ipecac is indi-
cated to relieve the spasm. Gu6neau recommends searwater
baths, or baths according to the following :
Sodium iodid 5 drams
Sodium carbonate 4 ounces
Sea salt 2i pounds
For one bath. — [l.f.a.]
A Case of Rectal Stricture Treated by Electrolysis. —
White {Advanced TherapeiUicn, Vol. xx. No. 1, 1902, p. 9) re-
ports a case in an anemic woman of 37 years, who suffered from
intestinal dyspepsia, anteflexion of the uterus and painful men-
struation. The stricture was 3J inches from the anus. The
electrodes used in the treatment consisted of the copper and
zinc olive-shaped bulb electrodes, and a large surface pad of 1.50
cm. diameter was used. Treatment was begun with a No. 50
copper olive rectal electrode as the cathode, with a pad at the
back for the anode, and a continuous current of 35 volts, 15 ma.,
taking 15 minutes to pass through the stricture. The size of the
electrode was gradually increased, in succeeding applications,
up to No. 78. The treatment was kept up for 10 months with au
interruption of two months, the frequency of applications
varying with the severity of the reaction. Toward the end of the
electric course, gauze and ointment were used between the
electric applications. A little over 11 months alter the begin-
ning of the treatment the patient announced that she had had
her first movement without pain. Two months later the stric-
ture had enlarged sutficiently to pass a No. 88 bulb, and the
mucous membrane was in a healthy state, [u.m.o.]
Mucous Disease of the Intestines. — Hawkins (Edinburgh
Medical Journal, November, 1901 ; Monthly Cyclopedia of Prac-
tical Medicine, Vol. iv. No. 12, N. S. p. 469) advises that the food
be more solid than liquid and that it be given in small quanti-
ties with an interval of three or four hours between meals.
Cold baths should be allowed only in the cylindric and tubular
types of the disease, in which exercise is also beneficial. Dur-
ing the passage of the tubes rhubarb and sodium bicarbonate
July 5, 1902]
THE PUBLIC SEEVICE
iAkbkioak HEDtcim 8d
may be given with advantage. Calomel in small doses appears
to render the feces less 'offensive. Glycerin suppositories or
even enemas may be necessary. Abdominal pain may he alle-
viated by means of hot compresses medicated with opium or
cannabis indica, and the use of belladonna internally. Later in
the disease, potassium bromid with iron is useful in some cases ;
others do better on quinin, arsenic and strychnin. In the hem-
orrhagic type, lead and opium pills are recommended.
[R.M.G.]
Paraldehyd. — Rapiteau (Journal des Pratidens, August 17,
1901) after a study of the action of paraldehyd finds that it pro-
duces sleep by acting successively on the brain, spinal cord and
medulla oblongata. In animals, Dujardin-Beaumetz obtained
a deep sleep lasting 24 hours, which was not accompanied by
anesthesia nor analgesia, and he was always able to awake the
animal by pinching. Usually the sleep produced by paralde-
hyd in man is calm, free from unpleasant dreams and restless-
ness, and is followed by an agreeable awakening. Sometimes,
however, cephalalgia has been observed. Mercam observed a
fleeting depressant effect on the nervous system in some indi-
viduals, manifested in a slight drooping of the eyelids, unsteadi-
ness in gait, and by a diminution in muscular force. In some
cases general hyperesthesia resulted from the injection of
paraldehyd ; in others there was a notable diminution in the
tactile sensibility. Paraldehyd has no unfavorable action on
the stomach or intestines, provided it is not given in too large a
dose and that there is no idiosyncrasy to the drug. Slight
decrease in the blood-pressure and temperature has been
observed. It is eliminated by the lungs and imparts a disagree-
able odor to the breath when taken in doses of from 45 to 60
grains. The usual dose is from 30 to 60 grains. The drug is
indicated in all cases of insomnia, especially in the different
forms of mania. It is very valuable in delirium tremens and
in alcoholic insomnia. It is an antidote to strychnin and all
convulsant poisons. Grood results have followed its use in
tetanus, eclampsia, and in morphinomania. Pouchet employs
the following formulas :
Paraldehyd crystals 5 drams
Tincture of vanilla IJ drams
Alcohol, 90% 3J ounces
Simple syrup 2J ounces
Each dessertspoonful of this solution contains 22 grains of
paraldehyd ; it must be given well diluted in order to avoid
gastric irritation.
Paraldehyd crystals 2i drams
Alcohol, 00% I „# ™ u c J
Boiled ciisti lied water | of each 5 drams
One teaspoonful contains 15 grains of paraldehyd and must
be given well diluted.
Paraldehyd crystals 2i drams
Tincture of vanilla 4 dram
Alcohol, 90'/, Ij ounces
Simple syrup 2 ounces
Distilled water 1 ounce.
Each dessertsi)Oonful contains 15 grains of paraldehyd.
Paraldehyd crystals 2} drams
Syrup of gooseberry 1 J ounces
Distilled water of lime-tree 4 ounces
Tincture of vanilla IB minims
One tablespoonful contains 15 grains of paraldehyd.
Paraldehyd crystals 30 to 60 grains
Yolk of egg No. 1
Marshraallow water 4 ounces
For one enema.
Paraldehyd may bo associated with potassium bromid or
tnorphin hydrochlorate as follows :
Paraldehyd crystals 1 dram
Potassium bromid 45 grains
Mucilage of acacia 2 ounces
.Syrup of bitter orange peel I oun<!e
Distilled water 2 ounces
Morphin hydrochlorate i grain
or,
Paraldehyd crystals 30 grains
Mucilage of acacia 23 ounces
Syrup of bitter orange peel 2 ounces
Tincture of vanilla 16 minims
To be taken in three doses at intervals of half an hour.
Hypodermically, paraldehyd may be given thus :
Paraldehyd crystals IJ drams
Distilled oleander water I, ...
Distilled water [ of each 4 drams
Each syringeful contains three grains of paraldehyd.
Suppositories may be made as follows:
Paraldehyd | , ...
Paraffin j of each 4o grains
Paraldehyd is counterindicated in patients taking iodids.
[i..p..\.]
A case of chronic eczema cured by static electricity
is reported by Maben (Journal of Advanced Therapeutics,
Vol. XX, No. 1, 1902, page 49). The eruption involved the elbow
and forearm down to the wrist ; the skin in places was deeply
fissured. At times there was intense itching and burning.
The case was obstinate and of long standing. Static electricity
was applied from the wooden ball electrode in the form of the
brush discharge to allay the itching, and in the form of long
sparks from the brass ball to relieve the burning pain, alter-
nating one with the other daily. A complete cure was effected
within a month, [r.m.o.]
Milk or Whey in Typhoid Fever. — Pridham (Lancet,
March 15, 1902) urges the use of whey in preference to milk in
the treatment of typhoid fever, [a.o.j.k.]
CItrophen is a remedy pleasant to take, and is said by
Syers ( Treatment, Vol. v. No. 11 , 1902, page 814) to be of distinct
service as an analgesic in a number of conditions, such as
migraine, the headache of anemia, neuralgia of various kinds,
lumbago and sciatica, chronic articular rheumatism, the noc-
turnal head pains of syphilis, and the "indetinito aches and
pains of neurasthenia." It is in the latter condition especially
that Syers recommends it. The administration of citrophen is
not attended by any depression or other unfavorable effects.
It is not an antipyretic, nor is it recommendeil for the pain of
acute rheumatism, or acute or chronic pulmonary inflam-
mations. For minor pains, however, it appears to be valuable.
The dose is from 10 to 15 grains, administered usually in
effervescing water. [K.M.O.]
THE PUBLIC SERVICE
Health Reporta.— The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
Qeneral U. S. Marine-Hospital Service, during the week ended
June 28, 1902:
Hmaluoz— United htatks.
Caaea Deaths
California: LosAngeles June 7-14 1
Sacramento ..„ Juiiq 14-21 .S
Colorado: Denver June7-i4 8
Florida: Jacksonville June 14-21 2
lUinolB- Belleville Juno 14-21 1
Chlcagu June H-21 7
Indiana: Indianapolis June 7-21 18
Terre Haute June U-Jl _ 2
Kansas: Wichita June 14-21 _ 1
Kentucky: CovlnxUm June 14 21. 2
Louisiana: New Orleans... June 14-21 „ 1 cose, 9
boura In city.
Massachusetts: Boston lune 14-21 t) 1
Cambridge June 14-21 41 1
Cbluopee June 14-21 li
Lowell... June 14-21- 3
Maiden June 14-21 „ 2
Worcester. lune l.H-20 _ 1
Michigan: Detroit lune 14-21 S 1
Ludington lune 7-14 S
Missouri: HU liouls June 15-22 2(> I
Nel)rHskH: Omalia lune 14-21 10
New Hampshire: Nashua June 11-21 II
New Jersey: Hudson county, luclud-
' Ing Jersey cTly Juncir>-22 88 S
Newark June 14-21 29 7
New York : EIniIra June 14-21 I
New York June 14-21 IW 8
Oblo: Cluclnnall June W-20 - 12
(Jleveland Juno 14-21 ..._ til 5
HamilUm June 14-21 8
Toledo lune 14-21 2
YoungsKiwn luiu'7-14 1
PennsTlvanIa : JnhnKtowii lune 14-21 18 1
' PhlladelphlH June 14-21 20 i
Herenton lune 14-21 S
Khode Island: Provliloncc lune 14-21 7
Month Canillna: (In-.-nvllle lune 14-21 1
Wisconsin: (4reen Bay Jun«lf-2:i
,MI,wniiket> Juno 14-21
40 American MedicihbJ
THE PUBLIC SERVICE
(July 5, vm
Porto Rico :
BelKlum:
Brazil ;
Colombia:
France :
Great Britain :
India :
Italy:
Mexico :
Russia :
Turkey :
Brazil:
Philippines :
India:
Japan:
Brazil :
Egypt :
India:
Japan:
SMAiiLPOx— Insular.
Ponce To May 14
SMALLPOX— FOREIGN.
Antwerp May 31-June7 ....
Pernambuco April Is-May 15..
Cartagena June 1-8
Panama.., iIunc»-IC
Hlielms June 1-8
Blrmlngtiam May 31-June 7„...
IjondoM May 3-June 7
South Shields May '24-.lune7 ...
Boml>ay May 20-27
Calcutta May 17-24
Karachi May 18-25
Madras May 10-16
Milan April 1-30
Palermo May :?1-June 7
(;ity of Mexico June 8-15
Moscow May 24-31
Odessa May 24-June7....
.St. Petersburg May 24-.Iune 7....
Warsaw. May 17-24
Smyrna May 18-24
10
2
188
8
5
12
5
15
11
24
2
42
1
29
1
n
2
1
2
2
2
3
1
1
2
Yellow Fever.
Pernambuco April I5-May 15..
Cholera— INSTTLAB.
Manila April 28-May 10.. 332
Provinces April 28-May 10.. 1090
Cholera— Foreign.
Bombay May 20-27
Calcutta May 8-24
Karatsu June 23 Present.
267
781
3
55
Plague.
Pernambuco April 15-May 15..
General May'28-June4 ... 48
Alexandria April 14-.Iune4... 18
Bombay May 20-27
Calcutta May 17-24
Karachi May 18-25 77
Nagasaki May 11-20 ]
61
2
11
174
20ft
66
1
Chanijes In the Medical Corps of the U. 8. Army for
the week ended June 28, 1902 :
Truby, First Lieutenant Albert E., assistant surgeon, now on tem-
porary duty at Fort H. G. Wright, will return to his proper station.
Fort Wadsworth.
Harvey, Captain Luther 8., assistant surgeon, is granted leave to
Include July 20, to take effect upon the expiration of his present
sick leave.
Overton, David W., contract surgeon, now at Fort Snelling, Is
relieved from further duty in the division of the Philippines, and
will proceed to New York City for instructions.
The following-named officers will proceed to the stations set after their
names for duty : First Lieutenant Roderic P O'Connor, assistant
surgeon, Bongabong, Nueva Ecija; First Lieutenant Conrad E.
Koerper. assistant surgeon, Llpa. Batangas ; First Lieutenant Roger
Brooke, Jr., assistant surgeon, Pantabangan. Nueva EciJa; First
Lieutenant Verge E. Sweazey, assistant surgeon, .Slniloan, Laguna ;
First Lieutenant Matthew A. DeLaney, assistant surgeon. Norza-
garay, Bulacan; First Lieutenant Paul S. Halloran, assistant sur-
geon, Tallsay, Batangas; First Lieutenant William R. Eastman,
assistant surgeon, Loboo, Batangas; First Lieutenant Perry L.
Boyer, assistant surgeon, Magdalena, Laguna ; Fletcher Gardner,
contract surgeon, Abra de Hog, Mindoro ; Captain Waller H. Dade,
assistant surireon, Tuguegarao, Cagayan, for temporary dulv .set-
tling accounts; Captain Edward A. Romig.assistantsurgeon. Dagu-
pan, Pangaslnan; Captain William G. Miller, assistant surgeon,
Malolos, Bulacan; George F. Owen, contract surgeon, San Fer-
nando, Pampanga. and report to the commanding general, second
separate brigade, for assignment to duty.
Buck, First Lieutenant Carroll D., assistant surgeon, now at Dagu-
pan, will proceed to San Isidro, Nueva EciJa, for duty.
Park.man, Wallace E., contract surgeon, is granted leave for 20
days.
Bradley, Major Alfred E., surgeon, will proceed to Malabang, Min-
danao, for duty as surgeon of the base hospital at Malabang.
Cox, Captain Frederick W.. assistant surgeon, leave granted Febru-
ary 26 is extended 1 month.
Wadhams, First Lieutenant Sanford H., assistant surgeon, leave
granted April 10 is extended 7 days.
May, James V., contract surgeon, is granted leave for 1 month and 10
days, to take effect about June 20, 1902.
Havard. Lieutenant-Colonel Valery, D. S. G., Is detailed to repre-
sent the medical department of the Army at the Second Interna-
tional Conference for the Prevention of Syphilis and Venereal
Diseases to be held in Brussels, Belgium, and will proceed to that
place not later than July 15. 1902, and after carrying out such
Instructions pertaining to the conference as he may receive from
the surgeon-general of the Army will return to his proper station
at Fort Monroe not later than October 15, 1902.
Mazzuri, Captain Paul, assistant surgeon, leave granted May 23 is
extended one month.
Woodson, Captain Robert 8., assistant surgeon, and Frank E.
Thomp.son, contract surgeon, having reported their arrival at San
Sranciseo, Cal., In compliance with orders heretofore Issued, will
report for assignment to duty with the Ninth Infantry, en route to
the department of the East, and upon the •ompletlon of this duty
will report by telegraph to the adjutant-general of the Army for
further orders.
LiPPiTT, Captain W. F., assistant surgeon, is granted leave for 15 days.
Wheeler, Lewi.s H., contract surgeon, now at Fort Yates, is relieved
from further duty in the division of the Philippines, and will report
at Fort Yates for duty.
Winterberg. Captain W. Hoepfner, assistant surgeon, having ten-
dered his resignation. Is honorably discharged to take effect July
31, 1902. Captain Winterberg will proceed to his home.
Fanning, George J., contract surgeon, now at San Francisco, Cal.. is
relieved from further duty In the division of the Philippines, and
will proceed to Fort Huachuca for duty.
MuNSON, Captain Edward L., assistant surgeon, is relieved from duty
in the office ot the surgeon-general of the Army, and will proceed
to San Francisco, Cal., in time to report for transportation U> the
Philippine Islands on transport to leave that place not later than
August 1, for assignment to duty.
GRUBB.S, First Lieutenant Robert B., assistant surgeon, is relieved
from duty in the division of the Philippines, to take effect about
September 17, and will then proceed to San Francisco, Cal., and
report by telegraph to the adj utant-general of the Army for further
orders.
Manning, Joseph H., hospital steward. Fort Sheridan, will be sent to
Fort Meade. Upon expiration of furlough authorized this date he
will report to the commanding officer at Fort Meade, who will send
him to San Francisco, (;al., with instructions to report to the com-
manding general, department of California, who will send him to
Manila, P. I., for assignment tf) duty.
Changes in the Medical Corps of the U. S. Navy for
the week ended June 28, 1902 :
Stone, E. P., surgeon, detached from the Dolphin and ordered to the
Mayflower— J une 20
R0S.S, J. W., surgeon, retired, ordered to the Pensacola navy yard-
June 21.
Hibbett, C. T., surgeon, detached from the Brooklyn and ordered
home to wait orders— June 21.
RiGGS, C. E., passed assistant surgeon, detached from the naval station)
Port Royal, and ordered to the Brooklyn— June 21.
Evans, S. G., passed assistant surgeon, detached from the Pensacola
navy yard, and ordered to the naval station. Port Royal, S. C— J une
21.
HoLCOMB, R. C, assistant surgeon, detached from the Manila, when
put out of commission, and ordered liome to wait orders— June 21.
Heneberger, L. G., medical inspector, detached from duty as a mem-
ber of the Medical Examining Board, Naval Laboratory, New York,
and ordered to the Brooklyn -June 23.
RiGGS, C. E., passed assistant surgeon, orders of June 21 modified, and
ordered to the Dolphin instead of the Brooklyn— June 23.
Fauntleroy, a. M , assistant surgeon, detached from the naval hos-
pital, Newport, R. I , and ordered to the Scorpion— June 23.
Garton, W. M , passed assistant surgeon, detached from the naval
hospital, New York, and ordered to the Columbia- June 24.
Wright, B. L., assistant surgeon, ordered to Fort Bayard. N. M , for
treatment at the United States General Hospital at that place —
June 24.
Changes in the Medical Corps of the U. S. Marine-
Hospital Service for the week ended .Tune 26, 1902:
Mead, F. W., surgeon, granted leave of absence for 2 months from
July 1— June 25, 1902.
Cobb, J. O., surgeon, to proceed to Missoula, Montana, for special
temporary dut}'— June 23, 1902.
Gardner, C. H., passed assistant surgeon, 2 days" leave of absence
from June 9, under paragraph 179 of the regulations.
Thomas, A. R.. passed assistant surgeon, 1 month's leave of absence,
on account of sickness, granted by Bureau letter of June 10, 1902,
revoked; and directed to proceed to Naples. Italy, and report to
Passed Assistant Surgeon J. M. Eager for duty— lune 26, li(02.
Hobdy, W. C, assistant surgeon, granted leave of absence for 14 days
upon being relieved from temporary duty at Brunswick quarantine
station— June 20, 1902.
Martin, H. McD,, acting assistant surgeon, granted leave of absence
for 30 days from June 16— June 25, 1902.
ROS.S, M. H., acting assistant sui'geon, granted leave of absence for 14
days from June 13 — June 13, UK)2.
Safford, M. v., acting assistant surgeon, granted leave of absence for
15 days from July j — June 25, 1902.
RVDEK. L. W., senior pharmacist, granted leave of absence for 11 days
from June 23— June 25, 1902.
Troxler, R. F., senior pharmacist, granted leave of absence for 7 days
from June 20, under paragraph 201 of the regulations.
Southard, F. A., Junior pharmacist, gianted leave of absence for 15
days from July 8— June 25, 1902.
Stier, Carl, Junior pharm.acist, relieved from duty at Memphis, Ten-
nessee, and directed to proceed to Mullet Key Quarantine Station
and report to medical officer in command for duty and assignment
to quarters— June 25, 1902.
Boanis Convened.
Board convened to meet at Washington, D. C, June 23, 1902, for the
ghysical examination of George W. David, Revenue Cutter Service,
etail for the Board— Surgeon R. M. Woodward, chairman ; Assist-
ant Surgeon B. S. Warren, recorder.
Board convened to meet at Washington. D. C, June 26, 1902, for the
physical examination of Third Lieutenant F. W. Smith, Revenue
Cutter Service. Detail for the Board — Surgeon J. H. White, chair-
man ; Surgeon L. L. Williams, Surgeon R. M. Woodward, recorder.
Apjiointmcnt.
Sanitary Inspector Lea Hume appointed acting assistant surgeon for
duty at Eagle Pass, Texas, to date from June 1, 1902— June 28, 1902.
American Medicine
11
GEORGE M. GOULD, Editor
G. C. C. HOWARD, Manotging Editor
CHARLES 8. DOLLEy
MARTIN B. TINKER, AuittafU Editort
Clinical Medicine
David Riesman
A. O. J. Kelly
H. H. Gushing
Helen Mokphy
Oeneral Surgery
Martin B. Tinker
A. B. Craig
Charles A. Orr
Orthopedic Surgery
H. AtrousTiTS Wilson
COLLABORATORS
Obstetrics and Gynecology
WiLMER KrUSEN
Frank C. Hammond
Nervous and Mental Diseases
J. K. Mitchell
F. Savary Pearce
Treatment
Solomon Solis Cohen
H. C. Wood, Jr.
L. F. Appleman
Dermatology
M. B. Hartzkll
Laryngology, Ele.
D. Bbaden Kyi.1
Ophthalmolcgy
Walter L. Pylb
Pathology
R. M- Pkarck
PUBLISHSD ViBKLT AT 1321 WaLNDT StBBBT, PhILADBLPHIA, BY THB AWEBICAM-UbDICINB PirBLtBRtHO CoMPAN
Vol. IV, No. 2.
JULY 12, 1902.
14.00 Yearly.
The Biirke Benefaction. — With so much money
unworthily bestowed and with so many beneficent
intentions defeated through tlie uncertainty of testa-
mentary dispositions, the benefaction of Mr. John M.
Burl<e, of New Yorlc, is especially worthy of note.
This philanthropist has placed $4,000,000 in the hands of
trustees to be administered for the betterment of men
and women unable to support themselves by reason of
sickness and misfortune. P^x-Mayor Hewitt, Edward
M. Shepard, Frank Sturgis, and William Hubbard
White, with the founder of the trust, constitute tlie
administrative board, and their character is sufficient to
guarantee both mind and heart in solving the problems
which necessarily come within their scope. There will
be no competition with the hospitals, since the plan is
to care especially for those dischargetl from the hospitals
but unable to resume work, particularly the independent
wage-earners, who so frequently through some prolonged
illness, find their savings gone, their positions filled,
and with weakened frame and languid mind are not
able at once to recoup their losses. It is frequently
noted in hospitals that such often return a second or
third time as charity patients, and that often an illness
under such conditions, with a tedious convalescence, is
the turning point to a general decadence. The class to
be benefited is less easily reached by ordinary methods
than any other class requiring assistance, and yet their
need is as urgent, although seldom brought to the atten-
tion of those who would mitigsite the hard conditions.
Such practical business-like charity is growing more and
more a characteristic of the true philanthropist, and
each succeeding example will but tend to make
others.
The Kouiance and Trajjedy the Physician Sees.
— Hir Frederick Treves has spoken wisely and truly of
the romance of medicine, viewing the subject from the
standpoint of the physician's own life and discoveries.
It has always seemed to us surprising that this fact has
not been more emphasized, but that which is of the
-upremest imjwrtance to men and women Is, by an old
law of i)rogress, precisely the last to which attention is
directed. More wonderful, however, than this aspi-ct of
the physician's life is the fact of the tragedies, comedies,
and romances of which he becomes the s|)ectator. No
one is allowed to see so deeply and frankly Into the
hearts of people, into the very hejirt of the world, as he.
By the nature of his calling there can be no sei-rets kept
from him, even if desired, and the strange longing of
the human heart for a confessor becomes an aid in the
revelation which even to the priest can never be quite
so complete. In these days when novelists si)end half
their lives in seeking "local color" and a knowledge of
the realities and conditions of the lives of their fellows,
it is remarkable that they have so little sought the sad,
the bright, the true truth of life, which presents itself
every day to the kind and conscientious doctor. There
is more romantic and tragic material here going to
waste — so far as relates to chronicling — than all the lit-
erature makers are finding elsewhere. This concerning
the Diehtinig, and when it comes to Wahrlteit no his-
torian or psychologist has yet dreamed of the extent to
which consciously or unconsciously, directly or indi-
rectly, sickneas dictates and dominates the actual lives of
nearly every one of us.
King Edward an<l His Physicians. — It is most
gratifying to note the uninterrupted improvement of
the King, with the announcement that he is at last out
of danger and that unless untoward symptoms would
develop he would soon Ix? transferred to the royal yacht
at Southampton in order that the sea-air might assist in
his complete restoration. The attendant success has
entirely justified his physicians, and no more is seen of
the attitude of criticism which had the result, not
entirely unexpecte<l perhaps, of bringing the critics as
well as the operators before the public eye.
Next to King Edward, the man who is at this
moment the most conspicuous figure on the world's stage
is Sir Frederick Treves, who by his attendant on King
Edward has in a short space of time Ik'c mie an inter-
national celebrity. The operation which has brought
him this sudden burst of fame was in itself neither dittl-
cult nor unusual. Times without numlK'r has he per-
formed operations re<iuiring greater surgiwd skill and
d-xterity, but at no time wen- the responsibilities so
tremendous. Not only were Treves and his colleagu«>s
accountable to the King and the royal family, they were
responsible to a nation— Indeed, to a world. Scarcely in
all history has there (K'currtsI a combination of circum-
stances that gave an operation so nnich lmi»ort«nce or so
much dramatic interest. One less cool of lutid and lei-s
42 AXKitioAN Medicini:;.
EDITORIAL COMMENT
[July 12, 1902
Bound of judgiiifnt than Treves might have hesitated
and bungled, but the intrepid surgeon disregarded the
high station of his patient, ignored the clamor of the
multitude, and did his duty as calmly as he would have
done it to the very lowest of his clients.
There are some undoubted advantages in a monarchic
form of government, one of them being the power and
privilege of the monarch to reward merit in conspicuous
ways. There was among the coronation honors bestowed
by King Edward a new order, called the Order of Merit,
given to a few individuals, selected by reason of their
distinguished services in different lines. Among these
was Lord Lister, another of the King's attendants in his
recent illness, and a representative of the highest
achievements in the healing art.
Modifications of the Quarantine Against Yellow
Fever. — In view of the discoveries by Drs. Reed and
Carroll, and of subsequent investigators, regarding the
transmission of yellow fever, demands have been made
on the Bureau of Public Health of the United States
Marine-Hospital Service for some modification of exist-
ing quarantine regulations. The Bureau has declined to
make any changes in time-honored measures without
definite justification therefor; but, in order to avoid
delay or the placing of restraints on travel or commerce,
unwarranted by the light of re(;ent discoveries and
experience, it was proposed by Surgeon-General Wyman,
in September, 1901, that a Yellow Fever Institute should
be organized, the object of which should be to collect all
facts concerning yellow fever, to designate the specific
lines of inquiries to be made, and to make them. The
object being also to help stimulate the spirit of scientific
investigation among offlcers of the corps. The plan
of organization having received the approval of the
honorable Secretary of the Treasury, the Institute was
organized with an executive board constituted as follows :
The Surgeon-General of the United States Marine-Hospi-
tal Service ex -officio chairman ; the Medical Ofiicer in
charge of the Bureau Division of Scientific Research,
secretary ; the chairman, the secretary, the Director of
the Hygienic Laboratory and the Medical Officer in
charge of the Division of Domestic Quarantine, the
Division of Foreign Quarantine, and the Division of
Sanitary Reports and Statistics, constitute the Executive
Board, whose duties are to direct investigations, correlate
reports and supervise publications from medical officers
of the United States Marine-Hospital Service. Several
meetings have been held and many prominent medical
men elected to active and corresponding membership.
In this way the Institute has taken on an international
character ; the membership list includes representatives
of Canada, Mexico, Italy, France and Germany. Several
interesting papers bearing on the general history of
yellow fever in Europe and America have been published
as special bulletins, and will be abstracted in the columns
of American Medicine. Arrangements have been per-
fected through the Consular Service by which informa-
tion of the first appearance of yellow fever will be
promptly communicated in order that working parties
may be despatched to the scene of the outbreak without
delay.
Lioeb's Experiments Concerning the Prolonga-
tion of Life in Sea-urchin's Eggs. — The recent obser-
vations of Prof. Jacques Loeb, of Chicago, regarding the
nature of the vital processes have attracted the attention
of the medical world during the past year to an unusual
degree. His observations have dealt chiefly with the
application of the modern theories of physical chemistry
to the problems of physiology. The deductions drawn
from one of his series of experiments (see Vol. VI, No.
."), Am. Jour. Physiology, "On the prolongation of life of
the unfertilized eggs of sea-urchins by potassium
cyanid ") have been opened to question by the recent
work of Gorham, of Providence, who, in March, in a
paper before the American Association of Pathologists
and Bacteriologists in Cleveland offers a more simple
and to many a more satisfactory explanation of the
phenomena. The nature of Loeb's conclusions are ex-
pressed in the first paragraphs of his article :
" The unfertilized mature eggs of a sea-urchiu die compara-
tively soon when deposited in sea-water. The same eggs, how-
ever, live a longer time when caused to develop either arti-
ficially, by extracting a certain quantity of water from them,
or, naturally, by allowing a spermatozoon to enter. Prom this
it is concluded that there are two kinds of processes going on
in the egg : one which leads to the death and disintegration of
the egg — a mortal process ; and a second which leads to cell
divisions and further development. The latter process inhibits
or modifies the mortal process.
" With this assumption the problem of the prolongation of
the life of a cell was given a concrete form. According to this
idea death and disintegration are due to specific processes which
take place in the egg, and possibly in other orall living matter.
These processes must be checked in order to render life pos-
sible. If this theory was of any value it was certain to lead to
the discovery of artificial means by which the life of unfertil-
ized eggs might be prolonged.
" The specific life phenomena are, as far as their chemic
side is concerned, chiefly, if not altogether, catalytic phenomena.
Hence it was to be expected that a checking of the specific mor-
tal processes should be brought about by agencies which inhibit
catalytic phenomena without permanently altering the consti-
tution of living matter.
" Among all the agencies which act in this way, potassium
cyanid seemed to meet this condition most perfectly. It
weakens or inhibits a number of enzymatic processes in living
matter without necessarily altering the constitution of the
latter. When the potassium cyanid is permitted to evaporate,
the original condition of the system may be restored.
"A series of experiments on the effects of KCN on the
unfertilized eggs of sea-urchins confirmed our expectations and
proved that by adding a small quantity of KCN to sea-wat«r
the unfertilized eggs of the sea-urchin can be kept alive a com-
paratively long time at a temperature of 20° C. or above."
As a result of these experiments Loeb found that sea-
urchin eggs in sea-water, to which had been added
enough of a n/10 solution of potassium cyanid to make
it a n/1,000 solution, were still capable of fertilization
after seventy-five hours, whereas those placed in normal
sea-water were usually incapable of fertilization after
twenty-four hours, and never after forty-eight hours.
Loeb concluded that death in the sea-urchin's eggs is
brought about by the development of an enzyme which
is checked by the catalytic action of the KCN. The
breadth of these conclusions must be obvious to any
reader. In reading Loeb's paper the idea occurred to
Gorham that possibly the socalled prolongation of life in
the sea-urchin's egg might be due to the inhibition or
lULY 12, 1902]
EDITORIAL COMMENT
.Vherican Medicine 43
prevention of the growth of bacteria in the sea-water in
which these eggs were placed. On looking up the
germicidal activity of KCN, Gorham found that a
n/1,000 solution (that recommended by Loeb in his
experiments) is exactly the strength at which the great-
est germicidal activity of KCN is exerted. The season
being too early to obtain the eggs of the sea-urchin,
trorham repeated Loeb's experiments upon the eggs of
the flatfish. He added varying strengths of potassium
cyanid to sea-water, placed the freshly removed flatfish
eggs in these solutions, and at varying intervals, with
the necessary controls, plated out the sea-water and
counted the colonies of bacteria thus obtained. He
found that just in proportion as the bacteria were
prevented from developing, just in that proportion was
the possibility of fertilization of the flatfish eggs pro-
longed.
This explanation has much to recommend it.
A review of the remainder of Loeb's article shows
that the other agencies to which he ascribes the power
of prolonging the life of sea-urchin's eggs, notably, plac-
ing the cultures in an atmosphere of hydrogen and
putting them on ice, are susceptible of the same explana-
tion, both of these agencies being capable of inhibiting
the growth of bacteria.
The charge that Loeb had entirely overlooked the
[)03sibility of Gorham's explanation cannot be brought,
inasmuch as in the last paragraph of his article he
described certain experiments made with the eggs of the
starfish. These eggs, which are transparent, wlien intro-
duced into sea-water showed that the potassium cyanid
arrested the progress of certain developmental processes
which may l)e observed when the eggs are placed in
normal sea-water. That this arrest of the process of
development in the eggs of the starfish definitely proves
that the prolongation of life is the result of the direct
action of potassium cyanid upon the eggs appears very
insufficient. It would be quite possible for the potassium
cyanid to arrest certain processes in the eggs as well
as to prevent its disintegration by inhibiting the growth
of bacteria. In justification of Loeb, however, it must
be f-tated that he realized the possibility of the KCN
])reserving the unfertilized eggs by bactericidal action.
( )n the whole, the explanation of Gorham appears to be
so much more simple and more in conformity with our
established views that we should hesitate in accepting
Loch's deductions. I'crhaps, as Dr. Leo Jjoeb suggested
in Cleveland, it would be possible to repeat these experi-
ments with certain fish eggs which liave an enveloping
envelope with which it would Ik" possible, by stripping
off' this envelope, to obtain a sttsrile ovum. This intro-
iUic('(l into previously sterilized sea-water and the
experiments repeated with the necessary precautions
to prevent bacterial contamination will be necessary
iK'fore Loeb's deductions can be accepted.
This series of experiments upon the so<alled " pro-
longation of life " of sea-urchin's eggs, it must be re-
membered, is but a small part of the many observations
upon which Prof. Loeb has based his general izivtions, and
if Gorham's position is 8ustaine<l this wouI<l not
necessarily affect the correctness of Prof. I>oeb's de<luc-
tioiis based upon other experiments.
The History of the Treatiiieut of Syphilis The
precolumbian inhabitants of Central America were
remarkablj- far advanced in medical matters according
to Motolinia. The Mexican Indians had well-construetetl
hospitals, supported by private beneficence, under the
charge of experienced physicians. They were especially
versed in the knowledge of plant medicines, and even
had colored plant atlases. An early missionary, Molino,
a learned and intelligent man, in his Spanish- Mexican
dictionary gives nine words meaning syphilis, the syph-
ilitic patient, the various types of the disease, the slight,
the severe, the pustular, ulcerous, etc. The therapeutics
of syphilis, according to Montijo, consisted of three
factors — a hunger-cure, the sweating cure and the treat-
ment by vegetable antisyphilitic remedies. Among the
latter the chief was guaiac wood. Its effect in the treat-
ment of the disease was held to be so good that Ferdir
nand and Isabella ordered that every ship returning
from the West Indies should bring a certain amount, to
be divided among the Spanish hospitals. Next to guaiac,
sarsaparilla, or zarzaparilia, was the most popular. When
the returning crews of Columbus first brought syphilis
with them from Hayti, and all Europe was overrun with
the terrible disease, the physicians were at fir-t iIu/imI
and utterly without knowledge or therapeutic resources.
The Grecians and l{onians luid known nothing of the
uses of mercury in any diseases and held it to be a
poison. According to the researches of .lolly the thera-
peutic uses of the metal were first discovered by the
East Indians ; it was in great vogue by tiiem as early
as 1235, but syphilis was unknown at that time and its
use for this disease is first mentioned in their medical
books in the sixteenth century. The Arab ptiy-ijcisins
brought the knowledge of mercury to the lumi.. ;ui
world, and by them its use topically for all kinds of skin
affections was widely perfected, liefore the time of
Columbus it was everywhere in use, both internally and
externally for a multitude of affections. It took several
years, however, for physicians, especially those of Spain,
to learn purely empiricly that mercury was the test of
all means to combat the disease. Almenar was, per-
haps, the first to use it as an inunction, in ir)02.
Tetanus. — The newspapers now chronicle mon' or
less accurately the usual numlK»r of cases of tetanus
following Fourth of July c-elebrations. To the medical
man these celebrations bring more tlian a thought of
demonstrative ex|)ressions of socalled patriotisui. Aside
from the general loss by fin' anfl accidents, there comes
to not a few individuals that dread dis««se, tetuiuis.
The etiologic factor in producing this malady is a small
bacillus which exists in barnyard soil, dust, < ii ., and
whicli gains entrance into the human wononiy by an
open wound, often so small as not to have attraiicd
attention. It does not pnKluce pus, cannot proliferate
without oxygen, produces little or no visible irritation in
the wound, and probably dcjes not invade the bloo<l nor
lymph channels. The periml of Incubation In th«' acute
form is usually from four to ten days, while in the
chronic form it is longer. The mortality in the latter
form is variously estimated, Itut in the former all agree;
that it is excee<lingly high, ranging from 80 ;f to '.)r,'/, .
44 ajHERICAN MBOICINEI
EDITORIAL COMMENT
[JCLY 12, 1902
The fact that the germ cannot proliferate in the
presence of oxygen gives a clue to the class of wounds
in which it is lilcely U) exist and their proper local treat-
ment. Punctures or small closed wounds forms its
favoriUi nidus. The inference to open up and permit
free bleeding from such suspected wounds is plain, for
here the germ proliferates and elaborates a most power-
ful toxin which, once in the circulating fluids, has pecu-
liar affinity for the cells of the nervous system. The
symptoms produced and the usual fatal termination are
well known.
The almost hopeless condition of the patient when
the cardinal symptoms of tetanus once arise is evinced
by the numerous methods of treatment advocated. The
hope of the profession in combating the acute form of
this disease appears to rest upon the earli/, frequent and
liberal injection of properly prepared antitetanic serum
in the subdural spaces of either the cranium or the
spinal canal. Recent reports of the results of this
method are sufficiently encouraging to fully warrant
such radical procedure.
Bad physiology and bad temperance,— such
must be pronounced the extremism into which the
Woman's Christian Temperance Union, led by Mrs.
Hunt, is plunging in its frantic efforts to control the
teaching of physiology in our public schools. Kote the
following from Mrs. Hunt's "History" concerning the
textbook war :
" This is not a physiologic, but a teniperauce movement.
In all grades below the high school this instruction should con-
tain only physiology enough to make the hygiene of temper-
ance and other laws of health intelligible. Temperance should
be the chief and not the subordinate topic, and should occupy at
least one-fourth the space in textbooks for these grades. Those
textbooks that are largely physiology with a minimum of tem-
perance matter ... do not meet the requirements of the
law and do not satisfy those who secured its enactment, and are
determined to secure it.i enforcement."
The teaching of physiology and hygiene in the public
schools of the United States has thus practically become
a mere tool and means of a socalled temperance propa-
ganda. " Of such books," says Professor Sedgwick, "it
may truly be said that they have no permanency of
their own and are only with difficulty preserved in alco-
hol." We have every possible sympathy with true tem-
perance reform by just and proper methods, but the W.
C. T. U. by its ill-considered methods has vitally in-
jured the cause it is supposed to have at heart, and has
turned into repulsion the sympathy of every true peda-
gog and scientist. Teachers and publishers of textbooks
have been browbeaten, and they do not dare resent such
action as it should be resented. The medical profession
can be of great service to the cause both of temperance
and of education by helping to make an end of this fool-
ish propaganda and by bringing the teaching of hygiene
and physiology back to K)und scientific and pedagogic
principles.
The Dating of Canned Foods — Notwithstanding
the fact that active fermentation is checked in hermeti-
cally sealed and "processed " foods certain deteriorating
changes are recognized as taking place in those which have
stood long in cans, especially those which have b<'en kept
through the hot months or in warm climates. The stale-
ness and tastelessness of much of the canned stuff sold
as food is undoubtedly due to some extent to imperfect
methods of preparation — to the lack of a skilled chef in
the canning factory. The sense of loathing, however,
which comes to boarders fed on canned goods (and which
is largely to blame for the innumerable witticisms on
boarding-house fare) is possibly due to alterations in
savor which follow the long-continued maceration of
delicately balanced organic compounds. The tin can,
though excluding the outside air still acts as an auto-
clave or digester, and in warm weather, or as the result
of variations in temperature, chemic changes neces-
sarily occur which at first insignificant are, in
time, sufficient to render the canned food unpala-
table and possibly unwholesome. The dangers that
arise from the prolonged action of organic acids upon
the impure tin and solder used in cheap tin cans
are illustrated in the cases of illness following the use of
tinned foods, and which are reported from time to time
in the lay and medical press. The suggestion offered in
a recent number of the British Medical Journal by H. E.
Mann, Medical Officer of the East African Protectorate, is
well based, viz., that all manufacturers of canned foods
should be compelled to stamp on the tins the date on
which the food is prepared.
Spitting from Open Cars. — Now that the season has
arrived for open cars on the trolley lines, passengers are
again liable to the annoyance of repeated sprayings of
saliva from those who expectorate from the moving
vehicle. It is not only the spitting passenger who
offends in this matter but as often the tobacco-chewing
motorman, who at regular intervals bends over the plat-
form rail and empties his mouth of an accumulation of
spittal that is distributed by the rush of air impartially
over the passengers behind him. The antispitting cru-
sade has done much to rid our cars, depots and streets of
a nuisance and source of infection, and the filthy and
usele,ss habit of spitting should be attacked on every
possible occasion. Spitting from the front or sides of
moving open cars should be strictly forbidden, and the
thousands who have felt the disgust incident to being
obliged to wipe the slimy salivary spray from their faces,
or who have had an otherwise pleasant ride spoiled by
the necessity of hiding behind a fan or newspaper to avoid
being intermittently besprinkled by some thoughtless
boor ahead, will appreciate action on the part of trolley
superintendents looking to the abatement of this nuisance.
The Stamping of "Compressed Tablets" by
the Roman Oculists. — Stamps have been found in
England which have been shown were used by the
Romans to stamp remedies for producing clearness of
vision, or for doing away with dimness of sight. The
object aimed at by the medicament was specified in the
stamp. It is noteworthy that the stamps so far discov-
ered were designed for remedies for ocular diseases.
The preparations were hardened with gum or some vis-
cid substiince, and were thus ready to be litiuefied at any
time. Thus our supposedly very modern ilevice of trit-
urates or compressed tablets is only a revival of an
ancient Roman custom.
JULY 12, 1902]
REVIEWS
[AMERICAN MBIIICINE 46
BOOK REVIEWS
Operations of Surgery, Intended Especially for the Use of
Those Recently Appointed on a Hospital Staff and (or
Those Preparing for the Higher Examinations. By W.
H. Jacobson, M.Ch., Oxon., F.K.C.S., Surgeon Guy's Hos-
pital, and F. J. Steward, M.S., London. F.R.C.S., Assist-
ant Surgeon Guy's Hospital and the Hospital for Sick
Children, (ireat Orinond street; Surgeon In Charge of
the Throat Department, Guy's Hospital. Fourth Edition
with 550 illustrations. Volume 1,727 pages; Volume II,
770 pages. 1902. Philadelphia : P. Blakiston's Son ct Co.,
1012 Walnut street.
Jacobson's Operations of Surgery has had so many Ameri-
can readers in the previous three editions that any description
of its scope would be entirely superfluous. In bringing this
work abreast of the times .lacobson and his coworker, Mr.
Steward, have rendered a most valuable service to the medical
profession. Very few criticisms of the work can be offered,
though there are a few omissions and matters of minor impor-
tance which might possibly be changed with advantage. For
example, in discussing resection of the ribs for empyema we do
not notice any mention of the method of decortication of the
lung which was first done by Fowler, of Brooklyn, but is com-
monly credited by continental surgeons to Delorine. We also
fail to notice any mention of the use of infiltration and local
anesthesia in abdominal surgery, specially in such cases as
typhoid perforation and strangulated hernia, in which this
method of anesthesia is so widely employed in America and
Germany. Crile's method of nerve blocking with cocain we
believe deserves mention in connection with interscapulo
thoracic amputation and other major amputations. Intraven-
ous injection of salt solution and transfusion are described in
some detail, but the simpler injection of salt solution into the
loose cellular tissue as is so f retiuently practised and after severe
operations in this country is not mentioned. We are glad to
notice in an English work on surgery a little less conserva-
tism in theoperative treatment of acute appendicitis, and are sur-
prised and pleased to notice .lacobson's statement, " I am cer-
tain that the results of the best American surgeons are far
superior to anything in this country and are but little known
amongst us." The omissions and changes are, for the most
part, of minor importance, and on the whole these volumes
form one of the most admirable treatises on operative surgery
which has yet appeared. A feature of great importance is the
very full description of operative methods frequently in the
language of their originators. The pointing out of details
which are often so necessary to the success of operation and the
critical judgment by the authors as to the value of the various
procedures under special discussion, also deserves special com-
mendation. Most surgeons want a book on operative surgery,
not because that they do not know the main steps of the opera-
tion, but for use as a reference book in looking up the details
for which they have not time to consult original articles. They
will not find these volumes disappointing for this purpose. In
addition, the authors give very many valuable suggestions
from their own wide experience. We knowof no work more
likely to prove helpful to all who are frequently called upon to
operate, whether it be the hospital surgeon who wishes to
refresh his memory or the occasional operator in emergencies.
Progressive Me<Iicine.— A (Quarterly Digest of the Advances,
Discoveries, and Improvements in tlio Medical and Surgi-
cal Sciences. Edited by Horaut .\m()RY Hare, M.D.,
Professor of Therapeutics and Materia Medica in the
Jefferson Medical College of Pliiladelphia, etc., assisted by
H. R. M. I,ANDis, M.D., Assistant Physician to the Out-
patient Medical Department of the .Jefferson Metlical Col-
lege Hospital. Vol. I, 1902. Philadelphia and New York :
Lea Brothers iV Company, 1902.
In the present volume of "Progressive Medicine" the
recent literature on the surgery of the head, neck and chest is
dealt with by Dr. Charles H. Frazier; that on the infectious dis-
easei, including acMite rheumatism, (jroupous pneumonia and
infiiienza by Dr. Frederick A. Packard; that on diseases of
iliildren liy Dr. Floyd M. Crandall ; that on pathology by Dr.
Ludvig Hektoen; that on laryngology by Dr. St. Clair, Thom-
\ son ; and that on otology by Dr. Roliert L. Randolph. The
volume is a valuable addition to contemporaneous medical
literature, consisting, as it does, not only of abstracts of all that
is really important in the recent literature of the subjects with
which it deals, but also of critical comments by those in charge
of the different departments. It is one of several similar publi-
cations—publications that have become essential to the progres-
sive physician— and it faithfully fulfils its object.
Transactions of the Chicago Pathologic Society.
The fourth volume of the " Transactions of the Chicago
Pathologic Society," covering the period from October, 1890, to
June, 1901, has just appeared. It is a large book of nearly 500
pages, tastefully printed and well illustrated, and covers a wide
range of pathologic subjects. As the character of the work
done in pathology is probably the best index of the state of
medical science in any locality, we may readily infer that medi-
cine is reaching a high level in the western metropolis. At
present the society publishes its proceedings in monthly fas-
ciculi.
Diseases of the Digestive Organs in Infancy and Child-
hood, with Chapters on the Diet and General Management
of Children, and Massage in Pediatrics. By Loiis. Starr,
M.D., late Clinical Professor of Diseases of'Children in the
Hospital of the University of Pennsylvania; Consulting
Pediatrist to the Maternity Hospital, Philadelphia, etc.
Third wlition, rewritten and enlarged. Illustrated. Pub-
lished by P. Blakiston's Son A Co., 1012 Walnut street,
Philadelphia. 1901. Price, $.3.00 net.
This little work has long enjoyed an enviable place as a
reliable guide to the practising physician. Although its path-
ology is not always in accord with present day knowledge, and
although reference to blood-studies in the various diseases of
which it treats are lacking, its sections upon diagnosis and
treatment are certainly most satisfactory and helpful. The
introduction comprises a chapter of 91 pages upon the general
management of children, and a brief section on massage in
pediatrics. The author's emphatic condemnation of the practice
of giving children food between meals is deserving of approval.
He also opposes the growing custom of allowing children to go
with bare legs and knees. Feeding, bathing, clothing, sleep
and exercise, and the care of weak and premature infants, are
discussed in this chapter with a detail that is found rarely in
textbooks. Artificial feeding naturally occupies a large share
of attention, and minute details are given. We are surprised to
find that the author has had only unsatisfactory results with
laboratory milk— this is certainly not the experience of all
physicians. He believes that the poor results are due to the fact
that all the fat is removed by a separator, whereby the natural
emulsion of the milk is destroyed and the digestibility of the
proteids lessened. The section dealing with infantile scurvy is
very good, and contains a tabular report of 26 cases from the
author's own experience. Under the head of treatment,
reference to the use of yeast in this affection is overlooked.
Simple atrophy, rachitis, and lithemia, are also taken up among
diseases of imperfect nutrition. In the section upon dis-
eases of the digestive organs proper, affections of the mouth,
pharynx, stomach and intestines, ami of the mesenteric glands,
the liver and peritoneum are discussed. The author's treatment
of appendicitis is conservative, and he does not think that
every case requires operation. In tuberculous peritonitis,
however, treatment t)y surgical procedure is, in his opinion, the
only method that gives any promise of radical cure. Under
noma, no mention is made of the frequent presence of the
diphtheria bacillus in the gangrenous lesions, nor to the use of
diphtheria antitoxin in the treatment. Wherever possible
throughout the book theauthor has intrrKluced specific diet lists
and daily bills of fare, which are of great value to that
physician who is not content with merely giving to the child's
care-taker general directions.
A Comprehenalve Oiiide-Book to Natural, Hygienic, and
Humane Diet.— By Sidney H. Beard, eilitor of The
Ifn-iild <if the Oolden Age. New York: Thomas Y.
Crowell iV Co.
Without going either to the theoretic or practical lengths of
the vegetarians, one can admit that men In general, and tpe-
cially our American people, oat too much meat, and eat meat
too fre(|uently. This book gives a variety of usef\il reelpoa for
the preparation of fruits, nuts and vegetables, and should serve
a useful purpose U^ those who desire a more sensible and varied
diet than that of the ordinary household.
46 AUBBICAN MeDICINEJ
AMERICAN NEWS AND NOTES
[JULY 12, 1902
AMERICAN NEWS AND NOTES.
OENERAli.
Dr. Park Honored.— Yale University has conferred upon
Dr. Roswell Parl<, of Buffalo, the degree of Doctor of Laws.
Mosquitos and Yellow Fever.— Dr. O. L. Pothier, path-
ologist to the Charity Hospital, and Prof. G. E. Beyer, of Tulane
University, New Orleans, have been appointed on a commis-
sion established liy the U. S. Marine- Hospital Service to study
the mosquito-yellow fever question in tropical climates. They
have left for Vera Cruz.
Changes in Medical Corps Uniform.— Important changes
are contemplated in the uniforms and insignia of the medical
corps of the Army. The advisability of substituting maroon
for green in the trimmings of the hospital corps is being con-
sidered. It is also proposed to substitute the caduceus for the
Geneva cross as the insignia of the medical corps.
Army Medical School.— Colonel Charles Smart, assistant
surgeon-general, has been assigned to duty as president of the
faculty of the Army Medical School in Washington. Dr. Smart
has rendered prominent service in the Civil War, in compiling
its medical history afterward, in the hospital corps, and in
sanitary questions in general, especially the use of slow sand
filtration for purifying water.
Health of Troops in Philippines.— The report of Chief
Surgeon Heizmann, for the month ending May 15, shows the
percentage of sick troops in the Philippines to be 6.01%, the
lowest figure yet reached. The large increase in the number of
deaths was largely due to cholera. The latter are stated to be
mainly due to disobedience of orders. With an American in
charge the natives do fairly well as assistants in sanitary work
against cholera.
National Association of U. S. Pension Examining
Surgeons. — This association was organized at Saratoga Springs,
June 9. An enthusiastic meeting was held. Efforts are to oe
made to induce every one of the 4,500 pension examining sur-
geons to join the association. Officers are : President, W. A.
Howe, Plielps, N. Y. ; vice-presidents, W. H. Hall, C. ij.
Stevens, C. J. Fox, G. Lair; secretary, Wheelock Rider, Roch-
ester, N. Y. ; treasurer, C. H. Glidden, Little Falls, N. Y.
Camphormanla. — A French medical journal tolls us that
the American ladies finding morphinomania out of fashion
have adopted the camphor habit. They imagine that this gives
them a fresh complexion. Little by little they become accus-
tomed to the drug and this in time acts the same as morphin.
With camplior habitues one observes somnolence, intellectual
torpor and general feebleness, and the face takes on an expres-
sion of apathy and indifference as if it were covered by a mask.
The journal does not say whether these ladies are real Ameri-
can Americans or Americans of the French variety.— [The
Medical Age.}
EASTEKN STATES.
Harvard Medical School.— Dr. James C. White delivered
his last lecture before the students on May 28, thus ending a 44
years' membershij) in the faculty.
Dr. Lodge Expelled.— Dr. P. C. Lodge has been expelled
from the Waterbury, Conn., Medical Association for claiming
that there was no smallpox in that town and writing on the
subject to the local papers. These were said to cast discredit
upon the fraternity in general and the health officer in par-
ticular.
NEW YORK.
Summer quarantine of passengers from Havana was
begun at New York June 30. The usual time of beginning is
May 17, but owing to the improved conditions in Havana post-
ponement was considered safe.
Hospital for Italians.- The McKinley Hospital and Dis-
pensary, of New York City, has filed application for approval
of the State Board of Charities. The hospital will furnish
medical and surgical aid, especially to persons of Italian parent-
age.
Improved Diet in Hospitals.- The diet for the 2.3,000
insane persons in the 11 State hospitals is to be increased and
improved at an annual expense of |50,000. Other improve-
ments, in administration and inspection, will more than balance
this and lower the per capita cost.
Tests for Escaped Gas.— The Department of Buildings
has lately been making a series of tests for leakage of illuminat-
ing gas in public buildings with the result of detecting gas in
the majority. Dr. Samuel Lloyd, of the committee on hygiene
• J Vi?""'? Medical Society, has been making similar tests
indwelling houses. Gas was found in one house which con-
tained two patients, one presenting typhoidal, the other malarial
i>ymptoms. t ive leaky sewer-traps were discovered.
PHUiADEIiPHIA. PENNSYIjVANIA. ETC.
Dead at Age of 116.— William Batton, a negro, died in
Philadelphia June 25, aged 116.
St. Francis' Hospital, Trenton, N. .1., is so overcrowded
that another addition is found to be necessary.
Anthrax In New Jersey.— Anthrax has made its appear-
ance among the cattle in the vicinity of Fort Mott.
Woman's Medical College.— Dr. Alice Seabrooke has
been appointed medical superintendent of the hospital of the
Woman's Medical College, she having lately resigned as direct-
ress of the nurses' training school at the Methodist Episcopal
Ho.spital.
Homeopathic Hospital Admits Regulars.— The McKin-
ley Hospital, of Trenton, formerly strictly homeopathic, now
allows any physician to treat his patients there. A number
have availed themselves of this opportunity and the hospital
bids fair to become popular.
Trenton Medical Library.— The recently organized Med-
ical Library Association at Trenton, N. J., is apparently
destined to be a great success. About 400 volumes have already
been secured. The city has donated the use of a room and the
services of a librarian. Dr. H. G. Norton is president of the
association.
SOUTHERN STATES.
Cancer Hospital In Virginia.— A hospital for the treat-
ment of cancer and kindred diseases will soon be opened in
Norfolk under the charge of Dr. P. H. C. Noble, of Richmond.
Johns Hopkins Funds Raised.— President Remsen an-
nounces that the endowment fund of $1,000,000 for the Johns
Hopkins University has been completed. None of tliis money
is to be used for buildings and the problem of moving to the
new site recently presented is the next matter to he taken up.
Johns Hopkins University. — The following promotions
have been made at the Johns Hopkins University : William G.
McCallum, to he associate professor of pathology; Guy L.
Hunner, to be associate professor of gynecology ; Walter Baum-
garten, to be assistant in medicine; Florence R. .Sabin, to
be assistant in anatomy ; Benjamin R. Schenck.to be instructor
in gynecology.
Louisiana State Medical Society. — At the annual meeting
held at Shreveport June 3-5, 1902, the following officers were
elected: President, Isadore Dyer; vice-presidents, H. B. Gess-
ner, E. D. Martin, W. E. Barker, F. M. Thornhill, J. C. Willis,
Charles McVea ; recording secretary, W. M. Perkins, New
Orleans ; corresponding secretary, A. G. Friedrichs, New
Orleans. Delegate to American Medical Association, R. Matas.
WESTERN STATES.
Dr. Harry B. Carrlel has been elected superintendent oi
the Central Hospital for the Insane at Jacksonville, 111.
Sale of Bodies for Dissection. — This is the latest charge
made by the Coroner against the management of the St. Luke
Society in Chicago. Evidence practically proves it to he true in
at least one case.
Physicians' Insurance. — An insurance organization has
been formed by several prominent Omaha physicians under
the presidency of C. C. Allison. It will be known as the Physi-
cians' Casualty Company of America, with lieadq uarters at
Omaha.
Union of Medical Colleges. — Tiie Denver College of
Medicine and the Gross Medical College of Denver, Colo., have
united under the name of the Denver and Gross College of
Medicine, Medical Department of the University of Denver.
A board of trustees consists of members from each of the
schools. The laboratories will be enlarged and the college will
offer a four-year course, with sessions eight months each.
CANADA.
Congress of French-Speaking Physicians. — The first
congress of French-speaking Physicians of North America met
at Laval University, Quebec, June 25. About 350 physicians
from Canada and the United States, the majority of them gradu-
ates of Laval, were in attendance.
Medical License Act for Canada. — An act establishing a
General Medical Council for Canada has passed the Canadian
Legislature. The council will consist of about 36 members and
will include three homeopaths, this concession Ijeiug due to the
fact that in certain provinces they possess rights which could
not be overridden. Under tlie new act the council will institute
examinations and grant licenses which will be valid for the
whole country, and reciprocity with England is one of the
objects it is hoped to secure. The curriculum will be five
years, the last being spent in clinical work. As the act is per-
missive, it cannot take effect until the consent of the several
provincial legislatures has been obtained.
JCTLY 12, 1902]
SOCIETY REPORTS
[AXKRtCAN MEDtCIKK 47
FOREIGN NEWS AND NOTES
M. Hericourt succeeds to the editorship of the Revue
Scientiflque, from which the eminent French physiologist
Professor Ch. Riehet recently resigned.
French Medical Excursion.— The annual excursion for
medical men and students through the health resorts and water-
ing places of France, organized by Dr. Carron de la Carriere, is
Bains, Luxeuil, Plombieres, Sal ins and Besancon. Foreign
medical practitioners and medical students are admitted to
share the special advantages accorded by the railways, hotels,
etc., and the cost of the entire trip, inclusive of traveling and
hotel expenses from start to finish, is 200 francs ( *8). Dr. Lan-
douzy, professor of clinical medicine at the Faculty of Medi-
cine of Paris, will take charge of the scientific branch, and will,
at each station, deliver lectures on the therapeutic properties of
the waters and on hydro- and balneotherapeutics in general.
(Medical rre.ss.)
GREAT BRITAIX.
Fee for Notice of Diphtheria.— The Urban Council of
Fenny Stratford has ordered tliat in cases notified as diplitheria,
in which svvabbings talien by the medical attendant are con-
firmed by the bacteriologist, a fee of 10s. (id. shall be paid the
attendant.
Bequest to St. Thomas' Hospital.— Charles Gassiot, of
London, Avho died in May, bequeatlied £250,000 to St. Thomas'
Hospital. This is one of the largest hospitals in Loudon
having 585 beds. It was founded about the year 1200, and has a
medical school in connection.
Eyesight Specialists.— The British Medical Journal calls
the attention of the Worshipful Company of Spectacle Malsers
to a violation of their rules by a Mr. Hayden, who advertises
his ability to deal with the most difflcult cases requiring
gla-sses. It is pointed out that he thus oversteps the restric-
tions of the company's diploma.
Jenner Institute, Chelsea.— Major Ronald Ross, F.R.S.,
has been appointed tiie head of a new department of the Jenner
Institute of Preventive Medicine, Chelsea. The department is
to be devoted to the systematic study of the animal parasites of
man and the lower animals, especially from the points of view
of pathology and epidemiology.— [PufiHc Ilen/th.]
CONTINENTAIj EUROPE.
The French Association f.«- the Advancement of
Science.— The French Association for the Advancement of
Science will meet this year atMontauban. The proceedingswill
open on August 7. The President of Section XII, which is
devoted to medicine, is Dr. Bories, of Montauban, who suggests
the following subjects for discussion : ( 1 ) Wine from a Medical
and Hygienic Point of View; (2) the Nature and Treatment of
Diabetes Mellitus; (3) the Surgical Treatment of Prostatic
Hypertrophy.— [B;-rtj«A Medical Journal.]
OBITUARIES.
Wyatt Gait Johnston, in Montreal, June 19, after an Illness of a
month due to septic Infection and phlebitis contracted during work as
medicolegal expert In the coroner's court He was graduated In
medicine at McGlll University In 188.5, soon afterward being appointed
demonstrator in pathology In that Institution. In ISM he was ap-
pointed lecturer In bacteriology; in 1(«).5 lecturer in medicolegal
pathology; in 1902 professor of hygiene. Ur. Johnston had paid
special attention to hygiene and public health, his modlllciuion of
Wldal's reaction of the typhoid bacillus now being almost universally
employed.
James Thomas Jelkg, at Hot Springs, Arlc., June 21, aged US.
Graduating from the University of .Nashville, he practised first In
Georgia, then in .St. I><)uls, and finally in Hot Springs, becoming one
of the most eminent physicians In Arkansii-s. He <x-cupied thechalrof
genitourinary surgery In the College of riiysicians and Hurgcons from
imi to 1H90, and the chair of gyne<:ol(>gy and syphilology In the Barnes
Medical College, St. lyouls, from 1S92 until his death. Dr Jelks' spe-
cialty was venereal diseases. Since 1891 he was edlU)r of the Jlol Upriny
MetUcat Journal.
Obed Latham Lusk, at Uot^kaway Beach, June 20, aged 42. At
onetime he was surgeon in the United Stoles Army and had been
deputy health Inspiwtor of the borough of tiueens.
John T. Winter, In Washington, June 22, aged HO. He wa« one of
till- founders of the National University .VIedlcul School.
John B. Vivian, of Oalesburg, 111., June 2«, aged 92. Ho had prac-
tised medicine for more than 70 years.
Keiijiiinln Andrews, In BnMiklyn, June 2(), aged 82.)
SOCIETY REPORTS
MEDICAL SOCIETY OF THE STATE OF NEW JERSEY.
One Hundred and Sixth Annual Meeting at Atlantic City,
N. J., on June 34, 25 and 26, 1902.
[Specially Reported for AmeHc^n MeUieiHe.]
FIRST SESSION.
The first session, held on Tuesday morning, was devoted to
routine business, including reports of various committees,
which were of interest to the members oply.
SECOND SESSION.
The second session opened with an address of welcome by
Alderman Mulock, of Atlantic City, who toolc the place of
Mayor Franlclin P. Stoy, who was compelled to bo absent from
the city. He expressed the pleasure in welcoming such an
eminent body to Atlantic City, which seemed to afford excep-
tional opportunities for such conventions, judging from the
number of times they had visited the place.
The report of the secretary showed that tliere had been
a marked gain in membership, but it was suggested tliat
still more could bo done in this respect. The remainder of the
session was taken up with reports of various kinds, the most
interesting being that of the committee on »Iilk as a Food
and a Means of Contagion. It was presented by Dr. R. C.
Nkwton, chairman, and contained a number of suggestions as
to the duties of boards of health with regard to the milk sup-
ply of cities and reeominendations as to what might be done in
outlying communities. The question of the transmission of
tuberculosis from the cow to man was also touched on and
while it was acknowledged that authorities differed on' this
point it was suggested that caution is desirable. Strong
rf commendations as to the temperature at which milk should
be kept, both iu the dairy and while under course of transpor-
tation, were made, the necessity for a plentiful supply of ice
being insisted on.
THIRD SESSION.
Annual Address of the President : The Nervous Sys-
tem in its Relations to Medicolegal Medicine.— John D.
McGiLi, (Jersey City) congratulated the members on the suc-
cess which has attended the society. It was one of the oldest
existing iu the United States and was regarded with affection
and veneration. Speaking of its conservatism he said it had
been a bulwark agamst many innovations. Students were apt
to be specialists before even taking their degree and this is a
tendency t<i be guarded against. The medical profession is a
most glorious one but degeneracy may creep in. They should
adhere to pharmacy as against nostrums, but at the same time
they should be progressive. Turning then more directly to the
sulject of his address the president said that its field is
almost unlimited. The question of the position in ca.ses wliere
personal damages were sought was touched upon and it was
urged that special care should bo taken in making a diagnosis.
The nervous system, it was shown, occupies a jJlace of para-
mount importance. Definitions of the physitsil and the psychic
were given, the nervous system described, tests for witne.sses
referred to, the use of instruments in making a diagnosis and
the difficulty in dealing with malingerers emphasized. It was
also pointed out that the definition of insanity dill'ers in law
and in medicine. Insanity lies in the fact that it is Impos-
sible for insane persons to understand that their hallucinatlonB
are false.
ProRress In State Medicine and HyKiene.— Kdwaud K.
Worn, (Newark) spoke of the work of the antipollution com-
mittee in connection with the Pas.saic \allcy, and the attempts
to restore the rivers of New .lersey to their pristine purity. It
would pay to establish sanatoriuins for tuberculous patients.
He described the attempt of the Newark Iloard of Health with
regard to the cure of tuljercnlosis, giving the method of pre-
paring serums and toxins and of examining sputum from
patients; the use of serum generally imxl need an imprf>voment
111 patients, liO patients having shown physical improvoment.
Ho quoted the case of a man 04 years of ago, wlio showwl an
increase of weight, a reversal of the usual order of things at
this age. He considers that the profession is on the e<lgo of a
great victory. Smallpox was then taken up and roferen<'e mmle
to its introduction by tlie troops rotnrnlng from the colonies, of
the peiHillar type existing and its rapid spread. He asked. Is
there too much refining of virus? Immunity is <-oiirerro<l liy vac-
cination, and the speaker Is against optional and in favor of
compulsory vaccination. The mosquito as a liarrler of disease
having been si)oken of, the author turned his attention to the
meiiical ins|>ection of schools, showing that the main points to
1)6 attende<i to are the maintenance ol cleanlinoss, the detec-
tion of contagious diseases of the eye, observation of the sight
generally, aU.'.
Progress in Diseases of the Nose And Throat.— H. A.
WADni.NiiroN (Salem) dealt with rhinitis, etc., the middle tur-
binate, deviate septum and suggestions of authors with regard
48 American Medicine]
SOCIETY KEP0RT8
[July 12, 1902
to these. The use of suprarenal extract in nasal hemorrhage
has made great change in methods and in the shape of adrena-
lin is very effective. Plugging the nares with cut sponges
steeped in vaselin produces good results.
Progress In Diseases of the Eye and Ear.— Talbot R.
Chambers (Jersey City) quoted authorities to show what
progress has been made. He recommended the use of the large
magnet to remove foreign bodies, and referred with commenda-
tion to the result of the use of the x-rays as reported by various
men. After pointing out the necessity for properly sterilizing
knives and keeping them free from rust, he pointed out that
one great step in advance has been made by the use of the x-rays
in curing cancer of the eyelids. There are still many fatalities
from aural suppuration and the mortality is large, but aural
surgery is becoming much bolder.
Progress in Bacteriology.— Ma zyck P. Ravbnel (Phila-
delphia), speaking extempore, referred to a number of recent
discoveries iu bacteriology, particularly that of Walter Reed ,
U. S. A., demonstrating that there is but one species of mos-
quito which carries yellow fever. The germ of yellow fever
has yet escaped us, and so has that of rabies, but we can now
make a rapid diagnosis, in 12 hours if necessary. After con-
sideration of the progress of bacteriology with regard to tuber-
culosis and reference to Koch and other authorities, cases were
quoted which, in Ravenel's opinion, tended to show that infec-
tion by bovine tubercle is more likely to occur than from the
human.
Some Diseases of the Fallopian Tubes.— Illustrated by
lantern slides. Philander A. Harris (Paterson). This
paper was illustrated by about fifty slides, showing the tubes
after their removal, and many of the cases had a strong resem-
blance. The author advocated the retention of the ovaries
where possible and generally was in favor of conservative sur-
gery, allowing every opportunity to the woman to have a future
chance of pregnancy.
The Pathology of Appendicitis. — From a histological
research of 50 cases, lantern illustrations. George E. Mc-
Laughlin (Jersey City). Owing to the lateness of the hour
the author contented himself with showing a number of illus-
trations, the paper being accepted as read.
FOURTH SESSION.
The Rural Surgeon: His Place, Privilege and Duty.—
A. W. Taylor (Beverly) stated that every surgeon practising
in any place outside of a city of 5,000 should be considered as
belonging to the rural fraternity of surgeons. For such both
the theory and practice of medicine is necessary. Their three
requisites should be: Nerve, knowledge, knife. The author
then briefly referred to the changes wrought by the introduc-
tion of anesthetics and the work of the trained nurse. From
the country surgeon or physician much more is demanded
than from his city brother ; often enough he has to be the family
friend and adviser, ready for all emergencies. Weelum
McClure, of Drumtochty, could be taken as their representa-
tive. There were certain operations which they should be pre-
pared to perform without calling in the aid of the specialist or
city surgeon. What is required is a cool hand, a clear
brain and a clean patient. Then came a description of what the
operating room in the patient's home should be— clean and
divested of carpets and rugs. It was convenient for the surgeon
to have a large armamentarium, but not necessary. Clean
sheets, which have been boiled and ironed are practically
aseptic. The author paid a glowing tribute to many of the
cool-headed, deft-handed women who had acted as temporary
assistants on many occasions, and referred to a country surgeon
who for many years had performed all his own minor surgical
operations, and many which might be included as major; even
amputating limbs with but little assistance. It was unfair for
the country practitioner to send surgical patients to the city
surgeon or the hospital on but slight provocation. Libraries
and medical journals were plentiful, and resourcefulness should
be cultivated. It is their duty to be prepared for any emer-
gency. They should have their brain and splint box ready.
History of Former Methods of the Kural Surgeon.— A.
Treganowan (South Am boy) related methods used away back
in the fifties, and spoke of the courage then required. He gave
an interesting account of what he thought was the first case of a
removal of the ovarian cyst, performed in New Jersey in 1852,
at which he (then a student) assisted Drs. Spencer and Stokes.
It was extirpated, not punctured, and the woman recovered.
The Present Methods of Education from the Stand-
point of the Physician.— Joseph Tomlinson (Bridgeport)
condemned the constant strain placed upon children attending
the public schools at the present day. All the facts should be
considered before determining the amount of mental work that
should be demanded from children, who are easily fatigued.
It was found that their recovery from mental fatigue is much
slower than it is from physical. It had also been found that
their resistance to disease is lessened and acute disease is
more prevalent during the examinations than at other periods.
All degrees of intellectuality are subject to the same studies,
and the question of sex is left out. Disorders of the nerves
are most common; kidney disease, brought about by mental
strain, is not uncommon, and there are other physical de-
fects. The baneful effects of examinations were pointed out, as
well as the deteriorating effects of the multiplicity of studies.
Children should receive mental discipline in school, which
should take the place of the present system of merely accumu-
lating facts. There was insufficient classification according to
physical and mental attainments. The conclusion of the author
was that the medical profession has an important duty to per-
form.
Discussion. — Richard C. Newton had always felt that in
the present system there is too little individuality and too
much uniformity. There is a foolish desire to excel, which
is fomented by the system of marks, etc. A good deal of it
is owing to vanity and the desire for applause, and this, in
children and parents, is one of the worst features. In this
there is a considerable difference between boys and girls. He
advised a change in the treatment of young girls, both with
regard to dress and play. W. B. Johnson (Paterson) said the
suTiject is both old and new. Great hygienic improvements
have been made, but with all their increased facilities the child
is living a more strenuous life now than formerly. The
range of the educator is limited, and his idea is to push
ever onward without due regard to the pupil. The curriculum
had been increased and the entrance examination to colleges
raised. It had been his experience, however, that girls gained
strength after entering college. Dowling Benjamin ( Camden)
said that nervous manifestations are far more frequently
observed after examinations in public schools than at any other
period. This is due largely to faulty grading. There should
be no difficulty in passing from one grade to another. Medical
inspection has been attempted in Camden, but the medical in-
spector did not inspect. The diagnosis is left to the teacher,
which he considered wrong. E.J. Ill (Newark) referred to
certain fatalities which had occurred within the last few months
in connection with medical examinations in New York, and
was of opinion that the reform should begin in medical schools.
D. C. English (New Brunswick) was inclined to think that it
would be wise for the society to appoint a committee to con-
sider the whole matter. The discussion was continued by a
number of other members of the society, the consensus of
opinion evidently being that the present methods of education
are not for the betterment physically or mentally of the
entire community, and the matter was finally referred to the
Committee on Legislation to bring in a report at the next annual
meeting.
Valvotomy as a Surgical Measure for the Cure of
Obstinate Constipation.— William M. Beach (Pittsburg),
a disciple of Thomas Charles Martin, of Cleveland, O., pre-
sented a specimen valve taken from a woman 64 years of age.
There has been, said he, a marked advancement lu rectal
surgery, which might still be said to be in its experimental
stage. He held that the rectal valve is always present, and
that it may become obstructive. The number varies. It has
a definite anatomic structure, although this is denied by some,
who call such valves by other names. He does not think it
matters what they are called if they are obstructions; he
considers the evidence that they are anatomic valves suffi-
cient. They may become pathologic, and, therefore, obstructive,
showing both local and systemic symptoms. In treatment,
surgeons may have difficulty in deciding whether massage is
be-tt, or whether valvotomy is necessary. When properly per-
formed valvotomy will remove obstipation and constipation.
In the operation the patient is placed in the knee-chest position.
The danger is from hemorrhage and peritonitis. (Previous to
beginning of fifth session Beach gave a clinic in the meeting
hall.)
Further Report on the Use of Ethyl Bromid as a
Primary Anesthesia to Ether.— Emery Marvel ( Atlantic
City) in tliis supplementary report furnished a number of
arguments in support of the use of ethyl bromid as indicated,
and referred to previous papers. The average amount required,
he said, was two fluid drams ; the time from nine seconds to
two minutes.
I To be concludeci,^
The Liecture Theater of Hippocrates. — The British
Medical Journal of June 21, 1902, contains photographs of an
enormous plane tree in the island of Cos, the island tradition
being that Hippocrates displayed his art of healing under its
branches. The tree is 18 yards in circumference, its large
branches being supported by pieces of antique columns. Near
by is a solid marble seat said to be the chair of Hippocrates.
The tree is reverenced, the Sultan, it is said, ordering it guarded
day and night, although there is no historical evidence that
Hippocrates actually taught under its branches.
Reorganization of the British Medical Association. —
The changes under discussion during the past year were voted
upon in extraordinary general meeting of the Association
June 18 and all ratified. "Stated in the broadest terms, the
object of the change now recommended to the Association is to
improve and extend the local organization of the Association
by providing small units of organization, to be called Divisions,
to utilize this local organization to provide a means for obtain-
ing an expression of the opinion of the Association at large
upon administrative or political questions and, finally, to pro-
vide a central organization for carrying out the expressed
wishes of the Association and of exerting more effectually its
influence on the Legislature."
July 12, 1902]
COREESPONDENCE
[Akerican Medicikb 49
CLINICAL NOTES and CORRESPONDENCE
[Communications are Invited for this Department. The Editor Is
not responsible for the views advanced by any contributor.!
I
ON FASHIONING APPARATUS FOR FLAT-FOOT AND
DEFORMITIES OF THE TOES.'
BV
ALBERT H. FREIBERG, M.D.,
of Cincinnati, Ohio.
Professor of Orthopedic Surgery, Medical College ot Ohio (Medical
Department of the Univer.sity of Cincinnati).
The reports of German writers showing that a desirable
material for tlat-foot supports had been found in celluloid, a
test of this material was undertaken. Difficulty in the manipu-
lation having Ijeeu encountered, a report of a metliod of work-
ing it and, in a preliminary way, an experience with it was
given in the Boston Afedical and StirgicalJournal of November
S, 1900. In this article it was suggested that the method
designed primarily for working celluloid might possess advan-
tages over previous methods in the fashioning of metal braces
for flat-foot.
Painstaking trial has convinced me that celluloid will not
answer the requirements whioli may be expected of it, at least
for adult patients. In order to withstand the body weight it
ha.s, in adults, to be of considerable thickness. In spite of
doing this the celluloid brace has not been found sufficiently
duraljle. It appears impossible to secure material of suf-
ficiently uniform characteristics, so that in patients who are at
all heavy the braces are liable to break within a very short
time. If this is fortunately escaped it will be found, again in
heavy patients or in the case of decidedly flat-foot, that the
brace fails to hold its shape. In children, on the other hand,
celluloid may be, at times, employed to advantage. It has
seemed better, however, to abandon its use altogether for val-
gus plates. •
Familiarity with the use of celluloid has, however, shown
it to be a material possessing advantages in the treatment of
hallux valgus and as well in the treatment of hammer-toe
where these are still amenable to mechanical methods. For
hallux valgus celluloid is used to make an adductor, for which
purpose a piece i inch thick, 1 inch wide and from :> to 7 inches
long is taken. Tape of 3 inch width being used to secure the
splint, slits of this length arc made near one extremity through
which a loop can be passed to engage the great toe. Near the
other extremity the tape is passed through two holes and is
used to liind the splint to the mesial aspect of the foot, passing
around the dorsum and sole. The degree of adduction is regu-
lated by bending the .splint in hot water. The splint is used as
a night appliance only either with or without the use of a toe
post for day wear as the case may require.
For hammer-toe, material of ^V inch thickness is employed.
At first a strip J inch in width and of suitable length is fastened
to the plantar surface of the toe by means of adhesive plaster.
This is renewed at intervals of a few days until the too has
become quite flexible. After this the splint may bo fastened to
the toe and foot by means of soft tapes through slits and in a
manner similar to that mentioned above. These splints have
been used with satisfaction in quite a number of cases for the
past year.
In fashioning metal plates for flat-foot it has been found
very satisfactory to use the method referred to. I will briefly
describe this as at present employed :
An impre.ssion is first taken by lightly but thoroughly
painting the sole of the foot with the following solution :
Tinct. ferrichlorld 50.0
Alcohol («0)i) 45.0
Glycerin 6.0
A cotton swab is used for this purpose, and the patient is
made to step upon a piece of white cardboard to secure the Im-
pression. While bearing his weight upon the cardboard a
l)encil is used to draw a contour of the loot, being especially
<areful along its Inner border and in the region of the astragalo-
scaphoid articulation, in order that the amount of i)ronation
I Read before tbe Amerlcau Urthopedio Association, June, IW-.'.
may be estimated. It is well at the same time to measure with
a tape the distance from the inner border of the foot to this
articulation when the weight is taken off, in order to ascertain
the required height of the inner flange. While the patient is
still standing one may also note upon the card the points corre-
sponding to the anterior tubercle of the os calcis and the middle
of the fifth metatarsal bone respectively. The impression may
now be developed by painting the card with a concentrateil
alcoholic solution of tannic acid. This impression is now used
to make a pattern of the l)race. This pattern is made in paraf-
fined paper, which is superimposed upon the impre.ssion and
with a pencil the pattern may be drawn, the footprint in plain
view. The shape of this pattern will vary according as one
wishes to produce one form or other of brace. The pattern is
reproduced in four-pound sheet lead. With a horn hammer
the lead pattern is now hammered simply by guess into the
shape of the future brace. In doing this the impression of the
foot with its contour outline is kept in view as a guide. This
having lieen done the patient returns and the pattern is fitted
to his foot. After the pattern has been fitted a plaster cast is
taken of its upper surface and this cast is sent to the artisan
from which to make a metal brace.
It is practicable l)y making use of this method to produce
any type of brace with which I am acquainted. Three forms
have been used by me within the last two years. The Whit-
man brace and a brace recommended by Ijange' are the forms
in which resistance at the outer border of the foot is olTered liy
means of Hanges. Lange's method has been recommended in a
somewliat different form by Sampson.' In this brace an ad-
ducted position of the foot is produced l)y having two external
flanges, the one making pressure upon the outer border of the
foot posterior to the flange of the internal border, therefore
against the os calcis. The second external flange is placed so as
to impinge upon the fifth metatarsal at about its middle. Both
the Whitman and Lange braces are exceedingly efficacious, the
latter being especially adapted for cases in which abduction
and pronation are features more prominent than the flatness.
The most valuable suggestion, however, may be found in the
article on " Pronation and its Holatlon to Treatment," by Hoke
and Bradford.' In this article it is shown how the lifting force
should be applied to the internal cuneiform and how the lift
should be carried forward to tlie third and fourth metatarsal
bones.
In no other manner which I have tried can the amount and
position of the lift which is to be given to the internal arch be
determined so well as in the method which I am recommend-
ing. This is even more true of the arching of the metatarsus
above referred to, and which I have found exceedingly impor-
tant. A much greater lift is borne by patients when this arch-
ing is made. The brace when made in this manner can, of
course, be provided with external flanges also. I have found,
however, that these arerarelynece.s.sary if the foot Is thoroughly
fle.xible, and, of course, it should be so before the application of
any brace. The brace when made in this manner has, of itself,
the appearance of a supinated position, and the foot will apply
itself to this in a very satisfactory manner.
In case external flanges are to be used, it Is best to leave
them flat on the lead pattern and, when fitting the pattern, to
hend these to the outer border of the patient's foot. This is for
the reason that it is otherwise difficult to tell what amount
of pressure is required or can be borne. It is also well in the
pattern to have both external and internal flanges somewhat
longer than necessary. They may then be cut In the fitting to
their required length by means of shears.
In a recent article, Nicoladoni ' has suggested that in those
severe ca.ses of flat-foot with convexity of the sole the flat-foot
brace as usually made Is inefficient. Ac<!ording to hint the
brace, made to act well enough in the standing position, loses
its effectiveness in the act of walking; during this, instead of
transferring the weight from heel to metatarsal heads by means
of the longitudinal arch, the sole rolls off of the plate as If It
were unsnpi>orted. In order to counteract this he proposes to
use a support convex, not only upon Its superior aspect, but
also upon its inferior. In this way. Instead of rolling off the
convexity of the sole, the foot rolls by means of the convexity
of the support, the vault being all tbe while supporte<l.
He offers a more practical solution In the form of a brace,
in which the whole plate Is to oscillate u|)on a pivot placed
horizontally at the medlotarsal Joint.
It nust be confessed that In tbe case of many supports
60 AMEKIOAN MEDICINB]
CK)REESP0NDENC1£
[July 12, 1902
Nicoladonl's objection holds eood. This is, however, for the
reason that the slope forward and downward from the highest
point of the lift in the plate is not sufficiently abrupt, or, to
refer again to the paper of Holie and Bradford, the great meta-
tarsal is not allowed to flex. If the support is made simply
from a corrected plaster cast this point is not lilfely to receive
the proper attention. With the lead pattern, on the other hand,
it is easy to determine the amount of flexion allowed to the
great metatarsal.
With the plate properly made in this way, I cannot see how
Nicoladonl's objection can hold. On the other hand, it appears
to me that with the adoption of any plan like that suggested by
Nicoladoni we abandon all hope of restoring to the flexors of
the toes their lost capacity for helping to maintain tlie arch, and
in addition cause the patient to wear an apparatus more com-
plicated, clumsier, and, I venture to say, not more efficient
than the old form if properly fashioned.
BIBLIOGRAPHY.
' Lange, Miinchener mediclnische Wochenschrlft, 1897, § 829.
2 Sampson, Amerlciin Medicine, January, 1902.
' Hoke and Bradford, Transactions of the American Orthopedic
Association, Vol. xlii.
< Nicoladoni, Deutsche Zeltschrift fiir Chirurgle, 63, § 166.
PROLAPSE OF THE UTERUS IN A NULLIPAROUS
WOMAN.
JOHN S. PEREKHAN,
of Chicago, 111.
M.D.,
To the Editor of American Medicrne .—In a recent article by
Dr. Henry D. Beyea, of Philadelphia, published in American
Medicine of May 17, 1902, " On acquired incomplete and com-
plete prolapse of the uterus and vagina in nuUiparous women,
with report of a case," I was somewhat surprised to learn of the
rarity of these oases. He was able to collect only 64 cases
reported, including the two treated at the Gynecean Hospital, in
12 years. Furthermore the doctor states that "men of large
and many years' experience, such as Olshauseu, Leopold,
Emmett and Kelly, have observed but a single, at most two
cases ;" and concludes that 1 % is a conservative estimate for jn-o-
lapses of the uterus occurring in nulliparas. Hence my report-
ing the following case :
Miss S. C, white, aged 64, weight 162 pounds, height 5 ft.
1 in., single, and positively a nullipara, gave the following his-
tory : Her father and one brother died from tuberculosis.
Mother died of typhoid fever, and one sister from spinal
trouble. Patient, aside of the usual childhood diseases, has
never been sick, with the exception of mflammatory rheuma-
tism, from which she suffered several attacks; at one time she
was in bed three months, and was unable to work for three
months longer. She has been employed as a cook in one family
for the last24 years. The first menstruation appeared when she
was 14 years of age, and had always been painful and the flow
very excessive, lasting at least one week ; menopause occurred
at the age of 50. •
Sixteen years ago the patient had a fall from a step-ladder ;
shortly afterward she noticed a small lump in the region of the
left groin (inguinal hernia). On consulting a physician, she
was advised to wear a truss which she did for nearlv 10 years,
when not being especially bothered with the hernia she dis-
carded her truss altogether. About six years ago for the first
time she noticed that something was wrong with her womb, she
could feel the cervix protruding through the vulva ; this condi-
tion kept on getting gradually worse until the womb was
almost outside the vulva. As it began to interfere with her
work and walking, in causing continuous irritation by rubbing
against her thighs, she was obliged to seek help.
I was consulted last November. On examination I found
the uterus in the third degree of prolapse, but no ulceration on
Its surfaces. Notwithstanding this prolapsed condition, with
5® j^'S^P*""^ °^ *^'^'^'' ''y^""'"'"'^ inconvenience of the mass,
she did not complain of any backache, bearing down pains or
any other symptoms so often complained of in these cases. As
she would not consent to a radical operation, I have been try-
ing to make her as comfortable as possible with different sup-
usually removed about once a week, cleansed, soaked in 2%
formalin sol., reinflated, then lubricated with zinc oxid oint-
ment and reintroduced. She is instructed to avoid lifting and
straining.
The causes of prolapses are admitted by most observers
to be, first, decreased support; second, increased weight;
third, increased intraabdominal pressure; the first and second
causes can in the great majority of cases be traced back to birth
of one or more children in the married, and in those in whom
the pelvic structures have been injured by laceration of the peri-
neum and vaginal walls, and suVjsequent enlargement of the
uterus due to incomplete process of Involution. I think in the
nulliparas increased intraabdominal pressure from excessive
fat, laborious occupations, constipation, straining at stools and
also during menstruation, when the latter is very painful,
are important factors in the causation of prolapses. Of course,
debility, loss of flesh, and absorption of the fatty cushion
around the uterus must not be forgotten.
SUSPENSION OF THE OVARY.
BY
BARTON COOKE HIR.ST, M.D.,
of Philadelphia.
To the Editor of American Medicine : — I have read with great
interest the valuable paper by Dr. Beyea in your issue of June
28, on suspension of the ovary. Since the three cases of mine
referred to by Dr. Beyea were published I have had a number
of others. One fact learned from this experience I should like
to emphasize. In intractable cases of retroversion of the uterus,
associated with prolapse of both ovaries behind and below the
womb, the suspension of the uterus and both infundibulo-
pelvic ligaments gives the most satisfactory physical and
symptomatic results. I have just examined a patient on whom
I performed this operation more than two years ago. She has
been delivered since under my care. Nothing could be more
gratifying than her present freedom from the distressing
symptoms that formerly tormented her and the position of the
uterus, tubes and ovaries leaves nothing to be desired.
To the Editor of American Medicine: — In connection with
your recent editorial comment on the hardship often involved
in the present noncooperative plan of separate State Board
examinations, permit me to record my own experience as
illustrating in concrete the truth of your position.
After graduating from one of our oldest and best medical
schools, and serving two years in two prominent hospitals in
an eastern city, I found it necessary, on account of my health,
to leave the coast. I settled in Minnesota and underwent the
rigid board examination required in that State. Six years later
the same cause compelled me to seek a still more favorable
climate, and I went to Arizona, reaching there shortly after the
establishment of the present Territorial Board of Medical
Examiners and a few days after the quarterly examination.
Having located 200 miles from Pha?nix, where all the examina-
tions are held, I went to the capital in July for the examination
— a trip requiring 24 hours each way, attended with much dis-
comfort, and at an expense of about S50. Some idea of the
hardship involved may be gathered from the statement that the
temperature was 110° in the shade in Phcenix and 94° at mid-
night on the way home.
Should I decide to exchange my present location in Arizona
for one in the contiguous State of California, offering a larger
and more attractive field of labor, I would again be put to the
anxiety, expense and, I may say, humiliation of another State
Board examination. In both these States the Minnesota certifi-
cate should be enough. The details of the hardships involved
in the present lack of cooperation among the State Boards
can be fully appreciated only by one who has actually ex-
perienced them. St'isscRTBER.
THE LATE PROFESSOR LEIDY'S LETTERS.
To the Editor of American Medicine: — The undersigned
has been for some time past collecting the correspondence of
the late Professor Joseph Leidy for publication. He would be
glad to possess copies or the originals of any letters of interest
that may be in the possession of readers of American Medicine.
Joseph Leidy. Jr.
July 12. 1902)
THE EFFICACY OF RECENT VACCINATION iamebioan mkdicink 61
ORIGINAL ARTICLES
THE EFFICACY OF RECENT VACCINATION.
BY
WM. M. WELCH, M.D.,
of Philadelphia.
Phyelclan-in-Charge of the Municipal Hospital for Contagious and
Infecllou.s Diseases, Philadelphia.
While it is true that the question of the protective
power of vaccination is mainly determined by statistics,
yet an intelligent person does not have to spend a very
long time in the wards of a smallpox hospital until he
is quite able to .settle this question in his own mind with-
out the aid of figures. The nurses, and even most of the
patients themselves, become convinced of the j)rotective
power of vaccination long before they know anything
about the figures that express the mortality rates of the
vaccinated and the unvaccinated patients. The much
larger proportion of deaths among the latter, the greater
amount of suffering endured by them, the more tedious
and critical convalescence when the acute stage is sur-
vived, and the more terrible physical deformities that
follow, are facts too evident to pass unnoticed, even by
an inexperienced observer. Indeed, there is a great deal
of strong and convincing evidence of vaccinal efficacy
brought to light in a large hospital that cannot very well
be expressed in statistics. As the saying goes, "seeing
is believing," and so an unvaccinated patient does not
have to occupy a bed in a ward for any great length of
time before he is convinced of his sin of omission and
realizes that he is paying the penalty. Frequently so
strong is this conviction that the patients desire to have
mes.sages sent to their relatives and friends urging them
to get vaccinated. On one occsision a kind-hearth man,
only a few hours before he was in the grip of death, dic-
tated a letter to his brother imploring him with all the
fervor and eloquence he could command to seek the
benefits of vaccination at once.
During the recent epidemic of smallpox in Philadel-
phia the admissions to the hospital comprised about an
equal number of vaccinated and unvaccinated patients.
The latter were made up mainly of young children and
adults in the prime of life ; the proportion of children
under 10 years being (juite large. The vaccinated
patients were almost wholly adults who had been vac-
cinated in infancy or early childhood. No vaccinated
child under ii years was admitted, and but few, if any,
under 10 ; excepting, of course, those that were vacci-
nated after infection by smallpox. In this connection I
would say that a colored boy, about 10 years old, who
was said to have been vaccinated four years previously
and showed a good scar, was admitted with a single
variolous vesicle. Also, I would mention that a white
l>oy, about 12 years old, who was said to have been vac-
cinated fiv(! years previously and showed a good scar,
was admitted with not more than two dozen variolous
vesicles, which dried up and disappeared quickly. With
these two exceptions I do not recall the admission of any
patient who had been successfully vaccinated as rtn-ently
as 10 years. Such evidence of the efficacy of recent vac-
cination is common in my experience, and it must be
equally so, I am sure, in the experience of others who
have had much to do with smallpox.
I have .just said that about one-half of the patients
aflmitted to the hospital were adults who had l)e»'n vac-
cinate<l in infancy or early childhood. This shows that
vaccination, especially when performe<l at an early peri(Kl
of life, cannot be de{)ended upon to confer permanent
immunity from smallpox. It is true, however, that
some persons are permanently immunized by an infantile
vaccination ; but in the vast nuijority of persons the pro-
tection either diminishes or is lost entirely through
lapse of time. Of course, the Immunity may be renewed
by re vaccination. It is in this waj' that the physicians
and attendants of smallpox hospitals are safe-guarded.
The eflieacy of recent vaccination was demonstrated
very conclusively by Jenner in his early work. His
first subject, James Phipps, was vaccinated May 14, 1796,
and, when the vaccinia had fully completeil its course,
Jenner says : " In order to ascertain whether the boy,
after feeling so slight an affection of the system
from the cowpox virus, was secure from the contagion
of the smallpox, he was inoculated the first of July fol-
lowing with variolous matter, immediately taken from
a pustule. Several slight punctures and incisions were
made on both his arms and the matter was carefully in-
sertetl, but no disease followed." ..." Several
months afterward he was again inoculated with vari-
olous matter, but no sensible effect was produced on the
constitution." Furthermore, Jenner says that all of his
early vaccinations were subjected to the .same crucial test
with like negative results. This shows how efl"ectually
he demonstrated the efficacy of his discovery before pub-
lishing it to the world. (Quoting his own words: "I
placed it on a rock, where I knew it would be im-
movable, before I invited the public to look at it."
While conducting his investigations, Jenner inocu-
lated with smallpox virus a number of persons who had
been accidentally infected with cowpox many years {)re-
viously ; in one instance the interval was as long as ."iS
years. None of these persons took smallpox, although
some were freely exposed to the contagion, as well as
subjected to the tt^t of variolous inoculation. He
selected these eases, he says, " to show that the change
produced in the constitution (by cowpox) is not affW-ted
by time." So convincetl was he that .such was the cjise
that he made use in his first paper, of this very positive
language : " But what renders the cowpox virus so ex-
tremely singular is that the person who has been thus
affected is forever after secure from the infection of the
smallpox ; neither exposure to the variolous effluvia, nor
the insertion of the matter into the skin, producing this
distemper." Hut as time elapsed, thus giving Jenner
greater opportunities for observation, he was forced to
admit that the immunity conferrwl by vaccination was
not invariably i)ermanent, and so he modified somewhat
his former statement, saying, " Duly and efficiently per-
formed, it will protect the constitution from subsequent
attacks of smallpox as much as that disease itsi'lf will. I
never expected that it would do more, and it will not, I
believe, do less." Of course, we all know that sec'ond
attacks of smallpox occur sometimes; but the statistic
data of a century show us what it was impossible for
Jenner to know, that smallpox after vaccination is far
more common than are second attacks of the diseiLse.
Fortunately, revaccination will supply this loss of pro-
tection.
The history of the introtluction of vaccination into
this country is interesting as showing how completely
its prophylactic power withstood the same severe test
that was applied by Jenner. Waterhouse, of Boston,
was the first person in this country whortn-eivtMl vawine
virus in an lu-tive state from England, and with it he
immediately vaccinated the memlM-rs of his own family.
About two months after his children had Ikhmi suwcss-
fully vaccinate<I he had them admitted into the small-
pox hospital at Brookline for the purpose of testing
their immunity. Finding they did not take the dis<«se
from exposure to the contagluni, he had them ukk-u-
lated with fresh inatter taken from a patient. .\s they
resisted the disease from this source also, Waterhouse,
being fully convince<l of the efficacy of vaccination, re-
marked, "One ffurt in such cases is worth a thousand
arguments."
During the early days of vac<'ination a dlfTcrenceof
opinion arose among the physicians of a ivrtnin town in
the State of Vermont in n^ard to the advisability of
adopting viu-cination in lieu of smallpox inoculation,
which was then generally practiseil. A town nie<'ting
62 Amkuican JIkdicine,
THE EFFICACY OF EECENT VACCINATION
(jui.Y 12, m2
was called to consider the question, and it was decided
to a|)point a committee to investigate the protective
l)ower of tliis new disease. Certain experiments were
deemed necessary, and with this object in view thecoin-
inittee assembled at the smallpox hospital. The first
experiment consisted in selecting 7.") persons among thos-e
who had been recently vaccinated and inoculating them
with warm smallpox virus immediately taken from a
patient suffering from that disease. The result was that
not one of the number took smallpox. Hut strange to
say the committee, as a whole, was not yet fully con-
vinced that the protection was due to vaccination. With
the ol'ject of settling the question to the satisfaction of
every member of the committee it was decided that the
exi)eriment should be made of allowing a recently vac-
cinated infant to take its daily supply of nourishment
from its mother's breast while she was suffering from
smallpox. Without nmch difHculty a woman was found
who was heroic enough to offer herself and her child for
the experiment. The infant was first vaccinated, and 48
hours afterward the mother was inoculated with small-
pox virus. The vaccine disease progressed in the usual
manner in the child, and so did the variolous disease in
the mother, while nursing was allowed to continue with-
out interruption. On the mother there were a consider-
able numtjer of variolous pustules, some of which being
near the nipple were kept raw by the lijjs of the infant
while sucking. And yet, we are told, "the child
appeared as well throughout the whole process as if it
had been nursed by a person not suffering from small-
pox." After this evidence of vaccinal efficacy had been
witnessed the committee asked for no further proof. I
inight add that I have more than once seen vaccinated
infants continue free from smallpox under similar con-
ditions.
As already stated, the efficacy of recent vaccination
has been proved over and over again by the experience
of every large hospital for the care of smallpox patients.
In the hospitals of London, from 1876-79, there were
admitted 11,412 smallpox patients who had been vacci-
nated in infancy, but not a single case was known to
have occurred in a person who had been successfully
revaccinated. It was the rule to revaccinate all nurses
and employes' before entering the hospital, and the num-
ber thus employed amounted to about 1,000; of these
only some half dozen took smallpox and they, for some
cause or other, had escaped revaccination. Dr. Marson,
Physician to the Smallpox Hospital of London for many
years, says : ' " In 35 years I have never had a nurse or
servant \vith smallpox ; I revaccinate them when they
come there." Dr. Collie, whose experience is also large,
says : * '-During the epidemic of 1871, out of 110 small-
pox attendants at Homerton all but two were revacci-
nated, and these fivo took sma/fpox.'"
At a meeting of the German Vaccination Commis-
sion (1884) Dr. Eulenburg-^ related "that a manufac-
turer in Posen had all his workmen vaccinated except
one, who refused. This man alone of the 150 took
smallpox shortly afterward and died." Many similar
instances have been observed by others and might be
referred to without much trouble.
My main object in presenting this paper is to call
attention to some facts showing the protective power of
vaccination, especially recent vaccination, that have
come to my notice during the recent epidemic of small-
pox in Philadelphia. I might add that these facts are
not new ; but it is hoped that cumulative evidence of
this kind may serve a useful purpose.
It seems to me that it would be impossible to convey
a better idea of the value of vaccination than to tell you
that no person who had been recently successfully vacci-
nated was admitted to the hospital with smallpox.
Since the outbreak of the disease in the city, which
' K. J. Edwardes, M.D , M.K.C. P., Loud. (The Practitioner, May,
sj.oc. cit.
occurred last fall, every phy.sician has been very busy
in the work of vaccination, and as a result of their com-
bined labor it is fair to assume that at least 500,000
persons have been vaccinated. If vaccination confers
no protection against smallpox, is it not reasonable to
suppose that some of these persons would have contracted
the disease and been brought to the hospital ? But no such
patient can be found among the admissions, which num-
ber nearly 2,000. Fortunately, we do not have to rely
upon such negative evidence, as strong as it is, to prove
the efficacy of recent vaccination. Opportunities which
enable us to determine its prophylactic value frequently
occur in the hospital. If time permitted I could give
many examples, but I shall present only a few. A child
of one year who had been successfully vaccinated about
10 days before admission was sent to the hospital with
roseola vaccinoea, which had been diagnosed as variola.
The child remained in the smallpox wards about three
weeks and continued perfectly well. Another child, of
nine years, with exactly the same history, returned
home perfectly well after a constant exposure of over
three weeks. An unvaccinated colored child, about two
years old, was brought into the hospital with a sister
who was suffering from smallpox. Immediately after
admission vaccination was performed, and although the
child was constantly exposed to the infection for three
weeks he did not take the disease. Several other children
and also some adults, who were sent to the hospital under
erroneous diagnoses, were vaccinated for the first time
after admission and were thereby rendered absolutely
immune.
In every epidemic of smallpox that has occurred in
Philadelphia within the past 30 years, instances have
been observed of whole families being removed to the
hospital because of an outbreak of the disease in these
families. In such instances the unvaccinated children
have suffered and often perished, while those who were
vaccinated remained perfectly exempt, although living,
eating and sleeping in the infected atmosphere for sev-
eral weeks. But I have yet to see a single unvaccinated
child escape the disease under similar conditions of
exposure. Furthermore, I have more than once seen a
vaccinated infant take its daily supply of nourishment
from the breast of its mother who was suffering from
varioloid and the infant continue as free from smallpox
as if the disease were 100 miles away and the food
derived from the most wholesome source. This is evi-
dence of the prophylactic power of vaccination that does
not appear in mortality reports nor in statistic records.
Not many weeks since, a pregnant woman nearly at
term was admitted with varioloid. In the course of the
disease labor occurred, and a male child weighing 8i
pounds was born. About five hours after its birth the
infant was vaccinated, two insertions being made.
Again, two days subsequently, two more insertions were
made. Four large vaccine vesicles developed, causing a
very sore arm, but did not give rise to any considerable
elevation of temperature nor to any apparent disturbance
of the health of the infant. After remaining in the
hospital 32 days and proving its newly-acquired immu-
nity to smallpox in a most indubitable manner, the
infant was taken home by its mother, who had made a
good recovery without any untoward symptoms. At the
request of the mother the child was fed from the bottle.
In the early fall of last year smallpox broke out in a
certain family, and the entire household, including
father, mother and six children, were admitted to the
hospital. The parents were vaccinated in infancy, but
as the protection had l.ecome somewhat diminished
through the lapse of time, they both suffered from a mild
attack of varioloid. Their four youngest children were
unvaccinated and they all had unmoditied smallpox.
Two children had arrived at the school age, one four
years and the other two years ago, but before they could
be admitted to school vaccination was necessary. Each
child showed a good scar. These children remained in
JULY 12, 1902]
THE EFFICACY OF RECENT VACCINATION
iAkkbioam Medicine 53
the hasi)ital three or four weeks, being in daily contact
with the worst cases of sinallpox, and at the end of that
time returned to their home witliout having shown any
sym[)toms wliatever of the disease. The father, like an
honest man, said: "I never believed in vaccination
before, but am now convinced of its efficacy, and when I
return home 1 shall preach it to my friends." I might
add that this man is not the only antivaccinationist who
has left the hospital fully converted. This institution
would be indeed a dangerous place for the president of
the Antivaccination League to visit if he did not wish
to lose his office.
In the early part of this year a colored child, aged 3,
was sent to the hospital with a few small pimples of no
very definite chanicter. Smallpox was suspected, as that
disease had broken out in the family. The child had
been successfully vaccinated about four months before.
After constant exposure for 16 days, immunity being
clearly d(!monstrated, the child was allowed to go home.
About the same time three white children were
brought to the hospital with their mother, who had
smallpox. They were not ill, but sent in because they
had already been exposed, and also because there was no
one left at home to care for them. These children were,
respectively, 7, 5 and 4 years old. Each had been vacci-
nated exactly three years and seven months before, and
each showed a good scar. Immunity to smallpox was
proved l)y their residing in the hospital for three weeks
free from the disease.
J. B., aged 29, married, and the father of three children, was
admitted March 27, with varioloid. On April 5, the wife of this
man was also admitted with varioloid, bringing witli her the
tliree children, as there was no one left at home to care for them.
One child, 5 years old, hatl been vaccinated six months pre-
viously and showed a good scar. The other two children, one
3 years and the other 10 months, were vaccinated March 30,
and each prasonted two vaccine vesicles that were developing
Serfectly. These three children remained in the hospital 17
ays under constant exposure without taking smallpox.
Similar evidence of the prophylactic power of vacci-
nation has come to my notice repeatedly, both inside and
outside the hospital. Very frequently indeed have I
been told by patients that their older children who had
to be vaccinatt'd before they could get into school were
left at home perfectly free from smallpox, while the
younger ones, teing unprotected, were brought in with
the disease. Oh, how often have I seen such parents,
after losing a loved one, grievously mourn and refuse to
be comforted l)ecause of the consciousness of having
neglected a most important duty ! I have often wished
that the ghosts of these innocent and helpless children
could return to haunt the anti vaccinationists, who are
largely responsible for this neglect of duty.
In order to provide accommodation for the unusu-
ally large number of cases of smallpox, and this number
rapidly increasing, it was necessary U) erect additional
buildings as well as enlarge those already in use. On
this work from 50 to 60 men were employed, and as they
were required to come constantly into close proximity
to the patients they were all reciuested to come to the
administration building and get vaccinated. This
r(!((uestwas complied with by all except two, and these
= two t^)ok smallpox. I would emphasize the fact that
' they were the only ones that were stricken by the dis-
ease. One, I understand, was a Christian Scientist, and
he trusted U) this delusion for his protection. Poor fel-
low ! it did not even save his life, as he fell a ready vic-
tim to a disease that respects nothing but vaccination.
Li\UT it was found necessary to enlarge still further
s(»m(! of these buildings, and other workmen were en-
gaged. Two of these, for some reason which I never
learned, neglwted to get viux-inated btifore commencing
the work, and they both took smallpox.
For the last thre<! years the medical schools of Phila-
delphia have had the i)rivilege of sending their more
lulvanced students to the Municipal IlospitiU for clinical
instruction in the various contagious and infectious dis-
eases therein treated. During the past winter 170
students received such instruction, not only in the diph-
theria and scarlet fever wards, but also in the smallpo.v
wards when there were about 300 cases of that disease on
hand. One of the re<iuirements was that each student
must show evidence of protection, either by having l)een
recently successfully vaccinated or by not responding to
vaccination after two or three careful trials. It gives
me great pleasure to state that not one of these students
contracted smallpox.
Since the present epidemic began, about 125 i)er8ons,
including physicians, nurses, ward maids, cooks, laun -
dresses, and the like, have been continuously expostnl to
smallpox in the hospittd, and not one has fallen with the
tlisease. I should jierhaps mention the case of an
employe who worked in the disinfecting plant which is
located on the grounds. It was his business to handle
infected clothing and bedding. He soon became dis-
siitisfled with this work and removed to the interior of
the State. When he had been there but a few days, I
am informed, he took smallpox. This man had been
vaccinated in infancy, but declined to lx> revaccinated.
All those employed in the smallpox pavilion, except
two or three who had the disease at an early periini of
life, owe their immunity to vaccination. Previously to
assigning them to duty each person is csirefuUy vacci-
nated, even though the vaccination of infancy and a sub-
sequent revaccination may show evidence of having
been successful. With this care I have never seen a
resident physician or nurse take smallpox. I do not
hesitate to say that after a recent successful vaccination
an individual can dwell in an atmosphere surcharged
with the most virulent variolous poison, and live and
breathe and eat and sleep there in safety. As the three
Hebrew children of old, under proper protection, walked
up and down in the flery furnace and came forth without
a single hair of their heads being singe<l, or even the
smell of fire on their garments, so nurses and others
when recently vaccinate<l need have no fear for that
malady which might be likened to "the pestilence that
walketh in darkness, nor for the destruction that wasteth
at noonday." Such absolutt^ protection under conditions
of extreme exposure is what has hapi)ened in every epi-
demic of smalliMjx since Jenner taught us how to control
the pestilence, and is happening today in the wards of
every well conducted hospital. What vaceination d(H's
for these persoiLs that dwell in the midst of danger it
will do for any one that is brought properly under its
influence.
Women students are not allowed to matriculate at the
University of Oottinnen.
Malarial Exhibit at Palermo, Sicily.— A special feature
of the Sicilian agricultural exposition at ralormo, Sicily. May
2(i 1(102, was a department devote<i to exhibits bearing on the
hygienoof malaria. This is in lino with the popular jiropa-
gauda at present being i)ushed in all i)aludal se<!tlons of Italy
with a view to arresting th<! devastation that forages has been
wrought by malaria in Otherwise prixhKaive agricultural dis-
tricts Simultaneously with the first wceli of the exjmsltlon, a
me<li<al congress was hold in the hall of the ITnivorsity of Pa-
lermo There was a spec^ial meeting to discuss the subject of
malaria. Seven hundred delegates from all parts of Sicily wore
nresent. Tho Italian Minister, Dr. Haccclli, spolie at length,
discussing the subject of malaria from all point* ol viow dwoU-
inir osDocially on the relation of the mosquito I" tho dmeaso.
The exhibit at the agricultural exposition is of a popular
nature A railroad station supplied with mosquito t)Brs and
similar appliances has been erected on tho grounds. I hese
stations are now in use on all Italian railroads running
through malarial regions. There are llguros of railroad ope-
rators protected againit mos<iuil<>s by suiUblo v(!ils. Large
models of tho culox and the anopheles bring out prominently
the morphologic characters of tho mosquilos. Maps showing
the lerriU)ries alHIctcd by tho disease have prominent pla<Hw on
tho walls. Intorosting pic.tnriw and diagrams demonslraling
tho life history of tho mosciuitx) arc exhibited. I ho whole sub-
ioct is nrosontod In such a prai'llcally demonstrative way lliat
it can not fail to imprftss tho hygienic lessons to be learncMl from
a precise knowledge of malaria, Ita cjiuso, prevention, and Irmtr
ment.— l/'ufcttc Health Ilrpmt.]
54 AMBiuoAK MBoiciNKj WHY NOT TREAT GALLBLADJ3ER AS APPENDIX ?
[July 12, 1«H
WHY SHOULD WE NOT TREAT THE GALLBLADDER
AS WE DO THE APPENDIX ':"
iiy
KOSWELl. PAKK, M.D.,
of Buffalo, N. Y.
Till' olyt'ctof tli(> prtwcnt jiapor is U) iiivik^ attention
to till! ro.s('nil)lanw8 in function iu'twoon tiw gallbladder
and the appondix, iw well a.s the similarities between
many of the i)athott)}?ic conditions which I would wisli
to have you interi)ret as calling e(]ually for radical
removal of the organ in question, whicliever it may be.
First of all, there are certain resemblances in func-
tion and structure between th&se two appendages. Both
of them are hollow receptjicles, both more or less tubular
in shape and arrangement, both normally contain a cer-
tain amount of secretion, and most important of all, both
are essentially superfluous organs, neither of them being
necessary for normal purposes of life. The gallbhwlder
is a reservoir lined with mucosa continuous with that of
the intestine. The vermiform appendix is scarcely even
to t)e dignified with the importance of a reservoir, is
lined witli the same mucosa and whatever its function
may originally have been, it is now almost useless. So
long as each of these cavities can discharge itself easily,
there is little likelihood of trouble. It is when occlu-
sion, no matter whether recurring or permanent, occurs
that trouble begins. This occlusion is produced in either
case by analogous processes, in which bacterial infection
plays a prominent part. Both cavities contain secretion
from which calcareous deposits may be ijrecipitated ; in
other words, in both is there liability to formation of
concretions. The amount of pain and disturbance which
may be produced by these small stones is, of course,
well known to you and is entirely disproportionate to
their size and apparent significance.
Much attention has of late been paid to the toxemia
or stercoremia which follows retention of appendicular
contents. There is a less general appreciation of a per-
fectly analogous toxemia which comes from retention of
morbid products within the gallbladder, although I
doubt if any man can reflect upon these ca.s&s intelli-
gently without recognizing that which has previously
escaped his notice. I have had such frequent occiusioii
to be amazed at the degree of toxemia which may be pro-
duced under these circumstances that I wonder that they
did not appeal to me in this regard many years ago as
they do now.
Further resemblances are seen in that each may
become anchored to its surroundings by a variety of
intrinsic or extrinsic lesions, and each when so anchored
produces a degree of tenderness of pain and of disturb-
ance of function which is not always to l)e measured by
the mere density or number of such adhesions. Each in
its place, moreover, may lead to coprost<isis by interfer-
ence with the motility of the colon. Each again may
cause localized pain and tenderness with acute exacerba-
tions which are a constant menace to the welfare of the
individual. Sometimes this tenderness is very easily
evoked, and other times it takes deep pressure to call
forth the response. Sometimes the enlarged organ can
be felt through the abdominal wall, and sometimes it
cannot. Still, in either case we may fall back on the
general expression of tenderness as a safe sign of disea.se
in the part below.
.Just as the appendix when compromised disturbs
the function of the cecum, so does the gallbladder when
involved especially and often disturb the normal action
of the stomach and of the pancreas; and numerous
cases of pain, tenderness and associated dyspeptic symp-
toms, referred primarily to the stomach, are in effect the
result of a compromised gallbladder. Moreover, just as
trouble may radiate from the appendix proper and dis-
June^l!»i^'^°™ "** American SurgicaT Association, Albany, N. Y.,
turb the function of the ovary or even of the bladder, so
may lesions of the gallbladder completely upset the
stomiM-h and i)roduce such symptoms as to be mistaken
for gastritis or gastric ulcer.
This incomplete list of resemblances might be well
supplemented by a further stat<,'inent that in either case,
when the i)art isdisea8e<l, it is a constant source of irri-
tation and even a menace to life.
Assuming, then, that the organs themselves and their
diseases so completely resemble each other, you will l>e
(juite ready for the imiwrtant surgical question, " Why
should we not treat •them both alike?" Kej)lying to
this self-raised question, I would further say that such is
now my custom and my teaching. Whether, then, the
case be acute and fulminating, or chronic and growling,
I would say that the diseased and troublesome gall-
bladder, like the diseased and troublesome api)endix,
should come out, and that we should now formally
include a cholecystectomy as the ideal oi)eration corre-
sponding to appendicectomy. My past year's experience
with a relatively large number of these cases has taught
me that one is no more dangerous than the other, and is
ecjually satisfactory. I now scarcely think of heaving an
evidently diseased gallbladtler, after exposing it, any
more than I would think of partial oi)erations upon the
appendix. It is in almost all cases not a difficult matter
to throw a ligature around the cystic duct near its
entrance into the common duct and to extirpate the
gallbladder from the lower surface of the liver, tying off
vascular adhesions, and, if neces,sary, 0{)ening the cyst
for the purpose of emptying it, in order to make this
extirpation more easy. In fact, I sometimes not only
open it, but widely, in order that with one or more
fingers in the inside I may expedite its separation from
the liver or adjoining viscera. This method is now-
demonstrated to be vastly preferable to the old method
of opening and drainage with too frequent and almost
permanent sinuses which remain thereafter.
It is fair to maintain that when the gallbladder is
occluded and contains calculuses with old, more or less
inspissated or altered mucus, it has ceased to functionates
as a gallbladder and is more than useless, is a source of
offense.
When it is thus removed it can no longer furnish
calculuses which shall cause trouble within the ducts or
which shall provoke or irritate the pancreas.
I would repeat again that it is astonishing what a
degree of toxemia can proceed from the contents of an
old and occluded gallbladder. On the other hand acute
gangrenous affections of the gallbladder are much less
common than those of the appendix, all of which is due
largely to the variations in their blood supply and ana-
tomic arrangement ; nevertheless, even in acute cases of
cholecystitis there are exceedingly strong and unmistak-
takable resemblances to acute appendicitis.
So far as the danger of the operation is concerned, I
have come to believe that operation on one is scarcely
more risky than upon the other and that there are the
same reasons for prompt and early intervention in one
case which we meet in the other. Looking hack ui)on
my own past experience I am perfectly willing to record
my regret that convictions to the above effect have not
overcome my prejudices years ago. I have never regretted
removing a gallbladder and have more than once had
cause to regret not doing so. It has now Ix-come with
me as standard a procedure a.s removetl of the ajjpendix
and seems to me one to be practised with much greater
fre(iuency and to be recroni mended in a large proportii)n
of cases which have hitherto been restrained from com-
ing under surgical management.
For Founding Hospitals in China. — An association has
been fornied in Tokio for tlie jmrpose of fonnding hospitals in
China, this being considered tlie best means of securing Chinese
sympathy with Occidental science.
July 12, 1902|
NEW METHOD OF BONE GKAFTING
IAmxrican Mrdicink
A NEW METHOD OP BONE
GRAFTING : REPORT OF
A CASE.
BY
A. W. MORTON, A.B., M.U.,
of San Fnmcisco, Cal.
Proft'ssipr i)f S<iiri;ory, College of I'livsi-
ciaiisamlSiirneoiistSurgeon-lii-Cliiel',
Morion's Hospital; Visiting SSiir-
geon, City and County Hospital;
Uonsniting Snrgeon, California
(ieneral HospilJil ; and Sur-
geon to the SantJi Fo Ilall-
road San Kraneiscit, Cal.
The (Icfefts in bone struc-
tures heal so slowly that it is
no wonder we are advised to
sacrifice many extremities
which might be .saved if we
better understood the metliods
of repair.
Many surgeons in their
efforts to restore bone have
attempted to use nonabsorbable
material, such a.s silver plates,
copper amalgam, plaster-of-
paris, platinum, iridium, gut-
tapercha, celluloid and many
I'Igure ).— Tho dog Incased.
1. t'osmetic effects in repair-
ing the deformities about tho
face. This method of tran.s-
planting a Hap, including tho
skin, superficial structures,
periosteum, occasionally the
ui)per layer of bone, with a
(jedicle attuchetl, is often made
use of to repair defects al>out
the nose, face and trachea, or
to close spaces about the
vault.
2. To fill in the cavity of
l)onesto hasten recrovery. Small
fragments of fresh bone from a
pernon, or lower animal, or <k'-
tutsionally the decidciflwl l>ono
chips of Senn, are used to close
a ,steril(> bone ciivity. These
reports should be considered of
questionable value when we
consider that one of the require-
ments is to cover the fragments
with periost<'um, which has the
power to reproduce bone;
again, years have elajjsed aiui
the bone chips have be<'n
found in the cjivity without
Figure 2.— liiniiliug the dog.
other substances, some of which have been
very useful.
Our knowledge of thi.s subject is lim-
ited, jiiid most of tlu^ work done has btieii
very unstitisfactory, which we would nat-
urally ex]KH-t when we consider that the
bone [iroper has very little tendency to
rei)air, and that it is principally from the
osteoblasts of the piTiosteum, and the my-
eloblasts of the medullary tissue.
In all tlu! methods in use it is nwessary
tu have not only an a.septic ciivity, but a
very limited one, and a bountiful supi)ly
of periosteum.
There are certain conditions in which
I laiisplantiiig of bone is especially indi-
cated :
Figure 8.— Time of ncpurulloii
66 AKBBICAH HBOIOXNI]
NEW METHOD OF BONE GRAFTING
(JULY 12, 1MB
Figure 4.— Bones placed In position, upper part closed
undergoing a change, simply remaining as a foreign
body.
3. The most important indication to bo met is to
restore the continuity of the long bones, to support and
protect the trunk. When extensive defects in a long
bone exist as the result of the destruction of periosteum
and medullary structure, by some mechanical injury or
disease, the only method by which it can be repaired is
to transplant a large piece of bone with vascular attach-
ments from some point near the defect, so that its petl-
icle will have plenty of blood supply ; the deformity
will seldom be in position to make use of any of the
ac\joining bone structures without interfering very
materially with the function of the part.
The case reported here shows the advantage of trans-
l>lanting bone from lower animals to repair bone defects
in man. This is unquestionably the first successful case
of l)one transplanting by vascular attachment from ani-
mal to man.
A.-B., aged 45, of Swedish decent, was free from any
hereditary tendencies to disease. His weight is 2t5 pounds,
his liealth has always been good, he uses liquor and
tobacco in moderation ; his occupation is that of a painter.
September 8, 1900, the patient fell about 12 feet, striking on the
sidewalk and producing a compound comminuted fracture of
the tibia and fibula of the right leg near the lower end. He
was admitted to the City and County Hospital on the same date;
the fracture was set, drained and placed in a fracture box, but
the leg became euormously swollen and sepsis soon developed.
The patient came under my charge October 5, about one month
after the injury; he liad the appearance at that time of a person
suffering from sepsis ; his injured leg, including the knee-joint,
was swollen ; temperature ranged from 100° to 103° ; pulse-rate
100 to 110. A few days later an incision was made over the tibia,
free drainage established and necrotic pieces of bone removed ;
the parts were placed in plaster cast (with window), and after-
ward removed and kept in fracture box. His general condi-
tion improved, but there did not appear to be any repair at the
seat of fracture.
November 14 the patient was placed under the influence of
medullary narcosis and the parts opened. I found the lower
end of the tibia denuded of periosteum and the end necrotic.
The lower five inches of this bone was removed with a chain
saw ; the fibula had united ; the wound was swabbed with tinc-
ture of iodin and drained. The patient was returned to the
ward, the leg placed in fracture box, with little doubt but that
It would be necessary to amputate.
In a few days the parts improved, and on the twenty-eighth
day of the same month the patient was again placed under
medullary narcosis, the periosteum resected back, and the
end of the bone freshened, so there was free liemorrhage. A
black-and-tan dog of medium size had been prepared by trim-
ming the hair, bathing and sliaving the fore legs. The dog was
placed under ether and the left fore leg thoroughly cleansed
and amputated just al)ovo the tar-
sus; the ulna was left one inch
longer than the radius; the skin
and muscles were divided by a
longitudinal incision for about four
inches and left attached, except
about three inches at lowest end,
wliich was removed to the perios-
teum; the cut ends of the ulna en-
tered the cavity of tlie tiljia one inch
and were united with silver wire
to same; tlie fibula was wired to
tlie end of the tit)ia. The upper
part of tlie incision in the patient's
leg was closetl by stitclies ; tliis
placed the dog's leg on nearly the
same plane as the man's leg; the
wounds were drained, as they
were not aseptic ; all the stronger
tendons in each leg of the dog were
severed by a subcutaneous incis-
ion ; the wounds were dressed
with gauze, and the other three
legs of the dog were encased in
plaster-of-paris separately ; the dog
and the leg of the man were incased
in a plaster cast, extending to the
knee of the patient. A space was
left beneath the dog to prevent soil-
ing from the urine or feces ; a win-
dow was left at the wound, so that
dressings could be changed. The
plaster cast was made heavy and
strong bjf imbedding splints in it.
The patient was returned to the
ward. The man suffered very little
pain, or inconvenience, except for
two or three days, during which the dog was restless, and
would attempt to move, and the more the dog would move, the
more pain was not only inflicted on the patient but also on
himself. He soon realized this, so that it was not necessary to
give any morphin to the dog after the fourth day. The dog and
man became very much " attached " to each other.
The patient's general condition gradually improved and his
Figure 5.— Callus forming
July 12, 1902]
CHEMIC PATHOLOGY OF THE SALIVA
[AxEBiCAN Medicine 57
temperature and pulse remained about
normal after the third day.
To Iceep the dog tightly incased in the
cast, it was necessary to pack cotton and
gauze around liini, as he lost considerable
flesh.
Five weeks later the man was again
placetl under medullary narcosis, and the
dog under ether ; the ca.st was removed,
the skin and muscles were separated from
the dog's leg, and the two bones divided
near the joint, and placed in contact with
the astragalus ; the skin and deeper struc-
tures were united, except at the point of
drainage, which slowly closed by granu-
lation, out at the lower angle a fistula re-
mained, through which a small fragment
of one of the bones passed, which was
broken at the time the dog was detached ;
this occurred four months later.
The skiagraphs taken three
month.s after the operation show
the callus around the bones, the
(log's lK)ne remaining in the center.
A recent one shows where the
lower end of the tibia has formed
bone corresponding in size to the
tibia.
Tlie patient walks about with
his cane, but can get around without
it, and has a very useful leg.
This case demonstrates that de-
flcienciPH of bone in man can be
successfully supplied by trans-
jjlantations from the lower ani-
mals by means of vascular attach-
ment.
THE CHEMIC PATHOLOGY OF THE SALIVA AND
PHARYNGEAL SECRETIONS (SIALO-SEMEIOL-
06Y) AS A MEANS OF DIAGNOSIS.'
BY
D. BRADEN KYLE, M.D.,
of Philadelphia.
In the course of my laboratory investigation I have
often been impressed with the importance of the chemic
changes which occur in various secretions, especially the
sjiliva and the tissues of the body. Very little is known
alK)ut the chemistry of what we call normal saliva, and
when we add to this pathologic materials and alteretl
chemistry it is easily understood why so little is deli-
nit*?ly known on the subject ; besides, the field for inves-
tigsition is ho exttmsive and involves the application of
orgiinic chemistry. It is a well-known clinical and
laboratory fact that a study of the products of the secret-
ing organs, which in their excretory functions throw off
waste material, gives us by deduc-tion a fair id(« of what
process is going on within the body. Yet this excretory
secretion or mat<>rial is altered in its chemic composition
and controlled by the chemic constituents within the
ho<Iy j)roper. There is no question that und(>r rertain
conditions, for (example, when the secretions are acid or
iilkaline, that the chemic pnx'css taking place within the
various secretory glands must vary and the product of
such variation in these unknown (juantities must be
sdmcwhat the same as the variations we would obtain
in dealing in the laboratory with known comi)ounds.
In oth(?r words, that th(> bcxly is largely a chemic labora-
tory, having on hand a certain amount of material and
having added to it daily other ingredients through the
respiratory and alimentary tract. Now, any i)erverted
condition from what is known as the normal chemistry
may bring about a series of changes and product? chemic
l)roductH which maybe harmless or productive of disease
• Head l)eforo the Twpiity-fourtli AiinuHl OiiifreHs of the American
I'UryngolOKlcal AHHociutioD, BoHtoii, Muhh., May 27, 1902.
Figure 6.-81X months after union.
Kigure 7.— At prencnt.
processes. On no other basis can we explain the various
diatluwes and [the pre<'ipitation of certain mHt<>rials in
the tissues of the bmly— for example, why uric acid
should Im- formed and prwipitat*^! in so many and varle<l
68 A.1CBRICAN MKOtOINR]
CHEMIC PATHOLOGY OF THE SALIVA
[July 12, 1902
forms ill wrtain individuals, while others are absolutely
free from wuch cliemic coiiipouiulH.
I dev<)t<'d a nuiiiher of lectures to this subject during
my course on jtathology in the Jefferson Medical ColhiKe,
1895-0, being so impresscid with the import of the
study of not only the excretions from the intestine and
kidney, but also of the saliva and various secreting
glands, carrying on, as time would permit, investiga-
tions in this line in my own private laboratory.
That cell nutrition depends upon the clieniistry of its
supply is illustrated in disease processes iissociated with
any form of infection or rise in temperature. This opens
up an enormous field for speculation and investigation.
The amount of Infection, the peculiar chemic change
l)roduced by temperature, the materials absorbed into
the body from infective procasses, or the autoinfection
from the intestinal tract, would in each condition pro-
duce its own peculiar chemic compound. Yet I believe
a general ba-sis or standard can be reached, at least suf-
ficiently accurate, from which to draw chemic and clinical
deductions. For example, of* peculiar effect on various .
structures in the body, brought about by an altered
chemistry, I will quote from an article which was pub-
lished in American Medicine, February 8, 1902, in
which I reported a number of ca.ses of enlargement of
the thyroid gland in which the cellular elements of the
thyroid structure were Increased, the enlargement not
being due to distended vessels, cystic condition of the
gland, or new growth. I reasoned the matter out as
follows : It is a well-known i)hysiologic and therapeu-
tic fact that certain drugs have a selective action on cer-
tain tissues or organs of the body, e. g., belladonna with
its selective action on the pharyngeal surface, sodium
phosphate with its selective action on the liver, etc. It
is also a physiologic fact that the normal chemistry
of the body controls the normal secretions from the
various secretory organs, that any perversion from
the normal necessarily alters the character and chemis-
try of the secretion, and that the products of sucih
alteration act as irritants to certain parts of the body ;
the difference between this and drugs administered
is that one is introduced into the body and one is
manufactured within the body. I therefore reasoned
that under certain conditions there was precipitated
— due to perverted chemic reaction — a certain material
which, circulating through the blood, had a select-
ive action on the thyroid gland, acting as an irri-
tant to that gland and stimulating its blood-supply.
While the treatment of these cases reported was largely
enipirical, I believe, however, that the drug introduced
into the body, by its chemic action, altered the chemis-
try of the material which was acting as an irritant,
either rendering that irritating material inert or forming
a compound which was non-irritating. I was convinced
that from the study of the saliva we could determine to
a great extent any variation in the chemistry of the
body. As these various secreting glands receive from
the blood the supply from which they elaborate certain
chemic compounds, if an analysis be made of the com-
position of such secretion it would give a good index to
the general condition of the individual, and while in
many cases the deductions have to be based on, or
rather associated with, clinical observation, I soon found
them to be of immense value from a standpoint of
diagnosis.
Some work has since been done in this line. Michaels,
of Paris, in his admirable paper read before the Interna-
tional Dental Congress, August 9, 1900, was the first, I
believe, to call attention to this subject, not in medicine,
but in its relation to dentistry ; also, since Michaels'
paper. Kirk of Philadelphia has taken up the investi-
gation. A few ca,ses will serve to illustrate the import
of the saliva from a standpoint of diagnosis, and I will
refer only to ciises which are intimately related to our
own specialty. The first case in which I made a study
was as follows :
Mr. C, aged 42, consulted me in regard to what he supposed
to be a catarrhal condition associated with ozena. His breath
was surely most offensive, but although pronouncedly so, it
was not the penetrating, clinging odor observed in atrophic
rliinitis with ozena. He had observed the condition rather
suddenly and it had existed continuously for some four or five
years. His history was absolutely negative as to any catarrhal
condition other than an occasional cold. He had consulted
specialists both in this country and abroad, not only as to the
possibility of the odor coming from the nose or some of the
accessory cavities, but had also consulted specialists on diseases
of the stomach, as well as having had a thorough inspection of
all his teeth. He had been told that he luid practically no
catarrh, and as his digestion was good and nothing found wrong
by analysis of the contents of tlie stomach, it was quite puz-
zling as to the source of this odor. After a thorough examina-
tion, and knowing that the men under whose care he had l)een
were most thorough and competent in their line, I reasoned that
there must be some source of the disagreeable odor outside of
the parts already mentioned. As this was in the winter of 1895,
and as my attention had been called to the import of the secre-
tions by other conditions, as well as a statement made to me by
the patient, I decided to investigate the saliva. The statement
which he made to me, which was most significant, was this:
That while his appetite was very good, and when his olfactory
nerve was stimulated by the odor of a delicious meal, causing
his mouth to water, the disagreeable odor and taste became so
pronounced as to almost nauseate him. I collected then some
of the saliva. The method I vised tor its collection I learned
from my experience in a dentist's chair; that while sitting
with your mouth wide open for a few minutes you have a most
profuse flow of saliva. This method practised just before meal
time enabled the collection of quite a large amount of the secre-
tion. The offensiveness of the secretion was at once detectetl.
Now, whether this offensiveness was due to a chemic reaction
brought about by the mixing of the various salivary secretions
and its exposure to air, I am unable to say: but one thing was cer-
tain, that when the secretion was collected and placed in a sterile
bottle it at once demonstrated the source of the odor. After
experimenting with a number of solutions I was able to demon-
strate the presence of a sulfocyanid, which, witli the ammonia
salts, caused rapid decomposition.
I have studied two other cases similar to the one
quoted in which the odor unquestionably came from the
saliva. Another case was a peculiar form of /evkop/a/cia
in which I believe the peculiar change brought about in
the surface epithelium was due to some chemic com-
pound formed from the salivary secretion. Four other
cases which I studied were peculiar ulceration involving
the tongue, lips and buccal mucous membrane. The
ulcers resembled very much those associated with certain
diseases of the stomach and described as aphthmis ulcers.
The salivary secretion in each case was strongly acid,
showing the lack of proper oxidation. Remedial agents
directed toward the changing of the chemic reaction of
the secretion speedily effected a cure in three cases ; the
fourth patient is still under observation, but much \m-
proved.
My studies of the saliva have been very much in the
same line as Michaels', although not so extensive, and
the deductions are practically the same as he gives
below. First, the study of the normal healthj* .saliva ;
second, the saliva from hypoacid individuals, and third,
the hyperacid condition. He also investigated the func-
tion of the biliary principles and the presence and
absence of these principles in the blood plasma and in
the salivary secretions. Ilis investigations proved that
many of the substances found present in the saliva by
chemic analysis could be traced to this source. This is
significant, as the presence or absence of such material
would enable one to determine the presence of hepatic
toxins. Michaels' invastigations also showed that modi-
fications of the saliva were in direct relation with consti-
tutional diatheses.
As the tissues and secretions depend upon the blood
plasma, any dyscrasia then would modify the chemic
composition of the body and produce local or general
manifestations. According to IJucloux, hypoacidity
favors chemic changes in the tissues, in hypoacid con-
ditions all the oxidation processes are exaggerated, and
in hyperacid conditions oxidation is incomplete ;
as a result there is an increase in the quantity of
organic acids. By the ordinary litmus test blood is
normally alkaline, but as Douin and Gautrelet have
shown, if we study the distribution of the acids and
JDI.Y 12, 1»02|
CHEMIC PATHOLOGY OF THE SALIVA
[American Mrdicinb 59
bases of the blood plasma we see that the reaction is
really acid and if the acid waste products are not elimi-
nated this acidity is increased. The secretions and excre-
tions then become of an acid reaction. This is illus-
trated in certain of the chronic diseases in which we
have a constant characteristic symptom in the increase
of the acidity of the urine.
" The ammoniacal salts and sulfocyanid in healthy
saliva are in equal proportion and in very small quanti-
ties ; in the hypoacid condition the ammonia exists in
greater quantities than the sulfur cyanid and tends rap-
idly to decomposition. S[n the hyperacid condition the
sulfocyanid is in excess and the tendency to decomposi-
tion is not so great as in the hypoacid condition."
The chemic reagents used as well as the laboratory
notes of such investigations are too long for repetition
here, but sufficient has been done to show that by care-
ful and continued investigation some definite basis can
be reached.
While my work in this line has been fragmentary
and is most incomplete, I feel that it is of such impor-
tance that it was my desire to call the attention of the
Fellows of this Association to this important subject
that others may be induced to take up the work. As it
involves organic chemistry and as you are searching for
unknown (luantities, it is a most tedious and laborious
task, and yet I believe the day will come when the sub-
ject of chemic pathology will be of as great importance
as that of morbid anatomy and morbid histology and
will be of the grejitest value in the prevention and'treat-
ment of disease. Some may object to the term ofiemin
puth()lo(/}j, as all chemistry is normal, yet the term
chemic pathology implies the chemistry of a morbid
proceJtK and not morbid chemistry.
Naturally, as Michaels states, it was necessary to
investigate the histochemistry of normal saliva, con-
cerning which subject the literature is very meager,
(iould covers practiciiily all the literature on the subject
in his definition. He defines the saliva as the mixed
secretion of the parotid, submaxillary and sublingual
glands, and the small mucous glands of the mouth.
Physiologically, three kinds of secretion may be distin-
guished ; a serous from the parotid, a mucous from
the mucous glands, and a mixed secretion from the
submaxil ary and sublingual glands. Mixed saliva is
opalescent, tast^ile^s, alkaline and has a specific gravity
of 1,1)04-1,009. The daily quantity secreted is approxi-
mat<'ly 1,500 cc. (Bidder and Sc^hmidt). Saliva contains
serum albumin, globulin, mucin, urea, and an amylolytic
ferment called ptyalin, and a proteolytic and lipolytic
ferment; also salts, among which is potassium sulfo-
cyanid, derived especially from the parotid gland.
Among formed elements are epithelial cells, salivary
cori)uscles and bivcteria. The functions of the saliva are
IJhysical and chemic. Its physical function is t<) moisten
substances, facilitate tasting and aid deglutition and
articulation. Its chemic action depends upon its fer-
ments, the most imjiortant of which is |)tyalin. This
convf^rts starch into dextrin and sugsir. The proteolytic
an<l liiKiIytic ferments are not imi)ortant. It is possible
that any other fermentation save th(> amylolytic is due
to l)acteria.
" It became necessary, therefore, to i)ay special atten-
tion to saliva, its essential physical and chemic proper-
ties, and its changes in composition, and the relation of
these fiictdrs to [uithologit^ strifes. It was found that the
saliva, like all rfu-rementitious strretions, is liable to
physiologic oscillations in constiint relation to the
changes in tli(^ fiuifls and solids of the body. The saliva
Is swallowed as soon as it is produced ; its emission Is
followed by a new absorption, and this results in the
formation of a sort of circuit very intt^rtisting to notice,
and of which account must be taken ; for the passage of
lli(! saliva into th*^ blood, ettW^ts, under normal condi-
tions, a sodiuin combination ; whili- it is eliminated in a
condition which varies, at times being acid, and at other
times alkaline or neutral. On the nther hand, every
crystallizable chemic principle, cNciy acid, alkaline or
neutral salt, even the alkaloids, biliary pigments or the
free acids, circulate in the plasma in variable propor-
tions, and are found in the saliva in certain diathetic
proportions. The organoleptic properties of normal
saliva are not characteristic, except when compared with
diathetic saliva, but in studying the differences we lesirn
quickly to recognize and distinguish one from the other.
By reason of the numerous characteristics which saliva
presents in the different conditions of health, the fol-
lowing problems have arisen for wnsideration :
" 1. What are the principles which differentiate phys-
iologic from pathologic sjdiva?
" 2. Is there any correlation between thechcinistry of
saliva and the different diseases?
" 3. Is the composition of the saliva simple or com-
plex ?
"4. Is it po.ssil)le to establish a classification of the or-
ganoleptic characteristics of saliva and refer them to
particular conditions of health?
" 5. Is it possible to point out the causes of the varia-
tions of saliva ?
"Certain specimens ofsuliva are clear, li(iuid and trans-
parent, while others are viscid and thick. Some are
reddish, yellowish, or greenish in color, while others
are as clear as water. This must depend upon the
chemic composition. Some have a greiit quantity of
froth, others have very little, or even none at all. In
the space of two days some kinds decompose, wliile
others even after a year have no odor. Chemit^ally, some
contain sulfocyanid in different proportions, others do
not contain any at all. In some we find crystalline .salts ;
others have none. Other specimens contain fatty sub-
stances or emulsions, and others biliary pigments or
urobilin."
The alteretl chemistry of the saliva presents many
possibilities from an eliologic standpoint. It is quite
possible that many forms of indigt^tion and diseases of
the stomach and intestines may be brought about by the
altered chemistry of the saliva. A great many morbid
processes are traced to uric acid in some of its many forms,
but I believe that many other .substances equally impor-
tant are deposited anrl eliminated, which substances act
as irritants, not only causing stomach and inttwtinal dis-
eases, but also may explain many of the socalled reflex
neuros€>s, e. (/., hay-fever. It is a vvell-known diniciU
fact that SiUiva from certain individuals is exceetlingly
poisonous, as is indicated by the infectious wound pro-
duced by thebitf! of such individuals, .showing that the
saliva may be the site of poisonous pathologic com-
pounds as well as physiologic compounds. It is (|uite
probable that .some of the soralled reflex disea.sw, for
example a.sthma, if the cause could be tmced, would
probably 1k> found to be du(> to a perverted salivary
se<!retion.
rn(iuestionably the chemic reaction of tin- secretions
of tlic body is an iinportant factor in the sus<'e|)tibility
ofindividualstodi.sea.se. I think there is no doubt of
th(^ fact that atone time the individual ri-si.sts dlsea.-*e
and at another time succumbs can be largely explainwi
on this basis. To l)e surt; it is a question of resistanct? on
th(! part of the individual, but that resistance is iarg<'ly
controlled by the chemi.stry of the cell or scH-retlon. It
also (h-nionstrates the fact of the accumulative phe-
nomena of certain of the di.sea.ses, as is illustrated in uric-
acid diathesis, which Haig lias descrilK-d as uric acid
storm. There is no reason why these same* phenomena
could not occur as thi' result of the accumulation ot ot/n-r
ma/erid/x brought almut by cJiemic changes which less<>n
oxidation and t<>nd to |)r(H'ipifiition and iicciininlatlon
of various morbid j)roduct><.
The adndnistnition of drugs for the relief of, for ex-
ami>lc, an infectiv*^ j)r(K'csH probably offe<'ts sueli a i)ro-
wss iM'iicrtcially, owing to the fact that in its action It
change's the chemistry of th(> secretions and bl<M)d eon-
60 AMtaaoAa MsoieiirB]
INFLUENCE OF ALCOHOL UPON INFECTION
(July 12, 1902
Htitu<'nt,s thereby producing a eheinic compound which
either prevents the formation of infectious material or
alters the nidun of infection to such an extent that it is
not suitable for the growth of bacteria.
THE INFLUENCE OF ALCOHOL UPON INFECTION
AND ITS USE IN THE TREATMENT OF ACUTE
INFECTIOUS DISEASES.*
BY
8. J. MELTZER, M.D.,
of New York City.
It is a very old idea that wine is a good thing for the
sick and the inflrni. <' Drink no longer water, but use
a little wine for thy .stomach's sake and thine often
infirmities," wrote a wise and holy man nearly 1900
years ago. And a few centuries before him wine was
ordered for patients by the greatest physician history
knows to record. Through nearly twenty-four centuries,
from Hippocrates down to our own days, physicians of
all creeds and systems have employed alcoholic bever-
ages as an aid in their struggle against diseases. Sys-
tems of medicine, however, influenced at all times the
extent to which this therapeutic agent wa.s employed ;
and as in the long history of the science of medicine
numerous systems came and went, rose and fell — con-
tinual changes, rises and falls, also mark the history of
the employment of alcohol as a medicine. The influence
of the systems, however, extended only to the degree,
the extent to which alcohol was used ; beyond and inde-
pendent of any system there seems to have lived, and
still lives in the minds of all observant practitioners, a
strong empiric conviction that some dose of alcohol " does
the patient good." The task of each new theory was to
provide the philosophers among the physicians with
arguments why alcohol should be given, and how it
affects the patient or the disease. The influence of the
theory upon the practice seems to vary with the mental
attitudes of the different civilized races ; the more phil-
osophic the mind of a nation is, the greater is the influ-
ence of a theory, for good or for evil. The socalled
Brunonian system offers an instructive illustration.
John Brown was an Englishman who lived in the
eighteenth century. Influenced probably by a concep-
tion of irritability, as it was established by Haller,
Brown brought forward the theory that life is kept up
by stimuli, and diseases are either asthenic or sthenic ;
their cure, therefore, has to be either an increase or a
decrea.se of stimulation. The employment of alcohol in
sickness found in this theory the most promising expla-
nation— alcohol is a stimulant. In Germany this theory
was received with enthusiasm, and it had the unfortunate
effect that physicians administered alcohol to their
I)atients in very large, harmful doses. This abuse, says
von .Jaksch,' killed hundreds of patients. With the
downfall of this theory, a strong and long-lasting reac-
tion set in against the abuse as well as against the proper
use of alcohol in disea.ses, and Binz ^ tells us that in the
forties of the last century a physician had to defend him-
self publicly for giving moderate doses of alcohol to a
typhoid patient.
In England, the home of Brown, but also the home
of the Baconian method of studying natural science by
actual observation, the Brunonian theory was never
received with great enthusiasm, and exercised only a
moderate influence upon the practice of using alcohol as
a drug. And here the downfall of the theory did not
produce such a reaction against the legitimate use of
alcohol. On the contrary, already in the thirties and
forties of the last century we see clinicians like Stokes,
Graves, and especially Todd, exerting their influence to
enlarge the indications for the employment of alcohol.
» Read at the annual meeting of the Massachusetts Medical Society
n a symposium on " The Use of Alcohol In Medicine."
It was the inauguration of that long period during which
in England alcohol was quite extensively used in febrile
disease, and which is now apparently on its slow decline.
In the second half of the last century, with the advent
of the experimental method of studying the sciences of
medicine, alcohol became the subject of extensive experi-
mental investigations, and it was especially in Germany
that numerous experimental studies were published by
Binz and his pupils and by many other prominent
investigators on the relations of alcohol to the tempera-
ture, the metabolism of the animal organism, the circu-
lation, respiration, etc. Greatly through the influence
of these scientific investigations akiohol again became a
factor in therapeutics in that country. In the eighties
and nineties of the last century we again find in Ger-
many a greater enthusiasm for the use of alcohol in
typhoid fever, pneumonia, puerperal fever, etc., than we
see at the same period in England. Binz' summarized
the reasons for giving alcohol in febrile diseases in the
following manner: "Alcohol is an antipyretic, is a con-
venient food, and it stimulates the circulation and respi-
ration." In addition to these points the recent progress
in medicine brought out a new factor in the discus.sion
of alcohol as a medicine.
Since the eighties of the last century most of the dis-
eases for which alcohol was prescribetl received a new
character — they are now known as infectious diseases —
and the question arose, What relation does alcohol have
to infection? Clinicians like Runge and others, who are
enthusiastic supporters of the use of alcohol in septic
diseases, expressed their belief that alcohol strengthens
the body in its struggle against the virulent invaders.
Binz* says that "the opinion of our clinical teachers
may in general terms be expressed as follows: 'Alcohol
in large doses increases in an extraordinary manner the
power of resistance to septic poison.' " Is this clinical
opinion borne out by experiment ?
One of the theses with which I was entrusted to
report today is on that subject.
It is, therefore, the first task of my paper to offer a
report on the experimental work done so far on the sub-
jects in question.
Binz, in fortifying his before-mentioned opinion,
quotes one experiment of his own. He injected into
two dogs septic material taken from a decubitus of a
typhoid patient. One dog received 10 cc. of alcohol
three times within 17 hours ; this dog survived, the
other dog died. Binz mentions this experiment in sev-
eral places, but it does not appear that he made more
than one experiment.
In attempting to produce cholera in animals, Koch
tried first to introduce alcohol into their stomaclis. This
method was employed systematically by Doyen,^ and he
found that animals which received alcohol became
indeed infected with cholera, while controls remained
free. Doyen was inclined to believe that it was due to
some local effect of the alcohol upon the acidity of the
stomach.
Thomas* has given rabbits for two consecutive days,
about 5 cc. per kilo, alcohol diluted four times with
water, and then injected cholera cultures intravenously.
Five alcoholized animals died, the control animals with-
stood infections with much larger doses. In one other
experiment Thomas found that the serum of an alcohol-
ized rabbit lost its bactericidal effect upon cholera organ-
isms.
The first extensive series of experiments were made
in this country by Dr. Abbott,' of Philadelphia, at the
instigation of the Committee of Fifty on the Alcohol
Question. Rabbits were given alcohol, .5 to 6 ct;. per
kilo per day, before or after inoculation with either the
Strepfococeics pi/offeties, Bucilltis coli, or the Staph }/lococcns
pyogenes aureus. In the inoculations with streptococcus
nearly all the alcoholized animals died, while most of
the nonalcoholized survived. In the inoculations with
the colon bacillus the alcoholized animals also showed a
July 12, 1902)
INFLUENCE OF ALCOHOL UPON INFECTION
(American Medicine 61
diminished resistance to the infection, although not so
pronounced as in tlie inoculations with streptococcus.
The inoculations with the staphylococcus did not bring
out clear results.
DelC'arde " has studied in rabbits the effect of alcohol
upon immunization against rabies, tetanus, and anthrax.
His conclusions are : that in rabies, the administration of
alcohol after infection will destroy the required immu-
nization ; and that in tetanus and anthrax no immuniza-
tion will take effect if alcohol is given simultaneously.
(l)elearde's statements give the impression of his hav-
ing had only one experiment for each of his conclu-
sions.)
Laitinen " studied the influence of alcohol upon the
susceptibility to infectious material on 342 animals —
dogs, rabbits, mice, guineapigs, chickens, and pigeons.
As infectious material he used anthrax, tubercle bacilli,
and diphtheria toxin. Alcohol was given either for a
number of days previous to the infection, or started soon
after. The quantity of alcohol used in these series of
experiments was not less than .5 cc. per kilo per day ; in
many instances the animals were distinctly intoxicated.
The anthrax experiments demonstrated unmistakably
the deleterious effect of the alcohol : most of the alco-
holizeil animals died, most of the nonalcoholized ani-
mals survived the infection. The experiments with
tubercle bacilli gave less striking results : in one series
the alcoholized animals died after an average of 30 days,
the nonalcoholized animals after 34 days ; and in a sec-
ond series the alcoholized animals died after an average
of 20, and tlie nonalcoholized after an average of
22 days. In the experiments with the diphtheria
toxin the alcoholization ha.stened the death of inocu-
lated animals. According to Laitinen the blood of
the alcoholized animals seemed to show a decrease in
its alkalinity ; this suggestion was already thrown out
by Abbott. (In a later publication,'" the original of
which was not acces.sible to me, laitinen has studied the
effect of smaller doses of alcohol : of 75 alcoholized ani-
mals Glfc died, and of 70 nonalcoholizwl animals 'Mfc
succumbed to the infection.) Laitinen credits Valagussa
and Ranelleti " with the statement that alcoholized
animals show a diminished susceptibility to the toxin of
diphtheria.
Pavvlowsky" gave whisky to guineapigs for some
time, and found that their resistance to infection with
Slapliytococrm citreiis was considerably diminished. He
also stiites that the alcoholized animals resieted to a sub-
cutan«)us injection with a diffuse edema, while in non-
alcoholized animals an injection caused an abscess. (I
would suggest that this difference might perhaps have its
explanation in the statement of Massart and Bordet,'-' that
alcohol (^ven in great dilution is negatively chcnnotactic.)
Gruber'* and Koegler have administered to guinea-
pigs small doses of alcohol (0.1 to 1.5 cc. per kilo), and
then infected them with the pneumobacillus of Fried-
laender. They found that the alcoholization increased in
general the mortiility of the animals.
(ioldberg'-'^ studied the influence of alcohol upon the
natural immunity of pigeons to anthrax. Of 12 pigeons
which were inoctulated with a cert^iin amount of an ivgar
culture of anthrax, all survived; of 15 other pigeons
which were inoculated with the same amount of anthrax,
but which recjeived soon after thci inoculation, or a day
or two later, comparatively large doses of alcohol, 12
di(Hl. The same occurred in another series in which
alcohol wa.s administered for some time prt^vious to
in(K!ulation. In a third serit«, 18 pigeons were inocu-
lated with fata! doses of anthrax, and one-half of this
number received twice a day } w. of alcohol. From the
results in this series, Goldberg concludes that the
administration of alcohol did not prolong the life of the
pig((ons. (But it should be added that the resultH also
(l(!monstrated that the alcohol did not shorten the life of
the animals.)
Ausems,'* working under Taliii:i, nlso found that the
administration of alcohol in small doses to rabbits before
infection diminishes their resistance to different infec-
tions. Small doses of alcohol, given after the infection,
reduce temperature, but do not influence the course of
the severity of the infection. Large doses of alcohol
reduce the temperature, but increase the length and
severity of the disease.
In contrast to this long list of experiments adverse to
alcohol, I am able to record only one brief statement in
favor of alcohol : According to ( Jruber " an intraperito-
neal injection into guineapigs of a freshly sterilized
culture of B. prodigiosus causes a strong collapse of the
animal; the temperature sinks to 34° C, and death fol-
lows in a few hours. Now Gruber states, in a pro-
visional brief report, that the fre^iuent administration of
small doses of alcohol to such animals prolonged their
life many hours, and two animals were even restored to
health.
Such is the report on the influence of alcohol upon
infection. It unequivfxally resKls adverse to alcohol.
Of the 10 different systematic investigations none came
out in favor of alcohol. It was studied on dogs, mbbits,
guineapigs, mice, chickens, and pigeons. The investi-
gations extended to infections with cholera vibrioi?,
streptococcus, colon bacillus, anthrax, tetiinus and
tubercle bacilli, rabies, and the toxin of <liphtheria.
In all these cases it was found that alcoholization before
infection, increases the susceptibility ; alcoholizsition
after infection decreases strikingly the resistwnce of the
animal ; it also destroys the natural and the iirtiflcial
immunity, and is rather favorable than ant^igonistic to
the fatal influence of the toxin of diphtheria.
What do these experiments on animals teach us
regarding the influence of alcohol u|Kin infectious dis-
eases in human beings ?
I venture to say that these experiments — striking as
they may appear — tesich us as yet very little new, uiid
nearly nothing definite — for the following reasons : In
every one of these experiments in which the alcoholiza-
tion proved to be definitely unfavorable, the smallest
dose which was administered to the animals amounted
to 5 cc. of absolute alcohol per kilo of animal, aiul in
many cases the dose was a good deal larger, for instance
10 cK.y and even more. For rabbits, the animal which
was extensively employed, the fatal dose is, accortling to
Dujardin and Haer, " 7.6 cc. i)er kilo. Ij<>t us take the
minimum dose of 5 cc. as a basis, and compound it for a
human being of the medium weight of 75 kilograms; it
would amount to 375 cc. absolute alcohol, or more than
a pint and a half of strong brandy. Now who has ever
given that cjuantity in a single dose, or even in two
doses, te a patient? Surely this would lead in a normal
individual to the most acute alcoholism, and perhaps
even to a fatjil issue. We would certainly ex|MH;t, witli-
out any experimental evidiMice, that any infcn-tion in
addition to such a toxic (los(! of alcohol would prove
fatal. Furthermore, we also knew long ago' that alco-
holic individuals luc Irss resistant to the ((feet of infec-
tious diseas(!s.
On th(! other hand, we have abundant proofs that
similar and even larger dos«w of alcohol, distril>ut<Ml
over 24 hours, administ^'retl to human In^ngs down with
infwtious dist>jtseM, do pasitively not show mich strik-
ingly delet<Tious effeds as wer«> observe<l in animals.
Al)bf)tt or Laitinen had in their resiKH-tive e.\p«'riments,
series of four or flvi' alcoholized infe«-t<'<l animals, all or
most of which diwl, while the (f)ntn)ls survived. Now
Itung<!'" published a table of 20 grave caw-s of put ipenil
fever with a recj)very of K0;ifc ; all of these iiatients
received for days and weeks very large dos«>H of alcoiiol.
If this dot»t not prove anything elst>, it provcH at l«^wt
conclusively that large doses of alcohol are not iw harm-
ful tos<*ptic human iK'ings iw they .seem to be to scittic
animals.
Observations of a sindlar kind have Ihkmi mkhIc liinc
and time again in typhoid fever. I5<'twe<'n IssI :iiiii
62 AMBKicAN MKmciNK] INFLUENCE OF ALCOHOL UPON INFECTION
[July 12, 1902
1887 I followed the custom of that time and treated
tyi)lii)iil iHitients with liirfje dosess of alcohol. I reiiiciii-
ber ImvitiK ffivcn to a youns tfirl of al>out :i() kilograiiiH
nearly one pint of whisky every day for 11 consecutive
days, without any untoward symptom. And it was
during this period that 1 did not lo^e a single case of
typhoid fever. Not that I wish to put up the claim
tliat the alcohol treatment wa.s the cause of the recov-
eries; I quotes this experience to show that large doses
of alcohol did not lower the resistance of my patients to
their infection. Hundreds of other physicians had sim-
ilar e.v periences. Thtwe experiments arc reliable clinical
evidence, sutHcient to warrant the assertion that doses
which proved so harmful to animals are comparatively
harmless when adniinistertnl to human patients in a
proper medical manner. These clinical observations
.seem to me t« be well establishetl facts, ecjual in their
reliability to those derived from the animal experimen-
tation. I shall try, however, to offer some explanations
for the differences in the results.
In th(( first place, as already indicated, in nearly
all the experiments the large quantities of alcohol
were administered in one dose or in two doses. In
administt^ring alcohol to patients we distribute the daily
quantity in 0 or even 12 doses. By a single large dose
the body cells might become damaged beyond recovery.
Then there are some other significant points. Take, for
instance, the mode of administration : in most of the
experiments the alcohol \va.s introduced into the stomach
of the animal through a stomach tube ; Abbott states
that this method led, in many eases, to erosions and
Inflammation of the stomach, which in some cases
resulted in distinctly complicating infections. Another
significant fact is that in none of the experiments is
mention made as to how the animals were fed ; it is
possible that the alcoholized animals had a good deal
less appetite for food and ate less than the control ani-
mals; we notice in many protocols the remark of the
loss of weight of the alcoholized animals. The physi-
cian, as you all know, pays a great deal of attention to
the feeding of his patient.
Furthermore, the reduction of the amount of alcohol
per kilo of animal does not offer a basis for a fair com-
parison. The rtisistance of large animals is greater
than that which is due to them on account of their num-
ber of kilos. An animal of 75 kilos may resist a quan-
tity of poison 7") times the dose which is fatal to an ani-
mal of one kilo.
Moreover, as we know, even individuals of the same
species vary considerably in their resistance to the effects
of alcohol. There is surely a great difference in this
regard between different species, and a per-kilo dose
which is fatal to the pigeon might indeed be of no
account to a man.
In addition I would call attention to one fundamental
difference^ between the experimental infections of ani-
mals and 'infectious diseases in man, a difference which
might have an import^mt bearing upon the different
results. In the experiments, the infection or intoxica-
tion is brought on at once by a single injection of a
nearly fatal dose of bacteria or toxins. The organism is
tjiken by surprise before it could bring its defensive
forces into action against the enemy. On the other hand,
a disease is rather similar to a break within an immu-
nization experiment. That main stage which we term
disease is preceded by a slow invasion of bacteria or
their jjroducts before and during tlu; long incubation
time. When the patient and his doctor recognize the
existence of an infectious disease, the struggle between
the human organism and its virulent enemy is already
well on the way for some time, and there are already at
the disposal of the attacked body— besides the well-
organized multitude of normal defensive forces— a good
many newly-formed immunization products capable of
taking care of a good many of the battleworn invaders.
Alcohol, therefore, might prove more harmful to the
already greatly exhausted enemy in diseases than to the
fresh, unrestricted, virulent intruders in experimental
infections.
However all this may be, we are bound to state that
the large number of experiments on animals at present on '
record can, at the utmost, serve only as a warning to the
practitioner to keep away from too large doses of alcohol
in infectious diseases. They do not throw any light
upon the ((uestion whether conservative doses of alcohol
properly given to a patient sick with an infectious dis-
ease, and under proper management and rare, are harm-
ful, indifferent or u.seful. New experiments are required
with a proper consideration for the actual conditions
existing in the infectious diseases of man.
I come now to the second thesis a.ssigned to me for
discussion :
The Use of Aixjohoi. in the Theatmext of the
Acute Infectious Di8j:a.sks, Especialey in Ty-
phoid Fever AND Pneumonia: an Expla-
nation OF THE Results OitTAi NED by its
Use in the Light of Oub Phakma-
coixjGic Knowledge of the Drug.
The use of alcohol in medicine is now on the defen-
sive; it is again apparently passing through one of
its historic crises. There are many causes for the
Ijtesent decline. Alcohol as a drug shares partly the
fate of drugs in general, which are less prescribed
at the present time in infectious diseases than in pre-
vious years. The advent of serums also contributed
to the decline in the use of alcohol. In diphtheria,
for instance, antitoxin has greatly reduced the former
extensive use of alcohol in this disease. Then the
national and international movements against the abuse,
as well as the general use of alcohol in health, ha.s, no
doubt, a good deal to do with much of the activity dis-
played against its employment in sickness. The most
spirited attacks which the use of alcohol as a medicine
had to face have been made within the last year or two,
and are based apparently on purely scientific grounds.
The conclusions to which these writers arrive are simply
sweeping, and read as follows :
The bacteriologic experiments, say the scientific
opponents of alcohol, have demonstrated that alcohol
favors infection. Alcohol is a proteid poison and not a
food, proclaims Kassowitz, and some others agree with
him. The newer school of pharmacology has proved,
they say, that alcohol is not a stimulant, but a depres-
sant. Furthermore, alcohol is not a stomachic, is of no
use as an antipyretic, and is a poor narcotic. In short,
there is no earthly reason for its use in disease, and there
are weighty reasons against its use. Permit me to dis-
cuss the validity of some of these arguments.
Beginning with the question of the influence of
alcohol upon infection, and the evidence to be derived
from the existing bacteriologic experiments, I shall
refer to what I have already stsited, viz., these experi-
ments as they stand now cannot lie used as an argument
against the employment of alcohol in infectious diseases
in man, and we need not discuss this point again.
The next important point in the discussion on the
value of alcohol as a medicine is its supposed stimulating
(luality. It is chiefly for this effect that many physi-
cians prescribe alcohol. The opponents of alcohol refer
us, however, to Schmiedeberg and his school, who hold
that alcohol does not stimulate anything, but, on the
contrary, exercises exclusively a depressing, paralyzing
oflect upon the functions of the body. It depresses the
higher nerve centers, by which a degree of narcosis and
a lack of concern is produced, and it causes i)aralysis of
the vasomotor centers ; in short, alcohol does not increase
but lowers the vitality throughout the animal body.
The socalled stimulating effect is simply a inisinter[)reta-
tion of the phenomena alcohol produces.
In full appreciation of the high merits of Schniiede-
l>erg and his learned followers, I venture to state that
JnLV 12, 19021
INFLUENCE OF ALCOHOL UPON INFECTION [Amkrican mkdicisk 63
their theory suffers from some Incompleteness in their
analysis of the phenomena of stimulation and paralysis.
We (tan all agree with the i)roposition that stimulation
has always the effect of increasing the display of a nor-
mal function, whatever this function may be ; and that
depression or paralysis invariably lowers or abolishes
the normal display of a function. However, if the term
"stimulation" lias in pharmacology and medicine the
same meaning which is attached to it in physiology, I
cannot see why alcohol should not act as a stimulus.
Any kind of a solutioYi which is not isotonic with the
body fluids will act as a stimulus on irritable tissue.
Even cocain or other local anesthetic will cause at first
stimulation of the tissues with which it comes in con-
tact. The Ifind of an effect which such a stimulus might
produce depends, of course, upon the nature of the tis-
sue which it irritates. Application of alcohol to a motor
nerve will cause contraction of a muscle ; application to
tiie peripheral end of the vagus will cause slowing of the
heartbeat; application to the chorda tympani will cause
dilation of the bloodvessels of the submaxillarj' gland.
Now the slowing of the heart by stimulation of the
vagiis appears as a reduction of lu-tivity, the effect of the
alcohol here is, nevertheless, not a depression, but the
stimulation of a function, because it sets to work the
inhiliitory mechanism of the heart.
Now it is with regivrd to just this point that Schmiede-
berg's theory shows a deficiency. This theory has in
view only either an increase of motor or sensory activity,
or a decrease of vitality, but it offers no room for stimu-
lation of an inhibitory mechanism by which a certain
activity might appear diminished and the vitality at the
same time lie actually increased. Let us take, for instance,
tlie flushing and turgescence of the skin after the use of
some doses of alcohol. Schmiedeberg considers it due to
a paralysis of the vasomotor center. I believe I will not
meet any contradiction from physiologists when I say
that the flushing of the skin is due to either a stimula-
tion of the vasotlilators, or an inhibition of the tonus of the
vasomotor center ; in either case it is the effect of stimula-
tion of a normal function, and not a paralysis of a function.
It must be mentioned that Binz, too, who believes in
the stimulating effect of alcohol, has in mind apparently
only tlie motor phenomenon. He therefore insists that
alcohol increases the number of heart-beats under the
supposition that a slowing of the heart-beat would not be
the effect of a stimulation. A practitioner would hardly
apiireciate the advantage of a stimulation which would
increase the heart-beats of a typhoid patient from 120 to
140 per minute. The observations of von Jacksch,™
according to which alcohol reduces the |)ulse in fever
patients, are surely more to the point ; alcohol stimu-
lates the inhibitory mtn-hanism of the heart, and thereby
reduces the number of its beats.
Before continuing the , discussion on the relation of
alcohol to inliibition, I wish to make a few remarks on
the relation of alcohol to vasoconstriction and vasodila-
tion. Tlie opponents of alcohol (hsny its stimulating
effect upon the circulation, among otlu^rs on the grounds
that alcohol either (siuses a lowering of the l)lood-pres-
sure, or has no afftxt upon it ; it surely does not incresiae
the blood-pressure. Permit me to say that actually there
are very few reliable investigations on the influence of
alcohol upon the conditions of the bliMxIvcwst^ls. The
statement whi('li is now fre<juently mmle without quali-
fication, that the blood-pressure is lowered by alcohol,
actually refers only to antemort<Mn conditions in fatal
(loses. Tli(( writings of the opponents of alcohol are full
of peculiar (juotations. Paessler, for instance, is often
((uott'd as saying that alcohol (lo«« not influen(*! the
blood-pressure ; what, howev(>r, he actually said, is that
his method flocks not permit the drawing of any (xwidu-
sion regarding the ctfM-.t of alcohol iii)on l)lood-pressure."
Robert ^^ worked with isolated organs, that is, with
orgiuis removed from all vasomotor influences; he is
nev(!rtheleHM quoted in support of the aasertion that
alcohol does not influence normal blood-pressure.
Although a further analysis of some of the writings
might indeed prove interesting reading, I will not
indulge in it, but shall confine myself to the simple
remark that to my knowledge there is nothing in the
literature on the subject which can seriously dis(|ualify
the following considerations.
It is an established fact that after taking a moderate
dose of alcohol ■ the skin becomes turgescent and
flushed. We have seen that this is due to a vasodilation
in the skin. This vasodilation could be either local,
confined to the skin only, or it could be a part of the
general dilation of all the bloodvessels in the body. In
this latter case there would be a lowering of the general
blood-pressure. For a decision of this alternative 1
would like to call attention to the following facts : The
area which is controlled by the splanchnic nerves (mii-
tains the largest part of the body's blood. When this
area is dilated it withdraws a good deal of blood from all
the peripheral organs, and when this occurs, the skin is
cool, pale, cyanotic and sallow. When the skin is rtnl
and turgescent, we can with safety assume that there is
surely no general vasodilation, no "bleeding into the
vessels of the splanchnic area " ; the va.so(lilation in the
skin is therefore only Icxiil. But as the quantity of the
body's blood remains constant, each hx-al vasodilation
has to be compensated by a constriction of the blood-
vessels in another region. We know that there is such a
mutual nervous arrangement between the periphenil
organs and the sj)lanchnic area, to the effect that each
vasodilation of the peripheral organs is accompanied by
a proportionate vasoconstriction in the splanchnic area.
The administration of a dose of alcohol, which has the
visible effect of oiusing redness and turgescence of the
skin, has the actual effect of distributing the blood in
such a manner as to cause vasodilation in the jteripheral
organs, including the brain, and vasoconstriction in the
splanchnic area. It is obvious that under tlu>se circum-
stjuices the blood-pr< ssure measured in the carotid
artery, or in any other manner, will not be changed, and
will not indicate that a change in the distribution of the
blood has taken place.
I maintain, therefore, that alcohol in not too large
doses does not affivt the g(tiieral bhxKl-pressnre, but
affects some change in the distribution of the bUxxl,
which may be indifferent, or even harmful to a normal
person, but which may prove to be of great importance
to a patient with an infectious diseases We know
through the investigations of Homl)(>rg and Paessler"
that infections, with the pneumocfKrus for instance,
cause a genctral vasodilation of central origin. The
l)atient has then a "bleeding in the splanchnic area"
and blood is withdrawn from all the iK'ripheral organs:
the skin, the extremities, central nervous system, litMirt,
kidneys, etc. Such a patient niiglit have a high n-clal
teuiiM-rature, but has cold extremities, livid skin, small
pulse, menfjd depression (from cerebral ant'iiila), and
voids v<Ty little, concentrated urine. We givi- him alco-
lidl and cause a degree of vasoconstriction in the splanch-
nic area and a vasodilation in all the iK-ripheral organs,
with the r<«ult that the heart receiv««s more blo(Mi and
the pulse g<^t« fuller, the extremities warmer, the skin
gets red, becomtw turg(^scent, dissipates more In-at,
thereby nnlucing the temjxTature ; the i)atieiit's min<l
Ih-coiik^s brighter, anil his urine is increased and less
concentmt<Hl. In short, the patient is stimulated and
feels better. This effect is sun-ly a stimulation, even in
the nslricted sense of the term in which it is usihI in the
schools of Binz and SchmiedelxTg. In (ttlier words,
alcohol d<H's not affect the circulation by increasing or
dtrreasing the general bliKxl-pressure, but by instituting
sucli a distribution of Ihe bUxnl which is es|»(^>ially favor-
ablct to patients sick with infectious disea.ses.
We return now to our discussion of the relations
of alcohol to inhibitory mechanisms. The contention
of Sclimi(H]elM>rg and hlM hcIuhiI that a gretit many
64 AMKBioAj. MKDiciKK INFLUENCE OP ALCOHOL UPON INFECTION
[July 12, 1902
of the HyinptomH caused by alcoliol appear to be of
a paralytic nature i.s perfectly correct. The climax
of them is the deep narcosis in acute alcoholism,
which looks indeed like paralysis. There, is, how-
ever, a cardinal difference between the temporary
state's of narcosis and states of paralysis which usually
involve a permanent loss of some degree of vitality ;
and it seems proper to avoid the confusion of the two
thoroughly different conditions. Whether narcosis
could be looked upon as a state of inhibition I do
not care to discuss here. However this may be, it seems
((uite certain that some of the lesser effects of alcohol
ui)()ii the nervous system can be interpreted as inhibitory
phenomena. We know that certain conditions of t«m-
pc^rature or of electricity, or certain degrees of stimula-
tion, or certain substances, favor either excitation or
inhibition. I will not attempt to discuss this intricate
subjwt, but shall state my hypothesis in a few words
thus: alcohol favors the irritability of the inhibitory
mechanisms. I do not doubt in the least that alcohol
stimulates also motor or sensory nerves or the organs of
activity in general. I only suggest that in a certain
dilution and at a certain stage, alcohol, when in contact
with the noTve-cells, either directly stimulates preferably
some of the normal inhibitory mechanisms of the body,
or increases their irritability. As a consetiuence of this
stimulation the percei)tion for finer differences becomes
decreased, the reaction time is prolonged, the formation
of associations and the irradiation of stimuli within the
central nervous system become restricted. Also the
tonicity of all the muscles is reduced and the execution
of motion is rendered difficult. While such changes are
surely undesirable in health they are very beneficial and
desirable in sickness. The fever-burned, ii)fected, septic
patient with his restlessness, hypersensitiveness, turning
and twisting in bed, soreness over all his body, subsul-
tus, etc., is surely greatly benefited when, by the admin-
istration of alcohol, his muscles become relaxed, his
sensitiveness diminished and his useless mental activity
is restricted. Alcohol enlists the aid of the inhibitory
mechanism to procure rest for the toxin-hunted patient.
Strychnin is a stimulant and alcohol Is a stimulant;
but strychnin stimulates i)referably the motor or active
mechanisms, while alcohol stimulates preferably the
inhibitory mechanisms. Too large a dose of strychnin
causes convulsions, but too large a dose of alcohol causes
what looks like paralysis. It is obvious that strychnin,
camphor or catfein cannot supplant alcohol ; but they
might profitably supplement one another.
My defense for the use of alcohol in infectious dis-
ease consists in that (1) alcohol stiinulates the patient
by effecting a favorable distribution of the blood within
his sick body; (2) alcohol protects the patient against
harmful excitations by stimulating some of the normal
inhibitory mechanisms of the body.
As to the claim of the opponents of alcohol that it is
a poison and not a food, I need not discuss it, as this
point has been already well taken care of by an author-
ity more competent to speak on that subject -than I.
All workers in that line of investigation seem to agree
now more and more that alcohol, when taken for a long
period, proves to be in the end as good a proteid saver
as fat and carbohydrates are. Ott^* reported very
recently that this proposition holds good also for the
administration of alcohol during a febrile disea.se.
Believing as we do that alcohol is a very useful drug we
should accept its additional quality as a food with special
appreciation. p]ven if we restrict the administration of
alcohol to such small doses as 1 cc. per kilo in 24 hours
it would represent the value of 500 calories for an indi-
vidual of average weight — which is about one-sixth of
his daily need. Surely an addition not to be despised.
Alcohol as an antipyretic or as a stomachic we need
not discuss here. They are, at all events, minor qualities
and will not, I believe, materially influence our decision
one way or another regarding the use of alcohol.
Some of the radical opponents of alcohol admit its
usefulness in collapse, but ascribe it to its narcotic effect.
In collapse, they say, the patient is greatly alarmed by
his condition and the narcotic effect of the alcohol
relieves him of his anxiety, liut such effect could be
better and more quickly accomplished by a whiff of
chloroform. Would the advocates of this theory risk
such a procedure? Patients in profound collapse have a
vacant look in their eyes and hardly know what is going
on around them. After being revived by some alcohol
a look of recognition returns into their eyes and they
wish to know what happened to them. Can this be
interpreted by assuming that the narcosis brought con-
sciousness to the patient ? Gruber's ''■' guineapigs rallied
from profound collapse brought on by the injection of
Ji. prodiffiostm cultures by the administration of alcohol.
Did the temperature of the animals rise again because
the narcotic effect relieved them of their anxiety?
But admitting even that the entire usefulness of alco-
hol rests upon its narcotic (luality, so long as it is useful,
why not use it? Here is the difference between opinions
based upon "the light of pharmacologic knowledge"
and convictions based chiefly upon jjersfjual observation
at the bedside. The attitude of Sir Samuel Wilkes* is
an instructive instance. He professes his belief that
alcohol is not a stimulant but a sedative, but advoctites
nevertheleas its use in typhoid fever with arguments of
the following character : He tells of a girl who was i n the
hospital suffering from a most severe attack of typhoid ;
she grew worse until her end seemed approaching.
When apparently dying, brandy was administered, and
this was continued for two days and nights until an
enormous amount hatl been given. She then began to
rally and shortly recovered. Now as regards the effect
of this brandy upon her, "I can see," says Wilkes,
" only three modes of reasoning : It did her good, it did
her harm, it was valuelass. Now 1 think few persons
would say that giving two bottles of brandy in a few
hours was of no importance ; that its action on the system
was nil and might be disregarded. It might then be
said that it did harm, but in such a case as this there was
only one step more to death and this nmst have inevit-
ably ensued had the patient got harm. The only alter-
native left is that it did good."
It is a noteworthy fact that among the opponents of
alcohol there is not a single clinical man of note who
comes out unqualifiedly against the use of alcohol basetl
simply upon favorable clinical results gathered at the
bedside. On the contrary, clinicians ranking high in the
profession, and thoroughly familiar with the pharma-
cology of the drug, are unwilling to be dej)rived of its
aid in dealing with diseases like typhoid or pneumonia.
Curschmann,'" writing on tyjihoid in "Nothnagel's Hand-
book," says that in spite of all theoretic objections, alco-
hol is indispensable for the patient, and certain stages of
the disease can not be successfully treated without it.
He says further that the stimulating effect of alcohol
upon circulation and respiration is a fact established
beyond all doubt, though it may he difficult to find its
theoretic explanation. Pel,^" in his well-known careful
address on the treatment of pneumonia, stiys that he is
well aware that the theoretic explanation of the effects
of alcohol is insufficient, but the experience at the bed-
side has the last word in this matter and here we gsiin
the conviction that alcohol stimulates and strengthens
the patient. .luergensen, von Jakscli and many other
celebrated clinicians express similar views.
Personally I am willing to be responsible for the fol-
lowing two statements : Alcohol in health is often a
curse; alcohol in disease is mostly a blessing.
BIBLIOGRAPHY.
' Von Jaksch, Verhandl. dcs Congresses fiir Innero Medizin, 1888.
- Bin/,, Verhandl. dcs Congresses fiir innerc Medl/.in, 188S.
■' Binz, Ibid.
' BInz, Ijectures on Pbarm.'icology, 1895.
' Doyen, Arch, de Physiologic, 1885.
° Thomas, Arch. f. expcrlmentelle Pathologic, Vol. 32.
Jni,T 12, 1902]
INHALER FOR OPERATIONS ON THE EYE OR FACE [American mbdicin. 65
' Abbot, Journal of Experimental Medicine, Vol. 1.
' Del&irde, Annalesde I'liistitiit Pasteur, Vol. i.\, ISUT.
' Laitinen, Zeitschrift fiir Hyglonc, Vol. 34.
1" Ijaitinen, Acta societiitis seientioniin Fennicoe, Vol. 21.
" Vaiagussa and llanelleti, Ann. d'lgiene, Vol. 9.
'sPawlowsky, Zeitsclirifl fiir Hygiene, Vol. 33.
'» MasKivrl and Bordet. See DelC'arde.
n (iruber, Wiener Iclin. Wochenschrift, I'JOl. p. 451.
IS Goldberg, Centralblatt fiir Baeteriologle, Vol. 30, Nos. 18 and 19.
10 Ausems, A. W.. DisserUtlon, Utrecht, 1900; Centralblatt fiir
innere Medizin, 1902, No 20.
" Baer, Engelman's Arch, fiir Physiologic, 1898.
'» Kunge, Arch, fiir Gyniikologie, Vols. 31, 33.
I* Kassowitz, Deutsche mf'd. Wochenschrift, 1900, No. :<3; George
Roscnfeld, l)er Kinduss dcs Alcohol auf den Organisnius, Wiesbaden,
1901 ; also H. F. Hewes and K. G. Culler, Boston Med. and Surg. Jour.,
March 13, 190i.
=" Von Jaksch, loc. cit.
2' Paesslcr, Verhaiidl. des Congresses fiir innere Medizin, 1898.
=2 Kobert, Arch, fur e.xperimentelle Pathologic, Vol 22.
'"Romberg u. Paessler, Verhandl. des Congresses fiir Innere Medi-
zin, 1896.
'* Ott, Arch, fiir e.iperlnientelte Pathologic, Vol. 47.
2a (Jruljer, loc. cit.
=• Wilkes, Brit. Med. Journal, 1891, il, Aug. 29.
« Curschmann, Nothnagcl's Pathologic und Theraplo, Vol. ill.
-' Pel, Verhandl des tJongrcsscs fiir Innere Medizin, 1900.
A NEW INHALER ESPECIALLY INTENDED FOR
OPERATIONS ON THE EYE OR FACE.'
BY
C. W. LeFEVER, M.D.,
of Philadelphia.
Clinical AssisUmt in Ophthalmology, Jelfei'son Medical College Hos-
pital; Instructor in Ophthalmology, Philadelphia Polyclinic
and College for Graduates in Medicine.
The (lifflfulties experienced in the administration of
general anestliesia during operations on the eye or about
the face, must have been observed by ail who have htul
experience in this branch of surgery, either as anestliet^
izer or surgeon. If the ordinary inlialers are employed
they are constantly in the way, both of the surgeon's
manipulations and the illumination. If gauze or cotton
sponges are substituted, the fretiuent renewals of the
anesthetic fluid which are necessary are equally annoy-
ing, to say nothing of the difticulty of keeping the
patient quiet. The latter is especially true when ether
is used. It was to overcome these ditticulties and to
attempt to make other improvements that the inhaler
herewitli i)resented Wius constructed, and it is the result
of many altt^rations from the original plan.
One of the principal difticulties met in the production
of an inlialer which would meet these requirements ha.s
been to secure proper admixture of air, and to have such
air i)ure — that is, coming from a supply not previously
deprived of oxygen. Exi)erim(!ntation has convinced
me of two facts, viz., that the greatest amount of oxygen
compatible with complete anesthesia is best for the
patient, and that this proper mixture of oxygen is
secured from a much less volume of air if each breath
comes from a source not breathed i)reviousIy. The con-
.struction of this inhaler is such that a free supply of fresh
air is admitted, and the ([uantity of anesthetic introduced
will be at the discretion of the anesthetizer, and will be
governed, of course, by the demands of the case. This
renders it equally useful for (rhloroform and ether, but it
must be remembered that all anesthetic dropiK^l into the
receiver is breathed by the i)atient, inasmuch as the
evai)orating surface is but little, and none is blown out
by the i)atient's l)reath. This establishiw the fact of its
economy, little more than half a.s much ether being
re(iuired as when the ordinary inhaler is used.
Th(! ()uesti()n of being out of tlie way has bet!n met by
having th(! face mask just large enough to embrace the
antt^ior nanw and mouth, without touching atany place
<'xc<!pt the rim. The receiver is placed at such a dis-
tance and at such an angle that it rests over sind near to
the upper part of the chest when the patient is prone.
The connecting tube Itsives the face mask just over the
lK)int of tlie chin, extending obliquely. Aftt-rthe patient
is once anesthetized renewals are not ne<«;s.sary at such
short intervals, and even if they should be, the hands or
arms of the surgeon are not apt to interfere.
Regulation of the amount of air and antssthetic,
respectively, has been secured by fitting the mask accu-
rately to the face, leaving the afferent and efferent cur-
rents under the control of valves anil the amount of
anesthetic to the judgment of the antsthetizer, as gov-
erned by the demands of the cuse. The gjiuze shouki be
placed in the receiver just closely enough to prevent the
anesthetic fluid from running through and ju-cumulating
in its bowl, and at the same time loose enough to j)ermit
the patient's breath to enter freely. Thisretjuires alK)ut
three yards of 2-inch bandage unwrapped and gathered
into a loose bunch. Should the fluid be pouretl in too
rapidly none will run through on the jtatient's face,
owing to the point of entrance of the connecting tube
and the rim of the afferent valve, which is near the re-
ceiver end of the tube. Any such accumulation of tuies-
thctic fluid would be detected at once by the coldness to
the baud which is supporting the inhaler.
Tlie face mask is made adjustable to different-shaiH-d
noses and faces by having a soft coi)per wire of consider-
able size turned into its rim, rentlering it caj>able of
being l)ent inward and therel)y made higher at the
bridge, or of being bent outward, making it narrower
and flatter at the bridge. The practicability of tiiis fea-
ture is demonstrated reatlily by placing a st<jp of cotton
or other material under the afferent valve, in the con-
' Uead before the Philadelphia County Medical Society, May 14,1902.
necting tulx', to pi-cvent its action, then adjusting the
mtisk to the shape of the face, [ilacing it in |K)sition and
making suction. The inhaler will be held in situ by this
force alone.
Its employment is simple enough. After adjusting the
face mask to the fact^ and j)liicing the gauze in the re-
ceiver as tefore directed, the inhaler is hehl .so that tlu^
rim of the mask is in exact conttu-t with tlie face at all
places, taking cjire that it is not .so far up as not to flt
snugly to the bridge of the nose, and not so low as to
protrude over the chin. The anesthetic is at first droppwl
in slowly and increa.st^d as rajjidly as the anesthetizer's
judgment may dictate. In the ca.se of ether, this will
bi! as rapidly," in most cases, as the gauze will pt^mit
without becoming over-satumted, and as stilted iK'fore, no
harm will result if a tiuantity .should iU'cuniulate in the
bowl of the receiver, as it will not run through to the
I)atient's face. When chloroform is the agent it must, of
courst!, be droi)pe<l in slowly. When using chloroform
I prefer to leav(^ the ca]) ott" the rec-eiver to ensure free
admixture of fresh air. If tin- patient is slow in i>a.ssing
through the active sUige with ether, as they sometimes
are with any form of inhaler, especially in alcoholic
subjects, it is well to add a few dro|>s of chloroform until
this stage is past. The visible movement of the vidv(M,
or their clicking with each respiration, keeps the nmt in
charge aware of the condition of the patient's breathing,
and th(! ability to waU-h the features is of gre»it value in
determining the approach of cyanosis.
Another advantage of much signiflcunce to some sur-
geons is the absenct^ of ether fumes from the air of the
nnnn when this drug is being employed.
Exhibition of Medical Appliance*.— An Intorastlnif exhi-
bition la«tin(t two weeks hax just rloHwl in Ilorlin. It w».s an
exhiliition ot' inat«iriai formed leal iiiMtnietion, ev<MVtliiiiK nwr-
eaiitilo heinc rJKidly exiiludod. Tim openiiiK Kpoecli wn.H made
1)V I'rofoHsor v. Bur((i>innM and iiotod phyHiciaiiM khvo ovoninR
addreH«e». Tlio Itiiienmtjwcopo, U8(Kl by Doyoit l<i illtiHtruto
operotiouH, aroused great interest.
66 /UlBKlUAN MCDIOIHB]
SURGICAL OBSERVATIONS IN BERLIN
[JCLY lA 1002
SPECIAL ARTICLES
SURGICAL OBSERVATIONS IN BERLIN.
IIY
NlC'lIOfjAS HENN, M.D.,
uf ChUmgo, 111.
Rerliti is today Uio most profitable center for surgical teach-
ing in the world. Tlie vant clini(!al material is in the hands of
men who know how to ntillze it in teaching not only the art but
also the s<!i(!nco of snrgory. The (iornian surgeon is a patholo-
gist and is guided in liis diagnosis and work by his knowledge
of the etiology and i)athologic conditions which underlie the
nuirbid (K)nditions he is called upon to correct. IJorlin is the
place above all others for postgraduate instruction. Its rich
museums and well-e(niii)ped laboratories, the numerous clinics
pertaining to all branches of the healing art offer facilities for
practical work far superior to tlioso of any other medical center.
The young surgeon can j)roparo liimself here for his life work
by visiting tlie clinics of von Bergmami, Konig, Kose, Sonnen-
i)urg, .lames, Israel and llahn, men whose names are household
words wherever modern surgery is practised. Nowhere is it
more a])parent than in Herlin tliat aseptic precautions have
recently become verymucli simplified. The greatest stress is
laid on the mechanical cleansing of hands by the liberal use of
warm water and soap followed by alcohol, with or without a
I>rovious ablution with a bichlorid solution. Rubber gloves
have been almost entirely discarded. I'^ther is used more fre-
quently than heretofore. Spinal anesthesia lias few If any
advocates.
Pricdriclishain llo.ipitiil. — This is one of the great hos-
))ita!s for the deserving sick poor of Berlin. It is built on the
pavilion plan around a huge open s(|uare. The main entranc<!
is vis (I vis with one of the largo public i)arks. The many build-
ings are («)nstructed on modern plans, and harmonize as a
whole. The operating rooms are e<inipped witli all facilities
lor aseptic work, and are well supplied with all necessary sur-
gical instruments. The institution lias a total (;apacity of 800
bods, of wliich number 250 are set aside for surgical patients.
rro/es.sor Ilahn'n iroi'fc.— Professor Hahii is well known to
the surgical world. He lias probably performed more opera-
tions upon the stomach than
any other surge(m. He is an
indefatigable worker, and
has done much in the ad-
vancement and perfection of
surgical technic. He oper-
ates every morning at the
Friedrichshain at 10 o'clock.
His well trained nurses and
experienced assistants con-
tribute muc'j to facilitate and
lighten his arduous daily
routine work. The asepsis
ill his operating room is as
nearly perfect as it can bo
made without any extra dis-
play of precautionary meas-
ures. No gauze turbans arc
seen here and no display
of white trousers, wooden or golf shoes or rubber boots.
Hand disinfection is made by thorough scrubbing with hot
water and potash soap, followed by sublimate solution.
Gloves are used only in operations for septic conditions,
and then only for the purpose of guarding against unnec.
essary contamination of the hands. For nine years he has
relied on silk exclusively as a suturing and ligature mate-
rial. In operations upon the gallbladder he occasionally makes
use of (iatgut. In his practice stitch aliscesses very rarely occur.
The motto in his operating room is iinii tangeri, a warning to
nurses and assistants not to touch anything that niiglit contami-
nate the hands after they have been rendered aseptic. One nurse
threads the needles, another hands the instruments, and the
third handles the sponges. One assistant administers theane.s-
thelic, the second assists the operator, and a third one uses the
sponge. Chloroform vapor from the .lunker-Kappeler appara-
tus is the anesthetic in general use. The visitors permitted to
witness his operations do so without being obliged to remove
their coats or wear a gown.
During the most difiicult operations ths work goes on
quietly and deliberately, without any manifestations of impa-
tience, sliowiiig the hand of a master, ample and careful ])repa-
rations, and the value of skilled assistants and well-trained,
wideawake nurses. It was a source of great pleasure and profit
to me to witness the following operations :
Professor Hahn.
(jASK I. — Gastrogastrostomy for hour-glass contracti<jn of
the stomach: The patient was a woman of about ;i0 years who
had been sulTering for several years from indigestion and fre-
<iuent and sometimes profuse hemorrhages from the stomach.
The patient was reduced to a skeleton. No positive diagnosis
was made between cancer and ulcer of the stomach. The
incision was made through tlie middle of the umbilicus with-
out the aid of grasping forceps by lifting up the alidominal wall
on each side, incising the fold, including the entire thick-
ness of the abdominal wall, when the incision was enlarged up-
ward by cutting with scissors. As the vertical incision did not
give free access to the stomach a transverse incision including
tlie entire rectus muscle was made on the left side. The stom-
ach was found divided into two unequal compartments, tlie
largest one on the cardiac side, by a cicatricial band. The firm
adhesions about the smaller curvature made it impossible to
deal directly With the ulcer, consequently the proper course to
pursue was to establish a new and free communication between
the pyloric and cardiac compartments of the stomach, this
was done by making a gastrogastrostomy by suturing. The
technic of this part of the operation was perfection itself.
Afler uniting the serous surfaces with a row of interrupted
Lembert stitches in a vertical direction to the extent of three
inches the muscular and serous coats were incised on both sides
about two lines from the line of suturing and another row of
sutures united the serous surfaces accurately, when the mucous
membrane on each side was iucisefl and sutured separately
with a continuous lockstitch suture. The anterior wound mar-
gins were united in the usual manner by tIzerny-Tienibert
sutures. Although the patient was very feeble and the opera-
tion consumed 70 minutes symptoms of shock were absent.
The abdominal incision was closed by two rows of sutures, the
first including all layers except the skin. Three small capillary
drains of gauze were inserted between the external sutures. In
applying the external dressing abdominal compression is
guarded against by liolding the internal part in place with a
number of strips of adhesive plaster whicli encircle only one-
half of the circumference of the body, over which a very thick
compress of absorbent cotton is applied and held in place by a
loose gauze roller. Professor Hahn is of the opinion that firm
compression favors the development of bronchial and pulmon-
ary complications after abdominal operations.
Case II. — Perforative appendicitis: Patient a woman of
(i6 years. Tliis was her first attack. The initial symptoms pre-
sented nine days ago were comparatively mild. There was no
rise in temperature, but there was some vomiting and frequent
eructations. Rapidity of pulse was the only grave progno.-tic
symptom. The abdomen was tympanitic, with pain and tender-
ness in the right iliac fossa. A muscle splitting incision was
made, and as soon as the peritoneal cavity was ojiened a large
quantity of thin fetid pus escaped. The cavity on the side of the
small intestines was tamponed at once and the perforated
appendix was brought into the incision without any difficulty.
A fecal stone escaped with the pus and a second one was found
in the blind end of tlie appendix. The perforation through
which the liberated stone had escaped was found near tne
Cecum. The first ligature cut its way through the softened tis-
sues and a second one i|^as applied with less firmness to the
stump. No attempt was made to flush the cavity, which was
then loosely packed with plain sterile gauze. The operator,
from a very large experience, has found that the tampon sliould
remain in place from five to ten days and then be reduced in
size gradually, as complete removal at one time, according to
his observations, ha.s not infrequently proved harmful. liy
the gradual removal of the tampon the suppurating cavity is
reduced in size as the foreign material is extracted and the
danger of damage to the granulating intestinal loops is mini-
mized. The copious external dressing is changed as often as
indications arise.
Professor Hbnig's Clinic. — Profes.sor Konig, the eminent
author and present authority on diseases of joints, conducts his
clinic at the CharitC Hospital every day except Sunday at half-
past nine in the forenoon. He is looking forward'with well-
founded impatience to the completion of the new clinical build-
ing, as the present quarters are entirely inadequate for the
existing demands. The amphitheater has only 136 seats alto-
gether, insufficient for the many students who seek instruction
in this clinic. The seats are numbered and assigned to the
students who are fortunate enough to receive them by early
applicatipn. Professor Konig has j ust celebrated his seventieth
JDI.Y V2, ISKK)
ADVANCE OF ORTHOPEDIC SURGERY
[Ambkican Medicine 67
birthday. He enjoys robust health and retains tlie enthusiasm
of youth. It does appear soiiieti nies sad to contemplate tliat great
men wlio have Ijoen of such incalculable assistance to science
and humanity must eventually succumb to tlie inevitable henile
decrepitude which at last conquers their pliysieal strength
and mental activity. Konig has always been an impressive
and popular teaclier, a rejmtation he has maintained to the
highest degree since he came from (iottingen to Berlin. His
language is concise and precise. Liike all (ierman teachers he
makes pathology the ground floor for his clinical teachings.
Tlie details of his aseptic teclinic are remarkable for their sim-
plicity. Hand disinfection consists largely of thorough scrub-
bing witli hot water and soap supplemented l)y an aljlution
Willi a 11000 solution of mercury bichlorid. The field of opera-
tion is disinfected in the same manner after the patient is under
the influence of the anesthetic. If rubber gloves wore ever used
they liave been discarded. As anesthetics, chloroform and ether
are used. I will give a brief description of tlie material pre-
sented and the operations performed during one of his clinics:
(/ASE I.— Kosoction of the head of the radius for ankylosis
of the elbowjoint following gonorrlieal arthritis.
The patient was a female of 25 years. The forearm was
fixed in flexion at an angle of 45° with complete suspension of
all rotary movements. The acute symptoms had subsided and
as the joint resisted all attempts at immobilization an incom-
plete resection was performed a few days ago. On opening the
joint on the radial side a bony ankylosis was found between
the articular surfaces of the radioulnar joint. The excision of
the head of the radius removed the mechanical diflicnlty and
the joint can now be flexed quite freely and i)ronation and
supination of the forearm have been restored. A small iodo-
form gauze drain was removed and the dressing and fixation
splint reapplied. It was remarked that in many cases of anky-
losis of the elbowjoint arising in the course of a gonorrheal
arthritis the mechanical difficulty is often to be found in a bony
ankylosis of tlie radioulnar joint and that a resection of the
head of the radius otters the only chance for restoration of
motion.
Cask II.-^Fracture of the humerus at the junction of the
miildle with the lower third complicated by paralysis of the
musculospiral or radial nerve and delayed union.
In this patient, a robust man of middle age, it was difficult
to decide between trauma and callus compression as cause of
the paralysis, as the patient's statements in reference to the
time when the paralysis appeared were indefinite. Four
days before an incision was maHo over the course of the nerve
exposing the seat of the fracture freely. The fragments were
found imbedded in a mass of immature callus, and the nerve
over it completely severed. The proximal end, as is usually
the case, was bulbous. The finding of the distal end was
attended by considerable difficulty. Secondary nerve suturing
was performed after freely vivifying the nerve ends. Accora-
ing to the operator's large experience, restoration of nerve
function is often delayed for months after tlio operation if
the operation is performed a long time after the injury. The
hope was expressed that the nerve-suturing would hasten the
process of bone repair.
Cask III.— Large abscess in left iliac fossa of somewhat
doubtful origin; operation four weeks ago.
Patient a young man who was attacked suddenly with
symptoms of peritonitis. The disea-se pursued a very rapid
course and, in view of the clinical symptoms, appendicitis was
suspected as its cause, although the physical signs indicated
an a(!cuinulation of pus in the left ilia<^ region, extending over
the bladder toward the right side. At the time the operation
was performed, over four weeks ago, the abdomen was very
tympanitic. Alino.st the entire linea alba was incised but noth-
ing abnormal could be found in the peritoneal cavity except
distention of the small intestines. The abdominal incision
was then closed and a transverse incision made over the piibes
and left Poupart's ligament and a large (juantity of extremely
ott'ensivo pus evacuated. The most careful exploration did not
reveal a palpable cause for the suppurative inflammation, but
it Is suspected that an abnormally situated appendix was the
starting point of the infection. The large cavity betiomes oblitr
eral(!d in a remarkably short time by granulations, and the
grave symptoms subsided jiromptly after the operation. The
abdominal incision is healed and only a limited granulating
field indicates the location of the transverse incision, (iauxe
was iiia<ie use of as a drainage material. Attention was (jailed
to the comparative harmlessness of fetid pus in dealing with
the siiiipurative inflammation giving rise to this variety of pus.
f^AsK IV.— Fetid empyema following rupture of an appen-
diceal abscess into the left pleural cavity.
This ca.se was an extremely ol)scure one. The patient, a
young man of IG, when admitted into the hospital presented all
the indications of emiivema. The early history of the case was
ol)M<!uie. A segment of the seventh rib was excised in the axil-
lary line and a large quantity of very fetid nus was liberated. The
patient not imiiroving as w'as oxjiected, the opening in the chest
wall was enlarged by resection of the adjacent lower rib. As
the suppuration and septic condition persisted, it was finally
decided to follow the abscess cavity its entire length in a down-
ward direction. The remaining lower rilis were exciso<l and
a perforation was found in the diaphragm. The abscess cavity
was followed by extending the incision downward as far as the
crest of the ilium. From this time the patient improved
rapidly and at the prasent time the enormous wound is granu-
lating satisfactorily and promises to heal in a short time. It is
believed that an appendicitis was the cause of abscess forma-
tion and that the secondary suppurative pleuritis resulted from
the entrance of pus into the pleural cavity through a perfora-
tion in the diaphragm.
Case V. — Diffuse peritonitis following appendicitis ; opera-
tion.
Patient a delicate girl of 10 years. This was her first attat-k,
the duration of the disease being less than two weeks. The
symptoms were strong from the beginning, vomiting was a
prominent symptom. The abdomen was distendetl, and the
presence of pus in the right iliac fossa was suspected. The per-
sistent vomiting, feeble circulation and marked tympanites
were regarded as grave symptoms. A long incision was made,
and as soon as the peritoneal cavity was opened a largo (|nan-
tity of fetid pus escaped. Intraperitoneal palpation proved
that the iieritonitis was diffuse, with no tendency to limitation.
The incision was then enlarged upward along the crest of the
ilium. There was free prolapse of small intestines and ce<'um.
The inflamed appendix came readily into the wound, was
ligated and removed. There was no gangrene and no perfora-
tion. The stump was l>urie<l with a few Lembert stitches.
The pus was pu.shed out by placing the patient on the right side
and the wound packed with iodoform and sterile jilain gauze.
The extent of the disease was mentioned as a contra-indication
to irrigation.
Cask VI.— Carcinoma of the posterior wall of the rectum:
extirpation.
This patient was a woman of Si. For twenty years she suf-
fered from a rectal diflicnlty which was regarded to be of a
hemorrhoidal nature. The prominent tumor excavated in the
center projected from the posterior rectal wall one and one-half
inches above the anus. The patient was place<l in the lith-
otomy position and the anterior retcal wall removed far beyond
the limits of the tumor by the perineal route. The iniportonco
of making a careful examination in all cases of rectal disease
was emphasized. lAke most surgeons. Professor Kiiiiig, as
the result of experience, has been letl to limit more and more
the indications for Kraske's sacral resections as a preliminary
step to operations for malignant disease of the rectum.
Berlin, May 15.
THE ADVANCE OF ORTHOPEDIC SURGERY.'
H. AUGUSTUS WILSON, A.M., M.D.,
of I'hllartilplila.
The Philadelphia members extend a (cordial greeting to Ihe
American Orthopedic Ass(wiation upon the occasion of the
fifteenth anniversary, meeting for th(^ se<Jond time in this city.
It is a coincidence that at this fifteenth anniversary there are 15
of the 35 original Fellows still active. Nine are deceased.
Some of the others, through lack of special Interest in ortho-
pedic surgery, have withdrawn entirely from the Association ;
some rarely attend or participate, some give more attention to
general surgery, and some to the general practice of medicine.
While some have fallen by the wayside, now and energetic
Fellows have, from time to time, been added, until now the full
number of «) prescribe<l liy the by-laws has l»een almost
attaiiie<l, and the Association Is confronted with a waitinit list
of desirable candidates.
This Association nee<ls tlie interast of every physician " in
g(KKl professional standing" who Is "especially intere.sted In
orthopedic surgery." Kvery tea<!lier of orthopedic surgery
requires the benefits to be obtolnod only by fellowship in this
A.ssoclation. Thus hand-ln-hand the l)est objecU of the A»»«>-
ciation can bo secured, tho stronger and more powerful the
A8.sociation, the better and more forceful will tho FelloWH
become. Each will receive the lieneflclal influences that have
so characterized the growth of our Association, an orgBnlzatl<m
based on harmony, and having the single object of advancing
thebo.st Interests of orthopedic surgery and all that pertains
thereto.
Tho As«<«lation has prospereil oven l«>yond the most
sanguine expectations of its founders. Its Influence Is appre-
ciated throughout tho world. The methisls of 15 years ago
have changed very materially as a result of the work of tho
at tbe
1 AddrcBH of lhi> l'rc»l(leiit of tluj Anicrlcan (IrtlioisMli- AkhocImIIoii
be Sixteenth Annual .Meetlng.lieUI»tl'hlltt"lel|)hlB, June 5,6,7. IIKB.
68 Ahkbioan Meuicinb}
ADVANCE OF ORTHOPEDIC SURGERY
[Jui,Y 12, 1902
Association In fosterinir careful Htiidy of etiology, pathology
and (!ollo<!tiv() study of results and procedures. The improved
work of individual uioml)ers has only been a part of tlie bene-
fit tliat lias been olitained by this organization. Uy precept
and l>y example, l)y didactic and clinical undergraduate and
postgraduate teacliiug, l)y addresses beibro medical societies,
by medical journal literature, by monograplis and textbooks,
the errors of the past are becoming loss conunon and patients
throughout the world are receiving direct tjenefit. Many of tlie
serious deformities of the past are now unknown. Many con-
ditions previously considered as incurable are now being
arrested in the beginning before destructive changes have
taken place.
It is evident tliat the force of the Association lies in uniting
the individual strength and power of its Fellows as prac-
titioners, as teachers, and as writers. In the president's
address, 1899, Slierman dwelt upon the teaching force of ou r
Fellows, and showed tliat from five medical colleges which in
1887 included orthopedic surgery in their courses the number
has steadily increased until now practically all medical colleges
provide instruction thereon. In many the dignitied and suit-
able title of professor is given, in a lesser number clinical pro-
fessor, and in very few associate or assistant professor. The
instruction is provided liy didactic and clinical lectures, demon-
strations, laboratory and ward classes, to the end that every
student upon graduating should be made an efficient general
practitioner and bo given a working or necessary knowledge of
the subject in addition to the thorough grounding in the other
essentials of medicine and surgery.
Various State Boards of Medical Examiners have from time
to time very properly included in the surgical examinations
questions upon orthopedic surgery subjects, thereby indicating
the necessity of at least an elementary knowledge of these.
This action on the part of the licensing bodies does not make,
nor tend to make, specialists of tlie graduating student, as some
would have us believe, but indicates tlie urgent necessity for
general practitioners being properly prepared to recognize aud
treat those diseases of the spine and other joints, the failure to
do which entails progress of the destructive changes and ulti-
mate permanent loss of function, and death. This action of the
State Boards of Medical Examiners should, it is believed, be
commended and encourged within proper limits.
In the president's address of 1898 Townsend directed atten-
tion to the pi-actical side of the subject by dwelling upon the
hospitals devoted entirely to orthopedic patients, and showed
great increase in the number of these hospitals during the past
16 years, until now there is at least one such institution in every
largo community, while in the large general hospitals special
departments of orthopedic surgery have been established.
Following the plans of Gillette, Bradford and others, educa-
tional institutions have been established that have for their
objects the mental and manual development during the long
time that orthopedic procedures are in operation.
It is appropriate that at this time and in connection with
the foregoing consideration of the advance of orthopedic sur-
gery the subject of its literature should be briefly alluded to,
for it is one of the legs of the tripod consisting of teaching,
practice and writing. To this end every Fellow has been urged
to send a complete list of his orthopedic and other writings that
have been published during the past 15 years. The list is far
from complete, as some Fellows have failed to reply, but an
aggregate of 1,938 titles have been received, a number far in
excess of the total number (518) appearing In the 14 volumes of
our Transactions.
In marked contrast to this vast array of work by our own
Fellows it is of interest to find that the complete list of ortho-
pedic literature published between the years 1825 and 1860 num-
bers only 172, according to Bradford's presidential address of
1889. Seven textbooks devoted to orthopedic surgery, and
published during the past 15 years, more clearly than anything
else demonstrates the importance of the subject. These text-
books are to be found in the lists of textbooks in every medical
college. Two journal periodicals, edited by corresponding Fel-
lows, would appear to indicate the possible future of our Trans-
actions.
Our Transactions is a storehouse of a limited list of papers,
limited to those read before the Association and accepted by
the publication committee, a very small part of the orthopedic
literature of our own Fellows, to say nothing of the many
valuable writings of those other than Fellows.
The annual volume of Transactions is at times quoted by
American and foreign writers, but far more frequently refer-
ence is made to the original publication in one of the medical
journals. If our Transactions is to be a storehouse, it is believed
that it should be such in fact as well as in name, and this can be
accomplished in several ways, some of whicli have been consid-
sidered in the past and one is now suggested. This plan, pos-
sibly previously discussed, is to transform our Transactions
into a Y^ear Book of Orthopedic Surgery. To include in its
pages not only the best papers that are read at the meetings and
the discussion thereon, but also all papers of decided merit, and
especially to include comprehensive abstracts of all orlhoijedlc
literature, no matter where published or in what language.
Titles give no conception of the contents of papers and are fre-
quently misleading, while good abstracts, preferably prepared
by the authors, would provide accurate knowledge of the scope
and purport of the papers. If authors failed to furnisli abstracts
of their papers, satisfactory abstracts could very frequently be
obtained from medical journals which are in the habit of regu-
larly furnishing such information to their readers, and thus
very few papers would require attention from our own editorial
committee.
The complete bibliography of the years 1899-1900, number-
ing 583 titles, that was furnished by the Boston Fellows, and
printed in the thirteenth volume of our Transactions for 1900,
confirms the recognition of the fact that very many valuable
papers upon orthopedic subjects are written by others than
Fellows of this Association, papers that are quoted as integral
parts of collective investigations and bibliographies. With a
corps of editors and collaborators such as this Association could
efficiently provide, with a suitable publisher, it would appear
possible to secure a large subscription list among those who are
not members nor likely ever to become such, and yet who are
more or less interested in some parts of orthopedic surgery.
Orthopedic surgery rather more than any other special branch
of the general subject of medicine extends into every field in
its preventive and corrective measures. The chronicity of
many of the bone and joint lesions and the necessity for pro-
longed orthopedic treatment, often demand the conjoint serv-
ices of the general family practioner, whose skill may be
demanded for the usual maladies during the period of ortho-
pedic treatment. General practitioners and general surgeons
may very properly be expected to add an Orthopedic Year
Book to their libraries.
The adoption of the suggested plan of publishing the Trans-
actions would not necessarily change the present method pur-
sued by nearly all Fellows of publishing their papers in gen-
eral medical journals shortly after they have been read at our
annual meeting and often months before they are said to be
buried in the Transactions.
The Cremation Bill. — This bill has passed the third read-
ing in the House of Commons and bids fair to become an act.
It gives local authorities in Great Britain the power to erei-t and
maintain crematoriums and provides for their regulation, site
of erection, fees, etc. The real object is to allow their building
without special act and to provide for proper equipment and
Inspection by proper authorities.
Dyed Milk. — Evidence is accruing that the practice of add-
ing artificial coloring matter to milk is increasing. Samples
are commonly met thus colored to give them a rich but
false creamy aspect. The natural color of milk bears no rela-
tion necessarily to the amount of cream present. It is very de-
sirable that this practice should be stopped. The recommenda-
tion of the Department Committee on Preservatives and Color-
ing Matter in Food that the use of any preservative or coloring
matter whatever in milk offered for sale in the United ICingdom
be constituted an offense under the Sale of Food and Drugs act
should speedily be put into force. We believe that annatto is
the dye commonly employed, and it is fortunate that it is harm-
less, though that fact does not justify the device. Certain coal-
tar dyes have, however, been detected in milk, and among them
methyl-orange, or in chemic nomenclature, the sodium salt of
dimethylaniline-azobenzene-sulfonicacid. — [Lancet.']
July 12, 1902]
THE WORLD'S LATEST LITERATURE
(Akerican Medicine 69
THE WORLD'S LATEST LITERATURE
Journal of the American Medical Association.
July 5, 190i. [Vol. xxxix. No. 1.]
1. The Treatment of Pneumonia. X. S. Davis.
2. Life and Work of the Late Prolessor Christian Fenger. Memorial
Acidresii Uelivcred to the Graduating Class of Hush Medical Col-
lege, .\pril 4, IStO-'. .N. SESN.
S. Nephrectomy, Subsequent Nephrotomy and Finally Huprapubic
Cystotomy. E. I). FERcr.sON.
4. The Surgical Treatment of Complicated but Aseptic Retroversions
of the Uterus in Fruitful Women. The Permanent and Harmless
Results that Should Constitute the Normal Minimum Require-
menl and by What Method They Are Best Olnained A. GoLD-
.SPOIIN.
!i. The Surgical Treatment of the Utero-Saeral Ligaments Through the
Vagina in Retroversion of the Uterus. J. We.slky BovEft.
1.— Treatment of Pneumonia.— The mortality from croup-
ous pneumonia has been iucreasing (or many years. In Chicago
in 1852 it con.stituted lM<Jc of deaths from all causes, in 1902
about 120,. Davis gives a historic survey of the various
treatments in vogue during the past century. Unquestionably
a moderate bleeding when a large are* is congested, but not yet
hepatized, is safe in full-blooded individuals, and will add to
comfort, lessen pain, lower temperature, slow respiration and
unload an overburdened heart. It may be resorted to when the
jugulars are distended, the pulse small and soft, the second
sound accentuated or the lungs filling with the rales of edema.
Elimination must be kept active, and food should be very
digestible and moderate in quantity. Subcutaneous salt injec-
tion^ should be given when the urine is small in amount and
there are evidences of deep intoxication. Oxygen may be
administered for cyanosis and digitalis when the pulse is over
100. Strophanthus and strychnin are also valuable. Ditt'usible
stimulants are often needed. Ammonia is preferable to alcohol
on account of the latter's anesthetic and paralyzing tendencies.
Baths and packs should be relied on for hyperpyrexia. The
medical profession is not free from blame for the prevalence of
pneumonia. Prophylaxis has not been enforced. The sputum
should be destroyed and anti.septic mouth washes used during
convalescence, and the room and all contaminated articles thor-
oughly cleansed, [h.m.]
4. — See American Medicine, Vol. Ill, No. 24, p 988.
5.— See American Medicine, Vol. Ill, No. 21, p. ^)^.
Boston Medical and Sur{;ical Journal.
June S6, 190i. [Vol. OXLVI, No. 26.]
1. The Importance of Milk Analysis in Infant Feeding. A. H. Went-
WORTH.
1.— Importance of Millc Analysis in Infant Feeding. —
Wentworth gives tables exhibiting the variation in the per-
centage of cream in the upper layers of various uiilks, showing
a dilferenoe of almost 100%. The percentage of sugar is higher
in the lower milk and of proteids in the cream. He describes
tlie methods of estimation. Unless explicit directions are given
as to home inodilication mistakes will occur. The most harm
is done to infants a few weeks old. The results of too little fat
are not so serious as too much. When the milk is poor in cream
it is impossible to modify so as to obtain a sufficiently low per-
centage of proteids. Wlien the upper { contains less than Vl% of
cream it is better to take off less than that quantity. Analyses of
■M specimens of commercial uiodifie<l milk showe<i every one in-
correct; the fat percentage was usually too low. In every milk
used for modification the percentage of fat should be accurately
determined once at least. It is advi.sable to repeat the tost when
tlie cattle's food is changed. Home modifications carefully
made are bettor and much cheaper than the commercial article.
[H.M.]
JulyS,19Ut. [Vol. cxi.vii, No. l.J
1. The Iniportani'c of .Milk Analysis In Infant Feeding. A. H. Wekt-
woRTH. (Concluded from . I line 2ii. Sec atjove.)
2. On the Classlllcatlon of the Benign Thyroid Tumors. .losEI'H Hek-
H K ^' I ' It A 'l"F
:i. Tuije'rc uloslH of the Tesllcle. Paul THOHNDiKEand W. T. BAILEY.
4. Tuberculosis of the Urinary Tract. Kdoah Oarceau.
."•.. Tubcr<uloslK of the Prostate, i.. R. O. CRANnos.
3.— Tuberculosis of the Testicle.— Thorndike and Bailey
liave compiled and analyzed 7o cases of tuberculosis of the tes-
ticle and they state that while the statistics are unsatisfactory
they show that the disease is one of young adults for the most
part, and that in about one case out of three a gonorrhea was
the immediate forerunner of the tuberculous process. In only
20f() of the cases were there any symptoms referable to the urin-
ary tract, and in only 16% was the vas deferens palpably
involvedat the time of operation. In spite of more favorable
findings by others the authors have never found the epidi-
dymis only involved, but in every case the testicle was also
involved. Kemoval of a tuberculous and inflamed testicle is
justifiable even though the disease exists in other parts of the
body. It is palliative but often brings mudi relief, [a. B.C.]
4.— Tuberculosis of the Urinary Tract.— Garceau has
collected aud analyzed 415 cases of tuberculosis of the urinary
tract which were operated upon. Nephrectomy constitutes the
largest single class operation, there being 257 cases. All are
related to the kidney in some way, nephrotomy constituting
the next highest list. It is significant that the total survivals
for two years was but 58, or a percentage of but 14. Of the 415
cases, 2(i«i were females, 12S miles, and in the remainder the f-ex
was not stated. The author states that this preponderance
against the female does not accord with necropsy stati>tics,
which just about reverse the figures. The miliary form largely
predominated, and of the 415 cases with urinary tuberculosis
54 had the disease iu other parts, 37 being of the lungs, [a.b.c]
5.— Tuberculosis of the Prostate. — Crandon states that
when the urogenital system suffers from tuberculosis the pros-
tate in two-thirds of the cases is one of the parts attected. It
occurs nmeh more frequently than is diagnosed Tuber-
culosis of the prostate is believed generally to be secondary,
but that it maybe primary is generally conceded. A correct
diagnosis of the condition is often difficult and must be deter-
mined by the symptom complex. The prognosis must always
be grave, since primary cases frequently do not lend them-
selves to diagnosis until there is extensive tuberculous disease
elsewhere, and secondary cases carry with them the implica-
tion of tuberculosis in other parts so serious as to be the more
important factors of a ease, [a.b.c]
Medical Record.
{July 5, 190?. Vol. 62, No. I.]
1. What Shall Wc Do with the Consumptive Poor ? S A. Knopf.
2. Intussusception, with a Report of Three Additional Operative Cases.
John F. Kkkmann. „ ^ „
3. On the Transportation of .Mosqultos by Vessels. Kdmond Si)U(HO».
4 Contagious Ophthalmia in Industrial, Residential and Public
Schools, and In Asylums and Hospitals. Richakp H. Dkrbv.
5 Subglottic Sarcoma Removed Endolaryngeally with Galvanocautery
Snare. J. W. Gleitsmasn.
a.— Intussusception.- Erdmaim has previously reported
9 eases of intussusception and lie now reports 3 additional
eases. Summing up the salient features presented in the
12 cases he states: That there were 10 operative cases, of
which 5 were of the iliocollc, 1 iliooecal, 2 enteric, 1 colonic
and 1 nmltiple— lliocolic and enteric, varieties; that only 1
case recovered by the use of injections; that 1 death occurred
in whicli enemas, etc., had been used, no operation being
allowed : that of 10 operative cases, 5 die»l and 5 recovered,
and of the deaths 3 were cases operateti upon as a last resort
after all mechanic means had been exhausted, 2 being re.sec-
tioiis for gangrene and the tliird septic from a seven-day dura-
tion of tlie intussusception; that tumor could lie palpated
through the abdominal wall In 5 cases, while through the rec-
tum only .i cases were palpable; that had we cases 1 and 2 to
operate again, resection wtnild not have been done, but a tem-
porary enterostomy would have been ma<ie; although the mor-
tality rate is W per cent, in the entire lot, It must be remem-
bered that the cases terminating fatally were of 2i, 3, 4 and 7
days' duration when operate<l upon, and that of thete, .'I «ere
practl(!ally moribund at the time of operation. [a.b.c.J
8,_Tran8i)ortation of Mosquilos by Vessels.— Souchon
gives the report of 10 examinations on fruit vessels trading
with dangerous ports. Six lns|>e<.'torH found no moHqulU)s, two
attributing this to rough weather. On four vessels they were
found, persisting In one case throughout the voyage. A more
systematic examination Is to be made, aud at the end of quaran-
70 Ahirican Meojcinx]
THE WORLD'S LATEST LITEEATUEE
[July 12, 1002
tine season about 125 reports will be on file, when it will be
possible to settle definitely the question of their presence or
absence, and if present the length of time they remain aboard.
[H.M.]
6.— See American Medicine, Vol. Ill, No. 23, p. 948.
New York Medical Jonrnal.
June S8, 190t. [Vol,. Lxxv, No. 26.]
1, A Case of Pregnancy Cornplloated by Fyonephrosls, with Remarks.
Charles Gbken Cumston.
2. Cerebral Localization and Brain Function. L. Harrison Mbttler.
1.— Pregnancy Complicated by Pyoneplirosis.— The
patient was a multipara, aged 29, four months pregnant, and
with a distinct swelling in the right side of the abdomen.
Catheterization of the ureters showed pus from the right.
Through lumbar incision two pus cavities in the kidney were
drained. Attempt to save the kidney failed, and nephrectomy
was performed 12 days later. Recovery was uneventful, and
the patient was delivered of a living child at term. Cumston
believes the kidney was congenitally hydronephrotic, and that
a secondary infection caused pyonephrosis, [a. O.K.]
2. — Cerebral Localization and Brain Function. — After
an exhaustive review of the subject Mettler reaches the follow-
ing conclusions: (1) The known motor and sensory areas of
the cerebral cortex are not sharply distinguishable one from
another, as was at first supposed by Ferrier and his followers :
(2) nor are they, as separate foci, of such a character and of such
relative unimportance as to render the action of the brain that
of a single organ, for which Goltz and his school contended
(3) there are separate motor and sensory centers within the
cortex, but they are closely intermingled and are most inti-
mately connected with one another; (4) both the motor and
sensory areas have foci of special intensity ; the former in the
central, the latter in the posteroparietal lobules ; (.5) while there
may be a general intercommuuioation between all the sensory
and motor elements of the cortex, there is the most intimate
connection between the related sensory and motor cells which
preside over corresponding parts of the body ; (6) the primary
function of these cortical sensory-motor groups of cells as coup-
lets is that of reflex action like that of the sensory-motor reflex
arcs of the various spinal cord segments. This is shown by the
morphologic and embryologic development of the entire cere-
brospinal axis, and it explains most satisfactorily the majority
of the sensory-motor phenomena of physiologic experimenta-
tion and clinicopathologic observation ; (7) mentalization
depends upon sensory-motor phenomena, and is therefore a
function probably of the cortex, basal ganglia, and entire nerv-
ous system. Conscious mentalization is probably a function of
the cerebral cortex alone. The relative importance of the cor-
tical areas in the production of the mind is not yet determined ;
(8) inhibition is apparently the latest and highest differentia-
tion in the functions of nervous matter, though it is Itself a
more or less latent function of all nervous substance, its degree
of activity varying merely with the stage of nervous develop-
ment; (9) inhibition is probably the special function of the
forebrain and therefore endows this part of the nervous system
with a commanding influence over the rest of the nervous appa-
ratus. The forelirain is therefore justly spoken of as preemi-
nently the psychic center, though when exhaustively exam-
ined, its inhibitory and reflex functions differ from the inhib-
itory and reflex functions of the ganglia lower down In the
cerebrospinal axis in degree rather than in kind; (10) the
inhibitory function of the forebrain appears in the sphere of
consciousness, and thus forms the basis of volition. It is pre-
eminent in force and manifestation, but it does not preclude the
exercise of the same function in a lesser degree by the lower
parts of the nervous system upon parts still lower; (11) the
sensory-motor functions of the cerebral cortex are psychic in
character, and influence the external parts of the body through
the mediation of the cord and special ganglia, just as the highest
of all the psychic centers, the forebrain and other association
territories still unknown, influence the body through the
sensory-motor cortex, special ganglia, and spinal cord; (12) in
fine, inhibition and reflex action being the special property of
all nervous matter, they are found, in varying graduation, as the
functions of the most highly organized matter of the cortex,
which therefore seems to be the special seat of mind, down to
the most primitive ganglia of the spinal cord which retain
only the lowest degree or most elementary form of reflex irri-
tability. [A O.E.]
* Medical News.
July 5, 1903. [Vol. 81, No. 1.]
1. A Plea for the Simpler Medicinal Treatment of Chronic Nervous
Diseases. Joseph Collins.
2. Asepsis and Antisepsis In their Relation to Modern Surgical Technlc.
K. H. Badger.
3. Tetany. Hanueb Brown.
4. The Examination of the Gastric Contents In Children. Louis
Fischer.
1.— See American Medii-ine, Vol. Ill, No. 2.5, p. 105.5.
1!.— .Vsepsis and Antisepsis.— Badger gives a definition
and explanation of the above terms. Discussion at some length
is had with reference to the principal germicides employed in
surgery ; the technic for the preparation of the patient for opera-
tion and a proper method for disinfection of the operator's
hands are given. The latter two accord in the main with the
methods generally employed in hospitals and private practice.
[a.b.c]
4.— Examination of the Gastric Contents in Children.—
Fischer describes the tests he uses in examining for hydro-
chloric, lactic and other acids, propeptone, peptone, pepsin and
rennet, and for motility and resorption power ; and tabulates
the results of examinations in a number of breast and arti-
ficially fed patients. Free HCl was not present in very young
children. That it was secreted was proved by the presence of
peptones. It forms acid albuminates with milk. HCl should
not be administered in these cases. In the first few weeks the
stomach is empty one hour after nursing; the maximum time
in the first few months is one and a half hours. Where cow's
milk was used food was found several hours after feeding. The
foundation of chronic dyspepsia is laid in infancy and is due in
the majority of cases to improper feeding. Dilation is caused
by excess of food and fermentation. The writer gives the
technic of lavage and discusses massage and medical treatment.
In atropic and subacute dyspeptic conditions HCl was absent
and the organic acids present. There was acidity in anemia
and athrepsia infantum. In healthy nurslings after the sixth
month lactic acid was in excess at the beginning of digestion
and free HCl was found at the end. Cheesy curd in rubbery
lumps was found two or three hours after a meal of sterilized
milk. Constipation disappeared with less treating. Breast
milk has a normal temperature of about 100°, and cow's milk
should never be fed at any other temperature, [h.m.]
Philadelphia Medical Jonrnal.
July 5, 190S. [Vol. X, No. 1.1
1. Progress in Neurology. The Presidential Address at the Meeting of
the American Neurologic Association. Joseph Collins.
2. Carclnomaof the Eyelids, with Secondary Involvement of the Eye-
ball; Removal of the Growth by Extensive Plastic Operations;
Recurrence. Wm. Campbell Posey and Edward A. Shumwav.
3. Climatology of California. Alexander G. Mc.\die.
4. Struraectomy In a Case Complicated with Tuberculosis Pulmonalis.
H. O. SOMMER.
1. — Progress In Neurology. —In this, the presidential
address at the meeting of the American Neurologic Associa-
tion, Collins refers to some of the most important contributions
of the year, and although none has been offered that can be
regarded as epoch making, the charge that neurologists have
become sterile and their fields of labor have gone to seed can
scarcely be maintained, [p.c.h.]
4.— Struinectomy in a Case Complicated with Tuber-
culosis Pulmonalis. — Sommer reports a case of goiter not so
much of interest for tlie tumor itself as for the complicating
tuberculosis pulmonalis. The operation verified the auteopera-
tive diagnosis of compression of the trachea, whicli was aggra-
vated by numerous colloid cysts deeper in posteriorly, as well
as some substernal extension of the main cyst ; and in spite of
the fact that an irritant general anesthetic was used, and that
considerable hemorrhage was incurred during the operation, no
bad pulmonary effects were noted, [f.c.h.]
July 12, 1902]
THE WORLD'S LATEST LITERATURE
(Akkbican Mbdicinx 71
CLINICAL, MEDICINE
David Ribsman a. O. J. Kelly
Borax and Boric Acid as a Food Preservative '■
The preservation of meat and other food-products by
means of boric acid and borax has aasume<l unexpected
importance, owing to the fact that the harmlessness of
tlie practice has been questioned in Germany. As that
country is one of our largest purchasers of these articles,
and as her action in such matters generally constitutes a
guide to other continental nations, the subject is of vital
significance to the American meat exporter, while its
sanitary aspects mal<e it of moment to all consumers.
It is difficult to eliminate from the question, which is
one in which the judgment of trained men of science
should rule, mere political considerations ; for instance,
the Agrarian party in Germany is determined, at all
hazards, to raise the wall of a protective, if not a pro-
hibitive, tariff against the importation of American food-
products. The American exporter and the American
pre-is, on the other hand, see in every act of the Imperial
Government that is antagonistic to American interests a
studied attempt at unjust discrimination.
In a recent number of American Medicine we pub-
lished an important article upon boric acid as a food
preservative by Dr. Victor C. Vaughan and Mr.
William H. Veenboer, of Ann Arbor, in which these
two observers, from a study of the literature and from
their own exiK-riments on the antiseptic value of boric
acid, laid down the following postulates :
"1. The use of boric acid or borax as a preservative
in butter and cream, in the quantities specified in the
recommendations of the English Commission, is justified
both by practical results and by scientific experimenta-
tion.
"2. The dusting of the surfaces of hams and bacon
that are to he transported long distances with borax or
boric acid, not exceeding 1 ..5^ of the weight of the meat,
is effective and not objectionable from a sanitary stand-
point.
"3. Meat thus dusted with borax or boric acid does
not become slimy, because the preservative used prevents
the growth of aerobic, peptonizing microorganisms."
Almost simultaneously with the appearance of the
foregoing. Professor Rubner' published a brief report
detailing the results of some experiments upon metabol-
ism when bori(! acid was administered with the food.
He contends, in the first place, that the harmlessness of
a [)reservative cannot be infernal from the absence of
complaints on the part of the consumer. The effects of
the agent may be so insidious that they are not recog-
nized, and are not attributed to their proi)er cause ; or
there may be slight gastric and intestinal disturbances,
which the individual never thinks of connecting with
the real cause. If he does not ascribe them to "cold "
and attributes them to the food at all, he will generally
conclude that the particular article in question was
spoiled, or was for some reason indigestible.
Rubner's experiments were made upon two men,
who were ((ach liept eight days in a respiration appara-
tus. Their ingesta and excreta, including the «\rbon
dioxid and water, were carefully estimated. The first
three days were for purposes of control. During the
next five boric acid was added to the food. The results
during these five days showed, in the first plax-e, an
increase in the fecal excretion, indicating a lessened
utilization of the food. In the second, there wits an
increase in tlie elimination of CO.^ and H,/), which was
found to be de|K-ndent upon an augmentation of the fat
and carbohydrate metabolism. The increase in fat
which had been noticed during the control days sank to
about halfduring the boric-acid period. These results
indicate a series of latent changes in metabolism, which
I H^KlenlHcbe Kundiicliau, February 15, 1U02.
must be of importance, although they are not recog-
nizable by the ordinary methods of investigation.
It cannot be said that these two experiments, made
under such unnatural conditions as obtain in a calori-
meter, are sufficient to flout the opinions of the English
Commission, but they warrant a careful reinvestigation,
the undertaking of which may well be a matter for our
national government. The Department of Agriculture
might very readily occupy itself with this <iuestion, and
might properly extend the investigation to all of the
food-preservatives in use.
Yellow Fever : Why Did Xot New Orleans Have Inva-
8ion8 of the Disease in Early Times AVhile Boston Did ?—
M.W. Glover' having made a careful examination of authorities,
answers this question to the effect that disregarding all sporadic
cases, Boston had its lirst epidemic in 1798, New Orleans in 1796.
Tliere was, therefore, but little difference in the time of the
advent of yellow fever in the two cities, both being infected by
the great wave of pestilence that swept over the country from
1793-18(>4. Even when sporadic cases are considered the con-
clusions are not materially different. [c.s.D.]
Yellow Fever in Kurope : A General Historic Heview.—
J. M. Eager ' tirst discusses the possibility of identifying among
European species of mosquitos such as are identical with the
yellow fever bearing species of North and South America.
De Gouvea states that the Calex calopus Hoffmann, of Portugal,
and the Oitlex cleganx Ficalbi, of Italy, are the same as the yel-
low fever tnosquitos of America. The earliest authentic appear-
ance of the disease in Europe was in 172;J in Lisbon, Portugal.
The European country whose yellow fever history is the most
extensive, however, is Spain; though there is no accredited
record of yellow fever having appeared in Spain prior to 17;18,
when it was imported into Cadiz from America. Repeated out-
breaks appeared thereafter in Spain and Portugal— the mortality
in the epidemic at Barcelona in 1821 reaching 25,000 in the brief
period of live months, while in a similar perio<l in 1857 over
1:5,000 were stricken with the disease in Lisbon, with a mortality
of nearly 50?^. The tirst importation of the disease into France
is said to have occurred at La Rochelle in 1700, but this lacks
scientific authority, the lirst properly verified occurrence of
the disease in France being at Brest, 1802. The history of the
disease in the British Isles is limited to five appearances
between the years 1817 and 1865, in Falmouth, Southampton and
Swansea. The disease was first introduced into Italy at Leghorn
in 1804 by a Spanish vessel trom Alicante and Cadiz. In 1881
yellow fever was epidemic at Torrea .\nnunziate, situated near
Naples, an outbreak which seems to have been completely lost
sight of in the overshadowing calamity of the terrible cholera
epidemic at Naples the following year. The history of yellow
fever in Europe closed in 1894 with two cases at Trieste, [o.s.ii.]
Yellow Fever in Portugal.— According to .1. M. Eager'
in the year 1723 yellow fever was imported into Lisbon from
Brazil, and according to do<;uments in possession of the Sani-
tary Council of the Kingdom of Portugal this was the first
appearance of yellow fever in Kurope. Subse<iuent epidemics
occurred in 1800, 18.'.1, 1856, 1S57 and 1858, that of 1K)7 assuming
gigantic proportions ; 13,751 persons were ill with the disease
and 5,()52 died. [c.s.D.
Yellow Fever in Spain.— J. M. Eager' |>olnt8 out that the
assertions made l)y Moroau de .lonnes as to the primary impoir-
tation of the disease into Spain in 17ft5 lacks scientific confirma-
tion, the authority of Villalba, the famous Spanish epidomolo-
gist, being generally accepte<i to the effwt that the original
introduction of yellow fever into Spain took place In 17'10, Iwing
introduced into Cadiz by a ship from America. Facts are given
concerning 22 sulmequent epidemics, the last of which occurred
In Madrid In 1878. [<\m.i>.J
A Note on MoiHiuitoa in llaKKOKC— S. B. Orublts' calla
attention t4> the enormous sanitary and quarantine interest
which attai^hes to the question. How far may a mosquito be
carried in baggage?— it having lieen demoDstrated in many
1 Yi'llow Kcver Iniitltiito Ilnllvtln No. 2, Mnrrh. 1(108.
• Yellow Vnvr Innllltiu- Hiilli'lln .No S, Marrh. 1902.
'Yellow Kever liiatltiite Hulletln .No. I, Mnreh, 1S02.
'Yellow Fever IniiUtiite Bulletin Vo ft, .Mareb, laOS.
> Yellow Fever Innltuie Bulletin No. t, March, IM2.
72 AjiXBIOAir MlDIOINai
THE WORLD'S LATEST LITERATURE
[July 12, 1902
tustiincos that niosijiiitos may be harbored for weeks iu vessels
and railroad trains. Experiments were instituted to determine
how long mosqultos would live packed in different places in
trunks more or loss full of clothing, and ordinary traveler's
articles, and under various conditions of temperature and moist-
ure, and sometimes in the presence of aromatic substances.
It was found in tlie case of (lalrx pungens that the insect could
live but a short time in close conlinement, and that the greatest
factor in prolonging its life was moisture. It is interesting to
note that the female mosquito regularly survived the male
under nearly all conditions. As the results of these experi-
ments and observations it seems tliat it is entirely possible for a
mosquito to enter ordinary baggage and live there long enough
to be carried from the infected ports within a few days' sail of
our foreign shores, but that in reality they are seldom so
carried, [c.s.d.]
Heniihypertonia Postapoplectica.— McCarthy,' discus-
sins: homihypertonia postapoplectica, reports a case in which
the main features were: (I ) An attack of dizziness associated with
numbnessin the left arm, and aphasia lasting 20 minutes; (2) an
attack of vertigo in 1898, followed by severe occipital iieadaches
for about a year; (3) the development, almost a year after the
second attack of vertigo, of intermittent, alternating flexor and
extensor spasms affecting the left lower leg and arm, asso-
ciated with a very pronounced increase of the muscle irrita-
bility and the knee-jerks. Reference is made to the likelihood
of the presence of an accessory contralateral motor speech
center, [a.o.j.k.]
Fallacies of Cystoscopy.— L. E. Schmidt '' cites some of the
conditions in which cystoscopy is apt to deceive the observer,
lead to wrong conclusions, and even cause unwarranted
operations. Frequently, when surveying the trigonum, a part
of the free plane of the prism is covered by a protruding fold of
the urethral mucosa ; the field of view is thus covered by a red-
dish tinge, readily conveying the idea that inflammation is
present. The ureteral openings are often overlooked, due to
the cystoscope being pushed too far into the viscus. An
inflamed and edematous mucosa may cover the openings of the
internal orifices of the ureters. Hypertrophic and edematous
folds of the internal urethral orifice, magnified by the optical
apparatus of the cystoscope, have been mistaken for tumors and
polyps. An erroneous diagnosis of a trabeculated bladder may
be easily made. The error to which he especially calls atten-
tion is the diagnosingofcystoscopic burns as idiopathic ulcers;
these are easily recognized by their location and the absence of
inflammatory reaction around them. A decisive test is that
these burns will heal within 10 to 14 days without any curative
interference, which is never the case in actual ulcers, [f.c.h.]
Mucomembranous Colitis.— J. Zahorsky ' regards this dis-
ease occurring in children, and the membranous enteritis of
adults as one disease, having a certain variation in the symp-
toms. The principal clinical symptoms which admit a com-
parison are constipation, moderate nutritive disturbance, the
passage of mucus, casts, masses and shreds from the bowels,
irregular abdominal pains, normal temperature, neurasthenic
symptoms, and chronicity and intractability. The author
believes that this disease is rare in children, and that the term
mucous disease should be dropped. Nothing specific is offered
in regard to medication. Castor oil in small daily doses is
recommended. Fowler's solution in gradually increasing doses,
and cold water enemas daily were of great benefit in a case
reported by the author. Nervines hold a prominent place in
the treatment, since it is supposed that the primary morbid
process is in the nerves. Rectal injections of large quantities
of oil high into the sigmoid and retained as long as possible is
highly recommended. [c.A.o.]
Contagiosity of the Feces of Tuberculous Patients.—
Some months ago Anglade and Chocreaux* (Alenfon) reported
on the occurrence of Bacillus tuberculosis in the alvine dis-
charges of tuberculous patients, even when there are no intes-
tinal lesions. They have since demonstrated by the inoculation
of guineapigs that the bacilli of swallowed sputum may pass
' Ti"*^L'i'"*'^''!?P'*l''ft'^e Medical Sciences, Vol. cxxlll d 791 1902
"sTnS.SL'it^S*^?'*'?'',' Ke«order. May 15, 1902. ' ^^ ''*' ^"^ "
» Interstate Medical Journal, May, 1902.
< Lii Semame M«dicale, 1901, p. 254, and 1902, April, p m
through the intestinal canal without any loss in virulence
Exposure of the l)acilliferous feces to prolonged desiccation and
to the action of extreme cold (0°— 10° C.) gave equally posi-
tive results, whereby it is to be inferred that the fecal matter of
consumptives contributes to the diffusion of the malady as well
as the sputum, [c.s.n.]
A. B. Craig
GENERAL SURGERY
Martin B. Tinker
C. A. Orr
On Sacrococcygeal Dimples, Siiiu.ses and
Cysts. — The occurrence of suppurating sinuses iu the
region of the coccyx and .sacrum are by no means very
uncommon and it is evident that very frequently the
usual cause of this condition is not recognized, for
patients often come to our clinics, where such sinuses
have been simply opened and paclted without any further
treatment. In a recent paper Markoe and Scliley {Ameri-
can Jourmdof tlie Medical tScie)ices, May, 1902) givea very
thorough review of the literature of this subject. They
believe that congenital defects in the form of dimpling,
furrowing, round depressions or sharply marked pits
indicating the mouth of a fistula or sinus are present in
a far Jarger number of cases than is ordinarily recog-
nized. The subject ha.s received comparatively little
attention from clinicians and is frequently noticed only
when some surgical complication arises. The size and
depth of these malformations range from the faintest
indentations through sharper and deeper pit-like forms
to sinuses of many centimeters depth possessing orifices
from the finest size to one so large that it may be mis-
taken for the anus itself. They are usually noticed any-
where from the anus to well up on the sacrum and
always exactly in the median line. By surgical writers
they have been described as pilous cysts, pilonidal sin-
uses, coccygeal dermoids or simple abscesses and phleg-
mons. Hodges, of the Ma.ssachusetts General Hospital,
gave the name of pilonidal sinus, by which these affec-
tions are perhaps most frequently known, and he consid-
ered three conditions essential to their formation : a con-
genital dimple or sinus, pilous development and lack of
cleanliness. They are to be regarded merely a.s a part of
the original way of communication between the medul-
lary canal and the skin surface and are destined for oblit-
eration. Sebaceous accumulations, proliferated epitlie-
lium, and especially hair products of the lining epidermis
having no o tlet or at best a greatly narrowed one, are
apt to be retained and lead to irritation and suppurative
inflammation. Retention and abscess formation result
frequently with burrowing of the pus and the establish-
ment of secondary fistulous tracts. These .secondary
sinuses sometimes open well out on the buttocks near
the sacroiliac synchondrosis or on the upper posterior
and inner surfaces of the thigh. In such cases they have
.sometimes been mistaken for tuberculous disea.se of the
sacrum or coccyx and these bones have been partially
curetted away. Very commonly the cause of the disease
is not re ognized and the supposed abscess or sinus is
simply opened and touched with silver nitrate or
swabbed with carbolic acid. If the sinus contains hair,
as is usually the case, of course tliis does not result in
permanent healing, and the only plan promising success
is complete extirpation of the whole tract down to the
periosteum of the bone as soon as is practicable.
Chloroform Anesthesia.- Thomas G. Sloan.' The report
of the Anesthetics Committee of the British Medical As.socia-
tion published in 1900 shows that chloroform is about ten times
as dangerous as ether. It is stated that there were 19 deaths in
l-3,393 chloroform administrations, but that only three of these
were due to the chloroform itself, or rather 16 of the 19 deaths
were dependent on the operation, or on pathologic conditions
which should have contraindijated chloroform as an anesthetic
1 Yale Medical Journal, May, 1902. ~~
July 12, 1902]
THE WORLD'S LATEST LITEEATURE
iAMERICAN MKDICIX-K 73
of choice. Sloan gives the followinK contraindications to the
use ol chloroform: (1) Myocardial weakness, fatty degenera-
tion, myocarditis, considerable fatty infiltration, and dilation of
the heart without hypertrophy; (2) valvular weakness. Valvular
lesions if well compensated do not contraiadicate chloroform ;
(3) shock, depression and hemorrhage, as in accident cases,
strangulated hernia, intestinal obstruction, and the like: (4)
operations involvin? considerable hemorrhage, or considerable
intestinal manipulation ; (5) very long operations, the danger
Increasing with the length of the operation ; (6) joint manipu-
lation, as merely deep narcosis is necessary and it may be
dangerous; (7) alcoholics do not take chloroform well, and
strong muscular men are apt to give trouble, muscular rigidity,
irregular breathing, falling back of the tongue, cyanosis and
vomiting being common ; (8) dental operations, particularly
i with the patient sitting up; (9) tumors pressing on the trachea
f or interfering with respiration, as goiter or Ludwig's angina;
(10) emphysema; (11) cyanosis or dyspnea; (12) empyema,
infusions of any kind in the pleura and operations on the chest
, In general ; (13) great effusions in the abdomen interfering with
I" respiration; (14) operations necessitating the prone position,
particularly in very heavy persons. Chloroform Is about
twice as dangerous in males as in females. Chloroform is par-
ticularly indicated in: (1) Nephritis, acute or chronic; (2) acute
inflammations of the respiratory system; (3) stout people
: usually take chloroform well if it is largely diluted with air;
(4) small children take chloroform better than ether ; (5)
; patients with atheromatous arteries and aneurysms ; (6) opera-
l , tions on the brain and thyroid ; (7) in labor, when given as an
analgesic only during the pains, and to the surgical degree as
'i the head is delivered ; (8) in cases in which complete relaxation
cannot be obtained with ether, [c.a.o.]
Surgical Interference in Cases of Floating Kidney. —
Floating kidneys manifest themselves in one of three ways :
Through pain, neurasthenic symptoms, or dyspeptic symp-
toms. From the surgical standpoint, the symptoms may be
purely renal, or they may point to other organs. Operation is
indicated in all cases of painful floating kidney, and in that
classof the dyspeptic type in which the symptoms are due to
mechanic disturbances, such as obstruction of the intestines,
pressure against the gallbladder, etc. If the dyspeptic symp-
toms are mostly nervous, if the disease is part of a general
splanchnoptosis, or if the neurasthenic type is diagnosticated,
operation should not be performed until after everything else —
especially the modified abdominal bandage — has been tried, or
the kidneys are clearly found to be the cause of the picture.
The surgical prognosis in the former is good, in the latter de-
cidedly poor. If hematuria appears, an indication for the oper-
ation exists. Tumors, renal stones, pyonephroses and pyelo-
nephroses should be treated as if no floating kidney existed.
Intertnlttent hydronephrosis is an indication for operation,
especially if it can be shown that a floating kidney is the cause
of it. Chevalier ' advises ureteral catheterization to make the
diagnosis a certainty. In most cases nephropexy is sufficient ;
in old or very large hydronephroses the sac will need opening,
either by puncture or, better, by nephrotomy. Ureteropelvic
anastomosis should be performed in all cases in which the
lesion is double, if the other kidney is diseased or has been
removed, if anuria exists, or if the patient's condition is pre-
carious. ■ [K.L.]
Successful Suture of Wound of the Heart.— Fontan '
reports the case of a man who had been operated upon two
hours after being 8tal)bed in the chest with a knife. This is the
second case of the kind in which he has had occasion to operate.
A thoracic flap taking in the fourth, fifth and sixth ribs was
turned up and the wound in the pericardium was found. This
was enlarged sufficiently to permit good exposure of the heart.
The wound was in the ventricle 1.5 mm. above the apex. It was
suture<l with Ilagedorn's needles with N'o. '1 catgut, complete
hemostasis being obtained 15 minutes after the beginning of the
operation. The patient was in condition of extreme shock
immediately after the operation, but recovered rapidly and got
along well for the first 16 days, when a pneumonia of the base
' Allgem, Wiener med. Zeltung. 1902, p. 121.
2 lA Semalne Mfidleale, I'JOI, Vol. xxl, p. .Sir..
of the lung developed, probably of embolic origin. Some
weeks after this an infection of the left pleura occurred, neces-
sitating thoracotomy. After this a phlebitis of the left lower
extremity developed, the last of the patient's complications. In
spite of these accidents the patient made a good recovery.
[m.b.t.]
Peritonitis Complicating Appendicitis.— A. J. Ochsneri
believes that peristaltic motion of the small intestines is the
chief means of carrying the infection from the perforated or
gangrenous appendix to the other portions of the peritoneum,
changing a circumscribed into a general peritonitis, and that
this can be prevented by prohibiting the use of every kind of
food and cathartics by mouth, and by employing gastric lavage
in every case in which there are remnants of food in the
stomach or in the intestines above the ileocecal valve, a.s
Indicated by the presence of nausea, or vomiting, or meteorism.
The patient can be supported by the use of concentrated pre-
digested food administered as enemas not ofteuer than once in
four hours, and not in larger quantities than four ounces at a
time. He believes that this form of treatment, when instituted
early, will change the most violent and dangerous form of
acute perforative or gangrenous appendicitis into a compara-
tively mild and harmless form and that cases of perforative or
gangrenous appendicitis with beginning general peritonitis can
usually be carried through the acute attack safely with this
method. This treatment will prevent a large proportion of the
most troublesome complications and sequels of appendicitis.
The patient should l)e permitted to recover fully from his acute
attack before an operation is performed, except in cases encoun-
tered within the first :W hours after the beginning of an
attack or in case of the formation of a superficial cireum.scrlbed
abscess. This treatment does not contraindicate the removal
of the diseased appendix before the septic material has ex-
tended beyond this organ, and the author believes it is indicated
in all intraabdominal conditions in which it is desirable to pre-
vent the distribution of septic material by means of peristaltic
motion, [c.a.o.]
liigature of the Inferior Vena Cava : Recovery. —
Houzel' reports the case of a woman of 3fi upon whom he
operated, performing nephrotomy for pyonephrosis. The
patient did not do well after the operation, however, and It
became necessary to do nephrectomy. The operation was very
difficult because of dense adhesions about the kidney in the
separation of which the vena cava was torn a distance of about
1 cm. Lateral suture was attempted but was unsuccessful.
Two ligatures of catgut were then placed about the vein above
and below the wound. The patient did well after the operation,
the only difficulty during convalescence being alight edema of
the lower extremities. One year has now elapsed since opera-
tion and the woman is apparently well and without any circu-
latory di-sturbance. [m.b.t.]
Laceration of the lilver ; Operation ; Recovery.— This
case is reported l)y Wiggin.' The patient was injured by being
struck in the abdomen with a piece of Iron. Shock was slight
and .symptoms improved until the fourth day when sharp pain
in the right side was followed by all the symptoms of shock.
There was vomiting of bloody bile and the passage of a bloody
stool. Operation showed a stellate rupture of the liver over the
fi.ssure of the gallbladder the wound being three inches in
length. It was sutured with catgut and the abdomen closed
without drainage ; recovery followed. Wiggins gives ana-
tomic reasons to explain how delayed shock, abscesses and
bloody vomit or stool may occur in these ca.s<>s. The anterior
surface of the liver l)oing In contact with the thoracic wall,
impact may cause rupture of the liver substance without caus-
ing a laceration of the serous and flbrous coats of the organ,
shock will lye limited and the blood and bile extravasation
will be confined under the capsule. Later abscess may result
or the capsule finally rupture, allowing the contents to pour
Into the ab<loraen. Before this takes place the pressure of the
fluid, which gathers along the fissures, will force blood through
the hepatic ducts Into the duodenum resulting In bloody vomit
or stool. fA.d.K.]
1 American Journal of Huntery and Gynecology, January, 1902.
» IjiHemalnc M6dlc«le, May 21, 1902.
I American Journal of Hantrry and Oynecology, June, 1902.
74 AinemoAW MBDicimtj
THE WORLD'S LATEST LITERATURE
[July 12, iwi^
GYNECOLOGY AND OBSTETRICS
WlI.MEK KrUSEN
Frank C. Hammond
Gonorrheal Peritonitis.— The socalled idiopathic
poritoniti.s is a thiiif,' of tht- past, and few surgeonn
believe in a primary form of tliis disesise. A plastic
peritonitis may be due to an aseptic cause and remain
limited ; but if we accept the views of Orawitz, Klom-
merer and others concerning the pathology of peritonitis
we class all forms together as septic or infectious. Some
observers, however, maintain that there may be a
simple peritonitis without infection, due to traumatism
or chemic irritiition ; and this seems to be supported,
sometimes, by surgical experience, which shows that,
although cultures throughout the course and at the end
of an operation show an absence of infection, yet for
the first two or three days after the operation the patient
may exhibit many of the symptoms of peritonitis. But
a-s time advances and investigation is more thoroughly
made, etiologic factors which were formerly obscure
become plainly evident. The role of the vermiform
appendix, which is termed by Price an "anatomic cess-
pool " and "deadly little assa.ssin," with no respect to
sex or person, in the production of peritonitis has long
since been well defined. Puerperal infection, perfora-
tion by gastric or intestinal ulcers, or the migration of
microorganisms through a damaged wall of the bowel,
are all conditions which have been fully recognized as
causative factors in the production of general peritonitis.
The Streptococcus pyogenes is the most virulent of the
ordinary microorganisms, and its introduction or escape
into the peritoneal cavity is one of the most dangerous
accidents. Until recently the possibility of the gono-
coccus possessing the power of exciting active inflamma-
tion of serous membranes was questioned. Every gyne-
cologist was familiar with the extensive injury produced
by this germ in the genital organs of the female, but it is
only recently that the etiologic role of the gonococcus as
a cause of general peritonitis has been conclusively
demonstrated. According to Gushing it is to Wertheim
that the credit is due for first demonstrating that the
gonococci can live upon the human peritoneum.
In a valuable contribution upon this subject by
Hunner and Harris,' a series of six cases is reported ;
the observations in the wards of Johns Hopkins Hos-
pital embrace a series of nine cases of general periton-
itis due to gonococcus, and the authors conclude that
surgical measures in gonorrheal peritonitis are of doubt-
ful therapeutic value. They emphasize the question of
diff'erential diagnosis and believe that when reasonable
doubt as to causation is present, operation should be
performed. The practitioner who does not see many
cases of general peritonitis should not treat anj' sus-
pected ease of peritonitis on the expectant plan without
sharing the responsibility with one who does a great deal
of abdominal worli and is thoroughly competent to make
a diagnosis. Every surgeon should be so familiar with
the complex symptoms of appendicitis as to make a
reasonably certain diagnosis of general peritonitis arising
from that source. The picture of a general peritonitis
arising from a gonorrheal infection is even more char-
acteristic in its preliminary phases. A history of blen-
orrhea of recent date or long standing, with the dis-
covery of gonococci in the cervical, vaginal, urethral or
glandular secretions, should make the surgeon very
suspicious. If with this onset there is a history of pelvic
pain and tenderness, and a mass can be made out in one
or preferably in both ovarian regions, the diagnosis
becomes probable. If a general peritonitis accompanies
the above conditions and has occurred immediately after
the manipulation of pus tubes or during the menstrual
period, or in the puerperium, the diagnosis is almost a
matter of certainty. The symptoms of an acute gon-
orrheal peritonitis — abdominal distention, tenderness
1 BuUeUn of Johns Hopkins Hospital, June, 1902
and rigidity, vomiting, elevation of temperature and
frequency of pulse— are similar to those of other forms
of general peritonitis; but the clinical course of the
disease is quite characteristic. After a very acute onset
and unusually stormy period of from one to three days,
the symptoms suddenly abate and the patient makes a
rapid recovery, usually preserving as a legacy an intra-
peritoneal exudate, pelvic adhesions or pus tubes. It i.s
generally believed that this disease is particularly fatal
to children. The writers think this is due, not entirely
to the susceptibility to infectious diseases characteristic
of childhood, but in a larger degree to the fact that
children fail to receive the treatment accorded to adults.
In the treatment of a case of general peritonitis due to
the gonococcus, they recommend absolute rest in bed,
hot turpentine stupes, alternating every half hour with
hot water stupes, mild catharsis, liquid diet, cold sponges
for the high temperature, and stimulative treatment
according to the severity of the symptoms.
Uroblliuuria in Pregnancy and Itjs Increase in Case
of Intrauterine Death of the Fetus.— C. Merletti,' after a
careful study of this subject, asserts that at least in the last
three months of pregnancy in apparent health the amount of
urobilin found in the urine is double or treble the amount found
in a nonpregnant subject, and he thinks that this increase, not
being associated with any symptoms of impaired health, can be
called physiologic. A noteworthy increase in the urobilinuria
of pregnancy takes place in some cases of the intrauterine death
of the fetus, and this increase, if further examination shows it
to be constant, serves as one of the objective signs of the death
of the product of conception in the uterine cavity, [vv.k.]
Vesicovaginal Fistula Cured by a Nevt' Method.—
McCann^ says that in closing an opening in any hollow viscus
two Important surgical principles must be borne in mind : to
avoid all tension on the stitches; and to avoid passing the
suture material through the inner lining of the viscus. Hence
in operating for vesicovaginal fistula, the principle to be
adopted should be a free separation of the bladder from the
uterus and vaginal wall in order to remove all tension, and
separate sutures of the opening in the bladder with Lembert's
sutures. The bladder sutures are inserted transversely while
the vaginal walls are stitched in a longitudinal direction.
McCann has abandoned silk sutures for this operation and pre-
fers properly sterilized chromic catgut. He does not use a self-
retaining catheter which may produce cystitis, but prefers
using a catheter at regular intervals until the patient can pass
the urine naturally. He has adopted this method of free sepa-
ration of the bladder in the treatment of ureterovaginal fistula,
thus bringing the separated bladder toward the fixed end of
the ureter, and implanting the latter into a new opening made
in the bladder. [w.K.]
Spirits of Turpentine in the Treatment of Metror-
rhagia.—The hemostatic properties of spirits of turpentine
pointed out in 1883 ;by Billroth have been but little utilized
of late, but attention is again called to the advantages it offers
by a Russian physician, L. F. Liengvitch-' (Astrakhan), who
employs it systematically for combating uterine hemorrhages.
The cervical canal is first wiped out with a tampon saturated
with a solution of one part phenol to three parts of glycerin ; the
canal is then dilated and the uterus packed with iodoform
gauze which has been moistened with pure spirits of turpen-
tine. The end of the strip of gauze is allowed to remain in the
vagina and the patient is made to lie quiet for three to six
hours. At the end of this time strong uterine colic sets in and
the packing is removed. As a result of this treatment the
hemorrhage is entirely arrested, there ensues an abundant
mucosanguinolent discharge, but in no case has there been any
toxic or other harmful effects, [c.s.d.]
Upon the Power of Agglutination and the Existence of
Bacteria in the l<^etus of a Mother with Typhus Fever.—
Ludwig Jehle,' after studying the literature of this subject and
three cases in his own experience, concludes that the observa-
1 Centralblatt fUr Gynakologie, April 19, 1902.
2 British Medical Journal, May 17, 1!IU2.
'LaSemaine Mfidicale, April 23, 1902.
< Wiener klinlsche Wochenschrift, May 13, 1902
July 12, 1902]
THE WORLD'S LATEST LITEEATUEE
[AMERICAN MEDICINB 76
tionsof others, as well as his own, show a negative result iu
relation to infection of the fetus through the placental circula-
tion, and that the blood-serum of the fetus, although free from
typhus bacteria, possesses very little or no power of agglutina-
tion. In cases in which the maternal blood serum coagulated
very promptly, the fetal bl )odserum required from half an
hour to an hour to coagulate. In many instances it showed not
a trace of agglutinating power and never coagulated, [w.k.]
Foreign bodies in the uterus may have been introduced
in efforts to prevent conception, or to produce abortion, or they
may remain there as the result of medical manipulation: or,
more rarely, may pass into the uterus from some adjacent
organ. For their detection Herman i recommends the exam-
ination of the uterine cavity, either digitally or with the sound.
This usually gives a sure diagnosis if the object is of a metallic
nature, but the use of a blunt curet may be necessary in some
cases. The extraction of the foreign body can usually be made
without difficulty by means of dressing forceps. Although
foreign bodies may remain in the uterus a comparatively long
time without producing much pain, yet the introduction of
pointed instruments to produce abortion when they are unster-
ilized may cause septic poisoning and be the source of great
danger. And the custom of thus preventing conception or pro-
ducing abortion may become a menace to the well-being of the
community and a danger to the State, [w.k.]
Dystocia Due to Ascites in the Fetus.— In the case re-
ported by .Savage'^ the mother was a multipara, attended by a
midwife, who endeavored for over two hours to deliver the body
of the fetus, and finally sent for the writer. .Suspecting dropsy
of the fetus, the fetal abdomen was puncturetl near the
diaphragm, when a brownish fluid escaped, the alxlomen col-
lapsed, and the trunk was immediately expelled. There were
no external abnormalities about the fetus, which was of medium
size, and weighed about seven pounds. The exact cause of the
ascites could not be ascertained, as permission could not be
obtained to perform an autopsy, [f.c.h.]
A gpeculnm foi- Vaginal and Uterine Therapy.—
Emilio Curatulo,» believing in the value of photography in
gynecology and obstetrics, has devised and gives an illustrated
description of a speculum which makes possible the use of dif-
ferent colored light baths in the treatment of the vagina or
uterus. Through the regular application of the ultra violet or
chemic rays by means of this speculum, important changes have
been made in the assimilation of tissue iu cases of metritis and
hypertrophy of the cervix. These baths of chemic rays have
been found of service in developing abnormally infantile uteri ;
they also promote the absorption of exudates in perimetritis
and parametritis. The yellow light baths are preferable in
some conditions, and in others the warm-red ray is used. By
this speculum these light baths may be used in connection with
vaginal irrigation, [w.k.]
The Histogenesis ofthe Socalled Kruken berg's Ovarian
Tumors.— Wagner* gives a detailed history of a case of ovarian
tumor with full histologic description of the tissues and (»n-
cludes from it that this tumor was undoubtedly a metastasis of
a scirrhus of the stomach with a slimy degeneration of the
cells. Krukenl)erg has collected a series of ovarian tumors
characterized as follows : The tumor is almost always on both
sides; it appears in the young as well as the older, and has a
long period of growth. As a rule ascites is present. It leads to
an enlargement of the eiitiro ovary, which remains unchanged
in form but is more or less tuberous on the surface. A sec-
tion shows a thick and firm texture near the surface with asoft
myxomatous interior. Its peculiar characteristic is a layer of
large, round bladdery cells lying between the fibrilli of the con-
nective tissue, and he believes these cells have their origin in
the cells of the stroma. Wagner quotes many instances from
different authors iu which the .section after death showed the
presence of cancer of the .stomach. This type of tumor has
been designated as mucocellular fibrosarcoma of the ovary,
[w.k.]
' MUnchener mcdlclnliiche Wochenschrlft, May )8, 1902.
s Maryland Medical Journal, June, 1902.
'Ceniralblatt far (iynUknloi^le, May 21, 1902.
* Wiener kllnlsche Wocliennchrlf', May lb, 1802.
TRILATRtENT
Solomon Solis Cohen
H. C. Wood, Jb. L. F. Appleman
Quinin and Urea Hjdnuhlorat*' iu Malarial
Fever — After nesvrly twenty years' experience with all
forms of malaria seen in thi,s climate, including a few
very severe cases in which the infection wsis acquired in
the Gulf States and in Cuba, and one in which it was
acquired in India, the editor of this department is more
and more confirmed in the opinion published by him in
1884, and reiterated from time to time since, that no prep-
aration of quinin compares in promptness end efficacy
and none is so well to be depended upon as the "double
salt" formed by quinin and urea with hydrochloric acid.
This preparation is quite soluble, practicallv in its own
weight of water, and is quickly absorbed. Its effect
upon animal tissues, either by reason of its quick absorp-
tion or through some chemic action not understood, is
more powerful than that of any other quinin prei)ara-
tion in equal dose. This statement might be made with
confidence merely upon clinitiil data, but experimental
evidence may likewise be adduced, notably the studies
of G. E. de Schweinitz on quinin amaurosis. The salt can
be given by the mouth in solution, in powder, or dry in
cachet or capsule, the latter method l)eing preferable
when there is no reason to distrust the solubility of the
envelope. According to the type and stiverity of the case,
or the age of the patient, the dose ranges from 1 to 15
grains daily, preferably in a single do.se, either before
breakfast or four hours prior to the anticipated time of
the paroxysm. If the daily quantity be given in two
portions, one dose should precede the time of chill by
about eight hours, the other by about four hours. Its
most powerful effect, however, follows hypodermic
injection, which may be given whenever convenient ;
perhai)s with best result about an hour before the time
at which a i)aroxysm is expecte<l. A single dose of 10
to 15 grains will interrupt for a period of either (!} or 13
days a series of quotidian or tertian i)aroxysinsof average
severity. In practice such injections may be confined to
the more severe typt^ or rebellious cases, and should
then be rei)eated with such fret^uency as is neceasary to
bring the infection to an end. This may be daily or on
alternate days, or even twice or thrii-e daily. After
apparent recovery the drug should be continued by the
mouth in appropriate dosage. Three cases of malarial
infection resembling pernicious anemia in the general
symptomatology and in the blood count were seen at
the Philadelphia Hospital alxiut two years ago. In one of
these no history of paroxysms (tf ague had b«>en given, the
malarial organisms were not discoveretl until after thei)a-
tient had t)ecome comatose, and although treatment uith
quinin and urea hydrochlorate was followed by tem-
porary return of con.sciousness and ai)i)arent disappear-
ance of the ])lasmodiums from the |><>ripheral blood,
death occurred in a few days. Autopsy was notobtaincd.
In the other cases the malarial hematozoons were dis-
covered on the patient's admi.s.sion ; the treatment was
instituted promptly, and recovery followed. A pe<'U-
liarly obstinate case of chronic malaria with hepatic
enlargement and recurrent .series of ({uotidian or tertian
paroxysms was seen in the jwrson of an Italian |>hysi-
cian who had Ikk-u attachecl to the American army in
Culm, where he becjime infecttHl, and who had fK-en
treatetl with (luinin .sulfate by the mouth In large doses
while in Cuba and afterwanl in two hospitals in the
United States. He had also himself continued to take
the drug in this form for some six months with little
l)enefit. Aft«'r taking 20 grains of the double hydnx-hlo-
rate in two doses of 1(1 grains each daily for three days,
fever (lisap|>eared and ])lasmo<liums could no longer
be (lemonstrate<l. For a we<'k the dose was continued
at 20 grains dally ; then reduced t<) l."> grains In a single
capsule before breakfast, daily for two weeks; then to
76 AXKBIOAS MEDICINBj
THE WORLD'S LATEST LITERATLRE
[July 12, 1902
to jyralns daily for two weeks; then to 5 grains and 10
>;rains on alternate days for two weeks ; then to 5 grains
daily, with a full dose of 1') grains every seventh day
for a month longer, when treatment ceased. Three
years have now passed witiiout return of symptoms or
reappearance of organisms in the blood. Certain pre-
cautions must be observed in the hypodermic use of
(luinin and urea hydrochlorate, to avoid cellulitis,
slough or abscess. The solution is to be thrown
det>piy into the subcutaneous tissue, no drop is to be
allowed to fall on the skin in withdrawal of the needle,
and the point of puncture is to be sealed with tincture
of iodin or iodoform-coUodion. AVe desire especially to
urge upon Southern colleagues, while awaiting the
extermination of the anopheles, to use this salt under
the skin, promptly in efficient dosage, and with due
repetition and persistence, in the severe types of malarial
infection that they encounter. In the North in average
cases, administration by mouth suffices.
The Treatment of Diarrhea.— Scbeffer (La MSdecine
Tl/orfcj-nc, September 4, 1901), in reviewing the remedies for
diarrliea, divides them into two classes: tliose which diminish
peristalsis, and those whicii decrease intestinal secretion.
Diminished peristalsis may be best obtained by the use of
opium or opium preparations. Among the most active are:
Powdered opium, given in the dose of from J to IJ grains ;
wine of opium, in the dose of from 5 to 30 drops ; and the
camphorated tincture of opium, which contains camphor and
benzoic acid, and is given in the dose of from i to 4 drams. The
opiates are indicated in intestinal catarrh due to cold, accom-
panied by violent abdominal pain ; also in diarrhea due to the
absorption of erosive substances. The astringents, which de-
crease intestinal secretion are: Bismuth subnitrate which has
given excellent results in the dose of from 30 to 60 grains in
children, and of from 2 to 3 drams in adults ; when a more active
antiseptic action is desired, bismuth salicylate in the dose of from
i to 2 drams; as an antacid and absorbent, calcium carbonate in
doses of from 15 to 75 grains. Tannin may be used in doses of
from 1 to 7.5 grains, but catechu or rhatany are usually substi-
tuted for it, as they are less disagreealjle to the taste. Tannigen,
a combination of tannin and acetyl, nearly insoluble in water,
is given in the dose of from 7 to 10 grains to an adult, or from
1 to 5 grains to a child, three or four times a day. It is decom-
posed only in the alkaline juices of the stomach, and may there-
fore be given without fear of altering the secretions of the
stomach. Comby considers it especially useful in infantile
diarrhea. Tannopin is given in the dose of from 4 to 8
grains, two or three times a day. This is a combination of
tannin and urotropin, nearly insoluble in water, dissolved only
in the intestine. Astringents are indicated when "diarrhea
shows a tendency to chronicity depending upon an intestinal
catarrh of slow progress, especially in children, or upon an
ulcerative process. Tannigen and tannopin are said to be pre-
ferable to tannin in the treatment of these conditions because
the appetite and normal gastric digestion are not disturbed.
[L.F.A.]
Hydrotherapy in Pulmonary Tuberculosis.— Aberg
(Reichi-Medicinal-Anzdger, 1895), a distinguished Swiss physi-
cian, recommends a special method which is readily carried
out, is really serviceable, and has also been highly praised by
Winternitz. Three procedures represent, as it were, three
different stages or grades of the treatment: 1. Sponging the
neck, back, face, and chest, at first for only a short time and
superficially, with an expressed sponge, followed immediately
by thorough drying of the parts treated. At the beginning
this is practised only in the morning, but later both morning
and evening, the sponge being less thoroughly expressed.
Reaction is permitted to take place in bed or in the open air.
The temperature of the water should be 0° C. (32° F.). 2. As a
measure of the second degree, Aberg applies affusions to the
head, neck, back, face, and chest, from a watering-pot. The
application is repeated, and the subsequent treatment is the
same as with the measure of the first degree. The temperature
of the water is also 0° C. (32 F.). 3. The third degree of Aberg
is the full bath of but momentary duration, the entire body
being immersed, including the head. Thorough drying is
practised as after the other procedures. The temperature of the
water is from 7° to 12° C. (44.6° to 53.6° F.). Aberg presents his
method as the outcome of 22 years' experience, and gives the
records of cases as an evidence of the extremely favoraijle
results of his plan.— Cohen's "System of Physiologic Thera-
peutics," Vol. ix.
Injections of Hermophenyl in Syphilis.— Reynes (Lyon
Midical, Vol. 97, No. 48, 1901, page 774) has employed sub-
cutaneous injections of hermophenyl, which is sodium mer-
curophenoldisulfonate, in the following solution :
Hermophenyl 3 grain
Distilled water 2J drams
One dram of this solution is injected at a dose, which repre-
sents i of a grain of metallic mercury. No pain, abscesses,
or other unfavorable symptoms occurred in 100 injec;ions.
[L.F.A.J
Tinospora crispa, Miers. (Menispermum erispum, L. ;
M. rimosum, Blanco; Cocculus crispus, DC). Nom. Vulg. —
Makabuhay, Tag. Uses. — Makabuhay is one of the most widely
known and used plants in the Philippines ; a sort of panacea
applied to all bodily afflictions. Its Tagalo name means liter-
ally "you may live." A shoot deprived of roots and dropped
in some moist place is soon covered with bright green leaves
and adventitious roots. This peculiarity of the plant made it
possible for me to take a large number of sprouts from Manila
to Paris where they arrived perfectly fresh after a voyage of 40
days, during which they lay almost forgotten in the ship and
the cars. The stem is the part employed in medicine. A decoc-
tion is given internally in the various forms of malarial fever
and of dyspepsia. Externally it is most useful as a wash for
ulcers of all kinds, rapidly improving their appearance. In
India the species T. cordifolia is used ; it differs but little from
T. crispa. It is official in the Pharmacopeia and has been intro-
duced into Europe. T. cordifolia has given excellent results in
the mild forms of intermittent fever; in general debility fol-
lowing long and severe cases of illness ; in chronic rheumatism
and in the second stage of syphilis. As the two species are so
much alike we shall add the preparations and dose of T. cordi-
folia which we have used on several occasions with good results.
Tincture of T. cordifolia. — Stems of the dried plant, 100
grams. Alcohol 21° (Cartier), 500 cc. Macerate seven days in
a closed vessel stirring from time to time. After decanting add
enough alcohol (21°) to bring the quantity up to 500 cc. and
filter. Dose. — 4 to 8 grams. Maceration. — Fresh stems cut in
small pieces, 30 grams, water .300 grams. Macerate for two
hours and filter. Dose. — 30 to 93 cc. a day. Extract. — Dry
makabuhay in small pieces 500 grams. Water 2J liters. Mac-
erate for 12 hours, filter the liquid and express the macerated
drug which is then macerated a second time in 2J liters of
water. Express again, unite the two liquids and filter. Evap-
orate in a water-bath to the consistency of a pill mass. Dose, }
to U grams a day in fractional doses.
Botanic Description. — A vine whose runners entwine
themselves among the tops of the highest trees, giving off
many adventitious roots which seek the earth. The stem is
covered with projecting tubercles. I^eaves heart-shaped,
pointed, entire with five well-marked nerves. Flowers yellow-
ish-green, dieeious, growing in axillary racemes. The male
flowers have a corolla of six petals, the three smaller ones
arranged alternately. In the female flower the stamens are
represented by three glands situated at the base of the petals.
Fruit, an elliptical drug.— De Tavera, " The Medicinal Plants of
the Philippines."
A case of lupus vulgaris treated with the static brush
discliarge is reported by Gibson (./ournal of Advanced Tliera-
pentics, Vol. xx. No. 1, 1902, page 48). The patient was a negress
of 21 years, with a tuberculous family history. The lesion was
of 10 years' standing, and she had been treated In all the clinics
of the city. It extended from both supraorbital regions to the
mouth, and from one inch in front of one ear to a like position
on the opposite side, covering- an area roughly estimated at
5x9 inches. The nose and upper lip were deeply ulcerated
and covered with foul, closely adherent crusts. The cheeks
were greatly swollen, and patches of scar tissue alternated with
July 12, 1902)
THE WORLD'S LATEST LITERATURE
AXERICASt HEOICINE 77
areas covered with crusts. The patieut was placed oq the insu-
lated platform and connected with the negative side of the
static machine, while a pointed wooden electrode, connected
with the grounding chain, was brought as close to the face as
the patient could bear. A powerful brush discharge was kept
U]) for from 15 to 20 minutes, the entire diseased surface being
exposed to the application. In all, 20 applications were made at
that time. Three months later, when the patient again came
under observation, the ulceration had entirely disappeared
except over a small area above the right eye, proliably because
the patient had shielded the eye from the brush discharge. The
skin over the entire area had the appearance of being made up
of innumerable small scars, as after a burn, and was as soft and
pliant a.s that of an infant. [r.m.«.]
Typhoid Fever.— Thayer {St. Paul Med. Jour., April,
1902) says that the amount of typhoid fever diagnosed malaria
Is ai)palliug; that the common continued fever of the United
States, north, oast, south and west, is typhoid fever. As an evi-
dence of the confusion of these two diseases he quotes statistics
from the Spanish war ; in one grouj) of 85 cases, diagnosed as
malaria, 80 were found subsequently to be typhoid ; and out of
another 90 cases diagnosed as malaria, 60 were typhoid, and
only 1 malaria, the other 29 being various diseases. In the
treatment of typhoid fever there are four points to be observed :
Complete rest, diet as nourishing as possible, relief of hyper-
pyrexia, and ever-watchfulness for complications. The diet, as
a rule, is preferably liquid, although in many mild cases a
greater degree of latitude than ordinarily allowed is not harm-
ful. The cold bath, which, by tlie way, was employed by
Nathan Smith in 1824, is of unquestionable value. The treat-
ment by intestinal antiseptics Thayer condemns for the follow-
ing reasons : At the time treatment is begun, it is probable
that the typhoid bacilli are comparatively few in the intestinal
canal, being scattered throughout the organism in positions
difficult to reach ; second, to obtain anything approaching effec-
tive intestinal antisepsis is impossible; and third, there is no
evidence of value supporting this treatment. The constant dos-
ing which is sometimes recommended in conditions of this
kind is harmful, becau.se it keeps the patient in a continual tur-
moil. He says that the results obtained in typhoid fever, espe-
cially in cases of perforation, are much better in hospitals than
in private practice. Further, " a hospital in which clinical
instruction is given offers distinct advantages over one in
whi(!h the students are not admitted to wards." This he
attributes to the careful observations which are only possible
with a large number of observers, such as may bo recruited
from the ranks of students. In regard to prophylaxis, he calls
attention to the fact that infected water is by no means the only
source of the spread of the disease. The introduction, for
ixiimple, of a few typhoid bacilli in milk, owing to their rapid
itinlti|)lication in this excellent culture medium, may be the
moans of carrying infection to many persons. .\8 has been
recently shown, the ordinary house fly is a very important
carrier of infection, [h.c.w.] [Nevertheless, intestinal disin-
fection by such agents as guaiacol, salol, naphtol, ben/.onaphtol,
etc., is both rational and useful, m.m.c]
Intratracheal Honte in Bronchitis.— Anderson (I'hysi-
ci(i)> and ■Sarffeon, February, 1902) has treated several cases of
bronchitis with good results by the intratracheal injections of
guaiacol 2*, or camiihor-meuthol B%,\a olive oil. The injec-
tion ahonld be made slowly during inspiration, the solution
being at body temperature. The method is not useful in the
early stages of acute bronchitis, [ii.c.vv.]
Gold Chlorid in the Treatment of Local Tuberculosis.
— In view of ttie fact that gold chloriil possesses antiseptic power
equal to that of iodin (Micjuel) O. Bn*"- {Ln Semaine Medicate,
April 2.3, 1902) has been led to its employment in the treatment of
noiisui>pu rati ve adenitis and in cold abscess with very gratifying
results. lie injects from 1 to i com. of a solution <;ont!)ining 1
gram of gold chlorid an<l 1 gram of sodium chlorid to .50 grams
of distilled water, repeating the inje<rtions two or three times a
week. From six to twenty injections eflfect complete cure.
[c.s.D.]
.Suprarenal Kxtract for Pruritus.— Meara (Merck's Ar-
ihiiies. May, 19(r2, iv, p. 177), reports a case of violent vulvar pru-
ritus in which the intense hyperemia suggested a trial of a solu-
tion of suprarenal gland. After the local application of this solu-
tion there was an immediate blanching of the mucous membrane
and relief from the itching. This effect lasted 14 hours and a
second application brought similar relief. A second case, like
this one in general but less severe, was also benefited by the
treatment, [h.c.w.]
PORMUL.^S, ORIGINAIj AND SEIiECTED.
Treatment of Pulmonary Tuberculosis. —i;. Wells {Bul-
letin General de Thgrapeutique, June 23, 1901 ) recommends that
tuberculous patients receive cachets, each containing:
Calcium hyposulflte .H to J grain
Strychnin sulfate ^ grain
Arsenious acid ^to^Vgrain
Powdered elm-bark 4 grains
One or two, three times a day.
He attributes greatest value to the calcium hyposulflte,
which by decomposition in the stomach disengages sulfuretted
hydrogen. This gas is absorbed by the veins of the stomach
and is eliminated by the lungs, exerting an action on the diseased
organ ; this has been sufficiently demonstrated by Dr. Bergeon,
who employed enemas of sulfuretted hydrogen in the treatment
of pulmonary tuberculosis, [l.f.a.]
ORTHOPEDIC SURGERY
H. Augustus Wilson
The Skilful Use of Spinal JackelH.— It l»a.s long
been accepted that ttie pla.ster-of-pari.s jacket is a potent
factor in .securing fixation of tiie spine and in removing
superinciinil)ent weight and thereby favoring recovery
from tuberculous disease of the vertebms. Its mechanical
possibilities as well a.s the coinparative ea.se of applica-
tion render it liable to abuse, or its use mLscon.struetl. It
is at times difficult to make patients understand that it
po.ssesses no therapeutic properties which by absorption
remove the concealed ills of flesh and bone. Even
in recent times patients have been known to resent
removal of the remnants of a jacket " because there wits
plaster still in it," while the limp condition of the
remaining rags gave emphatic indications of its failure to
support
Jn its very best condition the phtster-of-paris must
sooner or later lose its accuracy of atljustment by the
chanjred conditions of the patient and cea.se to fit the
parts. The period of its efficiency must therefore vary
greatly in different subjects and discernment is re<iuired
to determine when removal and renewal shall take
place. It seems impossible to demonstrate that a well-
fitting and carefully adjusted plaster jacket is just as
efficient in one month's time as it was when applied. A
jacket that has l>een on for six or eight months or
even longer can atvomplish no good purpose, but rather
conceal the adverse progress of the conditions within.
The unsanitary condition of such jackets long in use is
sufficient argument, but when the patients learn, as they
often do, to clean.se them.selves by passing a towel
between the jacket and their bodies and thus take a dry
rub, the clo.se adjustment of the jacket as a mechanical
support may be sjiid to be conspicuous by its absence.
There are few surgical resources more ca]>al>le of
variation in application, thereby giving a.ssurance that
the plaster jacket is not of itself remwilal, but the skill
with which it Is applied and care<l for must be n'sponsible
for beneficial results. The metho<ls of applying s|)inal
jackets api)licable to suitable cas«>s vary greatly and
many niodillctitions e.xist. K. 11. Sayre contiiiues to
re.sort to the suspension metli<Kl, so well known as being
advodited and i)ractise<l by his father. K. Tunstnll
Taylor, by means of his kyphotone, stn-ures a post«'rior
leverage position in the upright or rts-umlKMit |H)sition.
R. W. Lovett us«>s an ailju.stable ga.s-pipe fnime to obtain
the desiretl position anil maintains same while the jacket
is Ix'ing applied. The latter has nuiny modifications, us
that of (Joldthwait, McC-'urdy, Youngand others. Welgel's
78 AVEBICAK MEDICINBj
THE WORLD'S LATEST LITERATURE
(July 12, 1902
removable plaster-of-paris jacket seeni.s to obviate the
disadvantages of tfie immovable ones ; the benefits to be
derived from its use, however, depend entirely upon the
manner of its employment.
The inexpensive character of the materials is urged as
a reason for the use of plaster-of-paris, but this does not
take into iiccount the time and skill of the surgeon in
making it into a suitable jacket. Very large fees are not
unusual ($200 to $i!00) for a skilfully applied plaster-of
paris jacket, but such charges arc not conducive to fre-
quent renewal, but rather tend to long-continued use,
and therefore to loss of mechanical efficiency. The
expense may be considered as one of the disadvantages
even though a lesser charge is made for application, and
no one would want the jacket without the skill.
The disadvantages of plaster-of-paris jackets have
fostered the use of steel supporting appliances as being
more efficient because of ease of adjustment to meet the
changing conditions of the patient, diminished original
and subseciuent cost, and greater durability. The bene-
fits to be obtained from any of the many forms of steel
braces lies not in the material or construction so much as
in the skill of the surgeon in making frequent adjust-
ments by bending the steel bars to secure continuous
advantage of efficient support. The absence of the skill
of the orthopedic surgeon is the cause of the unfortunate
results of brace makers illegally prescribing and apply-
ing jackets in the manufacture of which they are skilled,
but they are without knowledge of the conditions for
which the jacket is applied.
The still too prevalent illegal practice of medicine
with which orthopedic patients are made to suffer is
based upon the error of physicians in thinking that the
brace manufacturer who makes must know how to pre-
scribe, apply and adjust the jacket. The materials and
methods of using them require peculiar knowledge.
The instrument and brace maker must of necessity know
all about the materials of which jackets are made. The
physician's skill should be employed to direct when and
how such materials should be used. Mr. Frederick M.
Bush ("Commissions to Physicians Upon the Sale of
Orthopedic Apparatus from the Manufacturer's Stand-
point," H. Augustus Wilson, Medical News, .July H, 1895)
said : " A man brought in a steam whistle to have
repaired, and at the same time said he wanted me to
make a brace for his child. He would not go to a phy-
sician, but wanted a brace after his own ideas plus what
I might suggest. All right, said I, I am not repairing
many whistles nowadays, but I will fix your whistle and
make your brace, but when they are both done I don't
care whether you put the whistle on the engine and the
brace on the child, or whether you put the brace on the
engine and the whistle on the child. I wash my hands
of the whole matter. I don't want to play with things
I don't understand, and it seems to me no one else should
do so, simply for the money there is in it."
The present disadvantages of spinal supports will
cease to exist when the mechanician's skill is confined to
making the brace, while the physician's skill will be
used to prescribe, apply, adjust and secure the best pos-
sible results for applications which in themselves are
more capable of producing harmful than beneficial
results.
A New Principle of Curing Clnb-foot in Severe Cases
in Ctilldren a Pew Years Old.— Alexander Ogston ' refers to
the various methods ordinarily in use in cases of the milder
types, and then indicates the severe forms that are susceptible
to the new procedure, which he thus describes : " The manner
in which the operation is performed is as follows : After the
usual disinfection an Esmarch'a tourniquet is applied to the
leg and tenotomy of the tendo-Achilles is performed. An
incision through the sliin is made, in a gentle curve beginning
in front of the external malleolus and extending forward, with
' British Medical Journal, June 21, 1902, page 1524.
its convexity toward the sole, until it terminates over the
calcaneocuboid joint on its dorsal aspect. When its edges are
retracted the outline of the astragalus is visible. The soft
parts covering it and the cartilaginous shell surrounding its
osseous center are then divided by a short incision in the same
line as the cutaneous one, the knife being made to sever every-
thing down to the bony kernel. A Volkramn's spoon, slightly
curved forward at its neck, is pvssed into the wound of
the cartilages and the whole bony center, save the upper part
constituting the pulley between the two mUleoli, is cautiously
scraped out. The feeling conveyed through the spoon at once
tells when the cartilarge is reached. The foot is now placed in
the attitude of rectification, and usually the improvement is
very great. If the correction be not sufficient, as will be the
case in very severe deformity, it is necessary to apply the same
treatment to the cuboid and calcis, which stand in the way.
The skin incision is glided over the cuboid till its outline can
be seen and felt, and it also is incised and its bony center com-
pletely scraped out, sparing all its cartilaginous shell. The
anterior end of the calcis is similarly treated, and then the
rectification is satisfactory." Ogston explains that this new
operation is very different from that described by Sedillot.
who scraped out the whole spongy center of a fully developed
tarsal bone for caries, and this has nothing in common with
the principle of treating clubfoot which is here recommended.
The Treatment of liocomotor Ataxia by Educational
Movements.— John H. W. Rhein' refers to his previous paper
in the Therapeutic Gazette, December, 1901, in which he dwelt
more upon the general principles involved. In the present
paper he describes in detail the forms of exercises and move-
ments which his experience has shown to be the most practical
and useful. The best results were obtained when the exercises
were simple in character and only a small number practised as
the patient was able to concentrate upon them and avoid con-
fusion. Short and frequent seances are always preferable and
at the first evidence of fatigue should cease. The exercises
are at first used with the eyes open and later closed. The treat-
ment lasts for months and years and should always be under
the supervision of a trained assistant.
Deformities Due to Muscular Paralysis. — W. R. Town-
send 2 See abstract American Medicine, June 7, 1902, p. 907.
Operations for the Relief of Paralytic Deformities. —
R. Whitman.2 See abstract American Medicine, May 17, 1902,
p. 829.
Technics of the Operation and Results of Tendon
Transplantation at the Hospital for the Ruptured and
Crippled.— V. P. Gibney.' See abstract American Medicine,
May 24, 1902, p. 877.
Neurologic Questions in the Operation of Tendon
Transplantation. — Joseph Collins.' See abstract American
Mrdinnr, May 24, 1902, p. 877.
Note on the Relief of a Distended .Joint by the Estab-
lishment of Subcutaneous Lieakage. — T. Pridhin Teale*
reports two cases of acute distention of the knee attended with
intense pain, suggestive of suppuration, in which he established
leakage with most satisfactory results, and says he is convinced
of the value of the method in suitable cases.
Acute Joint Disease of Infancy.— T. Halsted Myers.'
See abstract American Medicine, May 10, 1932, p. 785.
Treatment of Joint Disease. — A. M. Phelps.^ See
abstract American Medicine, May 17, 1902, p. 828.
Movable Bodies in Joints. — Joseph D. Bryant.* See
abstract American Medicine, May 24, 1902, p. 876.
Fracture of the Semilunar Cartilages of the Knee.—
Mayo Robsou.' See abstract American Medicine, May 17, 1902,
p. 854.
Diagnosis and Management of Some of the More
Common Iiesions of the Adult Knee. — V. P. Gibney."
See abstract American Medicine, May 17, 1902, p. 830.
1 Therapeutic Gazette, 1902.
2 N. Y. Med. Jour., May 3, 1902.
3 N. Y. Med. Jour , May 10, 1902.
<The Lancet, May 3, 1902, p. I2J9.
5N. Y. Med. Jour., April 26, 1902.
« Med. Record, May 17, 1902.
' Brit. Med. Jour., April 12, 1902.
« Fhila. .Med. Jour., May 10, 1902.
July 12, 1902]
THE WORLD'S LATEST LITERATURE
[American Medicine 79
Gunshot -wounds of the Knee-jotnt. — Louis A. La
(rirge.' See abstract American Mcdirine, May :il, 1902, p. (120.
Effect of Osteitis of the Knee on Growth of Limb.—
Henry Ling Taylor.- See abstract Anieriean Medicine, May 3,
1!»02, p. 743.
Internal Derangementof the Knee-joint. — H. W. Alling-
haui.^ See abstract American Afedirine, May 10, 1902, p. 786.
A Method of Treating Certain Conditions of the
Joints. — Swan.* See abstract American .Vedieine, J ii\y o, 1902,
p. 34.
Congenitai Displacement of the Hip-joints. — Xoble
S'nith.5 See abstract American Medicine, July 5, 1902, p. 34.
Gonorrheal Rheumatism. — J. Douglas Westervelt." See
abstract American .Ifcdiciiie, May 10, 1902, p. 785.
Osteomyelitis. — R. Tunstall Taylor.' See abstract Ameri-
can Medicine, May 31, 1902, p. 921.
On a Rare Form of Osteomyelitis Gravis. — Dr. Lanne-
longue.s See abstract .1 merican Medicine, May 24, 1902, p. 881.
Osteomyelitis. — F. Schlagenhaufer.» See abstract Ameri-
can Medicine, May 17, 1902, p. 841.
Bone Cavity Healed by Thiersch's Grafts. — John P.
Lord.i" See abstract Ameriran Medicine, June 7, 1902, p. 967.
Bone Cysts : a Case in which the Humerus was In-
volved ; with X-ray and Microscopic Findings. — Eugene
R. Corson " says that bone cysts are uncommon and the litera-
ture on the subject is scant with little definitely known of their
origin and pathology. Bibliography ia attached. After de-
tailed description of his case, he directs attention to the uncer-
tainty of the diagnosis by the x-ray. It could not differentiate
between a bone cyst proper and a portion of bone softened down
to a pultaceous mass, or to a collection of pus. Conclusions must
be drawn from the difference in density as shown by the x-ray.
Its real value lies in its marking the extent of the cyst.
.■%. Contribution to the Surgery of Spina Bifida. — Van
Buren Knott's i^ conclusions are: 1. Owing to the distressing
nature of the affliction, the high mortality should not prevent
attempts at surgical relief. 2. Menigiceles, meningomyeloceles
and syringomyeloceles may be considerably benefited by opera-
tion. 3. The improvement in function cannot with certainty
be estimated before operation and pronounced evidences of
nervous disturbances are not a contraindication to excision. 4.
Asepsis is absolutely essential, and, though difficult to secure,
miy be maintained by exercising extreme ca--e. 5. The plan of
hiving the suture lines of the meninges and the overlying
tissues on different planes will in the majority of instances
prevent leakage of cerebrospinal fluid. <i. The suggestion of
Pearson to prevent the escape of this fluid during a prolonged
operation by stuffing the canal with gna/.e, is a valuable one.
7. Fiarge Vjony defects may l)e effectually closed by muscle
much easier than be osteoplastic methods. 8. It is not neces-
sary to keep the child off its back during the healing of the
wound, as frequently advised. 9. Children with hydrocepha-
lus accompanying spina bifida should not be subjected to
operation.
.\bsceMS in the Riglit Iliac Region and Other Ijcsiotts
Not Gynecologic or Appendiceal Origin Mistaken for
Appendicitis — Joseph W. Spellisy " reports 194 cases with
lesions of 20 varieties of structure and i'A species of lesion not
one in the numbered cases of appendiceal origin and all so mis-
taken. The cases have been gleaned from the literature of the
past four years and its references. This elaborate study of the
difficulties of arriving at a correct diagnosis is a very great
addition to the literature of the subject, embracing as it neces-
sarily does absceises from bones, joints, muscles, glands, bow-
els, hernia, foreign bodies, etc. The concluding paragraphs
> Boston Med. and Hut. .loiirnal. May 22, ino2.
« N. Y. Med. Jour.. April 19, VMl.
' lancet, March 1,5, 1002
' Med. Press and Circular. January 20, IW02.
'' .Med. Press and Circular, January l.'i, 11102.
« Med. Record, .May 3, liKI2.
' N. Y. Med. Jnur., May 17, 11102
« iM. Semalne .VU-dlciilc, April 2. 1'JO.'.
"Centnilblatt filr liaklorlologle, I'aniBltcnkunde iind Jiifektlonu-
krankhelten, Bd..'il, Htt. 8, 11102.
'"Jour. .Vmer -Med. Ahboc., .May 17, 1(102.
" Annals of Hurgerv, April, 1»02, p. .Wi.
"Annals of Hurgery, .May, 11102, p. «24.
" Ann.ilsof Hurgery, June, 1902, p. 7.W.
are quotations from surgical textbooks and monographs, most
of them giving but slight indication of the difficult problem
that Dr. Spellisy has so clearly demonstrated.
Rotary Lateral Curvature and Pott's Disease.— Daniel
W. Marston.' See abstract American Medicine, June 7, 1902,
p. 907.
A Contribution to the Clinical Signittcauce of Absence
of the Tendo-Achilles-jerk. — Kd. Bramwell.' See abstract
Amei-ican Medicine, April, 1902, p. GM.
Genu Valgum.— Charles A. Morton' in a clinical lecture
gives a very comprehensive presentation of the modern views
on the subject, profusely illustrated with cuts and radiographs.
He believes that in severe cases, even in young children, if
there is reason to think that the stage of softening and yielding
of the bones is over, osteotomy may be done, but no doubt the
older the child the less the tendency to relapse. Often the
parents will have their children's legs straightened, even
though we point out to them the risk of relapse without the
greatest care for years after the operation. Carefully applie<l
splinting is always necessary in cases where the bone gives
evidence of yielding.
Pathogenesis of Flat-foot.- M. deVlaccos* points out that
the ecc-entric position of thecalcaneuni and astragalus in regard
to the vertical axis of the leg suffices to explain how a perpen-
dicular pressure acting more or less forcibly on the internal
aspect of the foot, though normally balanced by the action of
the tibialis posterior and the flexors of the toes, under exagger-
ated strain overcomes the equilibrium and leads to obliteration
and flattening of the plantar arch and downward rotation.
[C.S.D.]
Misapplied Mechanical Support to Weak Ankles of
Children.— Wilson ' believes that the normal human foot best
performs its functions when it is freest from restraint. The
majority of those who wear socks or moccasins or go bare-foot
escape the tortures and malformations that follow the wearing
of shoes such as are in use at the |>resent. Wilson considers
only the weak ankles occurring in ehildliood. The softer the
material of wliich an infants shoe is made the less hindrance
will there be to the normal development of the foot. A knitted
sock or an Indian moccasin is entirely free from objection.
When burdenetl by a misapplietl mechanical support the
natural foot is rendered weak, susceptible to injuries such as
sprains and to bunions, flat foot, wabble joint, etc. For young
children a low shoe or slipper is advised which does not cramp
the ankle and thus prevent its free use and development. The
upper of a shoe inhibits the motion of the joint and induces
atrophy from disuse, making the ankle weaker and less cj»pable
of assuming its normal function. Mo.st me<!hani(yil devices
such as high counters, corset shoes, arch raisers, and elastic
anklets tend to cripple the foot, and it is the duty of the medical
profession to discourage their use. Mechanical support is
required only for the enfeeble<l or rachitic. No routine plan
of treatment can be laid down, but whatever form of splinting
becomes necessary, care should bo exercised to secure a freely
movable joint. Internal medi<aition and careful attention to
hygienic measures are important, [m.b.t.]
Some Observations on the Pathogeny and Treatment
of Pes Cavus.— <,'larke» thinks it desirable to cliango the name
of tliis deformity to "talipes cavus." This condition usually
arises from the following causes: Congenital tali|>es cavus, an
increased arching of the foot without any other pathologic
change; as an element in congenital tali|>es etiuinovarus;
secondary to talipes equinus or o<iuinovaru8 due to Infantile
paralysis: secondary to paralytic Ullpes calcaneus ; secondary
talipes equinus from s|)astl<' paralysis, Friedreich's dis-
ease and other nerve affetttlons: apart of a contracture of the
ankle and foot due to gouty tendencies ; and from trauniatio
or ischemic changes in the soft tissues of the sole. In paralytic
cases, tendon transplantation should Ijo oniploye<l whenever
there is sufficient sound muscle present. In talipes calcaneo-
1 Jour. Amer. Med AuoclalioD, May SI, 1W2.
s Briiln. IWi, .No. W, Vol. xjilv.
J Brit. .Med. Jour., .June 21. pp. 1627 tti 1S)2.
< Itevue dc Chlrurgle, Auguat, UOl.
' AniiHlH of Hurgery, .March. IIW.
'Kdlnhurgh .Mmllcnl Journal, April, 1(02.
80 AMIBICAN MeDICINB.
THE PUBLIC SERVICE
[JULflr 12, 1902
vhIkus the AehiUes tendon should be shortened, and the sound
peroneal tendons implanted into it. In cases of gouty oontrac
ture, general medical management should be combined witti
surgical treatment. In such cases deformity is often accompa-
nied by inetatarsalgia, or other painful symptoms, and the final
good effects of operation are not obtained until all the remnants
of the previous painful condition have disappeared, [p.c.h.]
THE PUBLIC SERVICE
Health Reports.— The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, during
the week ended July 5, 1902:
SMALLPOX— United Htate-s.
California:
Colorado :
Illinois:
Indiana :
Iowa:
Kansas :
Kentucky :
Louisiana :
Massachusetts :
Michigan :
Missouri :
Montana :
Nebraska:
New Hampshire :
New Jersey :
New York :
Ohio:
Penusylvaala;
Tennessee :
Utah:
Virginia:
Washington :
Wisconsin :
Philippine Islands :
Austria :
Canada :
China :
France :
Ureal Britain :
Sacramento June 15 22.
Denver .June 14-21 3
Chicago June 21-28 7
Indianapolis June 21-28 3
Muncle June 1-30 2
Terre Haute June 21-28 2
Ottumwa May:il-June28.. ]0
Wichita June 21-28 1
Covington June 21-28 4
Lexington J une 21-28 1
Shreveport June 14-21 2
Boston June 21-28 8
Cambridge June 21-28 7
■ "• ■■" 2
1
1
2
4
2
4
5
B
1
7
18
11
20
46
2
1
17
3
8
1
9
I
Cases Deaths
2
Everett June 21-28..
Lowell J une 21-28..
Melrose June 21-28..
Newton ) une 21-28..
Somervllle J une 21-28
Taunton J une 21-28..
Detroit June 21-28..
Grand Baplds lune 7-28 ...
St. Louis June 22-29..
Helena June 1-30...
Omaha June 21-28..
South Omaha lune 'J^iSO ..
Nashua June 22- 9 ..
Newark June 21-28..
New York June 21-28 ..
Ashtabula June 14-21 ..
Cincinnati June 20-27..
Cleveland June 21-28 ..
Dayton June 21-28..
Toledo June 21-28..
Alloona J une 2 -28..
Johnstown June 21-28..
McKecsport June 21-28..
Philadelphia June 21-28 15
Pittsburg June 21-28
Memphis June 7-28
.Salt Lake City lune 14-28
Petersburg June 1-28
Tacoma lune 14-21
Green Bay June 22-29.. ..
Milwaukee J une 21-28
India:
Italy:
Mexico:
Russia :
Straits Settlements
Mexico:
Smallpox— Insular.
Manila April 26-May 10..
Smallpox— Foreign.
Prague June 7-14
tiuebec lune 7-14
Hongkong May 3-17
Paris June7-14
Belfast June 7-14
Birmingham ...lune 7-14
Gla.sgow June 13-20
Liverpool June 7-14
London June 7-14
NewCastleonTyne.May 31-June 14...
Sunderland J une 7-14
Bombay May 27- J une 3...
Calcutta May 24-31
Karachi May 24
Palermo June 7-14
City of Mexico June 15-22
Vera Cruz June 14-21
Odessa June 7-14
Singapore May 3-10
Yellow Fever.
Vera Cruz June 14-21
10
8
3
2
3
157
1
China:
India :
Cholera.
Hongkong May 3-17 71
Bombay .May 2r-June3 ...
Calcutta May 21-31
Karachi May 25-June 1 4
Straits Settlements: Singapore May 3-10..
China :
India:
Plagck.
Hongkong .May 3-10
Bombay .May 27-June !..
Calcutta May 24-31
Karachi May 25-June 1.
29
65
1
72
11m-
poi led.
5 52
133
1»2
72 60
ChanKes in the Medical Corps of the U. 8. Navy for
the week ended July 5, 1902 :
Ward, B. R., passed assistant surgeon, resignation accepted to take
elTeet June 28— June 28.
Gravatt C. U , medical director, detached from duty as president
of the Medical Kxamlning Board, Naval Laboratory, New York,
and to duty at the Naval Museum of Hygiene, Washington, D. C.
—June 30.
McCluro, W. a , medical Inspector, detached from the Olympla, and
ordered to the Kearsarge as fleet surgeon of the North Atlantic
Station— June 30.
Amfs, H. E., surgeon, detached from the Kearsarge, and ordered to the
Olympla— June 'M.
I'LEADWELL, F. L., passcd a.sslslnnl surgeon, detached from the
olympla, and ordered to the Kearsarge— June .30.
Anoenv, G. L., passed assistant surgeon, dftached from the Naval
Ijiboratory, New York, and ordered to the Ijancaster— June :«.
Tno.Mi'soN, E., passed assistant surgeon, detached from duly wlih the
marine guard, Charleston, S. C, and ordered to the Naval Labora-
tory, New York -July 2.
Changes in the Medical Corps of the U. S. Army for
the week ended July 5, 1902 :
Kellogg, P. 8., contract surgeon, is assigned to duty at Fort Egbert,
.\laska.
Pettyjohn, Joseph, contract sui-geon. now at Vancouver Barracks,
will report to the commanding officer. Battalion Eighth Infantry,
at Fort Lawton, June 30, to accompany that command as medical
officer, and proceed with Company D, Eighth Infantry, lo Fort
Gibbon, Alaska, reporting upon arrival at that station for duty.
Parsons, First Lieutenant James K., now at Fort Sheridan, will Join
his company (F) at Columbus Barracks.
Dean, First Lieutenant Elmer A., assistant surgeon, is granted leave
for one month, with permission to apply for an extension of two
months.
Amador, R. A., contract surgeon, is granted leave for one month, from
about September 1, with permission to apply for an extension of
one month.
Kellogg, William V., contract surgeon, is relieved from further
dutv in the division of the Philippines, and upon his arrival at
Fort Leavenworth with the Sixth Infantry, will proceed to Fort
Sill for duty.
New LOVE, George, contract surgeon, is relieved from further duty at
Fort Sill, and upon the expiration of his present leave will proceed
from Philadelphia, Pa., loFort Wood for duly, to relieve Contract
.Surgeon Julius C. Lee Hardy, who will proceed to San FrancLsco,
Cal,, and report for transportation to Ihe Philippine Islands, where
he will report for a.sslgnment for duty.
The lollowing-named hospital stewards, now at San Francisco, Cal..
are transferred to the stations designated : Joseph Schraml to Fort
Porter, Benjamin Hanson to Fort Screven, William E. Whelan to
Fort Washakie, Charles S. Elliott to Fort Stevens, James N. I^oth-
rop to the Army General Hospital, Presidio, Richard S. Noaks to
Fort Bliss.
The following-named hospital stewards, now at the stations designated,
when relieved by other hospital stewards, will be sent to San Fran-
cisco, Cal,, and report to the commanding general, department of
California, who will send them lo Manila, Philippine Islands, for
assignment to duty: John L. Gerlach, Fort Porter; Henry K. 1111-
kell.y, Fort Screven; John Van Kervis, Fort Washakie; George
W. ilcKenzie, Fort Bliss.
Sands, John R., hospital steward, Fort Clark, will be sent to San
Francisco, Cal., and report to the commanding general, department
of California, who will send him to Manila, Philippine Islands, for
assignment to duty.
The following-named hospital stewards, appointed June 24, 1902, now at
the sUitions designated, will be sent to San Francisco, Cal., and report
to the commanding general, department of California, who will send
them to Manila, Philippine Islands, for assignment lo duty: Carl
G. Brown and Grant Funderburg, Columbus Barracks: Charles W.
Albright, Arm}' General Hospital, Washington Barracks ; Howard
R. Jackson, Fort Snelling; Edward J. Hill, Fort McPherson ; Wel-
come N. Powell, Vancouver Barracks, upon expiration of furlough.
M.\RCUS, Samuel, hospital steward, appointed June 24, 1902, now at
San Juan, Porto Rico, will be sent to Mayaguez, Porto Rico, for
duty, to relieve Hospital Steward Clarence B. Hodgdon. Steward
Hodgdon will be sent to Fort Tolten for duty, to relieve Hospital
Steward Robert Burg. Steward Burg will be sent to San Francisco,
Cal., and report lo the commanding general department of Cali-
fornia, who will send him to Manila, Philippine Islands, for assign-
ment to duly.
Strong, Thomas J., contract surgeon, now at San Francisco, Cal., is
relieved from further duty in the division of the Philippines, and
will report to the commanding general, department of California,
for assignment to duty.
Bacon, .\lexander P., contract dental surgeon. Is relieved from duty
at Fort Clark, and will proceed to Fort Brown for temporary duly.
WiNNE, Lieutenant Colonel Charles K., D. S. G., by operation of law,
under the provisions of the act of Congress approved June 30, 1882,
is announced as retired from active service, June 30, 11102.
Davison, Thomas P., hospital steward, Morro Castle, Santiago, Cuba,
is transferred to Fort Getty to relieve Hospital Steward Frank Wag-
ner. .Steward Wagner will be sent to Manila, Philippine Islands,
for assignment lo duly.
Marsden, Robert, hospital steward, office of the chief surgeon,
division of the Philippines, Manila, Philippine Islands, is trans-
ferred to Fort Monroe lor duty.
Hicks, John R., contract surgeon, leave granted May 16 Is extended
one month.
Smart, Colonel Charles, A. A. S. G., is detailed as president of the
faculty of the Army Medical School, vice Brigadier General Wii-
liam H. Forwood, S. G., who is hereby relieved.
American Medicine
«■'
GEORGE M. GOULD, Editor
G. C. C. HOWARD, Managing Editor
CHARLES S. DOLLEY
MARTIN B. TINKER, AaUlant Editor!
Clinical Medicine
David Riesman
A^ O. J. Kelly
H. n. CnsHiNQ
Helen Murphy
General Surgery
Martin B. Tinker
A. B. Craig
Charles A. Orr
Orthopedic Surgery
H. AootrsTus Wilson
COLLABORATORS
Obstetrics and Gynecology
WiLMER KRITSEN
Frank C. Hammond
Nervous and Mental Diseases
J. K. Mitchell
F. 8a VARY Pearce
Treatment
Solomon Solis Cohkn
H. C. Wood, Jr.
L. F. Appleman
Dermatology
M. B. Hartzkll
Laryngoiogy, Ete.
D. Bbaden Kylb
OpIMalmologv
Waltbb L. Pylb
PtMology
R. M. Pearce
Published Wbiklt at 1S2I Walitut Stbiit, Philadblphu, b» thb Ambbicar-Mbdicinb PuBLnaim Cohtabv
Vol. IV, No. 3.
JULY 19, 1902.
.00 Yearly.
state Sanatoriiinis for Consumptives. — In an
excellent paper urging the establishment of a State
Sanatorium in Minnesota, Dr. H. Longstreet Taylor gives
a sketch of the movement to establish such sanatoriuras,
from which it appears that the German insurance com-
panies, finding that it was in the interest of economy to
treat their members in the public institutions, encouraged
their establishment, so that at the end of last year there
were forty-three sanatoriuras for the poor in operation
and nineteen more being erected. England has in such
institutions a capacity of 5,000 beds. In our own
country the movement, though late, is now being car-
ried on earnestly. One of the advantages emphasized
by Dr. Taylor from the care of patients in this
way is that these learn hygiene in the sanatorium and,
returning home, they become educators in their com-
munities in the prevention of tuberculosis. "As a life-
saving investment it more than repays any State." Ten
per cent, of the total number of deaths in Minnesota,
says Dr. Taylor, are due to tuberculosis, 1,600 dying
annually, and 0,000 suffering from the disease :
"A sanatorium for poor consumptives would save the lives
of many who, without it, are certain to perish. It would
diminisii the spread of the disease in the State by removing
centers of infection from among the people. It would diminish
the cost of caring for the sick consumptives, and would transfer
it from the families that it would pauperize to the county or
State treasury. It would relieve an untold amount of sufferinff.
It would reclaim so many useful lives that it would be a paying
investment ; the labor of those discharged cured would earn so
much wealth for the State that the original cost, as well as the
cost of maintenance, would be returned many times over."
" Ooctor of Achievement" — such is the degree
whicli the tSprhifi/wld Republican suggests should often
replace that of Doctw of Latos, now absurdly bestowed
upon men who have no legal knowledge whatsoever.
It is indeed strange that the degree of LL.D should come
to mean D()ctor-of-anything-you-please-becaus(>-we-wish-
to-honor-him. The degrees of M.I). and those of D.D.
have a very definite significance, and those of Ph.D., of
A.B., etc., have at lea.st some distinctive value; but
this cannot be said of the degree of LL.D., which is now
used to ci)ver a multitude of— I'xceliencies. The action
of King Edward in establishing the new order of merit
i> highly commendable, and this is without the cynics
ii-^ide, that all the others, of course, are "wo^ for
merit." There is something very attractive to Anglo-
saxons about the liepublican's suggestion. It would,
perhaps, serve to release the LL.D. degree from its
present function, For-all-and-anything, and would
make it possible for our great administrators, discov-
erers, social workers, etc., who, as much as any degree-
holder, have labored for the good of mankind, to accept
the honor with fitness and respect. The last suggestion
of the liepublican should also be singularly powerful —
why do not colleges manage better to honor endowing
capitalists? There is a deal of truth in the old saying
that. It is only by means of money, that we can obtain
what no money can buy and what is worth more than
all money.
Contract Practice — when is it unethical?— is a
question which is often asked us, and which frequently
ari.ses in the mind of almost every other practitioner.
There are so many Instances in which contract practice
is perfectly legitimate, so many in which it is certainly
not so, and the grades and intermixtures of the two are
so subtle and varying that often no distinct answer is
possible, and no rule that applies to all cases is likely to
be found. In England the Medicsil I>efence I'nion has
lately won two great viclorit^ — two of a thou.sand— in
the case of the Birmingham Consultation Institute, and
in the great Yarmouth ca.se, in lioth of which the limits
of professional ethics had been outrageously overstepped.
The fundamental principles to be held in mind in decid-
ing any case concern either the good of the public or the
good of the profession. Fortunately the two are inter-
dependent, and whatever is plainly harmful to one is
almost certainly so to the other. If the organization
"sweats " the physician, it is sure to turn out injurious
to the patient. An institution that advertises and can-
vasses for patients is beyond all doubt a curst? to lM)th
profession and public. Cunning middlemen, it will be
found, are using it for selfish pur|H)ses. In so far as
associations or institutions steadily keep in mind the
encouragement of thrift, and wise economy in their
members, and do not humbug themselves with (juacks
an<l (juackery, so long will then> Ihj no injury to medical
men or to members In contract practice. Physicians
having genuine medical knowletlge and skill will not
sell it for less than Its value. It is the sham article that
is sold at one-half, or, as in the ctwe of many che»»p soci-
eties, at one-hundredth of its cost. Ctni-tit riiifttor I
82 AXEBIOAN MEDICimj
EDITORIAL COMMENT
[July 19, 1902
Eminent Professor and Country Doctor.—
Probably few men combine those qualities which would
make them successful and happy in both these capmiities,
though we have frequently called attention to the large
amount of excellent work which has been done by the
country practitioners, and the possibilities open to them.
One of the best examples of this unusual tyi^e is to be
found in the life of Adolf Kussmaul, whose death at the
ripe age of 80 years we have recently recorded among
our obit uary notices. The son of a country doctor father,
an unusually strong character, Kussmaul in his early
years engaged in country practice in the lower part of
the Black Forest region. Three happy years of unselfish
work ended in a sad tragedy, a sudden paraplegia fol-
lowed exposure to cold in long rides through the heavy
snows of that district. But this seemingly overwhelm-
ing misfortune was turned into fortune by Kussmaul's
hopeful disposition and indomitable will, as he says
" die Krankheit hat mir statt Vederben Gliick gebracht."
Further country practice was out of the question, and
during the tedious convalescence he determined to fit
himself for an academic career. After two semesters
study with Virchow and KciUiker at the University of
Wurzburg Kussmaul settled in his beloved Heidelberg
where he had spent part of his childhood and student
days and where, at his retirement, he went to spend the
remaining years of his life. His health gradually
improved, and as the result of good work he was made
privatdocent. Without opportunity for clinical work
Kussmaul turned his attention to experimental investi-
• gations and literary studies, and his contributions along
these lines were so substantial as to bring him a call first
to a professorship at Erlangen, then to Freiburg i/B.,
and when the most distinguished men in German medi-
cal science were sought for the new university of Stra.s-
burg, Kussmaul was selected for the chair of medicine.
In his charming autobiography (Jugenderinnerung
eines Alten Arztes) he tells the story of his eventful life ;
he pictures his father the ideal country doctor ; tells of
his student life and of his teachers at Heidelberg, Vienna
and Prague in the days when the sun of German pre-
eminence in medicine was just rising ; he sketches his
experience as an army surgeon during the Schleswig-
Holstein war, ending his story just where an egotistical
man would have begun— at the beginning of his success-
ful career as a teacher. It is a most interesting story,
delightfully told, full of anecdotes, humor and poetry ;
full of the inspiration that comes from knowing a noble
character of remarkable courage, energy and achieve-
ment. It is a life of which we may all be proud, and
which should be familiar to all members of our profes-
sion, whether eminent professors or country doctors.
Physicians and Their Medical Journals That
earnest and noble worker in the cause of journalistic
reform. Dr. Burnside Foster, of St. Paul, recently read a
paper before the Minnesota State Medical Society upon
the subject of the reciprocal relations between physicians
and their medical journals. Inter alia he said :
" The Journal of the American Medical Association should
be received by every physician in America."
" In addition there are very few physicians who cannot
afford one other weekly medical journal. There are a number
to select from, each having something to commend it, and
while it is not my purpose to make any invidious comparisons,
it is my own strong conviction that the journal whose owner-
ship is divorced from all outside business interests, and which
is largely managed and controlled by medical men, is the one
which most deserves and which will best repay their support.
Such a journal can fearlessly discuss and expose the schemes
which are, and which always will be, from time to time devised
for the furtherance of individual interests at the expense of the
good name of medicine."
" The physician who does not live in or near one of the
great medical centers where the medical weeklies are published,
feels or should feel, another need which it is the function of
medical journalism to supply. This need, and a most impor-
tant one it is, is to keep in touch with the profession of his own
neighborhood."
" Where there are a number of rival medical journals in the
same State, it is the duty of each physician to ascertain the best
one, usually an easy task, and give that one his earnest support."
"Another thing which medical men owe to the good medi-
cal journals is not only to refuse to support, but to do all in
their power to discountenance the poor ones. There are a large
number of cheap medical journals, usually owned and managed
by persons having no interest in the medical profession, which
are conducted solely for the purpose of making money and
whose editorial and reading pages are for sale to the highest
bidder. These journals usually have a large circulation,
because, having practically no bona fide subscription list they
are mailed to physicians whose names are taken at random
from the medical directory, and they can make their circula-
tion as large as they desire. Such journals are not only a blot
on medical journalism, but they are distinctly detrimental to
the interests of scientific medicine and should be repudiated
and discountenanced by all decent physicians."
The Deglutated Frog.— A metropolitan medical
journal recently found room in its news columns for an
account of "a unique and quite surprising operation"
on Mrs. Charles Burtis, of Hopewell Junction, N. Y.,
from whose stomach it is asserted that "a live frog was
removed," whether by gastrotomy or by means of the
gastroscope and a fish-hook baited with red flannel we
are not informed. This gastricoline commensal, which
survived the operation but a few hours, is said to have
lived " in the patient's stomach for five years " and nat-
ural curiosity as to how it got there is met by the assur-
ance that it " was probably swallowed when in the egg
form or in its infant state, a tadpole." This allays the
suspicion that Mrs. Burtis having been afflicted with
' ' red- water ' ' had attempted a cure after the manner of the
yokels of Aberdeenshire, who relieve their cattle of this
affection by thrusting a live frog down the animal's
throat. However Mrs. B. came to swallow the frog,
the enlightened reader is expected to swallow the story
and will hereafter watch the news columns of the enter-
prising journal presenting it for some data as to the
present'-time use of the old remedy of Kiranides, " the
right hind foot of a frog done up in a deer's skin," men-
tioned by Sir Thomas Browne as a remedy for gout.
There is a lingering suspicion that Mrs. B. wa.s the vic-
tim of a delusion, of some form of batrachophobia, for the
relief of which deception lent ready aid ; the frog being
made to play the role of scapegoat, as was customary in
the time of Marcellus, who, to cure the toothache,
recommended the patient to spit in a frog's mouth and
request it to make off with the pain, or, as is still prac-
tised in County Cheshire, where a young frog is held for
a few minutes with its head inside the mouth of a child
July 19, 1902]
EDITORIAL COMMENT
(AXKRICiLS MkDICINK 83
afflicted with thrush, which affection is thereby trans-
ferred to the batrachian, a procedure so common as to
have given the name "the frog" to the ailment itself.
In like manner the frequent use and value of frogs for
the vicarious relief of whoopingcough is attested in
Shropshire by the whooping and coughing of the crea-
tures at night. In view, however, of the rarity of
para-sitic vertebrates, zoologists will be gratified by
the assurance that a type specimen has been secured
and " is now preserved in alcohol in the laboratory of
St. Catherine's Hospital, Brooklyn." Long familiar
through tradition, like the allied species periodically
reported by quarrymen as found alive, though hermet-
ically sealed in solid blocks of marble or granite, or by
woodchoppers as liberated from closed cavities in the
otherwise solid trunks of trees, this parasite has hereto-
fore escaped the curators of museums. Now, however,
we may look for some detailed description which will
fix its systematic position among American species, and
as to the method so successfully adopted to secure it
alive, but in the absence of taxonomic data we have
the temerity to suggest Sana cUucinatiotm as a provis-
ional name for this frog-in-the-throat.
Proffress in spelling reform is incidentally shown
by a little controversy in recent numbers of Science. A
correspondent who had frequently seen the word ecology
in Science, wrote that he could not find it in the diction-
aries. Replies soon proved that it was in most motlern
lexicons, but with the old spelling, cecotogy. A sneering
critic then wrote that the definition of the word as now
used had been changed, and that the botanists had no
more right to alter the meaning than they had to alter
the spelling, whereupon he is asked if we shall write
(Kconomy, oeconomic, cBcumenic, oedema, etc., as here
spelled. The wasteful ceconomist did not care to reply.
The dictionary maker who should follow out this rule
would better flee the country before his book should be
published. As the Greek wa.s oi, and not oe, the dese-
crating reformer who dared to alter the second letter
should also be sent to etymologic hades. This philologic
tempest in a teapot was of service in demonstrating that
since 1893 the mass of American scientific men and their
organ of publication spell equal, paleontology, ether,
hemorrlmge, ecology, anesthesia, edenut, etc., as here
given. So do the va-st majority of American physicians
and medical journals. The reasons why a few still hold
on to the ligatures are amusing, but they may not be
stat<'d. A quotation from one of these etymological
sticklers reads as follows : " In performing koiliotomy
the chirurgien may have his i)ra;ference as to an antes-
thetlc. One prafers tether, another (esteems chloroform
better or RKjually good. Neither may be called an
hwretic and sent to the cremetery or the (Mumenical
council, and our equanimity and iwiuilibrium should
not b€^ upset at either prteference. We do not pra-tend
to decide which is prieferable or the more oikonomical.
\V(! a'stimate that the dispute is archwological or palajo-
gniphical, aisthetical rather than anicsthetical. At the
time of the requinox and at the a-ciuator the danger of
hfcmorrhage, gangnene, oedema, and other phjenomena
refjuire prtevision," etc.
Suggestions on Institutional Accounting'. II. —
Having outlined briefly the accounts relating to princi-
pal, it is next in order to direct attention to treating of
income. The term income is not used here in its nar-
row, restricted sense, but rather to designate both the
receipt and expenditure of all funds applicable to cur-
rent expenses or maintenance, as distinguished from
funds invested in plant or securities and termed princi-
pal. Under the head of income, then, two subjects are
treated — revenue and expenditure. Considering first the
question of revenues, from whence are they derived and
what accounts lu-e needed for their lucid statement?
The sources of revenue must, of course, vary in institu-
tions of different chan^cter, but the following items will
apply in whole or in part to a large proportion of all :
1. Donations, under which should be grouped the con-
tributions received for the general support of the institu-
tion. 'In many cases it is test to divide this account, in
order to show the receipts from particular sources, as
auxiliary societies, or to show contributions to meet the
expenses of some special phase of the work, such as a
convalescent home. In passing, attention should be
called to the unfortunate habit exercised by many
worthy contributors of hedging about their donations,
even those of small amount, with vexatious restrictions
as to their use. In classifying donations it is wise to
confine the accounts to broad general groupings, rather
than attempt to specialize to the extent of meeting
every passing whim of the contributors. 2. Receipts
from patients or inmates, under which heading should
be included amounts receive<l, in whole or in part, from
inmates who pay for their board or treatment. 3. Sale
of drugs, manufactured articles, etc. In many institu-
tions considerable revenue is derivwl from such sales,
and in nearly all some transactions of this nature occur.
This revenue is by no meiuis all [)rofit, as the cost of the
articles must be providetl for; but it is best to show
here the gross amount of the sales, leaving the cost to
appear in a separate account. 4. Student or other fees,
which in teaching institutions conducting a number of
dei)artnient« may well be statetl according to each
department. 5. State, municipal or other appropria-
tions. In addition to the foregoing at'counts many
others may be used to advantage in special wuses ; but
the general principle to be borne in mind is that the
revenues, as well as the exi)enditures, should always l)e
classifltHl upon a rea»onat)le and logicjU basis, wlu'thcr
the necessities of the case call for a few accounts or
many.
The Termination -oma.— To follow the evolution
of a HU-diail or biologic term is somewhat like the estab-
lishment of the morphologic homology of any given
anatomic structure, and the lexicographer finds fre<iuent
illustration of the occurrence of per mltmn evolution
in the signiflciince of syllables, in sudden variations or
"sports" in the meaning of a suffix or pr<>fix without
etymologic warrant, etc. The termination -oma furnishes
an illustration. Where did it conn' from and how and
when did it come to mean tumor? Words bearing this
termination an- of every day <Krurrenit> and have l)een
frc'iuently coined of late years to (Uwignate j.reviously
81 AXXBICAN MeOIOINEJ
EDITORIAL COMMENT
[July 19, 1902
unrecognized neoplasms. The following incomplete list
will serve to illustrate the use of the terminations:
Adenoma, angioma, angiosarcoma, atlieroma, Ijlastonia,
carcinoma, cliioroma, cholesteatoma, chondroma, cylin-
droma, cystoma, endothelioma, epithelioma, fibromii,
glioma, helmintlioma, hematoma, hemangioma, himan-
toma, hippocoryzoma, hypernephroma, leiomyoma, lym-
phadenoma, lymphangioma, lymi)homa, lymphosarco-
ma, melanoma, myoma, myxoma, neuroma, edema-iur-
coma, osteoma, papilloma, paral>lastoma, psammoma,
rhabdomyoma, sarcoma, staphyloma, steatoma, syphil-
oma, teratoma.
The (ireek affords no suffix -u/zn from which to derive
the termination -oma; but we find its origin in the neuter
noun ending -/m, denoting the result of an action, as
a(iu/ia, that which is thought worthy, a resolve, a deci-
sion; 'OjKu/ta, that which is swollen — a tumor, a boil—
from 'Oj/ctiw, to swell up ; nfm)/ia, the thing done, the
affair, from npnanu, to do. Several medical terms ending
in -/la are traceable directly to Greek writers ; thus car-
cinoma is used by Hippocrates, mfiKcvui/ja, an eating sore
or ulcer, a cancer, from KapKmiu to inake like a crab (mfi-
Kivoi), to cause the disease cancer. According to (xalen
carcinomatous tumors were so called from the swollen
veins surrounding the part affected, bearing a resemblance
to the limbs of a crab. Philemon Holland, in his glo&s
to the "Natural History" of Pliny, says: "Cancer is a
swelling or sore coming of melancholy bloud, about
which the veins of a blacke or sweet colour spread in
manner of a creifish clees."
Notwithstanding these eminent authorities there
remains a suspicion that the word carcinoma really
carried to the minds of the students at Cos some notion
of behavior rather than mere fancied resemblance. The
habitual backward movement of the crab led to its
being given a place among the zodiacal signs in refer-
ence to the apparent retrograde motion of the sun at the
solstice. The -fin carried with it the notion that the
noun t» which it was suffixed represented the result of
some action, and it is possible that the rapidity with
which a cancerous growth invaded the underlying or
adjacent tissues or the speedy waning of the patient's life
as the result of the disease may have suggested the
retreat of a crab into its burrow.
However this may be, we ctm trace the idea of pre-
cedent action in several words ending in -/m used by
ancient writers on medicine, as in -yj.Ku/ia a sore or
ulcer, that which results from a wound, from 'EUdu, to
make sore, to bring suppuration (Diosco) ; 'Et/^Vi a
boiled liquid, from •Eitii;;^, to boil ; ,'//idTu,fia to be stained
with blood, from ai/iardu to make bloody ; oUti/ia a swell-
ing tumor (Hippoc.) from o;<5™ to swell, to become
swollen; SapKu/ta a fleshy excrescence, from ^apK6u to
make or produce flesh, to flesh up a wound (Hippoc.) ;
l-mTufia, a kind of fatty tumor (Galen) from s-fnroa), to
turn to suet, especially to get a steatoma. The original
meaning is also retained in the more modern melanoma,
from /leXavdu to blacken ; and in neuroma, from vevpdu to
strain the sinews.
The idea of tumor, seems, however, to have attached
itself to the termination -ma (-/ta) early in the history of
descriptive pathology as the great majority of terms in
which it is used carry no idea of previous action, unless
we may discover it in Syphiloma, the outcome of the
indiscretions of "Sj/philus " the shepherd hero of Fras-
catori's poem.
The modern signification of tumor has at any rate
become fixed with the termination -ma (-pa) enlarged to
-oma (-upa) for the sake of euphony, though the
modern disciples of " the antiquated doctrine of the
stoic etymon" fail to find tumor in the original mean-
ing, and we have the high authority of Greenough and
Kittridge for the advice that "we should never forget
that words are conventional symbols, and that any
word, whatever its origin, bears at any moment that
meaning which the speakers of the language have
tactily agreed to assign to it."
Speaking of scientific terminology recalls a remark by
W. K. Parker in his Croonian Lectures on Mammalian
descent, that " A rustic gymnast in a sack with nothing
but his homely features free and having the necessity of
jumping laid upon him, is not more an object of sym-
pathy than a biologist when robbed of his familiar terms,
his special nomenclature."
Old Clotliiiig and Bedding as a Source of Infec-
tion.— The spread of leprosy in the Soudan and other
arid regions is attributed to the custom of passing soiled
wearing apparel from person to person. Owing to the
scarcity of water, the cleansing of clothing is almost im-
possible, and it is customary for the original purchaser
of new clothing to wear the same until it becomes
unbearably dirty, when it is given or sold to some serv-
ant or person of lower station, by whom it is in turn
handed over to some one still more impoverished, and
thus passes along thQ line to the beggar or slave. The
daily calls of the old-clothes-man in our larger cities and
the advertisements seen in the daily papers offering the
highest prices for cast-off clothing, old feather beds, etc.,
remind us that more highly civilized communities are not
freef rom the same source of infection — cast-off apparel.
What guarantee has the public that the clothing purchased
of the old-clothes dealer has been properly disinfected ?
While it is impossible to trace the transmission of dis-
ease through cast-off clothing or second-hand bedding
with the same certainty that applies to the transmis-ion
of leprosy by similar means in the Soudan, it requires
little medical knowledge to comprehend the dangers to
which the poor are subjected by the unregulated traffic
in soiled clothes. Bromidrosis and hyperhidrosis of the
feet are affections of microbic origin, and the very sight
of rows of cobbled-up old shoes at second-hand stores is
certainly suggestive of stinking, sweaty feet ; the dis-
carded trousers of the wealthy rake and old feather beds
certainly present innumerable possibilities of infection.
If old clothing must be passed down the line, let it at
least be fumigated.
New Expedition of the Liverpool School of Tropical
Medicine. — In July a new expetiitiou from the Liverpool
School ot Tropical Medicine will be sent to the Gambia and to
Senegambia to follow up the investigations concerning the ani-
mal parasite trypanosoma, and its connection with disease in
human beings. Theexpedition will consistof Dr. J. E. Dutton,
the Walter Myers Fellow in the Liverpool school, and I>r. J. L.
Todd, of McUill L^uiversity, Montreal, who has been working
in connection with that school.
July 19, 1902]
REVIEWS
(AMERICAN MKDICINE 86
BOOK REVIEWS
A Systematic Treatise on Materia Medioa and Therapeu-
tics, with Reference to the Most Direct Action of
Drugs, l)y Fini.ky Elmngwood, M.D., Professor of
Materia Medica in IJennett Medical College, Chicago ; late
Professor of Clieniistry m Bennett Medical College ; author
of "A Synopsis of Medical Chemistry," "Manual of Urin-
alysis ; " editor of Chicago Medical Times. With a " Con-
densed Consideration of Pharmacy and Pharmacog-
nosy," by Prof. John Uki Lloyd, Ph.D., late President
American Pharmaceutical Association, Professor of Chem-
istry and Pharmacy in the Eclectic Medical Institute of
Cincinnati ; author of " Etidorhpa." Published by the
Chicago Medical Press Company, 103 State street, Chicago.
1902.
We have read this work with a great deal of interest and
shall devote an unusual space to its review for several reasons.
If there is any truth concerning the remedial powers of drugs,
or concerning the indications for therapeutic intervention
known to any, but that is not taught or practised among physi-
cians who refuse sectarian designation, it is evidently their
duty to acquire this knowledge and to incorporate it in their
teaching and practice. This author is evidently a man of edu-
cation, experience, and candor, and is firmly convinced of the
truth of his therapeutic creed ; he is, therefore, one of the best
teachers from whom to learn the present day theory and prac-
tice of the eclectic school. Tliere can be little doubt that con-
cerning the properties and actions of many medicinal plants,
and especially of those indigenous to America, the eclectics
have accumulated a body of knowledge and tradition which, at
all events, is worth intiuiring into, whether or not it may prove
of positive value. Finally, the history of medicine, both theo-
retical and empirical, must interest every thoughtful physician,
and any work which clearly sets forth the working methods
and guiding principles of a consideraljle body of practitioners
of contemporary activity who maintain colleges, journals, soci-
eties, and some of whom publish readable books, must have
considerable importance from this viewpoint. We confess,
however, to considerable disappointment in our endeavor to
obtain a clear view of the guiding principles of eclecticism from
the work before us. The author, who understands how to
write clearly, and whose specific directions for the use of drugs
are lucid and terse, becomes vague or confused in expression
whenever he attempts to set forth matters of doctrine, and con-
fusion of expression must indicate underlying confusion of
thought. This confusion of thought is evidently not peculiar
to the individual, for elsewhere he shows himself to be capable
of thinking clearly and writing plain— it is, therefore, insepa-
rable from the subject, and indicates that in the evolution of
eclecticism out of its somewhat defiant attitude toward science
there has been reached a stage in which the attempt at recon-
ciliation leads to a fogginoss akin to that which some years ago
was manifested by tlie reconcilers of genesis and geology-
most of whom, moreover, were but indifferent geologi.sts.
" Eclecticism," the author writes, "was originally composed of
many di.ssonsint facts. These have been fused or amalgamated
until now it has an essentially exact constitution, a homogene-
ous consistency, a characteristic individuality, which wins for
it the ap])roval of all consistent observers." We have attempted
to make out this individuality from a carefulstudy of the book.
The eclectic firmly believes in what he terms the " direct cura-
tive action of drug.s." The author, for example, quotes with
disapproval the advice of Xothnagel to sustain the patient while
nature brings about re<;overy. He advocates active and specific
interference. Turning to semiology rather than to etiology or
pathology for therapeutic indications, some i)rominent symp-
tom is recognized as the keynote of the case, directing attention
to the particular group of drugs from wliich selection is to bo
made. Choice of a special member of this group is then deter-
mined by collocation of minor symptoms with the predominant
one. f)r, looking at the matter from the standpoint of drugs, it
is asserted that every drug has a definite and direct »vX\on
upon certain functions, tissues or organs, with minor actions
upon other functions or structures; by cx)mparing the
picture offered by the disease with the pic'ture offered
by the drug, the remedy is to be chosen— probably upon
the principle of antagonism, though this is nowhere ex-
plicitly stated, and certain empiric recommendations seem to
have been founded upon the homeopathic theory. To afford a
concrete example: Among "drugs acting on the nervous
system," in the division of "sedatives and depressants,"
6r2/OHi« is considered among "agents commonly used to con-
trol fevers," and its " specific symptomatology " is, in part, as
follows: "In acute inflammations in the chest, with hard,
quick pulse, short, quick, harsh, hacking cough, »nite tran-
sient pains, increased on inhalation, face flushed, especially the
right cheek." Of rhiis, similarly classified, the following is
said: "Specific symptomatology. In inflammatory fevers,
with sharp, hard pulse ; acute Inflammation involving the skin,
with bright circumscribed redness, extreme soreness or sharp
burning pain ; extreme redness of local parts inflamed, with
great local heat and sharp pain ; sharp supraorbital pain, espe-
cially of the left orbit ; burning in the eyes with flushed face ;
inflammation with constitutional impairment, evidenced by a
sharp-red tongue and deep red mucous membranes. The
tongue has a pointed tip, upon which the papillas are elongated
and pointed. In subacute or in chronic dlsea,se, also, with the
above specific evidences, it is demanded." No principle is to
be found here, no logical relation of symptoms, no funda-
mental association of drug action with the requirements of dis-
turbed function, no utilization of pathologic and etiologic facts.
It is true that the author also speaks " of discovering the cause
of the whole disorder and removing it as quickly as possible,"
but his illustration is not happy. Few scientific physicians
will agree with him that an "intestinal antiseptic, and an
antiseptic flushing of the bowels, given in the initial stage of
typhoid, will often abort the disease within a few days by
removing the germ of the disease which underlies all the mis-
chief." And, while throughout the book we find evident
attempts to reconcile symptomatic medication and pathologic
indications, the understanding of the latter is usually as imper-
fect as that exhibited concerning the etiology of typhoid fever
in the advice above quoted. Nevertheless, the book is a good
one, and is to be recommended to physicians as a record of
empiric knowledge, more or lass accurate, concerning drug
actions in health and in disease; from which, upon occasion,
many useful facts and hints may bo learned of material benefit
in the management of patients.
A therapy based upon the matching of symptoms and drug
actions either antagonistic or similar, without regard to the causa-
tion or mechanism of the symptoms, and with little regard to
the mechanism of the drug action is, at this stage of physiologic
and pathologic action, hardly to be termed scientific ; and those
who pursue this path will find that it diverges further and
further from the main road of progress. It is to be hoped,
therefore, that broadmlnded and thoughtful men, such as the
author of the book under review, while still preserving their
faith in the powers of remedial agents to aid the organism in
combating the processes of disease, will see the necessity of
acquiring a Ijroad and detailed knowledge of the most funda-
mental proces-ses both of disease and of drug action, and of guid-
ing themselves thereby, rather than to remain content with the
study of what is a mere surface play, in either fiehl. .Mean-
while a debt of gratitude is due the practitioners of the ei-le<^llc
school for their persistent investigations of materia modUta,
and the increase of the physician's armamoutarium accord-
ingly.
In closing, special attention should bo directe<l to the cliMr,
accurate and s<;ientific contribution upon pharmacy and
pharmacognosy with which Dr. John I'ri liloyd has enriched
the pages of the work under review. It Is to be rcgrotl<Nl thsl
Professor Lloyd has not publi8he<l more definitely the method
by which he prepares the stwallod " specific niediciues." If
this method is better adapted to secure the full miHiicinal prop-
erties ofdnigs, It should be given to the professionsof nuHlichie
and pharmacy lu order that all manufacturers might adopt it,
the pharina<'opeias make it otllctal, and all physicians an<i all
patients reap its benefits. If, on the other hand. It is nut
superior to olficlal methcKis, that fact (mght to be brought out
Ijy the comparison of results obtained. We are inclined to
believe that in the case of certain of the drugs whl<'h Ur. Lloyd
86 Akksican Medicine]
AMERICAN NP:WS AND NOTES
[July 19, 1902
has studied, his methods ot preparation are, in some respects,
better than those of the U. S. P., and if this roally be the case,
we should like to see them adopted by the latter in all such
instances.
ProKresslve Medicine.— A Quarterly Digest of Advances,
Discoveries, and Improvements in the Medical and Sur-
gical Sciences. Edited by HonART Amoky Hare, M.D.,
Professor of Therapeutics and Materia Medica in the
Jefferson Medical College of Pliiladelphia, etc. Assisted
by H. R. M. Landis, M.D., Assistant Physician to the
Out-patient Medical Department of the .Jefferson Medical
College Hospital. Volume II, .lune, 1!»02. Philadelphia
and New York : Lea Brothers it Co. Per volume, ^'2.50;
per annum (four volumes), |10.
This, the second volume for 1902 of this now well-known
publication, fully sustains the reputation established by the
preceding issues. It comprises a discussion of recent literature
on the surgery of the abdomen, including hernia, by Dr. Wil-
liam B. Coley ; gynecology, by Dr. John G. Clark ; diseases of
the blood and ductless glands, the hemorrhagic diseases, and
metabolic diseases, by Dr. Alfred Stengel ; and ophthalmology,
by Dr. Edward Jackson. It is sufficient commendation to say
that all the noteworthy recent literature on the different sub-
jects is adequately discussed by those fully competent to do so.
The Artificial Feeding of Infants, Including a Critical
Review of the Recent Literature on the Subject.—
Bj' Charles P. Judson, M.D., Physician to the Medical
Dispensary of the Children's Hospital, and J. Ci.axton
GiTTiNGS, M.D., Assistant Physician to the Medical Dis-
pensary of the Children's Hospital. Philadelphia; J. B.
Lippincott Company, 1902; 8 vo., pp. 308.
Important as is the subject of artificial feeding to the gen-
eral practitioner, it is, as a rule, not thoroughly understood.
Every known substitute for mother's milk will agree with
some babies and disagree with others. In no line of work is it
more necessary to know the different methods to be employed
and the principles underlying them. The busy physician who
is unable to keep up with the voluminous literature on the sub-
ject will find in this little volume, critically arranged, the
views of the leading podiatrists and investigators of Europe and
America, as gleaned from the periodicals, monographs and text
books of the past eight years (1894-1901). He will also find
practical working methods for meeting the needs of individual
eases. The book is concisely comprehensive. An appendix
supplies many important recipes and laboratory methods.
Credit is given to John Forsyth Meigs for demonstrating its
scientific basis, and to his son, Arthur V. Meigs, for originating
the method of modifying cow's milk by addition of water and
cream.
Abbott's Bacteriology : A Practical Manual of Bacteriology
for Students and Physicians. By A. C. Abbott, M.D.,
Professor of Hygiene, University of Pennsylvania. New
(sixth) edition, revised and enlarged. In one 12mo.
volume of 036 pages, with 111 illustrations, of which 26
are colored. Cloth, $2.75 net. Just ready. Lea Brothers &
Co., Publishers, Philadelphia and New York.
In the various editions of this work which have appeared
since 1901 the author has endeavored to keep it abreast of the
wonderful advances made in the subject, than which no depart-
ment of biologic research has had more rapid development.
The purpose of the book requires directness of style in the pre-
sentation of the subject, and the fact that it has gone to a sixth
edition is proof of the admirable way in which the author has
accomplished his task. The introductory chapter reviews
briefly the historic development of bacteriology, and in the
succeeding 28 chapters the more important ideas and methods
of rtudy are presented, the chapter on infection and immunity
being particularly interesting, the conflicting theories being
clearly presented. The retention of the antiquated spelling of
cedema and septicsemia does not conform with the dropping
of the diphthong in hemorrhagic, while the spelling of generic
terms with lower case initial letters mars, to a slight extent,
the otherwise uniform excellence of style. The book is
thoroughly deserving of the success it has won as a standard
handbook.
AMERICAN NEWS AND NOTES.
OENERAIi.
Trinity University, of Toronto, has conferred upon Dr.
William Osier the degree of D.C.L.
Rockefeller Institute.— Dr. A. N. Richards, of the Col-
lege of Physicians and Surgeons, has been appointed to a
research fellowship.
The University of Pennsylvania has conferred the degree
of D.Sc. on Dr. W. D. Miller, professor of dentistry in the
University of Berlin.
Cultivation of Drug Plants.— The Bureau of Plant Indus-
try, U. S. Department of Agriculture, has in progress experi-
ments in the cultivation of drug plants, the most important
being at Washington and Dover, Mass. It now seems possible
that many of the crude drugs imported can be successfully cul-
tivated in this country. Digitalis, cannabis indica, the opium
Eoppy, and stramonium are showing evidence of their adapta-
ility to this climate and soil.
New Ration for Men in American Navy. — Defects in the
ration for the enlisted men of the Navy have been remedied by
establishing the following in the place of the ration fixed by
law in 1861 : " One pound and a quarter of salt or smoked
meat, with 3 ounces of dried or 6 ounces of canned fruit and 12
ounces of rice or 8 ounces of canned vegetables, or 4 ounces of
dessicated vegetables; together with 1 pound of biscuit, 2
ounces of butter, 4 ounces of sugar, 2 ounces of coffee or cocoa,
or i ounce of tea, and 1 ounce of condensed milk or evaporated
cream, and a weekly allowance of J pound of macaroni, 4
ounces of cheese, 4 ounces of tomatoes, i pint of vinegar, J pint
of pickles, J pint of molasses, 4 ounces of salt, i ounce of pep-
per, and i ounce of dry mustard. Five pounds of lard or a suit-
able substitute will be allowed for every hundred pounds of
flour issued as bread and such quantities of yeast as may be
necessary."
EASTERN STATES.
Boston Health Record.^The deathrate in Boston during
June was the lowest ever known in that city, one week being
as low as 13.52 per 1,000.
Floating Hospital of Boston.
first trip of the season July 8.
-This hospital made the
This is the hospital's first season
as an independent organization, its incorporation taking place
last November.
Contest Over Physician's "WiU Ended. — After years of
litigation the heirs of Dr. D. B. Whitney, of East Norwich, have
come to an agreement and the case has been taken from court.
The suit arose over the destruction of one of the two wills left
by the deceased.
Atlantic City Hospital.— The Board of Governors of the
Atlantic City Hospital have been obliged, by lack of funds, to
close the medical wards for men and women. The surgical and
children's wards will be maintained and the accident and
emergency departments kept open.
New School of Biology. — It is reported that there soon
will be opened at Sharon, a few miles out of Boston, an institu-
tion known as the Sharon Biologic Observatory, for the pur-
pose of studying animal and plant life, investigating bacteria of
the soil, etc. Some 300 acres of land are available.
New Jersey State Medical Examinations. — At the
annual meeting held July 5, 1902, 48 candidates were examined,
of whom 40 were licensed, 1 was expelled for criljbing and 7
failed. Of the 12 midwives who took the June examination
589o failed to pass because of insufficient knowledge of the
subject.
Mortality Among Children in Brooklyn. — Of the 11,000
deaths in Brooklyn during the past six mouths more than 3,700
have been children under 4 years. For some time the deathrate
of this class has been about double that of New York. Physi-
cians ascribe the large mortality to three causes : the taking of
babies on open trolleys without sufficient clothing, impure
water and impure milk.
State Manufacture of Vaccine in Massachusetts. — At
the request of the legislature the State Board of Health of
Massachusetts prepared in June a report on the production and
distribution of vaccine for free use in the commonwealth. The
report embodied a plan and an appropriation for carrying it
out. The legislature then passed a resolution authorizing the
State Board of Agriculture to investigate the feasibility and
probable cost of producing vaccine lymph at the Massachusetts
Agricultural College. This report is to be made on or before
January 15, 1903, thus delaying thequestion of free vaccine dis-
tribution for another year. There is intimation of interference
by the druggists, as there was said to be in the manufacture of
diphtheria antitoxin by the State.
July 19, 1902]
AMERICAN NEWS AND NOTES
■AMBBICAN MEOiCIKX 87
NEW^ TORK.
Immense Bathhouse. — Plans are under way for the con-
struction of an Immense floating bathhouse at the foot of East
Twenty-third street, New York City. The cost will be about
$200,000, and at least 18,000 people will be accommodated.
Liarge Sums for Charity. — By the will of Mrs. Mary J.
Walker, who died July 2, many charitable institutions in New
York will receive bequests, amounting in the aggregate to
$500,000. St. Luke's Hospital and the New York Association
for Improving the Condition of the Poor of the City, with
?100,000 each, are the largest beneficiaries.
Disposal of City Waste. — The jVew York Times states that
Commissioner of Street Cleaning Woodbury is entitled to an
editorial compliment on the fact that he has already practically
put an end to the venerable nuisance of dumping at sea the
sweepings and house refuse collections of the city. By the
new system, garbage and organic matter of all kinds are sepa-
rated from the ashes and burned, and what remains is sold for
filling.
Tablet in Memory of Honored Dead. — A memorial tab-
let has been presented to the College of Physicians and Sur-
geons, Columbia University, by the alumni, in honor of the
graduates who died during the Spanish-American war. In pre-
senting the tablet Dr. John G. Curtis, professor or physiology,
made a short address, giving an account of the careers of the
Columbia men who lost their lives in the war. President But-
ler responded for the university. The tablet, which Is of oxi-
dized bronze with raised letters of bright bronze, is in memory
of John Blair Gibbs, assistant surgeon U. S. Navy, killed at
Guantanamo ; George Washington Lindheim, assistant surgeon
Eighth Regiment, N. G. S. N. Y., who died of typhoid, Septem-
ber 16, 1898, and Harry Augustus Young, Eighth Utah Light
Artillery, who was killed at Manila, February li, 1899. — IJour.
Amer. Med. Association.]
PHTLADEIiPHIA, PENNSYLVANIA, ETC.
Woman Physician Demands Escort.— Dr. Mary Conard
has resigned from the resident staff of the West Philadelphia
Hospital for Women because, it is said, she was not furnished
an escort for protection when compelled to make calls late at
night.
Fire at Municipal Hospital. — A fire in the new wing of
the Municipal Hospital .July 8 threatened the 20 night nurses
who were sleeping in the building. The lire was soon sub-
dued, however, the inmates being unharmed and the loss
amounting to ?1,000.
Resohitions by Woman's Medical College. — The faculty
of the Woman's Medical College recently adopted resolutions
as an expression of their appreciation of the services of
the late Dr. Agnes B. Robinson-Messner, who had served as
a-ssistant demonstrator of anatomy.
Smallpox in the State. — Smallpox still exists despite the
warm weather. Cases in the State are decreasing, but in Jeffer-
son, Wyoming and Westmoreland counties there are 20 to .'JO
cases. Private citizens of Chester are to defray the expenses
of erecting a municipal hospital, there now being 40 cases of
smallpox in that city.
Decrease in Population of House of Correction. — Statis-
tics show that there has been a steady decrease in the number of
persons coutiued in the House of Correction since 1897, when
the average was 1,28<) as against 962 last year. Prosperous trade
conditions and stricter discipline are named as the chief factors
in causing the decrease. The inmates are now required to do
such work as they are able, and their relatives and friends are
not allowed to visit thoni.
Charter for Optical Collejfe Refused.— The application
of the Franklin Optical College tor a charter has been refused
by Judge Sulzberger. The institution was to provide instruc-
tion relating to the structure of the eye and the laws of vision
and to (lualify its students as skilletf opticians. Thoy were to
be Uiught to make glasses, fill oculists' proscriptions, and to
recognize pathologic conditions of the eyes. All this was to b«
completed in two months.
Pennsylvania Hospital for the Insane.— The annual
report shows that during the year 93 men and 98 women were
admitted and 96 men and 87 women discharged. The popula-
tion at the end of the hospital year was 4.Jl. In the report Dr.
John H. Chapin, chief physician, states that "it has been an
interesting experience of the year to note that 14 patients sutfer-
ing from neurasthenic conditions, with impaired physical
health, threatened with mental disease, voluntarily sought
admission Uy the hospital. If it were not for the unfounded and
unwarranted preitidico existing toward hospitals for the insane,
whicli even our laws indiro(rtly foster, together with a dispo-
sition to <!Oncoal what is somctiinos considered a blot on the
family, there is no doubt that the number of voluntary admis-
sions and reoxiveries would increase."
SOUTHERN STATES.
Typhoid at Camp Thomas.— Typhoid fever has made its
appearance at Camp Thomas, Chickamauga Park, Ga., for the
first time since the epidemic among the soldiers during the
Spanish-American war.
Free Treatment for Officers' Families.— Families of
naval officers in Washington may shortly be compelled to pay
for mediciU advice in case of illness. At present medical officers
on duty at the naval dispensary not only attend officers but also
their families. Secretary Moody may prohibit this as the result
of the refusal of Congress to increase the pay of me<lical otVicers
because of the number on shore duty.
Consolidation of Medical Work in District of Coinm-
bia. — The Executive Committee of the Medical Society of the
District of Columbia after a thorough investigation has recom-
mended that steps be taken to secure the consolidation of all the
medical work of the District Government under a single medi-
cal officer, the Health Officer. This includes the following
branches: Health department, Washington Asylum and
Workhouse, police and fire departments, sick poor, applicants
for admission to hospitals, applicants for license to practise
medicine, pharmacy or dentistry, examination of the alleged
insane.
San Antonio Hospital. — San Antonio is soon to have a
model institution for the care of the sick, designed to combine
the good features of the socalled sanitarium with those of the
general medical and surgical hospital. Thirty of the leading
physicians of that city, together with as many or more promi-
nent business men, have organized a §50,000 stock company and
have purchased a property consisting of almostan entire block.
The first building is to be a modern three-story brick structure,
and the plans provide for a future extension of some 200 or
more rooms. Such an institution as this has been much needed
in southwest Texas for the past 10 or 15 years. In future those
invalids who have heretofore had to travel hundreds of miles
to enter the private hospitals of the north and east will find
equally as good accommodation and as skilful nursing pro-
vided at this home institution. — [Texas Medical Journal.]
WESTERN STATES.
Cincinnati CoIIeRe of Medicine and SurRery.— Dr.
Edwin Kicketts has been elected to the chair of Abdominal and
Gynecologic Surgery.
American Institute of Homeopathy.— Dr. Joseph P.
Cobb, of Chicago, was elected president at the fifty-eighth
annual meeting in Cleveland.
Michigan State Medical Society. —This society has re-
cently adopted a new plan of organization and appointed 12
councillors. Prospects are favorable to greatly increased effi-
ciency.
Columbus State Hospital.— Dr. Eugene O. Carpenter has
been reelected superintendent. During his four years' service
he has inaugurated many improvements in treatment and
established a pathologic laboratory.
St. Luke Fire Not a Crime.- The grand jury in ChicAgo
has decided that no one should behold criminally responsible
for the fire which destroyed the Sanatorium of the St. Luke
Society on June 9, with the loss of 12 lives. The decision that
the hospital authorities had done everything jroasible to save
the lives of the patients was directly opposite to the finding of
the coroner's jury,
San Francisco Board of Health.— According to local
papers more (charges are being made against San Francisco a
f" Bubonic Health Board," as it is termed. It is allme<l that
employes of the health denartmont have been assessed to raise
funds for the legal iiroceedings which the lM)ard has instituted
to keep its members in office. The superintendent of the City
and County Hospital has been dismiHS(Hl, it Is charged, because
he refused to contribute a month's salary.
Duration of Human IjIOb Increasing in Chicaico.- The
bulletin of the City Health Department of ChUaigo, for the
week en(le<l Jiilv f), gives statistics to further i>rove the findinira
from lH<i9 to 1898, during which the duration of life Increased
from an average of l.t.9 years at the beginning to an average of
2!) 4 years at its close. Recent figurfw show that the nroportlon
of inhabitants who live to threescore and l)eyond is steadily
increasing, and the proportion of those who die under 6 years
is even more rapidly de<Teaslng. The doathrate for the week
wivs 12.97 per 1,000 of the 1,820,000 estimated population.
CANADA.
Ontario Medical Collrjce for Women.— This college has
completed one of the most successful years In Its history. In
their final examliiatioiis at Trinity and Toronto nnlvorslties
and at the College of Phvslclans and Surgeons none failed,
though XVh of all c-andidates faileil at the latter, of the 8 mem-
bers graduating, .") have apiMiintinents In U. 8. hospitals, 3 in
Philadelphia.
88 AmsiCAN Medicinej
SOCIETY REPORTS
[July 1», 1902
FOREIGN NEWS AND NOTES
GENERAIj.
Scholarship from Book Revenue.— Dr. Conan Doyle'B
book ou the war ha.s thus far yielde<l a revenue of £1,400, with
which he intends founding a South African scholarship in
Edinburgh.
History of Lieprosy fVom Ancient Documents. — An inter-
esting extract on lopois is quoted from the fortlicoming worlt
by Paul liicher, entitled " I'Art et la Medecine." The disease
is traced to 1,500 years before Christ. (Juotations and illustra-
tions are given from early manuscripts treating of this disease.
GREAT BRITAIN.
Royal Commission on Arsenic Poisoning. —This com-
mission, with Ijord Kelvin, chairman, presiding, held a meet-
ing in London June 13. Representatives of the Societies of
Public Analysts and of Chemical Industry reported the find-
ings of the committees for determining the best process of
detecting and estimating arsenic in beer and malt. They
recommend the Marsh- Berzelius test as being accurate ami
easy to use even by inexperienced people. It is to be preferred
to the Keinscli test. Prof. Del^piue, of Owens College, gave the
results of his experimental Investigation upon the action of
arsenical beer and other arsenical solutions administered to
rats. Some of the conclusions were that arsenical beer was less
injurious than watery solutions of arsenic of the same strength ;
when an animal was well fed the presence of a small quantity
of arsenic did not affect its health seriously for a time; doses of
arsenic greater than those found in arsenical beer might be
taken for one month without causing death, but that death was
liable to occur suddenly at the end of that time ; after arsenical
beer was taken for three months sudden stoppage might cau.se
disturbance of health.
CONTINENTAIi EUROPE.
Foar Thousand Operations for Cataract.— The Arch-
duke Carl Theodore, of Bavaria, the distinguished ophthalmic
surgeon, recently performed his four thousandth operation for
cataract.
Anatomic Museum at CardifT.- The Alfred Hughes
Anatomic Museum at University College, Cardiff, was form-
ally opened .Tune 20. The late Professor Hughes was the first
occupant of the chair of anatomy in that institution and donated
£3,50 for the purchase of specimens as a nucleus for the mu-
seum.
OBITUARIES.
John N. Tilden, In PeeksklU, N. Y., July 10, aged 60. After serv-
ing as surgeon in the Civil War he conducted the PeeksklU Military
Academy for several years. A severe burn received in 1892 left him
seriou.sly crippled.
Arthur Ward, the oldest physician in Newark, N. J., July G, aged
79. He was a graduate of Yale, and the College of Physicians and Sur-
geons and had practised in Newark for 55 years.
John K. Keinoehl, of Lebanon, aged U, was instantly killed in a
runaway July 10. Br. Beinoehl represented Lebanon County in the
legislature from 1S93 to 1895.
Robert Bell, of Medway, Mass., July 4, aged 57. He was born In
England but was educated In this country, obtaining his medical
degree at Harvard.
Charles C. Furley, of Wichita, Kan., July 6, of tuberculosis. He
was surgeon in the Civil War and the flrst practising physician in
Wichita.
John Wychenford Washbourn, of London, June 20, aged 39. He
was physician to Guy's hospital and to the London fever hospital.
Thomas Hackett, of Hillsboro, Md., July 7, aged 76. He was a
graduate of Washington College and of Jefferson Medical College.
J. A. Mlchle, EarljsvlUe, Va., June 3, aged 76. Dr. Mlchle was an
Influential Republican and led the party In his county.
John Calvert liutcher, at Urbana, O., June 19, aged 56. He was
an active Ma.son and had served as pension examiner.
Mary Damon, of Minneapolis, at her former home in Concord,
Mas.s., July 6, by suicide during despondency.
William Collins Hatch, ex-PresIdent of the Maine Eclectic Medi-
cal Society, at New Sharon, Me., June 16.
Ferdinand Sommer, director of the Anatomic Institute of the
University of Griefswald, aged 74.
Albanns Styer, A mbler, Fa., July 1, aged 76. He was a graduate of
Jeflfferson Medical College, 1819.
- .Ado'Pbe Schuermane, ophthalmic surgeon to the HOpltal Saint
3ean, KruRsels.
M. Tlchomiroff, professor of anatomy in the University of Kleff.
William Dale James, at Sheffield, Eng., June 16, aged 52.
Jean Joseph Ittelttor, Arlon, Belgium, aged 98.
SOCIETY REPORTS
MEDICAL SOCIETY OF THE STATE OF NEW JERSEY.
One Hundred and Sixth Annual Meeting at Atlantic City,
N. J., on June 24, 25 and 26, 1902.
[Specially Reported for Americ ,n Medicine.\
[Concluded from page W.]
FOtlKTH SE.S.SIOS (cONTINnED).
The Cause of Sore Arms Durin;; the Recent Vaccina-
tions.— Alkx. McAIjWstkr (Camden) referred to the compara-
tive immunity which the country had enjoyed from smallpox
for many years, until it was again imported by returning
troops at a time when the country was fairly ripe for a general
epidemic of the disease owing to the laxity of vaccination dur-
ing the previous years. Only prompt resort to vaccination or
revaccination was effective in averting a much more serious
epidemic than that who.se end we have not yet reached.
Twenty or more years of growing indifference to the value and
practice of vaccination suddenly terminated in the most urgent
demand for vaccination. Never before in the world's history
were so many persons vaccinated in so short a time. Com-
mendable progress has been made in the preparation of vaccine
material, and conscientious application of every approved pre-
cautionary measure in the technic, yet afairly large proportion
of arms inoculated developed inten.se sores, requiring from
eight to ten weeks to heal completely. As a consequence many
adverse criticisms were heaped upon the virus employed, or,
it might be, upon the vaccinator. Certain complications have
always attended the practice of protective inoculation, and to
reduce these to the minimum, the best talent in the profession
has been engaged at all times in an effort to improve the virus
a.s well as its commercial source. These efforts have been
fruitful of good results in many directions. The introduction
of bovine virus in place of human was one of the great im-
provements, removing the complications of the past. Those of
today are quite generally of local effect, and chiefly embraced
under the general term sore arm." There may be differences
but the main distinction is chiefly that of degree of inflamma-
tion and the resulting destruction of tissue. Sources of coin-
plications are: Impurity in the virus; lack of skill in the vac-
cinator; lack of proper care of the vaccine sore; peculiar
susceptibility of the vaccinated. McFarland says that " in
spite of all precautions it must be impossible to secure sterile
pulp, and that every class of virus contains three classes of
microorganisms, which as a rule are harmless, but only those
specific for vaccinia are desirable. The virus itself, if not prop-
erly prepared, or perhaps occasionally through unavoidable acci-
dent, may contain infectious organisms. The most important
of these are skin cocci, which occasion severe local lesions, and
the tetanus bacillus, which has done considerable mischief of
late." McAllister claimed that it had been shown in every
recent instance of tetanus complication that it was not
from germs introduced with the specific virus. The
mcst fruitful cause of sore arms is the introduction
of the skin cocci, which might be present in the virus
or introduced in various ways. Theoretically glycerin-
ized virus, if properly seasoned, is the purest virus to select,
but can never be guaranteed as sterile. Inoculation .should be
regarded as primarily an operation and thorougli cleanliness
insisted on from first to last. He was against the u.se of shields
and insisted on the necessity of proper care after the operation.
l)isci(«.sjo)i.— Shepaui) liad used human virus for 40 years
and never had an unnecessarily sore arm. His experience
with bovine virus during the last few years had not been so
favorable. He believes in virus from a pure, healthy baby.
The Cure of Cancer by the X-ray.— Uowlino Bkn.iamin
(Camden) had found remarkalile results; one case had been
cured after the knife had lieen resorted to. When the burn pro-
duced does not appear for two or three weeks what is happen-
ing in the interval ? We only know that a molecular change is
going on. It proves that the x-ray has an influence on inside
nutrition. Experience has shown that it has done much for
cancer. While the permanency of the cures could not be defi-
nitely stated the author has cases of over two years witli no
relapse ; four cases under treatment, but not sufficiently long
to report except in one case; pain stopped; in three Aveeks
patient reported as well.
Radical Operation for the Relief of Chronic Purulent
Disease of the Middle Ear.— F. C. Ard (Plainfield) puts the
facts carefully before the patient and warns that any chronic
discharge from the ear is not trivial, even although it might be
odorless ; insists on necessity of early operation ; he cited cases
in which temporary relief was obtained by late operation, death
following, another death followed after live days; in a third
case there was rapid recovery after operation being performed
early.
FIKTH SESSION.
Before the opening of the scientific session English
stated that at a meeting of the Fellows that afternoon it had
been resolved to offer a prize on " The Value of Vaccination."
July 19, 1902]
SOCIETY EEP0ET8
lAUBSICAN- HeSTCINK
The Cause and Treatment of Sterility In Women.—
Edward J. Il,i. (Newarkj. The sterile woman is an unliappy
creature. Mucli has been done for her and especially since the
practice of opening theabdomeu has been introduced. Sterility
IS a symptom, not a disease ; serious consideration of all the
circumstances is necessary ; and facts are essential. The male
semen must be normal ; the ovum and spermatozoon must
come together and in the right place. A woman must not be
pronounced sterile until the male has been examined. The
popular belief that in certain women the vagina will expel
semen should not be heeded. Tumors are a great cau.se of
sterility; myomatous women are generally sterile. One must
study symptoms before proceeding to consider operative meas-
ures. The author is not partial to removal of nodules. Fre-
?uently disease of tubes and ovaries exists and gonorrhea is a
re<iuent cause. We should operate on tubes and ovaries when
found diseased.
Discussion.— Vt. H. Ballerav (Paterson) thinks sterility
may be absolutely relative. A woman may be sterile to one
man and not to another ; this fact is observed in the lower ani-
mals. There are different kinds of sterility, and one should
try at the outset to determine the conditions which prevent
conception. Too many surgeons know comparatively little
about pessaries and their application. He quoted a case in
which he had removed a tumor the size of an orange, with re-
covery of the patient, who three months later became pregnant
and at term was delivered of a fine healthy boy. W. E. Car-
roll thinks that from whatever point of view this question is
considered it should occupy a primary position. Looked at
from the patriotic standpoint it is of the utmost importance.
Too early application of forceps is a frequent cause of future
sterility.
Cause of Tetanus Following Vaccination. — Alex.
Mc.*.LLisTER (Camden) gave the history of 10 cases of tetanus
occurring in Camden in persons who had been recently vacci-
nated. Of these eight ran short courses, ranging from one day
to a week, and ended fatally. Two cases were protracted and
ended in complete recover}^. The object in presenting the
paper was to give for record in the medical arcliives of the New
Jersey State Medical Society a concise history of this outbreak
and the result of the investigation which followed. The com-
mittee decided to investigate the nature and purity of the virus
employed, and the investigation showed, according to the com-
mittee, that in every instance the usual antiseptic precautions
had been taken in the technic of the vaccination. The bacterio-
logic investigation of the virus employed showed it pure and
entirely free from tetanus bacilli. It was the opinion of the
irommittee that certain atmospheric conditions, for example, a
long period of dry weather and high winds, explained the out-
break. Because of the conditions, or coincidentally with them,
germs of tetanus were present in extraordinary abundance.
The shifting nature of Camden soil enabled the wind to spread
the germs through the atmosphere to every exposed wound.
A Plea for Early Diagnosis and Treatment in Cancer
of the Uterus.— G. H, Balleuay (Paterson) believed that if
there was no traumatism there would be no cancer. In exten-
sive lacerations resulting from childbirth, or extensive involve-
ments, he advises removal of cervix. This is a bloody opera-
tion unless quickly performed. He does not believe in the
outcry against the use of douches, and keeps his patient in bed
and uses vaginal saline douches. He does not believe in sew-
ing up after laceration. Early diagnosis is most important, so
that operation may be performed if needed.
Brain Ahscess of Optic Origin. — Wklls P. Eaolbton
(Newark). Death in such cases is a r-ire occurrence, but there
may be a wrong diagnosis. Brain abscess is generally single,
but sometimes there may be two or three, and they may extend
very quickly. The large proportion of cases is chronic, and
sudden death has occurred in one who had scarcely complained.
In such cases diagnosis is hardly possible. No one set of symp-
toms can be relieil on. Treatment is invariably surgical. He
cited the case of a patient aged '14 who had dizziness accompa-
nied V>y vomiting, with no discharge from ear, but walked
alone to eye and ear ho.spital, and died immediately after
admission. KupturiB may occur on operating table, but they
should give the patient a chance. The operation is entirely
exploratory, and in 10 cases out of 100 there is a wrong explora-
tion. Failure may be due to the pus being .so thick that it
could not be drawn through exploratory neeule.
DisruHsion. — Cif.\MUKRM emphasizml the fact that not a
moment should be lost when on(;e the diagnosis has been
made.
Further Notes on the Hot Water Douche for Ahort-
Ing Mastoiditis.— Talbot K. Cha.miiers (.Jersey City) claims
wh(!n properly douched with water at 120° K., repeated fre-
juently, a cure will be effected. When there is any discharge
rom the ear the hot doirdie is distinctly indicated. Carols
necessary, owing to the heat of the water.
Discussion. — .Tohns<;n 'approves of (Jhambers to a certain
point. .Many patients object to tlio heat of the water. Doubts
diagnosis as to mastoiditis, and is doub'tfiil as to being able to
cure in that way. Wii.so.n agrees with^Tphnson that patient is
likely to obje(!t to liot water,
The Surgical Treat inent of fiaf)(ropifo«ls.— IT. 1). Bkyka
( I'hilailclphbi) saVs it is only of late y?;irs that this disease has
t)eon studiefl. Tlie cAuse isiiot dcliniteiy known. He reviewed
the syiuptoms and treatment, and' co;i«leiaaed tight lacing,
I
recommending ma.ssage. Medicine and meiliciual appliances
sor<ietimes give much relief. Considering surgical treatment
he cited cases in which r&storation to health was wonderful,
with increase of weight.
SIXTH SESSION.
This was taken up with routine business— the exhibition
of a new obstetric forceps by Benjamin ; the discussion of the
question proposed by the Business l^ommittee: AVhat are the
Best Methods to Prevent the Spread of Tuberculosis?
which was held as a paper read by title.
A Report of a Case of Tumor of the Orbit.— Oeorqe
E. Reading (Woodbury) read a short paper, in course of which
he gave history of a case in which he had made successful use
of adrenalin.
Next Place of Sleeting.— Asbury Park was selected, the
date fixed being June 23, 24 and 25, 1903. The miscellaneous
business brought on a discussion of the difficulties surrounding
the question of the requirements of different States in regard to
licensing and examining of <iualified physicians from other
States, in which many members took paj t.
Witchcraft Case in Court.— A witchcraft case has been
before a magistrate in Carlisle, Pa., Mrs. William McBride
and Edgar Zug being accused of extorting money from an aged
couple by convincing them they were bewitched and that the
" spells " could be removed. The woman, when on trial denied
being a witch doctor, but admitted " powwowing."
The Army Nurse Corps.- The War Department has issued
orders relative to the nurse corps established by the bill passed
February 2, 1001, which has been previously described. The
order details the duties, pay, status, quarters, etc. It is ordered
that army nurses shall be assigned to duty at military
hospitals and at hospitals where more than one nurse
is serving one will be assigned to duty as chief. The
tour of duty without the limits of the Unitmi States
will usually be at least two years. Nurses are appointed
for three years. A nurse must be a graduate of a hospital
training school and must pass satisfactory professional, moral,
mental and physical examination. All applications should be
made to the surgeon-general. After appointment the nurse is
to serve for at least three months in the United States, during
which period she will receive special instruction in army nurs-
ing, iter pay and allowance on active service is to be $40 a
month in the United States and $.50 when abroad. Chief nurse
will receive from $4.5 to $75. Nurses will be furnished quarters
according to accommodation available at each hospital. Each
nurse will receive one ration in kind per day and when sta-
tioned where rations cannot be furnishecl will receive commuta-
tions of rations at 75 cents per day. The total duration of leave
of absence with pay will be 30 days and an additional month
without pay will be granted when the service will permit. .\
nurse who has served faithfully and satisfactorily for at least
six months and received an honorable discharge will be placed
on the reserve list. A nurse will be dropped from the reserve
list upon reaching the age of 45 years, or if she ceases for five
years to practise her profession, or if she becomes permanently
incapacitated from Illness or other good or suthcient reasons.—
[Jour. Amer. ^fed. As.iociiilioti].
Fourteenth International Medical Congress.— The foN
lowing announcement is made by the secretary of the American
Committee, Dr. J. H. Huddleston, New York: The Fourteenth
International t'ongress of Medicine will be held in Madrid,
Spain, from April 2.') to .'tO, 100.1, under the patronage of their
majesties, the King of Spain and the (Jueen-Mother. The presi-
dent of the congress is Professor Julian (Jalleja y Sanchez, the
general secretary is Dr. Angel FernAndez-Caro, and the general
treasurer is Professor Josfi Gf'unez Ocafia. The preliminary
statement of regulations and program has just been issued, and
it announces that iiiemberH of the cxuigross will lie physicians,
pharmacists, dentists, veterinary surgo<ms, and other persons
working at branches of incdical science, both Spaniards and
foreigners, who have entered their namcts and paid their sub-
scriptions. Other persons who possesses scioiitifi<' and profes-
sional titles and who wish to take part in the work of
thecongress may share in it under the aliovo conditions. The
subscription is ISO pesetas, and this sum must be paid l>efore the
opening of the congress to the general secreti«ry, Faculty of
Medicine, Mmirid. A card of membership will be sent to the
subscriber. Until March 20, liKO, subscriptions may be paid to
the secretary of the national committetiby the subscriber, but
after that date subscriptions must bo paid directly to the gen-
eral secretary at .\Ia<lrid. Members will receive a Numniarv of
the pr<KH«xlings of the i-ongress and a full report of the work o(
the particular section whi(!h they Join. The oillcinl languages of
the congress will be Spanish, I' ronch, F.nglish, (ierman and
Italian. Papers must be sent to the general secretary before
January 1, 1!I03, to bo certain ofa place in the order of busitiens.
I'apprS presented lat<(r will bo <;onsidored after the discussion of
those regularly annoiincetl. <'ommunlcatloiis Hhould be accom-
panied liy a short abstract, which will Imi printed and distrlb-
uted among the member* of the congress.
90 AMBBICAN MkDIOIKB)
OORRESPONDENCB
[July 19, 1902
CLINICAL NOTES and CORRESPONDENCE
ICommunlcatlons are Invited for this Departrnent. The Editor. Is
not responsible for the views advanced by any contributor.!
TRANSMISSION OF LEPROSY BY FISH AND SPORE
LIFE OF THE LEPRA BACILLI.
BY
ALBERT S. ASHMEAD, M.D.,
of New York City.
I read in the New York Times of June 12 that at the leprosy
debate Vjefore the Royal Medical and Chirurgical Society, of
London, Dr. Hutchinson's theory that leprosy was communi-
cated by the eating of badly cured fish was discussed. Dr.
Hutchinson, it is said, claimed that the disease was not con-
tagious. " He declared his faith that the leprous bacillus would
soon be found in the fish, and reasserted his reasons from his
experience (in South Africa) for not believing the disease con-
tagious."
Allow me to observe that heretofore Hutchinson's theory of
propagation of leprosy through fish diet, has not embraced the
question of the presence of the bacillus in the flesh of fishes.
Evidently since his Investigations in South Africa he has
changed somewhat his theory. As Dr. Hansen should have
said, until we discover " not the fully developed lepra bacillus "
in fish or its spores Hutchinson's theory " cannot be proved."
Pish diet per se will not produce leprosy, as evidence of which
let me quote the following letter from Dr. Grenfell, a competent
leprologist and superintendent of the mission to deep sea
fishermen, now operating in Labrador. He found there " peo-
ple dying of cancer, dropsy and scurvy, who had never seen a
physician," but not of leprosy, yet they lived on fish.
Mission Hospital Ship "Strath Cove,"
Off North Newfo¥ndland,
May. 1902.
Dear Sir: Our dilatory post has brought me a letter from
you asking about leprosy, and dated September, 1901.
If I had any information to afford you, I would only be too
glad to do so. I have seen leprosv in Norway, and if I
remember rightly also in Iceland, and I had two oases under
my care in the London Hospital, England, some 15 years ago.
But to the best of my knowledge, I have never seen a case or
anything resembling leprosy among this population, who are so
poor, and who live on fish.
Wilfred Grenfell.
I merely add, that perhaps if those inhabitants had eaten
fish which was contaminated by even one leper who had been
transported there, leprosy might have been propagated to
them as in Hawaii by the operation of the fish theory which
takes cognizance of the bacillus and the intermediary host,
function of fish and mosquitos operating together. Nor would
It be " necessary to prove, as Hansen says it is, Hutchinson's
(Ashmead's) theory to discover the bacillus in the fish." For
the spore life of the bacillus is wholly unknown, and that
would suffice to transmit the disease. Many leprologists of
distinction believe in the spore life of the lepra bacillus,
BeavenRake and Arning among them. Until weknow the biol-
ogy of the lepra bacillus outside of the human body we cannot
prove transmission of leprosy through fish, even the living
(while the flesh quivers) raw fish diet of leprous-scourged
Japan. In the absence of a spore life of the bacillus of leprosy,
how would Dr. Hansen explain the following facts of transmis.
sion in Louisiana, where the New Orleans Daily Picayune says
there are 400 lepers.
Abbeville, La., October 15, 1901.
Dear Doctor Ashmead: The recent recrudescence of
leprosy in this town after a lapse of many years, and in the
absence of any competent proof of the source of infection, has
suggested to my mind the possibility of the bacilli remaining
active in the soil of the site of a former leper habitation, and it
is to tliis point I invite your opinion. I read some years ago in
the report of the East India Leprosy Commission that the
bacillus had been found in the earth and also in the soil of
a leper's grave, but I am uninformed as to the period of their
viability under such conditions.
Some 30 years ago two families of lepers resided in this
town ; some of the members went away to die, but one in each
family remained here and slowly rotted away. According to
the medical teaching of those days leprosy was held to be
hereditary and noncontagious, and no sanitary precautions were
observed, the dejecta and soiled dressings being pitched out
into the back yard to rot away with the refuse. The people
generally shunned these unfortunates, and held very little
intercourse with them. In fact, the husband of the first leper
died about 15 years later without any indication of the disease,
while the wife of the other patient is still living today, 24 years
after the death of her leper husband, a hale and hearty woman.
Of the cases occurring recently, one was in a family occupy-
ing tlie premises in the rear of the male leper, two otlier cases
in families residing within a hundretl yards of the infected
spot occurring in children born some years after the death of
the leper. Another case occurred in a woman who lived for
two years in a new cabin erected on the site of the leper
woman's home. Is there anything here of cause and effect?
Can the disease originate de novo, and is it endemic in South
Louisiana, etc. ^ -, ^^ ■«, T^
C. J. Edwards, M.D.,
Member Board of Control, Lepers' Home.
In my reply to Dr. Edwards, which was quite exhaustive of
the subject, I mentioned the fact that Dr. Heaven Rake in the
examination of leper graves in the cemetery of his asylum at
Trinidad had found rod bacilli in the top earth (which took the
leper stain) of the graves of seven lepers who had had autopsy
performed before burial. But that in the eighth grave, of a leper
who had had no autopsy, there were no such rod bacilli. Dr.
Rake seemed to think that the autopsies had released something,
which had developed into these germs. Yet they were not leper
bacilli, lit least not yet .'
Other leprologists besides myself believe in a sporular stage
of the lepra bacillus. Arning, formerly of Hawaii, who inocu-
lated Keanu, the Hawaiian convict, with leprosy by strapping
an excised tubercle into a wound of Keanu's arm, thinks that
while the bacilli of leprosy may, or may not, be in cells, and
the cells are by no means necessary to their growth, he thinks
that lepra bacilli have spores which give rise to the unequal
staining and knotted appearance so often seen in the bacilli.
He has found lepra bacilli in the earth from a grave in which a
leper had been buried for upwards of three years (long enough,
you see, to cover the incubation period of disease, which as
shown by his inoculation of Keanu, is over two years). He
thinks that mosquitos are a source of danger near a leper hos-
pital, though he has never been able to detect bacilli in them.
When lepra bacilli are not inside the cells, says Arning,
they appear to be embedded in some gummy matter. He thinks
the chief points to be elucidated in regard to leprosy are: 1.
How is it possible to distinguish between dead bacilli and those
that are still alive? 2. Has the lepra bacillus a spore? 3. Is
there a ptomain secreted by the bacilli? 4. Are the lepra
bacilli found in the lungs, and intestines of lepers ?
In my article, "Inoculation of Leprosy," which Hansen
kindly translated and published in Norwegian some years ago,
I spoke of direct inoculation by insects, especially mosquitos,
and transmission of the disease by spores through them and
raw fish.
The travel of spores to the top of graves and their gradual
evolution during the journey into bacilli is perhaps to be ex-
plained as the result of heliotropism.
A SIMPLE METHOD OF PERFORMING ENTERO-
ENTERAL ANASTOMOSIS.
BY
CECIL FRENCH, D.V.S.,
(McGlU University and Koyal Veterinary High School, Munich,)
of Washington, D. C.
To the Editor of American Medicine :— In your issue of
April 26, 1902, there is a communication from John J. Repp,
V.M.D., in which he refers to my method of performing entero-
enteral anastomosis on the dog, and suggests the possibility of its
applicability to human surgery. I may say that I did not call
attention to this point in the article in which I described the
technic of the operation, because it was addressed to the veteri-
nary profession through the medium of a veterinary journal,
and it would have been of little interest to the veterinarian. For
the veterinary practitioner a method is needed which does not
involve the employment of specially manufactured devices,
July 19, 1902]
COREESPONDENCE
■AMEBICAN MbDICIKB 91
which, excepting in large cities, are unobtainable at short notice.
The necessity for performing the operation invariably arises as
an emergency ; hence it is indispensable that the technic be as
simple as is compatible with favorable results, and that any
device necessary to facilitate the work be such as may be fash-
ioned out of material at hand and at short notice. With this
end in view I have contrived a method which I believe to be
peculiarly adapted to canine practice. The sole device of which
it is necessary to make use is a lady's hairpin, bent as figured in
the accompanying illustrations. Two of these are required,
together with three or four pairs of hemostatic forceps to act as
clamps.
For the suturing, a milliner's needle, size 8 or 9, should be
employed, and the suturing material should be the finest No. 2
black sewing silk. Nearly every surgeon who has experi-
mented on dogs recommends silk. Thick catgut remains
unchanged not over seven days as a rule, which is not a period
of sufficient duration for certain coalescence to take place, and
when tied the knots interfere with accurate approximation.
Fine catgut disappears in less time, while aseptic silk threads
can be tied with greater accuracy, and the knots never become
loosened, and its permanent presence never exerts any ill-
effect, for it becomes solidly encapsulated. In place of silk I
have used ordinary sewing cotton with good results.
In order to follow each successive step in a complete
enterectomy and end-to-end anastomosis by this method, let us
suppose that on exposing the viscera a tract of small intestine
Fig. 2.
Fig. 1.
is found to be in an advanced state of gangrene from the
presence of some obstruction, or owing to strangulation. The
operator miist first carefully inspect the local blood-supply,
bearing in mind that no mesenteric vessels must be obliterated
other than those supplying the area of intestine it is intended
to remove. This precaution must be rigidly observed, because
it is of the utmost importance that the circulation be preserved
lip to the very row of sutures. All the circulation possible is
needed to effect rapid coalescence of the parts and to ward off
fiirllier gangrene. The area of intended resection and the
blood-supply of the same being mapped out, the mesenteric
vessels are first secured by ligature, which is best done by
means of a curved needle and fine silk suture passed through
the mesentery and around them. The anastomosing loops
running near the mesenteric attachment are secured at a point
level with the proposed line of resection.
One prong of the hairpin is passed through the mesentery
at the upper point of resection, and, together with its fellow, is
brought transversely across the gut. The two are clamped
together with hemostatic forceps. The other pin is affixed in
the same manner at the lower line of resection. No other
bowel clamp is needed, as the lumen is closed from the outset.
The intestine is severed with the scalpel quite close to the
clamped prongs of the pin, and the incision extended to the
mesentery so as to remove a wedge-shaped portion. The pin
effectually inhibits all vermicular action of the wall. The
two pins are approximated and tied tightly together, or they
may be locked by
means of additional
hemostatic forceps.
The sutures are
now placed on one
side, starting at the
mesenteric attach-
ment. They are
tied before proceed-
ing to the other
side. The bowel is
turned over and
the sutures are ap-
plied in the same
manner on the
other side. The
pins are then un-
tied and severed at
their bent ends
with bone forceps or stout scissors, undamped and withdrawn,
one prong at a time. The remaining openings are closed with
one stitch each, particular care being exercised that the margin
is properly turned in at the mesenteric attachment.
Finally, the incision in the mesentery is closed with a
continuous suture.
I have performed this operation experimentally on
six different animals, all of which recovered except one,
which was only five weeks old, and which survived the
actual operation, but succumbed later to obstruction of
the canal owing to the formation of adhesions between
the line of coalescence and one side of the wall im-
mediately beyond, whereby an acute flexure was de-
veloped.
While conducting my experiments some 12 to 18
months ago, I requested a member of the local medical
profession to test the hairpin method on the bowel of a
human cadaver. He reported to me that he had done so,
but without success, giving as a reason that the human
bowel was too flaccid. At the same time he told me that
the body upon which he tried it was that of a person
who had died several hours previously. I am not familiar
with the condition of the human bowel either l)efore or
after death, but I cannot but believe, in view of the suita-
bility of the contrivance for tiie bowel of the dog, that
it must be well adapted to use on the human bowel, and
that the failure on the part of the practitioner in question
was due to the loss of elasticity of the tissues after disso-
lution.
I join with Dr. Repp in hoping that surgeons will give the
method a trial, at least on the fresh cadaver.
HABITUAL CRIMINALITY AS A MORBID CONDITION.
BY
CHARLES F. HOWARD, M.D.,
of Bunhlo, N. Y.
To the Editor of American Medifine .-—An editorial in your
issue of May 31, on " Habitual (Vimlnallty as a Morbid Condi-
tion," strikes the keynote of advanced ideas on the treatment of
the criminal. In my opinion, there should be nothing punitive
In the thought of those having the sentencing and care of crimi-
nals. It should be impressed upon every convict entering a
prison that he or she is committed there not as a punishment,
but simply for the reason that It Is dangerous to society to have
them at large. The indeterminate sentence should be adopted
by every State in the Union. When Inmates of a prison con-
vince those In authority that they have learned self-control and
have proved that there has been a reformation in their babita
92 AXBBICAN HEDICINUI
CORRESPONDENCE
[July 19, 1H02
and method of living, then and only then should they be per-
mitted to have their freedom.
At the New York State Reformatory at Elmira the oflBcers
are especially impressed by the present board of managers
that in many instances they are caring for men with mindu
dixeased, and that no restraint or disciplinary measures, cruel
in their nature, will l>e tolerated.
A proper length of time should be given to every young
criminal to reform. If after two or three years he still mani-
fests a tendency to continue his evil ways, then he should be
committed to an institution for the care of the habitual law-
breaker, and kept there for life if necessary. Law-abiding
citizens have a right to demand from the State that they be pro-
tected against this class, and the only way it can be accomplished
is to liave the indeterminate sentence apply to every person
convicted of a felony.
We are grateful for your favorable mention of the work we
are doing at Elmira regarding tuberculosis and insanity. Dur-
ing the past two years we have made great progress in mini-
mizing the number of cases of these two diseases, and in keeping
them under control. Every precaution is used to prevent infec-
tion by those suffering from tuberculosis, aud a lessening of
the continuous nervous strain has been the means of decreasing
the number of the insane.
TWO IMPORTANT POINTS IN INFANT FEEDING.
BY
WALTER G. MURPHY, M.D.,
of East Hartford, Uonn.
In the percentage method of infant feeding most authors
state that the basis of calculation is average cow's milk, repre-
senting fat ifo, proteid 4% and sugar 4.30%. Upon this basis a
modification is made so that cow's milk may closely resemble
the analysis of human milk. Elaborate formulas have been
suggested, often extending iuto higher mathematics, aiming at
an exact and scientific modification. There is no question as
to the utility of percentage feeding, but I wish to report a case
which illustrates a mistake, very liable to happen, when we
assume that average cow's milk always represents the standard
given in our formulas. To be exact and scientific we cannot
assume. We should know the composition of the milk we
wish to modify. Milk bought in open market is widely differ-
ent in its chemic composition, unless controlled by a con-
scientious health department or milk inspector, which is not
always done. Average milk means the milk of all breed of
cows and also the milk from dairies where cheapness of pro-
duciion is the standard, as well as the dairy where the standard
is high. To assume that all milk, which is average milk, can
be employed as a basis for calculation is not scientific and in
keeping with the good work done in the percentage method of
milk modificition. This method often fails because the modifi-
cation is made with a product far below the standard assumed
as the following experience will plainly show :
I wa3 called to attend Baby H., age 1 month, who was suffer-
ing from well-marked indigestion, the result of improper
reeding. I obtained the following history : The baby was born
after a normal labor, the birth weight was eight pounds, and
she was well and strong. The mother was unable to nurse, so
the baby was given the bottle, and several different prepara-
tions and foods tried, but not successfully. When I saw the
baby she was colicky, restless, cried a great deal, was consti-
pated and not gaining in weight. A mixture was prepared
representing fat 2.5%, proteid 80%, sugar 4%, and this agreeing
the percentages were gradually and carefully increased as the
symptoms improved. After the first week of treatment we
obtained a steady weekly gain up to about the fourth month,
when the baby developed a sharp attack of bronchitis. The
milk mixture she was then taking was reduced, and the baby
held a stationary weight for a week ; the second and third weeks
she lost a trifle, the fourth week a further loss. After the first
week the percentages wereincreased, and still further increased
TriafT^ -^K "^ ^^^^^^- The baby was not satisfied and cried a
ff<f,^t w^i'.h-J'*'? '"*''■'' °Of ymptoms of indigestion and not suffi-
cient bronchitis to account for the continued loss in weie-ht. We
whotf^'^ii'"' '"■''"«*^ ''^}^'' ™*1'' '"i'^'ure until very nearl|
whole milk was employed, and the baby was not satisfied I
mTlkhisoeXr of.f ^ '>" "^'"^ ^■?'^ ^ specimen was sent to the
SfimVlTonnt»r.!i}'''''','^''£T?°''ly^'8'«°d his report was that
the milk contained only 2% fat. This immediately explained
the difliculty, and a change of milk, which was up to the stand-
ard, was entirely successful, and the baby has since gained,
.fust why the first product should have dropped off when it had
been satisfactory I don't know, but it has taught me not to
assume that average cow's milk always contains 4% fat.
The second case I wish to report is one that emphasizes
very plainly the influence of bacteria in milk and the effects of
an acid fermentation in a milk correctly modified.
I attended Mrs. S. in confinement in .June, 1901. She had
been quite ill with dysentery for several days, and the confine-
ment was one month premature. The baby at birth weighed
about five pounds and was very weak. When we put the baby
to the breast ho was too weak to nurse, so when lactation was
freely established we adopted the expedient of drawing off the
milk with a breast pump every two hours and feeding from a
spoon. This did very well and the baby seemed entirely sati.s-
fied. Care of the breast and all apparatus was insisted upon
and the importance of absolute cleanliness and obtaining a
fresh supply of milk at each nursing was emphasized. While
the nurse was present these instructions were carefully ob-
served. When the mother was up and about, and the nurse gone,
she was not always particular to obtain a fresh supply for each
feeding, and would often keep the milk left over from one
feeding to use at the next. The weather became very warm
and the baby was taken suddenly ill with vomiting and diar-
rhea. At this the mother became thoroughly frightened, and
when I directed her to stop the use of the Ijreast pump and to
nurse her baby she was perfectly willing ; she had not been
before. The baby immediately Improved.
I obtained a specimen of milk which had been in the breast
pump lying on the table in a very hot room for two hours.
Chemic examination by Holt's apparatus was within normal
limits ; the reaction to litmus was very acid, and bacteria in
large numbers were present. A few days later, after the baby
recovered, a second specimen was obtained directly from the
breast, and this, on examination, was the same as the first
specimen chemically, but was alkaline in reaction and contained
few bacteria.
I present these cases to demonstrate two important facts in
infant feeding ; first, that without knowing the composition of
milk employed, modification is often misleading and is not
scientific; and, second, withouta good clean milk, chemic modi-
fications are not sufficient as a preventive of intestinal diseases.
A RARE FRACTURE.
BY
ANGUS McLean, M.D.,
of Detroit, Mich.
Following is a report of a case of fracture of the descending
ramus of the pubis and ramus of the ischium :
Mr. F., aged 36, was walking along an icy street, when his
right foot slipped suddenly outward ; he did not fall, but felt
something about his thigh " snap." He walked several blocks
to the car and went home. There was some pain in the upper
internal femoral region when he moved his limb in certain
directions, and some soreness of the muscles. A few days later
he consulted his physician, who diagnosed his trouble as rheu-
matism and treated him for a few months. About six months
after the injury a swelling appeared on the upper inner surface
of the thigh ; this increased in size and was accompanied by
some fever. His physician advised him to have it opened. This
was done, and a piece of bone IJ inches long and about the
thickness of the little finger was found loose in the abscess
cavity. Upon exploring the cavity with the finger it was dis-
covered that a portion of the pubic arch was not intact. The
piece of bone removed was evidently a portion of the descend-
ing ramus of the pubis aud ramus of the ischium that was
fractured at the time he slipped on the street. He did not fall
at that time and no violence was encountered. The fracture
was entirely due to muscular action (adductor muscles).
Prom the previous history I do not think there was any
pathologic change of the bone in that region.
This is a very rare form of fracture, and in looking over the
literature on the subject I find but one similar case reported,
that by Cappellitti (Ranking's Abstract, 1848), which terminated
in about the same manner. »
An Antivivlsection Drama. — It Is proposed to form a
touring company and present " The Vivisector." a play written
three years ago by Dr. E. A. Lutze, of Berlin, in the larger
towns of America. The play was presented in Hamburg and
Berlin in 1899 and caused great enthusiasm among tlie people.
It is in three acts and is designed " to catch the conscience of
the public " in respect to the " unnecessary suffering that
science imposes upon dumb animals."
July 19, 1902]
COMPOSITION OF THE TUBEECLE BACILLI
(Amkricam Medicxnv 93
ORIGINAL ARTICLES
THE COMPOSITION OF THE TUBERCLE BACILLI
DERIVED FROM VARIOUS ANIMALS.*
BY
E. A. DE SCHWEINITZ, Ph.D., M.D.,
AND
M. DORSET, M.D.,
of Washington, D. C.
Biochcmic Laboratory, Bureau of Animal Industry, Department of
Agriculture.
The preliminary work of Hammerschlag ' upon the
substances contained in the bodies of the tubercle bacilli
which could be extracted with ether and alcohol, and the
probable compasition of the extracts so obtained, fur-
nished considerable material for speculation. Nothing
further was done in this line, however, until the writers,
de Schweinitz and Dorset,^ reported investigations which
they had made confirming the work of Hammerschlag
and indicating the presence of a large percentage of ether
and alcohol soluble material in the tubercle bacilli. We
also found in these extracts volatile fatty acids and other
acids, attempts to determine the character of which, how-
ever, were made only by the melting points. We called
attention to the large percentage of phosphoric acid pres-
ent in the a-sh of the tubercle bacilli and to the fact that
this was the only acid found. This indicated that there
was probably a large percentage of lecithin or nucleo-
proteids in the germ cells. The presence of the former
substance had been noted previously by Hammerschlag.
We also called attention to the fact that the peculiar
staining proi)erti'es of the tubercle bacilli were probably
due to the large amount of fatty material which they
contain. Klebs' found considerable fatty material in
the tubercle bacilli. Weyl * reported that the fatty ex-
trtu't from the tubercle bacilli was just as tenacious in
holding the anilin dyes a.s Wius the tubercile bacillus itself.
Iluppel ° claims to have isolated three sorts of fatty sub-
stances. Aronson,* several years after de Schweinitz
and Dorset had published the work referred to, reported
the chemic examination of the tubercle bacilli which he
had matle. He failed to note the work done by the
authors referretl U), several years before. In his article
he claims that a very large amount of extractive mate-
rial is free fatty acid, which point, however, is not thor-
oughly conftrmetl by our own work. Levene' records
the results he obtained by extracting tubercle bacilli
with ether and ahiohol.
The writers of this article have extended their studies
in the examination of the composition of the tubercle
biu;illi to the following: 1. An attenuated biwillus of
human origin obtained originally through the courtesy of
Dr. ]•'-. Ij. Trudeau, which had been derived from a man
and passed through a guineapig. This had been grown
upon artificial media for about 160 generations. Although
originally virulent for small animals it had entirely lost
its [)athogenic properti(!s for guineapigs. 2. A virulent
ba<illus of human origin obtained also from man, which
had subse(iuently bfsen grown for .50 generations upon
artificial mwlia. This germ still retains itw virulence
and will cjiuse the death of guineapigs in five to six
wei'ks after subcutaneous injection of a small amount.
.'5. A virulent bovine bacillus obtained originally from
Dr. Theobald Smith, which was .still virulent for small
animals its well as for cattle. 4. A virulent swine biu-il-
lus, obtiiinc<l also through the kindness of Dr. Theobald
Smith, virulent for small animals. ">. A tuberculosis
geriri from the horse, obtained from Dr. liavenel, of
Philadelphia, and regarded by him as originally f,
l)()vine origin as the conditions indicatwl that the hc/se
had contnuted the diseitse from cattle; and, (J. An ^ian
• PiibllHhi'd tlin>UKh the courtesy of Dr. D. E. Balmoo^
Bureau of Animal Industry.
germ, the original culture of which was also obtained
from Dr. Ravenel. The bovine, swine, horse and avian
germs had also been grown upon artificial media for sev-
eral years, without passing them through an animal. In
order to obtain a quantity of material sufiiciently large
to permit of the chemic analyses recorded below, it was
necessary to grow these various germs in quantity, and
in order to made the analyses comparative, a uniform
medium was used. Its preparation and composition
can be seen from the following record, taken from the
laboratory books in which notes are made, of each lot of
culture media prepared : C?hopped meat one part, dis-
tilled water, two parts, heated at 45° to 60° C. for three
hours, strained, boiled, filtered, Ifo peptone and J fo acid
potassium phosphate added. Neutralized with sodium
hydrate; boiled one hour, 7^ glycerin addwl, filtered;
acidity = about 10 cc. N/10 sodium hydrate re<iuire<l to
neutralize 100 cc. beef broth, phenophthalein being used
as an indicator. It will be notetl that this medium dif-
fers from the ordinary broth used for the tubercle bacil-
lus by the substitution of acid potassium phosphate for
sodium chlorid, and further that the medium is left
with an acid reaction.
In Bulletin No. 13 of the Bureau of Animal Industry,
1896, the writers reportetl a study of the growth of the
tuberculosis bsicillus upon acid media, and ciilled atten-
tion to the fact that the iK'id reaction of the media
appears to be advantageous for the development of the
tuberculosis germ. Subsequently it was noticed that the
addition of acid phosphati' of potassium and the omis-
sion of sodium chlorid gave a liquid upon which the
germs would develo[) very much more rapidly than
upon the ordinary medium containing sotlium chlorid.
This substitution of acid i)otassium phosphate was natur-
ally suggested by the study of the composition of the
ash of tifie tubercle bacilli already referred to and pub-
lished in 1898. In fact, for a number of y«irs tubercu-
losis cultures of various sorts grown in this lalwratory
have been made upon media containing the phosphate.
The results have been eminently satisfactory not only in
securing a rai)idity of growth, but also apparently in
keeping up the virulence of the germs. This is a point
of considerable i)ractical importance to which attention
has not been i)reviousIy ailknl.
The cultures of the several tubercle bacilli made upon
the medium above descrilx-d were fn)m two to four
months old, and hatl l)een grown at a temi)erature of
from 37° to 38° C. The cultures of the different germs
were poured into jterfwtly clean, sterile flasks and heated
for a few minutes to the boiling i>oint. The Imcilli were
then allowe<l to settle and first washwl by decantation
(with hot water), then transferrtnl to a foldwl filter and
washe<l again with hot water so long as a reaction for
l)hosphates was noted when the flltrat^^ was test«'d with
silver nitrate. This same process was luloptetl also for
all the different cultures, the great<>st can' lH>ing used to
avoid contamination with any fon-ign nuitter. The
moist g(!rins were carefully reinove<l by means of a
spatula from the filt4'r paper, and dritnl over sulfuric
acid. They were then i)ow(lered into bits about the
size of very small bird shot and dried to a constant
weight at 60° C in an oven with a vacuum of 26 inches.
These drie<l Imcilli served us the starting iH)int for the
extnu'tions. They w«Te extracted first with hot ether,
then with hot alcohol and then with hot chloroform,
Knorr's extraction apparatus iK'ing uwhI. In <wh case
the extraction was continue*! so long as any material was
dissolved out, and the extract<>d sulwtanci- was agiun
dried to a constant weight In-fore proce«'ding to use the
next solvent. The time (HTUpiinl in this o|K'ration with
the different solvent! was from four to five flays each.
The (|uantity of nmterial extracte<l was <let<Tinine<l by
U>ss of weight, the germs ustnl lu'lng first welghe<l in the
tulK! and again aft(>r the diff"erent «'xtractions had U-en
coniplet«'d. The error ri-sulting from nuini|)ulatioii,
therefore, was the minimum. The following, Table I,
94 AMEBiCAN mkj>ici««i COMPOSITION OF THE TUBERCLE BACILLI
[July UI, 1902
sliovvH the results of duplicate determinations of the
ether, alcohol and chloroform extracts of the six differ-
eiil ^ii'iiis used :
Tablb I.— Ether, Alcohol and Chlobofoem Extracts of Tcberclk Bacilli.
the same way with approximately the same amount of
water, it is fair to presume that the percentage of ash
represents approximately, if not absolutely, the ash
Bovine Bacilli.
Bwlne Bacilli.
Horse Bacilli.
Avian Bacilli.
Attenuated
Human Bacilli.
Virulent
Human Bsicilll.
1
2
Aver.
1 1 2
Aver
1
22.00
8.18
0.2il
2
Aver.
1 1 2
Aver.
1
2
Aver.
1
2 Aver.
n.n
s.ia
0.4!)
«.i;t
O.ill
li%9
11.48
7.8.'!
0.20
12..%
7.8S
0.20
2:1.'«7
8.1S
0.12
2:<'JW
8.18
0.20
17.40 17.32
13.1.5 13..39
0.04^
17.3U
13.27
0.02
28.8«
7.22
l.:«
28..->9
7.49
(l.:«
28.72
7.36
1..S3
20;4O
7.21
0 48
20.'22
7.2:{
(0 48)
20.31
Alcoliol extmct
Cliloroforin extmct
7 22
0.48
2(i.2H , 2(>.:i2
lil.lfi
20.r,9
31 .S7
:i2.17
31.76
;«.59 :W.71
JSO.fti
37 41
37.41
:i7.4l
2S.09
27.93
28.03
It will be noted that by far the highest percentage of
ether extract Is obtiiined from the attenuated human
bacilli, and from the others in the following order :
Horse bacilli, virulent human bacilli, bovine bacilli,
avian bacilli and swine bacilli. The percentage of ether
extract obtained from the avian and bovine germs are
very near each other. When we consider the alcohol
extract the order is different. The highest percentage of
alcohol extract is found in the avian bacilli, and the
others in the following order: Horse, bovine, swine
and human bacilli, there being but little difference
between the quantity of alcohol extract in the two varie-
ties of human bacilli. The chloroform extract was
hardly worth consideration, except in the case of the
attenuated human bacilli and in the case of the virulent
human bacilli and the bovine bacilli. In tlio.se latter
the percentage of chloroform extract appeared to be
about the same. In the consideration of the totals of
these various extracts we find the following order : The
highest percentage in the attenuated human, the horse,
avian, virulent human, bovine and swine, following in
the order named, as can be .seen in Table I. This high
percentage of total extractive matter agrees fairly well
with the percentage noted in our original work upon
the human bacilli already referred to, reported in
1895.
In a recent article Kresling * reviews the work of the
various authors upon the examination of the tubercle
bacilli of human origin. He varied the order of the
solvents used but found that the total extractive material
was in all cases approximately the .same. The bacilli
which he used had been collected during a number of
years, from 1893 to 1897, and the medium upon which it
was cultivated was the ordinary glycerin beef broth con-
taining salt and peptone, the medium having when
inoculated an acid reaction of not over j\ cc. of N/10
NaOH to 100 cc. of the bouillon. This is a smaller
amount of acid than that present in our tuberculosis
culture media.
Following our earlier work we have also had ash
determinations made of the various germs that were
used for extraction and the determination of the phos-
phoric acid present in the ash. These analyses were
Table II.— Ash and Phosphorus in Tuberclj: Bacilli.
(Determinations made Ijy J. A. Emery.)
Moisture.
Ash.
I'»0-, in Dry
"Bacilli.
PsOjin
Ash.
1
2
1
2
1
2
1
2
Bovine bacilli
Swine bacilli
2.42
2.28
227
2.06
2.66
2.,37
3.63
3.96
2.44
394
2.67
2.31
3..5.5
3.94
2.31
3.92
i.i6
i.m
2.07
2.22
1.79
2.50
:*
1.55
1.31
2.02
2.19
1.71
238
55.00
,55.88
55.98
73.49
63 47
58.04
56.48
55 40
■55 63
74..S8
60.90
Horse bacilli
Aviiin bacilli
240
2.67
3.91
Human bac. (atlpn.)
Human bac. (vlrul.)
2..W
3.70
kindly made by Mr. James A. Emery, of this labora-
tory. As the material used for these determinations had
all been grown upon the same sort of media, washed in
which would result from a destruction of the organic
matter of the germs. Sulfuric acid and chlorids were
not found present, so that the percentage of phosphoric
acid, while higher in the human bacilli than in the
others, is apparently a constant one.
In our earlier article upon the mineral constituents of
the tubercle bacilli, published in 1898, the percentage of
phosphoric pentoxid was found to be a little over 5,') in
the human germ. As will be noted from Table II, the
percentage of jjhosphoric pentoxid in these human germs
was found to be, in the virulent over 60 J^, in the attenu-
ated over 10 fo. In comparing these figures with the
earlier results it should be remembered that the germs
used for obtaining the earlier data were grown upon the
ordinary glycerin media to which no phosphates had
been added, while all of the present germs were grown
upon a medium rich in phosphates. The amount of
material available for the phosphoric i^entoxld deter-
minations here reported was also small, so that there
may be some slight error due to manipulation, but
allowing for these facts, it is very evident that all of
these tubercle bacilli are voracious consumers of jihos-
phorlc oxid, in which property they correspond to a
great many other plants. Levene" reports an analysis
of human tubercle bacilli grown upon the ordinary beef
broth and mannite synthetic media. In these he found a
considerable variation, both in the percentage of ex-
tractive material and in the percentage of ash obtained
from the germs. His percentage of ash was in all
instances higher than that which the writers of this
article reported in 1895. In that work we used cul-
tures grown on beef broth and also on our synthetic
medium.'"
Aronson's assumption that the extractive matter of the
tubercle bacilli was very largely fatty acids, a conclusion
which does not follow from the methods that he hiis
reported in his article, led us to make some preliminary
determinations of the possible free acid present in our
various extracts. Kresling concluded that the chloro-
form extract of the human tubercle bacilli contains about
14^ of free fatty acid. Our determinations of the pos-
sible free fatty acid were based upon the acid value as
secured by titration with N/10 sodium hydrate. The
results are recorded in Table III.
The acid value was determined both in the ether and
alcoholic extracts separately. The total acid value which
can be noted in Table III .shows that the highest acid
value was obtained from the virulent human and the
others in the following order : Swine, attenuated human
and avian, bovine and horse. In the last column are
given the total percentsiges of the free acids in the
whole germ counted as oleic acid. The acids were all
calculated as oleic for the purpose of making a satisfac-
tory basis for comparison.
Until we have completed the determinations of the
exact character of the ether, alcohol and chloroform
extracts obtained from these various bacilli, which are in
progress at present, much speculation in regard to the
relation of the composition of the germ to its character
and virulence is not warranted. It is interesting to note
JUI.Y l!l, 1902]
SURRA" OR NAGANA
tAMKRICAK MESICISE 95
that the percentage of alcohol extract obtained from the
avian bacilli i.s very much greater than that obtained
from any of the other germs, while the percentage of
ativeofeachof the different bacilli, yet the results in
the human germs correspond so closely with those
obtamed in 1895 and also those reported by other work-
Table m.-Acip Value of Ether and Alcohol Extracts of Tubercle Bacilli.
IJovino bacilli
Swine i>acilll
Horse bacilli
Avian Ijacilli
Human bacilli (attenuated'
Human bacilli (virulent)
Acid Value.
Ether
Extract.
0.13
8.02
la.oo
12.77
11.02
Alcohol
E.\ tract.
20.10
23.4.5
18.47
13.11
14.57
Ki.lo
Total Acid
Value, Calcu-
lated on the
Sum of the
Ether and Al-
cohol Ext.
12.90
13.W
11.46
13.04
13.13
14.(>J
Free Acids In Alcohol
and Ether Extracts.
Ether
Extract.
4.74
4 0:i
4.70
«.41
7.04
Alcohol
Extract.
10.2.5
11.78
9.28
B..5JI
7.32
8.26
Percentage of Free Acids Calculated
Free Acids i for Whole Substances.
Calculated on '
the Ether and
Alcohol Ext. I Ether Alcohol
Combined. Extract. Extract.
6.48
7.02
.5.76
6..5.5
6.60
7.3.5
i
0.83
046
109
l.l.S
l.*l
1.42
0.83
0.i»2
0.7.5
0.87
0..53
0.50
The free acids were calculated from the acid value and were considered as oleic acid.
Total Per-
centage Frt^e
Acids in
Bacilli.
l.Sl
2.00
2.;«7
2.01
ciiloroform extract in the bovine bacilli and virulent
human bacilli is almost exactly the same, there being
but little chloroform extract obtained from the horse,
swine and avian germs, while a considerably larger
amount is secured from the attenuated human germ.
The variation in the amount of ether extract is also
noticeable, the human attenuated germ showing again a
very much greater percentage. The results certainly
indicate that as there is a variation in the morphology
of tubercle bacilli derived from different sources,
depending upon their surroundings, so there is a
variation in the composition of the body of the
germs themselves. They show, further, a point which
should be especially emphasized, that there is a greater
difference between the two human germs, the one
attenuated, nonpathogenic for guineapigs, the other
almost as pathogenic for guineapigs a.s the bovine germ,
than there is between the virulent human and the bovine
and hor.se bacilli. It is certainly not an unwarranted
assumption that po.ssibly this loss of virulence in the
human germ is tlue to the fact that the germ ha.s acquired
through its prolonged saprophytic exi.stence and its
conseiiuent immunity from the attacks of phagocytes
and other protective sub.stances in the animal body, the
property of producing smaller amounts of poisonous
substances, while in the ca.se of the virulent germ, the
bovine, hor.se and swine germs, which do not produce
nearly so large an amount of harmless fatty substances,
and con,se(i uently contain a lower percentage of extractive
matter, the relative amount of poi.sonous proteid pro-
duced is greater. That this i)roteid matter, belonging to
the cla-ss of nudeoproteids, as was already jjointed out
by ourselves in 189;") in the article before referred to, is
one of the principal poisons of the tubercle bacilli, has
been well demon.strated ; and if the bacilli are able to
produce larger amounts of thi>s(! poisonous substances, it
would neces.siirily follow that they are much mon^
virulent. A further .study of
is in i)rogress, as well as the
free fatty acids, fats, waxes and
rial.
It must be remembered, of course, that all of the
germs used for these analyses were washed with hot
water and all water soluble material had been extracted
befor<( the analyses were made. As pointed out by the
writers in ]8!)7," there is present in the cultures of the
human bacilli a very virulent acid-like necrotic sub-
st^mce readily .soluble in water. This sub.stanct% as
well its those of a similar nature, were nt!ces,Hiirily
•extracted in the prejjaration of the germs for analyses,
and hence do not come into considcnilioii in this re-
port.
Our results here rt^corded indl(".it<' the relationshl})
between the tubercle bacilli derived from various sources
and emi)hasize the difference betww^n attenuated and
virulent human tubercle bacilli. It must be rcmeml)ered
that these analyses were maile only upon one represent-
this proteid substance
identification of the
other extractive mate-
ers, that we can assume a like composition for the bacilli
obtained from similar sources.
biblioouapuy.
> Hammerschlag, Centralbl. f. kllnische Med., Vol. xli, iip 9-18.
= De .Schwelnitz and Dorset, .Jour. Amer. Chom. .Soc., Aug., 189.5 •
Centralbl. f. Bakt. a. Pai-aslt., l!>96, Nos. 18, 19 : Jour. Amer. Uhera. Soc..
Aug., 1898. '
3 Klebs, Centralbl. t. Bakt. u Parasit., 1 Abt., Bd. xx, p. 488.
* Weyl, Dcut.schc med. Wocbenschr., 1891. No. 7.
' Ruppel, Zcit-schr. f. Pby.slolog. Chemie, lid. x vvi. |> 218.
» Aronson, Berl. kllnische Wocbenschr., 18ft'.i. p. I<l
' Levene, Journ of Med. Research, July, 11)01.
« Kresling, Centralbl. f. Bakt. u. Parasit., Bd. .-i.vx, lice. 28, lUOl.
9 l,evene, Journ. of Med Research, July, 1901.
'" DeScbweinltz, Med. News, December, 1894.
" De Schweinitz and Dorset, Centralbl. f. Bakt. u. I'araslt., 1897.
Abt. 1, Bd. xxli, p. 209.
I, " SURRA " OR NAGANA.'
A Report of an Acute, Fatal, Epidemic Disease Affecting
Horses and Other Animals ; with Studies on
the Mode of Transmission, etc.
BY
JOSKPH J. CUHUY, M.D.,
Captain and Assistant Surgeon, U. H. Volunl»vrs; MemlH»r of the
Board of Medical Olllccrs appointed lo inve8t]j;..ilf I lii..
Diseases of the Philippine Islands.
[From the Army Pathologic tjiboratory, Manila, 1". l.|
Introductorii Note. — I am unable at i)resciit to ildcr-
niine which of the above names, "surra" or "iiagana"
is the j)roper one to apjily to the disea.se here dcscriluKl.
Probably l)oth terms are correct — that the surra of India
and the nagana of Africa are one and the same disease.
I have been able to obtiun but very little literature on
this subject in Manila, but from the snndl amount I
have read, it appears that if nagana and surra are not
identical, they certainly are very similar.
Hurra is descrilH^l (Ojiie) as a di.sea.se of horstw, mules
and ciunels, ocxnirring in India and liurmah, and i-au.siKl
liy a blood parasite (discovt^red by Evans) TnjiHmimtma
ErMnm. This parasite resembles closely the trypanosoma
of rats.
I'vvans, of the l".M;;"lisli service, ili.seovereil thi.s try-
panosoma in 1880 in Intlia and ISurinah in the blocnl of
animals ill with a disease the? natives aUk-d " surra,"
which means "rotten." The disease in India is com-
monly supposwl to Ix' obtained through infecte<l pastures
and infcrted footl.
In the ex|K'riiiieiit^ 111 Ia;iii- and others the ili^easo
surra was tninsmitted to healthy aninuils by subcuta-
neous and intravenous injiH-tions of the hhxMl of infectetl
animals. Horses fe<l on fr»>shly-dnvwn surni blo<Kl al.so
succnimhed to the dis("a.se. These observers, however,
were unable to produce Wiv disea.s(^ in liealthy aninuils
with blow! which had be«'n drawn from infecteil animals
24 hours i»revious, either by injtrtion or feeding.
Nagana, or tsetse-fly cliwaHt^ atTet-t.s liorm*), asses,
cattle, dogs, eats, and other animals. Nagana occurs in
• A report to the 8u ntcon-c in
the Army McdlcAl L.v. "m. Me
I'liil of the Army.
i!:l. I'. 1.
Paper road (wforo
96 Ahebioan MeuiciNK]
SURRA." OR NAG AN A
IJULY 19, 1902
Africa, where it has been studied very carefully by
Bruce, of the English army wervice. Kaiithack and
K(K'h hav(! recently studiwl the same disease in Africa.
Koch thinks surra and naganaare identical, while Kant-
hack, who confirmed the observation of Bruce on
nagana, thinks the availal)le evidence insufficient on
which to bast! such a statement.
The symptoms described (Opie) in nagana are fever,
8ul)cutiineous edema and emaciation, with moderate
an(!mirt. It runs its course in from a few days to several
months, and Is usually fatal.
Bruce's experiments have shown that under ordinary
conditions the disease (nagana) is transmitted by the bite
of a blood-sucking insect, the tsetse fly, Olossina monsi-
fanx (Westwood).
The disease may be transferred from an infected
animal to a healthy one by subcutaneous inoculation of
the infected blood. Bruce found constantly in the
blood of animals ill with nagana an organism possessing
an undulating membrane and a flagellum. This parasite
is very similar, if not identical, to the parasite of surra,
Tri/paiiosoma I'Jvansi. According to Bruce's observations
the parasite apparently does not undergo development
in the body of the insect, the tsetse fly ; but obtained
from an infected animal, it is transferred to the healthy
animal which is subsequently bitten. The fly acts as a
carrier, not as an intermediate host, as in the case with
malarial i)arasites and the anopheles.
Surra has been very fatal among the English cavalry
horses in India in recent years, at times destroying 50^
of these animals.
Nagana prevails throughout Central Africa, also in
South Africa, in Zululand and German East Africa.
The disease is confined to low-lying moist regions along
rivers and near the coast. It is very fatal to horses and
cattle.
Ilktory of the Investigations on Surra in the Philip-
pines.— As Smith has used the term surra, and as I have
also used the same in a report on the occurrence of
this disease in caribao, I will continue to call the disease
surra in this pai>er, using the term provisionally.
From the literature at hand there appear on the sur-
face some minor differences between this disease, as
studied in Manila and vicinity, and both surra and
nagana. These are probably only apparent differences,
and no doubt if access could be had to the complete
reports, experimental and otherwise, there would be no
essential differences between the disease prevailing in
the Philippines and surra (also, probably nagana).
On October 17, 1901, Captain Allen M. Smith, a.ssistant
surgeon U. S. Army, and J. J. Kinyoun, surgeon,
U. S. Marine-Hospital Service, published a preliminary
note on "A Parasitic disease of Horses." In this
paper. Smith and Kinyoun described the parasite found
in the blood of American horses and mules ill with an
unknown disease. They also described very accurately
the clinical symptoms. Accompanying this report were
excellent photomicrographs of the parasite which, at
that time. Smith and Kinyoun were unable to identify.
In a later rei)ort, December 7, 1901, published from the
Army Pathologic Laboratory, Captain Smith identified
the parasite as Trypanosoma IJvansi, and the disease as
surra. In this latter report. Smith describes the disease
further, and showed that it could be communicated from
one animal to another by subcutaneous inoculation of
healthy animals with blood from infected animals.
Smith called attention to the fact that this disease was
quite generally diagnosed as glanders by veterinarians
and others. He also made recommendations that ani-
mals ill with surra be isolated from healthy animals at
least half a mile. Smith found the parasite in American
horses and mules and native ponies, and produced the
disease in a healthy monkey by subcutaneous inoculation
of surra blood.
I will refer later to Smith's work on this disease,
especially his work go treatment. ...
I reported for duty in this division October 26, 1901, and
was assigned to the Army Pathologic Laboratory, Manila,
P. I., as a member of the board of medical officers
appointed to study the diseases of the Philippine Islands.
I assisted Captain Smith in his work, which for the time
was directt^tl toward the separation of animals ill with
surra and the treatment of the disease. So many ani-
mals were dying of this disease that it became a very
serious problem, so our first efforts were directed, after
identifying the disease, toward treatment, with a view
of saving some of the sick. In four months the (juarter-
miister's department had lost at the Manila and Pasay
corrals alone some 300 horses and mules. (Treatment
and its results will be described later.)
Etiology. — The parasite of this disease occurs in the
blood of afffected animals in varying numbers, cor-
Typanosomes of Surra, Horse's blood, mg. 1,000.
by Capt. Smith, U. S. A.
Pbotoniicrograph
responding generally to the degree of fever. When the
temperature of the animal is high the parasites occur in
great numbers, and when the temperature drops to nor-
mal or nearly normal there are very few parasites to be
found in the peripheral circulation. Sometimes the
parasites disappear altogether from the peripheral blood
for several days, reappearing with a rise in temperature
and exacerbation of symptoms.
The parasite belongs to the protozoan division of the
animal kingdom, class of Mastigophora and family of
Trypanosomata. It is an organism about three or "four
times as long as the diameter of a red blood-cell, possess-
ing an undulatory membrane, and having a single, slen-
der flagellum which is approximately one-half the length
of the whole parasite. The body occupies one-half or
more of the total length, and in width varies from \ to
J the diameter of the red cell. In the body of the para-
site there is frequently seen several refractive granules
which move from end to end of the body. The motion
of the parasite is complex ; it has a boring, wriggling
motion combined with a contractile, vermicular motion.
It moves with great rapidity and markedly agitates the
blood-cells in its vicinity. Its flagellum frequently
July 19, 1902J
"StJRRA" OR NAGANA
[Ajcerican Medicinb 97
becomes entangled in a red cell, either by envelop-
ing it in a loop or by piercing the cell. Frequently
under the microscope the red cells may be seen
undergoing fragmentation in the grasp of the parasite
during this violent agitation. The destruction of the
red cells is great and produces quickly a grave anemia.
This trypanosoma, which is apparently identical with
the parasite of surra ( Trypanosoma Evansi), closely resem-
bles the description of the trypanosoma of rats.
The parasites are found in all serous effusions, and
freiiuently in the aqueous humor of the eye as well as in
the blood of the animal. It has not been noted in the
urine which we have examined of affected animals.
The parasite is readily recognized in fresh blood films
with the yj in. dry lens. The first thing that attracts the
eye in looking for the parasite is the agitation among
the retl cells here and there in the field. On closer
examination and i)roper focusing we see this actively
wriggling parasite.
it must be borne in mind that the parasite disappears
completely oftentimes from the peripheral circulation
when the temperature goes down, therefore several
examinations may be necessary before the parasite is
obtained. The favorable time to examine for the para-
site is when the animal's temperature is rising; and
when it is in the vicinity of 103° to 105° F. the parasite
is usually readily found. Sometimes as many as 20 to 30
or more may occur in one microscopic field (with J in.
objective).
The parasite can be easily stainetl in dried blood
films, and in this manner preservetl for further study and
reference.
Skdning Methods. — The dried blood-films are fixed in
one of the various ways described by Cabot and others, —
by heat, by immersion in etjual parts of absolute alco-
hol and ether for a few moments, or by immersion for
one minute in a 1^ formalin solution in 95;^ alcohol.
The specimen can then 1x3 stained lightly by carbol-
fuehsin, or by a method which is a modiflcsition of
Thay(!r's method of staining the malarial parasites.
It is as follows: The drietl blood-film is fixed by one
of the above described methods, then stained (1) for
two to five minutes with a .5^ solution of eosin in 70^
alcohol ; (2) the specimen is then washed \n & \fo solu-
tion acetic acid for one minute (this brings out the
eosin stain sharply and seems to set it, preventing the
counter-stiun from "striking in ") ; (3) the specimen is
then stained from one-half to one minute and a half by
carbol thionin, or by Lottler's alkaline methylene-blue ;
(4) wash off excess of stain with water; (5) dry thor-
ouglily with filter paper and mount in Canada balsam.
By this m(!thod the parasite is stained a deep blue,
while th(^ red cells are a bright eosin color. This makes
an excellent differential stain for trypanosomas as well
as the malarial parasit<?s.
Pdtholoyic Anatomy. — A marked anemia is noticetl
early in the affecttnl animals. This anemia is pernicious
in chanu-ter ; no treatment seems to give any improve-
ment. It is progressive, the red cells falling fre(iuently
to one-third or one-fourth of the normal number per
cubic mm. just before death. Postmortem examination
shows marked anemia of all organs, and gen(^ral subserous
(Hlema; sulx-utjineous etlema Involving especially the
belly, sheath and legs; generally there is moderate
general glandular enlargement, and frequently broncho-
pneumonia and bronchitis. In these latt<'r ca.stis there is
often a profuse, mucopurulent nasal discharge, and lu-com-
panyiiig this, fret|uently a marked glandular enlarge-
ment, involving often the submaxillary glands. Kuch
cases have been very fre<|uently mistaken for glanders.
Symptoms. — As noted by .Smith in his report, the
symj)t<)ins are : Fever of a relapsing or remitt<!nt cliar-
act<'r; swellings about the sheath, abdomen and legs;
marked anemia of the mucflus membranes and fre(iuently
enlargement of the submaxillary and sublingual glands.
Tlu^ later Mymi)toms are weakness of the extremities, a
staggering gait, and very fretjuently bronchopneumonia
and bronchitis with a mucopurulent nasal discharge.
The disease lasts from 3 to 12 weeks, or even longer.
The usual duration is from 3 to 6 weeks, though death
may take place before 3 weeks, or the animal may live 3
or 4 months or more.
Diagnosis. — The diagnosis is based on the finding of
trypanosomas in the blood of the affectetl animal. The
technic has been described under etiology. .Surra has
been generally diagnosetl all over the islands as glanders.
To the casual observer there is some similarity between
surra complicjited with bronchitis or bronchopneumonia,
with nasal discharge, and glanders, but even in such
cases there should not be any difficulty in differentiation
by the other typical symptoms of surra (aside from
blood examination), /. e., the etlema of abdomen, sheath,
etc.
I do not know whether the two diseases, glanders
and surra, exist together. During two months, November
and December, out of several hundred animals examined
in the quartermaster's veterinary hospitals in Manila and
at Pasay, and in private stables, I have seen only five
cases of glanders. Some of these animals were in stalls
not far removed from surra-infected animals, but in none
of these «tses were trypanosomas found.
Mortality. — All the animals I observed, whose, blootl
showed the surra parasite, died. The veterinarian at
the (juartermaster's department veterinary hospital,
Malacan road, informs me that he knows of two or
three cases which showed the typical symptoms of
surra in American horses which recovered. The disease,
however, is almost invariably fatal. I am unable to
give accurate figures as to the number of animals
destroyed by this disease, which in certain places has
been a veritable plague. Among the ([uartermasler's
department horses and mules antl cavalry horses, con-
siderably over 2,000 animals have died during the past
six months, from .luly 1 to December 31, 1901, the
largest percentage from surra. In the provinces of the
(iunarines and Albay tlw loss among native ponies has
been very severe. Some pueblos in these provinces are
now practically without horses or caribao. Thoustuids
of ponies have died in this section of the island alone.
(Jaribao and other cattle, too, have died in great nundwrs
in these same districts during the past ywir from
rinderpest.
In view of my discovery that caribao are affecte<l by
surra in the same manner as hors«>s and mules, it may
be that many cattle in these districts died of surra
instead of rinderpest. 1 have seen caribao die in a litth^
over two wcH'ks after showing th<> first symptoms of surra.
Oeograpbir Di.itribution. — .Surra i>revails all over
Southern Luzon, in Northern Luzon, in Samar, Panay,
and in other of the southern islands. In other words,
the disease is widespresid throughout the archiiiclago.
In the Camarines and Albay, in iNIanila and vicinity, In
the Laguna district and in the Island of Panay the dis-
ease has been very fatal.
(Mgin of Infeflion. — We do not know from whence
surra came into these islands, nor the time and i)lace of
its first appeamnce. The diseast; had, up to the time
Captain .Surgeon Smith, U. S. Army, and Surgeon Kin-
youn, M.H.S., rwognized the diseas*', bet-n diagnose*!
generally as glanders. Captain Smith and Mi\)or Potts,
of the inspector's de|mrtment, are at presi'nt investi-
gating this disease. They will i)r()lmbly l)e able to
throw some light on the origin of this epidemic of surra
after returning from their tour of the islands.
Prophylaxis. — Prophylactic measures consist of (I) pro-
tecting healthy animals fn)m infection by the isolation
of the infected animals ; (2) by the prot<>ction of the dis-
eased animals from the biting, blood-sucking liors*'-
flies ; (3) by protivtlng the heailthy animals from the
flies; (3) 1)
biting fly ;
(4) by measures in the stables dir(X't<><l
toward tlu' di'struction and ke<^ping out of these flies.
In the first place, all surra-infiH-ted iiiiiiimls should bo
98 Amekican Mkdicink)
'SUERA" OR NAGANA
LJtJLY 19, 1902
isolated at least one-half mile from healthy animals.
These animals should be kept in well-screentid stables to
prevent flies from coming in, biting the diseased ani-
mals, and carrying out the infection.
It must be remembered that every surra-infected
animal can infect thousands of flies, and each fly is, for
a time, a source of danger to healthy animals ; therefore
it is of the greatest importance to protect the infected, as
well as the healthy, animals from flies. Frequent white-
washing of stables, and scrupulous care in keeping
stables clean and dry, prevent the multiplication of
flies.
Whether infection comes through food as well as by
flies we do not know. In India the theory of infection
by food and drink has been held for years. As a pre-
cautionary measure it is better, therefore, to feed animals
only on regular dried fodder, and avoid pasturing them
in socalled infected pastures.
Treatment.— Y&nous treatments have been tried in
the quartermaster's department veterinary hospitals.
The results have been very disappointing. Subcuta-
neous and intravenous injections of quinin have been
used ; methylene-blue and salt solution intravenously ;
arsenic subcutaneously and by the mouth, and various
tonics contiiining iron, cinchona, et(^ The animals died
with the same regularity in spite of the treatment.
The English in India have had the same experience
in treatment.
Quinin subcutaneously in large doses, and tonic of
arsenic and iron by the mouth, however, seemed to benefit
some of them.
Experiinentat Work. — In December, Colonel Humph-
reys, chief quartermaster of the division, placed the
services of two quartermaster's department veteri-
narians under my direction, and gave me a small store-
house building at the Veterinary Hospital pony corral
for an experimental station. Since then we have been
conducting experimental work on the "mode of infec-
tion of surra." The work had hardly begun when I
found that the blood-sucking stable-fly, found commonly
about all animals in this vicinity, carried trypanosomes
not only in its alimentary canal but in its proboscis. I
found trypanosomes in liundreds of flies caught on the
backs of infected horses, mules and caribao. I also
found the trypanosomes in the proboscides of the flies.
I have not been able to astablish the identity of this
fly further than that it is a biting, blood-sucking horse-fly.
It apparently is not the tsetse fly, but resembles it and
probably belongs to the same family. The tsetse fly, as
stated in the beginning of this paper, has been shown by
Bruce and others in Africa to be the carrying agent of the
trypanosomas of nagana, a disease similar to if not iden-
tical with surra.
I have satisfied myself that this biting fly we have
found on infected animals carries the parasite from sick,
and inoculates healthy animals. I believe that this fly
acts, as does the tsetse fly in Africa, as the carrier of the
parasite. It does not seem to act as an intermediate
host.
At the time I started work at the experimental
station the disease surra had been reported by Smith as
occurring in American horses, mules, native ponies and
monkeys. During the course of my investigations I
found the disease in two caribao at the pony corral and
in one caribao in a private stable in Manila. This is the
first time the disease has been reported in caribao. It
was not suspected that these animals were susceptible,
and it was only accidentally discovered during some
routine blood work I was doing to familiarize myself
with the blood of various animals.
We induced tlie disease in dogs, cats and rats by sub-
cutaneous inoculation of small amounts of surra blood.
I have a number of other animals, including a pig and
goat, which we have just inoculated and are now await-
ing results. The disease runs the same fatal course in
caribao, dogs, cats, rats and monkeys as it does in horses
and mules. The same biting fly attacks all these ani-
mals, so any and all may be a source of infection to
other animals. I have noticed some differences in try-
panosomes in difl'erent animals. These changes consist,
roughly speaking, of diflerences in size and motility and
in the number of granules contained in the bodies of the
parasite.
A large number of dried blood specimens from
various animals have been made for future study.
jVbfe. — Surra does not seem to be communicated to
man under ordinary conditions. I have watched stable
employes (native and Americans) coming in contact
with surra animals, and have made a number of exami-
nations of the blood of these men with negative results.
Experimenting with mixing infected monkey's blood
and human blood, trypanosomes lost their motility after
20 minutes and agglutinated. This would aj)pear to
indicate that human blood is an unfavorable nudium for
trypanosomes of surra. 1 found also that tlu; blood of
the chick, mixed with monkey's blood containing many
parasites, caused a slowing of the motion and the
clumping of the trypanosomes, the action of the chick's
blood on the parasites being very similar to that of
human blood.
It is worthy of note that I had inoculated this
chicken twice during the past two weeks with surra
blood with negative results. The chicken appears to l)e
immune. Reasoning by analogy, it would appear that
man also shares in this immunity from surra.
However, not enough work has been done on which
to base a positive statement. I relate this so that others
may take up this line of study and carry it further. —
That the serum of man and of the chick exercise an
unfavorable efl'ect on the typanosomes is important. It
suggests as a method of treatment well worthy of trial,
the inoculation of the infected animals with the serum of
immune animals.
In conclusion, I respectfully recommend that this
experimental work be continued under the direction of
the Army Pathologic Laboratory, where the work w-as
first begun. I regret that illness, compelling my return
to the United States, renders it impossible for me to con-
tinue the work myself.
I wish gratefully to acknowledge the assistance and
encouragement given to me by the chief surgeon of the
division. Colonel B. F. Pope, Assistant Surgeon-General
U. S. Army, and to express my indebtedneas to the
Surgeon-General of the Army, through whose assistance
and liberality our work has been made possible.
II. On the Dissemination of " Surra " by Means of the Biting
Fly (the Stomoxys Calcitrans), with Recommendations
as to Measures for the Prevention of This Disease :
A Report to the Surgeon-General of the Army.
I have the honor to report that the biting fly, which
I found to act as the carrier of the parasites of " surra,"
is the Stomoxys calcitrans.
During my investigations on surra in the Philip-
pines, from October to January last, I collected numerous
specimens of this fly and found the surra parasites in
the proboscides and stomachs of a large numlier. 1 n my
previous report I was unable to positively identify this
fly and so I sent a number of specimens to Dr. L. O.
Howard, Entomologist of the Department of Agricul-
ture, who informs me that it is the Stomoxys calcitrans,
as I had surmised. No doubt, as Dr. Howard states in
his communication to me, other biting flies as well as
mosquitos are able to carry the parasites of surra, but
my experience shows the Stomoxys calcUrans to be the
ordinary carrier. I examined many mosquitos and
flies caught in stables housing horses, mules and cattle
sick with surra, but found tlie trypanosomes only in the
Stomoxys calcitrans. This fly was present in enormous
numbers in and about Slaniia, particularly during the
rains, in all stables and corrals, both military and pri-
vate. In the streets of Manila I have frecjuently seen
July 19, 1902]
ANKYLOSTOMIASIS IN AN INDIVIDUAL
[Akbkican Ukdicihb 99
caribao literally covered with these vicious, blood-suck-
ing pests, and ou one occasion I found the same fly
attacking a sick dog.
When the i-ains ceased, early in December, the flies
became markedly fewer and less voracious and, at the
same time, the number of cases of surra decreased as the
dry season progressed. It is worthy of note in this con-
nection that an unusually high mortality prevailed in
Manila among native ponies and cattle, as well as
among the government stock, during the past rainy
season. This excessive mortality began with the rains
in .June, rea<;hed its maximum in August and Sep-
tember— the height of the wet season — ^and then gradu-
ally declined.
Exi)erimentally I have produced typical and fatal
surra in monkeys, dogs, cats and rats, by the subcuta-
neous injection of one minini of infected horse's blood ;
and in healthy liorses Captain Smith and I have had
similar results from the intravenous and subcutaneous
injection of from 2 to 5 cc. of freshly drawn infected
blood. Furthermore, I have found the trypanosomes
Ktill acfiee in the proboscides and the stomachs of the
Stoiiioxijs calcitrans 24 hours after they had bitten an
infectetl horse.
Inasmuch as surra prevails especially in the rainy
season, its api)arent absence or slight prevalence during
this dry season should not cause us to suppose that the
disease has disappeared, since with the next rainy
season it will probably reappt^ar and may again become
epidemic. During the dry season our efforts toward
the eradication of this disease can be carried on effec-
tively and with excellent prospects of success. All over
the archipelago, during tiie past rainy season, surra pre-
vailed extensively, causing in many districts an
immense loss among native ponies and cattle. In cer-
tain districts this loss was especially severe, a.sthe people
depend upon transportation for the maintenance of their
rice and tish supply. It destroyed several thousand
army horses and mules, in consequence of which the
transportation of trooi)s and supplies was, in places,
seriously interferwl with.
From an economic as well as a militiiry standpoint
the prevalence of surra is, the>refore, a very important
and serious problem, and it Is of imperative net^essity
that nu^itsures be taken at once {in this dnj aeannu) to
prevent the recurrence of another serious epidemic dur-
incf the (toming rainy season.
Tht! Stonioxi/s ealcitranx lays its eggs in the excrement
of horses and c^ittle, in which its larvas and pupas thrive.
As with the mosquito, the only effective way of combat-
ing th(^ pest is by the destruction of the larvas and pupas ;
and this can be ax'comiilished, according to Howard,
Marlatt and Aaron by treating the manure with lime
or petroleum. Other measures, such as have proven
succc^ssful in Cuba against the t'Htegomi/iu/usciattts, are also
advisable.
Dr. Howard informs me in his letter, of recent date,
that Dr. Stiles, of the Bureau of Animal Industry,
D(4)artment of Agriculture, is at present pre|)aring a
larg(! bulletin f)n surra for the use of arinysurgc^ons and
other investigators in the tropics and he will no doubt
cov(T the ground thoroughly, but I respectfully recom-
mend the following as preliminarij and immediate
measures :
1. The destruction of animal excrement in a// stables
and corrals, both government and i)rivat<'.
2. Carefid and systematic insiM'ction of all domestic
animals befort? the rainy s«!ason begins, and as the
dlsc^asf" bus proved in our experience to be invariably
fatal, the radical extermination of all infwtetl animals.
Dnrham University.— Hir W. K. Cliurch, prosidont of tlie
lloynl Collego of Pliysiniaiis, T<on(1on, and Dr. TlioiimH Annan-
(lalfi, profos.Mor of clinical surgory at Hdliilmrgh; have been
Ifivfin tlio dogroo of D.CL.
ANKYLOSTOMIASIS IN AN INDIVIDUAL PRESENT-
ING ALL OF THE TYPICAL SYMPTOMS OF
PELLAGRA.
BY
H. F. HARRIS, M.D.,
of Atlanta, Ga.
Case.— M. W., aged 29, an unmarried farmer, was first seen
by me on Marcli 8, ]!)0'2. He was iioiu in Appling County, this
State, and has always resided there. His fatlior died between
60 and 70 years of age of what was probably sarcoma, though
concerning this nothing can be said definitely. His mother
died at the age of ft'S of paralysis. He has two brothers and one
sister ; tlie sister and one brotlier liave never been in good
health, but neither of them has ever had any serious malady so
far as is known.
The patient was brought up in rather unusual poverty for
tliis part of tlie country, his father having died when he wa.s
quite young, and since tliat time he lias been forced to labor for
his livelihood. His broad has always been prepared from
Indian corn, and this lias constituted his principal diet since
infancy. The corn from which this bread was made has always
been raised upon the farm upoJi which the patient labored, and
he asserts that so far as he is aware it was never harvested in an
unripe state, but feels sure that it was not always well protecKxl
daring the winter, and that it was probably frequently wet as a
result of the driving rains that are very common in the South
during the fall and winter seasons. He asserts that he was per-
fectly healthy until about 15 years ago, when he began to
observe that in the latter part of the winter and spring he was
never so well as in the summer and fall months. This has
gradually grown more and more marked until within the last
few years his condition at these periods has been extremely
bad. In the fall and early part of the winter he feels strong and
vigorous, and weighs usually about 130 pounds, but last spring
his weight went down to S)8 pounds, and he was during this
period very anemic and extremely weak. The exact time
at which these attacks come on vary somewhat, but they usually
occur between January 15 and February 15, after which he
grows worse and worse until May or .June, and then begins to
improve so that by the end of July or early in August he is
generally well again. He states that bust spring his condition
was worse than ever before.
The first symptoms usually begin in the spring with loss of
appetite, thirst and a feeling of malaise, all of which rapidly
increase until in from six to eight weeks he is entirely unhl for
labor of any kind. At these times ho suffers to an extraordinary
degree from melancholia, and freely asserts that he would
much prefer death than to live on in his diseased condition.
His legs become extremely weak, and he himself calls attention
to the fact that sensation to pain over his whole body, but
especially in the lower extremities, is much below normal. He
complains that all of his food tastes very salty, as the result of
which he takes unusual quantities of water. He frequently has
sudden sensations of heat over the entire body, varying some-
times with a feeling of chilliness; the former is much more
common and pronounced than the latter— being oftentimes
present to such an extent that he has a strong desire to immerse
his body in cold water. In the spring at the time when he
begins his labors in the field, his hands, arms, and dorsal
surfaces of his feet becoms greatly infiamed ; blisters form in
considerable numbers followed by the formation of scabs in the
affected areas. He suffers greatly from constipation, and has a
strong distaste for food— particularly for broad matio from
Indian corn. During his si<;k periods he (Himplains of a con-
stant pain in the ne<^k and of tenderness and pain in the region
of the stomach. He jiarticularly complains of vomiting very
frequently, this following immediately upon the ingestion of
food. lie has never vomited blood.
Prenenl Condition.— \\\i\\ the exception of skin eruptions he
complains at present of all of the symptoms above described.
The patient is 5 feet (i inches tall and weighs 117 iiounds.
Both in walkingand in sitting he stoops decideilly. Ilis hair
is of a sandy color. The skin over the entire iKxly isoxtremely
pale, and especially in the face is thrown into numerous
wrinkles. It seems to be somewhat thinned, is <|uite sukhHIi
and very dry. On the face, neck, hands and lower parts of the
arms it is greatly pigmented, presenting a brownish hue, but
there is at present no indication of an exanthematous condi-
tion. He has very little beard. The fingers are somewhat
clubbed, and the nails are curve<l inward. The mucous mem-
branes are, like the skin, extremely pale. The tongue is moist,
shows indentations of the teeth, and Its epithelium appears to
be in a large measure absent. The teeth are small and <|uite a
number of them are do<Miyed. The pulse averages iK), respira-
tions 20, and the temperature W<° V. On removing the patient's
clotliing ho is found to be somewhat omaciaUHl, and the entire
body presents the extremely pale condition alreaily referred to.
Over the heart a soft, blowing systolic murmur is heard con-
stantly, and varies greatly in intensity at different tlm(^s;
sometimes it is heard loudest in the mitral area, while at other
times it is scarcely per<!eptlblo, but Is distinctly audible In the
pulmonary artery zone, ami can generally be diH(ingulsho<l In
Uie region of the tricuspid. On percussion the heart Is found
to be normal in size, and the lungs jirosont no abnorinality.
lOO AmtHicAN MBDiciNK] ANKYLOSTOMIASIS IN FLORIDA AND CUBA
{July 19, 1902
There Is a marked venous hum over the'riglit jugular. In the
right mammary line the upper border of the liver corresponds
to the lower margin of the fourth rib, and extends well down-
ward to the lower border of the ribs. Just below the ensiform
cartilage and to the left of this there is great tenderness. The
stomacii, however, appears to be of normal size, and its position,
as determined by inflation, seems to be in its natural situation.
After an Ewald trial-meal the total acidity of the extracted
contents was found to be (>4, HCl 40, combined HCl 4, phos-
jjhates 10. Neither the si>leen nor the intestines present any
abnormality. The feces were of a dark brick-red color ; on
microscopic examination great numbers of eggs of the anchy-
lostoma were found and many Charcot-Leyden crystals were
present. The urine is somewhat increased in amount, there
being about an average of 2,300 cm. excreted in 24 hours. It
was of a light yollowish-red color, its specific gravity was 1,012,
and its reaction faintly alkaline. No sugar was detected, but
at one time a faint ring of albumin with the potassium ferro-
cyanid and acetic acid test was found ; albuniose was not pres-
ent ; the urea excreted in 24 hours amounted to 21.15 gm. , and
the uric acid to 0.475 gm., chlorids 3.16, phosphates 2.87 gm., and
sulfates 2.82. On microscopic examination a few epithelial
cells were found in the urine, and a solitary very hyaline cast ;
this cast was probably not a true one, and doubtless belonged
to that class of bodies called cylindroids that are sometimes
encountered in the urine. On examination the number of red-
blood cells was found to be 1,760,000, the white cells 4,020. The
blood only contained 20% of hemoglobin. The redblood
cells show decided though not extreme poikilocytosis, and
there are a number of microcytes and macrocytes. A few
nucleated red cells were encountered. A differentiated count
of the white cells after staining by Ehrlich's method showed
the cells present in the following percentages : Small lympho-
cytes, 28; large lymphocytes, 14; transitional cells, 6; poly-
morphonuclear leukocytes, 50; eosinophiles, 2.
His eyes were kindly examined for me by Prof. Roy, who
has sent tlie following report of the condition found: Vis-
ion, right eye, 15/20 ; left eye, 15/30. Vision in both eyes made
normal by placing a minus glass of one-half diopter before each
eye.
Retinoscopy shows one-half diopter of myopia in each eye.
Pupils in Doth eyes react well to both light and accommo-
dation.
Perimeter shows practically a normal field with the excep-
tion of a slight contraction on both the nasal and temporal
sides in both eyes, more marked in the right.
In both eyes the optic discs appear pale and very indistinct
in outline. They look almost as if there might be a beginning
grey atrophy. Throughout the retina the choroidal pigment
causes the fundus to take on the appearance almost of a retinitis
pigmentosa. The bloodvessels appear normal.
From the foregoing it is seen that this patient pre-
sents all of the typical symptoms of pellagra — a disease
which is now generally believed to be the result of eat-
ing fermented Indian corn. If this be a genuine exam-
ple of the disease it is the first case of the kind that has
been reported in the United States, though instances of
it have been observed in Central America. In view of
the fax!t, however, that numerous eggs of the ankylos-
toma were found, and that it is well known that this
parasite gives rise to digestive disturbances and pro-
found alterations in the blood and other tissues it seems
not unlikely that the pathologic condition Is in a large
measure, if not entirely, due to this cause, but there are
some features of the ca.se that this supposition does not
explain. Of these the most prominent are the strange
tendency that the disease exhibits to manifest itself only
in the spring and early summer, and the fact that it has
existed for about 14 years. It is asserted by those who
have given the matter most study that the ankylosto-
mum does not live in the human body longer than five
years, or eight years at the very outside, and without
this individual has been repeatedly reinfected, the pres-
ence of these parasites cannot entirely explain the long
duration of the disease. From the symptoms as elicited
it seems therefore logical to make a diagnosis of anky-
lostomiasis, to relieve the sufferer of the parasites if
possible, and to observe the further course of the malady
with a view of determining as to whether or not the
patient also has pellagra.
There are two drugs usually employed for causing the
expulsion of the ankylostoma from the intestine ; these
are thymol and male fern. Since the former was
recommended by Bozzola' it has been generally em-
f»i iV''rtor'i'«„v.V?^f.'' **'* Anwendung der Thymolsaeure als iVurmmlT-
t«l In der Anchylostomem-Anacmle Cbl. f. klin. Med., 1881, No. 1, 8. 1.
ployed by clinicians and has been found to act admir-
ably in almost all instances. This drug was therefore
chosen as the anthelmintic in this case. On the day pre-
ce<ling the treatment the patient was directed to eat but
little and no supper was allowed at all. In the after-
noon 10 grains of calomel were given which acted thor-
oughly during the night. On the following morning at
7 o'clock 30 grains of thymol were exhibited in capsules,
and two hours later a similar amount was again iulmin-
istered. As the patient did not vomit or show any gas-
tric disturbances following this a purgative was not
given until 8 o'clock in the evening when a large dose of
salts was exhibited. During the night the patient had
several stools and the bowels during the following day
were loose. The feces were collected and strained
through a sieve and 420 of _the worms were
found ; it is, however, true that many of these
parasites escaped, the entire number pas.sed having
btsen certainly not le.ss than 600. The patient went to
his home a day or two later, and has recently written
me that he somewhat improved at first but is now no
better than liefore. Some of the feces passed four weeks
after the treatment has been thoroughly examined and
no eggs of the ankylostoma were found, showing that
the thymol had acted efliciently. Before he left he was
given a tonic consi.sting of arsenic and iron.
Should the patient prove to have pellagra the disease
is so far advanced that nothing could probably be done
for him, but I have recommended that he change his
place of residence to a cooler climate if possible, and
that in the future he should be extremely careful not to
eat decomposed Indian corn. It is said by those that
have had the greatest experience with this disease in
Italy, where it most frequently occurs, that a cure is
only possible after the first few years. Lombroso has
particularly recommended arsenic in the early stages of
the disease, and claims that it has a very happy action
in many instances.
In concluding my report of this case I desire to
express my thanks to my friend, Dr. F. W. McRae,
through whose kindness I first saw this patient.
ANKYLOSTOMIASIS IN FLORIDA AND CUBA : THE
NEW" SPECIES, UNCINARIA AMERICANA.
BY
JOHN GUITERAS, M.D.,
of Havana, Cuba.
Professor of General Pathology and Tropical Diseases In the Uni-
versity of Havana.
In American Medicine May 10, 1902, there appears
a paper under the title "A New Species of Hook-
worm, Uncinaria americana, Parasitic in Man," by t'h.
W. Stiles, Ph. D.
The ankylostomum found in Florida and Cuba, I
find, corresponds with the description given by Stiles of
the new species. I am sending Dr. Stiles .some speci-
mens from both localities.
The ankylostomum is evidently not as common in
Cuba as it is in Port Rico. I first discovered the worm
in Cuba in a child 10 years of age, who presented the
symptoms of an advanced stage of pernicious anemia.
The child was one of a family of six children, all of
them infected with the parasite. They had evidently
contracted the disease in Florida. I give the dates of
birth of these children, and the localities where they
lived:
Hattie A. I., born in Sanford, Orange County, Pla., April 9,
1881; Minnie, born in the same place, July, ISaS; the family
moved to Orlando, Orange County, Pla., April, 1884 ; the family
moved to Arcadia, De Soto County, Pla., in 1886; Effie, born in
Arcadia in 1887, Florence in December, 1889, Carl in Deceml)er,
1891, August in March, 1894. They all moved to Havana,
Cuba, in January, 1901.
Judging from the history of Carl, who is said to have been
July 19, 1902]
CASE OP SEVERE ANEMIA
[AnRICAN Mkdicinr 101
suffering with severe anemia when he arrived in Cuba, it is very
probable that the infection was contracted in Arcadia, De Soto
County, Fla.
When I first saw Carl at Ijas Animas Hospital, July 16,
1901, his condition was desperate. He was prostrated, weak,
and somnolent. Stools were involuntary, liquid and of a red-
dish yellow color; temperature was 39.7°C., pulse 159. His abdo-
men was swollen ; liver and spleen were enlarged. There was
general, moderate anasarca, with that peculiar transhicency,
intense pallor, slight icteric hue, and deficiency of pigmentation
of skin and hair, that are so characteristic of pernicious anemia.
The child had been for years a clay eater, and I suspected at
once the presence of ankylostoma. An examination of the
stools revealed the presence of 184 ova in a single micropscopic
preparation. Examination of the eye-ground revealed the
presence of neuroretinitis, and small retinal hemorrhages.
Under thymol treatment tlie child^recovered completely, out
has had two relapses.
The other members of the family, not so seriously
affected, have been treated in the same way. I do not
believe that the disease has been completely eradicated
in any of them, for lack of thoroughness in the treat-
ment.
I have further found ankylostoma in two patients ;
one frcjm the central part of the island, and the other
from Matanzas. They are both inmates of the asylum
school for orphans established in Havana. Most of the
children in the said asylum are infasted with trichoce-
l)halus. The first of the two Cuban children mentioned
had the symptoms of a pernicious anemia. The blood
examination showed 2,5(10,000 red cells; poikilocytosis,
nucleated red cells ; leukocytosis, with increase of the
small lymphocytes and eosinophiles. Hemoglobin 2Sfc .
Enlarged liver and spleen, and general appearance of
pernicious anemia.
It goes without saying that these patients had all
been treated for malarial cachexia.
After reading Stiles' paper I have examined the
specimens obt^iined from these cases, and I find in all of
them that the hooks are absent, though there are plates
on the anterior Iwrder of the mouth.
A CASE OF SEVERE ANEMIA CAUSED BY THE
UNCINARIA DUODENALIS.
BY
A. B. HERRICK, M.D.,
of Washington, D.C.
This case bears a marked resemblance ta pernicious
anemia and well shows the differential points between
the two diseases as manifested in the blood condition.
N. Bauer, aged .37, was admitted to Barnes Hospital, April
15, 1902, complaming of weakness and .shortness of breath. His
family history is negative. He was born in Ijorraine, Germany,
and lived there until 1897, when he came to this country. He
lived in Philadelphia until enlistetl in June, 1899. He had
always been healthy and gives a history of exceptionally good
habits. He was sent to the Philippine Islands in September,
1899, and the following Februar^ had an attack of malarial
fever of an intermittent type lastmg about two weeks.
Pi-enent itlnesH began in July, 1900, with an attack of diar-
rhea. He had from ten to fifteen movements daily for three
months with a moderate amount of tenesmus. Mucus and
blood appeared in the stools after the first month, giving them
a dark tarry api)oaranco. He lost weight and strength rapidly
during this time and gradually become short of breath on the
slightest exertion. This was followed by a period of improve-
ment, the stools becoming less frequent, but in January, 1!)01, he
became worse and was sent to the hospital at Hollo. .Since
then he has been confined to hospitals on account of weakness
and dyspnea. In September, 1901, the diarrhea ceased and
although he has gained a little in weight he has been steadily
growing weaker. At no time had he been subject to hemor-
rhages other than stated.
I'liyxiciit examiniilion shows an apparently well-nourished
man with a necidiar lemon-yellow pallor ; conjunctivas and
rnu<!ous membranes are pale; slight edema of the ankles is
present. He has markinl dyspnea on the slightest exertion.
The lungs are negative. The heart is enlarged; the point of
maximum impulse is in the fifth lnt<'rcostal space in the nip-
ple lino. A soft blowing systolic murmur is audil>ie at the
apex and in the pulmonic area. Mver dulness extends from the
SIX til intercostal si)ace in the nipple line to 1 cm. below the
(■ostal margin. The edge is palpable. The spleen Is enlarged
and the edge palpable at the costal margin. The urine is netnt-
tive.
The blood is very pale and watery: a moderate poikilocy-
tosis is present ; there are no nucleated red corpuscles and no
malarial organisms present. The blood count showed : Reel
corpuscles, 1,120,000; hemoglobin, 18% ; leukocytes, about 4,000;
polymorphonuclear, 5295, ; eosinophiles, 2().89'f ; small mononu-
clear, 14% ; large mononuclear, 4.4'/<, ; transitional, 2.89'f.
One month later, the patient meantime having been taking
arsenic and iron, the blood count was as follows: Red cor-
puscles, 1,450,000; hemoglobin, 229'f ; leukocytes, 2,000; i>oly-
morphonuclear, 61% ; eosinophiles, 18.2fc ; small mononuclear,
16.4% ; large mononuclear, 3.2% ; transitional, 1.2% ; no nucle-
ated red cells.
There had been practically no change in the patient's con-
dition. The liver and spleen were as in the former note, and
the dyspnea still marked. Numerous typical ovums of uncl-
naria were present in the stools, but no adult forms were seen.
After the usual thymol treatment about 60 adult worms were
found. They resembled in all respects Uiicinarin iluodeiialifi,
and were identified by l>r. Stiles as the old world hookworm.
The ovums present were in progress of segmentation, 4 to 12
cells being visible. None were seen containing an embryo, as
frequently occurs in the form Uneinaria umericana, dcscrtl>ed
by Dr. Stiles.
Blood examinations 10 and 20 days after the thymol treat-
ment was begun showed the following counts:
May 28. 1902 June 7. 1802
Red corpuscles 2,:»0,000 H.IOO.OOO
Hemoglobin 2:W 27«
rx>iiko<-ytes 2,.'i00' .1,000
Polymorphonuclear M^ 82*
Eosinophiles 2lj( Hjs
Small mononuclear 17)( llf
liiirge " fl)( M
Transitional iif, \i
The general condition also is improving rapidly, although
the parasites are not entirely eliminated, as an ovum is still
occasionally found in the stools.
The case bore a marked resemblance to ix'rnicious
anemia in the peculiar pallor manifested, the retention
of the adipose ti.s.sue, and the remarkably low blood
count with a leukopenia. The eosinophilia directe<l our
attention to something more than pernicious anemia, and
an examination of the stools — although there was no
diarrhea present — c^leared up the case. The points in
the blood examination showing the difference from per-
nicious anemia are the pre.sence of an eosinophilia, the
absence of nucleated re<l corpuscles, and the less marktKl
poikilocytosis. In the Porto Rico cases described by Dr.
Ashford nucleated red corpuscles were common. A
description of all the cases reported in this country Is
given by Dr. Yates in the Johns Jlopkhix Iloxpital But-
letin, December, 1901.
NOTES ON GASTRIC ACIDITY : FREE HCl.
A. L. BKNKDICT, M.D.,
of Bufmio.
In general, in all titrations with color-indicators, it is
a go<xl rule to take the reading at the point at which
further addition of a drop of sodium hy<lnvt<' solution
produces no contrast of color with the mixture already
in the capsule, ("are should be taken not to confu.se
with a distinct differen«' of tint, a mere diffc^renco of
intensity of color due to dilution. This rule, however,
must not lie foUoweil in testing for fre*- H("l by dimethyl-
amidoazolienzol, but the first appeamnc*' of color change
should be not<'«l.
The re<l of dimethyl changes through orange, yellow-
ish-brown into a light straw-yellow. Tlies«> suc<-«'«Hive
changes may cover ir>^ or more of acidity by decinor-
mal NaOH solution. Hy removing a drop of the mix-
ture from time to time and heating with lloas' r<>agent
c-onsisting of a .sf)lution of reson-in and ciine-sugiir, the
red ring on drying will Ik' found to iKrsist throughout
the suc«>ssive changes atxl to persist in a paler magenta
red for scvOrtd degrci-s after tin- dear yellow has In-en
formed permanently with dimethyl. For instamv, in
one of the titrations of highly acid chyme, free H("l by
dimethyl, retu-hed its limits at M^i, but a distinct
102 AHBKtOAN MkDICLSK]
NOTES ON GASTRIC ACIDITY
(July 19, 1902
magenta with resorcin and sugar was found at 101^ and
10!i'/o, and a tingo of this color at n5;;ffc. In anotlier
patient, tiio orange* color with dimethyl was struck at
•,\fo, the dear yellow at 11%, while the resorcin reaction
persist^^d up to 35/(,. Now, in the older, qualitative
inetliod of examining chyme, we were in the habit of
considering that a trace of free HVA was present
if any reddish tinsre occurred in the drying mar-
gin with the Boas test. To throw light upon this
(piestion, I made a dilution of pure IICI in distilU-d
water, roughly estimated at 20:10,000. By titration
with dimethyl, the actual strength wius found to cor-
respond to about 90'/c of decinonnal NaOH solution.
In this test, the actual proportion of HCl was .00.'!28. At
the end of the dimethyl titration, a faint r€>action
occurred with i-csorcin and sugar, but this had disap-
l)eare(l on adding NaOII solution to the extent of three
degrees additional. Hence I conclude that the Boas
test should be rigidly restricted to the appearance of a
distinct vermillion red ring, and that any rose or magenta
tint indicates not a trace of free HCl, but some other
acid factor.
But now another question presented itself: Might
not the reaction with resorcin and sugar be due to the
dimethyl already present in the contents of thecaj)sule ?
Numerous experiments showed that there was a point
well within the complete saturation of all acid constitu-
ents at which the filtered chyme plus dimethyl plus
enough sodium hydrate solution to pass the complete
decolorization of dimethyl, failed to sliow any reddish
or rose tinted band on heating with resorcin and sugar
in alcohol. On the other hand, a rose band with
the latter test did occur a few degrees after the complete
saturation of free HCl, according to the dimethyl test
which was carried to its completion. This change of
color might be due to some interaction among combined
chlorids, dimethyl and resorcin and sugar, under the
action of heat. For example, the complete decoloriza-
tion of dimethyl occurred at 48 fr, . On adding a drop of
the mixture from the titration capsule to the resorcin
and sugar reagent the rose ring appeared at 51 fn , but
not at 57 fc . Taking a fresh portion of filtered chyme
without dimethyl, and running in 47 fc of sodium
hydrate solution — decinormal in all these experiments —
the resorcin and sugar test no longer responded. Start-
ing again without dimethyl a marked reaction with
resorcin and sugar occurred at Mfo, a slight but still dis-
tinct reaction at 39 /o and 42^, while by adding a second
drop of partially neutralized filtrate at 45^, a trace of
vermillion was seen. Thus, the reading at the end of
the color change with dimethyl alone was at least 3 fc
too high, while the rose band with dimethyl and resor-
cin and sugar occurred at least Gfc too high.
Several experiments were then performed comparing
(1) the resorcin and sugar test applied to partially
neutralized chyme ; (2) the contact with a drop of dime-
thyl on a porcelain slab in the same way ; (3) the
ordinary titration with dimethyl in a capsule, under the
buret. At 19 fc , the contact test with dimethyl showed
an orange color, the resorcin and sugar reaction had been
pa.ssed, the dimethyl in the capsule was just beginning
to change from cherry to orange. Starting again with
the same filtrate at 15 /c, the contact test with dimethyl
and that with resorcin and sugar, indicated the presence
of free HCl. At 17%, the resorcin and sugar reaction
had been passed, that by contact with dimethyl showed
only a dull orange, while on adding dimethyl to chyme
in the capsule the color change was found just begin-
ning. At 22 /c, the color in the capsule was distinctly
orange, and this would probably have been the reading
under ordinary circumstances. At25fo the clear yellow-
had been struck. From a considerable number of titra-
tions it has been established that the dimethyl reaction
from the first appearance of a distinct change of tint to
the clear, unchanging yellow, has a range of 10% to 20^
—usually 15%. Indeed, if the first color change is
obscured, or if it is accidentally passed in the titration, a
fair idea as to free HCl may be obtained by subtracting
15 from the reading at the end of tlie dimethyl reaction.
I have tried to formulate a definite rule for correcting
the reading by dimethyl to conform with that by
resorcin and sugar, which seems to be the most delicate
and most exact test for free mineral acids, but such a
correction is not possible because (1) in dealing with
pure dilutions of HCl, or filt<^red chyme in which a large
amount of HCl has diminished organic acidity to a
minimum, resorcin and sugar will react to mere
traces of HCl which do not afftH;t dimethyl, and on the
other hand (2) in ordinary filtered chyme, and especially
in that in which HCl is comparatively low and there has
been considerable formation of fermentation acids,
dimethyl is afl'ected, while resorcin and sugar apparently
is not. This difference, however, is practically insignifi-
cant. For instance, it often happens that stomjuth con-
tents show a trace of free HCl with resorcin and sugar,
but not with dimethyl. In such cases, after adding 1 %
of decinormal sodium hydrate solution, I have invari-
ably found that the resorcin and sugar reaction no
longer appeared.
The phloroglucin-vanillin reaction seems to be prac-
tically identical with that by resorcin and sugar. The
latter reagent is more stable, keeping for several months
and is more easy to manage.
The estimation of acidity by conbvct methods is more
tedious than by methods in which an indicator is added
to the capsule containing the stomach contents. The
use of the former, discontinuous, methods practically
necessitates a preliminary titration to determine approx-
imately the maximum and minimum limits. If there is
plenty of chyme— usually there is not — and great accu-
racy is desired, the resorcin and sugar test may be
applied subsequently, removing a drop of chyme every
few degrees, beginning a little below the reading with
dimethyl.
Occasionally a recommendation is seen to use congo
red tropeolin OO, etc., as an indicator for free HCl. For
a pure dilution of IICl, or any other mineral aeid, any
of these reagents will give nearly identical results, but
if organic acids are present the readings will be too high.
Fven an alcoholic beet extract may be used as an acid
indicator, but, either on account of differences in deli-
cacy or of intrinsic differences in response to various
acid factors, the different indicators will vary in their
reaction to chyme or other mixed solutions. In general,
the less delicate an indicator is in responding to pure
dilutions of mineral acids, the more it will be affected
by other iicid factors in chyme. At present we have no
perfectly satisfactory capsule indicator of free HCl, but
dimethylamidoazobenzol is so far superior to all others
that it should supplant its rivals. For total free acidity,
Congo red and benzopurpurin 4B are about equally good,
while for total acidity, except proteid combinations, aliz-
arin is the best at present known. However, there are
various inconsistencies noticed which show that the only
titration tests for chyme upon which we can rely for
practical accuracy are that for free HCl with dimethyl and
that for total acidity usually made with phenolphthalein.
On account of the marked difference in tints, these two
tests can be applied in succassion to the same portion of
chyme. Dr. Mark I. Knapp has recently advised
the successive titration for free HCl, combined IWA
and total acidity, using tropeolin OO as the first indi-
cator. The objections to this method have been alludetl
to ; indeed, they are implied in the first American trans-
lation of Ewald 10 years ago.
Milk Preservatives Must Not be Used.— The Philadel-
phia Board of Health has instructed Chief Inspector of Milk
Byrnes to liave tlie niill<-supply of the eity systematically
examined, and to report all persons soiling milk containinfjany
chemic preservative. This action is taken l)ecause of the
recent introduction of sodium benzoate as a milk preservative.
July 19, 1902]
SURGICAL OBSERVATIONS IN BERLIN
[Amkbican Mbdicink 103
SPECIAL ARTICLES
SURGICAL OBSERVATIONS IN BERLIN.
Professor Olshausen's Gynecologic Clinic. — The Augusta
Hospital.
BY
NICHOLAS SENN, M.D.,
of Chicago.
Professor Olsiiausen occupies today the higliost position
as a teacher of gynecology. As an operator he is one of the prin-
cipal attractions of the medical faculty of tlie University. He
left Halle in 1887, when .50 years of age. His success in Berlin
has been phenomenal. The clinical material over which he has
complete control is. immense, l^our laparotomies a day is a
small estimate of his daily major operations. Every one of his
operations shows the hand of a master. He is never in haste,
and yet the operations are performed quickly. The most
difficult operations are performed with few instruments. He
liandles the instruments with an accuracy and dexterity that
astonish and charm his audiences. His earnestness and enthu-
siasm in tlie lecture and operating room are impressive.
Among his private patients are to be found the names of many
of the most prominent families from every country on the con-
tinent. IHsspeechand actions aii- well calculated to inspire
patients and pupils with confidcnc o. lie begins his operations
at 7 o'clock in the morning and seldom finishes his onerous
task before midday. No time
is wasted. He is punctual to
the minute. His splendid
stait" of assistants and well-
trained nurses anticipate all of
his wants, and the most com-
plicated operations are fin-
ished without a hitch or a
harsh word.
Chloroform by the drop
method is the anesthetic used.
Sublimate alcohol catgut is the
exclusive suture and ligature
material uswl with one excep-
tion, intestinal operations,
when silk takes its place.
tJathartics are given before
abdominal section and three
days after operation. The day
1,1 loic iiperationthe patient is given a bath, but the disinfection
of the Held of operation does not take place until the patient is
on the operating table and fully under the influence of tlie gen-
(^ral anesthetic.
This disinfection, as well as hand disinfeclimi, consists
largely in prolonged scrubbing with hot water and soap, fol-
lowed by sublimate solution and alcohol. The last antiseptic
is now considered the most important in guarding against
stitfsh abscesses.
The instruments, on a tray, are placed on astand within easy
re&t:h of the operator. One nurse threads and hands the needles.
A second nurse hands the sponges and the dressing material in
a receptacle, without touching them. The two great rules that
should govern the work in every operating room are displayed
con.spicuously. These rules are: "Noli Innaere" m\ii"Favele
tintjiiin." One assistant a.ssi.sts the operator, a second admin-
isters the anestlKdic and a third holds the pulse. The leading
points in his operative tochnic will be given in a few of the
operations I had an opportunity to witness.
Cask I.— Enucleation of a Mynffhroma of the Ulertis. The
patient was .'il years old ; Trendelenburg position. Disinfection
of the abdomen was obtained by shaving, scrubbing with
warm water and soap, followed by sublimate solution and
alcohol. Incision was made through the linoa alba. Peri-
toneum was ojiened in the upper angle of the wound so as to
avoid iniury to the bladiler. incision wa-s enlarged to the
extent of five Inches with l>liint)>ointi«l .scis.sors. tUcnis wsis
lifted forward into the wound and a Imiki- .,,nii,i(«s of (;ailzo
Professor Olshau.scii.
placed between it and the small intestines. To this large gauze
compress a tape was fastened, and to the end of the tap(^ a large
hemostatic forceps was applied. These precautions cAunot fail
to prevent the loss of gauze in the abdominal cavity. The
tumor, the size of an orange, involved tlie summit of tlie uterus
and was interstitial. The mantel of uterine tissue was incised
half way between the cornua in an anteroposterior direction,
when the tumor was gra.sped with vulsella forceps and easily
remove<l by enucleation. This part of the operation was done
largely by stripping the uterine tissue back with a gauze sponge.
The bleeding, which was very slight, was cJirefuUy arrested by
ligating with catgut. The visceral wound was closed by two
rows of continued catgut sutures, the first row including the
muscle tissue and the .second one approximately tlie serous sur-
faces. The bleeding from the needle punctures was arreste*) by
additional sutures often placed parallel with the line of incision.
The peritoneum was sutured separately with acontinne<l c«tgut
suture, the second tier includeti tlie fascia, and the third approx-
imated the skin. A drying powder was rubbeii into the punc-
tures of the skin, and the dressing, consisting of a few layers
of gauze and a comjiress of aseptic absorbent cotton, fastene*! in
place by three broad strips of adhesive plaster. Professor
Olshau.sen is of the opinion that ventral hernia after laparotomy
only occurs when the fascia, from favilty suturing or suppura-
tion, fails to unite. He lias no confidence in abdominal sup-
porters as preventives of tliis post-operation complication.
Case II. — ifultiple Afyoflhromn of the Uterus: ffupra-
vnginal Amputdtion. The patient is a multipara, 47 years old.
The uterus and tumors form a nodular, irregular mass the size
of an infant's head. The right ovary is healthy, and the left one
cystic. The latter was removed with the uterus. Division of
tubes and broad ligaments was made between double catgut
ligature. The ovarian arteries were liBate<l en max.ie. The
uterus was now drawn well forward and upward with traction
forceps, the peritoneum incised and rellectcd largely by pres-
sure with gauze sponge. All bleeding points were tied with
catgut, after which the uterus was amputated with one
sweep of the knife. Projecting bloodless stumps of ovarian
arteries were tied separately. The cut surface of uterine tissue
was approximated by continued catgut sutures when the serous
surfaces were carefully united by the same kind of suture.
Abdominal incision was clo.sed and dressed in thesame maimer
as in the first ca.se.
Cahr 111.— Retroversion of I'lmi.s: Ali:r.i,n/r,-'x < iii.ritl kiii.
Professor OLshausen commenced to perforin this operation only
three years ago, and is very careful in the selection of cases. He
limits the operation to (!ases of retroversion of a movalile
uterus which produces symptoms of sufficient severity to war-
rant operative interference. In this case the uterus could be
brought into normal position without any dilllculty. An
incision three inches in length was made from the pubic spine
and parallel with Pouparl's ligament. After incising the skin
and superficial fascia, the lower angle of tlie inguinal canal
where the round ligament expands and is attached wa.s .sought
for by rubbing with a gauze sponge. The ligament was iso-
lated at this point, grasped with hemostatic forceps, divided
below the forceps, and then taking the ligament as a guide the
inguinal canal was slit open with probe-pointed scissors, the
ligament detai'hed and bv traction and ba<-kward rubbing with
a sponge liberated to the extent of about four inches. 1 he
ligament was fa.stened in the canal by four transfixion catgut
sutures, the free end excised and the little wound closed by two
rows of catgut sutures.- Dusting powder and a small aseptic
absorbent dressing held in place with roller bandage finished
the operation. The operation on the opposite side was per-
formed in the same manner. The experience of the operator
concerning the remote results of this operation has been very
satisfactory.
The wealth of material of this dini. i^ shown by the fact
that about 700 patients suffering fnun retroversion of the uterus
apply annually for relief. Out of this number only from .15 to
40 eases are selected for an Alexander's operation.
At'OtrsTA Hosi'iTAi,.— This institution for the relief of the
sick of Berlin has an interesting history. It was foiinde<l by the
late Empress Augusta and has been a favorite resort for the sick
for more than a quarter of a century. It is managed by the
Women's Hospital Association, of which the Empress is honor-
ary president. It is probably the most homelike hospital In the
world. Its officers and Sisters are selected exclusively from the
titled nobility. In a largo and l>eautifully furnished rwrn the
Board of Managers holds its meetings, the Empress or hersuli-
stitute presiding. Here are found portraits of the royal family
and a register for distinguished visitors contains the namcja of
most of the distinguished men and women of the (Jorinan Em-
pire. The hospital, which has a capacity of 190 beds, presonte s
homelikeappoaranceand is surrounded by aiiiplogrounds, made
attractive by export gardeners. The furniture throughout the
entire house reminds one of the comforts of a private homo.
Two of the most dlsUngiiished medical men in Berlin are at the
head of the medical service. Professor Ewald has charge of the
104 Amkbican HboicinkJ
SURGICAL OBSERVATIONS IN BERLIN
(July 19, 1902
medical and Professor Fedor Kraiise of the surKical depart-
ment. These appointments are made by the Empress and are
for life. Professor Kraiise imbibed his unbounded enthusiasm
from his distinguished teacher, tlie late Professor von Volk-
mann. lie has written a valuable monograph on tuberculosis
of joints, and for a number of years had charge of the surgical
work of the Altona Hospital. Recently he has distinguished
himself in brain and nerve surgery. He received the present
appointment a year and a half ago, and is now in direct line for
early promotion. The care of the sick is in charge of Sisters
and nurses who receive their theoretic instruction and practical
training in tlie hospital. The Sister Superior receives her
appointment from the Empress. Sister von Arnim has served
Augusta Hospital.
in this capacity since the hospital was opened. All of the
Sisters, 20 in number, are of noble birth. The initia-
tion of a Sister is an important event, at which the
Empress Is always present, and presents the Golden
Roman Cross slie is expected to wear daring her service of
the balance of her lifetime. The selection of nurses receives
the same care. They are young ladies, from 20 to 25 years of
age, usually the daughters of clergymen or professors. These
nurses very rarely abandon their profession. The nurses must
remain in training for two or three years, and during this time
they are instructed in the theoretic part of their profession for
Augusta Hospital aud Gaidin.
three months by the senior home physician, who gives two
lectures a week.
The lectures are of the most practical kind. At the expira-
tion of the specified time they receive a certificate of proficiency
from the Sister Superior and are permitted to enter private
practice or hospital work in some other institution. The earn-
ings of these nurses flow into the treasury of the institution
from which they graduated. On the other hand, their alma
mater provides at all times for their subsistence and clothing.
In (iermany tlie loss of a nurse by marriage does not occur
as freqiiontly as in our own country, where the attractive and
most eflicient nurses only too often leave their chosen profes-
sion by entering married life, an occurrence which cannot fail
in weakening the nursing profession. In time of war or
other great national calamities, Sisters and nurses are
subject to call from the Red Cross Society of Germany,
with which this institution is identified. There is perhaps no
other hospital in which the sick receive better atten-
tion. A patient who pays fl.2.5 a day is entitled to a pri-
vate room with two beds, and $2.50 a day a single room
including tlie very best nursing and medical or surgical
attendance. The salary of the attending surgeon is less than
^1400 a year. The income of the medical profession of Germany
is greatly reduced by the questionable custom which prevails
in all hospitals throughout the empire of rendering free medi-
cal service to private patients occupying the most luxurious
rooms and by the only too prevalent contract practice among
the laboring classes.
Professor Krause's Work. — Professor Krause belongs to the
younger class of progressive surgeons of this city. His present
field offers him abundant and very interesting clinical material.
Ill the laboratory connected with the hospital excellent patho-
logic work is done. I examined here a large collection of
specimens of carcinoma of the pylorus removed by operation,
(iastrectomy and gastroenterostomy are frequently i)erformed
111 this hospital, as Professor Plwald, who has charge of the
medical service, refers his cases which require oi)erative inter-
ference to the surgical department. Two tumors of the spinal
cord were also shown. One of the tumors was a psanimoma
the size of a hazelnut removed successfully from the dorsal sec-
tion of the spinal cord. The symptoms before the oper-
ation were so characteristic that the surgeon wa.s able
to make an absolute anatomic and pathologic diag-
nosis. Paralysis of motion on one side and loss of sensa-
tion on the opposite were the most conspicuous clinical
features. The cord was freely exposed by resection of three
vertebral arches. The dura was incised and the encapsulated
tumor removed by enucleation. Nerve function has been
restored sufficiently so the patient walks readily with the use of
a cane. The other specimen illustrated the diffuse nature of
sarcoma of the spinal cord. The tumor had its origin in the
Cauda equina and was exposed by an extensive laminectomy
and was followed upward sufficiently far to satisfy the operator
that the case was hopeless. The patient died. Krause has had
a very extensive experience in nerve and brain surgery. In
neuralgia of the trifacial nerve he always resorts to peripheral
operation first. A beautiful collection of excised nerves was
demonstrated. From the point where the nerve is attached the
main trunk aud branches are followed as far as possible
so as to make the extracranial excision thorough. If the
operation does not prove successful he resorts to his intra-
cranial operation for the removal of the Gasserian ganglions.
He has performed this operation, up to the present time, on 36
patients. Only three of these patients died from the effects of
the operation; in those that survived the relief was prompt
and permanent except in one, in whom it failed to mitigate the
pain. This patient was a physician, who threatened to commit
suicide if the operation were refused. The cause of the pain in
this patient had a deeper aud inaccessible origin.
To Regulate Sale of Viruses and Serums in District of
Columbia.— The Executive CJommittee of the Medical Society
has recommended that the support of the society be given to
the following section of a bill to regulate the sa"le of serums,
viruses, and analogous products:
Section 4. That the Surgeon-General of the Army, the Surgeon-
General of the Navy, the Supervising Surgeon-General of the Marlne-
Hospltol Service, the Chief of the Bureau of Animal Industry of the
Department of Agriculture, and the Health Officer of the District of
Columbia be, and they are hereby, constituted a board with authority,
subject to the approval of the Secretary of the Treasury, to promul-
gate from time to time such rules as may be necessary, In the Judg-
ment of said board, to govern the issue, suspension and revocation of
licenses for the maintenance of establishments for the propagation and
preparation of viruses, serums, toxins, antitoxins and analogous prod-
ucts, applicable to the prevention and cure of diseases of man.
Intended for sale in the District of Columbia, or to be sent, carried or
brought for sale from any State, Territory or the District of Columbia
into any other State, Territory or the District of Columbia, or from the
United Stales into any foreign country, or from any foreign country
into the United States: Provided, That all llcen.ses issued for the
maintenance of establishments for the propagation and prepamtion In
any foreign country of any virus, serum, toxin, antitoxin or product
afoiesHld for sale, barter or exchange in the United States shall be
issued upon condition that the licentiates will permit the Inspection of
the establishments where said articles are propagated and prepared. In
accordance with Section 3 of this act.
July 19, 1902]
PREVALENT OBSTACLES TO PROFESSIONAL UNITY camkrican mbdicinb 105
ON SOME PREVALENT OBSTACLES TO PROFES-
SIONAL UNITY.'
BY
W. W. VINNEDGE, M.D.,
of La Fayette, Ind.
Doiil)tless all of us have our ideals as to mediciue. Some of
these may be sound, others may not. For present purposes a
good ideal may be defined as a medical standard of morals fur-
tiishing a working basis for all, not too low to fall short of
respect and confidence, and not too high to be impracticable. If
it is too low it fails to furnish a basis for harmonious fellow-
ship and consequent unity ; if too high it invites little coopera-
tion, receives half-hearted support and falls short of profes-
sional requirements.
In opening the discussion of our topic, to which my atten-
tion was recently drawn through the proposed reorganization
and unification of the medical profession within professional cir-
cles, I will try to measure public professional morals and profes-
sional conditions reasonably and fairly, and, at the same time,
point out some abuses and untoward professional conditions
plainly and truthfully, in order that some of the obstacles to
professional unity and harmony may be exposed.
The professional standard is the family phy.sician. The con-
fidence and esteem of the public for medicine in the past as at
the present time is lodged in him. Statesmen, divines, coun-
selors-atrlaw, authors, in fact the majority of the public, hold
medicine in the highest esteem because of memories of the
kindly professional officesand ministrations of the "old family
physician." Proljably the majority of active physicians today
were in tlie beginning influenced to espouse it as a lifework
through sentiment, through the suggestion or advice of close
friends having in mind the family physician as a model for
son, relative, or friend. Even in the debased times of Shakes-
peare the model in morals and close confidential relations was
the physician, no less than in our own times when the admir-
ing patient of "Old Doc Syphers" recounts that character's
wonderful doings and accomplishments to his liumble com-
panions. The good all-around physician will, no doubt, con-
timie to be in the future, as he has been in the past, the chief
custo<lian of the honor and integrity of the medical profession.
In collective or public relations the physician is less fortu-
nate. Too often he misreprasents his profession. The cause or
<'auses of his failure in public positions is a matter for both con-
cern and inquiry, and if possible, for remedy. The physician
who falls short of pul»lic expectations or requirements in a
given position is either deficient in culture, or defective int«l-
lecitually, professionally or morally. In many little obliquities
lie is tiioughtle.ss, careless, or both, as I will presently try to
demonstrate.
There is probably no more accurate index to current social
and professional conditions than our public laws. Legislation
is the sum of current social standards and conditions, so far as
it expresses the latter. Thus our Medical Practice Act and Its
amendments reflect prevailing social and professional condi-
tions. These are the creatures of politic's, largely me<lical.
One of the defects in the original Practice Act of this State,
as well as in many other States, is its sectarian character. Sec.
4, original Act, which took effect April 14, 1897, so stamps it. It
says :
Each of the four schools or systems of medicine having the
largest numerical representation in the State shall have at least
one representative on said board. Should a vacancj^ occur in
said board by death, resignation, removal, or otherwise, then it
shall bo the duty of the Governor to fill the vacancy from the
school or system entitled to representation by virtue of such
vacancy.
It is a matter of regret that our law recognizes sectarianism
in the profession— shall I say legalizes it— for it is certainly an
obstacle to i)rofessional unity and harmony. Its tendency is to
foster traditional jealousies and discourage cooperation, without
correspondingly good results ; it is therefore unwise and impol-
itic to keep it distinctively before the public mind through our
taoz.
> Read before the Delaware County (Ind.) Medical Society, May 2,
public records. In further illustration of the obstructive,
impolitic injurious effect of this feature of our law, I will point
to Rule 10 of the State Board of Medical Examiners, which pro-
vides for a sectarian examiner, and sectarian mat«ria mediea
and therapeutic questions for sectarian practitioners and stu-
dent applicants for license to practise medicine, surgery and
obstetrics within our State. I am unable to perceive public
benefit, or professional dignity, or professional unity, or
harmony from legislation of this kind.
At the time the original Act was pending in our General
Assembly I obtained a copy of it and rewrote it entirely, omit-
ting all reference to socalled " schools " and materia nietlica and
therapeutics, adoiiting the view that these divisions were
largely imaginary, certainly not welWefiued, and, without
doubt, only matters of opinion, and therefore impracticable and
unworthy of legislative attention. That this position is fairly
well sustained, through the efforts of our State Board of Exam-
iners to execute the law on sectarian lines, is, I Itelieve, reason-
ably well demonstrated. While the proposed legislation wa-s
being considered officially I argued before our official repre-
sentatives in the House and Senate that a State Board of Exam-
iners which the Governor would select would surely bo able to
examine all applicants for license to practise me<licine, surgery
and obstetrics in the State on the fundamental sciences of
medicine sufficiently to decide if they were qualified for pro-
fessional work and its responsibilities.
As a further example of the effects of this sort of legisla-
tion, the applicant for a license is asked to classify himself as
to socalle<l " schools " as follows : " I wish to be classed with
school.'" If for any reason the applicant does not classify
himself he appears in the board's report as "N. ("."—not
classed ; so, paradoxical as it may appear, ho isclassifie<l in the
public records, whether he would or not. In certain circles a
classification like this might be injurious, as it often misrepre-
sents and in a general way tends to discredit him to whom it is
applied.
There is not, it is almost needless to say, any wish or inten-
tion to reflect adversely on the official iu!ts of our State Hoard
of Exaininors, for our comments are offered in illustration of
unfortunate professional conditions. Nor is it intendeil by
these statements to argue that medical legislation in this State,
as a whole, is without value. Almost any definite public
record, however imperfect, has some merit. Certainly the
State is in need of good medical registration, not a registration
base<l upon arbitrary opinions as to classification, but one
reciting the salient facts about every physician in the State.
It is hoped that when our next General Assembly con-
venes it will during its session further amend our laws relating
to medicine, in order that our public records may be shorn of
all imaginary professional discriminations, so that the work of
the State Board of Examiners may be simplified and legislation
be made to contribute more largely to the public go<xl by aotuir-
ing to it greater unity and cooi)eration on the part of the motli-
cal profession. The only homogeneity that the profession
greatly needs is homogeneity of professional attainments and
impartial science. Let that be its high aim, and the rivalry of
"schools "and predilection for systems will 8<M)n disappear
from its records and fellowships.
The fields of scientific research are certainly widening and
deepening year by year in all departments of knowledge, an<l it
cannot be possible that the distinctive features which now
separate the sot«llo<l " schools " of meillcino will not fade away
under the light of new discoveries, new forms and now
thoughts. Why should it I* hindered by nursing a spirit of
faction instead of a spirit of unification ?
Allow me to point to another olmtacle to profossional con-
fidence and fellowship, one which Impaim rsBpec^t and ostooin
within the profession, at the same time the rospe<-t and estooin
for the profession on the part of the public, esptwjially the rcsfwct
and eateem of manufacturers and merchants having clone ImimI-
ness relations with physicians. 1 refer to the too groat willing-
ness on the part of physicians to aa^ept " sHinplcs." socalleil, of
"therapeutic agents" from inorohants and manufacturers; in
iHocond Annual Report of theHtate Board of Bxamlnen, IW, p.
214.
106 AMBBioAN MI.WCINK] PREVALENT OBSTACLES TO PROFESSIONAL UNITY
[Jui-Y 19, 1902
fact, I airi Informed that many physicians apply the needful
poHtago stamp to the printed special mailing (;ard enclosed to
thom by agKressivo, over-bold merchants, askingthem to solicit
"samples" by mail, which the too thoughtless or unwary
physician often does. Acts like this reveal a low standard of
business morals or thoughtlessness on the part of physicians.
The free sample to the physician is too often only a bribe, not a
sample at all ; it is a way the apparently gracious manufacturer
or merchant has of making the unsuspecting physician his
agent, often for the sale of cheap and useless drugs, and all at
the expense or injury of the innocent patient or public.
The proportions of the free sample advertisement, I almost
said scandal, may be .seen and understood through the follow-
ing facts which I have obtained from a respectable firm of
manufacturers of a line of standard remedies. I say the firm
is respectable, because I know it. I have known two of the
members personally many years, and I was furnished the
statement, a copy of which will follow, by the firm in confi-
dence, over its own signature. The statements as to where its
free samples were distributed during one year show that pro-
fessional inditt'erence or carelessness is widespread. In mak-
ing so many presents to physicians, the firm, no doubt on
business grounds, was obliged to place a higher price on its
goods to the trade, and, of course, indirectly to aOlicted persons,
in order to succeed in a business way. It may be asked why do
merchants and manufacturers submit to the free sample drain?
To this I reply, because each merchant and manufacturer feels
tliat he must meet competition ; he does the best he can for
himself as a merchant.
But the goods the merchant distributes, gives away as " free
samples," must be paid for by some one. The physician accept-
ing them does not pay for them ; the firm distributing them
does not give them away within the usual meaning of the word
gift; it figures on a return for them. Well, who pays for
them? The public, of course— the sick, the alUicted.
A copy of the interesting communication just cited (the
explanatory notes in parentheses by myself) reads as follows :
W. W. ViNNEixu:, M.D., Dec. 10, 1901.
La Fayette, Ind.
Dear Doctor :
Referring to your favor of recent date to which wo prom-
ised a reply, we would say tliat for our own information wo
have tabulated our sample account for the past year, which
shows the number of bottles of samples distributed by our
representatives, outside of the distributions made at the medi-
cal conventions. Our records show that our travelers have
called upon about 23,000 physicians, to whom we have distrib-
uted 53,5!»7 bottles of our jjroducts (each bottle worth about
00 cents wholesale). The distribution of the delivery of sam-
ples we are free to give you is as follows :
Hindis 1,
Chicago 3,
Indiana I,
liKlianapolis
Pennsylvania 2,
Pittsburg 1,
Philadelphia 4,
New York 2j
Brooklyn 2^
New York City 4^
Albany
Hyracuse
Rochester
Buffalo
Ti-oy
Arizona
Missouri
Kansas City ."']
St. .Joseph " '
St. IjOUIS '„',
Khode island
Maryland .""
Haitiniorc
Soiilli Ciiiolina
i.oviisiana *..'.'.*..'.".
Maine '....'.'.'...'..'.'.'.'.'.'.'.'.'
Minnesota '.'."'.".'.'.'.'.'.".'.'.'.
St. Paul and Minneapolis.!
Oregon and Washington
,298 Iowa
,n84 Michigan i
,3S6 California
296 Los Angeles
.093 San Francisco 1
,122 Florida
,«»2 Georgia
,029 Arkansas
,512 Virginia
,412 North Carolina
336 Kentucky
601 Mississippi
409 Tennessee 1
9t2 Texas i
336 Alabama
71 Ohio ]
766 Cleveland
,306 Colorado, Montana, Jilalio
242 and Utah i
613 New Hampshire
ti:^4 Connecticut ]
Iff7 Vermont '.'.'.
816 Massachusetts 2
76 Boston 1
506 Wisconsin i
278 District of Columbia '.
818
962
293
,427
206
.534
,08S
47
483
60
761
511
838
124
,169
,111
166
,549
910
.144
1,56
,221
328
,180
,048
,227
551
Total 5.3,597
anrt^nnJ^ ^Ti^il''^^ 7'^'* ""1^. ''"^"^ «' ^'<^ inhabitants
«m, nSw^^'tifr'* therefore come in contact with about one-
ITnitert 'ffnfL K.*'f°f"'*' ^""•I'fr of the medical profession of the
United btates, but from the statistics above given you will see
eacL nhvst'ian^'a, /'''"P^"' ''^^'f^^'' •"°" than two boTtles?o
resnect to ac,pnt. L^^ ^^ '^'"'?*« y°" y'^'' Position, with
respect to acceptance of samples, is an unusual one Tn
UsfeZre thanTH'^^" ''''^''\^' '" *^° ent"irel OoS°of otir
list not more than 25 decline samples. This question has been
under frequent consideration. We have reasoned that our
remedies have been before the medical profession for 30 years ;
that their remedial values and standards of excellence have
been determined by abundant clinical exjjerience, and that
there is no more occasion for distributing samples of ethical
preparations, such as we claim ours to be, than there would be
for the distribution of samples of morphin, quinin, or any
other standard fluid-extract. The formulas of our combina-
tions embrace only such drugs and salts as are recognized and
fully described in the U. S. Pharmacopeia and standard works
on materia medica, but when we present that matter of limita-
tion of samples to our representatives, they say that our com-
petitors are distributing from four to six bottles of their jjrepa-
rations to every physician they call upon, and that unle.ss we,
in a certain measure, keep pace with the lavish distribution of
samples of our competitors, we are outclassed and our work
goes for naught. Within the past week it has come to our
knowledge that a certain manufacturer of a proprietary com-
pound is giving $50.00 of stock of the company to every physi-
cian who will agree to prescribe their products. Our own
experience has been somewhat like this: We were the first to
manufacture in ; it was a new addi-
tion to the physician's armamentarium, and as such we felt
free to place samples in the hands of such physicians as were
desirous of becoming acquainted with the product and making
a clinical trial of its virtues, and we are of the present opinion
that it is only with new products tliat manufacturers are justi-
fied in giving, and physicians in accepting, samples. Other-
wise, the coudition seems to lie present that the manufacturer
who can bestow the largest gratuity in the shape of samples of
his wares, secures the clientage of the medica] profession with-
out respect to the questions of merit, ethics or integrity of the
different rivals for patronage. There is one point which is not
generally understood by the medical profession in connection
with the matter of samples. This Company packs -its
goods, including samples, in such a manner that by delabeling
the package no clue to tlie identity of the goods remains, but
without exception, especially in similar lines, the samples of
competing products submitted to the physicians have the name
of their products blown in the bottle, emblazoned on the caps
and burnt into the corks, so that if the physician presents to his
patient the sample bottle left with him, he informs the patient
that he is prescribing a proprietary article, the name of which
he can ascertain for himself, and if he is endowed with the
ordinary decree of intelligence, can save the physician's fee in
the future by simply going to the drug store and buying the
prescription in question. Tlie result is obvious, and it is a
matter of every day experience with us to have the laity .say,
" Why, I never heard of your goods nor anything about it, but
I have heard of ," naming one of our competitors who has
pursued this indirect method of popularizing this preparation
to such an extent tliat a large proportion of their sales come
from the laity who have been taught the habit of self-prescrib-
ing through the physicians distributing the samijles left in their
hands.
As you indicate, there should be a meeting ground for the
selfrespecting prescriber and the mauufacturer whose inten-
tions are honest in a desire to conserve the interests of his
patrons, and at the same time prevent his own interests from
being impaired by the some time unscrupulous and always
strenuous competition.
We frankly confess that we are perplexed and greatly in
doubt as to the proper methods to pursue to meet all the condi-
tions that are present, and while we have been often irritated at
the winning way of our friends, by some of the methods out-
lined, we have never yet hesitated in the conviction that a strict
observance of ethical modes of advancing the scale of our prep-
arations would in time receive due recognition, although this
solution at the present time seems much further from realiza-
tion than ever before.
We have been free to place many matters before you whicli
we have carefully kept to ourselves, and the only condition that
we impose with respect to the use of tlie statistics submitted is
that you do not indicate the source from which you obtained
your information ; and if there are any other points that occur
and which we have not made clear in "this, we shall endeavor to
aid you to the best of our ability — and as for a discussion of the
question or questions, we stand ready at all times to cheerfully
submit our views. Yours very truly,
Accoi-ding to the figures the goods given away by this firm
represent an outlay of about ^ILiVlO in one year, not including
the expense of traveling salesmen, physicians often, nor of
samples distributed during medical conventions. If one con-
servative firm expends this large sum of money during one
year on free samples to physicians, what must all the firms in
tlie United States give away yearly? What a comment this
furnishes on the business morals of physicians and manufac-
turers, especially the former, who make such injurious
extravagance possible.
Another point that I wish to make may be presented briefly
by reference to a too frequent condition of affairs which here
and there present themselves to the mind of the intelligent
July 19, 1902]
PKEVALENT OBSTACLES TO PEOFESSIONAL UNITY iamkbican Mkbicin. 107
citizen, and especially to the observant physician. It may be
found in towns and cities of moderate size. I suppose a case,
founded upon facts, to illustrate the evil :
In a town or city of say 2.'),000 inliabitants a vagrant negro
IS arrested by the police and held as a smallpox suspect. There
is on duty at the time a sanitary official of the city who hap-
pens to be a practising physician ; he takes charge of the
vagrant patient and isolates him in an unoccupied house upon
theoutsltirts of the city, provides him with an attending nurse,
aud visits him, we will assume, daily for a week or 10 days.
The patient does not appear dangerously ill, for in the midst of
his detention he sits up in a chair and has his photograph
taken, which in due time is reproduced in the newspapers,
showing his face lightly marked by the eruptive disease. As
described by the daily prints the case is one of that current
moderate type of smallpox which would, in an ordinary way,
detain the stranger in the hospital about three weeks— at any
rate we will suppose this to have been the fact. Recovery fol-
lows, and the patient is discharged to resume his vagrant
jonrneyings over the country.
We will suppose that the sanitary official is employed by
the city at a salary so much per annum, intended, it is under-
stood by the public, to remunerate him for the performance of
all his otlicial duties. But he construes it otherwise, for he
causes a voucher to be tilled out in his favor for asum, say JH25.00,
for the professional care ot the atoresaid stranger, aud with this
voucher endorsed by a member of the city council, the
city treasurer cashes it for him. The bill is not item-
ized and presented before the city council in the usual
way, but is passed througli the emergency route to the
city treasurer's office, thus avoiding scrutiny and, so far as
passible, criticism. The transaction we will assume is dis-
cussed a great deal through the partisan daily press at the time,
and that tlie discussion is not calculated to increase public'
esteem for the medical profession in said city. It is natural
that tlie low professional morals of one physician should be
applied in some degree indiscriminately by the public to the
profession as a whole, and so it always is.
In one such case, after the daily f)apers had informed the
public of the advantage taken of the city, the public caused the
city council to close further raids on the city treasury by means
of vouchers of that kind.
Take a furtlier ilhistration of professional venality:
A licensed physician, wo will suppose, is requested by a
public official to attend current smallpox patients in a public
way during a period of two or three months. As no stated fees
are agreed upon, the said physician presents the city council in
due time with a stateuuiut in whicli ho estimates his profes-
sional work at, say, jiKi.OO per ea<^li professional visit. In one
su<'h instance known to me council referred this bill to a com-
mittee, and in due time its i)ayment was refused altogether.
Now while the city was l)eing presented with large bills in a
public way, as the information was, other resident physi<^ians
wore attending alleged snuillpox patients for the customary fee
of ?2.00 per visit.
Besides these supposed cases numerous other illustrations
of low morals in professional relations in public places readily
suggest themselves to every one. Venality in official life is
regrettable, especially when physicians are allected.
Tliat present medical conditions are unwholesome through
being permeated by commercialism from dilferent sources
must be fairly apparent to every observing person, aud prob-
ably one of the most potent causes of this is the overabundance
of medical colleges and medical college products. Overcrowd-
ingof the profession, and the struggle for place and subsistence,
furnish many i)hysicians with ex(!Usos for laxity in morals and
tliereby limit the profassional public as to independence and
fairness and unity.
I beg to refer the student of this branch of the subject to a
vigorous article by Eniil Ainberg' which treats of medical
colleges and overcrowding of the profession, commercialism
and advertising, and in whif^h he makes a plea for medical
schools to be made (State institutions as a remedy for profes-
sional ambition and abuse. It will bo observed from his pro-
fessional and official relations that he has had ample opportu-
nity to speak with authority. In the paper cited ho quoted
with endorsement of sentimout these paragraphs : '
" Our 10() medical colleges, however, turn outannually a crop
of nearly li.ljod graduates, or over 2,000 more than can thus b«
provided for.
" It is certain that the multiplication of d(K:tor factories has
gone far enough in this country, though as yet it does not seem
to have been cuecked."
' I'hikttlelphia MediccUJourntU, March 22, 1902, p. 544.
' Journal of the American Medical Aitociation, J uly 27, 1901, p. 270.
He continues :
. "The status of the medical profession in our country today
will, I hope, in the future be understood and excused only by
\-irtueofthe historic method. There is nobody more proud
than I of the illustrious achievements of our own medical men,
but, unfortunately, we have today an oligarchic state of affairs.
1 am speaking of the great majority, aud try to compare in my
mmd the medical conditions of today with the state of affairs
which could exist if medical matters were arranged according
to the intellectual and moral standards of well educated and
conscientious American citizens."
The reflections suggested by the foregoing are many and
varied. To use a somewhat hackneyed expression, the profes-
sion does not have to do with a theory, but a condition. It is
plain that many active doctors— I do not say physicians— ought
to be remanded to the stable or cornfield, where acts guided by
low moral sUmdards are not so far reaching or injurious In
effect. There is undoubtedly a necessity for professional reor-
ganization, or more accurately stated, reform.
The division of fees between the specialist and the general
practitioner in cases in which the two are employed together
has been much discussed during the past year in current medi-
cal publications. But this is a minor offense in professional
morals compared with those to which attention and discussion
is here invited. What is the remedy for unfortunate existing
professional conditions, if any? Is it to be found through
national legislation, or in the creation of a national board of
examiners, as suggested by Dr. Stansbury Sutton,' or is it to
be found in whole or in part through a higher standard of
medical education, or as Dr. Amberg suggests, that " medical
schools shall be State institutions? "
All these recommendations are applicable in degree, but
standing alone neither of them is probably sufficient, and none
of them is hardly available without much closer professional
organization and unity than exists at present. For the present
allow me to suggest the use of that most potent and powerful
remedy, agitation, discussion, in line with tlie recommendation
of the late Dr. Jerome Cochrane, of Alabama, that pioneer
student in medical sociology in this country. In 1875 he said :»
" We have no hesitation in saying that the medical profession
is fully able to l)riiig about a reforniallon of all the evils from
which it suffers; but this consummation, most devottidly to be
wished, cannot be accomplished by wishing — cannot be accoin-
])lished by grandiloquent speeches or paper resolutions— can
indeed be accomplishe<l only in one way, namely, by wise reso-
lute work, and by thorough organization and concert of; action
among the members of the profession."
As an earnest student of this subje<!tfor many years I know
of no remedy for the general practitioner against these evil
professional conditions (combinations, I had almost said) e<]ual
to that of agitation. I^et the truth be told temperately, frankly
and openly, and iUs effect will not long bo a matter of doubt.
So long as the general practitioner is content to do pra<'tically
all of the professional drudgery in silence, so long he may and
will do it. The physician of today is solicltixl t<M) ollen to
undertake <iiiestionablo professional transactions, a sort of pro-
fessional drudgery— if not something more than this, particu-
larly by manufacturers and merchants of therapeutic com-
pounds, and by attorneys-at-law as aid-do-camps and helpers
in some of their schemes and eflTorts in courts of law and by
time-serving politicians.
Certainly thoughtful agitation is tlio best and most avail-
able weapon for use at present in behalf of a rational working
standard in morals in our historic profession. " Coiiscionce is
the law of laws," ' and must be appeale<I to on all opportune
occasions in our individual actw and words, as well as in our
colle<rtivo or public relations, if wo would have the profcwslon
united, harmonious and powerful, and perpetuate its most vhI-
uablo characteristics.
liCaK'ie /Vitainat PaliidiHin in CorHlua.— Through tho
clforls of M. Hxttesti a Ictigiu- iigainst iialudism has Ixmmi formed
in t!orsica. .\ br(K;hure on prophylaxis against the bile of
mosuuit'is has lieen issued, and elfurts to lower the price of
(|Uinin will be made.
' Ameriean MrUMnr. DeccinlsT 2S. 1001, p. I0-J8.
* Alabama Meillcal AhkocIhIIou Riik'H, p. 4W.
> I^amnrtlne.
108 Amkbioan MBoiomai
THE WORLD'S LATEST LITERATURE
[July 19, 1902
THE WORLD'S LATEST LITERATURE
Journal of the American Medical Association.
July It, 190t. [Vol. Mxix, No. 2.]
1. MuwMilivr Insufflclency of the Mitral Valve. Charlrs Spkkcek
WlI.I.rAM.SON.
2. Review of the Histology of the Dcnhil Pulp. V. A. IjAtham.
8. Prurlliis Anl: HtroriK Heat Its Best Kemedy : New Apparatus for
Its Appllcjitlon. Kdmund Andrbwh.
4. Electrotaermlc Hemostasis In Abdominal and Pelvic Surgery
ANOKKW J. DOWNKS.
2.— Histology of Dental Pulp.— Latham discusses the
importance of histologic and physiologic training in dental
schools if any great work is to be done. He describes the
function of the pulp as an absorbent organ in the deciduous
teeth and the pathologic conditions resulting from premature
death. Microorganisms in the dentine penetrate to the pulp in
8O9!, of cases. Almost all pulpless teeth are infected and give
abscesses later. The wasting of the alveolar ridge after removal
of teeth is due to extraction of the pul]), on which its
growth depends, as well as to the local damage caused liy
extraction of the tooth itself. Gingivitis, alveolitis and pyor-
rhea alveolaris may be a sequel of pulp degeneration. The
odontoblasts may be part of the sympathetic system and have
a vasomotor function. He considers the development of the
tooth and the relation between the papilla and enamel organ,
which he believes, from microscopic appearances, are united.
The odontoblasts and ameloblasts both contribute at first to the
intermediate tissue, until finally the latter are cutoff from their
base of supplies. He notes the chief ideas regarding the func-
tion of the odontoblasts, the relation of the pulp to the forma-
tion of dentine and nourishment of the tooth, the distribution
of the capillaries and nervous supply, and the relation of the
latter to the odontoblasts. Possibly a sluggish nutrition, by
means of the collateral plasmic circulation, may be carried on
in the dentine of teeth without a pulp, [h.m.]
3-— Pruritus Ani.— Strong heat almost instantly quenches
itching anywhere, relief lasting from one to several days.
Andrews notes its use in domestic practice in chilblains,
eczema and psoriasis. The anatomy of the anus makes the
usual heat^bearing appliances ineffectual. He has devised a
cylinder, closed at one end, which can be attached to inlet and
outlet tubes, and which is inserted two inches within the anus
while water of proper temperature passes through it. An intel-
ligent patient can use the instrument himself, [h.m.]
4.— See American Medicine, Vol. Ill, No. 24, p. 989.
Boston Medical and Surgical Journal.
July 10, 1902. [Vol. CXLVII, No. 2.]
^- I!"* Nutritive Value of Alcohol. Francis G. Benedict
i. The Basis for the Use of Alcohol In Therapeutics. Arthur R.
C-USH NY,
3. The Influence of Alcohol upon Infection and Its Use in the Treat-
ment of Acute Infectious Diseases. 8. J. Mbltzkr
4. The Common Use of Alcohol as a Beverage. Graham Lusk.
1.— Nutritive Value of Alcohol.— Absorption of alcohol is
so rapid that little enters the intestine. Its absorption requires
no action of the digestive juices. When only 72.5 gm. are given
in 24 hours, less than 2% of alcohol is excreted as such ; it is prac-
tically oxidized entirely in the body. It is not a tissue builder
but influences the storing of fatty tissue. Benedict describes
experiments with the calorimeter. In these no difference can
be detected between the energy furnished by alcohol and ordi-
nary food. Carbon dioxid production and oxygen consumption
do not vary more than with variations in ordinary nutrients.
Initial loss of nitrogen is corrected in experiments of long
duration ; it is not a proteid poison. When used in excess it
causes serious stomachic disturbances, and its habit-forming
property leads to excess. Its toxic properties are not possessed
by any other common food material, and if excessive doses are
so disastrous, we may suspect an insidious action from moder-
ate amounts not apparent in the necessarily short laboratory
experiments. The pathologist and psychologist must settle
this question Pathologic conditions in which nutriment from
this source alone can be used are comparatively rare. At times
it may be of Incalculable service to the physician, but in the
majority of cases its use as food is irrational, [h.m.]
2.— Basis for the Use of Alcohol in Therapeutics.— In
regard to the use of alcohol there is a tendency to substitute
impressions for verifiable facts. With intoxication in the
lower animals there is no excitement. In man, in the absence
of companions, exhilaration is less marked, or may be entirely
absent. The majority of experimenters lean to the view that
stimulation is only apparent. Kvidences of increa.sed mental
activity are illusory and are explained by removal of associa-
tions, which ordinarily inhibit the external manifestations of
emotion. There is lessened capacity for mental work. Ideas
are transformed into movement more quickly, but the move-
ment is executed with awkwardness and inaccuracy. Habitual
operations are least Impaired. Impairment of the psychic
powers from small doses persists from 12 to 24 hours. That
alcohol acts as a narcotic appears to be placed on a firm basis.
This does not condemn its therapeutic use. In acute disease
every effort is made to restrain the activities of the patient.
Anxiety and worry are allayed. This logically explains the
improvement noted. Increase in the amount of air inhaled
may be Induced by reflex movements from irritation of the
stomach. If so, the surplus oxygen is used in the work of
absorbing the alcohol without profit to the rest of the body.
Small doses do not affect the heart ; large doses depress the heart
and blood pressure. Alcohol does not increase gastric move-
ments. It augments the fluid, but not the secretion of ferment.
Appetite is increased by the flavor and promotion of socia-
bility, [h.m.]
3.— See American Medicine, Vol. IV, No. 2, p. 60.
4.— Alcohol as a Beverage.— By stimulating the appetite
alcohol aids in the preliminary "psychic secretion" of gastric
juice. A further flow is brought about by chemic reagents
acting upon the neurosecretory apparatus. Alcohol causes the
gastric glands to secrete even when introduced into the small
intestine or rectum. If too much is taken there is too great
irritation with decreased activity and dyspepsia. It is doubt-
ful whether in normal persons continued encouragement of the
appetite is desirable. The diminution of the sense of fatigue
through depression of the inhibitory centers brings cheer to the
weak and makes work seem easier, thus increasing ability at
first but afterward decreasing it. Alcohol is not favorable to
work of the painstaking kind. It reduces the power for both
mental and physical labor. [h.m.J
Medical Jlecord.
[July Ig, 1003. Vol. 62, No. 2.]
1. Notes on a Few Cases of Hodgkin's Disease and Lymphatic Leu-
kemia. Max Einhorn.
2. TheTreatmentof Pulmonary Invalids In Favorable Climate.s. Earl
S. Bullock.
S. Gynecologic Electrotherapeutics. Bernard S. Talmey.
4. Malaria as a Complicating Factor In the Diagnosis of Appendicitis.
Henry J. Wolf.
1.— Hodgkin's Disease and Liymphatic Ijeukemia. —
Einhorn reviews the literature of these diseases, especially the
more recent investigations, showing the close relation between
them. He reports several cases and notes that the condition of
the blood is different enough to enable us to separate pseudo-
leukemia from true leukemia, especially lymphatic leukemia.
The opinion of Pinkus and others that the relative number of
lymphocytes to the other white cells must be increased in
pseudoleukemia is not wholly in unison with these cases. We
may perhaps assume that in consequence of the disease the
energy of the lymph glands is expended on their own develop-
ment and thus there is no increased formation of lymphocytes.
The prognosis of both disea.ses is bad, leukemia taking a more
rapid course. The therapy is the same. Food should be given
often and in small quantity. Country air, cold ablutions and
rubbing are beneficial. Arsenic, sodium oacodylate and
uiethylene-blue may be used. The x-rays are worthy of trial.
[h.m.]
2.— Pulmonary Invalids and Climate.— These invalids,
other things being equal, have a much better prospect of recov-
ery in a favorable climate. They should not go with the idea
July 19, 1902]
THE WORLD'S LATEST LITERATURE
[AiCEBioAK Medicine 109
of roughing it. Creature comforts are imperative, and in the
southwest §100 per month is none too much. Cheerful hopeful-
ness is a large element in the cure. The important elements in
climate are conditions that allow the patient to remain comfort-
ably out of doors the whole year and dryness and sunshine,
which are inimical to bacterial life. Thus intercurrent affec-
tions, as cold, and pneumonia, and tuberculous reinfection, and
the mixed infections are avoided. High altitude causes
emphysema, which blocks the progress of the lesion. The
lowered circulatory tension lessens pressure at the bleeding
point. The sudden rise in erythrocytes in the capillaries is
due to this also, and may coexist with anemia. Specific medi-
cation is useless and unjustifiable. Drugs inay be used to alle-
viate symptoms. Forced nitrogenous feeding is a sheet
anchor. Cure can be perfect under long enough treatment.
Relapses in unfavorable environment may be due to the same
susceptibility as caused the first attack. The rational thing is
to make a new home in a new country, such as western Texas,
eastern Colorado, New Mexico and Arizona, [h.m.]
3.— Gynecologic Electrotherapeutics.— B. S. Talmey
makes a strong plea for the use of electricity as a therapeutic
agent in the treatment of many forms of gynecologic disease,
holding that its efficacy should be tried before resorting to
mutilative surgery. He explains the anatomic and physiologic
effect of the positive and negative poles, and advises its use
according to tlie principles laid down by Apostoli. The faradic
current, by reason of its contraction of tlie muscular fibers, is
used in subinvolution, postpartum hemorrhages, amenorrhea,
sterility and chronic metritis. The anticongesti ve action of the
positive pole is of value in metritis, endometritis, and hemor-
rhages. Apostoli used it also for its microcidal properties.
The denutritive action of the negative pole is made use of
mainly in fibroids where it causes the cessation of hemorrhage,
disappearance of all symptoms of compression, and the symp-
tomatic restoration of the patient. Keith found that out of
seven cases of fibroids treated by electricity, five had entirely
disappeared. Engelman found, in prolapsus uteri due to
relaxation of ti.ssue, the judicious use of the electric current to
be of the greatest value, at the same time affording perfect
immunity from pain. There are strict contraindications to its
use. Every suppuration in the pelvis contraindicates the use
of electric treatment. When febrile excitement arises, all
treatment is to be suspended. The exact diagnosis is, therefore,
one of the prime necessities before any electric treatment may
be tried. But the diagnosis once established, electricity can be
and has been used with safety and the best results by the
greatest authorities, [w.k.]
4.— Malaria and Appendicitis.— Wolf reports a ca.se of
malaria simulating appendicitis and another coexisting with
it. Aflections of the appendix seem to awaken long dormant
or unsuspected malaria. The chill and fever may be very mis-
leading and induce untimely operation when there is no his-
tory of previous occurrence and examination fails to reveal
Plasmodia. Malaria should be suspected when the ileocecal
symptoms, pain, tenderness, rigidity of rectus, are mild or on
the wane and do not harmonize with the gravity of the general
manifestations. If the grave symptoms are referable to the
appendix a rapidly acting antipyretic might shed some light
by depressing the temperature withotit a corresponding decline
in pulse rate or alleviation of other symptoms, [h.m.]
New York Medical Journal.
July ■'>, 1903. [Vol. i/XXVi, No. 1.]
I. .MinorlnJurleROf the Eye. Pkkcv Kbii)BNIikk<i.
■.; The DItrerontliil I)liiKn<»i« of Acut<; Polyarticular Hheuinatlmn,
from a Siirxlral stunilpoiiit Wai.tkr (i. Stkhn.
:i A Cttst^ of i'roKri'ssivc MiiMuliir Atrophy and oni' of I'HencIohyper-
tronhl.^ I'aralyslH In Viiiiiik (Milldren. M. Nkustakdtek.
i. Dlslnli-rllon. RoiiEKT.1. Wilson.
.1. The Kyc as a Kactor In CnusInK (ienemi Hymptom»; Illuiitratea by
tli« Ueporlofa Cb»c. James L. Minok.
I.. A Further Htudy relative to the Pelvic Organs, their Ansoclated Dl»-
ea!«M, 8ynipU>um. and Tretitmenl. Joh.n L. Jklks.
i.— Minor In,|urie8 of the Kye.— Kridenberg classifies
injuries of the eye. a<!i:ordiug to tlieir etiology and mode of
.iction, into (1) injuries l)y blunt violeue*— contusion or com-
motion; (2) injuries by penetration or laceration — wounds;
(3) injuries by retention and irritation — foreign bodies ; (4)
injuries by combustion and corrosion — burns and .scalds.
Injuries under each class, with their treatment, are considered
at length, [a. O.K.]
2. — Differential Diagnosis of Acute Polyarticular
Rheumatism. — Stern says that the features of acute poly-
articular rheumatism which may lead to difficulty in diagnosis
are: (1) The disease may manifest itself in only one joint
throughout its course ; (2) it may be of mild type and effusions
scant, and yet present later on all the grave endocardial symp-
toms of a severe case; (3) the initial acute symptoms atid the
polyarticular character may be maske<l, and the di.sease end
with a sudden attack on one joint, which becomes swollen,
painful, and ankylosed; (4) the swelling may not always be
situated within the capsule. He names 14 conditions from
which rheumatism is to be differentiated. The most difficult,
perhaps, is acute pseudorheumatic tuberculous arthriti.s, of
which two cases are given in illustration, [a.o.r.]
3.— Progressive Muscular Atrophy and Pseudohyper-
trophic Paralysis in Young Children.— Neustaedter gives
notes of one case of each of the above diseases. The first was a
Russian girl of 6, the .second an Austrian boy of 8. [a. O.K.]
5.— General Symptoms fVom the Eye. — Minor reports the
case of a colored woman of 67, who was blind in the right eye
from acute glaucoma one year previous, and had acute glaucoma
in the left, this being relieved by iridectomy. Although the
eyes gave pain at first, in each it was followed by nausea and
vomiting, prostration, etc., so that the attending physician had
made the diagnosis of bilious fever, [a.o.e.]
Medical News.
July li, 190t. [Vol. 81, No. 2.]
1. Therapeutic Uses of the Organle K.\tracU. O. T. Usbobnb.
2. Tendon Transplantation : lis History, Indications and Tccbnic. J,
Hilton Waterman.
:i. A Caseof.Strangulated HernlaoftheOvaryand Fallopian Tube. A.
T. Bri.stow.
4. The Bcsiirrectlonlst'! of London and Edinburgh. Francis R.
Packard.
l._See Amerinvi Medicine, Vol. Ill, No. 21, p. 850.
2.— Tendon Transplantation.— Waterman, in this valuable
paper, gives the history and evolution of tendon transplanta-
tion ; lie then sketches briefly the symptomatology and diagno-
sis of the conditions for which tendon grafting is performed ;
and, finally, the operation itself, its technic and results, is
described. The operation was first done for club-foot by Nico-
ladoni, in 18H1, but the operation of tendon grafting for severed
tendons which could not be sutured goes back over a century.
A description of the ordinary operation as done to relieve, if
possible, the condition supervening upon infantile paralysis, is
as follows: The mu.scle and tendon to be transplanted are
strongly stretched, in order to make them (■orro»p<md to the
natural state of relaxation. But before this is done the tendon
of the paralyzed muscle is drawn strongly forward, thereby
placing the extremity In a hyporoorrected position. The tendon
of the paralyzed muscle Is then freshened upon one e«lge or
else slit up, and the tondon of the sound muscle is united with
the freshened surface or grafted into the slit of the paralytic
tendon. A tunnel should be improvised with the forceps or
some like instrument, running from one tendon to another,
and the graft may be placed in this passage with the aNsurnnoe
of the formation of a new sheath and with little to fear from
adhesions, provided perfect asepsis has btwn observed through-
out. It is ixwt to make a butUm-hole for the reception of the
transplanttxl tendon, the suture material consisting of silk or
kangaroo tendon, [a.ii.c]
3.— gtrangulaied Hernia of the Ovary and Kalloplan
Tube.— The patient, a multipara, aged 44, had history of injury
when a child, followe<l by a hernial tumor in the groin, which
w^as easily roduce<i, but rocnirred from lime to time, four
years having elapsed between the present recurrence and the
preceding one. After lifting a heavy weight a sudden pain was
felt and the tumor in the left inguinal could not bo re<luced as
usual. The tumor in<Toas(Hl In sl/.e and became so painful as to
110 AKXBICAN MKOJOHfB]
THE WORLD'S LATEST LITERATURE
[Jur-Y 19, 1902
call for surgical treatment. The usual incision for hernia was
made when it was found that the hernia consisted of the left
Fallopian tube and ovary. The ovary was cystic and there was
an abscess of the tube about an inch and a half from its
extremity. The round ligament was also part of the hernial
contents. The sac and its contents were removed without open-
ing the abdominal cavity, the stump of the broad ligament
being sutured in the inguinal canal much after Kocher's method;
after thorough cleansing tlie external wound was closed with-
out drainage. The patient made a good recovery. The author
has collected records of about 100 cases of hernia of the ovary,
and his survey of the literature is accompanied by a bibli-
ography of the same. [C.S.D.]
Philadelphia Medical Journal.
July 12, 19011. [Vol. X, No. 2.]
1. Mutism and Aphasia. Hermann Gut/.mann.
2. The Political Side of Medicine. John B. Roberts.
3. Report of an Epidemic of Cerebrospinal Meningitis. F. Alan G.
Murray.
4. Intestinal Anastomosis. John R. Cook.
6. Some Points in the Treatment of Crushing Injuries Involving the
Large Joints. John Glendon Sheldon.
2. — See American Medicine, Vol. Ill, No. 25, p. 1063.
3. — An Epidemic of Cerebrospinal Meningitis. — Murray
details five cases of cerebrospinal meningitis. The patients con-
sisted of two males and three females ; the ages of the former
were 22 and 36, of the latter 10, 13 and 20. The girls were sisters
and lived together. All of the patients were in excellent health
until the onset of the disease, which was sudden, vomiting and
headache occurring in four of them. Of the patients, four had
Kernig's sign, opisthotonos and herpes on their lips and noses.
One case was evidently an abortive one, as it began the same as
the others, but ended on the fourth day in complete convales-
cence. In three cases the pulse-rate was slow and the tempera-
ture very high ; this was one of the most remarkable and inter-
esting features of the disease, and seemed to point to a fatal
termination, as all these patients died. Two of the cases ran an
acute course and then improved, finally becoming chronic and
dying from paralysis, [f.c.h.]
4. — Intestinal Anastomosis. — Cook details five cases of
intestinal anastomosis. In one case, gunshot wounds of the
intestines, the mesentery and bowels were so mutilated that it
seemed safer to excise than to suture each opening, 28 inches
being removed in one piece and two inches in another. Two
Murphy buttons were introduced. In excising the bowel a
V-shaped piece of mesentery was not removed, merely enough
of the mesentery being incised to detach the bowel from it, then
ligated in one large mass. When the ends of the intestines were
brought together the mesenteric mass was folded on itself and the
edges sutured to hasten union and prevent accident by a loop
of the bowel slipping through it. The patient made an unin-
terrupted recovery ; one button was passed the thirteenth day,
the other one in five weeks, [f.c.h.]
5.— The Treatment of Crushing Iiy'urles Involving the
Large Joints.— Sheldon strongly believes that primary drain-
age of compound injuries of a joint is not only unnecessary but
harmful. The injured tissues should be cleansed as thor-
oughly as possible. After the detached fragments of bone
have been removed or placed in their proper positions, the joint
cavity is completely closed by the suturing of ligaments or
muscles. The defect in the skin is not closed. Skin incisions,
made for the purpose of exposing deep structures, are sutured ;
but the traumatic wound is not repaired in any part. The
advantages of this method of treatment are, the clean joint
cavity is protected from the unclean superficial structures ; the
superficial tissues are thoroughly drained ; secondary infection
of the joint cavity is impossible. The possible disadvantage of
the method is that, if the deep structures have not been ren-
dered aseptic, secondary drainage becomes necessary. This
objection is not a serious one, as an opening into the joint
cavity can easily be made; and, if the osseous tissues are
extensively injured, secondary operative interference will
usually be necessary, even if the joint is drained at the primary
dressing, [f.c.h.]
CLINICAL MEDICLNE
David Biesman A. O. J. Kelly
Streptococci Characteristic of Sewage and
Sewage-polluted Waters, Apparently not Hith-
erto Reported in America. — In a preliminary com-
munication to Science (May 23, 1902), C. E. A. Wlnslow
and Mi.ss M. P. Hunnewell, of the Mas>sachusette Insti-
tute of Technology, call attention to some important
discoveries of the bacteriologists connected with the
Local Gtovernment Board of England. These latter in-
vestigators found two new organisms in sewage and
sewage-polluted waters, which, with Bacillus co/i com-
munis, are very likely to be of service in tracing the his-
tory of water-contamination. The organisms are BaciUiis
enteritidis sporogenes and the sewage streptococcus of
Houston. Houston isolated both streptococci and staphy-
lococci from polluted soils, from crude sewage, and from
impure water ; but he lays stress mainly upon organisms
of the former class as germs unlikely to persist for a
long time outside of the animal body, and, therefore,
when found, indicating fresh pollution. He maintains
that search for them should constitute a large part of
bacterioscopic analysis of potable waters. Winslow and
Hunnewell first isolated the sewage streptococci of Hous-
ton from 2 out of some 100 specimens of wash water
examined. Later, they found them in Boston sewage,
and in fresh feces. During March and April of this
year they examined 48 different samples of water from
the Charles, the Mystic, the North, and the Neponset
rivers. From 22 of the 48 samples the colon bacillus or
allied forms were isolated. From the remaining samples
(from 25) cultures were obtained which gave all of the
reactions of Houston's streptococcus. Stained prepara-
tions made from agar cultures showed short chains of
streptococci, mingled with irregular, plate-like masses.
They also found a second type, apparently not noticed by
the English observers, which has all the characteristics
of Houston's organisms, but liquefies gelatin, which the
commoner streptococci do not. The organisms are
closely allied to Streptococcus pyogenes; but until a
more systematic study is made of the group, it is recom-
mended that the sewage forms be provisionally known
as the sewage streptococci of Houston.
The observations of Houston and his fellow-workers,
and of Winslow and Hunnewell, are important, and
may lead to a more ready determination of contamina-
tion in potable waters.
Surra : Its Possible Introduction Into the
United States. — The discovery that this infection of
horses and other domestic animals exists and has existed
for some time in the Philippines has led to the exclusion
from the United States of all animals from these islands ;
but in view of the tremendous financial loss which
would result from an epidemic among American horses,
mules and cattle should it prove that the disease htis been
introduced by such animals as have already been landed,
and to guard against the introduction of surra or closely
allied if not identical diseases from other tropical coun-
tries, the Bureau of Animal Industry of the U. S. Depart-
ment of Agriculture has issued an " Emergency Report "
in order that veterinarians, health officers and stock
owners may i)romptly recognize the malady if met with,
and that proper measures may be adopted to stamp it
out. Surra is a form of trypanosomiasis, a specific, con-
tinuous, infectious, febrile disease ; caused by certain
flagellate, hematobius, protozoan parasites belonging to
the genus Trypanosoma. It is transmitted by the bites
of insects, by the ingestion of infected water or food, and
by congenital infection ; it occurs epidemic in tropical
Asia, Africa and South America, chiefly in the wet
season, and is invariably fatal, except under the serum
treatment recently discovered by Laveran.^
1 See " Nagana Serum," American Medicine, May 31, p. 893.
July 19, 1902]
THE WOKLD'S LATEST LITERATURE
[Ambrican Medicink 111
There are several kinds of trypanosomiasis recog-
nized, each with its specific hematozoon : Surra ( Trypano-
soma Eoami) of India ; Nagana or tsetse-fiy disease {Try-
panosoma Brucei) of Africa ; Dourine or maladie du coit
{Irypanosoma equiperdum) of Algiers, France and
Spain ; Mai de caderas {Trypanosoma equinum) of South
America; Rat trypanosomiasis (TVy/wjoanosowrt Leicisi)
of Paris, London and elsewhere ; Canine piroplasmosis,
a form of trypanosomiasis due to Piroplasma bigeminum,
was reported to the Academie de MCdicine of Paris, June
17, 1902, by Nocard and Motas.' Whether the various
forms of trypanosomiasis really represent distinct
maladies is still the subject of discussion, and we print
in the current issue of American Medicine valuable con-
tributions to the subject by Dr. Joseph J. Curry.
The timely warning given by the papers referred to
furnishes an excellent illustration of the advantjiges
which accrue from thorough biologic and zoologic train-
ing for physicians; and it is to be hoiked that it may
prove effective, confronted as we are by a rapidly grow-
ing commerce with tropical countries and a correspond-
ing danger of infection, in excluding from the United
States any infection of the nature of nagana, with which
all readers of works on African exploration are familiar
as being transmitted by the dreaded tsetse-fly.
Concerning Postluetic Conjugal Diseases of the Nerv-
ous System. — Discussing syphilis as a factor of etiologic
importance in tabes and paralytic dementia, Idelsohn '' makes
mention of the frequency with which the two are known to
occur in husband and wife. He believes that this is important
evidence in the consideration of the question as he does not
think this occurrence to be accidental. He has collected 45
cases from the literature and added five of his own. In 47% of
these both husband and wife were paralyzed ; in 20%, the hus-
band was paralyzed and the wife had tabes ; in 18%, the wife was
paralyzed and the husband had tabes ; and in 20% both had
tabes. At times the diseases occurred simultaneously in both
husband and wife; in other cases, at considerable intervals. In
most instances the husband suffered first, the wife succumbing
to the disease shortly before the death of the husband. Syphilis
was confessed but 36 times in these cases. The author con-
iludes that it would be better to forbid widows of paralytics to
remarry as they might infect their second husbands, and thus
expose them to the same disease as their predecessors, [e.i..]
The Use of Dormlol in Epileptics : A Contribution to
the Treatment of the Status Epilepticus.— Dormiol has
been used with satisfaction by Hopjje' in the treatment of the
status epilepticus. The remedy is given in enema. A solution
of 10 grams in 150 cc. is made; and of this 2 to 3 tablespoonfuls
are added to 1 to J of a liter of lukewarm water, [d.b.]
Brain Abscess In Typhoid Fever Due to Baclllos
Typhosus.— McOlintock * has found that so far there have been
reported 19 cases of meningitis in all of which Bacillus typhosus
was present, in the great majority in pure culture, and 5 cases
of brain abscess in none of which Bacillus typhosus was found.
He then reports an interesting case of brain abscess occurring
in the course of typhoid fever and found to be due to the
typhoid bacillus, [a.o.j.k.]
The Dellnltion of Hysteria.— Hysteria is a condition of
which no two men have identical conceptions. The cause of
this lies in the fact that writers are not explaining the disease
clearly. In many instances it is not even well defined.
Babinslil' cla-sses the symptoms of hysteria as primary and
secondary ones. Among the primary symptoms he places
I)araly8e8, contractures, anesthesias, convulsions, etc. An
instance of a secondary symptom is the atrophy which follows
upon nonuse of a jjaralyzed limb. His definition of hysteria is
as follows: 1. It is a psychic condition enabling the individual
I><)sse8singit to produce autosuggestions. 2. Its manifestations
are made up of primary and secondary disturbances. 3. The
primary disturbances are characteriy.ed by the posaibillty of
1 I^i MMlclne Modorno, Juno IK. 11102.
= SI I'llt TsbuiKcr iiicd. Woch., IWl, No. 4.1.
' Miiiichi ncr in( (liilnl«<-he WiKliciisrlirlft, April 29, ]»02.
» Miiciiciin Journal of the Aledlcjil SclenctH, Vol. CXXIU, p. SeS, IMB.
» Alli?. W'lenir mcd. /ellung, liKfi, p. 48.
being reproduced in certain Individuals with rigorous exacti-
tude, through suggestion. They can be made to disappear
through the method of persuasion only. 4. The characteristic
point of the secondary disturbances is that they are intimately
subordinated to the primary ones, [e.i..]
A Rare Cause of Leatl Poisoning: Treatment of the
Colic with Atropln.— Weber ' reports an outbreak of lead
poisoning in several families, which was traced to the use of
water that had been conducted through lead pipes. In another
outbreak the disease was traced to the contamination of flour
by lead ; and it was found that one of the millstones upon which
the flour had been ground had a hole in it, which had been
plugged with lead. In the treatment of the colic, good results
were obtained with atropin. [d.r.]
Kepeated Fainting Spells Following Injections of
Antldiphtheric Serum.'- In view of the incontestable toxic
properties of antldiphtheric serum it is not surprising that its
use is signalized by accidents, local or general erythe-
mas, suppuration, peripheral edemas, etc. These troubles,
often accompanied by more or less alarming general
symptoms, particularly by cardiac collapse, may be delayed for
several days, even to the end of the second week. Somers
(Selby, England) reports cases in which syncope followed the
Injection of antldiphtheric serum at the end of two hours.
This is confirmed by A. M. Saward (London) in two cases
which were very alarming and in which the patients were
revived with great difliculty. [c.s.n.]
Paralyses Following Upon Suppurations.— Serenin ' dis-
cusses neurites and paralyses following upon infectious dis-
eases and suppurations. He has found many cases dealing with
the former condition ; none with the latter. He, however,
publishes three cases of his own belonging to the latter class.
The first was one of parenchymatous neuritis of the external
popliteal nerve, complicating osteomyelitis of the tibia. The
extensor and perineal groups were completely paralyzed, as
shown by the atrophy of the muscles and by the reaction of
degeneration. There was also complete anesthesia to touch,
pain and temperature. The second case was one of left-sided
pyosalpinx, surrounded by a large inflammatory mass, which
also surrounded the uterus. At the beginning of the third
month — the inflammatory mass in the meantime, becoming
much smaller— the upper and lower extremities began to grow
weaker and weaker, until the lower were almost completely
paralyzed, and the upper were so weak that the patient could
hardly feed herself. .Sensibility was also much diminished.
The diagnosis was multiple peripheral neuritis, produced by
the suppurative condition of the tube and ovary. The third
patient had a suppurating cervical gland which was removed.
At the end of the third week the muscles of the shoulder and
lower part of the neck began to feel numb and to grow weak.
This increased until almost complete paralysis of these muscles
existed. Inasmuch as the nerves supplying these muscles were
far from the field of operation, the author concluded that this
also was a case of parenchymatous neuritis following upon the
suppuration. Under the use of massage, galvanism, and toni(«,
all three cases recovered, [k.l.]
A case of hemianesthesia of over eight years' duration,
resulting from destruction of the sensory crossway and lenticu-
lar nucleus without direct Implication of the thalamus. Is re-
ported by Dercum and Spillor.«
Comi>08ltlon of Cerebrospinal Fluid.— SWarek ' had an
opportunity to examine a large quantity of cerebrospinal fluid
from a healthy patient. He found glucose (0.1% with the
polariscope) and a trace of albumin. The dry residue amounted
to 10.4.')2 grams, the organic substances to 2.0»B grams, the ash to
8.356 grams. Of inorganic substances chlorin and siHllum oxid
were present in larger quantities than any other sul>stancos
(4.245 grams and 4.294 grams respectively). [n.K.]
liocomotor Ataxia and SyphllU.— Kournlor* found In
925 out of 1,000 patients a history of syphilis. In the other cases
the syphilis may have been so benign as to escape notice, or It
TmUikIii'Ikt niedlclnlHolie Wochcniirhrlft, April 29, 11)02.
t Iji Sciniilup MMU-nlc, April DO. MHK.
'AllKPiii. WIcn. intKl. /oIlmiK, 1I«W. No. 8.
• American Journal of llio Mt-dliral HoliMii-oii, Vol. cxxlll, p. 444. IBM.
•• HopiK^H<"ylpr'H /,clt. f. phyrtlol. (.'hiinli', Bd. xxxv, Hofl. :), IIHW.
« .Mudlcal PreiiK and Circular, January ■it, 11102.
112 AXKB'CAT* MEDICINI
THE WORLD'S LATEST LITEKATUEE
fJULY 19, 1«U2
may have been h(!r6ditary or conceptional. However, loco-
motor ataxia uiay be due to various spinal affections. Although
it may follow any form of syphilis, yet in 'JO^ii of the above
cases the form was benign; that is, the secondary symptoms
were small in number, sliglit in character and of shortduration.
All syphilitics are threatened, but not in the same degree. The
accidental predisposing causes are nervous exhaustion, nervous
heredity and inadequate treatment of the syphilitic disease.
[ri.M.]
Paratyphoid Fever.— Meltzer ' describes a disease of which
probably a dozen well-studied cases are on record, which clini-
cally is at once considered to be typhoid fever, but in which the
Widal reaction has, at repeated examinations, been found nega-
tive. The serums of such patients react very promptly, how-
ever, with bacilli that are isolated either from their blood or
from their excrements. These bacilli belong to an intermediate
group which is related to the " Fleischvergiftungsbacilli " ;
but they are easily distinguished from these. The symptoms
of the disease are those of typhoid fever— headache, drowsiness,
continuous fever, slow pulse, enlarged spleen, rose spots, and
the diazo reaction. Even epistaxis, internal hemorrhages,
delirium, respiratory complications, and OS teomyeliticab.scesses
have been recorded. In seven of the cases the primary diar-
rhea became changed to constipation. The author prefers the
name paratyphoid bacillus for the microorganism, and para-
typhoid fever for the disease. He suggests that in cases in
which the Widal reaction is obtained only in dilutions of 1 : 10
or 1 : 20 the paratyphoid reaction be studied ; and, should it
exist in greater dilution, that further study may reveal the
case to be one of paratyphoid, instead of typhoid fever, [e.l.]
Electric Phenomena During Volcanic Eruptions and
Earthquakes.— Onimus,^ referring at tlie SociCtf' de Biologie,
of Paris, June 14, 1902, to the many evidences of great electric
disturbances during the eruption at Martinique, recalls the case
of a telegrapher at the fort of Tcte-de-Chien, near Monaco, who
was paralyzed by a violent electric discharge precisely at the
moment of an earthquake shock in 189t). [c.s.d.]
Reflex Convulsions Due to Ascaris liumbricoides.—
Naab,' a practitioner in Asiatic Turkey, has seen a number of
instances of convulsive and comatose states, apparently due to
the round-worm, and disappearing after the expulsion of the
latter with santonin and calomel. He calls attention to a pecu-
liar symptom that he has found in every case— the abundant
discharge of water from the mouth during sleep, [d.r.]
A Case of Syphilitic Plexus-Neuritis Arising During
Narcosis.— A syphilitic, who was probably also an alcoholic,
had to have his hands tied behind him, on account of great
excitation, during an operation lasting two hours. After the
narcosis the patient developed bilateral lirachial paralysis, last-
ing a month, and disappearing under mercurial inunction.
Sarbo * believes that the tearing of the plexus-fibers produced
by the backward bending and tying was not sufficient to create
the palsy, but thinks that the latter was caused by the syphi-
litic condition, and only provoked by the tearing. A decision
as to whether the alcohol could be considered as the main fac-
tor in producing the paralysis is not possible, but it was most
likely an assisting factor, [e.l.]
Myelitis Following Acute Encephalomyelitis.— Huis-
mans'^ reports a ease of a woman, aged 24 years, who at the age
of 4 years had measles, and subsequently an uncertain gait.
At the time of the report the gait was distinctly ataxic, the
patient swayed when standing with the eyes closed, and she
fell when she turned suddenly ; the knee-jerks, as well as the
other tendon and periosteal reflexes, were absent ; the Babin-
ski reflex was present; no lancinating pains ; the pupils did not
react to light and but slightly to accommodation ; slight nys-
tagmus and slight strabismus; no intention tremor and no dis-
turbances in speech, although the patient was dull mentally. \
It is presumed that the measles acting as an infection produced |
an acute disseminated encephalomyelitis and that the present
1 New Yorker med. Woch., December, 1901.
- La medicine Mo<lerne, June 18 19o^
SMiinchenermedicinlsche Wocnenschrlft, May 13. 1902.
<La Presse Meateale, WOI, No 12 »j ■^, imj-.
-Zeitschrlft fiir kljnlsche Medicin, xllv, 32ti, 1902.
alTection is a myelitis referable to the earlier infection. Dis-
cussing the question of myelitis more fully it is conclude<l that
every myelitis is due to bacterial infection and that other
factors, such as intoxications with chemic poisons, formerly
looked upon as of etiologic significance, of tliomselves produce
no myelitis, but at the most merely a predisposition, or they
increase a predisposition already existing. This predisposition
consists of a congenital or acquired alteration of the spinal
vessels favoring thrombosis. Acute myelitis follows the course
of embolism; chronic myelitis, the course of primary arterial
thrombosis. The occurrence of acute myelitis does not neces-
sarily presume a predis])08ition; chronic myelitis, however,
develops after the combined action of predisposition iand infec-
tion. Acute myelitis may heal with unirritating sclerosis, or It
may progress to chronic myelitis. In many cases the myelitis
is chronic and progressive from the beginning, [a.o.j.k.]
The Etiology and Symptomatology of Arteriosclerosis.
— Hirz ' divides the causes of arteriosclerosis into three cla.sses :
(a) diathetic, (b) toxic, (c) infectious, (a) Under diathetic,
gout, acute and chronic rheumatism, obesity, lithiasis, and
neurasthenia are the most important factors, (b) Among the
toxic, autointoxications, excessive eating, alcohol, and lead.
(c) Among infectious causes the author mentions rheumatism,
variola. Influenza, typhoid fever, measles, scarlet fever, malaria,
tuberculosis, and syphilis. Heredity, in his opinion, Is an
Important factor. He has seen probably a dozen cases
of arteriosclerosis in children. The physical signs include
hardening of superficial vessels, such as the temporal and
radial; characteristic sphygmographic curves; increased blood-
pressure ; a double murmur in large peripheral arteries ;
enlargement of the heart ; a buzzing thrill felt over it; galloj)-
rhythm ; and accentuation of the second sound. In some cases
nothing but tachycardia Is noted; or signs of Insufficiency of
the peripheral circulation may exist. These include numb-
ness, formication, cramps, claudication, gangrene, loss of
memory, aphasia, dizziness, transient or permanent paralysis,
convulsions, softening of the brain, angina pectoris, polyuria,
and albuminuria. Death is usually caused by uremia,
asystole, pneumonia, or edema of the lungs, [e.l.]
The Importance of Slight Variations in Atmospheric
Pressure for the Human Organism.- Rosenbach ^ calls atten-
tion to the importance of slight variations in atmospheric
pressure upon the human organism. These changes can be
readily estimated by means of v. Hefner-Alteneck's variometer.
The apparatus shows that, even in a closed room during a
period In which the barometer is perfectly stationary, there are
constant changes in the .pressure. It is probable that these
slight changes must be taken into consideration in explaining
the catching of cold, [d.r.]
Pseudocirrhosis of the Liver.— Strajesko » reports the
the case of a man of 02, who had dyspnea, pain in the chest, and
edema of the lower extremities, scrotum, and abdomen. His
apex-beat was weak, and found in the fifth interspace, 1 cm.
outside the nipple. There were no murmers, but the second
sound was reduplicated at the base. The apices of both lungs
were infiltrated, but no tubercle bacilli could be found in the
sputum. The patient voided 200 cc. of urine in 2ri hours. He
was tapped, and improved somewhat under cardiac tonics and
calomel ; but his edema persisted. Six months later he pre-
sented himself, witli complete loss of compensation, gallop
rhythm, and a systolic murmur at the apex. The liver was felt
7 cm. below the margin of the ribs. It was hard and painless.
At the autopsy were found adhesive pericarditis, chronic inter-
stitial myocarditis, and tuberculosis of both apices. The liver
was large and glistening, and adherent to the surrounding
structures. There was also thickening of the peritoneum.
Microscopically beneath the capsule of the liver were found
tubercles, no. fibrous bands connecting the capsule with the
liver. There was but little proliferation of the connective
tissue. The author calls attention to the existence of the en-
larged liver and the tuberculosis, considering the latter an
important factor in the production of the disease, [e.l.]
' La Medicine Modeme, 1902. No. 6.
- Miinchener me<liclhl.sche Woclienschrlft, April 2) 190'
■'Allgcm. \Vien. med. Zeitung, 1902, p. (iO.
July id, 1902]
THE WORLD'S LATEST LITERATrRE
(Ahebican Medicine 113
A. B. Craio
GENERAL, SURGERY
Martin B. Tinker
C. A. Orr
The Surgical Treatment of Sterility iu the Male.
—The influence of the husband in a barren marriage is
usually overlooked, and frequently women are subjected
to examination and gynecologic treatment unnecessarily
for this reason. In 192 examinations of both husband
and wife for the cause of sterility, Orbss found that the
husband was certainly at fault in 33, or over 17 fr,. A
3Hvere double epididymitis has been generally recognized
as the common cause of sterility in the male. With a
view to clearing up this subject more definitely, Martin,
Carnett, Levi and Pennington (University of Pennsyl-
vania Medical Bulletin, March, 1902) have recently car-
ried out a series of studies and experiments of much
interest. Human spermatozoa were stained and care-
fully studied to determine their morphologic character-
istics and considerable normal variation was found ; most
interesting, however, were their experimental studies
upon dogs which led to one operation on a man. Study
of the conditions in numerous cases of double epididy-
mitis showed that azoospermia following double epididy-
mitis was usually caused by obstruction in the tail of the
epididymis ; motile spermatozoa may be found in
great numbers in the epididymis above the obstruction,
and the route is usually clear from the region of obstruc-
tion to the urethra. This suggested the j)ossibility of
switching out the seat of obstruction by a short circuit,
the short circuit to be made by attaching the vas to the
epididymis on the testicular side of the obstruction.
Basing the hope of successful results on the fact that
actively motile, well-formed spermatozoa are found in
all parts of the epididymis, three dogs were etherized
and subjected to the anastomosis. In all the vas was
ligiitetl and cut obliquely above the seat of ligation, a
piece was snipped out of the head or body of the epididy-
mis, and into this opening the split end of the vas was
implant<!d. In all of the dogs active spermatozoa were
found in the urine or seminal fluid from the urethra
about two weeks after the operation. The results of
these experiments seemed to justify the operation upon
a man in whom a childless marriage was de|)endent upon
azosopermia consequent upon double obliterating gonor-
rheal epididymitis. In this patient repeated examina-
tion failed to show the presence of spermatozoa. The
operation was carried out in very much the same way as
the experimental operations. A few spermatozoa were
found in the fluid expressed from the cut epididymis.
Semen examined nineteen days after the o|)eration and
twelve hours old showed motile, apparently healthy
sjiermatozoa corresponding on microscopic study to the
type observed in the epididymis of the human testis
removed after death and subjected to examination. At
the time this work was undertaken the exp<Timenters
had no knowledge of any previous work of this kind
having been done, but since then, on search through the
literature they find that a similar anast/)mosis had been
attempted by Hardenhauer and also by Scuduto. The
results of experimental operations by these ojyerators
were not successful, however. It is a question which
might be considered debatable as to how desirable it is
that the class who generally get double gonorrheal
epididymitis should propagat<' their kind. As to th(>
character of the work reported, there can be no two
oi)iiiions, however. It is most interesting, ingenious and
original ; there can be no doubt but that another Held for
successful surgical intervention has been ()|)ened.
I'Vaclnrc of the Base of the Fifth Metatarsal Bone by
Indirect Violence.— Jones,' of Liverpool, reporlH the fracture
of the base of hiH fifth metatarsal bono iiH he trod on the outer
side of his foot while dancinj;, his heel at the moment being off
the lloor. Within a few weeks five other (Mses were seen. It
> Annalnof Hiirgery, Jime, IIHK.
is almost impossible to demonstrate the fracture without the
aid of the x-ray, there being geaerally no crepitus, deformity
or yielding on manipulation. The symptoms are pain when
the patient puts pressure on toes or inner side of foot, when he
fixes the toes, or attempts to invert. The history of the acci-
dent is important in the diagnosis, the fracture being caused by
body pressure on an inverted foot while the heel is raised. The
fracture is therefore an indirect one, contrary to many text-
books. Jones explains it by the fact that the strong ligaments
binding the base to the cuboid and the fourth metatarsal do not
allow dislocation, [a.o.e.]
Venereal Ulcers Treated by Cold.— Brandweiner • recom-
mends this method quite highly. He proceeds as follows : The
secretion of the ulcer is carefully cleansed with mercuric chlorid
solution. Then the wound is sprayed with ethyl chlorid, such
as is used for a local anesthesia, for from three to five minutes.
The active hyperemia which follows this treatment he con-
siders the chief factor in producing favorable results. During
the use of the spray the ulcer becomes at first anemic and then
the ulcer and its periphery are quite hard. At the beginning of
the treatment the patient feels a burning sensation, but this dis-
appears with the freezing. When thawing out there is a great
deal of hyperemia and usually considerable hemorrhage.
During this time there is a severe burning sensation. This
treatment is repeated daily, or in patients confined in the hos-
pital twice a day. Alter using the spray, iodoform powder is
sprinkled over the ulcer. Brandweiner has treatetl 10 cases in
this manner, with very satisfactory results in 33 of the cases
and fairly good results in all. (It seems questionable how
much good should be attributed to the cold alone, as venereal
ulcers treated by careful cleansing with mercuric chlorid solu-
tion and the application of iodoform powder usually yield read-
ily without anything further.) [m.b.t.]
Severe "Burns" from Becquerel's Rays.— Becquerel
(DruggiMs' Circular, September, 1901) confirms the fact that
the rays of radium have an energetic and peculiar action on the
skin. He carried a few grains of intensely active radiferous
barium chlorid in a sealed glass tube, within a pasteboard
box, in his pocket for six hours. Ten days later he noticed a
red mark on the skin corresponding to the position of the tube ;
inttammatlon followed, the skin peeled oflf and left a suppuratr
ing sore which did not heal for one month. A similar burn
appeared later in a position corresponding to the opposite
corner of the pocket. P. Curie observe<l a similar result after
exposure of his arm to a less active specimen tor a longer time.
Experimenters find that after handling tubes containing the
radiferous material the ends of their fingers bfconie hard and
painful; in one case the inflammation lasted 15 days, was fol-
lowed by loss of skin, and the painful sensations had not dis-
appeared at the end of two months, .[l.k.a.]
Sarcoma of the Mesentery.— Bernays ' reports a case of
sarcoma of the mesentery in which the growth and 1I!> Inches
of the small intestine wore removed. The patient had gained
much in weight and was in good condltioii 01 days after opera-
tion. A Uble of 36 cases of resetalon of the small intestine as
collected from surgical literature is given. Tlie question of
how much of the small intestine can be removed without detri-
ment to tho mitrilion of the body is discaMse<l. The length In
different persons is so variable that dofinito statements are
impossible. The amount remove<l is of less Importance than
tho length which is left, [a.ii.e.]
Is «"hloroforin More DanuerouH than Klhcr? — To de-
termine this question Crouch and Corner' have followed over
3,000 anesthesias given at St. Thomas' llt>spital, Ixindon, very
carefully during the past 12 months. There were l>ut 10 (Mses of
respiratory complications, undoubtedly due to tho anosthetlc,
all of which followed ether anesthesia. Tho trouble occurred
at all ages. Tho previous history of tho patlonUand condition
at tho time of operation were uniformly good. The operations
were all on the trunk except a case of extensive variooso veins.
The anesthetics were well taken the patients having no ten-
dency to cyanosis or extjesslve secrelhm and not riH)uiring
large amounts of ether. .Seven out of the 10 ca»e» occurred
1 Wl.-m-r kllnlwrhc Wi>cbcnwhrin, 1902, Vol. l^ p «I8.
' AnnniK "f Mnnjery, June, ilKB.
' Ijineot, May 24, IW2.
114 AMBBIOAM MBDJCim]
THE WORLD'S LATEST LITEEATUEE
[July 19, 1902
durine the summor. The patients were anesthetized l)y the
house oflicors, not by the staff anesthetists, who are naturally
more experienced. Bandaging of the chest and abdomen
restricted the respiratory movements considerably and pre-
vented the sputum being expelled /reely. Six out of nine cases
that recovered healed by first intention ; two had slight stitch
abscesses and in one case there was sloughing and suppuration
of a flap. One patient died of bronchopneumonia. There were
no cases of true lobar pneumonia. Under the same conditions
precisely, none of 600 patients who were given chloroform
developed any form of respiratory trouble. Estimating the
deathrate from chloroform at 1 to 3,000 and with a mortality as
in this series of 1 to 2,400 from respiratory troubles following
ether anesthesia, these writers consider it doubtful whether
chloroform should not be considered the preferable anesthetic.
[M.B.T.]
A new Bottini incisor is described and illustrated by
Hugh H. Young.' It dilfers trom the Preudenberg instrument
in having four interchangeable blades of different sizes, a beak
of different angle, a connecting handle with more extensive
contact surfaces and a few minor changes in construction. By
the simple elevation of a sliding bar on the rotary wheel one
blade may be removed and another Inserted. The author
claims that the new beak cannot possibly slip by the prostatic
orifice into the urethra, whereas with the Freudenberg instru-
ment this is liable to occur. By these changes the disagreeable
overheating of the contact screw, which was undoubtedly due
to insufficient contact, is said to be entirely obviated. [c.A.o.]
The Status Lymphaticus. — Blake ^ reports seven cases
of the above condition observed at the Roosevelt hospital and
the Sloane Maternity hospital during the last 1 J years. Autopsy
in each case showed general lymphoid hyperplasia. The
lymphoid tissues also showed certain lesions described by
Oertel in diphtheria and by others in other infections, these
being rather suggestive of the toxic nature of the condition
associated with status lymphaticus. Death in none of the cases
could be explained by any mechanic factor. Of the 7 cases, 6
were adults and 3 were negroes. Four deaths occurred during
anesthesia. The thymus gland varied in weight from 22 to 135
gm. in the adults, the patient with the largest having exoph-
thalmic goiter. Chloroform is considered to be the most dan-
gerous anesthetic in these cases, though Blake's four cases with
oue reported by Ewing, gives two chloroform to three ether
deaths. This number is too small to draw conclusions. Death
may occur at any stage of the anesthesia or even after some
hours have elapsed. The symptoms are those of cardiac and
respiratory failure. The definite diagnosis of status lymphati-
cus is probably impossible before death, but careful physical
examination may elicit signs which should lead to suspicion.
Evidences of lymphatic hyperplasia are of chief importance.
The tongue, nasopharynx, and fauces should be examined, in
addition to the superficial lymph nodes. The spleen is usually
only slightly enlarged. Ewing found lymphocytosis in one of
his cases, but the blood is usually negative. The presence of
rachitis or thyroid enlargement are of value in diagnosis.
[A.G.E.]
Liitliolapaxy and Suprapubic Cystotomy in the Treat-
ment of Stone in tlie Bladder.— Frisch,' in concluding his
article on the treatment of 400 cases of stone in the bladder, com-
pares the various methods of procedure, specially litholapaxy
and suprapubic cystotomy. As to the mortality of the two
operations, the matter of greatest importance, he believes that
there can be no question but what suprapubic cystotomy is a
much more dangerous operation. Formerly the mortality was
from 30% to 40%. Even at present it usually ranges from 13%
to 20%. Guyon gives his mortality for the past ten years as
28%. On the other hand, the mortality from litholapaxy is 2%
to 3%. The duration of time of recovery is much shorter with
litholapaxy than any of the cutting operations. On the aver-
age the patients are confined from 6 to 8 days, often a very
much shorter time; while after suprapubic cystotomy with
complete suture they are confined to bed from 27 to 30 days and
if the bladder is drained over 50 days. Moreover, the conva-
1 Maryland Medical Journal. April. 1902.
s Annals of Surgery, June, 1802.
» Wiener klinlsebe Woohensehrift, 1902 Vol. 1.5, p. 388.
lescence is much more likely to be uneventful after lithola-
paxy. Complications are very rare. The operation is a slight
one and oftentimes a general narcosis is unnecessary. As to
recurrences Frisch had 12 recurrences in 94 patients after supra-
pubic cystotomy, 12.8% as compared with 8.2% after litholo-
paxy. This result is very similar to that in Zuckerkandl's 150
cases, in which he had 22% recurrences after the cutting opera-
tion and 12.6% after litholapaxy. As contraindications for
litholapaxy he considers very large stones which prevent free
use of the instrument, very hard stones, stones that are fixed In
diverticulums, cases complicated with cystitis or inflammatory
affections of the kidney and in cases of prostatic hypertrophy in
which it is diflicult to get an instrument into the bladder. The
cutting operation should be limited to the fewest possible num-
ber of cases and litholapaxy should be considered the opera-
tion of choice unless some of the complications mentioned are
present, [m.b.t.]
Ligation of tlie External Iliac Artery for Iliofemoral
Aneurysm and Otlier Tumors.— H. G. Croly ' reports three
such cases. The first is that of spontaneous iliofemoral aneu-
rysm, in which the highly satisfactory termination of the case
is largely attributed to the preparatory course to which the
patient was subjected, namely, perfect rest, Tufnell's diet,
digital and instrumental pressure, which gave time for fibrin-
ous deposition in the very large sac and the establishment of
a free collateral circulation. The second case was that of mel-
anotic sarcoma in the groin. The third operation was also for
a tumor in the groin. The disease returned and death followed
in both cases. A sudden death from arterial hemorrhage in a
case of inoperable carcinoma of the groin caused the author to
decide that in the future he would ligate the main artery in
such conditions. [c.A.o.]
A Case of Echinococcotomy of the Liver. — Alexinsky '
reports the case of a woman 24 years old who, eight months
before the onset of the disease, was thrown to the floor by a dog
and sniffed at. From that day on she began to lose weight.
Shortly afterward she complained of symptoms of dyspepsia,
and she developed a pulsating, movable, fluctuating ma.ss in
the epigastrium, which apparently belonged to the left lobe of
the liver. Under chloroform, two echinococcus cysts were
removed completely, a third one in part. The wound was
closed without drainage. During the next nine days the patient
had three attacks of urticaria, cardiac syncope (pulse 150), cough
with mucoid expectoration, etc. The wound was then reopened
and drained. Much serosanguiueous fluid was removed, also
the rest of the third cyst wall, as well as a complete fourth cyst
wall. After this recovery was uninterrupted. The author con-
siders this a case of poisoning through absorption of fluid and
toxins from the fourth cyst, and warns against complete closing
of the wound In cases of multiple hydatids, [e.l.]
Fracture of the Carpal Scaphoid, with Dislocation
Forward of the Central Fragment.— Stimson ' reports two
cases of this kind occurring in his service at the Hudson Street
Hospital during November. In the first ca.se a man of 46 fell
from the fourth floor of a building, fracturing his thigh and
injuring his wrist. A movable bony prominence was found
under the skin in the middle of the anterior surface of the
wrist. The appearances were similar to those of anterior dis-
location of the semilunar bone, but by the x-ray the real nature
of the injury was discovered. The fragment of bone which lay
directly under the skin was removed, and the patient regained
very good use of the wrist joint. In the second case a man of
26 fell, bending his wrist forcibly in palmar flexion. When
seen two weeks later the left wrist was slightly swollen and
there was a projection forward on the radial side. Crepita-
tion had been felt by those who examined the wrist soon after
injury. Under anesthesia some of the details of the injury
could be made out. It seemed possible to bring the fractured
surfaces into proper place, but it was difficult to maintain the
contact, hence the fragment was removed and uneventful
recovery followed, but the range of movement in the wrist is
restricted. Stimson states that these are the only examples of
this form of injury which have ever come to his notice. By a
' Medical Press and Circular, April 16, 1902.
2 AUgem. Wiener med. Zeitung, 1902, p. 101.
3 AniiaU of Surgery, May. 19o2.
JULY 19, 1902)
THE WORLD'S LATEST LITERATURE
[Ajcbbicar Hkdicinb 115
search through the literature he has been able to find reports of
three similar cases, [.m.b.t.]
Traumatic Epilepsy with Adhesions of Slcln to Brain.
— Rushtou Parker 1 reports that a man now 38 years old fell
violently in 1884, sustaining a compound depressed fracture in
the region of the left half of the coronal suture. He had
occasional fits at intervals of several years until 1895, when the
author found a cystic condition in the scar after which he had
no more convulsions until 1901, when they suddenly became
very frequent. Operation showed the skull opening to be oval
in shape, and more than an inch in the longest diameter. The
skin was directly adherent to the brain tissue. This was dis-
sected free and gold foil inserted between brain and skin and
the wound closed. One convulsion on the following day was all
he has had since and he is now enjoying perfect health, [a. B.C.]
Thoracic Ii\)ury Involving the Lung. — LeBoutillier'
reports two cases of this kind. A boy of 15 was run over by a
wagon, causing rupture of the lung without fracturing his ribs.
Severe dyspnea developed after the injury with pain in the
epigastrium and left side of the chest. Aspiration was twice
practised. For relief of the symptoms of pneumothorax which
were present, but very little air was withdrawn. The patient
died 34 hours after the injury. At the necropsy there was a small
effusion of blood (only 5 ounces was found), and it was evident
that the pneumothorax had caused death. In the second case a
man of 24 was shot by a 32-caliber revolver, causing a penetrat-
ing wound of the right lung. Symptoms of hemothorax devel-
oped, for which excision of a rib was practised. Infection with
the bacillus aerogenes capsulatus occurred, however, and from
this the patient died. A thorough review of the literature of
the subject is given. LeBoutillier sums up the indications for
operation as follows : When largely open thoracic wounds with
external hemorrhage occur, there is no question about attempt-
ing to arrest the hemorrhage; it seems equally clear that when
internal hemorrhage from any source threatens life, an attempt
should be made to arrest it, and that extensive pneumothorax
should never be allowed to cause death from suffocation without
intervention. Operation is not only justifiable but imperative :
(1) In distending pneumothorax from whatever cause. If aspira-
tion or the introduction of a trocar does not give relief, thora-
cotomy should be done, and the lesions found treated appropri-
ately; (2) in large hemotliorax in («ises of fractured ribs,
contusions of the thorax without external wound, and pene-
trating wounds of the thorax without regard to the nature of
the weapon producing the injury; (3) in extensive and pro-
gressive subcutaneous emphysema after thoracic injuries. The
nature and extent of the measures resorted to must be deter-
mined according to the needs of the particular case. Explora-
tory operations may be proper in order to determine whether
wounds in the lower part of the thorax have penetrated the
diaphragm or peritoneum ; or to satisfy one's self as to the integ-
rity of the heart or pericardium as well as of the internal
mammary or intercostal arteries ; or to provide proper drainage
in wounds where infection is suspected, [m.b.t.]
GYNECOLOGY AND OBSTETRICS
WiLMEB Krcsen Frank C. Hammond
Pedicle Torsion In Ovarian Neoplasms. — Two
Htronfif arf^uments in favor of csirly operation in new-
{^rowth of the ovary are : First, the impossibility of any
relief being afforded l)y medical treatment and the cer-
tainty of i)rogressive increa.se in size and .symptoms ;
second, the danger of the pedicle becoming twisted and
producing symptoms which demand immediate opera-
tion. During the past we<!lc we have seen two cases in
which this accident had occurred, i)roducing marlced
symptoms and requiring immediate surgicjil interven-
tion. In one of these an ovarian fll)roid was present
and evidences of inflammation and ascites were found.
In the other case, a glandular cyst about the size of a
> British Medical .lournal, Muy 24, IIHK.
' AiinalB of Wurgcry, Mny, llK/2.
coeoanut, showed necrotic areas, due to the axial rotation
of the pedicle.
Rokitanslcy found torsion of the pedicle in 12 fc of
all cases of ovarian tumors, and in 6/c of the cases it was
the cause of death. Various causes have been suggested
for this axial rotation. It has been attributed to alter-
native distention and evacuation of the bladder. Kuest-
ner ascribed it to peristalsis and the changes from the dis-
tention of the rectum ; Carlo, to sudden belly pressure ;
and Mickinwitz, to contraction of the tranversalis
muscle. Any sudden jar or motion of the body, such as
jumping, dancing, or falling, may be a factor. Torsion
is more apt to occur in cysts of small and medium size
than in large tumors. The direction of rotation is
usually toward the median line, although it may take
place in the reverse direction. A spherical, nonadherent
cyst with a long pedicle is peculiarly liable to this axial
rotation which, checking the venous outflow from the
tumor, causes hemorrhage into the interior, sometimes
severe enough to result in the death of the patient. If
the patient survives this accident the cyst assumes more
the nature of a foreign body, exciting a violent inflatn-
mation in all the contiguous parts of the peritoneum
and becoming attached to it by vascular adhesions, which
more or less replace the normal blood supply. A mod-
erate twisting of the pedicle of 90° produces no symptoms.
It is only when the torsion is sufficient to influence circu-
lation, or above 180°, that symptoms are produced.
This accident is especially liable to occur when an
ovarian cyst complicates pregnancy or tlie puerperium.
According to Kelly, a csiuse of rotation of cysts is that
large multilocular cysts exhibit a notable tendency to the
formation of one large cyst cavity, with a number of
subsidiary ones, and the tumor will invariably turn
until the convex surface of the large cyst comes to lie in
relation to the concavity of the distended anterior
abdominal wall, and that the alternate relaxation and
contraction of the anterior abdominal walls act most
decidedly upon that part of the tumor which is nearest
the median line. The result of this change of position
depend upon the extent of the torsion and the rapidity
with which it has occurred. The effect is first felt by the
veins which are more compressible than the arteries, and
the venous blood-current becomes obstructed while the
arteries remain open. The tumor may increase rapidly
in size and in acute cases the patient complains of severe
pain in the abdomen associated with meteorism, marke<l
tenderness on pressure, acceleration of the pulst^ and
sometimes singultus, vomiting and fever. According to
Montgomery, in the more chronic condition, when the
blood-supply is not completely obstruct^xl, the pain and
unfavorable symptoms are more gradual, though many
patients are bedridden and sliow a distinct loss of
strength produced by the absorption of the altered con-
stituents of the tumor, musing a condition resembling
cachexia.
The treatment for ovarian tumors in genen»l is ovari-
otomy, a simple operation in uncomplicate<l cases. As
it is 'impossible to det-ide with i-erUdnty whetlier the
given neoplasm is not malignant or to insure against the
occurrence of such accidents as pedicle torsion, cyst
rupture or infection, extirpation is positively indicated.
A Case of Choriocpit hellonia MallKnuin.— <iraefo ' thinks
that the instances of this dlsoa.se have rapidly Increaiied In recent
years. He reports the ca»e of a woman of 37, three years mar-
ried, and delivered of the first child U years before. After
a few months' menstrual irregularity, a bemorrhaffO occurred
with roiieated discharge of large bUxMl-clots 8up|X>Bod to be an
abortion. Hut as the hemorrhages continuo<l, <iraefe was sum-
moned, and upon examination found near the fundus a nnilig-
nant choriooplthelloma, which was romovc<l. In a month
there was a slight recurrence, which apparently yielded to
treatment; but after the lapse of only a few days the trouble
rapidly Increased and the discharge soon became very olTensI ve.
I centralhlatt fOr Oynakolocle, May 17, HOT.
116 AMERICAN MKDICINX^
THE WORLD'S LATEST LITERATURE
[July 19, 1902
Tho utorus was removed but the patient died in a few days.
Graefe considers tliis case as a new evidence tliat after every
abortion, wiienever possible, tliore sliould Ije a digital examina-
tion and cleansing of the uterus. In the case here given the
rapidity of the recurrence was very remarltable. [w.K.]
Precocious Sexual Development.— Roger Williams ' re-
ports over 100 authentic cases of precocious sexual development
collected from the literature of the nineteenth century, the large
majority of which belong to the earlier part of the century. This
anomaly is of mucli commoner occ\irrence in females than in
males, the proportion in this series being 80 females to 20 males.
All nationalities in civilized communities are prone to this
anomaly, but there is no evidence of its occurrence among
savages. The different types of sexual precocity in females are
classified as follows : Menstruation appearing prior to other
signs of sexual evolution; precocious menstruation with the
early appearance of other signs of puberty ; precocious sex mani-
festations without menstruation ; early conception and preg-
nancy ; sexual precocity with intraabdominal tumor. Trans-
itory vaginal hemorrhages in newly-born children, lasting for
a few hours or for several days, are of such almost invariable
occurrence that they may be regarded as physiologic and as
the prototype of the menstrual flux. In the cases reported the
time of menstruation varied from birth to six years. At
later periods so many examples are mentioned that it is un-
necessary to cite individual cases. There were I'J cases of pre-
cocious sexual development associated with intraabdominal
tumors and 15 instances of precocious pregnancy, the age vary-
ing from 8 to 12 years. Sexual precocity is not incompatible
with healthiness, yet most of those afflicted have health and
are generally short-lived. A large proportion are rachitic, espe-
cially the females, and their dentition and skeletal development
are generally backward. The mental qualities of these anoma-
lous children never corresponds to their sexual development ;
either they are psychically childlike or they are unusually dull,
mentally defective, or even idiotic, and seldom manifest any
passion for the opposite sex. They generally come of large
families, but rarely more than one in the family is affected.
Female precocity of the less extreme kind, as menstruation
between the normal period and the tenth year, is generally
indicative of vigor and vitality above the ordinary. Such
females generally marry early and have more children than the
average. Among the different races of mankind the lower ones
are more precocious than tlie higher ; with the advance of civil-
ization, precociousness tends to become less and less, and there
can be no doubt as to the correctness of Delaunay's dictum,
that " precocity is a sign of biologic inferiority." The higher
tissues and organs also are much more slowly evolved, and
much less prone to precocity, than the lower ones. This is
especially true of the human brain, which appears not to attain
its developmental maximum until very late in life— even up to
the fiftieth year; and it is noteworthy that this organ is hardly
ever affected in cases of precocity.
A Double Catheter for the Prevention of Cystitis in
Women.— P. Rosenstein,^ being convinced that cystitis requir-
ing long after-treatment is often caused by the continuous use
of the catheter after operations of various kinds, has devised a
double catheter, or rather a catheter with a double tube, so con-
structed that the inner tube which enters the bladder never
comes in contact with any infected surfaces, and all conditions
producing cystitis are avoided. He describes the instrument
with illustrations, and says that while its use may not prevent
cystitis in all cases, since some other factors may play a part in
causing this disease, yet in his experience it has greatly reduced
the number of cases of postoperative cystitis, and, therefore,
deserves the attention of the profession, [vv.k.]
The Hemoglobinuria of Pregnancy.— Brauer " gives the
history of several successive pregnancies in the same woman
with accompanying symptoms of hemoglobinuria, such as
icterus, pruritus, prostration and general anemia, with the
result that most of the children were born prematurely, or, if
born at full term, were very weak and anemic. There were
never any fears of eclampsia and there were rarely any abnor-
1 British Gynecological Journal, May, 11)02
2 Lentralblatt fiir Uynfikologle, May 81 1902
■'MQnchener medicinlscbe Woehenschrift, May 20, 1902
malities of the urine; the distressing symptoms pre.sent be-
fore labor, which soon diminished after delivery, seemed due
to hemolysis and obstructed circulation, also to defective
assimilation accompanying the pregnant condition. [w.K.]
Fuller's Pills. — The Journal des Pniliciens, Vol. xv. No. 35,
1901, page 568, reports excellent results from the adminis-
tration of Fuller's pills in amenorrhea or dysmenorrhea with
chlorosis. They contain :
Socotrine aloes 1 ounce
Senna 4 drams
Asafetida 2 drams
Galbanum 2 drams
Myrrh 4 di-ams
Saffron 1 dram
Mace 1 dram
Iron sulfate IJ ounces
Oil of amber 1 dram
Syrup of mugwort 4 drams
To be made into three-grain pills; one or two before the
principal meals. These pills are well borne by the stomach :
appetite returns, flatulence is relieved, and the constipation
produced by the iron is combated by the asafetida and aloes
which are combined witli it. The condition of the blood is
improved, and with this improvement the menstrual disturb-
ances cease, [l.f.a.]
Castration by Uterine Atmokansis in Hemophilia. —
Ludwig Pincus' advocates the use of uterine atmokausis as a
remedy for abnormal hemorrhage in persons suffering from
hemophilia. He has known of instances of young women, just
at the age of puberty, bleeding to death in simple menstruation.'
In such eases he believes life might and should be saved by
intrauterine atmokausis, although it destroys the function of
the uterus. For such radical treatment it is well to have the
consent of the patient and her family. This method of treat-
ment may also be employed in the puerperium in case of Iffe-
threatening hemorrhage associated with hereditary diathesis,
and at the climacteric for uncontrollable hemorrhage, or for
postabortum hemorrhage in known cases of hemophilia. [w.K.]
Albuminuria of Pregnancy. — Veit,' as a result of his
investigations and microscopic studies in relation to albumin-
uria, has reached these conclusions : Through the introduction
of a sufliciently large amount of placenta into the abdominal
cavity of dogs one produces albuminuria ; the pigment of the
skin of the pregnant woman contains iron ; the urine of the
pregnant contains somewliat more iron than that of the non-
pregnant; the bloodsernm of the pregnant contains hemoglobin
only in exceptional cases; the bloodsernm of the woman in
labor contains hemoglobin somewhat more frequently ; and
the bloodsernm of the newborn child usually contains no
hemoglobin,, although it has been observed as an exception.
As an explanation of these facts Veit mentions tlie admission of
cells to the periphery of the ovum, in consequence of which
there take place, physiologically in tiie blood of the pregnant,
changes which may suddenly or by slow continuous increase
become pathologic and cause an abnormal condition of the kid-
neys peculiar to pregnancy. With modern scientific methods
we hope for further advances in knowledge in this direction.
To the skilful obstetrician belongs, not only the mastery of the
best methods of delivery, but also the improvement of our
knowledge of the effects of pregnancy upon the entire female
organism. The better we know the favorable influence of
pregnancy upon the woman, the more we should comprehend
by what power nature overcomes its disadvantageous results,
so as to serve more efficiently the welfare of womankind, [w.k.]
Bilateral Intraligamentous Pibromyoma. — Alfred J.
Smith' reports a case of the aljove, in which the tumor had
undergone extensive mucoid degeneration. The tumor weighed
10 pounds, and consisted of a large fluctuating mass apparently
growing in between the folds of the broad ligament, Ijilobed
and symmetrical on both sides, [f.c.h.]
Treatment of Vaginal Hydrocele Avith Zinc Chloric!. —
Blanc {Bulletin General de Thfrapcutique,\ o\. cxlii, Xo. 21, 1901,
page 831) has obtained good results in the treatment of vaginal
hydrocele by the injection of zinc chlorid. A small quantity ot
1 Centralblatt fiir GyiifikoUigie. May U, 1902.
2 Berliner klinische Wocbcnschril't, Junc2 and 9, 1902.
3 The Medical Press, May 21, 1902.
JULY 19, 1902]
THE WORLD'S LATEST LITEEATUEE
[AXERICAK MBDICIKE 117
liquid is first withdrawn from the sac in order to reduce the
tension. Then one-quarter to one hypodermic syringelul,
depending upon the size of the hydrocele, of a 109ii solution
of zinc chlorid is injected slowly, and the position of the
needle varied in order that the solution may be thoroughly
mixed with the liquid in the sac. The needle is then withdrawn
slowly. The patient should remain at rest for 36 hours. Symp-
toms of peritoneal irritation have been rare, and ceased rapidly.
The advantages claimed for this treatment are simple opera-
tive technic, no pain, no complications such as hematocele,
phlegmon, etc.; the results are rapid, being obtained within 10
days ; the success of the treatment is definite and constant.
[L.F.A.]
Myoma Teleangiectodes of the Uterus, with Genuine
Myomatous Metastasis in Liver and Ijungs.— Schlagenhaufer'
states that there are five cases mentioned in literature in which
metastasis accompanied the usual typical form of myoma.
Notwithstanding this fact, the possibility of such a metastasis
is scarcely recognized in textbooks and he feels justified in
reporting an additional case. The patient, a married woman of
58, was operated upon May 14, 1898, and an egg-sized tumor
removed from the uterus. The diagnosis, after a microscopic
examination. May 18, was myofibroma. The death of the
patient on June 1 was followed by section on June 2. There
were found in the right lung three nodules, one the size of a
cherrystone, very hard, and sharply and conspicuously set out
from its surroundings. The cut surface was grayish-white in
color and fibrous in texture. The other two were of similar
character ; there was also one in the left lung. The flaccid,
fatty degenerated liver had in the posterior part of the right
lobe three apple-sized tumors and more smaller ones in the left
lobe, all sharply defined with a grayish-white fibrous structure
like a myoma of the uterus. Similar small nodules were found
in the peritoneum and the diagnosis of uterine myoma with
metastasis of liver and lungs was fully confirmed. [w.K.J
Curative Kflfects of X-rays Upon Callous Sinuses of the
Abdominal Wall.— D. Berry Hart,'^ knowing how annoying to
both surgeon and patient are persistent sinuses, reports two
cases wliich wore cured after two or three applications of
x-rays. In the first case an x-ray photograph was taken so as
to obtain the correct topography of the sinus and he was struck
with the almost magical healing of the sinus after its use, when
plugging for several weeks with iodoform gauze had failed. In
the second case the sinus had persisted for several weeks after
an operation for extraperitoneal gestation, where the fetal bones
had been retained for five years. The sinus healed after three
exposures to the x-rays. In view of such favorable results
in these cases, he thinks that further trial should be given to a
form of treatment now available in most large hospitals. [w.K.]
Treatment of the Vomiting of Pregnancy.— R. Couda-
min (Lyon Midu-nl, Vol. xcviii, No. 5, 1902, page 145) reports
the case of a woman suffering from obstinate vomiting of preg-
nancy who was cured by lectal injections of 10 ounces of arti-
ficial serum frequently repeated. The author recommends: (1)
Absolute rest for the stomach, entirely withdrawing all food,
liquid or solid, for 8 or 10 days: (2) daily rectal injections of
from three to four quarts of artificial serum. If the rectum be-
comes irritable a few drops of laudanum may be added to each
injection, or the serum may l)e given hypodermically ; (3) at
the end of 10 or 12 days the patient may take a few swallows of
liquid and return gradually to ordinary food, still continuing
the injections for some time. The object of this treatment is to
aid in the elimination of toxins which are believed to be the
cause of vomiting, [l.f.a.]
The Advantages of Bossl's Dilators, Especially In
Kolampsla.— L(!opold' states the results of using Bossl's dila-
tors for the rapid and complete dilation of the os uteri In twelve
cases of eclampsia. In all cases the os was opened wide within
20 or .'iO minutes, so that the child could be readily delivered
without any noteworthy laceration, and all the mothers were
discharged from the hospital in a healthy condition. In seven
cases the children were dolivere<l alive, though two of them
died in a few hours. Leopold concludes that for the practical
' Wiener kllnUche Wocbenschrlft, May 15, 190i{.
"■ Kritlsli .Medical .lournal. May 31. 190J.
(entnillilall lUr Oynilkol"!«1o, May 10, 1902.
obstetrician Bossi's instrument is of great value in the treat-
ment of eclampsia. [w.K.]
TREATMENT
Solomon Sous Cohkn
H. C. Wood, Jr. L. F. Applbman
lodoforin iu Pulmonary Tuberculosis. — One of
the few drugs of proved value a.s an aid to hygienic
treatment in pulmonary tuberculosis is iodoform. No
other iodin compound yet brought forward as a substi-
tute can take its place'; and only iodin compounds are
to be considered in this connection. Its chief value is
in cases presenting signs of infiltration without softening ;
but even if limited softening be present in one portion
of the lung, the drug is of service in combating the
extension of infiltration elsewhere. After extensive
softening and cavity formation have occurred its use
should give way to that of the creosote group of drugs.
To be beneficial in the highest degree iodoform should
be given in gradually increasing doses over a long
period. At first one-half a grain or less may be given
thrice daily after meals, and increments of one-fourth or
one-half grain be added every week or ten days, until
tolerance is well established. In the course of some two
or three months a daily dose of 9 or 10 grains will have
been reached, which may then be pushed by somewhat
larger increments and a little more rapidly up to a max-
imum of 15 grains daily. A good way to administer the
drug is in capsule, balsam of Peru (3 to 5 grains) making
an excellent excipient. If necessary a digestive agent
may be added or a dose of es-sence of pepsin may be
given about an hour later. If deemed a<lvisable arsenic
iodid may be combined with the iodoform. There is no
chemic incompatibility, and therapeutically the drugs
are synergists. Xo one who has Icarnetl how to give
iodoform and who has had the courage to persist in its
use for a year in each of, say six, ca-ses of the type
described, is likely thereafter to abandon it in favor of
any of the transient fads of the day.
Ichthyol Baths In the Treatment of Typhoid I'erer.—
Polacco ( /?«//<;</" Odie.ral de TMrapciiHque, December 15, 1901)
obtained good results from the employment of ichthyol l)ath8
in typhoid fever. Two ounces of ichthyol is dissolved in a bath
having a temperature of 82°. During the bath, which lasts
from 10 to 15 minutes, the temperature of the water is lowered
to 75° or to 71°. An icebag should be kept on the patient's head
while in the bath. By this means tomi)erature is reiluced, the
pulse becomes less fre<iuent, and respiration is fuller, so that
thelower portions of the lungs functionate more actively. After
a bath the patient experiences a sense of contentment and often
falls into a quiet, refreshing sleep lasting several hours. Kach
patient receives from two to six baths. In the m^ority of cases
the fever was notably de<Teased after the first or second batb
and In all cases the course of the disease was modilled and
greatly shortened. Il.f.a.] [The influence of hydrotherapy Is
clear— that of the ichthyol is by no means proved, s.s.c]
Kesults of Intradural In.|ectlon» of Cocain In Painful
AfTeotlons.— Thiollouiout (Th!-se <l<' Parin, 1901, No. fl:i3) has
studied the elTeca of extradural injections of cmmin and of
physiologic sernm In the treatment of sciatica and lumbago,
and finds that the injection of physiologic serum, In the pro-
portion of 2 to 1,000, produces results e<|ua11y as good as the
cocain solution. Laporte {Thi'/ie <l>- Piinn, IHOl, No. «2:i) sUtes
that with hiui the Intra and extradural Injection of cocain has
given romarkablo results In sclatlcji. lie prefers this method
to the subarachnoid method ; the cx>caln dlffuHos less, acts more
on the nerves than on the cord, and produces no untoward
effect. He employs 1.6 drams of a 0.5% solution, or 3 drams o(
a 0.2.5% solution at each Injection. Brward {T/ifne dr Pari*,
1901, No. 543) has been able to euro or ameliorate lumbar
neuralgia or neuralgia of the lower limbs by the epidural Injec-
tion of 30 minims of a 1% solution of cocain. This method has
also been etilcaclous tn the pain of ulcer of the stoiuuch, Iu
118 AXXBIOAN Mkdioink)
THE WORLD'S LATEST LITERATURE
(JOI-Y 19, 1902
sciatica, InmbafTO, herpes zoster, and in the pains of locomotor
ataxia. Sicard was unable to obtain anesthesia sutlicient for
surgical operations by this method. The subarachnoid injec-
tion of cocain for the production of anestliesia in the aged can-
not be used entirely in place of chloroform or ether. According
to Beynot ( ST/i^ae de Paris, 1901, No. 589) it is most useful in
visceral operations, and is the method of choice in old people,
who bear the injection of cocain well. These injections have
not been followed by any unpleasant results, save a vague
numbness and a slight temporary sensation of having been
bruised, [l.p.a.]
Saline Solution for Infusion Tlierapy. — There can be no
doubt that the pure sodium chlorid solution alone may in cer-
tain ways be injurioiis from its toxic effects ; that, furthermore,
a solution of the single salt, as weak as the 0.6% commonly
employed, has a hemolytic effect upon the red corpuscles. The
desirability, therefore, of administering a fluid which shall not
only be nontoxic, but which shall be as nearly as possible
isotonic with the blood — that is, shall have a molecular concen-
tration corresponding to that of the liquor sanguinis— is evi-
dent. This isotonicity of the blood naturally varies consider-
ably under different clinical conditions, and at the present time
we have no way of determining it for the individual case.
Under normal conditions. Hamburger, by a test which depended
on the determination of that percentage of saline which failed
to lake the red corpuscles, and von Koranyi, who established
the molecular concentration by determination of the freezing-
point, have shown that the proper proportion of salt in a sodium
chlorid solution varies from 0.9% to 1.3%. A 0.9% solution may,
therefore, be considered safe and proper to employ for human
beings under ordinary circumstances; and as a modification of
Ringer's solution a combination such as the following:
Sodium chlorid (NaCl) 0.9
Calcium chlorid (CaCl) 0.026
Potassium chlorid (KCl) 0.01
Distilled water (H2O) 99.064
100.0
may, in the present state of our knowledge, be recognized as
the most nearly perfect solution to be applied for the generality
of cases. Such a solution is employed as the routine infusion
fluid in several hospitals in which attention has been given to
the subject. When great quantities are employed it is con-
venient to have a concentrated solution of the saline carefully
made by the apothecary, a certain number of cubic centimeters
of which, necessary to make the desired percentage, can be
added to a liter of distilled water when it is made up for steril-
ization. Thus the tedium and errors incidental to the weighing
out of the salts for each separate flask of solution are avoided.
[This may be termed " clinical saline solution." Certain man-
ufacturing chemists have placed upon the market somewhat
similar solutions, presumably prepared with due care, in sealed
vials containing each the correct quantity for one liter (or
quart) of water.— Ed.]— Harvey Gushing in " Cohen's System
of Physiologic Therapeutics," Vol. ix.
Pulmonary Extracts in Diseases of the Lungs.— i'£feo-
lution Midicale, Vol. i, No. 7, 1901, page 108, declares that excel-
lent results have followed the administration of the pulmonary
extracts, such as pulmozyme, in the dose of four or five des-
sertspoonsful daily, in acute laryngitis or tracheobronchitis.
The most troublesome colds disappear in a few days, the
patient from the first being greatly relieved ; expectoration is
facilitated, cough is lessened and attended with less discomfort,
and fever, if present, falls rapidly. In children the results are
equally beneficial. Pulmozyme acts as a prophylactic against
pulmonary tuberculosis by calming and promptly curing
cough or bronchitis in persons predisposed to the disease. Free
purgation is a useful adjuvant in the treatment of bronchitis.
In chronic diseases it is first necessary to combat the underly-
ing cause or diathesis by appropriate treatment and then ad-
minister pulmozyme to combat the catarrhal element, [l.p.a.]
Influence of Alkaline Medication.— Dalche and Carteret
(Jouriial des Pralieiens, Vol. xv. No. 50, 1901, page 793) have
noted that the administration of 75 grains of sodium citrate, or
60 grains of sodium bicarbonate, causes a slight temporary or
permanent polyuria, with diminution of the urea, and an
increase In the phosphates and chlorids. As a result of this,
Dalche has administered 2J drams of sodium citrate daily in
the treatment of diabetes. This was followed by a decrease in
the urea eliminated, and also in the amount of sugar, [l.f.a.]
Cocain for Gastric Pain.— Dieulafoy (Bulletin Oiniral de
Thirapeutique, Vol. cxlli. No. 18, 1901, page 716) reports a case of
gastric ulcer, with excessive pain and absolute intolerance to
food, which he treated by the administration of one teaspoonful
of the following solution every hour, with a tablespoonful of
iced milk :
Morphin hydrochlorate i grain
Cocain hydrochlorate 4 grain
Lime water 3J ounces
An ice-bag was also placed on the epigastrium. The follow-
ing day the pains were less severe. Two tablespoonfuls of iced
milk were then given every hour, and the quantity increased
gradually without producing vomiting, until the patient was
able to take from two to three ounces of milk every hour when
combined with the above solution. At the end of 15 days the
pains had nearly ceased, and the patient was able to take from
40 to 50 ounces of milk daily without vomiting, [l.f.a.]
Treatment of Dysmenorrhea. — iia.a\ta.in(Bulletin Giniral
de Thirapeutique, November 23, 1901 ) considers that the treat-
ment of dysmenorrhea with drugs is very unsatisfactory, as
although they relieve the symptoms temporarily they do not
prevent their return. He advises uterine dilation and intra-
uterine dressings. Tliis treatment applies equally to unmar-
ried and married women. In the former chloroform anesthesia
will usually be required for examination and operation.
[l.f.a.]
Deschamp's Cardiac Binder in Hypertrophic Dila-
tion of the Heart. — Merklen {La MMeciiie Moderiie, Vol. xii,
No. 49, 1901, page 397) has employed Deschamp's cardiac binder
in six cases of hypertrophic dilation of the heart. The results
were favorable in three cases, imperfect in two, because of ex-
treme hyperesthesia of the precordial region, and negative in
the sixth, because of obesity. This apparatus is indicated in
cases of palpitation, with or without dyspnea, of nervous or
organic origin, [l.f.a.]
Treatment of Neurasthenia.— Lemoine {Bulletin OinSral
de Therapeutique, Vol. cxlii, No. 20, 1901, page 796) has cured
many patients with neurasthenia by the hypodermic adminis-
tration of from i to IJ drams of the following solution every
other day :
Sodium phosphate 45 grains
Sodium chlorid 30 grains
Boiled water 3J ounces
This treatment is never given by the mouth, for in order to
obtain a result, it would have to be continued for years. Rectal
administration may be substituted, giving 15 grains of sodium
phosphate at each injection. Hot douches, without pressure,
spongings with active friction, and rest in bed are useful adju-
vants to this treatment, [l.f.a.]
Starch lodid as a Therapeutic Agent. — Salmon (Bulletin
Oeniral de Thfrnpeutique, Vol. cxlii, No. 20, 1901, page 791) em-
ploys starch iodid, internally and externally, in all cases in
which iodin is indicated ; it may be used with advantage in
place of potassium iodid when the latter drug is not well borne.
Starch iodid is prepared by triturating 5 parts of iodin with a
small quantity of water, and adding to it slowly 95 parts of
starch; this is mixed tlioroughly until a homogeneous and
uniform bluish-black mass is obtained. This is dried slowly,
triturating carefully, until it is reduced to a very fine blue
powder. Starcli iodid is insoluble in water, has a slight odor,
and the characteristic taste of iodin. It is administered in
doses of from 3 to 8 grains, in capsules, pills or tablets. When
large doses of iodin are not well borne starch iodid may be used
in the same proportion, without producing any disagreeable
effects, [l.f.a.]
Globucidal Action of EtherobacilUne. — Camus and
Paquiez (La Midedne Moderne, Vol. xii, No. 44, 1901, page 358)
in a study of the action of the local products of the tubercle
bacillus on the red blood-corpuscles, found that the etherobacil-
line of Auclair, which had been purified and freed from all
trace of ether, was still globucidal. This action is peculiar, the
July 19, 1902]
THE PUBLIC SERVICE
[American Mkdiciks 119
etherobaciUine, which is not soluble in saline solutions, acting
only on the corpuscles immediately in contact with it. The
diffusion is plain in a few hours with corpuscles of man and of
the rabbit. The corpuscles in tuberculous patients do not differ
from those in a healthy individual. The serum of healthy or
tuberculous men brought previously in contact with ethero-
baciUine interferes with the globucidal action of this substance.
[L.P.A.]
Nutritive Value of Eggs.— Lebbin ( Therapeutische Mon-
litxhefte, Vol. xv, Xo. 2, 1901, page 5.52) finds, as the result of an
analysis of six eggs, the average per cent, of proteids to be
13.076, of fats 11..567. He also determined that the weight of an
egg is increased by five minutes boiling on an average 0.619!,.
Lebbin's article contains elaborate tables showing the percent-
age contents of the yolk and the white of egg separately ; a
table showing the effect of boiling the egg, based on 22 speci-
mens ; and a minute report of an experiment on a human sub-
ject to determine the nutritive value of eggs as an article of
diet. He concludes that eggs are justly valued as an article of
food and that they afford a ready means of supplying the body
with the material necessary to restore lost nerve tissue in a
short time, [r.m.g.]
Mustard Baths for Suspended Animation In the New-
born.— Besson {Bulletin Qiniral de Thirapeutique, Vol. cxlii,
No. 24, 1901, page 941) has obtained good results with mustard
baths in the treatment of apparent death in the newborn. Two
cases were observed in apparently normal infants in which
cyanosis and muscular relaxation occurred about one hour
after birth. In the first case Besson employed rhythmic trac-
tion of the tongue, artificial respii-ation, hot and cold baths,
with no result ; the infant remained lifeless, the cyanosis in-
creased. A single mustard bath of about 10 minutes' duration
caused all the symptoms to disappear. Similar results were
obtained in the second case. Besson insists on the remarkable
eflicacy of mustard baths in these conditions. They have also
been successfully employed by Lemoine in the treatment of
infantile bronchopneumonia, [l.f.a.]
The General Action of Therapeutic and Toxic Agents. —
E. Mauriel (Bulletin. Oeneralde Thirapeutique,Vol. cxlii, No. 16,
1901, page 606), after a study of the effect of different therapeutic
and toxic substances on the tissues of the body, formulates the
following laws which appear to govern their general action :
1. a, For each therapeutic or toxic agent the different ana-
tomic elements possess given sensibility or toxic liability which
remains the same in all vertebrates ; 6, for certain substances
the order of sensibility and toxic liability is the same, but for
others it is different; in either case the above law remains con-
stant. 2. An agent is able to act on an intermediate anatomic
element only on condition that it acts on all the other elements
placed before it. 3. Among the agents acting on the same ana-
tomic element some increase its function, others decrease it ;
but even in therapeutic doses, at least in certain cases, the dom-
inant action is preceded by a contrary action. 4. The toxic
action of certain agents on an anatomic element is the same as
their therapeutic action ; of other agents this action is contrary to
the first. 5. a. The sensibility to different therapeutic and toxic
agents varies with each species of animal ; 6, this difference
of sensibility does not depend at all on the place which that
species of animal occupies in the zoologio series. 6. «, The
order of sensibility and toxicity varies for each therapeutic and
toxic agent ; b, there is no anatomic element which, in origin
and by nature, may be more sensitive to therapeutic or toxic
agents than the others ; c, the orders of sensibility and tox-
icity constitute the physiologic formulas for each agent.
[L.K.A.]
FOR INVESTIGATION.
Brief reports of results of the use of drugs mentioned In this sec-
tion are Invited, for the Editor's Information and for publication. (See
editorial article In Issue of January 4, p. 42.)
Acetozone (benzyl-acetyl hyperoxld) in Typhoid Fever.
— Wasdin {Therapeutic Oazette, May ir>, 1902, page 289) after
making the two remarkable statements that the cycle of typhoid
fever is 14 days, and that it is an infection of the respiratory
tract, proceeds to dilate on the value of benzyl-acetyl hyperoxid
in typhoid fever. The remedy is admlnistereil with large
amounts of water. As the result, probably of the water, there
is an increased secretion in the kidneys ; and as the result of
the acetozone the author claims that the stools may become
absolutely sterile. He says he has never observed any bad
symptoms from the substance and is therefore inclined to regard
it as nontoxic. It is excreted through the kidneys as hippurio
acid. [H.C.W.]
Two Local Applications for Poisoned Wounds.— Hard-
man {Eclectic Medical Gleaner, June, 1902, Vol. xiii, page 191)
recommends as a local application in polyps and chronic ulcers
the use of a solution of thuja, applied topically. He also says
that he has obtained good results in snake-bite by the continued
use, internally and externally, of echinacea, [h.c.w.]
FORMUIiAS, OBIGINAIi AND SELECTED.
Treatment of Dyspepsia with Phosphatufia.- A. Robin
{Bulletin Qiniral de Thirapeutiqiie, Vol. cxlii. No. 21, 1901, page
832) employs :
Arsenious acid J grain
Powdered ignatia 7..'5 grains
Powdered rhubarb 37.5 grains
Powdered opium 7.5 grains
Extract of gentian a sufficient quantity
This is made into 50 pills, 1 of which is given during the
principal meals, [l.p.a.]
Sedative Dusting Powder.— Reclus {Bulletin Q&nfral de
Tfigrapeutique, Vol. cxlii. No. 20, 1901, page 800) recommends the
following dusting powder, which is antiseptic, deodorant and
analgesic :
Iodoform 15 grains
Salol 30 grains
Powdered boric acid 75 grains
Powdered antipyrin 10 drams
[L.F.A.]
THE PUBLIC SERVICE
Health Reports.— The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, during
the week ended July 12, 1902:
California:
Georgia :
Indiana:
Kansas :
Kentucky :
Maryland :
Massachusetts :
Michigan:
Minnesota:
Missouri :
Netjraska:
New Hampshire:
New Jersey :
New York :
North Carolina:
Ohio:
Oregon :
PeunsylTanla :
Tennessee :
Wisconsin :
Austria:
lielKlumt
Hni/.ll:
('at)ada:
Clilnu:
Colombia;
Krance :
81IAI.I.POX— UNrrBD Status.
San Francisco June 22-29.
Stockton June l-.W
Augusta June l-:tO
EvansviUf June'iS-July 5....
Wichita luneiS-July .\...
Covington June 28-July .■>....
Cumberland lune l-"*)
Boston June 2S-.Iuly 5....
Cambridge lune 28-July 6....
Melrose June 28-July 5....
SomervlUe June 28-July 5....
Detroit June 28-July 5....
Minneapolis May IT^uly 5....
St. Louis Iune:«>-Juiy «....
Omaha rune28-.Iuly 5....
Nasluia June 28-July .1....
Ciunden Fune28-July fi ...
Elizabeth Mar. 2»-June 21..
Hudson County,
Jersey City lncl....Junc22-JulyC....
Newark Inm- 2^-.lllIy .'.....
New York liim-Js .liil\ .)..,.
Beauft)rt
(vicinity of). ...May l.'V-July 4.,..
Cincinnati.. June '.fT-July 4....
Cleveland June 28-July S....
Dayton June 28-July 5....
Yoiiiiijslowii June 21-28
Portland July 1
Erie Juno2»-July 5....
Johnstown June 28-July fi....
McKeesport June 28-July 5....
Philadelphia lune 28-July i)....
PItUburg June2H-,Iuly6 ...
Memphis lune 28-July 5....
Oreen Kav Juno29-July 8 ...
Mllwauki ' June 28-July 6....
Oaan D«aths
8
SMAI.I.I'OX — KOKKION.
I I 'Jl .
21..,
Prague Mini
Antwerp Iuir
IVmambuco .May l.'V-SI...
Winnipeg Iune7-i8 ...
Hongkong.. .May 17-24...
Panama lnne2S-30..
J'aris June 14-21 ..
St. Etlennc May l.VIll ..
2
S
17
7
3
1
1
24
80
II)
«
7
27
2
I
26
2
8
8
7
14
2
8
5
11
14
120 AMBBicAir Medicine
THE PUBLIC SERVICE
(July 19, 1902
Great Britain :
India:
Italy:
Japan ;
Mexico:
Netherlands :
Bu88la :
Straits Settlements
Switzerland :
Brazil :
Colombia :
Mexico :
Brazil:
China :
India:
Turkey :
China :
India :
Japan :
Straits Settlements
Birmingham June 14-2« 18
Liverpool June 14-28 4
London June 14-21 107
HonibHy Iune3-10
Calcutta May 31-June7....
Madras May 3I-June6....
Naples June 7-14 8
Palermo June 14-21 11
1
2
1
1
34
«
27
1
24
U
1
1
2
« 2
10 5
21 10
Yokohama May 31-June7..
City of Mexico June 22-29
Vera Cruz )une21-2«
Rotterdam June 14-28
Moscow May 31-June 4....
Odessa June 14-21
Bt. Petersburg Iune7-21
; Singapore May 10-17
Geneva May 31-June 14..
Yellow Fever.
Bahla Iune7-14
Panama June 23-30
Coatzacoalcos June 14-21
Vera Cruz June 21-28
Pl.!\GUE.
Pernambuco May 15-31 13
Hongkong May 17-24 .S3 3
Macao June 3 Present.
Bombay June 8-10 101
Calcutta May 31-June 7.... 90
Pera July 1 Declared.
Cholera.
Hongkong May 12-24 38 31
Bombay June3-10 2
Calcutta May 31-June 7.,.. 51
Saga Ken June 16 28 8
Singapore May 10-17 92
Changes in the nfedical Corps of the V. 8. Army for
the week ended July 12, 1902:
Kendall, Major William P., surgeon, will proceed to the Presidio
and assume command of the Army general hospital at that post.
relieving Lieutenant Colonel Alfred C. Girard, D. S. G.
Painter, Captain George L., assistant surgeon, is granted leave for
1 month, with permission to apply for an extension of 1 month.
Gray, Major Williak W., surgeon, is granted leave for 1 month and
15 days, from about July 15.
Drake. Major Charles M., surgeon, is granted leave for 1 month,
with permission to apply for an extension for 1 month.
Pabk.wan, Wallace E., contiuct .'iurgeon, is relieved from duty In
the department of Culitornia, and will proceed to Vancouver Bar-
racks tor assignment to duty in Alaska.
Hull, A. R., contract surgeon, is granted leave for 1 month.
Trijby, First Lieutenant Albert E.. assistant surgeon, will proceed
irom tort Wadsworth to Fort Hancock for temporary duty until
the arrival of First Lieutenant Clyde S. Ford, assistant surgeon,
when he will return to his proper station.
DUTCHER, Captain Basil H., assistant surgeon, is authorized to avail
nim.self of the leave for 4 months granted him by orders 107, upon
the arnval at Fort Hancock, (or temporary duty, of First Lieuten-
ant Albert E. Truby, assistant surgeon
Kean, Major Jefferson, R., surgeon, and James Carroll, contract
surgeon, will proceed to Chlckamauga Park, Ga., for the purpose
;'■ """King a careful and thorough sanitary inspection of Camp
1 nomas, and will submit to the adjutant-general through the sur-
geon-general of the Army a report of such inspection together with
such recommendations as may be deemed desirable. Major Kean
will make such suggestions and recommendations t« thecommand-
or which may pos.sibly occur. Upon the completion of the duty
nerem ordered Major Kean and Contract Surgeon Carroll will
rejoin their proper station.
Woodson Captain Robert 8., assistant surgeon, having reported his
arrival at Madison Barracks in compliance with orders heretofore
issued, will report to the commanding officer of that post for duty
Woodson, Captain Robert S., assistant surgeon, is granted leave for 2
months, with permission to apply for an extension of 1 month.
Hart James W., contract surgeon, will proceed to Fort Foote for
outy with United States troops in camp at that post, and will
return to his station, Fort Washington, when his services are no
longer needed at Fort Foote.
Borden, Major William C, surgeon, is granted leave for 1 month
and 13 days, from about July 15.
Crosby, Major William D., surgeon, is relieved from further duty at
fort McPherson and will report at Camp Thomas, Ga., for duty.
Thompson, Frank E., contract surgeon, now at Fort Niagara, is
lelleved from further duty in the division of the Philippines, and
will report at Fort Niagara for duty.
**" u/"^"? '^^ orders of May 15, as directs Contract Surgeon Hugo A.
wani upon his arrival at San Francisco, Cal., to report by letter to
me surgeon-general of the Army for annulment of contract, is
amended so as to direct him to report to the commanding general,
department of California, for assignment to duty.
Baigent, John, hospital steward, now at Erie, Pa., will report on or
oerore expiration of furlough to the commanding officer at Fort
rorier, who will send him lo Fort Wadsworth to relieve Hospital
»teward Harry Harson. Steward Harson will be sent to Manila,
t". I; for assignment to duty.
McCoMYN, Richard H., hospital steward, Paris, OnUarlo, Canada, will
report on or before expiration of furlough at Madison Barracks for
duty at that post.
BuBKABD, Oscar, hospital steward, now In Washington, D. C. hav-
ing relinquished the unexpired p 'rtion of furlough granted him at
Fort WIngatc, is relieved from further duty at that post. He will
be sent to Manila, P. I , for assignment to duty.
Brown, Clark L., hospital steward, now at Syracuse, N. Y., will
report on or before expiration of furlough at Fort Monroe, to
relieve Hospital St<'ward George C. Douglass. Steward Douglass
will be sent to Manila, P. I., for duty.
Changes in the Medical Corps of the V. S. NaT; i<t
the week ended July 12, 1902 :
Seaman, W., assistant surgeon, ordered to the Naval Hospital, Yoko-
hama, for temporary duty, from Naval Station. Guam— July 4.
Drake, N. H., surgeon, detached from the Philadelphia and ordered
to the Mare Island Navy Yard — July 7.
Loveking, p. a., surgeon, detached from the Mare Island Navy Yard
and ordered to the Naval Hospital, Cavlte, P. I., August 9— July 7.
Gardner, J. E., surgeon, detached from the Naval Hospital, Cavlte,
and ordered to report to the Commander-in-Chief, Asiatic Station
for duty— July 7.
Page, J. E., passed assistant surgeon, ordered to report at the New
York Navy Yard for duty with a recruiting party to leave that
yard July 15 -July 9
Crawford, C. A., passed assistant surgeon, detached from tlie Naval
Hospital, Chelsea, Mass., and ordered lo report at the New York
Navy Yard for duty with a recruiting party leaving that yard July
12— July 9.
Furlong, F. M, passed assistant surgeon, detached from the Naval
Hospital, Norfolk. Va., and ordered lo report at the New York Navy
Yard for duty with a recruiting party leaving that yard July 12—
July 9.
Plummer, R. W., assistiint surgeon, ordered to the Naval Hospital,
Chelsea, Mass.— July 9.
Arnold, W. F.. surgeon, detached from the Naval Hospital, Yoko-
hama, Japan, and ordered to the Marine Brigade.
Changes in the Medical Corps of the U. 8. Marine-
Hospital 8ervice for the 2 weeks ended July 10, 1902:
White, J. H., surgeon, to proceed to Baltimore, Maryland, to Inspect
the quarantine steamer Neptune— July 3, 1902.
Williams, L. L., surgeon, detailed as a member of a Revenue Cutter
Service Retiring Board— July 10, 1902.
Woodward, R. M., surgeon, detailed as a member of a Revenue Cutter
Service Retiring Board -July 10, 1902.
Stoner, J. B., passed assistant surgeon, to proceed to Berlin, Mary-
land, as inspector— June 28, 1902.
Nydegger, J. A., passed assistant surgeon, granted leave of absence
for 3 days from July 7— July 3, 1902.
Lumsden, L, L., assistant surgeon, granted 5 days extension of leave
of absence from July 12— July 8, 1902.
Berry, T. D., assistant surgeon, granted leave of absence for 1 month
from July 17, 1902, on account of sickness— July 3, 1902.
Foster, A. D., acting assistant surgeon, granted extension of leave
of absence for 7 days from May 31— June 30, 1902.
Ransom, S. a., acting assistant surgeon, granted leave of absence for 7
days under paragraph 181 of the regulations.
Sweeting, C. B., acting assistant surgeon, granted leave of absence
for 1 month from July 1, on account of sickness- June 28, 1902.
R1CHABD.SON, S. W,, senior pharmacist, detailed for special t«mporaiy
duty at Washington, D. C— July 5, 1902.
Carlton, C. G., senior pharmacist, upon being relieved by Junior
Pharmacist F. Siedenburg, to proceed to Chicago, 111 , and report
to medical officer in command for duty and assignment to
quarters — Inly 9, 1902.
Troxler, R. F., senior pharmacist, 7 days leave of absence gi*ant«d
under paragraph 20 1 ol the regulations amended so that said leave
shall be for 6 days only.
Phillips, W. C, Junior pharmacist, granted leave of absence for 25
days from July 1— June 30, 1902.
Siedenburg, Frank, Junior pharmacist, relieved from dityat Chi-
cago, 111,, and directed to proceed to New Orleans, La., and report
to medical officer In command for duty and assignment to quarters,
relieving Senior Pharmacist C. G. Carlton— July 9, 1902.
Boards Convened,
Board convened to meet at Washington, D. C, June 30, 1902, for the
Bhysical examination of an officer of the Revenue Cutter Serylce.
'etail for the Board— Surgeou L. L, Williams, chairnidn ; Surgeon
R. M. Woodward, recorder.
Board convened to meet at Washington, D. C, for the physical exam-
ination of applicants for position in the Coast and Geodetic Sui"vey.
Detail for the Board— Surgeon L. L. Williams, chairman; Surgeon
R. M. Woodward, recorder.
Board convened to meet at New York. N. Y., July 10, 1902, for the phys-
ical examination of an officer of the Revenue Cutter Service.
Detail for the Board— Surgeon G. W. Stoner, chairman; Passed
Assistant Surgeon T. Clark, recorder.
Board convened to meet at San Francisco, Cal., July 14, 1902, for the
physical examination of applicants for position of Second Assistant
Engineer, Revenue Cutter Service. Detail for the Board— Pas.sed
Assistant Surgeon W. G. Stlmpson. chairman; Passed A.ssistant
Surgeon H. S. Uumraing, recorder.
Promotion.
Junior Pharmacist F. A. Southard promoted to be senior pharmacist
from July 1, 1902.
Appointment,
J. C. Elfers, of Wlscon.«tn, appointed to be acting assistant sui^on for
duty at Sheboygan, Wisconsin, June 30, 1902.
American Medicine
GEORGE M. GOULD, Editor
G. C. C. HOWARD, Managing Editor
CHARLES 8. DOLLEY
MARTIN B. TINKER, AuUtant Ettttort
Clinical Medicine
David Riesman
*.. O. J. Kelly
H. H. Gushing
Helen Mukphy
General Surgery
Martin B. Tinker
A. B. Craig
Charles A. Orr
Orthopedic Surgery
H. Augustus Wilson
COLLABORATORS
Obstetrics and GyTieeology
WlLMER Khusen
Frank C. Hammond
Xervoitg and Mental Disemea
1. K. Mitchell
F. Savary Pearck
Treatment
Solomon Solis Cohen
H. C. Wood, Jb.
L. F. Appleman
Dermatology
M. B. Hartzell
iMryngolooy, Mt.
D. Bkaden Kylb
OplUhatmolomi
Walter U Ptlb
Pathology
R. M. Pearo
PnunHlD W«E«ir «T IMl Wal«ut Stbxt, PBU.kDii.piiu, .r Tn Aanuou-HiDiciio PcaLnHiaa Coap»T
Vol. IV, No. 4.
JULY 26, 1902.
$4.00 Yeably.
Scientific medicine wins against politics— not by
any niean.s everywhere and generally, but at least once,
in Ohio. The illustration occurs in the appointment of
Dr. A. P. Ohlmacher as Superintendent of the Ohio
State Hospital for Epileptics at GaIlipoli.s, Ohio. The
appointment was made upon purely scientific and pro-
fessional grounds, and the fact gives encouragement to
all who hope and work for the complete elimination
of politics from the management of the charitable
and scientific institutions of Ohio, and indeed of all
States. Tlie members of the profession know of the
valuable work of Dr. Ohlmacher in researches ujwn the
pathogenesis of epilepsy, and also in other pathologic
and bacteriologic studies. It is not the least of his
commendations that he is not an old man. When the
tests of experience and character have been made, the
advantage of the energy and ambition of youth in
positions such as this are very great. We congratulate
Governor Nash and the trustees of the State Hospital in
thus rising to a proi)er realization of their duty and
opportunity.
University Medical Education. — Every i)hysician
and every university man, whether medical or lay,
should weigh carefully the wise words of Professor Bar-
ker on " Medicine and the Universities," published in
the present number of American Medicine. Reflection
and judgment load every line, and though there may be
cause for difference of opinion upon some points, there
can be none as to the general trend of the contention and
advice. We wish the proprietary medical school were
to be extinguished as certainly and as speedily as Dr.
Barker appears to think, and we are not quite sure that
we appreciate accurately his distinction between the
l)seudouniversity and the semiuniversity medical col-
lege. But we hejirtily concur in the view that the
scientific subjects should form a large part of those
whicii the modern university shall offer to the modem
young man to prepare him in the best way for his future
life. The essence of Professor Barker's address is that
the coming medical college must be part of a university
and the teachers must be university teiu-hers. The
proi)rietary medical college, the pseudomedical college,
which is worse, mu.st die, and even the semimwlical
also, and must pass into the university. But we fear
they will not die willingly nor soon. There are so
many grades and degrees, so much old wine to be
jammed into the new bottles, that one is tempted to
repeat' the old saw, phis ^a change plus c'est la mSme
chose. But hope is a moral duty, and Dr. Barker
encourages us to do our duty.
The University Professor and Private Practice.
— It was, doubtless. Professor Barker's greatest difticulty
to reconcile the demand for university professors of prac-
tical medicine and surgery who should devote their lives
to teaching and investigation without private practice,
with the demand for the widest and most living experi-
ence on the part of the teachers. Private practice,
beyond all question, is different from hospital practii-e,
in one important particular at least (to which Professor
Barker does not allude), that of manners. It would,
indeed, be a misfortune if all young physicians should
be over-hospitalized, if one may so speivk, either in
clinical and surgical methods, or in the formation of dis-
position and manners. The university and the ialxira-
tory and the hospital, when well combined, and thor-
oughly dominating methods of practice will we fear run
a great danger of stifling what we think is already too
much ignored and forgotten, the symptomatology of
diseiise, and the value of spontaneity in diagnosis and
treatment. None will deny the tremendous value of
original research and experiment, but Professor Barker
will agree with us that our kiiowknlge has alrejidy fur
outrun our practice, that all diseases are by no niejins
infectious, nor are they organic, and that the general
deathrate is twice as high as it would be if our attidned
science were realized in practical social life. The sug-
gestion, therefore, seems to us most excellent that the
teacher who is in active private practice must not be
eliminated from the university. To do ho would Ik? a
misfortune alike for the Institution, the profession and
the public.
The relation of the HiiecialUt and the uni-
versity medical school is not alluded to by Proft>ssor
Barker. lie urges the prime importantH- of nniking the
professors and other teachers otticers of the university,
whose services shall be entirely paid for out of uni-
versity funds, and who shall be without private practice.
In certain departments this rule may be modifled so
that private practitioners may at Umst in part t*'ach the
122 AXXBIOAN MEDtCINBj
EDITORIAL COMMENT
[J ITLY 26, 1902
fourth year classes. But a most important thing remains :
What about the specialties? More and more are
they becoming differentiated ; more and more is down-
right medical progress dependent upon them ; more and
more is every practitioner, even the so-called general
one, becoming a specialist. Assuming with Professor
Barker that the many millions of dollars may be
found for endowing the right sort of university medical
schools and hospitals, we may hardly expect they will
very soon be found for each and all of the dozen most
important specialties. For many years this will be
impossible, and the university will be compelled to accept
the gratuitous services of professors in the departments
who still make their living by private practice. Since ,
therefore, neither the privately practising general phy-
sician, surgeon, obstetrician, and psychiatrist cannot and
perhaps should not be altogether eliminated from the
teaching force, and since also the privately practising
specialist cannot and must not be excluded, it follows
that some systematic and permanent modus vivendi
must be devised. To formulate such a method of union
and action will be a problem of peculiar delicacy.
A Word Wanted, and Suggested A correspond-
ent writes us who wishes to know if there is any word
descriptive of the condition following oophorectomy, the
cessation of the catamenia, castration, etc. He asks if
the words desexualize, asexucdUy, etc., will express all
such conditions. We should say not. Sex seems to us
to lie deeper than the mere power of procreation. A
girl before puberty and a woman after the menopause,
or after oophorectomy, is not by any means unsexed, or
an asexual being, and neither is a man not a male after
castration. If there were not absolute psychologic war-
rant for holding the distinction, there are sociologic and
medicolegal ones. Sensual sexualism does not end with
the loss of the power of procreation ; and with its reten-
tion, of course, there is the same power of the transmis-
sion of venereal disease. The root sea;- cannot therefore
be used in any coinage designed to meet the very real
need our correspondent has found. Neither will the
words sterilize, sterility, etc., answer the purpose. We
can think of none with any likelihood of acceptance
better than improcreant and improcreance. This root
admits of the formation of no single word verb, such as
desexualize, etc., and requires such a circumlocution as
to render improcreant. On the other hand the noun,
improcreance, invites all such adjectival modifiers as
natural, acquired, prepuberal, menopausal, inflammatory,
gonorrheal, syphilitic, surgical, etc.
The Nomenclature of Syphilis In his valuable
historical study Der Ursprung der Syphilid, Dr. Bloch
brings together and classifies the names given to syphilis
by the horror-struck peoples when, as a new disease, it
swept through Europe in a few years. We have been at
pains to make a count of these terms and find that there
were —
34 designations according to the supposed country of origin.
46 in reference to tlie piiysical symptoms.
18 these two combined.
12 after tlie part of the body chiefly affected.
34 according to the cause and extent.
12 general names.
14 named after saints.
24 especially used in Spain.
26 in Italy.
110 in France.
41) in Germany.
17 in England, etc.
9 in Holland.
7 in Denmark.
4 in Sweden.
12 in Portugal.
11 in Russia.
37 in Poland, etc.
As to the word syphilis itself, much has been written,
but no definite conclusion is to be reached as to its ety-
mology. All we may say is that it was used in a poem
by Frascatoro, written before 1521, and entitled Syphilis
sive Morbus Oallieus. Where he got it, or how he made
it, will likely never be known. The other name for the
disease now in general use, Lties Venerea, was first pro-
posed in 1527 by the French physician, B6thencourt.
The multiplicity of names for syphilis teaches chiefly
that it was a new disease, unknown before it appeared
after the return of the Columbus expedition from Hayti
and the scattering of the disbanded army of Charles
VIII. Hence, hundreds of new names were given it.
Its quick dissemination through Europe also left no
time for learning the new names already coined else-
where. The relative number of names invented in
each country is also, in a way, indicative of the degree
of sexual degradation of the country, the preoccupation
of the minds of the people with lubricity and a fairly
accurate register of the extent of syphilization.
Medical Aphorisms — It is often said to be a sign of
conscious literary purpose when the thoughts of men run
into aphoristic form. We are glad, then, to note a distinct
tendency in present day medical literature toward the
aphoristic style of expression, since surely, in medical
writing, more than in any other department of letters,
there has been too much of the lack of consciousness of
literary aim. Brevity is the soul of wit, even in serious
medicine, and the old Saxon word wit implies much
more than any mere play on words. A good thing is
worth saying well. A great thought may be buried in a
maze of weak words that would be striking if aptly
expressed. We published recently a series of aphorisms
from Dr. Rockwell, of Worcester, Mass., in an article
" Some Things not Learned on the Benches," which
attracted the attention of a number of our medical con-
temporaries, among them that representative of literary
values the London Practitioner.
We find in the recently issued von Leyden Fest-
schrift a series of expressions of the concentrated wis-
dom of a wise practitioner which seems worth calling to
the attention of the American medical profession gen-
erally. Their author is Dr. Buttersack, a member of
the staff of the Prussian Army. Some of Dr. Butter-
sack's aphorisms can not fall to prove an inspiration for
the sincere though perhaps struggling physician. For
instance :
Science is sacred. It takes only such oflferings as come from
a pure heart.
July 26, 1902]
EDITORIAL COMMENT
AMSKtCAN MKDIOtKK 123
Not only with the brain, but also with the heart must a
physician strive to reach the height of his profession.
Not knowledge, but self-discipline, raises men to a higher
plane.
The broader the foundation, the higher can be the building.
The aim of his endeavors, the energy of his will, and the
purity of his motives, give us the criterion of the moral worth
of a uian.
Scientific knowledge elevates the religious feeling.
Some of the aphorisms have a direct reference to the
physician and his practical duties, rather than to pro-
fessional ethics. Several of these constitute expressive
formulas of the most important practical truths that the
physician can keep before him :
Even the universal specialist is far from being the true
physician.
The natural scientist and the physician must first of all pro-
tect themselves against autosuggestion.
The gun does not make the marksman, nor the laboratory
the investigator.
The imponderables often weigh heavier than the metals.
The physician is the physiologic conscience of his fellow-
men.
Nothing would be better than for the practising phy-
sician to keep truths so vital and so well expressed where
they could be frequently read and meditated. Such
maxims represent a precipitate of practical wisdom, the
reaction of years and experience with duty, whose value
is not of a day, but of a lifetime. They are expressive of
the high and serious purposes of a profession whose
nobler aims are prone to \>e lost sight of in the hurry
and hustle of invasive commercialism in our time.
Distinction as to Ntirsing'. — How best to popular-
ize nursing, to safeguard the standard of the profession,
while at the same time protecting the physician and
patient, is of vital concern not only to the medical pro-
fession but to every one in the community. It is a
popular fallacy that the modern trained nurse is a lux-
ury which only the hospital and the rich can aflford.
Popular education and high professional standards are
no more incompatible than are science and true religion.
Cheap morals and cheap biology are usually very expen-
sive. The dividing line between superficial and thor-
ough training must, however, be clearly marked. To
accomplish this end the registration of trained nurses
under laws providing for competent examining boards
with fixed requirements for the candidates applying
should be estiibiished. The organization of classes in
"First Aid to the Injured" by our large hospitals, the
admission of special students to the training schools for
nurses who shall take partial courses designed to fit them
to act intelligently in times of sickness, the inauguration
of spe(!ial departments on home nursing conducted by
thoroughly qualified teachers in periodicals of general
circulation — these and many other means can properly
be used to disseminate right views as to the care of the
sick. The university extension idea with perfect pro-
priety might also be extended to include technical sub-
jects. The courses so given should be designed to give
a general familiarity with the broiul principles involved
without going into the details which the si)ecialist must
accjuire. These courses could also serve as part of the
preliminary training of those who later expect to take
the full course in a recognized training school— just as
special courses leading to medicine are now given in
many colleges and high schools. But there should be a
clear and distinct division between the course leading to
a diploma and that giving a theoretic and surface train-
ing only.
Anthropometry and New Stirpes. — In the attemps
to classify human races by anthropometric methods,
there seems to be an oversight of the fact that nature
at times evolves new animal stirpes by the perpet-
uation under certain surroundings and conditions of
marketl varieties of the original specific type, par-
ticularly adaptetl to exist under the peculiar condi-
tions involved. It may refjuire many generations to
establish a new type or species, the individuals of which
are capable of transmitting acquireil characteristics to
their descendants. On the other hand, a new stirp or
prepotent race may at times originate suddenly, as in
the case of the Niata breed of pygmy or bulldog oxen,
the bighorned Franquieros cattle of South America or the
straight^wooled Mauchamp sheep of France. Sfime
time ago two Danish officers, Oloufsen and Philipsen,
returning from a journey of exploration of the Pamir
country, where they had reached plai'es heretofore
untrodden by Europeans, reported having met with fire-
worshiping, totally uncivilized tribes of exceedingly
small men, possessing animals of etjually diminutive
proportions ; bulls and cows no larger than a European
foal, donkeys the size of a large dog, and sheep the size
of a small poodle. It would be as absurd to claim
genetic relationship between these little men and the
pygmies of North and South Afric-a on the ground of
physical measurements as to claim that the little Pamir
cattle are related to the Niata cattle of South America.
All these cases represent stirj)es or rtjces of distinct and
separate origin, but aipable of perpetuating their pecu-
liar and similar bodily structures. Is it not of e<iual
likelihood that such peculiarities as dolichocephalism
and brachiocephalism may have arisen repeatedly and in
widely separated regions one from the other or from
mesocephulic types, either by gnulual modification or by
some sudden prepottmt sport? If tliis be ix)ssil)le, what
dependence or value can be placed upon anthropologic
classifications or the relationships based uiKin cranio-
metric or other measurements relating to external form
and dimensions ?
Handwritings Tics. — In connwtion with the legal
importance attaching to the study of graphology and the
demonstration by ex|H>rts of minuti> fluctuations or
irregularities in the penmarks of individuals, which are
attributed to idiosyncrasies as to the nervous motor
impulses— the relation of tics to chirography assumes con-
siderable interest. Henry Meige contributes a paperon the
subject entitled " Tic et C-criturt! " to the (iuzftle J/rMnma-
(hiire de Mfdeciue et de Vhirunjie, June 12, 1902, in which
he conies to the conclusion that spasnuxiic twitchings of
epileptics are at times directly connected with the effort
of writing, fntiuently developing as the result of over-
strain, l)ut that the character of the pennumship is not
materially affecte<l by the nervous seizures. The mak-
124 AXEBIOAN MeSICINEJ
EDITORIAL COMMENT
(JCLY 26, 1902
ing of blots, scrawls, zigzags, letters deformed or show-
ing tremor is exceptional— contrary to the case in motor
troubles of organic origin (tabes, Frietlrich's disease,
paralysis agitans, etc.). Ticqueurs are frequently calli-
graphists, they recognize fully the two automatic acts :
the one abnormal, the tic — the other normal, of writing ;
and even when the movements of the tic are frequent
and violent they are able to find time between the
muscular shocks to correctly trace the letters for several
words or even lines. On the other hand numerous persons
who have developed abnormal movements of the head are
able to trace the aflfection directly to over-exertion in
writing, while graphospasm and mogigraphia most fre-
quently develop in neuropathic or psychopathic subjects.
Auonyiuous Coiinimuicatious. — Since journalism
began the editors of every periodical have been com-
pelled to re-repeat the old notice that unsigned letters
and articles cannot be published. And still the warning
is as much needed as ever it was. Every week we
receive one or more anonymous letters, which, of course,
must go into the waste basket. These letters or articles
have a thin and poor mask of seriousness or science,
which might deceive the inexpert, and which perhaps
did help the writer to delude himself. But somewhere
in the writing will be found the personal or faddist
element which motived the whole. If there is any
abuse or wrong that needs righting it will never be done
by the man who is so little in earnest that he will not
put his name to his work. In this world men must
stand for and behind principles, whether they are good
or bad ones, and if one is in downright earnest as to
medical and professional progress he will at once not
only see the necessity but he will be glad to place his
personality at the service of the cause he advocates. It
is true that there are in every million a few tuppenny
characters who trade their worthlessness for the ftime
they get in injecting their names as exponents of an
unpopular cause. These hobby riders, however, are not
reformers, and they succeed in doing some good as sub-
jects of study for morbid psychologists. Neither the
anonymous egotist nor his self-exhibitionist brother has
any altruistic purpose at heart. "We cannot read or
publish anonymous communications."
The Becquerel Kays in Ocular Diagnosis
The x-rays have come to occupy so prominent a place in
medical and surgical diagnosis that it will not prove a
source of much surprise to find that the more recent dis-
coveries with regard to the socalled Becquerel rays are
just announced as having a cognate diagnostic applica-
tion. The Becquerel rays are the radiations emitted at
normal temperatures by certain metals. Professor Bec-
querrel first called attention to the fact that various
compounds of uranium glowed in the dark and possessed
in this regard a property resembling phosphorescence.
The metal itself did not, however, lose weight as the
result of this emanation of light, and it was found that
the light was due to a disturbance of the ether causing
light waves but without any of the development of
energy usually considered necessary for the production
of light. Other metals were found to act the same way,
notably certain rare new metals, as jwlonium and
radium, socalled because of its radiant quality. It was
discovered that these metals might have an efl'ect upon
the skin not unlike that produced by the x-rays in the
socalled x-ray burns. Salts of uranium carried in a
phial in the pocket have been known to produce redness
of the skin followed by desquamation and subse(iuent
soreness that did not heal for several weeks.
Recently M. Curie, of Paris, the discoverer of the
new metal radium, has been experimenting with certain
possible uses of this metal in ocular diagnosis. It is
often of extreme importance to know whether the retina
behind opaque ocular media is still capable of respond-
ing to stimulation by rays of light — is, in a word,
capable of vision if the opacities of the media should be
removed by operative procedure. The radiations from
radium are said to penetrate absolutely opaque media
and demonstrate the sensitiveness of the retinal nerve
fibers very clearly. Among others, the distinguished
French ophthalmologist, Javal, has been attracted to the
study of the subject. .Javal is blind as the result of
chronic glaucoma, for the cure or amelioration of which
every means known to science was emploj'ed in vain.
He hopas to find in the new metals and their radiations
certain helps for the blind and also some lights on the
physiology of vision and the nervous conduction of light.
The whole subject is one of those fascinating phases of
advancing science that holds out attractive promises of
important results. Observations so far made certainly
encourage the idea that there may be significant practi-
cal improvements for ophthalmology to be derived from
the new science of radiology.
Maleficent Benevolence. — One who has worked for
a lifetime to better the condition of the poor writes :
The good woman sends her check to the benevolent soup-
house in the morning and loses her maid iu the afternoon.
Within a week a case made this clear. To make the tale
pathetic two children were imported that starvation might be
pleaded. This made its impression upon the visitor of the
benevolent society and the woman secured all the soup she
wanted. Why should she work? I know of nothing that so
fosters poverty and vice [and he should have added disease] as
some of our older and richer benevolent societies.
The habit is working to foster ill-health and the dis-
ease called "hospitalism." Free and indiscriminate
medical attendance at the dispensary often produces the
very diseases it would cure, and robs the physician of
the support he should have from those who could pay
for medical service. It is also unjust to the really
poor, who should and must have gratuitous treatment,
both for their own sake and for the protection of the
public health. There is no more unwise thing than to
break down self-dependence and to encourage the
habit of being done for. Such charity is selfish and
breeds selfishness. All help of the poor and unfortunate
should be of the kind that helps them out of their
trouble instead of fixing them more deeply in it. The
last report of the Philadelphia Society for Organized
Charity begins as follows :
" The mantle of charity is supposed to cover a multi-
tude of sins ; but what shall we say or do when many of
this multitude are sins of charity's own making."
July 26, 1902]
AMERICAN NEWS AND NOTES
■Ambbican Medicikx 126
AMERICAN NEWS AND NOTES.
OENERAIi.
Death of a Giant.— Lewis Wilkins, of Chicago, died July
10, of brain tumor. He was .?0 years old, 8 feet, 2 inches in
height, and weighed 365 pounds.
Vital Statistics of Slanila.— During March, 1902, the
deathrate per thousand was Filipinos, 37.36: Chinese, 8.15; for-
eigners, 22.51 ; Americans, 7.21, an average of 30.02.
Ophthalmic Association Chartered.— According to the
Baltimore .S'kji, the Henry F. Garey Ophthalmic Association
has been incorporated in South Dakota, with a capital of
82.50.000, for the purpose of making use of the oscillator invented
by Dr. Garey.
Cholera in the Far East.— Despatches received by the
State Department confirm the view that this is the worst cholera
year in the part of Asia containing American interests since
1882. It has been decided to form a sanitary cholera camp in
the suburbs of Manila and remove to it 40,000 natives from the
slums while their quarters are being disinfected.
Pire-ExtinKulsher Explodes.— A chemical fire-extin-
guisher recently exploded at Quincy, Mass., thereby injur-
ing a fireman. In rei)]y to the query of how much danger
attaches to their use, the manufacturer of the extinguisher in
question states that of the 62,000 machines put into service by
the company during the last 20 years this is the first to explode.
It had been in service seven years.
Germany's New Meat Law. — Consul General Mason, of
Berlin, has forwarded a synopsis of the German regulations for
meat inspection adopted in 1900 and which go into effect
0('toher 1, 1902. The new regulations are set forth with charac-
teristic German minuteness. The opinion of the consul is that
they will more or less diminish the supply and increase the
cost of meats for consumption in Germany.
Successor to Surgeon -General Designated. — The Presi-
dent has designated Colonel Robert M. ()'H(^illy as Surgeon-
General of the U. S. Army to succeed Surgeon-General For-
wood, who retires September 7. Colonel O'Heilly, who is at
present stationed in California, is a native of Pennsylvania and
a graduate of the medical department of tlie Wniversity of
Pennsylvania. His detail is for four years and will advance
him over five seniors.
Immigration Increased.— According to the Immigration
Bureau the number of immigrants arriving in the United
States during the fiscal year 1!)02 was 730,798, an increase over
1901 of 158,815. The principal increase during the la.st year as
compared with 1901 was as follows: Austria-Hungary, ,58,59!);
Italy, including Sicily and Sardinia, 42,379: Russian Empire
and Finland, 22,0!» ; .lapan, 9,001 ; Sweden, 7,5<i3 ; German Em-
pire, 6,6.5;i; Norway, 5,236; Greece, 2,194; Denmark, 2,005. The
principal decreases are: Ireland, 1,423; China, 810; Turkey in
Europe, 200.
Meager Coronation Honor. — A New York daily states
that the bestowal of a companionship of the Bath upon Major
Ronald Ross is a meager one when compare<l with those which
went to soldiers and politicians whose services to humanity are
infinitesimal beside those of this alile and illustrious surgeon.
The equipping of a man like him with such a title is amusing
and absurd. Major Ross' real reward is the frequent coming
of news like that from Dar-ts- Salaam, East Africaj where anti-
malarial measures suggested by him promise within five years
" to change the town from a plague spot to a sanatorium."
Liability of Telegraph Company.— The Supreme Court of
Neliraska affirms, on a commissioner's opinion, in Western
Union Telegraph Company versus Cliurch, a Judgment for ?9.50
damages against the company for a failure promptly to deliver
a telegram add res.sed to a physician, saying: "Come to L. C.
Church's at once. L. C. Church." The message was delivered
to the company for transmission at about 6 p.m., and was deliv-
ered at alwjut 9 p.m. of the same day. It had iieen previously
arranged with the physician to attend a confinement case in
that family, ami he started immediately to go to it on receipt ot
the telegram, but did not arrive until after the birth of the
child, a " foot presentation," during which it died. In the com-
missioner's opinion it was dear that the telegram itself,
addressed to a physician— one known to be such by the agent
of the telegrapii company at the place of delivery— was sulll-
cient to apprise it of tiie necessity of prompt delivery. It could
not tie supposed that a message of the character of that in con-
troversy should spetrilically sot out the actual conditions calling
for a physician's presence, the person who was sick, or the
nature of the disease; and it was not ne<ressary that this should
be done in order to apprise the tminpauy of the need promptly
to deliver the meH»a.ge.— [Journal Americaii Meilicai Atsocia-
tion,]
EASTERN STATES.
.Physician Sues Township.— Dr. John R. C. Thompson, of
Bridgeton, N. J., has brought suit again.st the township of
Downe for ?2,000 for attending a smallpox case during the
past winter. A written agreement with the authorities wiis
made, but they afterward claimed the contract was void because
it was made on Sunday.
State Dental Society of New Jersey. — At the recent ann iial
convention the following officers were elected: President,
Frank L. Hindle, New Brunswick ; vice-president, Herbert S.
Sutphen, Newark ; secretary, Charles A. Meeker, Newark ;
treasurer, Henry A. Hull, New Brunswick ; board of examin-
ers, B. II. Luckey, of Paterson ; executive committee, W. W.
Hawke, of Flemington ; A. Irwin, of Camden ; W. G. Chase,
of Princeton, and F. E. Riley, of Newark. Dr. Hull, who is
elected treasurer, is probably a life incumbent in that office.
Dr. Meeker, reelected secretary, has hold that office for 27 years.
He is vice-president of the National Dental Association, and
will be elected president at the meeting in August.
New Clinical Building at Yale.— Mrs. Thomas G. Bennett,
of New Haven, is announced as the donor of f96,000 for the site
and the clinical building of the Yale Medical School, which is
now nearly completed. It will exist as the Winchester build-
ing in memory of Mrs. Bennett's mother. Plans for a new
building to accommodate all the work of the medical school
have been prepared. One section, next to the clinical building,
is intended to accommodate the departments of anatomy and
pathology. Another section is for lecture rooms, administra-
tive offices and other general purposes, and the third for the
departments of chemistry anil physiology. The now general
building will be erected in sections. They will cost, respectively,
$132,0<X),^),000 and ?79,000.
NEW YORK.
Good Samaritan Dispensary.- Dr. Boleslaw Lapowskl
has been appointed attending surgeon to the skin department
ofthe(5ood Samaritan Dispensary.
New Yorlc Physician Weds. — Dr. J. J. Kindred, head of
the River Crest Sanitarium at Astoria, L. I., and Miss Ella
Cramer, of Poughkeepsie, were marriea in Luzerne, Swltsser-
land, July 10.
American Electrotherapcutlc Association. — This asso-
ciation will hold its annual meeting at the Hotel Kaaterskill,
Catskill Mountains, N. Y., on September 2 to 4, 1902. Excui>
sion tickets can be purchase<i in New York City.
New Hospital at Rochester.— A new hospital for conta-
gions disea-ses is to be erected at Rochester before next winter.
With its threateiie<l increase in smallpox, much criticism lias
been made of the present Hope Hospital, the chief one being in
regard to there being but 6 nurses for 80 patients.
Quarter's Deaths in New Yorit City. — Deaths for the
quarter ending July 1 were 17.173 as against 16,615 for the same
period in 1901. The increase Is entirely of children under 5 and
due to measles, whoopingcough and diarrhea. There was a
decrease in the number of deatlis from tuberculosis.
Vaccination Law Valid.— The Supreme Court of New
York has decided that the .State law excluding unvaccinated
cliildren from sc^lmols is constitutional. This decision was
based on the application of a citizen of U'leens borough for a
mandamus admitting bis son to school without having been
vaccinated.
Gas Xiilsance in Street Cars.-The Health Department of
New York City is endeavoring to stop the nuisance of sulAirous
acid gas in the street cars which have been equipped with
storage batteries. Inspectors report that the gas cjiuses much
coughing auKmg the passengers. The company claims that it
is practiiailly impossAile to stop the fuuiee from storage bat-
teries, and a suit is likely to result.
Result of Probation Courts.— The report of the chief pro-
bation officer for the first six months of the existence of these
courts shows thatfifl boys and 5 girls liave heeu released on pro-
bation, 58 of the former and 3 of the latter being charged with
iarcouy and burglary. Of these, 14 boys have violate<l the par-
ole and been sent to institutions. Tlie behavior of the others is
satisfactory. Probation is of great benefit for children lictwecn
tlie ages of 12 and 16, hut doubt as to its value for those under
12 is cxprcs.sod. The only hope for most of th(<se is to separate
tlioiii entirely from the bad home environment and place them
uiKler discipline in institutions.
Against (he Drug Trust.- An important dccisi<m ngainst
the (Irug trust has been handed down by the Hiiighamton
Appellate Hlvisioii in the case of John H. and Thomas Rourke
against the F,lk Drug Company, In whii-h wholesale drug com-
panies in New York, Philadelphia and Omaha, which have
combiiHHl to keep up the prices of drugs, are concerncMl. The
Rourke Brothers rofiiMed to sign a contract to keep up prices of
[latent medioines, and were blacklisted by the combination,
126 AuEBtCAK Medicine:
FOREIGN NEWS AND NOTES
(JULY 26, 1902
which refused to sell them goods, and did all in their power to
injure their business. The Rourkes brought a suit for $50,000
damages for consjjlracy against the various firms, the Elli Drug
Company assuming the defence. The defendant interposed
several demurrers which were sustained by the Supreme Court,
and it is its decision that the Appellate Division overrules, say-
ing that since the combination is proliibited and made criminal
by law, every act of the defendants in furtherance of the objects
of the combination is unlawful, and any person suffering
special injury on account of such combination has a right, to
bring an action.
PHIIjADEIjPHIA, PENNSYIiVANIA. ETC.
Poreifcn Physician Visits Philadelpliia. — Thakur
Bhowani Singh, physician to tlie Maharajah of Karauli, British
India, recently spent several days in tliis city while on a tour
of the United States.
Physician's Bill Reduced.— The Pittsburg Orphans'
Court has settled the Browning-Magee case by awarding the
former $29,239.25. The claim of the plaintiff. Dr. Walter C.
Browning, of this city, was for $317,000, part of which was for
professional services and part an investment alleged to have
been made for him by Senator Magee. The case will probably
be appealed.
Lehigh Valley Medical Association.— The twenty-second
annual meeting of this association was liold at Easton, Pa., .July
10. Charles P. Knapp, of Wyoming, delivered the president's
address, the annual address ijeing delivered by W. H. Porter,
of New York. The new officers are : President, E. M. Green,
Easton ; secretary, Charles Mclntire, Easton ; treasvirer, Aljram
Stout, Bethlehem.
Negro Population Increasing. — The negro population of
Philadelphia is rapidly increasing, and statisticians claim that
if the present rate of increase continues the end of the next
decade will see this city the center of greatest density of the
national negro population. The increase is now about 5,000
yearly, and the tendency is toward a general spreading over
the city. A marked increase in the black population has been
caused by the importation of hundreds of negro laborers to
work on the new filtration plants.
SOUTHERN STATES.
Colnmhian University. — The following changes and addi-
tions have been made in the medical faculty of the Columbian
University, Washington: Walter Reed, U. S. A., general path-
ology; Thomas A. Clay tor, materia medica and therapeutics;
H. B. Deale and H. W. Hawkes, clinical medicine ; James Car-
roll, associate in pathology and bacteriology.
Insanity in Washington Apparently Increasing.— In-
sanity is apparently increasing in the District of Columbia.
Under the Indigent Insane Act there were committed to the
Government Hospital for the Insane from the District of Colum-
bia 3.36 persons during the year ending June 30, 1902. In 1901
there were 283; in 1900, 247 ; and in 1899, 217. So far as known
no other similar territory in this country showed such an
increase. Of the causes it is said that a great many of the cases
show symptoms of religious mania.
Innovation by Medical Examining Board.— The Medical
Examining Board of Virginia met at Richmond, June 16. The
Virginia Medical Semi-monthly states that "this was the first
session of the Virginia Board where those graduates of reput-
able colleges who had their certificates from other .State Boards
were submitted only to an oral examination. We learn unoffi-
cially tliat there was su.spicion of cheating by several of the
applicants, who had taken the pledge; but in only one instance
was the proof of cheating so unmistakable that the party was
advised to discontinue the examination and leave the i-oom.
The board, in its effort to remove the opportunity of cheating,
as far as possible, has determined hereafter on holding partial
oral and partial written examinations— the details of which
plan will be set forth in the official report of the board, which
will appear in an early issue of this journal."
WESTERN STATES.
Scarlet Fever Carried by Pigeons.— An epidemic of
scarlet fever m Cincinnati has been traced to tame pigeons.
Seattle's Low Deathrate.— The June report of the Board
01 Health of Seattle, Wash., shows a deathrate of 6.1 per 1,000. Of
the 59 deaths four were due to cancer.
Plague In San Francisco.- The Occidental Medical
limes tor July, 1902, contains a description of the autopsy on the
body of a Chinese boy aged 4 who died May 29, 1902, of the
plague, this being the fifty-eighth case.
Ti^„^U'''?*^ii™f?,?'*'?'T,,P*"l'"'"<^™«'»t8 Raised. — The State
Boam ot Health of Illinois has adopted a new schedule of
minimuui requirements for applicants to practise medicine.
The required course of study will be more exacting and the ses-
sions must be seven instead of six months for each of the four
years.
Vital Statistics of Michigan.— The deaths in Michigan
during June numbered 2,234, being 4.52 less than during May
and 100 less than in June, 1901. The deathrate was 11.1 per 1,000
of population. All of the age periods and individual causes
sliowed a decreased number of deaths except in whooping-
cough, cancer and violence.
Quarantine Improvements at San Francisco.- Improve-
ments in the quarantine service are being made with the view
of placing San Francisco on the same plane of efficiency as the
large eastern cities. A floating disinfecting barge will be con-
structed and also a transfer barge for conveying passengers and
crews to and from the quarantine station.
Ohio State Hospital for Epileptics.- Dr. A. P. Ohlmacher
has been elected superintendent. He was formerly director of
the pathologic laboratory of that institution, and made an inter-
national reputation by his work on the causes of epilepsy. Dr.
Ohlmacher was the first to produce antitoxin in Cleveland. He
is a medical scientist rather than a physician, as he had never
practised medicine.
CANADA.
Swamp Fever Among Horses. — Dr. Gordon Bell, provin-
cial bacteriologist in Manitoba, is investigating the epidemic
of swamp fever among the horses of the northwest, many
thousands of animals having died from that disease. It has
been spreading for the past two years. No treatment yet de-
vised is of any avail.
Suppression of Smallpox. — The secretaries of the Health
Boards of Ontario and Quebec have recently been endeavoring
to secure uniformity of action in tlie two provinces regarding
the suppression of smallpox. It is stated that the disease is
under control in Ontario, although there are some 15 centers of
infection. But two or three cases are in each place.
FOREIGN NEWS AND NOTES
OENERAIi.
Honorable Distinction. — The Society of Geography, of
Paris, has coliferred the Ducros-Aubert prize, a gold medal, on
Dr. Huot, a physician in the French colonies.
Plague in India. — This epidemic is reported to be rapidly
declining. For the week ending June 7 there were 4,214 deaths,
as against 5,498 the previous week. The famine is still further
spreading. More tliau 457,000 people are now on the relief list.
Cigaret Smoking Increasing in India. — The natives of
India are constantly increasing their imports of tobacco,
mainly in the form of cigarets, the weight of these imported
being over 1,000,000 pounds. It is common to see natives
smoking American brands.
Statistics of Cremation. — Thompson {Lancet, July 5,
1902) gives statistics of various crematoriums for 1901. Germany
has 7, with 693 cremations during the year ; England 7, with
445 cremations, as compared with 301 in 1900 and 240 in 1899. In
France there were 306 cremations, as compared with 297 in 1900.
The United States has 26 crematoriums, 24 of which are in
operation.
The Goddess of Smallpox. — A correspondent of the Lan-
cet has sent from India a Hindu idol, worshiped under the
name of Amma, and which represents the goddess of variola.
The statue is 20 cm. in height and is made of copper, silver-
plated. It represents a robust, kneeling female. Tlie figure is
covered with a detachable mask of metal, which bears tlie
marks of smallpox.
Molds on Cigars. — Mrs. Flora Patterson, an expert in
mycology, has identified the molds which form on tlie heads of
cigars as Aspergillus candidus Link and Penicillium glaucum
Link. It seems that they are not saprophytic on the tobacco,
but grow in the film of tragacanth paste used for fastening the
wrapper. If a saturated solution of boracie acid be used in
making this paste the growth of mold may be prevented.
Russian Prison Discipline. — A political convict named
Donskoff, who had undergone 18 out of 20 years' sentence in
Siberia, petitioned the Governor for release as a reward for
exemplary conduct. The petition was torn up and the con-
vict sentenced to 40 strokes of the knout for bothering the
Governor. Soon afterward Dunskoff petitioned again, witli the
result that he received .50 strokes. IJuite recently, hearing that
the Governor was expected at Stretensk, Donskoff took a nine
days' tramp thither and just missed him. When the authori-
ties heard w-hat he had come about they ordered him to receive
80 lashes and to be imprisoned for a further.six years. — [y. Y.
Times.]
July 26, 1902]
FOREIGN NEWS AND NOTES
'AMKBICAN MlEBICINB 127
Medical Monks. — An advertisement in the Catholic Times
calls attention to the merits of certain medicines prepared by
the Benedictine monies of Buckfast Abbey, Devon. They
include pills, salves, tonics, liniments, and other paraphernalia
of quackery. An English contemporary expresses surprise at
the emanation of such advertisement from a body of religious
men, and recommends investigation by the bishop of the
diocese.
GREAT BRITAIN.
New Match.— It is reported that two engineers of Sweden
have invented a match that can be lighted on even a wet sur-
face, contains no phosphorus, and is less dangerous than the
ordinary match.
Charing Cross Hospital. — The Duke of Connaught, on
Friday, .June 20, laid the foundation stone of the new buildings
of Charing Cross Hospital, with full Masonic ceremony, and
expressed the wish that one of the new wards should be named
the " Louise Ward," in compliment to his sister, the Duchess
of Argyll, president of the hospital.— [3/ed»ca/ Pres«.]
Cuspidors for Consumptives. — The officials of Sweden
have approved a series of cuspidors constructed by Dr. Rickardt
van Post. One of these does not differ materially from the
ordinary cuspidor. A second is of a shape suitable for fasten-
ing to a wall, railway coach or steamer, while a third is so con-
structed that it can be used at night or by a bed- ridden person
without raising the head.
Cambridge Medical School. — It is claim ed that ths school
is in danger of being liampered by a lack of business-like
capacity in those who now control its affairs. The physiologic
department is crippled by the absence of Sir M. Foster for 3i
years, and the anatomic department is inadequately supplied
with material, as many as 18 students being occupied in the
dissection of one cadaver.
Ophthalniology at Oxford. — Mrs. Margaret Ogilvie has
established a fund which will yield at least £200 yearly for the
maintenance of a readership in ophthalmology at Oxford
University. Tiie reader is to deliver 12 lectures yearly, 6 of
which may be clinical, and is to conduct original research upon
the pattiology and therapy of diseases of the eye. He must be
honorary surgeon to the Oxford Eye Hospital. The first holder
of the readership is Robert Walter Doyne, who has already
distinguished himself in research work.
CONTINENTALi EUROPE.
Honorable Distinction. — Dr. Dubail, surgeon and chief of
the hospital at Mans, has been named Chevalier of the Legion
of Honor.
Foreign Universities. — Paris: Dr. Fournier, the noted
syphilologist, has reached his seventieth year and is about to
retire. He will be succeeded by Hallopeau. G6TTiNr»EN : The
matriculation of female students has been refused by the Senate.
Phwnician Origin of the lieprosy of Brittany.— M. Lan-
nelongue presented to the Academii'' de M('(lecine, Paris, at a
meeting held June 3, a note from Royalski ( Folkestone) demon-
strating that leprosy, which is called in Armorica le mal de
Saint-r^azare, is a relic of the voyages of Phienicians affected
with this disease before the Roman conquest.
An Ambulance Bicycle.— A bicycle that can be quickly
transformed into a hand ambulance or barrow is now on trial
in the .Austrian Army. The bicycle is changed into a sort of
stretcher, but it is on wheels, so a wounded [lerson can be car-
ried on it by one soldier instead of two, as for the ordinary
stretcher. The weight of the machine is 53 pounds and the cost
about $44.
Poisoning by Salted Fish.— In view of the great frequency
of cases of poisoning by fish toxins, the Al^ademy of Sciences
of St. Petersburg has instituted an international competition for
the elaboration of protective measures against these cases, pro-
voked entirely by the consumption of imperfectly salted fish.
The prizes offeretl are .5,0f)0, 1,5(K) and 1,000 roubles. The mem-
oirs may be written in French, German, English, Latin or
Russian and must be presented to the Minister of Agriculture
not later than the first day of < ictober, 1(»03.
The Centenary of the Hospital Internes of Paris.— On
February 23. 1802 (4 vontose an x), Chaptal, the Minister of the
Interior during the Consulate, and Doctor of Me<liciiie of the
Faculty of Montpollier, signed an order placing on anew basts
the Health Serviire of the City of Paris, and organized a System
of Internes of the Parisian hosplUils. <>n February last this
System of Internes attained the Olio hundredth year of its ex-
istence, commemorative of which a series of most interesting
celebrations worn inaugurated in the (trand Chamber of the
Trociidoro, M. Waldeck-Rousseaii presiding. On the evening
of the banquet at the Palais d'( )rsay, presided over by Professor
Brouardel, there was a reunion of over 7(X) internes. On the
morning of May 25 there was celebrated in Notre Dame a serv-
ice commemorative of those internes who had died during the
century, and in the afternoon in the Court of Honor of the Hotel
Dieu there was unveiled a monument in marble, designetl by
Puech, representing in high relief the operation of traclieotomy
and bearing on the base the names of those internes who fell
victims to their professional devotion. In connection with this
centenary there was also prepared a medal, designed liy L.
Bott^, an engraving of which is given in the Oazette Hebdoma-
daire de Mfdecine et de Chirurgie, June 1, 1H02,
Public Baths Experiment in France.- United States
Consul J. C. Covert, of Lyons, describes in Consular Reports
for July the public baths of that city as follows : In 1898 a con-
cession was given to a Lille company to build small bathhouses
on the public squares of this city, eight of which are now doing
business here. They are of porcelain, each 20 feet long by 144
feet wide and 12 feet high. Inside are six stalls, each of which
is divided into two compartments by a waterproof curtain, on
one side of which is a dressing room, containing a mirror, comb
and brush, clothes rack, chair and spittoon. The other side is
provided with an electric bell, soap and washstand, with warm
and cold water and all the appointments neces.sary for a good
shower bath, the water falling from above or from the sides,
according to the fancj' of the bather. The limit of hot water
given to each bather is a little over 10 gallons ; no limit Is fixed
to the use of cold water. The furniture of the apartment also
includes an iron basin for a foot-bath. In winter these little
stalls are never allowed to become cold, and in summer they
never become very warm. Under the bathhouse is a cellar six
or seven feet deep, in which are the coal, the boiler, a continu-
ously heated thormosiphon, and the appliances for heating and
driving the water. The price of a shower bath in' these little
concerns is fixed in the act authorizing them, at 3 cents, towels
and soap included. In no case is the woman in charge per-
raitte<l to ask more or to accept a gratuity. The towels must be
80 centimeters long and 50 centimeters wide (l.'ij by 19J inches).
The rules require the disinfection of every towel after it has
once been used. The companv that manages those bathhouses
receives from the city of liyons a subsidy of 20,000 francs ( J3,860)
per year and the free use of the ground for 30 years, at the end
of which time tlie establishment-s are to revert to the munici-
pality ; but if at the end of 10 years thenumberof persons using
the baths in the city is less than 200 per day, the experiment
will be considered a failure, and the city will have the right to
cancel the contract, first giving the company six months'
notice.
OBITUARIES.
Thomas H. Hoskins, of Newport, Vt., aged 74. He graduated In
Louisville, Ky., where lie practised for some ilmc before going to Bo»-
ton, where he engaged In teaching and literary work, tlnally going to
Newport because of spinal Injury from a fall.
William F. Curryer, of IndlannixiUs, July 5, aged 57, death Ijeliig
due to cerebral apoplexy. He was Secretary of the Indiana Htal«
Board of Medical Examluere and prominent in Bcleotlo and Homeo-
pathic Associations
Jerome M. Snook, one of the best known physicians In Michigan,
at Kalamazoo, July 8, aged 57. He was graduated from the University
of Michigan In l»7:i, and was prominent In the organization of lo<ial
medical societies.
liradiey Bartholomew, of Danville, Ind., July 4, aged 97. Bom In
Vermont he graduated from the Ohio and Miami Medlcjil Colleges at
Cincinnati. He organized the Hendricks County Medical Society In 1854.
Kmmet Enos, at Chicago. July 1«, aged 38. He was on the medical
stair of the Kankakee Insane Hospital for nve years, until his own
mental alTcctlon eom|)elled him to resign.
Washington Righter, of Philadelphia, July Itl, aged 57. He gradu-
ated from Jefferson Medical College In 1800, but never engaged In prac-
tice, entering the luml>er business.
Frederick B. White, of New York City, a graduate of t;omell, INS,
committed suicide by drinking carbolic acid July 18. He was 31 y«um
old.
J. C. Batts, city coroner of Norfolk, Va., was shot and Instantly
killed by a negro whose wife he was attending July 10.
.loseph Poialllon. Honorary .Surgeon of the Hotel l>leu and prom-
inent In I'arls medical circles. Is dead at the age of 48.
Charles A. Von UrlT, Itnioklyn, July 18, aced 86. He was a gradu-
ate of the I>>ng Island College HosplUil.
Walter Hayes Cumming, of Syracuse, July 14. Denth was due to
sniiml meningitis following measles.
.lohn H. Tucker, Salt lAkc City, July U, aged TA. He had lately
be«'n engaged In sugar reflnlng.
C. A. Delage. at 8t«. Bastle, Quebec, July !«, aged .V). He was a
gmdirnt*' of Ij»vnl fnlvontlty.
J. Wilson Wlshart, University of Pennsylvania 1861, at Pittsburg,
June '-'I, ageil 7;t.
Kniile Unnilron, otHilelrlcian to the Paris hospital, aged 8S.
F. X. Mayraod, of Hueboc, aged SJ.
128 AKBBICAN MBDIOIJOtJ
CORRESPONDENCE
(July 26. 1902
CLINICAL NOTES and CORRESPONDENCE
lOommunlcatlons are Invited for thU Department. The fiklltor 1>
not responsible for the views advanced by any contributor.]
A CASE OF QUININ RASH.
BY
J. GURNEY TAYLOR, M.D.,
of Philadelphia.
In reviewing the literature I find a series of cases of quinin
rash admirably reported by Dr. Horatio C. Wood, Jr. As there
seem to be comparatively few cases on record, I have accepted
this excuse to note my case.
Case.— M. L., aged 2.5, was born in Ireland. Her father and
mother are living and in good health. She lias had all the dis-
eases of childhood, rheumatism eight years ago, and three
attacks of tonsillitis during the past two years. Three years
ago she had diphtheria. At that time, during convalescence,
she had a very severe attsick of epistaxis, which she attributed
to the quinin .she had received at that time. No clear history
could be obtained at the amount administered, or the time after
the administration at which the epistaxis had occurred. About
the middle of May she con.sulted me for an attack of malaria.
For six days she had a chill every other day, increasing in
severity. I placed her on sulfate of quinin, three grains, three
times daily— no blood examination was made. Tonpue was
coated heavily, breath was fetid, pharynx and tonsils were
congested, lungs were negative, heart was negative, with the
exception of a soft hemic murmur at the second left intercostal
space; pulse was 76, full, with moderate tension, strong and
regular. Temperature was (»9°. Liver, dulness extended from
sixth rib to one finger's breadth below costal margin, 12i cm. in
right nipple line. It was slightly tender upon palpation.
Spleen, no enlargement could be outlined. Abdomen was soft
with no tenderness upon pressure.
There had been a chill on the morning of the day I had
seen her. The next day I was sent for to see her on account of
severe epistaxis, which appeared eight hours after taking the
first dose of quinin. I found a very severe epistaxis from both
nostrils and from the nasopharynx. A purpuric eruption of
large size upon the mucous membranes of pharynx, mouth,
gums and lips— the latter being much swollen. She vomited
blood, which was decidedly bright and a few clots, and also
passed considerable from the bowels. There was also blood in
the urine, also .59'r of albumin, specific gravity 1,025— no sugar,
no casts, few leukocytes. Temperature at this time was 100.2°,
Sulse 82. respirations 20. This condition lasted for about six
ays, when it began to fade slowly and all discolorations left
the mucous membrane and she was discharged in two weeks'
time.
A RARE FORM OF SKIN DISEASE.
DONALD PARKER, M.D.,
of New Woodstock, N. Y.
Doubtless all physicians at diflferent stages in their practice
meet their Waterloo as regards the matter of diagnosis.
The following case of skin disease is an example. It may
be due to a constitutional disorder but it seems to me of such
serious import that I desire to place it before the profession
with a view to obtaining more light upon it:
The patient was a little girl, aged 2i years. She had a nega-
tive family history and a personal history of unbroken good
health until two weeks previous to the final illness. During
these two weeks she was at times somewhat fretful and her
appetite gradually failed, although she played with her usual
vim.
When I first saw her, April 30, she was very irritable, as is
the ordinary child in teething. Upon her feet was a small pin-
point scarlet rash which was not raised. The gums were
swollen over the site of two teeth. Temperature, 99.5° ; pulse,
115. Bowels were somewhat constipated ; the body was moist,
and she had slight chills. There was complete anorexia.
On May 4 I was again called and found the little patient some-
what brighter and less Irritable. The. rash had now extended
into the hands, anterior and posterior surfaces, and in addition
the h^nds and feet were scaling to an extreme degree, some
scales reaching the size of a silver dollar. The larynx and
pharynx were inflamed, but very little swollen. The mouth
and tongue were cankered beyond conception. Temperature
was 100°; pulse 125. An almost Invisible rash was perceptible
over the lumbar region, but it disappeared the next day.
On May 6 the symptoms became greatly exaggerated. Her
eyes became glassy and her expression listless. There was a
moan on expiration, but examination showed the lung to be
normal. Deglutition was not painful. Hands and feet were
covered with pustules and entirely peeled, leaving a shiny red
appearance dotted with the pustules. She vomited twice, the
only times during her .sickness. The skin was moist. Tem-
perature, 104.3° : pulse, 160, and respirations .33.
On May 7, in consultation with Dr. Goflf, it was decided to
await further developments. The patient showed signs of great
prostration although her mind was clear when aroused.
Stomatitis was somewhat improved. The kidneys and bowels
acted freely. The hands and feet burned severely. She took
two cups of milk in 24 hours, the first of any account during
the illness. , . , , , „
Temperature, 104.2° ; pulse, 195. Voice and pulse gradually
grew weaker during the day and she breathed as if in pain. At
12 p.m. she lay in a comatose condition, pulseless and with an
extremely faint action of the heart. Respiration was quite
normal and easy without any signs of strangulation. She died
at 12.30.
The most noticeable features of the disease may be summed
up as follows : Low fever until the last two days and even then
a cool, moist skin. Rash limited (except lumbar region) to
hands and feet, no spots occurring elsewhere. Rish running
the course of macula, vesicle, scale, and pustule in the order
named. The tongue was not swollen, but very red, as was also
the throat. The mouth was blanched and cankered ; there
was no signs of strawberry appearance. The hands were
rubbed upon each other and held in the mouth if she was not
watched. There was no cough or other signs of cold at any
time and the face and body were not flushed. The kidneys
seemed normal although I could not obtain urine for examina-
tion. There were no cases of measles or scarlet fever within 10
miles of here during the previous six months and the patient
did not leave home during that time. There have been no vis-
itor^ from a distance during three months previous and the
house and surroundings were in good sanitary condition.
In conclusion, I would say that the diagnosis of the above
case is an open question. Who has seen in their practice or
read any literature of a similar case?
A CARBUNCLE IN THE HAND.
BY
FREDERIC GRIFFITH, M.D.,
of New York City.
Surgeon, Bellevue Dispensary ; Fellow of the New York Academy of
Medicine.
Carbtincles are not rare, but the site of the one described in
the following history is uncommon :
J. Mc, aged 20 years, is a chair dipper in a furniture manu-
factory, his work being to dip the pieces of furniture into vats
of varnish and finishing oils. Until the latter part of March
of this year the young man had been in perfect health. Three
weeks before I saw him there developed between the thenar
and hypothenar eminences of the palm of the right hand, near
the wrist, a condition which he described as being " like a little
blister." Opening this a small quantity of watery fluid was
released. Developing i-apidly in the course of the next three
days it became " a hard lump of flesh" of reddish-yellow hue
and in size covered an area equal to that of a silver half-dollar.
Under medical advice he used first a salve, then a poultice,
and at the end of a week, no change having taking place, an
incision about three-quarters of an inch was made longitudi-
nally through the hardened mass. The escape of a quantity
of blood and serum followed but no pus. Having obtained
no relief from the pain and swelling which was extending out
into the palm and above the wrist, the patient applied to the
hospital. Viewed at this time, the line of incision was bulging;
the coarse-grained cellular tissue pouting from the orifice
seemed dry and hard. An area of redness surrounded the inci-
sion and ther« was some swelling apparent in the palm, but
not at the back of the hand. Pain and tenderness at this time
were intense, the patient walking the floor at night.
Making gentle pressure at either side of the incision with
my fingers protected with mops of gauze, jets of liquid pus
started up from between the granules of the cellular tissue.
Rapidly becoming thicker the fluid welled up until I had ex-
tracted full three ounces, this without causing any pain. I had
thus a perfect demonstration of the part which the columnte
adiposie play in this affection.
The whole cellular mass seemed about to slough but could
not be detached ; so washing out the wound with a full strength
hydrogen dioxid solution I inserted a small twisted-rubber
tissue-drain, applied a light gauze dressing and placed the
hand in a high position by means of a sling. For home treat-
ment I ordered repeated immersions in water as hot as could
be borne for periods of from five to ten minutes. The patient
departed greatly relieved. He returned two days later to
JnLY 20, 1902]
CXiERESPONDENCE
AJCBBioAN Medicine 129
report that his aflfeotion had been painless since the last visit.
Removing the dressing with forceps and scissors I was enabled
to detach a large punk-like slough made up of the granulated
fat. This left a clearly-marked deep crater whicli extended
down to the deep palmar fascia and across the hollow of the
palm to the base of the first finger. The opening was irregular
in outline, an inch across by one and one half inches long. Two
other small openings appeared over the wrist, the lower one later
sloughing into the main cavity. At a subsequent visit I was
enabled to lift out the deeper portion of the sloughened mass,
leaving behind a healthy-looking wound. Hydrogen dioxid
with rubber-tissue strips were laid in the wound to protect it
from the Irritation of dry, sterile, fluffed gauze which made up
the dressing. Hot water applications were continued and the
hand kept in a sling throughout the entire treatment.
The use of hot water when properly applied to infected
wounds of the extremities is invaluable. The water must be
always as hot as can be borne and the dressing surrounding the
dipped wound very light to allow prompt evaporation to take
place. If these points are not observed pus progress is fur-
thered by the maceration which is caused. Slinging of the
hands is of especial importance, but too often neglected in the
treatment of infected wounds of the upper extremity.
A condition proving the energy with which repair of an
injured part is sometimes carried out in an otherwise healthy
body was demonstrated in this case by an accompanying hyper-
trichosis upon the back of the hand and fingers. In three
instances, all notable for the violence of the injury upon the
extremity affected (one of which was published in International
Clinics, Vol. i, twelfth series), I have noted the condition of
overgrowth of hair accompanying the reparative process.
The hair in this case grew black, thick and three-quarters
of an inch long, presenting a stron? contrast when compared
back to l)ack with the other hand.
TWO INTERESTING CASES OF ALTITUDE HEART.
BV
EUGENE STADELMAN, M.D.,
of Descubridora, Dgo., Mex.
Case I.— The patient a male, aged 29, is a mining engineer
and unmarried.
Family Ili.ttory.—VLis mother is living and well. His father
died from the effects of apoplexy at the ago of 64; two brothers
and one sister are living and well. An aunt died of heart
trouble.
Pluvious llhiess.—Kad the diseases of childhood, and several
violent attacks of rheumatism.
Prexent Illness.— Two years ago he had a sore throat which
was followed by an acute attack of dull pain in the chest,
slightly to the left of the sternum. Pain was accompanied by
dyspnea on exertion. The patient was not confined to bed.
The pain continued for several months, gradually disappearing.
At this time the patient was living at an altitude of 10,000 feet
and was not under professional care. He was perfectly well
until October 1, 1901, when he again noticed a pain in the
left chest. This pain was of a dull character, acconiJ)auied by a
sense of fulness in the cardiac region. It came on insidiously,
and wa.s at times accompanied by slight dyspnea, and occasion-
ally by numbness of the left arm. The physical examination,
November 5, 1901, showo<l a robust male. His weight was
150 pounds. He was siirt'oriug from an acute attack of pain in
the cardiac region, causing a sensation of suffocation. The
lungs were normal. Pulse was .56, very irregular, weak and
slightly compressible. There was no evidence of arterio-
fibrosis, but the pulse beat four times, lost one beat, and then
beat eight times and lost one beat. It was very regular in this
irregularity. Temperature was normal. Urine showed asp. gr.
of l.OTl. It was highly acid, a lemon-yellow in color, with no
sediment and no albumin.
Examination of the heart showed the apex beat in the
seventh interspac^e nipple line, two inches lielow the nipple.
The sounds were very muscular, and slightly prolonged, and
there was no evidence of valvular disease. There was a very
slight thrill which was transmitted down the sternum to the
umliilicus, l)ut the heart sounds were not heard at the angle of
the scapula. Aortic second sound was slightly accentuated.
The cardiac area was about normal.
The patient had been living at an altitude of from 3,000 to
12,0(K) feet for seven years. lie was very much relieved on
returning to sea level and gained 'M iKiunds in four months.
Cask II.— The patient was an unmarried American, aged ;«.
Family History.— Hisi parents, sisters and brothers are
living and well.
Previous Illness.— He haul measles in childhood, but no other
illness.
Present Illness.— He was examined for life insurance in Sep
tember, 1901, and accepted. He had always lived on the seacoast
until November, 1901, when he came to this place, where the
altitude is 5,500 feet. He was perfectly well until January, 1902,
when he came to me suffering with insomnia and restlessness.
This trouble continued to increase in severity until March,
1902, when he began to be seriously troubled with dyspnea upon
exertion.
At the physical examination made at that time, there was no
evidence of organic heart trouble. The urinary examination
was negative; temperature normal, and the pulse was never
below 85, even after several hours' rest in bed. The lieart beats
increased several beats daily until they had reached the average
of 1.S5. He was sent to sea level on May 1. At no time during
his residence here could I detect any sign of organic trouble.
The patient was very much improved by returning to sea
level, the heart beats coining down to 90, in three weeks.
THE LAWYERS FEE AND THAT OF THE PHYSICIAN.
BY
H. B. YOUNG, M.D.,
of Burlington, Iowa.
To the Editor of A meriean Medicine : — I am reminded by
your editorial remarks (Issue of April 19,1902) upon this sub-
ject that about a year ago I tried to convince a lawyer that a
physician's services were as valuable In a monetary sense as
a lawyer's. I did not succeed to any appreciable extent. But
the attempt was not without profit to me. because it showed the
futility of trying to meet the situation on ethical grounds. It
also makes me doubtful as to the efficacy of your remedy. "A
united and organized profession " I never expect to see. It
may come with the millennium — maybe will be one of the proofh
that the millennium has come.
But when it comes what can the " united and organized pro-
fession "do to balance the inequality? Suppose it endorses »
fee of .5100,000 for saving the life of a nmltimillionaire and the
" multi" says ho won't pay. Then to collect the fee suit must
be brought. But what chance is there to make good in a law-
suit when your lawyer (if you can get one of reputation) doesn't
believe the claim is just? As a rule, no good lawyer will take
a case under such circumstances; and the other kind— well you
know wliat he will do.
It is manifest, therefore, that we are blocked in this direc-
tion and must try some other tack ; or make a change of base
entirely. I vote for the latter.
In the first place, let us as physicians drop all this talk
about tjeing uncommercial. The charging of a fee is in itself
commercialism, pure and simple ; and talk to the contrary only
serves to make our position In the body politic questiotta))lo.
If we are not commercial, why sliould we care what lawyers
get iu fees? They don't deny cximmercialism.
The real trouble lies in the fact that, after all, we are com-
mercial, but are so afra'd of being found out that we don't take
commercial metlKxls for our own protection. If we did we
would be bettor paid.
It is not considered unethical for a lawyer to charge a lump
sum for given service, or a sum contingent upon the result
gained— time and money expended or saved ; and I know ol no
reason why a physician may not do the same.
Suppose, then, that we do as the lawyers— that Is : Before we
undertake a case havea definite understanding with the patient
either in writing or in the presence of disinterested witnesses
as to the value of the services wo are to render. We all know
how prone everybody is to l)olitllo the value of services after
they are rendered ; and how dlJlli^uIt it Is to estaiilish this value
before a jnry. The prior understanding (or call It contract) Is.
thus distinctly a safeguard against future misunderstanding
between the patient and physician. The patient knows before-
hand just what expense he must pn)vlde for, and the physician
that he has to prove nothing but his contract. And then your
lawyer, who would not take the case at first because of dU-
belief In the justice of your claim, may think your palienta
fool, but will do his best to make him fulfil his contract.
Maybe you will say that this plan Is not feasible; but In
support of my contention that It is, let mo refer briefly to a case
in point- one not unknown to many of your readers.
Some eight or ten years ago a Chicago physician, an Intuba-
tion expert, was called by a rich man to see his only son. who
130 AMKKICAN MKDICINBI
CORRESPONDENCE
(July 26, 1902
•was in extremis with diphtheria. Suffocation was averted and
the boy's life saved. The rich man was profuse in his oxpres-
■ions of admiration for the skillful handling and asked the
physician to send his bill soon. The physician complied with
this request and sent a bill for $2,000. Did the rich man pay
promptly and cheerfully? No. He absolutely refused to pay
■nch an " outrageous bill."
Now suppose the physician before putting in the tube had
■aid: "This procedure may not be eft'ective. If not, I will
charge you only for my time — ?20. If it saves the boy's life, I
will charge g2,000." You know as well as I that the rich man's
reply would have been : " Save the boy. The ?2,000 is nothing."
And there are others — plenty of them.
UNUSUAL INJURY OF THE SCROTUM.
BY
CHARLES D. HAUSER, M.D.,
of Youngstown, Ohio.
On May 28 I was called into the country to see an old gentle-
man who had been bitten by a horse. I saw him about an hour
after the accident occurred and found him with a gaping wound
of the scrotum which extended from just beneath the junction
of the penis and scrotum to the lower border of the scrotum,
and the left testicle, which had been denuded of its tunics, pro-
truded. An anesthetic was administered to the patient, the
wound cleansed with hydrogen peroxid and irrigation with
decinormal saline solution. Finding the spermatic cord was
uninjured I approximated the edges of the tunics by means of a
continuous fine catgut suture, thus restoring the testicle's cov-
erings, after which I closed tlie skin with a subcutaneous cat-
gut suture, inserting a small rubljer drainage tube. During the
first few days the temperature was about 100° F. There was
some suppuration with swelling of the testicle. This, how-
ever, subsided rapidly and the patient made an uneventful
recovery.
INTESTINAL OBSTRUCTION RELIEVED BY ATROPIN.
HENRY LEVIEN, M.D.,i
of Liberty, N. Y.
The medical literature has teemed lately with papers on,
and reports of, the beneficial action of atropin in intestinal
obstruction, and in the following case I grasped the opportu-
nity to give it a trial :
On January 22 I was called to see Mrs. S., aged 34,
mother of five children. She is afflicted with pulmonary tuber-
culosis. I found her suffering from severe abdominal pain which
lasted fully 24 hours, and which was more severe during the
night than on the previous day. Her pain was not of a colicky
nature, but constant, unceasing, and spreading over the whole
abdomen. She was subject to habitual constipation, and at this
time she had had no evacuation of the bowels for three days.
On examination of her abdomen I felt a tumor-like mass in
the hepatic region which I at first thought was an acute attack
of hepatic enlargement, left lobe, with obstructive jaundice.
She vomited twice during the night, but no fecal matter was
brought up. High enemas with soapsuds and hot water admin-
istered previous to my calling on her did not relieve her dis-
tress. On a table near her bed I saw a number of boxes filled
with triturated tablets, one of which contained " pills for
cough," of which pills she recently took quite a number, as her
cough was rather troublesome.
Presuming the tablets contained codein or heroin and prob-
ably morphin, I thought the last contributed largely if not en-
tirely to this acute attack— and this reasoning led me to the diag-
nosis of intestinal obstruction situated at the angle formed by
the ascending and transverse colon. I gave her two tablets of
.atropin, xJo of a grain each, instructing her to take one every
hour for the following three hours. I felt safe In doing so, as the
patient has taken large doses of opium.
When I called in the forenoon I was gratified and surprised
to hnd the tumor had disappeared from its original site, the
pain nearly gone, a sense of soreness felt only on slight pres-
sure; but no bowel movement had taken place. A full dose of
salts completed the cure.
Two weeks later the patient entered our sanatorium. Dur-
ing the four months of her stay under my care I convinced
myself (a) that she was not subject to obstructive jaundice,
nor to any hepatic disease, her habitual constipation being due to
laxabdominal walls, and yielding to appropriate diet and mass-
' Physlclan-ln-charge, Liberty Sanatorium, Liberty, N. Y.
age; (6) that the attack described was due to intestinal fecal
obstruction caused or intensified by injudicious consumption
of some form of opium, and (c) that atropin acting antidotally
causes relaxation of the paralyzed mucous membrane of the
intestinal canal and thus manifests its beneficial action in fecal
or any other obstruction not due to inflammatory adhesions or
to pressure from outside.
COMPLETE INVERSION OF THE UTERUS WITH PRO-
LAPSE.
BY
J. EDSON KELSEY, M.D., Ph.G.,
of Berkely, Cal.
Adjunct Chair Chemistry, Cooper Medical College, San Francisco.
Case. — In August, 1901, I was engaged to attend a prima-
para, who stated that her menses had ceased on March 20, 1901.
Upon examination I found a normal canal and an enlarged
uterus. Examination of the urine showed urea 2.2%, albumin
none. She seemed perfectly well, and I did not see her again
until October, when I again examined the urine and found urea
1.8%, albumin none. About the middle of December I was sent
for and told she had three fainting spells, brought on by ner-
vousness. She had fallen down several steps and the abdomen
was very tender upon pressure. She had no headache, and her
pulse and temperature were normal. The urine contained 1.7%
urea, and no albumin or oasts. From then on she complained
of weight and soreness in the abdomen. On December 23 I was
sent for, and found her complaining of slight labor pains. 'The
OS was not dilated and the uterus was quite high. I did not
think that labor was commencing, so ordered her to take 1 dram
of fluid extract of viburnum prunifolium every four hours, and
Eains ceased. On January 2, 1902, she again complained of pain,
ut the uterus did not contract, and at the end of 24 hours
viburnum was again given but with no results ; then tincture
of opium was added with no effect. All medicine was stopped,
and on .lanuary 6, 15 grains of jjuinin sulfate was given to cause
contraction of the uterus. This caused slight contraction Avith
dilation of the os. The same dose was repeated with no results
on January 9 and 11. To give her some ease I gave her on
January 13 more viburnum and opium, which allayed the pain
somewhat. On January 16, while still taking the medicine, the
pains returned, so the viburnum was stopped. On the evening
of January 17, 15 grains of quinin svilfate was given. This
seemed to increase her suffering without causing any contrac-
tion of the uterus, so I decided to try dilation. I inserted a
Barnes bag and dilated until the larger bag was expelled.
When I inserted my fingers I found that the head did not
descend much with each pain. I continued the manual
dilation until the head was expelled from the os. Pains were now
quite severe, about three minutes apart and of a minute's dura-
tion. After waiting for half an hour an examination was made
and the head found in the same position. The pains seemed more
severe, and in a half hour another examination showed the
head still In the same position, so the membranes were rup-
tured and the forceps applied. The head was brought to the
pelvic floor and the child was then delivered normally. After
waiting about 15 minutes I discovered the uterus very low in
the abdomen. I pulled the cord sliglitly and what I supposed was
the placenta, popped out with profuse hemorrhage. Finding it
was attached, I inserted my hand in tlie vagina to free it, and
found the uterus was inverted and entirely prolapsed, with the
placenta adherent to its entire surface. I detached it and got
the uterus partly replaced when the os contracted. I could not
replace the uterus. The patient was pulseless, so I gave her a
hypodermic injection of strychnin, and sent for Dr. Henry
Gibbons, of San Francisco. Upon the arrival of Dr. Gibbons
we gave the patient a transfusion under the breasts of a quart
of normal salt solution, and in half an hour had the uterus
replaced. We placed within the uterus a piece of alum the size
of a hen's egg. Upon examination of the placenta the cord was
found to be 13 incnes long, including what was on the child.
The mother made a very tedious recovery. On March 2 she was
able to sit up, and in a week to walk a little. The uterus lay
very low in the vagina, and when she walked it would prolapse
completely. She was put on a tonic of viburnum and hydras-
tis. Tamponing was done. At the present writing she is very
much improved. When the baby was a week old it was found
to have an umbilical hernia, which was treated with adhesive
strips.
The sanatorium conducted by the late Dr. A. J. C.
Skene, of Brooklyn, will be donated by his widow to Miss
Mary A. Fisher for the establishment of a Mary A. Fisher
Home and Sanatorium for writers, artists, teachers, and repre-
sentatives of any of the professions. Mrs. Skene will endow a
room in memory of her husband, this room to be always set
apart for the use of some physician in need of a home. The
donation is considered in tlie nature of a substitute for the hos-
pital planned by Dr. Skene before his death.
July 26, 1902)
LOBAR PNEUMONIA IN INFANTS
[AXBRtCAN HeDICINE 131
ORIGINAL ARTICLES
LOBAR PNEUMONIA IN INFANTS *
BY
WILLIAM FITCH CHENEY, M.D.,
of San Francisco, Cal.
Professor of Principles and Practice of Medicine, Cooper Medical Col-
lege; Physician to Lane Hospital.
From my experience with disease in infants, both in
my own and in consultation practice, I have learned
that lobar pneumonia is a common affection in this city
during the first two years of life. Because of this fact,
and because also in spite of its fre<iuency it is not always
diagnosed, I have chosen it as a subject that might be
profitably reviewed. The clinical history and physical
signs of lobar pneumonia are much modified in these
first months of existence, and one perfectly familiar with
the picture presented by the disease in adult life may
fail utterly to recognize it as it presents itself in infancy ;
and this is my reason for calling the matter to your
attention at this time.
The onset in infancy is usually sudden, but the initial
chill of adult life is rarely seen. Sometimes a convul-
sion takes its place, and it is extremely important to
remember that the spasm in infancy may always mean
more than simply disturbed digestion or teething. More
frequent than the spasm at onset is an attack of vomiting,
followed by several loose movements from the bowels
within a few hours, and many a time has this series of
events misled the wisest into diagnosing the trouble as
entirely digestive. There may be none of these decided
manifestations to mark the transition between health
and disease, but simply a languor and indisposition that
make the mother know her baby is ill, without giving
her any definite story to tell the physician when he comes.
Whatever the initial symptoms, there is usually this
positive history of sudden change in the child's con-
dition. The symptoms of disease in infancy are largely
those of disturbance of the usual (lisiX)sition and
manners. A healthy baby six months of age is bright,
vivacious, playful, and blessed with a strong desire for
its food. When such an infant within a few hours
becomes dull and listless and apathetic, and will take
but a part of its usual bottle, or will not nurse at all, the
observant eye of the mother ([uickly notes that some-
thing is wrong. Too often the physician, if unfamiliar
Avith infants, is inclined to make light of her fears and
to place little importance upon her description of symp-
toms that are at best indefinite. Such changes in dispo-
sition in infancy are always full of meaning and never
to be slightetl. To be sure they give no definite clue as
to the nature of the disease present, but they almost in-
variably indirate that some disease is present, and it
may he so serious an ailment as lobar pneumonia.
Coming to a baby with such a history, simply that it
went to bed well but i)assed a restless night and in the
morning had none of its usual vivacity and life and did
not want its food, the physician, if he is wise, will not
pooh-pooh at the vagueness of the story, but will sit
down csvlmly and investigate the case. I am convinced
that much Uw often disease in infants is overlooked
simply because? careful examination is not matle as
it would be in the adult. In this particular instance, the
first thing to do is to investigate the temperature, and if
the rectal temperature is taken, much will be learnftl at
once. In lolmr pnemonia fever is present from the out-
set, and usually it is quite' high, even higher in infants
than in adults. If the temtwrature by rectum is found
to b(! 104° or 105°, the physician will scarcely make
the mistake of assuming that nothing is the matter. If
next he counts the pulse and finds it running I.')0 or 160
to the minute, again he has positive evidence that some-
• Heart ix-fore the San Franclnco County Medical Society, May U,
thing is radically wrong. Still from these signs he only
learns that the infant is really ill, and gets no clue as to
the nature of the illness. During the latter half of the
first year, when the first teeth are coming, this process is
commonly enough supposed to be responsible for the
fever and all the symptoms that the mother has noted.
If the onset has been with convulsion or vomiting,
the attack is thought to be one of digestive disturbance.
Once in a while, prompted by a zealous parent, the
physician is even led to attribute the whole trouble to
"worms."
But there are certain definite signs, more or less con-
stantly present from the onset, that attract the attention
of a shrewd observer to the lungs, and convince him that
here is the true site of the disease. The first of these is
the breathing. The rate of respiration is invariably
increased in lobar pneumonia, and if it is counted while
the infant is asleep, and is found to be considerably
above the normal, we have another most important link
in the chain of evidence. The normal rate in the infant
six months to one year of age is about 30 to the minute.
If, therefore, the baby is found to be breathing con-
stantly 40 or 50 times to the minute, it is reasonably cer-
tain that the fever and the general symptoms noted
previously are due to some involvement of the lung.
Often the rapid breathing has been observed already by
the mother, who cjiUs the physician's attention to it. If
he heeds her statement and verifies it for himself, or if
he discovers this abnormality in the careful examination
that he ought to carry out, he neetl never make the mis-
take of diagnosing teeth or worms.
Almost as important as the rate of breathing is the
little moan or grunt that so often accompanies each expi-
ration. It is quite typical of lobar pneumonia in infants,
and when it is found together with the other symptoms
mentioned, it is practically diagnostic. It says as plainly
as if the infant spoke in words, that breathing is painful.
The expiratory moan, repei\ted with each breath the
baby takes, should tell pretty positively to the physi-
cian as he sits and watehes, that here is a case in which
the lung is involved; and no case that has this sign
should any longer be considered obscure. The only mis-
fortune is that not every case of the disease presents it.
The cough of lobar pneumonia in infants is often so
infretjuent in the beginning that it is overlooked. It is
never so much in evidence as in bronchitis, or broncho-
pneumonia. It may occur, for instance, but five or six
times during the day, and being so little a part of the
general picture its existence is often denie<l entirely
when the physician imiuiri's about it. Furthermore,
besides its infretiuency, it is usually suppressed aiul kept
back, and has none of the violence and paroxysmal char-
acter of the cough in bronchopiu'umonia. As a rule it
gives pain, and this is manift^sted in the baby by a con-
tortion of the face and a cry following it, that show
plainly enough it hurts. One need never knik for rusty
sputum as a diagnostic sign of lol)ar pneumonia in
infancy, nor for any sputum at all, for infants do not
expectorat*'. The statement that there is no cough is
therefore not to be considered in any case as a bar to the
diagnosis of lobar pneumonia ; it is im{M)rtant to remem-
ber this in summing up the evidence.
With such initial symptoms of convulsion, or vomits
ing, or sudden onset of languor and <lepr<'8sion, with liigh
fever, rapid pulse, rapid breathing, expiratory mojin,
slight supi)r(H-<e<l cough that is followwl by a cry, it is
usually easy to make the diagnosis ejirly. But even
though a day or two go by in uncertainty, the |H'rsistent
high tenijM'rature, the {H-rsistent rapidity of respiration,
the decidtKl prostration, the Increasing tH)Ugh, usually
make the observer positive within 48 hours. The dis-
ease runs a course very similar to that in the adult, as
regards duration and termination. It is about a we«>k
from the In-ginning symi)toms In-fore remission comes;
sometimes it is on the fifth day, sometimtis not until the
ninth. The typii«l crisis of adult life is (pilte common
1 32 American Mkdicine]
LOBAE PNEUMONIA IN INFANTS
[July 26. 1902
in infants as well ; and I have several times been hastily
summoned by the message that the baby was dying, only
to find upon my arrival that the temperature had fallen
within a few hours from 104° or 105° to subnormal, with
profuse perspiration and an appearance of pallor and col-
lapse that was indeed alarming ; all this occurring quite
suddenly after a week's siege of desperate illness, per-
suading the parents and attendants that the change
meant death. Sometimes, instead of this sudden crisis,
the fever makes a drop from the high notch it has main-
tained for several days, to a point 2° or 3° lower, and
then falls gradually throughout the next 48 hours until
the normal is reached. Persistence of the fever, of the
rapid pulse, and of the respirations, and of the other
symptoms beyond the twelfth day almost inevitably
means some complication ; and in infants this complica-
tion is almost inevitably empyema.
The physical signs of lobar pneumonia in infants are
often indefinite and misleading. P^specially at the onset
they are frequently not to be obtained, and hence give
no aid in the diagnosis. Occasionally it is several days
before they develop sufliciently to be plain, although
the symptoms meanwhile have been typical of disease
in one lung. In any case, the most characteristic signs
are found usually with the stethoscope. By inspection
it is extremely difficult to say that one side moves more
than the other ; by palpation there can be no delib-
erate investigation of the vocal fremitus as in adults ; on
percussion we never find more than a slight diminution
in resonance, because of the comparatively small consol-
idated area under the finger, and the over-distended
lung about this, which modifies the note ; after consoli-
dation is well established, dulness is usually well marked
at one base as compared with the hyper-resonance of the
other, but in the beginning the difference is commonly
so slight that one can not be positive it exists.
Auscultation, however, gives us fairly definite evi-
dence of the disease and it should always be relied upon
more than any other method of investigation. The
points that concern us are the following :
1. The Liteiuity of the Breath Sounds. — Over the con-
gested area in the first stage the breath sounds are dis-
tant and feeble as compared with the corresponding area
on the opposite side; this inequality in the loudness of
the sounds should always excite suspicion, even if noth-
ing else abnormal is noted.
2. The Qiiatity of the Sounds. — Often it is the harsh,
tubular, bronchial quality of the breathing over a cer-
tain area that particularly attracts attention. This is
more apt, however, to be found after the first 24 or 48
hours, when consolidation has become complete. It is
easy to note the abnormality if one compares the find-
ing with that over the opposite lung.
3. The Relation of Inspiration to Expiration. — The
diagnostic point is the prolongation of expiration until
it equals or exceeds inspiration ; and this distinguishes
the diseased area, even though the intensity of the
sound there is decreased. The healthy lung may have
louder breath sounds, but it never has the prolonged
expiration characteristic of consolidation.
4. The Discovery of Adventitious Sounds. — This is
probably the most important point of all ; the presence
of clicking, crackling rales at the end of insj)iration over
a certain area of the lung is a sign that should always
be especially sought for, and that clinches the diagnosis
when it is found. It is often present quite early, like
the crepitant rale of lobar pneumonia in adults. Later
on bubbling rales of various sizes are heard, especially
after crisis ; but the diagnosis is usually made one way
or the other some time before they appear. It is usually
a lower lobe that is involved in infants as in adults, and
it is therefore in the back, below one or the other scapula
that we look for the physical signs in a suspected case.
But each axilla should be carefully gone over, and in
fact the whole chest, before it is concluded that the lungs
are clear.
The diagnosis rarely gives trouble, provided time is
taken for careful investigation of the meaning of symp-
toms, and for repeated examination of the chest. If this
is done, no one can ever mistake lobar pneumonia for
the effects of teething or of worms. It is only the failure
to use eyes and ears and reasoning power that permits
such errors to be made. Sometimes the onset with con-
vulsion or with vomiting persuades the physician to look
no further than the digestive tract for the cause ; but
when the inevitable calomel that follows do&s not remove
the fever or relieve the symptoms in any way, almost
any man is ready to look further, and, as a rule, he has
only to look far enough and he will find. The disease is
easily distinguished from the other common disea.ses of
the lungs in infancy : acute bronchitis and bronchopneu-
monia. The sudden onset, high, persistent fever, infre-
quent, suppressed cough "and localized physical signs of
lobar pneumonia are in marked contrast to the more
gradual beginning, the moderate, irregular fever, con-
stant, paroxysmal and violent cough, and the generally
diffused physical signs throughout both lungs, that char-
acterize bronchopneumonia or acute bronchitis in infants.
Almost any disease of infancy that causes high fever may
give rise to nervous symptoms that simulate those of
meningitis; and not infrequently these symptoms are
the most prominent ones in lobar pneumonia and throw
the diagnostician off the track. Thus the case may be
misunderstood for several days, until at last the termina-
tion by crisis suddenly clears up the error. In those
cases in which, in spite of repeated search, no physical
signs of disease in the lungs can be found for the first
few days, one must depend entirely upon the symptoms
and can only suspect the true nature of the ailment.
Such cases are usually those of a central pneumonia, and
the signs become manifest only as the consolidation
extends to the surface of the lung.
The prognosis is almost invariably a good one, if the
baby is given a fair chance for its life and does not
become the object of too much professional zeal. In the
first two years of life the heart muscle is still sound, and
its valves intact ; the kidney epithelium has not yet
been forced habitually to excrete more poisons than
naturally fall to its task, and the digestive organs have
not yet been persistently abused. Nature is, therefore,
in condition to make a good fight, and lobar pneumonia
is not such a serious disease as in adult life. Most
patients under two years recover ; whereas most patients
past 50 years die.
The treatment is simple, for the disease is a self-
limited one, and comes to an end of its own accord.
The main object is to maintain the strength until the
affection runs its course. The food must be carefully
and regularly administered. If the infant is nursed at
the breast, let the breast continue to be used ; if on the
bottle, let the same food as previously given be con-
tinued at regular intervals, but diluted or peptonized if,
on account of the high temperature, it is not well
digested. For the fever, no antipyretic drugs should be
used ; cold sponging or bathing of the body is far more
efficacious and less depressing. For cough, if it is
troublesome, or for restlessness and insomnia, Dover's
powder is the most useful medicine ; and frequently this is
the only medicine ray little patients receive during an
attack of lobar pneumonia. For symptoms of prostra-
tion, such as a pulse above 150 and tendency to stupor,
brandy should be given regularly, in dose of 10 to 30
drops every two hours, well diluted ; strychnin, in dose of
T5(T to 20TT grain, according to age, every six or four hours,
and atropin in dose of ^^^,5 to ^^^ grain at the same
intervals. For the collapse that is apt to occur at crisis,
the best treatment is the hot mustard bath, followed by
vigorous rubbing of the surface of the body. In general
it is important to remember the motto of Jacobi — nif
nocere — do no harm ; for occasionally infants suffer more
from their vigorous medication than they do from the
disease that called it forth.
July 26, 1902]
PANCREATIC FISTULA
(ASCERICAN HEOICINF 133
A CASE OF PANCREATIC FISTULA OF THREE
YEARS' DURATION, WITH A CHEMIC STUDY
OF THE FLUID ELIMINATED.
BY
FRANCIS W. MURRAY, M.D.,
Professor of Clinical Surgery, Cornell University Medical College; Sur-
geon to New York Hospital and St. Luke's Hospital.
AND
WILLIAM J. GIES, M.S , Ph.D.,
Adjunct Professor of Physiologic Chemistry, Columbia University;
Consulting Chemist at the >'cw York Botanical Garden.
In about 80 Ji^ of the operated cases of pancreatic cy.st
on record, Gus.senbauer's method of incision and drahi-
age was employed, and the mortality due directly to the
operation was less than dfc. While this method is
attended with such favorable results and is safer than
extirpation, which is limited in application, there are
certain disiidvantages attending it in that the healing
process is slow, at times most tedious, and there is also
the danger of a permanent fistula. The duration of the
healing process varies from one to .several months, and
in a case recorded by Korte, 2i years elapsed before the
fistula closed.
As to the number of cases resulting in permanent
fistula we possess no definite information, since in many
instances details are wanting as to the ultimate result of
the fistula still existing when the ca.se was reported. It
is probable, however, that in a small percentage of the
cases the fistula was permanent, as not a few were cyst'
adenoma. In such ca.ses the conditions favor perma-
nency of the fistula, and extirpation of tiie entire cyst
offers the only means of cure. Since duration of healing
after Gussenbauer's method varies from one month to
2i yeius (as in Korte's case), one should wait a long time
before deciding in a given case that the fistula is a per-
manent one. If, however, at the time of operation we
had to do witi a cystadenoma, which did not allow of
extirpation, then the question of permanency of the
resulting fistula would be more ea.sily decided.
In the case we report the fistula has existed over three
years, has not diminished to any extent, in depth, and
its .secretion, while, as a rule, of small amount, steadily
continues. The clinical history of the cjjse was reported
at the meeting of the New York Clinical Society in
December, 1900, and was published, with two other cases
of pancreatic disease, in American Medicine, January 2'>,
of the present year. Since that time a very thorough
chemic study has been made of the fluid eliminated.
The signiflciince of the results of this chemic examina-
tion can be appreciated only in the light of the full
clinical history of the ca.se, which is, therefore, again
given in brief detail :
CI-INIOAfi HISTORY.
Be/ore A dminnion. — M. D., female, 19 years old, admitted
May 8, 1899, to St. Luke's Hospital. Family history: Father
died of Icidney trouble, mother of heart disease. Personal his-
tory: Patient had good healtli until seven years ago, since then
has suffered from attacks of gastritis, la.sting throe weeks at a
time. The attacks were attended with vomiting of foul and
greenish material, or cotree-grounds matter; no blood. During
the attacks there was epigastric tenderness and sharp shooting-
pains in tlie stomacli and radiating totlie I)acl{, pain worse after
eating. No history of clay-colored or fatty stools, no jaundice,
very constipated. Has had no appetite and has lost 10 pounds
in the past month. Six weeks ago her pliysician discovered a
tumor the size of an egg in tlie epigastric region ; since then the
tumor has steadily increa.sed in size. The tumor appeared just
after an attack of gastritis, l)ut there is no history of sliarj) pain
or collapse. Since then the patient has been free from pain or
stomacli symptoms. Last menstruation in March ; had pre-
viously t)een regular.
Oil Adinin.v'o)!. — Patient well nourished, skin dirty yellow,
mucous membranes pale, slight acne about face. Tongue
coated, teeth poor. Lungs normal. Heart negative, excoptmg
a systolic apex murmur transmitted to left; no aci^eutuation of
second pulmonic. Liver: dulness begins at fourtli riglit inter-
space and extends to free l)order, edge not felt. .Stomacli reso-
nance a little higher tlian normal. There is a smooth, hard,
tense, semifluctuating tumor, about the size of a large cocoanut,
which is a little to the left of the median line in the epigastric
and umbilical regions, and extends into the left hypochondriac
region. Its area of flatness begins just below ths stomach and
extends to the level of the umbilicus, where it meets the reso-
nance of the transverse colon. The flatness runs to the left and
backward to the spine, its upper border behind being IJ inches
below the angle of the scapula. About two inch&s below the
most prominent portion of the tumor in front, a free, sharp,
smooth edge can be felt running through the umbilicus to the
left in a curved direction. Right kidney palpat)Ie, freely
movable. Temperature 100°, pulse 90, respirations 24. Urine
light yellow, acid, sp. gr. 1,010, no sugar nor albumin, contains a
few vesical epithelia.
Diagnosis, pancreatic cyst.
Operation, Mny IS, ISyy.— Ether anesthesia. Through an
incision in median line beginning just below the eusiform and
continuing downward for four inciies, the peritoneal cavity was
opened. No adhesions found, stomach displaced upward, and
colon downward.
Pearl-colored cyst, seen presenting behind the gastrocolic
omentum, which was adherent to anterior wall of cyst. Peri-
toneal cavity was walled off by gauze packing, large aspirating
needle thrust intt) cyst, and 30 oz. of clear straw-colored limpid
fluid withdrawn. As the wall of the cyst collapsed, it was drawn
up into the abdominal wound and its cavity exposed through a
three-inch incision, and several ounces of similar fluid removed
by sponges. Cyst was thin-walled and lined with a smooth
membiaue, and ran upward l>ehiiid stomach. Careful probing
failed to reveal any communication between cavity of cyst and
adjacent organs. IncNion in cyst wall partially sutured with
KIg. 1.
catgut, upper half of abdominal incision closed with silk
sutures, cyst wall sutured with silk to parietal peritoneum in
lower half of abdominal incision. Large nil)t>or drainage tube
inserted into cavity of cyst, wigesof wouml pioteded with rub-
ber tissue and Iodoform gauze; sterile gauae dressing over all.
Operation lasted almut an hour, patient sent to ward in good
condition. Slight reaction followed operation, and conv«Ie»-
cenite was soon established.
The discharge from the cyst was profuse for al>out 10 days,
and then it gradually decreased, rcfiui ring a change of dressing
several times daily.
Chemic Qiinfilies of the Cynlic /^/uiV/.— Pathologist reported
that the fluid remove<i from the cyst was alkaline, sp. gr. 1,018,
opalescent, ami contained free fat, cholesterin and leukocytes.
It emulsified fats, changed starch into glucose and digested
albumin.
Coxvnlexcence. — The convalosccn<'e was uneventful, the
wouikI gradually became smaller, the discharge lessened, and
on .June '21 the patient was reforre<l to the out-patient depart-
ment with a narrow flstula discharging a small amount of thin
yellowisli fluid. The fistula was al>oiit five inches in dcjith, and
passed (lo« invard into the left hyp<i<-li<)ndrium. Since discharge
from the hospital the patient has been kept under obsorvaticiii,
and while the fistula has never healed, there has been a great
improvement. .She is strong and al)lo to work, has no more
attacks of indigestion, bowels are regular, and there has been a
great ini^ease in weight. .,,,,.
For a year after the operation a small rubber drainage tul>e
was worn, but owing to toe steady contraction of the wound in
134 AMXBIOAN MbDIOIKXJ
FANCEEATIC FISTULA
[JULY 20, 1902
the abdoiiiiiml wall, it was necessary to substitute a straight
silver tube three inches in length and of 32 F. caliber. Ihis
prevents any retention of secretion and is worn with no dis-
comfort, and at present one small dressing of gauze suffices for
24 hours. Should,
however, the pa-
,, ^^^^^^^^^^^^^^^^^^_ ticnt become ex-
^^^^^^^^^^^^^^^^^^* <^ited or nervous,
the secretion of
pancreatic fluid is
greatly increased,
and at such times
frequent dressings
are needed.
Remarks. —
This was a case
of pancreatic cyst
in a younj^ adult,
and as far as
could be ascer-
tained at the op-
eration the cyst
arose from the
distal portion of
the gland. The
etiology is ob-
scure ; there was
no history of
traumatism, and
the attacks of se-
V e r e epigastric
pain and vomit-
ing occurring at
intervals during
the seven years
Fig. 2.
probably bore an etiologic relation to the formation of
the cyst. It should be observed that the cyst was first
discovered after one of these attacks, and since then
there has been complete cessation of pain and vomiting.
This fact may suggest pancreatic calculus as the cause,
but as no stone was ever seen in the feces, and as none
was found at operation, although sought for by the
finger and probe, there is no substantial foundation for
considering calculus as the etiologic factor.
The cyst was of large size, had thin walls and was
lined with a smooth glistening membrane, and presented
none of the appearances of cystadenoma. Incision and
drainage was deemed safer owing to the firm adhesions
to the neighboring organs. The diagnosis was made
before operation from the location of the cyst, and its
relations to the stomach and colon when distended with
air, by the history of rapid growth, and finally by the
absence of cystic disease elsewhere in the abdomen.
Aspiration was not resorted to, as it is attended with
danger, and it should be discarded in favor of explora-
tory incision.
Sugar was never present in the urine, and fatty stools
were never seen. Efforts to heal the fistula by local
treatment have been made steadily and at frequent
intervals. Injections of iodin, silver nitrate, carbolic
acid, nitric acid, curetting and packing of the fistula,
have been tried, but so far in vain. The fistula is still
about five inches in depth, and its apparent capacity less
than an ounce, but on two occasions when the drainage
tube was left out, fluid to the amount of six ounces
accumulated in the cavity. The distention of the cavity
by the retained secretion aiused nausea and some epigas-
tric pain, which was quickly relieved by the introduc-
tion of the drainage tube.
The general condition of the patient at present is
excellent, she has gained in weight and strength, has no
trouble with digestion, is able to work and sutfers no
inconvenience from the fistula. Local treatment of the
fistula is still continued, and should it be considered
necessary for any reason to excise the remaining portion
of the cyst, it will be approached by a counter incision
through the lumbar region.
In Fig. 1 may be seen the size of the cyst, and its
relations to the stomach and colon as determined by per-
cussion, the stomach and colon being distended with
air. The dotted line below the tumor represents the
position and course of the free, sharp edge felt upon
examination at admission.
Fig. 2 shows the tumor in profile as it presents below
the ribs and between the colon and stomach.
RESULTS OF KECENT CIIKMKJ STUDY.
As has already been indicated, the chemic exami-
nation of the cystic fluid at the time of the operation, and
of that discharged somewhat later, showed that pan-
creatic constituents characterized it. It seemed desirable
at this late stage of elimination, also, to ascertain by
chemic means whether the continued discharge is
from a permanent pancreatic fistula or whether the fluid
hits other than a pancreatic origin.
The daily flow of fluid has been considerable. Usu-
ally the liquid has been thin, watery, turbid, almost
colorless. Occasionally it is tinged with hemoglobin or
hemoglobin derivative, and is somewhat mucigenous.
Our analyses were made of fluids collected at wide
intervals and under varying conditions, with a purpose
of securing a representative average of results. In the
examinations referred to below the fluid was collected
either with a syringe or a catheter, the patient lying on
her back or side during the process. Coughing favored
the discharge of the fluid, and was resorted to occa-
sionally, by direction, during the first two periods of
collection, in order to facilitate withdrawal. The meth-
ods of analysis were those commonly in use. Chemic
examination was made immediately or within a few
hours after the fluid had been collected.
A. January 21, 1902.— Alter the silver tube had been re-
moved from the fistula, a small amount of amber colored fluid
could be withdrawn at frequent intervals with a syringe. The
flow gradually increased, and, in the course of a half hour,
45cc. of fluid was collected. This is designated below as the
" first portion." With the aid of a catheter an additional quan-
tity of the fluid, 31 cc, which flowed somewhat more rapidly,
was withdrawn in 15 minutes. This was almost colorless,
though slightly turbid, and is referred to below as the " second
portion." , , , ,
a. First Portion, 45 cc— This was amber-colored, opalescent ;
contained minute flocks and possessed a slight, though distinct
odor, suggestive of volatile fatty acids. A trace of hemoglobin
was present, the blood having come from a very slight wound
of the tissue inside the orifice during the use of the syringe.
The fluid was allialine to litmus. Acid phosphate was
absent. It contained a slight amount of proteid coagulating at
ft3° to 65° C. A few erythrocytes were to be seen under the
microscope ; some leukocytes and, here and there in the field,
epithelial cells also. Xo crystalline matter was present. A
good IMuret reaction was obtained with the fluid and a trace of
reducing substance was detected in it. The phenylhydrazm
test showed that this was due wholly or at least mainly to dex-
trose. Calcium, magnesium, sodium and potassium salts of
phosphoric, sulfuric and hydrochloric acids were present in
minute amounts. , „ . , , j ^
Tested by the methods now in vogue, the fluid was found to
possess only slight tryptic and scarcely any lipolytic action;
was entirely devoid of milk-curdling and inverting power, but
showed comparatively marked amylolytic etfect. Pepsin was
absent. The emulsifying power of the fluid was the same as
that of lymph. . . ...
The fluid did not contain fibrin— no sign of coagulation
manifested itself at any time.
The following percentage results for general composition
were obtained :
Water W-*!
Solids OM
Organic matter [{•*
Inorganic matter "••^^
Of the total solid matter :
Organic 82.M
Inorganic ^'■"'
b. Second Portion, SI cc. — Almost colorless. Less turbid
or opalescent than the first portion. Peculiar odor missing.
No hemoglobin present. Qualitative factors otherwise were
the same as for the first portion except that a proteid coagula-
tion was obtained at 69° to 70° C. The fluid did not contain red-
cells and no lipolytic action was induced by it. Further, the
amylolytic action was relatively weaker.
July 26, 1902]
PANCREATIC FISTULA
'AMEBICAK Medicimi 135
The following percentage results were obtained in quantita-
tive analysis :
Water 99.54
Solids 0.46
Organic matter 0.19
Inorganic matter 0.27
Of the total solid matter:
Organic ; 42.32
Inorganic 57.68
B. February 10, WOi.— The tluid was removed about three
hours after a light breakfast. The fluid was 45 to 50 cc. in vol-
ume, light yellow in color, alkaline in reaction and turbid, con-
taining small particles. One-half of it was filtered.
a. Filtered Porfton.— Slightly opalescent. Qualitatively it
was the same as the second portion examined on January 21,
except that all ferment tests were negative save that for dias-
tatie enzyme.
The following percentage results for composition were
obtained :
Water 99.15
Solids 0 85
Organic matter 0.52
Inorganic matter 0.33
Of the total solid matter :
Organic 61.63
Inorganic 38.37
6. Unflltered Portion. — Quite turbid with flocculent material.
Leukocytes grouped in clusters made up the particles visible
to the naked eye. The fluid was the same qualitatively, other-
wise, as the filtered portion, except that very weak, almost
imperceptible, tryptic action was demonstrated in addition to
amylolytic.
The appended percentage composition results were ob-
tained :
Water 99.09
Soiid.s 0.91
Organic mutter 0.56
Inorganic matter 0.35
Of the total solid matter :
Organic 61.24
Inorganic 38.76
The striking features of the results under A and B
are (1) the very weak, practically negative, action of tlie
fluid so far as typical pancreatic enzymes are concerned,
under conditions which had been made particularly
favorable to them ; and (2) the very slight amount of
solid substance, particularly organic matter, contained
in tlie fluid. The tryptic action was .so slight and uncer-
tion that the enzyme may have come from the leuko-
cytes of the fluid. The dia.static action manife.sted, while
vigorous, was no more pronounced than that shown by
any serous fluid, a statement applying with equal force
to the observed lipolytic effect.
The generally negative results of the preceding tests
for typical pancreatic enzymes led us to examine fluid
collected at a time wlien pancreatic activity would be
most decided and when, therefore, the probability of
diffusion or direct delivery from the gland into the fis-
tula (if either process now occurs at any time) would be
greatest. Any duct, or pa.ssage, connecting with the
cyst would naturally empty more fluid Into the fistula
during such a period of glandular activity than at any
other. Accordingly, the collection was Ixjgun at the
patient's home ju.st an hour after the completion of the
heaviest meal of the day and continued into the third
hour after the meal ha<l been taken, with the following
results :
C. February 18, 1902. — There was a gradual increase of flow
after removal or the tube. At the end of three-quarters of an
hour it was comparatively rapid. In one hour and 10 minutes
12S cc. of the fluid passed from the fistula.
This surprising result is worthy of special notice. Although
as much as 20 liters of fluid have been removed from a pancre-
atic cyst (by Stapper) at the time of operation, no such arterflow
as this has been previously observed. Indemans noted a flow
ot 12fl-130 cc. per day for a few days after operation, but this
soou diminished in quantity.
The fluid above mentioned had only a very faint tinge of
yellow, was slightly opalescent, odorless and without appreci-
able sediment. Its specific gravity was 1,002.8. (Jualitativelv
it was the same as the flr.st portion collected on January 21,
except that coagulal)le protoid was separated at «8° C, red colls
were absent and crystals of calcium oxalate were obtained on
concentration.
The tests for enzymes were practically negative except for
amylopsin, which was present in comparatively active amount.
,? '■'■.yP'ie action could be shown even with the aid of dilute
alkali. The emulsifying action was slight and only such as
may be obtained with any serous fluid.
The following results for percentage composition were
obtained in duplicate:
1. 2. Average.
Water 99,520 99.620 99 520
Solids 0.480 0.480 0.480
Organic matter 0.329 0.321 0.325
Inorganic matter. 0.151 0.157 0.155
Of the total solid matter :
Organic 68.50 67.72 68.11
Inorganic 31.50 32.28 31.89
The analyses of February 18 were repeated, after a good
interval, with fluid collected under similar conditions, i. e.,
within 1 to 3 hours after the heaviest meal of the day. Samples
of the patient's urine, pa.ssed on the same and the previous day,
were also carefully examined. The results follow :
D. April 1, 1902.— The silver tube had been kept out of the
fistula during part of the day. Later, because of a tendency to
closure and retention, a rubber tube had been inserted. In the
evening, on removing the rubber tube, the first portions of the
fluid withdrawn with a syringe were amber-colored and con-
tained considerable mucus, leukocytes and some oil globules.
The insertion of the rubber tube required considerable manipu-
lation, which fact doubtless accounts, in part, for the greater
proportion of mucus, etc., in the fluid first collected. The fluid
collecte<l in this way is referred to below as the " first portion."
To facilitate further collection a catheter was inserted and
the fluid carried directly to a bottle. The flow appeared to be
uniformly rapid for more than an hour, when it seemed to slow
up somewhat. In 1 hour and 45 minut«s, 155 cc. of the fluid was
collected. (Compare with result of February 18.) This is
referred to below as the " second portion."
a. First Portion.— The fluid collected at first po.ssessed dis-
tinct diastatie action, very slight tryptic power, and only a trace
of lipolytic influence. It was composed as follows :
Water „ 97.75
Solids 2.25
Organic matter 1.58
Inorganic matter „ 0.68
Of the total solid matter :
Organic 70.89
Inorganic 29.31
Compared with previous analyses, the chief difference to be
noted is the somewhat increased proportion of solids. This
was imdoubtedly due to the mucus in the fistula at the time,
and which was taken up by the syringe. The catheter delivered
the fluid of the second portion as it gatheretl in the tistula. The
comparative analyses given below show that the mucus is a
variable and a secondary constituent.
6. Second Portion. — This was gi ven more extended analysis
than any of the other portions collected. Its speciflc gravity
was 1,003.6. With the exception of enzyme content, the fluid
possessed all of the qualitative characters of tliat collocto<l on
February 18, calcium oxalate, liowover, being more in evidence.
This fluid posses.sed comparatively vigorous diastatie
action even in the cold. At 40 C. it showed tryptic power
very qrailualty, and had some lipolytic action. Kven when
tested with ethyl butyratoand litmus, however.the latter action
was seen to bo comparatively slight.
The following substances could not be detected in' the fluid :
Bile pigment, prote<Jse, peptone, tryptophan, nuclein base,
urea, leucin, tyrosin, croatin, glycogen. These and previous
negative resulUs indicate that neither the liver nor a kidney is
involved in the production of the fluid.
In addition to the substances already found in each sample
of fluid collected, cholestorin crystals were olwerveil in this.
The coagulable proteid consisted of both albumin and globulin.
On boiling, the fluid gave off an odor suggestive of fatty acid,
in the cold, acetic ncXA precipitated a proteid insoluble in a
moderate excess of the a<-ld. This substance, which appears to
have been nucleoprotcid, was somewhat soluble, however, in •
slight excess of hydrochloric acid.
The amount of coagulable jtroteid was accurately deter-
mined. The first separation was made within two hours of the
time of collection, the second 12 hours later. The reeulta are
1>ra(^tically the same. The original fluid, in the meantime, waa
tept in a cool place— at 16° C.
First determination -■ O.IMM gram oongulable proteid per 100 oc.
Second " -0 2000 " "
Average -i 0.1W8 " '• " " "
The second result (or coagulable proteid content, compared
with lt« duplicate, shows, further, how little tryiitic action the
fluid was able to exert— though, of course, the conditions dur-
ing the int<!rval were not particularly favorable to such action.
At the same time, if there had been any signiflcAnt quantity of
trypsin in the fluid, a good pro|H>rtion of this small amount of
proteid would have been hydrated beyond the ooagula1>le
stage.
136 American MKDiciiraj
PANCREATIC FISTULA
(JUI.Y 26, 1902
The following results for general percentage composition
were ol)tainecl :
Water 99.07
Solids 0.93
Organic matter 0.58
Inorganic matter 0.35
Albumin, globulin 0.19
Of the total solid matter :
Organic 62.51
Inorganic 37.49
Albumin, globulin 20.06
c. Urine of Mdrch SI and April 1, 190S.— The results of our
examination of the patient's urine may be summed up in the
statementthat it was found to be normal for both days. Ex-
cepting mucus and a few epithelial cells, no proteids or pro-
teid elements could be detected. Sugar was absent, as shown
by negative results with Nylander's solution and with phenyl-
hydrazin.
Patty stools have never been observed, it should be
remarked again— the feces have been normal constantly.
REVIEW OF QUAIjITATIVE RESULTS.
A general review of our qualitative results shows that
the fluid is similar to a simple transudate. In no previ-
ous case has the specific gravity been as low as that
recorded here — 1,002.8. Gussenbauer found it as high
sui 1,610. Qualitatively, the fluid is like many of those
ftpm pancreatic cysts already analyzed. Quantitatively,
it is much different than the fluid from some; similar,
however, to others. The significant variations from most
of the fluids previously analyzed are the low content of
organic matter, indicating absence of particular inflam-
mation and the large proportion of water. Unlike a
number of such cystic fluids examined previously, it is,
further, entirely devoid of constituents representing
various stages of tryptic proteolysis. The noteworthy
content of oxalic acid (calcium oxalate) brings to mind
the similar result obtained by Zdarek in his examina-
tion of fluid withdrawn soon after operation.
These later examinations emphasize the deductions
drawn from the results of those of January 21 and Feb-
ruary 10. All of the data indicate that the case under
consideration is not now one of true, permanent pancre-
atic fistula, although they do not exclude the probability
that diffusion from the pancreas constantly takes place
to some extent, or that pancreatic tissue makes up part
of the wall of the cyst. Certain it is, at all events,
that the fluid is not pancreatic juice in the ordinary
sense.
SUMMARIES OF QUANTITATIVE RESULTS.
The following summary shows the uniformity of our
average quantitative analytic results :
Table I.— Gbnkbai. Percentage Composition op the Fluid from
THE Fistula.
composition — cells probably situated in the wall of the
cyst.
Januai-y 2 1 .
February 10.
February 18
Aprlll.
Av'r-
age.
a
b
a
99.15
0.85
0 62
0.33
61.63
38.37
b
99 09
0.91
0.56
0.35
6124
38.76
a
b
b*
Water
99..34
0.66
0.35
0.31
52.93
47.07
99.54
0.46
0.19
0.27
42.32
57.68
99.52
0.48
0.33
0.15
68.50
31.50
99.52
0.48
0.32
0.16
67.72
32.28
99.07
0.93
0.58
0.35
62.51
37.49
99.32
0.68
0.41
O.OT
59.5.5
40.45
Solids
Organic matter...
Inorganic matter
Of thetotal solids..
Organic
Inorganic
•The results of our analysis of the first portion obtained on April 1,
are not Included above, because of the exceptional amount of mucus,
etc.. In the fiuid at the outset of Its collection.
The significance of the above analytic figures may be
fully appreciated at a glance, on comparison of our aver-
age results with similar data for various lymphatic or
serous fluids given in the appended table.
Our results are almost identical with those for cerebro-
spinal fluid. They show clearly, we think, that the
fluid from our patient's fistula has the general characters
of a transudate and that it is very much like ordinary
lymph. The similarity to the cerebrospinal fluid also
suggests that selective cells have somewhat influenced
Table II.— General
Pkrcentagb Composition
OF Lymph
AND
Transudates.
a
u
3 C
OS
Is
.d
2
3
o
1.
1
"See
a
&
o
u
6
£ 3
6
S
o
s
<
s3
<2
Water
99.32
99.17
9i.m
98.68
98.63
98.4;^
97.^
90.09
93.S9
Solids
0.68
0.41
0.83
0.32
1.31
051
1.32
1.37
0 49
1.67
098
2.11
1 IS
.3.91
303
6.U
5.18
0.<:7
0,51
0.77
0.88
0.69
O.iW
0.88
0.93
1, *, 5, "Results summarized by Halliburton: Textbook of chemlo
Physiology and Pathology. 1891, pp. 334-,S.56.
2 Given In Schiifer's Textbook of Physiology, 18«8, 1, p. 123.
', ', 8To befound In .Mandel's translation of Hammarsten's Text-
book of Physiologic Chemistry, 1900, p. 193.
All of the analyzed fluids referred to in the above
table were samples of the fluid obtained on first with-
drawal, which naturally would contain more solid
matter, particularly proteid, than such portions as
might flow from the body immediately on formation.
In the former cases prolonged osmotic influences, par-
ticularly resorption of water, would tend to raise the
percentage of inorganic products, wherea.s cellular
activity would bring about increase of organic constitu-
ents. Our own patient's fluid on retention, would, for
the same reason, surely contain a somewhat greater pro-
portion of solid matter — as it did at the time of opera-
tion, when its specific gravity was 1,018.
The results summarized in the appended table show
that, so far as general composition is concerned, the fluid
we have examined is not very similar to pancreatic
juice — even such as is collected from a permanent fistula
— a further fact in harmony with our qualitative,
enzyme results. The figures for blood plasma are also
brought into comparison :
Table III.— Composition of Pancreatic Juice and Blood
Plasma.
Fluid from
our own
patient's
fistula.
Fluid from a
temporary
pancreatic
flstula.i
Fluid from a
jyermanent
pancreatic
flstula.2
Fluid from a
permanent
pancreatic
fistula
(dog).3
A
X
P.
■C J
o S
0 S
s
Water
Solids
Organic matter...
Inorganic matter
99.32
0.68
0.41
0.27
86.41
13.59
13.25
0.34
97.59
2.41
1.79
0.62
97.68
2 .32
1.64
0.68
90.29
9.71
8.86
0.85
1 Zawadsky : Centralblatt filr Physiologic, 1892. v, p. 179.
- Herter : Zeltschrlft filr physiologlsche Chemie, 1880, iv, S. 160.
■'Schmidt : Hermann's Handbuch der Physiologie, 1881, v-2, S. 189.
* Halliburton : Textbook of Cheraic Physiology and Pathology,
1891, p. 334.
Only a few quantitative analyses of the fluids from
pancreatic cysts have been recorded. The following
summary shows the general chemie relationships of the
fluid we have examined to those analyzed by previous
observers. In each case the analyzed fluid was collected
either at the time of operation or shortly after. Our
results, it will be seen, are more nearly in accord with
those of Zdarek than of any other :
Table IV.— General Percentage Composition of Panckko-
CYSTic Fluids.
oa
Si
o
1
a
M
98.70
1.30
0.36
0.94
i
i
3
Si
s
1
s
2
a
CQ
a
Water
99.32
0.68
0.41
0.27
98 94
1.06
0.19
0.87
98.55
1.45
0..55
0.90
98 21
1.79
1.00
0.79
98.14
1.86
Solids
7 32 ■ 13 .59
0 81 ! 0 34
Coagulable proteid
0.19
0.10
032
0.27
0,82
1.66 951
July 26, 19021
PANCREATIC FISTULA
(Akerican Hedicikk 137
KEVIEW OF CHEMIC OBSERVATIONS IN PREVIOUS CASES.
The published results of eheinie analysis of the fluid
of various established pancreatic cysts have shown that
the enzymes are frequently absent, not only from the
fluid withdrawn at the time of operation, but also from
that eliminated during the healing of the wound. As
Korte suggests, stagnation and consequent prolonged
contact with the other constituents of the fluid are
doubtless destructive to the enzyme. Analysis has also
shown that occasionally the enzymes have been absent
from the fluid retained in the cyst, but have appeared
for a while in the secretion thrown from the drainage
tube, only to again disappear, and that permanently. In
such instances it is probable that changes in the cells of
the gland due primarily to drainage, as in cases of per-
manent experimental pancreatic fistula, cause alterations
in the character of the fluid and the complete disappear-
ance of the enzymes. In other cases of pancreatic cyst
the enzymes were detectable in all samples of fluid with-
drawn. In one rather odd case, cited by Korte, the
enzymes were absent from all samples of fluid, but
could be extracted from the wall of the cyst.
These facts, together with the additional observations
by various investigators that lipolytic, proteolytic and
amylolytic enzymes are found in various pathologic and
lymphatic fluids, seem, in considering the qualities of
cystic contents, to lead to the conclusions that (1) the
presence of slight amounts of these enzymes does not
necessarily imply a pancreatic source of the fluid ; further,
that (2) the absence of these enzymes does not necessarily
mean that the fluid in question has an extra-pancreatic
origin.
Korte, in summing up, emphasizes the following as
the chief points in our knowledge of the characters of
pancreocystic fluid. It is usually tinged with hemo-
globin or its derivatives, reddish to black in color, some-
what slimy, alkaline, rich in proteids, specific gravity
1,010-1,020 and frequently contains enzymes and cellular
detritus. When the enzymes are present, in particularly
active quantity in the "puncture-fluid," the presumption
is strong that the fluid is directly derived from the
pancreas. The absence of enzymes from such fluid is no
evidence, however, that the cyst is not truly pancreatic
in nature.
That our own patient's cyst was truly pancreatic wa.s
definitely established at the time of operation. That the
fluid no longer partakes of the characters of true pan-
creatic juice harmonizes entirely, therefore, with obser-
vations of the past.
GENEKAT; OBSERVATIONS.
Transudation is mainly a physical, hydrostatic mat-
ter. But the permeability and the character of the
tissues separating the blood and the transudate naturally
determine the selective factors and largely influence
composition. The cyst wall is always very vascular.
In this case it was, at the time of operation, lined also
with a smooth membrane. In retention cysts the wall
is frequently the more or less altered wall of the original
structure. The vessels are thin and no doubt unduly
permeable. Pa.ssive congestion has probably become
chronic and has doubtless increased permeability. Under
these conditions the fluid of the cyst has lost it« original
qualities and is not easily comparable, except in a general
way, with any other. Degenerate cells may also be rtsspon-
sible in part for the character of the transudate.
The walls of pancreatic cysts are usually composed of
connective tissue, and incision and drainage has in
nearly all cas<>s favored ready granulation and rapid
hesiling. The cystic membrane in some cases has con-
sisted partly of pancreatic tissue, normal or degenerate
or Iwtli, or has been lined with a secreting epithelium.
8uch an epithelium naturally interferes with granula-
tion, may entirc^ly jirevent closure of the wound and
makes the flow of cystic fluid continuous. In our own
case, epithelial cells are to be found in the fluid along
with leukocytes and mucus, and in all probability the
cyst is still lined, in part or throughout, with a secreting
mucous membrane. Although the interior of the cyst
has been steadily treated with carbolic and nitric acids,
etc., healing has appeared to cease and the fistula
persists. The tube was lately kept out of the fistula
for several days. The aperture narrowed at once and
cumulative retention resulted, much to the physical dis-
tress of the patient. The tube has again been replaced,
the patient being thereby relieved, and the flow goes on
as before.
With the exception of the first of Korte's cases none
other like ours appears in the records. In Korte's case
a fistula similar to that in our patient remained 2J years
after the operation. Varied treatment repeatedly with
caustic substances, heat cauterization, etc., was without
result. Several times the fistula closed temporarily, but
as often opened up, with continued flow. Finally,
2J years after operation, complete healing suddenly
occuri-ed spontaneously. Several years thereafter Korte
saw the patient, found that the closure was permanent
and the patient enjoying good health.
Riegener has expressed the opinion that in Gussen-
bauer's operation of incision and drainage there is little
danger of a permanent fistula resulting. The facts
Korte recapitulates, as well as the experience our own
case affords, show that this possibility is not as remote
as Riegener imagined.
It has been fre([uently observed that during periods
of excitement or nervousness the fiow from the fistula of
our own patient has been particularly abundant. The
patient herself has come to associate special elimination
with such conditions. Since transudation is determined
largely by intracapillary pressure, it seems probable that
such periodic increases in the quantity of fluid are
dependent on vasomotor changes, with augmented blood-
pressure in the splanchnic region in general and the
capillaries of the wall of the cyst in particular, rather
than on special secretory activity of the pancreas. That
the increased flow is not due to formation of true pan-
creatic juice is very evident from our results. Several
of our analyses were made of fluid obtainetl in abundance
during the before-mentioned periods of nervousness.
CONCLUSIONS DRAWN FROM THE RKSULTS OF CHEMIC
ANALYSIS,
The results of our recent analyses and those made at
the time of and shortly after the oi)eration, seem to be in
harmony *ith the following conclusions:
Such connections of the pancreatic gland with the
cavity of the cyst as may have existed at the time of
operation have closed and direct secretion from the
gland into the fistula has ceased.
The fluid originally contained pancreatic products in
abundance. The fluid still leaving the fistula ap|K'ars,
however, to be a transudate, resulting probably from
chronic serous inflammation. It is possible, of course,
that lymph from the pancrejis <rontril)utes to the flow
and that the lining membrane, in part consisting of
abnormal pancreatic tissue, influences the composition of
the fluid.
That the pancreas is no longer seriously involved Is
evidenced by the continue*! vigorous health of the
patient — good appetitt*, abst'nce of fatty sttwds, neither
sugar nor proteid in the urine. At least sufticient nor-
mal pancre^iH remains to perform all of the observable
functions of the gland.
The case is similar to the exceptional one of Korte's,
in showing that after incision and drainage of a true
pancreatic cyst(l) general nn^jvery may he rapid, (2)
the functions of the pancreas remain normal, (:i) the
])atient enjoy excellent health thereafter, (1) with a
jM>rsistent permanent fistula eliminating a transudate
containing (o) a minimal proportion of .solid matter, (6)
138 AMERICAN MEDICINE. IMPORTANCE OF DRAINAGE IN BULLET WOUNDS
[July 28, 1902
a maximal percentage of water, and (c) little or no pan-
creatic enzyme.
The case is different tiian any otiier on record in (1)
the length of time, the fistula has persisted, and (2) in
the quantity of fluid steadily eliminated from it.
BIBLIOGRAPHY.
Practically all original paperson pancreatic cysts printed before]898
are listed by K6rte. Bee his monograph for references to the work of
observers mentioned atiove. KOrte: Deutsche Chirurgle; Die chirur-
glschen Krankheiten und die Verletzungen des Pankreas, 1898, Liefer-
nnglM, p. XV (Literatur).
MOmer, K. A. H. : Skandlnavisches ArchlvfarPhystologie, 1895, v,
8. 274.
Lenarclc; Centralblatt filr innere Medicln, 1898, xix, S. 773.
V. Brackel : Deut-sche Zeitschrlft fiir Chirurgle, 1898, xllx, 8. 293.
Payr: Wiener klinische Wochenschrlft, 1898, xi, S. 629.
Pollard : British Medical Journal, 1899, Pt. I, p 694.
Keitler: Wiener klinische Wochen.schrift, 1899, xli, 8. 784.
Zdarek : Ibid, 1899, xli, 8. 767.
Israel : Deutsche mediclnlsche Wochenschrlft, 1900, xxvi, 8. a52.
Bessel-HaKen: Verhandlungen der deutschen Gesellschaft fiir
Chirurgle, 1900, xxix, S. (i83.
Fltz: American Journal of the Medical Sciences, 1900, c-xx, p. 184.
Lazarus: Zeit-schrift furHeilkunde, 1901, xxli, S. 165.
8eeflsch: Deutsche Zeitschrlft fttr Chirurgle, 1901, lix, 8. 158.
Subbotlc: Ibid, 1901, ilx, 8. 197.
Murray: American Medicine, 1902, Hi, p. 141.
THE GREAT IMPORTANCE OF DRAINAGE IN BUL-
LET WOUNDS OF INTRAPERITONEAL VISCERA.
BY
L. M. TIFFANY, M.D.,
of Baltimore, Md.
Bullet wounds of the peritoneal cavity implicating
the alimentary canal, resulting from firearms of large
caliber or projecting bullets at low velocity, such as fall
to the care of surgeons in civil life, are necessarily
infected wounds, infection which is not limited to the
immediate wound itself; and while the infection may
perhaps be so small as to be taken care of by the tissues
involved and adjacent peritoneal membrane, yet such
limitation of Infection is not to be taken for granted by
the surgeon, but the wound after closure of the perfora-
tions should be drained. At present I am of the opinion
that sterile gauze is the best material for drainage.
The hollow viscera within the belly contain more or
less gas, and any quantity of infecting material ; they
fill the peritoneal cavity, accurately adapting their shape,
thanks to gas pressure, to it. The walls of the hollow
viscera are thin compared with their cavities, their size
and shape vary continually during life, and changes
are induced by peristalsis, the varying pressure of
abdominal muscles, diaphragm, etc. A honeycomb
with irregularly-shaped cells, instead of the classic
hexagons, suggests itself for comparison, honey being
replaced by food more or less digested according as one
has to do with the upper or lower portions of the
alimentary canal. It is probable that the interior of the
alimentary canal from end to end contains a wealth of
infecting material, microbic, etc., quite beyond calcula-
tion. The flora of the intestine is legion.
La Garde's experiments have taught us much about
the infection of bullets, and we may accept that the track
of a bullet after wounding the alimentary canal is
necessarily an infected wound. At first the infection is
confined to the intestinal walls and the wound beyond
the peritoneal cavity, but so soon as the perforations no
longer coapt from peristalsis or other cause, then infec-
tion IS dis.seminated by leakage usually, but even with-
out leakage from the fact that infected tissue is smeared
over adjacent peritoneum . It is likely that spasm of the
muscular wall of an intestine or stomach follows the
bullet injury, inducing quiet for a certain time, after
which motion and leakage are to be expected We
have absolutely nothing to show how soon after a bullet
wound is received leakiige is to be expected and general
infection commence, but there is no doubt about the
fact that there is direct relation between the period after
wounding and the amount of constitutional infection
present, the two going hand in hand. Abdominal sec-
tion has shown that the sooner the section is done the
less is the peritoneal inflammation, both in extent and
in intensity. Infection is something beyond macroscopic
examination. General washing by normal salt solution
of the peritoneal cavity is permissible only when very
extensive, what is called general, suppuration exists ; in
such cases flushing with many gallons of normal salt
solution is to be supplemented by free openings with
drainage in each loin above the pubes, to the outer edge
of each rectus abdominis, and elsewhere as may .seem
neces.sary. Very rarely after gunshot wounds does this
condition of affkirs obtain. Under other circumstances
when purulent inflammation is not present or is not
very extensive, washing by means of normal salt solu-
tion is unwise and uncalled for, since by means of such
washing infection may be carried to clean portions of the
peritoneum and disseminated through healthy areas.
By the use of sterile gauze used dry, or dipped in normal
salt solution and squeezed strongly, the areas exposed to
infection can be wiped thoroughly, and the peritoneal
cavity dried ; it is not necessary to always eviscerate the
patient, but each flank, and especially the pelvis, needs
careful attention. A large strand of gauze is then
carried to the bottom of the pelvis, or along the course of
the bullet, or both, according as the operator deems
expedient, and normal salt solution in large quantity is
injected into the patient's subcutaneous tissue. A large
enema should be given before the patient leaves the table ;
one of the bullet wounds can be utilized before suturing to
fill the bowel with salt solution, but care must be taken
that no wound exists in the bowel lower down, otherwise
feces will be washed into the belly. The object desired
is to fill the patient's vessels — to overfill them — with salt
solution and make free transudation into the dry peri-
toneal cavity possible, from whence the gauze will
remove it, thus causing the peritoneum to clean itself
and drain away from, rather than absorb into, the body.
Washing the peritoneum from within outward rather
than washing the cavity itself by pouring salt solution
into it is the better way, I think.
Fluid by the mouth is to be ^withheld, salt solution
enemas are to be given every four hours, and subcu-
taneous Infusion if expedient ; free outfiow by the gauze
from the peritoneal cavity Is a very favorable symptom,
and the sooner it appears the better for the patient. So
important do I believe this symptom that unless a
patient suffers from constitutional sepsis when free drain-
age appears, I feel justified in holding a favorable
opinion as to the ultimate outcome of the injury. The
drainage strands should not be moved for several days,
but the voluminous dressing resting on the skin may be
changed when necessary.
Plaeing a gauze drain to the bottom of the pelvis is
necessary only in extensive infections, it is usually
sufficient to lay gauze along the course of the bullet after
freely wiping and cleaning the peritoneal cavity.
Case I. — Bullet wound of liver, stomach and probably lung.
A bdominal section, suture of visceral wounds, gauze drainage, re-
covery. C. P., white male, aged 39, was admitted to the Univer-
sity Hospital April 7, 1895, shortly after being shot. The shoot-
ing was said to have occurred about 12:30 a.m. The bullet
entered the right hypochondriac region three inches from the
middle line, two inches below the margin of the rib cartilage.
Percussion showed dulness in the right flank. At 3 a.m. I
opened the abdomen by a vertical incision, six inches long,
Eassing from the margin of the rib downward through the
ullet wound. The right abdomen contained much blood and
clot ; the bullet had passed through the right lobe of the liver
and through the stomach (two holes) and then to the left with-
out wounding any other abdominal viscus. The stomach prob-
ably contained beer when wounded. The stomach wounds
were sutured, the liver wounds packed with gauze, the general
peritoneal cavity washed out and the gauze from the liver util-
ized for drainage, as well as a strand placed behind the stomach.
All went well. At first the gauze drained bile, then inflamma-
tion developed in the chest, and the patient expectorated bile-
stained pus. The bullet had probably passed into the chest.
Bile was discharged in large quantity through the drainage
July 26, 19C2|
FINGER TIPS TOTALLY LOST
AMKBIC&K MKSICmK 139
apertures but ultimately complete recovery followed and the
patient wa^ discharged June 19. Silk was used for sutures.
Case II. — A. L,., a mulatto female, aged 4-3, entered the hos-
pital March Vi, 1902, at 5-M p.m., having received a bullet wound
of the abdomen. The wound was situated two inches below
and one inch to the right of the umbilicus ; the bullet was
believed to have been fired immediately in front of the patient.
I opened the abdomen about three hours after the receipt of the
Injury, by an eight-inch incision parallel to the linea alba, pass-
ing through the bullet wound. The small intestine was
wounded in nine places, the mesentery in one, and one perfora-
tion of the posterior wall of the peritoneum existed where the
bullet passed into the back. (I neglect the perforation of the
peritoneum where adherent to the anterior abdominal wall.)
The bullet was not sought for. The patient was treated in the
way advised in this paper. A large drain of gauze was laid
along the course of the bullet and tlxe wound closed with inter-
rupted silver sutures through-and-through. The drain was
removed March 20. During the operation the patient received
1,500 cc. of normal salt solution by infusion ana afterward 1,000
cc. of same by enema every six hours. The lips were moistene'd
with cold water occasionally. The time consumed in operation
was 2 hours and 35 minutes, and at its close the pulse was 96,
respirations 32. The patient abstained from taking nourishment
or water by the mouth for six days. The bowels were moved
by enema on the fourth day and daily thereafter. Recovery
was without notable incident, and the patient returned home
April 12.
I have reported these two cases together, with a view
of comparing the treatment employed ; the latter being
the method which seems to offer the best outlook after a
severe surgical injury.
FINGER TIPS TOTALLY LOST: THEIR RECONSTRUC-
TION BY SPONGE EDUCTION.'
BY
GEORGE E. ABBOTT, M.D.,
of Pasadena, Cal.
There are certainly some little things in this world
that count for more than many larger ones, and among
these are the fingers of the human hand. I believe that
the saving of a finger is more important surgical work
than the removal of some large tumors, and not at all be-
neath the notice of any surgeon, however great he may be.
It is in saving fingers that minor surgery in technic
becomes major surgery in results. Injuries to the foot
of one's patient may be turned over to a student, if
one will ; but not thase of the hand. The surgeon may
dismiss a neatly healed finger stump with the thanks of
the patient, only to be cursed by the same patient when
he compares finger tips with his fellow-mechanic some
months or years afterward.
The statistics of railroad and factory surgery show
that from 26 fo to 40^ of all accidents are injuries of the
fingers ; a large proportion of which are those of the
right hand, the one most important to its owner. There-
fore any method of procedure which will restore lost
finger tips will certainly challenge the attention of the
surgeon, and command the gratitude of the patient. It
is to this end that I present this paper on the restoration
of finger tips, partially or totally lost by accident.
Before reporting two ca.ses and the procedure by which
I wits enabled to advance the fingertips from J to J inch,
1 would like to make one or two remarks of general
application which are important.
Many years ago I used to practise In Waterbury,
(Jonn. There are in that town several factf)rie,s and
innumerable machines for stamping out the various
parts of watches, clocks, etc. Some of the operatives
were very careless while at their work and in |)lacing
the blanks under the stamp they very often had a finger
punched, gouged, crushed, or cut off wmpletely. It was
a very common occurrence for the.st; wounds to do nicely
for three or four days, when all at once they would
change for the worse, would become inflamed, more
painful, granulation would c(;ase, while pulse and tem-
perature would slightly increase. It look a long time
■latlon, May 22
' FUnd before
and W, 1902.
he Southern California Medical A^
to find the cause of this change. We would accuse the
patient of putting on some patent medicine or old
nurses' pet wash ; of taking down the dres.sing ; the
men of drinking heavily, and the women of wa-shing-
dishes, etc., but all with no result. At last we found
the cause. It was simply a too early return to work ;
keeping the injured hand in the sling, it is true, but
working with the other hand. On taking down a dress-
ing, and finding the wound in bad condition, we would
at once say to the patient, " You have been working."
" No, I haven't, doctor." "Oh, yes, you have. I know
by the looks of this wound that you have betni work-
ing." Then the men would acknowledge that they had
" just worked a little in the gardens," and the girls that
they had "just swept the parlor with the other hand to
help mother ;" but all of them had kept the injured hand
in the sling all the time. The shock of the accident and
consequent pain would keep the patient quiet for from
three to five days, and all would go well ; but then they
would l)egin to work a little, as best they could, and a
relapse was sure to follow. Probably 90 fc of cases doing
badly would be traced directly to some sort of work,
even though the wounded hand was kept quiet.
It is the same old story of relapse that we see so often.
A mother gets out of bed on the fourth, fifth or sixth day
after confinement, immediately feels worse, and in the
fourth, fifth or sixth week wonders why she does not feel
well. A fractured bone does not unite and no one knows
why, until the physician cross-examines his patient to
find that he had been working when he should have
been absolutely quiet.
Healthy granulations in any part of the body demand
the whole attention of the system. They do not grow
well when the body is taxed in other ways. The sur-
geon cannot build finger tips or other lost tissue, unless
he has the entire control of his patient's system ; but,
with such control, it is comparatively easy to rebuild
lost finger tips, lost masses of muscle and lost areas of skin.
Cask I.— Figure No. 1 is a photograph of the left index and
the restored right index finger of a young lad of 14, brought to
me by his uncle. The finger tip liad been caught in a bicycle
Right. r,cn.
KlKun^ 1.
Index fliitten'. ptitlentof Cbbp I.— The tip of the riKht Imh \ niit;ir wax
(•ni8he<loirand destroye<l hI the line A, and from timl point Imslmefi
reeonstriieted by Hponge ediietlon, and led forward a half Inch to
ItH present iengtn ; Dclng buloni'-Rlxtcenlh Inch nhortcr than the left.
(rhaln and crushed nquarely off, leaving only -ff im-h of the
nail. After two or three day* the skin began to close in and to
round over the top of the finger. 1 NiigseHted to the lK)y's
uncle who was himself a thorough physician, but off duty
140 Ahsbican Medicinej
FINGER TIPS TOTALLY LOST
[July 26, 1902
bocauao of ill-healtli, that he allow me to incise the edges of
the gramijatiiig surl'ace and try to lead on the granulations by
means of a sponge graft so placed that the granulations of the
pulp would grow onward, and we would guide those of the
skin until we were ready for them to round over the point of
the linger. To this he assented cordially, as did the boy
himself.
In this way the finger tip was, by sponge eduction, led
onward, until now his right index is quite j inch longer than it
would have been had it been allowed to heal, as is usual in
these cases. It is but /c inch shorter than its fellow. The lad
has a good nail and no disligurement whatsoever, as will be
seen by Fig. 1. A half-inch at the end of the index finger
throughout life will mean much, very much to this boy, both
in bis social and practical life.
I believe this is rightly termed major surgery in results,
though perhaps not in technic.
Cask II. — Figure No. 2 is a pliotograph of the partially
restored right index of a young man of 24, who came into my
office, saying his finger had been crushed two weeks before and
was almost healed, except that the bone still protruded and
would have to be cut off. On taking off the bandage I found
that more than J inch of the right index linger had been
crushed off. The entire nail, and apparently all of the matrix,
was crushed; there was no nail whatsoever, a little callous
ridge alone showing an aborted attempt to redevelop tlie nail
during the rounding of the stump; and the stump had com-
pletely healed, except what appeared to be the round project-
ing end of the bone, about J inch in diameter and J inch in pro-
jection. On feeling this projection with a probe I found that
it was not bone, but merely exuberant granulations.
On learning that my patient played the guitar, as well as
being a good mechanic, I told him there were two plans I could
follow out: One to remove the proud flesh and let the stump
heal over at once ; or, if he could spare the time and sutfer a
little pain, I believed I could restore the tip of his finger, par-
Right.
Left.
Figure 2.
Index finger?, patient of Case II.— The tip of the right index finger was
crushed off and destroyed at the line A, and from that point has
been reconstructed by sponge eduction and led forward ahalf Inch
to Its present length. All parties Interested believe it could have
been restored completely had not the Illness of the physician and
the necessary return of the patient to business compelled a termi-
nation of the treatment.
tially, if not completely. He chose the latter, and, as you see
by the second photograph, the finger was advanced fully 4 inch,
and, had I not been taken ill, and the patient been compelled to
return to his work, I believe we would have succeeded in
restoring the entire length of the finger, as in the first case.
Operation and Method.— The patient was ane.stlietized
and a straight incision made from side to side through
the stump, just as one would pass a knife under the
matrix and root of the nail, had it been in place. This
gave one straight flap on the back of the finger, in which
the nail wa.s to develop, should any part of the matrix
prove to be still in a living condition.
The end of the stump was then incised into four tri-
angular-shaped flaps, having their apices at the center of
the nail-flap and their l)ases at the circumference of the
stump. (Figure 3-A.) These were then dissected up, .so
that when the finger was held upright they formed a
crown around the stump, except at the back which was
occupied by the matrix flap above referred to.
Into this crown, in close contact with the denuded
end of the finger, was placed the sponge graft into which
Figure 3.
the granulations were to grow. The sponge was held in
place by Z. O. adhesive plaster, bandaged with gauze,
and the sponge kept constantly wet with warm normal
salt solution. The sponge (in place) was syringed out
by me every day with pyrozone and boric acid solution,
using an ordinary gla.ss dropper as a syringe. Every
three days the adhesive strips and old. sponge were
removed and replaced by new.
Sponge grafts for surface work and eduction sponges
(mastoid-shaped portions of sponge used to stimulate
granulations for lilling up cavities and lost portions of
the surface deeper than those of the skin surface) can be
efficiently cleansed through their entire volume by thus
syringing with pyrozone and boric acid solution, one-
fourth part pyrozone and one-fourth saturated solu-
tion boric acid and one-half sterilized warm water.
Sponge Gfra/ts. — I hesitate to add a suggestion as to
sponge grafts before this society ; but, as in past
years, I have met some physicians, in many ways my
medical and surgical superiors, who have not been fortu-
nate in having their attention drawn to this matter, and
as it may have likewise escaped the attention of some of
you, I would say : First, the essentials of a sponge graft
are a fine-grained, stiff" sponge ; a coarse, .soft, open
sponge being of no use. Second, the sections must be
cut transverse!,!/ and not longitudinally to the pores of the
sponge. A carving-knife or sharp case-knife will cut
sections and scissors snip off" mastoid portions of sponge,
quite as well as the best microtome.
These sections should be one-eight one-sixteenth, or
one thirty-second inch thick ; they should, of course, be
thoroughly sterilized, and after being applied be kept
wet with sterilized normal salt .solution (a teaspoonful
of common table salt to a pint of water answers every
purpose). Sometimes I have also used bovinin, proto-
nuclein solution and other nutritious liquids.
Eduction sponges, or mastoid portions of sponges
for filling cavities, must likewise be cut transversely to
the tubes of the sponge, so that the granulations may
grow up into them by capillary attraction as it were,
the outer side of the sponge being placed against the
granulating base and sides of the cavity.
These must be removed every few days, or they may
July 2«, 1902]
TREATMENT OF PULMONARY TUBERCULOSIS iaxkbican mbmcink 141
be held so firmly by the granulations as to be removed
with difficulty, and with a tearing destruction of the
tender granulations.
I know of no method that will so quickly change an
abscess cavity, or an ulcer, or any part that has been
curetted because of a depraved base, into a healthy,
granulating surface, as by the sponge graft or sponge
eduction method. By it, lost surfaces and lost finger tips
may be restoretl to the extent of half an inch or more.
I close with the hope that this paper may be of some
advantage to physicians and to their patients.
DIETETIC TREATMENT OF PULMONARY TUBER-
CULOSIS."
BY
D. OLIN LEECH, M.D.,
of Washington, D.C.
It was but a little time ago — in the boyhood days of
many of us — that this admitted scourge of the human
race, tuberculosis, widely known as the White Plague,
was looked upon as incurable. Many prominent physi-
cians shared this belief. It is pleasant to say that that
day has forever gone. There is no physician who has
the true spirit of his profession but is full of the hope
of final triumph. Already the ratio of cure has greatly
incretised and is enlarging yearly. In the matter of pre-
vention of the disease the outlook is still more hopeful.
Hospitals and sanatoriums erected for the treatment of
the tuberculous, notably that of Loomis at Liberty,
N. Y., and that of Trudeau at Saranac Lake, N. Y.,
representing as they do the high-water mark of medical
knowledge and skill in their efforts to combat the
scourge, are not simply monuments of progress already
attained, but are a type and prophecy of results soon to
come, when the devoted spirit of our noble calling will
send hope and joy to multitudes whose outlook for this
life has had little of brightness.
There is no magic and but little medicine in the
treatment of tuberculosis. Universal experience makes
it clear that the three great specifics, both f(jr [)revention
and cure, are pure out-of-door air, freely taken by the
subject at all hours; rest, partial or complete, for those
already afflicted ; and abundant nourishing food prop-
erly prepared and administered. Wisely chosen drugs
liave their place as an aid, under certain circumstancas,
but the great reliance for success I have just stated.
It is my object in this paper to consider the phase of
relief represented Ijy nutrition. Beyond question, a vast
deal of our success depends on this. Sanitary surround-
ings are, of course, important, exercise and rest have a
large place ; but these will avail" little unless the body is
properly nourished, so that rich blood may build up the
tissues,'an(l give strength to resist the disease and main-
tain vigorous health.
Proper diagnosis having been made and the patient
being in suitable surroundings, climatic and hygienic,
there arises this vital matter of proper feeding. Cases in
which then? is no appetite, but rather a repugnance for
food with persistent gastric irritation, offer a very
unfavorable prognosis, and tax the physician sorely. A
good appetite with fair digestion is always looked upon
as most favorable. Many tuberculous patients have to be
fed in an entirely different way from others, and each
case is a law unto itself, although, as a general routine,
we have to start them all on a prescribed diet, varying
the same from time to time as the case may r(H|uire.
It is not wise to i)in one's faith to drugs with the
object of creating an appetite. While it is doubtless true
that a few of thi; bitter tonics, such as tincture of nux
vomica, cinchona, gentian, hydrochloric acid, or the
various preparations of the liypophosphites may do good
1 Read before the Amerlr'nn Therapeutic Society, Third Aonaal
Mpotliiif. held In N<-w York, .May 11. II. I-^). I'.XK.
in a few cases, I have rarely seen them maintain any
permanent beneficial effect.
Change of air and surroundings, salt air, a sea voyage,
during which enforced and absolute rest in a reclining
chair on deck may be secured, and a dry, cold atmos-
phere at a moderate altitude, are without doubt the best
conditions. It is truly remarkable how some of these
patients who loathe food of every kind begin to crave
nourishment under certain conditions of climatic change
and rest, (liven a case with loss of appetite and fever,
which latter is nearly always present when they first
come under observation, the patients should invariably
first be placed at rest and kept in the open air, well pro-
tected ; then he should be regularly fed at stated inter-
vals. From a fever diet we should gradually increase to
one rich, varied, and easily digested. Proper cooking
and the suitable preparation of food is a most important
desideratum for a tuberculous patient.
Dyspeptic symptoms should always receive careful
attention, since, in many cases, a successful issue dejiends
on the tolerance of the stomach for food, and the proper
assimilation thereof.
Nausea in the (!arly stiige in .some cases is allayed by
the use of carbonattnl waters, creasote and lime-water ;
calomel and soda in small doses. In a few cases I have
had to resort to cocain ; a tsiblet containing bismuth sub-
nitrate gr. 2, cerium oxalate gr. 2, and cocain muriate
gr. y'j, is an excellent combination.
The diet should consist of good, retl, juicy beef,
broiled, toasted or scraped, in a much more generous
proportion than for a healthy person ; young mutton ;
breakfast bacon— a streak of lean and a .streak of fat
alternating — broiled ; fish of all kinds, boile<l or broileil.
In fact, sea food of any kind in .season, with many pa-
tients is most acceptable. Fresh eggs, prepared in any
way except by frying ; plenty of fresh milk, cool, warm
or peptonized ; buttermilk, koumiss, digestible cocoa or
chocolate, cofltee or tea in moderation, and an abundance
of pure, cool water should be used. Desserts are allow-
able in moderation : farina, sago, tapioca, rice with fresh
cream ; custards, baked or steweti apples with fresh
cream, and any kind of cooked or fresh well-ripened
fruit.
The amount of starchy foods should be limited ; not
because they are of themselves harmful, but bwause they
fill up and require more power to digest. Thus they
les.sen the desire for more nourishing food. Plenty of
fresh green vegt>tables may be allowetl ; potatcK's, roasted
or mashed, with butter and cream ; spinach ; onions, in
any way except fried ; asparagus ; sliced raw tomatoes ;
cresses, lettuce and celery ; French salad dressing (pep-
per and salt, vinegar and olive oil) is a great addition to
these salads, shar|)ening theapj)etite materially. .Mayon-
naise dressing is very appetizing and nutritious. Just
here I may say that pure Lucca or olive oil is a most
valuable addition to our diet list. Many persons who at
first cannot eat it soon learn to like it, and can take and
digest an ounce or more, to their lulvantage. Tubercu-
lous persons should never eat fried food of any kind ;
nor salt fish, hash, gravies, veal or pork. Sweets, pastry
or sweet wines, .should not be allowe<l.
The arrangement for the time of meals is most Im-
portant. Most authorities hold to the three princliMil
meals with light nourishment on awaking and at 11a.m.,
4 p.m. and at bed-time. Minor, of Asheville, follows
this method. Weber and Di'tweiler recommend the fol-
lowing dietary arrangement, viz. : At 7 a.m., on wak-
ing a cup of milk with a tt«.spooiiful of cognac, or a cup
of tea or cocoa with a small piec«> of bread and butter;
9 a.m., breakfast: milk with tea, cofUf or digestible
cocoa with bread and butter, ham, fish or smoked meat;
11 a.m., a larg<^ glass of milk or koumis.s, or a cup of
bcef-tca'or other ini«t soup, a piece of brea<l and butter
with a glass of wine; 1.30 p.m., dinner: welU-ookwi
meat, game, fowl, or fish, with fresh veget4ibles, some
light puilding or c(K)ke<l fruit and a glass of wine; 4
\
142 AXERICAN MKDicnnij
lODIPIN-PHOSPHOR
[July 26, 1902
p.in. a glass of milk or koumiss ; a cup of tea or coffee,
well diluted with milk ; bread and butter or lif^ht bis-
cuit: 7 p.m., a substantial meal similar to diniur: 9. .30
p.m., bed-time, a glass of milk, bread and milk, or some
light farinaceous pudding with milk.
I have now under my care a young woman who is
far advanced with pulmonary tuberculosis, with constant
fever ; a hopeless case. I have her on the following diet
list: 1 a.m. and 4 a.m., if awake, a small glass of milk ;
7 a.m., a glass of milk and raw egg ; 10 a.m., 1 ounce of
liquid peptonoids with guaiacol ; 1 p.m., milk and egg
with a piece of dry bread ; 4 p.m., peptonoids; 7 p.m.,
milk and egg ; 9:30 p.m., cup of hot beef-tea or mutton-
broth ; 11 p.m., peptonoids. I treat this patient exactly
as I would a patient with typhoid or other continued
fever, excepting, of course, as to the bread. I have no
hope of a cure, but it is wonderful to note how, upon
this diet, she holds the strength she has.
(ravage, as used in D6bove's method of "over-all-
mentation " or " forced feeding," has to be used in some
instances, although when this has to be resorted to, the
case is almost necessarily hopeless. As Minor tersely
puts it: "When resorted to, it is generally too late to
expect anything from it but pain to the patient from the
tube, and a slight prolongation of a life he is anxious to
give up."
Concluding, let me say that as lovers of our race we
cannot overestimate the importance of two things in
connection with this disease : (1) The spreading through
the press and in every other legitimate way possible, a
sense of the necessity for the prevention of this flattering
but too often fatal malady, through scientific sanitation,
with proper physical culture and out-of-door life ; (2) that
of impressing society with the immense value of the
earliest possible medical treatment when threatening
symptoms have already appeared. Without attention to
these things tuberculosis can never be banished from
among men. Thousands are slowly dying around us
who might now be enjoying health had they estimated
these matters properly.
We may, I think, fairly congratulate our profession
on what has already, and largely in recent years, been
attained in successful combat against this plague. Let
each continue to do his best, buoyed up by the reason-
able hope that through our labors humanity may soon
be comparatively free from this disease.
lODIPIN-PHOSPHOR.
A Preliminary Note.
BY
PROF. ROBERTS BARTHOLOW, M.D., LL.D.,
of Philadelphia.
lodipin is described by Merck as "an addition-pro-
duct" of iodin, and as a chemic combination of iodin
with oil of sesame. As it appears in commerce, there
are two forms— one a 10^, the other a lh<fc iodin
strength. The latter is the one usually preferred. lodipin-
phosphor contains J,, grain of phosphorus in 10 minims
of iodipin of 25 fc strength. It is a dark reddish-brown
liquid, having an odor of garlic. As 20 minims is the
usual capacity of an ordinary hypodermic syringe, this
was adopted as the unit for iodipin-phosphor. In some
of my preliminary experiments with this remedy I
used only ^\-^ of a grain of phosphorus, but it was soon
ascertained that ^V of a grain was not too much for one
injection.
Iodipin-phosphor can be used internally in doses
three or four times larger than those employed hypoder-
mically, but thrown under the skin it seerns to 'me far
more effective, and this is the opinion and practice of the
Continental physicians who have administered iodipin.
When iodipin-phosphor is thrown under the skin it
causes some smarting and burning along the site of the
injection, but this does not continue very long, and no
inflammatory nodules are caused in or beneath the skin.
In a day or two after the injection nothing but a red
point marks the site where the needle entered. The
best position for the injection is the depression on each
side of the spinal column. It should be understood that
certain special arrangements are necessary to effect the
insertion of the medicament, c/to, tute etjurundo. A 20-
minim syringe, or an antitoxin instrument with a well-
fitting piston, should be selected for this purpose. The
needle should be of larger caliber than is usual and
should have a good cutting point. The instrument and
the needle should be warmed so as to fluidify the material
and facilitate its flow through the needle and under the
skin. Some force is neceasary, but no special difficulty
has been encountered in inserting the oily liquid,
although viscid and hard to move.
It has been observed on the Continent that the largest
doses of iodipin do not cause iodism. This is explained
by the character of the combination of the iodin and
sesame oil, whereby the former is given out so slowly
that systemic effects do not appear. Nor have there
been any of the toxic sympfrjms due to the action of
phosphorus, although I have used as much as ,V of a
grain repeatedly. Without any pronounced systemic
action, iodipin-phosphor promotes in a marked degree
the nutrition, increases the body weight and removes or
modifies the symptoms of various nervous affections not
readily amenable to treatment. The cases thus favor-
ably affected were examples of spinal sclerosis, anterior
and posterior, neuralgia, neurasthenia, gout, chronic
rheumatism, etc. The improvement in nutrition is so
marked a feature of its action that it is a promising
remedy in pulmonary tuberculosis and other wasting
diseases. My experience in these maladies is not so
extended as in the chronic nervous affections, but it war-
rants me in the assertion that it will, probably, prove
highly useful.
In a future paper I hope to deal more fully with
iodipin-phosphor in its physiologic and clinical aspects.
Conditions in Russia, medical and social are, if we may
tru-t newspaper reports, indicated by the circumstances of the
recent death of Dr. Dvorashin. Through some blunder the
superstitious peasants thought he was profaning holy pictures,
and the secular accounts say he was beaten, and that he became
violently insane. He was taken to a hospital constructed for
800 patients, but into which 1,300 were crowded, where from
exposure and such care as might be expected, he contracted
influenza and died. The hospital management was exculpated.
The WinilVed Masterson Burke Relief Foundation. —
John M. Burke, a retired merchant, has conveyed property to
the value of about ?4,000,000,to a corporation, to be held in trust
for the relief of certain worthy persons. He has named the
corporation in honor of his mother, who died 30 years ago.
The trust deed specifies that "the benefits of the foundation
shall be reserved for intelligent and respectable men and
women, who in consequence of sickness, or discharge from
hospitals before they have regained strength sufficient to earn
their livelihood, or in consequence of other misfortune, may be
in need of temporary assistance."
The Borderland of Quackery. — From an article under
the above heading in the British Medical Journal we take the
following: "Lastly, an appreciable proportion of our own
chemists, photographers, and instrument makers, most excel-
lent tradesmen all of them, have so far forgotten the limitations
of tlieir vocations that they have thought it not unbecoming or
improper to invade the borderland by laying themselves out
for x-ray work and other therapeutic measures with which
they have nothing to do and for which, we humbly submit,
they are absolutely unqualified. We have no fault to find with
this class of person if he merely serves the public by taking
skiagraphs. In doing this he is, after the same manner as the
ordinary photographer, performing a service which is conve-
nient both for the public and the profession. When, however,
this limit is exceeded and he arrogates to himself the skill to
diagnose the pathologic condition from the pictures he has
photographed ; or when, worse still, he ventures by means of
light rays to cure disease, he is trenching upon ground which
does not belong to him, and, like the pirates of old, is conceal-
ing his identity under a flag he has no right to fly. "
JULY 26, 1902J
MEDICINE AND THE UNIVERSITIES
fAjTERICAN HeDICINB 143
SPECIAL ARTICLES
MEDICINE AND THE UNIVERSITIES.'
BY
LEWELLYS F. BARKER, M.B.,
University x>f Chicago.
I wish to spend the time you have courteously allotted to
rae tonight in maliing a plea for the better organization and
endowment of the medical departments of universities. If you
will permit me to refer in a few words to the character of the
medical schools of the past and to outline to you some of the
features of the medical schools of the present, I shall be the
better able to make clear to you my opinion regarding some of
the needs of the medical school of the future.
THE PASSING OP THE PROPRIETARY MEDICAL SCHOOL,.
The majority of the medical schools in America have
developed as proprietary medical schools. Usually a group of
medical men, centering in one strong personality, formed a
combination with two objects in view: (1) the education of
young men in the medical art, (2) self-improvement and the
advancement of their own standing in the profession and with
the public. The course of instruction, brief at first, was
first extended to two years, and then to three. It is now in
most schools four years. The graded course was a relatively
late feature. For many years only one course of lectures was
given in the school. This course was repeated each year, so
that if a student who attended all the lectures in his first year,
came back for a second or a third year, he listened to the same
lectures over again. The introduction of the graded course by
the Chicago Medical College (now the Medical Department of
Northwestern University) was therefore a distinct step forward.
The division of labor among the instructors became more
marked, and the corps of instructors was correspondingly
increased. The necessity, on the part of the student, for a
grounding in subjects like anatomy and physiology, previous
to clinical work, became apparent. Chemistry, histology,
materia medica and pathology were subsequently added to the
preliminary training, though the latter subject was taught for
a long time chiefly in connection with the clinical work.
There were no requirements of preliminary education for
the students — or, if any, merely nominal ones. Many of the
proprietary schools, whose whole income was derived from the
fees of students, were able to pay all their expenses and to have
besides a handsome surplus at the end of each year for division
among the members of the staff. And aside from the profits of
the school itself, official connection with the staff of a medical
school came to be of distinct financial value to the practising
physician or surgeon. The public, naturally, employed practi-
tioners who were teaching in the medical schools. Also, young
graduates of the medical school who got into difficulties in their
own practice, usually called into consultation their former pro-
fessors. So valuable, indeed, became this connection that some
of the incorporated medical schools took advantage of the
opportunity in an interesting way. The members of the cor-
poration would agree to admit a practitioner to the teaching
staff on payment of a certain sum of money. The cost of
a professorship varied, of course, with the situation of the
school, and its standing in the community. I am informed
that professorships may still be purchased in some of our medi-
<ral schools, and that they are valued at as much as two
thousand dollars per chair. The demand for chairs in such
schools has been so great at times that a corporation could
choose the better men among the applicants.
As long as the teaching in the medical schools was purely
demonstrative the cost of medical education was at a minimum.
Anatomy was the first subject to l>e taught other than In a
demonstrative way. For as anatomic material became more
plentiful, students dissected for themselves. The material was
not, however, expensive, and the laboratories were of so crude
a nature that very little money was expended on the work-
shop. The clinical teaching was done in hospitals and out-
'An address delivered at the meeting of the Western Alumni of
Johns Hopkins University, held at Chicago, February 28, 1902.
patient clinics— usually public institutions— and cost the cor-
poration nothing. Students, perhaps, were required to pay a
hospital fee. The hospitals did not belong to the medical
schools, and it was accordingly necessary to include in the
medical faculty those physicians and surgeons who had been
fortunate enough or clever enough to secure appointments in
the hospitals and dispensaries. Where these clinical institu-
tions were in the hands of politicians, the best practitioners
were not always on the staff.
When the microscope became an Important factor in medi-
cal education in Europe, American students who had gone
abroad for postgraduate instruction came back full of enthu-
siasm for microscopic work, and began instruction in the use of
the instrument in histology and pathology. It was very soon
recognized that the medical school must offer extensive courses
in normal and pathologic histology. Tliis addition necessitated
more than simple demonstration of microscopic preparations,
although the instruction began in this way. It was soon found
that the students must themselves do work with the micro-
scope, and this, since laboratories in whicii microscopic work
could be given and the microscopes and their accessories were
expensive, involved a large increase in the budget. In addi-
tion, students doing such work require a great deal of personal
attention, much more than the short time given by instructors
under the lecture system. Very few practitioners had had the
opportunity of perfecting themselves in microscopic technic,
and the services of the men qualified to teach it were at a
premium. Indeed, the demand became so great that certain
men undertook especially to fit themselves for such work. The
schools which offered the best facilities in laboratory work
attracted the most students, and so competition arose among the
proprietary schools to excel in this direction. Pathologic
anatomy and histology now became important subjects, and at
about the same time experimental physiology developed, so
that it, with the other two, had to be given an important place in
the curriculum. With the advent of Pasteur's discoveries and
Koch's researches, bacteriology sprang suddenly into favor ; and
laboratories fitted out with thermostats, culture tubes, and oil-
immersion lenses were everywhere demanded.
But this necessary laboratory instruction in physiology,
histology, pathology and bacteriology made such demands
upon the students that those without previous experience in
chemistry, physics, and biology were seriously handicapped.
And since the standard of admission to medical schools was
very low, the students rarely entered the medical school with
such training, so that the medical schools themselves were
compelled to try to teach at least some of these subjects in the
first year of medicine.
The proprietary medical scliools thus found themselves in a
dilemma. For the enormous cost which accompanied these
changes in the curriculum not only reduced the surplus, but
wiped it out altogether, and, by those who introduced them,
rapidly increasing deficits had to be face<i. The fees of
students in these schools were found utterly lnad«iuate to
supply the money which the rapid change in teaching made
necessary. Some relief had to be sought. Endowment for
proprietary medical schools could scarcely l)e hoped for. The
only relief, apparently, lay in a combination of the medical
school, or at least a part of it, with the scientific departments of
a university which received government aid or had private
endowment. And so, between the proprietary schools and
such universities, various arrangements were entered into.
Sometimes a me<iical faculty was established in the university ;
sometimes an affiliation was agreed upon. In some schools
the chemistry, physics and biology were taught In the uni-
versity, all the other subjects remaining in the medical school.
Today, however. It Is regarded as imperative that anatomy,
physiology, pathology and bacteriology, physiologic chemistry
and pharmacology be taught on a university basis. For each of
those subjects requires the service of men who have made It
their life work. The kind of Instruction which hM to be ifiven
makes large demands upon the teacher's time; Indeed a con-
scientious teacher of one of these fundamental sciences In a
department of a university Bometlraos finds It difficult U) get a
sufficient amount of time to undertake research. Thus It has
gradually come to pass that in the go<xl medical schocls those
144 AHKBioAir Hin>rci2rEi
MEDICINE AND THE UNIVERSITIES
[July 26, 1902
who teach the subjects nieotioned no longer engage In the prac-
tice of medicine, but devote all of thoir time and strength to
the teacliing and investigation of the sciences which they
represent.
THE PSEUDO-UNIVERSITY SCHOOL.
The consent of a certain number of the universities to
undertake the instruction of medical students in some of, or.
In some places, all of the sciences fundamental to medicine
having been gained, there speedily ensued such an enormous
improvement in medical instruction in these institutions that
the desirability of tlie move became quickly and widely recog-
nized, and this not only by the medical profession, but by pros-
pective students and by the public at large. The success of the
schools combined or affiliated with the larger and better man-
aged universities has been so pronounced that most proprietary
schools having no such connection have tried everywhere to
enter into some such arrangement. In certain instances it can-
not be denied that medical schools have sought rather the pres-
tige of the connection than any material improvement in the
courses of Instruction. They are no more to blame perhaps
than are the universities that have been willing to receive them
as their medical departments. In spite of the fact that medical
educators are unanimous in the opinion that adequate medical
instruction cannot possibly be given when the fees of students
alone are available as a budget, some of the poorer universities,
and occasionally some of higher rank, have been willing to
undertake the responsibility of medical faculties, provided
they did not cost them anything financially, or only a rela-
tively small sum. Such medical schools I should designate
" pseudo-university schools."
The proprietary school, however, did excellent work in its
day. Magnificent examples of self-sacriflce are to be met with
in the records of the faculties of such schools. Especially
when the demands of advancing science increased the cost of
medical education do we find in them notable instances of gen-
erosity and unselfishness. When deficits began to appear,
members of the faculty instead of drawing salaries, recognizing
what the school had done for them in increasing their practice
and reputations, and having the welfare of medical education
at heart, mulcted their own pockets to make the sheets balance.
But now the period of usefulness of the proprietary school of
medicine has gone. The conditions are such that its contin-
uance is a menace rather than a help to the community. The
pseudo-university schools are worse than the proprietary
schools, for they are proprietary schools in disguise.
THE SEMI-UNIVERSITY SCHOOL.
There is a third class of medical schools at the present time
represented by six or eight of the best medical schools in the
United States. This class I shall designate as that of the semi-
university school. By this I mean that the subjects of the first
two years are taught In the university, by university professrtrs,
who do not engage in the practice of medicine, but who give
their whole time and energies to the teaching and investigation
of the sciences which they represent. The laboratories of
anatomy, physiology, pathology, etc., are installed In the same
way as are the laboratories of physics, chemistry, zoology and
botany. The professors and their assistants, running careers in
these departments, are paid on the same scale as, or, on account
of the difference in ratio of supply and demand, a little more
liberally than are the professors and assistants in the other
science laboratories of the university.
Generous sums have in the better universities been pro-
vided for laboratory furnishings and apparatus, models, books
and other kinds of equipment. The fees of students are not
even adequate to defray the annual running expenses, entirely
aside from the cost of initial installation, in the departments of
the first two years.
The results of making anatomy, physiology and pathology
true university departments have been most satisfactory.
Students are now able to obtain a thorough scientific training
in these branches fundamental to clinical work. Formerly
clinicians complained that the medical students came to them
utterly unprepared as regards the structure and functions of
the normal body and almost totally ignorant of the changes
which take place in disease. Now, students accustomed to the
well-regulated, thoroughly organized, rigorous work of the lab-
oratories on approaching the clinical work sometimes complain
of a lack of system in the teaching, of unsuitable arrangement
of studies, of imperfect adjustnfient between departments, of
insufficient attention to sequence of subjects, of unwarrantable
waste of time. In some institutions they may even admit that
an occasional clinical professor does not appear to be as familiar
as he should be witli the trend of modern work in anatomy,
physiology, physiologic chemistry and pathology.
Especially gratifying as a result of the change made by the
semi-university school have been the consequences for produc-
tive scholarship. Instead of the sterility which characterizes
the departments of anatomy, physiology and pathology when
they are manned by practitioners, in the semi-university schools
they have become beehives of industry, centers of original
investigation and the last decennium has seen the birth of an
American Journal of Experimental Medicine, an American
Journal of Physiology, an American Journal of Medical
Research, and an Am,erican Journal of Anatomy— tour scientific
journals in which the contributions are rigidly limited to the
publication of the results of original research!
The departments of the last two years, whether nominally
included in the university or not, are situated entirely differ-
ently in these semi-university schools. All of the men who
teach in these departments, or at least the majority of them, are
men who are practising medicine, surgery, obstetrics, or some
one of the specialties. The schools provide lecture-rooms, some-
times an outdoor clinic, and in the better ones clinical labora-
tories. In some of the schools a few of the younger men,
especially in connection with the clinical laboratories, or as
assistants to the professors, are paid to give their whole time to
the institution, and do not engage in practice. The professors
themselves, however, are either not paid at all, or are paid small
sums, nearly always less than the remuneration which pertains
to a university chair, and always too little to provide the pro-
fessor with a living income. These professors are often suc-
cessful practitioners, however, and make incomes varying from
?5,000 to ?25,000 per year, or even more. The universities
seldom own hospitals. Or, if they have hospitals they are, as a
rule, small and totally inadequate to provide the clinical facili-
ties necessary for the number of students taught. The profes-
sors in medicine, surgery and obstetrics, usually have sufficient
personal influence, or the school itself is influential enough to
permit them to utilize for teaching purposes the wards of vari-
ous charity hospitals. The hospitals thus utilized have nearly
all been built for a specific purpose, namely, to provide beds and
treatment for charity patients in the cheapest possible way.
The majority of tliem are political institutions, with all the
faults of administration thereto pertaining. Even when the
institutions are privately endowed, as long as the management
is not in the hands of the university itself, innumerable and
often previously inconceivable difficulties are put in the way of
clinical teachers. Continuity of service, for instance, is rarely
possible, and such a thing as a graded staff", directly responsil)le
to each professor — an arrangement absolutely indispensable for
satisfactory clinical work — is almost unknown.
It is obvious that if those who teach the clinical subjects
have to make their living from practice they will be compelled
to direct their activities so as not to interfere with practice.
When one considers the amount of time and energy which the
patients of a successful city practitioner use up, when one
remembers the large bibliography in English, French and Ger-
man pertaining to the clinical branches which must be waded
through weekly and monthly to keep pace witli one's subject,
and when one thinks of the discouraging conditions in the
hospitals in which these clinicians are compelled to visit, he is
forced to marvel at the excellent work which is daily being
accomplished, at the closeness in touch with the progress of
their subject maintained by the more strenuous of these men,
and at the fact that some of them, in spite of all these unfavor-
able circumstances, actually make contributions to the advance
of science by their original work. It says much for tlie energy
and character of the men who are attracted by clinical medi-
cine, surgery and obstetrics in this country. If so mnch can be
accomplished under such adverse circumstances, what might
not be done by such men if the subjects of the last two years
July 26, 1902]
MEDICINE AND THE UNIVERSITIES
[AlfCBICAN Mkdicihb 145
were placed upon a real university basis ? I should like to see
what the result would be if men with these capacities were bred
to university careers, were placed in charge of hospitals
especially constructed and endowed for university purposes,
and were sufficiently paid to permit them to devote their whole
time and strength to teaching and investigating in such
hospitals.
A BEAL UNIVERSITY SCHOOIj.
If one attempts to portray the characters of a school of
medicine developed throughout according to true university
ideals he will find it necessary to depict conditions which,
as yet, exist nowhere in completeness. In a modern university
an essential feature is the combination of the academia with the
.%rhola. The university must be a center of original research, as
well as a place of instruction. An institution which attempts no
more than the Imparting of knowledge already acquired to its
students is not worthy of the name of university. It is merely
a college or seminary. A true university is made up of a
group of scholars wljo are not only familiar with the results of
previous investigations, but who, endowed with unusual
capacities and skilled in the methodology of their respective
sciences, invade new territories, searching diligently for new
facts. Methods already devised are used when they are suffi-
cient; new methods are invented when old ones fail. Each
scholar works for the sake of truth in his own department. He
does not permit himself to consider too attentively the applica-
bility of the truths he discovers to conditions belonging to other
departments of knowledge. He may not be too regardful of
the compatibility of a new fact with the preconceived ideas held
by himself or by others. He will do well not to spend too
much time thinking of the effect of a new fact upon the
desires or the fears of the people. He must have a profound
belief in the ultimate value of truth, no matter how unpalatable
it may be, or how useless it may seem to those who live at the
time it is found out.
Each leader in a department of a true university is both a
teacher and an investigator. The really great teachers have
always been investigators. The really great investigators have
always been teachers, though not always, perhaps, of large
groups of students, nor always, it must lie admitted, in their
own generation. It is highly desirable that the two faculties ol
teaching and discovering be combined in every university pro-
fessor. There may be a place for the non-investigatingteacher In
a college or seminary, but he is certainly out of his sphere as
the leader of a department in a university. The great investi-
giitor, on the other hand, who cannot teach students directly,
may profitably bo housed and cared for in a university for the
sake of the contributions which he will make to knowledge
and the prestige his work will bring to the institution, but the
department in which he works should also be represented by
other men who can both investigate and teach. I am convinced
that the influence, for any considerable length of time, of a
non-investigating teacher cannot fail to be actually harmful to a
student. The student may possibly acquire large stores of
information, but he will not make progress in independent
work or in independent thought; indeed his powers in this
direction will be inhibited, if not in time wholly obliterated.
No less pernicious to the student would be the effect of an
investigator whose personality is repellent and non-sympathetic
and who has little or no capacity to interest students in his sulj-
ject, to inspire their enthusiasm for work, or to train them in
accurate observation, sound reasoning and vivid imagination.
If these views of what a university professor should lae
hold for the faculties of arts, literature and science— and it will,
I believe, be generally granted that they do— why should they
not also hold good for the professional faculties of law and
medicine? Surely there is need in these faculties for professors
of the same high type.
It is generally taken for granted that In the philosophic
faculty of a imiversity a professor shall give the whole of his
time and all of his strength (aside from necessary recreation)
to work for the university. The professor of economics does
not give a part of his time to the university and the other part
to the financing of city banks. The professor of mathematics
would scarcely be permitted to give his forenoons to calculus,
quaternions or the teaching of " groups " in the class-room, and
his afternoons to the work of actuary for a transcontinental
railway, or to the calculation of stresses and strains for a bridge
manufacturer; nor would the university retain as its professor
of chemistry one who divided his time between the university
laboratory on the one hand and a factory for the preparation of
aniline dyes, or a huge establishment for the manufacture of
drugs in a commercial way, on the other. Imagine the condi-
tion which would exist if the university said to its professor of
economics: " We shall be glad to have you as our professor of
this subject, provided you are willing to do the teaching we ask
of you without direct remuneration. Your position in the
university will make you so well and favorably known, that you
will easily be able to secure financial responsibilities in the city
which will give you a far larger income than we could afford to
pay you." Or if the president and trustees made a proposition
to the professor of chemistry that he be paid $1,500 per year to
take charge of the teaching and investigation in the chemic
laboratories, it being pointed out to him that the prestige of a
university professorship will enable him to secure lucrative
positions as commercial chemist to four or five manufacturing
concerns in the city in which he lives, or as analyst to baking-
powder companies and manufacturers of pure food prepara-
tions, some of the trustees taking the stand that the intimate
contact thus gained with chemistry as practically applied in the
business world is not only desirable for the professor but abso-
lutely essential in order that his influence upon his students
may not be too academic! Which think you, the university
interests or the other interests, would get the lion's share of the
time and energy of these professors, especially if they hap-
pened to have families with tastes as expensive as those of the
average American family of the better class? What think you
would be the rate of progress in original work in the sciences
of political economy and chemistry in a university so consti-
tuted? And yet there is not a medical faculty in a university
anywhere in America where this plan is not followed, at least
for some of the chairs. The law faculties have fared somewhat
better, perhaps, but I am told that the condition obtains also in
the msyority of these. Until this is wholly changed we can
scarcely hope for the disappearance of that opprobrium which,
it cannot be denied, attaches to the socalled professional facul-
ties of our universities. Until a new regime is entered upon,
we must, for these faculties, fain be content with work less in
quantity and poorer in quality than is consistent with the ideals
and dignity of a true university.
It is a rather prevalent opinion that the reason the philo-
sophical faculties of universities have been regarded as of higher
standing than the professional faculties and the faculties of
technical schools is to be found entirely in that aristocratic
prejudice which favors traditional " learning" and holds itself
aloof from science, and especially from science as applie<l in
professional and industrial life. I have as little sympathy as
any one with those narrow-minded academicians who believe
that the only learning and the only culture worthy of the name
are to be gained by a study of the ancient languages and liter-
atures. Indeed, I unhesitatingly join hands with those who
maintain that any academic training which does not include
the inculcation of the " fair, faithful and fearless spirit" of
modern scientific Inquiry falls of the l>est purjjose of e<luc«-
tion. What Is more, I am convinced that a reasonable admix-
ture of natural science studies, even if chosen from the domain
of applied science, with the courses in languages, literature,
hi.story and philosophy, will yield cultivating results of a far
higher order than can be obtained where programs from which
natural science is excluded are followed. For only through
the study of the natural sciences can we osc«|)e that dominant,
though unwitting egoism which makes man the center of the
universe. Our whole education tends too much to distort the
human relation. " Man so readily deifies himself, and so
gladly permits others to deify him; he o<'cuplo« himself prefer-
ably with himself, with his own intellect and its pr<xluct*<, he
(»ll8 his own intellect divine, takes pleasure In worshiping his
own image and imagines that at the same time ho Is exhibiting
a proper degree of humility." It is with great diniculty that
human beings resign themselves to the scientific view of man
and the universe. It is not eaiiy at first, as Billroth says, to
admit that even the greatest human being is a more atom com-
146 AMERICAN MEDtOINKj
MEDICINE AND THE UNIVERSITIES
[July 26, 1902
pared with the totality of natural phenomena, or to hear tlie
whole human race described as but one group of animals, active
but for a relatively short time upon the earth's surface, and, in
comparison to the whole universe, vanishing almost into
nothing. " Man may willingly humble himself before his God,
but he always values himself much liigher than the whole of
nature." There is a side of culture which only the study of the
natural sciences can give. A sanity and a balance are deriv-
able from them which can scarcely fail to be lacking when the
socallod " humanities " only are studied.
Though it may be true that prej udice born of the old monas-
tic influence still shackles the universities, and that there has
been in the past a " discrimination among learnings," I cannot
believe that it is lack of democracy alone, or predilection for
tradition (done, which accounts for the slowness with which in
the first place socalled pure science and later the scientific pro-
fessions gained recognition among the people and in the uni-
versities, or for the opprobrium that undoubtedly does attach
still in many minds to the terms professional school or techni-
cal school, when compared with the school of philosophy. The
cause lay much deeper. It was necessary for the professional
schools and the technical schools to win their spurs. So long
as natural science remained merely the recreation of the dilet-
tante, so long as medicine continued to be chiefly an empiric
art, and technology the passing on of rule of thumb, these sub-
jects were not coequal with their elder sister. No people began
its culture with the exact study of the natural sciences; these
could come to development only after the prolonged influence
of language, art, religion, law and politics. So soon as physics,
chemistry and biology began to make the tremendous strides
forward which characterized the last century they were taken
out of the medical faculties and incorporated in the philosophic
faculties of the universities with the happy results familiar
to all.
Recently, applied science has won its place. The enormous
expansion of commerce and industry has compelled the estab-
lishment of great technical schools. The old method of appren-
ticeship no longer suffices for the training of men. It has
become necessary to save time and energy, and to make the
instruction more extensive and more thorough by education in
institutions dedicated to applied sciences. The inventive
mechanic, the engineer and the electrician have revolutionized
the world within our own memories ; if we live out our three-
score and ten we may, perhaps, be permitted to witness even
greater transformations. In the schools of engineering, not
only are the known applications of science taught, but brilliant
minds are constantly at work devising ever new and still more
wonderful applications. America, especially, has reason to be
proud of the advances she has made in technologic education.
A foreigner commenting upon our educational system has
made the statement that " the engineering profession is today,
upon the whole, the best educated in America." The degree of
Doctor of Engineering from a good university or institute of
technology commands full respect. I shrink from comparing
it with the degree of Doctor of Medicine given by many of our
universities or medical schools. The governments of Germany
and Austria have made " the doctorates of engineering and of
the applied sciences, and the institutions permitted to confer
them, coequal with the doctorates of philosophy and their con-
ferring universities." The head of the great German Polytech-
nicum has been made a Rector Magnificus, proof enough
that the democracy of learning is gaining ground.'
The way to get the highest recognition is to deserve it; the
way to get rid of the opprobrium attaching to the professional
schools is to remove the cause of it. In medicine this cause is
fast disappearing. Anatomy, physiology and pathology have
followed physics, chemistry and biology into the university.
Large and well-equipped laboratories and libraries are devoted
to these subjects. Large amounts of money have teen given,
so that the professors and their assistants, though as yet inade-
quately remunerated, are sufiiciently paid to permit men who
will despise certain of the delights of life and live laborious
days to follow these subjects as careers. Students are taught,
Wor£^" '^n'^«^"'iS-"v T-''V'^?'!^S<nS;,'"' «^ ^^^^^er m the World'.s
worK. Pap. Sci. 310., N. \., \ ol. ix, 1902, pp. 346-359.
and important discoveries are being made In these branches.
The physiologist is as fully recognized as the philologist. The
men and their subjects are on an equality, not because they
have been made so by edict of sovereign or ruling of university
presidents, or vote of trustees, but because they really are so.
There is no reason why internal medicine, surgery, obstetrics
and certain other branches should not be similarly elevated ; on
the contrary, for the sake of people who need help in time of
illness, for the sake of the medical profession, on account of our
universities and for the prestige of the science of the nation,
there is every reason for that elevation. And this would speed-
ily be brought about if universities and their benefactors fully
understood the situation.
HOW CAN A SEMI-UNIVERSITY .SCHOOL, BE TRANSFORMED INTO
A REAL UNIVERSITY SCHOOI. ?
By putting all the departments, at any rate all the princi-
pal departments, on a true university basis. To do this several
things are necessary.
In the first place, a very large sum of money would be
required, for the university would have to build and equip
hospitals of its own, arranged on an entirely different plan
from that adopted in ordinary charity hospitals. The hos-
pital for internal medicine would be built with the definite
idea in view of teaching students and of making original
researches into the nature, causes and treatment of disease,
in addition to caring for a certain number of patients. In
other words, in addition to the facilities offered by any good
hospital, the university hospital for medicine would have to
house a university department of medicine with its teaching and
research laboratories. A second hospital would do the same
for surgery; a third for obstetrics. Two million dollars for
each of these hospitals would not be an excessive sum to make
the initial installment and to endow the university department.
In order to secure such a large amount of money it is obvious
that university presidents and boards of trustees must be fully
convincedof its necessity, for only when this is the case will
wealthy men be willing to contribute such immense amounts
to the universities for this specific purpose.
If such hospitals could be obtained, and such professor-
ships endowed, the men engaged to work in them should be
chosen with the same care as to talents, attainments and per-
sonality as is exercised in the choice of any other professor in
the university. The men chosen should, like other univer-
sity professors, give their whole time and energy to the work
of the university, to teaching in the hospitals and to investigat-
ing in the hospitals. They should be men who have already
made important contributions to knowledge and who are
likely to continue doing so for the next twenty years. They
should be well paid by the university. They should not
engage in private practice, even if the university has to pay
them double the ordinary salary now paid to a university pro-
fessor to retain them wholly in the university work. If any
patients at all, outside of the hospitals, were seen in consulta-
tion, and there is some force in the argument that the well-to-do
public should at least in some rare and ditticult cases be per-
mitted to profit by the opinion and advice of the university
professor, the fees received trom them might be contributed to
the budgets of the hospitals themselves, in order to remove all
temptation from the staff.
The objection is sometimes raised that university profes-
sors who gave their whole time to teaching and investigating
in hospitals would not come into contact in hospitals and dis-
pensaries with the kind of patients and the types of diseases
which are met with by the practitioner in private practice, and
that accordingly the student would not be taught how to deal
with private patients nor how to recognize and treat the cases
which he has actually to deal with later himself. This argu-
ment appears plausible until it is more closely examined. The
character of hospital patients is gradually changing and the
clinician who confines himself to work In hospital wards and
dispensaries does actually in these latter days see many more
of those people and of those varieties of complaints previously
seldom seen outside of family practice. On the other hand, in
a medical college in which the clinical professors engage in pri-
vate practice, the students are not taken by their teachers into
July 28, 1902]
MEDICINE AND THE UNIVERSITIES
[Amkbican MedicikK 14'
the homes of the patients, tUe private patients are not shown
and the "private-practice" diseases are not demonstrated or
studied in any practical way. The influence of his " private
practice" maybe visible, perhaps, in some special savoir faire
manifested by the instructor in dealing with patients; too often
it reveals itself in the more superficial examination of the
patient, the more hurried consideration of the case, the less
rigorously established diagnosis and the writing of a prescrip-
tion ut aJiquidflat, which the exigencies of private practice are
said sometimes to entail. Even if it were granted — and I, for
one, am ready to grant it— that something difficultly definable
but of real value to the learner emanated from the teacher who
spends a large portion of his time in private practice outside of
hosi)itals, which is lacking in the professor who gives his whole
time and energies to the patients in the university hospitals and
work in the laboratories adjacent to the wards, would it be com-
parable with the increase in scientific spirit which the student
might reasonably be expected to gain from contact with a pro-
lessor who, besides having the capacity for the best kind of work,
has the time, energies and opportunities to penetrate into the
innermost secrets of disease in a manner precluded by the de-
mands of private practice? If we had to give up one influence
or the other, would there be any doubt as to which we could
the more safely disregard? But we need not be deprived of
either influence, for in large cities both should be available and
the students should be permitted to profit by both.
It is not necessary or desirable (aside from being im-
possible) that a student, during the two or three years spent
in clinical work in the medical school, should see all kinds
of diseases, or even hear of all the symptoms or of all the
methods of treatment which have been advised. It is im-
portant that he .should be taught systematic methods of
accurate observation and investigation ; that he should be
taught how to get at and how to relate the e.xperiences of
his predecessors in interpreting his findings, how to make
judicious prophecies for the future from a consideration of the
past, and how to plan out a rational mode of treatment. He
needs thorough, conscientious drill in the fundamental methods
of examination, preferably on not too large a number of patients,
for a long time before he views the kaleidoscopic transfor-
mations of the " 20patients-per-hour " clinic, and is treated to
imposing demonstrations in "snap-shot" medical diagnosis or
spectacular amphitheater surgery. Rout-'ne lernl man allzu-
schnell.
I would not be misunderstood in tliis matter. No one
values perhaps more highly than I the rich and varied expe-
rience of the really great practitioner of private practice, nor is
any one more cognizant of the fact that many busy practitioners
are entliusiastic, careful, thorough, methodical teachers. There
is a proper place for this type of man, as well as for the univer-
sity professor, in a real university school. The finding of that
place is all-important for the future welfare of medicine. The
student at the beginning of his clinical work should be thor-
oughly drilled in all the methods of examination, and should
study a few cases laboriously, applying with strict rigor. the
methods he has learned ; later he might more safely be per-
mitted rapidly to widen his clinical experience by being intro-
duced to a greater number and a greater variety of patients.
My own opinion is that the work of the present third year might
be taught by professors and instructors who give their whole
time to university hospitals, and that those a.ssoclated clinical
professors and instructors who also engage in private practice
might teach in other hospitals in the last year of the medical
student's course. It is very desirable that the better practi-
tioners should continue to visit in hospitals for the good of
themselves and of their patients, as well as for the good of
medical students. University hospitals for research will of
necessity be few in number, and will l)y no means replace the
hospitals which at present exist. Particularly in the clinical
specialties must the private practitioner be retained as a teacher,
for but few universities will have the endowment necessary to
maintain full university chairs in clinical departments other
than those of medicine, surgery, obstetrics, and perhaps psy-
chiatry.
The great discoveries which have been made In practical
medicine recently have resulted largely from the introduction
of the experimental method. There is no doubt in my mind
that it is to experimental medicine that we must look for the
advances of the future. Had it not been for Pasteur's brilliant
discoveries and the ingenious methods devised by Koch, we
should not have had Lister's work and the aseptic surgery of
today, nor would a disease like diphtheria, formerly so fatal,
have been robbed of its terrors through the introduction of an an-
titoxin. But experimentation ought not to be confined to those
physiologists and pathologists who are not clinicians. What
we need above all at this time are physicians and surgeons
trained in physiology and pathology who will spend a part of
their time in careful observation in the wards and over the
operating table; who will there collect facts which will give
them ideas to be submitted to experimental test, and who,
during the rest of their time, will go down into the laboratories
adjacent to the wards and actually make these experiments.
The men who do this should give their whole time to the uni-
versity.
Will the money necessary for the introduction of research
hospitals and university clinical departments be available?
I believe firmly that it will, and that, too, in the very near
future. How many a fond and wealthy parent 50 years ago
would have endowed one or more great hospitals could he
have saved the life of his child dying of virulent diphtheria !
The organiz4tion of an Institute for Medical Research in New
York, and of a Memorial Institute for the Investigation of
Infectious Diseases in Chicago, are signs of the times. The
same is true of the Institute for Experimental Therapy in
Frankfort, and a number of others which I could name. The
place for such institutes is in the medical faculties of the uni-
versities. Wealthy philanthropists are recognizing the value
of the methods of research. There is no lack of money which
could be made available for the founding of university hos-
pitals for research and for the maintenance of true university
departments of medicine, surgery, obstetrics and psychiatry,
provided those in whose hands it lies awaiting distribution can
be convinced that it will be used to the best purposes.
I ask the cooperation of the alumni of this university in
influencing university faculties and university presidents, the
public and philanthropists to hasten the introduction of real
university medical schools in the different centers in this
country. The chief cause of delay, in most institutions, lies
with tiie university authorities. They are often more difHcult
to convince than are their financial benefactors. University
authorities are too prone to magnify the importance of obtain-
ing large numbers of students rather than to emphasize the
desirability of an elevation of standards. They do not always
recognize fully the needs of research, and are accordingly timid
in their requests for money for investigation, though they are
ever ready to demand money to teach more students. If this
fear continues, the universities will lose the research institu-
tions, for philanthropists will endow them as independent
foundations. Above all should the means for research be
afforded to the professional faculties. Poor professional
faculties drag down the philosophic faculties ; adequate schools
of medicine and law lend prestige to the school of philosophy.
Were there any tendency to internecine jealousies among the
various faculties of a university, self-interest alone should be
sufficient to suppress it. What is to the advantage of one
faculty will not fail to help the others. Each faculty should vie
with the others in working for the welfare of the whole uni-
versity. Each faculty, therefore, will demand that all the
faculties are provided with the facilities for seeking the truth
according to the most rigorous methods, and independent of
its apparent use or harm. The more intense the desire of the
people for truth and clearness becomes, the more pressing will
this demand grow.
UntversUy of KdinbtirKh.— The .lohn Usher Institute of
Public Health has been ojMjned. The building is i;B by 48 feet
in size and three stories liigh, and contains lecture rooms,
laboratories, research rooms, disinfection r<«)m», etc., and a
museum M) by 26 feet.
Oldest Physician in the United 8ta««i«.-Thp oWeat
nractising physician in the Unlte<l States, Dr. .Tohn P. Wood,
of Cotreevllle, Kan., was 100 vears old last January. He was
born in Dublin ami graduated from the '1 ransyivanla Medioal
College at Lexington, Ky., in IKM.
148 AMKBICAN MKDICINE)
RENAL SURGERY
[July 28, 1902
RENAL SURGERY AS PRACTISED BY PROFESSOR
JAMES ISRAEL.
BY
NICHOI.AS 8ENN, M.D.,
of Chicago.
The world admires the work of a master. This applies not
only to art, music, science, literature, war and oratory, but also
to surgery. The fame of the artist, musician, scientist, littera-
teur, warrior and orator spreads worldwide and is immor-
talized in prose and song; that of the master surgeon is limite<l
to within the narrow bounds of the profession he represents.
To my mind there can be no greater source of satisfaction than
to excel in work calculated to advance science and bene-
fit suffering humanity. The master surgeon occupies such
a position. He belongs to the most charitable of all profes-
sions. His genius adds to the advancement of science, his
art benefits the poor as well as the rich. The surgeon who
makes a careful and exhaustive study of the diseases of an im-
portant organ and devises new measures of relief merits the
admiration and gratitude not only of the members of the pro-
fession to which he belongs
but of the entire world.
Such a man is Professor
.James Israel, the master of
renal surgery.
In the preparation of
his classic work on the sur-
gery of the kidney he has
incorporated his vast clin-
ical material and has laid
down rules of action calcu-
lated to secure the best re-
sults.
This book is a veritable
mine" of information and
should be translated at once
into the English language.
It is safe to state that its
author has had more expe-
rience in surgery of the
kidney than any other surgeon. There are a number of serious
and obscure questions pertaining to the surgery of this organ
he has definitely settled. He very naturally demands of the
surgeon an accurate anatomic knowledge of the kidney and its
environment. He very correctly asserts, contrary to the
opinion generally entertained, that of all kidney operations
nephrectomy is the easiest. He strongly advocates conservative
operations whenever compatible with the structural changes
which have taken place. He emphasizes tho importance of
exposing the organs freely in all operations, so that the surgeon
can make a thorough examination, upon which depends final
diagnosis and the technic of the visceral interference. He
insists upon catheterization of the ureter in all operations upon
the pelvis for the purpose of detecting and removing mechani-
cal obstructions. He is satisfied that if this is done urinary
fistula never occurs. He does not look upon ether as a danger-
ous anesthetic in renal surgery. The local effect of ether on the
kidney tissue is of shorter duration than of chloroform.
It was my pleasure to witness a number of his operations,
which I will describe as briefly their importance permits :
Case l.— LUhiasis and Pyonephrosis of Right Kidney;
Nephrotomy. The patient was a woman, aged 35. She had
lumbar pain in the right ride and pyuria for several years.
Her general health was materially impaired. The right kidney
was the size of a cocoanut, freely movable. Diagnosis was dou bt-
ful. Tuberculosis has been excluded. There were decided symp-
toms of stone. Ether narcosis was obtained. Long transverse
incision was made revealing first preperitoneal fat, next retrore-
nal fascia, and lastly the kidney enveloped by its adipose cap-
sule. 1 he preperitoneal fat and retrorenal capsule were Incised
vertically toward the spinal side so as to guard against opening
the peritoneal cavity when these structures were reflected by
the use of. fingers and sponge pressure until the hiius of the
kidney was reached and the ureter was freely exposed. The
al^^^^ iu^^^I"^ '""*''' enlarged and uneven. The space
around the kidney was packed firmly with gauze before it was
i'roK'ssor James Israel.
incised. The incision was made on the convex side, from pole
to pole. A large quantity of fetid pus escaped and a number
of faceted stones were removed. Catheterization of the ureter
was now made. The operator declared that it is exceedingly
dilHcult and often impossible to find the ureteral orifice with-
out exposure of the ureter. Traction on the ureter causes
a dimple-like depression on the surface of the pelvis,
the deepest portion of which always corresponds with
the ureteral inlet. The probe and afterward the ureteral
catheter entered the bladder without difficulty. Catheter-
ization of the ureter before operation revealed Ijlood and pus
corpuscles in the urine from the opposite kidney. The
calyxes of the pelvis were freely slit open with a blunt^pointed
bistoury, and after thorough flushing all of the depressions
and pelvis were packed with iodoform gauze. The margins of
the visceral incision were stitched to the lumbar muscles and
fascia with catgut. A copious absorbent dressing was api)lied.
It is worthy of note that no safety pins are used. A long, heavy
silk thread is tied to the projecting part of each gauze strip.
The findingof calculuses in the kidney operated upon points
to the existence of a similar affection in the opposite organ. The
precision, thoroughness and neatness with which this operation
was performed would have pleased the most critical observer.
Case II. — Hematuria ; Exploratory Incision. The patient
was a woman 32 years of age, anemic and obese. For a number
of years she suffered from hematuria of renal origin. Ureteral
catheterization located the disease in the right kidney. Patient
appears to be the subject of a hemorrhagic disposition, as all
wounds have always bled freely. Ether narcosis was obtained.
Long transverse incision was made. Subcutaneous and preperi-
toneal fat were found to be very abundant. Kidney not enlarged
and very inaccessible. Palpation of pelvis was negative. A
hard mass the size of a hazelnut above the kidney and in close
proximity to the large vessels was discovered. No indications
were found for a visceral incision. It was surmised that a
malignant tumor in the pararenal space might account for the
hemorrhage by interfering with venous circulation by com-
pression. The incision was closed by deep interrupted sutures.
Case III. — Renal Lithiasis, Pyonephrosis^ Nephrotomy. The
Eatientwas a man, aged 42; premature senility. He has not
een well since he was operated upon for stone when a boy.
Evidently a cystitis developed after the operation, followed by
an ascending ureteritis, which culminated in pyelitis and
pyonephrosis. There were no symptoms pointing to the exist-
ence of a renal calculus. A long transverse incision was made,
the kidney was found slightly enlarged and firmly adherent.
The intention of the operator was to make a nephrectomy, but
the conditions revealed by the incision made such a procedure
impossible. When the kidney was incised half a teacupful of
fetid pus escaped. Digital exploration of the pelvis of the
kidney revealed the presence of a number of small stones, which
were removed. Catheterization of the ureter could not be
made. Suturing of visceral incisions to lumbar muscles and
fascia was done; tubular and gauze drainage. The external
wound was diminished in size by a few deep and superficial
sutures, and copious dressing of absorbent material completed
the operation.
Case IV. — Chronic Papillomatous Cystitis, Suprapubic Cys-
totomy. The patient, a man of 35 years, was well nourished.
Twenty years ago he was operated upon for stone in the bladder
by crushing. Symptoms of cystitis were not relieved. Bladder
is very small. Two years ago some papillomatous masses were
removed per urethraj-ZThis operation gave no relief. Tumor of
the bladder in the region of one of the ureteral orifices is sus-
pected. At no time was there hematuria of any consequence.
Urine was loaded with pus. Bladder was inflated with air and
patient placed in Trendelenburg's position. Transverse incision
severed insertion of recti muscles almost completely. Bladder
was brought well forward by making traction on two silk liga-
tures and incised transversely. Digital exploration revealed a
ditTuse papillomatous condition of the mucous membrane.
Urethral drainage was done by the use of a soft rubber catheter
with vesical end, expanded so as to hold the instrument in
place. The vesical wound was closed by two rows of catgut
sutures, the first one embracing all tissues except mucous mem-
brane, when it was covered by a second row. External incision
was united by deep silk sutures which brought the divided
muscles in accurate approximation.
All Emergency Disinfector. — A portable disinfecting
plant, for use at temporary isolation hospitals in rural districte
or at the patient's house, has been devised by Dr. Thresh,
health oflScer of Essex county. Tlie disinfecting agent is cur-
rent steam saturated with formaldehyd vapor. The apparatus
is specially valuable in smallpox outbreaks ; the initial cost is
small and working expenses low.
A Medical Mnltiinillionaire. — The late Dr. Thomas Kid-
ley, of Sheffield, left property of the estimated value of over
je500,000, and his will was contested on the ground that the tes-
tator was not at the time " of sound disposing mind." The
.Judge, however, decided in favor of the will. We may take it
for granted that the deceased gentleman did not derive this
large fortune from the practice of medicine, and this may
account for the fact that he did not leave any of it to further
the interests of the medical profession. — [Medical Press.}
July 26, 1902]
THE WORLD'S LATEST LITERATURE
[AXERICAJI MbDICIKE 149
THE WORLD'S LATEST LITERATURE
Jonmal of the American Medical Association.
July 19, 190i. [Vol. XXXIX, No. 3.]
1. The Treatment of Yellow Fever. James Carroll,.
2. Ulcer of the Bladder. Louis E. Schmidt.
3. Muscular Insufficiency of the Mitral Valve. Charles Spencer
Williamson.
4. The .Socalled "spotted Fever" of the Rocky Mountains. A Prelimi-
nary Communication. Louis B. WiL.soNand Wm. M. Chowning.
•5. .Some Notes Concerning Preparation of Teeth for Microscopic Study.
Martha Andkksos.
1.— Treatment of Yellow Fever.— Carroll reviews the
treataients in vogue from the middle of the seventeenth century
down. In previously healthy subjects mortality can be reduced
to zero by careful treatment at the beginning. The lesions and
symptoms are due to the toxin acting especially on liver and
kidney and causing a damming up of the portal vein and its
tributaries. The supposed uremic symptoms «re probably
from ammonia compounds in the blood usually converted into
urea. The primary indications are elimination and support.
A mustard footbath is of great service in the earli&st stage, and
contraindicated later. A sinapism over the stomach for nausea
and cold for head pain should be applied. Calomel and sodium
sulfate and plenty of fluid by mouth or rectum must be admin-
istered. Baths and niter will reduce temperature. All food,
except possibly milk with lime water or Vichy, should be
withheld the first three days. In the second stage strychnin
may be used for heart failure, ice bags, champagne, cocain or
hypodermics of morphia for vomiting, unless black, when
turpentine may be given. Olive oil with lime water prevents
degeneration of the cells of the capillaries and consequent
hemorrhage. Barley, rice, milk, ice cream and fruit juices may
l^e allowed if the stomach is reasonably quiet. Secretion of
urine may be stimulated by urea. Trained nursing is indis-
pensable, [h.m.]
2.— Ulcer of the Bladder. — .Schmidt describes the appear-
ances of ulcers following nongonorrheal cystitis, also those from
gonorrhea, traumatism, tuberculosis, necrosis of a neoplasm,
and those of the solitary and perforating type, as seen by the
cystoscope. Treatment by irrigations and instillations is not
suflicient. The coatings and granulations should be cureted
away and the thermocautery applied to stop hemorrhage. In
generalized nongonorrheal ulceration thi> bladder must be
opened and the entire surface cureted and drainage inserted to
put tlie bladder at rest. In cystitis dolorosa curetment must be
followed by tamponing, and this kept up until .sensitiveness
has disappeared. In tuberculosis preliminary operation on
kidney or ureters may be neces.sary. When ulceration is due
to inoperable neoplasm cauterization may les.sen pain and the
ammoulacal condition of the urine. Perforating ulcers require
resection. The writer reports several casas. [h.m.]
S.— Muscular Insuiflciency of the Mitral Valve.— The
valves may be normal and the mitral ring of such size that the
curtains suilice to close it, yet the valve be incompetent (because
of the imperfect functionating of its muscular apparatus. There
may be only a little dilation. It must not be confused with in-
sutiicientla cordis, which meansexhaustionof the myocardium.
Williamson traces historically the development of pre.sont ana-
tomic and physiologic knowledge, and gives clinical histories
and diagnoses based on his personal observation. He explains
the function of the ring and papillary muscles and chordae, and
gives cuts of IIes.so's preparations, showing the shape of the
heart and valve in diastole and systole. In acute muscular in-
sufficiency the essential lesion is acute infectious myocarditis
accompanying typhoid, scarlet fever, etc. ; in chronic cases
it is almost always a chronic interstitial myocarditis, or Ijetter,
myodegeneration, usually with arteriosclerosis. In the acute
form the heart is moderately dilated without hypertrophy, the
symptoms appear late in the infectious disease causing the con-
dition, usually lasting two or three weeks, and then disappear-
ing. The absolute dulness is Increased about an inch outward,
the apex beat is correspondingly dini>laced, a soft systolic mur-
mur, not trHn8iuitte<l, is heard. Only the progress of the disease
makes differentiation from endocarditic insufllciency possible.
In chronic cases dyspnea and swelling of the ankles, slight
cyanosis, arcus senilis and arteriosclerosis may or may not be
present There are signs of moderate dilation of both ventricles.
[H.M.]
•*•— Spotted Fever.— Chowning's report is based on the
scant literature of the subject and the investigations inaugu-
rated by the Montana Board of Health. He gives the history
and clinical symptoms of the disease as described by others.
The pathology and etiology have not hitherto been reportetlon.
Autopsies revealed enlargement of the spleen to three times its
normal weight, with slight enlargement or the liver and sub-
capsular hemorrhages in the kidneys, and petechiae elsewhere.
In all cases cutaneous tick bites were present. Many red cells
in the capillaries contained parasites. In the spleen, liver and
kidneys were numerous phagocytes, each containing from one
to eight red cells, in nearly every one of whlcli was a parasite.
The disease is definitely limited in locality, occurs from March
to July, is not transmitted from one human being to another,
is not traceable to food or water supply, and all the symptoms
and lesions point to a specific infection through tick bites. The
protozoa found resemble the microorganism of Texas fever,
but are larger, having active ameboid movements. Three
stages In its development have been observed. It is pmbably
conveyed by but one genus of ticks, and the long period
between cases of the disease in human beings would point to
the possibility of the red cells of one of the lower warm-blooded
animals being the habitat of the protozoon in the stage of its
life cycle not passed within some arachnid. The common gray
gopher best fulfils the conditions of such parasitism, [u.x.]
Boston Medical and Surgical Journal.
July 17, 190t. [Vol. CXLVII, No. 3.]
1. A Report of Two Cases of "Typhoid Spine." Qkoboe Wiltow
MOORKHOUSE
2. Empyema In Children. F. J. Cotton.
3. The Influence of Alcohol Upon Infection and Its Use in the Treat-
ment of .\cute Infectious Dlsetises. 8. J. .Mkltzkh.
1.— Typhoid Spine. — Moorehouse has been able to collect
but 15 articles reporting 21 cswes, and adds histories of two of
his own. Exact determination of the imthology, as the outcome
is uniformly favorable, is practically impossible. Inflamma-
tory processes secondary to typhoid are usually or often de-
structive, yet in this no case has gone on to suppuration and
deformity does not usually persist. The presen<!e, however, of
febrile reaction in a number of the cases with the appearance of
a kyphosis loads to the belief that typhoid spine is a symptom
complex due to an inflammatory process. Pain in the back fol-
lowing typhoid but due to other conditions, should not be con-
fused with it. Prognosis as to recovery and deformity is excel-
lent. It has caused marked disability for months, many cases
suffering from exacerbations arising spontaneously or from
trivial cau.ses. For relief from pain, recumbency may be suf-
ficient, or mechanical devices, as a jacket or brace, and anti-
rheumatic, sedative and hypnotic remedies may l>e required.
Tonics and potassium iodid have been used with benefit. [H.M.]
2.— Empyema In Children. — Cotton's conclusions are
as follows: Empyema in children usually follows lobar
pneumonia- after a varying interval; the infection is
usually with the pneumocoocus ; spontaneous euro, even
when aided I)}' tapping, is rare; operation should not be
delayed, as time lost is strength lost, and the iasue is largely
one of nutrition ; the l)est form of operation is in general the
subperiosteal resection of an inch of the eighth or ninth rib in
the posterior axillary line, the evacuation of pus and fibrin
masses, and tube drainage ; irrigation at or after operati<in is
not usually advisable: the routine aftortreatmcnt in fresh
cases should be tube-drainage, the tulw lieing progressively
shortened, and removed when the cavity is nearly h«ale<l.
Where failure to heal seems to depend on failure of the lung to
reexpaud, treatment by valve or suction apparatus is Indicatctl.
This is especially of value in the more chronic cases: the mor-
tality is about one In seven; in small childrou it is nuich
groiitor than in those over five years. The (Causes of mortality
are, in the main, beyond our control ; the great majority of
cases heal even when the healing is dolayetl for many months;
chronic empyema, iu the strict sense. Is rare In children; the
closure of the cavity de|>endn mainly on nutrition and on ade-
160 Ambrican Meoicinb]
THE WORLD'S LATEST LITERATUKE
[July 26, 1902
quat« drainage; recurrences may occur from faulty drainage
at any time, and tliey may occur years after apparently sound
healing, without obvious cause; deformity of the chest is
usually temporary and yields to treatment; long-continued
discharge from the cavity is not infrequently followed by chest
deformity and scoliosis of a severer type, permanent and some-
times extremely severe, [a. B.C.]
3.— See American Medicine, Vol. IV, No. 2, p. 60.
Medical Record.
[July 19, 1901. Vol. 62, No. 3.]
1. Mosquito Work In Havana. W. C. GOROAS.
2. Appendlcilis as Viewed in the Early Part of the Last Century, with
a Few Nott's on the Essay of Miller. Thomas H. Manlky-.
3. Ear Complications of Measles and Their Treatment. Herman
J ARSCKY
•1. Some Popular Objections to Vaccination. William R. Fisher.
5. The Hygiene of Pregnancy. Frederick W.Smith.
1.— Mosquito Work In Havana.— Gorgas gives an account
of the methods used in 1901 in destroying the species which
convey yellow fever and malaria. The mayor issued an ordi-
nance requiring every collection of water to be kept mosquito
proof and enforced it by fines. Every house was inspected for
larvas. Kerosene was poured into all drains and cesspools that
could not be otherwise protected, and when families were poor
the department covered the rain-water barrel and put a spigot
in the bottom. When mosquitos are troublesome in a house
they are bred there or in contiguous houses, as they seldom
leave the place of their birth. At the first inspection larvas
were found on 26,000 premises, at the last one only 200, and the
number of mosquitos has been reduced to one-tenth. The
rooms occupied by yellow fever patients were screened immedi-
ately on notice, at public expense, and the rest of the house and
adjoining houses were fumigated. After convalescence the
sick rooms were fumigated with pyrethrum, stupefying the
mosquitos, which were then collected and burned. Since Sep-
tember, 1901, there has not] been a single case of yellow fever.
To destroy the anopheles bred in the irrigated lands immedi-
ately adjoining the city the district was drained, and where
drainage was impossible, oil was used. The results are a
marked decrease in malaria. The cost of the two crusades was
?7,000. [H.M.]
2. — Early Discussions on Appendicitis. — Thomas Man-
ley calls attention to an article written by Dr. L. Mfilier, and
published in the Journal of Medicine, Surgery and Pharmacy,
second series, 110, 39, p. 317, in 1827. Manley's object is to sub-
stantiate a former claim that M61ier was the first to write defi-
nitely on the subject of appendicitis, as against the claim made
by an English authority that a London surgeon was the first to
write definitely on the subject, in 18.38. The author translates
verbatim from Miller's article a complete and comprehensive
report of eight cases which he had collected in literature, seven
of which were undoubtedly appendicitis. Mglier had recorded
most accurately the cardinal symptoms and the postmortem
findings in each case, and had reasoned most accurately and
comprehensively upon the etiology and pathology of the con
dition. He even suggested surgical interference for relief
of the condition. Dupuytren had opened the abscess in one of
these cases May 14, 1812, which was probably the first operation
for appendicitis, [a.b.c]
3. — Otitis Following Measles. — Jarecky states that ear
complications following measles are usually slight and soon
progress to recovery. But a certain percentage of cases experi-
ence serious consequences. This arises from continuity of
inflamed mucous membrane. No one germ is always respon-
sible for the condition, but any of the pus-producing organisms
may be the disturbing factor. The condition is always aggra-
vated by adenoids. The purulent is generally associated with
severe cases and often results in destruction of the ossicles and
the tympanic walls. The symptoms arising in any of the sev-
eral conditions which may obtain, and the treatment for such
condition, are such as are found enumerated in the later books
on the subject. The author emphasizes the importance — even
necessity— of early incision of the ear drum in case of bulg-
ing; and urges the more careful and universal examination of
the nose and throat in young children, [a.b.c]
5.— The Hygiene of Pregnancy.- As a rule meat should
be eaten sparingly, and should be excluded when urea elimina-
tion is deficient or albuminuria exists. Sweets should be
avoided. Cereals, fresh vegetables, olive oil, fruits and milk
may be taken in abundance. If nausea exists meals must be
light and taken four times daily. Warm water with salt a hall
hour before rising is better than any drug. Alcohol is pro-
hibited ; coffee and tea may be used moderately. In dressing,
undue compression of the abdomen must be avoided. Exer-
cise should be plentiful and systematic ; walking is best. More
sleep and rest is required than in the nonpregnant. Frequent
bathing or the flesh brush promotes general well-being. After
the fifth month the nipples should be bathed frequently with
boric acid, quercus alba and glycerin. For disturbances due to
pressure the knee-chest or recumbent position, with the hips
elevated, will often give relief. The woman in advance<l preg-
nancy should not sleep on her back. Depressed or anemic con-
ditions call for easily assimilated diet and promotion of elimi-
nation. Exalted nutrition or plethora requires restricted diet,
exercise and attention to excretion. The amount of urine
voided daily should be observed and frequent quantitative
analyses for urea made. The average amount is 40 grains less
than in the nonpregnant. Less than 300 grains demand active
treatment, hygienic and dietetic. Walking from three to five
miles daily and excessive water drinking is beneficial. Serious
cases demand an exclusive milk diet. The psychic condition
in pregnancy should be carefully looked after, [h.m.]
New York Medical Journal.
July IS, 1901. [Vol. lxxvi. No. 2.]
1. New Apparatus for Therapeutic Applications of the Rontgen Ray to
the Larynx, Tongue, Rectum, Prostate, Cervix of Uterus, Vagina,
etc. E. W. Caldwell.
2. A Case of Peliosis Rheumatlca. Charles J. Aldrich.
.S. Otitis Media Purulenta Treated by the Dry Method. F. W. Davis.
4. Electric Light In Diseases of the Respiratory Organs. W. Fkkuden-
thal.
5. Tetanus. Kenneth E. Kellogq.
6. Polyhydramnios: Its Differential Diagnosis and Treatment, with
the Report of Cases. Edward P. Davis.
7. A Case of Amaurotic Family Idiocy. A. Hymanson.
8. Spinal Cocainlzation with Double Amputation on a Child. Wil-
liam W. Brooke.
1. — A new apparatus for therapeutic applications of
x-rays has been devised by Caldwell. It may be placed in the
mouth in such a position that the x-rays will be thrown
directly upon the larynx. The tubular projection carrying the
target may be readily introduced through any of the common
forms of vaginal or rectal speculums for applying the rays
directly to the cervix, the vagina, the rectum, or the prostate
gland through the rectum. Since the outer surface is of smooth
glass it may be easily cleaned and sterilized and it may even
be inserted through an artificial sinus in the abdominal wall
for applying the rays directly to advanced malignant growths
of the viscera. Cuts illustrating the new tube are given [c.a.c]
2.— Peliosis Rheumatlca.— Aldrich reviews the literature
of the subject and reports a case in a woman of 24. The pur-
puric eruption began on the outer side of the left ankle and
extended upward to disappear midway between its origin and
the knee. Another patch of purpura was present on the outer
side of the left thigh just above the knee. She had pain in the
left chest, sore throat and a temperature of 102°. Auscultation
revealed mitral insufficiency which probably dated from an
attack of polyarticular rheumatism at the age of 9. The ton-
sils were swollen and the fauces of a bluish red. The condition
cleared up in a few days under the administration of 7J grains
of salophen every two hours, the patient being unable to retain
sodium salicylate, [c.a.c]
3.— Otitis Media Purulenta.- Davis believes the dry
method of treatment to be the best in the treatment of either
acute or chronic purulent middle ear Inflammations. The dis-
charge should be thoroughly wiped away with the cotton-
carrier, exposing the drum perforation or the tympanic cavity
if the drum is destroyed. In the latter case the cotton-carrier
can be introduced into the middle ear and cleans it of all secre-
tion. A narrow strip of dry sterile gauze should now be intro-
duced through a speculum and the canal loosely packed to the
meatus. This should be allowed to remain until soaked with
July 26, 1902]
THE WORLD'S LATEST LITERATURE
[AnjtlCAN Medicise 151
the discharge, whether it takes 1 or 24 hours. Tt should then
be removed and a piece of dry cotton placed in the meatus and
left until the next packing,which should usually be twice daily
in acute cases. In chronic cases, in which the discharge is
offensive, a few instillations of boric acid in alcohol before each
packing correct the fetor. [c.A.c]
4. — See American ^fedicine, Vol. Ill, No. 26, p. 1083.
5. — Tetanus. — Carbolic acid injections are advocated by
Kellogg in the treatment of this condition. After the parts have
been thoroughly incised and, in case of sloughing, the edges
excised and all pockets exposed, and the parts thoroughly irri-
gated, a0.59fi watery solution of carbolic acid should be injected
in a circular manner surrounding the wound. If there are
already evidences of a general absorption, the injections should
be made along and on each side of the spinal column. Any-
where from two to four grams may be injected, and for the first
few days these injections should be made every three or four
hours. The use of phenol does not contraindicate the adminis-
tration of antitoxin. The author says that phenol has given
better results tiian antitoxin in cases treated alternately. [c.A.o.]
6. — Polyhydramnios. — The presence of pregnancy and
ovarian cyst, pregnancy and ascites, i)lural pregnancy, a
hydatid mole, a very large child, or a malformed fetus must be
eliminated. The condition may accompany ectopic gestation.
When polyhydramnios is slight and not increasing, the patient's
health remaining good, pregnancy should not be interrupted.
When distention increases rapidly and the patient's health is
impaired, the uterus must be completely emptied and made to
contract. A hot intrauterine douche of a 10% solution oflysol,
tamponing with iodoform gauze, the hypodermic use of strych-
nin and ergot, and other stimulation is necessary. The con-
dition is dangerous to the mother from overdistention, relaxa-
tion, hemorrhage and increased danger of sepsis. [c.A.c]
".— A case of amaurotic family idiocy in a child of 15
months is reported by Hymanson. The chief features of the
disease are : Idiocy, weakness of all the muscles, terminating in
paralysis ; gradual loss of sight, and characteristic changes in
the macula lutea, marasmus and death at the end of the second
year. [c.A.o.]
8.— Spinal Cocainization.— Brooke reports the case of a
boy aged 9 whose feet became gangrenous following freezing.
While waiting for a line of demarkation a septic temperature
ranged lietween 99.2° F. and 106° F., with rapid, feeble pulse
and marked delirium. When he had rallied sutliciently it was
decided to operate under spinal cocainization. Thirty minims
of a 2% solution was injected. In three minutes there was
complete anesthesia in one leg and in five minutes it was com-
plete in both. Both legs were amputated at tlie middle third,
the stumps healing in nine days by first intention. No severe
after effects followed the operation. [c.A.o.]
Medical News.
July 19, 1901. [Vol. 81, No. 3.]
1. Illiistmtlve Errors and Dimeulties In the Diagnosis of Affections of
the Biliary System. C. L. liiBSON.
2 The Nonhciedlty of Acmilred Characters. Lawrkncb Irwell.
:i. The Morning Drop ; Its 'Treatment. Febd. C. Valentine.
4. Is Vivl»e<'tionn Benefll to Animals and Man and Justlflable? E.
5. Hepatic Gout and Us Treatment. .1. LKFKtsowEi.i. Hatch.
«. Reporlof a Case of Cerebral Tumor. Fkask Hali.eck Stephen-
son.
7. Observations Upon Two InterestinK Cases of the Local Manifesta-
tions of Hysteria In Joints and .Muscles Prkscott Uk BKurrON.
1.— Difflculties in the DlaRnosls of Affections of the
Biliary System.— (iibson's paper hiis to do with the difficulties
which may arise in making a diagnosis of disease in the biliary
system. In this region we have the right kidney, pylorus,
duodenum, head of the pancreas, the liver proper, large and
small inte.stine, etc.— any one or more of which when diseased
may present symptoms suggestive of biliary disease, this to
say nothing of the complk»tion which may arise from disease
of the stomach, appendix and other remote organs. The author
insists upon more careful and painstaking effort to know fully
the patient, his physical condition, history, etc., before a diag-
nosis of biliary disease is made. [a. B.C.]
li.— Nonheredlty of Acquired Character*.— The average
medical man does not understand biologic terminology. There
is no proof that characters acquired by the individual during life
are hereditary. Acquired alcoholism is not transmitted ; the
alcoholic diathesis is. If acquired traits are usually transmitted,
the race which has longest used alcohol would be the most
inclined to drunkenness, but by the process of natural selection
the heaviest drinkers are weeded out, resulting in the disap-
pearance of those with the alcoholic diathesis. A parent is in
reality a trustee, and his influence over his productive ele-
ments is little greater than that of a host over a parasite.
There is no sucli thing as hereditary syphilis. Any disturb-
ance affecting the individual from without while in utero is
acquired or congenital. Only that which is derived from the
germ plasm is hereditary, [h.m.]
3. — The Morninj; Drop ; Its Treatment. — This is the
subject of a valuable and comprehensive article from the pen
of F. C. Valentine. A brief abstract can give but a meager
idea of the scope of the paper, and since the conditions are so
many the treatment, which is the most valuable part, cannot be
abstracted and should be read in the original. Conditions giv-
ing rise to the " morning drop" are enumerated as follows:
Chronic gonorrhea, involvement of the crypts and glands, gon-
orrheal posterior urethritis, nongonorrheal posterior urethritis,
aseptic urethritis, prostatic and seminal vesiculitis, stricture,
tight meatus, growths, erection drop, constitutional causes,
overtreatment, etc. The author draws the following brief con-
clusions : The morning drop is ordinarily a symptom of local
or constitutional disturbance ; when it is not due to either of
these it is maintained Viy overtreatment or artificial sexual irri-
tation; according to its cause it must be treated locally, if due
to a local cause, and constitutionally if faulty metabolism or
food irritation be the provoking element ; if sexual irritation
be the cause this must be stopped ; if the morning drop be due
to overtreatment it must be discontinued ; the cause of the
morning drop is not difficult to ascertain, and its treatment is
within the sphere of the general practitioner, [a. B.C.]
5.— Hepatic Gout.— Tlie chief differential feature between
rheumatic " bilious attacks " and those due simply to hepatic
torpor is the excess of uric acid and heavy deposit of urates fol-
lowing an attack with subsequent relief, as well as the history
of previous acute articular rheumatism. The symptoms are due
to the excess of uric acid. These may be completely removed
by colchicin and salicylic acid. Hatch recommends the com-
bination known as colchisal. [h.m.]
6.— Cerebral Tumor.— Stephenson reports a case which
necropsy proved to be one of cerebral tumor, and which accord-
ing to the author was remarkable in the following respects :
Its onset and general appearance suggesting neuralgia; the
short duration of the symptoms of suffering in comparison to
the serious ravages in the brain by the tumor ; the absence of so
many symptoms of brain tumor when a growth of so great size
(hen's egg) and so much destruction were present; the absence
of mental impairment, when such an extent of damage had
resulted ; the marked improvement in the use of the left hand
and arm, when much damage had occurred in the brain ; though
of course this was due to the miraculous escape of some of the
motor fibers from the effect of pressure, which was probably
relieved by absorption of l)roken-down tissue, no hemorrhage
having been found ; the early and continuous ne<'k and occipital
pain, which latter disappeared almost entirely, its place being
taken by supraorbital pain dire<!tly over the seat of tumor.
[a. B.C.]
7.— liocal Manifestations of Hysteria.— Prescott Le Bre-
ton reports the case of a man who having sprained his ankle
was treated by plaster casts, etc., until it was evident there was
no apparent cause for the great pallor. liyi>er»ensitivenes«,
rigidity, etc. The patient was neurotic. The writer gradually
remove*! the casts, told the patient he would make a good re-
covery, set up passive motion, massage, etc. The re<!overy was
complete. He reports the ease of an apparently healthy girl of
15 who developed a torticollis and goiter following a sore throat.
The condition was Iwlleved by the author to be largely hysteric,
since she evinced the various stigmas of hysteria. Under a
courseof suggestive and internal therapeutics, ami exorcise to
correct the muscles, she made a good re<!ovory. [a. B.C.]
152 AUKBICAS MEDIOnnij
THE WORLD'S LATEST LITERATURE
[July 2G, lt(u2
Philadelphia Medical Journal.
July 19, 1901. [Vol. X, No. 3.]
1. Tlip Miiitnl DlsPHSCs of Children. (To be Continued ) F. X. Dekoi'M.
2. Ki'cpnt I'loKnss In Prostatic Snrgeiy. G. Kkank Lydston.
3. Hcinonlmglc. Infuretlon of the Kidney, with lleport of a Case.
(iEOKOB IV Dale.
1, MutlHni and Aphasia. (Concluded.) Hermann Outzmann.
2.— Prostatic SurKery.— I^ydston believes that a distinct
advance in our knowledge of prostatic pathology and thera-
peutics has been the steadily growing belief that in a large pro-
portion of instances the socalled .senile disease of the prostate
Is due to chronic congestive and inflammatory conditions,
developing at a period remotely antecedent to the appearance of
the first definite symptoms of mechanic urinary obstruction.
lu many instances the cause of the primary hyperplasia and
inflammation of the prostate is some irritative affection of the
prostatic urethra, or even of the pendulous urethra acting
reflexly. By attention to these oouditions, prostatic hyper-
trophy may be prevented in a certain proportion of cases. Tlie
most rational method of dealing with prostatic hypertrophy
and its congeners is the radical operation prostatectomy. He
believes that the brilliancy of the results thus far reported from
all quarters in which the Bottini operation has been advocated
can only be compared to that of the multitudinous reported
operations of the Ramm-White method, with which the jour-
nals teemed a few years since. What is most needed is a
general recognition of the necessity and wisdom of early
prostatectomy, a period when tliere are no secondary conditions
with which to deal, [f.c.h.]
3. — Hemorrhagic Infarction of the Kidney.— Dale re-
ports the case of an Irish female, 21 years of age, which shows
the great extent to which important functionating organs, as
the heart and kidneys, can be disturbed and yet carry the
patient through many hardships, [f.c.h.]
•4. — Mutism and Aphasia.— Gutzmanu has discussed his
subject at length, and details several cases. The article does
not lend itself well to abstracting, so the reader is referred to
the original, [f.c.h.]
CLINICAL, MEDICINE
David Ribsman A. O. J. Kelly
The Etiolog-ic Slgniflcauce of the Acid-reslstiug:
Group of Bacteria, and the Evidence iu Favor of
their Botanic Relation to Bacillus Tuberculcsis. —
For some time alter the discovery of the tubercle bacillus,
this organism wa.s, barring the lepra bacillus, the sole
representative of the acid-proof bacteria. But, from
time to time, discoveries have been made of organism.s
that, in their resistance to deeolorization by acids, re-
.semble the tubercle bacillus ; and in rare instances these
new organisms have been the cause of lesions that,
macroscopically, could not be easily distinguished from
the characteristic product of the tubercle bacillus. At
the present time there are nearly thirty bacteria which
have been found in different localities and habitats, and
which more or less closely resemble Koch's bacillus.
Their presence in situations in which the tubercle
bacillus may also be present is, naturally, a confusing
factor in diagnosis; and a thorough investigation of
their interrelationship has, for some time, been a
desideratum. Supported by the Rockefeller Institute
of Research, Abbott and Gildersleeve {University of
Penmylvania Medical Bulletin, June, 1902) undertook
the task, and have performed it most creditably.
Organisms belonging to the confusing group, a,s the
authors call it, have been found in the intestinal con-
tents of man, horses, and cows; in stable manure; in
the smegma about the vulva, manmia, and anus of
normal man, cows, horses, dogs, guineapigs, and white
rats ; in the sputum from [xitients with pulmonary gan-
grene ; even in the saliva of nontuberculous individuals ;
in a suppurating ovarian cyst ; in butter ; and in certain
kinds of fodder. It is probable that the thirty or more
organisms discovered do not, at the most, represent
more than two distinct species.
Though resisting deeolorization by acids, this prop-
erty is not so strongly developed as in Bacillus tut>er-
culosis ; the organisms of the confusing groui> have a
much lower resistance to acid decoiorizers. For instance,
if 26 fo to 30^ nitric acid .solution is employed, as in the
original Koch-Ehrlich method, they are at once decolor-
izi^d — a fact that in Abbott and Gildersleeve's experience
served to distinguish them immediately from the genu-
ine group of tubercle bacilli.
Morphologically they resemble, in certain phases of
development, the tubercle bacillus ; but they are at once
distinguished from it by the fact that they grow more or
le.ss abundantly at from 2i)° to 22° C. With the po.ssible
exception of those found in cold-blooded animals, they
all grow quite readily at 87° or 38° C. Under similar
conditions they all grow much more rapidly than the
tubercle bacillus, and the growth produced by them
differs from that of the latter organism ; on solid
mediums the two cannot be confounded.
As to their pathogenesis, the results obtained by
experiment vary. If injected in pure culture and alone
there is often no effect; but if previously there is in-
jected into the peritoneal cavity of either rabbits or
guineapigs some sterilized butter, a fibropurulent peri-
tonitis asually results, and small round or oval nodules
may form, which have the appearance of tubercles, but
which, histologically, partake more of the nature of
suppurative than of tuberculous collections. Intra-
vascular injection, which is the best method of studying
the organisms, produces, in from twelve to eighteen days,
larger or smaller nodules in the internal organs. Curi-
ously enough the lesions are, for the most part, confined
to the kidneys. Histologically, the nodules may resem-
ble true tubercles, having a central necrosis and giant-
cell formation ; but more often they are of a suppurative
character. There is no tendency toward fusion of neigh-
boring nodules. Injection of the grass bacillus of Moller,
which may be regarded as a type, into large animals —
calves and hogs — produces no results of any importance.
Studied from the botanic point of view, there can be
no question as to the existence of a relationship between
Bacillus tuberculosis, the acid-resisting bacilli, and the
ray fungi ; nor is there any doubt of the inaccuracy of
the designation "bacillus" for the two former. The
authors favor the suggestion of Lachner-Sandoval that
the entire group be called actinomyces. They examined
fifty samples of butter from various sources, and found
acid-resisting bacilli in five; genuine tubercle bacilli
were discovered in none ; organisms capable of causing
acute peritoneal or general infection were present iu
twenty-one. The authors believe that the presence of
the acid-proof bacilli in dairy products is of no etiologic
significance, but may be considered an accidental con-
tamination from the surroundings, and not a.s an evi-
dence of disease in the animals.
Recurrent Herpes of the Male Urethra. — Bettmann '
reports a case of this kind iu a syphilitic patient 26 years of age.
The condition was characterized by a urethral discharge, slight
burning, enlargement of the inguinal glands, and during one
attack herpes upon the prepuce. The chief features of the
affection are: (1) The periodic appearance of a urethral dis-
charge free from gonococci, which disappears without any local
treatment; (2) a combination of the attacks with herpetic
eruptions elsewhere, particularly on the genitalia, and (.3) a
characteristic endoscopic picture, consisting in minute erosions
on the mucous membrane of the urethra, beginning 1* cm.
behind the meatus and extending for from 2J to 3 cm. Herpes
of tlie urethra is a harmless condition, but gains importance
from the fact that it may lead to the diagnosis of gonorrhea and
may cause great anxiety to the patient, [d.r.]
Albumin and Tube Casts After Fifty.- Osier' points out
the advantages of a trace of albumin and a few tube casts being
discovered iu the urine of tho.se who are living too high or
' Manchener medlclnlsche Woehenschrlft, April 29, 1902.
s West London Medical Journal, January, 1902.
:n
July 2B, 1902]
THE WORLD'S LATEST LITERATURE
(AXBBICAN HEDIdKB 153
under too great pressure, as it leads generally to a more rational
regimen. In the fifth and sixth decades albuminuria is not
infrequent and not always serious. It probably denotes pre-
senile arterial changes, a renal inadequacy, not of vital impoi^
tance. Points indicative of serious disease are persistent low
specific gravity, marked sclerosis of the peripheril arteries
with apex beat an inch or two outside the nipple line and
highly accentuated second sound, and albuminuric retinitis.
It is not always easy to reach a decision, as there are cases in
which a trace of albumin and a few casts first call attention to
serious disease. Primary arteriosclerosis with these expres-
sions must be carefully differentiated from the granular, con-
tracted kidney, [h.m.]
Three cases of cerebrospinal fever treated with anti-
pyrin— two recovering and one living 90 days— are reported by
Freeman.' Three other cases occurring at the same time and
treated in the ordinary way terminated fatally, [a.o.j.k.]
Eosinopbilia in Pilariasis.— William J. Calvert,-' of the
Municipal Laboratory, Manila, P. I., concludes that in the
early stages of filariasis, leucocytosis with an increase of the
eosinophiles may be looked for, and that as the disease pro-
gresses the leukocytosis and increase in eosinophiles gradually
decrease to normal. [c.s.D.]
Systole Interrupted attheAurlculoventrlcular Orifice.
— Belski'' reports the case of a patient with emphysema,
sclerosis of the arteries and heart, venous congestion, irregular
pulse, alternating tachycardia and bradycardia, Cheyne-Stokes
breathing, cyanosis, albuminuria, and anasarca, in whom be
observed a marked systolic contraction of the heart, followed
by a short, strong systole, and then a long pause, during which
(despite the resting of the heart) the jugular vein revealed
weak but distinct pulsations occurring in the rhythm of the
tachycardia. The venous pulsations during cardiac rest he
interprets as the clinical manifestations of systoles of the
auricles interrupted at the auricnloventricular orifice, confirm-
ing the observations of Wenckebach, [a.o.j.k.]
Normal Microbism of the Extrahepatlc Biliary Dact«.—
Gilbert and Lippman ' presented June 14, 1!»02, to the Society de
Biologie, of Paris, the results of their cultures of bile taken
with the most minute precautions from the gallbladder and bile
duct of dogs. Aerobic and anaerobic cultures showed uni-
formly the presence of several species of bacteria, results
directly contrary to the general opinion that the biliary ducts
are always aseptic, [c.s.d.]
A. B. Craig
GENERAL, SURGERY
Martin B. Tinkeb
C. A. Orb
Snrglcal Intervention for Obscure Gastric
Troubles. — American surgeons have for a long time
recognizt'd the fact that very little gastric surgery is
being done in this country ; if we want statistics as to
results of such operations as gastroenterostomy, pylorec-
tomy and pyloroplasty we are obliged to refer to the
work of Continental surgeons. Various resisons have
been attributed for this, some have maintained that
ga-stric ulcer and carcinoma were nmch less common in
America than in Continental P^uroiK- ; others have been
inclin(!d to blame the poor training of the general prac-
titioner, who does not recognize these conditions and
turn them over to the surgeon. Andrews (Chicago
Medicdl lievorder, June 15, 1902) suggests two obstacles
to the progress of stomach surgery in America: (1)
Inaptitude and want of originality ; (2) false con.serva-
tism and timidity, faults which, as a rule, cannot be
attributed to American surgeons. xVndrews uills atten-
tion to the advances in intestinal surgery so closely
allied to ga.stric surgery which have been made by
Americans, but lie notes the marked inferiority or nearly
total absence of original contributions on the surgery of
' British .Medical .loiimnl. May 24. 1901!
^.lohiiH HopkliiH KoHplUtl Kullflln, June. 190Z.
sZfllDchrirt Kir kiliilw lif .Mertlcin. xllv, 179, 1S02.
•La mC'dleliif Moderne, June W, ItKK.
the stomach. Americans traveling abroad have failed
to see or appreciate the newer stomach work and have
not introduced it into America : niedicsil precepts crystal-
lized by te.xtbook writers have tended to check progress.
As an example of this textbook con.«ervatism he men-
tions the teachings containe<l in good treatises ten years
ago against operation for the radical cure of hernia and
believes that a similar state of affairs exists in regard to
gastric surgery at present. In spite of his accusiitions
Andrews will find, if he reads American surgical literature
more carefully, that the latest and soundest teachings on
these subjects'have been adequately treated in articles by a
number of American surgeons within the pa.st few years,
and some important contributions Iwth in oi)erative
metho<ls and statistical studies have appeared in Ameri-
can surgieil literature.
Andrews' suggestions with regard to perforating ulcer
and hemorrhage from gastric ulcer contain nothing
specially new ororginal, but he csiUs attention to a class of
ca-ses very important in these days which has not, jierhaps,
received adequate consideration in Americ-a. There are
many sufferers, numbersof them women, with a train of
symptoms which go under the names of motor insuffi-
ciency, chronic hyperacidity, nervous dyspepsia, neuras-
thenia with dyspeptic complications, etc., who go around
from doctor to doctor for a long time, trying to ha cured
of their stomach troubles, sometimes getting temporary
relief, but who are never cured. Andrews believes that
many of these cases of gastric dyspepsia of obscure
origin, of dilated and prolapsed stomiu-h whose exact
pathogenesis is unknown, are probably due, remotely or
directly, to gastric ulcer which, if treated by gastnien-
terostomy, would make rapid and periiiHnent recoveries.
In operating he states that he has l)een surprised to find
the number of cases presenting dense white cicatrixes
showing unmistakably the presence or former existence
of ulcer. In many of these cases no ulcer had been sus-
pected because none of the classical symptoms were pre-
sented. As in appendicitis the esvrly interval operation
may be a part of wisdom, so in stomach surger>' we may
in the future forestall trouble and prevent lingering
complaints and dangerous complications by surgical
operations which are conservative and timely. These
cases are undoubtedly being sucees.sfully treated by many
Continental surgeons tiy operations which have a com-
paratively low mortality, while only a few of our more
progressive surgeons have re<'0gnized the necessity for
such operations. Andrews' suggestions are undoubt<Hlly
timely ; while indiscriminate operating cannot be
advisltl in these cases, carefully selected cases would be
much benefited by surgical oi)erative treatment.
PoreiRn Bodies In the IjunRS — Korteweg,' of I-eyden,
reports the case of a man from whoso right lung he removed the
fragmeutofa lyddite shell 4.5 cm. in length, and weighing 42
gm. Immediately following the accident there were scarcely
any symptoms of wounding of the lung, though the intssUe
lodged behind the medial part of the second rib, alxjut 7.5 cm.
behind the front wall of the thorax. About two months after-
ward expectoration of bIcKxl l)egan. At the end of six months
the man prfwented himself for treatment, and the question of
operation at that time or waitirg for untoward symptoms came
up. Operation was decided upon and the sec-ond rib resected.
When the pleural cavity was openetl a moist UmiM)n was
applied and the wonnd dressetl. Two weeks later the foreign
body was removjMl, Ih read-lwps being p»aMd through the
deeper tissues by full curve*! noodles before the lung tissue wa»
cut. Convalescence wa« rapid, and In two months the patient
was discharged as cured. Korteweg gives a lengthy discussion
of the question regarding the time to operate Incases of foreign
body in the lung. He holds that a bullet, as well as any other
foreign body In the lung, deserves attentiim even If at flrsl no
alarming symploms should appear. The simple pre«enoe of
any body in the lungs is to be cxmsldorod dangerous. Left to
Itself any permanently retolned body kills the paUent riowly
1 Annals of Hiirijery. July, 1002.
151 AMERICAN MeDICINB
THE WORLD'S LATEST LITEEATURE
[JtTLY 26, 1902
but surely. The vicious circle of swelling, stenosis, retention
of pus, ulceration and dilation becomes established and there is
no means of arresting it. An unfavorable condition in all these
cases is that the suppurating process is in the center and the
pleural membranes do not adhere as in other cases following
l)neumonia, etc. During the two weeks between operations,
waiting for this, the patient is in worse condition than before
and is apt to succumb if he is weakened by long continuance of
the process. Late operations may improve the patient's con-
dition but they will not eftect a cure. [A.a.E.]
Spina Bifida. — Nicoll ' reports a case of spina bifida in
which the child was operated upon at two mouths of age. The
tumor was found to be a pure meningocele, and the child made
a perfect recovery. He also reports a case of spina bifida in
which the child was operated on at 3 weeks. In the tumor
sac and attached to its walls were found four of the spinal
nerves, together with some smaller tumor masses. These masses
were dissected out, the nerves returned to the interior of the
canal, the sac excised and the stump closed. Previous to opera-
tion the feet and legs of the child were bluish, poorly nourished
and their motion was impaired. Since then the color and mo-
tion are much improved, [a. B.C.]
Surgical Treatment of Sciatica. — Very little has been
written about the bloodless method of stretching the sciatic
nerve, which should always be done under an anesthetic
because if not done completely the condition is worse than
before. Separation of adhesions between the nerve and the soft
parts doubtless plays an important part in the relief cause. The
finger should be passed up and down the nerve as far as pos-
sible to separate the adhesions before stretching. Halley^
advises pulling down as well as up, for many cases begin with
lumbar pain which passes to the buttock and down the thigh.
He reports six cases operated on successfully. Provided cases
are well defined, having no other pains and no other organic
disease in pelvis or elsewhere, nerve-stretching is beneficial,
and should be recommended early. Should the pain recur
below the knee, a second nerve stretching should be done lower
down, [h.m.]
Danger of Administering Chloroform by Gas liight. —
Galloway ' directs attention to the danger of the chlorin and
chlorin compounds formed from chloroform in the presence of
a gas flame. He believes that deaths have been thus caused.
If the conditions cannot be changed, danger may be avoided by
the anesthetizer keeping a towel moistened with ammonia
hung under the flame. So little is required that the ammonia
will not be obnoxious. Care should also be taken never to dis-
pense chloroform in a wet bottle, [a.g.e.]
GYNECOLOGY AND OBSTETRICS
WiLMER Kbusen Frank C. Hammond
Saline Injections in Hyperemesis. — There has
been no more valuable addition to practical therapeutics
since the introduction of anesthesia and antiseptics than
normal saline solution. The surgeon, physician and
obstetrician appreciate alike the great value of saline
solution, either introduced by hypodermoclysis, venous
transfusion or large rectal injections ; and many lives
have been saved by its timely employment. For the
relief of the shock due to hemorrhage, either during
operation or postpartum, and for the dilution of toxic
material in the system, whether associated with sepsis
or eclampsia, salt solution is unexcelled, and transfusion,
in which the blood from another person is introduced
into the venous circulation, has been practically super-
seded by this more satisfactory and scientific method.
In fact, columns might be written upon the particular
value of this therapeutic agent to the obstetrician alone,
and it is interesting to note that Condamin, of Lyons,
has secured splendid results in the treatment of persist-
ent vomiting of pregnancy by the systematic injection,
1 British Medical .Journal, June 21, 1902.
2 Scottish Medical and Surgical Journal, February, 1902.
'Merck's Archives, June, 1902. .». •
preferentially by the rectum, of from three to four liters
of artificial serum or saline solution, daily, in divided
doses of 300 grams each. The injection is made .so
slowly as to occupy from 10 to 15 minutes, and is arrested
if it induces peristalsis, to be recommenced when the
movements have ceased. Should there be intolerance a
few drops of laudanum may be added, or if necessary the
serum may be introduced hypodermically. During the
first ten days or so that the treatment is continued the
patient takes neither liquids nor solids by the mouth,
and then while the injections are continued for several
days, oral nourishment is gradually increased from a few
mouthfuls to the ordinary quantity. This treatment is
based on the idea that the persistent vomiting of preg-
nancy is due to general intoxication, and it averted the
necessity of inducing abortion in any of the eight cases
in which Condamin adopted it.
The Operative Removal of Tubal Pregnancy per
Vaginam. — Strassmann' reviews the causes of extrauterine
pregnancy, among which he mentions injury to the tube
through catarrh, inflammatory adhesions, polyps and diseases
in the vicinity, as ovarian cysts and myomas. Many instances
of ectopic gestation take place soon after a normal delivery in a
healthy woman, while the tube through involution has lost
some of its peristaltic power. Abnormal length of the tubes
may be a cause. Perimetritis predisposes to ectopic gestation,
also gonorrheal affections. As to treatment he prefers opera-
tion per vaginam whenever possible, as less likely to cause
future sterility. Scanzoni gives a table from the Leipsic Hos-
pital, showing that after laparotomy 1~% conceived, and after
operation per vaginam without removal of the gestation sac
55f(j conceived. Strassmann would use the vaginal pro-
cedure in an intact, unruptured tubal gestation in the early
months, operating by expression or evacuation of the tube ; but
would hold it advisable to remove the tube in case of rupture
and severe hemorrhage. For this method the size of the tumor
to be removed should not be more than that of the third, or, at
most, the fourth month. Laparotomy may be justified if the
diagnosis is uncertain, or in case of peritoneal perforation, in
appendicitis, etc, or in case of life-threatening hemorrhage. But
it should be considered the exceptional procedure. The re-
moval of a tubal pregnancy at the end or middle of the term
can generally be avoided, and at an earlier period the vaginal
method is preferable, as more certain and leas dangerous. He
gives the history of nine cases thus treated with illustrations.
rw.K.]
Infusion Through the Xavel Vein. — The first respiration
and the changed condition of circulation in the newborn child
inaugurates a new pathway for tlie circulating blood. Schuck-
ing ^ reports the case of a child which after prolonged version
from a transverse position was delivered in a deep asphyxia.
The child was without muscular tone and the ordinary reme-
dies failed to have any effect in restoring heart or lung action.
Cutting through the navel cord he introduced into the navel
vein 30 grams of a salt solution with an apparent increase of
heart action. Upon a second infusion of 20 grams a weak spon-
taneous respiration was observed followed by more efforts at
breathing. This was reinforced by Silvester's method and the
child lived. He believes the infusion stimulates the nerve
centers in the medulla and thus promotes respiration, [w. k.]
Sodium Bicarbonate in Large Doses for the Vomiting
of Pregnancy. — Moniu (BuUetin Oin&ral de Thlrapeutique,
November 23, 1901) prescribes from two to three drams of
sodium bicarbonate daily for the vomiting of pregnancy. This
(luantity is placed in five or six cachets, one being taken in
the morning upon arising, in the middle of the forenoon and
afternoon, and before retiring at night. This causes the forma-
tion of carbonic acid in the nascent state, and permits all the
generated gas to be utilized. In cases in which unleavened
bread is badly borne, 30 grains of sodium bicarbonate dissolved
in half a glass of water may be substituted for a cachet. In 30
patients thus treated the digestive disturbances disappeared
rapidly. The hepatic manifestations so often present during
1 Berliner kllnlsche Wochenschrift, Nos. 21, 25 and 26, 1902.
2 Centralhlatt fiir Gynakologie, June 7, 1902.
July 'M, 1902]
THE WOELD'S LATEST LITERATURE
[AKEBICA.N MEDICINS 155
and after gestation are greatly relieved by the alkaline medica-
tion, even when these disorders do not depend upon the inflam-
matory state of the stomach but are due to a mechanical cause,
such as compression of the biliary ducts by the pregnant
uterus, [l.f.a.]
The Suspended Position for DifBcnIt Liabor.— Engel-
mann ( Therapeutic Monthly, April, 1902, Vol. ii, p. 136) says that
although primitive people have for centuries suspended women
in childbirth it was only in 1889 that Watcher described the
effect of position on the diameters of the pelvis, giving scientific
basis for the employment of this method in dystocia. When the
woman is raised or partly raised by means of suspension from
shoulders and armpits the weight of the lower extremities — to
whicli may be added, if desirable, that of an assistant— draws
downward the anterior pelvic ring, causing an enlargement of
the conjugate. Engelmann especially recommends the semi-
suspended position, in which the woman rests on her knees
holding to a rope above her head, as it allows of utmost mobility
and consequent changes in the respective diameters of the
parturient tract as the labor progresses. Several illustrations
show these various positions, especially as practised among the
aborigines, [n.c.w.]
Treatment of Sepsis.— Weruitz,' of Odessa, advocates the
abundant and metliodical introduction of fluid per rectum as an
effectual means of combating sepsis. By this means the urinary
and perspiratory secretions are greatly stimulated and the
poison which is circulating throughout the organism is rapidly
eliminated. This elimination is so abundant and rapid that in
some cases of severe sepsis in seven or eight hours tlie danger-
ous condition is overcome by this simple, safe and practicable
means. At the beginning of this treatment there should be a
thorough cleansing of the intestinal canal and the freeing of the
same from gases. The excessive distention of the abdomen
Interferes with heart action and can easily lead to a fatal result.
Hence the emptying of the intestinal canal may be essential to
save life. In closing he emphasizes the statement that the
introduction of copious amounts of fluid per rectum is gener-
ally a valuable remedy for acute septic infection. [w.K.]
Therapy of Melena in the Newborn.— Dollner^ thinks
that the extravasation of blood, either by the mouth or the anus
in the newborn, in the absence of any traumatic or septic origin,
is due to the abnormal permeability of the walls of the blood-
vessels, aud that it ceases as soon as these vessel walls have
Ijecome reestablished. He believes that this abnormal dis-
charge of blood may be quickly relieved by the administra-
tion of a solution of gelatin. A case is given in whicli a 2?e
solution was administered, 10 cc. of this solution being injected
into the folds of tissue near the inner rim of the scapula. This
dose every hour for three hours gave decided relief, and after a
fourth dose abou-t three hours later the bloody discharge ceased
entirely. His colleagues have had similar good results from
this therapy. [w.K.]
TREATMENT
Solomon Solis Cohen
H. C. Wood, Jr. L. F. Appleman
The Medicinal Treatment of Pulmonary Cavi-
ties.— Does iiealing ever take place in larj^e pulmonary
cavities in crises of tuberculo.sis? Unquestionably, yes.
Is it to be expected in a fair proportion of cases? Yes
and no. Under favorable hygienic conditions, healing
is more likely to occur than under the environment of
the ordinary dispensary patient. Yet healing has been
observed even in such cases, provided th(; patient was
still able to walk .several miles daily and could be
induced to obtain an wcupation keeping him in the oi)en
air. It may be of interest to mention the varied meas-
ures that have seemed t<j influence favorably the healing
of cavities— that is to say, under which dry cavernous
breathing has taken the place of li(|uid rales as an auscul-
tation phenomenon ; percussion tympany or hy[>erreso-
1 Centnilblatt fUr Gynaholosrle, .luno 7, llKXi.
' MUnchener mediclnlaclie Wocheimchrin, May W, 1902.
nance, or cracked pot remaining unchanged, or dimin-
Lshed but slightly.
Mrst is the overlauded and overabused Bergeon
enema of carbonic acid and hydrogen sulfld. There can
be no question of its efficacy when used persistently and
intelligently. It is troublesome, but its failure to revive
the dead, or to do more than is here claimed for it, fur-
nishes no good reason for abandoning it. Other methods
of administering sulfur and eirbon dioxid are not etjually
efficacious.
Second is the application of flying blisters over the
chest in the area of cavernous signs. The blisters
should not be much larger than one inch square ; only
one should be applie<l at a time ; and it is usually best to
allow healing to take place in one spot before the next is
blistered. Thus from one to three blisters will be
applied weekly, according to circumstances. Persistence
in this plan for many months, perhaps for a year, is
necessary to the accomplishment of results. Its method
of action may be theorized about but cannot be demon-
strated. Empirically it is of proved service.
Third is the administration of creosote and its com-
pounds and congeners ; of which creosote carbonate seems
to be the most effective, simply because it can be given
in very large doses without producing gastric irritation,
toxic symptoms or nephritis. Whatever creosote prepa-
ration is employetl it should be given up to the maxinmm
dose ttjlerated. About four drams daily of creosote car-
bonate can be given to some patients ; much less nmst
suffice with others. Beechwood creosote is much cheajx^r
than the carbonate, but can rarely be tolerated for long
periods in doses of more than 10 minims thrice daily,
and some patients cannot bear 5 minims. It is l>est
given in milk or in oil. Sometimes it can be given in
comparatively large doses by the rectum, suspended in
milk or oil ; but even if gastric irritation is thus avoided,
the urine may become discolored, the kidneys and
bladder irritatefl. This is less likely to happen with the
better grade of creosote, which term applies to the
preparations of two, possibly of three manufacturers.
The creosote dispensed by many druggists when the
name of one of these manufacturers is not specified, con-
tains irritating by-products. Here, too, it is a question
of expen.se. ■ Some lay managers of dispensaries pur-
cha.se drugs by contract from the lowest bidder. This is
considered good "business jKilicy" and the physician
who objects to it is stigmatized as a "crank" and a
"kicker." It saves dollars but it costs lives. Such a
policy is especially objectionable in the case of a drug
like creosote, which must bt; given in large doses and for
many months continuously to pnMluce gootl effects, and
of which even the best preparations are toieratetl with
difficulty.
Fourth is to l)e ranked the internal use of sodium
sulfur compounds — of which ichthyolate is most con-
venient in the maxinmm dose toleratetl. This measure
is a relatively inefficient substitute for the Bergeon
injections.
Any or all of the.s*; measures will often fail ; in a
gratifying minority of cases, even among the p(K)r, Intel-
ligent jK'rsistence in their use will api)arently bring to
an end the activity of the liiiuefaction processes that
have Ixsen su|)eradd(Hl to the lesions and toxemia due to
the JiaciUus (Memilosu.
Tho Toxic Power of Atoxyl.— Blumenthal reporta (Med.
Worh., I'.KU, Xo. 15, p. 163) the results of some experiments on
rabbits with anilin metarsonite, commonly known as atoxyl.
He flnds tliat is only one-fortlolb as poisonous as Fowler's
solution, but that in sufllelent quantity It produces the char-
actoristhr lesions of arsenic poison. The anilin In It seems to
play no part in the poisoning, [n.c.w.]
Aspirin.— Morkel {Milnchener med. Woeh., March 4, 1002)
has found a-splrln useful In articular rhoumatlHm.Rout, dry and
exudative plourisy and muscular rhcumallsm. It proved un-
satisfactory In sciatica and lumbago. The drug is best admin-
156 AMERICAK MBDICINB]
THE WORLD'S LATEST LITERATURE
(July 26, 19W
Istered in the afternoon In gram doses, at hourly intervals, for
four or five hours. During its administration alkaline waters
are to be avoided, so as to guard against premature decompo-
sition. Aspirin is also obtainable upon the market in tablet
form, each tablet containing .5 gram— 7.5 grains. [ixR.]
[The dose advised is too large— dangerously go. I have
seen cardiac collapse from smaller doses. Good results can l)e
gotten from doses of 5 grains thrice daily for an adult and 1
grain thrice daily for a child of four years, s.s.c]
Treatment of Tubercnlou8 Ijupns by Potassiam Per-
manganate.—L. Butte (Bulletin CfinSral de Thi'rapeutique,
Vol. cxlii. No. 20, 19()1, page 799) recommends that the diseased
area be washed with ichthyol soap, or with the following anti-
septic emulsion :
Corrosive sublimate 5 grains
Tincture of benzoin 11 ounces
Tincture of soap 14 ounces
Distilled water 6 ounces
A compress dipped in a hot 2% solution of potassium per-
manganate is then applied to the part for 12 or 15 minutes. This
should be repeated daily for 10 days. At the end of this time
the tubercles are covered with blackish crusts, and are less
elevated ; the other portions of the skin are smoother and softer,
and in the case of lupus exedens, cicatrization has begun. The
treatment should then be continued every other day for two or
three months. If new tubercles appear at any time, renewed
applications of potassium permanganate will cause them to
disappear. Of 16 cases thus treated, 15 were cured at the end
of two or three montlis ; the other case required a year.
[L.P.A.]
Fatty Tumors and Obesity. — Two references to organo-
therapy are found in a lecture by Jonathan Hutchinson ( Clinical
Journal, January, 1902 ; Medical Sevieiv, Vol. v. No. 1, 1902). A
young woman of 18 years, who suddenly ceased to menstruate
and fattened, was benefited by ovarian extract, after atrial of
many other remedies. The other reference concerns thyroid
extract and is to the effect that it may be tried cautiously in
obesity, although it Is likely to reduce the patient's strength
out of proportion to the benefit obtained. [r..m.g.]
Exercise as an Aid to Treatment of Paralysis.- Stadel-
man (Bulletin Oenh-al de Therapeutique, Novembef 23, 1901) re-
ports the case of a child aged 6 attacked with paralytic phenomena
with marked ataxic movements of the limits. Motoraphasia,
convergent strabismus, and inability to stand or walk were also
present. The child was treated by methodic passive exercises.
At the end of three months the ataxic movements had disap-
peared ; the patient was able to stand and walk, and the para-
lytic phenomena had decreased, [l.f.a.]
Mechanical Treatment of ■Whoopinjfcough. — Fretln
(Bulletin Ohiiralde Therapeutique,Yol. c:s.lu. No. 21, 1901, page
830) uses massage of the cervical region, acting on the pneumo-
gastric, laryngeal and the sympathetic nerves. He also prac-
tises shaking of the cervical region, the base of the tongue and
the trachea as recommended by Kelgreen. Vibratory massage
by means of Carlsohn's vibrator is also practised for five min-
utes, or less, over the whole cervical region. He completes the
treatment by a series of passive or active respiratory move-
ments, with or without resistance according to the case, some
movements of the neck, and finally by a series of manual
vibratory movements and percussion of the back. No phe-
nomena of intolerance followed this procedure, and no parox-
ysms of coughing occurred during its application, [l.f.a.]
FOB INVESTIGATION.
Brief reports of results of the use of drugs mentioned in this sec-
tion are Invited, for the Editor's Information and for publication. (See
editorial article in Issue of January 4, p. 42.)
Garlic Cure for Tuberculosis. — Ringwood (Medical
Press, June 18, 1902, 066) tells of the favorable results which
Minchin had from the use of garlic in consumption. This is
supposed to have a bactericidal effect on the bacillus tubercu-
losis. [H.C.W.]
Therapeutic Action of Brewer's Yeast.— Hallion and
Charbon (Montreal Midical, Vol. ii, No. 4, 1902) have obtained
the following results from experimental researches on the
therapeutic action of brewer's yeast : (a) Brewer's yeast exer-
cises the most energetic direct neutralizing action on the toxin
of diphtheria, (b) Fresh or dried yeast remains living and fer-
ments actively in the gastric juice, even when there is hyper-
acidity. From these facts the following conclusions are drawn:
(1) It is justifiable to paint the accessiVjle diphtheric false
membrane with brewer's yeast. 2. Living yeast acts in the
gastrointestinal tract in two ways : in its struggle for existence
it prevents the multiplication of pathogenic bacteria; by
destroying certain toxins as it destroys the diphtheria toxin.
3. It is doubtless in this way that brewer's yeast cures diarrhea
(Thiercelin, Chevrey). It also acts in the same manner on
furunculosis and acne which are very often caused, favored or
aggravated by pathologic digestive fermentation, and by auto-
intoxication which results from it. [l.f.a.]
FOBMUtiAS, ORIGINAL AND SELECTED.
Syrupus Colse Compositus. — Frieser ( The Therapist, April
15, 1902, Vol. xii, p. 68) writes on the value of Hell's compound
kola syrup in neurasthenia, cephalalgia, and other neurotic
conditions. Its formula is
Quinin-ferrocitrate 48 grains
Strychnin nitrate 14 grains
Fluid extract of kola 1 fluid ounce
Sodium glycerino-phosphate 1 ounce
Dissolve at a gentle warmth In syrup of orange peel, 8 fluid
ounces.
One teaspoonful 3 times a day after meals.
[Remembering that the active principal of kola is cafTeiu,
it is easy to understand the effect of this preparation. H.c.w.]
For Bubo. — Leuf (Med. Council, December, 1901) prescribes
Ichthyol 2 drams
Fl. ext. belladonna 2 drams
Tinet. aconite 2 drams
Fl. ext. witch-hazel 2 drams
Apply locally several times daily, [h.c.w.]
DERMATOLOGY
M. B. Hartzell.
The Skin in tlie Diagnosis of Internal Diseases.
— In a recent address, an abstract of which will be found
in another place, Galloway discusses some affections of
the skin associated with renal disease, diabetes, and cer-
tain circulatory disorders. While no new facts are pre-
sented, the address is deserving of notice because it
serves to call attention once more to a much neglected
subject, viz., the relationship existing between general
diseases and diseases of the skin, a subject of much im-
portance to the general practitioner as well as the
specialist, not only from a therapeutic point of view, but,
what is not so well recognized, from the point of view of
general diagnosis. It has always seemed to us some-
what remarkable that so little attention has been be-
stowed upon the skin in the diagnosis of diseases of
internal organs. Many visceral affections are so fre-
quently, at some time in their course, associated with
abnormal conditions of the skin that the latter may
often be of much service in the diagnosis of the former.
It not infrequently happens that a pruritus or eczema of
the vulva calls attention to a glycosuria which has
existed, it may be for a considerable period, without the
ordinary symptoms of thirst and polyuria, or that a
xanthoma reveal a hitherto unsuspected diabetes. In
that curious and unusual affection, acanthosis nigricans,
carcinoma of the gastrointestinal tract has been so often
observed that this cutaneous malady ought always sug-
gest the possibility of the existence of carcinoma. Hol-
lander some two years ago called attention to the
frequency with which vascular, pigmentary and verru-
cous changes occurred in the skin of those suffering from
intestinal carcinoma, laying considerable stress upon
these as diagnostic symptoms. Many other equally
convincing examples of the way in which the skin may
reflect visceral pathologic alterations might be readily
adduced : and it seems to us that a careful examination
Jvirr 26, 1902]
THE WOKLD'S LATEST LITEEATUEE
I'AXUUOAK HXDtCtKK 157
of the skin in obscure internal diseases should be just as
much a matter of course as auscultation of the heart and
lun^ or the ophthalmoscopic examination of the'eye-
ground.
Fiiisen's Light and X-ray Treatment in Lupus and
Rodent Ulcer.— Morris and Dore (British Medical Journal,
May 31, 1902), after two years' experience with Finseu's method,
find that, while the results obtained fully justify its employ-
ment, it is not to be used indiscriminately nor to the exclusion
of other methods. In the treatment of lupus vulgaris it stands
first, both as to cosmetic effects and reliability. As to perma-
nency of results, the authors reserve their opinion as to its
superiority over other forms of treatment, relapses having been
common in their experience. The chief disadvantages of the
Finsen method are its tediousness, the length of time required,
the elaborate and expensive apparatus needed, and the large
staff of attendants necessary. Although the x-rays have been
found useful as an adjunct to the light rays, they are not
regarded as an adequate substitute for them. In the majority
of cases the Finsen method has been found more reliable, and
apparently produces more permanent results. Its effects are
more easily controlled and better scars are produced. In ulcer-
ating cases the x-rays are effective, producing rapid healing. In
disease of the mucous membranes, in situations not accessible
to the light, they are very useful, and may be advantageously
combined with the Finsen treatment. The authors believe
that the therapeutic effect of both agents is much greater when
a reaction occurs. In rodent ulcer even very extensive ulcera-
tion may be healed by x-ray treatment, healthy scar-tissue
being produced ; but the rolled, indurated edge is not so easily
removed, it being .sometimes necessary to produce moderate
reaction before it disappears. In small, nonulcerating lesions
the Finsen method seems to give more rapid results than the
x-rays, but in large lesions the Finsen method is not appli-
cable. As to relapses, the same may be said as in lupus vul-
garis—they do occur, but are readily managed. It is impor-
tant that the applications be continued for some time after
apparent cure. In a short paper upon " The Therapeutic
Employment of X-rays," Lancashire {British Medical Journal,
May .j1, 1902) summarizes a year's experience with this agent.
He used a coil giving a 12-inch spark worked at 600 interrup-
tions a minute, with a fairly "soft" tube. In exaggerated
forms of hirsulies the author unhesitatingly recommends it,
although in the ordinary cases electrolysis is still the speediest
and best method of treatment. Sycosis vulgaris has done
remarkaV)Iy well after repeated exposures, but it is yet impos-
sible to express any definite opinion as to the permanency of
the effects. In lupus vulgaris it is the longstaudiugand severe
cases in which the x-ray treatment isespecially indicated. The
cases in which there are individual nodules or isolated patches
are best treated with the Finsen apparatus. In rodent ulcer
x-ray treatment deserves special recognition. While it Is
especially effective in the ulcerating cases, excellent results
may also be obtained in the nonulcerating ones.
Signs on the Skin of Certain Common Diseases.— Gal-
loway {British Medical Journal, May 3, 1902), in a recent
address, calls attention to the important subject of the relation-
hip between the functions of internal organs and those of the
ivin, and briefly refers to certain eruptions which occur as
sequels or complications of internal diseases. In nephritis,
although skin manifestations are less frequent than one would
expect, slight eruptions are apt to occur an the result of the
internal administration of diaphoretics or external applications
employed for the purpose of producing sweating. P'rythemat-
ous conditions of the skin, miliaria, sudamina and even ecze-
niatous dermatitis may be thus produced unless care is exer-
ci8e<l in drying the skin. The author finds that greasy applica-
tions are not well borne in such inflammations. A much
graver class of skin manifestations in nephritis presents features
resembling those of urticaria or erythema multiforme. These
eruptions are usually of l)ad prognostic signifi<«n(«, indicating
serious alteration in the blood and kidneys. As has long been
known, diabetes specially predisposes the skin to invasion by
pyogenic microorganisms, so that ijoils, carbuncles and gan-
grene of the skin are very prone to occur in those the subjects
of glycosuria. Selwrrheic dermatitis is of frequent occurrence
in the "gouty" form of glycosuria, and when neglected is apt
to produce very troublesome forms of eczematous inflammation
in the axilla, the groin or perineum. A very distressing form
of dermatitis associated with intense pruritus is frequently
seen about the genitalia of those suffering from diabetes, due in
the first place to the contact of the saccharine urine with the
skin and secondarily to fermentative changes. In the treat-
ment of this distressing affection warm baths simple or made
alkaline are especially recommended; and lotions containing
from 20% to 50% of glycerin with 0.5% to 1% of carbolic acid are
of great service. In all cases it is most important to regulate
the diet. Another series of lesions of the skin is met in those
who present, according to the author, "a fixed condition of
depression of the vasomotor impulses, so that the whole of the
capillary and venous area of the cutis is constantly flooded,
without any recognizable lesion of the heart." In such persons,
when the extremities are affected, there may be a superficial
resemblance to Raynaud's disease. They suffer severely from
chilblains and subsequent superficial ulceration. A reticulated
hyperemia of the legs is frequently present resulting in reddish-
brown pigmentation of the same areas. In such individuals
slight injuries of the skin are frequently followed by chronic
ulceration. Finally, attention is called to the resemblance
between these lesions of circulatory origin and certain socalled
"tuberculides." In the treatment of those .suffering from the
vascular condition above described the nutrition should l)e
carefully regulated and watched. Great care should be taken of
the skin. Frequent warm baths followed by careful drying,
and warm and properly-fitting clothing are to be advised. In
mild cases cardiac stimulants, such as digitalis, strophanthus, or
strychnia, produce gratifying results.
Arsenic Dermatoses.— Kille ( Wiener klinUche Wochen-
schi-ift, April 24, 1902) considers a few of the dermatoses result-
ing from the internal administration of arsenic in considerable
doses for a length of time, more particularly herpes zoster and
hyperkeratosis. The occurrence of pigmentation, the well-
known arsenical melanosis which sometimes follows the use of
arsenic when given for a long time, is briefly referred to. The
author thinks the occurrence of arsenical herpes zoster is some-
what difllcult to prove. It would seem remarkable that a gen-
eral intoxication should limit its manifestations to a limited
nerve district. Moreover, as is well known, second attacks of
zoster are rare, while in other drug eruptions recurrences take
place with each new administration of the medicament; but
such a recurrence in arsenic zoster has never yet been reported.
Much more important is arsenical hyperkeratosis, the occur-
rence of which the author was formerly inclined to doubt, but
which ho is now convinced may take place. In view of its
infrequent occurrence in lichen ruber and psoriasis, the author
thinks this form of keratosis is much less likely to occur in
the scaly diseases than in the other affections treated by arsenic,
such as epilepsy, divers dyscrasias, pemphigus, etc.
The Ilolationship of Tuberculosis of the Skin to the
Internal Organs. — Petersen (Berliner klinisehe Wochewirhrift,
April 21, 1902) examined the skin in 53 cases of advanced tuber-
culosis of the lungs and found two cases of lichen scrofulo-
sorum, one of scrofuloderma (gummata tuberculosa ulcerata
cutis), one of acute cachecticorum ; in two there were scars of
old suppurating cervical glands, and 6% of the cuses showe<l
metastatic tuberculous skin affections. The author thinks too
little attention has been paid to the relationship of tuberculous
skin aflectioiis to the internal organs. Kvory local tulieroulous
aff(H;tion, whether of the skin, lK>nes, joints, or mucous mem-
branes, may, under certain circumstances, give rise to general
tuberculosis, as is shown in the general tuberculous infection
occurring i» some instances after cureting lupus vulgaris. Sys-
tematic observations are still wanting as to the frequency with
which general tuberculosis follows a l<M-al tuberculous focus,
and under what conditions this may occur.
Fal-Socretlng Glands in the Bnco»l Mucous Mem-
brane of Man.— (kilomblnl ( Mnnntxhfjte far prnktinche l>er-
matologie. Band xxxiv. No. 9. 1002) describes |>ecullar yellow
elevations the size of a millet-sued, usually arrange<l In smsll
groups, which be has observed In the mouths of many indi-
158 Amrbican Medicine]
THE WORLD'S LATEST LITERATURE
[July 26, 1902
vldnals. These bodies, which are identical with those pre.
viously described by Fordyce, and later by D. W. Montgomery,
are situated upon the mucous membrane of the lips and cheeks,
more particularly the latter, and are to be found in a large pro-
portion of individuals. They were observed in 1,073 out of
4,500 persons examined by the author, being most common
between the ages of 25 and 50. They were apparently inde-
pendent of any local or general pathologic condition. Histologic
examination showed that these bodies are glandular organs
situated superficially in the stratum Malpighl or between this
layer and the submucous connective tissue. They appear as
branched, alveolar glands, the acini of which open into a
common excretory duct which, after penetrating the Mal-
pighian layer, opens upon the free surface of the mucous mem-
brane. In the interior of many of the cells of these glands fat
droplets are present. The author is of the opinion that these
are a special form of fat secreting gland and not altered mucous
glands.
Herpes Zoster.— Debove ( The Medical Press and Circular,
April 19, 1902), in a recent clinical lecture, discusses the nature
of herpes zoster. He does not believe that it can be maintained,
either from a clinical or anatomic point of view, that it is only
a special form of neuralgia, anatomic researches showing that a
peripheral neuritis is not present in every case. The character
of the pain is not like that of neuralgia nor is it confined to the
course of the nerves. The author believes that the theory that
it is due to functional disturbance of the spinal cord is the only
one which accounts for the phenomena of the disease, more
especially as concerns the distribution of the eruption. He does
not think the evidence in favor of the theory of its infectious
nature is sufficient to establish it. He regards it as a syndrome
which may be met with under various conditions, such as trau-
matism, infective diseases, poisoning from various metals, etc.
As to the treatment, the indications are to relieve pain, either
giving opium by the mouth or using morphia hypodermically,
and to protect the eruption from secondary infection by the
application of antiseptic and absorbent powders.
Oil of Cade in the Treatment of Seborrhea.— Sabouraud
(Journal des Praticiens, Vol. xv. No. 49, 1901, page 776) recom-
mends oil of cade in the treatment of true, nondesquamative seb-
orrhea of the scalp or hairy skin. It may be incorporated with
ordinary vaselin in the proportion of one dram to the ounce,
but with yellow vaselin and lanolin the proportion may be
increased, e. g..
Oil of cade 2J drams
Yellow vaselin 1 ounce
or,
Oil of cade 1 ,
Lanolin J equal parts
Oil of cade may be combined with cacao butter as follows :
Oil of cade "I
Cacao butter \ equal parts
Vaselin J
Salicylic acid, pyrogallic acid, resorcin, the mercurial salts
and the spirits may be combined with the latter preparation if
required. One dessertspoonful of the following emulsion, when
added to a quart of water, is useful as a lotion in slight degrees
of seborrhea accompanied with pityriasis :
Oil of cade 3J ounces
Decoction of quillaja 1 ounce
Yolk of egg 1
Distilled water enough to make 8 ounces
[L.P.A.]
Faradization in Cases of Pruriginous Dermatoses.—
Bouveyron (Lyons) (La Semaine MMicale, June 18, 19m) has
demonstrated that faradization is susceptible of exercising a
quieting action on pruritus, analogous to that which is obtained
with static electricity, while it presents the advantage that a
costly and complicated installation is unnecessary. The simple
induction apparatus commonly used in medical practice is suffi-
cient. Bouveyron has used the faradic current in a variety of
pruriginous dermatoses, eczema, lichen, sudorous miliaria,
pityriasis rosea, and morphea, with almost identical results.
The treatment failed, however, in two cases of senile prurigo.
In suppressing pruritus, faradization favors cure without exer-
cising any noxious action. The positive pole seems to produce
sedative effects somewhat more marked than those produced
by the negative pole, [c.s.d.]
Treatment of Dry Seborrhea. — R. Leftwich (Bulletin
Qiniral dc Thirapeulique, Vol. cxlii. No. 21, 1901, page aSl)
employs benziu with a few drops of spirit of geranium to
loosen the crusts in sebaceous acne of the hairy scalp. This is
applied by means of the shaving-brush once every five days.
In the interval, the patient applies an irritating ointment every
morning, which at the' same time lubricates the hair. Benzin,
unlike the alkaline lotions usually employed in these cases,
possesses the advantage of leaving the hair intact. It may be
combined with an equal quantity of rectified alcohol in cases of
moderate intensity, [l.f.a.]
Carcinoma of the Scalp. — Robertson (Medical Bulletin
of Washington University,\o\. i, No. 1, 1902, p. 14) describes the
growth, which was situated on the top of the head, as about the
size of a man's fist 'and the shape of a truncated bone ; the top
was ulcerated and covered with a purulent discharge, while a
similar material exuded from a number of sinuses in the
tumor. A piece of the tumor was excised and under the micro-
scope proved to be glandular carcinoma. The patient was a
negress of 50 years ; she first noticed a lump on her head three
years previously and attributed it to her habit of carrying
things on her head. The general health was not impaired. The
tumor was excised down to the bone; after three weeks there
was a recurrence at the posterior border of the granulating
surface, which was again removed, and at the time of writing
there appeared to be a healthy granulating surface, [k.m.o.]
Treatment of Tinea by Pormol. — Demidoff (Bulletin
Oiniral de Thirapeutique, Vol. cxlii. No. 20, 1901, page 798) ob-
tained excellent results in tinea by the use of formol, as follows :
As many crusts as possible are removed by forceps, after which
the diseased area is painted with solutions of formol, varying in
strength from 5% to 10%. A gauze dressing is then applied in
order to prevent evaporation and to render the action of the
drug more efficacious. This treatment causes reddening and a
burning sensation of the skin. One patient who had suffered
from tinea for years and who had become nearly bald, was com-
pletely cured by these applications, the crusts and redness dis-
appeared and the skin became normal. When seen three
months later he had no return of the disease, [l.f.a.]
Chalodermia is the name given to a peculiar alteration of
the skin by Ladislaus Kelly (Archiv fiir Dermatologie und
Syphilis, 1901, Bd. 56, Heft 1), of Budapest. It consists of a
change in the deeper layers of the skin by which it becomes
loose and hangs in heavy wrinkles and folds, [c.s.d.]
Treatment of Pruritus with Licheniflcation. — Leredde
(Bulletin General de Theritpeutiquc, Vol. cxlii. No. 21, 1901, page
808) reports three cases of pruritus with lioheniflcation which
were cured by applying to the diseased area ointments or pastes
containing a large dose of a chemic agent having an energetic
action on the skin. These ointments contained such substances
as resorcin, salicylic acid, naphtol or soft potash soap, and were
left in contact with the effected part for a length of time vary-
ing from a few minutes to several hours. A violent inflamma-
tion of the skin was thus produced which persisted for a few
days ending in an intense desquamation or exfoliation of the
skin, with elimination of glandular products and cutaneous
secretions. Leredde states that: 1. By means of exfoliation
it is possible to cure simple circumscribed lichen ; to cause the
disappearance of tlie pruritus and infiltration of the skin. In
cases in which pruritus and infiltration were marked, and had
resisted all the usual treatments, high frequency electric cur-
rents were also used. 2. It is possible that in certain patients
the latter gives results which exfoliation cannot give. But as
there is at present no objective sign by which the cases wliich
can be relieved by electricity, and those which can be relieved
by exfoliation, may be differentiated, it seems best at first to try
the method easiest for the patient and the one of which the
effect may be judged most rapidly. The two methods may be
readily combined when the pruritus persists after repeated
applications, [l.p.a.]
Treatment of Lupus with Radium. — Danlos presented
to the Socifite de Dermatologie et Syphilographie, at a meeting
JULT 26, 1902]
THE PUBLIC SERVICE
rAKBBICAN MkOIOINK 159
held July 3 {La Semaine Medicate, July 9, 1902), a number of
patients afifected with very extensive tuberculous lupus, parti-
ally treated with the aid of radium. Most of the applications
had been made with placques having a radiant activity of 19,000
according to Curie's method. The duration of applications
varied from 24 to 36 hours. The ulcerations following the
employment of this therapy were in all cases superficial, and
healed within a period varying from one to three months. The
appearance of the cicatrices was very favorable as compared
with the reticulated appearance following other procedures.
The cures obtained by means of radium appear to be complete
and much more rapid than those given by phototherapy.
In the discussion which followed, Brocq remarked that the
results obtained by Danlos are remarkable, and that he knew
of no other therapeutic method applicable to lupus which will
leave such a perfect appearance of the skin. Hallopeau pre-
sented a man affected with verrucous lupus of the hand which
he had treated with radium. There appears to be, however, a
continuance of sclerotic alterations under the influence of this
therapy, and it is possible that the radium rays have a marked
sclerogenic action. fc.s.D.]
Notes on the Treatment of Syphilis.— Hardaway (Medi-
cal Bulletin of Washington University, Vol. i. No. 1, 1902, page 4)
dwells on the importance of individualization in the treatment
of syphilis, especially of tertiary lesions. The specific remedy
often fails of its elfects because the patient's vitality is reduced ;
mercury and potassium iodid must be suspended from time to
time and the system be given an opportunity to become
renovated. In many cases the simultaneous administration of
tonics and stomachics with the antisyphilitic drug works well.
Hardaway suggests the following formula which he has modi-
fied from one devised by the elder Bulkley :
Potassium iodid i ounce
Citrate of iron and ammonium 1 dram
Tincture nux vomica ' . . . 2 drams
Aqua IJ ounces
Composite tincture of cinchona to make . . 4 ounces
A teaspoonful in one-fourth of a glass of water after meals.
This mixture is not pleasant to take, but its therapeutic
virtues more than counterbalance its pharmaceutic shortcom-
ings. Before breakfast and at bedtime a pill containing i to i
grain of protiodid of mercury and J grain of opium is ordered.
[R.M.O.]
Treat ment of Nasal Acne and Permanent Destmc-
tion of the Hair Follicles. — Bloebaum (Bulletin Ofnfral de
Thfrapeatiquc, Vol. cxlii, No. 18, 1901, page 719) employs electro-
puncture in the treatment of nasal acne. In severe ca.ses more
energetic cauterization is resorted to, but areas of healthy skin
are always left from which growth may take place over the
cauterized points. He adopts the following method for the
destruction of the hair follicles: A needle, 3J mm. long, is
heated to redness and introduced into the follicle to the depth
of 3 mm., withdrawing it in order to reheat it, then again intro-
ducing it into the opening without touching the edges a second
and a third time. By this means the depth of the follicle may
be reached; with a single cauterization this resnlt is rarely
attainetl, for the needle cools rapidly in traversing the tissues
and leaves the deeper parts intact. The first cauterization is
but slightly painful. [i,.f.a.]
Kruptions Associated with Malarial Infection. — Eng-
man (Medical Bulletin of Washington University, Vol. i. No. 1,
1002) confirmed the diagnosis in each of 18 cases by demonstra-
ting the plasmodiums in the blood in two cases the estivo-
autumnal parasite, and in the remainder the quartan or tertian
variety. The fact that an acute eruption yields to quinin is not
sufllcient evidence of the malarial origin of the eruption.
The literature bearing on the relationship between malaria and
certain skin affections is briefly reviewed. Kngman presents
the following conclusions: It Is highly probable that certain
ntl'ections of the skin, ranging from pruritus to gangrene, may
'1 ilue to malarial poisoning. In such cases there is generally
ii periodicity in the intensity of the eruption symptoms. There
may be marked or slight constitutional disturbances, or the
eruption may occur without any other symptom of paludlsm.
Ill severe ca-ses nephritis may complicate tlio picture and
appear to be the cause of the eruption, whereas the malarial
infection is the sole etiologic flustor. When an eruption is
associated with malarial infection, It quickly disappears under
the specific treatment, [r.m.o.]
Treatment of Praritus by High Frequency Currents. —
Leredde (Bulletin G&nSral de Thfrapeutique, October Zi, 1901)
reports four cases of pruritus of the vulva and anus in which he
obtained excellent results by the use of high frequency electric
currents. Obstinate cases were completely cured by this treat-
ment after from 7 to 12 applications. The best results were
obtained in patients having limited pruritis with no, or very
slight, thickening of the skin. Patients presenting old thicken-
ing and reddening of the skin derived little benefit, [l.f.a.]
THE PUBLIC SERVICE
Health Reports.— The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, during
the week ended July !», 1902 :
SMALLPOX— UitrrED States.
California :
Florida :
Illinois :
Indiana:
Kansas :
Kentucky :
Massachusetts :
Michigan :
Missouri :
Montana ;
Nebraska:
New Hampshire:
New Jersey :
New York :
Ohio:
PennBylvanla:
Rhode Island :
Tennessee:
Utah :
Virginia;
Washington :
Wisconsin :
Argentina:
Austria:
Colombia:
Kgypt :
Great Britain :
India :
Italy :
Mexico:
Bumtla :
Colombia:
Cuba:
Mexico:
India :
Kussia :
Philippine Islands:
San Francisco June 29-July 6.
Live Oak „ July 11 1
Palmetto July 11 1
Belleville Junc5-12 1
Chicago „..July 5-12 5
Freep<irt July &-I2 1
Indianapolis June 29-July 5.... 11
Wichita. July 6-12 1
Covington July 5-12 6
Lexington July 5-12 1
Boston July 5-12 7
Cambridge July 5-12 IS
Everett _.June28-July 12.. 6
Lowell July 5-12...- 7
Melrose July 5-12 1
Newton July 5-12 1
Somervllle July 5-12 3
Detroit July 5-12 3
St. Louis July 6-12 18
Butte June6-July 1»„ 6
Omaha July 5-12 8
Nashua July 5-12 1
Hudson County,
Jersey City lncl....July 6-18 1»
Newark. July 5-i2 10
New York July .5-12 28
Cincinnati July 4-11 6
Cleveland July 5-12 88
Hamilton July ,5-12 1
Toledo June 2»-July 12... 8
Zanesvllle June 1-80. „ 1
AUentown July 5-U 1
Erie July 5-12 3
Pblladelphlik. July 5-12 „ 18
Pittsburg July 5-12. 82
Scranton June2S-July6.... 1
Providence July 5-12 1
Memphis July 5-12. I
Ogden June 10 »
Halt Ij<ke City July 5-12 8
Danville July 7-14 8
Tacoma. June30-July 6..... 1
Green Hay June 6-13 1
Milwaukee July 5-12 8
SXALLPOZ— FOBKIOH.
Montevideo. Jane 4-11 49
Prague June 21-28. 2
Cartegena June 28-29 _
Panama. J une 30-July 7.... 8
Cairo June 10-17 _
Birmingham .Junc28-July 6.... 2
Liverpool Junc3(>-July 5.... 8
London Juiie21-lis 128
Sunderland -...June 21-* - 1
Bombay June 10-17
Calcutta June 7-14
Karachi Juno 1-14 — 2
Naples June 21-28 6
City of Mexico. Juno 29-July «.... 1
MoHCOW- June 14-21 IS
Odema. June 21-28. »
Warsaw _ Juno 14-21
Ybllow Fbvkr.
Panama June SO-July 7.... 6
nibara July IB
Vera Cru« June 2»>luly 5.„. »
Plaooc
Bombay June 10-17
Calcutta...^ Jnne7-14~.
Odema ._ .„July 10
Cases Death*
5
17
W
3
H
1
3
U
65
..PrMMDt.
CHOLIkA— INSULAR.
Manila....
Prtjvtiic-"
.May l<>-24 2W \m
May 10-34 » 804 648
160 AUEBICAM MbDICINB.
THE PUBLIC SERVICE
[July 28, 1902
Cholbba.
' China: Kwellan July 12 10,000 deaths,
PInglo July 12 3,000deuths
Hhanghal June 1-30 20
Tangku tune7 Epidemic.
India: Bombay June 10-17 2
Caleutta June 7-14 82
Changes in the Medical Corps of the U. 8. Army for
the week ended July 19, 1902:
Majors Pkter K. Eqan, surgeon ; Joseph N. Henry, surgeon, and
Contract Surgeons Edward B. Bailey, Eoekton T. Wilson and
William E Hai.l will proceed to Cebu, Cebu, reporting to the
commanding general, department of South Philippines, for assign-
ment to duty.
Bbechemin, Major Louis, surgeon, Is relieved from duty at hospital
No. 3, Manila, to take effect June 1. and will report to the com-
manding general, donartment of North Philippines, for duty as
chief surgeon of that department; Major .lohn M. Banister, sur-
geon. Is relieved from <luty in thedepartment of North Philippines,
and will report to the chief surgeon of the division, for duty at hos-
pital No. 8.
Marrow, First Lieutenant Charles E., assistant surgeon, Is granted
leave for ;S0 days, with the privilege of applying for an extension
of 30 days.
The following-named assistant surgeons, recently appointed, will pro-
c?ed to the points designated for duty: Fli-st Lieutenant Nel-
son Gapen, to Fort Myer ; First Lieutenant Will Leroy Pyles,
to Piattsburg Barracks; First Lieutenant William Mitchell
8raart, to Fort Monroe.
Wood, Major Marshall W., surgeon, Is directed to report to Briga-
dier General William A. Kobbe, president of the Armv retiring
board at St. Paul, Minn., for examination by the board. Upon the
completion of his examination Major Wood will return to his
proper station.
McHenry, Captain Geokse A., assistant surgeon, leavegranted April
21 Is extended 10 days.
Roberts, Fir.st Lieutenant William, assistant surgeon, now under
treatment at the U. 8. general hospital, Washington Barracks, is
relieved from further duty in the division of the Philippines, and
will proceed to Fort Brady for duty.
Grissinqer, First Lieutenant Jay W., assistant .surgeon, recently
appointed, will proceed from York, Pa., to Fort Totten, for duty.
Baker, First Lieutenant Frank C, assLstant surgeon, having re-
ported his arrival at San Francisco, Cal., in compliance with orders
will report to the commanding general, department of California,
for assignment to duty.
McLeod, Angus, hospital steward. Army general hospital, Presidio,
will be sent to Fort Baker to relieve Hospital Steward Arthur
Eutroppe Steward Eutroppe will be sent to Manila, P. I., for
assignment to duty.
Collins, First Lieutenant Christopher C, assistant surgeon, leave
granted June 11 Is extended one month.
Connor, First Lieutenant Clarence H., assistant surgeon, recently
appointed, has been assigned to duty at the United States general
hospital, Washington Barracks.
Lambert, First Lleuienant Samuel E., assistant surgeon, recently
appointed, now at Mobile, Ala., will report at Fort Morgan for
duty.
The following-named enlisted men of the hospital corps, now at San
Fiancisco, Cal., will be sent to the stations designated: Hospital
Steward Patrick Haughey, to Rock Island Arsenal; Hospital
Steward Paul L. Whltraarsh to Fort Meade ; Hospital Steward
Joseph C. Kamp, to Fort Riley.
The following-named hospital stewards, now at the stations designated
when relieved by other stewards will be sent to Manila, P. I. : Isaac
C. Clarke, Rock Island Arsenal ; August Nickel, Fort Riley.
Griffith, George, hospital steward, now en route to Fort Slocum
with the Sixteenth infantry, will upon arrival at that post be sent
to WatervUet Arsenal to relieve Hospital Steward James M. Trute.
Hospital Steward Trute will be sent to Manila, P. I.
Block, Captain William H., assistant surgeon, is relieved from fur-
ther duty at Fort McHenry and will proceed to .San Francisco,
Cal., and report for transportation to the Philippine Islands, where
he will report for assignment to duty.
Snoddv, First I,ieuteuant Gary A., assistant surgeon, recently
appointed, has been assigned to duty at Fort Thomas.
Moncrief, First Lieutenant William H., assistant surgeon, recently
appointed, has been assigned to duty at Jefferson Barracks.
Moore, First Lieutenant Charles F., assistant surgeon, recently ap-
pointed, has been assigned to duty at Fort Ethan Alien.
Kirby-Smith, First Lieutenant Reynold M., assistant surgeon re-
cently appointed, will proceed from Sewanee, Tenn., to Fort Mc-
Pherson for duty.
Brown, Harry T., hospital steward, now at Washington, D. C, will
report on or liefore the expiration of furlough granted him in the
division of the Philippines at Fort Myer for temporary duty.
Changes in the Medical Corps of the U. 8. Navy for
the week ended July 19, 1902 :
Gatewood, J. p., surgeon, detached from duty as assistant to the chief
of Bureau of Medicine and Surgery, and ordered to the Lancaster—
COOK F. c passed assistant surgeon, detached from the Nav.il hos-
pital, Washington, D. C, July 19, and ordered to the Supply— July
Thompson, E., passed asslslantsurgeon, detached from the Naval labo-
ratory and ordered to the Montgomery— J uly 12.
MUNSON, F. M., assistant surgeon, detached from tlie Naval hospital.
July 12 ''" "" '"''i^red to duty with the torpedo boat flotllla-
Urie, Surgeon J. F., detached from the Naval dispensary, Washing-
ton, D. C.. July 17, and ordered to the Bureau of Medicine and Sur-
gery, Navy Department, for duty as assistant to the chief of bureau
—July 11.
Dr. Creel, R H., appointed assistant surgeon from July 1, 1902—
July 12
Curl, H. C , passed asslslantsurgeon. detached from the Naval hos-
pital. Mare Island, Cal , and ordered to Aspen, Col., for recruiting
duty— July 14.
Bell, W. L., a.ssistant surgeon, detached from recruiting duty July 25,
and ordered to the Naval hospital. Mare Island— July 14.
HoYT, R. E., asslslantsurgeon, detached from the Wabash and ordered
to the Naval hospital, Newport, R. I., for duty —J uly 15.
Changes In the Medical Corps of the U. 8. Public
Health and Marine-Hospital Service for the week ended
July 17,1902:
Sawtellb, H. W., surgeon, relieved from duty at Chicago, 111., and
directed to proceed to the purveying depot, New Vork, assuming
command and relieving Surgeon C. E. Banks— July 16, 1902.
Austin, H. W., surgeon, upon being relieved by Surgeon Fairfax
Irwin, to proceed to Detroit, Mich., and assume command of the
service, relieving Passed Assistant Surgeon E. K. Sprague — July
10, 1902.
IBWIN, Fairfax, surgeon, upon being relieved by Surgeon R. -M.
Woodward, directed txi proceed to Philadelphia, Pa., assuming com-
mand of the service and relieving Surgeon H. W. Austin— July 16,
1902,
Carter, H. R., surgeon, granted leave of absence for one month and
fifteen days from July 14— July 12, 1902.
BANK.S, C. E., surgeon, upon being relieved by Surgeon H. W. Saw-
telle, to proceed to Chicago, III., and assume command of the
service— July 16, 1902.
Pettus, W. J., surgeon, upon being relieved by Passed Assistant Sur-
geon J.B.Greene, directed to proceed to Washington, D. C, and
report at the Bureau for duty in the Division of Insularand Foreign
Quarantine— July 17, 1902.
Woodward, R. M., assistant surgeon-general, relieved from duty in
the Bureau, Washington, D. C.,and directed to proceed to Boston,
Mass., and assume command of the service, relieving Surgeon
Fairfax Irwin— July 16, 1902.
Wertenbaker, C. p., passed assistant surgeon, two days' leave under
paragraph 179 of the regulations
Rosenau, M. J., passed assistant surgeon, detailed as a delegate at
meeting of the International Sanitary Conference to be held in
Washington, D. C, October 15, 1902.
Nydegger, J. A., passed assistant surgeon, granted one day's exten-
sion of leave of absence, July 10— July i5, 1902.
Sprague, E. K., passed assistant surgeon, upon beingrelieved by Sur-
geon H. W. Austin, to proceed to Fort Stanton, N. M., and report
to medical officer in command for duty and assignment to quarters
—July 10, 1902:
WickES, H. W., passed assistant surgeon, granted leave of absence for
one month from August 11 — July 17, 1902.
Greene, J. B., passed assistant surgeon, to proceed to Cleveland, Ohio,
and assume temporary command of the service, relieving Surgeon
W. J. Pettus— July Iti, 1902.
Russell, H. C, assistant surgeon, relieved from duty at Boston, Mass.,
and directed to proceed to .stapleton, N. Y., and report to medical
officer In command for duty and assignment to quarters- July 14,
1902.
Heiser, V. G , assistant surgeon, upon being relieved by Assistant
Surgeon W. C. Billings, to proceed to Manila, P. I., and report to
the chief quarantine otllcer for duty — July 17.
Billings, W. C, assistant surgeon, relieved from duty at the immi-
gration depot, New York, and directed to proceed to Quebec,
Canada, relieving Assistant Surgeon V. G. Heiser and reporting to
the Commissioner of Immigration for duty under his direction —
July 17, 19u2.
Francis, Edward, assistant surgeon, to proceed to Point Pleasant,
N. J., for the physical examination of crews of the Life Saving
Service— July 17, 1902.
Warren, B. S., assistant surgeon, to proceed to Atlantic City, N. J.,
for the physical e.xamination of crews of the Life Saving Service —
July 17, 1902.
Hicks, W. R., acting assistant surgeon, granted leave of absence for
Ave days trom July 14, 1902- July 12, 1902.
Stevenson, J. W., acting assistant surgeon, granted leave of absence
for twenty-one days from July 18— July 12, 1902.
Maguire, E. S., senior pharmacist, granted leave of absence for thirty
days from June 7— July 10, 1902.
Richardson, S. W., senior pharmacist, relieved from temporary duty
at Washington, D. C, and directed to rejoin his station at St. Louis,
'relieving Junior Pharmacist C. W. Stephenson — luly 17, 1902.
Rogers, Edward, senior pharmacist, granted leave of absence for
twenty-eight days from July 12— July 10, 1902.
Southard, F. A., senior pharmacist, granted fifteen days' extension
of leave of absence from July 22— July 10, 1902.
Stephenson, C. W., Junior pharmacist, upon being relieved from
duty by Senior Pharmacist S. W. Richardson, to proceed to Louis-
ville, Ky., and report to medical officer In command for duty and
assignment to quarters— July 17, 1902.
Board Convened,
Board convened to meet at Baltimore. Md., July 17, 1902, for the phys-
ical examination of an officer of the Revenue Cutter .Ser^'ice.
Detail for the Board —Assistant Surgeon-General L. L. Williams,
chairman ; Passed Assistant Surgeon J. A. Nydegger, recorder.
Hesigiiation.
Junior Pharmacist W. C. Phillips resigned, to take effect July 26, 1902.
American Medicine
GEORGE M. GOULD, Editor
Q. C. C. HOWARD, Managing Editor
CHARLES 8. DOLLEY
MARTIN B. TINKER, AuittarU Editort
Clinical Medicine
David Ribsman
A- O. J. Kelly
H. H. CusHiso
Helen Murphy
General Surgery
Martiit B. Tinker
A. B. Craig
Charles A. Orr
Orthopedic Surgery
H. Augustus Wilsok
COLLABORATORS
Obstetric* and Gynecology
WiLMER Kruse:?
Frank C. Hammond
Nervous and Mental Diseases
J. K. Mitchell
F. SavaryPearce
Treatment
Solomon Solis Corsv
H. C. Wood, Jr.
L. F. Appleman
Der-maiology
M. B. Hartzell
Laryngology, Ete.
D. Bkadkn Kyle
Ophthalmology
Walter L. Pyle
Pathology
R. M. Peabck
PUBLMHID Weekly at 1S2I WaLWCT StBSBT, PbILADELPHIA. BT tub AMBBICAK-MBDICIXB PCBLtBRtM COMPABT
Vol. IV, No. 5.
AUGUST 2, 1902.
$4.00 Yearly.
The History of Diseases. — It Ls strange that, so long
and so diligently as the science of medicine has been
studied, it has occurred to few or none to envisage dis-
ease historicly. The history of medical men, of medical
discoveries, and even of medicine has been widely
investigated, but the more promising one of tlie history
of individual diseases has hardly been thought of. And
yet we know from all the other sciences that one under-
stands nothing thoroughly except when its origins and
history have been fully sought out and elucidated. If,
as none doubts, the mosquito intermediates the trans-
mission of yellow fever and malaria, then the history of
these disea.ses, when, where, and how occurring, would
surely have pointed toward, would at least have aroused
a suggestion of their pathogenesis. The profession is
under a debt of gratitude to Dr. Bloch for one instance
of this historic method, his fine tracing of the history of
the origin and transmission of sj'philis. It yet remains,
if it is not impossible, to follow up the historic clues and
hints as to the disease among the American Indians.
Even mythology, folk-lore, etc., should be thoroughly
ransacked, as already many pregnant suggestions have
come to us from such sources. The connection of special
diseases with certain food-supplies, with national and
racial characteristics, with association with animals,
with meteorologic conditions, ete., may yield unexpected
light. When headaches became common, and among
what classes of people, ete., would doubtless tell much as
to the conne(!tion of eye-strain and civilization. Why
with infinitely better food-supplies and cookery we
have nowadays so much dyspepsia is a pertinent ques-
tion. Medicine is applied biology, and there will be no
complete i)athology of many diseases except when their
biologic history and the interdependence of all animals
and man is followed up.
Tlie " Lacli of Moral Courage " of Pli.ysicians. —
According to the newspa{)er reports a prominent phy-
srt'ian of New York recently made the following public
•tatement:
"Thou«andn, tens ot thousands, of people die because their
physicians have not the moral couraRe to say to thoin : ' This Is
tiil)erculosis, and now is the time to talte precautions.' "
This charge presui)poses that in every case the truth
niU8tl)etold. We firmly believe in using all the frankness
with patients that is wise, but as we ail know it is not
always right to be absolutely frank. In the patient's
own interest such candor would often prevent the very
cure to secure which the physician is called in. This
fact nullifies a large part of the truth and applicability of
this grave indictment of the profession. Another would
be the conviction we all share of the curability of
pulmonary tuberculosis, and the consequent detennina-
tion on the part of the family physician to treat the
patient and if possible cure him without giving un-
necessary alarm. This methotl is also often justified by
the results, and by the fact, now admitted, that in
its incipient stages the disease is not contagioas but only
communicable. That some physicians are careleas about
proper warning there can be no doubt, but the greatly
lessened mortality from pulmonary tuberculosis, shown
by statistics, demonstrates that medical men are not so
guilty as the criticism quoted implies.
Musolino vs. Lombro.so. — Musolino was an Italian
bandit, who long defied the civil and military authori-
ties, and by means of a criminal condition of society
(there are annually about 4,000 homicides in Italy)
became somewhat of a Robin Hood in the esteem of the
people. When finally captured and placed on trial his
defenders were, greatly aided by pleas in his behalf by
the adherents of the Loiiibroso school, that the man was
a "moral idiot," a "born criminal," an "epileptoid," a
" tuberculotic imbecile," etc., and si-arcely almve the
mental and moral condition of an "anthroj)oid ajK'."
But this "science," or "psychiatry," was more than
Musolino could endure even to save his life, and he
"denied the allegation and defied the allegator" with
successful indignation. He was accordingly contlemncd
to penal servitude for life, nmch to the credit of society,
and not less to that of law and of psychiatry.
The Next Surgeon- General. — It is reiK)rt«l that
Col. Uoliert M. O'lteilly, one of the oldest and lK>st known
ofttirrsof the medical department of the Army, haslioen
designated by the President to succe<Hl Surgeon-tJeneral
Forwood ujwn the retirement of the latt«'r in Sep-
tenilKT. Owing to the fact that the appointment of Col.
O'Keilly involves hiswlvancement over five seniors, he
having only rtn-ently received the rank of colonel, it is sug-
gested that there may be some opposition to his confirma-
tion on the jmrt of the Senate. Should he l>e appoint<>d,
162 AMBBIOAN MBDICIHBj
EDITORIAL COMMENT
[AOOUBT 2, 1902
however, his detail will be for four years, and as he will
not retire until 1909, it is not unlikely that he will re-
main Surgeon-Cieneral of the Army until that time. Col.
O'Reilly is a Pennsylvanian and a graduate of the med-
ical department of the University of Pennsylvania.
He has seen forty years of active service, having entered
the regular Army as a medical cadet in August, 1862.
The following data concerning Col. O'Reilly's career are
quoted from the regular Washington correspondence of
the Philadelphia Public Ledger:
" He served at the Cuylor General Hospital at Oermantown
until Marcli, 1864, and later saw service in the field and also in
the McClellan General Hospital at Nicetown. He was dis-
charged in 186.5, but soon after was reappointed and assigned
successively to the Germantown Hospital, the McClellan Hos-
pital and the Mower General Hospital at Philadelphia. In
April, 1867, he was appointed an assistant surgeon, and entered
upon active service in the far West, chiefly in Arizona and Cali-
fornia. He was accidentally wounded by the discharge of a
revolver, and was himself a patient in an army hospital for the
best part of a year. He served as Post Surgeon at Fort
McPherson, at Fort Whipple and Fort Halleck. He was Chief
Medical Officer of the District of Upper Arizona, and from
July, 1870, until late in the fall of that year he was with the
Eighth Cavalry in the field. In 1874, he was Chief Surgeon
with the Sioux expedition. In 1875 he reiurned East and
served successively at Fort McHenry, Md. ; Fort Hamilton,
N. Y. ; Fort Ontario, N. Y. ; Charleston, S. C, and Atlanta, Ga.
He was with the United States troops in Maryland and Penn-
sylvania during the labor strikes of 1877.
" In 1884 he was assigned to duty at the White House as
physician to President and Mrs. Cleveland. In May, 1890, he
was assigned to duty at Fort Logan, Col., and was with the
troops in the field in South Dakota during the Wounded Knee
fight in 1890. In 1893 he was again called to Washington to act
as attending surgeon throughout President Cleveland's second
administration. When the Spanish war broke out, Colonel
O'Reilly was stationed at Mobile, Ala. He was promoted to
be a lieutenant colonel and Chief Surgeon of Volunteers. He
was successively Chief Surgeon of the First Independent
Division and the Fourth Army Corps at Tampa with General
Schwan. At the close of the war he was granted'sick leave,
and remained in Washington on special duty until the fall of
1898, when he went to Havana as a member of a special board
of officers. During the fall of that year he served as Chief
Surgeon on the staff of General Wade, President of the Com-
mission on Spanish Evacuation of Cuba. Until November 11,
1899, he served as Chief Surgeon of the Division of Cuba. He
was then transferred to Fort Monroe, and placed in charge of
the Josiah Simpson General Hospital. Last December he was
ordered to San Francisco as Chief Surgeon of the Department
of California."
The Pseiidouiiiversity and the Semiiiniversity
Medical School — Making more precise the distinction
drawn by Professor Barker, to which allusion was made
in last week's issue, we understand it to be as follows :
The " pseudouniversity medical school" is simply a
proprietary school to which a university has lent its
name because of some selfish advantage given or hoped
for, and without any real change in methods of teaching,
improvements in laboratory work, and without benefit
to the medical student. It is, iu other words, a sham
university school, in which the name and association are
given really for purposes of deception and not to change
or better the instruction. It does not contain true
university departments manned by professors who are
investigators as well as teachers, and who do not engage
in private practice. The " semiuniversity medical
school " is one which is in reality the medical depart-
ment of a imiversity in which at least half of the
chairs are filled by profes.sors who are really both investi-
gators and teachers who do not engage in private
practice, and who are just as truly university men as are
those, e. g., in the philosophic department. Examples
of this class of schools are Johns Hopkins, Harvard,
Columbia, University of Pennsylvania, Ann Arbor,
etc. The trouble with this classification is that it
does not distinguish the really indistinguishable and
unclassiflable facts. There are aU grades and degrees
of the pseudos and the semis. But it undoubteilly
helps the mind to appreciate more accurately the
sorry state of affairs in which we find ourselves.
It at least furnishes us with an artificial classifica-
tion by which we can seek to spur the pseudo into
the semi and, devoutly-wished consummation, the
semi into the real and genuine university medical
school. This in fact means that the poorer schools must
meet the rivalry of the better schools, i. e., they must
secure sufficient endowment to give their students an
education of far greater co>it than the student fees will
provide. They must at least place the subjects of
anatomy, physiology, bacteriology, pathology, etc., in the
hands of true university men who do not practise and
who devote their whole energy to teaching and investi-
gating. The greater the endowment of the better cla.ss
schools the better and greater amount of the instruction
that can be given for the student fees and the more
impossible will it be for the proprietary schools to com-
pete. A sad corollary of Professor Barker's classifica-
tion is that so far we have not in the United States a
true university medical school. But we are getting
ready for them and are- approximating the ideal very
closely.
A condition of reciprocity which should be
accepted by all States is that eminently wise and just
one that the lower standard States should accept the certi-
fied licentiates of higher standard States without demand-
ing that the higher standard States should do the same
for the low standard ones. If in State A the examina-
tions and conditions of admission to examination are of
practically the same standard as those in State B, A
should admit B's licentiates who underwent the board
examination. If, however, B's standards are higher, A
should admit B's licentiates without asking that those of
A should be admitted to practise iu B. The fact that
it is morally and professionally justifiable to admit candi-
dates with a better education and training without
asking that less highly educated licentiates shall be
admitted to practise in the medically stronger States
needs to be emphasized. One method of approximating
this is shown in the fact that the State Board of Medical
Registration and Examination has decided to admit
practitioners of Illinois to practise in Indiana if the
Illinois Board will give such applicants a special certifi-
cate under its seal that they have taken the examinations
under the Illinois Board in the subjects required by the
Indiana law. The Illinois Board must, however, agree
to recognize applicants from Indiana under similar con-
ditions. Moreover, according to report, the Illinois
Ac GUST 2, 1902]
EDITORIAL CX)MMENT
Ambrioan Hkdicink 163
Board has adopted the requirement that after January 1,
1903, the candidate must show evidence of having
attended four courses of lectures of at least seven
months each, and medical colleges, to be recognized as
in good standing, must require as preliminary qualifica-
tions for their students a high school education or its
equivalent as shown by examination. This will mate-
rially reduce the number of medical colleges recognized
by the board, and puts Illinois more to the front among
the States demanding higher qualifications. Under
existing conditions the gnwiuates of a considerable num-
ber of medical colleges will be barred from examination
in Illinois.
This raising of the standard in certain States and
exclusion of the candidates of a number of other States
will at once arouse the (juestion on the part of the citi-
zens and profession of the lower standard States, Why
are our rnen thus excluded f Immetliately there will be a
demand for such an elevation of standards as will bring
the desired reciprocity.
Institutional Accounting. Ill Having outlined
a general plan of accounts to exhibit properly the reve-
nue side of the income account it is next in order to
inquire what classification should be provided for the
other or expenditure side. In attempting an answer to
this question it must be borne in mind that much as to
details depends upon the circumstances governing each
individual case. What would be entirely suited to a large
institution might not answer for a small one. Again,
an institution containing many departments, possibly
. under more or less independent management, would
re<iuire something different than one of a simpler organi-
zation. But these are matters of detail and do not affect
the general principles involved. Here, as elsewhere, the
latter are of universal application. Whatever may be
the circumstances of any particular institution the
accounts of its expenditures should be stated in such a
manner as to show the cost of each of its several depart-
ments ; and items having a logical relation to each other
should be classed together. A negative illustration may
malic this clear — it is a practice bad, but too common, to
group items by alphabetic arrangement, resulting in
such absurdities as beef and buckets, paint and potatoes,
fruit and furniture, etc. ! A rational system of accounts
ought to show some such general divisions of expendi-
ture as follow, any or all of which may t)e subdivided
or amplified as may be retiuired : Salaries and wages,
food-supplies, lighting and heating, maintenance of
buildings and grounds, maintenance of equipment,
medicine and medical attendance, printing, stationery
and office supplies, insurance, interest on mortgage or
other indebtedness, misc!ellaneous expenses. A classi-
fication thus arrangetl is simple and logical, can be modi-
fled to suit the needs of a large or small institution, and
will present results in a comprehensive manner for
present refcrcnci- and futurt; comparison.
Progress in creHuitioii is shown by an epitome of
the statistics given in 'Hw Lunrel of July ."i, by Sir
Henry Thompson. There are seven crematorii's in
(iermuny, and the total number of incinerations in 15)01
was 693. In the seven institutions of England there
were 445 incinerations. In the 24 crematories of the
United States the following figures are given :
No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
SO
21
22
Location.
Fresh Pond, N. Y
nuffalo, N. Y
Troy. Earl Cemetery. n!y"
Swinburne Island, N Y " ~"
Watervlllc, N. Y „.' ""
St. I»uls, Mo "" "
Philadelphia, Pa
San Krancisco, "Odd FeUow8!"'tiV
San frnnclseo, "Cypress Lawn," Cal...!'.'.".'.!'.
Ujs AnRciea, Cal
Boston, Mass "
Cincinnati, Ohio....
Chicago, III !..!!"";; ~ ""
Mount Auburn Cemeteryi'Mass"!!"" "'
lltLiburg, Pa
Baltimore, Md ..", "
Uinciister, Pa _._."!"
Davenport, Iowa ".'. "'
Milwaukee, Wis. """
Washington, D C.. ..!".
Wa.sliington, •' Le Moyne." D. C ." ""
Pasadena, Cal ■■""
St. Paul, Minn '"
Fort Wayne, Ind .'..'.""!".™."!!'.".!'.!!'.'.™!!
Total
1901.
2,606
Total from
commence-
ment.
65i
4,587
SO
684
1«
IM
8
114
1
80
141
1,195
119
1,087
666
2,201
91
728
85
552
m
89
7M
182
877
119
lae
24
288
20
200
2
101
29
103
45
228
38
149
1
48
46
158
20
7«
5
IK
14.266
Gathering the obtainable figures together we find
that the following were the incinerations in 1901 :
Country.
Germany
England
Italy „
Switzerland ....
Sweden
Denmark
Paris
United Slates..
Total..
No. crema-
tories.
7
7
22
8
2
1
1
28
ee
No. Incinera-
tions, 1901.
698
445
•M&*
144t
u"
vn
2,au5t
4,461
*lBl2only. fin 2 only. J In 24.
It is gratifying to find that in our country there are
more than twice as many incinerations as in all the rest
of the world combined, and that the number every-
where is rapidly increasing.
In Germany a petition signed by over 3,000 medical
men has been presented in the Iteichstag to render com-
pulsory the cremation of thos*- who hav<? die<l of inftv-
tious di.sea.se. We think similar laws should In- enacted
in the Unitetl States. In Canada the clergy (RomaD
Catholic) have opposed the practice of cremation, but
the legislature of Quebe*' has declared it legal and a
crematory has btwn inaugurated at Montreal. In
Austria-Hungary the practice has not been lepilized. In
this respect Spain is more progressive, a royal decree
in August, 1!M)1, conferring legality, and basing it on
hygienic groumls. In Itiissia, despite the opposition of
Holy Synod, the government will soon decree that the
custom may be optional.
Ill and Evil.— The two words are not etymolo^oally
related and hence when they aroH<' tlie two oonoeptions
were not blended, nor did one g»ow out of the other.
The fact Is signifiwnt that morality and dlsea.'ie were
clearly ditfen'ntiatwl in the primitive languiige-making
mind. Hut still more stiggestive is it that at the end of
the middle ages the two wonls cjtme to Im' us^-d by the
164 Ajiebioan Medioinkj
EDITORIAL COMMENT
[AVOUST 2, 1902
European nations as synonymouw, ill being a mere vari-
ant or reduced form of evil. Tiiis seems to indicate
tlie terrible role played by sickness in these centuries,
culminating in the frightful conditions in which it
became almost the sole bad or wrong thing and thus
nearly supplanting conscience by physical affliction. It
is to be noted that the Latin word nudum, evil, had
already become the name for disease, as malum articu-
lorum, rheumatism ; malum eaducum, epilepsy ; malum
coxce, hip disease, etc. From this word we also derive
our words for evil and evil-doers, malice, malicious,
malevolent, malefactor, etc. This deduction from history
and philology is further emphasized by the terms applied
to syphilis, a disease which like a storm burst furiously
upon all Europe in the last years of the fifteenth century.
At no time of the world was sin, and especially sexual
sin, more universal ; at no time was conscience more
atrophied, and the very idea of sin lost. When the new
disease syphilis overran Europe, there was no name
for it, and men had become habited to the view that the
greatest evil was disease. The havoc which disease
wrought among the morally and physically defective
European peoples struck the imagination powerfully,
and these are only a few of the names at that time given
to it:
Malum francicum
Malum francigenarum
Malum francorum
Malum Castellanum
Malum Indicum
Malum pustularum
Malum St. Menti
Mai St. Gillain
Mai de la Isla Espaiiola
Mai de los Castillianos
Mai gallico
Lo Male de lo Brosule
Das Venerische XJebel
Malum franoia3
Malefrancum
Malum francosifB
Malum neapolitanum
Malum Americanum
Malum aphrodisiacum
Mai de St. Main
Mai St. R(5ml
Mai de simiente
Mai serpentine
Mai de Naples
11 msfle venereo
Mai celtlco
The Confessions of a Physician. — The New York
Independent for July 10, 1902, contains an anonymous
article with this caption that manifestly emanates from
one who knows the practical side of a physician's life and
appreciates the problems which are presented to the doctor
especially at the beginning of his career. The moments
of doubt that come to all physicians as to the worth of
the profession they have chosen are well brought out.
With the realization of their helplessness as regards
certain forms of disease there is apt to be associated a
sense of discouragement and almost failure instead of
the high humanitarian ideals that seemed so worthy of
the best aspirations. The danger of the reaction that
would under the stress of such thoughts make of
the professional man a mere getter of revenue is also
pointed out, and the necessity for a real vocation to
philanthropic work if the highest success is to be
attained. The idea has been insisted on by many of late,
yet this would almost seem to be a new presentation of it.
"Men who enter the sacred precincts of medicine
are supposed to have a vocation for this noblest of
all professions. Is it really true ? I do not mean by the
question to intimate that all the men who select medi-
cine as their lifework are ruled by sordid motives;
heaven forbid. Many are attracted by the opportunities
for benefltiag their fellowmen ; others are led by the
allurements which are presented by the student of
science ; others still like the dignity and resiiectability
inseparable from the profession and, finally, most of
us regard it as an excellent way of making money.
But, as I have said, the very great majority finally
reach a point where they wonder if they are really
fitted for the profession.
"I fervently hope that the time will come when a
real vocation for medicine wiU be the first requisite
demanded before a student can begin his studies."
Some of the young doctor's experience and his
pecuniary trials are given in detail with the danger they
involve of making anything like ideals in life seem
visionary and impractical. Yet the touch of suffering
humanity and the kinship of sympathy proves a saving
grace that keeps the earnest, serious minded man from
drifting for more than the moment into the vortex
of unworthy motives. Finally there is the exprassion
of the feeling that the opportunities for self-sacrifice
inevitably lead to the realization of the essential nobility
of the profession.
" It is a profession whose days are made of diplomacy
and whose nights are composed of crises. There is
always a high duty calling and there is usually a mere
human man trying to respond. Had I possessed in the
beginning the vocation for my profession which belonged
to a friend who built a great career upon the foundation
of a smallpox epidemic, I should long ere this have
been either famous or dead. Such fame comes to a
Jenner ; such death comes to a Damien, who if he had
not been a priest would have been a physician. AH that .
I would say is that the physician should possess the
intellect of a Jenner and the heart of a Damien.
"As for me, I am a doctor practising medicine."
EDITORIAL ECHOES
The Medical Journal and the Autoniobilists. —
The human race is divided into two classes — those who
ride in automobiles and those who do not. A certain
highly respected medical journal evidently strives to
please both classe.s, for in a single issue it contains two
erudite discussions — one proving that automobiling
leads to deafness, bronchial troubles, and catarrh, and
the other showing that automobiling, especially at top
speed, is a splendid renovator — for the man in the auto-
mobile. Both articles bring reason and learning to
prove their theses. The arguments for deafness, bron-
chial troubles, and catarrh are sufficiently obvious.
Anybody who cannot afford to have an automobile can
think them up readily. On the other hand, the argu-
ments for physical renovation are plentiful, if less
apparent. To ride in an automobile at top speed, it
seems, sends rushes of pure air through the nostrils into
the lungs, while the beating of this same pure air
against the face has the effect of hardening the muscles
and of quickening the circulation. It is admitted that
the result is a tense look on the face, but this only shows
how splendid the experience is. When it is all over
the face turns out to have been freshened up and made
younger. This, of course, in case it has not been bat-
tered by the ragged edge of a tin can or a stray boiler
cover, hurled by some irate pedestrian or avenging
small boy. Whether or not such occurrences also might
be considered beneficial the able writer doee not say.
[N. Y. Evening Post.']
August 2, 1902]
KEVIEWS
[Ajkerican Meuici>-e 165
BOOK REVIEWS
A System of Physiologic Therapeutics.— A Practical Expo-
sition ot the Methods, Other than DruK-giving, Useful in
"■?. t^revention of Disease and in the Treatment of the Sick.
Mited by Solomon Sous Cohen, A.M., M.D. Volume
\ Hydrotherapy, Thermotherapy, Heliotherapy,
and Phototherapy. By Dr. Wiluelm Winterxitz, Pro-
fessor of Clinical Medicine in the University of Vienna ;
Director of the (General Polyclinic in Vienna. Assisted by
Dr. AloihStrasser, Instructor in Clinical Medicine at the
Lniversity of Vienna, and Dr. B. Buxbaum. Chief Physi-
cian of the Hydrotherapeutio Institute in Vienna. And
Balneology and Crounotherapy. By Dr. E. Hkinrich
KisCH, Professor in the University of Prague ; Physician
at Marienbad Spa. Translated by Auqustis A. Eshxer,
M.p., Professor of Clinical Medicine in the Philadelphia
1 olychnic, etc., and with notes on American Springs by
(tUy Hinsdale, A.M., M.D. Including special chapters
on the Classiflcation of Mineral Waters and Their
Distribution in the United States, by A. C. Peale, M.D.,
Aid in the National Museum, Washington, D. C, in Charge
of Mineral Water Statistics of the United States Geological
Survey; On the Practice of Phototherapy and Ther-
motiierapy, by J. H. Kellooo, M.D., of Battle Creek,
Mich.; and on Saline Irrigation and Infusions, by Har-
vey CusHiNG, M.D., of Johns Hopkins Hospital, Balti-
more; also an Appendix by the Editor. Illustrated; 570
pages. Philadelphia: P. Blakiston's Son <fc Co. 1902.
Eleven volumes ; cloth, 827.50.
The foregoing (from the title page) succinctly describes the
general scope of Vol. ix of a System of Physiologic Thera-
peutics, concerning the earlier volumes of which we have
already had occasion to comment most favorably. The expec-
tation of superiority of production awakened by the prelimi-
nary announcement of the System has been fulfilled by each
volume as issued, and this Vol. ix of the series (Vol. vi in
sequence of issue) fully efjuals, if indeed it does not surpass in
point of merit, the volumes previously issued. It is difficult to
say whether the expositions of the principles or of the prac-
tices of the different varieties of treatment included within the
volumeare themore to be commended. Suffice it to say that
both are praiseworthy and that we have not heretofore read
such satisfy ing discussions of the remedial applications of water,
heat, and light as are to be found between these covers. The
book is especially valuable in that it contains minute directions
for the carrying out of those comparatively simple measures
available at the patient's house, as well as the slightly more
elaborate measures that may be applied in the physician's
oflSce, and those still more elaborate measures which, because
of their complexity or of their lime-consuining character,
require the facilities and apparatus of special institutes. The
important subject of drinking cures with mineral waters— to
designate which a new word, " crounotherapy," has been coined
by Dr. David Riesman— is given a full measure of consideration.
An extremely valuable and important feature of the book is
a chapter (introductory to Crounotherapy) in which Dr. A. C.
Peale clearly and authoritatively compares and correlates the
different schemes of classifying mineral waters in vogue
among American, English, French, and Gorman writers, and
in which he contributes a much-needed systematic arrangs-
iiioiit of the mineral waters of the United States, grouped
^ii^cording to their predominant chemic constituents, with
descriptive reference to their geographic distribution, and with
■ comparisons of analogous European waters. This should
stimulate interest in the really great natural balneotherapeutic
and crounotherapeutio resources of the United States, and
together with the description of Airterican health resorts in
Vol. IV of the series, places within the reach of the American
physician information, in many cases of vital importance to
his |)atient, that hitherto has not been available. The value of
tlie book to the American physician has also been much
"iihanced by the notes upon American mineral baths and
waters that Dr. Hinstlale has incorporated with the text of Pro-
fessor Ki.sch's contribution. The supplementary chapters by
Dr. Kellogg and Dr. Cushing are of a high order of merit. In
I>r. Kellogg's chapters the therapeutic uses of sunlight, of all
forms of electric light baths and of hot-air apparatus, are fully
described and illustrated. Dr. Cushing presents a scieDtiflc
and accurate exposition of the fundamental principles of the
therapy of "artificial serums;" and describes the technic and
uses of subcutaneous, intravenous and intestinal infusions of
saline solutions. His cautions against too rapid injection and
too large quantities of solution are needetl and should be heeded.
As indicative of the excellence of the translation of the contri-
butions by Drs. Winternitz, Strasser, Buxbaum, and Kisch, it
suffices to say that it has been done by Dr. Eshner. Finally,
though by no means least in point of merit, is the description
of " Additional Methods for the Therapeutic Use of Water,
Heat, Cold, Light, and Mineral Baths," from the pen of the
editor, and appearing modestly in the appendix. Dr. Cohen
has become so well known for his contributions [inter alia) to
extramedicinal therapeutics that it is a pleasure to read this,
his first avowed contribution to the really excellent system
that he edits. In this chapter are to be found many of the
details so commonly sought and so rarely found by the general
practitioner— details for giving cold baths, sprinkling, sheet-
baths, towel-baths, ice-rubs, ice-packs, sponging, hot-baths, hot-
packs, irrigation of the hollow viscera, Nanheim baths, etc.—
details that render the different measures as available at the home
of the patient as they are in special therapeutic institutions. As
a whole the volume far exceeds one's expectations, and certain it
Is that until one reads such a book— a took written with com-
mendable reserve and without extravagant claims— one fails ade-
quately to realize the therapeutic virtues inherent in the elements
about us. As each succeeding volume Is issued, the conviction
receives additional confirmation that the System of Physiologic
Therapeutics is destined to command a wide circulation and to
wield considerable influence in the field of therapeutics.
A Dictionary of Medicine. By various writers. Originally
compiled by Sir Richard Quain, Bart.. M.D., LL.D.,
F.R.S. Third edition. Largely rewritten and revised
throughout. Edited by H. Montaoi-e Murray, M.D.,
F.R.C.P., Joint Lecturer on Medicine, Charing Cross Med-
ical School. Assisted by John Harold, M.B., B.Ch.,
B.A.O., Physician to St. John's and St. Elizabeth's Hos-
pital, and W. Cecil BosANtjUBT, M.A., M.D., M.R.C.P.,
Physician to Out-patients, Victoria Hosnital for Children.
Half Morocco. Pp. 1892. New York : D. Appleton A Co.,
1902. Price, 810.00.
In this latest revision of Quain's celebrated work, a number
of new articles are included and many of the others largely
rewritten. The ever increasing incursions of surgery into the
realm of medicine have received adequate attention, although
operative surgery is not included. More attention is paid to
the medical aspects of the socalled specialties, but gynecologic
and obstetric operations are not described. With the exception
of remarks upon the toxicology of some of the common poisons,
materia medica and pharmacy are not treated. A number of
colored plates lend value to the text. For an American, the
indexing and cross-reference according to British custom is at
times confusing, as, for instance: The common term hypnotism
is croB.s-referenceJ to the less frequently used titles braidism
and mesmerism. Again, a number of popular .Vinerican meth-
ods of treatment are entirely overlooked. The combination of
the two volumes of the former edition into one very bulky
tome can hardly be called a Judicious change.
The Diagnosis of .Surgical Discaacs.— Ity Dr. E. Alrert,
Late DirtH'tor and Professor of the Frost .Surgical Clinic
of the University of Vienna. Aiilhorizeil translation from
the eighth enlargo<l and revised otlition, by lionKHT T.
Frank, A.M., M.D., with 4.'! illustrations. Published by
D. Appleton <fe Company, of New York, 1902.
Works on Internal medicine, with reference to diagnosis,
are plentiful, while those with reference to the diagiiosis of sur-
gical diseases are comparatively rare. The fact that this work
has come from the hands of one so well and favorably known
to the profession as was the author is suftlrient guarantee of Ita
high quality. The work having roachwl its eighth edition
nee<ls but few words from the reviewer. The fact is more
potent than many words. The translation by Dr. Frank bringa
the book within the reading scope of nil AmericaiiH. The
author has not attempte<l a systematic classiflcation of diseases,
but rather has taken up each important surgical malady and
contraste<l it with those likely to resemblii it in one or more
im])ortant points — and thus diseaseH are grouped according to
166 AMERICAN Medicine)
AMERICAN NEWS AND NOTES
[August 2, 1902
similarity of signs and symptoms. To both the student and
practitioner tiiiw work will prove of much practical value.
Ophthalmic Myology.— A Systematic Treatise on the Ocular
Muscles. By G. C. Savage, M.D., Professor of Ophthal-
moloev in the Medical Department of Vanderbilt Univer-
sity. Illustrated. Pp. 589. Nashville, 1902. Price, ^.00.
This is a painstalting and conscientious review of the whole
subject of ophthalmic myology, and is of especial interest to
American oculists. The style is clear, and the book is well
printed and contains 61 Illustrative cuts and six plates. In
addition to an epitome of existing literature, the author has
presented original explanations and propositions in regard to
points in which his belief is not in accord with that of generally
accepted authorities. Despite a distinct divergence of opinion
in many particulars, we cannot help admiring Dr. Savage's en-
thusiasm and iiidustry.
A liaboratory Guide in Elementary Bacteriology.— By
William Dodgk Frost, M.S., Instructor in Bacteriology,
University of Wisconsin. Illustrated. Second revised
edition. Published by the author, Madison, Wis.
This work makes no pretense to exhaustive Ijacteriologic
discussion but is designed and especially adapted to the needs
of the student in ordinary laboratory work. There Is discus-
sion with reference to the various culture media, and then a
general discussion on bacteriology. Germs which are similar
in character and growth are grouped together. Each important
one is studied separately and one or more blank pages is left
for the notes of the student. This feature is a useful one for
laboratory work. The work is well arranged and deserves and
will receive a place in the literature of bacteriology.
The State Board of Health's Annual Report to the Gov-
ernor of Ohio for the Year Ending Octobeir 31, 1900.
This voluminous report of over 600 pages contains matter of
much interest to sanitarians. The secretary of the Board, Dr.
C. O. Probst, who is the editor of the volume, is a wellknown
authority on sanitary matters.
During the year 1900 there occurred in Ohio 3,229 cases of
smallpox, with a mortality of 44, indicating a very mild type of
the disease. Since the first outbreak of the epidemic there have
been 4,489 cases, with 58 deaths — a mortality of 1.2990.
The report contains an interesting appendix upon the rivers
of Ohio as sources of public water supply, the investigation
having been undertaken under the auspices of the Board.
Compend of Special Pathology.— By Alfred Edward
Thayer, M.D., Assistant Instructor in Gross Pathology,
Cornell Medical College; Pathologist to the City Hospital.
12mo. ,3-32 pages, 34 illustrations. Philadelphia: P. Blak-
iston's Son & Co., 1902. Cloth, ?0.80.
It is sufficient commendation to say that for a book of its
size and pretensions it covers the subject of special pathology
as well as could be expected. Doubtless it will be found of
service by the student who cares more for the matter than for
the method of presentation. Tlie language is execrable— the
bad English, bad punctuation, and the jumble of Eatin and
English terms beimg inexcusable.
Index Catalogue of Medical and Veterinary Zoology. — By
Ch. Wabdell StjiJes, Ph.D., and Albert Hassall,
M.R.C.V.S., United States Department of Agriculture,
Bureau of Animal Industry. Bulletin No. .39. Washing-
ton : Government Printing Otliee, 1902. Part I.
We concur fully with Dr. D. E. Salmon, Chief of the Bureau
of Animal Industry, in his belief that this catalogue will prove
of very great value to persons interested in zoology in its prac-
tical relation to human and veterinary medicine and public
hygiene, and we are glad to note this publication as another
evidence of the steadily increasing interest shown by American
physicians in the subject of medical zoology. The ijubllcation
when complete will afford very practical aid to the student of
animal parasites, and all such should secure the catalogue by
application to the Superintendent of Documents, Washington,
D. C.
AMERICAN NEWS AND NOTES.
GENERAL..
New Healtli Commissioner at Manila.— Major Carter has
succeeded Colonel Maus as health commissioner of the Archi-
pelago. The former is noted for successful work against
cliolera and plague.
April Health Report of Manila.— This shows the death-
rate for the month to be : Filipinos, 67.38; Chinese, 13.04; for-
eigners, 15.5 ; Americans, 24.49, an avei-age of .53.46 per 1,000 of
population. The average birthrate, excluding Chinese, from
whom no statistics can be obtained, was 11.2.
State Department Interferes for Physician.— Active
steps are being taken to save the life of Russell Wilson, a young
Ohio physician held under arrest at Bluefields by the Nicara-
guan military authorities. Wilson was a member of a filibus-
tering expedition, but it is claimed that he was not a combatant,
being attached only in a medical capacity.
Resuscitation After Twenty-five Minutes.— Superintend-
ent Kimball, of the Life-saving Service, has received a report
from Captain Ludlam, of the Hereford Inlet Life-saving Sta-
tion at Anglesea, N. .T., to the effect that Stanley Holmes, 5 years
of age, was resuscitated after being under water for 25 minutes.
It is said that the superintendent has investigated the case and
finds the time corroborated by all the witnesses, including a
nurse.
American Neurologic Association. — The twenty-eighth
annual meeting of this association was held in New York City,
June 5-7, 1902, Dr. Joseph Collins, of New York, being presi-
dent. Many valuable papers were presented, and the discus-
sions were numerous and instructive, the latter being mainly
by the most prominent neurologists of tlie country. New mem-
bers elected are Leo S. Newmark, San Francisco ; Harold N.
Moyer, Albany ; W. E. Paul, Boston. The election of officers
resulted as follows : President, James W. Putnam, Buttalo ;
vice-presidents, C. E. Riggs, St. Paul, H. M. Thomas, Balti-
more ; council, W. H. BuUard, Boston, Joseph Collins, New
York ; secretary and trea-surer, G. M. Hammond, New York.
NEW YORK.
Smallpox at Geneva.— Smallpox has broken out in the
vicinity of Geneva, N. Y., aud quarantine has been established.
Sick Children's Mission.- Owing to the cool weather only
10 of the 15 pliysiciaus on the list of this mission have !)een
called into service thus far during the summer. This is the
thirtieth year of the medical work of the mission.
Smallpox Patient Sues City.— Agnes Smart, of Brooklyn,
has brought suit for 815,(100 against the city of New York
because she was taken to the smallpox hospital after she was
cured of an attack of that disease. Sanitary inspectors claim
that the patient violated the rules of the Health Department by
going to a Turkish bath before quarantine had been lifted.
Physicians May Not Speed Antomobiles.- Three Buflalo
physicians were recently arrested for speeding tlieir auto-
mobiles, their excuse being " hurry calls." The super-
intendent of police refused a request for allowing physi-
cians to exceed the speed limits wlien necessary as he feared
every call would be so classed. " The resalt would be that we
would have a lot of doctors racing around town aud in auto-
mobiles killing more people than they saved."
Garbage Disposal Abuse.— A report tending to show that
the Barren Island odors are due to neglect by the contractors
who dispose of the city's garbage has been made by the Depart-
ment of Health. Sorting of the material while on the con-
veyers, delivering it too fast for the digester, and leakage of the
lead gaskets in the digester heads are said to give rise to the odors
against which so many citizens have complained. The
report claims there is outrageous neglect of the requirements
to prevent causation of a nuisance.
The Charity Organization Society's Committee on
Tuberculosis needs not less than glO.OOO to meet the expenses of
the work it has undertaken. Expenditures will be made for
the following main objects: 1. Research into the social— as dis-
tinct from the medical aspects of tuberculosis. 2. Education ;
the publication of leaflets and pamphlets, the giving of lectures
and the promulgation in every possible way of the fact that
tuberculosis is a communicable aud preventable disease. 3. The
encouragement of movements for suitable public and private
sanatoria, both for advanced and for incipient ca.ses; for adults
and for children ; for free care and also for the care of those who
can pay moderate fees. 4. The relief of indigent consumptives,
by the provision of suitable food aud medicines, by the pay-
ment of rent when this is necessary to secure adequate light and
air, and by transportation and maintenance at a distanee when
in the judgment of the committee this is essential.
August 2. 1902)
FOREIGN NEWS AXD NOTES
■American Mkoicikx 167
Hospitals for Contagioas Diseases— The board of esti-
mate having placed half a million dollars at the disposal of the
Department of Health of New York City for making improve-
ments in the facilities for taking care of patients suffering from
contagious diseases, the department is now busily engaged In
elaborating plans for the utilization of this appropriation. The
sum of $75,000 has been set aside for the repairs and extension
of the Kingston Avenue Hospital, in Brooklvn, and of the
Riverside Hospital, on North Brothers Island. "The remaining
f425,000 will be devoted to the construction of new hospitals
in the Borough of the Bronx, the Borough of Queens and
the Borough of Richmond, which are at present wholly unpro-
vided for in this particular direction. In the Borough of Man-
hattan additional property is to be acquired adjacent to the
hospital for contagious diseases at the foot of East Sixteenth
street, where separate pavilions will be provided for the suf-
ferers from different diseases. A hospital will also be provided
in Harlem. All the new buildings will be fitted up with the
most improved appliances for the treatment of contagious dis-
eases and for the prevention of their spread.— [i>^. Y. Med. Jmir-
nal.\
PHIIiAJDEtiPHIA, PENNSYLVANIA. ETC.
Philadelphia Hospital.— Robert H. Smith, chief clerk, has
been appointed temporary superintendent in place of W. M.
Geary, who has been seriously ill for some time.
Camp Meeting Closed by Board of Health.— Two col-
ored camp meetings at Collingdale, Pa., were closed July 27 by
order of the State Board of Health to prevent the spread of
smallpox.
Potty's Island and Cannon Ball Farm Bills Vetoed.—
Mayor Ashbridge has vetoed the bills for the purchase of Petty's
Island as a site for the city almshouse and hospital for the
insane, and the socalled Cannon Ball farm in the Fortieth
ward as a municipal hospital site. The former is objected to
because it would be under the police and sanitary regulations
and laws of another State. The latter bill outlines too vaguely
the site selected and is not considered a desirable location.
Hi8tori<Jal Society at West Penn Medical College.—
This society has recently been formed with W. H. Ingram,
professor of pathology, as president; George Wright, secretary
and treasurer ; .lulius Koch, chairman of historical committee.
The primary object of the organization is the study of the his-
tory of medicine and medical men but it will be broadened to
include the whole university. A library is to be a feature of
the society, in which professors and students will meet on
equal terms.
WESTERN STATES.
Change in Chicago Faculty.- Dr. E. J. (Jardiner has
been elected professor of ophthalmology in the Chicago Eye,
Ear, Nose and Throat College.
Physician Banqueted.— Dr. Solon Marks, dean of the
Milwaukee medical profession, was recently given a banquet by
his fellow physicians of the city on reaching his seventy-fifth
birthday.
St. Louis to Exterminate Mosquitos. — The Health De-
partment of St. Louis has secured an appropriation to defray
the expenses of combating mosquitos. Crude oil will be
employed on all ponds in and near the city.
Olco Law to be Tested.— -Butterine manufacturers in ses-
sion at Columbus, O., decided upon a plan of action to test the
constitutionality of the recently-enacted oleomargarine law.
New York lawyers will conduct the case on the ground that it
is class legislation.
Michigan Medical Society. — The seventh annual meeting
of the T'ppor Peninsula Medical Society was held at Ishpeming,
Mich., .July 15 and 16, 1902, under the presidency of Walter R.
Hicks, of Menominee. The program included general medical
and surgical topics.
Chicago Health Report. — Statistics for the week ended
July 10 show a great increase of deaths of children from acute
intestinal diseases due to changeable tomperaturo, high humid-
ity, etc. There is also increased prevalence and mortality from
the acute contagious diseases of childhood. A marked increase
of smallpox in the territory surrounding Chicago is noted.
CANADA.
High Infant Mortality.— During the week endejl July 19
there were 108 deaths of infants in Montreal. The high mor-
tality is ascribed to " infantile debility " due to excessive heat.
Smallpox In British Territories. — Dr. Patterson has
returned to Manitolia after a throe weeks' absence in the Terri-
tories attending to precautions against smallpox. The disease
has been confined entirely to the halfbreeds, the white popula-
tion being free because of their care In bein^ vaccinated. In-
dians are also fairly free as they dread the disease and do not
try to escape vaccination.
FOREIGN NEWS AND NOTES
GENERAL.
Plague in India Still Decreasing.— During the first half
of June the plague in India greatly decreased, the mortality re-
corded on June 4 being 4,214, and on June 18 only 1,316. The
same districts are yet infected, but the mortality is at a lower
point now than has been reached before for a long time.
Enteric Fever During South African War.— The deaths
among the English troops from enteric fever and the rate per
, , ,"J2,"° "uriig the South African war are as follows: October
li, 1899, to October 12, 1900, .3,774 deaths, or a rate of '20.97 ; Octo-
ber 13, 1900 to October 11, 1901. 2,.561 deaths, a rate of 10.63; Octo-
ber 12, 1901 to May 30, 1902, 1,656 deaths, a rate of 6.84.
Prominent Anatomist Resigns.— The eminent German
anatomist, Albert von Kolliker, has resigned his professorship
at the University of Wurzburg, which he has occupied 55 years.
He is now in his eighty-fifth year, and his bodily and mental
powers are still well preserved for one of his age, a fact which
he attributes to his lifelong devotion to gymnastic exercises,
riding, swimming and hunting.
Cholera.— Cholera is apparently on the increase in many
parts of the world. At Cairo and Assivat in Egypt consterna-
tion prevails at the spread of the disease. At Mukden, Man-
churia, there were 757 cases between July 3 and 14, 81 Russians
and 363 Chinese dying. Tokio, Japan, now has cases of the
disease. It increased to 78 cases in Manila, July 25, the largest
since the outbreak, though it had previously been diminishing.
Naturalist Celebrates Birthday.— The famous Swabian
naturalist. Professor Gustav Jaeger, of Stuttgart, who is better
known in England as "the apostle of normal clothing" than
for his numerous learned contributions to zoology, biology and
anthropology, celebrated his seventieth birthday hist week. A
hundred men go to the haberdasher's shop to buy a Jaeger
shirt for one who goes to the bookseller's shop to get his great
two-volumed " Handbook of Zoology."
South Afk-ica and Medical Practice.— The Medical Prens
urges the necessity for caution and slow procedure on the part
of young medical men contemplating settling in South Africa,
especially to those who have neither friends nor funds. South
Africa is but at the beginning of the making, and selfish aims
should be set aside, only the best being sent to help in the
building of what is to be a great land. These remarks were
inspired by the advice of a distinguished professor to his
students regarding the great openings in the country men-
tioned.
GREAT BRITAIN.
Guy's Hospital.— The biennial festal dinner was held
July 1 at the Hotel Mctropole. Dr. A. L. Galabin preside<l and
about 225 past or present students or visitors were present. The
new library, founded by Sir F. Wills, is to be in working order
in about six months.
Distribution of English Physicians. — Statistics recently
published show that the town containing relatively the largest
number of physicians in the United Kingdom Is Clifton, with
36.8 per 10,000 of population ; Dublin has 13.8, Glasgow 12.8,
Lonaon 12, Sheffield 5.
The Raphael Nurses' Home.— On July 7 the Henriette
Raphael Nurses' Home at Guy's Hospital was formally opened
by the Prince of Wales. The building was erected at a cost of
£(iS,(XX), and contains beside living rooms 213 bedrooms, a sick
ward and a swimming bath.
Royal Institute of Public Health.— The annual congrewi
will be held in Exeter, August 20-27, 1902. The work will be
arranged in fiv^e sections: (1) Preventive medicine and vita!
statistics; (2) chemistry, climatology and bacteriology; (8)
engineering and architecture; (4) municipal and parliamentary
hygiene; (5) veterinary and farm hygiene.
Medical Research In Malay.— The Lancet reports that
the government of the Federate*! Malay States has ostabliRhed
in Kuala Lumpur, the capital, a research Institute which is
open to all workers, Irrespective of nationality. It Is fiilly
equipped for the study of special and general pathology, clinical
medicine, and for experimental physiology and bacteriology.
Students of tropical nie<liclne will there find ample field for
work.
Memorial Scholarship.— The Council of the nritlsh Med-
ical Association Is prepared to receive applications for a schnlnr-
ship of £200 (or the study of some subie(!t in the department of
State Medicine in memory of the late Mr. Ernest Hart. Appli-
cations must be sent In writing on or before October 4 next,
stating the imrticniars of the intended research, nualincationi
and work done. Forms of application for scholarships can
l)e obtained from the Oenoraf .Setirotary, Prsocis Fowke, 429
Strand, London.
168 AUEBIOAW MEDICIKE]
FOREIGN NEWS AND NOTES
[August 2, 1902
Cancer Research.— The scheme of orKanized and coordi-
nated cancer research has been finally approved by the Royal
Colleges of Physicians and ol Surgeons. An important change is
the exclusion of cancer departments in hospitals from partici-
pation in the subventions to be granted from the fund. This will
Erevent hurry in the work of research and competition between
ospitals anxious to show speedy results. However, the
scheme is as yet nothing more. Oflncers and committee are to
be elected and a place for work to be found. It is hoped that
special laboratories for the commission may be erected or
equipped. Want of money is now no longer an obstacle.
CONTINENTAL EUROPE.
Cold Drinks Prohibited in Berlin. — A late move of the
Berlin authorities is to issue an order to the public houses pro-
hibiting them during excessive hot weather from selling drinks
below a temperature of 50° Fahrenheit.
A Remarkable Medical Woman.— Madame Rosalion-
Sochalskaia, who died recently at Poltawa, Russia, began the
study of medicine at the age of 54, at the same time as her
daughter entered medical eofiege. She had done much literary
worK before, and continued it while practising medicine.
New Pasteur Institutes in French Colonies.- Three
new Pasteur institutes have recently been established in French
colonies. One of these is at Saigon, another at Saint Louis, in
Senegal, and the third at Tananarive. The Saigon Institute
was founded in the first instance by Professor Calmette, of
Lille. The director is Dr. M6tin, well known for his researches
on the serum treatment of dysentery.— [Brrt. Med. Journal."]
Cancer in Holland.— Circulars were sent to all the physi-
cians in Holland asking for information in regard to patients
under treatment October 15, 1900. Many physicians did not
reply to the appeal and consequently the returns are not com-
plete, but such as they are they show that the minimum num-
ber of persons affected is .0286% of the total population, and
that the majority of cases occurred between 61 and 70, then from
50 to 60 and from 71 to 80. The intestine was the seat of the
lesion in 49.88% ; 275 in men and 163 in women. In 18% of all
cases several members of the family were affected. Van Iterson
cites the case of two families with 14 members, of whom 8 are
certainly and 3 probably affected with cancer. Korteweg has
observed a case of cancer of the rectum in two sisters and can-
cer of the mamma in grandmother, mother and daughter. Viet
has observed two sisters with cancer of the cervix. A heredi-
tary disposition was apparent in 19.7% of all cases. Conjugal
cancer was noted in 11 cases and infection of one person by
another was admissible in 10.92%.— [J^om?-. Ainer. Med. Associa-
tion.']
Cancer Investigatioa in Germany.— A supplement to
the KUnisches Jahrbuch, 1902, gives the report of the German
committee for the collective investigation of cancer ; 55% of all
regular practitioners have supplied materials to the committee
for statistical study, and the report deals with the subject
almost entirely from this standpoint. Professor C. Hirschberg
has undertaken the analysis and tabulation of the large mass of
details collected. The distribution of the disease in both sexes
in different districts is first considered, and a table is given
which shows graphically the varying prevalence of the disease.
This appears to depend directly on the average duration of life
in the different districts. Up to the age of 60 female cases pre-
ponderate ; in the sixth decennial period the sexes provide
about an equal number, while in the seventh the female sex
again gives the higher number, but to only a slight extent.
With regard to the locality of the disease, in men cancer of the
stomach stands first with 413 per mille ; in women uterine can-
cer is first with 270 per mille, followed by breast cancer with
243. With regard to the question of marriage, among the
older subjects the unmarried are the more numerous, while the
opposite condition obtains in the younger cases. The tables do
not support some of the commonly held opinions as regards
predilection for certain trades and occupations; workers in
chemical factories and chimney-sweeps, for instance, are not
shown to contract the disease specially frequently. Different
types of cancer do, however, seem to preponderate among dif-
ferent classes. Those engaged in agricultural pursuits provide
cases of skin cancer in number much above the average, and
the timber trade gives a proportionately high number of cases
of cancer of glands and glandular organs. Cancer of the uri-
nary organs is specially common among the well-to-do. The
difficult question of heredity, transmission and predisposition
is also dealt with. In only 17% was a probabilitv traceable of
some hereditary taint ; infection was suspected in 435 cases,
chiefly among the married and among attendants on patients
suffering from the disease. Behla's opinion as to the prepon-
derance of the disease in houses with damp foundations and
cellars is confirmed; the apparent importance of alcohol,
tobacco, syphilis, injuries and abortion is shown in tabular
form, and it would seem that acid wines and cider give rise to
a predisposition to gastric cancer. The use of chemic manures
seems to predispose the inhabitants of the district to cancer of
the stomach. These questions of predisposition are, of course,
not capable of being treated in any exact way, and at the most
they are only suggestions.— [Brai.sA Medical Journal.']
OBITUARIES.
Patrick Thurbnrii Manson, the eon of the famous Patrick Man-
son, was born at Amoy, China, August 20, 1S78. He studied medicine
and began to follow the same lines of investigation as his father. In
1900, for the sake of proving the correctness of the mosquito theory of
malaria, he allowed himself to be stung by Infected anopheles sent
from Rome by Bignaml and BastlanelU. The Insects had sucked the
blood of a patient suffering from mild tertian malaria. Manson de-
veloped a typical tertian fever, and the Plasmodia were discovered In
his blood. The result of the experiment left no doubt of the truth of
the theory. Subsequently he suffered two relapses. In the spring of
1902 he went to the Straits Settlements to study berl-beri, but had a
gun-shot accident which resulted in his death. He was a man full of
promise, and, as Nuttall says, the ranks of the younger investigators
have sustained a great loss. In daring scientific zeal his name may
well be placed side by side with that of Lazear.
James G. Cooper, of San Francisco, July 19, aged 72. Dr. Cooper
was an historic figure In the record of scientific reisearch in the West.
He graduated from the College of Physicians and Surgeons of New York
In 1851, was a veteran of the Civil War, and author of standard works
on ornithology, conchology and other branches of science.
Eugene Grissom, of North Carolina, a noted neurologist, com-
mitted suicide by shooting, July 27, aged 71. He was a graduate of the
University of Pennsylvania, and for 21 years, from 18G8, was superin-
tendent of the State Insane Asylum In Raleigh, N. C. He was promi-
nent in Masonic circles, and was tendered nominations for Congress
and for Governor, both of which he refused.
Joseph Blddle Wilkinson, of New Orleans, July 21, aged 85. He
was a graduate of the University of Pennsylvania, and was active In
politics as well as in his profession. He retired from active practice
several years ago on account of age.
T. H. Horsey, M.D., of Owen .Sound, Can., representative for North
Grey In the Dominion House of Commons, was fatally injured by the
bursting of a flywheel inacement works July 23, dying soon after the
accident.
G. W. Pope, of Washington, D. C, July 21, aged 72. He was one of
the oldest and best-known homeopathic physicians In the District of
Columbia. He graduated from the Albany Medical College.
!Edwin Ij. Parker, of Geneva, N. Y., aged 28, was recently drowned
at Coney Island. He had been attached to the Long Island State Hos-
pital for the Insane for the past five years.
James E. Dwinelle, of Baltimore, July 18, aged 72, having never
fully recovered from an accident received last winter. He graduated
at Jefferson Medical College in 1854.
Seraphjne MathersoB, in Brooklyn, July 22, aged 57. She belonged
to the eclectic school of medicine, graduating from the Brooklyn
Academy of Medicine in 1865.
Edmund De la Fosse Bond, of St. George's Hospital, London,
July 1, aged 28, from scarlet fever which he contracted In the course of
his duties at the hospital.
Otto Zinsmeister, surgeon-in-chief to the Trappan Hospital, Ger-
many, aged 42. Death was due to infection from an operated ca.se of
osteomyelitis.
D. Matiag Serrano, Marques de Guadalerzas, editor of El Siglo
Medico and the doyen of the medical profession in Spain, July 3,
aged 89.
Thomas James Woodhouse, of London, June 2, aged 09. He was
medical officer to the Royal Hospital for Incurables.
Alexander E. Marsden, chairman of the general committee of the
Cancer Hospital, Brompton, London, July 2, aged 70.
A. E. Delipscey, of Houston, Te.x., was fatally shot by a real estate
dealer with whose son he had an altercation, July 17.
Ihsan Bey, of the Imperial School of Medicine, Constantinople,
shot in the street for motives of prlvat* vengeance.
Jonathan Rhea Gordon, of New Y'ork, July 18, aged 30, of diph-
theria contracted while attending patients.
Robert M. Anderson, of Petersburg, Va., July 19, aged 84. He was
at one time a member of the Legislature.
Carlos Imperatori, one of the oldest physicians on the East Side,
New York, July 24, aged 70.
Felix Nawrocki, emeritus professor of physiology In the Univer-
sity of Warsaw, aged 64.
Walter Prescott Smith, of Baltimore, J uly 18, aged 34, of multiple
neuritis.
E. Lee Wager, a retired physician of Charlestown, W. Va., July 23,
aged 78.
Martin Deschere, a specialist in diseases of children. In New York,
July 21.
Alexander Bbermann, a leader in medical reform In Russia, aged
71.
M. P. Ledward, of Manchester, Eng., July 2, aged 37.
W. W. Coggln, of Norfolk, Va., July 23, aged 66.
August 2, 1902]
CX)EKESPOXDENCE
[AKEBICAN HKOtCtNB 169
CLINICAL NOTES and CORRESPONDENCE
[Ck)mmunlcationsare Invited forthia Department. The Bklitor U
not responsible for the views advanced by any contributor.!
SHOULD THE TAMPON BE USED IN POSTPARTUM
HEMORRHAGE ?
BY
J. F. BALDWIN, M.D.,
of Columbus, Ohio.
A little more than a quarter of a century ago, as a pupil of
the late EUerslie Wallace, of Jefferson Medical College, I was
taught that the use of the tampon for the control of postpartum
hemorrhage was not only useless, but was a procedure fraught
with the gravest danger, since while the external hemorrhage
might be controlled the bleeding would go on internally with-
out hindrance, but rather with increased violence, owing to the
opening of the uterine sinuses. (The dangers of sepsis were
not recognized at that time.) We were taught that the tampon
could be properly used in cases of hemorrhage from miscar-
riage or placenta praevia. The student who would recommend
the use of the tampon for the control of postpartum hemorrhage
was loolied upon as not only grossly ignorant of obstetrics, but
also grossly ignorant of the general principles of physics and
of physiology.
When, therefore, at a recent society meeting a professor of
obstetrics in a medical college unhesitatingly advocated the use
of an intrauterine gauze tampon for the control of postpartum
hemorrhage, the suggestion came as a decided sliock ; and yet
a little investigation shows tliat such is the teaching of some, at
least, recent obstetric writers. When did this change in teach-
ing take place, and what are the arguments which can be ad-
vanced in favor of this procedure?
Hirst,' though admitting that postpartum hemorrhage can
be so profuse as to kill the patient in five minutes, recommends
kneading, compressing and rubbing the uterus ; introduction
of the hand into the uterine cavity, thus combining internal
irritation with the external manipulation ; the application of
ice upon the hypogastrium ; pouring of ether upon the hypo-
gastrium ; and introduction into the uterine cavity of gauze
soaked in vinegar. Should these means fail, he tells us, "the
uterine cavity should be packed with iodoform or sterile gauze.
In the intrauterine tampon we possess the surest and most reli-
able means of controlling postpartum hemorrhage." The
illustrative cut to which we are referred as showing the tochuic
of inserting tlie tampon is very amusing. It represents the
obstetrician introducing the gauze with dressing forceps in a
strip about an inch wide, the gauze being taken from a small
gla.ss container. Even if a thorough tamponade would control
the hemorrhage, the patient would be dead long before such a
tampon could be introduced by this method. Compared with
such a technic, the pleasant conceit of Mrs. Partington, sweep-
ing back the waves of the Atlantic with her broom, rises to the
dignity of one of the eternal verities.
Grandin and .larman state' that "it has been proved that
the intrauterine tamponade is not alone effective, but safe."
These autliors do not give us any cut showing us how the gauze
is to be introduced, but state (page 1")9) that "the gauze, for
purposes of the tamponade, should be two inches in width, and
fully five linear yards will be needed." A strip two inches wide
and 15 feet long represents apieceof gauze just 19 inches square.
It is, of course, barely possible that the writers intended to say
square yards instead of linear, but this idea is negatived by the
cut shown in Hirst's lx>ok. They assure us, however, that the
uterine cavity must bo packed full, including the upper vagina,
since the aim is to control the bleeding through compression of
the bleeding point; so we will assume Mcpiare yards.
I have re<!ently come across two cases in which the obstet-
rician had resorted to this use of an iodoform gauze tampon. In
one case, a five-yard roll was used; in the other, six yards.
The hemorrhage continued, however, as before the gauze was
Introduced, and wa.s only checked by a resort to other means,
while in both there developed subsequently a very uncomfort-
> Textbook of Obstetrics, 1901.
' Textbook on I'ractlcal Obatetrtos, 1898.
able degree of sepsis, though, fortunately, both patients
recovered.
Every obstetrician is familiar with the occasional, though
fortunately very rare, occurrence of concealed hemorrhage, this
hemorrhage taking place between the membranes and the
uterine wall, and being due to a partial and usually accidental
separation of the placenta. This separation may be so extensive
as to result in the entire detachment of both placenta and mem-
branes, and the hemorrhage may be so large as to prove fatal
very quickly ; indeed, the mortality in these cases of hemor-
rhage seems to be even larger than that connected with pla-
centa prsevia. In all these cases nature has already in place a
tampon that is applied more firmly and more uniformly to the
uterine walls than is possible for any tampon introduced by the
obstetrician. If nature's perfect tampon is, therefore, such a
complete failure, what can be expected of the artificial oneT
Furthermore, the gauze which is recommended absorbs blood
like a sponge, and even if introduced satisfactorily would
enable an enormous amount of blood to be lost to the patient
without any appearing on the outside.
In the American. Journal of Obstetrics for December, 1901,
is a most interesting article by Holmes on this form of con-
cealed hemorrhage. Among his conclusions he states that the
tampon has no place in the treatment of such a case, and it is
hard to imagine how any one would think of using an intra-
uterine tampon under such circumstances ; yet even Holmes fol-
lows the lead of others in advising the tampon in ease there
should be a continuance of the hemorrhage after the uterus has
been emptied. In the same journal. Dr. De Lee, of Chicago,
reports three cases of placenta prievia. In all of these gauze
packing was used, but in none of tliem did it seem to be of any
benefit, although it was in some cases repeated several times.
In his third ease, which proved fatal, after emptying the uterus
and finding oozing continued, " the uterovaginal tract was
tightly packed with lysol gauze." Hemorrhage at once ceased,
but the patient was pulsele.ss, restless, dyspneic, and evidently
sinking. This condition was at once explained when it •was
found that oozing had begun through the tampon. The tam-
pon was at once removed with the intention of retamponing
with gelatin gauze, but the patient died before the second
tampon could be introduced. In this case no attempt seems to
have been made to secure contraction by the old-fashioned
methods, but gauze tamponing was alone trusted to.
As showing the extent to which the tampon is resorted to, I
notice in the same journal that Dr. J. Clarence Wel>ster, of
Chicago, reports a case of marginal implantation of the placenta
in which, after promptly effecting delivery without any hemor-
rhage, after pressure was once instituted on the fimdus, he
delivered the pla<!enta manually and then " plugged the cervix
and vagina promptly with a piece of boiled sheeting." It is a
relief to know that " the patient made a good recovery."
I am not a professor of obstetrics, nor in any sense an
obstetric specialist. Years ago I had a large olwtetric practice,
and am still frequently called in consultation In difficult <»se8,
since the practice of operative obstetrics is naturally a part of
the practice of surgery. But this method of controlling |M>8t-
partum hemorrhage seems to me to be contrary to physiology,
to physics and to alt surgical principles. Hemorrhage we
know can, under certain circumstances, be controlletl by pres-
sure, but I do not believe It Is possible for any man to intrtxluce
gauze into the full-term uterus so as to prmlnce a sufllclent
amount of pressure to wmtrol the hemorrhage. It is simply a
physical impossibility, and any good effects which may have
been noticed following the use of the tamtK>n have, it seems to
me, resulted merely from its presence, producing sufficient
irritation to cause oontraotlon and thus a closure of the veuoiu
sinuses.
I have said nothing as to the dangers of sepsis, but I do not
think It Is possible for a sufficient amount of gauze to be Intro-
duced into the uterus with sufficient pnmiptness to avail any-
thing without its l)eoomlng contaminate<l more or less from
contact with the vulva and vagina, to say nothing of more
remote sources of lnfe<;tlon. To accompUah anything the gause
must be crowded In freely and quickly, and this cannot bo
done with any very great regard to asepsis, except under the
most unusual clrcunutaacea.
170 AKKHICAN MEDICINBJ
CORRESPONDENCE
[AUGUST 2 1902
For several years Dr. Joseph Price, of Philadelphia, has
been criticising what ho regards as the unsatisfaetoriness of the
modern teaching of obstetrics. If the use of the tampon to
checli postpartum hemorrhage, which seems to me unphysio-
logio and most emphatically unsurgical, is good obstetrics, that
fact should be widely known, and this communication is written
not in a spirit of controversy, but purely to ascertain the truth.
FRACTURES DURING DELIVERY.'
BY
JOHN A. WESSIXGER, M.D.,
of Ann Arbor, Mich.
A report of the following two cases will serve as a text for a
few brief remarks upon the subject of fractures during delivery :
May 11, 1899, at 9 p.m., I was called to attend Mrs. R., a
young German woman in her first labor. Examination showed
a well-dilated os, and a breech presentation quite well advanced
toward delivery. As the breech passed into the inferior strait
I gave chloroform. Hooking the index finger into the child's
left groin, I made rather firm traction. Not succeeding in this,
I applied forceps to the breech and delivered at 11 p.m. The
head was delivered with some difliculty witli forceps 15 minutes
later. While making traction in the child's groin a sensation
as if a dislocation had taken place was imparted to my finger.
Examination later proved this to be a fracture of the left femur
in its upper third. Tiie child was stillborn. The perineum was
ruptured to the right of and well below the anus. This was
repaired 12 hours after by daylight, since we had only candle-
light to work with during the delivery. The mother made an
uninterrupted recovery without rise in temperature. Perineal
sutures were removed on tenth dav.
On January 5, 1901, at 6 a.m., I was called to attend Mrs. S.
in her first confinement. The patient is a strong, healthy
woman, 22 years old. The os was well dilated at 6 a.m., and
at 8 a.m. dilation was complete. With L. O. A. presentation the
descent of the head into the inferior strait being somewhat
tardy, I gave chloroform at 9 a.m., and delivered with short
forceps. After delivery of the head I made traction in the left
axilla to deliver the body. During this maneuver I felt some-
thing " give," the sensation imparted to my finger being as if a
muscle had ruptured. The child when born was very active,
and in every way apparently normal. I examined the arm
closely after delivery, but found no injury. The trained nurse
noticed nothing wrong in bathing and dressing the child. On
the third day my attention was called to loss of mobility
together with some swelling of the arm. Examination at this
time revealed a complete fracture of the left humerus in its
middle third. Under proper splints the arm made a rapid and
complete recovery. 'The antecedents of both patients are
unknown to me.
There is no bone in the human body that is exempt from
fracture, and there is no period in the lifetime of a human being
during which fracture of the bony frame may not take place.
Even in the early periods of gestation, and throughout the pre-
natal life of the fetus this type of injury to the bones may
occur. I need hardly mention that the most common fractures
at delivery are those of the long bones, and of these the most
commonly injured are the humerus and femur, the humerus
much more frequently than the femur because cephalic prepon-
derates over podalic delivery. These injuries usually occur at
or very near the conclusion of the delivery, since they often are
the result of too violent traction or undue effort at extraction of
the fetus ; a contracted pelvis or uterine inertia may be causative
factors, or disproportion between the size of the child and the
maternal parts may enter as a cause. Then, fractures at this
period may be the result of criminal intention. Under such
circumstances, however, we usually find other lesions in asso-
ciation upon the child's body which will help to establish the
medicolegal aspect of the case. We may have fractures of the
skull resulting from faulty adjustment of the forceps. Fracture
of the ribs may also take place from the same cause. A child's
rib may be broken during a cephalic or podalic version. But
injury to the bones during such operations rarely occurs.
While these fractures are usually the "green stick" or
partial variety, yet we do see cases in which the bone has
broken completely through, and such can become even an open
fracture. While partial fractures are usually due to violence,
we can hardly admit that a complete fracture is always and
wholly due to this cause. In cases of rachitis and syphilitic
Infection the osseus tissue is very fragile. In such cases we
1 Read before the Ann Arbor (Mich.) Medical Club.
might say there is an inherent tendency to fracture on account
of the disproportion between the organic and mineral constitu-
ents of the bones. Another injury that sometimes occurs, and
perhaps more frequently than fracture, is epiphyseal separation.
The practical significance of this lesion is the liability to impair-
ment of the future growth of the limb. An epiphyseal separa-
tion can quite easily be overlooked and the resulting arrest of
development be attributed to neuritis or other nerve injuries.
Many of our textbooks have very little or nothing upon the
subject of fracture during delivery, yet it would seem that the
subject is of sufiicient importance, and the injuries occur
with sufficient frequence to merit a more extended eonsidera^
tion by the profession.
GANGRENOUS APPENDICITIS WITH PERFORATION.
BY
i<\ H. HOWARD, M.D.,
of Wllllamstown, Mass.
To the Jiditor of American Medicine .—Two cases of gan-
grenous appendicitis with perforation came recently under my
observation. Each patient had a pulse of from 50 to 5.5 for 2A
hours before perforation occurred. There was no fever in either
case until after perforation. In both instances a prompt opera-
tion revealed a perforation and a diffused peritonitis. One'of
the patients recovered, the other died.
The retardation of the heart-beat in these cases was probably
due to the irritation of the peritoneum as it became involved in
the necrosis. The phenomenon was similar to the reflex
inhibition of the heart often produced in the physiologic labo-
ratory by irritation of the endings of the mesenteric 'nerves in
the peritoneum.
I wish to suggest that in appendicitis a slotv full pulse may
be a valuable sign of impending perforation. It may likewise
be a sign of equal value in other intestinal necroses involving
the peritoneum.
I would appreciate criticism of this suggested "sign" by
some of your readers who have had much experience in the
condition under consideration.
MEDICAL LICENSURE RECIPROCITY.
To the Editor of American Medicine: — The author of the
article entitled " Medical Licensure Reciprocity," which
appears on page 10 of your issue of July 5, neglected to say
that the Medical Board of Ohio used all reasonable means to
induce the members of the class from which this gentleman
graduated to come to the June examination, and oftered to
accept certificates from the dean of their college, stating that
they would be graduated on a certain date as sufficient upon
which to admit them to the examination. The members of
this class, however, did not see fit to comply with this arrange-
ment. The Medical Board of Ohio is .always ready to accommo-
date in every possible manner those who are desirous of taking
the examination in Ohio, but it is unreasonable to suppose that
they can give a special examination to each one who feels
called upon to enter the practice of medicine in Ohio immedi-
ately after the receipt of his diploma.
N. R. Coleman, President,
Frank Winders, Secretary.
ABSENCE OF LEFT INFERIOR THYROID ARTERY.
BY
G. F. SHIMONEK, M.D.,
of Milwaukee, Wis.
To the Editor of American Medicine : — Following is a report
of a rare anatomic anomaly, absence of the left inferior thyroid
artery :
Case. — A male laborer, aged 49, has had a parenchymatous
goiter of the left half of the thyroid gland for the past 30 years.
The goiter is about the size of a large apple. Extirpation re-
vealed the absence of the corresponding inferior thyroid artery.
After ligation of the left superior thyroid, the isthmus and
veins, the tumor was removed without any hemorrhage what-
ever.
Al-ol'ST 2, l!K)2i
REPAIR OF CYSTOCELE
[AjfKKICAN UKOICINK 171
ORIGINAL ARTICLES
THE PRINCIPLES UNDERLYING THE REPAIR OF
CYSTOCELE AND AN OPERATION FOUNDED
THEREON.
BV
EDWARD REYNOLDS, M.D.,
of Boston, Mass.
There are two anatomic points which seem to me to
underly success in the operation for cystocele. Neither
of these points is original with me but one has, I think,
attracted too little attention, the other none at all ; and
a.s their observance has guided me to an operation with
which I have had much greater and more constant satis-
faction than with any other which I have ever tried, I
think it worth while to bring them to attention once
more.
To draw attention briefly to these two points and
describe that operation, is now my object.
The first point is, that to attain success we should
ascertain and utilize the natural supports of the anterior
wall instead of
simply denuding
and gathering to-
gether the over-
stretched portions.
The second, that
we should not only
avoid using any
part of the over-
stretched portion
of the wall, but
should actually
excise and do away
with it ; both of
which objects
sliould be attained
without the per-
formance of an un-
necessarily exten-
sive or severe
operation.
The mechanics
of pelvic support
are after all these
years still the sub-
ject of d i s p u t e ,
but a few points
Fig. 1.— The heavy straight lines indicate dla- are clear. The an-
granimalloally the position of the repaired fArifir vncinnl u/nll
wall. The lighter radiating Hues suggest J«"or \dgl mil wait
the line of force of the fibers of the broad has naturally tWO
ligament lus caught up by the sutures. It fivpd nninty Af nt.
is to he noted that this force is derived ! T;' l"""^^ "^ ai
from their attachment to the pelvic walls, tacnment. I he
Its situation In the diagram Is somewhat first is that of the
lower end of the
wall to the posterior surface of the pubes. This is
exceedingly firm and never yields. The same ainnot
be siiid of the attachments of the upper end of the wall ;
they are, however, sufficient for our present jmrpose.
We know that in prolapse of the uterus all the attach-
ments of the vault fail, but we also know thsit in pro-
lapse compliciite<l by cystocele, we cannot cure the cysto-
cele without restoring the prolapse, and our experience
of late years in the total extirpation of the uterus and
upper portion of the vagina for canwr has taught us all
that the only attiu-hment between the genital canal and
the pelvic wall, which is not retulily sejrarated with the
finger, is the insertion of the broad ligaments into the
lateral edges of the utt^rus and the vault of the vagina.
ThLsonly firm support of the vault furnish then the only
upper points which can rationally be used in the restora-
tion of the anterior wall. The utilization of the bases
of the broad ligaments has, moreover, the very great
incidental advantage, that it not only relieves the uterus
of the weight of the prolapsed anterior wall, but in
Itself, as will be seen, tends to restore the prolapse by
throwing the cervix backward. The first point in any
operation should then be the attachment to each other of
these two firm portions of the wall.
This approximation of the firm lower and upper
attachments of the anterior wall has been aimetl at in
Emmet's and Watkins' operation, and 1 believe under-
lies their suwess. To it should be addetl, however, in
my belief, the second principle of the excision of the
weakened portion of the wall. The anterior vaginal wall in
its natural condition is a short, firm, fascial and muscular
structure which extends from its origin at the firm bases
of the broad ligaments to its still firmer pubic attach-
ment, thus forming one of the strongest supports of the
uterus and other pelvic organs. Look now at its condi-
tion in cystocele. If any one will freely incise the anterior
viiginal wall in a well-developed cystocele, I believe he
will find, as I have done, that the cond:t::.n is that repre-
sented by the first figure, nt^lecting the diagrammatic
straight lines ; i. e., that the central portion of the protru-
sion is covered by an overstretched, thinned, and weak-
ened vaginal wall ; thus the support of the uterus is weak-
ened, while the base of the bladder has practiwvlly no
support. This thin portion of the wall is overstretche<l
because it has lost its elasticity, i. e., has lost its power of
resistance to further stretching, anil if we utilize for repair
any part of this weakened portion of the wall, we shall
have as a result a weak saxr which is necessarily predis-
posed to further stretching.
Cystocele is in effect a hernia of the bladder through
the muscular and fascial structures of the anterior wall of
the vagina, and this second principle involved in dealing
with it is essentially that which is already well estab-
lished in the treatment of other hernias. It has been
customary to treat cystocele by denuding the vaginal
wall of its epithelium, invaginating the protrusion, and
stitching the denude<l surfaces together. No one would
today think of treating any other hernia by denuding
the protrusion of its surface epithelium, invaginating it,
and sewing the surfaces together. I do not believe that
we should so treat the hernia of the bladder, which we
call cystocele. We are accustomed to treat other hernias
by reducing them and excising the .sac until we lay bare
strong, firmly attached fascial iniges. 1 believe that we
should so treat cystocele, if we can devise an operation
which win enable us to do it without undue severity —
and such an operation I have now to describe.
The anterior wall having Ixjon exposed, preferably in
Sims' position, the points .V A (F'ig. 2) at the sides of the
Fig.:^.
t«rvlx are marked by temurulums or tis-sue forct^ps. riu>
point C, the highest point in the anterior wall which is
still entirely intiu't and unthinnixl, is .seiz(>d with tissue
forwps and pushed upward along tlie mtHlian line until It
is upon the strett-h. The points H IJ, situat<><l laterally
exterior to A A, are then selivte I as thost? whli-ii iim be
drawn by teniuiulums or tissue forceps into apposition with
C on the me<lian line, and an* similarly marked. The
cnwcentic area indii»t4Hi in the <liiigram is then lightly
marked out with a knife at a guide in the exuision of the
172 AMEBICAN MBDIOINBJ
EEPAIR OF CYSTOCELE
[August 2, 1902
weakened portion of the wall, the point D being not more
than half an inch in front of the cervix. Its exact posi-
tion is unimportant. A short transverse incision at C is
then carried through the vaginal wall until the point of
cleavage between this wall and the bladder is found.
The handle of the scalpel is then pushed upward, easily
separating the vaginal and bladder walls until it is seen
to reach the inner edge of the crescent at D.
The vaginal wall is then, as a matter of convenience,
divided along the dotted line C D, and the vaginal and
bladder walls are then rapidly and easily separated by
the handle of the scalpel over the whole of one lateral
half of the area marked out by the knife. The separated
vaginal wall is then removed with the scissors and the
process is repeated on the opposite side, leaving the unin-
jured bladder wall exposed over the whole crescentic
area. The points B B are then connected with C by
sutures a-s indicated in the diagram, at C the needle being
Fig. 3.
made to pass deeply through the whole thickness of the
vaginal wall, and at B still more deeply in order to catch
the fibers of the lower portion of the broad ligament ;
these sutures having been tied, the incision falls into the
shape shown in the third diagram ; the remainder of
the wound is rapidly whipped together with a running
catgut suture, the needle passing at each insertion
through the whole thickness of the vaginal wall, and the
operation is thus completed, the lines of union lying in
the form shown in the fourth diagram.
As the result of this operation, the cervix is thrown
somewhat further back than before, and the anterior
vaginal wall is therefore rather lengthened than short-
ened, but its attachment has been transferred to the
firmest supports of the vaginal vault, the ba.ses of the
broad ligaments ; the uterus has thereby been relieved of
weight, and is found to be higher rather than lower ; and
the wall as a whole is drawn upward and forward behind
the Jpubes in a way which aifords a surprisingly firm
support for the base of the bladder. (See straight lines on
Fig. 1.) It might appear at first sight that a cavity
would be left between the unaltered bladder wall and
the line of union of the vaginal wall, but in practice the
contractile bladder wall at once shortens itself to its new
position, and no such cavity is left. The only vessels
divided are situated in the vaginal wall, and bleeding is
consequently controlled by the sutures. In practice I
have had no trouble from this source. The only objec-
tions to the operation which I have been able to find so
far are, that in case of failure of union a secondary opera-
tion would be more difficult than after a simple denuda-
tion, and that it is not well adapted for performance
at the same sitting with the repair of an unusually deep
laceration of the cervix. An ordinary trachelorrhaphy
does not interfere with it.
I have performed the operation six times.
Mrs. A. D. P., aged 38, is the mother of three children, the
youngest aged 3. The heart, lungs and urine were normal,
"uterus was heavy and retroverted. There was moderate eysto-
cele, with considerable rectocele. Operation was performed
January 24, 1902, in the presence of Drs. Hubijard, Wadsworth
and Allen. Cystocele was treated by the nietliod described.
Perineorrhaphy and ventrosuspension were done with excep-
tionally good results.
Mrs. M. Mc, aged 52, is the mother of two children,
youngest aged 20. The heart, lungs and urine were negative,
there was cystocele and rectocele. Operation was performed
.January 30 in the Free Hospital for Women. Cystocele treated
by method described. Perineorrhaphy was done and the peri-
neal result was good. Operation on cystocele was exceptionally
good.
Mrs. N. M. B., aged 56, has ten children, the youngest aged
21. She presented no constitutional symptoms. There was
cystocele with rectocele. Operation was performed March 4 in
the Free Hospital for Women. Cystocele operated on by above
method. Perineorrhaphy was done ; the results were good.
Mrs. A. D. W., aged 05, has five children, the youngest aged
30. Heart, lungs and urine were normal. Fundus was in nor-
mal position, but there was a greatly elongated supravaginal
cervix with prolapse of the anterior and posterior vaginal walls.
Operation was performed March 18 iu the Free Hospital for
Women. The cervix was amputated. Cystocele operated on
by above method. Perineorrhaphy was done. The result is
good.
Mrs. E. K., aged 49, is the mother of two children, the
youngest aged 26. She entered the Free Hospital for Women
with pain about an encysted hydrocele of the cord. The heart,
lungs and urine were normal. The uterus was retroverted and
prolapsed with cystocele and rectocele. Operation was done
March 13. Closure of inguinal ring and ventrosuspension was
done by Coley's method. On March 25, cystocele was treated
by above method. Perineorrhaphy was done and there were
good results all around.
Mrs. F. J. D., aged 42, was seen by me with Dr. A. N. Little.
She has two children, youngest aged 12. The heart, lungs and
urine were negative. A slightly low uterus, was large and heavy.
There was slight laceration of the cervix, rectocele and cysto-
cele. Operation was performed April 28. The uterus was
curetted and cervix repaired. Cystocele treated by above
method. Perineorrhaphy was done by Dr. Little.
In the sixth case the result was unsatisfactory. The
operation was preceded by curettage. The patient was
the subject of goiter, and profuse uterine hemorrhage
took place a few hours after operation. It was unex-
plained, unless as the result of the abnormal circulatory
condition of the patient. The operation was done at a
distance, and the attending physician was able to control
the hemorrhage only by a hurried packing of the
vagina. This resulted in suppuration and loss of union.
In the other five cases the results were eminently satis-
factory. The one failure was apparently the result of a
rare general pathologic condition, and although I wish
to give full emphasis to any possible objection to the
operation, it should not, in my opinion, outweigh the
fact that the other results were in every way better than
I have ever before been able to obtain in operating for
cystocele.
A Physician Honored.— At the regular meeting of the
Delaware County (lud.) Medical Society, held June 6, 1902, the
following resolutions honoring Dr. Vinnedge, of Lafayette,
Ind., were adopted :
Whereas. Dr. W. W. Vinnedge, of Lafayette, Indiana, kindly con-
sented to visit our County Medical Society on May 2, 1902, therefore
be it
Hesolved, That the Delaware County Medical Society hereby
tenders a vote of thanks to Dr. W. W. Vinnedge for his visit, and also
his valuable paper ••On Some Present Obstacles ta Professional Unity,"
read before our Society at its meeting on May 2, 1902, la Munele, ludi-
ana. That this Society concurs in, and endorses the sentiments of Dr.
Vinnedge In his efforts to purify the ethics and morals of our profes-
sion. That we request Dr. Vinnedge to offer his article for publication
in American Medicine, and that these resolutions be spread upon our
minutes and a copy transmitted to Dr. Vinnedge.
H. C. BURCHAM, Pres.
Muncie, Ind., June 6, 1902. UI.YSSES G. Poland, Sec'y.
August 2, 1902|
SIGNIFICANCE OF POSTOPERATIVE PLEURISY iamerican medicine 173
THE SIGNIFICANCE OF POSTOPERATIVE PLEURISY:
ITS RELATION TO PULMONARY EMBOLISM.
BY
G. BROWN MILLER, M.D.,
of Washingtou, D. C.
Associate Visiting Surgeon of the Columbia Hospital for Women,
Washington, D. C. ; formerly Resident Gynecologist In the
Johns Hopkins Hospital, Baltimore, Md.
In the records of the grynecologic department of the
Johns Hopkins Hospitiil from 1890 to 1901 inclusive
there are noted 16 cases of postoperative pleurisy. The
eases of pleurisy accompanying recognized pulmonary
tuberculosis are not included in this list. In reading
the histories of these eases my attention was attracted to
the large percentage of the patients who had suffered at
some period of their convalescence with a socalled
phlebitis, a pulmonary embolus, or a combination of
these affections. On studying the histories more care-
fully, the evidence seemed quite conclusive that in at
least one-half of the cases the pleurisy had its origin in a
pulmonary embolus and was probably the result of an
infarction of the lung. Phlebitis or thrombosis of the
crural vein, some of its branches, or one of the pelvic
veins was in most of these cases the apparent source of
the embolus. The belief that the signiflcance of the
signs and symptoms which give rise to a diagnosis of
postoperative pleurisy is not fully appreciated led me to
publish the series of ca.ses. The histories are much
abbreviated, the endeavor being to bring out only the
facts bearing upon the subject under consideration. I
have likewise copied from the literature some cases
which are illustrative of the subject.
Since Virchow's work upon embolism it has been
universally recognized that pulmonary emboluses fre-
quently give rise, when death does not rapidly take
place, to diseased conditions of the lungs, such as pneu-
monia, abscess, infarction. It is likewise universally
recognized that pleurisy often accompanies these condi-
tions. There are, however, many cases of pleurisy,
either with or without effusion, which are classified as
"probably tuberculous," rheumatic, etc., which bear a
direct relation to pulmonary embolism and its resulting
infarction, and to these cases which occur after operation
I wish to call attention.
Welch' says:
Bland embolism in modium-sizetl and small branches of
the pulmonary artery, and without serious impairment of the
pulmonary circulation, usually causes no symptoms and no
changes in the parenchyma of the lungs. Even in lungs struc-
turally altered and without serious disturbances of the circula-
tion such embolism may be without effect. The explanation of
the harmlessness of the majority of medium-sized and small
pulmonary emboli is that the collateral circulation through
the numerous and wide pulmonary cjipillaries is, under ordi-
nary conditions, quite capable of supplying sufficient blood to
an area whose artery is obstructed to preserve its function and
integrity ; and that the pulmonary tissue, in contrast to the
brain and the kidney, is relatively insusceptible to local anemia.
Often enough, however, medium-sized and smaller branches
of tlio pulmonary artery are occluded by emboli or thrombi
under conditions in which the pulmonary circulation is inca-
Eable of compensating the obstruction, and then the result is
emorrhagic infarction of the lungs. The most common and
important of the conditions thus favoring the production of
hemorrhagic infarction is chronic passive congestion of the
lungs from valvular or other disease of the left heart. It is
especially during the broken compensation of cardiac disease
that liomorrhagic infarction of the lungs occurs; sometimes,
indeed, almost as a terminal event. Other favoring conditions
are weakness of the right heart, pulmonary emphysema, infec-
tive diseases. Tlie source of an embolus causing pulmonary
infarction is oftener the right heart than a peripheral thrombus.
(This is reversed in postoperative embolism.)
The infarction may be caused also by thrombosis of
branches of the pulmonary artery, which are not infrequently
the seat of fatty degeneration of the intinia and sclerosis in
cardiac disease and in emphysema. Thrombi in larger
branches may give rise to emboli in smaller ones.
Ucmorrliagic infarction of the lungs maybe entirely latent;
often enough, however, the diagnosis may be made during life. |
The affection may be ushered in by a chill or chilly sensations, |
increase ma usually existing dyspnea, and localized pain in
tne sides. These symptoms are far from constant. The charac-
teristic symptom, although by no means pathognomonic, is
Dloody expectoration. Profuse hemoptysis was noted by Laen-
nec, but is very rare. The sputum contains clots and streaks
01 blood, or small coagulations; or more frequently, the blood
18 intimately mixed with the expectoration which is in small
masses and usually less viscid and darker than that of pneu-
monia, although It may resemble the latter. Blood may be
present in the sputum for one or two weeks, or even longer
alter the onset of an infarction. It acquires after a time a
R5°i^'?'** r."'®'' ""* ""'^ generally contains the pigmented epi-
thelial cells usually seen in the sputum of chronic passive con-
gestion. Circumscribed serofibrinous pleurisy is usually
associated with pulmonary infarction. Even with infarcts
not more than four or five centimeters in diameter the physical
signs of consolidation and subcrepitant rales can sometimes be
detected; usually in the posterior lower parts of the lungs.
These signs are referable not only to the infarction, but also to
the surrounding localized edema, and perhaps to the reactive
?i??"'"°°'"' '^^^'^^ fflay he moderate elevation of temperature.
\\ hen the characteristic bloody expectoration, together with
signs of circumscribed consolidation, appears in the later
stages of cardiac disease, or with peripheral venous thrombosis,
there is little doubt of the diagnosis.
Osier - says :
The pleura over the infarct is usually inflamed. . . .
The symptoms of pulmonary apoplexy are by no means
detinite. . . . When the infarcts are very large and particu-
larly in the lower lobe, where they most coinnionlv occur,
there may be signs of consolidation with blowing breathing.
Striimpell ' says :
Large peripheral infarcts may give rise in many cases to
dulness on percussion, crepitant rales, harsh and bronchial
respiration. We sometimes hear a pleuritic friction sound a
few days after we suspect an infarction has occurred. (Small
infarctions often cause no special symptoms, but in other cases
the patient feels a severe pleuritic pain due to irritation of the
pleura.
In fact, the authorities agree that a pulmonary embo-
lus which does not cause death to ensue too rapidly gives
rise under favoring conditions to a hcmorrhagic'infarc-
tion which is usually accompanied by a pleurisy. In
other instances an embolus will apparently give rise to
sudden sharp pain in the chest, dyspnesi, more or less
marked, an increased rapidity of pul.se rate, cough,
slight elevation of temperature; indeed to many of the
symptoms which lead to a diagnosis of pleurisy when a
careful physical examination is not made. In some of
these cases there may he no infarction and no pleurisy,
but the sym[)toms may \>e caused, as suggested by Mah-
ler, by "the impaction of small emboluses in the fine
branches of the pulmonary sirtery even to the pleura."
In most cases, however, there are deflnit*' signs of
pleurisy, as shown by the friction rub, and in certain
instances by an effusion. Following operations upon the
abdominal and pelvic viscera, especially in cases of (car-
cinoma, myoma, large ovarian tumors, and jK'lvic in-
flammations, the conditions are present which favor the
formation of thrombuses in the peripheral veins, and
likewi.se the formation of a hemorrhagic infarction
when a pulmonary embolus occurs. The latter, as given
by Welch, are : Chronic passive congestion of the lungs
from valvular or other disease of the left heart, weak-
ness of the right heart, fatty degeneration of the heart,
general feebleness of the circulation, pulmonary empliy-
.sema and infe<'tive disejL'ies. I'ozzi ' stiites that many
abdominal tumors cause an augnient«Hl vascular tension
and react on the cardiiu; muscle, [iroducing hypcrtrojihy
with or without dilation. Hofmcier' reports nine cases
of death aft<'r operations for alHlominal tumors, in all of
which there were found on anatomic examination either
fatty degeneration or brownatrophy of the heart muscle.
Mahler" reports 14 cases of fatal jiulinoimry embolism
following lalwr or gymn-ologlc operations. In 12 of
these cjisesan autopsy was made and in 10 of them there
were found pathologic changes In the heart muscle.
Kessler' found the caus«' of death in a patient whr) died
suddenly after an o{)eratlon for myoma to be <' myoHbro-
sis cordis."
Thus there is frequently found after these operations
174 AMKBioAN MBDiciNK] SIGNIFICANCE OF POSTOPERATIVE PLEURISY
[AUGUST 2, 1902
passive coHgestion of the lungH due either to the above-
mentioned or other lesions of the heart, general feeble-
ness of the circulation as a result of the disease itself,
hemorrhage either before or during the operation, shock,
the effects of the anesthetic, and occasionally to the
ehemic or toxic effects of infected emboluses. The favor-
ing condition being frequently present, infarction
actually occurs, and the symptoms before enumerated
are, probably, in a majority of the cases, referable to a
pleurisy which accompanies the infarct.
Mahler was probably the first to call attention to the
value of sudden sharp pain in the chest, frequently
accompanied by dyspnea and increased rapidity of the
pulse, in diagnosing a threatened serious pulmonary
embolism. He regarded these symptoms as due to the
impaction of small emboluses in the terminal arteries of
the lungs, even to the pleura, and calls attention to the
fact that as these symptoms are due to small emboluses,
larger ones may occur and consequently the physician
should be on guard when during a convalescence the
patient complains of such symptoms. Pinard," in the
same year wrote concerning the value of thoracic symp-
toms in predicting the occurrence of phlegmasia alba
dolens. He says :
When we note supervening upon the convalescence from
labor a stitch in the side, not marked, or a pain of sufficient
severity to cause the patient to cry out, pain at the point of the
shoulder, coincident with disturbance of the rhythm of respira-
tory movements, we think of the existence of pulmonary em-
bolism, of small emboluses which cause the above-mentioned
symptoms and which are followed after the lapse of two to eight
days by the appearance of a phlegmasia alba dolens. . . .
In twelve cases in which we have followed the course of the
accident we have seen phlegmasia supervene five times in one
leg, six times in both legs and once in the arm. . . . Phleg-
masia mav be announced by the precursory signs as fol-
lows : Stitch in the side, pain in the upper thorax or point of
the shoulder, dyspnea or orthopnea, variable and fleeting aus-
cultatory and percussion signs, bloody sputum, and finally
phlegmasia. Folet' remarks that instead of making the symp-
toms of an infarction a precursory sign of the formation of a
phlebitis, one can regard it as the result of that thrombosis.
Lequint '" says :
In looking over the published cases on this subject one can
find frequently, if not constantly, the signs indicated by M.
Pinard. At a date more or less distant from the operation there
occur the stitch in the side, oppression, bloody sputum with or
without physical signs in the chest, such as zones of impaired
or blowing breathing, signs of a dry pleurisy over the seat of
pain or a small effusion. ... In certain cases one can
place these symptoms to the account of a congestion of the lung.
. . . But with these thoracic symptoms there is not the
elevation of temperature indicative of an inflammatory lesion
of the lung.
The signs are due, he thinks, to a small infarction. He says
that in such instances it is necessary to be suspicious, for these
small emboluses are able, if not to cause serious disturbances, at
least to make us think of the detachment of larger emboluses.
These cases of small emboluses are relatively benign, and heal-
ing can take place, but the contrary may happen and the patient
may die in a few days.
In the following cases I have given all the recorded
information bearing upon the causes of the pleurisy :
Case I.— M. A., aged 46, was admitted October 3, 1892.
Past History. — She had typhoid fever during her flfteenth
year and occasionally since that illness her left leg had swollen.
On admission, it was sensitive to pressure.
Family History.— Her father died of pulmonary tuberculo-
sis. It was otherwise negative.
Physical examination was not noted.
Operation. — Multiple myomectomy (October 31, 1892), a
number of small myomas being enucleated.
Eleven days after the operation she began to complain of
sharp, lancinating pain in the lower right thorax and a short
hacking cough with little or no expectoration. There was a
sudden elevation of temperature to 101° F. and a corresponding
increase in the pulse rate. Examination of the chest revealed
a decreased vocal fremitus with flatness in percussion extending
as high as the eighth rib behind. Auscultation showed a rough
friction rub synchronous with breathing and the breath sounds
were heard more faintly over this region than elsewhere.
Aspiration brought away a small amount of clear fluid.
Note. — November 12: The cough has disappeared, but
there is still an area of dulness extending to the ninth rib. The
left leg is now swollen for the first time since her admission
and is tender to the touch.
This condition of the leg continued for 10 days. There was
some thickening of the pleura at her discharge from the hos-
pital.
While this case is only suggestive yet the sudden
onset of the pleurisy occurring on the eleventh day after
operation and followed by the signs of thrombosis of the
veins of the left leg makes one think of the relation
between the two.
Case II.— J. C, admitted May 9, 1895. Past and family his-
tories are negative. No note was made on examination of the
chest prior to operation.
Operation (May 11, 1895).— Hysteromyoraectomy. The re-
moval of the uterus with its myomas presented no unusual diffi-
culties. No thrombosed vessels were noted.
^o<e.— May 18, 1895: The patient felt well until this morn-
ing when she began to complain of severe pain in the left chest
synchronous with respiratory movements. She cannot take a
deep breath without crying out with pain. The respirations are
short, shallow and somewhat spasmodic. Percussion negative.
On auscultation, at the upper border of the eighth rib on the left
side a distinct pleuritic friction sound is heard over an area as
large as the palm of the hand. Heart sounds are normal. The
chest was strapped with great relief from pain.
May 19: The face is flushed. Temperature is 102° F., and
pulse 104.
May 20: Temperature is 103° F., and pulse 104.
May 23: Temperature is 99.5° F., and pulse 88.
May 24: The signs of pleurisy have entirely disappeared.
May 29: The patient had done well until today, when while
sitting on a commode she suddenly fainted. She was at once put
in bed. Her pulse was weak and had a rate of 120 beats per min-
ute. As soon as she recovered consciousness she began to com-
plain of a heavy aching pain over the sternum. She suffered with
dyspnea, the heart's action was tumultuous and Irregular, the
hands and feet were cold and she complained of dark spots before
the eyes and ringing in the ears. The symptoms increased for
several hours when after an examination of the lungs, which
was negative, a diagnosis of secondary hemorrhage was made
and an exploratory laparotomy performed. This showed noth-
ing to warrant the symptoms and the diagnosis was changed to
pulmonary embolism.
May 30: The patient has improved steadily since operation
but still has many of the same symptoms. Today she began to
complain of pain in the left leg.
May 31 : The patient has all the symptoms of phlebitis of
both femoral veins.
June 14 : She complains of pain along the right brachial
artery. No swelling of the arm noted.
She ultimately recovered from both affections.
This is a very instructive case. The following con-
clusions seem to be warranted : Following operation
there was a thrombus of one or more of the pelvic veins
which gradually extended, finally involving both the
femorals. The first attack (pleurisy) was the result of
a small embolus with its resulting infarction. The
second attack was occasioned by a pulmonary embolus
of considerable size.
The symptoms of phlebitis came on after the occur-
rence of the emboluses because the femorals were in-
volved later by the thrombotic process.
Case III.— M. W. was admitted November 8, 1895, and
operated upon November 11, an ovarian cyst being removed.
The sixth day after operation she developed symptoms of
localized pleurisy, i. e., pain in the axilla increased on breath-
ing, slight dulness on percussion, and a to-and-fro friction rub.
The pulse rate increased from 9«3 to 120, and remained rapid for
several days. The temperature was not elevated. The symp-
toms lasted several days. A note November 26 states that the
pain had entirely disappeared. She was discharged well De-
cember 5.
In this case there were no definite signs of embolism.
The sudden onset of localized pleurisy coming on six
days after operation and disappearing in a short time
with marked increase in rapidity of pulse, and no eleva-
tion of temperature are, however, suggestive of an em-
bolus as being the cause of the pleurisy.
Case IV.— E. E., operated upon December 30, 1896, the oper-
ation being a hysteromyomectomy. There was no history of
disease of the lungs. The operation was uncomplicated.
On .lanuary 10 she had a sudden elevation of temperature
from 99° F. to 101° F., and the pulse rate increased from 90 to
130. She complained of sudden sharp pain in the right axilla,
which was more severe on deep inspiration. On auscultation
pleuritic friction sounds were heard over the seat of pain.
On January 14 she began to complain of pain and stiffness
of the right leg, which was somewhat edematous and had a
" glazed " appearance. A note made January 30 states both the
pleurisy and "phlebitis" had disappeared.
AUGUST 2, 1902]
SIGNIFICANCE OF POSTOPEEATIVE PLEURISY iakkkicas mkdicihk 175
Case V. — E. F., operated upon January 21, 1897. the opera-
tion being a hysteromyomectomy. Tlie heart and lungs were
normal prior to operation. Following operation tliere was sup-
puration of the abdominal incision.
On February t! she developed a "phlebitis" of the left leg,
and on February 10 the right leg became similarly affected. A
note February l.'i says that both legs were massaged. On
February '2>) she developed sudden pain in the right upper
chest with the physical signs of pleurisy, )'. c, slight dulness
over the seat of pain, impairment of breath sounds, and a
pleuritic friction rub. Botli the pleurisy and phlebitis cleared
up, and she was discharged well.
Case VI. — F. L., was admitted January 24, 1899, and un-
derwent an operation (vaginal hysterectomy) for carcinoma
of the cervix uteri January 25.
The examination of the chest prior to operation showed the
lungs to be normal and a faint systolic murmur at the apex of
the heart which was not transmitted.
On February lii she complained of pain in the left leg, and on
February 17 had all of the symptoms of phlebitis. The femoral
vein was felt a.s a iiard, sensitive cord ; there was edema of the
leg, a temperature of 100° F., and an increased rapidity of
pulse.
On February 22 she suddenly developed a sharp pain in the
lower part of the right chest, worse on inspiration, and a hack-
ing cough. Physical examination showed a slight dulness over
the site of pain, a few subcrepitant rales and a pleuritic friction
sound were heard in the same region. This and the piilebitis
disappeared, and she was discharged well February 27.
Case VII.— M. S., operated upon July 21, 1900, for a multi-
nodular myomatous uterus (hysteromyomectomy).
The examination of the chest prior to operation was nega-
tive.
The patient did well following operation until August 3,
when she began to complain of a severe pain in the right lower
axilla. A well-marked pleuritic friction rub was heard over the
area of pain. No other note was made on the physical examina-
tion. The pain gradually lessened until August IH. On this day
she suddenly collapsed ; pulse 120, temperature 102° ; she was
cyanoseti, was somewhat irrational, and the extremities were
cold and clammy. She complained of a feeling of weight over
the sternum and pain at the apex of the left lung. A slight
cough developed, but there was no expectoration. A careful
examination of the chest showed on the right side a slight
loss of resonance throughout the lower axillary and subscapu-
lar regions ; the dulness, however, was not sulUcientto indicate
fluid. The vocal fremitus and breath sounds were slightly
enfeebled and a pleuritic friction rub was heard to the right of
the sternum.
These symptoms gradually disappeared and she was dis-
charged August 2-!. A note made then showed that she had
slight enfeeblement of the breath sounds of the right side, the
physical examination being otherwise negative. There were no
indications of a phlebitis of the leg veins at any time during
convalescence.
la litis ca.se the first attack was probably the result of
a small embolus from a pelvic vein. The second, which
was typical of pulmonary embolism, had a similar cause
with a larger area of the lung involved.
Case VIII.— This patient was admitted October 13, 1900,
complaining of epigastric and pelvic pain and symptoms of
neurasthenia. The examination of the chest showed a slightly
duller note in the right subclavicular region than in the left
one, but was otherwise negative.
She was operated upon October 17, 1900, for laceration of the
perineum and retroversion of the uterus. The gallbladder,
kidneys, stomach and vermiform appendix were examined at
time of operation with a negative result.
The convalescence was satisfactory until October 28, except-
ing an elevation of temperature to 99°-100° F. On this date she
began to complain of a severe pain in the right lower chest just
at the oostiil margin. This continued until Xoveuiber 3, when a
note was made as follows: The patient's respirations are
rather rapid and superficial. Deep respiration causes severe
pain. There is no expectoration. Her pulse Is 96. On the
right side the vocal fremitus is slightly lessened over the lower
right lobe, and throughout an area corresponding to this lobe
the percussion note Is markedly impaired, the dulness extend-
ing as high as the spine of the scapula. Over the lower axillary
and 8ul)scapular regions the breath sounds are enfeebled, here
and there a scratchy friction rub is just audible. In the apex of
the axilla and at the apex of the scapula the breath sounds
have a slightly tubular modification. The \e(t lung is normal.
The patient was transferred to the medical service where she
improved, and a note made .November 17 states that the dulness
was confined to a small area behind, the interpulmonary condi-
tion having cleared up. She was up and preparing to leave the
hospital when she suddenly collapsed and died. No autopsy
was allowed an<l the cause of death was given as nulmonary
eml)olism. .Vo sians of a thrombus nor any heart lesion were
noted at any time during convalescence.
Although in none of the.se cases could the diagnosis
of pulmonary enabolism be confirmed by autopsy, yet
the connection between the pleuritic attaclis and embo-
luses is extremely probable and in most of them hardly
a doubt exists in my mind that the pleurisy had
its origin in an infarction which in turn was caused iiy
an embolus. The features of the cases pointing to this
are: The limited area of the pleurisy, the sudden onset
of symptoms, the rapid recovery, the fact that most of
them followed operations for carcinomas or myomas,
the occurrence of the pleurisy in from one to three weelcs
after operation and in most of the cases the existence of
a phlebitis or the occurrence of a pulmonary embolus of
larger size giving rise to unmistalcable symptoms. They
could hardly have been due to tuberculosis because they
as a rule disappeared in a few days, and neither before
nor after the appearance of pleurisy wa.s any tuberculous
proceas discovered. In none was a diagnosis of broncho-
pneumonia made, although most of the cases were
examined by experts in physical diagnosis.
The following cases taken from the literature are
added because the patients had the same symptoms as
those already given in this article and in most of them
the diagnosis was confirmed by autopsy. A few have
been added becstuse they show tliat a pleurisy with effu-
sion may be the result of a pulmonary embolism :
Sehachtler" reports a case of a woman suffering with a
uterine fibroid, who. on November 9, had a dyspneic attack
accompanied with sudden sharp pain in the right side of the
chest. On November 20 she died of pulmonary embolus. The
embolus came from a thrombus of the uterine veins.
MacLennan " reports a ea.se of pulmonary emliolisni occur-
ring 24 hours alter the removal of the breast. The symptoms
were: pain in the left infrascapiilar region, temperature !W.ii° F.,
with slightly hurried respiration. The examination of the chest
gave negative results to palpation and percussion. Friction
sounds were heard over the seat of pain and pneumonic crepi-
tus over a small areaof the same site. She also had pain in tne
right thorax. The temperature rose, the respirations and pulse
increased in rate and the patient hsid the signs of pneumonia.
There were dulness, increase of fremitus, bronchial breathing.
She died and the autop.sy showed numerous hemorrhagic iufaro-
tions in both lungs as the result of emboluses. One of these in-
farctions was ac<!ompauied with pleurisy.
Piuard and Wallich " report a case of phlebitis which was
preceded by pulmonary signs. Aprimipara, the fourteenth day
after delivery while apparently doing well (she had, however,
a slight elevation of temperature for a few days) suddenly com-
plained of a sharp pain in the left side of chest, worse at the
point of the shoulder. Soon the respirations became panting
and exceedingly painful. Auscultation revealed sibilant rales.
Percussion was negative. On the third day after the begin-
ning of these symptoms there appeared a phlebitis. She event-
ually recovered.
Merklen '• puljlishetl the following case :
A primipara 10 days after confinement was seized with a,
violent pain in the chest, accompanied with cough and bloody
sputum. Some days after the first attack she had a similar one.
After a brief delay there appeared a phlegmasia in one leg and
after some days a similar condition in the other leg. She
died 23 days after the first attack of pain of a pulmonary
embolus.
Becker " reports this interesting case from the meiii-
cal clinic of Jena :
H. S., aged 27, was admitted February 5, 1896, and died
February 20, 1890. She was admitted with pleurisy following
immediately after an operation for tubal pregnancy. The opera-
tion had taken place 19 days prior to admission. The exudate
was hand depth, and on aspiration measured 650 c-c. It WM
clear serum and contained no bacteria. At first there had been
no sputum but laU'r the expectoration was blofxly. Klght dajr»
after a-spiration the exudate had disappcare<i and a throinl)0»ta
of the l(!ft femoral vein was apparent. Two liays after this she
collapsfHl and died. Autopsy showed that the pleurisy had
originated in an infarct of tne lung.
Mahler {vide stipm) rejwrts the following two ca«ej,
which were selected by nie from among a number of
others rejwrted l)y him in the same article:
Case I.— Patient 45 years; operation, total extirpation of
uterus and appendages for myomas of the uterus. .Salpingitis
and perioophoritis. At operation sniall throuil)Use8 were
noticwl In the voinsof theadne.xa. , , , ., . ^ , u.i.
( )ii the fifth day the patient had a Htlt<'h In the ohest ; eighth
dav a marked dysnnolc attack : tenth day, collapse, dyspnea
anil very weak pulse; twelfth day, left foot edematous; six-
teenth day, collapse and death. The temperature had remained
normal.
176 AMiaucAN MEBICIJ.K) PASSING SUTURE IN FIXATION OF KIDNEY
lAUGL-ST 2, 1902
The autopsy showed brown atrophy of the heart-inuscle,
hypertrophy and dilation of the right ventricle, fatty degenera-
tion of the aortic intima. Both lungs were adherent and
slightly emphysematous. An embolus was in each pulmonary
artery. Left femoral vein was thrombosed.
Case II.— Patient aged 50; operation, euretment and
cauterization for carcinoma of the uterus.
On the sixth day she had a stitch in the chest ; seventh day,
shortness of breath. On auscultation a friction rub was heard
in right side of thorax ; on the eight day, pain in right chest on
deep inspiration ; on the ninth and tenth days, patient felt well ;
condition good. On the evening of the tenth day there was an
attack of cfyspnea, and death.
Autop.f}/— High grade of fatty degeneration of the heart-
muscle ; dilation of the chambers ; pleura on both sides showed
a loss of luster with light adhesions ; over both lower lobes and
middle lobe, numerous pulmonary hemorrhages ; an embolus
at the division of the right pulmonary artery; thrombus in
vein of the leg.
Landgraf '* reports a case in which there was a large
exudate (serofibrinous) following pulmonary embolus.
Many cases of pleurisy occur without known cause
and the tendency of the day is to attribute most of them
to tuberculosis, although no other evidence of this dis-
ease be found. Considerable discussion has arisen as to
the causes of sudden death which sometimes occur in
cases of pleurisy with effusion, and a number of writers
have shown that pulmonary embolism is the cause in
many of these cases. Is it not reasonable to infer in
cases in which this is true that the origin of the pleurisy
could also have been a smaller embolus?
As evidence that many cases of pleurisy have their
origin in emboluses, the statistics of WoUfram and
Stintzing are very convincing. WoUfram" gives the
causes of pleurisy in 257 cases occurring in the medical
clinic at Jena as follows :
Tuberculosis 55
Miliary tuberculosis 2
Probably " 36
Rheumatic 51
Traumatic 4
After pneumonia 37
" bronchitis 2
" influenza 5
" scarlet fever 3
" diphtheria 1
*' typhoid fever 7
Polyartnritic rheumatism 5
Pyemia and sepsis 3
Kidney disease 10
Pericarditis 2
Endocarditis 16
Tumors of neighboring organs 4
Abscess of rib 1
Echinococcus 1
Carcinoma of mammary giand 1
Carcinomatous cachexia 7
Malarial •' 2
Leukemia 2
Stintzing'* says that in his clinic, in 256 ca.ses of
pleurisy, there were :
22.25( certainly tuberculous.
13.7^ probably "
9.9^ apparently rheumatic.
14.5«( metapneumonic.
6 2;; disease of the heart.
S.Stfi after kidney disease.
19.5^4 other illnesses
It is quite striking in these statistics how frequently
pleurisy is found in diseases in which an embolus is
liable to occur, as in endocarditis, rheumatism (heart
lesion), cachexia, etc. Excluding tuberculosis and pneu-
monia it occurs most frequently in those disea.ses in
which there is a liability to embolism, either from the
heart or th i peripheral veins.
As I have before stated, during convalescence from
labor, and operations which are either serious in them-
selves or from minor ones for such conditions as myomas
or carcinomas of the uterus, there is this tendency to the
formation of thrombuses in the peripheral veins, espe-
cially those of the pelvis. In such ca.ses pulmonary
embolism is liable to occur. Any symptoift which will
indicate the probability of the occurrence of so fatal a
postoperative or puerperal complication is of great value.
The symptoms of thrombosis of the pelvic veins when
the femoral is not involved are notoriously obscure.
In reading over the cases in the preceding pages one
must be convinced that pleurisy is, in a certain number
of cases, the result of a pulmonary embolus. This is
especially true in that form of the disease wliich occurs
after operation or labor, coming on suddenly with sharp
pain in the chest, dyspnea, which is of limited extent
and without known cause. In such cases one should
bear in mind the possibility of the occurrence of a fatal
pulmonary embolism of which the first is a precursor,
and take precautions to prevent any unnecessary mus-
cular movement of the patient until the danger of
embolism is past.
BIBI/IOOBAPHTr.
1 Allbutt's System of Medicine.
- Pulmonary Apoplexy. Practice of Medicine.
3 Textbook of Medicine.
< Traite de Gynecologic.
5 Zeltschr. f. Geb. u. Gyn , Bd. xl.
6 Arbeit. A. D. konlgl. Frauenkllnlk In Dresden, 11, 1895.
I Zeltschrlft f., Geb. u. Gyn., xlvii Bd., 1 Heft.
8 l.e Bulletin M«dlcal, Mai 10, 1895.
<■< ficho Medical du Nord, AoUt, 1899.
10 De I'embolie pulmonaire consgcutif aux interventions sur
1' Uterus et ses annexes, Lille, 1900.
u Beltrage zur Emboli der Lungenarterie. Ziirich, 1895.
12 Edlnb. M. J., 1900, N. S., viii, 422-424.
13 L'lnfectlon puerpfirale. Paris, 1896.
n Embolics pulmonalres et poussfies phl6bitiques tardives. ttocl6t6
mfidicale des hopitaux de Paris, 15 Novembre, 19(X).
15 Eln Beltrag zur Aetiologie der exsudatlven Pleurltls. Jena,
1898.
i« Zeitsch. f. kiln. Medicln, Berlin, 1892, xx, 181-202.
1' Cor. Bl. d. Allg. Arzt. Ver. 1. Thilrlngen. Weimar, 1891, xxiil,
317-325.
18 Behandlnngen Erkrankungen des Brustfells, etc. Handb. d.
spec. Therapie, inner. Krank., 1897.
A MORE RATIONAL METHOD OF PASSING THE
SUTURE IN FIXATION OF THE KIDNEY.
BY
MAX BRODEL,
of Baltimore, Md.
On account of the soft consistency of the kidney sub-
stance it has always been a problem how to pa.ss sutures
through the parenchyma, which will hold without injur-
ing the organ. The simple through-and-through suture
generally employed very frequently tears out, either
while being tied or soon afterward, as a consequence of
an especially vigorous diaphragmatic contraction. The
rea.son for this is that such sutures pai5s in the same plane
with the framework of the cortex ; i. e., the interlobular
vessels and straight tubules, neither of which furnish
any support for the suture.
That a suture which will obtain a firm hold on the
kidney, at the same time producing the minimum injury
to the parenchyma, must prove of considerable surgical
value is evident, and I believe the following method
fulfils thase requirements.
The principle of this new suture, which is applicable
not only to the kidney but to any other friable organ, is
as follows :
1 . The direction of the suture is not parallel to the
framework of the cortex, but at right angles to it.
2. The fibrous capsule, being the most resistant struc-
ture, is utilized instead of the kidney substance itself to
furnish the main support for the suture.
3. The suture is pa.ssed in a triangular manner
through the cortex so as to leave two suture bridges on
the surface of the kidney. These bridges bear the brunt
of the work, and traction on the suture is borne by them
instead of by the circulatory or secretory structures of
tlie kidney. To make this suture tear, the bridge must
pull the fibrous capsule into the cortical substance of the
kidney, a procedure requiring considerable force.
It was through my anatomic studies of the vessels
and tubular system of the kidney that this method of
suturing the organ first suggested itself. About two
years ago when handling a considerable number of cor-
roded celloidin injections of kidneys I happened to come
into Dr. Kelly's operating room in time to see him do a
suspension of the kidney. The sutures were placed
August 2, 1902]
PASSING SUTURE IN FIXATION OF KIDNEY iaxbbicak mkdicink 177
through and through, and as usual they tore out almost
as soon as they were tied. The mental picture I had of
the framework of the cortex, as seen in the corrosion
specimens I had just left, at once suggested to me the
possibility of establishing a firmer hold on the liidney
by changing the direction of the suture and in addition
by using the strong fibrous capsule as a means of support.
Having returned to the laboratory I began at once to
experiment with fresh kidneys and different suture
material and arrived at the following conclusions :
Simple through-and-through sutures, such as shown
in Fig. 1, tore out if a weight of 800 to 1,000 gr. was
suspended from them. The bight of the sutures was
from 2 to 2.3 cm. and the depth from 5 to 8 mm. Heavy
silk ligature held little better than fine silk.
Sutures passed according to the new principle sup-
ported a weight three or four times as heavy. Passing
at right angles to the vessels the strength of the suture
is doubled, and if it is arranged in a manner similar to
that shown in Fig. 2, leaving a bridge or bridges of liga-
ture on the capsule of the kidney, the suturas will hold
without tearing either capsule or cortex at a tension of
3,000 to 3,200 gr., which represents a force to which no
kidnev is ever subjected during life. Not infrequently
the ligatures broke while the kidney remained practi-
cally uninjured.
It soori became evident that the most important parts
of the suture were the bridges, whicli should not be
shorter than 7 mm. Two bridg(!S of 7 mm. each arc
stronger than one of 14 mm. The sutur«>s are best
placed so that the bridges run along or across the de-
pressif)ns between the lobules of the kidney, because the
fibrous capsule is firmest along these lines.
The length of the bight of the three legs of the suture
is of no aspecial significance ; it is well, however, not to
make it less than 12 mm. The |x)ints of entrance and
exit of the triangular sutures may be close together but
are better placed somewhat apart.
The depth need not, and in fact should not, exceed that
of the cortex. As the thickness of the latter is so variable
it is safer not to go deeper than 6 mm. While the vessels
at the base of the pyramids, if included in the suture,
might add to its strength, the slight advantage gained
does not justify the injury inflicted upon the secreting
and vascular structures. It should always be borne in
mind that the strength of the suture should not depend
upon the vessels and tubules but only upon the bridges
of suture material lying on the outside of the fibrous
capsule.
The apex of the triangle should be on top and the
bridges below (Fig. 3) so as to place the suture in the
most advantageous position to counteract the forces tend-
ing to bring the kidney to a lower level.
Two sutures will i>rove sufticient to suspend a kidney
and keep it securely fastened ; one as near as pnn'tical)le
to its lower pole and the other as high up as the position
of the pleural reflection will permit. It is nei-essary to
leave a certain amount of space l>etween the two sutures
so as to anchor the kidney in a manner pn-ventlng for-
ward rotation around its lower |M)le, which would In-apt
to occur if the sutures were both close together at the
lower iK)le.
The first trial of this suture was niatle by Dr. Cullen
on October 20, 1900, with thoroughly satisfactory out-
come. Dr. Kelly ha-s since then fre<iuontly employed
this suture, and it was found efiicicnt in all «vsi>s. At
the meeting of the American Me<li(id A»s<H'iatlon at
St. Paul, in June, 1!M)1, he reporti-d it, and the reiuson It
hiis not l)een made public l)efore was our ilesiro to
178 Amekican Medicine]
FOREIGN BODY IN STOMACH
[August 2, 1902
observe more closely its ultimate effects. The results of
the operation since using this suture have been much
more satisfactory than when the former methods were
employed, no ca«e having recurred so far as known.
I have just learned that Dr. Goelet, of New York, has
\)raf,"^
XI
F.g. 3.
independently worked out a similar procedure, guided
probably by the same thought, and that he has arrived
at a similar conclusion, seems to indicate that this method
of suturing a kidney is more rational, because based
upon the anatomic peculiarities of the kidney, than
the methods hitherto employed.
THE REPORT OF TWO INTERESTING CASES OF
FOREIGN BODY IN THE STOMACH, WITH RE-
MARKS UPON AN UNUSUAL ACCIDENT WITH
THE STOMACH TUBE.
BY
JULIUS FRIEDENWALD, A.M., M.D.,
of Baltimore, Md.
Clinical Professor of Diseases of the Stomach, College of Physicians
and Surgeons; Fellow of the American Academy of Medicine.
The first case that I wish to report is of considerable
interest from several points of view :
First.:— The patient suffered with an extremely dilated
stomach, due to the cicatrization of an old ulcer from
which a hemorrhage had occurred 15 years previously.
Second. — In the treatment a part of the stomach tube
had become detached and was swallowed.
Third. — A pyloroplastic operation was finally under-
ta,ken for the relief of the gastric dilation and for the
removal of the tube, with the complete restoration to
health of the patient.
J. M. B., single, aged 48, a barkeeper by occupation, first
consulted me February 5 of this year.
Family History.— Mother died during ciiildbirtli, after
giving birth to twins ; she had 7 children ; fatiier living, in fair
health. Patient has one brother and one sister living, in good
lioalth ; two brothers dead ; one died aged .34 of cancer of the
neck : the other brother of some inflammatory condition of the
bowels.
Previous History. — The patient had measles when 5 years
of age, scarlet fever when 7, typhoid fever when 21 ; contracted
syphilis when 22 years of age; had gonorrhea a number of
times; used alcohol to excess and smokes to excess: when 24
years of age he had a very bad attack of indigestion ; when
aljout 30 years of age he again suffered much from indigestion
and with pain under left costal arch; this pain continued for
about one year ; suddenly one morning he had a severe hemor-
rhage from the stomach ; after tiiis he felt better for a number
of years. He continued drinking alcoholic stimulants to
excess. He continued to suffer from indigestion periodically
up to throe months ago, when the present condition presented
itself.
Present History.— The patient has marked pains in his
stomach and back; is much nauseated and vomits frequently
more than can be accounted for by a single meal, and the vom-
itus frequently contains food taken one or two days before ; he
suffers continually with eructations, which are very acid,
sometimes having the odor of sulfureted hydrogen ; has
extreme fulness and pressure in his stomach, and is extremely
constipated. The patient feels very weak and is unable to
sleep ; he has lost 25 pounds in weight in six weeks.
Physical Examination. — On examination the patient is
found to be very poorly nourished and much emaciated ; weight
94 pounds ; his mucous membranes are pale; face very much
drawn and anxious, the pulse weak and the tongue coated ; the
radial arteries are somewhat thickened. Marked depressions
are found above and below the clavicles on both sides. The
heart is normal. A few rales are heard at the apex of left lung ;
lungs otherwise normal. On inspection the abdomen is found
much distended, and veins crossing over it are much dilated.
Peristaltic movements are visible. The kidneys and spleen are
not palpable; the liver is not enlarged. Points of tenderness
are noted on the abdomen, especially along the line of the linea
alba, from the ensiform cartilage to 5 cm. below the umbilicus ;
a marked splashing sound can be elicited in the region of the
stomach. On inflation the stomach is found to reach 5 cm.
below the umbilicus. After a small meal taken the previous
evening, the stomach is found the following morning to
contain a quantity, 2.50-450 cc, of food. The contents are
badly fermented, and contain much mucus, yeast spores
and sarcina in abundance. The total acidity is 90 ; free
hydrochloric acid .259c. After an Ewald testrbreakfast ;M0-
400 cc. of food remains are obtained, with an acidity of 110, free
HCl 0.29%. Numerous examinations reveal similar condi-
tions. The urine is normal ; the sputum shows no tubercle
bacilli. The red blood-cells number 4,000,000 in a cubic milli-
meter; hemoglobin 48% (Fleischl).
There could be no doubt as to the diagnosis of dila-
tion of the stomach due to a stricture of the pylorus
from an old cicatrized ulcer, in this case. The patient
was placed upon a liquid diet, and requested to continue
to practice lavage which he had previously done. He
was given daily doses of Carlsbad salts and liberal doses
of strychnin.
As the degree of dilation was very great, it was
apparent that nothing but surgical intervention could
radically correct this condition ; this the patient was not
willing to submit to. Without improving he continued
the treatment outlined above, until March 8. On this
morning in the process of washing out his stomach, a
portion of the tube became broken and was swallowed ;
the length of the part left in the stomach was 14 inches.
The symptoms immediately became greatly aggra-
vated. The nausea, pain and vomiting were excessive,
and in addition, edema of the limbs and ascites developed.
The patient was now willing to submit to an operation.
He entered the Johns Hopkins Hospital on March 18, ten
days after the tube had been swallowed, and was operated on
by Dr. J. M. T. Finney on the following day. On account of
the weakened condition of the patient, the larger part of the
operation was performed under cocain anesthesia. Dr. Finney
removed the tube and performed a pyloroplastic operation
according to his new metliod. The patient made a rapid and
uneventful recovery. He never vomited after the opeiation nor
did his temperature rise above normal. He left the hospital
April 15. He has gained 30 pounds in weight and can eat solid
food without distress. May 3: Ewald test-breakfast given early
in morning; 30 cc. of contents removed an hour afterward
showed total acidity 45; free hydrochloric acid, 0.15%: no food
remains from meal taken evening before, although a full meal
had been eaten, showing normal conditions in every respect in
regard to his digestion. June 1 : Patient weighs 136 pounds
(gain of 42 pounds), feels well a-id has a perfectly normal diges-
tion. Total acidity after Ewald test>-breakfast, 42; free hydro-
chloric acid, 0.13%.
AUGUST 2, 1902]
ADENOMA OF THE NOSE
[AXXRICAS MbDICIMK 179
The second case is interesting in that a broken stom-
ach tube was removed from the stomach by means of a
gastrotomy.
M. C, colored, female, age 20 years, was referred to me by
Dr. Wm. E. Harris, surgeon to the Provident Hospital of this
city. The patient was first seen May 8 in the dispensary of this
hospital by Dr. R. H. Johnson, the resident physician. She
gave the following history:
Up to three months ago she had been in perfect health ; had
never suffered with any digestive disturbance. At this time
she began to complain of heaviness and pressure after eating,
which at times would become very severe ; intense dizziness
was also present. She believed that she was under the influence
of a " spell " placed upon her by a jealous damsel. About April
1 she consulted an "herb doctor" at Sparrow's Point, who
induced her to allow him to use an instrument upon her. He
evidently used a partially broken tube, and the patient noticed
that in removing the same the entire tube was not withdrawn.
The symptoms now became greatly aggravated, the pressure
and fulness in the stomach became intense, and the patient
believed now that she could feel a foreign body in the stomach.
She was induced to enter the hospital.
On examination she was found to be a well-built woman ;
heart and lungs normal ; urine normal. The stomach was
found atonic. On palpation no foreign body could be detected.
On May 18 a gastrotouiy was performed by Dr. Harris. Two
parts of a stomach tube were removed ; one 9j inches and the
other 61 inches in length. The patient had an uneventful
recovery. The temperature never ran over 100°, and her diges-
tion has since been perfectly normal. She was discharged from
the hospital .June 11.
It is remarkable that, considering the frequency with
which the stomach tube is employed, a larger number
of accidents do not occur. The danger in employing
the tube in various conditions is treated at length in all
the textbooks on diseases of the stomach, but little is
said of the danger of swallowing the tube or of portions
of partially broken or cracked tubes. Leube' reports
an interesting case of this kind.
A woman of 60, who had been suffering from a markedly
dilated stomach, had her stomach washed out once daily for a
Eeriod of several weeks. After some time, desiring to leave for
ome, she was ordered to continue the lavage under the direc-
tion of her physician. She did not call in her physician but
secured the services of a barljer to assist her. (Jn one occasion
the connection between the stomach tube and the tube to which
the funnel was attached became loosened and as the water was
being poured into the stomach the entire stomach tube was
pushed into the mouth ; the patient.greatly frightened, suddenly
swallowed the whole tube. A pliysician was at once called in
and was unable to extract it. The patient immediately returned
to Leube. The tube could be easily palpated through the abdom-
inal walls. Numerous attempts at extraction with tubes
specially prepared provetl fruitless. Even vomiting produced
by means of apoinorphia was of no avail. Fever soon began
to manifest itself, on account of which the patient became very
much agitated and slie returned home, notwithstanding the fact
that she was urgently requested to remain. The conditions
became more serious at home ; however, later the fever disap-
peared. On the ninth day after the accident nausea set in at
9 p.m.; at 2 a.m. a sudden cough and a feeling of suffocation
manifested itself. The patient instinctively grasped back into
the pharynx in order to free herself from something which
seemed to be suffocating her and extracted the tul)e. The tube
measured 66cm. in length.
Nowadays since lavage is practised extensively the
physician rarely hesitates to allow the patient himself to
wash his own stomach without considering the dangers
connect^'d with this procedure. In advising the use of
the tube to patients themselves it is always wise to warn
them of the danger of using a tube partially destroyed
or cracked by age or even of the danger of swallowing
an entire tube if carelessly handle<l.
Pay of President McKinley's PhyslclaiiB.— It is reported
from Washington tliat on July 23 Secretary Shaw and Private
Secretary Cortelyou had a final conferen<« relative to paying the
physicians who attended President McKlnley during his last
illness. Just prior to tlie adjournment of ('ongross H^OOO was
appropriated to pay these claims. Each person interested in
this appropriation has been sent a request to forward regular
claims and vouchers for the amount due for the service renderetl
and the funds in payment will be 8ub»e<iuently forwarded.
ADENOMA OF THE NOSE, WITH INCIPIENT SAR-
COMATOUS METAMORPHOSIS.'
1)Y
EMIL MAYER, M.D.,
of New York City.
On December 26, 1901, William K., a native of Ireland, aged
68, was admitted to my service at the New York Eye and Ear
Infirmary, having been referred to me by his attending physi-
cian Dr. C. D. Kline, of Nyack, who gave the following history:
" Over 20 years ago he was kicketl by a horse and since then
his nose was depressed over the 1k>uc and for many years he
has had obstruction to his breathing. For the past six years
he has been under my care, during which time I have snared
oft numerous polypuses, giving some relief. During the past
year the character of the growth has changed and I am sus-
picious that it is now of a sarcomatous nature and have advi8e<l
a radical operation."
On examination I found Mr. K. a vigorous man, despite his
troubles, which made him a pitiable object to behold. There
was a constant dripping from his nose, a large tumor presented
on the left and both nostrils were occluded. The left side of
his nose over the nasal bones was distende<l fully 4 cm. The
tumefaction was soft and yielding to the touch, but not painful,
and liis mouth was habitually ojien. The entire hard palate
was depressed, the tumor presenting soft and yielding into tlie
mouth with the mucous membrane of tlie mouth covering it.
The slightest touch to the intranasal growth cause<l it to blee<l
freely. Posterior rhinoscopy showed a large mass extending
into the posterior nares ; the right nostril was entirely occluded,
the left almost so. He had the remains of an old keratitis:
hearing was not diminished ; his voice was indicalive of nasal
> Deutsche Archly f«r kllnUcbe Medicin, Bd. 3». H. 6.
obstruction. His discomfort was so great that he was prepared
to accept any operative measure that would afford hope of
relief
It was impossible to determine at that time how much of
the superior maxilla was involve<l. Tlie diagnosis of a niyoj
matouH tumor with probable malignant change was made and
a radical operation determined upon.
On January 2, 1902, in the presence of Dr. 1- rancis W. Mur-
ray and members of the Infirmary staff, with the assistance of
Drs / L. Leonard and A. L. Macken and the house staff, I
operated as follows: (Chloroform anesthesia; tra'-heotoniy.
Continued anesthesia through the tube.
The posterior nares were pa<'ked with gau>«, then the
mouth. The mustache ha<l been previously shaved and the
narts cleanHe<i. An incision was made beginning near the
inner canthus of the left eye and cloro to the edge of the tume-
faction l)roiight around close to the ala- and down U) and
through the iiiwlian line of tlie upper Up. The mucous mem-
brane of the nose which was Intact was cut through and the nose
drawn aside with retractors. The slight l)leeillng wsh checked
with artery clamps. An lininenso growth now presented,
which was thoroughly evnlse<l by means of forceps and curel.
It was found that the whole mass had originated from the left
middle turblnatmUKine and this place was thoroughly cauter-
ized There was entire absence of the vomer, the nasal
bones on the left, and of most of the snjHirlor maxilla that
formed the hard palate. The cartilaginous septum was not
affected, while the bones had liecoine entirely almorbeil. There
was no evidence, however, of Involvement of the iMine, bo
1 Itiiid iM'fon-llie AmrrlraD I^ryDgologlc AnsodaUonat ll»Twetity-
fourtli Annual .Meetlnn, May iK. IWB.
180 Amebioak Medicine]
DIAGNOSIS OF CANCER OF BREAST
[AUGOST 2, 1902
far as the growth was concerned ; hence no part ot the superior
maxilla was removed. The nose was now brought back to its
original position, the parts coapted and sutured, plugs removed
from the mouth, but not from the posterior nares ; the trache-
otomy tube left in situ, and the patient put to bed. There was
no subsequent hemorrhage and some of the packing was
removed each day, until on the fifth day no further packing
remained. The alaj having a tendency to fall in, two Mayer
tubes were introduced. On the tenth day the tracheotomy tube
was removed and the wound healed slowly by granulation.
The nose was cleansed frequently with sprays. At the end of
the third week the nasal tubes were removed and he was dis-
charged from the hospital cured, with very little cicatrization
'» ^^^^^^^^^^^^^^^^^^
.
k
Wp^ "^"^
w
m -^H-
'^^M
Mmfl^^^^m^K^
^
showing, breathing freely through both nostrils, and from
being an object of abhorrence and pity is now a useful member
of society in his sphere of life, and as he puts it, " a new man
and a happy one."
Four months have elapsed since the operation and
the illustrations show the difference in the patient's
condition.
The pathologic report is as follows :
New York Eye and Eae Infirmary,
„, January 11, 1902.
The tumor removed from William K. weighed 117 grams.
There were three large masses, the balance consisting of small
myxomatous polypuses, detritus of the tumor and surround-
ing parts removed by the ouret. Sections made of the typical
portion of the tumor showed it to be mainly papilliform adeno-
matous tissue. It presented some fibrous tissue, small round
cells m abundance ludicating irritation, a very small quantity
of myxomatous tissue and a few cells suggesting sarcomatous
degeneration. Both the myxomatous tissue and sarcoma-like
cells form a very inconsiderable portion of the growth and are
scarcely of sufficient importance to warrant considering them
very seriously in reaching a diagnosis.
The bloodvessels were well formed, the papillas clearly
marked and abundant, hence we must report the growth as a
papilloadenoma with a remote possibility of sarcomatous com-
plication later had the growth not been removed.
George S. Dixon,
Assistant Pathologist.
Clinically and histologically this case must be classed
among the adenomas with incipient sarcomatous meta-
morphosis ; these find mention mainly among the
records of adenosarcoma.
The literature of this subject has been thoroughly
presented by Wright, Hopkins and Leland in the Trans-
actions of the American Laryngological Association for
1897 and subsequently in the same Transactions for 1898
by Newcomb.
While there is nothing of an extremely unusual
nature in the pathologic character of this growth, its
very unusual size, causing absorption of so much bone
tissue, the cartilage remaining intact, and the extraordi-
nary method of operation required for its removal, make
the case seem worthy of pre.sentation.
DIAGNOSIS OF CANCER OF THE BREAST.'
BY
ALFRED ROULET, B.S., M.D.,
of St. Ix>uis.
There is no condition in which an early diagnosis is
of greater importance than in cancer, and in no other
condition is the failure to make a correct diagnosis
attended by more deplorable results. There can be no
doubt that in its earliest stages every cancer is a strictly
localized condition, and that successful treatment de-
pends entirely upon early diagnosis and immediate radi-
cal extirpation of the malignant focus.
An early diagnosis of cancer of the breast requires not
only a thorough physical examination, together with a
careful study of the best clinical history of the case
possible to be obtained, but a most searching analysis of
everything that could in any way have the slightest
bearing on the subject. The microscope should have no
place in the preoperative diagnosis of cancer, though it
is often of great value in confirming a diagnosis after
the tumor has been removed.
Little is known of the etiology of cancer, but the
parasite theory being as yet unproved, and assuming the
theory to be correct that all newgrowths develop
from a preexisting focus of embryonal tissue we can
only consider the influences which clinical experience
and observation would suggest as concerned in the
awakening of this dormant focus into activity. From
our present knowledge the absence of this focus would
preclude the formation of a tumor, no matter what influ-
ences were at work, while in the absence of a proper
stimulus a carcinomatous focus might easily remain
quiescent during the life of the patient.
Age is a factor of considerable importance, cancer
being most prevalent in persons past middle life. In
women it occurs most frequently between the ages of
40 and 50, immediately preceding the menopause. It
occurs next in order of frequency between the ages of 50
and 60 ; the decade between .30 and 40 comes next, and
is followed by that between 60 and 70. Cases before the
age of 30 are exceedingly rare. It is not altogether
improbable that, since cancer of the breast commonly
appears during the period of functional decline of that
organ, the frequently recurring hyperemia of the breast
incident to menstruation, pregnancy, and lactation, may •
be a predisposing factor in its development. The fact
that cancer occurs three times more frequently in the
breasts of women who have borne children than in those
who are sterile, and the extreme rarity with which it
occurs in the rudimentary mammary gland of the male,
would apparently substantiate this supposition.
Traumatism has long been considered a frequent cause
of cancer, and it is possible that fissures of the nipple,
chronic inflammations and long-continued irritations, as
the pressure of an ill-fltting corset, may exercise a con-
tributing influence, either by direc^tly stimulating the
development of a carcinomatous focus, or by reducing
the physiologic resistance of the adjacent tissues. In a
series of 114 cases collected by Winiwarter, 24 had had
mastitis, and in a series of 170 cases collected by the
same writer, 12 gave a history of previous injury.
The etiologic relation between Paget's disease (eczema
of the nipple and areola) and carcinoma has long been
recognized. In a paper on the relation of this disease
and cancer of the breast, read by Paget in 1874, he said :
" It has happened that in every case which I have been
able to watch, cancer of the mammary gland has fol-
lowed within at most two years, and generally within
one year."
Regarding the role of heredity in the transmLssion of
cancer the evidence, while suggestive, is not conclusive.
In a series of 1,164 cases collected by Gross, in but 55
• Read before the Tri-State Medical Society, Chicago, April 4, 1902.
AlTGUST 2, 1902]
DIAGNOSIS OF CANCER OF BREAST
Ajiericak Medicixe 181
was there a history indicating hereditary influence.
Senn reports that he has repeatedly met cancer of the
breast in two succeeding generations. Sibley relates an
instance of cancer occurring in a woman and in five of
her daughters. Broca has reported a case, quoted by
Billroth, of cancer occurring in a woman, in four of her
daughters, and in five of her grandchildren. I recall a
case in my own practice of a woman with cancer of
the breast whose father had died of cancer of the
stomach, and whose grandmother had died of a "run-
ning sore in the breast." Paget has reported 322 cases
in which a history of cancer wa.s obtained in 78. In the
investigation of heredity as a possible factor, it is not
enough to ascertain the existence or nonexistence of
malignant disease in the patient's parents and immedi-
ate family circle, but the investigation should include, to
the most remote degree, all blood relations about whom
it is possible to obtain anything like reliable information.
Shattuck has called attention to the fact that cancer
may show itself repeatedly in certain houses, and reports
four cases occurring in persons who were not related but
were living in the same house. Several similar instances
are on record. Dr. Daniel I^ewis, of New York, in a
recent special investigation of the town of Brookfield,
N. Y., found a large number of "eancer houses," so-
called from their having had two or more cases of cancer
develop in them, while in Plainsfleld township near by
a cancer center was discovered where nearly all the
houses within a radius of a quarter of a mile have had
from one to five cases each.
Ordinarily the first symptom noticed by the patient
is a hard, indurated mass or nodule in the breast, situated
as a rule in the upper outer quadrant or immediately below
the nipple. Usually this nodule is discovered by acci-
dent, as there has been no previous pain or discomfort
and no constitutional disturbances. Occasionally the
appearance of the tumor is preceded by sharp, stabbing
pains, but it is more than probable that there is not the
slightest connection between the development of cancer
and this pain, as many women between the ages of 35
and 45 suffer with neuralgia of the breast, especially at
or near the menstrual period. The development of
cancer is not necessarily attended with any particular
pain, though many patients do complain of sharp lanci-
nating pains occurring at varying intervals and lasting
but a few moments. These pains are by no means a
constant symptom, and their presence or absence is of
slight diagnostic value.
The idea that cancer is attended with the most
agonizing pain is unfortunately deeply rooted in the
minds of the laity and it is often difficult to convince
them that a csincer may occur without causing any appre-
ciable suffering.
The tumor is never distinctly movable, as are the
benign growths, neither can its outlines be clearly dis-
tinguished on account of the infiltration of the surround-
ing tissues. The nipple is frequently retracted, while
immediately over the tumor the skin may be more or
less pitted. As the tumor increases in size the overlying
skin becomes reddened and infiltrated and breaks down,
forming an ulcer, which progressively increases in size
and manifests not the slightest tendency toward healing.
The csincer not only involves the skin but it extencls
backward into the retromammary connective tissue, the
pectoral fascia, the pectoral muscles, and it may even
penetrate the chest wall and involve the pleura. As the
disease progresses, the axillary glands become enlarged,
and matted together, making a firm nodular mass which
completely fills the axilla. Often there may be noted a
fullness in the sui)raclavicular region on the diseased
side which is not present on the other. This means that
the axillary infection has extended iK'neath the clavicle
and that from this point it may follow the chain of
lymph nodes accompanying the internal mammary
artery, or it may involve the bronchial glands at the
root of the lungs. According to Volkmann, when the
tumor is situatetl near the median line the axillary
lymphatics of both sides may be affected. Occasionally
the axillary enlargement becomes so excessive as to
seriously interfere with the venous circulation of the
arm, and edema and gangrene may result.
In advanced cases of cancer of the breast, a positive
diagnosis is made with comparative ease, but in the
early stages it is much more difficult, and is made only
by a rigid process of exclusion. In all cases, abscess,
syphilis, tuberculosis, actinomycosis, sarcoma, and the
benign' tumors must be absolutely excluded before a
positive diagnosis of cancer is made.
A knowledge of the relative frequency with which
certain growths appear, the time of life most favorable
for their development, the age of the patient, together
with the size, the degree of mobility, the rate of growth
of the tumor, and the extent of lymphatic involvement,
are valuable guides in making a correct diagnosis. For
example, a soft, rapidly-growing tumor in the breast of
a woman of 20 would probably be either an abscess or a
sarcoma, but scarcely a carcinoma, while the develop-
ment of a dense nodular tumor in the breast of a woman
of 50 should be regarded with grave suspicion, especially
if it increased rapidly in size, was immovable in the
gland substance, was adherent to the skin, ulcerated,
and the axillary lymphatics became enlarged and matted
together.
While it is desirable to know the exact time at which
a tumor appeared, it is often impossible to ascertain this
point with any degree of certainty. Unless the tumor
is causing the patient actual discomfort the discovery
ordinarily will be entirely accidental. Nevertheless,
after making allowance for the inaccuracies of the
patient's statements, it is often possible to derive infor-
mation that will be of value in estimating the rapidity
of the growth. For example, by comparing the size of
the tumor when it was discovered by the patient with
its size when first seen by the physician, it is possible, by
considering the length of time that has elapsed, to form
an approximately correct idea of the rapidity of its
growth.
A careful examination of the lymphatics should be
made in all cases in which cancer is suspected. The pres-
ence of large matted lymphatics in the axilla on the dis-
eased side should suggest cancer or infection, but the
apparent absence of lymphatic involvement alone would
not justify the conclusion that the tumor was of a non-
malignant nature. It is sometimes impossible, as in
corpulent women, to detect nodes as large even as a
pigeon's egg. When the lymphatics generally, but par-
ticularly thosi> in the epitrochlear and postauricular
regions are enlargetl and indurated, syphilis should be
suspected and the tumor subjected to the closest scrutiny
to exclude the possibility of a gumma. Syphilitic
lesions are often multi|)le and show a tendency to heal
under vigorous antisyphilitic treatment. A carcinomat-
ous ulcer is almost invariably an isolated affwtion and
never heals, though it may remain stationary for a com-
paratively long time. Tul)erculosis of the breast is
rarely seen, but when it does otx-ur it is commonly sec-
ondary to tuberculosis of some other part of the Ixxiy.
The nodules may be disseminated throughout the gland
or they may be collecttnl in one or more comparatively
large masses. The history of the («.se is of the greatest
value in making the diagnosis.
A subacute afsct«s often bears a close res<>niblance in
signs and symptoms to a malignant growth. When
tenderness is pnjsent it is a diagnostic point of minor
Imiwrtanc-e. Tenderness is usually pre.s«nit in uIjhci'hh
and is usually absent in cancer. The most im|>ortant
])()int in the differentiation is the case history. A short
time ago, through the courtesy of Dr. A. C. Bernays, I
saw a patient who had been sent to St. Louis for an
oi)erati<)n for cancer of the breast.
The entire upper and outer portion of the ({liiiul whm i>cru-
pled l>y a hard nodular niaMH, with irronular, vaifuely defined
182 A.MKBICAN Medicine]
INTESTINAL OBSTRUCTION
[August 2, 1902
outlines. The skin was pitted and the nipple retracted. The
axilla was filled with a dense, hard mass. Fluctuation could
not be obtained at any point. The clinical picture of cancer
could not have been clearer. However, the investigation of the
family history brought out the fact that five mouths before, she
had had what she supposed was a felon on the middle linger of
the right hand, which had not been opened but had been treated
with poultices. After a few days the swelling went down and
a small hard circumscribed tumor appeared on the back of her
hand at the junction of the middle and ring fingers. The for-
mation of this tumorwas not attended with pain neither was it
tender on pressure. A few weeks later she noticed an enlarge-
mentin the axilla which, while not painful, interfered materially
with the use of her arm. Shortly after this she had discovered
a lump in the upijer outer c[uaarant of the breast which had
rapidly increased in size until she came to St. Louis. On exam-
ination numerous enlarged lymph nodes were found along the
forearm and about the elbow. Dr. Bernays' diagnosis was
abscess secondary to infection of finger. In the operating room
this diagnosis was shown to be correct. The axillary lym-
phatics had broken down forming an abscess which had
burrowed along under the fascia, dissecting up the pectoral
muscles, invading the retromammary connective tissue, and
extending into the gland itself.
Sarcoma of the breast closely resembles in appearance
the soft or medullary cancer. It appears most frequently
immediately below the nipple or in the upper inner
quadrant. It occurs more frequently in the young and
middle aged than in the old. As a rule it grows more
rapidly than a carcinoma, and during its development
may remain comparatively movable and free from attach-
ments. The tumor is smooth, the nipple is not retracted,
and the lymphatics are rarely affected. A sarcoma
attains a much greater size before ulceration occurs than
is usual with carcinoma. As the tumor increases in size
the subcutaneous veins may become immensely dilated
from interference with the circulation. The develop-
ment of a sarcoma is seldom painful, and the general
health is not affected until ulceration and metastases
occur. Great difflculty is often experienced in differen-
tiating chronic suppurative mastitis, retromammary
abscess, and sarcoma.
Of the benign tumors of the breast, probably aden-
oma is the most frequent. It is of slow growth and
ordinarily does not become very large, usually ranging
in size from a hazelnut to a hen's egg. It occurs in the
periphery rather than in the central portion of the
gland and is superficial rather than deep-seated. Both
breasts are rarely involved, but several tumors may
develop in the same breast. An adenoma is dis-
tinguished from a carcinoma by its slow growth,
mobility, and absence of lymphatic involvement and
ulceration. It occurs most frequently in the young,
rarely after middle age, and has no effect on the general
health.
INTESTINAL OBSTRUCTION.'
BY
EDWARD A. BALLOCH, M.D.,
of Washington, D. C.
Assistant Professor of Surgery, Howard University; Surgeon to
Freedmen's Hospital.
This paper is prompted by a recent experience with
three cases of intestinal obstruction occurring, within the
space of one week, each with a different causation. From
these cases I learned several valuable lessons and it is
hoped that their brief consideration may not be with-
out profit to others. A short summary of them may
serve as a text from which to draw some more or less
pertinent conclusions.
Case I.— January 24, 1902, I received a telephone message
aslcing if I could operate at once upon a patient with obstruction
of the bowels. Upon my arrival at the Sibley Hospital I found
the patient, C. P., white, aged 61, to be a well-nourished man of
good physique and exemplary habits. From his attending
physicians the following history was obtained. On the evening
• i^'iuary 20, the patient was taken with severe pain in the
rignt Iliac region, accompanied by vomiting. After suffering
16 lOffi^*"^ before the Medical Society of the District of Columbia, April
all night a physician was called the morning following. Find-
ing pain and tenderness at McBurney's point and the patient
suffering from vomiting and general abdominal distress, he
made a diagnosis of appendicitis, gave calomel in broken doses,
and advised the application of hot stupes. On the morning of
the twenty second, as the calomel had no effect, and as the
patient had been suffering with pain and vomiting all the time,
castor-oil was tried, but was ejected after a few hours. Hic-
cough was now noted. Another physician was called and more
cathartics tried as well as high enemas, but the pain, vomiting
and hiccough continued.
The next day a third physician was summoned. By his
advice, high enemas of Epsom salt, glycerin and castor-oil were
used without relief of the symptoms above noted, which con-
tinued in full vigor. On the morning of the twenty-fourth it
was decided that obstruction was present and that operative
intervention offered the only hope of relief. The patient was
accordingly removed to Sibley Hospital and I was sent for. I
found the patient with an anxious expression ; there was pain
and tenderness on pressure or percussion over the entire abdo-
men and the bowels were enormously distended and tympan-
itic. He was vomiting at frequent intervals. His pulse was
90, compressible ; temperature 98°; respirations 34 ana shallow.
As obstruction of some kind was clearly pi-esent he was imme-
diately prepared for operation and the abdomen opened by a
median incision, 6 inches in length. As soon as the peritoneum
was opened the tense and distended bowels rolled out. The
patient was practically eviscerateil, the intestines protected by
hot towels, and a rapid search made for the seat of the obstruc-
tion. It was found at the cecum and consisted of a band, run-
ning from the cecum across the ascending colon, and constrict-
ing the bowel at that point. The band wa-s composed of the ob-
literated appendix, reduced to the diameter of a darning needle
and embedded in a narrow band of fibrous tissue three-eighths of
an inch in width. This band was tied in two places and cut
away, freeing the constricted colon. Considerai)le time was
lost in cheeking the hemorrhage from numerous vascular adhe-
sions around the head of the colon, which were torn accidents
ally. Some difficulty was experienced in getting the distended
intestines back into the abdominal cavity, but they were finally
replaced and the abdomen closed rapidly by throughand-
through sutures, after being filled with hot salt solution.
The main feature of the after history of this case was
the incessant vomiting, which persisted in spite of every
remedy and device that could be thought of and tried.
The bowels moved twice on the day after operation, in
response to enemas, and gas passed freely per rectum.
There was also one action on the twenty-sixth and two
on the twenty-seventh, showing that the constriction
had been fully relieved. A fact of some interest was
noted in connection with the bowel movements. The
first stool after the operation consisted of ordinary yellow
fecal matter, while those following were of a black, foul-
smelling character, similar in all respects to the matter
vomited. This was interpreted as showing that at the
time of operation the decomposition of the intestinal
contents had not reached the ileum. With these favor-
able signs, however, the incessant, stercoraceous vomit-
ing continued. All thought of stomach-feeding was out
of the question as that viscus would not tolerate even
the smallest amount of the blandest liquids. Nutrient
and stimulating enemas were freely used but toward the
last the rectum became intolerant of everything and the
patient died on the evening of the twenty-seventh, worn
out by the constant vomiting, and poisoned bj' absorp-
tion of the decomposed intestinal contents. It was after-
ward learned from the family that he had suffered a very
severe attack of " inflammation of the bowels " in 1861,
and a less severe one in 1880. It was also stated that he
had had more or less trouble of a dyspeptic nature for
several years past, with frequent attacks of vomiting.
From the condition of the appendix at the time of oper-
ation it seems reasonable to attribute all these troubles
to an old attack of inflammation of that organ, of an
obliterative type, which ultimately resulted in the for-
mation of the band which caused the fatal constriction.
This case is offered, without comment, for the considera-
tion of those who believe that the medical treatment of
appendicitis secures as perfect an immunity from after
troubles as does the operative.
Case II.— Wm. J., colored, aged 25, was admitted to the
Freedmen's Hospital January 23, 1902, with the following his-
tory : Had always been healthy until August, 1901, when he
was taken with a severe attack of pain in the right iliac region,
with vomiting, which his attending physician diagnosed appen-
August 2, 1902J
INTESTINAL OBSTRUCTION
[AXBBICAM MeDICIKE 183
(Ileitis. After an illness of three weeks a swelling appeared In
the right loin. This was opened, giving exit to a large amount
of pus. A sinus resulted, which remained open two months
but finally closed. In tiie latter part of December he was again
attacked with violent pains in the abdomen, which have per-
sisted intermittently ever since. For the last three weeks he
has vomited nearly every day and has had more or less consti-
pation. He says that since January 17 the constipation has been
absolute, in spite of the administration of various purgatives,
and that vomiting has been almost constant.
Upon examination the patient seems emaciated and is much
prostrated. Expression anxious. Facepinched. Pulse weak
and rapid. Temperature subnormal. The abdomen is enor-
mously distended and very tympanitic, and peristaltic move-
ments of the small intestines are plainly visible through the
thin abdominal walls. A hard mass can be felt in the right
ihac region, from the iliac crest upward as far as the liver. In
the right loin is a puckered scar where the former abscess was
opened. There has been no bowel movement since his admis-
sion to the hospital.
The history seemed a pretty clear one of suppurative appen-
dicitis followed by adhesions, and the abdomen was opened
•January 25 by an incision at the outer borders of the right rec-
tus muscle with the full expectation of finding some such state
of things present. Within a few minutes after the abdomen
was opened the appendix was brought to view and, to mv sur-
prise, was absolutely normal in every way. Surrounding the
ascending colon was a hard mass which extended upward
toward the liver and was firmly adherent to the posterior wall
of the abdomen. In this mass the involved bowel was buried
and twisted in such a confused tangle as to make its dissection
impossible without the expenditure of more time than the
patient's weak condition would justify. The same objection
applied to anastomosis or resection, so the peritoneum was
united to the abdominal wall in the lower portion of the wound,
a coil of intestine stitched to the peritoneum, and the rest of the
wound closed. The pulse during the operation ranged between
120 and 144, precluding the possibility of elaborate measures
because of its feebleness, the use of strychnia being frequently
necessary. Six hours later the bowel was opened and exit
given to a large amount of liquid feces. The patient began to
improve immediately and made a rapid convalescence. He sat
up on the tenth day, and on February 6, twelve days after
operation, he had a large semisolid stool per rectum. Exami-
nation at this time showed the mass in the right iliac region to
be much softer than at the first examination. After the middle
of February the mass could scarcely be felt. As soon as the
V>owels began to move naturally the fecal fistula was com-
pressed by a pad and truss. This acted very efficiently, and
there was practically no leakage of intestinal contents, all the
stools passing per anum. He was up and al)out the ward, but
his emaciation did not lessen and he did not gain strength in
spite of generous feeding and abundant stimulation. His phys-
ical condition was never such as to justify an operation for the
closure of the fecal fistula, and he died suddenly, February 19,
2) days after operation, having been about the ward as usual
the day before.
Autopsy the next day by Dr. D. S. Lamb showed that the
opening had been made in the jejunum 30 inches beyond the
duodenum, and that it was securely adherent to the wall of the
abdomen, no leakage having taken place. The stomach and
duodenum were empty. The bowel below the listula contained
gas and feces. The mesenteric glands were enlarged. A thick
malignant tumor involved all the coats of the ascending colon,
narrowing the lumen and extending to the twelfth rib and kid-
ney, which, however, were not involved. The remaining
organs of the chest and abdomen were normal. The specimen
shows the growth to be apparently much smaller than it
seemed at the operation.
This mse i.s a good type of slow occlusion of the
bowl from pres.sure, and illustrates in a typical manner
how, at any time, such a chronic obstruction may
become acute without .special warning.
Another very intt'resting feature of abdominal
growth is also well illustrated by this case. I mean
the spontaneous disappearance of apparently malignant,
inoperable growths, after a mere ex{)Ioratory operation.
In this case the mass was palpatefl many times before
operation, and was very wirefuUy explored at the time
the abdomen was openetl. Its extent, as shown at the
autopsy, was decidedly smaller than at the operation,
and I see no reason to doubt that it was undergoing this
form of involution. Surgical literature contains many
instances of the occurrence of this interesting jihenome-
non, and it may now In; regarded us established that
ma.s.ses apparently malignant do disapiKtir in this man-
ner. At a meeting of the Royal Medical and Surgical
Society of England, held In January, 1894, Mr. (Jreig
Smith reported three cases, the leading features of which
were "the presence of a solid tumor in the alnlomen,
absence of pyrexia, clinical evidences of malignancy on
abdominal section, and ultimate disappearance of the
tumor with complete restoration to health."' Bland
Sutton ^ reports four similar cases, and a recent observer,
Mr. D'Arcy Power,' records no less than seven instances
of this nature. No satisfactory explanation of this
phenomenon ha.s as yet been offere<l. Oreig Smith is of
the opinion that these masses represent accumulations
of cells of a phagocytic nature, which are thrown out
around a minute opening in the bowel for the purpose of
protecting the peritoneum. This theory of "a leaking
fistula will not, however, explain all cases, and it is
probable that another suggestion, oflTered by Bell,« is
nearer the truth. He ascribes the disappearance of these
tuniors to a certain digestive action on the part of the
peritoneum, which action is stimulatetl in some way by
the operation. It is probably analogous to the absorp-
tion of tubercular masses in the peritoneal cavity after
the abdomen has been opened. Whatever the explana-
tion, the fact is beyond dispute.
Cask III.— Susan H., colored, was brought in the ambu-
lance to Freedmen's Hospital, .January 29, imi. She was unable
to give her exact age, but was apparently in the neighborhood
of 60. She was very much collapsed and in great pain. Owing
to her confused mental state she was not able to give a very
clear history. According to her statement she was taken ill on
the twenty-seventh with pain in the abdomen and vomiting.
A physician was called who administered various cathartics, in
the endeavor to move her bowels. These were promptly vomi-
ted. The pain and vomiting growing worse, he advised her
removal to a hospital.
Upon admission her pulse was 1.S8 and very weak ; respira-
tions 40. The nurse's notes state that the thermometer failed to
register, so presumablj- the tennierature was subnormal.
Shortly after her admission she vomited a quantity of greenish
fluid, and the vomiting continued at frequent intervals until
her death. A high enema was given which was soon expelled,
followed by a little mucus and blood. I saw her soon after her
admission, and found her almost inoril>und. Xo radial pulse
could be felt, and the extremities were cold. It was felt that
the case was practically hopeless, but it was thought that if a
coil of intestine could be opened, she might rally. As a general
anesthetic was out of the question, the operation was done
under cocnin. An incision 2J inches long was made in the
right iliac region, at the outer border of the right rectus
muscle. When the peritoneum was opened there was a free
flow of bloody serum, with a very foul odor. Two fingers
were inserted into the peritoneal cavity, but nothing aluiorinal
could be felt. The problem was whether to drain off the fluid
from the peritoneal cavity, or to disregard it and at one estab-
lish a fecal fistula. I compromised by stitching the peritoneum
to the abdominal wall all around anil sewing the bowel to the
peritoneum, except at the lower part, where a small drain was
inserted. The hope was that in a few hours the lluid might
drain off and sufficient adhesions form to render less likely the
contamination of the peritoneum when the bowel was opened.
The operation took 40 minutes, and during its performance the
pulse appeared at the wrist, and was found to be 120. This wag
probably due to the cocain. She was actively stimulated, but
failed to rally and died in collapse an hour and a half after the
completion of tlie operation.
,4 iilopxy the next day by Dr. I). S. I.diinb showed the greater
omentum <-outracted and the intestines in the lower abdomen
distended and greenish-black. Some bloody fluid was found in
the abdomen. Nine and one-half feet of intestine, from the
colic valve upward, had piisse<l through a congenital opening
in the mesctiterv, almut one inch in diameter, liad become
strangulated and was gangrenous in character. The p«rt
selected for opening was in sound bowel.
Taking these cases together we find certain signs and
syni|)toins common to all. In the first place may lie
mentioned the (Krurrenct^ of vomiting in ctimurtion
with aiisolute constipation. 1 M'gard this as almost
pathognomonic of obstruction, and I do not think that I
go too far in saying that it should Ik' considere<I an abso-
lute indii-ation for surgicid intervention. It is of the
utmost imiMirtimi-e that this fiu-t should 1k' niiliw*! wirly
in every case. The matt<'r vomit<'d is at first the con-
tents of the stomach, with (x'rhaps a little liile, but as
the fluid becomes dammiHl up by flie olistruction a re-
vers(xl iK'ristalsis occurs and the decomposed products of
digestion are eji-cted without an.v »'ffort. 1 am quite
sure that the picture present*"*! by one of thes*' cast's, in
which the black, foul-smelling Ii(|uid rolle<l out of the
patient's mouth without effort and almost without his
184 Amebican Medicinb\
INTESTINAL OBSTRUCTION
[August 2, 1902
knowledge, can never be forgotten by anyone who has
seen it. The decomposition of the intestinal contentii is
accompanied by the free generation of gas, so that tym-
j)anites is soon added to the clinical picture and may
reach an extreme degree. In this connection may be
mentioned a fact of some diagnostic importance : when
with the other signs of obstruction the tympany is slight,
the obstruction is probably high up in the small intes-
tine. Conversely, excessive tympany indicates obstruc-
tion in the large bowel or low down in the small one.
Another symptom is the well-known peritoneal facies
with anxious expression, sunken eyes and pinched nose ;
with cold extremities. Associated with this is usually a
subnormal temperature. The pulse shows a constantly
increasing tendency to weakness and rapidity.
While we may not see in any one case all the cardinal
symptoms of obstruction — viz., pain, constipation, vom-
iting, tympanites and tumor, we should, it seems to me,
be able to made the diagnosis without particular diffi-
culty. In my opinion the occurrence of vomiting, with
absolute constipation, renders the diagnosis practically
certain, while if to these is added distention and a
rapidly weakening pulse, obstruction is present beyond
reasonable doubt.
The allusion to constipation as a prominent symptom
in these cases leads naturally to the mention of the abuse
of cathartics when obstruction may exist. In the three
cases presented herewith there is a striking similarity in
the histories. The medical treatment in each was
largely the administration of one cathartic after another
in the vain hope of moving the bowels. If cathartics
are pushed in these cases the irritability of the stomach
and bowels is increased, the reversed peristalsis is stimu-
lated, the intestinal products are decomposed, and con-
sequently the vomiting comes on earlier and is more
persistent and intractable. The stomach is soon reduced
to a condition in which not even the blandest fluids will
be tolerated.
What has been said of cathartics does not apply to
the use of high rectal injections. These serve a twofold
purpose, as they conduce to the comfort of the patient
by clearing out the lower bowel, and are also of value in
the matter of diagnosis. If the administration of an
enema of this description is followed by the expulsion
of a little mucus and blood, the probability of obstruc-
tion is very strong. This sign was noted in the last of
the cases herein reported.
In the third place the utter uselessness of a purely
medical plan of treatment in cases of obstruction must
be apparent. It is true that there has recently been put
on record a respectable number of cases in which appar-
ent obstruction of the bowels was relieved by heroic, in
fact, poisonous doses of atropia. It is probable that
these were cases of paralytic ileus or volvulus, as I do
not believe that any case of true obstruction can be re-
lieved by the administration of drugs. Again, the cases
in which this plan has been tried and has failed are not
recorded. Such experimentation seems a waste of valu-
able time.
If, then, medical treatment is of no avail the neces-
sity for surgical intervention logically follows. But let
it be early. It is neither just to the sufferer nor fair to
the surgeon to wait until the patient is moribund, and
then expect a miracle to be worked by an operation.
The human economy will at times tolerate a surprising
amount of maltreatment, but there is a limit beyond
which we may not safely go. In these cases I feel that
this limit is reached when the ejecta becomes of the
socalled stercoraceous nature. This shows that the
bowel is irritable and that, as it cannot get rid of its con-
tents in a downward direction, it is endeavoring to force
theni upward. It is true, operation may succeed after
vomiting of this type sets in, but its occurrence increases
the chances of failure in a marked degree
While the curative treatment of acute obstruction
must, of necessity, be surgical, there is much that may
be done before operation to render the patient more
comfortable and enhance the chances of success after
operation. Chief among medical measures is lavage,
both of the stomach and colon. Lavage of the stomach
lessens vomiting and keeps that organ free from the
decomposed albuminoid matters which would otherwise
accumulate there. Free washing of the lower bowel
demonstrates the permeability of the colon ; occasionally,
as has been said, aids in diagnosis; and renders the
bowel tolerant of nutrient enemas, upon which we
must rely for nourishing the patient. Attempts at
stomach-feeding are not only useless but positively
harmful, a."? they tend to increa.se vomiting, which we
want to avoid.
In the presence of acute pain I do not regard the use
of opiates as absolutely harmful, provided always that
they are not given to such an extent as to mask the real
condition and lull the physician and patient into a false
sense of security, and thus postpone adequate means of
relief.
Surgical advice should be sought early. Like appen-
dicitis, this is a condition in which medicine and sur-
gery should go hand in hand. They are not antagonis-
tic, but complementary to < aeh other. The calling in of
a second physician is likely to mean delay until he has
had a chance to try his favorite cathartic. This may be
satisfying to the consultant, but it is very liable to be
disastrous to the best interests of the patient.
Of the operation itself it may be said that its chief
aim should be to remove the cause of the obstruction, or,
if this is impossible, to make a new way around it or to
provide a new exit for the contents of the bowel.
The first indication is fulfilled when we remove con-
stricting bands, remedy an intussusception, take away
newgrowths which are pressing on the bowel, or release
intestine which is caught in normal or abnormal open-
ings in the mesentery or elsewhere. This course of pro-
cedure is pi-eeminently successful in the early cases,
before the patient is exhausted by pain and vomiting or
poisoned by the absorption of ptomaines. There is time
for thorough work and we do not feel that necessity for
hurry on account of the condition of the patient which
we feel in the cases operated on in the later stages of the
affection. If the site of the obstruction can be definitely
located, the incision may be made directly over
it, otherwise a median incision should be made, to be
extended as occasion demands. Early operation then is
beneficial to the patient and decidedly more satisfactory
to the operator.
In some instances we may find it impossible to
remove the obstruction, or the condition of the patient
will not warrant the expenditure of the time required.
In such cases we may do one of two things. We can
unite the bowel above the obstruction to the bowel below
it, and thus, as it were, cut out of circuit the obstructed
portion, or we can content ourselves with making an
artificial anus. It all depends upon the patient's condi-
tion. If he is strong enough to withstand a somewhat
prolonged operation, we may adopt the first course. If,
as is usually the case, he does not come under the sur-
geon's care until all medical means have been exhausted,
it is a question whether his safety is not better secured
by simply opening the abdomen and stitching into the
wound the first coil of intestine which presents. My
own judgment is in favor of the latter course, unless we
are reasonably certain of the patient's ability to endure
the double shock of the operation and the anesthetic.
In classing the anesthetic as one of the dangers which
the patient has to endure in these cases, I speak
advisedly. A complete operation for intestinal obstruc-
tion, unless the case is extremely simple, means the
expenditure of nearer two hours, than one, of valuable
time, and two hours under either chloroform or ether is
an ordeal to which any careful surgeon must hesitate to
subject a patient already in a critical condition. When
the vomiting has been prolonged before operation, ether
AUGUST 2, 1902)
SURGICAL OBSERVATIONS IN BERLIN
(AXBBICAJI MeDICIKE 186
certainly does not tend to check it afterward, and I can-
not help feeling that many otherwise fatal cases might
be successful if we had some safe anesthetic free from
this objectionable quality. Spinal anesthesia does not
impress me as supplying this want. The making of a
fecal fistula has much to commend it. The mere open-
ing of a coil of intestine may be done with perfect ea.se
under local anesthesia by cocain, and the element of
danger eliminated. It relieves the urgent symptoms,
checks the vomiting, gives exit to the intestinal con-
tents and gives the patient a chance to rally and gain
strength enough to withstand an operation \vhich shall
permanently remedy the trouble. Taking all these facts
into consideration, I believe that the interests of the
patient, in many cases at least, will be served best by
what may be called this temporary method of relief. A
makeshift like this, which saves the patient, is preferable
to a more skilful radical operation with fatal result.
It seems hardly necessary to take up time with a dis-
cussion of obstruction from intussusception and other
causes. The symptomatology and diagnosis are not
radically different from that of the types already con-
sidered and their treatment is practically the same.
Permit me, then, in closing, to oflFer a few conclusions
which I think may fairly be drawn from the cases
presented :
1. Early diagnosis is the main factor in the saving of
life in cases of bowel obstruction.
2. Acute intestinal obstruction is characterized by
symptoms which should be recognized with reasonable
certainty in the majority of cases.
a. If obstruction probably exists, cathartics should be
withheld.
4. Chronic, slowly-increasing obstruction may at any
time become acute.
5. Surgical advice should be sought early.
6. In true obstruction the only remedy is surgical
intervention.
7. The choice of operation depends upon the condi-
tion of the patient.
8. Whenever possible the cause of the obstruction
should be radically removed.
9. Beyond question, in the last stages, and probably
in doubtful cases, the proper plan is to establish a fecal
fistula and thus gain time to get the patient in condition
for more radical operation.
10. General anesthesia is a distinct element of danger
in operative cases, and when a fecal fistula is to be
established, local anesthesia should be used by preference.
BIBI-IOGRAPHY.
■ Annals ofHurgerv, Vol. xxiv, p. 759.
'Ibid.
' Jjincpt, March 4. 1899.
4 AnnaU of Surgery, Vol. xxv, p. .524.
SPECIAL ARTICLES
Ijoomis Saiiltartum.— Dr. Herbert M. King:, of Grand
Rapids, Michigan, has been appointed physician in charge of
the Ijoomis Sanitarium, at Liljerty, N. Y. Dr. King's name is
well known throughout the West for his writings and re-
searches in pulmonary tuberculosis. He will bring to his
appointment the skill and experience of an expert.
Georgia Honors the Discoverer of Anesthesia.— The
commission ajjpointed by the last Georgia Legislature to select
two prominent Georgians whose statues shall occupy niches in
Htatuary Hall, in the Capitol at Washington, met in Atlanta on
.July 2, 1!)02. Tlie prevailing sentiment was that only one name
shoukl besolecteil a.s long as (icnoral John 1$. Gordon lives, and
accordingly the commission adjourned, after deciding on Dr.
Crawford W. I>ong.— [ Fir. Med. Semi- Monthly.']
Hospitals of St. .Tohn's Guild Crowded.— The Health
Department reports a larger mortality among children during
the month of .June, li)02, than for many previous years in that
month, and, bearing out this report, the hospitals of St. .Iobn'8
<iuild are now taxed to their utmost. On th<^ floating hospitals
24,1.3M patients have already been cared for and at the Seaside
Hospital the service has never been so great. The management
has been compelled to add to the already large stall" of nurses
employed.— [.V«n.]
i*r<ifrss(tr A. Hotla.
SURGICAL OBSERVATIONS IN BERLIN.
I. Professor Hoffa's Orthopedic Work. —II. Professor Sonnen-
burg and His Appendicitis Work at the Moabit Hospital.
BY
NICHOLAS SENN, M.D.,
of Chicago.
Professor Hofpa, although not more than 40 years of age,
is well known to the surgical profession by his clinical work and
most important literary contributions. His two books on
" Orthopedic Surgery " and "Fractures and Dislocations " have
been most favorably received and have contributed much toward
the advancement of these two distinct branches of surgery.
Three weeks ago he came
from Wiirzburg to till the va-
cancy caused by the recent
death of Professor .Julius
Wolff. He did not have to
wait long for work. His pub-
lic and private clinics are
crowded with patients. Some
idea may he formed of the
amount of his clinical mate-
rial by the 50 cases of congen-
ital dislocation of the hip-
joint which are now under his
treatment. I was given an
opportunity to see 20 cases in
the Polyclinic and to witnes.s
two bloodless reductions in
the Polyclinic in one after-
noon. Thirty cases are under
treatment in ambulances. The
work in the Polyclinic begins at 2 o'clock and continues
incessantly during the entire afternoon. A trained nurse and
a staff of physicians render the necessary assistance. Profes-
sor Hoffa is an orthopedic surgeon in every sense of the word.
His knowledge is not limited to mechanics ; he operates when-
ever he is satisfied that in doing so the desired result can be
reached in a shorter time and to a greater degree of perfection
than by the exclusive reliance on me<!hanical contrivances.
Every one of his operations demonstrates an intimate knowl-
edge of anatomy and sound surgical sense. Chloroform is used
by the drop method as an anesthetic and silk as suturing and
ligature material. The silk is sterilixod by boiling in sub-
limate solution. Surface disinfection consists in thorough
cleansing by mechanical measures, followed by sulilimate solu-
tion and alcohol. The name of Hoffa came prominently before
the profession by the bloody operation he devised for the reduc-
tion of congenital dislocation of the hip-joint. A large experi-
ence with this method has made liim an enthusiastic advocate
of the bloodless method as described and practised by Paci.
He is, however, of the opinion that in patients more than 8
years of age the bloodless method seldom, if ever, proves suo-
ce.ssful. In this class of patients he continues to perform his
operations with excellent results, as I had abundant oppor-
tunity to ascertain. In his private clinic a patient was exhib-
ite<l, operated upon seven years ago, who walked without a
limp. Thispatlent was one of the first operate*! upon t>y the open
method. In children less than 8 years of age ho always gives
the bloodless method a faithful trial before he resorts to the
knife and chisel. Several patients, one among them, a woman of
21, recently operated upon, were doing well. The operative
work of one afternoon in the Polyclinic iucludetl two cases of
bloodless reduction of congenital dislocation of the hip-Joint
and a case of tendoplasty.
Case I.— Congenital dinlocalion of Ir/t hip-Joint ; rfiluctionbp
Olnodtcxa method. The patient, a girl, Iwlweon throe and four
years, had a congenital dislocation of the loft hip-ioint with a
moderate degroo of shortoning. When fully under the influence
ofebloroform tho patient was brought into proper position by
bringing the |>elvis to the margin of tho table and resting up<m a
firm, flat pillow. .\n assistant flxe<l tho pelvis, and tlieoiiorator
abducted the thigh until it was at a right angle with the pelvis.
186 AMBRiOAir Medicine
SURGICAL OBSERVATIONS IN BERLIN
[August 2, 1902
With the thumb of the right hand, firm pressure was made
against the great trochanter, while with the Ij-ft the femur was
rotated forcil)ly outward. These movements were made at short
intervals and soon succeeded in lifting the head upon the margin
of the acetabulum, when during the next manipulation it
slipped into thedepression with an audiblesnap. The bone was
again dislocated and complete reduction effected with the same
ease. The limb was then abducted at an angle of 45 degrees,
strongly rotated outward and immobilized in a circular plaster-
of-paris" splint, which included the pelvis and thigh. During
the setting of the pla,ster, firm pressure was made against the
great trocnanter. In applying the splint, the child was first
placed in the ventral position ; the dressing was finished in the
dorsal position. If the reduction proves successful, the splint
remains for three months. The splint is made more durable
and kept clean for this long usage by coating it with water-glass
after it has become firm and dry. In this case a perfect result
is assured.
Case II. — Congenital dislocation of the hip^oint ; bloodless
reduction under difficulties. Boy, of four years, presenting a
dislocation of the left hip-joint with marked shortening. The
upper border of the great trochanter was near the iliac crest.
Repeated manipulations failed In effecting reduction. The con-
tracted adductor muscles were placed on the stretch and were
kneaded to overcome their resistance. Traction force in abduc-
tion was then applied on both limbs with an apparatus, the
perineum resting against an upright. The persistent strong
traction, aided by manual pressure against the great tro-
chanter, finally succeeded in reducing the head of the femur
into the shallow acetabulum. Fixation dressing the same as in
the first ease was applied without relaxing the traction, which
was continued until the splint became firm. Between the
splint and surface a smooth layer of cotton half an inch in
thickness was interspersed.
Case III.— Tendop/asty for infantile paralysis of exten-
sor and supinator muscles of the forearm. This patient
was a boy of 12 years. The original spinal attection para-
lyzed both limbs on the right side. The muscles of the
lower extremity regained function sufficiently so that the
boy can walk fairly well. Adductors of thigh contracted
with resulting adduction of thigh. Subcutaneous tenotomy,
with a small sickel-shaped tenotome, corrected this deformity
at once. The operation upon the forearm consisted in utilizing
the pronator radii teres as a substitute for the paralyzed supi-
nators, which was accomplished in the following manner: The
arm was rendered bloodless by elastic constriction. An in-
cision 3J inches in length was made over the pronator radii
teres on the ulnar side from its point of origin downward and
outward. The muscle was then isolated and detached from the
internal condyle of the humerus. A second incision about two
inches in length was then made over the external condyle, and
through the incisions a tunnel was made with blunt instru-
ments underneath the flexor muscles, through which the free
end of the pronator muscle was drawn and sutured to the
external condyle with silk. Hoflfa has performed this opera-
tion in three similar eases with very satisfactory functional
results. The second operation was made for the purpose of
making use of the flexor carpi radialis and ulnaris muscles
as substitutes for the paralyzed extensor muscles. Through a
short incision the tendons of these muscles were isolated and
divided immediately above the wrist joints. The tendon
ends were at once secured by a ligature. The next step of the
operation exposed the extensor tendons by a median dorsal
incision above the annular ligament. Through a slit in the
tendon sheath the tendon ends, drawn through the subcuta-
neous tunnels, were stitched with five silk sutures to the
tendons and tendon sheath. All of the wounds were closed
with interrupted silk sutures and dressed before the elastic
constrictor was removed. The operations were performed
with a neatness and accuracy that showed a perfect familiarity
with the anatomy and mechanics of the muscles concerned.
Case IV .—Gonorrheal synovitis of the knee-joint ; immo-
bahzatwn of quadratus extensor femoris muscle ; tendoplasty.
The patient, a female of 25 years, had a gonorrheal synovitis of
the left knee which resulted in fibrous ankylosis and functional
loss of the extensor femoris muscle. The limb was nearly
straight, the joint fixed. Several attempts had been made to
render the joint movable by brisement forci under a general
anesthetic without avail. It was decided to use two of the
hamstring muscles as a substitute for the extensor muscle.
1 he biceps and the semitendinous were selected. Each of these
tendons was exposed by a short incision and divided near the
insertion and sutured to the anterior surface of the patella and
on each side. The implantation was done through a small in-
cision over the inner and outer borders of the patella. The ten-
don ends were brought through a subcutaneous tunnel from
tneirnormallocation to their new destination. The operation
was performed under bloodless constriction and the four
wounds sutured without making any provision for drainage.
The next patients were operated upon in Hoflfa's private
clinic, 16 Achenbach street, Charlottenburg. The building is
new and in a most select part of the great city. It was built
recently for this express purpose at an ex pense of ?150,000. The
interior in appearance and furnishing resembles a private house.
It can accommodate 50 patients, and every bed is occupied.
A well equipped mechanical department furnishes the
apparatuses, most of which are designed by Hoffa. The hall for
gymnastic exercise is a revelation to the visitor. Massage and
electricity are applied in consonance with modern scientific
principles. The discipline throughout the house is faultless.
On the day I visited this institution I met Professor Neuber, of
Kiel, who had been studying Hoffa's methods for more than a
week. This one circum-stance satisfied me that I was in the
house of a master. A visit through the private rooms and small
wards satisfied me what skill can do to benefit crippled human-
ity. Paralyzed extremities were made useful by tendoplasty or
by the use of mechanical appliances. Patients that never
walked had abandoned all mechanic supports, and were practis-
ing muscles that were made to take the place of others that
had become useless.
Case V. — Calcaneo-valgus ; tendoplasty. This patient was
a girl of 10 years, with infantile paralysis, which resulted in
slight calcaneus and marked valgus deformity. The muscles
of the leg were decidedly atrophied. The defective muscles
were strengthened or their functional loss was restored by
tendoplasty. An incision was made over the tendo-Achillis
as far as its insertion into the os calcis. The tendon was
divided in the center anteroposteriorly and the inner half
severed from its insertion. An incision was then made over
the tibialis posticus tendon. This tendon was very small and
abnormally long. About three inches of this tendon were
doubled by a double purse-string suture of fine silk and the
base of the duplicated part ligated loosely with the same ma-
terial. Through a subcutaneous tunnel the tibial part of the
tendo-Achillis was connected with the shortened tibialis posti-
cus or by a number of fine silk sutures. The next step of the
operation consisted in utilizing the peroneus brevis to invert
the foot. This was done by first making an incision over the
peroneal tendons behind the posterior border of the external
malleolus. The peroneus brevis was severed and the remain-
ing peroneal tendon which had become dislocated forward
was replaced and fastened in its shallow groove by four fine
silk sutures. The internal surface of the os calcis was then ex-
posed by a short incision. The cut end of the tendon of the
peroneus brevis was then drawn through a tunnel behind what
remained of the tendo-Achillis and sutured to the periosteum
of the internal surface of the os calcis with four fine silk sutures.
The uncut part of the tendo-Achillis was then shortened by
suturing. All of the wounds were sutured with the same ma-
terial and included in the same dressing.
I was given an opportunity to examine many cases of tec-
doplasty for most diverse paralytic aflfections of the foot, arm
and hand with marvelous functional results, cases which but
a few years ago would have been pronounced hopeless. In
aggravated cases of equinovarusthe tendo-Achillis is elongated
and the tibialis posticus is used as a substitute for the extensor
muscles by implantation of its tendon into the common tendon
of the extensors above the ankle-joint. The cut tendon of the
tibialis posticus is drawn through a subcutaneous tunnel and
securely sutured to the extensor tendons and their sheath. The
elongated tendons are shortened at the same time by duplica-
tion. Tendoplasty as practised by Professor Hoflfa marks a
new era in orthopedic surgery and when once fully understood
and generally practised by surgeons will become the means of
restoring many helpless limbs to usefulness and will become a
source of great regret to the mercenary instrument makers.
Berlin, May 27.
II. Professor Sonnenburg and His Appendicitis "Work
at the Moabit Hospital. — Every general surgeon sooner or later
excels in some special branch of his profession. Nowhere is the
truth of this statement more clearly shown than in Berlin. In
brain surgery von Bergniann is the acknowledged authority.
Konig is the master in diseases of bones and joints. Hahn has no
superior in surgery of the gastrointestinal canal. Israel has a
well-earned reputation in renal surgery. Krause leads in sur-
gery of the nerves, and lastly, Sonnenburg speaks the last and
decisive word when the subject of appendicitis is discussed.
These are all general surgeons who can and do perform any
operation in surgery, but their reputation at liome and abroad
is largely due to what they have accomplished in the branch of
their profession which they have made the subject of special
study and investigation. Sonnenburg, the most gifted assistant
of the late Professor Luecke, of Strasburg, is one of the busiest
men in Berlin. His private clinic is large, and at the Moabit
Hospital he is in charge of 350 beds. He is a thorough scholar
and speaks several languages fluently. His contributions to
AUGUST 2, 19021
SURGICAL OBSERVATIONS IN BERLIN
•AMKBICAN llKDrCIJfE 187
surgical literature are numerous, but the climax of his literary
career was reached with the publication of his book ou appen-
dicitis. This classic monograph has, in a short time, reached
the fourth edition, the best proof of its well-merited popularity.
The value of this book is to be found iu the manner in which
the pathologic conditions of
the various forms of appendi-
citis are discussed and the logi-
cal deductions drawn there-
from, as well as in the accuracy
with which the complicated
cases are described. Last win-
ter the number of patients he
has operated upon reached
\ ,(XlO. The Internes in his serv-
ice at the Moabit celebrated
tliis event in an appropriate
manner with their chief. At
present there are 15 patients in
this hospital who were recently
operated upon for appendicitis.
Three operations a day is not
an uncommon occurrence.
Professor SoniK-nburg. The entire mortality of the
1,000 cases was 12%, and
of the cases operated upon during the interval only !%■
Grave symptoms during the first 24 hours of the attack
are looked upon as strongly suggestive of gangrene, and it
is in such cases that an operation is performed with the least
possible delay. In the absence of positive indications for
Immediate action, it is deemed advisable to operate during the
interval. In all pus cases the cavity is drained with a Miku-
licz tampon and the wound allowed to heal by granulation.
The gradual removal of the gauze drain employed in this
manner can be done with greater ease and is productive of less
pain than when the abscess cavity is packed with separate
strips of gauze. In amputating the appendix a transfixion
double ligature is used. The mucous membrane of the stump
is not cauterized and the stump is buried by two rows of
catgut sutures. The first row of sutures embraces all of the
coats of the cecum, contrary to the usual practice. Before
making the incision an assistant draws the skin two to throe
inches toward the median line for the purpose of securing for
the muscular part of the wound and the subsequent line of
union a covering of normal skin. Whenever practicable the
muscle splitting incision is made. If the incision is sutured, as
is always done when no pus is found, catgut is used for the peri-
toneum, silk for tlie muscles and fa.scia, and bronze aluminium
wire for the skin. The wire is very flexible and does not irri-
tate the tissues. A small absorbent pad held in place by a
gauze bandage constitutes the dressing. Irrigation is not used
in pus cases.
The Moabit Hospital accommodates 950 patients. It is made
up of a village of lio pavilions and administrative buildings.
The space included by the buildings is a large square beauti-
fully laid out, with a macadamized street and walks, and orna-
mented with exquisite flowers and blooming shrub.s. Two of
the pavilions are used exclusively for emergency cases. The
two operating rooms are modern and contain the most com-
plete outtit of surgical instruments I have ever seen in any
hospital. Trainetl male and female nurses take care of the sick.
In the operating room the necessary a-ssistance is rendered by
four salaried internes, two orderlies and a female nurse. The
orderlies take care of instruments, ligature and suture material ;
the female nurse hands the gauze sponges.
The catgut used in the operations is prepared by Saul's
method of sterilization. A large experience has proved this to
be reliable.
SAUt/.H MKTHOD OK CATOUT STERILIZATION.
Immerse and boll the catgut, which has been deprived of
all fatty material, in the following solution :
Absolute al<!Ohol 1.700 part*
Carbolic acid 100 pnrtH
Ulnlllled water 200 purtx
Preserve in same solution in sealed bottles of convenient size.
THREE CASES OF APPENDICITIS.
Case I. — Perforntive appendicitis ; cirritmscribeii suppura-
tive peritonitis. The patient is a female, aged 56, who is suflfer-
ing from a first attack. She was taken three days ago with
violent initial symptoms. There was vomiting and character-
istic pain. Temperature was 102° F., the pulse was lid and
small. Facial expression and muscular rigicfitj' indicated quite
extensive peritonitis. There is some dulness m the right iliac
fossa beneath the distended cecum. Operation was done by Dr.
Hermes, fl?st assistant. The incision was made very close to
the crest of the ilium and Poupart's ligament. The perito-
neum was reflected and when the posterior surface of the cecum
was reached several tablespoonfuls of fetid pus escaped. In the
abscess cavity a fecal stone was found. The perforation was in
the middle of the appendix, and the distal end was gangrenous.
The mesenteriolum was tied in several sections, the appendix
ligated at its base and amputated. The stump was buried by
two rowsof catgut stitches, the first including the entire thick-
ness of the cecal wall. The cavity was packed with a Miku-
licz drain.
The day after the operation all of the ^rave symptoms had
subsided, and unless new complications arise a speedy recovery
is predicted.
The Mikulicz drain is always used in pus cases. The
wound is left open and heals by granulation. If a hernia de-
velops in such cases, as not infrequently happens, a radical
operation is performed.
The next two ca.ses were operated upon by Professor Son-
nenburg the same forenoon.
In making the incision he draws the skin toward the median
line so as to cover the muscular wound with normal skin. In
doing so the skin sutures and the resulting scar are placed ex-
ternal to the anterior superior spinous process of the ilium. In
pus cases a free long incision is made ; in relapsing cases with-
out absce.ss formation, the muscle splitting method is employed.
In the latter class of cases the patients are confined to bed
from two to three weeks.
Case II.— Relapsing appendicitis ; extensive retrocecal ad-
hesions. The patient had three attacks, the first one being most
severe. He was a young man who was otherwise in good
health. The first attack occurred a year ago, the last one re-
cently. Through a comparatively short incision the attached
end of the appendix was found. A double catgiit lif^ature was
applied and the appendix divided between. The ligature on
the appendix was used in carefully dragging the appendix
toward the wound. The appendix was long and imbedded in
its entire length in a mass of adhesions, and much of it had to
be removed by subserous enucleation. Several other traction
ligatures were applied during the process of enucleation. The
mesoappeudix was ligated in several sections. The stump of
the appendix was burled by two rows of sutures, the first one
including the entire thickness of the cecal wall. Peritoneum
was sutured with catgut, uuiscles and fascia with silk sutures,
and the skin with bronze aluminium wire. A small absorbent
pad constituted the dressing.
C AUK III.— Subacute appendicitis; duration of disease two
months: operittion. The patient was a woman advanced in years.
The attack commenced two months ago witliout any abate-
ment of symptoms since. Continuous high temperature, a
rapid feeble pulse, pains in the ileocecal region and progressive
emaciation were the most prominent symptoms. The abdom-
inal wall was relaxed and there was no palpable swelling. The
abdomen was opened in the same manner. The sppenoix was
small and there were no adhesions.*
It was explained that there are cases in which the extent of'
the local disease does not correspond with the gravity of the
general symptoms.
Professor Sonnenburg is a very deliberate, neat and dext«r-
ous operator and a fluent speaker. He possesses all of the
qualifi(»tions which make a clear and impressive clinical
teacher. During the same forenoon he o}>erated on a patient
with carcinoma of the stomach.
Cask W .—Kzleniiive carcinoma of pylorus with difftute intll-
trntion of retroperitoneal glands : gastroeiitrroslomv. The
patient was a woman fi2 years old. Pyloric obstruction was
almost complete. Incision was made through the middle of
the left rectus muscle. The mesentery of the transverse i>>lon
and posterior wall of the stomach near the cardiac side were
transfixed with a strong silk ligature and after maklnga button-
hole in the latter the stomach was united with the upper part
of the jejunum with a largo Murphy l)uttxui. A few IJ4^mbert
sutures were applic*! over the inarKlii of the button as an addi-
tional so<'urity. .Soimenburg lliiiiKs well of the Murphy button
III porforinin'g ga«lroentero»toiny. The whole operation was
completed In less than 'JO minutes.
Br.HLiH. May 2M.
188 AMBBICaN Mkdicinb
THE WORLD'S LATEST LITERATURE
[AUGCSr 2, 1902
THE WORLD'S LATEST LITERATURE
Jonrnal of the American Medical Association.
July SO, 1901. [Vol. xxxix, No. 4.]
1 Jacques Davlel and the Beginnings of the Modern Operation <)r Ex-
(motion of Cataract. An Address Commemorative of the Tliird
Seml-cSnt^rTnial Anniversary of the Publication of the Klrst De-
scription of the Operation. ALVIN A. Hubbei,l. ,
2 A New Operation for the Relief of .Severe Cases of Rectovaginal
Fistula. A. Palmer Dudley. , „ ,
S Hiirh Amputation of the Cervix versus Hysterectomy for Carcinoma
of the Cervix. C C. Frederick. „ ,„
4. Operation for Recurrence of Cancer after Hysterectomy. E. W.
CUSHING.
l._See American Medicine, Vol. HI, No. 25, p. 1054.
2.— See American Medicine, Vol. Ill, No. 24, p. 989.
3._See American Medicine, Vol. Ill, No. 25, p. 1041.
4._See American Medicine, Vol. Ill, No. 25, p. 104.3.
Boston Medical and SurRlcal Journal.
July 2i, 190$. [Vol. CXLVII, No. 4.]
1 Remarks on Cancer of the Uterus. Maurice H. Richardson
2 The Present Status of the Operative Treatment of Cancer of the
Uterus. W. L. Burrage.
3 Operation for Cancer of the Uterus. Edward Reynolds.
4. Cancer of the Uterus. W. M. Conant.
5 Intestinal Invagination in Infants and Children, with the Report of
a Case Successfully Treated by Laparotomy. Charles Greene
CUM.STON.
l._Cancer of the Uterus.— Richardson answers a series
ol seven questions in regard to the surgical treatment of
uterine cancer substantially as follows: Permanent relief
by extirpation of the uterus may reasonably be expected
when the disease is confined to the uterus. If a cure is not
expected, removal is justifiable and demanded if it prom-
ises amelioration of the symptoms, such as relief from pain,
from hemorrhage, or from foul-smelling discharges. The
benefits of palliative operations are so great that the chances of
increasing the patient's suffering may well be risked. The
extirpation of the carcinomatous non-prolapsed uterus may be
considered a duty of the surgeon unless there exist strong
contraindications, as local hopelessness of the disease, abnor-
mal condition of the viscera, or general bad condition of the
patient making the prognosis distinctly unfavorable. When
the uterus is movable, when the disease is distinctly confined
to the cervix, and when the vagina is capacious, the best
method is vaginal hysterectomy; under other conditions the
abdominal route or the combined method should be used. Not
1 case in 10, perhaps not 1 in 50, justifies a radical operation.
Thickened masses in the broad ligament, remote metastases,
infiltrations about the ureters, infiltrations of the vagina, the
rectum, and the bladder— all are distinct contraindications to
hysterectomy. In at least 90% of cases a satisfactory diagnosis
can be made whether or not the operation is feasible. No oper-
ator of experience would look upon convalescence from the
operation and healing of the incision as a successful issue of
the case. No therapeutic measures, however, are indicated;
but the patient should be frequently observed, and, if there is
the least recurrence, it should at once be dissected out, when
dissection is possible. If at the end of five years there is no
recurrence, the disease may be looked upon as permanently
cured, [w.k.]
3.— Operation for Cancer of the Uterus. — Burrage
reviews the subject carefully and reaches these conclusions :
1. Absolute cure of cancer of the uterus by operation is rare.
By the best methods of operation thus far produced a small pro-
portion, 5% to 10%, of cases are well five years after operation,
and a smaller proportion 10 years after. 2. The results of oper-
ations for cancer of the body are much more favorable than
those for cancer of the cervix. .3. All cases of uterine cancer,
except those advanced cases which have developed vesico-
vaginal or rectovaginal fistula, should be operated on, if not
with the prospect of effecting absolute cure, to prolong life and
relieve suffering. 4. In early cases of cancer when the disease,
as far as can be determined, has not gone outside of the uterus
and the patient is in good condition, the best operation is the
abdominal operation of Werder, because operating in this way
the operator is able to form a judgment as to the condition of
the broad ligaments, ovaries and tubes and pelvic lymph glands
by sight and touch, and the danger of implanting carcinomatr
ous tissue is reduced to a minimum. 5. In the advanced cases
in which the disease has gone outside the uterus, in those
patients who are in too poor condition to withstand an opera-
tion, and in very stout patients, vaginal hysterectomy or curet-
ting and cautery are to be chosen, [w.k.]
S._Operation for Cancer of the Uterus.— Reynolds
divides the suffering which precedes death from cancer into
the discomfort incidmt to prolonged and increasing ex-
haustion; pain; the presence of disgusting and irritating dis-
charges. The first two are influenced but little, if at all, by a
palliative operation, but the third form of suffering is almost
entirely relieved, as usually the recurrence is within the peri-
toneal cavity ; and, moreover, there is often a period of many
months of comfort before the recurrence ; and these considera-
tions justify the operation under favorable conditions. The
next question is that of diagnosis, the importance of making it
early by the aid of microscopic and pathologic examinations as
well as clinical probabilities ; and he has reached the conclusion
that when careful and repeated curettings at the hands of an
expert have failed to arrest the hemorrhage and other uterine
discharges from an enlarged, but perfectly movable uterus, it
is for the patient's interests that itshould be removed, in women
approaching the menopause at all events. But in any case in
which the broad ligaments are stiffened or palpably thickened
in the presence of malignant disease of the uterus, and in all
cases in which a cancer of the cervix has extended to the vag-
inal wall, he believes that we should limit ourselves to the lesser
palliative operations of curettage and the amputation of any
accessible invaded tissue. As to method he considers that the
abdominal method is the easier, neater, more complete, and
more satisfactory procedure, [w.k.]
4.— Cancer of the Uterus.— Conant says there are two
forms of cancer most commonly met, the squamous-cell
carcinoma usually found in the cervix and the adenocarcinoma
most commonly seen in the body. The prognosis is most
favorable in the latter and least favorable in adenocarcinoma of
the cervix. In looking over a mass of statistics, one is some-
what appalled by the fact that the percentage of permanent
cures is so small. But if one looks over a series of cases and
picks out adenocarcinoma of the body or malignant adenoma,
he will be surprised to see how large a percentage of cures there
are after three years. It seems, therefore, that in the most
favorable form of malignant disease and also in the squamous-
cell variety when confined to the cervix and the diagnosis is
made early, we may expect a large percentage of cures. Hence
Conant concludes that in all cases of cancer which are seen
early, either of the cervix or the fundus, where nothing can be
felt outside of the uterus, a radical operation should be per-
formed. [w.K.]
5.— Intestinal Invagination.- Cumston gives a general
review of the literature on this subject, and says that intussus-
ception occurs most frequently in infants from the fourth to the
sixth months of life. Medical and surgical methods of treat-
ment show a very high mortality— in the former as a matter of
course, and in the latter, to a great degree, because it is often
instituted too late. When medical methods are used, internal
treatment, mechanic or otherwise, should only be employed
early and never at great loss of valuable time. Ijaparotomy
having been done, reduction of the invagination should be
done, accomplished, if possible, without serious injury to the
bowel, assuming that the latter is in a fairly healthy condition.
Resection ortheestablishmentof an artificial anus has met with
an exceedingly high mortality in children. The author reports
two cases, in one of which he was able to reduce the invagi-
nation after laparotomy, and the patient recovered. In the other,
in which the patient was in extremis, an artificial anus was
established, but the patient died, [a.b.c]
>Iedical Record.
[July 26, 190S. Vol. 62, No. 4.]
1. Typhoid Fever from Sources Other than Water Supply. M. A.
V EEDEB
2. Electrical Reactions of the Gastrointestinal Musculature and 'i heir
Therapeutic Value. G. W. McCaskey.
August 2, 1902J
THE WOELD'S LATEST LITERATURE
[American Medicinb 189
3. Peuetrating Injuries of the Eye with or without the Presence of a
Foreign Body in the Organ, and Their Treatment. J. Morrison
Ray.
4. Quantitative Changes in the Blood in Pulmonary Tuberculosis.
Martin L. Stevens.
6. A fla.sslcal Kxaraple of Landry's Paralysis. William Broadacre
PUITCHARD.
1.— Typhoid Fever from Sources Other Than Water
Supply.— Burying typhoid material in the earth without ade-
quate disinfection is the surest way of perpetuating the disease
and causing it to become endemic. The bacillus grows to the
surface like a fungus in a hot-bed and there is evidence that it
thrives luxuriantly amidst processes which originate nitrites
and nitrates in soil and water. The water may be contaminated
from these deposits, infection may be carried from them by flies
or the wind, or garden produce may be polluted. The closet
arrangements at many picnic grounds are responsible for oases.
There may be a spore stage in which the disease is air-borne.
Instant disinfection of dejecta with copper sulfate would
almost make the disease extinct inside of a year, [h.m.]
2.— Electricity and the Gastrointestinal Musculature.
—Symptomless digestion and adequate nutrition are possible
with gastric secretion very defective if the motor power of the
stomach is ample for its mechanic functions. McCaskey
describes his laboratory experiments and concludes that elec-
tricity is very valuable in muscular atony of the stomach and
intestines ; that faradism is the preferable form ; that the
resistance of the mucous lining of the digestive tube offers no
extraordinary obstacle to the passage of the current; that elec-
tric currents, when applied either percutaneously or with one
or both electrodes in mucous lined cavities, pass directly
through the abdominal cavity and the walls or parenchyma of
the contained viscera, thus following the lines of least resist-
ance ; that it is impossible to produce a peristaltic wave of the
stomach by electric stimulation ; that intragastric and possibly
percutaneous faradization produce an obvious increased tonicity
of the stomach wall and slight shrinkage in volume ; that intra-
colonic faradization, especially with the opposite pole in the
stomach, produces active intestinal peristalsis, [h.m.]
S. — Penetrating Injuries of the Eye. — Ray's paper is a
valuable and interesting one to both specialist and the general
practitioner, but .so many phases of the subject are discussed at
some length as to prevent its yielding itself to proper abstract-
ing. He says: "In dealing with eye injuries the question
demanding prompt consideration can be classed as follows : In
penetrating injuries of the eyeball how shall we manage the
wound, and what shall be done with the structures so often
found protruding? If the presence of a foreign body is sus-
pected, what is its character and what steps are necessary for
its removal? What are the dangers of sympathetic involve-
ment and what are the best means of prophylaxis? If the
injuries to the tissues and integrity of the organ are beyond
repair, shall enucleation be performed at once or later?" In
his experience the most dangerous foreign body in the eye is
gravel or stone. In his opinion sympathetic ophthalmitis is
not so common as is usually supposed, being in, probably, from
S% to 5% of injuries. The x-rays and the magnet have revolu-
tionized the surgery of the eye. The localizing method of
Sweet in this country and that of Davidson at Moorfleld not
only show the presence of the foreign )x)dy, but its exact loca-
tion as well. [a. B.C.]
4. — Changes in the Blood in Tuberculosis. — In but few
diseases are the external signs of anemia more clearly stamped
on the individual. The number of erythrocytes, however, is
usually higher than appearances would suggest, in many cases
amounting to normal. In .some hectic or septic cases there is,
temporarily, an increase amounting to 7,000,000, this being fol-
lowed by a decrea.se if the fever is long continued. Profuse
sweats and discharges from the lungs do not <!ause concentra-
tion, as the blood is jioorer than in cases that do not lose liquids
in that way. After hemorrhage the previous count is seldom
regained under a month. In amyloid degeneration erythrocytes
run low. The extreme pallor of many patients with a normal
count can be explained only by the lessened quantity of blood.
At autopsies diminished volume is seen to correspond with the
shrunken vessels observed during life. There is a true
oligemia. A low count is suggestive of low resisting power or
unfavorable complication. The hemoglobin value in all stages
is low, as compared with the count averaging for males 76%,
females 735%. The specific gravity in many cases is below that
of normal blood. Leukocytes vary from one-half to four or
more times the normal number, according to the stage of the
disease, the character of the infection, the resisting power of
the patient, and the presence of complications. In tuberculous
pneumonia leukocytosis is marked. A low count with increas-
ing sepsis is a bad omen. After hemorrhage there should be
from 10,000 to 20,000, according to the amount lost. [h.m.J
New Torfe Medical Journal.
July 19, 190t. [Vol. lxxvi. No. 3.]
1. Subcutaneous Division of the Tendo-AchlUis for the Relief of Equl-
nus Following Infantile Paralysis. Kt'.sSELL A. Hibbs.
2. On the Contraction of the Iliop.-ions Muscle as an Aid In the Diagno-
sis of the Contents of the Iliac Fossa. S. .). Mbltzbk.
. TheEarlyDiagnosisof Uterine Cancer; Operative Limitations. John
O. POLAK.
4. The Histrionic Element of Mental Disease. Theodore H. Kellooo.
1.— Subcutaneous Division of Tendo-Achillis. —Hibbs
reports 17 cases of subcutaneous division of the teudo-
Achillis for equinus following infantile paralysis. The cases
were studied with the view of determining whether or not the
increased length of the tendo-Achillis following the division
had any effect in modifying the function of the so leus and gas-
trocnemius. In 11 cases no force was felt in the calf after the
foot reached 80° in extension. In 4 ca.ses the force of the muscle
could be felt to 90°, in 1 to 95° and in 2 to 110°. In the 11 eases
there was marked retraction of the muscle. In 1 case the
muscle did not respond to either electrical current. In the 4
cases in which the action of the mu.scle was not felt beyond 90°
retraction of the muscle was apparent, and in the remaining
3 It was slight. Hibbs says that it appears that the modi-
fication of the function of the c^lf in these patients wa-s the
result of, first, the shortening of the muscle in the production
of the deformity ; second, the further shortening of the muscle
as a result of the lengthening of the tendo-Achillis by tenotomy
in the correction of the deformity; and third, the still further
shortening of the muscle as a result of the lengthening of the
tendon cau.sed by the elongation of the structure forming the
bond of union between the divided ends, [c.a.o.]
2.— Ilio-psoas Muscle.— Meltzer makes use of the thicken-
ing of the ilio-psoas muscle during its contraction as an aid in
palpating the contents of the iliac fossa. At first the foot is
rai.sed only an inch or two while the leg is extended. When it
is desired to have the patient execute abduction and adduction
the leg is to be raised above the level of the other leg. He says
the procedure is of great value in deciding whether a certain
tumefaction in the iliac fossa Ijelongs to the bone or periosteum
or to the viscera lying above the ilio-psoas muscle. The author
has utilized the contraction of this muscle to distinguish appen-
dicitis from circumscribed rheumatic myositis of the abdomi-
nal muscles. After pressing firml.y over the tender spot until
distinct pain is elicited, he relaxes the pressure to such a degree
as to leave just a minimum of pain and then induces the
patient to flex the thigh gradually to a strong degree. If the
pain is due to a tissue lying between the abdominal wall and
the ilio-psoas it becomes immediately intensifle<l. When pain
is due to a rheumatic myositis, the contraction of the muscle
has practically no otfect u{>on it. He has found the greatest
usefulness of this method to be in chronic and subacute cases of
appendicitis, [c.a.o.]
3.— Uterine Carcinoma.— Polak maintains that an early
diagnosis of this condition is possible. The menstrual history
of each patient should be carefully studied. She should be
interrogated as to menorrhagia, metrorrhagia, spotting, etc.
Spotting after coitus, or defecation, or exertion. Is signiflcAnt.
Every bleeding should be compared with what it has been in
the same patient. A careful vaginal and re<-lal examination
should be made in every case presenting any menstrual
vagaries. The author insists that the practitioner familiarize
himself with the uterus of his patient, that he may note any
pathologic changes. The relative percentage of hemoglobin is
always diminished, thougli the patient preseuls no apparent
anemia. The speciflc gravity of the blood is also reduced, and
190 AHKKIOAN MbdtcinbJ
THE WORLD'S LATEST LITERATURE
[AUGUST 2, 1902
in most cases there is leukocytosis. Later, when emaciation
and cachexia occur, the blood-count is contirmatory. The
leukorrhea at first is a mucopurulent discharge : later serous,
then serosanguineous, and finally seropurulent, acrid, and fetid.
Radical operations should be limited to those cases in which
the disease is confined to the uterine tissues. Polak believes
vaginoabdominal hysterectomy the operation of choice. [c..\.o.]
4. The histrionic element In mental disease is, accord-
ing to Kellogg, the direct outcome at times of irresistible
impulses and outbursts of emotions. It results at other times
from terrific delusions and hallucinations, which impel the
sufferer to tragic acts. It proceeds in some cases from a cen-
tral and organized false belief, which leads to sensational
monomaniac roles. Again, the theatrical phases develop from
morbid love, jealousy or other overwhelming passion, or from
actual changes of personality peculiar to insanity. The histri-
onic element taking the form of caricatures and mimicry is au
aberrant manifestation of the law of imitation, which is so
fundamental in all formative mental processes. As a matter of
clinical fact, he says the histrionic performances are spon-
taneous and involuntary in some patients, attended by slight
deliberation and self-control in others, and in a few cases
directed by the most perverse willful intent and insane cun-
ning. [c.A.o.]
Medical News.
July 26, 190i. [Vol. 81, No. 4.]
1. A Few Notes on Syphilitic Bubo. A. Ravogli.
■j.. Tobacco Heart : What Is It and What Its Treatment? Frank D.
Maine.
3. The Changes of the Leukocytes in Disease as an Aid to Diagnosis
and Prognosis. Thomas R. Bkown
4. A Study or Burns. Maby F. Munson.
1.— Syphilitic Bubo. — Ravogli describes the anatomy and
function of the lymphatic glands. In syphilis the changes in
them are analogous to those at the point of infection. There is
an enormous multiplication of cells which causes the swelling.
It is not a true inflammatory process. When suppuration
occurs, it is from mixed infection. The engorgement is not due
to the eruption or mucous patches, as it occurs independently.
The process is an irritative one. There is increased flow of
serum, hypertrophy of the tissues and infiltration. With the
exception of the connective tissue corpuscles of the sepiments
there are no giant cells or mast cells, thus differing from
gumma. The alterations of the glands are the cause of the
leukocytosis. The hypertrophy of the connective tissue and
bloodvessels of the gland induced by the virus prevents greater
elaboration of the white elements of the blood which in large
quantity remain in the alveoli as mononuclear lymphocytes on
account of the difficulty of going through the affected tissue.
The glands stop the progress of invading infection, but in the
case of a negative chemiotaxis offer a favorable culture medium
for microorganisms. In this way they become store rooms for
syphilitic virus, causing relapses. The possibility of avoid-
ing general infection by total extirpation has not absolutely
vanished. The glands may return to normal size or remain as
sclerotic masses. Inunctions of unguentum cinereum or appli-
cations of emplastrum hydrargyri or in obstinate cases injec-
tions of olei cinerei may ije used, [h.m.]
2.— Tobacco Heart. — Nicotin affects the heart not by direct
action, but by paralyzing the minute vessels which form the
batteries, so to speak, of the pneumogastric nerve. This fur-
nishes motive power for lungs, heart and digestive apparatus.
Proof of this action is seen in the congestive cough and dyspep-
tic symptoms in connection with tobacco heart. The char-
acteristic heart signs are rapidity, nervous palpitation and
irregularity. Prolonged use causes hypertrophy. The treat-
ment is total abstinence, [h.m.]
3. — Changes of the Ijeukocytes In Diagnosis and Prog-
nosis.— Brown gives the percentages of the various forms of
white blood cells and briefly sketches the various theories re-
garding their origin and significance. The absence of digestive
leukocytosis is important as indicative of gastrointestinal dis-
orders. The blood should never be examined for pathologic
changes during the height of digestion. In anemia
diminution of leukocytes below normal and relative in-
crease of small mononuclears is a bad sign. Diminished
leukocytes with persistent fever differentiates typhoid in
the early stages from central pneumonia, appendicitis
and various inflammatory processes. Leukocytosis in
typhoid points to a complication, as perforation. Decrease of
leukocytes in malaria distinguishes it, in the absence of the
parasite, from suppurative conditions. Absence of leukocy-
tosis in influenza excludes whoopingcough and, in the abdom-
inal type, appendicitis. In early diagnosis of scarlet fever and
measles leukocytosis is significant of the former and leuko-
penia of the latter. Eosinophilia in scarlet fever is of favoral)le
import. In diphtheria a high percentage of myelocytes and
low percentage of polymorphonuclear neutrophiles is imfavor-
able. In tuberculosis leukocytosis means secondary infection.
Diagnosis in leukemia, Hodgkin's disease, Banti's disease, etc.,
depends on the leukocytic picture. Eosinophiles differentiate
bronchial from other asthmas. In pneumonia leukopenia is
unfavorable. Leukocytosis aids in diagnosing secret drug
habits. Eosinophilia accompanies ankylostomiasis, trichi-
nosis and rabies. Leukocyte counting is of importance in
surgery, indicating virulence of infection and the resistance of
the patient both before and after operation, [h.m.]
4. — Burns. — Munson emphasizes the importance of asepsis
in preventing scars after burns. Glameide is a perfect antisep-
tic and vitalizer. She describes the technic of its application.
[H.M.]
Philadelphia Medical Journal.
July 26, 1903. [Vol. X, No. 4.]
1. The Treatment of the Infantile Diarrheas of the .Summer Seauon.
James H. McK.ee.
2. The Treatment of .'i.cute Milk Poisoning— Summer Diarrhea.
Thomson S VVestcott.
3. The Summer Diarrhea of Children. W. L. Harris.
i. The Treatment of Summer Diarrhea In Young Children. MAURICE
OSTHEIMER.
5. The Mental Disorders of Children. F X. Dercum.
1.— Treatment of the Infantile Diarrheas of the Summer
Season. — McKee divides these diarrheas into two classes, (1)
the dyspeptic, or acute intestinal indigestion, and (2) the infec-
tious, subdivided into fermentative diarrhea, ileocolitis, and
cholera infantum. The treatment is discussed under the fol-
lowing headings : Prophylaxis. — In order to prevent the occur-
rence of these diseases three requisites are necessary — the care
of the patient, the infant's food, and the environments. If these
three factors are carefully attended to, much can be done to
eliminate the diarrheal diseases. Die^.— The recognized meth-
ods of feeding babies on the breast and those that are on the
bottle are detailed. The Purge.— A. purge or laxative should
always be given as a preliminary to other treatment, and not
infrequently such may need to be repeated. Castor oil is
preferable if an indigestible substance is at fault. Calomel in
divided doses is indicated in cases presenting marked gastric
irritability and in all of the infectious cases. Astringents. — For
acute cases the salts of bismuth are the ones most frequently
employed. The massive dose of bismuth for the purpose
of suddenly checking the discharges in a case of chronic or
subacute ileocolitis is contraindicated. In such cases the strain
of elimination may be thrown upon the kidneys. In chronic
cases silver nitrate in doses of 4 grain, three times a day, half
an hour before feeding, is of value. Intestinal Antiseptics. —
Salol may be used for this purpose to decided advantage. For
an infant one year of age the dose is one grain every two or three
hours before feedings. Opium and its Preparations. — Opium or
morphin is needed in relatively few cases of infantile diarrhea.
Its indications are practically three : After the odor of the stools
has lessened and the patient's temperature has fallen and the
stools continue frequent in spite of the administration of bis-
muth ; to control pain with great restlessness and loss of sleep ;
and in cholera infantum. In order to ascertain a dose of opium
for an infant select a minimum dose for an adult and apply
Young's rule. Enteroclysis and Hypodermoclysis. — The former
is indicated when irritating material still remains within the
bowel and is giving rise to mechanic or bacterial disturbance ;
when, in acute cases, fever and foul-smelling discharges persists
for several days ; in cholera infantum when it should
be supplemented by lavage. It is used liere not only <ts
AP8U8T2, 1902]
THE WOELD'S LATEST LITERATURE
(AMBBICAN MbDICINK 191
a cleansing measure, but also to combat the anhydremia.
If such patients are seen early in the attack when the tempera-
ture is quite high, iced saline solution is very valuable for
lavage and enteroclysis. But when prostration has supervened
and the surface temperature is low, hot solutions are prefer-
able ; in acute eases one needs no other solution than the com-
monly employed one of sodium chlorid ; except in cholera
infantum, enteroclysis should very rarely be used more than
twice daily, and seldom more than once. In the former dis-
ease it is used more frequently until the results are accom-
plished ; in chronic ileocolitis, tannic acid or silver nitrate
injections given once daily may prove more valuable than any
drugs given by the mouth. Stimulants. — In mild cases alcohol
Is not needed, but when marked prostration is present it is
most valuable. Treatment of the fever. — The cold pack supple-
mented by friction is the best. In milder cases the cold sponge
will often suffice. Complications. — These should always be
anticipated and receive prompt treatment. Pneumonia and
nephritis are the most common. Convalescence. — This should
be most carefully watched and managed. Strychnia, arsenic
and iron in the various combinations are the drugs most fre-
quently employed during this period. In conclusion, it may be
said that the treatment of these diseases should be directed
toward prophylaxis, but when the summer diarrheas occur in
spite of preventive measures or because they are imperfectly
carried out, the majority of authorities are agreed upon the
essential principles of treatment, [p.c.h.]
2, 3 and 4. — The gist of these articles is practically
included in the above abstract, [k.c.h.]
5. — The Mental Disorders of Children — Dercum has
detailed at length the mental disorders of children. In tiie care
and training of feebleminded children, therapeutic methods
prove of comparatively little value, except in the single
instance of cretins. Allusion is made to the marked value of
thyroid extract in the treatment of myxedematous idiocy. In
the treatment of the insanities of children, much depends upon
the application of general physiologic and hygienic principles.
The main object should be to force up the nutrition by all pos-
sible means — rest methods, partial or complete ; massage ; full,
and if necessary, forced feeding ; exercises ; bathing; and outr
of-door living. Tonics may also be employed as they are indi-
cated, and this is also true of drugs that regulate the functions.
Sedatives and narcotics are indicated in periods of excitement,
but should always be given in minimunx amounts, never con-
tinued for too long a period, and varied from time to time. In
a certain number of cases, dementia priecox ceases to progress,
and in these the patient may be left in a condition in which
some restraining and reeducation is possible. In a small num-
ber the affection terminates in final and spontaneous recovery.
[F.C.H.]
CliLNICAL MEDICENE
David Riesman a. O. J. Kelly
Cystic Tumors of the Peritoiieiini, — Cystic tumors
of the peritoneum usually spring from the mesentery,
at times from the omeutun), are rare, and give rise
to diagnostic difficulties. They are not all of one
type, but can be cla.ssified, according to Victor Blum
(Centralblatt f. die Grenzgebiete der Medizin u. Chii\,
Vol. v., No. 11), who has just published an excel-
lent review of the entire subject, into chylous cysts ;
serous, or lymph, cysts; blood, dermoid, echinococ-
cus, and cysticercus cy.sts. According to the mode
of origin, they may be divided into congenital or
dermoid, parasitic, retention, traumatic, and neoplastic
cysts. The occurrence of mesenteric dermoids hius
been deniwi, but Blum has collected no less than five
cases ; and there is one reported in this country by J. V.
Mitcliell, of the John Hopkins Hospital. (See brief
account in Jour, of the Am. Med. Aimociation, January
1!), 11)01.)
Tiie most important group is the retention cysts,
an interesting example of which, involving the omentum
in a girl of 7 years, has been reported by Jacobi {JV.
Y. Med. Jour., July 20, 1901). Thestf cysts vary in
size from that of a pea t» a tumor filling the entire
abdomen, and are usually situated at about the level
of the umbilicus. They may or may not be fluc-
tuating, and are very movable. The cyst usually
springs from the root of the mensentery, and the
intestinal coils surround its origin like a cnivat. The
majority of the cysts are in relation with the small
intestine ; only 16 out of 137 were connecte<l with tlie
colon.
A peculiar feature in the wall of the cyst, noted also
in Jacobi's case, is the presence of smooth nmscle-
flbers, a feature considered to give strong support to the
theory that the cysts arise from hypertrophied lymph-
vessels, inasmuch as these vessels in the mesentery
contain abundant strands of nonstriated muscle. The
contents of the cysts are variable; the fluid may be
serous, chylcrlike, or creamy. Albumin and fat are
present in large quantities ; and cholesterin, fatty-jvcid
crystals, and sugar may be found. There are several
analyses of the cystic fluid in the literature.
Blum recognizes four modes of origin of the cysts :
(1) From embryonal or congenital rudiments (Anlagen) ;
(2) from neoplastic formations of the lymph- vessels ;
(a) from stasis in the chylopoietic system, through
obliteration of the thoracic duct or the large lymph-
vessels ; and (4) through tuberculosis of the mest-nteric
glands.
The symptoms are more or less characteristic. Sub-
jectively, they are paroxysmal pain, the result of
transitory intestinal ol)struction by torsion ; loss of appe-
tite ; prostration ; a sense of pressure in the alxlomen ;
anemia ; sometimes emaciation and cachexia ; and, in
women, menstrual disorders. The objec-tive features
have already been touched upon. The principal one i*
the presence of a very movable tumor in the umbilical
region ; occasionally, however, elsewhere. The tumor
is smooth, tense, and elastic ; if it is of sutticient sisse,
fluctuation can be obtained. The percussion note over
the cyst is usually dull ; although in rare cases the
intestine passes in front, and then there is tympany.
The cysts may occur at any time of life. The greatest
danger to which they subject their possessor is strangu-
lation of the bowel. They may also lead to IcK'alized
peritonitis, and occasionally death occurs in i-onsetiuence
of cachexia.
The treatment is oi)eration. The results are best
when this is umlertaken in the intervals Itetween painful
attacks. The percentage of cures is then 70. When
symptoms of intestinal obstruction are present, the
results are not so g(K)d" — 31 J* of cures. Four diftierent
operations have been performed : (1) Puncture with
aspiration of the fluid ; (2) puncture with subsetiuent
injection of the cavity ; (3) celiotomy, sutun- of the sac
to the abdominal wall, incision and dniinage (mar-
supialization); (4) celiotomy and extirpation, if there
are no adhesions, extiritation is to be preferretl ; if these
are present, marsupialization.
Other forms of cysts are very rare and need hardly be
discussetl. Pxhiuococcus cysts occur but seldom aa
primary peritoneal conditions. They are usually sec-
ondary to disease in other organs, esin-cially the liver.
Cysticercus cysts are small, rare, and of no clinical
importance.
With regard to the recognition of mesenteric cysts,
the same thing holds true as in other rare conditions,
viz., tliat the secret of a correct diagnosis very often con-
sists merely in bearing the disease in mind when study-
ing obscure c-ases.
Freciuciicy of Huiiuin ActlnomyooaU.— Poucet and L.
Barouard, In a communication to the Academic dc .Mfdicine,
April 1, IWA review the recent literature ooucornlnif human
actinomycosis and give a bibliography of the same. They con-
clude that the diseaMO Is much more frequent In France than Is
generally thought and uialutaiu that there would be a very
considerable incre««« in rt-cortled case* If physicians and sur-
192 Ahebican MedicinbI
THE WORLD'S LATEST LITERATUEE
[August 2, 1902
geons would give to the disease a current place in their differ-
ential diagnosis, [c.s.d.]
The Diagnostic Symptoms of Diseases of the Pancreas. —
Of diagnostic importance, according to Oser,' are the symptoms
which show that all or some of the functions of the pancreas
are not acting normally. I'irst of all are the symptoms of dia-
betes and glycosuria. Without a doubt, the pancreas possesses
a function connecting it with sugar metabolism. This can be
proved by animal experiments, as well as by facts gained in the
study of man. Should diabetes or fairly constant glycosuria
exist, we may conclude as almost certain that the pancreas is
diseased, although cases of both have been reported without
apparent changes in that organ, and grave changes have existed
without either diabetes or glycosuria. A second group of symp-
toms is developed through disturbance or entire loss of the
digestive function of the pancreas. We know that it has a fat-
emulsifying and fat/splitting, a proteolytic and amylolytic func-
tion ; it stands to reason, therefore, that pancreatic disease or
destruction must play havoc with this function. Disturbance
in the digestion of fats may be present in macroscopically,
microscopically or sometimes only chemically noticeable
changes in the stools. On chemic examination, such stools
contain neutral fats, fatty acids, and soaps. Of as great an
importance are the disturbances in proteid and carbohydrate
digestion. If the former, large amounts of undigested meat
will be found in the stools. A very noticeable symptom, even
to the patient himself, is the very largo volume of his stools,
out of all proportion to the quantity of food taken, and pro-
duced by deficient digestion, caused by either the absence or
the disturbance of the pancreatic function. A constant falllng-
off in weight, in spite of good and plentiful fare, and associated
with large, firm bowel movements, is a symptom which should
at once catch the attention of the physician and draw it toward
the pancreas. While these symptoms are the most important
from the standpoint of recognizing pancreatic disease, and must
always be thought of first, other signs, if existing, should also
put the physician on the scent of pancreatic disease. These are
bronzing of the skin, peculiar colic, and pain of a definite char-
acter in the epigastrium, tumors, or points of resistance in this
region, and certain forms of icterus. Only if associated con-
stantly or transiently with symptoms of glycosuria or deficient
digestion do they become of pathognomonic importance, [e.l.]
Relation of the Weight of the liiver to the Total
"Weight of the Animal, and to Its Total Surface.— Maurel ^
concludes, from comparative studies made with guineapigs,
rabbits, dogs, hedgehogs, chickens and pigeons, that for the
same species the quantity of the liver by weight is greater in
the young than in adults. With different species of approxi-
mately the same weight the weight of the liver in a general
way is higher for the carnivors than for herbivorous and gram-
nivorous animals. As regards size, first, for animals of differ-
ent species, but of equal weight, the relation is higher in
carnivors than with the other animals examined; second, for
subjects of the same species, submitted to the same regimen, the
relation between the weight of the liver and its size remains
practically constant at different ages, [o.s.d.]
Hepatic Insufficiency in the Dermatoses.— Gaston ^ holds
that the ensemble of the urologic symptoms occurring in these
affections depend on hepatic functional insufficiency, [c.s.d.]
Syphilitic Lesions of the Cauda Equina.— Cautley •''
reports a case of paresis of the extensors of the left leg, exacer-
1>ation of the cremasteric and patellar reflexes and abolition of
the plantar reflex, diminution of the sensibility to touch, to
temperature, and to pain, together with fecal incontinence, due
to a syphilitic lesion of the cauda equina. [cs-D.]
Toxic Action of Oxalic Acid.— Emile Decottignes,' in
Thesis No. 178 of the Faculty of Paris, presents his studies of
accidental and experimental poisoning by the oxalates, and
concludes that the predominant effect is on the nervous system.
He recommends the employment of glycerophosj:*! ate of lime
in subcutaneous injections for the neutralization of the oxalic
acid, [c.s.d.]
1 Deutsche Klinik, Vol. v. p. 151.
2 Gazette Hebdomadaire de M6declue et de Chirurgie, April 20, 1902
3 Gazette Hebdomadaire de Mgdeclne et de Chirurgie, April 13 1902
Chronic Swelling of the Bronchial Glands and Tuber-
culosis of the Apex of the liung. — The points of predilec-
tion of tuberculosis of the lung are, according to Birch-Hirsch-
feld,i the mucous membrane of a medium-sized bronchus of
the posterior portion of the apex and the adjacent subapical
parts, particularly in the right lung. Factors producing a dimi-
nution in the amount of air to this portion seem to be the cause
of its being the point of election. Schmorl ^ has found a groove
produced by a projecting first rib, and believes that it is the
cause of the poor development of the posterior bronchi. Accord-
ing to Freund' a shortening and premature ossification of the
first costal cartilage acts as a restraining agent to the develop-
ment of the apex of the lung, and in that way causes a predis-
position to tuberculosis. Esser * points out an additional cause
of coarctation of the bronchi, viz., enlargement of the bronchial
glands. The right bronchus is more often compressed than the
left, first, because in nearly all instances of disease of the
bronchial glands the right side is more markedly affected than
the left; and, second, because the bronchus is crossed by a
gland just where the branch going to the apex comes off. Chil-
dren with tuberculous glands are, therefore, in a double danger
— in the first place, because they have already a disease germ ;
and, second, because the glands exert pressure upon the
bronchi and lessen the amount of air going to the apex.
According to Barety, the apex is preferred because the branch
of the pulmonary artery feeding it is often compressed by
swollen lymph glands, [d.r.]
A case of complete and temporary paralysis of the
limbs in a child, probably a case of recovery from the initial
stage of acute anterior poliomyelitis, is reported by Bury.=
[A.O.J.K.]
Myxedema in mother and child is discussed by Macll-
waine.5 [a.o.j.k.]
"Liatah" Among South African Natives. — Gilmour' de-
scribes cases resembling those seen in the Malay peninsula.
The affection seems to be closely allied to convulsive tic and
akin to the emotional diseases not uncommon in all barbarous
countries. The susceptibility to suggestion in the cases seen
by the writer was aroused through auditory, tactile, or visual
stimuli. The duration of the hypnotic-like condition varied
from a few seconds to a few minutes or until the removal of the
suggestion. Consciousness and intellect remained clear, the
mimicry was unwilling, and every effort was made by the sub-
ject to escape from his tormentor. All had been afflicted for
many years, [h.m.]
Pneumococcus Meningitis. — As the results of microscopic
and cryoseopic examination of the cephalorachidiau fluid
obtained by lumbar puncture Achard and Laubrey ' claim that
they are able to draw a distinction between meningitis, essen-
tially grave and fatal, and meningism, an essentially curable
and benign disease, though presenting alarming appearances.
[c.s.d.]
Apoplectiform Septicemia in Chickens. — Victor A. Nor-
gaard and John R. Mohler* present a .study of an hitherto unde-
scribed affection of poultry, having as its causative agent a non-
pyogenie streptococcus, pathogenic to rabbits, mice, ducks,
pigeons and dogs. The disease is characterized by an extremely
acute course and certain fatality. Immunity may be produced in
susceptible animals by means of the filtrate of bouillon cul-
tures, sterilized bouillon cultures, and the serum from arti-
ficially immunized animals, [c.s.d.]
A case of Stomatitis gangrsenosa (Noma) following
scarlatina in a child of 7 and ending in recovery, is reported by
Fischer." The treatment consisted of cauterization with the
Paquelin cautery and the application of ichthyol. Cultures
revealed a nonpathogenic stapliylococcus and a nonpathogenic
bacillus resembling the diphtheria bacillus morphologically.
It is believed that several bacteria are concerned in the pro-
cess, [a.o.j.k.]
»Deut. Arch. f. kiln. Med., Bd. Ixiv.
s Munchener raed. Wocb., 1901, p. 1995.
»Beii. kiln. Woch., 1902, Ncs. 1 and 2.
< Munchener med. Woch., March 4, 1902.
5 British Medical Journal, May 24, 1S»02.
"The Scottish Medical and Surgical Journal, January, 1902.
' Gazette Hebdomadaire de Mfidiclne et de Chirurgie, April 3, 1902.
'Bureau of Animal Industry Bulletin, No. 38
" American Journal of the Medical Sciences, Vol. c.\xlii, p. 643, 1902.
August 2, 1902]
THE WOELD'S LATEST LITERATURE
(Akksican Medicikk 193
Venous Thrombosis in Pneumonia.— Walter R. Steiner i
giv«B in an abstract of a paper read before the Johns Hopkins
Hospital Medical Society, February 3, 1902, the results of a
study of 41 cases of peripheral thronabosis in pneumonia. In
the majority of cases the thrombosis occurred during convales-
cence, and it must he regarded as a sequel and not as a compli-
cation of pneumonia. The lower extremities are always
involved. Death occurred in nine cases, [c.s.d.]
A case of sporadic cretinism, in which a relapse occurred
owing to omission of thyroid extract, is reported by Hall.»
[A.O.J. K.]
Progress in the Domain of the Lmpus Treatment of
Finsen.—Kattenbracker 3 comments upon the great value and
the good resultsfromFinsen's treatment in cases of lupus. The
drawbacks to the carrying out of his scheme are the large num-
ber of individuals necessary to apply the treatment; the lim-
ited value of the light employed, as, of its rays, only the chemlc
ones are of use ; and the great cost of special institutions, made
necessary by these two factors. Kjeldsen's lamp does away
with all of these objections. Instead of carbon, he uses iron
electrodes, which are very rich in chemic and very poor in heat
rays. This lamp, using 5 amperes, gives the same results in
three minutes' treatment as was gained in one hour with the
old apparatus, using from 80 to 100 amperes. Its cost is but one-
tenth. Xo assistants are needed, and the small amount of time
required enables the ordinary practitioner to apply the treat-
ment during his consultation hours. Kattenbracker experi-
mented with this lamp, to determine the bactericidal power of
its rays. Anthrax bacilli were killed in 30 seconds ; typhoid
bacilli in 60. The growth of the bacillus of Asiatic cholera, of
tuberculosis, and of gonorrhea, and that of the streptococcus
and Bacterium coli communis, were inhibited in five seconds.
[E.L.]
Clinical Signiflcance of a Chronic Urethral Discharge.
—Christian* points out that there are three forms of chronic
urethral discharge — gleet, prostatorrhea, and urethrorrhea.
To make a correct diagnosis inquiry should be made into:
(1) The history of the case; (2) the macroscopic and micro-
scopic appearance of the discharge; (3) the effect upon the dis-
charge of indulgence in sexual intercourse or alcohol ; and (4)
the character of the urine. A table showing the differential
diagnosis is given, [a.o.j.k.]
Blood Cultures in Pneumonia.— The .observations of
Rufus Colei fail to confirm the work of Procharka and
Fraenkel, who claim to have had positive results in every case
In a series of cultures from the blood of pneumonia patients.
He concludes from his failure to secure positive results in any
buttherapre severe and fatal cases, that the pneumococci are
either more numerous or more resistant to unfavorable condi-
tions in such cases than in those of a mild type. The organisms
were found in only 30% of the cases examined. [c.s.i>.]
Is Pulmonary Emphysema Caused by the Playing of
Wind Instrument«?—This question is answered in the nega-
tive by Fischer.' [d.r.]
Peroral Intubation. — Kuhn« discusses the history of
intubation and the instruments that have been devised for
performing it, and adds to the list one which, extending from
the teeth to the trachea, acts as a dilator and as a speculum for
the air passages. He says that his instrument is the first one
to fulfil these promises, and speaks of his method as peroral
intubation, [k.i,.]
Islands of tiangerhans of the liion.— Qentes' reported to
the Rt'uuion Biologique de Bordeaux, May 6, some interesting
comparisons of the pancreas in animals closely related, but dif-
fering greatly in size, as the cat and the lion. It appears that the
quantity of these islands is very stable, the number remaining
practically uniform in both species of animals, while the mass
of the gland tissue properly speaking varies according to the
size and weight, [c.s.n.]
'Johns Hopkins HimpiUil Bulletin, June, 1902.
'BrUlHh Mcdiral .Journal, .May 21, 1902.
^Allgem. Wiener ined. ZeltunK. 1W2, p. 28.
<.\nitTlri>n Journal of the Medleal .s<-fcnce», Vol. cxxlll, p. 481. 1902.
'.Mllnchener niedlelnlsehe W<K:hen»chrl(t April 29. 19ft!.
»Fort«ohrlUe der .Med, I'JO.!, Nil. I
' Onzette Hebdomadalre de MCdecine at de Chlrurgie, June 1, 1902.
A. B. Craig
GENERAL SUKGERY
Martin B. Tinker
C. A. Orb
Infections in the Reiriou of the Liver FoUow-
ing Appendicitis — At present the question of compli-
cations during and after appendicitis is po.ssibly more
important than that of operative treatment which we
may consider quite definitely .settled in favor of early
operation, in this country at least. Munro' calls atten-
tion to acla.ss of complications which are of by no means
uncommon occurrence but which we believe are fre-
quently overlooked. He reports nine ca.ses of lymphatic
inlections with seven recoveries and eleven cases of
thromboses of the portal vein following appendicial in-
flammation with one recovery. In all these cases the
diagnosis was confirmed by operation, necropsy, or both.
This IS certainly a very creditable showing for Munro and
his colleagues at the Boston City Hospital, for without
operation it would have been impossible to have saved
even this small number. Munro believes the degree of
lymphatic infection is not dependent upon the extent of
the appendicular inflammation, mild chronic appendi-
citis at times giving ri.se to a severe lymphangitis. This
is in accord with what we know about thrombosis in
other regions and also pneumonia following infections.
In persistent fever following operation and without
evident cause one of these infections should be counted
among the possibilities. Spasm, tenderness and fulness
in the region of the quadratus lumborum indicate a possi-
ble retroperitoneal lymphatic infection, while chills with
hepatic tenderness suggest the iK)ssibility of thrombosis of
the portal vein. In all of these cases of obscure origin
the cause of trouble should be sought most carefully by
physicial examination, careful inquiry into the history,
and, if necessary, by an exploratory operation. It 'is
better surgery to explore too early than too late. If
infection be found, prompt and thorough drainage of
the liver is indicatetl, together with removal of the
inflamed appendix. The prognosis is fairly good in
cases of lymphatic infection, but only rarely a case of
pylephlebitis terminates in recovery. However, re-
covery without oijeration is out of the qut^tion and the
patient should certainly be given this small chance.
We may hoije that in the future inflammations in the
region of the appendix will be dete<-ted early enough and
brought to the surgeon with sufticient promptness so that
all complications may lie avoided. Until that time arrives
a second operation otters the only prospect of relieving
many of these serious complications.
Amputation at the Hip-Jolnt.— Edmund Owen ' states that
disarticulation at the hip-joint is done more often at children's
than at general hospitals, because the three conditions most
commonly demanding it— advanced hljvjoint disease, sarcoma
of the periosteum of the femur, and septic osteomyelitis— are
more frequent in children. Ho then gives the technic of his
method, which is (1) opening the crural sheath and ligating
the common femoral vessels; (2) cutting the limb, includinK
the femur, off square at a point just above the middle of the
thigh ; (3) enucleating the remaining part of the femur through
an incision running down onto the lione from the top of the
great trochanter. If the amputation !«) done for tul>erculous
or septic iutlammation, the periosteal and muscular att«<-h-
ments to the femur are 8eparate<l with a raspatory ; If for per-
ipheral sarcoma, the knife must be used and kept well away
from the bone. [a. (i.e.]
On the Necessity for Some Regulation of the InduHtrj
of Sterilizcil Prwlucln.— G. .Maurange,^ having examliie<l the
various Hocallod sterilized and aseptic materials supplied for
surgical dressings, gauze, cotton, etc., finds that in many cases
sterilization is exceedingly imperfect, and Inslato on the neoea-
I Iluiiton .Medical and HurKlcat Journal, ItOS, Vol. cxivl, pace 81.
« I Jineet, Juno 2H. \Wr2.
' UaEette Hebdoiiiadaire de M6decln« et de CblrurKlc, June 1, 1102.
194 American MKCioimCj
THE WORLD'S LATEST LITERATUEE
[August 2, 1M2
sity of some supervision of the industries supplying surgical
dressings to tiie army and tlie profession at large, [o.s.k.]
Liigation of the UnKna,l Artery Through the Mouth.—
Catheart' details his metliod of ligating the lingual artery
tlirough the mouth in excising half the tongue. The method is
based on the fact that the hyoglossus muscle can be reached
from the mouth when the tongue is drawn far out and the
mucous membrane has been divided l)etween it and the jaw.
The tongue is first split and the diseased half drawn well out of
the mouth. The hyoglossus muscle is then easily found, partly
divided, the vessel exposed and ligated before it is cut. The
advantages of this method are ease and certainty in securing
the lingual artery, diminished bleeding from small vessels,
greater certainty in cutting wide of the disease, leaving tissues
of neck intact for subsequent removal of submaxillary and
lymphatic glands. [A.fi.K.]
Buccal Endodiascopy. — Remy and Bouchacourt* have
employed with success a Rontgen tube introduced into the
moutli and excited by a unipolar current for obtaining pictures
on the fl uorescent screen in a case of fracture of the maxillary
bone. [C.S.D.]
Gastrotoiny for Recent Gastric Ulcer. — Moullin ■'' reports
gastrotomy for recent gastric ulcer in three cases. This with a
former report makes six cases, ftve of which were operated
directly for hematemesis. Of these four recovered, the fifth
being in an almost hopeless condition before operation. The
mortality in such cases if left without operation is near to 100%.
During the ftve years from 1895 to 1899, 210 cases of hematemesis
from gastric ulcer were admitted to the London Hospital, 202
being women and 44 men. Deaths numbered 10. The age inci-
dence of death was interesting. Under .30 there was 153 women
with 1 death ; over this age there was 49 women with 3 deaths,
or 6%. Of the men there were 5 under 30 with 1 death, and 39
over 30 with 5 deaths, or 12}% for the latter. Moullin concludes
that so far as the question of operation for hematemesis is oon-
cerned there must be one rule for women under .30 and another
for those over that age. This is still more emphatic in the case
of men. It is to be remembered that these figures are concerned
only with the mortality from hematemesis. With other causes
added, the deathrate from gastric ulcer, specially in persons
over 30, is much higher than usually believed. The treatment
of gastric ulcer is, and must remain in the hands of physicians.
The surgeon must adopt prompt measures in treating accidents
during the course of the ulcer. This is admitted by all physi-
cians in the case of perforation but the principle should be car-
ried much further. It should include cases in which, in spite
of rectal feeding and other remedies, the pain after food is taken
continues with severity; in which vomiting after food obsti-
nately persists ; in which the patient is steadily losing ground ;
and in which medical treatment lias been tried thoroughly for
a sufficient length of time, say for some months, and has failed.
[A.O.E.]
Continuous Baths In Surgery.— Pressly « reports several
oases, including crush of foot, severe contusion of thigh, pus
Infection of thigh, lacerated wounds, and burns treated with
excellent results by moans of the continuous bath. The water
should be clean, preferably running, warmed to about the body
temperature, and should have a specific gravity approaching
that of blood serum. In addition to adding warm water every
half hour it is necessary to change the entire volume of water
three or four times in 24 hours. The specific gravity may be
raised to approximate 1.028 by the addition of 1 drachm of com-
mon salt to the quart of water. Boric acid may be added for
its antiseptic influence. Good results can be obtained with the
ordinary bathtub and foottub. The following advantages are
claimed for this method : 1. The warm water is an anodyne, and
the patient suffers less pain and requires less opium than under
any other treatment. The afflicted member being floated by
the water, may be moved by the patient, and his comfort is
again increased by not being forced to remain immovable for a
more or less prolonged period. 2. The odor from offensive
wounds is controlled better than by any other way. 3. It con-
1 Annals of Surgery, July, 1002.
- (gazette Hebdomadalre de Mfidecineet de Chlrurgle, June 1, 1903.
'Lancet, July .D, 1902.
« Maryland Medical Journal, June, 1902.
stitutes the most perfect drainage attainable. In superficial
lesions the bath has its greatest usefulness, but even in deeper
infections brilliant results are obtained. The bath should be
kept up intermittently or continuously until the wound is pro-
tected by granulation tissue, [c.a.o.]
liitholapaxy and Bottinl's Operation at One Sitting. —
Willy Meyer ' discusses the treatment of prostatic hyyjertrophy,
associated with stone in the bladder by means of litholapaxy
and Bottini's operation at one sitting. Prostatectomy and the
socalled Bottiui operation are the two standard methods of deal-
ing with a hypertrophied prostate. If a surgeon who practises
l)oth decides on the latter in a given case when stone is also
present, the latter must be removed by litholapaxy. Shall
litholapaxy be done at the first sitting and Bottini's operation
later, or shall both be combined ? To reverse this order is but
very rarely indicated, perhaps only when the prostatic urethra
is encroached upon to such an extent that the passage of the
lithotrite will almost surely do damage. Meyer's object is to
show that litholapaxy — the operation of choice for stone of the
bladder — may well be done in prostatics, and that no trouble
is likely to result in consequence of the hitherto much-feared
resentment of the gland to the continued intraurethral and intra-
vesical in,strumental intervention. Bottini's operation is added
at the same sitting. A series of three cases is given to show the
good results of the combined operations. Every one of the
patients is entirely satisfied with the result obtained. Meyer
concludes that this method is destined to compete with that of
suprapubic lithotomy plus subsequent prostatectomy, [a.o.e.]
Fixation of Movable Kidney by Means of Strong Car-
bolic Acid. — Carwardine' reports six cases of nephropexy in
which he used carbolic acid instead of scarification or peeling
of the capsule. In two sutures were used, in four the gauze
method. The plan consists in freely painting the whole sur-
face of the kidney, except the hilum, with the strongest liquid
carbolic acid, so that the surface becomes covered with granula-
tion tissue within a few days. Good results were obtained in
the six cases. The scar in one case was cut through 20 months
afterward and no differentiation of the scar tissue was visible
until the cortex of the kidney was actually reached, so intimate
was the fixation. For these re'asons Carwardine is very favor-
ably impressed with the method of suspension with gauze
(Senn), combined with cortical carbolization. [a.g.b.]
Gangrenous Intussusception in a Child of Four Years ;
Intestinal Resection ; Recovery.— Dowd ' reports this inter-
esting case and discusses at length methods of uniting the ends
of the bowel after resection. The boy was operated on 10 days
after symptoms began, the intussusception being at the middle
of the ileum and 2J inches long. This, with 2 or 3 inches of the
intestine at each end, and a gangrenous piece of the mesentery
was excised. A circular enterorrhaphy wdn then done, the first
row of sutures passing through all the layers of the intestine
and bringing the peritoneal surfaces into close apposition at
the margin. A row of Gushing sutures was taken outside of
this. Recovery was uneventful. The method used possesses
the essential elements of the method of Frank, but no
knots of the inner row of sutures are left on the inside as are
his. The time of applying these sutures differs but little from
that required to insert a Murphy button. Dowd believes that
results of various operators are favorable to the use of through-
and-through sutures. There is no danger of diaphragm forma-
tion as a sequel. He also believes that the making of an artifi-
cial anus in cases of gangrenous intussusception is very rarely
justifiable, [a.g.e.]
Open Method of Treating Septic Arthritis.— Walter
Whitehead' reports that he removed one of the cartilages of
the kueejoint and througli some unknown source infection and
suppuration succeeded. The condition of the patient became
so grave that he was given the option of amputation or a free
transverse incision into the kneejoint. The latter was chosen
and performed the patella and ligaments being divided by the
transverse incision. The interior of the joint was cureted,
cleansed, packed with iodoform gauze and dressed in a right
angle position. Convalescence was at once established and
1 Annals of Surgery, July, 1902.
2 Lancet, June 28. 1902.
» British Medical Journal, June 21, 1901.
AOGVST 2, 1902]
THE WORLD'S LATEST LITERATURE
.Akkricah Ukdicins 195
progressed to complete recovery. Fifteen days after the second
operation tlie leg was brought to full extension and so main-
tained, resulting, of course, in a stiff joint, [a. B.C.]
The Pathogenesis of Appendicitis.— Kramer' says that
tiie germ most often found in inflamed appendices is Ba-
cillus coU communis, but as it is a constant inhabitant of
the normal appendix, there must be determining factors of
much greater importance than the microorganism. Because
of its situation and blood-supply the organ is subjected to alter-
nating periods of anemia and hyperemia. This, causing super-
ficial destruction of epithelium, favors infection. When a con-
cretion is present it compresses superficial capillaries and
causes death of a layer of cells which help enlarge the concre-
tion, as shown by the fact that at least the outer half, and in
many cases nearly all, of the concretion is made up of closely-
paelted cast-oft cells cemented together with mucus. The con-
cretion thus enlarges at the expense of the wall of tlie appendix
until by pressure at some point all the capillaries are occluded ;
necrosis and perforation then follow. The ultimate cause of the
formation of concretions is probably the lack of peristalsis in the
appendix. To determine this point, f'aradic irritation was
applied to the appendix in situ in two cases. In neither case
was there the slightest sign of peristalsis, though examination of
both organs after removal showed a well-developed muscular
coat. Kramer still believes in the existence of a stercoral
typhlitis, and details a case in support of this view. [A.a.K.]
Benefit of Operation on Malignant Growths in the
.•\bdomen.— Collier '' narrates the case of a man of 43, ill for two
and a half j-ears with gastric symptoms, great emaciation, and
inability to digest or retain food. A definite lump was felt in
the right epigastric region. Operation was performed as the
only means of prolonging life. A growth involving the pylorus
and adjacent stomach for two or three inches was found. The
pylorus with growth was firmly adherent to the liver and gall-
bladder and all the structures were matted together l:>y old
adhesions. A posterior gastrojejunostomy was done. The
man improved rapidly and now, 15 months after the operation,
is enjoying tlie l)est of health and strength and working at his
trade, blacksmith. The growth can still be felt, little, if any,
decreased in size, but is the seat of no tenderness or pain. The
case is reported to empha.size the fact that the course pursued
l)y malignant growths in the abdominal cavity after operation
differs essentially from what may be expected in other parts of
tlie body. The malignant process may be arrested for a time
and the patient make a steady gain in health, strength and
weight. Operative interference in caseji sucli as the one
detailed does one of two things, Ijoth in themselves desirable-
it shortens the misery by death or it prolongs life by recovery.
[A.O.K.]
Transvesical Cauterization in Prostatic Hypertrophy.
— Boullleur ■' advocates transvesical cauterization as a substitute
for the Bottini operation in the treatment of some forms of
prostatic hypertrophy. He considers the following disadvan-
tages and dangers of the Bottini operation: .Uncertainty in («)
diagnosis; (b) location of beak of instrument; (<•) tissues in
grasp of cautery; (rf) proper length of incision; (c) tempera-
ture of knife; (/) destruction of tissue ; (g) occu rrence of post-
operative hemorrliage. Its use requires unusual skill in use of
electricity and special instruments, there is danger of bending
blade, it is inapplicable in stricture of the urethra and in
l)eduuculateti jirojei^tions. These objections do not apply to the
use of a cautery through a suprapulnc opening. It would be
diflicnlt in contracted tiladder, l>ut here the Bottini is of no
value. With careful operative technic and catheter drainage
the danger of fistula is practically elimiaated. Two successful
'•asoH are reported, [a.o.k.]
Thrombosis of Both Femoral Arterie*.— Mackay' re-
ports a case in which tlio diagnosis l^ietween gastrointestinal
intluoii/.a and enteric fever wa-s in doubt Un the tliirteenth
day of the illness sudden exertion was followed by alidominal
pain which extende<l into the legs. Kxamiuation showed the
absence of pulsation in the dorsales pedis, the posterior til/ials,
and the popliteals. Pulsation was present in tlie femorals at
' Annuls of HiirgiT\-, June, Wti.
'Lanci't, .June -11, IIKW.
• AnnalH of «urgcry, July, 19W.
the groin and in Scarpa's triangle. Death ensued three days
later, no autopsy being obtained. The probable causes of the
femoral thrombosis are discussed and the conclusion readied
that it does not throw any light on the diagnosis, [a.o.e.]
Clinical Observations on the Surgery of the GaIll)Ia<I-
der.— Ochsner 1 tabulates 48 cases operated for disease of the
gallbladder during 1901 with 6 deaths. Of these 37 were females.
11 males. Only 1 wa.s under 30 years of age. Of the 48 cases, 37
complained especially of digestive disturbances. Only one-half
of the cases had biliary colic, only 12 had severe jaundice, and
but a few passed gallstones in the feces. The basis of diagnosis
must not be these three classical signs or mistakes will be
numerous. The symptoms most constantly leading to a correct
diagnosis are (1) digestive disturbances ; (2) dull pain extend-
ing from the right of the epigastric region on a level with the
tenth rib to near the spine and upward under the shoulder-
blade ; (3) a point of tenderness between the ninth riglit costal
cartilage and the umbilicus; (4) ahistoryof one or more attacks
of appendicitis or typhoid fever; (5) in many cases a slight
tinge of yellow in the skin ; (6) usually an increase in the area
of liver dulness : (7) there may be a swelling opposite the end
of the ninth rib. An interesting point is that some form of
appendicitis was a complication in 25 of the 48 cases. The
medical and surgical treatment are discussed. Attacks of gall-
stone colic are said to correspond with contractions of the
stomach and severe ones which resist morphin stop directly
when the stomach is irrigated with very liot water, to recur
when food is taken into the stomach, [a.o.jb.]
GYXECOLOGY AND OBSTETRICS
WiLMER Krusen Frank C. Hammond
Significance of Changed Character of the Blood in
Diagnosis.— K. E. Laubenburg' reports several cases showing
marked changes in the characteristics of the blood in cases of
genital disease. The results of his investigations show that in
the presence of pus formation the red corpuscles decrease and
the white increase ; that if the process of pus-formation is brief
and the abscess small, the blood quickly returns to its normal
condition; but in long enduring feverish forms of disease the
number of leukocytes varies with the intensity of the disease,
falls as the temperature diminishes, and with the cessation of
pus formation gradually returns to the normal. Hence he
agrees witli Dutzman that the number of white blood-cori)uscle8
will be, on account of their reliability, an indispensable means
of help in differential diagnosis of gynecologic diseases. [w.K.]
Intravenous Ii\|ections of Artlftcial Serum In Pueri>e-
ral Hemorrhages.— C"h. Maygrier {Joiiriml <les Piaticieii^,
Vol. XV, No. f), 1901, page 65) reports 15 cases of puerperal hemor-
rhage in 7 of which cure followe»i intravenous injections of from
10 to 60 ounces of artificial serum. The following concliisions
are drawn from this method of treatment: (1) The «ul)cuta-
neous injection of artificial serum is an excellent and efllcient
means of treatment in the majority of cases of posthemorrliagic
anemia ; in the cases, happily rare, in which this treatment
fails, intravenous injections must bo resorted to without hesita-
tion ; (2) intravenous injection should be practised from the
first when the general condition of the patient is too grave to
await the result of sulicutaneous injection; (3) thedose of serum
must always lie large, and the injections should bo repeated
several times if necessary until the desired effect is olitainml :
(4) when H woman has had profuse homorrhageB and does not
react to the usual modes of treatment, and when death seems
inevitable, It is a duty to attempt Intravenous injo<aion of arti-
flcial serum. [t,.F.A.]
Vaitinal Myoma*.— Pare myoinas of the vagina are very
rare, and thoir existence may usually be re(orre<l to the muscu-
lar layer immediately underlying the vaginal mucosa. Aoconl-
Ing to Machonhauer' they usually occur In the fourth de(»<Ioof
a woman's life, and very rarely above the fifth, and vary In site
from a oherry to a child'* head. In three-fourths of the
1 Annsl" of Huntorv. June, IKf.
tCciiinill>liiil for liynlkkolosle. May 81, 1003.
'C'entmliilHli riir Uynltkologle, May 34,1(02.
196 AMBBICAK MBDICIBB]
THE WORLD'S LATEST LITERATURE
[AnouST 2, 1902
they are situated on the anterior vaginal wall in the upper half
of the vagina. Tlieir symptoms are slight, unless from com-
pression or erosion and ulceration. The suppurating myoma
can be distinguished from sarcoma or carcinoma only by the
useof the microscope. The removal of most vaginal myomas
is comparatively easy and the prognosis good. [w.K.]
Fetal Malformation.— Popescul ' reports a case of malfor-
mation of the fetus in the form of a tumor of the neck, or rather
a dropsical cyst in connection with a spina bifida or a split in
the cervical canal. Such cysts, being very soft and flabby,
usually form only a temporary hindrance to delivery, as
their size and consistency allow them to pass through the birth
canal. [w.K.]
Diagnosis of Tuberculosis of the Female Bladder.—
Kronig 2 endorses Stoedcel's affirmation that without the use
of the cystoscope errors In diagnosis are quite liliely to occur.
He reports the case of a woman who had been previously treated
for symptoms ascribed to a retro verted uterus, but which were
due to tuberculosis of the bladder, as demonstrated by micro-
scopic examination of the urine showing the presence of
tubercle bacilli, and a cystoscopic examination, by which it was
seen that the left ureteral opening was swollen and the adjacent
surfaces of the bladder abounded in tuberculous nodules. The
diagnosis was primary tuberculosis of the kidney with second-
ary tuberculosis of the bladder. The left kidney and ureter
were removed with complete disappearance of the subjective
symptoms. [w.K.]
A New Simple Suturing Apparatus.- Elsenberg ' de-
scribes his new instrument for applying sutures, consisting of a
tubular hand-piece in which is placed a spool of suture material,
the free end of which is threaded in a needle adjusted at one end
of this hand-piece. He also details the process of suturing after
the instrument and the suture material liave been sterilized. Its
advantages are that after placing a suture there is no rethread-
ing of the needle, no interruption of the suture, and no loss of
time ; further, the patient suffers less pain as the drawing
through of the thick eye of the needle is avoided, and there is a
great saving of valuable suture material. The greatest advan-
tage, however, is the perfect asepsis, since after sterilization the
suture material is not touched by the hands. This makes it
specially valuable for use in the difficult conditions often exist-
ing in private practice. [w.K.]
Submucous Uterine Myoma Complicating Pregnancy.
— Seeligmann* gives the history of a woman of 34, who, liaving
had three deliveries and two abortions, consulted him for
abnormal hemorrhages from the genital tract in the fourth
month of pregnancy. The size of the uterus indicated a much
longer pregnancy, but examination showed that this was due to
the presence of a subm^ucous myoma about the size of a child's
head. The hemorrhage was partially checked by a vaginal
tampon, and the patient was brought to the hospital in a condi-
tion of such complete collapse that five days were given in
which to recruit lier strength. The myoma was then removed
by vaginal enucleation in small pieces. This furnished space
for the further development of the fetus, and a healthy, living
child was spontaneously delivered at term. [w.K.]
Iinmbar Anesthesia.- J. C. S. Gauthier^ reviews the use of
cocain by intraspinal injection in obstetric practice. Dol6ris
has employed it in 25 cases with excellent results, and con-
cludes: 1. That obstetric anesthesia may be obtained with
certainty by means of the lumljar injection of a moderate
dose of cocain, J to J of a grain. 2. That cocain employed in
this way is an efficient means of hastening labor. 3. That
cocain is a hemostatic of great value. 4. That the accidents
due to its employment are of no importance and the risk to
the mother and infant are insignificant. Paul Reclus differs
with the last statement. After an experience of abopt 8,000
local anesthesias and a great number of spinal anesthesias, he
has seen many serious accidents and some fatal ones which
he attributes directly to the cocain. Tuffier, on the contrary,
after an experience of 250 major operations performed under
spinal anesthesia, states that this method has given entire
satisfaction. He believes that spinal anesthesia occupies the
same rank as local or general anesthesia. Gauthier believes
that spinal anesthesia will be more generally employed after it
has undergone the proof of clinical experience, [l.p.a.]
Sarcoma of the Uterus.— Fairchild ' reports a case of sar-
coma of the uterus, the patient being 65 years of age, the mother
of several children and apparently in good health until two
years before he saw her. Physical examination showed the
uterus uniformly enlarged two or three times its normal size,
impacted in the pelvis but with no discharge from the organ.
When the abdomen was opened a considerable quantity of free
fluid was found therein. The uterus was greyish-white in
appearance, firmly adherent posteriorly, and masses of new-
growth extended on either side to the ovaries and broad liga-
ments. As it was at once apparent that he had to deal with a
sarcomatous uterus, any attempt to remove which would involve
dangerous hemorrhages with little hope of getting away all the
diseased tissue, he decided not to try removal. As there was no
uterine discharge he believes that the endometrium and sub-
mucous tissues were not involved. He had never before seen a
sarcoma of the uterus which had undergone cystic degeneration,
but taking into account the general appearance of the mass, the
free fluid in the abdominal cavity, the adhesions, and the ex-
tension of the growth onto the broad ligament, he was assured
that it would be much better to let it alone. Hence he simply
opened the cyst on the anterior surface, permitting the escape
of about an ounce of clear fluid, the incision being closed with
a purse-string suture, and gauze introduced for drainage. The
patient was able to return to her home in two weeks. The
growth has since rapidly increased and a fatal termination is
undoubtedly near. [w.K.]
Inguinal Hernia of the Fallopian Tubes. — Annibale
Ghedini * describes a case of inguinal hernia of the fallopian
tubes, his article being accompanied by a bibliography of this
rare affection. A similar case was described by A. T. Bristow
in Medical News for July 12. (See American Medicine, July 19,
1902, p. 109.) [C.S.D.]
TREATMENT
Solomon Solis Cohen
H. C. Wood, Jk. L. F. Applbman
1 Centralblatt fUr Gynakologie, May 3, 1902.
- Centralblatt fiir Gynakologie, May 10, 1902.
3 Centralblatt fiir Gynakologie, May 17, 1902.
■"Centralblatt fur Gynakologie. May 24, 1902.
' La Revue Mfidicale, Vol. v, No. 27, 1902, p. 313.
The Prevention of Malaria It is a trite saying
tliat tlie prevention of disease is a duty as imperative as
tlie cure of it. Tliere seems, however, no reason why
the whole burden of the combat should fall on the physi-
cian ; his interest in preventive medicine is, after all,
one of almost altruistic philanthropy. It is a pleasure
to note that others are beginning to take an active share
in the battle. Some of the larger factories have awak-
ened to the fact that they have a commercial interest in
the health of their employes, and no more convincing
proof is needed of the value of governmental aid in
overcoming infectious disease than the success of the
warfare against yellow fever as carried out in Cuba, albeit
the military governor who was largely responsible for
the results was a physician. One of the most recent
systematic attempts to stamp out a preventible disease
is that now being carried on against malaria, especially
by the Italian government.
As it is now generally conceded that the mosquito is
not only the carrier of the infection but the necessary
intermediate host for the development of the Plasmo-
dium, it is evident that destruction of the anopheles
exercises a permanent prophylactic effect. Bienstock '
remarks, very logically, that there are theoretically three
possible means of causing the extinction of the malarial
parasite — preventing its development in the insect host
by destruction of Anopheles; interfering with its
1 Western -Medical News, July 15, 1902.
2 II Policlinico : Bupplemento Settimanale, Anno vllt, Fasc. 32-33.
'Deutsche medicinlsche Wochenschrift, June 16, 1902, No. 2-i.
AUGUST 2, 19021
THE WORLD'S LATEST LITERATURE
(AKERICAN Medicine 197
inoculation into tlie human host by protecting the nrian
against mosquito bites ; and finally by the use of a drug
like quinln preventing the development of the Plas-
modium in the blood after its inoculation. The ideal
would seem to be a combination of the three methods.
A.S the chief breeding place of Anopheles is the
stagnant pools, and as we have in petroleum an agent
exceedingly poisonous to the mosquito larva, theoretic-
ally it is only necessary in order to caase the disappear-
ance of the insect and the disease with it to pour on all
such collections of water a sufficient quantity of coal oil.
Unfortunately this is not so simple as it seems ; rain-
barrels and other small bodies of water, possible places
for the growth of the insect, are so scattered as to make
a complete disinfection impracticable ; Koch claims that
they may even develop in the water which collects in
the leaves of certain plants. Nevertheless, that a great
deal can be accomplished in this way has been demon-
.strated by the results in the island of Asenaro, in which
before the use of petroleum there were 100 cases of ague,
but none the following summer.
The method of individual protection has been used
with brilliant results by the Italian government in con-
nection with railroad construction. By forcing the
laborers engaged in this work to remain between sun-
set and sunrise in mosquito-proof houses — that is, with
all the windows and doors protected by screens — they
were able to work in one of the most malarious districts
of Europe with almost no sickness from the disease at
all. Important as this means is, esiiecially from the
standpoint of the individual, it is manifestly impossible
to enforce rigidly the necessary restraint in any large
community.
Koch has proposed and successfully used as a substi-
tute for these a very ingenioas application of quinin.
The theory of his method is that if during the winter
season, when the mosquito is not active, every case of
old malaria is thoroughly treated with quinin until all
the plasinodiums are destroyed ; and if in the spring and
summer every freshly inoculated person is likewise
completely disinfected, the race of plasmodiums must
eventually die out for lack of suitable soil in which to
complete their life cycle. While the prophylactic use of
quinin is undoubtedly of the utmost value to persons
exposed to the infection for a short period, it can hardly
be trusted to as the sole means of combating malaria in
badly infected districts ; for, as Koch himself has found,
it is possible for the plasmodiums to exist in the blood
of a man without causing any symptoms, and the con-
tinued taking of quinin causes such a revulsion of the
system against the drug that it is impossible to force
<-ontinue<i use.
Treatment of "Wounds. — AuchC and- Tribondeau {La
Mfdeeinc Modenie, October .30, liK)l) calls attention to the action
of potassium permanganate and hydrogen dioxid in the treat-
ment of wounds, and to the fact that hydrogen dioxid is not
decomposed wlien applied to all tissues of the body, notably in
contact with albumin and Iteratin. If, however, the area is ttrst
treated with potassium permanganate and then with hydrogen
dioxid, the decomposition readily takes place with the free
liberation of oxygen. Infected wounds or the tissues which
are to be treated are (irst washed to remove all greasy material,
then bathed in a solution of potassium permanganate, varying
in strength from 1 to 10 parts to 1,000 parts of distille<l water.
Hydrogen dioxid water, 1 to 18 volume solution, is then applied
and the part covered with a dry dressing. This treatment is
very efficacious in soft chancre, old suppurating wounds and
in rebellious forms of suppurative stomatitis. It is counterindi-
cated for use in the eyes. [i..k.a.]
Vomiting with Acetonemia.— Marfan (Journal dea Pra-
I 'rieiui, Vol. XV, No. 49, 1901, page 777) describes a form of periodic
vomiting, associated with acetonemia, occurring in children of
between 1 and 12 years, who present neuroarthrltic tendencies,
Init who are usually in good health and do not suffer with diges-
tive troubles. The vomiting liegins suddenly, the patient
being unable to retain even pure water. The breath smells
strongly of acetone ; the urine emits the same odor, but less
strongly. Slight emaciation is noticed in two or three days
associated with extreme weakness. The disease lasts on an
average five or six days, but its duration may vary from three
to fourteen days. Recovery is usually rapid. Treatment con-
sists in the administration of :i grains of magnesia five times
daily. The diet should be carefully regulated ; 1 dessertspoon-
ful of a mixture of equal parts of iced milk and water should
be given every hour. As vomiting becomes less frequent, the
milk may l)e given In greater quantities, always iced. A
simple edema is also given daily. Hypodermoclysis of normal
saline solution should be practised, if the patient goes into
collapse. [L.F.A.]
Cltmatic Treatment in Chlorosis.— There are some chlo-
rotics who do not bear well the ordinary pharmaceutic prepara-
tions of iron, but who can take mineral chalybeate waters with
advantage. In such cases Spa, Pyrmont, Schwalbach, and
other health resorts with gaseous chalybeate springs are often
useful. In other cases spas like Homburg and Kissingen
answer better, owing to the waters containing sodium chlorid as
well as a certain quantity of iron bicarbonate. Spas with muriated
alkaline chalybeate waters, like Royat, with its tonic climate, in
the Auvergne, are sometimes serviceable, and waters contain-
ing arsenic, in association with iron sulfate, such as those of
Levico and Roncegno, in southern Tyrol, may likewise occa-
sionally be prescribed. In very mild cases high altitude resorts
with gaseous iron bicarljonate waters, such as St. Moritz, in
Switzerland, and Santa Catarina, in the Italian Alps, often do
good. When there is much constipation, pharmaceutic laxa-
tives or aperient mineral waters can be used simultaneously.
In the United States the most available chalybeate springs with
suitable accommodations for invalids are Sharon Springs and
Richfield Springs, Crab Orchard and Oak Orchard Springs, in
Genesee County, New York, the Fauquier White Sulfur, West
Virginia, Jordan White Sulfur, Massanotta, Montgomery
White Sulfur and Rawley Springs in Virginia, the New Alma-
den Vichy, Congress Spring, Geyser Spa Spring and Napa Seda
Spring in California, Thorp's Spring in Wood County, Texas,
the Ojo Caliente Spring in New Mexico. The Owasso mineral
water in Shiawassee County, Michigan, is a strong chalyl>eate
water, but the locality has not been utilized as a resort. The
Iron Ute Mauitou Spring in Colorado is an excellent chalybeate
water. Cheerfulness of surroundings is very important in the
treatment of chlorotics, for a condition of mental depression is
sometimes the determining cause of the chlorosis, aiid cure not
rarely follows removal of the depression. Among cases of
anemia it is, perhaps, the chlorotic class in which most supervis-
ion must be exercised in regard to the avoidance of fatigue.
Here the influence of the resident physician at the health resort
must make itself felt, for chlorotic patients and their friends
have often a firm belief that any amount of exercise In the pure
open air must necessarily do them good. It is owing to this
wrong impression and the absence of medical supervision that
these patients frequently come back from health resorts rather
worse than when they started.— Weber and Hinsdale in Cohen's
" System of Physiologic Therapeutics."
Treatment of Hepatic Colic. — Artault {Ln MMfciiie
Modeniv, Vol. xii. No. 49, 1901, page -Wi) has ol)talned excellent
results from the administration of oleic add in hepatic oolio.
He believes that oleic acid is a specific In this condition and
that it is to this substance olive-oil owes Its value. It rapidly
calms the pain of an attack of hepatic colic, and also hinders
the formation of now calculi, thus preventing sul>He<iuont
attacks. Artault administers from 8 to 1« mlnluiH In capsule
before breakfast. This is contlnuml every month for ton days.
The patient at the same time nmst be placed on the usual
dietetic and hygienic treatment employwl in theHC<-ases. [l.k.a.]
An Improvement in the Preparations of Senna.— Kite
(Arnerican Druggist, 1901,Vol. xxxlx, p. 140) says that Mnna as at
present employed causes much griping and nausea, even when
combined with aromatlcs. He claims that these irritating
properties reside In the resin, which has little to do with the
purgative action of the <irug. For the purpose of getting rid
of this objectionable feature he advises that the senna be
macerated and percolated with alcohol, which will dissolve the
198 American Mbdioinb]
THE WORLD'S LATEST LITERATURE
[AUGUST 2, 1902
resin and not the cathartic principles. The various official prep-
arations may then be made from this prepared senna, for
which he suggests the name of senna preparata or senna
deresinata. [h.c.w.]
Strychnin In Delirium Tremens.— Fernet (La MMecine
Moderne, Vol. xii, No. 49, ltK)l, page •!!*)) calls attention to
the value of strychnin iu delirium tremens and adynamic con-
ditions. He administers to such patients 1/12, 1/10 or 1/6 of a
grain of strychnin sulfate daily, in divided doses as asyrup or by
subcutaneous injections. The results have been good, which
tends to show that the excitation of alcoholics in crises of
delirium tremens is correlative with extreme nervous enfeeble-
ment. [l.f.a.]
Treatment of Typhoid Fever in Children. — Durieux
{Le Mois Ther(tpeutiqiie,yo\. ill. No. 1, page 9) states that cold
baths should not be given systematically in all cases of typhoid
fever in children. Their application is sometimes ditftcult, and
requires careful intelligent supervision which cannot always be
obtained, especially in rural practice. The indication for cold
bathing depends much less upon the temperature of the child
than upon the state of the nervous system. If there is torpor,
restlessness, or irregularity of the heart's action, cold baths
will be beneficial. In mild forms of the disease quinin has
been used with advantage, and may be given in large doses or
in divided doses ; it favorably modifies the progress of the dis-
ease, lowering the temperature and causing sedation of the
nervous system, [l.f.a.]
Treatment ofRebellioas Vomiting. — A. Robin (Bulletin
Oiniral de Thirapeutique, \la.y 30, 1901) recommends that the
patient remain in bed during treatment for persistent vomiting
and the stomach be given a complete rest. Small pieces of ice
may be allowed for refreshing the mouth, but all food should be
given by enemas, which may be composed as follows :
Yolk of egg 2
Solution of peptones 2 dessertspoonfuls
Solution of glucose, 10% .... 2J ounces
Salt 15 grains
Pepsin 7 grains
Wine of opium 2 drops
This should be thoroughly mixed. Nutritive enemas
shou'ld be given every six hours, and made to enter the bowel
as far as possible by the aid of a Nelaton catheter, the patient
lying on his side. The large intestine should be evacuated with
an injection of 5 ounces of boiled water given a half hour before
the nutritive enema. The injections of boiled water also tend
to allay thirst. If this treatment fails or for any reason is not
practicable, place fly blisters on the epigastrium ; in several
hours open the blister and dress with 2 grains of powdered
opium. This acts well, especially in the vomiting of typhoid
fever. When blisters cannot be used, order an absolute milk
diet, and the following solution of picrotoxin :
Picrotoxin J grain
Alcohol enough to dissolve it
Add to this :
Morphin hydrochlorate j| grain
Atropin sulfate J grain
Ergotiu 15 grains
Cherry-laurel water 3 drams
Filter.
Dose. — Five drops before taking the milk. Twenty drops a
day should not be exceeded, as picrotoxin is very poisonous.
Oxygen inhalations have given good results, especially in the
vomiting of pregnancy. In cases in which all other means have
failed, the author obtained good results from lavage of the
stomach with boiled water, [l.f.a.] (Much larger doses of
picrotoxin can be given with safety than text books state ; ^
grain is not excessive as a maximum dose for an adult, s.s.c.)
Potatoes In the Treatment of Diabetes.— Moss6 (Jour-
nal des Praticien.i, Vol. xvi, No. 10, 1902, p. 156) states that Coig-
nard, in 1886, published an article demonstrating the value of
potatoes in diabetes. A patient, aged 55, came under his care
suffering from diabetes, associated with gangrene of the right
great toe and with dysentery complicated by jaundice. The
urine contained 12 drams of sugar to the quart and about four
quarts were passed during the day. The patient had 10 to 12
stools in 24 hours. Treatment had consisted of a diet of gluten
bread, roast meats, no fruits and four glasses of vichy water
daily. Coignard replaced the gluten bread by boiled potatoes
and directed that fresh fruits be taken. The vichy water was
continued. Twelve days later the jaundice and dysentery had
disappeared. Tiie toe, dressed with iodoform, had improved.
Analysis showed that boiled potatoes contain less sweetening
material than gluten or toasted bread. Fried potatoes, on the
cx)ntrary, contain considerably more sugar, [l.f.a.]
Massage and Passive Movements in Hemiplegia. —
<Jraham (Edinhurgh Med. Jour., May, 1902) believes it possible
to aid the restoration of power in hemiplegics by the combined
use of movements and massage. The gymna-stics educate the
jjortions of the brain unaffected by the apoplexy to fulfil the
work of the centers which have been destroyed. The massage
is necessary in order to maintain the nutrition of the muscles
until the apoplectic learns to use them, [h.c.w.]
Treatment of Dental Carles. — AndrS and Demarioa
(Bulletin Qiniral dc Thirapeutique, Vol. cxlii. No. 18, 1901, page
720) recommend the following as a powerful disinfectant in
dental caries :
Formic aldehyd 3J ounces
Spirit of geranium 6 drams
Alcohol, 80% 3J ounces
This completely deodorizes dental caries after two or three
applications. It is very diffu.sible in aqueous liquids, [l.f.a.]
Heart Failure in Pneumonia. — Kronig (Kliii. med. Woch.,
1S)02, No. 18, p. 190) says that the occurrence of dry pleurisies in
pneumonia not only adds to the suffering, but is the cause of a
danger which is too often overlooked. As the result of the pain
there is a lessening in the depth of respiratory movements and
consequent diminution in the aspirating action which aids in
the filling of the right auricle. It is impossible for the ven-
tricle to keep the blood circulating unless it receives a free
supply from the auricle, and morphin, therefore, by lessening
the pain and allowing a more complete aspiration from the
great veins, will often accomplish more than powerful heart
stimulants. In a similar manner does a pleural exudate, and
to a still greater extent a pericardial effusion, interfere with the
filling of the right auricle. We must not, however, neglect the
ventricle, for the stimulation of which Kronig recommends
digitalis. When the right ventricle has become too distended
from the accumulation of blood, there is only one means of sup-
porting it, and that is by venesection, [h.c.w.]
Treatment of Osseous WhitloAV. — Schuster (Bulletin
Otniral de Thf.rapeutique, Vol. cxlii. No. 18, 1901, page 720) em-
ploys the following in the treatment of whitlow ;
Metallic iodin 1.5 grains
Tincture of iodin U drams
Tincture of rattany IJ drams
Potassium iodid 30 grains
Glycerin 1 ounce
For external use.
After the whitlow is incised an aseptic piece of gauze is
dipped in the above solution and introduced into the wound to
the bone; this is then covered with a compress saturated with
a solution of alumina acetate. By this treatment .Schuster
obtained nearly immediate cessation of the suppuration and
cicatrization of the wound in a few days iu some cases which
had not responded to the use of iodoform gauze, [l.f.a.]
A Nutritive Refrigerant Drink. — Tjeftwich (Edinburgh
Med. .lour.. May, 1S»02, 460) recommends very highly the follow-
ing refreshing and nourishing drink in febrile conditions :
Lemons 2
White of eggs 2
Boiling water 1 pint
Loaf sugar to taste.
The lemons must be peeled twice, the yellow rind alone
being utilized, while the white layer is rejected. Place the
sliced lemon and the yellow peel iu a quart jug with, say two
lumps of sugar; pour upon them the boiling water and stir
occasionally. When cooled to about the ordinary temperature
of tea, strain off tlie lemons. Now insert an egg whisk, and
wlien the lemonade is in full agitation add slowly the white of
egg. Continue the whisking for two or three minutes more.
While still hot, strain through muslin. Serve when cold. The
albumin so covers the acidity of the lemon that very little
sugar is required, [h.c.w.]
ACGUST 2, 1902]
THE WORLD'S LATEST LITERATURE
[AKKRICAN MEDICIKB 199
Treatment of Whoopingcongh by Formaldehyd Vapor.
-De Lamalleree (.Journal Midical de Bruxelles, Vol. xvii, No.
19, 1902, p. 298) employs inhalations of formaldehyd vapor
in the treatment of whoopingcough. He directs that a para-
form tablet (15 grains) be vaporized over an alcohol lamp every
hour, being careful to keep the room tightly closed. No other
treatment is administered. In 20 cases cited by the author the
vomiting ceased in from 24 to 62 hours ; the attacks of coughing,
which numbered before treatment from 18 to 37 in 24 hours, fell
to 2 or 3 after 48 hours at most. In 4 cases only did the cough
persist, varying from 5 to 6 attacks after the same lapse of time.
Of 22 cases seen by the author there were 2 in which this treat-
ment was unsuccessful, 4 responded slowly, and 18 were com-
pletely cured within 8 days. In order to obtain these results it
is necessary 1) that the patient be seen in the first 8 or 10
days that the disease is manifest; (2) that the patient be kept in
seclusion in a well closed room. This should be at a tempera-
ture of from 65° to 70° P. [l.p.a.]
The Uses of the Ice-bas.— Granger (Nexo Orleans Med. and
Surg. Jour., .July, 1902, p. 19) reports several cases of oozing
after abdominal operation in which the discharge from the
drainage tube was greatly lessened by the use of an ice-bag out-
side the dressing. He recommends its use as a routine measure
after celiotomies, especially when there has been much hand-
ling of the abdominal contents or when there is reason to expect
much oozing. He also gives a list of other uses for the ice-bag,
among which may be mentioned its application to the back of
the neck, over the medulla, for the nausea and vomiting after
anesthesia ; its continued use over the abdomen and head in
typhoid fever; its use as a stimulant to the expanded uterus in
prolonged labor, and its refrigerant effect in the ordinary
inflammatory conditions. [The use of an ice-bag over the heart
to reduce the frequency and improve the vigor of its contrac-
tions is not so general as it should be. This application must
not be too prolonged ; from 15 to 30 minutes once or twice dally
suffices. S.S.C.]
A New Suppository Base. — Crouzel (La Mfdecine Mod-
erne, Vol. xiii. No. 4, 1901, page 34) recommends the following
suppository base :
Paraffin 1 part
Anhydrous lanolin 3 parts
The advantages claimed are : That more homogeneous mix-
turfts of medicinal substances can be made with it than with
cacao butter, and that much larger doses of medicinal sub-
stances, such as extracts, alkaloids, mineral or organic salts,
and vegetaVde powders, can be administered with this as a
base. Anhydrous lanolin will absorb its own weight of water,
saturated saline solution, or solutions of vegetable extracts;
hence a large proportion of active principles soluble in water
may be incorporated in these suppositories, [l.p.a.]
Heroinoinaiiia. — The Medical PreH.t of June 18 calls atten-
tion to the tliesis of M. .J. L. de la .Jarrige on the subject of
heroinomania, showing that it is possible to establish a heroin
ha'jit and that the remedy is, therefore, an unsuitable one for
the treatment of morphinism, [ii.c.w.]
A New Treatment of Cancer.— Howitz {Journal des
l'niticien-1, Vol. xvi. No. 10, 1902, p. 156) reports favorable
results in the treatment of cnncer by freezing the cancerous
vegetations Ijy a jet of ethyl chlorid. This may be preceded by
curetment and cauterization with a hot iron, if it is indicated.
The author has employefl this method in treating inoperable
cancersof the uterus and vagina. He has employed it in only
two cases of cancer of the breast, but he believes that it may be
used in cancer of other parts of the body accessible to this treat-
ment. When the freezing jet is directed on a part of the vagina
or uterus invaded by cancer these parts are not blanched, or at
least much less than the healthy parts, which enables the oper-
ator to determine the extent of the cancer. Howitz believes that
this may even serve as a diagnosis between cancer and other
granularr vegetations resembling it. During curetment of the
uterus, when small cancerous areas liavc been left, the differ-
ence in the coloration between these areas and the healthy
mucous membrane is marked enough after freezing to enable
the operator to complete the curetment without touching the
healthy mucous membrane. After curetment the actual cautery
may be used if the tissues are deeply involved or if there is
abundant hemorrhage. If this is not done the uterus should be
packed with gauze. When this is removed the area is washed
with hot water and carefully dried. An ethyl chlorid spray is
then directed on the diseased area for not over five minutes.
This treatment should be repeated every two or three days at
first, later at longer intervals. When a suspected point is seen
it should be curettetl at once. Howitz has employe<l this treat-
ment in 12 eases with encoviraging results. The patient should
at the same time be placed on a tonic, internal treatment and
plenty of nourishing food, [l.f.a.]
PORMUIiAS, ORIGINALi AND SELECTED.
Dyspepsia Cachets.— A. Robin {Bulletin Giniral de Thfra-
peutigue. Vol. cxlii. No. 21, 1901, page 832) recommends the fol-
lowing in the albuminoid dyspepsia of patients having a hyper-
secretion of hydrochloric acid :
Pepsin 7.5 grains
Extractof malt 1.6 grains
Lactose 7,5 grains
For 1 cachet. One after each meal, [l.f.a.]
An Ointment tor Inflamed Nipples.— The Hauadoklor
recommends
Silver nitrate 10 grains
Bismuth nitrate 1 dram
Lanolin 1 ounce
To be ap5)lied morning and evening after washing the nip-
ples.—jV. Y. Med. Jour.
For Pruritus AnI. —
Carbolic acid 30 grains
Calomel 1 dram
Tar U drams
Menthol 20 gridiis
iflnc oxid 2 drania
Simple cerate 2 ounces
Wash the parts with hot water and spread the ointment on
a cloth. Apply and fasten with a T-bandage. — Merck's Archives,
March, 1902. [h.c.w^.]
For Summer Diarrhea.— The lower bowel having been
cleansed with a saline enema, the upper bowel may be emptied
with the following mixture given by the mouth ;
Castor oil 4 fluid drams
Aromatic syrup of rhubarb 6 fluid drams
Camphorated tmcture of opium ... 15 minims
Mix and shake well.
Dosage: For an adult, to be repeated every second hour
until effective. For a child of two years, one-fifth this dose.
If looseness of the bowels continues after the castor oil-
rhubarb stool, the following powder may be given :
Benzonaphtol 'i grains
Bismuth salicylate 7J grains
Mix.
Dosage : For an adult, one powder after each stool. Chil-
dren may take of this powder for a dose wliatever quantity
tliey can readily swallow, as it has no toxic action.
Should it be deemed advisable In severe, painful or obsti-
nate cases, a suppository of extract of opium and extract of bel-
ladonna may be given and repeate<l as needed ; or from 24 to 5
grains of Dover's powder for an adult; from A to 1 grain of
Dover's powder for a child may be added to the compound
bismuth j>owdered. The diet is to b« restricted to thin soup,
beef juice, or barley water, [s.s.c]
For Hay-fever.— Use the following sprays in order Indi-
cated, one to three times daily:
Spray No. 1 :
Sodium blcarlionate 20 grains
Sodium borate 'JO grains
<;iyceriu 1 tlu Id ounce
Carliolic acid (rheml<»lly pure) ... 4 rntins
Disllllwl rose water 31 fluid ounce*
Mix. Cleanse nasal passages thoroughly.
Spray No. 2 ;
Solution of adrenalin chlorid (1 : 1,000) . . Vi minims
Solution of Ho<liuni chlorid (0.9%) . . . . 45 minims
Mix. For two applications.
Spray No. 3 :
.Menthol 20 grains
Liquid petrolatum (parifled) bounces
Mix. Use freely. [».«.c.]
200 American MiedicinEj
THE PUBLIC SERVICE
(AD GUST 2, 1902
THE PUBLIC SERVICE
Health Reports.— The following oases ol smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, during
the week ended July 2(i, 1902:
California :
Illinois :
Indiana :
Kentucky :
Maasacbusetts :
Missouri :
Nebraska :
New Hampshire :
New Jersey :
New York :
Ohio:
Pennsylvania :
Rhode Island :
Washington :
Wisconsin :
Austria :
Belgium :
Canada :
China :
Colombia:
France :
Oreat Britain :
Greece :
India :
Italy:
Mexico:
Russia :
Spain :
Colombia :
Costa Kica :
Mexico :
China:
India :
Philippine Islands :
8JIALLP0X— United States.
Ca«e8 Deaths
Sacramento luly 5-12 3
Belleville July 12-19 4
Chicago luly 12-19 5
Joliet July 1-15 15
Indianapolis July 5-12 12
Covington July 12-19 11
Boston luly 12-19 8
Cambridge July 12-19 7 2
Everett July 12-19 3 1
Lowell July 12-19 3
Medford July 12-19 1
Newton July 12-19 2
Somervllle July 12-19 13 1
St. Louis July 13-20..
Omaha July 12-19..
Nashua July 12-19..
Hudson County,
Jersey City inci....July 13-20....
Newark July 12-19....
New York July 12-19....
Cincinnati July 11-lS...,
Cleveland July 12-19....
Dayton luly 12-19...
Hamilton July 12-19....
Erie July 12-19....
Johnstown July 5-19
McKeeaport July 5-12
Philadelphia July 12-19,...
Pittsburg July 12-19...,
Providence July 12-19....
Tacoma July 7-14
Green Bay July 13-20...
Milwaukee July 12-19...
11
3
2
3
7
15
4
32
3
2
Smallpox— Foreign.
Prague June 28 -July 5..,
Antwerp June 21-July 5 ,.,
St. John July 12-19
Hongkong May 21-June 14.,
Panama June 7-14
Marseilles June 1-30
Paris June 21-28
Gla.sgow July 4-11
London June 28-July 5...
Atlieus June 28-July 5 ..
Calcutta Junel4-!1
Karachi June 15-22
Madras June 14-20
Palermo June 2i-Juiy 6...
Vera Cruz July 5-12
Moscow June 21-28
Odessa June 28-July 5.,,,
St. Petersburg June 21-28
Corunna June 28-July o,,..
Yellow Fever.
Panama July 7-14
PortLimon July 3-10
Alvarado July 7
Cordoba July 7
Vera Cruz July 5-12
Plague.
Hongkong May 24-June 14..,
Calcutta June 14-21
Karachi June 15-22
CHOLERA— INSULAR,
Manila May 25-June7...
Provinces May 2,5-June 7...
Cholera.
Hongkong May 21-June 14...
Calcutta June 14-21
Karachi June 15-22
Karatsu June 22
14
1
4
13
3
10
2
3
1
3
2
3
1
4
1
1
1
4
H
1
2
.58
13
1
1
3
2
1
IS
4
1
1
10
4
4
10
1
1
3
1
1
Epidemic
Present.
22
9
194
191
5fi
20
IB
132
118
,018
729
53
49
31
45
37
41
21
China:
India:
Japan :
Changes in the Public Health and Marine-Hospital
Service for the week ended July 24, 1902:
Stoner, G. W., surgeon, detailed as Inspector of unserviceable prop-
erty at the Purveying Depot, New York— July 19, 1902.
Banks, C. E., surgeon and medical purveyor, granted leave of absence
for four days from July 21 or 22— July 22, 1902.
Peckham, C. T., surgeon, granted leave of absence for two days from
July 10, 1902, under paragraph 181 of the regulations.
Heiser, V . G., assistant surgeon. Bureau order of July 17, 1902, reliev-
ing Assistant Surgeon Heiser from duty at Quebec, Canada, and
directing him to proceed to Manila, for duty, amended so that he
shall report at Washington, D. C, en route to Manila— July 21, 1902.
King, W. W., assistant surgeon, granted leave of absence for eighteen
day.s from July 17— July 16, 1902.
McLaughlin, a, J., assistant surgeon, to proceed to Ocean City,
Chincoteague and Watchapreague, Md., for the purpose of making
physical examinations of keepers and surfmen of the Life-Saving
Service— .i uly 19, 1902,
McCoy, G. W.. assistant surgeon, upon being relieved from duty at
San Francises, Cal., by Acting Assistant Surgeon W. C. Bucker, to
proceed to Manila, P. 1.. and report to the chief qnarantine officer
for assignment to duty— July 19, 1902.
Kenan, Spalding, acting assistant surgeon, granted leave of absence
for four days from J uly 22— J uly 19, 1902.
Burkhalter, J. T., assistant surgeon, relieved from duty at the Gulf
(Juarantine Station, and directed to proceed to the Brunswick
Quarantine Station, assuming command- July 18, 1902.
Changes In the Medical Corps of the U. S. Navy for
the week ended July 26, 1902 :
Shipp, E. M.| passed assistant surgeon, detached from the Celtic and
ordered to Port Isabela, P. I.— July 17.
Guthrie, J. A., passed assistant surgeon, detached from Port Isabela
and ordered home via the Solace— July 17.
Bishop, L. W., assistant surgeon, detached from the Naval Brigade
and ordered to the Celtic— July 17.
Baker, M. W., Halloway, J. H., Ruckek, W. C, acting a.ssi8tant
surgeons, commissioned acting assistant surgeons from Jily 10,
1902— July 18.
Russell, A. C. H., surgeon, detached from duty as member and
recorder of the board of medical examiners. Naval Laboratory,
N. Y., August 25, and ordered to the Naval Museum of Hygiene and
Medical School, Washington, D. C, for duty as a member and
recorder of the board of medical examiners— J uly 18.
Stitt, E. R., surgeon, detached from the Hartford and ordered home,
and to wait orders— July 18.
HiBBETT, C. T., surgeon, ordered to the Franklin, August 1— July 18.
ALFRED, A. R,, passed assistant surgeon, detaclied from the Monad-
nock, and ordered to the Solace— J uly 18,
Seaman, W., assistant surgeon, detached from the Naval Hospital,
Yokohama, Japan, and ordered to the Monadnock— July 18.
Gkiffin. W. E.. assistant surgeon, detached from the Naval Hospital,
Yokohama, Japan, and ordeied to duty at Olongapo, P. I.— July 18.
Halloway, J. H., acting assistant surgeon, ordered to the Naval
Hospital, Boston, Mass.— July 24.
Baker, M. w., acting assistant surgeon, ordered to tlie Naval Hospital,
Norfolk Va.— July 24.
Changes in the Medical Corps of the V. S. Army for
the week ended July 26, 1902 :
Burns, John S., hospital steward, Junction City, Kan., will upon
expiration of furlough granted him at Fort Meade, report to the
commanding officer, Fort Riley, who will send him to Fort Mc-
Dowell with instructions to report upon his arrival to the com-
manding officer of that post, who will send him to Manila, F. I.,
for assignment to duty.
Shepherd, John M., contract surgeon, is granted leave for one month
from about August 1.
Devereux, First Lieutenant Thomas, assistant surgeon, recently
appointed, is assigned for duty at Fort Snelliug— July 12.
Moncreif, First Lieutenant William H,, assistant surgeon, is
relieved from duty at Jefl'erson Barracks, and will proceed to Fort
Getty for duty.
Davis, First Lieutenant William Thornwall, assistant surgeon,
recently appointed, will proceed to Fort McHenry, for duty.
Hess, First Lieutenant Louis T., assistant surgeon, is relieved from
further duty at the general hospital. Fort Bayard, and will proceed
to San Francisco, Cal., for transportation to the Philippine Islands,
where he will report for assignment to duty.
Boyce, J. Newton, contract surgeon, upon his arrival at Fort Mc-
pherson with the Sixteenth Infantry, will proceed to New York
City for annulment of contract.
BOYCB, J. Newton, conti-act surgeon, is granted leave for one month,
to take effect upon his arrival in New York City.
McCaw, Major Walter D., surgeon, will repair to Washington, D. C,
and report to the surgeon-general of the army for consultation on
business pertaining to the medical department, and upon the com-
pletion thereof will return to his proper station at Fort Wadsworth.
Newgarden, Captain George J., assistant surgeon, will proceed to
Hot Springs, Ark., and report at the Army and Navy General
Hospital for treatment.
MoLONY, Louis A., contract surgeon, is relieved from further duty in
the department of California, and will proceed to his home, Cincin-
nati,Ohio, for annulment of contract.
HOFF, Lieutenant Colonel John Van R., Is granted leave for one
month from about August 1.
PuRNELL, Firsc Lieutenant Harky S., assistant surgeon, recently
appointed, will proceed from Berlin, Md., to Columbia Barracks,
for duty.
RocKHiLL, First Lieutenant Edward P., assistant surgeon, having
reported his arrival at San Francisco, Cal., in compliance with
orders heretofore issued, will report to the commanding general,
department of California, for assignment to duty.
LoNGiNO, Captain Thomas C, assistant surgeon, is relieved from duty
in the office of the medical supply officer at Zamboanga, Mindanao,
and will proceed to Malabang. Mindanoa, for duty.
KiEKSTBD, J'irst Lieutenant Henky S., assistant surgeon, is relieved
from duty at the Army General Hospital, Presidio, and will proceed
to Fort Miley, for duty.
Williamson, First Lieutenant Llewellyn P,, assistant surgeon, is
granted leave for thirty days from about August i5, with permission
to apply for an extension of fifteen days.
White, Sa.muel J., contract surgeon, is granted leave for one month
from about July 17.
EwiNG, Major Charles B., is granted leave for one month.
Clayton, First Lieutenant Jebb B., assistant surgeon, is granted
leave for one month, from about August 1, with permission to apply
for an extension of one montb.
Kean, Major Jefferson R., surgeon, Is relieved from duty in Wash-
ington, D. C, and will avail himself of the leave granted him
April 19.
Jenkins, Frederic E., contract surgeon, Is granted leave for one
month.
Painter, Captain George L, assistant surgeon, leave granted June 2o
is extended one month.
Hansell, First Lieutenant Haywood S., assistant surgeon, Is assigned
to duty at Fort McPherson— July 11.
Collins, First Lieutenant George L., assistant surgeon, recently ap-
pointed, will pi-oceed from Dorchester, Boston, to Fort Warren,
Mass., for duty.
Pabkman, Wallace, contract surgeon, who was assigned to duty In
Alaska, by orders of July 5, has had the order revoked.
MONCRIEF, William H., contract surgeon, Jett'erson Barracks, will
proceed to Fort Leavenworth for temporary duty.
Raikes, Benjamin T., hospital steward, San Francisco, Cal., will be
sent to Fort H G. Wright for duty.
American Medicine
^iA
GEORGE M. GOULD, Edilor
G. C. C. HOWARD, Managing Editor
CHARLES B. DOLLEY
MARTIN B. TINKER, AultUmI, Bdilort
Clinical Medicine
David Riesmak
A. O. J. Kelly
h. h. cushino
Helen Murphy
General Surgery
Martin B. Tinker
A. B. Craig
Charles A. Orr
Orthopedic Surgery
H. Augustus Wilson
COLLABORATORS
Obtletriea and Oyneeotogy
WiLMER Krusen
Frank C. Hammond
yervous and Mental Diseases
J. K. Mitchell
F. Savary Peabce
TVeatjnent
Solomon Solis Cohkn
H. C. Wood, Jr.
L. F. Appleman
Dermatology
M. B. Habtzell
Laryngology, Ble.
D. Braden Kylb
Ophthalmology
Walter L. Pyle
Pathology
R. M. Pearce
PUBLIBHBD WniCLT *T 1821 WALMITr SnUBT, PbILADBLFHIA, BT THB ANBBlCAH-MBDICtNB PcBLtBHtMO CoKPAKT
Vol. IV, No. 6.
AUGUST 9, 1902.
$4.00 Yeakly.
Medicine and the Univer,sities. — The noteworthy
address of Professor Barker, printed in our issue of
July 26, has produced its desired reaction. If one may
judge from the inquiries concerning it and the comments
that it has already aroused, the address promises to be
the subject of discussion for some time to come.
Appearing as it has after the close of the academic
year when teachers and practitioners of medicine are on
their vacation and separated from libraries and journals,
the probabilities are that the present ripple of interest
will swell into a good-sized wave of contention when
the fall shall have brought the wanderers back to
work with renewed vigor and sharpened wits. What-
ever may be one's view as to the possibility of reali-
zation of the splendid scheme of medical education
outlined in the address, it must be conceded that Dr.
Barker has deflne<l in an adequate and spirited manner
the present status of the medical schools of this country.
While every informed person will admit the great
improvement in instruction given in the medical col-
leges, taken as a whole, he cannot fail to lament that the
ine<[uality between best and worst should be so glaring.
The most serious menace to improvements in medical
educational methods and standards might, at first sight,
be supposed to be due to the continued existence of
the old proprietary school. It is evident that modem
requirements in medical education make such schools,
subsisting entirely on the fees of students, a direct
financial burden to the staff, yet the indirect advan-
tages accruing to the members of the teaehing body will
continue to keep them alive, in spite of the relatively
poor work that they must do, until State enactions and
an enlightened public opinion compel them to find
ade(iuate support or U) close their doors.
The Pseudo-University Medical School. — Now
that medicine no less than its sister branches,
law, philosophy, and theology, has made for
itst>lf an enviable place in the university system,
.some university boards have permitted themselves
to l)ecome allied with proprietary schools, to which
they lend the advantage of their names and estab-
lished position, without either demanding a system of
instruction on a university basis or participating in any
serious way in the management, financial or educa-
tional, of the medical school's aflViirs. Dr. Barker haa
justified his contempt for such a destructive policy, and
has properly designated this class of colleges as " pseudo-
university medical schools." The grave responsibilities
which every university trustee accepts along with his
Installation into office makes it ineuml)ent upon him to
oppose any plan that will diminish the prestige and
value of the university, and to require that whatever of
extension is undertaken, be on a true and not fictitious
basis. For this reason the " pseudo-university " medical
school is a menace to public health and a clog to medical
progress. Bearing the name of a university without
sharing in its idesils or facilities it imixjses on a public
that must still for a long time fail to possess that dis-
crimination which will ensure an understanding between
what is bonafide and what is a mere pretence in educa-
tion.
The " Real University Medical School." — In the
sense that Dr. Barker uses this designation it does not
exist in this country or in Europe. Is it, may there-
fore be askeil, a wholly Utopian view to predict that the
medical school of the future will rest on a "real"
university basis? The best answer to this question is
found in the history of the medical education of the last
ten or a dozen years in this country. The rise of the
'* semi-university school " is no less surjjrising than
ftom our present vantage ground will he that of the
" real university school." In the Ix-st semi-university
schools almost one-half of the chairs are on a university
basis. Who would have predicte<i a quarter of a century
ago that in this country the surgeon would find himself
disqualified as a teacher of anatomy, or the professor of
medicine as teacher of {wthology, and that any bright
graduate in medicine would not suffice to give the Instruc-
tion in i)hysiologyand, jwrhaps, chemistry ? And yet the
confines of the country are now searched in order to Hn<l
the men who possess the special (|ualiflc)»tions to fill
these fundamental chairs, and institutions already rival
each other in securing the best and most distinguished
" scientists " to fill these offices. What a world of change
is embo<lied in that word "scientist," for strangt^y
enough, 8c-lentlflc, first-hand knowledge is what has
come to be one of the most important retjuisltes to
hold appointments in these branches. While character
and addn-ss are still important factors in iiiMucncing
selwtion for a professorship, that which is especially
202 AXBBICAN MeDICIMKJ
EDITOKIAL COMMENT
[AUGUST 9, 1902
demanded by the trustees of a seral-university school,
and even of some schools which cannot be Included In
this class, is fitness as determined by special Isnowledge.
The Clinical Chairs in the Real University Medi-
cal School Are anatomy, pathology and chemistry, it
may be aslced, worse and more inadequitely taught now
than under the old regime ? We take it that no competent
judge would essay that position. But on the other hand,
what an immense gain has accrued to the profession and
the public through this change ! Does any one doubt
that the intellectual position of the medical man has
been raised by a training at once scientific and practical ?
There are very few places in the civilized world that
the influence of definite Icnowledge and accuracy have
not entered to establish the position of the doctor on a
higher plane.
And now Dr. Barker proposes to do for medicine,
surgery, and obstetrics what has been done for the fun-
damental sciences of medicine, as teaching and research
subjects, from which accomplishment the profession and
world have benefited so greatly. The occupants of
tliese Important chairs shall belong to the university,
not merely visit that institution. Their energy, spirit
and knowledge shall belong to it in that the teaching
may be done at first hand and better and the domain
of discovery may be enlarged. This plan does not
seem Utopian. With hospital and dispensary sources
adequate to their needs, there can actually be but small
losses to the world for the absence of ' ' visits ' ' and
"office" consultations. It would take no elaborate
argument to show that it is the hospital patient who
really enjoys the greatest and closest attention. The
superficiality of "private" as opposed to "hospital"
examination is notorious. And in the end the student
does not see the " private " patient, — which may, indeed,
be regarded as a good fortune for him. Still Dr. Barker
would not deprive the community or the professor of the
advantages of consultation work ; but he wisely suggests
that the fees accruing from consultations should fall
to the hospital.
The Practicability of the Real University Medi-
cal School. — Admitting, for the sake of argument, that
such an arrangement were feasible, the question might be
asked. Could such chairs be filled ? The far greater emolu-
ments that fall to the successful practitioner might be
looked upon as an insuperable barrier. But Dr. Barker
seems not to fear the acknowledged " commercial " attrac-
tions of a large private practice. He believes, and we
might readily be induced to share his confidence, that as
good talent has been found to fill the fundamental chairs,
equally good, perhaps even better, talent will be found
to occupy the others. Devotion to the higher intellectual,
as well as practical pursuits of life, has never lacked
votaries. And the superior opportunities for indulging
the highest medical instinct that such positions afford can
be trusted to ensure the appearance of the " right " men.
Can such luxuries be afforded by the universities?
Here again Dr. Barker sounds no uncertain note. There
is no mistaking the spirit of philanthropy in this
country. Medicine cannot fail to be a large participator
in it. Already do the special institutes begin to appear
in order that medical research may be prosecuted. Why
should not these large gifts be made directly to the
universities? The only reason to be assigned is that
thus far the universities have not identified themselves
with medical research in a serious way. What is
re<iuired first is an established ideal of research that is
sadly lacking in the clinical branches of our best uni-
versities. The trifling hand-to-mouth investigations
carried on do no more than keep the cause alive. They
only emphasize our poverty in resource and in ideas.
The True University School and the «< Special-
ties."—In his description of what a real university school
shall be, Dr. Barker has dealt with the question of the spe-
cialties. He recognizes that the specialist will continue to
be a private practitioner. The reason for this difference in
status will result from the financial difficulties attending
the foundation of a staff that will make each chair a full
university position, with an adequate salary. But even
here the example of high attainment in certain clinical
chairs must react favorably upon the specialties. With
suitable hospital facilities they, too, can be made to yield
important results to the stock of medical knowledge.
No one will deny that there is no lack of the "spirit"
of research among the specialists ; but how many find
either the time or the facilities for carrying on systematic
investigation ? To live in an atmosphere of research is
the surest security of undertaking investigation. And
the hospitals that are to supply the facilities to other
branches must also be made to yield them to the
specialists.
A Characteristic Dift'erence Between Spencer
and Darwin Throughout his life I>arwin was a great
suff"erer from ill health, and spent a not inconsiderable
part of his time in hydropathic institutions and treat-
ment. As a vague cure-all for vague complaints these
institutions at this time had a great vogue, and at first
Darwin had a more profound faith in the efficacy of the
"treatment" than facts warranted. The proprietor of
his favorite establishment, however, made his diagnoses
by means of " clairvoyants " or "mediums," and his
medical treatments of the patients, so far as water, baths,
" packs," etc., were not all-efficacious, were by means of
mesmerism and "infinitesimal doses." Darwin's emi-
nently inductive and careful mind was not swung from its
conservative balance by this folderol, and despite the fail-
ure of hydropathy, or any other -pathy to cure him, he
never indulged in any antimedical dogmatisms and
prejudices. In his last book, " Facts and Comments," as
great a thinker and scientist as one may admit him to
be, Mr. Herbert Spencer exhibits the vice which some
claim dogs the footsteps of his entire system of philoso-
phy—that of the essentially deductive mind, the convic-
tion as to a theory before thorough consultation of the
facts, and consetiuently he does great violence— at least
in his last book — to the facts about which he writes. In
musical and in a number of other matters he also " has
his fiing " at the world, but in a way that the world
smiles sadly at the sutor ultra crepidam. The " sanitary
class," the military class, the state clergy, are all a bad
lot, all their acts being motived on self-interest of the
August 9, 19021
EDITORIAL COMMENT
AJCERKUJt MBOtOTNK 203
i
lowest possible kind. He is against many things medi-
cal, but chiefly against vaccination, apparently regardless
of facts, and even if it does produce immunity to small-
pox, on the ground that the vaccine interferes with the
order of nature and must produce " other eflfects," e. g.,
measles, influenza, etc. A dose of castor-oil, as suggests
our contemporary, the British MetUcalJoimial, also causes
"an interference with the order of nature."
Punishing Unlicensed Practitioners A justice
of New York has said that the fines of illegal practition-
ers should not go, as heretofore, to the County Medical
Society, the Dental Society, etc. Mr. Purrington, coun-
sel for the Dental Society, contributes to the Medical
Critic an article upon the subject recalling the fact that if
the medical societies were deprived of the fines they
could not, being so poor, enforce the laws. The police
force cannot and should not enforce the medical, dental
and pharmaceutic laws. Mr. Purrington says further that
" The unlicensed practice of medicine and dentistry is punished
as a first offence by a minimum fine of §50, leaving the maxi-
mum, as established by statute, $500. For second offences a
minimum fine of §100 is provided. It has been the custom of
the Dental Society to withdraw its complaints if such procedure
seemed to promise amendment of the accused, and to recom-
mend minimum fines where leniency seemed called for, as
where the accused truthfully entered a plea of guilty. But
experience has shown that the individuals receiving the mini-
mum punishment have resumed practice, in the majority of
cases, about as soon as they could return to their offices, only
exercising more caution and making detection more difficult.
They look upon the fine as a license fee. They would cheer-
fully pay 8250, the sum fixed in the statutes of some jurisdic-
tions as the license fee of peripatetics, if by such payment they
become immune for a year from arrest. When minimum fines
are imposed upon second offenders who perjure themselves by
false defences, the penalty becomes even less efficacious
upon the individual. We must look for the benefit of these
laws to the fact that their existence and enforcement incite to
the study of medical science many who otherwise would enter
upon the practice of medicine with no equipment. But the
unlicensed practitioner will not be deterred from violating the
law if it loses its terror."
Medicine and Politics. — Upon reflection, it must
appesir strange to any one that physicians do not interest
themselves more in public affairs. Not alone do their
education and their i)erpetual contact with persons of all
classes give them excellent opportunities for forming
opinions concerning the general welfare, but they are, as
a rule, close stutlents of the newspapers and are excep-
tionally well informed on current events. But instead
of using this knowledge for the advantage of their fel-
lowmen, they have for ages been deterred by tradition
from participating in an active way in the political life
of their communities. The reasons for this attitude are,
however, not alone tra<litionaI. The profession of a
politician is in such bad reinite in our day, particularly
in large cities, that a physician, jealous of his good name,
shuns to have that at present opprobrious term applied
to him. There is possibly another reason, namely this :
the leatlers of the profession are, for the most part, too
much engrossed in their spet^ial work to concern them-
selves with public matters. If a few of our great med-
ical men were to enter politics, the term "political
iloctor" would soon cease to be one of reproach.
In Kuiope tiMj physician is much more of a factor
m>)th civic and national politics than in this country.
Virchow has for almost two generations been an active
champion of the people, and has been their ablest repre-
sentative in the Reichstag ; indeed, so highly esteemed
has he been'that it has often been said he would have
been its first president had Germany become a republic.
There lu-e also many others in that country, of lesser
note, who, while maintaining their professional reputa-
tion, have fought for the welfare of the people in the
political arena. In France ' there are no less than 56
physicians in the Chamber of Deputies; as the total
number of Deputies is 591, the percentage of medical
men is nearly 9.5. In Italy a physician has even reached
the dignity of a cabinet minister. To him, certainly,
does not apply the stricture contained in the statement
of a British medical man, who warningly told a fellow-
physician interested in politics that medicine was a
jealous mistress ; for Guido Baccelli is not only one of
the ablest members of the Italian ministry and one of
the greatest Latiaists of the age, but he also ranks with
the stars of the first magnitude in the medical firma-
ment and is constantly engaged in advancing the welfare
of the people simultaneously in the capacity of states-
man and of physician.
We sincerely hope for more active participation in
public affairs on the part of physicians, and that the
members of the medical profession, both ajs a Iwdy and
individually as enlightened citizens, will make their
influence felt for good in city, State, and nation. In
nearly every community there are two political elements
— not necessarily parties— to choose from. Let physicians
in the choice not sin sigainst tiieir own light.
Vacation Schools — The first vacaition school was
opened in Boston by a private individual in 1878, al-
though the school committee of Cambridge had advised
their founding in 1872 to prevent idleneas and crime,
and to better the condition of children left unemployetl
and uncared for during the long hot sunniicr months.
In 1894 four schools were opened in New York, in 1896
the work was begun in Chicago, then in Brooklyn, Pitts-
burg, Cleveland, Philadelphia, etc., until now educators
and philanthropists are recognizing their value to the
community and progress is tjiking place everywhere.
Over 1,(MKI pupils are enrolle<l in Boston, and the teach-
ing staff numbers 70. The school program is exceed-
inglj' varied, including manual training, cooking, sew-
ing, housekee|)ing, nature study, color work, basket-
W(!aving, local history, story-telling, kindergarten games,
music and excursions. Spe<'ial emphasis will be laid this
year on the outdoor features of the work, and clas-ses
will be taken into the country as frtniuently as |M)ssible.
It swms probable, indeed, that the vacation scIukjIs
everywhere will in the future give more and more atten-
tion to nature study, ciirrie<l on through school ganleus
and field lessons. .Such work affords opportunities to
develop a side of the pupil's nature which is not touched
by the regular .S(!hool studl«'s. Miss Arnold, of Boston,
formerly sui)ervisor of sch(K)ls, S4iys that if the vacation
school must be, in nuiny casei*, the substitute for a real
vacation, it is admitted that whatever brings into the
> llritiiih Medical Jouriuil, June 7, 1901.
204 Ambbioan Mbdicinb]
AMERICAN NEWS AND NOTES
[AUGUST B, 1902
vacation school the fundamental elements of the real
vacation is of greatest worth. If the children cannot
spend the summer in the country or by the sea, the
vacation school should do something to furnish the
normal out-of-doors life to the children. Under wise
guidance the playground is the best vacation school. It
is not hampered by school traditions, it allows freedom
in the open air, and yet it affords shelter and care. The
field lessons, the excursions and the school-gardens are
the most profitable elements of the vacation-school
course. The medical aspect of this work will be apparent
to physicians, and should receive the hearty encourage-
ment of the profession. Why should a wise and inter-
esting share of physiology and hygiene not be mixed
with the subjects?
Institutional Accounting. IV. — An economical
and efficient administration of any enterprise can be
secured only by a combination of ability with a knowl-
edge of facts. It is important that the controlling body,
with its officers and agents, should have the proper
qualifications and training for the discharge of the duties
devolving upon them, and it is equally as important
that they should be in possession of such sources of
information as will enable them to act with intelligence
in any situation that may arise. Accounting does not
supply deficiencies in natural ability, but it does pro-
vide a means of knowledge without which the most
efficient management cannot be attained.
So closely allied to the subject of accounting that it is
almost a part of it is the matter of proper business
methods. It is not enough, for instance, that a suffi-
cient quantity of supplies be purchased and a charge
therefore be made to the right account, but purchases
should always be made in such quantities and on such
terms and conditions as will be most advantageous to
the institution, and the records should be made in the
simplest form consistent with clearness and the highest
degree of accuracy and safety. Economy has been such
a fetish in the management of charities that a wrong
idea of its true nature and larger meaning has in many
cases been the direct cause of gross waste. An institu-
tion considers itself too poor perhaps to secure a good
system of accounts, and to employ such clerical assist-
ance as may be necessary to maintain it, but the chances
are nine times out of ten that the greater portion of the
entire income is turned over in large blocks to a super-
intendent or a matron to pay bills contracted according
to his or her pleasure, in some cases it may be with a
"rake off," and in manj^ for goods of a quality not at
all commensurate with the price. After the money is
spent, a committee will look wise over the bills, all of
which have been receipted, solemnly count any cash on
hand, and disperse with the contented feeling of an
onerous duty faithfully (?) discharged. This condition
is not the result of any unwillingness on the part of the
individual members of such committee to perform more
fully their duty, but is rather the result of a bad system
of conducting the business affairs of the institution.
Given a good system, the average trustee or manager is
much more likely to appreciate his possibilities for
efficient service.
AMERICAN NEWS AND NOTES.
OKNERAXi.
liife of the Typhoid Bacillus.— A bacteriologie test of
specimens of earth taken from the site of Camp Thomas, at
Chickamauga, is being made to determine if the typhoid bacilli
responsible for the recent outbreak of typhoid fever had
retained their vitality since the epidemic during the Spanish-
American war.
Chinese Physician Returns.— The first Chinaman to re-
ceive a diploma from an American medical college is Dr. Yung
Wing, who was thus honored by Yale in 1854. He has just
returned to this country after several years' absence in his
native land, where he introduced many of the modern methods
of medical practice, despite the strenuous opposition of Celestial
doctors.
Origin of the "Water Cure."— A correspondent of the
Boston Transcript calls attention to the fact that the " water
cure" was employed by the Dutch nearly three centuries ago.
In Martin's history of the Indian Empire an account is given
of the struggles of the European powers to secure the rich trade
with the East Indies. In 1G23 the Dutch seized the .Japanese at
Amboyna and subjected them to torture to make them confess
to a conspiracy. " Each victim was placed on the rack and coin-
pelled to inhale water at every attempt to draw breath, until his
body became inflated and he swooned, was recovered, and the
same horrible process repeated."
Cause of Yellow Fever Not Found.— Regarding the
report from Havana that the U. S. Medical Commission at Vera
Cruz had discovered the cause of yellow fever, it is stated in
Washington that no report from the commission has been
received. Under the direction of Dr. Parker the commission
has been at work for more than a month, but as yet has reached
no definite conclusions. A physician of Vera Cruz, while
recently in New York, stated that yellow fever was now more
prevalent in the former city than for several years past.
The sanitary condition of the port is lamentable and persons
who have lived for long periods in the city and considered
themselves immune to yellow fever have been stricken.
Deathrate for 1901.— According to statistics just issued,
Washington had the third liighest deathrate among the larger
cities of the United States during 1901. Charleston, S. C, stands
at the head of the list with a deathrate of 29.11 per 1,000 ; New
Orleans next, 21.44; Washington, 21.14; Baltimore, 20.23; New
York, 20; Boston, 19.70; San Francisco, 19.34; Cincinnati, 18.88;
Philadelphia, 18.27 ; St. Louis, 17.67 ; Chicago, 13.88. Iowa was
the most healthful State, with a mortality record of 9.2 per
1,000, and among the territories, Arizona was first with a rate of
3.3. Louisiana had the largest percentage of deaths, 20.65. The
healthiest town in the United States was Ellsworth, Wis.,
where, with a population of 1,500 there was only two deaths,
one of those being from smallpox.
Insuring Against Illness.— The San Francisco Chronicle
states that over 8,000,000 persons in Germany are insured against
illness. Regarding the amount of insurance on King Edward,
it is said that if he had died at the time of the operation, British
companies would have lost §100,000,000. "There is no such
thing in the United States as insuring a second person, and if
such a line of business ever was thought of by our great leaders
in insurance, the exceedingly narrow escape of the British
companies has chilled the notion. It is to be hoped that our
home companies will never indulge in such insurance, no
matter how great the profit. So doing tempts murder and
anarchy. A great many thoughtful moralists are objecting to
child insurance, on the ground that it induces cruel mothers to
neglect or directly kill their infants for immediate gain."
Government Report on Hookworm Disease (Unci-
nariasis or Ankylostomiasis).- At the request of Dr. Walter
Wyman, Surgeon-General of the U. S. Public Health and
Marine-Hospital Service, Dr. Stiles, Zoologist of the U. S.
Bureavi of Animal Industry, has prepared an article, entitled
" The Significance of the Recent American Cases of Hookworm
Disease (Uncinariasis or Ankylostomiasis) in Man." This
article will appear in the forthcoming Annual Report of the
Bureau of Animal Industry, but an advance edition of 5,000
reprints will be issued about August 15 for free distribu-
tion among physicians. The report covers 37 pages, con-
taining a general discussion of the subject, full descrip-
tions of the parasites involved, with their life-history, also
symptoms, methods of infection, preventive measures,
treatment, abstracts of the cases thus far reported for this coun-
try, and a bibliography of American literature on the subject.
It is illustrated by 84 text figures of the parasites in dififerent
stages, and of the eggs of other parasites which are found in
feces and which might lead to errors in diagnosis. There is
also a description of the method to be followed in fecal exami-
nation. Applications for this publication should be made (pre-
ferably upon postal card rather than in letter) to the "Chief of
the Bureau of Animal Industry, Washington, D. C."
A0GXTST 9, 1902]
AMERICAN NEWS AND NOTES
[American Mkuicink 205
Sanitary Conference Postponed. — The International
Sanitary Conference, which had been called to meet in "Wash-
ington October 15, has been postponed until December 2. This
action was taken at the suggestion of Surgeon-General
Wyman, of the Marine-Hospital Service, in order to accommo-
date delegates to the conference who might wish to attend the
meeting of the American Public Health Association to be held
in New Orleans December 8. Valuable results are expected
from the conference in the way of crystallizing the fast-growing
sentiment among the Southern republics for concerted action
regarding quarantine laws and public health regulations. The
object of the conference is stated to be to encourage friendly
cooperation between the health organizations 6f the several
republics in the matter of quarantine and sanitation. With
regard to quarantine the deliberations of the convention will be
with a view to making it an adequate protection against the
introduction of disease from one country to another, at the
same time making it so reasonable that it may be maintained
with as little annoyance to commerce as possible.
Casualties In the Philippines. — Statistics from the Adju-
tant-General's office show the following casualties among the
4,1.35 ofllcers and 12.3,80.3 men who have been sent to the Philip-
pines, the total deaths being 4,155:
Unlisted
Officers. Men.
Killed or died of wounds 69 936
Deaths from disease 47 2,535
Deaths from accident. „ 6 125
Drowned H 257
Suicides 10 72
Murdered 1 91
Total 139 4,016
Wounded 190 2,707
Killed and wounded and deaths other than
by disease 282 4,188
A large proportion of the deaths by drowning occurred in
action or in active operations against the enemy. Major Parker
makes the percentage of killed and wounded to the strength of
the army 9.7.
EASTERN STATES.
Medical School for a Temple. — Plans are now being made
for remodeling the old Tufts College me<lical school building
in Boston into a temple of worship for the First Swedish IJap-
tist Church.
NEW YORK.
Appointment to State Hospital. — Dr. Alice K. Rowe, of
Springliekl, Mass., has been elected a member of the staff of the
Slate Hospital for the Insane at Gowanda, N. Y., to serve as a
specialist in gynecology.
Clean Bathing Beaches.— As one result of not dumping the
surplus garbage of New York City at sea, the bathing oeaches
at nearby resorts are practically clean this year, being in
iiiarke<l contrast to the miserable condition of former years.
State Hospital for Consumptives.— State Architect Hein's
plans for the purposed State Hospital for Consumptives have
been approved and work will likely lie begun this fall. The
hospital will accommodate 100 patients and will be located at
Raybrook, Essex County, between I^akes Placid and Saranac.
It will be a two-story brick and stone building, constructed on
the pavilion plan, with an administration building in the center
Jewish Sanatorinm. — The sanatorium for Hebrew children
at Rockaway Park will soon celebrate its twenty-fifth anni-
versary. On Mondays and Thursdays trains carrying children
and mothers are run to the park. ( Jood meals are provided and
milk is prepared for the babies under the direction of the doc-
tors. Sea bathing under the supervision of an expert swim-
ming master is oViligatory on all who are well enough to partici-
pate. The children must all undergo an examination by the
l>hysicians; the sick are separated from the well and are placed
in the large wards, wliere they remain until they have recov-
ered. Trained nurses and doctors are in attendance day and
night.
Contafrions Eye Diseases in New York Schools.— In a
letter to the Board of Education, July .30, Health Commissioner
Ledcrle asked tliat a room in each school besot apart for an
inspector from the Board of Health to examine the pupils. He
proposes to employ specialists for work not hitherto under-
taken in that city, and states that the " most important part of
the work is to be the examination of the .school children for
contagious eye diseases. During the last two weeks of the
school year just closed I appointed 12 eye specialists to find out
the extent of contagious eve diseases among the children. The
experts examined 55,000 children in 86 schools, and no doubt
you will be surprised and shocked as I was to learn that no less
than 0,670 children, or 129'(,, were allUcted with contagious eye
diseases. ( )f this number 2,.S28 were suffering from the severest
t.v|)(i of tra<;homa. All these children should lie excluded from
'^ili,if)l." The city superintcnchnit Ntate<l that there was some
oplithalmia among the children, but he thought the above
report was exaggerated. Physicians to examine children
should be employed by the Board of hMucation, and not by the
Board of Health. He has been informed that Inspectors from
the latter board have wrongly diagnosed the eye troubles of
children. After debate it was decided to set apart a room in
each school for the specialists.
New Street Washer.— Street Cleaning Commissioner
Woodbury has lately had in operation a machine for cleaning
asphalted streets that has given great satisfaction. The basis of
the scheme is a cylindrical tank, into which water is forced at a
high pressure until it compresses an air cushion. Connected
with the tank are valved tubes leading to the end of the vehicle,
which hivs been called a street washer. When the valves are
opened the cushion forces the water at a pressure of 25 pounds
to the square inch down on the pavement at an angle to the
street line and the pavement so as to cut its surface and sweep
what has collected on it to the gutters, whence it enters the cul-
verts.
The Purity of Bottled Table Waters.- The Board of
Health has adopted an amendment to the sanitary code, look-
ing to a standard of purity for artificial and bottled waters.
Every manufacturer and importer or other persons who manu-
facture or import mineral spring or other drinking water will
be required to file under oath with the Health Department the
name of such water, the exact location from which the water is
obtjiined, together with a chemic and bacteriologic analysis
thereof, also stating when the water was manufactured, the
exact formula used in its production, giving qualitatively and
quantitatively each and every item entering into its composi-
tion. Any one failing to comply with these requirements will
be refused a permit. — [Medical Rerord.}
PHIIiADEIiPHIA. PBNNSYIiVANIA. ETC.
Polyclinic Hospital.- Mr. Heatly C. Dulles has ^been
electetl to fill the existing vacancy in the Board of Trustees.
State Medical Examinations.- The i eport of the Penn-
sylvania State Board of Medical Examiners shows that of 405
applicants for license at the .Tune examination 43 failed, 6 with-
drew, and one was expelled for cheating.
Philadelphia Hospital.- William M. (Joary has resigned
the superintendency ot the Almshouse, as has been expected
since his health failed. It is stated that Robert H. Smith,
appointeil to fill the position for the present, will not accept
it permanently.
National Prison Association.— The annual meeting of this
association will be hold in Philadelphia September 13-17, 1902.
Fully :J00 delegates are expecte<l from the iTnited States and
Canada. In general, the sessions will be devoted to discussions
and reports and to the interchange of ideas regarding improve-
ment in the methods of criminal procedure. •
Crusade ftar Pure Food.— The fight against the beef trust
promised some months ago by the State Dairy and Food Depart-
ment has been inaugurated by swearing out warrants directed
against the Kansas (,'itv Beef Company and others. These were
based upon reports of Chemist (Jonth, afUir analyses of canned
meats from some of the largest concerns in the trust. The
meats were said to contain sulfurous and boric acids and were
injurious to health. One grocer of Philadelphia has lieen fined
$100 for selling renovated butter, and another ?50 for selling
spurious vinegar.
State Medical Society.- The fifty-second anniial ineet^
Ing of the Me<lical Society of the State of Pennsylania will
be hold at Allentown, September 10-18, 1002. The annual
address will be delivere<l by President Francis V. Ball,
Lock Haven, treading addresses on various branches will be
delivered as follows: Medicine, A. O. J. Kelly; »\irgery,({eorge
D Nutt: obstetrics, J. .M. Haldy ; hygiene, Edgar M. (Jreen;
mental disorders, .1. Moorhoad Murd(K:h ; ophthalmology,
George H. Halberstadt. .Vpplhration for spiujo for exhibits
should be made to Dr. P. H. Reichard, Allentown, and for hotel
accommodations to Dr. Eugene Dickenshieil, Allentown.
SOUTHERN STATES.
irnusually liow Deathrate In Now OrleBn«.--For the
week eniling .luly 2»i the deathrate for the white population of
New Orleans rcjichcd the exceptionally low mark of I Lilt for
each 1 000 of population per annum. The number of deal lis has
been low for weeks, but this mark is almost a nx-ord-breaker.
Field Hospital Work In Baltlmore.-The Fifth Rcglinent
hospital corps will go into camp in a Baltimore suburb about
August l'> for 20 days. The primary object of the c-ainp is to
drill the men inU) field hospiul work. They will be given
practice in hanilling woun<l('<l soUlicrM and making arrange-
ments for the (|uick and oirectlve treatment of wounds.
Problems of the Nbicto.— The Ilamptxm Negro Conference
held its annual meeting at Hampton Inslltulo, % «., .Inly 10 to
18 liM)2 This is a self-anpoint««l company of intelligent negro
men aiid women, organize<l for the pur|K)se of promoting self-
heln among negroes. Tlie conference covered a wide range of
sulijcts, including general Mtallstira, vlUl and eanltary prob-
lem« ilomcstlc science, the improvement of negro (arms, busl-
206 American Medicine)
FOEEIGN NEWS AND NOTES
[AUGUST 9, 1902
ness and labor, relifflon and ethics, cooperation necessary to
race unity, education and the condition of the colored woman.
Emphasis was laid upon the need of better Ctiristian ministers
and better homes. The chairman of the committee on ethics
called attention to the fact that the chief trouble with the negro
is that he lacks the vital force of dissatisfaction ; he is rarely
dissatisfied, and then never intelligently. A recommendation
of the conference was for more kindergarten schools to counter-
act the tendency to lawlessness among negro youth. The sug-
gestion was made that the National Educational Association be
asked to create a department of negro education. A report on
sanitation called attention to the diseases which are largely
responsible for the high rate of mortality among negroes,
malarial and typhoid fevers and consumption being named as
the leading maladies.
WESTERN STATES.
Compulsory Vaccination in San Francisco.— School
children are required to present evidence of vaccination but are
no longer vacciuated free by the Board of Health. Any parent
unable to pay for vaccination can, with the endorsement of the
principal of the school attended by the child, secure an order
on the Cooper Medical College for free vaccination.
Hot Springs Medical Journal.— Dr. F. W. Jelks has
relinquished his practice in St. Louis and removed to Hot
Springs, Ark., where he will assume the duties of his recently
deceased father, Dr. J. T. Jelks, in the management of the Hot
Springs Medical Journal. Dr. Jelks has for several years been
identified with the hospitals and public service of St. Louis.
Consolidation of Detroit Medical Societies. — The
Detroit Journal congratulates the medical profession of that
city on their voting to consolidate the Wayne county and the
Detroit medical societies. The liberal spirit manifested will
bring such a change in condition as cannot fail to give to the
new society more influence and more scientific importance
than either of the old ever possessed.
German Hospital, San Francisco. — The threatened
change in the medical staff of this hospital is not to take place.
The change under discussion was the dismissal of the regular
staff of physicians and replacing them with a larger number,
willing to work without salary. The rules have been changed
so as to impose a separate charge for medical attendance upon
patients not members of the society in control, thus contribut-
ing to expenses.
Board of Health Wins.— The following news comes from
Illinois: "The Board of Health has won in the Appellate
Court in the case of Millard F. Bailey, a graduate of the medi-
cal .department of the University of Tennessee in 1894, when
the board declined to issue a certificate based on his diploma
because the board had determined that the college was not in
good standing during the year named. The Appellate Court
olds that the State Board of Health is possessed of discretion-
ary power to determine whether a medical college is in ' good
standing,' and its action is not subject to review by mandamus
proceedings."
Bulletin of Chicago Health Department. — The Visiting
Nurse Association and members of the senior class of the
Harvey Medical College have tendered their services as mid-
summer sanitary inspectors in the tenement-house districts.
The Knickerbocker lee Company has offered to furnish ice
gratis to families recommended by the volunteer inspectors on
orders countersigned by the chief of the Visiting Nurse Asso-
ciation. Tlie following figures of child mortality in Chicago
are instructive: During the 10 years between 1882 and 1891
inclusive there were 161,170 deaths of all ages, of which number
78,236, or 48.5% were of children under 5 years of age. During
the succeeding 10 years, 1892-1901 inclusive, there were 244,132
deaths of all ages, of which number 96,540, or 39.5%, were of
children under 5.
CANADA.
For Women Inebriates. — The local council of women at
Ottawa has adopted resolutions asking that the government
establish cottage homes for inebriate women. They state that
in Ottawa intemperance among women and girl prisoners has
increased to the alarming extent of 75%, and that women in
many case under or about the age of 20 have been incarcerated
for drunkenness or for crimes committed while under the
influence of drink. Imprisonment to check this evil has
proved an utter failure, as there are women in a brief life of 40
years who have spent 20 years in jail. — [Journal of Inebriety.']
New Science Course in Toronto University. — Of special
interest to students entering medicine is the new curriculum in
science leading to a B.A. degree in Toronto University. It
embraces the purely science subjects demanded of students in
the primary years of medicine, and is so arranged that at the
completion of the fourth year in the arts course the student
has fulfilled the requirements of the first two years of medicine.
He can then enter the third year of medicine and graduate in
two years, thus making it possible to obtain the degrees of
Bachelor of Arts and Bachelor of Medicine after six years of
study.
FOREIGN NEWS AND NOTES
OENERAIi.
Alcoholism and Tuberculosis.— Dr. Wallis, Professor of
Pathologic Anatomy in the University of Stockholm, con-
siders these the two principal enemies of mankind, and sees no
hope for their being conquered for at least three generations.
He believes that the fight against disease and the great results
secured during the nineteenth century will never again be
equaled.
Cobra Venom as a Remedy.— In a recent number of the
India Medical Record Hen Chandra Sen has collected and trans-
lated formulas found in old Sanscrit works for the employ-
ment of cobra venom as a remedy. They consist of mercury,
sulfur, lead, aconite and sometimes salts of other metals mixed
with cobra venom and formed into pills. These pills, for some
inexplicable reason, must be soaked in the bile of five different
animals before they are ready for administration.
CONTINENTALi EUROPE.
Munich University.- Professor von Winkel, who has just
been elected rector of the Munich University, is an honorary
member of several American medical societies in New York,
Chicago, San Francisco, Buffalo and Milwaukee.
Swedish Emigration Increases.— Despatches from Copen-
hagen state that the transport lines there are coping with the
greatest rush of Scandinavian emigration to the United States
since the eighties. Every outgoing vessel, Scandinavian or
American, is crowded. The emigrants, who are mostly of an
excellent class, are leaving on account of hard times in Sweden
and are bound chiefly to the Western States, where they will
settle on agricultural lands. The total number of emigrants
which left this port for the United States during the nine
months ending with March, 1902, were Denmark 3,383, Norway
8,049, and Sweden 15,601.
OBITUARIES.
Edoardo Porro, Professor of Obstetrics, at Milan, Italy, July 18,
aged 60. Dr. Porro was born in Padua, where he graduated and was
assistant to more than one of his teachers. He served under Garibaldi
In the war between Italy and Austria In 1866, afterward returning to his
professional work and holding various positions until 1875, when he
was chosen to till the chair of obstetrics In the University of Pavia.
In 1882 he obtained the post of his ambition, that of director and con-
sultantrln-chief of the Souola Ostetrica of iVIllan. He was a prolific
writer as well as a tireless clinical worker. He was, perhaps, best made
known to the world by his description of the operation known by his
name, which he performed In 1876. Many civic and municipal offices
were held by Porro during his later years. Death was primarily due to
an infection received during an operation.
Captain Frederick W. Cox, A. S., U. 8. V., at the General Hos-
pital at the Presidio, San Francisco, July 28. He was formerly surgeon
In the South Dakota Volunteers, having returned from the Philippines
May 23.
J. Aubrey Davis, of Philadelphia, July 30, aged 37. Since 1894 he
had been assistant medical Inspector in the Bureau of Health. He
graduated from the University of Pennsylvania In 1887.
JSdward W. F. Stiven, of Harrow, Eng., July 12, aged 51. He
was born in India, served in the Servian war, and was prominent in
all medical and civic matters in his town.
r. O. Hooper, of Little Rock, Ark., aged 69. Until recently he was
superintendent of the State Sanitarium, and was president of the
American Medical Association In 18S3.
Abner m.. Miller, of Blrd-in-Hand, Pa., July 27, aged 68. For the
past three years he had not been in active practice, being Incapacitated
by several attacks of paralysis.
Robert J. Gunn, of Whitby, Canada, June 2f, aged 89. He was a
native of Scotland, was mayor of the town on several occasions and
was Jail surgeon for 30 years.
B, F. Passinore, editor of the Canton, Miss., Times, July 29. For
the past 10 years he had devoted himself to Journalism.
Benjamin Shoemaker, of Brownsville, Pa., July 23, aged 73. He
was a graduate of Jefferson Medical College, 1870.
Frank Wagner, a veterinary surgeon of Bradford, Pa., was killed
by a train in Boston, July 26.
E. M. Eagle, of Beaumont, Texas, committed suicide at Bowling
Green, Ky., July 29.
Lourenco da Fonseca, of Lisbon, Portugal, founder of the Oazeta de
Ophthalmologia.
Henry Hanenstein, a prominent dentist of Brooksville, Miss.,
July 25.
James Wallace, of Gate City, Va., July 29, aged 75.
B. E. McCandlegs, of Perry, Okla., July 7.
August 9, 1902]
CORRESPONDENCE
iAMKBICAM MEDICIKK 207
CLINICAL NOTES and CORRESPONDENCE
[Communications are Invited for this Department. The Editor is
not responsible for the views advanced by any contributor.]
AN ATYPICAL CASE OF TUBERCULOUS MENINGITIS.'
BY
A. P. HERRING, M.D.,
of Baltimore, Md.
Associate Professor of Anatomy, Baltimore Medical College.
My only motive in presenting a frequent and possibly to
some a trite disease of childhood, is that the socalled diagnostic
symptoms of tuberculous meningitis were absent and that the
pathologic findings may be of interest.
Case.— The patient, L. C, -was a male, aged 11.
Familii history is negative.
Past History.— 'PaXieat has not, had the usual diseases of
childhood, although he was never a robust or healthy child.
There is an indefinite history of an injury to the head received
while playing at school about three weeks before the illness
which resulted in death.
Present History.— Ahont a week previous to December 15,
the date on which I first saw the child, it was noticed that his
disposition had changed. He was peevish and inclined to be
drowsy and lie around the house; he did not care for his food
and complained of slight headache. When I saw the patient he
presented the following condition: An unhealthy emaciated-
looking boy, who complained of loss of appetite, slight head-
ache, lassitude, occasional vomiting spells and constipation.
Heart and lungs were normal; temperature and pulse were
normal ; tongue was covered with a white coating; there were
no painful or tender spots about the head, and no enlarged
glands. Thinking the case one of simple catarrh of the stomach
and bowels, I administered a mild laxative and thought no
more of the patient. On December 19, however, I was called to
see the child and found the mother much alarmed because her
boy could not talk. She told me that during the night he was
re-stless, and when attempting to talk could only utter a few
unintelligible sounds. There were no chills or convulsions.
The child showed no evidence of pain and was perfectly con-
scious. When he attempted to protrude the tongue it deviated
very much to the right side. The muscles of the right side of
the face were ftaccid and immovable, while those of the left side
were contracted, forming numerous folds. The eves appeared
normal, although the right palpebral slit was wider than the
left. Since December 15 the bowels had moved several times,
vomiting had ceased, but the tongue was still coated. Temper-
ature was 10U°, pulse UO, strong and regular. On December 20
the right arm became paralyzed. The child seemed restless
and would move from one side of the bed to the other, and on
one occasion got out of bed and walked around the room. There
was neither rigidity nor twitching of the muscles or crying out
as though in pain. The condition of aphasia and faciobrachial
monoplegia remained the same. The child's mental condition
was fairly good, although he appeared to be somewhat drowsy.
On December 21 and 22 the somnolence increased. The temper-
ature wa4 100.4°, pulse 99 and respirations normal. No improve-
ment occurring. Dr. Pole saw the patient in consultation.
Somnolence liad now passed into a stupor. The child's abdo-
men was depressed, forming a scai)hoid or boat-sliaped Ijelly.
Kernig's symptoms were absent and Stoker's sign, clutching
at the bed clothes, especially if they are pulled away from the
patient, also absent; right patella reflex was increased, on left
side it was normal. There was a slight lateral to-and-fro
motion of the eyeballs, the pupils slightly dilated reacted to light
and accommodation. Head was drawn toward the left side and
there was slight rigidity of the muscles of the lower jaw. There
was no evidence of ear trouble. From December 24 to 27 the
patient was in charge of Dr. Gabriel, as I was out of town ; dur-
ing that time the condition of the patient improved. Somno^
lenco disappeared, he was able to take nourishment, and
appeared so much better that we predicted a hopeful recovery.
Temperature was 99°, pulse 100 and respirations normal.
Aphasia and paralysis were still present. On De<;ember 28 and
29 the condition remained the same. On the morningof Decem-
ber '{0, however, the patient was stui>efled ; tein])erature 100.0°,
pulse was (juite weak and so rapid that it could l)e counted with
uidiculty. Patient continued getting weaker without having
cither convulsions or delirium, and died on the morning of
December SI, after an illness of 16 days.
Tho autopsy, which was performed six hours after death, was
confined to the head, the parents not allowing us to touch the
thorax or al)domen. There was no evidence of contusion of the
scalp. Calvarium was exceedingly thin and translucent, from
.1 to .3 (;m. in thickness. Over the left parietal eminence,
external plate, there was a small linear depression 1.5 cm., pos-
terior to this on the inner plate there was a fissure about 2 cm.
long. There was no evidence of depression or hemorrhage.
Dura was not adherent. After removing the brain there was
> Read b<!fore the Neurologic Section of the Medical and Chlrunrtcal
Kaculty of Maryland.
noticed a greenish-yellow serofibrinous exudate over the base
of the brain, especially thick over the pons and optic chiasm,
ext«ndmg along the course of the middle cerebral arteries.
Ihis was more marked on the left side, where the exudate could
be traced along the cortical branches in the pia as far as the
great longitudinal fissure. The vessels of the pia over the
Kolandic area seemed especially affected. The exudate also
covered the medulla and cerebellum to a slight extent, while
that covering the occipital lobes appeared normal. There was
slight flattening of the convolutions. On removal of the pia
mater, small, glistening, grayish nodules were seen all over the
surface, very abundant over the base of the brain, diminishing
in amount near the cortex, but still very evident, while a few
were seen on the mesial surface. No hemorrhagic or purulent
foci, or softening of the cortex, were apparent. No evidence of
inflammation or tubercles along the choroid plexus or
ependyma. Section of the brain shows the left ventricle very
much dilated, the right one not so marked, and both filled
with a seropurulent fluid. Sections were taken from the cortex
of the middle frontal convolution, from the superior temporal
convolution and from the anterior part of the corpus striatum,
also a section ol the pia. Sections hardened in formalin and
stained with hemotoxylin and eosin reveal under a 2/3 objective
the following condition: Along the pia, especially around the
small arteries, a collection of epithelioid cells and an enormous
number of small round cells. Here and there typical giant cells
are found. The nodules are avascular, and in some instances
show caseation. The vessels are engorged, and in many
places show a subendothelial proliferation with an acute endo-
arteritis. The tubercles, which are not as typical as those seen
in other organs, are compose<l almost entirely of small round
cells or leukocytes, spoken of by some writers as lymphoid
tubercles. The absence of polymorphonuclear leukocytes is
very noticeable and .somewhat characteristic of this affection.
The tubercles are confined exclusively to the pia and arachnoid.
Sections of the cortex and basal ganglions show an interesting
condition. The invasion and total destruction of the cortical
cells in numerous places by the leukocytes may explain the
paralysis occurring in this case. In the sulci of tne brain
there is quite an amount of fibrin, in the meshes of which is
noticed a large number of small round cells. The brain from
cortex to base is infiltrated with small mononuclear leukocytes.
No tubercles or foci of softening as sometimes occur in the
ganglions or crura are seen. The tubercle bacilli were found in
sections by Drs. Potter, Cone, and myself. The result of the
invasion of the infectious microorganism into the cranial <'avity
by way of the bloodvessels has been an enormous proliferation
and exudation of leukocytes, formation of miliary tubercles and
endarteritis and a disseminated encephalitis, with a destruc-
tion of superficial cortical cells.
The absence in this case of the projectile vomiting and of
the intense headache, or the rigidity and contraction of the
postcervical muscles or any evident primary tuberculous dis-
ease masked the affection so that we did not consider tuber-
culous meningitis at all. Quincke's puncture was not tried In
this case. It is interesting to note how many writers depend
largely upon four prominent symptoms in diagnosing tuber-
culous meningitis. Collins ' speaks of headache of increasing
intensity, vomiting without nausea, obstipation, rigidity of
head and neck, as being important diagnostic symptoms.
Oppenheim' mentions especially headache, delirium,
stupor and convulsions. Osier' considers the hydrocephalic
cry, irregular pulse, obstipation and rigidity of muscles as
characteristic. Scarcely any of these symptoms, excepting the
stupor, were present in this case.
Waibel* reports the ease of a girl who had been struck upon
the head by a companion. .She had al way s been healthy pre-
viously. On the third day after the injury symptoms of
meningitis were noticed. Twenty-three days afterward the
autopsy was performe<l. Tuberculous meningitis was present.
The bronchial glands were enlarged and contained cheesy, yel-
low tuberculous massas. The lungs showeil numerous gray
tubercles ; other organs were normal. The author considers
the bronchial glands as the primary focus of the disease from
which the meningitis and tuberculosis developed, and thinks
that the trauma produced a disturbance in the brain and chest
which made it possible for tubercle bacilli to enter neighbor-
ing blood and lymph vessels and be carried over the entire
body, especially to the brain, and there grow. May it not be
quit« possible that a condition quite similar to the one just
reported existed in the case which came under our notice, and
that the patient had somewhere In his body a latent tubercu-
losis, and that the blow upon the bead was the exciting cause of
the tuberculous meningitis?
Osier (loc. clt.) very aptly illustrates this point in the fol-
lowing paragraph: "The ultimate result lu a giveu case
208 AMEBIOAN MEDIOINSJ
CORRESPONDENCE
[AUGUST 9, 1902
depends upon the capabilities of tiie body to restrict and limit
tlie growth of the bacilli. There are tissue soils in which the
bacilli are in all probability killed at once— the seed has fallen
by the wayside. There are others in which a lodgment is
gained and more or less damage done, but finally the day is
with the conservative, protecting forces — the seed has fallen
upon good ground. Third, there are tissue-soils in which the
bacilli grow luxuriantly, caseation and softening, not limita-
tion and sclerosis prevail, and the day is with the invaders— the
seed has fallen upon good ground."
In our case the meninges proved to be fertile soil in which
the bacilli were victorious over the protecting forces in the
body.
BIBLIOGRAPHY.
1 Twentieth Century Practice of Medicine, Vol. 0, p. 3it9.
^Oppenbeim : Diseases of the Nervous System, 1900, p. 490.
aOsler: Practice of Medicine, 189S.
» Walbel : Miinchener medlcinische wochenschrlft, 1899.
EXTRAUTERINE PREGNANCY.
BY
GEORGE S. PECK, M.D.,
of Youngstown.
Consulting Surgeon, Youngstown Hospital.
To the Editor of American Medicine : — The following cases
of extrauterine pregnancy may be of interest to your readers :
Case I. — Extrcmterine and intrauterine twin pregnancy ;
rupture beginning of ninth week : operation during eleventh toeek
of pregnancy.— \V. W., female, aged 27, married, American;
residence, Weathersfield, Ohio; seen in consultation witli Dr.
H. E. Blott, when the following history was given : Family
history good. Has never been sick ; menstrual flow com-
menced at age of 15, always regular and never painful until
after marriage. Married September 27, 1899. Last menstrual
flow December 20, 1899. February 10, 1900, slight menstrual
discharge, very dark in color and resembling coffee grounds.
February 15, sudden severe pain in the right iliac region, with
nausea, vomiting and a feeling of faintness ; complexion very
pale. Dr. Blott was called and diagnosed a ruptured extrauter-
ine pregnancy.
Hypodermics of strychnin were given, and she continued to
improve until February 22, when she was seen by Dr. Crooks,
who catheterized her and removed about three pints of urine.
The black, tarry flow continued from February 10 to 23, when
it ceased and she was able to sit up.
F'ebruary 27 I was asked to see her in consultation with Dr.
Blott. Upon examination I could detect a small and very ten-
der mass in the right iliac region. My examination was very
careful, and yet it caused such intense pain, lasting so long that
I was fearful of a second rupture. The diagnosis was confirmed.
She was removed to the hospital (a distance of five miles) Feb-
ruary 28. Upon reaching the hospital she was in good condi-
tion, and I decided to give her some preparation for the
operation.
March 1, in the presence of the hospital staff, and assisted
by Drs. H. E. Blott and Welch, I made a median two-inch
incision and found the tube ruptured and adherent to the small
mtestines. Upon breaking up the adhesion free blood flowed
into the abdominal cavity. The tube was quickly ligated and
cut away. The clots and free blood were removed with dry
sterilized pads.
Upon examining the uterus it was found to be very large,
so much so as to cause me to suspect an intrauterine pregnancy.
The incision was closed with three layers of catgut, without
drainage.
The patient made a good recovery and was discharged March
22, 21 days after operation. September 14, 1900, 268 days after
the cessation of the last menstrual flow, Dr. Blott attended her
in confinement, when she gave birth to a healthy seven-pound
girl.
Case II.— Interstitial cornual pregnancy.— Mrs. K., aged 27,
American, residing at Alliance, Ohio. Patient of Dr. Lichty.
Family history of tuberculosis. Previous health poor. Was
married December, 1895 ; one child, born August, 1897; no mis-
carriages. Menstruation commenced at sixteen ; always regu-
lar, but painful until after the birth of her child. Afterward
each menstrual flow was excessive, lasting 9 or 10 days. In
March, 1899, menstrual flow was delayed one week; became
regular again until September, 1899, when it was delayed again
for one week. October 28, 1899, flow very painful for two days,
ltS5"*^ ® "'^ ^'^ ^^^"- ^''** menstrual flow, November 28,
1899, very pamful ; lasted ten days : amount excessive and clots
were passed. Felt well through December and January. In
February had nausea, vomiting and headache. February 17,
complained of considerable pain in the pelvis, tenderness in
right iliac region, abdomen somewhat full and distended ; tem-
perature 100° F., pulse 100. Digital examination revealed uterus
somewhat enlarged, with an inflammatory mass in the rip;ht
broad ligament. Treatment, rest and anodynes. Rapid im-
provement. March 12, passed several clots from the vagina.
Cervix was found dilated, and a curetment was done. Nothing
but clots removed. Profuse leukorrhea until April 16, 1900,
when she commenced flowing, and passed shreds and clots.
Flow lasted until May 16, 1900. Has complained of more or less
pain in the right side all the time since December, 1899.
She thought she was pregnant since November 28, 1899.
Does not think she was pregnant from the time child was born
until November, 1899. She was confined to bed about ten weeks
in all, and was sent to Youngstown City Hospital May 13, 1900.
Upon examination I could detect a large mass on the right side
of the uterus extending into the broad ligament. The history
of the case favored a diagnosis of extrauterine pregnancy, while
the pathologic condition found led me to think that I had a
myoma of the uterus to deal with. After three days' prepara-
Mrs. C. K.— Extrauterine pregnancy.
tion I opened the abdomen, and with a "V-shaped incision in the
uterus removed the specimen here presented, which upon
examination proved to be an interstitial cornual pregnancy.
The incision in the uterine tissue was closed with two
layers of catgut sutures, the abdominal cavity thoroughly
flushed with saline solution, glass and gauze drainage inserted,
and the incision closed with silkwormgut. Upon complete-
tion of the operation patient's pulse was 128. The amount of
drainage was large, and her pulse-rate was 140, continuing
rapid for 48 hours. At midnight (12 hours after operation),
with a pulse of 140, and after having removed from drainage-
tulje six ounces of blood, I gave her an intravenous injection of
one quart of saline solution, which increased the volume, but
did not decrease the rapidity of the pulse. The pulse ranged
from 140 to 155 during the entire first 48 hours, when it gradu-
ally dropped to 120, and in 72 hours it dropped to 100. The glass
drainage was removed at 11 a. m. May 20, the fourth day.
During the first four days I removed from the drainage-
tube 23 ounces of blood. The treatment was supportive in
every particular, and consisted of cardiac tablets hypodermic-
ally, saline enemas, and nourishing food. Improvement com-
menced on the fifth day, and continued uninterruptedly until
her discharge from the hospital, five weeks after operation.
Mineral Springs Increasinjf.— According to reports of the
U. S. Geological Survey now in press, a greater number of
mineral springs reported sales in the United States during the
past year than ever before. The increase is general throughout
the country, and with this increase in production has gone a
corresponding increase in value of the product. Tlie total
number of springs on the list for 1901 is 659, an increase of 98
over the previous year. Those actually reporting sales number
581. The total product increased more than 8,000,000 gallons,
and the average price per gallon from 12.5 cents to 13.6 cents.
The North Atlantic States show the greatest gain in the number
of springs, in production and in value. The main addition was
in Massachusetts, where the State Board of Health has recently
made a thorough examination of spring waters, with the result
that 35 new springs have been added to the list.
AUGUST 9, 1902)
TREATMENT OP CALCULUS
'Akkbican MEDictirs: 209
ORIGINAL ARTICLES
TREATMENT OF CALCULUS OF THE LOWER END OF
THE URETER IN THE MALE.
BY
HUGH H. YOUNG, M.D.,
of Baltimore, Md.
Head of Department of Genitourinary Surgery, Johns Hopkins Hos-
pital Dispensary.
In 1898 Fenger, in a classical work on the ureter, said :
"There is no difficulty in gaining access to the upper
three-fourths of the ureter by the oblique lumbar incision.
It is different with the lower fourth of the ureter, which
is located deep down in the pelvis and is even held by
Le Dentu to be inaccessible. But as Cabot has pointed
out, this portion is also accessible without opening into
the peritoneum by means of the sacral operation of
Kraske."
But no one has ased the Knuske incision, and in
December, 1899, Henry Morris, after an exhaustive
study of the literature, said that no case had been
noted of ureterolitliotomy for stone impacted in the
lower end of the ureter in the male.
The apparent rarity of such operations has led me to
consider the following cases worthy of publication :
Case J.— Calculus impacted in the left xireler for probably H?
years. Removal by extraperitoneal ureterolithotomy, through
an iliac incision. Intravesical ureterotomy for stricture of
lower end of ureter. Cured.
Tlie patient, a man aged 29 years, had had attacks of kidney
colic since tlie age of 2 years. Of late he has suffered with more
or less continnous pain located in tlio base of the bladder, radi-
ating to tlie glans penis, with occasional severe attacks of pain
in the left kidney region. Examination of the kidney and the
course of tlie ureter for tenderness was negative, and on rectal
examination nothing was to be felt above the prostate. The
urine was sli(;litly cloudy, and contained red lilimd-corpuscles.
On Sciitciiitx'r 4, 1901, a cystoscopic exiiinination was made
and tlic twii ureters cathctt^rized. The cystoscopc showed apor-
fectly normal bladder, with the exception of the loft ureter,
about the orifice of which was an extensive bulging of the blad-
der-wall. The orifice itself was much contracted, and situated
in a cone-like ])rojection. The ureteral catheter pa.ssed only
for a distance of 1 or 2 cm., when it met an impassable
obstruction. The right ureter and the region around it was
normal in appearance, and a catheter was introduced for a con-
siderable distance. The urine obtained from the right side was
normal ; there was no urine obtained from the left side, as none
came through the catheter. The provisional diagnosis of stone
Impacted in the lower end of the left ureter was made.
On September 1.5 an x-ray jihotograph was taken and
showed a shadow about as large as the thumb-nail in the
region of th<! end of the left ureter. There was nothing to be
found ill the kidneys or other ureter. Two other x-ray photo-
graphs confirmed the diagnosis of calculus of the left ureter.
On ScptcMrilicr 13 tlie patient complained consideral>ly of a
dull and aching pain in the left kidney and tlie urine contained
considerable blood.
On October 16 an operation was performed under ether
anesthesia. An incision seven inches long was made from a
point above the middle of Pomiart's ligament upward and out-
ward, passing about an inch from the sjiiiie of the ilium. As
soon a.s the jieritoneum was reached this was soparate<l from
the out<fr side of the abdomen t)y means of the fingers and the
stripping process carried rapidly downward over the iliacus
and psoas inagnus muscles until the iliac vessels were exposed.
Search was then made for the ureter, bearing in mind the fact
that it was generally to lie found adherent t<i the elevated peri-
toneum. Th(! peritoneum was found very nmch thickened and
the tissues greatly changed by fibrous hyperplasia. On this
atrcount it was very hard to recognize the ureter, whicli was
greatly dilated, being about one inch in diameter. When once
recognized, however, it was very easy to separate it from the
peritoneum, and to follow It down into the jxilvls, where at the
junction with the bladder a calculus was found impacted.
After some little digging with the finger the stone was finally
dislodged and brought upward in the ureter until above the
pelvic nrlin. where it was used as a bobbin for the introduction
of mattress sutures, two of which were inserted before the
ureter was cut, and the stone removed. The caU'iiliis measured
2cm. long, IJcm. wide, and \\ cm. thick, and Wius very hard in
coiislst(!ncy.
Before closing the urot<ir a long, slender probe was inserted
and the ureter searche<l above and below for other stones, but
without finding any. An attempt was then made to pass a
probe Into the bladder, because tlio cystoscopc had jireviously
Indicated the iiresence of a stricture there. It whs found im]>oH-
sible to pass any instrument into the bladder, probes, ureteral
sounds, and small catheters being used. The lower portion of
the ureter (below the incised wound) was still full of urine,
and an effort was made to force this into the bladder by niilk-
ing the ureter, but apparently none escaped into the bladder.
It seemed evident, therefore, that a tight stricture was present
and demanded operative interference. Numerous attempts
were made to dilate this with probes and with Dr. Kelly's
ureteral dilators, but without success. It then seemed best to
make an incision into the bladder and divide the ureteral stric-
ture with a scalpel. Instead of performing a suprapubic
cystotomy it was found possible by drawing the bladder over
into the wound to make an incision in Its left lateral aspect and
thus easily expose the region in the left ureteral orifice. Sev-
eral attempts were then made to pass a probe into the ureter
from below; but it was found impossible to insert it more than
1 cm., where a tight stricture was encountered. Inserting then
a small bulbous dilator of Kelly through the ureter above and,
with a finger making counterpressure in the bladder, covering
the end of the ureter, it was finally possible to push the small
end of the dilator through the stricture until it appeared in the
bladder. Palpation with the finger then showed a distinct hard
ring aroand the instrument, about 1 cm. dlsUint from the orifi<»
of the ureter, and of such strength as to prevent one from
pushing the bulbous part of the dilator through. The caliber
of the stricture was about 3 mm. and the thickness of the
ring about 4 mm. As it was impossible to dilate the stricture it
was thought best to cut It, and this was done with a long-handled
scaljiel, which was drawn along in contsict with the dilator until
the stricture was coin])letely divided. The inoisicm required
was about 1 cm. long, and had to be made by the sense of
touch. Large dilators and catheters were then easily passed
into the bladder through the ureter from above. The lateral
incision in the bladder was then closed by eight mattress
sutures of fine silk, and the ureter was also closed with three
similar sutures. The patient had an uninterrupted convales-
cence and neither ureteral nor vesical wounds leaked.
Examination fi\e months after operation show-etl the patient
to be perfectly well, and the cystoscopc showed that tlie cut
edges of the left urethral orifice had not grown together again,
but presented a long slit from which the urine was seen
spurting.
Case II. — Calculus impacted in the intravesical orifice of
the ureter. Detected by the cystoscopc, and extracted by means
of a ureter catheter cystoscopc.
The patient, a male, aged 31 years, was admitted to the
Johns Hopkins Hosjtital .Inly 8, 1901. He had siiflered with an
Cystoscopic extrscUon of Intravesical ureteral calculus.
attack of renal colic seven years l>efore and another six months
afterward, but since that had not ha<l an attack until tliree
months before h(> entered the hospiUil, when he was seized with
a severe pain in the left kidney, which desceniled after two ilays
to the region of the bladder. After this he had considerable
vesical irritation and a constant desire to urinate, associated
with pain at the end of his penis ; these synnitoms continued
up Ui his entrance intfl the hospital. On examination the bIkIo-
inen was foiinil to lie held so tense that palpation of the kidney
au(l ureter were difficult and nnsatlsfactory. The left ti-stlclo
was marke<lly retracte<l. The rectal examination sliowcil a dis-
tinct tenderness above the prostate, and a slight induration
could be felt, but nothing dcnnlte. A searcher iiassed into the
bladder dct<icted no stone, the urine was acid and contained red
l)l(K)d-«-orpiis<'les, but no bRct<»ri«. The cystoscoi>e show<>d the
iilndder to be normal, with the exception of the left ureteral
orifice, from which a small Irregular mass covered with fibrin
210 Akxbican Mediciss;!
TREATMENT OF CALCULUS
[August 9, 1902
projected into the l)lad(l<<r cavity. At first it looked like a masw
of fibrin, but after rei)oated -washings of the bladder it was seen
to be a dark (mlcnlus of irregular outline, which was caught in
the mouth of the ureter. The stone was four or five times as
large in diameter us the end of the ureteral catheter, but did
not completely fill the ureteral orifice, and on one side of it
there was a patency through which a fine stream of urine wa«
being intermittently ejected. The mucous membrane around
the orifl<!e was considerably inflamed. The catheter cystos<!ope
was then introdiuied and the stone finally extracted from its
incarceration liy means of the ureter catheter ; this was accom-
plished by pushing against its side with the end of the cathetor,
the calculus finally popping out and falling to the floor of the
bladder. Blood immediately began to flow from the ureter and
soon obscured the field of vision, so that the (talculus could not
be found. The patient was sent back to the ward, and 24 hours
later a small stone was passed per urethram, and preserved by
the patient. It was about 6 mm. in diameter and 3 mm. thick,
the surface was rough and covered with sharp irregular pro-
cesses and spicules. The patient experienced immediate relief
of the pain from which he had been suflt'erlng, after its extrac-
tion with the cystoscope, and was not aware when it escaped
through the urethra. A cystoscopic examination, i»erformed
one week later, showed a large round opening at the left ure-
teral orifice, but there was no other calculus to be seen.
Examination, March 26, 1902 . The patient states that he has
been completely cured. The urine is clear and contains no
pus. The cystoscope shows that the left ureteral orifice is now
small and somewhat rounder than normal, but not dilated. No
calculus present.
After a careful review of the literature I can find no
other case in which a calculus has been thus removed
from the ureter by the cystoscope, in either male or
female.
Case III. — Calculus impacted in the right ureter about S cm.
above its lower orifice. Demonstration by catheter cystoscope
and x-ray photograph. Complete disappearance after water
cure.
The patient, a male, 34 years of age, had his first attack of
colic in the region of the right kidney five days before his
entrance into the Johns Hopkins Hospital, on July 4, 1901. This
attack was characterized by very severe pain, which radiated
down into the testicles on the right side. The urine contained
a great deal of blood, but micturition was apparently normal
in frequency, though small in amount. Two days after the
beginning of the attack patient had a severe chill and fever; his
pain was so great that he required large doses of morphia. On
admission to the hospital he was still suffering with slight
pain in the right side, but on the second day this had disap-
peared. Examination then showed a palpable right kidney
which was distinctly tender on pressure ; no pain in the course
of the ureter, nor on rectal examination.
July 12 two x-ray photographs were taken, and each showed
a small shadow in a location corresponding to the lower end of
the right ureter. The shadow was much smaller than in Case I,
but in about the same position. The diagnosis of probable
ureteral calculus was made.
On July 13 I performed a cystoscopic examination which
showed the bladder to be perfectly healthy and ureteral orifices
normal. The left ureter was easily catheterized, but on the
right side the catheter passed only for a short distance, about
2 cm., when it met a definite obstruction. After several
attempts and considerable pressure, it finally passed by this
obstruction, and was then easily pushed up to the right kidney.
Examination of the urine showed nothing definite. The diag-
nosis of obstruction in the right ureter, just above the bladder,
probably due to a calculus, as shown by the radiograph, was
made. An effort was made to dilate the lower end of the
ureter by means of Albarran's catheters. For this purpose
his bougie was first passed into the right ureter and the cysto-
scope was then withdrawn and a catheter passed upon the
bougie, which Wius used to guide it into the right ureter. The
catheter refused to pass up the ureter, however, probably
becoming caught in the orifice, and after several attempts the
bougie was removed. The patient suffered only moderate pain
during these proceedings, had no return of colic after them
and was discharged, apparently in good condition, nine days
later. He was instructed to take urotropiu three times daily
and to drink as much water as he could, if possible one gallon
daily, with the hope of washing out the calculus.
On August 9 the patient reported to me that he had had a
severe attack of colic one week after leaving hospital, again
on the right side, and again radiating to the testicle, but since
then he has been free from pain and feels well. The urine was
clear and contained no blood. The patient was advised to con-
tinue use of urotropin, to take a holiday, and to drink large
amounts of water.
He went to a sanatorium in New York where he remained
for six weeks, and was greatly improved in general health and
strength.
On October 4 the patient had another severe attack of colic,
passed no blood, and after several hours the attack wore off and
the patient has had none since. A radiograph taken on October
11 showed no calculus, but was not a satisfactory plate.
Examination March S, 1902. — Patient says he has been free
from attacks since last October; he has not, to his knowledge
passed any calculus, and has felt perfectly well. He has drunk
a considerable amount of water, but not so much as during the
summer. He feels in perfect health. Examination of the
abdomen was negative, there was no tenderness in the region
of either kidney or ureter, and the rectal examination showed
nothing abnormal above the prostate. On bimanual examinar
tion a splendid examination wa.s obtained for a considerable
distance above the prostate, but nothing was felt in the region
of either ureter. The urine is clear and microscopically nega-
tive. A cystoscopic examination was made and showed the
bladder to be perfectly healthy. The ureteral orifices were nor-
mal and of equal size. The ureter catheter passes easily into both
ureters well up toward the kidney. There is no obstruction
met in the right ureter and no grating sensation felt. The
urines obtained from the two kidneys are of about the same
quality. It seems evident from the history and the cystoscopic
examination that the calculus has been passed. The fact that
it was not detected is of no consequence since we know that in
Ciuse II a calculus of considerable size was passed without the
patient's knowledge.
Case IV. — Removal of three large calculi from the lower end
of the left ureter through an extraperitoneal (iliac) incision.
Recovery.
I am indebted to Dr. Finney for the privilege of report-
ing this case. The patient, a man, aged 33 years, had been
subject to attacks of kidney colic for 10 years. When
admitted to the hospital July 12, 1901, he was in fairly good con-
dition ; heart and lungs were normal. Examination of abdomen
negative. The abdominal muscles were held so tense that it
was impossible to palpate the kidney or ureter successfully.
On rectal examination nothing was felt in the pelvis. The
bladder was searched for stone with negative results. The
virine was extremely cloudy and contained pus and bacteria.
An x-ray photograph showed a large oblong shadow in the
pelvis in the course of the left ureter. The upper end was near
the posterior wall of the pelvis and anterior end was at a point
near the bladder. Cystoscopic examination was not performed.
Operation was performed July 23, 1901, the kidney first being
explored by oblique lumbar incision. Thekidnev was in fairly
good condition, but the ureter was greatly dilated, and on fol-
lowing it down into the pelvis a large calculous mass was felt.
In order to remove this a second incision was made in the iliac
region and the ureter exposed extraperitoneally. After consid-
erable difficulty three large stones were extracted and the ureter
closed. The patient had an uninterrupted convalescence and
there was no leakage from the ureter. Six months after the
operation he reported that he was well.
STUDY OF CASES IN THE LITERATURE.
A careful review of the literature shows that rapid
strides have been made in the past two years since Mor-
ris asserted that no case of calculus, impacted in the
lower end of the ureter in the male, had been operated
upon.
A field which had been held to be beyond the reach
of the surgeon has now been successfully reached in
several ways.
The several routes through which calculi have been
extracted from the pelvic portion of the ureter are as
follows : We have grouped the cases together according
to the operation performed, and will take them up, not
in order of priority, but anatomically, beginning with
the intravesical, then successively the perineal, the intra-
rectal, the pararectal, sacral, the iliac (extraperitoneal),
and the intraperitoneal, describing at first the operative
variations of ieach.
I. The Iritravesical Route. — Those in which the calcu-
lus has been removed from within the bladder. This has
been done in the male in three ways, (a) through a peri-
neal urethrotomy, (b) through a suprapubic cystotomy,
and (c) through the urethra without incision, by means
of a male catheter cystoscope.
A. In his recent book Morris ' says : "The perineal
incision is said to have been practised by Desault and
Garengeat" for extraction of ureteral calculus. We
unfortunately have no description of their case.
In 1884 Morris had suggested that a stone impacted
in the vesical part of the ureter should be removed
through a perineal urethrotomy, or a suprapubic cystot-
omy, and had devised a special knife for this purpose,
but he has never made use of the method.
B. In six cases calculi have been removed through
suprapubic incision. Helferich,'^ in 1894, published a
•case. Pitts," in 1898, one case. Bishop,* in 1899, two-
cases, and Newman,* in 1900, two cases.
AUGUST 9, 1802J
TREATMENT OF CALCULUS
[Ambbican MKDicnrE 211
Helferich's case :
Case I. — The patient was an elderly man who had suffered
with pains in both Icidney regions three years before. Exami-
nation revealed a large calculus in the bladder, which was
removed by suprapubic cystotomy. The finger of the operator
detected in the base of the bladder a " small incrusted place."
Careful examination showed that this was no incrustation, but
the small end of a calculus projecting from the mouth of the
left ureter. Tlie orifice was dilated with great difficulty, and
the calculus finally extracted. It measured about 2 by 6 cm. in
size. Following its removal there was an escape of much pur-
ulent urine and three small calculi. The patient recovered
from the operation, but died eight months later.
Pitts' ca.se (reported by Morgan) ;
ulus,
ion
Case II. — A boy, aged 9 years, had symptoms of caloul
which was verified by examination. On bimanual palpati
two were felt, one in each upper lateral portion of the bladder.
That on the right was fixed, that on the left movable. Supra-
pubic cystotomy was performed and a calculus as large as
a plum stone removed with the finger, but no other stone
could be felt in the bladder. On repeating the bimanual palpa-
tion a stone could be plainly felt at the entrance of the right
ureter, and intravesical examination revealed a protrusion of
tlie mucous membrane. On probing the apex of the protrusion
a stone was found "encysted in tiiat part of the ureter which
passes through the bladder wall." The operator made an
incision through the mucous membrane, and " the stone,
which was pyramidal in shape, was made to project into the
bladder by the finger of an assistant in the rectum," and finally
extracted with a probe. The stone was one-half inch long in
its greatest diameter. The boy was discharged well in six
weeks.
Bishop's cases were as follows :
Case III. — Male, age 13, admitted July, 1893. He had com-
plained a long time of symptoms of vesical calculus, and was
sounded with that idea. A stone was easily felt, but appeared
more fixed than normal. It did not alter its position when the
patient's own position was olianged. Suprapubic cystotomy
was performed and a calculus found with the finger, a portion
free in the bladder cavity, tlie rest of it held in the lower end
of tiio ureter. It was easily removed with the finger, aided by
a small spoon. The stone was constricted in its middle at the
point where the lower end of the ureter had grasped it. The
size of the stone was about an inch lon^, and that portion in
the ureter about one-half an inch in diameter. The patient
made an uninterrupted rectovery. the suprapubic wound healed
within two mouths, and he is now well.
Case IV. — Tliis was in a Ijoy, 8 years of ago, from whom a
vesical calculus had been removed by suprapubic operation.
Eight days after the operation colic occurred in the region of
the right kidney and ureter, and on rectal examination a calcu-
lus was found impacted in tlie end of the right ureter and
removed through the suprapuliic wound.
Newman's cases were as follows :
Case V. — Male, aged .'$5. History of intermittent attacks of
renal colic for several years. Lately patient (complained greatly
of frequent micturition, but suffered little or no pain during
the act, and only twice had profuse hematuria. Tliere was no
pain in the region of the kidney, and Ijoth rectiil and aiidominal
examinations were negative. The cystoscope showed a cherry-
sizeii tumor witli a smooth well va-scularized surface immedi-
ately over the right ureteral orifice, which was diagnosed
fibroma of the bladder. Suprapubic cystotomy was performed
and the swelling seized with vulsellum forceps, but as soon as
a pressure was made the tumor cracked and a little traction
iirought away a calculus, with a thin but complete covering of
mucous membrane. No note was made as U> the result.
Cask VI. — This was similar to the last. In this, also,
Newman removed the stone with its ureteral covering by
means of a vulsellum forceps.
C. Ci/stoscopic Extraction. — This method of removing
a calculus caught in the lower end of the ureter has only
betin performed (as far as I can find from careful search
of the literature) in the case (II) reporte<l by me. As
rioted above, the patient, a male aged 31 years, had an
atta(-k of severe pain in the left kidney three months
before, and two days later the pain suddenly descended
to the bladder. After that he suffered with a ranstant
desire to urinate and pain radiating from the base of the
bladder to the glans penis.
The cystoscope showed a calculus engaged in the ori-
ttceofthe left ureter, but projecting somewhat in the
liladder cavity. With Casper's catheterl/.ing cystoscope
it was impossilile by lateral pressure with the end of a
ureteral catheter to dislodge the calculus, which rolled
down into the ba.se of the bladder, leaving a large, round,
patent ureteral orifice. Nine months later the patient
reported that he had had no further attacks, and was
well.
The female cystoscope of Kelly, which is merely an
open tube, is much better adapted for intravesical opera-
tions than the male instruments, and it seems surprising
that no calculi in the female have been removed
through it.*
An interesting case in which Kelly dilated a slight
stricture of the lower end of the ureter through his cysto-
scopic tube, which operation was followed by an escape
of calculus into the bladder 19 hours later, i.s' recorded."
Kolisher, Casper and Kreissl " have reported similar
cases.
Removal wUh LUhotrite. — Freyer " describes a ease in
a male, 53 years of age. A stone was seen in the right
ureteral orifice and removed per urethram by means of
a lithotrite. The patient recovered.
II. The Perineal Route. — This was proposed in 1898
by Fenwiek," who stated that if a stone could be detected
by rectal examination it could be easily and .safely
extracted through a transverse perineal incision in the
male. In Fenwick's opinion, if the calculus is found
below the pelvic brim the incision should be perineal or
vaginal. Fenwick's case was interesting in many ways.
Male, aged 18, seen March, 1895. Patient complained of pain
in the glans penis after micturition, and occasional pains across
the ba<ck. Tne onset symptom was blood at the end of micturi-
tion. Trouble began 18 months ago ; there was no frctiucncy of
urination. The urine was healthy. The rectsil examination
showed tiie prostate to be normal. Cystoscopy showed a pro-
lapsoof the right ureter, and crowning theeverted mucous inom-
brane was a villous tuft. Thinking tliat this villous papilloma
led to the prolapse, Fenwick removed the prolajise and villous
growth through a sui)rapubic cystotomy. On the following
night it occurred to him that this prolapse must have been duo
t<i an irritation higher up in the ureter. Ho therefore cxanilned
the rectum and found, high u]), a stone the size of a marble in
the right ureter. After the suprapubic wound had lieale<l a
stone W!i.s extracted through a small tranverse perineal
incision. With the aid of long, narrow-tongue retra(rtors, tlio
dissection between the rectum and the lower urinary tract was
made. He rapidly reached the ureter, being guided to it by
feeling the stone in it, forctd within reach of his finger by the
pressure of an a.ssistant's hand upon the abdomen. The .stone
was then extracted liy a longitudinal incision, and was found to
be about the size of a small peach stone.
III. The Intrarectal Route. — This has been einjjloyed
only by Ceci,' who in 1887 reported a ca.se in which he
had operatetl to remove calculi through the rectum.
Tlie patient, a man, ha<l suffcre<l for several years with
sympUjins of ureteral calculus, and on rectid examination a
large, hard mass was found in the region of the left ureter.
Operation was performed with the patient in the position for
perineal cystotomy. The anus was dilated and washed clean.
A bistoury was then inserted, an incision 3 cm. long made ui)on
the tumor an<l seven stones removed from the dilated left ureter.
Further examination then revealed (ralciili in the right ureter;
the operation was jmstpoued, but never performed on account
of the death of the patient 36 hours later.
IV. The Pararectal Route. — This has not been usetl
in the male, and only twice in the female, both by
Morris, who described the method in his recent book '
in 1901.
An incision five inches hmg was made parallel with the
sacral spines and two inches distant from the middle line, ex-
tending from the level of the third sacral spine to a |)oint IJ
inches oeyoiid the tip of the coccyx. The ed^e of the glutous
maxinms muscle and of the great sacrosciatic ligament were
divided, a bougie passed into the roctum and another into the
vagina to act as guides. A sound was inserted into the bladder
and a finger in the vagina, and after some trouble the ureter
was found, the part containing the impacted stone pushed Into
tlie wound, the ureter incised and the calculus removed. The
patient recovered, and the urinary fistula closed in four weeks.
The second patient likewise rociovered. Both were females.
Morris says: "When a stone is impact<'d in the
ureter near the lower end, but too far off to be removed
through the bladder or vagina, the sacral route .should
be employed. 1 have operate<l successfully in two cases
• Hliicc reading tbiH paper I find that Dr. It. B. Hall hax done thin,
the nalcuhiH belnif dInlodKed by a Hearcher tbrougb a Kelly cyMtoHi-ope.
To tic publlnbcd (n a rorthoomtng article by Or. Scbenck, In the Johru
Hopkini lloiinliil Report:
212 AMKBIOAW MBDIOtNK
TREATMENT OF CALCULUS
[AUGUST 9, 1902
by this route. In the male the prerectal route is avail-
able." The pararectal route is but a modification of
V. The sacral route, which was suggested by Cabot
in 1892,'* has so far never been employed in the male or
female. Cabot's idea was to remove the calculus through
a Kraske sacral flap, but he never used the method. In
this very valuable article he expressed himself thus :
If the stone is already projecting well into tlie vesical
cavity, or has actually passed through the muscular coat and is
lying under the mucous membrane, it may be removed easily
and successfully through the bladder, and this would certainly
be the method of choice. When, however, the stone has not
reached the bladder cavity, and an incision of the bladder wall
is therefore necessary to uncover it, this operation is a danger-
ous one, as urinary infiltration about the base of the bladder is
likely to follow it. It would be better then to reach the stone
A Sent I A,- dlMU-^v^
10 cm
B (JawO*^^^)A) "^wAj
Scm
^tbxJiMj
VwwcXwJvt/
Fig. A. — The ureteral hexagon.
in the vesical end of the ureter by an incision from the outside,
which would open a way for the escape of any urine that was
afterward extravasated.
As has been said, this part of the ureter cannot be reached
from above, and it is necessary, therefore, to seek some
approach to it from below. It occurred to me that a modifica-
tion of the incision employed by Kraske for excision of the
rectum would afford the desired access to this lower portion of
the ureter, and dissections have confirmed me in this belief.
I And that an incision along the border of the sacrum, on
the side upon which it is wished to reached the ureter, stopijing
just below the point of the coccyx, with a division of the sacro-
iliac ligaments and the removal of the coccyx and the lower
part of that side of the sacrum, lays open the pelvic cavity In a
most satisfactory way and gives easy access to the lower three
or fo\ir inches of the ureter. The only difficulty in this dissec-
tion is in finding the ureter, which in its collapsed state cannot
be made out. The peritoneum is very thin and there is consid-
erable danger of wounding it during a protracted search. For
a stone impacted in the male this would seem a very ready
and safe incision for reaching this portion of the ureter. The
space afforded is ample for a careful inspection of the parts,
and the opening, being dependent, affords good drainage.
No operator has adopted this method, and it seems
an unnecessarily severe and destructive procedure.
VI. 2he intraperitoneal route has never been em-
ployed in the male, and only three times in the female,
for calculus lodged in the pelvic portion of the ureter. One
of these patients died from peritonitis. The great major-
ity of writers on the subject condemn this route as being
dangerous, and generally more difficult of performance
(especially as to suture of the ureter) than an extraperi-
toneal route, and Morris insists that even in cases in
which the diagnosis ha.s been made by laparotomy, and
a ureteral calculus thus detected, no attempt should be
made to remove it through the abdomen. Several
operators have made use of the hand in the abdomen to
push the stone up to the kidney, and then extracted it
through the loin.
VII. The Iliac (Extraperitoneal) Route. — Although
Bardenhauer in 1882 removed a calculus from the upper
end of the ureter by an extraperitoneal incision, no case
in which a stone had been removed from the lower
segment of the ureter (in the depths of the pelvis) was
published until 1890, when Twynam detailed a case.'
Since then four other operators have used this method,
viz., Morison, Israel, Finney and Young. In all, seven
cases.
I. Twynam 's case :
The patient was a boy of 8 years, who had suffered with
pain in the abdomen and hematuria for 16 months. An explor-
atory laparotomy was performed, and a small ureteral stone
found by the hand in the abdomen. It was lodged near the
vesical end of the ureter. The operator wisely decided not to
remove it through the peritoneal cavity, but waited until a
later date to perform an extraperitoneal operation through the
ilia(^ region. He made use of an incision such as one would
use for ligating the common iliac artery, found the stone and
removed it by incising the ureter, the opening being afterward
Fig. B.
closed by silk sutures. The patient made a good recovery,
although desperately sick before the operation.
II. Morlson's case :
The patient was 46 years of age and in a condition of uremic
coma, from complete suppression of urine of three days' stand-
ing, when the operation was undertaken. Through the lumbo-
iliac incision the right kidney and the entire ureter were
explored, and two calculi found impacted at a point one inch
August 9, 1902]
TREATMENT OF CALCULUS
tAmerican Medicinb 213
from the bladder. The ureter was incised, the stones removed,
and the opening closed with catgut. The patient did not, how-
ever, survive the operation.
III. Israel's cases:
Israel, ol Berlin, was the third and last operator to report
male cases operated for calculus of the lower end of the ureter.
In a recent splendid publication of 300 operations upon the
kidney or ureter we find three cases of this sort recorded.
His first case was a man, aged 31 years, who had had attacks
of kidney colic in the right side for six years. He was In a
very weak condition, and had a loud systolic heart-murmur.'
Palpation of the kidneys and ureters and rectal examination
were negative, no tenderness being made out. The urine con-
tained blood. Through a lumbar incision the kidney was ex-
posed, and an extensive dilation of the ureter found present. A
sound passed down into the ureter was obstructed near the blad-
der. The lower end of the ureter was then exposed by lengthen-
ing the original incision, and a small stone detected in the juxta-
vesical portion of the ureter. It was dislodged with the finger and
removed by an incision higher up in the ureter. The patient
died of heart faihire S6 hours after operation.
His second case wivs a male, aged 33, who had had pains in
his left side for nine years. The cystoscope showed that the
left ureter papilla was very prominent, and from itcame clouds
of turbid urine. A nephrectomy was first performed, but as
the patient suffered from pain in the region of the left ureter,
a more careful rectal examination was made and a large calcu-
lus detected in it.
A second o])oration was then performed to i-emove the stone
through an iliac incision. When the ureter had been fully
FlK.
-The normal iircUr from the lilac hcnil to Its Intravesical orlflce and Its
mibdlvlslunx.
exposed a calculus l"i-m. long and 3 cm. in diameter was found.
It completely filled the ureter to the lower end. The ureter
with the stone inside was removed, after ligation at its blad-
der cntran<'e. The patient made a good recovery.
The third case was very similar to the second. In this case
also the kidney was tirst n-nioved on account of pyonephrosis,
and a total ureterectomy with the impacted calculus performed
at a s<tond operation. The patient nH-overinl.
The Hixth and seventh cases in which the extraperi-
toneal (iliac) operation has i)een performed for stone in
the ureter at the lower end, were those of Finney and
Young, which were fully reported in the first part of
this paper. As it will be remembere<l three stones were
removed from the ureter in Finney's case, and one in
mine. In my case the ureter below the stone was
tightly strictured and (being unable to dilate it from
above) by means of an incision through the lateral wall
of the bladder the stricture was cut intravesically. Both
patients recovered.
Tabulating our results we have therefore found 18
cases recorded in which calculi have been removed from
the lower end of the ureter in the male. We have
includetl cases in which the stone was lodged in the pars
intermedia pelvis or paraischial portion of the ureter,
but have had to exclude those in which the impaction
was at or near the pelvic brim (iliac and parasacral por-
tions). In this category are the ca.ses of Kirkhtiiii, Keen
and others.
The result obtained by the different routes were as
follows :
I. Intravesical, 9 ; result not noted, 3 ; recovered, 6.
II. Perineal (prereotal), 1 ; recovered.
III. IntrarectsU, 1 ; died.
VII. Iliac (extraperitoneal), 7 ; recovered, .5 ; died, 2.
Total 18 cases : Result not noted, 3 ; recov-
ered, 13 ; died, 3.
<iKXKRAL CONSIDERATION OP THE ANATOMY
AND PATHOLOGY.
Before taking up the question of diagnosis
and treatment it may be well to discuss briefly
the anatomy and pathology of the lower end of
the ureter.
The ureter after crossing the iliac vessels at
the pelvic brim runs first directly downward,
but soon curves outward, acro.ss the sjicroiliac
synchrondosis, and passes over on to the ischium
at a point above its spine. It then turns
sharply inward, making the most acute bend
in its course, and passes to the bladder in a fold
of the peritoneum — the posterior portion of the
lateral false ligament of the bladfler.
Measurements of the distance between the
two ureters show that they are about 5 cm.
apart at the brim of the pelvis, where they cross
the iliac arteries, and also about 5 cm. apart
where they enter the posterior wall of the blad-
der. At the paraischial bend they are about
10 cm. apart, or double the distance above and
below. Measurements also reveal that the dis-
tance from the t)end at the pelvic brim to the
paraischial bend is about 5 cm. and that the dis-
tance from this point to the entrance into the
posterior wall of the bladder is also !> cm. The
course of the ureters within the pelvis, there-
fore, form (juite a perfect hexagon, each limb
(and rivdius) of which is 5 cm., a.s shown in the
diagram ; thus, A and A' represent the bend at
the pelvic brim and are, of course, 5 cm. apart.
B and B' represent the paraischial IkmhIs and
are, of course, 10 cm. apart (double the radius),
C and C" the points of the junction with the
bladder and also 5 cm. distant. AB, A'B' and
B'(/' are likewise 5 cm. We see that such a
hexagon corresponds <iuite accurately with the
average anatomic distance of the ureters and
gives at once an easy and ftiirly accurate idea
of their intra|)elvic course.
The ureter as you are aware Is not a tube of uniform
caliber but as shown in the accompanying photograph of
anatomic preparations (Fig. C.) presents normally four
points of narrowing, the first just Ih'Iow the renal pelvis,
the second where it cn>sse8 the iliac vessels, the tliinl
where it ent<'rs the must;ular wall of the bladder and
the fourth at its vesicle orifice. Between these points of
214 A.HERICAN MEDICINKJ
TREATMENT OF CALCULUS
[August B, 1902
narrowing it swells out in a fusiform manner as particu-
larly shown in one of the figures.
These points of narrowing are of great importance in
determining the lodgment of calculi, and the statistics
show that they are
found impacted at
these four j) o i n t s
with much greater
frequency than at
all other portions of
the ureter com-
bined.
Calculi, then,
which have passed
the first and second
narrowing are most
apt to be lodged at
the junction with
the bladder, or at
its vesical end.
The occasional
lodgment of stones
at the point halfway
between the pelvic
brim and bladder is
probably to be ex-
plained by the
rather sharp bend ,
which the ureter
makes at that point,
the par a ischial
bend.
The course of the
lower ureter may be conveniently named from its re-
lation to neighboring structures thus :
The iliac portion, where it crosses the iliac vessels.
The parasacral, where it passes in front of the
sacrum.
The paraischial, where it makes a rather sharp bend
above the ischial spine.
The juxtavesical, that portion just above the bladder.
The intramural, that portion within the muscular
wall of the bladder.
The intravesical, the orifice within the bladder cavity
(pathologic).
In the 19 cases collected in this paper the points of
Fig. 2.— Calculus impacted in paraischial
portion.
female also several cases of intramural incarceration of
calculus have been reported, but only one in the male.
The accompanying diagrams show the different posi-
tions and forms of lodgment of ealculi as outlined above
(Figs. 1-6).
The intravesical type may be of two forms : one in
which the calculus, entirely covered by mucous mem-
brane, presents a rounded seasile or pedunculated tumor
in the bladder as in tlie two cases of Newman (Fig. 5) ;
and that end which the stone is partly in the bladder
and partly within the ureter, being constricted at the
orifice, the " wheat sheaf" type as in Bishop's first case
(Fig. 6).
The nomenclature suggested above gives briefly and
accurately the points of impaction of stones, and will
thus avoid the great confusion and Inaccuracy of descrip-
tion which now exists in the literature.
The pathologic reason for the impaction of stones in
certain parts of the ureter are both intraureteral and
extraureteral. Of the former strictures are the most
common, and are probably most often the result of the
injury, laceration, inflammation, etc., caused by the pre-
vious passage of calculi. Strictures may also be congeni-
tal, and we find in the literature several descriptions of
congenital stricture, especially at the vesical orifice.
Beside hindering the passage of calculi which have devel-
oped in the kidney, the dilation of the ureter just above
a point of stricture is of itself a fertile field of develop-
ment of calculus.
About two years ago I discovered in the course of a
cystoscopic examination a tight stricture of the orifice of
the left ureter, which had led to a globular dilation of
the intramural portion of the ureter above, which, with
eax;h jet of urine, sprang out as a small rounded intra-
vesical tumor, only to vanish as the peristaltic ejection
of urine had ceased.'^ Such condition must often lead to
a stone formation of the intravesical type.
The extravesical causes of the ureteral narrowing and
stricture are many, such as the pressure of tumors, and
inflammation of adjacent strictures with subsequent
cicatricial contractions, which sometimes lead to sharp
kinks in the ureter. The latter being particularly com-
mon in women, explains the greater frequency of calculus
of that portion of the ureter of females.
Fig. 3.— Calculus In juxtavtsical portion.
Fig. 4. — Calculus in intramural portion.
Fig. 5. — Intravesical ureteral calculus.
impaction of the calculi were as follows : Juxtavesical,
7; intravesical, 6; paraischial, 1 ; intramural, 3; juxta-
vesical and paraischial, 1 (three stones) ; juxtavesical to
iliac, 1 (17 cm. long).
As only the cases of calculi of the lower end of the
ureter in the male were considered the frequency of cal-
culi at the iliac region is not shown.
In the female the paraischial portion just behind the
broad ligament is a frequent point for the stoppage of
stones, while it is not so common in the male. In the
Diagnosis. — There seem to be few, if any, symptoms
of decided value in determining what position a stone
occupies in the ureter, whether high up or low down. In
both you may or may not get the classictil symptoms of
renal calculus. In one of my cases in which the stone
was caught in the orifice of the ureter, the patient suf-
fered severely with vesical irritation and pain running
down to the end of the penis, associated with frequent
micturition. Where the stone thus projects into the
bladder we would expect to get the symptoms of vesical
AUOUST 9, 1902]
TREATMENT OF CALCULUS
'AXSRICAK HEOICISl. 215
Fig 6.— Intravesical ureteral calculus.
calculus, as well as ureteral, and in Case II, which I
have reported above, in which the stone was intramural
or juxtavesical, there was a pain in the bladder and penis.
Thus the symptoms were those of vesieal calculus in the
cases of Emmet, Richmond, Czerny, Doyen, in the
female, and Helferich, Bishop and Newman inthemalel
The cases in the literature, however, do not show that
this is always the case, though the histories may not be
accurate on that point. Between attacks the pain may
entirely disappear, or evince itself as a dull ache in the
region of the base of the bladder or back of the symphisis
pubis. On account of the proximity of the vas deferens
as it winds over the end of the ureter, it seems strange
that testicular symptoms are so peculiarly infrequent.
Physical examination is often of little help. When
the stone is below the brim of the pelvis, the character-
istic tender point on
abdominal palpation,
which often indicates
the point of impaction
of calculi higher up
the ureter, is absent.
Rectal examination
will, however, often
show the location of
the calculus. In 14
cases of Israel, in
which the calculi were
located in the pelvic
section of the ureter,
they were felt by rec-
tal or vaginal exami-
nation in seven cases,
and Israel is of the
opinion that if exami-
nations are made carefully and frequently the stone
should always be felt on bimanual, rectal and abdominal
examination, except on fat subjects. In only one of my
eases did the rectal examination give any indication of
the presence of stone.
The cystoscope of Nitze is of great value, for we
nearly always find more or less extensive changes in the
ureteral papilla on the affected side. When the stone is
not immediately in the lower end, in the paraischial or
jtarasacral positions, we may only find a slight hyper-
emia and swelling around the orifice of the ureter. Inter-
mittent spurts of turbid urine may, however, be seen.
When the stone is in the juxtavesical portion one
generally sees a bulging of the wall of the bladder above
or at the ureteral orifice, and the same is true when the
^tone is impacted in the intramural section of the ureter.
When the stone is intravesical, it may be completely
covered by mucous membrane, as in the two erases of
Xewman, where the operator made the diagnosis of
pedunculated intravesical fibroma. In these cases the
orifice of the ureter could not be seen. When the stone
projects through the lumen of the ureter it will, of
course, be evident through the cystoscope, as in one of
my cases.
The catheterizlng cystoscope is also of great value.
By its means the distance of the stone from the ureteral
orifice can generally Ixi determined. A stricture may
also l>e detected, an<l in some cases dilated by means of
the catheters and bougies.
Of greater value, howdver, is the possibility of accu-
rately determining the condition of the two kidneys—
especially the opposite one.
Itecent advancements in clinical laboratory methods
have placet! at our disposal several valuable tests by
which we ciiii accurately gauge and compare the func-
tional value of the two kidneys.
With the det<'rmination of the urea, the freezing
points of the two separate urines, and the relative elimi-
nation of sugar by the kidneys after the hypodermic
injection of phloridzin, we are prei)ared to determine
accurately the value of each kidney, the chances of
unsuspected calculus on the opposite side, and foresee
the danger of postoperative suppression of urine.
The frequent report of deaths causetl by taking out
the only kidney, or where -the remaining organ was
atrophied, destroyed by cystic, hydronephrotic or
pyonephritic changes or blocked by an unsuspected cal-
culus, would not be found were the ureter cystoscope
more frequently employed.
Of very great value also is the x-ray, and the medical
profession owes a very great debt to Philadelphia for the
splendid service which has been rendered by C L.
Leonard, in proving that ureteral calculi can be detected
by the radiograi)h. It has been of very great assistance
in my cases, and no examination can be complete with-
out it.
There are of course slight chances of error. For
instance a phlebolith of the lateral veins of the pelvis, or
in the region of the seminal vesicles, where they are so
commonly seen might be mistaken for ureteral' calculi,
especially in those cases of chronic prostatitis associatetl
with slight hematuria. I have seen one such case, but
the cystoscope showed that we had no ureteral trouble.
But a good radiograph should always be obtained,
though we should not in our zeal take too many, sis I
have seen several very dissigreeable burns result there-
from. With careful history, vigorous repeated bimanual
rectal examinations, the radiograph and the cystoscope
the diagnosis of calculus, its location and the relative
condition of the kidneys, is easy and certain, and we are
now in position to decide upon therapeusis.
The therapeutic indications are so manifold, and I
have already consumed so much time that I can only
give a mere outline of the results of this study of the
question. The treatment inilic^ted depends on a multi-
tude of things ; the age, history, and duration of the dis-
ease, tiie freciuency and character of the attacks, the
condition of the patient, and above all the question of
what the effect on the kidneys has been. The frequency
with which calculi are passed one or more tinu-s, with
no subse(iuent recurrence, is sufficient to prove the value
of a waiting policy. One of the cases which 1 have
detailed has almost certainly passed a small calculus
which was located at the vesical junction of the ureter
(III).
Leonard's recent article in American Medicine (iioxem-
ber ;J0, li)01) covers the subject very well. Leonard shows
that small calculi may remain impacted for life on the
ureter without producing symptoms or interfering with
the junction of the kidneys. They may, however,
remain quiescent but destroy the kidney, which, after
fruitless attacks of colic may finally cease to stH.'rete, and
gradually atrophy, without producing any further symp-
toms, the other kidney ai^^uming the entire work. If
now the second kidney become blockinl by a stone, the
chances of fatal anuria and death after operation are
great. This is beautifully shown in the photograph
(Fig. 7) of one of my specimens. The left ureter is
blocked by two stones, the kidney above much atro-
phicKl, and the other kidney greatly hypertrophied.
These facts should lead, as Leonard suggests, to fre<iuent
x-ray examinations to (let<»rmine what is going on, and
I should add, to an accurate determination of what was
happening to the kidney, by uret<'r catheterization. If
the kidney were not functionating, (tperation should Ik?
performed to remove the calculus, regard less of symptoms.
When the attack is severe, suppression of urine or sepsLs
has set in, operation should of course be hnme<liate.
In some cases uret<'rnl stones have been crushe<l be-
tween the fingers in the vagina, and Bovsing reports a caae
in the male where a calculus was caused to be evacuated
by abdominal massage along the ureter and by vigor-
ously shaking the patient.
When it is proj«H-ting from the end of the ureter into
the bladder it may in rare Instances be extricateil by
means of a ureteral catheter, as In the cas** which I have
reported. In my case this was quite easily accomplished
216 AMBBICASr MKDICINEj
TREATMENT OF CALCULUS
(August U, 1902
by lateral pressure with the catheter, directed by the
view through the male cysto.scope. But this calculus
was small.
Cystosco[)ic dilation of t,he lower end of the ureter to
Fig. A.
make room for the escape of a calculus has been success-
ful in the male in three cases (Kolisher, Casper and
Kreissl "). I failed in my case. It might be more suc-
cessful if done through a suprapubic opening, a.s Leonard
suggests. When the stone is intravesical it can be most
satisfactorily removed in the male through a suprapubic
incision, and in some Cases it may not be dangerous to
incise the bladder wall to extract a calculus lodged in the
intramural or juxtavesical portion of the ureter. But
Thornton did this, produced a fistula into the peritoneal
cavity and lost his patient. The peritoneum often runs
down to the junction of the ureter and the bladder and
between them, and incision or dilation for stone in that
location seems a very dangerous procedure, and the iliac
extraperitoneal route is safer and to be preferred for
many reast)ns.
When the stone is above the vesical juncture it is
entirely out of reach from the bladder, and we have to
decide l)etween the several routes ad-
vised by different operators, viz. : The
perineal or prerectal, the intrarectal,
the pararectal, the sacral, the intra-
peritoneal and the extraperitoneal or
iliac route.
As we have seen above, the para-
rectal, the sacral and the intraperi-
toneal have not as yet been employed
in the male, and the j)erineal or pre-
rectal and the intrarectal only once
each, with fatal result in the latter.
On the other hand, the iliac, extra-
peritoneal route has been used seven
times with two deaths, and neither
attributable to the operation.
The evident difHculty of the per-
ineal and parasacral routes, the great
distance necessary to go to reach the
ureter, the inability to explore the
ureter or kidney above, or to deter-
mine accurately the presence of stric-
ture below, and the inability to attack
the higher tract without another
operation, seem to be sufHcient to con-
demn all the inferior routes.
Stricture of the ureter in my opin-
ion plays a greater part in the produc-
tion of calculi, in determining their
point of impaction, and in leading to
their recurrence. After the removal
of a calculus a careful search should
always be made for stricture below,
and ureteral bougies or probes should
be made to pass freely into the vesical
cavity from above. If this does not
succeed the milking process, which I
employed to see if the fluid can be
emptied into the bladder, may be
tried. If all attempts fail a stricture
is probably present and should be cut
if it cannot be dilated, and if situated
^t the vesical orifice it is a very simple
matter to do an intravesical ureterot-
omy after opening the bladder through
a lateral incision (without a new ab-
dominal incision). In my case (I) the
result is good, and the cystoseope shows
that the stricture has not recurred.
The question of destroying the
valve-like mechanism of the ureter is
of course to be thought of, and in cases
in which the kidney above is healthy
and the bladder infected the operation
may be contraindicated.
The only operative route through
which the kidney can be explored, re-
moved if necessary or advisable and
stricture of the ureter treated is tlie iliac extraperitoneal.
For this and many other reasons it should be the method
of choice in all cases in which the stone is not distinctly
intravesical or intramural. For calculi in the juxta-
vesical, and paraischial regions of the ureter, it is dis-
tinctly better in every way than the inferior routes, in
front of or beside the rectum, and for calculi in the para-
sacral position it is the only practical route.
The lower portion of the ureter in the male, which
was supposed only a few years ago to be beyond the
reach of the surgeon, has also succumbed to the persist-
ence and boldness characteristic of this age, and is now
proved to be as amenable to treatment a.s any other por-
tion of the urinary tract.
August 9, 1902]
X-EAY TREATMENT OF CARCINOMA
[American Medicixb 217
1900.
BIBLIOOBAPHY.
• Fenger, American Textbook of Genitourinary Diseases.
2 Morris, Renal Surgery— Hiinterian Lectures, 1898.
'Morris, Surgical Diseases of the Kidney and Ureter, 1901.
♦Bishop, Edinburgh Medical Journal, Vol. vi, 1899, p. 47.
5 Newman, British Medical Journal. Vol. i, 1900, p. 949.
'Fenwick Edinburgh Medical Journal, 1898, p. 281.
' Cecl, La Keforma Mediea, September .5, 1887, p. 1214.
'Cabot, American Journal of Medical Sciences, 18,92, p. 43.
•Twynam. British Medical Journal, February 1, 1890.
"Morris. The Lancet, November 10, 189i, p. 1093.
1 Israel, Chirurgische Klinik der Nierenkrankheiten, 1901.
2 Young, Maryland Medical .Tournal, November, 1901.
' Kelly, Journal of the American Medical As.soclation, March 3,
•Kreissi, The Chicago Medical Record, March, 1899.
'5 Freyer, The Lancet, 1899. p. 211.
11 Helferich. Archlv fur klinische Chirurgie, 1894, Bd. 48, p. 87.5.
" Morgan, The Lancet, 1898, i, p. .")60.
This paper is reported in full in the transactions of
the Philadelphia County Medical Society meeting of
March 12, 1902.
THE X-RAY TREATMENT OF CARCINOMA.
BY
WALLACE JOHNSON, M.D.,
of Washington, D. C.
Demonstrator of Pathology, Georgetown University ,Vledical School,
and in charge of the Pathologic Department of the Lionel
Laboratory at the Central Dispensary and
Emergency Hospital ;
AND
WALTER H. MERRILL, B.L., M.D.,
of Washington, D. C.
Formerly In charge of the X-ray and Photographic Department of
the Lionel Laboratory at the Central Dispensary and
Emergency Hospital, Washington, D. C.
In our article on " X-ray Treatment of Carcinoma,"
which appeared in the Philadelphia Medical Journal of
December 8 and 1 5, 1900, we reported .six cases treated
liy thi.s method and promised a later report on the same.
It is now nearly two years since that paper was written,
and as several inquiries have been received regarding
the future history of the cases, we deem it advisable to
report on them and also to give the results in the ca-ses
treated since that time. As interest centers in the .suc-
<'ssful cn.ses, detailed case histories of those only will be
j,'-iven ; but in the appended table will appear results of
all ca.ses treated by the x-ray, that the reader may form
his own estimate of the value of this treatment.
Case I. — Previously reported. The patient pre.sented an
ulcer about halfan inch in diameter on his cheek. This had been
diagnosed epithelioma by the surgeons who had charge of the
case and who had excise<l the diseased area. Treatment was
commenced September G, 1899, and was discontinued October 9
of the same year. The original scar resulting has remained
smooth and soft and is not noticeable at a distance. Two and
one-half years have elapsed since the treatment.
Cask V. — Previously reported. Mr. P. C. says that his di.s-
ca.se resulte<i from a razor cut of the external nasal septum,
which refused to lieal. At the time treatment was commenced
the whole end of his nose was much swollen, the septum was
very much broadened and thickened. Internally there were a
few small granulating surfaces near the external opening,
which caused clots of blood to form within the nostrils. Exter-
nally the surface was reddened and presented five ulcerated
surfaces, which were only slightly depre.ssed. There was a
<onsiderable quantity of purulent serum discharged, accom-
panied with a disagreeable odor. A section taken for micro-
vcopic examination proved the diseiise to be epitlielioina.
Treatment began .July 1, 19f)0, and was continued until .July 10.
1 n this ca.se live exposures were given, using the most intense
burning ray that could be produced; each exposure was con-
tinued from 4 to 7 minutes and resulted in a very severe derma-
titis, whicti tooti several months to heal entirely. When the
patient was last seen, a year after, the nose had become entirely
well, there was no evidence of any recurrence, and the pre-
sumption is that we would liave heard from him if he had had
a return of the trouble.
Cask VI.— Previously reported. Mr. >r. had a small super-
ficial ulcer, 4 to 5 mm. indiameter, on the tip of his nose. He
said that for two years this had been treated by dermatologists
and others without any beneficial result. In fad the place
be<;amo i)rogressively larger and worse. Treatment was com-
menced Augu.st3 with an e.xposure of seven minutes. This
was followed by seven-minute exposures on each of the follow-
ing dates, Augusts, 11, and 13. The surface promptly healed
over and two weeks later no remnant of the disease was appar-
ent. There has been no sign of recurrence up to the present
time, nearly two years later.
Case VII. — Not previously reported. Mr. 0. K., aged 75,
had a slow-growing epithelioma on the side of his nose for over
15 years. Five years after it first appeared it was excised, but
soon returned larger than before. When he applied to us the
diseased area was about J of an inch in diameter. Treatment
was commenced January 4, 1901, and continued until February
27, 1901 ; five exposures were given ; the ulcer healed after the
erythema subsided, with the formation of a smooth, soft scar.
There has been no recurrence.
Cask XIV.— Mrs. K. on her first visit presented an epi-
thelioma on the side of her nose and lower eyelid, which was
discharging freely. There had been a plastic operation for
this disease at which tlie lower eyelid and a portion of the .side
of the nose were removed. The recurrence first appeared along
the line of incision and subsequent curetments were also fol-
lowed by recurrences. The x-ray treatment was intermittent
for several months and when last seen, March V, there was no
evidence of disease remaining.
Case XVI. — Miss B., aged 26, was referred to us for treat-
ment September 24, 1901. She had on the side of her nose a
lupus patch, irregular in outline, covering about 14 square
inches. The disease had existed for several years, and persisted
notwithstanding curetments and caustic applications. Short
exposures were made on Septemlier 24, October 1, October 21,
and November 19. A pronotincod iuHammation over the entire
area was produced by the first treatment and tlie following ex-
posures were confined to small individual .spots which still
refused to heal. The patient has been under ooservation since
the last treatment on November 19, and has remained free from
any recurrence. • •
Cask XVII.— Mrs. B. was referred to us for treatment in
the spring of 1901, but the exposures were not begun until the
following October. There was an extensive area on the side of
her forehead extending from eyebrow to hair and down nearly
to the zygoma, which the eminent dertruitologists, who had
treated the patient, pronounced epithelioma. The previovis
treatment had been curetment and local applications, which
seemed to check the disease for a time, when it would break out
again over a larger area than ever before. Treatment begun
October 22, 1901, and continued until November 5, when tlie
exposure-! were stopped because of signs of infiammation. The
diseased area broke down entirel.y and shortly began to heal in
from tlie edges. By December 1."!, 1901, the surface was com-
pletely covered with new skin and has remained .so.
Case XXII. — Mr. L., aged 81, had a superficial ulcer on his
right cheek about lialf an inch in diameter; this had been pres-
ent for five years and was diagnosed epithelioma. The patient
was given two treatments beginning llecember 4, and the dis-
ease promptly healed, leaving no visible scar.
Case XXV.— Mr. H., aged 58, had a small nodule on his
right cheek where a growth had been previously excised. The
skin was not broken. Treatment consisted of three exposures,
commencing February 17, 1902. The usual inflainination was
produced, which on subsiding left no trace of the original
growth.
Case XXVI.— Mr. P., aged 45, was referred to us witli an
epithelioma of the lower eyelid. Treatment consisting of five
exposures was commenced March 12, 1902. The patient is still
under observation, with prospects of complete cure without
additional exposures.
From the appended table it will lie seen that of the IG
ca.ses of epithelioma traitetl, regardless of their length of
existence, extent of tissue involved, and previous treat-
ment received. 10 patients, or 62.5/c, are apparently
cured. And in addition 4 ca.ses, or 26 fc , show improve-
ment and 8 of these give promise of ultimate recovery
under further treatment. Only 2 csises, or 12.5/r , failed
to derive benefit from the treatment other than allevia-
tion of pain and diminution of discharge.
Of the seven carcinomas treated, all of which were
cla.ssifled as inoperable by the surgeons who referred the
cases to us, none showed any improvement beyond relief
from pain and probably a temporary delay in the tlnid
fatal termination.
The one case of lupus vulgaris gave a.s gtwxl a nwilt
as any of the ejiitheliomas and is consitlered of suHlcient
interest to be reported in detail.
From the tal)le it will l)e seen that lupus vulgarisund
superficial epithelioma or rodent ulcer hold out every
prospect of complete cure by this treatment, whereas
the de<'i)er seated carcinomas are at best merely relieved
of pain and jiofi-sibly retarded in their d(>structive
progr(>ss.
The flliromas show no change at all, and neither of
the two cases reportetl would have In-en treated if the
218 American MkdicineI
APPEARANCES OF NORMAL FOVEA
(August 9, 1902
patient could have been persuaded to undergo operation
for its removal. Our experience has taught us to advise
operation in all cases of carcinoma seen early, and
we believe that patients will apply earlier for proper
medical advice when they learn that any one form of
cancer is amenable to a painless treatment. Patients do
not distinguish between " cancers," and therefore delay
in consulting their physicians about every suspicious
lump or sore. But let the public learn that any one form
of cancer can be thus cured, and as many will consult
early in the hope that their case is favorable as now hide
the condition until too late. In this way not only will
the epitheliomas be cured by the x-rays, or by surgical
means, but the percentage of cures following operations
cides with the observation made by others that the x-ray
seems to have a selective action for the diseased tissues.
This was especially noticeable in Case XVII. After sev-
eral treatments of this patient the edge of the diseased
area showed an outline as clean cut as if with a knife,
whereas the area of redness from the reaction produced
in the exposed skin extended beyond this edge. The
number and variety of cases treated by the x-rays,
already reported on by numerous members of the medi-
cal profession, is now large enough to form a basis for
more definite conclusions, and we see no reason to
change the opinion expressed in our first report written
two years ago, "that the x-rays are a valuable addition
to the therapy of this dread disease."
0
6
bo
<
45
Diagnosis.
Duration
of
Disease.
Location of
Disease.
Previous Treatment.
i'l
Time be-
tween first
and last
exposure.
Result.
Time since
last
exposure.
Remarks.
1
Epithelioma.
8 years.
Nose and cheek.
Excision and actual
5
34 days.
Cured.
2% years.
Original resulting scar
cautery.
smooth and son
2
48
Epithelioma.
5 years.
Nose.
Chemic caustics.
Improved.
Treatment intermittent
owing to patient's
neglect.
3
60
Epithelioma.
M year-
Lip.
'
30 days.
Not improved.
Died 6 months after
treatment stopped.
4
33
Carcinoma.
1 year.
Breast.
Excision; 2 opera-
tions; chemic
CHtistics.
20
2 months.
Not improved.
Died from pulmonary
metastasis.
5
72
Epithelioma
5 years.
Nose.
5
16 d.ays.
Cured.
2 years.
See ease history.
6
55
Epithelioma.
1 year.
Nose.
Ointment and curet^
ment.
4
10 days.
Cured
i;4 years.
See case history.
7
75
Epithelioma.
15 years.
Nose.
Excision.'
o
2 months.
Cured.
1 year.
See ease history.
8
02
Carcinoma.
Breast.
Excision; 2 opera-
tions.
Num
8 months.
Not improved.
Died from extension of
disease.
9
60
Fibroma.
4 years.
Foot.
5
21 days.
Not improved.
Treated against our pro-
test.
Died from extension of
10 58
Carcinoma.
Breast.
E.xcision.
6
2 months.
Not improved.
disease.
11
43
Rodent nicer.
Nose and face.
Curetment and ex-
cision.
4
14 days.
Not improved.
Patient stopped the
treatment.
12
28
Carcinoma.
2 years.
Breast.
Excision,
5
30 days.
Not improved.
Treatment discon-
tinued.
13
50
Sarcoma.
1 year.
Forearm.
Ointments.
3
26 days.
Cured.
1 year.
Patient lost sight of.
14
42
Epithelioma.
Nose and eyelid
Excision and curet-
ment.
20
18 months.
Cured.
6 months.
See case history.
15
81
Epithelioma.
10 years.
Eyelid.
3
4 days.
Cured.
8 months.
See case history.
16
26
Lupus.
Bev'l yrs.
Nose.
Curetment.
4
2 months.
ured.
6 months.
See case history.
17
50
Epithelioma
5 years.
Side of face.
Curetment
7
12 days.
Cured.
6 mouths.
See case history.
18
60
Carcinoma.
2 years
Lower jaw.
Excision of lip.
10
30 days.
Not improved.
Advised to stop treatr
ment.
Died 4 months later
19
65
Carcinoma.
1 year.
Lower jaw.
6
23 days.
Not improved.
from extension of dis-
20
38
Fibroma.
3 years.
Brea.'-t.
6
27 days.
Not improved.
ease.
Patient stopped the
treatment.
21
81
Epithelioma.
12 years.
Eyelid.
12
Improved.
Still under treatment.
22
81
Epithelioma
5 years.
Cheel5.
2
4 days.
Cured.
6 months.
See case history.
23
81
Rodent ulcer.
20 years.
Orbit and face.
Excision and eye
enucleated.
13
Improved.
Still under treatment
24
75
Rodent ulcer.
14 years
Eye and nose.
10
Improved.
Still under treatment.
25
58
Epithelioma.
i year.
Cheek.
Excision.
3
18 days.
Cured.
3 months.
See case history.
26
61
Carcinoma.
IK years.
Lower jaw.
Excision ; 2 opera-
tions.
6
23 days.
Not Improved.
Advised to discontinue.
27
45
Epithelioma.
20 years.
Eyelid.
'5
16 days.
Cured.
1 month.
See case history.
on other carcinomas will be far greater, because seen
earlier by the surgeon.
As regards the method of treatment by x-rays, there
seems to be quite a difference at the hands of different
operators. Some use the static machine and daily treat-
ments, while others use an induction coil and le.ss fre-
quent exposures. Nearly all agree that a tube of low
vacuum is mo.st apt to produce superficial "burning."
All of those who use the less active tubes report cases
submitted to a long series of treatments, given until a
reaction of the skin about the growth is produced, when
treatment is discontinued until the reaction subsides. In
other words, they treat the di.sease until a reaction
appears, and jud','ing from their reports they have
obtained no therapeutic eff'ects until the reaction does
occur. In our cases we have aimed to produce the reac-
tion as soon as possible, taking its appearance as an indi-
cation to stop further t eatment, using this as an index
to the desired eflfect on the growth. In this way the
same result may be accomplished in three or four semi-
weekly exposures of 4 or 5 minutes' duration as is
accomplished by 25 or 30 daily exposures of 10 to 15
minutes with a less active tube. Our experience coin-
A NOTE ON THE OPHTHALMOSCOPIC APPEAR-
ANCES OF THE NORMAL FOVEA,
BY
HOWARD F, HANSELL, M,D.,
of Philadelphia.
Less attention has been paid by writers on ophthal-
mology to the physiologic variations in the ophthalmo-
scopic appearances of the macula and foveal region than
to those of the optic nerve head, not that they are un-
essential to an accurate picture of the eye ground but
because the foveal region presents, when studied by
means of any of the many different styles of hand
ophthalmoscopes, practically the. same form and color
in all. Yet the normal variations are extensive, inter-
esting and valuable for the definition of the healthy as
compared with the diseased fundus. They embrace the
size and shape, color, vascularity and boundaries, and
depend upon the extent of the field under observation
and the brilliancy of the illumination. The anatomic
basis for these apparent variations is difficult to deter-
mine but is probably disproportionately slight, for the
August 9, 1902J
EPIPHENOMENA OF CEREBRAL HEMOKRHAGE [Amkbican mki>icink 219
microscope could hardly reveal individual differences in
the fundi of normal eyes that could explain them.
In a number of liealthy eye grounds, approximately
1,000, examined in the pa.st few months by the Thorner
ophthalmoscope, the fovea! region and its immediate
neighborhood were carefully inspected. With this
instrument the personnel does not modify the descrip-
tion of the fundus, since exactly the same view under
precisely the same conditions is seen by every observer.
There is no room for differences of opinion as t« the details
of the fundus picture, although interpretations of the
findings may be different or the theoretic explanations
may vary. The examinations forced the impression
upon me that this region is equal to the papilla in the
consideration of those factors tliat constitute a normal
eye ground and that fine defects, readily overlooked or
beyond the capabilities of the hand ophthalmoscope,
would change the diagnosis from normal to abnormal.
With the magnification of the direct, and the extent
ofthe field of the indirect method of examination and
without reflexes, the average foveal region presents the
following characteristics :
1 . The Size and Shape.— The size, including the macula,
the circummacular zone and the boundary is about
eijual to that of the nerve head. The circumference of
the zone or tlie boundary is marked by reflected light,
which, while flitting and unsteady, is confined to the
outside limits of the region. The shape is round or
slightly oval with the long diameter horizontal, and
this is independent of the refraction. Astigmatism
seems to have little influence in determining the appar-
ent shape, and even high grades can be imperfectly
estimated by the very slight distortion that is excep-
tionally seen. Astigmatism is, however, at once mani-
fest by a comparison of the terminal twigs of the ves-
sels. The form antl extent of the foveal region is the
magnified and exact picture of the anatomic arrange-
ment of the retinal tissues ofthe part as seen under the
microscope. The glistening border marks the edge
of the excavation, the deep red the shelving sides
and the macula or yellow spot the anatomic and geo-
graphic center and lowest part of the cup.
2. Cbtor.— The color is the result of the -amount of
retinal and choroidal pigmentation, of the height of the
boundary, and steepness of the sides, and of the degree
of illumination. The pigment modifies the tone and
color according to its density. In the brunet the macula
stands out as a bright, yellow, circular dot, the circum-
macular zone is deep red, the circumference is glistening
and the whole region is surrounded by a zone of deeper
pigmentation than that of the rest of the fundus. In
the albino, the boundary is indistinct or invisil)Ie, the
macula less yellow, the intervening space light red
and the circumjacent zone absent. In the gradis of
pigmentation between the African and the an)in() the
region varies from a light red to almost black, the
central point always standing out in less or greater
contrast. The elevation of the edge,-, that of the fiber
layer of the retina, modifies slightly the color of the
depression. The more pronounced the cup and the
sharper the flistinction l)etween the foveal and the
extrafoveal retina the more brilliant and complete is
the glistening, flittering reflection of light that in most
Ciises compleu-s the full circle. The intensity of the
reflection naturally depends in great measure upon the
brightne.-s of the illumination. With the small kerosene
lamp, accurately adjusted before the semicircular aper-
ture, with which the German-made Thorner ophthal-
moscope is provided, the illumination is hardly appreci-
ai)ly less than with the Welsbach mantle substituted by
an American oplician.
8. The Vaxriiktrifj/.—The foveal region, excepting the
macula, is abundantly i)rovided with ves.sels. The
tortuous, terminal twigs, both arteries and veins can be
phiinly seen as they curve over the border of the
excavation and disappear in the circummaculHr space
before they reach the yellow spot. Contrary t« the
usually accepted statement, therefore, the retina within
the foveal region contains bloodvessels.
EPIPHENOMENA OF CEREBRAL HEMORRHAGE.'
BY
F. SAVARY PEARCE, M.D.,
of Philadelphia.
Professor of Nervous and Mental Diseases, Medlco-Chlrurglcal College
of Philadelphia; Neurologist to the PbiladelphTa
and to the Howard Hospitals.
By the prefix "epi" we refer broadly to addi-
tional or secondary plienomena in the course of dis-
ease, and in particular to disease as indicated by the title
—Cerebral Hemorrhage — around which there hovers a
degree of inaccurate tracing of symptomatology from the
earliest pathogenesis to the apopletic attack itself; and
indeed, in the remote symptoms following paralysis. It
is to emphasize the due recognition of the apopletic
state by the physician and the insistence upon the care
of, and by the patient, so that this serious disaster to the
central nervous system may be the more frequently pre-
vented that the subject is brought before this Society.
If this lesion, which is constantly growing among
active Americans, is to be at all lessened, it will be
necessary to enforce essentials for your consideration,
and this will entail the rehearsing" of a considerable
number of facts, wellknown, but frequently unheeded.
//ererf%.— There can be no doubt that hemorrhage
into the brain has its hereditary side, and this should be
studied closely in families in which such disease has
been found, that we may be able to enjoin care upon the
succeeding generations so predisposed — if we may use so
strong a term. Therefore, in persons after 40 who have
a family history of apoplexy, it is important to guard
the arterial system in every way. The vulnerability of
the vascular system in these persons is too patent to
nee<l defense; we simply wish to urge the necessity for
recognizing the facts, since treatment now is of vital
importance. The anatomic side to apoplexy needs care-
ful study in regard to stature, for undoubtedly a person
with a short neck and sanguineous temperament is more
liable to rupture of the lenticulostriate artery, for exam-
ple, than one who has small bloodvessels, along neck,
and is of less plethoric diathesis.
Prodroine.t.— In a man of 40, who has repeated
attacks of dull headache (" throbbing " in nature) asso-
ciated with florid ty\Hi of constitution, no matter whether
jmlse tension is high or not, we have reason to believe
that the vasomotor system in the brain is at fault;
l)aretic dilation of the bloodvessels is occurring and the
" breaking strain " is nearly reached on many occasions,
particularly after excesses in eating or drinking. We
have all frequently setui cases of the following type:
A man ot good physique overindulges in food or alcohol
and then complains of headache and sick stomach next
day, both of which are indices to the scientific medical
man for a crisis that will come in due time with these
oftrepeated congestions.
It was Dr. Charles K. Dana who made the statement
last year that the average limit for any human body is
3,000 alcoholic intoxiaitions. lam certainly convinced
that one or a hundred intoxications are too much for the
normal function of the brain antl its circulation, and that
each time tht! brain beci)mes so engorgwl we have ten-
dency toward cerebral hemorrhage. No physician should
doubt this who reads upon the face of a debauched that
grosser sign of a congested facial dermis, the aftermath
of a " night out." It is a sad picture to me personally,
for 1 seem to see the microscopic condition going on in
the liighest structure of the Ixxly — the nerve cell — and
the resultant malnutrition of the vasomotor system,
> Itead by Invitation l>efore the Lelninnii c.miiv Moiliciil Hix-let-y,
at r^ebanon, Pa.. May IS, 1002.
220 AMEEicAN MEwciNBii EPIPHENOMENA OF CEREBRAL HEMORRHAGE
[August 9, 1902
which in turn permits arteriosclerosis and fatty change
in the vessel walls, tending toward the sure approach of
apo|)lexy. I do not wish to moralize or preach a ser-
mon, but simply to give the scientific facts of the case of
the surrounding ("epiphenomena ") signs of apoplexy.
That one person undoubtedly resists the physical and
mental effects of acute alcoholism more than another is
true ; but I can find no statistics to oppose the fact that
thase same individuals prone to excesses are more
invulnerable to arteriosclerosis, inflammation of serous
membranes and liability to autointoxication from dis-
turl^ed metabolism — in fine, an increasing vicious patho-
logic circle with premature senility or early death from
apoplexy. How many tirces have you seen the
"healthy" man, described by the laity and quietly
presumed to be so by the physician, carried ofl' suddenly
by heart failure, socalled, cerebral congestion, throm-
bosis, embolism or apoplexy? No such man was well, in
scientiflc terms, for months or years preceding his demise.
I wish to emphasize the points rehearsed above, for
it is here alone that degeneration of the nervovascular
system may be prevented ; after the typical present pro-
dromes, which we all know so well, the danger line has
been surely passed. When vertigo, a high blood count
of the red cells, catarrhal gastritis, congestive headaches,
forgetfulness, hardened arteries are combined, we may
or may not save the patient by conscientious statements
of the facts to him, although we are exempted from
blame if he does not submit to the treatment we will
surely recommend and carry out for the just mentioned
symptom complex. As to treatment here the abandon-
ment of venesection at the present day is to be regretted,
for I have seen in my own practice cases in which the
patients who were plethoric and presented the signs just
rehearsed were greatly relieved upon withdrawing a pint
or more of blood, and the apopletic attack was undoubt-
edly prevented. Of course all other methods should be
enjoined, such as attending to the emunctories, especially
the kidneys, and to be on the sharp lookout for insidious
nephritis, a malady frequently simulating apoplexy.
Epiphenomena of Attack. — Some other surrounding
symptoms in the attack of apoplexy itself are worth while
emphasizing, e. g., the great arhythmia of the heart and
disproportionate high temperature on the paralyzed side
of the body in cases of hemiplegia following apoplexy ;
also the continuance of the extreme mental depression
or irritability with lacrymosis predominating as impor-
tant phenomena indicating a greater gravity of the case.
In these cases it seems to me
that the trio of dispropor-
tionate prominentsymptoms
mentioned only show the
profound affection of the
nervous system, whether it
be due to size or extent of
lesion or to the vitality and
resisting power of the p;i-
tient. Another important
point in prognosis, even
when neither the "attack "
or motor palsy of hemiplegic
type are prominent, is that
if sensory paralysis persists
on the palsied side we have
a surer indication of greater
extent of lesion at the parie-
tal lobe, a greater disorgani-
zation of the cerebrum, there-
fore, and the chances of
fatality greatly increased.
Another very important outstanding symptom to be
looked for both in the attack of apoplexy and following
the paralysis is the occurrence of acute or chronic
Bright's disease, from the diagnosis of which the disabled
cerebrum may be thus the more damaged and death
supervene if the kidneys fail, which they are much more
liable to do than in Bright's disease alone. I should
like to speak also of attacks of pseudoapoplexy due to
nephritis alone, of which I have seen several cases at the
Philadelphia Hospital this winter. We found a definite
nephritis and a definite hemiplegia with the history of
an "attack" socalled. At autopsy there was found
absolutely no organic lesion of the brain, although men-
tal symptoms of aphasia and hemiplegia point posi-
tively to cerebral intoxication on one side of the brain,
due no doubt to combined toxemia of the cortical neu-
rons and the "wet-brain" or edema from Bright's
disease. Such a condition may occur in other parts of
the body. The urine is to be carefully studied, there-
fore, as an epiphenomenon in apoplexy, since in an
irregular attack accompanied by Bright's disease the
prognosis of the paralysis will be good in proportion as
the nephritis will be amenable to curative treatment.
I have a case under treatment at the present time.
The patient is a woman who two years ago had an
attack of hemiplegia on the left side from which she re-
covered absolutely in a few months. ' Two weeks ago
she developed hemiparesis on the right side of the body
accompanied by motor aphasia, the urine was laden
with granular casts and albumin. This palsy has also
about disappeared, although the progress of intestinal
nephritis is well advanced and the pericardium inflamed
from the uremic poison.'
The occurrence of hyperpyrexia following in the late
clinical course of cerebral hemorrhage is frequently due
to disturbance of the heat regulating centers in the cor-
pus striatum when not due to a bronchopneumonia
from which so many perish. Sese accompanying chart
illustrating this point. In this case it will be seen the
temperature mounted to 107° F., and exacerbations to
104° and 103^ occurred on two separate occasions.
We would like to mention the possibility of the x-ray
being a favorable adjunct toward determination of blood
clot within the brain or not as a point in diagnosis
between hemorrhage or thrombosis and this confusing
class of Bright's palsies. In a case coming to autopsy at
the Medico-Chirurgical Hospital ten days ago. Dr. M. K.
Kassabian had been fortunate enough to find what he
thought was a " shadow " of the thrombotic area in the
left lenticulostriate area region, and this proved to be so
at the postmortem examination. In the case, however,
there was no complication of nephritis in making the
clinical diagnosis.
Epiphenomena FoUoicing Apoplexy.— ^o matter how
Fig. 1.
apparently well the patient becomes after cerebral hem-
orrhage, it should be enforced that he is a disabled per-
1 since writing this paper the woman died. The pathologle con-
ditions described were found, and in addition a small hemorrhage into
pest part of internal capsule and optic thalamus, proving association
of nephritis and cerebral hemorrhage.
August 9, l'M2]
SECONDARY ANEMIA
IAmkbican Medicine 221
son and should be most cautious in conserving energy,
especially of brain work. I have seen cases brought to
an untimely end by the endeavor to keep at the regular
employment of the mind, thus producing acute neuras-
thenia, symptoms of irritability and finally early pro-
gressive dementia. It is needless to emphasize the
regime to be carried out in the average postapopletic
state, except to recall the necessity for undue care when
the muscular element of the heart sounds is enfeebled,
indicating fatty change, or when the endocardium or
universal arteriosclerosis exists. I beg to remind you of
the great necessity for interrogation as to specific disease,
since these are the most fortunate cases in prognosis
through the persistent use of the iodids and mercury
bichlorid. The sorbefacient effect of the iodids is of much
value, even in cases of thrombosis, embolism or acute
hemorrhage, and when the pulse tension remains high
of ameliorating this most unfortunate condition I will
be repaid for the endeavor. I firmly believe that only
by such study alone will the percentage of cases be
reduced and amelioration of the attack be obtained.
10, IHOl.
Kij? 2.
with fairly good bodily nutrition. Occasional venesec-
tion will be of value, too, in preventing relapse, the possi-
bility of which is never to be overlooked, but attention
may be given with decreasing frequency until the fifth
year aft<^r the "stroke." The patient with fairly good
arteries and nutrition passing this time limit will prob-
ably survive many years with the hemiplegic disability,
providing the greatest care in hygiene is maintained.
The frequent use of Kissingen or Carlsbad salts for these
persons is of great value through its depleting effect
upon the overloaded bloodvessels. The use of nitro-
glycerin is also of value, as is static electricity through
the dilating effect upon the vasomotor system and the
conse(|uent relief of embarrassment to the circulation.
The painful condition in the paral.yzed parts in post-
apopletic patients which is due to an arthroneuritis, can
also be much relieved by initssage, hot baths an<l the
Swedish movements, accompani(>(l by the long spark of
the static current.
Ther(> are many other points which might be men-
tione<l iLs epiphenomena of importance in the disease
under discussion, but thos<' discussed seemed of the
most practical value to bring to your consideration.
If this contribution will have some influence toward
eiicouragingstudy of detail in individual csLsesasa means
A CASE OF SECONDARY ANEMIA OF THE PER-
NICIOUS TYPE ASSOCIATED WITH MARKED
JAUNDICE : RAPID RECOVERY.'
BY
ELEANOR C. JONES, M.D.,
of Philadelphia.
Member or the Medical Staff of the Woman's Hospital of Philadelphia.
Miss L. M., aged 25 years, a native of Germany, was
admitted to the Woman's Hospital of Philadelphia on Jannary
iA i,,r., fjgp family history was good. Her father, mother,
three brothers, and one sister are
all living aud well. Her personal
history was also a good one ; she
had not suffered any of the usual
iliseases of childhood. The only
illness of her childhood was an
attack of pneumonia when she
was ten years of age. She had
been well and strong up to the
time of her present illness, and
on her admission to the hospital
presented the appearance of a
person of unusual vigor. On ad-
mission she gave the following
history of her present illness :
She began to feel ill about four or
five weeks ago ; she felt weak and
tired, so that she was scarcely
able to work ; but she continued
at her occupation, that of a do-
mestic, until one week ago, when
she was compelled to go to bed,
because of the aggravation of all
her symptoms. She now had
severe pain in her back and
limljs, and also in the region of
the greater cxirvaturo of the
stomach; she also liad headache,
and her tongue became much
coated, and her bowels showed
the general alimentary disturb-
ance and became irregular, alter-
n a t e 1 y constipated and loose.
.Jaundice developed about one
week before admission to the
hospital. She had a slight chill
on .January 6, and also on Jan-
uary 7.
The case presents a history
of catarrhal jaundice, follow-
ing gastroduodenal catarrh.
The first evidence that the catarrh had involved the
bile ducts was in the jaundiced hue of the skin and
visible mucous membranes. A thorough examination
of the patient was made on her admission on January
10, and the following notes were made :
Skin shows a jaundiced hue, and is dark yellow; mucous
membranes and conjunctivas also yellow ; she complains of
pains in the left inguinal region, and some resistance is felt on
deep pressure at this point. There is an absence of tenderness
in the hepatic region and also over the gallbladder. The area of
liver dufness is slightly diminished; the lower edge of the
liver extends to one-half inc^h above border of ribs; no enlarge-
ment of the spleen is present; abdonion distended and tym-
panitic ; the pulse is slow and small, and of high tension— about
75 per minute; temperature, 9!».2° ; respirations, 20 per minute ;
stools sometimes yellow and sometimes clay-colored, and
always partly formed, rrinalysia shows color to be reddish-
brown and cloudy; specillc gravity, 1,01(1; no albumin or
sugar j)resent ; urea. i.O<ft> ; microscopically, epithelial cells,
also bile pigment and a few white and red blood-colls.
At this time the ca.se seeme<l to l)e one of ordinary
catarrhal jaundice, and treatment for that condition was
instituted accordingly.
From January l.'t to January 27 the stools remained clay-
colored, and the temperature remained below 100°. From
I Head at the Annual Meeting of the Alumns AMOoUktion, Woman'*
Medical Coll«Ke of Penniylvanla.
222 Ahebioan Medicink)
SECONDARY ANEMIA
[AUGOST 9, 1802
January 27 the temperature began to rise, and from Janu-
ary 27 to February 13 the temperature showed a range
from 10()° to 103.4°, and after January 27 the patient's condition
became rapidly and decidedly worse. On January 29 the icteric
hue of the sltin became deeper, and the urine was nearly black
in color, and also contained albumin, but no easts. The stools,
however, occasionally showed some yellow or green tinge,
showing bile was passing the common duct; but, as the jaun-
dice continued deepening and the temperature rising, the
catarrh was probably extending to the intrahepatic ducts. She
also developed an attack of urticaria, which lasted several days,
and she began to have frequent epistaxis. On January 31 a
careful physical examination showed the area of liver dulness
to be normal, and that there was no tenderness in this region,
but that the spleen was somewhat enlarged. On that day she
vomited a quantity of bile-stained fluid, which would show
that the common duct, which empties into the duodenum, was
not entirely closed, and so the bile could regurgitate into the
stomach.
The patient now seemed very ill, and the most extreme
depression and relaxation were present. On February 1, Dr.
Adelaide W. Peckham, director of the clinical laboratory of the
Woman's Hospital, made an examination of lier blood, and all
of tlie subsequent examinations of the blood were made by Dr.
Peckham. The blood showed: Red corpuscles, 2,068,750;
hemoglobin, 32^(, ; leukocytes, 3,914. The differential count of
the white cells showed: Small lymphocytes, 13%; large
lymphocytes, 13% ; polymorphonuclear, 72% ; eosinophiles, 1.4%.
The blood, however, at this time sliowed only a considerable
degree of anemia but no pernicious features. Tlie red cells
showed degeneration by varying in size and shape, and also by
taking up the nuclear stain. They were lessened considerably
in number. The white cells retained their normal proportions
to each other, but were lessened as a whole. Large quantities
of bile pigment were seen In the blood preparations.
On P^ebruary 2 a green tinge was apparent in the skin, and
this bronzing of the skin continued and deepened for over a
week. Osier says that the greenish-bronze color, such as
existed in this case, is never seen in simple catarrhal jaundice,
and such tints generally indicate an unfavorable prognosis.
On February 2 the patient was given 10 grains of calomel,
and this was followed on February 3 by magnesium sulfate, one-
half ounce.
A blood count was again made on February 3, two days
after the first count, but it now showed the most surprising
changes, as follow: Red cells, 1,087,500; leukocytes, 13,266;
hemoglobin, 22%. Here was a loss of over 1,000,000 red cells per
cubic millimeter in two days, and a rise of the white cells from
3,914 to 13,266, showing a considei-able degree of leukocytosis.
I do not think this very rapid diminution in the
number of red eelLs could in any way be associated with
the one large dose of calomel, for already, before the
administration of the calomel, the spleen « as enlarged,
the color of the skin a very deep jaundiced hue, and the
temperature high. I think it is likely that the red cells
suffered rapid destruction, consequent on the absorption
of the bile acids into the blood, for physiology lias shown
that these acids possess the power of destroying blood-
corpuscles.
The stools on February 3, following the first dose of
calomel, were bright yellow (a burnt-sienna color) and
green, also the urine became lighter in color, but now
contained blood-stained casts. The jaundiced hue of the
skin became temporarily slightly less marked.
Dr. Peckham at this time made a careful examination
of the feces in search of possible ameba, but with nega-
tive result. An examination of the urine at this time
gave the indican reaction.
On February 5, after having had 10 grains of calomel on
three successive nights, followed bv salines, and daily high
rectal enemas of cold saline water, she showed symptoms of
salivatKm, and her general condition also was very bad. She
seemed threatened with heart failure, despite vigorous stimu-
lation with strychnin, digitalis, and oxygen by inhalation. The
blood examination now showed still further degenerative
changes; a stained specimen showed verv marked leukocyto-
sis; the neutrophiles varied much in size; the nucleated r^ d
cells were quite abundant. The red cells were extremely de
generated and diminished in number (930,859), showing marked
poikilocytosis; also many megaloblasts were seen, and one
myelocyte, and the bile pigments were still in the blood.
Here are all the changes of the red cells that are seen
in pernicious anemia : the marked diminution in num-
ber (under 1,000,000), the altered size and shape, also the
nucleated red cells and many megaloblasts. Ehrlieh has
shown that megaloblastic blood is one of the significant
features of the blood in pernicious anemia. There is
also recorded by Dr. Peckham the occurrence of a few
myelocytes in this blood. The occurrence of the myelo-
cytes of Ehrlieh in the circulating blood is always to be
looked upon as pathologic, for it is the intrusion of
white cells normally found only in bone-marrow, and
Cabot as<;ribes their presence to an acceleration of the
function of the marrow. They indicate a very grave
anemia, though not necessarily a primary pernicious
anemia.
On February 6 the symptoms of salivation were marked,
although it may be that the stomatitis and hemorrhagic gingiv-
itis which developed were partly due to the blood condition,
for it has been reported that such conditions of the mouth are
common in pernicious anemia. The symptoms present were as
follow: Ulcers on the buccal surface, lips, and gums; the
tongue was swollen and covered with a heavy fur, and the
breath was extremely fetid ; the saliva ran coii.stantly from the
mouth, and the teeth and mouth were so tender that it was im-
possible for her to eat any solid food; also the submaxillary,
sublingual, and parotid glands were swollen and tender.
On this date the splenic area was found considerably in-
creased, extending to the nipple line anteriorly, and to the cos-
tal margin inferiorly. The liver was aLso enlarged, extending
one inch below the costal margin in the nipple line. The exam-
ination of the heart showed a loud systolic murmur at the
l)ase, and that the left ventricle was slightly dilated. Her vision
was not at any time affected. The urine showed the diazo reac-
tion for the first time, and continued giving this brilliant reac-
tion for several weeks, showing that the proteid bodies that are
present in typhoid fever and a number of other acute infectious
diseases were also present in this case.
Her mental condition was that of a low typhoid state ; mut-
tering delirium or sometimes coma vigil existed.
The blood showed its maximum changes on February 8,
when the count was reduced to 772,333 red corpuscles, and the
white corpuscles increased to 71,400, and the hemoglobin was
only 20%. The skin also on this date showed its most marked
greenish tint.
From this time the patient began to improve, and in two
days gained over 1,000,000 red corpuscles per cubic millimeter
and 10% hemoglobin, and the white cells were reduced to
16,066. The blood changes continued to undergo rapid improve-
ment, and her other symptoms continued to abate rapidly. On
February 2(i it was noted that only a slight icteroid hue of con-
junctivas, hands, and abdomen remained. On March 13 she was
discharged, a well woman, and with a blood condition that was
only slightly below the normal.
Red cells
Hemoslobin
Nucleated reds
Megaloblasts
Leukocytes
Differential count:
Small lymphocytes.
Large lymphocytes.
Hoiymorplionuclear
Eositiophiies
Transitional
Small mononuclear.
Large mononuclejir.
Myelocytes
Feb. 1.
2,068,750
32;<
3,914
l:^;i
iS't
1.3'i
Feb. 3.
Feb. 6.
1,087,500 930,859
marked
poikilo-
cytosis
22;i 25';
lto34
whites
lto3
normo-
blasts
li),C6:; 21,300
7.1^
4 :ii
8.2;f
4«
3-;
'j^j^^z ' ""'ill
i
Feb. 8.
772,:i"!3
20*
71,100
Feb. 12.
1,930,859
30^
1 to2«
whites
1 to2
nornio-
bla.sts
16,0(i(i
87.5;«
3.42;*
S.4)t
8;f
Feb. 14
Red cells 1 1,743,750
I
Hemoglobin . ...
\\'hite cells
Nu leated reds..
Megaloblasts.. .
Leukocytes
Neulrophlles ...»
Polymorphonuclear..
Transitional
Small mononuclear...
I<arge mononuclear...
Myelocytes
B^jsinophiles
1 to46
whites
1 to 7
normo-
blasts
23,739
83.6^
6.2r.
4.8ji
3 seen
Feb. 18.
2,195,355
5!<
12.400
Feb. 21. ; Feb, 28.
2 542,386
60;;
3,014,843
(improved
appeai>
ance)
80',
8,6.50
75.9
2 0';
17.3*
4.25-,
Mar. 13.
3,031,250
8,ltO
0.6;;
In looking over the literature of secondary pernicious
anemia I can find the re cord of but one case associated
August 9, 1902]
ETIOLOGY OF MUCOUS COLITIS
lAMEKICAN MeDICINB 223
with jaundice. Thiis case is one reported by Dr. Byrom
Bramwell in the lAincet (London), 1897. This case as
reported seems similar to my case in its clinical history,
blood changes, and favorable result.
The preceding table shows the blood changes in
detail.
These changes indicate a most severe or pernicious
type of anemia. The primary condition was catarrhal
jaundice, and the anemia developed as a secondary con-
dition. Cabot has drawn attention to the main features
marking a case of primary pernicious anemia from a
secondarv one, as follows :
Primary pernicious
anemia.
Severe secondary
anemia.
Red cells
About 1,000,000.
Usually decreased.
Often relatively high.
Constitute tlie majority
of the nucleated red cells.
Less numerous than
megaloblasts.
Increased.
Increased.
Decreased
Common.
May be 1,000,000 or less.
Relatively low.
Megaloblasts
Normoblasts
Size of red cells
Lymphocytes
Polymorphonu-
clear cells
Rare : never more numer-
ous than normoblasts.
Common.
Various ; not increased.
Usually diminished.
Usually Increased.
Rare.
This case is interesting because of the remarkable
rapidity with which the very alarming symptoms and
grave anemic changes in the blood developed, and
because of the equal ra[)idity with which restoration was
accomplished. She was admitted to the hospital Janu-
ary 10, and was discharged after an illness of only two
months, the blood in that short time having undergone
deterioration to a point that gravely threatened exist-
ence and having afterward become so nearly perfect that
on her discharge from the hospital on March 13 all the
functions of life were properly and easily performed.
This ca.se is also interesting and unusual because of
the grave and pernicious type of anemia and other
severe constitutional symptoms following in a case
beginning as a simple one of catarrhal jaundice.
A CONSIDERATION OF THE ETIOLOGY OF MUCOUS
COLITIS.'
BY
JOHN A. LICHTY, M.Ph., M.D.,
of Pittsburg, Pa.
3Iucous colitis, or membranous colitis, is a condition
of the large intestine characterized by the passing of a
peculiar formation of mucus, sometimes retaining the
shape of the bowel, but oftener being in the form of so-
called mucous shreds. The passing of this mucus is often
preceded by, or accompanied with, cramp-like pains in
the lower abdomen. The individual suffering with this
condition is usually of a neurotic; temperament.
The examination of the mucus, microscopically and
chemically, has thus far not given a .satisfactory idea
of the condition of the mucous membrane which will
excrete such a substance in such a form. Neither
have there been constant findings in the few cases
which have come to autoi)sy. In two ca.ses which
have been clinically studic^d and followed by autopsy —
that of O. Itothman and Huge, and that of M. Ilothman
— no anatomic change wa.s found in the intestinal tract
of one patient, while in the other a decided catarrhal
condition was demonstratetl. In two cases studied by
llenimeter no histologic evidence of any inflammation
could U- found. (" Diseases of the Int<;stintw," Hem-
meter, V^ol. I, p. 485.) The pathology of this disease is
not yet established. Speculation as to the cause of
mucous colitis has been rife ever since the condition was
' Read before the American Gastroonterologlc AMgociation, at
Washington, I). C, May I, 1902.
first described by DaCosta in a most interesting paper in
the American Journal of Medical Science in 1871. He
concluded that it was of nervous origin. Others,
especially French writers, held that it resulted from a
slight superficial catarrh. Subsequent writers have
adopted one or the other view. A few have held a
middle ground.
From a clinical standpoint it is not inconceivable
that a case may in the early stages have only a func-
tional disturbance, and as the perversion of function con-
tinues a pathologic lesion may supervene. But grant-
ing that such a sequence does occur, it still remains to
determine the cause of so decided a perversion of physio-
logic function. Dififerent causes may produce identical
changes in the function of an organ. The mucous mem-
brane of the bronchial tubes, for example, may become
congested as the result of various causes, direct or indi-
rect. No doubt a number of conditions may be respon-
sible for the formation of the mucous casts in mucous
colitis. A review of the literature upon this subject
shows that writers have generally agreed upon certain
causes, but each has advanced some particular condition
as the chief cause, and ha.s spoken of the others as con-
tributing causes. Among these conditions may be men-
tioned obstinate and habitual constipation, fretiuent
attacks of diarrhea, the continued use of enemas, the
continued use of cathartics ; coloptosis, and such nervous
conditions as hysteria, neurasthenia and hypochondri-
asis. As was before stated the patients suflfering from
this condition are usually of a neurotic temperament,
but it is doubtful whether the existing neurosis is at any
time a direct cause. Certainly in a great number of
cases the neurosis seems to be secondary to a previously
existing mucous colitis. No doubt each of the conditions
mentioned is now and then associated with the real
cause, but it can not be insisted that any one alone is
always the cause. Clinical evidence will not support
such a position.
It is only after such a preliminary statement that I
venture to call attention to a condition which I think is
directly causative of the formation of the peculiar mucous
casts and shreds which are so characteristic of mucous
colitis. I refer to a condition of mechanic hypostasis
which I believe is often if not always present in these
cases. To state my position more clearly, I will say
that I believe that the condition of ptosis of one, several
or all abdominal viscera, causes among other disturb-
ances a hypostatic congestion of the organs in the lower
abdomen and pelvis, and that while in this condition the
mucous membrane of the large bowel excretes mucus in
the form of casts and shreds.
The idea of mechanic hypostasis in ptosis is not new
or original with myself. 1 think those who have
recently written upon the ptoses of the abdominal vis-
cera have had it in mind, but I do not know that any
have referred to it as an immediate etiologic factor in
mucous colitis. I am fully aware that Glenard and
numerous other writers have called attention to the
relationship between coloptosis and mucous colitis but I
do not know that they have, in their observations, in-
cluded the ptoses of the other abdominal organ.s, nor do
I know that they have referred to a hypostasis, which
certainly exists in the.se cases, as the immediate cau.se.
I have come to this conclusion Inn-ause a large jwr-
centage of patients with mucous colitis have ptosis of some
or all of the abdominal viscera, because the pelvic organs
and contents of these patients reveal a state of conges-
tion, and beaiuse interference of the blood supi)ly. of at
least a part of the large bowel has often been ol)sc»rved
in cases of ptosis when the abdoniinul cavity was
opened.
Among 21 cases of mucous colitis I have found a con-
dition of ptosis in 16. In these H! the ptosis was of one
or both kidneys, plus ptosis of one or more of the other
abdominal organs. Four of the other cases were under
observation prior to the time my attention had first been
224 American Medicine]
ETIOLOGY OF MUCOUS COLITIS
[AnacsT 9, 1902
directed to splanL-hnoptosis. It is poasible tliat I may
liave overlooked the condition. If it is safe to base any
conclusions upon this observation, it might be said that
at least 80 f, of ail patients with mucous colitis have ptosis
of the abdominal viscera. Upon examination of the pelvic
organs there is every evidence of a state of congestion.
The uterus is usually enlarged ami displaced, the ovaries
are congested and prolapsed, the hemorrhoidal area is
congested, often there are hemorrhoids. The symptoms
referred to these organs are significant. This condition
is no doubt due to a disturbance of the circulation. It
is caused by the descent of the organs in the funnel-
shaped abdominal cavity. They are crowded together
upon the pelvic organs. There is torsion of the veins
and arteries, beside abnormal pressure upon them.
This favors congestion of the mucous membrane of the
large bowel, there is disturbance of function, and mucus
is Gxcrcted.
Attention has been called by Edebohls to a relation
between right movable kidney and appendicitis. The
pressure of the prolapsed kidney interferes with the
circulation of the appendix, which becomes congested,
catarrhal and the seat of inflammation. Whether this
view is correct or not, there can be no doubt that a gen-
eral prolapse of the abdominal organs produces a decided
disturbance of the circulation, together with a disturb-
ance of function of those organs.
That this sequence really occurs will be seen from a
case which I now report :
Case V.— Miss A. E., aged 31, consulted me first in Decem-
ber, 1897. She gave a family history of nervousness. There is
insanity on both the father's and mother's side. Nine years
ago the patient was thrown from a horse, and she has not been
well since. Her symptoms were first referred to the pelvic
organs, and at the end of three years of vmsuccessful medical
treatment it was decided to give her local pelvic treatment. A
year later a curetment and amputation of the cervix was done.
Two years later tiie right tube ^nd ovary were removed. These
various procedures were undertalien as the patient went from
one physician to the other, finding no relief. About the time
the first operation was performed the patient began to pass
mucus from her bowels. Its passage was preceded by intense
pain and cramps in tlie left inguinal region.
At the time this history was talseu the patient complained
of loss of appetite, pain in the stomach after eating, eructa-
tion of gas and food, nausea, irregularity of the bowels, and
attacks of crami)-like pains, followed by the passing of mucus
from the bowels in the form of casts and shreds. She also
complained of headache, pain in the lower part of the back and
along the left costal border. All of these symptoms she re-
ferred to an offending left ovary, which still remained.
The patient weighed 9i) pounds. Her maximum weight
which she had reached a year ago was 115 pounds. Slie was
nervous, apprehensive, and at times much depressed. Every
week or 10 (fays the bowels became constipated, much uric acid
appeared in crystal form in the urine, cramp-like pains began
in the left inguinal region, and finally a diarrhea. The stools
contained well-formed casts of mucus. As the diarrhea sub-
sided the casts gave way to shred-like mucus, which disap-
peared as the stools became regular.
Upon physical examination I found the heart and lungs
normal. The abdominal muscles were flabby and relaxed.
The stomach was moderately dilated and prolapsed, and the
right kidney freely movable. The pelvic organs were in
normal position, but hypersensitive. The rectum was con-
gested. There were no hemorrhoids.
The urine was scant, highly colored, and contained a heavy
deposit of uric acid crystals. There was a decided indican
reaction. There was no albumin or sugar. The blood was
normal. The stomach contents, after an Ewald test-breakfast,
were practically normal.
With the aid of massage, electricity and a forced diet con-
sisting mostly of fat-producing foods, the patient gained 29
pounds in weight. The symptoms of m ucous colitis disappeared .
The stomach was normal in position and size, and the kidney
was still palpable.
I fitted a suitable bandage to the abdomen with the hope of
keeping the kidney from being a source of irritation, and sent
the patient to the country for six months. Upon her return I
found that she had lost 20 pounds, and that some of her symp-
toms had returned. I'pon my advice she consulted a surgeon,
who decided to do a nephropexy and an exploratory celiotomy.
When the abdominal cavity was opened adhesions were encoun-
tered which bound the omentum and the bowels to the anterior
abdominal wall. They were thickest about the scar of the
former section and were highly vascular. The veins of the
mesentery were full and tortuous. The left ovary was con-
gested and contained a few cysts. These were punctured, the
adhesions broken up and the right kidney stitched into its
place. The marked congestion of the abdominal and pelvic
organs and tissues was thought to be due to the prolapse of the
organs.
If there is such a relation between splanchnoptosis
and mucous colitis as I maintain, the question will nat-
urally arise, why are there so many of the former cases
when there are so few of the latter? Among 2,558 con-
secutive examinations of men, women and children, I
have found 313 cases of splanchnoptosis, 41 males and
272 females. Only 21 of these 2,558 patients examined
had mucous colitis.
1 think I his question can be satisfactorily answered.
It is well known that not infrequently during the exam-
ination of a patient a condition of ptosis is found with-
out any symptoms having been referred to it. In such
cases there has been established what may be called a
condition of perfect compensation, and physiologic func-
tion has not been disturbed. The condition is analogous
to the compensation which is establislied in the circu-
latory system when there is disease of the heart or of
the kidneys, and no symptoms are present. When,
however, this compensation is lost or disturbed, the
symptom-complex of mucous colitis appears.
As a case illustrative of such a course of events I give
the following history :
Case XIX.— Miss M. W., aged 15, consulted me first in
February, 1902. She had been perfectly well until nine months
ago when she had a severe attack of tonsillitis. Following this
attack she had alternate constipation and diarrhea. Long
mucous casts and shreds were noticed in the stools. She
recounted the typical symptoms of mucous colitis. She has an
older invalid sister who, at tne age of 12, had an illness which
began with similar symptoms. At various times since she
has liad a curetment, an Alexander's operation and a nephro-
pexy.
Upon examination of my patient I found the stomach
dilated and decidedly prolapsed, the right kidney was freely
movable and the lelt was palpable, the uterus was retroverted
and the rectum was decidedly congested
The urine contained a trace of albumin but no casts. The
blood showed a condition of anemia. The stomach contents
were hyperacid, and the starch granules were poorly digested.
Some of the mucous casts recovered from the stools were over
40 inches long and very thick and tenacious.
This patient evidently had a congenital splanchnc
ptosis, but had perfect euphoria until she had tht
attack of tonsillitis. With this attack, compensation
was disturbed or lost and the symptoms of mucous colitis
appeared. Such cases are not at all rare. The symp-
toms in this case appeared rather suddenly, for there
was no mucus noticed in the stools previous to the
attack of tonsillitis. This does not always obtain, for in
some there is a history of having passed shreds or clumps
of mucus before the typical symptoms appeared. It is
probable that this mucus is an evidence of a disturbance
of the compensation which I have suggested. In 31 of
the 313 cases of splanchnoptosis I found that occasionally
there was stringy mucus, though the symptoms of colitis
were not present.
It is beyond the scope of this paper to enter into a
consideration of the etiology of splanchnoptosis, though
such a consideration would naturally follow if it plays
the role in mucous colitis which I have suggested. Of the
313 ciises to which reference has been made, a large
number were due to unhygienic methods of dressing,
such as constriction of the waist by too tight clothing
and suspension from the waist of too heavy clothing. An
equally large number were congenital, and the remain-
ing few were due to traumatism, frequent pregnancies,
emaciating diseases, etc.
Of the 21 cases of mucous colitis which form the basis
of this paper, 17 were in females, and 4 in males. The
males all had splanchnoptosis. Two patients traced the
beginning of their disease to an attack of typhoid fever.
I found this to be the case with two other patients whose
cases are not included in this paper. All of these cases
following typhoid fever were in patients who had
splanchnoptosis. Five patients were decidedly lithemic,
AUGUST 9, 1902]
SALSOMAGGIORE
American Medicinf 225
one of them having had several severe attacks of
acute articular rheumatism. In all of these cases there
seemed to be some metabolic disturbance with the pass-
ing of mucus. There was with it always a heavy
deposit of uric acid crystals in the urine, the amount
depending upon the severity of the spasm. In all of the
21 cases there seeme<l to be an abnormally large amount
of indican in the urine. The gastric secretion was
studied in 8 patients ; in 4 it was hyperacid ; in 2 it was
normal ; in 1 it was hypoacid, and 1 patient had achylia.
SPFCIAL ARTICLES
SALSOMAGGIORE.
HV
<;. SANDISON BROCK, M.I)., Edin. and Rome., F.R.S.E.
English Physician to the Magnaghi Baths, Salsomagglore.
SITUATION' AND SURROUNDINGS.
It may prove useful to medical men in America, many
of whose patients have already visited Salsomaggiore, to
have placed before them a few facts vpith regard to this
rising Italian watering-place and the claims which are
made on behalf of its waters as therapeutic agents. In
Italy the healing properties of these saline springs have long
been recognized and widely utilized by a yearly increasing
throng of health seekers from all parts of the peninsula, but it is
only within the last year or two that their reputation has begun
to spread beyond its borders and to attract visitors from other
countries. This extension of its fame Salso owes chielly to the
energy and enterprise of a few commercial men, who perceiving
its great possibilities, have expended much capital in provid-
ing it with the comforts and convenience it formerly lacked, as
well as in making known far and wide the unique composition
and character of its waters and the great therapeutic powers
which they undouV)tedly possess. These efforts are already
being rewarded by an extraordinary influx of foreign visitors
drawn mostly from England, but also from neighboring
countries and from America.
The village of Salsomaggiore is situated in the Province of
Parma, not far from the university town of that name. It lies
in one of the valleys opening out from the undulating hills at
the foot of the Apennines on to the great plains of Emilia and
Lombardy, magnificent views of which, with the snow-capped
Alps in the background, are obtained irom many points in the
vicinity. A light railway connects it in .SO minutes with the
main line from Milan to Bologna and Florence at a point
(Borgo San Dounino) about two hours distant from the first of
these cities. It is thus easily accessible to visitors both from
North and South. The altitude above sea level is about 500
feet, the situation salubrious and the surroundings pleasing
and picturesque. As regards accommodation for visitors,
Salso is now exceptionally well off, thanks to the enterprise of
the wellknown hotel proprietors Ritz and Pfyffer, who have
providetl in that respect at the Grand Hotel des Thermes all
that the most fastidious can possibly desire. A special com-
mission recently sent out by the Lancet to Salsomaggiore
r. ports' that the drinking water supplied to this hotel is of
rxieptionally good (|uality and character, and ranks among
the purest potable waters known.
THE .MINKRAL WATERS.
The mineral waters of Salsomaggiore are derived from
a number of deep artesian wells from which they either
rise spontaneously owing to eruptions of gas, or are drawn by
means of pumps. On emerging they have a very constant
temperature of about 20° C, and a density, measured by
BeaumC's aerometer, of about 16° V. ( - sp. gr. 1,119). The fol-
lowing table {vide the Lancet Commission's Analysis, op. cit.)
shows their chemic composition to be of a remarkable kind,
unique, indeed, among waters of the lodo-bromo-saUne class.
'The Lancet Mpeclal Analytic and Sanltory Commliwlon on the
l.Klo-broraii-saline walem of SalHomagglore. The Umcet, July 12, IHtB,
p. 'J4.
Besides the commoner constituents of muriated waters, they
contain, as will be seen, a phenomenal amount of lithium, stron-
tium, iodin, and bromin.
ANALYSIS OF SALSOMAGGIORE NATURAL MINERAL WATER.
(According to the report of the Lnncet Commission.)
Grams per liter.
Sodium chlorid 148.2940
Calcium ehlorid 1.5.2375
Magnesium chlorid 50861
Amnionluni cblorld O.SOO
Strontium chlorid U.50oO
Lithium chlorid O.mii
Strontium sulfate- _ U.486S
Magnesium bromid 0.3022
Magnesium lodid 0.0«64
Ferric oxid 0.1000
Total mineral constituents 160.3129
The oxid of iron is precipitated when the water is exposed
to the air, giving the baths their peculiar and somewhat forbid-
ding turbidity. The lithium chlorid amounts to more than
40 grains per gallon, and the total quantity of this compara-
tively rare salt discharged in one day by all the springs has
been calculated by Professor Nasini, of Parma, to amount in
the aggregate to 500 kilograms, or nearly half a ton. Of the
other important constituents the amount of bromin is nearly 20
grains, and that of iodin over 4 grains per gallon, while the
salts of strontium reach the proportion, probably unparalleled
in any other natural water, of nearly 70 grains per gallon.
The gas accompanying the water in its eruption is composed
of methane and ethane, with heavy hydrocarbons and carbonic
acid. It is collected in a gasometer and utilized for working
the pumping engines of the wells and for illuminating the
town. There also issues with the water a considerable quantity
of petroleum, which is separated from it by simple decantation
and sent to an oil factory to be refined. This oil gives the
waters their characteristic odor ; it contains bituminous bodies
and sulfur, but neither iodin nor bromin. The Lancet Com-
mission, however, discovered a fact which may have great
importance therapeutically, namely, that on exposing the
mixture of water and oil as it comes from the well to light and
air iodin is liberated and afterward partly absorbed by the
petroleum ; further, that when the water is reduced to a very
fine spray, as in the inhalation room, in the presence of light
and air, iodin is also liberated, and traces of iodo-oil are formed
with the oil still retained in the natural water after decantation.
It was also found that when iodin was added to the natural oil
of Salsomaggiore and mixed with water and atomized, the
resulting spray had precisely the same iodous smell as that
which characterizes the inhalation room of the Terme Mag-
naghi. The presence of an organic iodin compound, even in
minute quantities of the spray used for inhalations, may in part
explain the therapeutic effect of that method of administering
the Salsomaggiore water.
One of the saline springs is reserved for the manufacture of
common salt, which in Italy is a monopoly of the government.
The " muttalange" or "acqua madre" which remains after the
extraction of the salt has a density of 32° Beaum^ ( =■ sp. gr.
1,270), and holds in solution in the same volume about 15 times
as much of each salt as is contained in the natural water
(except of the oxid of iron, which is removed before evapora-
tion is begun). It is this "acqua madre," partly deprived of
the excessive quantity of its calcium and magnesium salts,
which is employecl in a dilute<l form for the "getto dlretto" or
spray, an excellent remedy in catarrhal conditions of the con-
junctivas and the upper part of the re8|)iratory tract.
For bathing purposes the temperature of the waters is
raised and their density reduced by means of ordinary fresh
water, a supply of which, hot and cold, is laid on to each l»th.
Both temperature and density are carefully graduated according
to the nature of the case and the tolerance of the patient. Expe-
rience has shown that the success of the treatment greatly
depends upon this system of graduation. The baths are usu-
ally begun at a temperature of .34° or :to° C. and a density of 2°
or 3° lieaunK"', the temperature and density being gradually
Increased to about .38° or .ii)° C. and 10° to 12° B., respectively.
The average duration of the course of baths is three weeks.
The boneflcial effects may msnlfostthemselvos after a few baths
have been taken, or not until near the end of the course, or
226 AUERICAK MeDICINEJ
SALSOMAGGIOKE
lAUGL'ST 9, 1902
agaiu only after it 18 finished. A second course is often desir-
able, and it is found that such a course is most elfective if taken
within six months of the first. Lastly, in certain cases a yearly
visit to the baths is indicated.
The baths may be taken either in one of the three large
bathing establishments or "terme," of which the " Terme Mag-
naghi " are the most modern and best equipped, or at the Grand
Hotel des Thermes, each floor of which is fitted up with baths
for the convenience ol its guests. The Mugnaglii liathing estab-
lisliment, in addition to the baths, has rooms for administering
tlie water by inhalation. Of this two systems are in use, viz.:
the Siegle and Pirey and the Jannigeu and Beiselen. By the
former of these the " acqua madre," at a density of from 1° to
8° Beaumc, is thrown in the form of a spray directly into the
throat of the patient, who is seated with the mouth widely open
in front of the spray-producing apparatus. In the latter method
the natural water (reduced in density to about 8° Beaumfi) is
atomized into a fine mist, filling a large room, in which the
patients, wrapped in white robes with white cowls covering
their heads, may move about freely, chatting with one another,
reading a book or engaging in some form of gymnastic exer-
cise, for which last various kinds of apparatus are provided.
Throughout this model establishment, as well as in the Grand
Hotel des Thermes, admirable precautions are taken to secure
cleanliness, and the most thorough disinfection of baths, linen,
etc., is carried out.
The " Terme Magnaghi " are further equipped with a very
complete electric installation, including a Rontgen ray appara-
tus, Tesla coiLs. electric and electric-light baths, vibratory
machines, etc., by means of which the ordinary bath treatment
can be supplemented in any way that may be desired. There
is also a cheraic and bacteriologic laboratory, uuder the direc-
tion of a medical man. The medical staff attached to the estab-
lishment consists of four "medici ordinarii " (one of whom is
English), whose duty it is to advise patients undergoing the
" cure," and to supervise the hygienic conditions, and of a large
number of consulting physicians who are available for special
cases. There are trained assistauts in attendance for massage,
Swedish movements, etc.
The " season " at Salsomagglore begins in April and lasts
till November. The spring and autumn are the favorite times
for foreign visitors, but the Italians prefer the warmer months
of July and August, in an endeavor to combine the profit of the
bath treatment with the pleasures of the " villegiatura." For
certain maladies there is doubtless also some advantage in
choosing the hotter summer months.
THERAPEUTIC USES OP THE WATERS.'
The uses to which the waters of Salsomagglore are now put,
as well as the methods of employing them, have been largely
determined by the nature and the mode of treatment of the first
few cases recorded by Berzieri, the village practitioner of Salso-
maggiore, to whom the original inspiration came (in 1839) of
utilizing them for therapeutic purposes. The first case in which
he used the baths was one of caries of the bones of the foot, no
doubt tuberculous, and to this day the waters continue to enjoy
the reputation earned by the success of that treatment in a great
variety of tuberculous lesions, whether in bones, joints, glands
or skin. It is, perhaps, chiefly for this class of cases that the
waters are most esteemed among the common peojjle in Italy,
the various communes sending for treatment to the sanatorium
at Salsomagglore batches of patients, mostly of this kind, every
three weeks throughout the summer and paying their expenses.
No better testimony to the efficacy of the waters could be given
than the fact that the same communes, encouraged by the great
benefit derived, continue to send such patients year after year,
and that in many instances these patients return from time to
time of their own accord and at their own expense when
assailed by recurrences of their maladies. No don lit the change
of air and the better food which such patients obtain at Salso-
magglore contribute largely to the success of the treatment in
these cases; nevertheless, they must still be regarded as among
the mo.st promising of those indicated for the Salsomagglore
' For much information on this head I am Indebted to my colleague
at the baths, Professor Zoja.
The alterative, absorbent, and healing properties displayed
by the waters in these scrofulous cases naturally led to an
extension of their use to all afifections where in connection with
a localized morbid process there existed open sores, sinuses,
inflammatory swellings, or exudations. Their beneficent
action in the chronic stages of inflammatory diseases forms,
indeed, the basis of their fame at the present day. In the acute
stages they are generally regarded asoontraindicated (although
this is by no means a settled question), but the acute stage once
over all are agreed that great benefit is derived from their use in
such affections. In cases ofappendicitis where a certain amount
of pain and swelling remain after an acute attack or where an
abscess has been opened or has burst leaving painful adhesions
or exudations behind in the neighborhood of the colon the
absorbent and healing effects of the baths are often very remark-
able. For sequels of peritonitis, of plevirisy, and of synovitis, for
arthritic troubles after dislocations, for the thickening of bone
and periosteum following fractures and other injuries, or
indeed in most chronic inflammatory processes accompanied by
pain, stiffness, swelling, or deformity, the soothing or stimulat-
ing properties of tliese waters, or of applications of the mud
deposited from them, are found to be highly beneficial. Espe-
cially satisfactory are the results obtained in arthritis conse-
quent upon acute rheumatism or relapses of that malady, as
well as in that occasioned by gout. In these cases the baths
exercise a strongly soothing and absorbent influence locally,
and at the same time stimulate powerfully the excretory func-
tions of the body, enabling the system to throw off rapidly
the poisonous waste products of the skin, ttie lungs and the
kidneys.
The remarkable absorbent effects of the waters have led to
their very extensive employment for diseases of women. It is,
perhaps, in this connection that they are most known and made
use of in Italy among the well-to-do classes. All possible
varieties of gynecologic ailments find their way to Salsomag-
glore, and it is really wonderful how many different maladies
in that large category of diseases find relief from the treatment.
This is explained by the fact that the greater number are of an
inflammatory nature in the chronic stage so favorable to the
healing action of the waters. Among those most amenable to
the treatment are the various inflammatory affections of the
uterus and adnexa — to wit, cervicitis, endo-, para- and peri-
metritis, salpingitis, pelvic peritonitis and pelvic cellulitis.
Lacerations, displacements and newgrowths cnay derive bene-
fit so far as certain secondary effects produced by them are
concerned. Sterility is often cured, as might be expected when
the cause producing it is susceptible of removal by a course of
the baths. Functional derangements of the sexual organs of
the most diverse kind often yield to the treatment— such as
amenorrhea, monorrhagia, dysmenorrhea, or irregularity of
menstruation — a result due, probably, to a general tonic effect
which the waters exercise upon the nutrition of the body.
The large quantity of iodin present in the waters has sug-
gested their use in diseases due to infection by specific germs
other than that of tubercle, and they are, in fact, found of great
value in the later stages of syphilis (both for the secondary mani-
festations in the skin, the mucous membrane and the periosteum,
and for the tertiary changes in the bones and the organs), as
well as for the sequels of gonococcic infection, whether in the
genital organs themselves (as urethritis, orchitis, metritis, etc.)
or in other parts of the body (post-gonorrheal rheumatism,
arthritis and synovitis).
A considerable number of neurasthenic and anemic patients
also benefit often quite remarkably by the Salsomagglore treat-
ment. In those cases the restf ulness and quiet of the place itself
must greatly contribute to the successful result, but the sooth-
ing effects of the baths and the alterations which they are capable
of producing in the nutritive processes of the body through
the nervous system and the circulation have also, we may be
sure, an important share in bringing it about.
A popular belief has gradually arisen iu the power of the
waters to give tone to the mucous membrane of the respiratory
tract and so to prevent attacks of coryza and ordinary bronchial
colds. Many go through the " cure " regularly every summer
with the idea that they are thus ensured against such attacks for
August 9, 1902]
THE WOELD'S LATEST LITEKATURE
(American Medicine 227
the whole of the ensuing year. This virtue is especially attrib-
uted to the inhalations which form a great feature of the treat-
ment as it is now carried out at Salsomaggiore, and undoubtedly
they have proved to be a most valuable adjunct to it, both by
means of their local effect upon the parts witli which tliey come
into contact, as well as by indirect action exercised through the
blood upon the system generally. While there seems to be aa
yet no satisfactory evidence that any absorption ot the saline
and other constituents of the waters takes place through the
skin during bathing, there can be no doubt that during a pro-
longed stay in the inhalation-room a certain amount of the
lodiu and other Ingredients of proved therapeutic value does
actually enter the blood, and it is therefore reasonable to sup-
pose that their presence there may exercise a distinct influence
upon morbid processes in the body and contribute appreciably
to their cure. The ordinary course of baths is for this reason
often supplemented by the use of inhalations even when there
is no local affection of the respiratory apparatus calling for
their f mployment. But where such exists excellent results are
frequently obtained either by directing a spray of the "acqua
madre " (deprived of some of its calcium and magnesium salts)
on to the affected part, or by causing the patient to breathe for
a considerable length of time the atomized natural water in the
inhalation-room. The direct spray is used for affections of the
upper air-passages (rhinitis, pharyngitis, laryngitis, and
trachitis) ; where the lower part of the respiratory tract is
involved, as in chronic bronchitis and bronchial asthma, a pro-
longed stay in the inlialation-room is also frequently beneficial.
In chronic catarrhal conditions of the conjunctival mucous
membrane a spray or douche of the diluted "acqua madre" may
be used with benetit. In all cases where the direct spray is
used it is essential to begin the treatment with weak solutions
of from 1° to 2° Beauinc, gradually increasing the strength to
7° or 8° Beaumg. The use of the direct spray and of the inhala-
tion-room is often combined in these catarrhal affections, for
both have a beneficial effect by soothing irritation, reducing
congestion and swelling, liquefying and loosening thickened
adherent mucus, and thus bringing about a healthy condition
of the mucous surfaces.
When a powerful local effect is desired — as, for instance, in
cases of glandular enlargements, arthritic joints, injuries by
sprains, damage to parts by old wounds, dislocations, fractures,
etc. — the Salsomaggiore mu<l, or " fango," is made use of. This
mud, collected from the tanks into which the springs flow on
emerging from the artesian wells, is saturated \vith the salts of
the waters and strongly impregnated with the oily bituminous
ingredients contained in them. Applied hot in the form of a
poultice over or around the affected part it has an excellent
etfect in sootliing pain, reducing swelling and removing stlff-
nes.s. These mud applications are kept on for from 20 minutes
to half an hour, and are scraped off just before the pitient
enters his bath. They are a most useful part of the Salsomag-
giore treatment and are much in favor among patients on
account of the speedy relief which they generally afford.
The indications for the Salsomaggiore treatment may be
summed up briefly as follows:
1. Tuberculous disea.se in bones, joints, glands, or skin.
2. Gynecologic ailments, more especially those of an inflam-
matory nature.
S. Rheumatism and gout, especially the arthritis associated
with them.
4. Inflammations In general, in the chronic stage; catarrhal
affections of eyes, ears, nose, mouth, and throat, and bronchitis
and bronchial asthma.
5. Various results of injuries, wounds, etc.
fi. Tertiary syphilis and postgonorrheal affections.
7. Neurasthenia, neuralgia and neuritis.
8. Anemia and retarded convalescence from acute illnessea.
2, Via V'bnbto, Rome (In winter).
THE WORLD'S LATEST LITERATURE
A Memorial to Italian Physician.— On .June 15 there
was inaugurated in Home a monument bearing an artistic bas
relief in l)ronze, representing science and charity giving succor
to suffering humanity, as a memorial to the eminent Italian
physician, Enrico Bondi.
Journal of the American Medical Association.
August H, 190i. [Vol. xxxix. No. 5.]
Cryptorchidism, with a Report of Two Cases of Natural Eunuchs.
Henrv G. Anthony.
Evolution of the Pulp. Eugene 8. Talbot.
A Comparative Study of the .\ttachraent of the Teeth. Frederick
B. I^OYKS.
Acute Gastroenteritis or Summer Diarrhea of Infants. Makgabet
Taylor Shutt.
Milk Idiosyncrasies In Children. Iiouis Fischer.
The Improvement of Bieast .Milk and the Prolongation of Lactation.
Thomas S. Southwokth.
7. Infant Feeding. Some of the DIfflculties Growing Out of the Neces-
' slty for Kesorting to Artificial Feeding. Alexander McAl-
lister.
1.— Report of Two Cases of Natural Eunuchs.— Anthony
reviews the literature of cryptorchidism and gives the notes of
two cases of complete absence of the testicles in men of 40 and
2(i. The first is mentally weak, but is 6J feet tall, his appear-
ance suggesting akromegaly. There is no evidence of heredi-
tary syphilis or of tuberculosis. The second is not intellect-
ually bright, but beyond this showed no peculiarities until
after puberty. Occasionally there is a hemorrhage from the
penis, which friends interpret to be menstruation, but Anthony
suspects the cause to be a foreign body introduced into the
organ. According to literature, natural eunuchs are rare.
Xecropsy is necessary to determine the exact condition. In
neither of the cases reported can an ectopic testicle be found
in the usual locations of such organs. Regarding the question
of impotence from castration, Anthony sees no reason to
believe that this operation before puberty does not effectually
produce irnpotency. There is also very little evidence that castra-
tion in adult life does not quickly produce impotency. [a. O.K.]
2.— Evolution of the Pulp.— Talbot discusses at length
degeneracy of the teeth and their pulps In relation to evolution.
The evolution of the pulp, from that in the lowest forms of
animal life to its highest development, is traced. The varia-
tions which produce toothless birds, etc.. Indicate a degeneracy
in an organ which is for the temporary benefit of the type as a
whole When the dental blood supply is cut off, in man and
some lower vertebrates, teeth virtually become foreign bodies.
Decay is, therefore, a natural process of excretion. Tooth decay
is controlled by the trophic nervous system and the pulp is still
a transitory structure in human evolution, [a.o.e.]
4, 5, 6, 1.— See American Medicine, Vol. Ill, No. 24, pp.
1047, 1048.
Boston Medical and SarKical Journal.
July SI, 19iit. [Vol. CXLVII, No. 5.]
1. Nonopemtlve Head Injuries: Diagnosis and Treatment. T. J.
Robinson.
2. Indications for (tperatlon in Head Injuries. Edwin wellks
DWIUHT. ^ ^
3. Indication for Operation In Head Injuries. William N. Bullakd.
4. Gunshot Wounds of the Head and Cranium. Louis La Gabde.
5. Technic and After-Care of Operations Upon the Cranium. Charles
L. .ScuDDEK and Harry H. Habtwell.
1.— DiaKiiosis and Treatment of Nonoperativo Head
In,|uries. — Robinson classifies these injuries as follows:
Injuries to the scalp, certain forms of vertex fractures,
fractures of the base, cerebral concussion and contusion,
certain cases of compression, certain cases of laceration.
If diagnosis is doubtful in scalp injuries, make an open
incision. In fractures the important thing is to allow no
depre.ssed fracture to pa.ss for a linear fracture. Cases of con-
cussion and contusion shade into each other, and the only
means of differentiation is the severity and persistence of the
symptoms. Two things are of great importance in the treat-
ment of all nonoperative head cases: (1) ICxtrome and immedi-
ate care in the antiseptic treatment of all wounds and abrasions
of the soft parts of whatever degree; (2) extreme care In the
feeding and general nursing. In this way septic and pulmo-
nary complications are best avoided and the patient given the
best chance of recovery, [a.ii.e.]
2.— Indications for Operations In Head Iixlurlea.—
Dwight gives conclusions drawn from personal experience and
from a study of ftW cases in which a fraiaure of the skull was
demonstrated by operation or autopsy. He states that a tre-
228 AUEBICAir Hedicinb
THE WORLD'S LATEST LITERATURE
[AnGOST 9, 1902
phiiie opening should be made through the average skull
within two minutes from the beginning of the scalp incision.
He has repeatedly made it in U minutes. There is no serious
danger of thus injuring the brain, it being of no serious impor-
tance if the dura be opened. Profound and absolute uncon-
sciousness is present in but 5% of head injuries, thorough con-
sciousness is present in 11%. The Hutchinsonlan pupil is not
more common in extradural than in subdural hemorrhage. In
a general way, when a single pupil is dilated the hemorrhage is
on the same side in TO'/c, on the opposite side in '^0% ; when a
single pupil is contracted the hemorrhage is on the same side
in 30%, on the opposite side in 70%. The symptoms presented
in the majority of the cases of head injury are ill defined and
not such as might be expected from a study of tlie literature;
they ai-e best defined in those cases that are least apt to be bene-
fited by operation ; in the vast majority of all oases of injury to
the brain where an operation may be expected to give relief the
symptoms are indefinite and may be entirely wanting, [a.o.e.]
3. — Indications for Operation in Head Injuries. —
BuUard concludes (1) it is usually advisable to opera'e on any
compound fracture ; (2) simple fracture without symptoms
does not, as a rule, require operation ; (3) absence of uncon-
sciousness does not contraindicate operation; (4) when uncon-
sciousness lasts more than 24 hours, operation should be con-
sidered; (5) marked rise of temperature suggests serious injury
to the brain ; (0) severe pain in the head continuing for some
time after a head injury, if organic, indicates operation ; (7) con-
vulsions, taken In connection with other symptoms, usually
favor operation. These statements refer to adults only. [a. O.K.]
4. — Gunshot Wounds of the Head and Cranium. —
La Garde gives statistics of gunshot wounds in the Civil and
Spanish-American wars. The mortality among all head
wounds that reached the hospitals was nearly the same in both,
28.93% in the former, 26.0!)% in the latter. The lesser frequency
of glancing shots with the new firearms Is show n by the fact
that in the Civil war there were 7.739 flesh wounds and 4.350
fractures, while in the Spanish-American war there were 40
flesh wounds and 31 fractures. This augments the fatalities so
that the humane features attributed to the steel-jacketed bullet
do not apply to wounds of the head. Military surgeons are
unanimous in recommending early and free exploration of all
cases of fracture of the skull by gunshot, [a.g.e.]
Medical Record.
[August 2, 1902. Vol. 62, No. 5.]
1. Diet, Drugs and Diagnosis in Typhoid Fever. Charles H. Lewis.
2. aummer Disorders, Dietetic Management and Milk Substitutes In
Children. Louis Fischer.
3. Causes of Cancer. Kobert Keyborn.
4. Hunchback : Rectifying of Spinal Deformity by Forcible Traction ;
Immediate Straightening. J. V. Young.
5. Diagnosis of Incipient Carcinoma of the Endometrium. J. A.
SCHMITT.
1.— Diet, Drugs and Diagnosis in Typhoid Fever.—
Lewis, after extended clinical experimentation, has selected
calomel, in half-grain doses twice daily, as the best drug for
relieving tympanites and cleaning the bowels in typhoid fever
patients. The proper amount of nourishment for such patients
is one pint of milk diluted with an equal quantity of Vichy for
each 24 hours. The inhibition of water, preferably acidulated
with dilute HCl, 3ss-5j to the quart, is encouraged as much as
possible. None of the socalled intestinal antiseptics appeal to
Lewis, either on practical or theoretical grounds. Intestinal
hemorrhage, which is a rare complication in his cases, forms no
contraindication to the calomel or laxative treatment. Ten
grains of calomel and 20 of sodium bicarbonate will stop a slight
hemorrhage of the bowel. A tabulated record of the 90 cases
upon which the treatment recommended is based accompanies
the article. The results in6i cases tested for the Widal reaction
can be vouched for. Of these 54 gave a positive reaction at some
time during the disease, [a.g.e.]
a.— Summer Disorders, Dietetic Management and Milk
Substitutes in Children. — Fischer gives directions for prepar-
ing barley water, oatmeal water, vegetable proteids, and other
substitutes for milk. Cow's milk used for infant feeding
should be tested for acidity by blue litmus paper. Acid milk
is entirely unfit for infants. A point emphasized is that when
milk has stood for several days, no amount of boiling, pasteur-
izing, or sterilizing will destroy the toxins developed by the
colon bacillus, [a.o.e.]
3. — Causes of Cancer.— Reyburn states that the first and
probably the most powerful predisposing cause of cancer is
senility of the tissues and organs of the body. The second
cause is the habitual use of the various forms of alcohol as
articles of diet. The third cause is the consumption of too
much meat and nitrogenized food, [a.g.e.]
4.— Spinal Deformity Rectified by Forcible Traction. —
Young gives the technic employed in overcoming a traumatic
deformity in the spine of a boy of 13. No anesthetic was used,
a force of at least 140 pounds being exerted. A plaster jacket
was applied before traction was relaxed, [a.g.e.]
.5. — Diagnosis of Incipient Carcinoma of the Endo-
metrium.—Of the three subdivisions of uterine cancer, car-
cinoma of the body of the uterus is specially marked by the
uncertainty and obscurity of its initial symptoms. A bloody,
serous or seropurulent discharge in a woman whose menstru-
ation has ceased months or years before, is, from a clinical point
of view, about the most importaut for diagnosing the beginning
of endometrial cancer. Patients with this disease usually begin
early to suffer pain, which varies in character. It may be con-
tinuous, dull, and heavy ; or it may be spasmodic, labor-like,
and apparently attributable to the attempt of the uterus to
expel the newgrowth or particles of it. .Schmitt points out
the fact that various conditions may be mistaken for carcinoma
of the endometrium, such as the different forms of endome-
tritis, a retained placenta, a polypus, a submucous fibroid sar-
coma of the mucous membrane, etc. ; and he cites cases of each
kind. In order, then, to guard against erroneous diagnosis
there must be a systematic use of all means at our command for
exploring the uterine cavity. These are probing the uterus,
digital exploration after dilation, and microscopic examination.
The most important method at the disposal of the gynecologist
is the digital examination which in conjunction with micro-
scopic investigath u accomplishes everything that is needful
for a correct diagnosis. The preliminary dilation of the cervix
may be splitting through the posterior cervical wall or by the
use of laminaria tents. If the latter method is used, a tent
about the size of the finger should be inserted 24 hours previous
to examination. Whichever method is used, it is of the utmost
importance that the dilation should be sulHcieutly great to
allow the unimpeded introduc'tion of the finger. [w.K.]
New York Medical Journal.
July 2G, 190$. [Vol. lxxvi. No. 4.]
1. Excision of the Knee for Vicious Deformity and Tuberculous Dis-
ease in the Adult. Virgil P. Gibney.
2. Spinal Cord Conditions in Severe Anemias. Archibald Church.
3. Some Clinical Observations in Intestinal Surgery. ApMorgan
Vance.
4. Late Manifestations of Hereditary Syphilis in the Kose and Throat, .
with Reports of Cas-s. Willis S. Anderson.
5. A Ciise of Epithelioma of the Auricle and Auditory Canal, Thomas
K. Fooley,
1. — Excision of the Knee.— Gibney reports three such
cases. The first is that of a woman of 38. The development of
the disease in early life, the apparent cure, the attempt at
motion years after the cure was supposed to be completed, the
instability of the limb following this operation, the finding of
two or three little foci in the head of the tibia, and the final
relief by excision are points of interest. The second case illus-
trates the influence of a distinctly neurotic element and the
presence of pain even after excision. The third was that of
rectangular deformity of the knee dating from childhood, with
the usual history of a tuberculous knee accompanied by sup-
puration. Excision with one inch shortening was done. The
author believes that a synostosed knee gives much less trouble
than one that is ankylosed. He also shows the baneful effeOts
of excision in growing children. [c.a.o.J
2.— Spinal Cord Conditions in Severe Anemias. — Church
discusses the degenerative processes in the spinal cord second-
ary to or associated with severe anemia, and reports six eases.
The posterior half of the cord, being less vascular, is the first
to suffer and undergoes nutritional reduction and consequent
retrograde changes. These show themselves in f?clerotic condi-
August 9, 1902]
THE WOKLD'S LATEST LITERATUEE
(Amebioan Medioiitb 229
tions. In cases of long duration and extreme degree, the other
portion of the cord, including the anterior horns of gray matter,
are involved with corresponding functional disturbance and
physical signs. These changes occur not only in the classical
pernicious anemias, but in cachectic states of long duration
attended by toxic factors. Women are affected about three
times as frequently as men. The condition is commonly mis-
taken for indications of locomotor ataxia, spastic paraplegia or
multiple neuritis. These patients complain in a major degree
of disturbance of sensation, usually in the lower extremities,
sometimes in all four extremities. Disturbances of the mind
are commonly encountered. The prognosis is dependent
entirely upon the condition of the blood. Much can be done,
even in the most pronounced cases of pernicious anemia, by
continuous efforts to render the intestinal canal aseptic, and to
add to the quantity and quality of circulating blood. [c.A.o.]
3. — Intestinal Surgery. — Four cases are reported by
Vance. The first is that of an abdominal gunshot wound with
one mesenteric and four intestinal perforations, the second is
a gunshot wound of the stomach and duodenum, the third is a
gunshot wound of the stomach, liver, ileum and mesentery and
the fourth is that of strangulated hernia in which a portion of
gut was resected at the end of 11 days and end to-end anastomo-
sis done by Wolfler's method, modified. The author believes
catgut to be the best suture material for all intestinal work and
the ordinary round needle is preferred. The best suture is the
Lembert or some modification of it. [c.A.o.]
4t. — Hereditary Syphilis of Nose and Throat. — Three
cases are cited by Anderson to illustrate unusual forms of
syphilis. Puberty in each of the cases was the time of develop-
ment of the late lesion, and they all occurred in females. He
says these late manifestations are prone to attack the upper
respiratory tract, and may, and often do, produce lesions which
in extent and seriousness are comparable to the severe forms of
the tertiary stage of the acquired disease. The palate is the
most frequent site of these lesions, but the nose, nasopharynx,
buccal and lingual surfaces, or the larynx may be involved.
The character of the lesions varies, but they conform closely to
the tertiary forms. Attention must be given to the general
health and antisyphilitic and local treatment given. Where
there is a gummatous deposit the writer believes that mercury
as well as the iodids is indicated. The use of the drug by in-
imctions is thonjugh and satisfactory. [c.A.o.]
3.— A case of epithelioma of the auricle and auditory
canal in a man of 58 is reported Ijy Pooley. The growth was
situated in the upper part of the helix and a whitish reticular
tissue extended down and involved the concha, tragus and
antitragus and extended into the auditory meatus. It had been
treated by caustics and pastes and once by operation before the
patient came to the author's notice. It was removed, but a
recu rrence was noticed in 14 months when It was again re-
moved. [c.A.o.]
Medical News.
August 2, 1902. [Vol. 81, No. 5.]
1. Carcinoma Limited to the Appendix Vermlformls • Discussion of its
Orlj?ln and Its Relation to Appendicitis. Richard H. Uartb
and Robert N. Willhon.
2. Anuria. Clinical Memoranda In the Observation of a Case. Ai^kxis
V. .MOSCIICOWIT/.
8. Dextrocardia Due to Pulmonary Cirrhosis, with Presentation of
Case. Hknry IjKVIkn.
i. The Modern Treatment of Pterygium. F. B. LoRiNG.
5. Report of a Case of Grave Anemia. J. .s. Tkiplktt.
1.— See American Medicine, Vol. Ill, No. 24, p. 996.
2.— Anuria.— Moschcowitz reports a case of suppression of
urine, the patient being a Koumanian woman with previous
history of malaria and abortion. The diagnosis of suppression
of urine due to a left-sided pyelonephritis with reflex anuria of
the right kidney was made. Operation showed the left kidney
tf) Vje distended with 1,000 cc. of fluid, no stone being present.
Incision of the right kidney obtained several drams of pus.
Abortion followed the operation. High temperature led to
removal of the right kidney 12 days later. It was found to con-
sist almost entirely of fibrous and fatty tissue. The wound on
the left side closed In 44 days, the woman finally recovering.
The various causes of urinary suppression are considered at
length. [A.G.B.]
3. — Dextrocardia Due to Pulmonary Cirrhosis. — Levien
reports a case, a male of 26, in whom the apex beat is in the
fourth intercostal space, half an inch to the right of the sternum.
There is a cavity in the middle lobe of the right lung anteriorly.
The history is a typical one of tuberculosis, tubercle bacilli
being present in the sputum, [a.g.e.]
4. — Treatment of Pt«ryKluin. — Loring commends highly
the treatment introduced by Coe — the direct application of the
cautery to the apex of the pterygium on the cornea — its use in
23 cases having met with complete success, ligation of the vessel
being necessary in only one case, a very large and vascular one.
An alcohol lamp and a platinum wire are the only instruments
needed. There is no pain at the time of application and no
iuttammatory reaction. Loring believes that heredity exerts
an influence on the production of pterygium, [a.o.e.]
Philadelphia Medical Joornal.
August 2, 1902. [Vol. X, No. 5.]
1. A Case of Albumosuria of the Pernicious Anemia Type. Herman
F. ViCKERY.
2. Cocain as a Thermogenic; Its Modes of Action. Edward T.
Reichert.
3. The Open-air Treatment of Tuberculosis in the State Forest Iteserva-
tions of Pennsylvania. J. T. Rothrock.
4 The Early Diagnosis and Treatment of Acute Mastoid Intlamraa-
tion. T. H. Ualstbd.
1. — See American Medicine, Vol. Ill, No. 19, p. 764.
2. — Cocain as a ThermoKenic. — Reichert details the fol-
lowing series of experiments which were performed to deter-
mine the modes of action of cocain upon thermogenesis. The
actions of cocain upon curarized dogs ; the actions of cocain
upon morphinized dogs ; the actions of cocain upon dogs after
section of the spinal cord at its junction with the bulb; and
the actions of cocain upon dogs after section of the crura cere-
bri, injury to the caudate nuclei, etc. These experiments have
demonstrated the following facts: (1) The rise of temperature
caused by cocain is due to an increase of heat production, the
latter depending upon two actions — one, upon the cortex, caus-
ing niotor excitement, and the other, upon the caudate thermo-
genic center, causing heat to be produced independent of motor
activity; (2) cocain possesses very little power as a thermo-
genic in animals lightly curarized, because of the motor quiet-
ude and the depression of some other portion of the thermo-
genic apparatus ; (3) cocain is absolutely without thermogenic
power in animals in which the pathways of thermogenic
and corticospinal motor fibers have been cut, as after sectiou of
the spinal cord at its junction with the bulb and of the crura
cerebri ; (4) cocain is effective as a thermogenic when only a
small portion of the caudate center is left intact with the parts
below; (5) cocain and morphin are direct antagonists in their
actions upon the caudate and cortical centers which are directly
or indirectly involved in the changes of temperature and heat
production, [f.c.h.]
8.— The Open-air Treatment of Tuberculosis in the
State Forest Reservations of Pennsylvania.— This is a cir-
cular letter which is sent by Dr. Kothrock, the Commissioner
of Forestry to the State, to persons suffering with tuberculosis
who inquire about the opportunities to regain health in the
mountains of Pennsylvania, [f.c.h.]
4.— The Karly Diagnosis and Treatment of Acute Mas-
told Inflammation. — Halstod details the symptoms of mas-
toiditis and their relative value. The treatment depends upon
the stage of the intlammation and the cause of the middle-ear
infection. In every case of middle-ear suppuration, good
drainage should be effected by a free Incision In the drum.
The incision should be matle in the posterior and inferior
quadrant ol the drum, extending it well up behind to the
region of the attic should there be bulging, as exists in the
majority of severe cases. Syringing the canal with a hot
boric acid or other mildly antiseptic solution may be suffi-
cient to maintain free drainage. If there be unusual amount
of swelling In the postsuperlor wall of the auditory canal, a
free lnc:islon, extending from the margin of the drum outward
and through the periosteum to the bone, should be made and
280 Ambbican MbdicineI
THE WORLD'S LATEST LITERATURE
[AtrecsT 9, 1903
made early. The practice of insufflating the auditory canal
with powdered boracic acid is mentioned only to be condemned.
It this treatment does not relieve the pain, ice should be
applied from 24 to 36 hours. If pain is not then relieved, it
should be continued until the termination of 48 hours. If after
using ice, pain on deep pressure over the antrum subsides even
slightly, general tenderness diminishes, and the discharge from
the ear continues freely, operation may be postponed. If, on
the other hand, pain over the mastoid increases in severity and
extends up the side of the head, a slight elevation of temper-
ature persists, and swelling and redness of the posterior-
superior wall of the external auditory canal increases, the mas-
toid should be opened, [p.c.h.]
CLINICAL. MEDICINE
David Riesman A. O. J. Kelly
Treatment of Nontuberculous Joint Diseases
by Bier's Method. — The treatment of joint diseases
by congestion, known as Bier's method, had its origin
in the well-known fact that the pulmonary congestion
of mitral disease is more or less antagonistic to acute
tuberculous processes in the lung. At first Bier em-
ployed heat in order to induce an active hyperemia in
the joints ; but as his results were not encouraging he
had recourse to passive hyperemia. This, according to
Laspeyres {Centralbl.f. d. Grenzgebiete der Med. u. Chir.,
May 27, 1902), he induces in the following way : The
peripheral portion of the limb is wrapped with two or
three layers of bandage up to the affected joint. Above
the joint a rubber bandage is applied firmly enough to
cause a decided passive hyperemia. To avoid injurious
pressure a gauze bandage is first wrapped around the
limb at the point of application of the rubber bandage,
and with the same object in view the position of the lat-
ter is changed at least twice in twenty-four hours.
The treatment is continued, without interruption,
day and night for weeks and even months. One of its
advantages is that it permits the patient to use his limb.
The dependent position, moreover, favors stasis.
At first Bier applied his method only to tuberculous
joints, but the results were so satisfactory that he
extended it to the treatment of other forms of arthritis,
e.g., the gonorrheal and rheumatic.
In the case of acute articular rheumatism the method
is of secondary importance, as the salicylates are usually
efficacious ; but when they fail, or when the disea.se per-
sists in one joint, or when the pains are particularly
severe, then it may be tried. The best results are
obtained when the hyperemia is very active, causing
redness, heat, and even vesiculation of the skin. In
arthritis deformans and in chronic rheumatism the
results have been variable, but on the whole good. No
effect was achieved in true gout. In pyemic arthritis
and in joint stiffness after trauma or prolonged immo-
bilization, the results were good.
The effect produced by the method seems to depend
upon the nature of the congestion secured. There is a
" hot stasis," which is the most efficient ; a " cold stasis,"
with but little power to cure, and a "white stasis,"
which is entirely inactive. It is somewhat strange that
the application of a firm bandage can cause peripheral
heat and redness. In chronic rheumatism and in
arthritis deformans this type of congestion is not readily
induced.
It is not easy to explain the rationale of Bier's
method. In a review of the subject published last year.
Bier attributed four properties to the stasis hyperemia :
(1) A bactericidal or at least growth-inhibitory lU'tion ;
(2) the power to cause connective-tissue proliferation and
cicatrization ; (3) a solvent action of the blood-serum and
leukocytes, affecting especially the diseased tissues ;
(4) an anodyne action, which is exceedingly prompt and
marked, both in acute and chronic joint troubles.
Several experimental studies of Bier's method have
l)een published, and confirm the results of clinical expe-
rience. A wider application of the method, particu-
larly by internal clinicians, is therefore indicated.
The Cause of the Deficiency of Hydrochloric Acid in
Carcinoma of the Stomach.— Reissner' details the result of
some interesting studies that lead him to the conclusion that,
contrary to the prevailing opinion in many cases of carcinoma
of the stomach, the total excretion of chlorids into the stomach
not only is not diminished, but that it is really increased. He
believes that the clinical deficiency or absence of hydrochloric
acid is due not to deficient secretion, but to abnormal neutral-
ization of the acid by an alkaline secretion that he believes the
carcinoma produces, and that this may be aided by (a) a reflex
deficiency of secretion caused by the alkali ; (6) general reduc-
tion in the amount of chlorids in the body the consec^ence of
excessive secretion by the stomach, and (c) atrophy of the
mucous membrane of the stomach. It is believed that the
ehemic conditions in the stomach are changed only when the
carcinoma has ulcerated, and that this ulceration alone is the
cause of the reduction of HCl. It is believed that this supposi-
tion suffices to explain (a) the frequent early absence of free
HCl in gastric carcinoma independently of the situation of the
tumor, and its absence also in carcinomas of other organs; (6)
the relatively rapid development of atrophy of the gastric
mucous membrane ; (<■) the preservation of the ferments ; (d)
the not uncommon persistence of free HCl in cases of carcinoma
that develop from gastric ulcers; (e) the rapid, often sudden
disappearance of the free HCl ; and (/) the reappearance of the
acid after the removal of the tumor, provided extensive atrophy
has not already occurred, [a.o.j.k.]
The Etiology and Symptoms of Congenital Heart
Lesions. — According to Monti,^ congenital heart lesions are
often associated with malformations of other organs, and are
due to faulty development of the heart. In some instances they
are found in several generations of the same family, and are due
to some constitutional disease, especially syphilis. They follow
infectious diseases of the mother during pregnancy ; atelectasis
produces others. Often no symptoms betray the existence of
such a lesion ; in other cases, physical examination shows dis-
placement of the heart, intensification, and broadening of the
apex-beat, abnormal sounds (systolic and diastolic murmurs),
accentuation of normal sounds and tachycardia, with or without
cyanosis, the amount of exertion producing the tachycardia
being ordinarily insufficient to bring it about. Enlargement of
the area of dulness without murmur indicates congenital
hypertrophy and dilation of a part or all of the heart. A sys-
tolic murmur at the apex with accentuated second pulmonic
and hypertrophy with dilation indicates mitral regurgi-
tation. If the murmur is heard best over the aortic region,
aortic stenosis exists. If the murmur is diastolic, it means
mitral stenosis. A systolic murmur over the right ven-
tricle, with a broadened heart and pulsating jugular veins,
indicates insufficiency of the tricuspid valve. If the mur-
mur is heard best over the pulmonary cartilage, pulmonary
stenosis is present. If the murmur is diastolic, the tricuspid
orifice is contracted. A double murmur at the apex, heard best
during systole, usually indicates an opening in the septum. A
buzzing murmur over the aorta with localized pulsation means
aortic aneurysm. Many heart lesions, such as absence of a
septum, situs perversus of large vessels, an origin of the aorta
from both ventricles, etc., do not present characteristic symp-
toms. The prognosis in all cases is bad, few children reaching
the third year, [e.l.]
Alternating Pulse.— Wenckebach ' believes that the alter-
nating pulse may be explained as follows : When the contrac-
tility of the heart muscle is diminished the heart is in a
hypodynamic condition, and its contractile force remains
uniform only so long as there occurs no irregularity; the
slightest irregularity disturbs this uniformity of contractile
force, and the alternating pulse results. For instance, should a
stimulation to contraction occur too early, it encounters the
heart muscle more hypodynamic than did the previous stimu-
1 Zeitschrlft fUr klinlsche Medicin, xllv, 71, 1902.
SAUgem. Wien. med. Zeltung, 1902, p 110.
» Zeitschrlft far klinlsche Medlcln, xllv, 218, 1902.
AUGUST 9, 1902J
THE WORLD'S LATEST LITERATURE
[Amxbican Medicinb 231
lus, and the following contraction is not only smaller, but it
occurs also more quickly. By the time of the occurrence of the
following stimulus, the pause having been longer, the contrac-
tility of the heart will have recovered itself and the contraction
will be stronger and longer, and the following pause shorter
and the contraction again weaker. These being repeated,
account for the peculiarities of the alternating pulse, [a.o.j.k.]
AdministrarlTe Control of Tnbercalous Diseases.—
Pattin 1 expresses his conviction of the wisdom of : 1. Reliable
information of the whereabouts of tuberculous patients which
can be acquired only by obligatory notification. 2. Rigorous
adoption of consequential administrative measures as to
destruction of sputum, etc., and disinfection and improvement
of affected dwellings, and sometimes their condemnation and
removal. 3. Provision of sanatoriums for recuperative treat-
ment either by sanitary authorities singly or conjointly ; and
4. Instruction in all elementary schools in the means of propa-
gation, and the methods of prevention in dealing with tubercu-
lous diseases, [a.o.j.k.]
Chickenpox with Abnormal Development of the Ex-
anthem. — Von Hoesslin^ reports a case of chickenpox in
which the eruption became necrotic ; but the course of the dis-
ea.se was not unfavorably influenced in any way. [n.R.]
Cardiac Death fW)iu Diphtheria Toxin.— Stejskal,' after
an exhau.stive discussion on the subject, supported by consid-
erable experimental investigation, concludes as follows: The
methods to measure the power of the heart chosen by Romberg
and his associates are insufficient to enable us to demonstrate,
in diseased conditions, changes in the work of, or damage to,
the heart. Estimation of the arterial pressure alone affords no
indication of the work of a diseased heart. By more exact
methods, however, it is possible to demonstrate that poisoning
by diphtheria toxin first induces some improvement in the
work of the heart and that this is followed in a short time by a
transitory impairment in the power of the heart. Following
this, the primary action of the diphtheria toxin, there occurs a
second, analogous to the first and differing from it in point of
time. During this period, however, it is possible to determine
that the heart is no longer capable of its normal activity — the
normal reflex excitability of the heart through irritating a
nerve is absent. Concurrently the diphtheria toxin damages
the va.somotor system, although there are periods in which
while the heart is no longer capable to reflex stimulation the
vasomotor system still responds to such stimulation. There
occur therefore at least two parallel and concurrent actions,
that on the heart and that on the vasomotor system, resulting
in ultimate damage to both the heart and the vasomotor system.
The condition, therefore, is not, as claimed by Romberg and his
associates, a secondary weakness of the heart due to vasomotor
paralysis ; on the contrary, the cause of the damage to the cir-
culation brought about by diphtheria toxin must be sought in
lesions of both the vasomotor system and the heart. The vaso-
motor paralysis acts injuriously on the heart, not in supplying
it with too little blood, but because the paralysis of the vasomo-
ter centers in the medulla gives rise to a dilation of the heart
and its overdistention with blood, [a.o.j.k.]
Concerning; the Influence of the Diaphrajfin Upon the
Liver, and Concerning Hepatic MassaKe. — According to
Walz ' the movements of the diaphragm have a decided influ-
ence upon the shape of the liver. It is possible to distinguish
the following positions: 1. During Ordinary quiet respiration:
(a) a stage of rest of the liver; (b) an inspiratory stage of the
first degree. The convexity of the liver becomes flattened, and
the blood and bile are pressed out. Tiie alllux by way of the
portal vein is more or less retarded; the efllux into the vena
cava facilitatc<l. It is possible that during expiratiou there is
a sort of suction, because the vessels, compressed during inspi-
ration, become dilated during expiration in consequence of the
elasticity of their walls. 2. Forced abdominal breathing. In
addition to the stages previously described, we have in this the
following: (a) The stage of forced expiration. The alxlominal
pressure becomes increased, the liver is compressed on its
I British Medlciil Journnl, .Iiinp", 1902.
■■' .Manchcncr mcdiclnlsclic \ViM:li«n»<-bilft, April 29, 1902.
'ZcllNotirlft nir kllnlHchc .Mcillclii, xllv, 367, 1902.
'MfUichencrineU. Woch.. May l!l, 1902.
lower surface, and the blood is expelled. The gallbladder, if it
is filled to any considerable degree, is energetically compressed
between the quadrate lobe and the right lobe, aud thus the out-
flow of bile is favored, (b) The stage of inspiration of the
second degree corresponding to the deepest inspiration. The
compression of the upper surface of the liver and the stretch-
ing of the lower reach their maximum. The blood is
expressed principally into the cava. The gallbladder becomes
relaxed. From these data it is seen that respiratory massage
of the liver is of use. Deep inspiration and, still more so, deep
expiration should be methodically employed. They influence
the circulation of the liver, and expiration promotes the expul-
sion of the bile from the gallbladder. Methodic diaphragmatic
breathing is particularly valuable for the female sex, the corset,
which interferes with deep inspiration, being laid aside, [d.b.]
A. B. Craig
GENERAL SURGERY
Martin B. Tinker
C. A. Orb
Some phases of inflaininatiou of the appendix
were recently discu.sse<l by Sir Frederick Treves.'
One miglit tliink tliis subject altogether removed from
the field of polemics, but this article by Treves conveys
much that is new. He gives credit to M(?lier for his
writings on this subject, which appeared in 1827, and to
John Burne, who.se publication was some ten years later,
but states that the first precise, detailed and fully demon-
strated account was by Fitz in 1886.
Appendicitis, properly speaking, may exist, according
to Sir Frederick, without symptoms— that is, there may
be inflammation of the structure of the appendix and
even sloughing of its mucous membrane and yet the
patient be undisturbed. Once, however, the inflamma-
tory process extends to and involves the peritoneal coat
the socalled "attack of appendicitis " is ushered in.
Every "attack of appendicitis" is a peritonitis more or
less extensive ; usually, of course, it is and remains
localized. It is stated that 80 fc of the collected cases
have occurred in patients under 30 years of age, and
that 73 /c of all cases are among males. Attention is
called to three somewhat isolated points in etiology :
Life in tropic or subtropic countries by inhabitants of
temperate climates — which appears to predispose to
gastrointestinal disorders ; among female patients the
outbreak of an attack of api>endicitis is frequently coin-
cident with the menstrual i)eriod ; and the strong pre-
disposition to appendicitis afforded by a loaded cecum
and consequent constipation. Treves makes it plain
that he is unconvinced of any necessary relation between
tenderness at the socalled McBurney's point and appen-
dicitis. That tenderness exists there in appendicitis is
of course granted, but tenderness is readily found at this
particular point in many persons in perfect health, and
in subjects of colitis involving the cecum. To use the
author's own words, " It does not serve to indicate the
starting point of the disease or even the chief point of
the disease (this Dr. McBurn|K allows). It does not
indicate the situation of the diiJI&jJ* apix-ndix, nor does
it even correspond in the subject" with the bast> of the
appendix." The structure most uniformly found
beneath McBurney's iK)int is the ileoctxal value. This
fact the author states is based on the findings of Addison
and Keith, who found in 50 ca.ses that the lltHKH'cal valve
was in 22 cases beneath, in 14 ca.scs above, and in 14case»
below McBurney's point. Tenderness at this jwint in
health is ascrit)ed to the abundant nerve supply of the
valve in question and the surrounding structure.
The author is skeptical conwrning the claims of
thosti who profess in certain instances an ability readily
to palpate the diseaseft appendix. He believes that
which is palpate<l is a phantom due to contraction In the
1 BrltlHh .Medical Joumal, Inne 28, 1901.
232 Ahkbioan Hesioine]
THE WORLD'S LATEST LITERATURE
[AUGnST 9, 1902
outer edge of the rectus muscle or occasionally in the
internal oblique or tranversalis muscles.
The great majority of cases of appendicitis, all grades
being included, terminate in recovery without operation
— the mortality being estimated at 5^ . Operations car-
ried out during the attack show a mortality of 20 'fo or
over. Treves disapproves of operation in all cases so
soon as the diagnosis is made, but says: "Immediate
operation is demanded at the earliest possible moment,
in all ultra acute cases. These embrace those very hojie-
leas examples which present from the onset the phe-
nomena of intense infection." And again: "Immedi-
ate operation is demanded in every example in which
there is reasonable suspicion that suppuration has taken
place." In cases not included in the above he would
watch and await results. He ventures to assert that
when any patient has had one definite attack of appendi-
citis, and escaped operation or worse, the appendix
should be removed during the quiescent state. In over
1,000 operations in the interval he has lost but two
patients. The danger of the operation is infinitely less
than the danger from a subsequent attack.
Excision of Chronic Gastric Ulcer. — Kellock > reports
the excision of a chronic gastric ulcer, the patient being a
woman of 36 who had suffered from dyspeptic symptoms since
she was 17. Operation revealed a V-shaped opening In the les-
ser omentum, and directly behind this a single hard round
baud attached by one eud to the hepatic part of the lesser
omentum and by the other to a hard depressed spot in the pos-
terior wall of the stomach. This was excised and proved to be
a circular ulcer J Inch in diameter. The stomach was closed
and recovery of the patient was uneventful, [a.g.e.]
Intestinal Obstruction.— Edward A. Balloch ^ details three
cases of intestinal obstruction : 1. White male, 61 years of age.
Obstruction caused by a band running from the cecum across
the ascending colon and constricting the bowel at that point.
This band was composed of the obliterated appendix, reduced
to the diameter of a darning needle and embedded in a narrow
band of fibrous tissue 3 of an inch In width. The band was
tied In two places and cut away, freeing the constricted colon.
Considerable time was lost checking hemorrhage from numer-
ous vascular adhesions around the caput coll, which was acci-
dentally torn. A diagnosis of appendicitis was made early in the
attack, and later on changed to one of Intestinal obstruction.
Death occurred three days later from exhaustion, as the stomach
and rectum would not retain nourishment. 2. Colored male,
aged 25. About a year ago he had a swelling in the right loin
containing pus, which was incised, and a sinus persisted for
two months. When the case came under the care of the author
every evidence pointed toward an acute suppurative appendi-
citis. When the abdomen was opened the appendix was found
to be normal in all respects. Surrounding the ascending colon
was a hard mass which extended upward to the liver. The
mass was firmly adherent to the posterior wall of the abdomen,
and In It the involved bowel was buried and twisted in such a
confused tangle as to make its dissection Impossible without
the expenditure of more time than the patient's weak condition
would justify. The same objection applied to anastomosis or
resection, so the peritoneum was united to the abdominal wall
in the lower portion of /.he wound, a coll of intestine stitched
to the peritoneum and the rest of the wound closed. The con-
valescence was rapid. Death suddenly occurred 25 days subse-
quent to the operation. The autopsy showed that the opening
had been made in the jejunum 30 inches beyond the duodenum
and that it was securely adherent to the abdominal wall, no
leakage having taken place; mesenteric glands enlarged. A
thick malignant tumor involved all the coats of the ascending
colon, narrowing the lumen and extending to the twelfth rib
and kidney, which, however, were not involved. 3. Colored
woman, about GO years of age. Owing to the marked degree of
collapse, cocain anesthesia was employed. The bowel was
stitched to the peritoneum and an artificial fecal fistula estab-
lished. The patient died Ij hours later. Autopsy showed the
1 Lancet, July 12, 1902.
« Washington Medical Annals, July, 1902.
greater omentum contracted and the Intestine in the lower
abdoinen distended and greenish-black in color ; 9j feet of Intes-
tine, from the colic valve upward, had passed through a con-
genital opening about 1 Inch In diameter In the mesentery,
and had become strangulated and more or less gangrenous.
The following conclusions are drawn as a result of a study of
these cases : Early diagnosis Is the main factor in the saving of
life in cases of bowel obstruction ; acute Intestinal obstruction
is characterized by symptoms which should be easily recog-
nized ; if the probability of obstruction exists, cathartics should
be withheld; chronic, slowly Increasing obstruction may, at
any time, become acute; surgical advice should be sought
early; In true obstruction the only remedy is surgical interven-
tion ; the choice of operation depends upon the condition of the
patient, and should, if possible, be radical; beyond question.
In the cases in the last stages and probably in doubtful cases,
the proper plan is to establish a fecal fistula and tlius gain time
to place the patient in condition for a more radical procedure
later; general anesthesia is a distinct element of danger in
operated cases, and when a fecal fistula is to be established,
local anesthesia should be used by preference, [p.c.n.]
Operative Treatment of Diseases of the Pancreas.—
Tilton ' says that the lesions of the pancreas most frequently
requiring operation are cysts, inflammations and solid tumors.
In the New York Hospital during the past ten years there have
been 15 cases of pancreatic disease— cysts, 8; acute hemorrhagic
pancreatitis, 3; supi)urative pancreatitis, 1; chronic pancrea-
titis, 1 ; carcinoma, 2. In the treatment of cysts aspiration is
of doubtful therapeutic value, is a useful means of diagnosis,
but should be condemned on account of Its danger. Drainage
by Incision is the treatment, extirpation being feasible only in
exceptional cases. In acute pancreatitis with hemorrhage or
necrosis the diagnosis is usually very much In doubt. An
exploratory incision In the epigastrium should be made at the
earliest possible moment. The diagnosis will be more often
made In the future and cases saved which were formerly let
die. In draining a necrotic pancreas or peripancreatic abscess
anterior incision is advisable, afterward making a counter-
Incision posteriorly, if Indicated. Tumors of the pancreas offer
an unsatisfactory field for surgical treatment. Attention Is
called to the differential diagnosis between chronic inflamma-
tion and carcinoma of the head of the pancreas. The diagnosis
of the former Is often made on too few data, [a.g.e.]
Cases of Obstruction of the Bowel.— George T. Vaughan ^
details three cases, as follows : 1. A case of volvulus associated
with a strangulated scrotal hernia, congenital variety. The
scrotal tumor was about the size of an adult head, 28 inches of
intestine were resected and the ends united with a Murphy
button, reinforced by a row of Lembert sutures. Convalescence
was undisturbed, and the button was passed on the fourteenth
day. 2. Colored laborer, age 35; right inguinal hernia. Pa-
tient's condition was so grave that an operation was not consid-
ered justifiable. At the autopsy 1,000 co. of dark, bloody,
offensive liquor was found In the peritoneal cavity. The small
Intestine was black and leathery, ofi'ensive in odor, and con-
tained a similar dark bloody fluid. The bulk of the gangren-
ous intestine lay on the left side of the median line. The
mesentery was twisted from right to left and from below
upward through an arc of 180°, the upper edge of the twisted
mesentery compressing the Intestine at a point eight feet from
the pylorus, enough to leave a marked Indentation. The
superior mesenteric artery and vein were included in the
twisted mesentery, and the vein was filled with a large throm-
bus ; hence the enormous amount of gangrenous intestine, 12
feet 8J inches of small Intestine, and Including the cecum, which
was also gangrenous, a little over 13 feet. 3. White male, age 42.
A diagnosis of chronic obstruction of the bowel, probably at
the ileocecal valve, was made. Either tuberculous ulcer or
cancer was suspected. The abdomen was opened through the
right rectus muscle, opposite the navel, and a tumor of the
hepatic flexure of the colon discovered. Six inches were
resected and an end-to-end anastomosis made by Connell's
suture. The tumor was an adenocarcinoma, [f.c.h.]
'Annals of Surgery, July, 1902.
« Washington Aledlcal Annals, July, 1902.
August 9, 1902]
THE WORLD'S LATEST LITERATURE
[AMERICAN Medicine 233
New Trephine for Osteoplastic Resection of the Skull.—
Da Costa ' describes an instrument designed by Dr. T. C. Stell-
wagen, Jr., a Inedical student, for cutting an osteoplastic flap
in a minimum of time and without inflicting serious concus-
sion upon the brain. Tiie instrument consists of a shaft, to
which is fastened at a right angle a movable bar carrying at the
end a knife or saw, as desired. Da Costa has used this instru-
ment in one case with eminent satisfaction. He thinks the
ordinary trephine is still the instrument for making a moderate
sized opening ; for removing large circular pieces of bone the
new instrument should be given the preference, [a.g.e.]
Operative Treament of Hemorrhoids.— C. F. Nassau,'
after criticizing some of the common operative methods for
hemorrhoids, describes the method employed by him, which is
as follows : After cleansing the parts in the ordinary manner
the patient is placed in the lithotomy position. The operation
may be done either with general or local anesthesia, although the
former is preferable as a rule. The first step is a slight stretch-
ing of the sphincter, which should not be carried to the extent of
paralyzing the muscle. A gauze tampon is next carried well
up into the bowel, and a circular Incision is made just within
the margin of the skin, which should include more than half
of the anal circumference and be carried through the whole of
the rectum to the fibers of the external sphincter, being careful
not to wound this muscle. The bowel can be readily pulled
down and the dissection carried above the hemorrhoidal area,
aided by the index finger in the rectum. Before the incisions
are closed all bleeding points should be ligated. Subcutaneous
sutures of silk are placed to anchor the bowel to the skin.
These [sutures should include the whole of the bowel but not
puncture the mucous membrane. The redundant hemorrhoidal
tissue is then cut away, bleeding points ligated, and the skin
and mucous membrane approximated by interrupted fine
sutures. In order to obliterate any " dead spaces," a half-inch
rubber tube, four inches long, wrapped with gauze and smeared
with boric acid ointment, is placed in the rectum. This rectal
plug should be left in from six to twelve hours, and in some
cases has been left in for several days without much discom-
fort, [h.c.w.]
Treatment of Intraperitoneal Abscess of the Appendix.
— Wallis' reports eight cases of abscess of the appendix, seven
of the patients ranging from 11 to 20 years. Wallis' experience
has been that suppurative appendicitis is much more common
than the recurrent form in young people, and that surrounding
adhesions are much more frail than in adults. The treatment
adopted is walling off the general peritoneal cavity, opening
the abscess, sponging the abscess cavity dry, removing the
appendix if in sight, dusting with iodoform, and packing with
iodoform gauze. In some cases hydrogen peroxid was used to
cleanse the cavity before packing. In Case 8 the right iliac
fossa and the pelvis contained a large quantity of seropurulent
fluid with no appearance of localization. The fluid was removed
and the same treatment as in the other cases employed, the
only addition being a drainage tube in the rectovesical pouch.
Recovery followed in each case, there being a ventral hernia in
one. [a.o.e.]
GYNECOLOGY AND OBSTETRICS
WiLMEB Kbusen Frank C. Hammond
Ethyl Clilorid as an Obstetric Anesthetic. — Sir
.JiuneH Y. Simpson mailt- a memorable flfriit for the use
of ani'sthietics in midwifery, since which time the pro-
fession has advanced sufficiently to realize the impor-
tance of relieving the pangs of woman enduring the
martyrdom of maternity. Were the niiisculine .sex
burdenwl with the task of parturition we have no doubt
that the employment of anesthetics would l>e very gen-
'i-iil. Kut because women have suffered, and bear suf-
fi^ring with fortitude and e(}uanimity, many times they
are allowed to suffer unnecessarily. It is customary for
surgeons to administtsr an anesthetic for slight operations
> AnnaU orHurgery, July. 1002.
« Medicine. April. i«02, p. 277.
'Lancet, July 19, 1902.
in which the sufffering would be incomparably less than
that experienced during labor, and yet they refuse to
give the slightest relief to the often agonizing parturient
pains, fearing that labor may be prolonged, or the force
of uterine contractions lessened. Properly employed,
there is rarely any contraindication during the latter
part of the expulsive stage of labor, and judicious use of
an anesthetic spares the patient unnecessary exhaustion,
and is indicated on both humane and scientific grounds.
Some physicians are even in the habit of applying
forceps and performing minor obstetric operations with-
out anesthesia, which seems an unwarranted barbarism,
(Juite recently the intraspinal cocainization has been
practised by Kreis of Germany, Marx of New York,
and others for obstetric analgesia with satisfactory
results, but this method offers no apparent advantages
over other anesthetics, while it has not a few disadvan-
tages and dangers. We have repeatedly called attention
to the value of ethyl bromid as an anesthetic agent,
requiring a small amount and producing analgesia
rather than anesthesia. It eases the pain quickly, does
not suspend muscular contractions, nor predispose to
uterine inertia; but the majority of the profession
regard it with distrust because of some unfortunate
results occurring when an impure drug has been
employed. More recently the ethyl chlorid, which
has been in the hands of the profession for many years
as an agent which, by its rapid evaporation, could be
used as a local anesthetic, has been brought forward as a
valuable means of general anesthesia when given by
inhalation. It was in 1896 that Soulier and Briau first
ma<le known the anesthetic properties of the ethyl
chlorid and Von Hacker made the first clinical test of its
value in 1897.
As to the value of ethyl chlorid in obstetric work we
refer to the testimony of Lepage and Lorier.' After re-
porting in detail 14 obstetric cases they summarize its
advantages as follows: Itiseji.sy of administration, the
dose being always the same ; anesthesia is obtainetl in
from 30 to 60 seconds at the most, and lasts four minutes
without repeating the dose ; the return to consciousness
is very rapid and rarely accompanied with any nausea.
It can be used with advantage under the following con-
ditions : (1) In the course of labor when it is necessary
to extract the fetus with forceps or to perform version by
internal maneuvers or to lower the anterior foot in
incomplete breech presentation. In the last circum-
stances the ethyl chlorid has this advantage, it per-
mits a rapid awakening of the patient, who can then by
her own efforts terminate the expulsion of the fetus ; (2)
its use is also indicated when manual removal of the pla-
centa from the uterine cavity is requiretl ; or if in the case
of very weak women it is deemed wise to extract the
membranes when they remain in grait i)art in the
uterus ; (.'!) after delivery this mwle of anesthesia may
be uswl while making any necessary sutures of the peri-
neum. It is also recommended when during pregnancy
an examination under ani'sthesia is indicated to deter-
mine any abnormal or vicious pelvic condition of diag-
nostic difficulty.
The writers then urge their confreres to state whether,
in their use of ethyl chlorid as a genend anesthetic,
they have olwerved any accitlents or known of any con-
traindications. Convinced that, primarily, not to injure
is the capital duty of the physician, they will c-ontinue
their experiments in the use of this agent all the more
willingly if their collwigues can confirm their observa-
tions that the ethyl chlorid is efllcac!ious and, what Is
more imi)ortant, that it is harmlms.
The Clinical SiKnIflcanoe of R<'lroflexio MobtlU Uteri.
— Wormsor,' from his studios and clinical experiences, con-
cludes: 1. The uncomplicated mobile retroflexion of the uterus
1 Gazette hcbdomadalre de MMeclce et de Cblrurgte, May 4, 1902.
« MUncliener medlclntscbe Wochenschrirt, July 8, 1902.
23 4 Auebica:; MEDioiincj
THE WORLD'S LATEST LITERATURE
[August 9, U)02
In absolutely healthy women iu the majority of cases causes no
pain or distress, hence it requires no treatment, except perhaps
in case of pregnancy. 2. The symptoms of which women with
mobile retroflexion complain iu the great majority of cases are
due to secondary causes ; either they originate with some com-
plication not easily recognized, or they form the expression of
a more or less marked disturbance of the nervous system. In
both cases the retroflexion as such is not responsible for the
symptoms. The treatment has, therefore, as its chief object the
healing of the nervous system. When this therapy fails the
attempt to correct the malposition must be undertaken. In a
recent work by Theilliaber, the author states that in the last
nine years he had among 1,000 patients with retroflexion of
the uterus seen no case of reflex neuroses, [w.k.]
Operative Treatment of Malignant Disease of the
Uterus. — Taft,i in considering malignant disease of the cervix,
claims that when there is an infiltrating growth of the cervix
with little ulceration, bleeding very little and causing only
slight discharge, and on examination evidence of some exten-
sion of the disease to the broad ligaments is discovered, it is
probable that no advantage will result from removal of the
uterus. When, however, there is a large sprouting or slough-
ing growth of the cervix, causing serious and recurring liemor-
rhages or profuse and offensive discharge, there is no question
that removal of the uterus gives great relief, and prolongs life,
even when a permanent cure cannot be looked for. Such
patients often increase in weight, improve in color and, for a
time, at any rate, they are able to enjoy life and perform their
ordinary household duties. In deciding to advise operation in
any case of this kind it is essential that the uterus should be
fairly movable, so that the operation can be completed without
undue difficulty. Any extensive involvement of the cellular
tissue around the uterus causes fixation of that organ and
makes it impossible to drag the cervix down toward the vulva.
Such cases are absolutely unsuitable for any radical operation.
An important symptom in connection with the operative treat-
ment of cancer of the cervix is the presence of pain. If a
patient is still free from pain the case may or may not be a
suitable one for operative interference. The presence of per-
sistent pain referred to the back or to the sacroiliac synchon-
drosis is a contraindication to operation, as it indicates the
involvement of nerves in the parametric tissue by the malig-
nant growth. As a palliative operation he recommends vaginal
hysterectomy and endorses Martin's words, " When the opera-
tion is an easy operation it is a good operation ; when it is a
difficult operation, it is a bad operation." When there is too
extensive disease for any radical operation to be recommended
a considerable amount of relief may be obtained in certain cases
in which there is a large amount of sloughing or sprouting
growth, causing severe hemorrhages or offensive discharge.
These masses of growth should be cut freely away with a pair
of scissors, and the cautery applied to the bleeding surface left.
The vagina should then be packed with iodoform gauze. After
this treatment patients are often relieved from any excessive
discharge for many months. On two occasions when the
writer performed this operation in patients past the menopause
the anterior and posterior surface of vaginal mucous mem-
brane united over the stump of diseased cervix left, and the
patients were entirely free from discharge for about 12 months.
For malignant disease of the body of the uterus, when tlie
vagina Is sufficiently capacious and the uterus not of very large
size, vaginal hysterectomy can be strongly recommeued, as it
is an operation which exposes the patient to very slight imme-
diate risk, and at the same time the ultimate results of the
operation are very satisfactory. When the uterus is too large
to be removed through the vagina entire, it should on no
account be removed by any process of morcellement, as it is
most Important to keep the growth entirely shut off from all
freshly incised surfaces and from the peritoneum. In all these
cases it is best to remove the uterus by the combined vaginal
and abdominal methods, as this permits of more free removal.
[w.k.]
NonsurRical Treatment of Retrodisplacements.— While
uncomplicated ratrodisplacements rarely cause uneasiness,
1 The Practitioner.
the occurrence of complications produces a train of marked
symptoms which find no permanent relief without correcting
the position of the uterus. According to Montgomery' the
tendency today is away from mechanic measures as surgical
ones are regarded as more certain and effective. But when the
latter are refused by the patient we are forced to use mechanic
measures, usually tampons or pessary. The pessary should
never be used to correct a faulty position of the uterus, but to
maintain it in a correct position. The best methods of corrects
ing a faulty position are Ijimanual manipulation with the
patient in the dorsal position, or the use of Sims' speculum with
the patient in a genupectoral position. These methods may be
used only when the uterus is freely movable, otherwise pre-
liminary treatment may be necessary to loosen adhesions, such
as pelvic massage, painting the cervix and vaginal vault with
tincture of iodin, and the use of medicated tampons. The
uterus being restored to its normal position, a suitable pessary
may be employed, that of Mundc or Thomas being preferable.
The proper length of the pessary can be determined by pressing
two fingers into the posterior fornix and estimating upon them
the situation of the posterior border of the symphysis; the
width is determined by separating the fingers. The pessary
should not make undue pressure at any point and should be
large enough so that it will retain its position. The patient
sliould be instructed how to remove the instrument should it
give pain. She should consult the physician occasionally to
see that no injury is done. Cleanliness should be secured by
irrigation with hot water or a weak formalin solution. Solu-
tions of mineral astringents should not be used because their
salts are deposited upon the instrument, making it rough and
producing injury, [w.k.]
Operation for Cancer of the Uterus. — Sinclair^ gives a
liistoric review of the relation of the various operations for
cancer of the uterus, describes in detail their technic, including
Schuchardt's operation, or paravaginal section, and its results ;
Wertheim's modification of Freund's radical abdominal opera-
tion; and total extirpation per vaginam. The last operation
maybe undertaken when the uterus is entirely free in its move-
ments, with the hope of permanent immunity from recurrence,
or when the uterus is not absolutely normal in its movements,
with the intention of obtaining palliation in the extreme degree.
He describes the operation and expresses the opinion that
should recurrence take place, the course of the disease is, as a
rule, euthanasia, compared with the sufferings of the case
which has run its course without interference from the first.
Sinclair states that in Germany the old experienced operators,
with few exceptions, adhere to the vaginal operation, or only
try the newer methods to abandon them. Even in France the
genuine gynecologists prefer the vaginal route in operating for
cancer. The same is true in Italy and Holland, but in America
the evidence is conflicting. In regard to palliative surgical
treatment his experience is chiefly in the use of zinc chlorid,
and a description of his method of applying it is given. Among
the advantages of tliis method of treatment are the arrest of
hemorrhage, and, to a very large extent, of the foul-smelling
discharge. There is also a restoration of appetite, with better
assimilation, and in nearly all cases there is, for a longer or
shorter time, a marked change for the better in the patient's
mental and physical condition, [w.k.]
TREATMENT
Solomon Solis Cohen
H. C. Wood, Jr. L. F. Appleman
Mechanic Treatment of Movable Kidney. — That
movable kidney and the associated ptoses of abdominal
viscera, especially of the stomach, are quite common,
and in the hurry of general practice often overlooked, is
a proposition from wliich few hospital physicians or sur-
geons will dissent. While the hour-glass corset is not
the only cause of these conditions, their relative infre-
quency in men and their great frequency in women lend
' International Med. Magazine, July,
! The Practitioner.
1902.
August 9, 1902]
THE WORLD'S LATEST LITERATURE
[Akkkican Medicine 235
support to the theory that It is the ordinary cause. Sur-
gery is not always to be desired, and not always success-
ful. It is probably unavoidable when great and perma-
nent displacement of the kidney or of the stomach
exists, but these cases are the minority. In our personal
exr>erience, in many instances through haste or super-
ficial examination diagnosticated as nervous dyspepsia,
neurasthenia, hysteria, and the like, minor degrees of
niovability have been found ; and in two instances, the
one mistaken for hepatic colic, the other for renal colic
by good observers, intermittent displacement of consid-
erable degree was demonstrated. In the Therapeutie
Gazette, July 15, 19(i2, p. 445, et seq., Dr. A. Ernest
Gallant, of New York, discusses the subject fully and
wisely. Premising that the condition is difficult to
treat, requirmg patience and implicit obedience on the
part of the sutferer, gentleness and perseverance on the
part of the physician, he advises a routine that may
thus be summari7,ed : 1. li^st in bed from three to six
weeks. The foot of the bed must be elevated to favor
replacement by gravitation. An ordinary muslin binder
snugly pinned is to be applied continuously. 2. To
ensure restful sleep for the first few nights, chloral and
bromid may be needed. 3. For the first few days all
nourishment is to be withheld and a neutral water
administered in doses of six ounces hourly to flush the
kidney, liver and bowel. After this liquid food and
hot water, then semisolid diet, then full nourishment
(in the third or fourth week) may he given. 4. Massage
and passive and active exercises of an appropriate char-
acter are carried out with gradual increase of activity.
5. To improve cardiovascular conditions, nitroglycerin
.strophanthus, digitalis and strychnin are given. 6. Vis-
ceral support is affbrded by means of a corset as long in
front as (;an be worn. It must be flattened over the
suprapubic triangle (bounded laterally by Poupart's liga-
nients and above by a line joining the anterior superior
iliac spines) where maximum pressure is to be exerted.
At the waist line there should be just enough contrac-
tion to support the kidney, and above that point nega-
tive pressure. Measurements for the corset must be
taken with the patient lying on her back. The corset
must be cut from measurements taken while the patient
is lying upon her back, and it will I)e found that owing
to gravitation of the viscera upward toward the
diaphragm the circumference on a level with the anterior
superior spines will have decreased from three to six
inches, the object being to retain the viscera in this por-
tion of the abdomen. A more rounderl, graceful (fash-
ionable) outline can be given to the flgure by fitting pads
over the hips, and these, if sewed inside the corset, can-
not be displaced, nor are they discernible when the
woman is dressed. When about to put on the corset the
woman places it around the waist, lies down upon the
bed, draws up the knees, and fastens the hooks from the
lowest one upward. Before fastening the second catch
she must raise the hips into a semiopisthotonos position
to displace the viscera still further upward and facilitate
the adjustment of the corset. All sources of irritation,
physical and mentjil, should be removed, the former
by skilful treatment^gynecologic, surgical, ophthalmic,
medicinal, or as may be needed.
Treatment of Lupns by Means of Caustics.— The J^owr-
nal den Pratieienn, .Iiine 22, 1901, states that the treatment of
lupus by caustics is inferior to Finsen's method, cauterization,
scarification, or the radical cure, but that it may l)e employed
when the other methods cannot be used. Uuna has used the
following:
of each i dram
Salicylic acid
Solution of antimony chlorid .
Creosote I . , . ,
Extract of cannabis Indies .... | o' ea<!li 1 dram
Lanolin 2 drams
After cocainization this paste is applied to the diseased area
with a spatula, covered with a zinc oxid plaster and allowed to
remain for 48 hours, and then renewed. If the lupus is hard
and unyielding, the tissues surrounding the nodules may be
softened by means of alkaline caustics, such as :
Caustics potash ]
Slaked lime . . „ , ,
Black soap .....'. ^ of each equal parts
Distilled water '.....'. . . ' J
This is applicable only to lupus which is superficial.
[L.F.A.]
Speedy Method to Relieve the Pain of Piles.— W.
CATter {Liverpool Medico-Chir. Jour., March, 1902) relat<is the
immediateandpermanentrelief of extreme pain caused by a
suddenly protruded pile by a single application of a suppository
composed of 10% of cocain and 20% of menthol in cocoa butter.
[g.c.c.h.]
Phototherapy In the Treatment of Neurasthenia.— The
important modifications which occur in the nervous system fol-
lowine treatment by colored-light rays or decomposed light
have suggested to P. Joire( Lille, La Semaine iUdicale, April
23, 1902) the utilization of phototherapy in combating neuras-
thenic troubles. Red rays are to be preferred from theirgreater
penetrative power and their regulatory action on the circula-
tion. Their use is particularly indicated in hyperesthesias,
and their anodyne effect is supplemented by a beneficial effect
on the general tone of the patient, an increase in appetite and a
general regulation of digestion and nutrition. Notwithstand-
ing their great sensibility, neurasthenics bear treatment with
red light without difficulty, the vibrations of these colored rays
being very slow. [c.s.D.]
Hypodermic Injections of Gelatin Solution.— C^rac (ie
Mois ThSrapeutique, Vol. xlii, No. 2, 1902, p. 24) does not con-
sider that the hypodermic injection of gelatin solution is a
specific in the treatment of hemorrhages, but it is an excellent
hemostatic agent, particularly in rebellious cases in which
hemostatics are usually employed. In hemoptysis and hema-
temesis Ci5rac has obtained good results from the subcutaneous
injection of gelatin solution when all other hemostatic proced-
ures failed. [n.r.A.]
Climate for Dysmenorrhea.—" When this condition is
connected with chronic conge.stive conditions of the pelvic
organs and subinvolution of the uterus, it may be treated by
simple thermal baths, tliermal baths of mud and peat, and
other thermal baths at various health resorts, and l)y internal
courses of muriated, muriated alkaline, and sulfated alkaline
waters, the last especially when there is constipation. In
America, mud-baths with suitable medical supervision are
found at Las Vegas Hot Springs, in New Mexico, at Mudlavia,
near Attica, Indiana, and at Klamath Hot Springs, in Califor-
nia. Chalybeate and arsenic spas, associated with gentle
hydrotherapeutic measures, may be useful when there is
anemia. For delicate, thin patients of an irritable, nervous con-
stitution, simple thermal spas during summer and warm
climates during winter may be tried ; but the condition in
these 'neura.sthenic' subjects is often very intractable, and in
some cases may bo more or less persistent through the whole
period of sexual life. An open-air life, with suitable occupation
and muscular exercise, but with the avoidance of physlcjil and
mental overexertion, may do much good, and this may be ren-
dered possible by selecting warm climates for winter residence,
where much time can be spent in the open air. It is probable
that proper attention to tho physical development of growing
girls by encouraging open-air exorcises and games, for exam-
ple, walking, cycling, riding, swimming, rowing, lawn-tennis,
and tho like, and the prevention of all overexertion, and
especially of too prolonged Indoor occupation, have a pre-
ventive action in regard to tho neurotic forms of dysmen-
orrhea."—F. P. Wober, "Climatology and Health Itosorl-s."
Olive Oil In Treatment of Pyloric Duodenal Stenosis.
—Paul (johnlioim (/>i> Thcrapie der Orgeiiwarl, 1902, No. 2), of
Horlln, emphasizes the value of large do.sos of olive oil in the
treatment of organic and spastic stenosis of the duodenum and
liylorus and in their sequels (gastroe<;taals). He employs the
oil in doses of 80-260 grams at body temperature, before meals.
Treatment of Ocular Tuliorcniosis by Injections of
Air Into Che Anterior Chamber.- W. Koster (,La Semnine
MMicale, April 23, 1902), Professor of Uphthalmology In Ley-
236 A.1IBRICAN MBSICINE]
THE WOELD'S LATEST LITERATURE
[AUGUST 9, 1902
den, has treated successfully two cases of tuberculosis of the
iris by injestions of air into the anteriorchamber. The needle
of a hypodermic syringe partly filled with sterilized air is intro-
duced into the anterior chamber and the aqueous tumor aspi-
rated, thereby lowering the syringe so that the fluid falls to the
bottom of the instrument; pressure on the piston serves to
force the air into the anterior chamber, [c.s.c]
Geraniiie in Diabetes. — Bulletin Oingralde Thdrapeutique,
Vol. cxliii, No. 5, 1902, p. 192, states that geranine has been used
in diabetes in the dose of 10 drops of the fluid extract three
times a day. The amount of sugar in the urine has been mark-
edly decreased by its use. It has also been employed success-
fully in certain cases of dyspepsia and nervous disorders.
[L.F.A.]
Intratracheal Medication. — Donellan {Therapeutic Ga-
zette, May 15, 1902, p. 297) speaks very favorably of the intra-
tracheal method of introducing remedies in various bronchial
and pulmonary conditions, from chronic bronchitis to tubercu-
losis. By this route not only is disturbance of the stomach
avoided but direct local action of drugs on the lung is obtained.
If attention is paid to technic no unpleasant symptoms result.
He uses an antitoxin syringe with a glass barrel of two drams
capacity and a graduated piston with an asbestos plunger. The
piston is fitted with a thumb ring, and attached to the barrel is
a revolving collar, with rings for the insertion of the index and
middle fingers of the right hand — a device of much value in
steadying the instrument during its use. To the syringe is
attached a suitably bent laryngeal cannula with a closed tip but
having four fine lateral openings. The larynx is first anesthet-
ized with a 4% solution of cocain on a cotton wound-applicator,
the syringe is then charged with the selected medication — one
to two drams being the amount employed — the patient is in-
structed to protrude the tongue and hold its tip in a napkin
while the operator, guided by the laryngeal mirror in full
illumination, inserts the tip of the syringe between the vocal
cords, and while the patient takes a deep inspiration the injec-
tion is slowly discharged into the trachea. The remedies em-
ployed are creosote, menthol, guaiaeol, or camphor, in 1% to i%
in olive oil or liquid petrolatum. Donellan reports several
cases illustrative of the good results, [h.c.w.]
Arrhenal. — Gautier (La MSdecine Moderne, Vol. xiii. No. 9,
1902, p. 77) calls attention to this new arsenic compound, which
is disodium methylarsenate, of the cacodylate group. It
does not cause irritation of the stomach and has no unfavorable
after-effects. Gautier has used it with extraordinary results in
the treatment of tuberculosis; cough diminishes, appetite
returns, gastric pain and vomiting cease, and the anemia is
markedly decreased. Equally good results have followed its
use in the obstinate vomiting of pregnancy. The usual dose is
from i to IJ grains, administered hypodermically or by the
mouth. When so given it has effected a cure In some cases of
malaria which resisted absolutely the action of quinin. In
severe cases it may be used in double the above doses, [l.f.a.]
A Comparison of the Climate of Algiers with That of
the Riviera. — Thompson (Jour. Balneology and Climatology,
Vol. V, part 3, 1901, p. 169) gives an account of the various spas
at Bisk rah and Hammam R'Irha in Algeria. These springs
should be better known if only because, owing to their summer-
like surroundings, they are available during the winter months
when European and American spas are closed. Algiers can be
reached from London in two days, and the trip from Marseilles
by boat, which lasts about 24 hours, is an enjoyable feature of
the journey. The climate of the town of Algiers itself is dis-
tinctly relaxing, owing to the proximity of the sea, differing in
this respect from that of Biskrah and the other desert resorts.
The town is surrounded on the west and north by the hills of
Mustapha SupSrieur, which shelter it from the wind, and at the
same time cut off much of the evening sun. Some of the houses
at the top of Mustapha Sup6rieur and El Biar are at an elevation
of 800 feet, and have a glorious climate. Even in summer, life
at Algiers is enjoyable. The various views regarding the
climate of Algiers are explained by the fact that the town, being
situated at the bottom and at the top of a range of hills, has two
or three distinct climates ; the rain comes in torrents for a
week or more, at which time the humidity is excessive ; this
being followed Vjy periods of drouth, during which, but for the
heavy dews, vegetation would suffer. Algiers is not suitable
for cases of chronic or acute rheumatism ; it is especially
suited to cases of tuberculosis in which there is an irritated
bronchial, laryngeal, or pharyngeal membrane. In emphysema
asthma and particularly in cases of weak heart, w'hether func-
tional or organic, the sedative quality of the air is of much
value, especially is this the case in Bright's disea.se. [r.m.o.]
Treatment of Bronchopneumonia in Children.— Poli-
euctov (Tm Midicine Moderne, Vol. xiii, No. 18, 1902, p. 150)
employed the hot bath in 37 cases of bronchopneumonia in chil-
dren and obtained 34 cures. The hot baths seem to stimulate
resolution of the pulmonary process, lessen the cardiac activity,
gradually lower the fever, thus hastening the termination
of the morbid process, and, finally, stimulate the appetite and
general nutrition. Polieuctov directs that the patient be placed
in water at a temperature of 96.8° P., then rapidly raise the tem-
perature of the water to 102° or 104° P. One or two baths may
be given in 24 hours, each not lasting more than 15 minutes.
After the bath the patient should be wrapped in woolen covers.
Rigorous antisepsis of the mouth and nasopharynx should be
practised. The total duration of bronchopneumonia under this
treatment was from two to three weeks, [l.f.a.]
Aspirin. — GOrges ( Medical Press, June 18, 1902, p. 663) uses
aspirin instead of the ordinary salicylates altogether. It has
much less tendency to cause unpleasant symptoms; he has
given as high as 15 grains daily to a child of eight. He finds it
useful in all cases in which tlie salicylates are indicated, as
acute or chronic rheumatism, chorea, neuralgia, etc. [h.c.w.]
[The dose stated is rather large. Caution is necessary in the
use of this drug, s.s.c]
Treatment of Hemorrhages in the Infectious Dis-
eases.— Roger (Journal des Praticiens, Vol. xv. No. 52, 1901,
page.823) states that in hemorrhages from the lungs and kidneys,
during the infectious diseases, the patient should be immobi-
lized, and bathing should be discontinued. If the patient is
restless, delirious, or if there is much cough, he should be
calmed by opiates. Following these precautions, acid drinks,
such as citric or sulfuric acid lemonade, are often prescribed to
increase the coagulability of the blood. The following acid
elixir of Haller has been used in hemorrhagic smallpox :
Xhii '^'='' }°fe-^ 3o<i-p«
Syrup 3J ounces
Distilled water 13 ounces
Calcium chlorid has given good results in some cases.
This drug can be employed only by the mouth, for in hypoder-
mic injections it causes sloughing and eschars. Roger pre-
scribes it in the average dose of one dram daily, which is
usually sufficient to control the hemorrhages, although the dose
may be increased gradually to three drams in the 24 hours.
Purgation was not produced by its use. Roger administers it
in the following formula :
Crystallized calcium chlorid 1 to li drams
Rum 1 ounce
Tincture of cinnamon li drams
Distilled water I3 ounces
The alcohol should be omitted from this prescription if
lesion of the kidney exists. In hemorrhagic nephritis, the
hematuria disappears rapidly in two or three days. When the
source of hemorrhage is accessible, very hot or very cold appli-
cations may be employed. Hemorrhage from the mucous
membranes may be arrested by the application of antipyrin,
which produces local constriction. Alum, tannin and rhatany
are the astringents usually employed. Carnot has had excel-
lent results follow vaginal or nasal injections of gelatin solu-
tion, as follows :
White gelatin ) , . gl drams
Sodium chlorid ( °' ^^"^^ ^^ arams
Corrosive sublimate 7.5 grains
Distilled water 3J ounces
The local application of pure hydrogen dioxid will arrest
local hemorrhage, but it causes some pain, [l.f.a.]
[Pure calcium chlorid may be used in moderate amounts,
hypodermically, if well diluted. It may be used as rectal infu-
sion in the proportion of a dram to a half-pint. Administration
August 9, 19*2]
THE WOKLD'S LATEST LITEEATUKE
fAKXBIOAK MeBIOINB 237
by the mouth is usually preferable. Thymus extract is an
excellent local hemostatic, s.s.c]
Artificial Serums In the Treatment of Mental Dis-
eases.— Buvat (Joiirnal de.i Praticieiis, Vol. xvi, Xo. 2, 1902,
p. 26) states that serumtherapy must not be used exclusively
nor applied systematically in the treatment of mental diseases,
its indications depend upon the physical state of the patient and
upon the symptoms that he presents. The dose should be large,
one i)int at least, and repeated every day or every three to five
days, according to the eftect obtained. The artificial serums
stimulate the physiologic functions of the body, removing
waste products by favoring eliminating secretions ; the general
condition of the patient improves rapidly. Sodium chlorid
serum, 0.75%, is valuable in recent and acute toxiinfectious
psychoses, which may occur in the form of melancholia, mania,
or mental confusion; in the depressant forms with cardiac
asthenia, 15 grains of caffein may be added to one quart of
serum. In some cases the psychic troubles disappear as the
general condition improves ; in other cases the psychic troubles
remain stationary or become chronic and the physical troubles
improve. Bromid serum consists of :
Sodium bromid 90 grains
Sodium chlorid 22 grains
Water 1 quart
This is indicated in all cases of melancholia with nervous
restlessness, in maniacal agitation, and in certain aged patients.
In epilepsy it acts better in a great many cases than the admin-
istration of bromids by the mouth, while the acne disappears
and all physiologic functions are stimulated. lodid serum,
composed of:
Sodium chlorid 90 grains
Potassium iodid 30 grains
Sodium sulfate 30 grains
Water 1 quart
is employed in general syphilitic paralysis. Patients sub-
mitted to this treatment for a year have improved greatly.
[L.F.A.]
FORMUIiAS, ORIGINAL AND SEIjECTED.
Treatment of Dysentery.— Dabney (Therap. Oaz.) recom-
mends
Morphin sulfate J grain
Sodium sulfate 1 ounce
Dilute sulfuric acid 1 dram
Cinnamon water 4 ounces
Tablespoonful in 2 ounces of cool water every 2 hours.
[H.C.W.]
For Chlorosis. — Mendel (Therap. Monatsch., April, 1902)
prescribes
Sodium cacodylate 30 grains
Syrup 6 drams
Oil of peppermint 2 drops
Water, enough to make 6 ounces
Teaspoonful 3 times a day. [h.c.w.]
NERVOUS AND MENTAL DISEASES
J. K. Mitchell F. Savaky Pkarce
Itapid and Slow lieNpii'iitiou Especially During'
Sle«p »>♦ Evidence Toward Organic Disease of Pons
and Me«lulla— One of the last careful papers of the
late J. T. Eskridge' takes up the subject of " ex-
ceedingly rajiid and very slow respiration," the author
reporting clinically and pathologically a case coming
under his observation. " Hysteria was painted on an
organic background" (S. Weir Mitchell) in the case
detailed. Tlie woman wits 29 years of age, a school
tcaciier, married at 19 ; was in a railroad wreck at 19J
years of age ; immediately after this great pain devel-
oped in the occipital region, and over the cervicodorsal
spine ; she was confined to lier IkhI three months and
finally developed general hysterical paroxysms in which
she assumed an ()|)isthotonic position, etc. Tht>se par-
oxysms continued irregularly until the development of
her fatal illness nine years later. In the meantime she
> Denver Medical Times, May, 1902.
had borne a syphilitic child (her husband was proved to
be infected by lues) and shortly afterward while at an
altitude of 9,000 feet (October 25, 1899) she was seized
with a fainting spell which was followed immediately
by an hysterical paroxysm. Morphin administered
hypodermically gave transient relief. Her pulse, tem-
perature and respirations when seen in an hysterical
attack were 120°, 100, and 24 respectively. Eskridge
records at this date that " while many of the patient's
symptoms are hysterical in character, she is suffering
from some obscure organic lesion of the brain ; its exact
nature I am unable to determine." November 14 the
respirations became intermittent in character only while
a.sleep, 29 in three minutes. Intermissions 25 .seconds in
length occur. Next day the patient was in a stupor, the
legs which previously were flexed at knees and hips
were so no longer. November 23 temperature was about
normal, pulse 110 and respirations 10 to 11 while awake,
34 while asleep. Death occurred January 9, the respira-
tions running from 50 to 100 or more, while 15 minutes
before death they eame down to 24.
Necropsy showed on the lateral surface nothing save
at the fissures of Sylvius, where the temporosphenoidal
lobes are separated with difficulty from the frontal
lobes on account of thickenings and adhesions of the
membranes. The pia could not here be detached
without tearing the cortex. The upper formations of
the flasures of Sylvius were found to be the seat of
inflammation. Numerous tubercular nodes were found
along these portions of the middle cerebral arteries. At
the base the lower portions of the fli?sures of Sylvius were
found in the same condition as the upper. The pia around
the chiasm was thickened, accounting for the optic neuri-
tis. Both lateral ventricles contained excess of thick
turbulent fluid.
Microscopic examination revealed areas of round-
celled infiltration in the region of the respiratory center,
particularly numerous in the region of the floor of the
fourth ventricle.
This patient had not come from a neurotic stock, l)ut
had become hysterical after a railroad injury, when she
was thrown lorward, her head striking on the civr seat in
front of her. From that date to the end of her life she
remained hysterical, having at first remained in bed
three months. The author says an injury to the medulla
from the trauma may have determined the location of
syphilitic lesion of this organ. To what extent the
tubercular lesion of the membranes may have modified
symptoms is difficult to fathom. The irn-gular fever,
being higher in the early morning than during the latter
part of the day, was rather in favor of an inflammatory
lesion complicsiting it. The irritative lesion of the
exciting centers of respiration must have been the cause
of the rapid respirations, while irritation of the inhibitory
centers of respiration no doubt cause tlie slowing at
times of respiration, at one time to one or two per minute
and on one occasion arresting respiration entirely, it
being restored artificially.
Eskridge, in concluding his inten.sely interesting and
important cuse, makes the perhaps not premature asser-
tion : " Let me add that when we find a cast> of hysteria
we perceive the veil that obscures or the cloak that
hides the symptoms of organic di.sea.se or gravely dis-
ordered functions of some important organ."
The value of the contrii)ution we have given with
some detail has its sidelights, particularly as to medico-
legal consideration. For if the author is cornn-t, con-
cussion of the l)rain may i)roduc-e at least a vulnerability
of important centers (respiratory) in the brain ; and why
not lesion? Ha<l this woman not had the specific infec-
tion the liysteria may have gone on for another decade,
but it is certain she was from the first a disabletl person,
due to accident and trauma. The writer has a patient
under his care who nine years ago, while driving, was
struck by an engine and has been an hystt^riml invalid
ever since, with intense pain in the occipital and cervical
288 AJOEBtOAN MEDICIKX]
THE WOELD'S LATEST LITERATUEE
[AUGUST », 1S02
regions, increased by the slightest mental or physical
effort. She had also developed shifting esophoria of from
4° to G° and more. Her respirations are not much affected,
though averaging 20 to 30 per minute. May it not
be that this woman has had an irritating lesion of the
oculomotor centers ?
The Early Diagnosis of Paresis. — No branch of
neurology is fraught with greater difficulty. The psy-
chiatrist is frequently too dependent upon mental aberra-
tion, while the neurologist is apt to give prominence to
physical signs of this insidious affection. Alas ! we are
delimiting our horizon. No alienist or savant has
become truly entitled to distinction until he has plowed
and sewed his mental fields with regard to that widest
aspect so well described by that Teutonic word ueber-
schitu.
Dercum, ' in considering this subject, speaks of
the difficulties of the matter since we are ''confronted
with borderland conditions and overlapping states."
The general disturbances preceding the special symp-
toms indicative of organic disea.se are too mucli over-
looked. The physiognomy of the patient, his general
lack of vigor, the constriction type of headache, tinnitus
and vertigo, associated with easy tire, may lead to the
mistaken diagnosis of neurasthenia. The malignancy,
as it were, of paresis as compared with Beard's disease
is, however, readily determined by the careful student,
because in the latter the patient is acutely sensible to his
condition, while in paralytic dementia the synthesis, so
to speak, of the mind is greatly at fault, and though the
symptoms when revealed are often at this early stage
much the same as those of neurasthenia, yet are obtained
from the sufferer almost entirely in an objective manner.
Neurasthenia, on the other hand, is subjective largely
from the first. The paretic may early enough appreciate
his incapacity, but in the psychology of the malady, as
in many of the insanities, it is characteristic that he will
not admit the disability, nor even will he try to shield
the mental failure. Periods of remission and progres-
sion are also more manifest in paresis. The shooting
pains and neuralgic headache of early paresis is wanting
in nervous exhaustion, as is the incoordination and lack
of precision found in the paretic, as shown for example
in his handwriting.
The impairment of memory in neurasthenia is not
real, as the patient remembers the smallest details of
life, while the paretic early loses these. Affection for
friends, etc., is wanting in the case of paresis. The
depression with exhaustion, symptoms associated in
many cases of paresis, may lead to a mistaken diagnosis,
thus confusing it with melancholia ; but in the latter dis-
ease the idea of personal unworthiness or of self-condem-
nation is patent.
As soon as physical signs of paresis present such
as the blank features, monotonous speech, etc., there
can be no excuse for mistake in the diagnosis.
We wish simply to call attention to this great urgency
for early diagnosis of paresis in which a much better
prognosis following definite lines of treatment will, in
the near future, be brought about ; for we have reason to
believe a greater percentage of cases is due to other
causes than syphilis, and therefore more amenable to
prophylaxis or amelioration, with prolongation of life.
On the Mental Analysis.— N. Vaschiile^ and CI. Vinopas
in following out their line of research attempt " to describe the
role ol mental analysis as applied to certain psychopathic dis-
turbances," and in the present contribution speak of the
delirium of introspection brought about by mental analysis of
the subject himself, but when applied by the subject to
his surroundings this "delirium" is engrossed by one of
metaphysical nature. The authors claim to have brought to
light, therefore, the mechanism of deliriums. They claim
' American Journal of Insanity. April, 1902.
»The Journal of Mental Pathology, Vol. 11, No. 2, March, 1902.
that the solution of phenomena due to pathologic changes are
not really so deep or fundamental as those where organic
change has not been found. They attempt in the present study
to elucidate the genesis through conditions of psychologic
development for the construction of delirium which latter the
authors contend requires more than simple exaggerated mental
analysis pushed to excess. Conceptions of import differ from
trivial ones in the degree of mental analysis and the sagacity of
the subject. An intense mental image, an ideation which
exteriorizes itself, destroys the power of attention, the moral
synthesis being directed instantly toward that image and
adapting itself intimately to it. When the hallucination is
very intense, however, the state of distraction is replaced by a
true condition of mental confusion. Certain psychophysic
causes of deliriutns exist, as seen in poisoning as by hasheesh or
morphin, or in various toxin infections. It is pointed out as
noted by clinicians that hallucinations follow delirium or are
at least evoluted at the same time. "In order to be a happy
mortal it seems that one has to content one's self with the
crudest possible facts of mental analysis."
Some Unusual Drug Effects Upon the Nervous System.
—Arthur W. Dunning' speaks of the very unusual effectts of
some drugs and refers to the fact that occasionally, as in lead
multiple neuritis, through administration of potassium iodid
the neuritis may be increased by too rapidly unloading the
toxic agent from its storehouses in the internal organs. Digi-
talis will at times produce mental symptoms in moderate
dosage. In an instance of the latter drug poisoning, the
patient's symptoms began by sleeplessness at night and nerv-
ousness during the day. She was very emotional and devel-
oped violent mania within four days, and in her ravings
complained of a ring of tire about objects seen (chromatic
dispersion). Withdrawal of the drug, together with forced
feeding— whisky and mild sedatives— effected a practical cure
at the end of three weeks and the incidents of her illness were
remembered as those of some horrible dream. A case of anemic
neuritis is also reported in this paper ; a motor palsy pre-
ceded sensory paresis (this point is contested by some authors).
The use of 10 drop doses of Fowler's solution three times a day
for six weeks was the cause of the neuritis in the case.
Causalgia was the unusual sensory phenomenon noted.
The Relation of Arteriosclerosis to Disease of the
Brain.— Windscheid,^ after some general remarks on the causa-
tion of arteriosclerosis, states that sclerosis of the peripheral
arteries does not, of itself, permit of the conclusion that the cere-
bral vessels are similarly affected ; but it, with the arterioscle-
rosis of the peripheral vessels, the symptom complex of sclerosis
of the cerebral vessels exists, then the inference is justified. The
symptoms of arteriosclerosis cerebri are, primarily, a certain
mental fatigue and exhaustibility, associated with headache,
vertigo and failing memory. In persons that have long had
arteriosclerosis without symptoms, cerebral trauma may often
be the starting point of marked nervous symptoms ; among
others, a traumatic hysteria, [d.r.]
Statistical Contribution to the EtioloRy and Symp-
tomatology of Paralysis of the Insane. — Raecke,' from
Siemerling's clinic, publishes a statistical report based upon an
analysis of 136 cases of general paralysis of the insane. The
oases constituted 5.2% of the total admissions of insane patients.
Syphilis wa-s positively determined iu 57.3%, and was probable
in 20.9%. As showing the influence of alcohol, the largest pro-
portion of paralytics was found among tavern-keepers and bar-
keepers. Regarding age, 75.5% of the cases occurred between
the thirtieth and fiftieth years. There was loss of pupillary
light reaction in 58.2%. The patellar reflex was exaggerated in
55% ; absent or diminished in 33.6%. Ankle clonus was found
15 times. That there was no definite relation between the
pupillary reaction and the patellar reflex is shown in a table,
according to which the patellar reflex was exaggerated 3A
times; diminished or absent, 27 times, in cases with absent
pupillary reaction. Romberg's symptom was found 19 times.
Ataxia existed 10 times with exaggerated patellar reflex, and 17
times with diminished patellar reflex. Speech disturbances
1 St. Paul Medical Journal. May, 1902.
2 Munchener med. Woeh., March 4, 1902.
SArcb. f. Psych, u. Nervenkrankh., xxxv, 1902,Hfte. 2.
August 9, 1902]
THE PUBLIC SERVICE
■Ambbican Medicikb 239
were found in 19.1% of the eases ; transitory aphasia, in 13.6% ;
sphincteric paralysis, in 48 cases ; syncope and vertigo, in 38
cases ; epileptic and apoplectiform attacks, also in 38. In 8% ol
the cases with symptoms of Involvement of the pyramidal
tracts, the first symptom seemed to be an uncontrolable drow-
siness ; this symptom wag never found in cases with absent
patellar reflex, probably because in them tlie first symptom to
attract attention was lancinating pains, [d.u.]
Psychoses and Neuropathies. — Frantz G16nard ■ refers to
these problems in relation to cause — toxic, surgical, etc. He
speaks of psychoses due to disturbance of function or secre-
tion of the ductless glands, such as the thyroid, ovaries, hypo-
physis and suprarenal capsules, and that while many cases of
neurasthenia are idiopathic is so far as the cause is not deter-
mined, yet in the vast majority some such etiologic factor
exists. Gastroptosis or genitourinary causes should be cor-
rected in order to ensure the best results in the treatment of
the diseases in question. Nor must one fail to interpret aright
the gastrointestinal disorder ; for example, the reviewer has
in mind the case of prolonged neurasthenia in a middle-aged
gentleman who was told he had cancer of the cecum, but which
proved to be a mass in the right iliac fossa from overloaded
bloodve-ssels, due to overtaxing of the lower bowel. The man,
after being an invalid for two years, is now well. Treatment in
this case was directe<l to the digestive tract.
Note on Status Epileptlcus. — A. R. Urquahart* comments
upon the rarity of epilepsy in Scotland compared with England
and gives his experience at Perth in about 800 cases seen during
the last 22 years in subjects of the middle class, among which
number but five deaths occurred. Three of the five cases passed
into status epileptlcus before death ; one patient died " worn
out bodily and mentally ; " the other ot exhaustion. The ques-
tion of venesection in status epileptlcus is considered, some
authorities favoring, others opposing, this mode of treatment.
The use of large doses of chloral and potassium bromid per
anum is commended, as well as inhalations of chloroform.
Gowers approves of chloroform, morphia or hyoscin, but urgeS
careful use of the morphia, and the writer of the paper regards
this carefulness just as essential in the administration of hyo-
scin. He has seen no benefit attend the use of amyl nitrite and
oxygen in status, and FlechsigVs opium treatment has been tried
without efficient results. In one organic case of epilepsy the
patient died apparently of failure of respiration at the end of
extreme inspiration. [The writer has seen two cases in partic-
ular where venesection was undoubtedly beneficial In status
epileptlcus.]
A Case of Disseminated or Insular Sclerosis in a Girl
Aged 22 Years.— .7. Magee Finney ' reports this case. The
illness dated from August, 1897, over four years ago. The onset
was peculiar in that this was rapid without any known cause
or previous sickness. Within a month she was completely
paralyzed as to motion in both arms and legs. She lost control
over bladder and rectum and bedsores formed over the sacrum.
After four months the power gradually returned, and after a
period of 15 months she was discharged. Present state: Para-
plegia of complex nature; but little sway. Can walk a few-
steps, gait spastic. Tendon reflexes extremely exaggerated.
Babinski's sign present. Bladder and rectum slightly affected.
There are coarse and irregular intention tremors. Speech is
characteristic : deliberate, slow, pronouncing each syllable ;
nystagmus causing her to lose place when reading. Field of
vision is contracted. No optic neuritis, but partial optic atro-
phy. The reporter speaks of hysteria as a possibility in the
case, but from the constancy of symptoms favors the diagnosis
of insular sclerosis.
Localization of the Mental Faculties in tlie Left
Prefrontal Ijobc— Charles Phelps* in this analysis speaks of
tliree groups for examination of the evidence: (1) Atrophies;
(2) pistol-shot wounds; (3) abscesses and tumors. Atrophies
are tlie least common, 12 cases being reported. Pistol-shot
wounds are well calculated to exemplify differences in symp-
toms. Of 26 cases of injury to the right side of the frontal lobe
' Le froKTiH MC'dlcal, March 8. 1902.
' Kcottlsh Mc<llp«l and Wurglcnl Journal, April, 1902.
••Jndlan Medical Record. I'ebruary 2«, 1902.
« American Journal of Ihc Medical Kclenees, May, 1902.
there was no mental or emotional disturbance, aside from the
stupor or delirium characteristic of concussion. In 51 cases of
abscess or tumor of the left frontal lobe 46 presented symptoms
of mental default or disorder and five did not. The author's
conclusions are that the integrity of the mental faculties remain
unimpaired in right frontal lesion. The more absolute the
lesion is limited to the left prefrontal lobe the more positive
are mental symptoms.
Nasal Vertigo and Epilepsy.— A. Jousset,' of Lille, reports
four cases of nasal disease (deviation of the septum and hyper-
trophied turbinates) associated with vertigo and epileptic
attacks associated with a nasal aura. He ascribes the nasal dis-
ease as reflexly provocative of attacks of epilepsy, therefore, in
a number of instances coming under his observation. He
speaks, in passing, of the abuse of the actual cautery in nasal
disease ; in one case the cicatrix formed produced severe facial
neuralgia; and calls attention again to genital, intestinal and
other occasional reflex causes of epilepsy.
Sympathetic Insanity In Twin Sisters.— Geo. S. Walker »
reports the instance of two girls who had the singular predilec-
tion physiologically and pathologically, as shown in similarity
to joys, sorrows, likes and dislikes ; finally to having attacks of
pneumonia at the same time and last of all acute mania, falling
into dementia at about the exact day-to-day changes in symp-
tomatology. Simulation Is excluded by the fact that the cases
were separated.
Thirty Years' War Against Iiunacy.— Thomas C. Shaw »
holds that progress has been gradual and sure during this
period, in spite of the ineffectual organization and the erroneous
views of the nature of insanity up to recent years. Tlie author
urges that asylums are hospitals, and should be dominated by
medical men. He considers that Dr. Hughlings Jackson's teach-
ings rendered this modern movement possible. The writer
then refers to the better organization and more accurate clinical
teaching of insanity, and insisted upon the close connection of
neurology with insanity.
THE PUBLIC SERVICE
Health Reports.— The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, during
the week ended August 2, 1902:
Smallpox— United Statbs.
California:
Colorado :
Illinois :
Indiana :
Kansas :
Kentucky :
Maasacbusetts :
Missouri :
Nebraska :
New Hampshire :
New Jersey:
New York :
Ohio:
Pennsylvaaia:
Texan;
Utah:
Wisconsin :
Cases DeatbR
1
4
Los Angeles July 5-12....,
Sacramcmo July 12-19...
San Kranclsco July 0-23 2
Denver .July 12-19 1
Belleville July 19-26 3
Chicago July 19-26 2
Indianapolis July 12-26 18
Wichita. July 12-2« 2
Covington July 19-'.fll 4
Boston July l«-2« 7 2
Cambridge July 19-26 « 3
Everett July 19-2» S 1
Lowell July 19-26 2 1
New Bedford July 80...- 1
Newton July 19-20 1
Carthage May 1-June I I"J
Carthage _ June 1-July 10.... 11
St. Joseph July 19-28 IS
81. Louis July vO-27 U
Omaha „ July 19-26 11
Nashua July 19-28 8
Camden July 12-20 „. 8
Hudson County,
Jersey City Incl.... July 20-27 8
Newark. July 19-28 « J
New York July 19-28 11 8
Cincinnati- July ll«-2o 8
Cleveland July 19-2« 19 «
Hamilton July 19-20 2
Toledo July 12-211 »
AUooiia July ■^1-2N 1
Johnstown _.July 19-211 2
McKeesporl July 12-19 2 ?
Philadelphia. July 19-20 4 1
PItUibnrg July 19-20 25 1
Hcranton July 12-19 8
Hnn Antonio ..June 1-SO 1
Halt IjikeClty July 12-28 8 1
Ureen Bay July 20-27 1
Milwaukee July 19-28 4
1 Uevne Hebd. de I^aryngologle, D'Otologle et de Rhlnologle,
March 15, 190!.
s Virginia Medical Hemi-Mnntbly, April 11, 1902.
'The Polyclinic, .March, 1902.
210 American Medicine.
THE PUBLIC SERVICE
[August 9, 1HU2
SMALLPOX— Insular.
Porto Ulco: Areclbo ToJunelS 381
Bayamon To June 15 3
Caguas To June 15 71
Camay To June 15
dales To J une 15
Corozal To June 15
Fajardo To June 15
Halillo To June 15
Humacao To J une 15
Isabela To I une 15
Lares To June 15
Ponee ToJune 15
San Juan To June 15
tjtuado To J une 15
Smallpox— Foreign .
St. John July 19-26
Panama July 14-21
Cairo June 17-July 1..
Paris June28-July 12,
Birmingham July 5-12
Dundee July 5-12
Gateshead July 5-12
Liverpool July 5-12
London July 5-12
Naples June 28-July 5.
Canada :
Colombia :
Egypt :
France :
Great Britain :
Italy:
Mexico :
Russia :
Straits settlements
Uruguay :
Colombia :
Costa Rica :
Mexico :
China:
Japan:
Straits Settlements :
California :
121
6
2
1
5
1
9
3
128
no
79
1
2
City of Mexico July 0-13 1
Moscow June 28-.luly 5..... (i
St. Petersburg June 28-July 5 4
Warsaw June21-July 5
Singapore May 18-June 7....
Montevideo June 11-26 93
Yellow Fever.
Panama July 14-21 3
Port Limon July 10-17 2
Cotzacoalcos June 28-July 5.... 4
Veracruz July 12-19 7
Cholera.
13
Changchow..
June 17 Epidemic
.Epidemic
..Epidemic
..Epidemic
..Epidemic
..Epidemic
..Epidemic
11 5
Chinkiang June 17
Hangchow June 17 ....
Kiangyin June 17 ....
Shanghai June 17
Soochow June 17
Wusieh June 17 ....
Formosa To J une 27
Mojl July 22 Present.
Nagasaki Kon ToJune27 3 2
Saga Ken ToJuue27 47 26
TokyoFu ToJune-27 5 3
Singapore May 17-June 7.... 136
Plague— United States.
San Francisco July 19-20 1 1
Plague— Foreign.
China: Choanchew J une 5 Epidemic
Tongan June 5 Epidemic
France: Dunkirk June 11-18 2 deaths on
S. 8 City of Perth from Calcutta, etc.
Cbanges in the Medical Corps of tlie U. S. Army for
the week ended August 2, 1902 :
Street, Lionel A. B., contract surgeon, is granted leave for one
month, with permission to visit Japan.
Banister, Major John M., is relieved from duty at hospital No. 3,
Manila, and will proceed to Cebu, Cebu, reporting to the command-
ing general, department of South Philippines, for assignment to
duty as chief surgeon of that department.
Byrne, Lieutenant-Colonel Charles B., D. S. G., will proceed to the
following-named posts and make a thorough Inspection of the hos-
pital atfairs and sanitary conditions of each ; Fort Meade and then
return to his station, thence to Forts Assinnlboine, Harrison, Mis-
soula, Yellowstone, Keogh, Yates, Snelllng.
KiNCAiD, Kenneth G., hospital steward, discharge camp, Angel
Island, Cal., is relieved from further duty in the division of the
Philippines, and assigned to duty at his present station.
SOHIER, Anton R., contract surgeon, is relieved from duty at Fort
Worden, and will proceed to his home, Burlington, Iowa, for annul-
ment of contract.
Harvey, Lleutenant^Colonel Philip F., D. S. G., having reported his
arrival at San Francisco, Cal., will await orders at that place for the
convenience of the government until August 25, on wbicii dale he
will report to the commanding general, depaitment of California,
for assignment to duty as chief surgeon of that department, to
relieve Colonel Robert M. O'Reilly, assistant surgeon-general.
Kean, Major Jefferson B., surgeon, who was relieved from duty in
Washington, D. C, by orders of July 18, has had the ordere revoked.
Ford, First Lieutenant Joseph H., assistant surgeon, is granted leave
for one month and twelve days from about August 15.
The following changes in the stations and duties of officers are ordered:
First Lieutenant George H. K. Gosman, assistant surgeon, is re-
lieved from further duty at West Point, N. Y'., and will report at
Fort Hancock, for temporary duty, to relieve First Lieutenant
Albert E. Truby, assistant surgeon. Lieutenant Truby is relieved
from further duty at Fort Wadsworth, and upon his relief from
temporary duty at Fort Hancock, by Lieutenant Gosman, will pro-
ceed to West Point, N. Y'., and report at the Military Academy for
duty.
The following-named officers will report to Colonel Calvin DeWitt,
assistant surgeon-general, president of the Examining Board at the
Array Medical Museum Building, Washington, D. C, for examina-
tion for promotion; Captains Allen M. Smith, Joseph T.Clarke,
William F. Lippitt. Jr., Merrltte W. Ireland, George M. Weils,
First Lieutenants Henry Page, Bailey K. Ashford, Jere B. Clayton,
assistant surgeons.
Dean, First Lieutenant Elmer a., assistant surgeon, leave granted
June 24 is extended one month.
Roberts, D. M., contract surgeon. Is granted leave for one month, with
i>erralsslon to apply for an extension of one month, to take effect
upon the return iVom detached service of the first squadron. Twelfth
Calvary.
RoBHiNs, First Lieutenant Chandler P., assistant surgeon, is relieved
from further duty in the Philippine Islands, and will proceed 1«
San Francisco, Cal., and report by telegraph to the adjutant-general
of the army for orders.
DAVIS. First Lieutenant William T., assistant surgeon, will proceed
to Fort Myer for temporary duty with tnwps going from post to
target range. He will return with the troops from the range to Fort
Myer and then Join his proper station. Fort McHcnry.
Harvey, Lleulenant^Colonel Philip F., D. S. G., has been ordered to
report on August 16 to the commanding general, department of
California, for assignment to duty as chief surgeon of that depart-
ment, to relieve Colonel Robert M. O'Reilly, assistant surgeon-
general.
The following changes in the stations and duties of officers are ordered:
Captain Robert S. Woodson, assistant surgeon, is relieved from
duty at Madison Barracks to take effect upon the expiration of his
present leave and will then proceed to Fort Clark for duty, to
relieve Captain Thomas S. Bratton, assistant surgeon. Captain
Bratton will proceed to Fort Sam Houston for duty.
Gregory, Vebdo B., contract surgeon, now at Bowers. Wis., will pro-
ceed to Vancouver Barracks for a.ssignment to duty in Alaska.
CABLE, George L., contract surgeon. Is relieved from duty at Fort .Sam
Houston and will proceed to Camp Eagle Pass, Tex., for duty.
Kellogg. Preston S., contract surgeon, is relieved from duty at Fort
Egbert and will proceed to Fort Robinson for duty.
Matthews, First Lieutenant George W., assistant surgeon, will pro-
ceed from Fort Warren to Fort Terry for temporary duty with troops
there during the army and navy maneuvers, reporting at tlie latter
post not later than August 1. Upon completion of the duty Lieu-
tenant Matthews will return to his station.
Cbanges in ttie Medical Corps of the U. S. Navy for
the week ended August 2, 1902 :
HoLCOMB, R. C, assistant surgeon, ordered to duty at the Naval Hos-
pital, New York— July 24.
Stitt, E. R.. surgeon, report to the surgeon-general, for duty at the
Naval Museum of Hygiene and Medical School, Washington, D. C.
—July 26.
Langhorne, C. D., passed assistant surgeon, detached from the Naval
Hospital, Philadelphia, and ordered to duty at Naval Hospital, Port
Royal, S.C.-July 29.
Evans, S. G., passed assistant surgeon, detached from the Naval Hos-
pital. Port Royal, S. C, and ordered to Naval Hospital, Norfolk,
Va.— J uly 29.
Pleadwell. F. L., passed assistant surgeon, detached from the Kear-
.sarge, and ordered to temporary duty on the Sylpli— August 1.
Changes in the Public Health and Marine-Hospital
Service for the week ended July 31, 1902:
Purviance, Geo., assistant surgeon-general, granted leave of absence
for twelve days from August 3— July 31, 1902.
Sawtelle, H. W., surgeon, directed to report at Washington, D. C,
for special temporary duty— July 29, 1902.
Cahrington, p. M., surgeon, to proceed to Denver, Colorado, for spe-
cial temporary duty— July 25, 1902.
Gepdings, H. D., assistant surgeon-general, granted leave of absence
for one month trom August 4-July 30, 1902.
Wertenbaker, C. p., passed assistant surgeon, granted leave of ab-
sence for thirty days from August .5— J uly 26, 1902.
Blue, Rupert, passed assistant surgeon, granted leave of absence for
twenty days from August 10— July 29, 1902.
CoFER, L. E., passed assistant surgeon, granted leave of absence for
two months from August 11— July 29, 1902.
Foster, M. H., assistant surgeon, granted leave of absence for three
days— July 31, 1902.
Heisee, V. G., assistant surgeon, detailed for special temporary duty
at Washington, L). i:.— July 26, 1902.
Ramus. Carl, assistant surgeon, relieved from duty at Fort Stanton,
N. M., and directed to proceed to San Francisco, Cal., and report to
medical officer in command, for duty and assignment to quarters-
July 25, 1902.
Bready, J. E., acting assistant surgeon, granted leave of absence for
twenty-three days from August 2— July 25, 1902.
Harris, B. Y., acting assistant surgeon, granted leave of absence for
thirty days from July 1,5— July 17, 1902.
Martin, H. McD.. acting assistant surgeon, granted leave of absence
for one month from July 16, on account of sickness— July 21, 1902.
Owen, Henry, acting assistant surgeon, granted leave of absence for
fourteen days from July 2:*— July 25, 1902.
Ross, M. H., acting assistant surgeon, granted leave of absence for
seven days from J uly 27— July A), 1!)02.
Tappan, J. W., acting assistant surgeon, granted leave of absence for
one month from July 16— July 5, 1902.
Weldon, W. a., acting assistant surgeon, granted leave of absence for
fifteen days from July 20— J uly 25, 1902.
Carlton, C. G, senior pharmacist, granted leave of absence for three
days under paragraph 201 of the regulations.
Board Convened.
Board convened to meet at Washington, August 4, 1902, for the physical
examination of candidates for appointment as cadet In the Revenue
Cutter Service. Detail for the Board-Assistant Surgeon-General
L. L. Williams, chairman ; Assistant Surgeon B. S. Warren, re-
corder.
Resignation.
Burford, R. E. L., acting assistant surgeon, resigned to take effect
July I, 1902.
American Medicine
GEORGE M. GOULD, Editor
G. C. C. HOWARD, Managing Editor
CHARLES S. DOLLEY
MARTIN B. TINKER, Aniatant Editor*
(Xtnical Medicine
David Ribsman
\^ O. J. Kklly
H. n. CnsHiNG
Hklek Murphy
Oeneral Surgery
Mabtin B. Tinker
A. B. Craiq
Charles A. Orr
Orthopedic Surgery
H. Augustus Wilson
COLLABORATORS
Obttelric» and Gynecology
WiLMER Krusen
Frank C. Hammond
Nervous and Mental IHseases
J. K. Mitchell
F. 8 A VARY Pearce
lyeaiment
Solomon Solis Cohkn
H. C. Wood, Jr.
L. F. Appleman
Dermatology
M. B. Habtzell
Laryngology, Bte.
D. Braden Kyle
Ophthalmology
Walter L. Pyle
Pathology
R. M. Pearce
PUBUBHSD TeBKLT AT 1321 WaLHUT StBBBT, PRrLADBLTHIA, BY TUB AwnUCAN-lllDICtMB PoBUBHIHA COMPAHT
Vol. IV, No. 7.
AUGUST 16, 1902.
LOO Yearly.
Professional Responsibility in the Construction
of the Panama Canal It has been said that every
tie of the Panama railroad reprasented a saerifleed life.
In the building of the canal our government and
our profession owe it to the world that no such dis-
grace, suffering and loss of life shall take place.
At this time, moreover, it is absolutely unnecessary,
because our knowledge of preventive and curative
medicine is such as to make It entirely possible to carry
out the undertaking without any such scandals. This is
indeed demonstrated by the experience in Cuba. A
similar foresight and science may be realized in building
the canal. For years 10,000 or 20,000 workmen must
live and work there, and if stringent regulations are
enforced as to the prevention of typhoid and other infec-
tious diseases there is no need that the mortality shall
be much or any higher than In enterprises carried out in
the United States. An adequate force of good medical
men must be provided, well-equipped hospitals must be
supplied, and an almost military discipline should be
maintained as to the prevention of disease and sanita-
tion. The medical profession of our country has here
another opportunity to exhibit to the world the national
and professional qualities which were so splendidly
shown in Cuba.
The question of fees will probably never be settled so
far as strict definiteness and absolute rules are concerned,
but there are certain broa<l lines of sense and policy that
may be accepted as guiding decision in the majority of
cases. Charges, for instance, by one physician for treat-
ing tiie family of another, we think impolitic and unpro-
fessional. If done it certainly should be agreed upon
in advance. In a recent case of a different sort a physi-
cian sent a bill to a rich patient which, in the subsequent
adjustment, was practically admitted by the physician
to bo about five times too high. This plan has l)een often
pursued in the past by men who should have gone into
ward i)olitic8 or the " bucket-shop " business instead of
medicine. We know of a numl)er of instances in which
such traders havi' charged a man several thousand
dollars for services, well knowing they will get only one-
fourth or one-tenth of the amount; and they would be
well satisfied if they could get one-twentieth for the same
service generally. Sucli a method is neither good busi-
ness nor gcxxl morals. The charge sliould be right to
begin with, and no compromise accepted. Because phy-
sicians treat so large a proportion of the sick without
payment, because so much of their life and energy must
be given unrewarded to the advancement of their
science, and because, in a final analysis, their services
cannot be rated in money-values, they should be far bet-
ter paid than they are. But let us not assent to exorbi-
tant charges, those in which greed is more than evident,
and there should be no foolish haggling, and reductions,
and compromises.
The role of consciousness in biology is clearly
brought to consciousness by the altogether admirable
address of Dr. Minot, as retiring president of the Ameri-
can Association for the Advancement of Science.' The
fundamental propositions of the address are that the
function of consciousness is " to dislocate in time the
reactions from sensations," and that "it has the power
to change the form of energy, and is neither a form of
energy nor a state of protoplasm." We think the words
or terms chosen by Professor Minot are often somewhat
unfortunate, at least in connotation. For instance, the
word distocafioti, with its significance of pathology,
would better have been replaced by some such term as
ge/ective ulUizalion. Instead of saying that consciousness
has the power to change the form of energy it seems to
us that it would have been more illuminative to say it
has the power to change the direction of energy. But
in essential meaning there can be little difference of
opinion on the part of careful biologists from that of
Professor Minot. It has long l>een recognlwxl that the
role of consciousness in evolution has been tremendous
and wonderfully overlooked. It is indee<l a means of
securing a better adjustment to external reidity, and there
is coming a great revelation of mystery in a patient
scientific study of the facts of consciousness and of its func-
tion, in this demonstration, coupled as it is with that
of the fallacy of monism, and with the assertion of the
old truth of "the teleologic nature of all life," Dr. Minot
has emphasized an aspect and duty of science worthy
of the attention and gratitude of all serious students.
The Kolo of Consciousness in I'nthology. — In
the address of Dr. Minot, to which we have alluded, he
does not even hint of the suggestion which must arise in
< Publlahed In Selencr, July 4, \Va.
242 AXBBICAN MKDIOINE
EDITORIAL COMMENT
[AUGUST Iti, 1902
the mind of the physician as he reads. There it is only
a question of evolution, psychology, and physiology.
But in pathology, in the morbid relations and reactions
of consciousness and the diseases of the body there occur
the most convincing and striking demonstrations of the
thesis. We must first of all note that science, and of
course pathologic science, is a creation of consciousness.
Then every good physician has constantly before his
mind in each patient the fact of the therapeutic or patho-
genic action of mind on body or of body on mind. Upon
whatever reality such delusions as eddyism are founded,
they also give evidence at least as phenomena and " epi-
phenomena" of the actuality of the interrelation. And
just as Dr. Minot pleads for and demands the study of
the facts and functions of consciousneas in biologic evo-
lution, so there is as certain a promise of coming light
from a more accurate study of the same in its relation to
medicine. Just now, led by bacteriology, we are minded
to ignore the reactions of consciousness and its function as
a maker or modifier of morbid procef^ses, but we are
doing this at our peril. For whatever progress and
light may come from the discovery and study of the
external eauses of disease, there can be no safe ignoring of
the equally important facts that by no means are all dis-
eases infectious, and even in those that are tlie ground —
the. physiologic organism, always unique and individual
— upon which the seed falls is of as valid significance.
The wood of which a table is formed is not the table.
The table-idea is of as great value as the crude material.
So it is with the crude objective materials out of which
consciousness makes sensation and the mental world.
And so it is even more true that when the relations are
morbidized, if one may so speak, of organism and of envi-
ronment, there can be no rational therapeutics that does
not admit as Minot says the two fundamentally different
things in the universe, force and consciousness.
Medical Education in Manchester, England. —
The address of Mr. Walter Whitehead, Consulting Sur-
geon to the Royal Infinnary, Manchester, England, as
president of the British Medical Association, recently
delivered at the meeting of the association at Manches-
ter, and forwarded to us in advance sheets by courtesy
of the editor of the British Medical Journal, is so largely
local in its interest that, instructive and interesting
as it would be to many, we regret our inability to
find space for it. Owens College first opened its doors
in 1851, and in 1872 the Royal Manchester School
of Medicine was incorporated with it. Preceding
and at the date of the amalgamation there was
much opposition to it, and Professor Morgan presented
the medical side of the question showing that of the
14,000 practitioners in England in 1874 only 28^ were
graduates of medicine, and that of this 28^, IQfc had
obtained their degrees in Scotland. He pointed out that
while there were 11 medical schools in London and 8 in
the provinces only 4 universities— Oxford, Cambridge,
Durham, and London — had the right of conferring
degrees in medicine, and adduced weighty reasons in
favor of founding a new university in the north of Eng-
land. The Crown's grant of the charter of the Victoria
University, as it was now called, was not obtained until
1 880, and then , owing to rivals, the right to confer degrees
in medicine was withheld. This was finally obtained in
1883. Manchester has thus been the pioneer of provin-
cial medical education in England, as it was in univer-
sity education itself, as " it was the first great commer-
cial city in England to secure, in spite of much opposition
and discouragement, the establishment of a great uni-
versity in its midst." Since the amalgamation in 1872-3
the percentage of medical students to the total number
of students has risen from 28.45 to 42.74.
University Medical Education in England. —
Professor Barker and his coworkers in encouraging the
university idea of medical education will find especial
interest in Mr. Whitehead's address, to which we have
alluded. Everybody in England who is concerned as
to higher educiition has suddenly awakened to the neces-
sity of founding universities and university colleges in
provincial towns, and the example of our country's
progress is always before their eyes. Manchester was
the first to establish a university college, and it was
owing to Manchester that the Victoria University was
founded, with its seat in Owens College, Manchester, but
with the university colleges in Liverpool and Leeds feder-
ated with it. Liverpool is now tired of the federation and
wants a university of its own ; Leeds is reluctant to
agree to the disruption, but will probably have to
give way, leading to the foundation of a Yorkshire
university, with university colleges in Leeds and
Sheffield as its constituents. This would then leave
Manchester free to federate its own higher university
institutions into a Manchester university, which would
probably retain the name of Victoria University. We
can assure our English confreres that with us the plan
of provincial or local genuine universities with federated
and really fused medical departments in the same cities
has proved of the greatest benefit to the universi-
ties, to medical education, and to the profession. Of
course too great multiplication is possible, and the size
of our country and the future number of millions of
inhabitants are also to be weighed. We know that in
England there will be no repetition of our mistake, the
" pseudouniversity " school, and we trust that the semi-
university will be made as nearly a whole as is con-
sistent with conditions and with a wise conservatism.
Why should national committees of each county not be
formed to work out the problems in a large way, with
visits and interchange of knowledge and experience ?
In this way the general principles and far-future needs
could wisely influence the adaptation to national and
local conditions. In Anglosaxon countries the value of
a wise distribution of universities seems esta'ilished,
and we are glad that English educators and physicians
are, though late, at last beginning to realize the great
truth.
Osteopatby is the Practice of Medicine. — The
Mobile Medical and Surgical Journal gives in full the
decision of Judge Tyson, of the Supreme Court of Ala-
bama, in the appealed ease of E. Eugene Bra^ vs. The
State of Alabama. This decision, as full of sound sense
as of sound law, should be read by all who are interested
ADGUST 16, 19021
EDITORIAL COMMENT
'AicEBiCAN Medicine 243
in the extinction of quacltery, and especially of that
branch of it called osteopathy. We trust that other
judges will exhibit similar sagacity and judgment in
dealing with this question. If they do there will be an
end of the foolish contention that osteopathy is not the
practice of medicine because no drugs are given and no
operative measures undertaken by the osteopathic prac-
titioner. "The question of osteopathy," pertinently
says the editor of the Mobile Journal, " is of minor
importance, the value of the decision consisting of the
definite determination of what is the practice of medi-
cine." The learned judge, after a thorough etymologic,
historic and legal examination of the word medicine,
says :
" Tlius it is made entirely clear both by definitions and his-
tory that the word medicine has a technical meaning, is a tech-
nical art or science, and as a science the practitioners of it are
not simply those who prescribe drugs or other medicinal sub-
stances as remedial agents, but that it is broad enough to include
arid does include all persons who diagnose diseases and pre-
scribe or apply any therapeutic agent for its cure.
" The very first enactment on the subject (1823) prohibiting
any person from prescribing for the cure of diseases for fee or
reward without obtaining a license is a clear, unequivocal and
unmistakable declaration of the legislative purpose to deal with
medicine and the practice of it in its broad and comprehensive
sense— as a science or art of healing and curing diseases. And
this purpose has been rather emphasized than otherwise in
subsequent legislation on the subject.
"Our conclusion, therefore, is that the defendant was en-
gaged in the practice of medicine within the meaning of the
statutes."
What is the Practice <)f Medicine in the Eyes of
the Law ?— Most or all of the statutes pertaining to the
legality of practitioners and the exclusion of quacks,
de|)end upon the definition of the term "the practice of
medicine." A physician (or doctor of medicine) is one
who practises medicine, and as such he must fulfil certain
legal requirements, be possessed of certain knowledge
and skill, and being authorized by law to carry on his
calling he is protected therein, in certain ways, by the
same law. In his most excellent judicial decision, of
which we have spoken. Judge Tyson shows that the
word "medicine" is a technical word denoting the
science or art of curing diseases, and that one so engaged
is commonly known asa " physician " or "doctor." That
medicine is not an exact science, and that its practi-
tioners differ from each other in atlvice as to remedies,
etc.. has nothing to do with the matter at issue. The
word medielne, according to etymology and the lexicog-
raphers, is shown to be a tetrhnical word denoting not
only therapeutics, but the art of understanding the
nature of diseases, their causes, their prevention, hygiene,
sanitation, etc. Judge Tyson shows that throughout
history no one system of therapeutics has been followed
i)y those who pnuttised medicine, "and perhaps never
willix'," while today all regular practitioners recognize
the efticaciousness of water, massage, electricity, etc.,
as scientific therapeutic agencifw. The rest cure is espe-
cially noted. There is, moreover, nothing in the
statutes which prevents us from giving to the word
medicine its legitimate t«x'hnicjil use or meaning. This
is demonstrated by extensive citations and (luotations.
Iiul('e<l, the legislative purpose was always to protect the
public against charlatanism, ignorance and quackery. In
Alabama, in 1875, the me<lical association ofthe State was
constituted a Board of Health for the State, and remains
today the State's medical adviser. The practice of medi-
cine does not, therefore, depend upon the giving of drugs,
or upon any special method of treatment, or upon any
theories and beliefs as to the cause or nature of disease,
or as to its cure. The practice of medicine is "the
science and art of preserving health, of preventing and
curing disease." Whoever undertakes any such function
is a physician or doctor — he practises medicine.
Child-labor in the Southern cotton mills has
become a national disgrace. According to the chairman
of a committee appointe<l to gather the facts, the number
of children under sixteen years of age employed in the
cotton factories increased 140.9^ during the decade end-
ing in 1880, and 106.5 /e between 1880 and 1890. Between
1890 and 1900 the increase was no less than 210.1 fc. Of
the 45,044 textile operatives in North Carolina, 7,996 are
under fourteen years of age, while the average wage of
the child has decreased from 32 to 29 cents per day in
that State. In some places in the South the daily wage
is as low as 9 cents a day, incredible as it seems, and this
for twelve hours of labor ! In all, it is estimated that
there are at least 22,000 such child victims, an(i.from
9,000 to 10,000 of these are under the age of 12. The
Springfield Republican bluntly says that
" The owner is the chief criminal. He opposes legislation.
A prohibition of child-labor would place all the mills on an
equal footing, giving no one of them an advantage on this
account over another ; but the stockholder is not satisfied with
this. He demands a continuance of child slavery for the advan-
tage in dividends which it gives over the northern mills ; and
he or his managers or representatives have been known to pro-
claim their abhorrence of such conditions while working with
might and main to defeat child-labor legislation in Georgia,
South Carolina, and elsewhere."
Whether this grave indictment of the capitalists is
true or not medical men and hygienists will join in the
rising protest t^ainst such preparing the ground and
sowing of the seeds of disease, such weakening of the
vital forces of the race. lAtissez fuire is done with,
whatever may say the sneerers at grandmotherly gov-
ernment.
Southern Blacks and Northern Cities. — The
influx of Southern negroes into Northern cities calls for
thoughtful consideration on the part of all good citizens,
and particularly of those in charge of sanitation and
public education. The Philadelphia Tiuies, July 16, in
an etlitorial comment on the unparallelwl increase in the
colorcHl population during the last decade, 59.5^ , or two
and a half times that of the population at large, recog-
nizes the added responsibility hereby placwl ui)on the
(iuaker City, which now possesses a black population
greater than that of any other city of the Union, exwpt
New Orleans and Washington. This rapid augmenta-
tion is not attrilititable to natural increase of resident
negro families; but to immigration from the South, par-
ticularly from Maryland and Virginia, and in the light
of the conclusions of such students ofthe negro problem
from a medimi standpoint as Dr. 1'. B. Burringer, Chair-
244 AMBBICaK Medicink'
EDITORIAL COMMENT
[ACOOST16, 1902
man of the Faculty of the University of Virginia, and
Dr. Seale Harris,' Health Officer of Bullock county,
(ieorgia, there can be no excuse for indifference to the
dangers incident to this rapid drift of the negro to the
city. Dr. Barringer, in his address entitled " The Sacri-
fice of a Race," delivered at the race conference held in
Montgomery, Ala., says:
"All thiugs point to the fact that the negro, as a race, is
rapidly reverting to barbarism, with the inordinate criminality
and degradation of that state."
Dr. Harris presents statistics showing the enormous
deathrate of 52.11 per 1,000 among the blacks, nearly
double the birthrate, 26.54 per 1,000. He says :
"One-third of their births are reported as being illegitimate,
a fact which merely suggests the degree of immorality among
them. Contrast this with the fact that among the whites less
than one-half of 1% of births are recorded as occurring out Of
the bonds of wedlock. . . . The negroes, as a class, have
absolutely no conception of personal hygiene. ... I believe
I do not exaggerate when I say that over 50% of fhe negroes in
the United States above tlie age of 25 have been affected with
syphilis. ... I believe that 90fc of the men over 25 years
have had gonorrhea. . . . The uterine tubal and ovarian
troubles among negro women, traceable to gonorrheal infec-
tion, would be astounding to one who did not have fre<iuent
occasion to examine them for such troubles."
Harris quotes Hoff"man's " Race Traits and Tendencies
of the American Negro" to the effect that
" In the city of Charleston for the year 1890, for every 1,000
white children born, there died during the year 200 ; of negro
children, 461. In the city of Richmond, for every 1,000 white
children born there died during the year 187 ; and of every 1,000
negro children born 530 died. If these statistics are true, what
can we expect from the coming generations, because statistics
of criminality show that the amount of licentiousness and
immorality among the negroes is rapidly increasing."
These facts, together with the wellknown suscepti-
bility of the negroes to influenza, pneumonia, tubercu-
losis and other infectious diseases peculiarly prevalent in
the crowded districts of great cities, suffice to indicate
the increased danger to health and morals accompanying
the rapid urbanization of Southern negroes.
Oil " Playing tlie Game." — When earnest belief
and purpose fade out of the minds of men, when the
conviction of reality behind phenomena is lost, when
monism, scientific or philosophic, has consistently
driven out of the mind the belief in freedom, duty, and
responsibility, the next step in the descensus Averni is to
look upon the whole affair, and also upon one's role in
it, as a play or game. At first, as is reported of a certain
King, the ideal is to " play the game rightly," which,
of course, means that although the real bases of honor
are gone, honor itself will be retained ; for a while, but
as the historian and psychologist knows, only for a while.
While that little while lasts we may indulge ourselves
in the stoic's pride, and in the comforting delusion that
honor without logic and without a source of supply can
endure or even be thoroughgoing. The certain thing,
it is said, is that life and the work of life is a game, to
be played with equanimity in loss and modesty in vic-
^ American Medicine, September 7, 1901, p. ,W5.
tory and in both without feeling toward one's adversary.
Through it all runs the tacit understanding that there is
no real object of life or of living, and that it is all a game
and to be played as such. This is the " religion " of what
is called society; it is "the tone;" it is "good form."
It is true that, carried to its rigorous logical results,
death itself may be the stakes of the game, and if you
are a duelist, or a soldier, you must " pay up " with the
same smile as if the bet were for a dollar. In the same
way the rules of the game of kingship, priestcraft,
wealth-getting, or any sort of " success," may be so
highly conceived and strictly enforced that the object-
lessness and resultlessness of the game itself is deftly
concealed, the players think very well of themselves,
and gaping Demos may not recognize the make-believe.
But good insight cannot be deceived.
But science is not a game. Here is one calling that
he who looks upon it as a game is surely most miserably
mistaken. The search for scientific truth dare not be
made as a sportsman, and discovery is impossible under
such a condition. As love can be had only by giving it,
as even the would-be buyer of love is aware that he can-
not really buy it, so truth only comes as the reward of
utter sincerity. It is the lawyer's honor that he must
defend his guilty client, even the theologic system must
often be upheld by the doubting priest, and the games of
success and of business are Darwinism logically carried
out ; but Darwinism itself, and all other scientific
theories, are established or disproved only by means
of sincerity, never as the result of the gamester's
method. The working hypothesis can never be turned
into truth by the scientific dogmatist, nor by any
amount of invented or manipulated facts.
There is one calling which, as none other, unites the
ideals of truth-finding and good-doing. The doctor who
fails to seek truth and love his fellow-men is not a
doctor ; he has utterly mistaken his calling. It were the
plainest shrewdness for him to leave the profession
speedily. He may possibly win temporary success, a
passing fame, even a worthless lot of money, but not
usually, and far less usually than he foolishly supposes.
If love cannot be assumed, the playing at the game of
philanthropy by the hypocrite will be quickly revealed
to others, as quickly become nauseous to one's self. If
truth cannot be discovered by one who seeks it for his
own advantage, then the selfish physician will not learn
the old truths nor discover new ones in physiology and
pathology. And if neither love nor truth come to the
game-player,surely the science of therapeutics will always
be to him a mystery, and its art beyond the reach of his
poor skill. In every city and town of the country there
are to be found a few physicians who are looking upon the
practice of medicine as a game. Too many of them will
cheat, are t ricky gamblers, or soon become so, but even
the best of them are so inept as to think that medicine is
a game, and that they can play it successfully. It needs
but a few years to find them reaching the logical conse-
quences of their erroneous premises, and all their dull
sharpness, secret advertising, and stupid cunning come
to naught. Then the serious seeker for medical truth,
the sincere pitier of the sick, in his slower but surer and
better success has his reward. It is one tliat endures.
August 16, 19021
EEVIEWS
■Ahbbican Mkdicinb 245
BOOK REVIEWS
Visual Economics.— By H. Magnus, of Breslau. and 11. V.
,„^'""'=*''^^^> '^' Milwaukee. E. Perth: Milwaukee,
1902. 8vo, pp. 14i. Price, ?2.50.
Heretofore the estimation of the damage from ocular injuries
and the proper indemnity to be allowed therefrom has been
made only from a philanthropic standpoint. Following
Zehender, Magnus made calculations founded upon anatomic
and mathematic data ; and with the aid of an expert mathema-
tician. Dr. Hugo Rohr, he compiled a series of very valuable
tables, which may be used by insurance companies, business
corporations, legal authorities, etc., in fixing indemnity after
Injuries to the eyes. The original German work has been
entirely rewritten in English and greatly amplified by
Dr. Wiirdemann, and made to meet the special requirements of
American law. Part I considers the " Legal Status of the
Physician in Relation to Accident Insurance and Indemnity
for Accidents; Different Methods for the Estimation of the
IjOss of Earning Ability from Ocular Accidents; General
Principles for the Estimation of the Relation of Ocular Injuries
to the Earning Ability ; Conception of the Earning Ability and
of Injuries Thereto; Estimation of the Damage to Economic
Vision; and Methods of Mathematical Calculation." Part II
is devoted to the " Special Consideration of Various Ocular
Injuries and Visual Defects." Part III relates to the " Estima-
tion of the Pecuniary Loss to the Individual by Reason of
Visual Imperfections." Part IV is made up of 22 tables for the
"Estimation of the Different Forms of Damage to the Visual
Earning Ability." A bibliography, five plates and a copious
alphabetical index follow. Drs. Magnus and Wiirdemann have
placed in their debt not only the members of the medical and
legal professions, but also the officials of many American and
British commercial corporations, and we trust that they will
find substantial reward in a large circulation.
Practical Manual of Insanity.— For the Medical Student and
General Practitioner. By Daniei, R. Browkk, A.M., M.D.,
LL.D., Professor of Nervous and Mental Diseases in the
Rush Medical College, etc., and Hknry M. Bannister,
A.M., M.D., formerly Senior A.ssistant Physician, Illinois
Eastern Hospital for the Insane. Pp. 426. Copiously
illustrated. W. B. Saunders & Co., 1902. Price, J-i.OO.
This manual, the collaborated work of two men of wide
clinical experience and ability, commends itself for lucid
expression in clear-cut English so essential for the student in
any department of medicine. The book is divided into 24 chap-
ters. While the authors set down their own definitions, such
other opinions are expressed from difl'erent writers as to make
the arciuirement of fundamentals by the student more difficult.
With due regard for opinionsof authorities the reviewer believes
in the authority of the writers of the book before us, who are
capable of portraying the scientific facts concerning insanity
without confusing the beginner with numerous definitions.
This is pointed out in the spirit of the teacher who believes the
student body is frequently led away from definite opinions by
too much definition. Then, again, medicolegal expert testimony
will continue to be surrounded with a halo of mysticism if the
positive premises are not resolutely upheld in our teaching.
AVe are pleased to see a forceful chapter on the acquired
insanities- a type of insanity the public hygiene demands
enforced, if the pathogenesis, such as overwork, autointoxica-
tion, etc., are to be overcome and this growing cla.ss of mental
alienation reduced. Toxic insanity is fully considered. With
this broader interpretation, too, of mental disease in the future
we will be able to secure treatment more and more in "psy-
chopathic hospitals" rather than "insane a.sylums," so prev-
alent today. The puerperal (exhaustive or septic types)
in.sanities are, as a rule, a class of ca-ses especially suited to
treatment ojiMtde of the a.sylum. Confusion in nomenclature
often comes from naming disease according to cause or to
pathology, or to the clini<«l aspect of tlie mental disease-. The
fetich for cla.ssiflcation at the present day is wisely mixlifiod by
the authors of the manual so as to include a comprehensive
understanding of the cause and the symptoms, a method of
classification that alone is accurate and permissible at this period
of medical progress and therefore unsettled state of knowledge.
Treatment is one of the best features of the book, and for
this aspect is especially commended to general practitioners.
The withholding of properly carried out drug use has been too
much lauded in insanity, where mind disturbance so frequently
is the result of definite and known physical disease.
A Textbook of Practical Therapeutics, with Special Refer-
ence to the Api)lication of Remedial Measures to Dis-
ease and Their Employment Upon a Rational Basis.— By
HoBAHT Amory Hare, M.D., B.Sc, Professor of Thera-
peutics and Materia Medica in the Jefferson Medical Col-
lege ot Philadelphia ; Physician to the Jefferson Medical
%o'lege Hospital ; One-time Clinical Professor of Diseases
of Children in the University of Pennsylvania; Laureate
of the Royal Academy of Medicine in Belgium, of the
Medical Society of London ; Corresponding Fellow of the
Sociedad Espailola de Hygiene of JVIadrid; Author of a
lextbook of Practical Diagnosis," etc. Ninth edition,
enlarged, thoroughly revised and largely rewritten.
Illustrated with 105 engravings and four colored plates.
Lea Brothers & Co., Philadelphia and New York, 1902.
A work that has reached a ninth edition calls for little
critical comment. The possible slips of early editions have
been corrected, and the various articles gradually enlarged,
built up and modified until the work, as a whole, represents
the practical therapeutics of the day in a very authoritative
manner. Sufticient attention is paid to remedial measures
other than drugs to indicate to the physician who refers to the
book their importance and give a good idea of their methods ;
perhaps, also, to induce him to seek in special treatises the
detailed information necessary for their systematic use. The
author's personal opinions are given in a positive and unmis-
takable way, and his summaries of the observations of others
are clear and concise.
A Manual of Practical Anatomy.— By the late Professor
Alfred W. Hughes, M.B., M.C. Edin., F.R.C.S., Edin.,
etc., Professor of Anatomy, King's College, I^ndon;
Examiner in Anatomy Royal College of Surgeons,
England, etc. Edited and completed by Arthur Keith,
M.D., Aberd. ; F.R.C.S., Eng. ; Lecturer on Anatomy, Lon-
don Hospital Medical College, etc. In three parts. Part
I, The Upper and Lower Extremities. Illustrated by .38
colored plates and 116 figures in the text. Published by
P. Blakiston's Son A- Co., 1012 Walnut street, Philadel-
phia. 1901. Price, 1.100 net.
It is almost trite to assert that a proper knowledge and con-
ception of anatomy forms the foundation for the whole super-
structure of medical science. We have examined the first
of the three volumes of this work— the volume devote<l to
the upper and lower extremities— and find here a most able
and well-arranged manual on the subject of anatomy. Little
that is new can now be adde<l to the subject under considera-
tion except in arrangement, abridgment and illustration. All
of the qualities mentioned are set forth in the present volume.
The scope of the volume suggests the arrangement; the work
is not made voluminous with infinite details which are practi-
cally valueless to the student and practitioner; and the hand-
some colored plates and the additional illustrations combine to
produce a manual complete, compact and concise.
Outlines of Anatomy: A Guide to the Methodical Study of
the Human Bodyin theDissecting-room.- By Ehmund W.
Hoi^MKs, A.B., M.D., Demonstrator of Anatomy, Uni-
versity of Pennsylvania ; Surgeon to the Methodist Epis-
copal Hospital; Constilting Surgeon to the State Asylum
for the Insane, Norristown; Consulting Surgeon to the
Northern Dispensary. Se<!ond edition. Press of New
Era Printing Company, Lancaster, Pa,
This little book Is intended as an outline work to be fol-
lowed daily by the student in the dlssootlng-room, and If the
author's experience of many years in the dissecting-room can
count as authority the plan is a valuable one to follow. The
student 1)eing assigned a part — the bo<ly under this method con-
sisting of four parts— the book outlines the work and enumer-
ates the various structures to be exposed and studied oach day
separately for three weeks, the fourth week lieing devoted to a
review of the whole ground covered during the three previous
weeks. The plan is l>elievvd to b« a good one, securing, as it
must, mothml, system and definite aim in the dissecting-room.
This alone would have much to commend it.
216 AMIIBIOAN MEDIOINEJ
AMERICAN NEWS AND NOTES
lAuauBT 16, 1962
AMERICAN NEWS AND NOTES.
OENEBAX.
Smallpox in Barbadoes.— Because of an outbreak of small-
pox in Barbadoes all the other British West Indian islands have
imposed a quarantine against that colony. The cases number
17, all discovered within a few days.
Yellow Fever off Maine Coast.— The British bark Bir-
nam Wood, from Kio Janeiro for St. John, N. B., after drifting
in fog for several days anchored off the eastern coast of Maine,
August 3, and reported yellow fever on board, three of the
crew having died. The vessel will be held in quarantine and
fumigated.
Cholera In the Philippines. —Since the outbreak of
cholera in the Philippines there have been 21,408 cases and 16,105
deaths in the archipelago. It is believed that many cases were
not reported and that 28,000 is nearer the correct number of
cases. In Manila 48 Americans and 18 Europeans have died
since the epidemic began.
Awards for Plague Fire in Honolulu.— The Japanese and
Chinese have appealed to their respective governments for
relief in the payment of the losses sustained by the plague fire
two years ago. The awards, aggregating $1,473,000, nave been
made and one-third was to have been paid this year but Con-
gress failed to make the necessary appropriation. This leaves
a deplorable condition which may be settled only by raising
territorial taxes.
Social Iiife of Liepers in Molokai.— Reports state that
the new superintendent of the leper settlement in Molokai, by
more liberal rules in the matter of amusements by encouraging
sports and social entertainments, has aroused the unfortunate
lepers from their lethargy and made life much more endurable
and enjoyable. July 4 was celebrated by athletic sports, fire-
works and dancing. More freedom is allowed the lepers in
many ways, and conditions in the settlement are greatly
improved.
Excess of Surgeons in the Philippines.- The War
Department has been advised by General Chaffee that 100 con-
tract surgeons can be spared from the United States Army in the
Philippines, and that if any of them desire to resign their
resignation should be accepted. All of them expect to be
mustered out by February next. The information that so large
a number of medical officers can be dispensed with in the Phil-
ippines is in the nature of a surprise to those who have been
under the impression that the epidemic of cholera was of start-
ling proportions.
Opium Kating in Hawaii.— Hawaii is said to be a para-
dise for the opium eater. Nowhere else is its sale so unre-
stricted or its use so widespread as in this territory since its
annexation. Under the provisional government opium was in
the sole control of the Board of Health. After annexation these
laws were declared obsolete, and, according to the Boston
Transcript, there is no restriction now as to the use of the drug
or its sale. Nearly as much of the drug is taken to the islands
as to the entire United States. An effort is to be made to enact
some law against its use which will stand in the courts.
Manila Health Board Criticized. — Native newspapers in
Manila are strongly opposed to what they call the unnecessarily
harsh measures of the Manila Board of Health to check the
spread of cholera. They state that medical inspection is too
rigid, that Americans are exempt from many of its unpleasant
features and that quarantine causes affected people frequently
to suffer from hunger. One of the most prominent papers
states that " the next revolution cannot be laid at the door of the
Filipinos. Present measures and lashings will be responsible."
Officials of the War Department admit that the measures are
severe. But medical inspection must be conducted as it is,
because the natives are hostile and give no assistance in the
search for traces of cholera.
The Status of Consumption in Michigan. — A case has
been decided in Michigan in which the jury found "that con-
sumption is the most prevalent disease in Michigan, and causes
more deaths than any other disease : that it is a disease danger-
ous to the public health; that it is contagious from man to
man, but that it is not by reason of its contagious nature a dis-
ease dangerous to the public health, and that it is not to be
classed with such wellknown diseases, dangerous to the public
health, as smallpox, scarlet fever, measles, cholera, and diph-
theria." The proceeding was by the people against a physician
to recover a penalty for violation of a statute requiring every
physician to give notice to the health officer whenever he shall
know that any person whom he examines or is called to visit
is infected " with smallpox, cholera, diphtheria, scarlet fever,
or any other disease dangerous to the public health." A judg-
ment for the defendant, setting aside a verdicrt against him, has
been reversed by the Supreme Court of Michigan. The court
decides that the question wliether consumption is a disease
dangerous to the public health is to be determined only on
evidence, and that judicial notice cannot be taken of such fact.
—iN. Y. Times.']
EASTEBN STATES.
Large Public Bequests.— More than $400,000 in public
bequests is provided by the will of the late Captain William J.
Cheever, of North Andover, Mass. Many hospitals, homes,
relief associations, and similar charities are the beneficiaries.
NEW YOBK.
Homeopathic Pharmacies.— There is said to be only six
homeopathic drug stores left on Manhattan Island. There is
not one on Broadway.
Trachoma in Syracuse.- An alarming increase of tra-
choma among the children of Syracuse is reported. Blindness
has resulted in several of the many cases being treated.
Mosquito Extermination.— Health Commissioner Lederle
is to prepare for systematic work against mosquitos during the
coming year by collecting information as a basis. .Sanitary
inspectors and district workers will prepare a map showing all
pools or accumulations of stagnant water where mosquitos can
develop. Owners will then receive orders to abate the nuisance
in one of three ways— draining the pool, filling in the land, or
covering the water with oil.
The Craig Colony for Epileptics at Sonyea, in Uvingston
county, wants to secure the services of recent graduates in
medicine to act as medical internes. The positions are unpaid,
but those who hold them get board, lodging and laundry free.
The opportunity offered is the very best for studying epilepsy
and other nervous diseases, and considerable experience may
also be had in general medicine and surgery. For further
information write Dr. W. P. Spratling, medical superintendent,
Sonyea, N. Y.
Physician Sues Village.— Dr. Charles F. Wicker has
brought suit against the village of Saranac Lake, N. Y., for
$1,200 for attending three cases of smallpox last winter. The
Board of Health passed a resolution appointing Dr. Wicker to
take charge of the cases— no price being agreed upon— and when
the bill was presented the board cut it to JSIS, basing their right
to fix the price upon a law which says a Board of Health may
hire anhysician and fix his compensation. The village trustees
upheld the action of the health board, hence the suit.
PHIIjADEIjPHIA, PENNSYIiVANIA. ETC.
Pharmacists to Meet in Philadelphia.- The semicen-
tennial meeting of the American Pharmaceutical Association
will be held in Philadelphia, beginning September 8 and con-
tinuing two weeks. It is expecttd that 1,000 delegates, includ-
ing many from foreign countries, will be present.
Filtered Water.— The promise is again made by the
Department of Public Works that a part of Philadelphia will
soon be given filtered water. Two of the filter beds in the lower
Roxborough plant have been entirely completed and filled with
sand. The Water Department is now waiting for the filtering
material to " mellow" before turning the water into the reser-
voir. Manayunk and parts of Germantown will be first fur-
nished. West Philadelphia following, it is expected, some time
next year.
Change in Marine-Hospital Staff.- Dr. Hiram W. Austin,
who has served the prescribed term of four years as surgeon in
charge of the U. S. Marine-Hospital Corps at the port of Phila-
delphia, and of the government quarantine station at Reedy
Island, left August 5 for his new post at Detroit. Dr. Austin
became very popular during his stay at Philadelphia, and
made many improvements in the quarantine service. He
will be succeeded by Dr. Fairfax Irwin, who comes from the
Boston Marine Hospital.
SOUTHEBN STATES.
To Study X-ray Treatment of Cancer.— Dr. Frederick H.
Baetjer, assistant resident physician at the Johns Hopkins
Hospital, has been sent to Europe by that institution to study
for one year the x-ray treatment of cancer.
Three Famous Physicians of Maryland.- A recent paper
at the Johns Hopkins Historical Club dealt with the Doctors
Gust4vus Brown, of whom there were three, all being leading
physicians in their day. The first was born in Scotland in 1689
and came to Maryland in 1708. He was rich, was a successful
physician, and was active in political and religious affairs.
The second Gustavus Brown was a son of the first, boru in 1747.
He graduated in Edinburgh and settled in Maryland, Dr.
Benjamin Rush being a fellow student. He achieved great
fame, and was summoned in consultation during the last ill-
ness of Washington. He died in 1804. The third Gustavus
Brown w.is a grandson of the first and nephew of the second.
He was born in 1744, graduated in Eiinhurgh, and practised in
Maryland. He also was called in consultation to see Washing-
ton, who died while Dr. Brown was on his way to Mt. Vernon.
He died in 1801. Both the second and third Gustavuses were
among the 101 founders of the Medical and Chirurgical Faculty
of Maryland in 1799.
August 16. 1902]
FOEEIGN NEWS AND NOTES
[Ahkbican Medicini 247
\irESTERN STATES.
Embalmers to be Licensed.— The State Board of Health
of Michipraii will meet at Battle Creek September 12 to examine
applicants for license as embalmers. Candidates must file
applications, accompanied by a lee of $5, as individuals and not
as a firm.
Want Child-Ijabor Abolished.— The e.xecutive council of
the American Federation of Labor, in session at San Francisco,
has adopted a resolution supporting any legislation for the
abolition of child-labor in States where such laws do not now
exist. Another resolution declares the intention of the council
to press the enactment of laws abolishing prison labor wherever
it comes in competition with free labor.
Healtli of Chicago.— The bulletin for the week ended
Augu.st 2 states that May, .June, and July were the wettest cou-
se<'utive three months during the last ten years. In 1892 the
rainfall for the three months was lO.M inches. In that vear
there were 1,489 deaths from typhoid fever, Chicago's typhoid
deathrate being the highest of 22 principal American cities.
This year the rainfall for the three months was 17.31 inches,
and there is already 40% more typhoid fever in the city than
there was one year ago. Thus far the disease is comparatively
mild, owing probal}ly to the moderate temperature. The lesson
enjoined is tlie sterilization of water and milk.
Osteopathy in Iowa.— The July number of the Iowa
Health Bulletin contains ■ an announcement which on first
sight is somewhat amusing. " The next examinMion of
Ehysicians and osteopaths will be held," etc. The State
as definitely determined the status of the osteopath. Else-
where in the Bulletin is given the requirements of the law
of April 8, 1902, and put into effeet July 4. Examinations will
be held at the .same place, time, and in the same manner that
physicians are examined, the same questions being used and
the same average being required to pass. The branches
required at present are anatomy and histology, chemistry,
obstetrics and gynecology, pathology, and physiology. The
penalty for practising without a certificate is the sanie as for
practising medicine.
Chicago Sewage and the Drainage Canal. —The State
Board of Health is al)out to publish a third report on the sani-
tary investigations made by the board of the Illinois river and
its tributaries, and also the Mississippi river. The first report,
issued in 1899, gave the results of analyses made prior to the
opening of the Chicago drainage canal, and the second, in 1901,
brought the results of analyses made down to April of that year.
In the investigatious;in 1899 to 1901 the Illinois river at its mouth
was found to be in better condition than most of its tributaries.
The amount of albuminoid ammonia in the river at its point of
entrance into the Mississippi was found to be far less than in
the Mississippi at the same place, and the oxygen consumption
markedly less. Practically no organic matter remained in the
Illinois river to tell of the enormous pollution 320 miles above.
In the opinion of the board this remarkable destruction of
organic matter was due to organic oxidation. The results set
forth in the reports of 1899 anal901are confirmed and strength-
ened by the investigations conducted in 1901 and 1902, a report
of which is about io be published. These investigations, how-
ever, were confined to the Illinois river at its mouth, the Mis-
sissippi river a short distance above the mouth of the Illinois,
and the Missouri river at its junction with the Mississippi.
The analyses revealed the significant fact that tlie Illinois river
at its mouth contained less pathogenic and sewage bacteria
than the Mississippi and Missouri rivers at the points named.
— [,Jour. American Medical Association.l
CANADA.
Regina Jail Surgeon.— Dr. David liOw, of Kegina, has
been appointoti jail surgeon at that place.
Canadian Medical Association.— The Canadian Medical
Association will meet in Montreal, September 10-18, 1902. The
Dental Association will hold an organization meeting at the
same place and time.
Precautions Against Smallpox.— The Provincial Board of
Health for Ontario has notified employers of labor in unorgan-
ized districts to employ only vaccinated persons ; to contract
with a medical pra(aitioner for their employes and works ; to
provide a hospital for the caroof the sick and to have the camps
and surroundings regularly inspected and nuiintained in a good
sanitary condition.
Census Bulletin.— The latest census bulletin issued con-
tains tables to show the number of people of various ag;es in
different parts of the Dominion. The largest proportion of
people under 10 years of age is found in the Northwest Terri-
tories, with (iiiehec and Manitoba closely following. British
Columbia, Matiitolia and the Northwest Territories are the
regions of young men, as shown by the large proportions of
those between the ages of 20 and 45. Comparison of the four
censuses of 1871 to 1901 shows a remarkable decrease in the pro-
fortions of |)orsons under the age of 1 year in Ontario and
'rince Edward Island.
FOREIGN NEWS AND NOTES
OENERAIi.
Death ft-om Ptomain Poisoning.- The death of 12 boys,
sons of American and European merchants and missionary
residents in China, at the China Inland Mission School, Che
Foo, July 7, from ptomain poisoning is reported. An outbreak
ot cholera was at first suspected, but the cause was traced to
ptomain poisoning from chicken pie which had been served.
Consanguineous Marriages Prohibited. — A London
news agency is authority for the statement that the Pope has
notified the reigning houses of Europe that no more dispensa-
tion for consanguineous marriages will be granted. It is the
wish of the Pope that royal personages contract marriages
with otlier than royal families, in order to check degeneration.
Mosquitos and Malaria. — Japanese military authorities
in Formosa lately made an interesting test by mechanically
protecting soldiers from the bites of mosquitos. A battalion
was thus protected during 101 days and not a case of malarial
fever occurred. During the same time and at the same place
259 cases of malaria occurred in another battalion not so
protected.
Cholera and Plague Inoculations in India.— Inocula-
tions against cholera and the plague liave greatly decreased in
India, not from any decline in their value but apparently from
indifference of the authorities, its use being optional with the
people. Results from its use have been satisfactory. The sani-
tary commissioner argues for inoculation as against disinfec-
tion, but the lieutenantrgovernor is unable to accept his argu-
ments.
Cholera.— Cholera is still spreading in many parts of the
east, notably in Egypt and Manchuria. The victims in the lat-
ter region are mainly Chinese, but Russians and other Euro-
peaus are also dying from the disease. The epidemic in Egypt
IS creating almost a panic and many residents are hastening to
Europe. The native Egyptian hates the interference of sani-
tary authorities, which greatly handicaps measures against the
disease.
A Prize in Physiology.— Professor Joseph Seegen proposes
to otfer a prize under the auspices of the mathematical and
natural science class of the Imperial Academy of Sciences, in
Vienna, for the best answer to the following question, " Is any
part of the nitrogen of the albuminates which have undergone
metaliolism in the animal body eliminated either by the lungs
or by the skin in the gaseous form?" The value of the prize
is 6,000 kronen, about |l,000. The essays may be written in
German, French, or English, and must be sent in before Feb-
ruary 1, 1901.
Shorthand System for the Blind. — At a recent meeting
in the interests of the blind held in the Church House of Lon-
don, a blind stenographer, Ijy the aid of a recently invented
machine, took a verbatim report of each of the speeches. The
system is the outcome of a prize offered two years ago by a
Braille magazine and is built upon several systems adapted to
the Braille method of dots. These dots are embossed by the
machine, whicli is noiseless, upon paper tape. This Hows into
a basket, to be read back by the fingers of the stenographer and
recorded on a typewriter.
Aid Asked to Cope with Malaria in Ismallia.— The
Liverpool School of Tropical Medicine has received from the
Suez Canal Couipany a request for cooperation in a (concerted
effort to cope with malaria in Isinailia. A formal request for
the services of Major Ronald Ross to start operations there
against mosquitos is also made. The school is making arrange-
ments to enable Major Ross to proceed to Isinailia in September,
when malaria is most prevalent. Major Ross has been reap-
pointed to the position of Walter Myers, lecturer t<5 the school.
Steps are being taken by the school to raise an endowment for
a chair of tropical medicine in the new University of
Liverpool.
GREAT BRITAIN.
Typhus Fever in Ireland.— An epidemic of typhus fever
is prevailing at Clifilen, on the west coast of (iahvay. Of the
trained nurses sent from Dublin two were attacked by the dis-
ease, one of them. Miss Tyrrell, dying, the other being now
convalescent.
The Surgery of Homeopathy.— The following item is from
The Medical I'ickh : " At the recent British Homeopathic Con-
gress the president dwelt on the Important developments of
surgery, and admitteii that in the realm of practical surgery
'homeopathic methods' could not be followe<l.
Sanatorium l<>r South Wales.— The Soiitli Wales branch
of the Association for the Prevention of TuberculoHis has
adopted a report n-commending the erection of a sanaUirium to
accommodate 20 patients. It Is to be erected by volunUry
donations and maintained by annual subscriptions.
248 AMKBICAN MEDIOtKB)
CORRESPONDED CH.
[AUGl.'ST 11), 1902
Osborne House for Convalescents.— The coronation gift
of King Edward to the nation is Osborne House, the Isle of
Wight residence of the late Queen Victoria. It is the wish of
the King that a portion of the house be converted into a conva-
lescent home for officers of the army and navy whose health has
been impaired in rendering service to their country.
Cost of Smallpox Epidemic.— It is stated that the present
epidemic of smallpox in England has cost upward of two mil-
lions sterling, and will entail the expenditure of several mil-
lions more before it subsides. The imposition of a tax rate of
3iSd. on the pound will open the eyes of the public to the fact
that a smallpox epidemic is a very expensive luxury and
should be a valuable object lesson. On .July 18 there were 469
cases of smallpox under treatment in the institutions of the
Metropolitan Asylums Board in London.
Long Live the KiiiK !— The coronation of Edward yester-
day had a far broader significance than the crowning of a mere
titular monarch. It was the coronation of modern antiseptic
surgery. The Englishman on whose head the crown was placed
in Westminster Abbey was really Joseph Lister— the head from
which came the discoveries in the application of the antiseptic
treatment by which the life of Edward and the lives of many
thousands of other sufferers apparently doomed to death have
been saved. Long live the King!— [iV. Y. Sun.]
Heavy Sentences for Illegal Practice.— A Birmingham
druggist has T)een sentenced to seven years' penal servitude for
causing an aVjortion which came near terminating fatally. It
was shown that for some time he had been using instruments
and administering noxious drugs to women who applied to
him for assistance. In the case of a Staffordshire druggist, sen-
tenced 20 years ago to be hanged for thus causing the death of a
girl, the punishment was commuted to a life sentence, the pris-
oner lately Being released. He soon committed a similar criiue
and has just been again sentenced to penal servitude for life.
CONTINENTAL EUROPE.
University of Vienna. — Carl Gussenbauer, professor of
surgery, has been appointed rector, and Ernest Ludwig, pro-
fessor of chemistry, dean of the university.
Woman Professor in Italian University. — Dr. Kina
Mastio has been chosen as professor of anatomy at the Univer-
sity of Milan. This is the first instance of a woman being
appointed to a professorship in an Italian university.
Italian Congress on the Care of Children.— A congress
to discuss questions of every kind relating to the care and
education, physical and intellectual, of children will be held in
Turin in September. Among the promoters are many of the
leading sanitarians, pediatrists and philanthropists of Italy.
University of Berlin. — It is reported that Dr. Schweninger.
Bismarck's famous physician, has been removed from his
position as professor of diseases of the skin in Berlin University.
The position given instead is said to be merely nominal and
practically means his retirement from any prominent position
m academic medical circles.
Pasteur Statue Unveiled. — A statue of Pasteur was un-
veiled August 3 at his birthplace, Dole, Jura. Triumphal arches
were erected and on most of the houses there were garlands of
flowers, inscribed "To the Benefactor of Mankind." The min-
ister of commerce and the academician Thureau-Dangin deliv-
ered orations on Pasteur's discoveries and his noble character.
OBITUARIES.
Erasmus Darwin Beach, one of the oldest physicians in New
Orleans, August 6, aged 87. He graduated from the Ohio Medical Col-
lege in 1842. While coroner of New Orleans, after determining the
cause in a death by accident, he would frame an ordinance to prevent
loss of life again from the same cause.
Thomas Christie, at Lachute, Que., August 6, aged 78. He was
born in Scotland, graduating at McGlU Medical College in 1848. He
was member of Parliament for Argenteuil the majority of the time
since 1875.
Henry Darling, of Brightwood, D. C, August 6, from cancer of the
stomach, aged 58. Dr. Darling was born in Maryland, graduating
from the University of Maryland in Baltimore.
Dr. Ordenstein, a German physician of Paris, was recently mys
teriously assassinated in a railway carriage, an abdominal wound
causing death the day following its receipt.
George L. Hicks, a prominent ^ibysician of Dorchester county,
Md., July 13, aged 63. He was a graduate of Columbian University.
William Warwick, of Belfast, Ireland, long respected as one of the
old school of family physicians, July 10, aged 77.
George Waters, of Cobourg, Can., August 4, aged 65.
Henry Jolin liranson, of Sheffield, Eng., iigfd 61.
W. D. Hcniphlll, of Clonmel, .July 6, aged 86.
CLINICAL NOTES and CORRESPONDENCE
[Communlcattong are Invited for this Department. The Ifiditor Is
not responsible for the views advanced by any contributor.]
COMPOUND FRACTURE OF HUMERUS FROM GUN-
SHOT WOUND.'
BY
JAMES W. GEISr, M.D.,
of Wilkesbarre, Pa.
On April 2, 1901, H. F., aged 27, came to my office and said
he had been shot and his arm broken. I took off his coat, care-
fully cutaway the sleeves of the shirt and undervest, and found
that the ball had entered to the outer side a little above the
middle of the left arm, apparently taking an oblique downward
course.
There had been sufficient hemorrhage to saturate the sleeves
of the inner garments with a spot about the size of a hand, but
there was now only a slight oozing. Crepitus was evident upon
the least motion. He complained of great pain, and I gave him
hypodermically i grain morphia with jjo grain atropia. I
washed the arm with a solution of biehlorid, placed a pad of
sterilized gauze over the wound and temporarily immobilized
with a circular felt splint and a sling to the forearm. I did no
probing.
In the afternoon Dr. Stewart saw the patient with me. We
removed the splint and dressing and thoroughly examined the
June 11.
arm, and agreed that there was an oblique fracture which could
be secured by an internal splint and shoulder cap, and that it
would be best to treat it as a case of simple fracture so long as
no symptoms of sepsis appeared.
On April 9, seven days after the injury had been received, a
drop or two of pus showed. The next day we enlarged the
track of the wound sufficiently to admit a drainage tube.
Through this I washed with solutions of biehlorid, hydrogen
peroxid and sterile water once a day and sometimes twice. I
now used a plaster shoulder cap with a window over the wound
so that the dressing could be changed and irrigations made
without disturbing the splints. For five days the condition re-
mained about the same, then the increase of pus, great swelling,
edema of the elbow and forearm, with a rapid pulse and rising
temperature, all indicated that the septic process was extend-
ing.
At this time it was our opinion that the ball, after having
struck and fractured the humerus, had glanced off and lodged
near the elbow-joint, because a great amount of pus would dis-
charge when pressure was made at this point. I made a coun-
ter-opening here on April 20, and enlarged the original wound
so that two fingers could be carried down to the fragments.
We now found that the fracture was of such a nature that it
could barely be held in place by direct pressure of fingers and
thumb, and that the ends of the fragments were denuded of
their periosteum.
The next day, in counsel with Drs. Stewart, Guthrie and
Trapold, it was decided to wire or nail if possible. I enlarged
the wound in both directions until it mieasured about six inches.
I Head before the Luzerne County Medical Society, Novemt)er 18,
1901.
AUGtJST '6 1902]
CORKESPONDENCE
lAHBRICAN MEDtCINK 249
We washed out the clots and searched for the ball, but could
not find it. The musculospiral nerve had slipped in between
the fragments and had a rather ragged or chewed appearance.
Upon turning out the ends it was found necessary to remove 23
inches from the upper fragment and li inches from the lower.
So little was left for overlapping that nailing could not be done.
August 2.
Therefore a hole was drilled fr, of an inch from each end antl
ordinary copper telephone wire passed through and twisted
tight with a pair of pliers.
When the united humerus had been replaced within the tis-
sues the nurse accidentally exerted some leverage upon the
arm, which broke the wire. This, jierhaps, was fortunate, for
the broken wire I slipped the nerve back between the ends to
the outer side and found it plenty long enough. In tightening
the loop of the second wire I left it more lax than I had the
first, and bent the projecting ends downward. The ends of the
wound were brought together with a few deep wormgut sutures,
leaving a good-sized central opening. A drainage tube was
drawn through from the counter-opening and a double tube
directed under the overlapping bone. The arm, slightly flexed,
was placed in a wire-cradle with a rubber sheet at the bottom
and a small pillow to support the hand.
During the first 3G hours following the operation the patient
was quite weak and very restless. To reduce, if possible, the
amount of septic material aljsorbed, continuous irrigation was
used on April 23, 24 and 25, and at two and three hour intervals
on April 20 and 27. For five days his general condition was not
promising. The pulse ran as high as 140, the temperature
104.0°, the respirations 52. He complained of pains in tlie
hepatic, right iliac, and cardiac areas. The heart was irregular.
There was congestion of the base of the right lung, with cough
and expectorations. But these symptoms gradually amelio-
rated, and from May 1 he began to mend, although pressure
sores had formed over the scapula and spine, causing consider-
able discomfort.
On May 5 an obtuse-angled splint was put on the arm so
that he could be turned on his side. He again had great pain
in the arm, which, in the natural progress of tlie case, was
thought unavoidable, but which afterward was found to have
been caused by insufficient padding under the internal con-
dyle. On May 15, a right-angled splint with a shoulder cap
Augunl'i.
I had undoubtedly twisted it too tight, and it might have hap-
pened at a loss favorable time. I had also loft the muculospiral
nerve falling over the bone from the inner side, because it
seemed too short to bring around to its natural position while I
had the fractured ends outside of the muscles. After removing
August 2.
allowed him to sit up. The counter-opening had healed and the
central opening was discharging little pus. For a month and a
half I packed narrow ribbon gauze througli a small packer into
the several sinuses which remained.
Dr. Ahlborn took the lirst radiograph on .June 11. This
showed that the ball had been split in two, the pieces lying in a
line witli the original point of entrance and the axilla. I do not
think that, from the appearance of this picture, one could say
whether there was union or not. The second radiograph was
taken on August 2. This showed good union, with the lines of
the upper and lower fragments coming together at an angle
instead of being parallel as in the first picture. The third
radiograph was taken on October 13. This showed very good
union, and is l)y far the best picture, even showing the line of
the marrow if carefully examined. Massage was given the
shoulder, elbow, forearm, hand, and fingers, from the middle
of September to the middle of October.
On Octolier 10, with the assistance of Drs. Stewart, Trapold,
and Ahlborn, I cut down a little below the lower border of the
axilla and removed the two fragments of the ball, and through
an incision in the old scar took out the wire and three pieces of
exfoliating bone. Hefore he came out of the other wo forcilily
broke up the adhesion in the elbow, wrist and fingers. He
remained in bed a few days, but there was no rise of pulse or
temperature.
He then again had massage, somotlmos preceded bydry hot
air; and every third day Dr. Trspold and \ f()rcil)ly flexed and
extended the arm. This was very painful, and made the patient
twist into all sorts of positions. On November 2, in making
250 AVKHICAN MEClCINEl
CORRESPONDENCE
[AUGUST 16, 1902
forcible extension, there was a distinct snap tliat could be beard
across the room, and for the moment we thought we had
refractured the arm. Tliere was very free hemorrhage from
tlie wound, great pain, but no crepitus or abnormal mobility,
and we must either have torn off some muscular attachment, or
sprung loose one or more exfoliating shells of bone. I again
put the arm in a right-angled molded paper splint for a week.
Since then there have been discharged through the opening
two small pieces of bone. On the evening of November 18, we
examined the arm with the fluoroscope and found it in good
condition.
At the present time the patient has wrist-drop, partial lossof
sensation on the back of thumb, inability to close hand, imper-
fect pronation and supination. All these have improved dur-
ing the last few weeks, and we hope that six mouths or a year
may restore a usefnl arm.
October 18.
Note.— After the discharge of the pieces of bone mentioned
the wound healed rapidly and was entirely closed by Novem-
ber 26. At present. May 24, 1902, there is IJ inches shortening
with slight internal rotation of the hand. The muscles of the
arm and forearm have filled out well and are almost as large as
those of the other arm. The motion of the shoulder and elbow
is perfect. The wrist-drop remains, for which he wears a sim-
ple glove and elastic apparatus that overcomes the difficulty.
Whether the wristrdrop is due to the primary injury sustained
by the nerve or whether the nerve was subsequently caught
and pressed upon by the callus has not been determined. How-
ever, the power of the grip of the hand has more than doubled
in the last few months.
OKIGIN OF PRE-COLUMBIAN TUBERCULOSIS.
BY
ALBERT S. ASHMEAD, M.D.,
of New York City.
Berlin excitedly puts forth as a new case of the transference
of animal tuberculosis to man that of a butcher who was lately
operated on for lupus of the hand at the Berlin University
clinic. Dr. Erich Lexer expressly emphasized this case as
contrary to the theory of Dr. Robert Koch.
Your editorial in A^nerican Medicine for June 7, on the sub-
ject of " Pet Animals and Disease Distribution," especially
relative to parrots and their disease psittacosis, and possibility
of transference of this disease by flies, mosquitos, birds, etc.,
prompts me to allude to a subject which I have studied
for some years: the origin of pre-Columbian tuberculosis
(lupus) as depicted on the huacos pottery of Peru. Experi-
ments recently made in leprosy-scourged Colombia (old
Peru), South America, show that chickens fed on refuse from
leper asylums can transmit the disease through their flesh to
man; their eggs, too if eaten uncooked transmitthedisea.se.
Thus, tuberculosis might be communicated indirectly to man
from the flocks of parrots in the Andes, which are highly
tuberculous ; chickens might get the disease from them. In a
country where there are 30,000 lepers, and where parrots are so
numerous as to obscure the sun when they fly, the question
reasonably may be asked whether there may not be some con-
nection between parrots, and not only one, but two human dis-
eases, for we all know the similarity between the tubercle and
lepra bacilli, and the frequency of lung tuberculosis among
lepers. We also know that as leprosy declines in a country
once smitten with it, where it has been for a long time endemic
— even epidemic — tuberculosis takes its place ; for instance,
Norway and Hawaii today.
Many different bacilli which prey upon mankind have
come from animals. As for leprosy, its origin is unknown,
although its oldest habitat was Central Africa, the home of the
lion and the elephant, whose names were preserved by the
students of the diseases leontiasis and elephantiasis. It is
easier, perhaps, to trace the origin of the bacillus most like the
leper bacillus— that of tuberculosis. The bacillus of what is
called aviary tuberculosis is likely to be a race of human tuber-
culosis. Aviary tuberculosis inoculated in rabbits gives to
that animal general tuberculosis, identical in many respects
with that produced by the human bacilli. But when passed three
times through rabbits it does not produce the disease when
inoculated on chickens. Tuberculosis cannot Vje produced
in chickens after they have been inoculated with fluids from
guineapigs that had been inoculated with aviary tuberculosis
six months previously. Thus the aviary tubercle bacillus, by
sojourn in guineapigs, loses its virulence for gallinaceans. Two
chickens that were inoculated in Paris with human tuberculo-
sis showed tuberculosis which produced tuberculosis in a
guineapig, but not in a chicken. A hen fed upon aviary
tuberculous tissue presented visceral tubercles. Ingestion of
human tuberculous tissue gave to hens nvimerous tubercles.
The identity of mammal and gallinacean tuberculosis is
believed in by many observers who were able to inoculate
spontaneous tuberculosis of a rooster into a guineapig and pro-
duce general tuberculosis in the animal.
Experiments have also been made by Inoculating different
aged cultures of aviary tuberculosis in rabbits and guineapigs,
and with tuberculous tissues of a hen inoculated with the same
cultures. The following conclusions were drawn : 1. The hen
is not refractory to tuberculosis of mammals. 2. The digestive
canal is an entrance for the disease with the fowl. 3. Human
tuberculous lesions can be propagated seriatim in the hen by
inoculation. 4. Bacilli of aviary origin, long removed from
aviary influence, can produce general tuberculosis in guinea-
pigs and in rabbits. 5. The bacilli having these properties lose
them by a single passage through the hen. Mammsls, there-
fore, are more resistant to inoculation of aviary tuberculosis
than to cultures of aviary tubercle bacilli.
Therefore, aviary tubercle bacilli and those of mammals are
only two varieties of the same species. Moreover, it has been
shown that the morphologic characters of the cultures and the
pathogenic properties of the bacilli, of tuberculosis of the horse,
the hog, and that of man, are identical. Chickens, therefore,
which are cared for by the tuberculous might be, through their
flesh and eggs, a means of propagating the disease.
Dr. .Jos6 Mariano Macedo, "Etiology, Topography and Treat-
ment of Uta (lupus skin tuberculosis) of Peru," says (trans-
lated from Spanish) :
"Insects f long-shanks), flies, butterflies, spiders and ticks
may propagate the disease. The common belief that the bite
of the long-shank (Oulex pipiens), a kind of mosquito; of the
tly {Lucilia Iwmiiiworn), of the tick (Ixodes (imericanus); the
spit of the spider (Aurigalus domesticun), of a butterfly, etc., is
the cause of uta, implies diversity of origin and, consequently,
a single one could not be the special producer of the disease."
I hold that the parrot of the Andes is probably the origin of
the tubercle bacillus in pre-Columbian American man.
AUGUST 16, 1902]
INFLUENCE OF EONTGEN RAY UPON SARCOMA [amkrican medicine 261
ORIGINAL ARTICLES
THE INFLUENCE OF THE RONTGEN RAY UPON
THE DIFFERENT VARIETIES OF SARCOMA.'
BY
WILLIAM B. COLEY, M.D.,
of New York.
Surgeon to the General Memorial Hospital.
So far as I have been able to ascertain from a careful
search in the literature of the Rontgen rays, this treat-
ment has been employed in but a very small number of
cases of sarcoma.
Dr. Williams, in his recent paper read before the New York
Academy of Medicine, stated that he had one ease of spindle-
celled sarcoma which sliowed marlied improvement.
Dr. W. A. Pusey, who had done so much and such excellent
work with the x-ray in malignant disease, in his recent paper
entitled " Report of Cases Treated with Rontgen Rays " ^ re-
ports four cases of tuberculosis of the skin, eight cases of
epithelioma of face and nose, five cases of carcinoma of the
breast, six of deep-seated carcinoma of neck and head, four
of carcinoma of the abdominal cavity, but only three cases
of sarcoma. One of these, an osteosarcoma of the right
shoulder with cachexia and evidence of general sar-
eomatosis, was given six exposures without effect upon
the tumor other than considerable relief from pain. The sec-
ond case, in a woman 60 years of age, with extensive inoperable
sarcoma of the right pectoral muscles and shoulder, was treated
for a month, with considerable relief from pain, but with no
apparent effect upon the tumor. The third case was that of a
man, aged 24, with a history of round-celled sarcoma of the
left side of the neck, first noticed in February, 1901. Four
months later a tumor developed on the right side. In August,
1901, the primary tumor was removed by Dr. Ochsner, and the
patient was sent to Dr. Pusey on September 2 for the x-ray
treatment ol the other side. At the time of the beginning of
the treatment there was a hard, diffuse swelling, immovable,
rendering the neck almost completely rigid. Under one mouth's
x-ray exposures this tumor entirely disappeared. The patient
gained 12 pounds in weight. Five months later, however, there
was a slight return. Further treatment was advised, but the
patient thought it impossible for him to return to the city.' The
diagnosis of this ease was made by Dr. F. R. Zeit, Associate
Professor of Pathology at the Northwestern University, who
stated that it was unquestionably small round-celled sarcoma.
Under date of November 16, 1901, Dr. Carl Beck, of New
York {N. Y. Med. Jour.), published a case of recurrent
melanosarcoma of the thigh and groin in which the x-rays
showed a very decided inhibitory action. There was marked
improvement, but the case was too far advanced to expect a
cure. The patient has since died.
The next wise, in point of time, that I have been able
to find, is that of a round-celled sarcoma of the neck,
treated by Dr. C. 1-]. Skinner, of New Haven, and pub-
lishe<l by Dr. Frank A. Kirby {Journal of Advanced
Therapeu.iic.1, February, 1902). This case is a very strik-
ing one and deserves to be referred to in detail.
The patient, male, 64 years, three years ago received a blow
from a wagon pole, leaving a contusion which lasted about a
week. Two months later a swelling appeared at the site of the
injury. This grew very slowly for about sixteen months, when
the patient severely wrenched his neck. Almost immediately
afterward the tumor began to grow more rapidly and became
painful. Hy November, 1901, the tumor had become very large
and occupied the greater portion of the left mastoid and cer-
vical region, measurements being 7 inches laterally, 10 inches
vertically, with some ulceration and breaking down. Micro-
scopic examination by Dr. Archibald McNeal, of the New
Haven Board of Health, showed the tumor to be round-celleid
sarcoma. The x-ray treatment was begun November 20, 1901,
by Dr. Skinner, a Van Houtfin A' Tenbrook ;i2-inch plate static
machine being used. Dr. Skinner states that in the incredibly
short space of time of six weeks the patient was apparently
cured, the tumor having disappeared, the surface healecf and the
patient being free from pain and atile to resume his work.
On June 27, 1!K)2, I made a personal examination of this case
and foimd the following condition:
In the left side of the nock and mastoid region is a very
large, broad cicatrix, measuring 2Jx3J inches, but there is
al)solutely no trace of a recurrent growth. In the lower part of
the cervical region there can bo felt on deep pressure very
slight enlargement of one or two of the deep cervical glands,
apparently not larger than peas.
' Read before the American Hurgical As.soi^iatlou at Albany, June
» .four, of the Am Med. A«.so., April I'A 1902.
»In the discussion heforc the Amcrkan Hurglcal Association
(June .-), KKW) Dr. (Jchsnei- sUitcd that the patient had returned to t'hl-
c»((o for treatment and that the recurrent growth had again disap-
peared under the x-ray.
Inasmuch as so few cases of sarcoma have as yet been
treated by the x-ray, I feel justified in giving a brief
sketch of the histories of ten of my own cases. These
cases were treated in part personally and in part by
Mr. W. P. Agnew (under my direction), who has charge
of the x-ray department of the General Memorial Hos-
pital. The apparatus used in all cases was a Willyoung
12-inch coil, with fairly high tubes, and the usual dis-
tance being 8-10 inches. The whole method is still in the
experimental stage and I do not pretend that the technic
that I have employed should be taken as a guide for
others. I merely wish to place these cases before you as
a slight addition to the slender data we now possess upon
which to base an opinion as to the therapeutic value of
the Rontgen ray upon malignant tumors.
Case I. — Inoperable round-celled lymphosarcoma of neck,
pectoral region and axilla. M. L. A., a lady, 45 years of age,
first noticed a tumor just above the clavicle about two years
ago. This was removed. Shortly after a recurrence was noted
in the right cervical region, which grew with great rapidity,
very quickly involving the axillary glands on the same side.
In July, 1900, the axillary tumor was removed by Dr. C. B.
Nancrede, of Ann Arbor, Mich. The tumor in the cervical
region showed such extensive involvement of the deeper struc-
tures that it was considered entirely inoperable. Microscopic
examination was made by Dr. King, professorof pathology of the
Dartmouth Medical School, who pronounced it small round-
celled sarcoma. The patient was referred to me by Dr. Nancrede
for the toxin treatment in October, 1900. Physical examination
at this time showed a large tumor in the right cervical region, ex-
tending from the clavicle to the mastoid process of the temporal
bone. There were some enlarged nodules below the clavicle
and several small tumors in the region of the cicatrix in the
axilla. The toxins were begun at the General Memorial
Hospital, October 1, 1900, and continued with intervals of
rest for six months. There was a very decided decrease in
the size of the tumors and increase in their mobility. This
continued for about three months, and then, in spite of further
injections, the improvement ceased. At the end of six months
the growths slowly began to increase in size, and it was not
thought wise to further continue the injections. Since .Tune,
1901, no treatment further than palliative has been used, and
the patient has since then been awaiting with great courage and
composure what was regarded as the inevitable and not long to
be delayed end. The tumors slowly but steadily increased in
size, and at thebeginningof February, 1902, hercondition was as
follows: The tumor masses encircled the entire neck, ending at
the vertebral line, and extending from the mastoid process to
the clavicle on the left side, on the right side involving the
entire cervical, supraclavicular, pectoral and axillary region.
The largest protuberance was in the right cervical region, about
the size of two fists. The constriction of the trachea was so
great as to cause frequent and severe attacks ot dyspnea. She
was confined to the bed the greater part of the time. With
little hope of causing even temporary improvement, but more
as a matter of experiment, I determined to try the x-ray. The
treatment was begun February 10, 1902, four to five exposures
per week, at a distance of eight inches, being given. The
instrument used was a Willyoung coil, 12-inch. At the
end of three weeks a marvelous change had taken place. The
tumor masses had decreased fully one-third in size, and had
become very movable. A small burn was produced in the
upper right cervical region over the most protuberant part of
the tumor. The skin in this place had become very thin from
the pressure of the disease. The burn healed in two or three
weeks. The treatment has been kept up at the rate of four
exposures a week until the present time, and rapid improve-
ment has continued steadily. Today, June 5, the patient has
entirely recovered her general health, and she is able to go out
daily walking and driving. The tumor masses on the left side
have entirely disappeared, with exception of one or two small
nodules not larger than peas. On the right side, on which the
tumor mass was nearly as large as two fists, there now remains
a nodule not larger than an olive. The masses in the front,
over the trachea and extending into the mediastinum, have
entirely disappeared, as well as those in the supra and infra-
clavicular regions. There remains a small nodule in the right
axilla, about the size of a hickory nut.
On June 18 the small nodule in the neck was removed
under ether for the purpose of making a microscopic examina-
tion with a view of finding out what changes has taken place
in the structure of the tumor. The nodule was situated Just
beneath the inner edge of the right sternomastoid muscle, near
the middle, and was no larger than a snmll marble (one-half
inch in diameter). The specimen was examined by Dr. (Jeorge
P. Biggs, pathologist of the New York Hospital, who stated
that it showed the typical structure of round-celled sarcoma.
The patient leR the hospital entirely well July 8, 1902.
Cask 11.— Sarcoma of the femur. A. O., aged 19 years, first
notice<l a swelling in the lower portion of the left femur in
November, liKll. This graduallv increjised in size accompanied
by loss of weight and deterioration of general health. The
patient came under my observation February 5, 1902. At this
252 AMERICAN mbdicink. INFLUENCE OF EONTGEN BAY UPON SARCOMA
[AUGUST 16, 1902
time physical examination showed a large tumor extending
from the condyles of the left femur to the junction of the middle
aud upper thirds. The tumor consisted of a fusilbrm enlarge-
ment of the entire lower two-thirds of the femur; on the outer
aspect of the thigh, about IJ inch above the joint, there was a
soft, fluctuating area, just covered by thin and reddened sink.
There was slight impairment of the functions of the joint, but
no swelling of the joint itself. An incision was made under
cocain into the fluctuating area and three ounces of clear serum,
similar to that which is found in cystic degeneration of sarco-
matous tissue, was evacuated. The curet passed into the cav-
ity of the bono, and typical sarcomatous tissue was removed.
Microscopic examination, by Dr. E. K. Dunliara, showed it to
be round-celled sarcoma. The patient absolutely refused opera-
tion, although he was told this was the only thing that offered
any hope of saving his life. The x-ray treatment was tried
entirely as an experiment, with tiie result that the tumor
decreased one inch in circumference. After a month's treatment
the exposures were discontinued for two weeks, at the end of
which time the tumor had increased nearly an inch in size. The
treatment was again resumed and the growth slowly decreased
in size, until at the end of another month the circumference of
the thigh over the center of the tumor was one inch less than the
original measurement. The treatment has been continued four
times a week up to the present time, June 3, with slow decrease
in the size of the tumor, although the patient has lost two
pounds in weight. During the last week, however, he has
developed signs in the right lung which point very strongly
toward beginning of metastases. The tumor shows a decrease
in size of two inches from the original measurements.
Case III. — Small round-celled sarcoma of the pectoral
region. E. M., aged 35 years ; family history good. First
noticed a tumor in the right pectoral region, near the anterior
axillary line in the latter part of 1H98. This grew rapidly in
size and was operated upon by Dr. M. H. Richardson in
November, 1900. The tumor at this time was the size of a fist.
Extensive removal of the mass and part of the muscle was
made. Microscopic examination by Dr. W. F. Whitney,
pathologist to the General Memorial Hospital, showed it to be
a small round-celled sarcoma. The tumor recurred about six
months after operation and grew very rapidly. A second
operation was performed in October, 1901. The growth then
involved the pectoral and axillary region so widely that it was
found impossible to remove it. Amputation of the upper
extremity was considered, but not thought advisable. The
patient was referred to me by Dr. Maurice H. Richardson in
December, 1901, for the mixed toxin treatment. The toxins
(prepared by Dr. B. H. Buxton, and also by Parke, Davis
& Co.) were administered five to six times a week for a
period of three months, the doses being gradually increased
until a reaction of 102° to 103° was produced. The tumor
laegan to soften and a spontaneous opening occurred in
January, 1902, with evacuation of about a pint of necrosed
tumor tissue. The growth had thus considerably diminished
in size, when on February 10, 1902, I began the x-ray treatment,
which was continued for two weeks without any further
decrease in the size of the tumor. The toxins and x-ray were
then given in combination four times a week, and since this
time the growth has steadily and rapidly decreased in size.
Une week ago he was able to clasp his hands behind his back
for the farst time m eight mouths. The mass in the axilla has
entirely disappeared, movements of the shoulder which were
greatly restricted are practically normal and there now remains
only a very small, freely movable mass, not more than two
1?,°."®!'" diameter and very superficial in the pectoral region.
This disappeared.
This was believed to be only the induration caused
by the toxin injections, and a specimen removed under
cocain, June 7, proved— on microscopic examination by
Dr. E. K. Dunham, the pathologist of the General
Memorial Hospital— this supposition to be correct, and
no evidence of malignancy could be found. The patient
has remained in good health, and was discharged
apparently well June 8, 1902. As an indication of the
hopelessness of this case, I will quote from a letter
received from Dr. Richardson, under date of May 6, 1902 :
" I feel so sure that he is going to die that I have
told him not to accept any discount on the face of his life
insurance policy. In other words, I have not the least
confidence in his ultimate cure."
Physical examination made June 27, 1902, shows the
small area of induration mentioned before, and proved
by the microscope to be nonmalignant, to have disap-
peared. The patient is in the best of health.
TVT ^r^^i' ^y.— Round-celled sarcoma of the fascia of the thigh.
M. \ ., female, aged 37 years, was referred to me in March, 1900,
^7r.^L ^^^n^^ ^''^\\''^ ^?'^ York. At the time of her admis-
»i?r^? .^ ^<'°«'"?1 Memorial Hospital there was a tumor at the
the left thf^h^''''«L"r*f\f i^"'" anterior and upper portion of
nUal Hn.^^^cr ;i,P^ }^ ^^^ *.^° operations at tEe French hos-
pital during the past six months; the last one, a very extensive
operation, had been done six weeks before. The tumor, when I
first saw her, was about three inches in diameter. Both the tox-
ins and x-rays were tried for a month, neither having the
slightest apparent effect in decreasing the size of the tumor,
which was of rapid growth. The treatment was then abandoned.
Case V. — Very rapidly-growing round-celled .sarcoma of
the parotid ; death within six months from dale of origin. R. B.,
aged 25 years. Family history negative. Without any known
trauma. First noticed a small swelling in the left parotid
region in the latter part of September, 1901. In November,
when about the size of an English walnut, the tumor
was removed by Dr. Ralph Seelye, of Springfield, Mass.
The last of December tliere was recurrence with rapid
growth. On January 15, 1902, a second operation was per-
formed, but it was found impossible to remove the entire
growth. The patient first consulted me in the early part of
February, 1902. At this time there was a tumor occupying the
entire region of the left parotid, firmly fixed at the base and ex-
tending behind the tip of the ear. The patient was treated for
three weeks with small doses of the mixed erysipelas toxins.
At first there was a slight decrease in size and considerable
diminution in pain, but after two weeks the growth increased
in spite of the treatment. On February 14 Dr. W. A. Downes,
my associate, tied the external carotid on the same side. This
seemed to have no effect in checking the growth of the tumor,
and 10 days later the x-ray treatment was begun. Only five ex-
posures were given, as the growth increased very rapidly and
the patient's general condition became very bad. His pulse
was rapid and weak, and he had constant nausea and vomiting.
Neither the toxins nor the x-rays nor the excision of
the carotid seemed to have the slightest influence in
checking the growth. Although further treatment was
advised against, the patient was taken to another place
and the x-ray treatment with a static machine was used
for a few days. The patient died, however, within 10
days after leaving my care.
Case VI. — Recurrent melanotic sarcoma of the iliac glands.
Mrs. N., aged 37 years, was first operated upon five years ago for
a small sarcoma starting from the irritation of a mole in the
region of the left ankle. About a year after its removal a recur-
rence took place in the femoral glands. I operated upon this
four years ago, and three times since at intervals of about a year.
At the last operation, done three months ago, I removed under
ether a sarcomatous mass the size of an egg from the left femoral
vein. Several other masses could be felt in the iliac fossa, but
it was impossible to remove them. For the last two months
the patient has had x-ray treatment three or four times a week.*
Case VII. — Spindle-eelled sarcoma of the upper jaiv. T. N.,
46 years of age ; married ; farmer.
Family History. — Great-grandfather and grandfather died
of cancer of the face. Uncle died of epithelioma of the lip, a
cousin of sarcoma of neck. Gonorrhea seven years ago; nosyph-
ills. Teeth always carious and many removed. Typhoid in
1897; pleurisy with effusion in 1892, otherwise always healthy
and strong, except for present trouble.
About January, 1899, he began to have severe frontal head-
aches. April 1, 1899, he noticed a smooth, somewhat painful,
rapidly increasing swelling of right cheek. In June, 189!f, a
mass the size of a walnut was removed through the mouth
from inner side of antrum. In a few weeks the swelling
returned, and in August, 1899, a large part of the superior max-
illa was removed. These operations were done at Pittsburg,
Pa. In January, 1900, the swelling again returned and increased
in size until he came to the Presbyterian Hospital in June, 1900.
The swelling was almost painless, the size of an orange and
occupied the right side of face from orbit to floor of mouth.
There was no loss of flesh or strength. The patient was oper-
ated upon by Dr. McCosh in June, 1900. The right external
carotid was first tied and then an incision made. It was found
that most of the superior maxilla had been removed in previous
operation. More was removed from alveolar process and from
malar bone. The tumor had infiltrated into the inner canthus
of eye and considerable tissue and bone were removed from
there. The skin, which was adherent to the growth, was cut
away and the wound closed, after relieving the tension by
incisions lower down. According to the pathologic report, the
disease was spindle-celled sarcoma, cells being of moderate size
with some mltrosis. At the time of the patient's discharge from
the hospital there was a small sinus with some purulent dis-
charge. This closed up entirelj' in two weeks and patient had no
further trouble until July, 1901, when he again began to have
some uncomfortable sensations at the site of the old tumor. In the
beginning of August a recurrence was noticed. This increased
in size with moderate rapidity until October 1, when the patient
began to use some caustic paste. This caused a more rapid
increase in size. The skin over it broke down and there was a
free air communication between the wound and the nasal pas-
sages and a week later a purulent discharge set in which
remained. The mass completely obliterated the right nasal
'June 4 the patient is still under treatment three times a week.
The tumors In the groin and iliac fossa have not increased any in size,
and there is apparently a slight diminution. The general condition of
the patient improved for a time, but at present she Is losing; weight
slowly and I have no hope of ultimate cure.
August 16, 1902]
INFLUENCE OF KONTGEN RAY TPON SARCOMA (Americai* mewcine 253
passage proje ting into the oral cavity. Two weelis before
admission to the hospital, October 5, the patient noticed a small
lump just below and to the left of external occipital protuber-
ance. It has been painless, not tender and he did not think it
had grown very much. There has been no loss ol flesh and
strength at any time. October 19 the patient returned to the
hospital with a large inoperable sarcoma at the site of the
former operation, involving the whole of the right superior
maxillary region and extending into the roof of the mouth and
pharynx. The condition was considered inoperable by Dr. Mc-
Cosh and the patient was referred to me for the toxin treat-
ment. He was admitted to the General Memorial Hospital on
October 25, 1901, and treated with the mixed toxins for several
months. At the end o| the first month's treatment the im-
provement was very striking. The growth decreased two-
thirds in size and the remainder was easily curetted out, leav-
ing a clean base. For a time it seemed probable that entire
disappearance would take place, but after two months' treat-
ment the inhibitory action of the toxins seemed to have been
in** iS^iJ. u'^ growth slowly began to increase in size. February
10, 1902, the toxins were discontinued and the x-ray treatment
was tried for three weeks.
In this case the x-ray seemed to have little, if any,
effect in controlling the pain, which was gradually
becoming very severe. Although the tube was placed
but a short distance (not more than eight inches) from
the tumor, and the exposures of considerable duration
(10 to 12 minutes) were given, no effect upon the growth
of the tumor was noticeable and at the end of three
weeks the treatment was discontinued.
Case "VIII. — Siwill round-celled sarcoma of gracilis muscle,
four times recurrent. W. J. P., male, aged 22 years. This
patient hrst noticed a small lump at the inner side of the left
thigh one year ago. This increased slowly until July, 1901, at
which time it was about the size of a hickory nut. It was then
renioved by Dr. William T. Bull. A local recurrence followed
in September, when a second operation was performed by Dr.
Charles Peck, of New York. Shortly after the second operation,
at the request of Drs. lUill and Peck, I began the injections of
the mixed toxins as a prophylactic. In spite of the treatment,
a recurrence followed about six weeks later, this time in the
mgumal glands and growing very rapidlv. A third operation
was performed by Dr. Bull on November 11, 1901. A large
mass, involving the inguinal glands and extending into the
Iliac region was removed. It was found impossible, however,
{* 6'^t'rpate the entire amount of infected tissue. -V few days
later I began using fresh bouillon cultures of virulent strepto-
coccus of erysipelas in order to produce an attack of erysipelas.
Moderate reactions were obtained, the highest temperature
peing lOJ . After three weeks' treatment with the living cul-
tures the toxins were resumed in doses of 5 to 7 minims. This
treatment was kept up for eight weeks, the patient being able
to get about most of the time and attend to his business. No
recurrence followed until 13 weeks later, when a small nodule,
deeply situated, about the size of a hazelnut, appeared at the
site ot the original operation, at the inner side of the thigh. The
x-ray treatment was then begun and has been continued since
with exposures of 8 to 15 minutes in length, a Uerman tube
vvith a high vacuum being used. The first month's treatment
snowed the growth apparently not increasing in size, although
It was not perceptibly smaller. At the end of this time small
closes of the toxins were given in conjunction with the x-ray
treatment, whether or not influenced by the toxins, it is
impossible to say, but, for the first time, the growth showed a
decided decrease. After remaining quiescent, neither increas-
ing nor decreasing for about a month, the growth has since the
la-st three weeks again begun to slowly increase in size in spite
ot the x-ray treatment, which has been given six times a week.
On .) une 3, 1902, under ether, I removed the tumor, the size of a
small hen s egg, deeply placed beneath theadductor muscles and
tjeneath tlio lemoral vein, about throe inches below the insertion
ot the adductor tendons. Its deep situation possibly explains
the slight action of the x-rays. The report of the microscopic
examination by Dr. Geo. P. Biggs, pathologist to the New York
Hospital reads as follows : " It is very difficult to make com-
parison between the slides from old and recent operations in
this case. In the first place there is but one slide from theolder
operation and the section on it is rather thick. As to how well
It represents the general structure of the whole tumor might be
questioned. Wliile there appear to be some differences in
structure, I wouhl not make any positive statements on this
point and certainly would not ascribe them to the use of the
x-ray without confirmation in other cases. Section from the
Older tumor shows a larger percentage of small cells and less
norouH tissue than the later tumor. There are several giant
ceils in the latiT tumor and apparently none in the older. Inter-
cellular subsUince, partly homogeneous and partly fibrillary, is
more abundant in the later tumor. Both are quite vascular
anu in Imth tliere are areas of necrobiosis. Neither are typical
iilustrationsof small round-celled sarcomas, buttheolder tumor
18 very properly placed In this class." The patient remains
well August 6. 1902.
It is worthy of note that the sarcomatous disease left
in the inguinal and iliac region at the time of the last
operation apparently disappeared under the influence of
the living cultures and the toxin treatment, and although
the groin has not been subjected to the x-ray treatment,
no recurrence has been noted in this region.
Case 1^.— Small round-celled sarcoma of the back. W. J.,
8 years. Family history good. In the latter part of August,
1901, the patient fell from the porch, striking the back. Two to
three weeks later the mother noticed a swelling over the left
scapular region, w^hich increased in size rather rapidly. It was
soft and fluctuating from the start. The patient was referred
to me in December, 1901, by Dr. Polhemus, of Nyack, N. Y.
Physical examination at that time showed a cystic swelling
the size of an orange in the left scapular region. "The skin was
normal, the tumor fluctuating, situated apparently just beneath
the skin and superficial fascia. The diagnosis of hematoma
was made, and on the twelfth of .lanuary an incision was made
under ether anesthesia; several ounces of dark blood were
withdrawn with a small trocar. There was no evidence of and
tumor at this time. The wound was closed without drainage
and healed by primary union. Two to three weeks later the
tumor slowly began to re-form ; it was still cystic in character
and increased steadily in size, until on May 6 it had become
about twice as large as prior to the first operation. A second
operation was performed. This time, in addition to fluid blood
and clots, there was a marked thickening of the walls of the cyst,
which made me suspect sarcoma. A portion of this thickened
tissue was removed and examined by Dr. H. T. Brooks, pro-
fessor of pathology of the Postgraduate Hospital, who pro-
nounced it small round-celled sarcoma.
Two weeks after operation, before the wound had entirely
healed, x-ray treatment was begun, and at present, June 5, the
patient has had 10 exposures. There has been no increase in
size, but it is impossibletosay as yet whether there has been any
decrease. The area is so extensive that it would be almost im-
possible to remove the entire base successfully by operation.
August 6, l!t02. The treatment has been kept up three times a
week to presenttitneandthe tumor has entirely disappeared.
Case yi.— Inoperable sarcoma of the parotid. M. H.,
female, 57 years. Family history good. Seventeen years ago
first noticed a small lump, the size of a pea, in the region of the
left parotid gland. It grew very slowly until about a year ago,
when it increased in size more rapidly. In May, 1901, it had
attained the size of an orange and was operated upon by Dr.
W. C. Wood at the Brooklyn Hospital ; the tumor was sup-
posed to have been entirely removed. There was a recurrence
in August, and a second operation was performed in January,
1902; it was impossible to remove all of the disease at this time
and growth was very rapid after operation. Physical examina-
tion April 18, 1902, showed the woman in good general condi-
tion. In the left parotid region there was a tumor the size
of a fist, irregular, protuberant, and ulcerated in several places,
extending from the orbit to below the ramus of the jaw and
from the left ala of the nose to a short distance behind the ear.
The ulcerated areas have a tendency to bleed easily.
The patient has now had six weeks' treatment with the
x-ray at the General Memorial Hospital here, four times
a week the exposures being given at a distance of 6 to 8
inches and of 10 to 12 minutes duration. At flr.st a great
deal of the tumor sloughed off. The pain decreased,
and While the tumor mass is still large, it is steadily
decreasing and the va.scularity has greatly diminished.
June 21, 1902 : The growth has shown slight increase
at the lower portion beneath the jaw. The mixed toxins
were begun June 19 in addition to the x-ray treatment.
I am greatly indebted to Dr. L. H. Warner for care-
ful examination of the blood in several cases while the
patients were taking the x-ray treatment.
Examination of bloodinCnse 7".— Sarcoma of the neck. May
5, 1902, showed; Hemoglobin. ry5%; rod cells, 3,800.000; white
cells, 8,tK)0; lymphocytes, 22%; polyneudear, GOf ; eosino-
philes, 12%; myelocytes (small), 4%; myelocytes (large), 2%.
May 10, examination showed: Hemoglobin, 48% ; red cells,
3,300.000; white cells, 10,400. (At this time the tumor had
nearly disappeared.)
Examination of blood in Case If. — Sarcomaof femur. May
5, 1902 (after the tumor had decreased in size nearly two
inches): Hemoglobin, 47%; red cells, 3,-300,000; white cells,
11,100; lymi)hocytos, 11%; polynuclear, 69%; eosinophiles,
2% ; myelocytes (small), 8%.
Examination of blood in Case /A/.— Sarcoma of pe<-toral
region and axilla, su<-cessful. May 16, 1902: Hemoglobin, 76% ;
red cells, 3,130,003; white cells, 10,200; lymphocytes, 7%: poly-
nuclear, 72% ; mononuclear, 20% ; myelocytes (large), 1%.
Two cases of carcinoma showed moderate leukocy-
tosis, one 14,000 and the other 9,700.
In addition to these ca.ses I have watched with great
interest four patients with inoiH'rable sarcoma who hail
been for a longtime under my observation and on whom
the toxins of erysipelas jiad been carefully tried liut
without success. A brief history of these cases follows :
254 AKKBioAN MBDioiNKj INFLUENCE OF RONTGEN RAY UPON SARCOMA
[AuanST IB, 1902
Case I. — Small round-celled sarcoma of the neck six times
recurrent (case of Dr. James E. Fisk). G. V. H., 70 years of age.
About 10 years atfo a lump was first noticed in the left side of
the neck. Nine years ago this was removed at tlie New York
llospital. The tumor recurred one year later in the scar and
grew much larger. The patient has had four subsequent opera-
tions within the la.st seven years. One tumor was removed
from the right side of the neck, the others recurring in the
region of the cicatrix of the original growth on the left side and
beuiud tlie ear.
The pathologic rwordH of the New York Hospital
show the following :
February 21, 1892. G. F. H., aged 60 years, has had a tumor
on the left side of the neck posterior to the scalenus anticus
muscle for three years and four months. Of slow growth at
first, the tumor has increased in size rapidly during the last
three months. No glands were involved. Operation February
20, 1892 : The specimen is an oval tumor, 7 x 4J inches ; no cap-
sule; on surface the voluntary muscle fibers are seen invaded
by the tumor tissue at sevei-al points. Micro.scopically the
tumor is a typical round-celled sarcoma with small amount of
fibrous tissue struma, apparently derived from tissues in which
the growth originated.
On May Li. 1901, the patient was referred to me by Dr. E. M.
Foote, of the Vanderbilt clinic, as a case of inoperable sarcoma
of the neck, for treatment with the erysipelas toxins.
Physical examination at that time showed a tumor the size
of an orange occupying the left mastoid region. The tumor
was very vascular and semi-lluctuating. There was glandular
involvement behind the jaw on the right side; also agrowth the
size of a small orange in the right femoral region. There was
a hard, freely movable glandular tumor in the right axilla the
size of an English walnut. The patient was treated with the
mixed toxins of erysipelas and Bacillus prodigiosiis from
May 13 to .Tune 5, during which time 13 injections were given,
the highest temperature readied being 102°. On .June 5 I tied
the external carotid artery on the U ft side, under ether anes-
tliesia, using chromicized tendon for the ligature. The wound
healed by primary union and the patient then left the hospital,
but returned July 16 for another course of the toxin treatment
and remained until July 27—11 days. At first there was some
slight improvement following the injections of the mixed tox-
ins, but later on there seemed to be very little influence from
the treatment, if any. The patient seemed to become rather tired
of hospital life and was discouraged. Hereturned home on July
27, the tumor at the time being about the same size as when he
entered the hospital, the base occupying tlie mastoid region and
extending down to the neck, pushing the ear forward. It was
not attached to the bone, but was absolutely inoperable and,
as I believed, hopeless.
Decem~ber 22, 1901, the patient was treated by Dr. James E.
Fisk, of Brooklyn, with the x-rays. He states that for several
years he had been trying to find a physician or surgeon to
give him the x-ray treatment, but failed, until Dr. Fisk
took him in charge, off'ering to give him two weeks of
treatment, but holding out very little hope as to the
result. A static machine was used and exposures of ten
minutes' duration each day were made for two weeks,
when the treatment was continued for further two weeks, the
the exposures being made for 15 minutes. At the end of four
weeks' time the exposures were lengthened to 20 minutes. In
all the patient had six weeks' treatment. His condition at the
time of the beginning of the treatment was as follows: On the
left side of the neck, just behind the ear and extending down-
ward, was a large tumor, fully the size of two fists, pushing
theear lar forward. There was also in the right axillarv region
a tumor the size of a goose egg. Almost immediate ilnprove-
meut was noticed after the beginning of the treatment and the
mass rapidly diminished in size; at tlie end of four weeks it
had entirely disappeared. The patient states that at the end of
three to four weeks he noticed a softening of the tumor in the
right axilla, although no exposures were made in any other
region except the neck. This softening continued and the
\^}}}°^' sradually disappeared until at present, February 20,
1902, It can scarcely be felt.
At the x-ray meeting of the Academy of Medicine,
March 9, 1902, I .showed the patient in perfect health
and there was not the slightest suspicion of tumor or in-
duration in the neck. The tumor in the right axilla had
also disappeared.
On June 19, 1902, 1 made a careful examination of the
patient and there is no trace of a recurrence. Since April,
1902, he has had x-ray treatment for nodules in both
groias (size of an egg) and they have disappeared from the
left groin and nearly disappeared from the right groin.
This case is certainly one of the most remarkable of its
kind yet recorded, showing the beneficial influence of the
x-rays upon sarcoma. The repeated recurrences, together
witli the numerous microscoiiic examinations at the New
York Hospital, confirmed by a recent more careful exam-
ination of the old sec;tions by Dr. Geo. P. Biggs, the path-
ologist, place the diagnosis absolutely beyond a doubt.
Cask II. — Spindle-celled sarcoma of the abdominal wall. M.
J. H., female, aged .34 years, was referred to me by Dr. Maurice
H. Richardson, of Boston, on April 19, 1901. The patient had a
well-marked family history of malignant disease. She had
been operated upon three years before for what was regarded as
a fibroid tumor of tlie uterus ; tubes and ovaries also were re-
moved. No microscopic examination was made. Two months
ago she first noticed a hard tumor in the lower part of the
aljdominal wall in the region of the cicatrix. There was no pain
nor discomfort, but rapid increase in size. When the patient
came under my care physical examination showed a tumor the
size of a cocoanut in the lower part of the abdomen filling up
tlie entire iliac fossa, extending nearly to the umbilicus and two
inches beyond the median line to the loft. The tumor was very
■ firmly fix(d and seemed to involve the abdominal wall. An
incision was made under cocain, and a portion of the growth
which infiltrated all the muscles of the aVidominal wall was re-
moved for microscopic examination, which showed it to be
fibrosarcoma. The erysipelas toxins were used tor ten months.
During the first two montlis the growth decreased more than
half in size, and for a long time thereafter while there was no
decrease tliere was no distinct growth. Later on the influence
of the toxins seemed to have become lost and there was a slow
but gradual increase in size. In January, 1902, the tumor was
growing rapidly, and at this time the abdomen had the appear-
ance of that of a woman seven months pregnant. I advised a
trial with the x-rays, and she went to New Haven, Conn., where
she has since been under tlie care of Dr. Clarence Skinner, and
has had regular, systematic treatment. Dr. C. A. Bevan.of New
Haven, with whom she is staying, in a letter sent me about a
month after the treatment was begun, stated that her general
condition had become very greatly improved and that she was so
well that she would be able to resume lier duties as teacher if
slie could arrange to have the treatment.
I examined the patient about the middle of May, and
while her general condition was much improved no de-
crease in the size of the tumor was noticeable ; in fact, it
seemed to have slightly increased. I do not believe a
cure possible.'
Case 111.— Recurrent small round-celled sarcoma of the
superior maxilla. W. D. L., the patient, a dentist, aged 38
years, was operated upon by Dr. Wm. T. Bull in the spring,
1901, for small round-celled sarcoma of the superior maxilla
with excision of the entire bone, with exception of the orbital
plate. The growth promptly recurred, and three secondary
operatioas were perfoi-ined by Dr. Bull and myself, the last in
August, 1901. The patient was treated with mixed toxins of
erysipelas and Bacillus prodigiosiis for several months by Dr.
Gertrude Kelly, un ler my direcion, w th temporary improve-
ment aud soma decrease in the size of the tumo-. But at length
the toxins seemed to have no further effect and an attempt was
made to produce erysipelas by inoculating living erysipelas
cultures. A slight attack was produced with much improve-
ment in the condition of the growth. Soon, tiowever, the tumor
began to grow rapidly and involved a large portion of the cheek,
nose and orbit, causing exophthalmus of the left eye. Feeling
sure that nothing further could be done either by operation or
the toxins, I referred the patient to Dr. W. B. Snow in the
latter part of January, 1902, for the x-ray treatment. Dr. Snow
has treated him three to four times a week ever since with a
static machine, and the growth has not only been checked, but
has diminished very markedly since.^
Case IV. — Osteosarcoma of the mastoid and temporal
regioii. S. M., aged 22 years. Four years ago first noticed a
tumor just in front of the right ear. This was excised, but was
followed by a recurrence a year later. The recurrent growth
was treated with caustics without success. The patient was
referred to me fir the toxin treatment by Dr. , of
Lexington, Ky., in October, 1900. Physical examination at
that lime showed a tumor involving the mastoid region of
the temporal bone, completely surrounding the ear and
forming a mass the size of an egg in the parotid region. The
growth originated in the bone, was absolutely fixed ; the skin
over tlie parotid portion was normal and not adherent. The
posterior tumor projected to the level of the ear and the skin
was involved and destroyed, being replaced by a series of hard,
small, round reddish protuljeratices, with little tendency to
ulceration. The tumor was unquestionably a sarcoma,
although no microscopic examination was made. Tlie patient
suffered agonizing pain, for which large doses of iiior|iliiii were
required. She had lost much flesh and strengih, and her pulse
ranged between 110-120. The toxins were given for three
months, but her condition was so poor that she was never able
to lake more than one-fifth to one-third of a drop injected into
the tumor. Even these small doses produced some decrease in
the size of the growtli and slight improvement in her general
condition. At the end of three months she returned home and
treatment was continued for three months by her family phy-
1 June 20, 1902. I have Just learned that her general condition is
getting worse and that she is k>slng weight. Her symptoms attributed
to malaria are more probably due to absorption from the tumor.
2 June 5 there is still some exophthalmus, a considerabJe portion of
the tumor remaining but It is not more than oue-quartcr of Its original
size, and Is still Improving. June 27 I examined the patient and found
htm decidedly Improved.
AlTOCST 16, 1902J
INFLUENCE OF EONTGEN EAY UPON SARCOMA [ameeican medicine 255
sician. After the treatment was discontinued tlie tumor
slowly began to increase in size, and she returned to
New York for further treatment in November, 1901. The
tumor had increased considerably in size, the mass behind
the ear being the size of a hen's egg, and the mass in front
nearly as large, although the skin was normal. It presented
the appearance of a uniform, cone-like bulging of the entire
side of the head, the external auditory meatus of the ear occu-
pying the apex of the cone. The tumor was extremely sensi-
tive to the toucli, and the pain was more severe tlian the year
before, requiring J grain of morphin every two hours to give
lier moderate relief. She was still much emaciated, pulse is
weak and rapid (lli)-120 per minute). Her susceptibility to the
toxins was still marked; a dose of not more than i minim
would produce a severe chill and temperature of l(yz''-103° and
marked prostration. She was treated with minute doses
<J drop) four times a week, for three months, up to the middle
of .lanuary. While there was apparently no increase in growth,
there was no decided decrease, and inasmuch as it was impos-
sible to give her larger doses, I believed it useless to continue the
treatment. Having carefully followed the results obtained by
the x-ray treatment in epithelioma and a few cases of carci-
nomatous nodules iu the breast, I thought it wOrth while to try
the effects of the x-ray treatment before abandoning the case as
hopeless, and accordingly referred the patient to Dr. Wil-
liam J. Morton, on .January 25, 1902. Since that time she
has been treated four times a week by Dr. Morton, with 10
to 12minute exposures, at a distance of 8-10 inches. The
immediate effect of the treatment was a marked influence upon
the pain, which ceased almost entirely after three or four treat-
ments, and there has been very little pain since, making it
possible for her to nearly discontinue her morphin. The
effect upon the tumor was an almost immediate diminution in
size, and this has been constant ever since. There has been no
breaking down or necrosis, but a steady disappearance by
absorption.
Physical e.Kamination on May 18, 1902, showed the
tumor to have almost entirely disappeared, at least the
protuberant portion ; very little difference could be
noticed between the two sides of the face and head.
The patient has gained some in weight and looks greatly
improved in general health.
June 1.5. — About a week ago the patient began to have
more pain in the cervical region, with slowly increasing
swelling and tHnderness. Witiiin the last 10 days the pa-
tient lias lost several pounds in weight and has developed
marked weakness and prostration. Tliere has been consid-
erable discharge from theear, and theeellulitisof the neck
has probably been caused by infection from the broken-
down tumor tissue. There has been no ap[)arent increa.se
in tlie size of the tumor, but the patient's general condi-
tion is so bad that I do not believe recovery probable.
On June 22, under ethyl chlorid anesthesia, I in-
cised the neck, evacuating several drams of thick,
foul pus. With free irrigation with peroxid the dis-
charge from neck and ear decreased rapidly, and on
July 1 tlie patient's general condition had improved
suftlciently to permit removal to her home in the south.
While none of these cases can a,s yet be rej)orted as a
cure, they nevertheless furnish the strongest ground for
encouragement. It seems proved that in a certain pro-
portion of malignant tumors we have found an agent
that will cause the disappearance of the growth after all
other means have faik^d. Whether the patients will
remain well sufticiently long to justify us in CiUling them
cured, time alone will tell. The entire disai)i>earance of
a large tumor of the neck in four patients— Skinner's (of
New Haven), Pusey's (of Chicago), Fisk's (of Brooklyn)
and my own case of much more extensive round-celled
.sarcoirni of both sides of neck, clavicular aiMl a.xillary re-
gion (the diagnosis of sarcoma being confirmed in every
case by competent pathologists)— give us great cause for
congratulation. When we consider how large a i)ropor-
tion of sarcomas have their origin in the neck and how
hopeless they have proved to operative treatment, we
realize the importiince of these rtnient observations.
In my collection of 207 personal ca-ses of sarcoma
analyzed in the "Twentieth Century Practice of Medi-
cine," 18!)7, \'ol. xvii, no less than IC ca.ses were primary
in the neck. J have never yet seen a case of sarcoma of
the neck cured by oiKsration, nor have I been able to find
an authentic case reported by other surgeons ; hence, if in
the x-ray we have a means of destroying these growths,
or a certain proportion of them, it means a great advance
over present methods.
As regards the action of the x-ray, no one has yet
been able to explain just how the x-ray influences malig-
nant tumors. There have been a great many opinions
advanced but none is susceptible of proof. Pusey states
that his "sections show that x-rays cause a degeneration
of some sort of carcinomatous tissue and a disappear-
ance of this degenerated substance, presumably by
absorption. However it occurs, the fact stands that
gross embryonic tissues and other tissues of low vitality
are made to disappear under the influence of x-rays
without destruction of the uninvaded healthy tissue, and
such a fact is pregnant with possibilities."
Personally, I believe that there are strong reasons for
regarding the action of the x-rays upon malignant
tumors as new evidence in favor of the micropiirasitic
origin of such tumors. In support of this view I would
cite the fact that nearly all lesions in which the x-ray
has been used with such beneficial effect are of known
or probable microbic origin, e. f/., lupus, tuberculous
disease of various forms and many varieties of skin dis-
ease, including alopecia areata. It will be objected by
some that the x-rays are not bactericidal or so to only a
slight degree. The answer would be that the action of
the x-ray in a te^t-tube culture of a given germ might
be of a very different kind from the action of the same
rays in the living body, with the possibility of forming
some chemic change in the living tissues that might
destroy the organisms or inhibit their growth. With
the destruijtion of the microorganisms, the continued
presence of which in the tumor cells are the supposed
cause of their proliferation, the neoplasm may undergo
fatty degeneration and absorption.
It is worthy of note that in the two cases in which
the tumors (both large, inoperable, round-celled sarcomas)
have almo-it completely disappeared the patients had
been treated with the mixed toxins of erysipelas and B.
prodigiosm for several months. In one case the tumor
had diminished at least one-half in size as the result of
the toxins, and then showed little improvement from
the x-ray alone ; and in the other, while the growth was
not checked entirely, the toxin treatment had a marked
inhibitory action as evidenced by the slower progress of
the disea.se.
Proper Limitu of the X-ray Treatment. — The question
will naturally arise. In what class of cases should the
treatment be employed? We must confess that the
method is still in the experimental stage and while in
this stage I do not believe it wise to employ it except
in inoperable cases or incases in which serious deformity
would result from the operation, e. g., facial cancer or
cancer involving the eyelid or nose. There Is a possi-
bility that if the present results prove permanent it will
supersede ojierative treatment in very many cases,
especially cases in which operation would necessitate the
amputation of a limb.
CONCLUSION'S.
I am conscious that the present series of cases is too
small and the time of ob.servatlon too short to justify one
in drawing any dogmatic conclusions as to the perma-
nent therapeutic value of the Rontgen ray in sarcoma.
Still I Ix'lieve we are warranted in stating :
1. That the re-sults in the crises thus far treated prove
that the Rontgen ray has a remarkable inhibitory action
upon the growth of all forms of malignant disease and
that this is especially true of sarcoma.
2. That this action in many cases of even far-advanced
and inoperable malignant disea.se may result in the total
disappearance of the tumors, often without any breaking
down of the tissues, the new-growth being apparently
absorbed.
3. Whether the |)atlents have been cured, or the dis-
ease has been merely arrested, to reai)j)ear at some
future date, is a question that time alone can dwlde.
266 Amerioak Medicine]
ARTHRODESIS OF ANKLE
[AUGUST le, 1902
4. Recent observations and experiments upon the vari-
ous forms of carcinoma and sarcoma prove that an agent
supposed to be of value only in a very limited class of
superficial epitheliomas promises to be of as great or
even greater value in practically every variety of can-
cer.
5. While at present there is little evidence to show
that deep-seated tumors in the abdomen and pelvis can
be cured or benefited by the E<)ntgen ray, there is still
some reason to hope that with improved apparatus or
with greater knowledge and skill in using the appa-
ratus that we now have, even these cases may be bene-
fited.
6. The Rontgen ray has a very marked influence
upon the pain of nearly all types of malignant tumors,
causing entire relief in many cases.
KEMARKS ON ARTHRODESIS OF THE ANKLE FOR
INFANTILE PARALYSIS.'
BY
JOHN DANE, M.D.,
of Boston.
The condition known as paralytic calcaneo valgus
is far too well known to require any further descrip-
tion. Especially is this the case after the admirable
paper on this subject read before this Association a
year ago by Dr. Whitman. Most of us are accustomed
to treat this deformity by means of some form of
mechanical apparatus, and if we think of operat-
ing at all, to do so when the child is older. The
present paper deals, therefore, with only one phase
of the problem, and is, in fact, little more than a
condensed plea for early operation. The difficul-
ties and disadvantages of apparatus are so familiar
to you that the briefest mention of them is all
that is necessary. Braces will break no matter
how well tempered the steel ; they are steadily
being outgrown, and must be replaced by larger
ones ; each increase in size requires stronger and,
therefore, heavier irons, until the weight of the
apparatus becomes no inconsiderable burden ;
when added to that of a paralyzed or partially
paralyzed extremity, it often proves too much for
the nearest groups of active muscles, which are
perhaps more or less affected themselves; even
in small children the weight and inconvenience
of the brace often prevents them from attempting
any more movement than is absolutely necessary,
or perhaps from any at all ; lastly, braces must be
retained in position by straps, which necessarily
compress the muscles and interfere with their
proper nutrition and consequent growth.
In the great majority of cases the onset of the
paralysis is before the end of the second year.
During the first six or eight months following
there is a greater or less Improvement in the symp-
toms. After that the injured muscles can be
benefited but slightly, what increase in function
there is, coming rather from an hypertrophy of the
unaffected groups than from any gain in power of
those injured by the disease. A year after the
onset we can tell with approximate accuracy what
the amount of permanent damage has been ; and
the malposition, due to the action of the remain-
ing groups unbalanced by their natural antago-
nists, has begun to be indicated.
The first point 1 wish to emphasize is, that at this
early period there is neither unreducible malposition of
the foot as a whole, nor malformation of any of the
separate bones. If left to itself, both of these unfor-
tunate conditions are practically certain to develop. If
phiaf^une5fl902 ^^^ '^'"*'"'<^*" Orthopedic Association, at Phlladel-
treated by apparatus, there is little to expect save a life-
long bondage to an iron support, with a possibility at
least, if not a probability, that an operation will be
required " when the child is older," either to rectify a
malposition that has develope<l in spite of the apparatus
or to escajje from the increasing difficulty of retaining
the limb in the api)aratus. While fully aware that
orthopedic surgery aims, at least primarily, at the treat-
ment of deformity by means of mechanical support, it
seems to me that this is one of those conditions in which
we can accomplish our end better by an early use of the
knife, supplemented, if necessary, by a relatively simple
apparatus.
It is not my intention now to speak of those slighter
cases in which a tolerably useful limb can be attained
by tendon transplantation in its various forms — Dr.
Whitman has left little to be said regarding these — but
rather to consider the question : Why do we delay in per-
forming an arthrodesis in the severer cases? In favor
of an etirly operation there are several points to be urged :
1. By avoiding the use of costly apparatus for a
period of years a considerable saving in money and a
still greater saving in trouble is effected for the parents
as well as the child.
2. At an early sttige in the trouble the bones are rela-
tively normal, both as regards their shapes and their
mutual articulations ; nor are there marked malpositions
of the foot as a whole, which so often have to be overcome
in operations at a later stage. (Had the girl from whom
x-ray No. 2 was taken been operated at an earlier period
— she was nearly seven years old at the time — the
No. 1.— Anteroposterior view of ankle after operation— boy.
marked malposition of the os calcls would not have
been encountered and the amount of possible correction
would have been decidedly greater than that now shown
in the plate.)
3. The tissues are then in a period of great plastic
activity, when repair is both (juicker and more perfect
than in the older child. Cartilage is being changed into
August 16, 1902]
ARTHRODESIS OF ANKLE
iAMKSICAN MbdICTNE 257
bone all through the foot, and we have less fear of a fail-
ure to secure bony union at the site of operation.
No. 2.— Anteroposterior view of ankle-joint after operation— girl.
T4. When at an early age the foot is secured in a
relatively normal position the statics of the lower limb
are not so much disturbed, and growth goes on
under more nearly normal conditions than can
be possible when there is a constantly increasing
tendency to the transmission of weight along
abnormal lines.
5. By avoiding mechanical support the un-
affected and partially paralj-zed muscles are not
subjected to the injury inseparable from the use
of constricting bands and straps. They have, in
consequence, a freer blood supply and develop
more rapidly. The improvement in muscular
power in the two cases which I have to report
was, however, in excess of what I can account
for from this cause alone. Provisionally I
would suggest that it may l)e due to the rigid
fixation of the ankle-joint preventing abnormal
movements from overextending the weakened
muscles and exciting reflex action, and still more
to Its giving the child a sense of security which
causes it to exercise more freely and naturally.
The ono from which x-ray Xo. 1 was taken was
that of a boy, aged 6, wlio was paralyzed when 12
months old, anil who was treated by means of a valgus
sho6 for 4J years. Massage and electricity hail been
freely used. At the time of operation no voluntary
muscular power could be detected in any of the
intrinsic; muscles of the foot, nor the long flexors and
extensors of the toes.
The operation consisted in a careful arthrodesis of
the ankle by means of the external incision and reten-
tion for 7J months in a plaster-of-paris bandage and
splint. Seven months after the operation, without the
aid of massage or electricity, llexion and extension of
the toes was <iuite strong, and sejjaration of the toes
possible. The mediotarsal joint was somewhat iriore
movalile than in the normal foot, thus giving a certain
amount of elasticity in walking, but not enough to
cause any weakness or feeling of instability. He
walks with a scarcely perceptible limp, and runs well.
The second <'ase — x-rays Nos. 2 and .'J— was that of a
girl, aged 11 years, paralyzed at 2 years, and treated for
the past six years by massage, electricity, and a steel
shoo. The feet and legs were greatly atrophied. Hhe had slight
muscular power below the ankles, and walked with a bad limp;
the foot, which showed a very marked cavus, flopi)ingiutoacal-
caneo valgus position at each step. In the first operation I failed
in thoroughness ; as a result there remained an arc of motion at
the ankle of 30 degrees, which was constantly increasing.
Eight months afterward this Avas remedied by a second opera-
tion, when the joint was rendered immovable. She wore a
plaster-of-paris bandage, and then a very light iron brace for
seven months. The muscles showed the same sort of improve-
ment as in the former case, but to a less marked extent. Her
feeling of confidence was such that she wished and was allowed
to go skating 16 months after the second operation.
Against the early operation two strong objections have
commonly been urged. They are (1) the fear of an
insecure cartilaginous union, which will make the use
of retaining apparatus as necessary as it was before;
(2) the danger of inj ury to the lower tibiofibular epiphysis,
causing interference with the growth of the limb and a
consequent shortening. Information upon both of these
points is furnished by the x-ray pictures here shown.
In all of them the spicules of new bone forming between
the tibia and the astragalus can clearly be seen, thus
confirming the clinical examination, which showed the
two bones to be rigidly united. If these two cases show
bony union, it would follow that we may expect it
in others, especially in younger children. In order
to secure this union I would lay special stress upon the
necessity of an accurate approximation of the opposing
denuded surfaces. It is not enough to scrape away most
of the cartilage and bring the bones " fairly well
together." The joint must be thoroughly exposed and
then an attempt made to secure as square a line of
contact between the bones as in a " typical " excision of
the knee. A lack of this fundamental precaution in the
second case made a second operation necessary. X-ray
No. 1 shows the scjuare mortising of the bones which
was then practised. With this precaution I have found
it unnecessary to resort to pegging or wiring the bones
together ; nor do I believe it will ever be necessary if
No. ».— Lateral view of ankle-joint after operaUon— girl.
the early operation is adopted, for as pointwl out, the
process of ossiflcjition is thus rapid and sure. Admirable
268 AMERICAN MKDICIUai
RECURRENT VOMITING
(August 18, 1902
as is the method of Dr. Whitman for later cases, I can-
not but feel that it will be found unnecessary in the
early cases to shorten the limb by removal of the
astragalus ; but that the lack of fine bony ankylosis,
necessitated by it, will not be so beneficial to the con-
sequent muscular development. According to Wolf's
law we can expect that the whole trabecular structure
of the astragalus, the lower extremity of the fibular,
and if necessary the os calcis as well, will be rebuilt,
welding them into one organic whole that will remain
permanent for life.
Under the second objection, of injury to the growing
epiphysis, there are two points to be considered : (a) Its
destruction ; (b) irritation. The distance between this
epiphysial line and the field of operation is clearly seen
in Plates 1 and 2 ; it is so great that its destruction
could only arise from the grossest carelessness on the
part of the operator. Indeed it would seem that this
danger must be one of theoretic tradition rather than of
actual practice. In fact I should be skeptical whether it
is even irritated by the operation, unless this is done
intentionally. Now it is a well-recognized fact that
a moderate amount of irritation of a growing epiphysis
acts as a stimulus and causes not a retardation but
an increase of growth, and it has been suggested in
Germany that use should be made of this fact in opera-
tions upon paralyzed joints. It would, therefore, seem
possible that we may in the future be able to replace the
old dread of inflicting an injury upon the epiphyseal
line, with its resulting shortening of an already atro-
phied limb, as a logical attempt to cause an increase in
its growth through a judicious irritation of the epiphysis
at the time of operation. This can only be demon-
strated by careful series of measurements, which as yet
I cannot give, but I hope at some future meeting to be
able to bring before you.
RECURRENT VOMITING.
BY
CHARLES W. LARNED, M.D.,
of Baltimore, Md.
Under the various titles of cyclic, recurrent, fitful,
periodic, and persistent vomiting, different observers
have described a condition of considerable interest,
occurring as a rule in children under the age of 10.
Leyden' has spoken of a somewhat similar condition
occurring in adults, differing, however, in some respects,
and more particularly in the fact that in the great
majority of the cases the vomiting was associated with
abdominal pain that at times was intense and strongly
suggested the gastric crises of tabes. I am not prepared
to say whether the disease as described in adults is
identical with that occurring in children ; certainly
in adults the paroxysms point rather to a gastric
neurosis, being a.ssociated with other neurasthenic mani-
festations, whereas in children the whole picture suggests
rather an acute toxemia, and must not be confounded
with gastric disturbances dependent upon indiscretions
in diet, and attacks such as those described by Symes,^
Esmond ' and others.
The histories of two cases which were recently
encountered in my practice are briefly as follow :
Case I.— The patient was Clara M., aged 4 ; white.
Family History.— Psirenta are both healthy, not neurotic:
one sister has always been frail.
Present Illness— Vntn 18 months ago she was a robust,
healthy child. At this time she had an attack which was
termed by the attending physician cerebrospinal meningitis,
hhe was very ill for about three weeks, and according to her
parents the most pronounced symptom was incessant vomiting.
About SIX months after this she had a similar though much
mnaer attack At this time she was not a patient of mine, but
from her mother's account I feel sure that the illness referred to
"v^,^ "^^ cerebrospinal meningitis was the initial attack of
.H^vTh- k",""^5^L ^^."^^ ^^""^^ months later I saw her in an
attack V, hich lasted three days ; and in well-defined recurrences
after 5, 10 and 13 months, respectively. All of these attacks, as
regards severity and duration, were about alike. The details of
the first follow :
On Thursday, about 4 p.m., the child was suddenly seized
with vomiting, bringing up at first what was apparently normal
Stomach contents. The vomiting continued at intervals of
every half hour or so, and when seen by me the ejected matter
consisted only of a little water and mucus, the retching being
very distressing. During the night there was no relief; the
child slept but little, though not complaining except of thirst.
The condition continued about the same all the following day
and night; toward Saturday midday the paroxysms began to
grow less frequent: no vomiting occurred after 7 p.m.; the
child had a good night and was much better on Sunday morn-
ing, convalescence being rapid thereafter.
During the attack the stomach rebelled at absolutely every-
thing, a teaspoonful of water being sufficient to start vomiting.
The face soon assumed a drawn, haggard expression, the general
bearing was decidedly apathetic ; the child appearing thoroughly
exhausted. The abdomen assumed a boatrshaped appearance
after the vomiting had continued 36 hours ; no pain was elicited
on palpation, but slight uneasiness in the epigastrium was com-
plained of. The pulse was about 110 throughout the attack, the
temperature not exceeding 100°. Constipation was quite marked,
enemas being only partially effectual. The bowels moved on
Sunday afternoon for the first time in three days. The urine
was scanty, dark in color; no albumin, no sugar. The micro-
scopic examination was negative.
Case II.— Spencer M., white, bom September 28, 1896.
Family History. — Father is not robust and has a tuberculous
history. The mother is quite neurotic, a frequent sutfererfrom
neuralgia, and has slight attacks of arthritis.
Previous History.— The patient had a severe attack of sum-
mer diarrhea in 1897 ; measles and typhoid fever during the
winter and spring of 1899. At about the age of IS months he
nearly died in an attack of persistent vomiting which lasted
about two weeks, and was diagnosed " brain fever" by the
attending physician. From this time on, at various intervals,
he has had milder attacks.
Present Hhtess.^The first well-defined attack of vomiting
in which I saw the patient, occurred shortly after convalescence
from typhoid, in 1899; the next in June of the same year;
another in September and several during the winter of 18SJ9 and
1900. The details of the last attack, which occurred in October,
1900, follow :
For about 12 hours before the onset of the vomiting the boy
was fretful and peevish ; appetite was poor; the bowels consti-
pated. Broken doses of calomel were given, which acted after
active emesis had commenced. The stools were rather light in
color and very offensive. Vomiting began at 8 p.m., October 12,
the material consisting at firstof stomach contents. It continued
all that night and the following day and night, at intervals of
about 20 minutes. On October 14 the intervals lietween seizures
became longer, the vomiting ceasing entirely at 9 p.m. The
vomited material, after the food had been expelled, cxjnsisted
at first of water and mucus, but toward the end of the attack
contained considerable blood and bile. The face soon became
drawn ; depression was marked, the child being apathetic to a
degree, complaining only of intense thirst. During the night
of October 13 and the following morning the pulse became
weaker, the rate at times being 130 to the minute. The tempera-
ture never exceeded 100°, reaching this point on the morning
of October 14. Abdominal palpation was negative, except for
slight epigastric uneasiness. Respiration was rapid, shallow
and associated with frequent sighing. The urine was scanty,
highly colored and showed a trace of albumin, with a few
granular casts. Urticaria appeared October 14, and continued
for some days after convalescence was established.
These two cases would appear to represent typical
instances of the condition under consideration. I
regret very much that I have not been able to work
out more thoroughly certain points in connection with
the urine and gastric contents which might throw some
light on the pathology. This was, however, impossible
in Case I, as I have never seen the child in an attack
since making a correct diagnosis, and the patient now
lives in another city. My notes were taken when I saw
her during the first attack, thinking at the time that I
had an acute intestinal obstruction to deal with. The
second patient has now gone 18 months without fur-
ther attacks.
The two cases are very similar, although in Case II it
would appear that the factor of heredity deserves some
little consideration. The initial attack in each in.stance
was in all probability incorrectly diagnosed cerebro-
spinal meningitis. Case I gives no record of any pro-
dromal symptoms, while with Ca.se II for a few days
before the attack comes on there is nearly always more
or less change in the child's disposition, with loss of
appetite and slight constipation. The vomiting having
August 16, 1902)
RECURRENT VOMITING
fAMERICAN MEDICINK 259
once begun, was almost incessant in both children, the
second child having had 61 seizures in the course of 24
hours ;in both cases toward the end of the attacks the
vomitus contained more or less blood and bile. Consti-
pation during the attacks was most obstinate in both
children, the stools when passed being decidedly light in
color and very offensive. In neither case was it possible
to determine the condition of the urine just before an
attack. During the early stage, in both instances, it
was very scanty, high-colored, but showed neither albu-
min nor casts. Toward the end of the attacks in Case II
it wa.s not at all uncommon to find a trace of albumin
and a few granular ca-sts, this condition rapidly clearing
up after convalescence was established.
The scaphoid abdomen was noted in both instances
after vomiting had lasted for some hours. In neither
case was abdominal pain complained of, and only slight
uneasiness was elicited on palpation. Neither child had
headache, nor a temperature over 100° F. There was
intense thirst but desire for food was absolutely want-
ing, although both children betame ravenous as soon as
the vomiting had subside<l. The respiration was not
recorded in Case I, but in Case II it was quite shallow,
rather rapid, with frequent sighing. The pulse became
rapid in both cases as the attacks progressed ; but
always remained of good character. In Case II it would
at times become irregular as to volume and frequency,
but not intermittent. Restlessness was not a marked
symptom ; on the contrary, both children lay quiet dur-
ing the greater part of the attack, only moving occasion-
ally to change their positions. There were no skin
lesions noterl in Case I. Urticaria followed the
attacks in Case II. The duration of the attacks was
from one to four days in both children. In neither
child was there the slightest regularity as to the time of
recurrenw.
In searching the literature on the subject I have been
led to believe that the condition is more common than
has been generally supposed. (Jee' appears to have
been the first observer to report instances occurring in
children ; since then Snow,^ Holt," llotch,' Rachford,"
Whitney,' Comby,'» Marcy," Sollelis'^ and Griffith"
have all published one or more cuses.
Aca^rding to Holt " This condition is one which has
received but little attention. It is elassetl by some as a
gastric neurosis. While at the present time we are not
in a position to give it a definite pathology, it seems to
be associated with a general derangement of nutrition
which is in some way connected with the formation and
excretion of uric aci(l. It is not certain that all these
cases have the same origin.
"The disease is characterized by periodic attacks of
vomiting, recurring at intervals of weeks or months
without any ade<iuate exciting cause. The vomiting is
severe and uncontrollable, and usually lasts from twelve
hours to three days. It is attended with symptoms of
general i)rostration which may be alarming. The chil-
dren who are subjects of it may show in the interval
nearly all the signs of perfect health."
C/inic(d Afu/iifeskt/ionft. — In the great majority of
cases reported there is but scanty reference made to any
prodromes. In some instances, however, there is more
or less malaise, loss of appetite, headache, some disturb-
ance of the bowels, most frequently constipation, but
otrasionally diarrhea, feverish breath, furred tongue and
possibly com|)laints of indefinite abdominal pain. In
one of (iritfith's cases the premonitory symptoms lasted
a wtH'k ; (ie<' reported a similar instiince. The loss of
appetite noted so constantly would not appear to be due
U> faulty gastric digestion.
Vomiting, as a general rule, is the symptom which
ushers in an attack. It is at first forcible, but toward
the end of th*; attiu-k, when exhaustion becomes marke<i,
is unaccompanied by much effort. In Case II of (jrif-
flth's series the exhaustion was so great that the child
lay helph'ss on his side while every few minutes a little
blood-stained fluid ran from his mouth. The vomitus
at first consists of the stomach contents, and later of a
little water mixed with mucus ; as the retching becomes
intense it is not uncommon for both blood and bile to be
ejected. In my second case the amount of blood at
times was so great as to be alarming. As the patient
progresses toward recovery the intervals between the
paroxysms become longer, and with the cessation of
the vomiting convalescence is at once established.
Constipation is most obstinate, it frequently being
impossible to"procure an action from the towels until vom-
iting has ceased and the child is able to retain calomel or
some other aperient. It does not appear that the con-
stipation has any direct influence upon the vomiting, for
in my second case the calomel taken before emesis began
produced three evacuations after vomiting was well
established, but with no apparent effect upon the dura-
tion of the attack. In Whitney's case the bowels were
loose throughout the attack. The color of the stools is
described by Gee, Holt, Still,'* and in fact by nearly all
observers, as lighter than normal ; this was certainly
true in both my cases.
Except for slight uneasiness, abdominal palpation is
generally negative. In Case III of Griffith's series slight
abdominal pain was always present. In his Case IV, as
the diagnosis of appendicitis was made by a consulting
surgeon, we must infer that there was more or less
severe pain. This absence of marked abdominal pain is
one of the most striking difterences noted between the
cases reported in children and the instances of " recurrent
vomiting " in adults. The abdominal walls are as a rule
retracted.
The pulse usually becomes rapid as the prostration
increases, and may become irregular and weak. The
temperature has been described as subnormal, normal or
slightly elevated. Snow, Rachford, Marcy and Griffith
state that there was marked fever in some or all of their
cases.
The respiration is decidedly affected, being rapid and
having a peculiar sighing character. The respiration
and pulse seemed to follow a corresponding curve in my
second case.
Convulsions occurred in Snow's case. This child
had a decidedly neurotic family history ; the mother and
two brothers had convulsions during infancy, and one
sister was an epileptic. The convulsions, did not, how-
ever, occur in every attack.
Itching of the skin was present in two of Griffith's
cases. In my second case urticaria followed each
attack.
There seems to be a difference of opinion among the
various observers as to regularity in the intervals
between attacks. Sollelis, Comby, Whitney and Kin-
horn,'* are among those who favor a definite periodicity.
In Marcy's, (irlffith's, and in my own eases this was
absent.
The duration of the attacks is likewise variable, even
in the same individual. In neither of my cases did any
of the atttu'ks last over 86 hours, and usually liy the end
of 48 hours the patient had enterwl ui)on convalescence.
The change in 24 hours after vomiting had ceased, was
always most striking ; the child, who a few hours before
could not retain the least thing, would beg for food of
any and every description, the only indication of the
attiick being more or less pallor and a certain amount of
physical wraknoss. Convalescence is generally rapid,
but llotch and Snow report attacks after which it was
slow ; the duration of the attacks having been much
longer than usual and the vital force proi)ortionately
The vomitus, iiccording to Fenwick,'" is not uncom-
monly cither neutral or only faintly acid in reaction,
IICl being absent. Boas " and Kinhorn agree with this
view. In Snow's cast? IICl was present in excess. I
examined the vomitus in the last attack in my second
case and found that that which was ijectwl at the very
260 AMERICAN MKDIOINBJ
EECURRENT VOMITING
lAuoCST 16, 1902
onset contained but very little free HCl, the total acidity
being below normal ; later there was a total absence of
free HCl, the reaction being neutral. I did not have an
opportunity to examine the vomitus in Case I.
Between attiicks tlie children, as a rule, are in perfect
health.
Etiology and Pathology.— AM\\o\x%h quite a num-
ber of theories have been advanced as to the patho-
genesis of recurrent vomiting, none are very satisfac-
tory.
Charcot '» holds that so far as adults are concerned
there is not sufficient evidence as yet to place these gas-
tric crises in a class by themselves, regarding them as
in all probability an early manifestation of tabes.
Leyden, Debove," R6mond, Snow, Still, Rotch, and
Whitney are inclined to the belief that the underlying
factor is a gastric neurosis.
Bouv6ret* has observed similar attacks which he
thought were due to supersecretion, while Einhorn does
not think the gastric secretion plays any notable part in
the causation.
Mathieu ^' thinks nephroptosis may account for the
attacks in adults.
Gee and Fenwick are inclined to the opinion that
indulgence in certain articles of food may have a certain
bearing upon the establishment of the condition, which,
when once established, has a marked tendency to recur.
Marcy says: "The conditions which provoke an
attack are varied, but are probably due for the most
part to the ingestion of certain kinds of food, coupled
with an imperfect intestinal digestion and lowered vital
force, the result being ptomain poisoning." He bases
this conclusion on the following data :
1. A study of the urine before an attack shows that
it is always increased in (luantity, of high specific
gravity, very acid, and containing large amounts of
indican. The uric acid, while not in excess, is rarely
much below the normal.
2. During the first few hours of the disease there is
but little change in this respect, but gradually the quan-
tity of urine diminishes, the indican disappears, and
acetone in large quantities is found. Acetone is also
given off by the breath, and causes a peculiar odor,
which is almost pathognomonic.
SoUelis evidently dissents from this opinion, for he
reports a case which proved fatal, but which he held was
an instance of intestinal autointoxication or cholera
sicca, as described by Hutinel,^'' and therefore not to be
classed with ca.ses of recurrent vomiting.
According to Pepper, '^^ " the vomiting may be elimi-
native of some ptomain recently produced or accumu-
lating in the system, and the increased toxicity of the
urine, observed by Hunter in one of Holt's cases, is an
important support of this view, but the origin of such a
possible ptomain is unknown."
Griffith thinks that the condition may be a neurosis
of toxic origin, being in some way connected with faulty
metabolism.
Eachford attempts to account for the attacks by the
presence in excess of certain of the xanthin group of
alloxuric bodies in the body media. This group is com-
posed of xanthin, guanin, paraxanthin and heteroxan-
thin. Guanin being nonpoisonous, and xanthin but
slightly so, are discarded as possible factors. Paraxan-
thin and heteroxanthin, on the contrary, are quite toxic,
and in certain pathologic conditions can be easily isolated
from the urine. Kriiger and Salomon" separated 12.5
grams of paraxanthin and 7.5 grams of heteroxanthin
from 10,000 liters of normal urine. Rachford claims to
be able to procure from a liter of urine passed by patients
during these seizures a sufficient amount of these bases for
purposes of demonstration. It is not known how, where,
or from what, these bodies are manufactured, but once
formed they are excreted by the skin, kidneys and intes-
tinal canal, the kidneys probably playing the most
important role. Rachford's belief that paraxanthin and
heteroxanthin are important factors in producing the
clinical picture is founded upon the following proposi-
tions, which he claims to have repeatedly demon-
strated :
1. Uric acid and its compounds are not poisonous.
2. Paraxanthin and heteroxantliin are very poisonous leu-
komains, and not uncomnaonly associated in their excretion
with uric acid.
3. Paraxanthin and heteroxanthin are found in such small
quantities in normal urine that their poisonous properties are
lost in dilution.
4. Paraxanthin and heteroxanthin are excreted in enormous
excess by patients suffering, from certain litheraic attaclcs.
5. The urine of these patients does not contain an excess of
paraxanthin or heteroxanthin except at the time of these lith-
emic attacks.
6. Lithemic paroxysms are not themselves the cause of the
appearance of paraxanthin and heteroxanthin in excess in these
urines.
7. Paraxanthin and heteroxanthin are excreted, but not
formed by the kidney. Their presence therefore in the urine
means that immediately prior to their excretion they were
present in the blood.
8. The paraxanthin and xanthin separated from the urine
of patients sutt'ering from certain lithemic manifestations, are
capable of producing in the mouse and guiueapig a group of
symptoms similar to those from which the patient suffered.
9. No other poisons have been demonstrated in lithemic
urine which are capable of producing tlie symptoms of lith-
emia.
He also states that hereditj- is a most important fac-
tor in the production of this socalled lithemic condition
in children, one or both parents always manifesting some
form of the diathesis. Sollelis is evidently inclined to
agree with Rachford, though he has no experimental
evidence to offer.
Other factors which are given by nearly all observers
as predisposing causes are exposure to cold, fright,
fatigue and over-excitement. Griffith, however, has not
found that these factors were of import in his cases.
Over-excitement seems to have had some bearing upon a
few of the attacks in one of my cases, but certainly not
in every instance, since they often come on without any
well-defined cause, either dietetic or otherwise.
The history of a recent infectious fever has been noted
by several observers. I have no such history in either
of my eases.
The age for the initial attack is as a rule, between
the second and fifth years. Sex has little bearing, about
a.s many boys as girls having been reported among the
sufferers. It seems to be more common among the
better class than among the very poor.
My own observations have led me to the conclusion
that the condition is certainly due to some toxic sub-
stance, its nature and origin as yet remaining to be satis-
factorily demonstrated. It may be an autointoxication,
with the intestinal canal as the ofltending focus, or it may
be due to some failure on the part of the excretory
organs to eliminate certain poisonous substance or sub-
stances which accumulate in the organism and i)roduce
toxemia. I cannot believe the stomach to be primarily
at fault, the vomiting being merely a symjitom such as
we frequently see in uremia and other allied conditions.
Rachford's theory, though a very attractive one, has
not been verified by further investigation. The same
may be said of intestinal autointoxication. It probably
rests with the physiologic chemist and not the clinician
to discover the true nature of the condition.
The diagnosis becomes easy in most instances when
the attending physician is aware that such a clinical
entity exists. I say this feelingly, as I was two years
in recognizing my first case. Having attained this much
knowledge and remembering a few of the cardinal
points of the recurrent form, viz., the history of pre-
vious attacks, the sudden onset, persistency of the vom-
iting, freedom from pain, and absence of symptoms
referable to the general nervous system, we will, as a
rule, have but little difficulty in arriving at a correct
diagnosis. We will, however, at times have to differ-
entiate between this and various other morbid condi-
tions, more particularly the following :
August 16, 1902)
FILTRATION OF STOMACH CONTENTS
[AHEBICAN MeDICIK'^ 261
In acute meningitis we often obtain a history of a
previous middle-ear disease ; there is usually intense and
continuous headaclie ; unconsciousness is an early symp-
tom ; delirium is frequent ; convulsions are not uncom-
mon ; epileptiform attacks, which come and go, are
highly characteristic of direct irritation of the cortex ;
rigidity and spasm, or stiffness and retraction of the
muscles of the neck are important symptoms ; hyper-
esthesia of the skin and muscles, strabismus or ptosis
may occur. The pupils at first are likely to be con-
tracted and later dilated or unequal ; a slow pulse is a
striking feature in the early stage. Lumbar puncture
may be resorted to in prolonged attacks, if doubt still
exists as to the diagnosis.
In tuberculous meningitis prodromal symptoms
extending over some weeks are not uncommon ; convul-
sions may occur together with intense headache, vomit-
ing and fever. The hydroceplialic cry may be noted, or
the child may scream continuously ; respiration is rarely
altered ; the pulse is slow and at times irregular ; there
may be twitchings of the muscles or sudden startings
during sleep ; as the disease progresses the child becomes
more or less delirious ; the head is often retracted ; the
pupils are dilated or irregular, or possibly there may be
strabismus. Toward the end, coma, spasmodic contrac-
tion of the muscles, convulsions, and involuntary pass-
age of urine and feces are not uncommon.
With intestinal obstruction there is abdominal pain,
colicky at first, but subsequently continuous and
intense. The vomitus consists at the beginning, of gas-
tric contents, later of bile, and often becomes stercor-
aceous, an important diagnostic point, for fecal vomiting
never occurs in the recurrent form. The bowels may be
constipated but tenesmus and bloody stools are not
uncommon. On abdominal palpation it is often possible
to make out a sausage-shaped tumor, the abdomen at
times being exquisitely tender. Distention rather than
retraction is the rule. The symptoms of collapse super-
vene early.
In acute indigestion there is frequently a history of
overeating or some indiscretion in diet; the vomitus
will often show undigested food. There is a tendency
to diarrhea. The vomiting usually relieves the attacks.
An early examination of the urine is usually sufficient
to exclude acute nephritis.
JProf/nosis. — Until Marcy published his two fatal cases
the outlook had always been considered favorable, the
attacks usually growing less frequent as the child
advanced in years, and ceasing altogether at puberty.
As SoUelis has remarked, "On ne meurt pas de vomis-
sement p6riodique, pas plus qu'on ne meurt d' un acc6s
de migraine." He also agrees with Rachford that the
condition is an early manifestation of the socalled lithe-
mic diathesis, this condition developing later in life. In
the first fatal case before mentioned the patient had an
acute nephritis coincident with the last attack of vomit-
ing, which Marcy attributes to the intensity of the tox-
emia, death occurring on the second day from heart
failure. There is no postmortem report in this case.
The second patient diwl of exhaustion, after an illness of
nine days. The postmortem findings are given in detail.
Dr. A. (). J. Kelly gives the following anatomic diag-
nosis: "Necrosis of the mucous membrane of the
.stomach and intestines ; fatty infiltration of liver ; slight
parenchymatous degeneration of the pancreas, spleen
and kidney." This child's death seems to have been
undoubtedly due to the condition under consideration.
In the first case, however, in view of the fact that there
was a coincident acute nephritis, with suppression of
urine, there may be some reasonable doubt as to the pri-
mary cause of deatli, though the child had undoubtedly
had j)revious attacks of recurrent vomiting.
Trent rneiil. —Up to the present time nothing has boon
found efficacious in cutting an attack short, though cer-
tain measures seem to alleviate somewhat the suftering
•of the jiatient. The first indication is to stop all food
and drugs by the mouth, as they do no good and their
exhibition merely increases the frequency of the vomit-
ing. Medication and feeding should be entirely by way
of the skin and rectum. Morphin and normal salt
solution through the skin, predigested food, salt solu-
tion and opium by the rectum are useful. In the
majority of cases it is not necessary to resort to hypo-
dermic medication, as the thirst seems fairly well con-
trolled by retained injections of salt solution. Tincture
of opium in the same way seems to act about as well as
morphia hypodermically. The secretion of urine seems
also to be as favorably affected by this method as by
hypodermoclysis. The bromids and chloral have advo-
cates, but they are certainly inferior to opium. Flushing
out the lower bowel once daily with a copious high
injection of normal salt solution seems of some benefit.
Blisters over the epigastrium merely increase the child's
discomfort. With the subsidence of the vomiting, a
calomel purge is indicated. Between attacks the child
should lead an out-of-door life ; he should not be sub-
jected to over-fatigue or excitement ; the bowels should
be carefully regulated, and most important of all, he
should be made to drink a good deal of water. I can-
not but feel that the large amount of liquid which I
have insisted upon since October, 1900, in my second
case has had much to do with the long continued free-
dom from an attack.
BIBIilOGRAPHY.
•Leyden, Ztschr. fiir kllnische Medicln, 1882.
2Symes, Dublin Journal Med. Sciences, 1897, civ, p. 112.
3 RCmond, Archives G6n6rales de .Mfideclne, JulUet, 1889 and 1890, i.
p. 641.
■•Gee, St. Bartholomew's Hosp. Reports, .xvill, p. 1.
sSnow, Archives of Pediatrics, 1893. p. 986.
0 Holt, Dlsea,ses of Infancy and Chlldiiood, 1897.
TRotch, Pediatrics, 1896.
8 Rachford, Archives of Pediatrics, xiv, pp. 561, 661. 742.
B Whitney, Archives of Pediatrics, Nov., 1898.
louomby. Archives de Mgdeclne des Enfants, J899, 11, p. 860.
" Marcy, International Clinics, ill, 9th Series, 127.
isSoUells, These de Paris, 1899.
"GritHth, Am. Jour. Med. Sciences, c.xx, p. f&i.
"Still, Encyclopedia Medica, Iv, p. 98.
isElnhorn, Twentieth Century Practice of Medicine, vlli, p. 343.
>« Fenwick, Diseases of Digestion in Infancy and Childhood, 1897.
" Boa.«, Deutsche med. VVchnschr.. If 89, xv, p. 864.
"Charcot, Policllnique du Mardi,19 Fevrler. 1889.
I'Debove, Communication a la .Socifitfi Medicate des H6pltau.x,
seance du 11 Janvier, 18H9.
»>Bouveret, Revue de MC-decine, 1891. p. 1.56.
2iMathleu, Soci6t6 Mfidtcaie des Hopilaux, 21 Oetobre, 1892; and
Tralt6 de M6dcclne, iv, p. 23.3.
"Pepper, Cyclopedia of the Diseases ot Children, Keating, ill, p. 22.
ssHutlnel, Semalne MCdIcale, 25 Janvier, 1899.
2< Krilger and Salomon, Ztschr. f. physlol. Cherale , xxi, 1695.
FILTRATION OF STOMACH CONTENTS: CHANGES
IN CHYME DUE TO DELAY IN EXAMINATION.
A. L. BENEDICT, M.D.,
of Bufftlo, N. Y.
There has been considerable discu.ssion as to whether
the examination of stomach contents should take place
on the unfiltered or filtered chyme. The qualitative
tests for fermentation acids, for carbohydrates, for fer-
ments and my own quantitative te.sts for i)roteid diges-
tion must obviously be performed on filtered chyme,
except that some few of these may be performed with
approximate results on a reasonably clear decantate. It
has been held that the titration of acid constituents
should be made on unfiltered chyme on a<;count of their
adhesion to semisolid particles, this being especially true
of combined chlorids. Until retfently I have shared this
view, but careful consideration of the subject has reversed
this opinion. In certain cases the amount of chyme
extracted is so small or it is relatively .so deficient in
gastric secretion that one must examine unfiltered mat-
ter or else perform exi)eriments on so small an amount
that errors of measuring — especially that flue to capil-
larity in glaHS — and of reading end-reactions are multl-
262 AMKKicAN MEDICINE] POSTMORTEM OBSERVATIONS ON APPENDIX
[AUGUST 16, 1902
plied by too large a faetor. As a rule, all acid constitu-
ents are apparently a few degrees higher in unflltered
than in filtered chyme. I am inclined to believe, how-
ever, that this is, in a measure, due to the uncertainty of
appearance of color changes in mixed contents as com-
pared with the sharp distinctions that can be drawn in
a clear liquid. If, however, the stomach contents con-
tain much fat or mucus, this collects at the top of the
vessel and renders the first tests lower than the later
ones or than those made on filtered chyme. For instance,
Mrs. K., free HCi by dimethyl, lOfc with chyme con-
taining mucus, 15Jif after simply removing mucus with
a swab. The ordinary opposite result is illustrated by
the following : Mr. C, untiltered chyme, 57^ to end of
reaction with dimethyl, 80^ total acidity by phenolph-
thalein. The tests with filtrate, made as soon as possible,
filtration having occurred promptly and the two tests
being made after the same delay, except the few minutes
used in the first titration, were iSfc and 09%, respect-
ively. The end-reaction with dimethyl was chosen to
avoid an error in comparison as the appearance of the
first color change is somewhat a matter of the personal
equation.
In general it may be said that more liquid specimens
occur with a high degree of hydrochloric acidity, the
relative clearness tending to minimize the influence of
semisolid particles while the hydrochloric acidity tends
to prevent fermentative changes. In a case of acholor-
hydria GO cc. of chyme yielded 20 cc. of filtrate. The
latter had a total acidity of 22% . After standing over
night in a warm room the semisolid portion diluted, and
the reading based on the actual amount of sediment
used showed a total acidity of 105% . This is, of course,
an extreme instance. The fermentation changes are
considerably greater in the unflltered portion, as would
be expected, for instance :
Total
HCl acid.
Immediate examination of unflltered chyme VHf V22i
After 1-2 hours, tlltrate 101* 13(W
AfterSdays, flitrate 97^ Vai
AfterSdays, unflltered 95* 140*
While on this subject it may be said that stomach
contents change very little within three or four days if
kept at or below 40° F., although there is usually a
slight evaporation of free HCl and a moderate increase
in total acidity, due mainly to the formation of fermen-
tation acids. The last process depends on nature of
stomach contents, amount of HCl, other antiseptic fac-
tors, indigenous and aerial infection, as well as on tem-
perature and time of exposure before testing, so that no
definite rules can be laid down. Beside the tests already
given, the following may be cited in illustration :
Total
acid.
Mrs. J. B. B., original, unflltered, trace of HCl by
dimethyl 61<t
Mrs. J. B. B., warm room 2 days, trace of iici by
dimethyl 92*
R. B., original, unflltered, ,W-.% HCl 90*
K. B., unflltered, 2 days at 10° F., 48 HCl 9>H
Mrs. J. .McC , original, unflltered, 11 HCl 87*
Mrs. .1. McC, unflltered, after 4 weeks, 23 HCl 71*
Mrs. F. K.. original, flltered. 17 HCl, total acidity 60*
Alter 15 days, 17 HCl, total acidity 75*
The last can scarcely mean an absolute increase of
HCl and I make no attempt at explanation. It could
not be a variation in reading a color-reaction, as in all
these comparative tests the end-reaction with dimethyl
was used, for the reason already stated. Several years
ago I had quite a number of examinations but the re.sults
were not saved in detail, as all agreed in the practical
point that in a cold room no considerable change
occurred within two or three day.s— a point of great
value to the bu.sy practitioner, whether specialist in
digestion or not, as it warrants a rea.sonable delay so
that time may be economized by making several exami-
nations at once.
The filtration of chyme is at best a tedious process. •
After trying various filter papers, cotton and other plugs
in the Iwttom of a funnel, etc., I have found the follow-
ing method the quickest :
1. Centrifuge two tubes ol 15 cc. each. A water or electric
centrifuge aids materially in all centrifugal processes. Tiie
chyme is separated into tliree layers, at the top, mucus and fat;
in the middle, clear liquid; at the bottom, starch cells, etc.
The top layer may be removed with a cotton swab.
2. Filter the decantate by suction through ordinary thin
filter paper, wet only with the liquid to be examined. If, as
often happens, there is still considerable mucus or starchy
sediment poured off from the centrifuge tube, care should be
taken to deposit these around the upper part of the filter paper,
so as to leave the apex at the bottom free. A drop should pa.ss
the funnel two or three times a minute after the paper be-
comes wet. If the filter becomes clogged it saves delay to pour
off into a fresh filter. Sometimes bacteria, etc., will penetrate
the filter and make a haze which tends to separate into cloudy
masses. These do not interfere with titrations, but a second
filtration without suction is necessary to clear for proteid esti-
mation.
I shall be glad to learn of any simpler and fairly
rapid method of filtering stomach contents, as I have
experimented with colanders and various other devices
in vain.
The filtrate from chyme represents digestive activity,
actual and potential. Even the amount of filtrate is
important. F'or instance, Mrs. / . ) . 4. one hour after a
bread-and-butter and water meal yielded 70 cc. of 79 %
total acidity and 13% free HCl, which would indicate
nearly a normal condition but there was considerable
mucus and only 10 cc. of filtrate. Norniallj', there
should be at least half or two-thirds of filtrate. In diag-
nosing hyperchlorhydria, one must also be guided by
the amount of chyme. The normal free HCl percentage
should be from 2,5% to 60%, the lower figure falling
short of half the total acidity, the latter equaling or
exceeding all other acid factors. In a patient whose free
HCl amounts 1 to ,50% to .5.5%, the ease was considered
hyperchlorhydria because the total contents amounted to
500 cc, whereas the test-meal, including water, came to
about half this amount. The acidity percentages did
not fall much under treatment but the bulk of chyme ■
did and the proportion of clear filtrate also diminished,
showing that there was a real diminution of secretion
and not merely a more rapid passage through the
pylorus. I may explain that I do not agree with the
cla.ssification that places a very low standard of free HCl
as normal and that considers hyperchlorhydria com-
patible with a considerable production of organic acids.
In the case of Mr. ''.6.8. , there was apparently good
secretion and digestion, the total acidity being 90%, the
free HCl 23%, the albumin 3%, and the albumose and
peptone together, 38 % . The total chyme obtained was
45 cc, which is sufficient though not up to the maximum
normal limit in these days of more patient effort to
empty the stomach, but there was only 18 cc of flitrate,
which is somewhat low and would reduce our estimation
of gastric function by approximately 25% .
POSTMORTEM OBSERVATIONS ON THE APPENDIX.'
BY
GEORGf; BOODY, M.D.,
of Independence, la.
Assistant Physician Hospital for Insane at Independence, la.
This small organ may well be likened to a quill
because of its similarity to it in color, diameter, form and
length. If it has a function other than that of causing
great pain and suffering to the human family, it is not
yet understood. Because of its susceptibility to di-sease
it has attracted the attention of the medical profession
the world over, and now the skilful surgeon does not
' Read before the Cedar Valley Medical Society at Waterl<!0, la.,
October, 1901.
AUGUST 16, 1902]
POSTMORTEM OBSERVATIONS ON APPENDIX (Ambkicajj medicine 263
hesitate when once he has discovered that it is the seat of
disease to remove it. However, he does well to remem-
ber that the appendix is not always found in its normal
position ; it may be found in any part of the abdominal
cavity. For this reason it becomes the duty of every
physician and surgeon to study its relations to other
organs, and its possible situations. Accordingly the
members of the medical staflf in the Hospital for Insane
at Independence, la., have carefully noted its dimensions
and position in 528 autopsies held during the past few
years. The appendix varies much in dimensions. The
smallest diameter observed in this series was 2 mm., and
the greatest 12 mm. The greatest length was 20 cm.,
and the least 1.5 cm. In seven ca.ses the length was
2 cm. The average for the series was 7.3 cm.
When situated normally the appendix is found in the
right iliac fossa, just behind the cecum, into which its
lumen opens, and which it
resembles closely in structure
— being indeed a rudimen-
tary cecum. It lies in this
region across a large mus-
cular structure, the psoa.s
muscle, and is directed up-
ward and inward, pointing
toward the spleen.
In the series here re-'
ported, the appendix was so
situated in 269 eases (about
51 f,). In the remaining 259
(about 49 <fc ), the position was
abnormal. In these 259
cases, 215 were situated nor-
mally or nearly so, a.s re-
gards the base ; while the
remaining portion showed
abnormality in direction.
In 38 cases (about 5^) the organ was directed up-
ward— 28 of these were internal to the psoas, and 10
external to it. Of the 28 cases internal to the psoas, 23
extended directly up behind the cecum and colon, three
deviated a little from this position externally, and two
internally. Of the lOcases external to the psoas, one may
be mentioned which extendetl up and externally until
its extremity rested against the lateral peritoneal wall.
In 25 ca.ses (about 1.5^) the appendix pointed down-
ward ; eight on the anterior surface of the psoas, 17 on
its inner aspect.
In four cases (about .8fc) it lay directly across the
muscle, pointing toward the median line of the body.
In 11 cases (about 2.5^) the appendix was found on
the inner aspe<^t of the psoas, pointing almost directly
backward.
In 73 cases (about 14^) the appendix lay on the
external surface of the psoas and was directed downward
and backward.
In 04 cas(;s (about 12;^) the organ extended down-
ward, inward and backward. One case extended upward
and inward on the inner aspect of the psoas with its
extremity against the sacrum.
This completes the analysis of the 215 cases in which
the base was nearly in normal i)Osition.
Of the remaining 43 cases, 24 (about Aft) were dis-
l)laced in connei-tion with displacement of the cecum and
a portion of the colon. Of these 17 were disphiced down-
ward into the pelvic cavity, five upM'ard, and two to the
left of the me<lian line. Of those displaced into the
pelvic cavity, five were found in well-defined pouches.
()n(! of these pouches is perhaps deserving of special
notice. It was formwl internally by the ileum, externally
by a fibrous band passing from the cecum to the parietal
peritoneum, posteriorily by the psoas muscle and ante-
riorly by the cecum. Three contained sjnall fecal con-
cretions, the mucous surface of the third being thickened
and engorged.
Of the five dl8place<l upward, three were situated in
the region of the liver, one extending upward until its
extremity came in contact with the liver and containing
within its lumen a quantity of fecal matter ; one lying
in the form of a semicircle with its convexity upward
and resting against the liver, and the third in contact
wiih the gallbladder. A fourth was found with the
base 6 cm. above the umbilicus, and the remaining por-
tion extending downward, while the fifth was displaced
with ihe cecum to a point a little higher than, and
posterior to, the first part of the colon, where it was
coiled upon itself, as if to hide from the surgeon.
The two cases (.4^) displaced to the left of the
median line were as follows : The first, with the cecum,
was found in the left iliac fossa and was directed upward
and inward until it rested against the external surface
of the psoas muscle ; the second, together with the
cecum, was lying above the umbilicus and to the left of
the median line. Its length was 12 cm. and within its
lumen were a number of fecal concretions.
The remaining 19 were, for various reasons, of special
interest, and will be mentioned separately without any
attempt to classify them. Four were found with the
base lying close up in the apex of the angle formed by
the sacrum and the psoas muscle, while the remaining
portion of each extended directly downward. One lay
with the tip up and the base down. One was found
external to the psoas muscle behind the cecum imbedded
in a mass of old fibrous bands. Each of two others was
concealed within a well-defined pouch behind the cecum.
In one case the appendix was found to be divided at
its middle portion and the two parts separated for a dis-
tance of 1 cm., the part furthest away being held in
place by old fibrous tissue which also acted as a con-
necting link between it and the part which was still
attached to the cecum. It appeareid altogether probable
that the appendix had been diseased some time in the
life of the individual, and that its middle portion had
been destroyed, and finally disappeared altogether. The
two parts were each 1.5 cm. in length.
Another was coiled upon itself external to the psoas
muscle and surrounded by pus and a quantity of recent
fibrinous exudate. It contained a quantity of fecal
matter and the vessels of the mucous surface were
engorged, but there was no
rupture. One was situated
behind the cecum and filled
with liquid, while in its
wall appearwl a small per-
foration and an ulcer. One
extended directly toward the
spleen until it passed over
the median line, when it
changed its course and
passed backward. It wa'^
full of concretions and its
length was 12 cm. One, 10
cm. in length, restctl with
its base on the external sur-
face of the psoas muscle and
extended directly toward the
spleen with its first half,
then turned at an acute
angle and descendetl along
the internal border of the
psoas. It was adherent throughout to the post-
peritoneal wall. One extended with its first half
upward behind the cecum, then curved outward and
downward. It was adherent to the cecum, was 1 cm.
in diameter and 15 cm. long. It contained fecal matter,
which was easily pushe<l into the cecum. One was
folded uix)n itself at normal level with the first part of
it behind the t«cum while the remaining portion lay in
plain view over a coil of small intestine.
One, in normal position, was coiled ujion it^lf poste-
rior to the co(mm and was also stu-culated, tlie enlarged
portion teing near the extremity. One in a similar
264 Amkbican Mkdicinbj
HEMATOLOGY OF EHEUMATISM
[ACOCST 16, 1U02
position was enlarged and gangrenous at both its middle
portion and its extremity. One contained a number of
concretions and showed induration of the wall of the
appendix directly over each concretion. In one the
lumen wa.s occluded at a point near the base, and the tube
beyond the occlusion was filled with a licjuid which had
caused the appendix to increase in size until it had
assumed the form and appearance of a cyst. Fortunately
the specimen showing this unusual condition was pre-
served entire, and is shown in the accompanying illus-
tration.
The appendix was free from adhesions in 402 cases
(about 76f£>) and in the remaining 126 cases (about 24/^)
it was attached in part or whole to the cecum, or to the
cecum and colon, or to the postperitoneal wall, by
strong fibrous bands. Concretions or fecal matter were
found within the lumen in 39 cases (alx)ut Ifc).
Pus Was found in three cases, in two of which death
had occurred from disseminated miliary tuberculosis,
and tubercle bacilli were demonstrated in the pus. In 32
cases (6^ ) the appendix was coiled or folded upon itself.
The conclusions to be drawn are as follows :
First. These statistics perhaps vary somewhat from
those of healthy people. A parallel series of cases might
show very few of the more common malpositions of the
appendix herein described, and none of those far re-
moved from the normal. Even parallel series from
among those sick, and with mental and nervous com-
plications, might show far fewer abnormalities.
Second. In view of the fact that in this series the
appendix was found far removed from its normal situa-
tion a number of times, that it was found in nearly
every region of the abdominal cavity, the diagnostician
would do well to bear in mind that a diseased appendix
might be found far removed from the right iliac region.
REMARKS ON THE HEMATOLOGY OF RHEUMATISM.
BY
A. M. DAVIS, M.D.,
of Philadelphia.
Pathologist to the Gennantown Hospital ; Ex-resldent to Blockley.
Rheumatic fever was described first by Sir Thomas
Sydenham, in the seventeenth century, who dififerenti-
ated between it and gout at that time, and since then
Garrod, Niemeyer, Fuller, Lebert, Bristowe, Bouillard
and a host of others have striven to advance science and
benefit humanity by devoting tireless energy and labor
to a careful study of this disease, but still its specific
etiology remains a mystery.
Certain pathologic changes appear to be present more
or less constantly in the joints and serous membranes,
but these are by no means so constant in the blood, since
alterations in its acidity and cellular elements vary
greatly during different stages of the disease, and in
individuals in the same stages. The blood, therefore,
offers the greatest stimulus for study and research,
since it is highly probable that the poison or poisons
(toxins, ptomains, living microorganisms or deleterious
chemic products) circulate through this medium, produc-
ing both local and general manifestations.
Regarding the adherents of the microorganismal
theory, Cohen ( " International Clinics," eleventh series,
page 102) believes it to be a specific infection, although
the specific microorganism has not been satisfactorily
demonstrated. Maragliano found in typical cases of
acute articular rheumatism that the blood contained
two microorganisms, one resembling a bacillus (non-
pathogenic) and the other a micrococcus, which he
regards as the specific agent of the disease. This organ-
ism resembles Stuphj/lococom aureus, but is only one-
half its diameter, and is found massed in groups of from
6 to 60. It is motile, easily stained by anilin dyes, and
readily cultured on gelatin. It develops best at the
ordinary temperature of the body (98.6° F.). When
injected into rabbits, symptoms of acute rheumatism
present themselves ([)olyarthritis, endocarditis, peri-
carditis, etc.). This coccus has been found by others,
notably Collin and Guttman, in the articular exudate of
patients suffering from recurrent or chronic rheumatism.
Nettler has discovered a streptococcus and I^ng a
bacillus in acute articular cases. Singer noticed a rela-
tion between the number of pathogenic bacteria and the
severity of the symptoms in acute rheumatism. Anders
writes of a number of cases having been reported in
which there was evidence of direct contagion. Mac-
Clagan, of London, believes it to be a miasmatic disease
bearing a distinct analogy to malarial fever, for the fol-
lowing reasons :
(a) It is most apt to develop in low-lying, damp localities,
in certain climates and at certain seasons of the year. (6) Cer-
tain people are more liable to be attacked than others, (c) It is
not comn-unicable from the sick to the healthy, (d) It has no
definite period of duration, (e) It is irregular in type, charac-
terized by variations in its course like malaria. (/) Profuse
perspirations occur in both, (g) In both diseases the urine is
usually loaded with urates, but this is true of any fever.
(h) As in malaria, one attack seems to render more liable to a
recurrence. {») Rheumatism often yields to salicylic acid as
malaria does to cinchona and its compounds.
Sir Dyce Duckworth (" International Clinics," Vol.
iv, eleventh series) holds it to be due to a preexisting
diathesis combined with microorganismal invasion as the
exciting cause. In support of this view he writes :
Regarding all forms of rheumatism, as I believe we are now
entitled to do, as of an infectious nature (due, that is, to a spe-
cific and particulate microbe), we have to inquire why so many
persons who must be freely exposed to the infection "escape the
malady. I am of the opinion that only certain persons are
prone to be infected and they are the subjects of that habit of
isody which is recognized in the French school as the arthritic
diathesis. Baziu is believed to have first propounded this doc-
trine which has long had the support of the great masters of
our art in France and was completely adopted by Laycock.
This diathesis is of no more universal prevalence than is the
strumous habit of the body. Like all conditions, it is heritable
and it denotes a peculiarity of textural proclivity which pro-
vides a suitable soil for the reception and development of the
rheumatic peccant matter. We find, therefore, a condition here
analogous to that which we have noted in respect to the relation
between the strumoud habit and tuberculosis.
Charcot regards the arthritic disease as a basic condi-
tion from which two main branches extend, giving rise
to a rheumatic and gouty stock. Persons of this habit
are liable to suffer all forms of rheumatism and have an
inherent tendency to develop gout. Garrod and Hayem
assert (Cabot) that the blood constitutes, as in syphilis, a
most valuable measure of the intensity of the sickness,
which is parallel to the severity of the blood changes
rather than to the number of joints affected. The fever,
the intensity of the lesions and the state of the blood
run parallel, in a general way, but the degree of anemia
is a more delicate index of the patient's condition than
even the temperature chart.
The Blood as a Whole. — The fibrin is greatly increased.
In no other disease excepting pneumonia is the network
thicker or more rapid in formation. According to INIac-
Clagan this is to be explained by an increase of tissue
metamorphosis. Coagulation, on the other hand, is not
quicker but slower than normal.
Hed Cells. — Osier and Hayem state that the poison of
acute rheumatism is a powerful and rapid destroyer of
red cells. In acute cases, according to Hayem, the red-
cells lose at least 1,000,000 of their number, and in cases
which drag along and relapse, the loss is from 1,500,000
to 2,000,000. When an attack is cut short by salicylic
treatment, the drain on the corpuscles is stopped. So
far as can be learned from 43 cases in the Massachusetts
Hospital, this diminution does not occur in all cases.
Eight patients who were sick over 20 days averaged
4,462,000 ; in those sick between 1 and 21 days the
average was 4,540,000. The lowest count was 3,608,000.
August 16, 1902]
PHYSICIAN'S OBLIGATION TO SECRECY
lAMEBICAlf MBDicina 265
According to Hayera, 4,000,000 is the usual count in
acute cases and 3,000,000 to 3,500,000 in those which
drag on and relapse.
Leukocytes. — All observers agree that leukocytosis is
the rule and that its degree is roughly paralleled to the
acuteness and severity of the attack and the amount of
fever. In acute cases the average number is 16,800
(Cabot) ; in those mild and more chronic (socalled " sub-
acute " cases) it is 9,760, while in chronic rlieumatism the
number is not increased. In five cases of arthritis de-
formans the blood was normal in all excepting two,
which showed a slight deficiency of hemoglobin.
Hemoglobin. — As in all secondary anemias, the cor-
puscles get thin and pale before they die, hence the col-
oring matter is diminished more than the count. The
average hemoglobin percentage in this series is 67, and
the color-index .76 (Cabot). Hayem noted that in some
patients during convalescence that as the red corpuscles
slowly increase the color index remains low or even
goes lower.
JReaction. — The alkalinity of the blood is almost con-
stantly diminished in acute rheumatism, its occurrence
being supposedly due to the presence of lactic acid,
either alone or in combination. Indeed llichardson
claims to have produced rheumatism by injecting lac-
tic acid in the tissues and by its internal administration.
The metabolic theory of the etiology of rheumatism de-
pends upon the existence of a morbid product protluced
within the system due to defective processes of assimila-
tion. Pratt first suggested that the material was lactic
acid and later Latham found the same substance in com-
bination in the blood of rheumatics. I"'oster claims also
to have produced symptoms resembling rheumatism
(acid sweats, muscular pains, etc.) by the subcutaneous
injection of lactic acid. His theory has many followers.
On the other hand, the antagonists to the lactic acid
theory believe that as lactic acid is a normal product of
muscle metabolism (being found in the blood during
active muscular contractions), and that, so far as known,
rheumatism is the only disease in which it is found in
excess, its presence simply indicates increased muscular
metabolism in that disease. No explanation seems to
be given as to why this occurs. These also claim that
the symptoms of rheumatic fever bear no ratio to the
amount of lactic acid in the blood and that alkalies
given to neutralize its excess have no control in influenc-
ing the progress of the disease.
Hammarsden ( * ' Textbook on Physiologic Chemistry ")
states that, from an analysis by C. Schmidt of human
bloo<l, 100 parts of serum are found to contain the fol-
lowing amounts of salts and their percentages :
KjO 0.3K';-O.l(K
N,0 4.2i)fo-).2>.K
CL (ill combination as sodium cblorid) 8 36^-3.*iS;i
CAO 0.1.5H).15i<
MGO 0 101:<
In the estimation of sodium chlorid the percentiige
remained almost constant, so that with food containing
an excess it was quickly eliminatetl in the urine, while
with food that is poor in chlorids the amount decreases
first in the l)lood but increases after subtracting chlorids
from the tissues. The elimination of chlorids in the
urine is thus diminished.
The amount of phosphoric acid (calculated as acid
sodium pliosi)hate, NaJI Po,) in the serum has been de-
termined as varying from 0.02 /r to0.0P/(. The small
amount of iron sometimes found probably originated
from a contamination with the blood-coloring nuitters.
What ettw't active exercise has in increasing or
diminishing the secretion and elimination of these salts
referred to, or any reference as to their percentages in
the various forms of rheunuitism, could not be found in
consulting textbooks upon the subject.
In testing the total acidity of the blood two prlnci-
l»al methods are (-mployed. The first, which is known
as Landois' method (modification oi Jaksch), consists ot
a number of solutions of sodium sulfate (saturated) with
tartaric acid (1/100 to 1/1,000 normal) combined in grad-
uated strengths in separate receptacles. To each cubic
centimeter of the different solutions 1/10 cc. of blood-
serum is added until the solution is found with which it
gives a neutral reaction. The strength of the tartaric
acid solution which neutralized the blood serum is
then read off and the alkalinity of the blood estimated
in terms of sodium hydrate.
The second, and by far the most practical method is
that of Lowy's: Five cubic centimeters of blood is
obtained by venesection and placed in a small flask con-
taining 45 cc. of a .25 <fc solution ammonium oxalate
(the presence of this solution prevents coagulation).
This is then titrated with a .4 ^ normal solution of tar-
taric acid, lacmoid paper wet with a saturated solution
of magnesium sulfate being used as an indicator. As
normal solution of tartaric acid contains 75 gms. to the
liter, a .04 normal solution contains 3 gms., and 1 cc. of
the .04 normal solution will exactly neutralize 0.0016
sodium hydrate.
Thus, if 10 cc. of the .04 normal solution were neces-
sary to neutralize the 5 cc. of blood, the alkalinity in
terms of sodium hydrate would correspond to 0.016
grams and the alkalinity of 100 cc. of blood would equal
0.016x20 or 0.320 grams; i. e., 320 mg. In a case of
acute articular rheumatism in which I recently tested
the blood, the red blood cells numbered 4,813,333 ; white
cells, 17,400; hemoglobin, 81.33/(., and total acidity
0.176, the latter being diminished as compared with the
normal acidity of 0.33 to 0.38 in terms of NaOH (Musser).
Although the tests just mentioned are of practically
no clinical significance, as they do not help to arrive at
any definite conclusion concerning the real condition of
the blood, yet it is to be hoped that laboratory methods
will be devised in the near future by means of which
definite and reliable analyses of the free and combined
acids can be made and that their detection may tend to
solve the problem of the specific etiology of rheumatism.
SPECIAL ARTICLES
THE PHYSICIAN'S OBLIGATION TO SECRECY.
BY
WILLIAM C. TAIT, LL.B., Ph.D. (TUbingen),
of San Francisco, Cal.
American Afedicineot Tsi^yZ, 1902, contains an article from
the pen of William C. Woodward, LL.M., M.D., entitled "A
Brief Statement of the Principles Underlying the Physician's
Obligation to Secrecy." The medical profession will find the
legal decisions bearing upon this interesting and intricate sub-
ject reviewed at length in the excellent work of Taylor, "The
Law in Its Relations to the Physician." Before the appearance
of Mr. Taylor's book I had occasion to discuss tho subject of
privileged communications between physician and patient,
calling attention to the contradictions in our various statutory
regulations and judicial interpretations of the rule of profes-
sional secrecy, and urging tho necessity of according tho same
degree of legal protection to the confessions of the jiatieiit as Is
universally granted to those of the client and the religious
communicant.' Dr. Woodward's article now furnishes the
proof that my contention Is supported by the time-honored tra-
ditions of the medical profession, for he says:
" So runs the Hippocratic oath. And so tho physician has
lived and practise<l for 2,O0Oyearsand more. . . . Kveusoearly
in its history our profession was insisting that the sufferer
might uncover himself to his medical advisor, body and soul. In
his search for aid, without the vestigo of right in his neighl>or
or even in the state to know what had passed between them."
Dr. Woodward believes, however, that our more complex
modern conditions demand a departure In certain cases from
' Journal American Medical Association, AUKQit U, 1889.
266 Amerioah Medicinei
PHYSICIAN'S OBLIGATION TO SECRECY
[AUGUST 16, 1902
tUe ancient rule of the profession, In tbe interest of society and
the state. He says :
" But when we try to find the meaning of this formula as it
bears upon present life, difflculties arise. What is it that ought
not to be spoken abroad? Who shall be the judge in any par-
ticular case? And then, too, is there not in some cases a duty
of disclosure opposed to this obligation of secrecy ? "
Are these the natural and characteristic doubts of the
modei'n profession, or are they only those of such of its mem-
bers as have made the study of the law a preliminary to the
study of medicine, and then proceeded to mix them ? Does not
the average physician of experience answer the first of Dr.
Woodward's questions in the true spirit of the Hippocratic
oatli, with " Nothing should be noised abroad," and the second
with " None but thepatient, if he is of full age, or a court of
justice, shall be the judges."
All of our States have enacted laws providing in substance
that the physician or surgeon shall not be compelled to disclose
information acquired while attending his patient, without the
latter's consent. Some States foolishly confine this prohibition
to civil cases. These various statutes were enacted as much for
the general welfare of society as for the benefit of the patient.
The characteristic feature of all similar legislation is that it
did not owe its existence to the failure of the physician to
guard the secrets of the patient, but rather to the harm com-
mitted by the tyrannical and absurd policy of the State in
forcing a disclosure in the supposed interests of justice. The
State neither prohibits nor punishes the betrayal of profes-
sional secrets. It merely provides that the physician shall not
be required to divulge them iu a judicial proceeding. The
statutes have merely sanctioned tlie universal custom of the
medical profession. They abrogate the ancient rule of the
common law, which unsealed lips of both the physician
and the spiritual adviser. The State, by sanctioning this uni-
versal custom of physicians, recognizes the superior wisdom of
the medical profession. We may say that Hippocrates was
wiser than Solon, and that these beneficial statutes, which were
aimed at the State rather than at the physician, were the fruit
of the latter's unwillingness to betray the confidence of his
patient, of his protest against the action of the State in forcing
him to betray it.
The folly and contradiction of the old common law rule is
well illustrated by the Duchess of Kingston case.
This was tried by the House of Lords in the reign of
George HI. The duchess was charged with bigamy, a crime
once punished with death. Dr. Hawkins, the physician of the
duchess, held the secret of her former marriage, and of the
birth of a child, and was compelled by the celebrated Mans-
field, against his protest, to divulge it. Mansfield, in reply to
Hawkins, who thought the disclosure of the secret inconsistent
with his professional honor, advised him that he would be
guilty of no impropriety or indiscretion in disclosing the infor-
mation, if required to do so by the court, but declared that he
would, under other circumstances, " be guilty of a breach of
honor or of grave indiscretion." Other witnesses also objected on
the score of honor, but Mansfield made no distinction between
Dr. Hawkins and the lay witnesses.
The law was commonly supposed to be the perfection of
reason. Such was Blackstone's definition of it some time
before the Kingston trial. Yet, iu the matter of confidential
commtinications it was lamentably unreasonable. Had Mans-
field advised Dr. Hawkins not to answer the question concern-
ing his knowledge of the marriage of his patient and of the
birth of her child, his ruling might have obviated the necessity
for legislation upon the subject of confidential communications
between physician and patient. But he was, unfortunately, not
oftheopiniouof Belloc, who in his" Coursde Medecine Legale"
(page 17) declares that "the tribunals never ought, nor have
they the power, to exact from a physician the revelation of the
secret confided in him because of his office. At all events he
may and ought to refuse to tell. Keligiou, probity; nay, the
rights of society, make this the law." Belloc thus sanctions
the heroic attitude of the ancient practitioner who denied the
right of the State to force him to divulge what had passed
between himself and his patient. I believe Greek and Roman,
as well as French law, denied this right to the State.
Should Dr. Hawkins have reported his information to the
authorities after the second marriage of the duchess? I ask
this question because Dr. Woodward says:
"The physician is likely to experience the greatest difficulty
in determining his duty when he l)ecomes aware that his
patient is suffering from injuries, the outcome of the patient's
own unlawful act. Injuries of this sort vary from trivial
wounds inflicted possibly in some family quarrel lo those
resulting from criminal abortion or serious affrays and likely
to terminate in prosecutions for murder. It is not probable
that any physician will find difficulty in determining his duty
in either of the extreme cases— in the first he will keep his
secret, and in the last he will promptly communicate to the
proper authorities the information he has acquired. . . . The
law which determines the duty of a physician who, in the
course of his professional work, becomes aware of the existence
of a crime otherwise unknown, is not always clear, and its
application to particular cases maybe extremely difficult. In
the absence of statutes regulating matters of this kind they are
governed by a certain unwritten law known ordinarily as the
common law. It is impossible here to undertake an analysis of
the statutes regulating such matters; they vary with the juris-
diction in which they are in force; and what is law here is not
law across the nearest State line. But where the common law
prevails, any citizen having knowledge of a felony or of an act
of treason which is about to be, or which has been committed, is
bound to make the facts known to the proper officers so as to
prevent the commission of the crime, or to bring the guilty
parties to justice. The person, be he physician or not, who
disregards this obligation, is guilty of the offense of misprison
of felony or of treason, as the case may be."
His reasons for these views are as follows :
"The principle upon which it becomes theduty of the physi-
cian to report certain cases, even to the detriment of his patient,
finds its justification iu the fact that tlie state undertakes to
secure to the individual citizen safety of person, property and
reputation only so far as may be consistent with the safety of
the community at large, and correlates its undertaking to an
obligation on the part of the citizen to conduct himself so as not
to jeopardize the general welfare. The State has long refused
to guarantee safety to those guilty of felonies or treason, and
tlie law of the state is necessarily administered upon the basis
that this is known to every sane citizen who has reached years
of discretion. The felon has by his crime made himself an out-
cast. Society owes him nothing further than a fair aud impar-
tial trial by a jury of his peers, and to this very trial he is
entitled only on the ijresumption of his innocence. He may be
lawfully killed by any one if killing is the only means of pre-
venting the felonv, and the private citizen who knows of his
crime may arrest Lim without warrant aud maintain the arrest
if it becomes necessary, even at the cost of the felon's life. The
citizen who, knowing of a felony, receives, comforts and assists
a felon iu order that he may escape punishment, himself
becomes an offender against the law of the land. He who is
acquainted with information relevant to the crime and fails to
make it available for the use of the state in its efforts to bring
the offender to punishment, does an act subversive of justice
and tending to destroy government itself, aud of him the state
will demand punishment for his wrong-doing, even though the
information which he has wrongfully withheld was communi-
cated to him by the felon in his efforts to secure relief from his
sufferings or to save his life. As it is the physician's legal duty
to bring such an oflender to justice, there can be no lawful
obligation by either implied or express contract authorizing or
requiring him not to do so."
This is very strong and positive language. It is not true,
however, that afelon has by his crime made himself an outcast.
The commission of a crime does not deprive a citizen of all his
constitutional rights, save that of an impartial trial. Society
may regard him as an outlaw aud an outcast. The law, how-
ever, does nothing of the kind. It regards him as innocent of
the crime until tried and convicted of it. This is one reason
why the physician should not usurp the functions of court or
jury, but guard the confession as religiously as the priest
would, for tbe guilty patient may be acquitted. If he is, what
shall prevent him from suing the physician for slander ? It
is a dangerous thing to treat even the guilty as outcasts.
Here, in San Fraucisco, a leading daily was sued for libel
by an acquitted murderer whom everybody believed to be
guilty, but who was acquitted on his third trial. The jury
awarded the plaintifl' a verdict of several thousand dollars.
The following scene from the Duchess of Kingston case illus-
trates the attitude of the law toward the prisoner at the bar :
Sergeaut-at-Arms: "Gentleman usher of the Black Rod,
bring your prisoner Elizabetli, Duchess Dowager of Kingston,
to the bar." The prisoner when she appeared made three rever-
ences and then fell on her knees at the bar.
Lord High Steward: " Madam, you may rise." Tbe pris-
oner then rose up and courtesied to his grace the Lord High
Steward and to the House of Peers, in return to which compli-
ment his grace and the lords bowed. (Italics mine.)
His grace and the lords returnetl the compliment, because
by the time-honored traditions of English law the duchess.
ArGUST 16, 1902J
PHYSICIAN'S OBLIGATION TO SECRECY
[American Medicine 267
although accused of a heinous crime, was theoretically innocent
of it.
I do not believe that Dr. Hawkins, although convinced of
lier guilt, treated the duchess as an outcast. What might have
become of his practice after her discliarge, had lie so treated his
former patient? As it was, the secret had to be dragged from
him. What if lie had volunteered it? Would he not have been
guilty of" a breach of honor or of grave indiscretion" liad he dis-
closed the information even to the authorities? Dr. Woodward
declares that the common law will demand the punishment of
a physician who withheld information communicated to him
bj' a felon in his efforts to save his life, or otherwise. That
may be true, theoretically, but who ever heard of such a
prosecution?
Do not both the priest and the attorney, who tlirough their
offices " become acquainted with information relevant to a crime
and fail to make it available for the use of the State in its efforts
to bring the offender to justice, do an act subversive of justice,
and tending to destroy government itself? " Yet the law unseals
the lips of neither. On the contrary, it sanctions their silence
by expressly prohibiting their testimony as to such informa-
tion. Neither does the law permit the conviction of a husband
or wife by the revelation of the confidences of either. In all of
these confidential relations, the policy of the law is to suffer the
guilty to go unpunished rather than to break down the barriers
necessary for the preservation and welfareof society, and which
the State has itself, in fact, erected to that end. The pliysician,
as well as the attorney and the priest, invites confidence, for
without this confidence his art would be in vain. The priest
knows only the communicant, the attorney only the client, the
physician only the patient. The priest will not suffer the
church or the confessional, theattorney will uotsuffer his office,
to become the adjunct of those of either the district attorney or
the chief of police. Neither will the reasonalile physician do so
unless he wishes to Ijecome involved in the mazes and meshes
of the law. He will not assume that the district attorney is
thoroughly familiar with the law of privileged communica-
tions, or that the chief of police is a man of discretion and knows
his business, nor will he unbosom himself to either. The folly
of a physician in reporting the confession of a crime is well
illustrated by the case of People vii. Browei; 5S Hun. S17, in
which a New York physician followed the advice of Dr. Wood-
ward and reported a case of criminal abortion. The facts of the
case as disclosed Ijy the testimony of the physician were that
the defendant came to his office and said :
" For God's sake hurry up, my wife has a fit or has fainted.
Prol)ably you would like to know what the difficulty is before
yon leave the office." I said, " Yes, it might be a help to me,
because I might need something that I would not take with
me." Ho said, " This lady down to the house I am living with
I am not married to, but I expect to get a divorce from my wife
and get married. The lady is about three months gone in the
family way, and she introciuced a catheter with a wire in the
womb, and after she had introduced it far enough, I blew in it."
I said, " What did you blow in it for? " He said, " We did it
before and it worked all right." The woman died shortly after
the doctor's arrival.
This testimony of the attending physician and that of the
autopsy physicians was the only evidence offered at the trial. The
jury convicted the defendant of manslaughter in the first degree.
The doctor nat a rally supposed he had done his d uty in disclosing
so heinous a crime. Dr. Woodward says in his paper that " In the
casen of criminal abortion the physician should not keep his
secret but promptly c )mmunlcate to the proi)er authorities the
information he has acquired." The physician in the Brower
case folio wed this ad vice. The information of the crime undoubt-
edly came from him, for the defendant was convicted solely
upon hU testimony. The district attorney and the judge of the
trial court both believed his testimouj- admissible. Tliey had
roisonable grounds for their opinions, for the highest court of
the State had not long before declared that the rule of profes-
sional .secrecy could not be invoked to shield a murderer. The
facts of the two cases differed, but district attorneys and trial
judges seldom draw the tine distinctions of appellate courts.
The Supreme Court, to which the convicted and guilty defend-
ant appealed, thought the physician had abused the confidence
reposed in him by the defendant. Us judgment reversing the
verdict for conviction was in substance a rebuke to the former.
The court held that " the defendant employed a physician to save
Mrs. Brower's life. His alarm and anxiety were great. He
knew what had taken place, and suspected that it might be the
cause of her sudden prostration, and felt that the physician
ought to know it, and to govern his treatment accordingly.
The physician did want to know. In this critical moment, for
the sole purpose of saving the Avoman's life, he disclosed the
secret to the physician to enable him to act rightly. To have
withheld the disclosure would have made the defendant a con-
senting party to the woman's death. We have no doubt that
the .statute both in letter and in spirit, protects the confidence
thus reposed in a physician and forbids him to betray it."
Dr. Woodward says that in a doubtful case the physician
should be sure before making a disclosure that the obligation not
only is enforcible, but will be enforced. But how can the physi-
cian be sure, in a doubtful case, of such a duty? Can he
solve this question by consulting statutes and judicial
decisions? If he does so, they will not solve his doubts, but
will only increase his perplexity. He will not lie able to recon-
cile their apparent contradictions, nor will he discover in
them any general underlying principle, but will find that each
case is governed by its own peculiar circumstances. He will,
therefore, if a man of sense, conclude that the ruling of the
judge is, after all, the only test in such matters. If he believes
that he can accept the opinion of his attorney as law in a doubt-
ful case, let him consult other attorneys, and learn that diver-
sity of opinion among lawyers upon a point of law is as
common as that of judges. What attorney can say positively,
for instance, that a physician may, or may not, be compelled to
disclose at a coroner's inquest a confidential communication of
his patient, or whether he may, or may not, be compelled to
furnish such testimony in a lunacy proceeding? The patient
may waive his privilege. But how and under what circum-
stauces does he waive it? Does tlie secret die with the patient,
or are his heirs or executors entitled to know it for the benefit
of his estate? All these and other questions relating to the law
of privileged communications in the case of the physician are
still unsettled. As this law is subject to the general law of
evolution, lor this reason even the .simplest case is apt to be
doubtful. The safest course for the physician to pursue is,
therefore, to obey the injunction of the Hippocratic oath, to
suffer none but the patient, when of full age, or the judge, to
break the seal of professional secrecy. Let him follow the
example of Dr. Hawkins, who, in a tyrannical ago, destroyed
his records and meraoraada so that neither the public nor the
State might learn secrets intended for neither. Let him do as
that man of honor did when asked by the prosecution to betray
the confidence of his patient — first protest against the dis-
closure, then seek the advica of the court. If the practitioner
follows any other course he will be likely to incur the fate
which the taker of the Hippocratic oath invitetl upon himself
in case of its violation— loss of the enjoymsnt of life, of the
practice of his art, of the esteem of all m in, at all times. The
wise inventor of thit oith, reoogniziag the necessity for pro-
fessional secrecy, pledged the physician to maintain it, and
made the enjoyment of life, public favor aud esteem, etc.,
dependent upon its faithful observance, and caused him to
invite upon himself, as a penalty for its breach, the very fate
which its violation is likely to entail upon the patient. The
physician gives the same pledge and promise of secrecy,
although unspoken, to every patient. Tlie Hippocratic oath is
the unwritten law of the medical profession of which the State
at first refused, but was finally compelled, for the welfare of
society, of which it is but the organ, to reognize the wisdom,
at least in a general sense.
The litstcr Family.— The foUowInK Is ou the authority of
the Afej:i(ii)i If<'ialil: "The number of tlioso bearing the name
of Lister who have lieen eminent in medical science is romark-
al)le. Kdward Lister, educated at Kton and ('ambrldge, was a
physician to till /.abeth and James I, and his younger brother.
Sir Mathew, filled the same office to Anne of Denmark, James I
and Charles I. .Martin Lister, son of Sir Martin and a nejihow
of Sir Mathew, was a famous zoologist and second physi<'ian to
(Jueen Anne. fjOrd Lister is now 7o and has the distinction of
being the first medical peer."
268 AMBBIOAN MEOICINB]
INTERNATIONAL RED CROSS
[AUGUST 16, 19J2
THE SEVENTH CONFERENCE OF THE INTERNA-
TIONAL RED CROSS
BY
NICHOLAS SENN, M.D.,
of Chicago.
Delegate from the IJnitedJStates.
The International Red Cross Society has for its principal
objects to render war, when it becomes inevitable, more
humane and to provide prompt relief in case of great national
calainities. The horrors of Sebastopol, Gettysburg, Solferino,
Waterloo, Sedan and other great battles during the present cen-
tury will have no equal in the future. Ignominious death from
cold, starvation and preventable diseases will not figure so
conspicuously in the mortuary records of future wars as they
have done in the pa.st. Governments
and nations are beginning to realize
more fully the importance of pro-
viding the soldier with food and
clothing conducive to the preserva-
tion of his health and bringing into
effective action sanitary rules and
regulations calculated to guard
against preventable diseases. The
government is not always ready and
prepared to meet sudden emergen-
cies. The representatives of the Red
Cross Societies are. They follow the
moving armies, take care of the sick
Her Majesty, Empress Marie and wounded and distribute freely
Kfiodorovna, Patroness of j , • , <! ii, • i i
the Red Cross Society of food and drink for the sick and
Russia and the Seventh articles of comfort not obtainable in
Conference of the Inter- ,,
national Red Cross. any other way.
In great epidemics, devastating
floods, destructive earthquakes, sweeping conflagrations and
burning drouths, they are the first to reach the seat of disaster
to provide the unfortunates with shelter, clothing and food. The
gospel of humanitarian warfare was conceived by Henry
Dunant, of Geneva, Switzerland, during and after the battle of
Solferino, and was fully expounded in his now famous pam-
phlet, " Souvenir de Solferino." His suggestions to militate the
horrors of war laid the foundation for the proceedings of the
Geneva convention, which met April 22, 1864. The International
Red Cross Society, the precious fruit of the Geneva convention,
has now its representative organizations in all parts of the civil-
ized globe, and is the pioneer agency in disposing of the bar-
barities and unnecessary cruelties of active warfare, and in
bringing prompt aid to the sufferers of great national calami-
ties. The growth of this society has been phenomenal. From
the transactions during the present conference it is evident
that this great international Samaritan is desirous of cultivat-
ing closer relationships between National Red Cross
Societies and to extend the scope of humanitarian work.
The International Red Cross Society meets every five years,
and is made up of delegates sent by governments and
representatives of Red Cross Societies, the traveling expenses
of the official delegates being paid by the respective govern-
ments. Some of the Red Cross Societies do the same for their
representatives. The delegates appointed by the Russian gov-
ernment were all military officers of high rank and important
government officials. The only female delegates are from the
United States. The names of the delegates embrace 20 different
countries and various local organizations.
All of the meetings are held in the Hall of Nobility, a
palatial building used for the entertainment of the nobility.
On this occasion it was tastefully decorated with flowers and
shrubs. Lieutenant-OJeneral von Richter presided, and Mr.
Odier occupied the desk of the secretary-general. The audience
was a brilliant one. The full-dress uniforms of the nobility,
military officers and high government officials made an impos-
ing and enchanting picture. The weather was in harmony with
the objects of the meeting. A few minutes after 2 o'clock the
audience rose in a body as Her Majesty, the Empress Dowager
Marie Ffiodorovna entered the ball accompanied by her son, the
Grand Duke Heritier Michel Alexandroviteh. As soon as
these distinguished members of the royal family had taken
their places in the Imperial box the president opened the meet-
ing with a short address. The Minister of Justice, Mouravieff,
made the principal speech, in which he emphasized tlie impor-
tance of the Red Cross work in the dispensation of charity, and
extended a cordial welcome to the delegates. "Von Knesebeck
and Schjerning followed with short speeches, and the first
meeting was adjourned.
The program was varied and the reports of the numerous
committees were very interesting. The discussions were char-
acterized by harmony and good feeling. Articles of the Hague
Peace Convention were frequently referred to, and from the
remarks made it is certain that those two great international
organizations will cooperate heartily in maintaining the peace
oftlie world, and in case of war they will do all in their power to '
divest it of all unnecessary cruelties and suffering.
Russian hospitality is almost proverbial. The Moscow-
International Medical CJongress gave the visiting doctors a
good insight into what Russians can do when they entertain
their guests. If there is any fault to be found with the Seventh
Conference of the International Red Cross it is the fact that too
Palace where Emperor and Empress received the delegates.
much time was lost in entertaining the delegates. Carriages
were placed at the disposal of the delegates from the moment
they entered the city, free of expense. The Central Russian
Committee looked after the comfort of each delegate. The
principal entertainments were :
1. Informal reunion the first evening.
2. Banquet at the Tauride Palace, second evening, at which
plates were set for 250 guests.
3. Third evening. Steamer excursions on the Neva, followed
by lunch at the Zelaguine Palace.
4. Reception by the Empress Dowager at the Gatchina Pal-
ace, Saturday, May 31. „ j,
5. Monday, June 2. Reception by the Emperor and
Empress at the Tzarkoe Selo Palace, followed by lunch.
6. Sunday evening. Theater and concert.
7. Monday evening. Reception by the mayor at the City
8. At the close of the session, Wednesday, June 4, excur-
sion to Moscow.
The conference was in session a whole week and the meet-
ings were well attended. The French language is the official
one, although the German and English languages are recog-
nized. The transactions are published in French.
St. Petersburg, June 3.
Medicine Men as Scapegoats. — Some Indian tribes in
America have an uncomfortable custom, when they are visited
by an epidemic, of offering up a medicine man as a propitia-
tory sacrifice for the expiation of the sins of his tribe which
are held accountable for the outbreak. In accordance with this
custom, "Padre," a "big medicine man" of the^_uma Indi-
ans, who live on a reservation near Yuma, Arizona, was
recently offered as a sacrifice on the occasion of an epidemic or
smallpox. The " medicine man," divining the Indians' inten-
tion, fled to the mountains, but wandered back to the Indian
village in a half starved condition, and pleaded for mercy. He
was promptly bound and conveyed by a delegation of Indians
to Mexico, where he was tied to a tree and tortured, death ensu-
ing after several hours of suffering. We have among us fanat-
ics whose views as to the etiology of smallpox are even more
absurd than those of the untutored Indians of Arizona, and
who, if we may judge from the truculence of their invectives
against the medical profession, would not be sorry to have the
opportunity of treating the doctors as scapegoats in times of
epidemic— [BrittsA Medical Journal.]
AUGUST 16, 1902]
THE WORLD'S LATEST LITERATURE
[American Mkdicink 269
THE WORLD'S LATEST LITERATURE
Journal of the American Medical Association.
August 9, 1902. [Vol. xxxix. No. G.]
1. The Advantages of the Kiiee-Uhest Posture in Some Operations
o T%, '^R?" "•" Vesical End of the Ureters. Howard A. Kelly.
J. ine ireatment of berpiginoiis Ulcer of the Cornea. Chakles .7.
?■ I?? -^ature and Treatment of Pterygia. John O. McReynolds.
4. inioslnamin. Clinical and Experimental Observations with Refer-
ence to Corneal Opacities and Other Ocular Lesions. George F.
SUKER.
5. A New Operation for Complete Laceration of the Perineum. De-
signed for the Purpose of' Eliminating Danger of Infection From
theKectum. George H. Noble.
6. Plastic Surgery of the Female Urethra, with a Report of a Unique
Case. Henry P. Newmann. >.ju>h"o
7. Observations on .Some Recent Cases of Orthodontia. E. A. BoGUE
S. J^lectric Ozonation in .Neuralgia. G. Leno.-c Curtis.
». Results Obtained in the Treatment of Acne by E.xposure In the
X-ray.s. R. R. Campbell.
1.— The Knee-chest Posture in Operations Upon the
Vesical End of the Ureters.— Kelly further emphasizes the
value of this method of opening the bladder in women,
described by him in 1901, and reports an interesting case of
ureteral calculi removed in that manner. The method advocated
consists in placing the patient in the knee-chest posture and
then letting air into the bladder through a catheter or a specu-
lum. If the posterior vaginal wall is then lifted tip so as to
expose the entire vaginal wall from cervix to urethra, a suita-
bly curved knife may be plunged through vesicovaginal sep-
tum into the air-distended bladder and the cut lengthened fore
and aft to make it the desired size. The case reported was that
of a woman of 45, who had an impacted calculus in the lower
end of the right ureter. Efforts to extract the calculus by
means of forceps introduced through the urethra failed, because
of the size of the stone. The bladder was then opened in the
manner described and the calculus easily extracted. The
vesicovaginal opening was then closed with silkwormgut inter-
rupted sutures down to an opening left large enough to admit a
mushroom self-retaining catheter. After three days the cathe-
ter was pulled out when the hole closed at once, spontaneously,
without any subsequent leakage. A case in which a papilloma
was removed in this way is also mentioned. [a.o.b.J
2, 3, 4.— See American Medicine, Vol. Ill, No. 25, p. 1050.
5.— New Operation for Complete Laceration of the
Perineum.— Noble has devised a flap operation for repair of
complete laceration of the perineum for the purpose of elimi-
nating danger of infection from the rectum. It consists in
splitting the rectovaginal septum, dis.secting the lower end of
the rectum from the vagina and drawing its anterior wall down
through and external to the anus. In this way it converts a
complete tear of the perineum into an incomplete laceration.
After the wound is closed the sutured flap is turned forward
and anchored over the perineal incision with a mattress suture
of kangaroo tendon. This suture absorbs readily, the rectal
flap retracts within the anus and returns to its normal position
in .seven or eight days. Advantages of this operation are : Re-
moval of liability to infection from the rectum, avoidance of
rectal stitches, early evacuation of bowels without jeopardizing
results, slight blood loss, ease of performance. Notes of five
cases are given, [a.o.e.]
".— Ilecent Cases of Orthodontia.- Bogue reports in
detail the treatment of two patients, brother and sister, of
eight an dnine, who presented the anomaly of irregular decid-
uous teeth, due to contracted arches. Nonremovable appa-
ratus was employed with very satisfactory results, the enlarge-
ment of both arches being accomplished without complaint of
pain by either child. Points emphasized are: A perfectly
arranged lower arch in ordinary cases guides the teeth of the
upper arch into their proper positions, and holds them without
additional appliances ; thftse operations may be almost or quite
painless; they maybe accomplished with groat rapidity, and
with no perceptible detriment to the teeth; the regulating
fixtures themselves may be retained as retainers weeks or
months after they have finished their corrective work ; retain-
ing fixtures may touch the teeth so slightly that the teeth may
lie thoroughly cleansed around them, [a.g.k.]
O.— Results of X-ray Treatment of Acne.— Campbell
reports results in 15 cases of acne treated by exposures to the
x-rays. Complete cure was obtained in all but two or three
cases, and in these the improvement was so marked as to
practically amount to a cure. An interesting feature in one case
was the existence of a goiter, which has almost disappeared,
this apparently being due to the x-rays, as neither internal nor
external medication was employed while the patient was
under that treatment. [.4.O.E.]
Boston Medical and Surgical Journal.
August 7, 1902. [Vol. CXLVH, No. 6.]
1. The Present Status of the Pessivry 1 n the Treatment of Displacements
of the Uterus. F. H. Davenport.
2. Electricity: Its Use in Gynecology. W. H. White.
ii. Multiple Fibroids of the Uterus. Samuel Breck.
4. A Sell-retaining Tongue Depressor. Harris Peyton Mosher.
1.— Present Status of the Pessary.- Davenport says that
the pessary, the use of which 25 years ago was the sole method
for the treatment of uterine displacements, has,with the develop-
ment of surgical methods, suffered a temporary neglect. It is
now regaining its position to some extent, and the indications
for its use are better understood and are upon a more scientific
basis. In uncomplicated cases in young women who have not
had treatment operation should be advised. Operation is the
only method which holds out prospect of cure in cases compli-
cated with lacerations, enlarged uterus, or much prolapse. In
other cases, especially when the uterus is small, when symp-
toms have been present but a short time, and particularly if
they are associated with neurasthenia, treatment by pessary
will often result in a cure, probably in one-half of such
selected eases. Even when cure cannot be hoped for by pes-
sary its temporary use is often of value in relieving symp-
toms and in aiding to restore the general health. Some princi-
ples governing the use of the instrument are given. In case of
retroversion or Hexion, always replace the uterus before adjust-
ing the support, as the pessary cannot be relied upon to do this.
In fitting a support choose one which fits exactly, if possible;
but if not, have it rather too small than too large. The patient
should be seen at regular Interval.s while she is wearing a pes-
sary, and when deemed advisable to make an attempt to go
without it, it should not be removed at once, but a smaller one
substituted, to be worn a month and then a still smaller one,
which may then be finally removed, [w.k.]
2.— Electricity in Gynecology.— W. H. White has found
electrical treatment of advantage in many forms of gynecologic
disease, and tells briefly the kind of current and method of
applying it in cases of relaxed tissues, amenorrhea.menorrhagia,
metritis, ovarian inflammation and salpingitis. Strictures of
the cervical canal and of the rectum have been cured by proper
use of the electrical current. In the treatment of tumors he
considers surgery preferable in most cases, but recommends
electricity sometimes as a palliative measure in inoperable
cases, [w.k.]
3.— Multiple Fibroids of the Uterus.— Breck gives an
illustrated description of a multiple uterine fibroid obtained
at the autopsy on a negress, aged 47 and single. The largest
tumor, about the size of a watermelon, had become cystic and
ruptured into the peritoneum, though theopeniug was .sealed by
an exudate at the time of the autopsy. The tumor and the
abdomen were full of a thin greenish ]>us, in quantity about
half a pailful. The tumor and the peritoneum were covered
with a recent fibrinous exudate. In addition to the main
tumor, which was pedunculated and ro.se to the epigastrium,
were numerous small ones, varying from the size of a cherry-
stone to that of an orange. They were subserous, the uterus
being but little enlarged. The tubes and ovaries were healthy.
As a somewhat rare complication, there was a complete prolapse
of the vagina, with elongation of thesupravaginal cervix, [w.k.]
Medical Record.
[August 9, 1902. Vol. 62, No. ().]
1. A New Use for the U.seless Appendix In the Surgical Treatment of
Obstinate Colitis. Robrht K. Weir.
2. The Medicolegal Value of the iUnlgen Rays. Carl Beck.
8. A Case of .Multiple Personality. .1. .\llk.v (iiLnERT.
4. Some Hlnl*i t« the General Pra<;tltl<>iicr on I he Treatment of Chronic
Nasopharyngeal Catarrh. W. Kkkudkntiial.
1.— See American Medicine, Vol. Ill, No. 25, p. 1040, under
" Discussions."
270 AXXBICAK MEDICINK}
THE WORLD'S LATEST LITERATURE
[AUOUST 16, 1902
a.— The Medicolegal Value of the R^intKen Bays.—
Beck cites many cases to show the medicolesal bearing of
x-ray worli. Several of them emphasize the statement that a
mediocre or even indistinct plate should never be admitted in
court. A skiagraph alone is not conclusive for the purpose of
estimating the degree of functional disability. A nonmedical
skiagrapher will, therefore, never be able to give expert testi-
mony in any case of injury. The questions of securing the
identity of the patient skiagraphed, x-ray burns, new ulcer-
ation or intlammation during therapeutic treatment, etc., are
discussed, [a.o.e.]
3.— A Case of Multiple Personality.— The remarkable
personage described by Gilbert is a young man of 22, admitted
to a hospital suffering from concussion of the brain, as indi-
cated by the history of a fall and by his symptoms. After
recovering from the injury he acted queerly for more than a
month, being discharged and readmitted several times. He
was finally hypnotized in order to get the history of his past
life, and awoke in a state of fright, not recognizing any of the
attendants. Further questioning developed the fact that the
case was one of multiple personality. Hypnotism was used to
change the patient from one personality to another, the history
being taken during full consciousness in the ensuing person-
ality. In this way three distinct personalities were found, and
by taking the three lives and writing the stories as they dropped
and picked each other up, almost the entire life of the man was
traced. To verify the history, letters were sent to parties men-
tioned by the patient and 28 answers verify the history accu-
rately. The man had enlisted in the army two different times,
and had been arrested as a deserter. The whole process may
be called a psychoepileptic exchange of personality, [a.o.e.]
4.— Treatment of Chronic Nasopharyngeal Catarrh. —
Freudenthal states that it is nonsense to attribute the prevalence
of catarrh in New York to its great climatic humidity, as many
physicians do. People have become practically cave dwellers
again, and it is the air of the tightly-closed rooms they inhabit
about 23 of the 24 hours daily that must be considered instead of
the air in the harbor. Personal investigations regarding the
amount of moisture in houses have shown that instead of a
relative humidity of between 50% and 60%, the highest point
reached was 30%, and 25%, 20% and even 18% was not uncommon
during protracted cold weather. Inhalation of this furnace-
dried air causes catarrh. In the treatment of chronic naso-
pharyngeal catarrh the hygienic part Is far more important
than the medicinal. Change of climate, swimming, sea bathing,
etc., for the summer, and a mild, moist atmosphere for the
winter, is often of great benefit. At home, lukewarm baths,
with the room full of steam from hot water, are to be taken.
Fresh air is of vital importance, and patients should be out of
doors as much as possible. Douches and sprays have done
more in producing affections of the accessory sinuses than in
curing catarrh. Carbonic-acid gas for local treatment has given
good results in the author's experience. Other means at the
physician's disposal are internal massage and the electric cur-
rent. [A.G.E.]
New York Medical Journal.
August S, 1902. [Vol. lxxvi. No. 5.]
1. Inflammation Within the Female Pelvis, and Its Treatment. Neii,
Macphatter.
2. Further Observations Regarding the Malarial Origin of 2k>ster.
James MacFart.ane winfield.
3. Some of the Therapeutic Uses of the X-ray. E. D. Bondurant.
4. A Case of Foreign Body In the Male Urethra. J. Edward Her-
man.
1.— Inflammation Within the Female Pelvis.— Macphat-
ter discusses the anatomy of the female pelvis and its organs
and gives cuts illustrating his methods of evacuating abscesses
in that region. The majority of cases of inflammation and pus
within the pelvis is the direct result of gonorrheal infection, but
miscarriages, abortions and other conditions are frequently the
initial cause. Abscesses within the folds of the broad ligament
and lying adjacent to the wall of the uterus are evacuated
through an incision in the capsule on the side of the cervix, the
capsule being separated from the uterus by the finger until the
abscess is reached. In cases in which the abscess is not formed
close to the uterine wall, but rather to the outside of the pelvis
and adjacent to the ilium, the initial incision is made one inch
below and a little to the inner side of the anterior superior
spine of the ilium. The finger is used to burrow down beneath
the peritoneum and into the pus cavity. In cases in which the
abscess fills up the entire side of the pelvis from the uterus to
the ilium the double operation offers more speedy and perma-
nent relief, [c.a.o.]
2. — Malarial Origin of Zoster. — Winfield maintains that
Plasmodium malarue should be considered one of the causes in
the production of herpes zoster, and reports a total of 25 cases
examined, 19 being males and 6 females. The ages ranged
from 9 to 50 years. Although all the patients examined had
symptoms suggestive of some infection, either malarial or the
intoxication of some other organism, only 14 gave positive evi-
dences of paludism, as proved by the presence of the malarial
parasite in the blood. Fifteen of the patients were afilicted
with intercostal zoster ; two had the eruption on the face, neck
and shoulder ; in two it was over the gluteal region ; two others
had it over the neck and occiput. In another the side of the
face and neck was involved ; one was of the ophthalmic
variety, another was over the lumbar region, and another
began on the neck and extended down the arm. One case was
bilateral and one was a case of recurrent zoster. Tlie author
reviews the literature of the subject and cites many similar
cases among which are eight previously reported by him, in
which four showed the malarial parasite in the blood. He
does not believe that this special organism is the only causative
agent, but that many different varieties of bacterial intoxica-
tion could bring about the same effect, [c.a.o.]
3.— Therapeutic Uses of the X-ray. — Bondurant dis-
cusses the subject and reports several cases successfully
treated. The first is that of long-standing carcinoma of the
face in a man of middle life who had previously tried almost
every known treatment without success. The carcinoma-
tous area was treated by exposure to the rays generated in a
medium vacuum Crooke's tube for 10 minutes every other day.
After two weeks the pain had ceased entirely. Within a month
there was no discharge, no bad odor and the deeper portions of
the ragged cavity were beginning to show healthy granula-
tions. The healing process is steadily progressing. The sec-
ond case is one of apparent cure of an epithelioma of the face
which had been twice removed. At the time of reporting these
cases the writer had under treatment an epithelioma of the face
which had been removed twice. The results were very satis-
factory. He also reports a case of lupus under treatment which
after 10 sittings showed the ulcerating surface healing and the
nodules shrunken, [c.a.o.]
4. — A case of foreign body in the urethra is reported
by Herman. A man aged 00 had forced a hat pin six inches
long into his urethra. The point was imbedded in the tissues
of the penis near the glans. The author removed the pin by
forcing its point through the tissues near the corona on the dor-
sum of the glans, then extracting the shaft by turning the pin
so that it came forward through the natural opening head end
first, [c.a.o.]
Medical Ne^vs.
August 9, 1901. [Vol. 81, No. 6.]
1. fhyslology of the Pancreas. Russell H. Chittenden.
2. Some Aspects of the Pathology of the Pancreas from the Standpoint
of Recent Investigation. George Blumek.
3. Hemorrhagic Pancreatitis; Operation; Recovery. William A.
Batchelor.
4. The Significance of Glycosuria. Warren Coleman.
5. Some Etlologlc Factors In Diseases of Women. E. K. Browd.
6. Note on the Administration of Water in Disease. G. Frank Lyd-
ston.
7. Report of Two Cases of Temporary Hypertrophy of Glands of the
Skin of the Axilla in Puerpera. C. S. Bacon.
1. — Physiology of the Pancreas.— Chittenden gives the
early history of researches regarding the pancreas, from the
discovery of its duct by Wirsung, in 1643. Not until 1846 was
the digestive powers of the pancreatic juice Investigated. The
remainder of Chittenden's article is largely a consideration of
the various theories regarding the function of the pancreas.
He believes that the secretion of pancreatic juice is controlled by
true secretory fibers, although the vascularity of the gland
exercises a very potent influence. A scrutiny of the results
August 16, 1902]
THE WOKLD'S LATEST LITERATUEE
(Ahkbican Medicine 271
obtained by many Investigators makes it seem probable that in
the pancreas there is located certain specialized cells which
manufacture an internal secretion which exercises a controlling
influence upon certain lines of metabolism in the body. The
glycosuria following extirpation of the pancreas is not wholly
due to increased transformation of glycogen stored up in the
liver and other tissues of the body. The excretion of sugar
continues after the glycogen of the body has entirely disap
peared, and the ratio of sugar to nitrogen in the urine is such as
to point conclusively to the origin of the Sugar in proteid.
Whatever view is correct it is manifest that complete loss of the
pancreas leads to much more than a mere disturbance of the
relationship between sugar and glycogen formation. Chitten-
den concludes by saying that there are indications that some
forms of socalled pancreatic diabetes are to be explained, not
through a simple disturbance of the pancreas, but rather as the
result of a physiologic disturbance of the interrelationship of
several allied glands or structures, [a.g.e.]
2.— Pathology of the Pancreas.— Blumer's article is a
review of recent investigations regarding the pathology of
the pancreas. In a pancreas from a case of diabetes he found
the only change to be hyalin degeneration of the islands of
Langerhans. The further study of these islands is believed to
be of great importance in making clear the nature of pancreatic
disease, [a.o.e.]
3. — Hemorrhagic Pancreatitis ; Operation ; Recovery. —
Batchelor reports this interesting case, the patient being a man
of 41, with a history of sudden attack of abdominal pain. Dur-
ing the last attack there was pain in the entire abdomen, but
more marked in the region of the transverse colon. The pulse
was about 100, temperature 100° to 102°. On the third day there
was an acute exacerbation of pain with symptoms of collapse,
and for the first time an enlargement in the epigastric region.
On the seventh day the diagnosis of hemorrhagic pancreatitis
was made and operation performed. Areas of fat necrosis were
fo)ind in the omentum and mesentery. The pancreatic tumor
was opened and six to eight ounces of blood clot and necrotic
gland-tissue removed. The cavity seemed larger toward the
bead of the pancreas. There was no hemorrhage. Drainage
was profuse for ten days. After six weeks the patient was
readmitted to the hospital, and a new sinus, or branch of the
original one which was still open, extending toward the tail of
the pancreas was opened and drained. The wound was entirely
healed two months later. Ample drainage for these cases is
the point emi)hasized. [a.o.e.]
5. — Diseases of Women. — Browd divides the causes of
di-seases of women into predisposing, exciting, and induced or
criminal. Under the first he includes overwork at an early
age in factories ; habitual constipation, often occasioned by
sedentary habits and indoor life; and exposure, deficient cloth-
ing, and absence of proper bathing. Exciting causes are
gonorrheal infection and syphilis. Among the induced or
criminal causes he places measures to prevent conception and
induction of abortion. He also adds that women during
accouchement are often exposed to many evil influences and
infections, these dangers being augmented by ignorant mid-
wives, careless physicians and untrained nurses. Another
cause is the expediting of delivery by early use of forceps,
frequent vaginal examinations, cervical dilation and all the
methods of unnecessary interference in order to gain time.
Along with the intelle<;tual culture of today there Is needed
more knowledge and care of physical development, so that our
new woman may have the strength of the Roman matron with
the intelligence of the twentieth century. Browd's observation
leads him to believe that the average American woman of today
with her record of one or no children is getting prematurely
old and fading away at Xi or 40, while her Dutch sister, belong-
ing to the colonial procreating race, is exceeding her in health
and vigor, [w.k.]
a.— The Administration of Water in Disease.— Lydston
emphasizes the inlluonce of excessive water drinking upon the
motor function of the ga.stric muscle. The disturbance is
especially marked if the fluid be ingested at mealtime. By the
"renal water habit" Lydston designates the condition of the
kidney l)rought about by the indiscriminate ingestion of large
quantities of water. When in this condition the kidney carries
on its function very imperfectly unless stimulated in that man-
ner. He believes that certain waste products, which are rapidly
removed by the kidney, and the formation of which is limited
by restriction of proteid food elements, are necessary to the
normal performance of the renal function. Hence the frequent
desirability of a certain amount of proteid substances in the
diet in some cases of renal disease. Lydston's conclusions are r
(1) While the ingestion of large quantities of water in various-
affections is often of great value, the treatment is sometimes-
extremely detrimental; (2) the nutritive value of the blood i»
often impaired by the relative hydremia produced by the inges-
tion of large quantities of water; (3) disturbances of the circu-
latory and nervous systems are frequently produced by it ;
socalled weak heart, palpitation, nervous irritability, lassitude
and exhaustion on slight exertion are among the phenomena
that may result; (4) serious digestive disturbance, involving
impairment of the secretion and composition of the gastrointes-
tinal juices, and gastromotor insufficiency may be produced by
the ingestion of water in large quantities ; (5) edema and ana-
sarca, while often relieved by the free ingestion of water under
favorable circumstances, are not infrequently enhanced by it ;
(6) renal water habit may develop, by virtue of which the
kidney becomes permanently sluggish unless it receives it»
wonted stlmxilus of large quantities of water; (7) acute and
chronic inflammatory affections of the kidney are sometimes
aggravated by giving water in excess simply by overworking
the renal organs ; (8) inflammatory affections of the lower por-
tion of the genitourinary tract are often deleteriously affected
by excessive water-drinking through the mechanical disturb-
ance necessitated by the resultant frequent and copious mictu-
rition, [a.o.e.]
7. — Temporary Hypertrophy of the Glands of the Skin
of the Axilla After Labor. — Bacon reports two cases, each
being a primipara. The swelling began the fourth day after
labor and persisted about five days. No secretion could be
obtained from the mass in one case, no attempt being made in
the other. [a.g.e.J
Philadelphia Medical Jonrnal.
August 9, 1902. [Vol. x, No. 6.]
1. Ascites with Abdominal Tumors. A. IjApthokn Smith.
2. The Normal Third Btjvge of r>abor, with Special Keferenco to Its
^Management. Kudoli'h Wieseb Holmes.
3 Menial Defectives : Their Classlflcat on and Training. Martin W.
Bakk.
4. A Case of X-ray Dermatosis. Linnaeus H. Prince.
5. Report of a Remarkable Ca.se of Urinary Retention, with Recovery
After Perineal Section. N. G. Krirle, Jr.
6. Varicosity of the Superficial Kplgastric Vein, Probably as a Result
of an Old Operation for Bubo. Otto Hommer.
1. — Ascites with Abdominal Tumors. — Smith thinks that
it is difficult to explain satisfactorily the presence of fluid. He
has operated on 15 cases of papilloma of the ovary which have
proved of interest. In some of these cases ascites has been
present, the omentum shrunken, and the condition inoperable,
the cases being malignant and the patients dying a few months
afterward ; while in others there was no shrinking of the
omentum and no ascites, and the patients are still alive after
many years. The following questions appear pertinent: Is the
ascites due to mechanic obstruction of the large veins such as
we see in enlargement of the liver, or is it due to irritation of
the peritoneum by the excretions of theovary ? Whyis ascites
present in solid tumors of the ovary and not in liquid tumors
of the same size? Smith thinks that ascites may be caused by
the tumor being solid and sufficiently free to rest upon the in-
ferior vena cava and cause obstruction and exudation of serum
through the walls of the veins ; or, if the tumor i.s malignant, it
quickly affects the liver by metastasis and blocks the portal
circulation, as well as the inferior vena cava passing behind it,
causing both back pre-ssure and exudation of serum from the
veins of the stomach and intestines, as well as from the inferior
vena cava and its branches. Another exi>lanatton is that there
is some irritant poison given off by a diseaseil ovary which in-
creases the secretion of the peritoneal surfaces or closes the
mouths of the absorbents, which under normal conditions are
able to carry off large quantities of serum in a few hours. Many
of his ca-ses with abdominal tumors had albumin in the urine,
which disappeared upon the removal of the tumor, [f.c.h.]
272 A.MBBIOAN HEDICINE]
THE WORLD'S LATEST LITEBATUBE
(August 18, 1902
8. — Mental Defectives. — IJarr gives the followiug classifi-
cation, universally accepted in America, which places tlie
feebleminded infour divisions: (1) The idiot, {a) apathetic, (6)
excitable ; unimprovable, to whom nothing can be given but
asylum care ; (2) the idio-imbecile, improvable in sliglit degree ;
(3) the imbecile, (a) high grade, (6) middle grade, (c) low
grade, trainable in various lines ; (4) the moral imbecile, («)
high grade, (6) middle grade, (c) low grade: amoral, or lack-
ing completely the moral sense, trainable only under custo-
dial care. Each of these divisions is detailed. The benefits of
this classification are seen in that the child is quiclvly and
almost unerringly placed in an atmosphere best suited to its
needs, the family unhesitatingly informed as to its present con-
dition and probable future, and the public more easily enlight-
ened as to the different demands which abnormality malies.
[F.C.H.]
4. — X-ray Dermatosis. — Prince details a case which he has
been able to study very closely, as his own left liand is the part
affected. On two previous occasions the same hand (posterior
surface) was involved, but the dermatosis disappeared. The
third attack has pi'oved rebellious to all treatment and persists.
[F.C.H.]
5. — A Caseof Urinary Retention, with Recovery After
(Perineal Section.— Keirle reports the case of a male, 57 years
of age, who has been blind since a few days after birth. Had
gonorrhea first in 1866 and eight times between 1860 and 1880.
In 1889 his urine stopped entirely, and a fistula which subse-
quently healed formed in the scrotum. In 1894 the urethra
again closed, and a fistula appeared in the same place. In 1895 a
perineal section was done, since which time he has had abso-
lutely no attention, voiding all urine through the perineal open-
ing. During the beginning of this year the opening in the bladder
gradually closed. Shortly afterward a swelling appeared in
the right groin, extending upward and downward. Several
■days subsequent to this he was admitted to the Bayview Hos-
pital, Baltimore. The entire scrotum had sloughed away,
•exposing the testicles, the skin covering the penis had sloughed
and upon the abdominal walls as high as the umbilicus the tis-
sues had become so filled with water that the skin and super-
ficial muscles had been torn from their attachments, and at
Poupart's ligament had been torn away. The skin and the
duternal and external oblique muscles had been dissected out
and could be lifted up and turned over, this condition existing
only on the right side. On the left side and upon the thighs the
tissues were filled with water and looked dark and mottled,
but were not torn away. The patient was operated upon by
Dr. Frank Martin. It was impossible to insert into the urethra
the smallest filiform. A perineal section was done without a
guide, the urethra being found after a great deal of trouble. A
free opening was made into the bladder and a rubber tube
inserted. Sounds were passed every second day, and the wound
•dressed by washing with a bichlorid solution and keeping the
•surfaces packed with sterile gauze, [f.c.h.]
CLINICAL, MEDICINE
David Riesman A. O. J. Kelly
" The Fluorescence of Qiiinin and Other Kenie-
■dles in the Cure of Malarial Fever In a recent issue
we took occasion to comment upon the views and spec-
ulations of Dr. A. F. A. King, of Washington, D. C,
with reference to the influence of light and fluorescence on
the malarial parasite. Dr. King, it will be remembered,
maintained that the malarial parasite would not sporu-
late in the dark and that the light that it obtained in the
blood is necessarily red— whence it was assumed that
the malarial organism may act as does the ameba pro-
teus which streams in the presence of red light and
ceases to stream in the presence of violet light. As a
corollary it was suggested that the curative action of
quinin might be due to its fluorescence, to its producing
violet rays of light in the blood. In a more recent com-
.niunication {American Journal of the Medical Sciences,
June, 1902) Dr. King adduces some evidence to support
this view. He points out that two other vegetable
products possessing blue fluorescence in a remarkable
degree have long been known as eff'ective remedies for
intermittent fever— esculin and fraxin (or fraxinin). He
mentions a number of old reports illustrating that both of
these substances found favor with some medical writers
during the past two centuries, and he states that one
observer, Mandet, was so convinced of the efficacy of
fraxin as an antiperiodic that he surnamed it quinquina
(V Europe. The success that Is said to have attended the
use of preparations of iodin in intermittent fever is
attributed to the action of the blue or violet iodid of
starch (formed by the action of the iodin on the starches
of the food)— in which respect the curative influence of
the tincture of iodin would seem to fall in line with that
of Prussian and methylene-blue. While stating that
the antiperiodic eff"ects of the fluorescent substances
esculin and fraxin favors the idea that fluoresence may
be the curative property in quinin. Dr. King admits that
the proof is insufficient, and that we need direct experi-
ments showing that quinin actually produces fluorescence
in the body, and that coincidentally the symptoms and
phenomena of malarial fever disappear. He believes
that such results actually were obtained more than 30
years ago by Rhoads and Pepper, of Philadelphia. Fol-
lowing the observation of Bence Jones that all parts of
the animal and human body possess a fluorescence that he
attributed to a substance that he named animal quinoidine,
Rhoads and Pepper endeavored to ascertain "whether
there might not be, as an attendant upon the patholog-
ical processes in malarial disease, a rapid and marked
diminution in the amount of 'animal quinoidine' natu-
rally existing in the tissues." The results of their
investigations showed that the fluorescence of the blood
of malarial subjects is below thp normal standard, and
they state that their observations "indicate, by the
uniformity of the results, a close connection between the
diminution of ' animal quinoidine ' and malarial dis-
ease." In 1875, C. K. Mills, of Philadelphia, suggested
that fluorescence may aflbrd an explanation of cincho-
nism, stating that animal fluorescence "is decreased
below a normal standard in malarial affections, and that
it rises in the scale pari passu with the giving of the
cinchona preparations and the improvement in the symp-
toms of the disea.se." Dr. King believes, then, that it is
the peculiar relations of the cinchona preparations with
light that give a clue to the explanation of their curative
effect, and that possibly the same may be said of all
assimilable substances that fluoresce a violet or blue
color. The fact that quinin fails to cure some cases of
malaria is accounted for by the fact that in these cases the
parasites, the crescents, are not generally found in the
peripheral blood where they can get light, but that they
are found in the spleen, liver, bone-marrow, and brain,
than which no darker recesses of the body can be
imagined, and consequently where the fluorescent prop-
erty of quinin must be impotent. The ordinary par-
oxysms are believed to be due to sporulation of parasites
contained within erythrocytes so swollen as to become
arrested in the capillaries of the skin where they are
exposed to the light of the sun. The ingeniousness of
Dr. King's theories must excite our admiration, and
without stopping to point out the loopholes in his purely
speculative reasonings, we may state that the relations
of light to the malarial parasites will bear extended
studies and investigations.
On the Presence and Diagnostic Value of Protozoa in
the Digestive Tube of Man.— Cohnheim discussed at the
Society of Internal Medicine, Berlin, July 12, 1902, the role
played by such protozoa as Trichomonas hominis, Megastoma
entericum, and Pagiomonas hominis, in the human economy,
whether that of real parasite or of inoffensive commensals.
Cohnheim inclines to the latter view, and points to the fact that
these protozoa are capable of living in the fluids of the gastroin-
testinal tract only when these fluids are alkaline in reaction,
August 16, li)02]
THE WORLD'S LATEST LITERATURE
fAHERTCAir HESIOINE 273^
and they appear in the stomach and esophagus only when the
fluids of these cavities have become abnormally alkaline in
consequence of cancerous disease. These organisms, therefore,
possess an important diagnostic value when found in the fluids
of the upper portion of the ali mentary canal. [c.s.D.]
Two Cases of Tubercnlous Meningitis.— S. S. Adams"
details two cases of tuberculous meningitis, both verified by
autopsy. Case 1.— Colored girl, 8i years of age, showed general
miliary tuberculosis, tubercles in lungs, liver, spleen and intes-
tinal and bronchial glands. The brain presented a characteris-
tic appearance; small granulations over cortex and along the
superior longitudinal fissure, along the course of blood-vessels ;
flbrinopurulent exudation between pia and cerebral convolu-
tions generally present over base, especially well marked in fis-
sure of Sylvius ; this exudation extended also to cerebellum and
medulla and along the sheaths of the cranial nerves ; ven-
tricles much distended ; marked congestion everywhere pres-
ent; the lungs were universally involved; no cavities. The
tubercle was demonstrated. Case 2.— A colored girl aged o
years. Autopsy showed marked tuberculous involvement of the
lungs, liver, spleen and brain ; miliary tubercles everywhere.
The cranial dura mater was thickened and congested ; over the
.sides of the superior longitudinal fissure were many tubercles;
brain much congested and softened; ventricles filled with
fluid ; over the motor region, on the right side, was a small
blood clot. At the base of the brain the pia arachnoid was much
thickened and bound down; lobes adherent; small gritty,
millet seed masses everywhere and fibrinous exudate. The
tubercle bacillus was demonstrated, [f.c.h.]
New Procedures for Examining the Blood and Bac-
terial Cultures.— Wright 2 writes on the possibility of dis-
pensing with the standard pipets and micrometric rulings of
the hemocytometer ; on a method of determining under the
microscope the number of microorganisms contained in a
bacterial culture, and on a simple procedure for obtaining
coagulation tubes of standard caliber and the information
obtained from the coagulometer. [a.o.j.k.]
Syiidrome of Weber-Gluber.— S. Bivoua' records a case
of this syndrome very rarely found in man, a phlebitis of the
left lateral sinus following suppurative otitis media. [c.s.D.]
Importance of Attention to the Heart's Action During
Illness.— As stated by Alexander Duke,* the paramount im-
portance of attending to the heart's action during illness of any
severity cannot be too strongly enforced on the practitioner.
Too frequently patients are suffering from marked symptoms
of functional disorder of the kidneys, lungs, liver, etc., when
the heart has been entirely overlooked, and no examination
mafle of that all-important organ. He has frequently seen a
steamkettle pouring out volumes of moist air which the patient
was breathing under the delusion that the bronchial tubes were
at fault, while the real cause (cardiac) was left untreated.
[K.C.H.]
The Kdema of Anemia.— Houston,' from an exhaustive
experimental study of the questions involved, concludes: 1.
The absence of loss of weight in anemic conditions, and the
fact that the patient seldom seems emaciated ,''18 mainly due to
the fact that there is an abnormal accumulation of fluid in the
blood and tissues. If this excess of fluid were deducted it
would probably be found that in these, as in other chronic ill-
nesses, there is a progressive loss of weight in proportion to the
severity and duration of the disease. 2. In the cure of such
anemic conditions, especially chlorosis, the first stage seems to
be the getting rid from the blood and tissues of this excess of
fluid. .'5. A gain of weight in a case of pernicious anemia under
treatment, and without any improvement in the hemoglobin,
is to be regarded as an unfavorable sign, indicating dilution of
the blood and conseciuent escape of serum into the tissues. It
may, however, be a critical phase of the disease and indicate the
first step toward concentration of the blood. Immediately
after this sudden increase iu edema there is either a marked
improvement or the patient dies. 4. The edema of anemic con-
liily, liKK.
' Wii»hln(tton Medical AnnalH,
2 l,«nc«'t, .July .5, 19(tt.
» II J'ollcllnloo; Hnpplcmenlo Hentlriianalc, June 11, 1902.
'The Medical PrrKH, .Inly 2. I!102
'British .Medical .lourmil, .Iinie II, 1IK)2.
ditions seems to result from a hydremic plethora of the blood,,
and is somewhat different in origin and nature from the edema
usually found in Bright's disease. 5. Careful observations in
the manner indicated of anemic conditions, namely, a record of
the weight and hemoglobin value of the blood may furnish
very Interesting results. The points to direct attention to are
the occurrence of hemorrhages (epistaxis, etc.), edema, diar-
rhea and profuse sweating, which symptoms are often the
result of dilution of the blood, and may be merely nature's
method of counteracting the exces.sive and abnormal volume of
the blood, [a.o.j.k.]
Symmetric Acroasphyxia. — Antenore Conelli > describes
an interesting case of the singular malady sometimes spoken of
as Raynaud's phenomena. This condition of vasornotor neuro-
sis, found in connection with hysteria and allied degenerative
conditions, consists in its ultimate analysis in a defect in the
moderating action on equilibrium of the superior nervous cen-
ters, accompanied by a disturbance of the automatism of the
bulbomedullary centers, conditions produced by the presence
of some toxin circulating in the blood, either of exogenic or
endogenic origin. Certain alkaloids have the capacity of pro-
ducing pharmacologic syndromes entirely analogous to sym-
metric acroasphyxia. Certain bacterial toxins also have the
power of producing similar effects, which are frequently attrib-
uted to tuberculous toxemia, diabetes, nephritis and autointoxi-
cations of gastric origin, all of which may hold direct relation
to Raynaud's disease. The author noting in this connection a
certain degree of hypertrophy of the right lobe of the thyroid,,
was led to interpret the trouble as a manifestation of hyper-
thyroidism and instituted a therapy in which thyroid insuffi-
ciency was compensated for by the progressive administration
of Merck's thyroid tabloids, which was followed in the course
of seven days by great improvement and by marked regression
of the spasticoasphyxic phenomena of the extremities, and in
the course of two months by an amelioration of the general
condition. [c.s.D.]
Floating Kidney as a Cause of Obstructive Jaundice-
and Hepatic Colic— Hutchinson ' reports two cases of recur-
ring jaundice in young adult women, both of which were cured
by nephropexy, and he points out the necessity of taking into
consideration floating kidney as a cause of jaundice and hepatic
symptoms in young adult women. Undertaking an investiga-
tion to ascertain the cause of the obstruction, especially to ascer-
tain whether there is, as asserted by Weisker, a hepatorenal
band that accounts for dragging on the neck of the gallbladder-
by the floating kidney, he came to the conclusion that no such,
band exists, and that the obstructive jaundice occurring with
floating kidney is to be explained by: (1) Downward displace-
ment of the third part of the duodenum, with stretching of the
common bile duct ; (2) displacement of the gallbladder and-
sharp kinking of the cystic duct; and (3) torsion of the verti-
cal part of the duodenum and perhaps even of the bile duct. In.
addition Hutchinson reports a case of temporary glycosuria in
a case of floating kidney— the glycosuria disappearing under
rest in bed. [a.o.j.k.]
Is Adrenalin the Active Principle of the Suprarenal'
Gland?- T. B. Aldrich-' takes issue with the conclusions of'
Abel, V. Furth, Fraenkel, Moore, and Metzger, that adrenalin is
not identical with the native principle found in the suprarenal
gland, since it retluces Fehling's solution while the latter does
not. Aldrich explains the failure of the product used by these
investigators to the fact that they wore imperfetdly prepared or
that partial oxidation of the active principle had taken place.
Ho concludes that: I. All concentrated aqueous extracts of the
suprarenal gland reduce Fehling's solution on boiling. 2. The-
adrenalin obtained from a certain amount of the aqueous.
extract reduces Fehling's solution approximately in the same
proportion as the original extract from which it was ol)tained.
3. The mother liquor, after removal of the greater part of the
adrenalin, except in comparatively largo amounts, does
not reduce Fehling's solution. 4. Adrenalin is not a reduced'
form of the native principle, since it was ol)tAined without the-
useof a reducing agent, such as hydrogen snifld. 5. Adrenallni
1 II Pollcllnlco; HuppIemcntoBentlmanali" .\nno vlll, Fnsc. 18.
s Practitioner, Ixvlfl, IHfl, liKB.
» American Journal of Physiology, July 1, IW2,
274 AUBKIOAN Medtgink]
THE WORLD'S LATEST LITERATURE
{AuausT 16, IM»
is the same whether obtained by using sodium carbonate solu-
tion or ammonium hydrate as a precipitant. 6. Epinephrin,
and the other questionable products obtained from the gland,
roust be oxidized or at least a changed form of adrenalin, the
active principle, since they do not reduce Fehling's solution.
7. Adrenalin is identical with the copper-sulfate-reducing body,
the blood-pressure raising substance, as found in the gland, and
is therefore the active principle of the same, and not a modified
or changed form, as Abel contends. [c.s.D.]
Concerning Hay-fever. — Thost' has collected statistics
from over 400 hay-fever patients. These statistics indicate,
first, that there is an exciting cause, which is connected with
vegetation ; but that, in addition, there must be a local and a
general predisposition. The former has its seat in the mucous
membrane of tlie nose or upper air-passages, the latter in the
central nervous system. Regarding the exciting cause, the
author found that in a given locality all the hay-fever patients
become ill almost on the same day. Slight variations are seen in
iarge cities, owing to the presence or absence of parks or large
gardens in certain sections. Where the vegetation is sparse,
hay-fever does not exist. In North America the disease pre-
sents the same symptoms, but appears at an entirely different
season, constituting an autumnal catarrh, while in Europe it
sets in during the early summer. Examination of the nasal
mucus showed the presence of pollen-grains in only a few cases,
and there are some observations which directly contradict the
theory that pollen-grains are the cause. There is reason to
believe that the attacks are produced by extremely minute
olfactory substances— ethereal oils, perhaps— which develop
under the inrtuence of strong sunlight upon the early blossoms,
especially in fields of rye. Such an olfactory substance would,
of course, also cling to the pollen. Weil found a white staphyl-
ococcus in the nasal mucus of hay-fever patients, but did not
succeed in producing the disease with cultures of the organism.
Begarding the local predisposition, the statistics show that the
majority of patients were predisposed by pathologic changes in
the upper air-passages. They suffered from nasal obstruction,
■chronic pharyngitis and laryngitis, cold feet and moist skin ;
and many of them had a tendency to catching cold. As regards
the general predisposition, the old view that men are princi-
pally affected is disproved by the author's statistics : Among
his 400 patients there were 248 men and 152 women. It seems
that the disease principally attacks persons in the higher walks
of life ; as Thost puts it, the aristocracy of birth and mind.
The disease may be divided into the mild type, or hay-fever,
and the severe type, or hay asthma. There were 134 of the
former and 266 of the latter. As regards age, there were 22
under 5 years, 38 between 6 and 10, 55 between U and 15, 61 from
16 to 20, 59 from 21 to 25, 38 from 26 to 30, 23 from 31 to 35, 17 from 36
to 40, 11 from 41 to 45, 4 from 46 to 50, 1 from 51 to 55, 1 from 56 to
60, 1 from 61 to 65, 1 from 66 to '70. In England, gout is consid-
ered a predisposing cause, but the author's statistics do not
corroborate this, [d.r.]
The Connection of the Lymphatic Ganglia with the
Resistance of the Organism to Tuberculosis.- Luigo Man-
fredi and B. Fisco, in a contribution to II Policlinico, May, 1902,
point out the fact that the lymphatic ganglia may be considered
as the habitual seat of a true latent microbism, that these
ganglia exercise an additional action on pathogenic bacteria,
and that they exercise also an immunizing influence, and finally
that in some cases they act as the point of departure of crypto-
genic infections. There may be a tuberculous infection exclu-
sively gangliar in its character, and the question arises as to the
condition of the tubercle bacilli which may exist in one or
more ganglia without producing either local or general tuber-
culosis, and as to how long this condition of latent potential
infectivity may exist before extragauglial infection takes place,
and whether in cases in exclusively gangliar infection it is
possible, by augmenting the resistance of the gangliar system,
of producing an antituberculous imnmnization. The researches
of the authors have been directed toward ascertaining the
effects of interlymphatic inoculations with tuberculous virus
in minimum and in gradually increasing doses. [c.s.D.]
1 Mflnchener mediclnlsche Wochenschrlft, April 29, 19a2.
A. B. Craig
GENERAL SURGERY
Martin B. Tinker
C. A. Orr
Pncumococcic artliritis, a condition of much in-
terest and importance, is the subject of an instructive
and comprehensive study by Herrick (American Jour-
nal of the Medical Sciences, cxxiv, 12, 1902), who has been
able to add much of value to our knowledge of the sub-
ject and to report nine additional cases. These, together
with the case-i previously collected by Vogelius, Leroux,
Cave and others, makes a total of 52 cases so far re-
corded. Happily the disease is of relative infre<iuency,
but two cases occurring among 2,292 casas of pneumonia
treated in different German clinics ; but two cases among
3,293 cases of pneumonia treated in the Charity in Ber-
lin ; but one case among 650 cases of pneumonia treated
in Munich ; but three cases among 1,215 cases of pneu-
monia treated in several clinics in Paris, and but six
cases among 4,256 cases of pneumonia collected by Net-
ter — thus but 14 tases among 11,706 cases of pneumonia,
or one case to about every 800 cases of pneumonia. The
complication is more common in men than in women
(40 males to 7 females) ; it occurs at any age, and it de-
velops oftenest during or shortly after croupous pneu-
monia— sometimes, however, as late as the third week
after the crisis. The infection may be primary in the
joint, and severe and even fatal constitutional symptoms
may result from the toxemia thus induced. In primary
pneumocoecic arthritis pulmonary infection may or may
not occur. Previous damage to a joint as by trauma,
rheumatism, or gout favors the local infection. The
lesions may be limited to the synovia, or they may be
more extensive, involving the cartilages, the bones and
even the periarticular structures. The lesions- vary
with the duration of the inflammation, the virulence of
tlie microorganisms, and the general and local resistance
of the" individual. In the acute cases, often little more
than a synovitis is seen. The exudate varies from a
serous or serofibrinous fluid to the more commonly
found thick, creamy, yellowish pus that contains the
pneumococcus. In the same patient one joint may con-
tain a purulent, and another a serous exudate. In
other ca-ses, and particularly those of a subacute or more
chronic character, the changes are more extensive and
destructive. The cartilage may be eroded, the bone in-
vaded, the ligaments destroyed and the tendon sheaths
and muscles in the vicinity of the joint involved. In a
few cases the destruction may be extreme, amounting to
complete disintegration of the joint. Usually the lesions
are confined to a single joint (61. 6;*^) — the largest joints,
especially the knee, being oftenest involved. Clinically
the disorder is recognizetl by the ordinary signs of acute
or of chronic inflammation. The development of arthri-
tis during the course of, but especially during con-
valescence from pneumonia, sliould excite suspicion of
pneumocoecic infection of tlie joint; and color would be
lent to the supposition if the patient were an alcoholic,
and if the affected joint were the seat of previous trauma
or injury from rheumatism or gout. It is important,
however, to bear in mind that an arthritis complicating
pneumonia need not be due to the pneumococcus. The
diagnosis of the nature of the infection, therefore, de-
pends upon examination — microscopic and bacteriologic
— of the fluid obtained by puncture. The prognosis of
pneumocoecic arthritis is grave, the mortality being
65^, the consequence in large part of bacteremia and
the concurrent involvement of other and more vital
parts of the body — meninges, pleura, pericardium, etc.
However, spontaneous recovery even in cases of purulent
exudate may take place. In the event of suppuration
the joint should be incised immediately and drained;
should the effusion be serous in nature, healing may
result from aspiration, rest and compression. In all
cases the complication is of serious motnent, and although
AUGUST 16, 1902]
THE WORLD'S LATEST LITERATURE
[Ambbican Medicinb 276
it is of uncommon occurrence, it appears advisable to
draw attention to it, if for no other reason than to em-
phasize the fact that bacteremia is a constant concomi-
tant of pneumonia, and that pneumonia is not a disease
of the lungs alone but a general infection of which the
most serious manifestations frequently are not the pul-
monary lesions but the intoxication and the bacteremia.
lodin as a Specific for Surgical Tuberculosis.— Her-
manseni has been guided in his investigations as to iodin by
the relationship between tuberculosis and syphilis in their his-
tologic products and in their infectious, chronic and recurrent
character ; also by the value of iodin in scrofula. The latter
led to the belief that it might be a specific against other forms
of tuberculosis and that permanent cure might be obtained if it
was used in large doses and for a very long period, with regular
intervals several times a year, and repeated on signs of recur-
rence. In pulmonary tuberculosis iodin seems to have no
specific value, but reinforces the general health. The formula
used in surgical affections is: Inf. rhei alkalini, sol. pot. tar-
trat., tr. cinchon. comp., augram 30 ; sol. iodi spirit (5% iodum),
eraml5; tr. pomi ferratau, gram 20 (Pharmacopeia Danica).
A teaspoonful half an hour after meals should be given for two
to six months, abandoned for a time, and then resumed for two
or three months, then again a pause, and so on until the disease
is extingaished. Kven with much larger doses there is seldom
a ca.se of iodism. It is well to give the treatment several
months before operation, when this cannot be dispensed with,
and continue it afterward. The writer reports nine cases sub-
jected to this treatment, [h.m.]
Recent Operations on the Stomach. — RiddelP reports
recent cases and says of 5 cases of gastroenterostomy, or gastro-
jejunostomy, done within the last nine months, 3 were for
malignant disease of the pyloric end of the stomach, 1 for
inflammatory tumor and 1 for gastric ulceration in that region.
Operation was undertaken to relieve the patient of the distress-
ing symptoms of pyloric obstruction and as a possible prelim-
inary to removal of the obstructing tumor. In the first case
the jejunum was united to the front wall of the stomach, while
in the other four the "posterior" method was .selected, the
bowel being fixed through a vertical hole torn in the transverse
mesocolon to the posterior wall of the stomach. Owing to the
disadvantages attending the use of Senn's bone plates. Mur-
phy's button, and direct suture. Mayo Robson's bobbin was
employed in all the cases. Its advantages from ease of applica-
tion and efficiency are very great. The bobbin was fixed by a
running suture of silk in the openings, and the stomach and
bowel then united by a covering continuous fine silk thread.
The edges of the wound in the mesocolon were stitched to the
stomach wall and the abdomen closed. The advantages of the
"po.sterior" method are considerable. All of the patients
recovered from the operation, but one has since died. The
author also reports a successful cholodochotomy for a number
of stones in the common duct; a successful cholecystenteros-
tomy for benign obstruction in tlie common duct. [a. B.C.]
Subacromial Dislocation from Muscular Spasm. —
Mynter' reports a case of this sort which is interesting from the
etiologic standpoint and from the fact that the patient suffered
from a shoulder dislocation for three months without suspect-
ing it or seeking surgical treatment, he all the time believing
that he had rheumatism. The patient was a strong, muscular
man of 38, the lameness in the shoulder persisting after an
attack of nocturnal epilepsy which was seen by his wife. A
skiagraph of the dislocated humerus is shown. Forcible reduc-
tion was accomplished under anesthesia after a special appa-
ratus for fixing the scapula had been applied, [a. O.K.]
Sodium Bicarbonate In Surjtery.— Mallet* draws atten-
tion to the use of sodium bicarbonate in surgery. It saponifies
the greasy materials of the skin, softens the epidermis and
ha.stons its fall. The cutaneous functions and secretions are
stimulate<l. The alkaline solution does not act as an antiseptic
to wounds, but by its alkalinity stimulates the cellular ele-
> Mcdlral Press and Circular, April Zt, 1902.
«l!rlll»h Medical .louriml, July 12, 11)02.
" AnnalM of HurRcry, .Inly, 19o2.
*Tli68c do ThCnipeutlque de I'urls, February, 1902.
ments to over-activity, which enables them to counteract the
effects of infectious germs more readily. Sodium bicarbonate
may be employed in powder, in ointment and in solution, the
latter being the most useful. A 5% solution is generally used.
Moist sodium bicarbonate dressings should be used only after
previous disinfection of the wound, and they must be renewed
daily. The following advantages are claimed for the sodium
bicarbonate dressing : (1) It is cheap; (2) it is easily employed;
(3) there is no danger of producing toxic effects ; (4) it retards
suppuration; (5) it diminishes odor; (6) it soothes the pain;
(7) by increasing the activity of the tissues, it hastens cicatriza-
tion of wounds, [l.f.a.]
Perforating Gastric Ulcer.— Heaton ' estimates that about
15% of all peptic ulcers perforate into the general peritoneal
cavity. A great majority of ulcers occur on the posterior gas-
tric wall, the most of which cause an inflammatory process and
adhesions which prevent perforation. Of those which occur on
he anterior wall probably 60% to 70% perforate. Robson is
quoted as having collected 486 operative cases from literature,
with a mortality of 55.4%. The author has collected reports of
40 oases operated on in wellknown London hospitals in which
the perforation was actually found and sutured. In these there
wasadeathrate of 65%. The writer reports five of his own cases,
two of whom had perigastric abscess from an old perforation
and three had acute perforation. One of the cases with abscess
recovered and likewise one with acute perforation, [a. B.C.]
Operation in Appendicitis.— Pye-Smith '' advises opera-
tion in appendicitis so soon as the diagnosis is made. The
operation he regards as less dangerous than the delay. The
only circumstances under which operation is counterindioated
are when capable assistants cannot be obtained or when there is
a grave constitutional disorder as hemophilia or heart disease.
[H.C.W.]
Rare Cases of Sarcoma of the Thyroid.— Daniel ' details
minutely 4 cases of sarcoma of the thyroid gland. The ages
of the patients were 57, 59, 60 and 69. Of the sarcomas 3 were
round-cell, 1 giant-cell in type. The 4 cases terminated fatally
in 8, 9, 12 and 17 months after the growth was first observed.
In Case 1 no embolic deposits were found. In Case 2 secondary
growths were found in the dorsal and lumbar vertebras,
both kidneys and adrenals, the celiac and cervical lymphatic
glands, and the stomach. In Case 3 both kidneys and the cer-
vical and thoracic glands were ' involved. In Case 4 the
stomach, intestines, pancreis, and cervical glands were in-
volved. The growth was primarily of the right lobe in 3
cases, and grew faster in the right of the fourth. Interesting
points are (I) the association of myxedema with sarcoma of the
thyroid in Case 4, the development of the symptoms of myx-
edema, with one exception, that of slow speech, being coinci-
dent with enlargement of the thyroid ; (2) sarcomatous ulcera-
tion of the stomach in Cases 2 and 4. This is believed to have
been due to involvement of the jiharynx and larynx, [a.o.k.]
Acute Nonsuppurative Perinephritis.- Newman* re-
ports that a patient had been in good health up to eight weeks
before he came under observation, when he suffered for four
weeks from jilenrisy, which began high on the right side and
later extended to the base of the lung. The patient apparently
recovered, and for three weeks had been about, when he sud-
denly began to feel pain in the right lumbar region. This con-
tinued and increased in severity. There was no fever and none
of the cardinal signs of renal disease. On examination under
chloroform the whole space between the right costal border
and the crest of the ilium was found occupied by a swelling
extending forward to within four inches of the median line. It
was nonfluctuating, firm and slightly elastic. An exploratory
incision passed through .3J inches of intlammatory tissue. The
kidney, which appeared healthy and contained no calculi, was
surrounded by this great mass of inflamed tissue. Several
incisions into the same failed to lind pus. Drainage tubes were
inserted and the patient made a slow recovery, [a. B.C.]
Abscess In the Right lllat; Region, and Other tiesions
Not of Gynecologic or Appeudlceal Origin Mistaken for
> British Mi'dical .lournal. July 12, 1901?.
' Medical Tress and Circular, April 23, 1902, 436.
a Lancet, July 19, 1902.
* British .Medical Journal, J uly 19, 1902.
276 American MkdicinkI
THE WORLD'S LATEST LITEEATURE
[August 16, 1902
Appendicitis.— Spellissy" reports 194 cases, 7 for the first time,
with lesions of 20 varieties of structure and 68 species of lesion,
not one being of appendiceal origin and all so mistaken. Of
these 30 were lesions associated with the gallbladder. The
question arises, "Is the diagnosis of appendicitis difficult?"
The summary of writers on the subject is that it is ordinarily
unattended with difficulty. Because of this the possibility of
other lesions occurring in the right iliac fossa is not sufficiently
borne in mind. From both points of view, that of mistaking
appendicitis for other lesions, and that of mistaking other
lesions for appendicitis, the conclusion is reached that a diag-
nosis in cases with symptoms pointing to the right iliac fossa
should not be made without a routine, conscientious examina-
tion for, and exclusion of, the various troubles that may exhibit
misleading symptoms and signs, [a.g.e.]
Diagnosis of Diseases of the Sigmoid and Keetum.—
Edwards ^ says the diagnosis rests on symptoms such as pain,
tenesmus, discharges of pus, blood and mucus, protrusion, ab-
normal defecation, etc. He urges the necessity of digital exami-
nation in every case of suspected disease of the lower bowel.
He asserts that cancer of the lower bowel has gone unrecog-
nized for want of such examination until the condition was
hopeless and inoperable. In examining a patient complaining
of rectal pain, it is well to ascertain the time relation which the
pain bears to defecation. The symptoms— pain, hemorrhage,
protrusion, discharges, etc.— are discussed at length. The use
of the proctoscope has revealed and enabled us to treat many
hitherto unrecognized and untreated maladies, [a.b.c]
Intestinal Polyposis and Carcinoma.— Three cases of
intestinal polyposis are reported by Niemack." A certain degree
of contagiousness, or at least family predisposition, is suggested
by the cases, which were a girl of 12, her father of 45, and his
nephew of 29. The girl died of exhaustion after 100 polyps had
been removed from the rectum without improvement. Autopsy
showed the colon and several inches of the ileum to be studded
with polyps. The father was operated for adenocarcinoma of
rectum, above this growth being numerous polyps. Hueter's
incision was used for this operation, Niemack believing this to
be the operation of choice in every lowseated carcinoma in
preference to the posterior incision. The young man has had
intestinal hemorrhages for two years, and examination shows
two polyps five inches above the anus. Over his abdomen are
felt small indurations, as were present in Case I. [a.g.e.]
Motor Aphasia ft-om Injury to the Head.— Newman *
reports three cases of motor aphasia. In Case I the injury,
without fracturing the skull, induced complete unconscious-
ness, followed by epileptiform convulsions and complete paral-
ysis of the right arm and leg. Operation was performed on the
tenth day, and recovery was complete on the twentieth day. In
Case II there was a depressed fracture of the skull, with com-
plete unconsciousness, followed by epileptiform attacks. Oper-
ation on the fifth day was followed by recovery, complete on
the twenty-eighth. In Case III the injury produced aphasia
and unconsciousness only ; operation was not performed, and
the patient made a slow recovery during four months, [a.g.e.]
Duodenocholedochotoiny for Retained Gallstones. —
Robinson ^ reports two cases — one a man of 46 and the other a
woman of 43— which presented the symptoms of gallstone at
the duodenal end of the common duct. In the first case the
third operation was performed before the stone was found, and
then only after most careful palpation of the duodenum where
the common duct empties. In the otlier there were two stones
at the situation above mentioned. In both cases the duodenum
was opened and the stones extracted by enlarging the common
duct opening. Recovery followed in each case, [a.b.c]
Fracture of Spine ; Laminectoiny ; Recovery. — Bow-
den* reports this case, the patient being a man of 52. Opera-
tion on the fiftli day by Watson Cheyne showed fracture of the
ninth dorsal vertebra, the lamina of the eighth, ninth and
tenth being fragmented and removed. One piece was pressing
on the cord. Movement of the legs, which had been entirely
■ Annals of Surgery, .June, 1902.
2 British Medical Journal, .July 19, 1902.
' Annals of Surgery, J uly, 19U2.
* Lancet, July 28, li)02.
' British Medical Journal, June 28, 1902.
« Lancet, July 19, 1902.
lost, began returning in three weeks, but progress was very
unsatisfactory for three months, power over the bladder and
rectum being absent. Improvement then began and now, at
the end of a year, the patient can walk two miles without
fatigue, is in perfect health, the bowels move naturally and
urine is passed fairly well though it is thought advisable to use
the catheter once daily, [a.g.e.]
GYNECOLOGY AND OBSTETRICS
WiLMEB Krusen Frank C. Hammonb
Pioneers in English Gynecology. — It is refreshing
to note that Hoyd Roberts,' in his introductory remarks
at the opening of the recent meeting of the Section of
Obstetrics and Gynecology of the Britisli Medical Asso-
ciation at Manchester, took occasion to pay tribute to
the founders of that body, one of the most remarkable
of whom was Charles White. He was born in Manches-
ter in 1728 and was a fellow-pupil of John Hunter. In
the early part of the eighteenth century midwifery was
not practised to the same extent by men as it is at the
present time, and the treatment of lying-in women wa.s
crude and insanitary. After labor women were kept in
rooms heated to excess, the windows and doors being
closed and covered with curtains so as to prevent, so far
as possible, the access of fresh air. White had the cour-
age to revolutionize this most objectionable usage, and
in consequence the most prevalent complications of labor
became much less common. Among other important
advances in treatment advocated by White were : Not
tying the navel cord before cessation of circulation ;
removal of placenta and membranes by manual extrac-
tion aided by pressure on the fundas ; and the recogni-
tion of the possible septicity of the lochia with the
recommendation to inject antiseptic solution into the
uterus. He thus anticipated the discoveries of a later
century.
Next to White in eminence was his friend and con-
temporary, John Hull, born in 1761. In 1800 he pub-
lished an essay on " Phlegmasia Dolens," including an
account of puerperal peritonitis. He wrote extensively
upon the subject of cesarean section and established the
necessity of the operation in certain well-defined con-
tractions of the pelvis. Another of the founders was
Kinderwood, who was the first to advise, in certain
severe cases of placenta prtevia, the entire detachment of
the placenta from the os and the cervix uteri leaving the
rest to nature. Thomas Radford was one of the first in
England to advise abdominal section for the removal of
diseased ovaries and gave much assistance to Charles
Clay in his early ovariotomies. Clay was one of the
most remarkable men among the early gynecologists.
He was born in 1801, settled in Manchester in 1839, in
which year he performed his first ovariotomy, removing
a tumor weighing 36 pounds. In 1845 he removed the
whole uterus for a fibroid tumor, nearly 25 years before
Koeberle's case. Clay may be fairly regarded as the
father of ovariotomy as far as Europe is concerned,
although American operators will always regard as the
great pioneer in this work Ephraira McDowell, who
performed the first ovariotomy December 13, 1809. At
the time Clay performed his operation, leading surgeons
of the day placed ovariotomy under interdict, and those
who performed the operation were held up to obloquy,
and even threatened with criminal prosecution should
one of their patients die after the procedure. Clay,
however, held firmly to his conviction that ovariotomy
was justifiable and that in the future it would be
accepted by the profession and would yield brilliant
results, predictions that have been amply verified.
Roberts also pays high tribute to several other men of
marked ability but of less distinction, all worthy labor-
ers in this department of medicine.
1 British Medical Journal, August 9, 1902.
AUGUST 16, 1902J
THE WORLD'S LATEST LITERATURE
[American Medicine
277
Milk Sugar in the Urine of Nursing Women. — Doug-
las • examined 56 cases for milk sugar and found it present
in 859f. In only 2% was lactosuria absent after full lactation
had been established. Most of the observations were made
between the third and seventh day after delivery. Of 4 unde-
livered cases 2 revealed no sugar (sixth and eighth month),
while 2 at full time showed traces. It was found in a v-para,
though the woman was not nursing, and in another case four or
five days after nursing was stopped. The importance of recog-
nizing the physiologic character in connection with life insur-
ance examinations, and as affecting prognosis in surgical and
other conditions, is evident. That the reducing substance is
milk and not grape sugar must be decided more by exclusion
than any positive reaction. If the urine responds fairly well
to Fehling's solution, but does not yield any crystals with
phenylhydrazin and does not ferment, except very slowly with
yeast, we may be practically certain that it is milk sugar which
it contains, [h.m.]
li^ukorrhea.— W. Gill Wylie '' states as the main causes of
leukorrhea imperfect development and bad local condition of
the glands and infection, chiefly gonorrheal. Leukorrhea in
children and young girls is often due to infection from the
nurse, who has some contagion. Absolute cleanliness of the
parts, obtained by a weak solution of nitrate of silver, is the
best means of curing the disease. Leukorrhea of children is
also caused l)y bad condition of the clitoris. In addition to
cleansing of the parts, in such cases a slight operation is re-
quired. The leukorrhea which so often occurs at or after the
first menses is generally due to imperfect development, and
often on examination the cervix uteri is found so abnormal as
to call for careful treatment. Obstinate and almost incurable
forms of leukorrhea are due to gonorrheal infection. For local
treatment in such cases the various forms of nitrate of silver are
the best agents, a weak solution giving just as good or better
results than a stronger one as it is less liable to injure the tis-
sues and thus aggravate the case. ( )ne-half grain to the ounce is
sufficiently strong in chronic forms of gonorrhea unless the dis-
ease has entered into the deeper glands and fallopian tubes,
when a stronger .solution is required. In acute cases curetting
with free divulsion and drainage is probably the best treatment,
but it must be persistent. Leukorrhea later in life may be due
to laceration of cervix, with disea.sed glands and follicles, to
gouty or rheumatic diathesis, or to any newgrowth which
causes destruction of tissue, or any fluid which irritates the
mucous membrane. If the discharge is bloody, or thin and
watery, cancer is suspected, [w.k.]
The Clinical Features and Postmortem Appearances
of a Case of Deciduoma Mallgnum.— J. Halliday Croom*
believes that consensus of opinion is in favor of deciduoma
malignum being opitheliomatous, the result of pregnancy, and
originating from the coverings of the villi. An iuteresting
feature connected with the origin of the growth is the great
frequency with which it follows myxoma of the chorion. In
the recordefl cases the average time of the occurrence of decid-
uoma malignum after labor has been 6.9 weeks, after abortion
11.4 weeks, and after myxoma 10 weeks. Croom detsuls a case
in which the rapid development of this tumor six years after a
recognized pregnancy rendered the diagnosis of deciduoma
malignum most unlikely, and it is difficult to see what relation
there could be between the last recognized pregnancy and the
development in the uterus of a tumor containing any of the
elements of a pregnancy. In the case here detailed the woman
was extremely emaciated. There was a tumor hard, firm and
consistent, extending to midway between the pubis and the
umbilicus, which from the history and the nature of the case
was taken to be a rapidly growing sarcoma. On the left labium
was a small tumor, about the size of a walnut, situated in the
region of the Bartholin's gland. This was diagnosed as an
ordinary retention cyst, and as it gave rise to considerable
pain, was opened previous to attempting an operation on the
tumor. Surprise was evinced when it was discovered that it
was not a Bartholinian cyst, but a small solid mass, which could
only be enucleated with difficulty. Upon microscopic section
' ScoulNh Mi'dlcHl and HurKlnil .(ournal, March, IVK.
- McdiiuL Kxumliicr and I"nu-lltli)ntr, .July. \Wi.
Till- -Mi-dical I*ii's.s a iid Clnriilar, .June 25, 11)0!!.
it presented appearances similar to those of deciduoma malig-
num. It was then decided to operate upon the uterine tumor
without delay. Unfortunately, the patient sank rapidly, lung
complication having set in, and death intervened. The tumor
proper was infiltrating and expanding the fundus of the uterus.
The weight of this mass was seven pounds seven ounces. The
lungs showed a secondary deposit, [f.c.h.]
Uterus Duplex Separatus.— Pauer ' reports the case of a
woman in her eighteenth year suffering from severe dysmen-
orrhea. The diagnosis was a normal uterus with an adnexal
tumor about the size of a man's fist. When the abdomen was
opened it was found that the apparently normal uterus had no
left appendage ; but there was a second or rudimentary uterus
on the left, to which the left tube was attached and connected
with which was the adnexal tumor. This second uterus was
connected with the vagina by a piece of connective tissue about
the size of a finger. The tumor was first removed and then the
rudimentary uterus, while the normal utei us and right adnexa
were left in situ. In the omentum was found |a smaller tumor
which was also removed, and proved on microscopic examina-
tion to have been connected with the spleen. The patient
rapidly recovered, and 10 days after the operation had normal
menses without pain. The extirpated tumor proved on exam-
ination to be a hematosalpinx and a hematometra, which last
had developed in the second oi- atresic uterus without portio or
OS uteri, [w.k.]
A New Operation for Retrodisplacement. — Baldy ''
considers that the Alexander operation is obsolete. The
intraabdominal shortening of the round ligaments is the ideal
operation for retrodisplacement of the uterus. In view of this
he describes his modification of the operation as performed by
Webster, of Chicago, which retains every advantage of the
latter's operation and does away with all its disadvantages. The
round ligament on each side of the uterus is picked up and a
ligature thrown about it close to the uterus, so placed as to
secure the artery. The round ligaments are then severed close
to the ligatures. This leaves the uterine ends of the ligaments
ligated and the other ends free and bleeding. The bleeding is
controlled by a fine ligature to each vessel or by the sutures
which fasten them in the next step of the operation. A pair
of forceps is now made to perforate the broad ligament from its
posterior aspect (at the point at which the round ligament is
cut on the posterior surface), and the cut end (the pelvic end)
of the round ligament is grasped in the bite of the forceps and
pulled through the hole in the broad ligament (made by the
forceps in perforating) until it protrudes on the posterior side
of the broad ligament. The opposite side is treated in a similar
manner. The cut ends of the round ligaments are now attached
by means of sutures to the cornuas of the uterus on the pos-
terior aspect of the uterus directly back of the original point of
attachment of the normally attached round ligament. The
point of attachment may be higher or lower than this, as the
surgeon may find necessary to accomplish the result. If nec-
essary as much of the round ligament is cut off, before suturing
it to the uterus, as is necessary to take up any slack and give
the proper amount of tension and support to the uterus.
The suture is a continuous one and may be either chromicized
gut or silk. [K.C.H.]
The Passage of Microorganisms Through the Placenta.
— Nei'low ' concludes as the result of a series of experiments
that while nonpathogenic bacteria do not pass from the mother
to the fetus, there is no evidence to show that the placenta pos-
sesses any special phagocytic powers. [o.s.D.]
Treatment of Chronic Endometritis.— Page < employs
the following treatment of the various forms of chronic endo-
metritis: The patient is placed in bed and given a daily hot
bath previous to operation ; after having cleaned the vagina and
dilated the cavity of the uterus, a cotton-tipped applicator
dipped in fuming nitric acid is introduced into its cavity, but
at the same time a continuous intrauterine irrigation is prac-
tised. The vagina is then dried and a tampon dipped in a S%
glycerin solution is placed in it. This cauterization is repeated
' Ccntralblatt fUr OynttkoloKie, .June 21, 1902.
'The Anierlciin Journal of Obstetrics, May, IIIOZ.
aCentralblatt f. Hact., J line 8, 1(KI2.
< Journal des Prutldens, Vol. xvl, No. 10, IW, p. 167.
278 Amicbican Mkdicikbj
THE WORLD'S LATEST LITERATURE
[AuotrsT IB, li)02
every eight days, and the cases treated by the author were
cured after five applications at most. This treatment Is not
painful, It presents no danger, and does not cause atresia of the
cervicouterine canal. The author adds to it laxatives, pro-
longed rest in bed, and very hot vaginal injections, [l.f.a.]
Cjsts of the Broad Ligament Complicated with Myx-
oma.— Two instances of this rare disease are reported by Horn-
ibrooli • occurring in his practice within a few mouths. Growths
of this character seldom form adhesions to the neighboring
parts, probably because of the peculiar nature of their epithe-
lium made up of cylindrical cells. Hornibrook's first case was
that of a woman, aged 42 years. Upon operating he found the
whole abdomen filled with myxomatous cysts, varying in size
from 1 inch to 3 inches in diameter. These were only slightly
adherent to the abdominal wall and viscera and were rapidly
peeled off without hemorrhage and made about 3 gallons in
amount. The main cyst, which was large and multilocular, was
then emptied. It was attached to tlie broad ligament by a ped-
icle at least 5 inches wide and uearly an inch thick. This was
ligated in eight sections and the peritoneum drawn over the
stump with Lembert sutures. Three pints of salt solution were
injected under the breasts before the operation, during which
the patient became pulseless frequently, but rallied when salt
solution of a temperature of 110° to 115° was poured into the
abdominal cavity. Strychnia also was used hypodermically.
A high enema of salt solution was given before removal from
the table. She rallied rapidly and made an uninterrupted
recovery in three weeks. The second case was first seen by
Hornibrook on July 20, and diagnosis of ovarian cystoma made.
When he saw her a month later he recognized the myxomatous
character of the growth but was not permitted to operate until
September, by which time the patient was greatly reduced iu
strength and tlie action of the kidaeys much impaired. The
abdomen was filled with myxoma, and the original cyst, which
grew from the broad ligament, was ruptured. Normal salt
solution was freely used and she appeared to bear the operation
well, but after the first eight hours began to fail, and died in 12
hours after the operation. Hornibrook believes that an earlier
operation might have saved her life. [w.K.]
The Treatment of Dysmenorrhea.— John CarapbelP di-
vides the cases of dysmenorrhea into the following classes:
Cases with no pelvic lesion— the anemic and the neurotic ; cases
with pelvic lesions— the uterus abnormal, appendages normal ;
the uterus normal, appendages diseased ; and the uterus dis-
placed and appendages damaged. The first class of patients do
not even need a pelvic examination nor local treatment, and
readily respond to a course of general hygienic treatment. For
the anemic and neurotic cases a course of iron and purgatives
between the periods. For a week before and for the week of
the period the iron should be stopped and the following given:
Potass, bromid, gr., x; tr. cimicifuga, m. xx; tr. belladonna,
m. x ; aq. chlorof., s ss., 3 times a day. When it fails i grain of
extractor cannabis indica 2 to 3 times a day during the period
will answer. Diseased organs demand removal. Removal of
the uterine appendages for pain, unless there is gross disease
necessitating their removal, is a mistake. The woman who has
painful ovaries will almost certainly have painful stumps. The
same applies to fixations. The most thorough breaking down
of adhesions and the most accurate attachment of the uterus, by
intra or extraperitoneal methods, will not enable one to prom-
ise improvement. If any of these operations are done for pain,
menstrual or otherwise, they should only be done when all else
has failed, and the fact that cure is very uncertain should be
very clearly stated. In spite of the advances of modern gyne-
cology, bad cases of dysmenorrhea remain very diiffcult to
remedy, and the fact must be admitted, [f.c.h.]
Dangerous Injury from a Peculiar Form of Intra-
uterine Pessary.- Keferstein » reports five cases of severe inj ury
from a form of intrauterine pessary known as " obturator,"
and condemns its use. Pritsch speaks of the use of the stem
pessary as a last refuge, and the writer thinks the condition of
a patient must be very peculiar that without other treatment
would justify the use of a remedy so full of danger. [w.K.]
iWesU-rn Medical Kcview, July 15, 1902.
» The Medlea Press and Circular, June 25, 1902.
'Centralblatt fUr Gynakologle, June 7 1902
H,
TREATMENT
Solomon Solis Cohen
0. Wood, Jr. L. F. Applbman
Influence of Electricity Upon Electricians.- Jellinek
(Journal des Praticiens, Vol. xvi. No. 16, 1902, p. 253) reports
the results of his investigation of the action of electricity upon
young healthy men who work In tlie presence of electric cur-
rents. In these men the arterial tension and the condition of
the arteries were normal. When a constant current of 50 to 100
volts was allowed to flow through one of these men the arterial
tension was always increa.sed. The lower the arterial tension
was before the passage of the current, the higher it became
during its passage. Tiie frequency of the pulse was rarely
increased. Interrupted currents produced a fall in arterial
pressure and an increase in the pulse-rate. These facts are the
more conclusive because these men were accustomed to electric
discharges, which produce very little effect on them. In
persons unaccustomed to electric influences the arterial tension
and the pulse undergo marked oscillations, [l.f.a.]
A Dressing to Prevent Eschars.— The Bulletin G(nAral
Therapeutique, Vol. cxlili. No. 2, 1902, page 72, recommends :
Gutta-percha l dram
Chloroform i ounce
Balsam of Peru 16 minims
To be applied to the affected area, twice daily, with a fine
brush, [l.f.a.]
Eserin in the Treatment of Corneal Affections.— R. A.
Katz, St. Petersburg {La Semaine Medicate, April 23, 1902)
finds that eserin exercises a favorable influence on keratitis
without abscess and particularly in peripheral infiltration of
the cornea. He employs a pomade containing .03 ctgr. of
eserin to each 6 or 8 grams of excipient. [c.s.d.]
A Practical Process for Increasing the Solubility of
Boric Acid.— Ed. Crouzel (Bulletin OSneral de Therapeutique,
October .30, 1901) gives the following procedure to increase the
solubility of boric acid : Ten parts of boric acid are dissolved
in 100 parts hot water ; one part of prepared chalk is then added
and the solution is filtered at once. After cooling it is allowed
to stand for 24 hours, when it is filtered again to eliminate the
greater part of the calcium borate which has been deposited on
the sides of the flask, in the form of arborescent crystals. By
this means solutions of boric acid may be obtained in strengths
varying from 1 to 15 parts to 100. [l.f.a.]
Chloroform in Cardiac Diseases.- Huchard (Journal des
Praticiens, Vol. xvi. No. 7, 1902, p. 97), after reviewing the use
of chloroform as an anesthetic in diseases of the heart and
aorta, draws the following conclusions : 1. Accidents attributed
to chloroform occur no more frequently, in the majority of
cases, during cardiac or aortic disease than in other diseases.
2. Cardiac and aortic affections are not counterindications to
chloroform anesthesia, provided that they are not iu the acute
stage, nor that the patient is very feeble, and that the chronic
cardiac affections have not reached the asystolic or dyspneic
periods, and, too, that there are no symptoms of pericardial
adhesions. 3. Chloroform must be administered in small pro-
gressive doses, and continued until there is nearly complete
suppression of the palpebral reflex. 4. Ordinarily, "chloro-
form well prepared, and especially well administered, does not
cause deatii." [l.f.a.]
Cliraatotherapy of Grave's Disease.- F. Parkes Weber
("System of Physiologic Therapeutics," Vol. iv) believes that
" for most cases and for all the acute and severest forms of
exophthalmic goiter, perfect rest and quiet are indispensable,
and removal to health resorts is not to be advised. In chronic
cases, however, residence in elevated regions sometimes gives
good results. S. E. Solly believes that any undue exertion is
more likely to have an unfavorable ert'ect on patients with
Grave's disease at high altitudes than at low ones: but if
fatigue is avoided, a residence extending over many months
and years not rarely exercises a curative influence. In mild
forms of Grave's disease and in allied vasomotor disturbances,
the soothing effect of treatment at simple thermal spas, such as
Schlangenbad, Healing Springs, Virginia, and similar resorts,
and the tonic effect of gaseous thermal muriated baths, as
August i«, 1902]
THE WORLD'S LATEST LITERATURE
(ASEBICAN MbDICINB 279
obtained at Nauheim and elsewhere, may be beneficial, and the
removal from the excitement and worries of home life is often
likely to aid the spa treatment. In some minor forms and in
chronic cases the careful use of hydrotherapeutic measures,
massage, Swedish gymnastics, and Schott's resistance exercises
may likewise be employed, according to individual indications.
The lesser symptoms of Grave's disease connected with various
temporary conditions of the sexual organs in women, require
generally no special treatment by climates or mineral waters."
The Employment of Lecithin.— Arifis (Le Mois Thfra-
peutique. Vol. xiii, Xo. 2, 1902, p. 21) reviews the history of the
employment of lecithin and its application in the treatment of
malnutrition in the aged. It gives good results in these cases
and in convalescence from prolonged disease. Examination of
the urine shows the following modifications in the organic
changes in the majority of cases : An increase of urea ; diminu-
tion of uric acid ; very marked increase of urinary acidity.
Contrary to tlie general opinion elimination of the phosphates
was also increased, at least in old people. The average daily
dose of lecithin by the mouth is 5 grains ; hypodermically it is
given in doses of from \ to !..'> grains every day or every other
day. [l.f.a.]
Balsam of Peru in the Treatment of Bronchitis. —
Liegeois {Journal des Praliciens, Vol. xvi. No. 9, 1902, p. 134)
believes that the expectorant value of balsam of Peru depends
less upon the cinnamic and benzoic acids, which it contains in
the proportion of from 8 to 10 parts to 100, than upon a volatile
oil, cinnamine, which it contains in the proportion of 50 parts
to 100. Its anticatarrhal virtue depends upon a resin which it
contains. An Italian practitioner employs the following com-
bination in the treatment of bronchitis with difficult expectora-
tion :
Tar I
Balsam of Peru { of each 2 grains
Powdered licorice 5 grains
Powdered iris 2 grains
For one capsule. One to four daily.
Huchard prescribes the following to patients suflfering from
tuberculosis with difficult expectoration :
Creosote 1
Iodoform „> „„„u i „!„
Eucalyptol f of each 1 gram
Balsam of Peru J
For one capsule. Four daily at meal time, [l.f.a.]
The Herzian Current In the Treatment of Hemorrhoids.
— R. Pisani refers (Annali di ElectriciVi Medica e Terapia
Fimca, April, 1902, No. 6) to the observations of Doumere and
other elect rotherapists on the use of electric currents of high
frequency and high tension in the treatment of hemorrhoids.
The splendid results obtained and the simplicity of this method
render it in many cases preferable to surgical intervention.
The Herzian current is innocuous and easily tolerated, as is
also the Te.sla current ; the duration of the application is about
eight minutes daily, [c.h.d.]
Hypnopyrin. — A new hypnotic, analgesic and antipyretic
drug is d<!scribed under this name in Journal des PraticieiiH, Vol.
xvi. No. 22, 1902, p. 'M. It is a chlorin derivative of quiuin ; it
occurs in tine crysUils, very bitter to the taste, soluble in about
eight times its wiMght of water, very solul)le in hoiling water
and alcoliol, insoluble in etlier and chloroform. Hypnopyrin
is given in capsules or pill form, in doses of not over iiO grains
a day. It is said to be of value in riieumatism and various
forms of neuralgia. [r..F.A.]
Anesthesia with Kthyl Bromid. — Hafft/er ( linl lelin OSni-
i-'tl lie ThfinpeuUqne, Vol. cxlii. No. 20, 1901, page 792) has em-
ployed ethyl bromid in over 200 patients requiringan anesthetic
for minor surgical operations. The purity of the drug should
be determined by pouring a small quantity on the hand, from
whidi it should evaporate quickly without leavingany residue;
if It is agitated with water and then filtered the filtrate should
be neutral, and should give no reaction with silver nitrate; the
a<ldition ofconcentrattKl sulfuric acid should not cause a brown
discoloration. Ilalfter gives the following conclusions: (1)
Kthyl l)roniid acts with great rapidity and, usually, without a
period of excitation ; it is harmless when employed in small
doses, and is rarely followed t)y disagreeable se<!ondary effects ;
(2) the best metluKl of administration is to pour the total quan-
tity to be employed under an impermeable mask which is
applied so as to cover the mouth and nose of the patient; (3) as
a rule, the operation may be begun in from 15 to 20 seconds after
the first inhalation, but the duration of the anesthesia will be
short, and is applicable only for short operations ; (4) there are
but few patients, principally alcoholics, who cannot be anes-
thetized by this means; (5) there are no contraindications to
the employment of ethyl bromid in small doses and for short
operations, [l.f.a.]
A New Liocal Anesthetic— Carl von Noorden' reports
upon two years' experience with para-amidobenzoicacidester, a
white powder, tasteless and odorless, soluble w:th difficulty in
cold water, somewhat more freely in warm water, and still
more freely in alcohol, ether, chloroform, fats and oils. It
forms ointments without undergoing decomposition. It is a
local anesthetic devoid of toxic properties. Given to rabbits
even in colossal doses the only noteworthy effect was a transient
methemoglobinemia. The name anesthesin has been proposed
for it. It may be given by the mouth in powder form, from 4
to7J grains two or three times daily, for hyperesthesia of the
stomach. In lozenges and the like it relieves cough and dysp-
hagia. As a laryngeal application, by injection of 10% emulsion
in water and gum tragacanth, or by direct insufflation of the
undiluted powder, it was found to possess all the anesthetic
qualities of orthoform without any irritation. Suppositories of
3 to 7i grains were useful to mitigate the pain of hemorrhoids.
Soluble bougies containing 5 grains each relieved vesical tenes-
mus. A 10% ointment, in wool fat, relieved pruritus, and
especially the pruritus vulvse of diabetes, [s.s.c]
The Bicycle in the Treatment of Dyspepsia.- Fiir-
bringer (Journal des P)-aticiens, Vol. xvi. No. 3, 1902, p. 41)
believes that the moderate use of the bicycle gives excellent
results in the treatment of subacute or chronic dyspepsia.
These patients are not true neurasthenics, Ijut nervous dyspep-
tics, fatigued by a sedentary lite, overeating and want of fresh
iiir. A ride of six or eight miles on the l)icycle will stimulate
their appetite and allow of their eating food which they
formerly could not digest; it will relieve the painful sensations
of pyrosis and cardiac distress. Fiirbringer considers this form
of exercise better than walking for the cure of these conditions.
[L.F.A.]
A Phototherapeutic Apparatus.— G. Baudouin {Bulletin
GinPral de ThfrapeiUique, Vol. cxliii, No. 20, 1902, page 773)
describes the phototherapeutic apparatus of Andre Broca and
Chatin, employing an arc of iron, without the necessity for
cooling. Ttie positive electrode is composed of a mixture of
iron and carbon ; the negative electrode resembles those used
for the production of light. In spite of tlie increased electric
current which may be employed with this apparatus, the skin
maybe held at a distance of four inches from the arc for any
length of time without causing pain, while it is impossible to
maintain the surface of the body at the same distance from an
ordinary arc of e<|ual power without cooling. A much stronger
current may therefore be used without a heat reducing appara-
tus. The actini(^ j)ower of this apparatus is very intense ; in 23
cases of lupus treated by this mean.s, the reactions have always
been marked. Treatment is continued from 15 to .'iO minutes at
each application, using a current of 15 or 20 amperes, the patient
being three or four inches from the apparatus, [l.k.a.]
PORMUIiAS, OBIGINAIi AND SELKCTED.
Mouth Wash. — The Denial Cosmos recommends as a mouth
wash :
Tincture of calendula Xi ounces
Carbolic acid 40 grains
Water, enough to make 8 ounces
[H.C.W.]
Neuralgia and Myalgia.- 7'Ae Practitioner suggests the
following as a local application :
Tincture of aconite 2 drams
Tincture of belladonna 2 drams
Tincture of opium 4 drams
Spirits of chloroform 1 ounce
Spirits of camphor, enough to make .... 4 ounces
Apply locally, [h.o.w.]
' Berlin kiln. Woch., .\prll 2«, 1902.
280 AMBKICAN MBOICIKa^
THE PUBLIC SERVICE
(A (.OUST 1«, 1002
THE PUBLIC SERVICE
Health Reports.— The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine- Hospital Service, during
the week ended August 9, 1902 :
Alabama :
Califorula :
Colorado :
District of Columbia;
Illinois :
Indiana :
Kentucky :
Maryland :
Massachusetts :
Missouri ;
Nebraska:
New Hampshire :
New Jersey :
New York :
North Carolina :
Ohio:
Pennsylvania :
Vermont :
Washington :
Wisconsin :
Austria :
Belgium:
Colombia :
Great Britain :
India :
Italy:
Mexico :
Russia :
Straits Settlements
Switzerland :
Costa Rica :
Mexico :
China :
India ;
Japan:
Java:
Straits Settlements
California :
Hawaiian Islands ;
India:
Smallpox— United States.
Mobile Aug. 2
IjOS Angeles July 19-28
Han Francisco July 20-/7
Denver July 19-26 »...
: Washington July 27-Aug.2....
Belleville July 27-Aug. 2 ...
Chlojigo July 27-Aug. 2 ...
Indianapolis July 27-Aug. 2 ...
Covington July 27-Aug. 2 ...
Baltimore July 27-Aug. 2 ...
Boston July 27-Aug. 2 ...
Cambridge....: July 27-Aug. 2 ...
Chelsea July 27-Aug. 2 ...
Everett July 27-Aug. 2 ...
Kail River July 27-Aug. 2 ...
Lowell July 27-Aug. 2 ...
Maiden July 27-.\ug. 2 ...
Medford July 27-.\ug. 2 ...
New Bedford July 27-Aug. 2 ...
Newton July 27-Aug. 2 ...
Somerviile July 27-Aug. 2...
St. Louis July 28-.\ug. 3...
Omaha July 27-Aug. 2 ...
Nashua July 27-.\ug. 2 ...
Hudson County,
Jersey City lncl....July 28-Aug. 8 ...
Newark July 27-Aug. 2 ...
Elmira July 27-Aug. 2 ...
New York July 27-Aug. 2 ...
Hancock Aug. 2
Newbern Aug. 2
Cincinnati July 26-Aug. 1 ...
Cleveland July 26-.\ug. I ...
Butler July 10-17
Eric July 27-Aug. 2 ...
Johnstown July 27-.\ug. 2 ..
McKeesport July 27-Aug. 2 ...
Burlington July k7-.\ug. 2 ...
Taeoma July 27-Aug. 2 ...
Milwaukee July 27-Aug. 2 ...
Smallpox— Foreign.
Prague July 5-19
Antwerp July 12-19
Cartagena July 7-13
Birmingham July 12-26
Liverpool July 12-26
London July 12-19
Bombay June 17-July 8 ...
Calcutta June 21-July 5 ...
Karachi June22-July 6 ...
Madras June 21-July 4 ...
Naples: July 5-12
Palermo July 5-12
City of Mexico July J3-27
Odessa luly 5-19
St. Petersburg July 5-12
Warsaw July 5-12
Singapore June 7-14
Geneva Iune-28-July 12...
Yellow Fevkr.
Port Limon July 17-21
Coatzacoalcos July 12-26 ..
Veracruz July 19-26
Cholera.
Amoy May 3I-June 14...
New Chwang To June 28
June 21-28 121
Tientsin June 7-21 581
Bombay June 17-Juiy 8 ...
Calcutta June 21-July 5 ...
Fukueka Ken July 3-5 49
Nagasaki Ken lulyS 2
.Saga Ken June 1-July 3 62
Shizuoka Ken i
Tokyo Fu June 28-July 3 ... 15
TokushimaKen July 4 1
Batavia June 1-19 39
Singapore June 7-14
Plagcb— United States.
San Francisco July 18 1
" '• July 21 1
PLaque— Insular.
Honolulu July 23
Plaque— Foreign.
Bombay June 17-July 8 ...
Calcutta June 21-Juiy 5 ...
Cases Deaths
1
1
7
2
3
1
5
7
1
3
6
1
2
1
1
1
2
1
1
2
14
3
1
9
4
1
4
1
1
7
41
2
2
6
2
1
3
2
3
3
6
16
48
2
13
4
5
12
2
8
19
1
I
15
17
3
1
4
120 cases
estimated
330
126
401
2
47
7
2
3;^
30
51
110
64
fv,,.^'^";"^®? j"."*^ Medical Cok-ps of the U. 8. Army for
the week ended August 9, 1902 :
^'^fl'f^fw'£^P^V° Robert E., assistant surgeon, leave granted June
26 is extended for one month.
LiND, Hospital Steward Oscar, Fort Du Pont, will be discharged from
the Army, by way of favor.
Eakthman, Major Vernon K., surgeon, granted leave for two months
with permission to visit tlie IJnlltd States.
Beal, First Lieutenant Howard W., assistant surgeon, having
reported his arrival at Han Francisco, Cal., will proceed to Fort
Columbus for duty.
Smith, Hospital Steward Charles L., Army General Hospital, Wash-
ington Barracks, will be relieved from duty at that hospital August
I, MUd will be sent to Chicago, 111., and report to the commanding
general, department of the Ijakes, for duty in the office of the
attending surgeon at department headquarters.
Calvert, First Lieutenant William J., assistant surgeon, resigna-
tion of his commission as an officer of the Army has been accepted,
to take effect August 9, 1902.
The following changes in the stations and duties of officers are ordered:
Major Edwin F. Gardner, surgeon, having reported his arrival at
San B'rancisco, Cal., will proceed to Fort Totten for duty, to relieve
Major W. Fitzhugh Carter, surgeon. Major Carter will proceed to
San Francisco, Cal., and report for transportation to the Philippine
Lsiands, where he will report for duty.
Drake, Major Charles M., surgeon, leave granted July 5, is extended
one month.
The following changes in the stations and duties of officers are ordered :
First Lieutenant John L. Shepurd, assistant surgeon, is relieved
from duty at Fort Logan and will proceed to Fort Apache for duty,
to relieve First Lieutenant George H. Richardson, assistant sur-
geon. Lieutenant Richard.son will proceed to Fort Logan for
duty.
De Witt, First Lieutenant Wallace, assistant surge<m, is relieved
from duly in the division of the Philippines, to take effect Septem-
ber SO, and will then proceed to San Francisco, Cal., and report
by telegraph to the Adjutant-General of the Army for further
orders.
Wythe, Contract Surgeon .Stephen, is granted leave for 14 days, to
takeeffect July 28.
Changes in the Medical Corps of the U. 8. Navy for
the week ended August 9, 1902 :
Baker, M, W., commissioned an assistant surgeon, from July 23, 1902
—August 2.
Changes in the Public Health and Marine-Hospital
Service for the week ended August 9, 1902 :
White, J. H., assLstant surgeon-general, directed to proceed to Phila-
delphia, Pa., to inspect the steamer Dagmar, and to Rhode Island
quarantine to Inspect the station— August 1, 1902.
Kalloch, p. C, surgeon, granted leave of absence for two days from
-Vugust 4— August 4, 1902.
Brooks, H. D., surgeon, to assume temporary command of the Port-
land, Maine, quarantine during absence of Surgeon P C. Kalloch-
.\ugust 4, 1902.
Stimson. a. M., assistant surgeon, to report to medical officer in com-
mand at New York, N. Y., for duty and assignment to quarters —
August 2, 1902.
RucKER, W. C , assistant surgeon, to report to medical officer in com-
mand at San Francisco, Cai., for duty and assignment to quarters
-August 2, 1902.
Ward, W. K., assistant surgeon, to report to medical officer in com-
mand at Boston, Mass., for duty and assignment to quarters-
August 2, 1902.
Creel, R. H., assistant surgeon, to report to medical officer in com-
mand Immigration Depot, New \ork, N. Y., for duty— August 2,
1902.
Kbersole, R. E., assistant surgeon, to report to medical officer incom-
mand at Gulf quarantine lor duly and assignment to quarters—
Augu.st 2, 1902.
Brown, B. J., Jr., acting assistant surgeon, granted leave of absence for
14 days from August 1— .August 1, 1902.
Harris, B. Y., acting assistant surgeon, department letter granting
Actliig Assistant Surgeon Harris leave of absence for 30 days from
July 15, amended so as to read 20 days from August 5 — August 2,
1902.
Hunter, S. B., acting assistant surgeon, granted leave of absence for
7 days Irom August 7 —August 6, 1902.
Safford, M. V , acting assistant surgeon, relieved from duty at the
Immigration Depot, New York, jT Y., and directed to proceed to
Boston, Mass., and report to medical officer in command for duty
in connection with the Inspection of immigrants — .July 31, 1902.
Stearns, H. H., acting assistant surgeon, granted leave of absence for
21 days from August 10— August 2, 1902.
Macdowell, W. F., pharmacist and disbursing agent, granted leave
of absence for 30 days from August 2— July 31, 1902.
RoEHRiG, A. M., pharmacist and chemist, granted leave of absence for
16 days from August 16— August 2, 1902.
Carlton, C. G., senior pharmacist, granted one day's e.xtenslon of
leave of absence under paragraph 201 of the regulations.
Board Convened.
Board convened to meet at Wasliington, D C, for the purpose of
preparing regulations relating to the duties of medical officers in
connection with the Immigration Service. Detail for the Board—
.\ssistant Surgeon-General L. L. Williams and Assistant Surgeon
V. O. Heiser.
Appointments.
ARTHUR Marstob Stimson, Of Ncw York ; William Colby Ruckeh,
of Wisconsin; William Krafft Ward, of the District of Colum-
bia ; Richard Henry creel, of Missouri ; and Ruel Elberton
Ebersole, of Virginia, commissioned as assistant surgeons
(recess) In the Public Health and Marine-Hospital Service— July
26, 1902.
American Medicine
GEORGE M. GOULD, Editor
G. C. C. HOWARD, Maiuiging Editor
CHARLES S. DOLLEY
MARTIN B. TINKER, Aisiatant Editors
Cltnical Medicine
David Biksman
A. O. J. Kklly
h. h. cushino
Helen Murphy
General Surgery
Martix B. Tinker
A. B. Craig
Charles A. Orr
Orthopedic Surgery
H. Augustus Wilson
COLLABORATORS
Obstetrici and Gynecology
Wilmer Krusen
Frank C. Hammond
Nervous and Mental Diseases
J. K. Mitchell
F. Savary Pearce
Treatment
Solomon Solis Cohen
H. C. Wood, Jr.
L. F. Appleman
Dermatology
M. B. Hartzbll
Laryngology, Site.
D. Bradkn Kyle
Ophthalmology
Walter L. Pyle
Pathology
R. M. Pearce
PUBLIHHKD WkKKLT AT 1321 WALHITr StRSKT, PhILADSLPHIA, BY TBS AmISICAN'MidICINI PtTBLURtMa COMPAHT
Vol. IV, No. 8.
AUGUST 23, 1902.
$4.00 Yearly.
Comparative statistics of murder should teach
us some lessons of national humility, because, blink it
as we may, crime, and especially that of homicide, is a
pretty accurate measure of the attainment of civiliza-
tion. There are about 10,000 murders a year in the
United States. Mr. Robert Anderson, of London, has
lately astonished his readers by stating that in the
6,000,000 of inhabitants of London there are annually on
the average only about eighteen murders. In a sermon
on crime a clergyman of one our smaller American cities
recently stated that in his city (of about 200,000 inhabi-
tants) there were in the last five years an average of
nearly thirty homicides a year. Supposing, therefore,
that these people would not become far more criminal
when massed together by millions, it follows that if the
clergyman's city were as large as London there would
be nearly 900 murders a year in it instead of eighteen.
But worse is yet to come : Out of the 14.5 murders in five
years there were only 23 convictions, and the very worst
is the fact that not one of these convicted murderers suf-
fered the tleath penalty ! Upon one side, surely, the retort
no longer holds that the doctors put their bad work
beneath the ground and the lawyers hang it up above it.
"So much hemp grown, so little used," may be perti-
nently quoted.
Deaths from Casualties. — In his report as Medical
Kxaminer-ln-Chief of the Royal Arcanum, Dr. Hans-
com tabulates the mortality of his company from cas-
ualties from 1877 to 1902. The total reaches the surpris-
ing number 1,613. The extent to which the railroad
"uters into our life is indicated by 388 deaths due to rail-
way accidents, 23 of which were, however, from trolley-
car accidents. The exceptional danger of the railway
engineer's life is illustrated by 77 deaths in this calling;
there were 33 conductors killed, 23 brakemen, and 15
ttremen. Of the 1,613 deaths, 47 were of machine
workers, 48 in building trades, 46 conne<;te*l with sea-
faring, 21 of miners, and 2.5 of farmers. liesldes 161
falls from buildings, ladders, etc., there were 28 deaths
due to falls from carriages, 15 from falls from trolley-
cars ; it is surprising U) find as many as 29 deaths from
" falling down stairs." The bicycle is charged with 14
deaths. There were 212 cases of accidental drowning,
• )ie of which occurred in a bath-tub, and 106 cjuses of
iccidental shooting, —again teaching a never-learned les-
son as to over fondness and carelessness in the use of
firearms. Plain, old-fashioned sin serves its function in
78 homicides. One is surprised to find 62 deaths from
sunstrokes, all in States north of Virginia and Missouri.
Fifty deaths came from the " pursuit of pleasure,"
yachting, boating, bathing, etc., as against 460 conse-
quent upon regular avocations. Perhaps the strangest
item is that from overdoses of medicine, 70 deaths from
this cause being due to morphin, 10 to chloral, 7 to car-
bolic acid, 5 to strychnin, 4 each to chloroform and
laudanum, etc., — In all 126 cases, — none suicidal. The
irony of fate Is exemplified in the record of 7 cases in
druggists and 9 In physicians, precisely those in whom
one would expect the most care. Does the fact illustrate
a variant of the old saw as to familiarity breeding con-
tempt? No other profession or calling suffered so
severely from a misuse of drugs.
The way to reciprocity is to begin recipro-
cating, and having begun to keep on ; that seems a
practical lesson to be drawn from the fact that a large
number of State boards empowered to do so are not in
fact reciprocating — i. e., recognizing the certificates of
other boards. And yet the boards are composed of
medical men, and their colleagues have been filling
medical .journals and society meetings with bitter and
jastifled complaints as to the hardship of nonreciproeity.
Why not ask, oh, ye righteously indignant, your own
boards and officers and confreres to do that which they
are emj)Owered to do ? There is before us a summary of
the laws and regulations concerning the practice of medi-
cine in the United States, extracted from the rejjort of
the Illinois State Board of Health of March 1, 1902 (Dr.
James A. Egan, Springfield, secretary), which says that
the following Stiites are " empowered to recognize cer-
tificates of other boards : "
California,
New .Jor.sey,
Delaware,
New York,
Illinois,
Pennsylvania,
Indiana,
Puerto Uico,
District of Columbia, Kansas,
Ohio, Texas,
Maine,
Virginia,
Michigan,
Washinjfton,
New Hampshire,
Wisconsin.
If reciprocity is desirable, and If empowered to recog-
nize without reexamination, why do these boards not at
once and simply begin rwlprocity?
282 AjniBICAN Mbdioinb
EDITORIAL COMMENT
[AUOUST 25, 1902
Illinois the Leader in Practical Reciprocity. —
The Illinois State Board of Healtii in July, 1899,
adopted and on October 25, 1901, amended a resolution
so that at present
"Applicants for a State certificate to practise medicine and
surgery in the State of Illinois, who have been examined and
licensed by other State Examining Boards maintaining stand-
ards not lower than those provided for in the act to regulate the
practice of medicine in the State of Illinois, in force July 1,
1899, may be granted certificates without further examination,
on payment of the fees required by the act, providing that the
applicant, who must be a graduate of a medical college in good
standing with this board, shall present with his license a state-
ment signed by the president or secretary of the State Examin-
ing Board under seal of the board, showing that the require-
ments of said examining board at the time of his examination
were equal to those exacted by this board under the present
law, and providing further that the said State Examining Board
will grant licenses without examination to applicants holding
certificates issued by the Illinois State Board of Health under
the act now in force.'"
If, therefore, we do not err, the State Board of Health
of Illinois is the only licensing and examining board in
the United States which recognizes licenses issued by
other boards without the express sanction of law. There
is nothing in the law regulating the practice of medicine
and surgery in the State, in force July 1, 1899, which by
implication even empowers the board to accept a license
issued by another board in lieu of an examination. Yet
the board over three years ago adopted the resolution
quoted and since that time has enforced it. The board
now stands ready, as it has in the past, to issue a certifi-
cate without examination to any person a graduate of a
recognized medical college who has passed an examina-
tion before any State Board of Health or of Medical
Examination and Registration in the United States
which has requirements practically equivalent to those
demanded by this board, provided, of course, that the
board in question will recognize certificates issued after
examination by this board.'
Reciprocity in Michigan — On June 11, 1902, the
Michigan State Board of Registration in Medicine
adopted the following qualifications as the basis for the
reciprocal exchange of certificates :
Qualification No. i.— That a license or certificate of regis-
tration of at least one year's date, based upon presentation of a
satisfactory medical diploma of graduation, and an examina-
tion before a State Medical Examining Board in specified
branches of medicine and surgery, shall be accepted at the dis-
cretion of this board in lieu of an examination and as a basis
upon which a certificate of registration may be issued by the
secretary with the endorsement of the president and chairman
of the Registration Committee of this board.
Qualification No. ^.— That a license or certificate of qualifi-
cation issued by a State Board of Registration or Medical
1 Under the provisions of the act to regulate the practice of medi-
cine In the State of Illinois In force July 1, 1899, an applicant for a cer-
tlflcat« to practise medicine and surgery In the Stat« must present
evidence of being a graduate of a medical college in good standing as
may be determined by the board, and must pass an examination in
those general subjects and topics, a knowledge of which Is commonly
and generally required of candidates for the degree of doctor of medi-
cine lay reputable medical colleges in the United States. JSo medical
colleges will be considered in good standing after January 1, 1900, which
do not require of all graduates receiving diplomas after that date as a
condition of graduation an attendance upon four full courses of lec-
tures In four separate years.
2 The requirements of this board demand that as condition for
examination graduates after 1899 must show evidence of adequate pre-
liminary education and must present a diploma from a medical col-
lege which requires as a condition of graduation an attendance on four
full courses of lectures in four separate years.
Examiners of at least one year's date, based upon presentation
of a satisfactory medical diploma, and upon the recommenda-
tion of a State Board of Registration or Medical Examiners as
to the reputability of the applicant, shall be accepted at the dis-
cretion of this board in lieu of an examination and as a basis
upon which a certificate of registration may be issued by the
secretary with the endorsement of the president and chairman
of the Registration Committee of this board.
Resolved, That the provisions of qualification No. 1 as above
carried shall apply only to those applicants for a Michigan
certificate of registration who have obtained their medical
diplomas of graduation and State licenses subsequent to July 1,
A. D. 1902, and that the provisions of qualification No. 2 as
above carried shall apply only to those applicants who have
obtained their medical diplomas and State licenses previous to
July 1, A. D. 1902.
The "satisfactory medical diploma" is ba.sed upon a
minimum standard of preliminary medical education in
the fundamental knowledge of English, history, mathe-
matics and the natural sciences, and a "minimum stand-
ard of medical examination," as follows :
LECTURES AN
.30 hours in Electro Therapeu-
tics.
160 hours in Physiology.
100 hours in Pathology.
80 hours in Histology.
200 hours in Practice of Medi-
cine.
100 hours in Obstetrics.
60 hours in Bacteriology.
15 hours in Medical Jurispru-
dence.
D TEACH INO.
160 hours in Anatomy.
160 hours in Chemistry and Tox-
icology.
130 hours in Therapeutics.
30 hours in Hygiene.
200 hours in Surgery.
30 hours in Gynecology.
48 hours in Diseases of the Eye
and Ear.
100 hours in Pharmacology.
LABORATORY WORK AND DEMONSTRATIONS.
240 hours in Anatomy. 180 hours in Chemistry and Tox-
120 hours in Pathology. icology.
100 hours in Histology. 200 hours in Surgery.
120 hours in Bacteriology. 120 hours in Practice.
30 hours in Obstetrics. 32 hours in Dermatology.
60 hours in Eye and Ear. 120 hours in Gynecology.
180 hours in Physiology.
The medical course to cover a four years' course of
not less than six months in each year, no two courses to
be taken in one year, and the beginning of the fourth
or final six months of such course shall be dated from
October preceding the year of the final examinations for
the degree of M.D.
Ag'ain the Plague in California Press reports,
both lay and medical, indicate increase rather than
abatement of the rottenness which for the past two years
has characterized political jugglery of the plague situa-
tion in California. The Occidental Medical Tinted for
August records the occurrence in San Francisco of six
cases of plague within as many weeks and reports the
autopsies of the last four cases, three of which were of
the bubonic and one of the pneumonic variety. Yet the
plague has never existed, officially, in California reports.
That the San Francisco Board of Health has been ren-
dered practically powerless by the efforts of newspapers,
the State Board of Health, and an unscrupulous Governor
and Mayor to conceal the existence of the plague, is
common knowledge. But the .situation is truly deplor-
able when it inspires the Times to state editorially that
"the Public Health and Marine-Hospital Service, under
the merciless dictation of politics and under the selfish
AUGUST 23, 19021
EDITORIAL COMMENT
American Medicine 283
sway of commercial interests and the public press, by
yielding to efforts to suppress the facts and by being
forced to follow the injunctions of Gtage's newspaper
commission as to the method and manner of disinfection,
has virtually admitted its failure to cope with the situa-
tion, or at least its inability to overcome the unscrupu-
lous policy imposed by California's politicians. The
Surgeon-General of this service stands today totally
unable to do anything directly under the law for the
relief of so lamentable and unpleasant a predicament."
If these things be true, the highest power of the govern-
ment should be invoked to aid in wiping out a disease
which, unless handled in the most radical manner, is a
menace not only to California but to every State in the
Union.
Union of Medical Societies in Detroit. — On July
25 a joint meeting of the Wayne County (Michigan)
Medical Society and the Detroit Medical Society was
held at Detroit to consider the advisability of uniting
the organizations to form one society— the Wayne
County branch of the Michigan State Medical Associa-
tion. The meeting was addressed by Dr. A. E. Bulson,
president of the Michigan State Association, and Dr. P.
M. Foshay, of Cleveland, as a member of the Committee
on Organization of the American Medical Association.
The sentiment of the meeting, which was remarkably
large and enthusiastic, was strongly for a union of in-
terests, showing the good results of the effective mis-
sionary work that had already been done by Dr. Leartus
■Conner and others. After some discussion it was agreed
by a unanimous vote to enlarge the Wayne County
Medical Society so as to include the entire membership
of the Detroit Medical Society, which will thereujjon
disband. The prof€«sion of Detroit should be heartily
congratulated upon the fine spirit displayed in thus by
unanimous action in a very large meeting demonstrat-
ing its willingness to lay aside old and cherished asso-
ciations for the sake of taking action that gives every
promise of being for the benefit of the whole profession
of the city. This action in Detroit and the previous
similar one in Cleveland are very significant to the
student of medical sociology. It is evidence that the
profession of the middle west is keenly alive to the
tendencies of the time, and that professional esprit de
corpn has there reached high development. In this
connection also is the noteworthy fact that the members
of the Committee on Orgimization of the American
Medical Association, as also the president of the Associa-
tion for the year when the initial step toward effective
organization was taken, are grouped in the typically
active portion of the central west. With the impetus
thus given to the unification movement by the action
taken in these two cities of the (Jreat Lakes district, it is
not unreasonable to expect further similar good news
from other parts of the country.
The Medical Seliool of the Future an Kndowcd
Institution. — Before making his million-dollar gift to
the Harvard Medical School Mr. Rockefeller had the
condition of the school and its hospital facilitits thor-
oughly investigated by an expert. The following is
taken from an extract of the report which was handed
him giving reasons why a great medical plant might
weU be at Harvard University (Harvard GraduaUa''
Magazine, 1902, Vol. x, p. 521): "Medical teaching in
the future must be carried on in large establishments.
So long as the old method obtained of teaching by lec-
tures with only a very little laboratory work it was pos-
sible to establish a medical school almost anywhere and
on an independent basis, as the medical schools in the
earlier days were money-making cxincerns. This, how-
ever, was a bad thing for the country, as the schools were
able to give degrees and resulted in turning out a horde
of wretchedly educated practitioners. Improved methods
of teaching will tend to do away with this abuse, as small
schools can no longer furnish the instruction which mod-
ern methods require. The great medical schools of today
must be connected with large universities. They are no
longer self-supporting, as the increased cost of the train-
ing under the new methods largely exceed any possible
revenue from students. It is necessary, therefore, that
they should be heavily endowed and such endowments
cannot be secured except for schools which are under the
conservative control of larger universities." A further
reason for university connection is that it is impossible
to get men of first-class ability and reputation to connect
themselves with schools which do not have university
association. Other reasons given were the ready access
of abundant hospital material and the large completely
equipped laboratories for pathologic research which
were at the disposal of large universities.
Public Sentiment and the Progress of Science.
—Another claim which Mr. Rockefeller's expert made
in favor of Boston as the site of a great medical school
was the general {Kjint of view prevailing there. It was
claimed that in certain cities the dominant idea of the
students graduated had been to establish a large practice
as early as possible, while in Boston there had been
a markeil desire for scientific work in recent years which
had taken the precedence of the desire to iriake money.
As a result there is a large proportion of well- trained
scientific observers, enthusiastic men who are desirous
and able to pursue scientific investigations and who have
been trained as investigators and teaxihers and not as
practitioners. These investigators must be discovered.
They cannot be made. It must not be supposed, how-
ever, that the Harvard Medical School is mainly devoted
to the training of investigators as distinguished from
practitioners. About 98 fc of the gnuluates become
practitioners and only from \fc to 2^ are capable of
becoming original investigators. The best of these are
taken on the teaching staff, or are called to similar posi-
tions in other schools. In this way the best ideas are
spread over the country, and one teacher thus trained
may in the end do more good for the community by
increasing knowledge and the power to use it in the
students under him than a thousand poorly trained
practitioners.
As to the question of training of investigators as a
class entirely distinct from practitioners, there can be no
doubt about its importance. The work of a single Vir-
chow or Pfisteur is of more importance to the world in
284 AMERICAS MEDICINK
EDITORIAL ECHOES
(AUOCTST23, 1902
preventing and curing disease than the combined efforts
of many hundreds of ordinary practitioners, and pro-
vision must be made for maintaining the supply of such
men. Every practitioner of medicine should have
something of the spirit of the investigator ; the desire
to learn everything possible about every case which
comes under his care, to exhaust every means at his
disposal for determining the patient's condition and
devising the best means of treating him. It has been
abundantly proved that men trained under investiga-
tors and more or less inspired with their ideals and
familiar with their methods have proved most successful
practitioners.
Boston is beginning to reap the reward of the work
of those who have labored there to establish and main-
tain high scientific and ethical standards. The hun-
dreds of students who flock to Germany from all parts
of the world for advanced study show the value of the
highest educational institutions to a country, bringing
not only fame but wealth to the cities and States in
which they are located.
" The Natural History of Disease as the Basis of
Therapeutics " is the subject of the excellent address in
medicine by Sir Thomas Barlow, advance proofs of which
have been kindly sent to us by the editor of the Journal
of the British Medical Assonation. By the title (unfor-
tunate, we think, because the term natwal hiMory in
biology first became ambiguous, and is now quite dis-
used) the author of the address means the help derived
from pathology (including bacteriology) in our treatment
of disease. It is admitted that "the basis of our prac-
tice is empiricism, as is also the basis of our practical
life," but recent advances show at last a degree of suc-
cess accomplished and far more promised from the
scientific method. The results of this scientific method
are instanced first and emphatically in diphtheria, the
mortality statistics showing a reduction by the use of the
antitoxin of from one-third to one-half. Tetanus and
rabies are also cited, tuberculosis and other diseases, and
smallpox, especially, as showing a similar progress. Of
plague, cholera, and typhoid nothing is said, because the
"inoculation methods are still sub Judioe/^ We are
surprised that while a goodly amount of space is devoted
to malaria, in which, as well, no inoculation methods
have been devised, and no remedial advance made as a
consequence of the discovery of the role of the mosquito,
there is not a word as to the demonstrated role of the
mosquito in cholera infection, and of the splendid results
American investigators and physicians have brought
about in Cuba and elsewhere. We think this scarcely
generous or just. All will agree with the lecturer
in his earnest plea to " maintain, develop and de-
fend experimental research in alliance with clinical
work."
" Our countrymen are wakening from their complacency,
and beginning to realize that iu our great industries it is impera-
tive, if we would keep our place, that well-directed scientific
research should be liberally and steadily maintained. And
shall it be said that in the care for the life and health of the
community, the noblest and most precious of all industries, we
are to be left crippled and poverty-stricken by the .absence of
suitable equipment? "
Summer Infantile Mortality. —Statistics of the
New York Health Department recently published in the
Times indicate the necessity for a careful study of the
reasons for holding what are at present generally
accepted views regarding the relation tetween tempera-
ture and infant mortality. That excessively hot weather
produces a corresponding rise in the deathrate is well
known. That moderate temperatures, other things
being equal, mean a comparatively low deathrate is also
a popular and professional belief. This is not supported
by the statistics in question, which compare the hot
weather and deathrate of last summer with the cool
weather and deathrate of the present season. The dif-
ference between the two is partly shown by the fact that
during last summer there were in New York City 1,267
deaths from thermic fever and heat exhaustion, while
the number thus far this year is but 31. However, the
total number of deaths for the quarter ended June 30,
1902, exceeded those for the corresponding period of 1901
by 558, this increase being almost entirely of children
under 5. The greater number of these deaths was due
to diarrhea, there being 254 more deaths from this cause
in children under 2. This increased infant mortality
persisted until July 19, since which time the rate is
slightly in favor of 1902, an improvement which may
safely be attributed to the services of the summer corps
of physicians under the direction of the Health Depart-
ment. To account for the coincidence of low tempera-
ture and high infant mortality, there were prepared
charts plotting the temperature, humidity and deaths
for each day. These bear to each other no relation war-^
ranting a conclusion. The health authorities are quoted
as attributing the increased mortality of infants to the
use of improper food, but there is no evidence that this
has been of an inferior grade during the present year.
On the contrary, cool weather predicates better preserved
food. The fact remains, practically unexplained, that
an unusually cool summer has witnessed an unusually
high infant mortality from diarrhea.
EDITORIAL ECHOES
Franklin District Medical Society of Green-
field, Mass. — In a circular letter to the members of
this society the secretary says : " The work which such
a society as ours might accomplish is unlimited, and
lack of space prohibits the mention of even the barest
outline and but just one thought will be enlarged upon.
As a profession we need to be better united and thus fall
into line and become a part of the twentieth century
progress. It needs no prophetic vision to see that the
exemplification of the laws of the conservation of energy
and the survival of the fittest are to be the characteristics
of our century. Much progress has already been made in
uniting the medical profession, but much more must be
done before we can successfully cope with the great
problems of public health and preventive medicine.
Let us this year promote professional unity in every
possible way — as, for example, the supporting of profes-
sionally owned medical journals, regular attendance upon
the meetings of local. State and National Associations,
and last, but not least, appreciate more fully the desira-
bility of having a greater sympathy with our confrere,
even though he be a competitor."
August 23, 1902]
AMERICAN NEWS AND NOTES
(AMERICAN Medicine 286
AMERICAN NEWS AND NOTES.
GENEBAIj.
Diagnosis by Exclusion.— " There is nothinK the matter
with you," persisted the Eddyite, "absolutely nothing. Can I
not convince you?" "Let me ask you a question? " replied
the sick man. "A thousand, if you like." ^' Well, suppose a
man has nothing the matter with him, and he dies of it, what
didn't he have the matter with him ? "—[Philadelphia Press.]
Cholera.— Surgeon-General Porwood considers the cholera
situation in the Philippines well under control and expects a
general diminution in the number of cases from now on. A
chief factor in this is the rainy season, which will continue
until November. Another ground for this belief is General
Chaffee's recommendation of a material reduction in the num-
ber of medical officers assigned to duty in the archipelago.
Osteopaths Subject to Medical Laws.— The Supreme
Court of Illinois has rendered a decision similar to that of the
Alabama Supreme Court in regard to the legal status of osteo-
paths. A magnetic healer in Illinois, when prosecuted for the
illegal practice of medicine, won his case in both the circuit
and appellate courts, on the ground that he did not use medi-
cine or surgery. The Supreme Court reversed the decision.
Guam Leper Colony.— Commander Schroeder, Governor
of the Island of Guam, reported to the Navy Department that
the leper colony would be ready for occupancy July 1. Inves-
tigation has developed the fact that many victims of the disease
have been secreted by their friends in various parts of the
island, and it is Commander Schroeder's plan to gather them
together in one place in order to prevent spread of the disease.
Yellow Fever. — During the month of July there were in
Vera Cruz, Mex., 62 cases of yellow fever and 38 deaths, for the
week ending August 2 the record being 14 eases and 9 deaths.
In Progreso and Merida, Yucatan, there has been respectively
7 cases, 2 deaths, and 3 cases, no deaths. The disease is also
appearing in adjacent country districts where no record is kept.
The case removed from an Italian steamship at Tampico in
July is now convalescent, and there have been no develop-
ments from it.
Supposed Second Attack of Yellow Fever.— Acting
Assistant Surgeon Hodgson reports from Vera Cruz a case of
what was apparently a second attack of yellow fever. The
patient was an American who on June 4 had unmistakable
symptoms of the disease, which ran its course, the patient being
discharged on the twelfth day. On July 10 the man again ex-
hilaited symptoms of yellow fever, and the members of the
U.S. Commission at work there were called in consultation.
They examined the patient's blood and made the diagnosis of
yellow fever, this being confirmed by subsequent symptoms
and treatment. The man was discharged convalescent on
July 19.
Sanitary Affairs In Havana.— The sanitary report of
Havana for the month of June shows a condition at that port
which is still creditable to the efficacy of the new health regula-
tions established by the United States. The deaths averaged
one a day less than during May, though tliere was an increase
of deaths among young children and from typhoid fever. This
is considered largely due to the objectionable methods of Chi-
nese gardeners in the raising of vegetables, most of which are
eaten raw. None of the old diseases that caused so many deaths
in former times have recurred. The two cases of yellow fever
reported were brought from another jjrovince, but isolation
prevented spread of the disease. The city has now had nine
consecutive months of immunity from yellow fever and not a
single case of smallpox was reported from any part of the island
in June.
EASTERN STATES.
Institutional Bequests. — The will of the late John B.
Glover, of Boston, provides for charitable institutions a total of
J.3.37,0(X). Four of the medical institutions which are given ?5,000
each also divide among them a trust fund of J100,000.
Carneifle Institute to Control Marine Laboratory. — It
is reported that tlie property of the Marine Biologic Laboratory
at Wood's Holl, Mass., has been turned over to the Carnegie
Institute on tiie assurance that the work will be put on a per-
manent basis. This is considered to be the first 8tei> in the
foundation of a marine biologic laboratory that will surpass all
other institutions of the kind.
NEW YORK.
Home for Indigent ConTaleBcent«. — To further his
plan to endow homes for indigent convalescents, John M.
Burke recently conveyed ti) the Winifred Masterson Relief
Foundation a plot of land in Orange, N. J.
Increase In Insanity. — The present summer has shown a
decided increase in the number of patients admitted to the
insane pavilion in I'.ellevuo Hospital. The Times states that
the daily average has been eight as compared with a former
average of three. The proportion of women hasjbeen greater
this summer than ever before. In previous years the numbers
of men and women were about equal ; this year about) 75% are
women.
Modification of the Law Concerning Rabid Dogs.— Sec-
tion No. 95 of the Sanitary Code, which provides that a dog
which has bitten a person or shown signs of hydrophobia shall
be killed, is to be modified. The new measure empowers the
Board of Health to keep such dogs under observation in the
laboratory at the foot of^ East Sixteenth street for 10 days. If
at the end of that time they show any signs of hydrophobia
they are to be killed, otherwise they are to be returned to their
owners. It is declared unlawful for any person to take such
animals from the jurisdiction of the Board of Health.
Tetanus 'Antitoxin.- The Department of Health of New
York State now furnishes tetanus antitoxin prepared in its
laboratory to inmates of State and other charitable institutions
and to persons in the State unable to purchase or obtain the
remedy. Physicians obtaining antitoxin for use as above noted
must agree to report the results from its use. The June bulle-
tin of the department gives many points in the treatment of
tetanus by antitiixin and by other methods. While the results
obtained from the use of antitoxin have not been as favorable
as at first expected, a study of reported cases and statistical
reviews Indicates that the deathrate has been lower in the cases
when it has been used. The remedy should be used in every
case where it can possibly be obtained, and it is the intention of
the State department to make such use possible.
Coroners' Physicians. — A test case now pending in the
Supreme Court will decide the legality of the positions held by
coroners' physicians. The question arose in connection with
the vacancy caused by the resignation of Dr. Hamilton
Williams and the apnointment of Dr. Otto E. Schnlze, who
stands at the head of the eligible list of the Civil Service Com-
mission, or of Dr. S. E. Whitman, who had lost the position he
previously held in the borough of Richmond when the number
of coroners were reduced. Counsel for Dr. Whitman held that
his client was eligible to the position through the mandatory
provision in the charter, which provides that persons put out
of civil service office by abolition of positions should be
appointed to the first vacancies. In opposition to this it was
stated that the doctor could have no standing in the service as
his term of office was the same as that of the coroner who
appointed him, and that the latter was now out of office, and
further that the law gave the right to coroners to appoint their
own physicians. Decision was reserved.
PHILADELPHLA, PENNSYLVANIA. ETC.
New Hospital for Coatesville.— Ground has been broken
for a new hospital at Coatesville, the cost of which is to be about
?60,000.
White Haven Sanatorium. — Although in operation for
only a year the sanatorium is overwhelmed with requests for
admission. There is now a waiting list of 100, which is con-
stantly lioing augmented. President Flick declares that at a
cost of 80,000,000 tuberculosis could be stamped out of Pennsyl-
vania in 15 years.
Hospital Quarantined.— A case of smallpox was recently
discovered in one of the wards of the Mountain Side Hospital,
at Montclair, N. .1. Great consternation was evidenced among
the patients and nurses, and many were promptly vaccinated.
The patient was removed at once to the isolation hospital, and
the hospital placed under quarantine for two weeks.
Inebriates Barred at Philadelphia Hospital.— A new
regulation at the Philadelphia Hospital is designed to j)revent
habitual drunkards from making their homes in that institu-
tion. Laxity in the regulations regarding the admission of
intoxicated persons has been largely responsible for increasing
the population of the hospit;il from 3,000 a few years ago to more
than 4,000 at present. In the future only cases of exceptional
drunkenness will be admitted, and they will be forced to
work.
Sanitary Ordinances.— A measure recently adopted by the
Orange Board of Health provides that all barbers' implements
must be thoroughly washed in boiling water before use, and
that the razors must be washed in an antiseptic each time they
are used. A second ordinance requires saloon and restaurant
keepers to have all glasses and drinking vessels washed in water
used solely for this purpose lieforeadrmk is served. Violations
of either ordinance are jiunisliable by a fine of $10. Inspectors
have been appointed to see that the provisions are obeyed.
Emergency hospitals are to be established in connection
with the 22 plants of the American Steel and Wire Company.
The buildings will be nearly uniform, made of brick, two
stories in height, with sitting-rooms, library, dining-room and
bed-rooms for the nurses. Each hospital will have six beds,
which is considered sufficient for the maximum number or
cases requiring attention at one time. A resident physician,
six nurses, two druggists and an ambulance service will be re-
quired for each hospital. It is estimated that the total cost of
the buildings will be about $.100,000.
286 American Medicine]
FOEEIGN NEWS AND NOTES
lAuonST 23, 1902
SOUTHERN STATES.
Gift to Hospital.— The new city hospital of Knoxville,
Tenn., is the recipient of a gift of $'25,000 from Henry K.
McIIarg, of New York City. Of this sum ?5,000 will be used to
add to the hospital equipment and the remainder will he held
in trust.
Insanity Among Negroes.— Reports of the superintendents
of various insane hospitals in the Southern States would indi-
cate that mental diseases among negroes are constantly increas-
ing. In the District of Columbia there are about 400 Insane
negroes in a population of 90,000, and about (iOO white insane in
185,000 population, indicating a larger percentage of insamty
among negroes than among whites. The statement is made
that there was comparatively little insanity among negroes
before the war, but since then there has been a steady increase.
Various explanations are given for this fact, but it is generally
held that the greater dissipation, irregular life, greater priva-
tions, increased responsibilities, and the nervous strain induced
by competition are responsible.
Typhoid Fever in the District of Columbia.— According
to a late report nearly 200 cases are now under treatment. This
is far in excess of the number of cases reported for many years.
The average number of deaths from the disease for July during
the past 22 years, including 1901, is placed at 15.3, whereas in
July of this year there were 31 deaths. For the first week of
August 11 deaths were reported. The cases are widely scat-
tered throughout the District, and after a thorough investiga-
tion of each case the authorities are agreed that Potomac water
is responsible for the present outbreak. In accordance with
these findings. Dr. Woodward of the Health Department
advises the boiling or filtering of all water to prevent progress
of the disease.
WESTERN STATES.
Anthrax in Wisconsin.— State Veterinarian E. D. Roberts
reports the situation in the vicinity of La Crosse to be alarm-
ing. Since the outbreak 30 of 68 exposed cattle have succumbed
to the disease.
Nurse to Direct Hospital in India.— Miss Etha Butcher,
of Virginia, 111., is soon to sail for Bombay, where she will act
as superintendent of nurses in Thers hospital at Jhadsi. Miss
Butcher is a graduate of Knox College and Johns Hopkins.
Mortality of Michigan During July.— The deaths in
Michigan during July exceeded those of June by 113, the death-
rate being 11.3 per 1,000 population. Smallpox caused 4 deaths,
tetanus 4, pulmonary tuberculosis 152, cancer 140. There was a
slight increase in the number of deaths from typhoid fever.
Lane Medical liectures.— The seventh course of the Lane
Medical Lectures in Cooper Medical College, San Francisco,
^ill be given in 1902 by Mr. Charles B. Ball, Regius Professor
•of Surgery in the University of Dublin, an eminent authority
on diseases of the rectum, which will be the subject of the
lectures. They begin Monday, September 1, and will continue,
two each day, for five days.
A crusade against tlltUy money has been inaugurated in
Cleveland, Ohio, by the Health Department. It is claimed that
many cases of smallpox and other contagious diseases can be
traced directly to this source. Many of the banks have agreed
to assist the movement by issuing new bills in the place of old,
and a number of the stores are only giving new money in
change.
Illinois Requirements for Medical Colleges. — The State
Board of Health of Illinois adopted on July 8 a schedule of
minimum requirements for medical colleges to be determined
in " good standing " by that board, and has sent a copy to every
medical college m the United States and Canada. These re-
quirements, which will be in force on and after January 1, 1903,
relate in part to conditions of admission, advanced standing,
length of lecture courses, attendance and graduation. No
medical college will be determined in " good standing " with
the board unless it complies in every particular with the pro-
visions of the schedule, and no graduate of any college not so
doing will be admitted to examination or permitted to practice
medicine in the State of Illinois.
Hospital for Insane Overcrowded.— The responsibility
lor conditions at the Dunning (111.) Hospital for the Insane
which made it possible for a patient to be fatally injured
recently during a fight with other patients is placed by a physi-
cian who some months since was on a committee to study the
needs of the hospital on an apathetic public which has failed
to provide the patients with adequate accommodations or a
sufficient number of attendants. The deductions from that
Inquiry amounted to the generaj statement that the accommo-
dations and attendant staff were suflicient for less than half
the number of patients being cared for. In the ward where
the patient who lost his life was cared for there were 62 patients,
violent and quarrelsome, and only three attendants on duty
•during the day and one at night.
FOREIGN NEWS AND NOTES
OENERAIi.
Cholera. — Cholera has spread from Manila and the ports of
China to Japan, but the epidemic, especially in the northern
Sortion, is abating. Up to June 28 no case had been reported in
;orea, and every precaution was being observed to prevent its
entry. From June 28 to August 15 the deaths in China num-
bered over 14,000, in Japan about 1,700, in India about 400.
Accidents In the Alps. — Statistics show that the number
of fatal accidents in the Alps during the last 10 years is 275, of
which 375^ occurred in the Central Alps, including Switzerland,
13% in the Western Alps, and 133 accidents, or nearly 50%, in
the Eastern Alps. The total is not so very great, when it is
remembered that the number of mountaineers has increased
enormously, and that 100,000 expeditions are made every year.
Of the 301 deaths resulting from the 275 fatal accidents, 190 were
those of Germans or Austrians, 48 of Swiss, 23 of Italians, 18 of
Englishmen, 15 of P>enchmen and 2 of other nationalities.
Seven ladies were among the victims, as well as 73 guides and
14 porters.
GREAT BRITAIN.
Antlspittlng Crusade. — The London Health Department
has issued circulars asking the cooperation of the public in an
attempt to restrict the common practice of expectorating In
public resorts and thoroughfares. In Glasgow and Liverpool
spitting on the municipal tramway cars has been made a finable
offense.
International Conference on Tuberculosis.— The first
meeting under the auspices of the Central International Office
for the Prevention of Consumption will be held in Berlin
October 2'2-26, 1902. Each country is to be represented by at
least two delegates, many of whom are scheduled to read
papers on the subject of tuberculosis, and how to check its
spread.
Wounded and Surgeons on Modern Warships. — Sir
Henry Norbury, Director-General of the Navy Department,
calls attention to the fact that the modern warship has no special
accommodations for those wounded in action and the surgeons
who must attend them. Investigation revealed the fact that the
wardroom, which is situated on the upper decks and is ex-
tremely likely to be destroyed in a hard fight, is the only place
that the surgeons could be stationed. Even with the poor shel-
ter thus afforded it would be practically impossible to convey
the wounded there from all parts of the vessel. To remedy
this it is suggested that a surgeon be placed in each fighting
division of the vessel. He would then be where he was most
needed and also comparatively sheltered. This would neces-
sarily mean the appointment of more surgeons, as at the pres-
ent time even on nrst-class ships carrying 600 to 700 men there
are but two surgeons.
London School of Tropical Medicine. — Sir Francis
Lovell has returned from his tour of the tropics made for the
purpose of securing the support of British residents in behalf
of the London School of Tropical Medicine. His mission was
very successful ; the welcome from authorities, the profession,
merchants, and others being sympathetic and their interest
being practically proved by contributions and promises of
active support. At Bombay a wealthy Parsee contributed
100,000 rupees. In Ceylon a committee of medical men was
formed to raise funds, as was also done in Singapore. In Japan
and Canada it was found that the time was not yet ripe for
application to the government for aid. Altogether the result of
the mission was cash to the amount of nearly £10,000, and
promises of subscription of £1,000 yearly. In addition to this
Sir Francis has obtained for the school the right of appoint-
ment in perpetuity to the office of Director of the Research
Institute recently established at Kuala Lumpur by the govern-
ment of the Federated Malay States. This appointment, which
is of the value of £750 yearly, with free furnished quarters,
maybe regarded as a liberally endowed scholarship olfering
exceptional opportunities for the study of tropical diseases. It
is tenable for three years. The London school has secured the
continuance of the valuable services of Sir Francis Lovell by
electing him its dean.
CONTINENTAL EUROPE.
Medical Students' Union. — In Paris 500 medical students
have founded an association in defense of their moral and
material interests. Political questions will not be dealt with.
The objects of the association are defined as follows ; To find
out and put into practice the most useful methods for the moral
development of the profession ; to transmit to the proper
authorities the decisions arrived at by medical students in their
general meetings, so long as these decisions have to do with
scholastic or professional matters ; to facilitate by every possi- '
ble means professional instruction among the members ; and to
bring about the strongest possible bonds of union between
medical men, professors and medical students.
AUGUST 23, 1902]
CORRESPONDENCE
;a.mebican Medicinb 287
Ambulance Cars for German Railroads. — For furnish-
ing itninediate aid to persons injured in train wrecks tiie State
Railway Administration lias decided to maintain arnljulauce
cars at 77 of the principal statious iu (Jerrnany. The cars will
contain a full hospital equipment, including operating tables
and beds, and be in charge of a medical ottlcer. All railway
employes will be required to take training in the performance
of hrstraid duties. The cars will be so located that none will be
more than IJ hours' run from a hospital, thus furnishing quick
transportation for injured persons requiring serious attention.
Belgian Surgical Society. — The annual congress of the
Belgian Society for Surgery, usually held in Brussels, in June,
will this year meet September 8-10. The deliberations will be
exclusively devoted to the three following questions : (1) The
treatment of appendicitis. Lecturers: Mil. A. Broca, Paris;
A. Gallet, Brussels; C. Koux, Lausanne, and Sonnenburg, Ber-
lin; (2), The treatment of fractured limbs. Lecturers: MM.
A. Depage, Brussels ; Rottschild, Frankfort, and Th. Tuffler,
Paris ; (3) Asepsy of the hands, of the operated area, of the
.sewing and ligature material. Lecturer: M. Walravens, Brus-
sels. The presence at the congress of so many foreign sur-
geons has induced the society to lay the foundations of an
International Society of Surgery, in accordance with a proposi-
tion of the president. The surgeons who have not yet answered
this invitation are requested to do so without delay.
Bacteriology of Garments and Bedding.— Experiments
recently made in Italy show that garments are capable of hold-
ing microorganisms varying from a minimum of 915 to a maxi-
mum of .571,962 for each sq. cm. of goods. The greater number
are saprophyti<:, but pathogenic germs are also found. The
number of bacteria found in garments in actual contact with
the human body is in direct ratio to the number of days the
garments are worn. In general, the number of bacteria found
in the clothing of a person is proportional to the activity of his
occupation ; wool is a more favorable habitat for bacteria than
are cotton and silk. Under all conditions, whether garments
are worn, hanging iu a wardrobe, or alternately worn and hung
away, pathogenic bacteria undergo a gradual attenuation and a
diminution of their virulence. Conclusions are that garments
are a potent means for the diffusion of infective agents, and
that without special treatment pathogenic germs can retain
their virulence in human raiment for a considerable, but not
indefinite, period.
OBITUARIES.
Karl Gerhardt, profes.sor of clinical medicine In Berlin University,
Inly 20, aged 09. Dr. Gerhardt received the degree of M D. from
Wiirzburg University in ISiW. He held various teaching positions in
Tiiblngen, Wiirzbnrg and Jena, Anally going to Berlin In 1885. He
was the author of many articles on laryngeal diseases, aircctions of the
circulatory and respiratory organs and on diseases of children, having
contributed a textbook on the latter subject. During the past nine
years be was one of the editors of the Milnchener medicinUche Wochen-
Hchrift.
Thomas I>«throp, one of the leading physicians and philanthro-
pists of Bufl'alo, August?, aged 66. Dr. Lothrop was graduated from
the medical department of the University of Michigan In 1858, residing
In Buffalo since 1871. Since 1879 he was senior editor of the Buffalo
Medical Journal, was one of the founders of the Buffalo Women's Hos-
pital, and consulting physician to many of the hospitals of that city.
He was greatly interested in charities and public affairs and gave
frt-eiy of his money, time and professional services to the worthy poor.
Martin Luther Hoi brack, of Mew York, August 12, aged 72. Dr. Hol-
briiok was noted for his efforts In the line of preventive medicine, being
associated at one time with Dr. DIo Ijcwis In Boston, afterward going to
New York, where from 1861 to 1898 he was editor of the Iferatd of lUiiUh.
He had much to do with army sanitation during the Civil war, and
"•"in afterward established the first Turkisli bath In New York City.
Kdwaril P. Hcales, at Newton, Mass.. .\ugust 14, from concussion
I the bmin resulting from a fall, aged 71. Dr. Scales was one of the
oldest homeopathic pbysicians In the State, having received his degree
at Cleveland In 1859.
J. A. s. Rrunelle, a prominent Montreal physician and professor
'■I pathology at Laval University, at Mountain View, N. Y., August 6,
aged .W.
•Jesse Ilradford, of Conesus Center, N. Y., August 6, aged 75. He
graduated from the University of Vermont and served in the Civil war.
J. K. Hecker, Jr., at Philadelphia, .\ugust 13, aged 27. He was a
graduate of the Midico-tjhlrurgical College.
Alexantler Tultt, In Philadelphia, August 15, aged 58. He gradu-
ated at HaliMt-mann Medical College in 1!^5.
Leo|M>ld Schenk, In Styrla, August 18, known for his theory of
<i.'iermii»atl(m of sex.
H. !». Walk«r, of Danville, Va., August 12. He graduated In Phila-
delphia In 18.58.
Nicholas WIIIiamnoD, ex-mayorof New Brunswick, N. .1., August
15. of typhf)id fever, aged .57.
Peter Duggaii Walsh, In Boston, August 10, aged 79.
CLINICAL NOTES and CORRESPONDENCfi
(Communications are Invited for this Department. The Editor is
act responsible for the views advanced by any contributor.]
ALBUMINOUS EXPECTORATION FOLLOWING
THORACOCENTESIS.
BY
ARTHUR J. PATEK, M.D.,
of Milwaukee, Wis.
To the Editor of A merican Medicine : — Apropos of the case
of "Albuminous Expectoration Following Thoracocentesis,"
reported by Dr. David Riesmau in the American Journal of
Medical Sciences, April, 1902, I wish to report a similar case
that came to my notice in August, 1901, in the person of a
patient of Dr. F. p;. Walbridge, whom he had left in my charge
during his absence from the city :
Tlie patient, a young man, aged 28, was suffering from
right-sided pleurisy with effusion, the flatness extending to the
spine of the scapula posteriorly, and anteriorly to within an
inch of the clavicle. There being no effort at absorption, it
was decided to withdraw the fluid. Thoracocentesis was per-
formed at about 2 o'clock p.m. When about three liters of
straw-colored serum had been withdrawn, complaint was made
of a sharp pain in the side, and a little hacking cougli ensued ;
thereupon the needle was immediately withdrawn. I was sum-
moned at 5 o'clock aud found the patient suffering greatly from
pain in the chest and intense orthopneic distress ; he was rather
cyanotic ; his breathing was shallow and rapid ; pul.se was
accelerated ; he coughed incessantly, and expectorated quite
continuously and copiously a thin, straw-colored, frothy serum
bearing a strong resemblance to the fluid aspirated. Morphin
aud strychnin were administered hypodermically, but gave
little relief He was transferred to a hospital near by, where I
again saw him at 8 o'clock. Strapping the chest with adhesive
plaster gave some relief, and the strychnin and morphin with
atropin injections were continued throughout the night. By
palpation and auscultation numerous small mucous rales were
found in both lungs, the condition being recognized as one of
Eulmonary edema. On the following morning the symptoms
ad ameliorated appreciably, though the dyspnea still existed,
and the serum expectoration continued, but to a less marked
degree. The expectoration continued throughout the day,
covering a period of about ,36 hours, and in small amount, and
at infrequent intervals fully 24 hours longer.
Unfortunately the fluid expectorated was thrown away
before it could be measured and examined. I estimate its
quantity to have approximated 750 cc. Though no chemlc
analysis was made, there is, of course, no question that this
serum expectorated was of the albuminous variety set forth by
Riesman in the article quoted.
My own explanation of this phenomenon was that the acute
withdrawal of a large quantity of pleural fluid resulted in a
sudden relaxation of the compressed lung and tliiit this nega-
tive pressure gave rise to a condition of pulmonary edema. I
am gratified to find that this is the explanation shared in large
part by others, though Riesman believes, and rightly so, I
think, that added to the pulmonary edema there exists a great
afflux of blood to the lung, i. e., a marked degree of congestion
due to the lung's sudden release from pressure, and he proposes
for this the very apt term " congestion by recoil."
VACCINATION VERSUS DISINFECTION.
BY
JAY F. SCHAMBERG, M.D.,
of Philadelphia.
To the Editor of American Medicine: — The recrudescence
of smallpox in Cleveland after but a brief ab.sence of the dis-
ease is exciting the good people of that community. It will bo
remembered that the health officer of that municipality took to
himself no small credit a year or so ago for the eradication of
variola from the city. He was free to express his lielief that
vaccirintion had failed and that disinfection was the only sure
means of accomplishing the desired end. Accordingly vacci-
nation was abandoned and formaldehyd fumigation was ndied
upon to exterminate the pestilence. And in a short pericxl of
time smallpox disappeared from Cleveland and the health olHcer
was acclaimed as a great man, and formaldehyd was placed
on the pedestal formerly occupied by tlie Jcnnerian procedure.
Even conservative men shook their lieads and said, "The dis-
288 AJfBBICAN MEDICINE)
COKKESPONDENCE
[AUGUST 23, 1902
^aso Is exterminated, and we must give due credit to the man
and the metliod, althougli we are surprised at liis antivaccina-
tion utterances." Unfortunately the credit was given to the
man and the method without an examination of the facts anil
circumstancos of the epidemic and tho manner of its termina-
tion. After smallpox had existed in Cleveland for over two years,
after a couple of thousand of individuals had fallen victims to
the disease, after thousands of persons had been vaccinated, and
at a time when less than 20 cases of smallpox existed in the city,
the h(!alth officer began his forraaldehyd crusade and exter-
minated the disease. An examination of the histories of small-
pox epidemics will show that they all have an end, and that
they usually do not last as long in any one locality as did the
epidemic in Cleveland. The health officer, furthermore, exter-
minated smallpox during the summer months, a season which
is commonly the terminal period of variolous epidemics.
Ho was in the fortunate position of the second physician
who is called in attendance upon a patient just before the
favorable change takes place. No one would deny that disin-
fection is a valuable procedure. It has a distinct field of useful-
ness, but it has its limitations. You cannot destroy the germ
of smallpox in the living host by disinfection ; the majority of
cases of smallpox are contracted by contact with individuals
sufTering from the disease, many of them in the earlier stages
before the diagnosis is made. Disinfection is powerless against
this means of transmission.
In dealing with an epidemic of smallpox, isolation of the
patient and disinfection of infected articles and apartments are
valuable adjuncts, but the paramount and important weapon is
vaccination. If vaccination and revaccination were carefully
and universally employed smallpox would disappear from the
face of the earth. To depend upon disinfection to the exclusion
of vaccination in warfare against smallpox is, in the light of
one hundred years of incontrovertible evidence, criminal folly.
A sanitarian who advocates such a policy is an unsafe man in
whose hands to entrust the healtli of a community.
Truth inay be submerged for a time, but it ultimately rises
to the surface. The health officer of Cleveland abandoned vac-
cination in his fight against smallpox about a year ago. He
has allowed inflammable material to collect in the city with the
result that the first spark of infection has again ignited it.
According to the Marine-Hospital reports of August 8, 1902.
Cleveland has now more cases of smallpox (June 21 to July 20,
1902, 133 cases) than any other city in the United States.
ACUTE NEPHRITIS BY METASTASIS FROM PARO-
TITIS.
BY
C. B. SYLVESTER, M.D.,
of Harrison, Me.
On May 24, 1902, I was called to see A. S., aged 17. He was
a student in an academy where there had been an extensive
outbreak of mumps. He had been exposed freely to the dis-
ease within two weeks previously. His face had been swollen
noticeably at angles of tne jaw, with characteristic expression of
mumps for the last 24 hours, with pain and difficulty in open-
ing the mouth, headache, etc. The temperature was 102.5°. He
also complained of considerable pain in the epigastrium. The
diagnosis was stated to be mumps, a mild antipyretic and laxa-
tive was ordered, and the patient was left with instructions to let
me know if he was not more comfortable the next day. I was
summoned 24 hours later, and found him with a temperature of
103° and in delirium. He was throwing himself about the bed,
his muscles were twitching, eyes rolling, pupils dilated, and he
was apparently in the beginning of convulsions. The signs of
mumps had disappeared entirely, so completely that the family
thought a mistake in diagnosis had been made. On inquiry, I
found that he had not urinated for more than 24 hours. There
were two points of tenderness, with some swelling on the right
and left sides anteriorly, exactly over the kidneys, as shown by
the slightest touch causing distress. A hypodermic injection
of J grain of morphin producing no effect, it was repeated in
an hour, and this was followed by three more J-grain doses
during the night. The whole amount (li grains) made but little
impression, save in finally quieting the nervous manifestations.
I had at first given freely mild chloride, followed by magnesium
sulfate, had established free sweating, and had applied turpen-
tine stupes to the back. A free evacuation was secured at
4 a.m., which was accompanied with some urine; I was unable
to examine the first urine, as it was mixed with feces. The
amount was thought to be small. Th6 patient afterward estab-
lished the fact that it had been over ;H0 hou rs since he had u rinated.
Uy morning the mind was clearer, the pulse better, and the tem-
perature was down to 101°. Toward night the temperature rose
to 101.5°, and he complained of pain in the stomach, with head-
ache growing more and more severe, until he finally became
delirious, but in loss degree than the night before, responding
more readily to treatment. For three or four nights this
delirium, which was not distressing now, continued. As before
stated, he would first complain of pain in the head and stomach
growing more and more severe, and, as he lost consciousness,
he would say that he was " all right," would sing hour after
hour in the same pitch and key, and when asked, would
respond that he felt " first rate." His treatment now was ice-
cap to the head, bromids and potassium acetate, with infusion
of digitalis.
I had told the family that the only similar case recorded
was one in Paris, which was followed by orchitist Surely
enough, on the eighth day when all the symptoms had amelio-
rated, the mind being entirely clear and bodily functions nor-
mal, an orchitis developed, but it was limited to the left side.
This subsided after a few days, and in two weeks the patient
was up. In three weeks he appeared entirely recovered with no
trace of albumin in the urine.
To Review. — A perfectly typical case of mumps of more
than ordinary severity ; sudden cessation within 24 hours of all
parotid swelling and tenderness, with substitution of swelling
and tenderness in the kidneys and cessation of renal function ;
characteristic cerebral symptoms, which continued after the
renal function was established; the transitory nature of the
renal affection, albumin disappearing rapidly from the urine at
the end of the first week, and at the first examination obtain-
able, the albumin was not so abundant as is usually seen
in puerperal uremia or in true acute nephritis. The orchitis
came on schedule time, i. e., the eighth day of the disease, just
the same as if the disease had run its course in the parotid
gland.
This case was very interesting to the consultants, owing to
the well-marked and definite signs and symptoms. To their
desire that it should be recorded is owing this report.
OVARIAN IRRITATION AS A CAUSE OF PSEUDO-
CYESIS.
BY
HANNAH M. THOMPSON, M.D.,
of Wilmington, Del.
To the Editor of American Medicine : — I have been inter-
ested in an article published in your issue of .Inly 5, 1902, by
Dr. P. Thompson Schell, on the subject of ovarian irritation as
a factor in the etiology of pseudocyesis. Within the past seven
years I have had three well-marked cases of pseudocyesis
occurring in women who were not at all hysteric, but were the
subjects of ovariaii or other pelvic disease. In two cases the
ovaries were enlarged and prolapsed, and in the other there
was a small fibroid tumor of the uterus.
In all three cases there was irregular menstruation, menses
being absent in two cases for five and six months. Abdominal
enlargement was well marked and the breasts contained milk.
They were all strongly desirous of pregnancy, and were so
confident of their condition that they prepared for the event
against the opinion of the physician, in one case at least.
I have given these cases (without going into detail) because
of my ditficultyin finding any definite light upon their etiology
and the fact that each case noted may help in the solution of
this interesting subject.
SALINE INJECTIONS IN CHOLERA PATIENTS.
BY
CHARLES PRANCIS,5M.D.,
of Brooklyn, N. Y.
To the Editor of American Medicine : — In reading the life of
Sir James Paget an interesting fact was brought to my atten-
tion. During his apprenticeship to a physician, saline injec-
tions were used in cholera patients. In one case the physicians
entertained great hopes of the efficacy of this procedure, but
later the patient succumbed. You will observe that what we
consider new ideas are but old ones that have not been thor-
oughly tested.
AUGUST 23, 1902]
CHRONIC NEPHRITIS
[American Medicine 289
ORIGINAL ARTICLES
PROGNOSIS AND TREATMENT OF CHRONIC NEPH-
RITIS.
BY
DbLANCEY ROCHESTER, M.D.,
of Buffalo, N. Y.
Associate Professor of the Principles and Practice of Medicine, Uni-
versity of Buffalo ; Consulting Pbyslcian. German Deaconess
Hospital; Attending Physician, Erie County Hos-
pital ; Assistant Attending Physician, Buffalo
General Hospital.
In order to formulate a plan of treatment for a given
disease it is important to bear in mind not only the
etiology, morbid changes and symptomatology of the
disease, but, also, and this is of even greater importance,
the modes of death in such cases. By considering the
modes of death we are in place to formulate measures to
prevent the occurrence of this undesired end.
The etiology has already been considered in detail.
Briefly we may say that the origin of most — probably of
all — cases of chronic nephritis is toxemia and the effort
on the part of the kidney to rid the system of noxious
materials. The toxemia interferes with the nutrition
of the kidney and the poorly-nourished organ endeavors
to do excessive excretory work. It often fails in its
attempt, its cells become disorganized in one way or
another and we then have some form of chronic neph-
ritis to deal with. So far as the morbid anatomy is
concerned, we may say in a general way that there are
three forms of the disease recognizable. In all the mor-
bid pr(K!es3 is a diffuse one, involving the whole struc-
ture of the kidney ; in one form, the large white kid-
ney, as it is commonly called, the pai'enchyma is most
pronouncedly attacked ; in the second form, the small
white kidney, the interstitial tissue bears the brunt of
the attack. This is the least common form of the dis-
ea.se. In the third form, usually known as the small
retl kidney, the contracted kidney, the cirrhotic kidney,
etc., the process is also one of great incredse in the inter-
stitial tissue, but may usually be considered as a local
expression of a general arteriosclerotic process, though
occasionally it may occur as a primary independent
affection. Amyloid and fatty degeneration may be
present to a greater or less degree in any of these forms
of chronic nephritis. I'atients with chronic nephritis
die from toxemia ; either from the original toxemia
which produced the kidney lesion or from that produced
by the nephritis, or from that of a superimposed acute
infection, or from a combination of any two or all of
these.
The symptoms of the parenchymatous form of the
disea.se, the large white kidney, are briefly anemia,
dropsy, usually dyspepsia, sometimes vomiting, often
severe diarrhea sometimes alternating with periods of
constij)ati()n ; headache, disturbance of vision and of
hearing; vertigo and occasionally convulsions occur,
though convulsion is less frequent in this form than in
the interstitial form of the disease; edema of the lungs,
hydrothorax smd ascites may occur with the anasarca,
and octrasionuUy the pulmonary edema and hydro-
thorax occur without tlie general dropsy.
The tcnii)erature is ordinarily somewhat below nor-
niiil, any rise above the normal causing suspicion of some
acute infection. The pulse is usually increased in fre-
quency, is regular, small in volume and of moderate
tension. During what we may call uremic explosion the
tension Ijecomcs decidedly increased and the pulse may
hfK'ome irregular.
The urinary findings and the i)lan of treatment to be
f'oliowetl are well illustrattnl by the following case:
Cask I.— On August 7, 18!>2, W. K. T., a young man, con-
sulted nifi, presoutini; the following history: In .January, 1892,
he had had diphtheria, from which he had recovered, Imt about
a month afterward he had noticed some putllness about his eyes ;
this had very gradually increased and spread, so that when he
came to my office he had general edema of the subcutaneous
areolar tissue, ascites, and edema of both lungs, headache,
dizziness very marked, and tendency to constipation. There
was no evidence, upon physical examination, of disease of the
heart, but there was great tension of the pulse and some thick-
ening of the arterial coats. Examination of the urine showed
the following : Amount in 24 hours, 550 cc; color, dark ; trans-
parency, cloudy ; reaction, acid; specific gravity, 1,018; urea
6 grams; albumin, abundant; sugar, none; microscope,
amorphous urates and hyaline and a large ntimber of granular
casts. I put the patient to bed, gave him milk diet, called upon
his skin and his bowels to relieve his kidneys, with the most
gratifying results. He was made to sweat by steam baths given
in bed. These baths were given every day for a week or two ;
then the intervals between the baths were lengthened until two
a week sufSced to keep him in good condition. At the same
time that the sweats were instituted copious evacuations from
the bowels were produced by means of calomel, followed by
the free use of Epsom salts.
After free catharsis had been once produced in this manner,
one or two daily evacuations were kept up by one daily dose of
the saturated solution of Epsom salts. After a few days of this
treatment, together with dry cupping of the chest to relieve the
edema and congestion of the lungs, the ascites and anasarca
rapidly subsided. Tincture of ferric chlorid in 1.50 cc. doses
was added to the medication, and massage followed each steam
bath.
On October 4, 1892, two months after treatment had been
begun, the analysis of urine was as follows : Amount in
24 hours, 2,400 cc; color, yellow ; transparency, slightly cloudy ;
reaction, acid ; specific gravity, 1,012 ; urea, 16.47 grams ;
albumin, abundant; sugar, none; microscope, granular and
hyaline casts.
Three months later, five months after treatment had been
begun, there was no material difference in the analysis from
that just given. The patient was feeling much better, the
oedema pulmonum had not reap-
peared, there was no fluid in the
abdomen, and only slight edema of
the legs and occasionally pufflness
of the eyelids.
The patient then disap-
peared from view. The follow-
ing ca.se illustrates the value of
prompt and decided metisures
when death seems imminent :
M
Case II.— Mrs. F. 0. P., aged 53, was seen March 2, 1893.
She was sitting up in bed gasping for breath and suffering from
repeated attacks of angina pectoris which recurred at con-
stantly diminishing intervals. She was markedly constipated,
her head ached violently, and she vomited whatever she tried
to eat. Her family was grouped about her in expectation of
her immediate demise. Examination showed a spare, pale
woman with thickened and contracted arteries, edema of lower
extremities, congestion and edema of both lungs, aortic obstruc-
tion and insufficiency, dilated left ventricle, and occasional
safety valve yielding of the tricuspid valve. The amount of
urine passed in 24 hours was stated as less than 180 cc., but
as the exact amount was not known, the urea was not esti-
mated. It contained albumin and epithelial and granular
l" ordered for her a hot footbath given In bed every two
hours; dry cupping for the chest in front and behind, the use
of Bethesda water as a drink, and strophanthus, strychnin and
caffein as medication ; a dietof peptonized milk ; opening of the
bowels with calomel and lOpsom salts.
In two days the urine had increased to 1,000 cc, contaming
24 grams of urea ; albumin and granular casts still present.
The footbaths were discontinued and a steam bath given
every day. Under this treatment she steadily improved— .so
much so that she thought best to discontinue treatment for
a while, when a return of former symptoms warned her to l>egin
again. Her urine was examined every week for eight weeks.
At the time she stopped treatment the amount of urine dropped
to 718 cc, and the urea to 8.5.')(> grams. Upon resuming treat-
ment, the urine rose in amount to 1,200 cc, and the urea to 21.6
grams. Two later examinations revealed neither albumin nor
casts present. This patient kept well by continuing hot air
baths for six or eight months. She then tjcgan to let up on this
treatment. Fift.een months later she died from acute broncho-
pneumonia. , .
Case III.— Mrs. M. was tirstseen in May, 1888— complain-
ing of dizziness, vomiting and diarrhea. She was short of
290 AJUCEKIOAN HKDICINK]
CHRONIC NEPHRITIS
[AUGUST 23, 1902
breath and anasarcous. Temperature subnormal, pulse small,
irregular and of low tension ; heart sounds feeble, emphysema
and edema of lungs, anemia; urine small in amount, sp. gr.
1,030; albumin in abundance; epithelial and hyaline casts.
This case has been under observation for 14 years. If she
keeps up hot air baths regularly once or twice a week, keeps
her bowels open by a saline, and keeps her urine bland by
drinking large amounts of pure water with a mild alkali, such
as potassium bicarbonate, and takes an occasional dose of calo-
mel followed by salts, she keeps very well. Her diet is limited
merely by excluding fried foods, pork in any form, highly
seasoned or made up dishes, rich puddings and excess of meats.
Milk is made the chief article of diet, but she is allowed almost
anything not excluded by the above list. She is warned, how-
ever, to eat sparingly. She constantly wears light woolen
undergarments. Her exercise is regular, but never excessive.
She submits her urine for examination every four to eight
weeks. Sometimes an excess of indican shows itself. This I
have learned to consider a warning. It is evidence that the
kidney is doing abnormal excretory work, and if it is not re-
lieved almost invariably there appear albumin and casts in the
urine and soon the proper excretory function is interfered with
and dizziness, nausea, dropsy, etc., supervene. If the indican
warning is taken, her diet cut down to milk and distilled water
and a dose of 0.25 to 0.50 gm. of calomel is given followed by
Epsom salts, the urine neutralized by alkalies and the restric-
tion diet, saline relaxation of her bowels and hot air baths kept
up for several days, neither the uremic symptoms nor the albu-
min appear.
This patient also takes Basham's mixture for six to eight
weeks at a time. Then it is omitted for two to four weeks and
again administered.
The small white kidney may be the termination of
the precedinia: form or it may arise independently. The
Fig. 2.
symptoms of this form of the disease
are not materially diflferent from those
of the preceding form, though the
dropsy is usually not so marked and
convulsions are more apt to occur.
In the urine, which is usually greater
in amount than in the preceding
form, there is, as a rule, less albumin
and decidedly fewer epithelial casts,
the hyaline and granular forms pre-
dominating ; the sp. gr. is generally
low, though not so low as in the small
red kidney.
Clinically it is often impossible to
differentiate these two forms of renal
disease, excepting those which repre-
sent the extremes of the types. Tlie
following is a case in point :
Case IV.— Mrs. G. P., aged 76. History
of attacks of dizziness, nausea, weakness,
shortness of breath and persistent watery
diarrhea, with occasional blood and mucus. No evidence
of lesion of brain or spinal cord ; lungs slightly emphy-
sematous in patches; heart muscle weakened and left ventricle
slightly dilated ; no evidence of valvular lesion. Kxamination
of uriiie March 16, 189.3: Amount, 400 cc: color, brownish-red ;
cloudy; reaction, hyperacid; specific gravity, 1,015; urea, (i
grams; albumin, none; sugar, none; microscope, epithelium
of various kinds, several small granular easts.
I wish to call especial attention to this urine because
it would pa.ss the ordinary insurance examination, the
microscope not being used when there is no albumen or
sugar present and the specific gravity is 1,01.5. But the
quantitative examination of the total amount passed in
the 24 hours shows immetliately that the cause of her
dizziness, nausea, shortness of breath, weakness and
diarrhea is the poison locked uj) in her system that
should be carried off.
She was given daily hot-air baths, plain, digestible diet, a
little strophanthus and strychnin (in spite of her diarrhea) and
Bethesda water to drink. In two weeks the analysis of her
urine showed: Amount. 750 cc; color, yellowish-red; reaction,
hyperacid; specific gravity, 1,017; urea, 25 grams; albumin.
trace; sugar, none; microscope, considerable columnar epi-
thelium, granular and epithelial casts.
The diarrhea had ceased without the administration of any
diarrhea mixture; the nausea had disappeared, and she was
hungry and digested her food well; the dizziness, shortness of
breath and general muscular weakness had markedly dimin-
ished, though still present.
This patient kept very well for over three years by attention
to diet, the regular use of the hot-air bath and an occasional
dose of calomel and salts ; though she finally died at the age of
80 from edema of the lungs and brain, the result of her nephritis.
In the small red kidney the on.set of the disease is
exceedingly insidious and its existence is much more
common than is ordinarily suppo.sed.
In many cases of apparently slight disturbance of the
nervous, digestive, circulatory, respiratory and cutaneous
system, if careful examination of the 24 hours' excretion
of urine is made, the kidney will be found at fault. In
all cases that come under his observation it Ls the duty
of the physician to make careful quantitative examina-
tion of the urine and thorough microscopic examination
of the centrifuged sample. The presence of casts, usually
of the hyaline variety, or of cylindroids, is one of the
earliest evidences of kidney degeneration. Next to the
appearance of casts, a diminution in excretion of total
solids and especially of urea with a relative increase in
the water is of considerable importance. The total
quantity of water passed is seldom below the normal and
as the disease progresses it often increases to from 2,000
to 5,000 cc. in the 24 hours. Thus the great importance
of the study of the total quantity excreted is demon-
strated. Albumin is of rare occurrence in this form of
the disease and usually appears only in trace.
The patient usually consults the physician on account
of weakness, debility, nervousness, irritability, head-
ache, nausea, anorexia, diarrhea, shortness of breath,
cough or some disturbance of sight or hearing ; occasion-
ally the occurrence of a convulsion is the reason for con-
sulting the physician ; in such cases, however, a pre-
ceding history is obtainable of disturbance along one of
the lines mentioned. It is not uncommon for the patient
to say he wants a tonic. When questioned, he generally
states that he has been trying one or more proprietary
tonics.
What he needs is to get rid of poisons through excre-
tion. The following case is quite typical :
Case V. — Mr. S., age 50, of German birth, consulted Dr.
Howe, of Buffalo, on account of difficulty in seeing. Dr.
Howe recognized an albuminuric retinitis and referred him to
me. I first saw him in February, 1897. At that time he was
slightly short of breath, of a yellowish pallor, showed slight
subcutaneous edema. His pulse was frequent, small, of mod-
erate tension, vessels slightly thickened. His heart was a little
enlarged— apex in nipple line in fifth interspace, first sound
weak, second pulmonic a little accentuated. Urine showed
only 600 cc. in 24 hours j sp. gr., 1,022 ; urea, 0.3 gms. ; albumin, a
trace — crystals of calcium oxalate and uric acid and a few
hyaline and granular casts.
This patient was under observation for three years. He has
not been seen since April, 1900. At that time he was in
good general condition and his urine was better than when he
was first seen.
During the time that he was under observation his urine
was examined twenty-four times. The urea only once fell as
low as at the original examination. Once it reached as high as
34.5 gms. ; five times it was between 20 and 30 gms. ; ten times,
while below 20, it was 14 gms. or over; six times it fell below
14, and twice it was, through some oversight, not recorded.
While the excreting powerof his kidneys was thus improved
and his general condition was better, his disease was still pres-
ent as shown by the persistence or rather recurrence of albu-
min and casts in tlie examination. Casts were present 10 times
and albumin 17 times, though always in small amounts.
The accompanying table gives the main features of
his urinalyses.
The treatment followed out in this man's case was as fol-
lows:
Diet. — Fresh fish, boiled or broiled; baked potato, boiled
rice, bread (24 hours old), milk, fresh fruit — two quarts of pure
water.
Medicine. — An alkaline powder consisting of one part potas-
sium nitrate and two parts each of sodium bicarbonate and
Rochelle salts; tincture of nux vomica in increasing doses;
August 23, 1902)
CHRONIC NEPHRITIS
[American Medicine 291
Basham's mixture in 10 cc. doses t. i. d. ; a steam bath every
second day.
As he improved fresh vegetables were added to his diet and
the baths were reduced in number to one or two a weel{. At
the beginning of the treatment, and occasionally through the
course of the disease, he was given calomel followed by salts,
and for a period of two to four weeks his diet Avas limited to
milk.
The cases that I have chosen to use as illustrative of
the method of treatment that seems to me most appro-
kidney was the original cause of the nephritis." With
the last proposition I think we will all agree and
that the changes in the renal circulation the result of the
displacement are chiefly active in the morbid changes ;
the restoration to place and consequent mechanical
ability for the kidney to empty itself and restore the
equilibrium of the circulation is the restorative factor in
my opinion.
As to his proposition that "chronic nephritis is
Urine in the Case of Mr. s.
Date.
February 15, 1897 ..
March 10, 1897
April 12, 1897
June 10, 1897
June 24, 1897
September 10, 1897
December 18, 1S97..
February 19, 1898 ..
April 21, 1898
May 21, 1898
July 9, 1898
September 10, 1898
October 11, 1898 ....
December 10. 1898.,
December 24. 1898.,
January 21, 1899
February 24, 1899...
March 18, 1899
Junes, 1899
November 20, 1899.
Decembers. 1899....
December 17. 1899.,
JanuHry 9, 1900... .
March 22. 1900
April .5, 1900
500 cc.
200 cc.
,250 cc.
MOcc.
200 cc.
,000 cc.
,0i0cc.
.500 cc.
8U0CC.
900 cc.
,000 CC.
,900 cc.
,000 CC.
4,50 CC.
000 CC.
,200 CC.
700 CC.
150 CC.
,700 CC.
,500 CC.
,800 CC.
000 CC.
.500 cc.
,600 CC.
eoocc.
Reaction.
SUghUyacld.
Slightly acid.
Neutral.
Acid.
Neutral.
Neutral.
Acid.
Slightly add.
Acid.
Acid.
Neutral.
Slightly acid.
Slightly acid.
Acid.
Acid.
Alkaline.
Acid.
Slightly acid.
Slighllyacld.
Slightly acid.
Acid.
Slightly acid.
Slightly acid.
Acid.
Slighllyacld.
Specific Gravity.
1,022
Urea.
Albumin.
6.3
1,018
10.8
1,021
16.25
1,020
8.
1,014
8.4
1,015
15.
1017
14.
1,016
22.5
1,012
18.2
1,014
21.8
1,012
16.
1,011
12.35
1,003
6.
1,020
29.
1,010
16.
1,018
15.
1,012
16.8
1,016
20.2
1,018
15.
1,020
34.5
1,012
10.12
1,014
20.
1,011
Not recorded
1,021
Not recorded
1,010
14.4
Trace (?).
Trace.
Trace.
Present.
Trace (?).
None.
Slight.
None.
Slight.
None.
None.
None.
Slight trace.
Siightamount.
Trace.
None.
None.
Trace.
Present.
Present.
None.
Present.
Slight amount.
Present.
Present.
Casts.
Hyaline, granular.
Calcium ox'late
and uric acid.
Urates.
Hyaline.
Hyaline, granular.
Uric acid.
Urates.
Hyaline.
Urates.
Urates.
Urates.
Hyaline, granular.
Hyaline, granular.
Hyaline.
Hyaline.
Uric acid.
Uric acid.
Hyaline, granular.
Urates.
Crystals.
priate, have been selected because they were all serious
ca.ses and show well what can be done even under
decidedly unfavorable circumstances.
Before summarizing the general plan of treatment
that seems to me advi.sable in these cases and indicating
the lines along which a prognosis may be defined, I
wish to refer briefly to what ha.s recently been brought
forward as the surgical treatment of nephritis.
In 189(i, Mr. Reginald Harrison reported some cases
operated upon for the relief of certain pathologic con-
ditions of the kidney. The pathologic conditions sought
for were not present, but the symptoms disappeared after
the capsule of the kidney had been split and in some
ca.ses the cortex incised so that the pelvis might be
explored.
In 1901 he made the subject of his address to the
Surgical Section of the British Medical Association
" The Relief of Renal Tension by Surgical Procedure,"
and reported a number of interesting rases.
In the MeAiral NewK for April 22, 1899, Dr. George
M. Edebohls, of New York, reported 154 nephropexies
on 1 18 patients. Of these, he says there were si.\' " who,
at the time of operation and for a greater or less pre-
ceding period, were known to have had chronic neph-
ritis. . . . In none of the first five cases was the neph-
ropexy undertaken with any idea of favorably influenc-
ing the (chronic nephritis known to exist. . . . The
fortunate! effects in three of these five ca.st>s influenced
me to regard the chronic nephritis of the sixth as a new
indication ... of nephropexy for movable kidney."
The histories of the six cases are given in some
detail. Finally, Dr. Edebohls .says: "The fiict that
stands out strikingly in the above record of clinical
experience is the (lisappearance of all symptoms and
-igiis of chronic nephritis in four out of six patients
after, and, in all human probability, as a consequence of,
nephropexy.
"An important clinical fact indicated by the four
successful rases is that chronic nephritis is probably
iinilat<Tal much oftener than is usually su.spected. . . .
"The fact of the disiippearance of chronic nephritis
without further treatment after nephropexy amounts
almost t^) i)roof positive that the displacement of the
unilateral much oftener than is suspected," autopsies
will hardly bear him out except in such cases as those in
which there is a local cause, as for example displacement
of the kidney or pressure upon the kidney or the ureter
from some intraabdominal growth or other misplaced
organ.
I heartily agree with Mr. Gilbert Parker,' who, in dis-
cussing Mr. Reginald Harrison's paper on the relief
of renal tension by surgical procedure, said: "That
renal tension often exists there ran be no doubt, but that
it is bilateral as a rule there can be equally no doubt. A
limited number of cases of unilateral tension may
exist, but they are not yet well defined. Some of the
latter class are probably relieved by incision of the
organ involvetl, but the majority of cases of renal
tension belong to the former class, and can only be
relieved by medical means and by local treatment
applicable to both sides, such as cupping, wet 'or
dry."
The indications for relieving tension surgically in
cases of nephritis have been stated by Mr. Harrison
as follows: "(1) Progressive signs of kidney degener-
ation, as shown by the persistence or increa.se of albumin
when it should be diminishing or disappearing from the
urine, as in the natural order of inflammatory dis-
orders ending in resolution ; (2) suppression of urine or
approaching this state; (3) when a marked disturbance
of the heart and circulatory apparatus arises in the
course of inflammatory renal disorders."
The second and third of these conditions can be so
decidedly relieved by prompt and energetic medi<'al
I)rocedures as illustrated in the cases of Mrs. F. C'. P. and
Mrs. (t. p., as reported, that it seems to me a (luestionable
procedure to submit a patient in the condition describtnl
to the ad<k'd danger of an anesthetic.
In the first of the conditions, when the case is
apparently pa.ssing from an acut«! through a subacute to
a chronic disease, the procedure seems to me worthy of
consideration ; but as a method of treating true chronic
nei)hritis it seems to me entirely out of place. RfHiogniz-
ing the fact that true chronic nephritis is an incurable
> British Medical Journal, October 19, 1901.
292 AJUBtOAX MeDICINX)
CHRONIC NEPHRITIS
[August 28, 1902
disease, that, as Anders has well said, "we cannot
transform connective tissue into secreting renal cells
or restore; the destroyed renal parenchyma," it becomes
our duty to so handle our cases that we may slow
the progress of the degenerative changes and keep
the individual in as good a state as possible for as long a
time as possible. The prognosis in a given (sise of
chronic nephritis depends upon the secreting power that
may be develojted in the kidneys by proper treatment,
the prew^nce or absence of albumin and casts being
of much less value from a prognostic standpoint than the
dettsrmination of the total amount of urea and other
solids excreted in the 24 hours. The prognosis is also
materially affected by the condition of the circulatory
apparatus. If the arteries are much diseased and the
nutrition of the myocardium consequently interfered
with, the prognosis is not good even though we may be
able to cause free excretion through skin and bowel.
The condition of the skin — especially of the sweat
glands — has a direct bearing on the prognosis. If there
is any decided atrophy of the sweat glands so as to
interfere witli their stimulation to hypersecretion in
order to take up some of the work of the disabled kid-
neys, the prognosis is not good.
If the degree of anemia is great and cannot be made
to improve the prognosis is not good.
The sudden development or the frequent recurrence
of marked uremic symptoms is a bad prognostic
omen.
On the other hand, a fair condition of the blood and
of the circulatory apparatus, a skin that sweats easily
and a quick response to treatment with improvement of
the general nutrition and a diminution or disappearance
of uremic symptoms are all favorable prognostic indica-
tions. J'>om the cases reported I trust tliat I have made
plain that the treatment of cases of chronic nephritis
should be along the lines of elimination and improve-
ment of nutrition.
As regards elimination, we should not try to stimu-
late into activity an organ tliat is inflamed or degener-
ated, by the use of drugs that excite functional activity
of that organ.
In the case of chronic nephritis of any of the three
types we should rarely, if ever, have recourse to stimu-
lating diuretics or to diuretics which, like digitalis, act
by increasing arterial pressure. Occasionally after we
have relieved venous congestion by diaphoresis or
catharsis, or both, a diuretic may be used for a short
time.
.In order that the materials to be excreted by the
kidneys may come to these organs in the most unirritat-
ing form, the metabolic processes should be carried to
qpmpletion. To aid in the accomplishment of this result
the selection of the diet is of great importance. The
chief ingredient of the diet should be milk. In acute
exacerbations or in uremic states milk should be the
only article of diet. Ordinarily, however, we may
allow fresh fruits, green vegetables, sometimes potato or
rice, and occasionally fish, or a little meat.
In the effort to carry the metabolism to completion,
next to diet regular systematic exercise is of importance.
This is to be obtained by massage when active exercise
is not advisable, by inhalation of pure oxygen gas and
by dilution of the catabolic materials by drinking large
amounts of distilled water or one of the mildly alkaline
mineral waters.
The anemia that so frequently accompanies these
cases is best met by the use of oxygen gas inhalations
and the administration of iron either in the form of the
carbonate or of the tincture of the chlorid or of Basham's
mixture. Iron should not, however, be administered
SIS a routine practice in cases of nephritis. The neces-
sity for it should be demonstrated by careful examina-
tion of the blood.
As the symptoms indicative of the existence of
chronic nephritis are the result of toxemia which de-
pends upon the nonelimination from the body of cer-
tain cataijolic materials that should normally be car-
ried off through the kidneys, and as these organs are
in such condition that they caimot accomplish all the
(!Xcretory work that they should, all other avenues of
elimination should be opened up for the escajxi of these
poisons. This is to be brought about by keeping the
bowels open, by the u.se of salines and the occasional
administration of a dose of calomel ; by occasionally
washing the contents of the colon with copious enemas
of mildly alkaline water or water with a little salt dis-
solved in it followed by a high enema of 400 to 600 cc.
of pure olive oil as originally suggested by Fleiner,' but
above all by exciting the activity of the skin by means
of hot air or steam baths accompanied or followed by
massage. If in the course of a case of chronic nephritis
there suddenly occurs, as is sometimes the case, a de-
cided diminution or a cessation of the secretion of urine,
the loins back of the kidneys should be thoroughly
wet-cupped, a full dose of calomel administered, fol-
lowed by Epsom salts in saturated solution ; the patient
put to bed, the diet limited strictly to milk and mildly
alkaline or distilled water ; a hot-air bath given once or
twice a day, preceded if necessary by the hypodermic
administration of a small dose of pilocarpin hydrochlor-
ate (0.003 to 0.005 gm.) and after the calomel and salts
have operated freely there should be given hypodermic-
ally, once or twice a day, 500 to 1,000 cc. of normal salt
solution. Strychnin, digitalis, potassium iodid and
oxygen may be administered at such times if indicated
in the particular case under observation.
How to give a steam or hot-air bath at home is
sometimes considered a matter of great difficulty,
whereas the technic of such a bath is very simple. The
patient is placed entirely nude between blankets in bed
and covered with two extra blankets ; the boiler B is a
little more than half filled with water, which is brought
to the boiling point ; the cover C is then firmly fastened
on and the nozzle D is introduced under the bed-cover-
ing, so that the patient becomes enveloped in steam ;
this bath is kept up for half an hour to an hour, accord-
ing to the effect produced.
Th6 method of giving the hot-air bath is by means of
the apparatus here shown. The patient lies in bed as
for the steam bath. The nozzle end of the pipe is intro-
duced under the bedclothes, the inverted funnel end
standing on its legs on a tray beside the bed ; an alcohol
lamp is placed beneath the inverted funnel and lighted,
suflticient air for combustion being supplied by the open
space between the legs. The same thing can be brought
about by the use of an elbow of a stovepipe. Care must
be exercised that bedclothing is kept from the pipe by
means of asbestos wrapping or by an arrangement of
barrel-hoops cut in two, or the ordinary "cradle" for
keeping bedclothing off' of fractured legs.
If the patient is strong enough to sit up the bath may
be given in a cabinet, but the cabinet is not necessary ;
a firm wooden-seated chair is chosen, the patient, in a
nude condition, sits upon this chair, a blanket under his
feet ; another blanket is then thrown around the patient
and the chair, so that only the patient's head remains
outside, the blanket being gathered around the neck and
fastened at the back, the laps folding one over the other
down the outside of the back of the chair to the floor ;
over the blanket a rubber sheet is fastened in the same
manner. An alcohol lamp resting on a tray is now in-
troduced from behind and placed under the chair and
lighted, the blanket and rubber sheet being closed at the
back.
In giving all these hot-air and steam baths the com-
fort of the patient is materially increased if cloths wrung
out i!i cold water are kept upon the head. A copious
draught of hot water often starts thesweat when it seems
slow in coming.
' Berliner kllnlsche Wochenschrift, 1893, Nos. 3 and 4
August 28, I902|
INFLUENCE OF STRYCHNIN ON LARGE INTESTINE i American medicinb 293
ON THE INFLUENCE OF THE CONTENTS OF THE
LARGE INTESTINE UPON STRYCHNIN.
BY
WILLIAM SALANT, B.S., M.D.,
Fellow of the Rockefeller Institute, New York.
(A PRELIMINARY COMMUNICATION OF AN EXPERIMENTAL STDDY
FROM THE ROCKEFELLER INSTITUTE FOR MEDICAL RE-
SEAKCH. CARRIED OCT UNDER THE DIREC-
TION OF DR. 8. J. MELTZER, NEW YORK.)
In the .study of Meltzer and Halant • on the effect of
subminimum doses of strychnin upon nephrectomized
rabbits the remarkable fact was found that notwith-
standing the removal of the chief eliminating organs, the
kidneys, a good deal more than the fatal dose can be
gradually injected into these animals with hardly any
cumulative effect. As a possible explanation of this
phenomenon it occurred to us that after the removal of
the kidneys perhaps vicarious elimination into the gastro-
intestinal canal becomes developed. The appearance of
urea in the alimentary tract in advanced cases of nephritis
seems to favor such a suggestion.
To test experimentally this hypothesis, I set out to
examine for strychnin the contents of the gastrointesti-
nal canal of nephrectomize<l rabbits, which gradually
received a considerable dose of strychnin. Of the
methods for the separation of strychnin I first employed
those of Otto Stas and of Dragendorff, but later I followed
out scrupulously the method described by Haines.'^
In four experiments in which the nephrectomized
rabbits received gradually do.ses of strychnin amounting
respectively to 2, 3/'5, 0 and 8 mgrs. the entire contents
of the gastrointestinal «uial including the feces were
carefully searched, but no strychnin could be detected.
To test the efHciency of the method 1 mgr. of strych-
nin was added respectively to blood, crushed brains,
liver, etc.; here strychnin was easily detected.
However, before deciding that in our nephrectomized
rabbits the strychnin was not eliminated into the
alimentary canal, 1 mgr. of strychnin was added to the
gastrointestinal (contents of these animals, and, to our
surprise and disappointment, the strychnin could not be
detected. To exclude the bare possibility that in
nephrectomized animals some unknown substance is
depositetl in the gastrointestinal canal which prevents
the detection of strychnin, the contents of the gastro-
intestinal canal of normal rabbits were taken for further
experimentation.
In three experiments 1 mgr. of strychnin was added
to the entire gastrointestinal contents of one animal ;
2 mgrs. was atlded to the entire gastrointestinal contents
of the second animal, and 1 mgr. was added to half of
the contents of a third rabbit; in none of these experi-
ments could strychnin be found, rarefully as it was
searched for. Since there was no difficulty in detecting
stryclinin in any other mixture of organii- substance, the
failure to detect it her(> could not be ascribed to imper-
fect methods or faulty technic.
But now this outcome appeared to have an important
prac^tical bt^aring. In numerous medicolegal cases it was
claimed that strychnin was found in the stomach of
poisonwl human beings, and this finding had probably
assisted more that» once in deciding the fate of an
accused. The question was now, How did the medico-
legal experts suiiceed in separating and detecting strych-
nin in the cont((nt« of the gastrointestinal canal? Is it
different with the contents of the gastrointestinal canal
in human beings ? Here another idea occurred to us.
In most of these cases it was the contents of the stomach
alone in which strychnin was found. We therefore
started to examine separately the contents of some of the
se<-tions of the alimentary tract of the normal rabbit,
with the following remarkable results :
1 Journal of Experimental Medicine, Vol. vl.
' .\llen McLane Hamllton'H 8yiit«in of Ij gal Medicine. Vol, 1, pages
451 lo+W. IWM.
One mgr. of strychnin added to the contents of the
stomach alone : strychnin easily detected ; 1 mgr. of
strychnin added to the contents of the small intestine r
strychnin detected ; 1 mgr. of strychnin added to the-
contents of cecum and colon : no reaction of strychnin.
The same uniform results were obtained in repeatetl ex-
periments. It is, then, the contents of colon and cecum
alone in which strychnin cannot be detected.
This failure to recover strychnin could be interpreted
to mean simply that the methods followed for its detec-
tion in organic substances are not adopted for its separa-
tion from the contents of the cecum and colon of rabbits.
However, we have seen that strychnin could not
be detected in the contents of the entire gastrointestinal
canal, which could only mean that the presence of the
contents of the large intestine prevents the detection of
strychnin, even when dissolved in another medium.
This fact was now established again directly by the fol-
lowing experiments:
One mgr. of strychnin was added to two-thirds of the
contents of the stomach, with which one-third of the
contents of the large intestine was mixetl : strychnin
could not be detected. One mgr. of strychnin added to
the contents of the small intestine, to which some of the
contents of the large intestine were admixed : here,
likewise, no strychnin was found. The presence of
some of the contents of the large intestine then prevents
the detection of strychnin in any other part of the con-
tents of the alimentary canal.
This series of experiments leads up api)arently to the
very remarkable conclusion that the contents of the large
intestine of normal rabbits contains something whicli,
to say the least, interferes with the detection of strych-
nin (even 2 mgs.) by the methods at our disposal.
By experiments which are now in pri)gress we will
soon be able to state whether and how far the contents of
the large intestine interfere al.so with the physiologic
effect of strychnin.
In conclusion, I take the opportunity of acknowledg-
ing my indebtedneas to Dr. W. J. Gies, professor of
physiologic chemistry at the College of Physicians and
Surgeons, Columbia University, for his generosity in
according to me all the privileges of his laboratory, in
which the chemic work of this research was carried out.
ARE NOT SOME DEATHS DURING OPERATION IN
REGION SUPPLIED BY TRIFACIAL NERVE DUE
TO REFLEX INHIBITION OF RESPIRATION AND
OF THE HEART ? '
BY
WILLIAM HARMAK GOOD, A.M., M.D.,
of Philadelphia.
Demonstrator of Physiology at Medico-Chlrurgical College.
This paper is the outcome of certain observation.'*
made in the physiologic laboratory of the Me<Uco-
Chirurgical College while experimenting on rabbits. It
is also due in part to statements like that of Gay,' who
remarks : "A person in ordinarj' health desiring a minor
operation, such as incision of an abscess, i'xtraction of a
tooth, or correction of a strabi.smus, inhales a few whiff?*
of anesthetic and with little or no warning stops breath-
ing, the heart stops, and he is dead. An autopsy fails
to reveal any adequate cause of death ; the only rational
conclusion is that death was due to the anesthetic. About
40^ of the fatalities from chloroform occur in reasonably
healthy persons about t^) undergo an o|)en»tion which it*
itself lacks the element of danger. The unfortunat*^
result also takes place in many eases in the early stage*
or before anesthesia is complete."
' Read before the Nor hwestjrn .Medical Society of Philadelphia at
the June meeting.
' (niernatlonal Texth- ok of t^iirgery.
294 AM«BICAN MKDICIKIJ
REFLEX INHIBITION
(August 23, lti02
Another characteristic .statement is that of Hewitt: '
" Durinff the jHjrforinance of certain operations, as liga-
turing hemorrhoids, respiration is sometimes interfered
with t)y reason of reflex spasm of laryngeal and other
muscles, a condition more especially likely to arise when
anesthesia is only moderately deep."
Lautenbuch^ says : " I do not pretend to know why
operations in this region— nasopharyngeal adenoids-
seem to predispose to fatal results from anesthesia ; but
as it is a truth, even though not clearly explainable at
present," etc.
It is a wellknown fact that the peripheral sensory
nerves all stand in a reflex relation to the cardioinhibi-
tory center. We also know that the respiratory center
is readily excited through reflex action. By experience
we have found that cold water dashed upon the body
causes reflexly a marked inspiration followed by a
momentary inhibition of respiration.
Those who have by mistake inhaled strong ammonia
know that it is several minutes before they can get their
breath, or technically speaking, before the inhibition of
respiration passes off.
In etherizing rabbits, it is noticed that as soon as the
ether is applied to the nose the animal stops breathing
over a more or less prolonged period. At the same
time the heart is markedlj' inhibited, in fact almost
stopped. These facts especially led my thoughts in this
direction.
The questions to be answered were : First. Is the
inhibition due to the effect of the ether directly on the
respiratory and cardioinhibitory centers? Second. Is it
due to irritation of the vagi endings in the lungs?
Third. Is it due to irritation of trifacial fibers in the
nasal mucosa, and if so, would other irritants act simi-
larly ?
It is easy to decide as to the answer of these ques-
tions. In rabbits breathing through a tracheotomy tube,
the application of ether to the nose, is followed by this
inhibition of heart and respiration. This reaction is so
rapid as to preclude the possibility of the absorption and
transmission of the ether through the blood to the
medulla. Then, too, application of ammonia or pinch-
ing the tip of the nose has the same effect.
From experiments on rabbits it can readily be proved
that the respiratory and cardiac movements can be re-
flexly inhibited by irritation — either mechanic or chemic
— of trifacial nerve endings.
During general anesthesia in man, may not irritation
of the trifacial nerve cause a reflex inhibition of respira-
tion and of the heart, and death ensue ?
This of course would occur most likely during the
time when the reflexes are still active though conscious-
ness has been abolished — in other words, during partial
or incomplete anesthesia.
Gay, in the statement to which I have already re-
ferred, points out the fact that the fatalities frequently
take place during minor operations, "before anesthesia
is complete." Hewitt states clearly that the interference
with respiration more especially arises when anesthesia
is only moderately deep.
In support of this idea of the possibility of reflex
stoppage or inhibition, I have collected a few cases that
seem to me to prove that this has actually occurred.
In the winter of 1900 H. E. Ellis, one of our students
at the Medico-Chirurgical College, came to me for an
explanation of certain curious phenomena that occurred
during massage of an epithelioma of the lower lip.
The patient was a man, aged 53, of temperate habits, nervous
and occupied most of the day in his office.
The epithelioma was on the lower lip, to the left of the
median line. It was about H inches in diameter and sur-
rounded by a markedly indurated and inflammatory area. In
the center of the ulcer there was a small whitish-gray area
which was very sensitive. Ellis in massaging gradually
1 MedleoCbirargical Transactions, Vol. Ixxlv.
2 Paper read before the American Medical Association In 1899.
approached this area, and had hardly passed over it when the
patient cried: " Don't cut my wind ott! You are choking me! "
He gripped the chair and grew dark in the face, breathing hard,
with a pulse running up to at leaist 100, butsubsiding soquickly
that there was not time to count it. From this high rate it fell
in jerks to 20, and remained there long enough to be taken easily.
The respirations were about 12, and feeble. The patient's fore-
head was bathed in cold perspiration.
The next day the patient was quite weak and nervous irom
this experience. But at the request of the family light massage
was given ; this was hardly begun before the alarming symp-
toms began to reappear. As a result the massage treatment was
given up.
If a surgeon had attempted under moderately deep or
incomplete anesthesia to remove this epithelioma, would
not the patient more than likely have died froni reflex
inhibition of respiration and of the heart?
The following case reported by Jackson ' is very con-
clusive :
At Mr. S ^'s request I called at the residence to administer
chloroform to Mrs. S. to annul the pain of extracting a tooth.
I found her suffering severely, with cheek and gum very much
swollen (trifacial irritation). The tooth proved to be the second
upper molar on the left side with the crown entirely destroyed,
leaving the three fangs to be extracted separately. Two ounces
of chloroform were used in the usual mode by pouring upon a
handkerchief, folded cup-shape, and held sufficiently far from
the face to admit a little atmospheric air. Complete anesthesia
was induced but once, when the gums were freely scarified by
Dr. Samuel Ramba, surgeon-dentist. In consequence of the
hemorrhage complete anesthesia was not produced again, and
the effects of the chloroform passed off so rapidly that only one
fang was extracted. Believing it to be unsafe to continue the
inhalations longer, from the sudden depression of the pulse
from 8i to 56 beats a minute, I withdrew the chloroform. At
Mr. S 's urgent request, I returned at 4 p.m. to repeat the
administration. One dram was poured upon the handkerchief;
after 8 or 10 inspirations Mrs. S. was seized with a violent clonic
spasm ; the spasm lasted for a minute or two ; complete relaxa-
tion supervened. F/very symptom of severe apnea presented
itself, the functional action of the heart and lungs ceased, not
the faintest indication of the action of either could be detected.
The usual means of resuscitation were vigorously used but
unavailingly. Insufflation suggested itself. Closing the nos-
trils with one hand and supporting the chin with the other, at
the same time pressing the thyroid cartilage down and back-
ward, I applied my mouth directly over Mrs. S 's and inflated
the lungs. The elfect was instantaneous, the chest expanded
and contracted, the eyes opened, a sigh was breathed and the
heart pulsated a few seconds, when all functional action again
ceased and death apparently claimed his victim. The insuffla-
tions were repeated two or three times until the functions of
life were reestablished. The next morning Mrs. S. was more
quiet, pulse 80, respirations 32, labored ; complains of slight
pain in the precordial region.
In the report he goes on to state that there was
another paroxysm of apnea during the afternoon, pre-
senting the same phenomena as the first. She was
restored by insufflation by her husband. Con.sciousness
existed in the last paroxysm.
The following case reported by Hunt '' is not so clear
as the preceding one :
The operation was a tenotomy of internal rectus (trifacial
area). The child was completely anesthetized in 1} minutes by
i dram of chloroform and the operation commenced. While
performing it the child showed signs of returning sensibility
and another half dram was administered. Very suddenly and
almost immediately following the administration of the second
dose the patient became pallid, the heart, at first weak, soon
ceased to beat, the pupils became widely dilated, respiration
ceased and the pallid hue changed to livid and the child was
dead.
In this case there is a possibility t*at the chloroform,
acting directly on the medullary centers, was the cause
of death. Still it can readily be explained by a reflex
inhibition. The accident took place at a time when
sensibility was returning ; that is, when the reflexes had
returned. Then, too, the child had taken but a small
quantity of chloroform.
Professor I. Ott gave me a copy of the report of the
foUowing case which he found in the literature':
The patient, a child of 7 years, was admitted to the infirm-
ary for the removal of adenoid growths in the pharynx.
1 New Orleans Medical and Surgical Journal, 1850.
''British Medical Journal, 1876.
'■> British Medical Journal.
AUGUST 23, 19021
ANGINA PECTORIS
[American Medicine 295
Chloroform was administered by being dropped on a towel.
With the patient lying on her bacls, the adenoids were removed
with Lowenburg's forceps, the operation being completed by
cleaning the nasal passages with forceps passed down the nose.
The whole operation occupied about a minute and a half. The
anesthetic was discontinued from the commencement of the
operation. There was no excessive hemorrhage. Immediately
after the operation, it was noticed that the patient became
cyanosed, but not markedly so ; there was no struggling,
coughing, or sign of dyspnea. She was at once inverted and
artiticial respiration resorted to. Brandy was given by the
rectum and strychnin injected hypodermically. Hot cloths
were applied to the cardiac region, and the surface of the body
stimulated with a strong electromagnetic current. About 20
minutes after the commencement of the bad symptoms
tracheotomy was performed, and the lungs inflated through
the wound. In spite of every effort, continued upwards
of an hour, to restore animation, the patient never showed
the least improvement. Tiie pulse was not observed at the
very beginning, but shortly afterward was imperceptible.
Death occurred without a struggle.
The possibility of death from refle.x inhibition of
heart and respiration was pointed out by the effects of
irritants on the nasal mucosa of the rabbit.
1 think that these few cases which I have been able
to collect show that irritants have the same effect in man,
and that some deaths during operation in the trifacial
area may be attributed to reflex inhibition of the heart
and respiration.
Granting that this does take place, what can be done
to prevent it, and how can we overcome the reflex after
it has taken place ?
Some of the textbooks advise the performance of cer-
tain minor operations during the stage of primary anes-
thesia.
If one grants that the above statements regarding
reflex inhibition are true, it follows that the stage of pri-
mary anesthesia is a dangerous time to perform any oper-
ation. In fact, an operation should not be commenced
until anesthesia is complete and the conjunctival reflex
has been abolished.
Moreover, the patient should not be allowed to come
partially from under the influence of the anesthetic
during the operation.
The following is taken from a lecture of I'rofessor
Ott,' delivered at the Medieo-Chirurgical College : " Dis-
tention of the lung in the apneic state irritates the expira-
tory Hbers of the pneumogastric. But this distention,
while irritating the expiratory fillers of the pneumo-
gastric, also has an accelerating action on the heart."
This is due, he goes on to state, to a reflex lowering of
the tonus of the wirdioinhibitory center through the sen-
sory fibers of the pneumo^astric from the lungs. This
decrease of the tonus of thecardioinhibitory center allows
the heart to go faster.
Jackson, in his case of removal of a decayed tooth,
saved his patient, who was in the apneic state, by mouth-
to-mouth insutflations, that is, distention of the lungs,
and in this way he reflexly irritated the expiratory por-
tion of the respiration center and at the same time
lowered the tonus of the cardioinhibitory center, thus
relieving the inhibition of the heart. He repeated his
lung reflex* by insurtlation until "the functions of life
were reestablished."
Thus before Ott in 1898 gave the rationale of the treat-
ment, Jackson in 1850 had used the treatment with
marked success.
In conclusion, let me emphasize the treatment that
was pointed theoretically by Ott and that has practically
proved to beof service by Jackson. It consists simply of
distention of the lungs by forced inspiration, by mouth-
to-mouth insuttlation, or even by using the bellows a,s is
done in experimental work on animals. In using the
bellows care must be u.sed so that the lungs are not rup-
tured by excessive force.
Simple artificial respiration by the Marshall Hall or
Sylvester method would hardly suflBce to cau.se sufficient
distention to bring about the respiratory reflex.
•Medical Utilletlu.
ANGINA PECTORIS.'
BY
JAY PERKINS, M.D.,
of Provident-e, R. I.
Physician to the Department (out-patient) of Pulmonary Tubercu-
losis, Rhode Island Hospital.
Following is a report of five cases of angina pectoris,
as interesting and fascinating a disease as is found in the
whole list of human ills. Although two of these cases
proved suddenly fatal, they present points of difference,
and each of the other three represents a type of the dis-
ease. I will take them up in the order in which I saw
them and discuss them afterward.
Case I is that of a woman in whom the attacks first occurred
when she was about 60, and who died at 07. She had been very
active and a hard worker all her life ; weighed when married 100
pounds, and at 60, "250, and was 5 feet 4 inches in height. She
iiad suffered a great deal from muscular rheumatism, or rheu-
matic pains, but I am quite sure she never had an attack of
rheumatic fever. I examined her heart one or two years before
her death but could hear no murmurs ; all the sounds were very
feeble, however, possibly from an excess of fat in the chest
wall, and I think also from a feeble action of the heart.
The attacks in this case used to come on quite suddenly, but
I remember that she sometimes had premonitions that they
were coming ; or it may have been that these premonitions
were but slighter attacks preceding heavier ones. Severe
attacks did not recur very frequently and were brought on by
some sudden excitement, e.'iertion or indigestion. There was
little complaint of pain so far as I can remember, but there was
great complaint of distress about the heart, and collapse. I
was present through one attack which occurred on a Fourth-of-
July morning after she had been kept awake part of the night
by tlie noise. Between 9 and 10 a. m. there were numerous
giant firecrackers set off not far from the house and she began
to complain considerably of distress, until an unusually
heavy report caused her to seize hold of a chair into which she
fell with a groan, unable to move or speak. The pulse was
barely perceptit)le and her color was ashy ; she remained un-
conscious for over an hour and was not able to be on her feet to
any extent for a couple of days. This was two or three
years before her death and was her last severe attack, but never
after did she lead so active a life, though even at that time she
was able to do but little. The last years of her life were
typical of a failing heart.
Cask II. — J. li., a jeweler, aged 48, a constant smoker of
cigarets, without any previous illness for which he had deemed
it necessary to consult a physician, was taken suddeuly ill
early in the morning of October 14, 1899, with severe pain in
the region of the heart. A messenger started at once for
Dr. Terry, who arrived there in about three-quarters of an
hour, but the patient died before his arrival. He had com-
plained previously to his wife of pain in the region of the
heart, but not sufficiently to cause any anxiety, and he had
never suffered froai any symptoms of cardiac failure. The
evening before his death he complained of pains in the chest,
head and arms. Dr. Terry had attended other members of the
family for some time, but had never had his professional
attention directed to this patient.
On tlie same day we made an autopsy, and found marked
atheroma of the coronary arteries, the left being nearly occluded.
There were also atheromatous changes in the aorta, but no
valvular lesions of the heart.
Case III. — C. H. P., aged 70, foreman for the Providence
Gas Company, had no previous illness that required the serv-
ices of a physician, although his wife said that he had some-
times had dizzy spells, and that he was always cold. While
out driving with his wife he entered a drug store and drank a
glass of mo.xie. Soon after they were back in the carriage, he
complained of severe pain in the stomach and along the ^vhole
esophagus. They drove home, he got into bed, and Dr. S'awin
was called ; the pain continued intense, and in a sliort time he
w^s dead. It was between 3.15 and 4 p. m. when ho drank the
moxie, and he died before 5 p. m. The .tymptoms coming on
so suddeuly after he had taken a drink at a soda fountain, and
the pain Ijeing referred to the stomach, led to the belief that
poison had been administered by mistake. At5.;J0 p. m. the same
day I saw the body in sitting posture in l)ed, pupils normal, skin
pale, thumbs clasped inside of fingers, arcus senilis nuirked, and
no signs of irritation about the mouth. On going to the drug
store where he had drank the liquid, I loarne<l that it was moxie,
and that it had been drunk very cold. I then stated that I was
satisfied that he had died of an attack of angina pectoris, but
this did not satisfy the friends, and so I ollered to make an
autDpsy. The autopsy showed marked atheroma of the coro-
narios, aorta and the bases of the aortic valves, but .no signs of
any irritant in the stomach.
Case IV.— T. H., a physician, aged 46, bad b«eu per-
' Read before the Pawtucket .Medical .\ssjclatlon.
296 AMntlCAN Medicimx]
ANGINA PECTORIS
[AnensT 23, 1902
fectly well previous to the first attack. According to liis own
Mtatenient lie liad never had the slightest distress about the
heart, though for 25 years intermittent pulse would follow hard
smoking, lie had been an inveterate tobacco and coffee user
and used aU^ohol occasionally, but of late years never to what
is considered excess.
One Sunday night at !t o'clock he drank about siv of whisky
and on arising Monday morning had a pain in the left arm.
This for 20 years has been conse<iuent upon drinking too much.
During the day the pain continued and became more severe
than it had ever been before. Previously, the pain had always
been on the outer aspect of the arm from the root of the deltoid
to the external condyle, following the musculospiral nerve.
This time it took in the whole arm, the arm and hand feeling as
if asleep, this being e.specially noticeable in the little and ring
lingers and along the inner side of the biceps and the pectoral
as they form part of the axillary space. There was consider-
able perspiration in the palm of the hand. Monday night he
slept very poorly and on Tuesday the pain continued about the
same until toward night when it grew worse. Tuesday niglit
while out driving he was much colder than the temperature
warranted, and had a dull ache which was very uncomfortable.
Walking a short distance to my office caused a great deal of
distress rather than pain. Examination of the heart showed a
slight systolic murmur over the aorta, which had a soft sound
similar to a hemic murmur. That night he slept fairly well and
was out on Wednesday, but used great caution as to any exer-
tion. Wednesday night he slept poorlj' and Thursday morning
awoke at about 4.45 with his arm aching, though he said that
the ache was not sufficient of itself to awaken him. After he
was awake the pain grew worse and he sat on the side of the bed
and leaned over on his elbow trying to ease the pain, but it
continued to increase. He went into another room and got a
chair but found that every movement caused increased pain.
He then went into another room to awaken a servant to send
for me and became so faint and nauseated that lie had to hold
on to the side of a door. Tlie nausea continued until an eructa-
tion of gas caused a more comfortable feeling and he sat in a
chair until my arrival. There was a tight constricted feeling in
the chest, which, as well as the pain, was relieved by nitro-
glycerin so long as he remained quiet. At this time Dr. Carver
saw the patient with me and we agreed on the diagnosis of
angina pectoris. Friday and .Saturday his condition was much
improved. Saturday evening he did some work requiring the
use of bis arms, and on Sunday was worse again. Monday he
was much better, but a lamp was upset in a room up one flight
anl on hurrying up the stairs the pain returned.
As to the physical signs the only thing of importance be-
sides the murmur was the character of the pulse. From the
time of the severe attack on Thursday morning until the symp-
toms were well relieved, and after that whenever they returneti,
as after exertion, the pulse was of a high tension, sometimes
very high, and then as his condition improved the tension came
back to normal and there was no evidence of atheroma of any
of the superficial vessels.
The patient has made a complete recovery so far as can be
told at present. He gave up smoking and coffee and has taken
life a little easier. Xow, a year later, he smokes occasionally
without any ill effects. Medication consisted in the administra-
tion of potassium iodid.
Ca.se v.— This patient I saw once in consultation with, and
several times through the kindness of. Dr. P. Williams.
The patient, a housewife, aged 53, had reached the climac-
teric three years ago. She had been very active, but enjoying
more than the average freedom from care, has been, and is, of a
cheerful disposition, accepting restraint and the attentions of
others only under protest. For ten years she has had some pain
under the sternum, coming on at intervals of considerable
length and excited by exertion or fright. She is an excellent
swimmer and has had several attacks while swimming, none of
which was of great severity until four years ago when she had
a very severe attack while in the surf at Newport. This was
so severe that she has not cared to indulge in sea-bathing since.
The pain lasted three days, though the paroxysm was of short
duration.
She had an attack of what she describes as "suffocation"
six years ago, and a similar but much lighter one two years ago.
Since the distress while in bathing, four years ago, she has had
but little discomfort until an attack on December 10, 1900, since
which time she has had a number of seizures. Her first synfp-
tom is pain, which always begins below the middle of the
sternum, and is located under the lower half or a little to the
left of the sternum, always in the cardiac area. From here the
pain radiates to the left shoulder, arm and breast, occasionally
to the right breast, but never to the right arm. In the left arm
the pain does not extend so low as the wrist. The seizures
come on very suddenly, and if she is standing it is necessary
for her to remain quiet, and otten she has to grasp something
to keep from falling. She has never lost consciousness, though
she has at times felt so faint that things would turn black. The
attacks sometimes come on in the night and then she has to sit
up in bed, sometimes for half an hour. About the time I first
saw her she had an attack while ascending a flight of stairs and
had to grasp something to keep from falling ; for a few minutes
she was afraid she would not get up the stairs without assistance,
the seizures last but a short time, but there remains a dull,
heavy pain or a distressed feeling, sometimes of a throbbing
character, occasionally lasting all day. In one of the attacks
an observer said that she grew very pale and had a distressed
look which was alarming.
As to her family history, her mother died of heart disease
and most of her mother's people had heart trouble. Her father
and one sister died of cancer.
On physical examination the patient is well nourished and
excepting for her gray hair does not look as old as her years
indicate. She is stout but by no means obese, and while this
makes the examination a little difficult it does not prevent a
fairly satisfactory result being possible. The cardiac dulne.S8
is not increased and the sounds are normal except a slight
accentuation of the second aortic. There are no murmurs and
the pul.se varies from 72 to 80. No arteriosclerosis of the super-
ficial arteries is discoverable.
During the past six months she has been much improved,
having attacks only occasionally. About three weeks ago,
after exposure and cold, she had quite a severe attack, but the
other recent attacks have been slight. Treatment consisted iu
the administration of nitroglycerin and potassium iodid.
I present these cases of angina pectoris as an intro-
duction to tiie general subject. As can be seen from even
these few cases it by no means always presents the same
picture, indeed it seems almo.st as if it were more
entitled to be considered as a group of symptoms than
as a disease. It is an accompaniment of many different
cardiac lesions, and sometimes no lesion can be found ;
moreover there is no lesion that produces this group of
symptoms invariably. Yet there is a certain entity to
the group of symptoms and certain essential qualities
which give it the character of a disease rather than
merely a group of symptoms. The special characteris-
tics of the affection are pain and a sense of constriction
located in the heart, but every pain and feeling of dis-
tress about the heart is by no means angina pectoris, and
some excellent authorities cla.ss as angina pectoris certain
cases resulting in sudden death which are unaccom-
panied by pain.
This disease is much more common among men than
women, and is found especially among those engaged in
occupations or professions which, through nervous
strain, predispose to high arterial tension — such as finan-
ciers, politicians and physicians — rather than among
those engaged in more physically arduous labors. A
very large number of the ca.ses accompany arteriosclero-
sis, especially of the coronaries ; and so any cause of
arteriosclerosis may at the same time cause angina pec-
toris, one of the most prominent of these being syphilis.
The study of the morbid anatomy of the disease
throws no light upon the causation of the pain. The
heart muscle itself is but poorly supplied with sensory
nerves and is very tolerant of injuries. One of the most
plausible of the theories in accounting for the pain is
that it is a cramp of the muscle induced by fatigue, the
fatigue resulting from a diminished blood-supply and an
increa.se in the amount of work thrown upon the heart
by increased arterial tension.
The most common lesion found at autopsy is, by far,
arteriosclerosis of a greater or less degree. Out of 91
cases mentioned by Powell in "Allbutt's System of
Medicine," there was disease of the coronaries in 51, and
of the heart alone in 13 cases. Powell also quotes Huch-
ard to the effect that out of 145 cases coming to autopsy
in which disease of the coronaries was present : in 64 both
coronaries were affected ; in 37 the lesion affected the
left coronary ; in 15 the lesion affected the right coro-
nary ; in 12 the seat of the lesion was not specified, while
in 1 7 cases coronary disease was present, but no statement
was made as to the narrowing of the vessel.
In 128 of the 145 ca.ses there was obliteration or
stenosis of the vessels ; in 5 by embolism, in 2 by
compression, and in the rest by atheromatous narrowing
or thrombosis. This frequency of narrowing of the
coronaries has lead many pathologists to maintain that
this is the essential lesion of true angina.
Angina also accompanies dilation or aneurysm of the
aorta, chronic interstitial myocarditis, fatty infiltration
of the heart mu.scle, neuritis of the cardiac plexus ;
and sometimes occurs when no lesion can be demon-
August 23, 1902]
ANGINA PECTORIS
[American Mkdicine 297
strated (purely vasomotor origin), being perliaps due to
toxemia, caused by nicotin or coffee.
Whatever the pathologic lesion, the method of action
is still the same — a diminution of the nutrition of the
heart-muscle — to which, at the time of the seizure, is
added an increase in the work of the heart, through an
increase in blood-pressure brought about by bodily or
mental activity, or by stimulation of the vasoconstrictor
nerve-fibers, toxemic or reflex.
As is well known, the sympathetic nerve stimulates
the action of the heart and so leads to oxidation and
fatigue, while the phrenic nerve restrains the heart's
action and thus assists in its regeneration by lessening
the number of beats. The blood-pressure is regulated by
the vasoconstrictors and the vasodilators. Now the
vasoconstrictors pass to the vessels through the sym-
pathetic chain ; hence anything acting to stimulate the
sympathetic or to paralyze the phrenic nerve or the
vasodilators will destroy the normal equilibrium, and
produce the same effect upon the heart, i. e., diminish its
nutrition and increase its work, as will an anatomic
narrowing of the coronaries. It is true that some
authors, among them Professor Osier, call these cases
pseudoangina, but others make no such distinction.
The distinction is an anatomic one, those cases which
present some organic lesion being termed true angina,
while those presenting no organic lesion are called false
angina, the latter including toxic, hysteric and vasomotor
causes. Clinically, it is hard to follow out this classifica-
tion. Professor Osier says "while 15 of the subjects of
true angina on my list are dead, every one of the
20 patients with pseudoangina is alive." Yet under
diagnosis he says: "One must be a professional Ulysses
in craft and wisdom not sometimes to err in estimating
the nature of an attack of severe heart-pain. There is
no group of cases so calculated to keep one in a condition
of wholesome humility. When you jostle against a
hale, vigorous specimen of humanity, who claps you on
the back and says, ' The deuce take you doctors ! I have
scarcely yet gotten over my fright,' you would like to
forget that five years before you had almost signed his
death-warrant in a very positive diagnosis of angina
pectoris vera. On the other hand, Mr. X. has left you
with the full assurance that his cardiac pains are due to
overwork or tobacco, and you have comforted his wife
and lifted a weight of sorrow from both by your most
favf)rable prognosis. With what sort of appetite can yoti
eat your breakfast when, a week later, you read in the
morning pajx^r the announcement of his sudden death in
the railway station? Or take another aspect, poor
Mrs. Doe has gone softly all these years in the bitterness
of her soul since you took that grave view of her vaso-
motor or hysteric angina."
8o we see that while the diagnosis of angina is not very
difficult, the placing of an individual case in one or the
other of these classes may be very risky. Of the cases
reported herein the first three are certainly of the true
angina, the first having as the organic lesion a myocar-
ditis, beginning very probably as a fatty infiitration of
the heart, followed by degenerative changes and cardiac
dilation, the anginal seizures stopping after the heart
became dilated. The second and third cases were due
to atheroma of the coronaries. Of the fourth and fifth
cases there is still some element of doubt in my mind as
to where they belong under this classification. The
fourth, however, I consider as of toxic origin, as there
was certainly suflficient excuse for t)elieving it due to the
use f)f either tobacco or coffee, and the symptoms ceased
promptly after discontinuance of these articles. And,
further, there is a history of disturbance of the circula-
tion following the excessive u-^e of tobacco or alcohol for
years. Several years ago the patient told me that he
frequently had an intermittent pulse, and Dr. Carver,
who has known him much longer than I have, tells me
that he used to complain of these pains in the arm after
taking alcohol, 10 to lo years ago.
As to the organic changes in Case V, I am still in
doubt, but I am certainly afraid to tell the patient that
her trouble is unimportant for fear that "my appetite
might some day be spoiled " by learning of her sudden
death if she should lead her accustomed life. In other
words, I fear that she has a certain amount of arterio-
sclerosis. Her attacks certainly are neither neurotic nor
toxic, and so must be either true angina or of vaso-
motor origin, with, it seems to me, the evidence in favor
of the former.
Symptoms. — As regards the symptoms of angina, little
more need be said. The specially characteristic features
are the pain, and the sensation of uneasiness and dis-
tress, reaching even to extreme anguish, which accom-
panies the pain, or which may be present as the sole
symptom of the disease. The pain itself is probably no
different from other cardiac pain, but is distinguished by
its paroxysmal character and by the accompanying dis-
tress. The pain, as in the cases cited, is usually limited
to well-defined areas, the central point being under the
sternum or in the heart, and from thence radiating to
one or both shoulders or arms, usually the left. There
may be a sensation of numbness in some part, as the
arm, either constant or only during the paroxysms, or
there may be disturbances of some of the special senses,
as of sight or hearing, and dizziness or vertigo may be
present. Most of the other symptoms are inconstant.
The face is usually pale, but there may be local or gen-
eral lividity. There may be a struggling for breath, but
there is no difficulty in taking a long breath.
In cardiac asthma there are also the symptoms of
cardiac pain and difficulty in breathing, but it does not
seem as if there should be any difficulty in distinguish-
ing the two, as they differ in so many particulars. There
are also many cases of pain in the region of the heart
and in the left chest in persons who are anemic or are
insufficiently nourished from any cause, but these
patients are usually women and are younger than the
age at which arteriosclerosis is usually found. The
cases of this kind which I have seen, so far as I can now
recall, occurred between the ages of ;50 and 35 ; while
true angina is rare before the age of 40 or 45.
There are many patients who come to us complain-
ing of heart disease, because of pain and distress in the
region of the heart and also because of palpitiition or
flatulency and other gastric disturbances. These cases
are usually of gastric origin, but should not be passed
over too lightly, as sometimes gastric symptoms accom-
pany true angina, and gastric disturbance is a frequent
cause of the paroxysms. A careful study of the case
will, however, usually reveal readily a means of easy
differentiation.
Treatment.— '\^\\Q important thing in treatment is to
search out the cause of the disease and the exciting
causes of the attacks, and so far as possible remove
them. Of drugs, the one which seems to be of the
greatest value is potassium iodid, given in moderate
doses, not more than 10 or 15 grains, three times a day
for a long time. During the attack, nitroglycerin is the
best in many ceases. Frequently, however, the only
drug that will give relief is morphin, and sometimes a
good deal of it is needed. The cause of the pain is not
known, but it has been compared to that occurring in
other hollow organs, as in renal and biliary colic, and it
seems to me that the same precautions should be used in
the administration of morphin, for here and there the
paroxysms may end suddenly, and then the poisonous
symptoms due to the morphin will prevail. Therefore,
if the pain is not controlled soon by morphin, I would
use chloroform or ether.
Remarkable Peonndlty.— A Valencia journal is responsi-
ble lor the statmnent that a woman of 44, married for 24 years,
has given birth to 24 living healthy ohiklren at full term, all
being single births. One physician has assisted at the delivery
of 19 of these children.
298 AMERICAN Medicine]
TUBERCULOSIS
lAcouST 23, 1902
TUBERCULOSIS : ITS TRANSMISSION AND PREVEN-
TION.'
BY
HENRY B. HOLTON, A.M., M.D.,
of Bratlleboro, Vt.
It is estinmtt'd that one-sev(!nth of the world's i)<)pu-
lation die from tuberculosis, every year. In this coun-
try, indudinfT its insular possessions, there are upward of
half a million persons suffering from tuberculosis, and of
these cases 400,000 will ultimately terminate in death.
Were we engaged in a war which would neceasitate our
putting into the field half a million soldiers, four-fifths
of whom would perish in h period of two or three years
from contagious diseases, the press and the whole people
would demand of those in authority that etticient means
be taken to prevent so great a calamity. Anexampie of
the excessive mortality from this disease is shown from
the statistics taken in Germany during the time of the
Franco-Prussian war ; the mortality being twice as large
as that from the casualties of the war. The devastation
wrought by this " white plague " has led to our meet-
ing here with a view to formulate such measures as seem
best calculated to stay its progress.
In order that the tuber le bacillus may live and
flourish it must find suitable soil upon which to rest and
it must also be free from antagonistic elements which
would encompass its destruction. The great source of
these infective germs is undoubtedly from the expectora-
tion of persons suffering from the disease. Of the prob-
able other sources, meat and dairy products are to be
considered. Smith, Koch, and some others, hold to the
opinion that it is not proved that the bovine bacillus can
infect the human being ; it is to be noticed that they do
not say that it is impossible. The fact is well established
that man has been accidentally inoculated with bovine
tubercle bacillus. However, it is properly claimed that
this is different from natural infection ; although it
demonstrates conclusively to my mind that the bovine
bacillus is pathogenic to the human being. Eminent
bacteriologists claim that morphologically they are not
the same. Lartigan and Ravenel have demonstrated
that there is a marked difference in the appearance of
the tubercle bacilli found in the different tuberculous affec-
tions of the body. Chaveau, using material from
patients with acute miliary tuberculosis, that was pre-
pared in the form of an emulsion and fed to calves,
demonstrated that human tubercle bacilli were possessed
of sufficient virulence to produce the disease in these
animals, and when injected subcutaneously it caused
local tuberculous disturbance ; hence he claims that they
are practically identical.
Prof. Behring, in his forthcoming book on tuberculo-
sis in cattle, details the results of six years' investiga-
tions at ^larburg, where he wa-* a.ssisted by Drs. Ruppel
and Roemer. He affirms that tuberculosis in man and
cattle is propagated by identical bacilli, and that the
seeming differences between human and bovine bacilli
result from the capacity of the bacilli to accommodate
themselves to the organism in which they live. He
reaches the conclusion that, chemically and physiolog-
ically, tubercle bacilli in man and cattle are of the same
species. He has successfully infected cattle with virus
from human beings, producing fatal tuberculosis. He
has discovered a method to render cattle immune against
tuberculosis by vaccinating them when they are young.
This method is used on farms at Marburg, and he
declares it to be his greatest discovery.
This leads to the question, What effect environment
may have upon this vegetable germ? It is well known
that other vegetable seeds germinating under different
conditions of air, soil, humidity, heat— in fact, very dis-
similar environments— produce almost a different va-
1 Address of the President before the American Congress on Tuber-
culosis, June 2, 1902.
riety, or at least a very much changed product. Giving
due consideration to this fact, is it not proper to con-
clude that the observed differences in the bovine and
human tubercle bacillus may be owing to this change in
environment. The difference in virulence has been
claimed as another evidence that bovine and human
bacilli are distinct varieties, but we know that other
pathogenic bacilli vary in virulence under practically the
same conditions.
Many have claimed that unless the udder of the cow
was tul)erculous there could not possibly be any danger
from the use of the milk and its products. The report
made in 1895on " The Infectiousneas of Milk from Tuber-
culous Cows with no Lesion of the Udder," by Prof.
Harold C. Ernst, for the trustees of the Massachusetts
Society for Promoting Agriculture, seems to have been
overlooked. After giving a detailed report of each
examination he sums up the result as follows :
There were 121 examinations of milk and cream made, the
specimens coming from 36 different animals. The bacilli of
tuberculosis were found in one or more cover glasses upon 19
different occasions. Tiiese 19 positive results were obtained
Irom 12 different animals, and the bacilli were found in about
equal proportion in the milk and the cream ; they were seen
more than once in milk from the same cow, at different exam-
inations, six times. The bacilli were actually seen, therefore,
in specimens from one-third (3-!^%, ) of the animals examined.
That these animals were actually affected with tuberculosis,
and that the udHer was free from disease, was proved in all
possible cases by careful postmortem examinations. These
were conducted upon 20 out of 3G animals and the notes of that
examination are given.
A series of experiments were made by Dr. Ernst to
ascertain if it were possible to communicate tuberculosis
by the use of milk from cows affected with the disease,
yet having healthy udders. These experiments were
conducted under as careful precautions as could be
devised; first, injecting their milk subcutaneously in
other animals ; second, by feeding healthy calves posi-
tively free from tuberculosis with the milk of cows
having the disea.se, but who had healthy udders. The
results of these experiments showed that the dhea.se was
communicated both by inoculation and by using the milk us
food. In addition to these experiments, reports of
clinical cases in which the disease had been traced to the
use of milk as food were obtained by a circular sent
to both physicians and veterinarians, with the result
that out of nearly 1,000 replies about 6^. reported having
seen cases suspet^ted to have resulted from this cause.
These reports were made in 1890, when the fact that the
disease was the result of a specific germ was only
partially appreciated. It may be said that these clinical
reports are of small value as they are only opinions and
not actually verified in a thoroughly scientific way by
those reporting them.
As a result of these carefully made tests, Professor
Ernst draws the following conclusions :
1. While the transmission of tuberculosis by milk is prob-
ably not the most important means by which the disease is
propagated, it is something to be guarded against most care-
fully.
2. The possibility of milk from tuberculous udders contain-
ing the infectious element is undeniable.
3. With the evidence here presented it is equally undeniable
that milk from diseased cows with no appreciable lesion of the
udder may, and not infrequently does, contain the bacillus of
the disease.
4. Therefore, all such milk should be condemned for food.
It has been asserted that inoculation with bovine
bacillus will produce the disease in other animal species ;
this is corroborated by the reported cases of accidental
inoculation of human beings by the bovine Imcillus as
reported by Ravenel and others. Again we find the
disease communicated by milk, containing the bacillus,
used as food for other species of animals ; evidently the
experimenter did not feel at liberty to try feeding
human beings with milk containing the germs of tuber-
culosii, but numerous cases have been reported in Mhich
persons using the milk from cows found to have been
August ii, 1902]
TUBERCULOSIS
■ American JIemcinf 299
aifected with tubercle bacilli, have developed tubercu-
losis, from which they died.
Dr. .Jacobi, of this city, in a recent article calls atten-
tion to the following reported cases :
A boy of 5 months, who was perfectly healthy while at the
breast, when fed on raw cow's milk suffered from emaciation,
diarrhea and anorexia. He died after two months. There was
tuberculosis of the intestines and of the mesenteric glands; all
other organs were normal. The cow that furnished the milk
died suddenly two months afterward. She had pulmonary
and pleural tuberculosis ; the udders were intact.
Four children suffering with intestinal tuberculosis had no
hereditary predisposition, but had been fed with the raw milk
of tuberculous cows.
In a boarding school, 13 girls contracted tuberculosis ; six of
them died, several perished of primary intestinal tuberculosis.
The milk furnished came from a tuberculous cow with badly
infe<!ted udders.
The thoracic and abdominal viscera of a cow were received
for examination. This animal had had the reputation of being
the finest cow on the farm until she emaciated rapidly and died.
On account of her splendid condition her milk was selected by
the farmer for his own infant. This child commenced to pine
away and died of miliary cerebral tuberculosis at the age of 2J
years.
In connection with the experiments of Ur. Ernst it
is interesting to note that of 19 calves, dropped by these
tuberculous cows with healthy udders, and killed within
six days after birth, not one showed any evidence of
tuberculosis, although a most careful examination wa.s
made with special reference to this j)oint. This would
seem to be strong evidence that the disease was not
transmitted from mother to offspring. The consensus of
opinion seems to be that the tubercle bax?illus is not trans-
mitted from parent to child. There are, however, cer-
tain inherited conditions which predispose the child to
tuberculosis, viz. : Nervous lemperament, resulting in a
relaxed mucous membrane, which is easily abraded,
affording a particularly good nidus for the bacillus to
lodge and develop ; deficient nervous supplt/ to the assimi-
lating organs, resulting in impoverished and sluggish
gland secretion, which lacks the power to destroy the
germs when they find their way into the system ; 7iar-
row chests, which allow the mucosa of the lungs to be
more quiet and prevent proper aeration of the blood.
Ciuite as powerful agents are the various acquired con-
ditions which give place to and afford the desired rest-
ing place for the seeds of this dread disease.
Among some of the most active pretlisposing causes
, are intemperance, insufficient clothing, living in filthy,
damp localities, overcrowding, improper or insufficient
food; in fact, all the various conditions which tend to
reduce the vitality of the individual, thus rendering
them more susceptible when tubercle bacilli come
their way. Considering the number of persons born
with or awiuiringa nervous system and mucous surfaces
reatly to aid in developing the tubercle bacilli, and the
presence everywhere of sputum containing myriads of
these germs, and their existence in various food prod-
ucts, leads us to inquire why any have escaped this
scourge. Many germs are undoubtedly destroyed by
sunlight, while those that survive and find their way by
inhalation into the air passages or with food into the
alimentary canal, are met by secretions of various glands
" which a<*t as germicides, destroying a large portion of
them. In many individuals the remainder do not find
a proper lodgment, hence are thrown off without having
infected their host. With this brief review of the prin-
cipal sources by which tuberculosis is communicated to
human beings, we come face to face with the problem
which we have gathered to consider and which I trust
we shall in some degree solve, to wit : What means shall
be adoptwl to prevent this continual infection of the
human family?
First in importanex; is the education of the masses in
hettf^r methods of living; this is the foundation upon
which to rear the fabric of prevention. They must Ik» made
to a|)pr(H-iate fully the necessity of clean, well-ventilated
homes, with |)erfe(rt hygienic surroundings; to have
plain, properly-cooked food ; to avoid all excesses, par-
ticularly alcoholic; in fact, to avoid everything that
tends to reduce vitality. Especial care must be used by
those who contract the disease in disposing of expector-
ated matter. We must recognize the fax;t that in the
large towns and cities the dwellers in those portions
known as tenement-house districts cannot regulate
their surroundings, therefore influences must be brought
to bear upon owners of such property to build and keep
them in such sanitary condition as local health authori-
ties may require. If they do not do this, then legal
enactments should be secured giving health boards the
power to compel compliance with such sanitary require-
ments. We must insist that all tenement houses lie so
constructed as to give each room plenty of sunshine and
fresh air and that they are not overcrowded.
We should impress the laity with the truth that in
damp and low undrained localities, as well as in crowded
cities, the germs of this disea.se particularly abound.
Second, we believe that having taught the coinmuni-
cability of this " plague" by means of germs found in
the secretions of those suffering with it, compu/sori/ noti-
fication should be insisted upon. The head of the family,
the patient or the medical attendant should be made
strictly accountable in reporting a case of pulmonary
tuberculosis the same a.s any other communicable dis-
ease, not for the purpose of quarantine, but that the
family and all who may have daily associations with the
patient may be able to take necessary precautions, and
also that the patient and family may rec^eive such in-
struction as will prevent the patient becoming a source
of infection to others. The objection that such notifi-
cation will tend to shut the person out from all com-
panionship and prevent those who are able from
contributing to the support of themselves and others
dependent upon them, is not to be considered. With
proper care patients may remain in their families with-
out danger of infecting them. One o "ject of the notifi-
cation is to instruct all concerned as to what " proper
care " means. If the patient is to be cured, it should
be understood by every one that an early and accurate
diagnosis should be made and a dear and truthful state-
ment given of the condition found, with the further
information that under certain conditions a cure is prob-
able. To this end the earnest and faithful cooperation
of the patient must be obtained. He must thoroughly
understand his condition and what effort he should
make in order that a cure may be effected.
Requiring cases of tuberculosis to be reported is not
of recent origin. More than 125 years ago, in the King-
dom of Naples, not only was notification recjuired with
severe penalties for neglect to do so, but other require-
ments to prevent its spread were enforced by eciually
heavy penalties, as is shown by the following e<lict of the
Sovereign of the Kingdom of Naples issued on July 19,
1772 :
1. The physician shall report the consumptive patients
when ulceration of the lungs has been established, under
penalty, for the first offense, of 300 ducats, and upon repetition,
of banishment for 10 years.
2. An inventory shall be made by the authorities of tho
clothing in the patient's room, to be identified after his death,
and if any opposition shall be the made the person doing so,
if he belongs to the lower class, shall have three years in the
galleys or in prison ; if to the nobility, three years in the castle
and a penalty of 300 ducats.
3. The household goods which are not susceptible shall be
Immediately cleansed, and those that are susceptible shall at
once be burned.
4. The authorities themselves shall tear out and replaster
the house, alter it from cellar to garret, carry away and burn
doors and wooden windows and put in new ones.
5. The poor sick shall be removed at once to a hospital.
6. Newly-built houses cannot be inhabited before one year
from their completion and six months after plastering has been
finished and repairing has been done.
7. The superintendent of hospitals must keep In separate
places clothing and bedding for the use of consumptives.
Severe penalties are threatened to those who buy or
■sell objcicts which have Ijeen use<l by consumptives, and
300 AMEBICAK MEDIOUrZ]
TUBERCULOSIS
[AUGUST 23, 1902
to servants, members of the family and to any trans-
gressor whomsoever.
What was the apparent result of these stringent regu-
lations at tlie time they were promulgated ? The mor-
tality from tuberculosis in that kingdom was as nearly as
can be determined 10 per 1,000 of population; in the
same territory today it is 1.16 per 1,000, and Italy has a
lower rate of mortality from this disease than any
Euroi)ean country. Jt should be borne in mind that
when this edict was published it was not known in what
way the disease was communicated, but simply that it
was contiigious. A hundred years later Koch announced
the discovery of the tubercle bacillus, giving us an
opportunity to prevent its spread by simpler and
much less onerous regulations ; shall we, with this exam-
ple of prevention before us, hesitate longer to make
and execute the regulations that our increased knowl-
edge indicates will practically stamp out this pesti-
lence ?
We do not apprehend that there would be as much
trouble in collecting reports of cases as has been fearetl.
A most successful example is found in the April report
of Major Gorgas, Chief Sanitary Officer at Havana, who
having succeeded in eradicating yellow fever from that
city, has now entered upon a campaign to exterminate
tuberculosis. He says: "The great object of the
dei)artment has been to get the cases of tuberculosis
located, and through the various measures used we have
now about 2,500 cases on our lists. These names are
carded, with residence and other data, and popular lit-
erature sent to them, explaining their disease, its com-
municability and the best manner of care. I believe
that, if the system can be continued for four or five
years, tuberculosis can be eradicated as yellow fever has
been. We had 900 deaths last year from tuberculosis ;
placing the average length of a case of tuberculosis at
three years, which is a longer period than is usually
given to this disease, we would have 2,700 cases of tuber-
culosis on hand in this city. As we have at present
2,500 located and carded, it can be seen how thorough
and successful our system of reporting has been."
The third preventive which presents itself is of
marked importance, possessing dual properties of pre-
vention and cure. Sanatoriuras for the tuberculous open
to a large class an avenue of escape from certain death ;
at the same time they prevent the spread of this dread
disease to a considerable extent. The first institution of
the kind was established in Glermany in 1859, now there
are over 40. The first in this country was established by
Dr. E. L. Trudeau, at Saranac Lake in the Adirondacks
in 1884. Other private sanatoriums have been inaugu-
rated from time to time until now there are between 40
and 50. Massachusetts Wiis the first to open a public
institution devoted to the care of the tuberculous. Con-
necticut followed. New York City opened one last Feb-
ruary and several other States are reported to have made
provision for similar institutions. Abroad they are
moving rapidly in this matter. Sir Edward Cassell has
lilaced at the disposal of the King of England $1,000,000
for the establishment of a sanatorium for the tubercu-
lous. In order to ensure this institution being as perfect
as possible. His Majesty has offered three prizes of $2,500,
^1,000 and $500, open to men of all nationalities, for the
best plans and essays for the construction of a model
sanatorium. Our own government in 1899 established
one for the Army, Navy and Marine-Hospital Service at
Fort Bayard, New Mexico. By gathering as many as
possible into sanatoriums for treatment we prevent infec-
tion of other members of their families and can more
readily instruct the patient in the best methods to pre-
vent communicating the disease to others, and they are
also constantly under the watchful care of an experienced
medical man. They are thus gradually brought from
under the cloud of disease into the sunshine of health,
and they can then return to their former occupations
and associates, and they will act as missionaries, instruct-
ing others in right methods of living to prevent their
acquiring the disease. It has been found that the mor-
tality among patients living in the neighborhood of
sanatoriums has been much reduced through the infor-
mation imparted by the inmates as to the proper
methods of living.
The reported result of treatment in the various sana-
toriums is certainly most wonderful and demands the
attention of the profession and i)ublic. These reports
show that from 25^ to 90^ of ca^es are cured. The
variation in results depends in a, large measure upon the
stage of the disease when the patient is admitted to the
institution. Naturally, the earlier treatment begins, the
greater is the prospect for permanent cure. Hence, the
public as well as the profession should be impressed
with the great importance of an early diagnosis of tuber-
culosis. In the incipient stage before cough appears, or
tubercle bacilli are found in the secretions exjiec-
torated, when the patient seeks a prescription because
" he is run down," some degree of anemia is present, a
slight rise in temperature is noticed, and possibly
slightly diminished resonance at the apex of lung.
X-ray examinations may help to confirm diagnosis ; but I
would also advise the use of tuberculin. This has never
been in general use by the profession after its failure as
a therapeutic agent. Its principal use has been by vet-
erinarians for the purpose of diagnosing tuberculosis in
bovines ; for this purpose it has proved accurate and
reliable. A few practitioners have used it for the same
purpose in the human being with a like result. The
Superintendent of the London County Asylum for the
Insane, in England, who was desirous of determining if
certain of his patients had tuberculosis, reports that of
55 cases tested with tuberculin, characteristic reactions
occurred in 45, and 84 of these terminated fatally. Of
this number autopsies were made in 29 and active tuber-
culous infection was found in every instance. Ten of
the 55 did not react; of these 10 patients 5 have since
died. At the postmortem examinations no traces of
tubercle bacilli were found. The consensus of opinion
of all who have used it to any considerable extent seems
to be that it is accurate as a means of diagnosis, but is
entirely harmless both in the tuberculous, and nontuber-
culous. The time has passed when the expectant plan
of waiting for developments can be pursued ; for it has
always been a plan that led through much suflfering to
death. With the knowledge heretofore possessed it was
all that could be done ; now, however, no practitioner
can enter the plea that he is doing all that can be done
while he is waiting for developments without being
charged with being accessory to the death of the patient.
With an early diagnosis the person invaded by tubercle
bacilli is at once placed in position and surrounded by
the means to destroy and expel the enemy with proba-
bilities very largely in favor of ultimate and complete
victory. The various private sanatoriums offer to the
wealthy the way of escape from long invalidism, suffer-
ing and death, and lead them through pleasant avenues
back to health, the pursuit of happiness and useful occu-
pations, surrounded by loving friends who have been
anxiously waiting the auspicious result. But what of
the bread-winner struggling to gain sustenance for a
family of dependents, or of the youth trying to win his
way from poverty and obscurity to competency ? Shall
they remain as now, doomed to certain but gradual
wasting decay and death, with the added anguish that
they are likely to communicate the same plajsue to the
loved ones for whom they had cherished most lofty
ambitions? To this class the State 'owes a duty that
should not longer be delayed. It should provide sana-
toriums in which at the earliest possible moment the
victims of this terrible scourge can be placed and thus
given all aid po.-sible to bring him back to his just heri-
tage and all the duties of citizenship. For those who
through ignorance or neglect have advanced beyond the
curative stage there should be provided homes where
AUGUST 23, 1902]
ADMINISTRATION OF SALT SOLUTION
lAMERiCAN Medicine 301
they may be cared for at the same time they are pre-
vented from infecting others.
It will be the duty, and undoubtedly the pleasure, of
this congress to consider these various questions. We
believe that recommendations should be made to State
and Municipal Health Boards urging them to increase
their efforts with a view to educating all classes of our
citizens in the knowledge of the infectiousness of this
disease and the best means of preventing its spread,
also as to the notification of infected pereons, and the care
that should be exercised in the use of dairy products and
beef as food by the public in general.
Further action should betaken setting forth the duty
of State and municipal governments to provide sana-
toriums where the poor can seek cure in the earliest
stage of the infection, and hospitals for the care of
advanced cases, where the patients can be made com-
fortable and prevented from conveying the germs to
others.
THE IMPORTANCE OF PROPER TEMPERATURE IN
THE ADMINISTRATION OF SALT SOLUTION:
AN ACCURATE METHOD OF DETERMINING
TEMPERATURE.'
BY ,
R. C. COFFEY, M.D.,
of Portland, Oregon.
Surgeon to, and Medical Director of, the North Pacific Sanatorium,
Surgeon N. P. R. R., Member of the American Medical
Association, Oregon State Medical Society,
and City and County Medical
Society of Portland.
The multitudinous conditions, in medical cases as
well as surgical, for which normal salt solution is being
administered, brings sodium chlorid forward as one of
the most important therapeutic agents we have. This
is evidenced by the numerous papers which are being
written by medical men upon the use of this agent for
various conditions. At least 30 original papers have
been presented to the medical profession, through the
various journals, during the past two years, setting forth
the benefits which may be derived from the use of nor-
mal salt solution in a large class of ea.ses. In fact, if we
credit the literature of this subject, we must conclude
that it is more nearly a panacea than almost any other
remedj' which we have at our command.
The physiologic reason for this has been brought out
quite fully in the recent writings of Professor Loeb, of
Chicag(j. Dr. Woods Hutchinson, in his late book on
comparative pathology, anthropomorphically speaks of
the cells of the animal organism as citizens. He says :
" We talk about our body republic being an air breath-
ing and land living organism, but as a matter of fa<^'t, all
of our citizen cells, outside of the lung, are still abso-
lutely and necessarily aquatic in their habit, and marine at
that ; they cannot live except when kept continually
bathed in a normal salt solution." This explanation, as
well as that of Professor Loeb, gives us a scientific basis
for the many uses to which salt solution is applied.
Seeing, then, that this agent is of so great importance,
not only as a relieving agent but as a life-saving agent,
it has seemed to me for some time that its method of
administration is rather crude and inaccurate, and espe-
cially do I refer to the inaccurate methofl of dcterinining
the temperature of the solution.
I believe that all authorities agree that the tempera-
ture of salt solution should in all cases be above the nor-
mal body temperature. The exi)eriments which I shall
relate I think pnjve very clearly the inaccuracy of the
methods heretofore used for obtiuning an accurate tem-
perature of the solution as it enters the body. HoUopeter,
in a rec«nt article in the Philadelphia Medical Jourmd,
says, "The solution should be at least 115° or VM°, and
'Head before the Clly and County Medical Society of Portland,
Ore., April, 1902.
delivered to the tissues at 106°. This temperature must
be sustained throughout the procedure." Bov6e, in one of
his extensive articles on salt solution, says, "The tem-
perature of the solution when it reaches the tissues
should be 105° to 120°." He says this is important, as
the stimulating properties of the high temperature are
needed and particularly in shock, renal insuflSciency,
uremia, eclampsia, and sepsis, as the skin must act
strongly as an emunctory. He says : " I have seen hot
salt solution in the reservoir, and yet owing to some
obstruction in the needle or flow tube, it was cold when
it reached the tissues. Considerable allowance must be
made for fall in temperature of the solution in passing
through the tube." These statements are all very good,
but how do we know what the temperature of the solution
is when it reaches the tissues ? Bov6e lays much stress on
the temperature, and yet is so indefinite as to say, "Cbn-
siderable allowance must be made for fall in temperature
of the solution."
If any importance is to be attiuihed to the tempera-
ture of the solution then we have no right to allow the
life of a patient to hang on such indefinite threads as the
term "considerable." About two years ago a number
of incidents occurred which caused me to believe that
some patients who had been treated by salt solution and
who died might possibly have been saved had the tem-
perature of the solution l)een tested accurately and regu-
lated. 1 began a series of experiments with a crude
apparatus which opened my eyes to the uncertainty of
the methods which have commonly been used for the
atlministration of salt solution. I find that the heat loss
of the solution in going from the solution jar to the
needle through a tube six feet long may vary from 2°
under certain conditions to 40° under other conditions.
Therefore, under one condition we might i)rwluee a
sloughing due to excessive heat of the fluid ; while, on the
other hand, the good effects of the salt solution may he
302 Ahebioan MBSiciircj
ADMINISTRATION OF SALT SOLUTION
|Al-f;r:
counterbalanced by a temperature below i)0°. I find
that there are a number of conditions which greatly
modify the temperature of the solution when it
reaches the ti.ssues. I recently called for salt
solution for saline infusion in a case of severe
shock, and noticing that the jar was rather cold,
I had the temperature taken and found that
the solution in the jar was just 92°. The tube
was six feet long and the needle was but a lit-
tle larger than a hypodermic needle. Experi-
ments prove that in this case the solution would
have been at the temperature of the room when
it reached the tissues. 1 observed that the tem-
perature of the room had much to do in in-
fluencing the temperature; that the length of
the tube greatly influenced the heat loss ; that a
small tube lost less heat than a large one ; that
an old tube which had been boiled a great many
times lost much more heat than a new one ; that
a corrugated tube seemingly lost more than a
smooth tube, but that the chief difference lay in
the size of the needle.
Following are some statistics from actual
experiments, which will show conclusively that
if the temperature of the solution is to be con-
sidered at all, it is essential that we should have
definite means of determining the temperature
at the end of the tube next to the needle. I
also noticed in running through 89 jars of solu-
tion that air bubbles passed out through the
needle in three instances. I presume that it is
not known whether or not any considerable
influence is brought to bear by the introduction
of air into the tissues or even into a vein, but
I h'^ve arranged in the apparatus, which is shown
herewith, to have a trap blown on the tube which
very effectually catches any air bubbles that may
go down the tube toward the needle. Person-
ally I question whether air bubbles do serious
damage. If not, the trap is a useless appendage on the
appliance.
Kind of Tube.
White corrugated tube..
Smooth black pure gum..
6ft. Kin
6 ft.
Smooth black rubber 6 ft.
Smooth white rubber...
Old corrugated tube..
6 ft.
6 ft.
^^m
Vsln.
Kin.
fin
3 ft,.
3 ft.
3 ft.
3 ft.
3 ft.
M'
130°
120°
110°
100°
110°
120°
110°
100°
120°
110°
1.30°
120°
110°;
100°
86° I.W°
120°
110°
100°
70°; l;M°
120°
110°
100'
*'s .
.o ,^
83=
130°
120°
122°
113°
106°
96°
103°
116°
107°
ii8°
113°
104°
121°
113°
10B°
123°
11.5°
107.,')°
98°
118°
113°
103°
116°
108°
S = 8
120°
111°,
104 .,5°
94 5°
101°
114°
105 5°
96.5°
Ill.ft°
102.5°
119°
111°
104.,5°
v5.5°
l.>lo
113°
104.5°
96.5°
116°
111°
101 ..5°
94.5°
114°
106°
Experiments Showing the Influbnck of the Size of the
Needle upon the Tempek.\ture.
Pres-
sure.
Length
Tube.
Temper-
ature In
Jar.
Length of Time
required to run
through .500 grm.
'Si: S£
3 a
3 ft.
3 ft
3 ft.
3 ft
4 ft.
4 ft.
4 ft.
6 ft.
6 ft.
120°
120°
121°
120°
120°
19 minutes.
1 ■
3 "
19
3
1
98° Small (No. 1).
108° Medium (No. 2)
l-iO" Large (No. 3).
9;° Small (No. 1).
118° Large (No. 3).
In the device represented in the accompanying cut
the .solution is held in a graduated jar in which is held a
stationary thermometer passed through a rubber cork.
At the lower extremity, near the stop-cock, a thermom-
eter is fastened in the center of a glass tube which allows
the solution to surround the bulb of the thermometer.
Next, I have used a three-way stop-cock which serves
more than one purpose. First, in case it is necessary
during the administration of an infusion to stop, the
cold solution in the tube may be run out through a side
arm until the temperature is brought down to the point
desired. Second, in case the solution is too cold, a por-
tion of the solution may be run out at the side arm and
thus the temperature may be regulated to a nicety and
the temperature at which the solution is administered
will be as exact as any other problem in physics.
The device is not complicated, and the two essential
things are the thermometer and three-way stop-cock.
These may be used with an ordinary rubber bag or foun-
tain syringe and perfect accuracy may be obtained, and,
in my opinion, some lives at least will be saved by this
precaution. The three important points in this device are :
stationary thermometer in the jar, thermometer in the
tube and the application of the three-way stop-cock.
While it is probable that intravenous or subcutaneous
transfusion has a more important bearing on this subject
than abdominal flushing with salt solution, we have all
seen very bungling work done in irrigating the abdom-
inal cavity. One assistant .says the solution is too hot,
another that it is too cold, and the operator thinks it is
just right, depending upon the part of the surface which
is touched by the water or the amount of tolerance
which has been produced by a long continued operation.
We are very much surprised when we take the tempera-
ture of the solution.
I have also devised a glass pitcher in which is held a
August 23, 1902]
STATE CAEE AND SUPERVISION OF INSANE jakbricas mkdioine 303
stationary thermometer held in a rubber cork which
enables the nurse to mix the solutions and get the exact
temperature desired, before any portion of it is poured
into the abdominal cavity. This at times greatly facili-
tates abdominal flushing and must necessarily be of
benefit to the patient when the solution is applied to the
peritoneal cavity, as the condition for which it is used is
generally extreme shock which all authorities recognize
as one which is benefited by hot applications.
Note. — Since the cuts represented were made, I have
found that it is ditHcult to have a square top blown upon
the solution jar and have therefore decided to have a
convex top and but a single cork through which both
the thermometer and the gla.ss tube will pass. I think
it will also be as well to leave off the bulb for air bubbles
as it is of but little pra 'tical benefit.
SKIN GRAFTING : A NEW METHOD.
BY
.S. T. RUCKER, ii.D.,
of Chattanooga, Tenn.
Attending Surgeon, Erlanger Hospital.
I am led to believe from the following case that
large strips of the entire skin can be transplanted to old
granulating surfaces and made to grow. The method,
so far as I know, is original with me ; though the
same principle is involved in plastic operations, as about
the face, where pieces of skin are dissected off, excepting
a pedicle attachment, and shifted to cover some surface
where the skin has been destroyed by disease or trauma.
Effie R., aged 12, white, health good, was run over by a
tram car. All the skin and superficial fascia was torn from the
inner and posterior surface of the left leg. from knee to ankle.
She was sent to Erlanger Hospital in January, 1902, from Soddy,
Tenn. Pour attempts were made to graft by the Thiersch
method, but for some cause none was successful. When she
came into my charge in April, I found a large granulating sur-
face, and learning of the failures of the former grafts, I deter-
mined to try a different method. She was prepared in the
usual way, and the wound and part from which graft was to be
taken were wrapped in wet bichlorid gauze for 24 hours pre-
vious to operation. When she was brought to the operating
room the parts were again cleansed and irrigated with salt
solution. With the patient under chloroform, the granulations
were carefully pared down with a sharp curet, and wrapped in
gauze wet with warm salt solution. From the outer surface of
the right thigh I dissected off a strip of skin, one inch wide and
six inches long, down to the superficial fascia. The graft was
irrigated with warm salt solution, and then applied whole,
diagonally across the granulating surface. Each end of the
graft was anchored or sewed with silk suture to bared edge of
skin on either side of wound. The sides of the graft having a
tendency to roll under, two guy threads were placed on each
side of the graft equidistant, and the other ends fastened to the
skin outside of the wound. This kept tlie graft in correct posi-
tion. It was covered with gutta percha tissue: then a layer of
sterile gauze and absorbent cotton, followed by a roller band-
age, lightly applied. A straigjht side splint was fastened to the
outside of the leg to immobilize the knee. The wound where
the graft was taken was closed by continuous silk suture. The
patient was put to be<l and kept on her back. The dressing was
removed on the fourth day, and the whole of the graft was
found adherent and of light purple color, showing small blood-
vessels pushing >ip through it. It was irrigated with warm
salt solution, and the same kind of dressing applied. The
special dressing was dispensed with in ten (lays. For some
weeks following, the wound healed readily about the graft.
On .July .5 another operation was decided on. The patient was
prepared as before, and under chloroform I dissected oil' a strip of
skin 44 inches long and 1 inch wide from the anterior surface of
the lefl thigh, and placed this lower down on the wound. The
same technic as in the first operation was followed. Tlie dress-
ing was removed the third day, and the whole of the graft was
found adherent. At present writing the last graft is growing
nicely, and the wound bids (air to heal soon without further
interference.
City Charities Petition for Former .Superintendent,—
The 2.') charitai>le and philanthropic associations of San Fran-
cisco have united in signing an appeal to the governor, asking
that former superintendent O. E. Osi)orno be reinstated in his
position in the Home for the Care and Training of Feeble-
minded Children. This position was lately made vacant by the
expulsion of Dr. Lawlor.
SPECIAL ARTICLES
ESSENTIALS OF AN ADEQUATE SYSTEM OF STATE
CARE AND SOPERVISION FOR THE INSANE.'
BY
FREDERICK PETERSON, M.D.,
President of the New York Stat« Commission in Lunacy.
Twenty-tliree years ago I was a resident physician in a gen-
eral hospital in a city of perhaps 200,000 inhabitants. The
nearest asylum for the insane was 200 miles away. As a conse-
quence acute cases of insanity had to be placed in police stations
or in the general hospital pending arrangements for their re-
moval to the asylum. On inquiry you will find that in nearly
all the cities and towns of this country at the present day the
acutely insane receive their first therapeutic ministrations, such
as they are, in a jail or station house. In some cities a general
hospital is made use of to a certain extent. For instance, dur-
ing my residence in the general hospital mentioned an average
of two or three mental cases per month was received, the major-
ity of which were there cared for and treated for a few days or
weeks, and discharged recovered or improved, while a small
number were transferred to the asylum. We had, however, no
special provision for these cases, and they had to be taken into
the wards or private rooms together with all other classes of
patients. If we had had a separate pavilion we might easily
have received all the mental cases of the city without the inter-
mediary of the jail, and immediate medical care and nursing,
so important in early cases of insanity, could have been supplied
for as long a time as was judicious previous to a possible trans-
fer to an asylum.
We have emergency hospitals for broken bones or acute
fevers, but when the most important organ of the body— the
brain— becomes affected with an acute disease the emergency
hospital is the jail.
This deplorable condition of affairs has led to a steadily
increasing agitation of the subject of emergency hospitals for
the insane. It is an axiom among physicians versed in psy-
chiatry that early diagnosis and speedy treatment are of para-
mount importance in nearly all acute cases of insanity. Surely
nothing could be worse for a delirious mind than the sight of
police officials and prison walls. I advocate, therefore, as the
fundamental basis of a system of care for the insane the estab-
lishment in all large towns and cities of emergency pavilions or
independent hospitals for the reception of the insane. These
need not be isolated special hospitals. Two small wards in a
general hospital, or a pavilion in connection therewith, will suf-
fice for the early treatment and humane care of the insane in the
large towns. In cities of considerable size, say with a popula-
tion of 100,0(X) or more, provision should be made for the insane
in independent psychopathic hospitals. The hospital for the
acutely insane should be located in the most populous portion
of the city in order to afford convenient and speedy access from
every quarter. The same rules that guide us in selecting a site
for a general or emergency hospital should aid us here. Since
the acutely insane are usually put to bed or restricted to single
rooms or wards, situation in the heart of the city is of no
greater disadvantage to this than to other hospitals.
The psychopathic hospital should have much the same
administrative arrangements as any general hospital. There
should be a medical superintendent with experience in the
care of the insane, and a staff of internes, together with a corps
of consulting physicians representing the various specialties of
medical and surgical practice. All the nurses should be gradu-
uates of asylum training schools. An out-door department or
dispensary should form a part of the organization, in order that
cases of incipient insanity may be seen at the earliest possible
moment. Such a plant as this would afford abundant oppor-
tunity for the medical schools to conduct clinics and provide
medical men with a knowledge of psychiatry before they go
into practice. It is probably not familiar to you that little or
no instruction in insanity is given in the majority of the inedi-
1 Read before tlie National Conference of Charities, at Detroit,
Mich., June a, UKK.
804 AioEicAN MKoiciMEi STATE CARE AND SUPERVISION OF INSANE
[AUGUST 23, 1902
cal Bcboolg in this country. A general diffusion of knowledse
of the methods of dia(|:nosig and treatment of the insane would
bo achieved through the instrumentality of the psychopathic
hospital, and early attention ensure more frequently than is now
the case to theHe unfortunates.
The laws rolating to the insane should be so changed that
patients could be admitted as emergency cases for a period of
perhaps ten days. Due regard must be paid to the preservation
of personal rights, but legislators have seemed too often to
regard the insane as malefactors or delinquents, and too seldom
as sufferers from serious illness requiring immediate nursing
and medical attention.
From the standpoint of humanity and from that of economy
we should establish these reception pavilions or psychopathic
hospitals wherever there is sufficient population to warrant it.
Let it be remembered that the acute cases are those which will
always require our greatest care and attention, and the largest
per capita cost for construction and maintenance. This is true
economy, for it has been estimated that each patient not cured
becomes an ultimate cost to the state of ?6,000.
Thus far we have considered the reception hospital as the
foundation of any adequate system of care of the insane. We
must now proceed with the development of such an ideal sys-
tem from the foundation described. It is, unfortunately, true
that insanity is prone to run a chronic course. Disorders of the
delicate mechanism of the brain, unlike diseases affecting other
tissues of the body, are usually tedious in their progress and
all too frequently permanent in their effects. In the State of
New York, for instance, the excess in the number of patients
received in asylums above the number discharged is between
600 and 700 every year. There is then an accumulation of
chronic and incurable patients with an average duration of
asylum life of 12 or 13 years. The proportion of acute and
curable patients who are to be treated in the psychopathic
hospitals to the vast aggregations of chronic and incur-
able patients is exceedingly small. The proposed ideal
system of care of the insane, then, must provide for enormous
numbers of the latter class, and it is to these we must now
direct our attention. The chronic and incurable class is made
up of a great variety of types— of sick, aged and infirm, excited,
quiet, dangerous, harmless, paralyzed. The word "chronic"
does not mean incurable, but merely long-continued, and many
of this type recover in time. A very large proportion, perhaps
TOfc to SOfo of these chronic and incurable insane, are physically
strong and well, and are able to work. Their work has an
economic value, and occupation is, moreover, one of the best
remedial agents at our disposition in the treatment of the
insane. The kinds of labor best adapted to their needs are of a
simple sort, preferably out-of-door work. Hence agriculture,
gardening, road-making, quarrying and brick-making have
been found to be the most useful employment for men ; house-
work, sewing, laundry-work, kitchen-work, light gardening,
weaving, rug and basket-making for women. Now, in order to
properly classify and segregate these numerous types of the
chronic insane, a considerable number of different kinds of
buildings is required, and in order to provide the occupations
above described a large and fertile tract of land is essential.
The location selected must be near a center of population and
on some railway or waterway, for ease of access is a prerequisite
to economy in the transportation of supplies, to speedy transfer
of patients to and from the cities, to visitation of relatives and
friends, and, in short, to the success of the system. These
premises lead to but one conclusion, viz.: that the institution in
the country for the mixed classes of insane should be organized
on the colony or village plan. It is a system of segregation and
is directly opposed to the old scheme of immense aggregations
of insane persons under one roof. This old scheme, still so
generally in vogue, had its origin at the period in the history of
the insane when they were first separated from the criminal
classes in the prisons and for economic reasons were transferred
to abandoned convents and monasteries. By a process of evolu-
tion the abandoned monasteries gave rise to the more or less
ornate corridor style of asylum architecture with which we are
so familiar, for every State and country has numerous exem-
plars. To this order of institution various names have been
given, such as the monastery style, corridor style, cathedral
style and the barrack system. The block or pavilion system is
a mere variation of the scheme with surface or underground
corridor connections.
Before outlining the details of the colony or village idea,
your attention must be called to one cardinal fact in relation to
every asylum whatever be its situation, in the city or in the
country, and that is that all types of insanity will inevitably
gravitate to it from every direction within the radius of easy
access. The psychopathic hospital in the city, designed though
it be for acute cases only, will attract to it the chronic and in-
curable insane of the community as well ; these will be trans-
ferred to the colony immediately after admission. But the
colony in the country will also afford to the surrounding coun-
try districts a ready means of disposition of acute cases of
insanity. This rule has so often been tested by experience that
there is little need to refer to it here. But I might cite as an
instance of this law its effect in the .State of Xew York, where
at one time asylums were constructed ostensibly for acute cases
at Utica, Poughkeepsie and Buffalo, and ostensibly for the
chronic insane at Willard and Binghamton. A few years after
this system came into vogue I found that the asylums for the
chronic insane were receiving all the acute cases of the neighbor-
ing counties, while on the other hand in the institutions for the
acute insane at least three-quarters of the patients were chronic
and incurable.
The result of this practical fact determines one important
point in the establishment of the colony, and that is that the
first building to be erected on the grounds for patients must be
a small hospital for the acutely insane. The necessity for this
is apparent from what has just been said, and another argument
in its favor is that there will be received at times in the city
psychopathic hospital certain acute cases whose improvement
will be hastened by transfer to the pavilion for acute cases in
the country institution.
After the construction of an administration building and
hospital for acute cases the colony is further developed by the
addition of an infirmary for the sick, idle, decrepit and dis-
turbed chronic patients. These buildings form the nucleus of
the colony. After these follow the cottages on the village green
for the women patients, and the cottages for men clustered
about the various centers of industry, the farm, garden, brick-
yard, quarry and shop. A village or sort of farming hamlet is
the result. Probably a population of 2,000 should not be
exceeded. In organizing a scheme of this nature, the selection
of suitable land, conveniently situated for transportation, good
water supply, and proper sewerage disposal is presupposed.
The whole plan and arrangements of buildings should be laid
out beforehand by a landscape architect, not only because all
public construction should aid in the general education of the
people to standards of beauty, but especially to ensure artistic
harmony in the whole, and to arrange with economy the roads,
walks, water mains, sewer system, and lines of lighting and
heating from the central plants. The details of the colony sys-
tem I have elaborated in other papers on this subject, and I
need not dwell upon them here, but let us go over briefly the
arguments in favor of the village scheme as compared with the
old block or monastery plan :
The whole scheme having been first laid out, any small
portion, such as a single cottage, may be constructed first, and
the colony increased to any capacity by yearly additions with-
out detriment to the original arrangement. The materials of
construction may be varied and the per capita cost of the Ijuild-
ings adjusted to the needs of the various types of insanity
mentioned above, instead of equal accommodation and an
equal per capita cost as in the ordinary corridor system.
The original cost of the simple villa structure is less than
that of the great blocks of buildings with their waste of space
in corridors, their expensive underground tunnels, and their
elaborate plumbing, heating and ventilating devices.
The annual cost for repairs is less in the village system.
The cost of maintenance is no greater in the colony sys-
tem, and the director of AltrScherbitz, the most complete
colony for the insane in the world, points out that the per
capita cost of maintenance there is less than the average of Ger-
man asylums.
Sanitary conditions are more satisfactory in scattered
August 23, 1902]
PIROGOFF MUSEUM
[Ajcerican Medicine 305
groups of buildings ttian in great structures where masses of
human beings are assembled together.
The matter of food distribution from a central kitchen is
readily acomplished by horse and wagon, food-carts or out-of-
door tram, and at a cost which is less than that of the under-
ground tunnel system with lifts.
The above are arguments of a practical nature, and such
as appeal to the taxpayer as reasonable and satisfactory.
But there is a far more convincing argument in favor of the
colqny system, and one which I feel will appeal with equal
force to the taxpayer when he is made aware of its nature and
importance. This argument concerns the welfare of the
patients. This object, the welfare of the patients, should guide
us, in fact, much more than questions of economy. The citizen
does not desire to see extravagance in structure or maintenance,
but he does not ask for a stinting of money if wise expenditure
will lead to better treatment and more humane care of the
unfortunates for whose support he is taxed.
The home idea is the very foundation of the colony scheme
of care. In the large asylums thorough classification and
segregation are admittedly impossible. All who have had to
do with the insane in the present asylum system have only too
often observed the effects upon patients with acute insanity of
admission into the startling environment of a large asylum
ward with 30 to 50 noisy, violent, filthy and destructive patients
barred in one corridor like himself. The individual is lost
sight of in this congregate system where a thousand patients
live more or less closely together and may even eat together in
one huge dining room. Think of the abrupt change in a
patient's life when transferred from his home to surroundings
so extraordinary, so abnormal. A sane person is shocked and
terrified on beholding such a ward for the first time. What
must be the effect upon an individual suffering from an acute
mental disease, with an imagination already sensitive and dis-
ordered, keenly alive to every siglit and sound in his environ-
ment ?
The colony system permits of the most careful and com-
plete classification, in widely separated buildings, of the acute
cases, the sick and infirm, the suicidal, the noisy and destruc-
tive, and of the quiet, chronic workers, instead of their indis-
criminate commingling in the block or corridor scheme.
In this colony system there arises a greater intimacy
between the attendants and their charges, a deeper personal
interest in the welfare of the patients, and a generous rivalry
between the various cottages that can only be stimulating to
both attendants and patients, whereas in the block plan the
attendants are prone to lose sight of the patients, to treat them
not as individuals, but en masse, because their attention is so
much divided.
If you will read carefully the books on insanity and the
reports of the medical superintendents of asylums, you will
find much which pertains to the socalled moral treatment of
insanity. All tiiese authorities agree that more is accomplished
by means of moral treatment, or appeal to the mind, than by
any form of medication. Since, then, it is chiefly tlirough the
mind that we must operate in order to restore balance to the
faculties, it is surely of the highest importance to place the
patient in surroundings which shall be soothing and pleasant
to his disordered intelligence, where he shall be individualized,
and where the associations shall be homelike, orderly, friendly
and familiar. In fact the environment should be made as
nearly normal as possible. An essentially abnormal environ-
ment cannot but be detrimental to an abnormal mind.
Therefore we must conclude from the premises above
stated that an adetiuate system of care of the insane must con-
sist in the twofold organization of psyi-hopnthic hospitals for
the acutely insant: in the. a'lies, and.colonieH for the mixed classes
of insane in the adjacent country.
" Psychopathic hospital and colony " should be the motto of
twentieth century workers in this field.
The system is not experimental, not new, not untried.
Every university town in (iermany has its psychopathic hos-
pital. There are successful colonies for the insane in Germany
and France, and Lancashire and Massachusetts are severally
organizing a Colony institution at this writing. Albany, N. Y.,
has estatjlished a reception hospital for the insane already.
Ann Arbor, Mich., is constnicting a psychopathic hospital.
The Craig Colony for Epileptics at Sonyea, X. Y., is a model
colony scheme which might well be followed as it is equally
adapted to the needs of the insane. I might mention in passing
that the colony system is the one adequate scheme for other
classes of dependents, the feebleminded, the inebriate, and the
youthful delinquents of reformatories.
I must take this occasion also to advert to the scientific fea-
tures of an adequate system of care of the insane. Especial
stress must be laid upon the need of provision for scientific
work and study in connection with both the psychopathic hos-
pital and the colony. This twentieth century finds us on the
verge of remarkable development of clinical and laboratory
methods of research in the domain of morbid psychology, and
it is the duty of the state to encourage and foster a work whose
far-reaching consequences we cannot yet foresee, but whose
results will benefit the insane immeasurably by improving our
methods of care, treatment and cure.
I must briefly allude to a system of boarding out of the
chronic and quiet classes of insane which has found vogue in
some countries, notably Belgium and Scotland. I doubt if it
would be successful in this country, because in the State of
of New York, at least, the per capita cost of maintenance has
been reduced to such a figure (a little over $3.00 per week) that
there would be no economy in the plan. Probably no families
could be found who would take boarders even if their labor
were of value at less than the figure mentioned.
The relative advantages and disadvantages of a system of
State as opposed to county care have been threshed over so
often that I shall only refer to the two methods in a cursory
way. In New York the county care system is now a matter of
history, but no one could read over the details of that record of
political and moral turpitude without thanksgiving that the
State at last assumed the entire guardianship of her unfortunate
children. I have no personal knowledge of the workings of
the Wisconsin system, which is, I believe, the antithesis of
the method prevailing in New York, but competent criticft
decry it, and an unchallenged statement in a recent number of
Charities, a periodical with which you are familiar, to the effect
that the whipping of patients as a disciplinary measure had
been discussed at a meeting of the superintendents of the county
institutions, is a sufficient commentary upon the standards
accepted in Wisconsin.
THE PIROGOFF MUSEUM, ST. PETERSBURG.
BY
NICHOLAS SENN, M.D.,
of Chicago.
The name of Nicholas Pirogoff stands out preeminently in
the medical history of Russia. As a military surgeon he had
no superior. He was to General Todleben, of Crimean fame,
what Baron Larrey was to Napoleon Bonaparte. Pirogoff's
8urgi(«l work was fully appreciated by his contemporaries, and
his devotion to the sick and wounded of the Crimean war made
him the idol of the soldiers and the recipient of the gratitude of
a great nation. His vast military experience, his keen powers
of observation and his unquenchable thirst for something now
and better, placed him in a position to speak and write authori-
tatively on everything pertaining to military surgery. His
classic work on this subject was translated into nearly all
living languages, and is to be found in all medical libraries
of any pretension. It can be read with interest and profit
by the students and surgeons of today. His dcMcrijition
of hospital gangrene, sepsis, and pyemia as he saw and studied
those messengers of death in camp and field make a pen picture
perfect in every detail and which, when studied with the nec-
essary care, reflects the darkest part of the angry war clouds
which hovered over and about Sebastopol during the memor-
able years of 1854 and 185"). His a<!counts of the immediate and
remote effects of the large caliber bullets, shrapnel and frag-
ments of exploded shells were baseil on careful observations
and a thorough study of an immense clinical material. The
conclusions he reached were fully verified by the experiences
of our surgeons during the great Civil war. Pirogoff was a pro-
gressive surgeon and a true humanitarian. The great personal
306 Amkrioan Medicink]
PIROGOFF MUSEUM
(AUGUST 2», 1902
sacriflces he made for the defenders of his country live In the
memory of a grateful nation. His name is a household word
throughout Uussia. The medical profession reveres and honors
his memory. Husts in snow white marljle and duralile bronze
Immortalize the thoughtful, kindly face of the distinguished
dead in all places where medicine is taught in Russia to remind
students of what he did for his country and the science and art
of surgery.
What a pity that a man who spent his whole lifetime in
relieving sufToring humanity should die of one of the most
cruel of all diseases ! This was the fate of poor Pirogoff. When
advanced in years and when his task on earth was nearly fin-
ished, he became the victim of carcinoma of the upper jaw.
The disease pursued a slow course. The unfortunate patienti
who had dealt with this disease so often with scalpel and caus-
tics, visited Professor Billroth and begged to be given the
benefits of radical operation. Pirogoff then was 82 years
of age. The great surgeon whose services he sought
weighed the evidences for and against an operation well
and with tears in his eyes revealed to his distinguished col-
league the hopelessness of his condition. Pirogoff returned to
St. Petersburg discouraged, but resigned to the inevitable. He
was met at the station by an enormous crowd of admiring,
sympathizing colleagues and friends, and a host of grateful
soldiers and patients. Soon after his return death came to his
relief, and his noble soul departed from the mould of clay that
was disfigured by the relentless disease. St. Petersburg has
honored the memory of Pirogoff in a most worthy manner by
establishing and maintaining a museum known as the Pirogoff
Museum. This is a handsome, solid square building, two
stories high, in the immediate vicinity of the Imperial Military
Academy, separated from it by a narrow street. The building
was originally a storehouse for army supplies, and was pre-
sented by the War Department to the medical profession of
St. Petersburg for this special purpose, a well deserved
and gracious recognition on part of the government of
the valuable services rendered by the distinguished dead
to his country and his profession. The building has been
thoroughly renovated and serves at the same time as a meeting
place for all of the medical societies of St. Petersburg. On the
first floor is a hall with 300 to 400 seats for the general meetings.
The next room on the same floor and communicating with the
assembly hall is the museum proper. The collection contains
some very interesting and rare specimens and historic surgical
instruments. The surgical instruments used by Pirogoff dur-
ing the Crimean war occupy a very prominent place in the
last-named department. A velvet-lined pocket case with old-
fashioned scalpels, scissors, etc., shows the wear and tear of
that memorable campaign. In a separate glass case is exhib-
ited a part of the tumor preserved in alcohol and a microscopic
section of the same which terminated the life of the famous
military surgeon. A fine portrait in oil and a marble bust
reminds one of the name of the place they are in and a photo-
graph of the deathbed with the lifeless remains shows only too
plainly the ravages of the fatal disease. The first floor also con-
tains a nucleus for a general medical library. The second floor
is devoted to the different specialties in medicine, each of which
has its own room and library. For the maintenance of this ideal
medical institution the members of the different medical
societies pay ten rubles (^.00) annually. The Pirogoff Museum
is an ideal home for the medical profession, containing as it
does a rich museum, a hall for general meetings, and all that
could be desired for the different specialties in medicine, with
general and special libraries. The physicians in Chicago and
iu other large cities in our country have for years labored in
vain to establish a somewhat similar institution. Here in St.
Petersburg is an object lesson which if applied to our conditions
might solve many difficulties we have had to contend with in
the past. On my way from Moscow to Constantinople I
remained long enough at Sebastopol to visit the battlettelds
whore Pirogoff made his international reputation. Every
schoolboy is familiar with the stirring events that made Europe
tremble in 1854 and 1855. Only a very few of the participants of
that bloody drama remain to relate the sufferings and priva-
tions of that eventful campaign so devoid of practical results.
The valiant charge in the valley of Balaklava and the stub-
born struggles on the plains of Inkermann were events that
stand out prominently in the history of the middle of the nine-
teenth century. The Russians held the eminence tjehind the
invincible harbor of Sebastopol, and within a thousand yards
of their line of battle the English occupied the great Redau
(Greenhill) supported by the French on the right and on the
left. The plain of Inkermann remains today much the same
as it was when the contending forces left it — a series of entrench-
ments. A railway track between the headquarters of the Eng-
lish army and the city of Inkermann could be used today
without much alteration as a roadbed for a modern railway. The
English fleet finally landed at Halaklava, and from that little
seai)ort town, nine miles from Sebastopol, the army attacked
the Russians on the left flank, with the disastrous result so
familiar in history. The battlefield of Balaklava is now cov-
ered with fertile vineyards and peaceful happy homes. The
large and well-kept Knglish, French and Russian cemeteries
contain the remains or memorial slabs of over 200,000
who lost their lives in the defense of the cause they
represented. In riding over the stony, sterile plains of
Inkermann I found a number of men here and there
plying the pickaxe and shovel in search of war relics. For
nearly 50 years this strange industry has been a source of con-
siderable income and it is by no means exhausted. Cannon-
balls, bullets, shrapnel, fragments of exploded shells, buttons,
buckles and rusty horseshoes are brought to the surface daily
and are sold to the visitors for what they are willing to pay. On
the summit of the Redau is a handsome monument erected by
the English army to the memory of the fallen heroes. In the
office of the English cemetery is a complete list of all the names
of the British dead, and I noticed it contained the names of an
unusually large number of surgeons. This can be readily
explained by considering the causes of death. It is well known
that the great mortality of the allies was duo largely to acute
infectious diseases. Cholera, dysentery and camp diarrhea
decimated the ranks rapidly, which in connection with
inadequate clothing and food supply, contributed much
to the failure of the campaign. The Russian army
met a similar fate. Pirogoff saw more actual suffering
than any other military surgeon in the same length of
time. He worked night and day on the field and in the hos-
pitals in and about Sebastopol in the care of the sick and
wounded. It was work of a most discouraging kind. All
efforts to arrest the spread of the death-dealing diseases proved
futile. The most careful and assiduous treatment only too
often proved powerless in averting death. The most skilful
operations proved useless in saving limb and life, for the
wounds, as a rule, became infected, and a very large per cent,
of those operated upon died from sepsis, pyemia, erysipelas,
hospital gangrene and secondary hemorrhage. It takes courage
to follow the course of duty under such trying circumstances.
Pirogoff remained at his post as long as his services were
required, and performed his onerous duties with an enthusiasm
and faithfulness that commanded the respect of his colleagues
and won the love and veneration of those who came under his
care. When physicians hear or readof the Siege of Sebastopol the
name of Pirogoff invariably suggests itself as the central figure
of the noncombatants of that disastrous conflict. The monu-
ment that commemorates his deeds in the most worthy
and useful manner and that will immortalize his fame is the
Pirogoff Museum. The Russians have honored the memory of
their most famous surgeon in a manner that merits imitation.
Can we say the same of our countrymen ? What have we done
for Benjamin Rush, one of the signers of the Declaration of
Independence, the eminent physician, the erudite author, the
great teacher and the first Surgeon-General of the United States
Army ? For years the American Medical Association has tried
in vain to collect enough money to erect a suitable monument
to the memory of the patriot physician in the Capitol city.
Why not found and maintain a Benjamin Rush Museum in
Chicago, or some other large central city, on the same plan as
the Pirogoff Museum, as a permanent home for the American
Medical Association and its official organ ? Let the medical
profession of the United States answer this timely question by
word and deed.
Balaklava, Russia, June 7.
AUGUST 23, 1902]
THE WORLD'S LATEST LITERATURE
[American Medicinb 307
THE WORLD'S LATEST LITERATURE
Journal of the American Medical Association.
August II}, 1902. [Vol. xxxix. No. 7.]
1. How May the Topics in Examination for Llcen.se be Best Arranged
by Examining Boards ? Henry Beates.
2. Deflected Presentation in Labor Gustav Kolischer.
3. Massage and Exercise in the Management of the Puerperium. C. S.
Bacon.
4. A Contribution to Urcleral Surgery, with Four Cases, Including
a New Operation for Double L'reterovaginal Fistula. X. O.
Wkrder.
5. Stricture of the Ureter. Howard A. KELi.y.
6. The Modern Dentist from a Medical standpoint. William Ksioht.
7. Sodium Glycocholate in Diseases of the Liver. T. W. Keown.
8. The Present State of Our Knowledge Concerning Socalled Partial or
Graduated Tenotomies and the Heterophorias. J. Elliott Col-
BURX.
1. — Arrangement of Topics by IC.xamiiiinK Boards. —
Beates bases his article on the statement that examining and
licensing boards by directly and legally controlling licensure
indirectly standardize medical education, corrective amend-
ment of defects of medical law is still dangerous and it is better
lor examining boards to arrange topics in such a manner as to
approach uniformity of standard rather tlian to attempt to
modify existing statutes. One fact is plain : there is not, in the
pedagogic sense, a medical curriculum. The M.D. degree still
represents anythiiig from that ignorance of medicine born of
illiteracy to scholarship in both general and medical education.
Examining boards must separate these and maintain a standard.
To obtain something of uniformity among the various States,
topics for examination should include those sciences which the
various acts of assembly embody in common as a whole. Topics
thus included will indirectly compel every medical college to
teach them. This will compel teaching and examination in the
applied phases of the fundamentals and the establishment of
the much-needed curriculum, [a.q.e.]
2, 3, 4, 5. — See American Medicine, Vol. Ill, No. 25, p. 1044.
7. — Sodium Glycocliolate in Diseases of the Liver. —
Keown concludes that good results from the use of this drug are
to be expected only in those cases of gallstone formation of so-
called torpid liver as found in alcoholism, drug habits, melan-
cholia, constipation, chronic malaria; it materially aids the
digestion of fats and may prove a useful adjunct in wasting dis-
eases of all kinds, [a. O.K.]
8.— Tenotomies and the Heterophorias. — Colburn dis-
cusses the status of partial tenotomy as a legitimate procedure
when employed for the correction of heterophoria. If hetero-
phoria is not relieved by refraction and correction, Colburn
gives a course of ocular gymnastics, comprising about four
office sittings and as many home exercises. The data from
these measures enables him to offer the patient the choice of
two propositions: Three to six months of ocular gymnastics
and tonic treatment or two to six weeks of development of the
error and its corref;tion by operations. He states that prism
exercises are of curative "value only in ca.ses of functional heter-
ophoria. The question today, then, does not seem to be
whether an operation in certain cases is good practice, but what
lorin of operation sliall be employed, the partial or the guarded
tenotomy or an advancement, [a.o.e.]
Boston Medical and Surgical Journal.
August 14, 190i. [Vol. cxLvii, No. ".]
1. The Diagnosis of Hip Dl.sease ; an Analysis of 95 Cases. Robert W.
LOVETT.
2. A Consideration of Uremia. William H. Robey.
;;. Demonstration of a Model of the Thoracic and Abdominal Viscera
Prepared from u liuman Subject Hardened In Formalin. .lOHN
Wakken.
1. A Case of Possible Fatal Morpbin Poisoning; a Difficult Diagnosis.
F. A. Harris.
1.— See American .\fedicine. Vol. Ill, No. 24, p. 1000.
2.— Uremia.— Robey gives notes of several cases, including
autopsies, and discusses the mechanic and tlie toxic theories
of uremia. His cases show that the patient who presents all
the signs of marked degeneration of the kidneys and whose
daily excretion is far below normal does not necessarily die of
acute uremia and need not have any uremic symptoms, while
one in whom the insufficiency is apparently very slight (as
shown by urinary examination and autop.sy) may suddenly
develop uremia. There may be total anuria for days without
uremia. In past years the kidneys have been considered ade-
quate if they were secreting a fair amount of the solid constit-
uents of the urine, but Robey says we must radically revise our
ideas of renal insufficiency and must learn to recognize new
elements in urine or blood before we can justly make a progno-
sis in any case of chronic nephritis, [a.o.e.]
4.— Case of Possible Fatal Morphin Poisoning.— The
case related by Harris was that of woman who had been given
morphin, probably half a grain, by a u.ser of the drug who was
a doubtful medical graduate. When alarming symptoms de-
veloped a charlatan was called who gave atropia and coffee,
having diagnosed opium poisoning. The woman died. Harris,
as medical examiner, was then called by the police. He viewed
the body and laid all the facts before the district attorney, who
declined to authorize an autopsy. A certificate of death from
" heat exhaustion, combined with hypothetic morphin poison-
ing," was given. Harris discusses at length the question of
what the proper action of the medical examiner should be in
such cases, [a.o.e.]
Medical Record.
[August 16, 190S. Vol. 62, No. 7.]
1. Pelvic Deformity in New York. James Clifton Edgar.
2. .Some Chronic Pathologic Processes Seated in the Deep Urethral
Region Involving the Male Se.xual Function and Nervous Sys-
tem. J. M. Thompson.
;^. The Mysteries of Life and Mind. John P. Hubeh.
4. Hypertrophic Rhinitis and Its Sequels. F. M. Haye-s.
5. The Mosquito on Board of Vessels at Quarantined Ports as a Factor
in the Transmission of Yellow I< ever. EnMOND SoucHON.
1.— Pelvic Deformity in New York.— J. C. Edgar, from
his study of 1,200 consecutive cases of confinement occurring
in the service of the Mothers' and Babies' Hospital, New York,
reaches the following conclusions: (1) Of the 1,200 cases meas-
ured 41.58% were American-born women: 17.91% Irish; 10.83%
Russian; 8.75% German; 2.50% black; (2) contracted pelves
occurred in 44 cases, or 3.66%. (jenerally, contracted pelves
occurred in 30 cases, or 2.50%, and flattened pelves in 14 cases, or
1.10% ; (;!) twenty, or 45.45% of the cases of pelvic contraction
were among American-born women, and deformity occurred in
4% of these ; (4) three, or 6.81% of the contracted pelves were
among black Momen, and deformity occurred in 10% of these;
(5) his material gives a frequency of contracted pelves (1,200
cases, 3.()6%) midway between the conclusions of Williams
(Baltimore, 1,000 cases, 13.1%), Orossen (St. Louis, 800 cases,
7%), Reynolds (Boston, 2,127 rases, 1.13%), and Flint (New
York, 10,22;i cases, 1.42%), (6) his statistics, 3.06% of contrac-
tions in 1,200 cases, differ from those of England (F. Barnes, of
London, 38,065 cases, 0.5%), of France, 5 to 21.11% ; tiermany,
9 to 9% ; Switzerland, 8 to 16% ; Austria-Hungary, 2 44 to
7.8%; Russia, 1.2 to 5.1%; Italy, 18.13%; Hollaud, 3..51% ; (7)
special or irregular forms of pelvic contraction, as osteomalacia,
obliquely contracted cosalgic, double coxalgic, spondolisthetic
and kyphotic, fractured pelvis, are infrtquent in this country ;
(8) the generally-contracted pelvis is the most Irequcut deform-
ity met with in New Y'ork. He found twice as many gener-
ally-contracted as flattened pelves in his material (30.14%). Wil-
liams found practically the .same condition in Baltimore
(79.45%); (9) records kept of private and consultation cases in
New York over a period of 10 years show a somewhat higher
percentage than the results obtained from tlie 1,200 hospital
cases, namely, about 5% for all deformities, the genoraily-cou-
tracted pelvis being twice as frequent as the flattened. [w.K.]
2.— Chronic Deep Urethral Conditions Altteoiing Sex-
ual and Nervous Functions.- Thompson asserts that the
prostate gland is not even related to the urinary tract except by
accidental position, but is a very essential i)art of the male sex-
ual apparatus. This being true of the seminal vesicles it is
seen that a peculiarly intimate relationship exists between the
deep urethra and the sexual apparatus. Tlie effect of clironic
disease of these organs upon the sexual function and the nerv-
ous system is detailed. The Ireatuient of such disease is rectal,
urethral and constitutional. The rectal is chiefly massage and
the urethral is irrigation. Three cases are reported, [a.o.e.]
4.— Hypertrophic Khinitis.— Hayes speaks of the inter-
ference with treatuienl of asthma and hay-fever ('aused by
308 AHIBICAS MKDICIintj
THE WORLD'S LATEST LITERATURE
(AUOD8T 23, 1002
hypertrophic rhinitis and the usual accompanying nasal
growths. He considers in detail the five pathologic conditions
which may be found in ordinary cases of nasal catarrh: (1)
Nasal polypi ; (2) hypertrophic rhinitis; (3) adenoids ; (4) antral
disease; (S) frontal sinus disease. The diagnosis and treat-
ment of vasomotor rhinitis are also mentioned, [a. O.K.]
5.— Mosquitos and Transmission of Yellow Fever. —
Souchon states that during 15 years l,2(i0 fruit vessels came to
New Orleans, these being denied shore communication. Dur-
ing the same period 1,600 other vessels, not denied shore com-
munications, came to the same port. Yellow fever developed
on 5 of the former and on 29 of the latter. Souchon interprets
this as showing that the mosquitos aboard the vessels had very
little to do with the development of yellow fever, and that the
cause of infection was ashore. The Board of Health is now
endeavoring to determine if the mosquitos aboard vessels are
different from those ashore. Souchon cannot see how, in the
light of such cases, they can modify witliout risk the quaran-
tine regulations preventing vessels from having communica-
tion with the shore in quarantined ports until tho.se ports have
permanently and reliably eradicated yellow fevor by destroy-
ing mosquitos and all other possible causes of infection.
[A. O.K.]
New York Medical Journal.
August 9, 19011. [VoL. Lxxvi, No. 6.]
1. Diagnosis In Abdominal l^esions. Thomas H. Manley.
2. Primary Epithelioma of the Uvula and Soft Palate and Treatment
with the Rontgen Kays; Report of a Case. .James Fkascis
McCaw.
3. .Some Cases of Sympathetic Ophthalmia. N. D. McDowell.
■t. The Viicctnatlon Question Theresa Bannan
fi. The Successful Treatment of Hay-fever. J. Wilkinson .Ibrvby.
0. Traumatic .\bscess and Necrosis of the Nasal Triangular Cartilage.
with Report of Cases and Special Treatmeut tot Prevention of
External Deformity. Robkrt C. M ylhs.
7. A Noteworthy Case of Aortic Regurgitation. Leo Jacob y.
8. The Importance of Individual Predisposition In the Development of
Tuberculosis, with Some Remarks on the Relation of Metabolism
to Human Susceptibility. H Edwin Lewis.
9. The Antiseptic Treatment of Rectal and Genital Chancroid. Sin-
clair TonsEY.
10. A Fluoroscopic and Percussion Sign of Pleuritic Effusion Hitherto
Undescrlbed ; Report of Two Illustrative Cases. Chahlis Ly-
man Green K.
U. Report of a Case of Successful Removal of the Cecum and .Vscend-
Ing Colon for .Adenocarcinoma. .1. B. Boocher.
12. The Maturation of Ova in Relation to Puberty and the Menopause.
Jennie G. Drennan.
13. Artificial Respiration In an Asphyxiated Newborn Babe. (jEOKgk
W. Greene.
1. — To be continued.
2. — See American Medicine, Vol. Ill, No. 26, p. 108.3.
3. — Sympathetic Ophthalmia. — Five cases have been
observed by McDowell, and one is reported in full. The treat-
ment in each was practically the same, sweating, calomel,
leeches, hot bathing and atropin. Enucleation, which was
practised in two cases after the disease had developed, did not
seem to do good, but in the case reported the writer believes
that early enucleation was responsible for the mild attacl«. He
advocates early enucleation of the suspicious eye, especially if
it is useless for visual purposes, and says that it is of undoubted
value during the socalled irritative stage of the disease. [c.A.o.]
4. — Vaccination. — Bannan discusses this question and
urges greater care in selecting and preserving virus. Scarifica-
tions made through the drop of virus carries it to a greater
depth and ensures inoculation. The only primary dressing ad-
vised is thin transparent adhesive plaster no larger than the
area scarified. This may be worn throughout the course of
vaccinia. [c.A.o.]
5.— Hay-fever.— Jeryey says the three essentials of this
disease are: (1) A peculiar nervous susceptibility; (2) some
abnormality (hyperesthesia or malformation, or both), perhaps
apparently trifling, in the nasal structures ; (.3) the presence of
some individually irritating substance in the atmosphere.
Much can be done for the second condition. Two cases are
reported. The first was one of localized hyperesthesia in the
nasal mucosa. After thoroughly spraying the nose with an
alkalin antiseptic solution (a 10% coeaiu solution being alter-
nately used with the spray in order to open the nose), an
aqueous solution of suprarenal extract was applied. The blood-
vessels and swollen tissues were promptly reduced to a practi-
cally natural condition. A drop or two of the suprarenal solu-
tion was also put into each conjunctival sac. The patient was
directed to spray his nose frequently with Dobell's solution,
followed with a solution of suprarenal extract, and to take
internally three grains of the extract (palatably combined with
licorice powder) every three hours. The attack was aborted.
The next year the conditions returned as usual, but with much
redu<-ed severity, and a 1-4000 solution of adrenalin chlorid met
the indications and promptly conquered tliem. The second
patient was relieved in the same way. A few days later the
writer removed a polypoid enlargement from the region of the
middle turbinate, and the patient has since had no return of the
hay-fever. She took internally besides suprarenal extract the
elixir of phosphate of iron, quinin and strychnin. The bowels
should be kept very regular, and the diet should be simple.
The nose and throat should always be put into thoroughly
good condition, using both topical applications and surgery
when necessary. An excellent tonic and nerve food is elixir of
glycerophosphates of lime and soda. Exciting atmospheric
conditions should be avoided as much as possible. [c.A.o.]
6.— Disease of Nasal Cartilage.— Myles has had three
cases of traumatic abscess and necrosis of the na.sal triangular
cartilage caused by sawing off a part of the septum. The car-
tilages, a few days after the operation, became necrotic, turned
white, and gradually softened as the necrosis progressed. All
cartilage was removed that would come away without much
force and the cavities packed with gauze and pledgets of cotton
which were covered with equal parts of boric acid and aris-
tol. The cavities gradually filled without deformity and the
cartilage formed again in portions of the destroyed area.
Another case reported is that of traumatic hematoma with sup-
puration involving a section of the cartilage that extended from
the lower border to its upper anterior margin. Incisions on
the sides of the cavity were made for drainage, the cavity
washed with boric acid solution, cureted and packed with
gauze. [c.A.o.]
7. — Aortic Regurgitation.— Jacobl reports an interesting
case in a musician of 85. Following a severe exertion while
playing at a concert he was suddenly seized with a breast pang
followed by dizziness, headache, and substernal oppression.
On approacliing the patient a loud musical sound resembling
that elicited by pulling the bass string of a violin is heard. The
note seems to proceed from the depths of the patient's chest
and the hand placed over the latter becomes conscious of a dif-
fuse, purring thrill. The murmur is loudest over the ensiform
cartilage, but most distinct at the aortic ring. The sound is
audible during diastole and is well transmitted into the
carotids. At the apex, the first sound is mutlled, the second is
replaced by the murmur, which is much enfeebled at this
point. A clear note is audible over the smaller arteries as far
as the palmar arch. The musical phenomenon may be dis-
tinctly heard at the foot of the patient's bed. [c.A.o.]
8. — Development of Tuberculosis. — Lewis states that
individual predisposition is a far more important factor in the
development of clinical tuberculosis than ijacterial infection
per se, and that the constancy of a pronounced failure in meta-
bolic equilibrium during and preceding clinical tuberculosis
points to its importance as the constituting factor of individual
predisposition. The study of ferments in physiologic processes
shows that the enzymes are the working elements in the main-
tenance of normal metabolism, and justifies the conclusion that
conditions of malnutrition are the result of their aVjsence,
decrease or variation. The writer states that immunity to
tuberculosis may be considered as the result and complement of
those metabolic changes in living tissue whereby the enzymes,
through greater potency than those of Bacillus tuberculosis, are
able to maintain a normal osmotic and functional activity in
the ultimate cells. [c.A.o.]
9.— Rectal and Genital Chancroid.— Tousey says the
following treatment as compared with the application of nitric
acid is practically painless, the ulcer becomes innocuous more
quickly and without loss of substance, and heals more promptly,
and that cases of secondary lymphatic abscesses are almost
unknown. A recently made saturated solution of potassium
permanganate is freely applied to the ulcer. This is washed oft'
after one minute and the surface decolorized by hydrogen per-
oxid. The full strength of the latter is used for cutaneous sur-
August 23, 1902]
THE WORLD'S LATEST LITERATURE
[American Medicine 309
faces, but is diluted about three times for mucous surfaces.
Then for cutaneous surfaces a dressing is applied which is kept
wet with
Alum 25 grains
Lead acetate 2 drams
Water enough to make 6 fluid ounces.
For intrarectal or intravaginal chancroid, after the application
of the permanganate and peroxid, the surface should be cleansed
and a suppository of cacao butter with 10 grains of boric acid
introduced, [c.a.o.]
lO.— Sign of Pleuritic Effusion. — Greene says it may be
absolutely confirmed if necessary by the fluoroscope that in
unilateral pleural effusion the heart-border corresponding to the
opposite side shows a marked change in position as between
full inspiration and full expiration when the patient is sitting
or standing. Such a range of excursion does not occur in the
normal chest or in those conditions likely to be confounded
with pleuritic exudation. The border will be displaced out-
ward by the expiratory movement. Percussion of the upper
border of flatness posteriorly shows a well defined rise of the
fluid in full expiration coincident with the outward displace-
ment of the heart, [c.a.o.]
11.— A successful removal of the cecum and ascending
colon for adenocarcinoma is reported by Boucher." The
growth involved the lower end of the ileum, cecum, vermiform
appendix and the lower end of the ascending colon. It filled
the right inguinal region and extended into the pelvis. The
entire mass was removed, the ascending colon closed, and the
small intestine anastomosed into the transverse colon. Unevent-
ful recovery followed. [f.A.o.]
13.— Artificial Respiration In an Asphyxiated New-
born Babe. — A simple instrument, which consists of a rubber
bag with one-half of a rubber ball on the nozzle, has been
devised by fTreene. To excite respiration in a case of asphyxia
the ball is applied to the mouth of the baby, its nose lield and
the bag squeezed repeatedly until the lungs are filled, [c.a.o.]
Medical News.
August 16, 1902. [Vol. 81, No. 7.]
1. Chronic Joint i)lsea.se in Children. Henry Ling Taylok.
2. A Study of Gastrorrhagla.wlth Special Consideration of Hemorrhage
Due to Ulcerative Processes and Their Surgical Treatment;
Report of Cases Henry M. Joy.
8. A Case of Isolated Neuritis Complicating Typhoid Fever. Charles
J. Al.DKIClI.
4. Pathology of Kmpyema of the Antrum of Hlghmore. Hebeb Nel-
son Hoofle.
5. The Misuse of Glasses. F C. Hortz.
6. The Etiology of Typhoid Fever. William Egbert Robertson.
1. — Chronic Joint Disease in Children. — Taylor states
that chronic joint disease in children in 9 of 10 cases, prob-
ably oftener, means tuberculosis. Statistics of more than 13,000
cases show rather more than two-fifths vertebral, some-
what less than two-fifths in the hip, and about one-fifth in all
otherjoints. Of this fifth the knee claims more than half. One
of the most marked characteristics of tuberculous joint disease
is its insidiousness. Too much stress should not be laid on
the family history, which is often perfectly good. Persistently
recurring gastralgia should cause examination of the spine.
The medical student clings with desperate tenacity to the knee
pain of hip di.sesise as a pathognomonic symptom. Disease of
the lumbar spine, knee disease, and other affections may cause
pain in the knee, and it is often absent in hip disease. There
seems to be a well-marked antagonism between rickets and
joint tuberculosis, a single case only of such a joint in a rachitic
child being found during several years, [a. O.K.]
2.—Ga«trorrhagla.— .Joy speaks of the diagnosis between
hemoptysis and bematemesis. In profuse gastrorrhagia the
diagnosis lies between ulcer, mechanic congestion, and carcino-
ma. Treatment is considered from the surgical standpoint, two
conditions — f>rofuse or repeated hemorrhages— indicating surgi-
cal intervention. Attention is called to the fact that the typical
round ulcer is not always the cause of the gravest symp-
toms. Two cases of multiple erosions near the pylorus are
reported. Both had the typical symptoms of gastric ulcer. The
bleeding points were ligated with purse-string sutures of catgut.
One patient recovered, the other died during a second oi)eration
made necessary a few days later by hemorrhage from erosions
in the cardiac end of the stomach, [a.o.e.]
3.— Neuritis Complicating Typhoid Fever. — Aldrich
reports the case of a man who had, during convalescence from
typhoid fever, paralysis of the left external popliteal and left
ulnar nerves, [a.g.e.]
4.— Empyema of the Antrum of Hlghmore.— Hoople
belteves that the air cavities in the bones of the face functionate
as air-pumps and evaporating surfaces, the air passing over the
small openings, acting on the principle of the Sprengel air-
pump. The effect of this action is to cool the tissues surround-
ing the cavities by abstracting their heat in vaporization. This
theory is supported by the sense of fulness, depression, etc., felt
during the closure or inflammation of these cavities during
a cold, influenza, etc. A point emphasized is the vague and
varied symptoms that may attend empyema of the antrum.
[a.g.e.]
5. — See American Medicine, Vol. Ill, No. 17 p. 676.
Philadelphia Medical Journal.
August 16, 190$. [Vol. X, No. 7.]
1. Physiognomy. W. Arbdthnot Lane.
2. Malarial Fever Mistaken and Treated for Thermic Fever. I. Valen-
tine Levi and Joseph M. Asher.
S. The Infectious Origin of Purpura Hremorrhaglca. A. W. SCHRAMM
and W. H. Rubovits.
4. Indications that Our Methods of Fumigation are Faulty. G. E.
Pfahler.
5. Papilloma of the Larynx. John 8. Miller.
6. The Treatment of Acute Uncomplicated Gonorrhea. Hugh Wil-
kinson.
1.— Physiognomy.— As detailed by Lane there are several
forces of importance which exert an influence on the form of
the bones of the face and of the cavities they surround. By far
the most important factor in the form of the face is the degree
of development of the nasopharynx. When a child possesses a
well-developed nasopharynx a good volume of air is constantly
passing freely and forcibly along this cavity and it is chiefly on
the presence of this mechanic influence that the nasopharynx
and the bones of the face depend for their full development.
The results of improper development of the nasopharynx and
its effects on physiognomy are detailed. The part played by
the complete eruption of the teeth, and of the tongue as a
mechanic factor is fully described. [t-\c.H.]
2.— Malarial Fever Mistaken and Treated for Thermic
Fever. — Levi and Asher detail three cases admitted to the
Pennsylvania Hospital during the extreme hot weather in
July of last year, beiug brought in with a large number of gen-
uine cases of thermic fever. From the lessons these cases
taught they were enabled to prevent further similar mistakes,
as the receiving ward was equipped with a microscope, and
every patient admitted suffering from hyperpyrexia was imme"
diately subjected to a blood examination. Subsequent to the
cases herein reported the Plasmodium was found in six cases
admitted to the receiving ward as cases of sunstroke. In the
first case of the series no Plasmodium was found, which appears
to be the exception rather than the rule in pernicious malaria,
still the case was diagnosed as one of malaria. The diagnosis
was based on the history, splenic enlargement, pigmentation
and the therapeutic test. There are cases, however, of malarial
fever complicated with sunstroke. Even if this be true the
value of the linowledge that malaria is present is self-evident.
[K.C.H.]
3.— The Infectious Origin of Purpura Hicmorrhagica.
—The pathologic findings of purpura hscmorrhagica, of which
the case detailed by Schramm and Rubovits is typical, have
revealed nothing which may be interpreted as the characteristic
morbid changes of an independent affection, a disease per ae.
None of the conditions found, either clinically or pathologlcly,
is sufticient evidence to accord to the socalled primary or idio-
pathic purpura the dignity of an independent affection, but
they are rather the manifestations of a morbific influence, of
which the purpura is a prominent clinical sign. The degenera-
tive tissue changes, the intestinal changes, the altered blood and
purpura, and the circulation of microorganisms in the blood,
are characteristic in every respect of septicemia. If we note
the diseases other than the socalled primary purpura, in which
310 A.xKRtoAN Medicine]
THE WORLD'S LATEST LITERATURE
[August 23, 1902
hemorrhftffes occur into tlieskin, they will largely be found to be
either the acute or chronic infectious diseases. In a number of
these of known microbic origin the pathogenic microbe has
been found in the hemorrliagio spots. In all the other diseases
in whicli hemorrhages occur, symptomatically, as in the chronic
wasting diseases and the various intoxications, no doubt toxic
causes are the producing factor. If tliese secondary hemor-
rhages are of toxic and infectious origin, why not search for
infectious causes in the primary purpuras, especially since
cnlturos in all the purpuras have again and again given positive
results, [f.c.h.1
4.— Faulty Methods of Fumigation. — As stated by
Pfahler, the requirements of a disinfectant are: (1) It must
penetrate to every part of the room and destroy surely and
quickly the most resistant forms of bacteria present; (2) it
must not injure the materials with which it comes in contact;
(S) it must be easy of application and not too expensive. All
the past methods of fumigation have been discarded in favor of
formaldehyd gas as most nearly fulfilling the above conditions.
Judging from his results and others, formaldehyd will need an
improved method of application, or should likewise be dis-
carded. Pfahler details the experiments which he pursued to
prove the efficacy of formaldehyd gas, and found that cultures
of the various microorganisms used in the experiments grew as
well after as before exposure. Formaldehyd gas is, without
doubt, the best disinfectant known, but a more satisfactory
method of application is necessary, this probably meaning an
apparatus capalile of generating the gas ten times as fast or in
more concentrated form. The statement of a manufacturer as
to the efficacy of any apparatus should not be accepted, [f.c.h.]
5. — Papilloma of the Larynx. — Miller considers the suc-
cessful removal of a papilloma of the larynx to be one of the
most delicate, if not one of the most difficult, of all surgical
operations. Great tact and skill is required in the clean re-
moval of these growths. Removing the growth by morcella-
tion is useless, if not positively dangerous. Not unlike malig-
nant disease imperfectly removed in any part of the body, these
growths appear to be stimulated into returning when the attack
upon them is feebly or injudiciously made, [f.c.h.]
6. — The Treatment of Acute Uncomplicated Gonor-
rhea.— Wilkinson advances a simple line of treatment and dis-
courages the use of the almost universally employed syringe
with its commonly painful and dangerous injection fluid. Rest
is of paramount importance, and could it be secured abso-
lutely, with a bread and milk diet, the disease would, in most
cases, pursue an uneventful course and rapidly disappear.
Diet, in all events, should be restricted to bread and milk for at
least one week. Points in the drug treatment are : keep the
bowels open, maintain the urine in an antiseptic and unirritat-
ing condition, and increase its flow so as to make it dilute and
efficient as an irrigating fluid. Urotropin is the best modern
urinary antiseptic. He condemns gonorrhea bags of all
descriptions, and advocates a piece of common white muslin
pinned to the inner side of the shirt or undershirt and tucked
about the genitals, [f.c.h.]
CLINICAL MEDICINE
David Riesman A. O. J. Kelly
Diabetes Insipidus. — An extremely valuable con-
tribution to our knowledge of diabetes insipidus has
been furnished us recently by Futeher {Johns Hopkins
Hospital Iteports, x, 197-247, 1902). Having had an
opportunity to study five cases, all occurring in men
varying in age from 25 to 44 years, he concludes that
the disease is uncommon in this country— only four
cases, or 0.001^, occurring out of a total of 356,637
cases treated at the Johns Hopkins Hospital and Dis-
pensary. Inasmuch as the nitrogenous constituents of
the urine are almost entirely dependent on the nature of
the food, it is stated that the old classification of cases of
diabetes insipidus under the headings of hydruria,
azoturia, and anazoturia is no longer tenable. Although
border line cases difficult to classify occur, clinically
almost all cases come under one or two headings : (a) the
primary or idiopathic cases — those in which there is no
evident organic l)a.sis for the disease, and (6) the second-
ary or symptomatic cases — those attributable to definite
organic changes either of the nervous system or abdom-
inal viscera, to physical disturbances, etc. Although
some observers classify those cases in which thirst is the
first symptom as an independent disease under the
name of primary piolydypsia, the evidence in favor of
this view at the present time does not seem to be suffi-
cient. Tumors involving the medulla and the floor of
the fourth ventricle, cerebral hemorrhages, and basilar
meningitis are the commonest organic lesions causing
the disease, but cerebral syphilis apparently is the cause
of a larger number of cases than is generally supposed —
the lesion being most frequently a syphilitic basilar
meningitis. Four of the five cases reported by Futeher
showed marked cerebral disturbance ; one was undoubt-
edly due to sypliilis, two others were probably due to
syphilis, and another was probably due to some cerebral
lesion. In all five cases thirst appears to have been the
first symptom, at least the first symptom to attract atten-
tion. In four cases the knee-jerks were exagger-
ated, in one case they were diminished. Usually there
is no marked disturbance in the metabolic functions.
Futeher concludes that although the nature of the dis-
ease is uncertain, one may say that it is due to some
nervous influence causing a vasomotor disturbance of
the renal vessels, leading to constant congestion of the
kidneys. There is no constant anatomic finding at the
necropsy — the most frequent lesion being enlargement
and congestion of the kidneys. The prognosis is less
favorable in the secondary or symptomatic cases than in
the primary or idiopathic cases ; the longest duration of
the disease in the cases reported was ten years. Unfor-
tunately treatment is very unsatisfactory, and usually
fails to afford relief. In the syphilitic cases antileutic
treatment at times causes a marked improvement in the
general health, as in two of the eases reported, and also
occasionally an almost complete cessation of the thirst
and polyuria, is in one of the cases ; on the other hand,
as in another of the cases, it may be of no avail.
Endovenous Injections of Corrosive Sublimate. — Prof.
O. Parisotti^ communicated to the Reale Accademia de Medi-
cina di Roma the splendid results obtained by the endovenous
injection of corrosive sublimate in a case of ocular syphilid, in
which danger of losing the eye made energetic methods neces-
sary. The same journal publishes an account by Corrado
Coseri, of the endovenous injection of corrosive sublimate in a
grave case of malignant pustvile. The first two injections,
which consisted of 12 mgm. of sublimate produced no unpleas-
ant subjective sensations. The general conditions, fever, delir-
ium, unconsciousness, were promptly relieved and a third
injection of 10 mgm. served to complete the cure. These cases
illustrate the Indisputable efficacy of intravenous injections of
antiseptics, [c.s.d.]
Hypertrophy of the lymphoid tissue at the base of
the tongue as a cause of cough is discussed by Jarecky, '
who reports several illustrative cases. A positive diagnosis is
readily made by applying a b^fc or 10% solution of cocain to the
hypertrophy, whereupon the coughing stops, except perhaps in
those cases in which the epiglottis buries itself in the mass.
[a.o.j.ic]
Phrenic Phenomena, a New Sign of Tetanus. — Solovieo '
reports two cases of tetanus in adolescents in which, in addi-
tion to the usual symptoms such as contractions provoked by
compression of the injured limb (Trousseau's sign) and the
mechanic excitability of the facial (Chvotek's sign), the
patients presented a peculiar trouble which appears to have
been heretofore undescribed, and which consists in rhythmic
spasms of the left half of the diaphragm. The patients being
undressed, the left epigastric and hypochondriac region was
seen to be the seat of frequent pulsations, accompanied at the
1 II Policlinlco ; Supplemento Sentlmanale, Anno viii, Fasc. 18.
^American .Journal of the Medical Sciences, cxxiv, 76, 1902.
» Roussky Vratch, .May 11, 1902.
August 23, 1002]
THE WORLD'S LATEST LITERATURE
{AHERICAK MEDICXNS 311
same time by a heaving of the inferior parieties and an efface-
ment of the Intercostal spaces. These phenomena, which were
synchronous with cardiac systole, but independent of the car-
diac pulsations, properly speaking, were more marked on
palpation, and only disappeared on profound inspiration at each
contraction of the diaphragm. A bruit de sanglot was percept-
ible, evidently due to rapid penetration of the air into the
lungs, dilated as the result of the lowering of the diaphragm.
Solovieo, in view of the absence of all organic heart trouble,
attributes these movements to the isolated contractions of the
diaphragm, which iuterpretatloa was confirmed by radio-
graphic examination. He proposes to apply to the symptoms
in question the name phrenic phenomena. [c.s.D.]
A. B. Craig
GENERAIi SURGERY
Martin B. Tinkkr
C. A. Orb
Decortication of the Luug for Chronic Empy-
ema.— If all cases of empyema were treated by timely
resection of one or more ribs and free drainage, the
question of extensive operation for the cure of long-
standing empj'emas would rarely, if ever, have to be
considered. Plain as art^ the physical signs, and simple
as it is to use an aspirating needle, it is remarkable how
many empyema.s are overlooked by physicians and are
treated for malaria, tuberculosis or some other malady
until the condition of the patient is most critical. The
inflammation of the visceral pleura over a lung com-
pressed by a purulent exudate is frequently sufficient to
cause much thickening so that even when the exudate is
removed the thick, inelastic pleura does not permit the
lung to expand. Tiius the pleural cavity is converted into
an immense abscess which nature vainly attempts to
close by granulation. Such neglected cases, while fortu-
nately rare, are still common enough, so that all surgeons
are occasionally called upon to treat them. George Ryer-
son Fowler, of Brooklyn, was the first to treat this con-
dition by decortication of the contracted lung, stripping
off the thickened pleura which prevented its expansion
with a very sucxjessful result. His operation Avas per-
formed October 7, 1893, and was reported in the Medical
Record of December 30, 1893. Fowler's operation was
performed without knowledge of experiments on the
cadaver of somewhat similar character by Delorme,
reported April 3, 1893, before the C;ongr(>s Frangaise de
Chirurgie. Though Delorme did not operate until some
time later, he is freciuently credited with this operation,
which, as in so many similar instances, belongs to an
American surgeon. Last year Fowler collected the
cases, 30 in number, which had been operated upon
up to that date and drew some valuable conclusions
from his study (Medical News, 1901, Vol. Ixxviii, p. 933).
The most complete review of this suiyect which we
have noticed, however, is that by Kurpjuweit (Bel-
trilge zur lclmi»chen Chirurgie, 1902, Vol. xxxiii, p. 627),
who reports five eases from Garry's clinic at Konigs-
berg and has collected 56 ca.ses of this kind from the
literature. His deductions from a study of this series
do not differ specially from those of Fowler. He finds
35.7^ of complete ret»veries ; 19.7 ;2c improved; 33.9^
not recovered; 10.7^ dead. The only other possible
method of dealing with these cases successfully which
has thus far ijeen devised is the closing of the cavity
formed i>etween the chest wall and the contracted lung
by extensive resection of ribs, thus allowing the chest
wall to fall In until in contact with the lung. Estlander, of
Helsingfors, Finland, first suggested this procwlure, and
Schede introductxl the important mo<liflcation of excising
the much-thickened parietal pleura, which is an obstiicle
to collapse of the cliest wall in many cases. Comparing
the results of these operations with those of decortication,
Kurpjuweit found that extensive resections of ribs give
iS.^fj of cures, 20^ improved, '\fc unimproved, 20^
dead. The percentage of deaths following resections
is almost twice as great as aft«r decortication, a matter
of the greatest weight in favor of the latter operation.
The percentage of cures after decortication is not so great,
however; 56.3^ compared with 35.7% in favor of exten-
sive rib resection operations. While this is true it should
not be forgotten that decortication, if successful, permits
expansion of the lung more or less completely. The
importance of this is not to be underestimated, for in at
least one case in this series a patient recovered from a
severe pneumonia of the sound lung by the aid of the
crippled lung which had been partly restored to its func-
tion by decortication. The deformity is also much less
than after extensive rib resections. Most of the deaths
have resulted in tuberculous cases which are not suitable
for operation. Kurpjuweit is of the opinion that decor-
tication should be tried in every case of chronic empy-
ema ; in case it proves unsuccessful from any cause the
other methods are still available. Fowler emphasizes
the importance of respiratory exercises in the after-
treatment of these cases. We believe that the attention
of American surgeons has not been sufficiently directed
to this American procedure in the treatment of these
very chronic cases, the only other paper of which we
have knowledge being that of Ferguson, of Chicago
{Jour. Amer. Med. Asso., January 9, 1897). The advan-
tages of lower mortality, less deformity and the possi-
bility of much-improved lung function should certainly
entitle it to a trial.
Cholecystectomy.— Southam ' reports operating upon a
woman of 41 for cholelithiasis. The gallbladder was much dis-
tended with fluid, and contained 64 gallstones. The explored
cystic duct was found nonpatulous, and for this reason the gall-
bladder was excised and the cord-like remnant of the cystic
duct ligated. The patient made a good recovery, [a. B.C.]
Perforation of the Appendix Within a Hernial Sac:
Resection of the Cecum and Ileocecal Junction.—Basil
Hall > reports that a young man of 2:!, while lifting a heavy
weight, suddenly developed a right inguinal hernia. This
reduced spontaneously on his lying down, but would recur
when in the erect position. His temperature and general con-
dition being unsatisfactory, operation was performed on the
tenth day after the accident. The hernial sac contained bloody
fluid, pus, a ruptured appendix, two fecal concretions, a gan-
grenous cecum and ileocecal puncture. In addition to the
appendix the latter two were removei, anastomosis between
colon and ileum being effected by means of the Murphy but-
ton. A radical cure was effected and a good recovery followed.
[a. B.C.]
Enterectomy Oontra8t«d with Artificial Anus. — Barker '
reports a list of 12 cases operated upon either for gangrenous
gut from strangulation or for malignant disease of the gut.
Formerly he was in the habit of making an artificial anus in
most of these conditions. In this series he rejected the latter
method and in each case did an anastomosis. Of the 13 cases 8
recovered and 4 died. In no case was the Murphy button used,
but in all but 2 cases (cecal) end-to-end anastomosis was
accomplished. The author is encouraged by the result obtained
as contrasted with the method previously employed. The cases
in which he used gauze drainage did no better than did those
in which it Wiis not used, [a.r.c]
GYNECOLOGY AND OBSTETRICS
WiLMER KB08BN PrANK C. HaMMOND
Clinical Aspects of Carcinoma In Women. — Prof.
W. J. Sinclair '' draws a contrast between i)athol()gic and
clinical work which is not i)articularly flattering to the
former, stating, however, that pathology has not been
misleading to the gynecologist, for he has never truste<l
to its guidance. He reviews the older pathology, partic-
ularly the work of Hegar, and lays especial stress upon
1 British Medical .Journal, Juno 28, 1002.
'Address In Obstetrics annual ineetlnij British Mpdiral Association.
Kroin advance sheets by courtesy of the Kdltor of the BrilUh Mnlical
Journal.
312 AMKBIOAH HKDIOIirBl
THE WORLD'S LATEST LITERATirRE
[AUGUST 28, 1903
the necessity for preventing irritation, maintaining
nutrition, studying individual ciiaracteristic's, occupa-
tion and time of life, and the avoidance of infection, as
far as possible, from sucli diseases as lues and gonorrhea.
He considers that recent investigations have shalten, if
not shattered, the whole blastodermic theory. He refers
to the parasitic theory, calling attention to the work of
Gaylord on one hand and the report of the Cancer Com-
mission of the Harvard Medical School on the other,
the latter body concluding that the work done during
the past two years in the study of the etiology of cancer
has been wholly negative in its results in the sense that
an increasing doubt has been thrown upon the parasitic
origin of the disease and upon the pathologic significance
of the socalled cell-inclusion. Sinclair believes that we
have heard too much of cancer as a neoplasm and too
little of it as a disease. If we set aside all consideration
of etiology and |)athology and keep in mind only the
clinical aspects of the disease, nmch has been achieved
in the last quarter of a century. The clinical work has
been wholly surgical ; what is not surgical is futile ; it is
hardly knowletlge. So far from the pessimistic view
being the true view, the results obtained by many of the
best known operators continue to improve and to give
the greatest encouragement for continued effort in the
future. They are obtaining better immediate results and
the number of " cures " increases — that is, the percentage
of immunity for at least five years after operation be-
comes greater. The percentage of cases operable when
first seen also increases, because the patients come earlier
for treatment, and improvements in technic have ex-
tended the indications. The proof of all this lies in the
statistics of carefully-reported work done under circum-
stances in which the sources of error are reduced to the
minimum.
Sinclair has no hesitation in saying that a large num-
ber of the extended, radical abdominal hysterectomies
for cancer are murderous vivisection which nothing
hitherto advanced in their support appears to palliate,
much less to justify. Most of the cases recorded have
been too far advanced for any operation, however radi-
cal. The immediate mortality is terrific and the pro-
ceeding unjustifiable, as the experience of remoter results
shows that the patients who escape with their lives from
the operation are no better off in relation to recurrence
than those who have undergone the comparatively safe
operation of vaginal extirpation. Cancer of the cervix
occurs almost exclusively among the prolific poor, the
chronicly overworked and underfed ; harassed, drained
women, who have fissures of the cervix, neglected lacera-
tions, venereal diseases and remnants of puerperal sep-
sis. It is a difterent disease from cancer of the body and
is bound to decrease as the social condition, the physical
well-being and the consequent comparative happiness of
the people improve. Hope of immediate amelioration
must rest upon surgery. The general practitioner must
be trained to make an early diagnosis of the disease. He
asserts that the presence of friable tissue in the cervix
uteri indicates the existence of disease which is clinic-
ally malignant whatever the microscope may say, and
concludes with the statement that. If we are ever to
arrive at the causation of carcinoma of the uterus, we
must reach it by the rigid application of logical methods
of induction to clinical work.
This scholarly address is convincing that in the
present nebulous state of knowledge upon the etiology
of carcinoma the first practical and active duty is to
make an early diagnosis of the disease ; and Knowsley
Thornton, in an address given before this same associa-
tion in 1895, states that an early diagnosis of malignant
disease of the uterus can only be made by clearly neglect-
ing no menstrual departure from the normal, however
trivial it may be at first appearance, by encouraging the
patient to describe accurately her symptoms, and above
all by insisting in the most determined manner upon a
local examination.
Tho Rational Conduct of the Third Stage of Liabor.—
Rudolph Wieser Holmes ' details the third stage of labor from
its anatomic, physiologic and clinical standpoints. He is in
perfect accord with those who declare that a proper conduct of
the third stage will give a minimum amount of aberrancies,
but he declares he can prevent the evil consequences of atony
ofthe uterus from faulty innervation ormaldevelopmentof that
organ, from pathologic distention of the pregnant uterus, the
enervating influences of " society," unhygienic surroundings,
partial or complete retention of the secundines, etc. The
methods of delivering the placenta as suggested by Cred^,
Kabierske, Dohrn and Ahlfeld, are detailed. Holmes holds
one hand on the uterus until the completion of tho second
stage of labor, and when the placenta passes from the upper to
the lower segment, which may be within ten minutes to two
hours, at the height of a contraction the uterus is grasped
anteroposteriorly, brought to the middle line, if necessary,
raised perpendicular to the brim, and then compressed and
depressed. All lacerations are sutured at the termination ot
this stage, [p.c.h.]
An Unusually Large Pyosalpinx. — Thome' reports that a
woman of 24, who asserted that she had previously possessed
good health, complained of slight, right-sided, abdominal pain,
and there had been several instances when there was partial or
complete retention of urine. Vaginal and abdominal examina-
tion revealed a large mass in the right lower abdomen. There
were no other evidences of salpingitis. Operation revealed a
dilated fallopian tube, which measured in situ 10 inches from
above downward, and 12 inches in circumference in the largest
part. It was removed, [a.b.c]
A Case of Fibroma ofthe Vulva. — Willi Thomas^ reports
a case of fibroma of the vulva occurring in a nullipara aged 17.
It was about the size of a hen's egg, situated between the ure-
thral orifice small labia and the lowest part of the anterior vag-
inal wall. It was removed with scissors, and microscopic
examination showed the characteristic fibromatous structure.
Real fibroma of the vulva are of great rarity, [w.k.]
Puerperal Eclampsia. — Harry Morrell * reviews the etio-
logic factors of this serious obstetric complication. The exami-
nation of the urine of pregnant women to determine the
presence ot albumin alone in the light of modern investigation
is not sufficient to estimate properly and scientiflcly the
approach of dangerous symptoms. For practical purposes the
percentage of urea, the sp. gr. and the amount voided must be
determined, and even these only serve as a clinical index of the
amount of waste products successfully excreted. The treat-
ment is considered under the following headings, the prophy-
lactic, eclampsia occurring before labor, and eclampsia occur-
ring after labor. When the eclamptic attacks occur during
labor, the uterus should be immediately emptied. Veratrum
viride is considered a very useful drug in the treatment of this
condition, [p.c.h.]
TREATMENT
SoiiOMON Sons Cohen
H. C. Wood, Jr. L. F. Appleman
A Case of the Reverse Action of Sodium Salicylate in
Acute Articular Rheumatism.— Cahen (Bulletin General de
Therapeutique,Vo\. cxliii. No. 3, 1901, page 89) reports the case of
a man, attacked with acute articular rheumatism, who had been
given four drams of sodium salicylate in three days, without
its having any effect upon his temperature. As he had a
slight albuminuria which did not disappear, the salicylate was
discontinued; immediately the temperature fell. Four days
later the salicylate was prescribed a second time. He took IJ
drams the first day; the temperature at once increased. The
drug was continued for three days, during which time the fever
remained high. Upon again withdrawing the drug, the tem-
perature fell immediately, [l.f.a.]
' Chicago Medical Recorder, July 15, 1902.
•- British Medical Journal, July 19, 1902.
'■I Contralblalt fOr Gynakologie, June 21, 1902.
* Northwestern Lancet, July 1, 1902
August 23, 1982)
THE WOKLD'S LATEST LITERATURE
iAMEKICAN MkSICINE 318
Remarks on the Use of Unguentum Crede. — Toff
(Munchener medicinische Wochenschrift, April 29, 1902) reports
five cases In which Crede's ointment proved beneficial. The
first was one of puerperal septicemia; the second was in a
child presenting symptoms of meningitis ; the third was one of
sepsis after abortion ; the fourth, one of catarrhal pneumonia
with meningeal symptoms; and the fifth, one of puerperal
sepsis. [D.R.]
Treatment of Choroidal Affections.— Galezowski {Bul-
letin General de Thirapeutique, Vol. cxlli, No. 20, 1901, page 800)
uses the following solution, in the form of hot fomentations,
applied many times daily, to combat the progressive atrophic
choroiditis of myopia and the disseminated choroidal atrophy
occurring in gouty individuals:
Mercuric cyanid 5 grains
Neutral coeain hydrochlorate 4 grains
Cherry-laurel water 1 ounce
Water 9 ounces
[L.F.A.]
The Exercise Treatment of liocomotor Ataxia.— Hirsch-
kron (Therapeutic Monthly, April, 1902) claims that one of the
most important modes of therapy in locomotor ataxia is the
compensatory exercise treatment of Frankel. In this the idea
is to educate the sufferer to control voluntarily those muscles
whose automatism has been disturbed by the loss of sensibility.
This method is especially useful in the early preataxic stage,
but should not be neglected even In the paralytic stage. Optic
atrophy, great debility, affections of the heart and kidney, and
general gastric crises are counterindications to its use. For the
exercise therapy to be successful it is necessary above all that
the patient is willing, and second, that he has sufficient intel-
ligence to understand the object of the treatment and to perse-
vere in it. In the use of this cure he is first taught simple
exercises, such as while in a recumbent position raising and
lowering the legs, placing one leg over the other, sliding the
heel of one foot over the other shin, touching a certain point
with the tips of the toes. Similar exercises are repeated while
sitting and standing. Gradually he is taught more complex
movements, such as walking, at first with a support, later with-
out, then learning to walk a line, etc. In ataxia of the hands
there may be simple exercises, such as drawing wooden pegs
out of holes, catching swinging balls, and sorting pieces of wood
and money, [h.c.w.]
Cure of Tabes by the Injection of Calomel.— Leredde
(La Medecine Moderne, Vol. xiii. No. 11, 1902, p. 96) reports the
case of a man aged 43, suffering from syphilis since 1897,
whom he treated for 2J years, and who showed grave cerebro-
spinal symptoms of tabes during one year. Injections of mer-
curic cyanid were given for one year, and then for IJ years ; the
treatment consisted in weekly injections of U grains of calomel
for a period of six weeks alternating with a like period of
repose. During this time the symptoms lessened, some disap-
peared ; no new symptom appeared, and the evolution of the
disease was considered arrested. Leredde believes that this
treatment offers the best chance of improvement in many para-
syphilitic lesions, especially tabes, [l.p.a.]
Prophylaxis of Scarlet Fever.— Shepherd (Bulletin Qin-
ernl de Therapeutiqae, Vol. cxliii. No. 13, 1902, p. 509) believes
that potassium iodid acts as a prophylacticagainst scarlet fever.
He has observed that persons taking potassium iodid, who were
undoubtedly exposed to scarlet fever, escaped the disease. A
child who was taking potassium iodid for a cervical adenitis
did not contract scarlet fever after having been with two
brothers who had the disease. In another instance scarlet
fever broke out in a family of 8 negro children ; fi were attacked,
and 2 died. The children of a white family, who lived near
and who mingled with the negroes, had been submitted to the
iodid treatment a few days before the scarlet fever broke out,
and none of these was attacked. Shepherd cites other cases in
which potassium iodid seemed to have a prophylactic influence.
[I..1.-.A.]
Phosphommanitlc Acid and Phosphommanitates.—
L. Fortes and G. Prunier (Gazette hehdomadai re de Medecine
et de Chirurgie. June 1-8, 1902) describe the conditions neces-
sary to the etherification of phosphoric acid by mannite and for
the preparations of phosphomannate of barium, magnesium,
iron, calcium, potassium and sodium, which, with the excep-
tion of the salt of magnesium, are amorphous and more solu-
ble in water than the corresponding phosphates. [c.s.D.]
Treatment of Granular Conjunctivitis With lodin.— B.
Melconian (Journal des Praticiens, Vol. xvi. No. 5, 1SK)2, p. 7)
believes that the application of a solution of iodin in granular
conjunctivitis produces more permanent results than any other
medication. He employs the following :
Metallic iodin 1 grain
Liquid vaselin 1 ounce
For local application.
This solution may be modified according to the case. In
acute cases or in young patients, the quantity of iodin should be
reduced one-half. The affected eyes should first be cleaned
with a tampon dipped in boric acid solution. The lids may
then be turned and the iodin applied to the diseased areas by
means of the end of the finger, at the same time performing
liglit massage. No other instrument is necessary. The lids
should be kept closed for five or ten minutes after the treat-
ment, and should then be protected from dust and strong
light. This application should be repeated morning and even-
ing, and in the middle of the day one or two drops of the solu-
tion should be instilled into each eye as a coUyrium, followed
by light massage over the closed lids. This treatment is gen-
erally well borne ; the patient can follow his daily occupation
without inconvenience. Immediately after the application, the
eyes become red, there is laorimation and some photophobia.
All these symptoms disappeared from one-half to one hour. In
some cases, however, the reaction is so great that the redness
and irritation persist for eight or ten days. Under these
circumstances it is better to begin the treatment with a 1%
ointment of yellow mercuric oxid. Melconian has had good
results from this treatment, which must be continued for 2 to 5
or 6 months, [l.f.a.]
The Hot Pack as a Means of Preventing Eclampsia.—
Ahlfeld (Bulletin Gfngral de ThSrapeutiqae, Vol. cxliii, Xo. 14,
1902, p. 554) employs the hot pack systematically in pregnant
women who present edema, albuminuria, or other threatening
signsof eclampsia, in order to relieve the kidneys by stimulating
the other emunctories of the body. The patient is stripped and
wrapped in a sheet which has been dipped in hot water and
wrung out ; a dry blanket is then wrapped over the sheet,
care being taken that the arms are not exposed ; another cover
is placed over the patient and she is allowed to remain thus for
about three hours, during which time she may be given plenty of
water or milk to drink. This procedure is repeated twice a day.
Of 38 patients thus treated, 23 of whom were primlparas, not
one had an eclamptic seizure. One patient, who in two previous
pregnancies had presented albuminuric retinitis, was enabled
to go through her third pregnancy without any return of the
trouble by the use of the hot pack daily for seven weeks. The
usual medicinal treatment of those cases should be continued
at the same time, [l.f.a.]
A New Mercurial Disinfectant. — Moir (The Therapist,
April, 1902, Vol. xii, p. 61) contributes an article on the value of
mercuric-sulfate-ethylenediamine, commonly known as subla-
min, as a disinfectant. It has the advantage over corrosive sub-
limate in that it is more penetrating and less irritant to the skin.
He especially recommends it as a means of cleansing the hands,
used in solution in the strength of 3 to 1,000. [h.c.w.]
Modification of Chloroform Anesthesia.— Wohlgemuth
(Bulletin GenHrdlde Thfirapeutiquc, \qI. cxlii, No. 18, 1901, p.
718) mixes oxygen with the chloroform a few minutes before be-
ginning its administration. This is done in a special apparatus.
It being important to exclude the atmospheric air. In 140 anes-
thesias the pulse remained slow and full ; no respiratory dis-
turbances or syncope were observed ; recovery was rapid and
complete in from 5 to 10 minutes. Vomiting rarely occurred.
The number of anesthesias is still too small to decide upon the
harmlessuess of this method without possible error, [l.p.a.]
Curative and Pr*phylactio Treatment of Tuberculosis.
— CouCtoux (Bulletin O&nfralde Thfriipcutiqtie ,\ o\. (mlW, No. 20,
1901, page 705) believes that much may be done to prevent the
spread of tuberculosis by the fumigation of houses of tubercu-
lous patients who are unable to isolate themselves and of public
314 AUKBIOAM MEDICINBJ
THE WORLD'S LATEST LITERATURE
[AUGUST 23, 1902
schools or halls where large numbers of people assemble.
Schools, especially, should be fumigated daily. Cou6toux calls
attention to the value of these prophylactic measures In the
treatment of diphtheria and other contagious diseases, and as
the tubercle bacillus can be destroyed with equal facility he
believes much can be done in this way to limit the spread of
tuberculosis. [r,.F.A.]
Danger of Taxis In the Reduction of Hernias.— Guinard
(Journal des Pnilicieus, Vol. xvi, No. 4, 1902, p. 03) reports a case
of Morestins in which a strangulated inguinal hernia was
reduced by taxis. Nevertheless, the symptoms of strangulation
persisted, accompanied by symptoms of peritonitis. Lapar-
otomy was performed and the patient was found to have acute
peritonitis due to perforation of the gangrenous intestine. The
perforation was sutured and the patient recovered. Celiotomy
is preferable to taxis in the treatment of strangulated hernia as
it is less dangerous, [l.f.a.]
PATHOLOGY.
R. M. Peakce
Cirrhosis of the Liver Due to Biliary Obstruc-
tion.— Although it has been recognized for many years
that long-continued obstruction of the bile-ducts might
cause an increase of the iibrous tissue of the liver, yet
obstructive biliary cirrhosis was only established as a
distinct pathologic condition in 1873. In that year
Wickham Legg's experimental work on this condition
appeared under the title "On the Changes in the Ijiver
which Follow Ligature of the Bile-ducts." In this
work Legg tied the common bile-duct in 16 cats, 12 of
which were left for a sufficiently long time to obtain
characteristic changes in the liver. He was able to
demonstrate by these experiments well-marked jaundice,
great emaciation, and finally at autopsy an enlargement
of the liver, a distinct increase of interlobular connective
tissue and an atrophy of the liver-cells. A similar result
had been obtained by Wyss in 1806 and by Mayer in
1872, but not so conclusively. In Legg's clinical obser-
vations, published in 1874, two cases are reported, one an
interlobular cirrhosis of the liver with obstruction of
common duct due to gallstone, the other compression of
the common bile-duct by an hydatid but an absence of
cirrhosis, although jaundice had been present nine
months prior to death. Later, in 1876, this observer
published a case of congenital absence of the common
bile-duct with well-marked interlobular and intra-
lobular cirrhosis of the liver. In the same year
Charcot and Gombault's well known monograph on the
diseases of the liver appeared, and in this the authors
report four cases of cirrhosis following obstruction of
the bile-ducts. The obstruction in these ca.ses was
caused by gallstones, cancer of the head of the pancreas
and inflammation of the larger bile passages. Charcot
was also able to produce definite interlobular cirrhosis
in seven rabbits by ligation of the common bile-duct.
Both Legg and Charcot, because of a lack of antiseptic
precautions, necessarily obtained greater or less infec-
tion of the liver in their experimental cases. In 1822,
MangelsdorfT, of Leipzig, summed up the various clinical
and pathologic observations on this subject. He reports
321 cases of cirrhosis, and of this number 184 ea-ses were
shown to be due to obstruction of the biliary passages.
Ford has recently completed the list of such ca.ses up
to the present time, and has contributed a study of three
of his own, so that to the 184 cases of obstructive cir-
rhosis collected by Mangelsdorff", 24 more must be added,
making up to the present time 208 reported eases. One
of the most frequent causes of complete obstruction
to the flow of bile is the congenital deficiency of the
common bile-duct, the latter structure being usually
represented by a solid cord. The livers of such cases,
which usually die in from six to eight weeks after birth
are, as a rule, large, and have a rough, hard surface.
On section they reveal a typical cirrhosis. Gallstones
stand next in order of frequency in the production
of increased connective tissue in the liver. The ob-
struction may be caused by lodgement of one or
more stones in the hepatic or common bile-duct or in
the duodenal portion of the common bile-duct or con-
tnu'tion of a scar about an ulcerated area produced by
pressure of a rough stone. In some one of these ways
stasis of bile is produced, and at autopsy distinct cirrhosis
is discovered. Cancer of the head of the pancreas occurs
rarely as a cause of obstructive biliary cirrhosis. The
growth of cancerous tissue in the pancreas completely
obliterates the lumen of the common duct, and thus
causes complete obstruction to the flow of bile. I5nlarged
glands at the hilus of the liver exerting a pressure on the
common or hepatic duct in rare instances, may bl(x;k the
liver secretion sufficiently to ^cause cirrhosis of this organ.
Macroscopically, such livers' are enlarged with a rough,
jaundiced surface and considerable perihepatitis. The
organ is hard, cutting with great difficulty, and showing
on section greatly dilated biliary passages and islands of
new connective tissue. In the later stages the contrac-
tion may be considerable, so that the majority of such
livers resemble in appearance the atrophic liver of
Laennec. Histologic study reveals dilated bile channels,
dilated bloodvessels, an increase of fibrous tissue about
these dilated channels and a cirrhosis of the liver which
may be either interlobular, intralobular, or pericellular in
type. The presence of new bile-ducts is noted in nearly
every ease, and Ford has pointed out that these ducts
are arranged at the periphery of the portal canal or next
to the liver cells. They cannot, however, be considered
diagnostic of any variety of cirrhosis, as they have
been described in practically all varieties of this disease
and in certain intoxications. They have been noted in
cases of gallstones, in alcoholic cirrhosis and in chronic
obstruction of the hepatic veins ; they have been
observed in regenerating liver tissue, and it has recently
been shown by Neisser, of Leipzig, that the injection of
phenol solution and substances like phosphorus into the
circulation is followed by the appearance in the liver of
these new-formed bile-ducts. Ackermann has shown by
injections that these columns or tubules of cells are in
reality true bile channels, for he has been able to trace a
direct connection between them and the larger bile pas-
sages. Recently, Findlay has called attention to the
mode of formation of these new bile-ducts, regarding
them as simply liver cells, degenerating and reverting to
their embryonal or epithelial type. He proposes to call
them intermediate or pseudo bile-ducts.
The Ifature of the Bence- Jones Albumin and
Myelopathic Albumosuria. — Since Bence-Jones, in
1847, first described the peculiar form of albuminuria
that goes by his name, and is now generally recognized
as a form of albumosuria, the condition has attracted
considerable attention ; recently it has excited an inter-
est altogether disproportionate to the number of reported
cases, which is still small. In this country the subject
has been discussed by Fitz {American Journal of the
Medical Sciences, cxvi, 30, 43, 1898), by Hamburger
{Johns Hopkins Hospital Bulletin, February, 1901), and
quite recently by Simon {American Journal of the Medi-
cal Sciences, cxxiii, 939, 1902). Simon reviews thor-
oughly the literature and the reported cases, of which
there are but 23 ; and he discusses at length the reactions,
the nature, the significance, and the probable source of
the substance. From his study of the reported cases he
concludes that the presence of the Bence-Jones albumin
in the urine of man usually indicates the existence of
multiple newgrowths affecting the bones, and generally
of myeloma ; that myeloma may apparently occur in
the absence of this peculiar albuminous substance ; that
the existence of the urinary condition in association
with other diseases without involvement of the bones is
not as yet proved by the report of any case in which a
AtJGUST 2$, 1902)
THE WORLD'S LATEST LITERATURE
^Amkrican Mesicike 315
careful postmortem examination has been made ; and
that malignant disease of the bones, in general, may
exist in the absence of the Bence-Jones albumin from
the urine. Discussing critically and thoroughly the
reactions of the substance he concludes that the most
characteristic general reaction of the substance is its
coagulability at a temperature of from 50° to 58°C. All
writers are agreed that this is one of the peculiarities of
the substance, but there is considerable difference of
opinion with regard to the behavior of the urine
on further heating. Some writers, such as Kuhne
and Matthes, report that in their cases the urine
cleared entirely on boiling, whereas others, such as
Ribbink, Huppert, Rosin, Magnus-Levy, Rostosky and
Simon found that the urine in their cases did not clear
on boiling. The possible supposition that different
observers were dealing with different substances is
disposed of by the fact that all possible variations
in the solubility of the precipitate at 100° C. may be
observed not only in the different ciises, but even in the
same case, and by the fact that, as Magnus-Levy first
pointed out, it is possible to render the body soluble at
100 C, or insoluble, at will, by simple measures that in
themselves am hardly be supposed to change the chemic
nature of the substance. From these Simon concludes
that the solubility of the precipitate at 100° C. is
dependent upon the associated presence of some other
substance or substances in the urine, among which the
salts, no doubt, are of prime but not of exclusive im-
portance. What other factors are here of moment, how-
ever, is as yet unknown. The important point upon
which Simon insists is that it is no longer admissible to
speak of the solubility of the coagulated substance at
100° C. as a characteristic and typical reaction, so far as
the urine is concerned. This, however, is a characteristic
of a solution of the Isolated substance in the presence of
a certain amount of acid and of salt. After considerable
discussion of the nature of the substance, Simon states
that he is forced to the conclusion that it cannot be an
albumoso, and while he acknowledges that he encoun-
ters many difficulties in endeavoring to classify it among
the remaining groups of proteins, he is disposed to be-
lieve that it is closely related to the globulins, if, indeed,
it is not a globulin itself. While unwilling to express a
positive opinion as to the probable seat of origin of the
Bence-Jones substance, he considers suggestive the
observations of Ellinger and Wood, who found the sub-
stance in the diseased portion of the bone tissue but not
in the bone nuirrow in any other portion of the body.
Simon states that it is unwarrantable to assume that the
amount of albumin that may appear in the urine is too
large to have originated in the small tumor masses, for
we may readily imagine that the substance could result
from the common albumins of the blood — such as serum
globulin for example — through enzymotic activity re-
ferable, in myeloma at least, to the plasma cells of the
bone marrow. Being thus an expression of disordered
functional activity of cells proliferating abnormally to
form tumor masses, the substance is foreign to the body
and should be excreted by the kidneys — a supposition
that finds some support from the results of certain ex-
perimental inoculations. Evidently our knowletlge of
the substance — of its reactions, its nature, its seat of
origin, and its clinical significance— is still deficient, but
the investigations of Simon constitute an extremely val-
uable contribution to the subject.
A Conccssioii to the Pathologist. — In the midst
of a fruitless discussion concerning the practic-al value of
laboratory methods of diagnosis as applied to clinical
medicine and surgery, it is refreshing to find at least one
surgeon who honestly and fearlessly admits a failure
which might have been prevented had the opinion of an
expert pathologist l)een obtained at th(! proper moment.
Such a case was reported at a recent meeting of the
I'athological Society in a certain large city in the United
States and both the case and the moral are worthy of
careful consideration. Following the exhibition of a set
of necropsy specimens of gangrenous pancreatitis and
disseminated fat necrosis by the resident pathologist of
the hospital, the attending surgeon arose ana stated that
a mistake in diagnosis had been made which precluded
appropriate surgical treatment of this case. The trouble
was diagnosed intestinal obstruction instead of pancre-
atitis. An exploratory laparotomy was done by the
attending surgeon in consultation with another promi-
nent surgeon. At the operation the omentum protruded
and was found to be studded with opaque foci. The
attending surgeon admitted he did not know what these
foci were, the prominent surgeon insisted they were
flakes of fibrinous exudate although it was protested to
him that the foci were deeply seated in the fat. A por-
tion of the omentum was excised and ultimately submit-
ted to the expert pathologist, who at once recognized the
lesion as fat necrosis. By this time it was to late to give
the patient the benefit of an appropriate laparotomy,
exposing and draining the lesser peritoneal cavity with
its gangrenous pancreas. In the discussion of this frank
and admiration-compelling confession by the attending
surgeon another instance was cited where two prominent
surgeons in the same large city had failed to recognize fat
necrosis during an exploratory laparotomy on a case
which subsequently proved to be one of pancreatitis,
the suspicious foci in the omental fat being passed as
healed tuberculosis. For fear the moral is not sufficiently
obvious, permit us to suggest that the expert pathologist
be hereafter called in consultation (along with the promi-
nent surgeon if need be) so that his knowledge may be
turned to account during the life of the patient. It
would surely be quite as satisfactory to the patient if the
anatomic diagnosis of the expert pathologist was made
antemortem instead of postmortem. It would also be
more comfortable for the attending surgeon, and the
expert pathologist could have no reasonable objection to
having his skill adequately recognized and his special
knowledge turned to useful account.
The Changes Produced In the Heniolyniph Glands of
the Sheep and Goat by Splenectomy, Hemolytic Poisons
and Hemorrhage. — In an exceedingly interesting article
Aldred Scott Wartiiiu' gives tlie following results which were
obtained by producing extirpation of the spleen in sheep and
goats. Eight experiments in all were performed ; the animals
being allowed to live for varying lengths of time, and at autopsy
all the hemolymph nodes and ordinary lymph nodes were pre-
served for examination. The author linds after total splen-
ectomy in the sheep there is no evidence of regeneration of the
primitive spleen or of the new formation of splenic tissue. The
structural changes following splenectomy are : Hyperplasia of
existing lymphoid tissues, transformation of hemolymph nodes
into ordinary lymphatic glands, and a new formation of hemo-
lymph nodes out of lobules of fat tissue, and a later proliferation
of the red marrow. There is no evidence of the formation of
red blood-cells in the lymph nodes after splenectomy. The
function of hemolysis is taken up first by the hemolymph
node, later by the ordinary lymphatic glands. The hemolytic
function of the hemolymph nodes and hyperplastic lymph
glands exceeds that of the primitive spleen, causing an ex-
cessive destruction of red cells. The resulting anemia is later
compensated for by an increased activity on the part of the
bone-marrow. It would appear, therefore, that the removal of
the spleen leads to an increased production or retention of some
hemolytic agent usually disposed of by the spleen. The effect
of this hemolytic agent is either to stimulate the phagocytes in
the hemolymph nodes to increased activity, or so to change the
red cells that they are more easily destroyed by these phago-
cytes.
On the Ksophageal Complications of Typhoid Fever.—
James F. Mitchell.' Esophageal complications are excessively
rare in typhoid fever; ulceration, stricture, hemorrhage and
iTbe Journal of Medical Kesearch, Vol. vli, No. 4, p. 43o.
<The JobDH Hopkins Hospital Keport«, Vol. vlll, lUOO.
316 AMKBICAN MbBICIHK]
THE WORLD'S LATEST LITERATURE
(AUGUST 23, 1902
dysphagia are observed with variable and not always apparent
cause. The author has made additions to the subject by a
review of cases treated in the Johns Hopkins Hospital, and
hopes by further careful wori< to demonstrate whether these
lesions should 1)6 grouped with true typhoid manifestations or
as secondary, but characteristic, typhoid complications.
The HlsloloKlc anrt Histojtenctic Features of a Malig-
nant Medullary Hypernephroma of the Kidney.— .J. C.
Ohlmaclicr' describes a tumor removed from tlie superior
extremity of the Itiduey, and which was found to have
encroaclied upon the renal 8ul)stance so as to occupy the upper
two-thirds and l)ilus of the organ. The original tumor presents
the usual anatomic appearances of a malignant hypernephroma
and a thorough histologic study not only confirms this, but
shows it to belong to that more rare class of adrenal new-
growths which reproduce the medulla of the adrenal. The data
upon which he^bases the idea of medullary origin may be given
in brief as follows. The disposition of the reticulum is pre-
cisely lilte that in the adrenal medulla of the dog, and the
character of the component cells, which are large and poly-
hedral, with large, faintly-staining nuceli, and a scanty, poorly-
staining vacuolated cytoplasm, is identical with that of adrenal
medullary ^cells. The presence of embryonic medullary cells
beneath the capsule of the tumor is also like that seen in the
developing normal adrenal.
The Changes Occurring in Striped Muscle in the
Neighborhood of Malignant Tumors.— F. P. Anzinger,'' after
a careful study of the changes found in striped muscle pro-
duced by carcinoma, epithelioma of the lip, and sarcoma comes
to the following conclusions : The changes occurring in muscle as
result of invasion by carcinoma and sarcoma are not identical,
and the essential difference between the two may be briefly
Stated as follows : Retrograde changes are marked in the case of
carcinoma; in sarcoma they occur to a very slight degree, or
may be entirely absent. In sarcoma the atrophy is apparently
only mechanic, while in carcinoma it occurs at a distance from
the tumor under conditions which make it very probable that
It is of a toxic nature, or due to a withdrawal of nutrition.
The morphologic changes in the muscle fiber are more marked
in carcinoma than sarcoma, and this may be explained in the
same way. Nuclear proliferation is marked in the case of carci-
noma; in sarcoma it occurs to a slight degree, and in the
majority of cases is absent. Regeneration forms are numerous
in sarcoma, but were never found in pectoral carcinoma. Their
presence in lip epithelioma may be due to the extensive inflam-
matory changes present.
A Characteristic Form of Necrosis of the Liver.—
Curschmann's ' conclusions may be stated as follows : There is
a form of necrotizing hepatitis arising, for the most part, in the
center of the lobule about the central vein which, in conse-
quence of its intensity and universal distribution throughout
the entire liver, causes great impairment of function. Without
septic manifestations, l;)ut from the first with signs of pro-
gressive marasmus, death occurs as a result of perversion of
the internal liver secretion. Such a condition results from
blocking the large bile passages with gallstones. The obstruc-
tions may not therefore be continuous, and as a result at no
time in the sickness need a severe grade of icterus be present.
Evidently this incomplete obstruction of the bile-ducts favors
the essential means— the entrance of pathogenic microorgan-
isms into the bile passages. It has been found that the pro-
duction of pus is not essential, but that the toxins present
apparently act most violently on those liver cells the nutrition
of which is disturbed by bile stasis, and produce definite death
of these.
The Liymphomatous Tumors of the Dog's Spleen.—
The observations of Herbert U. Williams and Frederick C.
Busch * are based on autopsies of 720 apparently healthy dogs.
In 17 of these, or 2J%, tumorlike nodules were present in the
spleen. None of the dogs gave macroscopic evidences of leu-
kemia or pseudoleukemia, or showed enlargement of lymphatic
glands or other lymphoid structures, nor were lymphoid
'The Journal of Medical Research, Vol. vli No 4 p
2 American Journal of Medical Sciences, Vol. cxxill.
' D. Arch. f. kiln, med., Bd. W, S. 564.
<Tlie Journal of Medical Research, Vol. vli. No. 3, p. 408.
421.
No. 2, p. 268.
deposits visible in other organs. The number of tumors seen
in a single spleen varied from one to seven, and they usually
occurred in otherwise normal spleens. In shape they were
roughly spherical, in diameter from 6 mm. to 4 cm. On section
they were found to be small, soft, white, translucent masses,
resembling Malpighian bodies, but larger. These masses, with
low magnification, were found to difter from the structure of
the spleen in three particulars : In the absence of trabeculas
except at the edges ; in the large size of the lymphoid masses as
compared with the Malpighian bodies of the normal spleen, and
in the absence of a central artery in the lymphoid masses, as a
rule, though not invariably.
The Presence of Typhoid Bacilli in the Urine.— Schich-
hold' found typhoid bacilli present in the urine in 5 out of 17
cases of severe typhoid fever. In all these cases a nephritis was
demonstrated in the presence of albuminuria and casts, while in
albumin free urine no typhoid bacilli were found. The elimi-
nation of typhoid bacilli through the urine seems, therefore, to
be associated with a nephritis, and can appear with this upon
the appearance of rose spots.
The Endothelial Phagocytes of the Tonsillar Ring. —
J. h. Goodale ^ finds in the tonsillar ring two forms of phago-
cytic cells : first, polymorphonuclear neurophilic leukocytes,
and second, large mononuclear cells resembling morphologic-
ally, epithelioid cells. Both these forms of cells may be observed
to incorporate foreign substances, with the difference, however,
that whereas the leukocytes are phagocytic for bacteria and for a
variety of amorphous detritus, the epithelioid cells on the other
hand are capable of incorporating living cells. The epithelioid
cells represent without doubt the endothelial cells of the reticu-
lum. He concludes that in normal tonsils, both of man and of
a variety of lower animals, large mononuclear phagocytes are
present which appear to be derived from a proliferation of the
endothelial cells of the reticulum. In hyperplasia of the tonsils
there Is a proportionate increase in the proliferation of the en-
dothelial cells of the reticulum without a corresponding
increase in the number of the lymphoid cells. In atrophy ot
the tonsils, the endothelial cells of the follicles are seen first to
diminish in number, while the lymphoid cells persist rela-
tively longer. In acute inflammation there is heightened pro-
liferation of the endothelial cells of the bloodvessels, with
increased number of lymphoid cells. Where abscess formation
occurs in the follicles an increased proliferation of the endothe-
lial cells both of the reticulum and the capillaries is invariable
in the vicinity. Where an intense irritant acts upon the endo-
thelial pells of the tonsil, degeneration and necrosis result in the
immediate vicinity. At a greater distance proliferation appears
to be excited in these cells.
Staphylococci Pyemia.— G. Muscatello and J. Ottaviano'
have studied the simple bacterial forms of pyemia in contradis-
tinction to the thromboembolic form with the idea of determin-
ing why in different infections of this character animals may
recover, may die suddenly or abscesses form and in the latter
condition why confined to certain organs especially. The sub-
cutaneous injection of a 24-hour staphylococcus bouillon cul-
ture of moderate virulence never produces metastatic abscess
formation. A localized abscess is formed or in large doses a
purulent or hemorrhagic edematous infiltration occurs followed
by death of the animal in from IJ to 9 days. With subcutane-
ous injection of highly virulent cultures the animals die of a
toxemia to which in the case of large doses a bacteremia is
added. In these cases degenerative changes were found in the
different organs but no abscesses. Intravenous ingestion of J
to J cm. of moderately virulent or -^i, ccm. of highly virulent
culture produced death of the animal in 18 hours with all the
phenomena of bacteremia. Multiple abscesses were produced
by intravenous Injection of Vtr to j",, ccm. of a moderately viru-
lent culture or 2V to tJo ccm. of a highly virulent culture.
Death occurred in from 15 to 6 days. To determine the manner
of localization of the cocci, the authors killed the animals at
different periods after the intravenous injection of the " pye-
mia-produclng dose" and took from each organ an oese
of fluid and counted the colonies arising after incubation.
> D. Arch. f. kiln. Med., Bd. 61, .S. .505.
- The Journal of Medical Research, Vol. vil, No. 3, p. 391.
3 VlTchow's Archlv, Bd. 166, 1901, S. 212.
AUGUST 23, 1902J
THE WOELD'S LATEST LITERATURE
[American Medicinb 317
After two to six hours the largest uumber of cocci wete found
in the liverjand the spleen, then followed the bone-marrow, kid-
ney and blood, while the lungs were found almost entirely free.
Between 12 and 24 hours the organisms were decreased in the
liver, spleen, bone-marrow and blood, but increased in the kid-
ney. After two days the cocci were, absent from the blood and
had begun to form abscesses in the organs. The abscesses were
found most frequently in the kidneys, then in the myocardium,
volimtary muscle, and infrequently in the liver, lungs and
spleen. Abscesses of the kidney were found most frequently
about the convoluted tubules or Henle's tubules which because
of the degeneration of the epithelial cells and desquamation
afford a suitable place for bacterial growth. In voluntary mus-
cle the abscess was found to follow the long axis of the muscle
libers and its localization seemed to depend upon trauma. The
abscesses of the myocardium were found irregular in distribu-
tion. The authors consider localization of abscesses in the dif-
ferent organs determined in part by the natural resistance of
the particular tissue, but to a greater extent by the amount of
degenerative change which the organ has undergone before the
localization of the cocci to produce abscess. This explains the
relative frequency of abscess formation in the kidney.
Nephrotoxius.— At a meeting of the Society de Biologic,
May 17, 1902, .J. Castaigne and F. Rathery > reported having pro-
duced lesions of the tubuli contorti by means of injections of
renal emulsion or by nephrotoxic serum. The injection of a
rabbit with serum providetl by another rabbit treated with
injections of its own kidney (autonephrotoxin) and the injec-
tion of a guineapig with serum provided by a rabbit treated
by injections of the kidney of the guineapig (heteronephro-
toxin) caused death, preceded by progressive emaciation and
albuminuria. The cells of the convoluted tubules presented
very clearly a protoplasmic cytolysis of varying degree, [c.s.d.]
Lead Poisoning. —I^abbC and Ferraud (Journal den Prati-
Ciena, Vol. xvi, Xo. -i, 1902, p. 45) report having ol)served four
men, employed in the manufacture of electric accumulators,
who showed signs of severe lead poisoning. Two were suffer-
ing from lead colic and presented profound anemia. Two
others were attacked with paralysis and muscular atrophy,
affecting the scapular region, the arms, the forearms and hands.
In these patients the lead, employed in the form of the oxid,
was absorbed by the respiratory tract, which favored the dis-
semination of the poison and the spread of the paralysis, and
explained why the muscles of the thorax and shoulders were
attacked to a greater extent than the other limbs, [l.p.a.]
Contribution to the Pathogenesis of Rronchopulmo-
nltis.— A. Dionisi,' of the Anatomic and Pathologic Institute of
the ITniversity of Home, publishes an interesting article on this
disease, called by Steinhaus bronchopulmonitis morbilloso.
The author refers briefly to the literature of the disease; to its
discovery in the year 1708, in Borgogna, by Daubenton, and its
description in 1802 as the result of the nematode /^trnngylus
fll'iria Rudolphi, the cause of " sheep-cough " or " hoose." In
184.5 Jortsitz, of Klausenburg, in Transylvania, found Slrongylus
longevaginatun Diesing, afterward identified by Ijeuckart as
Strongylus paradoxus Meblis, in great abundance in the pul-
monary parenchyma of a child. Reference is also made to
Bacillus omsepticHs, which has been described as determining
the etiology of bronchopulmonitis. [c.s.d.]
On the Transmission of Aphthous Fever From the Cow
to Man by Means of Milk.— Josias' reports to the Acad(Smi6
lie M<5decine of Paris, at a meeting held May 27, his observa-
tions of a l.'J montlis' infant affected with aphthous fever which
was traced directly to the animals of the dairy furnishing the
milk. [o.s.D.]
The lielatioii of Flea8 to the Plague.— The Nupplcmento
■Sentimanalf o/ // Poliidinico for .lune 7, 1902, contains an inter-
esting discussion on the possibility of the transmission of
plague by means of the tieas of rats and otlier animals associ-
ated with man, making spe(!ial reference to Tjiphlopsilla
mHHCuU and Pulex fascialuH of rats and mice, and tlie Pulex
1 Gazette liebdoniadalre de MC-decine et de CblrurKlo, May 29 1902
» II Pollc.Unlco March 1.11*02. '
'■Gazette bebdomadalre dc M«decine et deChlrurgle, June 1, llMK.
serraticeps of cats and dogs. The experiments of Agata (Cen-
trnlblatt fiir Backterienkunde, xxi, Nos. 20-21) made in 1897, in
which plague was produced in rats by inoculation with tritu-
rates of fleas obtained from rats already infected with the dis-
ease and analogous results were obtained by Linaud (Annales
de V Tnst. Pasteur, 1898, No. 10), who first proposed the hypo-
thesis of the transmission of the plague from rats to man by
means of fleas, an hypothesis confirmed and accepted by other
authors, and fully treated of by Galli- Valeric (Revista di Igiene
e Saiiita Pubblica, February 16, 1902), are referred to by
Zirolia (// PolicHnico, Sezions PracHca, 1902), and he pro-
poses preventive measures based on experiments made in the
Zoological Institute and in the Bacteriologic Laboratory of
Naples. Reference is also called to an interesting work having
relation to this question by C. v. Holub, of Odessa (Centriil-
blattf. Bacte.riologie, Vol. xxx. No. 1). [c.s.d.]
On the Pathogenic Agent of Whooplngcough and the
Application of Serotherapy toThls Affection.— C. Leuriaux '
(Brussels) describes an ovoid, aerobic, mobile bacillus, which
he has isolated from the sputum of patients affected with
whooplngcough ; it grows rapidly on agar plates, in potato cul-
tures and in peptonized bouillon. Inoculations of the rabbit,
dog, pig and guineapig gave rise, when subcutaneous, to violent
irritation ; when intravenous, to all the symptoms of the dis-
ease and finally death. Similar phenomena were produced by
the toxins secreted by this microbe and obtained by filtration
following the usual procedure in immunizing animals to the
poison of diphtheria. Leuriaux succeeded in the course of
from three to four months in effecting complete immunization
of horses to the action of this bacillus and its toxin. As a
result of these experiments lie has employed with great success
the serum obtained in the treatment of whooplngcough and is
able to check the symptoms of the gravest cases in the course
of a few days, [c.s.d.]
Brief Duration of Vaccinal Immunity in Tunis. —
Sehoull - cites several instances to sliow that owing to the influ-
ence of climate and of the cutaneous secretions the period of
vaccinal immunity in Tunis is unusually short. Infants vac-
cinated during their first year contracted perfectly character-
ized variola within four years, [c.s.d.]
Hyperkeratosis Lacunaris Pharyngls. — This condition,
also known as pharyngomycosis leptothricia, is characterized
by the presence of numerous hard white masses projecting
from the follicles of the lymphoid ring about the pliaryn.x.
Sometimes the masses develop into long horny spines, firmly
attached to their base. It was formerly thought that the con-
dition was produced by the leptothrix. Arnsperger ' observed
a case in a girl of 17, and proved conclusively, as others had
done before, that the leptothrix had nothing to do with it and
was merely an accidental parasite. Tlie treatment has hitherto
not given very much .satisfaction, but Arnsperger found
removal of the bodies with a sharp spoon, after previous cocain-
ization of the pharynx, productive of cure. [n.R.]
Microbe of Dysentery. — In a communication to the Socif'tt'-
do Biologic, Paris, June 14, Losagc ' announces the discovery
in tlie l)lood, in the intestinal contents, and in the pus of an
hepatic alisc&ss, in dysenteric patients a virulent microbe of
the genus Pasteui-ella. [c.s.d.]
Canine Rabies. — According to R. Menger,* San .Vntonio,
Texas, has during the last three months been infested with an
epidemic of a peculiar disea.se among the dogs— which at first
diagnosed as a croupous or laryngeal affection, accompanied
with brain and spinal congestion, is now regarded as rabies
owing to three deaths following dog-bites within the la.st six
weeks. Rabies among different species of animals has been
unusually prevalent in the recent droughty months throughout
Texa.s, especially among the prairie wolves, [c.s.d.]
On the Presence of a Pathogenic Substance In the
Urine of Patient* Affected with Parasitic Orchitis.- At a
meeting of the SocKJto de Biologie of I'aris, May 17. Dorland '
1 1-a .Semulne M6dlcale, .lulv IH, 1902.
2 Ga/.ettc helxlomadalre de Mfideclne et de Chlrurgie, June 1, 1902.
■' .MOniheiier mod. Wooh., March 1, 1902.
< Uazelte helHioinaduIre de Mfdiwlueel de Chlnirgle, June 19, 1902,
'•flie Texas Medical Journal. July, 1902.
<>Gazettt!liebdomadalr(!de Mddeetne et de Chlrurgie, May 29, 1902.
318 American Medicins]
THE WORLD'S LATEST LITERATURE
[AUGUHT 23, 1902
refers to his havitiK obtained from the urine of patients afflicted
witli ourlienne oriiliitiH a new substance of albuminoid nature.
The injection of this product into the testicle of a dog uniformly
provoked the rapid appearance of a true orchitiw, the evolution
of which always led to suppuration and eventually to sclerosis
of the gland. This phlegmatic power is definitely demonstrate*!
to be a property of the toxin and not of the normal elements of
the urine, [c.s.o.]
On the Presence of Metachromatic Corpuscles in Bac-
teria.— A. (Juilliermond ' contributes a study of the interest-
ing protoplasmic elements contained in many bacteria and
characterized by their strong affinity for stains ; elements
regarded by Neisser'and Ernst as organs equivalent to spores,
and named by Babfis, who has found them in diphtheria
bacilli, metachromatic corpuscles. Biitschli found them in a
large number of microorganisms (bacteria, algas and protozoa).
Ouilliermond finds tliat these granules may bo present or absent
in the colls of a given species or in the individuals of one or
other cultures, their appearance being very variable. They
probably depend upon the chemic composition of the culture
medium and they appear to have a distinct relation to the viru-
lence of the microbes, and may be regarded as a criterion of
virulence, becoming more abundant in the cells of bacteria
which are being transformed from an avirulent to a virulent
•st+te, and disappearing on the other hand as the cultures lose
their virulence, [c.s.d.]
Xotes on an ancient cretino-goiterous endemic center
in a commune of the Department of Meurthe-et-Moselle
form the suljject of an interesting historical article by P. Haus-
halter and P. .Jean de r^ize.' The little village of RosiOres-aux-
Tours, or as it was afterward called Rosieros-aux-Salines,
appears to have been a center of cretinism from the earliest
historic period. The name ona-oua is the term applied in the
local vernacular to persons afflicted with this disease, an affec-
tion which it seems the domestic animals share equally with
the inhabitants of the district. Under modern improved sani-
tary conditions there seems to be a practically gradual abate-
ment of the malady. [c.s.D.]
Petal Variola.— G.Jacontini' reports an interesting case
of a multipara whose stillborn child possessed some 20 or aO
perfectly characterized variola pustules, although the mother,
who had been for some 30 days prior to the birth of the
child in constant association with smallpox patients,
showed no fever or exanthemas, or any disturbance of her gen-
eral health. Petal variola is well known, it being frequent that
a variolous female gives birth to a stillborn child covered with
pustules. Primary fetal variola, however, is very rare, [c.s.d.]
On the Diabetogenic Leukomains.— R. Lfipine and Bou-
lud,* in a communication to the Acadfimie des Sciences, Paris,
June 9, have ascertained that while the subcutaneous injection
of the extract of 30 grams of blood of an asphyxiated dog pro-
duced in a medium-sized guineapig a glycosuria lasting several
days, the extract of the same quantity of blood is not diabeto-
genic if before the asphyxiation the nerves of the pancreas are
faradized. The extract of the blood of the dog collected several
hours after the abolition of the pancreas is powerfully diabeto-
genic. The extract of the blood of many pneumonic patients
was demonstrated to be diabetogenic, while that of a uremic
patient was not. The diabetogenic substance is localized in the
serum to the exclusion of the red blood-corpuscles, and is
crystallizablo. [c.s.d.]
Parathyroid Infections.— Coleman and Buxton » review
critically the reported cases of parathyroid infections, and report
an additional case clinically identical with typhoid fever, from
the blood of which a paratyphoid bacillus was cultivated.
They point out that practically all the cases of paratyphoid
infection passed clinically for typhoid fever, without a Widal
reaction, until careful bacteriologic examination revealed their
true nature. The peculiarities of the bacillus isolated are given
in detail, [a.o.j.k.]
Hemolytic Power (in vitro) of the Pest Bacillus.— The
' Lyon Mgdicale, July 13, 1902.
^Gazette hebdoraadalre de Mgdecine et de Chlrurgle, May, 25, 1902.
» Rlforma med., March U-15, 1902. , i^^o', ^, ii>v^.
JQazette hebdomadairp de Mfidecine et de Chirurgip, June 19 1802
'American Journal of (he Medical Sciences, cxxlli7976, 1^. '
researches of Bordet, Ehrlich, Morgenroth, Madsen , Bulloch,
Hinter, WeingerofT, Neisser, Wechsberg, Lubenau, and of E.
and P. Levy having called attention to the hemolytic action of
bacterial cultures, A. Raybaud and J. P. Pellissier' have made
researches to determine whether Jiacillun pestis possesses
any notable hemolytic power in vitro. Their conclusions
(1) That bouillon cultures of Bacillus pestis contain but
minute quantities of hemolysins ; (2) that this substance is pro-
duced in variable quantity according to the culture used ; (3)
that it exists in largest quantity on the tenth day of the develop-
ment of the culture ; (4) that perhaps the degree of virulence of
these bacilli is directly connected with the production of this
pestolysin. [c.s.d.]
On the Presence of Polar Granules in Vibrio Lingualio.
— A. Bajardi ' calls attention to a point of importance in the
differential bacteriologic diagnosis of the bacillus of diphtheria
and of those which resemble it closely. The microbe described
by Weibel as Vibrio lingualis and occurring on the tongue and
fauces may be distinguished from that of diphtheria by the
method of Broastein, by which the vibrion is colored yellow
while its polar granules remain colorless, [c.s.d.]
Xanthocroma of the Cephalo-rachidian Liquid in the
Course of Pneumococcus Meningitis. — G.Milian andChiray'
communicate to the Soci^tC Anatomique, of Paris, .June 6,
their observations of pneumocoecus meningitis in which the
cephalo-rachidian fluid was of a greenish-yellow color. This
proves once more that xanthocroma of the cephalo-rachidian
fluid is not pathognomonic in intraarachnoidal hemorrhage.
[c.s.d.]
Chronic Interstitial Pancreatitis with Involvement of ■
the Islands of Langerhans in a Diabetic— Steele* reviews
briefly the literature on chronic interstitial pancreatitis, point-
ing out that there have been reported in all 35 cases of diabetes
in which autopsy showed an atrophy of the pancreas which
involved the islands of I^angerhans and in which other causes
of pancreatic atrophy were absent, and in none of which could
any other cause for the existence of glycosuria be discovered,
lie reports a personal observation, [a.o.j.k.]
Trypanosoma in the Blood of Sewer Rats.— Breard '
reports to the Reunion Biologique de Bordeaux, July 1, the
discovery in the blood of 17 sewer rats, captured in that city, of
a trypanosome identical with that described by Laveran and
Mesnil. It was impossible to discover any parasites in the
blood of the 11 fetuses in a pregnant female in whose blood they
were abundant, [c.s.d.]
Bacillus of Gangrenous Septicemia. — G. Xiegros* pre-
sents in These de Paris, Xo. 297, some interesting conclusions in
connection with his bacteriologic researches concerning acute
gaseous gangrene. He has isolated an aerobic bacillus, which
he has described under the name Bacillus septieus <ierobictis.
This organism in some characteristics approaches Vibrion
sepfique of Pasteur, but in many other essentials is distinguish-
able from that microbe. There are other species, aerobic and
anaerobic, capable of determining gaseous gangrene, and their
number Is likely to be augmented by further Imcterial observa-
tion, [c.s.d.]
The Seroantitoxiclty of Alcohol in Tuberculosis and
the Use of Alcohol in the Treatment of that Disease.-
The serum of normal human beings has an antitoxic action
toward the toxic protein substances obtained from the tubercle
bacilli by the method of Maragliano, which consists in boiling
the bacilli in water. According to Mircoli,' alcohol in proper
quantity and quality has the power of increasing these anti-
toxic properties of the blood. During the period of alcohol
dyscrasia — that is, when the alcohol produces serious symptoms
—the antitoxic property of the serum diminishes. Maraglieno's
serum has also a beneficial effect upon the system of alcoholics.
In order to study the effect of alcohol clinically, Mircoli inves-
tigated the incidence of tuberculosis and its course among the
'longshoremen of G«noa, who generally consume about three
'Gazette hebdoraadalre de Mfideciue et de Chlrurgle, June 12, 1902.
2 II Pollclinlco ; Supplcmento .Sentlinanale, June U, 1902.
J Gazette hebdomadal re de Mf'declne et de Chlrurgle, June 19, 1902.
'American Journal of the Medical Sciences, cxxlv, 71, 1902.
"Gazette hebdomadaire de Medeclne et de Chlrurgle, July 17, 1902
« Gazette Hebdomadaire, j uly 20, 19D2.
' Milnchener med. Woeh., March 4, 1902.
AUGUST £1, 1902J
THE WORLD'S LATEST LITERATURE
[American Mkdicinb 319
quarts or more of wine a day. He concludes that alcohol
endows the system with the power of neutralizing tuberculous
toxins, and he believes that an abundant — but not an excessive
—use of alcohol has a beneficial action upon the individual suf-
fering from tuberculosis. He advises that alcohol be used
liberally in the treatment of the disease, [d.r.]
Human Parasite " Sarcocystis tenella." — P. Vuillemin '
communicates to the Acadfimie des Sciences, Paris, May 20, a
note relative to a sarcosporidian parasite very common in
sheep, and which, during recent years, has been twice encoun-
tered at Nancy in man, once found by Baraban and Saint-
R6my in the vocal cords of an executed criminal ; another time
by Hoche in the muscles of a tuberculous patient. In both
these cases the sarcosporidian was discovered by accident. It
is presumed that systematic search would show that the species
in question is frequently parasitic in man. [c.s.d.]
Renal Origin of Urobilin. — In a communication made to
the Soci^tg de Biologie, June 28, 1902, Gilbert and Herscher,»
having made a systematic comparative examination of the
blood-serum and urine of all the patients in the Hospital Brous-
.sais during the past year, note that sometimes urobilin exists
in the i?erum, though it is usually lacking in that liquid, while
the urine at the same time contains it very abundantly. The
different theories which have been proposed for the origin of
urobilin are the sanguine, histogenetic, intestinal, and hepatic;
none of which take into account the fact of urobilinuria without
urobilinemia. The only hypothesis which is capable of accept-
ing this is that there is a transformation in the kidneys of the
biliary pigments into urobilin. After discussing the various
theories in detail the authors conclude that urobilin is nearly
always of renal origin and that urobilinemia has no value for
judging the state of the hepatic cells: it simply indicates the
presence of biliary pigments in the blood and may be consid-
ered in this connection as one of the more important signs of
cholemia. [c.s.d.]
Experimental Rheninatoid Arthritis. — Poynton and
Paine' report a case in which a diplococcus was present in the
synovial membrane of the knee-joint of a man of 67, several of
whose joints showed the chronic destructive changes of one
type of rheumatoid arthritis. This was isolated and culti-
vated. Intravenous inoculation into two rabbits produced in
one an osteoarthritis without cardiac lesions, and the authors
consider the diplococcus as the cause of the arthritis in both
man and rabbit, [h.m.]
A New Method ofKxtracting Tetanus Toxin iVom Solid
Viscera. — H. J. Waring • described, at the Pathologic Society of
I^ndon, April 15, 1902, a new method of extracting the toxin of
tetanus from the liver and other solid viscera. The details of
the method were as follows: As soon as convenient after death,
the viscera which were intended for experimentation were
removed from the body and as much blood as possible squeezed
out of them by pressure. The material was then cut into small
pieces either with a knife or a mincing machine. It was then
weighed and mixed with an equal quantity of pure glycerin
in a closely-stoppered glass jar. The process of mincing and
mixing should be carried out in a dark room or away from
direct sunlight, since the latter soon rendered the toxin inert.
The jar was then placed in a cool, dark cupboard and left there
for three or four days. It was recommended that the jar be
occasionally shaken so as to bring the material and glycerin
into closer contact. At the end of several days the mixture was
filtered through glass wool so as to separate the glycerin and
the substances soluble in it from the solid and insoluble debris.
Details were given of a series of experiments on mice in which
varying amounts of the glycerin extract were injected into the
tissues. These in most cases were followed by the develop-
ment of symptoms which appeared to be those of mouse tetanus.
Five cases of acute traumatic tetanus which terminated fatally
in St. Bartholomew's Hospital provided the material for these
investigations. The author drew attention to the difference of
the lime of appearance of ordinary mouse tetanus and that
induced by large doses of the glycerin extract, and explained
> iM Semnlnc Mfidlcale, May 2J«, 1902
' Gazelle bi't>(ti>madalre cle MfideelDe et de Chlrurgle, July 3, 1902.
' Medical I'rcss and Circular, January 22, 1902.
4 British Mfdiciil Journal, April 19, 1902.
the absence of the incubation period in these cases by suggest-
ing that the toxin in the liver was probably in the form of a
toxigen. He drew attention to the possible application of this
method of investigation to the establishment after death of a
correct diagnosis in those cases of patients who had presented
indefinite symptoms of tetanus and in whom a bacteriologic
diagnosis had not been possible, or had been negative. Dr. F.
W. Andrewes, who read a paper upon the same subject, said :
" So far as I am aware, the employment of glycerin as a solu-
tion for tetanus toxin is a new departure for which Mr. Waring
is entitled to the credit." [c.s.d.]
Chromatic Reactions of the Blood -corpuscles of Dia-
betics.—J. Le Cioff,' by adding to normal blood a solution of
glucose in physiologic serum, has been able to modify the
normal corpuscles and to give them the property of staining in
the same fashion as the corpuscles of diabetic blood. It appears'
therefore, logical to admit that in diabetic blood the hemoglobin
and the glucose are in a state of combination, [c.s.d.]
A New Method of Rapidly Preparing Histologic
Specimens. — W. liamsay Smith ^ describes a method which he
has successfully used for four years. A Vilock of tissue is
placed between the halves of a split cork, the end projecting
one-fourth inch beyond the thick end of the cork. This is
placed in the clamp of the Cathcart microtome so that its top is
flush with the top of the cylinder. The exposed parts of the
tissue are then sprayed with ethyl chlorid and the clamp is
gradually tightened. As the tissue freezes the block becomes
hard and immovable. This is cut with an iron plane while a
slow continuous motion of the screw brings up the tissue.
Everything from blood-clot to bone, fresh tissues and those
preserved for years can be examined in this fashion. He de-
scribes the technic minutely, giving points in preserving,
staining and mounting specimens, [h.m.]
Contribution to the Study of Brinton's Disease : liiiii-
tis Plastlca. — Among the numerous observations published
under the name of Linitis plastiea there are a certain number
which represent distinct maladies and which are nothing less
than cancer of the stomach. Ren6 Tourlet ( Thise de Paris) '
insists that the term Linitis plasti<«i should bo reserved for the
distinction of a special aflfection of the stomach characterized
principally by diffuse hypertrophy of the submucous connect-
ive tissue and which does not present the anatomic charac-
teristics of cancer. According to the author there exist two dis-
tinct forms of this disease ; the one affecting the entire stomach
and frequently accompanied by peritoneal lesions, characterized
by Hanot and Gombault under the name of callous retroperi-
tonitis, wliich has a rapid evolution. The other has the lesion
situated at the pylorus to the exclusion of the rest of the
stomach. This last form is characterized by Habershon under
the name fibrous disea.se of the pylorus; by Tilger, as stenotic
hypertrophy of the pylorus ; by Boaz, as stenotic hyi)ertrophic
gastritis. It has a slow evolution and comports itself as a
benign tumor of the pylorus, giving no trouble, except stenosis
of that orifice, [c.s.d.]
Experimental Researches on the Toxicity of Urine. —
Albu' after calling attention to the researches of Hijmaiis
van den Bergh according to whom intravenous injection of
urine owe their toxicity principally to the salts of potash which,
by diminishing renal permeability impede the reestablish-
ment of isotonic equilibrium in the injected animals, points
out that the rapidity with which the injections are performed
plays an important role in the phenomena of intoxication.
Hypertonic solution of sea salt and of urine gave no toxic
results unless the injection exceeded a speed of 2 to .S cc. per
minute. Below this limit there is time for the establishment of
isotonic equilibrium if the emunctory function of the kidney
is normal. Under these conditions intravenous injections of
human urine are inoffensive. Following nephrectomy the
accessory organs a.ssume the function of maintaining the natural
rate of excretion; such accessory organs are the intestinal, lac-
rimal and pituitary glands; the normal excretions of the skin
are notably exaggerated. C0.8.D.]
1 iM Hemalne Mfdk-ale, May 2S. 1902.
'TheScoItlsli .McdicHl and Suriflcal Journal, January, 1902.
' (Jazittt- lulKloiiiHdalrc de .Mfneclne et de Chlrurgle, June 20, 1902.
'Ari'h. f. pathol. Anat. u. FhyKlol., elxvl, I.
320 American Medicini
THE PUBLIC SERVICE
[August 23, looa
THE PUBLIC SERVICE
Health Reports.— The followiug cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, during
the week ended August Hi, 1902:
SMALLPOX— United Htatks.
Casm Dtratbs
California: liOs Angeles luly Hfi-Aug. 2.... 2
San Kranclsco Inly JT-Aui!. :l ... 8
Colorado: Denver Inly 26-Aiig. 2 1
District of Columbia: Wushlngton Aug. 2-9 4
Florida :
Illinois :
iudlanu :
Iowa:
Kentucky :
Maine :
Massachusetla :
Michigan :
Missouri :
Montana :
NebrH.ska :
New Uampsbl re :
New Jersey .
New York :
Ohio:
Pennsylvania :
Utab:
Philippine Islands :
Argentina :
Austria :
Belgium:
Brazil :
Ceylon :
Cbina ;
Great Britain :
India :
Italy:
Netherlands :
Mexico :
Russia :
Spain :
Uruguay :
Brazil :
Colombia:
Mexico :
Philippine Islands :
Cbina:
fil^^
Japan :
Java ;
Hawaiian Islands :
Philippine Islands:
China :
India :
Madagascar ;
Jacksonville Aug. 2-9..
Chicago Aug. 2-9 8
Indianapolis Aug. 2-v 2
Ottumwa Ju'y5-Aag. 2 8
Covington Aug. 2-» 3
Portland Aug. 2-9 1
Boston Aug. 2-9 10
Everett Aug. 2-9 2
Lowell Aug. 2-9 1
Somerville Aug. 2-9 «
Detroit Aug. 2-9 2
.St. Joseph July 26-Aug. 2 ... 17
St. Louis Aug. :j-10 4
Bulte Inly 27-Aug. 3 ... 1
Omaha Aug. 2-9 3
Na.shua Aug. 1-8 1
Elizabeth July 5-Aug. 9 1
Hudson County
Jersey City lncl....Aug. 3-10 1
Newark Aug. 2-9 6
New York Aug. 2-9 5
Cincinnati Aug. 1-8 4
Cleveland Aug. 2-9 42
Toledo July 26-Aug. 2 ... 1
Altoona Aug. 2-9 3
Johnstown Aug. 4-11 b
McKeesport Aug. 2-9 H
Philadelphia Aug. 2-9 4
Pittsburg Aug. 2-9 18
Salt Lake City July 26-Aug. 2 ... 2
Smallpox— Insular.
Manila June 11-21 2
Smallpox— Foreign.
Buenos Ayres .May 1-31 10
Prague luly 19-26 I
Antwerp July 19-26 4
Pernambuco June 1-30
Colombo June28-July 5....
Hongkong June 14-July 5.... 3
Dundee luly 12-19 I
Liverpool July 26-Aug. 2 6
London July 12-19 48
July 19-26 23
Bombay July 8-15.
Calcutta July ."i-li
Madras July 5-11
Naples.... July 12-26 2
Palermo July 12-26 ... 11
Rotterdam July 26-Aug. 2 ... 1
City of Mexico July ^-Aug. 3... 4
Moscow July 12-19 13
Odessa July 19-26 1
St. Petersburg July 12-19 9
Warsaw , luly 12-19
Corunna ,. July 1-31
Valencia luly 16-Sl
Montevideo June ;JO-July 7 ... 2L
Yellow Fever.
Pernambuco June 1-30
Panama July 2i-Aug. 4 ...
Coatzacoalcos July 26-Aug. 2 ....
Merlda To Aug. 5
Progreso To Aug. 5
Vicinity of Pro-
greso July 27
Vera Cruz July 26-Aug. 9
10
1
m
I
So
I
2
2
15
4
3
1
1
1
20
Cholera— Insular.
Manila June 8-21 277 207
Provinces Mar. 2(V-June2l.. 5,892 4,268
Cholera— Foreign.
Amoy June 7-28..
Hongkong June21-July 5
Tientsin June 21-30 222
Maucha July 15-23 227
Bombay July 8-15
Calcutta July 5-12
Madras Iuly5-U
Nagasaki July 12-20 11
Batavia June7-July 5 92
Plague— Insular.
Honolulu July 28
Manila June 8-21 1
Plague— Foreign.
Hongkong June 14-July 5... 125
Bombay July 8-l.S
Calcutta July 5-12
Majunga June 8-22
275 cases
estimated
26 17
222 197
227 162
2
31
1
124
22
20
37
Changes in the Medical Corps of the V. S. Army for
the week ended August 16, 1902:
Probst, Merton A., contract surgeon. Is granted leave for one month
with permission to apply for an extension of one month.
Darnall, Captain Cakl R , a.sslstant surgeon, isgranted leave forone
month, with permission to apply for an extension of 15 days.
Pakkma.n, Wallace E., contract surgeon, now at Vancouver Bar-
racks, will proceed to Kort Worden for duty.
Mkrkill, Major James C, surgeon, is granted leave for four months
on account of sickness, to take ed'ect June 5.
.Markow, First Lieutenant Charles E., assistant surgeon, leave
granted Is extended one month.
.Sturtevant, C. A., contra<rt surgeon, Is granted leave to Include
August 31.
Hakt, James W , contract surgeon, is granted leave for one month, to
take efl'ect when bis services can be spared by his post commander.
I'ERRY, Clifford H., hospital steward, now at Oswego, N. Y.,wlll
reporton or before expiration of furlough granted him from head-
quarters, department of California, at Fort Greble, to relieve Hos-
pital Steward Henry B. Staley. Steward Staley will be sent to
West Point, N. Y., and will report to the commanding officer of
that posi, to relieve Hospital Steward Max Dohle. Steward Dohie
will rje sent to Fort McDowell and will report to the commanding
ofllcer of that post, who will send him to Manila, P. I.
Harris, Herbkkt I., contract surgeon. Is granted leave for one
month, with permission to apply tor an extension of one month, to
take etfect about November 1.
Walker, William H.. contract surgeon, now at Fort Harrison, Is
relieved from further duty In the division of the Philippines, and
will proceed to Vancouver Barracks for duly.
Pinquari), .Joseph, contract surgeon, now at San Francisco, Cal , Is
relieved from further duty in the division of the Philippines, and
will proceed to Fort Leavenworth for duty.
Seibert, i;. G., contract surgeon, is grantetl leave for 17 days, fn)m
-Vueust 18.
Hubbard, William H., hospital steward. Fort McDowell, is trans-
ferred to Benicia Barracks, to relieve Hospital Steward Herman
Miller. Steward Miller will be sent to New York City and will
report to the attending surgeon. Army building, 39 Whitehall
street, In that city, for duty in bis office.
Wood, Ma.|or Marshall W., surgeon, having been found by an Army
Retiring Board incapacitated for active service on account of dis-
ability incident thereto, his retirement from active service, August
12, 1902. under the provision of Section 1251, R. S., is announced.
Major Wood will proceed to his home.
Leepf.r, John F., contract surgeon, is granted leave for 15 days.
Perley, .Major C, surgeon. Is relieved from further duty at Plattsburg
Barracks and will proceed to St. Louis, Mo., and assume charge of
the medical supply depot in that city, to relieve Captain Merritte
W. Ireland, assistant surgeon, of that duty.
Ireland, Captain Merritte W., assistant surgeon, in addition to his
present duties, will assume temporary charge of the medical supply
depot at St. Louis, Mo., until the arrival at that place of Major
Harry O. Perley, surgeon.
Orders of August 11 are so amended as to direct Contract Surgeon
William H. Walker to proceed to Camp Thomas. Ga., for duty.
Shortlidge, First Lieutenant Edmund D., assistant surgeon, is
relieved from duty in the division of the Philippines, and will
proceed to San Francisco, Cal., and report by telegraph to the
adjutant-general of the Army for further orders.
James, Harry M., contract surgeon, Is relieved from duty at Camp
Thomas, Ga,, and will proceed to his home, New York City, for
annulment of contract.
Snyder, Captain Henry D., assistant surgeon, is relieved from duty
as attending surgeon and examiner of recruits in New York City,
to take eflTect upon the expiration of his present leave, and will
then proceed to Plattsburg Barracks for duty.
Changes in the Medical Corps of the U. S. Navy for
the week ended August 16, 1902 :
Pleadwell, F. L., passed assistant surgeon, detached from the Sylpb,
and ordered to the Kearsarge — August 9.
Marcour, R. O., assistant surgeon, detached from the Abarenda,
and ordered home to wait orders — August 11.
Morgan, D. H., pa.ssed assistant surgeon, detached from the Philadel-
phia, and ordered to the Boston— August 12.
Wilson, N. D., passed assistant surgeon, detached from the Marine
Brigade, Cavite, and ordered to duty at Olongapo, P. I —
August 12.
Dunn, H. a., assistant surgeon, detached from the Naval Hospital,
Yokohama, Japan, and ordered to duty with the Marine Brigade,
Cavite, P. I.— August 12.
Odell. H. E., assistant surgeon, detached from duty at Olongapo, P. I.,
and ordered to the Solace— August 12.
LippiTT, T. M., assistant surgeon, detached from the Washington
Yard Septembers, ordered to be examined by Retiring Board, and
thence home to wait orders — August 13.
Williams, R. B., assistant surgeon, detached from the Kearsarge and
ordered to the Naval Hospital, Newport, R. I., for treatment —
August 14.
Changes in the Public Health and Marine-Hospital
Service for the week ended August 14, 1902:
Glennan, a. H., granted leave of absence for one month from Sep-
tember 1— August 12, 1902.
Williams, L. L., assistant surgeon-general, granted leave of absence
for 15 days from September 1— August 13, 1902.
Smith, A. C, pa.ssed assistant surgeon. Bureau letter of June 9, 1902,
granting Passed Assistant Surgeon Smith leave of absence for 30
days from July 10, 1902, amended so that said leave shall be for 27
days from July 10— Augusts, 1902.
Hastings, Hill, passed assistant surgeon, granted leave of absence
forone month from September 3.— August II, 1902.
Hamilton, H. J., acting assistant surgeon, granted leave of absence
for 3 days— August 8, 1902.
Board Convened.
Board convened to meet at Washington. D C, August 11, 19P2, for the
Bhysical examination of an officer of the Revenue Cutter Service,
'etall for the Board — Assistant Surgeon-General G. T. Vaugban,
chairman; Assistant Surge n B. S. Warren, recorder.
American Medicine
OEORQE M. GOULD, Editor .
a. C. C. HOWARD, Ifanaging Editor
CHARLES S. DOLLEY
MARTIN B. TINKER, Attittant Editor*
CXtnieal Medicine
DAVID RIKSMAN
A^ O. J. Kklly
H. H. CUSHING
HSI.KII HnKPHY
General Wlirgery
Maktin B. Tinker
A. B. Craig
Chablks A. Orb
Orthopedic Surgery
H. Augustus Wiiaon
COLLABORATORS
Obstetrics and Gynecology
WlLMER KRUSKN
Frank C. Hammond
Nervous and Mental Diseases
J. K. Mitchell
F. Savaky Pbabcb
T^reatnient
Solomon Solis Cohsn
H. C. Wood, Jr.
L. F. Applkman
Dermatology
M. B. Uartzell
Laryngology, Eta.
D. Braden Kylk
Ophthalmology
Walter L. Fyli
Pathology
R. M. Pearok
PCBLiaHSD WbEKLT AT ISSl WaLMUT StUST, PmUDBLPHIA, IT TH« AlflBieAlf-lfBDICtini PuBLmBflia CoMPAHT
Vol. IV, No. 9.
AUGUST 30, 1902.
$4.00 Yeakly.
Au Oversight in Practice. — We have recently
learned of several instances in which a patient consult-
ing a second physician continued taking medicine pre-
viously prescribed by another. The error was due to the
neglect of the second practitioner to inquire or warn as to
previous prescriptions, and the patient negligently and in-
nocently followed inclination, ignorant of the danger of
taking drugs from two physicians. There is perhaps a
growing wilfulness on the part of patients in taking medi-
cines of their own choosing — catching up some old pre-
scription or asking for " headache powders " at the drug-
store, or for " something good for indigestion." There
is a growing use of remedies that " if they do no good will
do no harm" — an evidence of stupidity on the part of
wiseacres that should suggest an inquiry as to their
sanity. This carele&sness of patients is possibly charge-
able, to a certain degree, to our failure to instruct them
that they must not take other drugs except those last
ordered. One naturally supposes that patients will not
be so foolish as to take two kinds of medicines, of one of
which the last consultant is ignorant. But patients are
freciuently precisely as foolish as that. We have known
a patient to take a certain powerful medicine continu-
ously for five years, and not one of six different physi-
cians consulted in this time knew of the fact. It should
be a routine practice to warn every patient that no other
drugs should be taken except those now prescribed.
The Public Schools and the Public Health.—
Those interested In the highly important questions of
school hygiene and sanitation will find encouragement
in the fact and results of a joint meeting of the State
Board of Health of Ohio and the superintendents of
public schools, devoted entirely to the consideration of
these subjects. The report is published in the Ohio
Sanitary Bulletin of March-April-May, 1902. The
president of the board, Dr. Byron Stanton, rightly
emphasized the duty of the State to attend to the sani-
tary conditions of the schools because she makes school
attendance compulsory ; but he as plainly showed that
this duty is neglected, both in legislation and practice.
There should lie a competent and responsible medical
inspector who shall cooperate with local Imards and
teachers, and he should also be armed with certain
administrative powers, either as a member of the State
hoard or as an independent ofHcial of the government in
power. In few States is there any effective and intelli-
gent control even of the simplest matters pertaining to
the erection of school buildings, and as regards light,
heat, and ventilation. The magnitude of the financial
interests alone would justify a more discriminating
supervision. There are in Ohio $46,000,000 worth of
school property, 26,000 teachers, and 830,000 pupils, and
about $15,000,000 was last year spent on the public
schools. One of the speakers showed a rare wisdom in
urging that school buildings should not be located on
streets where there are street-cars or many heavy
wagons passing, as voices and dispositions both suffer
from the noise. We do not think he was so right in
advising only one-story and two-story buildings, because
of the " slight development of the muscular system "
of many of the upper grade girls.
Unsanitary Indecency In Public Schools. — It is
more than strange that the condition of the water-closets
of the public schools of the United States are allowed to
be in such an indescribable condition. We do not speak
of those in a few of the city schools (where indeed they
are by no means always what they should be), but of
those of the great majority of the schoolhouses in the
country and in villages. At a recent meeting of health
officers and school superintendents in Ohio, Dr. Hurty
tells of his inspection of a country schoolhouse, used as
a hogpen in summer, and of another where there was
no "out-house" whatever; and one of the trustees,
replying to remonstrances, said that none was needed,
as there was none where, as a boy, he went to school.
Other speakers at this meeting thought that such a
shameless iniquity needed "outlawing," and it was cron-
cluded that every county should have an inspector of
school buildings not a member of the school board.
Health and morality must suffter from such disgusting
negligence, but it may be doubted if they are so much
outraged as in the existence for the uncared for "out-
house." Perhaps there is no better indication of essen-
tial civilization and of inherent self-respect than the
condition of the water-closets of the homes and of the
schoolhouses of a people. The nearer the location of
these to the schoolhouse the greater the danger from
infection and indecency, and where in towns and cities
they are put in the school building the greatest strict-
neas as regards their care is needed. To subject the child-
322 Akebican MKDionntl
EDITORIAL ECHOES
[AugcstSO, 1802
mind to the horrors of the physical and moral contami-
nations of the ordinary country schoolhouse " out-house "
is to pollute it at least with images which must last for-
ever. It is not especially a national shame, because all
nations are similarly barbarous in this respect. But
cannot the State which compels attendance at school
really grapple with the evil in some thoroughgoing
hygienic way? Boards of health are devoting much
time to vastly less important reforms and abuses.
School Gardens. — Probably tbe majority even of
educated Americans never heard of school gardens, and
asked off-hand would have no true conception of the
meaning of the term. And yet Dr. Helen G. Putnam,
of Providence (in a lecture before the Rhode Island
Normal School delivered April 1, 1902), tells us that
there are over 100,000 in Europe, exclusive of kinder-
gartens. Every parent and every teacher (that includes
every physician) should read Dr. Putnam's interesting
paper. Austria is " the classical land of school gardens,"
and Dr. Erasmus Schwab, the founder of the movement
there, wrote some 25 years ago the following significant
words :
" One hundred years hence It will seem inexplicable that for
centuries there could exist among cultured nations public
schools without school gardens, and that in the nineteenth cen-
tury communities and nations in generous emulation could
furnish the schools with all things dictated by common sense
and profit and care, except, in thousands of cases, an educa-
tional medium that should suggest itself to the mind of even
the common man. . . .
" The school garden will exert a powerful influence upon
the heart of the child, and upon his character ; it will plant in
the children the love of nature, inculcate the love of work, a
generous regard for others, and a wholesome esthetic sens e
The school garden, as Austria is carrying it out, is a nursery
for a practical knowledge, and a noble enjoyment of home
nature, for the culture of the understanding, for the esthetic
sense, for public spirit, for better morals and higher prosperity
of the people ; it is an ideal thought but united with realism
and aiming at full life in all its relations."
It is strange negligence that makes England and the
United States the last of civilized countries to avail
themselves of the tremendous agency for good which the
school garden offers, and which has been more than
demonstrated in tlie 100,000 instances of which Dr.
Putnam speads. The interest, tirelessness, and energy
with which every child will dig and work at doing
something utterly useless educationally and in all ways,
should long ago have made the school garden a principal
department of every public school. The vacation school
is our method of beginning what must finally become
the systematic part of all public school education, the
school garden.
The hygienic aspect of the school garden is by
no means the least important one, and it is strange that
it has been so little recognized. It is true that the soci-
ologic and moral progress it stimulates have been the
chief ideals, but we are all too slow in recognizing the mor-
ality of medicine, and that there can be no genuine soci-
ologic advance except it is at the same time hygienic.
And vice versa the rule holds as well. Hence all medi-
cal men must look with especial delight upon a move-
ment that so powerfully encourages health and a healthy
home life as does the school garden. Our danger, one of
our great dangers, is the artificial and less wholesome
life resulting from concentration in cities, the great
diminution of homes, productive occupations, etc. Dr.
Putnam, in this connection, wisely says :
"Comparatively few reasoning from limited fields of
observation in cities where ideas of social betterment flourish
because of the concentrated evidence of its need, are endeavor-
ing to restore to childhoo<rand to municipalities certain miss-
ing factors in normal living; but have not yet attempted the
equally important prevention of unsuccessful city herding, by
requiring country schools to apportion their efforts justly
between studies to promote rural industries and happiness, and
those attracting cityward. Whatever may have been previous
justification, our slums, our army of tramps, the growing
millions expended in charity and for punitive measures, the
increase of divorce, of the unemployed (often unemployable),
of nervous diseases, the deserted farms and villages in the
older States, confront us with ne^ds similar to those of Euro-
pean countries — the need to provide for happier homes,
healthier occupations and recreations, and wiser ambitions."
Supervision of Water-supplies by State Boards
of Health. — What is the law and custom in the differ-
ent States as to the responsibility of their State Boards
for the purity of the water-supplies? In Minnesota
section 431 of the General Statutes of 1891 states that the
State Board of Health shall have the general supervision
of all springs, wells, ponds, lakes, streams, or rivers
used by any town, village, or city as a source of water-
supply, with reference to their purity, together with the
waters feeding the same, and shall examine the same
from time to time, and inquire what, if any, pollution
exists, and their causes. In trying to determine the
duties of the State Board of Health in relation to water-
supplies, the board's attorney, Mr. Harris Bichardson,
was asked for an opinion. His reply was as follows :
I am of the opinion that your board has full power and
authority to supervise thesources of all water-supplies of towns,
villages and cities in this State, with reference to the purity of
their water, and full power to examine the conditions of the
water-supplies, and in case of the pollution of any thereof,
to stop the use of such water wlienever the public health
requires it.
In my judgment, examinations with respect to the purity of
water-supplies should be made from time to time by your
board, upon resolution.
In case at any time yoii find that pollution of a water-
supply exists, a time and place may be appointed by your
board for hearing the parties to be affected. Notice of such
hearing should be given to all parties interested, and if upon
the hearing your board determines, in its judgment, that the
public health requires it, you may order the difficulty
remedied.
In case your orders are not obeyed, you are authorized to
apply to the District Court and have your orders enforced.
(Signed) Harris Richardson.
Following this instruction the State Board of Health,
at its meeting July 9, 1902, passed the following resolu-
tions :
" Resolved, That from this date all villages, cities and pub-
lic institutions contemplating putting in new water plants, or
repairing or extending old systems, shall submit to the State
Board of Health a statement showing the source from which
the water is to be taken, and the plans, if any, for purification
or filtration of the water.
" Resolved, That from this date all villages, cities and pub-
lic institutions contemplating putting in new sewerage systems,
or repairing or extending old systems, shall submit to the
AUGUST 30, 19021
EDITORIAl. COMMENT
American Medicine 323
State Board of Health a statement showing the course and
place of discharge lor all sewage from such systems, and the
plans, if any, for the purification or filtration of the sewage."
Dr. Bracken, the secretary and executive offlcer of
the board, is appealing to the villages and cities of the
State to aid the board in securing pure water-supplies.
It is the wish of the board to prevent the construction of
unsanitary water plants or sewerage systems and the
consequent waste of money.
Cheap Nursing and the State Regulation of the
Nursing Profession. — Announcement has just been
made of a comprehensive scheme for the education of
nurses in the South. At first the plan sfeems to be com-
mendable. In brief it is that training schools are to be
established in the Southern States wherein women of
moderate education and limited means can learn how to
nurse in time of sickness, with the double purpose of
better caring for ill members of their families and of
qualifying themselves to act as paid helpers in case of sick-
ness. With the idea of teaching first aid to the injured
every one is in sympathy— doctor, nurse and patient
alike — and if the movement stopped here it would be
hailed on all sides as a long step in advance. Reading
between the lines,^ however, and with a knowledge of the
parent organization which is to control the proposed
scheme of education, it must be admitted that the step is
ill-advised. An organization, said to have received a
large endowment for the above purpose, was established
to enable women, after a ten-weeks' course of lectures
from various instructors and on receipt of its diploma, to
enter the field as trained nurses, and to compete with
women who have undergone regular courses in a hos-
pital training-school. It is said in justification that
people of moderate means cannot afford to pay the hos-
pital trained nurse. Cheapness in nursing is aimed at,
and the standard of the nursing profession is lowered.
Like the parent organization, the Southern schools are
apparently to be established irrespective of hospital con-
nections.
At a time when our law schools and schools of medi-
cine are raising their standards, when in every profes-
sion there is a tendency to raise rather than to lower the
bars, it is most regrettable that philanthropic but
misguided people have seen fit to encourage a low stand-
ard in nursing, when by a different method the same
results could have been achieved without injury to any
one. The more important organizations of nurses are
now looking to the improvement of their profession, its
regulation, and to the adoption of more uniform stand-
ards of training. In the face of such movements as the
one under discussion it would seem that the only redress
will be State regulation. If an organization which has
alrea<ly been condemned by the College of Physicians of
Philadelphia, the Philadelphia County Medical Society,
and the American Society of Superintendents of Train-
ing Schools, is to compete on a large scale with our hos-
jiital training-schools and turn out half-trained nurses on
an unsuspecting public, there would seem to be no
remedy but that of legislation. It therefore behooves
the medical and nursing professions to make every effort
to secure legal recognition and control if the diploma of
the nurse is to be worth the paper it is written on, and
what is still more important, if the welfare and safety of
the patients is to be properly guarded.
"Teaching the Blind to See" is the title given
articles descriptive of methods of improving the vision
of those with high amblyopia. It is curious to prove,
as we have done in several instances, that there are
more cases of pseudoblindness than one would suspect.
It is strange that even a child would exaggerate ambly-
opia and take interest in seeming more " blind " than it
really is. And yet this is sometimes true. When vision
is very poor it may prove a difficulty and danger, and
renunciation of the attempt to see is found preferable.
This may be emphasized, and perhaps usually is, by the
desire of parents (and even of the child) to secure its
admission to some charitable institution. The term
blindness thus has often only a relative significance. If
the blindness is absolute, there cannot be such a thing as
"making the blind to see." Even in cataract, opera-
tion removes the obstacle to vision, permitting the func-
tional retina to have its normal stimulus. It is doubt-
less true that the sense of vision is capable of great
improvement in every person, but it is often surpris-
ingly so in many of the socalled blind. If those with
but a slight degree of vision are permitted to renounce
the little they have they in fact lessen it, whereas if they
try to improve it they may in fact increase it and make
it more and more useful. This accords with the general
physiologic law that disuse atrophies organs and exer-
cise develops them. The Literary Digest, translating
from Druot in La Nature (Paris, June 14, 1902), describes
the method pursued by M. Heller, a teacher of the blind,
near Vienna, in developing and educating the sense of
vision in two little boys. In daylight they were appar-
ently completely blind, but the sensation of light could
be stimulated in a dark room. M. Heller began by
arousing discrimination between light and darkness by
the use of brilliantly illuminated discs in a dark room ;
he then proceeded to the discrimination of form and
colors in the same way, until he finally succeeded in
making one boy tell objects in ordinary daylight. The
plan is an excellent one and would perhaps be similarly
successful in the case of many now supposed hopelessly
blind. Those in charge of our institutions for the blind
may find M. Heller's suggestion well worth carrying
out.
Health an<l Occupation. — The career of Mr. Alfred
Balfour, the recently appointed Premier of England,
possesses, according to a very widely known story,
special interest from a therapeutic standpoint. Mr.
Balfour has never been a strong man, and though an
enthusiastic athlete, especially as regards such milder
outdoor exercise as golf, his delicacy of health in early
manhood was a source of no little alarm to his friends.
He has always been an intense student and his over-
faithful devotion to his books, during the period between
his thirtieth and thirty-fifth year, just before and after
the publication of his work "Foundations of Belief,"
seem to have further undermined his health. In 1886,
when he secured the much-coveted position of Lord
824 /^KBRICAN MBDIOIKE
REVIEWS
[AuotTST 30, 1908
Rector of St. Andrews University, of Edinburgh, his
health was so dubious that many of his friends were
thoroughly persuaded that he was doomed to an early
death.
About this time a distinguished English physician
(we understand it was Sir Andrew Clark) is said to have
told him that his only hope for future good health lay,
not in constant care of himself, nor in a life of leisure,
however elegant, that would give him too many oppor-
tunities for depreasive introspection, but in his securing
some occupation that would demand all his attention,
absorb all his energies and if possible at the same time
give him an intense interest in his work. Within the
year Mr. Balfour found his opportunity to take such a
remedy as had been thus suggested. It was heroic, but
he took it without flinching. He was offered the post of
Chief Secretary for Ireland. This was at the very heighth
of the Land League agitation. Already several chief
secretaries had found themselves unequal to the trying
responsibility of the position. It was undoubtedly the
most strenuous post under the government. There was
no doubt that its occupant would have constant mental
occupation of the most intensely absorbing kind.
To the ability with which Mr. Balfour filled the
position he owes much of his after-reputation as a prac-
tical statesman. Brilliant as he was in metaphysics and
philosophy and devoted to his books it was the custom
to think of him even in friendly circles much more as a
scholar than in any sense as a manager of men. Polit-
ical opponents were prone to sneer at him as a dilettante
student and many were the prophecies that he would
make an egregious failure of the Irish chief secretary-
ship. In the midst of the intense strain Mr. Balfour
remained calm, cool and masterful. His very calmness
proved a source of power. He did not, of course, make
friends in Ireland. In recent years no chief secretary
has ever done that. Now, 15 years after the event, how-
ever, there are many even of his political opponents who
consider him to have been the best chief secretary Ire-
land has had for a quarter of a century. In the mean-
time under the stress of hourly calls to duty Mr. Bal-
four's health constantly improved and at the end of
his term he was ready for the other commanding
political positions that have come to him. Unfortu-
nately very few physicians can prescribe for a valetudi-
narian patient the chief secretaryship for Ireland with
any confidence that his prescription will be fulfilled, but
the lesson of the event is certainly a precious therapeu-
tic hint as to the beneficial use that may be made of the
influence of mind over body.
EDITORIAL ECHOES
BOOK REVIEWS
In all tills work there is apparent a turning away
from the "mechanical" and "environmental," arealiz-
ation of the prematureness and inadequacy of all biologic
"explanations" couched in terms of existent chemistry
and physics, and an appreciation of greater depth and
mystery in the life activities than had been previously
conceded. — [Professor W. M. Wheeler, in Science, June
20, 1902.]
Holden's Anatomy: A Manual of the Dissection of the
Human Body.— Edited by John Lanoton, Surgeon to
and IjBCturer on Anatomy at St. Bartholomew's Hospital ;
Member of the Board of Elxaminers, Royal College of
Surgeons of England ; Surgeon to the City of London
Truss Society ; Consulting Surgeon to the City of London
Lying-in Hospital, and to the Memorial Hospital at
Mitdmay Park. Seventh edition. Revised by A. Hew-
soN, M.b., Demonstrator of Anatomy, Jefferson Medical
College, Philadelphia; Professor of Anatomy, Philadel-
phia Polyclinic for Graduates in Medicine; Surgeon to
St. Timothy's Hospital; Dispensary Surgeon, Episcopal
Hospital ; Member Association of American Anatomists ;
Fellow of the College of Physicians, etc. In two volumes.
Volume II., Abdomen, Lower Extremity, Brain, Eye,
Organ of Hearing, Mammary Gland, Scrotum and Testis.
Illustrations. Philadelphia: P. Blakiston's Son & Co.,
1012 Walnut street, 1901.
To those acquainted with this work it needs little recom-
mendation. Its complete arrangement, its many splendid
illustrations, and its thorough and complete adaptation to the
dissecting room make it one of the most desirable works for
the purpose for which itis designed that has come to our atten-
tion. More and more we are coming to use the metric system,and
its incorporation in the text, together with the English system,
adds materially to the value of the book. The present edition
consists of two volumes, a fact which adds materially to the
convenience of handling. Since a thorough acquaintance with
anatomy forms the basis lor all future medical study, it is
important that the beginner should be supplied with textbooks,
such as the present volumes, which will afford every facility in
mastering this difficult branch of learning.
The Diseases of Children.— By James Frederic Goodhakt,
M.D., LL.D. Aberd., P.R.C.P., Consulting Physician to
the Evelina Hospital for Sick Children and to Guy's Hos-
pital ; assisted by George Freubrio Still, M.A., M.D.,
F.R.C.P., Assistant Physician for Diseases of Children,
King's College Hospital, and to the Hospital for Sick Chil-
dren, Great Ormond Street. Seventh edition. Cloth.
Pp. 813. London : J. & A. Churchill, 1902 ; Philadelphia :
P. Blakiston's Son cfe Co. Price, $5.00.
The appearance of the seventh edition of a book first issued
in 1885 gives better proof of the inherent value of the contents
than can any statement of a reviewer. The book is somewhat
larger than in previous editions, but the original purpose is
still held, that of making it a students' guide. Considerable
revision has been made of the chapters on infant feeding, which
now comprise 33 pages, and of those on diseases of the nervous
system. Diseases have been grouped into chapters, as Peri-
tonitis—Appendicitis— Ascites, and Tuberculous Meningitis-
Tetanus. The treatment of appendicitis by opium, belladonna
and poultices will not be followed by most American physi-
cians, who will hardly accept the statement, made during the
consideration of the surgical treatment, that " on the whole, the
trend of opinion now seems to be to let the acute cases alone if
possible." The general style of the book can be commended.
Definitions, when given, are concise and to the point, but many
of the diseases are not defined at the outset. This should be
done in a students' guide. The mechanical work on the book
has been well done ; the paper is of inferior quality.
Clinical Psychiatry.- A Textbook for Students and Physi-
cians. Abstracted and adapted from the sixth German
edition of Kraepelin's " Lehrbuch der Psychiatrie," by
A. Ross Defendorf, M.D., Lecturer in Psychiatry in Yale
University. The Macmillan Company, 66 Fifth avenue.
New York. Price, $3.50.
"The motive for this work is to make the teachings of
Kraepelin in psychiatry accessible to American medical
students and general practitioners — at the same time to provide
a full, concise textbook," the translator remarks in the preface.
The book is an excellent translation from the German into
the idomatic English expression, which makes a foreign com-
pilation readable and interesting in a new language. Tiie
classification is that of Kraepelin, one of the best expositions
of mental alienation being concisely expressed in the first sec-
August 30, 1902]
AMERICAN NEWS AND NOTES
[American Meuicinb 325
tion on " General Symptomatology," in which the usually
accepted definitions are clearly set down, together with their
explanations, where possible, from a psychophysical point of
view. Illusions and hallucinations, for example, always have
their origin in something previously conceived — a connection,
therefore, with a previous psychic act or falsification of percep-
tion, showing a close jconnection between these hallucinations,
illusions, and also morbid fears, and the patient's innermost
thoughts. Sense deception is, therefore, a common source of
origin of delusions, etc., along with other disturbances of
mental equilibrium. The author again refers to his unwil-
lingness to admit the word "apperception" into psychiatric
nomenclature, it being meaningless. Clouding of conscious-
ness and disturbance of apprehension are admissible to describe
these vague circles of diffusion, so to speak, in psychiatry.
Disturbances of mental elaboration is a classification well
taken, under which come disturbances of memory, disturbance
of ideas, of the sequent train of thought and compulsive ideas,
including the ramblings of hypomanias and desultoriness of
certain insane. Finally in this section heoonsiders disturbances
of emotions and disturbance of volition and action in vivid
fashion for the student. The forms of mental disease are then
considered in i:^ subdivisions; (1) The infection psychoses ; (2)
exhaustion psychoses ; (3) intoxication psychoses ; {■!) thyroige-
nous psychoses ; (.5) dementia prsecox ; (6) dementia paralytica ;
(7) organic dementia ; (8) involution psychoses, under which he
gives melancholia, presenile delusional insanity and senile de-
mentia; (9) manic depressive insanity; (10) paranoia; (11)
general neuroses, under which are classed epileptic insanity,
hysteric insanity and traumatic neuroses; (12) constitutional
psychopathic states, including congenital neurasthenia, compul-
sive insanity, and contrary sexual instincts; (13) finally he takes
up defective mental development, not true insanity, of course.
This comprehensive view of mental disease well merits the
textbook exposition of the subject, and "Clinical Psychiatry"
is the more scientific title than if the work had been styled
" Treatise on the Insane."
BOOKS RECEIVED.
Grayxon'H Laryngology: A Tren tl.se on the Dlscascsof the Throat,
Nose and the Associated Atrections of the Ear.— By Charles P.
Gkayson, il.D., Lecturer on and Instructor in Laryngology In the
Medical Department. University of Pennsylvania. In one octavo
volume of 540 pages, with 129 engravings, and 8 colored plates. Cloth,
JS.oO net. Lea Brothers & Co., Philadelphia and New Yorii, !»02.
The Principles and Practice of Bandaging.- By Gwilym G
Davis, M.D., University of Pennsylvania and (iotlingen; Member of
the Koyal College of Surgeons. Kngland; Assistant Professor of
Applied Anatomy, ITniversity of Pennsylvania: Surgeon to the Epis-
copal, St. Joseph's and Orthopedic Hospitals, illustrated from origi-
nnl drawings by the author. P. Blaklstou's .Son & Co., Philadelphia
1902. Price, S1..30 net.
Massage and the Original 8wrdiFh Movements: Their applica-
tion to various diseases of the body, r^ectures before the TrainlnK
Schools for Nurses connected with the hospital of the Univeraity of
Pennsylvania, German Hospital Woman's Hospital, Philadelphia
Lying-In Charity Hospital, the Philadelphia Polyclinic and College for
Graduates in Medicine, and the Kensington Hospital for Women of
Philadelphia —By Kl-bre W. Ostrom, from the Koyal University of
ITpsala. Sweden. Fifth edition, revised and enlarged, with 11.5 illus-
tmtions, P. Blakiston's Son & Co., 1002. Price, $1 .00 net.
Practical Gynecology.— By W, O. Henry, M,D.. Omaha Neb
Professor of tiynecology in the Crelghton Medical College. With Ave
full-page Illustrations and «1 Illustrations in the text. The Review
Press, Lincoln, Neb., 1902.
Woolsey's Surgical Anatomy: Applied Surgical .Anatomy R*-
glonally Presented, for the use of students and practilioners of uicdi-
clne.— By Geor«e Woolsey. A,B., M.D , Professor of Anatomy and
Clinical Surgery in the Cornell University Medical College ■ Surgeon to
Bellevue Hospital, etc. Octavo, 511 pages, with 12-5 iirustiations, in-
cluding M full-page Inset plates in black and colors. Cloth, $.5.uo net
r>eather, $« 00 net. Lea Brothers & Co., Philadelphia and New Yorkj
Pood Adulteration In AnstraHa.— Following is an
extract from the report of the new Health Commissioner of
Queensland, Australia:
".Samples of butter were found to be rough with boric acid.
Beers were rank with salicylic acid; wines were sweet to sick-
liness with sugar. Fruit syrups were discovered which had not
even a distant acquaintance with fruit, or were loaded with
'preservative!--.' Samples of tea were analyzed and proved to
have grown on no vegetable stem whatever. No less than 30
chests were found to have been ' made by mixing magnetic
oxid of iron with tea dust and sand, rolled by means of starch
into little pellets of various sizes in imitation of genuine teas.'
The roDort states that the common method of making whisky
is to dilut« essence of whisky with proof spirit and then arti-
ficially ' bead ' the mixture by adding sulfuric acid and olive
oil."
AMERICAN NEWS AND NOTES.
OENERAIi.
American Dermatoloi^c Society.— The twenty-sixth an-
nual meeting of this society will be held at Boston, Mass., Sep-
tember 18-20, 1902, under the presidency of Dr. G. T. Jackson.
Smallpox In the United Stat«8.— During the period June
28 to August 22, 1902, there were 4,818 cases of smallpox in the
United States, with 217 deaths. During the same period of 1901
there were 8,258 cases and 204 deaths.
Plague In the United States.— During the period extend-
ing from December 28, li)01, to August 22, 1902, there were in the
United States 13 cases of plague, all being in San Francisco,
although 2 came from Berkeley and Davlsville. There were 12
deaths.
Monument for Physician-Author.— A committee has
been appointed by the Board of Managers of the Society of
American Authors to solicit subscriptions for the erection of a
suitable monument to Dr. Thomas Dunn English, editor, law-
yer, soldier, physician, statesman and author.
Manila Health Report for May.— The annual deathrate
per 1,000 population for May was 65.81, distributed as follows:
Bilipinos, 8!.24; Chinese. 14..56; foreigners, 24.01; Americans,
18.16. The average birthrate for the same period was nine per
1,000. The number of lepers in the various provinces of the
Philippine Islands is 3,063.
Sander Prize Essay.- The August number of the Joxiriml
of Ihe Association of Military Surgeons of the United States
contains the first instalment of the Enno Sander prize essay on
"The Most Practicable Organization for the Medical Depart-
ment of the U. S. Army in Active Service," by Lieut.-Col.
Valery Havard, U. S. A. The essay will be concluded in the
September issue.
False Certifications in Cholera Cases — An ordinance
which has been operative in Manila since June 17 was adopted
by the Health Board, after it was discovered that false certifica-
tions regarding deaths from cholera had been made by native
doctors. It prohibits the issuance of a death certificate for the
interment of any body in the city of Manila during the exist-
ence of cholera until the cause of death has been ascertained bv
a member of the Board of Health or one of its agents, and that
any physician or person having charge of a case of infectious
disease who fails to report it to the Board of Health shall be
prosecuted. It was also decided that one peso should be given
to any person, not in the employment of the health board, for
reporting a cholera case to the medical inspector of the district.
EASTERN STATES.
Smallpox is stated to be practically eliminated from Cam-
bridge, Mass. There have been no new cases for over two
weeks, and a careful investigation leads to the belief that the
disease will not reappear for some time.
New Hampshire Sanitary Bulletin. — The July number
of this bulletin contains a portion of the transactions of the New
Hampshire School of InstriK'tion for Health Officers and Sani-
tary Confereuce for 1902, which recently held a tliree days'
session at the State Capitol. It contains a great deal of informa-
tion relating to practical disinfection.
The Backyard Nuisance.- The Boston Board of Health
have found a solution of this problem evidenced by the work
undertaken this summer. It was found that many buildings
apparently new and very attractive had very small yards, m
some instances completely filled with ells and sheds and high
fences, preventing sunlight from reaching them. These yards
were generally wet. Therefore, as a means to preserve the pub-
lic health, the board proposes to have removed auxiliary struc-
tures that prevent a clear space in the rest of dwelling houses
and to have the yards covered with a concrete surface. Several
gangs of laborers and carpenters have been engaged for the
work. Structures have been condemned and must oe removed
by the owners. Fences have been ordered cut down to six feet
at the highest. The board has authorized the erection of nar-
row sheds about five feet high for keeping wood and barrels.
In laying the concrete surface, owners must build catch basins
ill the center to relieve surface water, and a large chopping
block must be supplied for each house. In the places where the
work has been completed the yards are light and airy. It is
hoped to have two districts completed by thio end of the season,
with new yards admiiting as much fresh air and light as possi-
ble. The expense is twrne chiefly by the property owners.
NEW rORK.
Medical Inspector for the Port of HaTana. — Dr. Nestor
Ponce de Leon, a graduate of the Columbia University School
of Medicine, has been appointed to the position.
New Public Baths.- Three buildings to be used -for public
baths will beerected in different portionsof New York City. On
the first floor of each will be separate waiting-rooms for men
326 AXEBIOAN MSDIOINK]
AMERICAN NEWS AND NOTES
tAuousT 30, 1902
and women and separate baths tor both. The men's baths will
include ;« showers and 2 tubs and the women's 29 showers
and 6 tubs. The second tloor is to bo used entirely for men's
baths, cousistinpr of .36 showers and 2 tubs. The buildings will
be construoteil of l)rick, terracotta, stone, marble and copper.
It is estimated that the cost to the city will be ii22.'),()00.
Columbia Fellowships for PostKiaduate Study In
France.— President Butler, of Columbia University, is seelcing
to estabiisli a recipnx^l system of international fellowships
with France in order to encourage students of each country to
pass a portion of their periwl of advanced study in the other.
Two annual fellowships of the value of f 1,200 each are proposed
for Columbia University and for one of the French universities.
They will be open to graduate students only, those in law and
med'icine being permitted to compete for the fellowships on
equal terms with those who have taken the degree In arts.
Tunnel Declared a Menace to Health.— A report
tendered to the Rapid Transit Commission by the Health
Department calls attention to the conditions existing in the
excavations for the tunnel now under construction, declaring
them to be a menace to the health of persons living in the
vicinity. The unsanitary conditions exist in the whole length
of the tunnel, and are caused by the disconnection of sewers,
stagnant water, the escape of sewage, the use of the excavations
for dumping places and the prevalence of foul odors. The
commission has forwarded the report to Chief Engineer
Parsons who, it is stated, will have all sanitary nuisances
corrected.
Baths in Bad Condition.— A report to the New York
Board of Health states that various public and some of the
private baths are in a filthy condition. In another report
Assistant Sanitary Superintendent Dillingham said: " Investi-
gation of the floating baths situated on the water front of this
city shows that many of them are in an unsanitary condition
and are located near the mouths of adjacent sewers, which
cause the water to become contaminated with the sewage. I
would recommend that Section 200 of the Sanitary Code be
amended to read that no baths be maintained in the city of New
York or along the water front without a permit from the Board
of Health." Dr. Dillingham's recommendation was adopted.
Enforcing Medical Laws.— The Dental Society of the
State of New York, through its counsel, has answered the
statement of a justice of the Court of Special Sessions in which
he is said to have declared that the fines which now go to the
County Medical Society, the Dental Society, the Pharmaceuti-
cal Society and the Department of Health for prosecutions in
their respective provinces should instead be divided between
the State and city treasuries. The answer states that the fines
in question have been small during the last 20 years, never in
one year efiualiug— and often being less than half of— the cost
of prosecution and investigation. If societies were deprived of
the help of these fines they would have to stop trying to enforce
the laws. It would be a sorry day if the police force were
required in practice, as is expected in theory, to enforce medi-
cal, dental and kindred laws systematically. On the other
hand, the societies referred to are conscious that for false arrests
and malicious prosecutions by their agents they are responsible
in damages. Thus they have a selfish interest in safeguarding
the interests of accused persons, and this is a distinct gain.
PHILADEIiPHIA. PENNSYIjVANTA, ETC.
The Philadelphia Home for Incurables will receive
Sa,500 under the will of Sarah K. Davidson, of Philadelphia.
SOUTHERN STATES.
Surgeon to the President. — Dr. G. A. Lung has been
assigned to the position of surgeon to the President, succeeding
Dr. John F. Urie, who was made Assistant Chief of the Bureau
of Medicine and Surgery.
Baltimore Pasteur Institute.— Since its opening 322
patients have been treated in this institution. Of these 209 were
bitten by animals absolutely proved to have been mad. In 58
others the disease was suspected but not positively demon-
strated. Of all the cases only one terminated fatally, that patient
being a boy who was taken away from the hospital and only
brought back when it was too late to save him.
Change of Title. — The title of the chair of pathology at
Johns Hopkins, held by Professor Welch, has been changed to
the " Boxley Professorship of Pathology," in memory of Dr.
Henry Willis Boxley, an eminent surgeon of Baltimore, who
died in 1876. He was one of the first surgeons in Maryland to
operate for strabismus and to extirpate the lower jaw. He left
a large bequest for the founding of a chair in pathology.
New Municipal Institutions. — At a meeting of the Florida
State Board of Health it was decided by unanimous vote to
provide for the establishment of a bacteriologic laboratory.
Arrangements will be made for buying the apparatus and the
selection of the physician to have charge will be announced in
the near future. Special attention will be given to the scien-
tific investigation of indigenous dLseases. and an oflScial record
made in order to assist physicians in their struggle against dis-
ease. It was also agreed, if the county would lease the land, to
establish a hospital for the treatment of contagious diseases in
Jacksonville. It will be situated just outside the city limits,
and will take the place of the present institution, which is con-
sidered inadequate.
Johns Hopkins Hospital.— Acoordine to the thirteenth
annual report, the sum of §10,000 contributed by Dr. Howard A.
Kelly has been used for building on the north side of the public
gynecologic ward a large two-story annex, affording accommo-
dations for 24 patients, and including all the conveniences and
equipment necessary for such a building. Plans for a surgical
operating room to occupy the site of the present amphitheater
have been completed, and it will probably be erected some time
during the summer. The report calls attention to the fact that
owing to the decrease in rates of interest and the depreciation
of property belonging to the hospital the annual income has
been greatly diminished, so that even with the utmost effort it
barely suffices to cover the yearly expenditure. In view of the
Important contributions which the hospital is making to medi-
cal science and instruction, it is advised that an appeal be made
to the public to increase the endowment so as to give the facili-
ties necessary for medical teaching. It is stated that an increase
of about $20,000 in the income would be sufficient to extend the
work in needed directions. During the year ended February
28 there were 4,363 patients treated in the hospital. Of these
4,064 were discharged and 295 died.
WESTERN STATES.
Michigan College of Medicine.— Dr. K. C. Watson, of
Canada, has been appointed professor of rhinology and laryn-
gology in the Michigan College of Medicine, at Detroit.
Chicago Eye, Ear, Nose and Throat College.— Dr.
Harold N. Moyer has been elected to the chair of neurology.
His work will be on the lines of the " Clinical Aspect of Neu-
rology in Ophthalmology."
Epidemic of Dysentery in Illinois. — At Paris, 111., an
epidemic of great severity has prevailed for the last two weeks.
It is estimated that there are 500 cases of the disease, and up-
ward of 20 deaths, mostly among children, have occurred.
Mississippi Valley Medical Association.— The twenty-
eighth annual meeting of this association will be held in Kan-
sas City, Mo., October 15-17, 1902, under the presidency of Dr.
S. P. Ceilings, of Hot Springs. The oration in medicine will be
delivered by Dr. Hugh T. Patrick, of Chicago; the oration in
surgery by Dr. Geo. W. Crile, of Cleveland.
Cincinnati College Closed. — The faculty of the Cincinnati
College of Medicine and Surgery has decided not to reopen the
college for the coming fall session. This action was taken
because of diminished attendance, which has become marked
in all medical institutions of the State since the establishment
of rigid entrance re<iuirements. The college was founded in
1851.
Typhoid Fever in Chicago. — The bulletin of the Chicago
Health Department for the week ended August 9 is devoted
almost entirely to the consideration of typhoid fever, which
disease is more prevalent now than at any other time since the
three years immediately preceding the World's Fair. The
type of the disease remains remarkably mild, there being hun-
dreds of "walking cases" who do not consult a physician.
Attention is called to the fact that these are just as dangerous as
are severe cases in spreading the disease. The bulletin for
August Zi states that in the area of the city furnished with the
best water and containing less than one-fifth the total population
of the city, 73, or nearly 57%, of the 129 August typhoid deaths
have occurred. All the energy of the liealih department is
being concentrated in this " storm center." The prevalence of
malaria is adding a complication to the typhoid situation.
CANADA.
Hog cholera has appeared in Middlesex county, Ontario.
In order to check the disease the government inspectors have
1 had 100 animals slaughtered.
i
Unborn Child Heir with Other Children. — An unusual
point of law, the first of its kind ever raised in Canada, and it is
stated the second on record, has recently been pronounced on
and decided at Toronto by Mr. Justice Lount. A farmer in the
I western part of Ontario died, leaving a widow and four chil-
' dren. A fifth child was born four months afterward. The case
i turned on the division of a $2,000 insurance policy, which
according to the will was to be turned over to the widow and
children in equal shares. The administrators applied to the
court for advice as to whether or not the infant child born after
the death of her father was entitled to a share in the insurance
money. His lordship ruled that a child, although unborn, is
still a child in law, and takes rank as a child living at the death
of its parent. — [Joitr. A. M. A.']
August 30 1902)
CORRESPONDEN CK
AMERICAN MKDICINK 327
FOREIGN NEWS AND NOTES
OESETtAJi.
Mortality from plaKue is increasing at tlie rate of about
1,000 cases weekly, according to a dispatch from Simla.
Cholera In Siberia. — Tiie latest report shows no abate-
ment in the spread of the disease, there being 752 cases and 484
deaths.
Vlrchow Fond. — The committee having in charge the fund
raised to commemorate the eiglitietlj birthday of Professor
Rudolf Vircliow, announces that after the payment of all
expenses the sum of 53,6.52 marks remains for the Rudolf Vir-
chow Foundation.
GREAT BRITAIN.
Glasgow Smallpox Epidemic. — A report by the health
officer shows that from April, 1900, to July, 1902, there were in
Glasgow 1,759 cases of smallpox, Zii resulting fatally. The effi-
cacy of vaccination in stopping the epidemic is well shown, the
entire cost of such measures being more than £32,000.
Restrictions on Smallpox Hospital. — It. would appear
that foreign authorities are meeting objections somewhat simi-
lar to those of Philadelphia in the matter of locating smallpox
hospitals. The conabination of various English districts in the
erection of a centrally located smallpox isolation hospital
having been purposed, the local government board laid down
the following restrictions : 1. The site must not have within a
quarter of a mile of it either a hospital— whether for infectious
diseases or not — or a workhouse, asylum, or any similar estab-
lishment, or a population of as many as 200 persons. 2. The
site must not have within half a mile of it a population of as
many as 600 persons, whether in one or more institutions, or in
dwelling houses.
COXTINENTAL. EUROPE.
Congress of German Scientists and Physicians. — The
seventy-fourth annual meeting of this congress will be held at
Carlsbad, September 21-27, 1902. Sections allotted to medical
subjects include practically all branches oi medicine.
Increase in Insanity Due to Edncation.— In a paper read
before the Paris Academy of Medicine Dr. Solners seeks to
establish a correlation between the increase of insanity and the
dissemination of knowledge. According to his theory, which
is plausil)ly built on close observation of numerous incidents,
education acts upon certain brains in such a way as to produce
cerebral disorders. In fact, even the superflcial knowledge as
imparted in the lower schools or absorbed from newspapers is
considered sufficient to cause minor crevices in the gray matter,
giving rise to many forms of insanity not as yet catalogued.
For illustration he cites a list of abnormal happenings in a
single week together with many other instances, trom which he
deduces that the human race is chiefly composed of latent
lunatics.
OBITUARIES.
William Faithful Hendrickgon, at the Union Protestant Infirm-
ary, Baltimore, August 21, aged 26 Dr. Hendrlckson was born In Bal-
tlmori-. and graduated from .lohns Hopkins ITnlvcrsity In 1896 and
from the medical department In l!KX). Boon afterward he went to the
University of Pennsylvania where he hud since remained as Instructor
in pathology, declining calls to California and Iowa. June 1 he was
taken sick with broncho-pneumonia which shortly afterward devel-
oped into meningitis, this finally terminating fatally. Dr. Hendrlckson
was a member of the statTof this Journal, collaborating with Dr. U. M.
Pearee In the department of Pathology and In the absence of Dr.
Pearce conducting the department unaided. The fine collation of
facts presented In that department In American Medicine, August 23,
was his work and In Its conscientious particularity and careful weigh-
ing of fact Is an excellent contribution to the literature of Pathology.
Kdvrin V. Wilson, In Columbus, Ohio, August 18, of diabetes; for-
merly professor of therapeutics, electrotherapeutics and clinical medl-
<lne lu the Ohio Medical University. He graduated from the medical
department of the University of Pennsylvania In 188.5.
William J. I.armer, of New York City, August IH. His body was
found floating In the North river oti' l«9th street Hulclde wa« the
sup\x)sed <'ftu.se of death.
•Inlin Henry Longnevker, a retired physician, at Isllp, L. 1.,
\iigust 19, aged 80. He was a graduate of Jefiferson Medical College.
«lanieB N«wton, of Hanover, N.H., August 18, aged 81. He was
I lie first dentist In Hint city to use ether In his professional work.
George A. Ilodamer, of Philadelphia, August 20, aged V^, He
ijraduated rri>m the University of Pennsylvania In 18*1.
.1. C. Cowan, of Moss Point, Miss., August 18, agod 47.
CLINICAL NOTES and CORRESPONDENCE
[Communications are Invited for this Department. The Editor Is
not responsible for the views advanced by any contributor.]
A FOREIGN BODY IMPACTED IN THE LARYNX :
REPORT OF A CASE.'
BV
OMVER A. BLUMENTHAL, M.D.,
of Syracuse, N. V.
On November 25, 1901, W. A., a male adult, while eating
meat and vegetable soup, was suddenly attacked with severe
pain in the throat. Within a few moments hoarseness and
moderately embarrassed breathing developed. The various
conventional home methods for the displacement of foreign
bodies lodged in the throat or esophagus were tried in quick
succession, but without success.
The patient, much alarmed, sought the nearest physician,
who advised him to consult a throat specialist immediately. He
left the office intent upon following this advice. His anxiety
increasing, however, he called at the first physician's office that
he came to. This doctor made several ineffectual efforts to
relieve the patient— slapping his back vigorously and forcing
his finger deeply into the throat, producing vomiting and
intense retching. The latter manipulation was followed by a
hemorrhage, the quantity of blood lost being estimated by the
patient as equal to a half cupful— probably an exaggeration
dependent upon his mental state at the time.
The patient next consulted me. He was greatly excited, his
face was full and red, eyes bulging and glassy, moderate dysp-
nea of an inspiratory cliaracter, voice alternating in quality
between a comical squeakiness and marked hoarseness. At-
tempts to speak or to swallow caused intense pain, yet he seemed
determined to explain the circumstances, evidently anticipating
a better result if I were made acquainted with all the facts.
I sprayed the palate, base ot tongue and pharyngeal wall
with a 2% solution of cooain, and with the laryngeal mirror
easily examined the larynx and surrounding parts. At this
time I purposely refrained from spraying the larynx, the idea
being to avoid subduing its reflex excitability until I could at
least judge of the location and character of the foreign body.
Previous to extraction, however, I sprayed a 10% solution of
cocaiu directly Into the larynx.
The mirror showed a bone lying transversely in the larynx,
resting on the ventricular bands, the posterior surface of the
bone as it rested being in contact with the arytenoid cartilages,
the cartilages of Wrisberg and the arytenoid ends of the aryte-
noepiglottidean folds. Both ends of the bone appeared to be
impacted in the arytenoepiglottidean folds. The bone appeared
to be lying at about an angle of 45° with relation to the trachea.
The arytenoids and ventricular bands were congested, the left
arytenoid so swollen as to almost overlap the surface of the
bone presenting upward. The surrounding parts were more
or less injected.
The movements of the vocal cords and ventricular bands
during an attempt at phonation were imperfect, the approxi-
mation of the borders failing with more or less irregularity of
the borders. Considering the position and size of the bone and
the condition of the surrounding parts it seems rather strange
that movements were not more greatly impaired.
The lack of extreme dyspnea can be accounted for In that
there was not a complete blockade in the glottis. The accom-
panying illustration shows this, and the swelling of the left
arytenoid cartilage.
The bone was somewhat triangular in shape, with one end
extending to a sharp point, and measured IJ inches long, J inch
in width at its broad end, and J of an inch in thickness.
I released the bone with the I^uer laryngeal forceps, using
a laryngeal mirror to guide my movements. After grasping
the bone with the end of the forceps I madeaquick forward and
backward movement, then jerked it upward. The sharp-
pointed end was impacted in the left arytenoepiglottic fold, the
broad end in the right fold. This impaction of both ends was
evident from the force required to extract the bone, the lacer-
ated tissue in both folds, and the oozing of blood after extrac-
tion.
Of the objective methods of diagnosis I wish to mention that
of Kirstein. His method as originally introduced necessitated
an expensive outfit. Now all that is required is a specially long
tongue depressor curved downward at its forward end, with a
little notch in its anterior border to receive the ligament ex-
tending between the tongue and epiglottis, or the glossoepi
glottic ligament. The method is called autoscopy or direct
laryngoscopy, and enables one to see the larynx direct, thus
avoiding confusion to the inexperienced physician. There is
no half inverted image to annoy him. •
The late Dr. Thornor," of Cincinnati, reported the successful
' Kead l>efore the Syracuse Academy of Medicine, December 17, 1901.
• Autoscopy of th<^ Larynx and Trachea. Klrstcln-Thorner.
328 AJ<aBIOAl> Mbdioinxi
COEEESPONDENCE
[AUGUST 80, 1901!
removal ofa chicken bone by this method. The case was that
of a young adult in whose larynx a bone measuring nearly Ij
inches in length lodged, one end of which seemed imbedded
In the right ventricle of the larynx while the other rested
against the left aryepiglottic ligament. He used a slender ser-
rated forceps in Krause's straight tube and universal handle,
and extracted the bone in a few seconds without any inconve-
nience to the patient or himself.
From tills case as well as from several other personal expe-
riences, coupled with those of a number of writers, I feel
warranted in offering these conclusions :
When urgen(;y permits no delay, attempts should be made
by means of laryngoscopy or autoscopy, as introduced by
Kirstein, to locate and appreciate accurately the foreign body.
In children, half narcotization may be necessary. Drugs to
produce vomiting or sneezing should be interdicted, es]>ecially
if the foreign body is pointed or rough. These methods may
cause a foreign body to shift from an innocent position to one of
grave significance. In the case I reported, it is possible that
the retching and vomiting induced by the finger manipulation of
the doctor who saw the patient previous to me may have caused
a change in the position, or may have been the cause of the
impaction.
The larynx should not be sprayed immediately with cocain.
Only such parts should be sprayed as offer some hindrance to a
successful view of the larynx, namely, the palate, base of
tongue, and pharynx. This contention is deduced from the tact
Fig.
Fig. 2— Actual
size of bone.
that if the reflex irritability of the larynx is completely in
abeyance, a foreign body in an innocent position may readily
assume a grave or fatal one.
For illu.stration, if one end of the bone shown in the illus-
tration had been held firmly in one of the pyriform sinuses by
the contraction of the muscles, in releasing this contraction by
the use of cocain the body might easily have dropped into the
glottis and caused a blockade, or it might have been aspirated
into the trachea, a most serious circumstance.
"Voluntary coughing should not be encouraged ; if the body
has entered the trachea, coughing is advisable.
If time allows, the x-rays, making radiographs at different
angles, may be utilized.
It must be kept in mind that occasionally the swelling of
the tissues is so great as to hide the foreign body.
IMMUNITY AND ARTICULAR RHEUMATISM.
BY
EDMOND R. MORAS, M.D.,
of Chicago, III.
Does rheumatic fever or articular rheumatism "protect"
the patient in any way for the future? Assuming that there is
something essentially alike in the clinical experience of all
physicians, I may answer the foregoing question in the affirma-
tive. Yet there is scarcely an opinion more universally shared
than that rheumatic fever belongs to that class of diseases which,
instead of rendering the individual immune, actually increases
his disposition toward the disease. That this assumption or
belief is but seemingly and not strictly true of inflammatory
rheumatism is demonstrable. To be more explicit, my per-
sonal experience has been that one attack of acute articular
rheumatism confers local immunity against another, whether
the socalled individual disposition be increased or not. Thus
acute articular rheumatism of any given joint or joints confers
protection to such joint or joints against another attack in the
.same sense or degree that typhoid fever " protects " Peyer's
patches against a second invasion. Accordingly there seems to
be no plausible reason for rejecting the assumption that, in a
case of rheumatic fever, in which every joint had been typically
affected and complete recovery had ensued, the patient would
be strictly "immune" as regards future attacks. From the
standpoint of immunity the only clinical difference between
the two diseases seems to me to be that in typhoid fever the
local structures (Peyer's patches) affected are generally and
typically all involved during the one attack, while in rheu-
matic fever, as the local structures (joints) are so disconnected
and so numerous, only one or a few are typically affected dur-
ing one attack — leaving many more to succumb to another.
It surely seems no more than likely that, had an individual
two small intestines, one spell of typhoid would not protect
against another. The claim now made and supported by the
citing of four cases is this: Reinvasion by rheumatic fever of
a fully recovered joint does not occur. Of course this does
not apply to acute exacerbations occurring during the course
of subacute and chronic rheumatism.
Cask I.— A. P., aged 20, a driver, had acute articular rheu-
matism lasting two weeks in February, 1902. The right ankle-
joint was typically affected. Treatment was continued four
weeks after recovery. A second attack occurred late in April
and settled in the left shoulder and hip. The right ankle
remained absolutely free of any sign or symptom of rheuma-
tism.
Case II. — A domestic, aged 19, was treated by me in the fall
of 189.5 for severe polyarthritis which after two days' treatment
settled in both knees. One month's "treatment brought about
complete recovery. The next attack occurred In February,
1902. This time both ankles were alllicted, the right typically.
The knees were not affected.
Case III.— A housewife, aged 44, had acute rheumatism of
the right knee during the winter of 1896. Treatment was con-
tinued till recovery was complete. In the fall of 1901 another
attack occurred affectiug typically the right elbow. Right knee
was unaffected. A third attack of rheumatism in January and
February, 1902, involved the right ankle and carpometacarpal
joint of the right thumb, with absolute immunity of right knee
and elbow.
Cask IV.— A druggist, aged 36, had chronic articular rheu-
matism covering a period of three years. During this time he
suffered with three distinct acute exacerbations— each of which
involved different joints, leaving the previously affected joints
alone.
To these could be added a large number of similar observa-
tions ; but of greater value Is the negative evidence secured
from every patient who happened to have articular rheuma-
tism more than once. In no instance have I been able to satisfy
myself that acute, subacute, or chronic articular rheumatism
when once fully recovered from ever attacked the same joint
or joints again. If this view should find support it certainly
would tend to modify in a marked way our present views con-
cerning rheumatic " predispositions " and lead to more active
researches of nature's methods of disease prevention.
PUERPERAL ECLAMPSIA.
BY
JOHN G. WILKINSON, M.D.,
of Humphrey, Ala.
I was called to see the patient, a primipara, after she had
been having convulsions for 8 or 10 hours. After chloral and
bromid were administered hypodermically for six or seven
hours the convulsions ceased. On consultation it was decided
to empty the uterus. This was done by digital dilation of the
cervix uteri and the application of forceps. The seven-month
fetus was alive, but lived only a few minutes. The patient
recovered consciousness 12 hours after delivery and made an
uneventful recovery. A remarkable peculiarity was the insati-
able thirst of the patient. Water was given at frequent inter-
vals until she drank several gallons.
The point for discussion : Was the immediate delivery the
better plan or should we have waited to see if convulsions
could have been controlled, and thus saved the child ? We did
not consider it safe to delay.
AUGUST 30, 1902]
EFFECT OF REST
[AKEiiicAN Medicine 329
ORIGINAL ARTICLES
THE EFFECT OF REST UPON THE PROGRESS OF
SEPTIC INFECTIONS.'
BY
A. J. OCHSNER, B.S., P.R.M.S., M.D.,
of Chicago, 111.
Surgeon-in-chlef of Augustana Hospital and St. Mary's Hospital, and
Professor of Clinical Surgery In the Medical Department
of the State University of Illinois, Chicago.
My subject is so old that it scarcely seems worthy
of your attention at this time, for I believe every
surgeon will admit at the outset that absolute rest is
theoretically one of the most important means to be
employed in the treatment of conditions which are due
to septic infections. In practice, however, my observa-
tions have taught me that this concjition of rest is but
rarely secured, and but seldom systematically striven
for, except in the treatment of inflamed joints ; and for
this reason it seems worth the effort, once more, to
direct attention to this important therapeutic aid.
In the clinical observation of septic infection in any
part of the human body, no feature .stands out so promi-
nently as the beneficial effect of rest applied to the part
involved. It seems Impossible for the practical surgeon
to overlook this, because its recognition must point out
the proper treatment in many of these cases.
Septic infections progress through the lymphatic cir-
culation, and to retard as much as possible the circulation
of lymph by inhibiting motion of the surrounding
.structures is an important aid in keeping the sepsis
localized, and in causing the infection to subside. If
through a free incision the lymph stream is directed
away from the body, the infection also subsides, the in-
fectious material being no longer in a position to do harm.
These features can be observed most readily in infec-
tions of the extremities as a result of pin pricks,
scratches, dissection-wounds, etc. A most simple infec-
tion of this kind may become exceedingly violent
if the patient continues to use the extremity and thus
forces the infectious material through the body, for
we know that the muscular contractions force the
infectious material through the lymph channels. The
infectious material may progress slowly or it may
advance with great rapidity. If for instance it is at the
tip of a finger, it is very likely to enter the palm of the
hand unless the extremity is kept at rest. Further
motion, extending over a period of a few hours, may
force it into the forearm. In the same manner it may
be forced on into the arm and then into the axilla.
Without this pumping of the septic material through
the lymphatics by means of muscular contraction the
septic material would have caused the formation of
a small circumscribed abscess, which might contain a
drop of pus and whose emptying by a slight incision
would be followed by a rapid recovery.
In one c&ne the new field of invasion gives rise to
greatly increa.sed vigor in the activity of the septic micro-
organisms ; in the other its confinement to a circumscribed
location seems to make the microorganisms harmless.
Every practical surgeon has ma<:le the following
observation upon his patients many times and probably
also upon himself. A slight infection of the finger
occurs from a prick with a needle or from sf)me other
slight injury. During the day the finger and even the
hand becomes painful. The next morning the pain has
entirely disappeared and the patient imagines himself
well ; but (luring the day the pain returns, possibly
a little more severe than the day before, and, on the fol-
lowing night, it again disapi)ears, only to a less extent.
After a few further repetitions, a serious infection may
be<'ome establishe<i, resulting in the destruction of a
considerable amount of tissue, which will probably be
'Address on Surgery, read by Invitational the annual meetlns of
the Ohio HtaU' .Medical Society, May 'ii, IIHW.
followed by a marked impairment of the function of the
extremity.
The explanation is very simple. During the day
when the extremity is moved frequently the infectious
material is carried from its circumscribed area to the
points further up the arm. The following night this
progress is again inhibited and there is a corresponding
diminution in the symptoms. If the rest is continued
the progress is permanently inhibited, and the patient
recovers completely. If this is not done it will ordinarily
progress until the patient is so ill that rest is com-
pulsory.
I have had all the histories of cases of severe infection
of the hand which I have treated in the Augustana Hos-
pital during the three years from January 1, 1899, to the
present time reviewed (52 cases in all) in order to illus-
trate this principle. I find that all the patients who came
under treatment at the hospital before incisions had
been made, recovered without deformity or stiffness
of the fingers ; while of those who had been treated
without being kept at rest, in whom abscesses had
formed and had been drained by free incision previous
to their admission to the hospital, a considerable propor-
tion recovered with more or less deformity, some with
very severe deformity and with more or less impairment
of function. In those admitted to the hospital, the
treatment consisted in obtaining as nearly as possible
perfect rest for the extremity, by placing the patient in
bed, applying a large dressing composed of sterile gauze
and absorbent cotton, saturated with a mild antiseptic
solution, the solution employed most commonly being
hot saturated solution of boric acid, to which one-third,
by volume, of strong commercial alcohol had been added.
The whole dressing is covered with oiled silk or rubber
cloth. Even in cases in which only the end of a finger
is involved the entire extremity up to the shoulder is
included in the dressing. This makes motion of the
extremity almost impossible. It is likely that the hot
moist antiseptic dressings are beneficial in themselves,
but I am positive that the enforced rest is of equally
great importance, because if this part is neglected it will
prevent a rapid and perfect recovery.
The value of this treatment can be seen from the fact
that in this entire number of 52 cases there was not one
in which the infection was not inhibited in its progress.
Moreover there wtjs not a single death, although many
of the patients were brought to the hospital in an
extremely septic condition with high temperature and
pulse and frequently delirious.
Aside from the treatment by means of enforced abso-
lute rest on account of the large moist dreasing, the gen-
eral hygiene of the patient was always given proper
attention. Elimination was encouraged by means
of cathartics, and proper nutrition was employed.
There can be no doul)t but what the moist anti-septic
dressings and the hygienic conditions had something to
do with securing such satisfactory results, but in cases in
which all of these measures excepting rest had previously
been employed without benefit, speedy improvement
followed so soon as the element of rest was added. The
dressings were never disturbed more than once in 24
hours and usually they were left in place for two to four
days, fresh fluid being poured upon the dressings every
six hours.
For a time we attributed most of the good results to
the action of the moist antiseptic fluid which was
applied, but I am more and more impressed with the
part which rest has to do with the improvement of these
infections. I have observed freciuently that an exami-
nation accompanied with much manipulation for the pur-
pose of determining any points of fluctuation would
invariably result in an increase in the infection. I have
observed in a few cases that unnecessary manipulations
during the changing of dres-sings by assistants who did
not fully comj)rehend the importance of rest would
result in the same increase in the septic conditions.
830 AJIICBIOAM MBSICINE]
EFFECT OF EEST
[August 30, 1902
Many of these patients came to the hospital for the
expreased purpose of having an amputation performed
in order to interrupt the progress of the septic condition ;
but this became necessary only in one case. This was a
violently septic infection of the hand punctured with a
rusty file, the patient being brought into the hospital
with a pingrenous thumb and two fingers. The infec-
tion had been so violent that although it ha<l existed less
than two days the patient was delirious ; his tempera-
ture was 105° F. and his pulse 190, still the infection
subsided rapidly under this treatment and there was no
further progress of the gangrene. Many other equally
striking cases might be added if time permitted, but the
important point I wish to impress is shown by the satisfax;-
tory results generally, which I believe must be attributed
largely to the element of rest. The same principle can
be observed in connection with infection of other parts.
In all forms of acute peritonitis for instance resulting
from an infection from the vermiform appendix, the
fallopian tube, the gallbladder, an ulcer of the stomach
which threatens perforation, the same principle obtains.
In all these ca.ses it can be observed easily that the
infection is greatly exaggerated by motion. So long as
the infectious material is in the vicinity of its original
location the patient is not very seriously ill whether this
be about a fallopian tube, appendix, gallbladder or the
stomach ; but so soon as it is carried away from its orig-
inal location either by the lymphatic circulation or by me-
chanical means the conditions are entirely changed at once.
In these cases it is, however, the mechanical distribu-
tion which is most mischievous, because of its splendid
facilities. A surgeon who has experimentally placed a
small piece of gauze in the abdominal cavity among the
small intestines of an animal and has in a short time
attempted to find this, has usually discovered great diffi-
culty because it may have been carried to any part of the
abdominal cavity by the motion of the small intestines.
It is just so with the septic material which has come in
contact with the small intestines if their peristalsis has
not been inhibited.
We have had an excellent opportunity to observe
these conditions especially in patients brought into the
hospital suffering from peritonitis following criminal
abortion. Some years ago we systematically gave these
patients large doses of saline cathartics, curetted, irri-
gated and disinfected the uterine cavity and this resulted
in the death of quite a large percentage. This method
of treatment had been highly recommended, but it did
not contain the necessary element of rest, the saline
cathartics having exactly the opposite effect. The
unsatisfactory results and an appreciation of this
principle caused us to abandon this form of treatment.
During a number of years our plan of treatment has
consisted in keeping these patients positively at rest.
This is accomplished by removing any contents of the
stomach by means of gastric lavage, and then placing
the patient on exclusive rectal alimentation. The differ-
ence in the mortality has been most marked. It has
been reduced to almost nothing.
I refer here to the typical cases of peritonitis following
criminal abortion. Some midwife has produced crimi-
nal abortion. The patient has been infected, she is cared
for by the abortionist until the latter becomes frightened,
then she is sent into the hospital. When she arrives her
abdomen is distended, she is septic, her facial expression
is bad, she complains of severe pain in the abdomen ;
there has been complete obstruction to the passage of
gas, her temperature is from 102° to 106° F., and her
pulse from 110 to 160. In former years we immediately
anesthetized the patient, curetted and irrigated the
uterine cavity, gave large and frequently repeated
enemas, administered saline laxatives in the hope of
overcoming the intestinal obstruction ; administered
alcoholic and other stimulants and expected the patient
to die in from two to four days. Now we simply apply
the one principle of rest. The pharynx is sprayed with
a 4% solution of cocain, ga.strlc lavage is performed in
order to wash away any food or mucus which might
give rise to peristaltic motion of the small intestines.
The obstruction t*) the passage of gas, being looked upon
as a result of the disease and not a cause and being in
itself favorable to the production of rest, is not disturbed
either with cathartics or food. An ounce of one of the
various concentrated liquid foods in the market mixed
with three ounces of warm normal salt solution is given
as a nourishing enema every four hours through a soft
rubber catheter inserted two inches. A hot poultice or
an ice coil is applied to the abdomen to increase the
patient's comfort. If necessary morphia is given hypo-
dermically to relieve the pain ; this is, however, but
rarely necessary if absolutely no food and no cathartics
are given by mouth.
Aside from this the patient is given a hot vaginal
douche every three hours and gauze pads saturated with
equal parts of alcohol and hot water are applied over the
external genitals and covered with absorbent cotton and
a T bandage. The alcohol dressing is applied fresh after
each douche. I mention these last steps because they
are carried out as a matter of routine. It is likely that
they are of no special importance, their use being ba.sed
entirely upon a superstition which I acquired from one
of my chiefs in the early days of my professional exist-
ence. The beneficial effects of the douches might easily
be explained by the fact that they favor drainage and
those of the pads by the fact that the moist warm pads
are agreeable to the patients and that the alcohol has
antiseptic properties.
Clinically I can state that a class of patients which
gave an exceedingly high mortality before this method
was employed is now almost without any mortality.
Within 24 hours the temperature is usually below
100° F., the pulse has decreased correspondingly in
frequency ; the abdominal distention is subsiding, the
pain has entirely disappeared and the patient's appear-
ance is no longer that of an extremely sick person.
After two or three days the patient is usually nearly
normal in every way. An examination will still
demonstrate the presence of an induration in the pelvis
which may absorb entirely or an abscess may form, but
there is no longer a tendency toward extension of the
inflammation. All that has been accomplished is the
result of rest in the vicinity of the inflammation. The
infectious material has not had an opportunity to be
carried to all parts of the peritoneal cavity. Whatever
explanation we may desire to make, the fact remains
that many patients who would die within a few days
under what might be called vigorous active treatment will
recover regularly under this form of passive treatment.
During the war in South Africa the surgeons
found the same clinical fact to obtain in penetrating
wounds of the abdomen. If the patient was wounded
while hungry and no food was given by mouth, quite a
large proportion of the patients recovered, while of
those in whom the alimentary canal was not kept empty,
none recovered.
In severe local peritonitis accompanying attacks of
gallstone colic the condition becomes localized, and
absorption will take })lace if peristalsis is inhibited by
abstaining from food by mouth. I have repeatedly
observed that pain which would not subside after the
administration of from | to 1 grain of morphia would
disappear upon performing gastric lavage and pro-
hibiting the use of food and cathartics by mouth in
patients suffering from gallstones. The same clinical
condition can be observed to a still more marked extent
in the presence of severe localized peritonitis due to the
presence in the peritoneal cavity of a perforated or
gangrenous vermiform appendix ; this is true even in
cases in which the peritonitis is progressive at the time
the treatment is begun.
If complete rest is obtained by removing any food or
mucus which may exist in the stomach, by means of
August 30, 190Z]
PRIMARY MALIGNANT TUMOR
[AMERICAN MEDICTKB 331
gastric lavage, and then prohibiting the use of fooil and
cathartics by mouth, the inflammation will regularly
remain circumscriljed in the presence of gangrenous or
perforative appendicitis, while it will as regularly
become diffuse if these precautions are not taken, unless
at the same time the local cause of infection, the ap-
pendix, be removed and free drainage of the peritoneal
cavity instituted.
Many other instances of this principle can be men-
tioned, such as the result of strapping in the treatment
of mastitis during the beginning of the attack, the use of
the splint or plaster-of-paris casts in inflamed joints,
strapping of the chest with rubber adhesive straps in
pleurisy, a dark room and bandaging of the eyes in con-
junctivitis, etc.
What I wish to emphasize particularly is the fact that
the element of rest should be borne constantly in mind
in the treatment of all forms of inflammatory conditions
in any part of the body.
A CASE OF PRIMARY MALIGNANT TUMOR OF THE
THYROID COMPOSED OF ADENOCARCINOMA
AND PERITHELIAL HEMANGIOSARCOMA (SAR-
COCARCINOMA).
BY
PAUL G. WOOLLEY, B.S., M.D.,
of Montreal, Canada.
Governor's Fellow in Pathology, MeGlll University, Montreal, Canada.
From the J. H. R. Molson Patliologic Laboratorv, McGill Univer-
sity, and the Pathologic Laboratory of the Montreal General Hospllal.
The patient was a farmer, ajjed 42. He entered the Montreal
Oeneral Hospital on February 22, 1902, in the service of Dr.
Armstrong, complaining of a swelling in the neck which caused
pain and respiratory distress, and which was increasing in size.
His family history was entirely negative. None of his people
had had goiter. He was born in the Province of CJuebec and
had lived in that locality all his life. He had been a healthy,
strong man ; had had measles at 21 years of age and inflamma-
tion of the lungs at .'iO. He suffered somewhat from slight dys-
peptic attacks after dietary indiscretions. He chewed a con-
siderable amount of tobacco, had not used much alcohol and
had had no venereal trouble. He is married and has three
children, all of whom are alive, and well. When he was 5
years old a small swelling appeared in the neck just above the
sternal notch. This his mother treated with an iodin salve, and
it remained quiescent for 25 years. During this time, however,
enlargements appeared on both sides of the neck, which caused
him no discomfort. In the fall of 1901 these lateral swellings
were injected with iodIn to reduce their size, his physician
having told him that they were increasing in size, though he
had not noticed it. Five weeks before his entrance to the hos-
pital the tumors increased more rapidly in size, and began to
cause considerable pain and respiratory distress. This pain
radiated, sometimes to the mastoid, sometimes to ttie pharynx.
After this the growth was continuous and rapid, his voice
changed and he lost weight and appetite.
The man's condition on entrance to the hospital was as fol-
lows : He was well nourished ; the mucous membranes were of
good color ; the temperature, pulse and respirations were nor-
mal; there was no appreciable abnormality in the circulatory
or respiratory systems; his teeth were fairly good, the tongue
coate<l, the breath foul ; his bowels were constipated and irreg-
ular ; he was nervous and slept poorly. In the neck, extending
7 cm. to the right of the mid-line and 14 cm. to the left, and
reacliing from tlie sternal notch below to about 13 cm. above the
middle of the left clavicle, was a rounded, partly nodular,
tumor mass. The history does not state whether it pulsated or
not, but it was of semisolid consistency, with tinner parts.
The trachea was pushed to the right and the tumor moved with
the trachea. Palpation caused pain in the right sternocleido-
mastoid line and at the upper right pole of the tumor. There
were two palpable glands in the left axilla.
The first operation was done by Dr. Armstrong on February
25, 1002, three days after admission. The tumor was removed
without difficulty, the skin wound closed and the cavity
drained. The tumor was a large one, containing much blood,
and with an area of ossification in the left lobe. Convalescence
was rapid and uninterrupted and the patient was discharged
on the tenth day after operation.
About a month later the man came back complaining
of hemorrhage from the old wound. He stated that dur-
ing the last of March he first noticed small nodules growing
along the line of the incision. Most of these were subcutane-
ous, but one, to the left of the median line, was bluish in color
and had grown very rapidly, attaining the size of a large
marble in four days. Hemorrhage had occurred at the site of
this nodule. For two weeks preceding the second operation
the oozing and discharge were persistent. The discharge was
abundant and foul, curetment and cautery giving but little
temporary relief ; pain was persistent. The patient's skin took
on a sallow subicteroid tint, and his condition became progres-
sively worse. Other nodules appeared in the scars, and these
all showed a tendency to rapid growth.
On April 27 he began to have gastric symptoms, and
vomited several times. On April 28 he was again operated
upon, by Dr. Elder, and the nodules and the old scar were
removed. On May 10 the edges of the lower angle of the
wound were everted and covered with unhealthy and rapidly-
growing granulations, but his general condition had improved.
The next day there was a small nodule noticed in the right
angle of the wound. The wound itself, just above the sternal
notch was an angry-looking one, with firm, thickened edges of
a bluish-purple color. Between the edges the space was filled
with rapidly growing granulations which discharged a thin,
bloodstained fluid. The man was discharged on May 11, 1902,
at his own request. At this time the cervical chains of glands
were enlarged. He suffered from pains in the head, neck and
lumbar regions, and was slowly losing weight.
It is unneces-sary to say that the future history of the
case will be most interesting, and that it will be reported,
if possible.
Pathologic Examination. — This showed a most interesting
condition. The material from the second operation was received
first, and Ijecause of the interest that attached to its examination I
later sought out the old specimen, which fortunately had been
preserved.
The first material, which included the skin with the recur-
rent growths, was a mass of tissue that resembled in every
detail the ordinary adenomas of the thyroid. The cell collec- .
tions were either large or small. The large ones formed alveoli
lined with a single layer of epithelial cells and with the central
mass of colloid material. The smaller alveoli were usually of
the same character, but there were many instances in which the
alveoli were composed entirely of cells with no colloid. In such
areas the cell groups were packed closely together with but
little intervals of fibrous tissue. This thyroid tissue was in
small amounts. The mass of the specimen was made up of a
more or less vvhorled tissue composed of well stained cells of
the character of young connective tissue. In this were many
spaces filled with red blood-corpuscles.
When these areas were more closely studied it was seen that
the whorls of spindle cells were arranged about the blood
spaces, and that these spaces were in the majority of instances
provided with an intact endothelial lining. The picture was
that of a perithelial angiosarcoma, composed of short spindle
cells. Many of the bloodvessels were filled with colloid.
Beside this mass of sarcomatous tissue there were also some
small areas that had the general appearance on cursory exami-
nation of carcinoma. These areas seemed to have a definite
relation to the smaller alveoli of the adenomatous parts of the
growth. The cells were round or polygonal, and in tne majority
of cases more deeply stained than those of normal thyroid cells.
There were a considerable number of mitotic figures, most ot
them in the skein and aster stages. These cells varied also in
size— some had the appearance of those occurring in small
round-celled sarcomas, others were larger and apparently car-
cinomatous. But there was the perialveolar infiltration about
the alveoli extending into the surrounding sarcomatous growth.
With this interesting picture before me I went back to the
original tumor, a larger one, about the size of two closed fists,
with a distinct capsule and partially cystic ; the mass of it was
filled with hemorrhage and with what appeared to be a piece of
bone in the left lobe. Only a small part of tne mass showed well-
staining tissue witliin the capsule. The hemorrhage had been so
great and the tension such that most of the parenchyma had
undergone degeneration. But in the left lobe there was a small
mass of tissue that had not degenerated. This was composed
almost entirely of typical adenonui with large and' small alveoli
with and withoutcolloid. It was only after an extensive search
through my sections that any other tissue was found. This was
in very small amount and was composed of tissue that resem-
l)le(l the sarcomatous tissue in the recurrences, except that it
was less densely cellular and more fibrous. The area supposed
to have been bone proved to be simply a hyalin tissue with cal-
careous infiltration.
The case was then one of sarcocarcinoma of the
thyroid. Such cases are extremely rare. Only three
others have been reporttKl so far as I can discover.
Of these otie occurred in a dog and was reportetl by
G. H. Gideon Wells {Jour, of P<UhoL and Bacf., June,
1901). In this paper of Weils' the other two cases are
discussed. They were described by Kaufiuiin and
Kuintner. The photographs of Wells' illustrate the
present tumor perfectly.
My thanks are due to Dr. George Armstrong and to
Dr. Elder for the privilege of reporting the case and to
Dr. Campl)ell Howard for clinical notes.
832 AicmioAN MEDicimt:
TETANUS
[August 30, 1902
TETANUS IN THE LIGHT OF MODERN TREATMENT,
WITH A REPORT OF THREE CASES.*
BY
LAWRENCE E. HOLMES, M.D.,
of Blltmore, Ashevllle, N. C.
Tetanus is a disease which at all times must be of the
greatest interest; it is especially so at this time in con-
nection with the subject of serum therapy and on
account of the various new methods of treatment which
have been recently introduced, for all of which more or
less extravagant claims have been made, and which, for
the most part, have proved disappointing.
I wish, with a report of three cases, to review^ briefly
the subject of tetanus, particularly with relation to its
treatment, and try to determine, in the midst of so many
conflicting reports and opinions, what, in the light of our
present knowledge of the disease and of the various
recent methods of treatment, is the proper thing to do
when we meet a case, and what we are likely to accom-
plish.
Though it is, I believe, a rare disease in these parts,
it is, nevertheless, one with which it behooves us to
keep ourselves familiar, for it is extremely important
that it should be recognized at the outset, for if treat-
ment is to be of any avail, it must be begun very early
in the course of the disease. This is so true that some
observers advise beginning treatment before the appear-
ance of any symptoms ; that is, in a neighborhood where
tetanus is not uncommon they consider it the safest
plan to administer a prophylactic dose of the antitoxin
as a part of the routine treatment of all lacerated or
punctured wounds which cannot be thoroughly cleaned.
In some cases the results of this method have been
very satisfactory, all the evidence going to show that
tetanus has been averted. In certain parts of France,
where this prophylactic method has been given a more
thorough trial than elsewhere, particularly in veterinary
practice, the results have been very encouraging. In
Prague an epidemic of puerperal tetanus in a lying-in
hospital is said to have been broken up by this method.'
Admitting this to be the case, we can safely say that the
prophylactic use of the antitoxin is far more satisfactory
than is its curative use ; for, though great things have
been claimed curatively, in looking over the cases recently
reported it is hard to convince one's self that it really has
any curative power. The explanation of its inefficiency
IS, probably, the wellknown fact that the toxin produced
by the tetanus bacillus has a selective affinity for the
nervous system, especially for the motor cells in the
anterior horns of the spinal cord ; and when once it has
attacked them the antidote cannot act, since the affinity of
the toxin for the cells is greater than for the antitoxin,
though while the poison is in the blood it may be acted
upon by the antitoxin.'
That the tetanus toxin has a special affinity for the
cord has been proved experimentally bv the fact that an
emulsion made from the anterior horns of the spinal
cord of a patient dead from tetanus after the subcuta-
neous use of antitoxin, has produced the disease when
inoculated into animals, whereas the blood-serum of the
same patient, inoculated in the same way, failed to pro-
duce the disease.'
_ Tetanus is produced by a specific bacillus, anaerobic
in character, which usually gains access into the organ-
ism through a wound, more commonly, though not
necessarily, a lacerated or punctured wound of the hand
or foot; and the fact that the bacilli are found in the
soil easily explains the greater frequency of tetanus
after wounds of these regions, more especially of the
foot.
Tetanus may occur sporadically almost anywhere;
though m some localities the disease is almost unknown,
Ashevme,jMnel,\w2.''"""°'"''^ ^^- ^'^ ^"""^^ '"''<"<'»' Society, at
in other places it is epidemic ; and in hospitals, espe-
cially lying-in hospitals, it may betjome epidemic.
The bacilli, outside of the body, are most frequently
found around stables and in the soil of gardens, where,
it is presumed, they are carried in the manure. It has
been suggested that they develop in the intestinal canal
of horses and cattle, since they are so fre<iuently found
in manure ; for being anaerobic, it is not likely that they
develop in the soil. In the body, they are found only
at the point of entrance, for, unlike streptococci in sep-
ticemia, they are not carried in the blood-current to all
parts of the body, but remain in the wound, where they
multiply and produce their characteristic toxin, probably
the strongest poison known, its toxic power being said
to be almost two hundred times as great as that of
strychnin. Though most cases of tetanus are dependent
upon a wound of some sort, through which the bacilli
gain entrance into the body, in some tauses, those of so-
called idiopathic tetanus, no wound is demonstrable. In
these cases it is probable that the bacilli have gained en-
trance through the mucous membrane of the nose or
mouth, for experiments on animals have shown that the
upper respiratory tract offers favorable conditions for the
development of these microorganisms and the production
of the disease, especially when any catarrhal condition
is present, which is so frequently the case. As the toxin
is produced it is carried to the nerve centers, chiefly, if
not wholly, in the blood-current. There is some evi-
dence, however, in favor of the theory that it is partially
carried to the cord along the nerve trunks, and this
might explain the localized muscular rigidity (socalled
local tetanus) which always occurs when the disease is
produced experimentally in animals, and which is some-
times seen in traumatic tetanus in man. It would also
give an anatomic reason for division of the nerve trunks
above the wound, which was formerly recommended sis
a mode of treatment in traumatic tetanus. It might,
too, explain those cases in which the symptoms come on
some time after the seat of infection* has been totiilly
removed, as in Case II, herein reported, for, if it does
take place at all, transmission of the poison along the
nerve trunks must be much slower than through the
circulation. The inflatned and congested condition of
the nerve trunks sometimes found postmortem might
be explained by the same theory, as the result of the
local irritation set up by the toxin. This mode of trans-
mission, however, has never been actually demon-
strated.
At this time it may be worth while to refer to the
numerous cases of tetanus following vaccination that
have occurred in the past few months. These cases have
been used as a strong argument against vaccination, by
the antivaccinationists, and if they could have been
traced directly to vaccination it would of course have
given good cause to hesitate before subjecting one's self
to the danger of being inoculated with tetanus. On
account of the large number of cases which occurred in
Camden, N. J., an ofticial investigation was undertaken,
which fortunately proved that in no case could the tetanus
be traced to direct inoculation at the time of the vaccina-
tion, but in all probability it was caused by infection of
the vaccination ulcer at a later stage, just as any other
wound might become infected as the result of careless-
neas and lack of protection, which are so common with
vaccination ulcers. It is not neces.sary to go into all the
details which justify this conclusion, but there can be no
doubt in the minds of the unprejudiced that it is the cor-
rect one. The details of most of these cases have not
been published so far,* but in the two cases of which I
have seen a report,^ both were in children whose fathers
were employed in a stable, where, as is well known,
tetanus germs are frequently found, and this fact might
* since this was written an article by Dr. Robert N. Willson, of
Philadelphia, containing a report of a large number of these eases has
appeared in the Jo((ni<f/ o/" //IP American Medical Axmcialian Mav 3
1902. * '
AUGUST 30, 1902]
TETANUS
(American HeoicikA 333
explain the infection in these cases. Though the manu-
facturers of the vaccine used in the cases in which tetanus
followed vaccination are in no way to be held respon-
sible for the development of the disease, the same, unfor-
tunately, cannot be said of the makers of the
diphtheria antitoxin in St. Louis, the inoculation
of which was in many cases so speedily followed
by fatal tetanus. In those cases investigation
proved beyond a doubt that the disease was pro-
duced by the use of antidiphtheric serum which
had been taken from a horse that very shortly after
developed symptoms of tetanus.* A somewhat similar
accident occurred in northern Italy in the early part of
1901, when eight deaths from tetanus followed the use
of diphtheria antitoxin. In these cases the antoxin was
prepared at the Serotherapic Institute, Milan.
The hypodermic use of gelatin is another recent thera-
peutic measure by means of which tetanus may be con-
veyed to an individual accidentally. A ca«e of this kind
has recently been reported from Budapest ; subsequent
bacteriologic examination of gelatin from the same
source as that employed showed it to be infected, though
the symptoms of tetanus did not make their appearance
until the seventh day after the injection.
There are no characteristic lesions found in the body
after death from tetanus. The brain and cord are fre-
quently found congested, this condition, however, being
produced by the convulsions ; and as mentioned before,
the nerves may be red and swollen, and softening of the
multipolar cells in the anterior horns of the spinal cord
has been reported in some casas. In traumatic cases the
wound has no special appearance to distinguish it from
a wound uninfected by the tetanus bacillus. In a num-
ber of cases reported the wound has healed by first inten-
tion, the first symptom of the disease appearing many
days later, the wound showing no signs of infection at
any time. In Case II of this report the first symptom
appeared four days after the amputation of the hand for
gangrene, following a severe crush and laceration three
days previous to the amputation. The amputation
wound healed by first intention, and at no time showed
signs of the slightest irritation. Yet the patient passed
through a characteristic attack of subacute tetanus, from
which he finally recovered.
It is not necessary to go over in detail the symptoms
and diagnosis of the disease. Difficulty in swallowing
is commonly one of the earliest symptoms noticed by
the patient, though often not elicited without special
Inquiry, and this should immediately suggest a further
examination of the ca.se. In the case of one man, I
remember, who walked into my dispensary, it was the
characteristic expression, the socalled risu^s sqrdonicus,
that suggested the condition. A week or so previously
he had been at the dispensary complaining of a slight
stiffness of the neck, which had been ascribed to a rheu-
matic condition. As the rigidity gradually grew more
marked he returned to the disjiensary, where, as stated,
his characttiristic facial expression suggested the diagno-
sis of tetanus, which other symptoms confirmed. (This
case was reported in detail by Dr. G. G. Davis, Anna/s of
Surgeri/, August, 1898.)
Sometimes the muscles in the neighborhood of the
wound of infection are the first to show the effect of the
poison ; thus, in a wound in the hand, stiffness may first
be noticed in the muscles of the forearm. This condition,
however, is rare in traumatic tetiinus in man ; though,
as mentioned before, it is the rule in tetanus produced
experimentally in animals. Usually the throat, jaw
and ntH!k muscles are the first to become affected, dys-
phagia, trismus and cervical rigidity being the earliest
symptoms. The rigidity gradually extends, involving
the muscles of the back, abdomen and legs, sometimes
one set of muscles and sometimes another being more
powerfully affected, thus producing the various positions
of orthotonos, opisthotonos, emprosthotonos or pleuro-
. thotonos. The muscular spasm never fully relaxes.
but is greatly exaggerated during the paroxysms. I
remember seeing a case in which the opisthotonos was
so marked that between the paroxysms the patient's
body rested only on the back of the head and the heels,
and it was necessary to tie him in bed to prevent his
being thrown out by the violent convulsions, which
accident actually did occur more than once. This
patient, severe as was his case, finally recovered, after a
long and painful illness. (This case also was reported
by Dr. G. G. Davis, Annals of Surgery, August, 1898.)
In the milder cases the muscles may be uniformly
contracted, producing orthotonos, in which condition
the body is in a straight position and so rigid that it
cannot be flexed in any direction. Emprosthotonos and
pleurothotonos are more rare. In a well-marked case,
locking of the jaws is absolute, it being impossible to
separate them in the slightest degree. In such cases
rectal feeding may be necessary, for though liquid
nourishment may be poured between the teeth, degluti-
tion cannot take place, and any attempt at it is apt to
set up a general convulsion. It is this permanent mus-
cular rigidity that distinguishes tetanus from strychnia
poisoning, for in the latter the muscles relax after the
paroxysms; in the latter, also, the jaw muscles are
among the last to be affected, while in tetanus they are
affected very early in the disease.
In the very acute cases a convulsion may be the first
thing to indicate the onset of tetanus, as in Case I, though
usually, if inquiry be made, it will be found that the
patient has had, at least, a feeling of constriction in the
throat, and probably some trismus may be detected.
The convulsions, are, of course, of the typical tetanic or
spinal variety, in which consciousness is not lost, except
as the result of the cramp asphyxia, which may be
extreme, the fatal termination being not infrequently
brought about in this manner. In the more chronic
cases convulsions may not occur at any time.
In regard to the prognosis of tetanus, Osier in his
" Practice of Medicine," 1900, says : " Two of the Hip-
pocratic aphorisms express tersely the general progno-
sis, even at the present day, ' the spasm supervening on
a wound is fatal,' and ' such persons as are seized with
tetanus die within four days, or if they pass these they
recover, ' " and this, unfortunately, as a broad statement
is only too true in spite of the various new methods of
treatment. The acute cases developing rapidly a short
time after an injury almost invariably prove fatal within
three or four days, often in less time, in spite of all that
can be done, antitoxin having apparently no more
effect on the disease than any of the other numerous
remedies that have been tried in vain. If a case con-
tinues over five or six days, the chances of recovery
are fair, while many of the patients with chronic cases-
recover.
Like many other new methods of treatment, when
first introduced much was hoped for the antitoxin treat-
ment, which is undoubtedly a step in the right direc-
tion therapeutically, and the early statistics seemed to
justify this hope. Lambert,' in 1897, stated that the
morhility of all cases without antitoxin was 60%; with
antitoxin 30%. After a longer experience with anti-
toxin, we know that this statement is altogether too
siinguine, and it is scarcely too much to say that in care-
fully reviewing the subject, it is almost impossible to
make up one's mind whether the mortality has been
materially reduced by the use of antitoxin, though prac-
tically, I think, the patient should always be given the
benefit of the doubt, and antitoxin ustid in every case
in conjunction with other methods of treatment in
the hope that it may possibly have some beneficial
effect.
The socalled Idiopathic cases are more favorable, the
mortality being less than 50%; of the traumatic cases
the mortality may be said to be from 60% to 80%; the
acute cases being almost invariably fatal. Of the 70
cases that I have found reported in the last 18 months.
334 Amkbican Mkdicinkj
TETANUS
[AUGUST 30, 1902
there were 47 deaths, a mortality of over 67%. The
treatment varied greatly, but dividing the cases into
those in which antitoxin was used (almost always com-
bined with other methods of treatment) and those in
which it was not, we lind that of the former there were
47 cases with 82 deaths, a mortality of over 68 fc ; of the
latter there were 33 with 1 5 deaths, a mortality of over
45 fo . Of course the number of cases is too small and
the details of the cases too meager to justify drawing
any final conclusions, but the indications are certainly
not in favor of the antitoxin treatment. That many
patients recover under its use is true, but this is true
with other methods of treatment ; and it may be safely
said that there are very few, if any, of those who have
had much to do with tetanus who have not been greatly
disappointed in the serum treatment.
The very number of the remedies that have been
employed in the treatment of tetanus is in itself evi-
dence of their powerlessness and unreliability. The
treatment of the disease may be divided into the local
and general. Local treatment consists in thorough
cleansing and disinfection of the wound, if there be one,
though it is very doubtful whether this will modify the
course of the disease to any great extent, since, in most
cases, by the time the symptoms manifest themselves
the danger to the nerve cells has been done. Disinfec-
tion of the wound may, however, prevent the produc-
tion of more of the poison and should never be omitted.
Amputation of the limb, if the infected wound is on
one of the extremities, has been recommended, but as a
curative measure, for the reason before mentioned, it
can be of little use and is rarely, if ever, justiliable,
• except when called for by the nature of the injury. As
a prophylactic measure, in ordinary cases, it is not to be
considered, though when it comes to the question of
primary amputation in severe crushes or compound
' fractures of a limb the possibility of tetanus certainly
ought to be considered and thrown into the balance in
favor of amputation, especially in a locality where
tetanus is common. It is quite possible that in Case II,
removing the infected hand had more to do with the
recovery than anything that was done in the way of
■curative treatment, though the amputation was per-
formed four days before the appearance of the first symp-
tom of tetanus. This being the case, it again serves to
emphasize the greater value of prophylactic measures, as
compared with curative.
It is highly probable that if in Case I the patient had
been willing to have the crushed limb removed at once,
tetanus would not have developed and her life might
have been saved.
The various methods of constitutional treatment may
be divided into two classes, which may be designated as
symptomatic, and specific or antitoxic. The former
method includes the use of sedatives and depressants of
various kinds, the most reliable being the bromids,
chloral, opium and physostigma ; innumerable other
drugs have been suggested, but are of little or no use.
No specific action is claimed for these drugs, but in a
certain number of cases they will control the spasms and
thus may prevent, or at least postpone, the occurrence
of death from cramp asphyxia. In this way they may
aid in bringing about a cure by prolonging the patient's
life until the severity of the disease is past, though hav-
ing no direct action on the course of the disease itself.
They are frequently required for their quieting eff'ect,
and opium is often necessary for the relief of pain, which
may be very severe.
The specific or antitoxic treatment depends upon the
introduction into the system of serum taken from ani-
mals immunized to tetanus. Experimentally, this
method has been far more successful than in actual
practice. Those who believe in the etflcaey of antitoxin
■ claim that it is given, as a rule, in too small amount,
which is probably true. It is impossible to state the
doses in so many cubic centimeters, unless one special
make is referred to, as the different preparations vary in
strength. That put up at the Pasteur Institute, Paris,
is probably as good as any. Of this from 50 to 100 cc.
or more may t^ given in 24 hours, not less than 50 cc.
being given at the first dose in a well-marked case. The
usual method of administering the antitoxin is hypo-
dermically. On account of the many failures of this
metliod it has been tried intravenously, intraspinallj'
and intracerebrally, tlie cranium being first trephined.
By all these methods the results have been very much
the same and can scarcely be said to jastify the various
procedures, certainly not those necessary for the intra-
cerebral administration. Of 52 patients treated in this
way, 33 died, a mortality of over 63^. This includes
acute and chronic cases. Out of 24 acute cases there
were only 3 recoveries, a mortality of 87.5^. " When
it is considered that in the majority of these cases intra-
venous and subcutaneous injections of antitoxin were
also made, and one compares these statistics with those
without intracerebral injections," and we might add
without the use of antitoxin by any method, " this
new method does not impress one favorably." **
In the intraspinal or subarachnoid method, the pro-
cedure is similar to that of the ordinary Quincke punc-
ture, the needle being introduced between the third and
fourth lumbar vertebras, 6 to 10 cc. of fluid withdrawn,
and then 10 to 20 cc. of antitoxin slowly injected, the
dosage being smaller than in the subcutaneous method
of administration. Jacob" gives a summary of 12
patients treated in this way ; of these 6 died, a mortality
of 50 ^ , 3 of the fatal cases being in infants. This, on the
whole, is not a bad showing, though the number of cases
is too small to justify any definite conclusions.
Another method of treatment which in some respects
may be considered specific or antitoxic is the Baccelli
method, consisting in the hypodermic injections of car-
bolic acid. This has been employed in Italy more than
anywhere else, and on the wliole the results have been
very favorable. The carbolic acid is given in solution,
the strength varying from 2/o to 10^. One observer
reports a case in which he gave 18 minims of a 33^ solu-
tion every 2 hours for 6 days. The amount commonly
recommended is from 3 to 10 grs. in 24 hours.
In a recent article, Cioffl " quotes statistics showing a
mortality of 50^ to 80^ with antitoxin, and from 12^
to 30 ^ with Baccelli's method, a most excellent showing.
He says that the dose should never be less than 1 centi-
gram (it gr.) for every kilogram (2i lbs.) ; 3 grams
(46 gr.) have been administered daily without ill effect.
The tolerance for carbolic acid is thus seen to be very
marked in this condition, though of course it is very
important, to watch carefully for any toxic symptoms.
Smokiness of the urine is not necessarily a sign of
danger, though the disappearance of the sulfates from
the urine is. " Their presence can be determined by
acidulating the urine with acetic acid and then adding
barium chlorid in excess, when we get a copious white
insoluble precipitate of barium sulfate." "
H. C. Wood, Jr.,''' says that " from a study of Ital-
ian literature on the subject, it would seem that carbolic
acid gives better results in tetanus than any other form
of treatment."
It may be said that, experimentally, the Baccelli
method has not proved successful. Josias '^ came to the
conclusion that it not only does no good, but does posi-
tive harm. His experiments were made on goats ; of
those treated with carbolic acid, those receiving the
smallest doses lived longest, though not so long as those
receiving none at all. It may be observed that in
experiments on goats the subarachnoid injection of anti-
toxin proved equally useless, death from tetanus occur-
ring in every case, while under the same conditions dogs
recovered ; this would seem to indicate that goats have a
special susceptibility to the poison of tetanus.
Another recent method of treatment is the subcu-
taneous injection of an emulsion of the normal brain
AUGUST 30, 1902]
TETANUS
(Americait Medicine 335
tissue of some animal, that of rabbits or pigs being more
commonly used. I have seen no reports of cases treated
in this way in this country.
Krokiewiez '^ reports a total of 10 patients treated by
this method, with only two deaths, which is certainly a
very good record. He considers it the most reliable
method of treatment, and one deserving further trial.
He made an emulsion of a rabbit's entire brain and
injected it. In one case this was repeated four times.
Rostowtsev " reports a case in which he used 10 grams
of pig's brain, rubbed up in normal salt solution. This
was repeated several times with final recovery, improve-
ment following each injection. The theory in regard to
this treatment is that the tetanus toxin circulating in
the blood will attack the nerve tissue in the emulsion in
preference to the nerve tissue of the individual. Admit-
ting this to be the ca.se, it is hard to see how much good
could be accomplished, as by the time the symptoms
manifest themselves the danger to the nerve cells has
been done ; and this explains the fact that antitoxin
seems far more reliable prophylactically than cum-
tively.
The introduction into the system of large amounts of
normal salt solution, either by hypodermoclysis or intra-
venous injection, has been recently tried in tetanus, as
in many other conditions, and the reports, so far as they
go, seem to be favorable, and indicate that it may pos-
sibly be of some value by diluting the poison and aiding
in its elimination, though, of course, it can have no
specific action on the disease. Venesection has also been
employed, either in connection with, or independently
of, hypodermoclysis or saline infusion, but is of little
value, though in plethoric patients there is no reason why
it should not Ije tried in connection with other methods.
Unfortunately these methods cannot, as a rule, be em-
ployed till it is too late.
We have now briefly reviewed the various methods
employed in the treatment of tetanus, and have seen
how little reliance can be placed on any of them. In
the face of all these methods, and knowing that in most
cases the chances are against us whatever we do, what
shall be our line of treatment when we meet a case of
tetanus '? In the absence of any reliable remedy, and
realizing the great fatality of the disease, it is only right
that we should give the patient the benefit of every
doubt and possibility. If there is a wound it must, of
course, be thoroughly cleansed, and in rare cases and
under certain conditions, amputation of a limb is advis-
able. The patient must be put in a darkened room and
kept as quiet as possible. Antitoxin should be at once
administered freely, and continued daily in large
amounts, as frequently as the condition indicates. The
hypodermic is the simplest method of administration,
and probably as etfic"acious as any, though the intraspinal
may be tried, if convenient. At the same time I would
strongly recommend the hypodermic use of carbolic
acid, as 1 know of no reason why the two methods of
treatment should not be trietl at the same time. Seda-
tives should be given freely, the amount t)eing deter-
mined by the condition of the nervous system and their
effect on the heart. Opium should never l)e omitted,
the more powerful depressants being given as reciuired ;
but in our efforts to allay the nervous irritability, we
must be careful not to dei)ress too much, as it is impor-
tant to keep up the strength, especially in the chronic
cases. During the convulsions inhalations of chloroform
or amyl nitrite may be tried, but are not of much value,
as during the spasms bresithing is so greatly interfered
with that very little of their vapor could reach the
lungs.
In some cases, late in the di-jease, stimulants may be
indicated, though they, should always be administered
with caution, strychnia, of course, being avoided under
all circumstances so long as the disease is in its active
stages. During (!onvalescence, it may be profitably
employed.
The question of feeding is often a difficult one. Deglu-
tition is much interfered with, and often impossible,
when, of course, rectal feeding must be resorted to. To
allay thirst, hypodermoclysis of normal salt solution
may be freely resorted to, as it causes less disturbance
than giving fluid by the rectum, and the fluid is more
certain of being absorbed ; and besides, the rectum
should be reserved for nutritive enemas, which may
have to be kept up for some days, so that it is important
to irritate it as little as possible. The subcutaneous in-
jection of brain emulsion may be omitted justifiably, as
being in the experimental stage. If we follow the
treatment outlined, we may feel satisfied that we have
done the best we can for our patient, whatever the re-
sult may be.
The three cases I wish to report were all under my
care while resident physician in the Episcopal Hospital,
Philadelphia. Case I was in the service of Dr. G. G.
Davis ; Cases II and III in that of Dr. H. C. Deaver.
The antitoxin employed was from the Pasteur Institute,
Paris, with the exception of that used in Case II
between August 14 and 18 inclusive, and that employed
the last day in Case III, this having been put up by Mul-
ford, of Philadelphia. It was all administered subcu-
taneously.
Case I.— Clara T., aged 50, was admitted March 3, 1899, with
a compouud comminuled fracture of the left tibia and fibula,
caused by being struck by a train; the tibia was sticking out
through the torn stocking and the soft parts were severely lacer-
ated. It was decided to try to save tlie limb, so after careful
cleansing and putting the bone in position, it was put up in a
fracture box. As was expected, suppuration occurred, and the
wound was dressed frequently. One week after the injury, at 5
p.m., the patient was suddenly seized witha violent convulsion.
After this passed off, rigidity of the muscles of the jaw, neck
and back was noticed. The patient then informed us that she
first noticed some slight difficulty in swallowing in the morn-
ing, and stiffness of the jaw at midday, but had said nothing
about it. A diagnosis of tetanus was made at once and 20 cc.
antitoxin given immediately, that being all we had in the house
at the time. Three hours later, at 8 p.m., 20 cc. more antitoxin
was given and the same amount repeated at midnight. About
noon the next day, 40 cc. more was administered. At 1.45 p.m.
the same day the woman died in a convulsion. Thus, witliin
19 hours after the disease manifested itself, 100 cc. antitoxin
was given, yet in 21 hours the patient was dead, liromids and
chloral had been given freely from the outset, first by mouth
and then by rectum, and morphin hypodermically, but nothing
had the slightest effect on the progress of the disease. Numer-
ous general convulsions occurred, during which the face be-
came almost black, respiration being prevented, tlie pulse run-
ning up to 100 per minute ; when the spasm relaxed tne woman
would fall back apparently dead. The convulsions lasted
longer each time, death eventually occurring during one, from
cramp asphyxia. The highest temperature reached was 101.6°,
soon after tlie onset of the disease, and it gradually fell until
the time of death.
Case II.— John G., aged 20, was admitted July 28, 1900, for
a very severe laceration of the left hand, caused by iiaving it
caught in a carding mill. The wound was cleansed and dressed
in the usual manner ; two days later, as the tissues did not look
very healthy, and the odor was offensive, continuous irrigation
with a solution of mercury bichlorid was employed. The next
day, however, tlie hand was gangrenous and amputation was
advised, but refused. The following day, August 1, however,
four days after receipt of the injury, amputation through the
middle third of the forearm was performed. On Augusts the
patient noticed the slightest stiffness of the jaw, although he did
not speak of it till the next day, when he had some slight diill-
culty in chewing his food. Examination discovered slight
rigidity of neck and back. A diagnosis of tetanus was made and
50 cc. of antitoxin was administeretl during tlie day. The next
day, August 7, the trismus, opisthotonos and dysjihagia were
mucli more pronounced. The stitclies were removed from the
wound, which had healed by first iutentiimand showe<l not the
slightest sign of irritation, nor did it do so at any time. Sixty
cc. of antit.)xin was given during the day. August 8 the tris-
mus was absolute, the abdominal and back muBcles rigid and
the back retracted. The patient was unable to swallow even a
drop of water, so rectal feeding was begun and continued for
three days, by which time he was able to swallow liqui<ls,
poured between the teeth, as the jaws were firnily locked and
remained so till August 21 (the fifteenth day of the disease), by
which time they could be separatod from one-tjuarter to one-
half inch, and liy August 29 (the twenty-third day) aliout three-
quarters inch. The rigidity of the abdominal and back muscles
was as slow in disappearing as that of the jaw muscles, iiy the
twenty-third day ol the disease the patient was able to sit up
for the first time and at the end of tlie fifth week he left the
hospital, though some muscular rigidity was still present. At
336 AMKBIOAK MeDICINBI
DIAGNOSIS OF DEMENTIA PRECOX
[AUGUST 30, 19 2
no time were there any symptoms of great nervousness or
Irritability, the patient being quiet and restful all the time, and
never sulferinK, so no sedatives were given.
From August 9 to 13 inclusive, 30 cc. of antitoxm was given
daily • from the fourteenth to the eighteenth inclusive, 40 oc.
daily • from the twentieth to the twenty-fourth inclusive, 20 cc.
daily •' and 10 cc. each day on the twenty-fifth and twenty-sixth.
After' this no more was given. Altogether, 680 ec. was given
in about 40 injections. At no time was there the slightest infec-
tion from the injections, though a diffuse erythema appeared
about the lifteeiith day of the disease, most marked on the
chest abdomen and back, less so on the face. This lasted a few
days 'and then began to fade, totally disappearing in about
eight days. There were no subjective symptoms connected
with the eruption. , . ,,. , .,, j- ■ ,
The temperature during the course of the disease remained
around normal most of the time; only once did it go over 100°,
and that was on the sixth day, when it reached 100.6° ; the pulse
varied from 80 to 120 per minute.
Cask III. — loseph F., aged 23, was admitted for tetanus
August 12, 1899. A week previously he had stepped on a nail,
puncturing the ball of his right foot. Two days later the foot
became painful, and the day before admission he noticed a
slight stifl'ness of the jaw. On admission the same condition
was present, and he complained of a sense of constriction in the
throat and chest. The foot was tender and somewhat swollen.
Treatment was begun at once; the wound was enlarged and
thoroughly cleansed, and an incision made in the dorsum of the
foot, but no pus was found ; 60 cc. of antitoxin was given the
first day in three different doses. The next day, August 13,
trismus was very pronounced ; muscular twitchings present :
violent general convulsions occurred in the evening. The head
was retracted, and swallowing was impossible. Sixty-five
cc. of antitoxin was given during the day in three different
injections. Bromids, chloral, morphin and eserin were all
tried when the nervous irritability became marked, and digi-
tiilis was given hypodermically on account of the depression ;
nourishment was given by the bowel. On August 14 the patient
was weaker. Muscular twitchings, local spasms and a few brief
eneral spasms occurred, but no severe convulsions. The pulse
jecaine rapid and feeble. On account of cardiac weakness, the
depressants were stopped. Sixty cc. of antitoxin was given dur-
ing the day. During the night he gradually grew weaker, and
died at 2,45 a.m. the morning following, about 3i days after
the first symptom of tetanus made its appearance. Altogether,
185 cc. of antoxin was given, but had no effect whatever on the
disease. The depressants seemed to have a quieting effect, as
no violent convulsions occurred after the system was once
under their influence ; it is possible that they prolonged life a
few hours, as it is quite likely that the ease would have termi-
nated sooner, during a convulsion, as did Case I, had it not been
for their sedative effect, but they had no effect whatever on the
outcome of the disease. The temperature varied from 97.5° to
104°, which was reached shortly before death. The pulse
varied from 74 to 140.
These three cases may be taken as more or less typ-
ical of the three diflferent degrees, if I may so express it,
of traumatic tetanus ; the fulminant, in which the prog-
nosis is absolutely hopeless ; the acute, in which it is
almost so ; and the subacute or chronic, in which the
prognosis is more favorable. The proportion of recov-
eries, one to three, may also be considered a fair aver-
age, whatever treatment is employed. The futility of
curative treatment in the acute cases is also well shown,
the case ending in recovery not being of the acute vari-
ety. From observation of this case, I am not at all con-
vinced that the large amount of antitoxin used had
anything to do with the recovery. As I suggested pre-
viously, it seems to me more likely that the total removal
of the seat of infection, by amputation, several days
before the onset of the first symptoms, had more to do
with recovery than did the antitoxin which was used so
lavishly.
BIBLIOGBAPHY.
1 Monthly Cyclopedia of Practical Medicine, August, 1901, pp. 301,
303.
- Rostowtsev, Vratch, February 24, 1901.
' K. von Leyden, Therapie der Gegenwart, August, 1901.
* Lambert, Annals of Surgery, December, 1897.
s WiUson, Tetanus Appearing in Coui'se of Vaccinia, American
Medicine^ December 7, 1901.
1 Report of Investigation Commission, Philadelphia Medical Jour-
nal, November 30, 1901.
' La Semaine MMicale, March 19, 1902, p. 90.
8 Monthly Cyclopedia of Practical Medicine, August, 1901.
' Vratch, January 19, 1902.
1" Riforma Medlca, January 20, 1902.
" Monthly Cyclopedia of Practical Medicine, August, 1901, p. 303.
" Meroli's Archives, May, 1899.
" Wiener kllnlsche Wochenschrlft, August 9, 1900.
" Vrat<h. February 21, 1901.
" La Medecine Moderne, October 16, 1901.
ON THE DIAGNOSIS OF DEMENTIA PR.S;COX.
BY
WILLIAM RUSH DUNTON, Jb., M.D.,
of Towson, Md.
Assistant Physician, Sheppard and Enoch Pratt Hospital, Towson, Md.
Undoubtedly we owe a great deal to Emil Kraepelin
for the suggestiveness as well as the ingenuity shown in
his cla-ssiflcation of mental diseases. Although the
method adopted by him is open to criticism, still it gives
us a satisfactory working ba-sis. Kraepelin affirms that,
judged by their termination, a large number of cases of
mental alienation fall into one of two groups. Those
ending in recovery are diagnosed as manic-depressive
insanity, while those culminating in dementia are called
dementia prsecox. The initial symptoms of the two
groups are sometimes so similar that a diagnosis is very
difficult.
In my work in the neurologic clinic of the Johns
Hopkins Hospital I became particularly interested in a
number of patients, who in addition to neurasthenoid
symptoms, sutfered from mental alienation of such a
mild degree that its real significance in the hi.story of the
case might easily be lost sight of as a factor of diagnostic
importance. Following is the abstract of a case which
shows more marked mental symptoms than the
majority of the cases presented :
Case I. — The patient, aged 17, is single, white and has no occu-
pation. She was admitted to the clinic April 30, 1902, complain-
ing of nervousness and lack of ambition.
Family History. — Oldest brother is a patient in a hospital
for the insane. At six years of age he had scarlet fever, fol-
lowed by " dropsy of the brain." Later he drank to some extent
and "had some bad personal habits." At about 21 years he
began to act queerly, and this progressed to such an extent that
his confinement in a hospital became necessary. He is now 30
years old. The remainder of the family history is negative.
Previous History. — The patient had chickenpox, whooping-
cough, mea.sles and influenza. She has never had rheumatism,
typhoid, pneumonia, nor convulsions. As a child she was
bright and studious until 14 years of age, when she became
nervous, began to worry over her studies, and on this account
was removed from school. When about 16 years of age she
came to the medical clinic suffering with amenorrhea, and after
six months' treatment was discharged improved.
Present Illness.— The patient has always been more or less
bashful. About Christmas, 1901, she became dull and apa-
thetic, and did not care to mingle with her associates. Although
this aversion to the society of others has continued, yet she does
not like to go out of the house alone. She is very reticent, even
to her mother. She brightens up when taken to the theater or
where she will see young people, but does not care to mingle
with them. She cries without apparent cause, and frequently
seems to be frightened. Formerly she helped her mother with
the household duties, but now refuses to do even this. She fre-
quently expresses a desire to go to bed, but does not sleep well,
and wakes in the morning feeling tired and with pain in her
legs. She frequently complains of a feeling of oppression across
her chest. She sticks pins into the ends of her fingers, bites her
fingers and nails, and twists her hands about a great deal. Her
sense of order is hyperacute. She is constipated, has a poor
appetite, and has lost flesh. In February she had a copious
menstrual flow, but since then has had none. Her mother
thinks her sexual desires strong, and suspects masturbation.
Her mother not being present, the patient admitted having had
coitus shortly after Christmas, and of fearing that she was preg-
nant. It was not until the patient had been seen several times
that this was found to be a delusion. Patient says that she has
an occasional headache and sometimes feels dizzy.
On examination the patient appears young for her age, has
a sallow complexion, and is anemic. She acts in a shy manner
and speaks in a slow, monotonous tone which is scarcely
audible. Sensory stimuli seem to act promptly and are appar-
ently appreciated quickly, but the patient takes several seconds
to answer questions. She is evidently mentally depressed. She
blushes easily. Dermographia is present. Pupils react to
light and accommodation. The finger nails are bitten off short
and the last finger-joints are swollen and sore. Pulse is irregu-
lar and not very strong. Heart normal. Blood pressure 134
mm. There is a slight movement of the orbicularis palpebra-
rum on tapping over the facial nerve. In shaking hands, the
patient clasps and retains her hold but does not shake the hand.
It is hardly worth while to occupy space with more
examples. It is sufficient to indicate the character of
some of these early cases. I have been so fortunate as
to continue my observation of some of them in the
wards of the Sheppard Hospital and so have had a more
August 30, 1902]
DIAGNOSIS OF DEMENTIA PR.ECOX
[AuBBiCAir Mra>ictin[ 337
exact knowledge of their course and >iymptoms than
would have been otherwise possible. I was also better
able to understand some of our patients at Sheppard
in whom I had had no opportunity to observe the early
symptoms. Some of these dispensary cases ultimately
passed through an attack of mania or depression and re-
covered. Others passed through similar attacks and
became demented quite rapidly. Still others recovered
under dispensary treatment, the mental symptoms sub-
siding rapidly, the physical more slowly. The experi-
ence of observing the early symptoms of mental cases is
one which is not often granted to those whose work lies
for the most part in the wards of hospitals for the insane,
and I am sure that the observations which are made
in the Johns Hopkins neurologic clinic, where a
.special day is set apart for mental cases, will ultimately
be of great value to all students of psychiatry. Certain
symptoms which I have observed seem to me to be of
great diagnostic importance in differentiating neuras-
thenia with depression from the initial stage of demen-
tia precox. The purpose of this paper is to draw
attention to a few of these. It is hoped that other
observers will be able by experience to prove or dis-
prove the points advanced here. The physician in gen-
eral practice and the neurologist have a much better
opportunity to observe the early symptoms of mental
trouble than the alienist, and it is toward the former
that we should look for an increase of our knowledge.
In considering any disease it is best to have a clear
conception of what it is. Especially is this true as to
mental diseases, of which, unfortunately, it seems almost
impossible to have clear conceptions, based as they are
on a symptomatic classification. Before discussing the
diagnosis of dementia prwcox I would like to call
attention to Kraepelin's definition. We must bear in
mind that it is a condition and not a disease that we are
considering. Kraepelin, in his Textbook,' says: "We
provisionally gather together under the term dementia
prtejox a series of clinical pictures whose common char-
acteristic is a termination in a peculiar weakened state
of the mind. This unfavorable ending may not occur
in every single case, but it is better for the present to
adhere closely to this general name." You will note
that Kraepelin does not insist that the patient become
demented. This on the face of it is rather confusing.
Why should we call a patient demented when he is not?
Simply because our knowledge is not yet exact enough
to tell why the patients who show a group of symptoms
which usually ends in dementia get well. If we add
another form to our classification to include these cases
we are not adding to our knowledge but are doing away
with the stimulus for further investigation. Kraepelin
affirms that about I'H'/c of the patients exhibiting the
.symj)tom-group of dementia pnecox apparently recover,
but believes that ultimately they relapse. Other writers
dissent from this view. Tromner ' thinks this percent-
age of apparent recoveries too high, and Christian ' de-
clares that no patients recover!
Kraepelin * has said that probably in the mass of
cases included under the term dementia pnecox there
is a smaller group to which the term might be applied
more properly. This seems most reasonable, and prob-
ably, as time goes on, we will find that we are able to
classify our cases more exactly, and under the term
dementia pra»cox will group a class of cases with more
definite symptoms than we arc able to do at the present
time. Arndt^ has recently, in a most interesting paper,
given the history of catatonia. He has shown how this
symptom-complex has gradually come to be considered
as an entity, and yet all cannot accept it as such. How-
<'ver, we have no space here to consider this nmch dis-
<'ussed (juestion. Undoubtedly, many cases of catatonia
which have been reporte^d are really cases of dementia
jwrwcox, and it seems to me that the disease entity of
<lementia pnecox to which we look forward will have
most of the characteristics of catatonia.
The diagnosis of dementia prsecox is not especially
difficult in the later stages. The dementia itself is usu-
ally characteristic, and the other symptoms, together
with the history, make diagnosis a fairly simple matter.
When, however, we have to make a diagnosis in the
early stage, the matter is much more difficult, and it is
not surprising that many cases of dementia prsecox
should be first classified as neurasthenia, melancholia, or
mania. Every one, I think, will admit the importance
of an early diagnosis, and any symptom-group which
aids us in makitig this will be of value.
Masoin* has dwelt particularly on the motor phe-
nomena, such as tics, grimaces, stereotypy, impulsive
movements, eccentricities of manner (for example, in
giving the hand), and peculiarities of speech (verbigera-
tion, echolalia). He says that while the motor symp-
toms are not an exclusive symptom of dementia prsecox
they are here shown in their maxinmm of frequency
and intensity. It seems to me that in the motor phe-
nomena there is a field that has not yet been fully inves-
tigated and in which there may be discovered symptoms
which, considered by themselves, will be even more
helpful in aiding diagnosis than those shown by the
mental state. This view of Masoin's is not especially
new, but he considers the motor phenomena to be of
more importance than does any other writer on dementia
prajcox.
There is a symptom which Kraepelin notes, but does
not emphasize, and which I have seen as a very pro-
nounced symptom in a number of cases, one of which has
been reported elsewhere.' This is the mechanic irrita-
bility of the facial nerve, which, when present and asso-
ciated with mental aberration, is of diagnostic value.
It is shown in the following manner : When the patient
is tapped lightly with the percussion hammer over the
cheek, just in front of the ear, care being taken to ex-
clude any visual impulse, there will be noticed a con-
traction of the orbicularis palpebrarum varying in inten-
sity from a marked contraction of the whole muscle,
combined with that of other muscles of the face, to a
slight quiver of the fibers of the inferior part of the
orbicularis. It will be noted that this phenomenon is
quite different from that recently described by D. J. Mc-
Carthy." As yet I do not feel that I have investigated
this phenomenon sufficiently to make any very positive
assertions concerning it. It is not present in all cases,
and sometimes when I have most expected to find it, it
has been absent. It seems to be most marked in the
later stages, and unless pretty constantly present as an
early symptom, will not prove of much value from a
diagnostic standpoint. So far I have not been able to
obtain it in all early cases, though present in the
ma;jority. Ijater I hope to have sufficient data to make
a further report on the relative diagnostic value of this
symptom. Meanwhile I would be very glad if others
would investigate this phenomenon and publish their
results, or communicate the same to me.
The increase in the reflexes is most important as a
means of diagnosis. In every case of dementia prsecox
which I have seen the knee-jerks and other tendon
reflexes have been exaggerated. The superficial reflexes
have also been increased, and it is a question which I
hope to see settled some day, whether they become exag-
gerated before or after the deep.
Christian considers the tendency to sudden impulses
a most important feature, both from a diagnostic sttind-
point and from the standpoint of safety to others. My
own observations have letl me to agree with him. It is
usually easy to distinguish these impulsive or impera-
tive acts of a precocious dement from those of a paretic,
paranoiac, or maniac. The sudden acts of pr(>cociou8
dements usually occur without any warning, as some
one has said, " like a thunderbolt out of a clear sky ;"
they are motiveless, the patient is usually unable to give
any rea.son for his act, and often denies that he did it.
When stupor or confusion has \xen present, it is usually
838 AMBKICAN MED1CIH1!\
CHRONIC CARBON MONOXID POISONING
[AUGUST 80, 1902
increased after the act. When impulsive or imperative
acts occur in mania, paranoia, or paresis, there is a
motive, usually emanating from a delusion, or arising
from some provocation, and the patient is able to give
this motive. This last is not true for certain imperative
acts, but here the patient recognizes the fact that his act
is foolish. Of course there are many other facts which
aid us in differentiating these sudden impulses, and these
are to be found in the history of the case and in the
other symptoms. While I have said that the impulsive
acts of precocious dements are motiveless, we must
remember that there are gradations in this form of
mental trouble, and in the very early stages we may find
a motive which inadequately explains the patient's
action, and frequently attracts our attention the mental
deterioration. Ijet me give an example :
Cask II. — The patient is a white female. She is single and
a housemaid.
Familii History.— V»X\e\\Vn mother is exceedingly jealous
of her husband and of another daughter. Her father looks and
acts as though he were slightly below par mentally. A«on
greatly resembles him in this respect.
Previous History.— Vatient left school at 13 years, owing to
failure to " pass." She menstruated at 14, always regularly, but
her periods were always attended with an unusual amount of
nervousness and depression.
Present Illness.— Ahoni nine months ago the patient was
indefinitely noticed as being somewhat depressed, but there
was no marked change until about a month afterward, when
she accepted a position as a servant, and was assigned to sleep
with another servant older than herself. She conceived the
idea that this companion did not like her or might do some-
thing to her, so late at night the patient got up, dressed, and left
the room with the intention of leaving the house. Just as she
crossed the threshold into the dark hall she became fearful
that there might be a trap in the floor, she therefore returned to
her room, went to the window and without any premeditation,
jumped out. The ground happened to be soft and the patient
was not hurt. She ran some distance to the street-car and
went to her home. From the first there has been marked men-
tal confusion. The patient has no power of decision. There
has been motor restlessness. She has been suspicious, but has
made no definite accusations, though intimating that her sis-
ter's friends were not proper associates and refusing to see
them herself. However, she would come downstairs in her
night-dress and listen at the parlor door. She has shown con-
siderable dislike for certain objects, has torn up photographs
without giving any reason, and taken pictures from the wall
and torn the frames apart.
When brought to the Johns Hopkins clinic she presented
a picture of rapidly alternating moods of depression, with
weeping and excitement, accompanied by laughter and a ten-
dency to sarcastic witticisms. She did not improve on dispen-
sary treatment and was admitted to the Sheppard Hospital,
where she is still under treatment. Without going into her
case in further detail, I would say that there is some psycho-
motor retardation, a slight reaction on tapping over the facial
nerve, active reflexes, occasional auditory hallucinations and a
mild degree of dementia, which is shown more in her writings
than in speech. She is a little more quiet than when first
admitted, but there is no real mental improvement. When
attempting to explain any of her actions she cannot pursue one
line of thought long enough to finish her explanation, but
wanders ott" to other subjects.
In the paranoid form of dementia prsecox we find the
patient explaining his impulsive or imperative acts by
motives which emanate from his delusions, and in this
form these acts are of less value as a means of diagnosis.
It is usually impossible, until the dementia is quite
marked, to differentiate paranoid dementia prsecox from
true paranoia.
The slow psychic reaction, or psychomotor retarda-
tion, is of value from a diagnostic standpoint. It has
been present in every case of early dementia prsecox
which I have seen. It is also interesting to note that of
a number of precocious dements which have been treated
at Sheppard, the majority have been first diagnosed as
confusional melancholia, the slow psychic reaction hav-
ing been a prominent early symptom.
Negativism hits been defined as the "silly purpose-
less resistance to every external impulse." Kraepelin
does not give so precise a definition as this, appa-
rently does not restrict negativism to quite so narrow
limits, and believes that a very close relationship exists
between it and the sudden impulses. I have found it
Impossible to differentiate resistance based on a delusion
from negativism. The following will illustrate :
Case III.— This patient, aged S3, married, was a housewife.
She has been an inmate of the .Sheppard Hospital since Decem-
ber, 1899, and is now in a condition of incomplete dementia
with periodic attacks of excitement. When approached by the
physician she usually turns away and hides her face, but fre-
quently runs and hides behind a cliair. or wardrobe, when she
hears him coming. When "cornered," she refuses to hold out
her hand or look the questioner in the eye. After she had been
behaving in this manner for some time she one day told
her nurse that she thought the doctor wanted her to act as
she did.
In this connection it is of interest to refer to an article
by Cahen' on stereotypy in which he agrees with Wer-
nicke that the stereotypy is ordinarily caused by
an insane idea." It seems probable to me that the
negativism may be caused in the same manner. The
patient of Case III was said, by one who had studied
under Kraepelin, to exhibit negativism in a most
typical manner, yet she gave a rea.son for her action.
Her insane idea is perhaps rather indefinite, but it
sufficiently illustrates the point which I wish to make,
namely, that we cannot be too cautious in accept-
ing the socalled negativism as a symptom, for it is so
easily confounded with motived resistance. When neg-
ativism is observed late in the course of the dementia
can we be sure that it has not had its origin in an insane
idea, and become mechanical like stereotypy ? I feel that
in the present state of our knowledge this question can-
not be answered positively, but my present opinion is
that negativism does have its inception in an insane
idea.
In this paper I have not attempted to touch upon the
symptoms which have been so thoroughly discussed by
Kraepelin and others, and which are to be found later
when the dementia is showing itself more or less plainly.
I have simply indicated certain symptoms which I have
found helpful in differentiating dementia pnecox from
neurasthenia and the recoverable psychoses.
In conclusion, I wish to express my indebtedness to
my colleagues at the Sheppard and Enoch Pratt Hos-
pital for much assistance in the preparation of this
paper.
BIBLIOGRAPHY.
1 Kraepelin, Psychiatric, 6th Ed., Lelpslc, Bd. 11, p. 137.
- Das Jugendirresein, lilOO.
'^ Annates Medico-Psyciiologiques, 8th Series, Vol. Ix.
< Die Kllnische Stellung der Melancholle, Monats. i. Psych., Bd. vi,
8. 325.
5 Arndt, Centrall)lalt f. Nervenh. und Psych., Bd. xlv, s. 81.
•Journal de Neurologie, An. 7, p. 61.
T Anierifun Journal of Medical Sciences, Vol. cxxill, p. 109.
8 Nmrologisches Centralblatt, Jahrg. xx, p. fOO.
» Cahcn, Albert, Contribution ft I'Etude des Stereotypies. Archives
de Neurologle, Vol. xii, p. 476.
CHRONIC CARBON MONOXID POISONING AND CAR-
BONYL HEMOGLOBINURIA: THE LATTER A
HITHERTO UNDESCRIBED CONDITION.
. BY
THOMAS J. YARROW, Jr., M.D.,
of Philadelphia.
Pathologist and Bacteriologist to the Samaritan Hospital; Clinical
Pathologist and Hematologist to the Charity Hospital; Member
of the Philadelphia Pathologic Society; Fellow of the
Electro-Chemie Society, and Member of
th; Franklin Institute.
In a paper which appeared in the New York Medical
Journal, April 7, 1900, I first called attention to chronic
toxemia resulting from the constant inhalation of small
quantities of illuminating gas from leaky gaspipes or
fixtures. I also stated my firm belief that it was more
frequently than imagined the cause of obscure symp-
toms, which were seldom ascribed to their true source,
or to the exact agent whith produced them. The pos-
sibility of confounding chronic carbon monoxid poison-
ing with various other conditions, such as acute and
chronic gastroenteritis, ptomain and leukomain poison-
August 30, 1902J
CHRONIC CAEBON MONOXID POISONING
[AUEBICAK MBDICINE 339
ing and other autointoxications is marl^ed, unless the
subject has been brought prominently before one's mind.
Since this paper appeared I have made a careful investi-
gation of leaky gas-fixtures, and have observed that it is
the exception rather than the rule to find them perfect
in our houses. It will be noticed on close examination
that at least one room will contain gas-fittings that are by
no means impermeable. It is a peculiar fact that those
engaged in placing these fittings in houses soon lose the
sense of smell as regards the odor of illuminating gas
(unleas it escapes in large amounts). So it is with indi-
viduals exposed to a constant small or almost impercep-
tible leakage : they soon grow accustomed to its presence
and cease to notice it. At the present time the danger
is increased by the almost universal use (in this city at
least) of gas-ranges for cooking purposes. It is very
ttliiiWiiifffi I ill 1 1 1 1 1 1 1 it' I I I I
F-ig.
IliliiiliiiibilTiiili
JUSSv
Fig. 1.— Wave length scale, calculated by me (from Interpolation curve). Fig. 2.— Hematin
ethereal solution. Fig. 3.— Hemoglobin (oxy.), 1;< in normal salt solution. Fig. 4.— Alkali hematin.
I'lg. 5.— Reduced alkali hematin or hemachroraogen.
■|ililiiiiiiii[|iniliiiffnii1lidi
SOftf.
Illllllllll
liiii'indiiiffii
F.9.S
I I I I I I I
Fig. 6.— Urobilin in acid urin. Fig. ".—Acid hematin. Fig. 8.— Methemoglobln. Fig. 9 —From blood
impregnated with illuminating gas for 15 minutes. Fig. 10— Heduced hemoglobin.
easy not to turn the valves completely off, and I have
collected a number of cases from this source alone which
I will mention later. Carbon monoxid, as is well
known, forms a very stable combination (chemic) with
hemoglobin, so that blood once impregnated with this
deadly gas lo.ses its power as an oxygen carrier to the
ti.ssues of the bo<ly. The compound which is formed is
of a bright florid crimson or purplish-red color, totally
unlike normal blood, which is more of a yellowish-red
hue. Individuals acutely poisoned with carbon mon-
oxid show this peculiar color in their complexions.
Blood artificially treated with carbon monoxid by pa,s.s-
ing a stream of coal-gas through it, shows no tendency to
lose its unu.sual color, even after being exposed to the
atmosphere for years. Some pathologists have used it
as a sub.stitute for ink, while it has been substituted for
hemoglobin in the hematinometric estimation of hemo-
globin(oxy). To review the specific blood poisons we
may divide them as follows :
Those which act by entering into combination with
the hemoglobin without affecting the corpuscles ; among
these are carbon monoxid, nickel carbonyl, cyanogen,
sulfureted hydrogen, hyponitric acid and nitric oxid.
The latter forms a more stable compound, if possible,
than carbon monoxid, and produces a, fortunately rare,
very fatal type of pneumonia.
Those which disorganize the corpuscles (used in the
arts and in the practice of medicine) : Among these are
mushrooms (genus Helvella, due to the contained hel-
vellaic acid — also produces hemoglobinuria (Boehm) ;
vapor of osmic acid, tellureted hydrogen and seleni-
ureted hydrogen (Bruere) ; potassium chlorate, nitro-
glj'cerin, nitrite of amyl (nitrites
generally) ; nitrobeiizol, arseni-
ureted hydrogen, pyridin, snake
venom, anilin and many of the
coal-tar series.
Those which decompose the
hemoglobin, producing hemato-
porphyrinuria : Among these are
sulfoual, trional and tetronal, etc.
Those which produce methe-
moglobinemia: Antipyrin, acet-
anilid, paraldehyd (Quinquad),
pyrogallic acid (Danilevsky), hy-
droxylamin hydrochlorid (Binz),
dioxynaphthalin (Lepine), salts of
uranium, chromic acid, acetylhy-
drazin (Gutmann), and benzol.
That decreasing the erythro-
cytes : Sodium fluorid (Waddell).
Those producing hemoglobi-
nuria : Q u i n i n , B-isoamylene
(Kleindienst), etc.
Decrea.sing coagulation : Albu-
moses, phenol, carbon disulfld,
quinolin (Donath), antimony and
pota.ssium tartrate, chloral (Rich-
ardson).
Those increasing coagulation :
Calcium chlorid, gelatin, carbon
dioxid gas and solanin and solan-
idin (also disorganizes the erythro-
cytes— Perles).
Depressing the oxygen-carry-
ing power of the erythrocytes :
Cytisin (Kobert-Radwillowiez).
Producing a peculiar effect :
Picric acid (and the picrates)
causes a leukocytosis, changes the
color of the blood and makes the
erythrocytes appear as if they
were nucleated (Krb).
I have suggested that the
changes in the blood observed
in poisoning by the above class
divided into four groups, as fol-
¥
of substances be
lows :
Macroscopic. — In which the blootl ajipears of abnormal
color to the unaided eye, such as the cherry color of
carbonyl hemoglobin, the brown or chocolate color of
methemoglobin, sulfuryl hemoglobin, etc.
Microscopic, — In which the cellular constituents are
seen to be altered from the normal-poikilocytosis, micro-
cytosis, macrocytosis, unusual pallor (as in poisoning by
potassium chlorate or other niethemoglobin-producing
agents) ; also the presence of normoblasts (and nuclear
changes) in attempted reorganization. Lastly, the
pre.sence of leukocytosis with pathologic viiriations in
the differential count of the same.
Spectroscopic. — In which the characteristic absorption
bands are present, such as those of carbonyl hemoglobin,
340 AKKBicAN Medicine.
CHRONIC CA.RBON MONOXID POISONING
[August SO, 1902
sulfuryl liernoglobin, nitrosyl hemoglobin, methemo-
globin, otc.
Chemh.—ln which the blood reacts with certain
chemlc Hubstances unlike normal blood.
The Inhalation of gas from leaks in gas-pipes (mains,
etc.), sewers, privies, burning charcoal in a close atmos-
phere, constitute the chief sources of [)oisoning by carbon
monoxid. A wellknown and favorite method of suicide
in France, also practised in ancient Rome, is by the
Inhalation of the fumes of burning charcoal or coke ;
while men engaged in iron-working establishments,
especially those constantly exposed to the effect of
furnace gases, often suffer from an anemia of severe
type, occasioned more often, formerly, by the danger-
ous operation of fllling blast-furnaces at the top. This
is now being discarded, mechanic means having l)een
substituted to obviate the great menace to life.
It would seem highly probable that in chronic car-
bon monoxid poisoning, parenchymatous changes and
fatty degeneration occur in various organs, as will be
noticed in the urinary examination in the case which I
reported in the JVew York Medical Journal; while it is
wellknown that hemorrhages into various organs,
marked fatty degeneration, and parenchymatous changes
have occurred as tlie result of the administration or
inhalation of many of the poisons previously mentioned,
such as abrin, ricin, phosphorus fumes, arseniureted hy-
drogen, etc. Carbonyl hemoglobin exhibits characteristic
absorption bands with the spectroscope, which are an
unmistakable proof of its presence in the blood or urine
when taken in conjunction with certain very simple
chemic teste (used in combination with this extremely
valuable instrument). These bands differ froin those of
oxyhemoglobin in not being reduced to (reduced) hemo-
globin by Stokes' reagent, or what is much better for the
purpose, ammonium sulfid. They are also a little
closer to tlie violet than the latter, but if one depended
solely on their position, I am sure that in certain
instances one would be apt to be misled, as the width
of all absorption bands varies with the strength of the
solution used. A more valuable test, in my opinion, is
the simple test of putrefaction for a few days (or a week)
if necessary, as this is a very easy method of reducing
oxyhemoglobin, and also distinguishes carbonyl hemo-
globin from hematoporphyrin, pathologic urobilin and
other pigments or coloring matters which are sometimes
present in the urine. .Although carbonyl hemoglobin will
putrefy as readily as any other form and acquire a most
repulsive odor, the characteristic bands even under this
circumstance will persist, and remain unaltered for years.
It is this strong affinity that carbon monoxid possesses for
hemoglobin that renders recovery almost impossible in
cases of severe poisoning by it. Everything has been
attempted in the treatment of acute poisoning without
success (of course I am speaking of severe cases), and I
will not weary the reader with the long list of unsuc-
cessful means which have been employed. Darrah has
performed some interesting experiments with transfusion
in dogs, but this would be of slight value in its appli-
cation to the human being, if we take into consideration
the usual circumstances attending illuminating gas
asphyxia. As a general rule the poisoning has pro-
gressed to such an extent when the individual is found
that little avails. Suicides generally provide for the
possibility of their detection before accomplishing their
purpose, by stuffing up cracks in doors, windows, etc.,
so that their end is usually fully assured by the over-
whelming amount of gas to which they are exposed.
The very nature of the combination seems to preclude
the possibility of recovery, and it is probable that an
atmosphere containing less than 1 ^ would prove fatal
to a human being if exposed to it for a half hour or
longer. There is no method of determining just what
the fatal quantity is for a human being, but I have come
to the conclusion that people who are constantly ex-
posed to its presence, such as plumbers, gas-house
employes, and gasfltters, acquire in time a slight immu-
nity, as occurs with other poisons, while on the other
hand there are persons who are extremely sensitive to
its influence. In chronic poisoning by carbon monoxid
the latter coexists in the blood with oxygen, so that the
hemoglobin still retains a crippled function of carrying
oxygen to the tissues. When the individual is exposed to
a small but constant quantity of this gas in the atmosphere,
as from a leaky gaspipe or drain, the effect upon his health
is soon made apparent. The symptoms, though some-
times vague and misleading, may be summed up as fol-
lows : Anemia, generally symptomatic in character, with
or without a leukocytosis (which may or may not be
accompanied by a polymorphonuclear increase), frontal
headache (worse in the morning on arising), anorexia,
tinnitus aurium, vertigo, foul taste in the mouth (some-
times expressed as "gassy"), abdominal pains, very
often of a colicky character ; constipation, and per-
sistent disorder of digestion. To these symptoms may
be added weakness and lassitude, amounting at times to
complete prostration. The patient, to use his own
words, "never feels well," although he is much
improved when in the fresh air and out of doors for a
while. This latter fact should excite suspicion as to the
cause of his illness. The chronic form differs markedly
from the acute, as in the former type the florid counte-
nance is seldom or never seen.
In examining the blood or urine for carbonyl hemo-
globin, especially in chronic cases of toxemia from this
agent, some form of spectroscope is indispensable. The
method which I employ may be briefly outlined as fol-
lows : The finger or ear of the individual is pricked, as
in other blood examinations, and the drops of blood
drawn into a pipet and then mixed and diluted with 5 to
10 cm. of distilled water. The mixture is then placed
in a test-tube, if using the common hand spectroscope,
or more conveniently in a small hematinometer of special
construction (as those generally supplied are too heavy
and clumsy). The absorption bands are noted, and their
position mapped by means of an accurate wave-length
scale (using the chemic spectroscope), with a sodium
flame to mark the position of D. Stokes' reagent or am-
monium sulfid is addetl and the effect, if any, noted
upon the bands. The mixture should be thoroughly
stirred with a platinum loop, and slightly warmed to
favor rapid reduction. If carbonyl hemoglobin is
present it will be found that the normal reduction to
(reduced) hemoglobin does not take place, but that the
alpha and beta bands of carbonyl hemoglobin persist, and
are somewhat closer to the violet than those of oxyhem-
oglobin. Other tests have been employed (in acute
poisoning and in experimental work), but for delicac.v
the spectroscope surpasses them all. In fact, when a small
quantity is present it would be almost impossible to
detect ite presence by any other method than that of
spectroscopic analysis. An instrument which will detect
carbon monoxid in the blood, six weeks after acute
poisoning, will be admitted to be far superior to simple
but coarse chemic tests. Zaleski adds a few drops of a
solution of acopper salt to 4 cm. of the suspected sample,
diluted with an equal quantity of water. With this
test normal blood gives a chocolate-brown precipitate,
carbonyl blood a brick -red. Salkowski shakes the blood
with sulfureted hydrogen, which turns normal blood to
a dirty green color in a few minutes. Katayama uses
ammonium sulfid and acetic acid in the same manner,
and Richter substitutes formic acid and proceeds as the
foregoing. Rubner finds a similar reaction to that of
Zaleski, but uses a lead acetate solution, as does also
Wetzel. Hoppe-Seyler advocates, as a proof of the
presence or absence of carbon monoxid in the blood, the
fact that blood exposed to putrefactive changes still
shows the two absorption bands as before mentioned in
the spectrum. This test, I agree, is the most conclusive
when any doubt exists. When putrefaction occurs, it
will be noticed that two sets of bands exist — those of
August 30, 1902j
CHRONIC CARBON MONOXID POISONING
lAMxsacAx Mbdicike 341
•earbonyl hemoglobin superimposed upon the broad band
of reduced hemoglobin and usually sharply differen-
tiated from the latter.
By passing carbon monoxid through a solution of
oxyhemoglobin, adding alcohol and freezing, crystals of
earbonyl hemoglobin separate, and it will be noticed that
their color is much more of a blue shade than those of
■oxyhemoglobin. Hoppe-Seyler states that they are not
affected by pancreatic ferment or putrefaction. I have
found in a solution of earbonyl hemoglobin which had
stood in my laboratory for over two years, crystals and
amorphous masses which closely resembled hematoldin
in their form and measurements. It is well to have,
also, a portion of the suspected blood diluted, before the
comparison prism of the spectroscope to compare with
the portion to which ammonium sulfld has been added.
The Sorby-Beck and the Abbe-Zeiss microspectroscopes
leave nothing to be desired in their construction, except,
perhaps, a more convenient method or scale for measur-
ing the wave-lengths of absorption bands. In the
former instrument this is accomplished by means of a
•quartz plate, cut to show 12 interference lines or bands
when placed between two Nicol or polarizing prisms,
and viewed with the spectroscopic eye-piece. It is
adjusted to the side or comparison slit, and the spectrum
is thus divided into 12 parts, the width of the interfer-
ence lines varying with the frangibility of the spectral
rays. When properly adjusted, Dis placed exactly half-
way between the third and fourth line. This is difficult to
use when the exact (or even approximate) wave-length of
a band is desired, unless the value of the lines has been
worked out accurately by means of a wave-length scale.
1 accomplished this by means of solutions of the anilin
dyes diluted to give a certain wave-length, with an
accurate wave-length scale, on a chemic spectroscope
and then finding the absorption band which corre-
sponded to the interference line of the quartz-plate polar-
izing apparatus. This is a good method for clinical
work when the observer wishing to tabulate his results
in wave-lengths possesses only the Sorby-Beck micro-
spectroscope. The Abbe-Zeiss has a photographed scale
which is viewed with the spectrum. As it is not a mat-
ter of difficulty to procure enough blood for a thorough
examination, the microspectroscope may be discarded
And the chemic form used, except in medicolegal work,
when it is impossible to procure at times more than the
faintest trace of a blood stain. The latter instrument
gives a much larger and perfect spectrum than the
former, although the bands are not seen with the dis-
tinctness of the direct vision instrument. I'or all around
■work with blood, urine, anilin dyes, various coloring
matters, etc., it is best that it should be provided with
an accurate wave-length scsile instead of the ordinary
■one divided into millimeters. The sodium flame should
always be used before making an examination to deter-
mine that the scale is in its proper position, by means
of the D line.
To detect small quantities of earbonyl hemoglobin,
L. De Saint Martin {Comptes rendus, 1898, Vol. cxxvi, p.
1036) strongly advocates exhausting the suspected fluid
twice — first to get rid of all gases other than carbon mo-
noxid (these are carbon dioxid, oxygen, nitrogen and
traces of hydrogen). A second exhaustion is made to
remove the carbon monoxid mixed with traces of carbon
dioxid and nitrogen. It is needless to add that such a
method will never be employed in clinical work. Des-
grez and Xicloux find that carbon monoxid is continu-
ally present in the blood of animals confined in large
cities, and have made interesting researches on the sub-
ject in the city of Paris. I have endeavored to obtain
the ssirne results here (Philadelphia) with dogs, but with-
out success and cannot confirm their researches. It may
be that the extensive use of charcoal for cooking and other
purjjoses in French cities has some connection with the
condition. Friedi)erger and Krohner do not mention the
subject in their work, " The Pathology and Therapeutics
of the Domestic Animals." (Translated by my col-
league. Professor Zuill.)
Herter, in his admirable researches with adrenalin
chlorid, mentions the occurrence of glycosuria following
the administration of this substance. He also mentioned,
when reading his paper before the Philadelphia Patho-
logic Society, that carixjn monoxid (also with other
agents) produced glycosuria in dogs, when allowed to
come in contact with the living spleen, in the ingenious
manner which he described, for studying the effects of
various substances upon separate and living organs. I
have been much interested in the reports of glycosuria
following carbon monoxid poisoning, and since 1894 have
studied the urine in 15 cases of acute poisoning. I have
never found dextrose present shortly after the poisoning
nor in fact at any time in these cases, including those
which had a fatal termination. I do not mean to say
that Fehling's solution was not reduced in several
instances but that the substance which effected the re-
duction was not dextrose, as shown by the melting point
of the compounds formed by the phenylhydrazin test.
In all these cases the compound was washed and dis-
solved in alcohol ; the alcohol driven off and the melt-
ing point determined. The deposit in all the cases was
amorphous. It would seem, therefore, that glycosuria
is not common, although I do not deny the possibility of
its taking place when we consider the effect of carbon
monoxid on the oxidation processes in the body.
It is of the utmost importance to detect this gas, when
its presence is suspected in the atmosphere of a house,
and especially when the quantity escaping is so small as
not to be detected by its odor, as in the leakage of coal
or water-gas. The dangers of burning charcoal in a
closed apartment are too well known to give any caution
regarding them. The excellent method of Vogel may
be attempted for the detection, when carbon monoxid is
suspected to be present. Fresh normal blood is added to
distilled water until the latter is tinged faintly red, and
about 3 to 5 cm. are placed in a flask of the capacity of
100 to 150 cm. The flask is then shaken for several
minutes in the suspected atmosphere, and if carbon mo-
noxid is present the diluted blood will assume a bright
rose-red tint. On adding ammonium sulfld and making
a spectroscopic examination, the two bands of oxyhemo-
globin will be replaced by the band of reducetl hemo-
globin, but the two bands of earbonyl hemoglobin will
persist unchanged. The delicacy of this test may be
increased by using a larger fiask. Haldane has called
attention to the fact that in Boston where 90 /« of the gas
used is water-gas, that one out of every 800 deaths is due
to accidental poisoning. If this is true, there must be a
large number of cases of chronic carbon monoxid poison-
ing in this city which escape recognition, as I have never
seen the subject alluded to or even heard it mentioned.
The New York MedicM Record, February 24, 1900, p. 322,
makes the astonishing statement that coal-gas is com-
paratively harmle.ss. I see no reason why carton mo-
noxid poisoning should be confused with influenza, if a
careful bacteriologic and spectroscopic examination are
made at the same time, and it only adds to the already
existing confusion in medical nomenclature to coin such
a combination of words as " fuel-gas grippe " as has been
recently done. This term is reminiscent of " typhoid-
pneumonia" and others. Acute or chronic bronchitis
does not accompany chronic carbon monoxid poisoning
often enough to be termed a characteristic symptom,
although it is by no means infrequent.
I will briefly take up the effect of some of the con-
stituents of illuminating gas upon the living being.
Probably the most poisonous, carbon monoxid, acts on
the system like a narcotic poison, possessing irritiint
qualities also (in chronic cases), and the atmosphere need
contain but little for it to manifest its injurious effects.
It protluces vertigo, headache, prostration, followed by
deep coma or stupor (when inhaled in any quantity)
from which there is small hope of arousing the victim.
842 AxEBiCAN Medicine)
CHRONIC CARBON MONOXID POISONING
[August 80, 1902:
Methane or marHh-gas, the firedamp of the mines, is not
considered poisonous when mixed witli air, as many
have been exposed to it without serious disturbance.
Carbon dioxid probably plays little part, as it is nearly
all removed in the purification. We may consider the
chief injurious effect of the inhalation of illuminating
gas t« be due to carbon monoxid, the other constituents
playing a subsidiary role. In some ca.scs of asphyxia
there is no doubt that the fatal end is hastened by the
deprivation of oxygen which takes place when a room
is filled with coal-gas. I will briefly repeat the details
of the first case of carbon monoxid (chronic) poisoning
which I reported in the New York Medical Journal (see
date above) :
J. W. L., white, aged 52, had not felt well for a number of
years, and now complained (June 17, 1899) of anorexia, nausea,
frontal headache, rapid pulse, colicky pains in his abdomen,
indisestion and obstinate constipation. His weakness anionnte(l
to prostration, and he had been confined to his bed for several
days in a room which was very badly ventilated. Being struck
by the odor of illuminating gas when I entered the vestibule of
his residence, I made on the same day a spectroscopic examina-
tion of his blood and found carbonyl hemoglob'n present, as
shown by the position of the absorption bands and the impossi-
bility of reducing them to hemoglobin (reduced) with ammo-
nium sulfid, to the single band of the latter. It was also pres-
ent in the blood of a sister of the patient, but was absent from
the blood of the other members of the family. The rooms of
the patient and his sister were poorly ventilated, especially at
night. The other members of the family slept upon an upper
floor of the house and their rooms were always well aired.
This probably, together with the fact that they (husband and
wife) took a great deal of outdoor exercise, explains their free-
dom from the deleterious effects of the escaping gas, which came
from a leaky pipe in the cellar, and found its way up the heater
flues, etc., to the rooms of the patient and his sister. The blood
of the patient at the first examination contained 3,700,000 ery-
throcytes and a moderate leukocytosis was present. A differ-
ential count of 1,000 leukocytes (Ehrlich-Biondi-Heidenhain
stain, heat fixation at 140° C.) gave the following: Polymorpho-
nuclear, Wfc ; small lymphocytes, 30.8 ; large lymphocytes,
3.8%; eosinophiles, 3.6%; myelocytes, 8%. It will be noticed
that a comparatively large myelocytosis was present, otherwise
the blood was that of symptomatic anemia.
Examination of Urine. — Color, amber ; odor, normal ; trans-
parency, hazy ; sediment, none visible to naked eye ; reaction,
acid; specific gravity, 1,026; albumin (serum), globulin
ids, normal; phosphates Increased ; nucleoalbumin and ace-
tone, normal. Microscopic examination showed numerous
renal epithelial cells in a state of fatty degeneration ; hyaline,
fatty and broad granular casts, squamous epithelial cells, granu-
lar debris and a few cylindroids. This examination shows, I
think, the effect of the toxemia upon the kidneys. A diagnosis
of chronic carbon monoxid poisoning being pronounced, the
patient and his family removed to the suburbs, where he was
advised to remain in the fresh air as much as possible. He was
placed on a tonic treatment with bone-marrow, and commenced
to improve immediately. One month after his removal I
examined his blood and urine and found them to be in a per-
fectly normal condition.
A heavy trip-hammer operating in the neighborhood of his
house had been responsible for the continual leakage of illu-
minating gas in the cellar. The premi-ses had been thoroughly
investigated from time to time, notwithstanding there was still
a leakage due to the heavy, intermittent, jogging vibrations of
the hammer, which jarred the house.
The first case in connection with the use of the modern
ga.s-range was in a negro cook, who was employed in a
large restaurant for 12 to 14 hours a day. I will not repeat
his symptoms as they did not differ from the ones I
have already given.
Carbonyl hemoglobin was easily found and the bottle
containing his blood has stood on my shelves without
losing its characteristic color for nine months.
Four other cases presented the same symptoms, with
the urine containing granular, fatty and hyaline casts.
There seems to be an irritation of the kidney in all
cases. Up to this time I had never witnessed a hemor-
rhagic condition (hemoglobinuria or hematuria) of the
kidney in connection with chronic carbon monoxid
poisoning, although I was sure that such a condition
must sometimes exist, judging from the pathologic
changes which take place in connection with other, what
might be truly termed the specific, blood poisons.
The following ca.se is the first, I believe, to -be
reported, of carbonyl hemoglobinuria following or accom-
panying chronic carbon monoxid poisoning :
Miss S., Irish, aged 58; occupation, a small storekeeper;;
was admitted to the Samaritan Hospital on March 20, 1901.
Family History.— Vather and mother dead at 68 and 63
years, respectively; former died of pulmonary tuberculosis
and the latter of senility. One sister dead, cause unknown, also,
one l)rother, of plumbism. Patient states that her health was
always fair until 10 years ago (she has been keeping this store
for that length of time), when she grew very nervous and was-
easily startled by a trivial occurrence, such as a door opening
suddenly. Noticed at this time that her hands were commenc-
ing to tremble and shake, especially when she wrote. She has
suffered from grip every winter for the last five years ; other-
wise, although she has not felt well, she has not been confined
to bed. She has grown steadily worse, however, for the last-
three months, until a week ago she was sent to this hospital by
a physician who made a diagnosis of beginning typhoid fever.
Physical, examination reveals a marked tremor of the lower
jaw, increased when the patient assumes the recumbent position
and also when her attention is drawn to it. Inspection of the
chest negative, apex beat cannot be localized when the patient-
lies down, but readily appears on palpation when she rises to a
sitting posture. The first sound of the heart is slightly weak-
ened in intensity at the base and aortic cartilage, but the pul-
monary second sound is markedly accentuated. Auscultation-
reveals sibilant rales. pre-sent over the region of the right bron-
chus. She is suffering from a subacute bronchitis with mod-
erate emphysema. Widal typhoid-reaction negative. No
symptoms of typhoid fever present. Patient states that illu-
minating gas has been escaping in her store (a small one) for a
longtime, and that she has endeavored to have the leak repaired,
but always unsuccessfully. She has always been able to detect
the odor of escaping gas until four or five months ago, but has.
not been able to since then, as she thinks that she has grown
accustomed to its presence. It has always been her habit to sit
in the store all day, and especially at night. She has never
taken much outdoor exercise. The store I found to have a
small bulk-window, closed by sliding glass doors ; one door is
always left open at each side. One door opens behind
the counter where she is accustomed to sit and read, and
the other door opens directly opposite the entrance-door of
the store. A gas-bracket directly over her head, inside the
bulk-window, about two feet from her face, leaked, and the
manner in which she became poisoned by the escaping gas is
very interesting. The gas leaked slowly and filled the bulk-
window, not in large quantity, it is true, but sufficient to fill
the enclosed space. When the store door was opened by a cus-
tomer the draught carried the ga.s through the bulk-window,
through the open sliding-door into the patient's face, and she
thus inhaled it. This was repeated every time the entrance-
door was opened. She was thus exposed to larger quantities of
gas than she would have been if her position had been else-
where in the room, but in this instance she was exposed to
nearly all there was in the window. I will leave this for a.
moment to show the condition of her urine and blood on her
admission to the hospital. As it is my invarialjle rule to
examine all specimens of urine spectroscopically, I was quite
surprised on receiving this specimen to observe that it po.s-
sessed an unusually florid or crimson color, reminding me
strongly of blood impregnated with carbon monoxid, the color
also being much brighter in hue than that of urine containing
hematoporphyrin. When placed before the slit of the spectro-
scope it showed two bands (alpha and beta) exactly like oxy-
hemoglobin except that they were a little closer to the violet
than the former. 1 attempted reduction with Stokes' reagent
and ammonium sulfid, but the bands persisted and were
irreducible, in spite of the large quantity of ammonium sulfid
which I purposely added. I next tried putrefaction (which
was really hardly necessary, as the urine was decomposed when
1 received it), but after standing a week no change occurred
either in the original intensity of the bands or their position.
Examination of urine, March 22, 1901 : Color, bright crim-
son ; odor, slightly fetid and faintly ammoniacal ; transparency,
very cloudy with flocculent masses in suspension; .sediment,
heavy, compact and fawn-colored; reaction, neutral or nearly
so; specific gravity (by direct weighing method at 15° C),
1.01873 ; albumin (serum), a fair trace with cold nitric and sali-
cylsulfonic acids ; globulin (serum) and albumoses, a trace. A
characteristic reaction with the latter, clearing on heating and
clouding on cooling, after separating serum albumin and serum
globulin. Dextrose, negative with Fehling's, Boettger's and
the phenylhydrazin tests ; urea, 2.00% ; urobilin band extends
nearly to F (with spectroscope) ; urates and uric acid (ammo-
nium urate), markedly increased; bile, negative; indican,
markedly increased ; chlorids and phosphates, normal ; nucleo-
albumin, normal ; acetone, markedly increased. Microscopic
examination showed granular (broad) and hyaline casts in mir
numbers, triple phosphate crystals and balls of ammonium
urate (with spines) in great quantity. No erythrocytes (after a
careful search), a few leukocytes, many bacteria and much
granular debris. With the spectroscope a layer of the urine
2 cm. thick was used. The specimens have stood since March,
1901, and no change has taken place in the position or appear-
ance of the carbonyl hemoglobin bands.
Attgust 30, 1902]
STRONGYLOIDES 8TERC0PALIS
(AXKRICAN MSDICINB 343
As there is no other substance which would not undergo a
change in this length of time in decomposing urine, except the
above, I think that the presence of carbonyl hemoglobin may
be accepted without doubt, though I have never seen the
slightest reference made to it in medical literature, and from
the evidence, it is undoubtedly true that the nephritis arose
from the intoxication produced by the inhalation of the gas.
Examination of urine, April 13, 1901 : Color, still bright
crimson — a little darker in hue; odor, strongly urinous and
fetid; transparency, markedly turbid and opalescent ; sediment,
flocculogranular and of moderate size; reaction, very acid;
specific gravity (weighing method at 15° C), 1.0155; albumin
(serum), a trace too small to estimate by centrifugal analysis ;
globulin (serum), negative ; albumose,atrace (small); dextrose,
negative (with tests as before) ; urea, 1.75% ; urobilin, normal ;
urates, normal ; bile, negative ; indican, normal ; chlorids
and phosphates, normal ; nucleoalbumin, moderately increased
as is also acetone. Microscopically : Squamous, round and
flattened epithelial cells and leukocytes in fair numbers. A
few erythrocytes and granular debris in slight amount. Many
of the epithelial cells are stained a brownish-red color, and
there are a few masses (amorphous) closely resembling hema-
toidin free in the urine. The casts have disappeared. With
the spectroscope, carbonyl hemoglobin is still seen to be present
in a layer of 6 cm. It answers the same tests as before.
A third specimen of the urine examined a week later still
showed its presence, although it was rapidly disappearing as
the kidneys were regaining their normal function. There has
been no hematoporphyrin or pathologic urobilin present at any
time, or any of the blood pigments, such as acid or alkaline
hematiu, etc.
Examination of blood: Erythrocytes, 4,000,000 ; leukocytes,
5,000; hemoglobin, normal in amount. When the latter is
allowed to putrefy, carbonyl bands persist. A differential
count of 1,000 leukocytes showed the following: Polymorpho-
nuclear, 62.00% ; small lymphocytes, 28.00% ; large lympho-
cytes, 5.00% ; eosinophiles, 4.00% ; myelocytes, 1.00%. The
erythrocytes show slight variation in size and slight poiki-
locytosis ; there is no pallor of the red discs, however,
and they stain well with eosin, and also with orange
G. of the triple stain. Neither her urine nor blood have
had at any time the slightest odor of illuminating gas.
Her temperature rose to 101.4° on the day of admission, prob-
ably due to excitement, as it dropped soon after, and with the
exception of reaching 99° one day, remained normal.
She was discharged from the hospital on April 17, 1901,
feeling perfectly well. The urine at this time was normal,
excent that in a layer 16 cin. thick the bands could still be
faintly perceived, though considerable eye-strain was necessary
to detect them with the chemic spectroscope. The urine was
of the natural amber color at this time. I did not see the
patient again until May of the present year (1902), when I
investigated the production of the toxemia, which I have
described.
Examination of urine. May 10, 1902: Color, slightly pale
amber ; odor, normal ; transparency, clear ; sediment, small
flocculent, white; reaction, acid; specific gravity, 1.01.3; albu-
min (serum) none, with cold nitric acid or more delicate tests;
globulia (serum), negative; dextrose, negative; urea, 1.5%;
urobilin, decreased ; uric acid, normal ; bile, negative ; indican,
markedly in(^reased; chlorids, phosphates, nucleoalbumin and
acetone normal. Microscopic examination showed sediment
scanty by the centrifuge. A few erythroctyes, leukocytes, and
squamous and round epithelial cells. Small round epithelial
cells witii a concentric nucleus. Granular debris in small
amount. No casts.
In a layer 7.5 cm. thick, faint bands of oxyhemoglobin can
be seen. These are easily reduced to hemoglobin (reduced)
with ammonium sulfid. Carbonyl hemoglobin is, therefore,
not present.
The tremor of the jaw is not as marked as it was, and the
patient may be said to be in fair health for her age.
In conclusion, I will reiterate what I stated two
years ago, that chronic carbon mono.xid poisoning
occurs more frequently than is imagined, and is
undoubtedly responsible for many obscure conditions
which occur in the practice of every phy.siclaii and often
remain an unsolved puzzle. The large increase in the
use of gas for cooking purposes will not lessen the evil,
and we should be prepared to make a diagnosis of this
toxic condition as readily as we do of tlie acute form. I
would make an earnest plea for the more extensive use
of the spectroscope in daily clinical work, as skill with
the instrument is easily a(!quired. That chronic poison-
ing by illuminating gas should occur seems inexcusable
to me, if proper precautions are taken to see that gas-
fixtures are impermmble to gas. Servants should be
apprised of the danger of not turning off the valves of
gas-ranges completely.
When we consider the ]jroducts of the analysis of
tobacco-smoke, which are strikingly like those of the de-
composition substances of coal, we are forced to believe
that the quantities inhaled or absorbed must be very
minute, or that the system speedily acquires immunity.
My object in this paper is to draw emphatic attention
to and to illustrate the dangers of the careless use of illu-
minating gas, and to advocate the more extensive use of
the spectroscope in diagnosing obscure affections.
STRONGYLOIDES STERCORALIS, THE CORRECT
NAME OF THE PARASITE OF COCHIN CHINA
DIARRHEA.
BY
CH. WARDELL STILES, Ph.D.,
Zoologist, U. 8. Bureau of Animal Industry,
AND
ALBERT HASSALL, M.R.C.V.S.,
Acting Assistant Zoologist, U. S. Bureau of Animal Industry.
In recent medical and zoologic literature authors
have used the name Strongyloides intestbialis to designate
the parasite associated with Cochin China diarrhea. One
of us also has used this name in a paper now in press
and in other papers, without having tested its validity
according to the code of nomenclature. There are, how-
ever, two reasons why the specific name intestinalis is not
valid, namely :
First. The oldest name given to the species is Anguil-
lula stercoralis. This name was proposed by Bavay,
and the earliest place of publication we have been able
to find is on page 316, Comptes Rendtis de r Acadfynie des
Sciences, Paris, v. 83 (5) for July 31, 1876. The name
AnguiUula intestinalis does not appear to have been pub-
lished until 1877, the first mention of it being on p. 266,
Comptes Bendus de PAcadSmie des Sciences, Paris, v. 84
(6) for February 5, 1877. Thus, according to the law of
priority, the specific name stercoralis undoubtedly has
precedence.
Second. When Bavay used the name AnguiUula
inlestinaUs in 1877, he overlooked the fact that this was
preoccupied, hence not available. Ehrenberg (1838, p.
354), in fact, had already given the name AnguiUula
intestinalis to a parasite which von (Jleichen (1776) found
in the earthworm. Thus by the rule of homonyms, the
specific name iniestiiMlis is not available for this species.
The worm is now placed in the genus Strongyloides by
most authors, and its corrected name is Strotigyloides
stercoralis (Bavay, 1876) Stiles and Hassall, 1902. The
change of name at this date is unfortunate, but can not
be avoided.
Inquiry Regarding French Tiiquors. — About a year ago,
in the course of a Parliamentary discussion upon the law as to
drinks, a Socialist deputy. Dr. Valliant, proposed that the
Academy of Medicine should be requested to make out a list of
alcoholic drinks, such as liqueurs, aperitifs and the like, which
contain essences dangerous to public health, with a view to
interdict the manufacture or sale of such. As the minister
concerned did not accede to this request, the Academy has at
last sent into a Parliament a report on its own account. M. La-
borde has published the report in the name of the commission
appointed by the Academy. The report states that the essences
used are very poisonous. Synthetic essence of anisette con-
tains a quantity of hydrocyanic acid. The inhalation of a little
of this essence from an open bottle containing it causes grave
syncope and a feeling of illness lasting tor several days. Char-
treuse is very poisonous and <!ontains 13 substances, which can
bring about serious effects. Vulnerary contains 15 very poison-
ous substances. The genuine vegetable essences are bad enough,
but these are not used now and the essences are all made with
synthetic flavorings, which are even more poisonous than the
genuine vegetable essences. Gin (genirtvre) contains a poison,
and bitters are also very dangerous. M. Laborde proi)Oses that
the sale of the following should be absolutely forbidden, except
for medicinal use: .\bsinthe and its compounds, bitters, ver-
mouth, noyoau, chartreuse, gin and vulnerary. It is proposed
that the authorities shall forbid the manufacture or sale of these
drinks as containing substances harmful to public health.—
[fyiincet.]
344 A.MBBIOAN MBDiciNit] SCIOLOGIC ASPECTS OF PREVENTIVE MEDICINE
(August 30, lim
SPECIAL ARTICLES
SOME SOCIOLOGIC ASPECTS
MEDICINE.'
OF PREVENTIVE
A. B. COOKE, A.M., M.D.,
of Nashville, Tenn.
Professor of Anatomy and Clinical Professor of Proctology, Medical
Department, Vanderbllt University; Secretary Tennessee
State Medical Hoclety ; Ex-presldent Nashville
Academy of Medicine, etc.
In the olden days the greatness of a century was judged by
Its wars and the results territorial and political which grew out
of them. When the history of the nineteenth century shall be
written its true greatness will prove to consist in the develop-
ment of those ideas and agencies whicli looked to the preserva
tlon of life rather than to its destruction.
In the magnificent progress of medical science during the
past hundred years preventive medicine played a part ever
more conspicuous and commanding. Today it may be truly
said to dominate the profession— in the importance with which
it is regarded, in the universal interest it elicits, and in the
amount of thought and attention devoted to it. Explanation of
this great and growing predominance is to be sought in the
steady growth of the sociologic idea which with thinking
people occupies the central place among the problems of modern
life.
But while preventive medicine is essentially a sociologic
question, it is other and more than a mere problem in eco-
nomics. Little lasting good can result from the study of social
conditions and efforts to ameliorate them unless physical life
and physical health are recognized as the fundamental factors
to be reckoned with. Thus, though sociology embraces pre-
ventive medicine, preventive medicine, properly considered, is
the very foundation of sociology.
With reference to disease, one important difference between
preventive medicine and other departments of sociology should
be noted and emphasized. The sociologist, using the term in
its broad customary sense, warns, expostulates, denounces— in
other words, preaches; the entire medical profession is the liv-
ing, ever active exponent of the gospel of prevention it pro-
claims. Both admit that all measures directed to the uplifting
of humanity and the betterment of society must be based
primarily upon physical conditions. But the sociologist's are
the views and plans, often pathetically impracticable, derived
from a long-distance study of these conditions ; ours from direct
and constant contact with them. How much more effectively
we have labored is shown by the fact that medical and sanitary
science have accomplished in 200 years what the preacher-
theorists did not succeed in doing in more than 2,000 years, i. e.,
doubled the average length of human life.'
The literal truthfulness of the following statement will
«xcuse its personal nature : Medicine is the only vocation the
followers of which are habitually and systematically working
against their own material interests. Consummation of the
ideals for which we strive would mean little less than profes-
sional suicide. This permits of but one interpretation. Let
carpers and critics say what they will, no such striking
example of practical altruism and philanthrophy has ever been
presented in the world's history. There is little probability
that contemplation of this idea will beget a spirit of boastful-
ness or complacency on the part of the profession. It is certain
that its due recognition and not too modest dissemination could
not fail of a salutary influence upon the public whose confi-
dence we must have if our labors in its behalf are to be crowned
with success.
In the contemplation of the great work still ahead, there is
some danger that the achievements of the past may be lost
sight of. Limiting our backward glance to the past 100 years,
we find that the legacies of the nineteenth century to the
twentieth along the line of preventive medicine are at once its
glory and its inspiration. A detailed review of these might
1 Special address delivered before the Nashville Academy of Medi-
cine, Tuesday evening, March 4, 1902.
prove of interest, but a brief allusion to a few of the more con-
spicuous ones will better subserve our purpose.
When in 1775 Edward .Jenner first observed that persons
who had suffered from cowpox were virtually immune to
smallpox, the discovery which has proved one of the greatest
boons of modern civilization had its birth. Previous to that
time smallpox had the entire world for its habitat and its
harvest of deformity and death had for centuries been so fright-
ful tliat it had come to be the most dreaded of all diseases. His-
tory tells us that the population of many European cities was
literally decimated by tliis malady during the latter half of the
eighteenth century and that no race or climate was so fortu-
nate as to escape its ravages. It is stated that when .Tenner per-
formed the first vaccination in 1796 one-tenth of all the deaths of
the human race were being caused by smallpox. One statis-
tician estimated that 60,000,000 of the inhabitants of Europe died
of this disease during the eighteenth century, an average of
600,000 a year, and this is regarded a moderate estimate. When
smallpox was introduced into Mexico by the Spaniards in 1520,
3,500,000 of the natives died of the disease in a few years. In
the year 1757, lOfo of the inhabitants of Greenland died of small-
pox. It is believed that the deaths of fully 6,000,000 North
American Indians are attributable to this cause." And so illus-
trations of the destructiveness of the disease might be multi-
plied.
If any fact connected with medicine has been conclusively
demonstrated it is that vaccination prevents smallpox. That
this loathsome disease is today other than a medical curiosity
is due in part to popular ignorance and prejudice, but chiefly,
perhaps, to the prevalence of social conditions which render
the universal application of the remedy impracticable. When
the enlightenment of the people increases to the extent of
demanding compulsory vaccination as a matter of public policy,
and when governments become as assiduous in its enforcement
as they now are in tax-gathering and census-taking, smallpox
will soon cease to be a reproach to our civilization.
Probably the most noteworthy contribution of the nine-
teenth century to preventive medicine was the discovery of
diphtheria antitoxin. Formerly the scourge of childhood, this
dread disease has been robbed of many of its terrors. The
reduction within a single decade of the mortality of a disease
as widely prevalent as diphtheria, from approximately 40% to
less than lO^fc, represents a saving of life almost incredible.
But this is not the whole story. While impossible to estimate
it in figures, the power of antitoxin as an immunizing agent
has doubtless produced results fully as beneflcent. Foi-raerly
exposure to diphtheria meant infection, and when the disease
had once gained a foothold in a family the number of cases was
often limited only by the number of children. Now, under
the intelligent administration of antitoxin, not only has the
little victim first attacked a better chance for his life by four to
one, but it may reasonably be expected to confine the disease
to the single case.
The thing to be deprecated and condemned in connection
with this great discovery is the commercialism wliich from the
first has invested it. The national government would achieve
glory and confer a great boon upon humanity by undertaking
the manufacture of antitoxin, or at least supervising and regu-
lating it.
Smallpox and diphtheria probably furnish the mo.st con-
oreteexamples of the power and value of preventive medicine,
but they constitute only siiort chapters in a long and glorious
story. Considered from a sociologic standpoint, no one will
question that public sanitation and quarantine were the most
potent factors in the social evolution of the past century.
These are the splendid, though tardy and often grudgingly
extracted, contributions of legislation to the great cause of pre-
ventive medicine. It is not too broad an assertion to say that
sanitation and quarantine have done more in the last 50 years
toward the realization of the true ends for which government
exists, viz., the protection of life and the promotion of the com-
fort and welfare of the people, than all other l^islation combined
in the same length of time.
Two of the most malignant and devastating diseases which
ever prevailed in this country were epidemic — cholera and yel-
low fever. Yet it is more than probable that there are a num-
August 30, 1902]
SCIOLOGIC ASPECTS OF PREVENTIVE MEDICINE iamekicajj memchjb 345
ber of physicians who never saw a case of either. The older
members of the profession will recall the gloom and terror,
often amounting to actual panic, produced V>y the announce-
ment of a first case of cholera in their community, and the
desolation which speedily followed in its wake. In 1873 we
are told that the average rate of mortality from this disease in
Nashville, then a city of a little over 25,000 population, was
in the neighborhood of 60 a day for a considerable period. On
June 20, " Black Friday V as it was called, tlie deaths reached
the enormous .number of 117. At the time of this epidemic
there was no law providing for the registration of deaths ; but
from the most authentic sources available, the total number is
learned to have been between 1,200 and 1,500, fully nine-tenths
of which occurred in the three weeks from June 7 to July 1.
This was an appalling mortality when we interpret it as mean-
ing that 5% of the entire population of the city died from one
disease in less than a month. Since that time, now nearly 30
years, it is doubtful if a single case of genuine Asiatic cholera
has been seen in Nashville. And what is true of this city is
true, in a general sense, of the entire country. The promise is
that our brethren of coming generations will be interested in
the disease only because of the prominence accorded it in the
history which some of us have helped to make.
Yellow fever was another terribly fatal guest by which our
country was visited at intervals during the first three-quarters
of the past century. The early visitations were confined to cer-
tain northern cities, notably Philadelphia and Baltimore. In
1853 the disease first gained a foothold in the South, 8,000 people
dying of it in that year in New Orleans alone. The epidemic
of 1878 and 1879, in which our sister city, Memphis, suffered so
cruelly, is still fresh in the memory of most of us. The story
of this epidemic is one of the most harrowing in all the history
of disease. The epidemic of 1878 covered a period of about
three months— from August 8 to November 10. Practically no
records were kept, and the following figures, while based on
the most reliable data available, do not purport to be strictly
exact. The population of Memphis at this time was estimated
to be about 50,000, and fully one-half of these are thought to
have fled from the city in the first weeks of the epidemic. This
left about 25,000 for the disease to prey upon and it is estimated
that from 70% to 90% were attacked. Taking 80% as approx-
imately the true proportion, there occurred not far from 20,000
cases— more than 5,000, or 25%, of which were fatal. This was a
mortality for the entire population in excess of 10% in three
months.
In spite of this awful mortality, out of the suffering and
death of probably the most disastrous epidemic which ever
visited an American city, Memphis emerged purified and
regenerated, and today points to her splendid system of sewer-
age, clean streets and sanitary laws, and proudly boasts that
there is not a nore hygienic city in the Union, nor one freer
from pestilence.
Since 1879, while there have been a few cases reported from
time to time in different sections, yellow fever has gradually
been disappearing from the country. In future we may hope
that what quarantine fails to do for our protection from this
disease will be accomplished l)y the growing recognition of the
life-saving value of public sanitation and its more systematic
and rigid application to towns and villages, as well as cities.
Thanks to tlie labors of our colleagues in the laboratories,
the secrets of many other infectious processes have been dis-
covered and our efforts in combating them have been rendered
a hundredfold more effective. Noteworthy among these are
typhoid and malarial fevers, tetanus, erysipelas, ophthalmia
neonatorum, meningitis, puerperal septicemia, tuberculosis,
etc.
If it were possible to sum up in figures the saving in life
and money which has resulted from preventive medicine in the
last generation alone, the total would be beyond tlie power of
mind to grasp. Yet, properly speaking, all that has been done
was merely preliminary and preparatory. The nineteenth cen-
tury was chiefly concerned with disease as it attected the indi-
vidual, and marvelous progress along all lines was made in its
treatment and cure. The problem of the twentieth century is
disease in its relation to society, and tlie development of meas-
ures looking to the prevention of the one and the protection of
the other. This is preeminently the age of preventive medi-
cine.
Recognizing the number and complexity of the problems
relative to preventive medicine, we will take but a superficial
glance at a few of the more important, with reference particu-
larly to their sociologic bearings and the imperative nature of
our duty concerning them :
1. Tuberculosis. — It is a true and familiar statement that
one person out of every ten dies of tuberculosis ; this means
that out of the 76,000,000 people in the United States, if the past
ratio is maintained, 7,600,000 will die of tuberculosis. It is esti-
mated tliat approximately one person in every sixty has the
disease at any given time, which would give a total in round
numbers of 1,267,000 cases in this country today. In the United
States 1,039,094 deaths from all causes occurred during the last
census year, and of this number 111,059, or a little more than
10.5%, was due to pulmonary tuberculosis alone. Bringing the
issue nearer home, according to the official report there were
1,642 deaths in Nashville in the year 1901. Of this number 227,
or 14%, were due to tuberculosis.
Further study of statistics reveals the fact that approxi-
mately 90% of all deaths from this disease occur between the
ages of 15 and 60; in other words, at the time of life at which
tlie victims should be of the greatest value to society. To re-
duce the resultant loss to a money basis a more or less arbi-
trary valuation of life must be assumed and a definite standard
of wage-earning capacity. To be conservative let us fix these
at $1,000 and ?300 per annum respectively. The average dura-
tion of nonproductive illness for every fatal case of pulmonary
tuberculosis is probably not far from two years, and during
this time each one of the afflicted either spends or is the object
of special expenditure by his family, city, or State to the
amount of at least $200 per annum. Now we have seen that, in
round numbers, 111,000 people died of the disease in the United
States in the last census year. Applying the above estimates of
the resultant loss, we find the cost to the country of the fatali-
ties for a single year to be as follows :
100,000 lives (90'; of 111,000) at $1,000 »100,000,000
Loss of wages 50,000 males (6(V,< of 100,000) two years at SiOO .... 30,000,00»
Incidental expenses (111,000 cases) at 8200 '22,200,000
Cost of 111,000 burials at 850 5,500,000
Total cost of the fatal cases for one year 8157,700,000
But enormous though these figures are there is another and
even greater source of economic loss. It has been stated herein
that 1,267,000 persons are estimated to be suffering from pul-
monary tuberculosis at any given time. Furthermore, since
90% of the deaths occur between the ages of 15 and 60, it is
reasonable to infer that the same proportion of cases occur
between these ages, or in other words during the productive life-
of the victims, and that this 90% are unable to work more than
one-half the time. Reducing these items to dollars, we have;
Amount annually expended by (or for) 1,267,000 consump-
tives In consequence of their disease, at 8200 $25.'!.400,000
Loss In wage-earning 171,045,000
Total cost exclusive of fatal ca»es for one year $424,445,000-
Adding to this the yearly loss due to the fatal cases we have a
grand total of $682,145,000 as a rough, but conservative, estimate
of the cost of tuberculosis in the United States alone for a sin-
gle year. If a like basis of calculation were available for the
whole world these figures would be multiplied many hundreds,,
probably thousands, of times.
This almost inconceivable sum, nearly $600,000,000, repre-
sents only the money tribute which the white plague is regu-
larly exacting of society. Yet it constitutes only a small
portion of the total cost. Human sorrow and suffering can not
be reckoned in dollars and cents, but they are infinitely more
to be considered. No victim of tuberculosis ever bears his
affliction alone, none ever dies but some are left to mourn. Sen-
timent no less than economics is concerned in the question.
In view of the facts presented it is easy to understand the
prominence which tuberculosis has come to assume among the
great problems of preventive medicine. It is gratifying to
know tliat something has been done toward its solution ; but
the factors involved are so many and varied that progress is
necessarily slow and the task at times seems all but hopeless.
Tuberculosis will probably never be wholly eradicated. Ifi
346 A.HKBIOAN MRBiciNE] SOCIOLOGIC ASPECTS OF PREVENTIVE MEDICINE
(August 80, 1902
such a state is even approximated, it can only be through the
systematic and loffical employment of civilization's two greatest
agencies, education and legislation. Ijegislation to bo effective
must reflect the intelligent will of the people, and such basis
can only be attained through widespread information upon the
subject legislated about. We have then as the first requisite,
education of the masses as to the nature and dangers of the dis-
ease, and by this means the creation of a public sentiment
which will not only endorse but demand all the protection
which legal enactment can give. It is in the nature of things
that the medical profession must of necessity bear the burden
of the fight. But it sliould not be expected to bear it alone, nor
made to bear it in the face of opposition often apparently little
less malicious than ignorant.
The most difficult as well as important step in the desired
direction has already been taken in the widespread dissemina-
tion of the knowledge that tuberculosis is a communicable dis-
ease, and at the same time that it is as fully amenable to pre-
ventive measures as any other form of infection. Today the
intelligent of every community are more or less familiar with
tliese ideas and their attitude upon the subject is both receptive
and expectant. With these notable points gained, is not the
time ripe for the enactment of more efficient legislation than is
represented in the notoriously inadequate compulsory notifica-
tion and "antispit" ordinances? I would not appear as an
advocate of extreme measures, but in view of the fact now
recognized universally that every tuberculous subject is a
menace to the entire community, I believe that the occasion is
sufficiently urgent both to justify and to demand the enactment
of laws. State, and if need be, national, the chief aim of which
shall be the prevention of the disease rather than its control.
Experience has abundantly proved that to depend on local
measures is to waste time and court defeat. We cannot hope
for success unless we arm ourselves with weapons commensu-
rate with the power and prowess of the enemy.
The three following suggestions along the line indicated
seem worthy of consideration :
First, legal regulation of the marriage of consuroptives.
The question of the transmlssibility of tuberculosis opened up
by this suggestion cannot here be argued. It is sufficient to
say that whether the phenomenon be termed predisposition or
true hereditary transmission, the number of cases developing
among the offspring of tuberculous parents is so disproportion-
ately large that a positive etiologic relation cannot be denied.
This idea of the regulation and restriction of marriage is
by no means new. One of the specific recommendations of the
Sociologic Committee of the Tri-State Medical Society of Ala-
bama, Georgia and Tennessee, in its last annual report, covered
this point, a sworn statement of freedom from pulmonary
tuberculosis, or a thorough medical examination, being advised
as one of the compulsory requisites to the issuance of a mar-
riage license. Recently the Bohemian Society of Physicians of
Austria succeeded in getting a bill introduced into the Reichstag
which provided for a similar certificate, and the legislatures of
several of our own States have from time to time been brought
face to face with the same issue. If we will lay aside senti-
ment and consider the question from a practical standpoint but
one conclusion is possible: Marriage is a civil contract insti-
tuted to promote and protect the social interests of the State.
The marriage of consumptives propagates disease and increases
the burden of society. Therefore the state has no moral right
to license such marriages.
In answer to the argument that such restrictive legislation
would "interfere with the sacred rights of personal liberty," it
may be truly said that this country is suff'ering from the effects
of too much "personal liberty" as it is. The rights of the
individual are only sacred when they do not conflict with the
rights of the masses. This principle is the inspiration and pur-
pose of all law, the very foundation of the social fabric. The
rights of the individual are great, but the rights of society are
greater.
If the opponents of this suggestion desire precedent for the
legislation advocated several notable instances may be cited.
Leprosy is a disease which is under a universal ban in civilized
countries. Immediately upon the development of a case the
unfortunate victim, without his wishes being at all consulted.
is rushed off to an isolation hospital, and soon, as a life member of
the nearest leper colony, loses both his personal liberty and his
personal identity. The same is true of the mentally alienated.
In this case the patient does not voluntarily commit himself to
asylum or sanatorium ; but the law steps in and the individual
during the continuance of his affliction is deprived of every
right, including marriage, the exercise of which would jeopar-
dize the interests of the state at large.
It is not contended that we can make health by law any
more than we can make saints by law. But, given a whole-
some, popular sentiment which will recognize the wisdom and
demand the enforcement of the necessary legislation, and much
can he done in the interest of future generations.
Second, the establishment by the state of special hospitals
for tuberculosis and the enactment of laws making it manda-
tory for all patients whose means are insufficient to ensure the
proper hygienic and sanitary precautions at home to be removed
to these institutions for care and treatment. It may be objected
to this suggestion that it would mean " class legislation." But
surely not more so than many statutes now in operation, as, for
instance, those exempting church property from taxation, the
protective tariff laws, etc. The welfare and protection of the
community are regarded as sufficient justification for these
laws ; and so it should be with reference to the one proposed.
For the classes concerned it would be humane and beneficent,
for society in general salutary in the highest degree. Even
granting that it were class legislation in its most obnoxious
sense, it may still be insisted that classes no less than individ-
uals may well be required to sacrifice any prerogatives which
operate to the detriment of the commonwealth.
Third, more rigid laws with respect to the sanitation of
tenement houses, factories and sweat-shops. This suggestion
has more especial reference to the larger centers where the evils
mentioned flourish widely ; but with respect to at least one of
them its application is practically universal. The dangers of
the sweat-shop are among the most serious and insidious which
menace public health. The majority of these abominations are
located in the basements and cellars of tenements, where pure
air and sunshine never penetrate and where the miserable
toilers are huddled together in utter disregard of the first prin-
ciples of sanitation. Here are found veritable hotbeds of dis-
ease. Among these people familiarity with disease has bred
contempt, and tuberculosis and other infectious maladies pre-
vail the year through as normal features of the surroundings.
Even under the most hygienic conditions the contact between
the garment and the maker is Intimate enough. How much
more so in the average sweat-shop, where we are told the cloth-
ing is often used for bedding at night and by day is exposed to
contamination from sputum and other forms of disease-carry-
ing agents. Only a few weeks ago I read an article entitled
" New Wearing Apparel and Hygiene," ' in which the signifi-
cant fact was set forth and emphasized by case reports that
such apparel may be the medium of conveyance of various
contagious skin affections. If this is true, and there seems no
reason to question it, may not many of the graver forms of dis-
ease be conveyed in the same way? Except in a few States this
important question has received little .serious consideration.
Most of the States have socalled factory inspectors, but their
duties do not embrace the needs here referred to, and if they
did, the office-holders, as a rule, are utterly incompetent to per-
form them.
In New York City it is estimated that there are fully 35,000
people suffering with pulmonary tuberculosis at any one time,
and of this number more than 7091 live in the tenement-house
districts. The Fourth ward, one of the most offensive from a
sociologic standpoint in the entire city, presents a striking
example of the relation between social conditions and the dis-
ease. This ward is situated well down on the east side in the
heart of the tenement-house sweat-shop district. According to
the official report of the health office the average mortality of
this ward from tuberculosis for the three years, 1897, 1898 and
1899, was 5ft') per 100,000.^ There are annually about 9,000 deaths
from this cause in New York. If the rate for the Fourth ward
prevailed throughout the city this number would be increased
to more than 20,000.
What is true of New York is true to greater or less extent of
AUGUST 30, 1902]
SCIOLOGIC ASPECTS OF PEEVENTIVE MEDICINE tamerican mkdicinb; 347
«very other city. Whether it is admitted that the love of money
is the root of all evil or not, it is certainly the root of this evil.
And the sacrifice of human life resulting, all the more appalling
because so needless, constitutes one of the darljest blots upon
our boasted civilization.
2. Vene7-eal Diseases.— 'So reliable statistics on this subject
are available. In spite of the wellknown ravages of these dis-
«ases in all countries, among all races, classes and ages, judging
by the records, or rather absence of records, they seem to be
tabooed as completely by the health authorities as they are by
society in general. For instance, according to the last census
bulletin of vital statistics there were only 1,591 deaths from
venereal diseases during the census year in the entire country,
152 of which out of a total mortality of 70,229 occurred in New
Yorl< City, 63 out of 30,572 in the State of Tennessee, and the sur-
prising number of 1 in the city of Nashville. No sane man who
is at all conversant with the facts will for a moment credit the
accuracy of such figures. On the contrary, they serve merely to
emphasize the inadequacy of statistics, or perhaps the stupidity
of statisticians.
In the report of the Committee of Seven on the Prophylaxis
of "Venereal Diseases, made to the New York County Medical
Society in 1901,^ it was estimated that the number of cases of
venereal diseases treated in New York City during that year was
in excess of 225,000, or in the ratio of about one to sixteen of
population. This estimate, astounding thougli it may seem,
represents the deliberate conclusion of experts specially
appointed to study the subject and whose entire report is
characterized by a spirit of rare conservatism. With reference
to the mortality due to these diseases the following passage
from the report may be quoted :
Now as regards the mortality from venereal diseases, a
matter which properly comes within the scope of the commit-
tee's inquiry, the vital statistics record 177 deaths from syphilis
(for the year 1900). The Board of Health readily admits that
this number affords no correct indication of the mortality from
this disease. From a regard for the feelings of relatives and an
indisposition to brand the patient's memory with the stigma of
a compromising disease, deaths from syphilis are concealed
under a variety of causes— in the adult scrofula, compression of
the brain and other innocent titles ; in children, marasmus,
infantile debility, convulsions, etc. In but a fraction of the
cases is the real disease mentioned. But if we consult the
mortuary records we shall find that syphilis is buried under a
variety of names. In many of the 1,179 cases of premature
births ; in 2,136 deaths recorded as due to marasmus ; in the 28
deaths from hydroceplialus, etc., syphilis was doubtless a
causal factt)r. In many of the 5,590 deaths from diseases of the
nervous system, such as 50 deaths from locomotor ataxia, 341
from general paresis, 875 from softening of the brain, 232 from
hemiplegia, 96 from paraplegia, 83 from aneurysm, and in dis-
eases of other important organs, syphilis doubtless entered as an
etiologic factor. The records of the Randall's Island Nursery
Hospital show that 8% of the deaths from all causes in that
institution are due to hereditary syphilis.
(jonorrhea is not mentioned as a cause of death, but we
find in the group of " urinary diseases" and in diseases of the
"organs of generation" a large number of deaths in some of
which gonorrhea might well be considered as the remote
cause.
While it is doubtless true that syphilis and gonorrhea pre-
vail more widely in New York and other large cities than else-
where, they are encountered so frequently in every portion of
tlie land as not to occasion remark. Out of the 30,000 deaths
charged up to Tennessee for the last census year, it is probable
that 1,06-J represents the real number diie to venereal diseases far
more accurately than the ridiculous 63 recorded.
In a paper read before the American Medical Association in
1874" Dr. S. D. Gross estimated that more than 5% of tlie entire
population of the United States were infected with syphilis,
and similar oliservations have since been made repeatedly by
other eminent authorities. The statement often glibly made in
discussion of this question that " there are 5,000,IR)0 syphilitics
in this country today " is much more nearly correct than is
usually credited.
In other countries syphilis prevails as widely and with
effects as deadly as in this — in many even more so. Tlie story
of this disease constitutes one of the remarkable chapters of
medical history. Except in the relatively few (^ases of heredi-
tary origin, syphilis is practically always transmitted by direct
contact between individuals, and the fact that within a period
of 400 years it has compassed the entire world in its malevolent
embrace is a sad reflection upon the morality of the human race.
With respect to the prevalence of gonorrhea it is probably
within the bounds of the strictest truth to say that fully 75% of
all men who reach the age of 30 years contract the disease. Nor
is it the harmless malady it is popularly supposed to be. On the
contrary, many authorities are teaching that gonorrhea and its
complications and sequels are responsible for a larger mortality
than syphilis. The difference is that the dangers and fatalities
of the latter disease have long been recognized if not recorded ;
those of gonorrhea are only now coming to be appreciated.
Particularly in the work of the gynecologists do the disastrous
effects of gonorrhea become apparent. "In reply to the ques-
tion asked by letter of the most prominent American and foreign
gynecologists as to the percentage of pelvic inflammations
attributable to gonococcal infection . . . the reports of 24
prominent workers indicated no less than 41% of such disorders
as distinctly secondary to supposedly cured male gonorrhea.
As to the extent to which sterility is due to gonococcal infection
the estimated percentage by the same workers is 42%." "
In view of these frightful facts and figures it is utterly
absurd for us to shut our eyes to the truth that syphilis and
gonorrhea are well at the head of the list of the most widespread
and deadly of all human affections. The most conspicuous fact
in connection with this truth is that they are wholly and abso-
lutely preventable. Chastity is the only prophylaxis required.
If this virtue were practised consistently even for one genera-
tion the last vestige of these diseases would vanish from the
earth. But of course no such Utopian idea is urged as a practical
measure, not because it is an impossible one, but because in the
present unhappy condition of society its realization is hopeless.
Prohibition has long been tried. On the statute books of every
State in the Union there are unmistakable laws against fornica-
tion and adultery ; yet these evils are winked at, in many in-
stances even utilized for personal gain, by the very officials
whose sworn duty it is to suppress them.
As in the case of tuberculosis, the preventive measures
which must be relied upon to combat venereal diseases are
education and legislation. And here again they are named in
their proper sequence. That the public is not yet prepared for
prohibitive legislation on the subject has already been pointed
out, and that such legislation must remain entirely futile until
demanded by the masses instead of by the few is self-apparent.
Until the dawning of that brighter day when education shall
have done its perfect work, we can hope for nothing more from
legislation than in some measure to restrict the spread of these
diseases, not to prevent tiiem. Undoubtedly much can be done
to this end by the enforcement of proper legal measures directed
to the regulatioi;! of prostitution, sucli as registration, segrega-
tion, sanitary inspection, etc.
But our chief hope for the solution of this great and press-
ing problem centers in education. To be effective this must be
universal and should begin with the medical profession itself
and include the health authorities as well as the general public.
First of all the profession must be made to realize the true
nature of these diseases and to look upon them with greater
seriousness. Even today the ideas prevail to greater or loss
extent among physicians that gonorrhea is of no graver import
than an acute coryza and that it is unnecessary if not impossible
to differentiate between the " hard " and "soft" chancres. The
disastrous consequences of such ideas need no comment. But the
treatment of the individual cases involves only a small part of
the duty and responsibility of the profession. Quoting again
from the report of the Committee of Seven : " The importance
of deciding intelligently upon the conditions of admissibility
to marriage of venereal patients can not be overestimated. The
dangers introduced into the family life V)y the premature mar-
riage of a syphilitic man, or of a man suffering from a latent
urethritis, to which the sanction of the physician may have
been given, involve a heavy responsibility upon the medical
profession. Dr. T. Gaillard- Thomas says: 'A marital quaran-
tine is as necessary today in social life as a national quarantine
is for contagious diseases in general.' "
In the second place, the health authorities must be im-
pressed with the importance of their obligations to the public
with reference to these diseases. The need is not so much for
318 AMEHI0A3. MEDICINE SOCIOLOGIC ASPECTS OF PREVENTIVE MEDICINE
[AUOCST 30, 1902-
more leffislation as for the proper utilization of that already in
existence. The boards of health of every city and State are
clothed with ample power, in the absence of specific legislation,
to atlopt any regulations and institute any measures demanded
by the public health. Yet, strange to say, as matters now
stand, venereal diseases are not even officially recognized,
though probably far more dangerous to the public welfare than
scarlatina, smallpox and diphtheria combined. Because it can
not hope to annihilate the causes of contagious diseases, sani-
tary science does not relax its efforts to prevent their spread.
Nor is it logical or excusable because boards of health can
not eradicate the social evil, that they should ignore the dis-
eases growing out of it and resign themselves to an attitude of
hopeless impotency concerning them.
But the greatest hope and promise as to the prophylaxis of
venereal diseases lie in the education of the people. For the
creation of the sentiment which will demand this, an enlight-
ened and conscientious profession must be the chief depend-
ence. But the work itself must be largely done by parents and
others to whom is committed the most sacred of all human
charges— the care and training of children. From my point of
view ignorance'is the most potent factor in the spread of these
diseases, and in every instance of such ignorance somebody is
morally (culpable. The fundamental error, apparently, is the
pernicious falsejmodesty which is inculcated from the earliest
Infancy concerning the body and its functions. These are not
things to be ashamed of. Yet even in our most enlightened
homes boys and girls are growing up in utter ignorance of
knowledge which would conduce both to their safety and happi-
ness. Vice and suffering are the inevitable harvest. A child
can not be expected to control what it does not understand.
Perhaps the most available aid in the direct prophylaxis of
venereal diseases is the promotion of masculine chastity. The
Committee of Seven in the report before quoted very aptly
says " prostitution is largely a matter of supply and demand."
The problem, then, is to minimize the demand. The
feasibility of this will depend upon the point of view. Those
who hold and teach that continence in the male is a physical
impossibility will, of course, ridicule the idea; but their con-
tention is obviously founded upon a misinterpretation of
nature's laws. That continence is both possible and compati-
ble with perfect health is constantly being demonstrated by the
males of many species of animals, and the laws of nature's God
upon the subject are so plain that they can not be misunder-
stood. The real issue here is the question of habit formation.
It is not contended tliat the average man has the power of will
to resist a habit which he has for years been cultivating assidu-
ously. But surely it is possible for a rational human being not
to form a habit. This is the practical point I would impress-
that young men should be taught, helped, encouraged, not to
form the habit of unchastity. To this end much could be
accomplished by acquainting them with the dangers of promis-
cuous intercourse. Every young man should be made to real-
ize that a venereal disease once contracted may not only blight
his own life irremediably, but constitute a direful legacy to
the confiding and innocent ones with whom he hopes some day
to round out and crown his manhood.
Specific recommendations directed to the prophylaxis of
venereal diseases have not been indulged in for the reason
that they present themselves in too great numbers. Before
leaving the subject, however, I desire to mention without dis-
cussion two evils which are so insidious in their influence as to
demand recognition and suppression :
(a) Obscene and demoralizing publications of every kind,
especially certain illustrated periodicals.
(6) Advertising of patent specifics either by publication or
by posting in water-closets and other public places.
Vice Is a monster of so frightful mien
As to be bated needs but to be seen ;
Yet seen too oft, familiar with her face,
We first endure, then pity, then embrace.
3. Alcoholum.—Ferha,ps the fact of greatest significance in
connection with this subject is that alcoholism is now univer-
sally regarded as a disease rather than as a crime. And statis-
tics are not lacking to prove that it is one of the most deadly in
its effects of any that curse humanity. In its sociologic bear-
ings inebriety is a more important problem than either tuber-
culosis or venereal diseases, in that in some sense it may rightly
be considered to occupy a causal relation with reference to ijoth
these evils. These only begin the enumeration of the social
burdens for which it is responsible. Leaving out of considera-
tion the question of crime, it is recognized as tlie chief and
never-failing source of supply for almshouses, hospitals for
the insane, and other eleemosynary institutions.
According to the vital statistics bulletin of the last census
the total number of deaths due to alcoholism for the census year
was 2,811. But we all know that only such deaths as are
directly and unmistakably attributable to this cause are so
reported. If it were possible to determine the number of deaths
otherwise recorded, which were in reality due to this evil, the
result would be far different. Thus : .
117,579 appear as due to diseases of the nervous system,
75,791 " " " " ' " '• circulatory system,
60,229 " " " " " " " digestive system.
44,941 " ■' " " " " '■ urinary system (exclusive of ve-
nereal diseases),
57,513 to accidents, suicides, homicides, etc., and
40,539 to unknown causes, a total of nearly 400,000.
As in the case of venereal diseases, we know that many of
these deaths were due primarily, even if remotely, to indul-
gence in alcoholic drinks. Any estimate of this proportion
would necessarily be conjectural. But if no larger than 259fc,.
without considering the many other diseases not included in
these groups in which alcohol plays a causal role, we would
have an annual deathrate chargeable to this vice of nearly
100,000.
In the suppression of this stupendous evil lies one of the
greatest and most urgent problems of preventive medicine.
The attitude of the medical profession upon the use of alcohol
has long been one of endorsement, or at least tolerance. But
happily this is changing. With the firmer establishment of the
truth that alcohol in any quantity is a poison to the human sys-
tem has come a keener realization of the duty we owe the public
whose dependence we are and must continue to be for correct
teaching and safe guidance in all such matters. This duty
devolves upon us both as physicians and as citizens, though it
is unquestionably in the former capacity that our influence will
be most felt.
In conclusion I merely mention two practical aspects of the
physician's duty concerning this subject :
1. Greater circumspection in the recommending and pro-
scribing of alcoholics.
2. A more aggressive attitude toward the advertisement and
sale of that large class of patent medicines which owe their
effects chiefly, if not entirely, to the alcohol they contain. The
consumption of this stuff is simply enormous, and the worst
feature about it is that, indiscriminately introduced into the
home, tliese pernicious agents come to be regarded as household
specifics, and the women and children become their victims.
Many of the widely-advertised concoctions are doubtless often
responsible for the production of the very diseases they are
exploited to cure.
Such are some of the great problems which preventive
medicine presents in this morning of the twentieth century.
What the results miglit be under ideal conditions we can
readily imagine ; what they are likely to be under the very real
conditions which must be faced we dare not venture to
prophesy. But this much at least is true, that the outlook is
hopeful. A secure foundation has already been laid and the
future is pregnant with possibility and with promise. As physi-
cians we appreciate what preventive medicine can do for
humanity ; as citizens let us strive to bring about the conditions
necessary to this great end. The physician-citizen and a disease-
free world, these are companion ideals which our profession
can well afford to cherish.
BIBLIOGRAPHY.
1 Gould : American Medicine, August SI, 1901, p 323.
2 Crandall : American Medicine, December 7, 1901, p. 895.
3 Heidingsfeld : Cincinnati Lancet-tMinic, February 1, 1902, p. 114.
< Fishberg : American Afedicine, November 2, 1901, p. 095.
'- Medical News. December 21, 19(1, p. 961.
""Syphilis in Relation to Public Health." (Quoted by Gould).
' Gould : American Medicine, August SI, 1901, p. 325.
AUGUST 30, 1902]
THE WORLD'S LATEST LITERATURE
(Ambbioan Mkoicine 349
THE WORLD'S LATEST LITERATURE
Journal of the American Medical Association.
August 2S, 190t. [Vol. xxxix. No. 8.]
1. Neuralgia of the Bladder. G. Frank Lydston.
2. A Plea for the Early and Correct Diagnosis of Ectopic Pi-egnancy.
Hbnry D. Ingbaham.
3. Cesarean .Section Made Necessary by Vent roll .\atlon. \Vm. M.
FiSDLEY.
J. Vasrinal Section for the Relief of the Uncomplicated Symptoni of
.Sterility. Is it iustiflable to Enter the Peritoneal Cavity Under
the Circumstances? J. Riddt.k Goffe.
•i. 'i'he Intluence of Prolapse of the Kidney on the Production of Dis-
ease of the Female Pelvic Organs Augustin H. Qoblkt.
«. .\n Operation for Establishing a Culdesac for the Wearing of an
Artificial Eye. Report of Cases. JOHN E. Weeks.
7. The Relative Indications for Enucleation and the Mules Operation.
N. J. Hepburn.
8. Description of a New Anopheles. C. S. Ludlow.
C. Six Years In a Dermatologlc Clinic A Report of Service, with Re-
marks on the Treatment of the More Common .Skin Diseases. E.
A. FiSCHKIN.
1.— Neuralgia of the Bladder.— Lydston states that the
term neuralgia of th« bladder is logical in its application only
where the pain is disproportionate to the extent of the lesion to
which it is secondary. Picard's classification of cystalgia,
with a few additions, is considered an excellent one. Lydston
is very skeptical regarding the influence of cold, per se, in the
etiology of vesical neuralgia. In the treatment care should be
taken not to treat too radically lesions of the urinary way,
which are mild as compared with the neuralgic manifestations.
Narcotics are useful for the relief of pain, as are hot hypogas-
tric applications, hot sitz baths, belladonna, and stramonium.
General treatment is by far the most important, [a.q.e.]
2, 3, 4, 5, 6. ".—See AmeHcan Medicine, Vol. Ill, No. 25,
pp. 1044, 1051.
S. — A New Anopheles.— Ludlow describes minutely a
mosquito which has been named Anopheles philippinensis
(Ludlow). It was discovered during the classification of the
mosquitos of the Philippine Islands lately begun under the
auspices of the Medical Department, U.S. Army. No patho-
logic work has l.)een done to determine if the Plasmodium
develops in this mosquito, [a.o.e.]
9.— Six Years in a Dermatologic Clinic. — Fischkin gives
an analysis of the dermatologlc cases treated in the years 1896-
1901 at the United Hebrews Charities Free Dispensary of Chi-
cagf). In all, 2,5:^5 cases are tabulated. The percentage of
syphilis was only 0.9'/c as compared with 11.8% in the returns
of the American Dermatologlc Association. The age of these
persons causes reflection. Among the 21 cases of acquired
.syphilis there was one boy of 8 and two girls of 11 and 14,
respectively. Only one case was over 40. The paper discusses
the treatment of eczema, psoriasis, lichen, syphiloderma, im-
pctigo, and the dermatomycoses. [a.o.e.]
Boston Medical and Surgical Journal.
August 21, 190t. [Vol. CXLVII, No. 8.]
1. The Preparation of .\nlmal Vaccine. Theobald Smith.
■>. Vaccination : The Technlc. KuoENK A. Darling.
;. Vaccinations: Accidents and Untoward Effects. John H. Mc-
COLLOM.
I. Smallpox : Its Diagnosis. John T. Bullabd.
1.— Preparation of Animal Vaccine. — Smith speaks of
the various methods of preparing vaccine, stating that it is of
interest to ni>te that vaccine dispensed by different institutes is
not derived from one and the same stock. There are three
sources: (1) The virus descended from spontaneous cowpox
and contiimod through an indefinite series of animals — the
true animal vaccnne; (2) virus olitained from animals which
have been inoculated with lymph from human vaccine pustules,
either directly or indirectly tlirough a scries of calves. This is
known as retrovaccine; (3) vaccine obtained by passing
smallpox virus through the cow — the socalled variola vaccine.
It would pr<)t)ably be impossible for many vaccine plants to
trace the genealogy of their current stock back to its begin-
nings. In Germany the use of lympli from the arms of chil-
dren (retrovaccine) has been a favorite mode of rejuvenating
impaire<l animal virus. The («>ntrovcrsy between those favor-
ing glycerinized pulp and those advocating lynipli dried on
jMiints, Smith considers unnecessary, as botli contain the
microbe of vaccinia. The vaccinal pulp, however, is probably
much richer in specific virus than the dried lymph ; the virus
is less tenacious of life when dried, and the elimination of
extraneous bacteria is more rapidly accomplished by the
glycerin product. These facts in general speak in favor of the
latter. Assumptions that pyogenic bacteria of animal life
readily produce disease in man should be cautiously made,
but no pains should be spared in removing organisms when-
ever this can be done without impairing the virus. As to
tetanus following vaccination, the condition is so rare— practi-
cally unknown in Germany, the most thoroughly vaccinated
nation— that careful investigations will be necessary to deter-
mine to what extent, if at all, tetanus spores may germinate and
multiply in the vaccinal eruptions of the cow. For safeguard-
ing vaccine, its preparation by the State would give very great
advantages. Publicity in improvements, as well as failures,
would also tend to this result. There is a dearth of scientific
publications upon vaccine in this country which contrasts very
unfavorably with the work done in Europe, [a.o.k.]
2.— Technlc of Vaccination. — Darling considers the
lymph, the condition of the patient, the operation and the after-
treatment. The best age for the primary vaccination of children
is 3 to 6 months. Compulsory revaccination, say at 12, as prac-
tised in Germany, is to be commended. Antiseptics are not
required in preparing the site of the operation. A shieldshould
invariably be removed alter a few hours, as they are always to
be condemned as permanent dressings, [a.o.k.]
3.— Accidents of Vaccination.— McCollom gives statistics
obtained from 1,859 members of the Massachusetts Medical
Society, aggregating 2,525,083 vaccinations. In 2,516,684 cases
there were no injurious results ; in 68 instances there were
moderately severe results ; in 54 cases extremely severe effects
were noted, and there were 35 deaths. Of tliese 35 deaths 11
were attributed to tetanu-i. [a.o.e.]
Medical Record.
[August SS, 190f. Vol. 62, No. 8.]
1. When and Why Does Ijibor Begin ? George P. Shears.
2. Some Varieties of Surgical Tuberculosis, with Special Reference to
a New Method of Treatment. L. F. Garrigues.
,S. Primary Carcinoma of the Vermiform Appendix. D. S. D. JE.ssrP.
4 The Venous System of the Temporal Bone and Its Relation to the
Complications of Mastoid Disease. Skvmouk ohpknheimer.
5. A Case of Epithelioma of the Margin of the Eyelid .\pparently
Cured by the Use of a Solution of Adren..lln Chlorld. Wilbur
B. Marple.
6. Summer Diarrhea in Infants and Young Children. Martin J. Syn-
NOTT.
1.— When and Why Does Liabor Begin ?— After a careful
and logical review of the process of labor. Shears answers the
question as to the time and cause of the beginning of labor as
follows: The statement made in many textbooks tliat the cer-
vix maintains its entire length during pregnancy is incorrect.
The statement that the canal of the cervix remains closed until
the beginning of labor is also incorrect. Usually in multiparas,
and occasionally in primiparas, the canal, including the inter-
nal OS, is dilated to the extent of admitting one or two fingers
two or three weeks before labor begins. Dilation of the exter-
nal or internal os, or of the cervical canal is not per se an indi-
cation of the beginning of labor. Dilation of the clinical
internal os, or ring of Muller, in such a manner that it begins
to form part of the uterine cavity is at once the anatomic com-
mencement and the diagnostic sign of true labor. Dilation at
this point is the final result of uterine distention and conse-
quent cervical eversion. Dilation at tliis point, owing to the
greater resistance offered, by its effect upon the cervical
ganglion, and the consequent reflex awakening of effectual
uterine contractions, is the physiologic cause of labor, [w.k.]
2.— Surgical Tuberculosis. — Garrigues states that of all
microbic diseases seen by the surgeon, surgical tuberculosis
ranks second in importance only to those produced by the pyo-
genic microbes. He never operates on tuberculous glands in
their early stages until the patient has been under treatment for
one or two months. Four indications are to be met: (1) The
stomach put and kept in perfect condition ; (2) the appetite
stimulated ; (3) the blood enriclied ; (4) an alterative given that
has special selective action on the glands. When suppuration
360 AXEBICAX Medicine,
THE WORLD'S LATEST LITERATUEE
[AuauHT 30, ItiOZ
hBH contiiiued for some time and the glaDds have become
densely adherent, instead of oureting and injecting iodoform
emulsion, he uses the butter of antimony. To remove glands
the incision should be so large that all glands can be removed
under guidance of the eye. In well nourished persons, not too
fat, drainage is not indicated. For localized tuberculous peri-
tonitis, laparotomy and drainage with iodoform gauze is indi-
cated. In bone tuberculosis, thorough cureting is done and
the whole infected surface covered with butter of antimony.
This is repeated every four days until healthy granulations are
secured, [a.g.e.]
8.— Primary Carcinoma of the Appendix. — .Jessup
reports a case of adenocarcinoma of the appendix in a woman of
36, who had no symptoms referred to the appendix. Tliirteen
other cases are reported from literature, [a.o.e.]
4. — Venous System of the Temporal Bone and Its
Relation to Mastoid Disease.— Oppenheimer believes that
in many cases of sinus thrombosis and brain abscess complicat-
ing aural suppuration the infection is carried by venous chan-
nels, three distinct systems of which are presented: (1) The
veins of the brain membranes ; (2) the diploic veins; (3) those
ramifying through the temporal bone. A further study of these
venous channels will elucidate many obscure points in the
complex problem of these complications, [a.o.e.]
5.— Epithelioma of the Eyelid Cured by Adrenalin
Chlorid.— Marple reports the cure of an epithelioma of the eye-
lid by several months' application of solution of adrenalin
chlorid, 1 to 1,000. The patient was a woman of 45, the epithe-
lioma being of six years' standing and diagnosed by micro-
scopic examination. The adrenalin apparently acted like a
ligature in cutting off nutrition. The patient was remarkably
susceptible to the blanching effect of adrenalin, as proved by
local application to healthy areas, [a.g.e.]
New York Medical Journal.
August 16, 1901. [Vol. lxxvi. No. 7.]
1. My Summer in Wood's Hell. Beaman Douglass
2. Tenotomy and Myotomy, with Reports of Elglit Illustrative Cases.
Prescott Lb Breton.
3. Active Movements in the Chronic Stage of Paralysis. E. H. Arnold.
4. On the Remittent Limp in the First Apparent Stage of Hip-Joint
Disease, with Remarks on the Early Diagnosis of this Disease.
Newton M. Shab'fer
.5. Diagnosis in Abdominal Lesions. Thomas H. Manlky.
6. Consideration of the Aortic Aneurysm. .James Dudlky Morgan.
1.— Wood's Hell.— Douglass relates his experiences at this
resort and gives an account of the various courses of lectures
and lalioratory instruction given in botany, zoology, physiol-
ogy and embryology, most of which are of great interest to the
physician, [c.a.c]
2.— Tenotomy and Myotomy.— Le Breton reports eight
illustrative cases, and discusses at length the subject of ten-
otomy and myotomy and their indications. In infantile spinal
paralysis flexion at the hip, except in very severe instances, is
best treated by traction in bed, or partial tenotomy followed by
traction, as -tenotomy in this region is rather formidable, owing
to the fact that in advanced cases everything down to the cap-
sule of the joint requires cutting before correction is complete.
At the knee mild flexion may yield to bandaging or plaster-of-
paris splints, but the hamstrings are ordinarily severed and
suitable apparatus provided. Deformities of the feet require
tenotomy and immobilization in the corrected, not overcor-
rected, position. In cerebral paralysis division of the spastic
muscles has greatly simplifled treatment. The t«ndo-Achillis,
plantar fascia, tibials, hamstrings, thigh adductors and various
tendons of the arm and hand may all require cutting, depend-
ing upon where the spasticity and incoordination exist. Trac-
tion is of no service, as deformity recurs immediately. Other
cases in which tenotomy may be of service are : Clubfoot and
clubhand ; congenital and acute spastic torticollis ; severe eases
of psoas contraction of Pott's disease ; long-standing hysterical
contractures in which structural changes have taken place in the
muscles; flexion deformity of the hip and knee at an advanced
period of the lesion ; pseudohypertrophic muscular paralysis
in its later stages ; Friedreich's ataxia and posttyphoidal con-
tractures. [c.A.o.]
3.— Active Movements in Paralysis. — Arnold uses a
smooth board for active bilateral movements in the chronic
stage of paralysis. To diminish the resistance between the
nude part and the board he has had a little car built with a
groove on top for the reception of the part, a strap securing it
still further to this groove, the car moving on four hardwood
ball-bearing castors. The author states that this apparatus has
showed volitional control to be present where one would least
suspect it. When the movements have become fairly easy for
the patient the resistance against the horizontal movement is
increased by attaching by means of a hook, rope and pulley so
much weight as the patient can pull without much exertion
and fatigue. Later the movements are made on a vertical plane
The use of electricity, massage and passive movements are also
of great importance, [c.a.c]
4. — See American Medicine, Vol. Ill, No.24, p. 1001.
5. — Diaicnosis in Abdominal Ijeglons. — Manley discusses
the diagnosis of some abdominal lesions thnt frequently come
within the domain of surgery, and shows the importance of
repeated and deliberate examination by every possible means.
In speaking of acute general peritonitis he says the aim must
be in the direction of detection and arresting the primary
sources of contamination. Some authorities deny its hemato-
genous origin or that it is ever a primary infection. His
experience with cases of severe abdominal crushes has been
that no recoveries occurred in those laparotomized in full
shock, while abstention treatment has generally carried them
through when the injury was not hopelessly mortal. In regard
to grave gunshot wounds of the stomach he says that to subject
a patient in deep shock to another fresh trial of his resisting
powers, to the depressing influence of anesthesia and an addi-
tional mutilation, it is to remove whatever possible prospect of
recovery remains, [c.a.c]
6. — Aortic aneurysm is more frequent as we approach the
heart: First, the ascending aorta; second, the arch; third, the
largest branches ; fourth, the descending, and, fifth, the abdom-
inal aorta. Morgan considers the pathology and principal
symptoms of this disease and quoting Jenner's injunction,
" Suspect anything else but aneurysm in examining a pulsating
tumor of the abdomen," he points out the great similitude with
which the abdominal aorta of a neurasthenic may take on an
aneurysmal feature, [c.a.c]
Medical News.
August 2S, 190S. [Vol. 81, No. S.]
L Some Points In the Treatment of Acute Rheumatism. W. H. Thom-
son.
■1. The Symptomatology and Diagnosis of Acute Articular Rheuma-
tism. Leonard Weber.
3. On the Pathogenesis of Acute Articular Rheumatism. Heinrich
Stern.
4. The Complications and Sequels of Acute Croupous Pneumonia. . H.
A. Uarb and Arthur Dare.
1. — Treatment of Rheumatism. — Thomson states that
beside controlling pain, and thus allaying the accompanying
irritation, the salicylates have but little effect on the course of
this disease. Aside from them, however, there is no specific
antidote, and, granted tliat the disease is bacterial in origin, the
first step in combating the infection is to prevent its entrance.
The tonsils are tlie most probable portals of entrance, at least 25%
of cases of acute rheumatism having an antecedent tonsillitis.
A thorough douching of the throat morning and evening with
a solution of potassium chlorate is an efllcient preventive
against further infection at the first sign of sore throat in
patients previously susceptible to rheuinatisn*. Soothing lini-
ments with abundant dry dressings should bo provided for the
inflamed joints. Thomson believes that the displacement of
alkalies by the salicylates has been followed by greater fre-
quency of heart troubles. Alkalies should always be prescribed
at the least sign of heart involvement. To secure rest for that
organ, aconite should be given throughout the course of the
disease. Salicylates are valuable, but must be used with dis-
crimination. In tedious subacute cases, it is often advanta-
geous to omit the salicylates and prescribe lemon juice instead.
[a.g.e.]
2. — Symptoniatolojjy and Diagnosis of Acute Rheuma-
tism.—Weber's article is ciiiefly a consideration of the ditt'er-
ential diagnosis of acute rheumatism from gonorrheal arthritis,
August 30, I9a21
THE WOELD'S LATEST LITERATUEE
(Amekican Medicine
351
septic arthritis, multiple arthritis of acute infectious diseases,
multiple neuritis, acute osteomyelitis, and gout, [a.g.e.]
3.— Pathogenesis of Acute Rheumatism.— In this admir-
able article Stern reviews the various theories regarding tlie
etiology of rheumatism and propounds a somewhat hypothetic
theory requiring further elaboration but which is founded on
much less hypothesis than are both the bacterial and lactic acid
theories, and which explains the clinical phenomena more
rationally than either of them. Stern found in nine cases that
the blood allcalescence in acute articular rheumatism varied
but slightly from the normal. In 28 specimens of urine the
acidity was practically normal. A diminutiou in the chlorids
of *he urine is one of the most positive diagnostic signs of the
presence of acute articular rheumatism. After an extended
discussion of the physical factors underlying the production of
rheumatism, Stern, in part, concludes that "the rheumatic
process is possible only on the basis of increased permeability
of white fibrous tissue contained in the habitually engaged
parts of the motor apparatus, particularly in that of the serous
and synovial membranes. The altered periueal)ility, or a pre-
disposition to the same, may antedate the rheumatic involve-
ment or it may be of synchronous or almost synchronous
occurrence with the latter. The augmented permeability of
this tissue is effected by the calcium salts of the blood which
extract the cementing substance from the fibrous texture. Cal-
cic Ijodies occurring in loose proteid combination in the blood
are thrown out, deposited and temporarily retained in the
articular tissues where their reactivity is displayed. The pre-
cipitation of the calcium salts from the circulating blood must
be due to its altered composition, which latter may have arisen
through any physical or metabolic disturbance. The increased
permeability may permit passage of such bodies which diffuu-
date noL at all, or with difficulty, only through the unaltered
membrane. Among the permeating substances we find fibrin,
whose occurrence is dependent upon the presence of calcium
salts. The hematic calcium salts aiding in the formation of
fibrin very lilcely are identical with those which effect extrac-
tion of the cementing substance. The passage through the
texture and into the synovial tubes, or their analogs, and the
temporary retention therein, of abnormal quantities of fluid
and salts and voluminous bodies lilce fibrin— practically a state
of disturbed osmotic equilibrium for the time being— is speedily
followed by all the usual manifestations of acute articular
rheumatism." [a.g.e.]
4. — [To be abstracted when completed.]
Pbiladelphia Medical Journal.
AuguHt S3, 190g. [Vol. X, No. 8.]
1. Yellow Fever. Frank U. Hancock.
2. The Etlolony and Diagnosis of Fractures In the Newborn. W. Rey-
nolds Wilson.
3. Unusual CompUcationK Supervening In a Simple Extirpation of a
MultUocnlar (Jyst of the Ovary. Burdett Atkinson Tekkett.
4. The Nerve Element In Diseases of the Ear, Nose and Throat. W. (i.
B. Harland.
■>. Rectal strloluros, with Re-narks on Electrical Treatment. Walter
H. White.
1. — Yellow Fever. — Hancock reviews the contentions of
those who liave advanced the claims of a specific agent of their
own discovery, and details methods of fumigation and quaran-
tine, [f.c.h.]
2.— Fractures In the Xewborn.— Wilson details the etiol-
ogy and diagnosis of various fractures In the newborn. In
general, there are certain positive signs which should lead to
the diagnosis of fracture; among these are the infant's cry indi-
cative of pain, disal)iiity as to motion, dimpling of the over-
lying tissues, swelling of the soft parts and undue mobility.
The evidence of displacement revealed by the radiograph is, of
course, conclusive. On the other hand, tiie degree of displace-
ment and the differentiation of fracture from dislocation is
sometimes ol>scured b.v the presence of fat in overgrown
cliildren. [f.c.h.]
3.— Unusual Complications FoIlowSnK the Extirpation
of a Multllocular Ovarian Cyst. — The case was that of a
uiultilocular cytit of the left ovary, giving off a smaller pedun-
culated cyst long enough to occupy the right inguinal region,
this becoming siifiiciently attached to the parietal peritoneum
to hold it in situ, and thus simulate a second and entirely inde-
pendent growth. Complications were : an abrupt rise of tem-
perature 10 days after the operation, and the subsequent forma-
tion of a pelvic abscess without apparent assignable cause.
This abscess, after its evacuation, resulted in the development
of a urinary fistula which closed spontaneously one week after
its discovery, the abscess itself becoming obliterated without
apparent damage to adjacent structures ; the later development
of an abscess in the abdomen over the site of the cut omentum,
which abscess formed a fecal fistula that ultimately closed of
itself, the abscess proper undergoing final obliteration ; the
presence of the streptococcus in the pus of both abscesses,
demonstrating the common origin of the dual pus formation ;
the necessity of two extra alidominal, one lumbar and one
vaginal incision ; more than two months spent in bed when
every indication of an early and absolute recovery from the
primary operation seemed assured, [p.c.h.]
CLINICAL MEDICINE
David Ribsman A. O. J. Kelly
The prevention of malarial fever furnished a
theme for some Interesting and suggestive remarks made
hy the president of the section, Sir William R. Kynsey,
C.M.G., F.R.C.P.I., at the opening of the section of
tropical diseases at the meeting of the British Medical
Association. Pointing out that an epidemic of malarial
fever is among the most costly in life and money that can
befall a town or district, he states that an epidemic of
malarial fever differs from other outbreaks of disease in
that its effects are not limited to the deaths that it causes,
but that it often leads to years of suffering, poverty, and
depopulation. He states also that he has high authority
for the opinion that, taking one year with another, ma-
laria destroys twice as many people in India as cholera,
smallpox, and all other epidemic diseases together. He
refers then to the experiments undertaken by Drs.
Sambon and Low in the Roman Campagna and in Lon-
don, and to similar experiments conducted under the
auspices of the Japanese government, proving conclu-
sively that mosquitos only are capable of transmitting
malarial fever, that protection from their bites implies
absolute immunity, and that such protection may be
easily obtained. Mention is made of the work of Ross who,
from a study of the life history and surroundings of
Anopheles, and from varied and long continued experi-
ment, determined the best means of preventing malarial
infection — the extermination of Anopheles, a difficult
though not impossible task. These mosquitos breed in
small pools of a certain kind easily recognized and easily
dealt with, and always close to human habitation, since
the females must pass frecjuently between the pools
where they lay their eggs and the liouses where they
obtain their food. If Anopheles are found in a
house, the breeding places are certain to be close l)y.
Kynsey then goes on to express his belief that the dis-
covery of the malarial parasite and the investigations
into the life history of the mosquito that conveys it to
man have placed us in a position to suggest measures
which if carried out would have the effect in an un-
healthy district of largely reducing the amount of ma-
larial fever and eventually of e.xterminating it. He
suggests: 1. Malarial fevers should be included and
notified among the infectious dist^ases, so that precau-
tions could be taken to prevent their spread. 2. Per-
sons, especially children, suffering from malarial primary
infections or recurrents, shoukl be isolated and treated
with quinin to prevent as far as possible the infection of
mos([uit<)s. 3. Persons infected with malaria should be
preventetl from coming to a healthy place to infect mos-
quitos. 4. The puddles in which Anopheles breed
should be drainetJ and filled up or treated with kerosene
to destroy the larvas. o. Doors and windows of houses,
gaols, and hospitals in mahirious districts should be
352 American Medicine]
THE WORLD'S LATEST LITERATUKE
[AUGUST 30, 1902
screened with wire gauze, and beds should be provided
with netting to prevent mosquitos entering and biting
the occupants.
On Benzin Poisoning.— Dorendorf presents a paper to
the Zeitachrifl filr klinische Medicine, Ixiii, 1-2, on two cases of
poisoning by benzin. The first case was that of a man, 37 years
of age, employed in the manufacture of rubber, who, as the
result of his occupation, was seized with violent pains in the
muscles and articulations of the limbs, particularly of the right
side, which trouble was at first presumed to lie chronic articular
rheumatism. A second attack was accompanied by mental dul-
ness, absence of memory, difficulties of speech, loss of appetite,
heaviness of the extremities, particularly of the right side, and
violent pains in the bones, together with sensation of cold in
the hand and leg of the right side. Another patient employed
in the same factory exhibited similar symptoms, together with
marked gastrointestinal disturbance. The atmosphere of the
workshop in which these men were employed was saturated with
vapors of chloridof sulfur and of benzin, used in the process of
vulcanization. A guineapig subjected for some time each day to
the action of these vapors was seized with trembling and con-
vulsions, and succumbed at the end of 14 days, the autopsy
showing enormous subpleural ecchymoses and deposits of yel-
low pigment in the different organs, especially in the spleen.
The ganglion cells of the cerebrospinal axis treated by Niesser's
method sliowed a strong chromatolysis. Experiments repeated
with the separate vapors showed that the chlorid of sulfur was
nontoxic, whereas results identical with those described were
obtained by means of benzin vapors, [c.s.n.]
Movements of Lymphocytes.— Jolly ' points out that
lymphocytes are not destitute of movements but that move-
ments are perceptible in a certain number of the cells examined
in normal blood, in lymphocythemia, and in the lymph of the
thoracic duct, and that while these movements are restricted
they are probably sufficient for diapedesis. [c.s.D.]
Analgesia of the Teeth by Electricity.— L. R. Regnier
and Henry Didsbury ' were induced by d' Arsonval's success in
producing anesthesia of the skin by means of currents of high
frequency and high intensity to utilize such currents for
obtaining analgesia for the extraction of teeth and curettage of
painful nonpenetrative dental caries, and they report their ex-
periments to have been crowned with success. [c.s.D.]
Some Experiments on the Precipitins. — Castellani,*
having detailed the results of some experiments, concludes:
1. The blood serum of animals treated with different prepara-
tions of natural albumins contains specific precipitins for the
albumins. 2. The blood serum of animals treated witli unfil-
tered bacterial cultures produces a precipitate in filtered cul-
tures of the organisms in question. 3. The serum of animals
treated with filtered cultures of bacteria likewise develops
specific precipitins which produce precipitates in the filtered
cultures of the same bacteria. 4. An exception occurs in the
case of diphtheria cultures, the injection of which did not lead
to the production of precipitins. 5. Animals which were
treated with dialyzed typhoid cultures develop the specific
precipitins in their serum ; and (6) there is a close connection
between the agglutins and the precipitins, [a.o.j.k.]
Nencki's Oxydase.— The late Professor Nencki * is reported
by Mme. Sieber-Schumowa to have isolated from the spleens of
swine and calves, from calf-fibrin and from fishes and oysters,
powerful oxydases capable of destroying bacterial toxins.
[c.s.D.]
Parasitic Action of Corrosive Sublimate and Formol
on Hydatid Cysts.— D^vi' ^ communicated to the Soci^te de
Biologic, Paris, May 17, the results of experiments which
demonstrate that Ife solutions of corrosive suljlimate and 5%
solutions of formol destroy the vitality of hydatid germs after
a contact of two or three minutes. It is thus possible to pre-
vent secondary postoperative echinococcosis by a parasiticide
1 La Semaine Mfidlcale, July IB. 1902.
■■* Gazette hebdomadaire de MSdeciiie et de Chirurgie, June 12, 1902.
' La Medeclne Moderne, June 18, 1D02.
< British Medical Journal, June 28, 1902.
' Vereins Beilage der deutschen medicinischen Wochenschrlfl,
March 27, liX)2.
» La Semaine Medloale, May 21, 1902.
injection of the hydatid cyst before making the large opening.
[c.s.D.]
Phlegmasia Alba Dolens and Peripheral Neuritis.—
Debovf^' characterizes phlegmasia alba dolens as essentially
distinguished by white and hard edema, accompanied by violent
pains and functional impotence of the part, and concludes from
the history of a number of cases that most of the symptoms
are due to a neuritis more or less associated with venous obliter-
ation. [c.s.D.]
Some New Clinical Points of View on the Doctrine of
ArterioscleroslB.- Orassman 2 reviews the subject of arterio-
sclerosis in an exhaustive manner, without, however, present-
ing anything new of moment, [d.b.]
Hydrating Power of Pure Renal Extract.— i:. G6rard,»
in a note to the Acad6mie des Sciences, Paris, May 26, states
that he has found that the extract of the kidney of the horse
deprived of all traces of blood by artificial circulation possesses
the property of hydrating glycogen, guaiacol, oxaluric acid and
lactose, but has no action on starch or inulin. This hydrating
power seems to depend on the existence of a diastase, as the
extract when boiled no longer possesses it. He was able, by
precipitation with alcohol, to obtain a substance possessing the
same properties as the extract itself. [c.s.D.]
Observations on the Eoslnophilia of Helminthiasis.
— U. Arcangeli and A. Cimoroni,* in a communication to the
Societa Lincisianadegli O^pedali di R )mi. May 24, 1902, call
attention to the eoslnophilia which accompanies infection with
various helminths (ankylostoma, oxyuris, a.scaris, taenia
mediocanellata, trichina), and to the eoslnophilia which was
first observed by Memmi in cases of echinococcus is and since
then described by Milian, Darguin and Tribondeau. The
eoslnophilia appears to mark the acme of the helminthic infec-
tion. This relationship of eoslnophilia with helminthiasis is of
diagnostic importance and should be borne in mind in obscure
cases. [c.s.D.]
Histologic Diagnosis of Rahies.- U. Biffl ' contributes
to Annali d' igiene speriementale, xi, 1, the results of a large
number of experiments with animals of divers species
affected with rabies, both by artificial inoculation and by bites
of rabid animals. The essential fact resulting from this work
is that the most characteristic lesions for the diagnosis of rabies
are represented by the multiplication of endothelial and con-
nective tissue nuclei in the connective tissue of the central
nervous system, and particularly by the accumulation of these
nuclei associated with migratory elements, about the neurones
and the vessels, both in the ganglion of the vagus and of tlie
bulb. In this connection the observations of Anglade and
Choocreaux (d'Aleuvon) (La Semaine Medicate, May 28, 1902)
are of interest. They point out that in the reaction due to the
presence of the virus of rabies in the dog there are contem-
porary alterations of the capillaries and of the neuroglia. By
their special method of staining they are able to demonstrate
the proliferation of the endothelium and the perivascular infil-
tration of nuclei of neuroglic origin. It appears, as a result of
their researches, that the virus of rabies requires only a few
days to provoke le-sions which, in other affections, are not
realized until after several years. [c.s.D.]
An analysis of seventy-one cases of typhoid fever
treated in the Children's Hospital of Philadelphia during 1901
is given by Hand and Walker.^ It is said that while typhoid
fever may sometimes run a mild or even abortive form in chil-
dren, yet its clinical picture does not differ from that in adults
in any essential feature save in the somewhat lower mortality.
[A.O..I.K.]
Oxygenated Endovenous Injections. — Gartner com-
municated to the Royal Society of Medicine of Vienna, May 23,
the results of experiments with oxygenated injections into the
jugular veins of morphinized dogs. The animals withstood
the injections very well. Part of the oxygen was alssorbed by
the venous circulation and the rest reached the heart, where its
presence was indicated by the bruit de glou-glon. The pulse,
1 Gazette hebdomadairfTde Mfideclne et de Chirurgie, June 1, 1902.
s Miincheiicr mod. Woch., March 4, 1902.
3 La Semaine Mfidicale, June 4, 1902.
* II Pollclinico ; Supplemento Sen timanale, June 14, 1902.
5 La Semaine Mfidieale, May 21, 1902. ,^
'American Journal of the Medical Sciences, cxxili, 990, 1902.
AUGC8T 30, 1902]
THE WORLD'S LATEST LITERATURE
(Amkrican Medicinu, 353
respiration and blood-pressure were scarcely modified. The
introduction of large quantities of oxygen gave rise to gaseous
emboluses in the veins. The innocuity of oxygenated injec-
tions into the veins is due to the facility with which the gas is
absorl)ed. Air, on the contrary, being absorbed with difficulty,
renders its introduction into the venous system very dangerous.
Animals poisoned with carbon dioxid recovered rapidly when
treated with injections of oxygen, and Gartner concludes that
we have here a method capable of being used with man in cases
of asphyxia due to toxic gases. [c.s.D.]
Vaccinations Against the Pasteurelloses. — J. and M.
Ijignl^res > communicate to the Acad^mie des Sciences, Paris,
the successful results of their efforts to obtain a vaccine capable
of preventing the affections which have been included under
the name of pasteurelloses, a name covering a large number of
the old group of hemorrhagic septicemias. Here belongs the
■typhoid fever of the horse, the disease of puppies, chicken
cholera and the hemorrhagic septicemias of sheep, cattle and
swine. The method employed in the preparation of the vaccine
consists ill attenuating the virulence of the germ and in prepar-
ing cultures on gelose-agar with resowings every other day,
which are transplanted to a bouillon peptone, which is sub-
mitted for two to five hours to a temperature of 42° to 43° C.
The vaccine which tliey have prepared is polyvalent. It con-
sists of a mixture of the vaccines of six Pasteurella types,
those of sheep, cattle, dogs, horses, swine and birds. Injections
of this vaccine in doses varying from 0.125 ccm. to 1 ccm.,
according to the size of the animal, confers immunity which
persists for at least one year. [c.s.d.J
Telephoning Through a Nerve.— An interesting experi-
ment was that recently performed by Professor Wedenski,^ St.
Petersburg, in which he inserted the ischiatic nerve of a frog
in a telephone circuit — with the result that the musical tones
were successfully and clearly transmitted by means of a micro-
phone. [c.s.D.]
The Treatment of Incipient Bronchopnenmonia in
Infants.— Zangger ' at the onset of pneumonic symptoms
(high temperature, diminished resonance, small noncrepitant
or crepitant rales, apathy, increased heart beat and respiration
rate) gives the child a bath at 8G° F. for two minutes and then
slowly reduces the temperature of the bath by adding cold
water for from two to three minutes until a temperature of 76°
is reached. The body of the patient is rubbed with a sponge or
cloth or the hand to promote reaction of the skin and reduction
of the body heat. The bath water need not, and in feeble chil-
dren should not, quite cover the body, but tlie water can be
sponged on the chest, the patient lying in the arms of an attend-
ant. If definite pneumonic symptoms be present the bath may
have to be repeated at intervals of from 8 to 24 hours. The
symptoms of bronchitis may be relieved by a bandage applied
as follows: (a) Beginning under the right axilla, passing over
the left clavicle and around the chest to the right axilla; (6) from
here around the chest horizontally; and (c) from the right
axilla to the left and over the back and the left clavicle to the
front (or left axilla). This bandage should be of linen, IJ
inches broad for infants, and five inches for adults, and from
two to three yards long ; it sliould be wrung out in cold water
(54° to 66°). After it has been applied it should be covered in a
similar manner by a flannel bandage. This pa<^k may be ap-
plied at night and left on until morning, when upon removing
it the chest must be rubbed with a cold, wet towel, and then
rubbed dry. Ileportsof several illustrative cases are appended.
[a.o.j.k.1
Graphic Study of Rhythmic Oscillation of the Head
(Musset's Sign) In AlTectlons <>f the Aorta and In Healthy
Persons. — H. Frenkel and (J. Lafon' point out that, contrary
to the generally accepted opinion tliat Musset's sign is exclu-
sively observed in patients with aortic atTections (insulliciency
of the orifice, aneurysm, dilation of the aorta), the most char-
acteristic tracings of this sign may be easily obtained in healthy
subjects by means of a graphic method, the only difference
' Ui Heinalne Mfidlcale, May 28, 1902.
2 Verolns Kellage dcr deutschen medlclnlgchen Wochengchrlfl.
March 27. 1902.
' British Medical Jotimal, June 28, 1902.
Qazette hebdomadal re de Mfide-clne et de Chlrurgle, June 12, 1902.
consisting in the amplitude of the systolic oscillations, which
are less in the normal condition, and in their duration, which is
slightly longer in healthy subjects. As a result of this study it
is seen that the sign of Musset is not pathognomonic for aortic
affections, moreover, that it is sometimes visible to the naked
eye in normal subjects. [c.s.D.]
Influence of Atropin on the Pancreatic Secretion. —
Camus and Glaey ' call attention to tlie fact that atropin exer-
cises its antagonistic action to pilocarpin in connection with the
pancreatic secretion as well as with other secretions. The pan-
creas is provoked to activity Viy the intravenous injection of a
solution of propeptone in doses of 0.02 cgm. per kgm. This
secretion is, however, very greatly diminished by a previous
injection of 0.005 mgm. of atropin per kgm. [c.s.D.]
Persistence of the Diphtheria Bacillus after Serum-
therapy. — Gregoire- reports the ca.se of a child who con-
tracted a sore throat with slight systemic disturbance from
being with another child who had recovered from an attack of
diphtheria by the use of antitoxin serum 26 days previously.
Bacteriologic examination of the secretion of the throat revealed
the bacillus of diphtheria. The patient recovered without
having a virulent attack. By this observation it was demon-
strated that the diphtheria bacillus persisted in the mouth for
at least 26 days after serumtherapy. The bacillus transmitted
from mouth to mouth required three days to develop, but
because of its lack of virulence it did not produce its ordinary
effect. Gregoire believes tliat any child recovering from an
attack of diphtheria should not be allowed to come in contact
with other children for at least a month, [l.p.a.]
A. B. Craig
GENERAL SURGERY
Martin B. Tinker
C. A. Orr
Late Recurrences After Operation for Carcin-
oma.— Although great advances have been made in the
operative treatment of carcinoma during the past decade
there is still great room for improvement. More careful
study of the clinical aspects of cases of carcinoma before
operation and systematic examinations of the condition
of the patients at regular intervals after operation with
careful records are greatly needed. Such studies with care-
ful examination of pathologic material would no doubt
prove of great value in settling questions now not under-
stood. The committees for the investigation of carcin-
oma which have been formed recently in several coun-
tries are endeavoring to systematize the work which has
been done. In a circular which the Gterman committee
sent out to clinics is the following: ''The committee
considers large statistical studies of the permanent re-
sults after operations for carcinoma very desirable and
they are likely to prove of aid in determining the cause
of the disease, whether infectious, inherited or from
other cause ; they will also prove of help in the study of
the development of the disease." One of the first of these
papers which we have noticed in respon.se to this retjuest
is by Ijabhardt, of Garre's clinic in Konigsberg. (See
abstract in this issue.)
l^abhardt's paper is of considerable interest, though
nothing very new or striking is brought out. Some of
his conclusions are no doubt incorrect. It is certain that
in his study of cases of brea.st carcinoma he has over-
looked some of the most important later papers and he
has classed together papers written 25 years ago with
those written only one year ago. A number of opera-
tors for breast carcinoma find recurrences, not only early
but late, far more frequent at some point remote from
the site of the jirevious operation. The necessity of more
careful histologic study of carcinomatous tumors excised
and their cla.ssiflcation to determine the relative malig-
nancy of dift'erent forms is justly emphasized, and should
be heede<l by all who have command of material of this
• Im Bemainc Mfidlcale, May 7, 1902.
2 Montreal M«dlcal, Vol. 11, No. 3, 1902, p. 121.
36 I AKSalOAN MiDTOINX]
THE WOELD'8 LATEST LITEBATUEE
IACOD0T 30, 1902
kind. The conclusionw from this statistical study are
necessarily faulty, and show the necessity for more full
and careful records and reports of such cases by those
who have clinical material at their disposal. When we
consider the very considerable number of late rec-ur-
rences, our prognosis should always be guarded. A
patient who lias survived an operation for three years is
by no means out of danger, although the probability of
recurrences decreases rapidly as the years after the opera-
tion increase.
Late Recurrence of Oarciaoma After Operation.— Lab-
hardt" has studied the histories of cases in the KOnigsljerg
clinic and lias collected statistics of several thousand opera-
tions, mostly from the German clinics. He concludes from tlie
result of his study that the patients who are in good health
in the fourth year after operation are still quite subject to recur-
rences. Local recurrences in the scar of operation are found
most frequent. In cases of breast carcinoma, 66% of the late
recurrences were local, 109}; in glands, and 24% metastases. In
carcinoma of the lip 81% were local recurrences, 14% in the
glands, and 5% metastases. Although the histologic form of
carcinoma was not given in many of the reports, it was found
in the cases in which this was stated that late recurrences tend
to occur much more frequently in the slow-growing, relatively
benign tumors, such as scirrhus. In 2,142 cases of carcinoma
of the breast he found 3.7% of recurrences after the third year.
Ijate recurrences after operation for carcinoma of the rectum
are even more frequent. In 491 cases of this kind there were
4.4% of recurrences after the third year, forming 9% of all recur-
rences. Carcinoma of the lip and face, which give the smallest
number of late recurrences, in 1,300 cases there were only 2.5%
of late recurrences, forming 9% of the total number of recur-
rences. Some investigators believe that these late recurrences
should not be classed as true recurrences, but as a new appear-
ance of the disease. Labhardt considers this unlikely from the
following reasons: If a hundred individuals be taken in the
years in which carcinoma is frequent and compared with a
hundred individuals who are living in apparent health three or
more years after the operation for carcinoma, a comparison
shows that the latter class is far more likely to suffer from car-
cinoma, the relative frequency being 20% of the latter class as
compared with 5% in the first category. It is also striking that
the great majority of late recurrences, about 75%, are in the scar
ot the operation.
Operations Upon the Kidney. — Deaver'^ reports 34 opera-
tions for fixation of floating or movable kidney, 7 for nephro-
lithiasis, 3 for pyonephrosis, 2 for hydronephrosis, and 2 for
sarcoma. Of the floating kidneys 29 were right, 4 left and 1
bilateral. The modified Senn method was used in 28 cases.
Of the seven cases diagnosed as stone two revealed absence of
stone. One had given a positive shadow twice by x-ray, the
other was not x-rayed. Of the five cases of stone, three were
positive to x-ray, two were not x-rayed. Of three cases of
nephrectomy for pyonephrosis all recovered. One of the two
for hydronephrosis died of uremia, [a.g.e.]
Removal of One-third of the Stomach and a Portion
of the Duodenum.— Thomas * reports a case of malignant dis-
ease involving the pyloric end of the stomach and the duode-
num to such an extent as to require removal of one-third of the
stomach and Si inches of the duodenum. The severed ends of
both were closed, they being too widely separated for anasto-
mosis. Gastrojejunostomy was then performed, the patient
making a good recovery. The author insists that this anasto-
mosis be so effected and the gut given the proper curve in order
that the stomach contents may be forced distally. Otherwise,
annoying emesis will occasionally occur. He has previously
reported a case in which two-thirds of the stomach was success-
fully removed, [a.b.c]
Sudden Dislocation of the Hip-Joint During the Course
of Acute Inflammatory Rheumatism. — Gevaret* reports the
case of a girl of 13 in whom, after the symptoms of inflamma-
1 Beitrage zur kllnlschen Chtrurgle, 1902, Vol. xxxiil, p. 371.
= Annals of Surgery, Julv, 19('2.
s British Medical Journal, Julv 12, 1902.
< AUg. Wlen. med. Zeitung, 1902, p. 38.
tory rheumatism had subsided, the loft hip-joint was found dis-
located, the head of the femur being displaced downward and
forward into the obturator foramen. After 16 months operation
was allowed. During this interval the femoral head had acci-
dentally redisplaced itself upward and backward onto the
dorsum of the ilium, the girl squirming violently while dressing
herself. The patient was put under the influence of chloroform
and the femur was replaced after the method of Lorenz (simul-
taneous abduction and extension). Considerable traction had
to be used. A plaster-of-paris dressing was applied for six
weeks, with a very satisfactory result. Degez has collected 80
cases occurring during acute infections, in most of which the
displacement was upward and backward. The condition is
produced either through hydrarthrrtsis, the head being pushed
out of the joint or through atrophy of the periarticular muscles
and tendons. The treatment should consist in manual reposi-
tion at as early a date as possible. The prognosis is better the ■
earlier the operation is performed. If this should fail, other
procedures would have to be considered, [e.l.]
The Role of Bacillus proteus vulgaris in Surgery.
—Ware' reports the occurrence of a sublingual abscess in
a man who had been ill for three days, who had marked pros-
tration, jaundiced sclera and skin with intense itching of the
latter, enlarged spleen, liver and cervii-al glands. The pus from
the abscess contained a streptococcus and BaciUiis proteus
viitgari/i. Ware holds that the proteus is not capable of pro-
ducing a primary infection, but acts only after the tissues have
been weakened by other bacteria— streptococci in the case re-
ported, [a.o.e.]
Tropical Abscess of the Liver. — Godlee * has found peri-
hepatic peritonitis an almost invariable accompaniment. This
shuts off the part, preventing at the time of rupture a general
peritonitis. It affects oftenest the convex surface, leading to
adhesion to the diaphragm and partial dulness in the lower
part of the chest, except when the lung is adherent to the pleura
and cannot be displaced upward. If the peritonitis occurs on
the under surface of the liver the results are much more serious.
Escape of all the bile through the wound is not common. It
does not necessarily lead to anorexia or indigestion, but causes
emaciation, which may be extreme. From the flow in the
lymphatics of the diaphragm being upward pleurisy is common.
Rupture into the pleura is one of the most dangerous complica-
tions, causing rapid effusion and collapse of the lung. Pleural
adhesions may save from these grave dangers. Pulmonary
abscess consequent on hepatic abscess should be opened with-
out delay on account of the dangers from burrowing and of
brain abscess. The thick, slimy, chocolate-colored pus may
contain the ameba coli, when fatal hemorrhage occasionally
occurs. Some abscesses have a remarkably long period of
latency, others are septic from the first and hopeless. The
majority of tropical abscesses are single. Imperfect drainage
may lead to diagnosis of a second one. The seat of election for
operation is the lower axilla, the incision being transverse,
parallel with the lower margin of the pleura, the portion of rib
that crosses the wound being removed. If the pleura is injured
it should be sutured. After opening the diaphragm the liver
may be sutured to it and the chest walls, or the parts around
the opening may be carefully packed with antiseptic material.
Hemorrhage may be stopped by the finger or careful plugging.
[H.M.]
Movable Liver with Greatly Distended Gallbladder:
Condition Relieved by Cholecystotomy.— Xewman^ reports
this case. The patient was a woman, aged 50, who had had
several attacks of pain in the back and right loin. Very little
urine was passed during the attacks, and unusually large quanti-
ties following them. An ill-defined tumor could be detected in
the right side of the abdomen. Operation revealed a movable
liver and an enormously distended gallbladder which, when
incised, discharged 30 ounces of fluid, containing a large num-
ber of minute gallstones. No stones were found in the ducts.
The patient made a good recovery, [a.g.e.]
Carcinoma of the Penis. — Englisch* has collected 540
■Annals of Surgery, July, 1902.
! Medical Press and Circular, July 16, 1802.
3 British Medical Journal, July 26, 1902.
* AUg. Wleu. med. Zeitung, 1902, p. 163.
AUGUST 30, 19621
THE WORLD'S LATEST LITEEATUEE
.American Mkdicink 355
cases of carciuoma of the peais, and briefly discusses the dis-
ease from all its aspects. He considers the removal of the
tumor, either by excision or amputation, the only rational pro-
cedure, and emphasizes the importance of removing all glands
in the neighborhood to prevent recurrences, [k i^.]
Hydatid Cysts of the Kidiie,v.— Haynes ' reports a case
of hydatid cyst of the kidney which furnished no previous
history suggesting this condition, it being accidentally found
during an operation for appendicitis. Tiie patient was a male,
Italian, aged 32. No trace of renal tissue was found in the
tumor. The pathology, symptomatology, diagnosis and treat-
ment are discussed from the standpoint of re<'orded cases in
literature, [a.w.e.]
Prolongation of Nitrous Oxid Anesthesia. — Kirkpat-
rick- describes Patterson's na.sal inhaler. Two small metal
tubes are let into the nose piece and to these are attached rubber
tubes which lead to a gas bag, a two-way stop-cock intervening.
A moulli cover may be used to diminish the period necessary
for the production of anesthesia, liy fitting a movable cap over
the expiratory valve Kirkpatrick is able to shut this valve out
of action and has at will either a valved nose piece for the
induction of anesthesia or a closed one for its maintenance.
This gain in efBciency is obtained without any sacrifice in the
simplicity of the original apparatus. A mouth prop should
provide sufficient space between the teeth for the introduction
of Mason's gag, but the lips should be closed during induction
of anesthesia. The average time is from three-quarters to one
minute. By increasing pressure in the gas bag pressure in the
nasopliaryux can be so raised as to push the soft palate for-
ward against the tongue, so enabling the gas to pass freely
witliout admixture of air. If there are any signs of anesthesia
passing off the pressure can be still more increased, or if oxy-
gen is indicated the pressure can be reduced. Gas has been
administered by tiiis method as long as 17 minutes, during
which time 30 teeth were extracted. Every operation that can
be done with gas and oxygen combined, and many that cannot,
may be done by this method. He has used it in 400 cases.
[H.M.]
Intussusception of a Diverticulnm, with Secondary
Ileocolic Intussusception.— This interesting case is reported
by Travers.' The patient was a boy of 10 who had sudden onset
of symptoms of obstruction. Operation revealed an inverted
diverticulum causing almost complete obstruction, with about
14 inches of the ileum intussuscepted into the colon. Keduc-
tion was effected and recovery followed, [a.o.k.]
Gastrostomy. — Carless * describes a modification of Frank's
operation, by which he has obtained excellent results. A 2J
inch vertical incision is made downward from the tip of the
seventh or eighth costal cartilage. The omentum is pushed
down and the stomach drawn into the wound so a cone of gas-
tric wall fits the opening in the peritoneum, the upper limit
being as near the cardia as possible and the apex at the upper
angle of the skin wound. The base of the cone is stitched to
peritoneum, tlie posterior layer of the sheath of the rectus and
fibers of the transversalis by (continuous or interrupted sutures,
according to tlie length of time allowable. The point to bo fixed
to the skin is punctured carefully to avoid stripping the muscu-
lar from the mucous coat, a drainage tube is introduced three
inches with six inches remaining outside, and secured in posi-
tion by two or three catgut stitches. The rectus is separated
posteriorly from its sheath so it can be brouglit together and
sutured over all but the small apical portion of the stomach,
thus IVirmlng a sphincter, the serofibrinous adhesions soon
becoming strong. The nipple-like projection is finally fixed to
the angle of the wound by sutures passing through the skin
and serous and muscular coats of the stomach. The rest of the
vertical wound is closed in the usual way. Rectal feeding for
two or three days, if possible, is desirable. The tube loosens
about the seventh day. [11..M.]
Rupture of Spleen.— Balloch ' reports a case of traumatic
rupture of the spleen in a negress of 17, the injury lieing a kick
by a drunken man. Splenectomy was performed nine days
1 AnnalH of Surgery, .July, hfOi.
s Mixilcttl Pnns una Clriii iir, .July 10, 1902,
'Lancet, .July 19, ma.
'Kdlnhurgli .Medical .louriial. .luly, liiOJ.
after the injury. The patient died six days later of pneumonia
and gangrenous peritonitis of colon and lower portion of ileum,
probably due to injuries at time of assault. The laceration of
the spleen ran the entire length of the organ posteriorly. The
pedicle was approached from behind at operation, and was thus
easily reached and clamped, [a.g.b.]
GYNECOLOGY AND OBSTETRICS
WiLMER Krusen Frank C. Hammond
Ovarian Pregnancy. — The existence of ovarian
pregnancy lias been contested, and many suppo.setl cases
have been proved to be tuboabdominal, with intimate
but secondary adhesions to the ovary. According to
Kelly, in order to prove the existence of an ovarian preg-
nancy it is necessary to demonstrate the criterions laid
down by Spiegelberg, viz., that the tube is intact and
has no organic connection with the gestation ; that the
tumor is connected with the uterus by the uteroovarian
ligament ; that the walls of the sac contain graafian fol-
licles in various places ; and that the albuginea of the
ovary passes directly into the tumor wall. In the very
full collection of the museum of Vienna, Bando found
only one specimen of ovarian pregnancy and almost
questioned the possibility of its existence.
A. Martin found one instance of ovarian pregnancy
in 77 cases of extrauterine gestation coming under his
personal observation, and cases have been satisfactorily
demonstrated by Sanger, Leopold, Mackenrodt, van Tus-
senbroek and others. Quite recently John P. Thompson,
of Portland, Maine (see abstract in this issue), has added
an interesting case in which careful microscopic exami-
nation demonstrated ovarian gestation. Although the
clinical interest of differentiation of the type of ectopic
gestation is not great, the scientific value is sufficient to
demand a patient investigation of every case likely to
prove one of this interesting and exceptional variety.
Ovarian Pregnancy. — .John F. Thompson • has demon-
strated by careful microscopic examination a case of ovarian
gestation. The patient was a multipara, aged 32, and the preg-
nancy occurred in the left ovary. No rupture had taken iJlace
previous to the operation. Just inside of the base of the tumor
was a small opening on the surface of the ovary with ectropion
of the lining of the graafian follicle. The fallopian tube was
unobstructed in its movement, freely falling forward when the
specimen was raised by grasping theovary. The flmbrias were
entirely free from one another and the tube was patulous. The
fetus was found attached to the wall of the ovisac by an umbili-
cal cord I..5 cm. in length. The fetus itself measured 1.2 cm. in
length, not extended. Its appearance was exactly similar to a
fetus of the same age developing in the uterus. The points
which substantiate the claims of this individual case are : The
tube is not concerned in the development of the pregnancy ;
there is no supernumerary tube ; the pregnancy undoubtedly
did not occur at or near the fimbriated end of the tube, as the
sections made from the tube near the fimbriated end showed no
evidence that the structure had been the seat of pregnancy ; the
fimbriated end was found at the time of the operation to be
entirely free from the ovary, so that the case is not one of tubo-
ovarian pregnancy ; the fimbria ovarica in this case is found in
what must be considered its normal place, extending from the
end of the tube to the outer end of the ovary ; the pregnancy
has occurretl at the extreme inner end of the ovary ; there is no
evidence to be derived from the examination of sections of
ovarian tissue that the fimbria ovaries has passed up over the
surface of theovary ; an examination of more than 100 sections
from difl'eront parts of the wall of the ovisac shows no cells
which can be considered as decidual ; there is no trace of
decidual tissue to be found in any part of the specimen ex-
amined.
Hysterokataphraxis.— By the word "kataphraxis" Cat-
terina' designates the method by which a misplaced organ is
I American Oynccology, .July, ItKK.
'CciiMalblatI fdr Uynitkologle, .lime 21, IWi.
366 American MbdicimbI
THE WORLD'S LATEST LITERATUHE
[August 30, 1002
flxed as it wore, in a metallic house. This method which he
first used in connection with the Itidneys he has now applied to
the prolapsed uterus. He opens the abdomen as in hystero-
pexy, draws the uterus between the edges of the incision and
then at the height of the lower third of the organ, draws a
meto'uic suture, either gold or pure silver, through the layers
of the abdominal wall, except the skin, then through the broad
ligament, and passes it around behind the uterus until it
appears at the other edge of the incision, at which point it is
passed through the broad ligament and the several layers of
the abdominal wall of the other side. Another suture is drawn
parallel with the first through the broad ligament at the base
of the point of insertion of the round ligaments. The tying of
these sutures can be accomplished either before or after the
completion of the suturing of the abdominal wall. Sometimes
only one, the upper, of these sutures is used. The results from
both of these methods have been excellent, [w.k.]
Two Hysterectomies for Fibroid Tumor with Marked
Anemia.— John H. Girvin ' reports two eases that demonstrate
easy convalescence under different circumstances. In one case
there was long standing anemia, due to the amount of blood lost,
and marked symptoms. At the lime of admission to the hospital
the amount of hemoglobin was 36%. The patient was kept in
bed seven weeks, at the expiration of which time under proper
treatment the hemoglobin had increased to 42%, when she was
submitted to an abdominal hysterectomy. The operation
lasted two hours, requiring but five to six ounces of ether. In
the other case there was rather an acute anemia, not due to any
severe loss of lilood, with no symptoms. The amount of hemo-
globin at the time of operation was 40%. It steadily increased
during convalescence and advanced to 43% a week after the
operation, and today is 45%. Abdominal hysterectomy was
done, la.sting somewhat over two hours, requiring 16 ounces of
ether. The former was a submucous and the latter an inter-
stitial growth. [r.c.H.]
Treatment of Puerperal Eclampsia.— According to J.
Veit,' when the cervix is fully dilated the indication is for
immediate delivery; if it is partially so mechanic dilation
should be practised. When the cervix is closed expectant
treatment is usually the best. Of the remedies recommended
to lessen the convulsions morphin is the most important, but
it can not be regarded as in any way curative. The most that
can be said for it is that it lessens the severity of the attacks.
Chloral is also useful. Potassium bromid, veratrum viride
and amyl nitrite have not given brilliant results. Bleeding
with injection of salt solution and also sweating are probably
of use. Veit does not believe either cesarean section or forcible
delivery justifiable in uncomplicated eclampsia. When, how-
ever, the convulsions are growing more severe and labor does
not progress, the latter method should be adopted ; or in the
eclampsia of pregnancy when the narcotics have failed section
is indicated, [h.c.w.]
Abdominal Extirpation of Carcinomatous Uterus Ac-
cording to Wertheim. — Doderlein,' not finding the results of
his work in operating for uterine cancer very satisfactory or
encouraging, has tried Wertheim's procedure in 26 cases, but
without any decided improvement in results. He would not
give greater scope to these efforts, since the cases of permanent
cure seem to him too small and the lengthening of life too
slight to warrant an operation so difficult. He would attempt
the extirpation of a recurrent cancer only when the cancer is
sharply defined, or definitely circumscribed, and even then the
peeling out of the carcinomatous tissue is attended with great
difficulty, [w.k.]
Why Vaginal Hysterectomy Should be Done in Can-
cer of the Uterus in Its Early Stages.— .1. E. Janvrin '
ardently advocates vaginal hysterectomy in cancer of the uterus
originating in the cervix and still in its early stage. In one
recorded series he reports a cure of 37.5%. The success obtained
is due in part to the technic. When the disease extends further
up or outward on one side than on the other the forceps or
angiotribe are first applied to the broad ligament of the side
least affected, and from below upward. When this side has
• The American Journal of Obstetrics, May, 1902.
= Therap. Monatsh., April, 1902, xvl, 169.
^Centralblatt fur Gynakologie, June 21, 1902.
been cut the fundus is brought forward and downward into tlie
vagina and the cervix pushed into the culdesac ; the peritoneum
and rectum are protected by sterile gauze and the forceps or
angiotribe applied to tlie remaining ligament from above down-
ward, thus obtaining large grasp and including all the diseased
tissue, or at least all that can be recognized as such, [f.c.h.]
The Rapid Expansion of the Cervix with Rossi's Dila-
tors.— Rissmann' gives the history of three cases in which he
used Bossi's instrument, describes the method of introduction
and claims this advantage, that its use enal)les one to see the
pulsation of the fetal liead and thereby to determine by sight
whether the child is living. But there is also the disadvantage
that in this procedure there is no thinning of tlie edgesottheos
uteri; they remain thick and the obliteration of the os never
occurs. There is danger of cervical laceration if delivery takes
place immediately after the dilation. He advises waiting after
the dilation, perhaps using the colpeurynter meantime, until
there are strong and frequent pains before the extraction of the
child. With proper care in its use, Rissmann considers that the
addition of Bossi's dilators has enriched our ol)stetrical instru-
mentarium. [w.k.]
A Case of Extrauterine and Intrauterine Pregnancy. —
E. (Justav Zinke' reports a case of ectopic gestation compli-
cating normal pregnancy. Thegestation sac ruptured, celiotomy
was done and the patient recovered. The uterine pregnancy
was uninterrupted, labor at term, mother and child living. At
the time of operating, a period of 15 weeks had elapsed since
the last day of the menstrual period. The tumor mass was in
the folds of the right broad ligament. Zinke believes that the
pregnancies occurred simultaneously. From the history of the
ease rupture probably occurred 28 days after the last menstrua-
tion, but it is probable that the ovum continued to grow and de-
velop thereafter for a short time at least. .ludging from the micro-
scopic section, death of the ovum occurred about the thirty-sixth
day of pregnancy, or about one week after the first symptoms of
rupture, and was caused by hemorrhage around and perhaps into
the ovum. The lancinating pains incident to rupture and subse-
quent thereto were believed to be due to the passing of renal
calculi. The excessive vomiting, the existing normal preg-
nancy, and the dysenteric evacuations accompanying each
attack of rupture of the ectopic pregnancy, masked the real
cause of the trouble, although a few days prior to operating a
mass was detected in the right broad ligament. Ectopic gesta-
tion was not suspected. A tabulated record of 88 cases of
ectopic gestation complicating normal pregnancy is given, and
the results of a study of the same detailed, [f.c.h.]
Ovarian Organotherapy. — Dalche and I^epinois' have
shown that certain women suffering from uterine disturb-
ances, chlorosis, and disorders at the menopause, have been
greatly benefited by ovarian extract. The authors have also
found it useful in the treatment of chronic osseous rheuma-
tism. In tliese cases it was found most efficient in young
women or at the time of the menopause. Powdered ovarian
extract was administered in capsules, each containing 1.5
grains of the dried active principle, of which six were taken
daily. This quantity corresponded to two sheep's ovaries.
[L.F.A.]
The Undeveloped Uterus. — C. L. Bonifield ^ discusses the
undeveloped uterus from its various causes, and advocates the
following treatment : Either before or after hypertrophy of the
body, thorough dilation, curetment, and packing is usually the
best and most successful method. The electric treatment has
no advantages and numerous disadvantages over the surgical.
At least six months should intervene between one curetment
and another, while the troublesome symptoms may recur after
an absence of as much as two years. In the cases of pubescent
uteri that do not finally yield to this treatment when properly
done, the ovaries will always be found to be at fault. Ovaries
much undersized and having more or less completely under-
gone cystic degeneration are the kind which are most frequently
found when the severity and persistence of the symptoms have
justified an abdominal section, [f.c.h.]
The Diagnosis of Fetal Hydrocephalus in Rreech Pre-
1 Centralblatt fur Gynakologle, July 12. 1902.
2 The American Journal of Obstetrics, May. 1902.
'Journal des Pratieiens, Vol. xvi. No. B, 19U2, p. 92.
AUGUST 30, 1902]
THE WORLD'S LATEST LITERATUBE
[American Medicine 367
sentations. — It is with the greatest difficulty that a diagnosis
of hydrocephalus can be made in cases of breech presentation.
A. S. Bleyer ' details some of the signs whidh may be of decided
help in making a diagnosis of this condition : Hydramnion,
this is the rule when the uterus contains a hydrocephalic
fetus ; previous delivery of a hydrocephalic fetus ; cephalic
version is recommended in suspected cases for the purposes of
facilitating diagnosis by vaginal examination of the head ; the
size of the arrested head is ascertained by abdominal palpation ;
arrest of head, with arms delivered — the pelvic measurements
normal — and no other ascertainable cause of obstruction;
shriveled or misshapened body, although this sign is disputed
by the more recent writers ; detection of separation of frontal
bones by the index finger, guided by the root of the nose ; the
hand passed entirely into the uterus to reach the fontanelles
and fluctuating space at the sagittal suture. This is a method
of necessity rather than election, though with careful asepsis
such a procedure is warranted. Chantrenil mentions the
height of the shoulders in the vagina, when arrest is due to a
very large head, [f.c.h.]
Instrumental Perforation of the litems. — Schulze-
Vellinghausen' reports two cases of instrumental perforation
of the nonpregnant uterus, in which the bad condition of the
uterus led to its removal. He gives a full report of the results
of the pathologic examination of the uterus in both cases, and
concludes that there is no doubt that not alone such condition
as atrophy, anemia, tuberculosis and malignant disease are
predisposing causes of the easy perforation of the uterus, but
also other peculiar changes of the uterine muscle facilitate per-
foration. These histories also teach us to be exceedingly care-
ful in our judgment, since perforation may occur without the
apparent use of the the smallest force, the uterine wall seem-
ingly offering no resistance because of its abnormal condition.
A great number of uterine injuries are never published ; many
never come even to the knowledge of physicians, since in cases
in which there is no infection there are often no especial symp-
toms. [w.K.]
Acquired Incomplete and Complete Prolapse of the
Uterus and Vagina in NuUiparous Women. — H. D. Beyea'
details the case of an American white woman, 57 years of age,
positively nuUiparous. At 32 years of age she noticed that the
cervix presented at the vulvar orifice. During the past seven
years procidentia ha.s existed. The only conclusion to be
gained from a study of the cases of prolapse of the uterus in
nuUiparas thus far reported is that commonly its objective
etiology is chiefly dependent, first, upon poor health, physical
weakness, and general tissue-relaxation; second, frequently
upon want of development of the uterus and its supports. The
exciting causes are diseases, laborious occupations, and great
physical ettort, which actively increase the intraabdominal
pressure, [f.c.h.]
Number of Leukocytes in the Blood of the Pregnant
Parturient and Puerperal Woman. — Zangemeister and Wag-
ner,* in the University clinics of Leipsig, made an extended
study of the relative number of leukocytes in the blood under
different conditions and found that while there was often some
increase of leukocytes during pregnancy, especially in the lat-
ter months, that during labor the number rose very rapidly and
under normal conditions declined at once upon delivery. If, how-'
ever, the puerperal condition was abnormal with any infection,
or any absorption of lochia, the leukocytosis continued in vary-
ing degrees until a normal or healthy condition was restored.
The writers cannot allow any prognostic or diagnostic value
in puerperium to the previous examination of the number of
leukocytes, as there seems to be no connection between their
number at the end of labor and the course of the puerperium.
But, on the other hand, they consider that there is much sig-
nificance in the fact that under physiologic conditions of labor
thereappears an increase in the number of leukocytes in the
blood, such as had been observed hitherto only in severe infec-
tious processes. [w.K.]
Lipoma of the Vulva.— Churchill Carmalt' details a case
' Courier of Medicine, .July 1, 1902.
' Centralblalt fOr UynttkoWle, July 5, 1902.
»The American .Journal of Obstetrics, May, 1902.
« Deutsche modlclnlsche Wochenschrlft, July 31, 1902.
of this rare condition. The patient was a multipara 25 years of
age. Some years ago she fell astride a chair, striking the left
labium majus. This injury was followed by a painful swell-
ing, on the subsidence of which there remained a somewhat hard
nodule. This gradually increased in size until it was 15 cm.
long, 5 cm. wide, and 2.5 cm. thick. It was not painful, but
interfered with walking and coitus. The tumor was removed
under nitrous oxid and ether anesthesia. The pathologist
reported the growth to be a lipoma, [f.c.h.]
Early Diagnosis of Carcinoma of the Cervix.— Alfred
Roulefi tersely states that the importance of an early diagnosis
in malignant disease of the cervix cannot be overestimated.
The responsibility rests with the family physician. The diag-
nosis is made from the history ; the symptoms, the physical
examination, and a microscopic examination of cuttings from
the diseased tissue. It will be necessary to differentiate cancer
of the cervix from the following conditions : Eversion of the
cervical mucosa ; simple erosions or ulcerations of the cervix ;
cystic cervical glands ; cervical polyps ; cervical myomas ;
tuberculosis, and syphilitic lesions of the cervix. The common
symptoms of cancer of the cervix are hemorrhage, discharge
and pain. Pain is a symptom of very uncertain value. It is
neither constantly present nor is it at all characteristic. Pain
as a rule, appears late in the disease. Women should be taught
to regard with the greatest suspicion any menstrual irregulari-
ties near the time of the menopause or any postclimacteric
rem of the menstruation, [f.c.h.]
Clinical Notes of Four Cases of Severe Puerperal Tox-
emia Treated by Accouchement Force.— James F. Mc-
Cone' details four cases of puerperal toxemia treated by accouche-
ment forc6, the mothers making a good recovery in each instance.
Two of the patients were six months pregnant, the others five
and seven months. In one case the onset of the disease was so
sudden and the severity so great that the patient was operated
on without anesthesia. Temporizing with such a ease would
have been unjustifiable. The woman seven months pregnant
was delivered of a living child. In two cases the fetuses were
dead, thus being a clinical refutation of the statement often
made that convulsions cease when the fetus perishes, [f.c.h.]
TREATIttENT
Solomon Solis Cohen
H. C. Wood, Jr. L. P. Appleman
Stimulating^ Cold Applications in Typhoid
Fever. — That reduction of temperature is tiie least of
the benefits of cold water applications in typhoid fever
has been taught by all hydrotherapeutists, and should be
fully appreciated by all physicians. Upon the stimula-
tion of nerve centers by the bath, ablution, douche or
spray depends its therapeutic utility, and unless the par-
ticular form of application employed produces this effect,
that is to say, unless there is a good therapeutic reaction,
the method should be modified. This fact was well
illustrated in a case recently under the care of the editor
of this department. The patient was brought into Jef-
ferson Medical College Hospital in a stuporous condition
and without an intelligible medical history. A rather
coarse eruption of raised red spots occupied the trunk
and upper extremities. The temperature was about
101° F. The spleen was enlarged. The dorsum of the
tongue was coated with a dry, brownish fur, its edges
and tip were red and glazed. There was involuntary
micturition, the urine showing a trace of albumin but
no casts. Leukopenia was present but the Widal reaction
was negative. The heart was feeble, the first sound
especially weak, the pulse lacking in tension and vary-
ing from 80 to 90 beats in the minute. Careful exami-
nation failing to reveal other lesion the tentative
diagnosis of typhoid fever was made by exclusion, and
despite the comparatively low temperature, cold bathing
was instituted. Brief immersions (from two to five
' American Journal of Hurgery and (Jynecology, July, 1902.
•The American Journal of Obstetrics, May, 19v2.
368 AMBBICAW MbDICIKB]
THE WORLD'S LATEST LITEEATUEE
[AUGUST 30, 1902
minutes) were made, with active douching of the head,
neck and shoulders, and brisk general friction. The
first plunge was made into water at 80° F., reduced by
rapid addition of ice to 75° F. ; the second at 75° F.,
reduced U) 70° F. ; the third at 70° F., reduced to 65° F. ;
the later plunges at 65° F. or 60° F. The douching was
always with ice water. Immediate good effect upon the
heart and mental condition was manifest. The patient
regained consciousness for a time after each bath, and
finally the stupor entirely disappeared. The body tem-
perature was but little affected for the first few days, but
later fell after each plunge, and at one time reached
97° F. Hot bottles were then placed about the patient,
but cold water continued in the form of a spray of Ice
water, following or alternating with a spray of hot water
(105° F.). The temperature then rose to about the pre-
vious level (100° t« 101° F.), and the hot applications
were discontinued. Intermittence of cold applications
was followed by a return to a condition of semistupor,
from which, however, the patient could readily be
roused ; and resumption of brief cold spraying (ice water
for two to five minutes, with brisk friction during and
after the application) was followed by renewed improve-
ment. The general course of the case and the later de-
velopment of the Widal reaction confirmed the diagnosis,
as the result justified the treatment.
Details concerning this case have been given to make
a concrete illustration of the two theses here set forth : 1.
That not temperature-reduction but nerve-stimulation is
the chief benefit and principal object of hydrotherapy in
typhoid fever. 2. That not the form of the application,
but its effect, is the principal matter of practical concern.
For the reduction of pyrexia, comparatively pro-
longed applications at moderate or gradually reduced
temperatures are most eflicacious.
For nerve-stimulation, brief applications as cold as
can be borne are to be made, and if necessary preceded
by hot applications, in order to prevent undue reduction
of body-temperature. Friction must not be neglected,
as good reaction is imperative.
When pyrexia is to be reduced or controlled, and also
nerve-stimulation to be brought about, a combination
of these measures appropriate to the individual, the
case, and the conditions present, must be devised. The
Brand routine offers this for the majority of cases, but
like any other routine is not universally applicable, and
must, therefore, be held subject to judicious modifica-
tion. Above all, the great value of douches and sprays
which can be given in bed and with a minimum of dis-
turbance to patient and household must not be over-
looked. On the other hand, the removal of the patient
from the bed to the bath-tub is in some instances a posi-
tive factor in the remedial action. The question of the
special measures to be used in the treatment of typhoid
fever with cold water is thus, like all other problems of
therapeutics, one of good judgment under all the cir-
cumstances of the individual case and its environment.
Treatment of Anthrax.— A. Sacchetti {Bulletin G6niral de
Thirapeutique, December 15, 1901) has had excellent results fol-
low the treatment of anthrax by the following method : The
patient having been anesthetized, a crucial incision is made
through the affected area of such a depth and length that the
healthy skin is reached. The blade of a strong bistoury is
then inserted at the base of one of the four triangles outlined by
the two arms of the cross, and all the triangular flap is dissected
away, beginning at the periphery and working toward the
center, the bistoury always being kept deeply in the tissues.
The dissection completed, the flap is thrown back and the
adjoining triangle treated in the same manner. The four tri-
angles having been thus treated, the field of operation resembles
an envelope which has been unglued and the four sides
folded back. Hemorrhage is controlled by means of gauze
compresses wrung out of very hot sterilized water. After
bleedine has been controlled, the whole area of the wound is
covered with tampons of wool which have been dipped in a
solution of iron perchlorid, and the flaps placed in position
over them, care being taken that their edges are separated
from each other and from the bottom of the wound by means of
a layer of cotton. An antiseptic gauze compress completes the
dressing. By this treatment temperature falls, pain disappears
and the general state of the patient improves. At the end of
ten days the slough may be removed in a single piece, leaving
clean, healthy tissue beneath. The flaps are then fixed in posi-
tion and held in place by an appropriate dressing. Union
occurs quickly with a smooth, regular cicatrix. The benefits of
this treatment result from removing all venous and lymphatic
communication between the diseased area and healthy tissue,
while the caustic and antiseptic action of the iron perchlorid
renders the wound dry and unfavorable to the multiplication of
pyogenic microorganisms, [l.f.a.]
Argemone Mexicana, li. — {Poppy family). Nom. Vulg. —
Kasubhag-d.io, Hoc. Uses. — Padre Blanco says that the yellow
juice of this plant " is used by the natives (Filipinos) to treat
fissures of the corners of the eyes." The negroes of Senegal
use the decoction of the root to cure gonorrhea. The milky juice
to which Blanco refers is used in different countries to treat
various skin diseases, including the cutaneous manifestations
of syphilis and leprosy; to remove warts, and as an eye wash
in catarrhal conjunctivitis. The English physicians of India
state that it is dangerous to use the milky juice as an applica-
tion to the eye, although Dymock claims the contrary. The
flowers are narcotic by virtue of a principle resembling mor-
phin perhaps identical with that alkaloid. The seeds yield a
fixed oil on expression, which is laxative and relieves the pains
of colic, probably by virtue of its narcotic properties. Physi-
cians in India praise this oil highly; not only is it a sure and
painless purgative, but it is free from the viscidity and disgust-
ing taste of castor-oil ; besides it has the advantage of operating
in small doses, two to four grams. Its activity is proportionate
to its freshness. Dr. W. O'Shaughnessy does not value this
oil highly, but the experience of many distinguished physicians
of India has proved the purgative and other properties that
have just been mentioned. Possibly the difl'erences of opinion
may arise from the fact that oils from different plants were
used in the trials. The seeds yield a fixed oil, yellow, clear, of
sweet taste, density 0.'J19 at 15° ; it remains liquid at — 5° ; is
soluble in an equal volume of alcohol at 90° ; characterized by
an orange-red color on adding nitric acid. From its soap Pro-
licher has obtained acetic, valerianic, butyric and benzoic acids.
Charbonnier claims to have found morphin in its leaves and
capsules. Dragendorf has isolated from the seeds an alkaloid
which presents the principal characters of morphin. It is,
then, probable that morphin is the narcotic principle possessed
by this plant, which is not hard to believe when one considers
the family to which it belongs. Botanic Description. — A
plant of American origin nowadays acclimated in almost all
warm countries. Its stem is green, pubescent, 30 to 40 cm.
high. Leaves alternate, thin, sessile, lanceolate, covered with
rigid green thorns. Flowers hermaphrodite, terminal yellow.
Calyx, three sepals with conical points. Corolla, six rounded
petals. Stamens indefinite, free, hypogynous. Ovary free,
triangular. Capsule expanded, oblong, angular, thickly set
with prickles : it opens inferiorly by five valves.— De Tavera,
" The Medicinal Plants of the Philippines."
Treatment of Psoriasis. — F. Balzer and Al. Schimpffe
(Bulletin Oineral de Therapeutique, November 23, 1901) have
obtained good results from the employment of baths of oil of
cade in psoriasis. An emulsion is made according to the fol-
lowing formula:
Oil of cade 1^ ounces
Fluid extract of quillaja . 3 drams
Yolk of egg No. 1
Distilled water enough to make 8 ounces.
The yolk is placed in a mortar and small quantities of the
oil of cade are added very slowly. The mixture is very thick
at first, but becomes more fluid as the proportion of oil is
increased. A small quantity of the fluid extract of quillaja is
added from time to time. When all the oil is emulsified, the
water is added. At the time of using, it is best to mix this with
a quantity of hot water which is then added to the bath. The
bath should last from one-half to one hour and should be
August 30, 1902J
THE WOKLD'S LATEST LITERATURE
rAiraKICAN MroioisB 359
repeated every day or every two days according to indications.
Moderate friction should be applied by the patient over the dis-
eased area while in the bath, [l.f.a.]
The Electrolytic Treatment of Angioma. — Gabriele
Arienzo contributes {Annali di Electridta Medicate Terapia
Fisica, April, 1902, No. 6) a report of 10 cases of angioma suc-
cessfully treated by the application of electrodes after the
bipolar method, and the use of currents having a strength of
from 10 to 35 milliamperes. As the result of his experiments,
he arrives at the following conclusions: (1) That electrolysis
should be considered as a method to be chosen in the treatment
of angiomas, and should be tried in all cases before surgical
intervention ; (2) the bipolar method should be employed in all
cases of angioma, because electrolysis acts by molecular dis-
aggregation of the tissues and by the production of connectival
sclerosis, which is determined by both poles ; (3) the. use of
high intensities is not be recommended, because there may be
produced at the negative pole a scab which, becoming detached,
may give rise to hemorrhage; (4) platinum electrodes are
preferable because of the ease with which "they may be disin-
fected. [C.S.D.]
Treatment of the Pulmonary Forms of Grip. — Ld
Affdecine Moderns, Vol. xiii, Xo. 11, p. 92, states that the pul-
monary complications in the present epidemic of grip consists
of the usual catarrhal affections in a particularly intense and
persistent form. Quinin is recommended as the basis of treat-
ment in these conditions, combined with other drugs as follows :
Powdered terpin 4 grains
Sodium benzoate ] „, „„„v, ,,
Benzonaphtol } <>' each 3 grains
Spartein sulfate i grain
Quinin hydrochlorate 2| grains
Fori cachet; to be taken 4 times a day.
Or the following may be used :
Powdered terpin 4 grains
Sodium benzoate 3 grains
Potassium iodid 1.5 grains
Benzonaphtol 3 grains
Quinin hydrochlorate 2i grains
Powdered nux vomica j grain
Spartein sulfate i grain
Ergotin 5 drops
For 1 cachet ; to be taken 4 times a day.
The cough may be controlled by using :
Potassium bromid 3 grains
Codein J grain
Antipyrin 4.5 grains
Morphin hydrochlorate J grain
For 1 cachet; 2 or 3 cachets may be given daily.
[L.F.A.]
Adrenalin Chlorid in Eye Surgery, — Carrow ( Therapeu-
tic Gazette, May 15, 1902, p. 300) says that adrenalin Is useful in
cases of engorgement of the conjunctival vessels in which it
relieves the pain consequent upon the hyperemia and, he as-
serts, it also possesses antiseptic qualities (!). He has likewise
found it useful in operations on the eye to prevent bleeding
and thus give the operator a clear field. He uses it in strength
of 1 to 2,000. [h.c.w.]
Treatment of BHght's Disease With Edema and
Abundant Albuminuria. — An exclusive milk diet. The legs
should be kept wrapped in cotton-wool, which in turn is
covered with oil-cloth. Every day for 4 days the patient
should take 5 pills, each containing:
Powdered squill ]
Powdered scjimmony > of each 1 grain
Powdered digitalis j
Podophyllin I'i grain
Each day 4 dessertspoonfuls of the following solution in
milk should be given:
Strontium lactate 10 drams
Water 10 ounces
—Bulletin OfnPral de Thirapeutique, Vol. cxliii, No. 16, 1902.
[l.f.a. ]
Concerning the Hygiene and Treatment of Infantile
Hyphllls. — Rothschild (Allgem. Wiener med. Zeituvg, 1!K)2,
No. 1 ) bemoans the fa<'t that in the fight against the rav-
ages of gastroenteritis, tuberculosis and alcohol, those of
syphilis are almost entirely forgotten, although this latter
disease probably causes more deaths in early childhood than
any of the others.- In fact, according to Fournier, as many
as 50% to 60% of children conld be kept alive but for it. In
syphilis, more than In all others, the results of preventive and
curative treatment are considerable. From the standpoint of
prevention the author recommends most thorough and lengthy
treatment of the parents before and after conception. Of cura-
tive treatments he recommends, in every case, a warm bath as
soon as possible after birth, followed by transference to an
evenly heated incubator, the child being wrapped in ordinary
cotton wool. Great care should be taken to avoid a cold tem-
perature during nursing or changing the clothing. Several
mustard baths should be given daily, followed by massage
with warm oil and cologne. If possible, the mother's milk
should be used exclusively for feeding; if impossible to obtain
or insufficient in quantity, sterilized cow's milk should be used
to take its place or to make up the deficiency if the child is
mature. If it is premature, peptonized milk should be used ;
or, if that cannot be procured, the cows' milk should be followed
by a coffee-spoonful of a mixture of pepsin, 15 grains; pancreatin,
15 grains ; alcohol, 75 m. ; dil. hydrochloric acid, 10 min. ; water
sufficient to make 3 ounces, as their digestive powers are at
a very low point. Mercury should be given either by mouth
or by inunction. Van Sweeten's solution, in doses of from 20
to 50 drops daily, depending upon the age, is given in milk ; but
inunction, with from 15 to 30 grains of mercurial ointment, is
better. Mercurial baths are also very useful, the solution rang-
ing from 1 : 1,000 to 1 : 5,000. They should not be employed if
many ulcers are present. In such children contagious diseases
should be especially guarded against, as they are more subject
to these than are others, [b.l,.]
FORMULAS, ORIGINAL, AND SELECTED.
For Chordee.— Bjorkman {Merck's Archives, March, 1902)
recommends
Extract of opium 1 grain
pjxtract of cannabis indica 2 grains
Extract of hyoscyamus 2 grains
Lupulin 6 grains
Cocoa butter enough
Make into 3 suppositories.
One to be inserted at bed time. [H.c.w.]
Inhalation for Mixed Infection in Pulmonary Tuber-
culosis.— H. E. Lewis {New York Med. Jour.) says that in
cases of mixed infection with marked purulent expectoration,
for allaying laryngeal irritation and cough, the following
inhalation has proved most satisfactory :
Compound tincture of iodin 4 drams
Tincture of tolu J ounce
Tincture of cinnamon 1 dram
Carbolic acid 1 dram
Chloroform 1 dram
Alcohol, enough to make 4 ounces
Use in a bottle with a large cork, through which 2 glass
tubes are run. Inhale by drawing through the shorter tube,
which must not reach down to the liquid, [h.c.w.]
Bath Pastil.—
Boric acid 1 part
Sodium bicarbonate 2 parts
Alcohol sufficient
Mix and make damp with alcohol perfumed with
Attar of roses 1 part
Oil of orange 2 parts
Oil of bergamot 2 parts
Press the mixture into a mould holding about 2 drams ; dry
in air until the mass is hard enough to be wrapped in tinfoil.
This pastil, dissolved in hot water and added to the bath, is said
to make the water soft and pleasant to the skin, to reduce the
quantity of soap required and to diffuse a delightful odor.
The following is a formula for "Sulfur- Bath Tablet: "
Sulfurated lime 3 ounces
Rock salt IJ ounces
Sodium hyposulphite 1 ounce
Sodium caroonate, crystals 80 grains
Gum arable 3 drams
Glycerin i ounce
Water a sufficiency
Make into a stiff paste and divide into two tablets.— PAar-
mitceutical Era.
360 AMEBICAN MKDIOIN*;
THE PUBLIC SERVICE
[Anou^T cO, It 02
THE PUBLIC SERVICE
Health Reports.— The following cases of smallpox, yellow
fever cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, during
the week ended August 23, 1902 :
California:
Florida :
MansacbasetU :
Michigan :
Missouri :
Montana :
Nebraska :
New Jersey :
New York :
Ohio:
Pennsylvania:
Kbode Island:
South Carolina :
Utab:
Wisconsin :
Austria :
Barbados :
Belgium :
Great Britain :
India :
Bmali-pox— United Statbs.
San Francisco Aug. »-10..
fensacola Aug. 8-16 ..
Boston Aug. 8-16 .
Brockton Aug. 8-16.
Casen Deaths
2
4
..8 3
1
Italy:
Japan :
Russia :
Straits Settlements
Colombia :
Mexico :
Cambridge Aug. 2-16 5 3
Everett Aug. 8-l« 1
Fltchburg Aug. 8-16 1
SomervllTe Aug. 8-16 1
Detroit Aug. 8-16 2
St. Joseph Aug. 2-16 36
St. Louis Aug. 10-17 2
Butte Aug. 10-17 I
Omaba Aug. 8-16 4
Camden Aug. 8-16 I
Newark Aug. 8-16 3 8
New York Aug. 8-16 2 1
Cincinnati Aug. 8-15..... 1
Cleveland Aug. 8-16 58 8
Hamilton Aug. 2-9 1
Altoona Aug. 8-16 1
Jobnstown Aug. 8-16 3 2
McKeesport Aug. 8-16 1
Philadelphia Aug. 8-16 1 1
Providence Aug. 8-16 1
Charleston Aug. 8-16 2
Salt Lake City Aug. 8-16 2
Milwaukee Aug. 8-16 S
Smallpox— Foreign.
Prague July 26-Aug. 2 ...
July 29
Antwerp July 18-25.
Liverpool Aug. 2-9
London July 26-Aug. 2...
Bombay July 1.5-?^
Karachi July 6-20
Madras July 12-18
Palermo July 26-Aug. 2
Formosa :.May 1-31
Moscow luly 17-26
Odessa July 26-Aug. 2....
St. Petersburg July 17-26
: Singapore Junel4-July 12...
Yellow Fevek.
Panama Aug. 4-11
Coatzacoalcos Aug. 2-9
Progreso July 15-Aug. 9....
Cholera.
China: Nluscbwang July 12-19
Egypt: Aboukoukas Aug. 19
Asslout Province ...Aug. 19
Cairo .\ug. 19
Charkleh Aug. 19
Mlnleh Aug. 19
Alexandria Aug. 19
India : Calcutta Inly 12-19
Karachi July 6-20
Japan: Formosa May 1-21
Fukuoka Ken To July 10
Kobe July 15
Naga.sakl July 1-19
Mogi To July 20
Okayama Aug. 9
Tokyo July 9
Straits Settlements: Singapore. Junel4-July 12..
Plague.
Brisbane April 1-May 31...
Bombay luly 1.5-22
Calcutta July 12-19
Karachi July 6-20
Formosa May 1-31
Australia :
India:
Japan :
2
15
4
11
1
44
7
3
1
2
8
22
4
5
3
3
1
2
1
1
9
I
4
3
66
78
:«
Serious.
3
19
43
2
73
191
13(1
1
4
101
m
Prese
nt.
5
2
23
16
Present.
1
170
45
17
■Xi
19
74
60
700
555
Changes In the Medical Corps of the U. S. Army for
the week ended August 2:3, 1902 :
Wheeler, Lewis H., contract surgeon, Is relieved from duty at Fort
Yates and will proceed with Company M, Twenty-flrst Infantry, to
Fort l^lncoin. ISf. D., and there take station.
McCaw, Major Walter D.. surgeon, will proceed to Fort H. G.
Wrightfor duty during the Array and Navy maneuvers, and will
return to his station, Fort Wadsworth, after the close of the
maneuvers.
Carter, Major W. F.. surgeon, is relieved from temporary duty at
Fort H. G. Wright and will return to his station". Fort Totten, N. Y.
Girard, Colonel Alfred C, assistant surgeon-general. In addition to
his present duties Is detailed as a member of the board of medical
officers for the examination of candidates for admission to the
medical corps of the Army.
W1L.SON, Captain Jambs 8., assistant surgeon, is honorably discharged
as major and surgeon U.S. Volunteers, only, to take etTect August 15.
Wilson, Captain James s., assistant surgeon, having reported his
arrival at .San Francisco, Cal., in compliance with orders heretofore
issued, will proceed to New York City and relieve Major William
J. Wakeman, surgeon, from temporary duty as attending surgeon
and examiner of recruits in that city. Major Wakeman will pro-
ceed to Fort McPherson for duty.
Whittington, Major William L., surgeon, leave granted March 26,
Is extended one month.
COLLINS, First Lieutenant Chhistophkb C, assistant surgeon, exten
slon of leave granted July I2 is further extended seven days.
Dubois, Captain Prank, assistant surgeon, and Contract Surgeon
Clarenob a. Warwick arc relieved from duty at their present
stations and will proceed to Manila, P. I., for duty with station in
Manila.
smith. First Lieutenant Herbert M., assistant surgeon, is relieved
from duty at the Army pathologic laboratory, Manila, and will
report at First Keservc Hospital, Manila, for duty.
Beasley, Major Shadworth O., surgeon, will proceed to Cebu, Cebu,
for assignment to duty.
DAVIE.S, Captain William O., assistant surgeon. Is granted leave for
two months with permission to visit the United States.
Gregory, Verdo B., contract surgeon, will proceed to Fort Gibbon
for duty.
Edmonuson, Captain James J., assistant surgeon, having tendered his
resignation, is honorably discharged, to take eBect September 18.
Captain Edraondson will proceed to his home.
Edmondson, Captain James J., Is gninted leave to Include Septem-
ber 18.
Skinner, Captain George A., now at Fort Harrison, will proceed to
Fort Snelllng for duty.
VoSE, First Lieutenant William E., assistant surge<jn, having re-
ported ills arrival at San Francisco, Cal., In compliance with orders
heretofore Issued, will proceed to Columbia, Tenn., and report at
Columbia Arsenal for duty.
Holland J. W., contract ►urgeon. Is granted leave for one month
from August 20.
KARNES, Howard T., hospital steward, now at Galllpolls. O.. will
report on or before the expiration of furlough at Fort Du Pont for
duty at that post.
Blanchard, Robert M., contract surgeon, will proceed to his home,
Batavla, O., for annul ment of contract.
Ten Eyck, Major Bkn.iamin L., surgeon, Is granted leave for one
montli, from about September 1.
Beal, First Lieutenant Howard W., assistant surgeon, upon arrival
at Fort Columbus, will Join the Eleventh Battalion, Field Artillery,
at Fort Hamilton, or wherever it may then be, for duty with it dur-
ing its practice march to Montauk Point, L. I., and return to Fort
Hamilton. Upon completion of this duty Lieutenant Beal will
rejoin at Fort Columbus.
Dean, First Lieutenant Elmer A., assistant surgeon. Is relieved from
duty at Columbia Arsenal, Tenn., to take etfect upon the expira-
tion of his present leave, and win then proceed to Fort Strong for
duty.
Howell, First Lieutenant Park, assistant surgeon. Is relieved from
duty at Fort Clark and will then report at Camp Eagle Pass, Tex.,
for duty.
Snyder, C. D., contract surgeon, now at Fort Niobrara, will proceed to
Fort Clark for duty.
ChanKes In the Medical Corps of the U. 8. Navy for
the week ended August 2.3, 1902 :
Huntington, K. O., passed assistant surgeon, granted sick leave for
three montlis— August 15.
Lung, George A., surgeon, ordered to the Bureau of Medicine and
Surgery, Navy Department— August 16.
Changes In the Public Health and Marine-Hospital
Service for the week ended August 21, 1902:
Irwin, Fairfax, surgeon, granted leave of absence for one month
from September 1— August 18, 1902.
Kalloch, p. C, surgeon, granted leave of absence for three days from
August 27— August 20, 19U2.
Glennan, a. H., surgeon, to report at Washington, D. C, for special
temporary duty— August 19, 1902.
Brooks, S. D., surgeon, to assume temporary charge of the Portland,
Maine, quarantine, during absence on leave of Surgeon F. C.
Kalloch— August 20, 1902.
Grubbs, S. B., passed assistant surgeon, granted leave of absence for
fourteen days from August 19— August 18, 19u2.
Fricks, L. D., assistant suigeon. relieved from duty at Boston, Mass.,
and directed to proceed to Savannah, Georgia, quarantine, and as-
sume temporary command during absence on sick leave of Acting
Assistant Surgeon W. J. Llnley— August 19, 1902.
Heiser, V. G.. assistant surgeon, to proceed to Immigration Depot,
New York, N. Y., for special temporary duty— August 16. 1902.
Berry, T. D., assistant surgeon, granted Hfteen days extension of
leave of absence, on accoantof sickness, from August 17— August
14, 1902.
Trask, J. W., assistant surgeon, relieved from duty at Detroit, Mich.,
and directed to proceed to Fort Stanton, N. M., and report to medi-
cal officer in command for duty and assignment to quarters-
August 20, 1902.
KiMMET, W. A., acting assistant surgeon, granted leave of absence for
thirty days from August 10— August 14, 1902.
O'Reilly. W. J., acting assistant surgeon, granted leave of absence
for eight days from .-Viigust 18— August 14, 19J2.
Gahn, Henry, pharmacist and chemist, granted leave of absence for
twelve days from August 18— August 14, 1902.
Miller, Charles, senior pharmacist, granted leave of absence for
thirty days from September 9— August 14, 1902.
LaGranqe, J. v.. senior pharmacist, granted leave of absence for
thirty days from .September 2— August 16, 1902.
Watters. M. H., Junior pharmacist, granted leave of absence for
thirty days from August 18— August 14, 1902.
Appoinlment,
John William Trask, of Michigan, commissioned (recess) as assist-
ant surgeon— August 16, 1902.
Boards Convened
Board convened to meet at Southport, N. C, August 21, 1902, for the
physical examination of an officer of the Revenue Cutter Service.
Detail for the Board— Surgeon John Godfroy, chairman ; Assistant Sur-
geon T. 13. McCllntic, recorder.
Board convened to meet at the U. S. Marine-Hospital, Stapleton,
N. Y., August 25, 1902. for the physical examination of officers of the
Revenue Cutter Service. Detail for the Board— Surgeon Preston H.
Baliache, chairman ; Passed Assistant Surgeon A. C. Smith, recorder.
American Medicine
y
t'
GEORGE M. GOULD, Bditor
G. C. C. HOWARD, Managing Editor
CHARLES S. DOLLEY
MARTIN B. TINKER, Aaittant Kditori
fXinical Medicine
David Riesman
A. O. J. Kklly
H. H. CnsHiKO
Helen Murphy
General Surgery
Maktix B. Tinker
A. B. Craig
Charles A. Orb
Orthopedic Surgery
H. Augustus Wilson
COLLABORATORS
Obstetrics and Gynecology
WiLMER Krusen
Frank C. Hammond
Nervous and Mental Diseases
J. K. Mitchell
F. Bavary Pearck
Treatment
Solomon Solis Cohkn
H. C. Wood, Jr.
L. F. Appleman
Dermatology
M. B. Hartzbll
Laryngology, Mte.
D. Braden Kylb
Ophthalmology
Walter L. Pylb
Patftology
R. M. Pbarce
PcrautHBD Wkkklt at 1331 Walnct Stsmt, Pbiladklpbu, Br thb Awkwcak-Mbdicini Publubims Co«
Vol. IV, No. 10.
SEPTEMBER 6, 1902.
1.00 Yeakly.
The Early Choice of a Specialty in Medicine.—
In season and out of season we have for years insisted
that the universal and emphatic advice of every one
who wrote or spoke upon the subject — that a long period
of general practice should precede the choice of a spe-
cialty— has been an error. We have been frowned upon,
and far worse than that, and the voice of every editor and
graduation orator has rung all possible changes upon the
warning. At last we heave a sigh of relief and take
heart in our loneliness. The Bos/on Medicai and Sur-
gical Journal, in an editorial of characteristic soundnes.s
and common sense, shows the fallacy of the old teaching
and tegs the young practitioner to do one thing well
instead of many things ill, and not to waste valuable
time in superficial socalled general practice. " Make a
choice at the very earliest moment of the line of work
you design to follow." "Take anything that comes,"
our respected colleague says, is " positively unethical,"
and in this we heartily agree. The generalist is indeed,
as we have frequently contended, just as much a special-
ist as any other. To use his patients as "clinical mate-
rial " for gaining knowledge and acquiring technic,
when the special (or general) knowledge and the skill are
not to be usetl after the choice of a specialty, is not an
evidence of true professional spirit. It is surely a waste
of time and needleas postponement of the real work of
life. In fact, the great orators might as wisely have
urged that the road to general practice should lie through
intelligent si)eclalism. The truth is that the early choice
and prosecution of a specialty in an intelligent and
broad-minded manner is the way of future professional
progress.
The fatalism of epilepsy, according to Dr. Sprat-
ling, should be done away with. It has been too long
tlie rule mechanically and as a routine method to give
the bromids at once, regardless of cause or kind, and to
keep on giving them until the patient dies either of
epilepsy or of bromism, or of a combination of both dis-
eases. Now, however, there is growing up a resolve to
individualize every case of any disease, and even of
epilepsy, and as this plan is followed it is found that
epilepsy is often curable if the many causes of this terri-
ble affection are carefully and persistently sought for.
It is even more necessary to do this in the cast; of func-
tioiiiU and noninfectious diseases, such as epilepsy, than
in organic and contagious cases. Dr. Spratling's conten-
tion that the lesson is especially for the general or family
physician certainly needs reiterated emphasis, as it is
under his care that these patients first come. The ad-
vice is moreover especially needed because acute epilepsy
so soon becomes chronic, one seizure rendering the
nervous system less capable of resistance to the next,
until the epileptic habit is established. Hence the im-
portance of most careful examination into the cause,
the individual cause, as early as possible. This oppor-
tunity, as many others, is most fretiuently offered to the
general physician, and is one that requires all the diag-
nostic intelligence of the most expert in the profession.
The International Unificatiou of the Pharma-
copeias.— Secretary Hay has appointed Dr. H. C. Wood
and Dr. F. B. Power to represent the United States at
the International Convention for the Unification of the
Formula for Heroic Medicines, which is to be held at
Brussels, September 15. It is hoped that the convention
will work out some method by which concord, at least
so far as concerns the more powerful drugs, in the
strength of the galenic preparations of the various phar-
macopeias may be brought about. At present there
exists a useless and harmful discrepancy concerning the
mode of preparation and strength of many commonly
employed remedies. For example, a prescription con-
taining tincture of belladonna written in New York,
and i)ut up by any chance in Canada according to. the
British Pharmacopeia, would contain about twice the in-
tended amount of atropin ; while tincture of cantharides
varies from a 20^ solution in Be gium to a 1.25^ solu-
tion in England, the American being a 5fc preparation.
"Milk in Relation to the Pnblic Health " is the
title of a monograph by Dr. George M. Kober, published
by the Government Printing Office, Washington, as
Senate Document, No. 441 ; it should be in the reference
library of every physician and sanitarian. It is one of
those most excellent epitomes of a special suljec-t which
Amerimns have shown themselves so capable of pro-
ducing. Dr. Kober is chairman of the Committee on
Mediciil Legislation of the Metlical Society, District of
Columbia, and chairman of the tommittee on Public
Health. The work is an argument for the necessity of
the enactment of Senate bill entitled "A Bill to Regu-
AXXKICAN MBtaciKa)
EDITORIAL COMMENT
[September 6, 1902
late the Production and Sale of Milk and Cream in and
for the District of Columbia." The first part recites the
bill in question, shows the necessity for legislation, sets
forth the facts as to what is pure milk, etc. Appendix
A is devoted to the consideration of normal milk ; Ap-
pendix B to milk inspection, milk analysis and methods
of detecting adulterations and preservatives ; Appendix
C to dietetic and therapeutic uses ; Appendix D to the
causation of infectious diseases ; Appendix E to the
cultivation and study of bacteria ; Appendix P to im-
pure milk in relation to infantile mortality ; Appendix
G to a plan for the improvement of market milk ; Ap-
pendix H to abnormal milk and milk-borne diseases.
The book closes with a valuable bibliographic list of 164
titles, and tables of milk-typhoid, milk-scarlatina and
milk-diphtheria.
Epidemics of Typhoid Fever Due to 3Iilk Infec-
tion.— Dr. Kober, in the capital work to which we have
called attention, tabulates the chief facts of 195 epidem-
ics of typhoid which have been traced to milk infection.
It is plainly impossible to get statistics of all deaths
from this cause, and those even of the number of cases
are, of course, not complete. We have been at pains to
foot up the figures given in the table, and find that in
161 epidemics the number of cases ascertainable reached
the astonishing total of 10,247 ! The highest number of
cases in any epidemic was 508 with 69 deaths, at Glas-
gow, in April, 1880, and was traced to the washing of
soiled discharges at the dip-well from a dairyman and
maid sick with typhoid. In the next most serious epi-
demic there were 431 cases w^th 62 deaths ; it occurred
at St. Pancras, July to October, 1883. It invaded 276
families all using milk from a particular dairy farm
where enteric fever started in a boj^ who arrived July 6
and sickened July 16. In May, 1893, at Oakland, Cal.,
an epidemic occurred in which there were 862 cases, all
traceable to typhoid fever dejecta — thrown upon the
ground near a dam in the creek from which a pipe sup-
plied a tank with water for dairy purposes. In 148 epi-
demics the evidence showed that the disease prevailed at
the farm or dairy. In 67 the infection probably reached
the milk by soakage of the germs into the well water
with which the utensils were washed. In 16 instances
the intentional dilution with water (that was polluted)
was demonstrated. In 7 instances the infection is attrib-
uted to the cows drinking or wading in sewage-polluted
water and meadows. Four epidemics were caused by
ice cream prepared on infected premises. In 24 the dairy
employes acted as nurses. In 10 cases the patient was
sick with mild typhoid and continued dairy work
for the first week or ten days of illness. In 2
cases the milker was a night-soil scavenger. Dr.
Kober emphasizes the role of flies in conveying the
germs.
Epidemic of Scarlatina Due to Milk Infection. —
In Dr. Kober's table the data are gathered of 99 epi-
demics of scarlatina due to milk. In 70 of these there
wereat least 5,312 cases of the disease. In August and
September, 1887, an outbreak of scarlet fever occurred in
Dundee in connection with a number of dairy premises
from which milk was sent to Dundee. The number of
cases reported were in all 1,596. In December, 1886,
and January, 1887, at South Wimbledon and Merton,
England, there was an explosive outbreak which affected
as many as 119 persons in one day, mostly consumers of
one particular milk-supply ; 29 cases occurred among
patients supplied from a different dairy, but the cows
had been in contact with those of No. 1. A communi-
cable disease of the udder was the probable source of the
infection. There were in all 635 cases. In the Halifax
epidemic, in January, 1881, there were 510 cases and 86
deaths. The man who milked the cows and brought the
milk to Halifax had four children ill of scarlet fever.
Other methods of conveying the infection were: To
adults by cream in tea (" which seems in certain cajses
to increase the virulence of the poison "). Few children
using milk frona the same dairy were affected ; by flannel
cloths left by a peddler ; by the dealer pushing his arm
with infected coat-sleeve into the deep cans, etc. In 68
epidemics the disease prevailed at the milk farm or
dairy. In 6 instances persons connected with the
dairy either lodged in or had previously visited infected
houses. In 2 cases the infection was believed due to
the mere visit of the dairyman, taking the bottles with
him, to the infected house. In 17 instances the dairy-
men or maids were suffering from the disease while at
work, and in 10 cases the person acted as nurse while
doing dairy work. In 19 instances the infection was
attributed to disease among the milch cows. In many
cases in Great Britain both scarlet fever and diphtheria
have been attributed to local conditions of the teats of
the cows.
Nationality and the Reports of Epidemics from
Milk Infection Dr. Kober has tabulated 195 epi-
demics of typhoid due to milk infection, 99 of scarlet
fever, and 36 of diphtheria, a total of 330. Of this num-
ber 243 have been recorded by English authors, 52 by
American, 14 by German, 11 by Scandinavians, and
5 each by Australian and French. The explanation
given by Dr. Kober of this disproportion in different
countries is that the English and Americans usually
drink milk in its raw condition, while on the Continent
it is sterilized by boiling. The fact is not held to be
indicative of a greater interest in preventive medicine
in this country and in England. Dr. Scholl, of Wies-
baden, in 1891 is quoted as regarding the reports of epi-
demics by American physicians with distrust, to which
Dr. Kober replies our reports compare favorably with
those of the best English authors in the presentation
of evidence and attention to details. " Dr. Scholl
should remember," says Kober, " that it was, after all,
an American hygienist who first demonstrated the
nature of cheese poison, which as a venenum casei had
baffled the efforts of European scientists for over a cen-
tury, and that the same Professor Vaughan was also the
first physician who presented bacteriologic evidence as
early as 1881 in an instance of milk typhoid infection,
and that another American isolated in May, 1893,
Eberth's bacillus in suspected water, which was several
years before Itehn demonstrated the presence of
Bacillus colt communis in suspected milk, and five years
September 6, 19021
EDITORIAL COMMENT
Amebican Medicine 363
before Frankel and Kister found typhoid bacilli in
buttermilk."
Rev. Dr. Thomas Gallaudet.— The death last week
of Dr. Gallaudet in New York City has a triple signifi-
cance— national, sociologic and medical. His father, of
the same name, when a young man was struck with
pity for a little girl who had lost hearing and speech
from scarlet fever, and he soon taught her to read. The
child's father, Mr. Cogswell, of Hartford, Conn., was
thereby moved to secure the establishment of a school
for deaf-mutes at Hartford, the first in America. The
elder Gallaudet was sent abroad to study the subject of
teaching these afflicted ones, and secured Laurent Clerc,
a pupil of Secard, as instructor. The son who has just
died took up the work inaugurated by his father, and
during a long life has devoted his best energies to it.
He was the founder and manager of the Church Mission
for deaf-mutes in New York, of the Gallaudet prome in
Poughkeepsie, and of schools in Rome, Rochester and
Malone, N. Y., and in Beverly, Mass. His life was
largely spent in traveling from State to State, preaching
his silent sermons to the deaf and dumb. Eight deaf
and dumb clergymen were ordained as a result of his
enthusiasm. He founded the St. Ann's Free Church in
New York in 1852, and after forty years of labor there
he became pastor emeritus of the church in order that
he might give his time to broader missionary fields.
Both father and son had deaf-mute wives. One cannot
measure the added happiness which has been brought to
many thousands of pathetically suffering deaf-mutes by
the self-sacrificing labor of these noble men. Our pride,
both patriotic and professional, is also stimulated to a
grateful recognition of their splendid service.
How Clevelaud Was Rid of Smallpox,— Under
the above caption the Ohio State Board of Health pub-
lishes in the September number of the Ohio Sanitary
Bulletin a succinct statement of the facts regarding the
management of smallpox in Cleveland since July 20,
1901, the date on which began the administration of its
present health officer. The abandonment of vaccination
by that official, his use of formaldehyd disinfection, his
published statements regarding the efficacy of the lattt r
method, and the widespread use of those statements by
antivaccinationists, trade journals, and newspapers have
been curn-nt news of the past year. In view of the
many inquiries regarding the matter and of the harm
that was being caused, the State Board deemed it wise
to permit the health officer himself to explain matters
by an official statement to the public. For that purpose
he was invited to attend a meeting of the board held
Jun!^' 28, 1902. There he stated that he had stopped
va<*cination in Cleveland because impure virus had pro-
duced internal results, and that vaccination would be
resumetl when virus free from pathogenic organisms
could be obtained. An investigating committee of the
board met in Cleveland July 1 and decided to arrange
for the purchase of such virus. After this was done, a
second meeting was held July 28, when the health
officer informed the committee that he had already
made satisfa<;tory arrangements for securing virus, and
that he had appointed public vaccinators and instituted
free vaccination. It was then agrted that the health
officer should make, in response to an official inquiry, a
public statement that would remove all misunderstand-
ing regarding his attitude toward vaccination. This not
having arrived by August 7, he was requested by letter
to furnish such statement at once. In answer to this
request an unsigned (probably by oversight) communi-
cation was received August 11, giving in detail the
methods now being employed against smallpox in Cleve-
land. These include the appointment of vaccine physi-
cians, house-to-house work in infected districts with
vaccination of every person willing, disinfection, quar-
antine, etc. On this the board comments as follows :
As this statement in no way modifies or contradicts the
claim that an epidemic of smallpox was arrested in Cleveland
by disinfection, without vaccination — the only point at_ Issue —
and as this claim has done, and is still doing, great harm to the
cause of vaccination, the board deems it unwise to refrain
longer from publishing all the facts in connection with small-
pox in Cleveland. To allow the statement to go uncorrected
may induce other communities to abandon this most useful of
all measures in fighting smallpox — vaccination. Records show
that the city of Cleveland was handed over to the present health
officer July 20, 1901, practically freed from smallpox, and that
it remained so for some months, but that anotlier epidemic,
which is of a severer type than the previous one, has been going
on for se\ieral months in spite of disinfection. It will be a
relielf to all communities endangered by smallpox in Cleveland
to know that In addition to other proper measures to suppress
the disease, vaccination is now being vigorously pushed.
The Ohio State Board of Health is worthy of com-
mendation for the stand it has taken in this affair
by insisting on vaccination and by making public
all the facts from the beginning. In view of tlie pub-
licity given former statements we deem the subject of
sufficient importance to merit this somewhat lengthy
review.
Hereditary Fecundity and Hereditary Sterility.
—Medical men as well as students of zootechny are
aware that fecundity is hereditary; "the tendency to
have large families runs in families," and associated
with this is the tendency to twinning and to the exten-
sion of the child-bearing function beyond the usual
{jeriod. This is frequently illustrate<l in certain families
of sheep and horses. That sterility is also hereditary is
asserted by a writer in a recent number of the British
Medical Journal, and much may be said in support of
this seemingly paradoxical proposition. Fecundity is a
characteristic attribute of the lower organisms. Nature
is full of compensations, and in the struggle for existence
those organisms least able to care for themselves or for
their offspring are endowed with proletaneous powers
which ensure the survival of some by providing progeny
so numerous as to defy the most adverse conditions.
Authorities on heredity have calle<l attention to the fact
that in times of adversity the birthrate is incrcasetl.
The helpless oyster throws into the sea during a sin-
gle breeding season ovums enough to cover the seabot-
tom for miles about were it possible for them to reach ma-
turity, some 15,000,000 eggs being extruded by a single
spawning female within the course of a few weeks.
Many fishes whose habitat renders it impossible for
them to remain by their young approach the inverte-
364 Ahbsioan Msdicine]
AMERICAN NEWS AND NOTEB
IBeptbmber 6. 1902
brates in their begetting powers ; whereas other fishes
having acquired the habit of earing for their young, con-
struct a nidus and deposit therein a relatively small
numter of eggs. Corresponding to the ascending scale
of animal intelligence is seen a decrease in the number
of young produced. As the activities of life become
more complex with increased perceptive and functional
ability, so the period of infancy is prolonged and the
power of the parents to provide and protect through the
period of growth and adolescence is limited to a few off-
spring. There exists, therefore, a tendency to the limi-
tation of the total number of offspring produced by a
shortening of the productive period of life and to a
limitation of the number of young brought forth at any
given birth. High mental and nervous development,
therefore, seems to lead to a condition the opposite of
that of fecundity. Many of the lower orders of mamma-
lian society are markedly prolific, the higher orders
markedly the reverse. The tendency among highly
bred mares to barrenness or to but a brief period of
fertility, and this often restricted to alternate years, is so
great as to have made the exceptions noticeable and to
call forth an article in a recent New York paper on
"Old Mares as Producers." A correspondent sends us
a clipping of the same, with the query " How about the
relatively limited child-bearing period of the human
female?" to which we would reply that the matter lies
in the fact that the human female represents the highest
mammalian type, in which the development of mind has
made it possible to effect the survival of a greater pro-
portion of the offspring, and thereby to do away with
the necessity for extreme fecundity. That this relative
sterility is an acquired trait and that the ancestors of the
present day man were not so well adapted to survival is
evidenced by the atavistic phenomena of polymastia and
multiple births ; and the many-breasted Ephesian
Artemis, the goddess of fertility and fruitfulness, may
have had a traditional significance heretofore unsus-
pected.
EDITORIAL ECHOES
Sentimentalisni and Insolation. — There is no proof
that any horse every suffered from the effects of the
sun's rays falling upon its head. Among the human
race it is now a well-recognized fact that socalled " sun-
stroke" is due to a microbial invasion of the body ; in
other words, it is a kind of specific fever, and can be
contracted in the shade. — [The Medical Press.']
Rotation in office, oracularly announces our Dame
of the Delusions, "promotes wisdom, quiets mad ambi-
tion, satisfies justice and crowns honest endeavor."
And instantly, the " First Readers" and the "Second
Readers " begin to step down and out, leaving the posi-
tions they have found so pleasant and so profitable!
Thus, too, is the Itness of the Eddy " demonstrated,"
as they say in the language of the initiated, and a closer
approach to the ideal dead level established in the
"churches." Of course, the principle of "rotation in
office " does not apply to Mrs. Eddy. She remains, fixed
at the receipt of incense— and royalties. No " honest
endeavor " will lift its eyes to where she sits enthroned,
and she will take careful precautions to prevent "mad
ambition" from doing it.— [A': Y. Times.']
AMERICAN NEWS AND NOTES.
OENKRAIi.
Yellow Fever in Brazil. — Yellow fever is raging in the
Amazon valley, prostrations and deaths being numerous.
Former acting Consular Agent Fletcher, at Manaos, is reported
to have died of the disease .luly 23.
Jjaboratory Positions at Manila. — On September 9 an
examination will be held by the Civil Service Commission to
select a pathologist and bacteriologist for the government lab-
oratories at Manila. The salaries of the positions are ?1,800 and
1 1, 500 respectively.
Casualties by Cable. — The President has authorized the
transmission by cable of reports of casualties in the enlisted
force in the Philippines, these having come by mail since the
withdrawal of the volunteer regiments from the islands. It is
said this will mean an expense of $30 to the government for
each case.
Army Nurses of the Civil War. — The National Associa-
tion of Army Nurses of the Civil War will hold its annual con-
vention at Washington, D. C, OctoVjer 7 to 9, during the National
Encampment of the G. A. R. Through the courtesy of the
encampment executive committee free entertainment for three
days will be provided for all members of the association.
To Restrict Use of the X-ray. — At a recent meeting the
Chicago Electro-Medical Society adopted resolutions declaring
their opinion that the medical practice act of the State of Illin-
ois should be so interpreted, or if necessary so amended, as to
make it unlawful for any person not legally qualified to prac-
tise medicine to expose to the x-ray for any purpose whatever
any part of the living human body for hire or expectation of
reward.
Increased Mortality in Fraternal Orders. — At the
National Fraternal Congress, held recently in Denver, the
medical section received a report showing a deathrate at 40
years of 13.9%. It was also shown that the mortality had
increased 3% over that of the tables that have been standard in
the United States or Canada. Probable causes are the desire to
increase the membership of the lodges and the payment to
medical examiners of about one-third the sum paid by old-line
companies for a like amount of work.
New Division in Public Health and Marine-Hospital
Service. — Dr. Charles Wardell Stiles, zoologist of the Bureau
of Animal Industry since 1891, has been transferred to the
U. S. Treasury Department as chief of the " Zoological Divis-
ion, Public Health and Marine-Hospital Service of the United
States." The Zoological Division is a new division recently
authorized by Congress for the purpose of investigating the
practical relations of zoology to public health matters. It is
made a part of the hygienic laboratory authorized by Congress
several years ago.
Reduction of Medical Force in Philippines. — The War
Department has decided to reduce the force of medical officers,
hospital corps men and nurses in the Philippine Islands, a less
number being now required, owing to the reduction of the
forces in those islands and the decrease in the number of cases
of Asiatic cholera. The decrease will be made by the gradual
■withdrawal of volunteers. As the law authorizes 50 majors and
200 captains of volunteers in the medical department and directs
that they be discharged by February 2, 1903, or before, if their
services can be spared, the reduction will be made from this
class of officers. They will be given leave of absence for 30 days
before their discharges take effect. All those volunteer medi-
cal officers who are now in the United States on leave or for
other purposes will be discharged, and a sufficient number to
make up the remainder will be selected for discharge upon
recommendation of the chief surgeon of the division of the
Philippines. The commanding general of the division notified
the War Department some time ago that about 1,800 hospital
corps men would now be required in the islands, and the force
has been gradually reduced to that number. About 54 female
nurses are required and orders have already been issued look-
ing to a reduction to that number.
EASTERN STATES.
The Boston Insane Hospital is to be enlarged by the erec-
tion of four new buildings, bids for which have bean received
by the trustees.
Sanitation and Perjury. — The statement comes from New
Jersey that since the law requiring witnesses to kiss the Bible
when taking an oath was repealed perjury has increased to a
marked degree.
Hospital Nurses Discharged. — Twenty-two women nurses
have been discharged from the Worcester Insane Hospital, 11
for taking an evening off to which they were not entitled under
the rules and 11 for refusing duty after the discharge of the first.
8EPTEHBEK 6, 1902)
FOREIGN NEWS AND NOTES
[AMERICAN MEUICISB 365
This is the outcome of the nurses' dissatisfaction with their
worli and hours and the refusal of their demand for an addi-
tional night a week to themselves. Siuce their discharge the
nurses have made charges against the management of the insti-
tution which, if true, demand an investigation.
Bogus Medical Diplomas. — Two Armenians have been
arrested in Boston on the charge of forging the names of Tufts
College officials on a diploma of the medical school. One of
the men is a graduate of Tufts and the other, though an en-
graver, ranked among Armenians as a physician.
NEW YORK.
Trachoma AmonK Immigrants. — Nearly 100 cases of
trachoma were found among the steerage passengers of the " La
Gascogne," which arrived at Ellis Island August 25. The only
punishment that can be inflicted on the French line is to send
the immigrants back at its expense. This is inadequate and
is provided for in new immigration laws not yet through Con-
gress.
PHlLiADEliPHIA. PENNSYliVANIA. ETC.
Smallpox in Carbon County. — .\n ontlireak of smallpox
is reported from Parryville, a town of 500 population, near
Mauch Chunk. Nearly one-tenth of the people have smallpox
and armed outbreaks have occurred because of attempts of
neighboring townships to establish quarantine. The secretary
of the State Board of Health was appealed to and has succeeded
in restoring temporary friendly relations.
SOUTHERN STATES.
Telephone Calls to Physicians Free.— The Maryland
Telephone and Telegraph Company will give free use of pay
stations to persons desiring to call a physician.
Sweatshop IJaw.— Clothing contractors are contemplating
a legal resistance to the '" sweatshop law" adopted by the Mary-
land Legislature. They claim it is unconstitutional, the chief
objection being to the section prohibiting the manufacture of
clothing and other articles in any tenement or dwelling used
for sleeping and eating by more than one family.
Results in Pasteur Institute of Baltimore.— Reports
show excellent results from this department of the Baltimore
City Hospital, which was founded five years ago. A total of
322 persons have been treated, with 1 death. The cases are
divided as follows : Animals demonstrated rabid iiy subdural
inoculation of rabbits, 182; other animals or human beings
developed rabies as a result of the bite, 27 ; symptoms those of
rabies but not demonstrated, 58 ; escaped observation, no reli-
able history, 52 ; wounds not the result of bites, 5, and demon-
strated not rabid, 12.
Naval Medical Service. — Surgeon-General Rixey is formu-
lating plans to build a new naval hospital on the site of the old
observatory in Washington and the opening of a me<lical
school in the Museum building, where assistant surgeons will
receive a special course of training for several months before
entering upon the duties of active medical service. The old
hospital has been found entirely iuadetiuate to care for the sick
of the Navy and Marine Corps. It has been proposed to sell
the building or else turn it over to another branch of the gov-
ernment for other uses. If sold, it is estimated that the pro-
ceeds will he nearly sufficient for the new hospital, which will
be erected according to the pavilion plan. The opening of the
new medical school, although an independent proposition from
that of the hospital, will be an adjunct to that institution.
Althougli recruits to the medical staff are graduated physicians
It has Iteen found that they are ignorant as regards several im-
portant features of the medical service of the Navy, for instance,
military training, keeping of medical journals and papers per-
taining to tlie sick, and bacteriologic and laltoratory work.
The idea in establishing the school is to make every member of
the mediciU service expert along these lines. The Medical
Examining Board, which lias been ordered from New York to
Washington, will constitute the faculty. The physicians will
also l)e given clinical practice in connection with the hospital,
which will lie a great advantage to them and will also provide
the hospital with an expert medical force. It is proposed to
open the s(^hool sometime during the coming winter. Tlie iios-
pital plan will be sulnnitted to Congress at the coming session.
WK.STERN STATES.
St. liouis Medical Society.- The St. Louis Medical So-
ciety of Missouri announces a memorial address on " William
Beaumont, the First and (ireatest American Physiologist," by
Dr. William Osier, of .lohns Hopkins. The lecture takes place
at the Odeon, Saturday, October 4, at 8 p.m.
Antitoxin for Hog Cholera.— It is reported that a Dr.
Frederick Kemmer, of Wayne county, Indiana, has discovered
an antitoxin upon which injection into hogs will render them
immune from cholera for eiglit montlis, when the ojieration
~>iould be repeated. It is stated that of over 400 animals
treated with the antitoxin, not one has died. The disease has
been epidemic in the eastern part of the State for the past two
months.
Examination of Illinois School Children.— Acting upon
the suggestion of the Chicago Board of Education, the Illinois
State Board of Health has recommended that the school authori-
ties inaugurate a system of examination of the eyes and ears of
the school children of the State. The examinations are to be
held once yearly by teachers and embrace ten questions of a
practical nature which can be answered in five minutes. If a
defect is found, the parent is notified by a card of warning.
Examinations are not made compulsory.
Sanatorium Vetoed.— The Supreme Lodge of the Knights
of Pythias have vetoed the propdsition to erect a sanatorium at
Hot Springs, Ark., for sick and disabled knights. It was held
that under its constitution the Supreme Lodge had no right to
tax members for such purpose. The project had been before
the Supreme Lodge for 12 years, the government having offered
to give a 99 years' lease of five acres of land, upon which it was
Eroposed to erect buildings at a cost of ^0,000, the expense to
e borne by a semiannual tax of 10 cents on each member for
a period of five years.
Strange Disease Induced by Tick Bite.— Surgeon J. O.
Cobb, of tne United States Public Health and Marine-Hospital
Service, who was detailed to investigate a strange disease
prevailing in the Bitter Root and Lolo valleys, known locally
as "spotted fever," found it was confined to an area 20 miles
wide and 40 miles long on the west side of the valley. The
victims of the disease present a peculiar bluish spotting of
the skin, the tongue is coated, the face and extremities pufl'y
and bloated. This year it is almost invariably fatal. Investi-
gation resulted in the discovery that the disease was not
infectious nor contagious, but was introduced into the human
body by the bite of a tick. It was found that all ticks did
not harbor the parasite, leading to tl«e conclusion that the
host was some animal infested with the insects. This was ulti-
mately found to be the ground squirrel, and as this animal will
not cross water except under extraordinary circumstances, it
gives the necessary explanation why the disease is restricted in
area. The disease has been known in the valley for a number
of years, and has always been limited to the spring months.
An Indian has never been known to contract the malady.
Sources of Typhoid.— Cultures made in the city labora-
tory from foodstuffs obtained in the section of Chicago known
as the Ghetto revealed typhoid bacilli in nearly every instance,
'fhe results of the tests warranted the destruction of large
quantities of vegetables, meats, and fruits for sale in the open
market. For this purpose a squad of inspectors were sent into
the district with kerosene cans and orders to pour oil on all
condemned foods. A vigorous and united crusade will also be
made against the use of unfiltered or unsterilized lake water,
the other source of the disease. Heads of the higher educa-
tional institutions have signified their willingness to cooperate
with the health department in every way possible. To this
end printed slips will be issued to thousands of students arriv-
ing in tlie city from the outdoor life of the country and small
towns warning them against using city water unless it has first
ioeeu filtered or boiled. Pupils in both public and private
schools will be warned against the polluted water and formally
instructed as to the precautions that must be taken to preserve
good health. It is stated that the public school supply will be
turned oft completely if it is found that drinking water is
drawn directly from the hydrants. Housekeepers will also be
urged to boil all water before use.
CANADA.
Smallpox at Gracefleld. — It is reported that smallpox is
spreading rapidly in the Gracefield district. Shantymen mani-
fest unconcern, entering quarantined houses and thus spread-
ing the disease.
FOREIGN NEWS AND NOTES
OENERAIj.
Danger In Inkstands.- Newspapers report the discovery
in (Jerniany of a microbe that infests inkstands which are sel-
dom cleansed or corked. It is said to be pathogenic for rats and
guiiieapigs.
Professional Secrecy.- A physician in Nuremberg, Ger-
many, has l)een upheld by the courts for saying nothing of his
discovery of the mutilated remains of a newly-born infant in a
vessel under the bed of a woman he was called to attend. Crim-
inal orocoedings followetl, but the courts decided that the physi-
cian's interpretation of his duty was correct.
GREAT BRITAIN.
Decrease of Blindness.— Statistics indicate that the pro-
portion of blind to seeing persons in Great Britain has, during
366 Amkrican Mkdioinb
COKEESPONDENCE
[Beptembeb 6, 1902
the last 50 years, fallen from 1,020 to 870 in the million, a decrease
of more than 14fc. This is ascribed to better conditions of liv-
ing, improved surgery and the lessening of perilous employ-
ments.
New Patholojfic Scholarship. — Mr. J. Francis Mason, of
Oxfordshire, has offered a scliolarship of ^6200 yearly for the
pur])Ose of an investigation into the physiology and pathology
of the thymus gland, including if necessary collateral investi-
gations on the other ductless glands. The pathologic labora-
tories at Cambridge will be at the disposal of the scholar.
Cardiff Seamen's Hospital.— Nearly 40 years ago the
steamer Hamadryad was moored in proximity to the Cardiff
docks and fitted up as a hospital with 40 beds for the use of sea-
men who frequented that port. During the 40 years 225,000 men
have been treated in the hospital, and of late the need of a
building has been keenly felt. This was made possible by the
contribution of a site and fund by the late Marquis of Bute, and
the cornerstone was laid August 8.
Air in London Tunnels.— Recent investigations show that
the air in tunnels not contaminated by locomotives contains
about twice as much carbonic acid as the statutes permit in the
air of crowded workshops and factories. Engineers recommend
the closing of a trap door behind each train as it leaves a
station. It will then pusli vitiated air in front of it and the par-
tial vacuum created will be filled iby air from the outside
admitted through a channel constructed for that purpose.
Cigaret Smoking Among Juveniles. — A number of
school boards in England liave undertaken a crusade against
cigaret smoking among young boys. The Plymouth board
has issued circulars to the parents of children under their
charge, calling attention to the growth of the habit and its per-
nicious influences, and at Leeds the board has souglit the
assistance of eminent medical authorities in an effort to curtail
the habit. Other school boards have submitted reports com-
menting on the mental, moral, and physical deterioration of
the cigaret smoker as observed in the schools under their
charge.
CONTINENTAL EUROPE.
Serum Diagnosis of Tuberculosis. — The Societa Medico-
Chirurgica, of Bologna, offers a prize of 500 lire for the best
work on the above subject received before 1903. It may be
written in Latin, French or Italian.
Beer Consumption in Berlin. — Statistics show that the
annual consumption of beer by each individual in Berlin
increased from 199 liters in 1895 to 232 liters in 1900. The aver-
ages for all Germany were respectively 115 and 124 liters.
The Warsaw Pasteur Institute. — The Pasteur Institute
of Warsaw was founded 15 years ago, and during that period
some 500,000 antirabic inoculations have been performed.
Recently an accident occurred of which there had been no
previous example. Of 40 persons inoculated on November 29,
1901, 22 were attacked with illness. Of these 6 were children, 4
of whom died with symptoms resembling those of scarlatina.
The other persons presented only local manifestations. The
institute was closed and disinfected, and the performance of
Inoculation was not resumed till December 20, when fresh
spinal cords procured from St. Petersburg and Cracow were
employed. Dr. Palmciski, the director of the institute, is
investigating the cause of the outbreak, which is believed to be
due to secondary infection, and on completion of the inquiry
the results will be made public— [British Medical Journal.]
OBITUARIES.
Aaron Friedeuwald, an eminent physician and philanthropist of
Baltimore, August 26, aged 65, death occurring shortly after an opera-
tion for cancer of the stomach. Since 1873 Dr. Friedenwald had been a
member of the faculty of the College of Physicians and Surgeons. He
took an active interest in Jewish affairs and held many ofHces in their
various organizations.
James Thomas AVare, of Tllford, Eng., .July 30, aged 85. He was
active In founding the Metropolitan Convalescent Institution, the
pioneer of its class.
Cesare Taruffl, professor of pathologic anatomy in the Univer-
sity of Bologna and an authority on teratology, aged 82.
Michael Bradley, a retired army medical inspector, at Philadel-
phia, August 28, aged lii.
Karl Marlnus Kelsa, professor of pathology In the University of
Copenhagen, aged 73
Otto Braelimer, a strong advocate of medical and sanitary reform
in Germany, aged 04.
L. G. Mallam, of Armldale, New South Wales, of pneumonia,
June 29, aged -H.
ElHs C. Garee, of Baltimore, August 30, of typhoid fever.
CLINICAL NOTES and CORRESPONDENCE
[Communications are invited for this Department. The Editor la
not responsible for the views advanced by any contributor.]
SOME SURGICAL CASES MET IN PRIVATE
PRACTICE.
BY
BENJAMIN BRABSON GATES, M.D.,
of KnoxvlUe, Tenn.
Professor of Surgery in the Tennessee Medical College; Visiting Sur-
geon to the KnoxvlUe General Hospital, Knoxvllle, Tenn.
The following report of a serious gunshot wound of the
abdomen is taken from notes in my oa.se book as recorded at
the time of the injury :
Case I. — About noon on March 28, 1899, S. H., a lad, aged
7, accidentally shot himself with an old-fashioned five-inch bar-
rel revolver, S. A W. .38-caIiber. The ball entered at the umbil-
icus and made its exit just below the posterior superior spinous
process of the ilium, on the right side. I saw him about 30
minutes after the accident. He was pale, lying on tlie right
sidp, with legs drawn up toward the belly. There was no
tenderness over the abdomen and only occasional paroxysms
of pain. His pulse was rapid and feeble. His temperature
was 97° F.
On examination a large ragged wound was seen at the
former site of the umbilicus. The clothing, edges of the wound
and the skin around it were powder burnt ; this powder-burned
skin slipped off" easily. I advised operating at once, and the
family consented.
Dr. S. M. Miller anesthetized the patient and Dr. C. Dead-
erick assisted in the operation. I made an oblique incision
over the track of the ball, downward and outward, through the
deep epigastric artery. Blood gushed from the wound and I
removed several clots as large as a hen's egg. Turning out the
bowels into hot towels I discovered the mesentery perforated
in three places and blood oozing from as many divided arteries.
I stopped the hemorrhage with silk. The ileum was found
about four feet from the cecum and almost entirely divided in
its transverse diameter. I resected the gut an inch on either
side of the wound and closed the divided bowel with a Murphy
button, backing it up with a Cushing's silk suture. About 18
inches from the Murphy button toward the stomach I found a
hole one inch long by about one-third iucli wide on the convex
surface of the longitudinal diameter of the gut.
This rent in the bowel I closed with Lembert's and Cush-
ing's silk sutures. No further injury of the bowels being found,
I flushed out the belly.cavity with Hayem's salt solution. After
filling the belly cavity with the salt solution, I closed the
external wound with silkwormgut sutures, wrapped the
patient in hot blankets and placed him in bed with hot water
bottles around him. The operation consumed about one hour.
Dr. Miller continued giving him the Hayem's .solution under
the skin; this improved his pulse and respiration. At 9 p.m.
his pulse ran up to 138 and his respirations to 44. I gave 1 liter
of Hayem's solution under the skin. The pulse dropped to 124
and respirations to 35. The kidneys began acting very freely.
There never was any tympany and the temperature never went
beyond 101°. He commenced to take milk and cream by the
mouth .30 hours after the operation, and did fairly well for a few
days, when he contracted a severe cold, w hich made me very
uneasy for several days. This gradually improved, and he had
no further trouble till the sixteenth day after the operation,
when he had hard paroxysms of pain in the right iliac fossa,
inside tlie right thigh and the right knee, with contraction of
the right leg. I supposed this was due to tlie Initton passing .
through the ileocecal opening. On Friday, at 4 p.m., 17 days
after the operation, he passed the button. I kept him in bed
one week longer and allowed him to get up on the twenty-first
day. Prom that time he improved rapidly and has had no
untoward symptoms to the present time. May, 1902.
Remarks. — Had I treated this lad on the expectant plan, he
would have succumbed to the hemorrhage in a short while,
because one of the divided arteries was largerthan acrow-quill ;
again, the folly of waiting was seen when, upon opening the
belly I found the gut divided in twain in one place and a large
hole in another. Surely no more eloquent appeal for early
operations in gunshot wounds of the abdomen can be made
than is presented in this case. The wound of entrance was as
large as my thumb and the wound of exit about as large as the
diameter of a lead pencil.
Case II.— On March 12, 1901, at 2 a.m. I was called to the
City Hospital to see W. B., a young man who was shot in the
back while running from revenue officers. The ball entered
tlie Ijack on the right side tliree inches from spine and below
twelftli rib, coming out in front just below the tenth costal
cartilage. The patient was in shock, with blood oozing from
the wound in front. Dr. C. Deaderick saw the case with me.
September 6, 1902]
COERESPONDENCE
/AMERICAN MeDICINH 367
and we both advised operating at once, which was refused.
About 8 a.m. I was advised the patient had agreed to an opera-
tion. Assisted by Dr. Deaderick I opened the belly by an
oblique incision along the lower margin of the ribs. The liver
was cut at its upper and lower surface, about two inches from
its anterior border. The outer side of the ascending colon had
been grazed by the ball, bruising and tearing the outer coats for
half an inch. I closed the wound in the gut in its longitudinal
diameter with Lenibert sutures of silk, removed several fair-
sized clots, packed the grooves in the liver with iodoform
gauze, and allowed the belly wound to heal by granulation.
The patient recovered.
Remarks.— Ka.d I treated this patient by the expectant plan,
the wound in the colon would no doubt have sloughed, and the
patient would have died of septic peritonitis. Again, the
wound of the liver was of great interest to me, because of the
grooves cut in the upper and lower surfaces. I explain this on
one or two theories. First, the ball either split and both pieces
made exit at the same opening— hardly possible — or else the
ball having grazed the under surface of the liver with such
force as to throw it against the ribs with violence enough to
tear the upper surface. The liver was not perforated through
and through. The kidney escaped.
Case III. — Tuberculosis of gladiolus ; operation : recovery.
J. B. Wright, Avhite, a farmer, aged 69, always had good health
until October, 189(3, when he struck his "breast bone" against
a grain drill. From that time on he had severe pain of a sharp,
stinging character in his sternum, then "it rose and broke,"
discharging a quantity of " matter." He was operated on by
another physician the latter part of March, 1897, with negative
results. I first saw him the last of March, 1899. He had necro-
sis of the gladiolus. He was emaciated, quite feeble, with an
intermittent, irregular heart.
Opeja/(OM.— April 6, 1899, assisted by Dr. Joe Parker, I
removed the right side of the gladiolus, cureted, and packed
with iodoform gauze. As the wound apparently did not do
well, on May 12, 1899, I removed the remaining portion of the
gladiolus, the costal cartilages, and portions of the second
third, fourth, fifth and sixth ribs, packed, and allowed the cav-
ity to fill up from the bottom.
In spite of the arteries ligated, blood oozed from the entire
surface of the wound, saturated the dressings, and trickled over
his body. There being no firm background, I could not pack
the wound firmly without giving him pain and bringing on
violent paroxysms of coughing. However, on changing the
dressings once or twice the hemorrhage stopped. The following
day his pulse showed signs of weakening, and he had difficulty
in getting his breath. Mucus rose in his throat, and owing
to feebleness and pain in his chest he was unable to clear it
out.
I concluded he was having edema of the lungs and at once
took him out of bed and placed him in a large chair by a win-
dow. He began to breathe better, his pulse grew stronger, and
he went steadily ou to a permanent recovery.
Case IV. — Tuberculosis of the sternum, tvith removal of the
manubrium: recovery. The patient was A. F., white; male;
aged .04; occu]5ation, farmer. Father died of "old age" at
83 ; mother died at 67 of " cough ; " one brother died of asthma.
He has ten children, all living and healthy. He was well until
April 1, 1900, when he noticed a swelling over the manubrium,
wliich was painful and tender to the touch. This was opened
Tiy the attending physician. Two years previous to the appear-
ance of this tumor, when making a " hay-rack," he bruised his
breast bone by pressing on it with a brace-and-l>it.
On July 2.5, 1900, assisted by Dr. C. C. DeArmond, I operated,
removing all of the manubrium, except a thin shell on the pos-
terior surface of the upper border, for articulation with the
clavicle, which appeared healthy, and the cartilages of the right
second and third ribs, and packetl with iodol'orin gauze. The
cavity filled up, although a small fistula was left.
This listula persisting, and on account of the constant pain
under the right clavicle, I operated on him December 3, 1901,
assisted by Dr. C. Deaderick, removing the ccstal cartilages of
the first, second and third ribs; the first rib as far as the
axillary vein ; an inch or more of the second and third ribs, and
the under surface of the inner third of the clavicle, attempting a
complete operation as far as the eye could see, swabbed uie
wound witli lO^i! chlorid zn. sol. and packed with iodoform
gauze. The patient finally recovered.
liemarks.—lji addition to washing a tuberculous cavity
with iodin aud mercuric solutions, I think it a good routine
I>ractice every day, or at the most every two or three days, to
swab the tuberculous surface with a 10% zinc chlorid solution
until the patient is entirely recovered; because only in that
way can we ever hope to rid a tuberculous cavity of tubercle
bacilli and prevent mixed infection with pus microbes.
Case V.— J. Y,., male, farmer, aged .")8, was sent me by my
colleague, Dr. S. M. Miller. Family history good. Personal
history good up to -Vi years of age, when he noticed he had
difficulty in breathing and swallowing. At the same time he
noticed a tumor at the base of his neck in front. The tumor
disappeared, with the other symptoms, till the age of 56, when
the tumor reappeared, grew rapidly, and caused pressure
symptoms over the larynx and esophagus. On November 12,
1900, assisted by Drs. S. M. Miller and C. Deaderick, I removed
the thyroid gland, except the upper part of the right lobe. The
patient rallied, improved rapidly, and left for his home in
North Carolina in three weeks with the wound almost well and
the pressure symptoms removed. He has remained well nearly
two years, with no syirptoms of myxedema.
Case VI. — Mrs. J. D. P., white; housekeeper; aged 48.
Family history good. Personal history good up to July, 1901,
when she noticed that twice a month she would have cramps
in her bowels, followed by vomiting and constipation. These
attacks increased in force and frequency, with loss of flesh and
strength. It was Impossible for her to have a stool without large
doses of purgatives.
Examination showed the patient much emaciated ; abdomen
with thiu walls and distended with gas. She had a floating
kidney on the right side, and ou deep pressure a spindle-shaped
tumor could be felt in the left iliac fossa. An operation was
proposed and accepted. On February 13, 1902, assisted by Drs.
J. M. Boyd and C. P. McNabb, I opened the abdomen over the
tumor in the iliac fossa, and found this spindle-shaped tumor
involving the sigmoid flexure of the colon. I resected four
inches of the sigmoid, with its mesentery, in the center of which
was a hard nodulatf d mass constricting the lumen of the bowel.
I then united the ends of the cut, bowel with an extra large
Murphy button. The pAtient passed the button on the thirty-
sixth day. She is now. May 30, 1!»02, sound and well, eats
heartily and is having good stools daily.
Remarks. — An examination of the tumor after resection
showed a stenosis of the lumen of the bowel which would admit
an ordinary leadpencil. The mesosigmoid removed showed
two enlarged lymphatic glands, one of which had commenced
to ulcerate. I could discover no other affected glands. The
tumor, after removal, appeared more annular than spindle-
shaped, and was about as large as the extra large Murphy button.
The inner coats alone appeared to be involved, the serosa
appearing sound and as if a string had been tied around it over
some hard substance, causing a circular groove to be formed
around the entire bowel.
ON THE NATURE OF THE BLOOD CHANGES DUE TO
ALTITUDE.'
A Study of the Effect of Altitude on the Blood of Normal
Individuals and of those Suffering from Pulmonary
Tuberculosis, Made at the U. S. General Hospital, Fort
Bayard, N. M.
BY
JOSEPH J. CURRY, M.D.,
of Ft. Bayard, N. M.
The following preliminary report is based on recent studies
at Ft. Bayard of the effects of altitude ou the blood ; The val-
uable blood-counts at sea level were made, through the courtesy
of Colonel A. C. Girard, Assistant Surgeon-General, U. S. A.,
formerly commanding the General Hospital at the Presidio of
San Francisco, Cal., by Contract Surgeon C. F. Craig, U. S.
Army, pathologist of that hospital. The results of my observa-
tions to date on the nature of the changes in the blood of both
normal individuals and of those suffering from pulmonary
tuberculosis are shown in the following tables :
Table I.— Showing the character of therhaiige in normal blood due
to altitude.
Hemoglobin
Red ceiis
Leultooytes
StMJcltlc gravity
Voliuno of red cells by hematokrtt
Value of one degree of the heraatokrlt wale.
Average diameter of the red celLs
DItlerentlal count of leukoeytos :
Polvnuclear neutrophlles
Small lymphocytes
Large lympliooytesand transitional forms
Eoslnophiles
•Ft. Bayard,
N. M. Eleva-
< Sea Level.
tion 6,040 ft.
100)(
100;«
5,000,000
8,800,000
7,500
9,000
1,0.58
1,0.W
«K
t-,1.-^
100,000
134,000
7..V.
«.S625;i.
B2-70:<
6»<
l»-30;<
4-W
fU
0.6-4^
8.6?
lA report to the Hurgeon-Oeneral U. 8. Army, July 22, 1902.
«Calx>t, Boston, Mass. "Clinical E.\amlnatlon of the Blood."
' Cuiry, .) . .1 , from a study of the blood of 15 normal male adults at
Ft. Bayard, N.M.
868 AlfXBIOAK HKDIOINEI
CORRESPONDENCE
[September 6, 1902
It will bo seen with the increase in the number of red cells
there is such a proportionate diminution in the size of the indi-
vidual cells that their combined surface area, or the respira-
tory area of the blood, remains practically the same both at the
sea level and at the altitude of Ft. Bayard.
There is likewise no change in the hemoglobin percentage;
In the volume of red cells as determined by the hematokrit;
nor in the si)ecific gravity of the blood. The relative number
and difforential proportions of the leukocytes are found to be
the same as at sea level.
Table II.— Hhowing the rapid and marked Increase of the red cells In
patients transferred from the U. 8. General Hospital, Presidio of
San Francisco, Cal., tothe U. 8. General Hospital, Kt. Bayard, N. M.
3
6
Presidio 68^
Ft Bayard 9(V;
Presidio "frf
Ft. Bayard Siyi
Presidio i k&i
Ft. Bayard i 70;;
Presidio ivyi
Ft. Bayard -(yi
Presidio 80*
Ft. Bayard ; 9 ^
Presidio 1004
9if
10
Ft. Bayard
Presidio
Ft. Bayard
Presidio
Ft. Bayard
Presidio i 85;;
Ft. Bayard I 95*
Presidio j 7bf
Ft. Bayard 90i«
3,35«,000
6,iaii,ooo'
.3,«t8,000
f),fl8;,0(10
4,01(1,000
.5..5ai,000
■i.ma,(m
■l,7W,0OU
■l,l.')8,(X)0
5,880,000
4,904,000
6.048, 00
4,480,000
5,001,000
5,200,000
0,228,000
4,985,000
6,528,000
4,208,000
6,704,000
9„W0
21,400
8,000
12,000
10 200
12,.>10
«,780
16,600
8,-'.50
6,800
8,5N)
5,800
7,800
8,600
8,.50O
8,200
^..-
i 5 w
Eh i«
! 2,980,000
4 days.
2,a3(i,00O
4 days.
1,520,000
4 days.
1,314,000
4 days.
1,722,000
4 days.
1,144,000
4 days.
1,121,000
7 days.
1,028,000
6 days.
1,.513 000
12 days.
2,496,000
7 days.
Remarks.
Tuberculosis.
Tuberculosis.
Tuberculosis.
Tuberculosis.
Tuberculosis.
Tuberculosis.
Tuberculosis.
Tuberculosis.
Tuberculosis.
Tuberculosis.
Presidio— Sea level.
Ft. Bayard-6,040 feet elevation.
Note.— .\verage gain per patient, 1,723,400 red cells per cmm ■
average length of time between examinations, 5.6 days.
These observations were made on 10 patients who recently
returned from tropical service (in the Philippines) and who,
with one exception, were more or less anemic and in poor
general condition.
Nevertheless, I found similar changes in their blood, both
in character and degree, as occurred in normal individuals, and
in six cases in which the examinations were made within 24
hours after arrival no nucleated red cells or other evidence of
new red cell formation was observed.
The largest increase in the number of red cells was pre-
sented in Case I in which it was 2,980,000 in four days, an aver-
age of 745,000 per day.
In the 10 cases the average increase was 1,723,000 in 5.6 days
or 307,750 per day. In all the cases the urine was normal and no
apparent symptoms resulted from these blood changes.
Were the increase of red cells due to their concentration in
the superficial capillaries, the hematokrit would show an
increase in their volume, and if diminution in size were due to
the action of the atmosphere or of the lowered barometio pres-
sure on the blood after it had been withdrawn from the body,
there should occur crenation and other irregular changes in the
corpuscles. On the contrary, aside from their smaller diameter
the cells present the same appearance and react to stains sim-
ilarly to those at sea level.
THE TAMPON IN POSTPARTUM HEMORRHAGE.
BY
T. CATLETT GIBSON, M.D.,
of Salt Lake City, Utah.
To the Editor of American Medicine .—In your Issue of
August 2, on page 169, Dr. Baldwin, of Columbus, Ohio, asks :
Should the tampon be used in postpartum hemorrhage? "
In my opinion it is not good practice. The time required
to tampon the uterus eflfectually with an aseptic tampon is too
great to make it of much practical value, and if it is done hur-
riedly, as it would have to be in most cases, there is too much
risk of infection. For the above reasons, and also that I think
we have a better method at hand, I have never used the tampon.
I believe at present the use of intrauterine injections of hot
water, with or without astringents, to be the surest and safest
method. The water should be 110° P. The advantages of thw
treatment are that we always have hot water at hand ; that the
uterus will promptly contract when injections of it are made
within its cavity, and there is a minimum risk of infection. A
tablespoonful of common salt to a half gallon of hot water
makes one of the best injections. A fountain syringe should be
used, and the nurse instructed to keep it full. It should be
hung about five feet above the patient, and the water allowed to
flow before inserting within the uterus. An ordinary vaginal
nozzle can be used, as the os is patulous. One hand can be used
to make pressure externally if necessary. In a few minutes
the uterus should contract and hemorrhage practically cease.
Firm contraction can then be kept up by the administration of
ergot.
$200 IS OFFERED FOR A SUBJECT UPON WHICH
TO DEMONSTRATE BLISTERS OR OTHER PER-
MANENT ANATOMIC CHANGES PRODUCED BY
SUGGESTION.
BY
JOHN MADDEN, M.D.,
of Milwaukee, Wis.
Is it possible that an " act of the mind," " a mental atti-
tude," "an act of the will," or "suggestion," either with or
without hypnosis, can produce an anatomic change in a defi-
nitely limited part of the surface of the human body?
We have the evidence of Jendrassik, Krafft-Ebing, Liebault,
Bernheim and others that hypnotic suggestion or simply sug-
gestion has produced burns, some of them followed by severe
blisters and wounds which were weeks and months in healing,
resulting in indelible scars. These burns, according to report,
resulted from the patient being made to believe while in the hyp-
notic state that objects with which he was touched were red
hot, when, as a matter of fact, they were cold, or that nonirri-
tating substances, such as pieces of paper or postage-stamps
were bound or stuck to the body, the patient told that they
were sinapisms and that blisters resulted. Moreover, there
seems to exist a general but not well-defined belief among
physicians that a long continued concentration of the mind
upon a certain part or organ will beget disease, attended by
anatomic change in that part or organ. Some gf) so far as to say
that to "think tumor" in a part will produce tumor, to think
cancer will produce cancer, to think infiammation will pro-
duce inflammation. Prominent among physicians who have
expressed this opinion in writing are Forbes Winslow, C.
Lloyd Tuckey and Hack Take. On the other hand, equally
prominent members of the medical profession repudiate the
doctrine in toto. Indeed, the great majority of medical men
cast it away with scorn as unworthy of a second thought.
If the statements of hypnotists and others who hold the
belief mentioned are true, they assume an importance of the very
greatest magnitude to the profession of medicine. It is a re-
markable circumstance that no one has taken the trouble to
produce unimpeachable testimony on this point. Of the great
mass of evidence which I have examined I cannot find a single
instance in which it is above doubt. If the mind alone can cause
wounds of such severity. Christian science and similar cults
assume an importance which is second to nothing in scientific
medicine. If it is true, we must admit the miraculous cure of
disease.
It is solely for the purpose of attempting to settle this ques-
tion, so vastly important to medicine, that I make this offer. The
subject must permit the process to be watched from beginning
to end, photographed, and studied microscopically. For obvious
reasons, moreover, the anatomic change must take place within
a reasonable time. Wetterstrand's subject was blistered in
eight minutes after suggestion; Liebault's in a few hours. I
will entertain no proposition from a case requiring days or
weeks.
Bkptkmber 6, 1902]
SURGICAL FEATURES OF TYPHOID FEVER (American MKwciKfi 369
ORIGINAL ARTICLES
SURGICAL FEATURES OF TYPHOID FEVER.
Being a Summary of Those Cases with Surgical Features in
the Wards of the Johns Hopkins Hospital from June,
1900, to June, 1902, with Especial Reference to Intesti-
nal Perforation.
(From the clinics of Professor Osier and Professor Haisted.)
BY
THOMAS McCRAE, M.B.; M.R.C.P., Lond.,
of Baltimore, Md.
Associate in Medicine, .lolins Hopkins University ; Resident Physician
in the Johns Hopkins Hospital ;
AND
JAMES P. MITCHELL, M.D.,
of Baltimore, Md.
Instructor in Surgery, Johns Hopkins Univei'sily; Resident Burgeon
In the Johns Hopkins Hospital.
During the last two years there have been treated in
the .service of Dr. Csler at the Johns Hopkins Hospital
27.5 eases of typlioid fever. Recognizing the importance
of familiarity with typhoidal conditions, and especially
tho.se connected with the abdomen, and the value of fol-
lowing the complications from their onset, we have
made a practice of having the medical and surgical serv-
ices work in the clo.sest harmony. With this in view,
our rule is to have a surgeon see all cases i)resenting any
alidominal features. The importance of this is empha-
sized by Dr. Osier,' who says : " It .should be the especial
duty of hospital physicians hereafter to study with more
than usual care the earliest symptoms of perforative
cases. . . . What is essential in every serious case is
the watchful care of a man wlio will be quick to grasp
changes in the patient's condition, and who in such cases
is in hourly collusion with his surgical colleague. . . .
To leave the diagnosis of perforation to the attending
physician is in too many cases to sacrifice the life of the
patient."
In this paper the surgical features shown by the
patients in the past two years will be considered.
The cases with surgical conditions can be divided
into two groups: (1) Conditions other than abdominal ; (2)
abdominal conditions. Those in the first group are, as a
rule, of minor importance, and in the present series
include (a) furunculosis and abscesses, including otitis
media ; (6) periostitis and perichondritis, and (c) glandu-
lar affections. There have been no bone lesions or surgi-
cal complications or sequels other than those mentioned.
In the second group are include<l : (a) Affections of the
liver and gallbladder; (6) appendicitis; (c) intestinal
perforation ; (d) suspected perforation, operation ; (e)
conditions causing abtlominal symptoms, in which oper-
ation was not thought to be indicated.
(iKOUP I. — (ON'UITIONS OTHER THAN ABDOMINAL.
(A) Furunculosis and Abscesses, includiiif/ Oliiis Media.
— Furuncles have occurred in 13 cases. The most fre-
quent location was the buttocks. Some have been
single, but the majority multiple, and in one case they
were distril)utetl over the whole body. They occurred
as early as the eleventh and as late as the thirty-fourth
day, the majority being in the third and fourth week.
They had no influence on the course of the disease other
than to prolong convalescence. Two subsided, one rup-
tured spontane<jusly, and the others were treated by
simple incision. Cultures were obtained from two,
yielding in both instances NIaphj/lococcm py(xjene« aureus.
In view of the danger of infection from the bathtub, the
patients suffering with boils are bathed in isolated tubs.
Abscesses occurreil twiw^, once in the a.xiila on the
eighth day, and once on the buttocks on the twenty-
ninth day. Both were treated by incision, and cultures
showed Staphylofjoocus pyogenes aureus. There was one
ease of otitis media. On the thirty-first day there was
pain in the right ear with pain and tenderness over the
mastoid. The leukocytes were 3,600. The temperature,
which was running high, was not infiuenced. On the
thirty-fourth day the tympanum was perforated and a
small amount of thick yellow pus was obtained, from
which Streptococcus pyogenes was grown. The discharge
ceased in a few days. There was slight deafness.
(B) Periostitis and Perichondritis. — Periostitis was ob-
served twice, the clavicle being affected in both instances.
The first occurred on the thirty-sixth day, when distinct
swelling was observed over the outer end of the left
clavicle, which was very tender. Ati icebag was kept
constantly applied, the symptoms rapidly subsiding and
disappearing completely by the forty -first day. The
second occurred on the forty -first day, during convales-
cence, with pain, swelling and tenderness over the left
clavicle. The swelling was marked. There was severe
pain on pressure, and the skin was reddened. The tem-
perature rose to 101.5° ; the leukocytes were 12,000.
Under the constant application of an icel)ag the symp-
toms had subsided by the forty-fifth day, although the
temperature was still 100°. On the forty-seventh day the
temperature was normal and the tenderness gone, but
there was still some thickening about the clavicle.
Perichondritis : A single instance of this has been
observed, occurring in a very severe case on the twenty-
third day. The patient complained of pain on swallow-
ing. There was considerable swelling and tenderness
over the thyroid cartilage. The leukocytes were 9,000.
On the twenty-fifth day the swelling had increased and
the skin was reddened. Death occurred on this day. No
autopsy was obtained.
(C) Glandular Affections. — Enlarged cervical glands
were observed in one case on the sixty -seventh day, asso-
ciated with tonsillitis. They did not suppurate and sub-
sided in about 12 days.
Mastitis occurred in three cases, which have been
reported in full.'^ It appeared on the thirtieth day in
two of these cases, in which one breast was involved.
In the third case there was involvement of the right
breast on the thirteenth day ; of the left breast on the
eighteenth day and again on the fifty-second day. Sup-
puration did not occur. There was rise in temperature
and leukocytosis in two, in only one of which there was
suppuration. The nonsuppurative case subsided with-
out surgical interference. Two cases suppurated and
were incised. One of these yielded Staphylococcus pyo-
genes albus in cultures. In the other no culture was
taken. They healed rapidly and the complication had
no especial influence on the disease.
GROUP II. — ABDOMINAL CONDITIONS.
(A) Affections of the Liver and Oallbladder. — This
division includes one case of abscess of the liver and
five cases in which cholecystitis was suspected.
Cask I. — Typhoid fever ; intestinal hemorrhages ; abscess
of liver; leukocytosis 87,000; operation; postoperative intesti-
nal obstruction ; recovery.
Bacteriology: Cultures negative; no ainebas found.*
Bemarks. — This patient on admission was very ill,
his condition being rather alarming. The most striking
features were the pallor and the recurring paroxysms of
severe pain in the upper abdomen, between which he
was comparatively comf(jrtal)le. On examination the
persistent signs over the gallbladder region with jaun-
dice and the large leukocytosis were the most important
points.
On looking back over the case the diagnosis seems
simple. At the time, however, having cholecystitis
strongly in mind and the general opinion then tending
toward symptomatic treatment of this affection, the
mediciil side advised delay, especially as his general
condition rather improveti after admission, the con-
* Full reports of all cases summarized In this paper will be found In
Johns Hopkins Hospital Rei)orts, Vol. x.
370 AMERICAS MRDiciNE SUEGICAL FEATURES OF TYPHOID FEVER
[Sbptehbek 6, 1902
stantly increasing leukocytosis being the only sign of
progress in the process. The possibility of subphrenic
abscess was considered but no conclusion as to its origin
could be reached. Only one other case of abscess of the
liver in tyi)hoid fever appears in the hospital records.
In this the abscess caused no signs which were recog-
nized during life and was only found at autopsy. It
was part of a general staphylococcus pyemia.
Keen' states that in the literature previous to 1898
only 21 cases of hepatic abscess could be found, the first
having been reported by Lewis in 1841. In most cases
it is primary, though it may be secondary to suipura-
tion elsewhere. Most probably in a majority of cases
pyogenic bacteria and the colon bacillus alone may pro-
duce the abscess. Five of his patients had multiple ab-
scesses and 16 a single one. Of these 21 cases all but two
patients died. Dr. Keen states that " Surgery can do but
little actively in these cases. The treatment must be
entirely symptomatic. The few that recover must be
most fortunate and owe quite as much to nature as to
the surgeon."
Da Costa* in 1898 reported 22 cases.
Curschmann^ states: "I know of no case in which
the abscesses are due to a localization of the typhoid
bacilli in the liver."
Perthes'' in March, 1902, reports a esse of abscess of
the liver which developed during convalescence. The
patient had been out of bed for a week, when, on the
fortj'-ninth day, the temperature began to rise. On the
sixty-ninth day he complained of pain in the epigas-
trium. He was operated upon on the eighty-first day
and a large subphrenic abscess was drained. The patient
recovered. Coverslips from the pus showed strepto-
cocci and bacilli. Baeillm hyphosus was isolated from
cultures. He reviews the reports of the cases, in three
of which, including his own, Baeillm typhosus was
obtained in cultures from the pus in combination with
pyogenic cocci. All three of these cases were published
after the work of Keen and Curschmann.
Cholecystitis has been suspected in five cases of this
series during the course of typhoid fever. Three patients
were not operated on and recovered ; in one perforation
of the gallbladder (x'curred, followed by general perito-
nitis and death, without operation, and the fifth was
operated upon and recovered.
Case II.— Typhoid fever; relapse; symptoms of cholecys-
titis on eighth day of relapse ; recovery without operation.
Remarks. — This case at the time impressed us as one
of cholecystitis. The pain was so severe in the right
hypochondrium, localized over a small area and associ-
ated with such marked muscle spasm and leukocytosis
that the suspicion seemed at any rate well founded. It
is of interest that this occurred during the relapse.
Case III.— Typhoid fever; convalescence; symptoms of
cholecystitis on nineteenth day and again on fiftieth day ; recov-
ery without operation.
ifewarAs.— There seemed little question as to the
diagnosis in this case. In view of the unfortunate result
from noninterference in Case V we would be inclined
now to advise operation as offering the greater safety.
Case IV.— Typhoid fever; mild attack; convalescence;
symptoms of cholecystitis on twenty-third day and again on
forty-eighth day ; recovery without operation.
i?ema;-fe.— This case closely resembles Case III,
except that here there was no jaundice. Convalescence
was established. The patient was doing well when the
sudden rise of temperature accompanying the abdominal
symptoms was ample evidence of an acute intraabdom-
mal process. Here, as in Case III, the trouble developed
while the temperature was normal in convalescence.
Case V.— Typhoid fever ; severe attack ; abdominal symp-
toms marked throughout; symptoms of cholecystitis on the
ninth clay : intestinal hemorrhage ; no operation ; death.
Autopsy: Cholelithiasis; perforation of gallbladder; gen-
eral peritonitis.
Remarks.— 'Vaxii patient was seen constantly in sur-
gical consultation. Undoubtedly operation should have
been advised when first seen. The diagnosis of chole-
cystitis was evident, but because the gallbladder was
never distended, operation was not advised. The
possibility of the perforation of an undistended gall-
bladder was never considered. The case is important as
suggesting the advisability of an exploration of the
abdomen when the diagnosis of cholecystitis is evident.
It is difficult to state when the actual perforation
occurred. A strong factor in its production was undoubt-
edly the presence of a single large stone.
Case VI.— Typhoid fever ; severe attack ; abdominal symp-
toms on sixth day ; symptoms of cholecystitis on twenty-second
day ; operation : cholecystostomy ; recovery.
Bacteriology : Bacillus typhosus of pure culture from gall-
bladder ; cultures from peritoneal cavity negative.
Retnarks. — In this case there was no question as to
the diagnosis, the symptoms from the first pointing to
an inflamed gallbladder. The rise of temperature to
101.8°, the presence of tenderness and muscle spasm in
the right hypochondrium, with, lastly, the presence of a
visible rounded timior, associated with a rising leukocy-
tosis, all evidenced an active process. The boy himself
realized the advisability of operation and begged to have
it performed.
Revieiv of the Symptoms. — In considering these five
cases it is seen that the time of the onset of the cholecys-
titis varied widely. The earliest was on the ninth day
and the latest on the fiftieth day during convalescence.
In two it occurred after the temperature had become
normal and in both it caused a sharp sudden rise to over
104°. In one it came on during a relapse. The onset
was sudden and with pain in all. In one there was pain
and vomiting and in another a chill.
Of the symptoms, pain occurred in all, usually fairly
constant, but in Case VI paroxysmal. The pain was
severe and a striking feature in all. Tenderness or pain
on palpation below the right costal margin, and with it
muscular rigidity or muscle spasm occurred in all. Vom-
iting was present in only one instance. There was a
chill in one after the onset. Definite rise in tempera-
ture, associated with increased pulse-rate, occurred in
four of the cases, in only one of which, however, was the
rate of respiration also higher. Jaundice was present in
one case only. Leukocytosis, varying from 10,000 to
20,000, was present in four instances ; in the fifth the
highest count was 7, .500. The gallbladder was positively
felt in only one case. The duration of symptoms, when
no operation was done, varied from four "to eight days.
The picture of symptoms as shown by these cases is a
sudden onset with pain in the right hypochondrium
with which chill or vomiting may be associated.
The pain continues with tenderness and rigidity or
muscle spasm on palpation. Moderate leukocytosis is
usually found. The temperature and pulse-rate usually
rise. The gallbladder may be felt. Jaundice of a slight
grade may follow.
Treatment. — With expectant treatment three patients
recovered and one died, who at any rate would have had
a much better chance with early operation. The only
operative case recovered. Tapping cannot be consideretl
now a justifiable procedure, and the indications that
justify tapping surely justify exploration. To advise
tapping a suspected appendix abscess is about as rational
as to advise tapping the gallbladder with cholecystitis.
As to the indications for operation, one must decide in
each case. Certainly with well-marked and severe
symptoms, as in Case III, an exploration means less risk
to the patient than waiting. Of course, seeing a patient
from hour to hour, one hopes to appreciate increasing
gravity in the condition and advance in the symptoms,
but error is easy ; a perforation may occur without
much increase in the symptoms and the time for inter-
ference be past, or at any rate the chances for recovery
diminished. Exploration means but little risk. Ex-
Septembkk tj, 19021
SURGICAL FEATURES OF TYPHOID FEVER
[Amebican Mkdicinb 371
pectant conservatism may mean the same, or it may
mean the loss of the patient, as we found in Case V.
Cholecystostomy is one of the most satisfactory cocain
operations, as is shown most strikingly in Case VI,
the patient being a boy only 8 years of age, and children,
as a rule, being the poorest of cocain subjects.
The boy scarcely complained at all, while his pulse
and general condition were absolutely unaffected. As
is brought out by Lennander,' there is great difference
in the sensibility of the parietal and visceral peritoneum.
The gallbladder itself can be handled and sutures passed
through its walls without any pain. The parietal peri-
toneum, on the other hand, must be treated most care-
fully, and in introducing the gauze packing we have
found it of the greatest assistance to depress the gall-
bladcler and pass the gauze into place along the surface
of the gallbladder, allowing it to touch the parietal peri-
toneum only when pushed up by the gallbladder return-
ing to its natural position. We may add that the
gallbladder should always be explored for stones,
although the presence of bile will show that there is no
permanent obstruction of the cystic duct, and will
exclude the probability of a lasting biliary fistula.
(B) Appendicitis. — This group may be divided into
two classes : firstly, those which are admitted with
symptoms strongly suggesting appendicitis, and sec-
ondly, appendicitis developing in the course of typhoid
fever. In the first class are three cases. In the second
there is a single case.
Case VII. — Typhoid fever; admitted with diagnosis of
appendicitis ; no operation ; recovery.
Case VIII. — Typhoid fever; admitted with symptoms of
appendicitis ; no operation ; recovery.
Case IX. — Typhoid fever ; marked symptoms of appendi-
citis on admission ; no operation ; recovery.
These cases are noted especially to emphasize the
necessity of keeping in mind the possibility of mistak-
ing the abdominal symptoms of typhoid fever for those
of an acute appendicitis. The onset may be moderately
acute and not a suspicion of typhoid fever even enter-
tained. The mistake is not uncommon, and one hears
of patients with typhoid fever being operated on for this
rea.son. In the present case it may be said that in none
was the diagnosis long in doubt. The low leukocyte
count in typhoid fever is usually a very helpful point.
In none of these three cases was the count above 7,000.
Only once have we observed an acute appendicitis
developing during the course of typhoid fever. There
was no evidence that this was due to a typhoid process,
either through ulceration or infection of the appendix
with the typhoid bacillus, the only organisms obtained
teing liaeiUus siMilis and saprophytes.
Case X. — Typhoid fever ; abdominal symptoms on twelfth
day ; operation : preperforative ulcers and acute appendicitis ;
death.
Autopsy: Typhoid septicemia; no perforation of intes-
tines.
Bacteriology : Bacillus sublilis and saprophytic bacilli
from peritoneal cavity at operation.
Remarks. — It would seem impossible to make a defi-
nite diagnosis of appendicitis, as the symptoms cannot
be distinguished from those of perforation. In this case
it was clear that there was some acute process in the
right iliac fossa and the condition undoubtedly demanded
an exploration, but it is well known that tliis same
region presents most frequently the signs of perforation.
Even at the oi)eration it was impossible to siiy whether
the symptoms hatl not been in great part due to the con-
dition of the intestines and the inflamed peritoneum,
both parietiil and visceral. Directly beneath the point
of greatest tenderness there was an area of inflamed
parietal peritoneum, and directly l)eneath this two
ulcerated Peyer's patches in the ileum. These patches
were elevated on the serous surface and surrounded by a
zone of prominent and tortuous lymphatics and blood-
vessels. The handling of this intestine caused the
patient to complain of the severe pain which he had felt
on pressure over this region before operation. The find-
ings about the appendix, however, were undoubtedly
due to an acute inflammation of this organ and entirely
separate and independent of the condition of the ileum.
In spite of the outcome in this case the advisability of
operation was not questioned. The subject of acute
appendicitis occurring in the course of typhoid fever,
and the importance of immediate operative interference,
has been discussed by Deaver.*
(C) Intestinal Perforation. — During the period covered
by this report, perforation of the intestine has occurred
eight times, twice in association with intestinal hemor-
rhage. Seven patients were operated upon ; in the eighth
case operation was not advised on account of the hope-
lessness of the patient's condition. Two have recovered
and a third lived one week after the operation, dying
then of profound toxemia. Cases XII, XIII and XVII
have been previously reported by Dr. Osier.'
Case XI. — Typhoid fever; perforation of the ileum on the
eleventh day ; operation : suture of perforation and drainage ;
recovery.
Bacteriology : Bacillus coli communis, B. proteus vulgaris
and other ijacilli from peritoneal cavity ; no typhoid bacilli.
Remarks. — This case is especially instructive, as we
saw it from the beginning and constantly had i>erforation
in mind. The case has to be studied in two periods :
First, from onset about midnight (between September 6
and 7) till 7.30 a.m., and second, after 7.30 a.m. Dur-
ing the first period the question was doubtful ; in the
second, the existence of a severe abdominal complication
was clear.
Review of Symptoms. — Onset was sudden, with complaint
of severe pain while the patient was on the bedpan, beginning
in the penis and extending into the abdomen.
Pain was very variable. At times there were severe parox-
ysms, during which the patient would not speak. With the
pain of onset there was profuse, clammy sweating. The pain
did not increase as the symptoms progressed.
Facies sliowed nothing especial until 9 a.m.
The abdomen showed no distention until i) a.m., i. e., for
nine hours.
Respiratory movements were always well marked. The
walls had been held rather tensely since admission ; they were
somewiiat more so during the night, but before 9 a.m., no
muscle spasm was made out. Tlie tenderness was marked
from the beginning, at first just to the right of the navel, and
afterward almost general. There whs no dulness in the flanks.
Liver dulness was absent from admission, in the right
mamillary line, and present throughout in the right axillary
line.
Respirations increased in rate at once and remained high.
Pulse showed little change.
Leukocytes : The possibility of the count of 8,000 at 3.30 a.m.
being the first wave of leukocytosis was considered, but the
later counts did not seem to Ijave any especial significance and
no conclusions could be drawn from them.
Case XII. — Typhoid fever: perforation of ileum on six-
teenth day; operation: suture of perforation, drainage; general
peritonitis; death.
Autopsy : General peritonitis.
Bacteriology : Typnocolon bacillus from peritoneal cavity.
Remarks. — The onset was very sudden and decided.
The patient cried out with severe pain, which he referred
principally to the penis. The subsequent pain was
paroxysmal, sharp in character, coming on without
handling of the abdomen. There was no sign suggestive
of shock. The pain was very great in severity and was
referred to the lower hypogastrium.
Tenderness, which was present from the onset, varied
in amount and situation, but was fairly constant in .the
lower hyj)ogastrium.
The respirations were practically unchanged, usually
26,
At the onset at 9.05 a.m. there was more rigidity in
the abdomen than at any later {)eri(Kl. It was not constant.
Respiratory movements were a little less marked in the
morning. Distention increased rapidly during the after-
noon. It had bet^n noticed that in this patient the
abdominal symptoms were marked tiiroughout his
whole illness, and he was carefully watcht-d for the signs
of a perforation. The delay in recognizing the condition
372 AMKEicAN M.DimK«j SURGICAL FEATURES OF TYPHOID FEVER
[Bkptember 6, 1902
can be attributed partly to the severity of the abdominal
syniptoins throughout his whole illness. His death was
due to general streptococcus peritonitis.
Cask XIII. — Typhoid fever; perforation of ileiitn on
elKht<>entli clay; operation: suture of^perforation and drainage;
broncliitix ; protrusion of intestines from wound seven days
after operation; operation; replacement of intestines; recovery.
liemarkn. — The onset in this case was with severe
pain, which was paroxysmal in character. Fortunately,
night rounds were being made at the time of onset of
one of these attacks and attention was therefore drawn
to the patient. JIad it been a few minutes later when
the pain was over and the patient not conii)laining, the
condition might not have been recognized until the next
day. For some days before this the patient had com-
plained of abdominal pain, with which there had been
leukocytosis, but no very marked local abdominal symp-
toms. ' The pain with the perforation was much more
severe. It was more or less constant, but with exacer-
bations of great severity. The local abdominal symp-
toms were well marked. The tenderness, muscle spasm,
diminished liver dulness, without any great increase in
the distention and movable dulness in the flanks, seemed
almost conclusive. The sudden increase in the leuko-
cytes is to be noted, but the fact that this had also
occurred before the perforation rather diminished its
value. Operation was done about eight hours after the
perforation.
Cask X IV.— Typhoid fever ; perforation of ileum on thir-
tieth day; operation: suture of perforation, drainage; im-
provement; death one week after operation : no autopsy.
Bacteriology: Bacillus coli communis {roa\ peritoneal cavity.
Remarks. — Perforation occurred probably at 12 noon
on September 15, with sudden onset of pain. The opera-
tion was done at 8 p.m. The pain was sudden and
severe at the onset, and recurred at intervals of about
three hours, apparently only with the movements of the
bowels. After 4 p.m. there was little complaint of pain
excepting on palpation.
Review of Symptoms.— Hesxiirationfi increased almost at once,
and at 3 p.m. they were only 24, but usually over 30. The pulse
had increased. Since admission the pulse liad been rapid,
small and running.
Bowels : Frequent movements, six in three hours ; thin and
watery. Considerable pain with each.
Hiccoughing and vomiting: None.
Facias: The boy had looked badly since admission, emaci-
ated and sick, with a sallow grayish color. There was little
change before the operation.
Temperature remained elevated.
Leukocytes increased 44 hours after perforation to 8,000, and
5J hours to 12,000.
The abdomen was flat and slightly excavated until about 6
p.m.,' after which it became level and was at 7.30 slightly full.
The respiratory movements were marked until 6 p.m. Then
they rapidly became limited, first below the navel. There was
marked general tenderness at 3 p.m., later there was little or
none. There was no special local tenderness until about 6 p.m.,
and no definite or constant muscle spasm or rigidity made out
during the first six hours. Liver dulness was diminished at
3 p.m., with an undistended abdomen ; no special change until
about fi p.m. No dulness in the flanks was made out at
4.30 p.m. Auscultatory percussion was of no assistance. Rec-
tal examination was negative.
It is seen that the symptoms can thus be divided into
two periods, those during the first six hours and those dur-
ing the second two hours. Six hours after perforation there
was a definite change, after which time all the signs and
.symptoms were much more definite. At the operation
we were very hopeful of recovery, as the process in the
abdomen was comparatively local. So far as the perito-
nitic condition was concerned he did perfectly well.
Death at the end of a week resulted from the toxemia
due to the severity of the disease. It may be correctly
said that the perforation and operation were only inci-
dents in the course of the attack, and did not contribute
to the fatal issue.
Case XV.— Typhoid fever ; myoma of uterus ; bronchitis ;
perforation of ileum on sixteenth day ; operation : suture of
perforation, drainage ; death.
No autopsy.
Bacteriology: Bacillus coli communia from peritoneal
cavity.
Itemarks. — The onset seems to have been sudden at
9.30 p.m., although there was some pain complained of
l)etweeii 8 p.m. and 9 p.m. The symptom to attract
attention was the complaint of pain. The operation was
done at 1 a.m., 3} hours after perforation. Pain was
evidently severe. The patient had been very dull and
drowsy early in the day, but in spite of this she groaned
with the pain. It was not continuous, but paroxysmal.
It was fortunate that she was having one of these parox-
ysms when the resident physician came into the ward, as
otherwise the gravity of the condition might not have
l)een so strongly impres.sed upon him.
^w»ipto»i«.— Abdomen : There was no distention apart from
that due to the myoma.
Respiratory movements were present above, but absent
below the navel and apparently rather less than they had been
in the morning.
Pain was referred to the neighborhood of the umbilicus.
Tenderness was marked with any pressure, more on the
right side below, the greatest tenderness being in the right iliac
fossa.
Rigidity was not marked but slight on firm palpation.
Muscle spasm was not present.
Liver dulness was present and not especially diminished.
Flanks: Some dulness in the right. The patient was not
turned to make out the presence of shifting dulness.
Respiration perhaps slightly increased but not markedly.
Pulse-rate was somewhat higher but no special change.
General appearance: The facies was not very striking when
quiet, but marked distortion as with pain followed when the
abdomen was palpated. The most striking thing was tlie find-
ing of the patient with the legs drawn up, groaning with pain,
which increased greatly on palpation — a picture seen in typhoid
fever usually only with perforation.
Leukocytes showed no special change. Only one count was
made before operation after the symptoms began.
Bowels : There was apparently no movement or expulsion
of flatus after the perforation. The operation was done only 3J
hours after perforation. The peritonitic condition offered the
most favorable prognosis. The operation was short and had
no effect on the patient's general condition.
Death can be attributed to the general typhoidal con-
dition. The patient was extremely ill on admission and
a grave prognosis had been given before the occurrence
of perforation.
Case XVI. — Typhoid fever ; intestinal hemorrhage ; per-
foration of ileum on twenty-fifth day; operation: suture of
perforation, drainage; death.
Autopsy : Extensive peritonitis.
Bacteriology: Baallus typhosus and Staphylococcus pyo-
genes aureus from peritoneal cavity.
Remarks. — The probability is that the perforation
occurred at 5 p.m. on April 21. When seen at 7 p.m.
the general appearance should have carried more weight.
This suggested some marked change, although the abdo-
men was negative. On April 22 there were several
confusing facts. The opium had masked the symptoms.
The abdominal features were slight and the pulse had
become markedly better. At 11 p.m. on April 21 it was
144, of poor volume and tension, while on April 22 it
had fallen to 108 and was of decidedly better volume.
The operation was done at 6 p.m. on the latter date.
Mcvicw of the Symptoms in Detail.— If the onset was at 5 p.m.
on April 21, which seems probable, it was sudden, associated
with severe acute pain and an intense shaking chill.
Facies : This was striking at the time of onset and shortly
after, principally on account of the profuse sweating. Other-
wise there was no special change until about 4 p.m. on April 22.
Hiccoughing : Some occurred ou tjje twenty-second, which
might have been explained by the abdominal distention.
Vomiting : Occasional during the twenty-second, once after
the taking of a dose of turpentine.
Respirations: These showed no special change; rose to 28
at midnight on the twenty-first, but were slow on the twenty-
second, averaging about 20.
Pulse: This was markedly affected at the onset on the
twenty-first, rising from 100 at 4 p.m. to 160 at 6 p.m. This we
thought was probably due to the hemorrhage. Afterward the
volume and tension became better, which was very misleading.
Abdomen : Distention was moderately marked on the
twenty-second in the morning ; rather less marked in the after-
noon. The respiratory movements were good throughout, both
above and below the navel. Rigidity was marked with the
distention on the twenty-second. Muscle spasm was only
September 6, 1902j
PLA.STER-OF-PAEIS JACKETS
lAMKBICAN MKDICtNE 373
obtained at 4 p.m. on the twenty-second after the effects of the
opium had worn off.
I/iver dulness was much diminished after the onset on the
twenty-first. No special change afterward, except slight dimi-
nution in the midaxillary line.
Percussion : Auscultatory percussion was negative. There
was some dulness in tlio right flank throughout.
In considering the abdominal symptoms, two things
have to be Itept especially in mind — first, the occurrence
of hemorrhage, and .second the opium given from 8 p.m.
on the twenty-first to 0 a.m. on the twenty-second. A
very unusual feature in this case wa.s the .severe chill at
onset with a sudden elevation of temperature from 103°
to 106°. After the chill there wa.s almost a continuous
drop. This is the only case in which we have observed
a chill at the time of perforation, wherea.s a chill, or at
least chilly sensations with hemorrhage, is more or less
common.
Case XVII. — Typhoid fever; intestinal hemorrhage ; per-
foration of ileum on the fifteenth day; operation: drainage;
death.
No autopsy.
liemarks. — It is to be kept in mind that every one
seeing this patient had in view the possibility of per-
foration from the onset of the symptoms. On the even-
ing of November 15 this was discussed and morphia
given only after its probability seemed unlikely at that
time. The operation was not done until 11.30 p.m. on
November 16. There were two points which led us
astray — first, the onset of symptoms with hemorrhage ;
and second, the absence of any marked abdominal signs
until 8 p.m. on November 16. There were two points
which should have set us right earlier hatl we given
them enough consideration. One was the blood count,
which on admi&sion was 6,080,000 red cells with 84 fc of
hemoglobin. On November 16 after the hemorrhage the
only change was a drop in the reds to 5,900,000, and the
hemoglobin to 80 fo . At the same time there was so much
shock — if one may so term the condition — that our sus-
picions should have been strengthened and a further
cause than the hemorrhage looked for. The second
point wa^ the marked sudden decrease in liver dulness
with a much retracted abdomen. This should have
been considered more than it was.
The case also illustrates a cycle of events described
by some writers, namely, a period of collapse followed
by a time of improvement. About noon on November
16 the condition was much better than it had been
earlier in the day. This was attributed to recovery from
the hemorrhage. The fact that the patient was given
some morphia after the onset may have influenced the
abdominal symptoms somewhat.
To note some of the features in detail :
The onset was probably about 9 p.m. on November 15, with
some pain and the passage of the bloody stool. The pain was
severe a short time later and came on in paroxysms.
Facies showed no special change. From admission the
patient had a pinched, anxious expression.
Hiccough : This only came on during the night of the fifth-
teenth, and then usually with the movements of the bowels.
Vomiting : This only came on late on the sixteenth.
Respirations : These were slightly increased, but showed no
marketl increase.
Pulse: This increased from about 96 to 120 within a few
hotirs after the onset.
Abdomen : There was retraction until late on the sixteenth.
The resi>iratf)ry movements were present throughout until late
on the sixteenth with the onset of general alxlominal features.
Rigidity was not marked, but although slight should have
drawn special attention when occurring in a retracted abdomt n.
Muscle spasm came on late. Liver dulness, as already noted,
was early and diminished marke<lly.
Percussion and auscultatory percussion were practically of
little service.
Leukocytes: These varied from 7,500 at onset to 14,000 to
17,500 during the sixteenth.
Cask XV^ III.— Typhoid fever; perforation of ileum on the
twelfth day; general peritonitis; operation not advised ; death
on January 8, at 7.45 a. m., two days after perforation.
Autopsy: Perforation of ileum; general peritonitis.
liermirkx. — It is ditHcult to say when the perforation
(X'curred, although possibly on the morning of Janu-
ary 5. It had been notefl that the abdominal symptoms
were marked throughout his illness. He had cried out
with pain and with complaints of various kinds. He
was always a difficult patient from whom to get a satis-
factory answer. When seen by Dr. McCrae on Janu-
ary 7, for the first time, there did not seem to be
anything especially suggestive about the abdominal
condition. There was marked complaint of pain through-
out the illness. The leukocytosis and varying abdominal
signs all contributed to the nonrecognition of the con-
dition, although its possibility was ever in mind. It is
interesting to note that with the general peritonitis and
perforation, the bowels moved and the patient passed gas
by rectum very frequently.
[jTo be concluded.']
A FRAME FOR THE APPLICATION OF PLASTER-OF-
PARIS JACKETS IN POTT'S DISEASE.'
BY
ROBERT W. LOVETT, M.D.,
of Boston, Mass.
Plaster-of-paris jackets in Pott's disease are applied
by many methods, and much discussion as to the relative
value of these methods has taken place without having
succeeded in uniting the medical community on any one
plan in preference to others.
The object of the jacket is, of course, to hold the
spine in such a position that pressure between the dis-
eased vertebrae shall be diminished as much as possible.
Under the best conditions there should be slightly less
backward deformity in the jacket than without it. That
is, the spine above the diseased part should be bent
slightly backward at the site of the disease. The whole
spine need not be hyperextended, and the more accu-
rately the force can be localized at the seat of disease the
Fig. 1.— Frame with webbing straps.
more satisfactory it would seem to be, from a mechanic
point of view.
A practical requirement of the jacket in dorsal dis-
ease too often overlooke<l is that it should come up high
in front, pressing back the sternum, shoulders and upinr
lateral part of the chest.
The apparatus here described has the merit of being
cheap and simple. It locates the hyperextending force
at the seat of the disease and allows the jacket to be
closely applied against the upper part of the chest and
shoulders.
Several exi)eriments have bt«n made with it in th«^
case of children by taking a tracing of the deformity
while the child lay on its face, l)efore the application of
the jacket. After the jacket was hardened a long strip
down the middle of the back of the jacket was remove<l
alH)ut an inch wide and another tnu-ing taken through
the slit, showing in all cases a very marke<l diminution
in the deformity. In no one of these (stses was anything
but a mild degree of force used.
The apparatus consists of an oblong gaspipe frame
I Read before the American Orthopedic .\»»oclatlon at Philadelphia,
June &, 1902.
374 Amekican Mkdiuinc
BLOOD AND ITS MEDICOLEGAL ASPECT
[September (i, 1902
of the ordinary pattern. Fastened to this near the middle
and hinged so a>* to l)e raised to any degree is another
section of gasi)ip(? lying on tJie frame proper and of the
same shajx' and size as the upper half of the frame. To
this movable section is fastened at right angles to it and
movable on it a gaspipe bridge rising about 18 inches
from the movable; section.
Instead of lying on a hammock the patient lies face
downward on two stnips of webbing one inch wide run-
ning from buckles attached to the bottom of the frame
to buckles attached to the end of the movable section.
A cross piece of webbing, padded, runs across tlie mov-
able section and furnishes a head rest ; another croas
piece of webbing runs from side to side of the main
frame and crosses just below the pelvis, and another
cross piece running from side to side of the main frame
supports the legs. The cro&s pieces should be fastened
below the longitudinal strips to prevent sagging of the
latter.
One of the chief difficulties in the application of
jackets by the hammock method lies in the fact that if
the hammock is at all tight it stands away from the
upper part of the
chest and shoul-
ders, unless a
hole is cut for the
head, which sac-
rifices some of
the good posi-
tion. If the ham-
mock is very
slack the whole
spine is hyperex-
tended, and it is
obviously better
to limit the hy-
perextension so
far as possible to
the diseased sec-
tion, and to leave
the rest of the
spine so far as
possible straight.
For the pur-
pose of enabling
the jacket to be
closely applied to
the upper part of
the chest, the
Hg. 2.— Patient on frame before application of bridtrp nttaphpH
Jacket KIg.s.-Jacket applied as high as ^ M^ auacnea
kyphos and frame elevated. to the movable
section was
added to the original frame. Without it the apparatus
IS much the same as the ordinary hammock frame,
except that no windla.ss is necessary.
When prepared for use two strips of webbing, lying
one over the other, run from each of the buckles at the
bottom of the frame. The lower pair of these strips are
tightly drawn and run to the buckles at the end of the
movable section. The upper pair are loosely fastened to
the bridge over the movable section.
The cross pieces are tightened and the patient laid
face downward on the webbing strips, which may if de-
sired have laid over them a folded piece of sheet wad-
ding. The strips, however, even in adults, are not un-
comfortable.
The patient should be placed in such a way that the
seat of disease comes opposite the hinge where the mov-
able piece is attached, and the head and pelvic webbing
supports are adjusted to their proper places.
4- .The deformity must be very heavily padded by thick
felt pads placed on each side of it. The jacket is then
applied in the usual way up to and only as far as the
level of the apex of the deformity and allowed to
harden. If a quick-setting plaster is used this is a mat-
ter of only a very few minutes. After the plaster has
hardened, a piece of webbing or stout cotton bandage
running from side to side of the main frame (not attached
to the movable section) is passed over the upper back
edge of the jacket and firmly fastened to the sides of the
frame. This is to furnish the resistance for the hyper-
extending force and must be firm.
When this is fastened in place the movable section of
the frame Is lifted until the desired correction is ob-
tained at the seat of the deformity. It is easy to see by
inspection, as well as to feel by the amount of resistance,
how much is being done. When the desired point is
reached the movable section is fastened in position and
a few turns made with a plaster bandage, going up two
or three inches above the deformity. Then the straps
running to the end of the movable section which have
been the chief hyperextending force are unbuckled and
turned up over the bridge and the patient remains sus-
pended by the straps running from the bottom of the
frame to the bridge. These are closely applied to the
front of the chest and shoulders and permit the upper
part of the jacket to be firmly applied around the
sternum, upper ribs and front of the shoulders, holding
the chest well back.
If desired a head-piece may be added to tiie jacket
while the patient lies on the frame, as the neck and head
are free, except for the band on which the forehead
rests.
When the plaster has hardened the webbing strips
are unbuckled and the patient is removed from the
frame. The webbing strips are easily pulled out from
under the jacket and are used again. The band which
runs over the top of the jacket is incorporated and its
ends cut off near the plaster.
The method consists simply in applying a jacket as
high as the kyphos and then bending back with as much
or as little force as desired the part of the body above
the kyphos and completing the jacket in that position.
The upper back edge of the lower section of the jacket is
used as a fulcrum, and the padding of the deformity
must be unusually heavy or the apex of the deformity
will be crowded against the plaster.
The advantage of the method seems to lie in the easy
regulation of the amount of force used and in the localiza-
tion of that force at the point of disease. Webbing
support is preferable to that of tiie cloth hammock
because no cutting away or adjustment is necessary, it
is more comfortable, and it can be used over and over
again.
THE NEW ANTISERUM METHOD OF DIFFERENTI-
ATING HUMAN FROM OTHER BLOOD, AND ITS
MEDICOLEGAL ASPECT: PRELIMINARY RE-
PORT OF EXPERIMENTS.*
ARTHUR .J. PATEK, A.B., M.D.,
AND
WILT.IAM C. BENNETT, B.S., M.D.,
of Milwaukee, Wis.
The identification of human blood has always been
a point of acrimonious contention in the giving of
expert testimony in criminal cases, since the only
method approximating accuracy in its determination
has been the measuring of the red corpuscles, and this is
surrounded with so many difficulties as to render testi-
mony so based of doubtful value. We gather frpm
various authorities, first, that an expert is able to deter-
mine that a given specimen of fresh blood is not that of
a bird, reptile, or amphibian ; second, that a given
specimen is not that of any of the domestic animals —
save only the rabbit or guineapig ; and third, that it is
not inconsistent with human blood. With dried blood
• Read before the Milwaukee Medical Society, April 8, 1902.
September 6, 1902)
BLOOD AND ITS MEDICOLEGAL ASPECT
[Akkricah Medicink 376
the difficulties are increased and the value of the expert
testimony is lessened correspondingly. The method
which has been recently discovered for recognizing not
only human blood, but also the blood of all species of
vertebrate animals, promises now to provide a certain
and easily applied test which must prove to be invalu-
able. Already those who have been working in the
field of serum-diagnosis during the past year have been
able not only to identify human blood in all cases, but in
addition, have found it possible to differentiate accurately
j the blood of a great many other species of animals.
- There can be no doubt that sufficient data will soon be
; accumulated to make the test of great forensic importance.
Before detailing our own experimental work, it may
be well to follow briefly the various stages in the evolu-
tion of this highly interesting and valuable contribution
to practical scientific research.
Tlie blood-serum has had such a large share of atten-
tion bestowed upon it during the past decade, and has
yielded such rich returns to investigators, that one
might think this mine had already given up its best
treasures. Not so, however, for its various properties
are unfolding themselves, and we are confronted with
new uses to which these may be put.
The investigations into the question of immunity
liave demonstrated that the serum of animals reacts in a
very brilliant manner to poisons that are introduced in
gradually increasing doses: antitoxins that neutralize
these poisons are formed, and the means of antagoniz-
ing these poisons in human beings have thus been put
at our command. Furthermore, upon the injection of
certain bacteria (cholera, typhoid, i>est) into the system
of animals, products are formed that agglutinate and
dissolve these bacteria (agglutinins and hemolysins).
Animal cells, when injected, also produce these agglu-
tinins, and MetschnikofT has found that the serum of
rabbits into whose belly-cavities, lymph-glands and
spleen had been injected, agglutinated and dis.solved
leukocytes from the animals from which these substances
were taken. Spermatozoa and various epithelial cells
gave a like specific reaction.
The product-ii of cellular action were also found to give
rise to agglutinative antibodies. Thus Bordet ' first
determined the fact that after repeated injections of
cows' milk a substance forms in the serum of the animal
so treated that precipittites the albumin of cows' milk
when added to it. ('. Fisch '' found that these substances
(iactosera) are specific, and demorjstnited the fact that
the serums of animals treated with cow, goat, and human
milk precipitate the ca.sein of their respective varieties
of milk. Wa-ssermann ' made a similar observation.
Uhlenhuth ' made another series of experiments, wish-
ing to demonstrate whether or not specific antibodies
developed in the blood-serum of animals treated with
egg albumen. He injecte<l rabbits at intervals of several
days with the whites of two or three chicken eggs, dis-
solve<l in physiologic salt solution. After several injec-
tions he found that when a few drops of the blood-serum
drawn from these rabbits were added to a 5% to 10^
solution of chicken egg albumen in normal salt solution
a dwided turbidity resulted, and later a i)recipitate.
Furthermore, be it known, this biologic test for albumin
far surpasses all known chemic tests in delicsu-y. Uhlen-
huth was able to obtain an albumin reaction with his
-;crum in a dilution of 1 : 100,000, while the limit of
sensitiveness with the nitric iu;id, acetic acid and ferro-
cyanid of potassium, and magnesium sulfate tests was in
ii dilution of 1:1,000. This serum reaction was, with
one exception, specific in character: No albumin reac-
tion ocrurred when it was added to solutions of horses',
rows', lambs' and asses' serum, a slight turbidity
occurring only with pigeon-egg s«irum. Liutlainche and
X'alK-e ^ injected human urine containing 1 to 2 grams of
albumin to the liter into rabbits intravenously. A
scrum was obtained after several injections of 20 to ;50 cc.
of urine on several consecutive days, that gave an
almost immediate precipitate when added to albumin-
ous urine, while no reaction occurred in urine free from
albumin.
Particular interest attaches to the experiments with
blood precipitins, and a number of comprehensive
reports have been issued in the past two years. Tchisto-
vitch " was the first to find specific precipitins in the
blood of animals treated with the serums of other
animals. He experimented with eel- and horse-serum.
He found that the antiserum of a rabbit that had been
treated with eel-serum gave a precipitate when added to
eel-serum only, and a similar reaction was obtained
with horse antiserum taken from a rabbit that had been
treated with that serum.
The experiments of Uhlenhuth, Wassermann,
Schuetze, Stern, Nuttal and Dinkelspiel, et aL, are so
thorough in execution, and have been followed by us
with such satisfactory results, that it may be instructive
to state their interesting work in greater detail.
Uhlenhuth was the first to attempt to differentiate
various kinds of blood-serums by means of this test.
The serum of a rabbit that had been treated with chicken
blood gave a reaction (turbidity followed by flocculent
precipitate) when added to a dilute solution of chicken
blood only, and none with the blood of the horse,
donkey, ox, lamb and pigeon.
This success stimulated him to further experimenta-
tion with a view to obtaining a method of differentiating
the blood of various animals, and more particularly of
recognizing human blood.
In a second contribution Uhlenhuth ' reports his suc-
cessful experiments. At intervals of six to eight days
he injected into the belly-cavity of rabbits 10 cc. of defi-
brinated ox-blood. After five such injections the blood-
serum of the rabbits was collected. Solutions of various
kinds of blood were then made with ordinary water, to
which an equal quantity of double normal salt solution
was added. All solutions were made of approximately
e(iual dilution. Blood from the following animals was
used : horse, ox, donkey, pig, lamb, dog, cat, deer, fal-
low-deer, hare, guineapig, rat, mouse, rabbit, chicken,
goose, turkey, pigeon and human being. Upon adding
six to eight drops of the serum of the rabbit that had
been treated with bovine blood to several cc. of each of
the above-mentioned blood solutions, a turbidity occurred
only in the tube containing bovine blood, all others
remaining perfectly clear.
Kncouraged by this result, Uhlenhuth injected rab-
bits with human blood-serum and obtained an anti-
serum that was absolutely specific : that is, a turbidity
resulted upon the addition of a few drops of this rabbit
serum to human blood only, and no result was obtained
upon its addition to any of the 19 varieties named
above.
Wassermann and Schuetze" made similar experi-
ments independent of other observers, and found that
the blood-serum of rabbits treated with human blood-
serum had a specific action upon a solution of human
blood, but upon no other save that of apes. Stern*
came to the same conclusion independently.
Uhlenhuth '" reports experiments made with blood in
various states of preservation, and found a positive
reaction, lus well in old dried and in decomposing and
putrefying blooil, as in fresh blood. Urine contami-
nated with menstrual blood, and blood in soap water,
also responded to the test.
/iemke" experimented with the following material:
Fresh fluid blood, dry blood two years old, blood on cloth,
blood in soil, old blood on steel, plaster, wood, glass,
paper, and putrefied blood. The results were positive in
practically all tests made.
Uhlenhuth " made further experiments with speci-
mens of old blood coUectefl from various substances and
obtaine<l a |)ositive result in each case. Having pre-
pared human, pig, horse, fox, cat, lamb and ox-blood
rabbit serums, he was able to recognize in all instances
376 Ambbioas Medicike,
BLOOD AND ITS MEDICOLEGAL ASPECT
ISeptbmbkr 6, 1902
the kind of blood presented, with tliis exception, viz.,
tiiat allied animals reacted, though in varying degree,
to the same antiserum.
Nuttall and Dinkelspiel " made an elaborate series of
experiments with the serum of dog, sheep, ox, horse,
cat, and with human blood and pleuritic exudate. Pre-
cipitins were obtained in all, save those treatetl with cat
blood. They tested the blood of 36 animals, including
four species of monkeys. Human rabbit-serum pro-
duced a slight but distinct reaction with the monkey
blood ; also with the serum from a blister on the foot, a
burn blister and nasal and lacrimal secretions. Human
blood, when mixed with other blood, was readily re(!Og-
nized when the antiserum for human blood was added
to the solution.
Schirokich '* confirms the experiments of Uhlenhutli
and others and suggests that the antiserum may be i)rc-
served in sterile capillary tubes or on filter paper.
According to him only the changes taking place during
the first hour should be taken into account.
Mertens," having in mind the results achieved by
others in demonstrating that the rabbit could furnish a
human antiserum when injected with human blood,
and also that the albumin in human urine was precipi-
tated by the addition of serum obtained from a rabbit
treated with albuminous urine, made the following
deduction : If it be true that the albumin of nephritic
urine is derived from the blood, then the blood and
urine antiserums ought to produce precipitates inter-
changeably in blood and albuminous urine. His experi-
ments proved the truth of this deduction. The human
blood antiserum caused a precipitate with human blood
and with albuminous human urine, and the human albu-
min antiserum caused a like reaction.
Dieudonn6 '" arrived at the same conclusion inde{>end-
ently, and found that human transudates (pleuritic and
peritonitic) produced an antiserum like that of blood,
though less intense in reaction. He found further that
the three human antiserums (blood, albuminous urine
and pleural exudate) reacted interchangeably, though
each reacted more markedly with the corresponding
serum.
Mertens (toe. cit.) made the additional interesting
observation that the serum of the fetus of an immunized
animal reacted like that of the mother.
Attention having been drawn to the interesting fact
that human antiserum precipitates to a slight, though
distinct degree, the blood of the lower monkeys,
Griinbaum " repeated these experiments, and found
that the blood of the anthropoid apes, gorilla, orang-
outang and chimpanzee, reacted very distinctly with
human serum. He made the further observation that
these four serums (human and three anthropoid apes)
reacted with one another interchangeably, nor was he
able to notice any appreciable difference in this reac-
tion.
Believing that the mass of accumulated and uncon-
tradicted evidence here ofl'ered was proof of the exist-
ence of a method of recognizing human blood that was
incontrovertible, we determined to put this matter to a
practical test, more particularly because we had been
retained by the District Attorney of this county to pass
upon certain evidence he had gathered for use in a mur-
der case. This evidence consisted of blood-bespattered
chips of wood, pieces of plaster, cloth and glass, that
came from the house of the defendant who was accused
of having killed his wife.
Our first experiments were only partly successful : it
was impossible for us to obtain human blood-serum in
sufficient quantity at the time, so we resorted to the u>e
of pleuritic fluid. This was injected into a rabbit sub-
cutaneously in quanities of lOcc. The blood was drawn
on the nineteenth day, too early to give a satisfactory
result. However, we obtained a faint reaction with
known human blood. Our final attempt was successful.
Human blootl was used and the injections were distrib-
uted over a period of two months. Four fair-sized,
apparently healthy rabbits were procured and weighed.
One of these was kept as a control animal and the other
three were used in the experiments. Our method of
|)rocedure, essentially that of Uhlenhuth's, was as fol-
lows : Into each animal there was injected intraperi-
toneally 10 cc. of human blood-serum at intervals of
eight to ten days. Some loss of weight followed the
majority of the injections, though this was usually
regained before another treatment was given. The rab-
bits seemed to suffer very little discomfort from these
injections, and after licking the small wound for a few
minutes, took to their cabbage leaves and carrots with
great avidity.
Several days after the sixth injection the rabbits
were thoroughly anesthetized, their carotids cut, and
the blood collected in sterile glass-jars. These jars were
placed on ice and the serum pipetted off 24 hours later.
Chloroform was added to part of the serum and no pre-
servative to the remaining portion. The blood-serum
of a rabbit that had no treatment of any sort was also
collected in the manner detailed.
The blood to be tested was treated as follows : If
fluid, it was diluted first with tap water, and then with
an equal quantity of double normal salt solution until
pale pink in color. It was then divided into two,
three or four nearly equal parts, placed in small test-
tubes, and three drops of the test and control serums
added to the several tubes. These were then placed
in the incubator at .'3.5° C. and observed at intervals up
to IJ hours.
If dried blwjd were being tested, the spot was soaked
up with tap water, filtered if necessary, and an equal
quantity of double salt solution added ; it was then
treated like the other. In all cases in which a reaction
occurred, /. e., in specimens known to be human blood,
this reaction set in in half an hour or less; while in
other specimens known to be not human blood, there was
no response to the test at all. Most of the known
human blood was fresh, but some specimens were dried
on glass, wof)d, cloth and paper.
In the suspected murder case we obtained a positive
reaction in three instances, two from stains on wood and
one from cloth. Some tests gave a negative reaction, but
in these cases only a very minute amount of blood could
be obtained, and this may account for the failure ; on the
other hand, it is possible that some of the stains were
not those of human blood, .fudging from others' and
our own experience, we felt that we would be justified
in testifying that the test was positive and definite for
human blood as opposed to all domestic animals, and
that in the three positive reactions which we obtained
in the suspected murder case, the blood examined could
not be other than human. Unfortunately for the med-
icolegal adaptation of this evidence, the blood-stained
materials were not admitted in evidence — having
been collected several days after the alleged murder —
and we were not called upon to testify. This does not
detract from the value of the evidence, had it been pre-
sented.
It seems to be only a ([uestion of time — allowing for
a sufficient number of experiments which corroborate
and extend to other species those already made — when
serum diagnosis will be considered thoroughly reliable
medicolegal evidence in the identification of human
blood. It is hardly likely that the reaction produced by
the blood of anthropoid apes will interfere in any way
with the value of this test.
It is probable, too, that improvements in technic will
add much to the simplification of present methods of
obtaining the specific serums, and that, as is the case
with the antitoxins, it may soon be possible to obtain
antiserums from the laboratories of the large manufac-
turing chemic and drug establishments.
We append a tabulated record of our experiments
and also the bibliography of this subject.
SEl'TEMBER G, l!itt2]
RUPTURE OF HEART
"■American Mbdicink 377
NO.
Blood Tested.
Serum Added.
Result in 1 hour or less.
1
Fresh dried human
H. R.*
Heavy flocculent precipitate
2
H R.
5 minutes, faint turbidity
15 " marked turbidity
3
" " '*
o.t
No change
4
Fresh human
o.
No change
5
tt i*
H. R
10 mln., initial turbidity inc.
*
'* *'
H. R.
45 min.. decided turbidity
7
O.R.I
No change
8
*' *•
C. H. R il
Turbid
9
H. R.
Turbid
10
it t(
O. R.
No change
U
I. *.
O.
No change
12
" *'
C. H. R.
Turbid
18
'* *i
H. R.
Turbid
14
'* "
O. R.
No change
15
" il
O.
No change
10
" "
H. R.
Turbid
17
ii ti
O. R.
No change
18
H. R.
Turbid
19
ii
O. R.
No change
20
it Ii
O.
No change
21
Human, on paper
H. R.
Turbid
22
»• t.
O.
No change
23
Human, on wood
H. R.
Turbid
24
•i ••
O.
No change
25
Human, oa cloth
H. R.
Turbid
2(i
O.
No change
. * H. R —Humanized rabbit. % O. n.— Ordinary rabbit. | C. H. R —
Humanized rabbit to which chloroform had been added, t O.— Nothing
added.
Blood Used.
Serum Added.
Chiclten
Human
ral)bit
Ordinary
rabbit
Chloroform
human labbit
Nothlng
Dog
Turlity
Ox
-
8heep
Cat
Mixed
Pig
Rabbit
-
(Fresh blood, old
blood on paper,glass,
wood and cloth.)
+ = Positive reaction. — = Negative reaction.
Bl.OOD FKOM V'AUIOUS AKTKT.E.S IN B-
Cask.
No.
Taken From.
Serum Added.
Result in 1 hour or less.
I
Step 2.
H. R.*
10 minutes, marked turb.
2
" 2.
O.
C H. R|
10 minutes, no change.
.|
'■ 9.
" 9
No change, yery dilute.
" 10.
ii ii ..
6
" 10.
O. R.J
ii ii ii ti
7
Lower step.
H. r:
Turbid.
»
i< ii
O. R.
No change.
9
Towei.
H. R.
Initial turb. increased.
10
*'
O. R.
" not increased.
11
Plaster 6.
H. R.
No change, very dilute.
12
a.
0. R.
ii ii ii i.
13
'• 6.
O.
ii ti it it
14
steps.
H. R.
it it ti it
15
' 5.
O. R.
ti .. t. it
10
" 5.
O.
*H. R.— Humanized rabbit. JO. R. „
Humanized rabbit to which chloroform has been added,
adilril.
Ordiruiry rabbit. I C. H. R.—
" " ^O.— Nothing
BIBLIOGRAPHY.
1 Bordet, Annales de I'Institut Pasteur, Vol. 12.
= C. Flsch, St. Louis Courier of Medicine, Feb., 1900.
* Wasscrmann, Deut. med. Woch., Verelns-bciiage. p. 178, 1901.
< rhlcnhulh. Deut. med. Wochenschrlft, No 46. 1900.
•' I.aclalnche and Valine. La Semalne MMicale, No 4, l»0i.
• Tchistovltch, Annaitsde I'Institut Pasteur. Vol. 13.
" rhicnhuth, Deut. med. Wochenschrlft, No. H, 1901.
' Was.sermann and Schuetze, Berliner kllu. Wochenschrlft, Feb. 18.
1901. '
'Stern. Deut. med. Wochenschrlft, No. 9, 1901.
"IThlenhuth, Deut. inert. Woih<ii«lirlft, No. 17, 1901.
' Ziemke, Dent, med Wocliinsclirift, No. 20, 1901.
■> I'hlenhuth. Deut. me<l. W<K:hcu.schrifl, No. ;iO, IDOL
1 Nuttall and Dinkelspiel, Journal of Hygiene, July, 1901 ; British
Med. .lour., p. IIU, 1901.
fSfhlroklch, Vratch, July 21 ; abst., Phlla. Med. Jour., Nov. 18, 1901.
Mcrtcns, Deut. med Wochenschrlft, No. 11, 1901.
■ liicuiionnC-, MOnchener med. Wochenschrlft. No. 14, 1901.
' UrOnbuum, Lancet, Jan. 18, 1902.
Smallpox.— There have been 1,876 cases reported in the
Barbados since .Inly i;!. Many of the bijdics of the dead are
lieinK thrown into the sea.
RUPTURE OF HEART.
By
R. L. LEAK, M.D.,
of Ogdensburg, X. Y.
Assistant Physician St. Lawrence State Hospital, Ogdeusburg, N. Y
In connection with the recent review of the litera-
ture ' of this subject, it may be of interest to note the
history of a few cases that have occurred in the St. Law-
rence State Hospital since 1891. There have been 560
autopsies performed, and in five death was due to rupture
of the heart, thus making a ratio of 1 to every 112 deaths
coming to autopsy. In this paper I will give, briefly,
the patient's condition on admission, with such clinical
facte as may have some bearing upon the cardiac condi-
tion and the sjmiptoms just prior to death. The report
of autopsy will include only the lesions found in the
heart, although complete operations were performed.
Case I. — W. B., a man, aged (S, was admitted to this hos-
pital May 25, 1892. He was a laborer and an epileptic dement.
He was found to be suffering from chronic bronchitis and
emphysema; arteries were fibrous ; there was no cardiac mur-
murs ; pulse 88. His habits were good so far as known ; physi-
cal condition was poor; weight was 118 pounds. In September
he began to fail gradually. On October 0, 1892, he had several
severe attacks of epistaxis. On October 7, about 1,50 p.m.. the
patient got out of bed, and while on his way to the bath-room he
fell dead.
Necropsy was performed by Dr. Cook. The heart weighed
9J ounces. Left ventricle was hypertrophied, the cavity being
small. There was some soft thickening of the mitral valves ;
the right auricle was adherent to the pericardium over an area
of about Ii inches in diameter where the pericardium was con-
nected to the diaphragm. There was, also, an ulceration of the
auricular wall, about i inches in diameter, extending
through the pericardium into the diaphragm. No blood or
increase ot serum was found in the pericardial sac, though
what appeared to be a single miliary tubercle was seen. The
tricuspid valves were somewhat thickened, though soft, and
contained a few plates of fibrous tissue. The patient presented
many tuberculous lesions of the lungs and other organs.
Cask II. — A. M. B., a woman, aged 80, was admitted .lune
14, 1894, suffering from melancholia. On admission the heart
and lungs were apparently normal. The pulse was 72 and
Irregular. The arteries were fibrous. Physical condition was
poor, weight79pounds; habits were unknown. She followed the
usual course of melancholia in senility and presented no marked
physical ailmentsexcept an attack of Influenza during the latter
part of August, 1895; from this she apparently recoverfd.
On .September 25, 1895, about one year and three months
after admission, she was suddenl.v prostrated with abdominal
pain, accompanied by tympanites with considerable dis-
tention. On September 27 she .seemed to rally and appeared in
the usual condition. The next day, about 4 a.m., she became
restless and noisy, and shortly after began to moan, and was
apparently suffering severe pain. She died at 4.50 a.m.
Necropsy. — The heart weighed 9 ounces, was firm and con-
tracted, and lay so well forward against the chest bone that the
pericardium was nicked by the knife on removing the sternum
and costal cartilages. From this incision a small amount of
cloudy, bloodstained serum escaped. In tlie pericardial sac was
about one ounce of this fluid. On the anterior surface of the
left ventricle was a purplish extravasation running lengthwise
for about two inches, giving a sensation of liardness to the
touch. Beneath the extravasation was a rupture of the muscle
walli At the apex and involving the muscular substance of
both ventricles and the intraventricular septum was an area of
friilile tissue intermingled with clotted blood. Under the
injected area on the anterior ventricular wall was a thick coagu-
lum which was incorporated with the muscular substance and
columnar carnic. The wall was attenuated to two layers of
tough connective tissue enclosing purplish blood.stainod soft-
ened tissue ; this all lying beneath and held in place by a thick-
ened and tough pericardium. The coronary arteries were
fibrous. The valves were somewltat thickened, but the edges
were free and appeared comj)etent.
Cask III.— .). A. B., a woman, aged 70, was admitted June
14, 1895. She was a senile dement, and was in feeble physical
condition ; her weight was 101 pounds. She was very delu-
sional, and complained of pains in various parts of the body.
She thought she was being eaten by animals, and was torn to
pieces. Pulse was irregular, of low tension, rate being 72. Ves-
sels were hard and tortuous. Veins were varicose, especially
in the legs. Heart was feeble and presented a systolic murmur.
On April 29,1896, she complained of considerable pain in
the l)owols and stomach, and at 1.45 a.m. became unconscious,
and died five minutes later.
Necropsy.— 'Vhe heart weighed lOj ounces ; the heart muscle
was friable and a small tumor presented at the apex, at which
^American Medicine, April 12, 1902, page tKW.
378 Ambricaw MKBICIKBJ
RUPTURE OF HEART
[Bbetkjibek 6, 1902
place there was a rupture in the wall of the left ventrk-le. from
which about six ounces of blood had escaped into the pericardial
«ac, where it was found in a thick coagulum. An extensive
pericarditis existed, as was sliown by the granular condition of
both visceral and parietal layers. The aorta presented numerous
calcareous areas.
Case IV.— E. M., a woman, aged 63, was admitted Septem-
ber 26, 1891, suffering from chronic melancholia. She was of very
strong physique, though very delusional and hypochondriacal ;
the heart was noruial ; pulse was 120 and strong in character.
March 2, 1900: The patient has continued well until yester-
day, when she complained of feeling sick. Ilorappetite became
poor. During the night she was visited frequently by the night
nurse, the hist time at 4 a.m., when she whs apparently sleep-
ing. Twenty minutes later she was found dead on the floor of
the lavatory, evidently after the act of defecation.
JVecrop«y.— The heart weighed 13 ounces. Upon removal of
the chest bone and a portion of the costal cartilages, a small cyst
was seen at the median portion of the upper left lobe of tlic
lung. The pleura was firmly adherent over almost the entire
left side. Adhesions were also found on the right side over the
upper and middle lobes only. Anthracosis was well marked,
Upon opening the pericardial sac, which seemed distended,
there was found an increased amount of pericardial fluid, also a
large, dark-colored blood clot, covering the right and anterior
aspects of the heart, and from which it was removed quite
easily, except at one point near the anterior ventricular groove.
Careful examination was made to find a rapture of the great
vessels near the heart before its removal, but none was foun<l.
Upon removal of the heart, sections of the right auricle and
right ventricle showed them to be apparently normal. Ipon
the left ventricle, about midway between the apex and base,
and near the anterior ventricular groove, was found a slit about
2 cm. long in the ventricle wall. Upon sectioning, the ventricle
walls appeared normal, but easily torn. In the ventricle cavity
in the place corresponding to the external slit was found a par-
tially organized blood clot, quite firmly adherent to the wall. A
bluiit probe could easily be passed through the opening iuto the
ventricle, showing a rupture of the ventricle to the extent of
about 2 cm. Coronary arteries and branches were found to be
somewhat fibrous. Pericardial fat in the upper portion of the
anterior ventricular groove was found to be somewhat increased.
Microscopic Bxamindtion. — Muscle cells were fragmented
and torn ; transverse striations were lost in places ; there were
also considerable areas of granular degeneration. Muscle tissue
was infiltrated with blood cells in the region of the rupture and
presents slight fatty changes. Throughout brown atrophy was
very markra. Small capillaries seemed thickened and fibrous.
Case V. — F. G., a laborer, aged 69, was admitted January
12, 1900, suffering from terminal dementia. On admission his
-ihysical condition was fair, weight being 119 pounds. His
ungs were normal; heart was labored and forcible; second
sound was accentuated but there was no murmur; pulse was
88; arteries were extremely fibrous and the circulation was poor.
He was intemperate in his habits and has probably had sypnilis.
March 31, 1902: No change of any note since admission;
today he suddenly fell to the floor complaining of great weak-
ness and dyspnea and pain in the arms only. His skin was
cold and covered with perspiration; pulse 70, was regular, of
high tension and large volume; respiration was regular and
kept the body free from a cyanotic condition ; heart was much
hypertrophied but there were no murmurs save one over the
abdominal aorta produced by a small aneurysm. These symp-
toms passed away in 24 hours under nitroglycerin.
April 6: He has kept in bed continually, but today he per-
sisted in walking about the dormitory. ' The heart's action
became very forcible but was controlled by aconite.
April 9: The patient seemed as usual until 5.15 p.m., when
after a slight attack of dyspnea, lasting about ten minutes, he
fell down and died almost instantly.
jVecropsj/.— Heart weighed 17 ounces. On opening the chest
the pericardium was found distended to its utmost limit. On
section of the pericardium serous fluid was found in the upper
portion of the sac, and when removed was found to amount to
450 cc. On removal of the fluid a large blood clot was uncov-
111
ered. This completely enveloped the heart and was found to
weigh 17 ounces. On examination of the heart in /ntu it was
found to have ceased to beat in systole. The right heart was
normal in appearance, but a rupture of the left ventricle i inch
in length was found on the anterior surface near the septum,
and one-third of the distance between the apex and veiitral-
auricular septum.
This rupture was
transverse to the long
axis of the heart. (See
illustration.)
Section of the
Heart. — Left ventricle
was moderately di-
lated and considerably
hypertrophied. Walls
were i ioch in thick-
ness, except in the re-
gion of the rupture,
where the.v were less
than i inch. Where
the latter condition
occurred the muscular
pillars were ruptured
in addition to the walls
of the heart itself.
Prom the appearance
of the tissue in this
area it would seem
possible that an an-
eurysm existed prior
to the rupture of the
ventricle. Muscular
color was normal.
Auricle was some-
what dilated, but
otherwise normal.
Walls were thicker
than usual. Bicuspid
opening was normal in
size; bicuspid valves
were somewhat thick-
ened, particularly
near the edges, and in
this region were also nodular and somewhat contracted. Right
heart was somewhat dilated and hypertrophied. The muscle
appeared normal. Tricuspid valves, pulmonary valves, and
right auricle were normal. There were no clots in the heart,
except small postmortem ones at the seat of ruptu re. The aorta
contained numerous small placques of atheroma. Aortic valves
were competent, but thickened, and near the ba.ses contained
atheromatous spiculae. Coronary arteries were fibrous and
the lumen decreased at least one-third. There were also numer-
ous fatty atheromatous patches. These changes were no more
marked, however, than in many cases of senility. The thinned
area through which the rupture occurred was of the size of a2.'>-
cent piece. The excavation was entirely on the inner surface.
The rupture itself was not straight through the wall of the
heart, but the blood followed to some extent the direction of the
layers of lamlnas of the heart walls. At first it coursed upward
and outward, then straight out for i inch, and then down and
out, ending externally opposite the beginning of the rent inter-
nally. Its upper course toward the base of the heart extended
g of an inch, thus creating a convex muscular lip which fitted
into the hollow in the muscular tissue.
Microscopic examination showed thickened capillaria* and
general increase in connective tissue, slight granular change in
muscle cells, distinct transverse striations, save immediately
near the rupture, where the muscle tissue was also fragmeuted
and infiltrated with blood cells.
From the above we can draw the following table for
convenience in comparing the chief and important fac-
tors in the cases cited :
Case v.— Showing rupture.
Case.
I,
II,
III
IV.
V.
Sex.
Man.
Woman.
Woman.
Woman.
Man.
Age.
Arteries.
fi2 Fibrous.
81 I Fibrous.
70 j Very fibrous.
63 I Very fibrous ; almost calcareous.
71 I Very fibrous; almost cjilcareous.
Pulse.
72
72; irregular.
120, but strung.
Heart.
Hypertrophied.
Normal.
Systolic murmur.
Normal.
Hypertrophied.
Habits.
Good.
Unknown.
Intemperate.
Good.
Intemperate.
Physical Condition.
Emaciated.
Poor.
Poor.
Good.
Fair.
Weight.
118
7»
101
Unknown.
11!'
N ECROPSY.
I
II
III
IV
V
Heart.
»5^ ounces.
9 ounces.
10^;^ ounces.
1.3 ounces.
17 ounces.
Place of Rupture.
Klght auricle.
Left ventricle.
Left ventricle.
Left ventricle.
Left ventricle.
Microscopic Examination.
Fatty and granular degeneration.
None.
None.
Marked brown atrophy, transverse striation.s, lost granular degeneration, cells frag-
mented caplUariessclerosed. cellular infiltration.
Slight granular degeneration, marked increase connective tissue, capillaries sclerosed.
8EPTKMBEK C, 1902]
PERFORATION IN TYPHOID FEVER
(American Medicink 379
PERFORATION IN TYPHOID FEVER, WITH REPORT
OF SEVEN OPERATIVE CASES.
BY
GEORGE L. HAYS, M.D.-,
of Pittsburg, Pa.
.\ssistanl Surgeon to Mercy Hospital; Assistant to the Chair of Prin"
ciples of Surgery and Clinical Surgery, Western
University of Pennsylvania.
The following report of seven operative cases of per-
foration occurring in typhoid fever is here presented in
order that they may be added to the increasing number
of such cases treated surgically.
Fortunately the treatment of these ca-ses is given to
the surgeon, who ha.s increased the number of recoveries
fully 20^ to the present time.
Three of my .seven operations were successful, which
gives for the series a recovery of 42.85% .
Case I. — The patient was referred to me by Dr. J. I. John-
ston, of the medical staff of the Mercy Hospital.
Typhoid Fever — Perforation — Peritonitis — Death.
^lrs. B., aged 32, was admitted to the Mercy Hospital Sep-
tember 3, 1899. She had been in bad health for four months
previous to admission, but was sick from typhoid fever for
about three weeks before this time. She presented a typical
case of the fever, wiiich was estimated to be about the beginning
of the third week. The temperature was not higli and her gen-
eral condition was good. At 1..30 a.m., September 6, 36 hours
after admission, she complained of pain in the abdomen. She
did not have a drop in temperature nor was there auy evidence
of collapse at this time. At 10.30 a.m. the pulse became rapid
and there wa-s general tenderness over the abdomen. At
8 p.m. when seen by Dr. Johnston, her attendant, and myself,
she showed every evidence of peritonitis and the diagnosis of
perforation was made. She was in a state of collapse and very
delirious and was therefore in an unfavorable condition for
operation, but we decided to give her a chance for recovery by
an operation.
Operation.— At 9.15 p.m. about 24 hours after perforation
occurred, Iaparot<^my was performed under cocain anesthesia.
The incision was made in the median line below the umbilicus.
The intestines were injected and sticky and the abdomen was
full of plastic'lymph, dark in color. The perforation was found
in the ileum near the cecum and was 3 mm. in diameter. The
opening was slightly closed by a few bands of lymph whi<:h
were stretched across it, presenting a cribiform appearance.
The edges of the opening were turned in and closea by two
tiers of silk Lembert sutures. The abdomen was thoroughly
flushed out with hot normal salt solution and a drainage
tube was insertefl to the bottom of the pelvis. The remainder
of the external incision was closed. The patient died five lionrs
after operation. No autopsy was obtained.
(,'ASK II.— This was referred to me by Dr. I. J. Moyer,' of
the medical staff of Mercy HospitHl.
Typhoid Fever — Perforation— Peritonitis— Recovery.
D. C, a Greek male, aged ;iO, was admitted to the Mercy
Hospital July 4, 1900. He could not speak or understand
English, HO a clear history could not be obtained, but he was
apparently in the latter part of the first week of the fever.
On admission his abdomen was greatly distended and he
complained of pain on pressure. He was treated by cold sponge
baths when his temj)orature was 10.3° or over. He had a very
severe infection but the fever progressed with no serious com-
plication until July 18, 14 days after admission and about the
twenty-first day of the disease. At 4..'i0a.m. of this date he com-
plained of much pain in the abdomen. At 9 a.m. the abdomen
was distended and very tender; the liver dulnoss was much
lessened; respirations were 32 and of a costal type; the pulse
was 108 and the temperature was 100.6° ; the peristalsis was
almost lost. The diagnosis of perforation was made at this
time by Dr. J. T. Foster, the medical resident, and it was later
confirmed by Dr. Moyer.
Operation.— At 1 p.m., with the assistance of Dr. J. H. Bald-
win, the surgical resident, the abdomen was opened under
cocain anesthesia, the incision being made in the median line
below the umbilicus. About 84 hours had pas.sed since the
occurrence of the i)erforation. The intestines were injected and
sticky and the abdomen was full of a dark colored Huid, and
but little plastic lymph had been formed. The perforation,
2 mm. in diameter, wiis found in the ileum near the ileocecal
valve. The opening was closed by two tiers of .silk Lembert
sutures, inverting the opening in the bowel. The alklomen was
thoroughly Hushed out with hot normal salt solution. A large
glass drainage tube was inserted to the bottom of the pelvis
and the remainder of the incision was closed. He made an
uneventful recovery. His temperature dropped to normal
eight days after operation and remaine<l there except for a
little variation which was fully a<;counted for by some enormous
bedsores which developed. To look at his temt>erature chart
one would not suppose that he had had so grave a complication,
for it is typi(;al of an uncomplicate<l case of typhoid fever.
Some of the fluid which was pumped out from the pelvis
through the drainage tube was examined by Dr. J. D. Single^
pathologist to the Mercy Hospital, and he reports that the fluid
contained a short rod-shaped motile bacillus. No attempt was
made to differentiate between the typhoid and the colon
bacillus.
As a matter of local history, so far as I have been able to
learn, this is the first successful operation done for perforation
in typhoid fever in Western Pennsylvania.
Case III.— This was referred to me by Dr. I. J. Moyer, of
the medical staff of Mercy Hospital.
Typhoid Fever — Perforation— Peritonitis — Death.
The patient was A. M., a male, aged 28, who was admitted to
the Mercy Hospital August 7, 1900, with typhoid fever supposed
to be in the beginning of the second week. Widal's test was
positive. He was treated with cold sponge baths when tem-
perature was 103° or over. He became very delirious on August
13, six days after admission. In the early hours of the four-
teenth, estimated to be the fifteenth day of the disease, perfora-
tion occurred. When seen by Dr. J. T. Foster, the medical
resident, at 9 a.m., the patient "had every evidence of peritonitis,
and he made the diagnosis of perforation at the time, and it
was later confirmed by Dr. Moyer. There was pain all over
the abdomen, which was slightly distended, the abdoininal
muscles were rigid, liver dulness was obliterated in the nipple
line, and the peristaltic action was very feeble. His tempera-
ture did not drop, and up to the time of operation there was no
material change in it. His pulse and respiration remained
nearly the same as they had been for several days previous.
Operation.— Ahont 12 hours after perforation the abdomen
was opened in the median line below the umbilicus, under
cocain anesthesia. The abdomen was full of a purulent fluid.
There was no free gas in the cavity. The coil of bowel con-
taining the perforation lay almost under the incision, and was
found to be in the ileum about 20 cm. from the ileocecal valve.
The perforation was closed by two tiers of silk Lembert sutures.
The abdominal cavity was flushed out with hot normal salt
solution, and a rubber drainage tube was inserted to the bottom
of the pelvis. The remainder of the incision was closed. He
was placed in bed in Fowler's position. He died 30 hours after
operation, evidently as a result of septic intoxication.
Case IV.— Referred to me by Dr. J. I. Johnston, of the
medical staff of Mercy Hospital.
Typhoid Feiier— Perforation— Peritonitis— Catarrhal Pneu-
monia— Fecal Fistulas — Recovery.
G. I., a male Italian, aged .iii, was admitted to the Mercy
Hospital May 23, 1901, with typhoid fever. He could not speak
or understand English, and so a definite history could not be
obtained. Two years ago he had an attack of pleurisy, and
since then he has not been strong. Widal's test was positive.
The course of the fever presented no unusual symptoms until
June 4, approximately the nineteenth day of the disease. At
11 a.m. he complained of slight pain in the abdomen, more
marked in the right iliac region. At 3 p.m. he was in great
agony, with pallor of the face and retracted lips. His abdomen
was flat and its walls rigid. There was general abdominal
tenderness, with liver dnlness obliterated and peristalsis
absent. His pulse and respiration showed no marked change
at this time. His temperature rose to 104°, which was 20°
higher than it had been for three or four days. .Vn examina-
tion of the blood showed no increase in the number of leuko-
cytes. The diagnosis of the perforation was made at this time.
Operation. — Five hours after the perforation occurre<l I
performed a laparotomy upon him, the incision being made in
the median line below the umbilicus under cocain anesthesia.
The abdomen contained a large quantity of a turbid reddish
fluid. There was no free gas in the cavity. The bowels were
intensely congested in the vicinity of the perforation. The
perforation was found in the ileum, 15 cm. from the ileocecal
valve. It was at the apex of a large ulcer and j)re.sented a
peculiar appearance. The necrosed tissue at the site of the
perforation was still attached to nearly the whole circum-
ference of the opening in the bowel, and if completely detached
would have left the opening 6 mm. in diameter. The perforation
was closed by two tiers of silk I.<embert sutures. The abdomen
was thoroughly flushed out with hot normal salt .solution, and
a large glass drain inserted to the bottoui of the pelvis. The
remainder of the incision was closed. He was placed in lied in
Fowler's position. There was not much adhesive lymph formed
in this case, which fact, tfjgether with the appearance of the
necrotic tissue at the site of the perforation, suggests that it
was of recent origin. Within five days a catarrhal pneumonia
and a fecal fistula developed. The fistula <'losed in two or three
days. .\s a result of the fistula, or possibly because it waH
necessary to leave drainage to the bottom of the pelvis for some
time, there remained an abdominal sinus which required a
long time to close. The stitches became infected and pus bur-
rowed into the abdominal walls on each side of the incision. A
large be<lsore developed over the sacrum. His abdoininal sinus
was closed and his bedsore almost well when discharged from
the hospital, July 4, 30 days after operation.
("ask v.— Referred to me by Dr. B. M. Dickinson, of the
medical staff of Mercy Hospital.
Typhoid Fever— Perforation— Peritonitis— Jteeovcry.
M. 15., a male Hungarian, aged 25, was admitted to the
Mercy Hospital Mav 23, 1901, with typhoid fever. He had
rather a typical attack of the disease. His temperature reached
880 AMCBICAir MBPtCIHK)
PERFORATION IN TYPHOID FEVER
[Bkitjdmbek 6, 1902
normal on tlio twenty-Hecond day of the disease and rcraaiaed
there for four days, when he had a relapse. His temperature
did not run as high as in the initial attack. On the thirty-ninth
day of his illness he complained of severe pain in the lower part
of his abdomen, more marked over the right iliac fossa. His
abdomen was flat but quite tympanitic, the muscles were rigid
(more marked on the right side), and there was tenderness on
pressure all over the abdomen, liver dulness was absent and
peristalsis was very weak, the pulse, temperature and reHpira-
tlon showed no marked change. The diagnosis of perforation
was made by Dr. Dickinson.
Operation.— Four and one-half hours after perforation
occurred I performed a laparotomy under cocain anesthesia.
The incision was made in the median line below the umbilicus.
There was no free gas in the abdominal cavity. The abdomen
contained a small amount of clear fluid and some flocculent
lymph. The intestines were slightly congested. The perfora-
tion, 4 mm. in diameter, was found in the ileum, 20 cm. from
the ileocecal valve. The site of the perforation was at the apex
of a large ulcer, which could plainly be felt on account of its in-
duration. The perforation was closed by two tiers of silk Lem-
bert sutures. The abdomen was thoroughly flushed out with
hot normal salt solution. A large glass drain was introduced
to the bottom of the pelvis, and the remainder of the incision
was closed. The patient was placed in bed in Fowler's position.
His pulse was 132 and his respirations were 28 at the end of the
operation. They went steadily upward, and at the end of four
hours he was in condition of collapse ; his pulse was 156, his
respirations were 38, he was perspiring freely and his extremi-
ties were cold. Under the use of hot applications and the
vigorous use of whisky, strychnin and digitalis his pulse be-
came lessened in frequency and the state of shock was less
apparent. At 3 a.m., 15 hours after operation, his pulse again
became weak, and he was given 800 cc. of normal salt solution.
At 6..S0 a.m., 3J hours later, he was given 600 cc. more. I am
firmly convinced that without this procedure he would have
died, as he was taking all the other stimulation he could stand.
Some of the fluid obtained from the pelvis 24 hours after the
operation was examined by Dr. A. Leteve, assistant director of
the Magee Patliologic Institute, who reports that tlie fluid con-
tained mononuclear and polynuclear white cells and many
bacilli which under cultivation ijroved to be typhoid bacilli.
Fifty-fi ve hours after the operation the glass drain was removed
for the reason that the quantity of fluid obtained was small and
contained no bacteria other than the typhoid bacillus. Before
removing the glass drainage tube a strip of gauze was intro-
duced through it to the bottom of the pelvis. This strip of
gauze was removed 12 hours later and a provisional suture was
tied, thus completely closing the abdominal cavity. The exter-
nal incision healed kindly, no infection occurring. He was dis-
charged from the hospital perfectly well 48 days after operation.
Case VI.— Referred to me by Dr. C. O. Goulding, of the
medical staff of Mercy Hospital.
Typhoid Fever — Perforation — Peritonitis— Death from acute
obstruction.
Wm. McN., male, aged 30, was admitted to Mercy Hospital
September 15, 1901, with typhoid fever. The course of the lever
was rather severe, especially the nervous symptoms, otherwise
it did not differ from the usual manifestations of the disease.
At 10 a.m., September 18, estimated to be the thirteenth day
of the disease, he complained of a sudden and severe pain in the
right iliac region. There was no drop in his temperature, but
the pulse rate increased. When seen by Dr. Goulding at 3 p.m.,
his abdomen was flat, his aljdorainal muscles were rigid —more
marked on the right side. There was pain on pressure all over
the abdomen, but it was more acute on the right side, the liver
dulness was almost obliterated and there was relative dulness
in the right iliac region, the seat of the perforation ; the peri-
staltic action of the bowel was almost absent. His mind was
perfectly clear, and his condition excellent.
The diagnosis of perforation was made by Dr. Goulding at
this time. A blood count made just previous to the operation
showed no increase of the leukocytes.
Operalion.—l operated upon hiin six hours after the occur-
rence of the perforation, under cocain anesthesia, the incision
being made in the right semilunar line on a level with the
cecum. The perforation was found in the ileum 20 cm. from
the cecum, and was 6 mm. in diameter. There was no free gas
in the cavity. The abdomen contained a small amount of red-
dish fluid. The intestines were slightly congested in the
vicinity of perforation. The perforation was closed by two
tiers of silk Lembert sutures. The abdomen was thoroughly
flushed out with hot normal salt solution, and a large glass
drain was inserted to the bottom of the pelvis. The remainder
of the incision was closed. He was placed in bed in Fowler's
position.
Some of the fluid obtained from the cavity was examined by
Dr. Leteve, who reports that it contained many white cells and
a bacillus which under cultivation proved to be the typhoid
bacillus.
This patient should have recovered, and I have no doubt
would have done so but for the occurrence of a complication
which I will describe later. He was by far in better condition
to stand an operation than any of the previous patients.
Before, during, and after the operation, ho was never in a
state of collapse. His brain was perfectly clear, his pulse was
good and his skin was perfectly dry. His pulse was slightly
accelerated after operation, but of good volume, and came
down to the rate which had existed for some days previous to
the operation. The peristaltic action of the bowel gradually
returned, and could be heard all over the abdomen and
remained to the end. The pain over the abdomen also gradu-
ally left, and at no time gave any uneasiness. An enema of
flycerin and turpentine was given 12 hours after o]>eration.
le expelled some flatus and the fluid expelled contained a
trace of fecal matter. Under these conditions we expected him
to recover. From this time he expelled no gas from the rectum,
his abdomen gradually became distended, and nothing could
relieve this condition. He died 48 hours after operation.
The autopsy, which was restricted, revealed the cause of the
distention of the abdomen. The portion of the ileum from the
site of the perforation to the cecum was sharply bent upon
itself and was held in that position by firm adhesions to the
end of the cecum, thus causing a total occlusion of the bowel.
After breaking up the adhesions, gas could be passed easily
from one position of the bowel to the other at the site of the
perforation, showing it to be patulous. The stitches in the
bowel were intact. There were no signs of peritonitis except
where the glass drain had been down to the ijottoin of the
pelvis and around the cecum, and in these two places it was a
plastic peritonitis. There were no other perforations.
A contributing cause of death was the acute obstruction,
and I feel safe in saying that had he not had this mechanic
obstruction of the bowel lie would have recovered.
I am aware that patients with an acute obstruction of the
bowel do not usually die so soon if nothing is done to relieve
the obstruction, but in this case we have other causes enter-
ing into the patient's demise, namely, the typhoid fever itself
and the possible toxemia of the peritoniti.«.
Case VII. — Referred to me by Dr. J. I. Johnston, of the
medical staff of Mercy Hospial.
Typhoid Fever — Perforation— Peritonitis— Death.
3. C, male, aged 25, was admitted to Mercy Hospital
December 15, 1901, with typhoid fever. He had been ill for two
weeks and when admitted had the common manifestations of
the disease, but until the twenty-fifth, ten days after admis-
sion, did not have symptoms out of the ordinary.
At 3.30 p.m. of this date he complained of a severe pain in
the end of the penis. At 4 p.m., after having a slight move-
ment of the bowels, he had a severe chill which lasted about ten
minutes. He was then given an enema of castor oil and tur-
pentine which produced a moderate movement. He rested
well during the night— until 2 a.m. of the twenty-sixth, when
he had paroxysms of pain lasting five to ten minutes. The pain
always began in the glans penis and extended from there up to
the abdomen. During the paroxysms the abdominal muscles
were rigid, but in the intervals the rigidity was not present.
The peristalsis was present and quite strong. The abdomen
was not distended. The skin was rather clammy; his pulse
was 80 and of good quality. He was given an enema of soap-
suds and turpentine, which produced a good bowel movement.
He complained of slight pain in the abdomen the rest of the
night and had to be aroused when given medicine. At 4 a.m.
his temperature was 99°, which was a drop of 3° from the time
of taking the temperature before 1 a.m. At 7 a.m. the temper-
ature wa-s 101.6° At 10 a.m. he was complaining of severe
pain in the abdomen; it was distended, rigid and very tender
on pressure, liver dulness was obliterated in midaxillary line,
peristalsis was absent, pulse was weak and he was perspiring
freely.
The diagnosis of perforation was made and it was decided
to operate, although he was in bad condition for it. The day of
the disease was estimated to be the twenty-sixth.
Operation. — The abdomen was opened in the right semi-
lunar line under cocain anesthesia. It was thought that the
perforation occurred about 12 hours previous to this time.
When the abdomen was opened gas and a dirty-colored fluid hav-
ing a fecal odor escaped. The intestines were deeply congested.
The perforation was found in the ileum 20 cm. from the ileocecal
valve. It was closed by two tiers of silk Lembert. sutures. The
abdomen was thoroughly flushed out with hot normal salt
solution and a large glass drain introduced to the bottom
of the pelvis. The remainder of the incision was closed and he
was placed in bed in Fowler's position. The fluid obtained
from the cavity contained Streptococcus pyogenes. The peri-
stalsis did not return. He did not react and died 13 hours after
the operation*. No autopsy was obtained.
Symptoms of this complication of typhoid fever
must not be confounded with the peritonitis the result
of the perforation. The symptoms of tlie perforation
have been given by many observers. Tlie first symptom
is usually a severe pain in the right iliac fossa which is
quickly followed by symptoms of collapse, recognized by
a feeble running pulse, a drop in the temperature, cold,
clammy skin, pinched countenance and feeble respira-
tions. A widespread peritonitis soon becomes aj)parent,
which has symptoms as follows : Tenderness all over the
abdomen with its muscles rigid, peristalsis partially sup-
pressed and sometimes entirely absent, liver dulness
obliterated. The abdomen may te distended and Is
September 6, 1902]
PERFORATION IN. TYPHOID FEVER
fAsCERiCAN Medicine 381
tympanitic. Tliere will be dulness in the flanks if the
abdominal cavity contains fluid. A great deal of stress
has been laid upon the drop in temperature said to occur
at the time of perforation. In my experience this did
not occur, except in one case (VII), and then not very
much. While no doubt a drop in the temperature some-
times does occur, even to below the normal line, I do
not believe so much consideration should be given the
temperature in the diagnosis of perforation.
I am aware that obscure cases do occur and will
puzzle any one, but ordinarily the diagnosis should be
made t asily. I would depend upon the following for the
diagnosis : A history of typhoid fever, a sudden and
severe pain in the abdomen (usually in the right iliac
fossa), followed by rigidity of the abdominal muscles
and tenderness over the abdomen, a lessening or sup-
pression of the peristalsis. The rigidity and tenderness
would be more confined to, at least more acute in, the right
side if seen early after perforation. The rigidity, tender-
ness and the lessening or absence of peristalsis in my
opinion demand surgical interference.
Time of Operation. — I am in favor of early operation,
and believe that when surgical interference is under-
taken early, we will have many more recoveries.
In my patients who recovered, the time of operation
after perforation in the first (Case II) was 8J hours, in
the second (Case IV) 5 hours, in the third (Case V) 4J
hours. In the patients who died the time of operation
after perforation was 20 hours in Ciise 1, 12 hours in Case
III, B hours in Case VI, and 12 hours in Case VII. The
contrast is quite marked. In the recoveries the longest
length of time liefore operation was performed was 8J
hours. In those who died, in only one case (VI) was
operation performed under 12 hours, and this patient
entirely recovered from the perforation and peritonitis,
but died from an acute obstruction already described.
No logic is here needed to make more effective the
advantages of early operation.
Dr. Keen,'^ in his tabulated report of 158 cases, reports
the greatest number of recoveries (30.76/c) to have
occurred in the second 12 hours. It seems rational to
my mind to suppose that had more of the operations
been performed earlier that it would have resulted in
more recoveries. In this same report there is given a
recovery of 30.74^ in which the time of operation is
not known. This is open to the objection that if it were
possible to place these recoveries in their [iroper places it
would alter to some extent the percent of the various
times of operation. The only condition which would
[irove a contraindication for operation is, I believe,
8h(x;k. When shock is present we have it to deal with,
of course, but we know that unless the perforation is
shut off from the rest of the peritoneal cavity there will
follow with great rapidity a peritoiritis, its virulence
depending upon the infective organism. Which is the
graver danger, shock, or shock and the peritonitis with
its toxemia? The peritonitis presents to my mind the
great danger.
When operation is postponed for any rea.son, unless
the i)atient is In extremis, an irreparable danger is
threatened and it usually follows. Perforations can he
divided intt) two classes — those without the condition of
shock and those in which it is present. I do not think
an arbitrary law can be applied to each case, hut the
question of operati(in will be governed by the symptoms
each j)resents at that time.
I am frankly in favor of early surgical interference,
even if Dr. Keen's report gives the greatest number
of re<'overies in the second 12 hours.
AneMhesia. — A local anesthetic is now, I believe,
recognized as the better method to follow in these cases,
as there is no danger from the lung and kidney compli-
cations which are likely to oc<;ur wlien a general narcosis
is produced. There is also the danger of heart failure
when chloroform or ether is used. The operation can
Ik- performed with but little discomfort to the patient
under cocain. The peritoneum is the most painful tissue
to cut.
Incision. — The incision I made in all but the last two
of my cases was in the median line below the umbilicus.
In the last two I made the incision in the right semi-
lunar line on a level with the cecum. This lateral inci-
sion I believe to be the better for several reasons. First,
the appendix can be exposed more easily for examina-
tion. Second, the ileum is involved, according to Fitz,'
most frequently, 81.4 fe. The perforation is frequently
close to the cecum. Third, if a fecal fistula develops, it
can be taken care of with less discomfort to the patient.
Fourth, every part of the intestines can be examined
through this incision except the stomach, the duodenum,
the beginning of the jejunum, the transverse and
descending colon and the rectum. These exceptions are
rarely the seat of the perforation. An incision not more
than two inches long is sufficient. In seeking for the
seat of perforation care should be used not to expose
more of the bowel than is absolutely necessary. When
the abdomen is opened, first locate the cecum in order to
find the ileum, which should be delivered for examina-
tion. When introducing the finger sometimes one is
able to feel the indurated ulcers in the bowel wall, and
by delivering this portion of the bowel will have
the part one wishes to examine. E.xamine first the
small bowel, then the appendix and large bowel. When
the perforation is found examine both ways a short
distance for other perforations and for places in the
bowel which are nearly perforated, which should be
treated the same as the perforation.
The perforation having been found, the edges should
be turned in and the opening closed by two tiers of silk
Lembert sutures. The peritoneal cavity should be
flushed out with hot normal salt solution and a large
glass drain introduced to the bottom of the pelvis.
If the perforation is very recent and no transuda-
tion has occurred the intestines in the immediate vicinity
should be dried with pads and gauze inserted to the seat
of the perforation after it had been closed. The remain-
der of the external incision should be closed.
The bed in which the patient is placed after operation
should have its head elevated 12 to 18 inches for reasons
well presented by Fowler,* of Brooklyn.
The fluid collecting in the pelvis should be removed
every hour for four or five hours, and after this time the
intervals may be lengthened, depending upon the amount
of fluid obtained and the organisms found in it.
The tube should be pumped with a catheter and an
ordinary glass syringe. p]very aseptic precaution should
be used in doing this so that no organisms may gain an
entrance to the abdominal cavity by way of the glass
drain.
The drainage tube should be removed as soon as pos-
sible, so that no abdominal sinus will persist. In Case
V, I removed the tube even when there was a small
amount of clear sweet serum containing the typhoid
bacillus. If there is present in the fluid any active pus-
producing organism, it would not be proi)er to remove
it until the intestines had iwlhered around the tube,
leaving an abdominal sinus extending down to the bot-
tom of the pelvis.
Case VI will have to be placed in the death column,
although the patient entirely recovered from the i)erito-
nitis. His death was due to the acute obstruction and
possibly to some extent from the fever itself. Had this
obstruction been recognized an ojieration for this condi-
tion might have saved him.
Case 107 (Finney) of Dr. Keen's tabulated report of
158 cases is such a case. The patient was operated upon
for acute obstruction following the operation for perfora-
tion and recovered.
Case 90 (Cushing^) was one in which the patient was
oi)erated upon three times and yet recovered, the third
operation being for intestinal obstruction and a perfora-
tion.
382 Amkbioas Mkdicih^
ATRESIA OF THE VAGINA
[8EITEMBEK 6, 1902
If I am permitted to place Case VI in the recovery
columa it would make the recovery 57.14^ instead of
42.86% .
When the operation is done early and when it is
done under strict aseptic surgical i)rocedures, under
cocain anesthesia, I believe that we will have a recovery
of Ix'tween 30% and 40 fo at least.
In conclusion I submit a short abstract of cases :
have each observed a case in which there was neither
uterus nor vagina. Ferguson described a prostitute
of 18 who had never menstruated, in whom there
was no vagina, uteras or ovary. Coition had been
(lone through the urethra, which was considerably
distended, though not causing incontinence of urine.
Hulka reports a case of congenital atresia of the
vagina in a brunet of 20, men.struation occurring
Case.
Age.
Sex.
Day of Disease.
Ijocatlon
of Perforation.
Anesthesia.
I
Time of Opera-
tion after Per- Result,
foratlon.
Remarks.
I
II
III
IV
v
VI
VII
82
80
28
86
25
30
25
F.
.VI.
M.
M.
M.
.M.
M.
Sixteenth
Twenty-first
Fifteenth
Nineteenth
Thirty-ninth ;
thirteenth day
of a relapse.
Thirteenth
Twenty-sixth
Ileum
Ileum
Ileum
Ileum
Ileum
Ileum
Ileum
Cocain
Cocaln
Cocaln
t!ocaln
Cocaln
Cocaln
Cocain
20 hours 1 Died
SV4 houis Recovered
12 hours ; Died
5 hours Recovered
i% hours Recovered
6 hours Died 4S hours
after operation.
12 hours Died 13 hours
after operation.
Death occurred 5 hours after operation.
Death occurred 30 hours afler operation.
The patient developed a catarrhal pneu-
monia and a fecal fistula.
The perforation occurred during a relapse;
the typhoid bacl.lus found In fluid of ab-
domen.
Death caused by acute obstruction by
kinking of bowel; typhoid bacillus found
in abdominal fluid.
SlreplueoecuJi pyogines was found in the
abdominal fluid.
IIIBLIOORAPHY.
' Penn. Med. Jour., August, 1900.
'J. A. IVI A., 1900, Vol. xxxlv, p. l.SO.
'Trans. Assoc. Am. Physicians, 1891, Vol. vl.
••Med. Rec., April 14, 1900.
'J. Hosp. Bull., 1898, Vol. ix, p. 267.
ATRESIA OF THE VAGINA (COLP ATRESIA), UNI-
LATERAL OVARY AND TUBE, WITH NO UTERUS.'
BY
CHARLES E. BARNETT, M.D.,
of Ft. Wayne, Ind.
Professor Genitourlnaiy Surgery and Surgical Anatomy, Fort Wayne
College of Medicine.
Atresia of vagina (colpatresia), unilateral ovary and
tube, with no uterus, is a rare anomaly. This vice of
conformation is due somehow to a lack of development
embryologically to the lower third of the miillerian duct
on one side and the upper portion of the wolffian duct
and body on the other.
In abnormalities of the urogenital tract we find that
the ureters, which open primarily into the Wolffian duct,
secondarily into the urogenital sinus, according to his-
tory fortunately are supernumerary rather than defi-
cient, with a tendency to open anomaly anywhere along
the genitourinary tract ; yet, on the other hand, with
due respect for history, I remember the catheterism of
a-day-old baby girl in whom I found the bladder dry.
In my opinion this was a case of nonpatent or imper-
forate ureter. Unfortunately a postmortem was refused.
In exstrophy of the bladder, in which the anterior
portion of the genitourinary apparatus is implicated,
J. William White says : " The arrest of development is
thought to be due to pressure by the umbilical cord,
when either its point of entrance into the fetus or a dis-
proportionate weight of the upper extremitias and head
do not permit of proper balancing of the fetus in the
amniotic fluid, thereby causing the head to hang down-
ward. The cord is thus pres,sed tightly against the
abdominal wall as it passes up between the legs of the
fetus." In the region of the wolffian and miillerian ducts
there is no such pressure, and an abnormality there must
be due to a lack of development from circulatory or
other reasons.
Medical literature, .so far as I am able to discover, is
sparingly pregnant with reports of this class of anomalies,
there are some 30 cases reported of complete absence
of the vagina. Among these Fournier '' reports the case
of " two females, who not having a vagina, copulated by
way of the urethra." Orifflth and Matthews Duncan
' ?tn'!>m„'n»J.'"l"**'*,^ M«lical Society, Toledo. Ohio, March, Tsi^
- .Anomalies," Gould and Pyle. ...
through the urethra. Bosquet describes a girl of 20,
with closure of the vagina and absence of the uterus, who
menstruated from the gums. Gosselin reports a ca.se in
which a voluminous tumor was formed by the retained
menstrual fluid in a woman without a vagina. An
artificial vagina was made, but the patient died from
postoperative hemorrhage.
Absence of both ovaries is seldom seen. One ovary
is sometimes found wanting, as well as a supernumerary
one found present. The latter may account for fecunda-
tions occurring after double ovariotomy. The fallopian
tubes are rarely absent on either side. Blasius reports
an instance of deficient oviducts, and Blot a unilateral
deficiency with atrophic ovary on that side.
Absence of the uterus is of frequent occurrence and
needs no further comment than that Phillips and Sedg-
wick claim that heredity is a prime factor in the cause
of this anomaly, Phillips citing a case of two sisters
with congenital absence of the uterus, Sedgwick quot-
ing an instance of absence of the uterus in three out ol
five daughters of the same family.
Case. — Miss L., aged 33, a machine worker in a laundry,
was referred to me by Dr. Gard, of our cit.y. She is a woman
of medium height, weighs about 110 pounds, and is fairly well
nourished. Her hips are somewhat small, but not markedly
so; feet are small, waist is small, and face is effeminate.
History. — She is one of 12 children, five of whom were
girls. At 13 years of age she had cramp in the uterine region,
from which it took six months to recover. She gives history of
monthly recurrence of pelvic cramps till one day, during a
paroxysm, her nose began bleeding violently. After she l)e-
came exsanguinated to a marked degree the pelvic pain sub-
sided. This vicarious menstruation continued up to the time
of operation.
She claimed that mammary development was greater in
herself than in her mother. An aunt had vaginal atresia.
Examination,.— Th^ vulva was found to be normal with the
exception of a slight enlargement of the clitoris. There was
no hymen. The vagina was 1 J inches in length and small in
caliber. Bimanual manipulation discovered a firm membran-
ous body in the uterine region, which seemed to be the uterus.
The right fallopian tube was enlarged to probably three times
its normal size, and led to the right ovary, which could be dis-
tinctly felt. On pressure a peculiar testicular pain was im-
parted. No left ovary or tube was found.
Operation was performed April 2, 1901. An opening was
made through the vaginal septum into a musculomembrano-
cartilaginous pouch, out of which a dark menstrual fluid came.
The fallopian tube could now be sounded through this passage-
way. The pouch in the lower portion of the tube was washed
out and packed with gauze.
According to Henry C. Coe, " when functionally
active ovaries are present, in the absence of the uteras,
oophorectomy should be performed." I believe the con-
census of opinion among gynecologists today is that on
account of the effemination, and also on account of the
nervous climaxes which follow the removal of all the
ovarian tissue in the body, no healthy ovarian tissue
Seftember 6, 1902]
MEDICAL INSTITUTIONS OF ST. PETERSBURG [American medicine 383
should be removed by the operator. For this and other
reasons the ovary and tube were not removed.
The results after resolution had taken place are as follows '
Vaginal measurement, 3* inches in length, 3S inches in circum-
ference (2 inches gained). Menstruation was established by the
natural route the fifteenth day after operation. Plow has
occurred in the same manner up to the present time (11 months)
without any unpleasant symptoms. The patient has gained
both in strength and flesh.
Conclmiong. — The retained fluid from the first men-
struation produced a parasalpingitis and endosalpingitis,
with pelvic peritonitis. Nature, in six months' time,
formed a pouch that was sufflcientl.v impermeable to
require a longer time for absorption of the fluid and con-
sequently less toxicity occurred therefrom. Epistaxis
depleted the body and relieved the congestion, the fallo-
pian tube supplied the uterine deficiency and did the
menstruating. It is easy to conclude that coitus is
contraindicated.
SPECIAL ARTICLES
MEDICAL INSTITUTIONS OF ST. PETERSBURG.
BY
NICHOLAS 8ENN, M.D.,
of Chicago.
St. Petersburg is an important medical center. Nearly
1,000 medical students are preparing themselves here annually
for their lifework. Russian women can now obtain their medi-
cal education at home. A medical school has been opened
recently for the exclusive use of women. Heretofore most of
the female medical students had to travel to Switzerland to
reach the goal of their professional ambition. Outside of this
school medical teaching is limited to the Imperial Military
Academy. This is the only institution in which clinics are
conducted. The Military Academy is an immense establish-
ment, cx)vering as it does several blocks of ground. It is under
military cjntrol and every teicher is a commissioned officer.
The great solid buildings face the majestic Neva, and from the
bridge present a magnificent appearance. The students must
study for five years before they are admitted to the final exam-
inations. The medical cadets, from 100 to 130, are educated
at the expense of the government. The final examination
they have to pass is very rigid and requires more than six
months. The hospital connected with the Academy has 2,000
beds and furnishes all of the practical branches in medicine,
with an abundance of clinical material. There is no need here
of extramural teaching. The facilities for dissection and lab-
oratory work are ample and well calculated to familiarize the
student with the fundamental branches of medicine. In this
great military institution gynecology and obstetrics are taught
in a most thorough manner by a military ofllcer. The nose,
throat and ear department, under the supervision of
the attending physician of the Empress, is probably the
finest institution of its kind in the world. It is a new
building, constructed upon most modern and ai)proved ideas
and lavishly equippefl with all the moans for clinical research
and scientific investigation. The surgical amphitheater is
somewhat unique. It is arranged on the amphitheater plan,
and can seat about 200 students. Inside of the amphitheater is
a small glass house, on the sides and on top of which are seats
for the students. These are reached by a very steep and narrow
staircase made of iron, and from every step the operation can
be seen to advantage. The professor first appears outside of
this house of glass, explains to the students the nature of the
case and the technic of the operation, and then enters the
sacred precincts and performs the operation without any further
remarks. The students watch his work through the glass walls
and ceiling while the operator performs his task silently, unin-
fluenced by the presen<« of his outside audience. This is a
plan that might recommend itself for postgraduate work, but
it is a very quastionable one in teaching the young student how
to operate. Kor a student to grasp the essential features of the
technic of an operation it becomes necessary for the teacher to
explain to him the why and wherefore of every step of what
he is doing. One of the impoi-tant elements in successful
teaching in this institution consists in limiting the attend-
ance. The hospital as a whole lacks the austere appearance of
such an institution. The halls and staircases throughout the
building are ornamented by works of art. The products of
sculptor and artist are on exhibition everywhere. This orna-
meutiition does much to divert the mind of the patients in a
useful direction, and to fascinate the attention of the visitors.
All of the sick of the local military force are treated in this
hospital, at the same time adequate provisions are made for
the civilian sick poor. Some of the buildings are several hun-
dred years old, palatial in architecture, recently renovated and
improved to meet all of the modern requirements, including
electric light and hot-water heating. The immense clinical
material is supplied by the outdoor department or polyclinic.
PROFESSOR VON WREDEN'S SUROICAI, CLINIC.
Professor von Wreden is a military officer of high rank.
He is in the prime of life, a diligent student and perfectly con-
versant with the surgical literature of the present day. He
knows no rest between the hours of nine in the morning and
six in the evening. He speaks German and English fluently.
He is popular with the students and is the friend of the poor.
His calmness and self-control in the operating room charm his
audiences and impart confidence in his patients. Surface dis-
infection is made by thorough scrubbing with warm water and
potash soap followed by alcohol and sublimate solution. The
administration of ether is limited to patients the subject of
cardiac lesions, in all other cases chloroform by the drop
method is employed. Catgut has been entirely abandoned and
its place has been taken by silk and silver wire. Orderlies and
female nurses take care of the sick. The latter are furnished
by the Russian Red Cross and receive a fair salary. The assist-
ants are military surgeons of large experience. Professor von
Wreden is a warm advocate of local anesthesia. He uses a 1%
solution of cocain. The average amount of this solution
employed is 60 minims. In more than 800 cases he has never
observed any serious toxic effects from this drug. I was given
an opportunity to witness three operations under this method
of local anesthesia.
Case I.— Staphylorrhaphy for isyphiiitic defect of the soft
palate ; operation under local anesthesia. The patient wa? a
middle-aged woman upon whom a rhinoplasty for syphilitic
defect of the nose had been performed a number of weeks ago.
The distal phalanx of the left little finger had been successfully
implanted and the cosmetic result of the operation was quite
satisfactory. A central triangular defect of the soft palate was
to be operated upon under cocain anesthesia. Witn a small
hypodermic syringe 60 minims of a 1% solution were injected
into the border of the defect and in the lines of incision near
the alveolar arch. The pharyngeal mucous membrane was also
anesthetized in the same manner. The patient was placed upon
a table in a sitting position and the operator stood in front of
her. No mouth-gag was used. Hemorrhage was arrested by
compression. The Langenbeck method was employetl. Three
silver wire sutures were introduced with an ordinary well-
curved Hagedorn needle. The twisting of the wire was done
with Sims' instrument. The index finger was used instead of
tissue forceps in using the needles. The whole operation was
completed in less than half an hour and evidently without
causing much pain. This method of anesthetization is em-
ployed in all operations for cleft palate in preference to the use
of chloroform or ether.
Case Jl.— Relapsing carcinoma of the roof of the mouth;
excision under local anesthesia. The patient was a man ad-
vanced in years. On March 5 of this year the left upper
maxilla was excised for malignant disease. Recently the
carcinoma returned along the border of the defe<!t on the roof
of the mouth. The growth was a spongy nia.ss, al)Out the cir-
cumference of a silver dollar. A 1% solution of cocain was
used in the same manner and quantity as in the first case.
Patient was placed in a sitting position upon a table. The soft
tissues at a safe distance from the margins of the growth were
divided down to the bone with the knife-point of a Paquelin
cautery ; with a chisel and hammer the excision of the tumor
in one piece was completed. The operation was finished in a
few minutes and without any particular complaint on part of
the patient.
Case \ll.— Central tuberculous osteomyelitis involving the
proximal phalanx of the middle .finger, eviaement under cocain
anesthesia. The patient was a pale and somewhat emaciated
university student. The disease was of long standing, and had
its starting point near the upper epiphyseal line of the proxi-
884 AXBBICAN MEDICINBJ
EULOGY OF DE. CHEISTIAJf FENQER
[Septexbeb 6, 1902
iiial phalanx of the right middle fluKer and bad terminated in
abscesa formation. A fistula led into the interior of the bone.
A number of injections were made in a circle around the fistu-
lous opening, some of them only into the skin, others into the
deep tissues down to the bone. An incision was then made
within the limits of the anesthetized area and parallel with the
bone. With a sharp spoon the tuberculous focus was removed
and the wound tamponed with iodoform gauze and a small
absorbent dressing or sterile wood wool applied. The manner
in which the patient behaved showed that the operation was
not a very painful one.
For the purpose of preventing the depressing effects of
coeain a liberal dose of port wine is administered immediately
before the injections are made. As a wound dressing, sterilized
wood wool made of the flr tree is largely employed.
RED CROSS HOSPITAL ALEXANDER.
The Russian Ued Cross Society is the wealthiest and most
influential in the world. It has the moral and financial sup-
port of the ICmpress Dowager. It has in its treasury at the
present time over $8,000,000. Its organization is perfect and
reaches the deserving poor throughout the entire vast empire.
The best hospitals in St. Petersburg and other large cities are
supported and managed by the Red Cross. The Red Cross
hospitals in St. Petersburg are the St. George, St. Eugt5nie,
Alexander and Elizabeth, all of them stately buildings and
wisely conducted. The Alexander Hospital is one of the finest
and best equipped hospitals I have ever visited. It is a solid
square building, two and three stories high. The interior is
'31 tkti
Red Cross Hospital Alexander, St. Petersburg.
elegant, the furniture luxurious. None of the rooms contain
more than two or three patients. The halls are ornamented
with fiowers, shrubs and worlis of art. Red Cross female
nurses take care of the sick. The size of the building is alto-
gether out of proportion with the number of patients it can
accommodate, which is only 50. There are no free beds. The
charge for room, board, nursing and treatment is from ?5 to *15
per week. The surgeon in charge lives in the institution in a
suite of rooms that leave nothing to be desired.
ASEPSIS OF PROFESSOR PAWLOFF.
Professor Pawlofl", who is in charge of the Alexander Hos-
pital, is a firm believer in strict asepsis. He has no use for
antiseptics. After each day's work his operating room, which
is an excellent one, is disinfected with live steam. The few vis-
itors who are permitted to witness his work must appear in
sterilized gowns and their heads must be covered with a sterile
worsted Red Cross cap. Soap and saline solutions are relied
upon in hand and surface disinfection. Linen thread sterilized
by boiling is the suturing and ligature material. In approximat-
ing the skin he makes use of metallic clamps in place of sutures.
These clamps are very quickly applied and readily removed.
A number of delegates to the Seventh Conference of the Inter-
national Red Cross were present at one of his operations.
• J'^" P*'''^"'' w*^ ^ rQa.\i, aged 70, who had a tumor in the
right iliac fossa. The anesthesia was commenced with ethyl-
bromid and continued with chloroform. An incision along the
inner border of the crest of the ilium and Poupart's ligament
exposed a soft tumor, which was attached to the inner surface
or tne mum. The center of the tumor was cystic and on rup-
turing It quite a large quantity of bloody serum escaped. The
diagnosis of sarcoma was not difficult at this stage of the opera-
^ihth h /" P^iJability it was a sarcoma of the iliac fascia
which had secondarily implicated the periosteum and bone as
the tumor mass lacked all indications of osteogenesis and the
surface of the bone was not extensively alfected. With forceps
and scissors the tumor was removed piecemeal and with chisel
and hammer the affected part ol the bone was excised. During
the dissection the retroperitoneal fat was freely exposed. The
wound was closed with two figure-of-eight deep sutures and
clamps for the skin, leaving enough space for drainage.
Professor Pawloft resigned from the faculty of the Imperial
Military Academy 12 years ago and is now devoting all of his
time and energies to the work of the Alexander Red Cross Hos-
pital.
! Skba.stopol, Kdssia, June 8.
A EULOGY OF DR. CHRISTIAN FENGER.
BY
D'ORSAY HECHT, M.D.,
of Chicago, III.
Born on November 3, 1840, in Copenhagen, Denmark,
Christian Fenger came of an ancient and illustrious family.
His ancestors had held positions of confidence and official trust
in the government of Denmark and had fostered the fatherland's
best Interests for many decades. Doubtless much that was
interesting in him was supplied by his foreign heritage. Few
of the incidents of Fenger's childhood and youth have come to
my knowledge; I have learned, however, that he enjoyed all
the fostering care which flows from parental solicitude and
affection. The data at hand of the doctor's early academic
career are also few and untrustworthy.
The enviable position and rank attained in the profession of
medicine by his uncle. Prof. Emil Fenger, undoubtedly influ-
onced Christian Fenger, the nephew, in his choice of a calling.
He had taken up his studies and pursued them almost to com-
pletion, when hostilities were declared between Denmark and
Prussia. Fenger, the student, swept along in the maelstrom of
national feeling, offered his services to his country in this con-
flict over the possession of Schles wig-Holstein. He was pressed
into that department of the service in which he could contribute
the greatest amount of good, the medical corps. During this
campaign, not a long one, he acquired an extensive knowledge
of medical and surgical diseases, which equipment was not
without great benefit to him in a similar though more strenu-
ous experience a little later in his career. The war at an end,
youug Fenger returned to his studies at the University of
Copenhagen and shortly thereafter, in 1867, was graduated a
" Doctor Medicinse Magna cum laude." During 1868-(i9 he was
an interne at the Fredrich Hospital, Copenhagen. It was at
this time that national unrest once more asserted itself on the
Continent, and Europe was confronted with the spectacle of
two great nations waging a bitter warfare. The international
challenge had passed between Germany and France in 1870, and
the first red signal fires of war were seen that had flashed since
the campaign between Denmark and Germany. Here was the
second opportunity which revealed itself to Fenger, and we
next hear of him as a surgeon, giving glorious account of him-
self in the Red Cross Ambulance Corps with the French army
in the field. I repeat that the lessons learned, the final impres-
sions gained in the " surgical campaign " of the earlier strug-
gle, were of inestimable value to him now. That he was serv-
ing in the cause of another country than his own mattered but
little to him, who recognized and espoused only one kind of
service, that of duty. As an alien, a dispassionate though active
service in this great struggle enabled him to profit far more in
this than in his former experience.
The " Furor Teutonicus " spent and peace declared, Fenger
went to Vienna to receive postgraduate instruction in surgery
under Professor Billroth, who at that time conducted the rank-
ing surgical clinic of Europe. Close application to work in
Vienna was not without its own reward, for the position of
prosector at the Copenhagen City Hospital awaited him upon
his return to his native city. The realization of this new ambi-
tion in 1874 afforded him the material for following up the "dis-
ease processes" with which he had familiarized himself in
Vienna. Now he began to betray his first intense interest in
the study of pathology ; here at the city hospital he laid the
Beptkmbrr 6, 1902]
EULOGY OF DR. CHRISTIAN FENGER
iAXKBtCAN MESICINB 385
foundation for a knowledge of histopathology. It had been the
privilege of but a few men before him to meet with so splendid
an opportunity and it must be added that no man brought to
his work a better preparation. So eager was he to acquire
knowledge himself, as well as impart it to those around him,
that he would expose himself for days and nights to the foul
atmosphere of the dead house, subjecting his physique to the
severest tests. Those moments which were spared him from
closest research work, the hours of requisite relaxation, were
devoted to the publication of his investigations, not to the com-
pilation and publication of the observations of others. In 1874
he presented a monograph on " Carcinoma of the Stomach ; Its
Anatomy, Development and Extension." This essay did not
pass unnoticed by his contemporaries; it recei%'ed more than
its share of criticism, and yet the author's capital defense of his
views gained for him the position of lecturer at the university,
and a few mouths later, at the age of 34, we hear of him as extra-
ordinary professor of pathologic anatomy.
Even in his early student days when enthusiasm is gener-
ally tempered by extraneous influences, Fenger was a laborious.
untiring worker and possessed in a high degree the prerequi-
sites of all true intellectual greatness, the habit of patient obser-
vation, long-continued attention and a singular love of labor.
To make himself a thorough anatomist and qualify as a teacher
of the new departure, pathology had been his chief aim. As
his later development showed, the cultivation of pathology,
thorough and exhaustive as it was, was but the means to an
end ; of transitional imiiortance, as it were, to a prospective
ambition in an allied field.
Whether it was an inherent nomadic disposition in the
man, or an unfounded pessimism that made him regard as
applicable to himself the truism "a prophet is not without
honor save in his own country," whether it was an opportunity
per He or perhaps a disappointment, suffice to say Fenger left
Copenhagen in 1875 and we next hear of him in Egypt as a mem-
ber of the "Conseil Militaire" and surgoou-in-chief of the
Khalifa quarter in Cairo. He remained there only two years.
Climatic, unsanitary and unhygienic conditions cooperated so as
to cut short his residence in Egypt, and the next move, one of
his own choosing, was doubtless the most momentous in this
the formative period of his career. This can be stated with
positiveness, because later in life, when many students came to
him earnestly soliciting his advice in the matter of a location, he
voiced the same thought that had counseled him when his occu-
pation in Egypt came to an end. " Never locate in a city of less
than one million population." A patience too easily tried,
coupled with a penchant for laconicisms, often made an attempt
to get at his " whys and wherefores " hopeless. What he meant
to convey was this: Given a man of sound body and mind,
ambition and energy, so place him that he can expend his
vitality and force in a manner beneficent to his community,
creditable to his pi-ofession and complimentary to himself.
Fenger was already a much-traveled man. He had come to
appreciate the large city as a center offering clinical and labora-
tory facilities. He had learned from a searching inquiry into
the status of medicine in our States that scientific progress was
necessarily emanating from our large cities only, due in part to
the then prevailing system and our territorial vastness. For it
can not be denied that the standardization of medical education,
with its glamor of professorial and professional dignity, had
not and has not even now found its way into our smaller cities
and towns, nor become a part of our national educational life as
comprehended by and realized on the Continent.
Of Christian Fenger it must be said, and without the least
reservation, that the " mirage of wealth " never broke upon his
vision, blinding him to all else as it had many others. The
monetary consideration never tempted this man. Some men
more captious in their criticism than others may consider any
and every allusion to this subject as uncalled for and indelicate,
but there is in this latter day, when the " fee " is so often made
the indication for the surgical operation, and the commission
and percentage system is discussed in accredited medical socie-
ties, there is, I say, a lesson to be learned from the life of one
who brought to the great, yea fierce, struggle encountered for a
livelihood In his calling the best equipment that years of appli-
cation had given him, but who, even in the crowning years of
his lifework, could demonstrate how far he stood above and
aloof from the perniciousness of pecuniary gain, how grandly
he towered above the popular worship of modern plutocratic
schemes and measures.
Chicago was Fenger's objective point upon his arrival in
America in 1877. The next few years were indeed memorable
ones for this foreigner. To surmount difficulties, to meet with
reverses, to receive knocks and setbacks, to become disheart-
ened and discouraged, but not embittered, implies the posses-
sion of attributes and elements so mixed as to constitute the
essentially strong, the truly great man in adversity. His first
opportunity came to him with an appointment on the surgical
staff of Cook County Hospital. Now for the first time the
means were given him to an end.
The past decades are especially significant to our chosen
profession in Chicago, for they have been fraught with the
realization of much that the pioneers had longed for ; much that
the early workers in surgery had exploited with reservation
and doubt. Fenger's ad vent in Chicago signalized a new epoch
in surgery. It remained for him to announce the era of release.
What followed the long enslavement, the reign of hospital gan-
grene and foul sepsis, with grim death lurking everywhere?
An emancipation— partial at first, gradually increasing and
complete at last, but first and last effected by the dominant
spirit of Fenger. Having gained a firm foothold In Chicago, he
found himself occupietl in a field which furnished him ample
scope for the exertion of all his powers as well as the gratifica-
tion of his highest ambitions. His preaching of the doctrine of
a.sepsls and antisepsis, his insistence in a practical exhibition of
an " antiseptic conscience," his scathing criticism of overytliing
that was a violation thereof, all this has come to be regarded as
the fulfilment of Fenger's mission in behalf of surgery in Chi-
cago and the great Northwest. It stands out in bold relief as the
monumental work of his life. It must have been a great conso-
lation to Fenger after his well-waged war upon the existing
system of general hygiene and sanitation to hear men say, even
though with flippant inflection, " everything a man does is not
necessary before he does It, but is necessary after he has done
it."
About five years after his arrival here he was called to the
chair of clinical surgery at the College of Physicians and Sur-
geons; ten years of most creditable and laudable activity were
spent in the interest of this school ; he then resigned in order to
affiliate himself with the Northwestern University Medical
386 AXCRICAIf MBDICtNB]
EULOGY OF DR. CHRISTIAN FENGER
[8BPTEMBEK G, liX)2
School, old Chicago Medical, in the same professorial capacity ;
and in 1890, three yearH after his acceptance of this position, he
was called to Rush Medical, now in affiliation with the Univer-
sity of Chicago, and presided jointly with his friend and col-
league. Dr. Nicholas Senn, over the surgical interests of that
institution. During the 25 years of his residence in Chicago he
had at one time or another been acting or consulting surgeon
on every important hospital staff in the city.
Dr. Kenger was devoted to the entire domain of surgery ;
he did not confine himself to the narrow path of surgical spe-
cialties ; he was from choice a respecter and operator of any
and all surgical affections to which human flesh is heir. Con-
fessedly, then, a general surgeon, he discouraged operative
gynecology, except as a science worthy of special development
by the "general surgeon," and deplored its practice in the
hands of the avowed "gynecologic surgeon," unfamiliar with
the abdominal cavity immediately above a line drawn so as to
pass through the anterior superior boundary of the pelvis.
If by a method of reasoning quite peculiar to himself he
regarded a case as " operable," no surgical procedure was too
formidable for his undertaking. Many men have possessed
greater technic and finish, but none was more fearless. No
amount of curiosity could induce him to venture beyond the
dictate of conservatism as he conceived of it. His profound
knowledge, extraordinary carefulness, thoroughness and his
observance of detail won for him the respect of his patients and
co-workers. Only the fewest of his colleagues were able to imi-
tate or follow him as a " reasoner." Philosopher, learned man,
scientist, linguist and surgeon was Christian Penger. Always
exhaustive, always logical, always conservative, small wonder
that his diagnosis was eagerly sought after and his judgment
accepted without appeal.
He " blazed more than one new trail " in the forest of surgi-
cal ignorance in the Northwest. He will be missed from his
accustomed seat in the faculty of surgery, but his work will
live on, perpetuated not alone by his name, emblematic of
scientific surgery in America, but by his " disciples," of whom
there are many, comprising a group of rising men steeped in
the methods and " thought-life " of their teacher, willing and
glad of an opportunity to emulate his principles, execute them
in their work and enjoy the moral and material distinction
accruing from past association with a master in their art.
Although he lacked fluency as a speaker, he had the ability
to illustrate his point with schematic drawings, which were
always models of their kind. His thoroughness, his keen
accuracy, his attention to detail and his relentless search for
the truth made him the excellent teacher that he was. Who
does not remember his board drawings and charts illustrating
anatomically and surgically the features in the operation for
tuberculous glands of the neck ? Who does not remember his
sketches illustrating "goiter operations?" The knowledge
acquired during his prosectorship in Copenhagen, his patho-
logic work in "Vienna now proved of incalculable value to him.
In his teaching capacity, his hospital work, and in his private
practice, he labored incessantly, improving every available
opportunity for studying the pathologic processes presenting
in the large material at his disposal. A study of every case
brought to light something of interest. Fenger's cases proved
interesting by virtue of his understanding, interpretation and
elucidation of them. His concluding remarks in his mono-
graph upon " Ballvalve-aetion of Floating Choledochus Stones"
is a point in evidence of his investigating spirit.
To men in search of the best in surgical literature, Fenger's
writings will always appeal as classics. As a writer he will
never be charged with having been so obscure as not to be
understandable; this may prove to be the criticism of those to
whom all profound treatises would be unintelligible. Nor
could he ever have been accused of the literary sin of compila-
tion. He used to say "any man can compile; that requires
only the poor talent of a poor litterateur, but to write, to affirm
an original thought, is quite another thing." Nor was he in
any sense a verbal trickster, whose only talent consisted, as it
so often does among medical writers. In vivifying common-
places or converting " dull nothings " into " brilliant para-
doxes," and giving to them the added significance of his name.
Such sallies in others had always the effect of lighting up his
face with a queer, quizzical, inscrutable smile, which invari-
ably gave way to the more stern mask he wore, followed in
turn by volleys of unqualified condemnation of recourse to
such methods. Christian Fenger's surgical contributions
written in the English language were, despite his foreign
birth, models of style; in suljstance, they were positive,
simple, broad, judicial and intellectual, in beautiful harmony
with his mental faculties, his conscience, his diligence, and
that austere self culture which eventually raised him to the
first and foremost rank among men of this day in surgery.
Fenger may never have impressed the stranger or even
those close to him as a man of studied etiquet, of manners, or
persuasiveness in ordinary address, nor of mingled dignity and
ease upon meeting men. He unconsciously fortified himself
with triple barriers of reserve ; he was gracious, and though
he discouraged familiarity he was sympathetic. He enjoyed
an exceptional exemption from the temptation of practical
measures in daily life. A man of finest sensibility, he loved
nature and everything in it, betrayed an intense fondness for
children and a rare fidelity to every trust imposed upon him.
For his home life, let it be said that a wife and two children
enjoyed with him the fullest measure thereof, and they who
survive him know better than all the rest how fathomless was
the depth of his love, affection and devotion. His linguistic
attainments, culture, refinement, morality and that nobility of
soul and intellect, of which but few can boast, drew forth the
admiration of his opponents in surgical issues. Those who
differed with him, or saw fit to invite comparison by opposing
him, recognized his preeminent powers of intellect. Every-
body felt in assailing such a consummate reasoner the restrain-
ing influence of modesty which a mister spirit always evokes
in the minds of his adversaries. He was his own most formid-
able foe, his own analyst, his own severest critic. To have
seen Fenger sit in judgment on his own mistakes, to have
heard him express himself in terms of strongest self-con-
demnation, to have noted him as his own accuser, is one of the
most pitiable of my reminiscences of him. The quick recogni-
tion and willing acknowledgment of man's own fallibility con-
stitutes another claim to greatness. Surely he possessed it to an
infinite degree. The "I don't know" and "it was a mistake"
were utterances that came from his lips frequently and unhesi-
tatingly. Once, after an autopsy had revealed a series of
pathologic surprises and had pointed out errors in number,
Fenger turned to the few celleagues present and is known to
have said, "As I look upon my surgical past I can see the
many murders I have committed." Gruesome and uninviting
as was this reflection in its dark and sinister coloring, it was
Fenger's apology for the earnest role he had elected to play in a
surgical drama, the action of which had been too fast, too furi-
ous, too feverish to admit of a sustained force from any indi-
vidual actor. Every man who has enacted a part in the sweep-
ing evolution of surgery should regard his integral effort as
infinitesimal, and his mistakes as inevitable in the progression
of the whole.
Whether Fenger was always understood by his confreres
or not must remain a matter of conjecture, for as one reviewer
of his life has correctly put it, " The personal element really
defies analysis." Hut there are those, who keep a vigilant eye
on the characters of men and their work, who, grateful because
of what has been bequeathed to them while living, rejoice in
inaugurating occasions that shall herald to the less familiar the
presence among them of a man of sterling qualities, of excep-
tional ability, of prodigious capacity, a star of great brilliance
and of the first magnitude. To know this should be a source
of infinite pleasure. Whereas men of his own nativity in
this country, and especially in Chicago, availed themselves of
every opportunity to applaud their countryman in his dis-
tinguished position, let it be said in justice to the representative
members of the American profession of medicine that Fenger
was the recipient of honors at a gathering in Chicago on Novem-
ber 3, 1900, which, for the character of the men in attendance and
the felicity of their remarks, is unparalleled in the annals of
kindred events. Upon this eventful occasion Christian Fenger
saw gathered about him the potential factors of our profession.
Men of many States far and near gladly came to shake the hand
of an eminent colleague and congratulate him upon his sue-
September (i, :902J
THE WORLD'S LATEST LITERATURE
(Amrkican Medicine 387
cessful termination of 25 years of residence and service in this,
the land of his adoption. The addresses delivered by those
most qualified to speak fairly teemed with expressions of
regard, respect, esteem, loyalty and love. This man thus hon-
ored had proved himself a man of excellent heart, a warm
friend, a sincere writer, a good citizen, a great surgeon, worthy
and honest in the widest terms, who had inspired trust and con-
fidence by his character, his principles and his virtues, had
upheld the best traditions of his profession, and was being
told so. Was there anything in all this of compliment to the
American profession ?
In a retrospect of what has been done in American medi-
cine and surgery during the past years, it is of first importance
to admit of the impossibility of drawing sharp lines of demar-
cation between contributors of native and foreign birth.
Rertecting upon the careers of men who have shed luster upon
the arts and professions, what matters it whether native or
foreign born? With the ages there has come a tendency to
foster a strong feeling of universal brotherhood, to encourage a
sense of unity which neither the limitation of language, race
nor country has been able to efface. Not the country, not the
creed, not the blood, but the man and his achievement should
merit our first, our supreme consideration. This spirit was
thoroughly infused into the Fenger celebration of that date,
and who will say that it was not admirable in its intention and
effect.
This deserved compliment came to Fenger upon the advent
of his sixtieth birthday. When a man has devoted 35 years to
the practice of an art which of itself comprehends and is
fraught with physical and mental tension of the most formid-
able kind, and we are familiar with his augmentative uncon-
trollable passion for work, we are not surprised at the major
and minor disabilities which Nature has ordained shall beset his
path in the declining years. Fenger enjoyed no e.xeniptions in
this regard. Grave organic disease never left its impress upon
him : he never experienced an acute insult but what his strong
constitution could throw it off without lasting effect. An infec-
tion, which meant to him the loss of a finger, may have tempo-
rarily impaired his health, iiut in no wise deflected him from the
onward course of his work ; his residence in an unhealthful
tropii-al climate may have proved for the time enervating, but
was without permanent embarrassment; then, too, his addiction
to tobacco was certainly not without some deteriorating influ-
ence, especially upon the heart's action ; but these ill effects in
no way incapacitated him. The cumulative effects of these
periodic and transitory disturbances, with their cooperative
force, did, however, most certainly tend to lower the vital re-
sistance, even in the absence of eruptive phases. In the last
years Fenger came to a realization of this fact and sought to
adjust his economy by reinforcing it with brief and frequent
vacations, during which he traveled or surrendered himself
entirely to the quiet and reposeful influence of his country
.seat.
Standing at the threshold of the seventh decade we find
him working hard, resting and then resuming work with added
vigor. A few weeks prior to his fatal illness he had visited
California, and the good beneflts derived from his sojourn there
.seemed manifest in every look, word and action upon his
return. lie felt uncommonly well — unfortunately, for it appar-
ently led him to overexert himself. In an hour of unbounded
enthusiasm for the preparation and conduct of his announce
surgical clinic at Rush Medical he dwarfed the importance of
some pulmonic symptoms, chief of which was a hara.ssing
oough. Pneumonia set in after an exposure of several hours in
the surgical amphitheater, and proved to be his undoing. Dr.
Fenger succumbed to an illness of but a few days' duration on
the evening of March 7, 1902.
When confronted with the inevitable issue he neither re-
belled nor feared. He had lived his life — had risen to the fullest
consciousness of his burden, and was willing in the crowning
years of his life and in the zenith of his fame to put it down
without a murmur.
We may well be proud of him, this colleague of ours;
whether or not we dedicate, whetheror not we consecrate, let
us as colleagues an<l men make ourselves worthy of the memory
of Christian Fenger.
THE WORLD'S LATEST LITERATURE
Journal of the American Medical Association.
August SO, 190t. [Vol. xxxix. No. 9.]
1. The Removal of Foreign Bodies from the Eyp. O. H.\ab.
2. Foreign Bodies in the Eye. William M. Swekt.
3. The Removal of Bits of Steel from the Interior of the Eye by the
Haab Magnet, without Incision in the Sclera. Myl.es Stakdish.
4. The Omentum as a Surgical Factor In Laparotomy. Henry O.
Marcy.
5. A New Operation for the More Satisfactory Repair of the Pelvic
Floor, with Special Reference to the Restoration of the Deep Nidus
of the Perineum. CHARLKS A. L. Reed.
6. Chronic Inflammation of the Uterine Appendages; Its Treatment
by Mercuric Cataphoresis. G. Betton Masses.
7. Oral Hygiene. George F. Eames.
8 Etiology and Treatment of Migraine. J. M. Aikin.
9. A Subsequent Report on a Case of Carcinoma, Discharged as Hope-
less and Reported as a Failure. William Allen Pussy.
10. General Nervous Manifestations In Relation to the Jaws and Teeth
George V. I. Brown.
I, 3, 3.— See American Medicine, Vol. Ill, No. 25, p. 1051.
4, 5, 6.— See American Medicine, Vol. Ill, No. 25, p. 1045.
7. — Oral Hygiene. — Persons on rising should rinse the
mouth, brush the teeth for three minutes or more with powders
or washes, brush the gums with rubber bristles, using an anti-
septic or menthol in vaselin, and if the condition of the mouth
requires it the following may be pushed between the teeth at
night: Vaselin, 5j ; white wax, 8grs. ; hydronaphthol.gr. xv;oil
cinnamon, gtt. ij. Toothpicks, preferably gold, may be used
after meals, taking care not to wound the gums. The tongue
should be self-cleansing, but a rubber brush may be used when
necessary ; penetrating bristles may cause infection. Foods
requiring prolonged mastication should be prescribed and
liquids be taken only after swallowing. Eames describes an
Instrument for polishing between the teeth, a douche for apply-
ing water at 110° F. to the gums, and an ointment syringe.
[H.M.]
H.— Migraine. — Aikin excludes headaches due to ocular or
nasal, abnormalities, improper alimentation, nervous exhaus-
tion or brain fatigue. Heredity is the most frequent etiologic
factor. Evidence tends to locate the disorder in the nervous
system, the cells holding out against the ptomaines in the circu-
lation until their cumulative strength causes an explosion.
Toxicity is a question of quantity rather than quality. Diuret-
ics, diaphoretics and hydragogues a.ssist elimination. The
lower bowel should be emptied by enem* followed by high
irrigation with normal salt solution. This and often repeated
draughts of hot water continued from 6 to 12 hours give better
results than purely drug medication. Copious water drinking
between the attacks will lessen their severity, [h.m.]
». — Carcinoma Treated with X-rays.— Pusey gives the
subsequent history of a case previously reported and discharged
as hopeless. Five months later the mass was shrunken and
the j)atient free from pain, showing the progressive and long-
continued effect of the rays. Their deepseated effect is also
evidenced by the fact that the tumor involved not only the
orbit but the surrounding intracranial tissues as well, [h.m.]
lO.— Nervous Manifestations in Relation to the Jaws
and Teeth.— Grinding of the teeth is generally considered a
result rather than an etiologic factor of nervous disorders. It
is dillicult to account .satisfactorily for nervous manifestations
due to dental irritation, yet patients have been repeatedly re-
lieved of pain, hysteria, muscular spasm, neurasthenia and
apparently of facial paralysis by attention to this grinding
hal)it, the symptoms returning with a recurrence of the rub-
bing. The teeth are often tightly pressed together without
sound, the pressure varying from 200 to 270 pounds. If, as
usually happens, the jaws be shifted slightly, certain portions
of the teeth alone must bear this force. This causes a local irri-
tation which is conveyed to the larger nerve trimks. The roots
are forcetl away from the apex of the socket, resulting in nerve
8tret<!hing where the branches of the fifth communicate through
the foramens. The strain keeps up day and night, the patient
being nu)st weary on awakening. When pressure is removed
hyperemia results, which, being frequently repeated, ends In
inflammation giving rise to reflex symptoms. As the lower
jaw at birth is larger than the upper, constant pushing upward
must exercise a radical influence on all the bones forming the
nasal cavities. In its early stages an abnormal habit maybe
388 WXBICAN MeOICISE]
THE WOELD'S LATEST LITEEATUBE
[September 6, 190.>
<!he<!ked. No dojrmatio rules as to troattneDt can be laid down.
One of the most beneficial appliances is a hard rubber plate
with soft velum rubber border extending over the occlusal sur-
faces of the teeth. It need be worn only at night, [h.m.]
Boston Medical and SnrKical Jonrnal.
August iS, 190t. [Vol. cxLVii, No. 9.]
1. The Changes In the Spinal Cord and Medulla In Pernicious Anemia
Frank Billings.
2. Cases of Prostatectomy, with Remarks on the Operation. Paul
TlIOBNDIKK.
S. Smallpox: lis Medical Treatment. Michael Kelly.
1. — JVill be abstracted when completed.
2.— Remarks on Prostatectomy.— Thorndike reports 9
cases with 1 death. Of the 8 patients living 6 are completely
cured. After giving his technic he concludes: (1) Great relief
can be given to all patients suffering from symptoms due to
obstructing enlargement of the prostate, either by palliative or
by operative means; (2) the time to resort to operative meas-
ures Is j ust as soon as palliative treatment carefully executed
by competent hands has failed to give relief; (3) complete
prostatectomy is always the operation of choice, because it is
the only operative procedure which cures or gives uniformly
good results when successfully performed in proper cases ; (4)
the best time for its performance is just as soon as palliative
efforts have failed, or are manifestly impossible of execution,
and before secondary changes in the bladder and kidneys, due
to long-continued obstruction, have taken place ; (5) in those
cases which come for surgical relief so late in the development
of the pathologic conditions that the bladders and kidneys are
extensively diseased and the patient is manifestly exhausted
by long-continued suffering, other less certain and perhaps less
severe measures may be advised, instead of a complete prosta-
tectomy ; but that such a decision can only be and must always
be made by the surgeon for the individual case, and cannot be
made the subject of a generalization, [a.g.b.]
Medical Record.
August SO, 190S. [Vol. 62, No. 9.]
1. Placenta Pra;vla, with Statistics from the I^ast Eleven Thousand Two
Hundred Deliveries of the Sloane Maternity Hospital Frank-
lin A. Dorman.
2. The Opinions of Different Surgeons and Pathologists as to the Orlein
and Cause of Fibroid Tumors. Mary A. Dixon Jones
3. Some Practical Pioblems in Sociology Shown by a Study of the
Southern Negro. M. L. Perry. j ^
4. Dust, Dirtj Dampness, and Darkness as Etiologic Factors in Tubercu-
losis. Charles R. Upson.
5. Out-of-Door Treatment: Its Special Relation to the Preparation for
and Convalescence from Operations. N. B. Aldrich
6. Treatment of Ulcers of the Leg. Cass Chenoweth.
1.— Placenta Prsevia.— Dorman says that in the last 11,200
deliveries In Sloane Maternity Hospital I here were 84 cases of
placenta pr»via, or 1 in lasj cases. The maternal mortality was
12% and the fetal about 43%. As important etiologic factors of
placenta prsevia he recognizes relaxation and subinvolution of
the uterus and chronic endometritis. As predisposing causes
to these factors he mentions age and multiparity ; chronic con-
gestion from renal disease or endocarditis; injuries from oper-
ative deliveries, especially laceration of the cervix ; ?nd new-
growths, such as fibroids or cancer. In the series given the
ratio of multipara to primipara was 8 to 1. For diagnosis
dependence must be placed upon the history of the case and
the results of vaginal examination; and such examination
must be made with excessive care, lest a fatal hemorrhage be
thus started. The treatment must vary widely with the widely
different indications. Expectant treatment is permissible only
before the seventh month ; never allow a patient with placenta
prajvia to go on in pregnancy beyond the seventh month,
remembering that at any time hemorrhage so profuse may
come on that the patient may die before the doctor can be
secured. In case of induction of labor one rule must absolutely
be observed, and that is not to leave the patient until she is
delivered, [w.k.]
2.-Origin of Fibroid Tamors.-Jones reviews the theo-
ries of many eminent writers, but she herself holds that both
tumors and inflammatory swellings are derived from preexist-
ing tissues, and has shown that a fibroid tumor of the uterus, or
a myofibroma, is a newgrowth, resulting from the tissues of
the uterus being, by .some infection or microbic cause, reduced
to inflammatory or medullary tissue. She asserts that the
rea.son why the uterus is so frequently the seatofthe.se growths
or tumors is not because any germinal material may lie there,
but I)ecau8e the uterus most unfortunately is the frequent seat
of infection ; and why the tumor that is developed is most fre-
quently a myofibroma is because the wall of the uterus, from
which the tumor is evolved, is composed of muscle fibers and
the reason why these tumors do not develop until after puberty
is because septic conditions are not so apt to occur till that
period. In every case of a fibroid tumor of the uterus seen by
the writer the patient has for a long time suffered from various
causes of ill health or from some abnormal conditions. This
would seem natural ; for there must be considerable disea.se
before a fibroid tumor can grow or be developed. Hence
fibroid tumors, like every other ailment, result directly or indi-
rectly from violations of the laws of health and they develop
only when there is disease, no matter what the age may be. The
writer thinks that most investigators in making a study of
tumors have failed to take into consideration the pathologic
conditions of the immediate or surrounding tissues, and have
made not the least reference to the condition of the uterus
where the tumors were developed. This seems a question of
supreme importance, and worthy of careful study and investi-
gation, [w.k.]
4.— Dust, Dampness and Darkness as Factors in
Tuberculosis.— Upson emphasizes the dangers of macadam
paving in cities. Turbinate hypertrophy is more prevalent
where this is used. This induces shallow breathing, favorable
to tuberculous infection. The dust also causes bronchial irrita-
tion at the same time that it carries the infecting germs. He
recommends asphalt, which can be kept clean by frequent
flushing, [h.m.]
5.— Preparation for Operations.— Aldrich does not be-
lieve it necessary or wise to confine the usual patient in bed
for more than one day before operation, and in certain cases he
confines them for only partof a day. He regulates their habits
for a week or more preceding operation, but avoids long bed
rest, as fresh air, out-of-door exercise, and proper hours for rest
are of as much importance in preparing the patient as are
enemas, cathartics, baths, etc. In convalescence this principle
is of equal importance and Aldrich gets patients out of Ijed as
soon as possible, sometimes six days after operating for appen-
dicitis. If a patient is doing well after an amputation, there is
no need of keeping him in bed longer than three days. The
whole article emphasizes the value of out-of-door treatment
[A.G.E.]
New York Medical Jonrnal.
August S3, 1902. [Vol. lxxvi. No. 8.]
1. Gas Leakage and the Public Health. James C. Bayles.
2. Clinical Cases of Gas Poisoning. Samuel Lloyd.
3. A Consultation with Professor Dieulafoy on Appendicitis. Edmund
L. Gros.
4. Gastric Acidity. L. H. Watson.
o. A .Vlethod of Preserving Gross Specimens for Museum and Class
Demonstration. W. H. Watters.
6. Observations on the Anatomy, Physiology, and Pathology of the
Normal Sacculi Ani, and on the Etiology. Pathogenesis, and
Diagnosis of the Abnormal Anorectal Pouches, Espeeiallv Those
Described and Treated by the Late Eminent l>r. Physick. Wm.
BODKNHAMER.
7. The Treatment of Hemorrhoids by Enucleation. George B.
Evans.
8. Report of a Case of Successful Removal of a Kidney for Intermittent
Hydronephrosis. J. B. Boucher.
1.— Gas Leakage and Public Health.— Bayles gives
statistics showing the enormous amount of gas lost by leakage
and discusses its mode of entrance into houses and its effect
upon vital statistics. He believes that carbon monox id from
gas mains is much the worst constituent of sewer gas, and that
the enormous leakage of illuminating gas in distribution
accounts for the general prevalence of anemic conditions in our
large cities. He says that gas main leakage is an evil vastly
greater in its influence upon the deathrate of cities than any or
all of those which have engaged the attention of those who have
conducted sanitary propaganda. [c.A.c]
2.— Gas Poisoning. — Several cases of chronic gas poison-
8EPTEMBEB 6, 1902)
THE WORLD'S LATEST LITEEATURE
(American Mkdicinb 389
ing are reported by Lloyd. The patients were generally
anemic, liad headache, temperature at irregular intervals, which
at times reached 104° F., coated tongue, anorexia, enlarged
spleen and a general feeling of malaise. In some cases typhoid
fever, in others malaria was suspected. Blood examination
showed only anemia. Change of location in each case resulted
in speedy recovery. [c.A.c]
3. — Appeudicitis. — Gros mentions some points of interest
in a consultation on appendicitis with Dieulafoy. He believes
in operating always, the sooner the better, unless the patient is
too weak to withstand the shock. Though the first 12 hours are
the most favorable, he does not hesitate to advise an operation
after three or four days. Appendicitis should not be considered
a local disease. There is a phase which is an acute toxemia.
He is also of the opinion that vomiting of blood in this disease
is nearly always a forerunner of a fatal termination. [c.A.o.]
4. — Gastric Acidity. — Watson calls attention to the usually
high percentage of HCl secreted in cholecystitis, cholelithiasis,
cholangitis, and hypertrophic cirrhosis of the liver. While
not of sufficient uniformity to base an absolute diagnosis upon,
it is well in all cases of hyperchlorhydria to examine the
urine for nephritis, and specially the gall-bladder and liver for
inflammatory troubles. When there exists no organic change
in the oxyntic cells it is the nervous system that we must study
to enable us to rectify the excess or lack of secretion. Sudden
emotional excitement usually lessens or suppresses it tempo-
rarily. Prolonged and constant worry through business or
other troubles increases the amount secreted, and thus becomes
a secretory neurosis, to be modified or cured by strict dietetic
plans, and, as nearly as possible, an adjustment of those mental
stimuli by change of scene, cheerful companionship and the
direction of the mind to other channels. [c.A.o.]
5. — A method for preserving gross specimens for
museum and class demonstration is described by Watters.
The solutions used are as follows : 1. Fix for 2-4 days in ( Kaiser-
ling Xo. 1)
I. Formaldehyd 200 cc.
Potassium nitrate 15 gm.
Potassium acetate 30 gm.
Water 1000 cc.
II. Drain and place in ordinary commercial alcohol for from
three to five hours.
III. Saturate from three to five days longer in (Kaiserling
No. 3)
Potassium acetate 200 gm.
Glycerin 400 cc.
Water 2000 cc.
IV. Imbed in
Kaiserling No. 3 15 parts
Cielatin . . 1 part
[c.A.o.l
7. — Hemorrhoids. — The Pennington operation for hemor-
rhoids by enucleation is discussed by lOvans and two cases
reported in which it was not satisfactory. In this operation an
ellipse is removed from the apex of the hemorrhoid com-
mensurate with the size of the tumor by means of sharply
curved scissors. This permits most of the blood to escape. All
of the angiomatous tissue is now removed by dissection, when
the remaining walls collapse. Each quadrant is treated in like
manner, a stream of hot salt solution flowing over the field of
operation continuously. The field is dnsted with antiseptic
powder, and a rubber-covered tampon introduced through a
teivalve speculum. In the first case perfect hemostasis was not
obtained. The rectum was found to be full of well organized
clots which were dammed up above the sigmoid. These were
removed and a fresh tampon applied so as to compress the
bleeding vessel. Ke<;overy followed. The second case was that
of sepsis following this operation in a woman of 41. The result
was fatal. The author states that in 20 cases the operation was
very satisfactory. In cases in whioli the varicosities are com-
paratively accessible, when from any reason there is no bowel
paresis and the plug can be placed securely to remain for a
time, thereby ensuring protection from hemorrhage and
probat>ly from infection, he believes the operation to be satis-
factory. [c.A.o.]
H.— Intermittent Hydronephrosis. — Boucher reports a
case of successful removal ot the right kidney and ureter in a
woman of 33, who for 13 years had been troubled with inter-
mittent hydronephrosis. The pain in the right lumbar region
was intermittent in character and occurred with the develop-
ment of a tumor which lasted from a few hours to a day or two,
occurring at intervals of from 2 weeks to 2 or 3 months. The
right kidney was found freely movable, very narrow and about
7 inches long, with a dilated pelvis and ureter 10 or 12 inches in
circumference. [c.A.o.]
Medical News.
August SO, 190S. [Vol. 81, No. 9.]
1. The Complications and Sequels of Acute Croupous Pnpuraonla.
H. A. Hare and Arthur Dare.
2. On the Causes, Variations and Slgnineance of the Color of the Feces.
Lewis A. Conner.
3. Suture of the .Solid Viscera. R. C. Coffey.
4. Pulmonary .Syphilis: Report of a Case. James M. Winpield.
1.— Complications and Sequels of Acute Croupous
Pneumonia.— This is a review of all the literature of the sub-
ject, including previously recorded case histories. The writers
conclude from this study that, independent to those due to
mechanic causes, the complications and sequels are best classi-
fied as pneumococcus infectious. Those affecting serous mem-
branes are first considered, including serous and purulent
pericarditis and pleuritis, endocarditis, malignant and ulcera-
tive, serous purulent and osteoarthritis. Next discussed are
those affecting the cerebral and spinal system— cerebral pneu-
monia, meningitis, hemiplegia, paralysis, cerebral abscess,
aphasia. Those exhibiting toxic action on nerve centers are
delirium, mania, convulsions, cardiac asthenia, brachial
neuritis, bilateral polyneuritis, trophic disturbances (herpes
zoster), temperature disturbances, albuminuria and nephritis.
Those belonging to neurotic tendencies are retention of urine,
and tetanoid and choreiform phenomena. Those pointing to
intravascular and hemic changes are pulmonary gangrene,
abscess and bronchiectasis, gangrene of lower extremities,
embolism of lenticulo-optic arteries, phlegmasia, alba dolens,
renal and splenic emboli, embolism of the brachial veins,
purpvira hemorrhagica and hemoglobinuria. Glandular infec-
tions include parotitis, bronchial adenitis, submaxillary
adenitis, thyroiditis, orchitis, ovaritis and hepatitis. Infec-
tions of the middle ear are reported. Those due to mechanic
interference are edematous laryngitis, fatty tumor of the right
auricle, jaundice from obstruction of the bile ducts, dilation of
the right heart from pulmonary obstructions or toxic myocar-
ditis, and delayed resolution and induration from cardiac
asthenia, [h.m.]
2.— Color of the Feces.- The color elements may be
grouped under digestive secretions, food residue, discharges
from intestinal mucous membrane, and accidental ingredients
as drugs. In starvation and fasting the stools become of dark
pitch-like appearance from the digestive juices acting on
mucus, desquamated epithelium and bacteria. Bilirubin is
oxidized into biliverdin, Ijoth appearing in meconium and the
stools of nursing infants, where putrefactive changes are
slight. After the first few months the bile pigments are
reduced through bacterial action into hydrobilirubin, the
normal yellowish-brow^n pigment. Food of a pronounced
color like spinach or carrots may tinge the stools. Vegetables
produce lighter stools than meat. Highly refractive bodies
like fat tend to make the feces lighter. Mucus in quantity
may give a yellowish-gray appearance. Pus from the large
intestine cau.ses a yellow-color serum, as in cholera a straw
color. Blood gives a color depending on quantity and prompt-
ness of discharge. Cold, huckleberries, etc., may give an
appearance of discharged blood. Bismuth causes blackish or
greenish stools, calomel greenish, iron blackish-gray, rhubarb,
senna and santonin yellow and methylene-blue cause a bluish-
green tint on exposure. Some bacteria develop a green pig-
ment. Clay-colored stools are duo to excess of fat. There are
colorless stools without jaundice, the bilirubin having been
reduced to leukourobilin. Excess of fat may result from
ingestion of an unusual <iuanlity, from disturl)ances of absorp-
tion in the small intestine or al)sence of the pancreatic Juice.
Biliverdin is found in many diarrheas associated with increased
alkaline reaction, [h.m.]
390 AXERICAir Mbdiciitej
THE WORLD'S LATEST LITERATURE
(September 8, 1902
3.— Suture of Solid Viscera.— Coflfey states that but little
progress has been made in Buturing the liver, practically all
attempts thus far being aimed toward a direct suture with
which it is impossible to control hemorrhage. The method
which he is at present testing on animals brings the pressure of
the stitches upon Glisson's capsule at three or four points which
are protected by a weave of catgut. Two sutures are used, one
Y-8hape<l, for incisions not entirely penetrating the organ, the
other X-shaped, for an entirely severed organ. A round curvetl
needle, at least four inches long, is used to insert a quilt suture
which passes through a catgut mat on each side of the wound.
A suture passed from the opposite side of the organ includes
these two threads at the bottom of the cut, returns and passing
through a single catgut weave is tied in the form of a quilt
suture, thus drawing the first suture well into the bottom of
the cut. The first suture is then tied and any amount of pres-
sure can be used, for the line of pressure is upon the catgut sup-
ports instead of the suture. This brings the bottom of the
wound in absolute apposition. If desired, a second row of
sutures can be passed through the edges of the supports nearest
the wound and including only the capsule, thus closing the
surface of the organ. This method applies specially to the
liver, but may also be used in suturing the kidney and spleen.
[A.a.E.]
4.— Pulmonary Syphilis.— Syphilis probably invades the
lungs as frequently as other tissues, but it is difficult to differ-
entiate it from tuberculous phthisis. It may coexist with the
latter or may be cured without being recognized. It may be
either congenital or acquired, and consists of a gummatous or
sclerotic inflltration. An interstitial pneumonia is produced.
The cavities result from the breaking down of gummata. The
first symptom is bronchial catarrh. Hemoptysis is not com-
mon. The sufferer may emaciate early or not until the disease
is far advanced. There is thickening of the clavicular perios-
teum. Diagnosis can be made from absence of the tubercle
bacillus, evidences of tertiary syphilitic lesions, history, and
the relief obtained from antisyphilitic remedies, [h.m.]
Philadelphia Medical Journal.
August SO, 190S. [Vol. x. No. 9.]
1. The Positive Diagnosis of Meningitis, Particularly Tuberculous by
Means of Lumbar Puncture. Alfred Hand.
2. Municipal Water Supplies and Their Examination. William G.
BiSSBLL.
3. The Treatment of Pulmonary Tuberculosis. William A Cald-
well.
4. Some Features of Medical and Surgical Study in London and
Berlm. A. S. Grimm.
5. Amyotrophic Lateral Sclerosis : Report of a Case. E.J. French.
1.— The Positive Diagnosis of Meningitis by Means of
Lnmbar Puncture.— Although Hand lays stress on the value
of lumbar puncture, it must be borne in mind that the clinical
manifestations must be closely studied. Positive conclusions
can be based only upon positive data. Referring to the per-
centage of uncertainty in the examination of the fluid drawn
by lumbar puncture positive results were obtained in 32 out of
37 consecutive cases, the results in 5 being classed as extremely
probable. Tubercle bacilli were found in 26, pneumococci in 2,
meningococci in 1, and 3 were normal specimens; probable
diagnosis was made in the remainder, cocci being present in 2,
1 being apparently serous meningitis and 2 an infectious menin-
gitis of undetermined origin. The technic of lumbar puncture
is detailed. From the above experience it seems safe to con-
clude that when meningitis is suspected, lumbar puncture will
definitely determine whether or not it exists and that, if proper
technic is observed, it will decide in the vast majority of eases
whether the process is tuberculous or not. [f.c.h.]
2.— Municipal Water Supplies and Their Examination.
— Bissell firmly believes there is no test more valuable to indi-
cate the relative degrees of purity of water than that described
by Stone for the detection of the colon bacillus, [f.c.h.]
3.— The Treatment of Pulmonary Tuberculosis.- Cald-
well considers that the following five points should be remem-
bered prior to beginning the treatment of a case of pulmonary
tuberculosis : (1) It is a preventable disease,by destruction of the
excretions known to contain the bacilli and by keeping the
organs and tissues of the body at their highest physiologic
function ; (2) it is a curable disease, as shown by the reports of
many sanatoriums in every part of the world and by postmor-
tem statistics ; (3) there is no specfic climate, although some
climates have greater healing influences than others, and the
disease may be successfully treated in all climates; (4) there is
no .specific medicine, but there are medicines which favorably
influence the disease; (5) to obtain the best results an early
diagnosis is necessary. We should not depreciate the great
value to be obtained from examining the sputum, but should
regard the presence of bacilli as confirmatory rather than diag-
nostic. For convenience of study the treatment is divided into
prophylaxis, hygienic-dietetic, symptomatic and drug treat-
ment, each of which is detailed, [f.c.h.]
4. — Some Features of Medical and Surgical Study in
London and Berlin. — Grimm states that an American student
may gather many useful things from the profession on the other
side of the Atlantic. On the other hand, some members of the
profession in Europe would be much benefited by a study of
our methods, [f.c.h.]
CLINICAL MEDICINE
David Riesman A. O. J. Kelly
Diphtheria Bacilli in Well Per.soiis. — Observa-
tions conducted for several years on both sides of the
Atlantic with reference to the prevalence of diphtheria
show that in nearly every year out of the past two or
three decades the month of September has shown a
decided increase in the number of reported cases. This
rise, both in the prevalence of the disease and in its
deathrate, usually occurs coincidently with the opening
of the schools after the long summer vacation, and these
circumstances have been considered by most sanitary
authorities as having the relation of cause and effect.
Laws and regulations relating to isolation, ciuarantine
and school attendance have been enacted, and while this
question of the relation of the disease to school attend-
ance may not be considered as absolutely settled, it is,
nevertheless, desirable that all possible means be em ployed
to prevent this annual increase in the spread of the dis-
ease. Sanitary authorities have found in bacteriology a
valuable aid, not only for determining the existence of
tliphtheria in doubtful ca.ses, but also in defining the
limits of its continuance in each individual case. Hence
the laboratory is now an important adjunct in the equip-
ment of the board of health of every large city.
One of the most perplexing questions with which
such boards have to deal is the frequent existence of the
diphtheria germ in the throats of well persons, and
especially of those who have been recently exposed to
the infection of diphtheria. The treatment of such
persons has given rise to much discussion, and two years
ago the Massachusetts Association of Boards of Health
considered the subject as of sufficient importance for the
appointment of a special committee, which was charged
with the duty of ascertaining what was being done in
American cities with well persons infected with diph-
theria bacilli. Circular letters were sent to health officers
in the principal cities asking their opinion as to the best
methods of controlling such cases. Some thirty-three
experts signified their willingness to enter upon the
work of observation, and a series of cooperative inquiries
was undertaken. This committee has now published its
report.'
The frequency of occurrence of tliphtheria ba-
cilli in Avell persons was the subject of the first ques-
tion. Allowing for some difference of opinion as to the
morphologic characteristics of true diphtheria bacilli,
the replies showed a wide divergence of opinion, vary-
ing from 1^ in Boston to as high as 22 /« in the District
' Report on " Diphtheria Bacilli in Well Persons." Journal of the
Massachusetts Association of Boards of Health, Vol. xll, July, 1902,
September 6, 19021
THE WOELD'S LATEST LITERATURE
iAMKRICAN MlDICINK 391
of Columbia. Most of the observations were limited to
persons who had not, so far as was known, been recently
exposed to diphtheria. When examination is made of
persons who are known to have been so exposed, accord-
ing to the observations of Chapin, Denny, Kohn and
Park, it appears probable that from 8/c to 507c of the
well persons in such infected families are infected with
the bacilli of diphtheria.
The virulence of the diphtheria baciUus when
found in well persons was next considered. Observa-
tions show that such persons often remain free from
clinical symptoms and mingle freely with others with-
out spreading the disease. It would, therefore, I^e im-
iwrtant to determine whether such bacilli occurring in
well persons are usually virulent or not. This can be
determined in two ways, by the guineapig test and by
clinical evidence. A sufficient number of guineapig
tests wa-s not made from which to draw general conclu-
sions. The committee concludes, from an examination
of the experimental and clinical evidence, that only a
small percentage of the morphologically typical diph-
theria bacilli found in well persons not recently exposed
to the disease are virulent ; but the number of infected
individuals well enough to mingle freely with others is
so great that, even if only a small proportion of them is
likely to transmit the disease, they constitute an im-
portant factor in the spread of diphtheria.
The danger of Infection from healthy persons
depends on the age, habits, surroundings, occupation
and intelligence of the infected person. A child who is
constantly putting its hands and other things into its
mouth, and who plays with susceptible children of sim-
ilar habits, is more likely to spread the disease than
an adult. Infected persons of cleanly habits are less likely
to spread the disease than the uncleanly. In crowded
tenements and in public institutions the disease is more
likely to spread than in private houses. The occupation
is important. Persons engaged in handling articles of
food (as milkmen) and those whose work brings them
into close contact with young children {e.g., nurses), are
more likely to spread the disease than laborers or clerks.
The conclusions of the committee are as follows :
First, with reference to well persons not recently
exposed to diphtheria, that it is impracticable to isolate
such persons. In consequence of the great number of
such persons it would be futile to seek them out and iso-
late the whole number. Second, with reference to well
persons in infected families, schools and institutions, it
is not advisable as a matter of routine to isolate such
persons. It is, however, advisable to keep the children
in infected families away from day schools, Sunday-
schools and all public places, and to keep them on their
own premises. Wage-earners may usually be allowed
to continue their work ; but teachers, nurses and others
who are brought into close contact with children should
not te allowed to continue their business. In schools
and institutions it is usually advisable, if the infection
is not too widespread, to separate from the others all
infected persons, sick or well. When diphtheria appears
in a conmiunity which has for some time been free from
it, it is advisable to isolate all persons who have been
brought in contact with the patient until it shall have
been shown that they are free from diphtheria bacilli.
As to isolation of well persons infected with
diphtheria bacilli, the committee, although Ix-lieving
it not practicable, recommend that an attempt should be
made to educate the public to care for their persons and
their secretions, so as to avoid the danger of infecting
themselves or others. They also call atte^ntion to the
importance of teaching cleanliness to sch(M)l children,
and of giving advice to families where diphtheria exists.
In aiming at these conclusions the committee does not '
wish to be understood a.s minimizing the possible dan-
ger from diphtheria infection, but simply recommends
what appears to be the most expedient course to pursue
after considering the various conflicting interests of the
public and the infected individual. The responsibility
is largely shifted to the latter, and in the case of intelli-
gent persons the individual responsibility in disseminat-
ing disease should be clearly placed before the infected
person.
The bacteriologic portion of the report deals
with the causal relation of the Klebs-Loffler bacillus to
the disease clinically known as diphtheria and the theory
of infection. The committee was assisted in carrying
out its investigations by several laboratory workers,
who were requested to make observations as to the
existence of diphtheria bacilli in the nose and throat.
For this purpose cultures were obtained from 3,9.53 per-
sons. The virulence of the bacilli was tested in 86 cul-
tures, and cultures were taken from 1,536 other persons,
which, in consequence of incomplete records, could not
be classified. As might be expected, infection appeared
to be much more widely spread among children in insti-
tutions than among day-school children. Much atten-
tion was given to the morphology of the diphtheria
bacillus. The committee classifies them as granular,
barred and solid forms, and still further by letters of the
alphabet as A A'', B B^ etc.
Plates are given illustrating these forms and types.
The granular are most commonly present in clinical,
diphtheria and would be classed as diphtheria bacilli by
all bacteriologists. The committee believes that the
question of the relation of these diff"erent types to clin-
ical diphtheria should receive further investigation.
The granular forms are found to be present in about 1 fo
to 2% of well persons, while the solid forms were found
in about 20 5^ to 25^ of healthy persons; the latter were
therefiire regarded as of little diagnostic value and any
attempt at isolating persons on account of the pressure
of these solid types would be an injustice. The follow-
ing conclusion, therefore, seems to be reasonable as the
result of the bacteriologic inquiry, so far as ^Nlassachu-
setts is concerned : " It seems reasonable to suppose that,
in Massachusetts about 1 /« to 2 /c of all persons carry
typical diphtheria bacilli. Of this number not all are
capable of transmitting the disease, for it is found that
bacilli morphologically identical with diphtheria bacilli
may have no power of producing toxins." Further
than this, examinations made to test the virulence of
the typical bacilli found in healthy persons showed that
only about IT/c of the existing Ifc to 2 fc had virulent
bacilli, so that about " 17 in 5,000 to 10,000 of all persons
have diphtheria bacilli which are dangerous to the pub-
lic health. The number of tests was too small to make
the above percentages of much value, yet they bring out
the fact that if a healthy person is found to have the
Klebs-Ixittler bacilli, and there is no connection trace-
able between that person and cases of diphtheria, the
chances are very much in favor of the bacilli being non-
virulent. Great care should therefore be taken not to
l)ut unnecessary restrictions on persons while the
chances are great that the bacilli are nonvirulent."
The frc<iuency of occurrence of <liphtheria ba-
cilli in exposed persons is not fully covered by their
investigations. Observation, however, shows that the
bacilli in persons who have been in close contact with
diphtheria are usually virulent ; so that the problem of
what to do with a person who has been exposed to diph-
theria is very different from what it is in the case of a
nonexposed individual. The bacilli in healthy exposed
persons are probably of the same virulence as those in
the diseased individual, the absence of symptoms in the
former typing the result of an acquired or artificially j)ro-
duced immunity. A healthy person who has diphtheria
bacilli as a result of recent exposure is, therefore, as
dangerous as a convalescent from diphtheria in whom
the bacilli are persisting after all the local symptoms
have disappeared. It is, therefore, theoretically rational
if convalescents are isolated to isolate also all healthy
itifected persons who have been exposed, until they are
free from bacilli. Such a course would undoubtedly
892 AlCKBIOAM MEDTOtsa]
THE WOELD'S LATEST LITERATUEE
[SEPTEHliEB 6, 1902
result in preventing the occurrence of some cases and in
saving some lives. It is found, however, that such a
course is not practicable for all boards of health to follow.
It is largely an economic question. The risk to the
public health must be weighed against the loss and j)ri-
vation to the individual from isolation. The eleven
members of the committee are all actively engaged in
sanitary work, either as bacteriologists or health officials,
but special credit is due to the chairman and secretary,
Drs. Chapin and Hill, as well as to Dr. Theobald Smith,
who contril)uted the introduction to the baeteriologic
portion, and to Professor Wesbrook, of Minnesotsi, for
valuable suggestions.
The Diagnosis of Carcinoma of the liargc Intestine-
According to Criiiner ' it is very important to make an early
diagnosis of cancer of tiie colon, inasmuch as surgical treatment
permits of a radical cure, provided tlie diagnosis is made in
time. Suspicion should arise if, in an individual of middle life
wlio has had normal intestinal digestion and bowels, the stools
become irregular and there are periodic attacks of colic, with
or without signs of bowel obstruction. Hemorrhages are also
significant. The colicky attacks are an important sign, but it
should be remembered that the use of tobacco may cause simi-
lar symptoms. In all cases of such colic the weight should be
carefully watched. If carcinoma is suspected, massage of the
abdomen is eontraindicated. Another symptom of importance
is that described by Nothnagel as " Darmsteifung "—intestinal
rigidity. A significant symptom is one discovered by the
author, and called by him the " pouring sound ; " »'. e., a sound
like that produced by pouring water from a pitcher upon the
floor. This is pathognomonic of stenosis, though not of car-
cinoma. Tenesmus is often present, and is greater the nearer
the carcinoma is to the anus. The importance of the practice of
making rectal examinations is emphasized. Often the patient
is said to have hemorrhoids because he has blood and mucus in
the stools, but a digital examination shows a hopeless carci-
jpoma. Examination is preferably made with a speculum, that
of Kelly being the best. In addition to blood, pus is occasion-
ally found in the stools; this is sometimes due- to a purulent
proctitis which, however, does not exclude the existence of car-
cinoma. Contrary to the usual teaching, Cramer insists that
cancer of the intestine does not produce any characteristic shape
of the dejecta. The form of the feces is determined by the
sphincter ani and the state of contraction of the colon or rectum.
In many eases of carcinoma, particularly of the descending
colon or of the rectum, the general nutrition suffers but little';
while, on the other hand, in intestinal atony the emaciation may
be so marked as to lead to the suspicion of carcinoma. Occa-
sionally large tumor-masses are discovered in the abdomen,'
suggesting metastasis ; in one case of the author's they turned
out to be of a fecal nature, [d.r.]
The Dlechoscope.— Troussaint- published in the Marseilles
MSdicale a description of an auscultation apparatus for the util-
ization of binauricvilar audition for tlie simultaneous perception
of two different sounds. The instrument contains a very sensi-
tive vibrating plate and a parabolic air chamber for augment-
ing the intensity of the sound. Pulmonary auscultation is
rendered easy by simultaneous comparison of two symmetrical
paints. Slight differences in rhythm, timbre, etc., are immedi-
ately appreciable, and the clinical value of the instrument for
the localization of valvular lesions and cardiopathic conditions
Is evident. [o.s.D.]
Tuberculous Peritonitis.— Shattuck,' studying 98 cases of
tuberculous peritonitis, states that the mortality, when based on
the condition of the patients at discharge from the hospital, is
13.29'(i. The mortality of the same series of cases after a period
of from 2 to 11 years is, on the contrary, i~.'3%. The ultimate
mortality of the patients in this series under medical treatment
is 6891:, and of those under surgical treatment, Sn.5% (two
patients have had recurrence, but are now well). It is believed
that: 1. Tuberculous peritonitis may be followed by apparently
complete recovery, even if complicated by tuberculosis else-
1 MOnchener med. Woch., June 17, 1902.
2 La Kevue Medlcale <Ju Canada, July 10, 1902.
"American Journal of the Medical Sciences, cxxlv, 1, 1902.
where either under (a) purely medical treatment, (&) by Up-
ping and (<) incision. 2. As in other forms of internal tuljer-
culosis, the best obtainable hygienic surroundings are all
important. Consequently no patient shouhl be kept in the hos-
pital longer than necessary, especially if more and better air
can be secured outside with proper care and food. 3. We are
encouraged in trying medical treatment for a time, especially
under first-rate hygienic conditions, tapping the abdomen if
there is sufHcient fluid to cause discomfort. 4. If the patient
under a month or six weeks of medical treatment fails to
improve, or in even less time if he seems to be losing ground,
surgical treatment should be advised, [a.o.j.k.]
Thyroid Accessories.— M. Crispino' furnishes an interest-
ing contribution to the histology of the accessory glands or
satellite organs of the thyroid gland, the parathyroids, the
thymic granules and the epithelial cysts. The paper considers
in detail the parathyroids as recognized in man by .SandstrOm
in 1880, and afterward described in the dog, cat, rabbit, horse
and ox, and in many other animals by Gley and by Cristiaui,
their real value being first pointed out by Baber in 1881 and
Rogowitsch in 1882. Crispino concludes that the parathyroids
do not represent embryonic structures normally destined to
the character of the thyroid gland itself, but he holds them to
be histologicly distinct, though in intimate rapport with the
thyroid. The thymic granules were discovered in man by
Lupo, in 1888, the discovery being confirmed by MuUer in 1896
and by Verdun in 1897, the structures being afterward
described by Kohn, Zienlinska, and Verdun, for cats, dogs,
sheep, rats and moles. These lobulated ganglions are con-
sidered by Kohn as rudimentary organs having a special
embryonic role. Histologicly, they are distinct and have
no relation with the thyroid glandular epithelium, and they
appear to be of a lymphatic character exclusively. The epi-
thelial cysts, which are annexed to the organs of the thyroid
region, were first pointed out Ijy Remach in 1843. They seem
to be of three kinds— epithelial retention cysts, thymic cysts
and embryonal cysts. This paper is accompanied by an excel-
lent bibliography, [c.s.d.]
The Ply as an Agent of Propagation of Disease and
as a Medium for Slicrobic Metamorphosis.— M. T. Bren-
nan^ discusses the interesting role played by these insects con-
sidered as impure animals in the Mosaic law, and whose habits
are well characterized by the names given to certain species,
such as scotophagous, sarcophagous, etc. The article deals
with the most common species: the domestic fly {Musca
domestica Linne), the black flesh fly {Sarcophaga carnaria
Meigen), the blue bottle fly (Musca ceasar&nA Musca coricina),
and the leg-striker (Stomoxj/s calcitrans), and after pointing
out the serious danger of infection which these insects present,
emphasizes the necessity for systematic efforts looking-to their
extermination, [c.s.d.]
Hyperplasia of the Pharyngeal Lymphoid Tissue
(Adenoids), with Especial Reference to Pi-lmary Tuber-
culosis of the Pharyngeal Tonsil.- I^artigau and Nicoll,'
from an extensive study of the subject and a thorough review
of the literature, conclude: 1. Adenoids consist essentially of
hpyerplastio pharyngeal lymphoid tissue. The epithelium and
fibrous-tissue changes are inconstant and variable and inde-
pendent of the age of the patient. The new-formed fibrous-
tissue is largely perivascular in distribution. It may occasion-
ally be one of the factors in the process of disappearance of the
adenoid. 2. The hyperplastic pharyngeal tonsil often contains
microorganisms, and these are mainly pyococcal forms. The
bacteria for the most part lie near the surface, and the infection
usually occurs from the surface, with or without demonstrable
lesion of the epithelium. 3. Primary tuberculosis of adenoids
is probably more common than most previous studies show.
Sixteen per cent, of our series contained tubercle bacilli, 10%
with characteristic lesions of tuberculosis. The tubercle bacilli
were present in small numbers. 4. The pharyngeal tonsil may
be a portal of entry for the tubercle bacillus and other micro-
' organisms in localized or general infectious. [a.o.j.Iv.]
The Clinical Association of Cancer and Tuberculosis
1 II Pollclinico, June, 1902.
2 La Hevue Medlcale du Canad.i, July 16, 1902.
sAmerioan Journal of the Medical Sciences, cxxlii, 1031, 1902.
September 6, 19021
THE WORLD'S LATEST LITERATURE
[Amkbican Medicine 393
— McCaskey' discusses the clinical association of cancer and
tuberculosis, and reports a case of extensive carcinoma of the
pancreas, liver, and contiguous structures, and widespread
tuberculosis of both lungrs. As far as could be ascertained the
carcinomatous process did not extend above the diaphragm,
nor the tuberculous process below the diaphragm. It is con-
cluded : 1. Cancer and tuberculosis are so rarely associated in
the same individual as to indicate a mutual antagonism
between the two diseases. Autopsies on 281 cancer patients
revealed only 119'(, of cases of tuberculosis. In the noncancerous
its frequency is nearly 20 times as great. 2. The antagonism is
not " diathetic," but it is probably due to the chemic products
of the two morbid processes, that of one being inimical to the
other. 2. There is a rather intimate relationship existing
between the two diseases in certain families. The existence of
either appears to favor the occurrence of the other, probably by
lowering of "resistive power" in the individuals of such fam-
ilies. 4. The two diseases are not absolutely incompatible.
They may very exceptionally exist in different parts of the
same individual. Still, more rarely, they may exist in the
same organ, and even in identically the same tissue. In the
latter case it is probable that the primary disease was quiescent
when the secondary one developed. 5. In view of the apparent
antagonisms, and the occasional retrocession of cancer after the
use of tuVjerculin (though very doubtfully attributable to the
latter), it would seem worth while in properly selected inoper-
able cases to try the systematic local injection of tuberculin in
the cancerous tissue, [a.ci.k.]
On the Presence of Lipase in Certain Bacteriologic
Fluids.— A. Zeri ^ reports the discovery in pathologic exudates
of an enzyme having the property of producing hydrolysis of
monobutyrates and monoglycerids of butyric acid, which
enzyme he finds analogous in its properties to lipa.se, first dis-
covered by Hanriot in blood-serum in the organs of many ani-
mals and in the oily seeds of certain vegetables, and which has
since been shown by Hanriot, Loevenhart, Berninzone and
others to play an important part in the phenomena of absorp-
tion and utilization of fats. The lipolytic action of blood-serum
and pathologic exudates is a matter worthy of note, [c.s.d.]
Peculiarity of Blooil-pressiire in a Tumor of the Medi-
astinum.—In a patient having a tumor of the mediastinum,
Ekgren » found the blood-pressure (measured with Gartner's
tonometer) to be equal on both sides, the patient being in either
the upright or prone posture. If measured with the patient in
the supine position the pressure on the right side was found to
be less than half of the normal, while on the left it remained at
the normal point ; this could also be illustrated with sphygmo-
graphic tracings. Nothing like it was found among 300 other
patients, another of whom had a mediastinal growth. In cases
of aortic aneurysm dift'erences between the right and left side
were noted. He concludes from this that he had to do with a
movable tumor of the right thoracic cavity which pressed upon
some of the important vessels when the patient was lying fiat
on his back. This conclusion was afterward confirmed by au-
topsy. [E.I,.]
A case of eosinophllia associated with hydatid dis-
ease of the liver is reported by .Seligmann and Dudgeon.*
The patient, a girl aged 22 years, had a leukocytosis of 17,000
ami eosinophilla amounting to bTJi. After the evacuation of the
hydatid the leukocytes fell to 7,000 and the eosinophile cells to
l^fc. [A.O..T.K.]
Grooves In the Nails of the Insane.— Pierret,* in a com-
munication to the Socit't* des Hopitaux de Lyon, July 27, calls
attention to the fact that there appears to be a direct relation
between a nuinl)er of mental affections and the appearance of
transverse grooves in the finger nails, and that a study of the
subject is likely to furnish interesting results from the stand-
point of diagnosis and prognosis in mental affections, [c.s.d.]
Clinical Ohservations on the Action of Some Supra-
renal Preparations.— Ijong worth' reports two cases of gradu-
• American Journal of the Medical Sclencen. cxxlv, 97, 1902.
*II l*ollcllnlco; .Snpplcnu'nto Hentlnianiile, June 14, 1902.
> Fortscbrllte d<T .Mcdlcln, February 1, 1902.
'Ijiiifct, .lunc Jl, liMK.
» (iazelte hebrtomadalrc dc M6dccine et de Cblrurgle, Jalv 17 1902
•BrItlBh .Medical Journal, July 19, 1902.
ally failing heart power in which sudden acute failure super-
vened and in which marked temporary improvement followed
the intravenous injection of adrenalin chlorid (subcutaneous
injection being without appreciable effect). With a view to
ascertain the effect of the administration of the prepai-ation by
the mouth, it was given to six patients, with the result that it
was found to be equally active when administered by the
mouth, but its effects were more transitory, and failed In sev-
eral cases to produce any sustained rise of blood-pressure.
[a.o.j.k.]
Anatomic and Physiologic Independence of the
tiobes of the liiver.— H. S6reg6 ' (Vichy) maintains the com-
plete independence of the two lobes of the liver, not only from
an anatomic but from a physiologic point of view. This is
demonstrated (1) by injections of methj'lene-blue, by means of
which the line of demarkation between the two lobes is clearly
established ; (2) by default in the homeogeneity of the blood
established by differences in density and cryoscopic behavior ;
(3) by constancy of localization in corresponding hepatic terri-
tory, of emboluses provoketl by intravenous injections made
in a given intestinal region ; (4) by tests of urea in each lobe of
the liver in dogs at different hours of digestion. From these
facts he maintains the existence Of a special coupling of the left
lobe of the liver with the stomach and spleen, and of the right
lobe with the pancreas and intestine, [c.s.d.]
Osteophytes of the Nasal Chambers.— MacCoy ^ states
that under an anesthetic certain osseous structures foreign to
normal nasal conditions may be found with the little finger ;
that these osseous masses are osteophytes, having the anatomic
structure of such bodies ; that osteophytes, clinically, are new
conditions to be considered and studietl ; that in operations for
deflection of the nasal septum, lack of complete success may
result from their presence ; and that osteophytes are loose in
structure aud readily removed with proper instruments.
[a.o.j.k.]
The Origin and Occurrence of Cells with Eoslnophile
Granulations in Normal and Pathologic Tissues. — Howard
and Perkins'' state that in the routine examination of 825 speci-
mens removed by operation, coarsely- granular eosinophiles
were found in the normal appendix in 10 cases, and in the
normal fallopian tube in 1 case. These cells occurred in
larger or smaller numbers in the tissues of blood-vessels, or
both, in 108 cases, or in 13.09% ; 83.3f<) of these lesions were
infectious in origin. In 7 cases (1 adult and 6 children), 4 of
which died of infectious processes, eosinophiles were present in
apparently normal tissues. In 120 consecutive autopsies 27
cases showed larger or smaller numbers of eosinophiles in vari-
ous organs showing pathologic changes. In this series they
occurred in the spleen in chronic interstitial splenitis in 11
cases, in the thymus in 5, in lymph glands in 3, in the stomach
in 3, in the intestine in 2, in the kidney in 5, in the lungs in 3,
in the liver in 3, in the heart in 1, in the skeletal muscles in
trichinosis in 1 case. In some cases these cells were Ijrought to
the part by the blood-vessels, and in others they were formed
in the lesions, while in still other cases their presence was to
be accounted for in l)Oth of these ways. In a large number of
cases the development of coarsely granular eosinophiles was
traced from plasma cells and in some cases from hyalin leuko-
cytes, [a.o.j.k.]
Typhoid Bacilli in the Sputum. — Edel * examined the
sputum of 11 typhoid fever patients, and in one of them he
found typhoid bacilli. In his opinion, therefore, the sputum
must be considered as a source of infection ; and to prevent such
infection he recommends the enforcement of measures advised
by Leube for the preveiition of the dis.semination of sputum-
droplets. Kach patient should have constantly by him not
only a cuspidor but also a glass vessel containing a mass of
moist absorbent cotton, which the patient must place before his
mouth before a coughing spell. After using it he must replace
it in the glass vessel. The cotton should be burned every 24
hours, and the vessel disinfected, [k.i-.]
Hyperplastic Tuberculosis of the Vermiform Appendix.
> Gazette Hebdomadaire de .M^dwlne et de Cblrurgle, April 20, 1902.
» American Journal of the .Medical Sciences, Vol. cx.\ill. p. 2»6, 1902.
> Johns Hopkins HoKPllal Reports, x, 249, 1902.
• Kortschrltte der Mcdlcln, liOl, No. 14.
894 AMBBIOAK MbBIOIHI]
THE WORLD'S LATEST LITEEATURE
[September 6, 1902
— Crowder,' reporting a case of hyperplastic tuberculosis of the
vermiform appendix and reviewing the literature, concludes
that secondary tuberculosis of the appendix is a frequent con-
dition and usually occurs by extension from the cecum; that
primary tuberculosis of the appendix is a rare disease; that
tlie tuberculous appendix may undergo hyperplastic changes
similar to those occurring in otlier parts of the body, chiefly
the cecum ; that hyperplastic tuberculosis may be limited to
tlie appendix, but that such limitation is very rarely met with;
and tliat the etiology of tuberculosis as a distinctly hyperplastic
process is not well understood, [a.o.j.k.]
The Action of Blood Serum on Paramecia. — Ledoux-
Lel)ard ^ communicjites to the Soci^te de Biologic, June 28, that
infusoria of the genus Paramecium offer a very sensitive
biologic reaction, wliich permits of studying the properties of
toxic substances. The dilute serums of divers species of
animals produce immol)ilization and agglutination of the para-
mecia. The agglomerations are of a radial character, the infu-
soria being disposed like tlie rays of a sphere, with their
posterior extremities uniting in the center, and their anterior
extremities free at tlie periphery. The serums of divers species
of animals differ much from each other in their toxicity as
regards paramecia. Heating from 50° to 60° C. suppresses, or in
certain serums diminishes, the toxic property. [c.s.D.]
Chloroma. — Bramwell' reports a case of his own together
with several of lymphatic leukemia. Chloroma is probably
more common than is usually supposed. In many of the re-
corded cases the green discoloration was noticed only after
death, but that in some cases It is not due to postmortem
changes is shown by the fact that the urine was green during
life. It is possible that it may be due to different causes in dif-
ferent cases and in some undoubted cases it may be absent.
Whether chloroma is a distinct disease or merely a variety of
acute lymphatic leukemia is difficult to answer. The peculiar
location of the lesions in the orbits and periosteum of the skull
bones, though not confined to these parts, the green color of the
tumors, the cartilaginous consistency in some cases, the erosion
and perforation of bones by growths has pointed sometimes
toward lymphosarcoma, but the condition of the blood is sug-
gestive of lymphatic leukemia, that and chloroma being the
only known diseases in which 95% or more of the white cor-
puscles are lymphocytes. [H.M.]
Placental Transmission, with the Report of a Case
During Typhoid Fever.— Lynch,* from an exhaustive study
of the question, concludes: (1) The typhoid bacillus may pass
from mother to the child in utero ; (2) the resulting disease is a
fetal septicemia; (.3) in cases of placental transmission there
are generally placental lesions of a hemorrhagic type; (4) the
child dies either in utero or soon after birth, there being no
evidence that the fetus may survive the infection in utero ; (5)
placental transmission is not the rule in typhoid fever ; (6) the
Widal reaction is not always given with fetal blood even though
placental transmission be proved. When present it cannot be
determined whether the agglutinating substances result from
the presence of typhoid bacilli, or whether they have filtered
through the placenta from the mother's blood ; (7) the aggluti-
nating substances may be transmitted through the milk of a
typhoid mother to the nursling. The reaction in the nursling's
blood is but transient and is always weaker than that of the
mother's, [a.o.j.k.]
Structure of the Thyroid in the Newborn.— G. G.
Perraudo contributes to Studi Sassaresi, published by the
University of Sassari, Vol. ii. Section ii. No. 1, an exhaustive
article on the structure of the thyroid in the newborn, with
reference to various anatomic and pathologic conditions. There
appear to be fewer variations in the glandular structure of the
thyroid in human features than in those of other animals. The
thyroid body of the female fetus is larger than that of the male.
The pathologic condition of the mother and of the fetus has
great influence on the weight of thefetal thyroid, augmenting it
normally in cases of syphilis, diminishing it in cacliectlc states
and in athrepsia. The first act of respiration brings about no
1 American Journal of the Medical Sciences, cxxiv, 286, 1902.
! Gazette hebdomadaire de Mfideeine et de Chirurgie, July 3, 1902.
3 Scottish Medical and Surgical Journal, March, 1902.
* Johns Hopkins Hospital Reports, x, 283, 1902.
appreciable change in the structure or secretory activity of the
thyroid. The state of asphyxiation in the fetus generally pro-
duces a colloidal hyperdistention of the follicles. Normally
the amount of colloidal secretion in the lymphatic spaces Is
scarce in the fetus and if it is much augmented it is an indica-
tion of pathologic condition. Many diseases of the mother and
the fetus, especially syphilitic infection, are capable of produc-
ing induration, and more or less accentuate retardation or
retrogression in the histogenesis of the thyroid. Hereditary
syphilis on the other hand may give rise to marked, and at
times enormous, enlargement of the organ through a conspic-
uous formation of fibrocellular elements. Augmentation of
the fibrocellular tissue is not always an expression of an
atrophic glandular condition. It is difficult to find syphilitic
granulations or gumma in the thyroid; on the other hand,
typical syphilitic alteration of the vascular parietes are easily
found. A bibliographic note accompanies the article. [c.s.D.]
Dipterous Larvas in the Human Body. — Hutton' re-
ports cases of intestinal myiosis in one of which the worm-like
creatures were found to be the rat-tailed larvas of the drone fly
(Eristalia tenax), the only case on record. In another case the
larva of Agrotis segetum, which feeds on turnips and other
vegetables, was found. He reviews oases reported by others,
including those from Piophiln casei (the cheese fly), Muaca
domestica, Miisca vomitoria and Anthomya canicularis. The
digestive juices generally destroy these larvas and we do not
know why in some cases they live. It is not due to dyspepsia
nor association with other parasites, for in 25% of recorded cases
these conditions were not present. Extraordinary stories are
told of cases in which the discharge recurs again and again at
intervals of wrecks or months as if bred in the bowel, but this,
if actually occurring. Is probably due to reinfection. The
symptoms are generally confined to the digestive and nervous
systems, as abdominal discomfort or colic, pinchings, loss of
appetite and hematemesis from the active movements and
bristly appendages of the larvas, and apprehensive feelings,
giddine.ss, fainting, headache and cough. Purgation and emesis
will generally cure forthwith. The writer briefly reviews the
literature of cutaneous myiosis common in tropical countries,
the most reliable remedy for which is chloroform. [h.m.J
A Case of Poisoning by the Seeds of Tebetia Iccotli.
—Daniel Garcia,'^ of Tepic, Mexico, reports a case of poisoning
by the seeds of the plant Tebetia iccotli De Caudolle, called by
the Mexicans yoyotli, codo, or muela de fraile. This plant,
which belongs to the ApocynacecB, is employed in the folk
medicine of Mexico in the form of an ointment as an infallible
remedy for hemorrhoids. According to the " Farmacopea
Mexieana," 1896, the seeds contain a toxic principle tebetosa
exceedingly poisonous In doses of 5 centigrams, acting as a
violent emetic and paralysant to the respiratory muscles, which
action existed in the case noted, [o.s.d.]
Food Intoxication of Unique Origin. — Ohlmacher' re-
ports an extensive outbreak of food intoxication affecting 218 of
a total of 607 patients in an asylum and manifesting itself by
chilliness, specially along the spine ; cold hands and feet, aching
limbs, severe headache, with sense of pressure, uausea and
vomiting in some cases ; profuse watery diarrhea, pain in the
abdomen, especially about the umbilical region, griping and
cramps with soreness of the abdomen ; dizziness and staggering
gait, fever and prostration. None of the patients died. The
intoxication was traced to oatmeal that had become infected by
bacteria-laden dust from a plaster ceiling that it had been found
necessary to repair, [a.o.j.k.]
Atrophic Rhinitis and Injections of Atropin. — Brindel *
presented to the SociiStS de Medecine et de Chirurgie de Bor-
deaux, June 27, two patients affected with atrophic rhinitis,
with ozena, with whom he had employed atropin injections.
Immediately after the injections the inferior turbinals had
acquired their normal volume, hypersecretion, crusts and odor
had disappeared. These patients had been injected about 4i
months previously. [c.s.D.]
The Functions of the Wolfflan Body in the Embryo.—
1 Liverpool Medlco-Chlrurgical Journal, March, 1902.
2 Cronlca Medica Mexieana, May 1, 1902.
' American Journal of the Medical Sciences, cxxiv, 68, 1902.
•Gazette hebdomadaire de Mfideclne et de Chirurgie, July 10, 1902
Sbptembkb 6, 1902]
THE WOELD'S LATEST LITERATURE
[American Medicine 395
According to a communication of Lorsel' to the Soci6t6 di
Biologic, Paris, July 12, the Wolffian body liberates and accu-
mulates fatty substances in the interior of its cells. It there-
fore plays the role of an embryonic organ, and at the same time
that of an excretory organ, [c.s.d.]
Ectopia of the Adrenal. — Radasch ' discusses the his-
tology and the histogenesis of the adrenal, mentions the cases
of ectopia of the adrenal hitherto reported, reports a personal
ob.servatiou of ectopia of that organ (in the kidney and in the
liver) and concludes: (1) Ectopic adrenals are found in both
sexes and all ages ; (2) their occurrence is far more frequent
than formerly supposed ; (.3) although they vary in size, most
of them conform to the general description of yellowish, oval,
or globular bodies which in section show a light periphery and
a dark center ; (4) microscopically these bodies consist of 2 or
3 zones of the cortex of the adrenal but seldom of the medulla ;
(5) the separation of the masses occurs early, before the Inclu-
sion of the medulla by the cortex of the normal gland; (C) the
distriljution varies greatly, the usual location being some point
between the kidney and the descended sexual gland; to this
may be added the unusual location, the under surface of the
liver and also within the organ, [a.o.j.k.]
Partial Internal Hydrocephalus. — Spiller' reports two
cases of partial internal hydrocephalus from closure of the
interventricular passages. In the first case the right cerebral
hemisphere was a mere sac, wliile the left was normal.
Althougli the lesion was unilateral, bilateral contracture was
very intense— a very uncommon condition. The right internal
hydrocephalus was the result of a partial closure of the right
foramen of Monro from inflammatory changes about this fora-
men, and the condition must liave been congenital or have
developed early in life, as shown especially by arrest of develop-
ment of tlie upper limb. The cause of these inflammatory
changes and proliferation of neuroglia at the foramen of Monro
is unknown, but possibly it may have l)een the result of tuber-
culosis. After some discussion of the question, it is concluded
that the bilateral contracture possibly may be explained by a
partial loss of cerebral inhibition, as a result of whicli the mus-
cular tonus was exaggerated, this exaggeration being also occa-
sioned in part by irritation of the excitomotor fibers. In the
second case the internal hydrocei)halus was the result of closure
of the aqueduct of Sylvius by proliferation of the neuroglia,
and caused the symptoms of cereljellar tumor. The ventricles,
except the fourth, were much dilated, the fourth being of nor-
mal size. It is suggested that when a tumor of the cerebellum
is suspected the possibility of internal hydrocephalus should be
borne in mind, [a.o.j.k.]
On the Etiology of Barlow's Disease. — H. Neumann*
indicated to the Society of Internal Medicine of Berlin, June 16,
the result of his observations on 18 cases of Barlow's disease.
He is unable to adntit the pretended relation of this affection
to raohitism. As regards the etiology of infantile scorbutus,
Neumann agrees with Heubner that the use of milk which has
l>een submitted to prolonged sterilization plays an important
role. Of the 18 cases observed, 16 were fed on milk sterilized in
industrial establishments and two on milk sterilized under
good conditions. On an average the disease appeared within
seven or eight months after the beginning of the alimentation.
[C.S.D.]
On the Toxicity of Boracic Add. — Abraham P^rez MirS^
contributes an article in whicli he presents facts establishing
the toxicity of boracic acid which seem to controvert the gener-
ally accepted opinion as to the innocuous character of this
drug. He cites various authorities for cases in which the in-
gestion of not over 10 grams of boracic acid has produced
nervous and muscular paralysis and acute albuminous neph-
ritis, and cases in which external use of the drug lias produced
cutaneous eruptions, vomiting, delirium, muscular debility,
nephritis, conjunctivitis, dysuria, collapse. The use of boracic
acid for intestinal and gastric lavage in proportion of 1 : 100 as
ordinarily employed is liable to cause toxic phenomena by
> Ouzptte hebrtomadalre dc MCjdccliie et de CUIrurgle. July 17, 1802.
s American JouriiHl of tlip Medical Holcnces, o.icxiv, 2o(l, 11)02.
' American .Journal of the Medical SclenccK, cxxlv, H, 1002.
< lyii Hemnlne M<''dlcalc, June 2.5. 1902.
» Kevl«ta .MCdli-a Cubana, July 1.5. 1902.
absorption, as in the case cited from Stuckvis, in which death
followed its use in gastric lavage, [c.s.d.]
Intratracheal Colloid Struma.— Theisen,' from a study
of a case of intratracheal colloid struma treated successfully by
operation, and a review of the cases reported in the literature,
concludes: 1. Cases of intratracheal struma are, perhaps, not so
rare as the few cases on record would indicate. If laryngeal
and as far as possible tracheal examinations of all cases of
goiter were made, particularly when the thyroid is only slightly
enlarged and the dyspnea is severe, more cases would probably
be discovered. 2. The term accessory, when applied to such
tumors, is not correct, because they really are " offshoots " of
the thyroid gland. 3. Pregnancy, as in tlie case reported, un-
doubtedly has a great influence on the development of the
intratracheal struma, [a.c.t.k.]
Six cases of ineninj^itis oconrring in one house, two
of which resulted fatally, are reported by Sweet.' [a.c.t.k.]
Radioscopy and Tumors of tlie Stomach. — Destot '
made a communication on this subject to the Socicti? MMicale
des Hopitaux de Lyon, June 20. The normal stomach is not
perceptible on the radioscopic screen. If the stomach is insuf-
flated with gas a progressively increasing white spot of regular
outline is produced on the screen. If we insufflate the stomach
of a patient afflicted with tumor the figure formed is not regu-
lar. We note on the outline a notch which indicates the site of
the tumor, [c.s.i).]
A Case of Polyneuritis Following Malaria, with
Autopsy. — It was but recently determined that a close etiologic
relationship exists between malaria and polyneuritis. This has
been proved in 40 reported cases. Luzzitto' reports a case in
which he positively made the diagnosis of malaria, although
the parasite was not found. Ttie patient developed polyneuritis
a week after the disappearance of the malarial fever. Three
months later he died of pneumonia. At autopsy the organs
revealed all of the typical lesions of malaria and polyneuritis.
Luzzatto was able to exclude alcoholism, lead poisoning and
other Infections; consequently he associates the cause of the
neuritis with that of malaria. Since the malarial parasite was
not found, the polyneuritis could not be ascribed to its
action. Theoretically speaking, Luzzatto thinks that the cause
may be a malarial toxin, yet in special cases when the poly-
neuritis is po.stmalarial, he considers, as a probable cause, the
formation of poisonous products from the destruction of blood
and connective tissue cells, [w.e.b.]
A case of typhoid fever with trichinosis and eoslno-
philia is reported by McCrae.^
Toxic Property of Extract of Strawberries.- Gley,« in a
communication to the SociMSde IHologie, Juno 12, reports some
experiments made on dogs in which lie made endovenous
injections of a dry extract of strawberries. This behaved like
a peptone, diminishing the coagubility of the blood and produc-
ing a considerable lowering of blood-pressure. Extract of
strawberries also produces agglutination of blood corpuscles.
[c.s.d.]
The Appearance of Hyaline Casts in the Urine in Artl-
flcally Produced Icterus. — It was noticed by Prof. Nothnagel
as early as 1874 that Icterus was regularly accompanied by casts
in the urine. Wallenstein' proved this by experimentally
producing icterus in dogs and rabbits. He found that in each
case these was polyuria, absence of albumin and the presence
of hyaline casts. He killed the animals at varying periods of
time following the operation for the production of the icterus.
He tlien found by micro.scopic examination of the kidneys and
the urine that epithelial and granular casts were but transitory
stages in the formation of hyaline casts. Wallenstein considers
the appearance of these elements in the urine as of diagnostic
value in conditions that obstruct the outflow of the bile.
[W.E.B.]
A Case of fjoconiotor Ataxia with Febrile Crisis.— With
the exception of a ca.se reported by Pel and another by Ostan-
! American JoHnial of the Medical Sciences, cxxlll, 1051, 1902.
2Ijincet,.luly 19, 11102.
3(iazeHi' hi'hdomadalre de M(!decliio et de Clilrurtjle, July 10,1902.
< Bciiliiir kllnlsche Wochcniichrift, April 28, 1902.
' .\merlcan .lournal of the .Medical Sciences, cxxlv, 80, 1902.
«(}nzette liet)domadnlre de MC'dlelne et de Chlrurgle, July 17,1902.
; Berliner kllnlsche Wochcnsehrlft, April 7, 1902.
896 AXIBIOAK MBDtOIICXJ
THE WORLD'S LATEST LITERATUEE
[Beptehber 6, 1902
kow the literature affords no light on the subject of febrile
crisis in locomotor ataxia. Oppler' reports such a case. He
had occasion to observe the patient during several such periods.
The attaclt was repeated seven times, accompanied by lancinat-
ing pains and once or twice by gastric symptoms. 8uch condi-
tions as malaria, os-teomyelitis and the like were positively
excluded, and consetjnently he considers the cause to be related
to the locomotor ataxia. Whether it is due to central irritation or
the absorption of toxins because of the atonic condition of the
stomach in gastric crisis is still unknown. Oppler believes that
careful watch for this occurrence in all cases of tabes dorsalis
may in the future solve the problem, [w.e.r.]
Anomalous Cases of Tabes Dorsalis.— Taylor ^ states
that looking upon tabes dorsalis as a disease essentially of the
afferent system characterized by wasting of the spinal cord, in
the posterior region especially, and having as its chief symp-
toms difficulty of ataxy in walking or in using the upper limbs,
lightning pains, girdle sensations and interference with the
action of the sphincters, he regards as anomalous (at least for
the purpose of his lecture) cases clearly recognized by certain
signs as belonging to the same category, but not differing in any
important respect. These he divides into two classes: Those
in which symptoms referable to the eye are the chief manifeiv
tations of the disease ; (2) those characterized by the obtrnsive-
ness of various unusual conditions, such as gastric crises, joint
troubles, perforating ulcer, or other trophic changes. These
manifestations are discussed in detail and 10 illustrative cases
are cited in brief, [a.o.j.k.]
The Disappearance of Liver Dnlness in Meteorism.—
Oppeuheim » claims that the liver dulness may decrease or
completely disappear because of a meteorism of the large
intestine. He proves this by means of the anatomic relation-
ship of the liver with its ligaments to the large intestine and by
several cleverly conducted experiments on the cadaver. The
change in percussion note is due to the pushing up of the liver
and its rotation upward and backward on its long axis. This
disappearance of liver dulness may occur with a dilated large
gut that gives no other demonstrable symptom. He gives as
the diagnostic use of this condition its possible value in the
diagnosis of an early slowly developing peritonitis following
an appendicitis. He believes also that decrease of the area of
liver dulness in distention of parts of the intestine, such as
the ascending and transverse colon, is of value in diagnosing
opium poisoning, [w.e.r.]
Causation of the Crescendo Murmur of Mitral
Stenosis.— Samways* believes the late closing of the stenosed
valve is not due to stiffness but to the systole of the auricle
being unfinished when the ventricle contracts. The nearly
emptied auricle can exert on residual blood a pressure as great
per unit area of blood as the large full ventricle opposed to it
can exert per unit on its larger blood surface. The loudness of
a murmur Is as much a question of instrument as of force. The
systolic murmur is soft though produced when the aperture is
at its narrowest and the ventricle contracting at its best. The
presystolic murmur is loud. The latter is produced by onward
flowing blood, the former by regurgitating blood. That auric-
ular systole runs into ventricular systolic time is shown by
cardiographic tracings. When stenosis is severe the left auricle
is hypertrophied, very rarely dilated. It may be of strength
dimensions comparable with the ventricle, and at the begin-
ning of the ventricular systole still force the residual blood
onward, thus keeping the mitral valves open for an appreciable
period, [h.m.]
liCukocytosis in Appendicitis.— Longridge,^ basing his
opinion upon a number of personal observations, states that in-
creasing leukocytosis may be taken as evidence that the inflam-
matory lesion is developing in severity and may be reaching
the stage of pus formation. Special importance attaches to a
disproportionate increase in the polynuclear leukocytes. It is
said that leukocytosis may be absent in appendicitis under the
following conditions: (1) In the mild catarrhal variety ; (2) in
lg<Tl'"" i^llnische Wochenschrift, April 14, 1902
I British Medical Journal, July lil. 1902.
* y^'i 1"'''' ?'?,'*'5!"'*'<''><^ Wocheusc-hrllt, Julys, 1902
* i-dlnburgh Medical Journal, August, iW'.
' Lancet, July 12, 1902.
fulminating appendicitis, when the resistance of the patient is
too feeble to react to the toxemia; (3) when an abscess is of
some standing and is thoroughly walled off. [a.o.j.k.]
A. B. Craig
GENERAL SURGERY
Martin B. Tinker
C. A. Orr
Late Results in Operations for Carcinoma of
the Stomach. — Only two decades have passed since the
first important work in the surgery of the stomach was
inaugurated by Billroth's successful pylorectomy. Dur-
ing this time many important atlvances have been made
in the technic of operation, but in the minds of many
the advisability of operation for carcinoma of the stom-
ach is still questionable. Not only do physicians .some-
times advise against operation, but even some surgeons
are not convinced that the operations are justified by the
results which have thus far been reached. Several ques-
tions come up for consideration : In the first place,
whether carcinoma is curable by operation ; and whether,
if not curable, the life of the patient is prolonged or at
least the symptoms relieved.
Kronlein, of the University of Zurich, attempts to settle
these questions in an article in which he gives the results of
more than 20 years' experience in the surgery of the stomach
(Arddv fiir klinische Chirurgie, 1902, Vol. Ixvii, p. 676). Within
this time 264 cases of carcinoma of the stomach have come
under his observation ; M were Inoperable, and 14 refused ope-
ration. Of 197 patients who were operated upon, exploratory
celiotomy was performed in 73 cases, with a mortality of 9.5% :
gastroenterostomy in 74 cases, with a mortality of 24.3<?: ; and
some form of gastrectomy in 50 cases, with a mortality of 2S%.
Thirty-nine of the patients died immediately after operation, a
mortality of 19.8 9() ; 2 died of intercurrent diseases; 1 of suicide;
166 of primary carcinoma of the stomach ; and 21 of recurrences.
There are now living 9 patients upon whom gastroenterostomy
was performed and 13 upon whom gastrectomy was performeci.
The exploratory laparotomy alone was performed only in cases
in which the growth was not removable and in which there
were no symptoms of stenosis, that is, in the more favorable
advanced cases. KrOnlein estimates that the disease had existed
at least nine months in all of these cases. The average length
of life in cases not operated upon was 102 days; that is, the
entire length of life from the beginning of the disease would be
9 months plus 102 days, or about 12J months. Of the cases oper-
ated upon, those upon whom exploratory laparotomy was
performed have had an average length of life of 13 mouths, the
gastroenterostomy cases an average length of life of 15* months,
and the gastrectomy cases an average length of life of 264
months. The slight increase of one-half month in favor of the
exploratory laparotomy cases is due possibly to the fact that
the disease was of a somewhat more favorable character than
the inoperable cases, and has no great significance. From these
statistics it would seem, then, that the average length of life of a
patient suffering from gastric carcinoma is about one year.
Gastroenterostomy lengthens life about 3 months, and gastrec-
tomy, in cases followed by recurrence, prolongs life about 14
months. Of the 13 cases surviving gastrectomy, Kronlein has
one patient who is living and in good health 8 years after the
operation, and 1 patient 4 years after the operation ; 2 patients
3 years, 3 patients 2 years, and 6 patients 1 year after the opera-
tion without recurrence and in good health.
So far as a cure of tlie disease goes, these statistics are
somewhat discouraging. A little less than o^c of the
cases operated upon can be considered cured, but how-
ever unfavorable this may seem, it must be remembered
that these patients have an average length of life of but
three months. They take the risk of three months life
of suffering, or, at least, discomfort, and have a fairly
well founded hope of gaining three to twelve months of
life with a few possibilities of permanent cure. All who
have seen the results of operation are aware of the
increased comfort to the patient after operation. The
rapid increase in strength and weight, the return of
normal appetite and digestion for several months at
least, makes life worth living, and the end is much less
uncomfortable than if the disease be allowed to run its
normal course.
Kronlein does not believe that the future will see as
great advances in operative technic in the treatment of
gastric carcinoma. Improvements in the statistics in
the future will come largely from the education of the
general public to seek operation in these otherwise hope-
8EPTEHBKB 6, 19021
THE WORLD'S LATEST LITERATURE
[American Medicine 397
less cases. When people can be led to see the great pos-
sible dangers in neglecting the first symptoms of what
may be a fatal disease ; when they consult physicians at
an early date for the relief of such symptoms, then
improvements in the statistics may be hoped for.
Probably the importance of the last suggestion of
Kronlein's can hardly be overestimated. Ten years ago
many valuable lives were sacrificed from the neglect of
the early symptoms of appendicitis. The public were
at that time not educated to the necessity of seeking
medical advice early, and no doubt the improved statis-
tics for the operative treatment of appendicitis of recent
years are fully as much due to the education of the gen-
eral public to the necessity for operation as to the
greater skill of physicians in the early diagnosis of this
disease. The early symptoms of carcinoma of the stom-
ach might easily be confused with those of a number of
other conditions, such as stenosis and adhesions from
healed ulcers, dilation, etc., in most of which operation
would offer the best prospects for relief, and the sooner
that not only the medical profession but the general
public appreciates this, the sooner we may hope to save
many valuable lives and relieve much unnecessary suf-
fering by a timely surgical intervention.
Organic Stricture of the Male Urethra.— E. G. Mark >
emphasizes the following : Organic stricture is capable of the
most disastrous results, not merely local but constitutional ;
the majority of strictures the surgeon is called upon to treat are
irritable, resilient, recurrent or iibrous in character; such stric-
tures cannot be dealt with successfully by dilation alone, and
that urethrotomy in some form offers the best hope of a perma-
nent cure; a stricture may be considered cured when, after a
minimum of six months after all treatment has ceased, a flex-
ible bougie a boule of the normal urethral caliber can discover
no narrowing. It is not sufficient that the urethra will admit a
full sized sound, [f.c.h.]
Ijate Results of Excision of the Rectum by Abdomi-
nal Perineal Route. — Qu6nu = gives the results of seven oper-
ations of this kind for carcinoma of the rectum, which was quite
advanced in many of the cases. But one death followed the
operation immediately. Oneof the patients died a short time
after from recurrence in the region of the wound, but involve-
ment of the liver was suspected at the time of the operation.
Another patient died from cerebral hemorrhage three years and
four moTiths after the operation. At the necropsy no sign of
recurrence was found. A third patient is living eighteen
months after operation without recurrence, but with some
inconvenience from partiaHncontinence of urine and abdomi-
nal pains. .^ fourth patient is living three years after operation
without recurrence. Two other patients are living four years
after operation in excellent health. Considering the fact that
the disease was quite advanced in many of these oases, the
results are justly considered extremely satisfactory, [m.b.t.]
Report of Cases of Obstinate Vomiting Relieved by
Operation. — Benjamin Brabson C'atos ' details two cases, as
follows: (1) Male, age 30, plumber. A hard round tumor was
found in the right hypochondrium reaching to the umbilicus,
and extending to the left hypochondrium. Upon operating the
tumor proved to be the liver full of nodules, adherent to the
anterior abdominal wall and stomach. The adhesions were
liroken up, and the vomiting ceased; (2) male, age 2!). This
patient was greatly emaciated, with a protuberant abdomen,
which on palpation felt like the contour of an enlarged and
dilaUfd stoma<-li extending nearly to the pubes. Upon oper-
ating the stomach was found several times larger than normal,
the pylorus being attached to the under surface of the left lobe
of the liver near its posterior border, forming an acute angle at
the point of junction of the stomach and the duodenum. This
angulation acted a.s a mechanic barrier to the passage of food,
and evidently aided in causing dilation of the stomach. The
adhesions were broken upand the patient made an uneventful
recovery. The vomiting immediately ceased, [f.o.h.)
' American Journal of .Hiirifpry and Gynecology, July, 11)02.
= lAi .S>-iniilm' MCMlli-ale. July Ml. I(lci2.
" American Journal of Murgcry and Gynecology, July, 1002.
GYlfECOIX)GY AND OBSTETRICS
WiLMER Kbusen Fbank C. Hammond
The recent death of Professor Schenk, who has
lived in retirement since his enforced resignation from
the Vienna Faculty of Medicine brings to mind his the-
ory in regard to sexual determination. For the unscien-
tific promulgation of this theory Schenk was severely
criticised by his confreres and censured by the govern-
ment and the faculty of the institutions with which he
was connected. Schenk had attained notoriety and
secured illustrious patients among the wealthy and
aristocratic in whom the desire for male issue was intense
for the purpose of entailing of estates or perpetuation of
dynasties. Whatever may have been the motive inspir-
ing this unfortunate man or however much we may
deprecate any attempt to throttle the freedom of scien-
tific speech or limit the possibilities of scientific
research, we can only condemn such efforts when they
emanate from a selfish spirit and are subservient to per-
sonal aggrandizement. It is highly probable that the
control of sex will never pass into human hands and that
the essential causes of sex differentiation will never be
discovered.
Many valuable statistical studies have been made to
determine the influence of parental age upon the sex of
the offspring. According to Sadler and Hofacker if the
husband be younger than the wife there are as many
boys as girls ; if both are of the same age there are 1 ,029
boys to 1,000 girls ; if the husband be older 1,057 boys to
1,000 girls. These laws are not to be accepted as conclu-
sive. The normal proportion between female and male
births is 100 to 105 or 106. In the case of illegitimate
births the proportion is reversed at least for the children
first born. Kalteuback calls attention to the fact estab-
lished by Hecker-Ahlfeld that there is a great excess of
male births in old primiparas, this being 124 and 140 to
100. According to a contribution of Janke published in
1891, if a boy be desired the sexual spher'fe of the wife
and her sexual appetite must be strengthened to the
utmost by generous even luxurious diet while the hus-
band lives more as a vegetarian. This reminds one of
the suggestion of Debay that in order that a boy shall be
produced the wife must for 20 to 25 days before the
impregnating coition live chiefly on nitrogenous foods.
There is probably as much truth in this theory as in the
statement made by a writer in the Arena, June, 1894, of
the relationship between nitrogen and evil. He says :
" Every good thought increases the proportion of oxygen
as a deep breath does and lessens that of nitrogen, mak-
ing the body finer and more beautiful. Every evil
thought or impulse that is indulged increases the nitro-
gen and has the reverse efli'ct on body and soul." So
we may presumably formulate a theory that nitrogen
breeds boys and badness and oxygen gives us girls and
goodness.
The more we read and study what is written upon
sex determination the more we are convinced that the
problem is unsolved.
Treatment of Retrodlsplacements of the Uterus. —
Reuben Peterson ' employs ventrosuspension more frequently
than any of the other operations, since the majority of his
patients have concurrent tubal and ovarian disease necessitat-
ing abdominal section. The diseased ovaries and tubes are
resected or removed according to the necessities of the case, the
pelvic adhesions are cared for, and then as a final step the uterus
is suspended to the anterior abdominal wall, [f.c.h.]
An Kmergency Hysterectomy. — Lucy Waite ' details the
case of a wonjan admitted to the Mary Thompson Hospital,
Chicago, suffering from a very severe uncontrollable uterine
hemorrhage. The patient was immediately prepared for a
curetmeut. No membranes or placental debris were to be
■American Journal of Surgery and Gynecology, July, 1902.
•American Journal of Hurgery and Gynecology, July, 1902.
898 AXSKICAN MbDIOINBI
THE WORLD'S LATEST LITERATCTEE
[September 6, 1902
found. The uterus was practically empty. The entire mucous
membrane felt soft, degenerated and irreftular. The uterine
cavity was sufliclently large to admit a hen's egg. Curetment
intensified the hemorrhage. Neither the hot douche, Mon^eira
solution, nor packing with gauze controlled the bleeding. Waite
then decided to do a vaginal hysterectomy, which was quickly
performed. Under proper stimulation the patient recovered
from the effects of the hemorrhage and the operation, and made
an uninterrupted recovery. Microscopic examination of the
specimen showed a typical round-cell sarcoma of the fundus.
[F.C.H.]
Treftttnent of Extraaterine Pregnancy. — Rieok ' recom-
mends the treatment of extrauterine pregnancy by vaginal
operation in the vast majority of cases. He thinks that the
younger university professors, outside of the school of Martin
and Duhrssen, employ colpotomy more and more, and believes
that the time is not far distant in which abdominal section will
become a rare operation in the healing of women who have
abdominal disease, [w.k.]
Inflammation of the Fallopian Tabes.— (iharles R.
Robins 2 concludes as follows : The treatment of inflammation
of the fallopian tubes should always be approached from the
conservative side ; many of the cases of acute inflammation may
be successfully treated by the ordinary methods employed in
treating pelvic inflammation, provided the treatment is insti-
tuted early and carried out intelligently and faithfully; success
depends on early recognition of the disease ; many cases re-
quire no operation; when abscess has developed it is best
treated, if it is accessible and can be thoroughly drained, by
ample vaginal incision and packing; no valuable time is lost,
as a rule, in instituting local treatment, as the history of the
disease shows that the patient can be more safely treated late in
the disease than in the acute stage; if the patient is cured by
vaginal drainage it is a better cure, if such a term can be used,
than by removal, as the retention of the organs of generation
ensures, although they may l)e damaged, a better state of health
than can be secured if they are removed. The removal can be
practised subsequently with no greater risk after an efTort at
vaginal drainage has been made. [p.c.H.]
Ovarian Tumor with Twisted Pedicle and Myxo-
fibroma of Round liigament.— D. G. Lewis' details a case
in which there was a large multilocular cyst in an advanced
stage of degeneration due to a twisted pedicle. A myxo-
fibroma of the round ligament was removed from the right
inguinal canal of the same patient. The latter growth had been
mistaken for a hernia by the family physician, who worked for
over two hours in an effort to reduce it. The cyst was dis
covered at the time of the delivery of the patient's last baby
and was tapped seven days subsequently, a large quantity of
fluid being removed. The ovarian tumor is of interest because
of the comparative rarity of large ovarian tumors, its coex-
istence with pregnancy and not interfering with a normal
delivery, and because of the twisted pedicle causing a danger-
ous degeneration. The tumor of the round ligament is of
interest from the standpoint of diagnosis, and on account of the
comparative rarity of such tumors, [f.c.h.]
Carcinoma of the Cervix as an Obstruction to Dellv-
ery at the End of Normal Pregnancy.-Bamberger • reports
the case of a woman, aged 36, mother of six children, who had
during the latter part of pregnancy suffered from genital hem-
orrhage at irregular intervals. He first saw her after 12 hours
labor, and the examination showed an inoperable cancer of the
cervix infiltrating the parametrium and obstructing the deliv-
ery of the child, which was still living. Taking into considera-
tion the weak condition of the mother he determined upon the
most expeditious method-made a cervical incision and deliv-
ered a living child. The uterus contracted well, but the patient
died two days later of septic peritonitis. The writer, after
reviewing much literature on the subject, concludes that the
method used was perhaps the best under the circumstances,
and that while the perfecting of the technic of vaginal opera-
tion and the introduction of vaginal cesarean section has made
Jnirt°n^®".^''.'"''^'"'°'*°'"« Wochenschrlft, August 5, 1902
,S •* Dominion Journal, July, imi. '
3 Washington Medical Annals, July, 1902
<Manchener medicinlsche Wochenschrlft, Augusts, 1902
the prognosis in cases of operable cancer of the cervix quit«
favorable for both mother and child, in inoperable cases the
prognosis still remains very unfavorable, [w.k.]
H,
TREATMENT
Solomon Solis Cohen
C. Wood, Jr. L. P. Appleman
Method of Administering Castor-oU. — To one dessert-
spoonful add sufficient brown sugar to make a firm consist-
ency. A bonbon is thus obtained which children will some-
times take voluntarily. — [La Medecine Moderne, Vol. xlii, No, 8,
1902, p. 05.] [L.F.A.]
Incompatibilities. — Brissemoret (Journal des Praticiens,
Vol.xvi, No. 3, 1902, p. 41) states that potassium bromid should
not be comi)ined with paraldehyd, because of the oxidizing
power of paraldehyd which forms with it potassium ijromate.
Another incompatibility which is often overlooked is the com-
bination of hydrastis canadensis with hamamelis virginiana.
When these drugs are mixed in the form of fluid extracts or
tinctures a dirty colored precipitate is thrown down. If the
solution is filtered it will lose the greater part of its medicinal
value; if it is allowed to remain the preparation is ugly from
a pharmaceutic point of view, [l.p.a.]
Santonin In the Treatment of Crises of Locomotor
Ataxia.— Negro (Balletin OinSral de Thin-apeutique, Vol. cxliii
No. 18, 1902, p. 717) has employed santonin in 11 patients, in the
dose of 5 grains every three hours until 15 grains were taken.
In 8 cases there was improvement; in 2 only temporary im-
provement ; in 1 no result was obtained. The method of giv-
ing 10 grains as an initial dose and 5 grains five hours later was
then adopted. Santonin was administered only during the
period of crisis. Pain was lessened two or three hours after the
first dose, and disappeared after the whole amount was taken.
[L.F.A.]
Treatment of Syphilis at Health Resorts. — F. Parkes
Weber says (Cohen's "System of Physiologic Therapeutics " )
that while neither climate nor balneotherapy can substitute mer-
cury and the iodids, there are certain cases of syphilis in which a
good health resort offers the following advantages : Freedom
from the ordinary business and social cares of daily life, free-
dom from the special worry of remaining at home while suffer-
ing from a secondary eruption on the face and an infectious
condition of the mouth and throat; good air, suitable exercise
and proper diet, without the necessity of hurrying through
meals ; special facilities for inunctions, baths, douches and the
care of tiie skin ; and last, though not least, in many instances,
supervision by medical men who have paid great attention to
the subject. Thus it is that many health resorts have obtained
a special reputation in the treatment of syphilis. Of these
Aachen (Aix-la-Cliapelle) in Germany is perhaps the most
generally known, chiefly owing to the work and writings of the
local physicians. The list of health resorts to which patients
resort for syphilis is very large, and includes Bagneres-de-
Luchon and Ax-les-Thermes in the Pyrenees, Uriage near
Grenoble, Aix-les-Bains in Savoy, Wiesbaden in Germany,
Hot Springs, Arkansas, in the United States, and a great num-
ber of places with thermal and sulfurous and common salt
springs. The baths at these places maintain the skin in good
condition during treatment, and probably favor the excretion
by the kidneys of the specific toxins of the disease. Internal
courses of waters likewise help to flush out the body and prolj-
ably minimize the deposition of mercury in the tissues. It is
possible, also, that sulfurous waters when taken internally may
help to ward off mercurial enteritis, as suggested by Neisser,
and that a course of sodium chlorid waters favors metabolic
processes generally, and therefore also those undergone by the
mercury in its passage through the body.
Therapeutic Action of Guaco. — Butte {Montreal Medical,
June, 1902, p. 172) reports the results of his investigation into
the physiologic action and therapeutic uses of the extract of
guaco, which is derived from a climbing plant found in Mexico,
belonging to the Aristolchia family. Experimental study
shows that it is depressant to the sensory nerve centers, and it
is this action which Butte sought in applying the drug in neu-
September 6, 1902]
THE WORLD'S LATEST LITERATURE
(American Medicine 399
ralgia and various cutaneous affections accompanied by con-
siderable itching. It proved remarkably efficacious in itching
eczema, generalized pruritus, senile pruritus, pruritus of the
genitals, urticaria, etc. It may be employed locally in the form
of baths, lotions or compresses, and may be given internally at
the same time. In nearly all cases the symptoms disappeared
rapidly. Excellent results followed its use in all forms of neu-
ralgia, particularly in neuralgia of the peripheral nerves and in
that occurring during grip, [l.f.a.]
Treatment of Convalsions of Unknown Origin. — Perier
(Bidlelin Giniral de Thgrapeutique, Vol. ciilni. No. 20, p. 800)
recommends the following treatment of convulsions in chil-
dren: 1. Loosen the clothing so that the neck, thorax and
abdomen are exposed, and lay the child on its back. If there is
constipation, a rectal injection of oil, glycerin or soap should be
given. 2. If there is indigestion, provoke vomiting by tickling
the uvula and then give a purgative injection. 3. At the same
time make the patient inhale a few drops of ether or chloro-
form from a handkerchief and open the windows. 4. If the con-
vulsions are prolonged, a hot bath or a mustard bath should be
given ; the patient should then be dried quickly ; in order to
prevent a return of the convulsions one teaspoonful of the fol-
lowing solution should be given every hour:
Potassium bromid )
Sodium bromid ^ of each 7.5 grains
Ammonium bromid )
Syrup of codein 75 drops
Syrup of orange flowers 1 ounce
Lime juice Bounces
If the child is unable to swallow, the following rectal injec-
tion may be used :
Musk 3 grains
Chloral hydrate 4.5 grains
Camphor 15 grains
Yolk of egg 2.5 drams
Distilled water 3 ounces
or, a suppository composed of the following may be used :
Chloral hydrate or hypnal 3 to 10 grains
Cacao butter 30 grains
5. The child should not be left alone until he has come out of
the convulsion, which is not definitely passed until he has
voided urine; and then the cause should be looked for. [l.f.a.]
Treatment of Whooplngcough. — Monti (Bnlletin Glniral
lie Thirupeutique, Vol. cxliii. No. 18, 1902, p. 713) gives the fol-
lowing review of the treatment of whoopingcough : 1. General
treatment: Place the child in a well-lighted and well-aired
room, the temperature of which should be kept between 64°
and 08° F. The removal of the small patients to a temperate
climate during winter is excellent. Avoid variations in
temperature. 2. Local treatment : Inhalations of boric acid
and sodium salicylate. Monti prefers inhalations of carbolic
acid and menthol, combined with quinin internally. Birch-
Hirchfeld recommends the following:
Carbolic acid .30 drops
Pure menthol 15 grains
Distilled water 6 ounces
Six drams of this solution should be inhaletl daily by means
of Siegle's apparatus, or one similar. 3. Internal treatment :
He prescribes belladonna, as follows:
Powdered belladonna 1.5 grains
Whirsu^r""'"""'" \°'-'^^ 22 grains
To be taken 1 to 3 times daily in a capsule.
Stepp, Feer and Marfan recommend the administration of
bromoform, as follows :
Bromoform 47 drops
Oil of sweet almonds 4 drams
This is shaken thoroughly and added to
Acacia 4 drams
Cherry-laurel water 1 dram
Distilled water 4 ounces
In Monti's experience quinin has given the best results. He
prescribes
(Miinin tannate ]
Sodium bicarbonate > of each 16 grains
White sugar )
For 6 powders, one every 2 hours, [d.p.a.]
Injections of Calomel in the Treatment of Clironic
Nonsyphilitic Arthritis.— De Gorsse {Journal des Praticiens,
Vol. xvi. No. 5, 1902, p. 72), believing that the arthritis of
chronic rheumatism is probably infectious, employed sub-
cutaneous injections of mercurial preparations in order to pro-
duce antisepsis of the blood as nearly as possible. He obtained
the best results by repeated injections of calomel. Under its
influence there was increase in functional power ; the pain,
hydrarthrosis and periarticular lesions disappeared, [l.f.a.]
The Serum of Trnnecek.— Huchard (Journal des Prati-
ciens, Vol. xvi. No. 18, 1902, p. 275) gives the following composi-
tion of this serum : Sodium chlorid, 75 grains ; sodium sulfate,
6.5 grains; sodium phosfate, 2 grains; sodium carbonate, 3
grains ; potassium sulfate, 6 grains ; distilled water, enough to
make 3J ounces. This contains all the alkaline salts normally
present in blood-serum and in their proper proportion. Trun-
necek injects this serum hypodermically in doses of 15 minims
every three or four days, and even every day, increasing the
amount until 1 or 2 drams are employed at each injection. In
Prague it has not met with favor, but in certain countries it
has been used with remarkable success. It is affirmed that with
this serum Trunecek has almost cured an aneurysm of the
subclavian artery ; that it lowers arterial tension in an unknown
manner. It relieves dyspnea ; cures arterial sclerosis, diseases
of the ears, sclerous otitis and deafness ; relieves vertigo, the
crises of eclampsia, epilepsy, uremic convulsions, etc., because
of the relations which exist between these dissimilar morbid
states and high arterial tension. After repeated experimenta-
tion Huchard believes "that the serum of Trunecek is a
therapeutic illusion ; it is harmless, which is the most that can
be said of it. It acts by autosuggestion in some patients and
some physicians, and its action is not based on any conception
of physiologic order. It does not lower arterial tension in a
definite manner and has never caused any improvement in
sclerous lesions, arterial, or other." [l.f.a.]
Treatment of Varicose Ulcers. —Silvy ( Th?se de Paris,
1900), believing that the disturbance of the trophic nervous sys-
tem is a cause of varicose ulcers, recommends fascicular dis-
sociation of the sciatic nerve, which is simple, rapid and may be
applied whatever be the seat of the ulcer. This operation is
especially efficacious against ulcers which are not too deep nor
too extensive ; no untoward effect hiis resulted from it. [l.f.a.]
Treatment of Smallpox by Brewers' Yeast.— Pietri {La
Medicine Moderne, Vol. xiii. No. 8, 1902, p. 65) reports excellent
results from the use of brewers' yeast in two cases of confluent
smallpox. Five to six teaspoonfuls were administered daily,
without other treatment. Tlie pustules dried rapidly ; there
was no suppuration nor fever, and no marks remained on
either of the patients. Pietri believes that if fresh brewers'
yeast is given early enough, it may completely absorb the pus-
tules, [l.f.a.]
Treatment of Malignant Pustnle.— Camescasse {Bulletin
General de Thfrapeutique, Vol. cxliii. No. 5, 1902, p. 186) re-
ports having treated 30 cases of malignant pustule by first
making a very free incision, then bathing slowly in several
drams of hydrogen peroxid and afterward applying sodium
bicarbonate. This is followed by rapid improvement in the
local condition, and a still more rapid amelioration in the gen-
eral condition of the patient. He considers this treatment bet-
ter than the use of the actual cautery, the injection of carbolic
acid, or tincture of iodin. [l.f.a.]
Surgical Intervention in Movable Kidney.— Chevalier
{La Midecine Moderne, Vol. xii, No. 44, page ;J51) recognizes
three forms of movable kidney: (1) The painful, which is most
frequent; (2) the neuropathic or neurasthenic ; (3) the dyspep-
tic. The digestive disturbances of movable kidney may be
divided into three varieties— purely mechanic disturbances,
which are rare; nervous disturbances of the digestive appar
ratus, which are very frequent, such as atonic dyspepsia, consti-
pation, dilation of the stomach by reflex atony, gastralgia and
vomiting ; disturbances due to concomitant enteroptosls. These
forms are less frequently relieved by operation than the pain-
ful forms of movable kidney. The neurasthenic forms of mov-
able kidney give the least favorable operative results. Nephro-
pexy in these cases results in 50% of cures, 36% of complete
400 AXKKICAN MEDICIKX^
THE PUBLIC SEEVICE
[Beptember 6, 1902
failures and lifo amelioration. Such cases should be treated by
medicinal and orthopedic means, operation being performed
after other means fail. The painful varieties of movable kid-
ney, which are not accompanied by nervous or digestive dis-
turl)ances, are the most satisfactory from a surgical point of
view. Nephropexy in these ca.ses gives 88% of cures; It
entirely controls the moliility of the kidney and the pain which
depends upon it. Mobility of the kidney in itself is not an
indic'ation for operative interference, because a large number
of very movable kidneys are painless, while kidneys slightly
movable are very painful. In all ca.ses mechanic treatment
should be tried liefore oj)eration. [r,.F.A.]
FORMULAS, ORIGINAli AND SELECTED.
For Pruritus Ani, Carbuncles, Endometritis, Etc. — Geo.
H. Candler (Mt;(l. Summary, February, 1902) says that the fol-
lowing is most excellent for pruritus ani, carbuncles, swollen
glands, eroded and ulcerated cervix in endometritis, purulent
condition of the appendages, etc.:
Ichthyol 1 dram
Tinct. iodin .3 drams
Glyc. hydrastis 5 ounces
Boroglycerid 6J ounces
In affections of the female genital tract this mixture is
applied on tampons, [h.c.w.]
For Chronic Bronchitis.— Bjorkman (Merck's Archives,
March, 1902) recommends
Thiocol 6 grains
Terpin 3 grains
Strychnin nitrate ^ grain
Dionin 1 grain
Make 30 such doses and dispense in capsules. One, 3 or 4
times a day. [h.c.w.]
Elixir Terpin Hydrate and Codein.— (S. H.)
1. Terpin hydrate 12'' grains
Saccharin 1 grain
Glycerin 2 11. ounces
Alcohol (i fl. ounces
Codein sulfate 16 grains
Simple elixir 8 fl. ounces
Dissolve the terpin hydrate and saccharin in the alcohol
with the aid of gentle heat; add the glycerin and then the sim-
ple elixir in which the codein sulfate has previously been dis-
solved. Let stand over night and filter through paper. Each
fluid dram of the finished elixir contains 1 grain of terpin
hydrate and i grain of codein sulfate.
2. Dissolve 17..5 grams of terpin hydrate in 400 cc. of alcohol
(a gentle heat may be applied to hasten solution), and add
400 cc. of glycerin, and lastly add enough distilled water to
make 1,000 cc. An elixir thus prepared will hold the terpin
hydrate in solution indefinitely at the ordinary temperature.
When exposed to a low temperature some of the terpin hydrate
will crystallize out, but this will redissolve on gently warming
on a water bath. The desired quantity of codein may be dis-
solved in the &\xx\r.— Pharmaceutical Era.
THE PUBLIC SERVICE
Health Reports.— The following cases of smallpox, yellow
tever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, durine
the week ended August 30, 1902 :
Smallpox— United States.
California:
Colorado :
lilinois:
Indiana ;
Louisiana:
Massachusetts :
Missouri :
Nebraska:
New Hampshire:
New Jersey :
New York :
Ohio:
Pennsylvania :
Cases Deaths
8
San Francisco Aug, 10-17.
Denver. Aug. 8-16 1
Chicago Aug. 18-23 4
Indianapolis Aug. 16-23 3
Shreveport Aug 16-23 3
Boston Aug. 16-23 8 3
Cambridge Aug. 16-23 1
Lawrence Aug. 16-23 2
St. Joseph Aug. 16-23 16
St. Louis Aug. 17-24 1
Omaha Aug. i6-2:j 4
Manchester Aug. 16-23 l
Camden Aug. 16-23 3
Jersey City Aug. 17-24 1
Newark Aug. 16-23 6
Passaic July 26-Aug. 23. 2
Butralo Aug. 16-18..: 4
New\ork Aug. 18-25 5 1
Cleveland Aug. 16-23 50 S
Allegheny Aug. 16-23 2
South Dakota:
Utah:
Wisconsin:
Canada :
Great Britain :
India :
Russia :
Brazil:
('olombla:
Dutch Guiana:
Mexico :
Altoona Aug. 16-23
Erie Aug. 16-23
Johnstflwn Aug. 16-23
MrKeesport Aug. 16-23
Philadelphia Aug. 16-23
Piltsburg Aug. 16-23
Sioux Falls Aug. 16-23
Salt Lake City Aug. 16-23
Milwaukee Aug. 19-26
Smallpox— FOKEioN .
Quebec July 26-Aug. 18...
Dublin Aug. 2-9
aia.sgow Aug. 8-15
Lelth Aug. 2-9
London Aug. 2-9
Bombay July 2.-29
Calcutta luly 19-26
Karachi July 20-27 1
Odessa Aug. 2-9 4
Yellow Fever.
Amazon Valley July 24 Kaging
Panama Aug. 11-18 3
Paramaribo July 1-:W 1
Coatzacoalcos Aug. 8-16 9
Vera Cruz Aug. 8-23 39
3
1
1
1
21
Egypt:
India:
China :
Egypt:
India;
Japan :
70
39
20
35
21
28
12
15
Plague.
Alexandria Apr. t4-Aug. 6 ...
Tukh District May 2-Aug. 6
Bombay July 22-2H
Calcutta luly 19-26
Karachi July 20-27
Odessa July 26 Offlcially
announced
Cholrka.
Niuschwang July 5-12 98 81
Tientsin June :10-July 11... 190 110
General July I.T-Aug. 6 981 819
Alexandria To Aug. 6 5 4
Assioul District, in-
cluding Moucha...July .5-Aug. 6 4.59 372
Cairo lulv 22-Aug. 6 ... 461 404
Bombay luly 22-29 4
Calcutta luly 19-26 .34
Karachi July 20-27 25 24
Fukuoka Ken To luly 28 287 168
Hiogo Ken July 29 Present
Kanagawa Ken July 29 1
Kuniarnoto luly 29 Present
Nagasaki July 29.. Present
Saga Ken luly 29 Present
Tokyo Fu July 29 »
t
Changes in the Medical Corps of the U. S. Army for
the week ended August 30, 1902:
Thompson, Louis A., contract surgeon, Is granted leave for one month
from about September 8. with permission to apply for an extension
of one month.
Ford, First Lieutenant CLvnK S., assistant surgeon, will Join the
Eleventh Battery, Field Artillery, at Fort Hamilton, or wherever it
may then be, for duty with it during its practice march to Montauk
Point, L. I., and return to Fort Hamilton. Upon completion of
this duty Lieutenant Ford will rejoin at Fort Hancock.
Bbal, First Lieutenant Howard W.. assistant surgeon, Is granted
leave for one month.
Gerahty, Robert F , ho.spital steward, now at the Army and Navy
Geni-ral Hospital, Hot Springs, Aik., when fit for duty will be sent
to Whipple Barracks for duty.
Porter, Lewis B., contract surgeon, now at San Francisco, Cal., will
report to the commanding general, department of California, for
assignment to duty in that department.
HoGUE, GUSTAVCS I , Contract surgeon, now at San Francisco, Cal.,
will report to the commanding general, department of California,
for assignment to duty in that department.
Smith, Captain Allen M., as.slstant surgeon, is granted leave for fif-
teen days from about September 1.
Chase, Alpha M, contract surgeon, now at Fort Assinibolne, will
proceed to Fort Reno for duty.
Torney, Major George H., surgeon, will proceed to Little Rock, Ark.,
at such time as may be necessary, to confer with the United States
attorney for the eastern district of Arkansas on business pertaining
to the Hot Springs reservation, and upon the completion of this
duty will return to his proper station.
Clayton, First Lieutenant Jere B., assistant surgeon, leave granted
July 17 is extended fifteen days.
Many, Harry C, contract surgeon, now under orders to accompany
troops to Fort Slocum, will upon his arrival at that post proceed to
Fort Riley for duty.
TiGNOR, Edwin P., contract surgeon, leave granted July 31 is extended
ten days.
Seaks, C. Edward, contract surgeon, now at Fort Niobrara, will
report to the commaudlng officer of that post for duty.
Hartung, Henry, hospital steward, now in the division of the Phil-
ippines, will be sent to Fort McDowell, and will report by letter to
the surgeon-general of the Army.
Changes in the Medical Corps of the U. 8. Navy for
the week ended August 30, 1902 :
Bell, W. H , passed assistant surgeon, detached from the Chesapeake,
and ordered to duty as a member and recorder of a Board of Medi-
cal Ofllcers at the Naval Academy, Annapolis, and thence home to
wait orders— August 22.
Benton, F. L , passed assi.stant surgeon, part of order of May '27,
detaching from Columbia revoked— August 26.
American Medicine
^
QEORQE M. GIOULD, Editor
G. C. C. HOWARD, Managing Editor
CHARLES 8. DOLLEY
MARTIN B. TINKER, AasUtant Editon
Clinical Medicine
David Riksman
A. O. J. Kelly
h. h. cushing
Hklen Murphy
Oeneral Surgery
Martin B. Tinker
A. B. Craig
Charles A. Orb
Orthopedic Surgery
H. Augustus Wilson
COLLABORATORS
Obstetrici and Oynecology
WiLMER Krusen
Frank C. Hammond
yervous and Mental ZHseaaes
3. K. Mitchell
F. Savaby Peakce
Treattnent
Solomon Solis Cohkn
H. C. Wood, Jr.
L. F. Appleman
Dermatology
M. B. Hartzell
Laryngology, JOa.
D. Bbaden Ktlb
Ophthalmology
Walter L. Pylb
Pathology
R. M. Fbabos
Pusluhbd Wsbklt at 1S31 Walhvt Stsiit, PBiLADiLratA, BT TUB Ahbuoar-Mbbicimb PlXBLnHnfa OOHPAJIT
Vol. IV, No. 11.
SEPTEMBER 13, 1902.
.00 Yeably.
The Death of "Virchow. — At 2 o'clock on the after-
noon of September 5, in Berlin, died Rudolf Virchow,
the greatest German representative of the methods of
scientific research inaugurated by his preceptor, Johannes
Miiller. As the originator of the theory of cellular path-
ology he takes rank as the father of modern medical
science. Scarcely a department of biologic science but
bears the mark of his mas-
terful workmanship, while
many owe more to his scien-
tific insight and indefatigable
industry than to the combined
achievement of his contem-
poraries. Founder: of muse-
ums, institutes, learned so-
cieties and publications; pro-
fessor, investigator, author,
editor and legislator; champion
of the people and persistent
opponent of militarism and
centralization, Virchow stands
preeminent as one of the " in-
tellectual glories" of the nine-
teenth century. Of him the
Emperor William, in confer-
ring the Great Gold Medal,
said: "You have broken new
ground and laid fresh foun-
dations for medical science,
your name is written boldly
upon the tablets of history and
ia honored far beyond the bor-
ders of the Fatherland." All
who see the image of the Creator in mankind will unite
with the scientists and s(!holars of the world in accord-
ing tribute to this clear-headed, big-hearted man, this
hero of scientific achievement.
The Cause of Summer Diarrheas of Infants. —
The attention of the metlical profession was first dis-
tinctly called to the importance of the summer diarrheas
of infants by the great American physician, Bei\jamln
Rush, and since his day, the contributions of American
physicians to our knowledge of this greatest cause of
infant mortality have been unsurpassed elsewhere in
numf)er and value. It has long been rec-ognized that
Rudolf virchow, born October 13, 1821 ; died Septembers, 1902.
this disease or group of diseases presents characters of an
infectious process, and diligent search has been made
for specific microorganisms which might be regarded as
the agents of infection. The most elaborate investiga-
tion of the intestinal bacterial flora in summer com-
plaint of infants was made a few years ago at the Wilson
Sanatorium in Baltimore by Booker, who came to the
conclusion that "not one spe-
cific kind, but many differ-
ent kinds of bacteria are con-
cerned " in the causation of
the disease. As is well known,
unusual difficulties attend the
search for specific agents of
infection in the varied bacterial
flora of the intestine. It is
gratifying to learn that these
difticulties appear at last to
have been overcome in the case
of infantile summer diarrhea,
and that, through the work of
American investigators, aided
by funds froni tlie Rockefeller
Institute of Medical Research,
the specific infectious agent of
this disease has been discovered
in the laboratory of the Wilson
Sanatorium in Baltimore, as
appears from tlie brief com-
munication of Messrs. Duval
and Bassett, published in this
number of American Medicine.
It Is hardly necessary to em-
phasize the far-reaching importance of this discovery.
Knowledge of the causation of a disease is the first step
toward the adoption of intelligent measures of preven-
tion and treatment, and it may reasonably he expected
that this latest important discovery will bear fhiit in
these directions.
Visual Hygiene in the Public Schools — The
time has surely come when it should be demanded of
the State that adequate and scientific hygiene must 1)6
provided if school attendance is made compulsory.
Those who have in general terms advocated this have
often shrunk from definite and detailed description of
402 AMBBICAK MESIOIHX'
EDITOfilAL COMMENT
[September 13, 1902
what this means for fear of the charge of self-seeking and
self-advertising. We must conquer such squeamishness,
because as we progress (or regress ? ) there is more danger
from the great machine which with "grind" and
"cramming " too often endangers the health and vision
of the children. In every State the law should command
that thoroughgoing testing of the eyes of every pupil
should be a8sure<l by a competent refraction 1st, either
supplied by the parents or furnished by the school
authorities. The ma,jority of young eyes are hyperopic
and astigmatic, and lifelong harm may follow their use at
a tender age without spectacles. There is an error all too
prevalent already that eye-strain means overuse of a
normal (or approximately normal) eye, whereas the term
means the results of the use of an ametropic eye. A
va.st deal of the ill-health and bad results charged gener-
ally to schooling and overcrowding, such as anorexia,
nervousneas, denutrition, headache, etc., are solely due
to ametropia, which itself is not a disease (except in high
myopia) but which with use of the eyes speedily begets
disease.
Ametropia in Kindergarten Children. — The eye
of the little child is almost always hyperopic and astig-
matic, and the ocular tissues are especially plastic and
easily injured by near work such as is common in kin-
dergarten schools. It therefore behooves all teachers of
these schools and parents who send their children to
them to see to it that the eyes of every child should be
scientiflcly tested by an expert oculist. Dr. News-
holme, of England, has especially directed attention to
the danger of injury to the eye at this time of life, but
with many others he fails to point out the true remedy.
It is not so much the postponement of attendance at school
until later years, when the eye shall have supposably
become more capable of resisting strain ; this should be
done, of course, if there were no other remedy. But
there is another remedy, viz., spectacles, if needed ; and
with this remedy applied there is obviated all the dis-
aster rightly described. The work of the ordinary kin-
dergarten is not harmful to the eyes or health of a little
child, providing that the eyes have been tested by a
skilled refractionist. If the child of five needs glaases
to prevent injury to the eyes and to the health, the
chances are that at a later age the double injury will not
be avoided except by glasses. All the nonsense about
" bespectacled children " and a " beglassed nation " must
be contemptuously put down. If the facts are as stated,
pride and prejudice must have no voice in the matter.
Accomplishments of the Blind. — It is fast becom-
ing true that, to paraphrase an old saying, in the lan-
guage of the blind there is no such word as impossible.
There is in Philadelphia a blind newspaper dealer who
without help conducts a successful business. (And there
are good men who go out of their way to buy their
papers of him !) But the veteran blind newsdealer,
Marcellus Betz, has just died in New York from a
fall while serving papers on his route. He lost his
eyes in 1860. He was 71 years of age and had been
selling papers since he was 8 years old. In Berke-
ley, Cal., there is a young woman of 18 who can
do most anything that others do — except to see. She
will be graduated next year at the usual age from the
high school. Besides all the usual accomplishments of
the blind she is a good musician, reading the raised
notes for the blind ; she is a good seamstress ; she not
only uses the typewriter for the blind, but the ordinary
one, taking down rapidly from dictation ; she plays
whist with interest and skill, by means of pin pricks in
the corners of the cards which she understands, touch-
ing each card as played by the others, and then
promptly playing her own. She is an expert bicycle
rider and has made her " century run." She rests her
left hand in riding on the right hand of her companion
and guides the machine with her right hand. We have
learned of a man blind, and like Laura Bridgman and
Helen Keller, also deaf and dumb, who traveled alone
all over the United States, lived a good and enjoyable
life, supported himself and family — all by means of a
most ingenious device, the letters of the alphabet tat-
tooed plainly upon the palm and fingers of one hand.
By pointing to these letters others soon learnetl to
understand what he "said," and their answers were
known to him by the spots or letters they touched upon
his hand in reply. And we most fortunate ones bewail
our difficulties !
"Patent Insides" and Patent Newspaperdoni
in Medical Journalism. — The irruption of cheap
newspaper methods into medical journalism is to be
extended to the " patent insides " principle. According
to a letter before us, emanating from New York, it is
said that "you" (i. e., the best medical journals) have
difficulty in getting good original articles, in fact " you "
find it " impossible " to procure them. To help the poor
editors of the "fifteen or twenty selected medical jour-
nals" the enterprising company offers to furnish them
with electrotypes of original articles from " the best med-
ical men in the United States." The editor's abstract
department is also to be supplied in the same way, as
said e. c. " have in their employ the best metlical ab-
stractors and translators," etc. This beats the method
of the editor of the country newspaper who, among his
patent insides and outsides, must insert something local
and individual about pumpkins, dances, engagements and
drunks. The medical editor will have nothing whatever
to do except to manage his own " reading notices " and
to pay for the " electrotypes " of the e. c. — But we forget :
he need not pay for them at all, except in advertising
pages. Eight of these each month — and what a price for
the twentieth "plate," even of the articles by "the best
men in the United States"— are to be set aside for the
e. c. to use for advertisements "as we may choose." We
have nothing but praise and good wishes for the success
of the e. c. We shall even take pleasure in watching it
carefully and in reporting on its future developments — if
it shall have such ; we shall possibly, for the benefit of
the profession and in the interests of journalistic prog-
ress, even list the "leatling journals," which in these
days of much writing cannot find original articles, and
also the " best men in the United States " who thus sup-
port the schemes of this most up-to-date of e. c's. Since
it is currently reported that certain members of the e. c.
8KPTKHBKB 13, 19021
EDITOEIAL COMMENT
AKERICAN MEDtCtNE 403
engaged In this "patent insides" scheme are also con-
cerned in a patent medicine venture, it will likewise be
interesting to note the advertising in the stipulated eight
pages in order to ascertain just what nostrums " the best
men in the United States" are thus assisting to exploit,
while gaining for themselves "not only publicity but
financial remuneration."
luteinperate Temperance Teaching'. — We have
previously alluded to the unscientific science of the text-
books and methods of the W. C. T. U., but as one learns
more accurately the fanatical ignorance of this propa-
ganda it becomes more disgusting. The everlasting and
dogmatic insistance upon the statements that alcohol is
not a food, that it is a poison, always harmful, and that
" medical writers without exception " so teach — these
and such things are doing the cause of true temperance
great harm. Prussic, oxalic, and citric acids are surely
poisons, and heat, light, and electricity also. Children
whose parents drink moderately cannot be convinced
that the lurid pictures or charts of hobnailed livers and
descriptions of delirium tremens are anything but false
and negligible. Even if true that is not the way to go
about the matter. "A cigaret-fiend won the last W. C.
T. U. prize in our school for an essay showing the eflFects
of tobacco. He still keeps on using cigarets." To ques-
tion 6 — " How many can trace their aversion to the use
of alcoholic drinks, or their disapproval of the same to
the teachings of the physiologies ? — none responded.
Much merriment in the Buffalo class." It seems that
the children scornfully call these books " the liquor
books" in which the teaching of physiology and hygiene
is synonymous with teaching the effects of alcohol and
narcotics. A committee appointed by the teachers and
principals of New York City to recommend changes in
the present course of study will soon report as follows : '
" The committee deplore especially the unwise and burden-
some teaching of physiology foisted upon our curriculum by
an arbitrary State law. We earnestly recommend that the
teachers' associations, and school authorities of the city inifiate
some movement looking toward a more rational use of the time
that is now devoted to socalled ' temperance physiology.' This
teaching is intended to give children an abhorrence of alcoholic
drinks; but, by the unpedagogic methods it employs, it suc-
ceeds only in cultivating in children an abhorrence of the beau-
tiful and useful science of physiology."
Temperate temperance teaching may be properly
called the conclusions reached by the committee of the
New York State Teachers' Association, which finds that
in excess alcohol impairs certain cerebral functions ; that
what is "excess" will differ with different individuals;
that in health and under ordinary circumstances alcohol
is not an economic food ; tliat spirits used its beverages
should be largely diluted and taken only at meals or
after the work of the day is over. The most important
part of the recommendations is that one which says that
youths under 21 should abstain altogether from alcohol,
except under s|K'cific medical advice. The rea.sons cited
f<)r this, as we hold it, wise limitation are that parents
' From "Hchool Instruction In the FIDTects of Htlmulantit and Nar-
cotics," a preliminary report of the comnnlltoe of the N, Y. State
Kclence TeacherH' AHK<M'|jill<)n upon the efliK:t« of alcohol, narcotlcH,
etc., published In The muciiliiinal RnHew, New York, June, 1902.
generally wish their sons to abstain, and that thoughtful
educators and hygienists agree that such abstinence is
decidedly advisable. That participators in athletic con-
tests are required to abstain is another argument. The
habit of inebriety is more ineradicably formed the earlier
it is begun, and conversely the habit of self-control is
more easily acquired in that time. The final recom-
mendations of the committee are noteworthy :
" So long as the existing statute remains in force, if truthful
instruction is to be given in the subject, the possible benefits of
alcohol when prescribed by physicians should be conceded.
The difference in the effects on the human body of fermented
beverages (beer and light wines) and distilled liquors should
also be noted. Emphasis should be laid, too, on the greater
susceptibility of young persons both to direct injury from the
use of alcohol in any form and to the danger of forming unde-
sirable habits. Pupils should be allowed also to know that
there is wide disagreement among authorities as to the physio-
logic effects of a strictly moderate use of liquors by adults. On
the other hand, attention should be called to the fact that the
moderate use of alcohol very commonly leads to excess, and
the teacher should emphasize the fact that an immoderate use
of liquors weakens the tissues so that they are made more sus-
ceptible to disease.
"Finally, if the teacher wishes to present the strongest
arguments in favor of either total abstinence or strict temper-
ance, and thereby fulfil the spirit rather than the letter of the
law, your committee recommends that comparatively little time
be spent in trying to teach the physiologic effects of alcohol and
tobacco. Let us frankly admit that we are discussing not so
much a question of physiology as one of morals and economics,
and let us devote the larger part of tlie time required by law to
a treatment of the question from the moral and economic stand-
point."
The Rage for Fame and Human Vivisection. —
Dr. Koch has more than once shown unprofessionalism
and unworthiness of motive in making dramatic pro-
nunciamentos which required greater proof than was
offered at the time, and which also received disproof and
modification at a later time. As usual, one evil breeds
another, and since Koch's London address on tubercu-
losis a number of people have offered themselves as sub-
jects to test the truth or falsity of Koch's opinion as to
the transmission of bovine tul)erculosis. Among these
the most open of the notoriety seekers is Dr. Garnault,
of Paris, who inoculated himself with tuberculous mate-
rial from cows, and who is found now to be suffering
with the characteristic disease. Koch is reported as
saying that Garnault's experiments are not scientific,
etc., and Garnault replies, in kind, as regards Koch's
character. Both appeal to the lay public, which, of
course, is no judge in the matter, and in the fact of the
appeal the contestants betray the unscientific motive.
As a cynic said of a type of modern marriage, it is a game
at which two can play and neither win. Surely, also,
neither science nor the profession is a winner, so it is a
dead loss to all concerned. Why not, therefore, quit
playing such a silly game?
The effects of tobacco on mind and hody are of
perennial interest to all interested in the health of others.
Among recent adverse criticisms of the use of tobacco
that of Seaver,' director of physical culture at Yale
University, is evidently based upon careful observation.
> Medical Examiner and PractlUoner, June, 1903.
404 AHKBIOAir MCDieiBX)
AMERICAN NEWS AND NOTES
ISeptembeb 13, 1902
He finds by a tabulation of records of the measurements
of all the students taken In the Yale gymnasium during
nine years that the smolccrs average 15 months older
than nonsmolcers and that their size in every respect,
except weight, was inferior. The height of the non-
smokers was seven millimeters greater; their lung
capacity 80 cc. greater and their weight was only 1.4
kilograms less, though over a year younger. The
observed rate of growth at this age would lead us to
expect that the smokers would surpa.ss the nonsmokers
by two millimeters in height and 100 cc. in lung capac-
ity. To estimate the effect of tobacco when they reach
full maturity on boys from 16 to 25 a comparison was
made of the men of one class which was divided into
three groups, the first not using tobacco, the second
using it regularly, and the third using it irregularly.
During undergraduate life, essentially 3.5 years, the
first group grows in weight 10.4^ more than the second
and 6.6^ more than the third ; in height the first group
grows 24^ more than the second and 11^ more than
the third ; in girth of chest the ^rst group grows 26.7 ^
more than the second and 22 ^ more than the third ; in
capacity of lungs the first group gains 77^ more than
the second and 49.5 /« more than the third. Seaver
refers to the observations made by Dr. Hitchcock, of
Amherst College, in a similar series of measurements of
young men, no doubt suggesting to Seaver the possible
value of such studies. It is impossible to determine the
effect of tobacco on mental processes, but as giving some
indication Seaver mentions that only 5 ^ of the highest
scholarship men at Yale used tobacco, and whenever it
is desired to secure the highest possible physical and
mental working ability, for example, in athletic sports,
tobacco is one of the first things forbidden. If the whole
period of physical growth is divided into periods of
seven or eight years the third period is devoted to
rounding out. At this time most strenuous mental
application is begun and opportunities for outdoor
recreation are curtailed ; at this period also the tobacco
habit is usually begun, if at all. As a large part of the
functional activity during this rounding-out period per-
tains to growth, Seaver believes that it is logical to
remove the motor depressant influences in order that
there may be the greatest possible increase in size and
improved activity. This position ha.s been taken by the
directors of governmental schools not only in this
country but in Europe. Many private schools have
been following their example during the past ten years
and Seaver suggests that other institutions would do
well to also take this step.
It is generally conceded that tobacco is distinctly
harmful during the growing period. As to its effect in
adults there is a good deal of difference of opinion.
Experimental physiologic studies are unsatisfactory and
definite information such as is furnished by this series of
measurements would be difficult to obtain. We have
no reason to think otherwise than that Hitchcock and
Seaver are perfectly unprejudiced and truthful in pre-
senting the results of their records. The remedy is
another matter, but steps taken in higher public schools
would probably have a great influence in lessening the
amount of tobacco used.
AMERICAN NEWS AND NOTES.
OENEBAX.
Smallpox, as officially reported in the United States from
June 28 to September 5, 1902, amounts to 5,021 cases with 317
deaths. For the corresponding period in 1901 there were 8,5.34
cases with 231 deaths.
Molokai Leper Settlement. — Dr. W. .1. Goodhue, medical
superintendent of the Marian Emerson Hospital, Eleete,
Kanai, has been appointed medical superintendent of the settle-
ment. He was selected among 45 other applicants for special
scientific worl< on leprosy.
Army Medical Department. — Brigadier-General Robert
M. O'Reilly, whose succession was announced editorially in
American Medicine, August 2, entered upon his duties as
Surgeon-General of the Army Medical Department, September
8. He was recently in charge of the medical corps of the
Department of California and has just completed a tour of
inspection of the principal military posts between San Fran-
cisco and Washington.
Examinations to fill vacancies in the Army Medical
Department began in Washington on September 8. Similar
examinations took place in San Francisco for candidates from
the far West. It is desired that the examinations be completed
and the successful applicants be appointed in time for the
course of instruction at the Army Medical School, which begins
the latter part of October. About 50 vacancies exist in the grade
of first lieutenant and assistant surgeon.
Quarantine at Manila.^Dr. J. C. Perry, chief quaran-
tine oflHcer for the Philippine Islands, in a report to Surgeon-
General Wyman, of the Public Health and Marine-Hospital
Service, states that an average of 40 vessels with about 4,000
persons are kept in quarantine at Manila for a period of five
days. Thus far no American vessel leaving the city has carried
cholera to other ports, although the disease has occurred on 23
vessels during the quarantine period, demonstrating the wis-
dom of such regulations. Complaints, both official and private,
have been made against the five days' detention, it being urged
that one or two cases occurring during the passage to San Fran-
cisco would not necessarily endanger those on board. In
refutation of this Dr. Perry cites several cases of soldiers who
were stricken with the disease after eating infected food which
they had carried on board, and of other men who became infected
from these, in one instance death resulting. Some of the original
cases occurred four days after the troops went on board, sec-
ondary cases sometimes occurring eight days after embarka-
tion. Dr. Perry demonstrates that conditions on a crowded
shipboard are very different from those in a detention camp
where those detained are kept in small groups, and that there-
fore a rigid quarantine is necessary.
NEW YORK.
The new medical directory of New York City for 1902,
gublished by the Medical Society of the County of New York,
as just been issued. It contains much valuable information
aside from the mere cataloguing of names.
Assistance for the Blind of New York City.— During the
past week the municipality distributed its annual donation
through the Department of Charity. Each l)lind person who
was declared worthy and needy received §50 in gold, nearly
1,000 persons being benefited.
New City Hospital. — Cornelius Zabriskie, a wellknown
banker of .Jersey City, has offered to give f 150,000 toward build-
ing a new hospital, provided the residents of the city will raise
an equal amount by subscription. Dr. John D. McGill, of the
Health Board, has volunteered to give ^,000, and says he will
do all in his power to aid in collecting the remaining 8125,000.
It is believed that the mayor will give the project his official
sanction in the near future. Mr. Zabriskie stipulates that poli-
tics must be kept out of the hospital management.
PHUiADEIiPHIA. PBNNSYIiVANIA, ETC.
The American Pharmaceutical Association, at its an-
nual convention, held in Philadelphia during the past week,
exhibited the various articles used in pharmacy during the
past 50 years, together with the new appliances recently
adopted. Over 700 delegates from all parts of the United
States and Canada were present.
Typhoid Fever Increasing.— During the two weeks ended
September 6 there were 256 new cases reported in Philadelphia.
The cases occur in various sections of the city, but as usual
West Philadelphia has the largest proportion. Report made to
the Board of Health shows that 34 eases were contracted at var-
ious places out of .the city, 15 of them being attributed to Atlantic
City.
Septkmbek 13, 1902]
FOEEIGN NEWS AND NOTES
[American Mkdicink 405
Bequests to Hospitals.— Under the will of the late Mary
E. Jackson, of Philadelphia, the Pennsylvania and Protestant
Episcopal Hospitals will each receive 85,000 for the endowment
of free beds. A reversionary bequest of ?6,000 for a free bed is
also made to the Protestant Episcopal Mission, to be held in trust
for the Hospital for Diseases of the Lungs.
SOUTHERN STATES.
Typhoid in Washington. — For the week ended August 30
there were 79 new eases reported, the total being 340 cases under
treatment. During the week there were 35 cases discharged.
There were 7 fatal cases.
A liarge but Long-delayed litthotomy Fee.— Dr. Benja-
min Winslow Dudley, of Lexington, Ky., was one of the most
famous lithotomists of his day. No surgeon in the South or West
had such a reputation and he more than any one else built up
the fame of the Transylvania school. In 1837 a poor lad with
stone was brought to him from one of the distant settlements.
The operation was successful and when the parents asked Dr.
Dudley for his fee, knowing their circumstances, he refused to
take anything. The young lad was deeply impressed by the
generosity of the great surgeon and made a resolve that if ever
he became rich the fee should be paid. About two years ago
one of the heirs of Dr. Dudley had a letter from W. G. Saun-
ders, of Iowa, stating that he was anxious to make arrange-
ments to pay a long-standing indebtedness and asked if a fee
of 8500 would be suitable for the operation of lithotomy per-
formed on him by Dr. Dudley in 1837. Last year the executors
of Mr. Saunders wrote that in a codicil of his will directions
were given to pay the fee with interest and they had much
pleasure in handing over the sum of ?2,390. — [Dr. William
Osier.]
'WESTERN STATES.
Hospital for Contagious Diseases.— The mayor of Toledo,
Ohio, has signed an ordinance appropriating ?20,000 to build a
hospital for contagious diseases.
Outings for Convalescents.— The Wabash Railroad Com-
pany has sent 40 invalid employes and 3 trained nurses from
its hospital in Peru, Ind., to San Francisco. If the invalids are
much benefited by the trip the company states that it is their
intention to send convalescent employes to the coast every
year, paying all the expenses entailed on the trip.
Charitable Bequests to Hospitals.- Under the will of
the late Mrs. Katharine B. Aultman, of Canton, Ohio, the Ault-
man Hospital of the same city will receive |100,000. Oscar
Rosenthal, who died recently in Chicago, left the sum of $1,500
each to the Michael Reese Hospital, Alexian Brothers' Hospital,
Chicago Home for Incurables and the National Jewish Hospital
for Consumptives.
Physician for Governor.— Dr. George C. Pardee, of San
Francisco, who has been nominated for governor of California,
first attracted public attention when a member of the Oakland
Health Board, becoming widely known as a persistent foe of
neglect or corruption in any form. Later as mayor he suc-
C/Ceded in correctmg many abuses. He is an ophthalmologist
and graduated from the University of Leipsic in 1885.
Health of Chicago.— There were 2,;ii0 deaths reported
during August, 1902, au excess of 161 over August, 1901.
Typhoid fever contributed nearly 70% to this excess, there
being 83 deaths from the disease in August last year, and 193
deaths this August — the greatest number of deaths ever
recorded in a single month from typhoid. There wore 9 cases
of smallpox discovered during the month and none of the
patients had been vaccinated. Acute intestinal diseases seems
resp<msible for the greatest number of deaths, 597 being
reported due to this cause. There were 610 deaths of children
under one year of age.
Milk Inspection by Mounted Police.- There is much
adverse comment relative to the alleged careless system of
milk inspection and inconsisten(ry shown in the prosecutions of
dairymen Ijy the San Fran(-isco Health Board. The board now
announces that all milkmen arrested lor adulterating milk,
whose acquittal is secured in the police court, will be deprived
of their license if it appears that they have been guilty of the
offense charged. The board claims that it cannot carry on the
work of milk inspection unaided, as it cannot afford to employ
more than one inspector. In view of this fact Chief of Police
Wittman has offered to devote some of the time of the mounted
police to this work. It is his idea to station the mounted officers
along the roads traveled by milk wagons from the dairies to
the (Hty. This would be the only effectual way, as few of the
wagons can be caught after they enter the city streets. He
advis(M the equipment of all officers with saddlebags contain-
ing small tin vessels for securing samples of milk. In order
that the same wagon may not be stopped by more than one
ofHcer, it is proposed to issue cards to the drivers which he can
show to the next officer, certifying the hour and date that the
milk on his wagon was inspected. Dr. Lewitt, chairman of the
pure food committee of ttie Board of Health, states that the
assistance of the police department will be gratefully accepted.
FOREIGN NEWS AND NOTES
OENERAIj.
Quarantine Replaced by Sanitary Inspection.— The
quarantine established by the government of the Danish West
Indies against vessels from Porto Rico, has been removed and
a sanitary inspection substituted. The government has also
ordered a sanitary inspection of all ships arriving from Cape
Colony, as plague is reported to have appeared at Port
Elizabeth.
GREAT BRITAIN.
King Edward's Hospital Fund.— Lord Strathcona and
Mount Royal, Canadian High Commissioner in London, and
Lord Mount Stephen, president of the Bank of Montreal, have
jointly contributed a sum which will yield $80,000 a year to the
fund.
Secretaryship of the British Medical Association.-
Mr. Fouke, whose resignation goes into effect in October, 1902,
will receive a pension of £600. He took the position in 1871,
when the association had 4,403 members and the circulation of
the journal was 7,000. He will be succeeded by Mr. G. EUiston,
who will commence on a salary of £600. The association now
has about 18,500 members and the circulation of the journal is
21,500.
CONTINENTAti EUROPE.
The Twelfth Congress of French Alienists and Neu-
rologists, held at Grenoble, August 1-7, 1902, brought out a
number of valuable papers and interesting discussions, the fol-
lowing subjects receiving special attention : Tics in general,
the states of anxiety in mental diseases, autoaccusers from a
medicolegal standpoint, involuntary diversion of the little
finger in certain affections of the cerebrospinal axis, and the
coexistence of this sign with troubles of articulation ; the evo-
lution of obsessions and their passage to delirium, cancerous
localizations in the peripheral nervous system, impulsive
anxiety from a medicolegal point of view, the innervation of the
vessels of the pia mater and of the cerebral cortex, false preg-
nancy in general paralysis, histologic lesions of the cortex in
atrophies of the cerebellum, remote results of the surgical treat-
ment of idiocy and epilepsy, sarcomas and sarcomatoses of the
nervous system, the cephalorachidian fluid in general
paralysis, alterations of the fundus of the eye in general para-
lytics, on the relation of the Argyll-Robertson sign with syphi-
lis, the polyinfectious origins of tabes, on the relation of gigan-
tium and akromegaly. A detailed report of the congress is
given in La Semaine mSdicale, August 6-13, and in the Gazette
hebdomadaire de MSdecine et de Chirurgie, August 14, 1902. The
next meeting will be held in Brussels. President, Professor
Francoz, of Liege ; secretary, Professor Crocq, of Brussels.
OBITUARIES.
Rudolf Virohow died September 5 m Berlin. He was born October
13, 1821, at Schufelbein In Pomerania. In 1885 he entered the gym-
naKium of Koslin, going from there to the Medical Frederic Wil-
liam Institute in Berlin, where he graduated In 1843. In 1844 he was
appointed assistant to Professor Floriep, giving courses in patho-
logic anatomy. In 1816 he was prosector in the Charltfi Hospital,
and in 1847 he Was recognized as prlvat decent in the University
of Berlin. In r»iH he was sent by the government to Upper Silesia to
study the ■' hunger typhus " epidemic which was then raging. Because
of his report, in which he drew attention to the downtrodden condi-
tion of the peasants and advocated radical changes in their political
management, he Incurred the displeasure of the government and was
deprived of his positions. Afterward he was partially reinstated, this
being mainly due to petitions urged by fellow members of the profes-
sion. In 1819 Virchow lea Berlin to assume the professorship of
pathologic anatomy at Wttrzburg, which position he held until 1856,
when he was made professor of pathologic anatomy at Berlin. He was
the organizer of the first laborsvtory devoted to pathology, and this has
since been the Mecca for students of ail countries. Perhaps VirchoW's
greatest pride was In the great pathologic museum he established,
which. In 1901, contained 20,88;) objects with 2,000 more not yet placed.
This was open to the public on Sundays from 12 to 2, Virchow and
his assistants being present to give information and Instruction.
In 1847 Virchow founded, with the cooperation of Dr. B. Uheinhardt,
his celebrated Archiv fiir palholnyische Anatomic und Physiologic und
fur kliniache Medicine, one of the greatest storehouses of faoU In scien-
tific medicine ever published.
Beginning his pathologic work in the fifth dec4»de of the last century
it was the great opportunity of Virchow to be a pupil of Johannes
MUUer, In whose time, a« Virchow himself said later, scientific
pathology was sllli struggling to free Itself from the vague mysticism
of the later empirics. His earliest studies were of the chemistry and
morphology of the blood, later of Inflammation, and then of the con-
nective tissues, the work marking the culmination of the first Berlin
406 AVXBIOAH UEDIOrVBI
SOCIETY REP0ET8
[September 13, 1902
and early Wdrzburg periods of lil8 Htudles, being that uiwn thrombosis
and embolism— a new and Important chapter In pathology. Later he
proved himself the greatest of reformers In scientific medicine by his
work on cellular pathology, that classic being published In 185S.
After many controversies there followed universal aeceptiitlon of the
great linth formulated by him— Omn<.« cellula e cellula. On this Is
bullded the superstructure of modern medicine. A study of Vlrchow's
special pathologic Investigations would lead one Into every branch of
pathology. The true position of pathologic anatomy was first clearly
defined by him, as he showed the Importance of clinical medlclnei
experimentation, study of allied sciences, etc., as aids to the Interpreta-
tion of pathologic conditions found at autopsy. He taught that disease
Is not an entity, but Is life under changed conditions.
Vlrchow's activity was not ox>nflned to pathology alone. He was
also a recognized master In anthropology and ethnology, a foremost
archeologlst, a competent Kgyptologlst. He mastered s<x5lal and
economic problems and look most advanced ground In politics. His
active political life dates from 1869, when he was elected to a seat In the
city council of Berlin, the duties of which position he conscientiously
performed for over 42 years. In 1862 he entered the Prussian Chamber
as a representative of the Frelsinnlg or Kadlcal party, in which
capacity he served until 1878, when he made over the Ijibenil leader-
ship to Eugene Rlchter. For 25 years he has acted as chairman of the
Committee on Finance, retaining his seat in the Chamber up to the
present year. For 13 years following 1880 he rejjresented a Berlin con-
stituency In the Reichstag. He always felt that he belonged to the
people, and hence was always found on the benches of the opposition.
As a result of this he was maltreated by the government to the full
extent of its possibilities. His main adversary was Bismarck, who
once challenged him to a duel. Nevertheless he was the greatest factor
in all sanitary measures in Berlin and in the founding of its hospitals,
and the organization of the medical care of soldiers in the campaigns
of 1866 and 1870 was largely his work. For many years he held the
presidency of the Belincr Mediclnlsche Gesellschaft, one of the most
important medical societies of Europe. As a linguist he was a marvel
to scientific men.
Vlrchow's eightieth birthday in October, 1901, was a memorable
event, and universal honor and tribute such as has been paid to no other
modem man while yet living was heaped upon him by the profession
in all parts of the world. A celebration attended by the prominent
physicians of Europe was held in Berlin, Vlrchow himself making a
most felicitous speech nearly two hours in length, an attestation of his
wonderful vigor. In America, meetings of representative medical men
to pay tribute to the man and Ills great work were held In New York,
St, Louis, Milwaukee and elsewhere. Festschrifts and special num-
bers of numerous Journals were dedicated to him.
Of less than average stature, Vlrchow was possessed of a constitu-
tion of unusual vigor, capable of withstanding continued activity In
the most exhausting duties. In manner he was modest and winning,
his expression searching but friendly, and though no orator his speeches
were efl'ective, and as a conversationalist he was most delightful. One
of Vlrchow's admirers in eulogizing him said : " He Is more nearly
omniscient than any other man the world has seen in a hundred years."
In January, 1902 Vlrchow, in stepping from a street car, fell, sustaining
a fracture of the femur, from which he never fully recovered.
Noah Cressy, at Hartford, Conn., August 31, aged 63. He graduated
at the Plttsfleld Medical College. After practising medicine for 12 years
he became interested in veterinary work. Later he was appointed
Htiite veterinary surgeon for Connecticut, which office was afterward
abolished. He occupied the chair of veterinary science In the Amherst
Agricultural College.
Claudius Buchanan Webster, the oldest living alumnus of Dart-
mouth College, from which he graduated in 1837, at Concord, N. H.,
September 7, aged 86. He was an assistant surgeon in the United .States
army during the Civil war. Ijiler he was appointed United .States
consul to .Sheffield, England, by President Grant, holding the consul-
ship until 1886.
Axon Backus, of Rochester, N. Y., September 3, aged 74. He ob-
tained his degree In medicine from the University of Pennsylvania
During the Civil war he was examining surgeon for the United States
Army.
William O. Xander, of Philadelphia, September 7, from injuries
received in a carriage accident, aged 3.5. He graduated from the
University of Pennsylvania in 1895.
D. 8. Waterons, in Syracuse, N. Y., September 5, from an overdose
of morphin taken with suicidal Intent, aged 50. He was formeriy a
practising physician in Chicago.
Mortimer V. Wilkie, at Cuddebackvllle, N. Y., August 31, aged
45. He obtained his degree in medicine at the Columbia University.
WUUam J. Wentz, of New Providence, Penna., September 5, aged
61. He was a graduate of the Jefferson Medical College.
Reuben Morris Sutphen, of Newark, September 2, aged 83 He
graduated from the University in New York in 1847.
Joseph Hubbard, of Roxbury, Mass., August 31, aged 65.
W. E. Price, at Magnolia, l^a., August 31.
SOCIETY REPORTS
AMERICAN ELECTROTHERAPEUTIC ASSOCIATION.
Twelfth Annual Meeting, Held at Catskill Mountains, N. Y.,
September 2, 3 and 4, 1902.
(Specially Reported for American Medicine.}
The meeting was conducted under the presidency of Fred-
erick H. Morse, of Melrose, Massachusetts. There was a
larger number of Fellows and visitors present than at any
previous meeting in the history of the Association.
Action and Uses of the X-rays in Therapeutics. — W.
B. Snow (New Yorlt). The paper contained a technic discus-
sion of the relative value of the various tubes on tlie market,
the special indications for a high and a low vacuum, and the
relative merits of static machines and coils. A general prefer-
ence for the static machine in therapeutic work was expressed
by the writer.
The Treatment of Cancer by X-rays. — Clarence
Edward Skinner (New Haven, Conn.) stated that the rays
had been applied by him on 33 individuals, 3 of whom had been
apparently cured and a large proportion of the remainder
improved, including some still under treatment. He believed
that the x-rays exerted a profound influence on the organisms
of cancer.
Oarcinoma and Sarcoma Subject«d to Rontgen Rays.
— J. D. Gibson (Birmingham, Ala.) also presented a prelim-
inary note on some eases with good results, notably in a case
of sarcoma of the neck.
Discussion. — It appeared that the Rontgen-ray treatment of
malignant diseases was in use in many parts of the country
with varying success, the opinion being expressed by some
that it might be ijreeeded at times by an application of mer-
curic cataphoresis or the knife, and that all patients should
receive the rays after attempted extirpation by the knife.
Wm. James Morton (New York) thought that the use of
screens, except for the hair and eyes, should be abandoned in
order that all tissues surrounding the cancer should receive the
radiation.
X-rays and Mercuric Cataphoresis in Epithelioma of
the Tongue. — Chas. R. Dickson (Toronto, Can.) reported a
case in which, after the failure of x-rays, the condition of the
patient had l)een greatly ameliorated by applications of zinc-
mercnric cataphoresis.
Apparatus for Sinusoidal Alternation of the Galvanic
Current.— L. Hall-Bkown (Brooklyn, N. Y.) presented a
new apparatus for a sinusoidal, slow and painless alternation of
the galvanic and other large currents, consisting essentially of
a papier mache tulj filled with water in which contact points
were iminovably fixed at opposite points and between which a
conducting arm rotated, the resistance of the water making the
alternations or current waves rise from zero to maximum and
vice versa without shock or irregularity.
The electric light bath was described by T. D. Crothers
(Hartford, Conn.), who had found it a valuable adjuvant in the
treatment of habit eases.
Portable galvanic batteries of small cost were dis-
cussed by Robert Reyburn (Washington, D.C.) and Robert
Newman (New York). The battery exhibited by the former
consisted of a suitable number of the small dry cells used in
portable electric pocket lamps, new sets being easily obtained
when exhausted. The battery exhibited by Newman was
made of Laclanche zincs and arc light carbons for ease of
transportation, an acid solution being poured in when in use
only.
Diffusion of lodin Into the Tissues by Electric Cur-
rents.—Marcus F. Wheatland (Newport, R. I.), from a
series of experiments with organic tissues, demonstrated that
iodin Is diffused only from the negative pole, the same rule
holding in the case of haloid components of all compounds.
Arthritis Deformans. — Francis B. Bishop (Washington,
D. C.) exhibited photographs of a case showing great improve-
ment. He employed both static and galvanic currents and laid
special stress on the value of a meat diet in this affection.
Cataphoric Treatment of Cancer.- G. Betton Massey
(Philadelphia) reported 15 cases of malignant disease treated by
mercuric cataphoresis since the previous meeting, of which 9
appeared to be cured, 2 temporarily relieved and 4 proved fatal
shortly after the application was begun.
The London Medical School for Women reports a steady
progress for the past year. At the annual distribution of
prizes which took place recently, a scholarship of ^£60 a year
was given by the governors of the endowed charities of St.
Dunstan's in the East. Other scholarships of equal and some
of greater value were also assigned. A due proportion of the
students passed the examinations, and a number have accepted
important appointments not only in England but in other
countries. Two new appointments of resident surgeon and
physician in the Royal Free Hospital have been filled by
women, and a large number of old students have received pub-
lic appointments during the year.
HEPTEMBKR 13, 1902]
COKKESPONDENCB
AMERICAN MEDICINS 407
CLINICAL NOTES and CORRESPONDENCE
[Communications are Invited for this Department. The Editor Is
QOI responsible for the views advanced by any contributor.]
A CASE OF DOUBLE POTT'S DISEASE.'
BY
R. TUNSTALL TAYLOR, B.A., M.D.,
of Baltimore, Md.
Surgeon in Charge of the Hospital for Crippled Children; Clinical
Professor of Orthopedic Surgery, University of Maryland;
Orthopedic Surgeon to the University Hospital,
Baltimore; Fellow of the American
Orthopedic Association, etc.
Case.— J. M. F., a boy, aged 7, presented himself to me
for treatment on December 5, 1901. He has a very unusual
case of double Pott's disease, with distinct isolated foci of
tuberculous disease involving the fifth, sixth and seventh dor-
sal vertebras above, and the first, second and third lumbar
vertebras below. Nowhere in the literature have I been able
to find a similar
case, and it is there-
fore unique. The
definition of Pott's
disease in all of our
textbooks is *' tu-
berculous disease
in one or more ad-
jacent vertebral
bodies."
The family his-
tory is negative for
tuberculous dis-
ease and deform-
ity, except that the
paternal grand-
inother died of pul-
monary tuberculo-
sis, and a maternal
uncle of pulmo-
nary tuberculosis
and osteomyelitis.
Personal His-
tory.— Patient was
not fed artificially,
as is usual in many
rises of bone dis-
ease, but was
nursed as a baby.
He walked and
talked at one year,
and dentition was
normal. Pertussis
was the only infan-
tile disease he had
had. The mother
thinks his spinal
trouble "came
from jumping off a straw stack in 1898," but he did not complain
of pain in the abdomen until eight months after, when the lumbar
disease began ; pain was so intense that the patient, as she de-
scribed it, "could not laugh at all, from jarring caused to the
Fig. 1.— Upper dorsal and lumbar kyphoses.
Fig. 2 —Upper dorsal and lumlmr kyphoses.
si)ine." He had the usual malaise, symptoms indicative of the
effort to support and prote'^t the spine, with lordosis in standing
and walking. Night cries appeared In 1901, but are not present
now. There seeine<l to be some vesical irritation, as the child
' Reporu-d before the American Orthopedic Auoclation at Phila-
delphia, June 5, IWW.
got up two or three
times nightly to
urinate. Five
mouths before he
came to me the
dorsal disease ap-
peared. This is in-
teresting, as we
would expect the
lumbar disease to
be secondary by
gravitation of tu-
berculous pus.
There is now pres-
ent slight psoas
contraction in the
left leg. On deep
palpation in the
iliac fossa a cold
abscess, the size of
a large lemon, can
be felt. This causes
no annoyance nor
inconvenience.
There is also left
inguinal hernia.
The treatment
that I have used
has been recum-
bency on a board
covered with a
blanket, except for
two hours in the
morning and two
hours in the after-
noon, when he
wears the Taylor
back-brace, head-
support and apron.
Medication c o n -
sists of codliver-oil.
Fig. 3. — Braro ami bead-support employed.
Fig. 4.— Foci of (llsoase. Fifth, sixth, seventh doi'sal and (Irst. second,
third lumbar vertebras. Clouding and Irregularity of outline
In the diseased areas, both of vertebral bodies and discs.
408 AjnCBIOAN MEDIOniS
OOREESPONDENCK
[Septehbeb 1H, 1902
iron and mix vomica, and tiieciiild is kept out of doors an mncli
as possible, which is practically from inorninK until night. The
Fig. 5.— Normal spine of child, showing clearly the intervertebral discs
and quadrilateral shape of vertebral bodies, neither of which
appear in early and late tuberculous disease (Pott's).
patient lives in the country, thus rendering the fresh air ele-
ment of the hygienic treatment more easily obtainable.
The x-ray of this patient is es-
pecially interesting as showing
clearly by the intense shadows the
two foci of disease, namely, at the
tifth, sixth and seventh dorsal ver-
tebras, and at the first, second and
third lumbar. At the dorsal focus,
the lessened space between the ribs
and the focus of tuberculous dis-
ease appearing through the heart
shadow are noteworthy. Also in
both foci of disease I will call at-
tention, as Kirmisson noted, to the
disappearance or irregularity of the
intervertebral discs, aud the ab-
sence of the quadrilateral shape to
the vertebral bodies {Revue iVOr-
thopidie, 1901, Vol. ii, p. 405).
The photographs and tracing
illustrate this case.
Fig. 6.
be moved from place
becoming wet.
to
Rock Island Arsenal Hos-
pital.— The numerous complaints
which have been made against the
present structure will probably re-
sult in another attempt to obtain a
new hospital. The present build-
ing, which is an old wooden one,
is reported to be drafty, leaky and
rotten and entirely unfit to shelter
the sick. The statement is made
that blankets must be hung around
the patient's bed to keep off drafts
and when it rains the bed must
place to prevent the patient from
FORMALIN IN OPHTHALMOLOGY.
BY
C. FONTAINE MAURY LEIDY, M.D.,
of Philadelphia, Fa.
The German ophthalmologist appears to be the pioneer of
the more recent uses of formaldehyd in its application to the
eye. The bleaching effect of formalin is well known, but it
appears to constrict also and deplete the minute vascular sup-
ply of the conjunctiva and the associated cli:oulatory supply of
the eyeball.
In congestive conditions of the eye of gouty origin with
pain and tenderness, I have found prompt relief not only from
pain, but almost instant clearing of the conjunctiva and associ-
ated vascular system, the congested eye clearing and appear-
ing almost normal, from the instillation of 2 or 3 gtts. of the
following :
Formalin 005
Cocain hydroch 1
Aq. dest 10.
The pupil becomes greatly dilated, but this is probably due
to the cocain hydrochlorate. The solution causes no pain,
while in similar conditions I have found the adrenal extract
to cause a sleepless night. This solution seems not only to
relieve the congestion of the superficial vessels, but relieves the
tension of the eyeball and the deeper vascular supply, the
patients describing a plea.sant cooling effect, improved sight
and relief of pain, lasting from one to two hours, the congestion
not returning until another acute attack.
I have seen the redness in a case of specific iritis markedly
reduced for a short period, although it was eventually neces-
sary to resort to atropia to destroy the associated synechia.
From the germicidal properties of formaldehyd it will
undoubtedly prove of benefit in all forms of conjunctivitis.
Although yet in its experimental stage, I believe it far superior
to adrenal extract in similar cases, the efifeets being of as long
duration and not causing the distressing pain that the adrenal
does.
CAUSES OF DEATH AS SET FORTH ON DEATH
CERTIFICATES.
MARION McH. HULL, M.D.,
of Atlanta, Ga.
To the Editor of American Medicine : — I had occasion
recently to look through the death certificates in theoflSceof
the Board of Health. The following were assigned as causes of
death in certain cases : " Broken thye," " bad blood," " hemor-
rhage from nable," " mesals," " heart dropse," " billions liver,"
" grastritis," " angina becgrois," " ptesis." " Parlices " caused
death in one, while "perrallisis" was the cause in another.
Multitudes died of " colery infantum ; " a few of " colarah
morbus ; " one physician was not sure whether it was " dirhea "
or " disentary ; " another, however, was quite sure that
" dyorhear " was the cause of the death of his patient. One
infant succumbed to " choaking croop ; " another patient passed
away for " want of proper treatment."
Attention is called to this, not only because of its amusing
feature, but principally to bemoan the fact that physicians are
allowed to practise who have so slight an acquaintance with
the rudiments of the English language and who are so careless
in making a diagnosis of the disease treated. .So long as this
continues the patients must be the worst sufferers and the ^'^a-
tistics of such offices will be utterly valueless.
Incarceration of Habitual Drunkards in Insane Asy*
lums. — The enforcement of the Iowa law which provides for
the confinement of habitual drunkards in insane asylums is
reported to have the most gratifying results. Many men who
became intoxicated regularly for years are said to have re-
formed and become more or less useful citizens. If it is true
that a few months' confinement in an insane asylum will cur^
habitual drunkenness, a .similar law should be universally
adopted.
September 13, 1902]
SURGICAL FEATURES OF TYPHOID FEVER iamerican medicinb 409
ORIGINAL ARTICLES
SURGICAL FEATURES OF TYPHOID FEVER.
Being a Summary of Those Cases with Surgical Features in
the Wards of the Johns Hopkins Hospital from June,
igoo, to June, 1902, with Especial Reference to Intesti-
nal Perforation.
(From the clinics of Professor Osier and Professor Halsted.)
BY
THOMAS McCRAE, M.B.; M.K.C.P., Lond.,
of Baltimore, Md.
Associate in Medicine, Johns Hopkins University ; Resident Physician
in the Johns Hopltins Hospital ;
AND
JAMES F. MITCHELL, M.D.,
of Baltimore, Md.
Instructor In Surgery, Johns Hopkins University; Resident Surgeon
in the Johns Hopkins Hospital.
[CoTicluded from page S73.]
Discussion of the Perforation Cases. — Probably the
best idea of the picture presented by cases of perforation
can be obtained by a consideration of the symptoms in
detail. We may again draw attention to a point .strongly
emphasized by Cushing," Shattuck, Warren and Cobb '"
and others, namely, that a distinction is to be made
between the symptoms of perforation and those of the
resulting more or less general peritonitis. The usual
textbook description is more of the symptoms of the
latter condition. So long as the operation is delayed
until this last stage there can be little hope for decrease
in our mortality.
Symptoms Before Operation. — These, which by some
writers are considered to be warnings, and therefore
by inference of some help, have in some cases served
only to confuse and render the diagnosis more difficult.
Of course, all ca.ses with suspicious symptoms should be
carefully watched and any increase in the abdominal
fefitures should call for surgical consultation, as has been
emphasized in the remarks of Dr. Osier previously
quoted. Yet we cannot but feel that in many of our
cases the sudden onset has been the most valuable help
in diagnosis. In a patient who has been having
abdominal symptoms for some days the onset of per-
foration, as we have learned, may mean little change,
and only the development of extensive peritonitis may
be recognized. Also when we consider the number of
patients with suspicious abdominal symptoms, such as
pain and tenderness, perhaps associated with leukocy-
tosis (as discussed in Group E) that afterward clear up
completely, we cannot fail to attach less importance as
an aid to diagnosis to the socalled warning symptoms
and preperforative leukocytosis. Such symptoms occur
so often unas.sociated with perforation that they cannot
be considered as even a frequent sign of impending
perforation, but should, nevertheless, act as a stimulus to
the most careful, fre<iuent and thorough observation
by both physician and surgeon. It must be remembered
that probably only hourly counts of the leukocytes can
be of much service in detecting a preperforative leuko-
cytosis, and as we have seen in many cases, the perfora-
tion may occur in patients whose previous condition
has not indicated the necessity of such counts. Four
cases of this series of eight presented no alxlominal
features before perforation. Three patients had disten-
tion, rigidity, and abdominal pain, in two instances
accompanied liy leukocytosis. In one case there was
intestinal hemorrhage one day before the perforation.
Onset. — One feature stiinds out in all but one of the
cases, namely, the suddenness of onst^t with pain. In the
eighth case there was pain throughout the attack, and
the time of perforation could not be fixed. The patients
usually cried out with the pain so as to attract the atten-
tion of the nurse or attendants. In two this occurred
during a tub-bath, in one while on the bedpan. The
pain is usually severe, and referred to various regions,
most often to the lower abdomen and the umbilical
region. In two instances it began in the penis and
extended into the abdomen ; in one case it was localized
about McBurney's point. In two patients the pain and
perforation were accompanied by hemorrhage from the
bowels. Chill at onset was observed in one case, in
which perforation occurred with intestinal hemorrhage.
Sweating was twice noted, both times profuse. An
immediate increase in the pulse-rate was not common ;
it was seen in two, in one of which it was accompanied
by immediate increase in the respiration (in this case
there was also chill, sweating and hemorrhage at the
time of perforation). It is noteworthy that in only one
case was there any drop in temperature at onset, and this
of between 2° and 3° and immediately followed by ele-
vation ; and that in six there was immediate elevation
after the onset.
Tmie of Perforation. — The earliest was on the eleventh
day of the disease and the latest on the thirtieth. The
others occurred on the twelfth, fifteenth, sixteenth (2),
eighteenth and twenty-fifth.
Symptoms After Perforation. —These depend upon or
are influenced by various factors : First, the position of
the perforation; second, the organisms escaping into
the peritoneal cavity, and third, the general condition of
the patient, all of which influence the rapidity of the
spread of peritonitis and the symptoms presented. It is
convenient to consider the symptoms under two heads —
first, general symptoms, and second, local abdominal
features. While in some cases which have gone for a
long time after perforation the symptoms can be divided
into two periods, those we wish to consider most care-
fully are the earlier ones. The later condition, in which
the symptoms are due to more or less extensive peri-
tonitis, is generally easily detected, and if possible is to
be avoided by operating before it has developed. In
certain cases the earlier stage Is overlooked. The symp-
toms in cases XI to XV occurred during the period of
3i to 13 hours. In the remaining three the time was
over 24 hours. In two of these the presence of intestinal
hemorrhage was a confusing feature, and the remaining
patient was not operated upon.
General Symptoms. — Facies and general appearances :
The facial appearance was practically normal in four
cases throughout, a fifth showing a pinched expression
only after some hours. In one there was the " risus sar-
donicus," and in two there was a distressed, anxious
look. The decubitus was dorsal in six throughout, three
of these lying with the knees drawn up. In two the
decubitus was right lateral with the knees drawn up.
Sweating was observed in three cases.
Collapse was present only twice, both times in asso-
ciation with hemorrhage.
Temperature : In only one case was there no change
in the temperature. In seven there was slight eleva-
tion following the perforation, and this in six instances
was followed by a fall in temperature, which in one case
reached normal. This was a case in which hemorrhage
accompanied the perforation.
Pulse : The rate showed practically no change in two
instances. In six the rate increased, two suddenly and
four gradually. As a rule the quality of the pulse be-
comes poorer as the symptoms progress, but this is not
certain enough to be of value.
The respirations were unchanged in three cases. Of five
showing increase in the rate, three rose gradually and
two increased at once. In two there was a subsequent
drop, both being cases of asso<!iated hemorrhage in which
the patients had received opium.
Hiccough occurred in three, in two of which it was a
rather late symptom.
Nausea and vomiting were observed in only one in-
stance, and then rather late.
Bowels : There are notes of the bowels moving in
410 AMKKicAN MEDiciNBj SURGICAL FEATURES OF TYPHOID FEVEE
[Septehbeb 13, 1W2
five cases after the perforation, one of these being a case
of general peritonitis. In two ciases the stools containe<l
large amounts of blood, and in one there was diarrhea
with pain. Three patients expelled flatus after perfora-
tion.
Leukocytes : In three cases there was practically no
change in the leukocytes after perforation. In one of
these the leukocytes were normal throughout, and in the
remaining two there had been leukocytosis previous to the
perforation, which did not change appreciably. In five
cases the leukocytes rose in varying degrees after perfo-
ration. It is significant that the two cases showing the
greatest rise in leukocytosis after perforation were those
in which hemorrhage and perforation coexisted. The
leukocytes in these instances were 14,000 and 17,o00. In
the remaining three cases the highest leukocyte counts
were between 8,000 and 12,000.
Local Abdominal Features.— Pam was a prominent
symptom in seven of the eight cases. In the eighth it
was severe at the onset, but disappeared after the admin-
istration of opium. In five cases it occurred in intense
paroxysms, while in two it was constant and varied but
little in degree. It was referred to the right iliac fossa
by four, the right hypogastrium by two, by one to the
umbilicus, and in the last ease it was general.
Appearance of abdomen : The abdomen was natural
and without distention in three instances, in one of
which there was retraction of the walls. In a fourth
there was no distention except of the lower abdomen by
a myoma of the uterus. The abdomen showed disten-
tion in four, in all of which it had been present before
perforation. In one instance the distention remained
unchanged as the symptoms progressed. In one it in-
creased greatly, and in another it decreased after move-
ment of the bowels, while in a fourth it varied in
amount.
Respiratory movements: There was no case which
showed immediate diminution of the abdominal respira-
tory movements. In four cases they were well marked
throughout. In three they were diminished, in two 6
and 24 hours respectively after perforation. In one case
there was diminution below the navel, due to a myoma.
Rigidity was present in some degree in all, being
greater on the right side in three and fairly general in
three. In one it appeared only as a late symptom.
Muscle spasm was never a very early symptom, the
earliest time at which it was detected being about five
hours after the perforation. In two cases there was none
noted.
Tenderness on palpation was usually an early and
striking sign, and often varied in degree. In four
instances it was fairly general, and in three of these
rather more on the right side. The point of greatest
tenderness was definitely located in the right iliac fossa
in three ; in the hypogastrium in one, and in two it
varied in position.
Liver dulness was not diminished in two cases, while
in two it had been diminished before the perforation
and was practically unchanged afterward. Of four cases
in which the liver dulness was decreased, it occurred in
two with a flat abdomen and in another without any
increase in the previous distention, while in the fourth
it was associated with distention.
Dulness in the flanks was made out in five cases, in
two of which it was definitely movable. Auscultatory
percussion was of no value in three cases in which it was
tried. Rectal examination was also negative, except for
slight tenderness in one case.
There is one condition sometimes associated with
perforation to which we would draw special attention,
namely, hemorrhage, as shown in Cases XVI and XVII.
Of the seven patients with perforation operated upon
the complication was recognized within nine hours in
five, but in the two with hemorrhage not until after 24
hours had passed. The combination is not rare ; among
the 34 cases of perforation in the medical service of this
hospital, in seven hemorrhage has occurred at the same
time. It may be added that in none of these was the
perforation recognized early. The symptoms were
always attributed at first to the hemorrhage. This
would seem to he worthy of consideration as a contra-
indication to the use of opium for hemorrhage; certainly
one would say until the possibility of perforation had
been excluded. But who can do this with certainty ?
We thought we had done it in Case XVI, but we were
wrong. The ssime may be said of Case XVII, when
every one seeing the case had perforation in mind as a
possibility throughout. It may be necessary to quiet a
restless patient having hemorrhages, but a small dose of
morphia, hypodermically, will do this and is to be pre-
ferred to opium by the mouth or bowel, the effect of
which will probably last much longer.
The Diagnom of Perforation. — One has only to see
a few cases of perforation or study their histories to
appreciate the fact that there is no regularity in the
symptoms, and that no symptom or group of symptoms
is pathognomonic. The classic description of the symp-
toms is not so much of perforation as of the resulting
changes. Not all cases are difficult. Between a case such
as No. XV of this series in which the diagnosis was made
at once on the first examination and one in which not a
suspicion is entertained until the autopsy shows general
peritonitis, there are all grades and variations. Any
case of typhoid fever may perforate. It may be said
that preparations for the diagnosis should be made long
before the perforation occurs. Much in its recognition
depends upon seeing the patient at the onset of symp-
toms. The nurses and attendants must be carefully
instructed to report at once anj^ suspicious symptom.
Abdominal pain, any sudden general change, alterations
in the pulse and respiration, etc., should be reported at
once. The house physician should never disregard such
warnings, but see the patient immediately. He may be
frequently called for conditions of no moment, but he
must not let this render him careless. There should
also be careful study and noting of the patient's condition
every day. These notes should be on paper and not l^ft
to the physician's memory. A careful description of the
previous general state, and especially the abdominal con-
dition, should be available in the event of complications
later in the disease. With the appearance of any suspi-
cious signs, of course, constant observation is most
essential. The patient should be seen every hour and
accurate notes written out. Along with this should go
a surgical consultation. The surgeon, who has seen the
case from the onset of abdominal symptoms, is in a much
better position to advise for or against operation. It is
well for the surgeon to familiarize himself with the ordi-
nary abdominal conditions in typhoid fever, some of
which so closely simulate perforation. So great is the
variation in the symptoms that no satisfactory general
description can be given, nor is it well that it should be
attempted. Those handling typhoid fever patients have
to realize that perforation comes under many guises, and *
that to attempt its recognition from any constant combi-
nation of signs is hopeless. No symptom is constantly
present, and no significance should be attributed to the
absence of any one. There are, however, certain points
which stand out, and of these a most important one is
the onset. This is usually sudden and with pain. Such
an occurrence should excite suspicion. In patients who
have had pain for days before the perforation, there may
be an exacerbation of the pain which attracts attention,
or there may be nothing more striking than before.
Other symptoms may accompany the pain, such as
nausea or vomiting, sweating, rise in pulse-rate, etc., but
the pain is by far the most constant feature. Other con-
ditions causing abdominal pain have always to be
excluded most carefully. These are many and have
been considered by one of us in another article." After
the onset we would say the most constant features are
pain, often in severe paroxysms, tenderness and some
8KPTEHBER 13, 1902]
SURGICAL FEATURES OF TYPHOID FEVER iamkrican medicink 411
rigidity. Others may be present, such as vomiting,
sweating, change in temperature, pulse and respiration,
impairment of abdominal respiratory movements,
muscle spasm, decrease in the area of liver dulness
(which is only of value if one ha.s careful notes as to its
extent previously, and is of little importance when there
is marked abdominal distention), movable dulness in
the flanks, leukocytosis, etc. But from the absence of
any of these no conclusion should be drawn. Their
occurrence is important; their absence is not. We
speak here of the early hours after perforation ; later
these features may all be present. Compare also the
symptoms in the group below in which perforation was
suspecte<l, and the difficulties of diagnosis are more evi-
dent ; pain, tenderness, rigidity, leukocytosis, changes
in pulse, respiration and temperature may all be found
without perforation. The difficulties are evident. Have
we any other means of making the diagnosis? The
only one of value is exploration. This should be done
under cocain, and is practically without danger. Certainly
it is better to take this slight risk than to let a doubtful
case go beyond the limit of recovery. In other doubtful
conditions of the abdomen we are accustomed to advise
exploration as a diagnostic measure considering the risk
le?s from operation than from delay. The suspicious
typhoid case is analogous, except that here the delay of
an hour corresponds to that of a month in an advancing
chronic case. We may say here, as of appendicitis, that
while exploration is often too late, we have never
regrettetl its being done too early. That all suspicious
ca.ses do not reijuire exploration is shown by the group
given subsequently. In some of these we waited from
hour to hour, ready to operate at once should any
advance in symptoms be noted. A positive diagnosis of
perforation always before operation is not to be expected,
nor is it wise that it should be demanded. What we
have to decide is whether the condition is of sufficient
gravity to warrant an exploratory operation to render
certain the existence or not of some abdominal compli-
cation.
Time of Opera' ion. ^The shortest time elapsing be-
tween perforation and operation in the seven cases was
3J hours. The two eases in which operation was long-
est delayed (15 and 26 hours) were both accompanied by
hemorrhage. In one case operated upon 13 hours after
the perforation some delay was due to a long operation
on an emergency case occupying the surgeon. The
remaining three patients were operated upon respectively
7}, 8, and 9 hours after perforation. The following
table shows the relation between the time of operation,
the leukocytosis, the bacteriologic findings, and the
result :
Case.
Hour?.
Leukocytes.
Result.
Bacteriology.
XI.
13
7,500
Recovery.
B.coH commu nw. B.proteua
vulgaris, unldentlfled ba-
cilli.
xir.
9
5,000
Death, 6.<ihrs.
lilrep. piing. Tj/ plio-colon II.
xiir
7M
11,600
Recovery.
Cultures negative.
XIV.
8
ii,m
Death, 7 days.
Ji coti communis.
XV.
SVt
15,»00
Death. 12 hrs.
B. coli communis.
XVI.
28
14,800
DciVtb,2ihrs.
li. colt communis. Staph.
XVII.
25
17,600
Death, Ihr.
Pi/Of/, aureus.
Streptococcus pyog.
Operation. — Anesthetic : In the first three cases cocain
was used in the beginning of the operation with whilfs
of chloroform after the peritoneum wa« opened. In the
last four ciises cocain alone was used. As is held by
Cushing '^ the successful use of cocain depend.s largely
ui)on experience.
Incision : The incision of choice is through the right
rectus muscle, separating the fibers. This we have used
in three cases. Three times the incision of r.ionnander
at the outer border of the right rectus was used, and in
one case an incision at the inner border of the same
muscle. The lateral incisions arc much to be preferred,
giving the best exposure of the ileocecal r^ion and
offering the most favorable conditions for drainage. ■<*
Condition of peritoneum : In three cases on opening
the abdomen there wa.s an escape of gas and in four there
were feces in the peritoneal cavity. There was usually
a considerable amount of free fluid, always turbid, and
in live cases definitely purulent. In one (3i hours after
perforation) the fluid was of very small amount and
confined to the immediate neighborhood of the per-
foration. Peritonitis was twice limited and five times
extensive. Of the patients which recovered there was
in one limited, in the other extensive peritonitis. The
mesenteric glands were usually enlarged. The intes-
tines were distended in four cases ; two of the patients
recovered.
Perforation : In only one case was there more than
one perforation. All were in the ileum and varied in
position from 10 cm. to 45 cm. from the cecum. The
size of the perforation whs from 2 mm. to 1 cm. in diam-
eter. They were usually clean cut and situated in the
center of a Peyer's patch.
Operative Procedures. — In one case only were we
unable to close the perforation on account of the fria-
bility of the surrounding bowel wall. The perforation
ha.s otherwise been closed by a purse-string suture of fine
silk, reinforced by one or two llalsted mattress-sutures.
Any suspicious-looking Peyer's patches may be turned
in by the same method. We have never had such a
suture fail to remain secure and at autopsies in the fatal
cases we have always found the suture intact, even in
the presence of general peritonitis.
Irrigation has been used in only one case in which there
was very extensive if not general peritonitis at the time
of operation, the patient dying immediately afterward.
We prefer to wipe away the exudate thoroughly with
gauze pads moistened with normal salt solution. Great
care is taken to keep the intestines within the abdominal
cavity during this cleansing, and so avoid the shock of
evisceration. The search for the perforation should be
systematic, beginning at the cecum as a landmark and
following the ileum upward. Much time may thus be
saved and the surface of the bowel cleansed as examined.
With a little experience on the part of the operator there
need be little pain cause<l by these manipulations. The
parietal peritoneum being more sensitive should be
avoided as much as possible.
Closure : The omentum is pulled down over the point
of suture and over any suspicious ulcers as an extra pro-
tection, and the region is drained with iodoform gauze
and protective wicks. In no case have we clo.sed the
wound without drainage.
Immediate Effects of Operation. — In one case death
immediately followed the operation, the patient being
almost moribund when placed on the faible, suffering
from the combination of perforation and intestinal hem-
orrhage. In three patients the condition was i)ractically
unchanged and three others showed almost immediate
improvement.
Subsequent Course. — In those patients who recovered,
the course of the typhoid fever was milder after the
operation. One of these (Case XI) ran a short and
uneventful amvalescence. The second ({!ase XIII) de-
veloped bronchitis, and from constant straining, the
small intestine was pu.shed out through the wound on
the sixth day. It was cleansed and replaced. .Subse-
quently convalescence was slow and there was a mild
nephritis. The patient left the hospital well. Int<istinal
obstruction from adhesions and exten.sive peritonitis
resulted fat^illy on the third day in one instance (Case
XII).
Ultimate Jiesutts. — Two patients eventually recoveretl.
One lived a week and died from profound toxemia. In
Case XVII the patient died one hour after operation ; in
Case XV, 12 hours; in Case XVI, 22 hours, and in Case
XII, 63 hours aftt^r operation.
Bacferiolof)}/ and Auiopgiea. — The bacteriologic and
412 AMBBicAN MKDiciNE) SURGICAL FEATURES OF TYPHOID FEVER
[8KPTEMBEB 13, 1902
autoj)sy flndingH are fjivoii in detail with the historieH
above. As would naturally be .supposed, the organisms
obtained from the peritoneal cavity are a good index to
the prognosis, those cases with the least virulent organ-
isms liberated having the best chances for rwovery.
Autopsies were obtained in three cases in all of which
the diagnosis of typlioid fever was substantiated.
(D) Siutpected Perforatum ; Operation. — Of two cases
explored on account of symptoms suggesting perfora-
tion one showed a mild grade of peritonitis, which
cleared up after the operation and the whole trend of the
symptoms was toward improvement. The patient
recovered and left the hospital in the seventh week. It
is an important case as showing that a cocain explora-
tion may have no injurious effect and here even seemed
to have a beneficial influence on the typhoidal process.
It is natural that one should not wish to operate unnec-
essarily. When in doubt, however, and perforation is
strongly suspected, it is certainly much wiser to sulyect
the patient to an operation, which is in itself harmless,
than by waiting for positive signs to allow an extensive
peritonitis to develop and so practically take away the
patient's chances for recovery.
In the second case of this series the symptoms were
evidently due to intestinal hemorrhage. The patient's
condition, which was desperate, was not affected by the
operation and she died of hemorrhage and toxemia'.
Case XIX.— Typhoid fever; abdominal symptoms; opera-
tion: mild peritonitis; no perforation ; recovery.
Bacteriology: Bacilli and cocci in coverslips from the peri-
toneal cavity ; cultures negative.
Remarks. — The character of the pain coming on sud-
denly at the time of the tub, the rigidity of the abdom-
inal muscles, the tenderness in the abdomen, which had
not been present previously, the rise in leukocytes, all
seemed to justify an abdominal exploration. The course
of the typhoid fever was certainly much milder after the
operation. The general trend of the symptoms follow-
ing operation was toward improvement. The fluid In
the peritoneal cavity containing baeilli and cocci evi-
dently indicated a low grade of peritonitis, which seems
to have been relieved by the operation. This case is of
si)ecial interest as an example of peritonitis without any
perforation. It is the first one that has been recognized
in this hospital. How far such a condition may explain
the abdominal symptoms such as are shown by the
patients in the next group is a difficult question to
answer.
Cask XX.— Typhoid fever ; hemoptysis; intestinal hemor-
rhage; abdominal symptoms; operation; no perforation ; death.
Autopsy: Ulceration of gastric mucosa; erosion of artery
and hemorrhage into stomach.
Bacteriology: Cultures and coverslips from peritoneal cav-
ity negative.
Hemarks.— This- case illustrates the great similarity
of the symptoms of perforation and intestinal hemor-
rhage; the sudden onset of pain, increa.se in pulse-rate,
rapid respiration, vomiting, abdominal tenderness and
pain, all suggesting perforation ; the rapid, weak pulse,
the vomiting of blood, the absence of rigidity and
muscle spa.sm, and the rapid drop in the hemoglobin,
favoring the probability of gastrointestinal hemorrhage.
The leukocytes were of little value, being 7,000 on the
day of admission, December 31 ; January 1, 8,000; Jan-
uary 4, 6,600 ; January 5, at .5 a.m., 6,300 ; at 5.30 p.m.,
7,000 ; at 6.30 p.m., 0,400 ; at 7.30 p.m., .5,400 ; at 8.30
p.m., 6,200 ; at 10.30 p.m., 6,000 ; January 6, 1.30 a.m.,
6,000 ; January 6, 8,000.
It is difficult to estimate the influence the operation
had in hastening death. Judging from the patient's
condition after the operation and up to a few minutes
before death, it would seem that there was no injurious
effect directly referable to the operation. She seemed
to be domg well up to the onset of the symptoms which
immediately preceded death. It was thought possible
that the sudden death was due to a fresh hemorrhage.
The absence of blood at the autopsy rendered this im-
probable. At autopsy it was thought that the hemor-
rhage had occurred at the .seat of the ulcer in the
stomach.
The following case we include with the typhoid group
because at the time of admission it was thought prob-
able that the patient was suffering from typhoid fever.
The disappearance of symptoms after the administration
of quinin, although no malarial parasites were ever
demonstrated, suggests the probability of malaria.
Case XXI.— Acute febrile attack with abdominal symp-
toms; operation; negative findings; recovery after taking
quinin ; no malarial organisms demonstrated.
(E) Conditions Camijig Abdominal Symptorrm, in Which
Operation loas not Thought to be Indicated. — In reviewing
the 11 cases which comprise this group, it must be .said
that in some at lea.st it seems difficult to understand
why exploration was not done. The symptoms as
viewed in the histories suggest very strongly .some
abdominal complication. In four of them the .symptoms
were apparently caused by abdominal distention with
severe toxemia ; one is explained by iliac thrombosis, one
by hemorrhage, one most peculiarly by a termination by
crisis, and two by a neurotic condition. In one other
case the symptoms seemed to be especially gastric, and
for another one no explanation can be given. In .some
of these the associated features give a clue to the cause.
Those with marked neurotic symptoms are most apt to
give difficulty in recognition only on the first mani-
festation. The cases with abdominal di.stention and
pain, along with local signs and perhaps leukocytosis, are
most puzzling. It is in the.se especially that familiarity
with the abdominal features, which may occur without
any complication, is mo.st important. The handling of
many cases gives one a knowledge of the marked symp-
toms that may be as.sociated with distention. The cases
of hemorrhage must always be difficult, and we have
found more possibility of error here than in any other
condition.
. , Case XXII.— Typhoid lever ; abdominal symptoms marked
throughout illness; no operation; death; autopsy.
Explanation, intestinal distention and profound toxemia.
Remarks.— Iha abdominal symptoms were marked
throughout the whole course of the patient's illness, both
before and after admission to the hospital. During the
last two weeks of his illness he was watched very
closely, with the possibility of a perforation ever in
mind. The increase of the abdominal symptoms with
distention, and the subsidence of these .symptoms with
the relief of the distention, pointed to it as a cause of
his .symptoms. The slight tenderness and rigidity with
the entire absence of muscle spasm and the free respira-
tory movements were opposed to peritoneal involve-
ment. An interesting feature is the gradual fall in
leukocytes during the last two weeks, a drop from 14,-
000 to 2,300, corresponding to the gradual increase in his
toxemia and decrease in resistance.
Case XXIII. — Typhoid fever; abdominal symptoms:
recovery.
Explanation, toxemia and intestinal distention.
Itemarks.—lxi this patient the sudden change in the
general condition, with much higher temperature and
increased pulse-rate and respiration, along with the
abdominal features, suggested an acute complication.
The marked toxemia and distention and the fact that
the abdominal symptoms did not increase in severity,
spoke against this. The frequent vomiting was, how-
ever, a very suggestive symptom. There was nothing
to explain the leukocytosis on admission.
Case XXIV.— Typhoid fever; abdominal symptoms; no
operation ; recovery.
Explanation, abdominal distention.
Re^narks.~'^\vQ condition of the patient at one time
certainly suggested the possibility of perforation ; the
SEI'TEMBER 13, 1<J02]
SURGICAL FEATURES OF TYPHOID FEVER (amkkican medicine 413
abdominal pain witii rather sudden onset, the nausea
and vomiting, the abdominal distention with rigidity
and tenderness, all favoring this opinion. The rapidly
increasing distention with no accompanying increase in
tenderness or rigidity, the entire absence of muscle
spasm, the good character of the pulse and the general
condition of the patient, suggested that the symptoms
were probably due to the distention alone, which fact
was substantiated by the rapid disappearance of the
symptoms after relief of the distention.
Case XXV.— Typhoid fever; aMominal symptoms; no
operation.
Explanation, abdominal distention.
Be/narks. — Perhaps the most important point in this
case is that in spite of the very severe general symptonas
the abdominal signs were comparatively slight and did
not increase in severity. They were probably due to
distention. The patient left the hospital against advice
and was lost sight of.
Case XXVI. — Typhoid fever ; abdominal symptoms asso-
ciated with pain in the legs following an enema; no operation;
recovery.
Explanation, iliac thrombosis.
Remarks. — The abdominal facies in this case was
quite marked, and associated with the marked leukocy-
tosis suggested an acute abdominal complication. The
pain in the legs for some days before, associated with
some leukocytosis, also the fact that the tenderness in
the abdomen was rather more marked over the course of
the iliac veins, along with the tenderness in the legs, all
suggested thrombosis. In addition to this, the fact that
we had hatl a previous lesson concerning the abdominal
features which might be a.ssociated with iliac thrombo-
sis, suggested this as an explanation of the symptoms.
It is of interest to note that the abdominal pain followed
the giving of an enema.
Cask XXVII. — Typhoid fever ; abdominal symptoms with
intestmal hemorrhage ; no operation ; three relapses ; recovery.
Pixplanation, intestinal hemorrhage.
lieinarks. — A point of special interest in this case is
the onset of abdominal symptoms with hemorrhage. The
IK)ssibility of perforation occurring with hemorrhage
and being overlooked was prominently in our minds.
The sudden onset of severe symptoms on August 16 sug-
gested that perforation had occurred, but their total dis-
appearance within half an hour, to return a few hours
later, spoke against this complication.
For a full report and discussion of this csise see War-
field, Johns Hopkins Hospital Bulleiin, June, 1902.
Casp; XXVIII.— Typhoid fever; termination by crisis on
fourteenth day, accompanied by abdominal symptoms; no
operation ; recovery.
Jienmrks. — The special point of Interest in this case is
the termination by crisis on the fourteenth day, the
temj)erature falling nearly 5° within about eight hours.
This was associated with marked abdominal symjjtomsas
noted above, and a leukocytosis of ir),(M)(i. The sudden
onset of abdominal pain with some rigidity of the walls
and droj) in the temperature, along with the leuko-
cytosis, all suggestefl some complication. The advisa-
bility of exploration was considered, but the absence of
general features, the fact that the pulse-rate did not in-
crease, and the clearing up of the symptoms under con-
stant observation decided us against this.
Case XXIX. — Typhoid fever; abdominal symptoms; no
operation ; recovery.
Explanation, gastric disturbance.
lli'nmrks. — After reviewing this case it is difficult to
see why an exploration was not done. The marked
general symptoms, the nausea, vomiting and hiccough-
ing, the ab(lominal pain and slight tenderneas, along
with the drop in tt^mperature, were all suggestive. The
lact, however, that the local .symptoms did not increase
in severity, the general condition was so good, and the
pulse-rate was undisturbed, spoke against it.
Case XXX.— Typhoid fever; repeated abdominal symp-
toms ; no operation ; recovery.
Explanation, general neurotic condition.
liemarks.—The attacks of abdominal pain were
accompanied by several striking features. The patient
cried out loudly, complained bitterly on palpation of the
abdomen, and throughout showed so many neurotic
features that our suspicions were aroused even with the
first attack of pain. The nausea and vomiting which
had been present from the onset were disturbing features.
The abdominal tenderness and at times rigidity more
marked on one side suggested an abdominal complica-
tion, but were offset by the fact that at times he showed
great hyperesthesia over the muscles generally. The
absence of distention and muscle spasm and of any great
change in the abdominal condition were against abdomi-
nal complication. After the first attack of pain the others
caused but slight anxiety, the neurotic features in the
case being well recognized after our first experience.
Neither the pulse, respirations, nor temperature showed
any great change.
Case XXXI.— Typhoid fever; abdominal symptoms; no
operation; recovery.
Explanation, general neurotic condition.
Hemarks.—The picture presented by this patient,
who was a nurse, at the time of onset of abdominal
symptoms, suggested very decidedly that of some acute
complication. How much her knowledge of the disease
had to do with simulating the symptoms it is difficult to
say. There could be no question of the rigidity and
muscle spasm on the right side of the abdomen. The
general suggestion of a neurotic condition was of consid-
erable help in arriving at the conclusion that no acute
abdominal condition existed.
Cask XXXII.— Typhoid fever; abdominal symptoms ; no
operation ; recovery.
No explanation.
Remarks. — In reviewing this case there do not seem
to have been enough symptoms to have justified an
exploration. The very sudden onset of pain with the
marked local abdominal .symptoms were very suggest-
ive. Probably it was the absence of a marked change
in the general condition, and especially the fact that the
pulse-rate was not affected, which infiuenced us in delay-
ing until the symptoms had cleared up.
In reviewing the symptoms shown by the 1 1 cases in
this group we find in two there had been abdominal
symptoms for some days before the onset of severe
manifestations. The onset was sudden in eight and
moderately sudden in the other three. In all abdom-
inal pain was a prominent symptom at the onset, in two
accompanied by vomiting. Of the symptoms after the
onset there was a suggestive facies in two patients (one
of whom had hemorrhage), vomiting in four, in three
accompanied by nausea. The temperature showed no
special change in seven, rose after the onset of symp-
toms in two and fell in two (one being a termination by
crisis). The pulse rose in rate in four and was unchanged
in the others. The leukocytes were below 5,000 in two,
betwcHjn 7,000 and 10,000 in four, and above 12,000 in
five citses. The highest leukocytosis was 20,')0(t. What
may be termed a " preperforative leukocytosis" was
prestmt in some. Of local abdominal symptoms pain
was present in all, tenderness in all but one, rigidity in
seven, and muscle spasm in two. The respiratory
movements were diminished below the navel in four;
distention was prt^sent in four and in the same number
the signs were more markiMl on tlu; right side than on
the left side. Liver dulne„ss was diminished in five,
with distention in all. In four the patients persisttintly
kept the knees drawn up.
Condmion. — In the discussion of the abdominal fea-
tures in this series of citses of typhoid fever we do not
414 Ahebican Medicimk]
EXTRACTION OF METALLIC FEAGMENT8
rSBPTBMBEB 13, 1902
pretend to have drawn a picture applicable to all cases
of jjerforation of the Intestine. We have given the feat-
urea of eight cases, but we realize that the next eight
may show a quite different group of symptoms. We
have tried to give the cases in which we were in error in
full detail, and they are, perhaps, more instructive than
the others. The group of suspicious cswes is worthy of
study. The majority of descriptions of the disease give
one little idea of their occurrence and features. In these
cases there may be something in the general picture
which influences one in advising operation or in holding
back. The absence of progress in local symptoms was
important in some of the doubtful grouj). It may be
impossible to convey in words why one waits in a given
CflSG.
We do not wish to be understood as advising opera-
tion recklessly or in every suspicious case. The number
of doubtful cases cjuoted above as left alone should prove
the contrary. The early recognition of perforation is
our only hope to diminish its mortality. To that end
every means should be used, and in certain cases explora-
tion seems to us a perfectly justifiable procedure.
To summarize our two years' experience :
1. There have been treated 275 cases.
2. Of these a certain number had unimportant com-
plications, as boils or abscesses, the cultures from which
in every instance yielded pyogenic cocci.
3. J'eriostitis and perichondritis have been seen
occasionally, always subsiding without surgical interfer-
4. Glandular affections, especially mastitis, occurred
but were not serious.
5. Abscess of the liver occurred once with recoverv
the cultures being practically negative. '
(5. There have been symptoms of cholecystitis in five
cases, of which three subsided without operation one
patient was operated upon and recovered, while in one
the gallbladder ruptured and general peritonitis result-
ing in death followed.
7. Appendicitis was suspected on admission in three
cases and developed once during the course of typhoid
8. Perforation of the intestine occurred in eight
patients. Of these seven were operated upon with two
recoveries, a third dying of toxemia after a week All
of these seven were recognized within nine hours, except
two, m which hemorrhage from the bowel accompanied
the perforation In one case operation was not advised
because the patient was evidently in extremis.
9. Exploratory laparotomy was done in two cases in
which no perforation was found. In one the symptoms
proved to be due to intestinal hemorrhage : in the other
rec^irr^^tred.^'""""'"'^- ''''' ^^^* ^'^ ^'^ ' '^^
10. Eleven patients with suspicious abdominal symp-
toms were not operated upon. Of these, two died and
the autopsies showed no perforation. The remaining
nine recovered. cujaiuiug
BIBLIOGRAPHY.
mHW^PiRii* mH?""? '""'*'' *^ '•"^'e^ tie literature.
I ?,%'• ^H''\: Med. Jour., igOL Vol. vil, p. il«
JMcCrae, Johns Hop. Hosp. gul., 1902,' Vol xiil p 20
I Kr,"A**."''i^'; «omplTcations and Sequels of TyplJold Fever 1898
< Da tosta, Trans, of Assoc, of Amer. Phy.. isM Vol x?v '
t-trines, JJeivt. /.thchr fur Chirurg e, 190A Bd s^ n in ""'^■"''•
' Lennander, Centralblatt Kir Cbirm-gie 1901, Feb' Is p 209
Junel ""'"• ^'"•"■<'" ""'^ C;obb, Boston Aled. and tim-e.' Jo^f^t im,
',' McCrae, N. Y. Med. Jour.. 1901, May 1.
12 Cushing, FbUa. Med. Jour., 1900, Mar. 3.
4S attributed to the delay in burying the many corpses wK
THE EXTRACTION OF METALLIC FRAGMENTS FROM
THE VITREOUS CHAMBER.'
S. D. RLSLEY, M.D.,
of Philadelphia.
The recent visit of Professor O. Haab, of Zurich, to
the United States has awakened a renewed interest in
the giant electromagnet devised by him for the extrac-
tion of iron and steel particles from the interior of the
eye. Those members of the profession who enjoyed the
opportunity of hearing his own eloquent presentation of
his methods and the analysis of his results in im cases
must have been impressed by his .skill as shown in the
large percentage of successes, and incidentally by the
great value and importance of extended experience in
the employment of his powerful instrument. The time
therefore, seems opportune for a discu&sion of the relative
merits of extraction by the giant magnet and the
methods heretofore more generally in u.se in this country
by aid of weaker instruments as represented by the
Hirschberg magnet.
That a more powerful apparatus is often desirable has
found expression in the more efficient instruments de-
vised by Dr. Lippincott, Dr. Johnson and Dr. Sweet, all
members of this society. It remains to be seen whether
a more extended experience will not demonstrate that
these instruments, when employed in conjunction with
our modern means of determining both the size and
exact location of the metallic body, are to be preferred
to the giant magnet, in the routine of practice, because
of their portability, practical efficiency and greater
safety. The claim of the giant magnet to superiority
must rest alone upon its greater power, while its size
and weight, and the powerful electric current required to
energize it, will always present the disadvantage of a
fixed position, which requires that the eye of the patient
must be approached to the magnet. It lo.ses, therefore,
the advantage of portability which permits a more ready
control of the force employed and of the line of direction
of the traction exerted upon the foreign body.
The principles which should guide in the discus.sion
of the modes of extracting metallic particles from the
vitreous chamber may be .set forth more briefly with a
few illu.strative cases as a basis for study. For this pur-
pose I have selected four typical examples, all occurring
at my Wills Hospital clinic in Philadelphia. A much
larger number could be brought forward were it neces-
sary for my present purpose.
„ ^^oa^, I.— J'ore/ffw bodp in vitreous of left eye. David Fox,
aged 26, blacksmith, while at work at his anvil on the morning
of August 2, 1901, received a fragment from his hammer-
head 111 the left eye. I saw him at the Wills Hospital three
hours later and found a small penetrating wound exactly at
the temporocorneal limbus on the horizontal meridian. The
media were transparent, the pupil was slightly distorted or flat-
tened at the temporal side, and the corresponding portion of
the ins did not react to light and shade, possibly from injury
to Its periphery in the region of the penetrating wound, but no
break in its continuity could be demonstrated. There was a
laint irregular line at a corresponding point in the pupillary
space, apparently a crack in the anterior capsule, but the lens
was tran.sparent. The pupil dilated widely under cocain and
atropia. The ophthalmoscope, with -)-6 D., the eye being
turned strongly downward, revealed a glistening metallic body
lying deeply in the eye-ground, apparently oblong in form,
with a quadrate end projecting backward along the vertical
meridian, the forward end being lost to view in the lower cili-
ary region. Vision, O.D.=6/vi. O.S. = 6/xxiv. Immediate
operation was advised. Ether was administered, the ball
seized with fixation forceps, turned strongly upward, and a
meridional incision, (J mm. in length made with a cataract
kuite, parallel with and along the estimated temporal border of
the inferior rectus muscle, beginning near the equator of the
ball and carried forward. The point of the knife was fine and
sharp and was made to enter the ball vertically to its tangent
at the point of entrance in order to avoid as far as possible any
danger of pushing the choroid and retina before it. A small
tJead of vitreous immediately presented, but there was no vis-
ible hemorrhage, as both cocain and a solution of adrenal
' Read before the American Ophthalmological Society, July, 1902.
September 13, 1902J
EXTRACTION OF METALLIC FRAGMENTS
[Amkkican Medicine 415
chlorid, sj^s. had been instilled before the section was made.
The short tip of the Hirschberg magnet was then introduced
just within the lips of the wound and the current turned on. It
was allowed to remain a moment and then withdrawn with the
particle of metal clinging to it. There was no reaction follow-
ing and the patient was discharged from the hospital on the
tenth day, the eye having at no time suffered any pain or shown
any considerable injection, V = 6;vii. The media were trans-
parent, the rent in the capsule having closed immediately, and
there was no notable external scar at the site of the operation
for extraction. There was a small cruciform scar at the site of
the foreign body in the fundus, surrounded Ijy a few pigment
masses. The hemorrhage, if any, from the incision in the
clioroid and retina, was at no time demonstrable. The patient
has returned from time to time as an outpatient, but vision is
unimpaired and the eye has remained well. There was at no
time any evidence of retinal separation or vitreous opacities
which might produce it.
Case II.— Fred Neidhart, aged 31, came to Wills Hos-
pital August 14, 1901, with a note from his physician, Dr. Seiple,
of Allentown, Pa., stating that on August 3, 11 days previous,
he had received a piece of steel in his right eye. He had been
treated with atropin and cold compresses, V = 6 Ix. The
wound of entrance was 3.5 mm. in length, vertical in direction,
5 mm. from the inner and upper quadrant of the corneal
limbus. The lens was transparent, but there were vitreous
opacities, and the location of the foreign body could be made out
as an opaque splotch, anterior to the equator in the upper and
inner quadrant of the globe. The man was admitted to the house,
ether administered, the wound of entrance reopened and
enlarged upward and backward, and the tip of the Hirschberg
magnet introduced and projected slightly in the direction of the
known locality of the foreign body. When withdrawn the
foreign body was found lying in the lips of the wound and
removed. There was some reaction following, which slowly
subsided under cold and atropia, and the man was discharged
from the hospital on September 6 with V = ()'xxi. He returned
Horizontal
section.
Side view
Front view ^^^ view
Front view
Fig. l.—B, foreign body, size 2 X 1 mm. Situation, 8 mm back of center
of cornea, 7 ram. above horizontal plane, 8 mm.
to nasal side of vertical plane.
Fig. 2.— B, foreign body, size 2x1 mm. Situation, 19 ram. back of
center of cornea, 9 ram below horizontal plane, 2
mm. to na.sal side vertical plane.
as an outpatient from time to time, but had no further trouble.
There was a stellate white scar visible with the ophthalmoscope
in the vicinity of the scleral puncture.
Case III. — J. C, aged 2), carpenter, Wills Hospital, Novem-
ber 29, 1901. On November 27 a fragment from his steel chisel
struck the right eye, entering the cornea on the horizontal
meridian just to the nasal side of the corneal pole. The wound
of entrance was linear and about 2.5 mm. in length. The lens
was swollen and opalescent ; a portion of the upper nasal
quadrant of the pupillary rim of the iris had been torn away,
leaving a ragged, incomplete coloboma. There wa.s no reflex
from the fundus, the vitreous probably being discolored by
blood. The approach of tlie magnet to the ball caused pain.
The man was sent to Dr. Sweet for a skiagraph, who reported
the presence of a foreign body 1 x2 mm. in size, situated 7 mm.
above the horizontal plane of the ball, 8 mm. back of the pole
of the cornea, and 8 mm. to the nasal side of the vertical plane
(Kig. 1). The patient refused operation until December 2. He
was then admitted to the hospital, etherized and a meridional
section made over tlie indicated site of the foreign body, which
was withdrawn upon the tip of a Hirschberg magnet. Ice
compresses were applied at once, but there was no reaction, and
two (lays later the eye was nearly white. Two months later
there had been no pain nor trouble of any kind. Tlie lens was
partially absorbed and V-^l/xxv. There was no evidence of
retinal separation.
Cask IV.— Wm. K., aged 28, laborer. Sent by Dr. Work, of
BethUhem, Pa. Came to Wills Hospital December 27, 1901,
and stated that he had l)een struck in the right eye iiyaplece
of steel on December 23. The pupil was 4 mm. in diameter but
tlie eye had been treated with atropia and cold compresses.
There was a vertical linear scar on the vertical meridian of the
cornea 3 mm. long extending to the limbus. The lens was
transparent except a gray, snowflake posterior polar opacity
which did not appear to be traumatic in origin and may have
been present before the entrance of the foreign body. No satis-
factory study of the fundus could be made, due apparently
quite as much to vitreous haziness as to the polar cataract.
There was marked ciliary injection, and chemosis of the con-
junctiva at the temporal aspect of the globe, V = 6'xlviii. He
was sent to Dr. Sweet for a skiagraph, who reported a foreign
body 19 mm. back of the pole of the cornea, 9 mm. below the
horizontal plane and 2 mm. to nasal side of the vertical plane,
and sent the accompanying diagram (Fig. 2, «, 6, c). On Decem-
ber 30, under general anesthesia, the ball was rotated strongly
upward and a Uraefe knife inserted behind the equator of the
globe at the nasal border of the inferior rectus and a merid-
ional section made 5 mm. in length. The short tip of the Hirsch-
berg magnet was introduced just within the lips of the wound,
allowed to remain a moment and was then withdrawn, leaving
the foreign body in tlie wound, which was tlien picked out by a
second application. There was no reaction until 30 hours later,
when pain, due to a smart iridocyclitis developed, which rap-
idly subsided under local bloodletting, cold compresses and
atropia. Six days after the extraction, the polar opacity re-
mained unchanged, but the patient said vision was clearer. The
man was discharged from the hospital on January 24, 1902, with
the eye free from injection. A dull view of the fundus could be
had with the indirect image showing a linear scar at the site
from which the foreign body had been removed, surrounded by
a maroon-colored band, evidently the remains of a choroidal
hemorrhage.
It will be observed that in all of the.se selected cases
the exact location, and in two of them an approxima-
tion of the mass of the fragment of metal was known,
in two of the cases by ophthalmoscopic examination,
while in the others it was located witli great precision
by Dr. Sweet, as set forth in his skiagraphic diagrams.
Without this knowledge of the location of the foreign
body the methods pursued for their removal would not
have been practicable.
Before the discovery of the skiagraph the method
pursued would have been feasible only for the compara-
tively rare cases in which the foreign body can be located
with the aid of the ophthalmoscope or possibly by the
sensation of pain produced when the tip of the magnet
is made to approach that part of the globe contiguous
to the metal fragment. Since modern science has made
it po.ssible to localize these bodies with such exactitude,
any discussion of the subject is not complete which fails
to recognize this as an important factor.
A number of questions present for consideration. In
each of the cases reportetl it is probable that the
giant magnet would have drawn the foreign body for-
ward til rough the vitreous body, the suspensory liga-
ment or zone of Zinn, and so onward through the
posterior into the anterior chamber. Once in front of
the iris a corneal section could have been made for its
final extraction. There can be no question, I think, but
that this method would have been better than to have
made a scleral wound at random, through which the tip
of a feeble magnet could be inserted more or less deeply
in the vitreous to blindly search for a piece of metal sup-
posed to be present somewhere in the vitreous chamber.
The problem before the surgeon is, however, quite
different when not only the presence of a foreign body
is known, but its exact locality and approximate size.
The (juestions, therefore, which remain to be .solved by
the surgeon are of a different import and cluster about
the relative amount of injury likely to be done to the
eye by the different procedures which may be adopted
for the removal of a foreign body, the presence, exact
location and size of which are known.
The procedure employed in each of the four cases
presented was practically identical, viz., a scleral punc-
ture at the known site of the foreign body, the shallow
insertion of the tip of a relatively weak magnet and the
successful withdrawal of the fragment. Fortunately the
result was all that could have been expected in each case.
Now it cannot be denied that certain deflmte dangers
cluster about any surgical procedure which involves an
incision through the .sclera, lamina fus«i, choroid, and
retina. In the first place it opens the eyeball, which is
always to be deprecated as a possible source of infection.
416 AlCBItlCAN MBDICINS;
EYESTRAIN AND EPILEPSY
(September 13, 1002
A l)ead of vitreous usually presents, and this, together
with the hemorrhage which must follow the cutting of the
choroidal vessels, may interrupt the subsecjuent prwesses
of repair in the retinal wound by flowing between the
retina and choroid and so clause a retinal detachment. In
any event, however favorable the healing may be, there
will be a scar, and therefore a circumscrii)ed blind spot at
the site of the wound. It is true that these dangers may
be reduced to a minimum by a.septic precautions and by
a small, always meridional, incision ; that is to say, an
incision parallel with the direction of the choroidal and
retinal vessels which will reduce the hemorrhage to a
minimum as compared to an equatorial section which
would cut across these vessels. Then, too, a meridional
scleral wound gaps less than when made equatorially.
In no case, notwithstanding the theoretic dangers men-
tione<l, have I seen any considerable hemorrhage or any
detachment of the retina. It is worthy of inquiry
whether these probabilities of permanent injury to the
eye which have been enumerated are greater than those
presented by extraction through the anterior chamber
with the aid of a powerful magnet. In Case I, for
example, the most favorable of the group for this pro-
cedure, since the injury was recent and the foreign body
could not therefore have been fastened in situ by inflam-
matory products, there can be no question but that the
giant magnet, placed near the pole of the cornea, would
have drawn the fragment into the anterior chamber if
manipulated with skill on a tractable patient. The frag-
ment of steel was lying in the bottom of the eye and
resting on the retinajust back of the ciliary processes. The
magnet, therefore, must have dragged it with its sharp
and ragged edges forward through a hitherto uninjured
portion of the vitreous, over the ciliary region and
through the suspensory ligament or zone of Zinn, thence
through the posterior chamber between the iris and lens,
necessitating its gliding over a portion of the delicate
anterior capsule of the lens before emerging into the
aqueous chamber. On the way there would be danger
of entanglement in the ciliary processes, or the posterior
surface of the iris, or of injury to the lens capsule. But
once safely through these possibilities, it would remain
to make an opening in the cornea for its final delivery.
This would involve the opening of the ball, the empty-
ing of the anterior chamber and the dragging of the for-
eign body away from a close imprisonment between the
iris and cornea, and the consequent traumatism to these
tissues, not to mention the possibility of hernia of the
iris or anterior synechia during the process of repair.
Added to these considerations is the additional possi-
bility of the foreign body having been impure, so that
the dangers of infection would have been greatly en-
hanced by its progress through a neAv and hitherto unin-
jured pathway through the tissues. In Cases II, III
and IV an additional factor was introduced. The for-
eign body had been present long enough to become fast-
ened to the retina by inflammatory products. It is
proljable that to have dragged these inward away from
their attachments would have endangered retinal separa-
tion and hemorrhage quite as much as a meridional sec-
tion through the sclera at the site of the foreign body.
These are questions which it is probable can be de-
cided definitely only in the light of extended experience,
but which have seemed to the writer of sufficient im-
portance to be presented to the society for consideration.
This much, however, may be said by way of conclu-
sion, that in the present state of our experience, in ab-
sence of definite knowledge as to the presence or exact
location of the metallic fragment, the powerful giant
magnet is an invaluable aid ; but that, given the knowl-
edge afforded by the skiagraph in exactly localizing the
foreign body, the less powerful instruments are efficient,
less costly, and more convenient in the daily routine of
office and hospital practice. It remains to be shown by
extended statistics which procedure will best conserve
the integrity of the eye.
EYESTRAIN AND EPILEPSY :
REPORT.'
A PRELIMINARY
BY
GEORGE M. GOULD, A.M., M.D.,
of Philadelphia, Pa., and Westfleld, N. Y.,
AND
ARTHUR G. BENNETT, M.D.,
of Buffalo, N. Y.
P^or the purpose of making a test as to the possible
influence of eyestrain upon the etiologj' and cure of epi-
lepsy, Dr. Gould had requested of Dr. William P. Sprat-
ling, superintendent of Craig Colony, Sonyea, N. Y., the
privilege of diagnosing the ametropia, etc., in a certain
number of casesof patients of the colony, and of prescrib-
ing spectacles for such as seemed in need of them. 'Dr.
Spratling and the trustees gladly accepted the off'er, and
the trustees voted $100 toward defraying the expenses of
the spectacles.^ Dr. Bennett consented to associate him-
self with Dr. Gould in the tests and in drawing up the
final reports.
The examinations of the eyes were begun on August
18, 1902, and continued for five days.
■ This preliminary report is published in order to show
those interested the object in view, th6 enormous pro-
portion of epileptic patients suffering from morbid
optical conditions of the eyes, and if possible to incite
similar tests by others.
We examined in all 78 patients, the youngest 10,
the oldest 59 years of age, the majority being young or
middle-aged adults. Of these 78, two were excluded
because of organic diseases of the eyes which rendered
them useless for the purposes of the tests in view. Five
more were excluded because of the impossibility, due to
psychic or ocular amblyopia, of diagnosing the ametro-
pia. This left 71 cases. Of these 3 were excluded be-
cause the ametropia was of so low a degree that it was
thought negligible. These patients needed no glasses,
either for the relief of ocular conditions or of reflex re-
sults. Only about 4fc, therefore, 3 out of 71 cases,
seemed to us to have eyes so near normality of optical
conditions that they required no further attention.
Our tests, therefore, concern 68 cases, 3.5 men and 33
women. These were chosen for us by the superin-
tendent regardless of all conditions of epilepsy, age, etc.,
except that we requested that only patients be given us
who were sane, and who could read.
The errors of refraction were estimated only after
thorough paralysis of the accommodation by means of
homatropin and cocain. Dr. Bennett diagnosed the
muscle-imbalance, made the opthalmoscopic examina-
tions, and estimated the refractive errors objectively by
means of the retinoscopic method. Dr. Gould made the
subjective refraction and accommodation tests, and
dictated the prescriptions. The subjective tests were in
all cases those finally relied upon when the patients'
answers could be trusted, and the results seemed the
more accurate. Of the 68 cases there were :
13 cases, approximately 20^?-, of myopic or compound myopic
astigmatism.
54 cases, approximately 80%, of hyperopia or compound hyper-
opic astigmatism.
33 cases, approximately 50%, of unsymmetrie astigmatism.
15 cases, approximately 22%, with normal acuteness of vision
(with correction).
23 cases, approximately 34%, with moderately subnormal acute-
ness (with correction).
30 cases, approximately 44%, with 20/40 vision or less (with cor-
rection).
3 cases only had regular, isometropic, compound astigmatism.
1 case only had simple regular astigmatism.
1 case only had simple hyperopia.
0 case had simple myopia.
' Published with the kind consent of Dr. William P. Spratling,
Superintendent of Craig Colony.
2 The Buffalo Optical Company, of Buffalo, offered to furnish the
spectacles at cost, and besides this they sent a member of the flim
twice to the colony to attend to the optician's work. Drs. Uould and
Bennett gave their professional services gratis.
SEiTEMBER 13, 19021
SUMMER DIARRHEAS OF INFANTS
^AilEBiCAN Medicine 417
9 cases were absolutely isometropic, i. e., about 77% had ani-
sometropia.
The muscle-imbalances of any hi<irh or complicating
sifrniftcance were unexpectedly absent. Indeed, in but
one case did we think them worth consideration, so far
as final correction was concerned.
The a-stonishing fact, and one that we think deserves
most serious attention, is the enormous proportion
among these patients of cases of injurious astigmatic and
anlsometroplc defects ; 07 of 68 cases had astigmatism ;
and it is most noteworthy that about one-half of the
entire number of patients had unsymmetrlc astigmatism,
a defect which almost inevitably produces the most
injurious results upon cerebral and assimilative function.
This terrible incidence of unsymmetrlc astigmatism in
epileptics is, we judge, 20 or mere times as great as
in ordinary patients. We do not say that these high
and most Injurious ametroplc defects caused the epilepsies
of these patients. That can only be determined in the
future by the careful records of seizures to be kept and
compared with those of the past. If none of the
patients is cured by the relief of eyestrain it would
still not disprove the theory that in a certain number
the eyestrain might have been the initial cause. And
even if this should ultimately be shown an error, the
duty of the State and the philanthropic to relieve these
patients of the other morbid effects of these atrocious
optical defects Is one that to longer defer becomes the
greatest cruelty. We have no hesitancy in saying that
.sewing or other hand work, without proper glasses, with
very high and irritating unsymmetrlc or other astig-
matisms, and with anisometropia, is ruinous to health
in one or several of many ways.
THE ETIOLOGY OF THE SUMMER DIARRHEAS OF
INFANTS : A PRELIMINARY REPORT.
BY
C. W. DUVAL,
of Annapolis, Md.,
AND
V. H. BASSETT,
of Baltimore, Md.
(FKOM the laboratory of THE THOMAS WILSON SANITARIUM AND
THE ROCKEFBLLEB INSTITUTE OF MEDICAL RESEARCH )
We desire to make a brief preliminary report of an
investigation, conducted under a grant from the Rocke-
feller Institute of Medical Research, upon the summer
diarrheas of infants. We are indebted to Professor Flex-
ner for his Interest in our work and the jiromotion of
the investigation. This research was made at the
Thomas Wilson Sanittirium, Mount Wilson, Baltimore
county, Maryland, a charitable institution where several
hundr*^ infants sick with summer complaint are treated
each season. We wish to express our thanks to Dr. J.
H. Mason Knox, physician in charge, for the oppor-
tunity of studying these awes.
A careful study of the bacterial flora of a numter of
these cases was made, and from 42 typical cases of sum-
mer diarrhea we succeeded in isolating from the stools
Bacilliig di/xenferke Shiga. The specific organism was
secrured, also, from scrapings of the intestinal mucosa at
autopsy, and in one case from the mesenteric glands and
liver. The dysenteric bacillus was present often in
large numbers in the stools of acute cases, but was
.secured with ditticulty from cases of mild character
and those of long duration on account of Its pres-
ence In relatively small niimbers and the antagonism of
the normal intestinal bsicterla. The specific bacilli iso-
lated from ditlerent cases of the disease are Identicjil,
and agree in morphology, cultural features, pathogenic
properties, and reaction to specific serum with the dysen-
teric bacillus isolatetl fwm cases of acute dysentery in
adultts by Shiga In .Japan, Flexner and Strong in the
Philippines, Kruse in Germany, and lately by Vedder
and Duval in this country. Agglutinative reactions
were obtained when the organisms were tested (a) with
the blood serum of the patients from whom they were
secured, (6) with theserum of other infants suffering from
summer diarrhea, (c) with the serum of adult patients
with acute dysentery, (d) with antidysenteric immune
serum. The specific bacillus was not found in the stools
of 25 healthy children, nor of those suffering with
simi)le diarrhea, marasmus and malnutrition ; nor
did the blood-serum of these latter individuals aggluti-
nate the dysenteric bacillus.
We believe our findings justify us in the conclusion that
the summer diarrheas of infants are caused by intestinal
infection with Bacillus dysenterke Shiga, and therefore
are etiologlcally identical with the acute bacillary dysen-
tery of adults. The cases studied, from which the
dysentery bacillus was isolated, include examples of
so-Ciilled dyspeptic diarrhea, of enterocolitis, and of mal-
nutrition and marasmus with superimposed infection.
A full report of our investigation will be published
in the Journal of JExperimenfal Medicine.
ARE THE SPECIFIC BIOLOGIC PROPERTIES OF
MILK CONCERNED IN NUTRITION?'
BY
C.\RLYLE POPE, M.D., and TORALD SOLLMANN, M.D.,
of Cleveland, Ohio.
The work of Bordet on milk and blood-serum has
opened new fields for thought and investigation. His
discovery of the specific biologic property of milk might
be thought, for instance, to be connected with nutrition,
and to furnish a plausible explanation of the limited
success attending the u.se of cow's milk in infant feedings
Our experiments were made with the intention of
throwing light on this question.
Bordet,' whose results were confirmed by Schiitze,^
found that if an animal was Injected with cow's milk
the serum of the animal acquired after a time the ability
to coagulate the protelds of cow's milk, but did not
affect those of human milk and goat's milk. Other
animals were Injected with human milk and goat's milk
and the serum always reacted with the kind of milk used
for injection and with no other. Flsch ' obtained the
same results by injecting an emulsion of cells from the
udder, Instead of milk.
In starting our experiments we first ased two rabbits
to confirm the results of Bordet and Schiitze for our own
satisfaction.
Rabbit " a " was injected subcutaueously with cow's milk.
We made three injections of 24 cc. eaeli at intervals of throe and
four days. About two weeks after the last injection the serum
of this rabbit, treated as described by Schiitze, coagulated the
proteids of cow's milk but ^ave negative results with human
milk. Rabbit "b" was injected with human milk. This
animal had four injections of 12 cc. each, and aljout a week after
the last injection the blood was drawn. The serum in this case
coagulatea the proteids of human milk and did not affect tlio.se
of cow's milk. The tasts were made by diluting the milk with
water in tlie proportion of 1 to 20, and adding 1 cc, of serum to
2 cc. of the diluted milk. When the reaction was positive the
precipitate could be detected in from five to ten minutes after
the serum was added. It first appeared as a linely-<lividod
coagulum which, iu the course of half an hour, became lloccu-
lent, and gradually settled to the bottom of the tuljo. Deflbrin-
ated blood gave the same results as the serum, but the precipi-
tate was more or less obscured by the presence of the corpuscles.
After keeping the serum on ice for a week it still reacted as
readily as when fresh.
In milk which was heateil to 167° F., the temperature ordi-
narily employed for Pasteurization, the ability to react with the
serum appeare<l to be unimpaired. After bringing milk to the
boiling point in a test tube we were able to demonstrate that it
did not react quite as readily with the serum, but tlie difference
was not striking. Sohiitze found that milk exposed to a tem-
perature of 212° P. for half an hour lost in part ito power to
react with the serum.
> Kxperiinents from the Pharmacologic Laboratory of Western
Keserve Medical College.
418 Ahkbican Medioihej
LOSS OF SLEEP
[Beptbmbeb 13, 1902
We thought it interesting to determine whether the
presence of the uclder cells in situ induced the same
specific modification of the serum of the cow as they
induce In the serum of the rabbit when injected into this
animal. We therefore added serum of cow's blood to
cow's milk, but no precipitate appeared in the usual time.
We then performed the special experiments which
we had in mind.
Two rabbits, " c," we injected with cow's milk which had
been raised to the boilinjf point. They were given five injec-
tions of 12 cc. each at intervals of three or four days. The
serum of these rabbits produced coagulation of the protoid the
same as in tlie case in which raw milk was used— that is to say,
the serum coaculated the proteids of cow's milk, but did not
affect those of human milk.
Two other rabbits, " d," were fed with cow's milk, which
they took readily. About 500 cc. was the daily quantity allowed
for both, and the feeding was continued for more than three
weeks. The serum of both these rabbits gave negative results,
Eroducing coagulation of the proteids neither in cow's milk nor
uman milk and behaving exactly like the serum of a normal
control rabbit which we tested at the same time.
The fact that the specific modification of the serum
cannot be induced when the milk is given by the stom-
ach renders it doubtful wheth'er this property is in any
way concerned in the nutritive value of the milk. For
the only property of this hypothetical substance which
we know is precisely that of producing these changes in
the serum, and this property does not appear when the
substance is given by the mouth. That this particular
property is connected with other properties valuable in
regard to nutrition is hypothetically possible, but it is
certainly not supported by any experimental evidence.
We may also say that these experiments throw no light
on the obscure changes produced in milk by sterilization,
for, as we have seen, heating to the boiling point does
not destroy the specific quality of the milk either as
regards its effect on the serum or the effect of the modi-
fied serum upon it. The milk and serum reactions,
therefore, although of great scientific interest, do not
seem to lend themselves at present to the solution of any
of the questions which are suggested by the specific
nutritive quality of the milk.
BIBLIOGRAPHY.
lAnnales de I'Institut Pasteur, 1898, xli.
2Zeit8chrlft fflr Hj'glene und Infectionskrankheiten, 1901, Band 36.
sbt. Louis Courier of Medicine, February, 1900.
LOSS OF SLEEP.
BY
J. ALLEN GILBERT, Ph.D., M.D.,
of Portland, Ore.
It has long been a wellknown fact that physiologic
and psychologic processes are changed materially during
sleep, and yet comparatively little experiment has been
directed toward ascertaining the effects of loss of sleep as
such. To exclude secondary agencies the insomnia must
be voluntary or at least enforced. Otherwise it becomes
secondary rather than primary in the consideration, for,
as a rule, in practice back of loss of sleep is to be found
an underlying pathology to account for the insomnia.
Difiicully in concentration of the attention when
sleepy suggested to me the experiments which furnish
the data upon which the present article is based. M. de
Manac6ine reported in 1894 some experiments upon
dogs in which the animals died at the end of the fourth
and fifth day under enforced insomnia. One of the most
severe punishments at one time in the code of the
Chinese was death by enforced insomnia. It is said of
one of the victims that after eight days had passed with-
out sleep he pleaded to be hanged, strangled, quartered,
burned or killed by any means whatever, that he might
be relieved at once from his extreme torture. He died
at the end of 19 days. To my knowledge no experi-
ments on enforced insomnia had been tried systematic-
ally on the human subject, and realizing that the
experiments would not be entirely devoid of discomfort
and perhaps danger, I subjected myself to the first pre-
liminary set of experiments to which two of my fellow
teachers submitted subseciuently. Professor G. T. W.
Patrick, professor of philosophy In the University,
assisted in the taking and publishing of the original
data. In reporting the results at that time our aim was
more particularly psychology and it was thought best to
deal with each subject separately, and not try to present
an average, as there were only three subjects experi-
mented upon. Since publication, further investigation
of the data shows that by striking a general average,
even though there be only three subjects, the results are
so significant as to justify their presentation in medical
literature. For individual data and minor details I
must refer the reader to the original article in A'ol. I of
the "Studies in Psychology " of the University of Iowa,
1897. The present article, for sake of brevity, must be
confined to general descriptions and deductions.
The subjects, three in number, were all in good health,
unmarried, aged 28, 27 and 24 years, and respectively
at'customed to 8, 9 and 8 hours' sleep each night. All
three were regular in habits and ideal subjects for the
experiments.
The plan of the experiments was as follows : To keep
the subjects awake continuously for 90 hours, to make a
series of physiologic and psychologic tests upon them at
intervals of six hours, testing pulse, temperature,
weight, power of grip, pulling (lifting) power, reaction-
time, reaction-time with discrimination and choice,
acuteness of vision, acuteness of hearing, memory, addi-
tion of figures, naming of letters (perception), voluntary
motor ability, fatigue and pulse as influenced by exer-
cise, the amount of urine, nitrogen and phosphoric acid
excreted each hour. The depth, character and amount
of sleep subsequent to the abstinence from sleep were
also investigated. Aftersleeping subsequent to the
sleep fast, the full set of experiments was repeated for
comparison. The subjects took their regular meals at
7 a.m., 12:30 p.m and 6 p.m. In addition a very light
lunch was eaten at 12:30 a.m. The appetite throughout
the tests showed but little, if any, variation from the
normal. Constant watch was maintained over the sub-
jects by one guard during the first two days and by two
thereafter. Often walking, playing games, etc., had to
be resorted to in order to keep the subject awake, but so
nearly as possible the occupations were made to conform
to the normal daily work of the subject. The taking of
each set of experiments, however, took nearly two
hours, and thus being repeated every six hours, one-third
of the time, both day and night, was occupied in this way.
The sleep fast in the case of the first subject lasted 90
hours, from 6 a.m. Wednesday till Saturday at mid-
night ; that of the last two was 88| hours, beginning
Tuesday, March 17, at 7 a.m. The time was thus
slightly shortened because of a sudden fall in the tem-
perature of one of the subjects near the close of the time
determined upon. On Friday, at 9 p.m., after a brisk
walk in the cool air, his temperature sank to 35.3° C.
(95.6° F.), but in 15 minutes rose again to 36.3° C.
(97.3° F.), when the last set of experiments was taken
and the subjects retired. Daily rhythm in sleepiness
was well marked, the sleepiest period being about
dawn. During the afternoon and evening sleepiness
was less marked. Persistent hallucinations of sight
occurred in one of the subjects, which, however, disap-
peared entirely after sleep.
A brief explanation of the tests is necessary to an
understanding of the data given in the table and charts
following.
The pulse was counted at the beginning of each
set of experiments, and also at the end of each set just
after the last test, which was for fatigue produced by
tapping as rapidly as possible for 60 seconds with the
forefinger. Temperature was taken in Fahrenheit and
changed to centigrade. Weight expressed in kilos
was taken the same time after each meal and in
Skptember 13, 1902J
LOSS OF SLEEP
[American Medicine 419
the .same clothing. Grip was taken in kilos with an ordi-
nary hand-dynamometer, which, it might be added,
was unsatisfactory, in that it made the hand sore and
it was impossible to grasp it each time in exactly the
same way. Pull, in case of the first patient, was taken
on the same hand-dynamometer, pulling with the
TABI.E I.
First Day.
1. Pulse
2. Temperature (C.)
3. Weight (kilo.)
4. Grip (kilo.)
5. Pull (kilo.)
6. Reaction- time!
(seconds). I
7. Reac tlon-timei
wltli discrimina-
tion and choice
(seconds).
8. Acuteness of vis-
Ion.
9. Discrimination of'
sound. j
10. Memory 1 143
U. .\ddltionofflgures|
12. Naming of letters.
1.3. Voluntary motor!
ability.
14. Fatigue (percent!
of ioss).
1.'). Pulse after fatigue
75.0
36.68
67.74
41.43
137.21
.129
198
10.4
171
40.4
20.9
79.7
3 p.m.
73.6
36.41
68.17
40.45
146^9
.138
.203
115 4
16.3
122
144
170
38.4
18 2
73.0
9 p.m.
68.6
36.43
68.35
40.14
143.89
.141
.251
119.6
11.3
120
166
162
37.0
21.3
73.6
Second Day.
3 a.m.
63 6
36.69
68 06
37 36
127.65
.138
.189
1:9.7
18 0
180
169
159
38.3
22.2
72 3
9 a.m. 3 p.m
74.0
86.78
68.13
40.' 3
87.89
.138
.201
132.2
17.8
150
159
173
40.7
25.5
77.6
70.6
37.04
68.34
38.83
115.67
.137
.198
136.5
14 0
140
158
1.59
39.7
23.1
70.0
Third Day.
Fourth Day.
9 p.m.
3 a.m.
9 a.m.
3 p.m.
9 p.m.
3 a.m.
9 am.
3 p.m.
9 p.m.
71.0
36.67
68.50
34.17
116.80
.139
71.8
36.17
68 50
29.03
96.39
.161
72.3
;M55
68.38
36.74
113.85
.U3
63.0
36.54
68.45
38.40
101.38
.137
64.6
38.41
68.63
88.71
100.93
.142
640
36.50
68.76
;«.40
81.42
.138
69.6
36.71
68.28
39.16
81.42
.140
68.3
36,28
68.41
42.56
103.18
.151
ft5.6
86.09 1
68.64
88.3:5 1
94 13
.194
.204
.201
.191
.212
.187
.172
.191
.173
.215
124.7
118.4
129.1
126.4
131.2
129.4
133.1
136.5
143.5
16.5
24.3
18.5
16.0
22.2
25.5
22 8
19.9
25.0
188
161
146
34.0
151
183
136
36.2
116
1.50
15.5
38.2
2.53
148
155
38.0
193
166
141
37.3
202
312
124
36.9
480+
144
152
40.7
373
188
142
39.7
7;«+
233
117
37.9
13.9
21.3
20.7
27.4
19.4
18.2
21.4
22.6
25.0
66.3
64.3
71.0
67.0
.57.6
61.3
70.0
640
61.0
o
<Xl.
75.6
86.87
67.97
41.88
124.74
.187
.201
126.7
19.0
97
165
179
41.1
20.5
87.6
-ZBEroNirflritun
/trrr.H TsTidUt
3P ^p lA 9^ JP it^ ii fn 3^ fP
''Vwi W f " >* i^ f " y^"Tr >>■ U
T^ 7F*~f^~
Timvinm tint.
DiscRimiriRTiofi " Sounn.
"iwiPiniP 3' 91 IP IP in 1A If fp ill fn ap ♦«
»Mf
.ni
,u
—UtAcTiom
'♦o Cwoitt.
"i
!wn JW if )» f» n »t M »A n M J» fA JV tp
/KiiYtma "IxTTtRs.
'^lOtiiHIi^ 3* H if iW H »* iP tfi >A >A J>» tp
K, Experlmentfl taken after sleeping. The arrow indi-
cat*m the last set of e.\|ierlment« before sleeping.
t In the chart on Mcinorj', indicates that one of the sub-
jects at these points tailed entirely to commit the figures of
^ one set; and hence the avernce time required should be
■ even larger than represented By the chart.
second finger J5 of
each hand. In the
last two patients it
was taken upon a
lift-dynamometer,
recording in
pounds, which
were afterward
changed into kilos.
Reaction-time was
taken in thou-
sandths of a second
on the drum and
smoked-paper ap-
p a r a t u s , with
sound for the stim-
ulus. For reaction-
time with discrim-
ination and choice,
a modification of
the reaction-time
apparatus was
used, the subject
reacting to only
the louder of two
stimuli, which
were used for the
purpose of dis-
crimination.
Acuteness of vis-
ion was tested in
the dark-room by
finding the great-
est distance in
c e n t i m e t e r s at
which the subject
could read a sec-
tion of a page from
Wundt's "Studi-
en" by the light of
one standard can-
dle shaded from
the eyes and placed
2.5 cm. from the
page. Discrimi-
nation of sound
was intended to
show the acute-
nes.s of hearing by
420 AJfEBIOAN MKDICIHI)
LOSS OP^ SLEEP
TABI.K II.
Hours
Amount of urine per hour (oc.)
Grains N. per hour
Grams P.O., per hour
Relation "P.Oi to N
First I Second
Day. i Day.
24
58.7
o.ir,-
o.(mn
1:8.0
24
59.4
0.72.')
0.1053
1:«.9
ISeptekbeb 13, 1902
Third
Day.
24
61 4
0 075
0.0981
1:6 9
Fourth
Day.
13.8
64.0
0 034
0.1010
1:6.1
During
81eep.
13.6
31.6
0.414
0.0658
1:7.4
Firth
Day.
36.9
0 614
O0MO4
1:7 6
Hlxth
Day.
24
61.3
0 819
0.0818
1:7.6
l/nint ««HOV*
di.scriinination of the intensity of two sounds made tf)
vary in intensity by gradual increase of one sufficiently
until the sulyect could distinguish a difference in the
intensities of the two sounds. There being no unit of
sound the results
represent only
relative intensities
produced by varia-
tion in the strength
of current passing
through a tele-
phone receiver.
For the test on
memory in the
tirst subject the
Ebbinghaus non-
sense syllables
were u.sed, but
they proved unsat-
isfactory, and in
the last two sub-
jects 18 digits, I.e.,
two each of the
digits from one to
nine, were used.
A random order of
these figures, each
on a small piece
of cardboard, was
made and then
modified to pre-
vent adjacency of
the s a in e figure
and suggestive
combi nations.
The number of
seconds required to commit the list was noted by a
stop wate'h. This test was repeated three times on each
person in each set of experiments and the average taken.
Here also the data of the first suljiject are excluded in
that the test was a different one. In the test on addi-
tion the sheets of figures used by Miss Holmes in study-
ing fatigue in school children, and described in the
JPedagogical Se>ninar}/\o\. Ill, ^o. 2, were used. The
subject was required to add each set of 40 figures by
twos, setting down the results. He then added the
results and finally the original figures in a different
order. The tables give the number of seconds required
for the whole process. Naming of letters consisted in
naming the letters from right to left on a page of the
Psyehological Beview. The tables record the num-
ber of letters — average of two trials — named in one
minute. This test was not taken on the first subject.
Voluntary motor ability is the number of times the sub-
ject could tap with the forefinger in five seconds. He
tapped continuously for 00 seconds. The number of
taps during the first and la.st five seconds was recorded
by appropriate device on the apparatus, thus giving the
voluntary motor ability in the number of taps during
the first five seconds as well as fatigue calculated in per
cent of loss in number of taps during the last five
seconds. These two tests, as well as the grip test, were
negative in results. Through the kindness of Dr.
Rockwood, Professor of Chemistry and Toxicology in
the University, urinalysis was made daily in each sub-
ject to determine the amount of urine and the quantity
of nitrogen and phosphoric acid excreted per hour.
Analy.ses were made daily of the urine excreted during
the sleep fast, during sleep and the two days subsequent to
the tests. In the first subject analysis was made of only
one day's urine subseciuent to sleep. As one of the sub-
jects fell asleep with the greatest ease when left to him-
self, an attempt was made at the close of the sleep fast
to investigate the effect of external .stimuli upon dreams.
The subject was allowed to sleep 30 seconds, one minute,
two minutes,'etc., .stimulated in various ways, and then
waked and asked as to his dreams. If the period of
sleep was less than one minute the subject at times had
a hazy memory of a dream which could not be put into
words, thus confirming the accepted opinion that dreams
are due to light sleep. Once during the sleep fast while
standing with open eyes watehing a piece of apparatus
on which were some ropes his head suddenly dropjied.
The shock awoke him and he said that he dreamed that
he saw a man hanged. Other instances during the experi-
ments showed the rapidity with which one can fall asleep
under such circumstances and also the extreme rapidity
with which events are depicted in dreams.
An attempt was also made with the first subject to
determine the depth of sleej), but the stimulus nece.s.sary
to awaken him was so severe that the te.st was abandoned
in the last two subjects. Michelson's and Kohlsehiitter's
investigations on normal sleep show the greatest depth
of sleep to be at the end of the first hour. In the case of
our test after the sleep fast of 90 hours, the most pro-
found sleep came at the second hour after falling asleep.
By means of a current pas.sed through the ankle bj' brass
electrodes on a garter attached to an induction coil in an
adjoining room, the subject was awakened each hour
by applying the current to him with increasing strength
till sufficiently strong to awaken him. It was agreed
that the subject should ring a bell by a button at the bed-
side as soon as awake. The current was applied by a
pendulum, which gave the stimulus for .334 second each
swing. The current was gradually increased each
.swing till the patient awoke. At the end of the second
hour the full current at our disposal was applied without
effect. The full current was then applied continuously,
when the subject awoke with a shriek of pain, but did
not regain consciousness sufficiently to ring the bell.
The operator hastened to him, but when he got there the
subject was already so deeply asleep that calling in a
loud voice failed to awaken him. The next morning he
awakened voluntarily between two periods for stimula-
tion. His ankle wa.s burned black by the garter, and it
was altogether out of the question for the subject to
endure when awake the current which was jxjwerle.ss to
arouse him at the second hour of sleep. Depth of .sleep
reached the maximum at the second hour, and decreased
thereafter, but more slowly than is sliown in curves for
normal depth of sleep, as would be expected.
The length of time .spent in sleep after the sleep fast
was not as long as expectetl, the subjects having slept
only 10}, 12 and \b\ hours respectively. Pitch awakened
refreshed, and with no perceptible evil effects. The
shortness in length of sleep is counterbalanced no
doubt by the depth of sleep — a fact difficult to explain.
Though one is not justified in making general laws
from data ba.sed on so few subjects, yet the accompanying
tables and charts are so positive and significant that it
may not be out of place to call attention to a few of the
more salient iwints indicated by them.
September 13, 1002]
TREATMENT OF CARCINOMA AND SARCOMA iamebicas medicine 421
Pulse is lowered by progressive loss of sleep. For
the first 24 hours exercise increases tiie pulse-rate, but
as loss of sleep increases the same exercise decreases the
pulse rate. After sleeping the rat« rises again to normal
or sliglitly above and exercise again increases tlie rate of
pulse l>eat. Temperature is lowered by excessive loss of
sleep, tlie normal being regained after sleep. Weight
increases rather constantly with loss of sleep and de-
<Teases again after sleep. However, so many elements
may be instrumental in producing this result that too
much emphasis dare not be put on the statement.
Strength as manifested by lifting ability is marliedly
decreased by loss of sleep and reinstated by subsequent
sleep. Reaction-time and reaction with discrimination
and choice are affected but little until tlie expiration of
72 Iiours of wakefulness, when the time is noticeably
increased, sleep again decreasing it. Acuteness of vision
is increa.sed while acuteness of hearing is decreased by
Joss of sleep, each returning partially to normal subse-
quent to the period of sleep. Power of memorizing is
aflfected but little for 66 hours, after which time it rap-
idly becomes poor, at times entire control being lost,
suiisequent sleep, however, restoring the full normal
power. Rapidity of addition of figures follows some-
what the same law as power of memorizing, though not
to su'-li a marked degree. Perception, as indicated by
the lapidity of naming letters, is markedly dulled by
loss of sleep, full power being restored subsequent to
sleep. The amount of urine excreted per hour during
sleei) fast was nearly double that during subsequent
sleep. Comparatively little was excreted during the 24
hours immediately succeeding sleep, the usual amount
being excreted, however, during the second 24 hours
after sleep. During the sleep fast the amount increa.sed
steadily during the first 72 hours. That of the fourth
day, taken from 9 a.m. to 9 p.m., instead of for 24
hours, showed a decrease per hour, but being taken thus
on a different basis from that of the first 72 hours deduc-
tion on the same basis is impossible. Less and less nitro-
gen was excreted per hour during tlie sleep fa.st and
relatively very small amount during sleep with increase
in amount thereafter. The amount of phosphoric acid
excreted was increased during sleep fast, relatively very
small amount being excreted, however, during sleep,
the amount increasing again subsequent to sleep. Thus
the relative amount of nitrogen to phosphoric acid de-
creases as loss of sleep increases.
CASES OF CARCINOMA AND SARCOMA RECENTLY
TREATED BY ELECTRIC STERILIZATION.'
BY
G. BETTON MASSEY, M.D.,
of Philadelphia.
In a paper read before the American Electrothera-
l>eutic Association in September, 1900,' I reported a
series of 38 malignant tumors that had teen placed
under the cataplioric diffusion of electrolytic salts of
mercury and zinc for destruction and sterilization, with
the following results : In K cases a cure was obtained ; in
20 cases the local disease was removed, but the patient
succumbed ultimately to metitstases that were appar-
ently existent at the time of the application ; in 8 cases
the method, while still new, had failed to stay the prog-
ress of tlielocaldisea.se; and in two cases the patients
died during the treatment.
A review of these cases at the jiresent time shows
that one patient reported as cured, with recurrent carci-
noma of the breast and axilla, has died from metastatic
growths in the mediastinum without return of the local
disease ; the remaining 7 successful cases have stood the
1902
Head before the Philadelphia County Medical Society, June 25,
2 Trans. Amer. Electrotherapeutlc Anboc., 1900-1901.
Fig. 1.— Case XLI before treatment,
.sketched from description.
test of tM'o more years without redevelopment of the
disease.
Since the date of that paper 15 additional cases have
been treated by me up to April 1, 1902, each of which
will be described in this paper in the order seen, the
unsuccessful cases being but briefly epitomized to save
space.
Case XXXIX.— Miss M., aged .37, of St. John, N. B., was
first seen October 20, 1900, with a small growth above the right
canine tooth. She was referred to Professor Cryer, of the l^ni-
ver.sity, for diagnosis,
who reported the tumor ..•••■■•,._
to be carcinomatous. Un-
der repeated minor appli-
cations of zinc-mercury
cataphoresis, with fine
needles, the growth was
destroyed in about three
weeks. There has been
no return of the tumor.
Casb XL.— S. J. C,
aged 60, was referred by
Dr. C. A. Groff, of Phila-
delphia, January 22, 1901,
with a recurrent carci-
noma of the tongue and
floor of the mouth. The
tongue had been ampu-
tated by the knife opera-
tion but seven weeks be-
fore. This early return,
and the extensive and
deep infiltration that had
so quickly reappeared,
rendered all effort appar-
ently hopeless ; yet, to
give him a last chance,
lie was admitted to a pri-
vate room at the Presby-
terian Hosjtital and a
major application made to the affected parts, under general
anesthesia, .350 to 500 milliamperes being employed for 2J hours.
This resulted in considerable destruction of the diseased struc-
tures, l)ut not complete sterilization. The growth reappearing
later he was referred to Dr. lOdward Martin, who removed the
tissues of one side of the jaw and neck down to the larynx, with
only temporary benefit, the patient shortly succumbing to the
disease.
Case XLI. — Mrs. , aged 53, was first seen March 5, 1901.
At this time there was an irregular growth beneath and involv-
ing the right ear, that was about the size of a split cocoanut, but
irregular in shape. (Pig. 1.) The lower half of the ear was
fused in the growth, which extended forward on the cheek and
downward between the jaw and the nenk to the angle of the
lower jaw. The skin did not seem to be involved, thougli
ulcerated tlirough at one spot, but the immovable base showed
a deep infiltration into the structures of the neck. Owing to the
patient's unwillingness no photograph was taken. The history
of the growth showed an existence of 19 years, including recur-
rences after two ex-
tirpations with the
knife and one caus-
tic application.
The first cutting
operation was per-
formed by the late
Dr. Agnew. in 1884.
The second opera-
tion of tlie same
character was done
in 1891, by a well-
known surgeon,
assisted by Dr. Ag-
new ; in this opera-
tion the seventh
nerve was severed,
resulting in paraly-
sis of the right side
of tlie face. Real-
izing that I had to
deal with a malig-
nant growth of slow
progression, and
not prone to metas-
tasis, and also with
a patient unwilling
to take ether again,
I decided to try tlie
effect of the minor
method cfzincmer-
cury cataphoresis,
employing zinc
needles amalgamated with mercury aud thrust into the growth
vmdercocain diffusion. Small currents were therefore applied
Fig. 2.— Case XLI alter treatment.
422 AjKBioAN MEDicisB] TREATMENT OF CARCINOMA AND SARCOMA
[September 13, 1U02
daily in tiiis manner for 30 minutes at a time. This treatment lias
continued over a year, witii some interruptions, and is even
yet applied once a week through the tiny openings in the skin
where the growth was, but the patient is now practically
cured, a depressed cicatrix with soft edges occupying the site
of the extensive tumor. (F"ig. 2.) I shall keep these openings
patulous for a time yet, and continue occasional applications
to make sure that the last germ of the affection has been
destroyed. During the course of the treatment a piece of the
tumor was removed and sent to the Philadelphia Clinical
Laboratory, which gave a histologic diagnosis of carcinoma.
Case XIjII. — Mrs. L., aged 63, was first seen in March, 1901,
with a large cancerous ulceration occupying the site of the right
breast, the growth measuring 11 by 7 inches and extending
down to the intercostal sjiaces. The outer edge of the infiltrated
border extended well up into the axilla, but, though the apex
of this space was infiltrated and the arm swollen, no glandular
nodes were found. This growth was evidently one of the
slower-growing class in spite of its great extent, for it had been
an open ulceration for more than three years, and had been first
noticed nine years before. The patient's general health was
profoundly affected, as indicated by the photogriiph (Fig. 3),
she was confined to her room, pallid and apparently cachectic.
The absenceof glandular infection and its long duration was,
however, taken as an excuse to give her the chance ottered by a
major application. On April 2, 1901, assisted by Dr. Hermance,
she was etherized and the zinc and gold-mercury cataphoresis
applied by means of 600 to 700 milliamperes for 2J hours. The
patient was so weakened by the disease that she did not recu-
perate from the prolonged anesthesia for several weeks. Her
condition was, however, so improved by June 15 that it was de-
cided to attempt further treatment by daily applications of as
much as she could bear, applied to the extensive areas of still
profoundly diseased structure that could not be reached in the
first operation. From 60 to 150 milliamperes were therefore
applied with sharp zinc-mercury points during the remainder
of June and the whole of July. By August 5, the minor appli-
cations having become too painful, a second major application
was made under ether, assisted by Dr. Hermance and by Dr.
F. G. Du Bose, of Selma, Ala. Eight hundred milliamperes
were applied this time for 1 hour and 35 minutes, followed
by quicK recovery. By November the patient was well enough
to make a journey to Brooklyn. In January, 1902, it was, how-
ever, seen that an edge remained still diseased between the
shoulder joint and the clavicle. (Fig. 4.) A third application
was therefore made January 28, 1902, requiring 500 milliamperes
for two hours. The patient is now apparently well in every
respect, though the large surface that was denuded by the dis-
ease has yet a smaller spot nucicatrized than shown in the final
Fig. 3 —Case XLII after first application.
photograph (Fig. 5). Apiece of this growth was removed at
the first operation and suomitted to microscopic examination
at the University Pathologic Laboratory, which reported as
follows : " The specimen consists of large nests of epithelial
cells contained within a delicate stroma of fibrous tissue. Cells
present an epithelial appearance and completely fill alveolar
space. Surface of the tumor is necrotic and invaded by leuko-
cytes. Diagnosis: Medullary carcinoma simplex of breast."
Case XLIII. — Mr. C. A. W., aged 47, was brought to me by
Dr. J. T. Rimer, of Clarion, Pa., May 11, 1901, with a large recur-
rent sarcoma in the left groin and enlarged glands in the right
groin. The primary growth had been a sarcoma of the left
testicle, which had been removed August 7, 1900, the extension
to the groin being noticed three months after the operation.
The Coley serum had been thoroughly tried in this case, and
rcMulted in apparently holding it in check and improving the
general health for about six months. When seen by me the
growth meisured 8x5 inches in superficial diameters and lay
directly over the femoral artery, the compression of the femoral
vein being evidenced by great tumefaction of the thigh. The
Fig. 1.— Case Xlill after second application.
diseased glands on the opposite side had the same dangerous
situation. It was decided to try the cataphoric method, and on
May 12 he was placed under ether and from 800 to 1,400 milliam-
Eeres employed for three hours. The next morning I found
ira sitting up in bed reading a paper in spite of this prolonged
anesthesia and powerful current. The edema of the leg had
subsided. On the separation of the eschar it was, however,
noted that some diseased tissue remained in the bottom of the
cavity, and as the tumor in the right groin had not been reached
at the first application, he was placed under a second, one
month after the first. At this time 1,400 milliamperes were
again employed for three hours. He reacted well from this
operation also, but unfortunately a secondary hemorrhage
appeared in the site of the smaller growth, causing death on
the fifth day.
Case XLIV.— Mrs. J., aged 36, was brought to me August
5, 1901, by Dr. F. G. Du Bose, of Selma, Ala., with a very exten-
sive recurrent carcinoma of the right breast, the primary
growth having been removed by the Halstead operation eight
months before. The whole right side of the chest was infil-
trated, producing cancer en cnirasse, and the arm swollen to
twice its dimensions. In spite of the patient being almost in
extremis, it was decided to attempt palliation of the ex treme pain,
for which she had been taking 9 grains of morphin a day without
relief. Twelve hundred milliamperes were employed to diffuse
the mercury and zinc salts for three hours. This resulted in
such relief of pain that the morphin was shortly reduced to
less than 1 grain a day. Her general condition continued to
improve until the end of the third week, when sudden prostra-
tion occurred resulting in death, apparently from heart-clot.
Case XLV.— Mrs. X., aged 84, was referred by Dr. D. F.
Woods, of Philadelphia, September 9, 1901, suffering from a pri-
mary carcinoma of the nose, and a large secondary growth in
the neck. As the left eye was about to be eroded by the pri-
mary growth it was decided to remove it by cataphoric sterili-
zation, but not to attempt interference with the secondary
growth in the neck because of the great age of the patient. A
current of 200 to 300 milliamperes was accordingly employed
with zinc-mercury points, the duration of the application being
one hour. The disease was arrested in this situation.
Case XLVI.— The mother of a physician of Western Penn-
sylvania, aged 60, was first seen October 26, 1901, suffering from
a recurrent carcinoma in the ischiorectal region. The original
growth involved a portion of the sphincter, and had oeen
removed by a Pittsburg surgeon ten months before by a modi-
fied Kraske operation. When seen, a sinus was found to the
left of the anus with infiltrated and indurated edges, communi-
cating with a cavity about two inches in depth, the whole growth
being about the size of a lemon. The rectal mucous membrane
September 13, 1902]
TREATMENT OF CABCINOMA AND SARCOMA (akbkicak mkmcisb 423
was intact, and apparently healthy. At the application the
cavity was filled with liquid mercury, and into the mercury
was inserted a gold tubular electrode, amalgamated, the two
together constituting a mercuric electrode that accurately fitted
the cavity in the center of the growth. From 400 to 650 milli-
amperes were maintained for one hour and 50 minutes. Dur-
ing the passage of the current the induration melted down, the
progress of the sterilization being determined by the progres-
sive disappearance of the induration. The application was well
borne, destroyed the odor of the discharge and relieved the pain.
After the separation of the debris the cavity very nearly closed
by granulations. Her condition six weeks later was greatly
improved, but it was at this time thought best to make another
application, as a part of the wound had not healed and looked sus-
picious. On December 15 she was, therefore, again anesthetized
and the process repeated with 200 to 800 milliiimperes. It was
only necessary to keep up this application 40 minutes. In a
letter received from her son today he says: "I saw mother
this morning and she is quite weak. I do not think there is
any return of the growth, but there is some supi>uration, which
may have been caused by several small balls of mercury
sloughing out. Her weak condition may be due to the fact that
she has had influenza three or four times this spring."
Case XLVII.— Mrs. P., aged 65, was brought to me October
29, 1901, by her physician. Dr. Charles M. Dalsen, of Philadel-
phia, with a primary carcinoma of the right breast of two years'
known duration. The growth had begun in the lower and
outer (|uadrant of the breast, but at this time the whole organ
was infected. The skin was adherent over the center of the
growth and was about to break down. The growth extended
well toward the axilla, but no glands were apparently affected
in this situation. The patient was pale and in poor health, but,
apparently, not deeply cachectic. Under general anesthesia the
major cataphoric application was made October 30, 000 to 700
milliamperes being used for three hours. Convalescence was
uneventful, but revealed some disease still remaining near the
axilla. A second application was therefore made March 9, 1902.
The present condition is shown in the accompanying photo-
Fig. 6.— Case X 1 .
iliiiil iippllciition.
graph (Fig. 6) revealing a small and healthy scar. A ])iece of
the tissue was removed just prior to the first application and
sent to the Phila<lelphia Clinical Laboratory for histologic
examination. The report showed the characteristic grouping
of the epithelial cells in " nests." Diagnosis, carcinoma.
Case xLVIII. — Mrs. S., aged .'i5, a patient sent by Dr. Anna
M. Reynolds, of Philadelphia. Six months before, the cervix
uteri had been amputated for carcinoma, the growth returning
in a few weeks. The usual symptoms of iiu)i>orable carcinoma
of the cervix were present, the pain being intense and the dis-
charge fetid. Examination showed a deep excavation at the
site of the cervix, and extensive infiltration of broad ligaments.
As the patient was comparatively young, it was decided to
make an effort to arrest thedisease. Assisted by Drs. Reynolds
and Wliite, a major application of mercuric cataphoresis was
made, the instruments being passed through an asl)est08 tube
impregnated with fused shellac to protect the vagina from both
the stray current and the heat that is developed when a single
ele<'tro(le is employed to concentrate a hign current. Five
hundred to 700 milliamperes were employed for two hours.
Peritf)niti8, unfortunately, developed within a few days, the
patient succumbing on the seventh day after the application.
Cask XLIX.— This ca.se represented an attempt to relieve
Fig. 6.— Case XLVII nine months after
application, showing a V-shaped
linear cicatrix.
the immediate suffering of a gentleman in Pittsburg, Pa., who
was already in extremis from a recurrent sarcoma of the palate,
threatening suffocation. The growth extended from the palate
through to the external parts below the right lower jaw, and
had but recently been under an operation for its attempted
removal. The pharyngeal growth was bloodlessly necrosed by
200 milliamperes, but tlie prolonged application and anesthesia
were too much for the
patient's strength, and he
succumbed to shock five
hours later.
Case L. — Mrs. E.,
aged 75, noticed a pimple
beneath the inner eanthus
of the left eye three years
before being first seen.
Some months later it was
removed at the Presby-
terian Hospital, but later
returned. She was placed
under a very minute
form of the minor
method, not more than -i
to 5 milliamperes being
employed without anes-
thesia for 10 minutes
with 2 or 3 fine zinc-mer-
cury needles inserted
about a millimeter each.
This was repeated a num-
ber of times during four
or five months. The
present condition may be
seen by inspecting the
patient, who is here to-
night. The tendency of
the skin to contract when
the germs are destroyed
is well exhibited.
Case LI.— Mrs. S., aged 68, sent by Dr. Wm. B. Ulrlch, of
Chester. Pa. Six weeks oefore being first seen by me a pimple
had appeared on the right side of the bridge of the nose. It was
painless, but its rapid growth induced Dr. Ulrich to send the
patient to Professor Duhring, of the University of Pennsyl-
vania, for diagnosis. Dr. Duhring pronouncetl the growth an
epithelioma and advised its removal by electricity. The patient
was accordingly referred to me December 23, 1901. A photo-
graph of the growth at this time was taken, the infected
base being about the size of a copper cent, and an attempt was
made to destroy and sterilize it liy a slightly stronger series of
office applications similar to those employed in the preceding
case. It was soon seen, however, that those mild applications
were worse than inadequate, seeming in fact to stimulate the
growth, which rapidly enlarged. We had to deal with a rapidly
progressive carcinoma. A major application was therefore made
January 16, 1902, 200 milliamperes being used with fine zinc-
mercury points for 50 minutes, assisted by Drs. Ulrich and
Hermance. This resulted in complete arrest of the growth,
which was found to involve the nasal bones, the latter coming
away as sequestra three months later. The patient is here for
your inspection, and examination will show no sign of the dis-
ease. It is my intention to advise that the small opening into
the nostril be closed by a plastic operation.
Case LII. — A granular surface growth of the chin, of long
standing, but unknown character, shown in the photograph,
was removed by zinc-mercury needles in one application
under cocain, March 3, 1902, .50 milliamperes being required
for 15 minutes. Complete healing and disappearance of the
growth resulted.
Cake LIII. — R. W., aged 50, was sent by Dr. Leonardo
Judd, March 28, 1902, with a diffused area of diseased tissue on
the outer surface of the right arm about 4 by 3 inches in super-
ficial area. The growth began three years before and gives him
much pain. According to the patient, several surgeons in vari-
ous hospitals declared that the arm would have to be ampu-
tated to get rid of the trouble. That it extended deeply into
the muscular tissue was shown subsequently when the eschar
produce<l by the application came away. This growth, though
of unknown histologic character, for the microscopist failed to
make a diagnosis from the piece removed for that purpose,
appeared to be a typical one on which to try the effect of Kont-
gen rays, but the patient was a workingman whose time was
valuable to him, and it was decided t<i employ the major
method of zinc-mercury cataphoresis. lie was accordingly
placed under ether the ne.xt day, and assisted by Dr. Hermance
and Dr. Goethe, of Georgia, I was able to destroy the growth
and sterilize its base in exactly .'JO minutes, employing 350 mil-
liamperes. At the jjresent time the diseased area is healed
over, excepting a small spot in the center which bears evidence
of being healthy.
Of the above 1.5 eases it will be seen that 9 patients
appear to be curetl, 2 patients were temporarily helped
without arrest of the (U.seaae, and 4 patients died shortly
after the application wa.s made. The widely differing
character of these cases and the desi)erate nature of those
424 AMBBicAN U.D1CINK] ASPECTS OF AMERICAN MEDICAL BIBLIOGRAPHY
[SEPTEMBEK 13, 1902
terminating fatally Rive, however, very little ground for
a statistical in(iuiry, the chief value of this report lying
in the study of the individual cases described.
Five of the cured patients were demonstrated at the
meeting.
SPECIAL ARTICLES
SOME ASPECTS OF AMERICAN MEDICAL BIBLIOG-
RAPHY.'
BY
WILLIAM OSLER, M.D.,
of Baltimore, Md.
Professor of Medicine, Johns Hopkins University.
I.
In conferring upon me the presidency o( this Association,
I felt that you wished to pay a compliment to a man who had
been much helped by libraries and who Itnew their value, and
I lioped that it was, perhaps, in recognition of the fact that a
practical and busy physician may be at the same time a book
lover, even a book worm.
You are familiar, of course, with the objects of this
Association, but as there are present with us also those who are
not members, this is an occasion in which a little missionary
work is timely, and I may briefly refer to some of them. An
association of the medical libraries of the country, our member-
sliip includes both the great libraries, with 50,000-100,000
volumes, and the small collections just started of a few hun-
dred books. The former gain nothing directly from an affilia-
tion with xis— they give more than they get, but the blessing
that goes with this attitude is not to be despised, and from
their representatives we look for guidance and advice. Please
understand that in this address I am not talking to the men in
charge of them who are familiar with what I shall say, and
who are experts where I am only a dabbler ; but I wish to catch
the inexperienced, those in charge of the small but growing
libraries, upon whom I wish to impress some wider aspects of
the work. In the recent history of the profession there is noth-
ing more encouraging than the increase in the number of
medical libraries. The organization of a library means effort,
it means union, it means progress. It does good to men who
start it, who help with money, with time and with gifts of
books. It does good to the young men, with whom our hopes
rest, and a library gradually and insensibly molds the pro-
fession of a town to a better and higher status.
We trust that this Association may be a medium through
which men interested in the promotion of the welfare of the
profession may do much good in a quiet way. We have to
thank some 20 physicians who have kindly joined us in this
work and whose subscriptions help to pay the expenses of our
exchange; but their names on our list do more — it is an
encouragement to know that they are with us, and as they get
nothing in return (except the Bulletin) they should know how
much we appreciate their fellowship.^ We have to thank, in
particular, many editors who send us their journals for distri-
bution, and the editors of many Transactions. The liberality
with which the work of our exchange has been aided by the
large libraries is beyond all praise. Time and again the Surgeons'
General Library, the Academy of Medicine of New York, the
Boston Medical Library Association and the College of Physi-
cians'Library of Philadelphia have filled long lists of wants
for smaller libraries. The profession is deeply indebted to
Drs. Merrill, Chadwick, and Brigham, to Mr. Brownne and to
Mr. C. P. Fisher for their disinterested labors. In some details
our machinery could be better adjusted, but we have had to
work with very little money, which means slight clerical help
' Address at the meeting of the Association of Medical Librarians,
Saratoga, June 10, l!Kj2.
-I would appeal to my colleagues throughout the country to Join
this Association. The subscription is S-i a year, and the money Is well
spent in promoting the work of our exchange, through which dupli-
cates and Journals are distributed to the smaller libraries. The secre-
tary Is Miss Noyes, »47 North Jiutaw street, Baltimore, to whom sub-
scriptions may be sent.
where much is needed, but with an increasing membership we
can look forward conttdently to a much more complete organi-
zation and to a wider field of usefulness.
But this Association may have other ambitions and hopes.
We desire to foster among our members and in the profession
at large a proper love of ))ooks. For its own sake and for the
sake of what it brings, medical bibliography is worthy of a
closer study than it has received heretofore in this country.
The subject presents three aspects, the book itself, the book as
a literary record, i. e., its contents, and the book in relation to
the author. Strictly speaking, bibliography means the science
of everything relating to the book itself, and has nothing to do
with its contents. In the words of a recent writer, the bibli-
ographer "has to do with editions and their peculiarities, with
places, printers, and dates, with types and illustrations, with
sizes and collatioiLS, with bindings and owners, with classifica-
tions, collections, and catalogues. It is the book as a material
object in the world that is his care, not the instruction of which
it may be, or may fail to be, the vehicle. Bibliography is the
science or the art, or both, of book description." '
But there is a larger sense of the word, and I shall discuss
some aspects of American medical bibliography in the threefold
relationship to which I have referred.
II.
The typographical considerations may be passed over with
a few words. We have no Aldus or Froben or Stephanus or
Elziver, whose books are sought and prized for themselves,
irrespective of their contents. With few exceptions the medi-
cal works published here at the end of the eighteenth and the
beginning of the nineteenth centuries were poor specimens of
the printer's art. Compare a Sydenham first edition of 1682
with Caldwell's CuUen, issued in Philadelphia more than lOO
years later, and the comparison is in favor of the former, and
yet there is much of bibliographical interest in early Ameri-
can publications. It would make an instructive exhibit to take
a series of surgical books issued in this country from " Jones'
Manual" in 1776 to " Kelly's Operative Gynecology; " it would
illustrate the progress in the art of book making, and while
there would be nothing striking or original, such volumes as
"Dorsey's Elements of Surgery" (1813), particularly in the mat-
ter of illustrations, would show that there were good book
makers at that date. At one of the meetings of the American
Medical Association a selection of the works issued during the
117 years of the existence of the house of Lea Brothers would
form an instructive exhibition. There are few medical works
in this country the genealogy of which require any long search.
Other than the " Code of Ethics " of the American Medical
Association and the "American Pharmacopeia," both of which,
by the way, have histories worth tracking, and the " Dispensa-
tory " of Wood and Bache, I know of no works 50 years old
which continue to be reprinted. Compared with the textbooks,
etc., the journals of the early days were more presentable, and
the general appearance of such publications as the Medical
Repository, of New York, the Medical Museum, of Philadel-
phia, and later the Medical and Physical Journal, the North
American Medical and Surgical Journal and the Medical
Recorder, not only compare favorably with European journals
of the period, but one gets an impression of capable and
scholarly editorial control and a high grade of original contri-
bution. The Medical and Physical Journal, founded in 1820,
has a special interest and should be put on the shelves just
before the American Journal of the Medical Sciences, into which
it merged, one of the few great journals of the world, and
the one from which one can almost write the progress of Amer-
ican medicine during the past century.
While there is not in American medicine much of pure
typographical interest, a compensation is offered in one of the
most stupendous bibliographical works ever undertaken. The
Index Catalogue of the Surgeon-General's library atones for all
shortcomings, as in it is furnished to the world a universal
medical bibliography from the earliest times. It will ever re-
main a monument to the Army Medical Department, to the
enterprise, energy and care of Dr. Billings, and to the scholar-
1900.
Professor Ferguson, "Some Aspects of Bibliography," Bdlnburgb,
SEPTEMBER 13, 1902] . ASPECTS OF AMERICAN MEDICAL BIBLIOGRAPHY (Ambmcan medicine 425
ship of his associate, Dr. Robert Fletcher. Ambitious men be-
fore Dr. Billings had dreamt of a comprehensive medical
bibliogi-aphy. Conrad Gesner, the learned Swiss naturalist and
physician, had published up to Section 21 his " Bibliographia
Universalis" (1545). Section 20, which was to represent the
quintescenee of the labors of his life and which was to include
the medical bibliography, never appeared, owing to his un-
timely yet happy death— Ac'' ■« mors Gesneri, as Cains says
in the touching tribute to his friend.' Merklin, von Haller,
Haeser, Young, Forbes, Atkinson and others have dipped into
the vast subject, but their efforts are Lilliputian beside the Gar-
gantuan undertaking of the Surgeon-General's office. One
work I cannot pass without a regret and a reference— the unfin-
ished medical bibliography of James Atkinson, London, 1834.
If not on your shelves, keep your eyes on the London cata-
logues. It only includes the letters A and B, but it is a unique
work by a Theleraite, a true disciple of Rabelais. I need not
refer in this audience to the use of the Index Catalogue in
library work; it is also of incalculable value to anyone inter-
ested in books. Let me give an everyday illustration. From
the library of my friend, the late Dr. Rush Iluidekoper, was
sent to me a set of very choice old tomes, among which was a
handsome folio of the works of du Laurens, a sixteenth century
anatomist and physician.- I had never heard of him, but was
very much interested in some of his medical dissertations. In
a few moments from the Index Catalogue the whole bibliog-
raphy of the man was before me, the dates of his birth and
death, the source for his biography, and where to look for his
portrait. It is impossible to overestimate the boon which this
work is to book lovers. One other point — the Inde.t is not used
enough by students. Take under the subject of diseases of the
heart. Only the other day I referred to a journal article which
had a very full bibliography, and I turned to Volume V in the
old series and to the just issued Volume VI of the new series,
and there was the literature in full on this subject and many
articles which the author had overlooked. The entire bibli-
ography might have been omitted with advantage from the
paper and simply a reference made to the Index Catalogue.
It would be well in future if writers would bear in mind that
on many subjects, particularly those covered by the second
series of the Catalogue, the bibliography is very complete, and
only supplementary references should be made to the articles
which have appeared since the volume of the new series dealing
with the subject.
III.
The second aspect of a book relates to its contents, which
may have an enduring value or which may be of interest only
as illustrating a phase in the progress of knowledge, or the im-
portatice may relate to the conditions under which the book
appeared.
It is sad to think how useless are a majority of the works
on our shelves— the old cyclopedias and dictionaries, the files
of defunct journals, the endless editions of textbooks as dead
as their authors. Only a few epoch-making works survive.
Editions of the Hippocratic writings appear from time to time,
and in the revival of the study of the history of medicine the
writings of such masters as Galen and Areta'us reappear, but
the interest is scholastic, and amid the multiplicity of studies
liow can we a.sk the student to make himself familiar with the
undents? We can, however, approach the consideration of
most subjects from an historical standpoint, and the young doc-
tor who thinks that pathology began with Virchow gels about
the same erroneous notion as the student who Ijegins the study
of .\merican history with the Declaration of Independence.
Now among the colossal mass of rubbish on the shelves
there are precious gems which should be polished and well set
and in every library put out on view. But let me first mollify
the harshness of the expression just used. The other day,
thinking in this way, I took from a shelf of old books the first
one I touched. It was Currie's " Historical Account of the
Climates and Diseases of the United States of America," pub-
lished in Philadelphia in 1792. I had had it for years but had
never Ijefore looked into it. I found the first comprehensive
study on climatology and epidemiology made in this country,
> Call Opera, Jebb'ii edition.
one which antedates by several years Noah AVebster's work on
epidemics. With remarkable industry Dr. Currie collected
from correspondents in all parts of the country information
about the prevalent diseases, and I know of no other work from
which we can get a first-hand sketch from the practitioners
themselves of the maladies in the different States. Then I had
to look up his possible relationship with James Currie, of
Liverpool, the strong advocate of hydrotherapy, the friend and
editor of Burns, who had had, I remembered, interesting affilia-
tions with Virginia. At the outbreak of the Revolutionary
War he was employed as a clerk at one of the landings on
the James river, and suffered not a little for the Tory cause.
His letters, given in his " Life," which are well worth reading,
give a valuable picture of the period. The American Currie's
book at least was not rubbish in 1792, but who will read it now ?
And yet it is on our shelves for a purpose. It may not be called
for once in five years ; it did a good work in its da.y, and the
author lived a life of unselfish devotion to the profession. As a
maker of much which in a few years will be rubbish of this kind,
let me take back the harsh expression, tent I wish to refer par-
ticularly to certain treasures in American bibliography which
you should all haveon yourshelves. Of course thegreat libraries
have most of them, and yet not all have all of them, but with a
little effort they can be picked up. Take that notable " Dis-
course Upon the Institution of Medical Schools in America," by
John Morgan, M.D., 1765. From it dates the organization of
medical colleges in this country, but there is much more in this
scholarly address. The introduction contains a picture of the
state of practice in Philadelphia which is in its way unique,
and for the first time in tlie history of the profession in this
country Morgan tried to introduce what he calls the regular
mode of practising physic, as apart from the work of the sur-
geon and the apothecary. What interests us, too, here is his
plea for the establishment of a medical library. Listen to his
appeal: "Perhaps the physicians of Philadelphia, touched
with generous sentiments of regard for the rising generation
and the manifest advantages accruing to the College thereby,
would spare some useful books or contribute somewhat as a
foundation on which we might begin." The biographical frag-
ments in the introduction show the remarkable care with which
some of the young colonial physicians sought the best available
education. Few today, after a protracted apprenticeship, do as
did Morgan, spend five years in Europe under the most cele-
brated masters, but he returned a distinguished Fellow of the
Royal Society of London, and a Correspondent of the Royal
Academy of Surgery in Paris.
John Jones' " Plain Concise Remarks on the Treatment of
Wounds and Fractures, Designed for the Use of Young Mili-
tary and Naval Surgeons in North America," 1770, was the vddc
OTecit?n of the young surgeons in the Revolutionary War. As
the first separate surgical treatise published in this country it
has a distinct biographical \'Tilue and when possible you should
put the three editions together.
Barcfs study on "Angina Suffocativa" (1771), or Diph-
theria, is an American classic of the first rank. It is difllcult
to get, but it is worth looking for. Get, too, his work on " Mid-
wifery," 1807, the first published in this country. An enter-
prising librarian will have all the editions of such a work.
Bond's "Lecture Introductory to the Study of Clinical
Medicine at the Pennsylvania Hospital," niKJ, remained in
manuscript until printed in Vol. IV of the Nortli A merican
Medical Journal, 1827, a copy of which is not dilUcult to obtain.
It is also republished in Morton's " History of the Pennsylva-
nia Hospital," and I republished it in the University Medical
Mas/azine in 1897.
The works of Rnsh should be fully represented even in the
smaller libraries. His collected writings passed throvigli five
editions and are easy to get. Rush "is the father not only of
American medicine, but of American medical literature, the
type of a great man, many-side<l, far-seeing, full of intellect and
genius; iiliusod and vilified, as man hn^dly ever was before, by
his contemporaries, professional and nonprofessional; misun-
derstood by his immediate successors, atid unappreciated by
the present generation, few of whom know anything of his real
character." I gladly quote this estimate of Rush by S. D. Gross.
Owing to the Impression that ho was disloyal to Washington,
426 AMBBicAN MKDiciNKj ASPECTS OF AMERICAN MEDICAL BIBLIOGRAPHY
[Septehbeb 13, 190*^
there nas arisen of late a certain feeling of antagonism to his
name. The truth Is he was a strong hater, and, as was common
at that period, a bitter partisan. I wish some one would give
us the account from contemporary letters, and from the side of
Rush. There is an astonishing amount of bibliographical
interest in the writings of Rush, and a good story awaits the
leisure hours of some capable young physician. His letters are
Innumerable and scattered in many liljraries. I came across
one the other day ("Bulletin of the New York Library,"
Vol. I, No. 8) dated July 27, 1803, in which, replying to an
invitation from Horatio Gates, he says pathetically, "A large
and expensive family chain me to the pestle and mortar," and
in a postscript he adds that as he now confines his labors to his
patients, without trying to combat ignorance and error, he is
kindly tolerated by his fellow-citizens.
Many early works of great importance are difficult to find,
such as North on " Spotted Typhus " or Cerebrospinal Fever,
1811. Noah AA'ebster's " History of Epidemics " has a special
value, apart from its interest as the most important medical
work written in this country by a layman.
The tracts on vaccination by Waterhouse— the American
Jenner— should be sought for carefully. Try to have a copy of
Nathan Smith's " Essays on Typhous Fever " (1824) to hand to
any young physician who asks for something good and fresh on
typhoid fever. There is a long list of important essays which
you should have. I cannot begin to name them all, but such as
Jacob Bigelow on " Self-limited Diseases," 1835, a tract which
every senior student sliould read, mark, learn and inwardly
digest. If not obtainable, his "Nature in Disease " contains it
and many other essays of value. Jackson's " Letters to a
Young Physician" are still worth reading — worth repub-
lishing.
The stories of the great epidemics oflfer material for careful
bibliographical research. Carey's graphic description of the
great epidemic of yellow fever in Philadelphia, while not so
lifelike and brilliant as De Foe's great story of the plague in
London, has the advantage of the tale of an eye-witness and of
a brave man, one of the small band who rose above the panic of
those awful days. It is a classic of the first rank. The little
book, by the way, had a remarkable sale. The first edition is
dated November 13, 1793, the second November 23, the third
November 30, and the fourth January 16, 1794. Brockden
Brown's "Arthur Mervyn," while it gives in places a vivid
description of this epidemic, is, in comparison, disappointing
and lame, not worthy to be placed on the same shelf with
Carey's remarkable account.
Even the smaller libraries should have the works of this
type. They are not hard to get, if sought for in the right way.
Early American works on special subjects should be sought
for. Such a collection of works on ophthalmology as is in
exhibit in the section on this subject at the meeting of the
American Medical Association is- most instructive, and shows
the early publications of this country.
IV.
The third aspect of medical bibliography relates to writings
which have a value to us from our interest in the author. After
all, the true bibliophile cares not so much for the book as for the
man whose life and mind is illustrated in it. There are men of
noble life and high character every scrap of whose writings
should be precious to us, and such men are not rare. The
works are not always of any special value today, or even of any
intrinsic interest, but they appeal to us through the sympathy,
and even the affection, stirred in us by the story of the man's
life. It is, I know, a not uncommon feeling— a feeling which
pervades No. XXXII of Shakespeare's " Sonnets " and is so
beautifully expressed in the concluding line, " Theirs for their
style I'll read, his for his love." Such an attitude I feel per-
sonally toward the literary remains of John Morgan, David
Ramsay, Daniel Drake, John D. Godman, James Jackson, Jr.,
Elisha Bartlett and others.
In our libraries under John Morgan, to whose remarkable
essay I have already referred, there should be also his " Vindi-
cation," which gives the story of the Army Medical Depart-
ment in the early days of the Revolution. One of the most
famous names in American medicine is David Ramsay, per-
haps the most distinguished pupil of Benjamin Rush, a man of
high character, full of zeal and ambition and devoted to his
profession, yet what he has left in general literature far excels
in importance his medical writings. The larger libraries
should have his famous " History of the American Revolu-
tion," 1789, his "Life of Washington" and the "History of
South Carolina," 1809. The memory of such a man should be
cherished among us, and one way — and the best — is to put a
complete set of his writings on our shelves.
Another noble soul of the same stamp was John D. Godman,
the tragedy of whose life and early death has a pathos unequaled
in the annals of the profession of America. Besides his ana-
tomic works, his " Museum of American Natural History "
and " The Rambles of a Naturalist " should be among your
treasured Americana.
There is a large literature in this group illustrating the
excursions of medical men into pure literature. A complete set
of the writings of Oliver Wendell Holmes should be in every
medical library. His Boylston prize essays on " Neuralgia," on
" Malarial Fever " and on "Direct Explorations" can be had
bound in one volume. One of his writings is inestimable, and
will he remembered in the profession as long, I believe, as
posterity will cherish his " Chambered Nautilus " or the " Ijast
Leaf." If you can find the original pamphlet on the " Con-
tagiousness of Puerperal Fever," a reprint from the New Eng-
land Journal of Medicine and Surgery, 1844, have it bound in
crushed levant — 'tis worthy of it. The reprint of 18.55 is more
accessible. Failing either of these, get the journal and cut out
and bind the article. Semmelweiss, who gets the credit for
introducing asepsis in midwifery, came some years later.
Occasionally a wellknown medical writer will dabble in pure
literature, and will sometimes, as in the case of Dr. Weir
Mitchell, attain a success as remarkable as that which he has
had in his profession. Put his writings on the shelves— they
illustrate his breadth and his strength. A volume of poems
may illustrate some strong man's foible. George B. Wood's
epic poem, " First and Last," and the " Eolopoesis " of Jacob
Bigelow illustrate the dangers which beset physicians who
write poetry.
Biography is a department which you will find a very
attractive and a most profitable field to cultivate for your
readers. The foreign literature includes several comprehensive
encyclopedias, but it is not a department very well represented
in this country. It is true that an enormous literature exists,
chiefly in periodicals, but the sort of biography to which I
refer has a threefold distinction. The subject is a worthy one,
he is dead, and the writer has the necessary qualifications for
the task. We possess three notable works on American medi-
cal biography : Thacher, 1828 ; Williams, 1845, and S. D. Gross,
1861, which remain today the chief works of reference to the
latter date. Thacher's is a remarkable production, and for the
period a most ambitious work. It has been a common tap to
which writers have gone for information on the history of medi-
cine in this country, and the lives of the prominent physicians
to about 1825. It is a rare volume now, but worth its price, and
I know of no more fascinating book or one more difftcult to put
down. Even the printed list of subscribers — a long one, too— is
most interesting. Many of Thacher's best known books come
in the third category, and are of value in a medical library only
so far as they illustrate the remarkable versatility of the man.
His " Practice," the first American one, you will of course try
to get, and you should also have one of the editions of his
" Journal of the Revolutionary War," through which he served
with pencil as well as scalpel in hand. It is a most graphic
account, and of interest to us here since he describes very fully
the campaign in this region, which led to the surrender of Bur-
goyne, the treachery of Arnold, and he was an eye-witness of
the tragic end of poor Major Andre. You will not find it easy
to get a complete set of his writings.
There are many single volumes for which you will be on
the look out. Caldwell's "Autobiography" is a storehouse of
facts (and fancies!) relating to the University of Pennsylvania,
to Rush and to the early days of the Transylvania University
and the Cincinnati schools. Pickled as it is in vinegar the
work is sure to survive.
Have carefully rebound James Jackson's Memoir of his
SEPTEMBER 13, 1902)
CONSTANTINOPLE AS A MEDICAL CENTER
(Ameeican Medicine 427
son (1835), and put It In the way of the young men among
your readers. Few biographies will do them more good.
For the curious, pick up the literature on the Chapman-
Pattison quarrel, and anything, in fact, relating to that viva-
cious and pugnacious Scot, Granville Sharpe Pattison.
There are a lew full-blown medical biographies of special
interest to us: The life and writings of that remarkable phi-
losopher and physician. Wells, of Charleston. The life of John
C.Warren is full of interest, and in the "Essays" of David
Hossack you will get the inner history of the profession in
New York during the early years of the last century. In many
ways Daniel Drake is the most unique figure in the history of
American medicine. Get his " Life," by Mansfleld, and his
"Pioneer Life in Kentucky." He literally made Cincinnati,
having " boomed " it in the early days in his celebrated " Pic-
ture of Cincinnati," 1815. He founded nearly everything that
is old and good in that city. His monumental work on " The
Diseases of the Mississippi Valley" is in every library ; pick
out from the catalogues every scrap of his writings.
I must bring these " splintery," rambling remarks to a
clo.se, but I hope that I may have stirred in you an interest in
some of the wider aspects of American medical bibliography—
I mean aspects other than the daily demand upon you for new
books, new editions and new journals.
Keep ever in view, each one In his circle, the important fact
that a library should be a storehouse of everything relating to
this history of the profession of the locality. Refuse nothing,
especially if it is old; letters, manuscripts of all kinds, pictures,
everything illustrating the growth, as well as the past condi-
tion, should be preserved and tabulated. There is usually in
each community a man who is fond of work of this sort.
Encourage him in every possible way. Think of the legacy
left by Dr. Toner, of Washington, rich in materials for the his-
tory of the profession during the Revolutionary War ! There
should be a local pride in collecting the writings and manu-
scripts of the men who have made a school or a city famous.
It is astonishing how much manuscript material is stowed
away in old chests and desks. Take, for example, the recent
" find " of Dr. Cordell of the letters of the younger Wiesenthal,
of Baltimore, describing student life in London about the mid-
dle of the eighteenth century. Think of the precious letters of
that noble old man, Nathan Smith, full of details about the
foundations of the Dartmouth and the Yale Schools of Medi-
cine! Valuable now (too valuable to be in private hands),
what will they be 100 or 200 years hence !
What should attract us all is a study of the growth of the
American mind in medicine since the starting of the colonies.
As in a mirror this story is reflected in the literature of which
you are the guardians and collectors— in letters, in manuscripts,
in pamphlets, in books and in journals. In the eight genera-
tions which have passed, the men who have striven and strug-
gled—men whose lives are best described in the words of St.
Paul, in journeyings often, in perils of water, in perils in the
city, in perils in the wilderness, in perils in the sea, in weari-
ness and painfulness, in watfjhings often, in hunger and
\ thirst and in fastings— these men, of some of whom I have told
you somewhat, have made us what we are. With the irrevoca-
ble past into which they have gone lies our future, since our
condition is the resultant offerees which, in these generations,
i have molded the i)rofes8ion of a new and mighty empire.
From the vantage ground of a young century we can trace in
the literature how three great streams of influence— English,
French and German— have blended into the broad current of
American medicine on which we are afloat. Adaptiveness,
lucidity and thoroughness may l>e said to be the characteristics
of these Anglican, (iallic and Teutonic influences, and it is no
small part of your duty to see that these Influences, the com-
bination of which gives to medicine on this continent its dis-
tinctively eclectic quality, are maintained and extended.
Indian Agency Appointment. —One of the best known
colored physicians in .St. Ix)uiM, Dr. S. P. Stiifford, has been
fti>p<iiiited a government physician ut Yakima Indian agency in
Washington. He was graduated from the University of Penn-
sylvania in 1897 and has since held positions under the govern-
ment.
CONSTANTINOPLE AS A MEDICAL CENTER.
BY
NICHOLAS SENN, M.D.,
of Chicago.
Emperor Constantin showed good judgment and a pro-
found knowledge of statesmanship and military strategy when
he chose for the site of a second empire city on the banks of
the Bosijhorus, the gateway between the Mediterranean and
Black seas, the narrow waterline which defines the limits
between two great continents. Constantinople is beautifully
situated, scattered, like Rome, over seven hills, reflected upon
the restless bosom of the Bosphorus and in view of the bare,
rugged mountains of Asia. It has few rivals in military and
commercial importance. Nature has made its fortification
easy, and it holds the key to the commerce on the great seas
which swarm with merchant vessels from all parts of the
globe. The city claims at present a population of 1,000,000,
to which must be added the several hundred thousand inhal)i-
tants of its many suburbs and Scutari on the Asiatic side of the
Bosphorus. The city has been growing quite rapidly, and
shows many signs of recent improvements. It lacks, however,
electric street railways and lighting. Telephones are unknown
throughout Turkey. The most promising Indications of a
growing civilization are to be seen in its many medical Institu-
tions. Constantinople Is the great and only medical center In
Turkey.
MEDICAL EDUCATION.
The only two medical schools in Turkey are in Constanti-
nople, one for civilian the other for military students. Both of
these Institutions are under strict government control and
nearly all of the teachers are military surgeons. The new-
medical university is located In Scutari near the great Hai'dar
Pacha military hospital. It Is supplied with all the modern
equipments for the scientific teaching of medicine and its allied
branches. The school for the civilian students has 500 matricu-
lants, the military 700. The students are required to study six
years before they are permitted to apply for the final examina-
tions. Tuition is free for the military cadets. After graduation
the young officers are required to serve as assistants In one or
more of the many military hospitals for a period of two years
before they can enter the regular service. If for any reason he
leaves the service before the expiration of 30 years, he must
refund the government for the outlay incident to his profes-
sional education. After 30 years of continuous service he can
be retired on half pension. A full pension is onlygranted after
50 years of service. Ample provision Is made for the civilian
graduates for interneship after their graduation, under the title
of voluntary assistants. Foreign graduates are permitted to
practice, but they have no legal rights and cannot hold govern-
ment appointments.
TURKISH MEDICAL LITERATURE.
Most of the medical books used in the university are trans-
lations from French and German textbooks. The books by
Turkisli authors are few. Among them are works on materia
medica, physiology, anatomy and on operative surgery by
Djemll Pacha. A number of Turkish medical journals bring
short abstracts of foreign medical literature so that the practi-
tioners are kept In touch with the advances in medicine and
surgery outside of the Ottoman Empire. The government
sends annually many of the military and naval medical officers
to Paris and Germany for postgraduate work, a movement
which has been the principal means of establishing Turkish
medical education and medical literature on a scientific basis.
The spirit of original research and scientific investigation has
taken hold of the rank and file of the Turki.sh profession, and
in a very few years we may look for a rich Ottoman medical
literature.
MEDICAL SOCIETIES.
Turkey has no national medical society. The vast expanse
of the country, the limited means of transportation, render It
very diflicult to organize the whole profession into one body.
Many of the physicians who live in small inland cities and vil-
lages are isolated and remain in communication with the out-
side world only by mail. Such segregation leads only too often
423 AMZBIOAN MKDlCIirEI
CONSTANTINOPLE AS A MEDICAL CENTER
[8EITKMBKB 13, 1902
to routine practice and clogs tlie vvlieels of progress. Coinpara
lively few civilian physician.^ avail themselves of postgraduate
work beyond the limits of their own country. It is for this
class of physicians that medical societies, large and small,
become the most useful postgraduate institutions. A national
medical society would be of the greatest utility in stimulating
the mass of the profession in this country to united action and
could not fail in advancing the cause of medicine and surgery.
Constantinople, the great medical centerof Turkey, has recently
made a good beginning in organizing the profession. ~It has a
medical society with Djemil Pacha as president. Tlxe society
holds weekly meetings which are well attended and at which
the scientific aspects of medicine and surgery receive merited
attention. The enormous clinical material offered by the
numerous hospitals of this great city should and will be made
available for the outside world through the excellent scientific
work of our enthusiastic and energetic Turkish colleagues.
HosriTAL.s.
Constantinople is well supplied with hospitals. The gov-
ernment takes excellent care of its soldiers when disabled by
injury or disease and its indigent sick. The city has no less
than 30 military hospitals. The largest one, the HaVdar Pacha,
with 1,500 beds, is located beautifully on a high elevation on the
Asiatic side of the Bosphorus. It was in this hospital that
F'lorence Nightingale gained her undying reputation during
the Crimean war. It was my privilege during the Greco-
Turkish war to visit these hospitals when the wards contained
hundreds of wounded soldiers. I shall ever remember witli
gratitude the many courtesies that were extended to me at that
time by the government and the medical officers. To visit any
of these hospitals it is necessary to secure a permit. This is
received on application through the Minister of the United
States, in the case of Americans, when the application is trans-
mitted through military channels. On my second visit Mous-
tafa Bey, a lieutenant-major at the Yildiz Palace, was detailed
as chaperon. How well the preparations were made for the
visit became evident when we called at the different hospitals
and always found the chief surgeon and his staff in full dress
uniform awaiting us at the entrance. The whole staff accom-
panied us on our tour through the different parts of the build-
ings. Coffee and eigarets were invariably served in the office of
the chief surgeon at the completion of the visit. I will only
refer to three of the larger hospitals visited.
Yildiz [Star) Hospital.— This hospital, near the Yildiz
Palace, was built during the Greco-Turkish war for the
wounded. In less than four weeks barracks for 1,(KX) patients
were in readiness. The buildings remain much the same as
during the war. The wounded have all disappeared, some of
the barracks are empty and only about 200 patients are cared for
at the present time. Brigadier- (ieneral Rachid Pacha directs
the affairs of this hospital, assisted by a staff of surgeons. The
main feature of this hospital at the present time is a large bath-
house for Turkish baths. It is noteworthy to make the state-
ment, ascertained by a number of inquiries at the different hos-
pitals, that venereal diseases are quite uncommon among the
soldiers of the Ottoman Army. The principal affections which
figure most conspicuously on the hospital register are bron-
chitis, pneumonia, typhoid fever, rheumatism, sprains and
fractures. Alcoholism is unknown. The operating room is
small, well lighted and supplied with the most necessary con-
veniences for aseptic work. In case of another war it is to this
hospital the wounded would find their way first, as its location
outside the noisy limits of the city and the general arrange-
ments of the buildings would recommend it for such special use
in preference to the other military hospitals.
Gumuche-Souyou Hospital.— Tina hospifail is located on the
north side of the city, and furnishes accommodations for 400
patients. The building, a solid two-story structure, is more
than 100 years old, and did excellent service during the Crimean
war. It is in charge of Colonel Selami Bey, a veteran military
surgeon. The halls and wards are at least 20 feet in height and
well lighted. This feature of the building, with the wide stone
stairs and columns of stone in the front, impart to it a palatial
appearance. The iron bedsteads, clean pillows, soft woolen
blankets and comfortable mattresses rob the old building of
its former austerity. The medical work in all of the military
hosjiitals is classified intosurgical and medical. Ophthalmology
is the only specialty that is recognized. In this hospital Dr. A.
Hazira is the operator, and Dr. H. Sarim the oculist. The con-
valescents find a pleasant place for recuperation in the tree clad
garden, beautified with flowers, in the front yard of the hos-
pital. A fountain in this garden is now in process of construc-
tion. The nursing in all the military hospitals, as well as all
housework, is done exclusively by men. The soldiers receive
well-cooked, plain, substantial food and wear comfortable
hospital clothes from the time they enter until they are dis-
charged. During the last year 5,842 patients were treated in
this hospital, with only 72 deaths, certainly a most gratifying
record.
The Hamidie Hb.spitoJ.— This is the finest and most complete
hospital in Turkey, and has few, if any equals of its kind in the
I
I
if
Hamidie Hospital. Main building and pavilion.
world. This hospital, the just pride of the Sultan and the local
profession, is a memorial to one of his favorite little daughters,
who died several years ago. It was built and is maintained at
the private expense of the Sultan. The outside world knows
little of the work of civilization and deeds of charity of His
Imperial Majesty, Abdul Hamid II. He has always manifested
a deep interest in the advancement of the science of medicine
and works of charity. A prominent Turkish physician says of
him :
His Majesty, the Sultan, is the greatest and most energetic
advocate of medical science in his great empire.
Before he ascended the throne there were few physicians in
Turkey, and science was not as far advanced as at the present
time. During the reign of our exalted and kind ruler, medi-
cine has so far advanced that we have a number of distinguished
surgeons like Djemil Pacha. Haireddin Pacha, Osman
Pacha, Fikry Bey, Noureddin Bey, Nazim Bey, Hazim Bey,
Kudrttt Bey, Halid Bey and Omer Bey. The same can be
said of internal medicine. In this field we also have in Turkey
distinguished professors, who received their education in
France or Germany and who upon their return entered our
medical school as teachers.
That the Sultan has been a much misrepresented man no
one who has traveled through Turkey can deny. Here is an
institution that serves as a living witness against the unfounded
charge of heartlessness and cruelty. An institution in which
the very air breathes a spirit of kindness, charity and a deep
concern for the proper care of the sick poor that will for all
times commemorate the greatest virtues of the present ruler of
Turkey. Let the monarchs of more civilized nations cover
their faces with shame when they visit the HamidiiS Hospital
in Constantinople. Every man has his faults, and no ruler of
nations is perfect, but here is an institution that will always
testify to the kindness of heart and liberality to the poor of
Abdul Hamid II. The annual expenses of the hospital amount
to about 1175,000, and they are all paid out of the private purse of
the Sultan. The scope of the hospital is limited to the treat-
ment of women and children. It is located in Schischli, in
Pera, at the northern terminus of the city, on a high hill, from
which the city, the Bosphorus, Scutari, and in the distance the
September 13, 1902]
CONSTANTINOPLE AS A MEDICAL CENTER
iAMERicAN Medicine 429
Sea of Marmora and the mountains on the Asiatic side can be
seen. No more healthful and pleasant location could have been
selected. A large tract of land around it is being planted
with trees and shrubs, and is laid out in parklike fashion.
Flower gardens and a fountain add much to the beauty
and charms of the place. The main building contains
rooms for the director and his assistants, the pharmacy, and 14
rooms for the employes, chapel and library. The dwelling
rooms are furnished in a most luxurious oriental style. The
hospital proper is built on the pavilion plan and can accommo-
date 100 patients. The wards are models of cleanliness and
comfort. The operating-room is all that money and skill could
make it. It is supplied with all conveniences for aseptic work
and a complete outfit of surgical instruments. The washhouse,
sterilization-room and steam-heating apparatus occupy a sepa-
ratebuilding. A military guardhouse is at the entrance to the
grounds and a small detachment of soldiers do guard duty. In
the well-equipped pathologic and bacteriologic laboratory the
best scientific work is being done. This department is in
charge of Fuad Bey, who qualified himself for this position
under Finkler, Kruse, Schulze, Behring, Marmkopf, Mttller
and Striimpell.all wellknown German scientists. Djevad Bey,
also a graduate of a foreign school, is the chemist of the insti-
tution and does his work in a separate laboratory furnished
with everything necessary for scientific work. Most of the
furniture and hospital supplies were bought in Paris and Ger-
many regardless of cost. The director's house is furnished in
princely style. The present medical staff consists of Colonel
Ibrahim Bey, medical director and physician to H. I. M. the
Sultan; Fuad Bey, Yakki Bey, Nouri Bey, Zia-Noumry Bey.
The greatest defect in all of the Turkish hospitals is the
absence of trained female nurses. The high class Turkish
women are not obtainable and the low class women do not pos-
sess the necessary education and intelligence to fit themselves
for the nursing profession. The HamidiC Hospital has found a
way out of this difficulty. Seven months ago five trained
female nurses were engaged in Berlin and after coming here
were placed in charge of the sick children and women. This
addition to the hospital has wrought wonders in the care of the
patients. Their services are highly appreciated. The head
nurse receives 70 francs a month, the rest from 40 to 50. These
five young women are happy and cheerful in their present
situation, although they have as yet made but little progress in
Medical stafT of the Hamldi£ Hospital.
acquiring a knowledge of the Turkish language. It is to be
hoped that their work and example will set aside the objections
of the highViorn Turkish women to join their work and open
the way to well trained native female nurses. If it were not for
the red fez a visit to this hospital would leave the impression
tliat the visitor had passed tlirough one of the most modern and
S(^iontilic liospltals in Germany. This hospital will furnish the
leaven in the further evolution of tlie science of medicine in
Turkey and will become an object lesson In the care of
the sick throughout the entire empire. No private hospital
offers more comfort, better nursing or more attentive and
careful medicaland surgical treatment, and yet it is a rule
established by the royal donor that no money should be
taken from any of the patients. Children from 1 to 12 years
of age embrace the largest number of patients. The gyne-
cologic department is well represented. Several pavilions are
devoted to acute infectious diseases. Serum treatment of diph-
theria is relied upon, and has given the most gratifying results.
Last year two children witli far-advanced diplitheritic stenosis
of the larynx were admitted. In both instances tracheotomy
was immediately performed, and both recovered. Tuberculosis
of bones, joints and lymphatic glands is quite a frequent affec-
tion among the children. Diseases of the skin and eyes make
up a large part of the clinical material. One of the provisions
tliis hospital has in view is the care of strangers that might be
taken ill in Constantinople. At the Sultan's special request 16
beds have been set aside for the treatment of patients that
might apply for relief to any of the legations. All that is neces-
sary to secure admittance is to apply to any one of the ambas-
sadors for a recommendation. I do not know of any other
monarchical or republican government that has made a similar
arrangement for the travelers of other countries in case of
illness — another indication of the Sultan's desire to benefit the
sick, regardless of their nationality or religious belief. The
question of religion is never raised In admitting patients. In
looking over the report for last year, I found that at least 33% of
all the patients were Protestants.
Polyclinic of the Hamidie Hospital. — One of the most far
reaching charitable institutions of Constantinople is the Poly-
clinic connected with the Haraidifi Hospital. The average daily
attendance is from 125 to 150. Last year 25,000 applied for treat-
ment. All patients must pass through the same gate. Inside
I'otyciinic or Haniutio Hospital.
of the gate is the first examination station. A physician elimi-
nates here all cases of acute infectious diseases which are
referred at once to the department for the same. Those who are
admitted enter the large waiting-room. Another physician
classifies the patients and refers them to the department to
whicli they belong. Five physicians, representing surgery,
internal medicine, gynecology, ophthalmology and nose and
throat diseases in separate rooms are in attendance from 9 a.m.
until 2 p.m. All of these rooms are well supplied with instru-
ments for diagnosis and treatment. A large dispensary in the
same building, presided over by several competent druggists,
supply the medicines free of charge. Ibrahim Bey is the soul
of the Hamidie Hospital. He takes great pride in its marvel-
ous success. He is a competent bacteriologist, a thorough and
earnest student of the German medical literature and passion-
ately devoted to the advancement of tlie science of medicine in
its broadest sense. Our visit in this model hospital terminated
with a most excellent dinner given at the special request of the
royal founder and patron, H. I. M. the Sultan.
THE TURK AS A SOLDIER.
The Turk makes an ideal soldier. He is above average
height with asplendid physique, muscular and devoid of super-
fluous fat. His simple, temperate'habits engender an endurance
far beyond that of the soldiers of any other European nation.
The Turk can subsist on a minimum of tlie plainest kind of
food without becoming disabled on forced marches continued
480 AxxBioAir Mbsxoinb)
THE WORLD'S LATEST LITERATURE
[Seftehbbb 13, 1U02
for many days. The Turkish soldier is content and obedient.
His sense of duly is keen and he will follow his leader in the
very jaws of death without fear. The Turkish army has become
a very formidable one. It is well-drilled and organized and
armed with modern weapons. All able-bodied Turks enter the
army at tho age of 20 and serve for seven years. In Constan-
tinople alone there are 17,000 soldiers who live in modern com-
fortable barracks. The Turkish cavalry is the iinest in the
world. The Turkish soldier is a desirable patient. He has
faith in his physician and is grateful for his services. Obe<li-
ence, courage and patience are his greatest virtues.
TH^: BED CRESCENT.
In the Turkish army the Red Crescent is equivalent to the
Red Cross. The red crescent on the sleeve and on the white
flag means the same practically as the red cross. The Red
Crescent Society of Turkey Is a very exclusive organization.
It Is made up almost entirely of military men who have dis-
tinguished themselves by meritorious service. Membership
In this society, in fact, means government recognition. At the
last Conference of the International Red Cross this society was
represented by the Turkish AmbaissadoratSt. Petersburg, who
attended all of the sessions and manifested a deep Interest in Its
proceedings.
Constantinople, June 13.
THE WORLD'S LATEST LITERATURE
Journal of the American Medical Association.
September 6, 190t. [Vol. xxxix. No. 10.]
1. The Modem University School : Is Purposes and Methods. John
M. DODSON.
2. Should the General Practitioner Have a Working Knowledge of the
Ophthalmoscope and Trial Lenses. Albert Rukus Baker.
3. Teaching Ophthalmology to Undergraduates. Frank C. Todd.
4. Psychology of Habit in Surgical Technlc. K C. Coffky.
5. The Teaching of Therapeutics and Pharmacology from the Experi-
mental Standpoint. ToraldSollman.
6. The Place and Importance In the College Curriculum of Materia
Medlea. Warren B. Hill.
7. The Place and Importance in the College Curriculum of Therapeu-
tics. Hobart Amory Hare.
8. Mental Therapeutics and the Need of Psychology In the Medical
Curriculum Howell T. Pershing.
9. Medical Schools In the United States and Canada.
2. — See American Medicine, Vol. Ill, No. 25, p. 1050.
3. — See American Medicine, Vol. Ill, No. 25, p. 1050.
4.— Psychology of Habit in Surgical Technic.-— CoflFey
discusses the nature and results of habit and the dangers of
carelessness In surgical technic, especially with reference to
surgical cleanliness. He describes the minute routine of
cleansing the hands part by part in regular sequence as taught
In the North Pacific Sanatorium and practised by the nurses
when off duty, and follows this by general rules for avoiding
contact with septic material after the cleansing, [h.m.]
6.-- Teaching Therapeutics and Pharmacology from
the Experimental Standpoint. — Sollman describes the
methods of the Western Reserve University, showing what Is
aimed at in the lectures, recitations, demonstrations, in physio-
logic and chemlc experimentation, in the keeping of laboratory
records and the writing of reports and theses by the students
and in the teaching of materia medica and prescription writing.
The optional conferences and opportunities for research virork
are also described, together with the reviews, the oral, written
and practical examinations, the method of grading, the organ-
ization of the laboratory and the arrangement of time and sub-
ject-matter, [h.m.]
O.— See American Medicine, Vol. Ill, No. 24, p. 992.
7. — See American Medicine, Vol. Ill, No. 24, p. 992.
8. — Mental Therapeutics.— With only insignificant excep-
tions a physician must always make a strong mental Impres-
sion on his patient. Hysteria is not the only disease in which
this Is necessary. In neurasthenia, digestive disturbances, etc.,
mental Influences are a large factor. Even In Infectious dis-
eases they count for something. The human mind Is not suf-
ficiently studied by the profession. Schools In the future will
teach psychology as part of the medical curriculum, [h.m.]
Boston Medical and Surgical Joaraal.
September i, 1902. [Vol. OXLVII, No. 10.]
1 The Shattuck Lecture : The Changes In the Spinal Cord and Medulla
In Pernicious Anemia. Frank Billings.
2. Legislation with Reference to Smallpox and Vaccination. .Samuel
W. Abbott. _
;) Vaccination Kruptions. Harvey P Towle.
I Appendicitis Complicating Pregnancy, with Report of Case; Re-
moval of Gangrenous Appendix at Three and One-half Months,
Delivery at Term. Francis D. noNOOHUB.
l.—Changes in the Spinal Cord and Medulla in Perni-
cious Anemia.— Billings reviews briefly the literature of the
subject, discusses the etiology and symptoms of the affection
and presents an analysis of his 86 cases with the following con-
clusions : 1. There Is a well-established relation of diffuse cord
degeneration with pernicious'anemia. 2. It seems highly prob-
able that the hemolysis and the cord changes are due to the
same toxin. 3. While the source of the toxin is unknown, the
fact that gastrointestinal disturbance Is so common in the dis-
ease would lead one to suppose that it is of Intestinal origin.
4. The diffuse degenerations which occur in conditions without
pernicious anemia do not differ essentially. 5. It is possible
that a common blood circulating poison exists which may
expend Its force upon the blood in one Individual, upon the
nervous apparatus in another and coincldently upon the blood
and spinal cord In others, [h.m.]
2.— Legislation with Reference to Smallpox and Vac-
cination.—Abbott reviews the existing legislation of Massa-
(;husetts which has grown out of various epidemics since 1701.
Five kinds of notice are required by law in each case of small-
pox : (1) By the physician and (2) by the householder to the
local health board ; (3) by the local board to the local school
committee ; (4) to the State board and (5) by the State Board of
Health to the State Board of C!harity. After notification pro-
visions are next made for removing the patient, providing a
hospital, retaining the patient where he is if he cannot be
removed without danger, giving public notice, regulating trans-
portation after death and disinfection. The writer refers to
various court decisions. He discusses the laws relating to vac-
cination and points out their weakness in that they require it
only at Irregular times and permit exemption on pretexts.
What the enforcement of sutficient laws can accomplish Is
shown in the record of Germany, where there are no cases
which are not Imported from neighboring lands. The law
should require a record of the date, name, age and sex of each
person vaccinated and of the result. An unfortunate circum-
stance connected with sanitary legislation is the absence of
medical men In the legislature, [h.m.]
3.— Vaccination Eruptions.— Towle discusses the erup-
tions resulting from pure vaccine inoculation alone. Secondary
local Inoculation may arise before protection has been obtained
through scratching, etc. Urticaria, erythema multiforme, etc.,
may occur before the vesicle has developed, as manifestations
of a general irritation. The most common eruptions after
development of the vesicle are vaccine lichen and urticaria.
The vesicular eruptions are often very puzzling. Some have
simulated chickenpox. It Is still under discussion whether
the " vaccine generalisge " of the French is due to autoinocula-
tion or a real generalization of the eruption. It has been
attributed to absorption by the digestive tract or absorption
into the circulatory or lymphatic systems from the seat of vac-
cination. Bullous dermatitis following vaccination has been
reported, lasting from several months to several years. The
sequels of vaccination include eczema, psoriasis, urticaria, etc.
They occur only in predisposed subjects. The cause of vac-
cination eruptions Is still In dispute. The author reports five
cases. [h..\i.]
4.— Appendicitis Complicating Pregnancy.- Donoghue
gives the history of a case of appendicitis complicating preg-
nancy In which the patient, a woman, aged 36, and In the third
month of her second pregnancy was seized with a severe pain
in the epigastrium, accompanied with nausea aud vomiting;
the bowels were and had been constipated. When seen the
next day by the writer the temperature was 100.5°, pulse 110.
The pain had abated, but the rigidity of the abdominal mus-
cles was very marked, especially of the right rectus, and even
aBPTEMBBB 13, 1902J
THE WOKLD'S LATEST LITERATURE
[Amkkican Medicini, 431
moderate pressure over the location of the appendix gave rise
to pain. Operation was at once decided upon and performed.
The appendix, which was darli -colored and full of concretions,
was removed in the usual manner. The surrounding purulent
serum was carefully sponged out. One strip of gauze packing
was passed down to the stump and another strip passed
down to drain the pelvis and incision closed except at the
lower angle. Four days later the gauze was removed, after
which the patient had two or three attacks of syncope accom-
panied by pains threatening abortion. The pain was easily
controlled by morphin sulfate subcutaneously, and the syn-
cope was treated by alcoholic stimulation. Subsequent recov-
ery was uneventful, pregnancy continued uninterrupted and
at term she was delivered of an 8-pound girl. The diagnosis
of appendicitis complicating labor should be easy, the most
important signs being localized pain, muscular rigidity, and
elevation of pulse and temperature. If the diagnosis is doubt-
ful, the examination of the blood for leukocytosis will be
valuable, as the occurrence of leukocytosis during the
first six months of pregnancy associated with local pain indi-
cates suppuration. This is important since SO^fc of the reported
cases of acute appendicitis have occurred during the first six
months of pregnancy. The treatment should be operation as
soon as diagnosis is made as the danger not only to mother
but to fetus increases rapidly with the increase in sepsis.
Pregnancy adds little, if any, danger to the performance of a
capital operation, while almost the slightest amount of sup-
puration will be fatal to the child and may lead to a fatal
termination for the mother from the extension of sepsis to the
uterus. In operating Donoghue believes thoroughly in the
rectus incision. It is fully as easy to reach the appendix in
this way ; tlie incision is easy to enlarge without cutting nms-
cle fiber, and in healing there is a constant tendency of the rec-
tus fibers to close the opening. If this incision is used and
properly closed there will be little danger of rupture before,
during, or after delivery, [w.k.]
Medical Record.
September 6, 1902. [Vol. 62, No. 10.]
1. OrganacldiaGastrica. Mark Knapp.
2. Estlvoautiininal Fever In Manhattan Island and Its Environs.
Henry Stl'art Patterson.
3. Wliy Is .Modern School Life So Often Disastrous to the Scholars,
Especially to Ulrls? Richard Cole Newton.
4. Prostatic Gonococcal Autoreinfectlons of the Urethra. Terry M.
TOWNSEND.
5. The EfTect of Ferric Perchlorlde in Large Doses in Erysipelas and
Similar Inflammatory Diseases. Jennie G. Drknnan.
6. VaKlnal Operations for Ketroverslons and Retroflexions of the
Uterus, with a Critical Review of Fifty-seven Cases of Vaginal
Snturing of the Round Ligaments (the Author's Operation).
Hiram N. Vinebkrg.
1. — Organacidla Gastrlca.— This takes first rank in dis-
eases of the stomach in importance and frequency. It has not
been recognized because there were no exact, ready means to
demonstrate the organic acids. Knapp reviews tests recently
described by himself. The disease may be diagnosed by the
microscope. Three distinct varieties exist: (1) Organacidia
gastrica simplex ; (2) gastrosis fungosa and (3) zymosis gas-
trica. The first is transitory due to excessive ingestion of
organic acids. The symptoms (heartburn, or cramps and
vomiting) disappear with an emetic or cathartic. The other
forms are chronic, due to mold and yeast. The yellowish-
green of vomited matter is mistaken for bile, the dark-red for
blood. The molds are pencillium glaucum, oidium albicans
and the aspergillus group. Succinic acid is the most frequent
product. The molds are inge8te<l witli foods, cooked and
uncooketl and flourish in saccharine media. The symptoms of
gastrosia fungosa are heartburn, rawness or pain, cramps in the
pyloric area or about the ninth dorsal vertebra, burning in the
epigastrium along the sternum or between tlie shoulder blades,
choking, thirst, polyuria, excessive perspiration, sour regurgi-
tation vomiting and fre<iuently frontal headache. The chyme
is floury, due to hypertony. The autlior describes the micro-
scopic appearances. Cure can be a.ssured within two months
by proper selection and preparation of foo<l, lavage and mineral
acids. Zymosis gastrica is due to yeast. The symptoms are
ilue to COj, vomiting to butyric and acetic acid. Foods
containing yeast and cellulose and sour foods must be avoided
and mineral acids administered, [h.m.]
2.— Estivoautuinnal Fever in Manhattan Island and Its
Environs. — Tertian intermittent fevers developing in or near
New York liave always been common though generally this
fact is unknown. The clinical experience of the last three
summers leads us to infer that estivoautumnal malaria has not
previously been recognized, or that something has happened to
increase the cases. In 1899 the first undoubted case was
observed. Domestic cases seem to date from the period of the
Spanish war. In diagnosis the choice usually lies between
malaria and typhoid. The blood-findings and reactions to
hydrotherapy will decide the question. Quinin and arsenic
together are more efficient than either alone, [h.m.]
3.— Why Modern School tiife is so Often Disastrons.—
Newton blames the parents for not cooperating with the
teachers and for allowing parental vanity to overbalance a just
regard for the physical and mental limitations of tlie child.
The physical inferiority of girls to boys is attributable to lack
of the same amount of active outdoor life, due to never-ceasing,
all-pervading care for their clothes from infancy up. [h.m.]
4. —Prostatic Reinfections of the Urethra.— Townsend
states that the pathologic changes occurring in the prostate
gland when the gonorrheal process proceeds to the prostatic
follicles and becomes subacute or chronic are those which
make possible the autoreinfections seen after intervals of appar-
ent health. He gives in parallel columns the symptoms of
acute infections as opposed to those of prostatic recrudescences,
and dwellsat length on the microscopic features of the urinary
sediment in the latter cases. Rational treatment demands
simultaneous attention to the prostate and tlie uretlira. This
may be accomplished by thorotigh massage of the gland fol-
lowed by irrigation of the anterior and the posterior urethra.
[a.g.e.]
5.— Ferric Perchlorid In Erysipelas. — In the zone of
spreading iuflainmation occurs stasis of the circulation, exuda-
tion of plasma and white cells, and formation of fibrin, which
enmeshes the bacteria, rendering escape difficult and making
them an easier prey to their own secretions. Iron increases
the obstruction by exuding into the tissues causing coagulation
and pressing on the capillaries from witliout. It takes large
doses to produce this coagulating effect, [h.m.]
6.— Vaginal Operation for Retroversion and Ketro-
flexion. — According to Vineberg, Mackenrodt's operation of
vaginal fixation still forms the ideal operation for retroversion
in women past the childbearing period, being used when a pes-
sary cannot be worn or the uterus kept in position ; also in
women approaching the menopause when the retroversion is
associated with marked prolapse, rectocele, and cystocele. In
these cases he sutures the anterior surface of the fundus
directly to the vaginal wall. For women during the child-
bearing period he prefers vaginal suturing of the round liga-
ments, an operation he devised in 1896. He reviews briefly 57
oases operated on by this method with a relapse in only ;t.69t.
In one case of relapse only one suture was employed on each
side and lie, therefore, deems it wiser to use always two sutures
for each round ligament. Considering pregnancy and labor as
the crucial test of an operation, he states that he can report eight
pregnancies in six patients going to full term with easy labors
in all. There have been two miscarriages, one of the patients
subsequently carrying to full term with normal labor, bonce
the first miscarriage was undoubtedly due to other causes than
the operation. Although the number of cases is small, still
from his experience he feels certain there is little likelihood of
dystocia following the operation; but to reduce the risks the
greatest care must be taken not to wound the anterior wall of
the uterus in bringing it into the vaginal incision, since the
raw surface of the uterus might lead to a union of the fundus
with the vaginal wall, a condition to be avoided. He is con-
vinced of the utility of this operation in those cases in which
the uterus is movable and a pessary cannot be worn ; in which
the uterus is more or less fixed by posterior adhesions; in the
same class of cases with moderate diseases of the adnexa.
About 75% of the cases he meets are adapted to the operation of
suturing the round ligaments to the vaginal wall, [w.k.]
482 A.KKBtOAN HbDIOIHeJ
THE WORLD'S LATEST LITEEATUKE
[SBPTEMBEB 13, 1902
New York Medical Journal.
August SO, 190t. [Vol. lxxvi, No. 9.]
1. The Education and Development of Neurotic Children. Ob^.me M.
Hammond.
2. The Passive Carrying Function of the Arm: Its Importance, It«
Destruction, and an Operation for Its Restoration. Puilii- Hoff-
mann.
8. A Harelip Incision. Thomas Fillebkown.
4. Radlodlagnosis of a Case of Traumatic Periostitis. Chables
Verge.
5. Gynecology and the Country Doctor. James Hawlby Bcbten-
6. Tlie Administration of Chloroform and Ether. Helen Hughes.
7. Amnesia, with Report of a Case. 8. D. Hopkins.
8. Nutritive Infusions. Southgate Leigh.
9. The X-rays In the Treatment of Malignant Growths. J. Rudis-Ji-
CINSKY.
10. A Successful Late Laparotomy for Gunshot Wound of the Intes-
tine; Remarks on Suturing. W. S. Pettus.
1. Neurotic Cliildren.— Some nervous disease on the part
of either parent or both is responsil^le for the neurotic tenden-
cies in many children. Alcohol and syphilis are also potent
causes. Hammond believes that this neurotic predisposition,
like the tuberculous predisposition, may be entirely eradicated
by a proper system of training. The diet of such children
should be mainly nitrogenous and the hygienic conditions well
regulated. They should also be taught strict obedience. The
physical culture of these children should be carefully con-
ducted, outdoor exercises preferred, but the important point is
that they should be continued with regularity for years.
[c.A.o.]
2. — See American Medicine, Vol. Ill, No. 24, p. 1002.
3. — A Harelip Incision. — Fillebrown reports a case in
which he used a modified form of the M incision for the cor-
rection of harelip. Cuts illustrating the same are given.
[c.A.o.]
5. —Gynecology and the Country Doctor.— Burtenshaw
urges a more thorough knowledge of the subject of gynecology
on the part of the country doctor, who too frequently is content
to treat symptoms and fails to recognize the true condition and
to institute a proper course of treatment. He discusses meth-
ods of teaching this subject and states the student should have
systematic drilling in diagnosis ; a thorough course in micro-
scopic work, in which normal as well as pathologic sections
are made the subjects of study ; oral examinations or quizzes
at frequent intervals ; and the study of wet specimens, both
normal and pathologic. Methods of treatment should figure
largely in clinical work, and advanced students should be per-
mitted to assist in operations. [c.A.o.]
6. — The administration of chloroform and etlier is
discussed by Hughes. The bulk of testimony is in favor of
ether as an anesthetic. A patient's heart may indicate chloro-
form, but the respiratory organs may be in such a condition
that it becomes a matter of choice between two evils, or a weak
heart may be accompanied by diseased kidneys making ether
nephritis to be feared. In cases of atheromatous vessels
chloroform may be used in the first stage and the narcosis con-
tinued with ether. In operations about the mouth or nose or
in confinement cases chloroform is preferred. Chloroform is
much more apt to be impure than ether. The anesthetist
should examine his patient and should obtain as accurate
information as possible on the condition of the heart, lungs and
kidneys. He should have within reach stimulants, etc., in
case they are needed and should watch the pupils, pulse and
respiration — also the color of the face, ears and nose and the
general expression for signs of approaching danger. [c.A.o.]
7. — Amnesia. — Hopkins reports a case in a man of 34 who
for six months had been drinking heavily and during that time
had noticed that his memory for recent events was poor,
although he could recall the main occurrences until he became
totally amnesic. For 45 days he was totally forgetful and
during this period had evidently performed hard manual labor.
When he awoke he experienced a peculiar sensation as though
some one was drawing a cap over his head and face. He dis-
covered that he was in Denver, Col., although his home was in
New York City, and he recalled having attended a dinner in
that city with his brother 45 days previously. [c.A.o.]
8.— Nutritive Infusions. — Leigh recommends the use of
egg albumen dissolved in normal saline solution for nutritive
subcutaneous injections. He uses about 12 ounces of the solu-
tion to each egg, stirs gently until dissolved and then filters the
solution through sterile cotton. This solution may be kept .36
hours if necessary, and before using the bottle should be gently
warmed by immersion in water at about 105° F. The author
has used the solution in a number of cases and has never had a
bad effect either general or local. It is absorbed as quickly as
the normal salt solution, and the resulting tenderness of the
injected part is about the same. He has not found the albumen
excreted in the urine unchanged. [c.A.o.]
O.— X-rays in Treatment of Malignant Growths.—
Rudis-Jicinsky discusses the subject and reports several cases
of malignant growths treated by x-rays. The first was that of
carcinoma of the right breast in a woman of 46. Ulceration had
begun and the glands in the axilla were involved. To get better
results the field of infection was treated with the x-rays for four
weeks previous to operation, then the whole breast with
lymphatic tissues in the axilla was removed, and the x-ray
treatment continued for eight weeks. The tumor under the
first application of the rays diminished in size, the ulceration
also diminished before operation and pain was wonderfully
decreased. No signs of recurrence. In other cases reported
there was a marked improvement. The author states that
superficial growths with no intervening sound skin may be
treated by a soft or soft medium tube, while internal growths
are attacked better with a high vacuum tube from the first.
[c.A.o.]
10.— Gunshot Wound of the Intestine.- Pettus reports
a case of gunshot wound in which a .32-caliber bullet entered
the body exactly in the median line, half an inch above the root
of the penis. The pelvic bone was slightly fractured. As there
were no symptoms of abdominal injury the abdomen was not
opened at once. About 31 hours later the patient grew rap-
idly worse, with pulse weak and rapid, and abdomen dis-
tended. The abdomen was then opened and found to contain
bloody flocculent serum and fecal matter. The adhesions were
separated and seven ragged perforations of the small intestines
found and closed with fine silk Lembert sutures. The abdo-
men was thoroughly washed out with saline solution and
closed with drainage. Recovery was uneventful. [c.A.o.]
Medical News.
September 6, 1902. [Vol. 81, No. 10.]
1. The Healing of Ulcerative Endocarditis. James B. Herri ck.
2. Characterlstlcsof Pulmonary Valve Affections, with Cases. THOMAS
E. Satterthwaite. . ,
3. A Brief Consideration ot the Scientlflc Treatment of a Few of the
Diseases of the Heart. I. Newton Snively.
4. The Pathology and Treatment of Endo- and Pericarditis. William
Henry Porter.
5. Some Notes on Tricuspid Diseases. Thomas E. Satterthwaite.
B. Embolism of the Mesenteric Artery. Alexandkr Lambert and
W. B COLEY.
1.— See American Medicine, Vol. Ill, No. 20, p. 807.
2.— Pulmonary Valve Affections.- The ratio of this to
other valvular diseases is 1 to 10. Temporary insufficiency is
of common occurrence; chronic insufficiency is not. Satter-
thwaite reports four cases. Errors in diagnosis are likely
from nearness to the aortic area. Congenital insufficiency of
the tricuspid is apt to be associated with pulmonary stenosis
and insufficiency. The chief causes of insufficiency are ulcer-
ative endocarditis, pulmonary stenosis, aortic aneurysm, pul-
monary dilation or some abnormality in the formation of the
valves. The congenital form is recognized by intense cyanosis,
clubbed toes and fingers and abnormal chest. In the acquired
form there are signs of defective nutrition with cyanosis and
dyspnea. The author gives the physical signs in detail. The
prognosis is unfavorable in congenital disease. In acquired
cases the patient may live to be 75. In prophylaxis infections
must be avoided and care given in pulmonary implication. Pul-
monary stenosis is a frequent congenital cardiac anomaly. The
valve defects are usually more curious than dangerous but
when the valves are not separated, are twisted or missing, the
expectation of life is seriously altered. A common associated
anomaly is persistence of the ductus arteriosus. As a single
congenital lesion stenosis is a great rarity. The acquired form
is due to rheumatism, aneurysm, syphilis and gonorrhea. In
the former there is usually, but not always, cyanosis and lack
Skptember 13, 19021
THE WORLD'S LATEST LITERATURE
fAMBKICAN MBDICINK 433
of development. In the acquired form development is not
affected and cyanosis is rarer. Diagnosis is never easy. Prog-
nosis is never good. Life should Ije uneventful and hygienic,
and matrimony forbidden, [h.m.]
3. — Scientific Treatment of Heart Diseases. — Each
patient showing a lesion must be a study by himself. No heart
medicine is needed unless the myocardium is unable to do its
work physiologically. The heart muscle should demand more
consideration than the heart murmur. Rest is the best thera-
peutic agent. We should try to prevent myocarditis in diseases
in which it is apt to arise, and after a severe disease insist upon
the patient resting in bed long enough to allow the myocar-
dium to be restored. We should improve general nutrition
and bring the blood to a normal standard by tonics, and we
should watch the kidneys. Exercise and diet are aids in treat-
ment, [h.m.]
4. — Endocarditis and Pericarditis. — After describing
the pathologic conditions in these diseases Porter emphasizes
the importance of rest in their treatment with general hygiene
and attention to the diet. For the pain and tachycardia direct
applications of heat or cold will often give prompt relief. In
some cases a fly blister may be required. Aspiration is neces-
sary if the heart's action is embarrassed, [h.m.]
5. — Triscuspid Diseases. — Serious affections of the tricus-
pid are, with the exception of pulmonary valve disease, the
most uncommon. They are still more rarely single. Insuf-
ficiency is usually relative. Organic lesions are generally con-
secutive to mitraljOr aortic diseases or general arteriosclerosis.
Yet insufficiency is common as compared with stenosis. Insuf-
ficiency may be congenital or acquired, organic or relative. A
certain amount of enlargement of theelementsof the valve may
take place and even keep pace with the enlargement of the
heart walls in fatty heart, chronic fibrous nephritis, etc. If
there has been any deposit of a fibrous nature in the valve,
however, contraction rather than expansion must take place.
Cervical venous pulsation is an important sign, but not pathog-
nomonic, and is best determined by pressing down the
column of blood, thus showing that the impulse is before and
not behind it. Stasis in the pulmonary veins produces cyanosis
and dyspnea. In organic insufficiency the valves and support-
ing structures become infiltrated and perhaps contracted. If
stenosis is only in the ring, narrowing may occur without insuf-
ficiency. Tricuspid insufficiency is seldom recognized during
life. The author describes the signs. The prognosis is bad.
Stenosis is very uncommon. The idea that it is congenital is
largely abandoned. The majority of the sufferers are women.
Rheumatism is the most frequent cause. Diagnosis has been
made in only six instances. Congenital cases seldom live
more than a few days. In acquired eases much depends on the
condition of life, [h.m.]
6. — Embolism of tlie Mesenteric Artery.— Lambert and
Coley report a case of this rare lesion. The patient was a male
alcoholic of 34, with an old history of chronic appendicitis.
Symptoms were severe, general abdominal pain, distention,
constipation, diminished secretion of urine. Temperature not
above 100°, pulse 112. Prostration and vomiting not marked
until late. Diagnosis in doubt. Operation about .52 hours after
onset disclosed thrombosis of mesenteric vessels and peritonitis.
Death occurred seven hours later. Autopsy showed multiple
infarctions of mesenteric and pulmonary arteries, following
thrombosis of right auricle. Thejrrf was marked general athe-
roma and fatty degeneration of all visceral parenchyma, notably
of the heart muscle. A brief review of similar cases is ap-
pended, [a. O.K.]
Philadelphia Medical Journal.
September 6, ISOt. [Vol. x. No. 10.]
1. The Diagnosis and Treatment of Tuberculous Cystitis. Joseph B.
BI88BI.I..
2. IndlcatlonH for. and Technlc of. Operations for Ncpbroptoslg.
AtJOUSTIN H. OOKI-KT.
3. The Treatment of Uremia (Mixed Toxemia). Eohert H. Ubandin.
4. A Note on Some PsychoseH of Early Puberty, with Keport of a Caso
In a Boy Twelve Years Old. Ai.kkkd Gordon.
5. Infantile (^rebral Paralysis. E. J. Huhnek,
1.— The DiaKnosfs and Treatment of Tuberculous Cysti-
tis,—Tuberculous disease of the bladder is rarely primary, being
generally secondary to a tuberculous condition of the prostate
or kidney. Hematuria is the most frequent and probably the
earliest symptom of the disease, so early in some instances that
it may be called a prodromal symptom. It usually occurs at
the end of urination, and varies in amount from a couple of
drops to a teaspoonful. Pain is frequently present, commenc-
ing early and continuing through the course of the disease.
At times it is so severe as to make one suspect calculus or
malignant ulceration. Tenesmus is usually present. Frequency
of urination is a fairly constant symptom, coming on early in
some cases. As the disease progresses the symptoms increase.
Later pus is always found. The frequent voidance of clear
urine without pain with a few drops of bright red blood at the
end of the urination, or less often preceding it, is almost
pathognomonic of beginning tuberculous cystitis. If the
tubercle bacillus is found it must be ascertained whether it
comes from the bladder, kidney, ureter, seminal vesicles, or
urethra, bearing in mind that the smegma bacillus resembles it
so closely as to deceive expert observers. The pulse is quite sug-
gestive, averaging from 90 to 110, any sudden exertion increas-
ing it to a considerable extent. At present, Bissell believes that
the best chance of recovery is in eliminating the cause, and
building up the resisting powers of the tissues of the body.
[f.c.h.]
2.— Indication for, and Technic of. Operation for Neph-
roptosis.— Nephroptosis always produces symptoms when the
whole organ is below the lower border of the last rib in front.
If symptoms are not found in this stage of descent of the kid-
ney, it is because they are not recognized. Operation is not
advised for prolapse of the first or second degree, except when
the loft kidney is found to be in the second degree of prolapse
at the time of operation upon the right. Then the left kidney
should be fixed at the same time to avoid the necessity of a
second operation which would otherwise be required subse-
quently. When prolapse of the third degree or beyond is dis-
covered, the operation for fixation should be done without
delay, unless the kidney is found to be irreparably diseased.
Operation is necessary in these cases, not because of the symp-
toms, which are seldom unbearable, but because prolapse of the
kidney in this stage gives rise to pelvic disease and because
structural disease of the kidney may develop at any time. The
method by which he fixes the kidney is detailed, [f.c.h.]
3.— The Treatment of Uremia (Mixed Toxemia).— Gran-
din believes that the symptoms depend on a toxin emanating
from the kidneys, liver and intestines, and when pregnancy ex-
ists, possibly from the body of the fetus, and discusses the condi-
tion as a postoperative sequel or as a complication of the puer-
peral state. The treatment may be considered as follows : The
prophylactic, which aims at warding off the toxemia; the
emergency treatment, which is applicable in the presence of
toxemia; and the surgical treatment, when pregnancy exists.
When toxemia is active chloroform should be administered. If
the pulse is full and bounding, venesection is to be preferred to
veratrum virlde, which drug he has found very unsatisfactory.
Opium is to be condemned. If it seems wise to use calmative
drugs at least 00 grains of chloral and 120 grains of sodium
bromid may be given per rectum. These two drugs should
always be given in large doses. The uterus should be emptied
as rapidly as is consistent with the integrity of the maternal
soft parts, [f.c.h.]
4.— A Note on Some Psychoses of Early Puberty.—
Gordon refers only to those degenerates whose mental symp-
toms are only episodic in character, symptoms which i)re-
sent psycopathic disturbances but with total lucidity of
mind. A very interesting case occurring in a boy aged 12 is
detailed, [f.c.h.]
5.— Infantile Cerebral Paralysls.-Huhner gives the fol-
lowing indicjitions for treatment: To maintain nutrition, by
means of massage and electricity ; and to correct deformity, by
surgical and mechanic measures. The greatest good is derived
from tenotomy. Hemiplegia and paraplegia are more benefited
Ijy this procedure than diplegia. Not only is the deformity cor-
rected but the mental condition is improved. Some retention
apparatus should be applied after the operation, [f.c.h.]
434 AnBioAN Mbdioikbj
THE WORLD'S LATEST LITERATUEE
[Septembeb is, 1902
ClilNICAIi MEDICINE
David Riesman A. O. J. Kelly
Hodgfkin's Disease (Pseudoleukemia) and Tuber-
culosis.— Recently Hodgkin's diseii.se, more especially
its reputed relation to tuberculosis, has attracted con-
siderable attention, and the literature of the subject has
been enriched by a number of valuable contributions —
more particularly those by Clarke and others, in a dis-
cussion on lymphadenoma, at the meeting of the British
Medical Association in 1901 {British 3Iedical Journal, ii,
701, 1901), by Musser {American Medicine, iii, 13, 1902),
by Sailer {Philadelphia Medical Journal, x, 615, 669,
1902), and by Dorothy Eeed {Johns Hopkins Hospital Be-
porls, X, 133, 1902). With regard to the undoubted a.ssocia-
tion of tuberculosis and Hodgkin's disease in some cases
reported in the literature, several views are entertained :
Thus, on the one hand, it is maintained that the tuber-
culosis is merely associated with, or occurs as a terminal
infection in, Hodgkin's disease ; whereas, on the other
hand, it is maintained that the tubercle bacillus is the
actual exciting cause of the lymph gland lesions in
Hodgkin's disease. Especial interest attaches to the
latter question. Though suggested previously, it was
first brought prominently to the attention of the pro-
fession by Sternberg, who, reporting the results of his
studies, maintained the essential tuberculous nature of
Hodgkin's disesise. Musser and Sailer incline to this
view of the subject, whereas Clarke and Reed take the
opposite view. Reed details the results of an exhaustive
study of eight cases of Hodgkin's disease, with especial
reference to the pathologic lesions. She maintains that
Hodgkin's disease has a peculiar and typical histologic
picture, consisting of proliferation of the endothelial
and reticular cells, the formation of lymphoid cells,
and characteristic giant cells, and a gradual increase
of connective tissue, resulting in fibrosis and, in most
cases, in the presence of great numbers of eosinophile
cells; and she concludes that we should limit the
term Hodgkin's disease to a clinical and pathologic
entity, the main features of which are painless,
progressive glandular enlargements, usually starting in
the cervical region, without the blood changes of leu-
kemia, and with a specific histologic picture— not a
simple hyperplasia, but changes suggesting a chronic
inflammatory process. She further believes that micro-
scopic examination of the gland tissue is sufficient for
diagnostic purposes, and that the diagnosis may be con-
firmed by the negative results of animal inoculations ;
that eosinophile cells, which are usually present in large
numbers, strengthen the diagnosis ; and that the patho-
logic agent is as yet undiscovered— tuberculosis having
no direct relation to the lesions. As opposed to these
may be mentioned the views of Musser and Sailer.
Musser, reporting two cases of Ebstein's disease (the re-
current fever of Hodgkin's disease) expresses the opinion
that the disease is in all probability a lymphatic tuber-
culosis, and Sailer reporting four cases of lymphatic
tuberculosis that resembled pseudoleukemia (or Hodg-
kin's disease), admits that none of the evidence hitherto
presented can be regarded as decisive, but inclines rather
to the opinion that the majority, if not all, the cases of
Hodgkin's disease will ultimately be regarded as tuber-
culous in nature, and he finds support for his opinion in
the statement of Pinkus, who says that " the question
whether tuberculosis is invariably present in those glands
which show changes of pseudoleukemia can only be de-
cided by a considerable increase of the available material.
The fact that the more carefully the investigations are
conducted, with all the aids of modern knowledge, the
more frequently has the tuberculous nature of the pro-
cess been proved, argues strongly for the influence of
tuberculosis in these cases." Important evidence of the
tuberculous nature of some of the cases is found in the
results of animal inoculations— the production of tuber-
culosis by injecting portions of diseased glands, and by
staining procedures that reveal the tubercle bacillus,
even in the absence of typical histologic appearances of
tuberculosis. Presuming the tuberculous nature of the
cases, interest attaches to the reason for the extraordi-
nary manifestations of the tubercle bacillus. This Sailer
explains by pointing out the well known variations of
the tubercle bacillus both in man and in the lower ani-
mals, and he suggests that in Hodgkin's disease we have
to deal with a variety of the tutercle bacillus that differs
somewhat from the one that ordinarily infects human
beings. The marked similarity in the clinical manifes-
tations of tuberculosis of the lymph glands and Hodg-
kin's disease (if this be a distinct entity) is certainly
striking, and has been commented upon by a number of
writers, some of whom have attempted to postulate
symptoms that shall serve to differentiate the two dis-
eases. In this connection Gulland {British Medical Jour-
nal, ii, 809, 1901) states: '*All this (certain symptoms
postulated of Hodgkin's disease), however, corresponds
so exactly with what we know occurs in generalized
tuberculosis of glands, that it is difficult to believe that
any other organism can produce effects so precisely simi-
lar, and one is forcibly reminded of the old joke that the
' Iliad ' and * Odyssey ' were not written by Homer, as
is usually supposed, but by another gentleman who lived
about the same time and bore the same name." Evi-
dently the last word on the subject Ijas not yet been
said, and should it ultimately be proved that Hodgkin's
disease is tuberculous in nature we shall still have to
explain the absence of a response to tuberculin injections
in one of Sailer's cases and in five of Reed's cases.
Postscarlatinal Diphtheria.— W. T. Gordon Pngh' begins
his article with a statistical review of this affection. Previous to
1895 only cases of scarlet fever which showed clinical diphtheria,
having membrane in the fauces or exhibiting laryngeal
symptoms, were designated postscarlatinal diphtheria; since
that year all cases of secondary throat illness a,ssociated
with diphtheria bacillus have been returned as diphtherial. It
is probable that the majority of the cases now seen would
formerly have been described as tonsillitis. The influence of
the change in the basis of diagnosis and the introduction of a
new method of treatment is noticeable in the statistical tables.
A terrible mortality occurred among patients attacked by this
complication in the years before the introduction of antitoxin,
when diphtheria assisted in producing a fatal issue in over 12%
of the scarlet fever deaths. This may be happily contrasted
with the conditions in 1901, when of 3,00t scarlet fever patients
under treatment only one died who had suffered from sec-
ondary diphtheria. The number of female patients develop-
ing secondary diphtheria is larger than that of males. Pugh
states that this aflfeetion leads to the following conclusions:
1. The principal cause of postscarlatinal diphtheria is the
admission into the scarlet fever wards of patients who, whether
suffering from clinical diphtheria or not, are carriers of viru-
lent diphtheria bacilli. 2. In large centers of population where
diphtheria always exists, diphtheria bacilli are to be found in
a not inconsiderable proportion of school children. In the ab-
sence both of evidence of clinical diphtheria and of a history of
exposure to that affection, the bacilli are, in a majority of cases,
of the nonvirulent or saprophytic type and of little hygienic im-
portance ; in cases, on the other hand, where the clinical sup-
ports the bacteriologic examination the bacilli are almost en-
tirely virulent, and therefore dangerous ; while in cases where
the patient is known to have been exposed to infection the
cliances are great that the organisms are of the pathogenic
variety, and such cases should always be regarded with grave
suspicion. 3. On account of the prevalence of the nonvirulent
bacillus and the fallacies of single cultures, it may be doubted
whether a routine bacteriologic examination of throat and nose
of all patients on admission would prove of sufficient value to
repay the labor involved. Chief reliance must be placed on a
careful inspection on admission, not only of the throat, but also
of the nasal cavities, bacteriologic examination being resorted
' Journal of Hygiene, July 1, 1902.
Septembkr 13, 1902J
THE WOELD'S LATEST LITERATURE
[American Medicinb 436
to in cases of doubt. 3. In eradicating infection from an in-
vaded ward bacteriologie methods are, on tlie other hand, of
prime importance, since children with apparently healthy-
throats and noses are often found to have acquired the virulent
bacillus. An attempt to stamp out any outbreak of diphtheria
by bacteriologie examination of the throat alone is, however,
futile, owing to the frequent infection of the nasal cavities.
5. Fibrinous rhinitis, which appears to be a not infrequent,
though often unrecognized, affection of children is a common
form of postscarlatinal diphtheria. 6. Althougli the treatment
of diphtheria in the same hospital has no appreciable influence
on the incidence of this complication of scarlet fever, it is
advisable that precautions should be taken lest nurses harbor-
ing diphtheria bacilli carry infection from the diphtheria to the
scarlet fever wards. 7. To limit the risk of exposure to infec-
tion many-bedded wards should be avoided, and the mixing of
patients from different wards prevented. [c.s.D.]
Causal Relation of Cocci to Rheumatism. — Bell'
thinks rheumatism a symptom of many different conditions.
The ordinary " rheumatic diathesis " is of a chemic nature and
productive of chronic manifestations. The other forms are due
to bacterial toxemias. They are for the most part of an acute
nature, of sudden onset, with more or less sudden termination.
The various cocci concerned may be modifications of one orig-
inal form, capable under certain conditions of undergoing re-
arrangement of morphology and properties. Where a bacillus
has been blamed, the case is probably one of mixed infection
with the presencb of cocci, as in postdiphtheritic rheumatism.
Acute rheumatic inflammation of the joints is nonsuppurative
because the toxemia is not produced at the site of the mani-
festation. Those joints wliich suppurate may begin as " rheu-
matic " joints, but later are visited by pyogenic organisms, as
in pneumococcal and gonococcal arthritis. He believes the
socalled specific diplococcus is a modification of either the
strepto or staphylococcus and that it is by this that the ordi-
nary nonsuppurating rheumatic fever is produced, [h.m.]
A Case of Meniere's Disease Cured by Galvanism.—
Geschiet '' reports a case of therapeutic interest. There was asso-
ciated with the Meniere's disease a chronic catarrh of the
mucous membrane of the tympanic cavity, and as the
catarrh was treated for several months with no results as
regards the Meniere's disease, and as the former remained
some months after the latter was cured, indicates that the
M6ni('^re's disease was not dependent upon the catarrh. Geschiet
believed the condition was caused Ijy passive hyperemia due to
sympatliotic disturbance. The patient had been treated with
potassium iodid which he could take no longer. Quinin was
next prescribed becaviso Charcot believes that by producing
deafness the feeling of vertigo will cease. A week later it was
found that his condition had grown worse, so the quinin was
stopped and galvanism begun. The positive pole was placed
on the tragus of the external ear on the affected side, and tiie
negative pole over the cervical vertebras. Geschiet >ised a
■! to 4 milliampere current in 3-minute treatments every other
(lay. After the hyperesthesia of the affected ear had disap-
peared the poles were placed on both tragi. After two treat-
ments the patient no longer complaine<1 of vertigo and after 25
treatments he experienced no more attacks, his gait became
steady and he returned to work. The galvanism is believed to
act by contracting the bloodvessels of the laliyrinth of the
internal ear and thus removing the venous stasis. [w.K.n.]
A case of hemorrhagic exudative erythema (Henoch's
purpura) is reported by Carter.' The points of interest in the
case are: At first apparently an ordinary attack of rheumatic
purpura with typical eruption and joint symptoms, prwreded
by sore throat; excessive amount of indican in the urine at
first, later never more than a trace ; temperature, i)ulse and
respiration never above the normal ; no hemorrhages from the
visible mucous membranes ; very severe alxlominal pain, lim-
ited to the upper half of the abdomen and usually most marked
over the stomach area, which began shortly after the appearance
of the skin eruption and increased In intensity, reaching its
' Kdlnhurgh .Medical .loiinial, Aiietist. lOOi.
2 Berliner kllnlHche WoeheiiHctirlft. April 7, 1902.
•American Juiirnal of the Medical Mclenccs, cxxlv, 296, I80Z.
climax when the eruption was most marked, except for the
slight modification in the last relapse; relapses 3 to 10 days
apart; entire illness three and one-half weeks; no hyperleuko-
cytosis ; the course of the disease and relapses and pain unin-
fluenced by salol, salicylates, ergot, gelatin, acetanilid, iron,
bismuth, alkalies, water, chloroform, calcium chlorid and poul-
tices ; pain only relieved by morphin. [a.o.j.k.]
The Significance of Bacillus coll communis in
Drinkini; Water. — William G. Savage,' after referring to the
significance of Bacillus coU communis and the history of its
occurrence in drinking waters, presents studies of his own and
concludes (1) that in estimating the significance of this organ-
ism in a sample of water the particular kind of water must be
carefully considered, also the exact part of the system from
which the sample is taken ; (2) the number of the organisms
present is an essential factor, but arbitrary standards of the
number of this organism allowable per liter are of but little
value and are fraught with considerable possibilities of error
unless the particular kind of water and the local conditions are
considered in every ease; (3) waters which show no Bacillus
coH in 50 cc. are of a high degree of purity, and therefore the
proved absence of this organism in this amount, and still better
in larger quantities, is of great value; (4) Bacillus coli should
be absent from at least 50 cc. of spring water, possibly from
greater amounts ; (5) in upland surface water the presence of
B. coli in 40, 10, or even 2 or 1 cc. means contamination, but not
necessarily a contamination which it is essential to prevent.
It may be from contamination with the excreta of animals
grazing on the gathering areas, and is by no means necessarily
from sewage or other material containing specific organisms of
infection. Further, there is no evidence that an amount of such
animal contamination sufficient to cause a considerable number
of iJa(n7/Mscoit per liter to be present in the water is harmful.
If B. coli are present in waters greater than 500 per liter (or
even in that amount) such a water is suspicious, as it is rare to
get so many in a water purely from the kind of animal contami-
nation indicated, and further investigation is desirable. In fil-
tered samples the number is as a rule considerably reduced ; (6)
chemic analysis cannot be considered a delicate method of
detecting organic contamination, becauseit may fail with many
waters in which pollution is undoubtedly taking place ; (7) in
surface wells B. coli in large numbers indicate surface or other
contamination generally very undesirable if not actually
dangerous. A knowledge of the position and possibilities of
contamination is very desirable in giving an opinion as to the
purity of the water, [c.s.n.]
The Chemic and Therapeutic Properties of Ijach-
nanthes Xinctoria. — Gardner, Spitta and Latham^ issue a
preliminary note concerning the chemic and therapeutic prop-
erties of lachnanthes tinctoria, which they have recently inves-
tigated. They state that lachnanthes consists largely of a
resinous substance or substances and some body precipitated by
lead subacetate, and soluble in water. So small a dose as 5cc.
of an aqueous solution of the material obtained by alcoholic
extraction of the plant is sufficiently powerful to kill guinea-
pigs, while doses varying from 1 cc. to 3 cc. of the same solution
do not exert any inhibitory action upon tlie progress of tuiier-
culosis, but rather seem to hasten it. Further experiments are
being made and will eventually be published, [a.o.j.k.]
GYNECOLOGY AND OBSTETRICS
WiLMEB Krusen Frank C. Hammond
Electricity in Gynecology.— The successful employ-
ment of electricity in the treatment of the cUsea.ses of
women probably dates from 1886, when Apostoli, of
Paris, published the results of five years' exijerience of
its use in gynecologic ca.ses. Many attempts had been
made in previous years to utilize electric energy in
various ways, but it remained for him to formulate
plans for more accurate dosage and systematic use. In
order that electric treatment should be successful a suit-
> The .Journal of Hygiene, July 1, 1902.
• Lancet, July 12, IMU.
436 AXXBICAN MBDICINB]
THE WOELD'S LATEST LITEKATURE
[September 13, 1902
able armamentarium is required, and a thorough knowl-
edge of the modes of application and of the action of the
various currents is essential. Results which have been
claimed by different advocates of this method of treat-
ment are nothing short of marvelous, and yet we find
very few of the practical gynecologists and teachers of
the j)resont decade who utilize or advocate the employ-
ment of this therapeutic agent. P^ither they have not
secured the satisfactory results claimed by special plead-
ers in behalf of this method or _they have found other
more rapidly acting and satisfactory methods for reliev-
ing their patients.
Electricity has been advised in amenorrhea, dysmen-
orrhea and menorrhagia ; in chronic uterine inflamma-
tion when una.ssociated with suppuration ; for the arrest
of hemorrhage and relief of pain and decrease of size in
myomatous growths of the uterus, and for chronic
ovarian inflammation. It has also been applied in cer-
tain forms of malignant disease ; and not many years
ago many obstetricians were advocating the use of elec-
tricity to kill the fetus in cases of ectopic gestation, and
one of the advocates stated that " it was safe to predict
that electricity would yet become the only method of
treatment in ectopic gestation prior to the rupture of the
sac," a prediction which fortunately has not come true.
In reviewing the claims of electrotherapy to suc-
cessful treatment of pelvic disorders and noting the time
required and the possibility of failure, one cannot but
feel that surgery is usually more safe, more satis-
factory and more successful. F'or instance, in the
treatment of uterine fibroids in which the best results
have been reported, the perfection of the operation
of hysterectomy, or of myomectomy in selected casas,
has diminished the necessity for palliative methods such
as the employment of ergot or the use of the galvanic
current. Many gynecologists have found that electricity
has not stood the test of time and experience. Accord-
ing to Penrose, it does not stop the growth of the tumor,
it has caused many deaths and it may produce peritoneal
adhesions which render subsequent operation most diffi-
cult. One of the great dangers in the use of an agent of
this kind is that the patient is lulled into a sense of false
security by being made to believe that a valuable reme-
dial agent is being employed until complications arise
from either increased size in the growth or in increased
density of adhesions to the viscera which render the
inevitable operation more difficult and dangerous. As
to the use of electricity in malignant disease of any of
the pelvic organs we can speak only to condemn. In a
condition in which only early operation can give the
patient any chance of freedom from recurrence, the use
of any other method than the surgical is unjustifiable, if
there is the slightest possibility of completely eradicating
the malignant disease. In general nervous disorders
occurring in women electricity, as employed by the
neurologists when tonic and sedative effects of a decided
character are desired for a general systemic influence,
has its proper place and is thoroughly appreciated ; but
for organic disease of the organs of generation it can at
least be said that other agents have proved more prac-
ticable, more rapid in their action and more generally
satisfactory to physician and patient.
Six Cases of Labor Induced by Elastic Metal Bougies.
— Because the absolutely certain sterilization of rubber bougies
is not possible, Schieb ' prefers to use metallic bougies as recom-
mended by Knapp, and gives a history of six cases in which
labor was successfully induced with favorable results; two
were cases of narrow pelves, one tuberculosis of lungs, and
three were heart failure in connection with chronic Bright's
disease and general edema. The advantages claimed for this
method are: (1) Absolute sterilization of the metal bougies by
boiling in 1% soda solution; (2) the greater flexibility of the
metal bougie in comparison with Krause's bougies, a quality
specially desirable in cases of deformed pelves; (3) the early
•Wiener kllnlsche Wochenschrlft, August 7, 1902.
beginning of labor after the introduction of the bougies, as
affirmed by Skutsch. [w.K.]
A Case of Extensive Pyometra of a Puerperal Uterus
Bicornis Cured by Operation.— Emil Seuger-Grefeld ' states
that he was first called to see the patient, a primapara, aged 2.5,
five weeks after a normal delivery. For three weeks the puer-
perium had been without fever, followed by an intermittent
fever, temperature 39.5° C, loss of appetite and decreasing
strength. Examination showed a tense, smooth swelling ex-
tending from the left toward the right and from above the
navel down into the lower pelvis. It was hard, painful, sensi-
tive to touch, without fluctuation, and not movable. His un-
certain diagnosis was that the swelling was a collection of pus
resulting from a circumscribed peritonitis and parametritis.
A test puncture gave yellow pus. He then made a long, curved
incision through the skin, separated the muscular coat, and
looked for adhesions, but was surprised to find none. The
peritoneum was free, but within lay a large tumor with a
smooth, serous surface. This proved to be the right horn of
the uterus. It was emptied of 5 or 6 liters of pus. Then
owing to the weak condition of the patient he partly closes the
abdominal incision with temporary stitches, packed the uterus
with gauze, pushed it to one side as far as possible, fastened it
with sutures to the abdominal wall so that it could not fall back
into the abdominal cavity, also that all escaping fluid might
flow outward. The patient's condition gradually improved
and about a week later the pus sac, or enlarged uterine horn,
was removed and the abdomen closed with sutures in three
layers. Recovery was satisfactory. Eight months later exam-
ination showed a uterus of normal size in normal position,
and the patient in good health with regular menses without
pain. The writer concludes that this left horn was practically
closed to the outer world, no passage connecting it with the
portio being perceptible ; but that there must have been a
microscopic connection suflicient to permit the passage of
enough fluid to become the seat of infection. [w.K.]
TREATMENT
SoiiOMON SoLis Cohen
H. C. Wood, Jr. L. F. Applbman
Treatment of Sciatica. — Brieger [Berliner klinUche
Wochenschrift, May 5, 1902) reports eight cases of sciatica which
were treated by hydrotherapeutic methods. Of 24 other ob-
served patients only one failed to recover. The principle of
this method depends upon the proper combination of heat and
cold. The recovery is more rapid if the hydropathic proced-
ures are accompanied by massage and movements. During the
application of a hot douche the leg is massaged, after which it
is exposed to a cold douche. Brieger cites several patients who
had been treated only by massage at a sanitarium and who
tailed to recover. He also gives hot tub baths at a temperature
of 38° C, and during the bath passive and active movements are
practised. If the latter be performed when in the hot water
considerable of the excruciating pain that accompanies motion
in sciatica is avoided. By this method of baths, douches and
movements patients of one year standing recovered in 46 days
and in one case of two years' duration the sciatica disappeared
in 13 days, [w.e.b.]
Treatment of Erysipelas by Heat.— A new treatment for
erysipelas is offered by Tregubow, of Charkow ( Deutsche medi-
einische Wochenschrift, July 3, 1902), which consists in subject-
ing the erysipelatous area to a flame until a burn of the first
degree is developed. He has proved in a large number of cases
that it is as effectual as simple. His method consists in igniting
a cotton ball saturated with alcohol and passing it by means of
a probe or swab-stick within 1 cm. of the affected area. As soon
as pain is felt the flame should be moved to another portion,
and so on until the entire region has been treated. No bad re-
sults occur if by chance the flame should touch the skin. An
ordinary alcohol lamp may be used. The treatment should be
repeated two or three times a day. Most of Tregubow's cases
required but two days' treatment, [w.e.r.]
> Wiener kllnUche Wochenschrlft, August 18, 1902.
September 13, 1902]
THE WOELD'S LATEST LITEEATURE
(Akebican Mebicikx 437
Electricity tn the Treatment of Cicatrices.— Ohmann-
Dumesnil (Cohen's "System of Physiologic Therapeutics")
writes that while it may be true that scars cannot be totally
obliterated by means of electric therapy, such good results may
be obtained as to amount very nearly to a total removal of these
unsightly secondary lesions. The three varieties of scars
usually encountered are the hypertrophic, the atrophic, and the
telangiectatic. In the first, cases arise in which a plastic opera-
tion cannot be performed, and here it is that electric treatment
yields excellent results. The purpose is to reduce the hyper-
trophy of connective tissue, and this is done best by passing the
electrolytic needle deep into the thickened tissue of the scar.
The needle may be single or multiple, and must be connected
with the negative pole, a sufficient amperage being employed,
but with care to avoid caustic effect. Shrinking and thinning
of the scar will be found to follow such a course of treatment.
On the other hand, in the case of the atrophic scar, which is
depressed, the electrolytic needle is passed in the tissues hori-
zontally, just below the epidermal layer, which is present, and
this latter is entirely removed. The current must be one of
sufficient strength to cauterize, the needle being attached to the
negative pole. After this operation has been completed, which
should be at one sitting, an impermeable dressing Is placed on
the denuded surface. This dressing may consist of surgeon's
adhesive rubber plasterer of a sufficiently thick layer of liquid
gutta percha. The depressed area will soon rise and assume a
more normal color. If one operation is not sufficient to obtain
the desired result, a repetition of it will generally be successful.
The telangiectatic scar, having distended arterioles running
over it and visible, is to be treated in the manner advise(f for
angioma. Scars are occasionally encountered that are pig-
mented, although neither hypertrophic nor depressed. The
discoloration may partially be removed by what might be
called electrolytic stippling. This is done by using a single
needle connected with the negative pole, a current of from four
to six milliamperes being employed. By making the punc-
tures at regular intervals, a general tint is given that is very
close to the natural. The short interval between the punctures
avoids imparting the dead white color that is as disfiguring as
the pigmentation.
Gaaiacol in the Extracting of Teeth.— B. Marichal(fie-
vista cle la Associadon Medico Fdrmacektica de la Isla de Cuba,
Vol. Ij, No. 7) recommends guaiacol as an antiseptic for dental
use employed in sterilized olive oil, 1 gm. to 10 com. Not
only does this exercise powerful antiseptic action but is valu-
able as an analgesic and antineuralgic in the treatment of pain-
ful symptoms of pulpitis. He recommends its use by injection
into the gums after the manner in which cocain is used. [c.s.D.]
Climatic Treatment of Habit of Abortion and Ster-
ility.-" In all cases, of course, such causes as anemia, syphilis,
the presence of endometris, and a chronically congested state of
the uterus must be looked for, and in some cases spas and
climates may take a share in the removal of such causes. It is
Ivardly necessary to refer to the necessity for rest and the avoid-
ance of mental excitement when there is a tendency to abortion,
and the possible advantages of a quiet health resort in such
cases. Repeated courses of the Nauheini treatment, assisted by
prolonged rest for the uterus, have apparently overcome the
tendency to miscarriage (II. Weber) in cases associated with
dilation of the heart. In sterility, balneotherapeutic treatment,
for instance, at Ems, in Germany, and at Healing Springs, in
Virginia, may sometimes have a directly favorable local action
by curing leukorrhea, endometritis, and kindred affections,
and thus correcting the acidity and abnormal <|ualities of the
secretion by which the spermatozoa are destroyed. The relief
of the constitutional disorder and the improvement of the
general health may account for the good result of visits to
health resorts in many cases. Sir H. Weber has seen good
results follow treatment by various climates and mineral water
health resorts, and is inclined to attribute them to the improve-
ment in the general health of the patients, to the long separation
from the husbands and the consequent rest of the sexual
organs, and to increased vigor, due to abstinence, on the part of
the husbands."— F. Parkes Weber, " CUmatotherapy," Book
It.
Intramuscular Injections of Soluble Mercurial Prepa-
rations.— Barthelemy, Levy-Bing and Lafay (La Midecine
Moderne, Vol. xiii, No. 19, 1902, p. 160) have made 1,050 intra-
muscular injections of an oily solution of mercury biniodid in
the treatment of syphilis, in the dose of J grain to each injection
of 15 minims. This treatment sometimes causes pain which
lasts for three or four hours, and it is likely to cause small nod-
ules at the point of injection, but a cure Is rapidly effected. An
aqueous solution may also be used, in the dose of J to J grain to
each injection of 15 minims. This solution is painless, does not
cause nodules, is less liable to cause stomatitis, and equally
good results follow its use. These injections were made daily
for from 20 to 25 days, [l.f.a.]
In the Second Stage of Acute Bronchitis. — A useful pre-
scription is
Ammonium chlorid 2 drams
Syrup of tar 3 ounces
Heroin hydrochlorate 2 grains
Compound tincture of cardamom 1 ounce
Anise water, enough to make 6 ounces
Dessertspoonful 4 times a day. [H.c.w,]
For Itching. — Dr. Hartzell (TherapexUic Gazette, Vol. xxvi,
No. 2) recommends the following :
Carbolic acid J dram
Glycerin , .... 2 drams
Camphor water, to make 4 ounces
This is mopped on the affected parts every 3 or 4 hours. Or,
Carbolic acid 10 to 15 grains
Suthsubnitrate } °' ^^ ^ drams
Petrolatum j ounce
[H.C.W.]
Offensive Breath. — The Practitioner for April publishes :
Solution of chlorinated sodium 1 dram
Peppermint water 6 ounces
To be used as a gargle, [h.c.w.]
Pills for Ovarian Neuralgia. —
Extract of belladonna 3 grains
Extract of stramonium 5 grains
Lactophenin 90 grains
For 20 pills ; 2 or 3 daily.
— Bulletin OinSral de ThSrapeutique, Vol. cxliii, No. 16, 1902.
[L.F.A.]
OPHTHALiMOLOGY
Walter L. Ptle
Subcutaneous Iiyection of Strycliuia in Atrophy
of the Optic Nerve. — In view of the fatality to vision
of progressive atrophy of the optic nerve, and the little
hope offered by modern ocular therapeutics, any care-
fully conducted observations in the treatment of this dis-
ease are of the utmost importance. Electricity has been
generally abandoned, and most authorities ignore or
mention without recommendation the method of treat-
ment by local subcutjineous injection of strychnia intro-
duced by Nagel in 1872. In fact the impression is
largely given that the same or better effects may be
obtained by internal administration of this drug. Has-
kett Derby ' protests against such attitude toward a pro-
cedure so valuable as Nagel's.
Derby has been able to collect from his own practice
the following statistics relative to 117 cases of optic
atrophy: ( )f these 78 were males, average age 43.7; 38
were females, average age 37.7. Both eyes were affected
in 8iJ cases ; one only in 31 cases. In 71 cases there was
no history to be traced. In the remaining 46 he found
the following probable causes : Abase of alcohol and
tobacco, 11 ; syphilis, 8 ; blow on head, 9 ; brain disease,
6 ; apoplexy, 1 ; epilepsy, 1 ; locomotor ataxia, 1 ; men-
ingitis, 2 ; optic neuritis, 2 ; erysipelas, after lacrimal
abscess, 1 ; mumps (both cases children), 2 ; following
pregnancy, 1 ; tumor of pituitary body, 1.
By the employment of subcutaneous injections of
strychnia in the temples in increasing doses in 26 cases,
1 Boston Medical end Surgical Journal, May 15, 1902.
488 Akbbioan MkdicinkI
THE WORLD'S LATEST LITERATOBE
[Heptembbr 13, 1902
he obtained appreciable benefit in 8, temporary benefit in
2, doubtful benefit in 1, and no improvement in 15 (the
disease progressing and terminating in blindness). In
each case the patient was under observation a sufiicient
time to allow conservative judgment.
There is good reason to believe that strychnia is a
stimulant to the optic nerve and even in normal eyes it
temporarily slightly increases the acuteness and field of
vision. In a i)rogre8sive case of optic atrophy Derby
thinks it is our duty to state clearly to the patient that
the local subcutaneous Injection of this drug has, to say
the least, coincided with an arrest in the progress of the
disease, and has been followed by a somewhat increased
acuteness of vision, which effect, however, ha.t not been
observed sufficiently to pronounce it permanent. The
patient threatened with incurable blindness may then
decide for himself as to taking the treatment. Either
temple is used alternately, and under antiseptic precau-
tions little local irritation is observed. Beginning with
gr. jV there is added gr. y J^ daily, until constitutional
effects are noticed, usually about the tenth day. As the
temple begins to be sensitive about this time the injec-
tions are discontinued for 10 days and then repeated.
Occasionally a third course will be found to be of advan-
tage. In some cases additional strychnia may be given
by the mouth. Derby mentions one case in a young
man of 23, who was first given gr. ^\ after each meal by
the mouth and the same amount by injection in the tem-
ple daily (gr. ^\ in all). In two months the dose was
gradually increased to gr. ^ after each meal and gr. ^
subcutaneously, making gr. J daily, which was kept up
for one year. At the time of report, gr. y' was given
by injection and gr. |f to gr. |§ after each meal, making
gr. 1/y daily, and this has been continued for several
months without untoward effect-i, except once when it
was likely that the gr. i of strychnia was injected into a
vein. Tonics were employed moderately, and at times
when pallor of the face was marked nitroglycerin was
used with benefit.
From inability to count fingers a year previously
this patient was able to distinguish some colors, see the
glass in his father's green-house, and even make out the
leaves on the plants. In another case, the patient, an
intelligent man of 33, who was given courses of injec-
tions at varying periods for ten years, stated after
Hiature deliberation that in three instances he considered
his disease to have been distinctly checked, while in the
other two " remarkable improvement " had followed.
The Use of Adrenalin Chlorid in Ophthalmology.
— This substance is dispensed commercially in 1 : 1,000
solution, and is used in the eye in further dilution up to
1 : 10,000. Boiled water or sterilized salt solution should
be used as a diluent, and the solution should be kept in
stoppered colored bottles, or it will turn red, although its
activity is retained. When in-tilled in the eye it causes
at first a slight smarting, and there is soon noticed a
blanching of the conjunctiva, particularly about the
caruncle, most marked in about five minutes. After
five or ten minutes this effect gradually subsides. The
solution does not produce anesthesia nor is the pupil or
accommodation affected, and it is likely that in weak
solution intraocular tension is unaltered, although adre-
nalin has been recommended to reduce abnormally high
tension. No toxic effects have been reported in ophthal-
mic literature. On account of the frequent instillations
necessary and the tendency to oxidation it is better to
use the adrenalin alone rather than in combination, and
before the application of cocain or atropin. It is not so
active in acute as in chronic hyperemia. It is rapidly
absorbed in the anterior chamber, and hence is of value
in iritis in conjunction with atropin. It is especially
efficient in relieving the photophobia due to infiamma-
tion of the anterior ocular segment, but must not be
used in certain forms of corneal ulceration associated
with marked denutrition. The instillation of the solu-
tion before and during ocular operations helps to control
hemorrhage, and no secondary hemorrhage has been
observed, although after section of the larger vessels
this may be quite possible. Two or three minims of
adrenalin solution injected under the conjunctiva has a
more lasting effect in tenotomy. Reynolds' contends
that in many cases adrenalin will so reduce swelling in
the lacrimal passages as to allow the use of Anel's syringe
without previous probing. It is claimed by Ferdinands '
and others that the instillation of adrenalin solution
seems to hasten the absorption of seroas exudation, and
certainly assists in the dissipation of subcorneal deposits.
There is, however, not entire unanimity of opinion
in regard to the effects of adrenalin. Stanley Green'
reports its employment in enucleation without benefit,
although he had previously used liquid suprarenal and
chloretone without any loss of blood. As a warning
against its promiscuous use, Lemere* states that the
superficial blanching of conjunctiva caused by adrenalin
is accompanied by engorgement of the deeper ciliary
vessels, and that if there is a tendency to iritis, as in
some cases of corneal ulceration, instillations of adrena-
lin are not without disastrous results. After a fair trial,
Marple believes that adrenalin is of little use in ophthal-
mology and may prove dangerous. He suggests that
the anemia following its employment may favor infec-
tion after operations, and he thinks that he has seen two
cases in which its application was likely the cause of
iritis.
Preventive Ophthalmology. — In no department of
medicine has prophylaxis achieved more brilliant re-
sults than in that to which belong disea.ses and defects
of the eye. What has been accomplished in decreasing
blindness through instruction and sanitary regulations
as to the prevention of ophthalmia neonatorum is
familiar to all. Through the examination of school
children's eyes for defective vision and errors of refrac-
tion much is being accomplished in certain cities in pre-
venting not only physical deterioration but intellectual
and moral as well. Dr. R. H. Derby calls attention in
a recent article to another field in which marvelous
results have been accomplished. In 1886 the New York
Academy of Medicine appointed a committee to investi-
gate the subject of contagious eye-disease in asylums and
residential schools. It was found that in many of these
there was no examination on admission and no quaran-
tining and as a consequence one out of every four
patients was suffering. An act requiring isolation,
which was immediately passed, has accomplished a most
remarkable diminution in these cases, one institution
having reduced its proportion from 66.5^ to 4Afe.
Statistics show that about 19^ of those applying for
admission to the instructions have trachoma. Most of
these children have been attending public schools. In-
spection ordered by the board of health in two schools
showed respectively 19.2^ and 15.5^ of trachoma cases.
In these schools all apparent inflammation was reported
by the teachers. The necessity for rigid examination
by competent persons in order to detect this insidious
and destructive disease is at once evident. Reform
moves slowly even in the face of startling and convinc-
ing facts. There are still but few communities in which
a penalty is attached to negligence on the part of mid-
wives and nurses in reporting to a physician inflamma-
tion of the eye in the newborn, but few places where
any examination of school children's eyes is required.
In the country conditions are worse than in the city.
Whatever is done will be done only on the initiative and
after earnest and prolonged effort on the part of the local
profession. This is a field in which the public- spirited
physician can look forward to most definite and mensur-
' Journal of American Medical Association, July 6, 1901.
- British Medical Journal, March 22, 190a.
s British Medical Journal, May 10. 1902.
^American Medicine, October 5, 1901.
8EPTEMBEK 13, 19021
THE WOELD'S LATEST LITEEATURE
[AMERICAN Medicine 439
able results as the sequence of whatever successful effort
he and his colleagues may put forth in influencing pre-
ventive legislation.
Subconjunctival Injections of Carbolic Acid in Gran-
ular Conjunctivitis. — Ni6mtchenkov,i a Russian military sur-
geon, ad vises subconjunctival in jectionsol a 5% aqueous solution
of carbolic acid solution in the treatment of trachoma. He uses
about one-quarter of the contents of an ordinary Pravaz syringe,
making an application at each angle of the everted lid. The
patient is not given severe pain, the reaction is not extraordi-
nary, no toxic symptoms are reported and no serious results
have followed. Ordinarily one injection is necessary, but two
or three may be given. An interval of five to seven days should
elapse before injection of the second ej'e or repetition of the in-
jections. Nifimtchenkov has thus treated with great success 43
patients.
Operations for Congenital Blindness. — Koenigsberg'
reports three cases of congenital blindness from cataract in
Russian peasants, and describes tlie educative visual exercises
following operation. The ages were 16, 18 and 28 years, clearly
showing how little such people are accustomed to seek medical
advice. From his study of the cases he concludes that in our
first application of the sense of sight we also make use of touch
on a large scale to ascertain the general appearance and detail* d
outline of objects, etc., and it is after this only that we arrive at
a correct understanding of these objects and remember them
later. From his clinical observation alone he is satisfied that
from the very first use of the eyes in vision objects are seen at
once as they are, and not reversed as they are reflected on the
retina.
Ocular Affections in Chlorosis. — Suker ' concludes,
from a bibliographic and clinical study, that the headache due
to refractive error and asthenopia are often aggravated by chlo-
rosis. "Pulsation in the retinal vessels is indicative of the
severity of the disease. The affections of the retina and optic
nerve may stimulate similar conditions seen in cerebral tumor
and nephritis. He believes that these lesions are the result of
an autotoxemia, and in nearly every ca.se, except with optic
atrophy, the prognosis is favorable, considering the severity of
the hemic disease. It is of the utmost importance to establish an
early diagnosis by blood examination and institute appropriate
treatment. As already stated in these columns (Atnen'can
Medicine, May 28, 1902) failure to recognize the disease had not
infrequently led to irreparable blindness and even death.
The Prognosis of Serpiginous Ulcer of the Cornea.—
Kipp* calls attention to certain features that he believes indi-
cate cessation of the infective process in infected corneal ulcers.
From the margin of an infected ulcer are commonly seen
diverging in all directions straight linear opacities in the paren-
chyma of the deepest layer. In nonprogressive or retrogres-
sive ulcers Kipp has found, on careful examination, at the fur-
ther ends of these opaque lines connecting grayish interme-
diate striae of the same width throughout, and running at right
angles to the wellknown diverging lines. A central ulcer, with
these connecting striae well developed, may be compared in
appearance with a spider's web. Kipp believes that such
ulcers never progress, and any treatment, such as cautery or
incision, involving further destruction of tissue, is not only
unnecessary, but distinctly contraindicated.
Sympathetic Ophthalmia, with Complete Recovery In
Both Kyes.— Vail ' reports the case of a healthy boy of 14, who
received a penetrating wound of the left eye, with hernia of the
iris. Iridectomy was performed and a scleral stitch applied.
The patient made prompt recovery with 20'4O vision. Seven
weeks later sympathetic inllammation occurred. The patient
was keptquiet in au absolutely dark room, atropin was instilled,
leei^hos applied and potassium iodid (gr. x t.i.d.) and ammo-
nium salicylate (gr. x every three hours) administered. Steam
baths were given every other day. After two months' treat-
ment the patient was disciiarged cured with normal vision In
each eye. Vail <!oncludes : 1. That sympathetic ophthalmitis
I Iji Hcnialnc MCclU-ule, .May 28, 1902.
2Hi-ot,tl»h Medical and SurKl<'al Journal, June, 1902.
a.Mi-dlriiic, .May. IDOi
• Joiirniil American Medical AsHOCIatlon, August 9, 11(02.
American Journal of Ophthalmology, junc, i902.
occurring in young persons is often not so violent nor so
fatal to vision as the same disease in adults. 2. That if no
foreign body has remained in the eyeball, it is often wise to
watch and wait. K That the rational treatment is complete
rest to the retina and accommodation, which can be brought
about only by total darkness.
An Operation for Pterygium.— McReynoldsi describes a
modification of Dgsmarrfi's transplantation operation, in which
there is no exposed conjunctival wound left in the palpebral
fissure. The details of the operation as given by McReynolds
are the following: 1. Grasp completely the neck of the ptery-
gium with strong but narrow fixation forceps. 2. Pass a Graefe
knife through the constriction and as close to the globe as pos-
sible, and then with the cutting edge turned toward the cornea
shave off every particle of the growth smoothly from the
cornea. 3. With the fixation forceps still hold the pterygium,
and with slender, straight scissors divide the conjunctiva and
subconjunctival tissue along the loioer margin of the pterygium,
commencing at its neck and extending toward the canthus, a
distance of one-fourth to one-half of an inch. 4. Still hold the
pterygium with the forceps and separate the body of the
growth from the sclera with any small, noncutting instrument.
5. Now separate well from the sclera the conjunctiva lying
below the oblique incision made with the scissors. 6. Take
black silk thread armed at each end with small curved needles
and carry both of these needles through the apex of the ptery-
gium from without inward and separated from each other by
a sufficient amount of the growth to secure a firm hold. 7.
Then carry these needles downward beneath the loosened con-
junctiva lying below the oblique incision made by the scissors.
The needles, after passing in parallel directions beneath the
loosened lower segment of the conjunctiva until they reach the
region of the lower fornix, should then emerge from beneath
the conjunctiva at a distance of about one-eighth to one-fourth
of an inch from each other. 8. Now, with the forceps lift up
the loosened lower segment of conjunctiva and gently exert
traction upon the free ends of the threads, which have emerged
from below, and the pterygium will glide beneath the loosened
lower segment of the conjunctiva, and the threads may then be
tightened and tied and the surplus portions of thread cut off,
leaving enough to facilitate the removal of the threads after
proper union has occurred.
It is very important that no incision should be made along
the upper border of the pterygium, because it would gap and
leave a denuded space when downward traction is made upon
the pterygium.
Tachiolo in Ocular Affections —A. Benedetti* presents
the results of his experiments with the fluorid of silver, a salt
discovered by Paterno in 1!K)1 and to which the name tachiolo
has been applied. He finds it useful as a collyrium, in solu-
tions varying in strength from 1:1,000 to 1:100. Solutions of
greater strength than the latter produce irritation. He finds
instillation of this salt very useful in cases of catarrhal con-
junctivitis, owing to its antiseptic potency and to its superiority
over nitrate of silver, [c.s.d.]
Klectric Light Conjunctivitis.— Grimsdale* notes that
this disease has received sciint acknowledgment in literature.
He reports several cases, with varying symptoms. The disease
Is more alarming tlian serious, and lasts only a few days. Cold
compresses give the greatest relief. One of the cases reported
shows that it is the ultraviolet rays and not the general illumi-
nation which produce the effect. Probably dark yellow glasses
would act as a preventive to both this and snow blindness even
better than the ordinary smoke tint. The conjunctivitis can
hardly ho from direct injury, otherwise wo should not get the
interval of quiescence after the immediate results liave passed
off before tliu acute symptoms come on. It must be due to a
disturbance of the nervous system, especially the vivscular cen-
ters, I>y direct stimulation of the afferent nerves, or the rays
cause some chemic change in the conjunctiva whoso products
act as strong irritants, producing local Inflammation. Tlie for-
mer seoms more prol)able. [h.m.]
■iJouT. of the Am. Med. Asso., August 9, 1902.
»I1 Pollcllnlco; Hupplcmento Hcltimanale, June 14, 19(«.
3 Medical Press an<l Circular, April 21, 1902.
440 Ajcsbican HBDioinaj
THE PUBLIC 8EKVICE
LSeptehbbb 13, 1902
THE PUBLIC SERVICE
Health Reports.— The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, during
the week ended September 6, 1902:
California :
Colorado :
Illinois:
Indiana:
Iowa:
Kansas :
Maine :
Massachusetts :
Missouri :
Montana :
Nebraska :
New Hampshire :
New Jersey :
New York :
Ohio:
Pennsylvania :
South Carolina :
Wisconsin :
Argentina :
Austria :
Barbados :
China:
France :
Gibraltar :
Great Britain :
India :
Italy:
Netherlands :
Kussia :
Spain :
Uruguay :
Colombia :
Costa Rica :
Ecuador :
Mexico :
China
fi
^^SV
Madagascar :
Philippine Islands :
China:
Egypt :
India:
Japan :
Korea:
Bmallpoi— United States.
IjOS Angeles Aug. 16-23
Sacramento Aug. 16-21
Denver. Aug. 16-21
Belleville Aug. 2a-30
Indianapolis Aug. 23-;i0
Otturawa Aug. 2-;iO
Wichita Aug. 2:i-30
Portland Aug. 2i-30
Boston Aug. 23-30
Brockton Aug. 23-:J0
Lawrence Aug. 21-30
Somervlile Aug. 21-30
St. Joseph Aug. 23-30
St. Louis Aug. 24-.31
Helena Aug. 1-31
Omaha Aug. 21-30
Manchester Aug. 23-30
Camden Aug. 23-30
Newark Aug. 23-30
New York Aug. V3-30
Cincinnati Aug. 22-29
Cleveland Aug. 23-30
Hamilton Aug. 2f-30
MIddletown July 12-Aug. 9 .
Erie Aug. 23-30
Johnstown Aug. 23-30
Cases Deaths
1
2
2
1
20
2
12
1
2
1
7
4
6
2
76
3
11
1
— -„ 12
McKeesport Aug. 23-30 2
Philadelphia Aug. i3-;i0 4
Pittsburg Aug. 21-30 12
Charleston Aug. 23-30 1
Green Bay Aug. 23-31 3
Janesville Aug. 2:l-.".0 1
Milwaukee Aug. 21-30 1
Smallpox— Foreign.
Buenos Ayres June 1-30
Prague Aug. 2-16 1
Trieste Aug, 8-16 1
July )3-Aug 12... 47
Hongkong July 12-19
Paris Aug. 2-16
Aug. 10-17 1
Dundee Aug. 8-16 1
Glasgow „ Aug. 16-23 1
London Aug. 8-16 24
Bombay July 29-Aug. 5 5
Palermo Aug. 2-9 5
Rotterdam Aug. 16-23 1
Moscow Aug. 2-9 I
Odessa Aug. 8-16 2
St. Petersburg Aug. 2-9 4
Corunna Aug. 8-16
Montevideo luly 9-23 43
Yellow Fever.
Panama Aug. 18-25 1
Port Limon Aug. 7-14 1
Guayaquil Aug. 8-16 5
Coatzacoalcos Aug. 16-23 5
Vera.Cruz Aug. 16-30 33
Plague— Foreign.
Hongkong July 12-19 21 20
Alexandria Apr. 14-Aug. 13.. 72 35
Bombay. July 2.+-Aug. 6.... 32
Calcutta July 26-Aug. 2.... ii
Karachi July 27-Aug. 3.... 12 5
Tamatave July 6-22 18 14
Cholera— Insular.
Cebu July 9-20 90 52
Cholera— Foreign.
Hongkong July 12-19 6 5
Alexandria Aug. 5-13 8 7
Cairo July 22-Aug. 13.. 5.56 490
Assiout Province,
includingMoucha.July 1.5-Aug. 13... 536 431
Behera Province Aug. 12-13 13 4
Beni Souef Aug. 11 i
Charkieh Provlnce..July 12-13 8 5
Galioubieh Prov-
ince Aug. 6-13 20 11
Gharbleh Province.. fVug. 13 1
Gulzeh Province July 25- Aug. 13... 159 93
Menoufieh Prov-
ince Aug. 9-13 6 6
Minleh Province Aug. 9-13 24 13
Bombay July 29-Aug. 5.... 1
Calcutta July 20-Aug. 2.... 22
Karachi July 27-Aug. 3.... 21 21
Osaka and Hiogo... July 26-Aug. 9... 2 1
Chenampo... Aug. 21 Severe
North Korea Aug. 21 Severe
1
2 im-
ported
1
4
Changes In the Medical Corps of the U. 8. Navy for
the week ended September 6. 1902 :
°^ o?i5rprt ^•Vi"''!'^"' <l«tached from the Mare Island Navy Yard and
oraered to the Solace— August 30.
DdBose, W. R.. surgeon, detached from the Solace upon reporting of
relief, and ordered borne and to wait orders— August 30.
Ulsh, W. H., assistant surgeon, ordered to the Washington Navy Yard
for examination, and thence home and to wait orders— August :10.
Mabmion, R. a., medical director, detached from duty as president of
the medical examining board, Washington, D. C., and ordered to
duty as president of the naval medical examining board and to duty
in charge of the Naval Museum of Hygiene and Medical School,
Washington, D. C— September 2.
Bradley, G. P., medical director, upon completion of duty as a mem-
ber of the board for the examlnallon of midshipmen, detached from
the Naval Museum of Hygiene, Washington, L). C, and ordered to
duty as a member of the medical examining board and naval
retiring board, Washington, D. C— September 2.
Kennedy, R. M., surgeon, detached from the Franklin and ordered to
the torpedo station, Newport. R. I. — .September 3.
Snyder, J. J., assistant surgeon, detached from the torpedo station>
Newport, R. I., on reporting of relief, and ordered to the naval
hospital, Philadelphia, Pa.— September 3.
Huntington, E. O., surgeon, order of August 15 modified ; detached
from the naval hospital, New York, and ordered home in obedience
to order referred to— September 4.
Changes in the Medical Corps of the U. S. Army for
the week ended September 6, 1902 :
Schlageter, Captain H. . I,, assistant surgeon, now at Bay,Laguna,
will proceed to Manila and report to the commanding officer, first
reserve hospital, for treatment.
Dessez, Captain Paul T., assistant surgeon, will proceed to Calaslao,
Pangaslnan, for duty.
Mead, Captain Jame.s E., assistant surgeon, will proceed to Bamban,
Tarlac, for duty.
Sandall, Captain Laurel B., assistant surgeon, now at Ibaan, Batan-
gas, will proceed to Manila, and report to the commanding officer,
Urst reserve hospital, for treatment.
Bailey, Edward, contract surgeon, will proceed to Fort Lawton and
report to Major Lea Febiger, Seventeenth Infantry, for duty with
battalion of that regiment, under orders for Alaska.
PuRViANOE, Captain William E., assistant surgeon. Is granted leave
for fourteen days.
Maus, Lieutenant Colonel Louis M., upon his arrival at San Fran-
cisco, Cal., will proceed to West Point, N. Y.. and report to the
superintendent of the United States Military Academy for duly, to
relieve Major James D. Glennan, surgeon. Major Olennan will
proceed to Fort Douglas for duty, to relieve Major Henry F. Hoyt,
surgeon.
Gorgas, Major William C, surgeon, Is relieved from duty at Havana,
Cuba, to take effect September 30, and will then repair to Washing-
ton, D. C, and report to the surgeon-general of the- Army for duty
In his office.
The following-named officers are honorably discharged, to take effect
October 10, their sevices being no longer required: Majors Henry
F. Hoyt, Damaso T. Lalne, William F. de Niedeman, Frederick J.
Combe, surgeons; Captains George L. Painter, Robert E. Williams,
William H. Block, W. Edison Apple, assistant surgeons, United
States Volunteers. The officers named will on the receipt by them
of this order proceed to their homes.
McCoRD, Captain Donald P., assistant surgeon, United States Volun-
teers, is honorably discharged, to take effect September 30, his serv-
ices being no longer required, and he will proceed to his home.
Captain McCord is gi'anted leave to Include September 30.
Newgarden, Captain George J ., assistant surgeon, is relieved from
further treatment at the Army and Navy General Hospital, Hot
Springs, Ark. and will return to his proper station at Fort Mason.
Roberts, D. M., contract surgeon, leave granted July 22, Is extended
one month.
Bacon, Alexander P., contract dental surgeon, now at Fort Clark, is
relieved from further duty in the department of Texas and will
proceed to Fort Yates for temporary duty for a period of six weeks,
or so much thereof as may be necessary, to perform dental work
urgently required at that post, and upon the completion of the duty
at Fort Y'ates will proceed to Fort Snelling and report by letter
to the commanding general, department of Dakota, for duty as
dental surgeon in that department.
TuTTLE, Arnold D., hospital st«ward, now at Baltimore, Md., having
rellnqulsh<»d the unexpired portion of furlough granted him from
headquarters, division of the Philippines, will report at Fort Mo-
Henry for duly, to relieve Hospital Steward Gustav Knapp. Stew-
ard Knapp will be sent to Fort Mackenzie for duly, to relieve
Hospital Steward John B. Anderson. Steward Anderson will be
sent to the Army General Hospital, Presidio, for duty.
The following-named officers, now at the places indicated, on leave of
which they availed themselves at San h rancisco, Cal., are honorably
discharged, to lake effect October 10, their services being no longer
required. They will proceed to their homes : Major Charles M.
Drake, Atlanta, Ga.; Vernon K. Earthman, Murfreesboro, Ttnn.;
William L. Whltllngton, St. Joseph, Mo., surgeons. United States
Volunteers.
Taylor, Ralph L., contract surgeon. Is directed to report to the com-
manding general, department of California, for assignment to duty
as transport surgeon on the transport Warren, to relieve Captain
Donald P. McCord.
RocKHiLL, First Lieutenant Edward P., assistant surgeon, Is granted
leave for iwenly-one days.
Combe, Maior Frederick J., surgeon, Is granted leave for one month,
with permission to apply for an extension of two months.
Peddicord, Harper, contract surgeon, now at Columbus Barracks,
win report at that post for duty.
McSwAiN, T. C , contract surgeon. Is granted leave to Include Septem-
ber 30.
Sturtevant, Charlbs a., contract surgeon. Is relieved from duty at
Fort Slocum, and will proceed to Madison Barracks for duty.
American Medicine
QEOBGE M. GOULD, Editor
G. C. C. HOWARD, Managing Editor
CHARLES S. DOLLEY
MABTIN B. TINKER, AttUiant Editor!
Clinical Medicine
David Riesman
tL. O. J. Kelly
h. h. cushino
Helen Murphy
General Surgery
Martin B. Tinker
A. B. Craig
Charles A. Ore
Orthopedic Surgery
H. Augustus Wilson
COLLABORATORS
Obslelrica and Gynecology
WiLMER Krusen
Frank C. Hammond
Nervous and Mental IHsenses
J. K. Mitchell
F. Savary Peakce
Treatment
Solomon Solis Cohkn
H. C. Wood, Jr.
L. F. Appleman
Dermatology
M. B. Hartzell
Laryngology, Ete.
D. Bradkn Kylk
Ophthalmology
Walter L. Pylk
Pathology
R. M. Peabcb
PUBLIBBID WlKKt-r AT 1S21 WALtTDT StSSKT, PatLADKLPHIA, BY TBI AuSRICAM-UlDtCtNS PuBLUBINe GoHPAKT
Vol. IV, No. 12.
SEPTEMBER 20, 1902.
.00 Yearly.
A scientific test of food preservatives, etc., of
unique kind and interest is to be undertaken by Dr. H.
W. Wiley, cliief of tlie Division of Ciiemistry of tlie
Department of Agriculture at Washington. It is to be a
sort of scientiiic boarding house, authorized by act of
Congress to test the effects of food preservatives, coloring
substances, etc., upon about 12personS in a state of health!
The question of the possible harmfulness of boric and of
salicylic acids will, we hope, be decided by the proposed
plan. The boarders will be intelligent, will conscien-
tiously cooperate and obey all orders, will eat no food
elsewhere, their digestion and other physiologic pro-
cesses will be scientificly tested, etc. Elvery boarder will
be weighed upon rising from bed in the morning. The
temperature will be registered three times daily. A
careful account of water consumed will be kept, as well
as of the food itself. The boarders will have no knowl-
edge of when different preservatives, ete., are being
tested, for at least half the time they will be eating a
diet which is thoroughly pure — a relaxation diet. The
object of this will be not only to prevent the system
from real injury, but also to tell how far into a period of
normal conditions the effects of former harmful ones may
persist. At each meal some men will be eating doctored
food, and some pure food, but they will not know which
is which. The quantities of adulterants employed will
nowhere be perceptible to the senses. The persons who
will apply the preservatives for these experimental
tables will be experts, and the quantity employed in each
instance will be measured accurately.
Centralization and Pure-food Licgislation. — It
is noteworthy that so many agencies arc unexpectedly
working toward centralization in our modern govern-
rjients, and in none more powerfully than in the most
democratic ones. Who would have prophesied that the
necessity of protecting the people from bad food-adul-
terants would be one means, and advocated by the manu-
facturers and dealers themselves, of furthering the
demand for United Htates instead of State legislation
upon the subject? It all comes about from the differ-
cnccs of .State laws in their demands upon packers,
manufacturers and dealers. These see an impending
annoyance to their business vastly greater than federal
legislation, consisting of the multitude of State require-
ments, differing so in details that the manufacturer of a
fruit preserve might be compelled to use forty-five dif-
ferent labels in order to sell his goods in as many States.
Standardsof purity and strength, in vinegar, in cream,
and all sorts of articles, are different in the different States.
Local legislation thus becomes annoying, especially
to the manufacturers of honest goods who intend to
comply with the law and to sell reasonably pure food.
Hence a national law, controlling, as it would, articles of
interstate commerce, would check State legislation and
doubtless secure the repeal- of such measures already
enacted as are a repetition in spirit of the national law,
but contradictory in details and troublesome in exe-
cution.
"The spirit of the era," says Dr. Foshay in the
noble address we print elsewhere — and his words carry
weight because they express his own spirit — "the spirit
of the era is that of harmony, of love for our profession,
of willingness to sacrifice something of self-interest for
the general welfare, of charity for each others' views,
and of tolerance for each others' ambitions." All physi-
cians who have taken heart at the success of the plan of
organization of the American Medical Association will
ponder well the advice given, born as it is of pure
motive, sound intellect and much experience. As to the
last, those who know will remember that Dr. Foshay
had much more to do with the organization than his
own historical notes would imply. We wish especially
to commend the admirable suggestion that each State
should have a paid organizer to create new county
organizations, and to instil more enthusiasm and energy
into the too often anemic old ones. As the national
organization is based upon the county society this
method of getting the members of the profession into
line and of making the large association truly represen-
tative becomes all the more needed.
Why do Reputable Men Contribute to Disrep-
utable Me<lical Journals ? — There is in the United
States a large number of periodicals that call themselves
medical and yet which are as unmedical and antimedical
as they can be. A correspondent asks us why certain
men who at least make a pretense of respectability con-
tribute to such journals and thus lend them all the sham
decency they possess. We think the question should be
asked of the contributors themselves. We have done so
442 AMKBICAN MEDICIHBI
EDITORIAL COMMENT
[September 20, 1902
occasionally, and the results of the inquiry revealed one
of three conditions :
1. Usually the socalled medical journal and its so-
called editor lied about the contribution ; not only were
they liars but thieves. The article supposed and repre-
sented to be a contribution of a man of decency was
stolen. It was either taken without credit from some
other journal, was a stenographic report, or was copied
from the MS., surreptitiously obtained, etc.
2. The author may have negligently allowed his
article to go to the fraudulent medical journal in ignor-
ance of the character of that journal, or his article having
been refused by the better class journals, was sent to the
low class journal in a spirit of mingled indifference and
pique.
3. Or the socalled reputable contributor is himself a
fraud, a quack at heart with a veneer of honor, who
plays the role of a physician while really an enemy, like
the periodical he supports, of the profession and its
spirit. There are thousands of these traitorous tricksters
and their cause is that of the pseudomedical journals.
One thing is beyond doubt : The article in a pseudo-
medical journal if stolen is usually worthless, and if
contributed surely so.
The Modern Church for the Proflts or the Law
and the Lady. — A noteworthy decision was made Sep-
tember 15 by Judge Arnold, of Common Pleas Court
No. 4, of Philadelphia, in his refusal to grant a charter
to the Philadelphia organization known as the "First
Church of Christ, Scientist." The application for charter
was first made five years ago and again in January last.
The opinion rendered by Judge Arnold is as follows :
The charter applied for in this case covers a double pur-
pose— a church and a business. We have power to grant a
charter for a church, but we have no authority to grant a
charter for a corporation for profit, that is, a business corpora-
tion.
That the application is for a charter for a corporation for
profits is shown by the statement in the proposed charter that
the purposes for which the applicants desire to be incorporated
are : " To establish and maintain a place for the support of pub-
lic worship and to preach the Gospel according to the doctrine
of Jesus Christ, as found in the Christian Science textbook, by
Mary Baker G. Eddy." What the Gospel, according to the
doctrines found in the Christian Science textbook is, is shown
in an article signed by Mrs. Eddy and published in the Christian
Science Journal of March, 1897, in which she has written that
" The Bible and a book written by me, called ' Science and
Health, with Key to the Scriptures ' and my other published
works are the only proper instructors for this hour. It shall
be the duty of all Christian Scientists to circulate and to sell as
many of these books as they can. If a member of the First
Church of Christ, Scientist, shall fail to obey this injunction it
will render him liable to lose his membership in this church."
This shows that the socalled church is a corporation for profit,
organized to enforce the sale of Mrs. Eddy's books by its mem-
bers, which is a matter of business and not of religion.
Judge Pennypacker refused the first application on
the ground that the socalled church was an institution
for the practice of medicine the practitioners of which
lacked the qualifications and licenses requisite under the
laws of Pennsylvania. On the second application Ex-
Judge Beeber, acting as Master, after taking testimony
recommended that the petition be refused on the ground
that the congregation engaged in the promulgation of
the doctrine that disease does not exist ; a teaching con-
trary to the laws of the State, which recognizes the
existence of disease. Judge Willson, who sat with Judge
Arnold through the argument on the latest application,
held that the teaching of "christian science" is pernicious
in that it discourages the employment of approved
methods recognized by legally authorized practitioners
of medicine for the maintenance of public and private
health. The fact that Switzerland, Massachusetts,
Rhode Island, Maine, Indiana, Ohio and Illinois have
granted charters to eddyite churches makes it all
the more worthy of note that in Pennsylvania three
Judges and a Master should concur in refusing the protec-
tion of the State to a delusive and pernicious doctrine
and to an organization which under the cloak of religion
seeks profit from its dupes.
Garnault's Experiment. — The Milncliener medicin-
ische Wochenschrift of July 1, 1902, contains an interest-
ing letter giving an account of Garnault's widely-ad-
vertised experiment. Garnault is a bitter opponent of
Koch, and in a book just published, entitled " Le pro-
ifesseur Koch et fe p6ril de la tuberculose bovine,"
indulges in scandalous vituperation against the German
scientist. He attributes to Koch the basest and most
mercenary motives, as regards his attitude both on the
bovine tuberculosis question and on tuberculin. While
such unwarranted attacks cast a sinister reflection on Gar-
nault's character, his courage cannot be disputed. By
means of a blister on the arm he produced a raw surface
12 cbmm. in size and applied the infectious material,
consisting of a portion of a tuberculous subdiaphrag-
matic gland, removed with aseptic precautions from a
cow dead of pearl-disease. The material was kept in
place on the arm for two hours. In case of failure
Garnault expects to inoculate himself with tubercu-
lous bovine matter into a joint or tendon sheath.
A positive result of either experiment cannot be used
to controvert Koch's postulate at the London Congress
that the use of meat and milk of tuberculous cattle is
not fraught with harm for man. The experiment is
made under conditions that do not obtain naturally.
Ravenel has, we believe, brought forth the best argu-
ments against Koch's statements, and they will be
neither strengthened nor weakened, whatever the results
of Garnault's foolhardy experiments.
French Medicine and Ethics. — The writer of the
letter to which we refer in the foregoing editorial, and
who is evidently a German, is greatly incensed over
Garnault's imputation or rather accusation of inethical
conduct on the part of Koch, and, in revenge, points out
some of the flaws in French medical ethics. Among
others, he denounces the widely-prevalent practice
of dichotomy, that is, the division of fees between
surgeons and the physicians who steer cases into the
hands of the former ; the self-advertising spirit of
specialists, as, e. g., the cinematographic exhibitions of
Doyen ; the falsification of returns by the medical exam-
ining boards, etc. These recriminations go to show that
medical ethics is not perfect in Europe ; indeed, were it
not unbecoming we should endeavor to bring proof that
September 20, 19021
EDITOKIAIi COMMENT
American Medicine 443
American deontology is at sligiitly iiigiier level than that
of any other country in the world.
Public Edwcatioii as to Vaccination. — The Im-
perial Vaccination League of England has issued an
appeal signed by many church dignitaries, by Lord
Kelvin and many eminent physicians and surgeons.
The objects of the league are to secure legislative
improvements in the Vaccination act, which expires in
1903, and to educate public opinion in support of vaccin-
ation. It insists on the need for obligatory revaccin-
ation of school children at a specified age as an amend-
ment of paramount importance — in Germany, where
revaccination was enforced by law in 1874, epidemics
have practically ceased — and wishes to formulate the
best expert opinion on the atlministration of the Vaccin-
ation law and the atleciuate provision of glycerinated
lymph. Such opinion will be then laid before members
of both houses. In regard to the instruction of pub-
lic opinion, the league purposes to set to work, by
assisting ministers of all denominations and other
persons working among the poor, to make known by
literature, lectures, and meetings the need for and value
of vaccination and revaccination. The British Medical
Journal and the Lancet, the Jenner Society, etc., have, in
England, done much to educate the people as to the
value of vaccination. In our country little of such
special work has been done in an effective way. Some
philanthropist could do a great work with a very little
money. If one-twenty-flfth of the money spent in one
Saratoga "party" could be ha<l for this purpose! Our
scientific energies now seem destined to be spent almost
entirely in discovering new truth. Should not 25^ at
least be devoted to saving human life with the old
truth ?
An Opportunity for Negro Physicians. — In con-
nection with what we said recently concerning the con-
ditions of the negro race in the United States, the high
detithrate, disease, and criminality among them, the
need of trained colored physicians should be brought to
the attention of philanthropists and of hygienists.
Whatever prejudice we may have in the matter disease
teaches us the solidarity of the race, and the degrada-
tion of the negro is at last our affair, and is indeed our
own degradation. Ilace prejudice in fact should be glad
to encourage the education of negro physicians. There
are 8,000,000 of their suffering people awaiting the right
sort of negro physicians. In a recent number of the
Chicago lie/iord-Herald, President Merrill, of Fiske Uni-
versity, says the competent colored doctor has an
"amazing opportunity" before him, inasmuch as the
black man turns to a physician of his own color as read-
ily as the white physician in the South turns away from
colored patients whenever he can honorably do so.
President Merrill was able to tell of the success of negro
dfxjtors in Nashville, all doing well financially, and half
of them amassing property. He reports also that it is
easier for a colored physician to build up a s(!lf-support-
ing j>ractice than for the white dfx^tor. The nwessity of
good medical schools for negroes should be plain to all,
even to those who doubt the wisdom of higher educa-
tion in the classics and natural sciences. New York
City, says the Evening Post, would benefit if there were
several hundred competent and professionally high-
minded colored doctors within its limits to do mission-
ary work in its terribly degraded " colored quarters."
The second meeting of the International Con-
gress for the Prevention of Syphilis and Venereal
Diseases has been of marked interest, not that any
sweeping reforms have been suggested, but because so
many sides of the question have been shown by the phy-
sicians and sanitary and legal experts that represented
the 36 countries who sent delegates. From the first it
was evident that the congress was divided into two
camps, one who hoped to diminish disease by . the
strictest laws pertaining to prostitution, which necessi-
tated the recognition of houses of prostitution for their
regulation, as well as making other regulating laws, and
the other, the abolition party, who held that because the
laws of regulation had hitherto been unsatisfactory, all
regulation should be abandoned and the treatment of
disease be a purely private and personal affair. To
diminish its frequency they hoped to do more along
moral and educational lines than by regulating laws.
Neither party succeeded in making a resolution that
could be unanimously adopted by the other, but as the
conference progressed it was very evident that a broader
spirit prevailed in the discussions. The abolition of all
regulation was shown to be a foolish step, but that better
methods of putting it into practice were necessary, while
it was advocated by every one that sensible and practical
education on the subject of sex and venereal diseases
should be made part of the education of youth in all
countries, and a necessary concomitant of treatment of
venereal diseases. The sharpest and severest penalties
were advocated for persistent moral offenders, such as
procurers and vicious and diseased prostitutes.
Belgium as a Leader. — It is an interesting fact
that in addition to all the reforms, inventions and prop-
agandas that have been successfully launched on the
world by the small, but by no means insignificant, king-
dom of Belgium, this congress for the mutual exchange
of national opinion over a universal social disease should
have been conceived and carried out by her. It is also
interesting to note that her Secretary of State is the pre-
siding officer of the congress, and that his office was by
no means an honorary one, but that he gave five days
of his time, from nine until four, at the conference, list-
ening to and weighing with the judicial knowledge of
long exijerience every argument that was advanced.
Belgium's contribution to the congress was almost as
large as that of the wealthiest nation. The United
States government and one other country were the only
ones who let the subscription list pass unnoticed. The
delegates from the United States put this down to ignor-
ance rather than to indifference, and will see that before
the next conference their government has had its eyes
open to the need of ofticially re<'ognizing a grave danger
to its citizens, with the idea of combating it.
444 AMERICAN MBDIOINB]
REVIEWS
[8KITEMBEK 20, 1902
BOOK REVIEWS
Atlas and Epitome of Operative SurRery.— By Dr. Ono
ZrcKKUKANDL, Privatdocent in the University of
Vienna. Second edition, revised and enlarged. Author-
ized translation from the (Joruian. ICditcd by .1. Ch ai.mehs
DaOomta, Profe.ssor of the Principles of Surgery and
Clinical Surgery in JelTerson Medical College, Philadel-
phia; Surgeon to the Philadelphia Hospital, etc. With
40 colored plates and 278 illustrations in the text. Phil-
adelphia and London : W. B. Saunders & Co., 1902.
To those familiar with the first edition, this valuable book
needs no commendation. Increased value, however, accrues in
the present edition from the addition of Ifl lithographic plates
and 61 additional figures in the text ; also from the fact that a
number of the chapters have been practically rewritten and the
whole work brought entirely up to date. The book is particularly
valuable to the student in operative surgery, and to the busy
surgeon who wishes a ready, terse and reliable description of
the various operations practised in general surgery. All the
established operations in major and minor surgery, and many
in genitourinary surgery, are tersely described graphically, and
for the most part by illustrations. Those operations which for
instruction to students are illustrated upon the cadaver are
described in detail, while those met with less frequently and
those for the most part by the skilled surgeon are described
concisely. The work is a valuable addition to the library of
either the student or the practitioner.
Diagnosis by Means of the Blood.— By Robert Lincoln
Watkins, M.D. Illustrated by 154 photomicrographs of
specimens of blood, as observed in general practice, show-
ing products that are found in definite diseases. 338 pp.
The Physicians' Book Publishing Company, New York
and London, 1902. Cloth, $5.00.
As a contribution to the appropriately diverting literature
of the summer season, this book appeared opportunely. In
many respects it is unique ; it is devoted exclusively to the
examination of the fresh, "living" blood; it is replete with
statements suggestive of a high-grade cerebral astigmatism ;
and we are informed that the author, desiring " the book to sell
only on its merits," refused to accede to the request of " a once
prospective publisher" that he " suffix various titles and socie-
ties to which he belongs to his name." Reference is made to the
prevailing fad of counting the blood-corpuscles and estimating
the percentage of hemoglobin— both of which are said to be of
little value, and especial attention is directed to the fibrin of the
blood — the " different states of which are pathological." It is
said that microcytes, especially when abundant, are very char-
acteristic of neurotic conditions (of which pernicious anemia is
one) and that " from a blood standpoint, all tuberculous people
have rheumatism no less than the regular rheumatics, but the
pain is more or less present. Rheumatism from this point of
view is characterized by a thickened, adhesive condition of the
red blood-cells. Most people with paralysis, emboli and apo-
plexies are rheumatic." " We have rheumatism of the joints,
of the muscles, of the eyelid, of the ear, in fact, of all parts of
the body. The blood shows them all " . . . " whether or not
the person has an attack at the time of the examination." In a
case in which the blood was both thick and thin " the white
cells, also, are abundant, especially the ameboid variety. The
glands are probably affected. From these facts you know this
person has not articular rheumatism and no hard fibroid
tumors." Tuberculosis is said to originate in the blood, the
prime factor in its production being a certain granular matter
present in the blood. This deposited in the tissues forms one
of the three constituents of a tubercle, the other two being pus
cells and epithelium. This granular matter is said to be the
blood platelets of Bizzozero, the hematoblasts of Hayem, the
yeast of Salisbury, the granules of Bayle, and it is " found in
the blood of all tuberculous subjects before the tubercle has
made its appearance and long before it has formed." The germ
of syphilis is described in detail ; it is said to show three stages
and to be found in the blood of all syphilitics. Sufficient these
for the bizarre views of the author. The book itself is embel-
lished with a number of photomicrographs illustrating healthy
and unhealthy blood, the socalled proper movement of healthy
blood under the coverglass, the reputed germ of syphilis as
well as that of tuberculosis in the blood ; socalled crystals of
cholesterin, triple phosphate, hippuric acid, uric acid and cystin
in the blood ; the blood of Sadie Martinet, shown by request of
the actress alongside that of Max O'Rell's, etc. To one in a
mirthful mood and desirous of relaxation the book may be
recommended; but the patient seeker after the truth in hemat-
ology would best forego the reading of the book. The many
misstatements of facts not connected with the study of the blood
will serve to betray, to the ordinary clinician, the total untrust-
worthiness of the book ; and let us hope that those unacquainted
with the modern developments of hematology will take counsel
of others before they unreservedly accept as facts the opinions
of the author. Finally, in view of the price at which the book
is offered for sale, one may point out that, although it contains
154 photomicrographs, of its 338 pages 144 reveal their virgin
whiteness unsullied by a single spot of printers' ink, and 25 or
more additional pages have each one line or less of printed
matter.
BOOKS RECEIVKD.
Die Bantgenstrahlen Im Dienste der Chlrurgle.— Von Dr. CABL
BEOK, Professor der Chlrurgle, New York. I Tell (Texll, pp.138; II Tell
(Tafeln), 85 Seitz und Schauer, Munchen, 1902
Diseases of the Stomach: Their special pathology, diagnosis,
and treatment, with sections on anatomy, physiology, chemical and
microscopical examination of stomach contents, dietetics, surgery of
tbe stomach, etc.— By John ■. Hemmbtkk, M.D.. Philos. D., Professor
In the Medical Department of the University of Maryland, Baltimore,
Third enlarged and revised edition. Price, W.OO net. P. Blakiston's
Son & Co., Philadelphia, 1902.
Diseases of the Anus, Kectum, and Pelvic Colon.— By .James P.
TCTTLE, A.M., M.D., Professor of Rectal .Surgery. New York Polyclinic
College and Hospital Klght colored plates; 338 Illustrations in the
text. Cloth, 86.00. Half leather, Se.50. D. Appleton & Co., New York,
1902 Sold only by subscription.
Dudley's Gyiiecologv: A Treatise on the Principles and Practice
of Gynecology.— By E. C. Dudley, A.M., M.D., Professorof Gynecology
In the Northwestern University Medical School, Chicago. New (,3d)
edition. Enlarged and thoroughly revised. In one very handsome
octavo volume of 756 pages, with 474 engravings, of which 60 are in col-
ors and 22 colored plates. Cloth, $.5.00, net. Leather, 88.00 net. Half
morocco S6.50, net. Uea Brothers & Co., Philadelphia and New Y'ork.
The International Textbook of Surgery: In two volumes.— By
American and British authors. Edited by J. Collins Warren, M.D.,
LL.D., F.K.C S (Hon.), Professor of Surgerj-, Harvard Medical School ;
and A. Peakce Gould, M.S., F.R.C.S., of London, England Second
edition, thoroughly revised and enlarged. Vol. I.— General and Oper-
ative Surgery. Royal octavo of 96.5 pages, with 461 illustrations and 9
full-page colored lithographic plates. Vol. II.— .Special or Regional
Surgery. Royal octavo of 1,122 pages, with 499 Illustrations and 8 full-
page colored lithographic plates. W. B. Saunders & Co., Philadelphia
and Ixindon, 1902. Cloth, $5 00 net. Sheep or half morocco, $6.00 net.
The Treatment of Fractures —By Chas. L. Scuddek, M.D., As-
sistant in Clinical and Operative Surgery, Harvard Medical School.
Third edition, revised and enlarged. Octavo, 480 pages, with 64.5 orig-
inal Illustrations W. B. Saunders & Co , Philadelphia and London,
1902. Polished buckram. 84.50 net. Half morocco, $5.50 net.
Kssentlals of Histology.- By Lotus Lekoy, B.S., M.D , Professor
of Histology and Pathology, Vanderbllt University. .Second edition,
thoroughly revised and greatly enlarged. Ki mo volume of 263 pages,
with 92 beautiful Illustrations. W. B. Saunders & Co., Philadelphia and
London, 1902. Cloth, $1.00 net.
Essentials of Diseases of the Kar.— By E. B. Gleason, S.B.,
M.D. Clinical Professor of Otology, Medlco-Chirurgical College, Phila-
delphia. Third edition, thoroughly revised. 16 mo volume of 214
pages, with 114 Illustrations. W. B. .Saunders & Co., Philadelphia and
London, 1902. Cloth, $1.00 net.
Atlas and £pitome of Traumatic Fractures and Dislocations.
—By Professor Dr. H. Helperich, Professor of Surgery at the Royal
University, Grelfswald, Prussia. Edited, with additions, by .Ioseph
C. Bloodgood, M.D., Associate In Surgery,. Johns Hopkins University,
Baltimore. Prom the flftb re%'ised and enlarged German edition. With
216 colored Illustrations on 61 lithographic plates. 190 text-cuts and SaS
pages of text. W. B. Saunders & Co., Philadelphia and London, 1902.
Cloth, 83.00 net.
A Textbook of the Surgical Principles and Surgical Diseases
of the Face, Mouth, and Jaws: For Dental Students.— By H. Horace
Grant, A.M., M.D., Prolessor of Surgery and of Clinical Surgery, Hos-
pital College of Medicine ; Professor of Oral Surgery, Louisville College
of Dentistry, Louisville. Octavo volume of 231 pages, with 68 tilustia-
tlons. W. B. Saunders & Co., Philadelphia and London, 1902. Cloth,
$2.50 net.
A Textbook of .Materia Medica, Therapeutics, and Pharmacol-
ogy .—By George F. Butlkr, Ph.G., M.D.. Professorof Materia Medica
and Therapeutics In the College of Physicians and Surgeons, Chicago.
Fourth edition, thoroughly revised. Octavo volume of 896 pages, Illus-
trated. W. B. Saunders & Co., Philadelphia and London, 1902. Cloth,
$4.00 net. Sheep or half morocco, So.CO net.
Transactions of the American l>ermato]ogical Aflsociatioii, at
Its twenty-flfth annual meeting, held In Chicago, III., May 30-31, .lune
1, 1901. Official Report of the Proceedings, by Frank Hdgh Mont-
gomery, M.D., Secretary. Rooney A Otten Printing Co., New York,
1902.
Fox's Atlas of Skin Diseases: Part 15. J. B. Lipplncott Co., 1902.
Diseases of Infancy and Childhood.— By Henry Koplik, M D.,
Attending Physician to the Mt. Sinai Hospital. Illustrated with 169
engravings and 30 plates in color and monochrome. Lea Brothers *
Co., Philadelphia and New York, 1902.
Skptkmbkk 20, 1902]
AMERICAN NEWS AND NOTES
[American Mbdicink 446
AMERICAN NEWS AND NOTES.
OENERAIj.
Health in the Philippine" Army.— Dysentery is reported
to be practically eradicated from the army. Typhoid fever has
largely decreased and cholera cases are also rapidly diminish-
ine. The medical department has also succeeded in eliminating
" dhobie itch." Investigation showed the disease was caused
by a parasite which was communicated to the human body
through careless methods in doing laundry work, the garments
being dried on bushes and grass containing the parasite, and
then pressed with cold irons. An order was issued that all
clothes must be dried on lines and ironed with hot irons. The
adoption of this latter method was ultimately followed by the
disappearance of the disease.
Unsanitary Conditions of the Panama Canal. — In an
article published in the North American Review former
Surgeon-General Sternberg emphasizes the importance of a
well-organized sanitary service under government control, to
enforce measures seeking to prevent the infectious diseases
which are likely to occur under the conditions which will exist
along the line of the proposed canal. The work of such a
service would be first to provide a pure water supply for the
entire line of the canal, and second, provision should be made
for the safe disposition of human excreta, either by sewers,
cremation, or burial in deep pits properly located and system-
atically disinfected. The men should be compelled to sleep
under mosquito bars. The head of the sanitary service should
be a man fully informed as to the sanitary problems to be
encountered and the best means of meeting them. He should
be given the necessary money and autocratic power for the
execution of sanitary measures to protect the health of the
employes. He should have the general direction of the medical
service, including the establishment of hospitals, the purchase
of medical supplies, etc. Physicians should be required to
make frequent inspections of employes for the purpose of
placing upon sick report or in the hospital any man who has
fever or dysentery, or any symptom indicating he is unfit for
work.
EASTERN STATES.
The new Beth Israel Hospital, at Newark, was formally
opened September 1.
Tuberculosis Investigation. — The Massachusetts General
Court has directed the State Board of Charity to make an inves-
tigation and report as to whether it is necessary or expedient
for the commonwealth to make additional provision for the
care and treatment of the tuberculous, and if so, whether such
provision should be made by establishing one large sanatorium
or by establishing several smaller institutions in different parts
of the State. The board, wishing to obtain medical opinion on
the subject, has sent a circular to all the medical societies in the
State asking prompt consideration of the matter, and requestr
ing them to submit their views before October 15. It is thought
that through the medical societies the question of the care and
treatment of the tuberculous will receive more serious atten-
tion than ever before. Last year 1,149 new cases were reported
to the Boston Board of Health.
NEW YORK.
Preventive Medicine. — Two hundred and eight essays
have been entered in competition for the two cash prizes, $1,000
and ?5,000, offered l)y the Maltine Company last February.
These essays are now in the hands of the three judges, Dr.
Daniel Lewis, of New York ; Dr. Charles A. L. Reed, of Cincin-
nati, and Dr. John Edwin Rhodes, of Chicago.
To Report Malaria Cases.— The New York City Health
Department has issued circulars to all physicians in the city
asking them to report all cases of malaria. The object of this
circularization is to receive all possible information as to the
occurrence and distribution of the disease with a view to adopts
Ing measures of prevention. Information regarding the loca-
tion of the disease is especially desired in order that steps may
be taken to correct any unsanitary conditions which may be
instrumental in causing it. Special postal cards will be sent to
any physician on request. The department will make free
microscopic examinations of the blood for malarial parasites
whenever they are requested to do so.
Lack of Hospitals.— The recent report of the trustees of
the Bellevue and Allied Hospitals shows the great noe<i for
new and enlarged hospitals in New York City. The (condition
of Bellevue is especially emphasized, great stress being placed
on the inadefiuate facilities for the reception and examination
of patients, tlie overcrowded sleeping-rooms of the house staff,
the dark and unwholesome quarters of the employes, the inde-
cent condition of the prison wards, the unsatisfactory methods
of cooking and serving food to the sick, and the unsanitary
plumbing that exists throughout the building. An appropria-
tion has been made for the erection of a new hospital in Har-
lem for which the site has already been purchased. Steps have
also been taken toward the erection of a new hospital in Ford-
ham, a bill having been passed by the State Legislature author-
izing the expenditure of $500,000 for site and building. The great
need of more hospitals for the treatment of infectious diseases
was recently emphasized by Mayor Low, who declared that at
least §2,000,000 should be expended for this purpose in the next
three years, besides the §425,000 already allotted.
PHUiADEIiPHIA. PEINNSYIjVANIA, ETC.
The disinfection of paper currency, which was stopped
for a while, is again being undertaken by the various banks of
Philadelphia. The bills are washed and thoroughly disinfected
with formaldehyd before being handed out for circulation. ■
Charitable Bequests.— Under the will of the late Miss
Harriet S. Benson, of Philadelphia, the following institutions
•will each receive the sum of §5,000: Seaside Home for Invalid
Women, Atlantic City ; Pennsylvania Institution for the In-
struction of the Blind ; Pennsylvania Institution for the Deaf
and Dumb ; Pennsylvania Industrial Home for Blind Women ;
Pennsylvania Working Home for Blind Men; Pennsylvania
TrainingSchool for Feeble-minded Children ; Women's Homeo-
pathic Hospital; Children's Homeopathic Hospital and St.
Luke's Homeopathic Hospital.
SOUTHERN STATES.
Fine for Smoking OiKarfets. — An ordinance recently
passed in Elizabeth City, N. C, makes it a finable offense for a
minor to smoke a cigaret upon the streets.
The Medical Society of Virginia will hold its thirty-third
annual session at Newport News, Va., September 23-25, 1902.
An interesting and varied program has been prepared.
The Public Bath Commission of Baltimore in their
report for August state that the indoor baths were patron-
ized by 15,397 men and boys and 5,404 women and girls. The
outdoor baths for men and boys were used by 11,456.
Mortality in Baltimore.— The Health Department re-
ported 915 deaths for August. For the same month in 1901
there were 893 deaths ; in 1900, 959 ; in 1899, 886. There were 38
deaths from typhoid fever during the month, and 159 new cases
of the disease were reported.
Mosquito Extermination.— A plan to be introduced into
the New Orleans Councils proposes to exterminate mosquitos
by infecting them with a fungus disease. Councils are peti-
tioned to assume the expense for the experiments required to
make the method successful.
WESTERN STATES.
Smallpox Carried by Lumber.— An experience gained
in fighting the disease in Oshkosh, Wis., during the past year
has led Dr. F. J. Wilkie, of the Health Board, to assert his
belief that most of the cases in Central and Southern Wisconsin
and perhaps Chicago have been due to infection from germ-
laden lumber obtained in the woods of northern Wisconsin and
Michigan. In nearly every family observed the first to become
affected was the father, who was invariably employed in a sash
and door or furniture factory. He claims that the lumber being
rough and porous easily becomes a vehicle for contagious
germs, and that the disease is thus carried from the camps
where the lumber is sawed and handled.
Prevention of Elephantiasis.— Dr. Vernon L. Kellogg,
professor of entomology in the Stanford University, who had
been engaged by the United States Fish Commission to study
the marine invertebrate life of Samoa, reports amon|; other
things his investigation of Pilaria sanguinis hominis. He
claims that mosquitos dying and falling into the stagnant pools
liberate the parasite which is scattered broadcast over the water
which the natives drink. Nearly one-half the population are
said to be suffering from elephantiasis contracted in this man-
ner. At Dr. Kellogg's suggestion warnings have been posted
all over the island, the worst jiools and streams have been
closed and steps have been taken to drain the swamps. The
natives are uncleanly and know absolutely nothing about sani-
tation, but it is thought by cutting off the infected water the
chances of contracting the disease will be greatly lessened.
Mortality of Michigan.- During August, 1902, there were
2,406 deaths reported to the Department of State for the month
of August, a slight increase over the preco<ling month. The
deathrate was 11.8 per 1,000 population as compared with 11.3
for July and 12.2 lor August, 1!K)1. There were 585 deaths of
infants under 1 year of age, 191 deaths of children aged 1 to 4
diphtheria and croup, .33; scarlet fever, 12; measles, 8; whoop-
ingcough, 27 ; pneumonia, 88 ; diarrheal diseases under 2 years
of age, 325: cancer, 124; accidents and violence, 173. There
were 3 deaths from smallpox : An infant in Kawkawlin town-
ship. Bay county ; an infant in Escanaba city, Delta county; an
adult in tiuincy township, Houghton county. One death was
reported from lightning.
446 Amkbioan Medicimk]
FOREIGN" NEWS AND NOTES
ISeptehbkb ao, 1902
FOREIGN NEWS AND NOTES
OENEBAIi.
Plajfue in Australia.— The Public Health Department of
Sydney reports that the last plague patient was isolated on June
12, since which time no cases of the disease have been reported.
Since November 14, 1901, there were recorded 140 cases with HH
deaths.
An outbreak of rabies occurring in Rhodesia, the native
chiefs have signified their willingne.ss to assist in the destruc-
tion of all dogs, excepting favorites. It is estimated that
over 60,000 will be killed. The government will destroy
the hyenas.
Prize Kssays.— The Brazilian Academy of Medicine ofTers
a gold medal and diploma for the two best essays submitted
during the academic year on any one of certain specified sub-
jects. Among the.se are : Influence of malaria as a determining
factor in aortic heart affections ; fevers at Hio de Janeiro ; clini-
cal study of inte.stinkl sutures ; treatment of umbilical hernia;
carcinoma of the uterus ; puerperal eclampsia ; study of
mineral waters of Brazil ; role of vegetable oxidases in thera-
peutics.
Cholera in the Bast. — Thfi latest despatches from the Orient
state that cholera is extending over a greater territory and with
an increasing mortality. Every city on the coast from the
Island of Java to Japan, and many cities in the interior are
furnishing numberless victims, and it is said that Europeans
are contracting the disease. In Hongkong up to August 0, there
have been 523 cases with 511 deaths, of which 6 Europeans fur-
nished 4 deaths. The last report from Tien-tsin gives 1,049
cases for the year, with 764 deaths ; and outside the city walls
1,015 cases with 69.S deaths. People are dying by the hundreds
and whole families have been extinguished. Cholera is mak-
ing fearful ravages through Japan. Prom Manila comes the
report that on August 30, 340 new cases were reported in the
provinces, the whole number to date having been 27,929, with
a mortality of 19,640. However, according to Major Burns, one
of the heath inspectors, the disease is decreasing. He reports
that whole towns have been depopulated by the epidemic. The
spread of the disease is accredited to the ignorance of the peo-
ple, which leads them to conceal cases of the disease rather
than have their sick receive hospital treatment. Our officers
are able to do but little with the natives in the way of sani-
tary improvement, as they look on disease as one of the phases
of late. Surgeon H. A. Stansfield, medical officer in charge of
Cebu, reports that the disease was first introduced into the
island by a man who insisted on bringing the I)ody of a
cholera victim from Leyte and burying it in Cebu. The author-
ities refused to allow the boat containing the body to land,
whereupon he went to Catmon and was there allowed to bury
the body, and the epidemic in the island resulted. A cholera
hospital has been established, but agitation is going on to have
patients treated in their homes. A recent despatch states there
were four cases of the disease with three deaths on the United
States transport Sherman which left Manila, September 1. The
vessel was quarantined at Nagasaki, Japan.
GREAT BRITAIN.
_ War Against Malaria.— The British school of Tropical
Science will send a number of fresh expeditions to the Gold
coast, Egypt, and the Congo. Major Ronald Ross, formerly of
the Indian Medical Service, in response to an invitation will
investigate malarial conditions in the United States.
Decrease in English Birthrate.— Recent statistics show
a decrease since 1S81 from 27.4 to 20.6 per 100 married women in
Liondon, this decrease being most marked in the fashionable
sections of the city, the slums remaining almost stationary :
outside the metropolis the rate is 25.8 as against 30.3 in 1881.
*,, Inoculation Against Typhoid.— Prof. E. A. Wright, of
. »• x""^5 Army Medical School, has published voluminous
statistics demonstrating the preventive and curative results
obtained by antityphoid inoculation. The statistics show that
a marked advantage accrued from inoculation, fewer cases
occurred and fewer deaths resulted in those contracting the
disease. The mortality is reported to be reduced fourfold.
Surgeon-General W. T>. Wilson, who was chief of the medical
corps in South Africa, does not place so much reliance on inoc-
ulation, stating that enteric fever can not be prevented when
the army is marching all day in the hot sun, and the men suf-
leriiig from the heat can not be driven away from water which
is slimy and muddy.
CONTINENTAXi EUROPE.
Some remarkable statistics are quoted from Berlin. Out
SSfi, ?'^'9''*''*'*'''*^'**^''8° ''orn since 1825 there are reported
.^2,441 sets of twins, 229 sets of triplets and three sets of quad-
^Tm^ \ Uuring the same period in London there were about
14,000 sets of twins, 75 sets of triplets and two sets of quadru-
?uplet figures show 7,500 twins; triplets, 25; no quad-
Medical liicenses to Marry. — Much comment has been
excited over a bill now pending in the French Chamber of
Deputies, which proposes to exact from men and women con-
templating marriage medical certificates as to their fitness to
become parents. Those in favor of the bill claim it is the only
way to keep the race physically, sound and normal, and to pre-
vent the appalling increase of criminals and degenerates. On
the other hand, it is held that the proposed medical investiga-
tion is incompatible with decency. It is reported that a large
number of deputies have pledged themselves to support the
bill.
Petroleum Drinking. — The Medical Society of Paris be-
lieve it lias become necessary to adopt measures tending to
check the alarming spread of petroleum drinking. It was
first thought that the increased tax imposed on alcohol by the
French government was responsible for the formation of the
habit, but investigation showed the habit was prevalent in
certain districts before this time, and that it has spread with
exceeding rapidity. Opinions differ as to the precise effects of
the petroleum on the system, but it is generally agreed to be
very harmful. It is noticed that the victim becomes morose,
but does not grow brutal.
French Infant Mortality.— According to statistics quoted
by M. Gaston Leroux in a paper published recently, an enor-
mous percentage of the mortality among children can be
attributed to the use of poisoned milk. He illustrates by a
map of France, which may be divided into two regions. In the
one to the north of the Loire, more than one-half the children
die of gastritis, while in the region to the south of the Loire not
more than one-third succumb to the disease. The high rate of
mortality in the former locality is attriliuted to the adulteration
of the milk, as butter-making is a great industry ; in the south
very little butter is made.
The International Conference on Improving the Con-
dition of the Insane opened September 1, in Antwerp, with
M. van der Heuvel, the Belgian Minister of Justice, as presi-
dent. Most of the leading countries of Europe sent delegates,
and China was also represented. The consensus of opinion
seems to be in favor of the cottage system. The following reso-
lutions were passed :
That the conflnement of the Insane henceforth be abandoned except
in the cases of those recognized as dangerous.
That the system of boarding Insane persons with families be carried
out whenever possible.
That It Is expedient to renew the wish formulated at the congress
at Paris for the establishment of schools for special classes of the men-
tally weak under medical supervision.
That the manner of placing patients be entirely left to physicians.
That forcible restraint should be condemned.
Centenary of Bichat. — La Society franyaise d'Histore de
la mgdecine, of Paris, celebrated on the twenty-second of July
the centenary of the death of Bichat. There were present at
the memorial exercises representatives of the Faculty of Medi-
cine and of the principal learned societies. Professor Blanch-
ard delivered an address in the morning at P6re-Lachaise. In
the afternoon a tablet was placed on the house 14 rue Chanoi-
nesse, in which Bichat died. A commemorative medal bear-
ing the effigy of Bichat was struck for the occasion. Marie
Francois Xavler Bichat, physician and anatomist, founder of
histology and pathologic anatomy, was born at Thoirette, in
the Department of Jura, France, November 11, 1771, and died
in Paris, July 22, 1802, of tuberculosis. He was the most capable
physician of his time and has been called " the Napoleon of
medicine." He distinguished the vital properties of sensi-
bility and contractility, and together with Goodwin, Hessen-
franz and Lavoisier he established the mechanism and purpose
of respiration. He made clear the differences between the
various tissues, showed the layers of the stomach and proposed
that the nervous system be divided into cerebrospinal and
sympathetic. He is the author of the aphorism, " Take away
some fevers and nervous troubles and all else falls into the
kingdom of pathologic anatomy."
OBITUARIES.
George S. Hull, at Pasadena, Cal., August 29, aged 50. He formerly
lived In Chambersburg, Pa. He obtained his degree from the medical
department of University of Pennsylvania in 1876. He was a Founder
of American Medicine.
St. George W. Teackle, in Baltimore, August 30. He graduated
from the University of Maryland School of Medicine in 1870.
John M. Wert, of Philadelphia, September 13, aged 52. He prac-
tised for many years at Edge Hill, Montgomery county.
Frederick G. Ibach, at Mauch Chunk, Pa., Sfepteml>er 11, aged 44.
He was a graduate of the Medico-Chlrurgical College.
Romanzo F. Crosse, of Lewlston, Me., September 9. He had prac-
tised In Boston, Brooklyn and Lewlston.
Edward B. Van Dyck, in Rocky Hill, N. J., August 31, aged 67.
He was a resident of Philadelphia.
Joseph Garland, in Gloucester, Mass., September 4, aged 79.
Wlllard C. StlUon, at Maiden, Me., September 8, aged 64.
Henry P. Shattuck, in Brooklyn, September 6, aged 57.
September 20, 1902]
SOCIETY REPORTS
(Ajtkkican Medicink 447
SOCIETY REPORTS
SECOND INTERNATIONAL CONFERENCE F0R1THE
PREVENTION iOF SYPHILIS AND VENEREAL
DISEASES. .
Held at Brussels, September i-6, 1902.
[From our Special Oonllnental Correspondent.]
First Letter.
The debates in the " Hall of Solemn Discussions/' as the
legend reads above the beautiful assembly room of the Brussels
Academy of Science, have been of a lively and interesting
nature during the past week. Some 200 delegates and members
from 36 countries have met to confer in the French language on
a subject wliich they all agree is " f unestre," but which they
have discussed with mingled jibes and wrath, -sarcasm and
ponderosity, and withal much good sense.
The outlook of the First International Congress held three
years ago in Brussels promised well for this meeting, and there
may have been some little disappointment felt that so little had
been done in the two years toward reaching conclusions that
would offer some practical solution of the problem.
, But when it is remembered that the diseases to be routed
are planted in every civilized country, and that the men who
were met to discuss them represented every form of govern-
ment, and were composed of physicians, moralists, sanitary
commissioners, public commissioners and philanthropic men
and women, it will readily be seen that it would take such a
diverse company some time to agree upon any methods that
would be applicable to all nations, and that the mere exchange
of opinions and bringing out points of ditt'erence was a valualwe
introduction to the complete understanding of the subject.
In the first congress the preliminary ground was well cov-
ered, the extent of venereal diseases was outlined, its menace
to society discussed, the part that prostitution and other modes
of dissemination played were all clearly set forth ; therefore, at
this, the second congress, the speeches were held to the new
questions in hand, and any man who waxed eloquent upon the
sin of prostitution, or any woman who denounced men as
unfair to women in making one-sided laws, was courteously but
emphatically interrupted by the gavel of M. le Jeune, the Belgian
Secretary of State, and asked to confine his or her remarks to
the subje<it. It was a delight to feel the guiding influence of so
able a chairman. As a statesman, interested in science and
intimately acquainted with the business and legal affairs of his
brilliant little country, and as a distinguished gentleman and
courtier, M. le Jeune combined every quality of comprehen-
sion, tact and discretion in giving the polyglot members of the
congress an opportunity to discuss tlie questions. Througli the
stormiest and most excited disputes between the extreme
" Reglementationists " and the "Aoolitionists," he sat as calmly
and patiently as the allegorical figures painted on the panels of
the hall ; but when the discussion proved fruitless, he would in
a few clear and concise sentences sum up the arguments at their
true value and give the lead to others. The work of the first
congress was chiefly to map out the various lines along which
practical ideas for the remedy of the social evil might be sug-
gested. It revealed such a lack of uniformity in the character
of the statistics on which each country based its conclusions
that it was evident that no results could be counted trustworthy
unless they were on a universally accepted basis of statistics ;
accordingly this second congress found the subjects for dis-
cussion divided into three main groups: I. Public Prophylaxis ;
II. Individual Prophylaxis: and 111. Statistics.
1. Under the subject of Public Prophylaxis it was agreed
that it was tlio duty of legislative autliorities to protect society
from the ravages of contagious diseases which Ijy the ease of
their dissemination threatened public health, and also to afford
protection to minors al^andonea by their families. With this
premise, the following questions were scheduled for discussion :
A. What legislative measures should be taken against
venereal diseasas, espe<;ially concerning (1) prostitution— (a) of
minors; (6) control of public peace and morality; (<■) pro-
curers and pimps ; (2) apart from prostitution — (a) for the pro-
tection of minors of both sexes: (b) for the organization of
public gratuitous medical treatment by public hospitals and by
mutual aid societies; (c) for control of wet-nurses, of infection
by niidwives and nurses, of infection by vaccination from arm
to arm, of infection through implements in the industrial arts,
for prr)tection of servants in employment bureaus, hotels and
lodging-houses.
B. Should the transmission of venereal diseases be made a
penal offense ?
II.— IntllTidual prophylaxis had for its oi^jeot of discus-
sion the best method of instructing the youth of this country,
their individual responsibility as healthy individuals in
exposing themselves to the possibility of contracting venereal
disea.ses, as well as individual instruction to thedisea.sed of the
infectious nature of their trouble, and their moral offense in
communicating it. It also invited suggestions concerning the
gratuitous treatment of the individual in clinics and hospitals,
etc.
III. Statistics.— The absolute need of a uniform under-
standing of what could constitute a reliable statement of con-
clusions was brought out long before the subject of statistics
was reached. In fact, it was evident from the moment of enter-
ing the building of the Academy of Science, for hung over the
great stone stairway was a series of charts, of which every
member received a copy. These charts showed a rapidly
descending scale of deaths from venereal diseases, under the
title of " Free England," with the assumption that the regula-
tion of prostitution, by the licensing of inspected houses,
encouraged vice, and consequently increased disease, and that
the abolition of regulation snowed less disease. Tlie advocates
of" abolition" were so .strongly in favor of moral methods of
reform only that they wished to abandon all systems of " regu-
lation," and on the second day of the conference the debates
waxed furiously exciting. A dozen members were on their
feet at once. Whenever the Regulation party presented honest
reports as to the failure of their system in especial cities or
countries the Abolition party took unto themselves the oppor-
tunity to cry out, "-46andone»- to Reglementation." An expos-
ure of the source and nature of the English statistics in their
neat little charts showed, however, that the decrease of disease
was based on the deaths of infants as recorded in insti-
tutions as "syphilitic," quite forgetting the fact that dur-
ing the years which the charts represented the study of
syphilis had introduced a new terminology that subdi-
vides the disease according to its manifestations, and
quite ignoring the fact that England has, without inspection
regulations, no adequate means of getting at the actual amount
of venereal disease present in adults in the country. The coun-
ter statements based upon facts, concerning the number of dis-
eased Parisian prostitutes that had escaped from the too rigid
French capital, and were unrestrictetUy plying their trade upon
the streets of London, showed how terribly the foci of infection
might al)ound in the very face of cheerful statistics.
A glance at the experience and opinions of representative
men from different countries concerning the legal control of
prostitution and its effect on the spread of venereal diseases can-
not fail in interest to the American physician, who will soon be
obliged to rouse himself to an active interest in an American
crusade against venereal diseases.
Dr. M. N. Pierson, Director of Heldring, allied himself with
the Abolitionists by maintaining that regulation was bad, partic-
ularly because it afforded an immoral opportunity for a safe
debauchery without risk of disease.
Dr. C. Boeck, Professor in the University of Christiania,
described the Norwegian system, which for a small country has
worked well, but with no results, however, yet available for
statistics. Each village has its committee of moral supervisors
who teach the young the nature of venereal diseases in simple
language, and wlio plainly advocate sexual morality. More-
over, every physician in Norway is compelled to report all cases
of venereal diseases under his special treatment.
Dr. Santoliquido Rocco, Inspector of Public Health in
Rome, reported that the system of freedom had worked well in
Rome. He advised free medical treatment and elementary
physiologic instruction bearing on sexual problems.
Dr. T. Barthelt'my, physician to St. Lazare, in Paris, gave a
most able and interesting presentation of the question. He
believes that legal restriction of prostitution is necessary, and
while lie admits that the present restrictive measures in
P>ance as well as in other countries have almost uniformly
proved inefficient, he nevertheless holds that it is false to
argue that "reglementation," or legal restriction, is a failure ;
and he advocates that attention be given, not to agitating their
abandonment, but rather toward making the laws more logical
and strict. He quotes Dr. Pournier, whose absence from the
congress on account of illness was universally regretted, as
saying that society has at least three methods of preserving
the healthy sexual functions of the race— moral means, medical
research and treatment, and administrative measures. He held,
as did most of the more conservative members of the congress,
that the l)est good could be accomplished liy a judicious com-
bination of the three, rather than by sacrificing any one to the
exclusive influence of the others. He states emphatically that
legal regulations should show no mercy whatever to the pro-
fessional prostitute, who, knowing that she is in an infective
state, nevertheless persists in her career. Tliis class, which is
always known to the police, should be compelled by law to
submit to treatment in closed hospitals and should on no
account be released while in the infectious stage.
Dr. Ferd. Valentine, of New York, spoke in favor of segre-
gation of prostitutes and of the prohibition of liquor selling in
such segregatetl areas.
Dr. Petrini, of Galatz, Professor in the University of
Bucharest, spoke of the prevalence of the infection of infants
through wet-nurses, and also of healthy nurses by sypliilitio
children. He advocated the necessity in his country, where
wet-nursing was a universal custom, of establishing a system
of medical inspection of wet-nurses and their charges.
But liy far the most important and complete of all the reports
was that presente<l by Prof. Neisser, of Breslau, which will he
discussed at length in our next letter.
A sanatorium for the treatment of tuberculosis is to be
established near Lisl^on. Among the contributors is the Queen
of Portugal, who has given g20,000.
448 AJntaioAif MssioiNEi
SOCIETY REPORTS
[SZPTBMBEB 20, IMS
MEDICAL SOCIETY OF THE STATE OF PENNSYL-
VANIA.
Fifty-second Annual Meeting, Held at Allentown, September
i6, 17 and 18, 1902.
[Specially reported for American Medicine.]
FIRST SESSION.
The society was called to order by the President, Francis
P. Ball, Lock Haven. Tiie members were welcomed to the city
ol Allentown by Mayor F. E. Lewis and by E. II. Djckenshied,
president of the Lehigh County Medical Society.
This session was devoted entirely to the reports of officers,
committees and delegates. The secretary reported a member-
ship of 3,518. The committee to examine school textbooks
reported that the majority of the 50 books on physiology and
hygiene examined were found to be faulty and inaccurate,
especially in statements regarding alcohol and tobacco. They
recommend an amendment to the law governing tlie adoption
of such books and also that their selection be made by medical
men. The State Board of Medical Examiners reported a gen-
eral advance in the standard of medicine in the State, but said
that it was not in the higher plane represented by New York,
Ohio, Minnesota, and Illinois. The report of the committee to
suggest changes to by-laws caused a lengthy and spirited dis-
cussion which was Anally ended by the adojition of a motion to
accept the entire report of the committee without reading.
SECOND SESSION.
The Ability of the Eye to Withstand Effects of Injury
and Disease.— P. J. Kress (Allentown) spoke of the relative
resistance of the eye in normal and diseased conditions of the
body of the individual and pointed out how various constitu-
tional diseases affect that organ.
A Case of Bitemporal Hemianopia; Optic Cellulitis
Following Bowman's Operation, with Introduction of a
Leaden Style.— Walter B. Weidler (Lancaster). The first
case was that of a woman of 41, tlie complete bitemporal hemi-
anopia supposedly being due to a tumor of the optic chiasm.
That lesion was discussed from the viewpoint of symptom-
atology. The second case was that of a young man subjected to
Bowman's operation. Severe cellulitis developed, incisions
were necessary and loss of vision in the affected eye was the
outcome.
Severe Burn of the Eye and Pace by Amyl Nitrite, with
Ijoss of Bye.— Edward A. Shumway (Philadelphia). The
subject was a young epileptic who, on the approach of an aura,
inhaled amyl nitrite from a small bottle. On one occasion he
spilled some of the drug over his right eye with a resulting
deep burn and slough of the cornea, loss of sight in that eye
and a severe burn of the surrounding tissue. The burn is
explained by Shumway as due to the formation of nitrous and
nitric acids in the amyl nitrite by repeated exposures to the air.
As a precaution against such accident he advises frequent test-
ing for acidity of specimens often used, or what is better, the
employment of the drug only in the form of pearls.
Phlyctenular Keratitis Complicating Smallpox, with
Remarks on the Ocular Lesions of Variola.— Edward
Stieren (Pittsburg) stated that lesions of the eye in smallpox
are practically the same as those on other parts of the body,
although this is a disputed question. He has observed the
marked resemblance of these lesions in 18 of 24 cases of small-
pox. In one patient, a colored boy of 18, there were eight phlyc-
tenules in one eye. He made a good recovery, was discharged
and returned a few weeks later with five more phlyctenules in
the same eye. Stieren believes that many staphylomas follow-
ing smallpox begin originally as phlyctenules.
Corneal Tattooing. — J. L. Borsch (Philadelphia) made
an earnest plea for the more extensive employment of tattooing
in the treatment of corneal opacities. He gave in detail the
technic of the operation, stating that most articles written on
the subject convey an incorrect idea of its performance. He
has never seen sympathetic irritation follow its employment.
By the performance of sphincterectomy and judicious tattoo-
ing many cases of corneal opacity can be greatly relieved and
even sight improved. At least removal of the eye is avoided
in many instances.
Discussion.— RiaLEY (Philadelphia) said it must be remem-
bered that eyes with corneal opacities are sick eyes. Blood
channels are still present and there is great risk of causing
excessive irritation by the introduction of foreign material into
them. Hence he practically abandoned tattooing years ago.
Further, the results of this operation look well for a little time,
but are not permanent. Lymph absorbs the material and repe-
tition of the operation is necessary. If tattooing is used at all
it should be only in selected cases which liave a minimum
vascularity.
Epilepsy as Related to the Ocular Muscles.- Wendeli,
Reber (Philadelphia) stated his belief that a common cause of
irritation in cases of epilepsy is some lesion of the visual cen-
ter. In every case of nonfocal epilepsy a most careful determina-
tion of refraction should be made. It will he found that many
cases can be improved or cured by means of glasses or, as a last
resort, tenotomy. Several cases personally observed were cited
m proof of this statement. Institutions or colonies for the care
of epileptics are not so much needed as the most careful study
of individual cases for some focus of irritation, either visual or
otherwise. ^ ,, ,, ,r.u-i
Chronic Sphenoid Abscess.- Lewis S. Somers (Phila-
delphia) reported a case of this lesion without cerebral or
ocular complication. This lesion is not so rare as its diagnosis,
most cases being treated as nasopharyngeal <',atarrh.
The Wisdom of Removing All of the Tonsil When-
ever Enlarged and Diseased.— Louis J. Lautenbach ( Phil-
adeli)hia) believes that every enlarged tonsil is a diseased
tonsil and should be removed by tonsillotome, reinforced by
cautery and scissors in order to make the removal absolute.
Feeblemindedness (Address in Mental Disorders).—
J Moorhead Murdoch (Polk) gave the various classifications
of the feebleminded, stating that there were 10,000 such people
in Pennsylvania, of whom 2,000 are in institutions. No other
condition of human beings is so easily transmitted to offspring,
hence the importance of placing those so afilicted in homes tor
theircare. The etiology was discussed by Murdoch, who in
800 cases found 106 with a distinct history of alcoholism in one
or both parents. Syphilis is not a potent cause, only 6 cases
being found in the above series. Tuberculosis is an important
factor, a family history of that disease being present in 79 of the
800 cases. Defective nutrition, infectious diseases, and the
administration of opiates to very young children are potent
causes. Medical treatment is mainly hygienic. Murdoch has
not seen improvement in a single instance of operation on
microcephalics. Feebleminded children do much better when
placed with their like than when placed with normal children.
They should be placed in homes early, preferably during their
fifth or sixth year. „ . ^
The Treatment of the Insane in Private Practice.— !• .
Savary Pearce (Philadelphia) spoke of the advances being
made in the treatment of the insane, and said that psychology
must be better understood by medical men if this advance was
to continue. Asylums are desirable for the treatment of the
chronic insane, the violent and many other types, but there are
some that are much better treated at home. Among these are
certain delusional forms to which is added an element of hys-
teria, delusions of the depressive type seen in exhausted
women about the time of the climacteric, cases of sexual degra-
dation, and others of like type. A closer study of psychiatry
will enable physicians to differentiate these and determine if a
case is of a homicidal or suicidal type, and consequently needs
institutional care. In many of the types above mentioned
prognosis is favorable. Pearce's study of insanity leads him
to become more and more optimistic regarding its treatment.
third session.
This was held Tuesday evening, the first number being an
address of welcome by ex-Judge Edward Harvey (Allen-
town), who dwelt at some length on the theme of physicians as
expert witnesses, giving some pertinent advice on that ques-
tion. Points of friendly criticism were the statement by physi-
cians that lawyers were severe in their examination of wit-
nesses, the disagreement of experts and the use of technical
terms by medical men in their testimony.
The annual address was delivered by President Francis
P. Ball, who spoke of the opposition met by all discoverers and
inventors in their efforts to benefit mankind. He then con-
sidered some of the antagonisms to scientific medicine by (1)
the theologians of the past in reference to treatment of the
insane, to dissipating witchcraft and the teaching of anatomy ;
(2) more modern oppositions, as those of the anti vaccinationists,
antivivisectionists and others.
[To be concluded.'] ,
Average Age of the Population.— A table prepared in
the Census Office shows that the average age of the population is
increasing. In 1880 it was found to be 24.6 years ; in 1890, 25.6
years ; in 1900, 26.3 years. Prior to 1880 the ages of the popula-
tion were not reported by single years, therefore this system of
computing the average cannot be applied to earlier censuses.
Many influences have produced this change in the age-compo-
sition of the populace, the most important being the rapid
progress of medical and sanitary science, the decrease in the
relative number of births making the earlier age-periods less
preponderant, while the adult immigrants have helped to in-
crease the number of older age-periods.
Sanitation in Manila.— Radical measures to improve sani-
tation in Manila will be undertaken by the Health Board,
assisted by Governor Taft, the American authorities being con-
vinced that only the most stringent system will avail to protect
the city from pestilence when conditions are favorable. The
plan provides that insanitary buildings must be torn down and
the material removed ; an up-to-date sewerage employed ; low
places in the city filled in ; walls built to hold back tidewater ;
and new buildings only be erected in accordance with strict
sanitary regulations. The statement is made that in order to
secure the grades required to drain the streets and houses it
will be necessary to fill in over the whole site of the city. It is
estimated that when the buildings in the slum quarters are
destroyed over 40,000 persons will be rendered homeless. Gov-
ernor Taft has promised to supply temporary camps for this
class and to look carefully after their needs.
SEPTEMBER 20, 1902]
COKRESPONDENCE
.'AMEKICAN MEDICIini 449
CLINICAL NOTES and CORRESPONDENCE
[Communications are Invited for this Department. The Editor Ifl
not responsible for the views advanced by any contributor.]
A HIGH BIRTHRATE.
BY
GEORGE G. BARNETT, M.D.,
of Ishpemlng, Mich.
Ishpeming, Michigan, claims the highest birthrate per 1,000
population of any city in the country. The statement is proved
Ijy the following report, which iacludes all births occurring in
the city since June 1, 1897, at which time the local law requiring
the immediate reporting and recording of births went into
effect.
It is obviously impossible to make a report of this kind
absolutely correct. We claim, however, that the following is
nearer the exact truth than any before published. We have
assumed that in a city of 12,000 population, one birth per month
might and probably does occur which would not be reported
on account of carelessness, ignorance or intentional disregard
of the law.
This report includes 2,.302 births, all white, and presents
several points of more than usual interest.
First: The unusual high birthrate — at least 10 per 1,000
higher than any we have found in other cities.
Semnd : The large excess of male over female births in 1897.
The excess of female over male births in 1901.
Third: The small number of illegitimate births is strong
testimony in favor of the social purity and general morality of
our community.
Fourth: The apparently l&rge number of "still-births" is
explained by the fact that the report includes all births after
and including the seventh month of pregnancy. Hence, many
births are recorded that are omitted from most reports of this
kind.
During the time included in this report, viz., June 1, 1897,
to January 1, 1902, there have been 793 deaths in our city.
Deducting the number of deaths from the number of births,
2,302, gives a natural increase of population of 1,509 for 55
months, or an average of 27.43 per month, 329 per year, or an
average yearly natural increase of .027%.
Nativity of Pabknts.
Bex.
Number
born.
Both
Parents
Foreign.
Both
Parents
Native.
Father
Foreign-
Mother
Native.
Father
Native-
Mother
Foreign.
Male
1,208
l,o:W
828
73.3
132
114
18«
160
60
41
Total
2.217
1,561
m
S46
94
Number of Births per Thousand PoptTLATiON.
Year.
Number of
Births.
Popnlatton.
Number of
Births per
Thousand
Population.
lflB7 (7 monihfll
2S4
SIC
496
498
&19
11,687
ll,fS7
12,000
1S,2SS
13,255
87 6
1898
i9oo.!.'.'.'."."!!!i!i!!."!"«*."~
1901
43.6
41.8
87.2
41.4
Average number births per thousand population for five years, 40.2.
Number Males per lOO Females.
Year.
Males.
Females.
No. Males to
100 Females.
No. Females
to 100 Males.
1897 (7 months)
18!tS
150
266
278
255
264
97
282
211
226
273
154.7
114.6
129,3
112.3
1899 „
1900
1901
108 4
1J08
1,039
116.2
TWINS.
Year.
Male.
Female
Total.
1897
2
4
6
4
6
2
4
0
2
4
4
8
6
6
10
1898
1899
1900
1902
Total
2-2
12
84
Both male, 20 ; both female, 10 ; male and female, 4 ; total, 34.
Year.
iLLEOrriMATE.
Stix-l-Born.
Male.
Female.
Total.
Male.
Female.
Total.
1897
1
3
5
2
0
1
0
4
1
4
2
3
t
4
2
13
14
14
8
2
3
7
4
9
4
1898
16
1899
21
1900
18
1901
17
Total
11
10
21
51
25
76
Births in the City of IsHPEMiNa, Michioan, from June 1, 1897,
TO January 1, 1902.
Year.
Male.
Female.
Unknown.
Total.
1897 (7 months)
1898
150
266
273
25.5
2M
97
282
211
226
273
7
12
12
12
12
254
510
1899 ,„
496
1900
498
1901
549
Total
1,208
1,039
65
2,302
(fATIONAMTY OF PARENTS.
Mothers born in
Fathers born In
1
s
aj
•a
S
a
O
■0
0
s
□
Ed
c
1
t
0
■a
g
HI
9
S
1
28
U
i42
■ i
>>
1
■0
s
«
a
S,
i
"0
1
4
4
ci
1
1
0 [
li
S 0
.. 1
a
J3
■6
a
1
United States
England
280
150
52
8
14
W
...„
16
2
2
4
5
1
2
1
579
20| 18i 5
294! 81 5
8CI6{ 10
li 111271...
'.-
:;;
"i'
-•-•
2 1
z
z
«-
Ireland
"ib
"i
327
"ii
....25
.... 2
"4 '.'.'.
Italy
50
MO
1...
1
"i Z".
85
"i
1
2
...
.. 2
...
...
Russia
■"i!.::_i...
1 1
...„!...„.„
11
"i
1 ...
2 2
.. 2
3 4
.. 2
3 6
"i
I
1
"4
1
"i
1
Austria
Scotland «
Bohemia
366
J...
1,
Iffi
*"i
i
Syria
Total
^
1-
^1
61
470
1
2,248
Finally, the above report fully and thoroughly illustrates
the importance, value and necessity of a law requiring the
prompt, complete, and correct reporting and recording of all
births.
TREATMENT OF NARCOTIC INEBRIATES.
J. B. MATTI80N, M.D.,
of Brooklyn, N. Y.
To the Editor of American Medicine .-—Experience gained
in 30 years' study and treatment of narcotic inebriates leads
one to comment on the paper of Dr. Frank Searles.' I regard
the condition as disease, and deprecate the use of the word
" habit" in its connection. I agree with Dr. Searles' condemna-
tion of the abrupt withdrawal of the drug in treating the dis-
ease, and would emphasize his statements by characterizing the
method as not only too radical but as brutal. Of the slow plana
^ Mmrrican Medicine, March 16, 1902, p. 486.
460 AXBBIOAN MEDIOimiJ
OOfiEESPONDENCE
[Septembek 20, 1902
of withdrawal, that of Dr. Oscar Jennings, of Paris, with slight
modifications, is best. For obtaining rapid disuse of the
dnig, I have a method, in all cases fitted for its use, which has
for its object minimum length of treatment and maximum
freedom from pain. In this method a strong factor is prelimi-
nary use of sodium bromid for its sedative effect, in increasing
doses for 7 to 10 days, reaching a maximum of 70 to 100 grains
semi-daily, during which the usual narcotic is gradually with-
drawn. .Judgment must be used in its giving, however. After
use of the narcotic has ceased, the consequent unrest and insom-
nia are best met by trional and codein, the former of which is
the best hypnotic in these cases, and possesses additional merit
as a spinal sedative. The proper use of codein, muriate or
phosphate, is of great value. The drugs mentioned are of chief
value in my treatment, but use is also made of baths, electricity,
hypnotism and tonics. After need of medical treatment is
ended , special care must be taken to prevent loss of tone. There
should be no premature return to work. Too much stress can-
not be laid on this point.
In this connection, notice may be taken of two socalled
methods, which have had some vogue. One is the giving of
bromid in large doses, to the extent of an ounce daily, for three
or four days, during which the drug-taking is ended. Insanity
and even fatal edema of the lungs have been known to follow
the use of this method. The other method is the frequent
administration of hyoscin hydrocarbonate, subcutaneously, in
doses of xio to ^ grain. This palsies and crazes, and demands
constant vigilance and the giving of strychnin or spartein to
avert or remove cardiac failure. There should be no place in
therapeutics for such measures, which I have no hesitation in
denouncing as irrational, unscientific, inhumane and danger-
ous. Modern medicine has done much for drug inebriates, and
never was their treatment so successful as now.
COMPLETE PROCIDENTIA UTERI IN NULLIPAROUS
WOMEN.
BY
M. ETHEL V. ERASER, M.D.,
of Boston, Mase.
Dr. Beyea's paper and subsequent discussion lead me to
report an interesting case now in my care :
Miss C, aged 25, American, and undoubtedly nulliparous,
was first seen Dy me at the gynecologic clinic of the Pope Dis-
pensary May 29, 1902.
Past History.— Aa a child she was delicate, easily tired, and
subject to dizziness and fainting attacks. She never could
indulge in the romping play of other children and was under
medical supervision for a heart atfection. Menstruation was
established at 17, was irregular, two to six months' type, and
always accompanied by pain.
She nursed her mother, a large woman, through a pro-
tracted illness. Since her mother's death, four years ago, she
has done the entire work for a fair-sized family.
Present History. — About four or five months ago patient
first noticed that " something was coming down," and for the
past two months the uterus has been entirely outside the body.
Examination showed a complete procidentia uteri with
slight retroversion, prolapse of anterior vaginal wall and part
of rectal. The cervical mucous membrane was everted and
eroded. The uterus was aboutthe size of a medium sized orange.
"The right ovary occupied a position slightly to the right in cul-
desac and was as large as an egg. The perineum was intact.
Appetite and digestion were poor and bowels constipated.
Patient slept indifferently and was exceedingly nervous and
subject to dizziness and faintness, especially on rising in the
morning.
A highly-arched palate gave characteristic speech. Heart
examination showed an aortic insufficiency combined with
mitral incompetence.
The uterus was readily replaced, and bi-weekly tamponade
has kept it in good position and in two months reduced the size
almost one-half.
It does not seem unreasonable to regard this as a hernia.
Some slight prolapse of the abdominal viscera suggests a true
ptosis. The highly arched palate and the cardiac lesion show
congenital detects which warrant us in thinking that ineffi-
cient anchoring, inelastic tissues and a life of hard work, con-
stant standing, walking and lifting were, in this case, sufficient
etiologic factors.
DANGERS OF INCOMPLETE ANESTHESIA.
BY
HARRY MORELL, M.D.,
of Lltchfleld, Minn.
To the Editor of American Medicine .—Apropos of Dr. Wil-
liam Harmar Good's article in American Medicine of August
23, 1{K)2, "Are not some deaths during operation in region sup-
plied by the trifacial nerve due to reflex inhibition of respira-
tion and of the heart? " I wish to quote from T. Lauder Brun-
ton's explanation which I cited in a communication to the New
York Medical News of April 12, 1899 :
The close connection between the roots of the fifth nerve
and those of the vagus can be demonstrated anatomically, and
it is probably in consequence of this that the irritation of the
fifth is able to exert such a powerful influence upon the circu-
lation. Some time ago, in a paper which I published in the
British Medicat Journal, I mentioned that one cause of death
during the extraction of teeth under chloroform was probably
the stoppage of the heart's action through the inhibitory fibers
of the vagus, associated with a reflex depression of tone in the
blood-vessels. The reason why the extraction of a tooth in a
f)erson who is not under the influence of an anesthetic is fol-
owed by no ill efi'ects is probably this: that in him the irri-
tation of the fifth nerve produces two distinct actions which
counterbalance each other. It may cause reflex stoppage of
the heart through the vagus ; but at the same time it causes
reflex contraction of the vessels through the vasomotor center.
This contraction of the vessels maintains the pressure in the
arterial system during the stoppage of the heart, and thus no
harm whatever is done. When an anesthetic is used, however,
one of these pieces of nervous mechanism may be paralyzed by
it while the other is not, and thus the extraction of the tooth
may stop the heart without causing contraction of the vessels.
The blood-pressure will then sink very rapidly in the arterial
system, and fatal syncope may be produced. If, however, the
anesthetic be pushed to a greater extent, so that both parts
of the nervous mechanism just mentioned are paralyzed, the
vessels are not contracted, but neither is the heart stopped.
The operation is therefore comparatively free from danger when
no anesthetic has been given, or when the anesthesia is perfectly
complete, the period of danger being that of imperfect anes-
thesia. (Italics my own.)
I think the foregoing explanation is much clearer than any
of those by the authors quoted by Dr. Good. It will be noticed
that it does not take into consideration the influence of reflex
inhibition of respiration. I think I am correct in stating that
there are more deaths from the administration of chloroform due
to reflex inhibition of the heart than those caused by reflex
inhibition of respiration.
MODERN TREATMENT OF SMALLPOX.
BY
G. METZLER, M.D.,
of Philadelphia.
Recently I was called to the northern part of Philadelphia
to see a boy, aged 4, whose father and mother had been sent to
the Municipal Hospital because of smallpox. I found the boy
delirious, with a temperature of 105°. I ordered a washtub
filled with cold water, immersed him in it and poured a pitcher
of cold water on his head. He was then lightly packed in a
bedsheet and blanket. The delirium ceased and quiet sleep
followed. The serious condition of the patient and the total
lack of proper attention suggested immediate removal to the
hospital. Upon being informed that the ambulance would not
be sent except by order of the Board of Health, I telephoned to
the board and described the condition of the boy and what I
had done for him. When I told of the cold bath, the person at
the telephone cried in apparent disgust, " What, a cold bath !
You would not give a cold bath if there were any indications of
smallpox?" This from a person apparently a medical man has
resulted in my having a more liberal feeling of charity to that
class of granny women who have such strenuous faith in the
power of heat and the value of blankets for patients with measles
" so that the measles will come out."
Telephone Inspection.— Bacteriologic examinations of
1 public telephones will be undertaken in Buff'alo, with a view to
determining some method by which infection from this source
may be averted.
8EPTEMBEB 20, 1902]
DIETETIC TREATMENT OF TUBERCULOSIS
[Ambbican MedicikK 451
ORIGINAL ARTICLES
THE RATIONAL BASIS FOR THE DIETETIC TREAT-
MENT OF TUBERCULOSIS*
BY
WILLIAM HENRY PORTER, M.D.,
of New York City. •
Professor of Pathology and Gfocral Medicine at the New York Post-
graduate Medical School and Hospital ; Attending Physician
to the New York Postgraduate Hospital, etc.
The dietetic management of disease is rapidly becom-
ing one of the most important branches of therapeutics.
In no disease is this assertion more true than in con-
i nection with the treatment of pulmonary tuberculosis,
since the great frequency of this aifection, its patho-
logic changes and the high mortality are essentially
the result of a marked and progressive defect in nutri-
tion.
Two things are essential to a thorough knowledge of
the dietetic therapeutics of pulmonary tuberculosis.
First, a clear conception of the methods pursued by
nature in the development of the processes that we are
to relieve by dietetic mea-sures ; second, a thorough
understanding of the chemic composition of the food-
stuffs, their digestibility, and the physiologic methods
by which the system utilizes the foods. The former is
comparatively easy to acquire, because the methods by
which the pathologic lesions in tuberculosis are devel-
oped is well understood ; but the latter is far from being
as easily attained. In fact, there seems to be no end to
the differences of opinion and contradictory statements
regarding the plainer truths of dietetics and their inter-
pretation— truths that ought to be understood clearly by
all who attempt to treat disease dietetically.
Tuberculosis is no longer regarded as an inherited
disease. It is now known that it must always be
acquired in utero or after birth. This terse statement
may be denied by some, but the weight of evidence, as
illustrated in the observations of Bolitz,' points so
strongly in this direction that we are fully justified in
making the assertion. The child may be born with a
decidedly low chemic nutritive force, hence its powers
to resist germ invasion will be very slight. This, how-
ever, does not constitute tuberculosis. It simply indi-
cates that the nutritive activity of such a subject is in an
abnormally low state and that a suitable soil for the
growth of the germs is easily favored by the slightest
errors in diet.
As the lowering of the chemicophysiologic forces
plays such a large part in the production of this much
dr««ded disease, and as errors in diet are so largely re-
sponsible for the deteriorated condition of the system,
we are fully justified in assuming that the predisposition
to tuberculosis can be bred and fed into a family ; or, on
the other hand, that the same can be bretl and fed out of
a family. If the parents are of a reasonably sound habit,
if they are so placed in life that they can live under
proper hygienic conditions, and if they confine their diet
to that which is plain, easily digested and yet highly
nutritious in (juality — other things being e<iual, their
ottspring will possess a higher chemiconutritive resistr
ance than when these conditions are reversed. They
will have a high resistance not only against tuberculosis,
but against all forms of infection. Therefore we, as guar-
dians of the public health, are in duty bound to try in
every way possible to educate the human race to be more
careful in the .selection of life partners. Theoretically,
both parlies should be carefully oxaminetl by competent
physicians before being allowed to close the final contract.
If such rules as are followed carefully in mating the
lower animals were applied to the mating of the human
• Read before the American Therapeutic Society, New York City,
Hay 14, 1902.
species, one great factor in the predisposition to disease
would be removed at once.
Every one, however, must realize that such radical
measures cannot be applied at once to this vital prob-
lem, but much may be accomplished in the line of pro-
gressive, common sense education on this subject if
every physician performs his full duty. When the
human species is more universally mated in accordance
with these ideal standards the problem will not be fully
solved, but rather just begun. It will still remain to
exercise the greatest care in the selection of proper diet
and in the establishment of perfect sanitary surround-
ings. This is especially true of the mother during the
childbearing period of life, if strong and healthy children
are to be produced. Too little thought is given to this
important question; consequently too many children
are brought into the world with enfeebled constitutions
when they might, with a little care on the part of their
parents, have been born strong and robust.
Taking this view of the subject, the treatment of
tuberculosis resolves itself into two distinct divisions:
The preventive treatment and the management of the
disease after it has been fully established.
The practical condition which we are called upon more
frec[uently to contend with is the management of chil-
dren born of unwisely mated parents ; or to deal with
offspring of parents who, though primarily healthy,
have been poorly fed, overworked and compelled to live
in unsanitary surroundings during the childbearing
period. In either instance the progeny is apt to be born
in a low state of chemicophysiologic activity. Yet, as
we study nature closely, it becomes apparent that the
nutritive vitality of the infant in utero is, as a rule, con-
served at the expease of the mother's nutrition. Thus
it not infrequently happens that a fairly healthy child is
produced by a weak and sickly mother. In such in-
stances the mother certainly is not the fit subject to
nurse her offspring ; or, if allowed to do so, it should be
for a brief space of time.
Viewed in this light the proper feeding of the mother
and the newly born babe is of the utmost importance if
we expect to reduce in any appreciable degree the num-
ber of tuberculous subjects among the human race.
During the childbearing period the mother should be
kept upon a well-regulated mixed diet, but one in which
the animal proteids predominate, because, as will be
shown later, this class of proteids always yields the
largest nutritive return with the smallest expenditure of
digestive and assimilative energy. This accomplishetl,
both mother and child, assuming that the hygienic con-
ditions are good, will develop and maintain the highest
possible nutritive standard. There will be produced,
also, the greatest power on the part of the system to
resist infections of all kinds. The mother, under such
conditions, will in all probability have a full supply of
milk of a good quality. Under these circumstances, and
under no other, is she a fit subject to suckle her own off-
spring. The nursing period, however, should never be
too long extended. It is now well established that milk
contains too low a percentage of nucleoalbumin for the
best quality of blood. Therefore, a protracted nursing
period has a tendency to develop an anemic child as the
months advance. This is one of the .strongest argu-
ments possible against a protracted use of milk to the
exclusion of all other kinds of foodstuffs.
When the mother is not in the re<iuisite physiologic
condition to be allowetl to nurse her offspring, or the
time has arrivetl when the child mast be weaned, other
arrangements for its nutrition must be made. In the
former instance it is a question of substitute in the form
of a wet-nurse or artificial feeding. If all that can be
desiretl is easily found in the form of a suitable wet-
nurse, this is unquestionably the host method to pursue.
In the majority of instances, however, this cannot be
done; hence, artificial feeding is the problem to be
solved. Here no fixed and arbitrary rules can be laid
452 AMBBioAK MBDiciKK DIETETIC TREATMENT OF TUBERCULOSIS
[Hepteuber 20, 1902
down. I^ach case must be studied by itself. As a gen-
eral rule, cow's milk should be substituted for mother's
milk rather tiian some one or other of the innumerable
artificial foods, all of which are claimed to be far supe-
rior U) those produced in and by the laboratory of
Nature. A child that cannot be made to thrive upon a
good quality of cow's milk properly sterilized and
diluted, or to which a suitable amount of egg-water or
barley-water has been added, will in all probability
become a fit subject for tuberculous infection. Pro-
longed sterilization of the food may be detrimental by
excluding from the alimentary canal the bacteria that
are essential for a perfect digestion, as demonstrated by
the experiments of Schottelius.^
As the child advances in age the diet must be aug-
mented by the addition of soups and beef broths, then
by the more solid foodstuffs, such as eggs, meats, bread
and butter, and a moderate quantity of judiciously
selected vegetable foods. In this connection it should
always be borne in mind that the animal proteid is the
most economic to the system, and that when the quan-
tity is properly adjusted with the limited use of the
vegetable class of foodstuffs it will yield invariably the
highest nutritive force attainable. These same rigid
rules regulating the diet, both as regards quality and
especially quantity, should be maintained throughout
life. If as time goes on we are successful in accomplish-
ing all that has here been outlined, the predisposition to
acquire tuberculosis will, in a large measure, be bred and
fed out of the human species.
In all cases of tuberculosis, excepting the few
instances that are localized and within easy reach of the
surgeon's knife, very little can be accomplished in the
line of destruction and complete removal of the bacilli
from the system. Therefore, in the cases of tuberculo-
sis that fall into the hands of the physician for treat-
ment, as contrasted with the surgeon, there is very little
that can be accomplished in the line of antiseptic treat-
ment.
What must be accomplished, if success is to crown
our efforts, toward decreasing the liability to acquire
tuberculosis and toward ridding the system of the dis-
ea.se when acquired, is the forced development of a
higher nutritive standard. To secure the best results
we must, as already stated, go back a generation and
guard carefully the mating of the human species, so that
the possibility of producing healthy offspring will be
augmented to the highest degree. Then the diet of the
mother and child must be regulated in accord with our
advanced scientific principles. In fact, the whole race
must be educated as to how and what they should eat.
This brings us directly to the consideration of the
dietetic management of the tuberculous subject. To
understand best what is required by a diseased system
necessitates first a clear knowledge regarding the require-
ments of the normal economy. This can be acquired
only by a careful study of the chemic composition of the
food products used, their digestibility, the percentage of
each absorbed and the ease with which they are utilized
by the system.
Regarding the composition, we find that almost all the
foodstuffs derived either from the vegetable or animal
kingdom contain inorganic elements, albuminous sub-
stances, starches and sugars, fats, and a still more complex
albuminous body to which phosphorus and iron are at-
tached. This substance is sometimes called nucleoalbu-
min and sometimes nucleoproteid. Whatever the name
may be, it is the iron-bearing and phosphorus-bearing
compound which is the important body, for this substance
is the precursor of the hemoglobin and lecithin formed
within the system — these two substances (hemoglobin
and lecithin) being formed by the oxidation reduction
of this complex molecule in the epithelial cells of the
liver. Hence, this nucleoalbuminous substance is an
important factor and one that must be fully considered
m the study of all food products. Especially is tliis true
in a condition like tuberculosis, in which a profound
anemia is a decided factor from the beginning to the end
of the disease.
Another thing to be considered in the composition of
the food products is the relative proportion of the con-
tained ingredients, so that the supply of each class of
elements is adjusted rightly to the requirements of the
system. The digestibility and percentage absorption of
each must also be accurately determined, otherwise wide
errors in the arrangement of the diet will be made.
Much accurate information has been furnished upon the
subject of digestion and absorption by the experiments
of Rubner,' Prausnitz,* Striimpell,^ Woroschiloff,"
Meyer,' Hofmann,* Chittenden and Cummins," Monk,"
and Konig." The results of their exi^eriments show
conclusively that the animal class of foo<Lstuffs is easily
digested and that the percentage absorption is very
large ; while the vegetable class is with difficulty di-
ge'feted and the percentage absorption low, leaving a
large amount of irritating residue to pa.ss through the
alimentary tract. Consetjuently the animal class is
much leas taxing upon the digestive powers and at the
same time furnishes to the animal organism the highest
possible percentage of available nutritive pabulum for a
given quantity of food ingested. The reverse is true if
the vegetable class is used. It has also been conclusively
proved that the animal class has the three constituents,
to wit, albumin, sugars, and fats, in such proportions
that the requisite amount of these three substances can
easily be furnished to the system without introducing an
excess of any one. With the vegetable class the propor-
tions are such that it is absolutely impossible to arrange
a diet in which there is not an exceas of one class of
compounds and a decided deficiency of another. In
other words, if the requisite amount of albumin is se-
cured by use of the vegetable class alone there will be a
large excess of the starches and sugars and a positive
deficiency in the fat ; and if the diet is so arranged that
sufiicient fat is supplied to the system there will be an
overwhelming preponderance of the starches and sugars
and an excess of the albumins. While it is possible to
secure with the animal class alone an almost i)erfect bal-
ance between these three classes of substances, animal
food is somewhat deficient in the nucleoalbumins or
iron-bearing constituents ; consequently the animal
class alone does not furnish an absolutely perfect diet.
In this one particular the vegetable cla.ss has the advan-
tage over the animal, as it possesses a high percentage
of these important iron-bearing compounds out of which
hemoglobin and lecithin are normally formed. There-
fore, the ideal diet is one in which the two classes are
properly blended. It should always be borne in mind,'
however, that a preponderance in the animal class is
absolutely essential if the highest grade of nutrition and
reparative activity is to be established.
With the composition and digestibility of the various
food substances accurately determined, it is next essen-
tial that some definite standard be established by which
the quantity of the proteids required daily can be deter-
mined. The same is equally true in regard to the sugars
and fats. Every one who has ever made the attempt to
solve practically this problem must have found it an
extremely difficult task. This is fully shown by compar-
ing the dietaries of Dujardin-Beaumetz,'* Moleschotte,"
Forster," Petti nkofer and Voit,'^ Ranke,'" At water" and
others, in which the quantity of proteids ranges from
100 to 145 grams ; the fats from 40 to 12.5 grams, and the
starches or socalled carbohydrates from 240 to 550 grams ;
the average for the proteids being 125 grams, that for
the fats 69 grams and that for the carbohydrates 451
grams.
Turning now to the estimates that have been made
by the various physiologists relative to the elimination
of nitrogen, we find that the average daily output of
nitrogen from the system is 23.541 grams, or in round
numbers 24 grams, distributed as follows :
Bepteuber 20, 19021
DIETETIC TEEATMENT OF TUBERCULOSIS
(AmtRicAKr Medicine 453
35.00 grams of urea contain 1.331 grams of nitrogen.
2.80 " urates " 942 " "
.80 " uric acid " .266 " "
1.00 " creatinin " 371 .< ..
,/?§ .'! hippiirlc acid " Mi
W.l^ sodium taurocholate.. " 2.098 " "
18.28 " sodium glycocholate.. " .446 " "
H.60 " bilirubin .: ■• 1 "7
14.60 " biliverdln '• 1430
90000 " perspiration " .330 " "
•02 " NH3 In respired air " .016 " "
Total 23.511
To the above there should be added the nitrogen
eliminated in the various digestive ferments, which will
probably bring the total nitrogen elimination up to 24.00
grams per diem.
It is not sufficient, however, to estimate the nitro-
genous waste only in constructing the dietary in health
or in disease, but the loss of energy in heat and motion
must also be considered. It is usually estimated in heat
equivalents, and these heat units must come either
directly or indirectly from combustion of the oxidizahle
substances contained in the foodstuffs utilized.
This energy loss per diem is given by McKendrick '«
as follows :
Work of the heart 50.400 kilogram meters.
Work of re.spi ration 11.700 " "
Mechanical work for 8 hours 125.000 " "
Equivalent of heat produced 620.000 " "
Total 807.000 " "
which is equivalent to 5,800,000 foot pounds.
Therefore, in arranging and estimating the value of
any dietary the main points to be kept in mind are the
ease of digestibility and utilization by the system, the
ability to furnish the requisite amount of nitrogen waste
and the recjuisite heat production. At the same time
the amount of food used to produce these results must
also be kept well within the limits of the oxvgenating
capacity of the economy. All this accomplished, the
highest grade of nutrition and reparative activity will
be secured and maintained.
Analyzing the various diet tables closely It at once
becomes apparent that none of them furnishes a sufficient
amount of nitrogen to the system to satisfy the daily
elimination of nitrogen estimatetl in the excretions in
health. This being true, the estimate must be wrong or
the patient must lose in weight. Hence, a more liberal
supply of proteid material must be furnished ; and as ani-
mal proteid is the most ea.sily digested and assimilated,
it rather than vegetable proteid should be secured. This
is especially true in all diseased processes and markedly
so in tuberculosis, in which the digestive powers are
exceedingly feeble.
Kstimating the heat production obtainable from all
the combustible elements contained in the average of
these dietaries the heat production is found to exceed
the estimates of McKendrick by more than 400,000 kilo-
gram meters, and in some in.stances by 600,000. With one
exception, they all exceed considerably the estimated
oxygenating csipacity of the animal economy, which is
given in round numbers as 750 grams of oxygen a day.
Some of the dietaries require as much as 800 to 900
grams of oxygen for their complete oxygenation.
What has l>een found to be true regarding the oxy-
genating capacity is equally true in reference to the
p<jwer of the system to produce and eliminate
carljon dioxid and water. They all greatly exceed the
capticlty of the system with one exception. Ranke's
dietary keeps within these limits, but it is defective in
all the ingredients, especially so in the proteids. lUnke
gives only 100 grams of proteid, when it requires the
perfect utilization and oxidation reduction of 150
grams of proteid material to furnish the 24 grams
of nitrogen estimated as the daily output in all the
excretions of the body. The overproduction of heat is
less detrimental to the animal economy than an over-
taxing of the oxygenating capacity or inability to fully
produce and eliminate the carbon dioxid and water
because the excess of heat will be rapidly dissipated
under normal circumstances; if it is not, the bodily
temperature will rise above the normal standard. Im-
perfect oxidation, on the other hand, is evidenced at
once by a fall in the output of urea and a rise in the
excretion of uric acid. When this occurs it indicates a
progressive deterioration of the system, and sooner or
later the more positive evidences of pathologic changes
in the animal economy will be declared.
This overproduction of uric a«id is not due, as so
many have claimed, to the u.se of animal proteid as
against that of vegetable origin, but it is more directly
due to the excessive use of the starches and sugars in a
dietary that exceeds the oxygenating capacity of the
system. Neither animal nor vegetable proteid contains
uric acid, as Haig'" claims for the former, and even
if they did, there is no evidence to warrant the assump-
tion that the uric acid as such would be absorbed
into the blood from the alimentary canal. On the other
hand, if uric acid were introduced into the intestinal
beaker, which at all times contains many strong alkaline
elements, according to the common law of chemistry it
would be rapidly converted into a urate. As such
it might possibly be absorbed from the intestinal tract
and ultimately find its way into the bloodstream. This
bare possibility, however, does not hold true, because it
is universally admitted by all physiologic chemists that
the salts of uric acid are never found in the bloodstream.
Neither are the experiments of Garrod,^" which are gen-
erally cited as proving the presence of uric acid in the
blood, of such a nature as to establish conclusively
the existence of uric acid in the blood. The same may
be said of Haycraft's method." They prove that uric
acid can be made, by a process of oxidation reduc-
tion, from the proteid constituents drawn from the
serum of the blood ; but that is far from demonstrat-
ing that the acid existed as such within the living
animal economy. The same may be said of Robert's
quadriurate theory.^^ Therefore, many of the theories
advanced regarding the production of uric acid and its
presence in the blood are built upon false chemic
premises.
Another fact that should always be kept in mind in
connection with the u.se of the two classes of proteids is
that they all have to be reduced to the monomolecular
state known as a peptone before they can be absorbed
from the alimentary canal and from there be discharged
into the bloodstream to form the many isomeric forms of
proteid molecules found in the blood. So far as I am
able to ascertain, there is no positive evidence tending to
show that the proteid substances derived from the
animal kingdom and contained within the systtmi are
less easily assimilated and oxidized than those derived
from the vegetable kingdom. On the contrary, the
evidence appears to point very strongly in the opposite
direction. Therefore, the true cause of imperfect oxida-
tion seems to be more directly due to the ingestion of a
larger amount of albumins, sugars and fats than the
system has the capacity to reduce. The vegetable diet,
or one highly charged with starch and sugar, is largely
responsible for the subnutritive condition of the system
which makes possible the tuberculous infection, while the
animal diet or one too highly charged with the animal
proteids is more likely to cau.se the degenerative class of
diseases such as gout, "Bright's disease," socalled, dia-
betes, etc.
This same law holds good in the lower animals. In
them we find tuberculosis frequently developed in the
herbivorous and rarely in the carnivorous class.*
• The presence of tuberculosis in animala as well as In man raises
the question as to the transmlfnlon of the disease from one to tlie oilier.
Koch has recently contended {Srit. Med. Jour., July 27, 1901 ) that t lie
tubercle bacillus Is not the same In the two species, and that the disease
Is not directly transfeired from the bovine to the hiimiin species. On
the other hand, the more recent e.xperinicnls of Hehrliig prove con-
clusively that the bacillus Is the same In the two species, and can be
transferred directly from the animal to man.
454 A.UKRICAN MkDIOINB]
DIETETIC TREATMENT OF TUBERCULOSIS
[8KPTEHBEK 20, 1902
It is in this study of dietetics that we find the true
reason for the great decrease in the number of tubercju-
lous subjects in this country during the last decades.
The more liberal use of a meat diet has raised the general
nutritive standard of the American people to such a
high grade that the liability to tuberculous infection is
much less than it was formerly. It has also made the dis-
ease more amenable to treatment because it is more ration-
ally treated. If the socalled " Beef Trust " continues to
be master of the situation and forces the human race to
adopt a more liberal use of the vegetable class to the
exclusion of the animal class, there is no doubt in my
mind that we shall see an increase in the number of
tuberculous cases and a higher mortality from this much
dreaded disease in succeeding decades.
Thus we And that all errors in diet tend sooner or
later, either directly or indirectly, to establish within
the system an imperfect nutritive activity of one type or
another, and is the great precursor of all pathologic con-
ditions. It is the method by which the foundation soil
is produced within the animal economy for the growth
and development of the innumerable microorganisms
that are today known to invade the system and cause the
many diseases ascribed to the action of these organisms.
Some years ago I formulated a dietary based upon
these principl&s.^' It was one that yielded the full
quota of heat production according to the estimates of
McKendrick. It also developed the heat equally at the
various oxidizing focuses in the body, such as the liver,
lungs and glandular organs in general. In it 130.32
grams of proteid was talcen as the standard, this being
above the average given in most dietaries. It was
deficient, however, in the amount of the proteid sub-
stances used. In this one particular it had to be
enlarged to furnish suflBcient nitrogen to produce the 24
grams of nitrogen eliminated in the excretions. Thus
amended it is one that accomplished all this with the
smallest possible outlay of oxygen, and is as follows :
198.44 gms. (77.00 ozs ) of wheat bread.
102.05
680.37
512.20
, 3.60
'21.00
18.06
) of eggs ; equal to two eggs.
) of milk.
) of meat, or its equivalent In fish.
Total, 1,493.06 " (122.66 " )
Of the above compounds, the breakfast should con-
sist of:
56.69 gms. (2.00 oza. ) of wheat bread.
102.05 " (3.60 " ) of eggs; equal to two eggs.
226.79 " (8.00 " jofnTlTk.
14.17 " (0.50 " ) of butt«r.
Total, 399.80 " (14.10 " )
For the mid-day meal :
85.03 gms. (3.00 ozs.) of wheat bread.
1417 " (0.50 " ) of butter.
256.09 " (9.03 " ) of meat.
Total, 355.29 " (12.63 " ) '
For the evening meal :
56.69 gms. (2.00 ozs.) of wheat bread.
14.17 " (0.50 " )ofbutt«r.
226.79 " (8.00 " ) of milk.
256.09 " (9.03 " ) of meat.
Total, 553.74 " (19.53 " )
The remaining 226.79 grams (8.00 ozs.) of milk can
be taken during the evening from 9 to 11 o'clock,
depending upon the time of retiring ; or it can be taken
with one of the other meals if for any reason it is
undesirable to take it separately during the hours just
mentioned.
From the total quantity of foodstuflfs as given in the
first table, there must be deducted the amount which
has been proved to pass through the alimentary tract
undigested and unabsorbed.
The investigations of Rubner, Meyer and others in
this line, which have already been referred to, show
that 19.9 fo of the proteid compounds contained in bread
pass through the alimentary tract as waste material and,
therefore, this amount must be deducted from the total
quantity of bread ingested. From the eggs, 2.9 ^ must
be deducted ; from the milk, 5.7^ , and from the meats,
2.Sfo. When this deduction has been made from the
total quantity ingested, the amount of proteid material
which reaches the blood is 150.00 grams (5.32 ozs.). This
is the average quantity necessary to carry on the con-
structive work of the system for 24 hours, and to furnish
the normal kind and quantity of nitrogenous excretory
material represented by the 24 grams of nitrogen.
With this proteid material there will also be intro-
duced into the system about 104.55 grams (3.67 ozs.) of
fat and 137.33 grams (4.84 ozs.) of glucose ; that is,
assuming that all the starch, minus the jiercentage
deduction already made, is finally converted into glucose
and absorbed.
In all probability, however, a much larger percentage
of the starch and glucose passes through the alimentary
tract than occurs in connection with the proteid sub-
stances. On this point, however, our knowledge is not
so exact as it is in regard to the albuminous compounds.
This loss in starch and glucose permits the use of a little
extra fat in the form of butter without very greatly
raising the heat production above the normal standard
commonly computed by physiologists.
This form of diet, when the proper deductions have
been made for the undigested and unabsorbed materials,
furnishes to the system during the 24 hours the following
clas.ses and amounts of the proximate principles :
150.00 gms. (5.32 ozs.) of protelds.
101.55 ■' (3.67 " ) of fata.
137 33 '' (4.84 " ) or glucose.
27.47 " (I 08 " ) of mineral salts.
Total, 419.35 " (14.86 " )
The chief difference between this and most other
dietaries is the larger amount of fat and the smaller
quantity of glucose with the rise in proteids already
described. Raising the fats and lowering the glucose
enables the system to produce the full amount of heat
and still keep well within the oxygenating capacity of
the animal economy, which can not be accomplished in
any other manner. Clinical experience also proves con-
clusively that this distribution of the proximate
principles gives the best results in the maintenance of
health and in the cure of diseased processes.
The heat produced by the complete oxidation of the
proximate principles constituting the 419.35 grams
(14.86 ozs.) which have been absorbed and can be utilized
by the system is found to be as follows :
150.00 gms. (5.32 ozs.) of proteid substances
yield 271,428 kilogram meters
104.55 gms. (3.67 ozs.) of fats yield 401,576 "
137.33 " (4.84 " ) of CHO substances
computed as glucose, yield 227,555 " "
900,558 " "
Equals 6,513,935 foot pounds.
Taking the 830,000 kilogram meters as the normal
.standard of heat production by the human economy
during the 24 hours, and the limit has been exceeded by
70,558 kilogram meters. This overproduction of heat,
however, is not so serious a matter, because the excess is
rapidly dissipated from the body. If it were necessary
to keep the heat production down, it could easily be
accomplished by decreasing the amount of fat taken.
As already stated, it is more than likely that a still
larger percentage of starch and sugar passes through the ,
alimentary tract undigested and unabsorbed than the
foregoing figures would indicate; therefore, the total
heat production will be less than the above estimate.
Computing now the amount of oxygen that mast be
consumed in completely oxidizing all the oxidizable
proximate principles into their complete and final cata-
bolins which enter into the system from the ingested
1,493.05 grams (52.66 ounces) of these mixed foodstuffs,
as already specified, the following results are obtained :
Septeuber 20, 1902)
DIETETIC TREATMENT OF TUBERCULOSIS
lAMEBICAK MEMCina
455
150.00 gms. (5.32 ozs.) of proteld substances re-
quire 206.96 gms. of oxygen.
104.5.5 gms. (3.67 ozs.) of fats require 308 51 " "
137.32 gms. (4.84 " ) of CHO compounds figured
as glucose, require 146.46 " "
656.16 " "
Total amount of oxygen used 656.93 gms. (23.27 ozs.)
Average respiratory capacity 750.00 " (26.33 " )
Surplus oxygen 93.07 " (3.06 " )
These figures show a small reserve of oxygen as com-
pared with the average oxygenating capacity of the
system. In other words, the respiratory capticity can be
reduced about one-seventh and still the patient can com-
pletely oxidize the 419.35 grams (14.86 ounces) of food-
stuffs absorbed into the circulation ; or the number of
red corpuscles in the blood, or the percentage of hemo-
globin contained in them, can be reduced one-seventh
and still complete oxidation can be successfully carried
on within the animal organism.
In a similar manner the amount of food can exceed
this amount by one-sixth and still the oxygenating
capacity will not be overtaxed. If the excess of food-
stuffs is confined exclusively to glucose or fat, no mate-
rial harm will be done. The body will be superheated
and an unusual amount of energy developed. The extra
heat, however, will be rapidly dissipated and the in-
creased amount of carbon dioxid can be carried by the
carbonates in the blood to the eliminating organs, the
lungs, and cast off without overtaxing the system or
materially impeding the absorption of oxygen.
On the other hand, if the proteid substances are in-
creased above 150.00 grams (5.32 ozs.), even though the
total amount of foodstuffs is kept well within the limits
of the oxygenating capacity of the system, the nitrogen-
ous excrementitious waste to be eliminated by the ex-
cretory glands is constantly above the normal standard.
So long a.s the catabolic bodies remain normal in compo-
sition they overtax the excretory powers of the liver and
kidneys to a limited extent ; but just so soon as the cata-
bolic bodies become abnormal in composition as well as
excessive in quantity, these organs are severely over-
taxed and temporary or permanent lesions are devel-
oped.
Thus it becomes plain that so long a.s the proteids do
not exceed 150.00 grams (5.32 ozs.) and the glucose and
fats are still kept within the oxygenating capacity of
the system, a perfectly normal state can be maintained.
Likewise, if the glucose and fats are taken in such
abundance as to constantly overtax the oxygenating
capacity of the system, then the sugars and fats, being
more easily oxidized than the proteids, are disposed of
first. This partially exhausts the oxygen supply and
leaves a deficiency of oxygen to transform the proteid
bodies. The r&sult is the development of a state of sub-
oxidation with a decrease in the perfection of the cata-
bolic products resulting from proteid metaboli.sm, but
previously dependent upon the excessive u.se of glucose
and fat. Under these circumstances the catabolins are
not only decrea-sed in perfection, but are increased in
number as well, so that instead of having the normal
amounts of urea, uric acid, creatin, biliary salts and
coloring matter, there Is a marked decrea.se in the quan-
tity of urea with a decided increase in the uric acid, bile
salts and pigments, to which are often added oxalic acid,
lactic acid, glucose and albumin, to say nothing of indi-
can and the long list of leukomains, ptomains and tox-
albumins, all of which are developed as the resultof this
imperfect transmutation of the proteid substances.
In this law of oxidation lies the secret of health and
its restoration if, for any reason, it has been impaired.
This is especially true in connection with i)ulmomiry
tuberculosis. Hence the neces.sity for a thorough knowl-
edge of this. subject in the dietetic management of this
class of cases.
Appreciating fully the oxygenating capacity of the
individual to be treated, and knowing well the composi-
tion and digestibility of the foodstuffs, and the state of
the system through a careful study of the catabolins
contained in the urine, the case can be handled upon
purely scientific principles. We shall not, as did Dr.
Debove,^* attempt forced feeding regardless of the capacity
of the system to utilize the food ingested, or the sur-
alimentation of Dujardin-Beaumetz.^^
As in all other cases, the food of the tuberculous
patient should be of the mixed type, containing fat,
starch and sugar, the starches and sugars being rated as
glucose, because this is the only form of sugar known to
be absorbed from the alimentary tract. The quantity of
glucose should be greater than the fat, but not to so great
an extent as has been given in the pa.st. When the fat
is raised and the glucose lowered, as it is in this dietary,
there will be no occasion to administer the various
oils that have so long been advocated in treating tuber-
culosis. The diet should also contain the requisite
amount of proteid substances. The proteids, however,
should, as a rule, always be taken chiefly from the
animal kingdom, simply because the animal proteid
is more easily digested and a larger percentage is
absorbed. In other words, it is the most economic
so far as the physiologic organism is concerned. This
fact should always be considered in dealing with all
abnormal conditions. The diet, however, should not be
confined too exclusively to the animal class, for, as
we have already found in the study of their composition,
they are defective in the nucleoalbumin compounds.
Therefore, a certain amount of the green vegetables and
legumins must be ingested. When this is done, the
quantity of meat must be proportionally reduced;
otherwise the oxygenating capacity of the system will
be exceeded.
The practical result of thus regulating the diet in
accord with these fixed principles is that the abnormal
catabolins rapidly disappear from the urine, and those of
normal composition only are found in this fluid. They
become not only normal in kind, but also normal in
quantity, which proves conclusively that a normal state
is being established.
The amount of carbon dioxid produced by the com-
plete oxidation of the 419.35 grams (14.86 ozs.) of food-
stuffs taken into the circulation is as follows :
150.00 gms. (5.32 ozs.) of proteid yield 226.41 gms. of CO2
101.51 " (3.87 " of &t yield 294.08 " " "
137.46 " (4.84 " ) of CHO computed as
glucose yield 206.S3 " " "
726.82 " " "
Taking 850.00 gms. (29.84 ozs.) as the normal standard
minus 726.82 " (25.00 " ) there Is left a surplus of
123.18 " ( 4.24 " )
The capacity of the system to eliminate carbon
dioxid has not been reached by the amount quoted :
123.18 grams (4.24 ozs.). This shows a very decided
gain in this direction, which further proves the economic
nature of this form of dieting.
The intrinsic production of water is comparatively of
little account as contrasted with the study of the oxygen
consumed and the carbon dioxid produced, yet it is
computed for the sake of completeness. The following
table will illustrate the production of water :
150.00 gms. (.5.82 ozs.) of proteid yield 68.74 gms. (2.24 ozs.) water
104.61 " (3.67 " ) of fat yield 113.74 " (4.01 •' ) "
137.46 " (4.84 " ) of UHO substances rated
as glucose yield 87 47 " (3.04 " ) "
264.95 •• (9.36 " ) "
The following dietary makes a very good practical
working standard when applied in conjunction with the
foregoing chemico-physiologic laws. It may have to be
modified somewhat at times ; as, for instance, if for any
reason a patient cannot take milk ; then some of the
other food products must be substituted to make good
the lo.ss in albumin, fats and sugar of the milk. In a
similar manner, if any of the enumerated foodstuffs is
found to disagree, owing to special idiosyncrasies, it
456 AMBRioAN MKDiciNij DIETETIC TREATMENT OF TUBERCULOSIS
[Septembeb 20, 1902
must be substituted by some other that does not disturb.
By observing these rules an ideal diet can at all times be
maintained.
FOB AN ABSOLtJTBLY BE8TBICTED DIET.
Buttermilk, skimmed milk, or milk, or some of the fer-
mented milks (kumyss, zoolak, kefir, sumal). Beef-tea, bouil-
lon, and plain mutton, chicken, clam or oyster broth.
AN IDEAL MIXED DIET.
Brenkfast. — Two eggs, 8 ounces of milk, 2 ounces of wheat
bread and butter.
Mid-day Meal. — From J to i pound of beefsteak, 8 ounces of
milk, 3 ounces of wheat bread and butter.
Night Meal.— From 1 to J pound of beefsteak, 8 ounces of
milk, 2 ounces of bread and butter.
Bed TV'OTe.— Eight ounces of milk.
Beefsteak is taken as the working standard among the
meats, as it is the most easily digested of all the foodstilflfs.
Under the heading of meat is included lamb, mutton, occasion-
ally veal ; all kinds of fish, including the shell forms, such as
oysters, clams, lobsters and crabs; poultry and game of all
kinds.
The meats to be broiled, boiled or baked.
The fish to be boiled or baked.
The oysters and clams to be eaten raw or stewed. The lob-
sters plain boiled.
A little crisp bacon may be taken from time to time, also
ham and corned beef, without cabbage.
Eggs may be taken boiled, poached or scrambled.
The milk is best taken warm or with a little limewater
added.
Wheat bread is taken as the standard because it is the most
easily and perfectly digested. It should be at least 24 hours old
or toasted ; rye, graham, zwieback, or the health food breads
may at times be substituted.
Weak coffee, without milk or sugar, or with a dash of milk,
may be taken freely as a beverage. Coffee taken clear aids
digestion, but with milk and sugar often disturbs digestion.
ADDITIONS TO ENLARGE THE ABOVE DIET.
In the line of vegetables : String beans, green peas, lima
beans, spinach, lettuce, asparagus and cauliflower. These are
chosen because they are the least likely to excite Intestinal fer-
mentation of an abnormal character. They should be well
cooked, and only one vegetable at a meal.
To the above may be added boiled rice and macaroni,
both of which should be well cooked. These two are
selected from the starch-bearing group of foods, as they
have been shown by long use to be the least disturbing
to the digestive apparatus and to give the best practical
results. These, together with the bread used, will fur-
nish all the starch and sugar required to meet the physio-
logic indications.
When a vegetable is taken with the meal there must
be a proportionate reduction in the quantity of meat or
milk, as given in the above tables. The rule also should
be to use only one vegetable at a meal instead of half a
dozen or more, as is too often the case.
FOODSTUFFS TO BE AVOIDED.
All fruits, either cooked or raw ; all cereals and breakfast
loods, nuts, sweets and pastry of all kinds, potatoes in all forms
onions, tomatoes, turnips, parsnips, carrots, celery, radishes,
cabbage, egg- and oyster3)lant, corn, etc. ; pork in all forms
except as before stated. Rich gravies and all forms of soup are
excluded. The latter, first, because they tend to destroy the
keen appetite which makes possible the eating of plain and sub-
stantial food ; second, because they destroy the appetite and
stimulate a strong desire for the entremets and highly sea-
soned foods ; and, third, because the mixed cream and rich stock
souijs tendto excite undue and putrefactive fermentation in
the intestine. Rich gravies, because they disturb digestion.
Jr-otatoes, that are so commonly used, are excluded for three
reasons : First, because they have a high percentage of starch
and a low percentage of proteid ; second, because they are so
apt to be taken three times daily, and are so often eaten fried ;
third, and chiefly, because of the ease with which the starch
contained in the potato is digested and assimilated within the
system. In consequence of this rapid utilization of the potato
starch, which yields to the animal economy only heat, the oxy-
genating capacity of the system is exceeded, and there is not a
n^^?l!"'T°"°*-S^''^lS«"l«" '""hin the body to perfectly
ox dize and assimilate the proteid constituents of the ?ood that
Sirffirt ^^Tk'^P^'^''-'''' >; a perfect state of health is to be main-
m^e«tiri tw"'??*''" *" '^e diseased conditions it is still more
Ss^mltatad w. tv^P'^'^'^^^'^*" ^e perfectly oxidized and
rn^dTo'i"dtri>du°cLnS^u^t'^\^*|°^"^^"*^'"^^
Frmts are excluded, first, because they are usually picked
before they are fully ripe ; second, because they frequently are
in a state of partial putrefaction, and are often covered with bac-
terial life when eaten, and often taken in excessive quantities.
Having reached the alimentary canal in this state, they excite
undue and putrefactive fermentation of proteid constituents
contained within the intestinal canal and thus prevent the per-
fect digestion and assimilation of the proteid elements of the
food.
When these rules are strictly followed, a good variety
in the dietary can be permanently secured and a high
grade of nutrition will be established and maintained,
provided the system can be made to digest, absorb and
fully assimilate these quantities.
It is at this point in the management of the tubercu-
lous subject that the real difficulty in the therapeutics is
encountered. With the pronounced loss of appetite,
which is a constant symptom in every tuberculous
patient ; with the enfeebled digestion and the progressive
anemia, it is almost impossible for the animal economy,
even under the most favorable circumstances, to digest,
absorb and utilize anything like the necessary amount of
food to maintain life and arrest the progress of the path-
ologic processes that constitute tuberculosis, to say noth-
ing of repairing the damage already done within the
system. Yet this is the only method by which these
results can be secured. To crowd the food beyond the
power of the system to digest it, and to transform the
contained ingredients into an absorbable pabulum is
doing more damage than good. In a similar manner,
crowding into the blood more nutritive pabulum than
the system can furnish oxygen with which to oxidize it
perfectly, is simply adding fuel to the fire and taking
away the small chance for recovery that exists. This is
especially true in regard to the administration of fat and
alcoholic preparations.
The main object in the management of tuberculous
subjects is to determine the maximum amount of the
foodstuffs that the enfeebled system can digest and fully
oxidize. This is especially true in reference to the use
of the proteids. Great care must be exercised in the
administration of fats and sugars ; otherwise the en-
feebled oxygenating capacity of the system will expend
its oxidizing force in the oxidization of these noncon-
structive, simple, heat-producing substances, leaving too
little oxygen with which to accomplish the more diffi-
cult and essential task of perfectly transforming the con-
structive proteids or true tissue builders. At the same
time sufficient heat energy must be produced to maintain
the nervous impulses which are so essential to perfect
physiologic action. To accomplish these results requires
careful watching of the stools, frequent quantitative
estimates of the catabolic bodies eliminated in the urine,
together with a systematic regulation of the diet and
exercise. While this is being done accurate estimates
should be made of the rise or fall in the number of red
blood-corpuscles and the percentage of the hemoglobin
contained in the blood. When all these examinations
are made frequently the attending physician is enabled
to detect the slightest improvement in the physiologic
activity of the system. He is in a position to know whether
to increase or decrease the food supply. As the diges-
tion improves, and provided there is a proportionate
increase in the oxygenating capacity, the quantity of
food exhibited can be increased until the pathologic
process is arrested and a complete cure effected. It is
the lack of attention to all these important details that
has so long rendered tuberculosis so generally incurable.
On the other hand, if the tuberculous subject is fortunate
enough to place himself or herself, early in the develop-
ment of the disease, in the hands of one who fully under-
stands the condition and will see that these principles
are accurately carried out, a very large percentage of
those afflicted with tuberculosis will recover completely.
This is especially so if there is not a pronounced predis-
position to tuberculosis. When a decided family predis-
position to tuberculosis exists, the dietetic treatment
should begin at birth before the system has become
September 20, 1902]
LEUKOCYTE COUNT IN NEWBORN
[Amekican Medicine 457
infected with tubercle bacilli ; and it should be continued
throughout the succeeding years to full maturity. Such
a plan successfully and universally carried out through a
generation would unquestionably reduce the number of
tuberculous subjects to a far greater degree than any-
thing which has heretofore been accomplished. If such
an ideal plan could be carried out for a century, this
much-dreaded disease might be completely eradicated.
The natural deductions to be drawn from this study
of the dietetics of tuberculosis are :
1. That a predisposition to tuberculosis is inherited.
2. That tuberculosis per se is never inherited, but is
always acquired after birth.
3. The disease can be fed into or fed out of the human
species.
4. The chief problem in the dietetic treatment of
tuberculosis is first to overcome the general malnutri-
tion, and next to establish a higher grade of local nutri-
tion at the infected focuses.
o. The composition, digestibility and percentage
absorption of the various fooodstuffs and the oxygenat-
ing capacity of the system is accurately known.
6. By this knowledge the quantity of food taken can
be accurately adjusted, so that the full heat production
and constructive utilization of the proteids is secured.
7. The oxygenating and carbon dioxid excreting
powers of the system must not be exceeded if the best
results are to be secured.
8. By following these accurate laws systematically a
perfect diet can be arranged, and the abnormal and
pathologic conditioas can be changed to the normal,
physiologically speaking.
9. The most difficult problem to contend with in the
dietetic management of tuberculosis is the loas of appe-
tite and the inability on the part of the system to digest
and utilize perfectly a sufficient quantity of proteid
material to maintain life and, at the same time, repair
the damage already wrought.
10. When this is accomplished a large percentage of
tuberculous patients are rapidly and permanently cured,
more so than by medicinal treatment or Simple climatic
changes.
11. A universal adherence to these laws through a
century might result in a complete eradication of tuber-
culosis from the human species.
BIBLIOORAPHY.
8.73,
' Bolltz, Jour. Cora. Path, and Therap., December, 1890, p. 370.
' Schottellus, Arch. f. Hyg., .\xxlv, p. 240.
'Kubner, Zcltsch. f. Biol., xv, 8. 115; xvl, 8. 119; xlx, 8. 45; xxx,
* Prausnltz, W., Ibidem, xxv, 8. 5.53.
> StrQmpell, A., Deutsch. Arch. f. kiln. Med., xvll, 8. 108.
• Worschlloff, IJotkin'8 Archlv, Iv, p. 1.
' Meyer, O., Zeltsch. f. Biol., vll, 8. 1.
8 Hermann, Fr., " Die Bodeutung von Flelschnahrung und Flelsch-
conserven," pp. 11, 4I ; Leipzig, IHMO.
» Chittenden and Cummln.s, Am. Chem. Jour., vi.
"> .Monk, Wevl's Handbuch d. Hyg. Ill, pt. 1, 8. 69, 1893.
i, Vo?."';'^'."!/''®'"''' **• menschl. NahruugH n. Genussmlttel.," Ber-
lin, ISJSz, ate Auf.
" Dujardln-Beaumetz, Yco's " Food In Health and Disease," p 208-
Lea Brothers & Co., Philadelphia, IKIW. ' ^
" Moleschotte, Pavey's "A Treatise on Food and Dietetics." np 4fi2-
463, Ix>ndon, 1875.
" Fon'ter. Table In Am. Textbook of Pbys., p. 305. Philadelphia,
1' Pettenkofer and Volt, Table In Yeo's " Food In Health and Dla-
ease," p. IW.
'" Kivnkft, Prof, v., DuBols-Reymond's Arch., p. 311. 18«2.
" Alwiiicr, U. .S. Don't Agri., Bull. No. 10l». Washington. 1802.
>" .McKendrIck, "A Textb<x>k of Phys.," 11, p 6. New York 1889
,on.",P"'*^'J,^"''',<i,^''''''"''^<^-"'"l edition, pp. 46-.<(77. Brit. Med. Joiir.
18»1, II, p. 1297. Ibidem, 1890, II, p. 91.5.
» (iarrod. Article " Of)Ut," In Reynolds' Sys. of Med., 1, p. 825 1868
Med. Chlr. Trans., xxx vll, p. 46, 1851. , ■ j/. <«o, looo.
«' Havcraft, Brit. Med. Jour., 188.5, II, p. 1100.
» Koberts, Sir. William, Proo. Med.Chlr. 8oc.,18(IO: Croonlan Lec-
tures, pp. .5-i;M9. London, 1892. . o.v, ..-.xnjumn «jc
" Porter, William H., Am. Med.-Surg. Bull., vl, p. 1168
" Debove, Ijccons cUniques et Thfirapeu. sur le Tubcrc. I>ara«lt., 18tM,
« Dujardln-Beaumetz, L'Hygiene Allmentaire, ParU, 1887.
Plaaruo is reported to have carried off ono-half the E.skinio
population of Koserefski, Alaska, and the surrouudine dis-
tricts. *
THE DIFFERENTIAL LEUKOCYTE COUNT IN THE
NEWBORN.
BY
LOUIS M. WARFIELD, A.B., M.D.,
of Baltimore, Md.
House Medical Officer, Johns Hopkins Hospital.
Since the time of Ehrlich's classic observations and
researches on the staining properties of leukocytes and
their differentiation by means of chemic dyes, the blood
as a whole has been the object of much accurate study.
Naturally the blood of adults has received the most
attention, while the blood of the newly born child has
been comparatively little studied. Gundobin, Fischl,
Schiif and others, notably Carstanjen and Japha, have
added much to our knowledge of the elements of the
blood of the newly born and the relation of the several
elements to one another. It is now well established that
both the number of red cells and the percentage of
hemoglobin are greater at birth than at any other time of
life under normal conditions, and that there is the socalled
"physiologic leukocytosis" occurring on the first day
of life. Furthermore, Gundobin and Fischl found that
the differential count of the white cells immediately
after the birth of the child was a rather remarkable one.
The polymorphonuclear neutrophiles were greatly in-
creased and the lymphocytes formed only about a third
of the total number of leukocytes. In other words, the
differential count was prac;tically similar to that of the
adult. Notwithstanding these observations made 10
years ago, the textbooks of the present day make no
reference to this fact, but say only that in infants' blood
there is a higher percentage of the small mononuclear
than of the polymorphonuclear cells.
Having made a number of differential counts at the
Thomas Wilson Sanatorium, Baltimore, Md., during the
season of 1901, on the blood of babies suffering with
summer diarrheas, it occurred to me that it might be of
interest to investigate the blood of the newly born, and
to see if possibly there might be some explanation for
the rather remarkable relations of the white cells which
obtain in infants who are ill with "summer complaint."
There was no aid to be received from current text-
books, consequently the work was well under way before
it was discovered that somewhat similar results had
already been reached by two observers, viz. : Gundobin
and Carstanjen. The former found in his observations
on the differential leukocyte count in the newly bom
the following :
Polys.
During last month of pregnancy 80.2
Immediately after birth 63.
Twenty-four hours after birth 68.
Forty-eight hours after birth 70.
Five days after birth 60.
Suckling 84.6
Carstanjen, in an exceedingly interesting and valu-
able series of observations, found the following in five
cases. Counts were made as follows :
Polys.
First day 73.45
Third day 66.18
Sixth day 41.81
Ninth day 86.12
Twelfth day S6.69
I. Om^half hour after birth, ,S, 6, 9 and 12 days after birth.
II. Two hours " " 3,6,9 " 12 '• " ■'
III. Three " " •' 8,6,9 " 12 " " '<
IV. Nine " " " 3,6.9 " 12 " " "
V. Nineteen " " " 8, «, 9 " 12 " " "
Nucleated reds were not found after the third day.
In a further series of cases he found that by the third
year the polymorphonuclear ceUa were relatively in-
creased, and the differential count from that time on
did not materially change.
Japha, in a large series of blood counts of infants
from a few weeks to a year old, found the average of
the leukocytes 13,.560, lymphocytes 54^, large mono-
nuclears 4^, polymorphonuclears 42^. These figures
jym.
Tra
12.9
6.
2.5.
12.
24.
8.
21.
».
■S2.
8.
59.
6.<
Ts^o?*"-
Trans.
8.43
L. Monos.
0.17
Eosin.
1.9
18.84
U.U
0.14
3.73
35.11
17.52
0,75
4.81
41.86
18.66
0.66
2.7
45.6
16.02
0.15
1.54
468 Amkrioan Medicine
LEUKOCYTE COUNT IN NEWBORN
ISkptembeb ^Q, 1902
can be taken with certainty to represent the average
for young children between the ages mentioned. He
also points out that the increase in the leukocytes is due
to an increase in the lymphocyte elements.
In counting the leukocytes after birth and on several
successive days, Schiff found that they were increased
after the child had had its first nourishment.
In my series the first count was made in evei-y case
before the child had received any nourishment, and the
attempt was made to obtain the blood as soon after birth
as possible. Usually this was within four hours, the
latest being eight hours after parturition. The blood
was taken from the lobe of an ear, by far the most con-
venient spot, and unattended in my experience with
any great difficulty. The leukocytes were counted with
Thoma-Zeiss hemocytometer, the average taken from 27
fields. In no case were less than 200 white cells actu-
ally counted, while in several cases over 800 cells were
enumerated in order to obtain the average. Blood
smears on slides or coverslips were made at the same
time. The smears were dried in the air in the usual
way, and, for the most part, fixed and stained with
Jenner's stain. Several specimens were fixed by heat-
ing them on a copper bar at 110° C. for two hours and
then they were stained with Ehrlich's triple stain. This
was done as a control. The Jenner stain was just as
accurate in diffierentiating the various granules of the
leukocytes, and, as it proved by far the simpler method,
it was employed in all cases. Leukocyte counts and
smears were likewise made on the third and eleventh
days of life.
The results which follow are estimated from 10 cases.
The babies were all healthy, normal children at term.
The labors varied from short, easy labors to long, hard
ones. The percentage of white cells was calculated from
500 cells counted every time the blood was taken. The
following table shows very clearly the results obtained :
In every case the leukocytes at birth were higher
than at any other count. There was in most cases a
decided drop on the third day and a rise on the eleventh
day (one exception, Case VII), which, however, did not
equal the original count at birth. The children born
after a long hard labor or after an instrumental delivery
following a protracted labor showed the highest leuko-
cyte count at birth. What the cause of this is would be
hard to say. The woman in labor has a definite leuko-
cytosis, but from a very few counts I have made not as
high as the child, so it could hardly be explained by the
wandering of the mother's leukocytes to the child.
Possibly the efffect of the pressure brought to bear on the
child by the contracting uterus may be a factor In the
causation of the high leukocyte count at birth. That
the nourishment may have some effect on the leukocytes
seems to be shown by the table; for during the first
three days of life the child gets practically no nutriment
and, in consequence, loses weight. When milk takes
the place of colostrum, the healthy child not only begins
to thrive but the leukocytes also show a very definite
rise. The nucleated red cells, in all my cases normo-
blasts, disappeared rapidly from the blood, as has been
repeatedly observed.
The percentage of large mononuclear and transitional
cells apparently is somewhat increased during the first
days of life. In eight of the cases the percentage was
lowest at birth, and the average percentage in the cases
is considerably higher than that found in adult blood.
Likewise the percentage of eosinophiles is lowest just
after parturition, but the average percentage diff'ers
practically none from that in the blood of the mature
individual. Fischl claims, from observations made on
only two premature infants, that the eosinophile cells
either do not enter the blood or are not formed until
after the seventh month of pregnancy.
The "mastzellen" and myelocytes show nothing
Case I.— Three hours after birth..
Third day
Eleventh day
Case II.— Three and one-half hours after birth..
Third day
Eleventh day
Case III.— Five hours after birth..
Third day
Eleventh day
Case IV.— Three and one-half hours after birth..
Third day
Eleventh day
Case V— Three and one-half hours after birth .
Third day
Eleventh, day i..'"
Case VI.— beven and one- half houi-s after birth..
Third day
Eleventh day
Case VII.- Four hours after birth.,
Third day
Eleventh day
Case VIII.— Four hours afterbirth..
Third day
Eleventh day
Case IX.— Four hours after birth..
Third day
Eleventh day
Case X.— Five hours after birth..
Third day
Eleventh day
Average results— First day
Third day
Eleventh day...
o
a
34,700
17,200
23,200
(18,000
9,000
11,500
27,600
8,500
13,600
11,700
11,100
11,800
29,300
18,400
16,700
28,000
7,600
16,500
21,000
18,900
14,000
32,600
14,000
18.600
30,000
13,000
16,600
28,000
15,000
15,400
26,090
13,270
15,740
&^°
*? C5 flj
Oa;„
got.
71.6
54.2
46.4
65.2
56.6
31.
83.4
53.
38.6
62.6
55.
36.8
776
56.8
40.
46.8
37.2
45.4
39.2
22.8
74.4
46.
20.2
74.
49.8
84.8
81.
74.2
34.2
70.42
53.16
84.2
14.8
25.6
30.4
15.4
17.2
51.2
112
28.6
49.6
10.2
27.3
49.6
11.6
23.
89.4
19.
33 8
42.4
41.6
26.8
51.6
19.2
31.6
59.2
14.2
31.4
43.2
7.4
11.2
40.6
16.46
25 65
45.72
3 =s o c
e t» o ®
3gl
12.2
15.4
18 6
16.8
28,
15.8
5.
10.6
8.4
20.4
16.0
8.8
82
19.
14.
10.8
18.2
18.6
9.8
25.2
21.8
56
17.2
14.2
8.6
12.4
19.2
10.2
10.2
20.4
10.76
16.67
15.98
Bo
O
1.2
5.4
3.4
1.8
2,6
1.6
0.2
6.8
1.2
6.
2.2
4.6
2.2
1.
6.
0.8
1.
1.6
2.6
88
4.
0.2
5.2
6.4
2.2
5.4
2.8
0.8
1.8
4.22
3.56
a
62
1
0
18
2
1
0
0
0
12
0
0
21
2
0
20
0
0
75
4
0
7
0
0
111
7
0
4
1
0
33
1.7
.1
SP
0.0
.1
.4
0.0
.4
.2
.6
.4
00
.2
.2
0.0
0.0
00
0,0
.4
.2
0.0
.6
.6
5C ^
0 t.
— 0)
.2
00
.8
0.0
.4
.2
0.0
00
0.0
0.0
0.0
0.0
o.o
0,0
0.0
2
0.0
.4
0.0
0.0
0.0
00
0.0
.6
.8
0.0
.6
0.0
0.0
September 20, 19021
TWO ANEURYSMS IN A SINGLE HEART
[Ambbican Mbdicink 459
worthy of note. The point of especial interest is the
relation between the percentage of the polymorpho-
nuclear and that of the small mononuclear cells. It will
be readily seen from the table that, quite contrary to the
generally accepted statement, the lymphocytes are rela-
tively more numerous in the blood of infants, and in
absolute confirmation of previous work by Gundobin,
Carstanjen and others, that in every case the count
showed an increase in the polymorphonuclear cells, in
two cases the percentage being above 80. Following the
counts on the third and eleventh days it is seen that the
percentage of polymorphonuclear cells steadily decreases,
while that of the small mononuclear cells just as steadily
increases, to reach on or about the eleventh dap the rela-
tions between the two varieties of cells given in all books
on the subject. The fact that the percentages of the cells
of the infant's blood have been reckoned from babies
two weeks old or more accounts for the error so widely
curftnt.
To state the results in a slightly different manner, it
is found that from a differential count the day of birth
strikingly similar to the normal adult blood count, with-
in 11 days from the time the child is born the leukocyte
picture has completely changed and the percentages of
the different cells are practically those which have been
established for healthy infants after the eleventh day of
life. Possibly the picture changes in cases as early as
the eighth or ninth day, depending, I think, on the
character of the labor, that is, whether hard or easy, or
on some complication occurring during the first few days
of life. That a prolonged or instrumental labor influ-
ences the count is shown in Ca.se I and Case V, and in
one other ca.se I have not included in this series jaundice
developed on the third day. A count later than the
eleventh day was not obtained. Case V also could not
be found after leaving the hospital. In Case I a count
made on the twentieth day after birth showed polymor-
phonuclear cells, 37.6^ ; small mononuclear cells, 39.2^ ;
large mononuclear and transitional cells, lAAfc ; eosino-
philes, 7.4 /c. In the other case, one of twins, the per-
centages at birth were 80 ^ , 74 /« , 8.8 /« , 2 /c ; on the third
day marked jaundice developed. The percentages
were: 54.4 /«, 17.4 /o, 17.4^, 9.2^. On the eleventh
day, 61.4/c, 21.6^, 12.2/c, 4^. It is purposed to make
observations in a series of " complicated " cases in order
to prove or disprove these suggestions. Doubtless could
the two cases before mentioned have been found and
counts made, there is every reason to believe that the
normal relations of the different cells would eventually
have been obtained, for it is scarcely to be conceived
that the relation at birth should obtain through infant
life, contrary to all statements made by various
observers. It is difficult to say what becomes of the poly-
morphonuclear cells during the few days after birth.
The actual number of the cells decreases steadily and
rapidly, while the actual number of the small mononu-
clear cells increiises. One sees in smears taken after the
first day a fair number of what seem to be degenerated
leukocytes, but the number seen is few compared to the
actual decrease in the polymorphonuclear cells. This
variety of cell is again not only relatively but actually
increased in certain diseased conditions in infants, as
Stengel and White, Japha, Knox and Warfleld have
shown.
The conclusions which follow from the foregoing
study are :
1. The leukocytes at the day of birth are more
numerous than at any other time of normal life.
2. Nucleated red blood-corpuscles rapidly disappear
from the circulating blood of the healthy infant within
the first three days of life.
3. The percentage of eosinophiles varies widely in
the blood of babies of the same age.
4. Myelocytes and "mastzellen" are only occasion-
ally found and are in very small numbers.
.'). The percentage of large mononuclear and transi-
tional cells is large compared to that found in the blood
of adults.
6. The polymorphonuclear cells at birth are not only
relatively but absolutely increased. They begin to
decrease in numbers soon after birth, and by the eleventh
day of a healthy infant's life they are fewer in number
than the lymphocytes, while the number of the latter
variety of cell has actually increased ; and the differ-
ential count of the leukocytes on the eleventh day is
practically identical with the count given in the text-
books as normal for the infant's blood.
BIBLIOGRAPHY.
Gundobin, Jahrb. f. Kindernellkunde, Bd. So; 1893.
Flschl, Zeltschr. f. Heilkunde, Bd. 13; 1892.
Schiff, Zeitschr. t. Heilkunde, Bd. 11; 1890.
Carstanjen, Jahrb. f. Kinderheilkuude, 1900.
Japha, Jahrb. f. Kinderheilkunde, 1901.
Knox and Warfleld, Johns Hopkins Hosp. Bull., 1902.
Stengel and White, Univ. of Penna. Med. Bull., 1901.
TWO ANEURYSMS IN A SINGLE HEART.'
BY
L. M. LOEB, M.D.,
of Chicago, 111.
Fellow In Pathology at Rush Medical College.
The heart to be described was obtained from a patient
in Cook County Hospital in the service of Dr. O' Byrne :
Case. — The patient was a negro, a porter by occupation, 26
years old.
Present Illness.— l^he patient was entirely well until three
weeks ago, when he developed a "cold" which gradually
became worse. He coughed and expectorated a whitisli mate-
rial, but no blood. There has been marked dyspnea, increased
by exertion and relieved only by sitting up, not by lying down.
Appetite has been poor and bowels constipated for about one
week. He thinks that his stools have been black. He has
vomited mornings and evenings for one week, never any blood.
He has had no epistaxis. Feet and lace have been swollen for
about three days. His urine is dark. He thinks that he had fever
about one week ago — was told so by a physician. He had " pal-
pitation of the heart" for about three weeks — a sharp pain runs
from tlie cardiac region to the left siioulder.
Previous History. — He has had the usual diseases of child-
hood and had cough before, but never dyspnea. Two years ago
he had two sores on the penis, which came about ten days after
intercourse, and were followed two weeks later by an eruption.
He had received medicine before the eruption appeared. He
has not had sore throat or alopecia and has never had rheuma-
tism or chorea. Ho had malaria (?) when a child. He suf-
fered from gonorrhea seven years ago.
Family history is negative.
Habits. — Once a week he drinks considerably. He is a
moderate smoker.
Examination. — The patient is a well-nourished, well-devel-
oped negro. There is great dyspnea, relieved to a large extent
by sitting up.
Heart. — Apex beat is seen and felt in the seventh interspace
in the left midaxillary line. It is equally distinct over an area
of about one inch in diameter. It was noted tliat the seventh and
eighth ribs were further apart than elsewhere at this place. Dul-
ness began in the second interspace to the left of the sternum,
passing downward and outward to the eiphtli rib in the midax-
illary line. To the right it extended to just beyond the right
border of the sternum. The area of dulness moved i inch to
right or left as the patient turned on the corresponding side.
Over the apex the tones were quite mufllod, in spite of the
forcible pulsation seen at tliis point. In the second left inter-
space second tone was accentuated. In the second right inter-
space was a loud blowing diastolic murmur, not transmitted far
in any direction.
The pulse was small, quick and moderately strong.
Urine was dark yellow, acid, of 1,019 sp. gr.; contained a
trace of albumin and leukocytes.
Lutigs.—H'ight: A friction rub in axilla and posteriorly.
Relative dulness one finger's breadth, flatness four inclies below
scapula. Tactile fremitus is decreased over this area. Aloist
rales all over the chest.
Left : There is dulness in line from apex to a hand's breadth
below the scapula.
Abdomen. — Liver was extended a hand's breadth below
costal arch, edge was round. It was quite tender. The abdo-
men was not tender eLsewhere. A soar on the upper right thigh
internally was said to be due to an injury. Both legs and feet
were sliglitly edematous.
While in the hospital the patient's temperature was always
subnormal, ranging from 95.4° to 97°. His dyspnea increased
1 Read before the Chicago Pathologic Society, May, 1902.
460 AMERICAN Medicine]
EXCISION OF CANCER OF THE RECTUM
[Ubptembbb 20, 1902
constantly and was accompanied by cough and much expectora-
tion, which was quite bloody. No tubercle bacilli were found
in the sputum. Pulse ranged from 110 to 150, was regular, but
very feeble toward the end. He died one week after admission
to the hospital.
The autopsy by Dr. E. R. LeCount showed :
1. Pilation aneurysm of the left auricle at apex.
2. Dissecting aneurysm of the aorta leading into the wall of
the left ventricle.
3. Hemorrhagic infarct of the lower lobe of the left lung.
4. Fibrous obliterative pericarditis.
5. Passive hyperemia of the lungs and viscera.
6. Cyanotic atrophy of liver.
7. Double hydrothorax.
8. Hydroperitonevim.
Owing to advanced postmortem changes, pieces were taken
only from the heart, liver and spleen for histologic exam-
ination. These showed nothing beyond passive congestion in
addition to some postmortem degeneration.
Heart.— With the pericardium and beginning of the great
vessels it weighed nearly 1,000 grams. Pericardium is adherent
all over, but is readily separable, except at the apex, where it
is firmly bound to the diaphragm. The endocardium is smooth
and free from changes. The mitral, tricuspid, and pulmonary
valves are normal. The auricles show no changes. Both
ventricles are dilated, but especially the left. The wall of
the left ventricle averages 16 mm., the right 5 mm. in thick-
ness. At the apex of the left ventricle is an opening 2i cm.
in diameter, which is perfectly round and which passes
into a cavity as large as a small hen's egg. The walls of the
cavity do not show the muscular trabeculation found in the
ventricles, but are almost perfectly smooth. The thickness
of its walls varies from 5 mm. at the upper end to the thick-
ness of tissue-paper at a point at its anterior and lower portion.
Here the wall is translucent. This aneurysm is not lined by
endocardium. The aortic valves are slightly thickened and
somewhat retracted. The aorta at its beginning is rough and
shows yellowish raised areas. .Just above the junction of the
anterior and right posterior aortic flaps is an opening in the
aorta 12 mm. in diameter perfectly round. The opening of the
left coronary artery is just in front of it. It leads into a space
3 cm. in its vertical, and approximately 2 cm. in its horizontal
diameter. This cavity occupies the anterior periaortic space
lying between the right and left ventricles anterior to the sep-
tum. The intima of the aorta extends into it a short distance
on all sides.
The musculature of the fresh specimen showed increase of
fibrous tissue in the papillary and septal muscle.
The diagnosis of this condition is hardly possible.
The presence of an aneurysm at the apex was once sug-
gested on account of the marked bulging in the seventh
interspace, previously noted, but was never considered
very seriously. It is easy though, now, to understand
the reason for the clinical manifestations: the sudden
occurrence of dyspnea probably followed upon the bulg-
ing at the apex, and, together with the bloody expectora-
tion, upon the infarction of the lower lobe of the left
lung. Everything else, of course, pointed only to
passive congestion.
It appeared peculiar that such thin-walled sacs should
not have ruptured, but, as a matter of fact, this rarely
occurs. In Vestberg's collection of 60 cases only one
ruptured into the pericardial cavity, and very few back
into the heart, forming false blofxl-passages. Of hLs
aneurysms 47 were of the periaortic variety, 5 were
parietal, and 8 were valvular; 16 originated in the
sinuses of Valsalva.
In the absence of gummas and suppurative processes
in any of the other viscera, it is somewhat far-fetched to
A— Aneurysm at apex.
assume their presence in the heart, and thus account
for the weakening of the cardiac walls. The history is
suspicious of syphilis, although the eruption may have
been one of the drug rashes so frequently occurring upon
the use of the volatile oils in the treatment of venereal
diseases. Again arteriosclerosis in a man of 26 without
nephritis strongly suggests lues.
I believe the following may have been the sequence of
anatomic changes in the present case : First, the adhe-
sive pericarditis produced the enormous hypertrophy of
the heart. This gave rise to a blood-pressure which the
sclerotic aorta could not withstand, and the aneu-
rysm at the base resulted. The possibility of the perfora-
tion of a socalled atheromatous ulcer should be con-
sidered. This aneurysm pressed upon the left coronary
artery, and in this way interfered with the chief source
of blood-supply for the apex and the tugging of the
diaphragm and greatly increased blood-pressure in addi-
tion were sufficient to cause the second aneurysm.
THE EXCISION OF CANCER OF THE RECTUM.'
LEWIS H. ADLER, Jr., M.D.,
of Philadelphia.
Professor of Diseases of the Rectum, Philadelphia Polyclinic and Post-
graduate College ; Prosector to the Professor of Anatomy,
Medical Departraeut, University of Pennsylvaula, etc.
There is no topic in the range of surgical nomencla-
ture which receives more notice or demands more atten-
tion than that of cancer. The mere mention of this
disea.se to a patient suspected of being afflicted with it
produces sensations not unlike those felt by the con-
demned criminal as he walks to the scaffold to expiate
the crime of murder.
When the growth appears upon the surface of the
body the surgeon sees the trouble in its ineipiency and
can choose the most favorable time for a complete enucle-
' Read at the fourth annual meeting of the American Proctologic
Society, held at Saratoga Springs, N. Y., June 10 and 11, 1902.
Sbptkmber 20, 1902J
UTERUS BICORNIS UNICOLLIS
[American Medicinb 461
ation of the growth with a resulting permanent cure.
An example of this is seen in cancer of the breast. At
the present day radical operative measures in these cases
have reduced the mortality very markedly.
Unfortunately, however, in cancer of the rectum we
have a disease which often exists without any marked
manifestation of its presence, such a-s pain, tenesmus,
discharge or diarrhea, until the trouble has progressed to
such an extent that complete ablation of the growth is
impossible. Perhaps when the laity have become more
enlightened as to the need of early consultation in all
cases in which symptoms exist (even though of apparent
slight importance), such as distress or discomfort in the
anal or rectal region, and when the profession have been
educated to practise systematically the careful examina-
tion of the rectum in all cases with intestinal symptoms,
the time may come when the conscientious surgeon may
be enabled to offer to such patients more encouragement
than is possible at the present time in favor of radical
operative interference.
From the foregoing remarks my position might be
assumed as one of antagonism to any and all attempted
excisions of the rectum for malignant disease. To as-
sume such an attitude would be the height of folly, for
it would mean the consignment of such patients to cer-
tain death, which in the language of James P. Tuttle,
JI.D.,' of New York City, is a death which ever slowly
but surely creeps onward, which must be looked squarely
in the face, and from which there is no possible escape.
Seven years ago, in a paper upon The Treatment of
Cancer of the Rectum,'^ read at the meeting of the
American Medical Aasociation, held at Atlanta, Ga., I
employed these words : " The ideal method of treating
cancer of the rectum would be by extirpation, as is done
in the cases of the same disease when the mammary
gland is the seat of the trouble ; but, unfortunately, it is
not often that the neoplasm is discovered in time to per-
mit the entire removal of the growth and of all gland-
ular involvement, consequently it is my belief that the
cases in which this operation is indicated will always be
confined to a relatively small number."
Subseciuent experience with this malady has only
tended to convince me of the truth, justice and fairness
of the position I assumed at that time.
My personal experience with cases of malignant dis-
ease of the rectum up to the present time numbers
about 217 cases. Of this number I have excised the
rectum in 3, cureted the growth in 7, and colostomized 27.
The number of operative cases named does not represent
by about 25^ the entire number of patients to whom
operation was recommended, for about this percentage
declined to follow my advice.
Making allowance for this increase in the number of
patients upon whom operative interference was either
advised or carried out, there still remains a large nimi-
ber of cases unaccounted for so far as surgical interven-
tion is concerned, and a natural query would be, Why
was such the case? I can answer this best by stating
that an inflexible rule with me, in these cases, is to try
and place myself in the position of the patient and from
that standpoint endeavor to determine what course I
should follow.
Advice given under these circumstances must neces-
sarily be the best that one individual can give to another,
and the relief to one's mind of undue responsibility —
when unfortunate results ensue — has been to me a great
consolation.
Relative to the three cases of excision, with which
operation this article is solely concerne<l, I would state
that one patient died within the year following the
operation from canctsr of the liver ; another died five years
after the excision at the age of 77, and at the autopsy no
' "Cancer of the Kectiim," reprinted from the Journal of the Amerl-
■caii Medical AHHoclatlon, .March 27-Aprtl S. 1U97, p. 5 of the reprint.
> Koprlnted from the University Medical Magazine, August, 1896,
J). 1 of reprint.
trace of the disease was discoverable, death being due to
senility ; the third patient is still alive and active,
though past 70 years of age; the operation was per-
formed six years ago. The major portion of the cases of
cancer I have seen have occurred in persons past the
prime of life — 50 years and over, the youngest patient
not being less than 34. The male sex have exceeded the
females in the proportion of four to one.
In conclusion, I would say that to me the simple
facts are that cancer of the rectum, at the stage usually
discovered by the surgeon, is less amenable to the knife
than cancer occurring in other portions of the body ;
that operation is followed by cure in a very small pro-
portion of the cases ; that the dangers following excision
are great, and the results as to comfort anything but
satisfactory ; and yet, that in properly selected cases —
those seen early— much good can be accomplished by the
operation.
Finally, this paper has been made purposely brief, as
it is designed to open up the subject for discussion so
that we may learn the most recent individual experience
and opinion regarding the merits and demerits of excision
as well as its limitations and indications.
UTERUS BICORNIS UNICOLLIS, WITH OVARIAN
ABSCESS AND PELVIC HEMATOCELE.
BY
WILLIAM HESSERT, M.D.,
of Chicago.
Surgeon to the Qerman and St. Francis Ho-spltals ; Instructor in Sur-
gery, Chicago Polyclinic.
Case.— M. B., aged 13, had always been healthy up to about
June, 1901. At that time she began to menstruate. The menses
were irregular, somewhat scant and were associated with con-
siderable pain before and during"the flow, most intense on the
right side and down the right thigh. The periods lasted for
from three to five days ; in tlie intervals she felt fairly well and
went to school. A physician was consulted, and found a tume-
faction on the right side of the pelvis, which bulged the vagina
considerably. In October, 1901, she was taken to a hospital
where she was " cureted and had a blood-tumor incised." Con-
siderable blood is said to have been evacuated through an
incision in the vaginal vault. She left the hospital, after about
three weeks, improved, and remained so for several months.
She attended school again, but was not very strong. In Jan-
uary, 1902, she grew worse, suffering constant pelvic pain inde-
pendent of menstruation, with pain along the right sciatic
nerve ; anorexia and increasing weakness ; dysuria ; slight
chills and flushes. The bowels were rather costive, at times
causing painful defecation. There was no vaginal discharge.
Physical Examination. — February lo, 1902: The patient is
confined to her bed, with a temperature of 100° P., pnlse 106.
She is tall for her age but poorly nourished; chest negative;
upper abdomen negative ; lower abdomen slightly protuberant
and pressure elicits some tenderness and a vague sense of re-
sistance. The vaginal outlet is roonw and relaxed for one so
young ; remains of hymen visible. The right vaginal wall and
vault are somewhat rigid and retracted ; on the right side, high
up, there is a small opening in the vaginal wall scarcely admit-
ting the examining finger. Passing over to the left, the exam-
ining finger seeking the cervix finds only a mass of irregular
protuberances; the vaginal portion is scarcely recognizable as
such. The whole pelvic cavity is filled by a ina.ss, evidently
intimately connected with the sides of the pelvis, for there is
only the slightest possible mobility. The mass is hard, resist-
ant, no fluctuation can be olicite<l and it is disposed like a horse-
shoo, open in front, for I can bring tlie two hands together
beliind the symphysis pubis. No uterine body can be outlined.
The mass extends to the pelvic brim above and is very sensitive
throughout, causing considerable abdominal rigidity, making
exploration very difTicult.
February 1(J: Under chloroform narcosis an attempt was
made to introduce a small probe into the cervical canal which
I thought must open somewhere among the ma-ss of caruncles
before montioned, but failed after a long trial. The opening in
the vaginal vault led into a small blind sac 2 cm. in depth. The
vaginal wall around was puckered liy cicatricial contraction. A
more thorough bimanual examination was, of course, made,
but 1 learned nothing additional in regard to the pelvic con-
tents; I still could not palpate a uterine body. The urine was
negative.
Diagnosis. — Notwithstanding the history of the case, the
patient's age, the physical findings, with the fever, I was still
unable to make an exact diagnosis. Previous to all operations
I make it a rule to put in writing my diagnosis and opinion,
which proves interesting and instructive reading afterward.
462 Akebioan Mesioikij
CONTRACTION OF THE PROSTATIC FIBERS
[8EPTEMBEB 20, IWB
My notes here read: "She mav have had a hematosalpynx
which was opened from below. To this an infection may have
been added, so that now the left adnexa is involved. I would
not be surprised to find some developmental anomaly present."
Operation. — This was done at the (ierman Hospital in Feb-
ruary, 1902, after the usual preparations for laparotomy. Nar-
cosis began with chloroform, later changing to ether. A median
incision .3J inches long was made above the pubes and the peri-
toneum sutured to the skin temporarily ; about an ounce of
clear, somewhat glairy fluid escaped from the lower angle of
the wound. On retracting the wound edges the omentum pre-
sented and was found very firmly adherent to the rim of the
pelvis, the bladder and the organs below, which it completely
covered. The adhesions were very firmly organized, and por-
tions of the omentum had to be severed between ligatures to
prevent tearing into the bowel below. After the omentum was
finally turned back the colon was encountered, one of the
long, convoluted variety of sigmoid, covering with its coils the
pelvic contents below. There were firm ad hesions of the sigmoid
coils to one another, to the bladder, and to the parts beneath.
After working long and patiently the adhesions were all sev-
ered without rupture of the gut, and the parts below finally
brought into view. However, while peeling the rectum from a
mass on the left side pus suddenly appeared. The peritoneal
cavity above had been protected previously with laparotomy
sponges. About an ounce and a half of pus escaped and was
sponged away. Finally the adhesions of rectum and colon were all
free. The organs below presented as follows: On either side were
two spindle-shaped
bodies, united below
at the base of the blad-
der like a V. The
bodies were about 7
cm. long and 3.5 cm.
in diameter at the
thickest portion ; at
the upper extremity
they tapered gradu-
ally into a tube which
averaged 1 cm. in
thickness, expanding
at the free end into
well developed fim-
briae. The uterine cor-
nua with their respec-
tive tubes were cov-
ered on three-fourths
of their circumference
by peritoneum, the re-
maining fourth of the
horn being in direct
contact with the side
of the pelvis ; at the
fimbriated extremity
Schematic drawing Illustrating case of uterus plfeated auT fOTn^ed"^a
''"'°™"- ligament 3 cm. long.
^ , The left ovary, the
size of a lemon, was closely applied by adhesions to the side of
pelvis, and was the seat of a large abscess ruptured in loosening
the rectum. The right ovary was 3x6 cm., had a well-defined
ligament which was inserted below the right tube. There was no
broad nor round ligament. On the right side were the remains of
an old blood-clol>-straw-colored gelatinous material, and firmer
yellowish or mottled bits of clot, partly organized into firm
fibrous tissue and adherent to a point below corresponding to
the scar m the vagina. The clot was formerly bounded above
and behind by the rectum, on the outer side by the wall of the
pelvis and fallopian tube, in front by the bladder, below by the
floor of the pelvis and the vaginal vault.
To remove the diseased masses, I incised the peritoneum
parallel to the rim of the pelvis and to the long axis of the tube,
above and below the same. This left only the areolar tissue
and vessels attached. The ovarian artery required a sepa-
rate ligature, after which the mass hung by the attachment of
the tube to the apex of the uterine horn. This was amputated
in the usual manner with catgut and the peritoneum was
brought together over the denuded strip on the side of the
pelvis with a continuous suture of fine catgut. The apex of
®f.cn, lioi'ii was caught in the suture and the peritoneum
stitched oyer it. Thus there were no denuded surfaces left,
except at the seat of the old blood-clot. The lower pelvis was
now filled up a few times with boric acid solution and swabbed
out thoroughly, for it had been bathed in pus when the abscess
was ruptured. A wick of iodoform gauze was now carried to
tne floor of the pelvis on each side and brought out at the lower
angle of the wound. The peritoneum and fascia were sutured
witn interrupted catgut and the skin with interrupted silk-
Time of operation, 2 hours ; the patient stood it very well
with a pulse never over 100; no stimulation was required.
^/?J^S-'""'!*'^®''^-^*'°° ^^^ ^»<i received hypodermically i grain
JSntSrin,^,^f ^J*T° ''■t''oP«' ^ grain strychnin sulfate. Unless
conterindicated I employ this
factory results,
iploy this as a routine practice with satis-
well^ n??n«"'i«t„t^'*''"'^-~^?'^°'^ '^*y= Patient is feeling
well, urine negative; spontaneous bowel movement and
flatus. Third day : Considerable oozing of bloody serum ; the
drain loosened and was pulled out a trifle. Fifth day : Last
strand of gauze drain removed ; considerable seropurulent dis-
charge; temperature 100°; bowels move regularly; small rub-
ber tube inserted. The patient is on liquid diet. Eighth day :
Silkwormgut sutures removed; primary union of skin and
fascia— only small sinus left ; temperature, 99° ; patient is feel-
ing fine. Fourteenth day: Removed tube; slight discharge;
good appetite; bowels move regularly. Eighteenth day:
Abdominal wound entirely closed ; small, firm scar. On the
twenty-first day the patient went home, having gained in
weight and feeling splendidly. She is now up ana around.
This girl was healthy until the advent of puberty.
She had a uterus bicornis unicollis. The trouble began
at the time of menstruation ; possibly by regurgitation
through the tube, blood was poured into the free peri-
toneal cavity. A plastic peritonitis and encapsulation of
the blood mass resulted. Fresh blood was probably
added at each menstrual period, producing the bulging
mass which was incised. At that time an attempt wa.s
made to curet. The vaginal portion of the cervix
looks as though it had been torn into shreds by
ineffectual attempts to pull it dov/n with vulsella
forceps. I could not determine whether there were one
or two cervical canals. From the small size of the
cervix I would judge there was but one, which divided
higher up into the two cornua.
Considering the history of the case and the age of the
patient, and the improbability of venereal infection, I
can find no cause for the infection, unless it occurred
at the time of the previous operation. Both tubes
were thickened, and contained pus ; the left ovary
was one large abscess sac ; the right was greatly enlarged
by chronic inflammation. Associated with this there
was the concomitant peritonitis, which resulted in the
matting together in one mass of the generative organs,
sigmoid flexure and omentum. No gonococci, but some
stephylococci were found.
The patient has now recovered entirely ; is about
actively, and has gained greatly in strength.
CHRONIC CONTRACTION OF THE PROSTATIC FIBERS
ENCIRCLING THE VESICAL NECK : REPORT OF
A CASE.'
BT
J. B. SHBLMIRE, M.D.,
of Dallas, Texas.
Chronic contraction of the prostatic fibers encircling
the vesical neck is evidently a subject considered by few
authors. After a diligent search I was able to find this
condition described in but one of our standard textbooks
on genitourinary diseases. The purpose of this paper is
to prepare for the recognition of this trouble should it
ever be encountered. I did not at first recognize the
true condition in my case and consequently the proper
treatment was not instituted. The disease is so well
described by Dr. Eugene Fuller in his late work, " Dis-
eases of the Genitourinary System," that you will
pardon me for quoting him quite extensively :
If one examines the writings of Civiale, Roux, Caudemont
and other contemporary French genitourinary authors he will
find much space allotted to what is termed by some of them
neuralgia of the vesical neck. The terms neuralgia and con-
tracture used by these writers are expressive of like conditions.
Contraction of the vesical neck is used much in tlie same sense
as spasm of the vesical neck, the only difference being that
spasm is supposed to represent a momentary condition of
tonicity of the muscular apparatus surrounding the deep ure-
thra, while contraction is indicative of a tonicity somewhat
more lasting. Slade, who studied under Caudemont, in trying
to explain the difference between these two expressions, says:
" Contraction is different from spasm, which is essentially
temporary. Although the former may commence with spasm
and also be complicated by it, contraction comes on slowly and
fenerally disappears in like manner." Contraction in the
'rench sense is entirely a functional condition. It is not per-
manent and it is associated with no pathologic change in con-
nection with the vesical neck. These terms are little used at
' Bead before the State Medical Association of Texa.s, at Dallas,
Tex., May 9, 1902.
Beptembeb 20, 1902]
CONTEACTION OF THE PROSTATIC FIBERS iakkrican mkdicink 463
Present, since it is now known that they do not represent true
iseased conditions, but only reflex vesical symptoms, which
frequently attend various pathologic states of the sexual appa-
ratus, the rectum, the kidneys, etc.
After these references to the French views on spaam
and contraction at the vesical neck, Dr. Fuller says :
The condition which I am now to describe as chronic con-
traction of the prostatic fibers encircling the vesical neck
represents a pathologic change in the part, and is consequently
totally different from anything mentioned in the French litera-
ture, reference to which has just been made. I am convinced,
however, that the condition of chronic contraction bears a
relationship to the functional one in that it represents a patho-
logic state which may apparently result from functional con-
traction or spasm in cases in which, owing to some settled
disorder of the sexual apparatus, the rectum, the kidney or
other part, functional contraction of the vesical neck has ex-
isted as a prominent symptom for a long time. The lesion in
these cases of chronic contraction can be compared with that in
connection with the sternocleidomastoid muscle in chronic torti-
collis. It is permanent, rigid and unrelaxable, even under pro-
found anesthesia. If a boutonniere perineal incision be made
while a patient of this description is under an anesthetic, and
the forefinger of the surgeon passed through the opening made
in the floor of the membranous urethra backward, in an
attempt to enter the bladder, the finger-tip will find itself
tightly engaged in a ring-like contraction in the deeper portion
of the prostatic urethra, where, under normal circumstances
the canal should be wide, funnel-shaped and elastic, merging
itself into the vesical cavity in such a manner that it is impos-
sible simply from the feel to determine just where the urethra
ends and the bladder begins. A contraction of this nature, as I
have said, is large enough in my experience to admit the tip of
the forefinger, and consequently its caliber is so nearly that of
the urethra that its presence cannot be detected by means of
a good-sized sound passed along the urethra. If the sur-
geon feels carefully with his finger-tip he will discover
the urethra just in front of the circular contraction to
be roomy and somewhat pouched. The mucous mem-
brane of the entire portion of the deep urethra will ordi-
narily feel perfectly normal and free from any evidence of
previous inflammation. If now an attempt be made to crowd
the finger-tip through the contraction and into the bladder, it
will be found either impossible or only possible as a result of
tearing apart the circular bands. In case the circular bands
cannot be ruptured they can be cut along the floor of the
urethra, thus allowing the finger to slip into the bladder and to
explore thoroughly the vesical neck. It will then be appreci-
atetl that there is no hypertrophy of the v)rostate, an absence of
which should also have been suspected from a failure to find
evidences of any enlargement from previous digital rectal
exploration. After the contracture has been thoroughly rup-
tured or cut through, little evidence will be left to the touch to
indicate the nature of the lesion which previously existed. I
have so far been unable to procure a histologic examination
of the unusual condition I have described, since all my patients
suffering in this manner have recovered as a result of opera-
tion. Xow, the clinical symptoms prominent in ca.ses of this
nature, and in fact, it might be said the only true symptoms
dependent on the lesion itself, consist in an inability, either
complete or partial, to void the urine. This inability is a grad-
ual development. It generally begins as a hesitancy in starting
the stream, and then as the act of urination approaches comple-
tion there is a dribbling, due apparently to lack of control over
the vesical sphincter, togetlier with a feeling that a want of
power exists to empty the i)ladder completely. The complaint
IS at first intermittent in character, but after a time it becomes
permanent. Next in order the patient experiences attacks of
complete retention. For a number of hours he may be unable
to urinate. Karly attacks of this nature may pass oflf
as a result of rest, sitting in hot water, etc., but after a
time it will be found necessary to employ a catheter and to
empty the bladder on one or several occlusions before nature
will reassert herself. Finally, all power to urinate is lost, and
permanent recourse to the catheter is necessary. If pain or
other symptoms are present they are due to the existence of
some disorder of the sexual apparatus, kidney, etc., which has
acted as the originator of the trouble at the vesical neck, or else
to vesical infection, which has resulted from instrumentation
or stagnation of urine, consequent on tlie retention. This
train of symptoms is of slow development, and three, four, or
Eerhaps more years may intervene between the time when the
rst difficulty in connection with urination was noticed and
retention occurs. A diagnosis of this condition has to be made
largely from the clinictu history of the case, together with an
exclusion of other causes for impe<liniont to urination, which
present tangible evidences of their presence, the only tM>sitive
evidence that clironic contra<:tion exists being atfoi doa by tlie
feel represented to the finger-lip introduced through a perineal
incision while the patient is under an anosthotic. If, however,
one studies the clinical history of his cases ciarefully, and thor-
oughly eliminates the causes of retention which present tangi-
ble evidences, he can make liimself fairly positive of the diag-
nosis before resort is had to operaMon, which serves the double
purfKwe of settling the diagnoBls and of correcting the disease.
The only treatment for chronic contraction of the prostatic
fibers encircling the vesical neck, which in my experience has
shown any favorable results, consists in thoroughly rupturing
or in cutting through them. This can be accomplished by means
of the finger or the knife, as the case may be, introduced through
a perineal incision. Perineal vesical drainage should be prac-
tised after the operation . Treatment such as tliis at my hands
has been followed by complete disappearance of all subjective
symptoms.
As the case of chronic contraction of the prostatic
fibers encircling the vesical neck which I have to report
was not caused by any recognized preexisting affection
of either the rectum or genitourinary tract I shall not
consider the differential diagnosis between such a case
and one caused by any of these troubles. The classic
description, as given by Dr. Fuller, will enable one to
understand fully the following case :
R. H., a strong, healthy country lad, aged 16, with an
absolutely negative venereal history, has had trouble in pass-
ing his urine since early youth. In March, 1900, he consulted
Dr. T. W. Wiley, of McKinney, Texas. He was then hav-
ing spells of retention. Urine was clear and free of any-
thing indicating disease of the genitourinary tract. Tumor
of bladder was diagnosed and a suprapubic operation done.
Contraction was found at vesical neck and moderately di-
vulsed. The operation gave partial relief for a short time.
In December, 1900, he had attacks of retention again. Dur-
ing one of these attacks the suprapubic wound gave way, and
until the next operation, in January, 1901, all urine passed
through this opening. On January 12, 1901, I was called to
McKinney to see the patient. Dr. Wiley still suspected a
growth at the vesical neck. The suprapubic opening was en-
larged. Cystitis had developed and there was a fair quantity
of pus in the last urine passed from bladder. Finding no
tumor, search was made with the finger for the opening into
the prostatic urethra. This was attended by failure until a
small catheter was passed which had been used for irrigation
after the suprapubic wound had been enlarged. The end of this
catheter served as a guide to the opening. Such was the con-
traction of the encircling fibers at the vesical neck that much
force was required to insert the index finger as far as the first
joint. With the right index finger in the contraction, with the
left a careful examination was made of the prostate gland
through the rectum. Not the slightest enlargement could be
detected. At this stage of the operation I remarked to Dr.
Wiley that I had encountered a condition which was entirely
new to me. The contraction was divulsed with the finger and
a large sized sound passed. The patient was soon able to return
home, the operation, however, giving only partial and tempo-
rary relief. On returning from McKinney I began to review
my textbooks for information, but could find no satisfactory
solution of the case. Some two weeks later I received the work
of Dr. Puller, from which I have quoted. I immediately wrote
Dr. Wiley of the light shed on the case, informing him of the
strong probability of the failure of the last operation. In the
fall of 1901 the patient was having serious trouble again, with
cystitis added to the symptoms caused by the contraction..
Toward the latter part of December the suprapubic wound
gave way again, followed by considerable sloughing of the sur-
rounding tissues. All urine then passed through this opening.
On January 4, 1902, I a^ain went to McKinney to operate on
the boy. Beside Dr. Wiley I had the assistance of Drs. Kirk-
patrick and Largent, of McKinney, and Dr. Calaway, of Mid-
land, Texas. The patient was given chloroform, and although
completely anesthetized we could not irrigate the bladder with
a recejitaclo seven feet high. No fluid could pass through the
contraction. It was necessary to pass a small stiff catheter for
the irrigation. After the bladder was thoroughly washed a
No. 28 grooved staff was passed with some difficulty. Perineal
section was then made, and on introducing the finger the mem-
branous urethra was found normal in size as well as the
anterior portion of prostatic urethra. At the posterior portion
of the prostatic uretnra the tip of the finger came in contact with
a tight circular contraction. Considerable force was required
to introduce the finger to the depth of the nail. After per-
mitting each assistant to examine the constriction, the left
index finger was again passed with much force as far as the
first joint. The circular fibers were cut on the floor and the
finger passed into the bladder. Not feeling tliat the contraction
was thoroughly relieved, a shallow cut was made on the roof,
of tlie canal. After the fibers were cut the canal felt normal.
There seemed no hypertrophy of these circular bands, and the
prostate from rectal touch was found normal. As described by
I)r. l''ullor, the urethra in front of the contraction was pouchedf.
Perineal drainage was kept up for several days with daily irri-
gation of the bladder. The boy recovered rapidly from the
operation.
A recent letter from Dr. Wiley states that the result
was all that could be desired. The urine is clear, and
the patient is entirely free of his old symptoms. A
No. 30 F sound is passed with ease. I have every
reason to believe that the cure will be permanent.
464 AMKBIOAN MEBICISEI
ORGANIZATION AND ETHICS
[Septbhbeb 20, 1902
SPECIAL ARTICLES
ORGANIZATION
AND ETHICS,
MEANS.'
OR WAYS AND
p. MAXWELL FOSHAY, M.S., M.D.,
of Cleveland.
Member of the Committee on Organization of the American Medical
Association, Kdltor of the Cleveland Medical Journal, Hecre-
tary of the Ohio State Medical Assoclatlcn. Member
of the Board of Trustees of the Ohio Hospital
for Epileptics, etc.
The general movement of the medical profession toward a
more effective mode of organization has been almost universally
spoken of as "the reorganization of the medical profession,"
but the term is a misnomer in that the medical profession as a
■whole has never really been organized. There have been medi-
cal societies, highly multiplied in number and variety, but
cohesive organization has been unknown, except locally in one
or two States.
For years close students of medical affairs have been telling
us that it is absolutely essential to our own welfare that we
should be thoroughly organized, and none ever spoke more
truly. For a time it appeared that physicians were apathetic,
and that they were not to be aroused by an appeal to their own
interest, let alone by altruistic sermons. But those who, like
Gould and a host of others, had for years been strenuously
preaching unity were happily destined to live until the time
when they should see that their efforts had not been for naught,
and that the seed which they had sown had fallen upon good
ground. As if moved by one independent and common tele-
pathic im.pulse, the day came when the entire medical profes-
sion awoke from its lethargy and demanded that it be organ-
ized, demanded that its members should be so closely banded
together that they could impress upon the world at large the
inestimable public benefits that are increasingly flowing from
the pursuit of scientific medicine ; that they could defend them-
selves against attacks from without and from within ; that they
might improve their educational, legal, moral and social stand-
ing. This demand was as unexpected at that exact moment as
it was wellnigh universal, and it was irresistible.
Need for Organization.
A moment devoted to analyzing the source of this move-
ment will not be wasted. In several States and in national
affairs the medical profession, together with some noteworthy
victories, had experienced some severe rebuffs when it asked
of lawmakers things that were not particularly for its own
betterment, but that were eminently calculated to be of perma-
nent benefit to the whole human family. It was seen that
education of public sentiment to the new standards of medical
thought was absolutely essential, and that physicians must
appropriate the spirit of the age in recognizing that unor-
ganized they could not expect to make the least impression upon
organized society. It was recognized finally that we are in an
age when the individual acting alone accomplishes little or
nothing, no matter how meritorious his project. In commerce,
in socjal affairs, in religion, in politics, in science, and indeed in
every department of human activity, the banding together into
a compact association of individuals having a common purpose
is the law of the social evolution of the age. Thus, then, we see
that the medical movement toward better forms of association
is but a part of the general tendency of our times. More than
any other calling medicine has the greatest need for organiza-
tion, because it has the most to give toward the benefaction of
humanity as a whole.
The New Era.
Again, as was proclaimed in ringing eloquence by Reed, at
St. Paul, in 1901, we are indeed living in a "new era of medi-
cine." We drifted into this new stage of existeuce so smoothly
that we had hardly noticed a jar, and so swiftly that the speed
of passing landmarks obscured our vision. Then, suddenly,
guided by the illuminating words and vigorous moral fire of
'An address delivered at Detroit, July 25, before a Joint meeting of
the Wayne County Medical Society and the Detroit Medical Society.
the speaker, we stopped to see what had happened— all but a
revolution in everything pertaining to medicine ! The methods
by which physicians gain knowledge of and command over
their science and art— medical education— have been entirely
revamped. The laboratory, with its exact knowledge, has dis-
placed the empiric theories of the past, of whose accomplish-
ment with the relatively meager facilities at hand there is no
reason to feel ashamed. The tremendous development of the
rational natural sciences has given us a rational science of medi-
cine, and we are ready with new tools still further to advance
into the realm of the unknown. Along with our improvement
in educational qualifications we have compelled most of the
States of the Union to recognize facts by giving us laws con-
fining the practice of medicine not to those of some particular
belief as to methods of treatment, but to those who have had a
good grounding in the exact knowledge that now forms the
only basis of medical practice. Our medical schools in this mar-
velous development of knowledge have found themselves in a
state of transition as apparent as that which marks the passage
of night to day. They are not yet adjusted to the new conditions,
but, considering all the factors of the intensely difficult situ-
ation that they have encountered, they already have accom-
plished wonders, and are now in full swing of ev^olution toward
fewer schools, better facilities, higher ideals of teaching, and
decreased number but enhanced quality of their output. In the
prof&ssion itself we find that we have become vastly more
tolerant in our views of the intellectual errors of our fellows.
We have succeeded in putting into a fixed place the concept
that therapeutic beliefs are but a minor part of medicine, and
may be utterly disregarded if the individual physician is but
honest and well trained in the fundamentals of medical science—
a complete revolution of our conception of medicine.
An Inspiring Example.
Facing these new conditions of professional existence, it is
little wonder that on the very awakening of our new conscious-
ness there arose so insistent a demand that we place ourselves
in such position as to enable us to play that high part in the
world's affairs for which we now are evidently prepared, and to
secure for ourselves that position in social evolution which
clearly belongs to us. Looking about us we saw that one State
had, through the prevision of a single keen, high-minded,
unselfish and far-seeing physician, Jerome Cochrane, of Ala-
bama, already prepared itself well for the new part that medi-
cine is to play. Almost 30 years ago this wonderful man was
writing and preaching in most eloquent words those same ideas
which the rest of us are only now framing into commonplace
speech. Under his magnetic and persevering leadership the
medical profession of Alabama for a generation has been thor-
oughly organized, and has spoken the deciding word in almost
every matter that in any way concerned the public health of
that State. So great was the intellectual power of this man that
he bent the very powers of the State itself in certain appropri-
ate particulars under the sway of the organized medical profes-
sion. It was but natural that the successful plan of organiza-
tion so well tried in Alabama should at once be turned to by
those who wished to see the whole profession harmoniously
associated. Other States in the East and in New England had
long had similar forms of organization, but in none had such
an effective plan been evolved as in Alabama by Cochrane. In
adapting this to general use, however, certain details have had
to be altered, but in the main the Alabama plan is that which
now is being adopted by the State medical associations.
Origin of tlie Recent Activity.
You will pardon a moment spent in placing upon the page
an unrecorded fact or two as to the manner in which this great
sentiment was crystalized. For some years in Kentucky a far-
seeing, kindhearted physician, as he went about his routine
duties, had been studying deeply the conditions of professional
existeuce. He had acted his own ideal of being always the
peacemaker between contending individuals or groups in the
profession. He had been organizing county societies and
sending country doctors to cities for postgraduate study. This
man, by his intense personal magnetism and evident absolute
honesty, had become a great moral power in the profession of
September 20, 1902]
ORGANIZATION AND ETHICS
[AMXRICAir Mesiciki 465
his State. Long a regular attendant at the annual sessions of
the American Medical Association, he had been dreaming of
persuading the Association really to organize the medical pro-
fession of the United States. He came to the Atlantic City
meeting of 1900 prepared to offer resolutions that should pave
the way to the attainment of his purpose. There he met another
physician who, before becoming editor of the Association
journal, and secretary of the Association, had had extended
experience in the work of organization in Nebraska. He, too,
had come to the Atlantic City meeting determined to see that
the chaotic state of the medical profession should endure no
longer. He, too, was actuated by clean ideals and by a great love
for his profession. He, too, was far-seeing and discerned the
destiny of our profession. At that same Atlantic City meeting
there was elected to the presidency of the Association a physi-
cian from Ohio who was overflowing with an energy guided by
high purpose, penetrating intellectual grasp, and genuine belief
in the greatness and real nobility of his chosen profession.
These three men then — McCormack, of Kentucky; Simmons,
formerly of Nebraska; and Reed, of Ohio— these three men, by
the very compulsion of a common purpose, spontaneously
joined hands to lead the profession in its quest for a better
mode of organization. Six months later, on December 23, 1900, 1
became the third member of the Committee on Organization by
the appointment of President Reed ; and the work of outlining
a harmonious plan of professional organization was at once
undertaken, beginning with the American Medical Associa-
tion. Of the rest of the story you know— the adoption at
St. Paul of a plan of organization that contemplated bind-
ing together the whole profession of the United States into
one compact interrelated organism ; the adoption by one State
after another of an organic law placing it in conformity with
the national body ; and now the strong movement to make the
county medical societies what they must be, the active living
exponents of professional will and the agents of professional
harmony.
This sketchy account of the history of the organization
movement is sufficient to give an idea of what has been done,
and, to some extent, of why it has been done. This much
seems to be in justice demanded by the spirit of this occasion.
The living present, and that hazy ghost of reality — the future —
now demand all our attention. The task is but begun, and the
way has only been staked out. The real work is yet to come,
and it can be accomplished solely through the willing coopera-
tion of every physician.
The County Society.
Today, and in the years to come, the county medical
society must necessarily be the chief center of interest. The
county medical society is now the only portal to the State
association and to the American Medical Association. Here-
after it alone is the sole judge of the eligibility to professional
fellowship of each and every applicant. It is a component part
of the State organization, and its treasurer collects the dues for
its own use and also for the support of the State association.
It must be built up and made strong and representative. No
applicant must be kept out who is eligible when judged by the
simplest standards of eligibility ; and " every physician in
good professional standing " is eligible. And the phrase " good
professional standing " is not difllcult of interpretation. It
means a physician who is in all things a gentleman, according
to the accepted standards of society, and therefore one who is
honest in his dealings with his patients and with his fellows.
What more is necessary ? The law provides that he must be
educated before he can legally become a physician, and his
therapeutic belief and practice are of no possible interest to the
profession, unless he poses before the world under some title
other than that of simply "physician." Manifestly it must
always constitute professional immorality for a man to pretend
that he practises something other than " medicine," for our
profession is, in the very nature of things, as indivisible (hon-
estly) as the law, as the ministry, as physiology, or as anatomy.
Ethics.
Because the county medical society has become the only
entrance into organized professional fellowship, and because,
therefore, the county medical society now becomes the sole
judge of professional qualifications, we cannot avoid giving
some consideration to the ethic principles that do and should
govern the conduct of reputable physicians. Up to the present
time it has been perfectly evident that the most important and
most urgent and most practical need of the medical profession
is a good plan of organization. Now, however, as the House of
Delegates of the American Medical Association has appointed
a committee to revise the Code of Ethics, the appropriate time
has come for a dispassionate consideration of ethic standards.
This is the more appropriate for the reason that the county
societies, now having become the arbiters of such problems,
should be given every opportunity to express their views
before our new declaration of ethic principles is finished and
placed among the statutes of medicine. While the American
Medical Association will deal no longer with personal ethic
questions, it is eminently proper, and indeed quite necessary,
that it should formulate general rules for the guidance of the
State associations and county societies. These rules should be as
few and as liberal as is consistent with maintaining an active,
living harmonious professional organization.
The Code.
A formal Code of Ethics found ample justification for its
adoption by the American Medical Association a half century
ago. The profession was wholly unorganized, largely unedu-
cated, and admittance to its ranks was governed chiefly by the
whim of the novitiate. Under such conditions self-protection,
if there had been no higher motive, would have led the edu-
cated and reputable minority of physicians to setup a standard
of professional conduct that would serve as a guide to those
entering the profession, and that would constitute a basis upon
which to judge infractions of upright professional conduct. As
Reed has so forcibly pointed out, the Code of Ethics was, in its
essence, the result of an effort on the part of the medical pro-
fession to regulate its own composition and conduct by volun-
tary legislation. That the endeavor was conceived in honesty
and executed in admirable spirit, and that the code in its day
has served a most excellent purpose, can be gainsaid by no
candid observer of medical history. In the half century that
has elapsed since the adoption of the code, far-reaching changes
have taken place in every phase of medical life. Education has
been infinitely improved, the morale of the profession has been
markedly elevated, and the growth of liberalism in medicine,
as elsewhere, is now rapidly exterminating sectarianism.
Voluntary restriction of the right to practise medicine
failed, and, at the instance of the medical profession. State
legislation has been efl"ectively substituted for many of the
provisions of the Code of Ethics. This has been done without
delaying to modify the voluntary laws adopted by the profes-
sion itself. Indeed, that which is best in the medical legisla-
tion of our States is the logical outgrowth of the operations of
the Code of Ethics. By the operation of these State laws many
of the old distinctions between physicians and sectarians have
faded from view before our very eyes, and those who do not
possess the capacity to know what is upright professional con-
duct, as well as those who do not care to govern themselves by
gentlemanly instincts, fiind it Increasingly difficult to enter the
profession.
A Point Overlooked,
Those who are urging that the Code of Ethics in its present
form is no longer useful to the medical profession overlook one
very important point when they argue that State laws have
wiped out the gap between physicians and the medical sects.
It is undeniably true that before the law, the recognized secta-
rian has had granted to him exactly the same privileges as
those enjoyetl by the members of our profession. This, together
with the diffusion of scientific medical knowledge and the
broadening of educational methods, has indeed led many sec-
tarians voluntarily to abandon their exclusive title and to
become simply "physicians." Every one of us is anxious to
encourage this tendency, and is willing to extend the hand of
fellowship to all former sectarians who have come to appreciate
the essential oneness of medicine. However, the forgotten fact
is not the less a fact because it seems to have escaped notice.
All our State laws— or very nearly all— by exact title, duly
466 American MiDictitE]
ORGANIZATION AND ETHICS
[Sbptkubbb 29, 1902
en/ramed in statute, recognize tlie existence of sects in medi-
cine. It follows, then, that these much-lauded and indeed infi-
nitely useful laws are probably about to become the chief stum-
bllng-blocks in the way of a complete reunion of the medical
profession. So long as the laws specifically recognize the sects
we cannot effectively tell the public that there is but one indi-
visible medical profession, and so long as a few sectarians
remain they will be able, by raising the cry of " persecution,"
to enlist popular support against any modification of the laws
that is intended to give recognition to the essentially estab-
lished unity of the medical profession. This practical obsta-
cle now confronts us and will sooner or later have to bo
met. Until that time, that is, so long as the laws specifically
provide for the propagation of those who hold that medical
science is a thing to be divided up into little patches to accord
with varying views of administering drugs— today one of the
smallest departments of medical knowledge— we shall have
some need for " ethic principles," even if not after these laws
are amended to accord with the facts.
Standards.
The operation of the laws and the improvements of educa-
tion are as yet not of sufficient duration to enable us to declare
that "every individual practising the healing art is eligible to
membership in our societies," and for some time to come, as we
have seen, these conditions cannot be altered. In addition,
physicians are but human beings subject to the usual failings
of human nature, and so our societies, in common with all
other organizations, must have certain standards of conduct to
guide those who need them and to govern those who sit in
judgment. In order that the whole profession of the United
States may have but one standard and that the county societies
and State associations may follow a uniform course in judging
questions of conduct, it is evidently necessary that the repre-
sentative national body of American physicians, the American
Medical Association, shall adopt a declaration of ethic princi-
ples. There is real need for uniformity in ethics as for uni-
formity in organization.
A Suggestion.
The best way out of these difficulties seems, therefore, to
be that the code shall be left unchanged as it has stood for so
many years, only hereafter existing purely as a historic and
educational document in no direct way related to the organized
profession. In its place, as a guiding principle for the subordi-
nate societies, let the American Medical Association, instead of
" revising " and of readopting as a standing resolution the Code
of Ethics, formulate a sharp, crisp, definite set of regulations—
" a declaration of ethic principles." This new document can
be made a standing rule of the Association, and can be printed
and distributed along with the Code of Ethics, which can be read
with profit by every physician, old or young. In brief, it may
be made to define all those actions that by common consent we
agree to class as "unprofessional conduct," and in a few con-
cise aphorisms formulate all that is necessary to guide the
individual physician in his relations with the public, with the
state, with his fellow-physicians, with the sectarians recog-
nized by law, and with the organized profession. This pro-
posal appears to offer feasible solution of one of the most intri-
cate problems that now confront our profession. It is offered
for what it is worth, in full confidence that free discussion of
this matter from now until the next meeting of the national
body will entirely clarify the ethic atmosphere. As the county
societies will be chiefly concerned with the practical enforce-
ment of any ethic rules that may be adopted, it should be their
right and privilege during the coming winter to discuss this
question and to register their opinions.
Hasten Slowly.
We are all agreed upon the utility of receiving into our
organization all former sectarians who have abandoned their
exclusive systems of practice, and most of us are prepared to
admit, indeed we are admitting, those sectarians who have
ceased to use the distinctive title, without stopping to ask what
their private therapeutic " beliefs " may be. Beyond this there
IS a growing number of us who would receive into our societies
every secterian who will apply for membership, provided his
personal character and professional habits are such as to fit him
for association with the great body of physicians. There is
much to be said in favor of this action, and the theory has tieen
put to the experiment in Dayton and in Buffalo. Probably it
may be well to await the outcome of the test. Certainly those
who are urging that we should at once open our incorporate
doors to every sectarian without regard to the narrowness of
his " beliefs " have not stopped fully to consider the conse-
quences. In the first place a very respectable number of physi-
cians do not desire such action, and any attempt to force the
matter can only result in wholly unnecessary and dangerously
disturbing disputation. From the standpoint of expediency,
therefore, and with a view to maintaining the integrity of our
new form of thorough organization, it is perfectly evident that
such a proposition may not at present be made with any hope
of permanent good result. In fact, it is my belief that, before
we reach this point in our development, we will be compelled
to secure the repeal of those portions of the State medical laws
that give legal recognition to the existence of the sects in medi-
cine.
Of course we all know that very few of the followers of the
exclusive sects today live up to their own doctrines, and that
even a smaller number exhibit to the public any evidence of
their sectarian affiliations. This condition has resulted from
the development of medicine as an applied natural science and
the consequent subordination of therapeutics to diagnosis and
pathology and pharmacology, so that today a man who gets
even a little medical education and who reads a few medical
books is unable to find a basis for therapeutic dogmas and a
priori standards of practice. In consequence of this situation
there are few sectarians indeed who are not now eligible to
medical organizations. But in spite of this there appears to be
good reason to hold to the former practice of not admitting
those who have not yet, in part at least, yielded to the liberal-
izing spirit of the time.
Thus I have frankly laid bare the real crux of the discus-
sion about revising the Code of Ethics, and it is for the profes-
sion to make its choice with deliberation and in a kindly spirit.
We turn now to other duties and functions of the county socie-
ties, as they are of paramount importance and of chief interest
this evening.
Tlie Paid Organizer.
The county societies must imitate the better methods for
reaching and retaining members, that are employed with suc-
cess by the churches, the secret societies and the trades unions.
In its final analysis there is no use hiding the fact that this
means that some one shall be paid to organize the profession.
Each State association should have a paid organizer to create
new county societies and to enlarge and encourage the older
ones. This will come very shortly, for simply as a business
method it will pay— quite apart from the great moral and scien-
tific benefits that will follow.
Ideals.
Of very necessity the county organization— by whatever
name it may be known— must be essentially the fundamental
unit in any cohesive plan of professional organization. Its
support by the physicians living within its geographic limits
requires a certain spirit that is not yet quite so universal as we
all wish, but that is preeminently the spirit of the era, destined
to overthrow all contrary tendencies. This spirit is that of har-
mony, of love for our profession, of willingness to sacrifice
something of self-interest for the general welfare, of charity for
each other's views, and of tolerance for each other's ambitions.
None of us can yet live up to its highest ideals, but each may
assimilate so much of it that friendly association of all honest
physicians will be easy and but seldom interrupted by differ-
ences allowed to reach the bitter personal stage. Indeed, in
this age of the world there is no convenient time or place for
the settlement of disputes between physicians arising from the
clashing of self-interests. At every step each of us must never
forget that the good of the whole profession is infinitely
more important than that of any one individual, and that the
professional community has no difficulty in picking out sooner
or later those actuated solely by selfish motives. This means
that, in the long run, the man who lives only for his own inter-
SBPTEMBKR 20, 1902]
MEDICAX, AND SURGICAL NOTES FROM ASIA [amebican mkdicink 467
est will inevitably lose that which is above everything else the
most worth living for— the respect ol his fellows. There is no
need for any display of inordinate self-interest in our profes-
sion. There is work for all, and present forces are strongly
tending toward a betterment of the material interests of the
profession.
Unite.
Therefore, because hereafter there can be in each county
only one representative society, it is evident that we all must
learn this lesson of submerging something of our self-interest
in the general welfare of our whole profession. Where multi-
ple societies now exist they must unite — so far as their repre-
sentative functions are concerned. In other respects we may
have as many societies as may seem desirable — that is, societies
devoted to the consideration of special branches of medical
practice. In such cases simple prudence dictates that these
societies should be related to the representative organization at
least to the extent of. requiring as an invariable prerequisite
for admission that the applicant for membership therein shall
first be a member of the representative organization of the
county. In this way there may be ample variety of societies to
meet all the needs of the profession and, at the same time, we
shall be presenting to our community one undivided whole
whenever conditions require it — as they not seldom do.
In Cleveland, where for years there formerly, but not lat-
terly, has been full experience with internal strife, there was no
difficulty in uniting the societies by merging them into one
new and more comprehensive body, and it was done by a unan-
imous vote in each of the constituent bodies. Because the pro-
fession of Cleveland is composed almost wholly of young men
who have readily and heartily grasped the professional spirit
of our time it is true that the task was easier than it may be in
some other communities. However, other cities and counties
have united their societies, so that in Ohio, for instance, there
are only three counties in which multiple societies exist, and
in each of these the eff'ort to unite is well under way. In Ala-
bama and other States there is but one representative medical
society in each county. We can make the same statement true
of any county. All that is required is for the profession prop-
erly to appreciate the acknowledged benefits of association, and
to see that multiplicity of societies is only one step less bad
than no society at all.
It is difficult to conceive of any professional community In
which the obstacles to be overcome in attaining professional
unity are so great as to be insurmountable. In the presence of
the philanthropic spirit of the new era in medicine, surely such
a situation is impossible.
Afethods.
In sortie instances the attachment for old names and for
honorable traditions is so strong that physicians who can curb
their self-interest are held back from concentration of effort by
this l)y-no-means-discreditable sentiment. But no matter how
admirable such a sentiment may be, it must not persuade us to
block the evolution of our profession. Perhaps a coni^rete sug-
gestion may not be here out of place, and possibly it may best
t)e stated by detailing the steps taken by the medical societies
of Cleveland in preparing for consolidation. In the first place,
each society appointed a committee of five to confer with a like
committee from tlie other society in order to determine
whether both were willing to consider terms of union. This
was readily ascertained, each organization pledged itself to the
principle of union, and the committees were authorized to draw
up a statement of terms upon which union could be effected.
This joint committee at the outset realized that a de facto union
of the existing societies would perhaps be difficult, because of
tlie sentiment on the part of members of each who hesitated to
see the honorable career of their own society mingled with the
traditions of the other. Therefore the members of the Joint
committee ceased talking of " union," and instead they at onoe
set about drawing up a constitution and by-laws for a new
organization that siiould entirely replace the existing societies.
Therefore, instead of uniting, the medical societies of Cleveland
really voted tlie willingness of their members to join in form-
ing a new organization, and voted themselves out of existence
when the new Academy of Medicine had in joint meeting
adopted the new constitution and by-laws. This method should
be applicable in many places.
A Splendid Example.
In Dayton, Ohio, there are two societies— a city and a
county organization— and each was formerly in affiliation with
the State association. Observing that the State reorganization
would bring with it the necessity that only one society in each
county could continue to be the representative organization,
the members of the Dayton Academy of Medicine solved the
difficulty by one of the most magnanimous actions ever taken
by a medical society. They voluntarily asked the State body
to permit them to withdraw their society from affiliation, so
that the county society should have no diflBculty in being
recognized as the representative organization. (Applause.)
That was an example of self-abnegation that is most admirable:
and that should serve to inspire physicians everywhere with a
determination to exhibit to the world similar evidence of the
magnanimity of the new era.
Tonight, then, after this rambling excursion over our field,
I close with thanking you most sincerely for the invitation that
gave me the opportunity to present these views. I beg of you
to overlook the faults that you may have readily discovered in
my rhetoric and in my argument, and to give a fixed place in
your mind to the chief text in my thesis— the appeal for profes-
sional unity of purpose and action ; and above all, for a recog-
nition of the necessity of cultivating increasing courtesy,
tolerance, forgiveness and brotherly love among ourselves.
MEDICAL AND SURGICAL NOTES FROM ASIA.
BY
NICHOLAS SENN, M.D.,
of Chicago.
It is a long time since the great continent of Asia was the
center of civilization, art, science and Christianity. For nearly
2,000 years progress has given place to decay. Her treasures of
art lie buried under her arid soil or have found their way into
the rich museums of distant nations. Her science has been
transplanted to a more fertile soil in foreign lands. The light
of Christianity kindled in Asia has become almost extinguished
by the worshipers of strange gods, and is now illuminating
more brightly Europe, Africa and the two continents that were
unknown when it was given to God's chosen people. The dark
clouds created by the relentless persecution of the Christian
church, the great power of civilization, still hover over the
unfortunate continent and are being only gradually dispensed
by the reintroduction of the teachings of Him who selected this
land for his soul-saving mission on earth. In a land where
there is no art and no science medicine cannot flourish. Super-
stition and medicine are incompatible neighbors. Science
should precede— it certainly must accompany— progressive
modern medicine. If Hippocrates could return to his birth-
place in the island of Kos, near the coast of Asia, he would find
ample indications that the science of medicine which he
founded 400 years before the Christian era had found a new
foothold in many parts of dark Asia. What progress has been
made in Asia in the teaching and practice of medicine during
the last half century has been accomplished entirely by outside
influences. The medical missionaries and foreign physicians
are establishing in many different places institutions where
modern scientific medicine is taught and practised and from
where the good work will gradually but surely extend over the
entire continent. It is my purpose to speak of a few such med-
ical centers in this communication.
SMYRNA.
Smyrna is one of the great commercial ports of Asiatic
Turkey. It has a mixed population of 125,000 inhabitants.
The Greeks are well represented and control much of its com-
mercial interests. They own and maintain a large hospital for
the sick of their own nationality. They gained a firm foothold
on this part of the Asiatic soil centuries ago, and have been
more successful in business matters than most of the other
exotics. The richest men In Smyrna are of Greek origin.
468 AjntHioAw MBDionntj MEDICAL AND 8UBGICAL NOTES FROM ASIA
[Septembeb 20, 190ii
The Yoaharalambas Hospital. — This institution lor the
Greelt sick poor in Smyrna is a credit to the little nation It rep-
resents. It is more than 150 years old and is located in the
very heart of the city. It is a solid square building two stories
high with a central open court where the patients enjoy the
luxuries ol a subtropical garden and pleasant walks. The
wards are large, well ventilated and supplied with all the com-
forts of a modern hospital. The medical staff is composed of
young men, graduates of the University of Athens, and most
of them have taken postgraduate courses in Paris. Smyrna
surgery is French surgery. One operating-room is devoted
entirely to aseptic surgery, in the other all the facilities for
antiseptic work are at the disposal of the operator. In the
aseptic room the appliances for sterilization of instruments,
dressings, suturing and ligature material are complete. Like
in all Oriental hospitals the absence of trained female nurses is
a deplorable feature. Dr. A. N. Psaltoif is the most distin-
guished member of the medical staff of this hospital. He spent
several years after his graduation in Paris, and is familiar with
French medical literature. He is an able and successful sur-
geon, and his example and teachings will contribute much
toward disseminating modern surgery in Asia. Other foreign
nations in Smyrna own and support their own hospitals, among
them the French and Austrian governments.
BEYRUT.
Beyrut is the Paris of Syria. It is a city of 75,000 inhabi-
tants, located on an eminence which commands a splendid view
of the Mediterranean Sea on one side and the Lebanon Moun-
tains on the other. Here a new civilization and modern medi-
cine have engrafted themselves more firmly than in any other
part of Asia, all through the strong influence of the Syrian
Protestant College.
Syrian Protestant College.— This is an American mission-
ary institution founded 36 years ago by the retiring president.
Rev. Daniel Bliss, D.D. It is known by the citizens of Beyrut
as the American College. The massive stone buildings are
distributed over a 36-acre lot located on the shore of the Medi-
terranean on one side and shut out from the city by a high
stone wall on the other. New buildings are erected as they are
needed. At present the great Post Hall is in process of con-
struction and when completed will be used as a science hall.
The Daniel Bliss Hall is a magnificent college building. The
college has an attendance of 600 young men who have come
here to obtain their education from various countries, includ-
Medical Hall.
ing Syria, Turkey in Europe, Greece, Palestine and Egypt.
The teaching force is composed of 40 professors and instructors.
The faculty includes a number of names of former graduates.
The college has six departments: preparatory, collegiate,
school of commerce, school of biblical archaeology and phi-
lology, medicine, and pharmacy. New departments will be
added as fast as the finances of this excellent institution will
permit. What is much needed is a department of dentistry
and agriculture.
School of Medicine.— This was organized by Prof. George
E. Post in 1867. It has a list of 91 graduates up to the present
time. It has more than 100 matriculants and the graduating
class for this year numbers 16. The faculty is composed of eight
members. Some of these teachers fill several chairs. For
instance. Prof. Adams teaches chemistry, rnateria medica,
therapeutics and dermatology, and Prof. Moore gynecology,
obstetrics, physiology and hygiene. Recitations constitute a
conspicuous feature of all didactic courses. One of the di fficul-
ties encountered by the college of medicine is the supply of
material for the dissecting-room. The cemeteries are the only
places where the material can be obtained and the midnight
excursions for this particular purpose are attended by great
difficulties. The bodies are carefully preserved in alcohol so
as to utilize them to the utmost advantage. Tlie college build-
ing compares favorably with some of our smaller medical
schools. Two amphitheaters serve as lecture-rooms. A
museum furnishes ample facilities for the study of compara-
tive anatomy, pathology and osteology. The present laboratory
advantages are not what they should be, but a large building
now in process of construction will remedy this defect at the
beginning of the next session. The tuition is ^0 annually and
half of this fee secures admission for graduates of the Syrian
Protestant Hospital, Robert College, Central Turkey College,
Anatolia College, and of Euphrates College. The requirements
for admission specify the minimum age at 17, and a satisfactory
examination in English, French or Turkish, geography, arith-
metic, elementary physiology, algebra, geometry and physics.
After four years' study and after having passed a satisfactory
written and oral examination, the students receive a certificate
of examination. This certificate entitles them to apply for
graduation to the Imperial Medical School at Constantinople.
In Egypt this certificate entitles the holder to enter into prac-
tice without any further examination. A number of the gradu-
ates are now serving as military surgeons in the Egyptian army
and others hold important municipal medical positions.
The Johanniter Hospital. — This hospital was founded in
1867 by the German branch of the Knights of St. John, and
receives the warm support and financial aid of this order. It is
a two-story stone building, situated on a high bluff which over-
looks the Mediterranean Sea. It contains 70 beds, and is in
charge of eight deaconesses from Kaisersworth. These eight
well-trained Sisters take excellent care of the patients and are of
great assistance to the attending staff. All ol the clinical teach-
ing of the medical school takes place in this hospital. Professor
Post holds his clinics Wednesday and Saturday forenoons each
week. The students attend in sections of from 12 to 20. As
there are no house physicians in the hospital the students assist
in operations and attend to most of the dressings. The operat-
ing-room is small but contains everything necessary for aseptic
work. All of the students wear gowns. Those who are called
upon to assist must undergo a most thorough hand disinfection.
Post is partial to silk as a suturing material, although occasion-
ally he makes use of catgut or silver wire.
On the day of my visit he operated for congenital inguinal
hernia occurring in a man about 35 years old. The opposite
side had been operated upon successfully six weeks ago. The
operation was performed under cocain anesthesia.
Post prefers local to general anesthesia in such cases. His
experience with this local anesthetic has been quite extensive,
and although he has administered in some cases as much as IJ
grains of the drug in this manner he has never observed any
serious after effects.
In this particular case the patient frequently manifested
pain on incising the skin and in making the deep dissection.
The omentum persisted in protruding on opening the sac and a
large part of it was finally amputated below a number of en
masse silk ligatures. This part of the operation appeared to be
painless. The hernial opening was very large and conse-
quently had to be closed by suturing instead of by a ligature.
The spermatic cord was not disturbed and the inguinal canal
was closed with a number of silk ligatures.
The operation was a somewhat tedious one and the two
other operations set for the same day, a cystic bronchocele and
a relapsing sarcoma of the face, had to be postponed for the
next clinic.
Among the interesting eases exhibited were : Ovariotomy
for dermoid cyst, enterectomy for fecal fistula following opera-
tion for strangulated hernia, thyroidectomy lor parenchyma-
tous struma of right lobe of thyroid, excision of carcinoma ol
Septembek 20, 1902]
MEDICAL AND SURGICAL NOTES FROM ASIA fAKBRicAw mewcinb 469
breast and a number of cases of tuberculosis of joiuts, all of
them progressing favorably.
Professor George E. Post is a most remarkable man. He is
the most popular physician in Syria, respected and honored by
all classes of people for what he has done for the country. His
students fairly worship him. He is the son of the distinguished
late Professor Alfred C. Post, of New York. He came to
Beyrut soon after his graduation in 1863 and has worked inces-
santly ever since. He loves the people and the country of his
adoption and his work will be revered and honored by genera-
tions to come. The secret of his almost unparalleled success has
been work. He has accomplished what he has by systematizing
his work, and his hours of rest are few, but are taken at a regu-
lar time. He has given to the college he loves nearly one-half
of^his time. Vacation he knows not, work is his recreation.
Besides a large and taxing surgical practice he has found time
to prepare an Arabic Commentary of the Bible and the Flora
of Syria, two books that will perpetuate his memory in the
history of Syria and in the scientific world. When Emperor
William visited Beyrut and the Johanniter Hospital he was made
aware of what Professor Post had done for the city, the coun-
try, and the hospital, and it was a gracious and timely act on
liis part when he conferred upon the hard- worked, faithful pro-
The Jobannlter Hospital.
fessor the decoration of the Red Eagle. The famous Emperor
never conferred a decoration upon a more worthy man. Pro-
fessor Post is a model of what a medical missionary should be.
He has acquired a perfect knowledge of the language of the coun-
try of his choice. He never fails in delivering every Sunday a
sermon in Arabic to the patients of the Johanniter Hospital.
Dr. Post has visited the United States only three times since
he gave his services to Syria. It is for good reasons that the
great hall of science in connection with the Syrian Protestant
College should be called the Post Hall, a recognition to which
he is entitled by his long and faithful services to the institution
that owes so much to his untiring efforts.
Other Hospitals.— The Catholic College in Beyrut has the
same objects in view as the Protestant College, but has not found
the same degree of favor with the natives. The French and
Greek hospitals take care of the subjects of the respective
countries, and will do their share in disseminating modern
medicine and surgery in Asia.
DAMASCUS.
This is a city that interests every biblical student. It was
made famous for all time by the conversion of Saul. The place
of his conversion on the road to Jerusalem and the house of
Ananias he visited by the Lord's request are the two places
every stranger is sure to visit. The city is much the same as
when this incident occurred. Some of the old walls that
sheltered it from invading forces at that time still remain.
It has now a population of 2.50,000 inhabitants, representing
Syria and its adjacent countries. Its narrow streets, small
shops and the mass of ragged citizens speak only too plainly of
its poverty.
Medical Practice in Damiiscus. — Damascus is not the place
for the physician whose principal desire is to accumulate
wealth. The city has 20 licensed practitioners besides the
military surgeons stationed here, who are permitted to practise
their profession outside their military duties. Ten cents pays
for an office consultation, and two to throe francs for a visit. A
large majority of the people are poor and cannot pay anything
for medical services. For this part of the population the many
medical dispensaries make provision. For instance, Dr.
Alexander Halabi, a physician of Arabian origin, has charge of
the Russian Dispensary and cares for 40 patients daily, a service
for which he is paid 80 francs monthly. Similar dispensaries
supported from other sources do much toward the care of the
sick poor of Damascus. I know of no other city in which.the
dispensary service does more good than in Damascus. Very
few emergency cases apply to dispensaries, as injuries are of
very rare occurrence. Smallpox has been stamped out by a
strict enforcement of the vaccination laws. Diphtheria is
seldom met. Venereal diseases are said to be quite common,
and among the natives pursue a mild course. Among the
acute diseases typhoid fever, malaria and rheumatism are most
prevalent. Tuberculosis of joints, bones and lymphatic glands
are common diseases of childhood.
Damascus Hospitals. — The city of Damascus has only three
hospitals, the Municipal or city hospital, the Military, and the
Victoria Hospital. The Municipal Hospital is a modern build-
ing with a capacity for 100 patients and is in charge of military
surgeons. Provision is made for a few private patients. The
furnishingsofthe wards are all that could be desired. The small
operating-room is supplied with everything necessary for asep-
tic work. The absence of trained female nurses in common
with most of the public Oriental hospitals is noticed more by
the transient visitor than anything else. The Military Hospi-
tal, with 500 beds, is an old building in the very heart of the
city, devoid of all modern improvements.
The Victoria Hospital. — This is the old Mission Hospital,
established and supported by a Scottish missionary society.
During the jubilee year of Queen Victoria the British subjects
of Syria raised the sum of JEIOO in honor of the occasion. This
sum was later appropriated to the use of the hospital, which
then assumed the name of Victoria Hospital. In recognition
of this devotion the Queen sent a fine steel engraving of her-
self to the institution ; this is now the main attraction in the
reception-room. The hospital can take care of 41 patients and
is in charge of Dr. Frank Irving Mackinnon, a graduate of the
Edinburgh school. Dr. Mackinnon is an enthusiastic mission-
ary physician and he has done much and will do still more in
disseminating modern medicine and surgery in Asia.
My next communication will treat of the hospitals in Jeru-
salem. The nursing is in charge of two trained Scotch Sisters
assisted by native women. A few private rooms are reserved
for patients who are able to pay. The hospital was opened five
years ago. The surgical patients outnumber the medical. A
few days ago the first case of ovarian tumor was operated upon.
The large garden with tropical trees and plants is a charming
place for the recuperation of convalescents.
Damascus, June 24.
Medical School of the Universityof Kansas.— Dr. George
Howard Hoxie, A.M. (Union), M.D. (Zurich, Switzerland),
has been appointed professor of anatomy to succeed Dr. S. W.
Williston, who goes to Chicago for the chair of paleontology.
Wife liiable for Medical Attendance on Husband.— The
Supreme Court of Nebraska holds, in the case of Leake vs.
Lucas, that when a husband is actually a part of the family,
living with it as such, and is temporarily helpless and incapaci-
tated by illness, his maintenance and support, including neces-
sary medical attendance, come fairly within the rule of the
statute of that State which makes the wife liable as surety for
ne<!essaries furnished the family. It further holds that, in such
case, where the husband and family, including the wife, remove
to a sister Slate, and no judgment can be obtained against him
in Nebraska, the obtaining of a judgment against him in the
courts where he resides causing an execution to issue thereon,
and having it returned unsatisfied, is a sufficient compliance
with the provisions of the statute to sustain an action against
the wife tf) recover for such medic&l attendance. In the com-
missioners' opinion it was stated that this was the first time
that this question of the wife's liability had been before them ;
that they found but little authority upon it elsewhere, and that
they did not intend to establish a rule of law by which they
should be conclusively bound in such cases hereafter, for every
decision on this question must necessarily be largely governed
by the facts existing in the particular case in which it is ren-
dertnl, but that it would seem that the medical attendance nec-
essary to cure the husband of the wife sued of his Illness, and
thus i)lace him in a position to labor and support the family,
herself included, was a necessary furnished for its benefit.—
[Jour. Amer. Med. Asso,^
470 Ajibbican Mbdioink]
THE WORLD'S LATEST LITEEATUEE
[Septembee 20, 1902
THE WORLD'S LATEST LITERATURE
10.
11.
gr. XXX
31qs
gr. XXX
Journal of the American Medical Association.
September IS, 190t. [Vol. xxxix. No. 11.]
1. rAnnmus as a Physician. Ludvig Hbktoen.
2. Injection Treatment of .Syphilis by Means of a New Mercurial VoT-
mula. M. L. Hbidingsfeld.
3. Treatment ot Tuberculous Peritonitis, with the Report of a Unique
Case. M. F. Porter.
4. Further Experiences with a Modification In the Operallve Method
for Inveterate Relapsing and all Aggravated Forms of Pes Equlno-
varus A. F. Jonas.
5. The Prevention of Deformity. W. R. Townsenb.
6. The Legal Status of the Term "Reputable" as Applied to Dental
Colleges. (J.C.Chittenden.
7. The Symmetry of Our Visual Apparatus as a Dual Organ : A Plea
to Modify the Customary Notation of the Ocular Meridians. H.
Knapp.
8. Amebic Dysentery In Michigan. George Dock.
9. What Cases of Placenta Prievla Can be Best Treated by Cesarean
Section? K. D. DoNOGirOE.
The Advantages of the Vaginal Operation in Obese Patients. W. H.
HOMISTON.
__, Postoperative Intestinal Paresis. F. H. WiGGiN.
12. The Influence of Biliary Acids on Surface Tension : A Preliminary
Report from the Clinical Laboratory of the Denver and Gross
College of Medicine. C. D. Spi yak.
2. — Injection Treatment of Syphilis. — Heidingsfeld
sums up the objections to treatment by inunction and by
mouth. Injection combines with rapidity of action, relative
greater efficacy, shorter treatment and diminished recurrences.
Objections to the latter on the ground of local pain and indura-
tion, oft-repeated dosage, instability, difficult preparation and
administration of the remedy have been in a measure relieved
by use of the following formula :
Lanolin 2
Mercury, bl distilled 6
Triturate until the mercury Is perfectly extin-
guished.
Liquid albolene 2
S.— Inject one grain (.06) every three or four days.
This combines stability with nonirritabllity. The injec-
tions should be made Into the buttocks alternately. Three
courses of 15 injections are administered the first year, two the
second, one the third, and one every two or three years there-
after. One needle suffices for more than 100 injections. Cases
responded promptly to this form of treatment that failed sig-
nally with other forms, [h.m.]
8. — See American Medicine, Vol. Ill, No. 24, p. 988.
4. — See Am.erican Medicine, Vol. Ill, No. 25, p. 1038.
5. — See American Medicine, Vol. Ill, No. 25, p. 1038.
6.—" Reputable " Dental Colleges. — Of the 47 enactments
in this country for the regulation of the practice of dentistry,
35 specially mention the possession of a diploma from a recog-
nized or reputable dental college as a necessary or important
factor in securing a license. The Board of Examiners is left
without any instruction as to the meaning of the word repu-
table. In certain mandamus proceedings the reasons adduced
as to nonreputability were proof of certain misrepresentations
by the faculty, deviation from generally accepted standards in
matriculation and transfer of students, in equipment, curricu-
lum, methods of and facilities for instruction, and methods of
conducting the school. The N. A. D. E. and the N. A. D. F.
have adopted rules and educational standards that are accept-
able to the profession at large and should be fixed as the cri-
terion of reputability, but in order to make these nationally
uniform it will be imperative that every State board adopt
them. Thus the statute in every State in the Union grants its
State board all the judicial power necessary to join in the
establishing of absolute national standards of dental educa-
tional requirements. The only way in which this country can
maintain its supremacy in dental educational standards is by a
concerted national legal standard, [h.m.]
7.— See American Medicine, Vol. Ill, No. 25, p. 1051.
8.— See American Medicine, Vol. Ill, No. 24 p. 986.
9.— See American Medicine, Vol. Ill, No. 25, p. 1045.
lO.— See American Medicine, Vol. Ill, No. 25, p. 1045.
11.— See American Medicine, Vol. Ill, No. 25, p. 1045.
12.— The Influence of Biliary Acids on Surface Ten-
sion.—Certain French writers have called attention to Hay's
test for biliary acids, which consists in sprinkling flowers of
sulfur on urine ; if it contains bile the sulfur will sink to the
bottom ; if free, the sulfur will float for weeks. The test is
based on the law of surface tension. The reaction is due to the
bile acids. One part of glycocholic or taurchollc acid in 120,000
parts of water lowers the surface tension. No other substance
in the body except soap has the same action. Acetic acid,
alcohol, ether, chloroform, essence of turpentine, benzoin and
its derivatives, phenol and its derivatives and anilin also cause
sulfur to precipitate. All fluids with a surface tension greater
than 50° per cm. do not allow sulfur to fall. With less it
rapidly settles. Specific gravity and reaction have no influ-
ence. The fluid must be clear and free from bubbles.
Heat reduces surface tension, and sulfur sinks in urine just
voided. Bile can be demonstrated by this test when Gmelin's
fails. Bile has been demonstrated thus in syphilis of the liver,
advanced tuberculosis and pregnancy. Stomach contents con-
taining bile failed to react. Several other powders give a like
but feebler reaction, [h.m.]
Boston Medical and Surgical Journal.
Septem,ber 11, 1902. [Vol. OXLVII, No. 11.]
1. The Symptoms and Treatment of Hepatic Cirrhosis in the Light of
78 Autopsies. George G. Sears and Frederick T. Lord.
2. The Clinical Value of the lodln Reaction In the Leukocytes of the
Blood. Edwin A. Locke.
3. Some of the Orthopedic Conditions of the Newborn Demanding
Early Surgical Treatment. Charles F. Painter.
4. Cirrhosis of the Liver In Childhood. John Lovett Morse.
1.— See American Medicine, Vol. Ill, No. 20, p. 808.
2.— lodin Reaction in Iieukocytes.- Intracellular iodo-
philia appears only in pathologic conditions. The reaction has
both a positive and negative value in diagnosis. No septic con-
dition of any severity can be present without a positive reac-
tion. By its absence septicemia, abscesses and local sepsis,
except in the earliest stages, appendicitis accompanied by
abscess formation or peritonitis, general peritonitis, empyema,
pneumonia, pyonephrosis, salpinigitis with severe inflamma-
tion or abscess formation, tonsillitis, gonorrheal arthritis,
hernia or acute intestinal obstruction where the bowel has
become gangrenous, can be ruled out in diagnosis. A positive
reaction several days after crisis in pneumonia points to delayed
resolution, abscess or empyema, and after opening of an abscess
to lack of thorough drainage. It is present in 50% of malarial and
typhoid cases. It is variable in gallstones, faint in pernicious
anemia, cardiac disease and nephritis ; negative in dry and
serous pleurisy, simple bronchitis, articular rheumatism, chlo-
rosis tuberculosis and extrauterine pregnancy. The glycogen
reaction when taken alone furnishes only a little aid, but when
combined with the report of temperature, leukocyte count,
signs and symptoms, enables us to draw much more definite
conclusions. The brown granules and extracellular masses
point to some degenerative process in the white cells from tox-
emia. We expect and find a marked reaction in those cases in
which the toxemia is so severe as to overcome the power of the
system to produce a leukocytosis. It is a more constant and
reliable indication of the severity of an infection than either the
v/hite count or temperature, [h.m.]
3.— Conditions of the Newborn Requiring Orthopedic
Treatment. — Painter enumerates congenital club-foot, in which
treatment should begin as soon as nursing is well established
and the child begins to grow ; flat-foot, which is rare and never
requires care until walking begins ; congenital dislocation of
the hip, which is not usually recognized until walking begins
and generally yields to a bloodless reduction, the treatment
commencing the latter part of the second year ; hematoma of
the sternomastoid, which is not due to syphilis and needs little
but manual correction ; spastic paraplegia, which requires
systematic rubbing, stretching, etc., continued through the
entire growing period ; obstetric paralysis, the result of an in-
jury to the brachial plexus ; and congenital absence of the tibia
or femur. Other deformities, as cleft palate, hare-lip, etc., fall
within the province of the general surgeon rather than the
orthopedisl. [w.k.]
4.— Cirrhosis of the liiver in Childhood.— The symptoms
are the same as in adults. It occurs in about 1 in 20,000 hospital
cases and most commonly between 9 and 12. The forms due to
obliteration of the bile ducts, syphilis and the one seen in India
are peculiar to infancy. Enlargement is more common than
September 20, 19021
THE WORLD'S LATEST LITERATURE
[American Medicine 471
diminution in size, perhaps because children die in an early
stage. Congenital syphilis is the most frequent cause in infancy.
Alcohol is responsible for 10% to 259'c. Fermentation and the
products of bacterial growth are more harmful than in adult
life. The eruptive fevers are said to play an important role, but
it is not proper to consider them a cause when so many thou-
sands of cases are not followed by this disease. Tuberculous
cirrhosis may be due to the toxins or there may be a miliary
tuberculosis of the liver as well. Cardiac cirrhosis may be
partly from infection of enteric origin. Morse describes the
disease as seen in India and the syphilitic form. In that due to
obstruction of the bile ducts no patient has lived longer than
eight months. The liver is usually but not always enlarged.
The etiology is obscure. The lesions point to a chronic inflam-
matory process. Irritant substances may pass through the pla-
centa to the fetus. The cholangitis is probably primary,
descending to the ducts. Points favoring this view are the
constant occurrence of cirrhosis with the obstruction, the large
size of the liver and the enlargement of the spleen, rare in
adults. [H.M.]
Medical Record.
September IS, 190?. [Vol. 62, No. 11.]
1. The Surgical Treatment of Chronic Bright's Disease. J . A. SCHMITT.
2. What Shall We Do with Our Consumptive Poor? Being a Discussion
of Dr. Knoprs Paper. Alfred Meyer.
3. The Primary Treatment of Ilailway Injuries. J. N. Baker.
4. A Further Contribution to Our Knowledge of Electric Ozonation as
a Remedial Agent, Especially in the Treatment of Tuberculosis.
G. Lenox Cuktis.
5. Two Unusual Complications Following Cataract Extraction: (1)
Death After Cataract Extraction from Diabetes; (2) Delirium
Tremens Following Extraction of Cataract. Thomas K. Pooley.
ti. Sanitary Protection for Rural Districts. Harvey B. Bashore.
7. Hyd rotherapeutics in Gastrointestinal Diseases. George Mann-
HEIMER.
1. — Surgical Treatment of Chronic Bright's Disease. —
Schmitt reviews the literature on this subject and then calls
attention to the essential features of the disease in its two prin-
cipal types. He is exceedingly skeptical regarding the benefit
of operation upon a kidney that is the seat of such disease, even
if diagnosis be correctly made by ocular and digital examina-
tion at time of operation. It is only to a certain extent that
the various types of the disease can be differentiated by such
examination which has only a positive diagnostic value. To
declare a kidney healthy because of the absence of any gross
alterations on the surface is not permissible. Schmitt concludes
that in acute infectious diseases anuria with uremic symptoms
can be successfully combated by capsular incison or renal
cleavage. Temporary relief from anuria with uremic symp-
toms occurring in the course of chronic Bright's disease has
been gained in some instances, but a permanent cure has never
been effected. When the kidney has ijeen operated upon directly
for the cure of chronic Bright's disease the result Jias been a
failure. Colicky pains and hematuria caused by chronic Bright's
disease have been greatly relieved by capsular incision or
cleavage, but the progress of the disease has not been inhibited.
Nephropexy may cure the ailments incident to movable kidney,
but if the movable kidney is affected by chronic Bright's dis-
ease, that affection will remain uninfluenced by operation,
[a.o.e.]
2.— Our Consumptive Poor. — Meyer emphasizes the view
that a large proportion of cures may be effected without banish-
ment of the patient to a long distance from home. He holds
that each community may solve its own tuberculosis problem
as follows : Institutions for curable patients should be estab-
lished not far from the city, and for incurable patients within
the city limits ; a series of wards should be established in city
hospitals as a clearing-house for doubtful cases; financial aid
to the families of patients should be avoided in order to
encourage early treatment. He dwells on tlie advantage of
establishing farm gardens and dairies in connection with sana-
toriums and gives the results of the experiment at the Bedford
Sanitarium, [h.m.]
3.— Primary Treatment of Railway Injuries.— Shock is
a state of general depression, retlexly produced by damage
(tone the peripheral nerves and with symptoms referable in the
main to vasomotor paralysis. In treatment energy should be
directed toward arousing the nervous system both centrally
and peripherally. Centrally this can be done by strychnin,
nitroglycerin, whisky, ammonia, morphin, or atropin, prefer-
ably the last two combined. Peripherally heat is indicated.
Intravenous saline infusions act in both ways. Baker gives
the technic of administration. The amount varies with the
condition; the time required is a half hour or longer; temper-
ature 108° to 110° P. So soon as reaction is established surgical
interference should take place. If there is mangling of the
tissues and crushing of the bones removal of the limb is the
only procedure, and the sooner done the greater the chances of
recovery. The importance of a plantar flap when the foot and a
palmar flap when the hand is involved is emphasized ; also the
necessity in operations on the leg and arm to go sufficiently
high to get flaps that will ensure primary union, [h.m.]
4.— Electric Ozonation in Tuberculosis.— Curtis briefly
reviews the modus operandi of the generation and administra-
tion of nascent ozone. The cabinet in which the patient is
treated is permeated with nascent ozone while he is exposed to
electric light and heat rays and thrown in a profuse perspira-
tion. After 20 or 30 minutes he is subjected to a shower bath
and massaged with the electrode. Ozone is carried into the
body by inhalation and forced into localized areas by the
Geissler vacuum tube and generator, thus ozonizing all the
tissues beneath the chosen locality. When the electrode reaches
a congested or Inflamed area pain is instantly felt, illustrating
its diagnostic value. As improvement occurs the strength of
the current can be increased. From two to six weeks' treat-
ment is required. While local conditions are yielding the gen-
eral nutrition is established. Tuberculous matter in the blood
disappears under its oxidizing influence, the disintegration
and absorption being hastened by acidulation by means of acid
drinks and inhalations. It is doubtless true that electric ozoni-
zation modifies the alkalinity of the morbid materials and
breaks down alkaline deposits. In addition to the foregoing, it
is important to disinfect the mouth and nares with electrozone
or hydrogen dioxid and the wearing apparel with ozone or
formaldehyd. [h.m.]
6.— Sanitary Protection for Rural Districts.- In dis-
cussing the subject Bashore argues that if the city expects to be
safe the country must be protected, since travel brings both into
intimate connection. The cities and towns take care of them-
selves fairly well, but the administration in the outlying dis-
tricts is varied and inadequate. Some States have county boards,
some township boards and some none at all. Half the country
does not understand the advisability of paying out sufficient
money for sanitary protection. The right men are not selected
because sufficient remuneration and dignity are not attached to
the office. In England the pay is twice as great and the sani-
tary protection is better than in any other country. A single
county health officer is the ideal method and he should be a
sanitarian appointed by the State Board of Health and com-
pelled to report to it. The township officer might be a layman
acting simply as a sanitary policeman under the county officer.
Adequate pay would add little to the burden of taxation, [h.m.]
7.— Hydrotherapeutics in Gastrointestinal Disease. —
Lavage and douching are the most important procedures.
Mannheimer reviews the various Indications for these and dis-
cusses also the external use of water in gastrointestinal di.sease.
His best results have been achieved by combining hygienic,
dietetic and medicinal treatment with hydrotherapy, [h.m.]
New York Medical Journal.
September 6, 190t. [Vol. lxxvi, No. 10.]
1. A Contribution to the DllTcrcntial Diagnosis of Appendicitis. Ed-
ward Stakiilin.
2. A Review of Forty-eight Cases of Postoperative Crural Thrombosis.
Ben.iamin R. Schknck.
3. Clinical Contribution to the Study of Empyema of the Frontal and
Ethmoidal Sinuses Complicated by Eye Disease. Max Toeplitz.
4. The Age of Consent. ISADORK Dyer.
5. The Use of Electricity In the Treatment of Habitual Conetipatlon.
SlOISMUND COHN.
6. New Mexico as a Health Resort. H. B. Masten.
7. Clinical Notes on Cardiac Diseases. .Stanley 8. Cornell.
1.— Appendicitis.- Staehlin reports several cases In which
the diagnosis was involved. The first is i^ case of multiple
neuritis, probably alcoholic, in which the diagnosis of appen-
dicitis had been made. The second case was thought to be
472 AKKBIOAjr Mkdicikkj
THE WORLD'S LATEST LITERATURE
[BEPTEMBEB 20, 1U02
typical of chronic catarrhal appendicitis. Upon opening: the
abdomen no adhesions were found and merely a scar at the
union ol the lateral strice. A small ovarian cyst on the right
side was removed and perfect recovery followed. In this case
the writer believes that during the attack of appendicitis an
abscess discharge<l through the gut and so led to a spontaneous
cure. The third case had been repeatedly diagnosticated as
appendicitis, but proved to be one of floating kidney on the
right side. In another case reported the diagnosis of pancrea-
titis with probable fat necrosis was favored. Later there was
marked tenderness and an exudate in the right side. Complete
recovery followed the removal of a diseased appendix. Two
especially interesting cases are reported because of their strik-
ing points of similarity and dissimilarity. Each was a primary
attack of appendicitis of a very acute and virulent type ; each
was followed very rapidly by a general septic peritonitis ; so
rapid was the development of peritonitis that a diagnosis of
gangrenous appendix was justified in each case, and yet neither
case showed a perforation. They differed, however, typically
in the progress of the infection ; one was a typical pyemia with
moderately high temperature and a strong bounding pulse, and
the patient, wildly delirious, died a maniac. The other was a
typical septicemia, with a small, thready pulse and high tem-
perature, and the patient died perfectly conscious. [c.A.c]
2. — Postoperative Crural Thrombosis. — Schenck gives a
clinical report of 48 cases of postoperative crural thrombosis.
Twenty-eight cases followed operations for the removal of large
pelvic tumors. In 10 cases the right leg alone was affected, and
in two there was well-marked thrombosis in both extremities.
In practically all the cases the patients were doing well and an
uninterrupted convalescence was expected, when suddenly
pain in the left thigh or leg was complained of and there was
an accompanying rise of temperature. The date of onset was
remarkably constant. The earliest was on the sixth and the
latest on the twenty-second day after the operation, while in 25
it was between the twelfth and the sixteenth, and in all but four
after the tenth day. Pain of a dull, throbbing character, some-
times in the thigh, but often in the calf of the leg or popliteal
space, and marked tenderness along the line of the larger veins
are noted in all the cases. Albumin occurred in the urine in
20 cases. The condition rarely follows extrapelvic operations
and in this series it was infrequent after infected cases. The
anemia and cachexia in consequence of newgrowths seem to
be factors in its causation. Traumatism at the time of opera-
tion should be borne in mind and deep retractors used with
extreme care. The results of rest and elevation for the full
length of time are excellent. When the time is lessened, swell-
ing and pain persist, and the danger of pulmonary embolus is
increased, [c.a.c]
3.— Frontal Empyema.— Toeplitz reports a case of empy-
ema of the frontal and ethmoidal sinuses complicated by eye
disease in a man of 48. The points of interest in the case are :
The course of the affection with its acute beginning and acute
exacerbation at the end, and a latent interval of four years
between the two attacks ; the formulation of the indications for
the intranasal and external operation respectively ; the occur-
rence of the eye complication Immediately after the intranasal
operation of curetlng and its diagnosis and treatment ; and
finally, the complete recovery. [c.A.o.]
4. — The Age of Consent. — In the common acceptance of
this term is understood that age at which consent to sexual
intercourse precludes a felony, to wit, charges of abduction,
seduction, etc. Dyer's argument is directed to the study of the
question concerning the age of consent as they bear upon the
physical being and their relation to questions of social impor-
tance and criminal acts. There is a wide variance of opinion, as
evidenced in the diversity of ages which the several States indi-
cate. The age varies between 10 years (in Alabama and North
Carolina) and 17 years (Florida). The writer believes this age
should be raised to a point of years where some actual discre-
tion may obtain ; that the laws of every State should restrict
marriage to those of sane mind and body, and that in both these
attributes the law should fix the period of ripeness in age. He
believes the age of consent should be raised to the age of
majority, and that the law should be directed promptly at
infractions of it. [o.A.c]
6.— Electricity in Treatment of Habitnal Conrtipatton.
— Cohn prefers to start the treatment of this condition with
static electricity, either in the form of the wave current or of the
static induced current; the first in the milder forms of consti-
pation, the latter in the very obstinate cases of long standing.
He has also found the sinusoidal current very effective. The
treatment is given daily, until improvement is noticed, then he
gradually leaves larger intervals between the treatments, and
lets the patient begin with gymnastics, paying special attention
to exercises of the abdominal nmscles. Of the 16 cases the
author has had under treatment, 9 were successfully treated, 3
showed negative results, and in 4, though the patients are
improving, treatment has not advanced enough to justify con-
clusions. He believes that the reduction of the abdominal cir-
cumference by the use of these currents is a proof of their tonic
influence upon the abdominal muscles, and that the most pow-
erful means of obtaining this tonic condition is the administra-
tion of the swelling or undulating current. [c.A.c]
6.— New Mexico as a Health Resort.— Masten points out
some of the advantages of that territory as a health resort.
Besides lung troubles the diseases for which he believes that
climate is particularly adapted are neurasthenia, gastrointes-
tinal disorders of all kinds, acute and chronic catarrhal
troubles, hay-fever and rheumatism. Except in a few places
along the rivers, malaria is unknown. The altitude in the
northern part is too great for advanced cases, but is of the
greatest advantage to incipient cases. Patients going to that
region should be sent to one of the numerous sanatoriums, at
least for a few months, for there only will proper care and diet
be provided. [c.A.c]
Medical Views.
September IS, 190$. [Vol. 81, No. 11.]
1. Empyema In Infants and Children : Its Frequency, Etiology, Symp-
tomatology and Prognosis. Henry Koplik.
2. Surgical Treatment of Empyema : A Report Based on 75 Cases, Ob-
served Chiefly in St. Mary's Hospital for Children. Charles
N. Down.
3. Pathology of Empyema. David Bovaird, Jr.
4. BroDchlectotlc Abscess of the Lung, with the Report of a Case Treated
Surgically with Success. C. R. L. Putnam.
h. A Case of Hepatic Abscess. FJmma W. Dumaree.
8. The Use of Simple Microscopic Methods by the General Practitioner.
Robert L. Pitfield.
1.— Empyema in Infants and Children.— Clinically it is
not possible to differentiate sharply the symptoms of pleurisy
with effusion from those of empyema. Of the cases, 40% are
purulent. Empyema follows some acute affection of the lung
in 95% of cases ; in 69 of Koplik's cases it was a pneumonia pure
and simple. The nature of the effusion varies. The disease is
marked by the symptoms of the main causal affection. The
physical signs must be taken into careful consideration in diag-
nosis. Kopllk shows how these differ from those found in the
adult. No diagnosis is complete without explorating puncture.
This should be made with the patient upright. The prognosis
of the metapulmonic form is good, especially if we can interfere
surgically at the right moment. Each patient should receive
due consideration as to the nature of the operative procedure to
be followed, whether incision or resection. Most patients in
whom there is a complicating secondary bronchopneumonia do
not recover. In tuberculous forms the outlook is better than
in adults, [h.m.]
2.— Surgical Treatment of Empyema.— Dowd reports
75 cases of empyema, 73 of the patients being between 2 and 15
years of age, and divides them into three clinical groups : (1)
Simple empyema, recovery conaing within three months or less;
(2) protracted empyema, recovery being delayed more than
three months ; (3) fatal cases. Treatment of each of these
groups is discussed. The patients in some cases of simple
empyema will recover after aspiration or simple incision, but
the best results are obtained by resection of a rib and free
drainage. This should be the routine treatment. Of the
reported cases 40 belonged to this group. In the second group
there were 24 cases, the principle of treatment being the clos-
ing of the cavity by causing contraction of the chest wall or
expansion of the lung. Fowler's method, dissecting the
thickened pleura from the lung, was used in four cases, two
resulting in cure. Dowd commends this method, but says it
cannot be expected to cure all patients in whom discharge from a
September 20, 1902)
THE WORLD'S LATEST LITERATURE
[American Medicine 473
tuberculous focus causes a persistent sinus. In the tliird group
were 11 cases. Tliree were definitely tuberculous, two probably
so. In one patient aspirated the pus contained pneumococci.
Thickened pleura, whicii was later excised, contained no evi-
dence of tuberculosis. Autopsy six mouths after operation
revealed miliary tubercles in both lungs. The ultimate results
in the entire series of cases are most encouraging. Examina-
tion of 44 of the patients at long periods after operation indi-
cates that recovery is usually complete in the simple cases and
that there is surprisingly little deformity in most of the severe
cases, [a.o.e.]
3. — Pathology of Empyema.— This study is based on 101
fatal cases— 24 were bilateral, 6 tuberculous. The effusion varied
with the proportion of serum, fibrin and pus. It is regularly
odorless. It is usually found posteriorly and may be free or
shut in by adhesions. Bovaird has not known it to perforate.
The lungs were compressed in 35 patients, consolidated in 56.
The consolidation was lobar in 10, bronchial in 27, indefinite in
14, associated with tuberculous lesions in 4, associated with
small abscesses in (i, and witli gangrene in 5. Association with
bronchopneumonia as compared with adults is striking. The
pulmonary consolidation is as a rule probably primary. The
associated lesions apart from those of the lung are acute inflam-
mations, as pericarditis, meningitis or peritonitis. The
majority of cases are due to the pneumococcus. This is regu-
larly associated with the thick, creamy exudate. When the
exudate is thinner the streptococcus or staphylococcus is found.
Primary tuberculosis of the pleura is rare in children. The
writer emphasizes the frequency of empyema in children, the
number of bilateral cases, the Impossibility of drawing sharp
distinction between serofibrinous pleurisy and empyema, the
creamy consistency of the exudate in many cases, the frequency
of sacculated effusions and of pneumonia, especially broncho-
pneumonia, as a preceding or accompanying lesion, and the
small percentage of tuberculous cases, [h.m.]
*•- Surgical Treatment of Bronchiectatic Abscess of
the linnR.- Putnam states that it is with infected saccular
bronchiectatic cavities that surgery has to deal and gives points
in the differential diagnosis of that condition from tuberculous
cavities, lung abscess, gangrene of the lung, actinomycosis and
hydatid cysts. Regarding the value of the x-ray for localizing
various lesions in the lung Putnam reports that in 11 cases
observed by himself and others, it was positively helpful in 6,
doubtful in 2 and negative in 3. The case reported by Putnam
is that of a child of 3, the expectorated pus having had a hor-
ribly foul odor for more than a year. Operation was performed
in three stages, the cavity being opened by the thermocautery.
Recoverj- was rapid and there is now no odor to the sputum,
though coarse rales still indicate the existence of general bron-
chiectasis. [A.O.K.]
5. — Ca«e of Hepatic Abscess. — Demaree reports a case of
hepatic abscess developing in a puerperal woman. Ten days
after delivery it first produced symptoms of pain in the right
side, rise in temperature and pulse, general malaise, tenderness
in the region of the liver, interference with respiration on the
right side and a troublesome cough. There was no swelling or
appearance of tumor, but the existence of pus was evident. As
even an exploratory puncture was refused, treatment was
directed to securing elimination and sustaining the patient.
Three days later there was a decided improvement, during the
night a considerable quantity of bloody pus had been passed
by the bowel. This continued some days, the pus containing
bloodflecked masses looking like microtomic sections of the
liver in a state of cloudy swelling. Then black sand began to
pass in large quantities. The abscess had evidently ruptured
Into the l)owel and soon temperature and pulse became normal.
At intervals of a few weeks there were two or throe recurrences
of these attacks beginning with a chill, but they eventually
ceased. During the height of the septic condition there was
almost complete suppression of milk, but at the end of three
months th(? supply had returned and artificial food was no
longer needed for the infant. The question arises. Were preg-
nancy and the puerperal state etiologic factors in producing the
pus and sand? Since Osier states that three-quarters of the cases
of gallstones occur in women, and quotes Naunyu as saying that
90fc of women with gallstones have borne children, it seems
highly probable that pregnancy may be an important causative
factor, and that it was such in the case reported. [w.K.]
Philadelphia Medical Journal.
September IS, 190S. [Vol. X, No. 11.]
1. Tumor of the Pharynx; an Accessory Thyroid Qland. Removal
Followed by Myxedema. B. L. Bhukly.
2. Note of a Case In which the Time Required by an Inappropriate
Food to Produce Scorbutic Symptoms was Accurately >oted.
D. J. Milton Miller.
3. Spinal Anesthesia, with Report of Cases. O. O. Coni>ER.
4. How to Recognize Tuberculous Changes in the Apices of the Longs
on Percussion. Hknky E. Stadlinger.
5. A Case of Puerperal Neuritis. Charles J. Aldrich.
1. — See American Medicine, Vol. Ill, No. 23, p. 948.
2.— Time Required by an Inappropriate Food to Pro-
duce Scorbutic Symptoms.— Miller details the case of a
female child of 3J months in whom the scorbutic symptoms
developed exactly eight weeks after commencing the use of
condensed milk. This is of value from a prophylactic point of
view, since it demonstrates how very soon scurvy may develop
when a baby is being temporarily fed on condensed, preserved
or proprietary foods, putting one on guard for the first symp-
toms of its appearance, [f.c.h.]
3.— Spinal Anesthesia.- Cooper reports three cases. He
believes that spinal anesthesia rightly used is a good procedure,
but it should not be used without some special indication and
employed only in selected cases. L^'-c.H.]
4.— KecoKnitlon of Tuberculous Changes In the
Apices of the liungs on Percussion.— Stadlinger calls atten-
tion to the Importance of this method in order to recognize
apical infiltrations before the tubercle bacillus is found, or even
before the elastic tissues appear in the sputum. He believes
that an earlier diagnosis can be made by this method than by
the ordinary one of percussion by comparison, [f.c.h.]
5.— Puerperal Neuritis.- Aldrich details the case of a
Bohemian of 27 in whom the diagnosis of puerperal neuritis,
paraplegic in distribution and ataxic in type, seems fully war-
ranted, [f.c.h.]
CLINICAL MEDICINE
David Riesman A. O. J. Kelly
Idiopathic Hematuria. — In addition to the usual
cases of hematuria in which upon investigation the
blood in the urine is referable to some distinct tliseased
condition, there occurs a class of csises in which the
cause of the hemorrhage is altogether unknown and un-
determinable. Although the subject is scarcely even
referred to in the textbooks on medicine— Tyson's book,
however, being a notable exception to this rule — it is
likely that the cases which, in the absence of knowledge
of the cause of the hemorrhage, have come to be known as
cases of "idiopathic hematuria" are by no means ex-
tremely rare. To the literature of the subject Graham
recently has contributed some interesting observations
(Lancet, May 3, 1902). He describes what he terms " idio-
pathic or congenital hereditary and family hematuria," a
condition that affected 15 persons — two brothers and two
sisters and eight children of the two sisters. Another
sister of the first generation and two other children of
the two affected sisters remained unaffected. The char-
acteristics of this idopathic hematuria are thus summar-
izetl by Graham : (1) It is hereditary, familial and con-
genital ; (2) the hematuria may be persistent for many
years, but it may vary in extent, in some cases it may
cease for a time, but in all it is apt to recur or to in-
crease in paroxysmal attacks or exacerbations ; (li) the
paroxysmal exacerbations are usually accompanied by
slight pyrexia, malaise, headache, vomiting and slight
pains in the back or limbs, they are often attributed to
catching cold, and they are associated with slight bron-
chial catarrh or with trivial ailments, such as toothache,
earache or tonsillitis. In some cases articles of diet-
such as black currants, asparagus, strawberries, claret,
and [K'rhaps rhubarb— have been held to produce them,
but the exacerbation may occur without complications
474 AUBBIOAN MbDICIKBI
THE WORLD'S LATEST LITER AT OEE
[Septeubeb 20, 1902
and in the absence of special causes. The duration
of these exacerbations is usually several days but
seldom exceeds a week or at most two weelcs, and
after the first few days the blood lessens in amount.
There is no law of periodicity or of frequency ; they may
occur at intervals of weeks, months or years, but they
appear to become less frequent after the first decade has
been passed. They occur with extreme suddenness by
day or by night and they are not influenced by posture.
Extremes of hot or cold weather seem to give rise
to them ; (4) idiopathic hematuria is not associated with
edema nor with ascites nor with the cardiovascular
changes following ordinary nephritis. Except at times
when exacerbations occur the subjects appear to be, and
are, in perfect health, though there may be temporary,
but not profound, anemia after an exacerbation ; (5) the
hemorrhage is not due to the presence of uric acid or of
oxalates ; (6) the urine is acid in reaction, normal in
amount, and its specific gravity is from 1,015 to 1,030.
It is nearly always albuminous, and the sediment con-
tains erythrocytes, blood-casts, but never hyaline casts ;
and (7) none of the subjects of idiopathic hematuria
is a "bleeder." The only drug that seemed to have
efflcaey in cutting short an attack was suprarenal extract.
Reference is made to several similar cases reported by
Attlee (M. Bartholomew's Hospital Journal, December,
1901), which are believed to be of similar nature. It is
stated that inasmuch as the hematuria is congenital, or
at all events occurs shortly after birth, all the ordinary
or known causes of hemorrhage may be excluded. The
most reasonable explanation is that there is some inherent
weakness or varicosity of the walls of the renal vessels
leading to what m^y be called renal hemophilia or renal
epistaxis, or the vasomotor system may be at fault
(angioneurosis), in which case the complaint might be
grouped with cyclic or postural albuminuria. But the
hematuria, however, is in no sense postural. The
probability of the correctness of the view that the
condition is due to varicosity or some inherent weakness
of the renal bloodvessels is indicated by the fact that
Fen wick (British Medical Journal, i, 248, 1900) has found
varicosity of the papillary plexus in cases of painless
unilateral hematuria in young adults, and has cured
them by papillectomy, as well as by the observations of
Suter (Omtraldtalt fiir die Krankfieiten der Ham- und
Semial-Orgam, xiii, 1, 1902), who reports a case of
unilateral hematuria due to telangiectasis of the pelvis
of the kidney.
Rickets and Sterilized Blilk.—Ausset' considers chronic
gastroenteritis a predisposing cause of rickets. Milli is not the
direct cause of this gastroenteritis, but the abuse of it, whether
it be sterilized or come from a wet nurse. Of 682 infants
observed, 456 had been nourished from the bottle, and among
these 349, who had been fed on sterilized milk or broths, were
rachitic. Sixty-one had been given thoroughly sterilized milk
but at no fixed interval. Forty-six who had been fed on similar
sterilized milk, but with all the necessary precautions, pre-
sented no sign of rickets. Of 167 infants nourished from the
breast, 19 were rachitic, these had been nourished only from the
breast, but at no fixed interval. It is therefore the careless
manner of administering milk which causes rickets. More
cases of rickets are seen with sterilized milk because the rules
of hygiene are more easily broken, [l.f.a.]
Extirpation of the Hypophysis and Transplantation of
Cancer Tissue and Thyroid Gland in the Hypophysis.—
Friedmann ^ instituted a series of experiments on cats to deter-
mine whether the removal of the hypophysis would affect other
organs in the body. He extirpated the hypophysis in cats
which, when killed at varying periods of time, showed absence
of the hypophysis, complete ossification of the bone defect at
the base of the skull, a normal thyroid gland and bony skele-
ton. He performed further experiments to determiue whether
an extirpated hypophysis would lead to retardation of develop-
■ Journal Medical de BruxeUes, No. 27, July 3, 1902, p. 430.
» Berliner kllnlsche Wochenschrift, May 12, 1902.
ment. He found that that organ is not necessary for bodily
development. Friedmann also transplanted in the hypophysis
pieces of cartcerous tissue and also of thyroid gland, and with
one exception got but unsatisfactory results. In one case a
small growth, carcinomatous in nature, was found in the men-
inges. [W.E.R.]
Concerning Narcolepsy. — Narcolepsy was first raised to
the rank of a clinical entity by G61ineau in 1880 ; but, owing to
a misunderstanding of that author's paper, there has been much
difference of opinion as to whether the condition is a distinct
entity or not. Loewenfeld,' in reporting a case of narcolepsy,
cites Gfilineau's original case. His own is as follows : A lad,
17J years of age, attended the Realschule from 1892 to 1898, being
one of the best scholars during the first four years of this
period. After that, both at school and at home, he had a ten-
dency to great drowsiness, after a time eventuating in attacks
of sudden sleep. The attacks recurred at frequent intervals,
five or ten minutes, and would last a few seconds. The patient
left school and entered a machine shop ; but even here, while
engaged in filing, drilling, etc., he would go to sleep. Some-
times this would happen even during meals. At night he slept
well. His memory was slightly impaired; and he had, in
addition, a peculiar nervous disturbance. During laughter he
would be seized with a relaxation of the muscles, so that, if he
were walking at the time, he would stumble and sink together,
and would have to catch hold of objects in order to prevent
falling. If he were holding anything in his hands he would
drop it. There were, then, two principal features in the case —
momentary attacks of sleep and inhibition of the motor or
locomotor functions. The inhibition was connected, to a large
extent, if not exclusively, with certain emotional states. The
results of treatment were not very satisfactory. The author
obtained fairly good results, however, by the use of hypnotism.
He is of the opinion that narcolepsy, in the sense of Gc'lineau,
is a distinct morbid entity, characterized not only by a ten-
dency to sleep, but also by an inhibitory process. The condi-
tion is undoubtedly a neurosis. He attributes the attacks of
sleep to a hyperexcitability of the vasomotor sleep-center, in
consequence of which not alone emotional stimuli, but also
trivial quantities of fatigue-products, which normally are
without effect, act upon this center, [d.r.]
The Problem of Hemiplegia. — Rothmann * gives the
results of his experiments on monkeys. He observed that hemi-
plegia was caused not only by destruction of the pyramidal
tracts, but also by interference with other cerebrospinal paths.
Hemiplegia occurs through disturbance of the leg and arm cen-
ters, or through the total destruction of the posterior areas of the
internal capsule. The route from the corpora quadrigemina and
its associated optic thalamus to the spinal cord remains intact.
It does not immediately take up the function of the pyramidal
tracts, but does send impulses to the cord for the proper main-
tenance of the tendon reflexes. The partial restitution of the
activity of the paralyzed muscles, which occurs in a few weeks,
is not due to return of function in the pyramidal tracts, nor to
the substitution of the other half of the cortex. On the con-
trary, it is caused by the gradual development of the inde-
pendent motor function of the optic thalamus and the corpora
quadrigemina. The return of activity in certain groups of
muscles and the continuance of paralysis in other groups
accounts for contractures. Rothmann says this does occur in
man and not in the monkey, because of the upright station in
the former and the consequent peculiar muscle enervation in
the legs and arms. In conclusion he advises against expecting
the recurrence of function in the old motor paths, but to look
for activity in new paths. In regard to the therapeutics of
hemiplegia Rothmann encourages immediate practising of
exercise for the paralyzed parts, [w.b.b.]
Contagiosity of Lieprosy.— Dr. Manuel P. Alfonso' main-
tains that Bacillus leprosus loses its virulence in contact with
the air, a theory which he bases on the actual history of the dis-
ease in the Hospital of San Lftzaro in Havana and on the au-
thority of Gorgas and Vild6sola, of Havana ; Hutchinson, of
London, and Ducrey, of Italy. He refers also to the experience
' Mttnchenermed. Woch., June 24, 1902.
'Berliner kllnlsche Wochenschrift, April 28 and May 5, 1902.
'' Revlsta M6dlca Cubana, July 15, 1902.
September 20. 1902]
THE WORLD'S LATEST LITERATURE
[Amebicai; Medicine 475
of Rafael Lucio, who for eight years has had charge of the
Leprosy Hospital of the City of Mexico, with 41 patients, and
to his associate, Alvarado, whose investigations are opposed to
the mediate or immediate contagiosity of the disease. He refers
also to the failure of the inoculation practised by Gallardo, of
Mexico, by Lucio and by Danielzen, and he regards the case of
the condemned criminal of Hawaii, who was inoculated in 1884,
as inconclusive, and concludes that the bacillus of leprosy is
normally saphrophytic, and that only under peculiar and
unknown conditions does it become virulent, [c.s.d.]
A. B. CRAia
GENERAL. SURGERT
Martin B. Tinker
C. A. Orb
Operations for the Radical Cure of Heruia.—
Fifteen years ago very few surgeons could be found who
would recommend operation for tiie radical cure of hernia
except in cases of strangulation or of incarcerated hernia
which were giving rise to dangerous or disagreeable
.symptoms. With perfected modern methods of anti-
septic technic the operation has become rapidly more
popular, and in many hospitals all patients coming for
consultation with hernias of whatever sort are advised
to undergo an operation. While this is, we believe, the
standpoint taken by leading surgeons of the best hos-
pitals in this country, the fact that standard textbooks
are still found in which the use of trusses is described in
detail ; and, indeed, that some lx)oks have been written
especially on the subject of hernia in which trusses are
given a prominent place, indicates that even at present
the operation is not generally accepted as necessary or
even advisable in ordinary cases of hernia.
From time to time various writers have published
their late results in extensive series of operations. One
of the latest and largest series which we have noticed is
that reported from Hochenegg's Clinic, in Vienna, by
Goldner,' who reports the results in 800 cases operated
upon from two to six and a half years previously by
Bassini's method. In this country Bloodgood reported
results of operations in 459 cases in the Johns Hopkins
Jlosjntal Jitports, 1899, Vol. vii, and Coley and others
have also given more or less careful reports of the after
results in large series of cases. As to the results of
modern operations Bloodgood states from the experience
of over nine years that the probabilities of death are
less than I fc , and the chances of suppuration in cases in
which rubber gloves are worn and silver wire is used as
a suture material less than 1 fc . The likelihood of recur-
rence in inguinal hernia in which the muscles are not
too widely separated to be included in the suture is less
than 4 fo ; while in less favorable cases the chances of
recurrence may be as great as 20%, The separation of
cases into groups, of those in which recurrence is more
likely and those in which recurrence is probable, seems
imperative ; for it would be unfair to represent to a
patient with a weak abdominal wall that the prospects
of recurrence are only 4%, while to a patient with a
strong abdominal wall the chances of recovery may be
safely said to be even better than this. Goldner, taking
all his cases together, reports 7.5^ of recurrences, which
is, perhai)S, about the average, taking favorable and
unfavorable cases together, even in the hands of skilful
operators. In advi.sing a i)atient to undergo an opera-
tion and in stating a likely prognosis, the factors causing
recurrence should be kept in mind. Suppuration of the
wound has be<'n a great bugtear with many surgeons, but
with the latest improved methods it .should certainly not
l)e a great factor in giving rise to recurrence. All who
are honest cannot deny that suppuration does occa-
.sionally occur. Macewen reported suppuration in 17/o
of his cases; Wolfer, in 14% of his ca.ses ; Franz, 18%
from von p]iselberg's clinic; Kocher, 6.8% in oper-
ations by his latest method ; and Bloodgood, 4%, which
I Arehlv f. kllnlHcbe Chlrurgie, 1802, Vol. l7vlll, p. 1.
has been reduced to le&s than 1 % since the introduction
of rubber gloves and silver wire as a suture material.
Operators who claim better results than those of these
wellknown operators probably are not careful in obser-
vation of cases after operation, or else their ideas as to
what constitutes an infection differ widely from those of
the surgeons whose percentages of wound infection have
been mentioned. Goldner does not find suppuration as
important a cause of recurrence as many writers have
believed. In 35 cases of recurrence there was a greater
or less degree of suppuration in 10 cases, while in the re-
maining 25 the healing was absolutely undisturbed.
There is still a great divergence of opinion as to the most
desirable suture material. Many prefer catgut, others
using kangaroo tendon, silk or silver wire. A large
number of modern writers, Goldner among others, have
noted improvements in results after giving up the use of
catgut as a suture material. Undoubtedly the best re-
sults reported, so far as suppuration goes, follow the
use of silver wire. Another factor beside suppuration
which is of great importance in the consideration of the
likelihood of recurrences is the natural strength of the
abdominal wall. Bloodgood and Macewen have both
emphasized the importance of a wide and firm conjoined
tendon. If this be present practically no recurrences
should follow at the lower angle of the wound. The
size of the veins of the cord is also a factor of great im-
portance. If the cord be transplanted according to Bas-
sini's method, or the old Halsted method, enlarged
veins frequently give rise to recurrences at the outer
angle of the wound. This likelihood can be much re-
duced by excising the veins, but excision of the veins is
attended with some danger of atrophy of the testicle, and
consequently is not considered justifiable by many oper-
ators. In the case of a bad hernia, it would seem that
the importance of excision of the veins in radical
cure should be presented to the patient and he should be
allowed his choice whether they be excised or not. The
occupation of the patient after operation is a factor who.se
importance cannot be overlooked or underestimated.
The chances of recurrence must certainly be much
greater among men who are engaged in laborious occu-
pations in which they do much heavy lifting.
As to choice of operation a number of methods have
very ardent advocates at present. Probably more men
are following Bassini's method more or less closely than
any other, but many Americans prefer the Halsted
method, which has certainly given a greater percentage
of permanent cures in the hospital in which it originated
than has any other operation. American surgeons
should take a certain amount of pride in the fact that
Halsted was the pioneer in the operation for the radical
cure of inguinal hernia, his first paper appearing in Vol-
ume I of the Johns Hopkins Hosqntal Bulletin, in Decem-
ber, 1889 ; while Bassini's first publication did not appear
until some month later.' Macewen's operation is warmly
recommended by certain surgeons, as is also the opera-
tion devised by Kocher, but in this country the opera-
tions of Halsted and Bassini are undoubtedly in most
general use. Probably any of the modern methods of
operation, in the hands of skilful operators and in favor-
able cases, will be followed by very satisfactory results.
It should be remembered, however, that the operation
for the radical cure of hernia is not an emergency opera-
tion and would best be left to surgeons of considerable
experience. Even with as high as 7% of recmrrences an
operation which is practically without any direct mor-
tality could well he recommendetl to any patient suffer-
ing from hernia, for aside from the danger of strangula-
tion, the inconvenience of wearing a truss for many
years and the interference in work and physical exercise
would be great enough so that most men would be more
than glad to take the slight risk which attends the
operation. At the present time, when local anesthesia is
> Arcblv f. kllnUcbe Cblrurtle, Vol. zl, p. 429.
476 AicaiuoAK MiDioumj
THE WORLD'S LATEST LITERATURE
[8BPTEMBEB 20, 1II02
80 generally used for all operations, the contraindications
of heart disease and affections of the lungs and kidneys
need not be a serious bar to operation. Goldner states
that until 1899 to 1900 nearly all the inguinal hernias at
the Vienna Clinic were done under local anesthesia, the
entire number being over 130 cases. Mikulicz divides
operations into three classes— those in which local anes-
thesia is definitely indicated, those in which general
anesthesia is definitely indicated, and doubtful cases.
He classes hernias in the last group, but uses local anes-
thesia as a rule. This is undoubtedly the experience of
the majority of operators, and a few patients who have
been successfully operated upon under local anesthesia
are the best advocates of the method in a ward among
other patients. We believe that few who examine the
reports of the results of operation from numerous sources
in this country and abroad can doubt the advisability of
operation in practically all cases of inguinal hernia. It
is not an operation to be undertaken by the inexperi-
enced, but with experienced surgeons the percentage of
recurrences is certainly very small, and with some of the
improvements which have been recently introduced there
is every indication that the results will be even better.
Anglotripsy as a Substitute for Ligature in General
Surgery.— Since the advocacy of the use of the angiotrlbe by
Doyen in pelvic work, many gynecologists have adopted it, but
few general surgeons have employed this method. The advan-
tages of the method which Mayer • suggests are that forcible
compression seals the bloodvessels much more expeditiously
than tying and it obviates dangers of infection from imper-
fectly sterilized ligature material and from repeated handling.
Ordinary hemostatic forceps may be used with supplementary
pressure of 1,000 pounds, applied by pressure forceps to the
jaws of the hemostatic forceps. He recommends a special form
of hemostatic forceps, which has a larger and broader snout
than the ordinary forceps. The inner surface of one of the
blades has even steel serrations in the steel, the other blade is
lined with alloy with serrations molded by pressure, so that one
blade fits exactly into the other. He finds that this kind of
fbrceps answers better than those with steel blades, steel upon
steel, as the latter has a tendency to cut through if there is
variation of the surface, and it frequently lacerates the tissues.
The pressure forceps which he used are 32 cm. long with a lock
IJ cm. from the end. They are grooved both in the longitudinal
and transverse direction for convenience in application to the
blades of the hemostatic forceps. By experiments on animals
Mayer finds that the tissues thus treated do not necrose, for the
life of the cells is not destroyed. He has used this method of
hemostatics in such operations as amputation of the breast,
thyroidectomy, excision of glands of the neck and numerous
other operations of general surgery. While large vessels have
been successfully clamped in animals, Mayer does not under-
estimate the danger or responsibility in using this method in
dealing with large vessels in man, and he advises ligature of
the large vessels for safety, [m.b.t.]
Anorectal Actinomycosis.— Theyenot = reports two cases
of this kind, the first occurring in a man 58 years of age, who
entered the hospital with pain and frequency in micturition.
Exploration of the bladder showed that there was no stone nor
any of the other usual causes of urinary trouble. Eight years
previously the man had suffered an injury which had affected
the region between the bladder and the rectum. At the time of
operation a large abscess containing actinomycotic material
was evacuated. The man is still under treatment. In the
second case, a man of S8 entered the hospital with an inflamma-
tory condition at the region of the anus and perineum and with
numerous fistulas. In spite of treatment he died six months
after admission. Thevenot considers the anorectal region spe-
cially favorable for the development of actinomycosis, because
of the large amount of cellular tissue In this region aud
the many possible routes of infection. He believes that
the parasite is frequently introduced directly by some
injury to the mucosa or by direct perforation with foreign
'Annals of Surgery, August, 1902
" Kevue de Chlrurgle, August 10, 1002.
bodies. In many cases the first symptom is diarrhea. Later on
an abscess and fistulas develop. In otlier cases there are signs
of stenosis. As the disease advances the skin of the perineum
becomes extensively infiltrated and perforated ty numerous
fistulas. The disease may then Involve the cavity of the pelvis
and later extend to the bladder, intestine and the peritoneal
cavity. The diagnosis in the later stages of the disease is not
difficult, though in the early stages if the only symptom isdiar>
rhea it may be difficult. The prognosis is particularly grave in
this form of actinomycosis. In 15 cases of which he has knowl-
edge there were seven deaths. In four cases the outcome was
unknown. Only three of the patients were apparently cured,
and one patient is still under treatment. There is not a single
instance of cure of long duration on record. Death usually fol-
lows from prolonged suppuration, which probably causes a
special form of intoxication from the products of the ray fungus.
[m.b.t.]
Transperitoneal Ligation of the Internal Iliac Artery
for Ruptured Aneurysm. —Page 1 relates the case of a man
aged 44 who entered the hospital five weeks after the beginning
of an illness during which he had suflfered severe pain in the
course of the sciatic nerve with tinglings in his toes. One day on
getting down from his coachman's box the patient noticed a
swelling in the right buttock that steadily increased uutil it
extended from the crest of the ilium to below the great
trochanter. It was fluctuating but did not pulsate. The
skin was of dusky color, and near the great trochanter
there was some inflammatory redness. An abscess was
exposed by an exploratory incision which showed nothing
but blood-clot. The possible diagnoses were ruptured aneu-
rysm, simple hematoma of unknown cause, and newgrowth.
The exploratory incision was enlarged and about two pints
of old and recent blood-clot were evacuated. Blood was
then seen coming in spurts from the region of the sciatic notch.
By a lucky grab with hemostatic forceps the vessel was seized,
but in such a position that the bleeding point could not be tied
and in an awkward position for leaving the forceps. Hence it
was decided to tie the internal iliac artery at once. With the
man still lying on his side the abdomen was opened, the perito-
neum incised and a silk ligature was applied. The patient did
well lor the first three days, when he developed a pneumonia
which resulted fatally, [m.b.t.]
GYNECOLOGY AND OBSTETRICS
WiLMER Krusen Frank C. Hammond
Placental Transmission During Typhoid Fever.
— We have previously called attention to the diiHculty
sometimes experienced in differential diagnosis when
the puerperium has been complicated by typhoid fever.
During the past few years, in which the fair municipal-
ity of Philadelphia has been disgraced by typhoid epi-
demics due to impure water-supply, many observers had
the opportunity of studying the effect of this disease upon
the pregnant woman and the fetus. From the time of
the observations of Louis, in 1827, until the present, hosts
of observers have studied this complication with preg-
nancy ; but with the advent of bacteriology it has been of
great interest in connection with the question of placental
transmission. The effect of the prolonged fever upon the
fetus and the frequency of abortion in a large majority of
the cases has been fully recognized ; but in those cases in
which the child is live-born it is important to note the
effect of the maternal typhoid upon it. There are two
possibilities of hereditary transmission of disease.
These are the germinal, in which the infection is directly
associated with the germinal cells and occurs at the time
of conception ; and the placental, in which the organ-
isms causing the disease are transmitted from the mother
to the fetus by means of placental circulation. Germinal
infection has been positively proved in syphilis and pos-
sibly in tuberculosis ; and the placental transmission of
smallpox, scarlet fever, tuberculosis and a few' other dis-
eases has been fully demonstrated. But although pla-
> Lancet, August 16, 1902.
September 20, 1902]
THE WORLD'S LATEST LITERATLTIE
(AMKBICAN MKDICIOT! 477
cental transmission has been proved possible it is by no
meitns a constant feature. Lynch ' has recently made a
thorough investigation of two cases occurring in Johns
Hopkins Hospital.
He has carefully reviewed the reported Investigations con-
cerning placental transmission of typhoid in man ; he has made
a thorough hematologic and bacteriologic study of the two cases
referred to and presents practically the following conclusions :
That the typhoid bacillus may pass from mother to the child m
utero; that the resulting disease is a fetal septicemia; in cases
of placental transmission, there are generally plsicental lesions
of a hemorrhagic type ; that the child dies either in utero or
soon after birth ; and there is no evidence that the fetus may
survive the infection in utero ; placental transmission is not the
rule in typhoid ; the Widal is not always given with fetal blood,
even though placental transmission be proved, and when pr^-
ent it cannot be determined whether the agglutinating sub-
stances result from the presence of the typhoid bacilli or whether
they have filtered through the placenta from the mother's
blood ; the agglutinating substances may be transmitted through
the milk of a typhoid mother to her nursling. The reaction in
the nursling's blood is but transient and is always weaker than
that of the mother's.
Is Craniotomy Ever Justifiable?— Krusen^ believes that
in these days of advanced obstetric surgery embryotomy has a
very limited field, and the satisfactory results secured by
cesarean section and symphysiotomy, or by the induction of
premature labor, have narrowed the field of craniotomy until It
is rarely indicated. The fact that the mortality of the cesarean
operation when performed early, and not as a dernier ressort.
has been reduced to less than 10% and that from 90?^ to 95% of
the children are saved, must influence the choice of procedure.
In the minor forms of dystocia the choice will probably lie
between craniotomy and symphysiotomy, or the induction of
premature labor ; and if the practice of pelvimetry were more
prevalent among all practitioners, the latter procedure would
often render unnecessary the more serious obstetric operations.
Hencehe thinks that in towns and cities with well-equipped
hospitals, with skilled surgeons within call, and with the facili-
ties for performing operations which may save both lives at
hand, craniotomy is never justifiable. But in country practice
where these things are not available the case is very different,
and as the interests of the mother must always take precedence
over those of the unborn child, craniotomy may become the
proper procedure ; for there is little doubt that if cesarean sec-
tion or symphysiotomy were attempted by an untrained physi-
cian with incompetent assistants, two lives instead of one would
almostsurely be sacrificed. As in many other difficult prob-
lems, the decision must be made upon the merits of each indi-
vidual case. [w.K.]
Is There any Keal " Declduoma maliennm " ?— Hubert
Snow ' reviews some of the evidence adduced in regard to these
peculiar growths, and pronounces it very defective. It is
largely based upon the examination of prepared specimens
only, and this method involves numerous errors and must be
stigmatized as vicious and preeminently unscientific, for the
process of preparation in thin sections completely disguises the
shape of the cells as well as other important characteristics. No
microscopic report is valid unless it contains a delineation of
the individual cells in the natural state, in addition to the
account of their distribution in the prepared sections. Experts
in the habit of microscopically examining other forms of malig-
nant tumor state that there is absolutely nothing in the socalled
"plasmodial" cell-masses which cannot be exactly paralleled
liy the sections of any rapidly-growing sarcoma from other
parts of the body. Snow then reviews critically a large num-
ber of cases of socalleil deciduoma malignum reported by dif-
ferent writers, after which he submits that the only conclusions
possible under the circumstances are that the term "deciduoma
malignum" is misleading and unscientific; that, so far, no
valid evidence of the generation of malignant growtlis from the
placental structures, whether decidual or chorionic, has yet
l)een adduced ; that tlio lesions described under the above title
do not differ, microscopically or clinically, from the ordinary
malignant diseases of the uterus, carcinoma, sarcoma or myo-
sarcoma. From the clini(^al facts reported he tlilnks these
lesions were established longbefbre parturition. It is highly
Mobiis Hopkins HoMpllal Ileimrts, Vol. x.
» InternatlonHl Medlojil Magazine. AugUBl, 1902.
:i British Gynec. Jour., AuguBt, 11102.
improbable that they can have commenced during pregnancy,
since cancer is not set up while healthy cell proliferation is
going on. The only inference possible is that the malignant
.development must have begun before impregnation, the phe-
nomena of cancer in the uterine body, always for a time obscure
and insidious, being masked by the pregnancy. Many of the
histories of these cases bear eloquent testimony to the futility
and indeed to the dangers of the curet in these puerperal cases.
The only valid treatment is complete hysterectomy, [w.k.]
TREATMENT
Solomon Solis Cohen
H. C. Wood, Jr. L. F. Applbman
Importance of Details in Hydrotherapy — While
it is true that the principal consideration in relation to
a hydrotherapeutic procedure is what Winternitz terms
" the measure of stimulation," and not the particular
form of application through which this stimulation is
brought about, it is nevertheless equally true that close
attention must be given to the details of the application
in order to produce the result desired. Nurses and even
hospital internes who have not been instructed fully in
the rationale and technic of hydrotherapy often neglect
some seemingly trivial direction, thus in some instances
greatly impairing the therapeutic value of the applica-
tion, and in a few unfortunate instances even making it
harmful instead of beneficial. Baruch, who may be
looked upon as the apostle of hydrotherapy in the United
States, forcibly and wisely insists upon the necessity of
accuracy in the hydrotherapeutic prescription. The
temperature, the pressure, the quantity, the time, the
force, and all other factors of the application of
water and of the subsequent or coincident mechanic
manipulations must be definitely ordered and the
order be exactly fulfilled. Among the minuta; of
the cold bath treatment of typhoid fever the preparation
of the bed for the reception of the patient after the tub-
bing and the method of drying the patient to induce
therapeutic reaction are of considerable importance. It
will usually be best for the physician himself to .superin-
tend the removal of the patient from the tub and the
application of the after treatment at least until the nurses
have been thoroughly drilled. To depend upon their
knowledge without making a practical test thereof is
often productive of mischief.
After the bath the patient may be allowed to lie
between blankets, or upon a blanket and covered with a
sheet, without drying, in order to continue the lass of
heat by evaporation of moisture from the surface of the
body ; and this plan is that most favored by Brand. It
is not, however, to be recommended in the majority of
cases. Usually, better results follow if the patient is
dried and warmed, and for this the bed must be pre-
pared sijecially. Everything should be in readin<»s
before the patient enters the water, so that there may be
no delay should it be necessary to remove him from the
tub sooner than was anticipated, and to relieve his
anxiety at the thought of possibly having to remain
longer in the tub than necessary while the bed is being
prepared. There are needed two warm blankets at a
temperature of not less than 100° F. (38° C.) ; three hot
water cans or bags should likewi.se be ready, properly
wrapped, to be placed one at the patient's feet and one to
each thigh ; and an ice-cap or rul)ber coil should be at
hand for his head. Over the lower blanket should be
placed a dry sheet, equally warm, and upon this the
patient is laid when he is lifted out of the tub. Ihe
sheet is then wrapped about him from the two sides and
tucked between the arms and the trunk and between
the two legs, so that no two surfaces of wet skin shall be
in contact. Friction is made over the sheet until the
patient is thoroughly dry— the back not being neglected
when the sheet is slip[>ed out and he is allowed to lie
between the blankets with the hot-water t^ns at his feet
478 A.UEBICAN MEDiCINE]
THE WORLD'S LATEST LITERATURE
[Beptembek 20, 1902
and against his legs and the ice-cap upon his head. The
patient continues thus for fifteen or twenty minutes
when he Is again robed in his nightdress and per-
mitted to lie between the sheets of his bed. After the
hot water cans have been removed, a cold compress, an
ice-bag or a cold coll Is applied over the abdomen, unless
too low a temperature for this has resulted from the
bath. The ice-cradle is a convenient means of applying
continuous cold to the abdomen, especially when the;
patient is restless under the weight of the coil or com-
press. In this matter of the application of continuous
cold to the abdomen the patient's sensations cannot be
depended upon a.s a guide ; there is no doubt that the
pnxjedure has a distinct efiect in keeping the tempera-
ture down and reducing the number of baths required.
In some ca.ses it seems to obviate the necessity of routine
bathing. It certainly diminishes the tendency to tym-
panites and probably reduces to a minimum the danger
of hemorrhage. Neither coil nor ice-bag should be
placed directly upon the skin, but a flannel or linen
cloth wrung out of Ice-water should be interposed. Some
physicians prefer to place the ice-bag over the right iliac
fossa, and this practice is often advantageous. In some
cases these applications have a better effect when occa-
sionally intermitted for an hour or so, or when the coil
or ice-bag is shifted at intervals.
Prophylactic and Therapeutic Indications in Pul-
monary Tuberculosis, Based on a Recognition of Its Soil.
—Robin and Binet' draw the following: conclusions from a
consideration of this subject : 1. The exaggerated tendency of
the organism to consume itself constitutes one of the character-
istics of the protopathic states of the soil of tuberculosis, what-
ever may be the origin of predisposition, whether heredity,
alcoholism or one of many excesses. 2. This discovery dis-
closes one of the fundamental conditions of these protopathic
states that have been vaguely termed states of organic decay.
It shows that however dissimilar they appear, these states pos-
sess a common element, the intensity of which must be deter-
mined, which gives to the soil a part of the importance which
the discovery of the bacillus of Koch seems to have removed.
3. This discovery shows also that the pretuberculous states of
decay arise from an exaggerated vitality progressing to auto-
consumption, and not, as has been stated, to decreased vitality.
4. It overthrows all of the principal ideas of the prophylaxis
and treatment of tuberculosis, consisting principally in the use
of tonics, which stimulate organic changes which are already
in a state of over-activity. 5. It demonstrates, on the contrary,
aside from theories and by the simple statement of facts, that
the prophylaxis of tuberculosis by the modification of its soil
must be accomplished only by drugs or agents capable of
reducing the power of the organism to consume itself. In the
treatment of a well-marked case, this indication still retains its
importance. 6. With this end in view the authors have util-
ized 40 drugs or medicinal agents. Among them codliver oil,
sodium arsenate and potassium arsenite in the dose of ^"5 of a
grain, sodium cacodylate in the dose of 1 grain, diminish the
respiratory changes. But when arsenic in any form is used
in double the above doses it accelerates these changes. We
thus possess a criterion of the dose which must not be sur-
passed under penalty of hastening the damage we wish to rem-
edy. 7. Researches on the respiration of hot dry air, hot moist
air, or cold air, and on the chilling or heating of the cutaneous
surface, solve the climatology of tuberculosis and its primary
states. 8. Examination of the respired air enables one to
determine whether high altitudes or the sea level are or are not
favorable to any particular patient. 9. Experience has shown
that there are drugs which modify the soil, and examination of
the respiratory changes enables us to determine these medica-
tions, as well as to know whether they are indicated in a par-
ticular case, and, consequently, if a predisposed individual has
lost his predisposition, at least temporarily. 10. This mode of
prophylaxis of tuberculosis, by modifying the soil, merits
attention as much as that which combats the bacillus, and the
struggle against tuberculosis will not be successful without
■ Journal des Pratlciens, Vol. xvl. No. 5, 1902, pTrs]
cooperation of these two elements. To the measures of public
and private hygiene employed against the bacillus of tubercu-
losis, it is necessary to add individual examination of the res-
piratory changes of all individuals known to be predisposed.
11. Finally, the treatment of confirmed tuberculosis must not
be confined to medication against the bacillus alone ; it must
recognize the condition of the consumption which renders the
organism liable to infection, and to modify it, not by stimulants
and tonics, but by medications which restrict the consumption
and fixation of oxygen by the tissues, and by food and medica-
ments which direct to themselves a part of the combustion
which weakens the organism, [l.f.a.] [More than 100 years
ago Thos. Beddoes, in a letter to Erasmus Darwin, announced
that pulmonary tuberculosis was duo to hyperoxygenation ;
but later with true scientific candor he modified the opinion,
saying that it applied only to one variety of the disease— florid
consumption. This he relieved by inhalations of carbon dioxid
and hydrogen gas and of nitrogen. Doubtless Beddoes and
Robin are right to this extent ; that hyperoxidation of tissue
characterizes certain stages of certain forms of pulmonary
tuberculosis. In its present form Robin's theory is too sweep-
ing. S.S.C.]
Hypodermic Injections of Digitalin.— Huchard ' states
that the pain and inflammatory phenomena usually caused Ijy
hypodermic injections of digitalin are avoided by using an oily
solution of Nativelle's digitalin as recommended by Rosenthal,
of Paris. Solution is accomplished by the aid of moderate
heat, and it is dispensed in ampullas containing 5^5 to jjs of
a grain of digitalin. Huchard employs it in doses of not over
^r, of a grain at each injection, and has never seen pain or
irritation follow its use. [l.f.a.]
Preliminary Study of Injections of lodomercuric
Cacodylate. — In 1900 Brocq, Civatte and Fraisse^ experimented
with acid cacodylate of mercury by subcutaneous injection.
The pain caused by its injection and the accidents to which it
gave rise forced the abandonment of the drug. It has since Ijeen
replaced by lodomercuric cacodylate, a substance in which
arsenic, iodin and mercury are combined by special chemic re-
action under the respective forms of sodium cacodylate, sodium
iodid and mercury biniodid. This preparation is soluble in
water, it can be sterilized at 120° F., and is miscible with blood-
serum without causing any precipitation. It is well borne in
subcutaneous injection, causes little or no pain, and is not fol-
lowed by abscesses. It is indicated especially in syphilis asso-
ciated with marked malnutrition, feebleness and neurasthenia;
in rebellious secondary manifestations of the mucous mem-
branes and skin, and in the tertiary stage, [l.f.a.]
Indications for the Serum of Trunecek in Arterio-
sclerosis.—Mercklen ^ states that the serum of Trunecek does
not modify sclerous lesions, but it causes certain subjective
symptoms of arteriosclerosis to disappear. He believes it is a
tonic especially applicable in asthenia and hyperexcitability
which, in patients suffering from arteriosclerosis, depend on
insuflicient irrigation and on nutritive alterations of the nerv-
ous system, [l.f.a.]
Electric Light Bath.— J. C. Kellogg* summarizes the
therapeutic effects and modes of application of the incandes-
cent light bath as follows: 1. General and local revulsive
effects, by dilating the cutaneous vessels. The reddening of
the skin begins within a few moments and becomes more and
more intense as the application is continued. The permanency
of the effect may be increased by a short cold application fol-
lowing the light bath. 2. Sudorific. It induces perspiration
more quickly and more vigorously than any other agent, and
with the least amount of inconvenience and discomfort. Care
must be taken to protect the heart and the head by means of cold
compresses. The patient should be made to drink water very
copiou.sly, both to encourage diaphoresis and to maintain the
normal blood volume. 3. Promoting the absorption of exu-
dates. Both general and local applications are valuable. In
France the general electric light bath has been used success-
fully in promoting the absorption of exudates in the cornea of
■ Journal des Pratlciens, Vol. xvl, No. 18, 1902, p. 283.
2 Bulletin General de Thfirapeutlque, Vol. cxllil, JJo. 18, 1902, p. 712.
' Journal des Pratlciens, Vol. xvl. Mo. 24. 1902, p. 382.
♦System Physiologic Therapeutics, Vol. Ix.
Septembee 20, 1902]
THE PUBLIC SERVICE
fAlIEHICAlT MeBIOINK 479
the eye, vitreous opacities, and similar patiiologic products.
Kellogg has used with success in promoting absorption of exu-
dates from the pleural and peritoneal cavities, and in and
about the joints, general applications of the electric light bath,
combined with local applications of the light to the affected
parts, and suitable hydriatric measures. A cooling bath is
necessary after general applications, and the alternate spray or
douche after local application to the joints, this to be followed
by the application of a heating compress. The local applica-
tion of light should be made at least twice daily, the general
application once a day. The heating compress should be
changed at least twice daily. Massage and, in some instances,
electric applications to the parts, and especially to the adjacent
muscles, are important adjuvants. 4. Tonic effects. No other
means excels short applications of the incandescent electric
light (three to eight minutes). A sensation of well-being,
similar to that experienced by one who stands before a glowing
fire, is pronounced, and when followed by a proper hydriatric
application, the stimulation to nutrition is of the highest possi-
ble degree.
Tuberculin as a remedy in tuberculosis of the lungs
is much commended by Wilkinson. ' Twelve patients in the
first stage of the disease were permanently improved : 23 patients
in the second stage were temporarily improved (14 of these are
now in relatively good health and can do ordinary work ; 3
have died); of 16 patients in the third stage 9 have died. In all
there have been 12 deaths among 50 patients treated, [a.o.j.k.]
Methylene-blue as an Abortive to the Ocular Complica-
tions of Variola and the Exanthems in General. — Morgano^
has obtained quick cures in the ocular infections occurring dur-
ing variola and other exanthematous fevers by the use of
methylene-blue. The method employed by Courmont and
RoUet, of Lyons, consists in the instillation of a 1 to 500 steril-
ized aqueous solution of methylene-blue into the eyes many
times daily ; lavage with boric acid and sometimes applications
of a 1 to 200 solution of methylene-blue may also be practised.
Morgano obtained good results with methylene-blue in corneal
ulcerations, membranous conjunctivitis, severe catarrhal con-
junctivitis and phlyctenular or suppurative keratitis. These
results are not astonishing, since a 1 to 70,000 solution of methyl-
ene-blue prevents the growth of Loffler's bacillus and
Streptococcus pyogenes, [l.f.a.]
Treatment of liupns. — Hallopeau' employs potassium
permanganate in lupus with success. In one patient the cure
was complete. It is necessary to continue the applications for
a long period in order to penetrate into the deeper tissues and
obtain the best results, [l.f.a.]
Kther as a Vehicle for Cutaneous Medication. — Sir
James Sawyer * points out that ether is the best vehicle we have
for applying medicinal substances to the skin. Its endosmotic
property is very great; it is very diffusible; it dissolves the
majority of medicinal substances or their active principles ; it
also dissolves the sebaceous secretions of the skin, which
enables the drugs to be more readily absorbed. He particularly
recommends the employment of belladonna, iodin, menthol
and capsicum in ethereal tinctures. The ethereal tincture of
belladonna root is made in such a way as to olitain a concentra-
tion equivalent to that of the official belladonna liniment. This
is valuable when applied locally in certain affections of the
heart when belladonna plaster or ointment is indicated. A solu-
tion of menthol, containing 1 dram of menthol in 1 ounce of
absolute ether, is very useful in superficial neuralgic pain.
[L.F.A.]
Treatment of BeKinninx Cataract with Iodin Solu-
tion.— fttiCvant* reports that in four cases of beginning catar-
act he was enabled to arrest the progress of the affection by the
use of potassium or sodium iodid as a collyrium in the propor-
tion of 15 grains to 10 grams of distilled water, as recommended
by Badal. He supposed this result was due to the absorption
of the iodin in contact with the cornea and conjunctiva. The
treatment was efllcacious only when the cataract was the result
1 KrltlHh Medical Journal, June?, 1902.
'Journal des Pratlclens, Vol. xvl. No. IK, 1902, p. 2»t.
» La M6(lcclne Mnderne, Vol. xlll, No 19, 1902, p. 1S9.
•Journal M^'dlcal de Hruxelles, Vol. xvli, .No. 19, 1902.
' Lyon .Medical, Vol. xcvlll, No. 6, 1902, p. 199.
of senile changes, and not when due to preexisting disease of
the eye. [l.f.a.]
Acid Stools : Their Relation to the Treatment of
Diarrhea. — G. Bardet ' speaks of the treatment of diarrhea as
recommended by Soupault, who administers hydrochloric acid
in order to complete gastric digestion, in the supposition that
the intestine is irritated by excessively acid food which is not
completely digested. Bardet believes that the administration
of hydrochloric acid also does good in these cases by supplying
nearly all the acid necessary for digestion so that the stomach
is not stimulated to over-secretion, and symptoms of irritation
are not produced. In cases of hypoacidity, hydrochloric acid
at the beginning of a meal will aid in the peptonization of the
food and prevent the formation of fatty acids which occurs
when the digestive process is prolonged, [l.f.a.]
FORMULAS, ORIGINAL AND SELECTED.
For Senile Pruritus.—
Thymol 8 grains
Solution of potassa 1 ounce
Glycerin 3 drams
Water J pint
To be applied externally, [h.c.w.]
For Persistent Vomiting. —
Codein J grain
Bismuth subnitrate 8 grains
Cerium oxalate 3 grains
Calcined magnesia 8 grains
Oil of peppermint J drop
One such powder 3 times a day. — Merck's Archives, May,
1902. [h.c.w.]
THE PUBLIC SERVICE
Health Reports. — The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, during
the week ended September 13, 1902:
California :
Colorado :
Massachusetts :
Michigan :
Minnesota:
Missouri :
Montana :
Nebraska:
New Hampshire :
New Jersey:
New York :
Ohio:
Oregon :
Pennsylvania :
South Dakota :
Tennessee :
Utah:
Austria :
Brazil:
Belgium :
Gibraltar:
Great Britain :
Greece:
India :
Italy:
Kussia:
Htraits Hettlementa
Venezuela:
Colombia;
Co8ta Hlca :
smallpox— United States.
San Francisco Aug. 18-31
Denver. Aug.2:K"»
Boston Aug. 30-Sept. 6.
Cambridge Aug. ;!0-Sept. 6
Quincy Aug. 30-Sept. 6.
Ludlngton Aug. 2;i-,30
Minneapolis July 5-A.ug. 16
Cases Deaths
.. 18 18
St. liouts Sept. 1-8 1
Butte Aug. 31 -Sept. 7 ... 1
Omaha .\ug. 31-.Sept. 6 ... 3
Manchester Aug. 31-Sept. 6.... 2
Camden Aug. 30-Sept. 6 ... 2
Hudson County,
Jersey City lncrd..Aug. 24-Sept. 7 ... 3
Newark Aug. 30-Sept. 6 ... 5
Plainfield Aug. :«>-Sept. 7.... 1
New York Aug. 3(KSept. 6.... 12
Ashtabula Aug. 30-Sept. 6 ... 1
Cincinnati Aug. 29-Sept. 5... 1
Cleveland Aug. .30-«ept. 8 ... 84
Dayton Aug. 30-Sept. 8... 1
Youngstown Aug. 12.3-30 1
Portland Aug. 1-31 4
13
..Aug. 14-21 1 Imp'rt'd
Butler..
Johnstown Aug. 30-Sept. 6. .. 7
MeKeesport, Aug. 31-Hept. 6 ... 3
Philadelphia Aug. 30-Sept. 6 ... 2
Pittsburg Aug. :«)-«ept. 6.... 19
Sioux Kails AUK. 30-.Scpt. «... 1
Memphis Aug. 30-«ept. 8... 1
Ogden Aug. 1-31 6
Salt Lake City .\ug. 23-Sept. 6 ... 3
Smallpox— FORBiQN.
Prague Aug. 9-23 1
Pernambuco July 24-31
Brussels Aug. 18-2:?.
Aug. 18-24 .
Dublin Aug. 23
Liverpool Aug. 9-28 _.
London Aug. 16-28..
Athens Aug. 16-V8
Bombay Aug. 4-12
Calcutta Aug. 2-9
Naples Aug. 9-23 7
Palermo Aug. 16-28 3
Moscow Aug. 9-16 6
St. Petersburg Aug. 9-18
Singapore July 12-26
Valencia Aug. 2S Present
Yellow Fkvek.
Panama. Aug. 2S-8ept. 1 ... 5
PortLlmon Aug. 21-28 " 1
1
1
1
17
18
1 BuUeUn General de Th6repeuUque, Vol. czllll, No. 16, 1902, p. SM.
480 AMERICAN MBDIOINs:
THE PUBLIC SERVICE
IBEPTKIfBEB 20, 1902
Cuba: Havana Sept, 1 1 case from
8. S. Monterey, from Vera Cruz.
Meslco: Coatzacoalcos Aug. 25-30 4
Progreso Aug. Ki-Zi 1 1
Veracruz Aug. 19-25 22 12
Venezuela: Valencia Aug. 2.5 Present
Cholera— Insular.
Philippine Islands : Manila J une 22-Jnly 12 .. 820 6W
Provinces June22-July 12„6,343 4,120
China:
Egypt:
India:
Japan :
Russia:
2
224
California :
Brazil :
Kussia :
Cholera— FOHE ign.
Araoy Aug. 2-19
Hongkong Aug. 22-29
Cairo Aug. 9-16
Calcutta Aug. 2-19
Karachi Aug. 3-10
Tokyo July 27-Aug. 2 ...
Okayama July 29-Aug. 3 ...
Amur District July 16-22 123
Charbln June H-20 112
GIrin July 14-20
Inkow July 6-17 128
Mudken July 12-15 87
Manchuria To July 19 54
Vladivostock Aug. 14 4
Zlzlkar J uly 11-13
Plague- United State.s.
San Francisco Aug. 20-31 6
Plague— Foreign.
Pernambuco July 9-23
Cairo Aug. 9-16 2
Bombay Aug. .5-12
Calcutta Aug. 7-14
Karachi Aug. S-10 3
Odessa To Aug.22 9
15 estlm'd
8 7
1
18
68
44
175
106
73
24
57
4
1
27
15
Changes in the Medical Corps of the V. S. Navy fo)
the week ended September 13, 1902 :
Parker, E. G , passed assistantsurgeon, detached from the Pensacola
and ordered to the Adams— September 10.
Changes In the Medical Corps of the V. 8. Army for
the week ended September 13, 1902 :
Vose, First Lieutenant William E., as.sistont surgeon, is granted
leave for one month.
Jenkins, Frederic E , contract surgeon, is detailed as a member of
the e.xamining board at Fort Barrancas, vice Major William D.
Crosby, surgeon, relieved.
May, James v., contract surgeon, is relieved from duty at Fort Strong,
Mass., and will proceed lo his home, Philadelphia, Pa., and report
for annulment of contract.
SiEVERS, Robert JS.. contract surgeon, now at Louisville, Ky., will
proceed to Fort Harrison, Mont., and report for duty to the com-
manding general, department of Dakota.
Mason, Major Charles F., surgeon, is. In addition to his other duties,
designated to act as chief surgeon of the department during the
absence on leave of Colonel Peter J. A. Cleary, assistant surgeon-
general.
Anderson, Robert A., contract surgeon. Fort DuChesne, Utah, is
granted leave for twenty days. Contract Surgeon James H. Hep-
burn will proceed from Fort Douglas, Utah, to Fort DuChesne,
Utah, and report for duty during the absence of Contract Surgeon
Anderson.
Skinner, Captain George A., assistant surgeon, FortSnellIng, Minn.,
with one member of the hospital corps of that post, will proceed to
Chicago, 111., on public bu8ine.ss, under verbal instructions from
the department commander, and on completion of this duty they
will return to their proper station.
Taylor, Lieutenant Colonel Blair D., deputy surgeon-general, Fort
Sneiiing, Minn., will proceed to Fort Missoula, Mont., and makean
examination of Captain Archibald A. Cabanlss, Twenty-fourth In-
fantry, and report as to the present physical condition of that
officer.
Skinner, Captain George A., assistantsurgeon. Fort Sneiiing, Minn.,
Is granted leave for one month, with permission to apply for an
extension of one month, to take efl'eet on the return of Lieutenant
Colonel Blair D. Taylor, deputy surgeon-general, United States
Army, from detached service.
Cox, First Lieutenant Walter, assistant surgeon, now on temporary
duty at Fort Wetherill, R. I., will remain at that post after the
departure of troops until he shall have completed the care and
transfer of the sick, packing and shipment of supplies, and other
duties in connection with the closing of the hospital, after which
he will return to his proper station. Fort Banks, Mass.
PURNELL, First Lieutenant Harry S., assistant surgeon, will proceed
to Fort Riley, Kan., by September 20, and report to Major-Qeneral
John C. Bates for temporary duty pertaining to the military
maneuvers to be held at that post in September and October, 1902,
and upon the completion of this duty will return to his proper
station.
Marrow, First Lleutenat Charles E , assistant surgeon. Is relieved
from duty as surgeon on the transport Hancock, and upon the
expiration of his present leave will proceed from Hampton, Va.,
to Fort Sheridan, 111., for duty.
Snoddy, First Lieutenant Cary A., assistant .surgeon, will proceed to
Fort Riley, Kan., in time to arrive there ntt later than September
20, and repon to Major-General John C. Bates for temporary duty
pertaining to the military maneuvers to be held at that post in Sep-
tember and October, 1902, and upon the completion of this duty
will return to his proper station.
GiRARD, Colonel Alfred C, assistant surgeon-general, is detailed as
a member of the examining board at the Army Medical Museum
Building, Washington, D. C, during the absence of Lieutenant
Colonel John Van B. Hoff, deputy surgeon-general, relieved.
SHOCKLEY, First Lieutenant M. A. W., assistant surgeon. Fort Nio-
brara will proceed to Fort Crook, so as to arrive there not later
than the fourth and report for duty with the troops ordered to Fort
Kiley to participate in the coming maneuvers at that post. Upon
return of the troops to Fort Crook, Lieutenant Shockiey will
return to B'ort Niobrara.
Field, First Lieutenant Peter C, assistant surgeon. Fort Robinson,
will proceed to Fort Leavenworth so as to arrive there not later than
the sixth and report for duty with the troops ordered to Fort Riley
to participate in the coming maneuvers at that post. Upon return
of the troops to Fort Leavenworth, Lieutenant Field will return to
Fort Robinson.
Cleary, Colonel Peter J. A., assistant surgeon-general, Is granted
leave for ten days, to take eflecl September 1.
Steer, First Lieutenant Samuel L., assistant surgeon, now on tem-
porary duty at Fort H. O Wright. N. Y., will remain at that post
after the departure of troops until his .services are no longer required
there, when he will return to his proper station. Fort DuPont, Del.
M0SE.S, First Lieutenant ARTHUR W., a.sslstent surgeon, is granted
leave for one month.
KiRKPATRiCK, Captain Thos. J., assistant surgeon, is granted leavi-
for one month, from September 28, with permission to apply for
extension of one month.
McC.iLLUM, Captain Francis M., assistant surgeon volunteers. Pre-
sidio, is granted leave for one month, upon surgeon's certificate,
with permission to apply for extension of one month.
McCaw, Major W. D., surgeon, will return from Fort H. G. Wright to
Fort Wadsworth.
Ewing, Major C. B., surgeon, will report at Fort H. G. Wright, for
temporary duty.
Hartnett, First Lieutenant E. H.. assistant surgeon, will report at
Fort Preble, Me., for temporary duty.
Darnall, Captain Carl R., assistant surgeon, now on leave. Is
relieved at Plattsburg Barracks, and will proceed to Washington
and report to the surgeon-general of the Army for duty in his office.
Daknall, Captain Carl R., assistant surgeon, is detailed as recorder
of the board of medical officers for the examination ol candidates
for admission to the medical corps.
FoRWOOD, Brigadier-General William H., surgeon-general, by opera-
tion of law, the retirement from active September 7, 1902, is
announced.
Probert. Merton a., contract surgeon, leave granted August 2 is
extended one month.
Carter. Maior W. Fitzhugh, surgeon. Is granted leave for one month
and five days, to take effect upon his relleffrom duty at Fort Totten.
Lambert, First Lieutenant Samuel E , assistant surgeon, is relieved
from further duty at Fort Morgan, Ala., and will proceed to Wash-
ington Barracks, D. C, and report for duty.
Blanchard, First Lieutenant Robert M., assistant surgeon. Is
granted leave for one month.
Changes in the Public Health and Marine-Hospital
Service for the week ended September 11, 1902:
White, J. H., assistant surgeon-general, granted leave of absence for
seven days from September 7— September 6.
Vaughan, G. T , assistant surgeon-general, detailed to represent Serv-
ice at meeting of Medical Society of Virginia, to be held at Newport
News, Va., September 23-26, 1902— September 11, 1902.
Pettus, W. J., assistant surgeon-general, to proceed to Baltimore, Md.
for special temporary duty— September 11, 1902.
Carmichael, D. a., surgeon, granted two mouths leave of absence
from September 9— September 6.
Wertenbaker, C. p., passed assistant surgeon, granted fourteen days
extension of leave of absence from September 6, 1902— September 10,
1902.
Thomas, A. R., passed assistant surgeon, gi-anted leave of absence for
ten days from September 5, on account of sickness— September 6,
1902.
CoFER, L. C. passed assistant surgeon, leave of absence granted by
department letter of July 29. 1902, amended to take effect from Sep-
tember 10, 1902- September 8, 1902.
Heiser, V. G., assistant surgeon, granted leave of absence for fifteen
days— September 9, 1902.
Berry, T. D., assistant surgeon, granted two months extension of
leave of absence from September 3, on account of sickness— Septem-
ber 5, 1902.
Lloyd, B. J., assistant surgeon, relieved from duty at Nome, Alaska,
on closure of navigation, and directed to proceed to San Francisco
Quarantine Station, San Francisco, Cal., and report to medical
officer in command for duty— September 11, 1902.
Bailey, C. W., acting assistant surgeon, granted ten days leave of
absence from August 27— September 4, 1902.
Burford, Hugh, acting assistant surgeon, granted leave of absence
for twenty-eight days from September 5— September 10, 1002.
Fraser, a. C acting assistant surgeon, granted ten days leave of
absence from September 15 — September 10, 1902.
Goldsborough, B. W., acting assistant surgeon, granted leave of
absence for seven days from September 16 — Septembers, 1902.
McGlNNis, R. H., acting assistant surgeon, granted thirty days leave
of absence from October 1— September 10, 1902.
Mason, W. C, acting assistant surgeon, granted leave of absence for
five days from September 15— September 8, 1902.
Scott, E. B., pharmacist, granted leave of absence for nineteen days
from September 6— September 8, 1902.
Board Convened.
Board convened to meet at Stapleton, N. Y., September 11, 1902, for
the purpose of examining revenue cutter officers on that date and from
time to time thereafter. Detail for the board— Surgeon P. H. Ballhache,
chairman ; Passed Assistant Surgeon A. C. Smith, and Assistant Sur-
geon A. M. Stimson, recorder.
American Medicine
,«'
GEORGE M. GOULD, Editor
G. C. C. HOWARD, Managing Editor
CHARLES 8. DOLLEY
MARTIN B. TINKER, AnUUmt Editors
Clinical Medicine
David Riksman
iL. O. J. Kelly
H. H. CnsHiNO
Helen Murphy
General Surgery
Martin- B. Tinker
A. B. Craig
Charles a. Orb
Orthopedic Surgery
H. AUOPSTUS Wilson
COLLABORATORS
Obstetrics and Gfynecology
WiLMER Krusen
Frank C. Hammond
yervous and Mental Diseases
J. K. Mitchell
F. Savary Pearce
Treatment
Solomon Solis Cohen
H. C. Wood, Jr.
L. F. Appleman
Dermatology
M. B. Hartzell
Laryngology, JBte.
D. Braden Kylb
Ophthalmology
Walter L. Pylb
Pathology
R. M. Peabce
PUBLISHZD WbBKLT aT 1321 WaLNOT StSBIT, PhILADBLPHU, BT THB AUBBICAN-MBDICINB FtTBLMBIRe COUPAHT
Vol. IV, No. 13.
SEPTEMBEK 27, 1902.
1.00 Yearly.
Virchow's Successor. — Since the death of Rudolf
Virchow there has been considerable speculation as to
who would succeed to the chair of Pathologic Anatomy
in the University of Berlin, and a numl)er of the best
known scientists in Germany have been mentioned. A
cablegram just received by us announces the appoint-
ment of Professor Johannes Orth, who is now Professor
of Pathologic Anatomy in the University of Gottingen.
There will be general agreement that no more worthy
choice could have been made, since Professor Orth is
widely known as a patient investigator as well as for his
scholarly attainments. He is perhaps best known for his
valuable work, Compendium der pathologiach-anato-
iniachen Diagnostik, nebst Anleitung zur Ausfilhrung von
Obductionen, first issued in 1876, and since then trans-
lated into French, and English (by Shattuck and Fitz,
of Boston), beside attaining its sixth edition in a much
enlarged form in German. Professor Orth was also
editor of the wellknown Lehrbuch der speeiellen Patfio-
logisch-Anatomie, a system in six volumes, issued
1887-1894. Professor Orth was born in 1847, and has
therefore every prospect of many years' work bef(>re
him. We congratulate the University of Berlin upon
the wisdom of its choice and Professor Orth upon the
compliment implied in his election, since the University
of Berlin, by the policy of the Imperial government,
must secure for its chairs the best men in the special
departments of science.
The Index Mcdicus Should lie Revived by the
Caraegie Institute.— Ever since the Judex 3fedleus
ceased it has been more and more recognized that the
publication was one of prime importance to medical
science and progress, and that its discontinuance was
one of great misfortune to the profession. All the vari-
ous plans that have been devised to resuscitate it have
failed, but we wonder if a common effort on the part of
physicians and medical societies might not succeed in
getting the Carnegie Institute to tsike up the work. We
can imagine no way in which the amount of money
required for this undertaking could be more wisely
expended or produce more benefit to the entire pro-
fession, and HO, of course, to that of the nation. We
appeal to the trustees of the Carnegie Fund to consider
the suggestion seriously and beg each of our subscribers
to second us in personal letters to the trustees, explain-
ing the great ble&sing the Index Medicus has been in the
past, and how it will become increasingly needed in the
future. We also suggest, should the trustees determine
to accept the duty, that they will take up the work
where it was discontinued in order that there shall he
no gap to afflict literary workers .and make all their
statistics and epitomes fallacious.
Unnecessary Bibliographic Reference. — We
wish to call particular attention to a most valuable sug-
gestion made by Dr. Osier in his address on "Some
Aspects of American Bibliography," printed in our
issue for September 13. In referring to that most
stupendous undertaking, the Index Catalog of the Sur-
geon-General's library, he remarks that it is not used
enough by students, and cites a recent writer on disesises
of the heart, who appended to his paper a very full
bibliography ; but when Vol. V of the old series and
Vol. VI of the new series of the Index were consulted
behold " there was the literature in full on this subject
any many articles which the author had overlooked.
The entire bibliography might have been omitted with
advantage from the paper and simply a reference made
to the Index Catalog. It would be well in future if
writers would bear in mind that on many subjects, par-
ticularly those covered by the second series of the Cata-
log, the bibliography is very complete, and onlt/ supple-
mentary references should be made to the articles which
have appeared since tlie volume of the new series dealing with
the sn/yject." Among the many advantages to be secured
by such action on the part of medical contributors would
be the valuable space gained in the pages of Jiiedical
journals ; and of not less importance the author would be
free from the imputation of seeking a reputation for
erudition on the basis of the citation of numeroas
articles which the reader suspects he has never seen in
the original.
Deportation and Local Responsibility for the
Insane. — We wonder if the various Sbites are strict
enough in guarding against becoming responsible for the
care of dependents properly belonging to other States or
countries? The (juestion is suggested by the experience
of Minnesota, which in the last five yejirs has made 260
deportations, " in some cases taking the patient to
482 AHEBICAN MEDICIKK
EDITORIAL COMMENT
[Seftehbbb 27, 1902
countries across the sea." The expense to the State in
malting these deportations was $1 8,500. Placing the low
estimate of the cost of the care of such patients at $1,000
each a year (New York and Massachusetts place it at
$1,500) the total saving to the State in five years by
these deportations has been $241,500. As accommoda-
tion for these patients is always behind the needs, the
additional room gained is as advantageous as the
economy in expense. The plan of deportation, however,
is of greater benefit in placing responsibility where it
belongs, and the stimulus this indirectly gives to a
proper endeavor to prevent the acute forms of the
disease from becoming chronic. There is no doubt
in the minds of those who have studied the subject at
first hand that many cases drift into chronicity unneces-
sarily, and that not a few patients, more or less con-
sciously, exaggerate their mental abnormalism, for one
or another reason. It is a sad fact also that relatives are
glad to be rid of responsibility. Deportation works
against all such abuses.
The Excellence of American Medical Book
Making'. — In its recent educational number, speaking
of the Medical Students' Library, the Lancet says :
" The purely book-making treatises have been to a con-
siderable extent of American manufacture, but in saying this
we must not lose sight ol the fact that to American enterprise,
industry and erudition we now owe an extensive medical litera-
ture. In particular do the authors and publishers of the United
States excel in the production of great dictionaries, and ency-
clopedic compilations of monographs by many writers."
We have repeatedly drawn attention to this fact and
are now delighted to see it acknowledged by so able a
judge. It has a significance deeper than commerce, and
even than national pride. It signifies that Americans
are fast becoming the leaders in practical medical science,
and possess those qualities of mind which are fast
making them masters in things beyond material success,
in that intellectual benevolence, or humane science best
illustrated by medical and sanitary science. For there
is vastly more in a good textbook, encylopedia, or dic-
tionary than erudition. The honorable union of the
publisher and author and their production of such great
works requires a broad basis of professional and national
culture, and a devotion unselfish, at least far-sighted, to
the good of future generations.
The aid and supervision of discharged pris-
oners is provided for by the law of the State of Minne-
sota. In how many other States is it so ? According to
Miss Grace Johnston (Bulletiti ofloioa Institutions, April,
1902) 597 prisoners have been paroled from the State
Prison, and 485 of them have kept faith and received
their discharge ; 45 are still on parole, and of the 67 who
have broken parole, 8 are still at large. Thus only
about 12 ^ of those released have failed to keep faith. In
the State Reformatory there were received 1,340 pris-
oners, and of these 906 were paroled, 151 of whom broke
their word ; 101 of these have been returned, leaving 50
still at large. The percentage of those breaking parole,
16.66^, is larger than in the State prison cases. These
results, however, are most encouraging. The lot of
those discharged from prison is hard enough even with
the best of supervision and aid, and Gailure to provide
such overseeing on the part of the State is as impolitic as
it is inhumane. Of these 1,240 who kept their word how
large a proportion, without supervision and help in
getting employment, would have i)ecome confirmed
criminals, costing the State far more than the expense of
the State agent ? In Minnesota Mr. F. A. Whittier is
this agent (there should surely be two such agents ! ), and
of his work he says :
" The State agent's duty with these men is not without re-
sponsibility, as he has their liberty in his hands to a consider-
able extent. He must be patient and kind-hearted but noj
sentimental. He must be sympathetic but should not allow
his sympathy to overcome his judgment. He must be a good
judge of human nature: he must be kind as well as firm; he
must be quick to discover their weakness and prompt to cor-
rect their follies. He should forgive but he should not forget."
Morbid illustrations of morbid facts is, we fear,
the way we shall have to describe the growing tendency
to the use of medical terms by lay orators to serve as
fillips to the inaguration of their audience. President
Roosevelt has lately been a little guilty of this sort of
philologic aberration of mind. For instance he recently
said to his audience :
" I feel that the profession of railroading is a fine antiscor-
butic— that it does away with tendency toward softness. A
man is not going to be a fireman or an engineer, or serve well in
any other capacity on a railroad long if, to speak technically,
he has a ' streak of yellow ' in him."
Now scurvy, we are told by the dictionary man, is a
disease due to a lack of a wholesome diet, especially
vegetables, and is characterized by spongy gums, extrava-
sations of blood, indurated patches of skin, hemor-
rhages from the mucosa, fetor of the breath and painful
contractions of the muscles. The trouble with the con-
ception of scurvy as " a tendency toward softness" is
that it is not scientificly true. The effeminate life of ease
and irresponsibility to which the railroader's life is a cor-
rective is not one producing the symptoms of spongy
gums, etc. ; indeed, one of the symptoms of scorbutus is
hardness, not softness of the skin. The President in
another speech made a similarly inaccurate use of the
word hysteria. We have the most hearty sympathy
with what President Roosevelt wished to say. Indeed,
his pleas for a return to old-fashioned ways and the
"homekeeping virtues" of honesty and simplicity are
beyond all question most needed.
Abolish the old-fashioned slate, because it is
impossible to prevent the dirty and dangerous habit of
using saliva and the fingers to "rub-out "the work
upon it. In the Ohio State Bulletin, May, 1902, Dr.
Hurty tells of an epidemic of diphtheria which broke
out in a district, the school being twice closed, and
the room thoroughly disinfected each time, but the dis-
ease broke out a third time after the death of two pupils.
Then the bacillus was found in the teacher's throat, who
had been ill with " a cold " all winter. The children's
throats harbored no diphtheria bacilli. The teacher,
8BPTKMBBR 27, 19021
EDITORIAI^ COMMENT
Amebican Medicink 483
it was learned, had the habit of correcting the
children's lessons upon their slates, and usetl her own
saliva to erase the figures, writing, etc., upon them.
After disinfection and isolation of the teacher the epi-
demic ended. Even on grounds of cleanlineas and good
habits in writing, the slate should be displaced by paper
and pencil. Paper good enough for such purposes is
now manufactured so cheap that its expense can no
longer be made an excuse for continuing the use of dirty
slates. One speaker referred to a porcelain slate for use
with the lead pencil, the writing on which could be
erasetl with a dry cloth. The cheap " scratch-block " of
paper would seem preferable.
Sanitation in Great Cities. — Mayor Low, of New
York, has rendered valuable service by his critical study
of the sanitary needs of the greatest of American munici-
palities, and through the widespread attention which
he has attracted to the subject of public sanitation by his
" talks " on the work of the Departments of Health and
Charities. Recognizing fully the excellent service which
the city has received at the hands of Commissioners
Lederle and Folks, and the very marke<l improvement
that has been effected in the care of the sick and poor, he
makes clear the urgent necessity for increased appropri-
ations for these departments in order that their efficiency
may be brought up to the standard of similar depart-
ments in the great cities of tiurope, and that the hos-
pital and almshouse facilities be made to meet the
enormous demand upon them. These talks by Mr.
Low affords suggestive reading for citizens other than
those of Greater New York, and his ambition to see New
York placed in the front rank of cities that make
adetjuate provision for the preservation of human life is
worthy emulation by every municipal officer in the
land. That " it is both easier and better to create con-
ditions that make for health than it is to cure people
after they have been taken sick," is the controlling idea
of the good work going on in New York City, and the
sanitary activity of the entire country will receive
impetus from the example furnished by Mr. Low and
his coadjutors.
Noiisense-kiiowledgre. — Some American historian
with a keen sense of the ludicrous should chronicle the
medical pseudoliteniture of our country. Every year
there are books issued, most solemn by intt-nt but most
funny by indirection. To a person as ignorant as their
authors they seem most learned, but to one with any
knowledge of the English language or of the a b c of
science, these bombastic "treatises" and "textbooks"
are most intt^resting contributions to the study of morbid
psychology. There was a little bw)k on jihysiology
issued once in I'hiladeipliia which, to a medical man
was inore mirth-provoking than anything ever written
by a i)rofessional humorist. Its rival has just come to
our book table — a treatise entitled The Microbe- Produc-
mtj-Dmxue Theory Incorminlent with tlie. Iaucs of Nuture
How I>iiieuiie.t are /'rodiwed A New Phyinologic(d Iaixc I^o-
midx/iUed. Schmitz Price, 50 Oents.^ From repeated refer-
1 To be had at 8321 Twenty-flnt atreet, San FranclRco, California,
the author axks u8 U> nay.
enees to his classes and the "Prof." that is placed before his
name, we take it that the author fills or overfills the
chair of Physiology in some medical college, but the
chair is so small and the author so big that we nowhere
discover the name or location or kind of a college thus
honored. It is certsiin that the entrance examinations
both of his alma mater for students, and of his present
college for Profs, could not have been of a very strict
kind, because of the most astonishing use of bad English
illustrated in every page, and in almost every sentence
of the book. In a profession as serious as ours we should
utilize all opportunities for increasing our own gaiety
and that of nations, so let us quote :
Here we notice that the law of the cycle of organic life is a
beautiful one ; that is, the dependence of the animal and plant on
the microbes ; on the other hand, the dependence of the microbes
on animals and plants. This law, strange to say, has never been
noticed, so far as I am aware.
The cause of the capillary circulation in the animal body is
peristaltic
External sensation lies in the sense-organ.
A poisonous dose of strychnine if properly eliminated, ter-
minates without killing the patient.
Suppose the bacteriologist produces the same disease in the
animal or person injected, does that prove that the microbes in
the decomposed "culture" produced the disease? By no
means. The poison of the culture done it.
Nevertheless, we know that the part the microbe plays in
the economy of nature is to separate and isolate nonliving
organic matter, fitting it forassimilation toother organic beings.
This shakes the bottom out of the niicrobe-producing-disease
theory, and confirms the already existing law that the microbes
naturally depend on the animal and vegetable, and these in their
turn on the microbes. [Double caps omitted.]
The " treatise " makes about twenty pages, but is fol-
lowed by a fourteen-page Glossary of Words and Symbols
used in this Treatise, which every lexicographer should
have, and, once having, he will surely hold. Not one-
tenth of the wondrous words, wonderfully defined, are
to be found in the previous "treatise," but — "that is
another matter." Let us cite a few definitions. Often
adjectives are defined as nouns, or vice versa, with spell-
ings that would please even the grimmest hater of
"Americanisms," or of phonetics:
Coma bacillus. A microbe having the form of a coma of
the smallest typts-print, discovered by Koch in Asiatic cholera.
Dkcay. Corruption of material substances ; decomposed
organic matter.
Life. Vitality : that state enabling metabolism within
itself; being living.
Malaria. A condition of disease produced by auto-toxlne
and caused by catcliing cold repeatedly on sultry-foggy nights
in low swampy places, where the excessive high heat in the day
time makes the air full of dust and oppression, the water foul
and stagnated, and where the heat interferes with the function
of proper digestion of the food.
Keflex (.'entue. Every nervous centre is a reflex centre.
Sensation. Vital organic representation.
Staph VLO. Bunch of grapes.
Toxical. A ^anc disease.
We are glad that in an explosion the author's "specks
saved his eyes," and that his life was also saved, the
" twitchings in the reflex centres of the spinal cord,"
subdued, and tetanus conquered, all without medicine,
and simply by hot stui)es. Mad the iu-cidcnt ended
differently we should not have had the disproof of the
absurd theory that tetanus is caused by microbes.
Neither should we have had this delightflil treatise.
484 Ajucbicjux Medioins]
AMERICAN NEWS AND NOTES
LMeptbmbeb 27, 1902
AMERICAN NEWS AND NOTES.
OENKRALi.
Preservatives In Butter.— The Commissioner of Interna!
Revenue has decided that the addition of boric preservatives in
limited quantities to fresh butter for the purpose of preventing
rancidity will not subject such butter to the tax of 10 cents a
pound imposed on adulterated butter.
Charitable Bequests. — San Francisco: Under the will
of the widow of Dr. I^evi Cooper Lane, the bulk of the estate,
aggregating over ^300,000, will go to the Cooper Medical College.
Hakbi.sbuko, Pa.: The Harrisburg Hospital will receive
$5,000 from the estate of the late Mrs. E. Kunkel, of that city.
New York City: The late John Keller bequeathed i'),000 to
the German Hospital.
Alleged. Remedy for Curing Leprosy.— It is reported
that 10 victims of leprosy in the hospital at Havana are being
successfully treated with a remedial agent obtained from red
mangrove. Drs. Duque and Moreno, under whose charge the
patients are, employ the medicine as a tonic and a .salve. These
physicians were recently allotted $2,50 a month by the House of
Representatives to continue their investigations, which were
begun under the military government, to seek a cure of the
disease.
New Sanatorium.— The Philippine commission has passed
an act which directs the governor of Benguet to establish a
sanatorium in one of the mountain towns that has an especially
salubrious climate. The institution is to be devoted exclus-
ively to the reception of civil invalid officers and employes and
their families. The governor will assign an attendant physi-
cian, surgeon and nurses to the sanatorium, which is to" be
maintained until the government buildings now in course of
construction are completed. Patients who can afford it will be
charged from §2 to $4 a day for treatment.
Antiseptic Treatment of Wounds.- The benefits derived
from this form of treatment as compared with the local treat-
ment of wounds without antiseptics which prevailed during
and before the Civil war, is demonstrated clearly by Major
Lagard, of the Army Medical Corps. According to the sta-
tistics, during the Civil war the mortality from large caliber
wounds was 53.7% and the recoveries 46.3%, while the records
since 1898 show that with antiseptic precautions the mortality
was 8% and the recoveries 92%. During the Santiago campaign,
when arms of reduced caliber were used, the record shows 100%
recoveries. Antiseptic treatment was first introduced in the
Russo-Turkish war in 1877-1878.
Pure Food Legislation.- The opposition to the Hepb
bill which has been before Congress for the last 15 years pre™
ises to be so slight in the coming session that its passage is con-
fidently expected. An attempt will also be made to amend the
law authorizing the Secretary of Agriculture to forbid the
importation of any food prejudicial to health; so that it will
read, ' or food products, the sale of which is forbidden in the
countries where they are manufactured." This, for the reason
that our lack of federal law on the subject renders the United
States a dumping-ground for goods which cannot be sold in the
placethey are manufactured, bringing to us all the misbranded
and doctored compounds of the world.
EASTERN STATES.
Mortality in Boston.— Since the beginning of July the
number of deaths has been much smaller than in the corres-
ponding period last year. Even with an increased population
there were only 1,993 deaths as against 2,143 deaths during the
same period in 1901. The deathrate among children under five
years is especially low as compared to previous summers.
Tuberculosis Inspector.— The Worcester Board of Health
will appoint an inspector whose duty it will be to detect and
report every case of tuberculosis in the city, so that steps may
be taken to prevent contagion. The new official is expected
to begin work October 1. Nearly 70% of all deaths occurring in
the city are reported as due to tuberculosis. It is thought that
the city will be able to establish a sanatorium in the near
future.
NEW YORK.
New Hospital.— Governor Odell recently laid the corner-
stone of a new hospital to be erected at Dobb's Perry on the
Hudson. Subscriptions received from a number of summer
residents furnished the moans necessary to begin building
operations. j s e
School Book Disinfection.- As a means to prevent infec-
tion from communicable diseases among school children the
Hunalo Health Board has decided to fumigate all books used in
the public schools. It is estimated that there are about 250,000
^?,ui' i? • 5°*^*^? '^'" ^^ placed in a large receptacle and thor-
ch^dx , *{f '^^S''*"^ ^''^'^ formaldohyd before being placed in the
urn
prom-
New York State Medical Society. — The following physi-
cians have been appointed to take charge of the program for
the next annual meeting to be held January 27-29, 1903, in
Albany: Ernest Wende, of Buffalo; Hamilton 1). Wey, of
Elmira; J. Montgomery Mosher, of Albany.
Ambulance Doctors.- On and after October 1 no one will
be allowed to act as ambulance surgeon in Brooklyn who is not
duly authorized by law to practise medicine. The statement is
made that in some instances young internes who are hardly
qualified for such work are puton the ambulances, and the idea
is to stop this practice absolutely.
An investigation of the excessive Infant mortality in
Brooklyn and Manhattan has been undertaken by the Health
Department. The great disproportionate deathrate has existed
for some years, but it is only recently that enough money has
been appropriated to pursue investigations. During the last
summer the deathrate in Manhattan and the Bronx climbed
from 25 to 44 in 10,000, while in Brooklyn it began at 25 and went
up to 80. Thus far much has been accomplished in equalizing
the rates by tenement house and food inspection, although the
source of the great difference is as yet undiscovered.
New York City Health Department.- During the year
the department made 3,500 more inspections of plumbing than
in the previous year; 3,000,000 more pounds of condemned food
were destroyed; |4,000 more collected in fines; 6,800 more
inspections of mercantile establishments, and 400,000 more per-
sons vaccinated. As many as 16,000 cultures were made and
examined for diphtheria bacilli during the first six months of
the year. The system of culture collection and report thereon
has been reorganized and extended all over the city so that
physicians are enabled to obtain the information they need
with greater promptness than heretofore. The department has
treated with antitoxin directly 411 cases of diphtheria in the
poorer tenement districts, and these show a very low mortality.
The success of modern medical science in combating disease is
shown from the fact that in 1894 the deaths in Manhattan and
the Bronx from diphtheria and croup amounted to nearly 2,900,
while for the first six months of this year there were only 589
deaths.
Medical Inspection of Public School Children.— The
complaints of a number of medical men who blame the lax
system of inspection in the public schools for the increased
prevalence each year of contagious diseases, especially skin
troubles, led to the inauguration in New York City, this school
term, of a new system for inspection. Formerly inspectors
were paid $.30 a month, for which they conducted a most cur-
sory examination, only a few minutes ordinarily being spent
in a day at a school, with the result that not once in a dozen
visits would the examiner find anything to do. President
Lederle now employs one doctor, where before he had three.
This man receives a salary of $100 a month and is required to
devote all his time to work, which consists in taking complete
charge of three or four schools. Under this new arrangement
each child is examined every third day, experience showing
that this frequent inspection is none too much. Out of 193,189 chil-
dren examined in Manhattan Borough the first week of the new
term 4,730 were excluded, and out of the entire city the doctors
sent home 6,524. An inspection of last year's records show
that the first 13 days of school only 66;} children were excluded,
while for the whole school term there were but 8,837. The
exclusions in Manhattan were for the following diseases:
Measles, 6; diphtheria, 2; scarlet fever, 16; whoopingcough,
17; mumps, 9: contagious diseases of the eye, 1,407; parasitic
affections, 3,087 ; chickenpox, 4 ; skin diseases, 89; catarrh, 75;
miscellaneous, 18. The eyes of all the pupils are to be exam-
ined, special attention being paid to myopia and hyperopia.
When defects are discovered prescriptions will be given for
glasses. In building future public schools a room will be
included for the special use of the health department.
PHIliADEliPHIA, PENNSYLVANIA, ETC.
Smallpox. — It is reported that 50 cases of the disease have
been discovered in the small village of Rock Run, north of
Coatesville, Pa. The town has been quarantined and aid called
from Philadelphia.
American Physician Honored by French Government.
—Dr. Ernest Laplace, of Philadelphia, has received from the
French government a decoration which carries with it admit-
tance to the Palmes Academiques.
New Jersey State Hospital for Consumptives.— A tract
of over 400 acres at Glen Gardner will be purchased as a site for
the proposed institution. The State Tuberculosis Commission
received an appropriation of $50,000 from the last legislature,
to be devoted to this purpose.
Hospital for Insane Overcrowded. — The monthly report
for the Norristown Hospital for the Insane, states that the insti-
tution is greatly overcrowded. There are 1,011 male patients,
of whom 230 are obliged to sleep in the halls, and 176 of these
have no beds but sleep on mattresses laid on the floor. Of the
1,116 female patients, 190 sleep on cots in the hall.
September 27, 1902]
FOREIGN NEWS AND NOTES
(American Medicine 485
SOUTHERN STATES.
The Tri-State Medical Society of Alabama, Georgia
and Tennessee will hold its fourteenth annual meeting in
Birtiilngham, Ala., October 7, 8, 9. A very interesting program
has been prepared.
Increased Appropriations Sought for Health Depart-
ment.— Dr. William C. Woodward, health officer in the District
of Columbia, has submitted to the commissioners estimates of
the appropriations he considers necessary for the health depart-
ment during the fiscal year commencing July 1, 1903. Among
other things lie asks that an appropriation be secured for
beginning work on the proposed municipal hospital, that Con-
gress be petitioned to provide medical inspection in the public
schools, that a public bathhouse be established, and that a
bacteriologic laboratory be instituted in connection with the
Board of Health.
Increase of Drug Habits.— Professor H. P. Hynson, of
the Maryland College of Pharmacy, states than in an investi-
gation of tills subject over 9(X) postal cards were sent to physi-
cians and druggists in various cities of Maryland, Pennsylvania
and Xew York to obtain information regarding drug-users and
the drugs most used. The physicians' reports showed an
alarming use of dangerous drugs, and it was found that each
f)liarmacist knew at least five chronic drug-takers. From the
atter fact can be deduced that there are at least 200,000 drug-
users in the United States, or an average of 3 to every 1,000
persons. A peculiar fact is that negro victims were reported
to be especially numerous.
WESTERN ST.^TES.
Chicago Eye, Ear, Nose and Throat College. — Dr. T.
A. Woodruff, editorial secretary of the Opht/ialmic Record, has
been elected Professor of Ophthalmology.
Against Child Labor. — An effort will be made to push a
stringent bill against child labor in Indiana through the next
legislature. The bill proposes an educational qualification to
hold positions.
Woman for County Health Officer. — Dr. Mary Ryerson
Butin has been appointed Health Officer for Madera county,
California. She is probably the first woman to hold such an
office, altliough in some Western States women have held the
position of county physician.
New Medical School. — The University of Nebraska Med-
ical School, which will be opened this autumn, provides for two
courses, one six years and the other four years in length. Grad-
uates of the first course will be entitled to the degrees B.Sc.
and M.D. and the second to M.D.
Child Ijabor. — A thorough campaign against child labor
has been undertaken in Chicago. The employment of children
under 14 years is to be restricted. All affidavits will be exam-
ined and when possible corroborated by baptismal and school
records. Sanitary conditions existing in stores, factories and
sweatshops will also Ije inspected.
Chicago Presbyterian Hospital. — .\n investigation into
the management of the hospital is being pursued as a result of
complaints made against it by Coroner Traeger. He claimed
that recently the death of three women patients occurred
througli carelessness. The court granted the coroner an order
to disinter the body of one of the patients in order to determine
the cause of death.
"Spotted Fever" Induced by Tick Bite.— In a former
news item on this subject, Americnn Medicine, September 6, an
error occurs in thatthe credit forthe discovery of the parasite
and method of infection was given entirely to Surgeon J. O.
Cobb in place of Drs. Wilson and Chowniug, w7io made a
thorough investigation before Dr. Cobii's arrival. A prelimi-
nary report of these investigations was published in the Jour-
nal of the American Medical Associntion, July 19.
CANADA.
Compulsory Vaccination for School Children.— The
Montreal Health Department has sent a circular to all directors
and managers of colleges, private and public schools, and (Min-
vents stating that they must insist on receiving a certificate of
successful vaccination from each child liefore it is allowed to
attend the sessions. Prompt prosecution in the recorder's
court is threatened for every violation of the law.
Exclusion of Undesiral>le Immigrants.— The new law
authorizing officials to exclude diseased immigrants or otiier
persons from entering Canada has not as yet been jiut in opera-
tion. Kegulations for enforcing it, however, are lieing drawn up
at Ottawa. The chief reason for the enactment of tlie present
law wa-s that owing to the stringency of the l.lnite<l States law
foreigners were advised to come l)y way of Canada, here they
met American inspectors with as mudi vigilance and strictness
as would beexorcisod in the Unitetl States, and as there was no
law requiring their deportation they remaine<l In Canada, the
number of those rejected by the inspectors and remaining in
the Dominion amounting from 200 to 400 persons a month. The
law, which is arbitrary rather than coirpulsory, prohibits the
landing of any foreigner who is suffering from any loathsome,
dangerous, or Infectious disease. Such prohibition may be
absolute or accompanied by permission to land for medical
treatment as provided liy order or proclamation. All persons
unlawfully landed may be apprehended without warrant by
the immigration agent or government officer and may be com-
pelled to return or t>e taken aboard the vessel by force if nec-
essary. Owners or masters of vessels who violate the ordi-
nance or refuse to take on board a rejected person, shall incur a
penalty not exceeding ?1,000 and not less than $100.
FOREIGN NEWS AND NOTES
GREAT BRITAIN.
Meeting of the Sanitary Congress in Blanchester. — In
the discussion of the measures that should be adopted for the
prevention of tuberculosis it was urged that the number of
sanatoriums be increased and the erection of liomes which breed
disease prohibited. It was announced that through the poor
rate alone England spent J5,000,000 annually on tuberculosis
and that the deathrate from the disease aggregated 42,000 an-
nually. The necessity for reform in the sanitary organization
of the British army was emphasized by Sir James Browne,
M.D., who said that during the South African war enteric fever
had reduced the fighting force by nearly 80,000 men.
CONTINENTAIj EUROPE.
3Ionuinent to Pasteur In Paris. — It has been decided to
erect the statue of Pasteur by FalguiCre in the Avenue de
Breteuil.
Germ of Cancer. — A series of experiments to be conducted
by the medical department of the University of Berlin during
the winter will have for their object the discovery of the germ
causing cancer.
The French Urologic Congress will convene at Paris,
October 2;?, 24, 25, with Professor (iuyon as president. The
chief question proposed for discussion is " The Indications for
and Results of Nephrectomy."
A monument has recently been erected in Tenon Square,
Paris, to Augustin Mfiflvier, a physician well beloved by the
Parisians for his self-sacrificing work in connection with the
establishment and conduct of a dispensary for children.
The Anti-tobacco Society of Savy. — Berlette, of Pas-de-
Calais, France, has erected a monument to Emile Dem-ois, an
army veterinarian and the founder of tlie society. The monu-
ment supports the bust of Decrois in bronze by Dcclin.
Monument to Raniond.- On August 3, 1902, there was
dedicated in BagnOres-de-Bigorre, France, at the foot of the
Pyrenees, a monument to Baron Ij. F. Ramond, doctor of laws
and of medicine, traveler, naturalist and poet. Raniond was
born in IT.IS and died in 1837. He was an intimate friend of
Hallcr, and prominent in the affairs during the first empire,
playing a considerable role in the affair of the Queen's necklace
in 1785. The bust placed on the monument is regarded as the
chef-d'fpuvre of the sculptor, Triquetti, and was made 35 years
ago.
Proportion of Carbonic Oxld Required In the Air to
Destroy Life. — Professor Mosso, of the Turin Physiologic Insti-
tute, liaii lieen carrying on a series of experiments, with a view
to discover the proportion of carbonic oxid in the air that will
destroy human life. Signer Scribante, who offered himself for
the experiments, was confined on three separate occasions in a
hernietically sealed iron room, the air of wliicli was mixed the
first time with l-;i'i3 <'arl)onic o.xid, the second with 1-28.5 and
the third with 1-233. Under the first two proportions Signor
Scribante experienced little inconvenience, lint under the third
he ceased to breathe and was found in a cataleptic state, from
which he was rescued by oxygen.
The International Congress forthe Amelioration of the
Lot of the Blind wliic'h was hold recently in Brussels, dis-
cussed the best means for the blind to earn their livelihood ; the
advantages and disadvantages of a system of "shorthand";
recreation ; causes of blindness in populous centers and the
means of prevention. In connection with the latter subject Dr.
de Mets, of Antwerp, enumerates three primary causes: (1)
(ieneral predisposition — congenital or acquire<l (consanguin-
eous marriages, alcoholism, etc.) ; (2) general or local affection
(scarlatina, typhus, et(^); (3) i>rofossional or social causes. Ho
recommends the following meiusuros of prevention: (1) Medi-
cal inspection of workshops, factories and schools; (2) improve-
ment of workers' lodgings; (3) establishmonl of dispensaries
for the blind in all centers of importance. Some interesting
information was given regarding the trcAtment of the newborn
affected with purulent liliudness, the statement being made
that out of 3,359 children treated with potassium permanganate
baths, 3,300 were cured.
486 AJIBBIOAIT MEDIOlNSj
SOCIETY BEPOETS
[Heptembek 27, 1902
OBITUARIES.
Edoardo Porro, born In Milan, 1S42, formerly Professor In the
University of Pavla, and later Director of the Gynecologic Service of
Milan. He was the author of the modifleatlon of cesarean section
known as Porro's operation, consisting In the removal of the uterus at
the cervical Junction together with the ovaries and oviducts, which
procedure he first described in his contribution, " Delia amputizlone
utero ovarica, como complements dl tagUo cesareo. Milano 1878.''
Porro was an active supporter of Garibaldi and since the unification of
Italy he had taken a prominent part in politics as a member of the radi-
cal party In the Italian Senate. His death is reported as having
recently occurred in Milan.
T. H. Phillips, a well known physician of Canton, Ohio, of heart
disease, August 30, aged 6.3. He graduated from the .Jefferson Medical
College In Philadelphia in 1SC4. He served as a contract surgeon in the
Civil war and In 18(19 went to Canton, where he has been located ever
since. He was a member of the American Medical Association, Stark
County Academy of Medicine, and the Union Medical Association of
Northeastern Ohio.
Clayton M. Daniels, a jirominent physician of BuflTaio, from blood
poisoning, September 6, aged 48. He graduated from the medical departs
raentof the University of Buffalo In 1880. For four years he was professor
of anatomy and clinical surgery in the Niagara University and was also
attending surgeon for .several railways. He was chief surgeon of the
Sisters' Emergency Hospital, of which he was one of the founder.s.
Edmund K. Perrlne, a well known ophthalmologist of Philadel-
phia, September 18. He was a graduate of the Jeffei-son Medical Col-
lege of Philadelphia, 1886, and of the lloyal College of Surgeons of
England, 1886. He was assistant ophthalmologist to the German Hos-
pital and was also ophthalmologist to the Deaf and Dumb Institute at
Mt. Airy, Pa., and to the Magdalen Home, Philadelphia.
Walker Curry, at Branford, Conn., .September 20, aged 67. He was
graduated in 1837 from the medical department of the University of
Pennsylvania. He earned distinction as a surgeon In the Confederate
Army during the Civil war. For over 20 yeare he had practised in New
York City.
Monroe T. Pultz, In Stanfordvllle, N. Y., aged 59 He committed
suicide by shooting himself through the head. He was vice-president
of the Duchess County Medical Association, a member of the New
Y'ork State Medical Association and the American Medical Association.
Julia M. Fatten, suddenly from heart disease while driving near
Somers, Conn., September 8, aged 13. She was graduated from the
Northwestern Woman's Medical School in 1880, and at the time of her
death was piuctising in Holyoke, Ma.ss.
George T. Scarburgh, of Accomac, Va., September 3, aged 66. He
graduated from the Jefferson Medical College, Philadelphia, 18.58, and
was an assistant surgeon in the Confederate Army during the Civil war.
William N. Mew, for many years chemist for the United States
Army, at Washington, D. C, September 19. He was a member of the
pharmacopeiai revision committee.
J. Francis Hamilton, at Philadelphia, September 1, aged .32. He
was a graduate of the medical department of the University of Penn-
sylvania, 1893.
James G. De I.a Fonte, at Springfield, Mo , September 5, aged 70.
He obtained his degree in medicine fronx Queen's College, London,
Eng., 18.56.
James C. Burch, at Baltimore, Md., of Bright's disease, September
21, aged 64. He obtained his degree at the University of Maryland in 1861.
Eugene E. Storck, at Buffalo, N. Y., September 10, of pulmonary
tuberculosis, aged 47. He was a graduate of the University of Buffalo.
John B. Kearney, in Oregon, Mo., September 5, aged 46. He was
a graduate of the New York Bellevue Hospital Medical College, 1881.
Kobert B. Benham, at Mabton, Wash., September 2. He grad-
uated from the Jefferson Medical College, Philadelphia, in 1876.
A. N. Becker, a recent graduate of the medical department of the
University of Pennsylvania, at Schaefferstown, Pa., aged 30.
Charles Merrltt, at Mount Vernon, N. Y., September 21, aged 89
He practised for many years in Bridgeport, Conn.
Erastus D. Williams, of North Islesboro, Me., September 16, aged
42. He obtained his degree in medicine in 1884.
John J, Schlawig, Jr., in Sioux City, Iowa, September 8, from the
effects of an overdose of chloroform, aged 35.
Caswell T. Poe, a graduate of the Cincinnati University, 1849, at
Grand Island, Neb., September 8, aged 72.
Moritz Neuhaus, of Baltimore, Md., from cancer of the stomach,
September 22, aged 57.
William Lapsley, a well known Canadian physician, at Chicago,
September 4, aged 6'J.
Chrlgtoplier M. Bell, of New York City, at Baden-Baden, Ger-
many, September 3.
Elbert A. Banks, in Columbus, Georgia, September 9, aged 61.
Edmund H. Cook, at Flushing, N. Y., September 14, aged 39.
Joseph A. Blouin, at Battleford, N. W. T., September 12.
W. B. Howard, at Troy, Ind., September 9, aged 45.
SOCIETY REPORTS
SECOND INTERNATIONAL CONFERENCE FOR THE
PREVENTION OF SYPHILIS AND VENEREAL
DISEASES.
Held at Brussels, September i-6, 1902.
[From our Special Continental Correspondent.]
Second Letter.
The first and most important division of the IJrussels
Congress, that of public prophylaxis, consumed the greater
part of the time, and yet no definite conclusions were adopted
by the congress as a whole to recommend to the different
governments. The two wings of the liouse were represented by.
Dr. Landouzy, of Paris, who summed up the opinions of those
who would abolish all legal inspection and regulation of
venereal diseases, and by Professor Xeisser, of Breslau, who
spoke for the " Regulationists." Each offered a resolution,
which was di.scussed at great length and with much excitement,
but without any result that could be expres.sed as the unani-
mous voice of the congress. Dr. Landouzy's resolution was as
follows: " Ijegal regulation of prostitution, as it actually exists
today, having been shown to be inefficacious, ought to be
abandoned. In any prophylactic measures directed against
venereal diseases, there should be a law that would affect men
and women equally."
Professor Neisser's resolution read thus : " The state has
the right, from the standpoint of hygiene, to combat, by legal
measures, the dangers caused by prostitution. The systems at
present in use, which are chiefly of a police character, should be
transformed into sanitary systems which should not be obliga-
tory, except as they are absolutely necessary to hygienic ends."
"As Professor Neisser's report was the most comprehensive
contribution to the congress, his conclusions are given almost
verbatim, for in no better language can the complex cliaracter
of the subject be shown than in the way he has handled it, not
only on paper, but in the actual carrying out of his principles
by the city of I5reslau,
In addition to the right which he maintains should be held
by the state in regulating prostitution to prevent disease, he
advances the following ideas :
1. In the efforts which are taken to prevent the spread of
venereal disease the State should not rest contented with adopt-
ing measures lor the restriction of prostitution, but should also
take advantage of the many opportunities which are offered for
contending against the spread of venereal diseases.
2. The most important and the most efficient means of pre-
venting the diffusion of venereal disease is by familiarizing the
public with the dangers and importance of these maladies.
Above all, young men should be instructed that not only is
chastity and continence not detrimental, but that these attrib-
utes are desirable from the medical point of view.
3. All measures adopted by the authorities with the object
of preventing venereal disease and of contending with the
melancholy consequences of prostitution should be sanctioned
by law. The principles of these laws should be as follows :
The administration of the law should be relegated to the
parochial or municipal authorities of each district.
4. The law should guarantee to every one suffering from
venereal diseases gratuitous hospital treatment, of which the
State should assume the expense, and for which it should erect
hospitals in every important town or community.
5. A sanitary commission should be appointed which
should be the central administrative machine which should
take all the necessary steps to ensure the treatment of venereal
patients and the prophylaxis of these diseases.
Compulsory medical notification should be introduced by
which doctors should report all persons suffering from diseases
of this character to the sanitary commission, who should lodge
a judicial complaint against anyone who persisted in a course
of conduct that would spread such diseases.
6. It is necessary to give every man in his educational
career adequate instruction in venereal diseases.
7. Prostitution itself should not, under these regulations,
be considered a misdemeanor. It should be punLshed when
the state or society are injured through the offender.
8. The State has the right to deal with existing prostitution
by measures specially directed against the dangers caused
thereby ; further, it has a duty to perform in preventing the
spread of prostitution by reforms adopted for the protection of
the community.
9. Any one who being repeatedly warned of the necessity
of obeying regulations indispensable from the sanitary point of
view, if such person or prostitute neglect to conform to regula-
tions, he or she should be condemned to detention of long dura-
tion. Prostitutes of incorrigibly bad character who defy regu-
lation should be confined in asylums or houses of correction.
10. The sanitary supervision of prostitutes should be
entrusted to the sanitary commission. Laws should l)e made
for the protection of minors analogous to the Prussian law of
July 2, 1900, to educate, treat and confine girls who are in danger
of becoming diseased prostitutes or who are already spreading
the disease.
SKPTEMBKR 27, 1902]
SOCIETY REPORTS
[Amkkican Medicins 487
When the subject of legal responsibility of transmit-
ting venereal disease was discussed it called forth opinions
from many jurists of continental reputation, whose remarks
were listened to with great interest. The technical difficulty of
holding a person responsible because he or she had communi-
cated a venereal disease to the other was shown by the fact that
so many cases were transmitted innocently or ignorantly. As
prostitution is not recognized by law, theft and violence are the
only crimes for which redress can be obtained. The difficulty
of proof as to the source of contagion, the opportunity ottered
for ijlackmail and the small chance of obtaining damages were
brought out, and the sense of the congress showed that not
much could be accomplished by making a person legally respon-
sible for the communication of venereal diseases, unless it were
proved that he was the enemy of society at large. Jurists Bell
and Le Foyer, of Paris, held, however, that the injury and
loss resulting to a victim of infection should be legally recog-
nized, and on that basis only could a satisfactory basis for legal
proceedings be established.
Prof. FouRNiEH was quoted as saying that one-fifth of all
syphilitic women have been Infected by tiieir husbands.
Divorce cannot free the wife from syphilis, nor can she oljtain
redress because of the difficulty of establishing proof against
her husljand. The only thing the law can do is to make it a
penal offense for a man who has been informed that he has
syphilis to marry. The dangers of venereal disease should be
taken into consideration in all contracts for marriage much as
other defaulting factors are provided for in business agreements.
Professor .Jadassohn, of the University of Berne, said that
the .Swiss Parliament at Berne had passed a law within recent
years making it a misdemeanor for a prostitute to continue in
her calling after a physician had pronounced her diseased.
Along this line it was clearly brought out that the State control
of the prostitute was a legal necessity because of her close con-
nection with crime, and that the abolitionists' desire to remove
this control would be a step backward.
The subject of the public dissemination of Icnowledge
was one on which most members agreed sufficiently to draw up
recommendations. It was decided that placards and signs
were less useful than books and pamphlets, but that the most
useful means were instructions in schools along the lines of the
sexual relations in plants and the lower animals, and the
removal of all mystery and secrecy from the sex of man, with-
out exciting sexual curiosity. The assistance of the clergy was
advocated as a very helpful means.
On the subject of individual prophyla.\is not much time
was spent as the subject had been incidentally touched from
every point of view in the previous discussions, but it was agreed
that as syphilis and gonorrhea constitute a menace to society
that all should be compelled by law to undergo treatment at
their own expense if they could afford it ; if not, at the expense
of tlie state, who should provide adequate means of treatment.
The suljject of a studv of the basis on which statistics
could be made was finally brought before the congress, but as
it involved so many details and provoked so much unprofitable
discussion, it was referred to a special committee.
The resolutions that were finally unanimously adopted by
the congress as suitable for recommendation to all the govern-
ments represented were in effect as follows:
That all recruits of regiments should be given a pamphlet
advising them of the dangers of gonorrhea and sypliilis, and
urging early and thorough treatment, which pamphlet the
soldier must possess with his discharge papers.
That the law should guarantee to eacli venereal patient, in
the largest degree possible, gratuitous and confidential medical
treatment.
That information concerning the danger of these diseases
constitutes the most cfUcacious means for combating them, and
that it should be taught that chastity and continence are not
only compatil)le with perfect health, I'jut most desirable.
That all statistical inquiries should be on a uniform basis
and reported to an international bureau, and that the president
of this l)ureau should transmit the general criticisms to each
government and oljtain their criticisms and suggestions.
That the problem of rational and progressive education in
sexual matters from a hygienic as well as a moral point of view
should be presented to all institutions devoted to the education
of youth. Further, tliat a commission be appointed to study
the editing of treatises along the lines of existing brochures
shall serve as means of instruction for the world in general.
An interesting feature of the congress was the perceptible
broadening oU'ect of the discussions upon the more radical
members. It was evident that some, especially among the
abolitionists, caine prepared to reform society at large by their
insistence on some line of action which they lielleved to be all-
powerful. But as experienced testimony' from every end of
the earth showed as many sides to the question as there were
social conditions the leaders of special propagandas gradually
fell into line with the greater men who still assumed the atti-
tude of seekers after wisdom.
The social functions of the congress were beautifully
arranged and in accordance with the hospitality and dignity of
the Belgian people.
The president of the conference, M. Jui.em r.E Jeune, tlie
Minister of State, gave a re<;eption to the members of the con-
gress at his stately home on the first evening. M. le Baron
VON DKE Bbuooen, the Minister of Agriculture and Hygiene,
also gave the members a further opportunity of becoming
acquainted, but the chief feature of the week was the banquet
at the Grand Hotel, where, in a dozen different tongues,
unloosed by the greater freedom of the occasion, speakers from
the whole round world inspired the assembly with the hope of
success in the undertaking of the congress.
M. Jules le Jeuue spoke most eloquently to the physicians
present, whom he said he envied, as untrammeled by the
boundaries of nations and the expediency of politics. To their
powerful intlueuce, if they would but exert, he looked for the
future betterment of the race.
CANADIAN MEDICAL ASSOCIATION.
Thirty-fifth Annual Meeting, Held in Montreal, September
i6, 17 and i8.
[Specially reported for Ameriean Medicine.]
As an evidence of the great success which attended this
meeting, the fact that more physicians registered on the first
day than on any other previous first day speaks volumes. At
the morning general session of the first day a resolution of
regret at the recent death of Professor Virchow, which was at
the same time one of appreciation for the great work of this
eminent pathologist, was proposed by Professor Adami, sec-
onded by Dr. Gardner, Montreal, and carried unanimously.
The meeting divided into sections, Dr. McPhedran (Toronto)
taking the chair at the medical session, while Dr. O. M. Jones
(Victoria, B. C.) looked after the surgical section.
Election of Otttcers.— T. G. Roddick, M. P., Chairman of
Nominating Committee, presented the report of this committee.
London, Out., was selected as the next place of meeting.
President: Dr. W. H. Moorhouse, London, Ont.
Vice-presidents : Prince Edward Island, James Warburton;
Nova Scotia, John Stewart, Halifax ; New Brunswick, W. C.
Crockett, Fredericton ; (iuebee. Dr. Mercier, Montreal ; Ontario,
Dr. W. P. Caven, Toronto: Manitoba, Dr. McConnell, Morden;
Northwest Territories, J. D. Lafferty, Calgary ; British Colum-
bia, C. J. Pagan, Victoria.
Local Secretaries : Prince Edward Island, C. A. MacPhall,
Summerside; Nova Scotia, Dr. Morse, Digby ; New Bruns-
wick, J. R. Mcintosh, St. John ; Quebec, R. Tait McKenzie,
Montreal : Ontario, Hadley D. Williams, London ; Manitoba,
J. T. Lamont, Trehern; Northwest Territories, D. Low,
Regina ; British Columbia, L. H. McKechnie.
General Secretary : George Elliott, 129 John street, Toronto.
Treasurer : T. B. Small, Ottawa.
Executive Council: Drs. Moore, Eccles, and Wishart, Lon-
don, Ont.
Medical Section.
FIRST SESSION.
Living Case, Splenic Anemia.— H. A. Lafleub (Mon-
treal) presented the patient, a man in middle life. There was a
tumor, a movable mass about midway between the lower ribs
on the left side and the crest of the ilium, with pulsation but
not expansile over the tumor. The first blood-count, made in
March, showed 75% hemoglobin, the red corpuscles 5,000,000,
the white 6,400. A blood-count made September 15, 1902, showed
4,000,000 and 5,800, respectively. The tumor changed according
to degree and distention of the stomach. There was absence of
mobility.
/>!Sc«.s.S(0)i..— OsLER referred to the difficulty and the lack of
complete mobility In diagnosing this case and of enlai^ed
spleen being often clinically mistaken for something else. This
was just one of these cases in which the diagnosis was more
surgical than clinical.
Some Further Results in the Treatment of Tubercu-
losis.—J. H. Km.iott ((iravonhurst). At a meeting of this
association in Toronto in 1899 a report was made upon 155 cases
of pulmonary tuberculosis under sanatorium treatment. This
paper is a further contribution covering some 400 additional
cases treated during the past three years. The nomenclature
used in the classification of discharged patients is that adopted
by Trudeau, "apparently cured," "disease arrested," "much
improved," "stationary" and "failed." Five years' experi-
ence has shown that almost all of the patients discharged
"apparently cured" remain perfectly well; of those with
"disease arrested" many have progressed to good health at
home by following the rules of lite learned at the sanatorium,
renewed activity of the disease when occurring having been as
a rule due to unfavorable surroundings, or the necessity of
again taking up unsuitable work. Not the least important part
of the work of a sanatorium is its educative influence. Each
patient who returns home is a teacher of the value and impor-
tance of a hygienic life to those who wish to retain their health
as well as those who are not strong. E.xperience is demon-
strating tlie immense amount of influence for good which
results from a properly-equipped and conducted sanatorium.
It is unfortunate that there are not more of tliem. It is hoped
that the attention of our philanthropists will be drawn to the
crying need of such institutions and that ere long we shall have
a number of them in tlie various provinces of Canada.
Discussion. — Osler congratulated Elliott on the promising
488 Amkbican Mkdtcinej
SOCIETY KEP0RT8
[Sbptehbbr zr, 1902
results which he has obtained. Two important points should
be kept well in mind : First, early diagnosis ; and second, get-
ting patient as soon as possible under proper professional
control. T. D. Walker (St. John, N. B.) referred to the con-
trol the physician in the sanatorium had over the patient.
.loHN Fkrouson (Toronto) spoke of the positive advances that
have been made along the line of the curability of pulmonary
tuberculosis. McPhedran (Toronto) emphasized training
patients how to care for themselves at home. He believes, too,
that it is true that the neighborhoods of sanatoriums are
always areas where tuberculosis is always diminishing.
Pleurisy as Associated with Tnberculosls.— John
HuNTKU (Toronto) first referred to the manner in which
bacilli reached the viscera and parietal pleura through the sub-
pleural, broncliial or tracheal lymphatic glands, and from the
cervical mediastinal and peritoneal lymphatics ; also from the
tonsils. In arriving at a diagnosis of pleurisy a vigilant
search should be m^e for a possible tuberculous origin. One
should not always consider the outlook gloomy, as with prop-
erly carried out treatment the progress is much more favorable
than in pulmonary tuberculosis. In at least two-thirds of
tuberculous pleurisy it is a curable affection. The rapidity of
the filling of the pleural cavity is especially characteristic of
tuberculous cases. Dwelling upon treatment during con-
valescence, deep breathing should be practised very assidu-
ously, and inflation witli rubber bags is a valuable exercise.
Then change to a suitable climate should be insisted on if the
progress toward recovery be retarded.
Clinical Notes on Blood-pressure in Diseased Condi-
tions.— A. E. Orr (Montreal) showed Gaertner's tonometer
and demonstrated the manner of its use. At the Royal Victoria
Hospital, Montreal, 400 patients were experimented on. The
normal pressure was found to be 110 to 120. Of typhoid fever,
70 cases were recorded in different stages, showing an average
blood-pressure of 104.5 mm. It was highest, but still sul)nor-
mal, in the first week. There was only one death, which took
place in a man of 35 years, in whom pressure was 105 on tenth
day, 110 on twenty-first day ; then three hemorrhages, and on the
twenty-fourth day a fatal hemorrhage. A large proportion of
these had cold baths or cold sponging. Of chronic nephritis, 19
cases were recorded. Of this group the highest was 260 : aver-
age 208.5. Of acute nephritis there were 7 cases ; only 3 oiE these
showed high pressure. Of arteriosclerosis, 27 cases were
recorded ; highest 110, 16 being 150 and over ; 4 from 130 to 145 ;
3 from 110 to 125 ; 4 subnormal. The highest was in a man of
72; glycosuria, no albumin. Valvular diseases of heart, 48
cases, including 11 cases of mitral regurgitation. In mitral
stenosis 8 oases were recorded, 6 being normal. Mitral stenosis
with mitral regurgitation, 14 cases. Eleven had practically nor-
mal tension. Aortic insafflciency, 3 cases. Myocarditis, 4
cases, one man, aged 60, having pressure of 80. Hypertrophy
and dilation of heart of unknown causation. 2 cases, 120 and 110
respectively. There were 18 cases with acute lobar pneumonia,
with an average for the series of 92.7 ; only 1 death. Pleurisy,
16 cases. Neurasthenia, 18 cases, 13 having normal pressure ; 3
from 135 to 140 ; one of 160. In malignant disease, cancer of
viscera, there were no high readines. Anemia, 6 cases, all
being normal. Addison's disease, both in early stage ; both
normal. Purpura hemorrhagica, 1 case; normal. Puerperal
septicemia, 1 prolonged case, ending in recovery, had extremely
low blood-count ; 930,000 ; above normal. One gallbladder case
with suppuration— a blood-pressure of only 50, 10 days before
death. One lead poisoning, 3 of jaundice, 1 of tuberculous
meningitis; 2 of diabetes; 2 of exophthalmic goiter ; 8 of acute
articular rheumatism, heart not affected ; chronic articular
rheumatism, 4 cases, all normal; gonorrheal rheumatism, 8
cases, 6 normal ; rheumatoid arthritis, 16 eases, 6 normal ; gout,
4 cases. There was one case of hemiplegia and 14 of tabes dor-
salis, 11 normal pressure ; cerebral tumor, 8 cases ; general
paralysis of insane, 1 case; Friedreich's ataxia, 1 with albu-
minuria, 140 ; one acute ascending paralysis, 140 ; 2 cases tic dolo-
reux, one 130 during the attack. There was one case of epi-
demic influenza and 36 miscellaneous cases.
Diseussion. — Osler considered this paper the best con-
tributed article on the sutjject.
Technic of Recording the Venous Pulse.— W. S. Mor-
row (Montreal) gave a practical demonstration on the black-
board and presented a living subject on this topic.
Surgical Section.
FIRST SESSION.
Amputation of the Upper Extremity for Sarcoma of
the Shoulder-Joint: Living Case.— J. Alex. Hutchison
(Montreal). The patient — a young woman — presented by Dr.
Hutchison gave a history of previous injury to the shoulder,
followed by the development of a growth in the head of the
humerus, accompanied by intense pain. An x-ray of the parts
revealed the presence of a large growth which invaded the joint
and involved the scapula. The patient was in an extremely
unsatisfactory condition for operation, and presented evidences
of marked cardiac disease. The incision extended from the
middle of the clavicle in front down over the pectoral regions
to the lower part of the axilla, and behind passed over the
scapula down to meet the anterior incision. After severing the
middle of the clavicle, the great vessels were ligated, the
brachial nerves divided high up, the muscles divided and the
scapula freed from its attachments. There was little hemor-
rhage, and the wound healed readily. Microscopic examination
of the growth showed it to be a mixed spindle-celled and round-
celled myeloid sarcoma.
A Fatal Case of Secondary Hemorrhage Four Days
Following the Removal of Adenoids.- Perry G. Gold-
smith (IJelleville, Ont.) dealt with the case of a child operatetl
on for obstructive deafness due to enlarged faucial tonsils. The
operation wa.s not unusual, and the condition of the patient on
the second and third day after the operation was apparently
satisfactory ; on the fourth day, however, repeated and alarm-
ing attacks of hemorrhage set in, resulting fatally in a few
hours. There was no history of hemophilia. The patient was
under the care of the family physician at the time of death, and
as no postmortem could be obtained, the cause of the hemor-
rhage remained unknown.
Occlusion of Posterior Naris. — H. D. Hamilton (Mon-
treal). The patient was a young man, aged 17, who complained
of constant discharge from right naris, with complete obstruc-
tion of the same side. Duration of the condition about 12
months. On examination the patient presented a complete
bony partition occluding the right choana. Family and per-
sonal history was negative. Treatment: The bony wall was
perforated and the opening further enlarged by graduated
bougies.
The Use of the Subcutaneous Injections of Paraffin
for Correcting Deformities of the Nose.— fi. Grimmer
(Montreal) spoke briefly of various other deformities which
had been corrected in this manner. In the preparation of the
paraffin it is first sterilized by subjecting it to high tempera-
ture. It is then injected by means of a sterilized syringe. In
the case of the nose the inner canthi of the eyes should be pro-
tected from the spreading of the parafBn by firm pressure
applied to the sides of the nose by an assistant's fingers. After
injection the parts are molded by the operator as required.
After-treatment : Collodion is to be applied to the needle punc-
ture and cold compresses to control edema of the nose and eye-
lids. Some possible dangers from the treatment are paraffin
embolism and necrosis of the skin over the parts. Dr. Grim-
mer exhibited two patients successfully treated in this man-
ner; also two rabbits which had been subjected to similar
injections.
The Telephonic Properties of the Inflamed Abdomen ;
a Sign Not Hitherto Described, Due to Paralysis of the
Bowel in Peritonitis.— George A. Peters (Toronto). In
auscultating the abdomen with a view to ascertaining whether
there was paralysis of the bowel in cases of appendicitis,
typhoid perforations, traumatism, and other conditions which
stand in a causative relation to peritonitis, Peters has observed
that where the gurgling souncls due to the passage of gas and
liquid in the bowel are absent from paralysis, the heart sounds
are invariably very plainly present over the whole abdomen.
In intense ca<-es, particularly in children, both inspiratory and
expiratory breath sounds may be heard. Peters' explanation
of the phenomena is, unlike the healthy bowel — where the gas
is retained in certain well-defined and circumscribed compart-
ments, each constituting a complete retainer in itself, with vital
walls possessing a nmscular tonicity under nervous control-^
the paralyzed bowel, by reason of its flaccid and atonic condi-
tion, permits an entire change in the disposition of the con-
tained gas ; the entire distended abdomen becomes practically
and acoustically considered, a continuous column of air or gas,
of the precise principle of the stethoscope. The effect of this is
further heightened by the rigid abdominal wall, which acts as
a snunding-board. The prognostic significance would seem to
indicate an unfavorable termination in those cases where the
sign is very well marked in cases of septic origin.
[To be concluded]
AMERICAN ASSOCIATiaN OF OBSTETRICIANS AND
GYNECOLOGISTS.
Fourteenth Annual Meeting, Held in Washington, D. C,
September i6, 17 and 18, 1902.
[Specially reported for American Medicine.]
The association met in the convention hall of the Haleigh
Hotel, under the presidency of Dr. Edwin Ricketts, of Cincin-
nati, Ohio. An address of welcome was delivered by Surgeon-
General Geo. aI. Sternberg (retired), of Washington, which
was responded to by the President.
Otticers for the Ensuing Year.— President, L. H. Dun-
ning, Indianapolis, Ind. ; first vice-president, Marcus Rosen-
wasser, Cleveland, Ohio ; second vice-president, Herman E.
Hayd, Buffalo, N. Y. ; secretary, William Warren Potter,
Buffalo, N. Y.; treasurer, X. O. Werder, Pittsburg, Pa.
Chicago, 111., was selected as the place for holding the next
meeting; time, September, 1903.
Pelvic Disease in the Young and Unmarried.— C. L.
BoNiFiELD (Cincinnati, Ohio). This paper will appear in a future
issue of American Medicine.
Removal of the Gallbladder Through the liumbar
BBFTEMBER Z7, 1902|
SOCIETY REPORTS
iAhkrican Medicine 489
Incision.— Waltek P. Manton (Detroit, Mich.). Tliis will
appear in a future number of American Medicine.
Drainage in Abdominal and Pelvic Surgery. — Joseph
Price (Ptiiladelphia, Pa.) stated thattlie more progressive and
suceessfui specialist doing painstalcing operations in every
detail, where filth and complications or adhesions were found
to exist, practised most extensive sponge pa<^king or drainage.
The modern operator did the same by his gauze pacli or the dry
operation. A number of operators doing fairly good work by
the suprapubic route condemned or partially rejected drainage.
He said some of them never learned and never would learn
how to handle drainage well. After aljandoning the supra-
pubic route these men were placed in the uncomfortable
position of admitting that drainage did what they had refused
to do by suprapubic surgery. Nothing had pleased the speaker
more in the last few years than a knowledge of the fact that the
young school of surgeons use<l drainage witli great success and
skill in spite of the fact that these young men had been under
the instruction of that class of men about the country and in the
hospitals condemning it. About all the repeated operations
were coming from operators in hospitals opposing drainage or
practising it only when they were compelled to do so, and he
thought it was curious that these men favored drainage when
they abaTidoned procedures or practised incomplete ones
The Vaginal Route for Operations Upon the Uterus
and Appendages.— J. H. Branham (Baltimore, Md.) stated
that the most common condition threatening the life of gyneco-
logic patients, caused by gonorrhea, abortion, tuberculosis and
other conditions not always discernible, and often requiring
prompt action to save life, was pelvic inflammation. Here the
vaginal method of treatment made its best showing. He had
operated on more than 100 cases Ijy this method, with but three
deaths. He concluded that vaginal drainage was the natural
method. It was far more eflfective and safer. Extensive pelvic
inflammation, associated with )>us formation, rapidly walled
ott' the general peritoneum. This wall should not be broken
through, in his opinion, and could not be interfered with with-
out daixger of general peritonitis. Opening through the vagina
was associated with a minimum amount of shock and hemor-
rhage, and was thus indicated in extreme cases associated with
severe toxic symptoms.
Ice Following Abdominal Section. — F. F. Simpson
(Pittsljurg, Pa.) advocated tlie local use of ice for the relief of
pain, to prevent or control peritonitis, and to limit the morbid
products following operation. These things, he thought, were
due almost wholly to inflammation, which was very slight and
purely traumatic in the vast majority of cases, but might be
bacterial in a very few others and in unclean cases. This use of
ice he began after observing its effects in several hundred cases
of pelvic peritonitis of all grades prior to operation. After hav-
ing seen many grave cases of this kind yield so favorably to
this measure, and having seen a few of them die later from
peritonitis following an abdominal section which removed the
great bulk of filth, leaving but little Ijehind in a fairly clean
cavity, it seemed to him that with the same infecting organisms
active in large numbers before operation, and in small numbers
after operation, we might expect like results if the same treat-
ment were employed in the two classes of cases. And further,
that by beginning the use of ice before peritonitis had actually
developed, we might succeed in preventing that condition.
The use of ice after operation in some hundreds of cases during
the last four years had been highly satisfactory.
Theoretic objections disappeared as physicians became
familiar with the use of ice. In his experience no injury to the
skin had followed its use; the healing of wounds had not been
retarded by it, and n(j depression of the general system had
been noticed. He attriljutetl the beneficial effect of cold to its
direct and deep penetration. This opinion was based upon the
known effects of cold on surface inflammation ; upon the satis-
factory results lie had gotten at the Ijetlside; upon the observa-
tions of Boklikoff, who showed that cold a(;tually penetrated
deeply into the human cavitias and tissues ; and upon his own
experiments on dogs which showed that by the local use of ice
there could lie produced within the abdominal cavity, and with-
out detriment to life or tissue, such a degree of cold as would
retard the growth of pathogenic bacteria and contract the blood
lyniph-chaunels, thus depleting the hypereinic areas and chock-
ing serous weeping into the peritoneal (lavity.
Two Fatal Cases of Tetanus Following .Ibdominal
Section Due to Infected liigaturcs, with a Plea for the
Angiotribe in Abdominal Surgery. — Waltkr B. Dorsett
(St. Louis, Mo.). Both cases, which were detailed at length,
were In women who had undergone ventrofixation of the
uterus. Tlie choice of the operation was ma<ie on account of
adhesions of the uterus to the surrounding tissues, due to pre-
vious inflammatory conditions. The material used for fasten-
ing the uterus to the anterior abdominal wall was kangaroo
tendon a little above the average size. Speaking of the angio-
tribe, he had used it successfully 25 times, as follows : Abdomi-
nal hysterectomy, 10 times; pus tubes, 5 times ; hemorrhoids,
1 : extrauterine pregnancy, 4 times; dermoid cy.st, 1; ovari-
otomy, 3 times and vaginal hysterectomy, 1. (1) Patients
upon whom it had been tried sutfered less postoperative
pain ; (2) no adhesions to stumps had foUowea its applica-
tion ; (3) no secondary hemorrhage had followed its appli-
cation ; (4) it can be applied, when two instruments wore used,
alternately by the operator and the assistant without the fear
that is incident to the slipping of a ligature knot, and in less
time.
Some Problems in Kxploratory Laparotomy. — Walter
B. Chase (Brooklyn, X. v.; said that the diversities and
uncertainties of physical signs and rational symptoms as
related to certain diseases of the contents of the peritoneal
cavity being insufficient for purposes of diagnosis, surgical
intervention might be necessary to determine the exact state of
affairs. Exploratory abdominal section for diagnostic purposes
was of comparatively recent date. Its growth had been pro-
gressive, but the limitations as yet were not clearly formulated.
Training and skill in diagnosis, judgment, having in it the
planning of soberness and daring, coupled with years of
apprenticeship would guide one to safe conclusions. In chronic
cases there might be ample time for study and analysis with
comparison of the progress and fluctuation of symptoms which
would furnish valuable data for forming deliberate judgment.
Surgical intervention was looked upon much more favorably
by a discriminating public today than formerly, so that the
suggestion by the surgeon that an operation was required
found a more ready response by the patient or the patient's
friends. The surgeon, however, owed a duty to the public
which had in many instances been neglected, namely, to make
it clear to the patient or the friends, and thus to the public, that
there was such a limitation to our knowledge that we were
perforce required to explore for causes. He believed that a
frank confession of this truth would, with right thinking
people, strengthen the position of the operator. There was a
widespread belief among the laity, not founded on fact, that
deaths following laparotomies and other major operations were
due to the operation per se, and not to the causes for which the
operation was done. The sooner these false beliefs were eradi-
cated the better it would be both for the profession and the pub-
lic. The duty of correction of this erroneous statement lay
with the medical profession.
Ruptured Pus Tubes.— Charles Greene Cumston
(Boston, Mass.). This paper will appear in a future issue of
American Medicine.
Treatment of Pelvic Abscess. — Herman E. Hayd (Buf-
falo, N. y.) said there was a class of cases in which vaginal
incision and drainage supplemented by curetage, when indi-
cated, should be first employed to get rid of the free pus, and
then later an abdominal section should be done to relieve the
patient of her suffering, when the danger and risks associated
with such an undertaking were reduced to a minimum. A
large collection of pus low down in the pelvis in a moribund
woman should be evacuated through the vagina, and nothing
more undertaken unless some grave complication set in. He
had reference to strong women who were suffering from acute
active streptococcic infection who had a high temperature, with
great i)ain and tenderness, who were in splendid physical con-
dition and under ordinary circumstances ready to submit to
capital operations, and in whom there could be felt an acutely
tender mass low down in the pelvis on one or both sides, and
even filling up the culdesac, and in whom one was positive that
there existed pus, which was easily determined by an aspirat-
ing needle passed through the vault of the vagina. In this
class he strongly recommended early vaginal incision for the
purpose of draining oft" all the free pus, and, if necessary, extend
the incision to one or both sides and evacuate tubal and ovarian
abscesses, if easily reached. This procedure was without dan-
ger, and instead of increasing the ditticulties of future opera-
tions, they were very much simplified. The size of the mass
would diminish : the immediate dangers of rupture into the
bowel and bladder, or peritoneum, were lessened ; the pain and
constitutional symptoms subsided, and the pus organisms were
lessened in their virulency, and the whole clinical picture of
the case improved and changed. Several interesting cases
were cited in which the author had practised this method with
success.
The Importance of an Apprenticeship in Operative
Gynecology.— GuRNEY Williams ( Philadelphia, Pa.) said that
the modern apprenticeship diftered materially from that of a
quarter of a century or more ago, when the specialty was being
developed by men with large and varied professional and sur-
gical experience. Again, the nature of the work in those days
differed greatly from the modern. Hospitals, now so common
in every State and city, were not giving their resident physi-
cians the practical e<lucation or using the vast amount of mate-
rial at their command for that purpose. He spoke from
experience in this matter, for after serving in two large hospi-
tals 36 months, it was necessary for him to go elsewhere for
practical instruction and tlie apprenticeship desired. All hos-
pitals, he contended, should be practical schools for the resi-
dents and the visiting medical and surgical staffs.
Technic of Biinguinal Celiotomy for Complicated
Aseptic Retroversions of the Uterus. — A. CJoldspohn
(Chicago) made a further report of remote results of the opera-
tion. The aigument ho advanced was that(l) surgical treat-
ment i:an be consistently recommended for this disorder only,
if it be not merely innocent of harmful effects to subsequent
gestation and labor, but if its good results are also not frustrated
by subsequent childbirth; (2) most of the operations in vogue
do not meet this more ideal requirement, nor have most of their
sponsors aimed so high; (3) the round ligaments of the uterus
are the only truly serviceable structures to deal with to get
such results, because they alone, as a part of the uterus, undergo
490 Ajixbican Mkdicihei
SOCIETY REPOKTS
[Septembbb 27, 1902
both evolution and involution with it during and after gesta-
tion ; (4) the route by which to gain their serviceability best is
by the inguinal canals; (5) with a proper technic the lateral
inguinal rings provide ample access for the intrapelvic worlc
in complicated but aseptic cases, without cutting and without
hernia following; (6) a table showing later results of about 35
new examined cases in addition to 72 cases previously reported
with no hernia in any of them ; (7) all known cases of subse-
quent childbirth retained their uteri, etc., in pronounced ante-
version and with good involution.
[To be concluded.]
MEDICAL SOCIETY OF THE STATE OF PENNSYL-
VANIA.
Fifty-second Annual Meeting, Held at Allentown, September
i6, 17 and 18, 1902.
[Specially reported for American Medicine.}
[Concluded from page OS.]
FOURTH SESSION.
Resolutions offered by Dr. S. Soils Cohen, reaffirming the
belief of the society in the efficacy of vaccination and urging its
necessity upon the people of the State, particularly at this time,
were adopted by the society.
Officers for the ensuing year were elected as follows :
President, W. M. Welch, of Philadelphia ; vice-presidents, H.
H. Herbst, Allentown; G. F. Bell, Newberry; G. W. McNeal,
Allegheny ; S. P. Heilman, Lebanon ; secretary, C. L. Stevens,
Athens ; assistant secretary, T. B. Appel, Lancaster ; treasurer,
G. W. Wagoner, Johnstown. The meeting of 1903 will be held
at York.
Medical State Board Sxami nations and Interstate
Reciprocity.— This article, the Address in Medicine, by
A. O. J. Kelly (Philadelphia), will appear in a future num-
hei of American Medicine,
Unilateral Renal Hematuria. — A. A. Eshner (Philadel-
phia) reported this condition as occurring in a girl of 20, it
being of 12 years' duration. Symptoms pointed to calculus of
the right kidney, but operation revealed an apparently normal
organ. The urine remained bloody for some days after opera-
tion, then cleared, and hematuria, pain, etc., have been absent
for a period of two years. Manipulation of the kidney may
have dislodged small calculi or have caused changes in the
circulation, although neither of these theories fully explain the
result obtained in this case. Eshner gave an analysis of 47
cases from the literature of the subject, 31 being females.
Discussion. — Kelly (Philadelphia) reported a similar case,
the patient having been without symptoms for 10 years since
operation. Martin (Philadelphia^ ascribes the results in these
cases mainly to the fixation of the kidney which follows opera-
tion. Hematuria may be due to a special vulnerability of the
kidney affected.
The Surgical Treatment of Gastroptosis.— HeJJry D.
Beyea (Philadelphia) reported very satisfactory results in 3
cases of gastroptosis operated by a method he devised in 1898.
The method has been used by other operators in 4 cases,
marked improvement or cure following in each of the 7. The
method in brief is the shortening of the gastrohepatic and gas-
trophrenic ligaments by means of sutures. This raises the
stomach but does not firmly anchor it as do those methods by
which it is fastened to the peritoneum or even the ribs. This
expedient is recommended by Beyea for cases which do not
yield to medicinal or mechanic treatment.
Pericardial Effusion as a Terminal Infection in Chronic
Interstitial Nephritis.— H. B. Allyn (Philadelphia). This
paper will appear in a future issue of American Medicine.
Infantile Scurvy : Report of a Case with Fracture of
the Femur and Multiple Epiphyseal Separations.— T. J.
Elterich (Allegheny) made this report. Several epiphyseal
separations occurred, and fracture of the femur at junction of
middle and lower thirds. This healed without shortening.
Hydrotherapy in Diseases of the Heart.— S. SoLis
Cohen (Philadelphia). This paper will appear in a future
number of American Medicine.
FIFTH SESSION.
The committee appointed to draft resolutions on the death
of Dr. W. Murray Weidman, of Reading, which occurred
since the last meeting of the society, presented their report,
which was adopted, Drs. Guthrie, Bishon and Cohen spoke
feelingly of the loss to the society of Dr. Weidman, and paid
high tribute to the memory of one who was a man in the truest
sense of that word.
The address in hygiene was delivered by Edgar M.
Green (Easton). One of the strongest evidences of the prog-
ress in hygiene during the past year is the increased interest
taken in the care of the tuberculous. The danger of contract-
ing this disease in the coaches and sleeping-cars was stated to
be tar less in this country than in Europe. Methods of prop-
erly disinfecting tuberculous sputum were given. Corrosive
sublimate must be of the strength of at least 5 to 1,000, and be
in contact for some time with dried bacilli. The need of
municipal hospitals in every city was emphasized. Attention
was called to the conflict of the compulsory school law and the
law requiring vaccination of school children. If the latter is
not done the former is evaded. The remedy is a compulsory
vaccination law.
The Unity and Intercommunicability of Human and
Bovine Tuberculosis.— M. P. Ravenel (Philadelphia) gave
a brief review of experiments which undoubtedly prove the
above attributes of these diseases. The fact of their unity is
based on: (1) A study of cultures of each ; (2) the changing of
human bacilli into bovine as shown by their morphology, cul-
tural characteristics and pathogenicity, by passing them
through a series of animals; (3) the gross pathology of the
lesions of each ; (4) the pathologic histology of these lesions.
Their intercommunicability is shown by : (1) The transmission
of the disease from man to animals : (2) transmission by inocu-
lation in four cases. Inoculations of human bacilli from the
mesenteric glands of a child caused the death of calves and cows
in from 17 to 27 days. Infection of man from animals may occur
by inoculation or from food. A point demonstrated is that the
tubercle bacillus may penetrate the intestinal tract and find
lodgement in the tissues without leaving a trace of such
entrance. The tonsils are probably a com mon point of entrance.
Recent Discoveries in the Domain of Etiology. — D. H.
Bergey (Philadelphia) said that recent developments pointed
to the suggestion that some of the diseases now of unknown
cause may be due to the presence of animal parasites. His own
investigations have convinced him that variola is thus caused,
the parasite belonging to the class of sporozoa, and that vaccinia
is caused by the same organism in a modified form.
The Treatment of the Infectious Diseases.— A dolph
KoBNiG (Pittsburg) announced briefly some general points to
be remembered in treating cases of infectious diseases. There
are fundamental conditions inseparable from these diseases,
and there should be like principles of treatment. Knowledge
regarding infectious diseases has greatly increased of late but
treatment largely remains symptomatic. The cause should be
aimed at, the elimination of the toxins being of the greatest
importance. The value of the ingestion of large quantities of
water in the treatment of scarlatina and like affections was one
of the points emphasized. To this should be added diuretics.
Some Observations of Typhoid Fever Epidemics
Caused by Infected Water and Milk.— I. C. Gable (York)
gave an account of the typhoid epidemic in that city in 1898,
during which there occurred 453 cases of that disease.
Review of an Outbreak of Smallpox.— A. R. Craio
(Columbia) offered this paper as a contribution to the effort to
make the masses realize the necessity and efficiency of vaccina-
tion. It detailed the history of an outbreak of smallpox in
Columbia, where there was no municipal hospital, where quar-
antine and disinfection proved of no avail and where the
authorities refused to order vaccination, because of the expense,
until virtually compelled to by the medical men of the town.
Over 86,000 had then been expended with no decrease of the
disease. At a cost of |1,300 compulsory vaccination then rid the
town of smallpox.
Discussion. — Schamberg (Philadelphia) spoke of the dis-
advantages and ineffectiveness of routine quarantine of 15 to 18
days at first inaugurated by that city. Later substitution of
two or three days' quarantine, vaccination, disinfection and
removal of actual patients to the hospital gave much better
results.
An Analysis of the Urine in lOO Cases of Smallpox.—
W. M. Welch and Jay F. Schamberg (Philadelphia). This
paper was based on 1,028 analyses of urine from 128 patients.
There is reason to suppose that the kidneys would be affected
in a disease in which, by actual computation, there occur from
30,000 to 40,000 pustules and the secretion of something like five
quarts of pus. In 66% of the cases of variola and 60% of vario-
loid albumin appeared in the urine. In from 25% to 50% of the
cases casts were present. The highest percentage of albumin
and casts occurred in a series of fatal cases. Albumin appears
early, about the fifth day of the eruption. It is also true that
albumin and easts may appear late in the course of the disease.
There is often a striking difference in the urine from day
to day.
Food Adulteration : Its Extent and Control. — An
address on this subject was delivered Wednesday evening by
the Hon. John Hamilton, Secretary of Agriculture of Penn-
sylvania. In it he stated the actual condition of affairs in the
State as found by examination of thousands of specimens of
food during the past 2J years, and then gave an outline of what
was being done for the control of the vast amount of adultera-
tion being practised. He spoke of the part played by the cook
and the employer of the cook in the adulteration of food by
improper preparation and additions. This is important and
cannot be reached by law. It is the province of the physician.
He believes that much of the sickness in military camps is due
to the foul condition of kitchen sinks. He would abolish the
kitchen ; let the men mess in fours and eat out of the dish in
which the food is cooked. An earnest appeal was made to the
society for the help of that organized body in securing needed
laws for the regulation of the food supply and in enforcing
them.
[To be concluded.]
Skptkmber 27, 1902]
CORRESPONDENCli
iAJIKItlCAN MeDICIKB 491
CLINICAL NOTES and CORRESPONDENCE
[Communications are Invited for this Department. The Editor is
not responsible for the views advanced by any contributor.]
THE TREND OF MEDICAL EDUCATION IN THE
UNITED STATES.
BY
BAYARD HOLMES, M.D.,
of Chicago.
To the Editor of American Medicine: — In order to get any
just idea of the progress of medical teaching in the United
States during the last twenty years, it is desirable to consult at
the same time tlie coincident progress of the country in popu-
lation, in wealth and in general education, and to note the
growth of the science of medicine and the growth of medical
education in Europe. The population of the United States has
nearly doubled and the wealth of the country has been enor-
mously concentrated, so that now one-ninth of the people pos-
sess at least eight-ninths of the wealth. General education
has made most remarkable progress. The ironclad graded
system in our public schools has given way to a more flexible
and natural method. The isolation of topics and the segrega-
tion of artificial groups has been displaced by the association of
language and number work with nature-study and sloyd, and
a unification of education about the interests of the child. The
elementary schools, the high schools, the college and the uni-
versity have succumbed to this educational revolution. Text-
books have been rewritten, buildings remodeled and a new sort
of teachers introduced. The needs of the student, the freedom
of the student and the happiness of the student have received
consideration. A new pedagogic literature has been evolved
utterly unlike that of twenty years ago. This spirit has touched
the professional schools only lightly, but in law there is the
" case system," and in theology the " higher criticism " to mark
its tardy influence.
The progress of medical science has been phenomenal ; 20
or at the most 25 years cover the growth of mycologic path-
ology and the era of antiseptic surgery and obstetrics. During
this glorious epoch the literature of medicine has been re-
written. Obstetrics and surgical technic have been reduced to
sciences, and medicine has been robbed of much of its mys-
ticism. To meet the requirements of this new science and these
new conditions it is but natural that the course of study for the
medical student should be extended, and that the equipment of
medical schools should be greatly increased. When we see
what has been done we should consider what remains to be
done and what has been accomplished in European schools. A
few dry figures may possibly be pardoned :
Twenty years ago we had in the United States a total of 89
malical schools with 14,934 students in attendance, an average
of 107 in eafh school ; 4,115 students were graduated, or 27% of
the attendance. No report as to the number of libraries was
made, and almost no report as to endowments. At the last
report (1901) there are 121 medical schools with 21,673 students,
an average of 179 to each school, of whom 4,720 receive the
degree of doctor of metlicine, or 21% of the attendance. The
total value of the buildings and grounds as reported to the
Bureau of Education is now 81O,2.')0,0OO, while the endowment
funds are about $2,0<X),000. It is j)robable that these sums repre-
sent only partially the resources of medicine, and that the
endowments are about twice this sum, or 84,000,000. The most
noticeable growth has been in the way of libraries. Eight
schools report libraries of such size that they could be of value
as engines of instruction. During the past three years there
have won several notable a<lvances made toward improved
medical e<lueation. The medical schools of three eastern uni-
versities have taken on renewed activity, and the medical
8<:hools of several State universities in the West have made
remarkable progress. Perhaps the most notable feature which
attracts the attention of the student of medical education is
the growing demand for thoroughly equipped teachers of the
elementary sciences, anatomy, physiology and pathology.
The medical school of 20 years ago was housed in a single
building that consisted of a couple of lecture-rooms, a laboratory
of chemistry in which students worked from two to six weeks
for a single year, a diss(wting-room and a few clinics in which
the student observe<l medical diagnosis and surgical treatment.
All of this has been changed. The amount of work required of
medical students is almost equally divided into three portions
between the time spent In laboratories of chemistry, physiology,
anatomy and pathology in the first place; in the lecture-rooms
for these subjects and the special subjects of medicine in the
second place ; and in the hospital wards and amphitheaters of
medicine and surgery in the third place. A large number of
medical schools have two or more buildings, in one of which
the clinical work is done and in the other the laboratory work
and lectures are held. A very few schools have separate insti-
tutes or departments for one or more of the major branches.
We have at least two institutes of auatomy and one institute
of pathology connected with our most advance<l medical schools.
The necessity of this method of concentrating the work of a
department in an adequate and thoroughly equipped building
becomes apparent when the work of the department is to be
prosecuted vigorously and profitably. The head of a depart-
ment of anatomy, physiology or pathology should be a man
whose life and work is devoted to advancing our knowledge in
the department over which he is placed. He should be a master
and leader in his line and known by his contributions to the
literature of his subject. Such men there are and such men
would rapidly be developed in suitable surroundings and with
adequate encouragement. Such a man should be free to select
his own assistants and conduct his department regardless of the
various governing bodies of the school. The department should
be hampered and limited only by its needs and not by the
extent of the annual appropriation for its support.
The greatest hindrance at the present time in the organiza-
tion of the medical school seems to exist in the ironclad course
of study which makes large classes necessary and thus prevents
utilizing the natural disparity between the equipment and
buildings, between the different members of the class and any
method of teaching which would divide the class. Not more
than three or four medical schools in the United States have
elastic and elective courses. Every student is obliged to appear
before a special teacher at a definite hour and undertake a
definite amount of work. No more unpedagogic or irrational
method can be conceived. There are only a few primary topics
in which a large class can be instructed with profit. The pres-
ent system demands the attention of the student to as many as
eight or ten branches and as many difi'erent professors during
a single week. This violates one of the most thoroughly estab-
lished principles of pedagogy, namely, the principle of concen-
tration and intensity of study. Until the ironclad curriculum
is broken up there is no place for institutes of anatomy, physi-
ology or pathology and there is no possibility of utilizing the
extramural clinics.
The progress of medical education has been made during
the past 20 years from three distinct motives. In the first place
the university had endowed medical education on higher
grounds and with higher ideals in at least two places in the
United States. In the second place, a few State universities
have followed the example of the endowed university in some
degree, and have provided material for a better medical educa-
tion for a larger number of students. This is notably the case
in Michigan, California and Minnesota, and in another form in
Nebraska, Kansas and Colorado. The third motive of improve-
ment in our medical education has come from the proprietary
medical schools. Some of these schools have furnished equip-
ment and instruction of a very high order as compared with
that of 20 years ago. The changes have been so rapid and the
tendency to follow good examples has been so great that there
has been a remarkable uniformity in the result obtained. At
the present time there seems to be a strong tendency to improve
the quality of the student by requiring more thoroughly edu-
cated men on admission, and to separate the study of anatomy,
physiology and pathology so far as possible from that of clinical
medicine and surgery. Nearly every well regulated school has
paid teachers of these three branches who devote their entire
time to this work, while the work of teaching clinical medicine
and surgery is left to the haphazard methods of unpaid practi-
tioners. Even these men are not always selected with any
regard for their ability to teach.
It will be noticed that the number of medical schools has
diminished during the past twenty years, both as compared
with the population of the Unite<l States, and f» compared with
the number of students in attendance. In other words, there is
a tendency on the part of colleges locate<l in some proximity to
unite their faculties and their clinical facilities, and thus dimin-
ish expenses and increase the size of classes. From the stand-
point of e<|uipment and organization this is a most desirable
tendency, and many educators look forward to the time when
no city will be large enough to hold more than one medical
faculty. From the standpoint of the student, however, the
large class is not an unmixed blessing. Dissection and labora-
tory work, oven of the most elementary and routine kind, is
extremely difHcult to carry on in classes of more than 15 or 20
students. The instruction must necessarily lie left to assistants
492 AUERICAN Medicine
COEEESPONDENCE
18BFTEHBEK 27, 1902
and student teachers, and the very valuable influence of the
mature teacher and enthusiastic professor is lost. The same con-
ditions prevail in a more exaggerated form in the clinical
branches. There, if anywhere, the student should come in con-
tact with the teacher and with the patient. If this contact is
denied by the enormous overgrowth of the class, the student
loses that most valuable instruction which he formerly had in
abundance, and possibly prematurely from his preceptor.
It is hardly conceivable that the fees of students and the
endowment of medical education combined will ever be suffi-
cient to pay enough clinical teacliers, of that quality which our
education demands, to give bedside instruction which will at
all equal in educational value that of the old-time preceptor.
Let ns imagine a school of 600 students of whom 300 are engaged
in the study of some one of the phases of anatomy. Each dis-
secting class of six sliould be under the charge of one student-
teacher or fellow. This man ought to be a graduate in medicine,
doing some original work in the department of anatomy, for
the privilege of which he receives a small compensation and
gives two liours of instruction daily. This would require 50
fellows for the whole class of 300. In order to secure proper
supervision and guidance of these fellows not less than eight
adjunct professors of anatomy and one head of the department
would be required. The institute of anatomy would then have
upon its payrolls about 60 teachers. The head professor oiight
to be a man who could command at least ?5,000 a year. The
eight associates could scarcely be secured and held in line for
less than ?2,000 a year. After the school and the department
had attained sufficient reputation and the precedent of selecting
associate professors from among the fellows had been thor-
oughly established, the 50 fellows could probably be secured for
an honorarium of ?500 a year, but this would depend very
largely on the character of the several professors. Thus the
department of anatomy would have an annual expenditure of
J4t),000 for salaries alone. Now, if the department of anatomy and
the department of physiology and physiologic chemistry, and
the department of pathology are to have about equal recognition,
the expenditure for salaries for these preliminary branches alone
will amount to nearly ?150,000 a year, and the additional expenses
of these three institutes would double this sum. When we come
to the teaching of medicine and surgery in all their various de-
partments, and when we remember that the equipment for a
laboratory of medicine means a hospital with at least as many
beds as there are students, the expense is almost appalling.
It is hard for us to believe that a medical education of this
quality and intensity can be offered to any very large number
of students in the confines of a single university campus. It is
possible, however, that the end in view may be attained by
other means. Allowing that the instruction in anatomy, physi-
ology and pathology are thoroughly conducted by the proposed
methods, the clinical work of the school could be conducted in
the various existing hospitals and dispensaries in small classes
scattered about the city. In other words, extramural teaching
could be established on an extensive scale. One city in mind
as I write has not less than 30 hospitals and other institutions in
which systematic instruction could be given, perhaps not with
the present staffs in their entirety, but with educated men
whose appointment would easily displace many of the present
incompetents, both with their ill-gotten patients and with the
hospital authorities; 60 attending men in these 30 hospitals
could give 300 students such clinical instruction on well-studied
cases as can now be offered only in the wards of Johns Hopkins
Hospital and two or three other institutions.
There is now, no doubt, a scarcity of men capable of con-
ducting adequate clinical instruction. The hospital cases are
notoriously neglected, so far as a proper study and record, and
so far as their real utility for medical teaching and literature is
concerned. This is partly due to the lack of incentive. The hos-
pital wards are closed to students and therefore to teachers, and
such medical men as teach. Open the wards to students, pub-
lish full histories of patients who die, and the body servants of
the politicians and the eleemosynary haberdasher will disap-
pear and with them the surprises which the postmortem room
now so constantly exhibits.
The State universities have a still wider and more varied,
though perhaps more difficult, field of activity. The State now
supports out of the resources of the people enormous hospitals
for the most defective classes. The medical service is farmed
out to medical men, often of narrow experience, and their work
is done without the espionage of the critical and unbribableeye
of scientific research and public teaching. Let every hospital
for the insane, for epileptics, the blind, and for the criminally
insane, become a part of the State university, and a site for
medical and sociologic instruction and study, and the standard
of our medical work would rise to a higher scientific basis,
neglect and scandal would disappear, and the State would
receive in return for its present enormous expenditure valuable
contributions to scientific medicine and a more thoroughly
trained army of physicians, which would compensate a thou-
sand times any additional expense. The almost illimitable
material of these institutions is now, so far as education and
literature is concerned, extravagantly wast«d. The ideals of
the attendants are unsupported by the scientific conscience,
and abuses not only creep in by way of business contact but as
well tlirough the ignorance or charlatanry of the politically
appointed staff. The searchlight of medical education in these
institutions would drive out ignorance and abuse and dispel a
tliousand irregularities and inhumanities. The medical school
and the State university would assume a popular and
extremely useful function and become, as they should be, the
conscience of the State.
If we will but compare our medical schools with those of
Europe we shall find a sad deficiency in this great commercial
republic. Little Switzerland has five medical schools, any one
of which would put our best to shame when measured by the
equipment it possesses, by the education it gives, and by the
contributions its faculty and students have added to scientific
medical literature. Germany, with half our population, has 19
medical schools, each of which has contributed and is contribu-
ting more to advance scientific medicine than all our medical
schools combined. France, Austria, and Italy, follow with
thoroughly equipped medical schools and vigorous productive
faculties. It is inconsistent with the resources of our country,
with the aptitude and capacity of our young men, with the
honor, dignity and high ethical standard which our American
profession has maintained, that our medical schools should
fall behind those of any European people.
The number of graduates in medicine at the present time is
not greater than the population and its diffusion, the standard
of life of our people, and the wealth of our country and cities
demand ; but the actual training of our medical schools is
embarrassingly deficient in literary comprehension, in thor-
oughness of practical bedside investigation, and in scientific
culture of the sober medical conscience.
CONSANGUINEOUS MARRIAGES.
BY
LAWRENCE IRWELL, Ph.D.,
of Bufltilo, N. Y.
To the Editor of American Medicine: — As has often been
pointed out, the problems of heredity are neglected by physi-
cians and are chiefly investigated by zoologists. This probably
accounts for the eccentric opinions held by many medical men
upon neo-Darwinism, upon telegony, etc. Your issue of June
14 contains Dr. Etnmert's oration upon State medicinedelivered
before the American Medical Association. Upon page 1025 we
find his views upon the effects of consanguineous mar-
riages. To avoid doing him any injustice I quote his words
in full: "There is not a physician who is entitled to that
name who does not know the physiologic reason for pro-
hibiting consanguineous marriages, but for the benefit of those
who do not know, I will state that besides degenerations, a mar-
riage between persons closely allied in blood is apt to produce
an offspring feeble in body and a tendency to insanity in mind."
It is undeniable that consanguineous marriages intensify exist-
ing diatheses, and that they are, as a rule, objectionable on this
account. To this rule, however, there are exceptions. Mar-
riages between .Tews who are related are not worthy of con-
demnation, for they have taken place for generations without
untoward results.
Dr. Emmert seems to believe that consanguineous unions
originate " degenerations " and are responsible for "offspring
feeble in body " and having " a tendency to insanity in mind."
After spending a considerable part of three years in the investi-
gation of the evidence which is supposed to prove that various
disorders, both physical and mental, are due to marriages of
near kin, I came to the conclusion that such unions have not
been proved to produce any disease de novo. Further, they are
not the vera causa of any " tendency toward insanity," although
they undoubtedly increase a previously existing tendency. I
feel almost certain that any impartial student of this subject
will agree with what I have written. If it is not presumptuous,
may I add that a brief historic sketch and the main points con-
cerning the effects of consanguineous marriages were given in my
article in the Philadelphia Medical Journal, July 21 and 28, 1900?
Septkmbke :
19021
SOME OBSERVATIONS IN EEGARD TO SMALLPOX iamerican medicinb 493
ORIGINAL ARTICLES
SOME OBSERVATIONS IN REGARD TO SMALLPOX.
BY
FREDERICK H. DILLINGHAM, A.M., M.D.,
of Xew York City.
Adjunct Professor df Dermatology, New York Polyclinic; Assistant
Sanitary Superintendent Department of Health, City
of Xew York.
The outbreak of smallpox all over the country during
the past four years has been the cause of a great deal of
controversy among physicians ; many failing to recog-
nize the true nature of the disease made diagnoses of
varicella, eczema, vaccinia, Cuban itch, pseudo smallpox,
Philippine rash, etc., and consequently observed none of
the necessary precautions for preventing the spread of
the malady.
The term varioloid is generally used to denote a mild
form of smallpox, modified by vaccination. We some-
times see just as mild forms of the disease in persons
who have not been vaccinated as in those who have, and
it is my opinion that all cases should be called smallpox
or variola, as otherwise a wrong imprassion may be
given to the public, many thinking that the cases are
not true smallpox.
Fifteen or twenty years ago cases of smallpox were
more or less typical in their objective characteristics, but
in late years there have been so many irregular types
seen that a correct diagnosis is, in many cases, extremely
difficult.
While I was diagnostician of the Department of
Health of the City of New York, and as such had
occasion to observe more than 1,000 cases of the true
disease, and an equal number of ca.ses that were incor-
rectly reported as smallpox, although I thought that I
ought to be able to recognize any true case of variola,
all my observations brought me to the conclusion that it,
is often one of the diseases most difficult to diagnose,
and that there are instances in which it is simply impos-
sible to make a decided diagnosis at any stage of the
affection.
A large number of physicians never see smallpox,
and the great majority of those who do see only a few
cases, and so cannot act from knowledge gained by per-
sonal observation, but for diagnostic characters must rely
entirely upon what others have written. This, so far as
the irregular class of cases is concerned, is frequently
very misleading.
For instance, in a recent article by a professor of
dermatology, the statements are made that the prodromal
symptoms are always present for three days or more ;
that the temperature falls to normal within a few hours
after the appearance of the eruption and that the lesions
are deep-seated ; also, that varicella rarely occurs in
adults, the author having seen only one case after
puberty.
Another article on the differential diagnosis between
smallpox and varicella, published this year by a well-
known authority, says that fever in smallpox lasts three
days, even in mild cases, but in varicella it is slight,
if present at all ; that the eruption in variola is a firm,
solid, reddish elevation, which continues so for at least
24 hours, and does not appear in successive crops ; that
the palm is a site peculiar to variola, and that for this
reason its involvement is almost absolutely diagnostic of
that disease, as it is observed most rarely in chickenpox,
and that the latter disease is very exceptional in adults.
The statement is also made that until the last three
years there has seldom been any controversy about the
diagnosis of smallpox. Although more of these irregu-
lar cast*) have been seen during that time a compara-
tively larg»' number have been observed in New York
during the last 10 years.
It is not strange, therefore, that health officers have
labored under great difficulties in combating the dis-
ease, as many of the cases were so mild that they were
not seen by a physician, and often when they were seen
an incorrect diagnosis was made and the nature of the
afiection recognized only after others had contracted the
disease.
A short time ago the health officer of one of the
neighboring cities called to consult me in regard to some
eruptive cases he had quarantined. He said his assist-
ant and a number of prominent physicians were posi-
tive that they were cases of varicella. Many of the
patients had slight prodromal symptoms, followed the
next day or so by papules appearing on the face and
gradually extending over the body. The eruption was,
as a rule, discrete, and the papules sharply limited, pin-
head in size and larger ; these were quickly converted
into vesicles, many of which were superficial and about
the size of a small pea ; with the vesicles were new
papules appearing ; many of the lesions became pus-
tular ; none of the patients was very sick, and the dis-
ease lasted about two weeks, leaving few scars.
The diagnosis of varicella was made by these physi-
cians on account of the lesions being so superficial ; the
eruption appearing in successive crops, and the cases all
being so mild ; some of them in children who had never
been vaccinated, and others in adults who had not been
vaccinated since infancy.
I told the health officer that he was unquestionably
dealing with an irregular type of smallpox. My diag-
nosis was made on finding the prodromal symptoms
lasting a day or more before the eruption came ; the
lesions appearing first as distinct papules, changing to
vesicles and pustules and being seen first on the face and
gradually extending over the body. If they had been
cases of chickenpox the prodromal symptoms would not
have been so marked, and the lesions would have
appeared as vesicles instead of papules, and most of
them would have been seen first on the back or on the
body instead of on the face.
During the recent outbreak, even among unvaccin-
ated persons, the disease has been so mild in character
and so peculiar in the appearance of lesions, so modified,
one might say, and the mortality so small, that in many
cases physicians have insisted that the disease was not
smallpox, and maintained the truth of their diagnosis,
even after experts had pronounced it to be such. Even
in Europe there has been a great deal of doubt expressed
as to the correctness of the diagnosis of smallpox in
many of the cases reported as such in the United States.
It is claimed by some that the disease has become
less virulent ; that this is due to a certain amount of im-
munity acquired through vaccination, not only in the
person, but through past generations. If this view were
correct, we should expect this modified form to have
been observed before the days of vaccination, when
smallpox was such a frequent disease. Another objec-
tion to this view is that the mild type of the disease has
been so universal all over the United States, even in
localities where little attention is paid to vaccination, but
it has not been seen in Europe, where vaccination is
more systematically performed.
Contrary to the general rule in infectious diseases
giving immunity, as in scarlatina, etc., these mild cases
have been seen at the outbreak, but after the disease has
lasted a year or so in any locality the type of the affec-
tion has become more severe and the mortality larger,
although a certain number of the mild cases may con-
tinue to appear. This view, therefore, can scarcely be
a<-cepted as accounting for the peculiarities of the cases
observed.
Another theory has been advanced, that there is a
diseiise between smallpox and varicella which has not
yet been recognized. A fatal objection to this view Is
that typical cases of smallpox may be contracted from
these cases, and persons who are protected by vaccina-
tion from smallpox ;irc iiiiiiiune to this socalled inter-
494 AMBBioAs MKmcnraj SOME OBSERVATIONS IN EEGARD TO SMALLPOX
[September 27, 1902
mecliate disease. In a number of Instances cases of
hemorrhagic smallpox have been contracted from these
mild cases.
In New York, patients having these irregular cases
are put in the wards with those showing typical and
severe cases, yet they never contract the disease, which
they would if they were not suffering from smallpox.
in New York City varicella is always prevalent, but
there are months at a time when there are no cases of
smallpox, and during this period these irregular cases
are never seen.
Some time ago a man in the city had a slight erui)tiou and
remained away from business only two or three days. His
physician diagnosed it as chicl^enpox. During the next five
weeks other members of the family contracted the disease and
it was considered that they all had chickenpox, until a younger
child died from confluent smallpox. A diagnostician of the
Department of Health visited the house and found a servant ill
with smallpox, the other patients having recovered. There had
been no other cases of variola in the neighborhood, but, un-
doubtedly, they had all been oases of that disease.
Smallpox is one of the most contagious of the exan-
thems and few persons exposed to the disease escape it,
unless protected by a previous attiick or by vaccination.
An attack of smallpox gives immunity for a longer
period than a single vaccination does, but my experience
has been that a recent successful vaccination more surely
gives Immunity than an attack of smallpox of some
time past. I have seen persons who have had the dis-
ease two and three times, but never one who contracted
it after a recent successful vaccination. None of the
diagnosticians of the Department of Health of the city
of New York or nurses of the Smallpox Hospital ha^
ever contracted the disease, and they are protected only
by recent vaccinations. To obtain complete immunity
from the disease for life it is usually necessary for the
person to be successfully vaccinated several times. The
correct plan, I believe, is to vaccinate a child at the age
of three months, again at five or six years, a third time
at the age of puberty and once or twice during adult life.
In some persons the immunity lasts much longer than
in others.
Although glycerinized virus is in every respect pre-
ferable to humanized lymph the latter gives longer im-
munity.
If a child is liable to be exposed to smallpox, I would
vaccinate it as soon as it is born, although it is often dif-
ficult to obtain a successful result so early in life, and it
may have to be repeated. I have seen several children
who contracted smallpox before they were a month old.
I have vaccinated more than 100,000 persons, and
have never yet failed to obtain a successful primary vac-
cination, although in a few instances I have had to vac-
cinate several times.
The contagium of smallpox is present in the exhalar
tions and secretions, and especially in the crusts. During
convalescence the scales, as a fine powder, are carried
some distance. There is no danger of contagion during
the period of incubation, and my experience has been
that it is much less during the prodromal symptoms than
after the eruption appears. In the general hospitals,
where patients are carefully observed, and isolated on
the first appearance of the eruption, we find that there
is not much danger of contagion.
Although there is a difference of opinion, I do not
think smallpox can be communicated by means of pus
secreted from sinuses, boils, etc., after the patient has
otherwise recovered from the disease. Dr. William H.
Park, however, is conducting some experiments that
will soon settle the question.
The period of incubation lasts from 7 to 21 days,
although it is not often longer than 15, and 14 is the
usual limit. Some time ago the rule of the Department
of Health was to keep persons who had been exposed to
the disease under surveillance for two weeks from the
last exposure, unless they were immune by a recent
vaccination, but the diseases developed in some instances
after a longer period and it has been deemed advisable
to extend the time to three weeks. It is not necessary,
however, to keep a person under surveillance for more
than 15 days after a successful vaccination.
About 15 years ago a vessel arrived at quarantine with
smallpox on board. The diseased persons were removed to the
hospital, the vessel disinfected, and the crew taken to Hofif-
man's Island, where they remained for 14 days, when, having
shown no signs of the disease, they were discharged after hav-
ing been successfully vaccinated. Three days later (17 days
after the last exposure) one of the men applied at a police sta-
tion for shelter, and on informing them that he had beeu on a
smallpox ship, an ambulance surgeon was promptly called,
who found an eruption on the man's leg and pronounced it
smallpox. I found that he had been successfully vaccinated 13
or 14 days before, and the vaccination had run its regular
course. He had no elevation of temperature and said that he
felt perfectly well. On his legs was an old eruption of purpura
haimorrhagiea. On examining him carefully I found two or
three vesicles on the fauces, and five or six small shot-like
papules on his forehead, each about the size of a pinhead, and
evidently of only a few hours' duration ; in fact he had not
noticed them himself. There were no other lesions on the
body. As they were fairly typical of smallpox, I thought it
best to send him to the Reception Hospital for further observa-
tion. 1 saw him the following day, when there was no diffi-
culty whatever in making a positive diagnosis. The lesions on
his forehead had become vesicular, and there were a few typical
papules scattered over the wrists and body. He had no other
symptoms, nor did he have any during the time he was in the
hospital. The lesions were very discrete and ran their course
rapidly, so that he was discharged in 10 days.
I have seen several other cases in which the period of
incubation was probably over 14 days, and there are
cases on record in which it was 20 days.
The invasion is usually marked by a chill (often con-
vulsions in children), intense headache and severe pain
in the back and limbs. There may be delirium, and
vomiting and nausea are often present. The tempera-
ture, as a rule, is high, and may reach 104° or 105° on
the first day ; pulse rapid and full ; skin dry, and face
flushed.
Usually the prodromal symptoms give some indica-
,tion of the severity of the disease, but I have seen cases
in which severe preliminary symptoms were followed
by a very discrete eruption, and again a confluent form
in which there were very slight prodroma.
Before the true eruption comes, usually on the second
day, a rash sometimes appears ; this is either scarlatini-
form, morbilliform or purpuric in appearance, and is
most frequently seen in the milder cases, more often in
men than in women. Its favorite locality is the inguinal
region, next in frequency it is seen in the axilla, but it
may also appear on the back and arms. As a rule, it
vanishes with the appearance of the papules. The most
common variety is the scarlatiniform. Its prol)able
cause is a disturbance of the cutaneous vasomotor system.
Another form is the hemorrliagic, which appears earlier,
often on the first day, and the eruption is very intense
with petechias, and covers the body and extremities.
Hemorrhages take place in the conjunctivas and various
mucous membranes and persist after the papules appear,
unless the patient dies in the meantime.
A case occurred in this city last year in which a man died
before the appearance of any papules, and his physician diag-
nosed it as malignant scarlet fever. Fourteen days later two
other members of the family developed smallpox, and subse-
quent investigation showed that the man had undoulitedly died
from that disease.
Another case was that of a woman who died after two days'
illness with a marked hemorrhagic eruption over the whole
body, with hemorrhages from the uterus, bowels, kidneys and
mucous membrane of the mouth. Careful inspection just
before death showed three or four smallpox papules on the
soles of the feet, but none on the rest of the body.
A short time ago a physician told me of what he con-
sidered the worst case of scarlet fever he had ever seen.
I asked him if there were hemorrhages in tlie conjunc-
tivas, and on his informing me that there were, I told
liim tliat it was probably a case of hemorrhagic small-
pox. This it proved to be.
I have known a number of similar cases in which
September 27, 1902]
SOME OBSERVATIONS IN REGARD TO SMALLPOX iakbbican medicine 495
death took place before the appearance of the regular
eruption, and no correct diagnosis was made until after
other members of the family had developed smallpox.
Sometimes the hemorrhages do not take place until the
vesicles or pustules are formed, and the later this occurs
the less unfavorable the prognosis. These are not true
cases of hemorrhagic smallpox, although they are some-
times so designated.
In a typical case of variola the eruption appears on
the third or fourth day as small red spots, which in a
few hours become papular; the papules are elevated,
indurated and seem shotty to the touch. It is usually
seen first on the mucous membrane of the mouth, then
on the forehead and wrists, then spreading over the face
and arms, and gradually extending over the whole body,
as a rule appearing first where there is the greatest sup-
ply of blood. The lesions have also been found in the
larynx, esophagus, stomach and rectum.
With the appearance of the eruption the temperature
generally falls, and the premonitory symptoms disap-
pear, but sometimes they continue for several days. The
papules increase in size, turn to vesicles with clear con-
tents on the fifth or sixth day, and then become umbili-
catefl. The eighth day the contents become yellowish
in color, the shape of the pustules change, becoming
globular, and the umbilication disappears ; there is an
areola around the pustules, the face is swollen and the
eyes may be closed ; the edema is usually intense enough
to cause considerable pain.
With the pustulation the fever and the general symp-
toms recur ; these latter may be very severe. They sub-
side after two or three days, although in some cases they
persist for a week or more. The pustules begin to dry first
on the face, following the course of the eruption. They
break and crusts are formed, and it may be some time
before they all disappear.
In confluent cases, which as a rule occur in persons
who have never been vaccinated, the symptoms are
more severe, and the lesions run together and coalesce.
The face is swollen and has a flat appearance, so that
often the patient cannot be recognized. The eruption
maj' be confluent on the face, hands and feet, and dis-
crete on the rest of the body. The severity of the dis-
ease can often be judged by the number of lesions on the
face.
In mild or modified cases there may be only a few, if
any, prodromal symptoms, the patient merely having a
feeling of malaise; the eruption may perhaps be the
first thing he notices, and this may be very slight and
may run a very irregular course. The lesions may be
very small and may dry in a few days, some of them
not advancing beyond the papular stage ; again, they
may run a typical course until they become turbid, then
there is a retrocession as in varicella. Some times the
lesions are very superficial and become vesicles during
the first 24 hours, appearing first on the body instead of
on the face. In a small number of mild cjises hemor-
rhages take place in the pocks on the legs during the
vesicular stage, and then the lesions abort. The hemor-
rhagic or confluent form is often contracted from the
mildest cases.
The lightest case I have seen was in a boy of 6 years who
wa8 .sviccessfully vaccinated for tlieffirst time 12 days before,
when his brother waa removed to tbe hospital witli smallpox.
I saw him the day before the eruption appeared ; he had no
fever, felt perfectly well and there was uothine on the skin.
Twenty-four hours later, although there was iiotninK to be seen
In the mouth, he had two small papules on his right wrist and
one on his forehead ; these were snotty, elevatoiiand firm. There
was no elevation of t<)mi)erature and he liad no symptoms dur-
ing the whole course of the disease. The next day I found six
lesions on the face and wrists; those were vesicular and some
of them were umbilicated. No other lesions appeared and all
disappeared in seven days, leaving very superficial scars. ,
Another very mild c*so was that of a child of seven years,
five years after a successful vaccination. There were no subjec-
tive symptoms, and aliout 20 superlicial characteristic vesicles,
similar to those in the other case, were scattered over the body.
They all disa]ipeared in ten days.
In both cases there was no difficulty in making a
diagnosis, but the disease might not have been recog-
nized if attention had not been called to it by the previ-
ous cases in the family.
I have never seen smallpox occurring within a shorter
time after a successful vaccination, and Dr. William M.
Welch, in a recent article, says that he has never seen it
within five years. However, some cases have been
reported, and although there may be a question as to the
quality of the virus and whether the vaccination was
successful, I think it safer to revaccinate persons who
may be exposed to the disease, even if they have been
vaccinated within five years.
A woman of 22, who had not been vaccinated since child-
hood,'gave the history of having a slight headache for a few
hours, but no other symptoms. The next day she noticed
3 or 4 papules on the face, followed by about 40 or 50 on the
body and extremities, each about the size of the head of a pin,
a few being larger. They quickly became vesicular, and a few
were pustular ; none of them was Irregular in shape. The
lesions were very superficial and the tops could be easily
knocked oft. The fourth day they commenced to dry down,
most of the crusts being no larger than the head of a pin ; they
all disappeared within ten days, leaving a very few superficial
scars that were scarcely discernible.
The diagnosis was between smallpox and varicella,
and that of smallpox was made on the fact of the erup-
tion appearing first on the face, forming vesicles soon
after, and later on turning into pustules ; also that most
of the lesions were very small and of about the same
size, and that there were no large, irregular, flat lesions,
such as are seen in varicella.
A woman, aged 25, vaccinated in infancy, had headache,
slight fever and backache for three days, after which they dis-
appeared ; she then noticed a few small vesicles, piubead in
size, on the abdomen ; these were followed by papules ou the
face and over the whole body. I saw her on the third day after
the eruption. The lesions were vesicular, discrete, pinhead in
size, and fairly superficial ; many on the body and legs were
slightly hemorrhagic and drying down, but they did not rup-
ture. There were a few vesicles on the palms of the liands and
soles of the feet, but no large or irregular lesions anywhere ou
the body. There was no pustulation or secondary fever, and
the lesions disappeared in about two weeks. She was vaccin-
ated on the first appearance of the eruption, but it was not
successful.
Syphilis was excluded on tlie prodromal symptoms, on
their disappearance ou the coming of the eruption ; on most of
the lesions appearing as papules and becoming vesicles ; on
their short duration, and on the absence of marked grouping.
Varicella was out of the question, also, on account of the
prodromal symptoms ; most of the lesions appearing as pap-
ules, all about the same size ; and there being no large, flat, irreg-
ular lesions, such as are seen in varicella.
A diagnosis of smallpox was made on the prodromal
symptoms ; most of tiie lesions appearing as papules of
about the same size, and being present on the palms and
soles. My diagnosis was doubted until her brother was
taken ill with semiconfluent smallpox two weeks later.
We find every gradation, both in the symptoms and
in the character of the eruption, between such mild
cases and the hemorrhagic and confluent forms.
Some years ago I saw a woman who was admitted into
Bellevue liospital for tonsillitis. The nurse said there was no
eruption noticeable when the patient entered, but the next
morning she observed some on the face and neck. I saw the
patient about an hour later, and there were then a few small vesi-
cles on tlie mucous memlirano of the mouth, and about a dozen
vesicles on the face and neck, all of them superlicial and irreg-
ular in shape ; three or four of them had ruptured, forming
crusts. The lesions were very similar to those in varicella, but
as tliore was none on the back or body, I considered the case
suspicious and liad the patient isolated. She was seen again in
the afternoon, when a number of characteristic smallpox
papules had appeared, and she was sent to the smallpox hos-
pital. I saw her there two days later, and the eruption was
feneral, but apparently of the seventh day instead of the third,
n this case only the first lesions were superficial, but In many
cases seen during the past three years all the lesions have been
superficial, and many flat and irregular In shape, and at no
time have there been any typical classic lesions of smallpox.
These are the cases that are most difflcult to diagnose,
especially when the lesions, instead of appejiring first on
the face and extending over the body, come out in sue-
496 AKEBicAs medicinbj 80ME OBSERVATIONS IN REGARD TO SMALLPOX
[Septehbeb 27, 1902
cessive crops ; so that we find papules, vesicles, pustules
and crusts in the sanae area.
The first well-marked case of this character that I ever saw
was in an Italian, about 10 years ago, and I made the diagnosis
of varicella. Several experts, who also saw the ease, agreed
with me. When I saw him first he had evidently been ill about
10 days, but I could not obtain any reliable history. He had,
scattered over the whole body, a discrete eruption, consisting
mainly of rather superficial pustules about the size of a small
pea, and crusts. There were also some vesicles and commenc-
ing papules. On the abdomen were papules, vesicles, pustules
and crusts, and traces also showed where the crusts had been
thrown off. Many of the lesions were fairly superficial, and
the duration of most of them was only a few days. A short
time after this several other members of the family developed
smallpox ; I changed my diagnosis, and he was sent to the
hospital.
About the same time I saw a young man with a profuse
eruption covering the whole body ; the lesions coming out in
successive crops, so that there were papules, vesicles and pus-
tules side by side. I made a diagnosis of varicella, and several
experts, who had also seen the case, made the same diagnosis
until his brother developed a typical case of smallpox.
In both cases I discarded the thought of smallpox
on account of the polymorphous eruption. At that time,
so far as I know, there had been no similar case reported,
and all the authorities maintained that such a condition
could not exist in smallpox. Since then I have seen a
number of such cases, and they have also been observed
by others. It is claimed by some that when a polymor-
phous eruption is present, it is a combination of small-
pox and some other disease. In the cases I have seen
all the lesions have been those of smallpox.
The following case shows a peculiar distribution of
the lesions :
A man the second day of the eruption had only three or
four papules on the face, and not more than a dozen on the
chest and arms, while the back was thickly covered with them.
With the exception of that on the back, the eruption remained
discrete.
An interesting case was seen by one of the inspectors
of the Health Department about 30 years ago, and I think
it was never reported :
A woman nursed her husband, who was attended by Dr.
Charles W. Packard, during an attack of confluent smallpox.
She was pregnant and gave birth to a six months' fetus which
had on the face and body pustules, apparently of the eighth day
of smallpox. The mother had had no eruption nor any of the
other symptoms except pain in the back, which was attributed
to her condition.
I have never seen a similar case, but have observed
several in which the disease had been contracted in
utero and the mother had the eruption. Almost invari-
ably the mother will abort, and I have seen a number
of cases in which the child was born with the eruption,
and others in which it developed a few days later. Also
one or two cases in which the child was vaccinated at
birth and escaped the disease.
The question is often asked whether it does any good
to vaccinate after a person has been exposed to smallpox
and probably contracted it. As a rule if the vaccination
is performed the same day as exposure, and is successful,
it will give immunity and the person will have no signs
of smAllpox. Vaccination a week later will have no
effect on the disease, but two or three days after expos-
ure, while it may not prevent it, will greatly modify the
smallpox.
The vaccination runs its regular course until the
eruption appears. If the areola is fully developed the
disease is modified, but if it is not well marked there is no
further advancement, and the vaccination quickly dries
and has little if any effect on the course of the disease.
A patient presenting an interesting case of smallpox
walked into Dr. A. R. Robinson's class at the Polyclinic a few
weeks ago to be treated for a burn on the right side of tlie face,
extending from the hair to the lower jaw. It was about IJ
inches wide, one inch being rather deep, involving the true
skin, the rest superficial, involving only the epidermis. He
had other lesions on the face and on the body, but these he did
not consider to amount to anything ; they had appeared the even-
ing before. On the mucous membrane of the mouth were a num-
ber of well-defined vesicles. The part of the face not affected by
the burn was thickly covered with papules about the size of a
small pea, elevated, firm and sholrlike in consistency. Similar
lesions were on the wrists, body and palms of the hands. The
area occupied by the superficial burn was thickly studded with
a number of lesions, not elevated and apparently macules, hut
where the burn was deep there were no lesions. A few shotty
papules could be felt under the skin on the legs. Besides the
papules on the right side of the neck there were three large
vesicles, irregular in shape, superficial and flat, resemljling
varicella. On the flexor surface of the right arm were four
indurated, utiiVjilioated vesicles, the size of a small pea. None
of the lesions were 24 hours old.
Dr. Beery, resident physician at the Smallpox Hospital,
rei)orted a few days later that the whole face, with the excep-
tion of the area of the burn, was covered with a semiconfluent
pustular eruption. On the superficially burned area the erup-
tion was pustular, but not elevated, and dried down quickly.
At no time were there any lesions on the deep portions.
This case is reported to show the behavior of the
eruption on a recently burned skin.
A man of about 35 years, who was vaccinated in infancy,
gave a history of headache, with a temperature of 106°, which
temperature became normal on the appearance of an eruption
on his face and body. I saw him three days later. On his face
were eight deep-seated pustules the size of a small pea. On the
back, chestand arms were a large number of vesicles, varying in
size from a pin-point to that of a small pea; all very superficial
and some just appearing. These lesions were similar to those
of varicella. On the back were also a few large, deep-seated
pustules, due to a mixed infection and similar to those seen in
a pustular syphilid. On the palms and soles were seven char-
acteristic smallpox papules, also one on the back of the left
hand, three on the wrists and a few on the legs. On these, and
the lesions on the face, a diagnosis of smallpox was made. If
they had not been present, it would have been impossible to
have made a diagnosis from varicella.
I saw another patient of Dr. A. R. Robinson's, a man
who had a pustular eruption from taking potassium
iodid. The lesions on the face were similar to tliose I
had seen in several cases of smallpox, and from them
alone a differential diagnosis could not have been made.
However, from the history and from examination of his
body there was no difficulty in making a correct diag-
nosis.
To show how extremely difficult it sometimes is to
make a correct diagnosis, I cite the case of a child, two
years old, who had never been vaccinated. It differed
in some respects from any case I had ever seen, and I
said that a diagnosis between variola corymbosa and
varicella could not be made.
The little patient was isolated and all precautions taken just
as though it were a case of true smallpox. The eruption
appeared first on the face as vesicles, pinhead in size ; these
dried down in two days, while similar lesions were appearing.
Covering an area of about three by four Inches in both groins
were a large number of distinct vesicles, all about the size of a
small pea, closely clustered together, fairly deep-seated, ele-
vated, firm and umbilicated. Surrounding these clusters the
skin was clear. On the back were a few vesicles, varying in
size from a pin-point to that of a small pea, fairly superficial.
A few discrete vesicles were present on the arms and legs, also
on the palms and soles, and while these lesions were drying
down a new crop appeared. At no time, however, were there
any lesions on the chest or abdomen. The child died on the
eighth day of the disease from edema of the glottis, and sepsis.
I saw the child again after death and noticed in the inguinal
region and on the arms and legs a number of deep-seated pus-
tules and crusts, similar to those in smallpox.
The character of the lesions on the face and back,
and their manner of appearing, and their course, would
favor a diagnosis of va^-icella, but the cause of death,
the eruption in the groin, and the deep-seated lesions on
the arms and legs made me incline toward a diagnosis
of variola. All those exposed to danger from the child
were immune from smallpox by vaccination, so that
there were no secondary cases which might have aided
in the diagnosis.
It is impossible to make a diagnosis before the erup-
tion appears, except in the pure hemorrhagic form ; but
.after a possible exposure to the disease, chill, fever,
headache and severe pain in the lumbar region should
make one suspicious and cautious as to diagnosis.
The eruption appears first on the mucous membrane
of the mouth, although in many cases it may not be
September 27, 1902]
SOME OBSERVATIONS IN REGARD TO SMALLPOX [American Medici>-e 4S7
present ; next on the forehead, at the margin of the
hair, and on the wrists. One can often hasten its appear-
ance on the body by a hot bath or by the application of
poultices. In doubtful cases the fact that the patient had
been recently and successfully vaccinated before a pos-
sible exposure is of great value in excluding smallpox,
and I think this fact is often not sufficiently considered.
Smallpox has been confounded with many diseases,
but those most likely to give difficulty are varicella,
measles, scarlet fever and syphilis.
Some physicians think that smallpox and varicella
are not distinct diseases, but I believe there is no reason
for such an opinion. A case of smallpox has never been
known to be contracted from varicella, nor has the re-
verse ever been true.
Chickenpox cannot be transmitted by inoculation, as
can smallpox. An attack of chickenpox does not give
immunity from smallpox, nor does an attack of small-
l)ox prevent a possible attack of chickenpox. Patients
ill with smallpox have contracted varicella and yfce versa.
Patients with chickenpox can be successfully vaccinated.
Lately we have vaccinated a large number of persons ill
with smallpox, and in no case has the vaccination been
successful.
In Xew York we always have varicella, but there are
years when there are no cases of smallpox, and beside,
vaccination gives no immunity from varicella.
Dr. William H. Park, of the Department of Health,
has made a number of interesting exijeriments by inocu-
lating monkeys with the secretions of the lesions from
persons ill with smallpox, and also from those suffering
from varicella. He obtained successful results in all
cases of vaccination with virus from smallpox, but
failed entirely when secretions from lesions of chicken-
pox were used. He is continuing his experiments, and
we may soon have a valuable aid to diagnosis in doubt-
ful cases. The objection to this method is that it some-
times requires three or four days to determine the result,
and in a majority of the cases it would be possible in
that time to make a diagnosis from the lesioas of the
patient.
In typical cases there should be no difficulty in mak-
ing a diagnosis of smallpox or varicella, but there are
cases of smallpox milder than the majority of cases of
varicella, and on the other hand I have seen cases of
varicella as severe as many cases of smallpox.
It is the unusual cases that are of especial interest to
the physician, and in these a diagnosis is often most dif-
ficult, even for one who has had a large experience.
Most authorities give some diagnostic i)oints, but
many of them are misleading, as there is not a symptom
or character of a lesion that is found in varicella that I
have not seen in smallpox, and the only way a diag-
nosis can be made is by carefully considering the history,
symptoms and character of the lesions, and even then
several examinations may be necessary before a conclu-
sion can be reached.
It is claimed by many that varicella does not occur in
adults, or that cases are extremely rare, but this is of no
value in making a diagnosis. I have seen a large num-
ber of such cases, and my experience has been that they
are very often severe.
Some of the severe cases of varicella with deep-seated
lesions are very difficult to diagnose.
I remember a most interesting case in whicli the
patient was a physician, whom I saw tlirough the cour-
tesy of Dr. A. R. Rol)inson, wlio liad made a diagnosis
of varicella, principally from the fact that all the lesions
commenced as vesicles and none as papules.
When I saw him on the second or third day of the eruption
it would have Ijpoii iiiiposNililo for any one to have made a posi-
tive diaffnosis from smallpox from seeing the lesions alone,
witliout IjnowinK their liistory. He gave a history of severe
headache, pain in the lumbar region, and fever, with marked
constitutional disturbance. The face and the whole body was
covered with vesicles about the size of a split pea, many of them
umbilicated and very few superficial. They were also present
in the mouth and on the palms of the hands. A day or two
later the diagnosis was simple. New vesicles were forming,
the older ones were drying and the contents exudiug, forming
crusts. Besides these there were many new, flat, irregular
lesions, especially on the back and chest.
A short time ago in consultation I saw a young lady
of 18 years who was supposed to be sutTering from a case
of modified smallpox.
She gave the history of headache, pain in the back, slight
constitutional symptoms, with a temperature of 101°, and on
the following morning she noticed two lesions on the left side
oi her neck, followed a few hours later by others on her fore-
head, the eruption gradually extending over the body. She
complained only of the discomfort caused by the lesions, and a
sore throat. On the fauces were distinct vesicles the size of a
suiall pea. The forehead and fjice showed about a dozen vesi-
cles, shot-like in character, some slightly umbilicated, also a
few lesions which appeared to be papules, but careful examina-
tion showed that they were commencing vesicles. These lesions
were all about the same size, none of them irregular in shape or
very superficial, and from them alone a diagnosis could not have
been made of either smallpox or varicella. On the left side of
the neck were two vesicles about i of an inch long by i of an inch
wide, elevated, flat, fairly superficial, irregular in shape; the
center had dried, forming a crust. The neck and chest was cov-
ered with a discrete eruption, consisting of vesicles, some piu-
head in size and some larger, some deep and firm, others super-
ficial, surrounded by an inflammatory area. A few lesions,
superficial, slightly elevated, pin point in size, were appearing;
these quickljr became larger and vesicular in character. The
same condition existed on the arms, although there were very
few lesions. The back was thickly covered with vesicles, some
of them just appearing, varying from pin-point to that of a
small pea in size. The majority were superficial but a few were
deep and firm. Two vesicles were large, flat, and irregularly
shaped. The lesions were just beginning to appear on the legs
and there were very few small vesicles. There were no lesions
on the palms of the hands or soles of the feet.
The diagnosis of varicella was made from the lesions
on the back and chest, there being no distinct papules ;
the life duration of individual lesions being short, most
of them superficial and irregular in size, the four large,
irregularly-shaped lesions and fully-developed vesicles ;
from the appearance of the new, superficial, pin-point
vesicles, with slight Infiammatory area ; and from the
fact that there was none on the palms and soles, and
very few on the wrists.
Some claim that lesions are always present on the
palms and soles in smallpox and never in chickenpox,
but this is not correct. I have seen many cases of variola
without lesions in those localities and a number of aises
of varicella in which they were present there.
The first such case of varicella that I saw was years
ago, in a boy of 7 years, who was vaccinated in infancy.
He had severe prodromal symptoms, delirium and a tem-
perature of KM", followed 24 hours later by an eruption that was
characteristic of varicella. There were vesicles In the mouth
and lesions on the palms of the hands and soles of the feet, but
there was no doubt as to the diagnosis.
The following points will aid in a differential diag-
nosis between a classical case of smallpox and varicella,
as these diseases usually appear. In the unusual varie-
ties there is great variation in the symptoms, and not
one of them alone can be relied upon.
In smallpox the invasion is usually more severe and
lasts three or four days, while in varicella the eruption
appears on the first day, and there is no secondary fever.
In some cases of smallpox the invasion is not noticed, or
does not last over 24 hours, and there may be no second-
ary fever.
In smallpox the eruption appears first on the mucous
membrane of the mouth, then on the forehead and
wrists, while in varicella, although it may be present in
the mouth, it is seen first on the shoulder and chest. In
smallpox it is on the exposed parts, while in varicella,
on the parts covered. However it may be seen on other
localities in both diseases.
In smallpox the temperature falls with the apjiear-
ance of the eruption, while in varicella it rises 1° to 2°
while the eruption develops. It may, however, con-
tinue in smallpox.
In smallpox the lesions are more uniform, and are
498 AxxBicAN Medicine]
THE TYPHOID-COLON GROUP OF BACILLI
[Septkmbek 27, 1902
deeply seated, while in varicella they are superficial, flat
and irregular in shape.
They may, however, be superficial in smallpox and
deep-seated in varicella, but in the latter it is very rare
not to find some large, irregular lesions, distinctly
characteristic.
In smallpox the eruption commences as small pap-
ules, not usually becoming vesicles before the second day,
while in varicella they appear as macules, becoming
vesicles in a few hours, and are almost never shot-lilce,
except occasionally on the palms of the hands and soles
of the feet, locations where they are not commonly
seen.
The first lesions in smallpox may be vesicles or they
may become vesicles in a few hours. By carefully
examining the patient, however, there can usually be
found some papules in the early stage of the disease
which will greatly aid in the diagnosis.
In smallpox, the vesicles, as a rule, have indurated
bases, while in varicella they are not generally in the
true skin, but are superficial, can be easily brushed off,
and collapse early.
Although one may find a few lesions umbilicated in
varicella, it is not as universal as in smallpox.
In smallpox, pustules generally remain whole for
several days, keeping their form, while in varicella they
become flattened and break in two or three days. The
secretion in varicella is more transparent, and the pus-
tules are composed of a single cell, while in smallpox
they are made up of several little cells.
In smallpox the lesions, as a rule, appear in a regu-
lar course over the whole body, while in varicella they
come out in successive crops.
Few scars result in varicella, and the duration of the
disease is commonly much shorter than in smallpox.
In measles, the catarrhal symptoms are a great aid in
diagnosis. The fever is not so high in the beginning,
but gradually increases, reaching its height while the
eruption, which usually appears on the fourth day, is
spreading over the body ; then the temperature becomes
normal. There is not the same rapid fall of tempera-
ture that there is with the appearance of the eruption in
smallpox. The lesions spread over the body more
rapidly, are larger, more superficial and crescentic, and
do not have the shotty character and never become
vesicular nor pustular.
In the morbilliform rash of smallpox the eruption is
less elevated than in measles, and disappears on pres-
sure. The eruption is usually found in the groin or
axilla, and the papular eruption soon appears.
The only cases of smallpox that would be mistaken
for scarlet fever are the hemorrhagic, and those in which
the initial scarlatiniform rash is present. In the hemor-
rhagic form the constitutional symptoms are more severe
than in scarlatina ; the eruption does not disappear on
pressure, and is of a more intense red color, which,
once seen, will not be forgotten.
Hemorrhages in the conjunctivas should exclude
scarlet fever. The characteristic tongue and throat
symptoms of scarlet fever are absent. If the patient
does not die before the appearance of the papular erup-
tion, this should make the diagnosis easy.
In many cases of hemorrhagic smallpox the eruption,
instead of being papular, appears first as superficial
vesicles, rather flat and flabby, and resembling those of
varicella.
In cases in which there is the initial scarlatiniform
eruption, it usually appears in the groin or axilla, while
in scarlet fever it appears first on the neck and chest,
and then spreads over the whole body. There are few,
if any, anginal symptoms, and the characteristic tongue
of scarlet fever and swelling of the lymphatic glands of
the neck are not present. The appearance of the papules
would decide the case when there might be any doubt.
Some claim that it is more probably smallpox if the
patient is an adult, but I do not consider this of any
value in making a diagnosis, although the larger num-
ber of cases of scarlet fever do occur in children.
A pustular syphilid is the form of syphilis most often
confounded with smallpox, but the history of the case
and the character of the eruption should seldom leave
any doubt as to the correct diagnosis in the minds of
those familiar with the disease.
In syphilis there may be some pain and fever, but
these do not disappear with the appearance of the erup-
tion, as in smallpox. The lesions are grouped and come
out in successive crops, and are not as uniform in size,
neither are they as often seen on the palms of the hands
and the soles of the feet. They do not run the course of
the lesions in smallpox, and there are usually papules
with vesicopustular tops, instead of true vesicles or
pustules.
I have seen cases of acne and impetigo contagiosa
that had been reported as smallpox, but here the lesions
were principally limited to the face ; there were very
few, if any, on other parts of the body. They are
simply local conditions, without constitutional dis-
turbances. Careful examination of the patient should
leave no doubt as to the exclusion of smallpox.
Typhus fever, typhoid fever, cerebrospinal menin-
gitis and influenza have also been mistaken for small-
pox, but the nonappearance of the characteristic erup-
tion should exclude the latter disease.
I have seen persons suffering at the same time with
smallpox and scarlet fever ; or with smallpox and
measles ; or smallpox and syphilis, but usually the
patient was convalescing from one disease when the
other developed.
I saw a man with a marked pustular syphilid and
smallpox, and when the latter disea.se was in the pus-
tular stage it might easily have been overlooked.
In conclusion, I can only repeat that each case must
be carefully studied in regard to its history, its
symptoms and its lesions ; the character and life dura-
tion of the lesions, individually and collectively, must
be taken into consideration, and even then in many
cases, and although backed up by a large experience, one
may fail in making a correct diagnosis.
TYPES OF INFECTION PRODUCED IN MAN BY IN-
TERMEDIATE MEMBERS OF THE TYPHOID-
COLON GROUP OF BACILLI.
BY
WARREN COLEMAN, M.D.,
of New York City.
Professor of Clinical Medicine, Cornell University Medical College;
Assistant Physician to Bellevue Hospital.
Until recent years the difficulties attending the differ-
entiation of the various members of the typhoid-colon
group of bacilli have been so great that an accurate study
of the group has not been possible. The application of
the Gruber-Widal reaction to this investigation, how-
ever, has served to clear up the field to a great extent,
and at the present time the differentiation is compara-
tively easy. Graertner's discovery of Bacillus enteritidis
in 1888 in association with epidemics of meat-poisoning
first gave impetus to the study of the intermediates.
Nocard's work on Bacillus psittacosis followed in 1892.
In 1893 Gilbert introduced the terms "paracolon" and
"paratyphoid" to designate bacilli of this group re-
sembling more nearly in biologic characters the colon
bacillus on the one hand and the typhoid bacillus on the
other, but at that time the organisms now known as
paratyphoid bacilli had not been identified. In the suc-
ceeding years followed the work of Achard et Bensaude
(1896), Widal (1897), Durham (1898, 1901), Gushing (1900),
and others. In the Journal of Medical Research for June,
1902, Buxton has given the latest and most complete
study of the intermediates yet published.
The intermediates include Bacillus enteritidis and
Seftembek 27, 19021
THE TYPHOID-COLON GROUP OF BACILLI
[American Medicine 499
similar organisms recovered from cases of epidemic
meat-poisoning, the gas-producing " typhoid " bacilli of
various observers, B(wiUus pitittacosis, Bucilins cholerce
Sim, Bacillus typhi murine, Bacillus icteroides, the bacil-
lus of calf septicemia of Thomassen, Widal's "para-
colon," Gwyn's "paracolon," and the various paraty-
phoid bacilli that have been described recently.
Dr. Buxton has been kind enough to furnish the fol-
lowing account of the bacteriology of the intermediates.
The bacilli intermediate between B. coli communis
and B. typhosus can be distinguished without difficulty
from them. They produce gas in glucose jnedia and in
this respect they differ from typhoid, but, unlike B. coli
communis, they have no power of fermenting lactose,
coagulating milk or forming indol.
They are not agglutinated by typhoid sera except im-
perfectly in low dilutions.
Among the intermediates themselves, however, two
main groups can be recognized, and it is proposed to call
these paracolon and paratyphoid groups, the former
appearing in some respects to be more nearly allied to
B. coli communis than the latter.
The main points of difference are that the paracolons
turn milk and whey alkaline after a short initial acidity
and form gas freely in glucose mediums, while with the
paratyphoids there is in milk and whey initial acidity
but no or very slight subsequent alkalinity, and gas
production in glucose mediums is much less pronounced.
Neutral red agar also differentiates between the two
groups. Like B. coli communis all the intermediates
reduce the color to yellow in 24 to 48 hours, but with
the paratyphoids after four or five days the red color
begins to return from above downward until in two to
three weeks the medium is again red throughout, while
with the paracoloas the yellow color is permanent.
Agglutination tests have taught us that the members
of the coli communis group do not constitute a distinct
species as in the case with typhoid bacilli. When these
tests are applied to the intermediates it is found that the
members of the paracolon group do not all show mutual
reactions, and the group must, therefore, be composed of
a number of distinct races as with B. coli communis. The
paratyphoids, on the other hand, none of which has so
far been isolatetl from cases other than typhoidal, inter-
act without exception ; that is to say, that an active serum
prepared from any one of the bacilli will agglutinate all
the members of the group. The paratyphoids, then,
appear to be a distinct species in the same sense that the
typhoid bacilli are a distinct species.
It may be found possible to distinguish various spe-
cies within the paracolon group. There are certainly
three members which afford mutual reactions : One of
those isolated by Schottmueller, one by Kurth and one
by Libman, and these might provisionally be called
,'i-paratyphoids. Since, however, there are others of the
paracolon group which have caused typhoidal symptoms,
yet do not appear to belong to this particular species, it
seems a little [)remature to attempt these fine distinctions
and for the present it will be sufficient to confine our-
selves U) the idea of the two main groups :
I. The Paracolons. — A grouj) of bacilli, the members
of which are culturally alike, but constitute several dis-
tinct species, some of which may give rise to typhoidal
symptoms in man.
II. The Paratyphoids. — A distinct species, culturally
unlike the paracolon bacilli, which causes typhoidal
symptoms in man.
I'athot/enicili/. — The majority of the members of the
typhoid-colon group of bacilli are pathogenic for man or
certain of (he lower animals. The various infections
both in man and the lower animals exhibit much simi-
larity in that the manifestations are largely of a gastro-
enteric type with or without constitutional symptoms.
Pathogenicity in man has been established for certain
of the intermediates. Broadly si)eaking there are three
tyi)es of infection :
1. Typhoid typk, caused by the paratyphoid bacilli
and certain of the paracolons.'
2. Epidemic mkat- poisoning type, caused by
Bacillus enteritidis and its allies.
3. Psittacosis type, caused by Bacillus psittacosis.
In addition to these three types Griinbaum has sug-
gested that febrile jaundice may be caused by one of the
intermediates.
More recently Eckardt has obtained a positive Widal
reaction in two cases of Weil's disease in as high dilu-
tion as 1 : 1,000. The author states that the Widal reac-
tion is often positive in jaundice from any cause, but
that in these cases it was not due to the icterus alone, as
it persisted, even at the same strength, after the icterus
had disappeared. He argues that Weil's disease may be
a peculiar abortive type of typhoid fever. It must cer-
tainly be admittetl that the positive serum reactions
against the typhoid bacillus obtained by him and by
Griinbaum in these cases lend color to the supposition
that Weil's disease is an infection caused by a member of
the typhoid-colon group of bacilli.
Zupnik has obtained a positive reaction against the
typhoid bacillus with sera from four of six cases of
Weil's disease, and at first was inclined to regard this
fact as evidence of the etiologlc unity of the two diseases.
But he now believes that the serum reaction depended
upon the cholemia.
Bacillus icteroides (Sanarelli), while probably an inter-
mediate, is no longer the accredited cause of yellow
fever. The most conclusive work yet done on this sub-
ject was published by Reed and Carroll in American
Medicine, February 22, 1902.
I. THE TYPHOID TYPE.
The Term Paratyphoid Feoer. — Though Gilbert intro-
duced the terms "paracolon" and " paratyphoid " in
1893, to designate groups of bacilli, Achard and Ben-
saude (189G) were the first to employ the term paraty-
phoid in a clinical sense. This use of the term was
sanctionetl by Schottmueller in 1901 and has been
adopted by several recent writers. But it may be seriously
questioned whether the term should be recommended as
it leads to somewhat unfortunate multiplicity. When
it is considered that infection with paratyphoid bacilli is
manifestetl by symptoms pnictically identical with
typhoid fever except for the Widal reaction, that there
are differences (biologic and in serum reactions) even
among the paratyphoid bacilli themselves (,<-paraty-
phoids) and that bacilli of the enteritidis type may at
times produce typhoidal symptoms, it seems no more
advisable to make a clinical subdivision of these cases
than of the cases of pneumonia or infective endocarditis
which may be due to one of several different microor-
ganisms. Paratyphoid infections do not constitute a
clinical entity. There is at least as great diversity
among the different types of typhoid fever as between
typhoid fever and paratyphoid infections. Moreover,
typhoidal symptoms may be produced by Petruschky's
Bacillus /(cculis alcaligenes (the author stsvtes that it was
obtained from the feces of patients suspected to have
typhoid fever) and yet this l)acillus is not an interme-
diate. It lies just without the group on tlie typhoid
side, in that it does not acidify any sugar-contiuning
medium (Durham).
These various considerations make it necessary to
abandon the itlea of the specificity of typhoid fever, else
the subject will become hopelessly confused. As in the
case of abscesses the physician recognizes the clinical
im-i, the bacteriologist det«rmines the causjitive agent.
It certainly seems better to confine the terms " paraty-
phoid " and " paracolon " to the domain of bacteriology
and to broaden the scope of the etiology of typhoid fever
to inclutle these several organisms — Bacillus /cecal is alca-
ligenes (?), Bacillus typhosus, Bacillus paratyphosus, and
> FctruHChky'H Bacillu* facnlit alcaligenet, while not iin lutorme-
(liate of the group (Durham) may bIho produce typhoidal symptoms.
500 AMKRIOAN MEmOIITEl
THE TYPHOID-COLON GROUP OF BACILLI
[Sei'Tembkb 27, 1902
certain members of the paracolon group (/3-paraty-
phoids).
The Reported Cases, Geographic Distrilmtion and Rela-
tive Frequency of Paratyphoid Infection.^ — Excluding
Widal's case, which did not present any constitutional
symptoms, 27 cases of paratyphoid infection have been
reported (August, 1902) : Two by Achard and Ben-
saude, one by Gwyn, one by Gushing, seven by Schott-
mueller, live by Kurth, one by Brion and Kayser, one
by Coleman and Buxton, one by Strong, one by Hume,
four by Johnston, one by Hewlett, and two by Long-
cope.
Libman's case has not been included because it did
not run a typhoidal course.
The cases have been widely distributed geographic-
ally, having occurred in Paris, Hamburg, Bremen,
Strassburg, Liverpool, Philippine Islands, New York
City, Baltimore, and Philadelphia. In our case, the
infection apparently took place in Elizabeth City, North
Carolina.
Very little can be said of the relative frequency of
paratyphoid infections. Gwyn's ca-se was the only one
of 265 cases which failed to give the Widal reaction.
Six of Schottmueller's cases occurred in a series of 68
and Kurth's five in a series of 62 cases whose sera were
tested for the Widal reaction. Johnston's four cases
Symptomatology. — It is a significant fact that many of
the reported cases of paratyphoid infection were consid-
ered to be genuine typhoid fever without the Widal
reaction until a bacteriologic study revealed their true
nature.
In order, however, to emphasize the identical clin-
ical nature of the two infections, it will be advisable to
give a cursory review of the main symptoms which
have been noted in cases from whom paratyphoid bacilli
have been isolated or whose blood has given a reaction
against a known paratyphoid bacillus while not against
the bacillus of Eberth.
Age and Sex. — The ages of the patients have ranged
from 7 months to 60 years, though the majority of
the i)atients have been young male adults. Eight of the
patients have been females.
Among the symptoms of invasion we find headache,
anorexia, chill with subsequent fever, malaise, prostra-
tion, epistaxis, diarrhea, fibrillary tremor of the tongue
and mild bronchitis. These symptoms have varied in
duration up to a week.
The further progress of the infection is characterized
by the development of a typhoid state, slight or pro-
found, according to the intensity of the toxemia, accom-
panied by tympanites, diarrhea or constipation, and
splenic tumor. The temperature is essentially that of
Paratyphoid fever temperature, taken every four hours from the sixth to the thlrty-flfth day of disease.
Asterisks indicate the administration of alcohol baths.
were found among 194 and Hewlett's one in a series of
26 eases of typhoid fever. The proportion of negative
Widal reactions is low in the statistics, but there is a
source of error here in that until very recently the tests
have not been made in proper dilution, that is, at least
as high as 1:40.
Postmortem Findings. — Autopsies were performed on
two fatal cases (Strong, Longcope). The interest in these
autopsies naturally centers on the condition of the intes-
tine. Strong states that both the large and small intes-
tine were normal throughout except for moderate catarrh
and a few superficial hemorrhages. The solitary and
agminated follicles showed no lesions. The mesenteric
lymphatics, however, and some along the small intes-
tine, were hemorrhagic. In Longcope's case the intes-
tine showed no changes either on gross or microscopic
examination. The spleen in both eases was enlarged.
The other pathologic changes were those common to
febrile conditions.
1 In the Zeltschrift far Hygiene, Vol. xl, August, 19a2, Htinermann
has reported an epidemic of 38 cases of paratyphoid infection occur-
ring in the earrison at Saarbriiek. His paper deals only with the bac-
teriologic pliase of the subject, stating that the epidemiologic and
clmleal aspects will be discussed later by others.
typhoid fever of varying severity, except that some of
the curves show marked remissions which cannot be
accounted for by the occurrence of complications. More-
over, the rise may be abrupt and the defervescence by
crisis. The pulse possess&s febrile characters and may
become dicrotic. The urine sometimes gives the diazo-
reaetion.
Hose spots have been observed in the majority of
cases. In one case an exauthem appeared, covering the
face and hands, and in another a scarlatiniform rash on
tlie back and neck after the disappearance of the spots.
Herpetic vesicles formed on the lips and alse nasi in one
of Longcope's cases.
Intestinal hemorrhages, furunculosis, initial bron-
chitis, cystitis, pyelonephritis (?), purulent arthritis,
bronchopneumonia and venous thrombosis have been
reported as complications. Osteomyelitis is the only
recorded sequel.
Relapses have occurred in four cases, in one of which
there were two.
The infection may be mild or .severe, but for the most
part the cases have been mild. There have been five
severe cases with two deaths.
September 27, 1902J
CLINICAL REPORT UPON URETERAL SURGERY iamerican medicine 501
The duration of the disease has varied from 12 to 84
days, with a majority of the cases continuing between 20
and 36 days. Some of the cases have been of short dura-
tion, lasting from 12 to 18 days.
Brill has reported a series of 17 cases which did not
give the Widal reaction, which were probably, though
not proved to have been, examples of paratyphoid infec-
tion.'
If Brill's cases were examples of infection with para-
typhoid bacilli, a noteworthy fact becomes apparent:
That infection with the typhoid bacillus does not neces-
sarily produce immunity against paratyphoid bacilli.
Case XI^" of his series, a female aged 25 years, had had
typhoid fever, with the Widal reaction, six months
previously and had entirely recovered. The serum
reaction against the typhoid bacillus persisted up to and
including part of the second illness, during the course of
which it disappeared. The second illness was charac-
terized by headache, lassitude, nausea, but no vomiting ;
epistaxis, constipation, coated tongue, flushed face,
.splenic tumor, slight tympanites, abdominal tenderness,
and slight roseolar eruption (about five spots), none of
which were found on the back. The duration of the
illness was 18 days.
Can it be possible tluit some of (he second (Macks of
ti/phoid fever have really been due to infection by a dif-
ferent member of the same group of bacilli f Cursch-
maun, in Xothnagel's Encyclopedia, says that in his
experience two attacks of typhoid fever are by no means
rare, and that third and fourth attacks have occurred in
the same person, though the latter are very unusual.
Of 1888 cases of typhoid fever in Hamburg iAfc were in
second attacks and one patient was in the third.
In typhoid fever there is not a progressive diminu-
tion of immunity as in the exanthemas. The second
attack may occur before the end of the first year or
within the first few years. In Brill's case, which before
the introduction of the Widal reaction would have been
regarded as due to the typhoid bacillus, the second
attack occurred at the end of the sixth month.
Since the statistics of typhoid fever are largely based
on cases observed before the introduction of the serum
reaction it may be possible that some of the abortive,
ambulatory and mildest cases of typhoid have been due
to infection by the intermediates. Until a larger expe-
rience with the bacteriology of the blood in typhoid
fever shall have been had it will not be pos,sible to do
more than speculate about this matter.
The Serum Reaction in Cases of Paratyphoid Infection.
— Since the introduction of serum reactions as a means
of diagnosis, it has been a well-recognized fact that a
small proportion of cases which are clinically typhoid
fever fail to give the reaction. Brill, adding to Cabot's
statistics, finds that of 4,879 cases 4,781 , or i»7.9 fo , gave the
reaction. Gwyn gives 99.6^^ as the percentage of posi-
tive reactions in the .Johns Hopkins Hospital. <^n the
contrary, in all the reported cases of paratyphoid infec-
tion a reaction against the Bacillus typhosus has been
absent. . It is probable, then, that some at least of the
typhoid cases with negative reaction were really paraty-
phoid infection.
On the other hand, it cannot be assumed that all cases
<;linically typhoid fever, which have been reported as
giving the Widal reaction, were cases of genuine typhoid
infection. The brilliant work of Dunham on the typhoid-
colon group of bacilli and their serum reactions has
brought out the fact that certain memlKjrs of this group
may be mutually interacted upon by sera of infected
patients and immunized animals. This is especially
true of sera in low dilution, and since in the eurlie'r
years of the Widal reai-tion the technic had not Ix-en
worked out, and dilutions were more fretjuently low
' It should 1)0 explained that Brill's ftillurc to And the ranse of the
liifeotlon In these diKes lay In the lack of metbodH for differentiating
the Intermediates at the time his study was made.
than not, some of the cases reported as typhoid fever
may have been infections with paratyphoid bacilli.
The simple fact that clumping of bacilli has been
obtained is not sufficient evidence for diagnosis. Gruber
and Dunham have proved that a serum reaction is not
in the strict sense specific, that it is only a specja/ reaction
and that it indicates not a certainty but a probability.
In our Case VII the serum reacted against the typhoid
bacillus at 1 : 20, though only partially and imperfectly at
the end of an hour, and failed entirely at 1 : 40 and 1 : 80
with another typhoid culture. Gwyn's "paracolon"
bacillus was agglutinated by typhoid sera of high
potency (1 : 300 to 1 : 1,100) in dilutions up to 1 : 5. One
typhoid serum (potency 1 : 900) gave an incomplete
reaction at 1 : 30.
■Diagnosis. — The only reliable criterions for diagnosis
are absence of the Widal reaction in proper dilution (not
less than 1 : 40) with a positive reaction against a known
paratyphoid bacillus or the recovery of a paratyphoid
bacillus from the blood, urine, stools, or complicating
inflammatory process.
The clinical type of the disease is of little value, so
far as our present knowledge goes. It has already been
stated that the reported cases of paratyphoid infection
have been both mild and severe.
The cases of paratyphoid infection are too few to state
what the prognosis should be. It can only be said that
the majority of the cases have been mild, though there
have been two deaths among the 27 cases.
CLINICAL REPORT UPON URETERAL SURGERY.
BY
CHARLES P. NOBLE, M.D.,
of Pbilalelphla.
Surgeon-in-Chlef, Kensington Hospital for Women, Philadelphia.
The surgery of the ureters is comparatively recent
and still in the developmental period. This fact is the
reason for the following report of all surgical operations
in which the ureters were involved which have come
under my personal notice. The cases are reported for
record, and it is hoped that the comments which will be
made upon some of the cases will be of sufiicient interest
to stimulate the discussion upon the problems involved.
Case I. — Stone in the vesical portion of the left ureter ; supra-
pubic cystotomy ; incision of vesical wall and ureter; removal of
stone ; interrupted but good recovery. Mrs. R., aged 59, the
mother of seven children, was admitted to the Kensiiigtou
Hospital for Women, March 7, 1893. She sought relief from
frequent and painful micturition. Her family and personal
liistory presented nothing of note. The bladder symptoms had
persisted for nine years. From time to time she had been cou-
nned to bed. From November, 1891, to March, 1892, she was in
the Jefferson Hospital, under the care of Dr. Parvin, who made
a fistula in the bladder, which was allowed to remain open for
four months and was then closed. The symptoms were not at
all improved. The urine contained blood and pus. Upon
bimanual examination a swelling could be felt in the region of
the left ureteral orifice. Tliis was supposed to be a tumor.
Tlie vagina was quite small from post-climacteric atrophy, and
for this reason it was determined to open the bladder by the
suprapubic route, which was accordingly done. The peritoneal
cavity was accidentally opened and immediately sutured.
Upon opening the bladder a circumscribed tumor was felt
about tfie orifice of the left ureter which was susjiicious of
stone, and this suspicion was confirmed by passing a tenaculum
through the overlying tissue and eliciting the characteristic
grating. As the stone was near the ureteral orifice, the bladder
wall and thinned ureter were incised, and the stone removed.
Drainage both by supi-apubic drainage tube and retention cath-
eter was maintained. Convalescence was interrupted by an
attack of mania. The patient was discharged March .31, 1893.
She made a tedious convalescence, but when seen some mouths
later was entirely free from pain and bladder discomfort.
Remarks. — In the light of our present knowledge
this case was very imperfectly studied, and nothing can
be said concerning the condition of the left kidney.
The absence of attacks of renal colic would indicate Its
integrity. It is believed that this case is a type of many
others in which a stone in the vesical portion of the
502 AMBRicAN MEDICINE] CLINICAL REPORT UPON URETERAL SURGERY
ISeptembbb 27, 1902
ureter has been mistaken for a socalled encysted calculus
of the bladder ; or, in other words, that many cases of
supposed encysted calculus are really cases of calculus in
the ureter.
Case II. — Ruptured tubal pregnancy ; intraligamentous
ovarian cyst; hematocele partly subperitoneal; hysterectomy ;
removal of loiver hnlf of ureter ; ureter stitched in abdominal
wound ; subsequent nephrectomy ; good permanent recovery.
Mrs. H., aged 30, was admitted to the Kensington Hospital for
Women on February 10, 1890, in a critical condition from rup-
tured tubal pregnancy of about six weeks' duration. She was
markedly anemic and greatly prostrated from internal hemor-
rliage. Abdominal section disclosed a ruptured tubal preg-
nancy and a right intr.iligamentous ovarian cyst. The blood
was partly intraperitoneal and partly subperitoneal. The com-
plications of the case — the extreme prostration, the sul^perito-
neal liemorrhage and the Intraligamentous cyst — led to the
surgical accident of removing the greater portion of the right
ureter. The patient's condition demanded a rapid operation,
which led to the removal of the ureter along with the intraliga-
mentous cyst. The accident was discovered, but the ureter was
too short to implant into the bladder, even had the patient not
been in collapse. It was therefore sutured into the abdominal
wall. The kidney was removed by lumbar incision April 6,
1896. Mrs. H. made a prompt recovery, was discharged April
21, and has since had good health. (Pennsylvania Medical
Journal, August, 1899.J
Remarks. — From the nature of the conditions present
the accident of removing the uret«r in this case was prob-
ably inevitable. Only a careful time-consuming opera-
tion would have prevented it, and in the condition of the
patient this would probably have led to a fatal result.
In spite of later investigations concerning the implanta-
tion of the ureter into the bowel and the suggestion that
the ureter be implanted into the ureter of the opposite
side, making a ureteroureteral anastomosis, it is believed
that under similar conditions the plan adopted in this
case is the wisest. The ureter was so short that it would
have been necessary to select the cecum for implanta-
tion, a plan of procedure net warranted by the results
of experimental studies. The ureter was too short to
implant into its fellow of the opposite side, even if
future experience would show that this operation gives
good results.
My own experience with the permanent results of
nephrectomy when one kidney is sound, or even when
it is the seat of moderate degeneration from septic
trouble, in connection with the general experience of the
profession, makes me believe that it is wiser to do a
nephrectomy than to implant the ureter into the bowel.
Such a procedure could properly be entertained when
the remaining kidney is known to be diseased, or in the
rare event of the patient having but one kidney.
Case III. — Large multilocular bilateral ovarian cyst;
double ovariotomy ; injury of the right ureter ; suture; death.
Mrs. T., aged 58, the mother of four children, was admitted to
the Kensington Hospital for Women on June 11, 1896, suffering
from a large double ovarian cyst. The right cyst contained 28
liters (7 gal.) while the left contained 4 liters (1 gal.). The
weight of the two tumors was 29,484 grams (65 pounds). The
tumors had been developing for a number of years. The his-
tory was not definite, but it is probable the tumors had been
growing for six or eight years. The patient's dread of opera-
tion had led her to postpone seeking relief until the immense
size of the tumors made it apparent that she could live only a
few weeks without operation. In the course of the removal of
the right cyst, which was partly Intraligamentous, the right
ureter was found to pass between two lobes of the tumor.
Although the ureter was separated from the tumor with great
care, its walls were so friable from edema that the lumen of the
ureter was opened through perhaps one-third of the circumfer-
ence of the duct. The rent was sutured and a vaginal subperito-
neal drain was placed. The patient died about 48 hours after
operation. There was no leakage of urine.
Case IV. — Papillary cancerous tumor of the left ovary ; oc-
clusion of the ureter; atrophy of the kidney ; division of ureter
in removing tumor ; recovery. Mrs. B., aged 58 years, was seen
in consultation with Dr. Pullerton, who operated upon her for
a papillary carcinomatous tumor of the left ovary. The tumor
formed a large mass filling the pelvis and lower abdomen. At
the operation the abdomen was opened and 2,500 cc. of fluid
withdrawn from a cyst, whose walls were found densely adher-
ent, with extensive cancerous involvement of all the pelvic
organs. The cyst was peeled out of the left broad ligament, tied
off and removed. The left ureter was then found divided, but
the patient was in such a bad condition that it was deemed inad-
visable to prolong the operation by the performance of ureteral
anastomosis ; and the end of the ureter was brought out of the
abdominal incision, which was closed. A flexible catheter was
placed in the ureter to conduct the urine away from the wound.
This was suggested to Dr. Fullerton as the result of my experi-
ence in the case of Mrs. H. No urine flowed from the ureter,
showing that the kidney had undergone atrophy from the grad-
ual pressure of the cancerous tumor upon the ureter. The
patient made a good recovery from the operation but her subse-
quent history is unknown. ("Operative Gynecology," H. A.
Kelly, Vol. i, pp. 464-465.)
Remarks. — The suturing of the ureter into the abdom-
inal wall was not only justified by the result in this
case but was demanded by the condition of the patient.
A patient suffering from extensive and incurable cancer,
and greatly prostrated at the time of the operation, is
not in condition to stand prolonged operative manipula-
tion.
Case V. — Epithelioma of the cervix ; com,bined hysterectomy :
vesical and ureteral fistulas; subsequent ureterovesical anas-
tomosis; recovery with vesical fistula. Mrs. E., aged 56, the
mother of three children, was admitted to the Kensington
Hospital for Women, March 15, 1900, with epithelioma of the
cervix uteri. Five years after the menopause, which took
place at the age of 51, and seven months before admission, she
noticed a slight bloody discharge, which reappeared several
times, the interval between the attacks becoming less, while
the discharge gradually increased. There were no other symp-
toms. Examination showed an epithelioma advanced to the
point at which it was doubtful whether or not a radical opera-
tion should be attempted. Vaginal hysterectomy was at-
tempted March 19. The vagina was extremely small, the
cervical tissues so friable that vulsella forceps would not hold.
In attempting the separation of the bladder from the uterus an
opening was made into the bladder. Owing to the lack of
room in the vagina and the friable nature of the cervix, vagi-
nal hysterectomy was abandoned and an abdominal hysterec-
tomy was carried out. The bladder wound was sutured. Mrs.
E. recovered from the operation and was discharged with a
urinary fistula. She was readmitted June 12, when it was
found that the fistula was ureteral in character. A uretero-
vesical anastomosis was attempted on June 16. Etherization
was very unsatisfactory, cyanosis and rigidity being present
throughout the operation. It was soon evident that the opera-
tion had been attempted at too early a date, as there was exten-
sive exudate in the pelvis, which greatly complicated the opera-
tion, making it much more difficult than ordinarily would be
the case. Owing to this fact and to the rigidity of the patient
from faulty anesthesia, the operation proved to be one of
almost insuperable difficulty. Finally the ureter was dissected
from its beef of exudate and the bladder prepared for implanta-
tion. At this stage the patient's condition became so bad that
it was evident a fatal result would follow if she were not
promptly put to bed. In consequence the suturing of the
ureter into the bladder was very unsatisfactorily and hurriedly
performed. In separating the bladder from the masses of
exudate about it an opening into the vagina had been made.
The result of the operation was the cure of the ureteral fistula,
but there resulted a small vesical fistula through which most
of the urine still escapes. The patient has since refused further
operative treatment. At this date. May, 1902, she remains free
from recurrence.
Remarks. — It is probable that the ureteral fistula in
this case was caused by the thermocautery, although
possibly due to the partial inclusion of the ureter in a
ligature. The extensive exudate present in the pelvis
three months after the hysterectomy made the freeing
of the ureter a matter of extreme difficulty and would
indicate that a secondary operation should not be at-
tempted too soon after the formation of a ureteral fistula.
Case VI. — Recurrent sarcoma of the uterus; hysterectomy ;
division of the left ureter ; primary ureterovesical anastomosis ;
perfect ureterovesical union; death on fifteenth day from chronic
nephritis. Mrs. J., aged 36, the mother of four children, was
admitted to the Kensington Hospital for Women, Septem-
ber 24, 1901. She complained of a recurrent tumor which filled
the vagina and caused a profuse and offensive discharge. Two
years before admission she was operated upon in a neighboring
city for such a tumor, the surgeon making a diagnosis of fibroid
tumor. In a short time the tumor recurred and. the same sur-
geon operated a second time, making a diagnosis of recurrent
fibroid. The second operation was performed February 15, 1901.
When admitted to the hospital she was greatly emaciated and
cachectic. On September 27, 1901, a sloughing tumor was re-
moved. It filled the vagina and sprang from the posterior lip
of the cervix. A diagnosis of sarcoma was made, which was
confirmed by microscopic study of the tumor. The conditions
were quite similar to the case of Mrs. X., operated upon by me
and reported in American Journal of Obstetrics, Yo\. xliv. No. 3,
1901. Following the operation the patient was greatly prostrated
and suffered from vomiting for ten days. During this time the
urine contained hyaline and granular casts and once epithelial
September 27, 1902]
CLINICAL REPORT UPON URETERAL SURGERY [American medicine 503
casts. Oil October 16, 1901, her condition had improved suffi-
ciently to make hysterectomy seem warrantable. The opera-
tion was performed by the combined method. It was evident
that the left broad ligament was involved, and in the effort to
keep beyond the area of infiltration the left ureter was divided.
Primary ureterovesical anastomosis was performed. A con-
venient point in the bladder was selected, the bladder was
opeuefl, the end of the ureter split, a transverse suture was
passed through the anterior half of the ureteral end and the two
ends of the suture were passed through the bladder wall from
within outward, so that when tied the ureter was fastened by
a mattress suture to the vesical wall. Fine chromicized gut was
used for this purpose. The bladder wall was then sutured
about the ureter with fine catgut and flue silk sutures and a
tension suture was passed fastening the bladder back to the
peritoneum, so as to take tension off the ureteral sutures. The
immediate operative recovery was entirely satisfactory and the
anastomosis succeeded perfectly. The patient died, however,
on the fifteenth day, of chronic nephritis. Vomiting was per-
sistent from the time of operation until death. Autopsy showed
a healthy peritoneum and a perfectly healed operation wound
between the ureter and bladder. Death was due to chronic
nephritis with reflex vomiting. After each of the three pre-
vious operations the patient had vomited for at least ten days,
doubtless due to the nephritis each time.
Hemarks.— The technic of the ureterovesical anasto-
mosis employed in this case \va.s entirely satisfactory. I
can see no possible improvement in the technic unless it
be to use two mattress sutures to fasten the ureter to the
bladder wall, the one introduced through the anterior
portion of the ureter, as in this ease, and the other
through the posterior portion of the ureter, the free ends
of each suture being passed from within outward through
the bladder wall, the needle being introduced through
the opening into the bladder. In another case I should
rely upon catgut, chromicized, and plain cumol gut, ex-
clusively.
In spite of the fact that this patient died from chronic
nephritis she passed at least the average quantity of urine for
some days after her operation, the amounts being as follows :
October 16, 1H02 (night following operation).,
" 17, ■
18,
1!),
'20,
21,
22,
■n,
24,
25,
26,
27,
28,
29,
30,
150 cc.
480 "
810 "
,200 "
,200 "
,140 "
680 '
840'
870 '
69(1 •
(i«0 '
(fifteenth day after operation) 420 '
Case VII. — Advanced epithelioma of the cervix ; pregnancy
advanced between fourth and fifth months ; ovum dead ; hemor-
rhages from the cavity of the uterus ; vaginal hysterectomy ; liga-
tion of left ureter ; death on the fourth day. Mrs. S., aged 33,
the mother of two children, was admitted to the Kensington
Hospital for Women, February 2, 1!)02. Menstruation had been
normal until October, 1901, when pregnancy supervened. Dur-
ing December, January and February she had had repeated hem-
orrhages. At the time of her admission she was suffering
markedly with pain, was extremely anemic, and had an offen-
sive bloody discharge from the vagina. Kxaniination of the
blood showed red cells, 1,508,000; hemoglobin, 30%. The
anemia was of such grade that operation was postponed, and she
was put upon supporting treatment to improve her condition.
This had a fair result, but there was decided tendency to bleed-
ing from the uterus, so on February 12, 1902, vaginal hysterec-
tomy was done. On this date the blood examination showed
red blood-cells. 2,500,000; hemoglobin, SSi/,. It was evident that
the left broad ligament was involved and a radical operation
would not have been done had it not been for the condition of
pregnancy. A hysterectomy was not considered more danger-
ous than to empty the pregnant uterus through the sloughing
cervical cancer. Owing to the involvement of the left broad
ligament there was marked tendency to hemorrhage, and it
was felt that some liberties were taken with the integrity of the
left ureter. The patient passed urine as follows after the opera-
tion : First day, 480 cc. ; second, 780; third, 1,440; fourth, 960.
She died on the fourth day. An autopsy showed that the left
ureter was occluded by one of the ligatures. The ureter and
pelvis of the kidney were distended with urine.
Hemarks. — This is the only case in my experience in
which it is known that a ureter ha.s been tied, either in
vaginal or in abdominal hysterectomy. In no ca.se in
which an autopsy had been made ha.s the ureter been
found tied, although all fatal cases have not been sub-
mitted to postmortem examination. The amounts of
urine passed after operation did not indicate that the
ureter had been tied. There was no pain in the kidney
involved.
Case VIII. — Supposed calculus in left ureter ; perforation of
ureter and peritoneal cavity by ureteral catheter ; celiotomy ; no
calculus found; ureter sutured; recovery. Mrs. H., aged 32,
the mother of two children, was admitted to the Kensington
Hospital for Women, November 25, 1901. Her personal and
family history presented nothing of note. The history of the
present attack was that she had had pain in the left side of the
abdomen for over a year. In August, 1901, there was an exacer-
bation with excruciating pain, which confined the patient to
bed for 18 days. During tliis attack she was nauseated, but did
not vomit. Urination was frequent and painful, with consider-
able vesical tenesmus. The urine contained no blood nor albu-
min. During the height of the attack the pain was distinctly
worse on alternate days. She was referred to me October 5,
1901, the family physician having made a presumptive diag-
nosis of stone in the kidney. This diagnosis seemed to me to be
open to question; and I advised a careful study of the urine and
an x-ray examination. An x-ray examination was made twice
by Dr. Leonard, who reported a stone in the left ureter at or
about the brim of the pelvis, and it was upon this report that
the patient was admitted for operation. The absence of blood
in the urine was carefully noted, but the po.sitive diagnosis by
Dr. Leonard was accepted. November 28, a ureteral catheter
was passed easily into the left ureter. This fact also was noted,
but it was felt that the stone might be in a pocket in the ureter,
which permitted the passage of the catheter. The operation
wtas performed November 30. It was intended to pass a
catheter into the ureter to serve as a guide in hunting for the
ureter in doing an extraperitoneal operation. Some resistaaeo
was encountered in passing the catheter. A fair amount of
pressure, which was not considered violence, was used, and the
catheter seemed to pass readily. In making the incision down
to the peritoneum, the peritoneum itself was wounded accident-
ally, when the opportunity was taken to make an intraperi-
toneal examination in order to locate the stone. Instead of
finding the stone, the vireteral catheter was found in the peri-
toneal cavity, showing that the ureter had been perforated.
The patient was at once put in the Trendelenburg posture, and
an ample incision made to expose the pelvis. The ureter was
carefully palpated, but no stone was found. Search was then
made for the opening into the ureter, which was found just out-
side the bladder wall. The peritoneum was opened, the
ureter was exposed and sutured with chromicized catgut. The
laroad ligament was then teased open down to the vagina, which
was subsequently opened from below to permit of drainage
into the vagina. After the careful suturing of the ureter, the
peritoneum was sewed over the ureter and the abdomen closed
with glass drainage in case there should be leakage of urine
into the peritoneal cavity. The ureter remained intact, there
being no leakage either into the peritoneum or into the vagina.
Mrs. H. made a slow but good recovery. Convalescence was
interrupted by a moderate cellulitis, perhaps induced by infec-
tion from the vaginal opening. The original symptoms for
which the operation was done persist. Should I encounter in
the future a similar accident, I would perforin ureterovesical
anastomosis in preference to suturing, as in this case.
Remarks. — This ca.se is reported to show two things :
First, that perforation of the ureter is possiljle even
when the catheter is passed by one having had consid-
erable experience and when no apparent force is used,
merely moderate pressure. Second, that a report of an
x-ray examination, even by an expert, is not absolutely
reliable. In this case the erroneous x-ray report led to
an unnecessary operation and, what was additionally
unfortunate, a mishap in carrying out the technic of the
operation.
Case IX. — Ureteral calculus; x^-ay diagnosis ; extraperito-
neal operation; removal of stone ; suturing of ureter ; primary
union; good recovery; stone situated S cm. below brim of the
pelvis. Mr. E., aged 35, married, occupation draughtsman, was
admitted to St. .Toseph's Hospital April 28, 1902, complaining of
recurrent attacks of renal colic. His personal and family his-
tory present nothing of note. The history of the nresent illness
is that two years ago he began having attacks of left renal collo
with suppression of urine, which have recurred until the pres-
ent time. The attacks are characttirized by a chilly, creepy
feeling, loss of appetite, vomiting for about six hours, severe
pain in the region of the left kidney which descends to the
bladder and left testicle. The pain is relieved by applications
of hot water, and he has never taken opium for this symptom.
At first the attacks came every two months and lasted two
days, and recently they come about every three months and
last one day. His general health is good, and he looks well for
a man having an indoor occupation. Repeated examinations of
the urine showed the constant presence of a moderate num-
ber of red blood-cells. I advised that he havi- an x-ray
taken, which was taken tliree times by Dr. lA>onard, who
reported the presence of a stone in the left ureter about the
pelvic brim. Operation was done April 30. An incision waa
604
AMERICAN MEDiciNi] THE PROPHYLAXIS OF VENEREAL DISEASE
[Septembeb 27, 1902
made parallel to the course of the ureter, being partly above
aud partly below a line drawn from the umbilicus to tiie left
anterior superior spine of the ilium. The peritoneum was
reached and pushed off from the posterior wall of the abdomen
until the iliac and abdominal vessels could be palpated. Tlie
ureter was not found upon the posterior wall of the pelvis, and
was then sought in the fatty tissues behind the descending colon.
The thickened ureter was found aud traced into the pelvis.
About 2 cm. below the brim of the pelvis— that is, just below
the iliac vein— a stone, which subsequently was found to weigh
0.5 gram, was located. The stone was ttrmly imbedded and
resisted force to displace it upward where it would have beeu
easier to suture the ureter after its removal. This was found to
be due to the fact that the stone was very irregular in shape.
Having satisfied myself that the stone could not be displaced
upward the ureter was incised over the stone, which was
removed. The incision into the ureter, whicli was about 1 cm.
or li cm. in length, was then closed by interrupted fine chrorai-
cized catgut sutures, between each of which sutures a second
suture of fine cumol catgut was placed. This reinforced the
first row of sutures without unduly narrowing the caliber of
the ureter. A small rubber tube was introduced and the
abdominal wound closed with tier sutures. The rubber tulje
was brought out at the lower angle of tlie wound. The patient
made an uninterrupted recovery, and was discharged on the
twenty-sixth day.
Under similar conditions I would make a second opening
external to the principal incision through which to pass the
rubber drainage tubei This would liave the advantage of per-
mitting a more perfect closure of the main operation wound
and would guard it against possible infection from the drainage
tube. In this case no trouble resulted. The highest tempera-
ture was on the third day after the operation, when the temper-
ature reached 100.4° F. The day before operation the urine
was normal except for the presence of red blood-cells, a few
crystals of calcium oxalate, triple phosphates and amorphous
phosphates. The day after the operation (May 1) redand white
blood-cells were numerous ; on the second, red blood-cells were
absent; on the fourth a few were present; on the seventh,
absent ; on the twentieth, absent. On the twentieth, the date of
the last urinary report, there were a few hyaline casts and one
large granular cast. The patient was discharged in good condi-
tion witli instructions to drink water freely.
Bemarks. — This case is reported as illustrating the
progress which surgery has made in dealing with stone
in the urinary tract. Also as contrasting strongly with
the last case in showing the importance of the x-ray in
this department of surgery. Whereas, in the last case
an erroneous x-ray report was the cause of an unneces-
sary operation, in this case it prevented the performance
of an unnecessary operation. Without the x-ray a diag-
nosis of stone in the Icidney would have been made and
the primary incision would have been a lumbar one to
expose the kidney. It would not have been suspected
that the stone was in the ureter until the kidnej' had
been unavailingly searched for stone, unless the operator
had taken the precaution to peel down the fatty capsule
and expose the ureter, and thus observe its dilated con-
dition. He might even have laid open the kidney in
his search for the stone which was not evident upon
palpation. Having the x-ray report that the stone was
in the ureter and that the kidney was free from stone, all
this unnecessary mutilation was avoided, and the opera-
tion was a direct and most satisfactory one.
THE PROPHYLAXIS OF VENEREAL DISEASE.
BY
JOHN C. SPENCER, A.B., M.D.,
of San Fmncisco, Cal.
Chief of Clinic for Genitourinary Diseases, Out-patient Department of
the Medical Department of the University of California,
In no profession or calling may it be said more truly
that altruism finds its highest development than in that
of the physician.
Our constant aim and ambition is to modify and pre-
vent the causes of diseases, as well as the disease itself.
Thus we are striving constantly to prevent conditions,
in the combating of which we find our sustenance. Pre-
ventive medicine, then, is essentially the watchword of
the practice of medicine in the twentieth century.
In order that in our contemplation of the onward
inarch of infectious and contagious diseases aftlicting
humanity we may not underestimate the importance of
the position occupietl by venereal di.sease, I submit the
following facts and opinions culled from various sources :
Morrow states that one-eighth of all the patients in the New
York hospitals suffer from venereal diseases or their conse-
quences. He estimates that from 60% to 80% of stillbirths are
due to sypliilis, and regards rickets as being almost exclusively
due to the same cause. He has seen more than M cases of extra-
genital chancre among medical men. Bulkeley, of New York,
is so impressed with the prevalence of syphilis insontium, that
he seriously recommends its removal from the category of
venereal diseases. Neisser places gonorrhea next to measles in
the order of prevalence of contagious disea.ses and claims fur-
ther that in some European cities three-fourths of the popula-
tion have had the disease. He holds tliat gonorrhea is a more
potent factor in depopulating countries than syphilis, 30% of
sterile marriages being due to gonorrhea. Saenger found one-
eighth of his gynecologic cases gonorrheal. Otlier German
authorities assert that 80% of deaths from diseases of the uterus
or adnexa are primarily due to gonorrhea. It is estimated
further that from 40% to 80% of the cases of metritis, endome-
tritis and parametritis resulting in sterility are due to gonor-
rhea.
Busch and Fuerbringer estimate that 90% of the cases of
azoospermia are due to gonorrhea.
Well do I recall the rude awakening caused at the time by
Noeggerath's published statement, tliat three-fourths of all
miscarriages at or before the third month of pregnancy were
due to latent gonorrhea in the male.
Neisser reports that tliere are at present in Germany 30,000
blind as a result of gonorrheal ophthalmia, and that before the
inauguration of the CredS method of treatment 10%-20% of the
inmates of the blind asylums were there from the same cause.
Fournier believes one-seventh of Paris to be syphilitic. By
some authorities syphilis is regarded as being twenty times
more contagious than tuberculosis, and almost as severe in its
ravages. Cunningham, commenting on the health of the
British army in India in 1895, states that over 53% had gonor-
rhea. If we are to judge, even approximately, of the condi-
tions among our own soldiery, which passed through liere en
route to the Philippines, at least 75% of the first contingent
leaving this port were suffering from venereal disease.
These facts prove the conditions to be truly appalling.
They give to venereal diseases the hideous distinction of
being second on the list of endemic contagious diseases
responsible for a large individual proportion of deaths of
the human race, tuberculosis being first.
It is to be hoped that the contemplation of these
data will not result in a benumbing of the perceptive
faculties, aud a begetting of indifference. It is easy for
us to sit passively regarding the inevitable results of
what is held, doubtless by tlie vast majority of medical
men and laymen, as being a necessary evil.
I do not appear before you as a prophet out of the
wilderness preaching a new doctrine or offering any
essentially new ideas or suggestions. It is with the aim
of awakening your latent consciousness to the distress-
ing and, regarded from the standpoint of economics,
disastrous consequences following in the wake of vene-
real contagion ; and to cause you to realize how great a
power, properly applied, for the amelioration of these
conditions lies within you.
The impetus for bringing about this change must
spring logically from a united medical profession. As
familiar with the minutiw of these diseases, the laity
must depend upon us for information and suggestions as
to the details for their curtailment, if not prevention.
The proletariat, always apathetic and indiffterent as to
its own welfare, may never be depended upon to do
more than follow its instincts and impulses in matters
concerning indiscriminate sexual gratification without
heed as to consequences or penalties. The initiative
must spring from us.
Assuming, for present purposes, that prostitution,
open or secret, is a human necessity, how shall we best
proceed in order to minimize and neutralize the evils
consequent upon the practice? The cruelties of the
English and French rulers of the Middle Ages, who
gathered all the prostitutes and either drove tliem into
the mountains to perish by exposure and starvation or
into the sea to drown, may not be practised today, irre-
spective of their efficacy.
A sub-committee consisting of Drs. Morrow, Fowler,
and Weiss, of New York City, appointed for the pur-
September 27, 1902]
THE PROPHYLAXIS OF VENEREAL DISEASE iAmbbioan medicine 505
pose of ascertaining the best means for the prophylaxis
of venereal disease, approached the solution of the prob-
lem by sending out a series of questions to physi-
cians. To this they received 1,065 responses. Of
these, 340 recommended the regulation of prostitution
by a system similar to the French, viz., police inspec-
tion, regular medical examinations and a strict isolar
tion of the diseased ; 203 recommended segregation of
prostitutes, after the manner of the Yoshiwara in Yoko-
hama ; 152 recommended regulation of those suffering
from venereal disease, through the medium of the
Health Department. To this department physicians are
to report the nature and origin of each case.
Let us for a moment consider these recommendations
a little more closely. First, as to the regulation of open
prostitution. The system prevalent in France also exists
in Belgium, Germany, Austria-Hungary, Russia, Spain
and Portugal. It was adopted in England in 1860 and
abandoned in 1881 ; Norway and Italy passed through a
similar experience for the same period ; Italy re-estab-
lished the system in 1891. Each of these countries unite
in acknowledging serious defects in the system : First,
that it gives an unusual power into the hands of the police,
who are prone to, and do, misuse the same ; that med-
ical inspection, even under the most favoring circum-
stances, offers no absolute security ; the isolation of those
affected is ridiculously inadequate, and in any event, the
system does not include the affected males. Outweigh-
ing all of these objections is the one that the entire sys-
tem j)Iaces a premium on secret prostitution. The en-
forced isolation, when the affection is slight, is naturally
regarded as exceedingly irksome by this class, with the
consequence that escape from confinement forces these
unfortunates into the ranks of secret prostitution.
Through this agency the likelihood of the spread of the
disease is greatly increased.
Next, as to segregation. This places a premium on
prostitution itself; affords a wellknown locality, to
which the voluptuary may at all times have ready
access. As a matter of fact, prostitution is self-segrega-
ting in most communities. In the general localities
where prostitutes may be found they are there by a
process of natural selection, similar to that which brings
the foreign element together in our larger cities. West-
ern Anglo-Saxon ideas of the proprieties have not yet
reached the degree of tolerance of those of the Far East,
which would, even tacitly, sanction or connive at the
establishment of a Yoshiwara in our midst. Such a
plan breeds a familiarity with the evil in the minds of
our youth, crystallizing their attention in that direction.
From the use of the settlement as a show plague-spot,
after the fashion with the purlieus of our own China-
town, the next step in the gratification of the morbid
curiosity would be to enter the portals.
Surrounding the reporting of cases with secrecy tends
to cause the indigent to yield more willingly to hospital
confinement anrl adequate treatment. The most de-
graded possess an innate repugnance to having their
physical ailments of this nature flaunted publicly and
their jiersonality associated with a loathsome disease.
Infinite, patient perseverance and tact must be ex-
erted to bring about the desired condition. The best
efforts of some of the deepest thinkers have been applied,
as yet unsuccessfully, to the solution of this problem ;
hence it may be expected that we shall stumble and fall
by the way many times before attaining a Utopia.
When we shall have succeeded in having such recogni-
tion of our importance accorded as the establishment of
a Department of Public Health at Washington and have
a representative in tlie Cabinet, we may reach the
millennial condition of uniform laws on sanitation and
hygiene which shall apply to our country as a whole.
Laxity in one community and stringency in another
will simply tend to concentrate profligacy and licentious-
ness in the former, with a concomitant increase in the
amount of venereal disease.
Under the head of regulation all recent students of
the evil — prostitution — are agreed that it may be best
restricted by education.
Dyer recommends " that this education begin at
home. A spirit of tolerance toward fallen women is to
be inculcated and not one of abhorrence. Our youth at
puberty, and even before, are to be instructed in the
physiology of their sexual functions, and the danger of
illicit indulgence of these functions pointed out to them.
Some practical form of instruction is to be applied to
criminals in corrective institutions and to inmates of
orphan asylums. Legislators and health authorities are
to have their beneficent attention aroused, and ways
pointed out fo them for the creation and application of
laws for the betterment of our social conditions in this
regard. Reform is to come from gradual adaptation
and not from any violent measures. Prostitutes are to
be offered opportunities of education along lines of
interest and are to have access to unadvertised homes, to
which they may resort." — (Without the feeling that they
will be embarrassed with reform propaganda during
their sojourn.)
" Recognize sexual perversion as a disease. Require
all cases of venereal disease, in those not well-to-do, to
enter a hospital and remain until cured. Make the
transmission of venereal disease punishable by fine and
imprisonment." The last proviso is a law in Austria-
Hungary. By way of illustration I recall having seen
a case in a Vienna clinic of an unfortunate housemaid
with an initial lesion just within the nostril, inoculated
from the finger-nail in picking the nose. The infectious
material was gathered on the nail from a sink which she
was obliged to clean, the same having been used by a
young man in her employer's family who was in the
habit of cleaning his penile chancre in this sink. The
man was fined and imprisoned for his selfish care-
lessness.
The final recommendations in the report before
referred to were " that the regulation and prophylaxis
of venereal disease should be wholly in the hands of the
Board of Health. Physicians should be required by law
to report the nature and source of all cases of venereal
disease, suppressing the name of the individuals. All
hospitals and dispensaries are to be required to report
C'ases of venereal disease. A separate bureau in the
health department is to be established, with its sepa-
rate inspectors, proficient in their knowledge of venereal
disease, with a laboratory fully eciuipped for making all
necessary examinations of secretions. Brothel-keepers
are to be required to report all cases of venereal disease
occurring in their houses, subject to fine for neglect of
the same. Hospital facilities are to be increased. The
penalizing of transmission is not regarded as feasible.
Minors are to be safeguarded by being sent to a pro-
tectory. The age of consent is to be raised, and procur-
ing is to be severely punished."
Under the caption of education, the report recom-
mends "the thorough instruction of medical students
and young men in the high schools on the dangers aris-
ing from licentious living. The idea that sexual inter-
course is essential to health or that gonorrhea is a trivial
ailment is to be vigorously combated." To quote
Gowers : " No man was ever made worse by continence
or better by incontinence." The report recommends
finally, as the most effective method of preventing the
dissemination of venereal disease, "the prompt sterilizar
tion of the source by treatment. Patients are to be
instructed as to the dangers from contagion, and mid-
wives as to the dangers from ophthalmia. Ejich general
hospital receiving State or municipal aid should be re-
quired to open its doors widely to cases of venereal
diseas(>. Advertisements in the {)ress or near urinals, of
' infallible remedies ' and ' sure cures ' should l)e sup-
pressed, and " (last but not least) "druggists should be
l)rohil)ited from prescribing for venereal diseases."
Bulkeley recommends that the legal control of syph-
506 AMBBioAK mbdicinb] THE PROPHYLAXIS OF VENEREAL DISEASE
[Septembeb 27, 1902
ilis should have first place among contagious diseases
under the control of the Health Board.
To enlarge a little upon certain of the above regula-
tions, it is a patent fact that hospital accommodations
for those afflicted with venereal disease are notoriously
inadequate. The majority of such patients require, as an
important part of the rational therapy, rest in bed. The
enforced omission of this part of our therapeutic arma-
mentarium, I regard a.s responsible for the unreasonable
prolongation of many of my dispensary cases of gonor-
rhea and for numerous remissions during the progress of
the disease. These unfortunates, with patience ex-
hausted by the prolonged course of the disease, or lulled
into a sense of false security by the momentary disap-
pearance of the discharge from the urethra, vanish from
the clinic. The latter class is unquestionaljly an impor-
tant factor in the propagation of the disease.
Subject to the moral effect exerted by hospital isola-
tion, as well as the opportunity for daily inspection and
modification of the therapy, coupled with the easy regu-
lation of the personal hygiene of the individual, I feel
certain that, with adequate hospital facilities, the per-
centage of uncured or latent cases would be reduced to
the vanishing point. Hospital confinement cannot be
supplanted even by daily inspection at a clinic for ambu-
lant cases for the reasons stated.
In Paris between 1,000 and 2,000 beds are devoted to
syphilitic cases ; in Berlin still fewer ; in New York
City, I feel safe in saying that the number would fall
short of 500 ; whereas in San Francisco certainly not 100
beds are devoted exclusively to the care of venereal dis-
eases. These apply naturally to eleemosynary institu-
tions.
In contrast to the figures presented stand the esti-
mates as to the prevalence of venereal disease in our
midst.
Facts and figures are superfluous, however, to cause
each of us to realize how ridiculously inadequate are the
provisions made for the proper housing alone of those
requiring suitable treatment for venereal disease. This
we know from our daily observation. Moral considera-
tions may and should be relegated to second place in
handling these conditions.
The effective productiveness of the laboring classes
suffers serious inroads on time and work from incapaci-
tation due to venereal disease. Approximate estimates
of the amount of money lost through detention of the
laborer from work for this cause have been made by
statisticians. The result in actual money loss exceeds
six figures.
In our army during the Hispano-American war
regiment commanders punished the acquisition of ven-
ereal diseases, because open acknowledgment of the
existence of the disease in the individual meant tem-
porary retirement from active duty and eo ipso a reduc-
tion in the fighting force. Thus commanding officers,
in numerous instances, refused to acknowledge the
presence of venereal disease in the ranks, and a premium
was placed on the secretiveness of the men.
The potential seriousness of gonorrhea and the sub-
sequent pathologic possibilities are surely sufficiently
well-recognized at the present to prevent the egregious
error on the part of the medical man of treating the
matter flippantly, or minimizing its dangers to his
patient. The individual should have constantly kept
before him the seriousness of his infection, that he may
not be remiss in any particular as to his part in the con-
duct of the case. Nothing should be allowed to inter-
fere with the continuance of a rigid sexual quarantine
toward the close of an infection. Not until every doubt
has been satisfied and every expedient resorted to to
establish a complete cure, should the embargo be
raised.
Counter-prescribing on the part of druggists has
already been referred to. Doubtless so long as secret
nostrums are permitted to be advertised a demand will
exist which renders the druggist the natural and will-
ing channel of supply. That paternal form of govern-
ment existing on the continent of Europe, which pub-
lishes the formulas of all proprietary remedies after
analysis by government chemists, giving ingredients
and actual market value, might have a deterrent ett'ect
in our own country on the too ready sale of nostrums.
Then I would refer to that spirit of narrow-minded
selfishness which, without adequate diagnostic equip-
ment or knowledge, or due regard for the welfare of the
unfortunate, presumes to prescribe a syringe and an
injection, and turns the patient loose on himself, so to
speak. The possible complications following such
injudicious and defective therapy are too numerous to
mention.
Laws similar to those regulating the division of
labor in all walks of life should apply equally in medi-
cine. The field is so vast and is growing so rapidly
that no one man may presume to be familiar with more
than a moderate portion of the whole. Therefore it is
but logical that some should possess more extended
knowledge and be better eciuipped in certain therapeutic
resources than others. On this ground, in the matter
of venereal disease, I plead for a more honest introspec-
tion on the part of the medical attendant ; a more sensi-
tive conscience, which shall not cause him to waver as
between his income and his duty. Let him be honest
with himself, and if he realize his own shortcomings,
let him consider his patient's best interests by placing
the latter in the hands of one who is competent to meet
all contingencies. This course should contribute greatly
in reducing the number of those treated imperfectly or
by thumb-rule.
The very list of remedies alone recommended for
the treatment of gonorrhea is prima facie evidence of
the non-specificity of any one. Hence the necessity for
wise judgment, and a most careful empiricism based on
extended observation.
In the matter of education not purely medical, l»egin-
ning with the duties presumably assigned to our honor-
able Committee on Education and Medical Legislation :
Since we have achieved one great goal for which we
have so long and so patiently striven in this State — the
regulation of medical practice — I would urge upon the
gentlemen composing the present, as well as future com-
mittees, the great necessity for enlightening our munici-
pal and State lawmakers upon the crying needs of at
least increased hospital facilities for the adequate care of
those afflicted with venereal disease. Let the boards of
education themselves throughout the State be educated
to the necessity of imparting judicious information to the
pupils in the highest grades under their jurisdiction, on
sexual physiology and hygiene and the dangers lying
in licentiousness. Let this be done through the medium
of a properly qualified medical man. Then following
the good work still further, let each of us constitute him-
self a committee of one to counsel wisely with the
fathers of families iu these matters, that they in turn
may begin with their own sons, and— through their
wives — with their daughters, at a rational age, making
no mystery of sexual physiology and hygiene, but ex-
plaining and guiding. 3Iany parents, through a miscon-
ception of the proper attitude toward their children,
never allude to that phase in the material development
of their offspring. The uniform result is knowledge of
a distorted and vicious character absorbed from un-
worthy and debased sources, which knowledge is applied
to perverse practices at the earliest opportunity. The
infectious results from licentiousness are scrupulously
concealed from the parent ; treatment of an imperfect or
pernicious character is sought through the misguided
suggestions of some friend ; resort is had to a proprietary
nostrum or to an advertising harpy, who, making a
prey of his unfortunate victim, despoils him only to
turn him adrift after a season, usually much depreciated
physically. Patients are continually appearing in dis-
September 27, 1902]
EELAXATION OF SYMPHYSIS PUBIS
lAItERICAK MEOICtlTB 507
pensary practice who have either-used some proprietary
nostrum or have fallen into the hands of some quaclc,
when, after having lost valuable ground and probably
developed complications, in desperation they resort to
the clinic.
My feeble words cannot paint the picture in lines
sufficiently striking to make an adequate impression on
my colleagues. The need is great for improvement in
the conditions regulating venereal diseases. :>Iy convic-
tion is thai the most effective methods for combating
the undesirable features and improving those already
working fairly well — for no perfect system, in part or as
a whole, may be said to have been evolved as yet — will
be found in heightening the standards of education as
to prophylaxis of venereal disease, and providing ample
facilities for throttling the sources of infection through
proper treatment. Such methods as these must be car-
ried to their highest perfection in order to be successful,
until that millennium shall have arrived when civilized
humanity will become artificially immunized against
all forms, or at least the venereal form, of microbic in-
fection.
BIBLIOGRAPHY.
Morrow, Phila. Med. Jour., April 6, 1901, December 1, 1901.
Dyer. Phlla. Med. .lour., February Hi, 1900.
Egan. American Medicine, December It, 1901.
Hammond, N. Y. .Med Jour , August .5. 1899.
Hill, Lancet, p. 570, 1871 ; Med. New.s. p. 961, 1901 ; Phlla. Med. Jour.,
December 1, 1901.
Miineh med. Wochenschr., p. 113, 1901.
.Southern Cal. Practitioner. December, IflOl.
Bulkeley, Jour. .\mer. Med. Assn., .\pril 6, 1901.
RELAXATION OF THE SYNCHONDROSIS OF THE
SYMPHYSIS PUBIS, FOLLOWING NORMAL LABOR,
TREATED BY RESECTION AND WIRING.
BY
B. R. SCHENCK, M.D.,
of Baltimore, Md.
Instructor In Gynecology, Johns Hopkins Medical School; Resident
(iynecologlst, Johns Hopkins Hospital.
Rupture and relaxation of the symphysis pubis dur-
ing labor are comparatively rare accidents, the reports
from the large obstetric clinics in Europe containing few
instances. Thus there were only three cases in 30,000
deliveries at Schauta's Vienna clinic,' and Savor'
ob.served it but three times in 64,149 confinements
which took place between the years 1878 and 1899 at
Crobak's clinic.
The literature, nevertheless, contains fairly numerous
reports of these injuries, and there have been several
excellent monographs written on the .subject. In 1876
Ahlfeld ' made the first extended report, and at that
time wa-s able to collect 100 ca.ses of separation of the
l)ubic bones. Schauta * added 12 more from the litera-
ture in 1889, while De Lee,* of Chicago, writing in 1898,
gave an e.xcellent consideration of the whole subject,
bringing the cases up to date and giving additional refer-
ences. The catalogue of the Surgeon-General's library,
together with the articles of Ahlfeld and De Lee, give
l.')!» references — practically the complete bibliography of
the subject. A few more recent references are here
iippended.
The chief points to be noted from a perusal of the
literature are the following :
Se))aration of the pubic cartilages occurs much more
frefjuently in multiparas than in primiparas, particularly
in women who have borne more than three children.
When occurring in primiparas it is usually in those in
the third or fourth decade of life.
A large percentage of cases have taken i)lace in
difficult labors, generally during a version or forceps
delivery. A generally contracted pelvis has most fre-
quently been found.
When there is an actual rupture, this often takes
place with a loud, cracking sound. When there is
relaxation of the ligaments, allowing the bones to slip
upon one another, the condition may not be discovered
until after confinement, usually when the patient first
moves herself in bed.
The chief symptoms are pain over the pubic arch,
pain while lying in any other position than on the back,
and pain and difficulty in walking.
Suppuration frequently occurs, destroying the articu-
lar cartilages. Duhrssen" reports 23 ca.ses in which
this took place.
Simple measures, such as strapping with adhesive
plaster, or the application of a tight bandage over the
hips usually suffices to keep the tissues in position until
union takes place. When there is no infection, this
generally occurs in from four to six weeks.
The following case of relaxation of the synchondrosis
is of interest on account of the severity of the symptoms,
the length of time the mobility persisted and the opera-
tion which was done for relief.
The loosening of the articulation evidently took
place about the fifth month of pregnancy, and was much
accentuated by the distention of the superior strait
during labor.
Mrs. L., aged .31, wa.s admitted to the service of Dr. Kelly, in
the Johns Hopkins Hospital, on May 10, 1902, complainiug of
pain over the symphysis pubis and inability to walk without
great discomfort.
She has been married 13 years and is the mother of three
children, tlie oldest of whom is 11 years, and the yoiineest 8
months. The three labors were comparatively easy and the
puerperia normal, except for a severe attack of phlebitis in the
left leg following the hrst confinement. She has always had
excellent health, and is a strong, very well built woman, weigh-
ing about 135 pounds.
In May, 1901, when about five months pregnant, she began
to suffer with pains over the lower abdomen, especially severe
after exercise. Tliese attacks gave her considerable discomfort,
and increased somewhat in severity until the end of pregnancy.
She describes the labor as more difficult tlian any of the pre-
vious ones, the second stage lasting about 4J hours. The child
presented by the vertex, and weighed 10 pounds. A physician
was in attendance ; no instruments and no anestlietic were
employed.
The first time she turned herself in bed after confinement
she felt a momentary sharp pain in the lower abdomen, fol-
lowed by a grinding sensation in the region of the symphysis.
This recurred each time she turned on lier side. Her physi-
cian left town, and without advice she left her bed on about the
fourteenth day.
When she first tried to walk there was felt at each side this
same grinding pain, with the sensation as if something were
slipping. Sitting up and walking became so painful that she
spent much of the next six months in bed. Aljout this time a
wellknown surgeon was consulted, who ordered a steel and
leather girdle, so constructed as to press the pubic bones
together. This, however, could not be worn tightly enough to
prevent the bones from slipping.
At the time she was admitted to the hospital (eight months
after confinement) she wa.s able to walk but a sliort distance
without great fatigue and with much discomfort, experiencing,
as she said, a " scrunching " pain over the symphysis at eacrii
step. Her gait was somewhat swaying in character, but this
was not marked. On grasping the pubic synchondrosis with
the thumb and finger there was felt an up-and-down movement
of about 1 cm., the bone corresponding totlie side on which the
weight was placed rising about this distance above its fellow.
The pelvic measurements were normal and the general physical
examination negative.
Operation was performed by Dr. Kelly May 12, 1902. Resec-
tion of the synchondrosis of symphysis pubis : wiring of pubic
l)ones. A soinid being jjlaced in the urethra and t)ie soft parts
held to one side a perj)etidicular incision was made over the
middle of the symphysis, exposing tlie fibrocartilages. The
thighs were supported by assistants on either side and the carti-
lage cutthrongh, allowing a separation of about 6 cm. After the
bladder had been freed from the posterior surfac^eof the bone the
cartilage and about 1 cm. of the bone on either side were sawed
off. Protecting the .soft parts posteriorly with a spatula, holes
were bored for three sutures, and aluminum bronze wire was
pulled through by moans of an aspiratinjt needle containing a
large eye at its tip. On attempting to twist the bronze wire it
broke into many small pieces, necessitating its removal and the
substitution of heavy silver wire. This ill success with the alu-
minum bronze was due, as we afterward learned, to its having
been in contact with bichlorid of mercury, as this forms an alloy
which is very friable.
Hy twisting the silver sutures tightly the ends of the pubic
bones were perfectly coapted and the wound was closed up
with catgut sutures. A retention catlieter was placed In the
urethra and the patient strapped down to a Kradtord frame.
508 AMKBicAN Medicine]
SCHOOL VACCINATIONS
[Skptembkb 27, 1002
For ten days after the operation the patient had frequent
cks of vesical spasm, causing excruciating pain. These
F.
attacks _ _ . . _ „ .
suddenly disappeared, and as the urine gave no evidence of
cystitis, it was conjectured that the bladder might have been
caught in a catgut suture, after absorption of which the spasms
ceased.
The Bradford frame, with the canvasses so arranged that
there was an outlet for the bladder and rectal discharges, and
with the ends raised on hassocks placed on a fracture board,
admirably answered thepurposeof an Ayres" symphysiotomy
hammock.
After resting on the frame five weeks the patient was kept
in bed two weeks, and after that was up and about, walking
more each day. She was discharged on July 29, and on leaving
the hospital was able to walk with absolutely no discomfort.
Examination revealed no callus, and there was no tenderness
over the short scar.
So far as I have been able to find, in only one other of
these cases was wiring done, that by Wyile and reported
by Ayres.'
BIBLIOGBAPHY.
1 Braun, Archlv f. Gyn.. Bd. xlvli, s. 105.
2 Savor. Wiener kiln. Woch., 189ii, Vi, s. liS6.
3 Ahlfeld, Schmidt's Jahrb., 1876, Bd. clxix, s. 185.
< Schauta, Muller Handbuch der Geb.. Bd. 11. s. -103.
5 Ue Lee, Am. J. Obs., 1898, Vol. xxxvlii, p. 483.
" Diihrssen, Archiv f. Gyn., Bd. x.xxv, s. 89.
' Ayres, Am. J. Obs., 1897, Vol. xxxvi, p. 10.
The following references complete the bibliography to date:
Bar and Keim, Cent. f. Gyn., 1889, s. 789.
Rudaux, Paris Thesis, 1898.
Rutherford, Louisville J. Med. and Surg., June, 1899.
Jelllnghaus, Cent. f. Gyn., October 28, 1899.
Himmelsbaeh. Phlla. Med. J , 1900. Vol. vi, p. 712.
Van Hassel, Bull, de la Soc. Beige de gyn. et d'obst., xli. No. 6.
Burkhard, Cent. f. Gyn., 1900, Bd. xxlv, s. 1381.
Josephson, ibid., s. 1413.
Ruth, Am. J. Obs., 1901, Vol. xliv, p. 556.
SCHOOL VACCINATIONS.
BY
WILLIAM R. FISHER, M.D.,
of Swlftwater, Pa.
Each year in our cities and towns, about the end of
August and the beginning of September, a ho.st of chil-
dren are vaccinated by way of preparation for the open-
ing of the public schools. It is not to be supposed that
all these vaccinations are successful. On the contrary,
there is good reason to believe that continuously a very
considerable number of children are attending school
who are unprotected by vaccination, although they have
complied with the law by presenting certificates of suc-
cessful vaccination from legalized physicians. It would
be interesting and instructive to know the proportion of
failures to successes and how many are really protected
against smallpo.x.
Legal enactments, requiring vaccination before ad-
mission to the public schools, appear on the statute
books in many parts of the country and the general sub-
mission on the part of the people to these exactions leads
some to believe that the first step has been taken toward
the establishment of compulsory vaccination and that
we will soon be on the way to protect the public at
large against smallpox by means of a more compre-
hensive legislation. Closer investigation, however, will
show that the real conditions which surround the subject
of school vaccinations are far from justifying any such
belief or expectation. Theoretically the children of the
public schools in our cities and towns have all been prop-
erly and successfully vaccinated ; practically these
schools contain a large number of pupils who have never
received the protection that proper vaccination atfords.
There is much to criticise about the methods that are in
use to regulate and to promote vaccination by legal
enactment. In this connection no account is taken of
the rural districts where there is no restriction upon ad-
mission to school and where the proportion of unvac-
cinated scholars is probably very high.
Physicians who are called upon to do much of this
autumnal school vaccination notice that each year
the number of primary vaccinations among the appli-
cants for certificates is steadily increasing. In other
words there is a growing tendency among parents to
abandon the old custom of vaccination in early infancy
and to put off the operation until the time comes for the
child to go to school. There can be no doubt that legis-
lation is responsible in some degree for this change in
public sentiment. Vaccination is apt to be looked upon
as a trying ordeal at best and it is natural that parents
should feel that once is better than twice, and put off
the operation until the time when the law makes it
obligatory. The obvious objection to this too common
habit is in the fact that it leaves a large number of young
children without protection at an age when suscepti-
bility to smallpox is great and the mortality is high.
Another objection, not so conspicuous as the first but
none the le.ss important, is based upon the influence of
season. It is a matter of common observation that in
general the course of vaccination in human beings is not
as satisfactory in summer as at other times of the year,
but many physicians are not aware that the influence of
season upon vaccination is not restricted to human
beings but is also shown to a marked degree in the prop-
agation of vaccine virus upon the calf. Not only does
hot weather tend to diminish the efficacy of vaccination
but it interferes decidedly with the production of good
active virus. The experience of propagators of vaccine
virus teaches that during the warm and dry weather
calves do not always respond as well to vaccination as at
other seasons of the year. The vesicles are apt to form
slowly, the serum is scanty, the yield of virus is less
abundant and the product is not so active in its effects
nor does it remain potent for so long a time. This fact
has a direct bearing upon the close relationship which
e.xists between smallpo.x and cowpox. The effect of
climate and season upon zymotic disease is nowhere
.shown more distinctly than in smallpox, for, while the
disease may exist at any time of the year and, indeed,
may be epidemic in summer, a study of its history shows
that the cooler seasons of spring and autumn are more
favorable to recurrences and that new outbreaks seldom
begin in hot weather. Sydenham (Section III, Chap. II)
goes so far as to assert that the symptomatology of small-
pox is determined by the time of year at which the dis-
ease sets in : the vernal form being milder and more
regular than the autumnal.
The failures which so often follow vaccinations when
performed in summer upon human beings should cause
neither surprise nor disappointment. One should always
remember that in hot weather, and especially during a
prolonged drought, conditions necessary for the produc-
tion of a high-grade vaccine virus cannot always be
secured, nor can a thoroughly active virus be protected
from injurious exposure to heat during transportation
and the handling to which it necessarily must be sub-
jected when in use by the physician. When, therefore,
t"he vaccination of school children is put off until August
or the beginning of September, physicians must expect
to meet a good many failures. On the other hand, hot
weather favors the development of those complications
which arise from septic infection, for during the summer
the irritation at the site of vaccination is apt to be
troublesome, and there is more scratching of the skin ;
the vesicle is liable to be broken and infection can easily
take place from the clothing, the finger-nails or the skin
of the patient. Septic infection from without is the
cause of most of the complications which follow vacci-
nation— cellulitis, lymphangitis, sloughs, prolonged sup-
puration and deep ulcerations— sequels that are some-
times accompanied with danger and always with pain
and discomfort to the patient.
These are some of the objections to summer vacci-
nation as they may be regarded from the standpoint of
the individual ; but the subject presents a wider out-
look when its effect upon the community at large is
taken into consideration. It is a serious matter to a
parent who has subjected his child to vaceiuation and,
8EPTBMBEB 27, 1902]
THE HOSPITALS OF JERUSALEM
%4JCKBICAN MbDICINX 509
believing it to be protected against smallpox, is rudely
taught by sad experience that througli somebody's ignor-
ance or carelessness the vaccination -vvas not successfully
performed ; but the importance of such a case is vastly
increased when we consider how the occurrence of such
misfortunes here and there in dilFerent jilaces is at work
to shake the confidence of the people in the efficacy of
vaccination. The accumulation of a few such instances
is sutHcient to place the antivaccinationist in a position
to ask the pertinent questions: " If vaccination does
not protect why must people be forced to submit to it,
and what better evidence can be had of its failure to
protect than that supplied by the school children who
have had certificates of successful vaccination and yet
have succumbed to smallpox ? "
If existing legislation is producing results which the
enemies of vaccination can make use of to their own
advantage the sooner it is amended the better. There
is no question that the intent of the law is to protect the
children of the State from smallpox ; but the means pro-
vided to accomplish that object are entirely inadequate.
In making admission to the public school dependent
upon the presentation of a medical certificate that vacci-
nation has been successfully performed it is evident that
the law does not recognize the radical differences of
opinion that exist on many matters relating to vaccination
among legalized physicians. The law assumes that each
one of them is favorable to vaccination ; is competent to
vaccinate and after doing so to determine whether the vac-
cination has been successful or is doubtful, spurious or a
failure. It does not take into consideration the wellknown
fact that very little instruction is given to physicians gen-
erally about vaccination ; that many know so little about
the subject that they regard the " raspberry excrescence "
a sign of succeas ; that others make the common error of
mistaking an infected sore for a successful vaccination, not
knowing that one may have a very sore arm after vacci-
nation and yet receive no protection against smallpox.
It does not take note that culpable carelessness may lead
some physicians to give certificates at the time of opera-
tion without waiting to verify their results, nor that
there may be unscrupulous doctors who for pay will give
out false certificates to oblige applicants who are unwill-
ing to submit their children to vaccination. In this
instance at least the law seems to regard all physicians
as equal in knowleflge, skill, care and honesty, and pays
no heed to the possibilities of false certification from
ignorance, carelessness or intention.
It is embarrassing to be forced to state that the med-
ical profession is at present in a position in which the cer-
tificates of some of its legalized members in reference to
vaccination are not to be accepted without question ; but
such being undoubtedly the case, it is the duty of those
who recognize the supreme importance of vaccination to
the community, as well as to the individual, to empha-
size the opinion that so long as this preliminary to
school registration is left entirely in the hands of physi-
cians in general, without responsibility, supervision, or
control, there will continue to be errors and abuses in
certification. A radical change in method is imperative.
The privilege, which is now too general, should be taken
away from physicians-at-large and be vested in oflicers
whose competency would be guaranteed by the sanitary
authority from whom they would derive their appoint-
ment and to whom they would be responsible. The mech-
anism for such a plan is already providetl. liCt the power to
issue certificates of vaccination be restricted to the health
officers of the Wtate, city, town or borough where, indeed,
it properly belongs. Then let these me<lical officers deter-
mine the question of the protection of each individual
solely by the existence of the typical vaccination scar.
Here is a certain, well-defined sign which cannot l)e forged,
and is not susf'eptible to the blandishments of the most in-
fluential patient. It tells a plain story which any intelli-
gent layman can be taught to read and to understand. Its
presence gives assurance that a successful vacciiujtion has
been performed; its absence shows the need for one.
There are some persons, it is true, who cannot be made
to react to vaccination, and such exceptions would have
to be provided for ; but these are few and far between.
Immunity to vaccination properly performed is a rare
condition.
The antivaccinationists have never before been so
active and aggressive as they are at the present time,
and their avowed purpose is to break down all legisla-
tion which may tend to sanction vaccination as a sani-
tary regulation or to make it obligatory. Every incident
that seems to count for their side is eagerly taken up
and exploitetl by them to the utmost, for they keep the
public well supplied with an abundance of reading mat-
ter by means of the newspapers, pamphlets and cir-
culars : most of it is absurd and illogical, but here and
there is a specious bit of argument that does not fail to
have its influence upon persons of intelligence and
education. They will find no richer fund for the supply
of erroneous statistics than that provided by a school
system that officially guarantees the successful vaccina-
tion of each scholar and at the same time permits the
attendance at school of unprotected children who uncon-
sciously stand ready to fall victims to the scourge of
smallpox at the first exposure. The supporters of vacci-
nation must look well to their defences and leave no
weak points open for attack. Above all they must not
allow their enemies to capture their guns and turn them
to use for their own advantage. This they will do if
the present laws relating to vaccination in the public
schools are allowed to stand without amendment.
SPECIAL ARTICLES
THE HOSPITALS OF JERUSALEM.
BY
NICHOLAS 8ENN, M.D.,
of Chicago.
A brief description of the hospital facilities of the ancient
historic city of Jerusalem may be of more than passing interest
to the medical profession of our country. The very name
Jerusalem carries our memory back to our earliest childhood
days. The great events which occurred in that city and so
vividly described in the Scriptures are familiar to every Sun-
day-school scholar, and the pictures formed of them in the
mind of the child remain as long as memory lasts. It is here
where the greatest miracles were performed ; where the Great
Physician taught and labored ; where he healed the lepers,
made the blind see, the deaf hear, and the lame walk. But
.Jerusalem of today is not the Jerusalem of those days. The
magniflcent temple of Solomon, the pride of the Holy Land, is
no more. The ruthless hand of time and the destruction
wrought by war and fire have left but few reliable landmarks
of the proud city of Zion. The descendants of the people who
built and owned it have been reduced to a condition worse than
slavery. The Jews of the Bible clamored for the cross ; the
Jews of today are held in subjection and are persecuted and
humiliated by the crescent. Thoy occupy the narrowest, most
crowded, and filthiest streets, conduct the smallest shops, and
furnish the largest contingent to the army of shoeblacks. The
large group of wailing .Tews that gathers so regularly every Fri-
day afternoon outside of what was once the city wall is an object
lesson which when once seen will never be forgotten. A mot-
ley crowd of men, women and children, with Hebrew Bible in
hand, lean against the wall and in pitiable, mournful tones •
lament their loss and in fervid prayer petition the God of Israel
for relief. For nearly 2,000 years these weekly wailings outr
side the walls of their former city have taken place with great
regularity, Ijut their position in life remains the same. David
street is the center of the Jewish settlement and It would be
impossible to find a dirtier thorouglifaro, less inviting stalls,
and more odorous human habitations anywhere. The present
number of inliabitants of Jorusnlom is 150,000 and of those
510 AMERICAN MEDICINBI
THE HOSPITALS OF JERUSALEM
[Septembsb 27, 1902
about one-half are Jews. The lack of sewerage and the scarcity
of water account for many of the prevailing diseases. Bathing
Is a luxury and not within the reach of the poor. In one of the
hospitals I was informed that a patient recently admitted said
that she had not had a bath in ten years and from what I saw
in the .lewish quarter of the city and elsewhere I am sure this
was by no means an isolated experience. When water has to be
bought and paid for out of the lean purse of poverty-stricken
people, the supply must necessarily be a limited one. Sewer-
age and an ample supply of wholesome water would make .Jeru-
salem the most healthful city in the Orient, as its geographic
location is an excellent one, at an elevation of 2,400 feet above
the level of the sea.
HOSPITALS or JERUSALEM.
Jerusalem has for a long time been a center of mission
work in which foreign nations and different religious denomi-
nations have taken an active interest. The extreme poverty of
the great majority of its inhabitants and the unsanitary condi-
tion of the city are largely responsible for the unusually large
number of sick poor. The different hospitals take care of at
least 1,000 outdoor patients every day. It is a great pity that
this enormous clinical material is not utilized to greater advan-
tage for scientific investigations. The oculist, the dermatolo-
gist, and the genitourinary surgeon would find here a rich field
for clinical study. The hospitals, some 12 in number, are all
small, and none of them makes any pretension to being entirely
modern.
The Oerman or Deaconess Hospital. — This is the best hos-
pital in the city. It is one of the many hospitals erected, main-
tained and managed by the Sisters of Kaiserswerth in Ger-
many. This order of German nurses has labored here since
1851 in the interest of the sick poor of all nations. The present
building is a new one and its doors are wide open to all in need
of medical treatment, at the same time ample provisions have
been made for private patients. Eight faithful Sisters attend
to the needs of the patients and are tireless in securing the
necessary funds to carry out the many charitable objects of the
institution. During the visit of the Gorman Emperor to Jeru-
salem the Empress honored the hospital by a visit. What
attracted her attention most was the imperfect supply of instru-
ments and facilities for aseptic work in the operating-room.
She dictated an order for everything necessary, sent it to Ger-
many, and the hospital has now the best equipped operating-
room in Palestine, all at her private expense. Visits like these
live in the history of any charitable institution. The hospital
is located in a quiet part of the city and can accommodate 60
patients. The outdoor department is visited by more than 5,000
patients every year. The relative proportion of the different
nationalities of the inmates for the year 1898 was as follows :
Arabs, 698 ; Armenians, 54 ; Germans, 45 ; Greeks, 14 ; Aus-
-^.. ,. 5 8 I' siai;!;!,
German Deaconess' Hospital In Jerusalem.
trians, 12 ; Bulgarians, 3 ; English, Swiss and Spaniards, each, 2 ;
1 American and 1 Russian. The institution is constantly grow-
ing in favor with the natives and its far-reaching influence, as a
center of true charity and as a house of refuge for visitors
stricken down with disease, cannot be overestimated.
The Russian Hospital. — This hospital is supported by the
Russian government and a local branch of the Red Cross. It
can accommodate 44 patients, and in a separate building there
are ten additional beds for patients suffering from acute infec-
tious diseases. The arched corridors and rooms correspond
in architecture with many of the more important buildings,
public and private, in Jerusalem. The sick are under the care
of two Russian Red Cross Sisters. The dispensary is large and
in charge of two competent druggists. The small operating-
room contains all that is essential for modern surgical work.
The outdoor department is popular with the mass of the people,
as it was visited by 22,000 patients during the last year. Dr.
Severine is the only medical attendant. He is a (ireek, studied
in Athens and after graduation spent two years in Paris. In his
outdoor work he sees many cases of furunculosis, aljscess,
lymphangitis and erysipelas. In the operating-room he relies
on chloroform as an anesthetic, and silk as suture and ligature
Operating-room in Kussian Hospital, Jerusalem.
material. The hospital is open for all deserving sick poor,
regardless of nationality or religious faith. During my visit I
was shown three cases of empyema recently operated upon by
the radical method. In all of these cases the suppurative
pleuritis developed in the course of croupous pneumonia.
The Greek Hospital.— This hospital was established by the
Greek Catholic Church in 1865. It has 54 beds, many of which
are occupied by pilgrims, who come annually in large numbers
to Jerusalem and who are taken ill on the way. Dr. Nicholas
Spyridon is the medical director. During the last 10 years he
has performed laparotomy for echinocoeous cyst twice ; one of
the patients died, the other recovered.
Hospital of Saint ioMf's.— This hospital was built by and is
in charge of the Sisters of St. Joseph, who came to Jerusalem 52
years ago. The present excellent building is 22 years old and
has a capacity of 85 beds. It is a solid stone building two and
three stories high, with a large open court in the rear orna-
mented with trees, flowering shrubs and flowers. The wards
are large, well lighted and scrupulously clean. The comfort-
able beds and spotless linen contribute much to the general
attractiveness of the sick-rooms. The hospital is in the very
heart of the city and is enclosed by a high stone wall. On an
average 300 patients call at the outdoor department every day.
Two physicians are in charge of the medical and surgical serv-
ice. The Sisters assist in operations and apply many of the
dressings. One of the Sisters, a graduate in pharmacy, is in
charge of the large dispensary. As all of the patients, indoor
and outdoor, are charity cases, it is a source of surprise to the
visitor to see the institution in such a flourishing condition.
The prayers of these hard-working, unselfish Sisters must find
a ready response from somewhere.
Hospice of the Sisters of Charity, St. Vincent de Paul.— This
is not a hospital proper, but a home for the blind, the crippled,
the incurables, the aged and the orphans. It is a charitable
institution in the widest sense of the word. Seventeen Sisters
labor here night and day to render life comfortable, and when
it can be done, useful. It contains at present 170 inmates. One
of the Sisters educates the blind children, another takes care of
the many infant orphans, a third one conducts a school, while
others are engaged in making life endurable for the incurables.
Here is a profitable and grateful place for modern surgery. The
sight of many of the blind could be restored and many of the
crippled limbs could be made useful by surgical intervention.
8 KPTEMBER 27, 1902]
THE HOSPITALS OF JERUSALEM
[Amebican Medicine 511
Let us hope that the Sisters may find the gratuitous services of
a competent oculist and surgeon to aid them in their philan-
thropic work.
Baron Rothschild Hospital. — This charitable establishment
was founded 49 years ago by the Rothschild family, and was
intended exclusively for the benefit of tlie Jewish population of
the city. The present site was selected and the hospital built in
1885. The hospital space is limited to 12 beds for men, an equal
number for women and six for children. Only Jews are
admitted into the hospital, while the outdoor clinic is open to
all who apply. There are no private rooms, and all expenses
are paid from a fund donated by the founders of the institution.
Sick mothers often bring their infant children with them, and
sick children are eijually often accompanied by their mothers.
The facilities for surgical work are very primitive, as very few
operations are performed. Dr. I. G. D. Arbelig is the attending
physician and at the same time conducts the outdoor depart-
ment, to which not infrequently as many as 325 patients apply a
day. The doctor is an Italian by birth and education, but spent
been renovated recently and is supplied with all facilities for
aseptic work. The question of nationality and religion is not
considered in admitting patients. Tlie outdoor clinic of this
hospital, which is a very large one, is in the central and most
accessible part of the city. A few years ago a radical change
for the better was made in the nursing force by placing the
patients in charge of three Sisters of Charity. The initiation of
these Sisters into their work in a Turkish government hospital
was an important event and the ceremony was attended by the
ruling Pacha and military officers of high rank. The Sisters
sleep in their own hospice and the only remuneration they
receive for their services is 60 piastres (or§:i.OO) a month, just
enough to pay for carriage hire. It is needless to say that the
patients appreciate to the fullest extent the kind and skilful
nursing of these faithful and devoted Sisters. Dr. Photios, a
Greek physician, has charge of the medical service. He is a
man of far more than average intelligence and ability and is
devoted to his profession and his patients.
Jesus-Hilfe. — This is an asylum for the care of lepers. At
A group of lepers In Jerusalem.
several years in Paris after his graduation. He speaks and
writes I(i languages, and has use for them all every day in con-
versing with his outdoor patients. He is a tireless worker.
His professional work often extends beyond the midnight
honr. The number of malarial cases he is called upon to treat
may be ajiproximately estimated from the statement he made
to me that he uses annually no less than 40 kilos of quinin. In
severe cases of malaria treated in the hospital he preferred to
use this drug by subcutaneous injections ; in the outdoor clinic
it is administered in pill or powder form. At the time of my
visit nearly all the beds were occupied iiy malaria patients.
Pronounced anemia, enlargement of the spleen and liver and
ascites from the last two affections were the most frequent
remote malarial complications. In the hospital a small syna-
gogue serves as a place of worship for the orthodox Jews.
Municipal Hospital. — Besides the military hospital this is
the only government hospital. It was built 15 yearsago, has 30
beds and is beautifully located on the highest hill in the city.
The hospital is well furnished and the little operating-room has
present the number of lepers in Palestine is estimated at from
300 to 400. These unfortunates form a large part of the profes-
sional beggars in the streets of Jerusalem. They have formed
an organization among themselves with a chief of their own
selection at the head for the purpose of making begging more
systematic and remunerative. These lepers mix freely with the
people in the streets and public places. Most of the lepers are
Arabs, the Jews are singularly exempt from this disease. The
tuberculous and anesthetic forms are about equally represented.
Many years ago the Moravian Brotherhood at Herrnhut, Ger-
many, conceived the happy idea of taking care of the lepers in
Palestine. In 1886 the present building, some two miles from
the city limits, was complete<l. It was found very dlfflcult to
induce the lepers to enter and remain in this excellent institu-
tion, erected for their special benefit. They hesitated in
exchanging their roaming free outdoor life for a pleasant home
in the asylum. In many instances they would remain for a
short time and then leave suddenly without permission and
resume their begging station in the most frequented streets;
612 Amebicaw Medioink]
MEDICAL EDUCATION
[September 27, 1902
when their business did not tlirive, when their scanty gar-
ments became ragged and finally when hunger tortured them
they would return to their former hospitable asylum home and
remain long enough to satisfy their immediate wants and then
disappear again as suddenly and unceremoniously as before.
Gradually, however, the confidence in their benefactors
increased and they realized more and more the unselfish benefi-
cence of the institution. At present the asylum contains 47
inmates. It is conducted in a most economic manner, but the
patients are well fed, comfortably clothed and receive the most
tender care. The asylum is presided over by Mr. Charles
and Mrs. Annie Schubert, and the patients are cared for by
Deaconesses Ehrle, Eisner, Miiller and Zimmer. Dr. Einsler,
the physician-in-chief of the Deaconess Hospital, directs the
hygienic and medical treatment. The serum treatment was
made use of in a number of cases, but the high fever caased by
the injections aggravated the disease and in a few cases hast-
ened the fatal termination. Among the 47 inmates of thg
Jesus-HUfe Leper Asylum.
asylum there is only one Jew. Dr. Einsler, during his long
and extensive practice in Jerusalem, has seen only three Jews
affected with leprosy, and of these one came from Salonik and
the remaining two from Morocco. It seems tlien that the Jews
of Jerusalem have in the course of time acquired an immunity
against this disease notwithstanding the increase of poverty
and unsanitary surroundings. The Jesus-Hilfe loper asylum
of Jerusalem is one of the most deserving charitable institu-
tions of Jerusalem and deserves the financial support of all
humanitarians.
British Hospitals. — The English people have done their
good share in the alleviation of the suffering poor of Jerusalem.
One of these hospitals, the Ophthalmic, is devoted exclusively
to the treatment of diseases of the eye; the other is a general
hospital. Eye affections are alarmingly common in Jerusalem
and throughout Palestine. In no other city are the blind more
numerous and inflammatory aff'ections so common. Bulbless
sockpts and opaque corneas are met every few steps in any of
the crowded streets. Specific infection and trachoma are the
most frequent causes of blindness. The number of blind
infants and young children is astonishing. The Ophthalmic
Hospital has 20 endowed beds, which are always in great
demand. Three times a week the outdoor department is
thronged with men, women and children who apply for relief.
This hospital has a wide range of usefulness in averting blind-
ness and in restoring sight in cases adapted for successful
operative interference.
Jerttsalkm, July 1.
MEDICAL EDUCATION.'
BY
CHARLES W. RICHARDSON, M.D.,
of Washington. D.C.
Medical schools throughout the land are at present strug-
gling with the problem of medical education. With the change
of the medical course from that of three years of six months
each to one of four years of eight months each, the problem of
medical education has become more complex. The study of
medicine has become so broad and its scope so extensive, with
its division of subjects, increased didactic and clinical lectures
and laboratory work, that there seems hardly time in the under-
graduate curriculum for serious and satisfactory compulsory
1 President's address before the American Larvngologlcal, Rhluo-
loglcal and Otologlcal Boclety, at Washington, D. C , Juuetliwi
work along the line of special teaching, even though concen-
trated within the fourth year of the medical course. It is not
noc^essary to more than note the improvement in the teaching
methods in all branches of medicine, which improvements
require usually more working hours on each subject. Within
the ranks of the teaching force there is noted a feeling of unrest,
uncertainty, and evidence of experiment as to the relation that
the various special branches should hold in the curriculum of
the undergraduate in medicine. This relationship of the special
subjects to the curriculum of the undergradute forms a most
interesting theme from the standpoint of medical pedagogics,
and cannot but interest most keenly those who are devoting
their energies to teaching the science of medicine along the lines
of their chosen specialty.
The method pursued in most medical schools within the
past few years is the introduction of the various special branches
into the undergraduate's curriculum, with or without concen-
tration, all having an equal value and each branch compulsory.
This method results in an overcrowding of the working time of
the undergraduate, imposing upon ihim detail work of a char-
acter which he is unprepared to acquire, and makes compul-
sory the acquisition of knowledge which will be of no future
use to him.
With the introduction of the special branches into the
already overcrowded curriculum of the undergraduate the
question naturally arises as to what we have been accomplish-
ing by this process. According to the method which is now in
vogue in the majority of the colleges of the country, I would
be rather inclined to believe that not as much had been accom-
plished as one would deiire. The increase in the number of
hours for didactic and clinical work demanded by the various
special teachers has necessarily resulted in the curtailment of
the amount of work done on the fundamental branches in the
third and fourth years, which has not resulted in the greatest
benefit to the mass of students. The overshadowing impor-
tance which the special branches have obtained in the fourth
year of the course, through the number of hours devoted to
them collectively and through the methods adopted by the indi-
vidual lecturers to impress the importance of their subject,
has no doubt led to laxity in major work during this impor-
tant year of the medical student's life. Can the method of the
teaching of specialties in the medical schools be improved
upon ? There is no doubt that the present system can and will
be altered markedly.
The two methods along which this line of improvement is
to be brought about are either through the reduction of the
scope of the special work in the schools or through the elec-
tive system of teaching. There is no doubt that the funda-
mental and all-important duty imposed upon the medical
school is the production of graduates skilled in the art and
science of medicine. The production of men skilled in the
special departments of medicine is not the province of the
medical school. In order to accomplish this work in the most
satisfactory manner the major portion of the undergraduate
medical course should be devoted to the thorough acquisition
of the fundamental branches of medicine, and the essential
importance of these should be constantly called to his atten-
tion. By the eliminative system the various special branches
should be limited in their scope and all attempts on the part
of each individual special lecturer to produce full-fledged
specialists in his particular branch through the medium of his
course of lectures and clinics should be abridged. The special
lectures should be so adapted to the fundamental branches of
which they form the integral part as to supplement and aid,
rather than to supplant them. They should be so designed as
to aid in the diagnosis of those conditions which the general
practitioner is most likely to meet and to differentiate these
conditions ; and to teach him how far he may go with safety,
and when he must desist. By this method, holding the special
teacher subordinate to and subject to the direction of the teach-
ers of the major branches of which they form the integral
part; by limiting their scope and the number and character
of the lectures, such special knowledge can be imparted to
the undergraduate that will be of incalculable value to him
as a general practitioner, and at the same time lessening the
amount of time and effort necessary to acquire it. Through
SEPTEMBER 27, 1902]
MEDICAL EDUCATION
[AicEBiCAN Medicine 513
this method, also, such an insight into special work will be
given the undergraduate as to develop tendencies that have
been hitherto unrecognized by him along the line of special
study which will later go on to fruition in a postgraduate
course.
The elective is that method by which the student is peT-
mitted some choice in the course of study which he is to follow.
All students, under this course, are obliged to take certain
majors which essentially form what are now known as the
fundamental branches of medicine, although they may express
a choice of topics in connection with these majors. Other
majors are elective with the student, the minors form cognates
to his elective majors, and should be so selected as to round
off the student most completely in his elective course. Through
this method it is expected that the student presenting himself
as an undergraduate has fairly in mind what he wishes to ac-
complish in his medical course and elects his majors, with a
certain degree of latitude, along the line which will bring
about this desired result. Under this elective course the vari-
ous special courses can, and must, have an unlimited scope,
and the teacher must and should be as thorough in his meth-
ods and as definite in details as is the lecturer on surgery,
obstetrics, or internal medicine. Such a method eliminates a
large amount of work which, under the other system, is com-
pulsory, and enables the student to concentrate his attention
more enthusiastically upon that field of work for which he
feels he has a special aptitude.
Which of these methods is likely to be productive of the
better class of graduates? The concentration method which
is now in vogue in most of the medical colleges is certainly
not accomplisMng the best results, as it overcrowds the med-
ical student with a rapid succession of compulsory special
subjects, which he neither has time to prepare nor to digest
mentally, and because in this compulsory course there is too
much time devoted by the various lecturers in minute detail
work which is not only tiresome but xiseless to the student.
Theoretically, the elective system is an ideal method, espe-
cially if the oVjject of medical undergraduate teaching be the
production of men skilled along certain lines, rather than gen-
eral practitioners. I am well aware of the fact that those who
advocate the elective system claim that there is no danger
through the adoption of this system of producing graduates
whose knowledge of general medicine will be below the
standing of graduates educated under the former system, and
such is possibly the result. In fact, it is claimed by those
who are competent to judge that by the elective system, so
far as worked, the students have shown no tendency to special-
ize or concentrate tlieir energies upon certain lines to the neg-
lect of others. While it is thus claimed by those who have
Instituted the elective system that there is no tendency to
specialize, they acknowledge this to be the great danger and
one around which safeguards must be thrown. Even acknowl-
edging that those safeguards can be maintained during the
medical student's undergraduate course, what is there to safe-
guard him after graduation? The graduate of such an elective
system, after the thraldom of his medical course is past, will
throw himself with the zest and enthusiasm of freedom along
the line which his whole medical course has been preparing
for him. The moment he receives his diploma he will begin to
neglect those branches of general medicine which he acquired
only as essential to his graduation and as a result we will
develop in this individual in many instances a narrow special-
ist who sees only one side of medicine and all medicine
through this special field. It is not wise for us to be always
allowed too much latitude in our inclinations in search of
knowledge. I doubt very much if the majority of under-
graduates in medicine at any time in their course are capable
of forming a conception as to what is best for them as to their
future welfare in medicine. I fear that there is in the mod-
ern system of education too much latitude given to the stu-
dent as to his choice of subjects, too much freedom in his
election. It is always more pleasant for us to follow our own
inclination, and we are always more enthusiastic in work that
pleases. In the romantic period of life onr elections, if followed,
would often bring us failure. In the undergraduate college
there is no doubt that the graduate of the classic course is the
type of perfection in college education ; he always has been and
always will be.
Place the classic graduate in postgraduate work in com-
petition along the lines followed by an elective graduate In his
college course, and the classic man will excel the elective man
in his own field. So I feel that the elective graduate in medi-
cine, through his narrowness and want of development along
the lines in general medicine will, in after years, be outstripped
by the graduate of general medicine who specializes in his
postgraduate period of life along the line followed by the elect-
ive student.
The elimination course remains to be considered, and it
seems to contain fewer undesirable features than any other sys-
tem. The central idea of such a course is to prepare men
skilled in general medical knowledge, the special work being
so narrowed in its scope and character as to be reduced to a few
lectures for each branch, which could be almost axiomatic,
making the clinics of these specialties as comprehensive as the
clinical material permits, such clinics being compulsory only
in three or four subjects. One following such a course would
be essentially a broad-gauged, well-developed student of gen-
eral medicine upon his graduation. The development of a
specialist from such a graduate is simply the natural evolution
along the line of his inclination or aptitude developed either
through experience gained in general practice or through a
term spent in a general hospital. A thorough postgraduate
course completes the process. Sucli a specialist is a broad-
gauged medical practitioner who sees his specialty through
general medicine, and not general medicine through his
specialty.
We all know how difficult it is to maintain that enthusiasm
for general medicine and keep pace with its marvelous prog-
ress while having our thoughts concentrated upon special
work ; how we must prod ourselves constantly in our vain
efforts to avoid narrowness. How much more difficult would
it be to him who has specialized during his undergraduate
course! Tome the ideal method for medical education is to
make the well-grounded general practitioner with no faddism of
election, and from such a product, through postgraduate edu-
cation, develop the specialist.
Statue of Pasteur at Dole. — In the city of Dole, Depart-
ment of Jura, France, there was recently dedicated with suit-
able ceremonies a monument of Pasteur, after the designs of
the sculptor. Carles, and the architect, Chifflot. The monu-
ment stands on the chief promenade of the city, le cours Saint-
Maurice, near the little tannery of the rue des Tanneurs (now
called rue Pasteur), where, on December 27, 1822, Pasteur was
born.
Allotment of the Carnegie Trust Money. — The Scottish
correspondent of the Lancet gives a short abstract of the letter
sent by the Carnegie trustees to the secretaries of the University
Courts of the four Scottish universities dealing with the allot-
ment of the money at their disposal for the four universities.
It may be said that the general plan is characterized by great
ability and a statesmanlike grasp and treatment of a problem
whicli to many minds appeared extremely intricate. The
trustees retain complete control of the .€5t),0i)() per annum,
which is the sum available. The sums allotted to the universi-
ties are as follows : Glasgow gets for five years £8,00() for build-
ings and permanent equipment; £2,000 for teaching, but £1,500 of
this are annually set aside for an endowment fund foraspecifled
chair; and t;i,0(X) for the library. This makes a total grant of
£11,000 per annum and so of £.55,000 in five years. Aberdeen
gets C45,000 on the same lines, St. Andrews £-12,()00, and Edin-
burgh ,£.57,500. As regards Edinburgh, £8,000 a year are allowed
for buildings and permanent equipment, and under this head
are included (1) natural philosophy iind engineering, (2) strong
room and alterations in library, (:i) apparatus, (4) pathologic
bacteriology, and (5) catjilogue of anatomical museum ; £2,500
a year are given for teaching and it is indicate<i that this sum is
for the en<lowment of motlern languages or some other purpose
approve<l by the committee ; and £1,(K)0 are allocated annually to
the library. By the allotment of .£2,.'>00 per annum for teaching
on the lines indicate*! by the trustees a professorship or lecture-
ship can be at once instituted with .£500 a year for its mainte-
nance for five years, while at the end of that period there will be
an endowment of £10,000 with accumulations of interest. At
tlie end of the period of five years the trustees keep themselves
free to rearrange the allotment of their funds as tiiey think fit.
The above disposes of £200,000 in five years, which leaves
£10,000 still in tne hands of the trustees, and they indicate that
this sum will to a considerable extent be devoted to the aid of
postgraduate research and to the foundation of scholarships
designed to stimulate original work in special directions.
514 AMERICAN Medicine]
THE WORLD'S LATEST LITERATUEE
[Sbptbmbeb 27, 1902
THE WORLD'S LATEST LITERATURE
Journal of the American Medical Association,
September gO, 190t. [Vol. xxxix, No. 12.]
1. Surgeryof Tuberculous Cavities of the Apex of the Lung. Deforest
WILLAKD.
2 Concerning the Symptomatology and Etiology of Certain Types of
Uveitis. G. E. de Schweinitz.
3. Analysis of 37 Cases of Uveitis. Hiram Woods.
4 Reraarlis on the Methods of Operations in Vogue for Cystocele with
and without Prolapse of the Uterus C. O. Thienhaus.
5. Surgical Treatment of Hemorrhoids. Wm. V. Metcalf.
6 The Causal Relation of Blood Poverty to Gastric Ulcer, with Report
of an Illustrative Case with Atypical Symptoms. R. N. Willson.
1.— See American Medicine, Vol. Ill, No. 23, p. 941.
2, 3.— See American Medicine, Vol. Ill, No. 25, p. 1052.
4, 5.— See Amencan Medicine, Vol. Ill, No. 25, p. 1040.
6.— %See American Medicine, Vol. Ill, No. 24, p. 986.
Boston Medical and Surgical Journal.
September IS, 1902. [Vol. CXLVII, No. 12.]
1. Notes on a Case of Acute Hemorrhagic Polymyositis. William
Sydney Thayer.
2. The Effects of Exercise on the Heart and Circulation. R. C. Larba-
BEE.
3. Suprapubic Cystotomy Without Distending the Bladder. Samuel
Ceowell.
1.— Acute Hemorrliagic Polymyositis.— Thayer briefly
review.s the literature of the various polymyositides and reports
his case in full detail. No other case has shown as marlied
muscle swelling with as little paiu and disability during the
attaclc. The widespread cutaneous discoloration indicative of
deep hemorrhage, almost without purpuric manifestations, was
a striking and interesting feature. The mildness of the tempera-
ture and the development of crepitus in the deltoid muscle
were of especial interest, [h.m.]
2. — Effects of Exercise on the Heart and Circulation.
— Violent exertion normally causes changes in blood-pressure,
temporary onlargemeut of the heart's area from dilation or
relaxation of the myocardium, and sometimes a fugitive mur-
mur. The cause of the latter is not obvious. Larrabee dis-
cusses the various theories, and thinks it most probably due to
insufficiency from myocardial relaxation. The chief result of
training is hypertrophy. As abnormal results of exercise we
have acute dilation, rare in healthy young men, especially if
well trained, and as a result of habitual overexercise, " irritable
heart ' ' and the other conditions associated with dilation, hyper-
trophy, or myocarditis, and generally due iu part to other pre-
disposing causes, [h.m.]
3. — Suprapubic Cystotomy "Without Distending the
Bladder.— Crowell says that surgical writers iu advising dis-
tention of the bladder preparatory to suprapubic cystotomy lose
sight of the fact that the loosely connected peritoneum can be
pushed back and the bladder entered without distention. He
details the history of two cases to show that a perfectly flat and
empty bladder can be opened quickly and easily without
injury to the peritoneum and with perfect safety to the patient.
A metal catheter is inserted into the bladder, the incision made
down to the peritoneum, which is stripped back, and the
catheter depressed so the beak shows about an inch in front of
the pubes. The peritoneum is held back with a sponge and the
bladder opened. Excellent results were obtained in the cases
reported, the bladder in each being closed immediately after
the stone was extracted, a catheter being inserted for 10 to 19
days to prevent distention of the bladder, [a.g.b.]
Medical Record.
September 20, 1902. [Vol. 62, No. 12.]
1. Hysteria and Organic Disease. Charles L. Dana.
2. The FamllyPhysiclanof the Past, Present, and Future. S.A.Knopf.
3. A Gunsliot Wound of the Abdomen, Intllctlng 19 Perforations of the
Intestines and 4 Lacerations of the Mesentery, with Recovery.
Robert F. Amyx.
4. Nasal Disturbances in Typhoid Fever and Their Sequels. Max
TOEPLITZ.
5. Diagnosis and Pathology. M. P. Overholzer.
1. — Hysteria and Organic Disease. — The objective stigmata
and symptoms of hysteria major may be grouped under five
heads — anesthesias, contractures, palsies and tremor, the attacks,
the peculiar mental state. It is oflenest associated with trauma,
but appears also with brain tumor, encephalitis, meningitis,
multiple sclerosis, talies and inflammations of the nerves. The
anesthesias are the most fugacious and amenable to remedial
measures ; the paralyses are more stable ; contractures may be
fugacious, but in the severer types are more obstinate than the
paralyses. They do not disappear under sleep or moderate
narcosis and seem under the control of a subconscious, auto-
matically acting center. The anesthesias may be unilateral or
segmental, or both. Analgesia is not true in tlie organic sense,
as hysterics never burn themselves. It is only in hysteria we
have anesthesia of the whole body. The automatically used
muscles are rarely affected by hysterical paralyses, and mono-
plegias and hemiplegias carry with them profounder sensory
disturbances. Hysterical paraplegia is doubtful ; quadru-
lilegia is extremely rare. The contracture, as a rule, occurs
suddenly, organic contractures slowly, as a sequel of paralysis.
There is no pain, mobility, palsy, or atrophy ; no exaggera-
tion of reflexes, or myotatic irritability, or morning relax-
ation ; there is active resistance to attempts to remove it.
Mental characteristics of hysteria are amnesias, abulias, modi-
fications of character, emotional and motor explosions, som-
nambulisms, deliriums, etc. Crises are uncommon in major
hysteria. The mental state is the hardest to readjust. Still we
regard hysteria as essentially curable. The article concludes
with a report of cases, [h.m.]
3.— See American Medicine, Vol. Ill, No. 24, p. 997.
3.— Nineteen Perforations of the Intestines and Four
Laceratloiis of the Mesentery.— Amyx reports the case of a
colored man of 21 wlio received a gunshot wound of the
abdomen, the point of entrance being in the right iliac region.
Operation two hours after injury revealed 19 perforations of the
intestines, 2 in the ascending colon, 3 in the ileum— one 3 inches
and two 3 feet from the cecum, 12 in the jejunum within 11
inches of the intestine, 2 in the sigmoid flexure. Of the perfora-
tions 7 were closed and the portion of the intestine containing
the 12 perforations was resected and an anastomosis made with
Murphy's button. Of the 4 mesenteric rents, 2 were resected and
2 were sutured. Twelve gauze drains were inserted, the opera-
tion requiring three hours. On the second day calomel was
given and the bowels moved daily thereafter by a Seidlitz
powder and 6 to 8 drops of carbolic acid. The Murphy button
was passed on the tenth day. Amyx lays emphasis on cutting
away the edge of each perforation to get healthy tissue before
suturing. Drains should not be disturbed before the fifth or
sixth day. [a.g.e.]
4.— Nasal Disturbances in Typhoid.— These are dryness
of the mucous membranes, abrasion of epithelium, erosion,
particularly at the anterior part of the septum, with occasional
bleeding, frequently intens'i. The erosion develops at times
with an ulceration, leading to perforation or adhesions wdth the
lower turbinate. Suppuration may occur in the accessory
sinuses. Treatment consists in antiseptic irrigations and pow-
ders applied to the erosions, avoidance of adhesions and plug-
ging for the bleeding, preferably from the nasopharynx, to
prevent the hemorrliage from occurring unoljserved. [h.m.]
5.— Diagnosis and Pathology.— Overholzer describes a
portable miniature laboratory-in-hand case for use at the bed-
side in clinical work. This is accompanied by a microscope.
By its means all practical methods of diagnosis by clinical
chemistry and microscopy can be carried out. Bacteriologic
examinations can also be made. The apparatus is 19 by 10 by
7 inches in cubic contents, and weiglis 29 pounds, [h.m.]
New Vork Medical Journal.
September IS, 190i. [Vol. lxxvi. No. 11.]
1. The Diagnostic and Therapeutic Value of Ureteral Catheterization,
with Report of a Case. Louis Gross.
2. What Means, other than Operative, have We for Prevenlmg and
Combating Inflammation of the Mastoid Cells? Samuel Theo-
bald. „
3. A New Method of Staining the Malarial Parasites, with a Descrip-
tion of the Staining Reactions. Charles F. CRAIG.
4. Ovarian Tumors : Suppuration and Malignant Degeneration. G. K.
CRAWFORD and J. Lynn Crawford.
5. The IdentlUcation of Human Blood. Justin Lisle.
6. A Case of " Black Water " Fever from the Philippines. Frederick
M. Hartsock.
8EPTEHBEB 27, 1902]
THE WORLD'S LATEST LITERATURE
[Amkbican Ubdicini, 515
7. The Logical Status of Vaccination, and the Exclusion of Unvac-
clnated Children from the Public Schools. Alfred W. Herzog.
1. — Ureteral Catheterization. — Gross reviews the litera-
ture of the subject and reports a case demonstrating the value
of ureteral catheterization as a therapeutic factor. The facts
thus obtained justified the diagnosis of pyelitis of the right kid-
ney. The treatment consisted of irrigations into the pelvis of
the kidney with 10 grams of a 1-1,000 silver nitrate solution.
Ten irrigations in all were made at intervals of four days. The
result was complete recovery. The method is of value in
determining whether the bladder or the kidney is the seat of
the affection ; the presence or absence of a kidney ; which
kidney is involved ; the site of the lesion ; the functional
capacity of each kidney ; the presence of a calculus in the ureter
or pelvis of the kidney and its exact location ; and the diagnosis
and site of ureteral fistulas. The pi-esence of a pyonreter; a
differential diagnosis between diseases of the kidney and the
surrounding organs, and at times a tuberculous kidney may be
determined, as may also the diagnosis of pyelitis, pyeloneph-
ritis, pyonephrosis, hydronephrosis, movable kidney, neo-
plasms of the kidney, renal lithiasis and abnormal congenital
conditions of the ureter. As a therapeutic factor it may be used
to cure pyelitis and certain cases of pyonephrosis and hydro-
nephrosis ; to drain pocket formations ; to dilate strictures and
to dislodge small calculi of the ureters; to drain the kidney
after nephrotomy ; to prevent injury of the ureter in certain
operations ; to prevent and cure renal fistulas ; and as a guide
to certain operations on the pelvis of the kidney. The author
believes there is comparatively little or no danger of infection
if the instruments are carefully disinfected and the bladder and
urethra thoroughly irrigated. [c.A.o.]
3.— Mastoiditis. — Theobald discusses the constitutional
remedies employed to prevent and combat inflammation of the
mastoid cells. In ca.ses of chronic inflammatory processes of
the ear he uses a combination of the phosphates of iron, quinin
and strychnin as a tonic and eliminates habitual constipation
by aloin, in doses of ^^ to J grain every night, as may be
required. Bichlorid of mercury in solutions of from 1-8,000 to
1-4,000 is the best antiseptic agent; the next most useful is
boric acid. To avoid implication of the mastoid cells in acute
otitis media from 6 to 10 drops of the following solution is
poured into the ear three or four times in 24 hours : Atropiu
(alk.), 2 grains; cocain (alk.), 4 grains; and oil of sweet
almonds, 1 fluid ounce. The local treatment is usually supple-
mented by one or two doses of calomel, scammouy and rhu-
barb. Sodium phosphate in 20-grain doses every two hours for
an adult or 10 or 15 grains for a child also exerts a controlling
influence upon suppurative processes. [c.A.o.]
3. — A new method of staining the malarial parasites is
reported by Craig. Two .solutions are employed, as follows:
Solution A : A saturated aqueous solution of methyl, violet B
(Dr. G. Grubler A Co., Leipsic). This solution should be pre-
pared with distilled water, and should be at least three weeks
old. Solutions: A 5% solution of eosin (Dr. G. Grubler A- Co.,
Leipsic). The very thin blood smears are hardened in absolute
alcohol for from 5 to 10 minutes. They are next carefully
dried and stained with solution A for 10 seconds, then thor-
oughly washed in water and .stained with solution B for from
3 to 5 seconds. The specimens are finally carefully dried and
mounted in Canada balsam. [c.A.o.]
4.— Ovarian Tumors.— The authors call attention to the
great frequency of suppuration and malignant change occur-
ring in ovarian tumors, and report two illustrative cases.
From 8% to 12% of ovarian tumors suppurate, and from 16% to
25% are malignant. They emphasize the importance of the
early recognition and removal of such growths while the
mortality is almost nil. [c.A.o.]
6.— Identification of Human Blood.— Lisle, besides giv-
ing the ordinary tests used to detect blood, gives in detail a test
for the identification of human blood. To identify blood as
human blood, it must excite the formation of a precipitate
when mixed with the serum of an animal that has been vacci-
nated with human blood. To make a serum that contains the
special precipitin for human blood, from 4 to (J injections of
10 cc. each of defibrinated human blood are made into the peri-
toneal cavity of a rabbit, at intervals of one week or 10 days
between injections. The serum of the prepared animal is
drawn off a week or 10 days after the last injection. This
serum can be kept in sealed tubes or closely stoppered bottles
for a long time, or a few drops of chloroform may be added as a
preservative. The suspected spot is washed with physiologic
salt solution, the solution centrif uged in order to free it from
blood globules and other debris and a few drops of the serum
added and set aside in a warm place. The formation of a pre-
cipitate in 24 hours indicates the presence of human blood.
[c.A.o.]
6.—" Black Water" Fever. — Hartsock reports a case that
occurred in the Philippines in a soldier, aged 22. The diagnosis
was made on the general symptoms, rapidly developing icterus,
absence of bile pigment in the urine, and hemoglobinuria. No
parasites were found after the first day. Quinin had no influ-
ence on the disease. [c.A.o.]
Medical News.
September W, 190i. [Vol. 81, No. 12.]
1. The Modern Treatment of Fractures of the Lower End of the Radius,
as Indicated by the Rontgeu Kays. Carl Beck.
2. Phototherapeutlc Apparatus. Milton Franklin.
3. The Influence of the Rontgen liay upon the Different Varieties of
Sarcoma. William B. Coley.
4. The Pre.sent Status of Cancer; Its Etiology and Pathology: The
^'ahle of Laboratory Research. Edward N. Liell.
5. Report of a Case of Non-traumatic Acute Suppurative Osteomyelitis
with Catiirrhal Co.'cltis, with Remarks. Henry I. Raymond.
1.— Treatment of Fractures of the Lower End of the
Radius. — Beck considers the modern treatment of these frac-
tures as indicated and aided by the x-ray. If a correct diag-
nosis is made, the principles of treatment are reduced to a few
points of simple common sense. The diagnosis can best be
made by the x-ray and it is invaluable in showing if reduction
is complete. In classifying the different varieties of fracture of
the lower end of the radius, Beck distinguishes : (1) Epiphyseal
(chondroepiphyseal and ostooepiphyseal) separation; (2) fi.s-
sure; (3) complete fracture (simple, without displacement);
(4) complete fracture (simple or multiple, with displacement) ;
(5) fracture of the carpal end of the radius associated with frac-
ture of the styloid process of the ulna; (6) fracture of the carpal
end of the radius associated with fissure, fracture or dislocation
of the lower end of the ulna; (7) fracture of the carpal end of
the radius associated with fissure or fracture of the scaphoid
bone (sometimes also with the ulnar end); all these varieties
may be intraarticular as well as extraarticular: (8) fracture
of little bone portions (chips), generally extraarticular. Each
of these is considered in the light of x-ray revelations, the
article containing 19 illustrations. Plaster-of-paris is preferred
for a fixed dressing, [a.g.e.]
2. — Phototherapeutlc Apparatus. — Artificial light is
best. The lamp should be as powerful as possible, as no
arrangement of lenses or reflectors will coax power out of a
feeble lamp. The lamp should be an electric arc using chemic-
ally prepared electrodes calculated to produce a spectrum
powerful in the ultraviolet. Incandescent lamps must be
avoided. Condensing and collecting lenses should be as large
as the angle of total reflection will permit, and should be
made of rock crystal or of some medium equally diaphanous to
the chemic rays. A glass flux has been produced that not
only transmits blue, violet and ultraviolet rays, but actually
extinguishes so great a proportion of the yellow, orange, red
and infrared as to yield a comparatively cool light. The cool-
ing apparatus should be a layer of water containing no other
substance, and sufllciently thick to alworb the greater propor-
tion of the heat rays. It should be enclosed in a vessel that will
not interfere with the passage of the chemic rays. The
machine should bo mounted so it can be turned and adjtisted
with the utmost precision. [it.M.]
3. — See AmeHcan Medicine, Vol. IV, No. 7, p. 251.
5.— Nontraumatic Acute Suppurative Osteomyelitis.—
Raymond reports the case of a boy of 13, who received a slight
injury to his ankle. Soon after constitutional symptoms
developed, and .severe pain was felt in the right groin in the
region of Scarpa's triangle. Induration became marked.
Incision later evacuated 80 cc. of pus from around the base of
the lesser trochanter. Drainage and immobilization gave
very good results. A symptom of great diagnostic import in
516 American Mbdicinki
THE WORLD'S LATEST LITER AT CUE
[8EPTBMBBK 27, 1902
osteomyelitic coxitis was present, viz., absolute inability to
move the affected limb when supported by the sound one.
[A.a.E.]
Philadelphia Medical Journal.
September SO, 1901. [Vol. x, No. 12.]
1. A Clinical Lecture on a Case of General Tuberculosis. Hale
White.
2. Medical Representation In Hospital Management. Adgustds A
ESHNER.
3. Preservative Solutions for Gross Specimens. Raudle C. Rosen-
BBKGEK.
4. Syphilitic Necrosis of the Nasal Cavity, Accompanied with Tolal
Blindness. Charles A. Todd.
1.— General Tuberculosis. — White believes that there is
no evidence of direct transmission of tubercle bacilli from
parent to oflfspring, and should there be that it is so rare it may
be set to one side ; however, there is distinct evidence of trans-
mission from the parent to the child of a lowered resistance, in
virtue of whieli the expectation of life is less in those of
tuberculous ancestry than those who have not such an ancestry.
[F.C.H.]
2.— Medical Representation In Hospital Management.
— Eshner gives the following ways in which satisfactory repre-
sentation can be given the medical staff on the board of man-
agement of a hospital: By electing one or more members of the
staff to membership on the board ; by periodic conferences
between the staff and the boardj and by conferences between
a committee of the staff and the board or a committee of the
board, [f.c.h.]
CLINICAL MEDICINE
David Riesman A. O. J. Kellt
EDITORIAL COMMENT
Paratyphoid Fever — During recent years, more
particularly since the introduction of the Gruber-Widal
reaction into practical diagnosis, interest has centered in
anomalous cases of typhoid fever. On the one hand
there occurs the group of cases without intestinal lesions
—cases demonstrated to be cases of typhoid infection by
the presence of the Gfuber-Widal reaction and by the
recovery of typhoid bacilli from the blood, etc. On the
other hand, there occurs a group of cases in which the
Gruber-Widal reaction is negative and in which the
bacillus isolated from the blood, intestinal discharges,
etc., is neither the typhoid nor the colon bacillus, though
it resembles both of these in some respects. Originally
called eases of paracolon infection, more recently these
ca.ses have received the designation of paratyphoid
infection or paratyphoid fever, and the causative bacillus
is now known as the paratyphoid bacillus. The subject
IS discussed at length in the August number of the
American Journal of the Medical Sciences: Johnston
reports 4 cases and critically analyzes all the reported
cases, of which there are 26 ; Hewlett and Longcope
both report a ca.se— and Longcope, in addition, gives the
details of the necropsy in his case. From his study of
the reported cases, Johnston concludes that there is a
type of disease due to infection with the paratyphoid
bacillus that in all its variations presents a clinical
picture identical with that frequently produced by infec-
tion with the typhoid bacillus. The disease, 'though
widespread and occurring in localities where typhoid
fever prevails, is rare ; though it may be severe, it is
usually mild and fatalities rare. Diarrhea and a termi-
nation of the fever by crises are apparently more com-
mon than in typhoid fever ; on the contrary, myositis
and purulent arthritis, rare complications in typhoid
fever, have been observed in paratyphoid infection.
Inasmuch as it is practically impossible clinicaUy to dis-
tinguish tetween cases of typhoid and of paratyphoid
infection, the diagnosis rests upon the results of bacterio-
logic investigation of the blood, intestinal discharges,
rose spots, etc. The disease, however, is suggested by
the absence, especially the persistent absence, of the
Gruber-Widal reaction, though this by no means is con-
clusive evidence — a point to which Johnston alludes.
The absence of intestinal lesions in some of the cases is
interesting — whence it is said by Johnston that absence
of intestinal ulceration may prove to be a distinctive
feature of the disease. That the condition is a general
infection is indicated by the facts at hand, the wide dis-
tribution of the bacillus in the body, its constant occur-
rence in the circulating blood, and the absence of any
localizing lesions. In this respect it resembles certain
cases of typhoid infection. The interest attaching to the
subject at present consists in the knowledge that there
may occur a fatal infection cliniavlly resembling typhoid
fever, but due to a distinct bacillus — the paratyphoid
bacillus.
REVIEW OF iirEKATCRE
Neutral Red in Routine Examination of Water.—
Ernest E. Irons' presents a study as to the value of this test for
the detection of Bacillus coli communis in water supplies. C S.
Rothberger, in 1899, called attention to the fact that Bacillus colt
communis caused a reduction of neutral red to yellow with green
fluorescence,while -Bacj'HMS <j/pAo«KS produced no change of color
lieyond an occasional fading of the red. Rothberger therefore
proposed neutral red mediator the detection of the two organ-
isms. R. H. Makgill, in 1901, showed that neutral red may be
found a delicate test for Bacillus coli communis in pure cultures
in water but that the presence of other organisms tends to dejay
the reaction. W. G. Savage, in 1901, concludes from 34 tests
made that the method gives approximately accurate results.
Irons concludes, as the result of the examination of 45 waters,
that organisms common in river waters other than Bacillus
coli communis give the neutral red reaction under the conditions
of the test, and he agrees with Scheffler and Rosenberger that
the reaction being essentially one of reduction is, as one would
expect from its nature, not specific for Bacillus coli communis ;
therefore, in the reduction examination of water the neutral
red reaction when used alone cannot be depended upon for the
diagnosis of this organism, [c.s.d.]
A case of rheumatic hyperpyrexia, followed by symp-
toms resembling those of disseminated sclerosis, is reported by
Allen and Russell.' The temperature is reported to have
reached a maximum of 115° F. [a.o.j.k.]
A Study of Pulque.— Antonia J. Carbajal contributes a
paper in the number of La Escuela de Medicina for May 1 and
continued in succeeding issues, in which he considers the
national drink of Mexico from a zymotechnic standpoint with a
view to the establishment of methods for the preparation of a
pulque of irreproachable purity, [c.s.d.]
Arsenical Poisoning Due to Contaminated Beer. —
Tattersall' discusses the chief facts in connection with the
recent outbreak of arsenical poisoning. The contaminated
beer contained on an average jV grain of arsenic to the pint ;
in some cases it may have been as much as ^ grain per pint.
Assuming that the beer contained on the average i grain per
gallon, the amount of arsenic taken by a socalled small drinker
(not exceeding one quart per day) would be J grain ; moderate
drinkers (not exceeding J gallon daily) would take about one
grain of arsenic a week ; and large drinkers (exceeding i gal-
lon daily) would take from two to four grains of arsenic per
week — amounts assuredly sufficient to give rise to disastrous
consequences. The chief symptoms in 296 cases were as fol-
lows : Running of the eye and nose, 106 ; pigmentation, 68 ;
skin affections, 107 ; sensory disturbances, 234; motor disturt)-
ances, 228; gastrointestinal troubles, 39; anasarca, 10, and
mental disturbances, 9. Tattersall believes that the epidemic
has demonstrated the great importance of some improve-
ment being made in the arrangements for the notification
to the health authorities of outbreaks of disease, and that
notification of an outbreak of unusual character should
take place as a matter of course. He believes also that
there is great need for a public department to watch the
introduction of manufactured substitutes for natural food
products and the use of preservatives in food, to investigate
their action, and to have power to condemn them or to lay down
' The Journal of Hy
^Lancet, .July 12, 190:
edl
lene, July 1, 1902.
'British Medical Journal, August 11, 1902.
BBPTEHBEB 27, 19021
THE WORLD'S LATEST LITERATURE
[AMERICAN Medicine
517
absolute rules for their preparation so as to safeguard the
public health. This outbreak is said to have shown the advisa-
bility of legislation maliing penal such want of care as led to
the outbrealis, and the Food and Drugs Act should be strength-
ened, making it penal to sell for food any article contaminated
with poisonous matter in appreciable quantity, whether to a
dangerous extent or not, and whether to the knowledge of the
seller or not. An improved and trustworthy test for arsenic in
small quantities also is much needed, [a.o.j.k.]
GENERAL SURGERY
Martin B. Tinker
A. B. Cbaio
C. A. Orr
EDITORIAL COMMENT
Primary carcinoma of the extremities is one of
the more infrequent forms of carcinoma, and fortunately
is one of tlie most satisfactory varieties to treat.
Various tlieories have been suggested to account for the
infrequency of catcinoma in the extremities, for the
extremities are undoubtedly more exposed to trauma than
the other parts of the body. It seems not unreasonable
that the suggestion of Michael, that the cells of the
extremities are of such structure as not to be influenced by
traumatic insults, may be a valuable one in explaining
this fact. Certain it is that carcinoma of the arm or the
foot is seldom seen, although the arm is more frequently
exposed to injury than almost any i)art of the body.
Interesting forms of carcinoma of the extremities arise
in the old scars of burns and several cases have been
quoted developing in leg ulcers and in osteomyelitic
cavities. The growth is usually fibrous and involves
tlie lymph glands quite late. For this reason local
removal of the disease if undertaken early is quite satis-
factory. An exception to the ordinary forms of carci-
noma of the extremities, so far as malignancy is con-
cerned, seems to be found in those which have their
origin in nevi, congenital warts, etc. These forms are
very frequently quite malignant and rapidly spreading.
As to the success of the operation, various operators
have reported from 60 fc to 75 fe of permanent cures
from operation. As in other forms of cancer, early
operation is very important, though the operation need
not l>e as extensive as in other forms of the disease.
An interesting paper on this subject has recently appeared
by Franze,' in which he reports 21 cases tliat have occurred in
von Hacker's clinic at Innsbruck during the past 20 years. Of
these 21 cases, 14 affected the lower extremities ; 8 involved the
leg and knee; 0 the palm of the hand ; 4 the sole of the foot; 2
the thigh ; and 1 the forearm. Three developed in old scars
from burns, 4 developed in leg ulcers, and 1 in an osteomyelitic
cavity. The disease is twice as frequent in men as in women,
and occurred for the most part between the ages of 40 and 70.
Only 1 case is reported in a patient between 20 and. 'iO. There
was involvement of the lymphatic glands in 12 cases; in 12 cases
removal of the growth alone was undertaken with recurrence
in 3 cases, necessitating more extensive operations ; exarticula-
tion wa.s necessary in 5 cases, and amputation was performed in
H cases. Of the 21 cases, 2 died very soon after the operation
from intercurrent diseases, and no word has been obtained
from one of the other patientfl. Of the 18 remaining, 11 had re-
currences after the operation,? remaining free from recurrence.
In 4 cases out of 11 recurrences, a second operation was per-
formed, and 2 patients remained perfectly cured. One was not
heard from, and the other died. Sixty per cent of the entire
number were permanently cured. The results of France's
study do not differ essentially from those reported by Volk-
nian, Michael and Schneider.
While this form of carcinoma is not very frequent,
surgeons shouUl always keep in mind the po.ssibility,
and tumors of doubtful chanu-ter developing in old scars
or leg ulcers would best be radically treated. If it seems
likely that the growth is csircinomatous, diagnosis need
not offer great ditticulties in most cases. If free excision
is undertaken early, a useful limb can usually be saved,
but if neglected, amputation or recurrence are almost
inevitable.
' Bcltrttge znr kllnlsche Chlmrgie, Vol. xxll, p. 171.
REVIEW OF LITERATURE
Tumor of the Spinal Cord Removed by Operation.—
Oppenheim and Jolly ' exhibited a case of successful removal of
a spinal tumor. The patient, a young woman, Avas seized in
August, 1901, with pain in the right hypoohondrium ; in Septem-
ber the left leg became paralyzed, and there was also moderate
scoliosis ; the gait was dragging ; the reflexes were exaggerated ;
ankleclonus and Babinski retlex were present. The patient at
this time stated that she had sustained a fall from a bicycle a year
previously. A diagnosis of tumor of the spinal cord was made.
After several months' sanitarium treatment the young woman's
condition was found much worse. She had severe pains in the
distribution of the ninth, tenth and eleventh dorsal roots, with
loss of sensation in this region, the corresponding abdominal
muscles showing partial reaction of degeneration. There was
spastic paraparesis of the legs, with disturbances of the muscu-
lar (positional) sense. There was not at this time, nor had
there been, any tenderness of the vertebral column. Radio-
graphic examination and tuberculin injection gave negative
results. The tumor having been localized in the region of the
ninth dorsal root, the eighth and ninth vertebral arches were
removed by Sonnenburg. Immediately the dura began to
bulge iu the opening, and after incision the tumor presented
itself. It was easily removed, and proved to be a fibroma. The
patient was entirely cured. In commenting upon the case. Jolly
remarked that it is practically impossible to determine whether
a tumor is intradural or extradural. The case is interesting in
the extreme, and although in the general discussion several
unsuccessful instances were cited, it encourages operative inter-
ference in a condition that, without the surgeon's help, is in
nearly all ca.ses utterly hopeless. Keen in this country has, by
his bold and brilliant work, done much to give standing to the
radical form of treatment of spinal tumor, [d.r.]
Treatment of Metatarsalgia.— Verger ^ finds that there
are cases of Morton's disease in which osteitis is absent, and he
has adopted with success the treatment employed in the clinic
of Pitrcs for neuralgias, i. «., the injection of cocain at the point
of departure of the pain, [c.s.d.]
Pseudomenlngocele.— Schrank » reports the case of a boy
44 years old who came under his observation with a large fluctu-
ating tumor on the back of his head. On opening this apparent
cyst bright yellow mucoid fluid was evacuated. A consider-
able area of the skull was exposed and a section of bone the size
of a three-mark piece was apparently neurotic. On perforating
the skull it was found that the disease involved the entire
thickness of the bone. This section was removed entire. After
the operation the patient made a very good recovery, though
secondary abscesses developed. Schrank states that this affec-
tion has been described by several writers under the name of
pseudoraeningocele or meningocele spuria traumatica. It has
occurred without exception in children, and usually follows
directly after some subcutaneous injury or some injury causing
perforation of the skull with a tear of the dura or a split of the
bone. In this case the cerebrospinal fluid escapes into the
scalp. A sharply-limited, fluctuating tumor the size of the
fist frequently develops. In most cases the bone is involved
and the affection may be regarded as one form of traumatic
osteomyelitis, [m.b.t.]
Permanent Suprapubic Drainage for Vesical Tubercu-
losis.—Powers * reports a case of tuberculosis of the bladder in
which he employed this method with a very satisfactory result.
In the management of these cases, the l>est possible hygienic
conditions should always be employe<l. The nutrition should
be improved, and bodily rest is important. Powers also
believes that the dry climate of high altitudes in Colorado,
which has proved so helpful in cases of pulmonary tubercu-
losis, has a favoraljle effect on the cases of surgical tuberculosis.
When in these cases of vesical tuberculosis urination becomes
almost incessant and there is great pain, suprapul)lc opening
not only gives great relief, but it may even lie possible, as in
his case, to arrest the disease process, [m.b.t.]
1 Berliner raedtclnlRche Gescllsrhart, June 18, 1902.
"Gazelle hebdoiiiadalro de Mfidleliie et de Cblrurglc, August 7, 1902.
» Berliner kllnlsobe WiKihensehrin, AugUHt IS, 1B02.
♦AnualK of Surgery, 1902, Vol. xxxvl, p. 42t).
518 A.uEiiiCAN Medicine]
THE WORLD'S LATEST LITERATURE
[Septembek 27, 1902
GYNECOLOGY AND OBSTETRICS
WiLMER Krusen Frank C. Hammond
EDITOBIAl, COMMENT
Venesection in Eclampsia. — Venesection is so
rarely practised today in general medicine that a promi-
nent therapeutist has observed that very many of the
profession have never abstracted blood for therapeutic
purposes, nor have ever seen it done by some one else ;
and yet bleeding is a measure undoubtedly of the great-
est value in many conditions. The indications for vene-
section are as clear and well defined as are the indica-
tions for any other remedy. In no condition is it more
positively indicated than in certain cases of eclampsia.
In this condition the reaction against the indiscriminate
use of the lancet has undoubtedly gone too far. Our
medical forefathers were wrong in making venesection
the common routine treatment in eclampsia, but we are
e<iually wrong in entirely rejecting it. It is of great
value in selected cases and often rescues the patient from
the impending danger of pulmonary edema and apo-
plexy. When the physician has to deal with a strong,
full-blooded patient with high arterial tension the
abstraction of from 20 to 35 ounces of blood is recom-
mended. In the report of 15 cases, cited by Hirst, in
which bleeding seems to have been the only thing done
there was only one death. By this procedure a large
amount of noxious principles in thfe system may be
directly eliminated, and, according to Peter, it further
removes from the convulsive centers the poisonous blood
by restoring contraction of the small vessels. Although
Winkel, Martin and others have condemned the prac-
tice, yet undoubtedly in strong, plethoric women with
great cyanosis it has favorable results. In all cases after
venesection it is wise to dilute the toxin of the blood
by the employment of hypodermoclysis. This is, we
think, preferable to direct venous transfusion as the
liquid is slowly absorbed and does not overtax the kid-
neys. We have recently observed successful results
from this treatment and believe that the profession
generally recognizes that it rests upon a sound clinical
basis.
REVIEW OF LITERATURE
Cure of Eclampsia by Chloralic Medication.— Com-
inandeuri comuiunieates to the Soci6t6 des Sciences Mgdicales
de Lyon the successful result of the employment of chloral in
cases of eclampsia according to the method of Fochier, viz.,
administration by the mouth after preliminary lavage of the
stomach, with a view to the elimination of the gastric toxins
and the checking of vomiting. Each gram of chloral should be
diluted by at least 100 or 150 grams of vehicle. From two to
four grams may be given as the first dose, followed by doses of
one gram every hour until chloralic sleep is obtained. [c.s.D.]
Surgical Treatment of Puerperal Sepsis.— According to
Montgomery ^ the febrile symptoms following parturition may
originate from two kinds of infection, the putrefactive and the
septic. The former is due to the putrefaction of a blood-clot or
a portion of retained membrane; is associated with putrid or
offensive lochia and rapidly improves with the removal of the
decomposing tissue and the irrigation of the uterine cavity. In
sepsis the onset is earlier and more insidious. The infection
makes its way through the continuous mucous membrane to
the peritoneum, or is conveyed by the bloodvessels or the
lymphatics. The patient runs a course of temperature, with
recurring chills, profuse perspiration and associated pain and
tenderness dependent upon the structures involved. Pus col-
lections may occur in the uterus, tubes, ovaries, cellular tissue
or peritoneum. Secondary abscesses may occur in any portion
of the body. With the continuance of the symptoms of fever
the natural inclination of the surgeon is to explore and scrape
the uterine cavity ; but when the uterus is free from decom-
posing products curetment is of doubtful service. The infec-
' Gazette hebdomadal re de Mfideclue et de Chlrurgie, August 7, 1902.
= International Med. Magazine, August, 1902.
tion has traveled beyond the mucous membrane and scraping
such a surface opens new avenues for the entrance of infection.
Digital exploration associated with irrigation with large quan-
tities of hot normal salt solution is often valuable, as it removes
all loose debris. This should be followed by an iodoform gauze
pack to keep the uterine walls separated. Careful exploration
should be made for the existence of an inflammatory exudate,
and when it is found an incision should be made through the
vaginal vault, the mass broken up and the cavity packed with
iodoform gauze. The occurrence of localized pockets of pus
should be regarded as an indication for immediate operative
procedure. This may involve the uterine wall, the ovary, tube
or peritoneum and require the removal of an ovary, tube or
even the sacrifice of the uterus. Hysterectomy has been advo-
cated by some in the majority of cases of sepsis, Ijut as the
microorganisms rapidly invade the tissues by the bloodvessels
and lymphatics, it can readily be seen that this operation is not
only unnecessary but frequently an evil. [w.K.]
Bilateral IntraliKainentous Flbromyoma Showing Ex.
tensive Mucoid Degeneration. — A. J.Smith' describes the
case of an unmarried woman who consulted him for an abdomen
rapidly increasing in size, accompanied with a regular profuse
menstruation lasting seven days. An elastic tumor as large as
an eight months' pregnancy could be felt on external palpation
which completely blocked the vagina. A large abdominal
incision was made, showing the uterus and adnexa nestling
snugly between the lobes of the tumor, which were firmly fixed
below and at the sides. Ligating the ovarian arteries at the
brim of the pelvis, making an incision between the ovarian
vessels and the uterine ends of the round ligaments, and push-
ing down the peritoneum so that the ureter, if displaced, would
be pushed down with it out of the way and escape damage, he
split the capsule and enucleated the tumor ; the uterine arteries
were then secured, the cervix amputated and the peritoneal
flaps brought together by a continuous top-stitched suture.
The tumor weighed 10 pounds and consisted of a semifluctuat-
ing mass apparently growing between the folds of the broad
ligament, bilobed and symmetrical on both sides. Microscop-
ically, the structure of the mass was that of a very vascular
and edematous fibromyoma undergoing very advanced mucoid
degeneration, since, when the growth was incised, a quantity of
mucoid matter flowed out. It was a typical example of tumors
of the mesometrium ; it illustrates the difficulty of diagnosis
and shows the advantage of a high incision into the capsule as
a means of protecting the ureters from injury. [w.K.]
TREATMENT
Solomon Solis Cohen
H. C. Wood, Jr. L. F. Affleman
REVIEW OF LITERATURE
The Medical and Surgical Uses of Normal Salt Solu-
tion.— Heineck 2 says that clinical saline solution has advantages
over drugs in that it is not toxic, cheap, and can be used in
unlimited amount. He prefers a solution of 7 parts to 1,000 of
sodium chlorid over the more complicated formulas which have
been advised. Among the very numerous purposes for which he
has found it useful may be mentioned : 1. As a spray or gar-
gle in various throat affections. 2. As an irrigating fluid for
wounds, especially in skin grafting, in which antiseptics
would destroy the vitality of the graft. 3. To flush out the
peritoneal cavity in infections he employs it subcutaneously
or intravenously. 4. In severe diarrheas, especially of choleraic
or dysenteric type. 5. In septic infections, surgical or puer-
peral, it may do good, either by aiding elimination of the toxins
or by stimulating phagocytosis. 6. In asphyxia neonatorum,
a pint of hot (115° F'.) normal saline solution into the rectum
with 10 drops of brandy. Other conditions in which it has
achieved good results are : Uremia, shock or collapse, puer-
peral eclampsia, diabetic coma and various forms of poisonings
by drugs or ptomains. In cases which are not critical he
makes use of the rectal route ; the technic is about the same as
for a high enema. The subcutaneous method has advantages
1 British Gynec. Jour., August, 1902.
' Merck's Archives, June, 1902, p. 226.
SbptEMBEB 27, 19021
THE PUBLIC SERVICE
i'Amebican Medicine 619
over the intravenous, in that it is less alarming to the family ;
necessitates no anesthesia nor operation ; there is no danger of
introducing air into the circulation ; there is no sudden increase
in blood-pressure; it requires less apparatus. The intravenous
route is preferred in cases of great emergency. The details of
the technic of the various means of introducing clinical salt
solution are given in tull. [h.c.w.]
Chloroform Anesthesia.— Barette ' reports that in over
6,000 chloroform anesthesias he has seen only three deaths. A
report of one ol these is given : To a young man, of 20 years,
chloroform was administered for the repair of a fractured
patella. Careful examination has failed to reveal any abnormal-
ity of his heart or other organs. The beginning of the anes-
thesia was regular, with a mild and very short period of excita-
tion. The operation proceeded normally until near its termina-
tion, when the patient suddenly took a deep inspiration and
remained immovable. The heart had stopped. Artificial respira-
tion for an hour failed to revive him. On autopsy it was found
that he had fatty degeneration of the ventricular walls of his
heart. Inquiry into his previous history revealed the fact that
he had been an habitual consumer of alcohol since he was 11 or
12 years old. Barette emphasizes the necessity for thorough
examination of patients and for careful training of young physi-
cians in the proper administration of anesthetics, [l.f.a.]
Recent Contributions to the Treatment of Whooping-
cough. — According to Delmas and Roeas^ the marked anti-
spasmodic properties of ozone are found to be of service in the
therapy of pertussis during the convulsive period when
employed in doses of from three to four inhalations of ten
minutes each every 24 hours. The number of coughing fits is
rapidly decreased in frequency, violence and duration. In
cases of pertussis complicated by bronchopneumonia, ozone has
no beneficial action. Baths of compressed air afford most satis-
factory results in the treatment of pertussis, the course of the
disease being considerably abridged and the convulsive attacks
lessened in intensity and duration. L. Baumel (ibid) recom-
mends the use of atomization of 25% solution of phenol at the
distance of 1 meter or IJ meters from the head of the patient
two or three times a day. The treatment aborts or produces a
marked attenuation of the disease. [c.s.D.]
The Seruintherapy of Cancer. — Charcot ' has undertaken
a series of researches on the serumtherapy of cancer. He in-
jected into the goat, sheep and horse fragments of epithelioma
which had been finely divided and macerated in physiologic
serum. The serum of the animals thus prepared was injected
into seven patients suffering from inoperable cancer in
doses of from 6 to 8 drams two or three times a week for many
months. These injections sometimes caused a slight elevation
of temperature, with a little nausea and vertigo, and at times
produced diffuse urticaria which rapidly disappeared after the
administration of 15 to 30 grains of antipyrin or 15 grains of cal-
cium chlorid, taken in the morning on an empty stomach, one
or two hours before the injection. As a rule the injections were
very well borne. The blood of the patients thus treated became
hemolytic for the blood of the animals which furnished the
serum, [l.k.a.]
Ether vs. Chloroform.— Renant* says that in heart disease
chloroform is especially dangerous on account of its irritant
effect on the kidneys, an action not shown by ether. [Although
ether is less harmful to the kidneys than chloroform it can
hardly be said to be absolutely innocuous.] [h.c.w.]
Acoin and Dionin. — Darier' has employed a 1% solution
of dionin as a local anesthetic in the eye for the relief of deep-
seated pains. When placed between the lids it causes smarting
and burning, and sometimes considerable edema, but atf the
same time it anesthetizes the eye and calms the pain located in
the cornea, iris or ciliary body; it calms the ciliary pain of
glaucoma and allows the patient to sleep without the use of
mori)hin, chloral or other general hypnotic. Darier also recom-
mends dionin for the relief of pain caused by a decayed tooth.
No toxic symptom has been observed from its use. Acoin pro-
1 Journal des Pratlclens, Vol. xvl. No. 9, 1902, p. 131.
' Gazette hebdfiniadalrc de MMeclne et de Chlrurgle, August 7, 1902.
»La Mfideclne Moderne, Vol. xlli. No. 3. 1902, p. 23.
•Medical HrcSN and Circular, April 23, 1H02.
'Journal de« PratlclenR, Vol. xvl, No. 7, 1902, p. 110.
duces local anesthesia only when the epithelium is destroyed
or there is a loss of substance by ulceration, under these cir-
cumstances its action is slower and more prolonged than that
of cocain. It is entirely devoid of toxicity in the doses
employed ordinarily. Darier has employed acoin as a local
anesthetic with subcutaneous or subjunctival injections of irri-
tating substances, such as corrosive sublimate, iodin or concen-
trated saline solutions. With 1% solution of cocain and acoin
he has obtained very satisfactory results in operations on the
eye, owing to the rapidity and duration of the anesthesia.
[L.F.A.]
FORMTJIiAS, ORIGINAL AND SELECTED.
Treatment of Migraine.— Robin ( Lyon Medical, "Vol. 97,
No. 48, 1901, page 775) employs
Antipyrin 7.5 grains
Potassium bromid 7.5 grains
Cocain hydrochlorate h grain
Caffein i grain
Powdered guarana 4.5 grains
for one cachet. To be taken at the beginning of the migraine.
[l.f.a.]
THE PUBLIC SERVICE
Health Reports.— The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, during
the week ended September 19, 1902:
California :
Colorado :
DIst. of Columbia:
Florida :
Illinois:
Kansas :
Kentucky :
Massachusetts :
Missouri :
New Jersey :
New York :
Ohio:
Pennsylvania:
South Carolina :
Tennessee :
Wisconsin :
Brazil:
Ecuador :
France:
Gibraltar :
Great Britain :
Bmallpox— United States.
San Francisco Aug. 31-Sept. 7.
Denver Aug. 30-Sept. 6.
Washington Sept. 17
Escambia Co., Pen-
sacola Included. ...Sept. fi-I3
Cases Deaths
4
2
2
India :
Kussla :
Bpain:
Colombia :
Ecuador :
Mexico :
Chicago Sept. ()-13 1
Wichita Aug. 21-:n 1
Covington Aug. 30-Sept. 6 ... 6
Boston Sept. 6-13 7
Chelsea Sept. 6-13 1
Fitchburg Aug. 30-Sept. 6.... 1
St. Joseph Sept. 6-13 1
Newark Sept. 6-13 3
Passaic Aug. 30-8ept. 13.. 2
New York Sept. 6-13 6
Cincinnati Sept. 5-12._ 3
Cleveland Sept. 6-13 84
Hamilton Sept. 6-13 1
Altoona Sept. 6-13 1
Johnstown Sept. 6-13 9
MoKeesport Sept. 6-13 18
Philadelphia Sept. 6-13 6
Pittsburg Sept. 6-13 25
Reading Sept. 8-15 5
Charleston Sept. 6-13 3
Memphis Sept. 6-13 1
Milwaukee Sept. 8-13 1
SMALLPOX— FOREIQN.
Pernarabuco Aug. 1-15
Guayaquil Aug. 23-;«).
Paris Aug. 16-23
Aug. 24-31 1
Liverpool .'i.ug. 23-30 14
London Aug. 23-30._ 11
Bombay Aug. 13-19
Calcutta Aug. 9-16
Moscow Aug. 16-23 2
Odessa Aug. 21-31 4
St. Petersburg Aug. 16-23 12
Barcelona Aug. 16-30
Yellow Fever.
Panama Sept. IS..
16
Philippine Islands :
China :
Egypt:
India:
Japan:
4 1
Among soldiers
Guayaquil Aug. 16-23 1
Coatjsacoalcos Aug. 80-Sept. 6 ... 4
Orizaba Sept. 7 .Epidemic
Progreso Sept. 12 1
Veracruz Aug. 30-8ept. 13.. 45 9
Cholera— I nso l a r.
Manila. July 12-19 2.50 189
Provinces To July 19 15,65511,691
Cholera— Foreign.
Amoy July 27-Aug. 2.... 40e8tlm'd
Hongkong Aug.2-9 6 «
New Chwang July lO-Aug.2 175 145
Alexandria Aug. .5-27 17 12
Cairo July22-Aug. 27... 913 816
Bombay Aug. 1.3-19 1
Calcutta Aug. 9-18 4
Ehinie Ken To Aug. 18 39
Formosa To Aug. 18 218 18S
FuitHoka Ken To Aug. 18 671 872
HlogaKen To Aug. 18 12 6
HIroshema Ken To Aug. 18 2
520 American Mbdicinjc:
THE PUBLIC SERVICE
IBeftehber 27, 1902
Japan :
Kagawa Ken To Aug. 18 606
Kiimamota Ken To Aug. 18 il
Kyoto Ken To Aug. IS 14
Nagasaki Ken To Aug. 18 90
Olta Ken To Aug. 18 12
Okayama Ken To Aug. 18 1,288
Java:
Russia :
California :
China:
India :
Japan :
Osaka Ken To Aug. 18 .
Saga Ken To Aug. 18
ShTmanur Ken To Aug. 18
Tokushima Ken To Aug. 18
Tokyo Ken To Aug. 18
WakayamaKen To Aug 18
Yamaguchl Ken To Aug. 18
Batsivia July 27-Aug. 2 .
Chabarowsk July 28-Aug. 7 .
Okowjannaja To Aug. 8
96
88
5
1
5
1
90
32
11
8
4
2
31
4
783
.')
53
1
25
8
5
Plagdk— United States.
San Francisco Aug. 31-Sept. 7.
PiiAQUE— Foreign.
Hongkong Aug. 2-9
Bombay Aug. 1:1-19
Calcutta .^ug- 9-lB
Yokohama Aug. 9-16
16
3
Chinese
34
35
9
4
Changes in the Medical Corps of the U. S. Armjr for
the week ended September 20, 1902 :
Daviks, Captain William O., assistant surgeon, volunteei-s. Is dis-
charged from October 15.
Wales, Captain Philip G., assistant surgeon, will report to president
of examining board, Washington, D. C, for examination for pro-
motion.
Brown, Colonel JusTtis M., assistant surgeon-general, is granted leave
for three months, to take effect upon the a.sslgnment of a medical
officer to take charge of the medical supply depot In New York
City during his absence.
Shaw, Captain Henry A., assistant surgeon, is relieved from further
duty in the division of the Philippines, and will proceed to San
Francisco and report for orders.
Wilcox, Lieutenant Colonel Timothy E.. deputy surgeon-general, chief
surgeon of the department, will proceed to each of the following-
named posts and make the inspection of medical affairs required,
and upon thecompletionof duty will return to headquarters: Boise
Barracks, Idaho; Forts Walla Walla, Wright, l-awton, Worden,
Flagler, Casey, Stevens, Canby and Columbia.
Bradley, Major .\lfred E., surgeon, having reported at headquar-
ters In compliance with orders, will proceed to Cebu, Island of
Cebu, via Manila, P. I., on the steamsliip Belgika.
Henry, Major Joseph N., surgeon, volunteers, now on temporary
duty in the office of the chief surgeon of the brigade. Is relieved
from that duty and will proceed to Camp Vicars, Mindanao, for
duty.
Hill, Captain John S.. assistant surgeon, volunteers, will upon de-
parture of Captain Henry A. Shaw, assistant surgeon, take tem-
porary charge of the office and duties of the chief surgeon of the
department In addition to his present duties.
De Keafft, Alajor S. C., surgeon, volunteers, now in Washington, en
route to Tacloban, Leyte, will proceed first to Catbalogan, Samar,
and report for assignment to station.
Black, Captain A. J., assistant surgeon, is r lleved from duty as a
member of the general court martial at Cebu.
Ruffner, F'lrst Lieutenant Ernest L., assistant surgeon, will report
to the officer In charge of the medical supply depot, Ilollo, for duty.
Heard, First Lieutenant George P., assistant surgeon, will report to
the chief surgeon of the brigade for duty in connection with the
sanitation of Iloilo.
Nelson, First Lieutenant Kent, assistant surgeon, will proceed to
.Santa Barbara, Panay, for temporary duty, relieving Contract Sur-
geon George F. Adair, U. S. army, who upon being thus relieved
will proceed to Iloilo, Panay, and report to the chief surgeon of the
brigade, for duty in connection with the sanit^itlon of Iloilo.
Bernheim, J. R., contract dental surgeon, lsa.s.signed to duty at Ilollo,
Girard, Colonel Alfred C, assistant surgeon-general, is relieved
from further duty in the office of the surgeon-general. He will re-
tain station in Washington as a member of the examining boards.
De Witt, Colonel Calvin, assistant surgeon-general, is detailed as
president of the faculty of the Army Medical Scliool, to relieve
Colonel Charles Smart, assistjmt surgeon.
The following changes In the stations and duties of officers of the med-
ical department are ordered : Lieutenant Colonel Louis M. Mans,
deputy surgeon-general, will assume charge of the medical supply
depot at .San Francisco, relieving Lieutenant Colonel John D. Hall,
deputy surgeon-general, who will report to the commanding gen-
eral, division of the Philippines, for assignment to duty. Major
Jefferson R. Kean, surgeon, having relinquished the unexpired
Portion of leave will report to surgeon-general for duty in his office,
irst Lieutenant Getime H. R. Gosman, assistant surgeon, is re-
lieved from duty at Fort Hancock, and will report at Fort Wads-
worth, N. Y.. for temporary duty. Major Walter D. McCaw, sur-
geon. Fort Wadsworth, N. Y., will repair to Washington and report
to the surgeon-general for duty in his office and as a member of the
faculty of the Army Medical School. Colonel Charles L. Helzmann,
assistant surgeon-general, is relieved from duty as chief surgeon,
department of the Ijakes, and will proceed to San Francisco and
report to commanding general, department of California for duty
as chief surgeon of that department, to relieve Colonel Philip F.
Harvey, deputy surgeon-general, who will proceed to Chicago, 111.,
and report to commanding general, department of the Lakes, for
duty as chief surgeon of that department.
Goltra, John N., contract surgeon. Is relieved from duty at Fort
Brady, Mich., and will proceed to Fort Asslnnlboine, Mont., and
report for duty.
Hartnett, First Lieutenant Eugene H., assistant surgeon, leave
granted June 11. is extended one day.
Rich, First Lieutenant Edwin W., assistant surgeon, now on duty at
the U. S. General Hospital, San Francisco, will proceed to Honolulu
and report to the commanding officer, Camp aicKlnley, Honolulu,
forteraporaiy duty, relieving Colonel Joseph B. Girard, assistant
surgeon-general, who will proceed to San Francisco and report for
orders.
Wilson, Captain Jahes S., assistant surgeon, will proceed from New
York City to Fort Riley In time to arrive there not later than Sep-
tember 20, and report to Major General Bates for temporary duty in
connection with the military maneuvers.
Maus, Lieutenant Colonel Louis M., deputy surgeon-general, will
upon his arrival in San Francisco, report for orders.
Bennett, Captain Irvin E.. assistant surgeon, volunteers, is dis-
charged, to take effect October 15.
Brown, Henry L., contract surgeon, is granted leave for two months.
Kirby-Smith, First Lieutenant Reynold M., assistant surgeon, Is
detailed as a member of the examining board at Fort Barrancas,
Fla., vice Contract Surgeon Frederic K. Jenkins, relieved.
Van Kirk, Harry H., contract surgeon, is granted leave for two
months, from November 1.
Williamson, First Lieutenant Lewellyn P., assistant surgeon,
leave granted is extendetl flfteen days.
Darnall, Captain Carl R., assistant surgeon, in addition to his pres-
ent duties in the office of the surgeon-general Is detailed for duly as
assistant professor of hygiene at the .\rray Medical School In
Washington.
Skinner, First Lieutenant Ira A., assistant surgeon, now temporarily
at Fort Michle, N. Y., will remain on duty at that post until further
orders.
Baker, First Lieutenant Frank C, assistant surgeon, is relieved from
further duty in Washington and as attending surgeon at Fort
Ma«on, Cal , and he will pro<^eed to the Presidio, Cal, and upon
arrival will report to the commanding officer. Companies E ana F,
Fifteenth Infantry, for duty witli and to accompany them to Mon-
terey, Cal.
RHOAD.S, First Lieutenant Thomas L., assistant surgeon, Presidio, Is
granted leave for one month with permission to apply for exten-
sion of one month.
Shepherd, J. M., contract surgeon, will report at Fort Myer, Va., for
temporary duty.
Changes in the Medical Corps of the U. 8. Navy for
the week ended September 20, 1902 :
Farwell, W. G., medical director, ordered to Philadelphia, Pa., for
duty in connection with recruiting — Septeml>er 12.
Biddle, C, surgeon, detached from naval recruiting station, Philadel-
phia, and to duty at York, Pa., with recruiting party— September 12.
Brownell, C. D., pa.ssed assistant surgeon, detached Irom Naval Hos-
pital, Chelsea. Mass.. and ordered to the Panther — .September 12.
Dennis, J. B., passed assistant surgeon, detached from the Hartford,
and ordered to the Brooklyn—September 12.
Williams, R B., assistant surgeon, discharged from treatment at
Naval Hospital, Newport, R. I., and ordered to the Decatur —
September 12.
Payne. .). H., assistant surgeon, detached from the Brooklyn, and
ordered to Naval Hospital, Newport, R. I.— .September 12.
MUNSON, F. M , assistant surgeon, detached from duty on the Decatur,
and ordered to the Naval Hospital, Washington— September 12.
HOYT, R. E , assistant surgeon, detached fi^om Naval Hospital. New-
port, R. I., and ordered to the Naval Academy — .September 15.
Ross, J. W., surgeon, retired, detached from the navy yard, Pensacola,
Fla.. and ordered to the Museum of Hygiene and Medical School,
Washington, D. C.— September 1-3.
IDBN, J. H., assistant surgeon, detached from the Lancaster, and
ordered to the Topeka — September 15
Gardner, J. E., surgeon, ordered to the Yokohama Hospital— Sep-
tember 15.
Waggener, R., pharmacist, detached from naval station, Key West,
Fla., and ordered to the navy yard, Pensacola, Fla.— September 12.
Mccormick, a. M. D., surgeon, detached from the Naval Academy,
Annapolis, Md., September 20, and ordered to the Hartford— Sep-
tember 15.
Changes In the Public Health and Marine-Hospital
Service for the week ended September 18, 1902 :
Glennan, a. H., surgeon, granted leave of absence for six days from
September 15, 1902— September 1.5, 1902.
Gardner, C. H., passed assistant surgetm, granted leave of absence for
one day, September 18, 1902— SeptemberiW, 1902
McMijLLEN, .John, passed assistant surgeon, relieved from duty in
office of Consul-Generalof the United States at London, England,
and directed ta proceed to Hong Kong, China, as inspector for a
period of two weeks; then to assume command of service at that
port, relieving Assistant Surgeon J. W. Kerr-.September 1.3, 1902.
Thomas, a. R,, passed assistant surgeon, directed to proceed to .San
Francisco, California, and report to medical officer in command for
duty and assignment to quarters— September 16, 1902.
Ramus, Carl, assistant surgeon, granted leave of absence for one
month from September 25, 1902— September 16. 1902.
Fox, Carroll, assistant surgeon, gi-anted leave of absence for seven
days from .September 1-5, 1902— September 13, 19u2.
Fox, Carroll, assistant surgeon, relieved from duty in office of
United States Consul at Liverpool, England, and directed to pro-
ceed to Manila, P. I., and report to the chief quarantine officer
for duty— September 15, 1902.
VoQEL, C. W., assistant surgeon, relieved from duty at Dutch Harbor,
Alaska, to take effect upon departure from that [Kirt of l«st revenue
cutter, and directed to proceed to San Francisco, California, and
report to the medical officer in command for duty and assignment
to quarters— September 15, 1902.
Beau, L. C, acting assistant surgeon, granted leave of absence for one
day, September H, 1902-September i3, 1902.
Olbaves, F. H , acting assistant surgeon, granted leave ot absence for
fourteen days from September fl. 1902-September 15, 1902.
Allen, G. C, pharmacist, to report to medical officer in command at
Baltimore, Md., for temporary duty during the absence on leave of
Pharmacist E. B. Scott— September 13, 1902.
Mason. M. R., pharmacist, relieved from duty at Dutch Harbor,
Alaska, upon closing of station and directed to proceed to San
Francisco, California, and report to the medical officer in command
for duty and assignment to quarters— September 15, 1902.
Board Convened.
Board convened to meet at the U. S. Marine-Hospital, Chelsea,
Mass., September 23, 1902, for the physical e.xaniinatiou of an officer of
the revenue cutter service. Detail for the board— Surgeon R. M. Wood-
ward, chairman; Assistant Surgeon W. K. Ward, recorder.
American Medicine
,v
GEORGE M. GOULD, Editor
G. C. C. HOWARD, Managing Editor
CHARLE» 8. DOLLEY
MARTIN B. TINKER, Astintant Editors
Ctinical Medicine
David Ribsman
A. O. J. Kelly
h. h. cushinq
Hklen Murphy
General Surgery
Martin B. Tinker
A. B. Craio
Charles A. Orb
Orthopedic Surgery
H. Augustus Wilson
COLLABORATORS
Obatetria and Oynecology
WiLMER Krusen
Frank C. Hammond
yervous and Mental Diseases
J. K. Mitchell
F. 8a vary Pearce
TVeatmeni
Solomon Solis Ck>HKii
H. C. Wood, Jr.
L. F. Appleman
Dermatology
M. B. Hartzell
Laryngology^ Bba,
D. Bbadkn Kylb
Ophthalmotogy
Walter L. Pylb
Pathology
R. M. Pearcb
PuBLUHBi> WnvLY AT 1331 Walhut STmsrr, Philadslphia, bt thb Amxsioam-Mbdicihb PuBuaatira Compavt
Vol. IV, No. 14.
OCTOBER 4, 1902.
$4.00 Yearly.
The Jfational Value of Wealth Devoted to
Science. — It is a truism that, used for selfish gratifica-
tion, wealth is a demoralizing agency, but the world is
only just beginning to realize that, devoted to the pre-
vention of disease and of evil, wealth is the essential
prereciuisite of human progress. Aspiration alone
counts for less and less in our modern world. It must
secure the means for realizing progress or beneficence.
In his recent presidential address before the British
Association, Professor Dewar illustrated this truth as
regards the relative use of chemistry by the English and
the German nations. In 1901 there were three times as
mnny trained chemists employed in Germany as in the
United Kingdom. The German chemists, furthermore,
are as superior in technical training and re<iuirements
as in numbers, for the English can only show 31 fc of
systematically trained chemists against 84^ in German
works. Yet these German industries, estimated at |250,-
000,000 per annum, are largely founded on basic dis-
coveries ma<le by English chemists never properly
appreciated or scientiflcly developed in England. And
the still more significant thing is not the appropriation
by the German of these industries, but the fact that it
will take two generations of hard work to enable
the P^nglish to reach the level already reached by the
Germans, while Germany possesses a national weapon of
precision which must give her an enormous initial
advantage in any and every contest depending on dis-
ciplined and methodized intellect. But if this is true of
chemistry, how much more true is it of the greatest asset
of a nation, her living citizens and their health ? The
recent demonstration in our country of a quickened
appreciation of the value of medical science, consisting
in the endowments for medical research and higher
education, are of tremendous importance not only to
metlicine, but to our national welfare and progress.
There is no way our wealthy men can raise such lasting
monuments for themselves, and at the same time do so
much good to their fellowmen.
A New Elciiieiit in the Codes of Ethics. — Since
the older documents were written a new factor has arisen
which seems to have escaped even mention in all recent
discussion, whether by those who would continue, abro-
gate, or modify these guides of professional conduct.
We allude to the trained nurse. The problems which
are involved in the relations of the two professions
appear as pressing and as needing determination as any
that are set forth in the older codes. In our country
there has thus far been less trouble than in older coun-
tries in fixing and defining the mutual duties of e<\ch,
but there is most plenteous and suggestive material
even here. In England these things have reached an
acute stage, one might almost say, of disease. "There
is," to quote from a private letter written by a most
careful and intelligent English practitioner, " an im-
mense amount of friction generated by district nurses,
by our parish church nurses, by nurses' homes, etc.;
. . . in fact, nurses are a greater evil to contend
with than opposing medical practitioners." The diffi-
culties vary in different countries, but that they are
numerous can scarcely have escaped the observation of
all active practitioners in any country. In our own
these difficulties are probably to be greatly increased by
the quack nurses, the growing ehiss which secure their
" training" in the six, or the ten, or the twenty weeks'
"schools." The almost insuperable obstacles meeting
any one who should attempt to codify the legal and ethi-
cal relations of the nurse and the physician will add
another to the many reasons advancetl by those who
think a socalled "code of ethics" is an anachronism in
our modern life, and that it is without power to regu-
late the conduct of its upholders, or to punish its trans-
gressors.
The Fuel Famine and Public Health. — The pres-
ent scarcity of fuel is sure to give rise to an enormously
increase<l demand upon the public funds available for
the care of the sick and destitute in the larger cities ; in
fact the trustees of funds for furnishing free coal to the
poor have already announcwl their inability to meet
even a small part of the demand upon them. The
appropriations to public charities are almost uniformly
inadcciuate to meet the ordinary demand, and it is prob-
able that the first cold spell will make dear the absolute
necessity for finding some immediate solution to the fuel
question if widespread distress and an appalling increase
in the deathrate is to be avoided. Where does the
responsibility rest? The action of the Heading R. II. Co.
in guaranteeing coal to charitable institutions is not
8uttici(!nt — some provision must be made for the needs
of the i)Oor who are still without the doors of these
522 AMBRICAN MBDICINB~
EDITORIAL COMMENT
[October 4, 1902
institutions if we would keep them out. Some way
must be found by which coal may be mined and calam-
ity averted. If the present operators are unable to cope
with the difficulty it would seem that the authorities of
the commonwealth might take temporary possession of
the mines and conduct them until some basis of settle-
ment is reached between the strikers and the operators.
A Judge's Opinion of Physicians as Expert
"Witnesses. — An expert, said ex-Judge Harvey at the
recent meeting of the Pennsylvania State Medical
Society, is one who has skill derived from experience.
Mere erudition or book knowledge will not qualify a
witness to be of use to the court, as his testimony is in
reality not Ills own, ha.s not been verified even by
experience, and therefore it is useless. How many
medical witnesses have demonstrated the truth of this
observation ? Physicians, again, it is said, often think
that the opposing counsel are unduly severe In their
questionings of the experts. In saying that this criti-
cism is always unjust and that lawyers are never unduly
cynical and over sharp, we think Judge Harvey himself
errs not a little, but we agree that the expert does not
always carefully base his opinions squarely upon
scientific principles, and when it is evident that the
expert's knowledge is not clear or that the scientific aim
is not plainly uppermost, then the severity of the ques-
tioner is in fact j ustlfiable. A corollary of this truth was
shown In the charge that the testimony of medical men
is often conflicting. This is a point which makes us
wince. When such contradictions by experts occur in
court our professional reputation suffers acutely. But
this is usually a result of devotion to partisan rather than
to purely scientific ends ; it furnishes the strong argu-
ment of those who would make the expert the officer of
the court. We also have a good deal of sympathy with
the opinion that too often physicians use technical
language In court which cannot be understood by the
lay public nor even by learned lawyers. This is a piti-
able error, but as Judge Harvey said, it is one usually
made by the poorest educated. It is an evidence of as
bad manners as of bad learning.
" The legitimate sphere of liomeopathy and its
limitations," according to Dr. James C. Wood, in his
noteworthy address as President of the American Insti-
tute of Homeopathy (the fifty-eighth annual session of
which was held at Cleveland, Ohio, June 17, 1902), are
thus classified : The homeopathic law does not relate to
agents Intended to affect the organism chemically ; for
mechanical efffect only required for the development or
support of the organism when in health ; to remove or
destroy parasites which infest or prey upon the human
body ; which act in a purely eliminatlve way to rid the
system of poisons and ptomains ; which act in a purely
physiologic way, as a food ; which act in a purely
stimulative way. We do not understand the first limi-
tation, a.s to chemical agents, because all drugs put in
the stomach must act chemically. As to the entire
series of limitations. Dr. Wood ha.s no doubt that much
work Is left for the homeopathic remedy to do. He
says:
" These conditions will limit the law of similars to its legiti-
mate sphere of action — the curing of diseases which are curable
by the principle of substitution, and leave its advocates free to
utilize all methods of cure or relief which will best subserve the
interests of the patient. There are, to be sure, men who will
claim that the homeopathic remedy is all-sufHcient for all con-
ditions. If these gentlemen have become so proficient as to
require nothing without tlie domain of the law of similars in
contending with disease and suffering, they are to be congratu-
lated ; there are comparatively few of us who possess the
knowledge to do so. Personally, I believe it the duty of the
physician, first to prevent disease, if possible; secondly, to'
cure disease which he cannot prevent by the safest, surest and
easiest method at his command; and thirdly, to bring comfort
and relief to the incurable by those means which are most
available and most satisfactory, whether homeopathic or other-
wise. This course leaves a wide scope for the application of the
homeopathic law, while it broadens our conception of the heal-
ing art. We are physicians first, and homeopaths secondly."
The Union of the Homeopathic and " the Dom-
inant" "Schools." — Dr. Wood's address is in such
admirable spirit and from so praiseworthy a motive
that we regret to point out what seems to us an illogical-
ity. We cannot do better than to place in closer contrast
several quotations :
" It is not yet time to surrender either our name or our dis-
tinct organization. The law of similars, or if you please, the
law of substitution, can no more be separated from the distinc-
tive name of ' homeopathy ' than can the teachings of Martin
Luther be separated from that of the Reformation."
" With this single reservation, then, that we shall hold fast
to our historic name and to our fundamental principle, we can
meet the liberally inclined gentlemen of the older school more
than half way in all matters pertaining to the public weal,
whether they have for their object the betterment of civic gov-
ernment or the advancement of medical education. There can
be no possible objection to affiliating ourselves with their socie-
ties, provided that in so doing we are not called upon to
renounce either our name or our principles."
No sincere and educated physician belonging to any
school should be ostracized because of his particular belief in
therapeutics. The one standard should be that of knowledge,
character, and professional conduct."
" In another twenty years the term ' homeopathic,' which
in the past has acted like a red flag flaunted in the face of an
angry bull, will not grate upon the ear of progressive and lib-
eral men of whatever school, any more than at the present time
do the terms ' psychopathic,' ' neuropathic ' and ' hydro-
pathic' The school which has so long been thrown into hys-
terics by the term 'pathy' is rapidly being split up into many."
The committee on the president's address says :
" We recognize the current tendency toward medical affilia-
tion throughout the land, but inasmuch as a recognition of the
law of similars is still withheld, we commend the attitude of
the president in urging continued separate organization."
The contradictions involved in these excerpts are,
that into however many -pathies we are "rapidly
splitting," we do not take these *-pathies Into our medical
society and demand that the other members shall sanc-
tion them with the official seal of the society ; we do not
as individuals call ourselves or advertise ourselves as
allopathists, hydropathists, etc. ; nor do we "ostracize"
anyone "because of his particular belief in tlierapeu-
tics ; " we also uphold the truth that " knowledge, char-
acter, and professional conduct " shall be the conditions
of membership in our societies ; we do not make any
" single reservation " as to "name," or as to "funda-
mental principle" in therapeutics, except that the first
shall be science and the second scientific, and we do not
October 4, 1902]
EDITOEIAL COMMENT
American Medicine 523
think Dr. Wood and his associates should commend
"continued separate organization."
Malthus and Medicine. — The New Yorlc Evening
Post in a thoughtful leader epitomizes the reasons
advanced by Professor Brentano, of the University of
Munich, for the fact that the civilization of today
appears to be disproving the Malthusian doctrine accepted
by political economists. Malthus, as is well known,
convinced serious students that the increase of popula-
tion tends to outrun the means of subsistence, and is only
neutralized by war, pestilence, etc., or at least by inten-
tional restriction of propagation. But the plainest
truth of our time is that there has been an enormous
increase of population in all civilized countries and a
sudden increase also during the last century, and with
it, despite Malthus, as great an increase in human com-
fort and prosperity. In England, for instance, during
the six centuries after William the Conqueror, the popu-
lation only doubled (estimated at 5,500,ij20), and in 1800 it
was only 8,500,520. But in the last century it rose to
32,500,000. In 1812 the percapita wealth was about
$800, while in 1885 it was as much as $1,350, and the
wages of the common workman rose 133^. Such an
increase of population, wealth, wages, and prosperity has
taken place in all civilized countries, but not in the
uncivilized ones. The reason is patent ; it is due to
science, which has many times multiplied the products
of human labor and comfort. Malthus is not disproved,
and the economists' "I told you so" is perhaps only
postponed. But in the grand result medical science has
played a leading role. At least the increase of popula-
tion has been due to it through the great decrease of
mortality, and particularly of infant mortality.
The medical student, the advantages and disad-
vantages of the medical life, the profession from the
physical, the financial, the intellectual, the ethical and
the social standpoints, the details as to the teaching,
studies, etc., of all the schools and hospitals— these and
a multitude of other valuable observations fill each year
the special educational numbers of our honored con-
temporaries, the British Medical Journal and the Lancet,
at the opening of the fall terms of the schools and hos-
pitals in Great Britain. We say valuable, and yet we
do not understand why all this comes at the time when
the student has irrevocably made his choice. For the
year, at least, the die has been cast. The medical pro-
fession has been chosen and also the institution wherein
his studies are to be prosecuted. All this valuable
information would be of great use, say several months
previously, to the undecided student hesitating whether
to choose medicine or some other career, and whether
to go to this or that of the many rival schools, offering
their iulvantages of teachers, clinics, laboratories, etc
The Ixmcet cites the interesting intiuiry made by Dr.
Arthur Keith, of the liondon Hospital Me<lical School,
as to the reasons of the adoption of the medical career
by 100 men at his hospital. In 7 cases their profession
was chosen for them ; 30 were born in the profession and
grew up in it ; 10 adopted it as a boyish ideal at a very
early age ; 12 chose it by a method like a diagnosis by
exclusion— it was the profession they had the least objec-
tion to ; 7 because it was the nearest akin to their favor-
ite subjects, zoology or chemistry ; 31 were led to it by
some accidental circumstance, and 3 drifted into it, they
could not tell why.
Melodramatic Science.— Years ago Dr. Charlton
Bastian thought, or represented himself as thinking,
that he had proved spontaneous generation, and Profes-
sor Tyndall was put to the trouble of exploding the
myth. He did this so effectually that, if one may so
speak, it has never since raised its head. Nor has Dr.
Bastian until recently. Now he has come forward
with a new scientific Jack-in-the-box called hetero-
genesis. By this term he means the sudden change of
one species into another, as e. g., "the transformation,
in the course of three or four days, of the entire contents
of the egg of Hydkitina senta into a large ciliated infu-
sorium belonging to the genus otostoma." The Royal
Society refused even to listen to the miracle-worker.
We have often been astonished, especially in France and
the United States, at the ease with which these pseudo-
scientists get a hearing — at least for a time. The immor-
tality-producers, the sex-dictators, the life-creators, the
materialism-provers, and the rest, flourish in pure
science, for their little day, just as do the quacks and the
miracle-workers in medicine and therapeutics. It is
perhaps a misfortune of the endowers of science and
the builders of institutions that they innocently stimu-
late such exhibitors to a fictitious productivity, but
they or their trustees may be relied upon to detect
both the false motive and the false method.
Bishop Potter on Intemperance. — We regret
that in urging upon the members of the recent Diocesan
Convention in New York a more intellectual diagnosis
and a more effective treatment of the drink-problem,
Bishop Potter traced the origin of the evil to mechanic
invention, which throws workpeople out of employment
or so lessens their interest in their work as to drive them
to drink. We think this condition has such consequences
in but the slightest degree. But one must admit that
" most of our efforts for dealing with the drink evil in
our day and generation are tainted with falsehood, dis-
honored by essential unreality, and discredited by wide-
spread and consistent failure." The remedy advised by
Bishop Potter is the establishment of a system like that
of the Public House movement in England, concerning
which our readers have been informed. In this particu-
lar the views of Bishop Potter have since received strong
support from the annual ofticial report of General Fun-
ston for the Department of Colorado, who says that in
the past year the percentage of trials by court-martial
has nearly doubled. He says of the abolition of the
canteen feature of the post exchange :
" Since this action was taken saloons of the lowest type have
been established just outside the boundaries of the various
reservations ; their proprietors are, in almost every case,
unprincipled scoundrels, who leave nothing undone to debauch
the soldiers and obtain their money. Being in all cases outside
the limits of any city, the proprietors of these resorts are sub-
ject to no municipal police regulations. The soldier whose
desire for a drink would ordinarily be satisfied by a few glasses
524 American MBDtoiirK]
REVIEWS
(OCTOBBB 4, 1902
of beer in the canteen of the post exchange, goes to one of these
resorts and does well if he escapes before he has spent or
gambled away all his money, overstayed his leave or engaged
in an altercation. There can be no reasonable doubt that most
of the trials by general courts-martial and summary courts, at
least so far as this department is concerned, are directly trace-
able to this cause. Since I have had command here there has
taken place the ruin and degradation of several noncommis-
sioned officers of long service and fine record. In short, the
recent legislation by Congress on this question so far as this
department is concerned, has had no effect except to lower the
discipline of the army, ruin scores of good soldiers and fill the
pockets of a lot of saloonkeepers, gamblers and prostitutes."
Physiology and the Gospel of Hustle. — From
Chicago comes the proposal that the suburban dweller
shall breakfast upon a trolley dining car in order that
he may save the half hour (or is it only ten minutes in
Chicago ?) lost in breakfa-sting at home. By this plan
the coming millionaire jumps out of bed and, boarding
the trolley car, finds that his previously-ordered break-
fast is ready for him, and by the time he has eaten it he
is landed at his office ready for business. But the physi-
cian and the ordinary human ruminant must in amaze-
ment ask, Why have any home at all ? What is the use
of marriage and children, all the old-fashioned ways,
and all the ridiculous old things such as health, religion,
ethics, poetry, love, peace, and the rest ? Why not have
meals served in the office, and supply one's self with a
patent desk which, at the end of the business day, by
the push of a button is transformed into a bed? If
sleep is slow in coming under such circumstances "the
hypodermic man " is at the command of the telephone.
When digestion fails, as it is likely to do after a few
years of machine-feeding, chemistry will probably sup-
ply all foods in a predigested state, and any way by that
time the "pile " will have been made. It is not added
that perhaps by that time the great physiologist, Death,
may have an important question to ask.
Home Hygiene Should be Taught in the Schools.
—In the Ohio Sanitary Bulletin, March-May, 1902,
several speakers at the meeting of the State Board of
Health and superintendents of public schools, held
April 18-19, 1902, wisely emphasized the influence
upon home hygiene that might be exercised by the proper
teaching of hygiene in the public schools. One said he
had known of charges of overwork in the school when
the children were really overworked at home. For
instance, one girl was taken from school, but investiga-
tion showed that she was practising music three hours a
day, besides taking dancing lessons, etc. Injured eye-
sight is also charged up to the school when the pupil is
reading novels in a bad light several hours a day. Dr.
Warner, of the State Board of Health, went into details
in a capital way, showing how a vast amount of informa-
tion as to the sanitary aire of households could be im-
parted in the school, the missionary influence of the
child being at once felt in the home. There is hardly
any child above kindergarten years that is not capable
of understanding the rudiments of the needs and meth-
ods as to cleanliness, fresh air, temperature of rooms,
clothing, exercise, food, sunshine, yard drainage, gar-
bage disposal, bathing, sleep, purity of water, care of
the nails, teeth, hair, etc.
BOOK REVIEWS
Die ROntgenstrahlen im Dienste der Chlrurgie.— Von Dr.
(Jaiil Beck, Professor der Ohirurgie, New York. I Teil
(Text), pp. 138; II Teil (Tafeln), 65. Seitz und Schauer,
Miinchen, 1902.
Beck's latest contribution to x-ray literature fully main-
tains the high standard of his previous writings on this and
other subjects. The text is divided into a general and a special
part. The first includes remarks on the importance of the
x-ray, armamentarium, and technic. The second is made up of
eight chapters dealing with skiagraphy of the head, neck,
chest, abdomen, pelvis and lower extremity, shoulder and
upper extremity, inflammatory conditions and newgrowths,
and pathologic and therapeutic considerations. An index to
the literature of the subject is given. The illustrations are
exceedingly good and cannot fail to emphasize the value of
skiagraphy. The lack of a table of contents for this small,
well-chaptered book is scarcely felt, but an index would have
added to its value. The typography is excellent.
Massage and the Ori^nal Swedish Moveinents : Their
application to various diseases of the body.— Lectures
before the Training Schools for Nurses connected with
the hospitals of the University of Pennsylvania, Woman's
Hospital, German Hospital, Philadelphia Lying-in Char-
ity, the Philadelphia Polyclinic and College for Gradu-
ates in Medicine, and the Kensington Hospital for
Women, of Philadelphia. By Ktirre W. Ostrom, from
the Royal University of Upsala, Sweden. Fifth edition,
revised and enlarged. Pp. 181, with 115 illustrations. P.
Blakiston's Son & Co., Philadelphia. 1902. Price, ?1.00
net.
The new edition of this valuable work is written in the
light of the author's better knowledge of the value of massage
as a remedial measure and of the actual wants of nurses gained
by further experience as a teacher. The whole text has been
revised, ten new illustrations added, and the practical instruc-
tions rewritten. This makes it of increased value to the physi-
cian, nurse and professional masseur. A bibliography of
English literature on the subject of mechanotherapeutics is
appended. The author sees no reason why such a powerful
remedial agency as massage should not be fully controlled by
the medical profession in this country as it is in Europe. He
also concludes that there should be examination and registry
for trained operators for the purpose of protecting themselves
and the profession as well as the general public.
A Manual of Instruction in the Principles of Prompt
Aid to the Injured, Including a Chapter on Hygiene
and the Drill Regulations for the Hospital Corps, U. S. A.
Designed for Military and Civil Use. — By Alvah H.
Doty, M.D., Health Officer of the Port of >few York, etc.
Fourth edition. Revised and enlarged. New York : D.
Appleton & Co., 1902.
A number of changes have been made in this edition to
meet the latest requirements. The introduction of the army
drill regulations adds considerably to the value of the book
from a military point of view, and the chapter on disinfection
has been especially improved. Those who have not had special
training will find this a valuable work of reference.
The Rontgen Rays in Medicine and Surgery.— By Francis
H. Williams, M.D. (Ilarv.), Graduate of the Massachu-'
setts Institute of Technology; Visiting Physician at the
Boston City Hospital ; Fellow of the Massachusetts Medi-
cal Society, etc. Second edition. New York : The Mac-
millan Company, 1902. Price, ?6.00.
In this volume of over 700 pages the author has presented a
most valuable treatise on the use and value of x-rays in medi-
cine and surgery. He discusses first the nature and properties
of x-rays, the equipment necessary to do good work, and the
methods for making x-ray examinations with the fluorescent
screen and x-ray photograph. Following this are shown the
appearances seen on the fluorescent screen in sucli diseases as
pulmonary tuberculosis, pneumonia, emphysema of the lungs,
pleurisy with effusion, hydrothorax, pneumothorax, aneu-
rysms, newgrowths, etc. Methods of examining the heart and
localizing foreign bodies are given in detail. The chapter on
October 4, 1902)
REVIEWS
iAmkkican Mkdicink 525
dental surgery gives an excellent idea of the progress which
lias been made in adapting the x-rays to the examination of the
teeth. The work is well illustrated, praiseworthy and most
readable.
Handbook of Bacteriologic Diagnosis for Practitioners,
including Instructions for the Clinical Examination of the
Blood. By W. D'Este Emery, M.D., B.Sc, Ijondon, Lec-
turer on Pathology and Bacteriology in the University of
Birmingham. Published by P. Blakiston's Son & Co.,
1012 Walnut street, Philadelphia, 1902.
This book, of some 200 pages, is not designed by the author
to take the place of the more extensive and exhaustive works
on bacteriology, but rather, as the title suggests, to instruct the
general practitioner, who, in all probability, has not been
schooled in the elements of bacteriology, to make actual micro-
scopic examinations for himself, and to enable him to properly
interpret his findings. Argument is logically made tiiat in the
great majority of cases V)etter and more accurate diagnoses will
be made in this way, where he who makes the laboratory find-
ings is at the same time fully cognizant of the previous history
and present condition of the patient thau even by the trained
expert who is without the clinical history. The work covers
the field usually covered by the works on bacteriology, includ-
ing instruments used, culture media, technic, the various bac-
teria and their significance, the Ijlood, sputum, etc. No small
work has come under our observation better suited to the needs
of the busy practitioner, who at the same time has the laudable
ambition to be for the most part his own microscopist.
Gibson and Rnssell's Physical Diagnosis.— Third Edition,
Revised and Rewritten. By Francis D. Boyd, C.M.G.,
M.D., F.R.C.P., Ed. ; Assistant Physician, Edinburgh
Royal Infirmary ; Physician to the Deaconess Hospital ;
Formerly Clinical Medicine Tutor, Royal Infirmary,
Edinburgh. 12mo. ; 448 pages ; 144 illustrations. New
York : D. Appleton <fe Company. Edinburgh and London :
Young J. Pentland, 1902.
Gibson and Russell's Physical Diagnosis has long enjoyed
a well-deserved popularity— a popularity likely to be main-
tained by the new third edition, revised and in part rewritten
by Dr. Boyd. In this edition new sections have been added —
on the examination of the blood, the examination of the gastric
contents, intestinal parasites, the cranial nerves, and clinical
bacteriology. In the main these are satisfactory, though brief,
in fact, too brief ; that on clinical Ijacteriology would have been
better expanded or omitted. The book as a whole will be read
with pleasure and profit; but in some few respects it is disap-
pointing— more especially in the discussion of certain heart
murmurs, of the physical signs of certain valvular defects of
the heart, and of the physical signs of certain affections of the
lungs and pleura. Though possibly a personal view of the
matter, still one is warranted in expecting definite statements
with regard to tlie cause and dilTerentiation of socalled aortic
:ind mitral murmurs, certain anomalous physical signs of
pleuritisand pneumonia, etc. Doubtless the size of the book
and a certain desired dogmatism precluded the incorporation
of such matters ; had they been added, however, the value of
the book would have been much increased.
The Essentials of Histology, Descriptive and Practical.—
For the Use of Student-s. By E. A. SohXkek, LL.D.,
F.R.S., Professor of Physiology in the University of Edin-
burgh ; formerly .Jodrell Professor of Physiology in Uni-
versity College, London. Sixth edition, revised and
enlarged. With 46.3 illustrations. 4W pages. Published
by Lea Brothers & Co., 70fi Sansom street, Philadelphia.
Price, »3.00 net.
The thousands of physicians who received aid in their ele-
mentary studies in histology from the early editions of this
excellent textljook will be gratified to see a new and somewhat
enlarged edition of the same. Few autliors have been more
successful in bringing into small compass the essentials of his-
tology, or to present the same both in text and illustration with
Ijetter judgment. Many of the illustrations in this sixth edition
have been selected from the most authoritative monographs,
while many were prepared expressly for this work by Mr.
Richard Muir, an adept in histologic delineation. Particular
attention has been given to the chapters on the central nervous
system, but we note on almost every page evidences of critical
revision. There is no padding about this book, it is solid meat
all the way through, carefully written, carefully printed on
thin but high grade paper, making it altogether better adapted
for students' use than many textbooks on the subject of more
pretentious appearance. '
International Clinics.— A Quarterly of Illustrated Clinical Lec-
tures and Especially Prepared Articles on Medicine,
Neurology, Surgery, Therapeutics, Obstetrics, Pediatrics,
Pathology, Dermatology, Diseases of the Eye, Ear, Nose,
and Throat, and other topics of interest to students and
practitioners by leading members of the medical profes-
sion throughout the world. Edited by Henry M. Cat-
TELi,, M.D., Philadelphia, U. S. A., with the collaboration
of John B. Murphy, M.D.; Alexander D. Blackader,
M.D.; H. C. Wood, M.D.; T. M. Rotch, M.D.; E. Lan-
DOLT, M.D.; ThomasG. Morton, M.D.; .Tames J. Walsh,
M.D.; J. W. Ballantyne, M.D., and John Harold,
M.D., with regular correspondents in Montreal, London,
Paris, I^eipsic, and Vienna. Volume II. Twelfth series,
1902. Philadelphia: J. B. Lippincott Company, 1902.
This volume contains a number of articles arranged accord-
ing to subjects under the following headings : Therapeutics,
Medicine, Surgery, Obstetrics and Gynecology, Biographical
Sketches of Eminent Living Physicians, Special Articles.
Among the most interesting of the individual lectures and
articles are those by Professor R. Lepine, on tlie Treatment of
Diabetes Mellitus; Herman P. Vickery, M.D., on Pseudoleu-
kemia with Chronic Relapsing Fever ; Arthur R. Edwards, on
Classification of Cirrhosis of tlie Liver; A. L. Benedict, M.D.,
on Auscultatory Percussion ; H. A. Kelly, M.D., on Some Notes
Upon the Management of a Modern Private Hospital ; P. L.
Daniel, J\R.C.S., on Pancreatic Cysts.
BOOKS RECEIVED.
Electrotherapeutlcal Practice: A ready reference guide for
physicians In the use of electricity. Seventh edition, revised, rewritten
and greatly enlarged.— By Charles 8. Niekwanoer, Ph.G., M.D.,
Professor of Electrotherapeutics, Postgraduate Medical School of
Chicago, etc. E. H. Colgrove & Co., Chicago, 1902.
General Paresis.— By Robert Howland Chase, A.M , M.D.,
Physlcian-in.<!hlef Friends' Asylum for the Insane, Philadelphia, etc.
290 pages, illustrated. Cloth, net, 81.75. P. Blakiston's Sou & Co.,
Philadelphia, 1902.
The Diseases of Infancy and CliDdbood By L. Emmett Holt,
A.J ^" '
clans
the N- - . ,
enlarged, with 22.5 illustrations, including 9 colored plates. Cloth,
SS.OO ; half leather, S<i..iO. D. Appleton & Co., New York, 1902.
Practical Diagnosis : The use of symptoms and physical signs In
the diagnosis of disease. Fifth edition, revised and enlarged.— By
HoBART AMORV Hare, M.D., B Hc. Professor of Therapeutics In the
Jefferson Medical College of Philadelphia, Physician to the Jefferson
Medical College Hospital, etc. Illustrated with £W engravings and 25
plates. Lea Brothers & Co., Philadelphia and New York, 1902.
Practical Obstetrics : A te.xtbook for practitioners and students.
—By EDWARn Reynolds, M.D., Visiting Hurgeon to the Boston Free
Hospital for Women, Fellow American Gynecological Society, etc.;
and Franklin H. Newell, M.D., Assistant in Obstetrics and Gyne-
cology In Harvard University, Physician to Ont^Patlents of the Boston
Lying-in Hospital, etc. Illustrated with 2.52 engravings and 3 colored
plates. Leii Brothers & Co , Philadelphia and New York, 1902.
Materia Medlca, Tlierapeiitlcs, etc.: A manual for studeiit.s and
practitioners.— By William .>jchleif, Ph.G., M.D., Instructor In
Pharmacy in the University of Penn.sylvanla. Series edited by Bern.
B. Gallauuet, M.l).. Demonstrator of Anatomy and Instructor in
.Surgery, College of Physicians and Surgeons, New York, etc. Second
edition, revised and enlarged. Lea Brothers & Co., Philadelphia and
New York, 1902.
Progressive Medicine : Vol. III. September, 1902. A quarterly
digest of advanced discoveries and Improvements In the medical and
surgical sciences. Edited by Hobart Amory Hare, M.D., Professor
of Therapeutics and Materia Medlca In the Jefferson Medical College
of Phlliulclphla. etc.; assisted by H. R. M. Lanuis, M 11, assishml
Physician to the Oul-Patlent Medlcul Department of the .liH.ison
Medloil College UospltJil. Lea Brothers & Co , Philadelphia and .New
York, 1902.
Physical Diagnosis: Diseases of the thoracic and abdominal
organs —By Eobkrt LeFevre, M.D., Professor of Clinical Medicine
and Associate Professor of Therapeutics In the University and Beilevue
Hospital Medical College, etc. Illustrated with 74 engravings and 12
raonorliromc plates. Lea Brothers & Co., Philadelphia and New York,
1902.
Disinfection and Disinfectants: A practical guide loi s;iiilia-
rlans, health and quarantine offlcers.— By M.J. Rosenau, Director of
the HyKknlc Laboratory. Illustrated. Price, S2.(X) net. 1". Blakiston's
Son & Co., Philadelphia, 1902.
Twenty-fifth Annual Report of the New Jersey .State Hoard of
Health, 11)01. John L. Murphy Publishing Co., Trenton, N.J.
Transactions of the New York State Medlca] Society, 1908.
Published by the Society.
Fox's Atlas of Skin Diseases i Part XVI. J. B. Lippincott Com-
pany, Philadelphia, 1902.
526 AUEBICAK Medicine]
AMERICAN NEWS AND NOTES
[October 4, 1902
AMERICAN NEWS AND NOTES.
OENKRAIi.
SinaIIpo3E, as officially reported in the United States from
June 28 to September 19, 1902, amounts to 7.168 cases with 367
deaths. For the corresponding period in 1901 there were 9,907
cases with 282 deaths.
Yellow fever is reported to be epidemic in Orizaba, a city
on the line of the Mexican railroad, between Vera Cruz and
Mexico City. It is believed that the disease was brought from
Vera Cruz or else infected Stegomyia were carried to the city on
the trains. Fears are entertained that Mexico City may also
become infected.
To Study the Cholera Bacillus.— It is announced that
Colonel Charles Smart, who has been ordered to the Philippines
as chief surgeon of the division, will make a thorough investi-
gation of the origin of the cholera bacillus with a view to pro-
vide for the adoption of permanent measures to check the
recurring epidemics of cholera in the islands.
Dysentery at St. Vincent. — According to information re-
ceived through Surgeon-General Wyman, of the Public Health
and Marine-Hospital Service, the published report of an epi-
demic of dysentery prevailing in the island of St. Vincent and
in Kingston is erroneous. A cablegram received by the State
Department announces that there is no epidemic and only three
cases of the disease exist at Kingston at the present time.
Yellow Fever Germ. — It is reported that the commission
appointed by the Public Health and Marine-Hospital Service
to study the epidemic of yellow fever at Vera Cruz has dis-
covered the germ causing the disease. The germ is said to
be an animal organism, and its character and habits have
been definitely fixed. The germ found in the bodies of the
victims of the disease is identical with that found in the
mosquitos, and the authorities have therefore adopted measures
contemplating the extermination of the mosquitos.
Charitable Bequests.— Philadelphia: The late David
Simpson, of Collingswood, N. J., bequeathed $5,000 each to the
West Philadelphia Hospital for Women ; Polyclinic Hospital ;
Rush Home for Consumptives and Allied Diseases. Boston :
The late Sarah W. Taber, of Boston, willed $1,000 each to the
Society of Sick Poor of Roxbury ; the Massachusetts Infant
Asylum ; Kindergarten for the Blind ; Home for Crippled Chil-
dren. Colorado Springs : The late W. S. Stratton left $1,000,000
to build the Myron Stratton Home for Sick Persons. After pay-
ment of various bequests, the remainder of the estate is to be
used to maintain the institution.
Health of the Army. — According to the annual report of
the Surgeon-General of the Army, the condition of the troops is
gradually improving. For the year 1901 there was considerably
less disease, injury and mortality as compared with the rates
for the preceding year. The deathrate from all causes is re-
ported to be 5.29 per 1,000 men in Cuba; 6.90 in the United
States ; 7.81 in Porto Rico, and 17.96 in the Pacific islands and
China. For the whole army, with a mean strength of 92,491
men, there were reported during the year 35,180 eases of malarial
diseases, 28,918 cases of intestinal diseases, 17,736 cases of wounds
and injury, 13,911 cases of venereal disease, 2,018 cases of alco-
holism, 1,805 cases of fever which were undetermined, 594 cases
of typhoid fever, 452 cases of pulmonary tuberculosis. There
have been 34 deaths from cholera reported from the Philippines
since July 1 and 13 deaths from cholera morbus.
EASTERN STATES.
The Stillman Infirmary, at Harvard University, was
opened September 25 for the accommodation of sick students.
It is to be conducted on the same lines as other private hos-
pitals, each patient being entitled to select his own physician.
NEW YORK.
The Harlem Medical Association. — At a meeting held
June 4, 1902, officers for the ensuing year were elected as fol-
lows : President, Dr. E. L. Cocks ; vice-president. Dr. W. H.
Luckett ; secretary. Dr. Percy Fridenberg ; treasurer. Dr. I. L.
Feinberg ; trustees, Drs. J. E. Lumbard, M. R. Richard and
Henry Heiman.
Whoopingcough to be Placarded.— The New York City
Board of Health has amended the section of tlie sanitary code
relating to contagious diseases, so that it now includes whoop-
ingcough. This makes it compulsory for physicians to report
immediately to the Board of Health all oases of the disease they
are called upon to attend.
Proposed Hospital for Diseased Immigrants.— Dr.
Lederle's action in terminating the contract between New York
City and the United States government by which the city takes
charge of immigrants suffering from contagious diseases will
probably result in the creation of a new island for hospital pur-
poses between Ellis and Bedloe's Islands. It is estimated that
the cost of such an undertaking will not fall short of $200,000.
The reason assigned for terminating the contract is the lack of
hospitals for the treatment of contagious diseases, and the
dangers arising to other patients through introducing into the
wards subjects that have been probably exposed to various
infections on shipboard where it is impossible to provide for the
proper isolation of contagious diseases. Emphasis was also
laid on the fact that the personal habits of many of the immi-
grants are uncleanly, rendering it difficult, expensive, and, in
many instances, impossible to keep the wards in the cleanly
condition necessary to the welfare of other patients.
PHUiADEIiPHIA, PENNSYLiVANIA. ETC.
Changes in the Medical Faculty at the University of
Pennsylvania. — Dr. Charles H. Frazier has been appointed
dean of the medical school, to succeed Dr. John Marshall. It
is announced that Dr. Frazier will retain his position as profes-
sor of clinical surgery in the institution. Dr. George de
Schweinitz will enter upon his duties as professor of ophthal-
mology, having been appointed to the chair left vacant by the
death of Dr. Norris.
Pennsylvania Society for the Prevention of Cruelty to
Animals. — The following from the history of the society is of
interest as showing the great strides that have been made in the
cai'e and treatment of neglected and abused animals: During
the 34 years of its existence the society has investigated 367,354
cases of cruelty and has been instrumental in eftecting great
reforms in the care of animals; 7,779 offenders have been prose-
cuted and punished ; 100,778 disabled animals have been sus-
pended from work ; and 9,085 suffering animals have been
killed ; an agent has visited the stock yards every day for many
years, seen that cattle were fed and watered, and remedied
many abuses.
SOUTHERN STATES.
Huxley Lectures. — W. H. Welch, professor of pathology
in the Johns Hopkins University, recently sailed for England
to deliver the Huxley lectures at the Charing Cross Hospital.
Chief Medical Referee of the Pension Bureau. — Dr.
Samuel Houston, of Pennsylvania, has been appointed to suc-
ceed Dr. Jacob F. Raub as chief medical referee of the Pension
Bureau.
Mortality of Baltimore. — For the month of August there
was a total of 915 deaths, of these 386 were of children under 5
years. Of the total number there were 283 deaths from infec-
tious diseases, 95 from pulmonary tuberculosis, 23 from pneu-
monia, 9 from bronchitis, 47 from Bright's disease and 38 from
typhoid fever. For August of 1901 there were reported 1,123
deaths, 208 more than for this August.
Quarantine Regulations. — The Louisiana State Board of
Health has officially notified quarantine physicians, medical
inspectors, marine medical inspectors and all interested,
of a resolution adopted September 2. It is provided that
on and after October 15 detention after disinfection will be
imposed only on vessels from ports actually infected, or
on those vessels which liave cases of quarantinable diseases
on board, or eases suspected of being such. Passengers
from healthy fruit ports will be released immediately
after their baggage is disinfected. In compliance with a
request made by the Health Board the Governor has issued a
proclamation withdrawing quarantine on and after November
1, except in so far as it applies to infected ports, or those sus-
pected of being infected with bubonic plague or cholera.
WESTERN STATES.
Cincinnati College of Medicine. — The announcement is
made that the institution was closed througli the great falling
off in attendance due to the enactment of a State law requiring
rigid entrance examinations. Previous to the passing of this
law each college had its own standard of entrance. It is believed
that the changed conditions will result in the closing or consol-
idation of the smaller institutions.
Food Adulteration Ordinance. — It is reported that the
San Francisco Board of Supervisors will be asked by its com-
mittee on hospitals and judiciary to enact a law requiring any
one selling an article of food to which a preservative has been
added to label the container of the food with a notice stating
that it contains a preservative and mentioning its name. If
this law is passed it would practically annul the existing ordi-
nance prohibiting the sale or use of any injurious food preserv-
ative.
New Hospital for the Insane. — It is reported that sub-
scriptions to the amount of §25,000 have been promised for the
establishment near Chicago of a private hospital for the
treatment of the insane, provided the names of the subscribers
are withheld until a larger sum is obtained. It is proposed to
conduct the institution on the same plan as the Bloomingdale
Asylum, near New York City, or the Pennsylvania Asylum,
near Philadelphia. It is stated that §200,000 will be required to
carry out the plan successfully, as it is proposed to erect build-
ings that will accommodate at least 100 patients and to purchase
a farm of 200 acres for the site. A large number of the wealthier
citizens of Chicago have been solicited to aid the plan.
October i, 1902]
SOCIETY EEPORTS
(American Medicine 527
FOREIGN NEWS AND NOTES
OENERAJi.
Relief Fund for Sufferers ft-om Calamities. — It is
reported that a native of Bombay has offered a sum approxi-
mating nearly §5,000,000 of United States money to be held in
trust for charitable purposes. It is proposed to devote the
income to the relief of persons deprived of their means of sub-
sistence in any country through sudden calamities.
The First Egyptian Medical Congress will convene at
Cairo, December 19 to 23, 1902. The congress will be divided
into three sections : internal pathology, tropical diseases, sur-
gery and ophthalmology. American pliysicians and surgeons
will be greatly interested in the transactions of the section on
tropical diseases ; special consideration will be given to bubonic
plague, Asiatic cholera, yellow fever and other diseases of hot
countries. Professor W. W. Keen, of Philadelphia, has been
elected honorary president of the congress.
GREAT BRITAIN.
Infectious Diseases in London. — At the close of the week
ended September 6 there were 95 cases of small-pox, 2,713 cases
of scarlet fever, 1,007 cases of diphtheria, and 303 cases of
enteric fever under treatment in the various hospitals of the
metropolis.
CONTINENTAIi EUROPE.
Serum Treatment of Scarlet Fever. — Dr. Moser, assists
ant physician at St. Ann's Hospital for Children at Vienna,
announced to the conference of German doctors recently
held in Carlsbad the discovery of a new serum which has
repeatedly proved successful in the treatment of scarlet fever.
He makes the statement that in 400 patients upon whom he
used it the mortality was but 8% or 9%, the rate in other hos-
pitals doubling this. It is reported that the government will
appropriate a considerable sum of money so that the serum
may be made in large quantities and distributed to all the
children's hospitals in Vienna.
The International Conference on Tuberculosis will con-
vene in Berlin, Octol>er 22 to 26. A careful investigation will
be made of various establishments for the treatment of the dis-
ease. The special suljjecte suggested for discussion are as fol-
lows : 1. Position of governments with regard to the preven-
tion of tuberculosis. 2. Obligation to give information to the
police. 3. Organization of dispensaries. 4. The task of schools
with regard to the prevention of tuberculosis. 5. Precautions
against the dangers of milk. 6. Tuberculosis during infancy.
7. Protection of labor and prevention of tuberculosis. 8. Clas-
sification and different modes of accommodating the tubercu-
lous. The meeting of the special committee on the last day of
the conference will be devoted to questions of organization re-
specting the work of the central olnce and the general regula-
tion of congresses.
OBITUARIES.
Alphonso L. Cory, at Chicago, 111., September 25, aged 51. He
was graduated from the Bennett College of Medicine and Surgery, Chi-
cago. 1S71, and from the Rush Medical College, Chicago, 1892. For many
years he was chief of the staff of attending physicians at the Engle-
wood Union Hospital. At the time of his death he was resident
surgeon for the Lake Shore and Michigan Southern Railroad.
Charles Carleton Smith, at Philadelphia, September 28, aged 66.
He was graduated from the New York Homeopathic Medical College
In 18fi2. He occupied the chair of Special Pathology and Diagnostics
In the Hahnemann Medical College In Philadelphia from 1871 to 1875.
William K. Higdon, at Kansas City, Mo., September 12, aged 3d.
He was graduated from the College of Physicians and Surgeons, Kansas
City, Kansas. In 1898.
Charles H. •Johnson, of Brooklyn, N. Y., September 18, aged 48.
He was graduated from the medical department of the University of
New York In 1880.
Dr. A. von Remmert, Honorary Body Physician to the Czar and
Inspector-General of the Medlcsil Department of the Russian Army,
died recently.
John W. Hughes, at fjitrobe. Pa., September 11, aged 64. He was
a prominent member of the Pennsylvania State Medical Society.
Martin Brown, at Anderson, Ind., September 17, aged 50. He was
graduated from the Medical College of Ohio, Cincinnati. 1880.
•Toshaa W. Ostrom, for 50 years a practising physician of Goshen
N. Y., at his home, l^akc Station, September 25, aged 87.
Henry I>. Orindel, at San Diego, Cal., September 14, aged 75. He
was graduated from the New York University In 1867.
Kdmund H. Cook, at Flushing, N. Y., aged 38. He was graduated
from tlic Kcllevue Hospital Medical College In 1893.
Kobert Clayton Frante, at South Mllford, Del., September 26,
aged ft"i.
Oeorge H. Moore, at Memphis, Tenn., September 16, aged 81.
SOCIETY REPORTS
CANADIAN MEDICAL ASSOCIATION.
Thirty-fifth Annual Meeting, Held in Montreal, September
i6, 17 and 18.
[Specially reported for American Medicine.]
[ Continued /r(mi page i55.]
General Session.
FIRST MEETING.
Address In Surgery: The Contribution of Pathology to
Surgery.— John Stewart (Halifax, N. S.). Owing to the
unavoidable absence of Dr. Stewart this paper was read by J.
W. Stirling (Montreal). The struggles of theearly surgeons
for a scientific knowledge of their craft were compared to the
daring exploits of the early navigators of the fifteenth and six-
teenth centuries. A parallel not altogether fanciful might be
drawn between those pioneers of ocean travel and the early
masters of our craft. 'They worked on two lines, the long,
weary and often fallacious track of empiricism and the ample
but often disconnected road constructed by those whose chief
aim was, in the words of him who led the vanguard, to " study
and search out the secrets of nature." The first advance
came with the anatomist, Vesalius, " and day dawned with
William Harvey, the Columbus of modern medicine," when
he instituted the application of experimental methods
to biologic questions. Finally came John Hunter, " the
father of scientific surgery," of whom Billroth says:
"From the time of Hunter to the present English sur-
gery has had something of grandeur and style about it."
But a great advance came from the study of plant life,
and the researches of Schwann and Schleiden paved the
way for the cellular pathology of Virchow, the basis of our
present system of pathology. And," said Stewart, " a shadow
falls upon us gathered here, as we realize that the veteran mas-
ter, the undisputed leader of pathologic thought and progress
for over 50 years, has fallen, and we unite in the desire to lay
our spray of cypress on the tomb of him whom we all consid-
ered the greatest German of our time." While with all these
new acquisitions the pathologist went on his way rejoicing, the
surgeon still lingered with anxious mind and heavy heart, for
the question of questions to him was still unanswered — the
healing of wounds was the enigma of surgery. By the close of
the eighteenth century many scientific workers were satisfied
the solution of this problem lay in the existence of pathogenic
microbes, but it was reserved for Schonlein to prove in 1839
tinea was due to the growth of a fungus. Later came Davaine
and Chaveau with their demonstration of the bacillus of
anthrax. And finally came Lister, " and," said Stewart, " the
dark hemisphere rolled in one grand movement from its age-
long penumbra into noonday. Modern surgery was born. In
the chronology of our craft, time is divided into before and
after Lister." Lister, like Hunter, united in himself the path-
ologist and the surgeon, and, like him, worked on the lines of
experimental pathology.
President's Address. — Francis J. Shepherd (Montreal)
spoke of the Dominion Registration bill, which has been so
ably pushed through, in the face of many obstacles, by Dr. T.
G. Roddick, and expressed the hope that no one province
would decline to act in accord with the almost universal desire
to see the bill finally made law. He entered a protest against
the freedom with which syphilitics are allowed to mingle with
the community at large, often causing the innocent to suffer
more than the guilty. Passing on to the subject of modern
laljoratory teaching, after referring to the large sums of money
that have been spent on the erection and endowment of labora-
tories for the encouragement of research work, he said that
" one danger of this great multiplication of laboratories is that
it induces men to pursue orijginal investigation who have not
the true scientific spirit, ana who are utterly unfit for such
work. They frequently collect and publish a mass of useless
and undigested material and therefrom draw inaccurate con-
clusions. .'Ml this will not redound to the credit of medical
science. Modern laljoratories are all necessary to our medical
schools, but they must not supplant other work quite as
important toa man who wishes to become a practising physician
or surgeon. Again, we must remember that the millennium
will not be brought about by laboratories, nor will all scientific
problems be solved by them. There is one laboratory which is
not so mucli frequented now as when I was a student. I refer
to hospital wards. Stiidents, white perhaps more scientific,
have not tlie intimate personal know-ledge of disease which
continued observation at the bedside gives them, so that when
started in some out-of-the-way place without their scientific
machinery, they are like fish out of water. It may soon be that
they will not be able to diagnose a fracture without the x-rays,
tuberculosis without getting bacilli in the sputum, and so on
without end. Students are not taught to observe so accurately
the evident symptoms of disease, and are becoming mere
moclianics who need an armamentarium, which only a great
hos|)ital or university can possess, to make an accurate diag-
nosis of an ordinary disease; the higher and more intellectual
528 Ambbioan Meoicinei
SOCIETY REPORTS
lOCTOBEB 4, 1902
means of drawing conclusions by inductive reasoning are
almost neglected. Laboratory teaching is essential, but we can
have too much of a good thing, and laboratories nowadays
take up too much of the student's time in the latter years of his
curriculum. The ordinary student should have a good work-
ing knowledge of laboratory methods, and this should be
obtained chiefly during his first two years, but the refinements,
if Insisted upon, will be acquired at the expense of some more
useful and practical information." Dr. Shepherd thought all
doctors should acquire a good working knowledge of all
specialties, but an excess of time should not be devoted to any
one. A year or two of hospital work, followed by some expe-
rience In general practice, should be managed by any one who
wishes to become a broad-minded specialist. At the close of
his most interesting address Dr. Shepherd paid a high tribute
to the late Dr. Wyatt G. Johnston, Dr. Wm. S. Muir, and Dr.
Brunelle, of the Hotel Dieu.
SECOND MEETING.
The address In medicine was delivered by William
OsLER, who chose for his theme Chauvinism in medicine.
Reviewing the noble ancestry, the remarkable solidarity, the
progressive character and the singular beneficence which con-
stitute the four great features of the medical guild. Dr. Osier
commented on that self-satisfied superiority to others which in
one form or other has proved an obstacle to progress to the indi-
vidual and the profession at large. Nationalism in medicine, " a
vice of the blood," rages as oi yore ; there is still extant a cursed
spirit of intolerance tnat makes the mental attitude perennially
antagonistic to everything foreign. As a corrective to this, the
speaker urged that Welt-cultur, that personal knowledge only to
be obtained by travel and by a thorough acquaintance with the
literature and the master minds of other than our native land,
by which may be developed widened sympathies and heightened
ideas which will serve through life as the best protection against
the vice of nationalism. An unpleasant variety of nationalism
Is the subvarlety provincialism or sectionalism which finds its
most serious and undemocratic exhibition in the imposition of
narrow restrictions by Provincial and State boards for the
licensing of practitioners. Osier advocates as a cure for this
vicious state a generous spirit that will give to local laws a
liberal interpretation, that will limit hostility to ignorance and
viciousness, that will have regard for the good of the guild as a
whole as much as for the profession of any province. Consid-
ering the parochial or more personal aspects of Chauvinism, the
speaker referred to the narrow spirit too often displayed in
filling appointments, and especially to the particularly un-
pleasant manifestation of collegiate Chauvinism. The illiberal
spirit exhibited by the general practitioner to himself, his
failure to recognize the need of a lifelong, progressive, personal
training, his indifference to broad generous culture, his ten-
dency to become a mere " practiser of physic," was pointed out
as a constant danger to be avoided. The open mind, the free
spirit of science, the ready acceptance of the best from any
source, the attitude of rational deceptiveness rather than of
antagonism to new ideas, the liberal and friendly relationship
between different nations and different sections of the same
nation, to an enlightened reciprocity, the speaker regarded as
the agents best suited to neutralize the characteristic tendencies
referred to.
The general meeting of the Association then entered into a
discussion on diseases of the gallbladder and bile ducts.
Alexander McPhedran (Toronto) introduced the medical
diasnosis in this discussion. He mentioned the fact that the
gallducts are narrower at their entrance to the bowel than in
other parts of their lumen, and as they lie nearly horizontally
the outflow of bile is easily retarded or obstructed. The ducts
are much exposed to infection from the intestinal tract. Of
the cardinal symptoms in these cases McPhedran considered
jaundice the most common, while pain varies, but is generally
intense. The attendant fever is generally due to toxic absorp-
tion. The main diseases to be considered in differential diag-
nosis are catarrhal and suppurative cholangitis and acute yellow
atrophy. Most catarrhal conditions are infective, but the
chills and fever may occur without pus formation. The most
common germ present is the common colon bacillus. In the
gangrenous cases the symptoms are often ill defined. A most
characteristic sign of gallstone is the recurrence of the attack.
Medical Section.
SECOND SESSION.
Kernig's Sign : the Frequency of Occurrence, Causa-
tion and Clinical Significance.— R. D. Rudolf (Toronto).
This paper will appear in a future number of American Medi-
cine.
Multiple Sarcoma ; Report of a Case.— F. N. Q. Starr
and J. J. Mackenzie (Toronto). MacKenzie read the notes
on the case. No autopsy could be made of the case. The patient
was a seamstress, aged 38. The personal or family history had
no bearing on the case. For a number of years before 1901 the
patient had a goiter which, under treatment, almost disappeared
in the winter of 1901. In April, 1901, a lump about the size of a
pea was noticed slightly to the left of the middle line of the
abdomen near the sympnysis pubis, hard but painless and sub-
cutaneous. In May two or three appeared in the middle line
an inch above the umbilicus ; then two or three were discovered
in the back. In June two others appeared to the right of the
middle line of the abdomen. In July several additional lumps
were discovered in the right breast, in size from a pea to a bean.
Loss of weight occurred. In August the liver was noticed to
be enlarging. Commenced taking arsenic in September. In
October a large tumor appeared in the left breast and a small
one was also noticed in the left thigh. Patient began to sutler
from rheumatic pains. In November and December the tumors
appeared in enormous numbers over the chest and back, abdo-
men, thighs, and arms above elbows, neck and over back, sides
and top of head. In January, 1902, chains of tumors, bean-
sized, were noticed in the cervical region, submaxillary and
suboccipital regions. Bjr March 8 she had thousands of tumors,
most quite hard. ExcLsions were made and microscopic exam-
ination revealed a type of spindle-celled sarcoma, in which the
prevailing cell was very long. As regards treatment, the
patient took arsenic with no influence on the condition. Thy-
roid extract produced slight diminution in the size of the
tumors. Patient died. Without autopsy one cannot say where
the primary seat of the disease was, although from the great
involvement of the liver, that might be the source of the dis-
ease.
Some Points in Cerebral Liocalization. Illustrated by
a Series of Morbid Specimens and Some Living Cases. —
At an early morning session held in the Royal Victoria Hos-
pital, Dr. James Stewart conducted this clinic.
On the Asylum, the Hospital for the Insane, and the
Study of Psychiatry.- Stuart Paton (Baltimore, Md.) advo-
cated hospitals or wards in insane asylums for proper treat-
ment of acute cases. He also pointed out the benefits to be
derived from having medical men to form a consulting staff to
an asylum.
Anesthetic Leprosy.— C. N. Valin (Montreal) presented
two very interesting patients, father and son. According to
him they proved to a certainty the contagiousness of this dis-
ease. From the way they had progressed under treatment
Valin considered the cases hopeful.
Surgical Section.
FIRST sEssiO'S—Coyicliided.
Filariasis in Man Cured by Operation. — A. Primrose
(Toronto). A man from the West Indies, suffering from lymph
scrotum, presented himself for treatment and gave a history of
attacks of fever which suggested the presence of filaria. On
examination of the blood one found the embryos present in
large numbers. The embryo filarias were found in large num-
bers at night, but disappeared from the blood during the day.
An operation was performed and a large portion of the scrotum
removed. The excised tissue was carefully examined by teas-
ing it in salt solution, and a parent worm was discovered and
removed alive. This proved to be a female and it was subse-
quently fixed and mounted in a suitable manner for microscopic
examination. Subsequent to the operation the filaria embryos
entirely disappeared from the blood, and the inference was that
the parent producing the embryos had been removed by
operation. The parent worm was afterward carefully studied
by J. H. Elliott (Toronto), late of the Malaria Expedition to
Nigeria from Liverpool School of Tropical Medicine, and a
report of his investigations with drawings of the worm formed
a part of the paper as communicated by Dr. Elliott.
[ To be concluded.]
AMERICAN ASSOCIATION OF OBSTETRICIANS AND
GYNECOLOGISTS.
Fourteenth Annual Meeting, Held in Washington, D. C,
September i6, 17 and 18, 1902.
[Specially reported for Americn Medicine.]
[Continued from page iSO.]
The Irrational Starvation Treatment of Appendicitis.
— John B. Deaver's (Philadelphia) experience of 98 cases for
the past 2i months had furnished a lesson from which objec-
tions to the rest or starvation treatment were drawn. The par-
ticulars of these cases were detailed. The lessons drawn were
that an early operation, preferably in the stage of appendiceal
colic, was the only rational procedure, and was the only treat-
ment which would reduce the mortality in acute appendicitis
to insignificant figures ; that the socalled rest treatment of
appendicitis failed to check peritoneal inflammation and would,
in the majority of cases, harm the patient. The statistics pre-
sented in the paper bore out the above statements to the letter.
Patients brought to the operating table several days after the
onset of the disease, in whom the starvation treatment had
been carried out and a local abscess or a mass of exudate and
adhesions found, had by no means convinced him that those
patients would not have been better off by early operation. To
attempt to foretell what the intraperitoneal condition was, or
what it would be a few days or weeks later, was assuming a
graver responsibility than was justifiable. Such a prediction
was never made by those whose experience with the disease
would justify such a confidence. He was willing to grant that
operation in the presence of an acutely inflamed general peri-
October 4, 1902]
SOCIETY REPORTS
(American Medicikb 529
tonitis was attended by great risk to life, and, therefore, it was
often wise to defer operation in the hope that the inflammatory
process would become localized. This was often his practice;
but he denied that the starvation plan of treatment promised
more in such cases than the more common practice of abstain-
ing absolutely from giving opium, keeping the bowels freely
open by solid cathartics, or, as some physicians preferred, a
hydragog cathartic, which was both antiseptic and germa-
cidal, giving nourishment by the rectum, when the stomach
was tolerant, and using ice or heat locally in the shape of poul-
tices or hot turpentine stupes.
Joseph Price (Philadelphia) discussed the surgical rela-
tions which the appendix region bore to pelvic suppuration and
operative complications.
Oar Shortcomings : Liet Us Reason Together. The
President's Address. — Edwin Ricketts (Cincinnati, Ohio)
called attention to the growth of the Association, and spoke of
the 1.3 volumes of transactions, also to more than 1,000 pages of
discussions, which stood as the result of 13 years' work toward
erecting a monument that was to be an honor of their unselfish
efforts to true special work. The general practitioner was the
backbone of medicine. It should not be otherwise. With just
and coequal considerate relations the best interests of the physi-
cian and specialist were not to be severed. With changed
relations toward the general practitioner complications were
sure to arise. Abdominal surgery and gynecology in the
hands of all operators was being accompanied with a higher
mortality than was true of that done by special workers.
Reasons were advanced why the physician and all those
engaged in the practice of specialties should enter the political
arena. It would teach them what organization was, what and
how power can be wielded for good. It would result in pro-
nounced efforts for the organization of the medical profession
which in due time was to command respectful consideration
from the National, State and county governments. Such would
make a free and independent profession. The true relationship
of the neurologist as bearing on special work should be bettor
appreciated. The neurologist should be called in consultation
oftener, and he in turn should consult with the gynecic and
abdominal surgeon before sending any of his patients to an
institution for partial or permanent detention. He urged a
national secretary of medicine, and this he believed would put
medicine on its highest and broadest plane. This would mean
dignity, higher regard, influence, and an equitable financial
remuneration.
8ome Cases of Appendicitis and the Lessons They
Teach. — Miles F. Portbk (Fort Wayne, Ind.) reported the
following cases :
Case I.— Chronic appendicitis of 11 years duration. Operation ;
abscess behind the cecum; small stump of appendix attached to the
t _ cecum. Complete relief for 6 months, then return of symptoms which
» were relieved by spontaneous opening of abscess. Beturn of symptoms
? probably due to the distal end of the appendl.x or a fecal concretion left
behind.
Case II.— Simple drainage operation done U months before, fol-
lowed by frequent recurrences of pain, etc., relieved by spontaneous
opening of sinus. Operation revealed a large fecal concretion and dis-
tal end of appendix free In center of abscess. Detached appendices or
fecJil concretions should be searched for In chronic cases and drainage
kept up for some time in case neither Is found.
Cask III —The only tender point was discovered between the blad-
der and rectum by rectal examination, altbough prior to this symp-
toms were typical of appendicitis. Operation revealed a deUiched
necrotic appendix enclosed In adbes nns at this point. Microscope wa.s
necessary to determine the nature of the necrotic tissue.
Case IV. — Emphasized the remote dangers of delay In operating.
First operation consisted of simple drainage of large pus cavity ; two
weeks lat^r a second cavity In the left iliac region was drained ; recov-
ery well esUiblished, when bowel obstruction necessitated a third
operation, and bowel had to be opened to allow replacement In abdo-
men. Five .years later a fourth operation was necessary for bowel ob-
struction Recovery ; good health three years since last operation.
Case V.— Case of appendiceal colic due to seed of unlcnown kind.
Tenderness circumscribed. I'aln and tenderness out of proportion to
the couBtltutional symptoms. Appendicectomy. Complete relief. Ap-
pendix not inflamed, but mucosa injured In several places by sharp
corners of seed.
Cask VI.— Complete occlusion of lumen of appendix. Some adhe-
sions. No sign of present Inllammiitlon; but history of possible pre-
vious attacks. Appendicectomy Incidental to diagnostic celiotomy.
Occlusion probably due to Inflammation, but may have been lack of
development.
Case VII.— Nothing unusual In this case save that the tumor, com-
posed of a mass of omentum enclosing inflamed appendix, was spher-
5 fcal and freely movable. Could be pushed to left of middle line. Dan-
';' ger of mistaking similar ease, If chronic, for tumor. Similar case
thought at first to be one of malignant tumor related to writer by 1)t.
A. J. Ochsner.
Case V'III.— Girl, age U. Three previous attacks. Came (m sud-
■ denly and disappeared in tiie same way. No tenderness after pain had
[ gone. Small tumor exquisitely tender Just above Poupart's llgument.
^ Diagnosis appendicitis. Operation proved case to be one of ovarian
cyst with twisted pedicle and eomnnmelng gangrene.
Case IX.— Cancer of Ileocecal valve mistaken by several, Including
author, for appendicitis. Relative absence of tenderness, as compared
with pain, together with anemia and loss of flesh, which were out of
proportion U> the Inflammatory symptoms, would lead in another case
to a correct diagnosis.
Cask X— Klrsliittack; symptf)m8 mild; appendicectomy. At the
site of the appendix there was a small retention cyst of Inflammatory
origin with a very thick covering.
Cask XI.— First attack ; vomiting; tympany, etc.. denoting severe
and spreading Infection. Openile<l at the end of 48 hours, when first
seen. Appendix perforated and gangrenous ; free muddy fluid lu abdo-
men. Recovery.
What would have been the result of starvation treatment in
this case ? Can any method corral germs already widespread
and pen them up securely within a small space ? Will any
medicinal treatment secure with certainty circumscribed
abscesses in all suppurative eases? Can anyone foretell the
result in a given progressing case with certainty ? He believed
that the case would have ended fatally had operation been
delayed. The sooner a case of appendicitis whicli was growing
progressively worse was operated the better. No man could
tell until lie saw the pathologic changes that had obtained.
Four Cases Illustrating the Dlillculties of Diagnosing
Appendicitis.— William Wotkyns Seymoi'r (Troy, N. Y.).
Case 1 had previously been operated upon for appendicular
abscess. He found a suppurating solid tumor of the ovary.
Temperature at the time of operation was 107° ; pulse 180.
Recovery. Case 2 was a woman with contracted pelvis deliv-
ered of a dead child. Twelve days later there were symptoms
of inflammation in the right iliac fossa, appendicular or tubal,
the result of infection. Operation revealed a suppurating gan-
grenous fibroid of the right anterior uterine wall, which was
enucleated, followed by recovery of the patient. Later he did
cesarean section on this patient; mother and child well seven
weeks after operation. In Case 3 he was summoned to a case
of appendicitis some 14 miles distant in the country. His diag-
nosis was ovarian cyst with twisted pedicle. The mass had
increased twofold since his previous visit to the attendant.
Removal of the cyst was followed by recovery of the patient.
Case 4, woman, single, age about 2B. Pains and intense ten-
derness in appendicular region ; began with joint pains.
Examination of lungs showed bronchial breatliing at left base ;
the next day diffuse bronchial breathing over both lungs.
Appendicular symptoms less marked. Toxemia of some sort ;
no appendicitis.
Intrauterine Fibroids Complicating Pregnancy, and
Retained Placenta Associated with Intrauterine Fibroids
Complicating Pregnancy. — M. A. Tate (Cincinnati, Ohio)
had collected 39 cases from the literature, and reported 2 which
had occurred in his own practice. Analyzing these 41 cases,
the histories of which were not complete, he noted that in 9
cases only were the names of reporters given without any men-
tion of history of the cases. In 6 cases the tumor became gan-
grenous; hemorrhage was a prominent symptom, in that it
•occurred in 18 cases ; 3 polyps were expelled spontaneously ;
7 polyps were removed ; in 3 cases the polyp was not removed ;
in 10 cases the labor was normal ; in 4 cases labor was difflcult ;
in 2 cases the child had to i)e destroyed ; 1 was a case of turning
and the other a breech ; in 4 oases the tumor was discovered
before, in all of the rest after labor ; 4 cases were reported in
which labor set in before time ; 2 were at the fifth and 2 at the
seventh, month. The following were the complications
reported : Septicemia, 8 ; measles, 1 ; puerperal mania, 1 ; re-
tained placenta, 4 cases. Treatment mentioned: Cold applica-
tions, ergot, iodids, whisky, vinegar cloths in the uterus,
packing of uterus with gauze and removal of tumor. Causes
of death : Sepsis, 3 ; hemorrhage, 3 ; peritonitis, 1 ; and collapse,
1, making in all 8 cases. If all of the other cases, including the
9 without histories, recovered, there would be 33 recoveries and
8 deaths, a mortality of 19.5%.
( To be concltided.]
MEDICAL SOCIETY OF THE STATE OF PENNSYL-
VANIA.
Fifty-second Annual Meeting, Held at Allentown, September
i6, 17 and 18, 1902.
[Specially reported for Atnerican Medicine.]
IConcluded from page ino.]
SIXTH 8K8SION.
Infant Feeding was the subject of a paper by Adelaiue
M. Underwood (Lancaster). The writer discussed at length
the care of infants from Ijirth, includitig baths and other points
in addition to wet-nursing and artilicial feeding.
The Home Modification of Milk for Infant Feeding.—
Alfred Hand, Jr. (Philadelphia). This paper will appear
in a future issue of American Medicine..
Address in Surgery.— George D. Nutt (Williamsport)
reviewed the work of the past year. He stated that surgeons,
especially teachers and leaders in that subject, should be
extremely careful in publishing new operations or modifica-
tions of old ones until fully assured of its value by personal
experience. Among the articles during the past year were 260
on appendicitis, a subject that is as unsettled and indefinite as
it was live years ago ; the truth seems to be that every ca.se is a
law unto Itself and personal experience must be the guide.
Worthy of mention are two points : t'irst, the influence of vital
forces in defending the abdominal cavity from invasion, and
second, the unreliai)ility of statistics. In two cla.sses of cases —
light attacks and explosive onset with pus formation— there
should be a mortality of not over 6%. In a third class— general
peritonitis following— the mortality is 40% to SOfc. No Impor-
tant discovery has been made in the last year. Advances have
been in the way of modified technic, preparation of patient,
occlusion of vessels witliout ligatures, the administration of
anesthetics, etc.
530 AuEBiOAN MKDxemns]
SOCIETY KEP0ET8
[October 4, 1902
Carcinoma of the Mammary Gland. — William M.
Rodman (Philadelphia) emphasized the following points:
(1) The anatomy of the lymphatics of the gland, of which there
are five sets ; (2) the Importance of early diagnosis, the age of
the patient being of great significance, 70% occurring in women
past 40 ; (3) prognosis ; the younger tlie patient the more rap-
idly fatal will be the disease ; (4) treatment ; Halsted's opera-
tion is the best yet devised, Warren's method being valuable in
avoiding sliin grafting ; (5) ultimate results. Rodman believes
that 50% should be cured, but as cases come to surgeons, 33% is
all that can be hoped for. Earlier diagnosis is the only hope of
lessening mortality. Every tumor of the l^reast should be
removed early. Examination of frozen sections by a patliolo-
gist is of great value in determining whether to do the radical
operation or remove only the tumor in doubtful cases.
Discussion.— HiiNRY Beates, Jr., (Philadelphia) said that
Dr. Rodman's remarlis about the many sets of lymphatics of
the mammary gland vv'as an argument in favor of a chair of
anatomy as applied to medicine. Not surgical anatomy, not
topographical anatomy, but anatomy" as related to medicine.
This would aid the medical man to interpret symptoms and to
make correct diagnosis and give accurate prognosis.
Empyema, with Special Reference to a Nevr Method of
Drainage.— Leon Brinkman (Philadelphia) described his
method of drainage, which does away with the use of tubing.
After opening the chest wall the pleura is brought up and
stitched to the edge of the skin wound. Convalescence ranges
from three weeks to five months. Brinkman reported 22 cases
operated by this method, 21 recovering. Anesthesia was used
in all — chloroform (which is considered the ideal anesthetic) in
16 of them.
Polypoid Growths in Children vs. Prolapse. — Lewis H.
Adler, Jr., (Philadelphia) finds in his practice nearly twice as
many polypoid growths of the rectum as of prolapse. He
believes that diagnosis is often wrong. Treatment was dis-
cussed, the simplest being to twist the polypus.
The Treatment of Spina Bifida. — William V. Laws
(Philadelphia) reported two cases operated upon by Nicliols'
method. One, a child of 10 weeks, died three days after opera-
tion. The sac contained many nerves. The second case was a
child of 7 months, the sac containing but one nerve. This was
loosened and the .sac ligated and removed. Recovery followed.
Discussion. — Rodman said that difficulty in diagnosis some-
times arose from the fact that a spina bifida was overlaid by a
layer of fat, this giving very much the appearance of a
lipoma.
A Case of Gunshot Wounds of the Stomach, Liver,
Lung and Head ; Operation ; Recovery. — G. W. Wagoner
(Johnstown) reported this interesting case. The man, a
foreigner, had two perforations of the stomach, one of the right
lobe of the liver, and one of the lower lobe of the right lung.
The wound of the head injured the frontal sinus. The stomach
wounds were closed and the bleeding of lung and liver checked
by the liberal use of gauze. No nourishment was given by the
mouth for four days afterward. Aiidominal distention follow-
ing the operation was relieved by epsom salts and alum
enemas. The packing was removed the sixth day, no hemor-
rhage occurring. On the twenty-fourth day the man was
anesthetized and the head wound cleaned. Recovery was
uneventful.
Z)MCM.s«ion.— Laplace (Philadelphia) said that an impor-
tant fact to remember was a patient's susceptibility to infection.
Those who receive great wounds at times recover and slight
wounds sometimes cause death. In some fatal cases the
mechanical principles of surgery may have been carried out
correctly and the surgeon is thus not to blame for the outcome.
The Practical Side of Electrothermic Hemostasis.—
Andrew J. Downes (Philadelphia) said that a man who now
advocated a method requiring a special set of apparatus and a
generating force was apt to be regarded as visionary. But this
method has been successfully used in over 100 cases with very
satisfactory results. The technic of the method was given.
The Rontgen-ray Treatment of Cancer.— C. L. Leon-
ard (Philadelphia) said that this treatment was more successful
than any other, except operation, but should not be employed
instead in operable cases. He reports no cures but a marked
alleviation in all inoperable cases treated. The combination of
operation and the x-ray seems the best method. The x-ray is
both stimulant and alterative to normal tissue and alterative to
tissufts of low vitality. There is a breaking down in lupus and
rodent ulcer before healing. There may be a retrograde meta-
morphosis ending in fatty degeneration. He thinks the rays
are a medium for the transmission of electricity. The reaction
of each individual and of the disease must be carefully studied
to determine time and intensity of exposure. A reaction of the
tissues is not necessary for therapeutic effect.
Report in Cases of Malignant Disease Treated by the
X-ray.— William S. Newcomet (Philadelphia) reported cure
of an epithelioma of the orbit, and great improvement, or appar-
ently cure, in severe inoperable recurrent cases of the breast.
-Oi'scM.ssiora.— Guthrie (Wilkesbarre) said that the popular
idea regarding the curative effects of the x-ray should be curbed
by physicians to prevent patients refusing needed operations.
Shoemaker (Philadelphia) said that one man in each locality
should make a specialty of x-ray work and make himself com-
petent to treat cases referred to him. Thompson (Scranton)
reported four cases of sarcoma treated by the x-ray. In one
three times recurrent enlarged glands disappeared under treat-
ment and a cure is apparently complete. In two cases sarcoma
of the jaw and near the jaw were removed and the x-ray
applied. No recurrence in either case. In one recurrence tlie
x-ray had no effect except to increase the pain. In closing
Leonard said that in one case of recurrent lymphosarcoma of
the neck the x-ray seemed to stimulate the growtli which caused
a rapidly fatal termination. The best results seem to be attained
in simple sarcomas and epitheliomas.
Penetrating W^ound of the Heart, with Unsuccessful
Attempt at Suturing. — J. H. Gibbon (Philadelphia) reported
this case. The patient was a man of 25, who had a stab wound
of the right ventricle below the pulmonary opening. A finger
closed the opening while a cartilage was being resected. A
suture was then passed, partly to close the wound, but mainly
for traction to make the wound accessible for suturing. At this
time the heart ceased to beat and efforts to restore motion were
ineffectual. There was no wound of the pleura, except a slight
one made during operation. Gibbon said it was a question in
these cases as to how much time should be taken in cleansing
the hands and the patient. He took the usual time.
SEVENTH session.
Address in Obstetrics.- J. M. Baldy (Philadelphia) first
discussed the encroachment of the general surgeon upon the
field of the gynecologist. With this he has no sympathy, as
many of them have not grasped the principles of gynecology.
The very fact of their claim that all is known of gynecology
is proof that they are not competent to be trusted with gyne-
cologic oases. Cancer of the uterus was considered at length,
the conclusions being that we do not know what cancer is, we
do not know its cause and we do not know a cure. Operation,
early and complete, is the only relief at present, and this is
very inefficient. Baldy has seen no reason for changing his
statement of 1901, that not more than 5% of cases of cancer of
the cervix are cured. The pathologist is the great hope of the
future. When he tells the nature of cancer some cure will be
devised. At present early diagnosis is the only hope.
Abdominal Extrauterine Pregnancy : Operation at
Full Term and Delivery of a Living Child. — W. L. Estes
(South Bethlehem). This case was reported with exhibition of
the child. He also exhibited a fetus, with membranes intact,
wliich had ruptured a tube and was found free in the abdomi-
nal cavity. The case under discussion was also one of this
variety, both broad ligaments being entirely free. At about the
middle of the left tube was a small depressed scar, from which
the ovum had evidently escaped into the abdominal cavity.
The sac had ruptured before operation. The placenta could not
be removed. Drainage was placed, but the mother died on the
fourteenth day from sepsis. Estes thinks that lumbar drainage
might be advisable in these cases.
Fistula Between the Gallbladder and Stomach. —
A. Barr Snively (Waynesboro) tabulated the cases hitherto
reported and added one, the patient being a woman of 52.
The Incision in Appendicitis, writh Especial Reference
to the McBurney Method and Weir's Additional Modifica-
tion Thereof. — R. H. Gibbons (Scranton) described minutely
this incision and highly commended it. He claims that its
enlargement, if necessary, can be easily and simply made.
Discussion. — Laplace (Philadelphia) said that the first
thing to determine was the presence or absence of an abscess.
If no pus make the incision over the appendix ; if an abscess,
make tlie incision over it. Hernia is a secondary consideration,
the prevention of peritonitis the first. Mordecai Price
(Philadelphia) said tnat it was not a question of the incision,
but of the treatment after the incision was made. When drain-
age is used, as has been necessary in all but 5 or 6 of his 200
cases, there is liability to hernia in any location. Noble
(Philadelphia) said he had never seen hernia follow incision
tiirough the rectus muscle. If it did occur cure would be easier
in that location.
The Danger Point in Appendicitis. — Ernest Laplace
(Philadelphia) said that this was from the very inception of the
disease. It is the most anomalous of all diseases. It is
uncertain (1) from the location of the appendix ; (2) because
abdominal pain need not be referred to the seat of trouble ;
(3) there is no germs in the foul cases that were not present
from the beginning. Their virulence depends upon the sus-
ceptibility of the soil. Operation is the only sure remedy, as a
medical cure is not a permanent cure.
Discussion.— BaIjVY (Philadelphia) said the disease was not
an anomalous one, but was perfectly plain. Waiting is allow-
able in some cases, and numbers are cured without operation.
One can tell absolutely in many cases whether suppuration is
going to follow. The latter statement was refuted by Price,
Noble and Laplace, who deemed such remarks unfortunate
and a very dangerous doctrine.
The Role of the Cystoscope in the Diagnosis and
Treatment of Diseases of the Urinary Tract.- Charles P.
Noble (Philadelphia) exhibited instruments and spoke of
their great value in advancing the knowledge of intravesical
lesions and their treatment. By this means our views regard-
ing inflammation of the bladder have been greatly changed.
In many cases it is confined entirely to the vesical end of a
ureter. The cystoscope is easily used, but little practice being
necessary for its satisfactory employment. To catheterize the
ureters much more skill is required.
OCTOBEK 4, 1902)
CORRESPONDENCE
.AMERICAN Medicine 531
CLINICAL NOTES and CORRESPONDENCE
[CommunlcatlonB are Invited for this Department. The Editor Is
not responsible for the views advanced by any contributor.]
A NEW SUTURE FOR SECURING FIXATION OF THE
KIDNEY.
BY
AUGUSTIN H. GOELET, M.D.,
of New York City.
The medical profession is greatly indebted to Mr. Max
Brodel, of the Johns Hopkins Hospital, for his graphic descrip-
tion of this suture, as published on page 170 of American Medi-
cine for August 2, 1902. The reasons given to prove it better and
more reliable than the transverse suture for sustaining the
kidney in position until it can become fixed are clear and per-
fectly correct. In ensures permanent fixation with the least
possible injury to the kidney structure.
As he stated at the conclusion of his article, I have
been working in the same direction quite independently for the
past two years or more. I first published a description of this
suture, or practically the same thing, in the Medical Record of
.Tune 1, 1901, in an article entitled " The Diagnosis and Surgical
Fig. 1. — Showing details of operation and method of insertlou of the sustaining sutures.
^.kidney. B, fatty capsule. CC, retractors separating margins of lumbar incision.
DI), T forceps drawing out fatty capsule. EE, the first or lower sustaining suture.
FF, second or upper sustaining suture. G, needle carrying end of suture from within
out through the structures of the back at upper angle of the wound.
Treatment of Prolapsed Kidney," giving an illustration,
page 844. I described it again in the Philiidelphia Medical Jour-
nal, October 2(i, 1901, giving a diagrammatic illustration; and
again, with illustration of the operation, in American Medicine,
December 28, 1901, and again in the InlernatiotMl Medical
Magazine, March, 1902.
In all of these different articles I have contended that the
fibrous capsule is the only reliable structure for holding the
suture, and that it is both unwise and unnecessary to penetrate
the kidney structure to any considerable depth. In the article
upon " Technic of Fixation of Prolapsed Kidney" in Am,erican
Medimne of December 28, 1901, appears the following statement :
When the sutures are tied the traction on them is in an
upward direction parallel to tlie fibrous capsule, and not at
right angle to it, as is the case with the transverse suture.
Hence the transverse loop must tear completely through the
fibrous capsule before the lateral insertions give way. There
is very much more resistance in the fibrous capsule to strain
of the suture upon it from without inward than from within
outward.
The transverse loop bears the principal strain, and in one
form of my suture lays exposed on the outside of the fibrous
capsule.
In the article entitled " Nephropexy for Prolapse of the
Kidney," in the International Medical Magazine for March,
1902, is found the following:
Tests made upon the kidney of a dead animal (the sheep,
for instance) with sutures inserted in this manner, show that
they will withstand a great deal more strain before tearing out
than the transverse suture. The chief strain is upon the trans-
verse portion of the loop and this is in a direction parallel to
the fibrous capsule and from without inward instead of at right
angle to it, as is the case with the simple transverse suture.
In the beginning I placed both sustaining sutures in the
lower half of the kidney, but later I placed the lower suture at
about the junction of the middle and lower thirds and the
upper suture about the center of the kidney or midway between
the poles.
The first time I employed this suture was on September 14,
1900, in an operation for fixing the right kidney, at St. Eliza-
beth's Hospital. My second operation in which this suture
was used was October 18, 1900. In all of my subsequent opera-
tions, 110 cases in all, of which in 27 both kidneys were fixed at
the same time, making 137 nephropexies, this suture has been
employed and always witli satisfaction.
There is this difference between the sutvire as I employ it
and as described by Mr. Brodel. I make three insertions under
the fibrous capsule for the lower suture, leaving two bridges of
suture expose<l on the outer surface of the fibrous capsule and
two insertions for the upper suture, leaving one bridge of suture
upon the outer surface of the fibrous capsule ; and the point of
first insertion of the suture and its final exit are
Isome distance apart. (See illustration.) The
suture ends are placed a distance apart on the
surface of the kidney because they are to be
brought out through the structures of the back
and tied upon the skin surface instead of being
tied in the wound. The needle carrying the
suture is small and curved and it is inserted
only beneath the fibrous capsule, care being
taken to avoid penetration of the kidney struc-
ture.
I have repeatedly declared that it is not
necessary to denude the kidney of its fibrous
capsule to secure fixation and that such a pro-
cedure is most unwise. In a demonstration at
the meeting of the American Urologic Associa-
tion at Saratoga in June, I showed that the
suture through the detached fibrous capsule is
most unreliable as compared with the suture
which is the subject of this communication.
Mr. Brodel certainly deserves much credit
for working out the principle upon which the
sustaining power of this suture depends, thus
emphasizing tlie claim that it is the most relia-
ble method of inserting tlie suture for sustaining
the kidney and securing fixation, I am very
glad to have him put the seal of his approval upon it from an
anatomic standpoint. In practice I have found it all that can
be desired.
VACCINATION VS. DISINFECTION.
BY
AZEL AMES, M.D.,
of Wakefleld, Mass.
Late Director of Vaccination, Department of Porto Rico.
To the Editor of American Medicine .—I cannot deny myself
the pleasure of expressing my gratification at tlie very perti-
nent way in which the letter of Dr. Schamberg, of Philadelphia,
calls attention, in your issue of August 2.!, to the recrudescence
of smallpox in Cleveland, Ohio, and to the heresy it uproots.
Nothing could have more signally set the seal of condemna-
tion upon the«worse than foolish (the dangerous and hence
reprehensible) claims made a few months since by the health
officer of that city in belialf of disinfection as the only needed
safeguard against smallpox, than this wliolesale outburst of the
disease now again alert and virile in Cleveland. It is true that
no one of judgment, and experience with both disinfection and
vaccination, ever doubted what must come. Disinfectloa has
its place, and an important one, as all practical men know and
532 AxBBicAK Medicine
COBKESPONDENCE
[October 4, 1902
agree, but no one not imbued with a recklessness unbecoming
a health officer, would ever throw aside the many sure and
certain fruits of a century's experience (e. g., those lately
assured by the results in Porto Rico) and discard the tested and
harmless safeguard vaccination, for the uncertain and often in-
applicable adjunct disinfection.
I followed with deep regret (because with entire certainty
as to the ultimate results) the pyrotechnic announcements and
the unwarranted applause which greeted them, of this great
discovery (?), because there is in the community a percentage
of uninformed, illogical and " viciously unteachable" persons
who are misled by, and derive great pleasure from, anything
subversive of and calumniating vaccination. As well assured
then as now, that their jubilation would have quick and bitter
ending, I felt it to be little less than criminal that any man in
charge of such vital interests of a great city, should dare— espe-
cially upon the exceedingly weak reasons the health officer
assigned — to throw aside the proved reliance of vaccination and
set up in its stead that which could at most protect but briefly
aud locally.
Dr. Schamberg has rightly stated the reasons for the les-
sened prevalence of the disease at the time at which such mighty
results were claimed for formaldehyd. Thousands of vaccina-
tions had done their work, 2,000 victims had sutt'ered by the
disease— a pretty large allowance for such a population as
Cleveland's in the history of any recent outbreak anywhere—
disinfection, isolation, the advent of warmer weather, when
oxygen (itself a very eflfective enemy of the smallpox bacillus)
had a chance to circulate, and with 20 cases only left, after two
years' run of the disease, a new evangel was announced. It has
had a brief day. Out, I say, upon such a travesty upon good
health administration and bounden regard for the victimized
community!
One must rejoice that the absurd and unwarranted heresy
was so soon exploded, however much he deplores the cost to
the good people of the fair city by the lake, who now suffer
thereby.
We are slowly and expensively learning that it will not do
to put any but safe, competent, fearless and alert men in charge
of public health administration.
CASE OF ARSENICAL NECROSIS.
BY
JAMES EDWARD POWER, D.M.D.,
of Providence, R. 1.
Externe Dental Department, Rbode Island Hospital ; Assistant Dental
Burgeon to St. Joseph's Hospital, Providence, E. 1.
Mr. H., aged .35, was among the patients at my clinic at St.
Joseph's Hospital, June 12, 1902.
Examination showed a well-developed necrosis of the
inferior maxilla, extending from one wisdom tooth to the other.
The inside of the mouth was highly inflamed and on the chin,
in the region of the symphysis, was a very tender spot, which
gave the patient considerable pain on being touched lightly
with the finger. His condition was poor, he had lost 22 pounds
since May 14.
He gave the following history : Previous to this time he
had been always healthy and rolnist, his mouth nevergave him
any trouble. All his teeth were present except the two molars
on each side of the inferior maxilla. On the evening of May 8,
1902, he complained of feeling sick— headache and nausea. His
condition remained about the same until Sunday, May 11, 1902,
when he noticed a dull pain in the region of the symphysis aud
extending all along the body of the bone. He thought it was
neuralgia, but the pain developed so during the day that he
took one grain of morphin at night, to subdue it. By this
time it was almost unbearable, causing him to lie awake all
night.
During the following night he took five i gr. tablets, but
pain continued and he was very delirious during this and the
following night. On May 14, 1902. a pliysician was called, who
found the patient's temperature 105°. He diagnosticated neural-
gia and advised application of hot salt and water bags to the
chin. This treatment was continued for eight days, during
which time the skin covering the chin was destroyed by the
heat, and the inflammation on the inside of the mouth was
increased. The physician incised the gum freely but did not
obtain much pus. The patient seemed to be temporarily
relieved while the heat was applied to his face, but on its
removal the pain seemed worse than before. Oh May 15 the
physician changed his diagnosis and .said it was an ulcerated
tooth, and extracted the inferior central incisor tooth. On May
16 the lateral incisor tooth was extracted. May 20 he advised
a mouth-wash, and on May 22 patient requested him to dis-
continue his calls, as he seemed to be no better than he was on
May 14.
On May 23 the patient visited an emergency hospital. His
temperature was 102°. The resident physician said he did not
know what was the trouble but advised the application of a
hot flaxseed poultice. After five days an abscess appeared and
was lanced. The patient continued to syringe the mouth until
about the first week in June, when he was referred to a dentist
for advice. The dentist refused to extract the tooth, saying
there was no cavity in it. About a week later he visited
another dentist who extracted this tooth, and later extracted
three more.
On June 11, 1902, he was told l^ the physician who was
attending him to visit St. Joseph's Hospital.
I advised immediate operation and on Saturday morning,
June 14, I proceeded to operate under ether, first extracting the
remaining teeth, two bicuspids on the right side and one bicus-
pid on the left, leaving the two last molars. Although the area
affected was confined to the body of the bone previously occu-
pied by the six anterior teeth, I deemed it advisable to make an
incision along the body of the bone (inside) from one wisdom
tooth to the other. With spoon-shaped curets I scraped all the
dead bone away and then cut away all sharp or jagged edges
with bone cutters.
I prescribed a mouth-wash and did not see the patient again
until 10.30 p.m., when I found him quite comfortable. The
following day his temperature was normal. I visited him
every day until July 20, when he was discharged cured.
An interesting point connected with this case was that
although the tissue posterior to the bicuspid teeth seemed
normal, the bone in this region was affected very extensively.
When I first saw the patient I was somewhat puzzled as to the
cause, and the special kind of necrosis with which he was
afflicted. When questioned he said he had never visited a
dentist, had received no recent injury to the part, had never
held matches in his mouth, and h,ad never had syphilis. His
family history was good, there was no tuberculosis. When
his chest was examined at this time for tuberculosis his lungs
were in excellent condition.
This information removed from the list of probable causes :
Necrosis from broken bone ; necrosis from arsenic used by den-
tists; syphilitic necrosis; phosphorus necrosis; tuberculous
necrosis.
Finally I asked him what he used to cleanse his teeth,
thinking that he may have liecome infected from the use of
cheap dentifrices sold by "fakirs," which, when applied,
" change black teeth to white instantaneously." He replied
that he never used anything except pieces of yarn, using this
to remove particles of food which became lodged between the
teeth. Closer investigation showed that he used yarn of all
shades, especially green and red. I then concluded that he had
become infected from the arsenic used in dyeing the yarn, and
requested him to bring some of the yarn to me. I examined it
and found that it contained arsenic, thus removing all doubt
as to the kind of necrosis with which my patient was affected.
The patient is now entirely cured and is wearing artificial
teeth and a plate to restore the contour of the face. With all
due respect to the practitioners who first treated this patient, is
it unreasonable to feel that this poor man had been done an
injustice, knowing the destruction this disease will cause in 24
or 48 hours, and considering that it was allowed to progress for
35 days without operation, and nothing to check its progress
but applications of hot flaxseed poultices and salt bags?
THE FREE LECTURE MOVEMENT.
To the Editor of American 3/erfiCi(ie.— Heartily endorsing
the free lecture movement, and especially Dr. C. D. Spivak's
remarks, I wish to call attention to the need, in addition to
physiology and hygiene, of lectures on that part of medical
ethics treating of the relations between the physician and his
patients and the community at largo. There is no better way
of wiping out quackery than lectures, popular lectures, on
medical ethics, which would have a morally elevating influence
generally, but more especially would enable the public to
differentiate the lionorable physician and his principles from
the dishonest charlatan, whether traveling or local, and the
dangers of self-medication and patent medicines.
RoUa, North Dakota. Thor Moellkr, M.D.
OCTOBER 4, 1902]
WHITE BLOOD-CORPUSCLES
tAsiEBiCAN Medicine 533
ORIGINAL ARTICLES
THE PATHOLOGIC RELATIONS OF THE WHITE
BLOOD-CORPUSCLES; A CASE OF HODGKIN'S
DISEASE OF TUBERCULOUS ORIGIN ; A CASE
OF LYMPHATIC LEUKEMIA *
BY
O. T. OSBORNE, M.A., M.D.,
of New Haven, Conn.
Professor of Materia Medlca and Therapeutics at Yale University.
It seems to me that this subject is of such intense
interest to us all that it would be well to consider just
how far we have progressed in understanding the white
blood-corpuscle and its role in health and disease.
Under the microscope we find various types of white
corpuscles, but physiologists are not yet ready to tell us
just what the functions of these varying shaped corpus-
cles are. The simplest microscopic classification gives
us first the lymphocytes, which are small corpuscles
with a round vesicular nucleus, seanty cellular substance,
and which are not capable of ameboid movements.
Second, the mononuclear leukocytes, which have large
corpuscles with vesicular nuclei and abundant cyto-
plasm, and a certain amount of ameboid movement.
The third class is the polymorphonuclear cells, which are
large corpuscles with their nuclei divided into lobes,
which are separated or connected by fine threads.
These leukocytes have very active ameboid movements.
This is Howell's classification, and we are not yet ready
for clinical purposes to subdivide the cells into the vary-
ing staining properties of the granules of the cytoplasm.
To trace the history of these white cells we find that
they are formed in the mesoderm of the embryo as are
also the lymphatic glands, which glands Ziegler says
retain their embryonic character and produce through-
out life the lymphocytes of the blood. It is a subject
that has not yet been settled by the physiologists as to
whether this lymphocyte is or is not the embryo of the
polynuclear leukocyte. These lymphocytes certainly
arise from the leukoblastic cells in the lymphoid tissue,
perhaps also some are formed in the splenic pulp and in
the red bone-marrow.
Moore' thinks that these lymphocytes are simply
the early stages of the polynuclear leukocytes, which
seem to be the highest form of development. This
lymphocyte is incapable of ameboid movement as above
stated, though H. Hirschfeld claims to have found some
ameboid movement in a patient suffering from lym-
phatic leukemia.
The next stage is the large mononuclear cell which has
some ainel)oid movement. Then the nucleus grows
irregular in shape, and later divides and we have the
multinuclear leukocyte, capable of active ameboid move-
ments, which cells are capable of passing through the
capillary walls into the surrounding tissue and wander-
ing about, and hence are termed wandering cells.
Warthin," in studying the lymph glands along
the anterior border of the spine, divides these into
" spleno-lymph glands" and "marrow-lymph glands,"
the former having some of the histologic arrangement
of tlie spleen and the latter composed of lymphoid cells
not grouped as follicles. He says the spleno-lymph
glands show some evidences that they form leukocytes,
while the marrow-lymph glands show multinucleated
cells and occasionally giant cells of the bone-marrow
type. He thinks tliat in grave diseases these glands
may take on the work of the spleen and bone-marrow.
Aloore suggests that the leukocytes may be produced
by diff"use adenoid tissue anywhere, especially in the
tonsils, in Pcyer's patches, and in the solitary follicles in
the Intestine. Certain it is that too much lymphoid
•Dissertation at the annual meeting of the Connecticut Medical
Society, held In New Haven, June, 1902.
tissue, as the socalled adenoids in the nasopharynx,
do produce something that is inimical to the health of
the individual. If careful blood-counts and urinary
examinations were made for the output of phosphorus,
and uric acid we might find some reason besides the
simple obstruction for the debility of children with
adenoids.
Rubinstein ' believes that the bone-marrow is the only
part of the body that produces the leukocytes of the
blood as distinct from the lymphocytes. He describes the
gradual development in the bone-marrow from the
lymphoid cell to the full grown polynuclear leukocyte.
Josue * also believes that the bone-marrow plays an
important role in the production of white blood-corpus-
cles, especially in the infections. He also has demon-
strated all varieties of leukocytes in the marrow, and
his exi)eriments show the power of the staphylococcus to
start the activity of the bone-marrow in producing fully
developed leukocytes. He thinks that the microorgan-
isms act directly upon the marrow after reaching it
through the blood.
Physiologically the leukocytes are increased in num-
ber after digestion, pregnancy and hemorrhages, and
pathologically in leukemia and suppurative diseases.
They are diminished in old age and in starvation.
Proportionately the young babe has more leukocytes
than the adult,' and there are always more leukocytes in
the capillaries and veins of the abdominal organs than
in the vessels of the skin or muscles. Incidentally it
may be noted that the pus cells are ordinarily dead
leukocytes which have undergone fatty degeneration.
If the lymphocytes of the blood are not the young
leukocytes, it is possible that they have something to do
with the absorption of fats from the intestines, or pos-
sibly, as they multiply in the blood by karyokinesis,
they also break up in the blood and may add something
to the plasma. Whether the leukocytes, i. e., the
polynuclear or highest form of white corpuscles, dis-
integrate in the blood or in the spleen, whenever such
disintegration is in exceas we have the uric acid output
increased, as uric acid has been proved to originate
principally from nuclein disintegration such as follows
the breaking up of these cells, the metabolism being
absolutely distinct from that type of proteid metabolism
which results in urea as an end-product.
With the uric acid increase phosphorus, a normal
constituent of nuclein, is also increased in the urine.
This increased output of phosphorus and uric acid or
other alloxuric bodies (purin bases) is markedly shown
in the splenomedullary form of leukemia, but not in the
lymphatic form. Theoretically, then, when there is a
leukocytosis we would expect an increased elimination
of uric acid and phosphorus. Some of these leukocytes
undoubtedly break up in the blood, others are probably
destroyed in the spleen, and there are probably other
parts of the body where they are destroyed.
Hannes^ has recently shown that profu.se sweating
causes a marked increase in the number of leukocytes.
In examining a large number of children with various
conditions he noted that in all instances in which there
was a deficiency of white corpuscles there was marked
rickets present.
Whatever may be the function of the lymphocytes,
we know something pathologically or physiologically of
the function of the polynuclear leukocytes, or the full
grown leukocytes. They have proved to be active agents
in the absorption of waste and noxious substances (Stas-
sano"). The duties of these full grown leukocytes is not
only to break up and furnish some proteid material to the
blood, but to protect the blood and system against patho-
genic bacteria. If an infection of bacteria is not severe
enough, or intense enough, or malignant enough to
cause the immediate death of the individual perhaps by
breaking up the red blood-corpuscles and causing acute
anemia, or if it is not intense enough to attack the
ti&sues and cause a necrosis, the multinucleated white
534 AJIBBtCAN MEDICINBj
WHITE BLOOD-CORPUSCLES
(October 4, 1902
blood-corpuscles proliferate and become active phago-
cytes. Whether it is the bacteria themselves or their
toxins that stimulate the production of more leukocytes,
is not known, but that these cells eat up and swallow
pathogenic bacteria is now generally accepted, and that
they furnish an antitoxic secretion, or furnish it by their
disintegration in the blood, is probable.
Dr. Mallory,' of Boston, says that these leukocytes
produced by bacterial irritation or toxin irritation are
" phagocytic beyond all bounds of necessity and destroy
great numbers of useful cells." This might possibly
account for the condition in which leukocytosis is nor-
mally present and desired and normally curative, and
yet the patient dies of exhaustion and anemia.
The term leukocytosis, now used so frequently, means
an increased number of white blood-corpuscles which
are not permanent, as distinct from a permanent increase
or leukemia. In this condition of socalled normal leu-
kocytosis there is no diminution in the number of red
corpuscles, and the increased number of leukocytes is
probably limited to the multinuclear variety. Besides
the normal physiologic leukocytosis mentioned above,
any infection embodying irritation and stimulation of
the lymph glands, and probably the bone-marrow,
causes an increased number of polynuclear white cor-
puscles to appear in the blood stream, i. e., a pathologic,
or better protective, leukocytosis. We can cause this
leukocytosis by giving substances which probably stim-
ulate these glands and the bone-marrow. This is true of
any nuclein preparation as simple nuclein or testicular
extract or thymus gland substance, and perhaps some of
the preparations of phosphorus, especially the glycerin
compounds.
In simple localized inflammation in which the lymph
glands are not involved we do not have leukocytosis
until pus is formed. Hence in suspected concealed pus
formations it becomes a matter of diagnostic importance
to ascertain whether or not there is a leukocytosis, which
if present to the amount of 1.5,000 or more is almost a
positive proof of pus. Other things being equal up to a
certain limit, the greater the amount of leukocytosis in
bacterial diseases the better the prognosis. However,
in pneumonia, for instance, the mere degree of leukocy-
tosis does not indicate directly the severity of the dis-
ease though ordinarily a high degree of leukocytosis,
15,000 or more, is seen in both severe and mild cases,
while a very slight leukocytosis is a bad prognostic sign
in diseases that normally cause this condition.
Becker* in his examinations says he considers the
eosinophiles, or the leukocytes that stain with eosin, to
be absent in all fatal cases of pneumonia ; hence he
considers their absence from the blood examination as a
bad sign.
Helm ' says that the eosinophiles are absent in croupous
pneumonia. He also says that these cells are present in
meningitis, pleurisy, and tuberculous pneumonia, hence
the diagnosis can thus be made in a doubtful case. As
to diphtheria, which is a disease with a large amount of
leukocytosis, Heim says that these leukocytes increase
rapidly even before the membrane appears and then
they gradually decrease, unless complications exist.
Antitoxin injections decrease this leukocytosis though
it rises again later. If the leukocytes do not decrease
after antitoxin has been given, not enough serum has
been used.
Besides these diseases just mentioned (diphtheria
and pneumonia), we have leukocytosis normally in
those infections that have associated glandular swell-
ings, as erysipelas, scarlet fever and septicemia. We
find some leukocytosis in general infections, as rheu-
matic fever and occasionally in typhoid fever, but in
acute and chronic tuberculosis, leukocytosis does not
occur unless there are some shut up pus formations.
Cerebrospinal meningitis and even cancer also give
leukocytosis, and this condition also occurs immediately
after the bites of venomous snakes.
So much for what we may term normal and protect-
ive leukocytosis. If the white cells without a[)parent
cause or reason rapidly multiply and continue to multi-
ply, we have the pathologic condition we term leu-
kemia. The condition called leukemia may be defined
as a permanent increase of the white blood-corpuscles
with some diminution of the red cells, associated with
an enlargement of the spleen, splenic leukemia, or an
enlargement of the lymph glands, lymphatic leukemia,
or both. I'athologic changes are also found in the
medulla of the bones, this most frequently with the
splenic form, giving what is called the splenomedullary
leukemia. The lymphatic tissue in the various organs
of the body may also be found increased.
Pathologic findings have not as yet shown us the
cause of this disease, and as we do not thoroughly
understand the physiology of the white corpuscles we
have gained no help from this source. Of the gross
etiology we may say that leukemia is more common in
males than in females, and occurs most freriuently
between the ages of 20 and 50 years. The alkalinity of
the blood in this disease is diminished and the specific
gravity is lowered, while the fibrin is increased (Osier '").
The enlarged spleen seems to be a simple case of
hypertrophy, a hyperplasia, and the same hyperplastic
condition of the bone-marrow is found. In the lym-
phatic form of the disease all of the lymphatic glands of
the body may be enlarged, as the cervical, the axillary,
the mediastinal, the mesenteric and the inguinal, as
well as the glands which cannot be demonstrated during
life. These glands perhaps rarely amalgamate and are
almost always movable. The liver is often found
enlarged, as are the tonsils.
Examination of the blood in these two forms of
leukemia is decidedly distinctive. In the splenomyelo-
genous form there is always a progressive anemia or
disintegration of the red blood-cells and the leukocytosis
is of the large polynuclear cells, while in the lymphatic
leukemia there is less marked anemia or red cell degen-
eration and an increased number of small white cells,
the lymphocytes.
In pseudoleukemia, the socalled Hodgkin's disease or
lymphadenoma, in which there may be enlarged glands
of the body, not only of the cervical glands, but of other
groups, these glands tending to amalgamate, examina-
tion of the blood may show no change from normal, or
if there are changes they are slight. Acute leukemia,
in which the lymphatic glands are the parts involved,
is a rare and fatal disease.
The symptomatology of chronic leukemia of either
form is that of the enlargement of the parts affected, of
the spleen or glands and perhaps liver, and the pressure
which these enlarged organs may exert with the symp-
toms of debility due to anemia and a tendency to hemor-
rhages. There may or may not be increased tempera-
ture.
In 1845 Virchow" first described the condition of
increased white corpuscles and gave it the name of
leukemia, or white blood. He described the two forms,
the splenic and the lymphatic form, but not until 1869
was the disturbance in the bone-marrow noted, and was
then described by Neumann." From that time to
this it has not been decided what is the cause of the
disease leukemia. Lately, when we are so much inter-
ested in the study of infection, this disease, which seems
to be a continuous and constant stimulation of the glands
or organs that form white corpuscles, has given rise to
the belief that this stimulation was an infection.
In splenomyelogenous leukemia we find a large
number of myelocytes or the large mononuclear leuko-
cytes as well as an increase in the polynuclear leukocytes.
These mononuclear leukocytes or myelocytes are not
often found in normal blood, though they may occur in
certain diseases, as diphtheria and pneumonia. These
cells are found only in the bone-marrow, and some
physiologists, as before stated, regard them as the pro-
OcrroBEE 4, 1902]
WHITE BLOOD-CORPUSCLES
[Ahericak Medicinb 635
genitors of the polynuclear cells. The blood also con-
tains nucleated retl blood cells in considerable number,
but not as many as are found in pernicious anemia.
Now as to the etiology of these blood changes out-
side of an infective germ which we have not yet found.
A chronically enlarged spleen has been thought to be
the etiologic cause in some cases. We can have an
enlarged spleen and anemia without evident glandular
enlargements or bone-marrow disturbance to wliich the
name of splenic anemia has been given. The blood in
this condition does not show leukemic changes. We
also have, mostly in young adults, the pseudoleukemia
or Hodgkin's disease, or lyniphadenoma as before
named, with the primary enlargements almost 'invaria-
bly in the glands of the neck. The question has lately
arisen as to whether or not these cases are not in their
incipiency, tuberculous adenitis. A number of these
cases have been known to finally develop a general
tuberculosis or a pulmonary tuberculosis and before such
appearance of tuberculosis have shown more or less
increased temperature. Even cases of splenomyelogen-
ous leukemia often terminate fatally, probably a mere
coincidence, from tuberculosis.
Let me relate a case of what was diagnosed as lymph-
adenoma, the patient later developing a pulmonary
tuberculosis which caused death.
An undeveloped, ill-nourished, and undersized girl, aged
15, first came to my clinic in .July, 1900. She had ga.stric indi-
gestion, a slight cough, said she was dizzy, and had enlarged
masses of glands in both sides of the neck and in the right
axilla. The duration of the enlargement of these glands was
stated as four months. The rest of the family were said to be
healthy and with no tuberculous taint, although later a young
sister of tlie patient was found to have tuberculous glands.
The lungs were carefully examined and no localized trouble
found. The tonsils were not enlarged, neither was the spleen,
but the liver seemed to be larger than normal. Examination of
the blood showed some anemia and 11,500 leukocytes, the
increase being almost entirely of the polynuclear cells. There
were very few eosinophiles present, and no nucleated red
blood-corpuscles. Though tuberculous adenitis was suggested,
it seemed to be a case of Hodgkin's disease.
Under treatment of iron and tonics she improved, but
Fowler's solution, which had been given for a considerable
time, was stopped. I believed it did her harm as itcaused con-
8ideral>le diarrhea. In March of 1901 she began to have an
increase of temperature, with a, rapid pulse, and soon lost
weight. From this time she was not seen until November,
1901. There was then marked tuberculous infiltration of both
lungs, and facial nerve paralysis of the left side, due to the
pressure of the enlarged glands. The sputum showed large
numljers of tubercle bacilli, and the blood gave 3,740,000 red
corpuscles, 50% hemoglobin, and 10,3.13 white cells, a decrease
of nearly 1,200 leukocytes as compared with the examination 17
months before. The patient died in January, 1902.
This was, then, a case in which tuberculosis was
undoubtedly at the bottom of the general appearance
and manifestations of Hodgkin's disea.se.
As far as the temjjerature is concerned it has been
repeatedly noted that an intermittent fever can occur in
pseudoleukemia. Also a moderate leukocytosis, as
was present in this case, often occurs in pseudoleukemia.
Sternberg'-' and Musser" both believe that the
adenitis of Hodgkin's disease is a tul)erculous process,
and the above case most certainly l^ears out tliat con-
clusion. On the other hand, many good authorities
l>elieve that this disease is allied to the malignant condi-
tion of lymphosarcoma, and that lymphadeiioma or
HfKlgkin's disease is due to some infective cause, although
the germ is not yet discovered. In a recent discussion
in England on this subject it was coDsidere<l that tuber-
culosis was an incident and not a cause of lyniphade-
noma, although many cases of reported Hodgkin's dis-
ease were really tuberculous adenitis. The subject Is,
therefore, still open to proof.
Wende," of Buffalo, has reported a case of lymi)hatic
leukemia apparently developing out of Hodgkin's dis-
ease. This man was given hypodermic injections of
Fowler's solution for weeks and months. At first the
examination of the blood showed the number of white
corpum-les to be subnormal, viz., only 4,000 to the cubic
millimeter. This arsenic treatment * did what I believe
it can do, and in five months the red blood-corpuscles
had gone from normal, over -5,000,000 to the cubic
millimeter, down to less than 2,000,000, and the whites
had increased to 34,000, mostly lymphocytes. This
man's blood gradually went from bad to worse so far as
the red blood-corpuscles were concerned, and he finally
died of an acute streptococcus infection. Before death
not only the red corpuscles were reduced to less than
1,000,000, but the whites had reduced to 600. The final
destruction of the white cells from 45,000 down to 600. by
the streptococcus infection is interesting, and the disap-
pearan e of the swollen glands stated in this case is
somewhat similar to the results which Coley gets with
streptococcus injections for sarcomas. During the last
few days of this patient's life when the white corpuscles
were disappearing there was a great increase of uric acid.
Rosenfeld" has also rejiorted a case in which the
treatment of lymphatic leukemia with arsenic caused
an evident decrease in the size of the lymph glands,
but a marked increase in the number of circulating
lymphocytes.
My primary object in taking up this subject is that
during this year I have had under observation a very
interesting case of lymphatic leukemia. It has been of
much more than ordinary interest on account of the
tractability of the patient and the opportunity of making
continuous and repeated careful blood examinations
under varying treatment conjointly with the scientific
examinations of the urine, and many times feces, made
by Dr. Yandell Henderson, our associate in physiology,
without whose help this case would not be complete.
The blood examinations were c^arefully supervised by
Professor Charles J. Bartlett, and I am greatly indebted
to him for his skilled help in the case. I am also greatly
indebted to Mr. G. H. Edwards and to Mr. V. A.
Kowalewski, both of the senior class at the Yale Medical
School, for their able assistance.
The patient to whom I refer is a man, aged 64, who was born
in Scotland, and whose occupation is that of a stone cutter. He
was referred to my clinic on July 15, 1901, and came for treat-
ment on account of a gradually increasing swelling of the
glands of the neck, the enlargement having been first noticed
1() months before. He had never before had any glandular
swellings, and had never been sick except from pneumonia six
years ago. There is no specific or tubercular history, and the
family history is negative. His tongue was coate<l, he had a
poor appetite, and complained of insomnia.
Examination showed most of the glands of the neck to be
enlarged and amalgamated, giving the appearance of Hodgkin's
disease. The axillary glands were enlarged and amalgamated
into masses, as were also the inguinal glands. Physical exami-
nation showed that the mediastmal glands were enlarged, and
a number of enlarged mesenteric glands could be distinctly pal-
pated.
The spleen was enlarged, though not markedly so, and was
harder than normal. The liver and tonsils were enlarged.
Examination of the blood showed 4,S)(>8,(XK) erytlirocytes, hemo-
globin tiSfo, and white corpuscles l(i3,000. This increase In the
white corpuscles was almost entirely of the lymphocytes, 98%,
t. e., of the white cells which are formed in the lymphatic
glands and are the youngest white corpuscles in the blood.
There were no nucleate<l red cells.
He was first given general tonic treatment, but on August
15 was put upon Fowler's solution with gradually increasing
doses. From the time of my first observation until September
25 I had not seen him ; his general condition was poor ; he was
losing strength and was very weak. Examination at this time
showed tliat the spleen was reduced in size, the enlargeil glands
had softened and there was less tendency to ainargamation.
The skin of the abdomen showed marked browning, the pig-
mentations being similar to that seen in Addison's disease.
Examination of the blood showed the red corpuscles were re-
duced to 2,719,000, with hemoglobin 00%, while the white cor-
puscles had increased to 173,000, consisting almost entirely of
lymphocytes. From the arsenic, tlien, in this case we got pig-
mentation, destruction of red corpuscles, and diminishing of
the size of all the enlarged glands, but In spite of this an in-
crease of the white corpuscles. Therefore arsenic did him harm.
The patient was now put upon tincture of iron and Armour's
red bone-marrow, and in three weeks the red corpuscles had
increased to 3,272,000, and the white corpuscles had decreased to
i34,<>90. By November under this same treatment the red blood-
corpuscles had increased to 3,9.31,1)80, tlie whites had agalu
• Bee also Uerter'g Lectures on (Jheiulo PatholOKy, p. 'M.
686 Akkbioan Medicinkj
WHITE BLOOD-CORPUSCLES
[OCTOBEK 4, 1902
Increased to 193,200, with the hemoglobin at 53%, and a very few
eosinophiles were found. The man had grown strong, his
appetite was good, and he was again able to do some worli,
while the glands were again enlarged and harder.
Daring this period the urine was carefully studied, all the
nrine for 24 hours being saved, and it was found that in spite
of this enormous number of white cells there was no increase
in the uric acid and phosphorus. This shows, as we know uric
acid to be due to nuclear breakdown, that these white cells,
though enormous in number, do not rapidly disintegrate.
On November 4, directly after the above blood count, the
red bone-marrow was stopped though the iron was continued,
and he was given five drops of Fowler's solution three times a
day. In five days he was complaining of dizziness and breath-
lessness, so much so that the Fowler's solution was immedi-
ately stopped, and on November 9 he warf again given bone-
marrow. The blood count at
this time showed that the red
corpuscles bad dropped to
3,296,000, a loss of more than
600,000 corpuscles. The white
corpuscles had increaseil to
203,900, and the hemoglobin
was 5.5%. The white corpuscles
were constantly founcf to be
chierty lymphocytes, there
being very few polynuclear
cells. This positively shows
what arsenic will do and can
do in these cases.
From this date, November
9, until November 18 the pa-
tient used red bone-marrow
with continued increase in
strength, though for two
weeks or more after the ar-
senic treatment the glands
showed considerable soften-
ing. He was later put upon
sodium bicarbonate, 1 gram
three times a day, for about a
week with the result of caus-
ing an enormous increase of
uric acid and phosphorus out^
put in the urine. Under this
alkali he became very weak,
the glands grew softer, and
the spleen reduced in size, but
the liver remained decidedly
enlarged. He now developed
a bad cough, and there was
considerable bronchitis with
expectoration of a peculiar
tenacious mucus and pus.
This was examined and no
tubercle bacilli found. Exam-
ination showed the lower and
middle lobes of the right lung
apparently somewhat consoli-
dated, the expiratory murmur
was somewhat prolonged, the
voice transmission was exag-
gerated, and some creaks were
heard. The condition was not
pneumonic and not pleuritic,
and repeated examinations
showed no tubercle bacilli in
the sputum. The question
arose as to some growth in
the lungs, but the symptoms
and signs were probably due
to the breaking down of some
of the enlarged bronchial
glands and their discharge
into the bronchi. Of course
this is an unproved surmise.
He soon became so weak that
he could hardly move, this fol-
lowing the sodium bicarbonate
treatment. The blood count
directly after this period
showed the erythrocvtes had
been reduced to 2,840,000, the
hemoglobin was 53%, and the
white corpuscles had in-
creased to 380,000 and were
practically entirely lympho-
cytes. Thealkaline treatment,
then, caused a softening of the
glands, an enormous output
of phosphorus and uric acid
-,. . „ ^ ^ ^. , „ . ... J, . and a breakdown of red blood-
Fig. 2.— Number of leukocytes, corresponding to red blood cells shown by Fig. 1. Column IK corresponds to pr>miisn1ps pvph morp than
column 1 In Fig. 1, and thereafter seriatim, until column 34 represents column 17 of Fig. 1. Column iX, jY^Hi!, ""',:„
10,000; column 19, 16S,000: column 20. 17.5,000; column 21, 134,690; column 22, 193,200; column 23, 203.900; col- 1"" \0'^ arsenic,
umn 24, 380,000; column 25, 2o<i,600; column 26, 3f 0,000; column 27, 292,000; column 28, 238,000 ; column 29, About UeceniDer SI ne was
68,000; column 30. 120,000; column 31, li'0,000; column 32, 135,000; column 33. 170,000; column 34, 236,000. The put upon the tincture of iron
uric acid curve begins at normal, .04 of a gram, and does not vary much from normal, except during the m a citric acid solution and
bicarbonate of soda period. red bone-marrow, from which
EXPLANATION OP PLATE. time he again greatly im-
The upper half of the plate shows the red blood counts under different treatments, the scale being 1° to proved, had less cough, less
each 420,000 corpuscles. The lower half of the plate shows the white blood counts under the same treatments, expectoration, and the glands
each column being directly under its corresponding red blood count. The scale is 1° to each 40,000 leukocytes. ■- - • ' ' ■
Fig. 1— Column 1, scale, 5,000,000 red blood cells per cubic millimeter; I"=420,C00 erythrocytes. Column 2,
before treatment, 4,968,000. Column 3, six weeks of arsenic, 2,719.000. Column 4, Iron and bone marrow,
3,272,000. Column 5, Iron and bone marrow, 3,931,000. Column 6, Ave days of arsenic, 3,296,000. Column 7,
one week of soda bicarbonate, 2,840,000. Column 8, one month of iron and bone marrow. 3,662,700. Column
9, iron and bone marrow continued, 4,060,000. Column 10, four days of nuclelnic acid, 4,400,000. Column 11,
additional week of nuclelnic acid, 3,112,000. Column 12, after chill without quinin, 3,616,000. Column 13,
day of Intcrmlltency, quinin begun. Column 14, after second chill. Column 15, day of intermittency.
Column 16, day of expected chill. Column 17, Iron and bone marrow, 2,800,000. The hemoglobin line rep-
resents the percentage found at the various readings, 11 beginning with 100;t,
The hemoglobin plotted line through the red blood counts shows the red cells to have nearly their comple-
'obln until the malarial period. In the middle '" " >-* ■ - ■■ - ..._., . u
rate of excretion which starts at normal 0.4 gram in 24 hours.
ment of hemoglob
ntil the malarial period. In the middle of the plate Is a line representing the uric acid
m In 24 hours. This line hardly varies from normal during
these weeks of varying numbers of white cells, except during the sodium bicarbonate period.
all became hard and larger,
and his strength increased.
The blood count on January
7 show^ed that the erythro-
OCTOBER 4, 1902]
WHITE BLOOD-CORPUSCLES
(Amebican Medicine 537
cytes had increased to 3,662,706, hemoglobin 60 fc, and the white
cells had decreased to 256,666.
On February 15, the same treatment having been persisted
in, the blood count showed the red corpuscles to have reached
4,060,000, the hemoglobin was 63%, the white corpuscles had
increased to 380,000, and almost no polynuclear leukocytes
were found. On February 24 we stopped the bone-marrow and
gave him nucleic acid, 20 cgm. four times a day, on the theory
that as this acid normally causes an increase of the polynuclear
cells it should increase largely such cells in this case, if the
lymphocytes are their origin.
In four days, March 1, the blood was examined, and it was
found to contain 4,400,000 red corpuscles, 63% hemoglobin and
292,000 white cells, nearly all of the lymphocyte variety. Hence
the polynuclear cells were not increased, and we have strong
evidence that the leukocytes do not come from lymphocytes,
but from the bone-marrow. The latter being diseased in this
case, nucleic acid did not cause its normal leukocytosis. We
then doubled the dose of nucleic acid for four more days, and
the blood count a few days later showed the red corpuscles
reduced to 3,112,000, hemoglobin So^'c and the white corpuscles
still reducing to 238,000. The man was again very weak, the
glands were softer, he was coughing, and had developed a very
bad edema of the legs. This showed that the specific gravity or
constitution of the blood plasma had changed for the worse.
Repeated examinations of the urine had never showed albumin.
He was again put upon the bone-marrow and given some digi-
talis, anj the iron, which he had never ceased to take since
early fall, continued. In ten days the edema had disappeared,
and the general condition improved.
On the evening of April 14 the patient had a very severe
chill, with which there were convulsive movements, followed
by a half comatose condition which lasted some hours. The
i next day, April 15, malarial parasites were found in the blood
and the white corpuscles were reduced to 68,000. The red blood
count at this time, which in the interim since the last examina-
tion must have increased in number, were now 3,616,000, with the
hemoglobin 55%. On the next day, April 16, although quinin
had been commenced in large doses, malarial parasites were
again found, but the whites had increased to 170,000. That
evening he had another chill, not quite as severe as the pre-
vious one. On the next day, April 17, the white blood count
had dropped to 120,000, not as great a reduction as previously.
On April 18 the whites had increased to 135,000. Tliere was no
chill on that night, and on April 19 they had increased to 170,-
000 and there were no malarial plasmodiums in the blood.
Quinin and the red bone-marrow were continued through this
period. On April 23 the white corpuscles had increased to 236,-
000, nearly as much as before the malarial period. Malaria had
reduced the red corpuscles to 2,800,000, and the hemoglobin to
L 40 fc, the lowest it had ever been.
I' This reduction of white corpuscles by an acute infection
has been noticed by other observers, but, so far as I know, has
never been noted in malarial infection. Synchronously with
this reduction of white cells, all of the external glands greatly
reduced in size, so that the typical Hodgkin's appearance of his
neck almost disappeared in four or five days. The mesenteric
glands could no longer be palpated, but the spleen remained as
before. The glands, however, after this week began to increase
again in size and hardness.
It is useless to map out the proper treatment for
leukemia, as its cause is so obscure. In its acute
forms it undoubtedly is a microbic disease. If it is such
in the chronic forms, it must be a very slow going
microbe. Leukemia is not pathologic disintegration ; it
may be normal function carrietl to excess. Wherein
the trouble lies, what secretion is perverted, what
abnormal chemic condition is perhaps present, and how
[ to antagonize it, is an unsolved problem. A chronically
enlarged spleen and a history of severe malarial i)oison-
ing, whether the white blood-corpuscles are increased or
not, seems to require (luinin ; though the dose would
probably not be large, it would certainly be indicated if
there is coincident anemia.
As the enlargetl spleen under any of these conditions
seems to vary somewhat in size from time to time, we
can aid this rhythmic diminution and cause it to dimin-
ish permanently by the splenic cold douche, or by the
use of electricity in the region of the spleen. The spleen
has been removtnl for chronic enlargement and in
malaria, and patients have recovered, but when the
spleen has been remove<l in leukemia, the patients have
i all died.
' If enlarged glands of the neck occur, whether they
amalgamate or not, whether it is a tuberculous adenitis
or adenomas which may lead to Hodgkin's disease, and
whether the origin of Hodgkin's disease is tubercle
biicilli or not, these enlarged glands, on the one hand
surely harboring tubercle bacilli and on the other giving
a tendency to true Hodgkin's disease with a probability
of subsequent tuberculosis, cause me to say emphatically
that when enlarged glands of the neck persist they
should be removed by the surgeon.
From a toxic standpoint we know that too much
tonsillar tissue and too much adenoid tissue in the naso-
pharynx is not conducive to the health of the individual
from the obstruction alone, but allows, especially under
th^ excitation of cold or dust-germs, something to get
into the blood which can produce an acute toxemia, and
the patient has fever for a day or two and is more
or less sick. Also, if these febrile turns recur he sooner
or later becomes flabby if not cachectic. I believe such
lymphoid tissue should be removed.
In leukemia either of the splenomeduUary or of the
lymphatic variety our first care is of the general nutri-
tion and hygiene of the patient, allowing only such
physical exercise as the condition of the heart and respi-
ration warrants. As to medication, it must be remem-
bered that with or without treatment there are periods
of remittance in this disease when patients may become
suddenly better and remain better for considerable
periods. Theoretically every medication, such as nuclein,
thymus, thyroid extract, and possibly phosphorus,
would not be indicated as tending to cause normally a
leukocytosis. Alkaline treatment, causing increased
metamorphosis and break up of nuclear elements, would
seem to be contraindicated. Iron is always indicated,
perhaps best in an acid preparation. Red bone-marrow
would seem theoretically and practically to be the
proper treatment. Certain it is that sooner or later
patients with leukemia have anemia added to it. I
believe arsenic is utterly unjustifiable unless during its
use the blood count is carefully made. If it causes
any such condition as it did in my patient it is vicious
treatment. Such ordinary tonics and laxatives as the
case might require, or possibly cardiac tonics, should of
course be used.
At least 10 years ago I advised against socalled die-
tetic treatment for diabetes mellitus only in so far as to
establish the diagnosis. This at that time was almost
heresy. I now state that I believe the apparent advan-
tage of arsenic in leukemia and pseudoleukemia has
been in the evident and palpable diminution of the size
of the glands, but in the meantime the patient went
down hill. I believe arsenic should not be used in this
condition.
Physiologically, with the case cited we have the fol-
lowing conclusions :
1. The lymphocytes are probably not the origin of
the polynuclear leukocytes, else with so many lympho-
cytes we ought to have an increase of the more mature
cells.
2. Normally, without medication to cause it, in
lymphatic leukemia, as has been observed by others as
well as ourselves, the uric acid and phosphorus output
is not increased, hence these cells do not break down
more rapidly than in normal individuals with only 8,000
or so leukocytes. This means that a normal person with
from 5,000 to 8,000 leukocytes has no more nuclear
breakdown than these patients with nearly 400,000 leu-
kocytes.
3. Arsenic, alkalies and nucleic acid reduced the size
of the glands and spleen in this case, but caused destruc-
tion of red corpuscles.
4. Nucleic acid alone seemed to reduce positively the
number of the white cells.
5. The red cells and the general condition always and
consistently improved under Armour's retl bone-mar-
row. Hence it is justifiable to assume that in this case,
if not in all ca.ses of lymphatic leukemia, the bone-
marrow is diseased.
6. The malarial infection reduced the number of the
white cells and the size of the glands more than any
treatment instituted.
638 AUKRIOAN MBDIOINBJ
EXTIRPATION OF GALLBLADDER
[October 4, 1902
BIBLIOGRAPHY.
' Moore, Buck's Reference Handbook of tUeMediiail Sciences, New
Series, Vol. 11.
» Warthln, Jour, of Boston Med. Hcl., Vol. v, November 9, 1901.
' Rubinstein, Zeltschrift. f klin. Med., Bd. xlU, Hen S^-4.
* Josue, Keviie de Mgdecine, December 10, 1900.
>• Hanues, Cenlralbl. f. Innere Med.. August 24, 1901.
6 8t«8sano. La Semaine Mf-dlcale, July 17, 1901.
' F. B. Mallory, Trans. Asso. Amer. Phys., 1900.
e Becker, Deutsche med. Wocli., August .SO, 1900.
» Helm, Archives de Midccine des Enfants, January, 1901.
w Osier, Practice, p. 8(13.
12 Nermann } *^"*'^ ''™'" Jewett, Phila. Med. Jonr., April 27,
'•i Sternberg.' Archly fUr Hellkundc, Vol. xix, p. 21.
» Musser, Avierican Medicinf, January 4, 1902.
" Wende Amer. Jour, of Med. Sol., December, 1901, p. 636.
>« Rosenfeld, Zeltschrift fUr kiln. Med., 1900.
MOl.
EXTIRPATION OF THE GALLBLADDER THROUGH
THE LUMBAR INCISION, WITH REPORT OF A
CASE."
BT
W. p. MANTON, M.D.,
of Detroit, Mich.
Gynecologist to Harper Hospital and the Eastern and Northern
Asylums for the Insane ; Professor of Clinical Gynecology and Ad-
junct Professor ot Obstetrics, Detroit College of Medicine.
Mrs. G. C, aged 38, was examined at the request of Dr. B.
P. Brodie, April 18, 1902. She had had five children and two mis-
carriages, the last of which occurred about a month previous
to the present examination. During her pregnancies she suf-
fered a great deal from abdominal pain and soreness, this being
particularly marked while carrying her last two children. The
labors were normal and she got up feeling fairly well. Her
mother died of gallstones, the father of " consumption " and a
brother is said to be suffering from gallstone diseases. As a
girl she had never been particularly robust, and the color of
the skin has always been rather pale and sallow. She has, how-
ever, been able to work, and now, although rather feeble, attends
to her household duties. Her present condition, she thinks, has
existed for two years.
Menstruation began at 12 and was regular until the miscar-
riages took place. The discharge lasts nve or six days and is
always profuse, the last menstruation, she states, " being as bad
as a miscarriage." At present she suffers a great deal from
sacral backache on the left side, and there is pain in both iliacs,
especially the right. On the right leg there are varicose veins
whicli give rise to a sensation as of blood trickling down. She
also suffers from numbness in hands and feet and just below
the ribsontherightside. Her head has not troubled her of late,
but formerly there was a " scalding and itching" sensation of
the scalp. There is a profuse thioK greenish leiikorrheal dis-
charge. She sleeps poorly and is nervous and easily worried.
Her appetite is poor, bowels constipated, and she has suffered a
great Seal from attacks of indigestion.
Pelvic examination shows a slight laceration of the peri-
neum, relaxed vaginal walls, and a small laceration of the cer-
vix uteri. The uterus itself is slightly enlarged. The ovaries
and tubes are very sensitive, but not enlarged. On the right
side the appendages appear involved in slight adhesions, run-
ning up toward the appendix. The abdominal walls are well
nourished but relaxed, and there is considerable diastasis of
the recti muscles. The left kidney moves downward to the
second degree. The right kidney is enlarged to about twice its
normal size, and its lower end has a knob-like projection which
extends to an inch below the umbilicus and points downward
and inward. On the outer border of the kidney a rounded pro-
jecting edge can be felt. The organ is fairly movable and is
very sensitive over all. The percussion note is dull over the
kidney mass. A diagnosis of nephroptosis with probably cys-
tic metamorphosis of the kidney was made.
The patient entered Harper Hospital April 28. At this time
the urine was cloudy, alkaline, sp. gr. 1,020, and contained a
faint trace of albumin, but no bile nor sugar. The sediment
consisted of numerous pus cells, squamous epithelia and triple
phosphates.
Operation, April 30: The uterus was cureted and the cer-
vical laceration repaired. The patient was then turned on her
face, a large, thick roll placed oeneath the abdomen, and the
nephropexy incision made. When the fatty capsule of the
kidney was reached it was found surrounded by a mass of
dense adhesions, and it was evident that these had given rise to
the feel of an enlarged kidney at the examination. On incising
the capsule the kidney appeared in good condition and of nor-
mal size. It was enucleated and delivered onto the back. The
fingers then introduced through the wound below the bed of
the kidney came upon a hard, rounded body embedded in adhe-
sions, the general feel of which resembled that of the kidney.
1 Read at the fifteenth annual meeting of the American Association
of Obstetricians and Gynecologists.
On separating the adhesions, however, a pearly white body
traced with liloodvessels presented at the wound. A hypo-
dermic needle was inserted into the growth and a syringef ul
of turbid fluid withdrawn. The body was then gradually enu-
cleated, the fingers following it upward to the under sur-
face of the liver to which it was attached. It was then
seen that there was a dilated gallbladder in the neck of which
and in the dilated cystic duct gallstones were present. Sepa-
ration of the adhesions aljout the sac was continued until
the cystic duct was freed, when the stones in this were crowded
back into the bladder, the duct clamped with forceps and then
tied off with a double catgut ligature. A broad attachment of
the fundus of the sac to an anterior linguiform process of the
liver was also tied with catgut and separated and a quantity of
gauze was packed around the gallbladder and the latter cut
away. The kidney capsule was then split and peeled off to just
below the lateral line, four fixation sutures of silkwormgut
introduced and the kidney returned to its place. Before closing
the external wound a strip of gauze was carried down to the
stump of the cystic duct and allowed to protrude from the
upper angle of the skin incision.
During the operation little or no bleeding occurred from the
deeper structures, l)ut an annoying oozing took place from the
cut edges of the skin and muscle. The patient made an unin-
terrupted recovery from the operation and was in good condi-
tion when last seen.
Subsequent examination of the removed gallbladder showed
it to consist of a thin-walled fibrous sac, containing about four
ounces of grayisli fluid and 19 gallstones the size of hazelnuts.
The bacteriologic examination of the fluid at the Detroit Clini-
cal Laboratory is reported as follows: " The fluid in the small
bottle contains a bacillus having the morphology and staining
properties of the colon bacillus almost in pure culture. The
fluid in the large bottle shows some leukocytes and a few of the
same bacilli, together with a long, large rod which retains the
violet stain when stained by Gram's method. This latter may
be an accidental infection. No staphylococci or streptococci
were found in either examination."
This case presents several points of especial interest.
It is, SO far as I have been able to ascertain, the first
instance of removal of the gallbladder through the lum-
bar incision. The operation was entirely extraperitoneal,
and unless we assume the gastric disturbances and the
scalding and itching of the head to have arisen from the
condition there was an entire absence of symptoms
pointing to disea.se of the biliary tract.
Several cases are on record in which the emptying of
the distended gallbladder and the evacuation of stones
have been done through the lumbar incision, but in most
instances in which disease of the gallbladder or ducts
have been discovered through the nephropexy incision
the operation on these parts has been completed through
an anterior abdominal opening, and the kidney aloue
treated through the lumbar wound. Whether the extra-
peritoneal position of the gallbladder in this case was a
congenital anomaly or the result of walling off by adhe-
sions cannot be determined, but it is certain that the
condition must have existed for a very considerable num-
ber of years, and complete occlusion of the cystic duct
occurred without giving rise to noticeable symptoms.
Regarding the choice of incision in uncomplicated dis-
orders of the bile passage it may be said that the
anatomic position of the gallbladder — its neck reaching
up into the fossa vesicalis of the liver, and its fundus
extending to the border of the rectus muscle and the
abdominal wall — renders the organ of easy approach
through the anterior abdominal incision, and I am (juite
in accord with Mayo Robson, who says that the lumbar
incision under such circumstances " is useful only in
theory, and is surrounded by so many difficulties as to
make it quite impracticable." But in the presence of a
nephroptosis or a morbid condition of the kidney
demanding operative intervention, together with an
enlargement of the gallbladder, either from stones or
fluid accumulation, I believe the lumbar route will offer
certain advantages over the anterior approach. With
the kidney removed and placed astride the wound after
the method of Edebohls, space enough is obtained to
enable the operator to work up under the peritoneum
and thus complete the operation successfully.
In closing this paper I desire to pay tribute to the
pioneer work of Edebohls, who has opened up a field of
operation which had previously lain uncultivated.
OCTOBEK 4, 19021
DISLOCATION OF ELBOW AND RESECTION
[American MKorciKE 639
OLD COMPOUND PARTIAL OUTWARD DISLOCATION
OF THE ELBOW, AND RESECTION.'
BY
MARTIN B. TINKER, M.D.,
of Baltimore, Md.
Assistant Resident Surgeon, Johns Hopkins Hospital.
Partial outward dislocation of the elbow-joint is .so
unusual that every case seems worth recording. Stimp-
son (" Fractures and Dislocations," Philadelphia, 1900,
p. 627) refers to only 13 cases, including one of his own,
which he believed to be all that had been reported in
the literature up to that time. To this number I am
able to add two cases. In one of my cases the injury
was compound, the second case of the kind which has
been reported. The history of this case follows :
A colored man, about 30 years of age, was lodged in a
neighboring asylum for the insane because of acute maniacal
symptoms following long-continued alcoholic excesses. At
the time of his admission there was an injury of the right
elbow, evidently of comparatively recent origin. The patient's
mental condition made it impossible to obtain from him any
satisfactory history of the cause of the injury and none of his
friends or attendants could furnish any information. The
amount of swelling made the diagnosis difficult and the
physician in attendance made a diagnosis of probable frac-
ture of the lower end of the humerus, involving the
elbow-joint. Under chloroform anesthesia the arm was
brougljt into what appeared to be very good position and put
up in splints, flexed at a right angle. About one week after
this, in an acute maniacal attack, the patient tore off his dress-
ings and broke the akin over the elbow, making his injury
compound. The swelling at that time had somewhat subsided,
and It was evident that the bones were not in good position.
The wound, then infected, was dressed with moist antiseptic
gauze, and later anesthesia was again administered and an
attempt made to reduce the supposed fracture. The bones at
the elbow could be brought into what seemed to be normal
position, but almost immediately slipped out of place again.
Aljout the eleventh day after the patient's accident I was asked
to see the case and to bring instruments for wiring a fracture.
At this time the arm was flexed midway between complete
extension and a right angle, the forearm was held pronated and
somewhat adducted. 'There was a great deal of swelling, so
that none of the bony prominences could be seen. The trans-
verse diameter of the joint was greatly increased and the internal
condyle was specially prominent. Just below the condyle
was an opening directly into the joint 2 cm. in diameter
which exposed the inner surface of the trochanter. .Synovial
fluid had been escaping from this opening in considerable
quantities. The olecranon could be felt just external to this,
and was much more prominent posteriorly tlian normal.
Extending upward from the olecranon the triceps tendon
could l>e felt as a tense band. Only about 5° of flexion
and extension were possible, and movement caused con-
siderable pain. No lateral motion was possilDle. The
external epicondyle could not be felt because of the extreme
swelling about the joint. The swelling involved not only
the joint, but practically the entire arm and forearm, and
there was considerable discoloration, though the ecchymosis
seemed to bo clearing up. The movements of the fingers and
wrists were normal, the radial pulse could be felt readily, and
there was no disturbance of sensation or other indication of
nerve injury. No evidence of fracture could be determined. A
diagnosis of compound outward dislocation of the elbow joint
was made. An attempt was made to reduce the joint Ijy hyper-
extension and outward lateral flexion. But all movements of
the joint were so painful, and the contracture of the muscles
was so great that nothing could be accomplished. Ether was
administered and attempts were again made to reduce the dis-
location by hyperextension and outward lateral flexion of the
pronated forearm with pressure by an assistant over the outer
side of the joint. The l)ones could be pushed into what seemed
to be very ^oo<l position, but there was considerable tension
about thepomt, and immediately Qn removing the pressure the
bones agam slipped out ofi)lace. It seemed that the ligaments
had all been torn aw.ay. The displacement had existe<l for sev-
eral days, and when the bones were put in normal position the
contracture of the muscles immediately pulled them out of
place again. As the arm was practically useless in its present
condition, the patient being unable to bring his hand^to his
mouth, and all movements being limited and painful, resection
seemed to offer the best prospects for a useful arm. The open-
ing over the internal condyle was (juite large, and I decided
to make use of it in performing resection. The opening was
enlarged upward and downward, giving a fairly good exposure,
but the location of the incision was not as favorable to resection
as a posterior incision and I afterward regretted not liaving
made the usual incision. On exposing the joint the location of
< Read before the Johns Hopkins Hospital Medical Boclety, March
8, liXti.
the bones could be readily determined. The head of the radius
was displaced external to and a little anterior to the external
epicondyle. The ulna was displaced so that the ridge along the
middle of the sigmoid cavity rested between the capitellum and
the outer prominent border of the trochlear surface. A sub-
periosteal resection was performed with some difficulty because
of the awkwardness of the incision on the inner side of the
joint. Enough of the ends of the bone were resected so that
free motion was possible even with the large amount of swell-
ing which had existed about the joint. The cavity was irri-
gated with mercuric chlorid solution 1:1,000, followed by normal
salt solution and the wound partially closed with interrupted
silkwormgut sutures. A small strip of iodoform gauze
was inserted at the site of the compound opening into the joint
for drainage. The arm was flexed at right angles and put in a
heavy plaster-of-paris cast from the tips of the fingers to the
shoulder-joint. In spite of the fact that there seemed every
reason to expect infection after a compound dislocation of this
kind the patient did very well. There was slight elevation of
temperature for the first three days but otherwise the progress
was uneventful. The first dressing was made one week after
the operation and the joint seemed to be in good condition. The
small iodoform gauze drain was removed and not replaced.
The swelling and ecchymosis about the joint were greatly
reduced, there was no tenderness nor pain and a limited
amount of motion was possible. The arm was again put up in
a plaster-of-paris cast. Fifteen days after the operation the
patient managed to tear off his dressings and break open the
incision by rubbing the plaster-of-paris cast against his iron
bedstead until he could loosen the edges. The next morning
the arm was found in a filthy condition. As might have been
expected an infection occurred, but in spite of this the patient
Dissection of partial outward dislocation. The capsule of the Joint Is
caught between the edge of the ulna and the prominent ridge
of the trochlea when the forearm Is In supination.
made a fairly good recovery. There has been no improvement
in his mental condition, however. He sits most of theday with
his coat drawn up over his head and he rarely attempts to use
his arm.
The second case occurred in the practice of Dr.
Eugene F. Cordell. Through his kindness I am allowed
to report the facts, given in a letter which he sent me.
" The case was that of a white boy, Charles H., aged 10. He
was playing on the top of some cars when he fell, throwing out
his hand, 80 he said, as he fell. I found him shortly after at
his home, crying with pain. His left forearm was half bent on
the arm and half pronated. The diagnosis was easy from the
relative position of the olecranon and the condyles of the
humerus, which made the nature of the injury at once appar-
ent. Any movement of the joint was very painful. I placed
him under the influence of ether, when upon extending the
forearm and pressing the elbow inward at the same time the
bones returned into their normal position with a loud snap. The
limli was kept in a pasteboard splint for two weeks, and the
recovery was perfect."
Dr. Cordell reported this case at the Medical Society
of the Woman's Medical College, of Baltimore, but the
minutes of the society have never been printed.
Lateral dislocations of the elbow-joint are very un-
common, and the number of cases of incomplete disloca-
tion, according to Stimpson's statistics, seems to be
considerably less than tho.se of complete outward dishx-a-
tion of the elbow. There has been considerable confusion
about the use of the terms outward and inward disloca-
tion to include also the outward and backward, and
inward and backward disloaitions. Stimpson telieveH
540 AMERICAN MEDICINE) DISLOCATION OF ELBOW AND RESECTION
[October 4, 1902
that in the great majority of cases consecutive displace-
ments, outward dislocation following backward disloca-
tion, are very rare, and that the great majority of these
cases belong by their essential features to the backward
variety of dislocations.
Etiology. — It can be readily seen that a very unusual
form and degree of violence is necessary to produce
this form of injury. In nearly all cases the displace-
ment results from a fall upon the outstretched hand,
although cases have been reported in which the patient
has fallen on the inner side of the elbow, or has received
a blow upon the forearm. Nicoladoni has made a series
of dislocations upon the cadaver to determine the origin
of this displacement, and believes that in most cases
evulsion of the epitrochlea also is produced through the
attached flexor muscles. This I did not find to be the
case in my experimental dislocations made on the
cadaver. Evulsion of the epitrochlea has been noticed
in a number of cases observed clinically and has been
X-ray showinic the way in which by extreme pronation the coronoid
process Is lifted out of groove between trochlea and capitellum,
so that it will slip readily into place.
attributed to the pull on the lateral ligament. The dis-
location can be produced experimentally by abduction
of the completely extended and pronated forearm. By
the turning on the humeroradial articulation as a center
the internal ligament is ruptured and the joint is thus
opened on the inner side. This permits the sigmoid
cavity to separate from the trochlea and the middle ridge
of the sigmoid to escape from the groove in the trochlea
when it slides over the outer ridge of the trochlea either
into the groove between this ridge and the capitellum,
or in cases of complete dislocation, even up on to the
supinator ridge, so that the sigmoid cavity embraces the
supinator ridge.
Signs. — The arm is usually held between flexion
at a right angle and extension, the angle varying in dif-
ferent cases. The forearm is pronated probably from
pressure under the pronator muscles attached to the
external condyle, making them tense. The forearm is
adducted, the axis of the arm being directed downward
and inward when the hand hangs at the side, rather
than in the normal angle downward and outward. The
internal condyle becomes comparatively much more
prominent and the skin is stretched tensely over it. The
transverse diameter of the joint is decidedly increased.
The olecranon becomes more prominent because instead
of the ridge of the sigmoid cavity interlocking in the
deep groove of the trochlear surface it fits into the much
more shallow groove between the outer margin of the
trochlear surface and the capitellum. The triceps tendon
stands out as a prominent band. The external epicon-
dyle may sometimes be made out by pressing in firmly
above the head of the radius behind the prominent
extensor muscles. Nearly all of these signs were present
in my case and the compound oi)ening directly exposing
the inner surface of the trochlea left no doubt as to the
character of the injury. If these cases are seen late the
differential diagnosis may be extremely difficult. This
emphasizes the importance of early recognition by the
profession, for if the dislocation remains unrecognized an
almost useless joint is certain to result. In the treat-
ment of recent cases or even of old cases, reduction
should first be tried. In recent cases the efforts at reduc-
tion by hyperextension and outward lateral flexion of
the hand are usually successful. My own experimental
dislocations, an account of which follows, showed the
great importance of combining extreme pronation with
the extension and lateral flexion. In the cases which
have existed ten days or over, reduction has seldom been
accomplished. In most of the unreduced cases which
have been reported the functional results have been
very poor. In three out of four cases reported by Nico-
ladoni attempts at reduction were unsuccessful, and a
stiff, painful, practically useless joint resulted. In such
old cases the advisability of resection should certainly
be considered. Hueter, whose experience is probably
greater than that of any other surgeon, has reported
three resections in cases of this kind with very good
results. Although the result in my own case is not by
any means brilliant, the mental condition of the patient
is responsible for this and the treatment by resection
seemed very definitely indicated.
Experimental Dislocations on the Cadaver. — The fact
that about three-fourths of the cases of partial disloca-
tion of the elbow which have been reported were not
reduced led me to believe that there must be some unusual
condition to account for this. To determine the force
which caused these dislocations, and the best method of
reduction, I produced dislocations on three different
cadavers. The extreme amount of force required to pro-
duce such a dislocation experimentally, leads me to
believe that such dislocations would scarcely ever occur
in the normal adult. It required the entire strength of
a muscular man and exercised for a considerable length
of time to produce these dislocations on the cadaver.
Probably this form of dislocation occurs only in persons
who have an abnormal weakness of the capsule and
internal lateral ligament of the elbow-joint. No doubt
this accounts for the great infrequency of this lesion.
Practically the only way to produce the dislocation is to
apply the force with the arm in extreme pronation with
the arm completely extended. By very strong lateral
flexion the internal lateral ligament is completely
ruptured. The internal epicondyle was not torn away
as Nicoladoni found in his cases. The fibers of the
outer part of the capusle usually stretch and yield
without tearing very much, and the muscles about
the joint are uninjured without some unnecessary
force is applied. A feature which I believe has
been responsible for the unreduced partial outward
dislocations which have been reported is the depth of
the groove between the capitellum and the outer promi-
nent ridge of the trochlea. Unless this groove is of
considerable depth it is difficult to see how a partial
outward dislocation could persist. In two of my cases
October 4, 19021
TREATMENT OF PULMONARY TUBERCULOSIS iAMEBicAN medicine 541
it WAS diificult to hold the bones out of place after the
dislocation had been made, this groove was so shallow.
The dislocation would have been very unlikely to have
occurred, whatever amount of force might have been
applied, in any of the cadavers upon which I experi-
mented, because of the strength of the capsule. In two
it surely would not have persisted, even if the displace-
ment had occurred, because of the shallowness of the
groove between the capitellum and the trochlea, while
in a third case this would have been possible. In this
case the capsule readily slipped over the ulna and was
caught between the ulna and humerus in such a way
that reduction would have been impossible by ordinary
manipulations. The only way to release the capsule
when it has slipped in between the bones is to strongly
pronate the forearm. By the rolling motion the tension
is released and the edge of the capsule is lifted so that it
slips over the edge of the trochlea readily and reduction
is then very easy. If this be borne in mind I am sure
that the reduction of all fresh partial outward disloca-
tions of the elbow will prove easy. In old dislocations,
after adhesions have formed, reduction without opera-
tion will always be attended with considerable difficulty.
The accompanying cut will give some idea of the way in
which the capsule may be caught between the two bones.
The x-ray shows the position of the ulna when the arm
is strongly pronated ; the coronoid process is lifted on to
the edge of the trochlea by the twisting of the forearm in
pronation when it will very readily slip in place. A feafr
ure of great importance, which of course does not exist
in experimental work on the cadaver, is the muscular
action. In my own case the muscles were held so
rigidily that very little manipulation was possible. Now
that the diagnosis in these cases can be quite readily
made by means of x-rays there should be no excuse for
leaving them unreduced if the proper manipulation is
practised. In old cases, resection very likely will always
offer the best prospect for a useful joint.
MEDICAL TREATMENT OF PULMONARY TUBERCU-
LOSIS.*
BY
JESSE SHOUP, M.D.,
of Washington, D. C.
From the nature and pathology of pulmonary tuber-
culosis we are forced to select for its medical treatment :
(1) Those drugs which promote that metamorphosis
which results in healthy tissue construction. The sys-
tem is constantly placed on the defensive and at no time
is it able to change front and assume the offensive. We
cannot eradicate the disease and we are, therefore,
obliged to conserve our patient's energy whenever pos-
sible. We must stimulate exhausted functions, and
through careful and diligent watching train our patients
for a long siege. 2. Thosie drugs which are bactericidal
and being eliminated by the lungs come as near as is
possible to attacking the disease in sUu. 3. That class
of drugs which stimulates phagocytosis.
Through the combined aid of these three classes we
aim to increase the constructive power of the animal
cell and decrease the destructive power of the bacilli ;
and I believe it is only when these three classes of drugs
are intelligently used in conjunction, each assisting the
other, that we get the best results in the treatment of
tuberculosis. In the first class we may mention iron,
arsenic, strychnin, phosphorus and vegetable tonics;
iron to increase the number and rejuvenate the red blood-
cells and fit them with the oxygen carrier, hemoglobin.
Iron is indispensable in the anemic condition and should
be given in the most easily a.ssimilated form, organic
iron. Arsenic stands second only to iron as a recon-
• Read at a meeting of the American Therapeutic Society, held In
New York City, May 18, 14, 15, 1902.
structive agent, increasing the number of red blood-
cells, and as a general nerve tonic. It has long been
used for the fever, night^sweats and the general debility
of tuberculous patients.
The new preparation of arsenic, cacodylic acid, has
received a great deal of attention lately, much having
been written of its efficacy in the treatment of tubercu-
losis. Frassi and Gautier' claim that in anemia and
tuberculosis the treatment with cacodylic acid is always
followed by a gain in weight and an increase in the
amount of hemoglobin. Barbary '' reports lasting benefits
from subcutaneous injections every other day of guaiacol
cacodylate. Gilbert ' and others have used iron cacody-
late, with resulting increase of body weight and low-
ering of temperature, disappearance of night-sweats and
amelioration of general conditions. Dose, 1 to li grains,
hypodermically, and 3 to 6 grains by the mouth. I have
used with good results arsenic in the form of arsenious
acid in ascending doses, two doses daily, one after
lunch and one after dinner, beginning with yV grain and
gradually increasing until the patient's tolerance for
the drug is reached ; phosphorus also in the form of
phospho-albumin, nucleins and nucleoalbumin. It
has been proved by excellent authority that better
results are obtained from proteids containing phospho-
rus than from phosphorus-free proteids to which inor-
ganic phosphorus has been added. Strychnin as a
respiratory, heart and nerve stimulant has no superior,
and should be given freely, as should also the various
bitter and vegetable tonics, to increase the appetite and
promote general nutrition.
Of the second class of drugs, those usetl for their bac-
tericidal properties, creosote may be taken as a type. I
have had good results with creosote in large doses when
it did not interfere with digestion. I prefer to give it in
ascending doses, and furnish the patient capsules and
creosote and let him fill his own capsules, increasing one
drop each day until the tolerance of the stomach is
ascertained, aiming to stop short of interference with
digestion ; or else give it in codliver-oil emulsion or
vaselin emulsions, increasing one drop a day. In this
way the signs of poisoning from the drug can be looked
for and its use discontinued before dangerous symptoms
appear. There is no doubt that creosote given in this
way lowers fever, lessens cough, changes the character
of the sputum and often arrests the progress of the dis-
ease. Considerable has been written of the action of
creosote in pulmonary tuberculosis and it is still a debated
question. Those who hold that its action is chiefly or
wholly on the alimentary canal, give creosote in small
doses for its local antifermentative effect, while those
who believe it is eliminated by the lungs in sufficient
(luantity to be bactericidal use the large doses. As a
proof that creosote is only local in its action, it is claimed
that animals infected with tuberculosis and treated with
creosote die as soon as those not so treated. Sputum
obtained postmortem from tuberculous patients who had
been treated with creosote seems as virulent as that from
those not so treated.
Creosote administered in other ways than by the
mouth is much less efficient. The strength of creosote
present in the tissues can not, according to laboratory
experiments, have any destructive effects on tubercle
bacilli. Against this it has been found (Cushny, Potter *
and others) that very dilute solutions of creosote reach-
ing the blood and tissue cells tend to increase the activity
of protoplasm. Dr. Potter claims theoretically that
enough creosote may reach the tissues surrounding the
tubercle to prohibit its growth. If this be true, it yields
a vital point in favor of creosote, for this alone may
often enable the patient to tide over a critical period. In
giving creosote by inunction, inhalation, or enema my
exiierience has been that by inunction the odor is too
disiigreeable, and the irritation caused too painful for
patients to endure it long ; by inhalation it is too irritat-
ing and not more efficacious than the essential oils and
542 AMERICAN MraiomE] TREATMENT OF PULMONAEY TUBERCULOSIS
[October 4, liKW
other less irritating substances ; by enema it soon becomes
obnoxious to the patient, and he cannot be prevailed
upon to continue it in that way. By intratracheal injec-
tions it at times succeeds in checking the distressing
cough and partially deodorizing and disinfecting the
sputum ; beyond this no benefit is gained over adminis-
tering it by the mouth. Guaiacol has to a great extent
superseded creosote in the treatment of pulmonary
tuberculosis on account of its being less disagreeable to
the patient. It is not so liable to cause gastric distress.
A favorable action of guaiacol is shown by its odor in
the breath within five hours after its administration.
Guaiacol carbonate is a favorite remedy with many
physicians, and I prefer it to creosote when gastric
symptoms are prominent. It should be given as
creosote is given — in large doses.
In passing the gastric digestion and being broken up
in the intestines, it is well suited to this class of cases.
I have found guaiacol valerianate very useful. It is an
admirable remedy in nervous cases, and large doses can
be borne. I have used thiocol, but found it in no way
superior to guaiacol. Dr. Moritz Cohen ^ claims the
credit of first using ichthyol in pulmonary tuberculosis.
He gives it mixed with equal parts of water, and
administers four drops of this mixture, well diluted
with water, three times a day, increasing one drop each
day until the limit of the patient's endurance is reached.
He claims it has distinct bactericidal qualities, and that
in a series of 100 cases he had uniform good results. There
was gain in weight ; bacterial growth was hindered ,
fever was lower ; night-sweats and cough diminished ;
the sputum changing from purulent to mucous and
frothj'. Dr. Scarpa," of Turin, has reported 150 cases of
pulmonary tuberculosis in which the patients were
treated with ichthyol, and considerable permanent
improvement was noticed. He gave as high as 200
drops daily.
Dr. Edward Stul>bert,' of the Loomis Sanitarium, has
reported good results from the use of ichthyol. He
claims the best results are obtained from large doses.
Schaefer, Spangler " and others have reported favorably
on the use of ichthyol. I have used ichthyol but com-
paratively little, discontinuing its use because of the
disagreeable eructations and nausea caused the patient.
Its action is dependent upon the sulfur it contains, and
I cannot see why sulfur may not be given as such.
Dr. C. R. Lane" reports that in two patients who
were treated with methylene-blue, the temperature fell
from 105° to normal in one week. He claims the drug
is eliminated, to some extent, by the lungs. Dr. iM.
LoewenthaP" reports three cases, the patients being
treated with aqua fluorformol with excellent results.
He says the drug is pleasant to take, is tasteless, non-
poisonous, and is perfectly tolerant to the stomach.
Dr. Maguire " has practised injections of formaldehyd
gas in normal salt solution. From his report it would
seem the drug is more dangerous than useful, symptoms
of albuminuria, hematuria and thrombosis appearing at
times. lodin and its compounds have long been used in
the treatment of pulmonary and other forms of tubercu-
losis. Inunctions and inhalations of iodoform, europhen,
aristol, iodol, nosophen, picrol, iodophenin and others of
this group are used to meet indications. Dr. 8. F. Flick "
reports favorably on their use. Good etfects have been
reported from the use of protargol.
The third group of medicines, according to our classi-
fication, those which chiefly stimulate phagocytosis,
include the serums and such other medicinal agents as
cinnamic acid which are given chiefly to stimulate and
to cause the multiplication of the leukocytes. Intrave-
nous injection of cinnamic acid in glycerin emulsion has
been practised by Landerer, who reports good results.
Dr. Hessen noted that cinnamic acid given hypodermic-
ally was of benefit, while Fraenkel has noted no benefit.
Dr. S. Maim^' reports good results from Landerer's
method of intravenous injections, but concludes by say-
ing that it is a difficult and troublesome treatment, a
conclusion which I think almost all will reach. It would
certainly be such to the general practitioner and nothing
less than a positive cure would induce any great number
to submit to the treatinent. Landerer claims that cin-
namic acid increases the number of white blood cor-
puscles fully 50 fc , and that it cures by setting up an
area of active inflammation around the tubercle. Others
confirm this action of cinnamic acid.
For the last four months I have given the following
prescription in my clinic and private practice, teginning
with three drops after lunch and after dinner and
gradually increasing to 20 drops :
Arseuioua acia 0.65
Fotasslum carbonate 1.1289
Cinnamic acid 1.944
Boil with distilled water to make 28.38
Add
Aqueous extract opium 1.944
Brandy 14.175
Distilled water 56.7
In incipient cases and in chronic cases, without the
mixed infection, patients seem to improve rapidly with
disappearance of night-sweats, lowering of temperature,
and gain in body weight. In all acute cases and cases
with mixed infection and when there was great debility,
it had to be abandoned, as it seemed to hasten the course
of the disease.
Dr. Harper " was led to give urea for tuberculosis on
the theory that carnivorous animals and animals excret-
ing a large amount of urea were practically free from
the disease. He claims that investigation will show
that rheumatism and tuberculosis do not occur, or sel-
dom occur, in the same families. He gives the urea in
20 to 60 grain doses three times daily, either by the
mouth or subcutaneously, and claims to have gratifying
results. Buch ^» reports favorably upon the use of urea
and, in a series of seven cases, says it has proved
almost a specific. Roberts agrees with Harper's theory
of the antagonism of the two diseases — tuberculosis and
rheumatism. I have seven patients who are now tak-
ing urea, but it is too early to give a report upon them.
So far, serum therapy in pulmonary tuberculosis has
not accomplished all that was anticipated. It has not
proved to be a specific, nor can we expect it to do so to
the extent that it has in diphtheria. The nature and
pathology of this disease are such that the very jjlaces
where the serum is most needed are closed against it,
thereby limiting its action. It must stand guard as a
sentinel around the areas of infection and attack the
bacilli and their products as they enter the circulation.
Whether we believe with those who hold that the action
of antitoxin serums is antitoxic to toxins, or accept the
theory of Metschnikofl' that all serums are simply stimu-
lating agents to phagocytosis, we have ample proof that
their action is dynamogenetic and, therefore, gener-
ally stimulating. Admitting that the microbial destruc-
tion and arrest of infection are due to phagocytosis,
we are right in our effort to increase the phagocytes.
Favorable results continue to be recorded from the use
of antitubercle serum. Dr. Baradat'" reports good re-
sults from the use of Bertin's and Picq's goat serum in
doses of 2 cc. every other day. Dr. Baradat claims to
get the same results from administering the serum by
the mouth, but larger doses are required than when
given hypodermically.
Goetsch," in a series of 224 cases during the last 10
years, has had excellent results with tuberculin O and
tuberculin R. He never gives it to a patient when there
is the slightest rise in temperature and never increases
the dose when the preceding dose produces any reaction
whatever. To avoid reaction he advises the patient to
remain in bed during the day of the injection and the suc-
ceeding day. He begins with .0001 mg. of tuberculin O.
If it is not tolerated, he gives tuberculin R, and as soon
as the patient can take 1 mg. of this he substitutes tu-
berculin O, beginning with .001 mg. He increa.ses the
tuberculin O until the patient can take 1 mg. without
October 4, 1902]
TEEATMENT OF PULMONARY TUBERCULOSIS iajukmcan mkdicink 543
reaction. Klebs'* considers tuberculin R almost a
specific.
If, however, we have no specific in the antitubercle
serums of Pacquin or Fish nor in the tuberculin O and
tuberculin R of Koch, I believe we have in them useful
adjuncts when use<l with other medicines. My experience
accords with that of those who claim that patients improve
faster when the serum is added to other treatment. The
time to give antitubercle serum, or tuberculin, is in the
first stages of the disease. If we could diagnose the
initial lesion with certainty before the bacilli have gained
a foothold and administer the serum at this time, no
doubt it would come nearer to being a specific.
Nearly all reports on new or old remedies contain a
statement that the remedy is suitable to early apex cases
or to the early stages of the disease. Indeed, there is no
mystery in this, for when we have the pus organisms
forming ulceration, with abscess formation In the lungs,
no remedy short of that which will evacuate the abscess
and promote drainage of the pus will cure the patient.
Do we treat abscesses in other parts of the body by con-
stitutional remedies alone, and content ourselves with
stimulating phagocytosis and let the leukocytes destroy
the pus ? The unalterable law is to open and evacuate
the abscess first. Nothing short of producing a similar
result will enable us to cure these latent cases of tuber-
culosis, with ulceration and abscess formation. In these
cases the tubercle bacilli, with the assistance of the
staphylococci and the streptococci, have long gained the
ascendancy and have exhausted the leukocytes to such a
degree that they are few in number and resist feebly.
If, then, the leukocytes are the antitoxin-producing
element, how can we expect antitoxin to be formed in
any great amount from weak, exhausted cells? Their
power has already been expended. We may as well
apply the whip to an exhausted horse. We may expect
the same result from any other remedy whose chief
action is to stimulate protoplasm, be it cinnamic acid or
any other remedy of 'this class. Until some means is
discovered whereby we can drain the abscess cavities
and apply our remedies more directly to the ulcerated
surfaces of the lungs, our success will most likely con-
tinue to be in the incipient cases.
Special Si/mptorm. — The most important special symp-
toms we have to meet in tuberculosis are indigestion and
gastric distress, for so soon as the patient fails to digest
and assimilate sufficient food the tide is turned against
him. No matter what medicine we give or what treat-
ment we pursue or what we feed our patient, if it is at
the expense of his stomach it will soon have to be
abandoned. In those cases in which indigestion with fer-
mentation exist, I have found nothing superior to hydro-
chloric acid, and it often seems (juite as effective when
given alone in the form of the dilute acid in large doses.
I prefer to give it immediately after meals. Strychnin
makes a good addition to a mixture containing hydro-
chloric acid and elixir of pepsin or papain. For gastric
distress with nausea, and to prevent fermentation, thy-
mol, menthol and cocain are useful. Thymol and men-
thol I believe to be among our best intestinal antiseptics.
The patient should be instructed never to swallow
sputum and to cleanse his throat with an antiseptic wash
at frequent intervals. I have had excellent results from
the use of vaseJin emulsion as a mechanic laxative and
lubrimnt to the bowels, and by its presence throughout
the alimentary canal it prohibits, to a degree, bacterial
growth.
Fever is best treate<l in this as in other diseases by
rest and cold baths, sponging with alcohol solutions and
solutions contidning menthol, (.iuinin, theoretically, is
counterindicated in doses sufficient to lower temperature,
on the ground that it lessens leukocytosis, and the coal-
tar prwlucts are too depressing to the heart. Whenever
they are given the heart should be guarded carefully
with strychnin or cafTein. Night-sweats are best
controlle<l by cold baths, sponging with alcohol and
mentholic solutions. When medicines are indicated, I
have found none better or more reliable than atropin ;
agaricin is also almost as effective, and aromatic sulfuric
acid in lo-drop doses, three times daily, is effective in a
large number of cases.
Cough. — For the irritable cough, codein is the most
reliable, and at the same time least objectionable ; less
apt to cause constipation than morphin and not so likely
to cause nausea and loss of appetite as heroin. When
heroin agrees with the patient, it is usually more effec-
tive in checking the cough than is codein. Inhalations of
oleaginous vapors containing menthol, iodin, carbolic
acid or the essential oils, or the intratracheal injections of
the same, form a useful means of quieting the cough
without disturbing the stomach with syrups and opium
preparations, and should be resorted to first or in con-
junction with whatever else is given for cough. Small
doses of codein, menthol and cocain combined into a tablet
and allowed to dissolve in the patient's mouth are very
effective. For the hemoptysis, rest and absolute quiet,
and ice to the chest if hemorrhage is severe ; morphia
and hydrastin internally or hypodermically have given
me the best results, aconite or veratrum viride when the
pulse is strong. Gallic acid is reliable, and injections of
gelatin may be practised.
For diarrhea a guarded diet with papain or pepsin
with guaiacol carbonate and bismuth subnitrate or tan-
nalbin or tannagen or iodomuth with opium, when
there is tenesmus, is usually effective in controlling this
condition. For the weak, failing heart, digitalis, stroph-
anthus, strychnin and alcohol are serviceable. Insomnia .
and the nervous phenomena are at times exasperating in
their persistency, and one must change from one drug to
another— trional, the bromids, paraldehyd, and at times
mori)hia will have to be tried. Hyoscin hydrobromate,
in grain ^^^ to ^l-^ in combination with 20 to 30 grains
of sodium bromid, has given me excellent results in
extreme eases.
When once we are certain that a patient suffers from
tuberculosis I think it our duty to tell him so, and not
to say that he has chronic pneumonia, chronic bronchitis,
or catarrh of the lungs, or that if he is not careful he will
develop tuberculosis. Interest him in himself. He
must know that health can only be regained by strict
adherence to hygienic laws. Teach him to live correctly,
and why. It seems to me that persons who most need
to husband their strength know the least how to do it.
Of all the diseases there is none that takes more inge-
nuity, untiring zeal and patience on the part of both phy-
sician and patient than tuberculosis, and I believe we
ought to impress this fact firmly upon our patient at the
beginning. Few patients will submit to the necessary
treatment, which of necessity will extend over months
and possibly years, unless we impress firmly upon their
minds that it is their only hope ; that an opportunity
lost now is lost forever; and even then periods of
despondency will be frequent. Give your patient a
thermometer and let him take his temperature frequently
at first, to establish the period of highest fever.
Tuberculous patients will be found almost invariably to
have a fever at some time during the day. We ought to
know at what time it reaches its highest point, so as to
be able to take measures of prevention. Most tubercu-
lous patients begin the day with a subnormal temper-
ature. This alone should be a suspicious symptom.
Teach each one why he should not exercise with a fever
and the fallacy of trying to "walk off" a fever as in
other diseases ; why he should exercise a little short of
fatigue, and to be careful of his diet during fever periods.
Impress upon him the importance of both appetite and
digestion. Thus you tesich him not only hoic, but why
he delivers himself over to the theories of modern treat-
ment, and at the same time you gain for youi-self assist-
ance and cooperation on his part, a cooperation whose
value cannot be overestimated.
If the patient can afford a change of climate, all well
544 AUEBIOAIT MBDfOIXEl
ANALYSIS OF DIPHTHERIA
[OCTOBER 4, 1902
and good, if he continues treatment at the same time ;
but, as Dr. Osier has said, 95^ of our patients cannot
afford a change of climate, with all it entails. We have
to do mostly with those who cannot change climatic
conditions, but who are obliged, as some one ha.s aptly
said, " to die in the harness." In such cases I believe
the patient should be seen every day, or every few days
at the longest. It is admitted by those in charge of
sanatoriums that if physicians outside would see patients
every day, as they do, and note symptoms as carefully
and be as thorough as to details, patients would derive
much the same beneflis at home. In seeing patients
daily we have the opportunity of watching each special
symptom as it arises ; the advantage of advising accord-
ingly is apparent under these circumstances.
As the machinist ever watches the movements of the
ingenious mechanism before him, with an ear so trained
and adjusted that it catches the first note of discord, the
first jar of an inoperative or weakening part, so must we,
the physicians, the caretakers of that far more intricate
mechanism, the human body, be ever watchful, espe-
cially in cases of tuberculosis, to note the changing symp-
toms, ever alert to catch the first ray of improvement or
the first shadow of retrogression, with determination
and readiness, with care and with hope, believing that
our profession is improving constantly in methods and
practice, and that the day of absolute cure is not far oft".
BIBLIOGRAPHY.
1 Gautler, Kevue de Tbfirap.. No. 13, 1899.
2 Barbary, Philadelphia Medical Journal, August 10, 1901.
'Gilbert, Gould's Year Book. 1901-1902.
•Potter, Journal of Tuberculosis, Vol. ii, 1900.
'Moritz Cohen, Practice of Medicine— Osier.
"Scarpa, Practice of Medicine — Anders.
■ Edward Stubbert, Proceedings Phlla. Med. Soc, Vol. Ixxli, 1902.
sSpangier, Proceedings Phila. Med. Soc., Vol. xxil, 1901.
»C. R. Lane, American Medicine, Vol. li, 1901.
i»M. Loewenthal, Phila. Med. Council, December. 1901.
" Maguire, British Medical Journal, Augu.st 10, 1901.
"S. F. Flick, Phila. County Med. Soc, V'ol. xxii, 1901.
13S. Mann, Trans. Colo. Med. Soc, 1900 and 1901.
I* Harper, Foster's Therapeutics.
i^Buch, London Lancet, June 15, 1901.
inBaradat, Boston Med. and Surg. Journal, Vol cxli, 1901.
" Goetsch, Deutsche medicinlsche Wochenschrift, June 10, 1901.
"Klebs, R6vue de la Tuberculose, February, 1901.
AN ANALYSIS OF FIFTY-FIVE CASES OF DIPH-
THERIA.
BY
HENRY G. GODFREY, M.D.,
of Philadelphia.
Resident Physician at Glrard College.
This report includes 55 cases of clinical and bacterio-
logic diphtheria under personal observation at the Girard
College Infirmary, which I present by courtesy of Dr.
W. S. Janney, visiting physician. The average age of
the patients was 10.5 years. The sites of the lesions
were the tonsil, the pharynx, the nasal mucosa and the
conjunctiva. There was no mortality. The conditions
were favorable for the study of the early symptoms.
The period of incubation could not be accurately fixed.
Prodromal symptoms were seen in 20 cases for a period
of 24 hours or less preceding the development of definite
lesions in the throat. Malaise, headache, pain on deglu-
tition and sore throat were usually complained of.
Injection of the pharynx and roughening of the mucosa
were .seen at this time. The onset was usually marked
by increase of restlessness (by slight delirium in two
cases) but not infrequently by dense apathy. An intense
blanching of the face was highly characteristic. A fine
erythema of the chest and abdomen was seeli in four
cases. Vomiting occurred at this time in 10 cases ; in 3
it was frequently repeated (4 to 6 time.s).
The temperature, which had been elevated 1° or 2°
during the prodromal period, took a sharp rise at the
formation of the membrane, the acme being attained in
12 to 24 hours. In five cases it was between 100°-101° ;
in 6, 101°-102° ; in 10, 102°-103° ; in 22, 103°-104° ; in
12, 104°-105°. There was no relation between the tem-
perature and the severity of the infection.
The pulse was accelerated out of proportion to the
temperature in the prodromal stage and increased coin-
cident with the membrane formation. The pulse fre-
quency was as follows: 90, 1; 101-110, 6; 110-120, 15:
120-130, 26 ; 130-140, 5 ; 140-145, 2.
The membrane appeared first on one or both tonsils in
35 cases ; as an exudate within the follicles of the tonsil
in 8 ; in discrete patches on the wall of the i)harynx in
G ; deeply hidden in a sulcus of the tonsil in 4 ; and upon
the nasal muco.sa in 2. Its extension was very rapid
during the first 12 hours, after which inten.se edema of
the subjacent structures developed, the bulging of the
anterior portion of the tonsil and the uvula often being
sufficient to obscure the patches visible several hours
before. A formation of membrane on the pharynx in dis-
crete, linear patches behind the posterior half-arch,
moist, greenish or brownish in appearance, was charac-
teristic.
Lymphadenitis was seen in 20 cases. It occurred early,
was usually unilateral. In 2 cases there was brawny
swelling of the upper half of the neck, with palpable
enlargements of the glands of the subclavian triangle. A
putrid odor from the throat was common in those cases
in which lymphadenitis was marked.
Vomiting was seen in 22 cases, in 10 at the onset. It
was persistent and frequent in 3 cases in which the naso-
pharynx was the site of infection.
A synopsis of the treatment is briefly as follows :
1. In the Acute Stage.— (a) Milk diet; (6) ab,solute rest in
bed, the patient being cautioned not to raise the head from the
pillow ; (c) concentrated diplitlieria antitoxin in dosage as
stated later ; (d) whisky and strychnin when cardiac symp-
toms indicated ; (e) local treatment by the use of an ice-bag to
the throat constantly, and an antiseptic mouth-wash.
2. In Convalescence.— (f) Rest in bed from one to three
weeks; (g) iron and tonic remedies; (h) local application to
tonsils and pharynx of silver nitrate (grains 40 to ounce) until
culture was negative for diphtheria bacilli.
Concentrated diphtheria antitoxic serum was used in
all cases in initial doses of 2,000 units or more. The
injection was made in the subcutaneous tissues of the
thigh. An immediate rise of temperature of 1° and
increase of pulse-rate of 6 to 12 followed. The vomit-
ing was relieved, the pallor and fades changed, the pulse
became fuller and in four hours the patient expressed a
sense of relief. In 12 to 20 hours the edema was less and
evidences of limitation of the membrane were seen in
its thickened, curled edges and in the zone of injection
in the surrounding mucosa. The temperature fell stead-
ily and the membrane was discharged in pieces or in
mass in 48 hours. In less favorable eases double the
quantity of the initial dosage was injected after 12 hours
or less. The average total do.sage was 4,500 units. In
14 it was between 5,000-10,000 ; in 4, 10,000-15,000 : in 1,
20,000.
In considering the indications for increase of do.sage
the clinical notes of the following cases are presented :
G. F., age 9. On admission at 12 m. ragged patches were
noticed on both tonsils with slight edema, submaxillary adenitis,
wiry pulse. Antitoxin, 3,000. At 8 p.m. there was extreme
edema of tonsils and uvula almost occluding the fauces, stridu-
lous breathing, deglutition impossible, vomiting, incontinence
of urine, dilated pupils, very small hard pulse. Antitoxin,
6,000. Dyspnea much relieved in two hours, pulse increased in
volume, fall of temperature of 3°. The patient slept several
hours toward morning.
On the second day, at 2 p.m., there was a sharp rise of tem-
perature to 102°, the distress of the previous day recurring ; the
pulse was small, irregular and intermittent ; the heart sounds
were feeble and of equal lengtli. Laryngeal involvement was
feared. Antitoxin, G,000, wa.s given, following which the urgent
symptoms subsided. The temperature fell slowly to normal in
the next 30 houi-s. The throat cleared on the third day.
E.G., age 10. On admission at 8 a.m. had large patches on
both tonsils, with brawny swelling of the left side of the neck,
thin nasal discharge. Antitoxin, 3,000. At 2 p.m. there was
rapid increase of swelling in the neck to the level of the cri-
coid cartilage, small masses of glands palpable in the sub-
OcroBKK 4, 1902]
RECTAL APPROACH IN OBSTETRICS
(Akebican Medicin* 645
clavian triangle, free nasal discharge, membrane seen on the
eonjuncti%'a of both lower lids. Antitoxin, 5,000.
On the following day, in view of the continued conjunctival
infection, the toxic symptoms and the unyielding adenitis, two
injections of antitoxin, 6,000 each, were given. The conjunctivas
and the throat cleared on the following day (the third), and the
induration of the neck softened magically under the last
dosage and was completely resolved on the fourth day.
The foregoing are types of the most malignant diph-
theria ; the first that of violent onset in which death
occurs from rapid extension to the larynx or from over-
whelming toxemia; the second, the dreaded mixed
infection in which diphtheria antitoxic serum is acknowl-
edged to be least potent, in wliich the adenopathy at
once becomes predominant and in which the patient
succumbs to septic infection. In the one case the infec-
tion was overpowered by the use of 15,000 units of diph-
theria antitoxic serum in 26 hours and in the second by
20,000 units in 32 hours. The specific remedy should
be used in quantity sufficient to control the disease in
24 hours. The initial dose may be high if necessary
(6,000 in one instance) ; and if grave symptoms persist
or increase, double the quantity of the initial dosage
should be injected in 12 hours or less. A secondary rise
of temperature, which indicates usually some extension
of the infection or a reformation of the membrane, call
for further resort to antitoxin.
Degenerations of the heart-muscle occur early in this
disease. Irregularities or intermissions of the pulse
were noted in 18 cases, in 10 on the second day. Anti-
toxin is not depressant to the heart.
The persistence in the throat of the diphtheria bacilli
is noteworthy^ — in one case for 37 days. The average
period was 13 days.
The complications in this series of cases were as fol-
lows : Nasal hemorrhage (2 cases), albuminuria (7 cases,
in 2 associated with epithelial and granular casts). There
were no palsies.
The untoward effects of the antitoxin were as follows :
Arthropathies of knee and hip in 2 cases ; urticarious
rashes in 8. In 1 the rash was preceded by vomit-
ing, and diarrhea and the urine showed increase of
albumin and casts. A hectic type of fever developed in
convalescence in one in whom pulmonary tuberculosis
had previously been suspected. All of these toxic mani-
festations made their appearance between the eighth and
eleventh days and were of short duration.
A series of blood counts were made in 10 cases, the
conclusions from which are as follows :
Leukocytosis is variable from 12,000 to 32,000.
Leukocytosis is progressively diminished by successive
doses of antitoxic serum.
Reduction of the erythrocytes is moderate, the count during
the entire course being between 4,000,000 and 3,000,000.
Hemoglobin is reduced disproportionately, the fall being
abrupt on the third or fourth day, and continuing into the con-
valescence. The greatest decrease was 34% ; the average, 20%.
It was expected, in view of the toxic manifestations in
those cases in which the antitoxin dosage had been high,
that a greater anemia would appear in them. However,
in that case in which 20,000 units were used the final
anemia was less than in two others in which but 2,000
were employed, and in which the infection was compar-
atively mild. The first counts in these were approxi-
mately equal. This suggests that the larger doses con-
serve the blood to a greater degree.
In Girard C/ollege, until recently, a method of com-
bined constitutional and local treatment in diphtheria
was used to the exclusion of serotherapy. In the last
ten months in which diphtheria antitoxic serum alone
has been employed, the results have been unprecedented
not alone in the absence of mortality, but in the infre-
quency and the trifling nature of the complications.
Mortality in San Francisco.— I 'uriug August there were
5(»7 deaths, making the annual rate 10.89 per 1,000 ; in August,
1!X)1, the rate was 15.92.
THE RECTAL APPROACH IN OBSTETRICS.
BY
W. A. BRIGGS, M.D.,
of Sacramento. Cal.
In American Medicine, February 1, 1902, I described
the technic and emphasized the advantages of obstetric
diagnosis per rectum. The technic corresponds essen-
tially with that of obstetric examination per vaginam,
and the advantages are avoidance of infection of the
genital tract and the poasibility of an earlier, more exact
and more positive diagnosis. Not only diagnosis, but
certain obstetric procedures also may be wisely under-
taken per rectum.
1. Dilation of the Os and Cervix. — A slow first stage
is often the cause of uterine exhaustion and the conse-
quent necessity of instrumental interference. Formerly
in such cases I sometimes dilated digitally per vaginam,
but always with hesitation and misgiving. Recently in
four instances I successfully dilated per rectum with
ease and perfect peace of mind.
Mrs. B., aged 32. Her first labor was very tedious and
terminated by forceps. She was taken in her second labor at
9 p.m., November 15, 1901 ; vertex presentation 1. o. i. p.; pains
every half hour during the night, increasing in frequency
during the forenoon to every 10 minutes ; at 4 p.m. November
10 OS, purse-stringed three-fourths of an inch in diameter.
Through the rectum I introduced the gloved index finger into
the OS brought the anterior lip forward, and in 35 minutes
dilated the os to the diameter of three inches ; expulsive pains
set in and labor was completed normally in three hours. In
the second case dilation was also successfully accomplished,
although with somewhat greater difficulty. In the third case
(1. o. i. p.) dilation offered ho special difficulty, but I was com-
pelled later to rotate manually and to deliver with forceps. In
the fourth case dilation caused considerable complaint, but was
easily accomplished and was followed by spontaneous delivery.
In none of these cases was there any rectal irritation or other
untoward result attributable to the manipulation.
2. notation of the Head. — Delayed rotation is another
frequent source of uterine exhaustion and consequent
instrumental delivery. With the right index in the
rectum crowding the sinciput backward or drawing the
occiput forward while the left hand crowds the shoulder
or possibly the occiput toward the median line, rotation
may be greatly expedited.
Mrs. F., a primipara. Her pelvis was normal. The cervix
dilated normally, but the second stage was slow on account of
delayed rotation. Pressure by the right index through the
rectum against the right temporal region, with traction toward
the median line on the shoulder, continued intermittently
during and between several pains effected rotation, and labor
then pursued its normal course. This manipulation must be
continued for some time, and perhaps repeated before the head
will retain its new position. In rotating, the head drags with it
the uterine tissues which, by their elasticity, tend to carry it
back to its former position. Little by little, however, the tis-
sues adjust themselves, and rotation is accomplished.
3. Progress of Labor. — The progress of labor is like-
wise hindered by delayed or imperfect flexion and by
delayed extension. These normal processes may both
be expedited either by simple rectal or by combined
rectoabdominal manipulation. In delayed or imperfect
flexion, place the index finger as far back on the wci-
put as possible and crowd the head forward (in relation
to the fetus) while the other hand on the buttocks forces
the body downward, thus approximating the chin to the
breast. This pressure should be applied before and con-
tinued during the pain, and generally repeated for
several successive pains, so that the parts may accom-
modate themselves to the new position. In delayed
extension, traction should he made well forward on the
sinciput, either with the finger through the rectum or
with palm of the hand applied to the perineum from the
coccyx forward.
4. Application of Forceps. — In applying the forceps
the index finger per rectum m^ be of great assistance
in guiding the blades and in adjusting them to the
parietiil surfaces of the fetal head. I have not yet had
an opi>ortunity of ai)plying the forceiw in this way.
546 AMKRioAir MMiciNEj INTESTINAL MUCOSA OF THE NORMAL RABBIT
(OCTOBEK 4, 190-2
SPECIAL ARTICLES
A STUDY OF THE BACTERIAL FLORA OF THE IN-
TESTINAL MUCOSA OF THE NORMAL RABBIT *
BY
MARGUERITE J. BULLARD, A.B.,
of WlUlmantlc, Conn.
The purpose of this Investigation was to determine (1) if a
particular bacterial flora exists in the mucosa of the digestive
tract of normal rabbits, and (2) in case there is such a flora, to
see if any relation exists between it and the bacteria occasion-
ally found in the solid organs.
The work which has already been done on the bacterial
flora of the skin suggested that possibly there is a correspond-
ingly constant flora in the intestinal mucosa of animals. In the
work of Welsh ' a micrococcus is described which seems to
exist quite constantly in the integument, and apparently has to
do with the cause of stitch abscesses. Later the results of Robb
andGriskey^ showed that the bacteria isolated from wounds
and skin stitches corresponded with those organisms regularly
found in the skin. Moore" found a close relationship to exist
between the bacteria found in the deeper layers of the skin and
those isolated in cases of botryomycosis, closed subcutaneous
abscesses, and infectious cellulitis in cattle, while Gay* demon-
strated the resemblance between the pyogenic bacteria of the
skin and those found in cases of fistulous withers, poll evil and
scirrhous cord in horses.
In the work of Gushing and Livingood * it is stated that the
condition of the intestines is unlike that existing in the skin,
with its definite glandular flora, since microorganisms do not
lurk in the recesses below the surfaces of the mucous mem-
branes. In the same article Gushing describes cases of com-
plete jejunal fistulas in which scrapings from the mucosa of the
lower part of the bowel, which was in the state of prolonged
fasting, were found to be absolutely free from microorganisms,
several inches from the fistula. This evidence, he says, that no
bacterial life whatever tended to remain on the mucosa and to
resist the propulsive action of the bowel, would argue against
the existence of any natural flora other than that furnished by
the ingesta. He also says that the mucosa in the upper part of
the intestinal canal is practically amicrobic, basing this state-
ment on the results of experiments in which cultures were
made from the contents of the intestine of a dog in eleven differ-
ent places from stomach to rectum. Gushing states, too, that
the stomach in its natural empty state in health becomes ami-
crobic, and that the existence of bacterial life in its lumen is
dependent only upon interference with the stomach's power to
expel its contents. The same principle, he says, holding true
for the duodenum, it is not impossible that a similar amicrobic
stage, following digestion with a canal completely free from
food and its accompanying bacteria, may be brought about as
far down as a condition of emptiness may be reached through
fasting.
Ford* found, in working on the bacteriology of healthy
organs, that in 34 animals killed, furnishing 93 organs (livers
and kidneys) of rabbits, guineapigs, cats and dogs, from which
he made 122 cultures, that there were definite growths from
80.6% of the organs.
The results of the examinations about to be described have
shown the existence of bacteria in the mucous membrane
throughout the intestinal tract of rabbits, while the cultures
from the organs did not reveal the existence of bacteria in so
large a percentage of cases as those published by Ford.
The rabbits used in these examinations varied in age from
12 weeks to adult animals. They were kept without food for at
least seven hours before they were used. In each case the rab-
bit was chloroformed, opened immediately after death and cul-
ture mediums inoculated, first with three loopfuls of the heart's
blood, and then with pieces of spleen, liver and kidney from one-
half to one centimeter in diameter. Then cultures were made
fi-om the mucosa of the following portions of the alimentary tract:
the esophagus, stomach, duodenum, jejunum, ileum, appendix,
•This work was done in the Bacteriological Laboratory of the
Medical Department of Cornell University, Ithaca, N. Y.
cecum, upper colon, lower colon, and rectum. Each portion
was opened separately, with instrumentssterilizedin the flame.
The ingesta, when present, was removed, and in all cases the
surface of the mucosa washed with boiled water. The mucous
membrane was then scraped from a small area with a sterile
soalpel and two loopfuls of the scraped mucosa transferred to
each tube of the medium used.
The medium employed was in all cases gelatin, and with
most of the animals agar, bouillon, glucose agar and glucose
bouillon as well. The heart's blood and pieces of the organs
were inoculated into tubes of liquid gelatin and agar, while
gelatin and agar plates were made from the scrapings of the
mucous membrane. The glucose agar tubes were inoculated
by Liborius' method, placing the scrapings in the liquid agar.
The results from the first two rabliits were less satisfactory
than those from the others. With rabbit I several of the cul-
tures became contaminated, and with rabbit II the gelatin
remained liquid for 24 hours, due to an unexpected rise of
temperature.
Rabbit I (12 weeks old). — In addition to the media inocu-
lated from the organs and mucosas, cultures were made from
the contents of the upper and lower jejunum and from the
ileum. At the end of 48 hours growths appeared in the gelatin
plates made from the esophagus, from both umcosa and con-
tents of the jejunum, from mucosa of ileum, of the upper colon
and of the cecum, from the contents of the appendix and from
the mucosa of the rectum. At the end of four days growths
appeared in plates made from the mucosa of the duodenum, the
stomach and the appendix. At the end of six days colonies
appeared in the plate made from the contents of the ileum.
The organisms which appeared in these cultures are as
follows : Bacillus subtilis from the mucosa of the duodenum
and cecum and from the contents of the appendix, an unidenti-
fied bacterium and bacillus from the mucosa of the duodenum,
a bacillus from the contents of the jejunum, a micrococcus from
the mucosa of the ileum and of the upper colon, and micro-
cocci and diplococci from the mucosa of the appendix.
The tubes inoculated with the heart's blood and pieces of
the organs from this rabbit remained clear with the exception
of a few contaminating colonies in the tubes from the liver and
spleen.
Rabbit II (15 weeks old) was chloroformed and opened
with the same precautions as rabbit I. Agar tubes were inoc-
ulated with the heart's blood and pieces of the liver, kidney
and spleen and a series of gelatin plate cultures were naade
from the mucosa of the digestive tract.
On the third day the agar tubes from the liver and kidney
contained many colonies. Colonies were also visible in each
of the plates from the mucosa of the digestive tract except the
one from the rectum, which contained a fungus only.
The bacteria which appeared in the cultures from the vari-
ous mucosa of this rabbit were unidentified with the exception
of B. subtilis isolated from the mucous membrane of the
appendix. The agar tubes from the heart's blood and spleen
remained clear.
Rabbit III (adult) was chloroformed and opened with the
same precautions as in the previous cases. From the organs
and heart's blood of this rabbit gelatin, glucose agar, bouillon
and glucose fermentation tubes were inoculated, while from
the mucous membrane of the digestive tract, except from that of
the stomach, gelatin plates and glucose agar tubes were inocu-
lated.
At the end of 24 hours colonies appeared in the glucose agar
tubes inoculated from the esophagus, lower jejunum, lower
colon, cecum, appendix and rectum, while gas formation
occurred in the tubes from the cecum and appendix.
At the end of 48 hours colonies appeared in the glucose agar
tubes from the mucosa of the ileum and both colonies and gas
production showed in the tube from the upper colon. Growths
appeared in all the gelatin plates except that made from the
esophagus, in which colonies appeared at the end of five days.
In the tubes inoculated with pieces of the organs and with
the heart's blood, growth occurred on the third day in the fer-
mentation tubes inoculated with pieces of the spleen and kid-
ney. All the other mediums inoculated with the organs and
heart's blood remained clear. The growth in the kidney tube
was probably due to contaminating organisms, while the
spleen tube contained Bacillus subtilis, which also must have
been a contamination.
In the gelatin plate made from the esophagus only one
minute colony appeared, which did not develop when trans-
ferred into bouillon. "The gelatin plate from the upper colon
contained fungi only. The glucose agar tubes from the duode-
num and upper jejunum remained clear.
Following is a summary of the organisms isolated from the
mucous membrane of the cfigestive tract of this rabbit: Bacil-
lus subtilis from upper jejunum, lower colon, cecum and rec-
tum. Micrococcus flavus dcsidens (Fliigge) from the ileum,
lower jejunum, appendix, cecum and rectum. An unidentified
bacterium from the duodenum, ileum and upper jejunum
described in the appended table as Bacterium A. A gas pro-
October 4, 1902]
INTESTINAL MUCOSA OF THE NOEMAL RABBIT lamerican mbdicinb 547
ducing red-shaped organism uncertain as to motility from the
appendix, described in the table as Bacterium B.
Rabbit IV (adult). — Inoculated gelatin, agar and glucose
fermentation tubes with heart's blood and pieces of the organs;
made gelatin and agar plates and inoculated glucose agar tubes
■with the scrapings of mucous memljrane from nine different
places of the digestive tract from esophagus to rectum.
At the end of twenty-four hours colonies appeared in the
glucose agar tubes from the mucosa of the esophagus, stomach,
duodenum, ileum, jejunum, cecum, appendix and rectum, the
tube from the upper colon alone remaining clear, (ias produc-
tion occurred in the tubes from the esophagus, stomach and
ileum. Colonies appeared on all the agar plates made from the
mucosa. At the end of three days colonies showed in the gela-
tin plates made from the jejunum and rectum. No growths
appeared in the tubes inoculated with the heart's blood and
pieces of the organs of this rabbit even after six weeks.
From the mucosa of the digestive tract of rabbit IV the
following organisms were isolated : Bacillus subtilis from the
esophagus, stomach, upper jejunum, cecum and appendix.
M.flavus desidens (Fliigge) from the duodenum, upper colon
and rectum. A bacterium apparently the same as bacterium A
which occurred in the duodenum, ileum and upper jejunum of
rabbit III was isolated from the ileum. A small, very actively
motile bacillus resembling Bacillus coli eotnmunis from the
esophagus, described as Bacillus C in the table.
Rabbit V (adult). — Inoculated media as in case of rabbit IV
with heart's blood and pieces of organs andin addition inocu-
late<l glucose agar tubes.
Inoculated media from scrapings from mucosa of digestive
tract the same as with rabbit I\ . Smear preparations with the
fresh mucosa were also made from the duodenum, stomach,
ileum, upper colon and appendix of this rabbit and stained
with methylene-blue.
Examination showed the presence of the following organ-
isms: Duodenum, many long slender rods and short rods with
square ends ; stomach was negative; ileum, many rods with
rounded ends, very short rods, and short chains of micrococci.
Organisms in this preparation were more numerous than in any
of the others; upper colon, short rods with square ends, rods
with rounded ends and micrococci ; appendix, micrococci only.
In this animal there was evidence of latent peritonitis.
There were a few adhesions attaching the lower colon and
rectum to the peritoneum. The lower wall of the rectum was
very brittle.
At the end of 24 hours colonies appeared on the agar plates
made from every part of the mucous membrane of the digestive
tract except in that from the stomach. Growth and gas produc-
tion occurred in the glucose agar and glucose bouillon fermen-
tation tubes from the organs. All the mediums inoculated
from the heart's blood continued clear. At the end of 48 hours
all the gelatin plates and all the glucose agar tubes from the
digestive tract, except the plate and tube from the stomach,
contained colonies. The gelatin plate and glucose agar tube
from the stomach remained clear.
With this rabbit only the cultures from the duodenum,
ileum, liver and spleen were carried further than the gelatin
and agar plates, glucose agar and bouillon tubes. The organ-
isms isolated from these four places seemed to be identical and
to belong to the colon group.
Rabbit VI (adult). — Made inoculations the same as in case of
rabbit V, with the addition of bouillon.
At the end of 24 hours colonies appeared in the agar plates
from the mucosa of the esophagus and appendix, in the glucose
agartubes from the mucosa of the jejunum, cecum and appen-
dix, and in the bouillon tubes from the upper colon and appen-
dix.
At the end of the fourth day colonies appeared in the gela-
tin plates made from the stomach and appendix.
The bacteria isolated from this rabbit follows : Bacillus
subtilis from the mucous membrane of upper colon, cecum
and appendix. Sarcina alba from the mucous membrane of
the esophagus, stomach, rectum and spleen.
The colonies which appeared on the gelatin plates made
from the mucosa of the jejunum, and the agar plate from the
lower colon failed to develop when transferred to bouillon. The
gelatin plates from the mucosa of ileum and upper colon con-
tained fungi only.
Rabbit VII (adult). — Inoculations were made the same as
in case of rabbit VI. Smear preparations were also made from
the mucous membrane of the duodenum, jejunum, ileum, colon,
cecum, appendix and rectum, and stained with methylene-blue
as in the case of rabbit V.
On examination the presence of the following organisms
was revealed : Duodenum, masses of short square-ended rods
and micrococci; jejunum, smaller masses of square-ended rods
and micrococci, apparently the same as those in the duodenum ;
ileum, masses of short square-ended rods, long slender forms
and micrococci; colon, masses of short square-ended rods and
micrococci ; cecum, masses of short square-ended rods, long
slender forms, and short very thick rods, short slender rods
and micrococci. The organisms in this preparation were more
numerous than in any of the others ; appendix, many short
rods and micrococci ; rectum, masses of short square-ended
rods, long slender forms, very short rods and micrococci.
At the end of 24 hours colonies appeared on the agar plates
from the mucosa of the stomach and cecum. Colonies and gas
production appeared in the glucose agar from the stomach and
cecum, and the bouillon tubes from the stomach and rectum
were cloudy. At the end of three days colonies appeared on the
agar plate from the colon and on the gelatin plates from the
duodenum and colon and in the glucose agar tube inoculated
with the liver.
The following organisms were isolated from this rabbit:
Bacilhis subtilis from the mucosa of the stomach, colon and
cecum. Bacillus mycoides from the mucosa of the stomach.
M.flavus desidens (Fliigge) from the mucosa of the rectum and
from the liver. A short, thick, actively motile, gas producing
bacillus isolated from the mucosa of the cecum and appendix,
described in the table as Bacillus D.
The colony on the gelatin plate from the mucosa of the
duodenum did not develop when inoculated into bouillon. The
media inoculated with the heart's blood, spleen, kidney, mu-
cosa of the esophagus, jejunum and ileum remained clear at the
end of six weeks.
In the appended tables are given the approximate numbers
of the different colonies which appeared in the gelatin and agar
Elates made from the organs and intestinal mucosa of the rab-
its used, also the descriptions of the cultural characters of the
organisms which were not identified.
Table I.— Showing Number of Colonies.
Organs.
Heart's blood,.
Liver
Spleen
Kidney
Ksophagus..
Wtoinach
Duodenum ..
Jejunum
Ileum
13 pper colon ..
Ix>wer colon..
■Cecum
Appendix.^...
Kcctum
Rabbit I.
Rabbit II.
Rabbit III.
Babbit IV.
Rabbit V.
Rabbit VI.
Rabbit VIL
Oel.
Agar.
Gel.
Agar.
Gel.
Agar.
Gel.
Agar..
Gel.
Agar.
Gel.
Agar.
Gel.
Agar.
Contam-
Cont'm-
Contam-
...
5
ei)
inated
Inated
inated
Contam-
8
inated
Cont'm-
Inated
Contam-
inated
...
Contam-
inated
...
100
Very
2 fungi
••>
150
27
1,100
Innu-
40
1
many
merable
contam-
%
inated
3
1
Lique-
fied
Llque-
25
2
Film
Numer-
Few
2
2 1 3,000
Innu-
1
ous
■ B
ned
merable
Numer-
Llque-
1
1
Film { Innu-
Innu-
12 and 2
ous
fled
merable
merable
fungi
Numer-
93
Numer-
Innu-
1
7
1
Innu-
Innu-
Ifu'gus
ous
3
OU8
merable
merable
merable
13 and 2
cr
Lique-
Innu-
3 fungi
6
1
2,000
Innu-
Ifu'gus
2
Film
fungi
fied
merable
merable
1
r
14 and 1
fungus
...
...
1
...
Nuraep-
1
Innu-
2 and
Innu-
Innu-
2
15
ous
merable
film
merable
merable
Numer-
25
Innu-
7
Film
700
350
Sand 1
Wrinkled
Llque-
4 and 1
ous and
merable
fungus
mem-
fledarea
fungus
1 fungus
brane
2 cm. di-
ameter
2
1 fungus
6
1
24
Innu-
Innu-
1 andl
Ifu'gus
merable
merable
fungus
648 AUEBICAN MbDICINEj
THE WARD CLINIC
[October 4, 1902
Tablb II.— Unidkntifibd Bactehia Refebked to in Text.
Name of Or-
ganism.
Bacterium A .
Bacterium B.
Bacillus C
Bacillus D
Source.
Mucosa of rabbit III..
Mucosa of rabbit 111..
Mucosa of rabbit IV..
Mucosa of rabbit VII
Morpbol-
ogy.
iSS
bed
Q
+ —
+ —
Biology.
Cultural Features.
Nut.
broth
tube.
Nut.
agar
tube.
Gel
plate
o.hS
_ y: o
d-o.
From such a preliminary study few conclusions can be
drawn concerning a bacterial flora of the intestinal mucous
membrane of rabbits, or of the relation existing between it
and the bacteria occasionally found in the solid organs. I have
found, however. Bacillus subtilis regularly in each rabbit and
in most cases this organism was isolated from the mucous
membrane of several different divisions of the digestive tract.
M. deaideiis and Sarcina alba occurred in almost every animal.
Bacillus coli communis was found only in rabbit V, and in this
animal it appeared in both the digestive tract and the solid
organs. Jloore and Wright' have found B. coli communis to
appear in the intestines of about one rabbit in four. Gushing
states in the article referred to that bacteria are not so nu-
merous in the digestive tract of rabbits as they are in that
of dogs, aud that this is due to the difference in the nature of
the food of these two animals. The rabbits used in these ex-
periments were fed in part with hay and consequently the
regular appearance of B. subtilis might be expected. Sarcina
alba and M. desidois are frequent inhabitants of water and
presumably they gained admission through that medium. The
facts seem to point to the conclusion that these organisms
entered with the ingesta, remained and possibly multiplied, as
suggested by the numbers, on the mucous membrane.
In these examinations the mucosa of the stomach contained
the smallest number of bacteria, due, probably, to the germi-
cidal action of the gastric juice. However, the presence of
B. subtilis in the stomachs of rabbits IV and VII, B. mycoides
in VII, and Sarcina alba in VI and VII, shows that these bac-
teria were not destroyed during a period of at least several
hours. Whether they had become permanent inhabitants of
the mucous membrane of the stomach is not clear from the
existing facts.
The plate cultures from the mucosa of the cecum and ap-
pendix in all cases, and of the rectum in most cases, contained
a larger number of colonies than did those from any of the
other divisions of the digestive tract. This agrees with Cush-
ing's statement that the lower portion of the tract contains a
larger number of bacteria than those portions nearer the stom-
ach. The mucosa of the esophagus contained a larger number
of bacteria than those portions of the tract following immedi-
ately after the stomach. Tlie organisms isolated from the eso-
phagus were the same as those found in other parts of the in-
testine. This malies it appear as though the bacteria taken
with the food not only remained localized in the esophagus, but
that the same species passed through the stomach and became
similarly localized in the lower part of the intestine.
It is of special interest to note that, contrary to the results
obtained by Ford, bacteria were found in the solid organs of
but two rabbits. These organisms were identical with the
species isolated from the digestive tract of the same rabbits.
The cultures made from the heart's blood remained clear in all
cases.
In conclusion, I wish to acknowledge my indebtedness to
Dr. V. A. Moore for valuable suggestions aud assistance re-
ceived throughout this work.
BIBLIOaRAPHY.
geon^ Vouf m °^ ""^ Congress of American Physicians aud Sur-
2 Johns Hopkins Hospital Bulletin, April, 1892
3 American Veterinary Review, January-ilarch, 1900.
Gel. stab.
Potato
tube.
Fer.
tube.
Blochemic Features.
>,3
as
£
+ ! +
— +
— +
— +
Lique-
Cactton
Gas
producllOD. TJ
i2
it
a
MUk.
* Ibid., March, 1901.
llam H."vVc'!ch'T4'.'' '"^ **'='*"''^ "' Medicine, by the pupils of Wll-
190o! '■'''^"'*'''=""°s o^t'he Association of American Physicians, Vol. xv,
' American Medicine, Vol. ill, p. 504.
THE WARD CLINIC
BY
JAMES B. HERRICK, M.D.,
of Chicago, 111.
For most medical colleges to talk about ward clinics re-
minds one of children in their play talking of what they will do
when they are grown up, married, rich and have houses and
lands of their own ; for the greater number of medical colleges
are without ward clinics today, and can only tell how glorious
they will be, how valuable they may be made as a means of
education, and how they will be conducted when once they
arrive. But ward clinic is the cry ; it is in the air, and one has
to talk about it and write about it; and it seems to be taken for
granted that if not the only method of teaching, it is, at least,
the best. It seems generally agreed that the small clinic is the
great desideratum. I will, therefore, be brief and speak only
m outline of the advantages of the ward clinic.
1. It brings into closest touch the teacher and student, an
easily understood advantage, rendering possible the subtle, oft-
unrecognized interchange of thought, and making felt that
intangible yet powerful something we call personal influence.
Instruction is here adapted to the individual and not to the
average man in the class.
2. It brings into intimate relations the student and patient.
In this way the student becomes acquainted with human nature
as seen in the sick, learns how to handle his patient and to inter-
rogate him and get his subjective history, an art too little culti-
vated even by physicians. One of our dispensary instructors
tells of a student who, knowing that ho should begin his inter-
rogations with inquiries as to family history as showing heredi-
tary tendency, hesitated and stammered a moment, not know-
ing how to begin, and Anally blurted out, " Well, how's all the
folks?"
He acquires knowledge of the phenomena and physical
findings in health aud disease that can be obtained in no other
way. No matter how vivid the textbook description or how
lucid or emphatic the clinician's description may be, the student
can not know what is a heart murmur, a bronchial breathing a
dicrotic pulse, a choked disc, a palpable spleen or a bone crep-
itus, until with his own senses he has perceived them. Bright
men without ward work in classes or as hospital internes learn
these things by practice on their patients. Dull and mediocre
men never learn them-and their number is legion-and we are
to blame.
3. The student learns proper methods of study. Each pa-
tient presents a problem to be solved. He is the unknown
compound requiring analysis or he presents isolated facts that
must be synthesized into a harmonious and stable whole. The
student is in a laboratory and human beings are his material.
He becomes enthused with the spirit of investigation. The
lAuthor's abstract of an address before the faculty and cnms nf
Instructors of Rush Medical College, Decembers; 1901 "^ ^ "'^
OCTOBKR 4, 1902]
THE WAED CLINIC
lAJOERICAIt HEDICISB 549
Study of each case is for him, or should be, a little " arbeit." He
learns to observe, to thinli for himself, to depend upon his own
powers of observation as they become more and more trained
by usage, he becomes to the best of his ability an independent
worker ; and all this, please note, without harm or suffering to
the patient, because over the student, to watch, guide, restrain,
is the carefully-chosen instructor. In no otlier way can the
accurate details of medical knowledge and the correct methods
of thought and study— and knowledge and method are the two
aims of education— be so well secured as in the bedside clinic.
Let me refer right here to a mistake that is often made as to
what a ward class really should be. It is not a small arena
clinic with an audience of five to ten. To get this number of
students into a side room with a patient, to demonstrate that
patient to them, even though the students verify or think they
verify all your findings, is not an improvement on the method
of the arena clinic ; it merely gives the student a hurried
opportunity for closer physical examination than the amphi-
theater affords. True ward teaching means for the student
access to the wards, frequent examinations of the patient, read-
ing and meditation upon the case, reexamination, the writing of
histories and the reaching of his own independent conclusions,
with reviews and criticisms by the instructor and at times the
necropsy corrections. It means a hospital where the teaching
of medicine is one of the fundamental objects of its foundation,
a free hospital under the control of the teaching force of the
college. Incidentally, it may be said that in such a hospital
not only do students benefit, but teachers and patients. For
there is no better stimulus to careful and thorough study of a
case than the knowledge that the case is to be shown at short
range to bright students who have also studied it.
I have a feeling that we are in danger of being carried too
far by our entliusiasm for the ward clinic. I recently heard a
speaker tell how powerful a good campaign cry was in forming
public opinion, how such phrases as " sound money," "Amer-
ica for Americans," " tariff for revenue only," etc., catch the
popular ear and carry conviction often without reason. So I
fear this cry of ward clinic has been a name to conjure with and
has cast a certain amount of disrepute upon the other methods
that, if not as valuable, are by no means to be ignored. The
other methods of teaching are by recitation, didactic lecture
and arena clinic.
Should there not be at the beginning of the study of any of
the broad subjects, like medicine and surgery, a general survey
of the topic by means of the recitation, a birdseye view, so
that diseases can be seen in their proper relations, one to
another, so that differential diagnosis shall be more clearly
understood and the bearing of the fundamental upon the prac-
tical branches more clearly seen ? The recitation should be a
conference and not a memorizing, and the textbook should be
the text, the nucleus only of the conference. Students in this
way learn how to read, how to study and how to express their
thoughts, and until they have written or spoken their thoughts
they do not know what they really believe.
The didactic lecture that is a mere repetition of a few details
from a textbook should go. But special topics by those who
have worked them out thoroughly can well be presented in
didactic form, giving not the result of study of one textbook
but of many, and above all, the results of study of monographs
and maga/.ine articles not yet incorporated in textbooks, and of
original work. All medical textbooks are behind the times
and must of necessity be so. I asked a wellknown professor
of pathology a few years ago if he lectured at all to the
students. With a somewhat apologetic air he replied that he
did lecture once a week on such topics as immunity and kin-
dred topics that had not yet got into the textbooks. A pro-
fessor of physiology, in speaking to me a short time ago, rather
apologized for giving didactic lectures, but said he knew of
no textbook that was up with the times, so he felt he had to lec-
ture. It seems to me that neither of these gentlemen should feel
oblige<l to apologize for didactic lectures of this character. A
didactic lecture that is thorough, systematic, with an up-to-date
presentation of facts, by one who has thoroughly studied his
subject, should need no defense. Such lecturing should be
regarded as one of the highest functions of the teacher.
And now as to the arena clinic, the clinic given to a large
class. Should this go ? We hear it said, not Infrequently, that
it is impossible to do good teaching to large bodies of students,
that the arena clinic becomes amphitheatric, it is burning of
red fire. That this is so in certain instances must be admitted.
But some of those who make this charge against the amphithe-
atric clinic disprove their statements every time they hold a
clinic in the amphitheater. They prove that it is not all red
fire. They are able to teach to small or large classes, demon-
strating the methods of examination, discussing etiology, prog-
nosis, differential diagnosis, treatment, and are able to show
the coarser symptomatology and physiognomy of disease. Is
it not better that a hundred or two hundred earnest listening
students should hear a good clinical teacher of wide experience,
a leader in his profession, discuss these subjects two or three
times a week than that this number of students should be split
up into small classes of eight or ten each and in this way
have the privilege of hearing him onl.v eight or ten times a
year? There are some men who will burn red fire in the
amphitheater, but these men will burn red fire in the small
ward clinic, in the medical society, in every article they write
for a magazine. The fault is not always in the clinic, it is often
in the man. An amphitheater clinic becomes too large just so
soon as discipline and order have to be considered, or when the
speaker is obliged to make a conscious effort to entertain his
audience, or to swerve from the path of instruction to arouse or
hold the attention of his students. When he does this then
the pyrotechnics begin. This difliculty has already been
largely eliminated in many of our colleges by the grading of
classes, by the better selection of students who enter, and by
the elective system. It naturally follows from these facts that
the students who make up an audience in a clinic are men who
are in earnest, who are prepared to be critical listeners and to
understand what is said, on an equal footing one with the other
and not as in the olden times, a mixture of the beginners and
seniors. Where the elective system obtains they have chosen
to attend the clinic because they wish to take this course, they
wish to listen to a particular instructor. They do not attend
because they are forced into the work. The question of order
and discipline with an audience like this seldom arises.
For the acute diseases and the terminal stages of diseases,
for continued frequent observation of patients, the hospital
is indispensable, but the same careful methods and many of
the facts can be taught in a well-conducted dispensary, a thought
permitting of expansion, but which is merely thrown out here
as a fact not to be overlooked.
It is wise to speak and think of the ideal ward clinics. It
should spur on every medical school to a determination to
make the dream a reality, to find somewhere and somehow in
a hospital already existing, or in some new hospital, a place
where, under college control, teaching can be done. But there
is a danger in spending too much time looking backward
and regretting what is lost and in looking forward to what one
hopes to enjoy. One should not live in an old man's reminis-
cent dream of the past, or in a child's glittering dream of the
future, but in a strenuous present. There are opportunities
right at hand and each college should make the best use of
them.
With what hospital connections it may have, with its out-
patient department, with extramural facilities, no college is
poor. The difliculty is in not utilizing our wealth as we should.
The colleges do not begin to realize the extent of the riches
that lie about them. So there should be no bemoaning of one's
fate, no postponing of plans for a year or two, but the deter-
mination on all Hides to make the clinics, large and small, in
the dispensary and in the arena, the best possible. Much can
bo done in this way, and shame upon the college that fails to
watch over the talent that has been entrusted to its care so that
it does not bring good returns. For only to those who show by
present performance capacity and fitness for greater things are
greater and better things given.
Cholera In Kjfypt.— The total number of fresh cases
reported for the week ended September 21 was 0,587. There
were ."),'J83 deaths during the week. In the previous week there
were y,805 fresh cases and 8,497 deaths. Up to date there have
been reported 30,931 cases, with 25,734 deaths. The general
condition is reported to be improving rapidly.
550 AMKKioAif Medicine
MEDICAL PRACTICE IN CAIRO
lOCTOBEB 4, 1902
MEDICAL PRACTICE IN CAIRO AND PREVAILING
DISEASES OF EGYPT.
BY
NICHOLAS SENN, M.D.,
of Chicago.
The name of Egypt brings up thought.s of antiquity. The
land of the Rameses, of the Pharaohs, has a history tlie begin-
ning of which extends back to the dark unknown— Egypt, the
most famous of ancient nations, once the center of science, art,
literature and commerce and which remains much the same as
it was more than two thousand years ago. The Pyramids
remain as silent witnesses of the power and ambition of its
earliest rulers and the waters of the same lordly Nile continue
to irrigate its fertile valleys. In the course of time, science and
art fled to foreign countries and the greatest commercial cen-
ters have arisen in countries which were unknown when the
glory of Egypt was the envy of the world. The Egyptian
works of art have found places in the large museums through-
out the world. The royal tombs have been robbed and their
precious contents are on exhibition in strange lands, strong
reminders of the limitation of life and vanity of earthly
power. Egypt was the cradle of the healing art. For centuries
Alexandria was the mecca for medical students. Its great
library attracted the scientific men from far and near. The
Arabic medical textbooks were accepted as authoritative every-
where and formulated the practice of all physicians who made
any claim whatever to education. With the gradual decay of
Egypt progress in medicine declined, but today the profession
of the western medical world is returning to the ancient center
of medical education in a new and much improved form what
was borrowed centuries ago. So great have been the advance-
ments in medicine during that time that the Arabic language,
the medical language for many ages, has become utterly inade-
quate to express modern medical ideas. Cairo is the door
through which scientific medicine is finding its way again into
the land where civilization had its dawn.
CAIRO AS A MBDICAL CENTER.
Cairo is the largest city in Africa. Its present population is
nearly 1,000,000. Located in the fertile valley of the Nile, on
the banks of this great waterway through Egypt and near
Alexandria, the great seaport town of the western coast of
Africa, it continues to command an important position in the
commercial world. The genial winter climate has made it also
a desirable and fashionable health resort. The city has a num-
ber of first-class hotels, and during the winter months is
crowded with wealthy visitors from all parts of the world
who seek recreation or a climate conducive to tlieir health.
The European part of the city has fine residences, beautiful
gardens, magnificent streets and boulevards, and is well
policed. Begging, the curse of the Palestine cities, does not
prevail, and the natives treat the strangers with respect and
courtesy. Modern medicine has gained a firm foothold in
Cairo and Alexandria. More than 100 European physicians
have located here and practice their profession with variable
success.
Medical Practice. — Egypt does not suffer from a lack of
physicians. The country has 10,000,000 inhabitants, and there
are from 1,000 to 12,000 physicians in readiness to respond to
professional calls. As at least 15% of the patients are unable
to pay for medical services, and as the competition in
the two large cities, Cairo and Alexandria, is keen, it is a
natural consequence that the fees should be small. Few
physicians in Cairo receive on an average more than a dollar
a visit and 50 cents for an office consultation. Surgical work
is better paid for, but $150 is considered a handsome fee for any
of the major operations. What makes surgery in Egypt not
more remunerative is the inborn aversion of the natives to
surgical operations. This aversion amounts almost to absolute
refusal among the Mohammedan women. This is the reason
why ovariotomy and hysterectomy figure so low in all hospital
statistics. The Arabs bear surgical operations well. Shook
and accidents from the administration of anesthetics are very
rare. The natives are grateful patients and never forget the
services of their physician. Of this I saw an instance in the
Municipal Hospital, Cairo. As we were passing through one
of the wards a man with a tracheotomy tuije in his trachea
approached Dr. Wildt, who accompanied me, prostrated him-
self and kissed his feet. The doctor explained that the man
was a former patient of his at a time when carcinoma of the
thyroid gland, whicli later made the tracheotomy necessary,
was still within reach of a successful medical operation.
Excision of the carcinomatous gland was proposed, but was
promptly refused. In the meantime experience demonstrated
to the patient only too plainly the correctness of his physician's
diagnosis and the wisdom of his advice.
The entrance into practice in Egypt is not difficult, all that
is necessary is to present a diploma from any recognized medi-
cal college. The graduates of the medical college in Beyrut are
permitted to practise on a certificate from that school. Consid-
ering the number of phy.sicians already in the country it would
seem advisable and timely to make the laws governing the
entrance into practice more stringent.
Medical Societies. — Egypt has at present two medical
societies, one in Cairo the other in Alexandria. The Cairo
Medical Society has a membership of 60, and meetings are held
every three weeks during the winter season. At these meet-
ings modern surgical and medical topics are discussed and
clinical cases and pathologic specimens are exhibited. The
Egyptian Medical Congress will be held in Cairo next Decem-
ber. This congress is called for the special purpose of discuss-
ing tropical diseases, and is international in its scope. Invita-
tions have been sent to all countries, and there are fair prospects
for a good attendance.
Dr. H. Wildt will present an exhaustive paper on "The
Surgical Aspects of Bilharzia." His immense experience
entitles him to speak authoritatively on this subject. Professor
Bitter, of the Hygienic Institute, will discuss " Madura Foot."
As the professor has made a special study of the parasite of this
strange disease for a year and a half the audience may expect to
learn all that is known of the etiology and pathology of this rare
disease.
The Egyptian colleagues ought to utilize this opportunity
and organize a national society. The annual work of such a
society would be of the greatest value in enlightening the medi-
cal profession throughout the entire world on many of the
tropical diseases, the nature of which as yet is but imperfectly
understood.
Cairo Medical College.— This is the only school in Egypt
devoted to the study of medicine. It is fairly well equipped,
and is attended during the present year by 60 students. Nearly
all of the professors are Englishmen, a few natives fill subordi-
nate positions. The students must study four years before
they are admitted to the final examinations. The clinical
teaching is conducted in the Municipal Hospital by a large
staff of professors and instructors, most of them of English
birth and education. As the classes are small and the clinical
material abundant, tliis part of instruction is all that could be
desired.
Kasr-el-Ainy Hospital.— This is the municipal or govern-
ment hospital. It is an old building which has recently been
much improved to answer modern requirements. It contains
400 beds. All the expenses are paid by the government, and
admission is free to all sick poor. The wards are large, airy
and well lighted. The hospital furnishings are plain, but com-
fortable and sanitary. The two operating-rooms are fairly well
equipped. One is used for surgical, the otlier for gynecologic
cases. Here I was given an opportunity to examine an unusu-
ally large number of bilharzia cases. In several patients the
disease had resulted in the formation of perineal fistula, in
others the kidneys had become involved. The ophthalmic ward
contained the usual large percentage of eye cases. Among the
other tropical diseases I noticed elephantiasis, ankylostonia
and a large number of pellagra cases. The latter presented,
without exception, the characteristic eruption. In one case the
disease was complicated by a partial dementia, but whether
this brain defect was a coincidence or the result of the original
disease, it was impossible to determine. I was informed that
in pellagra cases ankylostoma is very common. All of the
pellagra patients showed distinct signs of anemia. The nurs-
ing is in the hands of nine trained female nurses from England.
OCTOBER 4, 1902)
MEDICAL PEACTICE IN CAIRO
[Amsrioah Medicine 551
This hospital could make itself still more useful to the commu-
nity by the establishment of a training school for native women.
The Victoria Deaconess' Hospital. — This is a German hos-
pital founded and conducted by Sisters from Kaiserswerth. It
is by far the best hospital in Cairo. It was built 20 years ago
and can accommodate 100 patients. At present nine Sisters are
on duty. The operating-room is modern and is amply supplied
with instruments and appliances for aseptic work. Dr. H.
Wildt is in charge of the surgical service and is assisted by the
resident physician, a graduate of a German university. All of
the patients are expected to pay. They are divided into three
classes. The first class pays §2 a day, for which sum they are
entitled to a private room. The second class pays §1 a day
liilii
Dciic
. ittoria Hospital In Cairo.
and live in rooms with two or three beds. The ward patients
pay very little and those that are very poor are admitted free.
At the time of my visit Dr. Wildt showed me two cases of
liver abscess recently operated upon and eight cases of bilharzia
presenting the various clinical phenomena of the different
stages of this disease.
PRKVAILING DISEASES OP ECiYPT.
The governmentof Egypt (England, of course) has taken the
necessary steps and gone to the requisite expense to establish an
Institution which is intended to serve the purpose of offering alj
necessary facilities for the scientific study of infectious diseases,
with a special view to more thorough investigation of tropical
diseases and of formulating and enforcing effective sanitary
measures by building and maintaining the Hygienic Institute.
The Hygienic Institute. — This building is located in the
central part of Cairo. The building is a creditable one and is
well supplied with all necessary facilities for bacteriologic and
pathologic research. It was opened five years ago under the
directorship of Professor H. Bitter, a German scientist. Profes-
sor Bitter is the right man in the right place. He was a pupil
of Koch and other distinguished German bacteriologists, and
for several years was privatdocent in the Breslau University.
He is well prepared for his manifold duties and commenced his
work with an enthusiasm characteristic of the German scien-
tists. He possesses all the qualifications for the position he
now occupies. He is an expert bacteriologist and pathologist,
an artist and skilful photographer. Since he has taken charge
of the institute he served as a member of a commission of three
appointed by the government to visit Bombay for the purpose
of studying the bubonic plague, which was raging in India at
the time (lf97). He published the results of his far-reaching
observations in a paper entitled " On Haffkine's Preventive
Inoculations Against the Plague and on Plague Measures in
India." This paper appeared in 1899 and has been very exten-
sively noticed in the medical press of Europe and America. He
Is now engaged in investigating the fungus of madura foot and
its effects on the tissues. He makes the final diagnosis in
obsure cases in which tlie use of the microscope is essential in
ascertaining the bacterial nature of the disease. He makes
thorough investigations of the water supply in various parts of
Egypt and locates the source of infection in endemic outbreaks
of infectious diseases. He is also professor of hygiene in the
Cairo Medical School.
ACUTE INFECTIOUS DISEASES.
Bubonic Plague. — At the present time there are no cases of
bubonic plague in Cairo. The disease, however, has infested
nine or ten of the surrounding villages and every few days new-
cases are reported from Alexandria. The Syrian ports enforce
quarantine against Alexandria. Active measures are being
enforced to arrest further spi-ead of the disease.
Malaria. — This is very rare in Egypt. In Cairo it is
almost unknown and it is very uncommon in the valley of the
Nile. The only place in Egypt where malaria is engendered to
any considerable extent is along the banks of the Suez Canal
and a few other isolated places. Malaria is the prevailing dis-
ease throughout Palestine, more especially Jerusalem and its
surrounding villages. Professor Bitter explains this on the
mosquito theory. He says the mosquito of the Nile valley is
the ordinary culex, while the mosquito of the plains and moun-
tains of Palestine is the Plasmodium carrier — the anopheles. I
had a bitter experience with the latter. In Jerusalem and
Damascus they attacked viciously my hands aud forearms.
Swelling, redness and lymphangitis ensued, which caused an
intolerable itching and burning, rendering sleep impossible for
several nights. I considered it advisable to take a daily dose of
10 grains of quinin to prevent the development of malaria, and
so far this prophylactic treatment appears to have been success-
ful. I am satisfied that the sting of this kind of mosquito is
more virulent than that of the common culex.
Typhoid Fever. — Typhoid fever is the great scourge of Cairo
and many other parts of Egypt. In Cairo it is never absent.
In the Victoria Hospital 109 cases were treated during the last
year, with 12 deaths. The shallow infected wells are the breed-
ing places of Bacillus typhosus.
Other Acute Infectious Diseases. — Dysentery, rheumatism
and acute inflammatory affections of the lungs and air passages
figure heavily in the hospital records and the case-books of
physicians. Pulmonary tuberculosis and tuberculosis of the
lymphatic glands, bones and joints occur with the same fre-
quency as in our country. The same can be said of smallpox,
scarlatina and diphtheria.
Bilharzia. — The frequency with which this parasitic disease
prevails in Egypt became apparent to me from the number of
cases I saw in the Victoria and Municipal Hospitals. The para-
site enters through the skin, locates in the radicles of the portal
vein, in the wall of the rectum or bladder. The ova develop in
the submucosa of the rectum or bladder, cause ulceration and
often the formation of large granulomatous swellings. If the
disease invades the bladder the earliest symptom is a slight
hemorrhage after urination, followed sooner or later by vesical
and urethral irritation. Extensive ulceration of the mucous
membrane of the urethra results in periurethral infiltration and
the formation of a perineal fistula. Not infrequently the dis-
ease ascends along the ureter and ultimately leads to pyelitis
and pyonephrosis. The bilharzia cystitis often gives rise to the
formation of multiple calculi. Perineal section and suprapubic
cystotomy are often made necessary by extensive disease of the
uretlira and bladder. In rectal bilharzia perineal abscesses and
fistulas are the remote complications. Dr. Wildt has found tur-
pentine the most effective remedy for internal medication.
Ankylostoma Duodenalis. — This parasitic affection of tlie
intestinal canal is very common in all parts of Egypt. The
most common symptom is a pronounced anemia. In the Kars-
el-Ainy Hospital thymol has been found the most effective
remedy. This drug is administered in a single dose of two
grams followed by a castor-oil purge. After the expulsion of
the parasite iron is given to correct the anemia.
Madura Foot.— 'Vhis parasitic disease is quite rare in
Egypt. Dr. Wildt has seen only two cases in 2.'! years. Last
year only one case was observed in the Kars-el-Aiuy Hospital.
The parasite is a ray fungus which morphologically bears a
close resemblance to the actinomyces. The swelling of the foot
is almost typical. The plantar surface gradually changes from
a concave to a convex shape. The nodules in the skin are
552 A.UEBICAN MeDICINB]
THE WORLD'S LATEST LITEEATUfiB
lOCTOBEB 4, 1902
composed almost exclusively ot a pure culture of the lungus.
Two varieties occur, the white and the black. In the latter
variety the fungus is coal black. The intlammatory swelling
consists of granular tissue, which under the microscope might
readily be mistaken for a small round-cell sarcoma.
Abscess of the Liver. — In the tropics this disease is not
necessarily preceded by dysentery or any other grave lesions of
the intestinal canal. Its bacteriologic origin remains unex-
plained. When Professor Koch was in Cairo in 1883 he made a
careful bacteriologic study of the contents of a number of
abscesses of the liver, but was unable to come to positive oon-
Madura Foot (after Bitter).
elusions regarding the essential bacteriologic cause. No more
definite results have been reached since. I had an opportunity
to see two cases of this affection in the Victoria Hospital. The
patients were recently operated upon by Dr. Wildt. In one case
the abscess was located in the left lobe of the liver. This
patient was operated upon by abdominal section, and the oper-
ation was completed in one sitting. This is the invariable rule
followed by Dr. Wildt. The peritoneal cavity is protected
against contamination during the operation and drainage by a
gauze pack as long as is required. The same rule is followed
when the abscess has to be opened through the free pleural
cavity. Dr. Wildt does not fear pulmonary collapse and only
in one out of more than 300 cases was the operation the cause of
a subsequent empyema. Dr. Wildt has up to the present time
operated upon 340 cases of abscess of the liver, with the follow-
ing results: Mortality of the first hundred cases, 38%; the
second hundred, 329^ ; the third hundred, 20?;,. The statistics
prove that like in any other important operations the results
improve with increasing experience.
Streptococcus Infection.— The streptococcus is almost ubiqui-
tous, but there are places in which this microbe is rare or
entirely absent. It is said by Professor Bitter and others in
Cairo that the most careful bacteriologic investigations have
shown that it is almost entirely absent in Khartoum, Egypt.
In the valley of the Nile this pus microbe appears to be very
common. Many patients with furunculosis come to the clinics
and into the hospitals. This affection is here called the Nile
pustule. It appears in the form of a multiple suppurative affec
tion of the sweat glands. It attacks most frequently the exposed
cutaneous surfaces— the face, neck, hands and forearms. The
exciting cause in most instances is the streptococcus. Multiple
large abscesses are also frequently met, and in many instances
it is impossible to find a peripheral, recognizable infection-
atrium. I found two such cases in the Victoria Hospital under
the care of Dr. Wildt. These abscesses are not without danger
to life, particularly in patients suffering from anemia or some
other antecedent debilitating disease.
Cairo, July 6.
THE WORLD'S LATEST LITERATURE
Journal of the American Medical Association.
September S7, 1902. [Vol. xxxix, No. 13.]
1. Hospitals for the Neuropathic and Psychopathic. KrcHARDDKWET.
2. Abscess of the Lung Following Acute Lobar Pneumonia. Floyd
W. MoBae.
3. The Inoperable Nature of the Pulmonary Tuberculous Lesion.
Horace J. Whitacke.
i. The Diagnostic Importance of Keratitis punctata Interna (Desceme-
tltis). Harry PKrEDENWALD.
5. Injuries of the Eye Productive of Diseases of the Uveal Tract.
Howard F. Hansei,!,.
0. The Employment of Digitalis and Aconite In the Treatment of Car-
diac Disease. H. A. Hare.
7. The Origin of the Vesicular Respiratory Sound. C. F. Hoover.
8. Hepeated Small Hemorrhages as a Cause of Severe Anemia. James
B. Herrick.
9. A New Instrument for Intestinal Anastomosis. E. M. Lundholm.
10. Etiology and Treatment of Chronic Cystitis. A. C. Stokes.
1. — See American Medicine, Vol. Ill, No. 24, p. 990.
2, 3.— See American Medicine, Vol. Ill, No. 24, p. 987.
4, 5.— See American Medicine, Vol. Ill, No. 25, p. 1052.
6.— See American Medicine, Vol. Ill, No. 25, p. 10.35.
7.— See American Medicine, Vol. Ill, No. 24, p. 986.
8.— Repeated. Small Hemorrhages as a Cause of
Severe Anemia.— Herrick's attention was called to this subject
by having seen five patients with bleeding piles in whom a
grave secondary anemia developed. These cases he reports.
This form of anemia may prove fatal. It may be transformed
into the pernicious type. Immediate measures should be taken
for checking the hemorrhage. Recovery, though slow, is gen-
erally complete, [h.m.]
9. — A New Instrument for Intestinal Anastomosis. —
This instrument resembles auordinary clamp forceps with dull-
pointed blades at an angle of 125° to the handles. The smooth
inner surfaces are grooved to allow the passage of a sharp-
pointed stylet. Transverse grooves 1 cm. apart serve to mark
the distance the blade has been introduced and as fixing points
for thepuckering-string. The bowel is stretched transversely
and one blade pushed in as far as desired. The same is done
with the other part selected for anastomosis. The blades are
then locked, puckering-strings having been first tied over a
transverse groove if there is any tendency toward slipping.
The adjacent surfaces are now sutured along the edges of the
blades. The stylet is then pushed in the tunnel formed by the
longitudinal grooves thus dividing the visceral walls and a
dull heated stylet is uext introduced to prevent hemorrhage.
When the forceps are withdrawn a few more stitches will close
the remaining opening. Lavage of the stomach before or after
operation is not always needed. Gastroenterostomy patients
can generally be given a light diet on the second day. [h.m.]
10.— Etiology and Treatment of Chronic Cystitis. — The
etiology is a bacteriologic problem. The majority of cases are
associated with acid urine, i. e., are due to germs which do not
split up urea. Since we have various infections, it is well to
study the bacteriologic reaction in each case. There may be
several infections at once but one form is usually predominant.
Infection germs may be preseut without cystitis, as the urine is
an avenue of excretion for the body in general. The predis-
posing causes to cystitis are various mechanic and chemic irri-
tations. In treatment we must first consider the predisposing
cause. If it is extravesical it is hard to cure it by intravesical
treatment. Medication depends on the reaction. Urotropin
should be used only when the uriue is alkaline. Mercuric chlorid
should never be used in gonorrheal cystitis nor silver in the
tuberculous form. Eight cc. of a 10% solution of iodoform
in glycerin every two or three days gives good results in
tuberculous cystitis. Perineal drainage is superior to supra-
pubic in all cases except when there is a foreign body which
cannot be removed by the perineal route, [h.m.]
Boston Medical and Snrgtcal Journal.
September S5, 190S. [Vol. CXLVII, No. 13.]
1. The Creation of an Artlflcial Valvular Fistula : (a) For the Treats
ment of Chronic Colitis : (ft) as an Adjuvant to Certain Operations
on the Stomach. C. L. Gibson.
2. The Iliopsoas Bursa : Its Surgical Importance and the Treatment of
its Inflammatory Conditions, with Report of Three Cases. F. B.
LtJND.
October 4, 19021
THE WORLD'S LATEST LITERATURE
tAMBBICAN MEDICINB,
663
3. Opel
4. The
rative Treatment of Varicose Veins. J. B. Blake.
Local Pathology of Acute General Infections Arising Through
the Lymphoid Tissue of the Fauces. J. L. Goodalb.
1.— .■Vrtiflcial Fistula in Colitis and as an Adjuvant to
Operations on the Stomach.— Gibson details two successful
cases in which artificial fistula of the cecuui was created for the
cure of chronic colitis, the technlc being that of ICader's gastros-
tomy. He believes that certain forms of colitis can be cured
by it, the results being more direct, progressive and prompt
than are attained by nonoperative measures. This procedure
Is also recommended as an adjuvant to certain operations on
the stomach, the fistula being made in the upper part of the
jejunum by the same technic. The object of this fistula is to
furnish an additional means of maintaining the patient's
strength by feeding immediately after a severe operation on the
stomach, as gastroenterostomy or pylorectomy. It adds but
little risk to the original operation, can be made after discon-
tinuance of the anesthetic, feeding can be begun, if necessary,
on the operating table, and the fistula, when no longer needed,
will close in two or three days. Gibson contemplates it as a
substitute for gastroenterostomy in some advanced cases.
[a.o.e.]
2. — Surgical Importance of the Iliopsoas Bursa. —
Lund reports three ca.ses of disease of this bursa, two of them
being primary in the hip-joint. All of them simulated deep
abscess and in one the diagnosis of strangulated hernia had
been made. In 18 subjects examined in the dissecting-room,
this bursa was connected with the hip-joint by a free opening
In three. Lund believes that a preoperative diagnosis is possi-
ble in these cases if the bursa received the attention that its
anatomic and surgical importance demands. Full notes of the
three cases are given, the results of operation being very satis-
factory in two of them. In gonorrheal arthritis incision of the
bursa affords an easy method of reaching and draining the
joint. The bursa is best reached by a vertical incision just
below Poupart's ligament, between the anterior crural nerve
and the femoral artery, [a.o.e.]
3.— Operative Treatment of Varicose Veins. — Blake,
after discussing the various operations for varicose veins, says
that it is desirable to settle two points : (1) How often the deep
veins are actually and clinically affected in connection with
superficial varicosity, and how it is possible to determine the
condition of these deep veins before operation ; (2) the effect on
a large number of cases of all degrees of varicosity and its
complications by the same method of treatment, tracing the
results carefully for one or two years, [a.o.e.]
4.— See American Medicine, Vol. Ill, No. 23, p. &19.
Medical Record.
September S7, 1902. [Vol. 62, No. 13.]
1 Rational or Dietetic Treatment of Bright's Disease Contrasted with
Surgical Intervention. M'illiam Henkv Pokter.
2 Tuberculoslsof the Urinary Tract. P. Newmark.
3. Is It Wise for the Regular Practising Physician to .Spend Time to
Investigalc Psychic Tlierapeutlcs? R. OsoooD Mason.
4. Clinical Htudy of a Now Sliver Salt in the Treatment of Gonorrhea.
H. M. Christian.
5 Pulse and Itespiration at an Elevation of 10,200 Feet, as Ascertained
by the Examination of 100 Subjects. Maurice Rahn.
1.— Rational Treatment of Bright's Disease.— Porter
describes the function of the various renal elements. These
will maintain their integrity so long as their work is not too
great and the nutritive supply is good. In mild forms of incom-
plete oxidation uric acid is increased in the urine at the expense
of uroa, in more severe conditions oxalic and lactic acid, glu-
cose, etc., is added. When the proteid molecules are not
reduced at all an isomeric form of albumin is found. The first
condition increasing the work and lowering the nutrition of
the parenchymatous cells is excessive inge.stion of proteid, the
second is, putrefactive fermentation in the alimentary canal
resulting in toxins, indican appearing in the urine; the third
and most intense cause of degeneration is microorganisms.
These proljably act generally through the production of toxins
in the alimentary canal and not within the system. The author
explains by means of these three factors parenchymatous,
interstitial and diffuse lesions. In both health and disease
quantity and quality of food should be kept within the oxygen-
ating capacity. Uric acid points to overfeeding and indican to
putrefactive fermentation from excess of saccharine substances.
General hygiene has much to do with perfect digestion. An
exclusive milk diet is deficient in nucleoalbumin, out of which
hemoglobin and lecithin are formed. Beef proteid is most
easily assimilated of all the proteids, eggs and milk stand next,
the vegetable proteids last. An excess of starches and sugars
overtaxes the defective oxygenating capacity. The best results
are obtained by a well-regulated mixed diet, [h.m.]
2.— Tuberculosis of the Urinary Tract.— The sound,
catheter and cystoscope al-e quick aids in diagnosis but the
patient may suffer considerable damage in their use. In tuber-
culosis of the bladder frequent and painful micturition with
pain about the middle of the penis are prominent symptoms.
The urine exhibits the same morphologic elements as iii
chronic catarrh. Hematuria is frequent and tubercle bacilli
may be demonstrated by sedimentation or injection of the
urine in a rabbit. The writer describes methods of differentia-
tion from the smegma bacillus. The treatment is hygienic
with antituberculous and antiseptic drugs. Overdistention of
the bladder in irrigation aggravates the local condition. Instil-
lations of bichlorid are recommended for permanent drainage ;
to relieve tenesmus suprapubic cystotomy is best. If we find
tubercle bacilli in the urine with characteristic products of
kidney lesion we may diagnose renal tuberculosis. Cystoscopy
may reveal inflammatory changes around the ureters. Cathe-
terization of each ureter with injection in guineapigs will
make early diagnosis possible. Tuberculin is a valuable aid.
Before operation the condition of the other kidney should be
most carefully studied, [h.m.]
3.— Psychic Therapeutics.— There is a double motive for
using hypnotism as occasion warrants. It adds a potent agent
to the physician's armamentarium and in its use he may meet
cases of interest bearing upon mooted questions in psychology.
Mason reports a case of supranormal perception, [h.m.]
4.— Silver Vitellin In the Treatment of Gonorrhea.—
Christian reports 48 cases treated with this silver salt, which he
says is remarkably soluble. Treatment was begun with a 2%
solution, but this was increased to lO^fc without producing irrita-
tion. Of the 48 patients, 45 were cured, 3 unimproved. There
was prompt cessation of discharge in 31, more gradual reduction
in 14, very little effect in 3 cases. Gonococci disappeared as fol-
lows: In 2 days, 4 cases; 4 days, 8 cases; 6 days, 8 cases;
5 days, 5 cases ; 10 days, 10 cases ; 14 days, 8 cases ; over 5 weeks,
5 cases. In 9 cases there was apparent cure in 2 weeks; 17
cases, 3 weeks ; 12 cases, 4 weeks ; 7 cases, 6 weeks ; 3 cases, 8
weeks. Christian is convinced that silver vitellin is the best
silver compound ever offered to the profession for the treatment
of gonorrhea, [a.o.e.]
5.— Pulse and Respiration at 10,200 Feet.— The examina-
tions reported indicate that the almost universal fear of heart
failure at high altitudes must be groundless. The rates vary
slightly from the normal altitudes much lower— even two miles
lower. The average age of the 100 patients was 31.82 years, the
average pulse 76.50 a month, respiration 20.48. [h.m.]
New York Medical Journal.
September 20, 190S. [Vol. lxxvi. No. 12.]
I The Plague; Its "Dlirusive Tendency"; HafTklne's Antlplague
Virus vs. Dr. Yeraln's Serum. James Drummonu BCRCH.
2. The Radical Treatment of Cancer of the Penis. Edward Wallace
8. Perforating Ulcers of the Duodenum. John B. Murphy and J. M.
4. Coinphcatlons In the Pa-ssnge of a Gallstone. Neil Macphatteb.
(To be continued.)
1.— The Plague.— Burch discusses this subject and gives
statistics showing the results obtained by the use of Hafl'kine's
antiplague virus in comparison to those obtained by the use of
Yersin's serum. Advocates of Yersin's sernm maintain that
as the Haffkine prophylactic is a toxin of Bdcillm penHn it
greatly increases the danger of a person inoculated if the person
at that time is incubating the disease. The statistics given tend
to show that inoculation with ilaffkine's virus is harmless, that
it confers a high degree of immunity from plague and that it
does not aggravate an attack, [c.a.o.]
2.— Carcinoma of the Penis.— The radical treatment advo-
cated by Lee is total extirpation of the penis. In 11 cases in
554 AUBBIOAN MSDIOINE]
THE WORLD'S LATEST LITERATURE
(OCTOBBB 4, 1900
which this operation was done he has not known of a return of
the disease when it was confined to the penis at the time of
operation, but In several in which partial removal was resorted
to he has known recurrence to take place. The operation advo-
cated by Lee is the one devised by Pearce Gould in 1882, and
well described in " Bryant's Operative Surgery." This operation
ensures a very complete removal of the diseased organ ; a new
opening in the urethra is well established ; there is no risk of
infiltration oi* urine into the tissues of the scrotum ; and the skin
of the part is not irritated by the trickling of urine over it, as the
patient takes a sitting posture when urinating. An illustrative
case is reported, [c.a.c]
Medical News.
September 27, 1902. [Vol. 81, No. 13.]
1. Myomectomy vs. Hysterectomy. Andrew J. McCoSH.
2. The Relative Advantages of the Complete and Partial Hysterectomy.
E. E. MONTGOMEKi'.
3. Wounds, with a Discussion of What Constitutes Rational Treat-
ment. Frederic Griffith.
4. The Importance of Diagnosis In Skin Diseases Considered Generally
and as Applied to Particular Diseases. Isadore Dyer.
5. Advances In Ophtiialmic Therapeutics. D. B. St. John Roosa.
6. Bronchial Asthma and Allied Disorders ; TheirSummerTreatment.
Beveri^by Robinson.
7. School Life and Insanity. J. S. Lankfobd.
1.— See American Medicine, Vol. Ill, No. 24, p. 993.
2. — See American Medicine, Vol. Ill, No. 23, p. 945.
3.— Rational Treatment of Wounds.— Griffith says that
the one opponent to perfect healing of a wound is friction. The
common statement that wounds of the face and scalp heal
quicker than other parts owing to increased blood supply is
fallacious, for practically all tissues have capillaries, which are
the important factors in healing. A wound of the back or the
leg will heal as quickly as the ones mentioned if rest and free"
dom from irritation be secured. Rest, in its broadest sense, is
the end of treatment. Antiseptic solutions and dusting pow-
ders are irritants to wounds. The best direct application to a
wound surface after cleansing by hydrogendioxid is mem-
branous rubber tissue applied shingle fashion. Moisture in
the form of wet dressings should never be applied to open
wounds. [A.G.E.]
5.— See American Medicine, Vol. Ill, No. 21, p. 856.
6. — Bronchial Asthma. — Of the numerous drugs vaunted
to lessen suffering, shorten the duration of the acute attack,
while diminishing its frequency and lessening its later
intensity, none is so valuable as potassium iodid. It should be
combined with Hoffman's anodyne. In preventive treatment
the influence of climate is primary. The search for a place
must be an individual one. If the digestive organs are
impaired and in gouty condition, alkaline springs are useful.
When the respiratory tract is notably involved, sulfur springs
are even more beneficial, the air in these localities being cura-
tive. In women the pelvic organs must be examined besides
the nose and stomach. Very often it is the general nervous sys-
tem that needs toning. Chronic cases in which the acute
attacks have been severe are generally accompanied by cardiac
dilation, hence too great an elevation is to be avoided. Moist
atmospheres are also contraindioated. Rest, simple food, good
water, moderate exercise are the indispensables of a sensible
summer treatment for asthmatics. Spirits, tea, coffee and
tobacco should be used sparingly. If gout is suspected the use
of red meats and starches should be limited and lithia waters
taken. If the attacks alternate with eczema, arsenic does well.
The patients who recover permanently are young persons in
whom secondary complications are as yet undeveloped, [h.m.]
7. — School Life and Insanity. — It is impossible to keep
pace with the growing necessity for homes for the insane. An
important factor of the marvelous increase in mental trouble is
the high pressure in the school life of our children, a phase of
the American's inordinate desire to excel in everything he
undertakes. Many of the pupils, if examined, will ,be found
excitable, emotional, wakeful, discontented and suffering often
with headaches and nervous dyspepsia, the girls showing a
decided tendency to hysteria. The girls are the greatest suf-
ferers, this is particularly noticeable at the beginning of men-
struation. The course of study should be reduced, the body
developed coequally with the mind, the students should be
classified according to individual requirements, object lessons
should be used rather than books, and industrial training
should be introduced as rapidly as possible, [h.m.]
Philadelphia Medical Joarnal.
September 27, 1902. [Vol. x, No. 13.]
1. Chauvinism in Medicine. The Address In Medicine, Canadian
Medical Association, Montreal, September 17, 1902. William
Osler.
2. An Additional Case of Tumor of the Brain, Localized Clinically and
by the Rontgen Riiys. Charles K. Mills. Rontgen Ray Inves-
tigation. G. E. Pfahlkb. Operation. J. B. Deaver.
3. Leukocytosis In Lead-Workers L. Nai-olkon Boston.
4. On the Dosage in Radiotherapy. Georoe G. Hopkins.
1. — See page 528 this issue American Medicine.
2. — Tumor of the Brain.— Mills details the case of a female
of 21. The tumor was localized clinically and by the x-rays,
and was the largest he has ever seen. The Rontgen-ray investi-
gation was done by Dr. G. E. Pfahler and the operation by Dr.
John B. Deaver. The operation was performed in two stages.
In the first the skull was trephined in front of the line of the
central fissure, IJ inches from the mesal line of the skull, an
osteoplastic flap being employed. Owing to hemorrhage it was
decided to enlarge this opening; the bone, which bled pro-
fusely, was found to be eroded and corrugated. It was decided
to postpone any further procedures for the time being, and the
wound was closed. Later it was reopened, and the hemorrhage
controlled by compression of both carotid arteries before and
during the operation, as suggested by Crile. The tumor was
encapsulated and easily removed, and proved to be a spindle-
cell sarcoma. The patient died between three and four hours
after operation. Mills concludes as follows : So soon as a brain
tumor is clearly diagnosticated, if, presumably, it is in an
accessible area, operation should be performed at once; a
Riintgen-ray investigation should be added to the other
methods of making a diagnosis ; large openings in the skull
should always be made ; the operation should be osteoplastic,
in order not to leave a permanent opening in the skull and to
add to the chances of maintaining the vitality of the bone-flap ;
preparation should always be made to perform the Crile opera-
tion for temporary clamping of the carotids as soon as hemor-
rhage becomes threatening, and the operation in some cases
should be done in two stages, the propriety of this procedure
being determined by the circumstances attending the first
operation, [p.c.h.]
3. — Lieultocytosis in Ijead-worlcers. — Boston has made a
study of 24 cases, 9 of which he details. The longest period any
patient had worked before symptoms developed was 12 years ;
the shortest 6 weeks. Most of them, however, were aflFected in
from four to nine months after entering the lead works. In
those cases in which symptoms developed late they were always
severe. Three of the cases gave a leukocyte count below 10,000,
respectively, 4,000, 7,200 and 8,000. The remainder gave counts
varying between 10,000 and 25,500. The number of red cells and
the percentage of hemoglobin bore no constant relation to the
number of leukocytes present. The hemoglobin was found to
fluctuate between 32% and 85%. Eight of the detailed cases
showed basic degeneration of the red cells, [f.c.h.]
4. — On the Dosage in Radiotherapy. — This subject of
dosage is the great difficulty to be overcome by the x-ray thera-
peutist. Hopkins earnestly hopes that all those who are work-
ing in this field of medicine will concentrate their energies on
this vital point and aid in its solution. Could this be accom-
plished a vast stride would be made in this new tlierapy,
removing it entirely from the empirical and placing it in the
category of exact and scientific treatment, [f.c.h.]
CLINICAL MEDICINE
David Riesman A. O. J. Kellt
EDITOKIAL COMMENT
Cardiac Inadequacy. — In a recent number of the
Lancet Alexander Morison contributes some thoughts
on a condition that he proposes to term cardiac
inadequacy that are deserving of more than passing
notice. Recalling that the late Sir Andrew Clark used
October 4, 1902)
THE WORLD'S LATEST LITERATURE
[American Medicine 555
the term renal inadequacy in connection witli certain
cases in wliicli the kidneys on anatomic examination
were found apparently normal, but in which the average
functional activity of these organs was subnormal, he
proposes to use the term cardiac inadequacy to designate
a condition that at present may be suggested rather than
proved, and that need not be associated with histologic
changes in the heart, though of course such changes may
be encountered. In unfolding his thoughts he points out
the generally conceded relationship that the heart, in size
and volume, bears to the size and volume of the indi-
vidual—whether man or one of the lower animals, and
he refers to some of the better known cases of excessive
cardiac hypoplasia. He points out also that the weight of
the normal heart being due chiefly to the amount of car-
diac muscle that it po&sesses, heart force may be roughly
stated to be proportionate to heart weight, unless some
palpable defect in the organ renders its muscular advan-
tage nugatory. He does not fail, however, to call atten-
tion to the fact that the adequacy of the heart is the
expression not of one, but of three factors — muscle,
nerve, and blood. Referring to the difl'erences manifest
in some cases of disturbed cardiac compensation, differ-
ences in the maintenance of general and local circulatory
equilibrium, he expresses the conviction that it is
probable that the varying success of the physician in
securing cardiac compensation for disturbed action (and
this apart altogether from the nature and situation of
the gross mechanical lesion) is influenced by an essential
or congenital difference in hypertrophic power, in a
word, in greater cardiac adequacy on the part of one
heart as compared .with another. He likens the heart
to the poet that is born, not made ; but he points out
that as careful management may result in the production
of a very passable poetaster, similar care may do much
for a radically inferior heart. The manifestation of car-
diac inadequacy to which Morison directs special atten-
tion consists in an abnormal smallness of the heart in
proportion to the circulation that it is called upon to
maintain. The detecting of this smallness is as yet
scarcely within the domain of clinical recognition,
though it may be suggested by the results of physical
exploration, and the suggestion may find confirmation in
the results of x-ray examination. He reports a case that
he looks upon as an example of a small hypertrophied
heart (it was obtained from a man aged 57 years, it
weighed 7A ounces, and its left ventricle measured J of
an inch in thickness). This he regards as an originally
inadequate organ in an otherwise healthy organism, an
organ that had coped for a time successfully with a task
beyond its capacity and ultimately yielded to its over-
work, prematurely aged, and finally caused the death of
its containing organism. In another case a similar
inadequate heart was not the primary cause of the mor-
bid phenomena which marked the decay and death of
the patient, but it was regarded as having aggravated
the fatal conditions. Morison's observations are of value
not so much because they bear upon a question more or
less new (which they do not), but because they serve to
emphasize a fact that is becoming daily more apparent —
the importance of the persf^nal factor in medicine. So
.soon as the physician recognizes the importance of this
personal factor, so soon as he recognizes that the organs
of one person may differ markedly in functional capacity
from similar organs of another person and that a single
organ in an otherwise healthy organism may be more or
less inade(iuate, that soon will he find the solution to
many problems that battle his best endeavors, and that
soon will he ascertain the cause of success or failure in
apparently similar cases of disease.
REVIEW OF LITERATURE
Inoculation AKainst Typhoid Fever in South Afk*ica. —
Crombio,' adduciiiK statistics that hIiow that the period of
> Lancet, August 18, 1902.
susceptibility to typhoid fever is from 20 to 25 years of age in
the inoculated as well as in the noninoculated, states that it is
precisely at this period that the evidence of the protective effect
of inoculation is most marked. Up to the age of 30 years the
advantage of a single Inoculation is distinct, the incidence of the
disease In this class being 27 ^c, against 51 fo in the noninoculated.
Beyond the age of 30 years the advantage is with the noninocu-
lated, the incidence among them being only 14.3% against ^A%
in the inoculated. These figures would seem to suggest that as
the period of natural susceptibility to the disease is passing
away, inoculation is to be avoided as likely to increase the
liability to infection, [a.o.j.k.]
Erysipeloid.— Under this name Rosenbach' describes an
occupation disease peculiar to butchers, tanners and cooks. The
affection, which is due to the microorganism Glndothrix dicho-
tonia, usually starts from some superficial erosion of the epi-
dermis of the hands and is characterized by a limited infiltra-
tion of the skin, which may extend to the deeper tissues but
does not lead to suppuration, though the general symptoms
may be intense, the temperature reaching 39.5° C, with a not-
able swelling of the axillary and infraclavicular ganglia. The
course of the affection is benign and recovery occurs in two or
three months. [c.s.D.]
Statistic Studies upon the Consequences of Infantile
Syphilis, Acquired and Hereditary.— The series studied by
Martin 2 comprises 56 cases, of which 13 were examples of
acquired and 43 of hereditary syphilis. Of the 13 it was possible
to trace 10. Those under the age of two years died of intercur-
rent diseases. All of those that were over that age at the time
of infection reached puberty. Seven are healthy and married,
the males having numerous offspring. In the females, with
the exception of one, the progeny was small in number, whether
as the result of the lues it is not possible to say. No influence
of the syphilis upon the psychic development was noticeable.
Of the hereditary cases there were 13 of lues hereditaria prsecox
and 30 of lues hereditaria tarda. There were li times as many
tertiary as secondary cases. Of the 13 precocious cases of
hereditary syphilis 10 were traceable. Of the 10, 7 died under the
age of li years, 1 at 18, 1 was living, a moral imbecile, and 1 was
healthy and had two children. Of the tardy cases 19 were
traceable, of which 5 had died. The surviving 14 ranged in age
from 18 to 41 years. In a table, which it is unnecessary to
reproduce, the author shows the school record, the occupation,
the result of marriage and the mental caliber of these 14 cases.
In one case that was traced the development of measles seemed
to have a very unfavorable influence upon the syphilitic lesions.
There was no especial predisposition on the part of the infantile
syphilitics to any definite disease. Martin touches upon the
question of the admission of hereditary syphilitics to life insur-
ance and comes to the conclusion that many of those that pre-
sent tertiary hereditary phenomena subsequently become
entirely well. Every case must, however, be judged upon its
own merits, [d.r.]
Treatment of Tuberculosis with Tuberculin.— EngeP
reviews the use of Koqh's tuberculin and tuberculin-R, and
then reports its use with 14 patients suspected of tuberculosis.
Tubercle bacilli were foimd only in the sputum of 7 patients,
although all 14 reacted to tuberculin. None of them had fever.
He injected these 14 persons with tuberculin-R in solutions of
Increasing strength. No bad symptoms occurred. Three
patients became worse and the treatment had to bo stopped.
Six of tlie patients increased in weight and both their objective
and subjective symptoms becjime greatly improved. Bacilli
were found after this treatment in 4 of the 6 cases that had
them originally. Engel believes injections of tuberculin cause
an exudative inflammation of the tuberculous areas, and he
thus accounts for the reaction in temperature. He discusses at
some length the nature of immunization by means of anti-
toxins and comes to the conclusion that tul>erculin-R increases
the bactericidal power of the serum. He therefore advises Its
use in patients who have a family history of tuberculosis but
who have had no symptoms of that disease. [w.e.r.]
1 Deutiicbe Zeltflchria fur ChlnirKle, 1x1, 5-6.
« MUnchener raed. Woch., June 24, 1002.
» Berliner kllnlsche Wochenscbrlft, May 12, 1902.
566 Amebican Medicihki
THE WORLD'S LATEST LITER AT ORE
(October 4, 1962
A. B. Craig
GENERAL, SURGERY
Martin B. Tinker
C. A. Orr
EDITORIAL COMMENT
The Possibilities of Local Anesthesia. — To the
studies of American surj^eons, notably to those of Hal-
sted, we are indebted for the introduction of local anes-
thesia by injection of cocain solution. These early
studies, as well as those of Corning in spinal anesthesia,
were for many years entirely overlooked and even at the
present our countrymen are not given the credit which
they deserve in the introduction of cocain anesthesia.
Schleich undoubtedly deserves greatest credit for forcing
the profession to recognize the possibilities of local anes-
thesia and for developing methods of application for
different parts of the body. His book has not been as
widely read by surgeons in general as it should be, and
those who need its teachings most have no doubt failed
most completely to be reached by them. We refer to
those members of the profession who do not limit their
work to surgery but who are obliged to perform
numerous surgical operations, many of them minor
ones, which might readily be done to advantage under
local anesthesia. We know of men in our large medical
centers who limit their practice to surgery and who, up
to a year or two ago, were in the habit of administering
a general anesthetic for such trifling operations as the
amputation of a finger or toe. Oberst, in introducing
his method of infiltrating nerve trunks to cut off' sensa-
tion from the parts supplied by nerves, contributed an
important addition to local anesthesia, and in this coun-
try this method has been specially developed by Matas.
Cushing's cocain hernia operation is one of the best
examples of the application of this method of rendering
a large territory anesthetic by infiltration of nerve
trunks. There remains much for us to learn in local
anesthesia, however, before we can discriminate between
those cases in which general anesthesia is necessary and
the ones in which local anesthesia is preferable. It is
clear that before we can apply local anesthesia properly
we must know definitely just what organs are sensitive
to pain and in what degree. The recent textbooks in
physiology devote no attention to the sensitiveness of
the peritoneum or the abdominal viscera to pain,
although Haller in his Elementa Physiologioe, published
from 1757 to 1766, made the statement that peritoneum
had slight, if any, sensitiveness, and he believed that
the mucous membrane of the intestine and visceral peri-
toneum is not painful. A number of later writers have
undertaken to show the correctness of Haller's state-
ments, but few, if any, seem to have undertaken any
systematic study of this subject. About a year ago
Lennander, in a very suggestive article published in the
CentralbktU f. Chirurgie, expressed his belief that the
parietal peritoneum is very sensitive for all operative
interventions, but that the visceral peritoneum of the
mesentery, the stomach, intestines, the anterior border
of the liver, the gallbladder, the omentum and the
upper part of the urinary bladder were entirely lacking
in sensation of pain or to heat or cold. His suggestions
were based on observation of a number of cases.
During the past year Lennander has continued his observa-
tions, and his article, entitled " Observations as to the Sensi-
bility of the Abdominal Cavity," published in Mitteilunden aus
dein Orenzgebieten der Medieiri und Chiriirgie, 1902, Vol. x, p.
38, is by far the most thorough and systematic study of this
subject which has thus far appeared. He has performed
numerous different intraabdominal operations under local anes-
thesia and has had the sensations of his patients observed and
carefully recorded by three assistants, one of whom kept a
record of the different steps of the operation and the patient's
sensations stenographically and the others to estimate the
degree of pain, so that after the operation it was possible to
determine quite accurately just what amount of pain was
caused by the different steps of the operation. His farther
observations confirm his previous statement that the parietal
peritoneum has most to clo with the pain caused by operative
intervention within the abdominal cavity, and that the viscera
are practically all without sensation. Some points which have
not previously been settled and which he seems to have
determined in his observations are that the inflamed peri-
toneum Is not more sensitive than the normal peritoneum,
though some observers have believed the contrary. He also
finds that the peritoneum of the pelvic viscera is lacking in
sensation, and reports a hysterectomy carried out successfully
under local anesthesia. Several interval cases of appendicitis
were operated upon under local anesthesia quite successfully.
Lennander explains the pain at McBurney's point by the fact
that the point is located over that part of the posterior abdom-
inal wall where the lymphatics and lymph glands are located,
which receive feeders from the appendix, and which are first
inflamed. Many observers have believed that the mesentery
was sensitive to pain, but Lennander finds that it is possible to
cut across the mesentery without causing any pain, providing
it is not drawn upon so as to tug on the posterior parietal peri-
toneum. Many interesting points are brought out in regard to
special operations wliioh make this article of much importance
to the general surgeon, who must recognize the value of local
anesthesia in many intraabdominal affections with very weak
patients, or when there are complications referred to the heart,
lungs, or kidneys. . The attention to such points as the pro-
vision of a soft mattress on the operating table, the preliminary
administration of a good-sized dose of morphin, shutting off
tlie field of operation from the patient's view, completely plug-
ging the ears with cotton, and the importance of a good moral
anesthetizer at the head of the table to talk to the patient and
divert his attention from the operation, deserve special
mention.
There are still many points which might no doubt
be settled by just such careful studies as these which
Lennander records. The high hopes which were enter-
tained of the possibilities of spinal anesthesia have
fallen. Very few enthusiastic advocates of this method
can still be found. We are likely to be dependent upon
general anesthesia by ether or chloroform and local
anesthesia methods for many years to come. By care-
ful study of the various methods of inducing local
anesthesia and by the experience gained from practice
using these methods in all possible cases, we believe
that the majority of surgeons will find themselves able
to increa.se greatly the number of cases in which they
can use the local anesthesia satisfactorily and thus
reduce their mortality rate materially. While sudden
deaths from failure of heart or respiration on the operat-
ing table are not common, the ill-efl"ects which may
occur later must not be overlooked. Every surgeon
knows the dangers of ether pneumonia, of postoperative
thrombosis, and acute suppression of urine. The occur-
rence of these complications is much less frequent after
local anesthesia, and few will hold that even the slight-
est additional risk is justifiable when human life is
concerned.
REVIEW OF LITERATURE
A Method of Treatment of Empyema. — When the risk
of a general anesthetic is great Turner i finds it useful to drain
for a time through a cannula. The cannula and trocar are oval,
In transverse section to be used more effectively in the long
axis of the intercostal space. To allow for the long razor edge
the trocar projects nearly J inch from the end of the cannula.
Wounding of the lung is guarded against by noting the dis-
tance with an exploring needle and adjusting a movable shield
on the cannula. Slots in the shield allow the passage of tapes
to pass around the chest and keep the tube in place. The spot
of election for insertion is the seventh space on the right side
and the eighth on the left just in front of the latissimus dorsi.
After injection of eucain B and an exploring needle confirms
the presence of pus, and the lung is found far enough removed
from the parietal pleura, a IJ inch incision is made parallel to
the lung down to the external intercostal muscle, through
which the trocar and cannula are plunged. The latter is cov-
ored by a protective, which acts as a valve to allow pus to pass
out and prevent access of air. In three operations reported
this measure was sutflcient to bring about cure. In cases in
which quantities of lymph line the cavity, resection, explora-
tion and free drainage are demanded, but drainage by the
method described is of great use as a temi:)orary measure.
[H.M.]
1 Medical Press and Circular, August 13, 190!i.
American Medicine
^'
GEORGE M. GOULD, EdUar
G. C. C. HOWARD, ilanoLging Bdilor
CHARLES S. DOLLEY
MARTIN B. TINKER, AuUtanl EdUart
f
CXtnical Medicine
David Ribsman
IL. O. J. Kelly
H. H. CtJSHINQ
HELE>r MOKPHY
General Surgery
Martin B. Tinker
A. B. Craig
Charles A. Orr
Orthopedic Surgery
H. AUO0STUS Wilson
COLLABORATORS
Obstetrics and Gynecology
WiLMER Krusen
Frank C. Hammond
Nervous and Mental Diseases
J. K. Mitchell
F. Savaky Pearck
Treatment
Solomon Solis Cohen
H. C. Wood, Jr.
L. F. Appleman
Dermatology
M. B. Hartzkll
Laryngology, Ste.
D. Braden Kylb
Ophthalmology
Walter L. Pylb
Pathology
R. M. Peabck
PUBLIIHBD WnSLV *T 1521 WaLHUT StUIT, PhILADILPHIA, by TBI AWKaiCAM-MBDICINK PtTBLISHIRO COMPAl
Vol. IV, No. 15.
OCTOBER 11, 1902.
^5.00 Yeakly.
The subscription price of American Medicine
will hereafter be five dollars a year. As an inducement
for prompt payment a discount of 20 fo will be allowed
for cash within thirty days. Those who wish to sub-
scribe for three years and who remit within thirty days
will be allowed a discount of 33J^ .
For Medical Defence. — The Philadelphia County
Medical Society will deserve unqualified praise if at its
meeting on October 15 it accepts and earrles out a pro-
posal to amend the by-laws so that an attorney-at-Iaw
shall represent the society in all legal matters and in
suits or threats against members, and who shall assist
the District Attorney in prosecuting illegal practitioners.
The Board of Directors is to aasume the defence of suits
for alleged malpractice against members, but not for
acts prior to the qualification as a member of the society.
The Boai'd of Censors shall first decide upon the validity
of the claim. The society will not pay any damages
awarded by decree of court or upon compromise. It is
strange that so few medical societies have undertaken
such functions as these, and every one that has actively
In it the true spirit of the profession should at once set
about the realization of this most primal obligation.
The movers of the amendments of the Philadelphia
County Medical Society are content with a mere state-
ment of the purpose to prosecute Illegal practitioners.
We trust that when the attorney is appointed the society
will see to it that a good half of his official life will be
devoted to this most neglected and most imperative
duty.
Expen.sive economy must be calletl much of that
resulting from the legislation forced through by Gover-
nor Odell, of New York, in reference to the care of the
dependents of the State, and solely in the interests of
politics and finance. A saving is no saving that results
ill underfeeding, insufficient clothing, and overcrowding
of the hospital wards. It is especially no saving when it
only postpones a year or two the day of reckoning, and
al)Ove all when it increases the very evil which the hos-
pital is designed to cure. This is patent in the over-
crowding of the hospitals for the insane. The congested
condition of these institutions on October 1, 1901,
according to the thirteenth annual report of the New
York Lunacy Commission, is demonstrated by the fol-
lowing figures :
Capacity of No. of Patients
Institution. in Hospital.
Utica State Hospital 1,091 1,148
Willard State Hospital 1,905 2,;i36
Hudson River Stale Hospital 1,881 2,094
Mlddletown State Hospital 1,104 1,237
Buflalo State Hospital 1,631 1,913
Binghamton State Hospital 1,300 1,350
St. Lawrence State Hospital 1,652 1,671
Rochester State Hospital 500 581
1-ong Island State Hospital 3,305 3,975
Gowauda State Hospital 260 351
Manhattan State Hospital 4,006 6,098
Total number of patients 22,654
Total capacity of hospitals 18,638
Extent of overcrowding 4,016
The Carnegie Institution.— What to do with the
splendid gift of Mr. Andrew Carnegie is a weighty prob-
lem, and it seems that the trustees have not yet solved
it. Opinions differ widely as to the position the Car-
negie Institution should occupy. Professor Miinster-
berg,' of Harvard, suggests that a sort of over-university
should be founded in Washington, which should hold
the same relation to the universities of the country that
the postgraduate school holds to the academic depart-
ments. The faculty should consist only of great men,
perhaps 15 in number, with a salary of $10,000 each.
They should either be appointed for life, or .should
remain in Washington for one year, securing leave of
absence from their own schools for that length of time.
They should possess some measure of self-government,
and the Institution might become a model for the uni-
versities in which, to use Miinsterberg's words, " the
autocratism of the trustees is clearly a relic of the college
period, but quite unsuited to a university." The Ger;
man system of scholars choosing scholars should be
adopted. There might be .50 fellowships of $1,000 each,
to be distributed by the universities. Miinsterberg is
opposed to the application of the funds of the Institution
to the supj)ort of existing universities, as "every cent
from Washington disburdened to local officials is an
opiate for the feeling of responsibility of alumni and
trustees." The chief aim of the over-university .should
be the development of synthetic thought, which is a
greater function even than the fostering of experimental
scientific work. He also advocates a large printing
establishment for the publication of monographs, or even
textbooks.
1 Bolence, October 8, lOOi. "
562 AmCRICAS MedicibbI
EDITOKIAL COMMENT
(OCTOBEE 11, 1902
Professor Gage, of Cornell University, makes the
following propositions: 1. The Carnegie Institutipn is
not needed for educational purposes. 2. Its true place
is expressed in the first aim given by the founder— "to
promote original research." 3. It can most effectively
promote research by utilizing, so far as possible, the
facilities of existing institutions. 4. Its support of the
men selected to undertake researches should be gener-
ous, and abundant time should be allowed. 5. The
researches most demanded in biology at the present time
are complete investigations of the embryology, struc-
ture, and function of a few forms from the ovum to old
age and death.
Professor Branner, of Stanford University, sums up
his views in the following words: 1. The Institution
should try to help wherever help is needed and can be
advantageously used. 2. It should refrain from unnec-
essary or unwelcome interference in work already being
done by individuals and by other institutions. 3. Care
should be taken to encourage scientific work all over
the country. 4. Applications for aid should be received
from men engaged in scientific work, and these appli-
cations should be referred to committees of specialists for
advice. 6. The national government should cooperate
with the Institution by providing the necessary build-
ings at Washington and by permitting, so far as con-
venient and under proper restrictions, the utilization
of the scientific bureaus of the various departments.
6. Some means should besought to utilize the sabbatical
years of university professors engaged in scientific work.
According to President Jordan, one of the functions
of the Institution should be the esta,blishment of labora-
tories at Washington for special investigations. As an
example of such a laboratory, he mentions a breeding-
house or vivarium for the study of heredity and varia-
tion on a large scale, with a competent force for obser-
vation and record. Such an establishment should be in
charge of the man who, whatever his nativity, can
make the most of it. He emphatically opposes the use
of any part of the fund to pay the expenses of students,
as distinguished from tried investigators. Another
function of the Institution should be to make the
scientific resources of Washington available to those
who can use them.
Physicians are as deeply interested in the possibilities
of the Carnegie Institution as any other class of men.
While, of course, our profession has the generous Rocke-
feller foundation, there are innumerable problems
clamoring for solution in which a part of the Carnegie
fund should be used. In order to secure the very high-
est results, it is necessary that the Institution shall be
managed upon the broadest principles. While it might
be desirable to have the work of the Institution central-
ized at Washington, there is no reason why researches
might not be fostered in those places in which they can
best be undertaken.
Civilizing an Oriental Hospital. — In our columns
last week Dr. Senn, in his interesting series of articles,
speaks of the Kasr-el-Ainy Hospital and Medical School
at Cairo. A history of this hospital has been published
by Dr. F. M. Sandwith, through the (English) Ministry
of Public Instruction, which bears witness to the fatalism
of the Oriental type of mind, and at the same time of
what may be done by western science and physicians to
make civilization practical. The hospital was at first a
palace built in 1466, and became a hospital with the
PVench occupation. In it Larrey studied an epidemic of
fever that broke out in 1800, and also other diseases. It
was only in 1837, under Clot Bey, a Frenchman, that
Kasr-el-Ainy became a permanent hospital and school.
Clot Bey was chief surgeon to the Pasha's army. He
was followed by more than 150 J^ench and Italian sur-
geons and apothecaries, and he soon established a med-
ical school and military hospital in connection with the
camp near Abbasiya to the north of Cairo. There were
drawbacks in the hospital arrangements, for there was
an insanitary cemetery close by, and " the patients were
kept awake at night by the hyenas fighting over the
unearthed corpses." In 1837 this successful medical
school was transferred to Kasr-el-Ainy, where it still
subsists. There were then 64 wards of 40 beds each,
with chemical laboratory, pharmacy, museum, baths and
other necessary appliances.
" The medical course was at this time five years ; the pupils,
who varied la age from 20 to 25 years, consisted of three com-
panies o( 100 each ; they wore a military uniform and were fed,
dressed and lodged at the expense of the government. They
also received pocket-money, beginning at 40 piastres a month.
The professors, who were all Europeans provided with native
assistants, included Flgarl, who taught botany and materia
medlca; Pruner, who taught ophthalmology, and Gaetani, a
wellknown surgeon. Some of the original prejudices which
had to be overcome in inducing the Mussulmans to dissect dead
bodies were immense, and the dissecting-room had to be sur-
rounded by guards, who were kept Ignorant of what they were
guarding. Clot Bey began by dissecting a dog, ' not even a
Muslim's dog, but a Jew's dog or a Christian's dog.' Later he
got permission to use Christian subjects and black slaves, and
he was allowed to bring skulls and bones from disused ceme-
teries to his lecture room, though the Ulema had begun by
decreeing that the dissection of a human body was against the
tenets of the Mussulman faith."
Vaccination was introduced and for a time made
compulsory in spite of the opposition of every one
except that of the great Pasha, Mohammed Aly. After
1856 the institution was deprived of the support of
Mohammed Aly and of Clot Bey and declined until
1884, when Dr. Sandwith took charge of the Sanitary
Department of Egypt. He found Kasr-el-Ainy in a
terrible condition, justifying the popular belief that
" the hospital was merely a prelude to the cemetery."
English heroism and science have now brought it to a
state of honor and beneficence of which any country
might be proud.
What is the matter with Chicago ? is a question
asked of Miss Jane Addams, and she answers that the
principal disease of the city is disregard and disrespect
for the law. Without more detailed description one
would suppose that Chicago differs little in this respect
from other modern, and particularly American cities.
But Miss Addams refers especially to the tenement-house
regulations, the ordinances for the cleaning of yards,
alleys and courts, and all the other sanitary laws and
regulations. "If the proprietor of a tenement-house
has a pull with the alderman of the district," says Miss
October 11, 3902]
EDITOEIAl. COMMENT
Ahkbican Medicine 563
Addams, "he can disregard all the regulations with
impunity." The result of this is not only the harm
which follows directly. Repeated instances of it bring
the law into the condition of contempt of which com-
plaint is made. Miss Addams also believes that the
laws affecting sanitation and order in the congested dis-
trictv-3 are in many eases so weak as to be ineffective. For
instance, the law says that a doctor treating a patient
with contagious disease must have a notice posted con-
spicuously on the house containing the infected patient,
" or take the consequences." There are no consequences
and accordingly the physician does as he likes.
Another worker in a similar field as Miss Addams,
Mrs. Kelley, says that " the matter " is that the poor
children of the city are treated so badly. Illiteracy is
increasing, she says, at an appalling rate, and this is
largely due to the fact that in Illinois in the last four
years the number of children who work for wages has
more than doubled — from 9,000 to 19,000. In view of
the facts reported from the Southern mills one reads
with astonishment that " Illinois has the largest number
of children at work reported by factory inspectors in
any of the States." It is evident that Chicago suffers
from several intercurrent diseases— in this respect not
differing from many of our cities. Indeed, all of our
civic patients need not only accurate diagnoses but heroic
treatment by Dr. Ethic in consultation with Dr. Physic.
Pinching: the Poor. — It is possible that there are
other communities that would suffer by comparison were
their Departments of Health and Charities to receive
such a showing uj) as Mayor Low hiis given New York
City. Political and commercial greed and corruption is
bearing hard upon the poor and sick in many a town in
the " land of plenty," but where are the public o£Qcials
who will uncover to the public the niggardly methods
that characterize the conduct of some of our municipal
hosi)itals and almshouses? During the entire year of
1901 the inmates of the almshouses of New York City
" had no butter either at breakfast or at supper. Their
breakfast consisted of coffee, with a little sugar and milk,
and bread ; and their supper of tea, with a little sugar
and milk, and bread. Not even upon Thanksgiving Day
and Christma.s was there any variation from this bill of
fare for breakfast and supper." Inadequate clothing was
also common in the almshouses during 1902; hospital
furniture and equipment were deficient ; hospital patients
were not even supplied with chairs, but were given
stools without backs. Under the new management the
bill of fare has been placed upon a more liberal basis,
blankets and chairs have Ijeen supplied, but still the con-
ditions are described as " intolerable and utterly dis-
graceful." New York City has but one-flfth the facili-
ties for the care of sick poor that Ijondon has, and
Miiyor Low asks that the city's borrowing capacity be
increased in order that bonds maybe issued to the extent
of i^2,000,000 to cover the most urgent demands for
increased hospital facilities. In view of the reported
overcrowding of hospitals, such as that at Norristown,
Pa., where hundreds of patients sh^ep in the corridors,
and of a possible coal famine, the prest-nt time is admir-
ably suited to the making in all cities of a searching
inquiry into the conduct of charitable institutions. With
winter coming on and a coal famine already here, pro-
vision should be made for a very considerable increase in
the number of those who will require public aid.
The cost of modern original research as com-
pared with that of the past is clearly set forth by Profes-
sor Dewar in his presidential address before the British
Association. He obtained from the books of the Royal
Institution the actual outlay made by the Institution
during the past 100 years for experimental inquiry and
public demonstration which was $599,000, or an average
of $6,000 a year. Recalling the names of Young, Davy,
Faraday and Tyndall, Professor Dewar concludes that
" the exceptional man is about the cheapest of natural
products." The gist of the matter is perceived when it
is stated that the Carnegie Institution will dispose in one
year of as much money as the members of the Royal
Institution expended in 100 years. Professor Dewar
wisely adds :
" It may be doubted whether we can rea-sonably count upon
a succession of scientific men able and willing to make sacri-
fices which the conditions of modern life tend to render increas-
ingly burdensome. Modern science is in fact in something of
a dilemma. Devotion to abstract research upon small means is
becoming always harder to maintain, while at the same time
the number of wealthy independent searchers after truth and
patrons of science of the style of Joule, Spottiswoode and De la
Rue is apparently becoming smaller. The installations
required by the refinements of modern science are continually
becoming more costly, so that upon all grounds it would appear
that without endowments of the kind provided by Dr. Carnegie
the outlook for disinterested research is rather dark. On the
other hand, these endowments, unless carefully administered,
might obviously tend to impair the single-minded devotion to
the search after truth for its own sake, to which science has
owed almost every memorable advance made in the past."
Women and Higher Education.— The advocates
.of coeducation and of the higher education of women
are having a discouraging time of it nowadays. There
is a reactionary spirit everywhere manifest, and the
worst is that facts seem to justify it. At the twenty-
one universities of Germany the attendance of women
was last year over 1,200, but has now sunk to 887. In
Berlin there are 370, in Leipsic 53, in Bonn 84, etc.
Leipslc, Halle and others have decided not to recognize
the diplomas of the girl colleges of Russia, and Konigs-
berg has practically excluded women from its medical
department. Only 14 women took a degree in 1901, and
of these 8 were from North America and 5 from Ger-
many. Three were medical graduates. At the Uni-
versity of Helsingfors women have enjoyed full privi-
leges for thirty years, the total attt^ndance in this time
having been 749. Only \'2^ of these have taken examina-
tions, while the average for men is 40/e. "Nearly all
professors agree that the zeal of the women after a few
years begins to lag, and they fail to attain their end."
All of which should have been expect^Kl and does not
warrant disappointment or reactionism. The good
results of the higher education of women are not in
degre<>-taking. One might say that th(!y are manifest
in degree-giving — the higher and broader degree of
social elevation, purity and progress. Kducation makes
a woman a Ixitter mother, and it is the good mothers
664 Amebioan Mbdicine]
EDITORIAL COMMENT
[OCTOBKR 11, 1902
that produce great sons. Women at the universities, at
least, have a vast influence in civilizing the men there,
and for this poor reason, if not for others, they should
be kept there. The old savagery of male pride is evi-
dent in the matter, and all old savageries " die hard."
Railway accidents and iujui-les are not appreciated
by the public. It is well known that any official statis-
tics fall short of the actual number, and yet the reports
of the Interstate Commerce Commission show that dur-
ing the ten years ending 1900 there were killed 68,837,
an average each year of 6,883, and in the same time
there were injured 387,808, an annual average of 38,780
a year, or a grand total of 456,640, averaging 45,663 per
annum. And the rate of increase is greater each year,
the number in 1900 being over 46,300. What an excite-
ment and alarm there would be if a war should break
out between two of our States in which there were
within one year casualties amounting to about 50,000 !
Nothing better illustrates the dulling effect of repetition
and monotony. And yet these 50,000 deaths and maim-
ings are as expensive, as unnecessary, and as criminal as
would be those of the expensive, needless, and sinful
war. Whose is the fault and what is the remedy ? The
fault is public indifference, and the cure is public deter-
mination to hold to a strict responsibility the railroad
companies and the legislatures now so recreant to their
trust.
Suicides In American Cities. — If we may rely
upon the statistics quoted by the New Orleans Times-
Democrat, there are some strange facts as to the relative
rate of suicides in the different American cities. San
Francisco has the largest ratio, 39.1 per 100,000 of popu-
lation. Next comes Los Angeles, 29.8. Chicago is the
third in order with a ratio of 24.0, followed by the
neighboring city of Milwaukee, whose ratio is 22.2, ancj
then New Orleans, 21.8, and Cincinnati following close
with 21.2. New Haven is next with 20.9, and then
comes the Borough of Manhattan with 20.0, though
Greater New York, as a whole, is well down the list
with a ratio of only 13.6. This is less than Rochester,
Indianapolis, Philadelphia, Pittsburg, Baltimore, Bos-
ton, Detroit, Omaha and Louisville, besides all of those
specifically enumerated above. As to the foreign cities,
Paris leads the list with a ratio of 42, followed by Berlin,
36; Vienna, 28, and London, 23. There were more
suicides in Saxony than in any other country, 31.1 per
100,000. In Denmark the ratio was 25.8, in Austria
21.2. in France 15.7, in the German empire 14.3, and
Sweden, Norway, Belgium, Great Britain, Italy, the
United States and Spain followed in the order given.
Can any of our social philosophers explain why the
San Francisco and Los Angeles ratas are higher than
Chicago? The "foreign element" in Chicago, Mil-
waukee and Cincinnati cannot explain why their rates
are so much higher than New York City, where there
are also large foreign populations. Does New Haven, in
fact, have a higher rate than all other New England
cities? And why is the rate in Minneapolis almost
double whai it is in St. Paul ? Will the Times-Democrat
tell us where it got its figures ?
The proportion of accidents and disease is
brought out by an analysis of a recent census report
made by the Insurance Press, from which we learn that
deaths due to accidents and injuries were highest among
those whose mothers were born in Italy (119.5 per
100,000 of white population) ; lowest among those whose
mothers were born in the United States (62.7). The
deathrate due to accidents and injuries is highest among
persons 45 years of age and over. The average age at
death from accidents is about 33.5. The proportions of
deaths from accidents and injuries were greatest in the
Cordilleran regions, the Pacific coast region and the
Western plains ; they are least in the North Atlantic
coast region, the Middle Atlantic coast region and the
Northeastern hills and plateaus. The warmer months
show a larger proportion of fatal accidents than the
cooler months. A person is more liable to meet death
by accidental injuries than by any other single cause,
except tuberculosis, pneumonia or heart disease. One is
twice as liable to die from accident as from old age.
Typhoid fever, cancer, apoplexy, inflammation of the
brain and meningitis, paralysis, diphtheria, diseases of
the stomach, liver and brain, all these are slight
menaces to life compared with the accident hazard. If,
as seems not unreasonable, a person is liable to die of
any disabling accident that happens to him, what is to be
said concerning the 11,000,000 accidents that happen
every year ? It seems to be true that a person is 100
times more liable to "catch" an accident than a fatal
case of tuberculosis or pneumonia, and about 1,000
times more liable to "catch" an accident than a fatal
case of liver disease.
Why the Yellow Newspaper Is Against the
Medical Profession. — In his excellent address {Colo-
rado Medical Journal, July, 1902) Dr. S. D. ^'^an Meter
states that in 1901 the four leading newspapers of Denver
received about $72,000 for advertisements from the
illegal and advertising practitioners of the city. And
yet Dr. Van Meter says that if any one of these papers
would refuse such immoral and indecent advertisements,
and would champion the cause of right and public wel-
fare, there would be an instantaneous increase of circula-
tion, as a result of professional influence, that would
more than offset the loss of income from the criminal
advertising. The problem, therefore, is for the profes-
sion and honorable-minded citizens, first, to unite their
influen(«, and then to bring it to bear upon the cop-
scienceless newspaper publisher. The condition of
medical progress is thus demonstrated from another side
to consist in organization. Let us organize !
The source of typhoid iiifectiou in Bayside, in Queens,
has been traced to bottled milk sold by a local dealer. He has
been ordered to carry on the process of bottling milk more care-
fully and in a separate building at a considerable distance from
the dwellings and stables, that the rainwater system now in use
must be abandoned, that the well from which the water is
drawn must be lined, cleared, and disinfected and the dwelling
thoroughly cleaned and disinfected under the supervision of a
health inspector. From August 12 to August 20 there were 27
eases of typhoid reported from Bayside while for the week
ended August 16 there were 119 cases reported for the whole
city. The large proportion of cases reported from Bayside,
which only has a population of 1,500, resulted in the foregoing
investigation.
October 11, 1902]
AMERICAN NEWS AND NOTES
IAMKRICAN MkdicinI! 566
AMERICAN NEWS AND NOTES.
GENEBAIi.
Smallpox, as officially reported in the United States from
June 28 to October 3, amounts to 7,375 cases and 388 deaths, as
against 10,112 cases and 291 deaths in the corresponding period
of the preceding year.
Bubonic Plague Kradicated. — A recent report states that
the disease has been exterminated in Manila and very few cases
have occurred in the Philippines. This encouraging state of
affairs is the result of the vigorous campaign against rats, which
were found to spread bubonic plague bacilli.
Quarantine Station. — The Public Health and Marine-
Hospital Service has been given control of the Milaflores
Island in the harbor of San Juan, Porto Rico. It is proposed to
use the island as a quarantine station or to erect a marine hos-
pital or to use it for both purposes conjointly.
Cholera in the Philippines. — The totals reported for the
Philippine Islands up to the present writing are 70,222 cases and
48,402 deaths. The disease threatens to depopulate the island of
Samar, many of the towns having lost heavily through death
and the flight of panic-stricken persons. The epidemic also
continues unabated In Hollo. It is stated that the number of
victims makes ordinary sanitary measures impossible, but the
government is rendering every assistance possible, having
ordered additional doctors and medicines to the infected
districts.
Hospital Benefactions.— Newton, Mass.: The late Fran-
cis A. Brookes, of Boston, bequeathed ?5,000 to the City Hospital.
GwYNEDD, Pa.: Mrs. H. P. McKean and Mrs. F. E.Bond have
purchased a house, which will be fitted up for convalescent
children from hospitals in the vicinity. New York City,
N. Y.: Under the will of the late Samuel D. Babcock, St. Luke's
Hospital receives $20,000. Salem, Mass.: Under the joint will
of Abigail Osgood and Mary Elizabeth Williams, the Salem
Hospital receives |1,000. Watertown, N. Y.: Mrs. Emma
F. Taylor, daughter of the late Governor Roswell P. Flower,
has notified the trustees of the hospital that she will defray all
the expenses incident to the erection, on the hospital grounds,
of a new building for the treatment of contagious diseases with
the exception of smallpox.
EASTERN STATES.
Tuberculosis in Vermont. — At the tuberculosis conference
held recently in Burlington, means to perfect an organization
for the study and prevention of the disease were discussed.
Special emphasis was given to the necessity of obtaining a State
sanatorium for the treatment of cases.
Care and Treatment of Tuberculosis in Western Massa-
chusetts.—Legislature will be petitioned to provide for the
establishment of an institution in the western part of the State,
the Rutland institution being considered inadequate to care for
all the favorable cases for treatment in the State.
The new hospital for contagious diseases at Brookline,
Mass., is now ready for the reception of patients. The hospital
buildings are four in number and are made of red brick with
freestone trimmings. There are also two pavilions which are
practically separated except for an open corridor connection.
The hospital will accommodate 50 patients.
Worcester Insane Hospital Investigation.— In a detailed
report the trustees state that the charges made by several dis-
charged female attendants against the superintendent as to
misconduct of the institution and ill-treatment of the patients,
are entirely without foundation. They report that the institu-
tion is admirably managed and conducted by the superintend-
ent and his associates.
Against Tuberculosis.— The Health Board of Lowell,
Mass., has included pulmonary tulterculosis in the listof conta-
gious diseases, making it obligatory for physicians to report
every case. This step has been taken so that the department
will l>e aware of the number of cases in the city, and have the
authority to regulate the method of treatment. Later they may
provide receptacles for the sputum of the tuberculous and will
prol)ably make other provisions required to prevent a spread of
the disease.
NI3W YORK.
Ambulance Physicians.- Hereafter the ambulances of
Bellevue, Oouverneur, Harlem and Fordham Hospitals will be
in charge of physicians who have had at least six months'
experience in hospital work. It is thought by this means the
service will be greatly strengthened and mistakes and erro-
neous diagnoses avoided.
A course in practical physiology to begin this fall at
the University and Bellevue Hospital Medical College has been
offered to public school teachers of New York City. Only 30
applicants will be accepted. The course is identical with that
prescribed for second-year medical students and comprises
much experimental work on nervous physiology.
PHIIiADBIiPHIA. PENNSYliVANIA. ETC.
Philadelphia Hospital.- It is announced that the new
maternity wards have been completed and that in the near
future the children's house and skin disease wards will also be
ready for the admission of patients.
Orthopedic Hospital.— A five-story and basement build-
ing, to adjoin the present hospital, is now in course of erection
at Seventeenth and Summer streets. The building will be made
of brick, and it is estimated will cost in the neighborhood of
¥150,000.
Appropriation Sought for a Smallpox Fund. — At the
recent meeting of the Pennsylvania State Medical Society in
Allentown it was decided to ask the next Legislature to estab-
lish an emergency fund of $50,000 to safeguard tlie public against
smallpox.
Antispitting Ordinance.— The Woman's Sanitary League
of Pennsylvania have petitioned the Philadelphia Councils to '
pass an ordinance making it a punishable offense for any per-
son to expectorate in places used by the public. It is asked
that a fine of $5 be imposed on all offenders.
Against Tuberculosis.- Under the direction of the Free
Hospital for Poor Consumptives it is proposed to establish
throughout Philadelphia numerous clinics for the treatment of
poor consumptives who are unable to devote the time required
for treatment in a home or hospital. Numerous pamphlets
explaining the causes of the disease will be generally distrib-
uted, especially in the slum districts. An effort will be made
to carry the movement into every town in the State.
SOUTHERN STATES.
Dislocation of Both Shoulders Resulting from a
Sneeze. — An interesting case is reported of a man in Raleigh,
N. C, who while in a recumbent position with his hands under
his head, sneezed violently and dislocated both shoulders.
Typhoid Fever in Washington.— An encouraging de-
crease is noted in the number of cases reported. For the week
ended September 27 there were 57 new cases reported and 77
cases discharged, making a grand total of 365 cases under med-
ical supervision at the end of the week.
Improvements at Washington Barracks. — It is purposed
to erect if number of buildings, among which will be a general
hospital, situated on the west or river side of the reservation.
The general scheme of improvement has been completely out-
lined and approved by the War Department.
The hospital of theG. A. R. Encampment at Washing-
ton, comprising nearly 40 tents, will be maintained until noon
October 16, for the aid and medical attention of any resident or
visitor in Washington who may need help. A detail from the
regular Army hospital corps stationed at Washington Barracks
planned the camp and erected the tents. Captain A. M. Smith,
an assistant surgeon, who was in charge of the work, will have
control of the hospital until it is discontinued. He will be
assisted by 18 noncommissioned officers and privates. The
hospital will accommodate 108 persons.
WESTERN STATES.
The Ijang Hospital in Kansas City was opened recently
for the treatment of negroes exclusively. The institution, will
contain 50 beds, 20 being free and the remainder for the use of
pay patients.
Plague in San Francisco.- According to the reports to the
Surgeon-General of the Public Health and Marine-Hospital
Service, there have been 25 cases of the disease with 24 deaths
in San Francisco from December 12, 1901, to September 16, 1902.
St. Anthony's Hospital.— (Rockford, 111.) An addition
to the hospital now in process of erection will add 40 beds to
the^apacity of the institution. The new building, which it is
thought will be completed about Christmas time, will cost
about $75,000.
First Aid to Injured.- A special course for the purpose
of instructing firemen of Chicago in first aid to injured will
begin soon in the Harvey Medical College. The men will
attend the lectures in squads. In addition to the training, each
fire wagon is to be equipped with a complete outfit for first aid
to the injured.
CANADA.
Smallpox in Montreal.- The Health Department reports
the city to be practically free from the disease. From April .50,
lilOl, up to the present time there were 654 cases with 17 deaths.
Of the total number of cases, 561 patients had never been vacci-
nated.
Literary Examinations of Candidat«8 Desiring t«
Study Medicine.— At a recent meeting of the Ciuebec Medical
Council it was decided that hereafter all students desiring to
study me<licine, with a view to practising in tlie Province of
Quebec, must pass a literary examination prescril)ed by the
board.
566 Akkbicax Mbsioinkj
FOREIGN NEWS AND NOTES
[OCTOBER 11, 1902
FOREIGN NEWS AND NOTES
OEtTERAJi.
Leprosy in India.— According to the last census there are
about 400,000 lepers in India.
Against Boric Acid as a Food PreservatiTe.— The
fovernment of Peru has decreed that foodstuffs containing
oric acid for preservative purposes shall be debarred admit-
tance into the country.
Cholera in Egypt.— The totals since the outbreak on July
15^show 36,658 cases and 30,988 deaths. The Cologne. Gazette, in
commenting on the extreme gravity of the situation, urges
that a conference of the Powers be held to suppress Moham-
medan pilgrimage to Mecca, -which is a most dangerous center
•of infection. Thus far 1,200 towns and villages have been
affected.
Lilquor Law In Chile.— A law recently enacted provides
that no liquor shall be sold within 200 yards of any church,
school, charitable institution or barracks, in any place of public
amusement, in railway stations or on trains, to minors or
betwjeen the hours of midnight and 6 a.m. Further, no public
official shall own or be interested in any license, either directly
or indirectly. Every distillery and brewery must be placed in
charge of ajchemist appointed by the government, and the
penalties for adulteration are made very severe.
GREAT BRITAIN-.
Cost in Lives of the South Aft-ican War.— Of the 448,435
men who served the Kmpire during the South African war,
5,774 were killed in action and 16,168 died of wounds and dis-
ease, makiug a grand total of 21,942 deaths. The report shows
the number of wounded men to have been 28,829.
The Pasteur Institute.— Upon the request of the British
South African Company the Pasteur Institute will establish a
hospital at Buluwayo in South Africa. Dr. Loir, the former
director of the Pasteur Institute at Tunis, and chief of the labo-
ratory at Lille, has been appointed to take charge of the under-
taking.
Housing Problem in London.— During the 14 yeffrs of its
existence the London County Council has displaced 16,278 per-
sons from insanitary areas at a cost of over |5,000,000. At the
present time the council is about to provide 3,348 tenements
with accommodations for 21,526 persons, and plans are in course
of preparation for 9,879 additional sanitary buildings which will
accommodate .58,000 persons.
New Military Ambulance.— The prize of flOO offered by
the army medical authorities for the most suitable design for a
military ambulance has been granted to the royal army car-
riage department at Woolwich. The new ambulance weighs
2,300 pounds, and is furnished with special springs and rubber
tires. It can readily accommodate six men, whereas the old
ambulance could only accommodate two.
Telephone in Surgery..— It is reported that the surgeons
in several Loudon hospitals are employing the telephone when-
ever it is necessary to probe for bullets or metallic objects.
The technic is as follows : The receiver is placed on the head of
the operator and the patient is placed in the usual manner in
contact with a plate, the general medium employed being a wet
sponge or some paper saturated with a saline solution and
spread over the plate. The probe and the plate are connected
with the telephone by wires. On introducing the probe into
the wound it naturally vibrates as soon as it comes in contact
with a metallic substance.
CONTISnENTAXi EUROPE.
Tuberculosis.- A recent report states that there are nearly
226,000 persons in the German empire that are aflflicted with
some form of the disease.
The Stiebel prize of the Senckenberg foundation has been
conferred upon Professor Theodore Boveri for his work, " Ueber
die Natur der Centrosomen."
The infant mortality in Berlin for the period from
August 3 to 9 was only one-third of what it was for the corre-
sponding week of last year. The low rate is attributed to the
cool weather.
House in Which Pasteur was Born.— An effort is being
made to collect funds to purchase the house in which Pasteur
was born at Dole, with a view to its maintenance as a perma-
nent memorial.
Minister of Public Instruction.— Dr. Lukjanoff, profes-
sor of pathology at the University of Warsaw and director in
the Institute of Plxperimental Medicine at St. Petersburg, has
been appointed deputy minister of public instruction by the
Russian government.
A leper hospital which will accommodate 93 patients has
been liuilt in St. Petersburg by the Society for the Repression
of Leprosy. Tlie city pays the society 1,000 roubles annually
on condition that it will care for any cases of leprosy which are
found in the hospitals.
OBITU ABIES.
John Byrne, of Brooklyn, at Montreaux, Hwltzerland, October 2,
aged 77. He was graduat«)d from the Edinburgh Medical University in
1846. Two years later lie came to America and settled in Brooklyn.
He was one of the founders of the Long Island College Hospital and
organized St. Mary's Female Hospital. He took the lead In the e«tab-
lishment of the St Mary's General Hospital and since Its foundation
had been president of the faculty and chief surgeon of the institution.
He was widely known as a gynecologist and a few years ago was
elected president of the American Gynecological .Society at a congress
in Washington. He was an occasional contributor to medical litera-
ture and the Inventor of a number of surgical Instruments.
Morris J. Agch, of Mew York City, at Irvlngton-on-Hudson, Octo-
ber 5, aged 70. He was graduated from the Jefferson Medical College,
Philadelphia in 1885. During the Civil war he served on General Sheri-
dan's Staff. He was surgeon to the New York Eye and Ear luflrmary
and of the throat department of the Manhattan Eye and ISar Hospital.
He was a member of a number of societies and of the American Lai^yn-
gological Association.
Wlllard Humphreys, at Princeton, N. J., September 26, aged 35.
He obtained his degree In medicine from the Columbian University in
1888, but never practised. At the time of his death he was head of the
department of German at Princeton University.
Maximilian Muffat, of Palatine, 111., September 29, aged 50. He
was found In the road with his neck broken and Is supposed to be the
victlmof a runaway accident. He was graduated fTom the College of
Physicians and Surgeons of Chicago In 1890.
E. I.. Standler, at St. Louis, Mo.; October 6, aged 40. He was grad-
uated from the American Medical College, St. Louis, In 1886. He was
president of the National Eclectic Medical Association and of the
Eclectic Medical Society of Missouri.
John H. Justice, at Greenfield, Ind., September 16, aged 48. He
was graduated from the Medical College of Indiana, Indianapolis, In
1882. He was a member of the American Medical Association.
Henry H. Vlnke, of St. Charles, Mo., died recently. He was grad.
uated from the Missouri Medical College, St. Louis, In 1882. He was a
Founder oi American Medicine.
Harry A. Bell, of Butler, Pa., at Tucson, ArlF.., September 21, aged
28. He graduated from the medical department of the University of
Pennsylvania in 1897.
Charles W. Williams died recently at his home in Manzanola,
Colo. He was graduated from the Kentucky School of Medicine,
Louisville, in 1880.
Henry A. Armstrong, of Akron, Ohio, at Pueblo, Colo., September
19. He was graduated from the Bellevue Hospital Medical College,
New Y'ork in 188C.
Thomas B. \Vrlght, at Bowling Green, Ky., September 18, aged 10.
He was graduated from the Jefferson Medical College, Philadelphia,
in 1885.
Abel Mix Phelps, of New York City, October 6, aged 51. He was
graduated from the medical department of the University of Michigan
in 1873.
H. B. I^ackey, at Scranton, Pa., September ,S0, aged 58. He was
graduated from the Bellevue Hospital Medical School, New York, in
1868.
Bufus I,. McElroy, of Salt Lake City, at Portland, Ore., September
21. He was graduated from the Missouri Medical College, St. Louis, in
1 896.
Thomas Wilde, of Brooklyn, October 5, aged 65. He was graduated
from the Bellevue Hospital Medical College, New York, in 1866.
Silas F. Glfl'ord, at Avon, Mass., September 18, aged 78. He was
graduated from the Castleton Vermont Medical College In 1852.
Captain Frederick C. Jackson, an assistant surgeon In the Army,
is reported to have died of morphin poisoning at Manila, P. I.
B. J. Stokvis, Professor of Pharmacology and General Pathology
at the University of Amsterdam, September 29, aged 68.
John P. Mutchler, at Stroudsburg, Pa., .September 30. He was
graduated from the University of Pennsylvania In 1875.
Sydenham Walker, at Fountain Dale, Pa., September 26, aged 74.
During the Civil war he served as a brigade surgeon.
Jesse H. Peek, In Hampton, Va., September 20, aged 47. He was
graduated from the University of Virginia in 1875.
A. M. Burns, at Huntington, Ind., September 18. He was a grad-
uate of the Missouri Medical College, St. Louis.
Charles H. Meeker, at Railway, N. J., October 2, aged 77.
John B. Dlller, of Emaus, Pa., September 30, aged 65.
Baniel L. Wasser, in Pittsburg, Pa., September 19.
O. C. Brlckley, at York, Pa., October 3, aged 09.
OCTOBEK 11, 1902]
SOCIETY REPORTS
(Ahsbican Medicinb 567
SOCIETY REPORTS
CANADIAN MEDICAL ASSOCIATION.
Thirty-fifth Annual Meeting, Held in Montreal, September
i6, 17 fmd 18.
[Specially reported for American Medicine.]
\ Concluded from page SSS.J
General Session.
SECOND MBETiNO— Concluded.
Treatment of Gallbladder Affections.— A. D. Black-
ADER said he would confine himself principally to catarrhal
forms of the disease. He considers tlie condition more com-
monly due to altered secretion of the bile ducts, the altered
mucus causing inspissation of the bile. Infection of bile he
thought takes place in two ways, through the bile ducts and
through the portal circulation. In the matter of treatment he
considers that no drugs stimulate the flow of bile to the same
extent as the bile salts. The flow is increased by exercise and
deep breathing. Diet should be carefully considered, should be
simple and so far as possible should contain a large amount of
fat. Such patients should drink plenty of pure water or mineral
water. The patients should also have due regard to a proper
method of dress ; no corsets or constricting clothing should be
worn.
Surgical Diagnosis of Gallstone Disease. — .Tames Bell
(Montreal) said it was common to find early vague symptoms
of gastrointestinal indigestion which were often found to be
present for a long time V)efore an acute attack was precipitated.
He spoke of the colon bacillus and the typhoid bacillus as com-
mon causes of infective conditions.
Surgical Treatment of Disease of Gallbladder and
Ducts. — .1. F. \V. Ross (Toronto), in commencing his paper,
expressed a certain lack of faith in the socalled medical treats
ment of gallstones. Speaking of some details of gallstone
operations Dr. Ross advocated drainage through Morrison's
pouch. He laid great stress on the free use of gauze packing to
prevent leakage into the peritoneal cavity. In gangrene and
empyema of the gallbladder he does not advise removal of the
gallbladder but prefers opening, flushing and draining. In
many cases of cystic enlargement of the gallbladder, however,
he advised entire removal of the viscus. It is well to remem-
ber, after removal of the gallbladder, that gallstones may form
in the liver and be passed out into the intestines. Heeonsiders
mucous fistulas, which occasionally follow operation, as the
most troublesome, and said the evil should, so far as possible,
be prevented by the use of a small drainage tube. He also
drew attention to the importance of being sure that the drain-
age tubes did not become blocked. *
Diicuaifion. — G. E. Ab.mstrono (Montreal) recognizes and
recommends the employment of medicinal treatment first in
gallstones, etc. He does not advise removal of the gallbladder
for stone in the cystic duct. He recommends lavage of the
stomach before operating on all gallbladder cases, and as it is
difficult to know what the surgeon may encounter on opening
the abdomen he advises the administration of calcium clilorid
before and after operation to prevent possible hemorrhage.
The Importance of Early Operation on tlie Gallblad-
der.—Dudley P. Allen (Cleveland, Ohio) considers, in view
of the fact that an accurate diagnosis is often impossible, an
exploratory incision at least should generally be made early,
when, he claims, it is often found that many obscure cases are
quite amenable to surgical treatment, and, in fact, would fail to
recover if we were to temporize. He recited a number of cases
in which the diagnosis was uncertain, in whicli he had made an
exploratory incision and had ol'teu been gratified with the
results.
THIRD MEETING.
Dominion Health Bureau.— E. P. IjACHApelle, secre-
tary of the Board of Health of the Province of Quebec, moved
the following resolution, seconded by Dr. J. R. Jones, Win-
nipeg, which wa.s carried unanimously :
Wherbas, I'ubilc health, with all that is comprised In the t«rm
sanitary KclciiBe, has acquired greut prominence In all civilized
countries, and
Whkkbas, Enormously practical results have been secured to the
community at larse by the creation of health departments under
governmenUil supervision and c jntrol, ami
WiiKKBAS, Uroftter authority and usefulness are given to health
regulations sui;Kestions when they emanate from an acknowledged
government department, therefore be It
llnmlred, Tbal In the opinion of the Canadian Medical Association,
now In session, the time Isopportune for the Dominion government to
earnestly consider the expediency of creating a separate department
of put)llc health, under one of the existing mlnisU'rs, so that regula-
tions, suggestions, and corresponflence on sui;h health matters ait fall
within the jurlsillclU)n of tne federal government may be Issued
with the authority of a Department of Public Health.
That copies of this resolution be sent by the general secretary to
the Govemor-Uenetal In Council and to the Honorable the Minister of
Agrlcnlture.
Treasurer's Report. — H. H. Small presented this report.
Three hundred and seventeen members had been in attendance,
nearly 100 more than any other previous meeting. All out-
standing indebtedness had been paid, and there was in the
treasury $325 to the good of the Association. This announce-
ment was received with the greatest satisfaction. Votes of
thanks were passed to Mr. and Mrs. James Ross, of Montreal,
in whose handsome grounds had been tendered a garden party
on the afternoon of the first day ; to the Local Committee and
Transportation Committee, special reference being made to
Drs. C. F. Martin and J. Alex. Hutchison for their indefati-
gable efforts for the success of the meeting; to the treasurer,
the president, and the profession generally for their hospitality.
Thus was closed the greatest meeting in the 35 years of the
Association, and it is to be hoped that the profession throughout
Canada will still further take an active interest in the national
organization.
Surgical Section.
SECOND SE,SSION.
Foreign Bodies in the Vermiform Appendix.— James
Bell (Montreal) expressed his opinion that appendicitis never
depends on the presence of foreign bodies in the lumen of the
appendix. There is little doubt, however, that when foreign
bodies gain entrance accidentally into the appendix they aggra-
vate an otherwise septic infection. Among the foreign bodies
which he has found in the appendix are, in two cases pins, in
two cases seeds, in one case wood fiber, in one case gallstones,
and in another case a fish bone.
Three Cases of Congenital Dislocation of the Hip. —
A. E. Garrow (Montreal). The etiology of this condition is
not well established, but heredity seems to play a part.
Dr. Garrow spoke of two methods of reduction, (a) bloodless
method, (b) through an incision. The chief obstacle to reduc-
tion is generally due to fibrous stricture of the lower part of
the capsule. Dr. Garrow's experience has been mainly by tlie
open method.
Operative Treatment of Goiter, with Report of Cases.-
Ingersol Olmstead (Hamilton, Ont.). As the medical treat-
ment of goiter is very unsatisfactory, an operation is recom-
mended in the following conditions: 1. As soon as a goiter
becomes dangerous, that is, when attacks of dyspnea occur, or
inflammatory changes occur, or there is the sliglitest suspicion
of a malignant degeneration. 2. In all enlarged thyroids
having a tendency to grow toward the aperture of the thorax,
even if they are movable. 3. In goiters that have reached
considerable development from the formation of single large
colloid nodes. 4. When with a moderate goiter symptoms like
those of Basedow's disease appear accompanied with an in-
creased development of the goiter, the operation advised is
the one usually performed by Kocher, and is done under cocain
anesthesia. Twelve cases operated on during the past year
were reported. The average stay in the hospital was seven
days. The resulting scar was very slight, and little or no pain
was complained of during the operation.
Pathologic Prostate and Its Removal Through the
Perineum.- Alex. H. Ferguson (Chicago, 111.) in opening
his paper said he proposed to discuss more particularly hyper-
tropliy of the prostate. Some of the macroscopic changes in the
hypertrophied prostate are, first, increa.sed weight— may be up
to eight or nine ounces; second, greater size; third, any part or
the whole of the gland may be involved. Shape varies very
much. Mic:roscopically Dr. Ferguson found all hypertrophied
prostates were benign in character. He also found frequent
evidences of inflammatory changes. The effects produced may
be stated as, -first, the prostatic urethra is contracted and
elongated : second, the vesical meatus is often rendered patu-
lous and sometimes obliterated; third, the ejaculatory ducts
are also often patulous, allowing regurgitation of the semen into
the bladder, and they are also often obstructive. The effects of
obstruction on the kidneys and bladder are too well known to
require discussion. Treiilmeiit, — Dr. Ferguson's method of
removal is by tlie perineal route. He uses a prostatic depressor
introduced Into the urethra, then elevated in such a manner as
to press the prostate down in tlie perineum. The fingers of the
left hand arc passe<l into the rectum as a guide, and then he
makes one bold incision through the perineum down to the
prostatic capsule. Dr. Ferguson exhibited some special instru-
ments devised and used by himself in this operation.
Surgical Treatment of Knlarged Prostate.- G. E. Akm-
STRONd (Montreal) exhibited a specially constructed supra-
pubic vesical speculum devised by himself, with a lateral
opening which allows the prostate alone to come well in view
in the speculum. The speculum can be packed around with
gauze to protect the parts from possible burning, the offending
lobe or lobes are then cauterized with the therinocmutery. Dr.
Armstrong reported seven cases successfully operated on. One
point of advantage in this operation lies in the fact that the
cauterized surface does not admit of septic absorption. He
urges this method in early stages of prostatic hypertrophy.
The X-ray as a Therapeutic! Agent.— ('. R. DiOKSON
(Toronto) said the explanation of the rationale of the x-ray is
at best as vet but a hypothesis. Fortunately we have a practi-
cal proof of its utility as a therapeutic agent in many condi-
tions. Dr. Dickson has used it successfully in nevus, lupus,
vulgaris, tuberculous joints, scleroderma, subacute articular
rheumatism (it relieves pain in many ca.ses), neurasthenia,
carcinoma of the stomach (this patient gained weight* and iu
carcinoma of the rectum, which patient is also improving.
668 AJIEBICAN MBDICINBi
SOCIETY REPORTS
[OCTOBKB 11, 1902
The X-ray in Cancer. — A. R. Robinson {New York). A
strong plea is that the x-ray largely does away with the knife
and leaves little scar. It is probable that all superficial cancers
can be removed by the x-ray if seen early. In a delicate local-
ity, such as the eyelid, the rays should always be used as paste,
or the knife will do more harm. When malignant growths
have spread deeply the x-ray may be considered our best treats
ment.
THIRD SESSION.
Excision of the Cecum.— O. M. Jones (Victoria, B. C.)
cited four cases operated on. The first case lived about two
years after. A postmortem proved that the cancero\is growth
had not recurred at the point of the original operation. Symp-
toms in all cases were griping pains in the abdomen, loss of
weight and irregular action of the bowels, together with the
presence of a mass in the region of the cecum.
Three Cases of Perforating Typhoid Ulcer Success-
fully Operated Upon. — F. J. Shepherd (Montreal) reported
these cases. Dr. Shepherd has always made use of the lateral
incision, and has usually found the perforation near the ileo-
cecal valve. By this incision the site of the perforation is more
easily found than by the medium. He has always closed the
incision by turning in the bowel and making use of a continu-
ous Lembert suture, employing fine silk. Other ulcerations in
the neighborhood are treated in the same way. Rubber drain-
age is employed. There is always suppuration in these cases,
and usually a hernia as a result. General anesthesia is always
used in these cases. Early and rapid operation, seeing that
there are no others likely to perforate. The first case
was in a woman of 30 with ambulatory form. The second was
a woman of 28 years, admitted on about the eighth day. It is of
interest in this case that although perforation had taken place
there was no leukocytosis. The third was a male, aged 30, in
the third week seized with severe pain, and one hour after
there was obliteration of liver dulness and marked leukocy-
tosis. All are quite well with the exception of hernias.
A Case of Total Extirpation of the Urinary Bladder for
Cancer. General Considerations : Evolution of the Opera-
tion in Europe aud America ; Methods Employed ; Results
in lOO Reported Cases.— Lapthobn Smith (Montreal) said
that in his case there had been previous removal of fibroid by
myomectomy. This was followed by cystitis which was treated
first by medicine; then by injection, and afterward by drain-
age by permanent catheter, and then by button-hole operation,
when the cancer was detected by the finger. Extraperitoneal
removal of bladder and affected part of ureter and pelvic glands.
Recovery from operation, but death on the seventh day from
exhaustion.
AMERICAN ASSOCIATION OF OBSTETRICIANS AND
GYNECOLOGISTS.
Fourteenth Annual Meeting, Held in Washington, D. C,
September i6, 17 and 18, 1902.
[Specially reported for American Medicine.]
\Concliided from, page 529.]
Abdominal Section During Pregnancy. — J. Henry
Carstens (Detroit, Mich.) had had the following cases compli-
cating pregnancy: Appendicitis, 5; fibroids, 4; hernia, 1;
abdominal hysterectomy, 1; ovariotomy, 3; vaginal hyster-
ectomy, 3, and miscellaneous, 3 ; or altogether 20 cases, and 5
deaths, so that the mortality was 25%. This included all his
cases from away back. He thought that today the mortality
would be far less. All acute diseases requiring prompt opera-
tion could be operated upon just as well as if pregnancy did not
exist. Tumors that would interfere with labor should in all
cases be operated upon, as there was far less danger attached to
their removal during pregnancy than there was by noninterven-
tion and letting the woman go to full term. He had seen most
lamentable cases of the latter kind. Tumors above the brim of
the pelvis, or which could be shoved above the brim of the
pelvis, need not be interfered with ; still, as a rule, all tumors
took on a very rapid growth during pregnancy and the Increase
in size might interfere with the various functions of life and
then surgical intervention was required.
Deciduoma Malignum. — Lewis S. McMurtry (Louis-
ville, Ky.) reported a case. Since Sanger in 1888 and again in
1893 called attention to this form of malignant disease of the
uterus, numerous cases had been reported in Europe and
America. The diagnosis was not especially diflficult, but great
difficulty had obtained in establishing the exact pathogenesis
and making a definite pathologic classification of the disease.
Clinically the disease presented a well-defined history. The
disease appeared after abortion or labor, the tumor being sit-
uated upon the endometrium of the body of the uterus. Of 128
recorded cases in 40% the disease appeared after mole preg-
nancy. Hemorrhage was the first and most conspicuous symp-
tom and was not controlled by curetage. The discharge was
usually offensive, especially in the advanced stage. The disease
had a marked tendency to early metastasis; the lungs and
vagina were the most common sites for metastatic deposits.
The disease was so rapid in its course that the period from first
symptoms until the death of the patient was only a few weeks
or months. The only successful treatment was the early and
complete extirpation of the uterus. In the author's case the
disease appeared in a woman of .35 immediately alter abortion.
Persistent hemorrhage and fetid discharge from the uterus
prompted operative intervention. The uterus and its appen-
dages were removed by abdominal hysterectomy and the
patient made a prompt recovery.
Perforating Ulcer of the IJuodenum. — John B. Murphy
(Chicago) reviewed the salient points in the etiology, path-
ology and diagnosis of duodenal ulcers, and considered especi-
ally the surgical treatment of perforations. He had collected
from the literature 19 additional cases, including one of his
own, in which operations were performed for this, complica-
tion. An analysis of these cases showed : Average age in the
13 cases in which age was stated was 35 years. Of the 19 cases,
5 were females and 14 males. Of the 12 cases in which it was
stated whether or not there were symptoms present previous to
the perforation, in 9 they were present previous to perforation ;
in 3 there were no previous symptoms ; in only 5 cases did the
symptoms point to the stomach or duodenum ; in 6 cases it was
stated that the perforations were sutured ; of these 2 died, 3
recovered. In one the result was not stated. In 8 cases drain-
age only was used ; of these 7 died and 1 recovered. Conclu-
sions.— The diagnosis of perforating ulcer was difficult, or
better, practically impossible without an exploratory laparot-
omy. In many cases there was no evidence of duodenal dis-
ease previous to the perforation. The most important physical
sign, in addition to those of perforative peritonitis from per-
forations in other portions of the intestinal tract was the flat-
ness of the superficial piano percussion note in the right hypo-
chondrium. The leukocytosis in his case was pronounced,
showing an inflammatory condition, in contradistinction to the
usual absence of it in intestinal obstruction and fat necrosis of
the pancreas. Leukocytosis, however, was not a necessary
manifestation of perforation or of inflammation. It was a
manifestation of the reaction of blood to infection, biotic or
toxic. It was often entirely absent in typhoid perforations.
Collapse was absent in duodenal perforation, except where
associated with severe hemorrhage. Collapse in intestinal
perforation was tlie manifestation of the absorption of the pro-
duct of infection, and not a manifestation of the perforation per
se. Collapse was always secondary to abrasion or denudation of
the endothelial covering of the peritoneum, which abrasion
permitted of rapid absorption. In all cases of perforative peri-
tonitis, to which duodenal perforations were no exception,
operation should be done at the earliest possible moment after
perforation had taken place, and experience showed that the
mortality was in direct ratio to the length of time that elapsed
between the occurrence of perforation and the operation. In
perforation the longer the escaping material was in contact
with the peritoneum, the greater the danger of destruc-
tion of its endothelial covering, and thus the greater the danger
of absorption. Of 13 cases operated upon more than 30 hours
after perforation, all terminated fatally, while in 12 cases where
less than 30 hours had elapsed, 665% recovered. The opera-
tion must be complete; that is, it must be pursued to
an eflfective suture of the perforation. Drainage was insuf-
ficient, as of 18 patients treated by drainage alone, all died.
The suture of the opening can be easily inserted, as in 98% of
the perforating ulcers into the peritoneum the opening was
in the first portion of the duodenum, its most accessible por-
tion. When duodenal perforation is suspected, the incision
should be through the right rectus muscle. It could then be
carried upward to the costal arch, or downward to the sym-
physis pubis without dividing any of the transverse muscles.
The incision through the rectus muscle was the one which he
commonly made in operating for appendicitis. It could be
enlarged upward or downward without interfering with the
muscle fibers. Drainage or no drainage was a matter of
personal election, influenced more or less by the pathologic
condition present at the time of the operation. The after-
treatment was that commonly followed after abdominal section,
except that the patient was kept elevated in bed at an angle of
35° for the first 48 hours after the operation. The prognosis
depended, first, upon the virulence of the peritonitis produced ;
second, the time the material had been allowed to remain in the
peritoneum ; third, on the presence or absence of blistering or
abrasion of the peritoneum at the time of operation.
Peritoneal Tuberculosis.— Rrrus B. Hali. (Cincinnati,
Ohio) reported a few cases of operation for peritoneal tuber-
culosis, and made some remarks as to operating in this disease.
He contended that tuberculosis of the peritoneum in women
was not a rare affection. It occurred often enough to make it
necessary to consider it in the differential diagnosis of all
obscure diseases in the pelvis and abdomen. In a large
majority of cases coming under his observation there were no
appreciable manifestations of the disease in other parts of the
body. The symptoms of this disease simulated several other
conditions in the pelvis and abdomen, and it required patient
and careful study to difl'erentiate one from the other. The dis-
eases most likely to be confounded with this affection were the
recurrent attacks of appendicitis of the catarrhal form, small
fibroid tumors, with old tubo-ovarian disease, and recurrent
attacks of pelvic Inflammation. An ovarian cyst of moderate
size might be confounded with encysted tuberculous dropsy.
But he insisted that if the case was one of tuberculosis the
temperature chart would suggest this disease if the temperature
October 11, 1902J
COEKESPONDENCE
^AMEBICAN MeDICINK 569
was taken every four hours for a period of 10 to 15 days. In no
other condition was there the exact regularity in the afternoon
rise of temperature as In tuberculosis. All cases of peritoneal
tuberculosis in which there was encysted dropsy, or an accu-
mulation of pus or serum, should be operated upon ; after the
necessary surgical repair the abdomen should be drained. He
advocated vaginal drainage in women ; first, because it gave
perfect drainage; and second, it prevented ventral hernia,
which so often followed on account of the fact that the drain-
age tube must be kept in for so many days.
Surgical Treatment of Perforated Gastric Ulcer with
General Infection of Peritoneal Cavity. — H. Howitt
(Guelph, Ont.) stated tliat acute perforation with general infec-
tion of the abdomen wa.s caused usually by theacute, round ulcer,
but naight occasionally take place in the course of the chronic
ulcer, especially when it was situated on the ever-moving
anterior wall. AH the phenomena of acute perforation might
result in either form of ulcer in a more indirect manner by the
formation of a localized abscess which afterward ruptured
internally. Treatment. — In a case of perforation with general
infection of the abdomen, nothing short of early, bold and thor-
ough surgery could save the patient. A large irrigating tank,
capable of tlirowing a stream almost an inch in diameter, expe-
dited matters. All sutures should be threaded beforehand,
ready for instant . use. When patient was anesthetized an
incision from ensiform cartilage to pubis should at once be
made, Ijowels eviscerated and protected. Then the stomach
was examined and the perforated part brought as far as possible
out of the wound and the field guarded by sponges. The ulcer
perforation might be excised if considered advisable, but it
was generally merely closed with two or more rows of silk
sutures. Xow, every pouch and corner in the abdomen was
thoroughly inspected by sight and flushed clean. Three rubber
drainage tubes were used, not one of which was placed in the
wound, but through stabs, one at the back in each flank depres-
sion below the kidney, and one in the lower abdomen to the
right or left of the incision for the pelvis. After the intestines
were replaced and omentum was spread over them and fastened
below the lower end of the wound with a suture or two, the
incision was closed as quickly as possible and dressed. In a
desperate condition of the patient a pint of peptonized milk or
other suitable liquid food was injected intotlie jejunum during
operation. After-treatment. — Suitable measures to combat
shock : Patient was supported for first week by rectal enemas
and nothing by the mouth but sips of hot water. No morphia
unless it was evident that death was inevitable. Bowels were
to be regulated by injections of magnesia sulfate in solution.
A case he had operated on February 20, 1900, it was claimed was
the first time that an operation for a perforated ulcer of the
jejunum, as a result of gastroenterostomy, had been reported in
America. He was aware that many surgeons strongly objected
to evisceration in abdominal work, but maintained that in the
conditions under discussion it was impossible by any other
known method to make certain that the toilet of the peritoneum
had been done thoroughly, and said that imperfect toilet was
followed by more shock and was vastly more dangerous than
hours of properly-managed evisceration.
Carcinoma of the Cervix Uteri.— L. H. Dunning (Indi-
anapolis, Ind.) presented a summary of his 62 cases operated
upon Ijy hysterectomy. These cases showed on applying the
accepted test of time— .5 years — that the author had had an
encouraging number of cures ; they also showed the desira-
bility of early operative procedure. The operative methods
employed were indicated and the author's views of the same
were discussed. The essayist reported five cases of carcinoma
of the cervix uteri which were alive five years after hysterec-
tomy.
The Seegen Prize.— It is announced that Professor Joseph
Seegen, of Vienna, will give §1,000 for the best answer to the
question: "Is any part of the nitrogen of the albuminates
which have undergone metabolism in the animal body elimi-
nated either by the lungs or by the skin in gaseous form?"
The answers, written in either English, German, or French,
must be sent to the Academy of Sciences, Vienna, before Feb-
ruary 1, 1904.
Health of Chicago.- The typhoid fever epidemic is re-
ported to be abating. Although there has been some slight
improvement in the sanitary contribution of the water supply,
the favorable change is not attributed to this cause, but is
thought to be due to the information which has been widely
disseminated as to the nature and cause of typhoid and the
method of its prevention. During the week ended September
l.'t, there were 43 deaths from the disease, which is 12 less than
for the preceding week, and there wore only 240 patients under
treatment at the close of the week, which, when compared
with the 373 under treatment three weeks previously, shows a
decrease of 'A^fo. The total number of deaths from all causes
for the week is 494, .'(0 less than for the preceding week. Tlie
chief reduction is noted in the deaths of children under .5, this
decrease being probably duo to the low temperature, which has
helped t<5 conserve the wholesomeness and digestibility of the
food supplies, especially milk. Diphtlieria and scarlet fever
show an unusually low percentage, but who^pingcough still
continues prevalent, contributing a large percentage to the
annual mortality.
CLINICAL NOTES AND CORRESPONDENCE
[Communications are Invited for this Department. The Editor is
not responsible for the views advanced by any contributor!
HEROIN AS A LOCAL ANALGESIC IN TUBERCU-
LOUS LARYNGITIS.
BY
J. LEFFINGWELL HATCH, B.Sc, M.D., F.R.M.S. (London),
of New York City.
Late Professor of Laryngology in the New York Clinical School of
Medicine and Laryngologist to the German West Side Dispensary;
formerly Assistant Demonstrator of Morbid Anatomy and Lec-
turer on Bacteriology In the University of Pennsylvania ;
Pathologist to the Philadelphia Hospital; late Sanitary
Inspector for the Port of Antwerp, Belgium, i ■
in the U. S. Marine-Hospital Service, etc.
Since Prof. H. Dresser, of Elberfeld, Germany, wrote his
scholarly paper on heroin in the Therapeutische Monatshefte of
September, 1898, it has been carefully studied and used exten-
sively in the practice of medicine, both in Europe and America,
and has found great favor among practitioners, especially in
diseases of the respiratory organs. The following year Dr.
Carl Mirtl published in the Wiener klin. Rundschau the results
of his study of the analgesic action of the drug in his gyneco-
logic clinic, but it is not until May, 1901, that any account of
its having been used locally in throat aflfections is to be found,
when Dr. Ligowsky, assistant to Prof. A. Rosenberg's clinic at
Berlin, published in die Heilkunde the preliminary reports on
its efficacy in rhinolaryngology.
This paper was followed in November of that year by an
article in the same paper by Prof. Rosenberg, entitled " The
Local Application of Heroin Hydrochlorid," in which he sets
forth the mode of application, the strength of the solution used,
the results obtained, and quotes several cases.
It was from this article that I received the idea of trying
heroin hydrochlorid in tuberculous laryngitis and I have given
it a most thorough test with very gratifying results.
Heroin is the diaceticacidester of morphin with a rational
formula of CnHnNO (C2H302)2 or graphically
CnHn/OOC,CH3\NO
\OOC,CH3/
and is made by displacing two hydroxyl groups in morphin
(CnHisNOs) by the acetyl radical C2H3O2.
Its physical properties are as follow: A white odorless
powder made up of fine prisms isomorphic with morphin; it
is somewhat bitter to the taste and is alkaline in reaction ; it is
almost insoluble in water but is freely soluble in acetic acid
and acidulated water. The hydrochlorid is superior from the
fact that it is readily soluble in water and is put up in tablets
that make it convenient for hypodermic use. The dose is from
^2 to J grain, the action is comparatively rapid and is lasting, in
some instances continuing as long as eight hours after the
administration of a single dose. Its physiologic action is simi-
lar to that of morphin, save that it does not cause vomiting nor
contracting of the pupil, and there is no primary peripheral
nerve stimulation. Less of this drug is required to produce slow-
ing of the respiration than there is of codein, and ten times the
amount can be given witliout toxic effect. While heroin allays
the tendency to cough by partial inhiijition of the peripheral
nerves in the respiratory tract, it also, at the same time, stimu-
lates respiration centrally, so that both inspiration and expira-
tion are fuller, although the nu Tiber per minute is reduced on
account of the prolongation of each separate act. It reduces
temperature by retarding metabolic processes evidenced by the
diminished elimination of carbonic acid gas. It has no direct
action upon the heart, but acting vicariously in diseases of the
lungs, in which the increased resistance causes a rapid, hard
pulse, it reduces the heart's work by relieving the pulmonic
obstruction and we get a pulse of less rate but full and soft.
As a local analgesic, weak solutions cause an inhibition of
the peripheral sensory nerves, accompanied by a slight anemia
of the part due to vasomotor stimulation, while with stronger
solutions we get a paresis of the peripheral nerves and a sec-
ondary congestion following the anemia due to vasomotor
paralysis.
670 AlCXKICAN MKDIOINE
COKRESPONDENCK
(OCTOBEB 11, 1902
In the application of local anesthetics, the anatomy of the
part as well as the lesion to be treated has to be taken into con-
sideration as regards the modus operandi ; the mucous mem-
brane of the nose and pharynx can readily be strolled with a
pledget of cotton soaked in a solution to be applied, but in
ulcerative processes in the larynx this is sometimes next to
impossible, often giving rise to excruciating pains, especially
in such cases as tuberculous laryngitis, hence sprays have
gained much favor, and also direct injections into the part with
a hypodermic needle. When a drug can be used with impunity,
like a solution of menthol in albolin, the spray is preferable as
there is no needless irritation by the scraping of the part, but
in the case of heroin when the strength of the solution has to
be measured to a nicety, the spray is out of the question.
Following carefully the methods prescribed by Prof. Rosen-
berg in Berlin I commenced by using a b% solution of the
heroin hydrochlorid. One cc. of this solution represents 0.005
gm. of heroin or about i^ grain. By employing a Pravaz's
.syringe, in which the amount to be injected can be controlled
by a movable ring that screws up and down on the piston out-
side of the syringe, I was enabled to inject just 1 cc. of a b%
solution of the heroin hydrochlorid representing -^^ grain of
heroin.
In filling the syringe it is better to take more than the
desired amount and then press the plunger down to the 1 cm.
mark, thus removing all air from the needle, and wipe off the
drop remaining on the point of the needle with a piece of steril-
ized cotton, the syringe then contains the exact amount and is
ready for use. Of covirse, in laryngeal injections the long
curved needles are to be used by aid of the laryngoscope,
allowance for their length is always made by the manufacturers
of the Pravaz's syringe, so that the contents of any particular
syringe is exact as expressed by the figure on the piston or
glass cylinder of the syringe. The needle in every case should
be sterilized before an injection is made, by boiling in water
from fifteen minutes to about half an hour, and the point of the
needle should be dipped in absolute alcohol just before the
operation.
I next tried making applications directly on the dqucous
membrane by means of pledgets of cotton attached to an appli-
cator. In doing this I used a weaker solution as it required a
greater quantity of the solution to saturate the pledget
thoroughly than 1 cc. afforded. The solution used was about
3%, 15 grains of the heroin hydrochlorid being dissolved in one
ounce of water ; this would give the following proportions :
S 1,480 grains, contains 15 grains heroin
3 1, 60 " " 1% "
1 miu. or Idrop " ^ " "
If we take five drops of this solution we will have a
quantity representing about J grain of heroin, but as in all
applications with cotton pledgets about one-half remains in
the pledget absorbed by the cotton and does not come in con-
tact with the part, the real acting strength is therefore about ^
grain. The solution may be placed on the cotton pledget from
a dropper, or it may be put in a watch crystal and the pledget
dipped into it. Care should always be taken to apply directly
to the lesion whether an applicator is used or whether it is
injected hypodermically.
I used heroin most for laryngeal tuberculous ulcers,
although I also used it as an anesthetic in several cases of nasal
hypertrophy. In cases of tuberculous ulceration of the larynx
the action of the drug is twofold— it lessens pain in swallowing
and allays cough, and this last feature is of no small considera-
tion, not only to the comfort of the patient, but as regards the
conservation of force. Jul. Weiss, in the February number of
die Heilkunde for 1901, says : " When any one coughs hard
every 15 minutes for 10 hours consecutively, 250 calories are pro-
duced. This is indeed a respectable force and it is on account
of this that patients become so weak from coughing."
When heroin is applied to the throat, the sensation is sim-
ilar to that of cocain, there is loss of sensation and a dry, thick
feeling which lasts for hours.
In those cases of tuberculous laryngitis in which deglutition
is so painful that the patient almost prefers starvation to endur-
ing the untold agony of swallowing, this drug is a boon, for
after its use swallowing is performed with less difticulty and
pain, and in some instances it is painless. Of course the drug
has no curative influence on the tuberculous process, and is
intended only to relieve the pain and cough, but after the parts
have lieen soothed by its application it is comparatively easy to
apply curative agents directly to the seat of the ulcerative pro-
cess. In the patients I treated most of the applications were
made by injecting the heroin hydrochlorid directly into the
ulcer by means of a Pravaz's syringe. In some instances, how-
ever, direct application was made with a pledget of cotton. The
heroin was always followed a few minutes afterward by an
application of a saturated solution of europhen in ether. The
results obtained from this treatment were most gratifying. The
results obtained long ago from the use of europhen were very
satisfactory, still the application was always made with dif-
ficulty and more pain than it now is when the parts are first
anesthetized with heroin.
A study of 19 cases, representing tuberculous laryngitis
in different stages of progress, gives a broader view of the action
of this drug than we could otherwise obtain had its use been
restricted to any one period.
In some of the cases I found that the patients bore the
physiologic action poorly, the administration giving rise to
sinking spells, prolonged respirations with a fteling of oppres-
sion, and an irregular and weak pulse ; but all these cases were
those in which the pulmonary lesion was far advanced and the
patient naturally given to such symptoms from ordinary exer-
tions. The dose must he watched closely and not more than IJ
grains given hypodermically.
The results that liave been obtained warrant us in looking
upon heroin as a local anesthetic of no mean ability, and one
that will eventually outrival cocain, especially in throat affec-
tions.
LIQUID AIR IN THE TREATMENT OF CANCER.
GEORGE G. HOPKINS, M.D.,
of Brooklyn, N. Y.
To the Editor of American Medicine: — In your issue of
August 2 you quote the results obtained by Howitz in the
treatment of cancer by freezing. How long this treatment has
been used is not mentioned.
I began using liquid air for freezing cancerous growths
three years ago, and find this method far superior to the
cautery or ethyl chlorid. It does away with the necessity of
any cauterization with hot iron, and is absolutely painless. The
parts are frozen in a few seconds and can be peeled out with
perfect ease.
In the application of the liquid air, if the part has been sup-
purating, the contents of the ulcerated patches will shake out
like coarse cornmeal. Larger portions can be frozen to any
depth and readily removed with the curet. I have had most
satisfactory results with advanced carcinoma of the breast,
keeping the patient comfortable and comparatively free from
the oflfensive discharge and frequent dressings. The liquid air
is applied as frequently as indicated by return of the odor and
pain, both of which are controlled by this method. I have not
used it as a curative measure, as suggested in Howitz's paper,
but will take occasion to do so when a suitable case presents
itself.
Liquid air is not easily procurable, and is rapidly dissipated.
I usually get a gallon in Manhattan for use in Brooklyn when
a pint or half that quantity is needed, for the greater portion
resolves itself into normal air in the course of an hour. The
most satisfactory method of application is in the form of a
spray. This is done by vising a large test tube, of about an inch
in diameter, and a piece of glass tubing of a quarter inch
caliber; bend the latter at a right angle and draw down the
outer end to a third the normal caliber of the tube, dip the
large end into the tube, which has been previously half filled
with liquid air, and the air will be emitted in a spray which can
be readily directed upon the parts to be treated. The healthy
tissue should be protected by a thick layer of asbestos, as
the spray may inadvertently be carried beyond the disesised area.
Dr. Howitz's suggestions are worthy of trial, and I believe
can be better carried out with liquid air than with ethyl chlorid.
OCTOBltK II, 1902]
PATHOLOGY OF CHRONIC SPECIFIC DYSENTERY iaiokicah mbdicisb 571
ORIGINAL ARTICLES
THE PATHOLOGY OF CHRONIC SPECIFIC DYSEN-
TERY OF TROPICAL ORIGIN.'
BY
CHARLES F. CRAIG, M.D.,
of San Francisco, Cal.
Contract Surgeon, IT. 8. Army ; Pathologist and Bacteriologist to the
U. 8. Army General Hospital, Presidio, of San Francisco, Cal. ;
Member of the Association of Military Burgeons of
the United States, etc.
From the observations of Flexner, Curry, and Strong
it has been definitely settled that a considerable propor-
tion of the dysenteric cases occurring in the Philippine
Islands i.s due to a specific bacillus, which was first dis-
covered and described by Shiga. This form of dysentery
is Icnown as acute specific dysentery, in contradistinc-
tion to the more common form occurring in these islands,
due to the ameba and known as amebic dysentery.
In the following report I shall consider the pathology
of what I believe to be the chronic form of acute specific
dysentery. In the service at the U. S. A. General
Hospital, Presidio, of San Francisco, Cal., we seldom
see the acute forms of dysentery, almost all the cases
coming to us being of the chronic variety ; a large por-
tion of them chronic amebic dysentery, but a larger por-
tion being the form the pathology of which is about to
be described. I have considered this form to be the
chronic stage of the acute specific dysentery of tropical
origin for the following reasons :
First. The blood-serum of these cases gives an agglu-
tination reaction with a pure culture of the Shiga bacillus.
Second. A pure culture of this bacillus has been
obtained from the intestine in a few of the cases of this
form of dysentery.
For convenience of description I have divided the
cases which have come to autopsy into three classes — fol-
licular, diphtheric and gangrenous forms of dysentery,
but it should be distinctly understood that this is only
a classification from the most obvious pathologic lesions
present, and that in all probability the different patho-
logic lesions pre.sent all belong to one process, commenc-
ing as follicular and terminating in the gangrenous form,
providing the patient survives long enough.
The observations recorded in this report are based upon
autopsy findings in 103 cases of this form of dysentery,
of which 28 were of the follicular variety, 70 of the
diphtheric, and the remainder of the gangrenous.
While this classification into follicular, diphtheric and
gangrenous is useful and almost neceasary from a
descriptive point of view, it should be understood that
it is not a classification denoting disease entities, but
only stages in one process. While the morbid anatomy,
gross and microscoi)ic, differs very materially, still in
many ca.ses two or more of the stages are present at the
same time. The follicular form tends to merge often into
the diphtheric, and that again into the gangrenous, so
that it is at once seen that these are simply stages in one
pathologic process. While, therefore, we may consider
that the pathologic lesions found are but progressive
steps in the same general i)rocess, still there may be
S(!parat(!d these three distinct cla-ses from a pathologic
stiindpoint, each having its own peculiar lesions and
each to be studied, in conswiuence, separately. In
describing this form of dysentery the report will be
divided as follows :
First. The character of the dysenteric stools.
Second. The gross and microscopic pathology of the
follicular stage.
Third. The gross and microscopic pathology of the
diphtheric stage.
> with permission of the Surgeon-Oeneral of the Army. From a
Rpeclal report submitted to the .Surgeon-Oenerol, U.S. Army. Read
attbo eleventh annual meeting of the Association of Mllllary Hiir-
geons, Washington, I). C, June 7, 19l«.
Fourth. The gross and microscopic pathology of the
gangrenous sttige.
Fifth. The bacteriology of chronic specific dysen-
tery.
THE CHARACTER OF THE DYSENTERIC .STOOIjS.
Much can be learned as to the type of dysentery pres-
ent by a careful examination of the feces, both as regards
the physiclal characteristics and the microscopic con-
tents. The stools of the three stages of dysentery noted
here differ materially in macroscopic and microscopic
appearance. We will consider each stage separately.
TTie Feces of the Follicular Stage. — The feces are
characteristic as a whole, but it would be unsafe to diag-
nose this stage of the disease from an examination of the
feces alone. Both the diphtheric and gangrenous
stages are evidently simply an extension of the disease
process which is at first apparently localized in the fol-
licles of the intestine. This is shown by the fact that
many of the cases showing the stools of the follicular
stage have, after a time, presented the characteristics
found in the stools of the diphtheric or gangrenous
stages. The stools of the follicular stage exhibit macro-
scopically the following characteristics : In number they
vary greatly, usually from 3 to 18 or 20 during the 24
hours. There are periods of apparent improvement,
during which the stoolt may number only one or two a
day, or there may even be constipation ; such periods
are, however, generally succeeded by acute exacerba-
tions, during which the stools become more numerous.
They may vary greatly in character according to the
food given, the amount of degenerative change occur-
ring in the intestine, and the me<licines adjninistered.
Changes in color are due to the biliary secretions and to
certain drugs, such as subnitrate of bismuth.
As a rule, the stools are of a semifluid consistence,
and when a .strict milk diet is given the consistence is
that of a very thin mush, milk curds being often ob-
served. In patients upon a varied diet the stools present
particles and shreds of undigested food. The color
varies greatly, some being almost white, others, and
perhaps the majority, a light yellowish-green, while
others are gray, slate-colored, brown or dark green. In
a few instances an intense bright green color is noticed.
As a rule these stools show little blood, but mucus and
pus are often present. As regards odor, they are not
very offensive.
While the follicular cases show stools of the above
character most of the time, they one and all i)resent at
intervals more watery stools containing flecks and floc-
culi of mucus, streaked with thick, creamy pus. A few
of the stools of this character showed the presence of
blood, and they were often frothy, being filled with gas
bubbles due to fermentation. The color varied from
yellow or yellowish-green to reddish-brown. These
stools were very offensive.
During (luiescent periods of the disease the stools
very often were formed and resembled the ordinary
movement in health. But few of the stools from this
cla.ss of cases showed the presence of largo (juantities of
blood to the eye, but almost all showed numerous red
blood-corpuscles when examined microscopitally. The
microscoitic examination of the feces from this stage of
the disease gave the following results :
Blood : Almost every specimen examined showed at
least a few red blood-cells. They were most numerous
in the thin, watery discharges and least in the formed'
movements. In the first mentioned they were often
very numerous and well preserved in form and size. In
the mushy stools red blood-corpu.scles were (luite numer-
ous in soirie instances, while in others only a very few
could be found.
Pus: Numerous pus cells were found in a majority
of the cases examine<l, and they were especially in evi-
dence in the stmiifluid evacuations, although the semi-
fluid gruel-like stools often contiiined immense numbers
572 AMKKicAN mkdicinkj PATHOLOGY OF CHRONIC SPECIFIC DYSENTERY
[October U, ItXU
of pus cells. These were invariably very granular in
appearance and often contained bacteria.
Mucus and mucous corpuscles : A large majority of
the stools showed numbers of mucous corpuscles im-
bedded in a stringy, fibrous matrix, the mucus. The
corpuscles were identical in appearance with leukocytes,
save that they were more finely granular.
Intestinal epithelium : Almost all the stools exam-
ined showed numerous epithelial cells, derived from the
intestine. These occurred only in small numbers, singly
or in small groups, but in the worst cases large portions
of intestinal membrane were observed, composed gen-
erally of a single layer of epithelial cells. These cells
varied in size, possessing one or more nuclei, the proto-
plasm being very granular and sometimes vacuolated.
Some were so large that to one inexperienced in the
examination of the feces they might easily be mistaken
for amebas.
Undigested food: Fragments of undigested food,
such as bits of muscular tiasue, various vegetable cells,
milk curds, etc., were, as a rule, present. Many of the
stools contained crystals of ammonia, magnesia phosphate
and sulfate of bismuth.
Bacteria : The bacterial flora of the feces in the fol-
licular stage of dysentery was very varied and extensive.
The number of bacteria present was enormous, very
much greater than in healthy feces. Staphylococci,
streptococci and bacilli occurred, as well as torulse. In
all the examinations it was noticed, however, that the
bacilli greatly preponderated in number, and sometimes
hardly any cocci were present. A discussion of the bac-
teriologic forms present will be reserved for the section
of the report dealing with the bacteriology of the dis-
ease. Yeast cells were observed in numerous specimens,
as were also mould fungi.
Other parasites : In none of these cases was the
ameba of dysentery observed. Cercomonas intestinalis
was observed in a considerable proportion of the cases,
as was also the trichomonas. These were evidently,
however, only of accidental occurrence.
Character of the Feces in the Diphtheric Stage. — In
the diphtheric stage of this form of dysentery the
stools differ much from those just described. They are
composed, roughly speaking, of a serous body in which
are suspended shreds, strings and pieces of pseudomem-
brane, cells and small portions of intestinal mucous
membrane. With these are mixed blood and pus,
mucus and undigested particles of food. These stools
contained little true feculent material when the disease
was progressing, but as the patients improved the move-
ments became feculent. The mucus present is not the
glairy substance seen in the stools of acute dysentery,
but more closely resembles pus, which is also present in
large quantities in many of these cases. The color of
the stools varied from slate to red, the last being due to
the presence of large quantities of blood. The most
common color is a dirty brown, confined to the liquid
portion of the feces, while suspended in this are the
dirty, grayish-yellow or greenish bits and shreds of
pseudomembrane and intestinal mucous membrane.
When much blood is present, the liquid portion of the
stool may be dark brown or almost black in color.
These stools resemble very closely those found in amebic
dysentery. The characteristic features of the diphtheric
stool are the bits of pseudomembrane and portions of
the mucous coats of the intestines. These pieces of
pseudomembrane are derived from the diseased area in
the intestine, the process there consisting in the produc-
tion of a pseudomembrane over the mucous coat, result-
ing in necrosis of a greater or lesser portion of it. The
pieces of pseudomembrane and of the intestinal mucous
coats are generally very small, not exceeding \ cm. in
diameter. The typical diphtheric stool consists of
brownish, watery fluid in which are suspended multitudes
of these bits of membrane. The odor from these stools
was horribly offensive in every instance.
Microscopic examination of the diphtheric stool :
Blood, mucus and pus cells were invariably observed in
these stools. Many of the leukocytes presented ameboid
movements when the stool was examined immediately.
As a rule, but little mucus was found, although pus was
generally present in large amounts.
Pseudomembrane and portions of the intestinal
mucous membrane: The microscopic structure of the
pieces of pseudomembrane was that of a dimly fibrillated
membrane, in which numerous leukocytes and pus cells
were enmeshed. Leukocytes were, as a rule, numer-
ous, although there were often seen bits of membrane
which were granular and free from any cellular
material. In all these stools there were large clumps of
granular material, evidently the detritus of destroyed
mucous membrane. The portions of the mucous mem-
brane often showed the typical structure, but in a
majority of the cases only the pieces of structureless
membrane were to be seen.
Bacteriology of the diphtheric stool : Here, as in
the stools of the follicular stage, bacteria were present in
immense numbers. Bacilli were altogether the most
numerous.
Cercomonas intestinalis was found in a few of the
cases, but in none of them was the ameba of dysentery
observed.
Character of the Feces in the Oangrenous Stage. — This
stage of the diphtheric process is simply an intense
diphtheric infection in which the mucous and sub-
mucous coats of the intestine are in various stages of
gangrene, and large pieces of the diseased membrane are
found in the feces, together with pus and blood. The
consistence of the stools is that of thin, slimy syrup, of a
slate-brown or black color, in which are found pieces of
necrosed mucous membrane, often from .5 to L5 cm. in
diameter, together with particles of undigested food and
greenish pus. The odor from these stools is very
offensive.
Microscopic examination : This shows immense
numbers of blood and. pus corpuscles and bacteria. The
pieces of necrosed membrane comprising the mucous,
and often the submucous intestinal coats, presented
under the microscope the glandular structure, more or
less degenerated, of the intestine, together with an
immense infiltration of leukocytes. In many pieces of
membrane the necrosis had gone so far as to destroy
entirely all traces of structure, the result being a mass of
granular detritus.
From the descriptions given of the feces in these
stages of dysentery it will be seen that while each pos-
sesses characteristics of its own yet in certain particulars
there is a resemblance, indicating that it is only a step
from one stage to the other, and that they are all the
result of one pathologic process which varies in severity.
We are safe, however, in concluding that the character
of the feces in a given case of dysentery is of much value
in diagnosis, especially as to the severity of the patho-
logic lesions.
The gross and microscopic pathology of chronic spe-
cific dysentery : In considering the pathology of this
form of dysentery as observed at this hospital, I shall
describe as accurately as possible the appearances
observed in the three stages mentioned ; but while the.se
stages differ materially when not associated, it must not
be forgotten that very often a diphtheric process is en-
grafted upon a follicular one, and a gangrenous upon a
diphtheric, so that we find a combination of pathologic
lesions present in a single case. However, in the major-
ity of cases observed here the lesions have been so dis-
tinct that there has been but little difficulty in separating
the cases into the three classes noted.
THE GROSS AND MICKOSCOPIC PATHOLOGY OF THE
FOIiLICULAR STAGE.
The cases of follicular dysentery were typical examples
of the chronic process, there being always a history of
October il, 1902]
PATHOLOGY OF CHKONIC SPECIFIC DYSENTERY (amekicah MKDictNE 573
the disease having persisted for some time, generally for
several months, always for at least two months. These
patients complained little of tenesmus or general dis-
comfort, save during- acute exacerbations, which have
occurred from time to time.
Gross Pathology. — On opening the abdominal cavity
in these patients the intestines were found as a rule
dilated with gas, especially the ascending colon as well
as the ileum. In a few cases the abdominal cavity con-
tained an abnormal amount of fluid. Abnormalities in
the shape of the gut were observed in three cases, one
showing a normal sized ascending and descending colon
while the transverse colon was greatly contracted, being
smaller in caliber than the small intestine ; one present-
ing a large, sacculated pouch Just above the splenic flex-
ure, and one in which the duodenum was markedly
dilated along its entire course, being about three times
the normal in caliber. Most of the cases showed a decid-
edly sacculated condition of the large intestine.
The external color of the intestines varied somewhat,
but was generally of a dull gray or slate. The large
intestine was almost invariably this color, and often pre-
sented oval areas almost black, but these areas were not
connected with underlying ulceration. I believe these
areas were formed antemortem, for the reason that in
the cases in whicii they occurred the autopsies were per-
formed very soon after death. They were probably due
to extravasated blood, which, as in a bruise, is under-
going pigmentary change. In eight cases there were
noticed bright red areas due to recent capillary hemor-
rhage.
The color of the small intestine varied from almost
white to a bright pink, the most common being a bright
flesh tint as a ground color, from which the injected
capillary vessels stootl out as brilliant red lines. In most
of the cases the coats of the large intestine were thick-
ened and the caliber of the gut lessened. In one case the
large intestine was almost cartilaginous in consistency.
As a rule the intestinal coats were thicker than normaf
throughout this portion of the canal.
One of the most remarkable conditions present, and
one which was present in almost every case, was the
excessive thinness of the jejunum and ileum. In some
places the walls of this portion of the small intestine
were so thin as to resemble parchment, and there was
very extensive atrophy of the mucous membrane. In
ten of the cases the solitary follicles of the small intes-
tine were markedly enlarged.
\n all but one of the cases the follicular ulceration
was confined entirely to the large intestine, being
limited by the ileocecal valve. This limitation was very
noticeable, especially in cases in which the ulceration
was very extensive right up to the valve, but there
abruptly ceased. In one case there was a large ulcfer
atM)ut two inches al)ove the valve and the solitary fol-
licles in the vicinity were enlarged. The stomach in
almost every case was smaller than normal, and the
entire organ of a dark slate color. The mucous mem-
brane was very pale and poorly supplied with blood. In
three cases the stomach was very greatly atrophied, its
walls thickened, and the mucous membrane showed ex-
tensive chronic inflammation. In all the cases the
mucous membrane of the stomach showed some inflam-
mation, generally of chronic character.
The color of the diseast^d mucous membrane in the
large intestine varied considerably, but the most com-
mon was a gray slate color ; brownish pigmente<i areas
were observed frecjuently, and also patclies of acute con-
gestion. In those cases in which there was but little
ulceration, the mucous meml)rane ajjpeared thi(;kened,
while the follich:^ stood out as slightly enlarged and
tumefied areas, around the bases of which was often
observed evidf^nce of acute congestion in the shape of a
reddish circle, du(^ to the congested capillaries. Cystic
formation was not ol)serve<l in any of these cases. In
this stage of the disease the pathologic process seems to
be confined to the follicles of the large intestine. Where
follicular ulceration had commenced the mucous and
submucous coats were markedly thickened, as a rule,
the thickening being confined to a great extent to the
submucous coat. The caliber of the gut was generally
lessened, but in places there was marked dilation. In
such ctises the dilated portion was almost white, there
being but little pigmentation, but the thickened portions
of the gut were often pink or reddish in color. The
ulcerations in the follicular stage were absolutely charac-
teristic. They were situated, in the early stage, at the
summit of the follicles, and appeared first as minute
ragged openings, so small that close inspection was
needed to see them. As the process advanced the aden-
oid tissue of the follicle broke down, the ulcer became
larger, had undermined edges, and a greater diameter at
the bottom than at the top. These ulcers may run
together in the worst cases, thus forming irregular chan-
nels through the mucous membrane. The surface of the
gut around tlie smaller ulcers was not congested, but
around the large ones there was generally a slight conges-
tion. A peculiar characteristic of these ulcers was their
stamped-out appearance, as though they had been cut
into the mucous membrane by a sharp punch. The
largest single follicular ulcer observed measured \\ cm.
in diameter ; as a rule they measured from \\a \ cm. in
diameter. The floor of these ulcers, save in the very
early stage, was generally the submucous or muscular
■ coat. In the early stage the floor was generally formed
by the submucous coat or by the remains of the adenoid
tissue of the follicle. Cicatrices due to the healing of
these ulcers occurred in about 25^ of the cases, but were
by no means numerous.
In three of the cases the diphtheric process had
commenced shortly before death, being engrafted upon
the follicular condition. In these cases the colon, espe-
cially the rectum, was of a dirty greenish-gray color
patched with red. There were numerous areas covered
with pseudomembrane, which, upon being removed,
disclosed small follicular ulcers.
As regards the seat of the process in the large intes-
tine, the region around the ileocecal valve was most
often and most extensively involved, the next most
frequently involved region being the rectum. In the
majority of cases both these regions were involved
together. Above the splenic flexure for 20 cm. to 30cm.
the mucous membrane in most of the cases was but little
involved. In four of the cases the rectum and cecum
were alone involved.
The small intestine : The small intestine in every
case showed a remarkable thinning of the coats, espe-
cially in the ileum. The latter portion of the intestine
was often almost like tissue paper. The color of the
ileum in these cases was white, or at most very slightly
pink. The mucous membrane in the thin portions was
generally entirely atrophied, while in those portions in
which the coats were thicker the mucous membrane
was prestmt but evidently ill-nourished.
The mucous membrane of the duodenum and the
jejunum were more normal in appearance, but there
were usually patches of acute congestion and capillary
hemorrhiige. In six cases the ileum contained minute
pigmented areas.
Afiarosropic Pathology. — In describing the microscopic
pathology of this stage of dysentery I shall not touch
upon those cases in which the diphtheric process began
before death, as the pathology of that condition will be
considered in its proper place ; nor upon the bacteriologic
condition-i, which will also be referred to later. In
studying this subject we meet changes in the following
structures, /. c, nmcous coat, submucous coat, muscular
coats and the periton(>al coat. I shall first describe the
changes whi(!h take place in the intestinal coats where
ulceration luwnot as yet begun.
The mucous coat: The cellular elements of the
adenoid tissue were increase<l in number, so much so
574 AMBBioAN mbdicine] PATHOLOGY OF CHRONIC SPECIFIC DYSENTERY
[OCTOBER 11, IW2
that the tubular glands were compressed, and in some
places seemed to be filled with a dense mass of leulco-
cytes. The adenoid tissue in places has entirely
replaced the glandular tissue. Scattered through the
dense adenoid tissue is much brownish and black pig-
ment. The nuclei of the cells stain very deeply.
The submucous coat : The submucous layer of the
intestine was generally much thickened and infiltrated
by leukocyte^^. The latter are collected in irregular
masses, being especiallj^ numerous nearest the solitary
follicles. The muscular layers of the mucosie were often
entirely obscured by the masses of leukocytes. The
solitary glands or follicles were somewhat enlarged, the
number of cells being notably increased, and surround-
ing them were numerous leukocytes. The follicles pro-
jected markedly into the mucous layer and in some
places beyond it.
Muscular coats : The muscular coats presented some
leukocytic infiltration, the leukocytes being most numer-
ous in the circular coat, least in the longitudinal.
The serous or peritoneal coat : No change of impor-
tance was detected in tliis coat.
Where follicular ulceration had occurred the follow-
ing changes were noticed :
The mucous coat : There was a great increase in the
cells of the adenoid tissue lying between the tubular
glands. These cells produced two different results —
either they pushed or crowded the tubular glands
upward or they invaded them, causing their ultimate
destruction. Where the latter process occurred super-
ficial ulcerations in the mucous membrane were formed,
in which a portion of the glandular structure was
destroyed, the edge of the ulcer being marked by a dense
layer of leukocytes, beneath which were often observed
portions of the glandular structure still intact. These
ulcers were not follicular, but almost always occurred
along with follicular ulcerations. In two instances the
nonfoUicular ulceration just described had assumed a
more intense character, the ulcers penetrating to the
muscular coat, the mucous and submucous coats being
entirely destroyed. The edges of such ulcers were slop-
ing or ragged and composed largely of dense swarms of
leukocytes. The submucous and muscular tissue sur-
rounding these ulcers were also invaded by leukocytes.
In some portions of the mucous membrane the tubu-
lar glands were much deformed, being shortened or dis-
torted by the pressure of the increased adenoid tissue,
while in other places the glands were entirely filled with
leukocytes.
Submucous coat : The first thing which attracted the
attention in sections of the large intestine, from cases of
follicular dysentery, was the immense thickening of the
submucous coat. In the majority of the cases observed
it constituted at least one-half the entire thickness of
the coat, and sometimes nearly two-thirds. This great
increase was due to the invasion of the tissue by im-
mense numbers of leukocytes and the active proliferation
of the connective tissue cells.
In studying the sections the distribution of the new
cellular material was found to be somewhat peculiar.
Around the solitary follicles the leukocytes were present
in immense numbers, often entirely obscuring the fol-
licle. Beneath and within the muscularis mucosai they
were very numerous, and greatly decreased in number
as the muscular layer of the intestine was approached.
The bloodvessels of this portion of the intestine were, as
a rule, but little congested, but their walls often showed
some fibroid thickening. In a few of the sections there
were noticed peculiar areas having a homogeneous appear-
ance, taking the stain but poorly, and in which no defi-
nite structure could be demonstrated. These were prob-
ably areas of coagulation necrosis.
The solitary follicles : It was in these structures that
the most characteristic lesions of this stage of the dis-
ease were found. The first evidence seen in the sections
of the ulcerative proceas as it affected these glands was a
breaking down of the cellular structure of the gland at
the portion nearest the mucous membrane, that is, at
the apex of the follicle ; the cubical layer of epithelium
had disappeared and the proliferated adenoid tissue had
taken its place. At the same time a great accumula-
tion of leukocytes had occurred around the follicles.
Where the proceas was a little more advanced, there
was a marked excavation of the follicle, the mucous coat
forming an overhanging edge, while the necrosis per-
sisted laterally in the submucous tiasue. In some sec-
tions this process could be seen to have advanced until
the circular muscular coat had been reached, the floor of
the ulcer being formed by it. Such an ulcer presented
an excavated edge formed by the mucous and sub-
mucous coats, which were infiltrated by dense masses of
leukocytes, the floor being formed by the circular mus-
cular coat, which also showed marked leukocytic infil-
tration. All stages of the process were traced from the
ulceration of a portion of the solitary follicle to its entire
destruction, and the consequent spread of the ulcerative
process through the submucous and muscular coat. In
some of the sections the ulcers were seen to have joined,
forming large irregular aivities, involving most of the
mucous and submucous coats. In none of the sections
could the ulceration be seen extending more than half
way through the circular muscular coat; The margins
of some of the ulcers showed a very great degree of
excavation, the mucous coat forming a very marked over-
hanging edge, and in some of the solitary follicles it was
observed that the tubular glands had apparently become
incorporated with them, forming cyst-like cavities in
the dense mass of the adenoid tissue of the follicle.
Beside the immense accumulation of leukocytes and
connective tissue cells at the margins of the ulcers, such
cells were also especially numerous around the blood-
vessels and at the muscularis mucosa?. Some of the sec-
tions showed extensive hemorrhagic areas in the sub-
mucous coat, due to the destruction of the capillary
vessels in the vicinity. Large collections of golden-
brown pigment were often seen lying in the submucous
coat and nearer the margins of the ulcers, and also areas
of fatty degeneration, especially numerous at the junc-
tion of the mucous and submucous coats.
Muscular coats : The circular muscular coat was in-
variably found invaded by leukocytes, but sometimes in
very small numbers. The leukocytes were present in
immense numbers wherever the ulcer had penetrated to
the muscular coat, and in large numbers in those cases
in which the ulceration had nearly reached the circular
fibers.
The longitudinal muscular coat generally showed a
slight infiltration of leukocytes, and in those cases in
which an ulcer had penetrated partly through the circular
layer of muscular fibers the leukocytic infiltration was
much more marked. In such sections the muscular tis-
sue near the advancing edge of the ulcer was invaded by
a dense mass of leukocytes and connective-tiasue cells,
most numerous the nearer the approach to the ulcer. The
floor of the ulcer was irregular and composed of broken
down and degenerated muscle fibers and masses of leu-
kocytes, together with granular detritus.
The serous or peritoneal coat : Some thickening of
this coat was generally observed where ulceration had
occurred, together witli a slight leukocytic invasion.
From the study of the pathology of the follicular
stage of chronic specific dysentery, it will be seen that
the process consists essentially in a necrosis and ulcera-
tion of the solitary glands or follicles of the large intes-
tine, with an extension of the process to the mucous and
submucous coats and sometimes to the muscular coat ;
superficial and sometimes deep ulceration, nonfoUicular,
of the mucous and submucous coats, and invasion of the
mucous, submucous and muscular coats by immense
swarms of leukocytes and connective-tiasue cells, lead-
ing to atrophy and loss of function of the tissues
affected.
OCTOBBB 11, 1902]
PATHOLOGY OF CHRONIC SPECIFIC DYSENTERY iamebicaw medicthb 575
It should be remembered that any or all of the path-
ologic lesions described may be present in the same
section, as, for instance, superficial nonfoUicular ulcera-
tion ; but, however, combined, the separate pathologic
lesions conform to the descriptions given and are always
to be observed in sections of the large intestine from
cases in the follicular stage of this disease.
THE GROSS -VXD MICROSCOPIC PATHOLOGY OF THE
DIPHTHERIC STAGE.
In this stage of dysentery the pathologic lesions may
be divided into three classes, i. e., involvement of the
mucosa without any diphtheric deposit, involvement
of the mucosa and a deposit of diphtheric exudate upon
the surface of the membrane, involvement of the mu-
cosa, submucosa and even the muscular coat, with coin-
cident diphtheric deposits upon the surface of the
mucous membrane. Often all three of these lesions
were present in the same case, while in othere one only
was present. This stage of the disease is altogether the
most common in patients dying at this hospital.
Gross Pathology. — The intestines upon inspection
were generally dilated with gas and the small intestine
was of a leaden-gray or very pale flesh color. The large
intestine was generally of a grayish or greenish-blue
color externally, marked here and there by red or dusky
brown spots, connecting the more advanced diseased
areas within. Seldom was the intestine found at all
cartilaginous in consistency, although it was always
much thickened.
Abnormalities in the shape of the large intestine were
alwaj's present, there being numerous dilations in places,
while in other places the intestine appeared contracted.
This contracted appearance of the intestine was gen-
erally most marked at the lower p>ortion, while the
dilations were most frequent in the transverse and
ascending colon. The thickening of the intestinal coats
gave the intestine a peculiar feel. The walls of the
small intestine were almost invariably thinned.
The stomach presented externally little of interest,
being either pale in color and dilated with gas or present-
ing numerous reddish areas and more or less atrophied.
When the intestines in these cases were opened the
appearances presented varied much, depending upon the
stage at which the disease process had arrived before
death. In six cases, in which the disease had invaded
only the mucosa and there was no production of a diph-
theric deposit upon the inner surface of the intestine,
the mucous membrane appeared thickened and velvety
and was of a dusky reddish color, with lighter areas of
more normal tissue scatteretl here and there. This
appearance was confined to the rectum and around the
ileocecal valve, the mucous membrane of the rest of the
large intestine being more normal in appearance. Al-
though no diphtheric deposit was present in these cases
ulceration had occurred, the mucous membrane having
become necrotic and thrown off as a small slough. Such
ulcers were irregular in shape and very superficial.
While upon inspection no ulceration apparently existed
in some of these cases, incision tlirough the mucous
m<'mbrane often disclosed small ulcer cavities within the
mucosie. In these cases, also, there were numerous
elevations noted on the mucous membrane, which upon
incision were found filled with a somewhat thin glairy
substance which was almost colorless.
In those cases comprising the great msyority of the
ones coming to autopsy in which the mucosa was not
only invaded but a diphtheric deposit was formed over
it, the most chara<;teristic apjiearances accompanying
this stage of dysentery were obtained.
The color of the Interior surface of the large gut
vari(^ with the amount of exudation deposited. In the
worst cases, in which the entire surfat* of the intestine
was covered, the color was generally a dirty greenish-
gray or white; in the cases in which the diphtheric
deposit occurred in patches the color of the intestine
varied from a dusky red to a livid bluish tint, spotted
with dirty white or grayish membrane. This membrane
microscopically is seen to consist of a granular material
enclosing numerous leukocytes and immense numbers of
bacteria.
In a few of the cases the internal surface of the intes-
tine presented bright red areas, in these regions the
inflammation being acute. In all the cases the mucous
membrane of the rectum, where it was not covered
with exudation, was of a peculiar dusky red color and
very velvety in appearance.
As a rule the diphtheric membrane occurred in
irregular patches, varying in size from .25 cm. in diameter
to areas covering several centimeters. In all the cases
showing the membrane, sloughing had occurred in
many places, either in patches leaving superficial ulcera-
tions, or in the form of strings or shreds, leaving fissures
and hemorrhagic streaks through the membrane.
Shreds of nearly detached membrane were always found
in these cases, giving the intestine a very characteristic
and shaggy appearance.
All of the cases showing a diphtheric deposit pre-
sented numerous ulcerations, due to the destruction and
sloughing of the diseased mucosa and submucosa. These
ulcers were often very characteristic. They varied
greatly in size, from fine, pinhead excavations to ulcers
measuring 1 or 2 cm. in diameter. In all the cases
they were superficial, not extending deeper than the
submucosa, not one case showing an ulcer extending to
the muscular coat, although in many cases the process
had nearly penetrated through the submucosa. The
edges of these ulcers were not abrupt or overhanging,
but sloped gradually down to the base. The color of
the mucosa between the ulcers was a pale flesh tint,
covered with patches of dirty gray or greenish mem-
brane. In shape the ulcers were generally round or
oval, the latter most common, although irregular ulcers
were often observed. In most of the cases the bases
of the ulcers presented minute specks or dots of brownish
pigment, probably due to degenerated blood which had
been extravasated. The false membrane was usually
quite tenacious and tough, but in some cases was very
easily detached . In all the cases the deposit of diphtheric
membrane was greatest in the rectum and just below the
ileocecal valve. I have seen but two cases in which the
membrane had passed above the valve into the ileum.
In four of the cases the rectum alone showed the pres-
ence of the diphtheric membrane, although the
remainder of the large intestine was inflamed and
tumefied. Cicatrices of ulcers were not often observed.
Internally the small intestine presented patches of
more or less acute inflammation and areas in which the
mucous membrane was almost completely atrophied.
In most of the cases a peculiar hyperemic condition of
the summits of the folds of the mucous membrane was
noted, the capillaries in this locality being apparently
much congested. The mucous membrane of the stom-
ach presented in all the cases more or less evidence of
chronic inflammation, as shown by atrophy of the mu-
cous membrane, patches of congestion here and there
and pigmentation.
Microscopic Pathology.— In attempting to interpret
the microscopic appearances found in sections of the
intestine in this stage of dysentery it should be remem-
bered that all the lesions presented are merely steps in
one process, that no new histologic elements are im-
ported into the diseased tissue, and that in a single sec-
tion may be seen the lesions of one or more stages of the
disease. The process is essentially a necrosis of the mu-
cosa and submucosa, the necrosed ti.ssue sloughing otf
and leaving superficial ulcers.
Sections of the intestine at the very earliest stage of
the pro(!ess, before the production of false membrane,
present the following appearances, not varying much
from the appearances noted in the follicular stage of the
disease:
576 AMERICAN MEDiciNKj PATHOLOGY OF CHRONIC SPECIFIC DYSENTERY
(October 11, l!Ki2
The columnar epithelium covering the intestinal
mucosa and lining the glands had disappeared. The
adenoid tissue between the glands of Lieberkiihn was
infiltrated by a dense mass of leukocytes, which had in
many places invaded the glands and distorted them or
pushed them widely apart. At this early stage the leu-
kocytic invasion had only penetrated to the muscularis
mucoste, which seemed to limit it. When the process
had advanced further, however, the leukocytes could be
seen to have penetrated beyond the muscularis mucosae
into the submucous coat, being especially numerous
around the follicles of the intestines. A lesion of pecu-
liar character and of great interest during this stage was
the formation of small ulcers beneath portions of the
mucosa, often not extending into the submucosa. Nu-
merous areas were noticed in which small cavities were
seen entirely surrounded by the mucous coat in which
they lay, the tissue surrounding these cavities being
densely infiltrated by leukocytes and the glands of
Lieberkuhn in the neighborhood entirely obliterated by
vast numbers of the leukocytes. It is only a step from
this lesion to the fully developed superficial ulcers, all
that is necessary being the necrosis and sloughing of the
thin covering layer of adenoid tissue and leukocytes,
when the typical pseudodiphtheric ulcer will be pro-
duced, with its sloping or rounded edges and smooth
floor formed by the submucous coat. In sections from
the intestine when the pseudodiphtheric membrane
had already been formed, a somewhat different appear-
ance wa.s noted. Lying upon and within the glands of
Lieberkuhn and penetrating more or less between them
was a dense, fibrillated material containing numerous
blood-corpuscles, leukocytes and bacteria, /. e., false mem-
brane.
There was the same increase in the elements of the
interglandular adenoid tissue and the same infiltration by
leukocytes previously noted. In cases in which the process
was still further advanced, the submucosa was invaded
by masses of leukocytes, the capillary vessels distended
with blood, and numerous capillary hemorrhages had
occurred throughout the submucosa and also the mucosa.
The leukocytes were especially numerous around the
solitary glands, many of which had entirely disappeared,
being replaced by dense masses of these cells. The mus-
cularis mucosse had entirely disappeared, and there
seemed to be an increase in the fibrous material of the
submucosa. The circular muscular coat was generally
more or less infiltrated by leukocytes and connective tis-
sue cells. This great accumulation of leukocytes and
the pressure exerted by them and the newly formed
diphtheric membrane, together with bactericidal poi-
sons, lead inevitably to tissue necrosis and sloughing
and the production of ulcefs which, in the cases observed,
never penetrated to the muscular coat.
Sections of the intestine where such ulceration had
occurred presented the following appearance : The base
of the ulcer was formed by the submucous coat and was
usually quite smooth, the edges of the ulcer sloping and
formed by the mucosa. These edges were densely infil-
trated by leukocytes. The submucosa in the neighbor-
hood of the ulcer contained vast swarms of leukocytes,
and the bloodvessels were dilated and filled with blood.
In some sections the slough could be seen just before
becoming detached from the resulting ulcer, being com-
posed of degenerated leukocytes and granular detritus.
In many sections the pseudomembrane covering the
surface of the mucosa was very thick and almost homo-
geneous in structure. In such cases it often formed a
layer nearly as thick as the combined mucosa and sub-
mucous coats.
THE
GROSS AND MICROSCOPIC PATHOLOGY
GAXGRENOUS STAGE.
OP THE
This stage of chronic specific dysentery may perhaps
be regarded as a very intense type of the diphtheric
stage, or simply the further development of that stage.
It is characterized by almost total destruction of the
mucous and submucous coats of the large intestine, these
coats having become a mass of gangrenous tissue
streaked with greenish pus, and from which a terrible
odor is given off. In this stage the patient often has
general septicemia, metastatic abscesses being found in
other organs, especially the lungs.
Gross Pathology. — The intestines were found matted
together as a rule when the abdominal cavity was
opened, and could only be separated without tearing by
exercising great care. The large intestine was found to
be almost necrotic, tearing if the least traction was ex-
erted upon it. The color externally was greenish black,
with irregular areas inky black in color scattered over
it, corresponfling to areas within the intestine where the
mucous, submucous and portions of the muscular coats
had been entirely removed by gangrene. The rectum
and sigmoid flexure were a nearly uniform dark olive
green, and these portions of the intestine were markedly
contracted and distorted in shape. The region around
the ileocecal valve was greatly sacculated.
The notable feature of the external appearance of the
large intestine during this stage was the presence of
numerous tumefied elevations projecting through the
peritoneal coat and which when incised were found to
be filled with a purulent exudate. These nodules
appeared to be cystic cavities in the muscular coat of the
intestine, which were filled with pus.
In a few places the walls of the large intestine were
thickened, but as a rule they were thinned and very
fragile in consistency. Externally the small intestine
was a reddish color with numerous areas of bile-stained
tissue. The walls of the small intestine were very thin
and easily ruptured.
The stomach was dilated as a rule, of a greenish-blue
color and the walls thin. There were numerous pig-
mented areas present in the walls of both the small intes-
tine and the stomach.
Internally, the appearances presented in the large
intestine were so varied that a detailed description of
them is exceedingly difficult. The color of the mucous
membrane varied, in some places being reddish brown,
in others greenish, yellow or bluish, according to the
stage of the gangrenous process. In the rectum and
sigmoid flexure the color was a greenish black, streaked
here and there with yellowish-green pus. Nearer the
ileocecal valve the ground color was a dusky red, with
greenish and brownish areas where gangrene had
advanced more rapidly. The surface of the rectum and
sigmoid was bathed with a thick, yellowish-green pus,
and showed, here and there, deep, irregular ulcerations
with excavated edges, the floors covered with shreds of
bloody and pus-stainea tissue. In some places there
were marked rugse formed, while in others small nodules
and great tumefaction of the membrane was noted.
This condition resembled markedly the advanced stage
of amebic dysentery. There were numerous large areas
in which the mucous membrane was entirely destroyed,
as well as the submucous and a portion of the muscular
coats. Such areas were of a livid blue color, and
shreds of necrotic tissue were attached to them. In
other places the mucous and submucous coats were
reduced to a greenish-black mass, bloodstained in places,
and from which a yellowish-green pus exuded upon the
least pressure. Tiiis condition was especially noticeable
in the rectum and around the ileocecal valve. Tumefied
areas were observed, which when incised exuded pus
and a semitranslucent glairy fluid resembling gelatin.
There were no distinct ulcers observed in the rectum
or cecum where the gangrenous process was most intense,
but in the transverse colon there were numerous ulcers
varying in size and shape. A few were oval, situated
transversely, as in the eise of tuberculous ulcers, with
undermined edges and floor formed by the circular mus-
cular coat. These varied in size from 5 cm. to 2 cm. in
diameter. There were also large irregular ulcerations
OCTOBER U, 1901!]
PATHOLOGY OF CHEONIC SPECIFIC DYSENTERY iamrican medicink 577
with tumefied, undermined or sloping edges, formed by
the separation of large sloughs. The floor of such ulcers
was formed invariably by the muscular coat and was
not smooth but covered with stringy shreds of necrosed
tissue. A very few minute follicular ulcers were
observed.
In those portions of the mucous membrane where
gangrene had not as yet commenced, numerous super-
ficial ulcerations were observed, situated in the thick-
ened and dusky red mucous membrane. These ulcers
were irregular in shape and only involved a portion of
the mucous coat, being similar in all respects to those
found in the diphtheric stage. In two of the cases
observed the mucous membrane of the ileum was partly
gangrenous, being covered with necrosed tissue and pus,
and showing a few irregular ulcers extending to the
muscular coat. In all the cases the mucous membrane
of the small intestine showed a severe chronic enteritis.
The stomach presented areas of acute inflammation,
alternating with atrophic patches from which the
mucoas membrane had entirely disappeared.
Microscopic Pathology. — It is an exceedingly difii-
cult task to attempt to describe all the varied appear-
ances presented microscopically in this stage of dysen-
tery. I shall only touch upon the most salient features
which are of importance in understanding the pathologic
process, which is undoubtedly due to invasion of the
structures by immense hordes of microorganisms.
Sections through the rectum, where the gangrenous
process was most advanced, showed almost nothing but
a mass of leukocytes, red blood-corpuscles and granular
detritus. Such sections presented here and there broken
down muscular tissue and the remains of the longi-
tudinal muscular coat of the intestine. The mucous,
submucous and circular muscular coats had been de-
stroyed, all remaining of them being the mass of exu-
dation mentioned. In sections through a portion of the
intestine showing the irregular ulcers spoken of, the fol-
lowing appearances were noted : The mucous coat
was covered with a diphtheric membrane, consist-
ing of fibrillated muscle and leukocytes, while the
glands of Lieberkiihn and the adenoid tissue between
them were filled with an exudation composed of leuko-
cytes, red blood-corpuscles and granular detritus. The
ulcerations present were irregular in shape, with exca-
vated edges, and penetrated to the muscular coat, their
floors being irregular, showing small elevations, ragged
in outline, composed of fibrillated material in which
were numerous leukocytes and blood-corpuscles.
The submucous coat, where no ulceration was present,
was invaded by immense numbers of leukocytes. The
bloodvessels were dilated with leukocytes and red blood-
corpuscles, and numerous hemorrhagic areas had formed
throughout this coat. The muscularis mucoste had
entirely disappeared.
The muscular coats were greatly thinned, there being
many areas of dense leukocytic infiltration, especially
numerous around those places where ulceration had
reached the muscular coat. There were also seen the
peculiar cystic cavities previously noted, which were
filled with innumerable leukocytes, these cavitias lying
between the muscular fibers. As will be seen, the very
early stage of this process does not differ materially
from the diphtheric stage. The great infiltration of all
the coats of the intestine by pus in this stage of dysen-
tery is evidenced by the immense leukocytic invasion,
which is marked even in the longitudinal layer of the
muscular coat. This invasion causes thickening of these
portions of the intestine, but where the gangrenous pro-
cess had advanced the intestinal coats were greatly
thinned, owing to the rapid and extt^nsive destruction of
tissue, there being no new tissue formed to replace that
destroyeil. While the gangrenous proceas always pre-
dominated in the pathologic picture there were areas of
more acute inflammation scattered here and there
throughout the intestine. The amount of pus which
bathed the interior of the intestine in these cases is
remarkable, and it is obviously impossible that such a
condition could exist long without perforation resulting.
In summing up the pathology of the three stages of
dysentery described it will be seen that in reality the
condition is simply one progressing from the follicular
stage to the gangrenous. The follicular ulcer becomes
covered with a diphtheric exudate, and this exudation
increasing causes the necrosis of the underlying tissues.
BACTERIOLOGY OF CHRONIC SPECIFIC DYSENTERY.
In considering the question of the etiologic relation
of bacteria to this form of dysentery a most complex
problem is at once presented, but one which has, by the
labors of Flexner, Curry, and Strong, been solved appar-
ently, so far as the acute stage of the disease is concerned.
It is much more diflicult to be sure of our etiology in the
chronic form which has here been described. In the
feces and in the diseased intestine all classes of bacteria
are found. To isolate and actually demonstrate from
these great swarms of organisms the one really the cause
of the disease is a task of the greatest magnitude, and I
have been able in only three of the cases stated to sepa-
rate the bacillus first described by Shiga and studied so
thoroughly by the observers noted. While this bacillus
is undoubtedly the cause of the acute form of the dis-
ease, in the chronic form we have to deal with such a
multitude of organisms which are pathogenic, especially
the staphylococci and streptococci, that it is difficult to
say how much of the pathologic condition present is due
to Shiga's bacillus. It seems more probable that not one
but perhaps many bacteria are associated in the produc-
tion of the pathologic lesions found. Not only is this so,
but even in the acute form it seems somewhat doubtful
what cause is really at the bottom of the initial produc-
tion of the disease. While I have not been able to
obtain cultures of Shiga's bacillus in most of the cases
coming to autopsy, I have used pure cultures of
this bacillus in testing the action of the blood-serum of
these cases, and in all have obtained a marked agglutina-
tion reaction. This reaction has not been present in the
cases of amebic dysentery so far as I have been able to
discover, and I feel justified in believing, for this reason,
that these cases are the chronic form of the acute
specific dysentery prevalent in the Philippines. I shall
not enter into a description of the bacillus of Shiga, but
would refer the student to the excellent descriptions of
Flexner, Curry, and Strong. As regards the mass of bac-
teria in the sections of the large intestine, it may be
said that such organisms are always present, but their
number varies with the particular stage of the disease
studied. It may be stated broadly that the bacteria are
less numerous in the follicular stage and most numerous
in the gangrenous. In the follicular stage, as in all the
stages, the bacteria seem to invade the tissue of the
intestine by means of the lymphatic channels. Numer-
ous bacilli and micrococci were to be seen lying between
the tubular glands and sometimes within them. No one
species seemed to be in the ascendant, there being a
decidedly mixed invasion, bacilli and micrococci being
scattered in bunches and clumps throughout the tissue of
the mucous coat. Around the follicular ulcers which
had penetrated to the submucous coat, bacteria were
numerous, especially just beneath them. The most
numerous were micrococci, but small clumps of bacilli
could be seen here and there, and it was only very
rarely that bacteria were seen beneath the muscular coat
in the follicular stage. In the diphtheric stage bacteria
occurred in varying numbers in the following situations:
The diphtheric membrane, the mucous, submucous and
circular muscular coats. Immense numbers of bacteria,
micrococci and various forms of bacilli occurred in the
diphtheric membrane. In the mucous membrane
large numbers of micrococci and l)acilli were found ; in
all the diseased ti&sue the micrococci preponderated in
number. Besides this, wherever there was diphtheric
578 American Medicine]
THE TYPHOID-COLON GROUP OF BACILLI
fOCTOBKR 11, 1902
membrane within the tubular glands it was crowded
with bacteria. Wherever ulceration had taken place,
the tissue forming the walls of the ulcer was crowded
with bacteria, chiefly micrococci, which had also invaded
the surrounding tissue for a variable distance. In the
submucous coat there were many clumps of bacteria
situated between the bands of connective tiasue, in the
lymphatics and wherever ulceration was present, in the
tissue forming the edges of the ulcer. Micrococci were
more numerous than bacilli in these situations, but both
forms occurred. In the circular muscular coat clumps of
bacilli and micrococci were seen, especially where an
ulcer had penetrated to this coat. They appeared to lie
between the muscular fibers, probably within the
minute lymphatics, and were not very numerous.
In the gangrenous stage bacteria occurred in immense
numbers in the sloughs and in the diseased coats of the
intestine. Here the bacteria seemed to be diffiised more
generally throughout the tissues. In the gangrenous
stage, as well as the diphtheric, where hemorrhage had
occurred bacteria were seen to be very numerous around
the hemorrhagic areas, and many of the minute capilla-
ries were crowded with them. This condition of the
crowding of the capillaries with bacteria was espe-
cially common in sections from the gangrenous cases,
and as these cases often presented multiple pyemic
abscesses in the lungs, it is probable that the
blood carried to these organs the infected material
from the intestine. In general it may be said that
in the superficial mucous coat bacilli and micrococci
were present in nearly equal proportion in all the stages
of dysentery. But the deeper we go the more numer-
ous are the micrococci ; thus, in the submucous and mus-
cular coats the micrococci, especially streptococci, far
outnumber the bacilli, which occurred but rarely. The
microbic infection is least in the follicular form and
greatest in the gangrenous.
CONCLUSION.
In closing the report of these cases of chronic specific
dysentery it will be seen that the term " tropical dysen-
tery," as denoting dysentery due to infection with the
ameba, is unwarranted in the sense that amebic dysen-
tery is the only type occurring in the tropics. AH of
these cases originated in the tropics and are as really
tropical as amebic dysentery.
TYPES OF INFECTION PRODUCED IN MAN BY
INTERMEDIATE MEMBERS OF THE TYPHOID-
COLON GROUP OF BACILLI.
BY
WARREN COLEMAN, M.D.,
of New York City.
Professor of Clinical Medicine, Cornell University Medical College;
Assistant Physician to Bellevue Hospital.
\Ccmtinited/r&m page 501.1
II. EPIDEMIC MEAT-POISONING TYPE.
Gaertner announced his discovery of Bacillus enter-
Uidis as the cause of epidemic meat-poisoning in 1888.
A cow sick for two days with profuse diarrhea had been
slaughtered in Saxony and the meat sold for food. Of
the persons who ate of the meat 57 became ill, and one
died. Gaertner recovered the bacillus from the meat
and from the organs in the fatal case.
The work of Karlinsky, van Erminghem, Gtaffky and
Paak, Fischer, Kaensche, Gunther, Basenau, Durham
and others along the same lines, followed in succeeding
years.
Previous to the announcement of Gaertner the cause
of meat-poisoning had been held to be bacterial products,
and while this may be true in certain instances there is
no satisfactory evidence to support the contention. All
cases in which a thorough bacteriologic examination has
not been made must be excluded.
Two kinds of bacilli are concerned in the production
of meat- poisoning : 1. Anaerobic Bacillus botulinus of
van Erminghem, a saprophyte ; and 2. Bacillus enter-
itidis of Graertner, including the different strains of this
organism.
Of these bacilli Bacillus enterilidis is the more impor-
tant, having been concerned in the greater number of
epidemics, and causing true meat-poisoning. It seems
advisable, however, to say a few words, by way of dis-
tinction, on infection by Bacillus botulinus.
Botulism, allantiasis and sausage-poisoning are the
names given to infection by Bacilbis botulinus. The
infection of the meat takes place after the animal has
been slaughtered. The meat is of unsound appearance
and odor and can readily be seen to be unfit for food.
The symptoms begin from 12 to 24 hours after inges-
tion of the meat, with repeated attacks of vomiting and
abdominal pain. Soon the characteristic symptoms
appear ; paralysis, partial or complete, of the inner and
outer recti muscles of the eye, and disturbances of the
innervation of the pharynx and larynx, manifested by
imperfect vision, difticulty of speech and deglutition and
dryness of the throat. There are no disturbances of sen-
sation or impairment of consciousness and the disease
runs its course without fever. Constipation and reten-
tion of urine follow ; dyspnea and cardiac failure
appear, and bulbar paralysis may supervene, causing
death. In earlier years the mortality from sausage-
poisoning was from 30^ to 50^, but this has been much
reduced through a better understanding of the disease.
It may be prevented by thoroughly cooking the meat
and by refusing to accept from the butcher meat that is
the least tainted.
True Meat- Poisoning. — This form of meat-poisoning
is due to Bacillus enterilidis and in every instance the
animal is diseased at the time of the slaughter. It may
be combined with sausage-poisoning, since the meat of
diseased animals is sometimes surreptitiously put on the
market in the form of sausage.
Durham makes Bacillus enterilidis the chief type of
the intermediates and proposes the name "the enter-
iditis group." Buxton classes the bacillus with the
paracolons. For the biologic characters of Bacillus enter-
itidu the reader is referred to the foregoing description
and to Durham's original papers.
Bacillus enterilidis is pathogenic for cows, horses,
pigs, goats, mice and guineapigs, but not for dogs and
cats.
Tlie Infected Meat. — In many epidemics Bacillus
enterilidis has been isolated, not only from the organs of
fatal cases but from the suspected meat. The meat
does not differ in appearance or taste from that of
healthy animals. It has already been stated that it may
be made into sausages, and one epidemic at least has
been caused by eating " dried meat" consisting of large
pieces of the organs of sheep and goats nearly dried in
the sun and eaten cooked or merely softened by soaking.
Cooking does not always destroy the bacilli, as the
thermal death point may not be reached in the interior
of the meat. Infected meat which is not eaten immedi-
ately after it has been cooked is especially dangerous.
The meat has always come from animals sick at the
time ot slaughter. Cows and calves have most often
caused the epidemics, though horses, pigs and goats
have also been responsible. Durham says that no
known case has come from mutton, and that the pig has
been implicated in only one outbreak which has been
studied bacteriologically. In this connection it is inter-
esting to recall that Theobald Smith has insisted on the
similarity between the hog cholera bacillus and Bacillus
enterilidis.
The animals from which the infected meat has come
have sufliered during life from "puerperal fever and
uterine inflammations," navel infection in calves, " sep-
ticemia," "septicopyemia," diarrhea and local suppura-
tions, and have not infrequently been killed because of
OCTOBEK 11, 1902]
IMMUNITY IN LIGHT OF RECENT INVESTIGATIONS iakkhica-v mkmcink 579
their unsound condition. How animals become infected
is not known.
Durham thinks milk may be a source of infection in
man, but states that bacteriologic evidence of it is incom-
plete. Bacillus enterilidis has been found, however, in
the milk of infected guineapigs (Ba-senau).
Transmission to J/an. — The disease may be trans-
mitted to man in two ways : (1) By eating the infected
meat, by far the most common means, and (2) by man
to man according to Gaertner, van Erminghem and
Fischer. Durham found inconclusive evidence of this
means of transmission in one epidemic. Fischer thinks
transmission may take place through the excreta. It
will be seen that psittacosis may be transmitted from
man to man.
Epidemics of meat-poisoning may occur in any sea-
son, but are more frequent during the warm months.
Bymptomaiology. — While the characteristic symptoms
of sausage-poisoning relate to the nervous system, in
true meat-poisoning they are gastrointestinal. Fischer
divides meat-poisoning into three clinical forms : (1)
Typhoidal ; (2) choleraic ; (3) gastroenteric.
1. Typhoidal Form. — The incubation period is from
four to nine days. The disease closely simulates
typhoid fever in its clinical course. In the Kloten
epidemic there were 657 cases with 55 relapses and six
deaths. The typhoidal form of meat-poisoning is
seldom recognized. It may well be that the cases
described as the typhoidal form of psittacosis were
really the typhoidal form of epidemic meat-poisoning.
2. Choleraic Form. — The incubation period is from a
few to 14 to 30 hours. The symptoms are chiefly
chpleraic, as vomiting, diarrhea, rice-water stools, mus-
cular cramps, subnormal temperature, etc.
3. Oastroenteric Form. — This is the form of meat-
poisoning most commonly observed.
Bow&s and Ashton give the average period of inouda-
tion in their cases as from 6 to 8 hours ; the shortest
was 3, and the longest 29 hours. In Kaensche's cases
the period of incubation was from 3 to 16 hours irre-
spective of the amount of meat eaten. Mice fed on the
meat which caused this epidemic sickened in three to
four hours.
Gastrointestinal symptoms predominate in this form
and usually usher in the attack. In some cases, how-
ever, repeated rigors, not amounting to a distinct chill,
with headache, often intense, and muscular pains may be
the first symptoms. The patient is seized with griping
abdominal pain, followed by purging or with simul-
taneous vomiting and purging. The griping is severe
only in exceptional cases. In mild cases there may be
only a few loose stools a day, while in the severe, there
is constant purging. The stools may even be passed
involuntarily, and contain blood or bloodstained mucus.
While vomiting is a very constant early symptom,
it may disappear later. At first the vomited matter
contains bile, but afterward consists of the stomach
contents.
There is always more or less fever at the outset,
ranging in the majority of cases from 100° to 101° F.,
while in severe cases there may be hyperpyrexia. The
tongue is furre<l and moist, or dry, brown and thickly
furred according to the severity of the case. The teeth
and tongue may become covered with sordes. Thirst
is intense. Ilerjtes labialis is (luite common, and ecchy-
niosis or an erythema with subseciuent desquamation
may occur.
The heart becomes exhausted early, and is rapid,
weak and irregular. In severe cases cyanosis and cold-
ness of the extremities result.
Prostration is grejit, and, if the disease continues, the
patient enters into the typhoid state with drowsiiuss,
stupor, and sometimes delirium. Some patients become
iaundiced. Pneumonia is a feature of some epidemics.
In 1888, Ballard reported an oxtensive epidomh; of pleuro-
pneumonia with marked constitutional HymptomH, iu Middles-
brough, which he traced to the eating of infected pork not
thoroughly cooked. Klein isolated a motile bacillus from the
lungs of patients dead of the disease, and also from the sus-
pected pork which he called Badllus pneumonice. The bacillus
was pathogenic for mice, less so for guineapigs, and for monkeys,
reproducing the original disease. What the subsequent history
of this bacillus was I have been unable to learn, but the assumj)-
tion that it was one of the intermediates seems warranted
by the facts at hand. Neither Diplococcus lanceolatus of
Frankel nor Bacillus pneumonice friedlande-ri of Friedlander
wa.s found in the lungs.
While infected pork was the most common cause of the
disease, there was strong evidence that it was communicable ■
from man to man.
Briefly the symptoms were as follows : Invasion usually
sudden, though in some cases the patients had not been feeling
well for one or two days to a week or two. The first symptoms
were rigor, epigastric pain, and a rapid rise of temperature to
104° to 105° P. Prostration marked. Cougli was not a pro-
nounced feature, and in some cases there was almost none.
The expectoration, yellow and scanty at first, became rusty,
tenacious and even of prune-julce character later. The physi-
cal signs were those of pneumonia. Vomiting was often an
early symptom and sometimes persisted for several days. It
was not infrequently accompanied by diarrhea, or diarrhea
occurred alone. Delirium was a constant symptom. Herpes
labialis appeared in only one case. Epistaxis and hemorrhages
from the stomach and lungs were noted. Empyema, abscesses
of the lung, ankle and back, synovitis and venous thrombosis
are given as complications or sequels. Ballard remarks that in
many cases the constitutional disturbance was out of all propor-
tion to the local pulmonary disease.
The duration varied from a lew days to two weeks or more.
In the cases in which recovery took place a crisis came on the
seventh to the tenth day. Some patients had relapses.
At autopsy the usual pulmonary changes of pneumonia
were found; the spleen was sott and pulpy (size not stated),
and ecchymoses in the gastric mucous membrane, often
extensive, were common. The intestines were normal.
The above epidemic has been described at such length
because of its probable bearing on the pulmonary form of
socalled psittacosis. It may eventually be found that there is a
fourth clinical form of epidemic meat-poisoning, i. e., a pul-
monary form, and that this has been described by the French
observers as psittacosis.
The duration of the disease is varied. In mild cases
the patients may recover within several days (one to
five), severer ones often run for months with a prolonged
and tedious convalescence.
Prevention. — Since neither appearance nor taste
affords any clue to the noxious quality of the infected
meat its unfitness for food can only be told through
bacteriologic examination or a knowledge of its source.
Durham states that thorough cooking will kill the
bacilli, but it must be remembered that in the process
the thermal death point of the bacilli may not be
reached in the innermost portions of the meat.
[Zb &« concluded.]
IMMUNITY IN THE LIGHT OF RECENT INVESTIGA-
TIONS."
BY
D. H. BEROEY, M.D.,
of Philadelphia.
First Assistant, Laboratory of Hygiene, University of Pennsylvania.
The results of experiments miwle in recent years upon
the subject of immunity against disease have thrown a
great deal of light upon a very wide field of scientific
inquiry. These results are so important that their true
significance cannot be gauged at the present time because
they bear not alone upon immunity, but upon an
equally important, if not a more important, subject, viz.,
nutrition.
It had long been known, from repeated observations,
that nearly all persons recovering from an attiick of cer-
tsiin infe<!tious diseases pfwsessed an immunity from sub-
sequent attacks of the same di.sea«e. This was observed
to be the case with such diseases as measles, .scarlet fever,
whoopingcough, smallpox, chickenjwx and typhoid
fever, to an unu.sual degree, and in many other diseases
to a less decree.
1902
Read before the Montgomery County Medical Society, May 21,
580 AKJiBtoAN MMMoiNEi IMMUNITY IN LIGHT OF RECENT INVESTIGATIONS
[UCTOBEB 11, 1902
After the recognition and acceptance of bacteria as
the causative factors in certain infectious diseases,
scientists sought to explain the mechanism of immunity.
As early as 1880 Pasteur propounded a theory in expla-
nation of immunity which is known as the " exhaus-
tion " theory. In the light of his investigations on
infectious diseases of animals he formed the conception
that there was removed from the system of a person re-
covering from an infectious disease certain of the food
principles necessary for the life activities of bacteria, the
complete destruction of this substance in an organism
conferring complete immunity upon it. This theory
was found lo be fallacious, however, when it was seen
that after an animal had been rendered immune to cer-
tain bacteria it was still possible to cultivate those bac-
teria in its blood and tissues.
About the same time Chauveau proposed another
theory in explanation of immunity, which is to a certain
extent the opposite of Pasteur's theory, known as the
" retention " theory. Chauveau believed that the bac-
teria, instead of removing certain essential food prin-
ciples from the body, left within the body certain excre-
tory products, and that the accumulation of these
products tended toward preventing the subsequent in-
vasion of the body by the same species of bacteria.
Experimental research failed to substantiate this theory,
and it was finally discarded.
With the overthrow of these earlier theories two new
hypotheses were brought forward, both of which were
based upon scientific investigation, and, while neither
of them is at present regarded as fully explanatory of
immunity, they are both most important steps in
advance in our knowledge of the subject, and both play
an important role in natural immunity.
The first of these theories is that of "phagocytosis,"
advanced by Metchnikoff' in 1884. He demonstrated
that certain cells of the body had the power of taking up
bodily bacteria and other foreign materials when intro-
duced into the blood and body cavities. These phago-
cytes are then carried in the blood current to the large
glandular organs, where they digest the bacteria con-
tained in them. It is generally conceded that the
phagocytes play a most important part in protecting
against infection by removing the invading bacteria in
this manner, but this does not offer a complete explana-
tion of the mechanism of immunity.
Soon after the advancement of the "phagocytosis"
theory of immunity by Metchnikoff' it was discovered
by Nuttall that normal serum and other fluids of the
body are capable of destroying bacteria when brought in
contact with them for a short time. These facts were
substantiated by Buchner,.who advanced the " humoral "
theory of immunity, viz., that immunity is due simply
to the bactericidal action of the normal body fluids. The
active principle in the blood plasma which exerts this
bactericidal action is a proteid substance to which Buch-
ner has given the name " alexin."
These two hypotheses of the mechanism of immunity
have been the subject of prolonged controversy between
the school of Metchnikoff and the followers of Buchner.
Recently Metchnikoff conceded the fact that the real
destructive agencies of the body are the alexins in the
blood plasma, but he still contends that these alexins are
derived from the leukocytes. While granting the origin
of alexins in the leukocytes, Buchner contends that they
are derived from other body-cells beside the leukocytes.
In 1890 Behring and Kitasato published their studies
upon tetanus. They demonstrated that it was possible
to immunize animals against tetanus, and that the blood-
serum of such immune animals afforded protection to
other animals, when injected into their peritoneal
cavities. They also demonstrated that the blood-serum
of immune animals possessed curative properties, and
that the blood-serum of immune animals was capable of
neutralizing the poison, or toxin, generated by the teta-
nus bacillus.
The studies of Behring, Wernicke, and Kitasato
upon diphtheria demonstrated identical conditions in
this disease to those found in animals immunized against
tetanus, viz., that the blood-serum of the immune
animal possessed protective and curative properties.
They believed that the immunity produced against
tetanus and diphtheria was due to the formation of a
new substance in the blood of the immune animal.
This new protective substance they named antitoxin,
because of its power of neutralizing the bacterial toxins.
It was not long until Ehrlich demonstrated that it
was possible to immunize animals against such highly
poisonous vegetable substances as crotin, rlcin, and abrin,
and that the blood of the immune animals contained
antibodies which were both protective and curative.
These antibodies are, however, specific for only one
poison ; that is, the one against which the animal has
been immunized, just as the antitoxin of tetanus and
diphtheria were found to be specific ; that is, they were
capable of neutralizing only the poison produced by the
respective organisms.
In 1895 Pfeiffer published some experiments upon
the effects of the peritoneal fluid of an animal, immune
against cholera, upon the cholera organisms. He
demonstrated that if an animal was rendered immune
to cholera, and then received an injection of cholera
organisms into its peritoneal cavity, the injected organ-
isms underwent rapid deterioration and were com-
pletely destroyed in a short time. These experiments
demonstrated that immunity against the bacteria them-
selves was due not to protective substances normally
present in the body, but to something which had
developed during the course of immunization.
Investigations revealed the fact that, while all patho-
genic bacteria produce definite poisons, some species
produce poisons which are soluble in the surrounding
media, other species producing poisons intimately asso-
ciated with the protoplasm of the bacterial cells.
These bacteria which produce soluble poisons, or tox-
ins, are not affected to the same extent by the body fiuids
of an immune animal as those species whose toxins are
not soluble. It was soon demonstrated, however, that the
body fiuids of an animal immunized against a species of
bacteria producing a soluble toxin exerted a neutralizing
effect upon these toxins.
The bacteria with which these facts had been demon-
strated most successfully were those of tetanus and diph-
theria. This discovery was utilized in practice in a
short time in the treatment of diphtheria and tetanus,
and in the former disease has been instrumental in re-
ducing the mortality at least 50 fc , thus proving a great
boon to humanity. Fof certain definite reasons, to be
described later, the results from the use of tetanus anti-
toxin have not been nearly as gratifying.
The demonstration of the remarkable value of diph-
theria antitoxin has stimulated research upon every
infectious disease known, with the hope of discovering
similar antitoxic substances in each of these diseases,
notably in tuberculosis, typhoid fever, cholera, plague,
erysipelas, pneumonia, and dysentery. In none of
these diseases have the results been especially valuable
thus far.
Along with the investigations upon the preparation
of antitoxins in different infectious diseases, the dis-
coveries made stimulated the research upon the mechan-
ism of immunity to a still greater degree. These re-
searches were also stimulated by the fact that animals
could be immunized against a variety of substances
baside bacteria and their toxins, such as various highly
toxic vegetable poisons, ricin, abrin, and crotin ; against
snake venom ; against such substances as milk, saliva,
blood, and urine ; against leukocytes, epithelial cells,
spermatozoa, and yeast cells.
The demonstration by Bordet, in 1896, that one
species of animal could be immunized against the blood
of another species, and when so immunized the blood-
October 11, 1902]
IMMUNITY IN LIGHT OF EECENT INVESTIGATIONS iamkbican mkmcike 581
serum of the immuue animal was capable of dissolving
the red blood-eorpuseles of the species with whose blood
it had been immunized, opened up a new field of research
which has afforded most valuable information upon the
subject of immunity in general.
In the light of our later knowledge upon the subject
Ehrlich, in 1898, formulated his hypothesis of the
mechanism of immunity which is receiving very general
acceptance by scientists today. His theory of the
mechanism of immunity is based upon Weigert's teach-
ing of the process of tissue repair. It is a matter of
universal observation that nature is prodigal in her
attempts to repair an injury. This is shown in the heal-
ing process in an ordinary wound. A much larger
amount of material is thrown out to bridge the chasm
than is really utilized in the formation of new tissue.
The presence of an excessive amount of new material is
shown by the fact that the part is raised above the level
of the surrounding sound ti sue, and this excess is
removed gradually as the new formed tissue becomes
stronger and stronger, until finally the wound is marked
by a line of white-scar tissue, the excess gradually
pa.ssing into the blood current.
Ehrlich believed that the mechanism of immunity
was explainable on a similar basis. It had become evi-
dent from the experiments of Wasserman with the
tetanus bacillus that its toxin had an especial affinity
for the cells of the central nervous system. Experi-
ments with other bacteria pointed to the fact that the
toxins of different species of bacteria had an especial
affinity for the cells of different organs of the body.
When the amount of poison entering the body is insuf-
ficient to destroy the cells which have an especial affinity
for it, these cells may be injured only to such an extent
as to permit subsequent repair. In order to comprehend
Ehrlich's hypothesis it is necessary to conceive the cells
of the body a.s having a complex structure which may be
stated diagrammatically as consisting of a central mass
or nucleus from which radiate a number of " lateral
chains," or bonds, each of which serves to bind the cell
to other substances. In the case of the cells of the cen-
tral nervous system one of these lateral bonds has an espe-
cial affinity for tetanus toxin and suffers destruction.
The cell now finds itself in unstable equilibrium, and at
once proceeds to repair the damage wrought. As in the
case of tissue repair, the new material produced to repair
the breach is far in excess of the required amount. The
excess finds its way into the blood current. This
material now circulating in the blood current has the
same affinity for tetanus toxin as when united with the
central mass of a cell as its lateral bond, and can, there-
fore, combine with tetanus toxin floating in the blood
current, thus preserving other cells from injury. The
union formed between the lateral bond of the cell (which
is really the antitoxin) and the tetanus toxin results in
the formation of a compound which is physiologically
inert. According to Ehrlich's idea, therefore, the anti-
toxin is simply the excess of lateral bonds floating in the
blood Current. This substance can neutralize the effect
of the tetanus toxin in a test-tube just as readily as it
does within the body.
This new hypothesis of the mechanism of immunity
has l)een very materially strengthened by the extensions
of Bordet's experiments upon the immunization of ani-
mals with alien bloods which Ehrlich made in collabora-
tion with Morgenroth during the past two years. From
the results of these studies he has broadened his theory
of immunity so that it serves to explain certain facts
which were previously not fully comprehensible. Ehr-
lich now recognizees three types of iirmiunity which
differ in their mechanism according to the nature of the
substance employed in the immunizing action. His
.studies of the mw;hanism of the immunity conferred by
an alien blood revealed the fact that if the blood-serum
of an animal, immunized against an alien blood, was
heated to 56"" C. for half an hour it lost its hemolytic
power, but that this serum could again be rendered
active by the addition of a drop of normal blood-serum.
This fact demonstrated that the hemolytic power of the
immune serum was dependent upon two substances:
the one present in normal blood and destroyed by a low
degree of heat, and the other present only in the serum
of the immune animal and more resistant to heat. The
first substance he named the " complement " because of
its complementary action to the second substance which
he called the " immune body." He believes the comple-
ment to be of the nature of an enzyme, and, therefore,
the substance by means of which the immune body
really brings about the solution of the corpuscles. In
his later communications Ehrlich calls the immune body
the "receptor."
In the immunity conferred by toxins, for instance,
when antitoxins are formed, Ehrlich conceives the
receptors to be of the simplest nature, and he calls these
receptors of the first order. These receptors possess
simply one bond of attachment to which the toxin unites.
These bonds of attachment of the cells he calls their
haptophore group.
In the immunization of animals against such sub-
stances as milk there is formed in the blood of the
immune animal a substance which exercises a coagulat-
ing action when mixed with milk of the species against
which the immunization was made. This iirecipitation
or coagulation is brought about by receptors of the second
order which have a somewhat different constitution from
those of the first order. Here the receptor posseases, in
addition to its haptophore group, an enzyme-like ele-
ment by means of which it brings about the precipitation
or coagulation. In the immunization against certain bac-
teria, as for inst&nce Baci/lug t7/pho»tM, Bacillus dysenteria
and the cholera organism, there is formed a receptor of
this nature. The primary effect of bringing the bacteria
in contact with the serum of an animal immunized
against that particular organism is to produce a peculiar
glutinous condition of the exterior of the organisms which
serves to bring about the "clumping" of these organ-
isms ; that is, they are glued together in small masses or
clumps. A more pronounced action of the receptor
brings about the complete solution of the bacteria, as in
the Pfeiffer experiment, with the peritoneal fluid of a
guineapig immunized against the cholera organism.
This phenomenon is generally spoken of as the " agglu-
tinin reaction " of Widal, and is now in constant use in
the early diagnosis of typhoid fever. The test as
employed in practice consists in mixing a small amount
of the blood of a suspected case of typhoid feverVith a
drop of a typical typhoid culture and examining under
the microscope for evidences of clumping. If clumping
is observed, it indicates that the blood employed was
derived from a typhoid patient.
The precipitin reaction is also utilized in metlicolegal
cases for the purposes of identifying suspected blood-
clots as of human origin. Heretofore the positive
identification of blood-clots as human blood was far
from satisfactory, llecent experiments have shown that
if such old, dried blood-clots are dissolved in salt solu-
tion and then mixed with the blood-serum of an animal
immunized against human blood, a j)recipitate forms if
the blood-clot was of human origin, while no precij)itate
forms if the blood was derived from any of the lower
animals. The reaction is, therefore, a specific one.
Ehrlich's receptors of the third order are formed
when an animal is immunizefl against an alien blood, or
against bacteria, spermatozoa, leukocytes, or epithelial
cells. The receptors of the third order possess two haj)-
tophore groups, one of which combines with the comple-
ment, existing free in the blood, while the other unites
with the cells against which the animal has been im-
muniz(>d, thus bringing about their complete destruction
through the combined influence of receptor and com-
plement.
In certain diseases it appears that receptors of the
582 AMEBIOAir MbDICINX}
BREWERS' YEAST IN THERAPEUTICS
[OCTOBEB 11, 1902
second and third order are both formed. This is espe-
cially the case with typhoid fever and cholera. The
blood-serum in a well-developed case of typhoid fever
shows both the agglutinating and the bacteriolytic
action. In the immunization of animals against alien
blood and other foreign cells the same effect is noticed.
On mixing such cells with the blood-serum of an immune
animal an agglutinating action usually precedes the
destruction of the cells against which the animal has
been immunized.
Recent investigations by Ehrlich and Sachs ' indicate
that the earlier contention of Ehrlich for the multiplicity
of complements is correct. This fact has been disputed
by Bordet, but the evidence at hand indicates that there
is not merely a single complement but a number of com-
plements in the blood. These complements are con-
cerned in the intracellular digestion constantly going on
in the body.
With the substantiation of Ehrlich's conception of
the mechanism of immunity it appeared desirable to
determine, if possible, by what means a diminished
resistance to bacterial invasion is brought about. It has
been known for a long time that under the influence of
fasting, excessive exercise, loss of sleep, etc., the organ-
ism is less resistant to disease than when functioning
normally. It was also pointed out by Abbott^ that
through the influence of alcohol, rabbits could be made
more susceptible to infection by means of staphylococci
and streptococci. At that time no definite explanation
could be given as to the manner in which the reduced
resistance is brought about.
In the light of Ehrlich's conception of the mechanism
of immunity the question arose whether the reduced
resistance of rabbits under the influence of alcohol was
attributable to a reduction in the complement content of
the blood. In collaboration with Dr. Abbott I have
sought to throw light upon this problem by means of
comparative experiments upon normal and alcoholized
rabbits which were immunized against bull's blood. By
this means it was possible to demonstrate' that alco-
holized rabbits show a reduction in the hemolytic com-
plement of from lo '/c to 25 fo. Whether there is the same
reduction in complement operative in the destruction of
specific microorganisms, such as staphylococci and
streptococci, has not yet been determined.
The studies upon immunity against typhoid and
cholera, when considered in the light of the immunity
against alien blood, show that our ett'orts must be directed
toward the production of bactericidal serums in all bac-
terial diseases which are not distinctly toxic in character.
Such bactericidal serums can be produced, but when ap-
plied to the treatment of disease they do not show the
desired efficiency. The lack of influence of the specific
bactericidal serums may be explained from the fact that
the human complement does not compare in its config-
uration with the haptophore of the immune body derived
from the lower animals, and consequently it can not
unite with it.
Three suggestions have been made to overcome the
inefficacy of the bactericidal immune serums :
1. The simultaneous injection of complement derived
from the same species as that furnishing the immune
serum. Experience has shown that there is a tendency
for the complement to be utilized in the formation of
anticomplement so that it becomes ineffective for this
reason.
2. The employment of a mixture of immune serums
derived from a number of species of animals so that in
the multiplicity of immune serums the human comple-
ment may find sufficient receptors with haptophores of
like configuration to bring about the destruction of the
invading microorganisms.
3. The immunization of a . species of animals so
> Berliner klin. Wochenschr., 1902.
'^.louT. of Exp. Medicine, 1896.
3 Trans. Am. Philosoph. Soc., 1902.
closely related to man as to yield receptors with hapto-
phores that compare with the complement in human
blood. The latter suggestion appears to offer the most
ready solution of the problem, but the question has not
yet been decided experimentally.
BREWERS' YEAST IN THERAPEUTICS.*
BY
JULIUS ULLMAN, M.D.,
of Buffalo, N. Y.
Instructor in Clinical Medicine, Medical Department, University of
Buflfalo; Attending Physician, German Hospital, Buffalo.
The yeast is a fungus plant to be clas.sifled with the
lower form of biologic life. It absorbs oxygen and gives
off" carbon dioxid ; its life is also independent of light,
thus differing widely from green plants. Yeasts are of
importance to us because their study by De la Tour and
Schwann in fermenting beers and wines led Pasteur,
Koch and others to make the further wonderful observa-
tion which resulted in the evolution of the study of the
lowest botanic life, the schizomycetes, or bacteria ; and
their knowledge in turn made possible the great strides
medicine has made in specific causes of disease and
measures prophylactic and therapeutic for the combat of
disease as produced by such causes. For our purposes,
we can differentiate two kinds of yeasts : (1) The patho-
genic and (2) the nonpathogenic. Pathogenic yeasts may
be subdivided into those producing certain effects on
animals, as (1) pyogenic ; (2) granulomatous ; (3) toxic,
etc.
J. R. Foulerton ' separated pathogenic yeasts from
two cases of pharyngitis, as did also Busse.^ Rabino-
witch ' found in a study of 50 wild yeasts seven patho-
genic for lower animals. F. Sanfelice,* using Succharo-
myoes neoformam, produced new tissue formation in
lower animals, and thereupon R. Binaghi" and D. B.
Roncali " attributed the formation of cancer to blastomy-
cetes, although their observations have received no
verification either from the New York State Cancer
Laboratory, under the direction of Park and Gaylord,'
or the Harvard Cancer Committee, under Nichols.*
These experiences are mentioned because had it been
proved that yeasts were the cause of cancer, undoubtedly
a serum could have been obtained ; but the nodules as
produced are not identical with those studied in cancer.
Fabre Demorgue,^ in an article on serum treatment
of cancer, concluded as follows :
1. Serum therapy is logically applicable only to microbio
aflfectious or those which by symptoms are supposed to he such.
2. Cancer does not belong to this group, for (a) the fact of
its more frequent occurrence in one neighborhood or hou.se
only proves that the exciting cause is more frequent there and
not that cancer is contagious; (6) a parasite is not necessary for
the transplanting of a cancer or living cell, cancerous or not;
(c) the pseudococcidia have not been proved to be parasites.
3. The facts interpreted to prove the curative action of
serum injections (whether erysipelas toxin or juice of a sar-
coma) have the same value as those known before of the modi-
fying action of chemic substances, as oil of phosphorus or
picric acid, which cause a local aseptic necrosis which atti-acts
leukocytes so that the part is absorbed and the tumors undergo
a temporary diminution in size.
In view of these facts we may at this time exclude
the pathogenic yeast from our consideration of therapeu-
tic value, and consider the nonpathogenic yeasts of
which Sacoharomyoes cerevesice is a type in its relation to
therapeutics.
Yeast is of tremendous importance in the arts because
of its production of fermentation. In the presence of the
fungus, with small quantities of phosphates and albumi-
noid matter, glucose is converted into alcohol and car-
bon dioxid, together with small portions of glycerin,
succinic acid and other substances. Saccharomyces cere-
vesice is a powerful form of top yeast (Oberhefe). Micro-
* Read at a meeting of the Erie County Medical Association, Maj-
15, 1902, Buffalo, N. Y.
October 11, 1902]
BREWERS' YEAST IN THERAPEUTICS
IAMERICAN Medicink 583
scopically this yeast is composed of round or oval cells,
g:enerally multiplying: by gemmation or budding ; the
buds formed become divided from the parent cell by a
diaphragm ; but they frequently remain adherent after
giving rise to further buds themselves, so that chains of
greater or less length are formed according to the num-
ber of generations remaining attached. The cells are
enclosed with a thin membranous wall, and the granular
protoplasmic contents exhibit one, two or more vacuoles.
The size of the cells vary from 2^ to6 micromillimeters.
Many ferments have been isolated, and it may be
due to them in soluble form, secreted or contained in the
protoplasm, that it owes its therapeutic value. Among
these ferments invertin, which transforms cane sugar to
dextrose and levulose ; zymase, a monosaccharid splitting
ferment ; endotrypsin, a proteolytic ferment, and pos-
sibly a glycogenic ferment. Beside the ferments the
protoplasm contains a proteid nuclein.
From what deduction can we argue that brewers'
yeast is of value to the body?
The study of immunity has taught us that the natural
resistance of the body is due to one of several causes : (1)
The fixed and movable cells have an inherent property
of secreting a substance proteid in character which acts
protective to the organism ; (2) MetchnikofTs phagocytic
action of the polymorphous leukocytes acting by (a)
chemotaxis and (6) by secreting a substance germicidal
in character ; (3) the body is capable of producing under
stimulation of certain proteid enzymes the antitoxins, as
seen in the production of an antitoxic substance in diph-
theria and tetanus ; (4) when the body has lost its
resistance the presence of a secondary agent may retard
or inhibit the primary infection, as Coley's toxin injec-
tions in sarcoma.
Brewers' yeast is rich in nuclein, and nucleinic acid
is capable of producing a leukocytosis (Hul)er) thereby
increasing the body resistance. McClintock, Novy, and
Vaughan '" have shown that the nucleins are powerful
germicides and demonstrated that the germicidal quality
of the bloo<l is due to them. Brewers' yeast also
increases the vigor of the central nervous system." It
contains ferments which are of importiince to digestion.
Yeasts are present in giistric contents and feces. They
are not pathologic. It has been proved that bacterial
life, because of the ferments contained, is necessary to
normal digestion, so that it may be inferred that brewers'
yeast because of the many and varied ferments contained
or secreted is a powerful aid to digestion. It not only
atjts upon the food, as contained within the intestinal
tract, but its ferments in a soluble form may become
assimilated and have to do with body metabolism.
As an example, it has been shown that a quantity of
gluco.se which produces glycosuria cea.ses to do so if a
small quantity of yeast is administered. It is also pos-
sible that like lipase, a ferment which may not only break
up fat into its constituents, but also build it up in the
tissue from it« constituents, so yeast may contain a fer-
ment which not only breaks up glucose, but also returns
glucose back to glycogen to be stf^red in the body. On
this may depend the good results reported in the use of
brewers' yeast in diabetes mellitus. Brewers' yeast,
according to Toumier," has also an jiction not unlike the
phagocytes, that is, a power to attract and to devour
microorganisms.
TherapeuttcH. — Brewers' yeast has l)een employed for
many years as a therapeutic measure. Through the
works of Hansen, Duclaux, and De Bat^ker their fer-
ments were st»parated anfl the use of brewers' yeast
became an important product. In a general way, it
may be stated that brewers' yeast covers a wide field of
application, that is, whenever a defense of the cell is
refjuired. It has |)rove<:l itself useful surgically, in indolent
chronic ulcers ; when applied in pure form, granulation
ti.ssue is readily formed. In septic conditions, applied
directly to a slough, the necrotic tissue is thrown off and
granulation follows.
In a recent brochure Prof. Doyen," of Paris, notes an
almost specific action of a derivative of yeast in staphylo-
coccic infection, comparing its action to the antitoxin
of diphtheria and urging its use not only in diseases, such
as furuneulosis, bronchopneumonia, etc., but as a pro-
phylactic to induce immunity. In one case, under the
observation of Drs. Gary and Park, of ulcerative tonsil-
litis, followed by abscess of cervical lymph nodes and
pyemia, with metastatic abscesses, brewers' yeast in
large doses (two to three ounces) hastened recovery.
Mosse," as far back as 1852, used brewers' yeast in
the treatment of furuneulosis. It was used in 1895 by
Gobert.'* De Backer, in his work on ferments, speaks in
laudatory terms of its use in furuneulosis and ciirbuncles.
He concludes : (1) Brewers' yeast prevents the further de-
velopment and suppuration of the most rebellious furun-
cles and carbuncles; (2) it prevents repeated develop-
ment of furuncles in persons predisposed. L. Brocq"
used brewers' yeast on himself with good results. Alfred
Gordon," giving one dram of brewers' yeast t.i.d. to a
patient with furuneulosis, noted nausea and diarrhea,
but the peripheric inflammation lessened to a great
extent and the central nodule of all furuncles decreased
markedly in size. This author believes it has the power
to check suppuration.
In view of the favorable action of brewers' yeast in
furuneulosis, S. Petri '* used it in dram doses twice to
three times a day in two cases of confluent smallpox.
No other treatment was employed. The pus dried rap-
idly without the formation of any pitting and there was
no fever or suppuration. It seems that its use might
also be indicated in other pustular forms of skin diseases,
such as acne vulgaris, impetigo contagiosa, etc.*
Theodore Landau," of Berlin, has used brewers' yeast
as a vaginal injection, using 10-22 cc. in leukorrhea and
vaginitis. Its action here corresponds to the law of the
survival of the fittest, because the satxjharomyces remain
master of the ground over other microorganisms, so that
the effect is due not so much to a leukocytosis as to a
phagocytic action of the yeast cell, an antagonistic
bacteriotherapy. W. Albert {Centralbiatt fur Crj/tid-
kologie, Aug. 9-23, 1902) regards sterile yeast as a
physiologic disinfectant for the vagina ; obstinate vaginal
discharges and erosions of the portio diminished at once
and were completely cured after from five to six injec-
tions. Albert also uses yeast to disinfect the vagina
previous to operations. It is injected and allowed to
remain 12 hours before an operation.
Brewers' yeast has also proved 'a valuable *rem-
e<ly for certain internal diseases. Penzoldt,'^" in an article
on the effects of carbon dioxid on digestion, states that
it improves it in various directions, for the secretion of
hydrochloric acid begins sooner and reaches a higher
degree. The carbon dioxid also stimulates peristalsis, so
that in atony and anacidity fluids containing carbon
dioxid are beneficial. Carbon dioxid is one of the end
products and cause of the tympanites after the ingestion of
brewers' yeast ; besides the effects derived from the fer-
ments contained, furthering digestion and assimilation,
the carbon dioxid also exerts a beneficial and stimulating
effect, so that Koss^' using 50 eg. of fresh yeast, dried at
• Welch and Scharaberg, of the Municipal Honpltal for InfecUouB
Diseases, of Philadelphia, have kindly coiiiimiiilrnted their experience
with the use of brewers' yeast In the treatnietit of sniaUi>ox :
" We were prompted by the cneoumglnK results which are said I«
have bi-en obtained lu the treatment of bolls, abscesses and other pyo-
genic Infections, toen»ploy the remedy In the li*eatment of smalloox.
We admlnlstere<l the yeast In 10 or more cases. In various types or the
disease, and In the different stages. Two dmms were given In milk
every four hours, day and night. The yeast was well borne and was not
unpalatable t« the patients. We were not able, however, to observe
anv appreciable Inlluence of tills remedy upon the progress of the erup-
tions or the disease. The pustules proceeded Ix) full nuitunitlon, and
the secondary fever was In no wise modlttetl ; nor did tln^ yeast appear
to exercise any nstralnlng Inlluence In the prevention of the bolls and
subcutaneous abscesses wnlcb go commonly cxtmpllcate smallpox.
" In bjw'terlologic Investigations whUrli wo have made, we regard
the puslulaLlon In smalli^ox as an essential part of the variolous pro
cess, the result doubtless of the action of the agent which produces the
disease. 'I'be later pyogfulc (complications are due to secondary Infeo-
tlon with streptococci and other organisms. Even these latter condi-
tions were not materially Influenced oy the yeast treatment."
684 AMEBIOAN MESIOtNKj
BREWEBS' YEAST IN THERAPEUTICS
lOCTOBKB 11, 1902
a temperature of 30° C, noted a good effect in habitual
constipation.
Gunzburg " has used it as a remedy in enteroptosis
and describes its effects as follows : Its administration is
followed by meteorism, which is beneficial because it
anchors the organs and does not allow them to glide
hither and thither in the abdominal cavity. The tym-
panites, if too great, can be reduced by reduction of the
yeast taken, but in this affection tympanites is, for the
most part, pleasant to the patient. The pulsation of the
abdominal aorta is not so disagreeable a sensation,
because the inflated intestines arrange themselves between
the aorta and abdominal wall.
Under the administration of yeast Gunzburg noted
a gain in weight and strength, and the fat polster by
metabolic changes assists in again fixing or anchoring
the organs. The constipation and masses of mucus dis-
appear, so that the yeast exerts a laxative effect. Its use
is contraindicated in dilation of the stomach.
So long ago as 1852 G. B. Smith '■" used cerevisise fer-
mentum in the treatment of putrid sore throat, due, no
doubt, to the specific effect of staphylococcus infection.
Is it too much to say that it might be of value in acute
articular rheumatism which of late is regarded as an
attenuated toxic pyogenic infection ?
In diabetes mellitus, using the word of that cele-
brated authority, von Noorden, that the number of
drugs which have been recommended in its treatment
is legion — an evidence of the small benefit of any indi-
vidual one — even the most optimistic believers in materia
medica, rendered cautious by oft-repeated disappoint-
ments, become skeptical when any one praises a remedy
for diabetes.
We have shown that in those taking an excess of car-
bohydrates and producing an alimentary glycosuria that
yeast is useful, so that Nobicourt" suggests that by
administering yeast to diabetic patients they may
possibly take a large quantity of carbohydrate, because
the yeast attacks the nascent glucose formed from
the conversion of carbohydrates. It is also possible
that, as alluded to, yeast has a glycogenic ferment
which may change the glucose back to glycogen, to be
stored in the body.
Cassaert ''' reported good results from brewers' yeast
in three cases of diabetes mellitus. One of these cases
was very grave, another was tuberculous. It was given
in doses of 50 grams each day. The immediate effects
noted were that after a few minutes the patients passed
a large amount of gas which was followed by a fetid
diarrhea with a considerable evacuation of gas. After a
few days a tolerance was obtained and the patients felt
good. The appetite returned, their strength increased,
while sugar was diminished in the urine. The weight
of the three patients increased 3, 5 and 8 pounds, respect-
ively. On discontinuing the treatment a loss of weight
was noted. Debouzy '" used it internally in a diabetic
patient, with a great decrease in glucose, from 240 grains
to 10 grains in 24 hours. De Backer and Manders (Tour-
nier's article) used a pure culture of yeast ferment in
a case of diabetes, giving injections varying from 9 to 16
days apart. In one case (De Backer's) the glucose
decreased from 82 gm. to 45 gm. and the urine from
3 liters to 2 liters in 24 hours. In another case (Mander's)
glucose decreased from 187 grams to 41 grams and the
urine from 3 liters to 1} liters.
It is indisputable that a very large number of patients
with incipient pulmonary tuberculosis are cured by a
natural resistance to the infection. This is proved by
the large number of cicatrized lesions discovered in the
jjulmonary tissues of those who die from other remote
diseases, so that cases of incipient tuberculosis are amen-
able to treatment and offer a good hope of early recovery.
Many of these patients are cured by rest, fresh air and a
nutritious diet; some authorities claim results from
climate, others from sanatoriums ; others, as Goetsch,
from the use of tuberculin in combination with the
foregoing ; but in every case the cure is accomplished by
such means as increase the body to the normal resistance
of infection.
In the nuclein of the yeast we have a substance by
which the body may acquire a resistance. In 1893
Vaughan," in a paper on immunity and cure in infec-
tious diseases, prepared from yeast a nuclein which he
claimed not only to be germicidal but also toxicidal in
that it was capable of rendering inert bacterial nucleins
whether present in living or dead cells, in suspension or
solution ; and as a result of experimentation recom-
mended the use of nuclein in incipient tuberculosis. In
all cases he recommended that it be used early in the
disease before the secondary infection.
Wilcox^' and Garber™ were able to verify the results
obtained in early cases, Wilcox concluding that the good
results were obtained for three reasons : (1) Nuclein
increases the vigor of the central nervous system ; (2)
it has germicidal properties ; (3) it results in the produc-
tion of a polynuclear leukocytosis.
In a communication to the Journal of the American
Medical Association, 1901, I urged the use of fresh brew-
ers' yeast in large doses in cases of tuberculosis, and I
herewith report a case in which its action in combating
certain features of a secondary pyogenic affection occur-
ring during the course of pulmonary tuberculosis was
well marked :
Case I. — I had watched the course of a case of tuberculosis
in Mr. J. P. at one of the hospitals. He had advanced pul-
monary tuberculosis with formation of cavities and a very
profuse expectoration, with many tubercle bacilli and staphylo-
cocci in the sputum. He had coueh, was much emaciated and
had night sweats, with hectic flusn, and a marked rise of tem-
perature in the evening and morning remissions. He remained
in the hospital for some time and was discharged unimproved.
Some time afterward, having been called in attendance, I found
the patient in bed, much emaciated, and having hemoptysis.
As there were no means for proper nursing at his home, he was
advised to go to the German Hospital, where I attended him.
He was given large doses of fresh brewers' yeast immediately,
and though the patient was far advanced in the disease, an
improvement was noted in (1) the night sweats; (2) chills;
while the temperature curve from May 15 to May 28 was never
above 99.5°. The patient, however, eventually left the hospital
because we could not keep him longer, and I am informed after-
ward died of hemoptysis.
In this case there was an amelioration of general
symptoms due to the secondary septic process under the
use of brewers' yeast. Another case also illustrates its
effect, not in a curative way but in the lessening of
symptoms, i. e., in temperature, night sweats, etc., in a
case of pulmonary tuberculosis in which there was cavity
formation.
Case II. — Mrs. L. D., aged 22, an Italian and married.
Following a confinement she coughed for several months, there
being abundant expectoration in which the tubercle bacilli
were found. She is anemic, emaciated, and complains of night
sweats and pain in the left side. She entered the German Hos-
pital, May 5, 1901, with a pulse of 120, and respirations 25. The
left apex "and upper lobe were involved in an ulcerative process,
which later developed a cavity formation. She was given
creosote, codliver-oil, nutritious diet. At her entrance the
tuberculous process was quite active ; suberepitant rales and
friction were elicited on auscultation. The temperature did not
become normal until the morning of May 11, and it varied from
98° to 99.5° F. at night. About this time the physical signs
showed a cavity formation with rise in temperature curve.
Brewers' yeast in large doses, one to two ounces, was now
given, and on May 15 the temperature reached normal and
remained so 11 days (May 26), when, as a result of the constant
administration, a fetid diarrhea followed with a sudden rise of
temperature to 102°. The yeast was discontinued, a high bowel
wash was given, and the patient again returned to yeast. The
symptoms of the pyogenic process, night sweats, hectic fever,
etc., ceased, the patient's general condition improved, the tem-
perature remained normal until the patient left the hospital,
improved, July 27, a total of 30 days of natural temperature, and
went to the country.
In the two casas cited there was an undoubted im-
provement in the symptoms as seen in advanced cases,
and they are certainly the most hopeless ones for treat-
ment.
Case III.— J. E., aged 44, stone cutter,' married, entered the
hospital, April 15, 1901, complaining of cough, loss of appetite
lOCTOBER 11, 1902
TYPHOID SPONDYLITIS
[Ambrican Medicine 585
and weight, and night sweats. Temperature 100°, respirations 18.
The physical signs showed involvement of the apices in a
fibroid condition. The sputum, which was not abundant, showed
the tubercle bacilli. The treatment consisted of codliver-oil
and creosote and feeding. The temperature continued at 99°
and 100° for six days, when treatment with brewers' yeast, three
ounces t.i.d., in milk or water was instituted. The tempera-
ture dropped to normal and so continued with only an occa-
sional rise of .5° with morning remission of about the same, and
the patient was discharged June 23, 1901, much improved, hav-
ing had no night sweats or pyrexia for about 60 days. He
gamed about 10 pounds in weight.
Case IV.— Francis, aged 18, an Italian, came to Buffalo four
months ago. She had night sweats, chills, hemoptysis, and moist
purulent tuberculous process at the left apex. The sputum
revealed the tubercle bacilli.
The patient was sent to the German Hospital where
brewers' yeast was given in 3-ounce doses three times a day.
The temperature was reduced to normal, the night sweats
ceased, the process seemed uninfluenced and the yeast was dis-
continued, but notwithstiuidiug, whenever discontinued, the
septic symptoms were accelerated. The patient is still under
my observation, but is now in the country.
Brewers' yeast has also been employed by me in a num-
ber of cases of bronchopneumonia and with evident excel-
lent results. In bronchitis, especially the chronic forms,
and of the fetid variety, it is a remedy ^rthy of trial,
as it increases an expectorant action in conjunction with
its other properties. Regarding its use in tuberculosis,
it might be stated that in those who have marked gastric
atonic dihition it may produce nausea, vomiting and
diarrhea, but this may be overcome by lavage and bowel
washes, should it occur. Commencing with ounce doses
of fresh brewers' yeast and gradually increasing to three
ounces t.i.d., given in beer, sugar water, or plain water,
or even taken as such, brewers' yeast is well borne by
the patient in the majority of cases. If they complain of
tympanites, then the dose may be diminished.
The therapy with fresh brewers' yeast is applicable
only in such placas where it can be obtained fresh from a
brewer, and it must be obtained daily. It is, however,
a cheap way of applying therapeutics, and for that reason
may be given to the very poor. As obtained it is a red-
dish, frothy liquid, slightly acid in reaction, with theodor
of beer, and of pleasant taste. To overcome the difficul-
ties in obtaining it, there are, I believe, several effica-
cious derivatives on the market. De Backer and Tour-
nier have used a pure culture of yeast hypodermically in
tuberculosis, cancer and diabetes. The injection of J to J
a syringeful for an adult, 1 to J syringeful for a child are
used intramuscularly every 8 days then every 15 days for
three to four weeks until about four to six injections are
given. Tournier gives reports of a favorable action
ob.served in 20 cases of tuberculosis and three of diabetes.
Because Dr. Brault found an increased amount of glyco-
gen in sections of malignant neoplasms, it was used in a
number of cases of recurrent and inoperable malignant
growths in some of which the pain and later the growth
disappeared ("Cancer of Breast," by Tournier). There
are 10 such cases reported, and it is recommended in those
cases.
We must then conclude that brewers' yeast, because
of its ferments, nuclein, nucleinlc acid and phagocytic
action is a remedy of value in therapeutics ; its use is not
contined to anyone disease, but wherever an increased
resistance of the organism is required. It has proved
itself of value in furunculosis, carbuncles, diabetes, tuber-
culosis, bronchitis, bronchopneumonia, enteroptfjsis,
habitual constipation, cancer and other affecjtions. Used
in cases of advanced tuberculosis, an improvement in
-ymptoms indicative of secondary pyogenic infection
was noted.
BIBLIOOBAPHY.
1 Jour. Path, and Bact., 1809, B. 1. S7-((3.
'Centralblatt Bakt u. Paraslt., IWM!, p. 11.
3Zelt. Hyg. uiid Infck. Krank.. lS9ti, p. 11.
H'enlralbTatt f. Bakt. Paraslt. und Jnfek., Feb. 6, 18(«7.
5 Z«lt. f. Hygiene, -vxlll, H. :i, n. 2K!.
•Centbit liaki. t'nraKlt. und Infck., >)08. i) and 10, 1897.
■ Am. Jour. .Med. .Sciences, April, 1901.
'Journal of Medical Keseareh, April, 1902.
•Bril. Med. Jour.. Vol. II, I8II.5.
1" Mod. N(^ws, May and Oct., 189.3.
u Bleyer, .Med. Record.
■2 Les Levures purcs en particulier dans la tuberculose, le dlabfite,
le cancer, published by Eugene Devillers, Belfort.
's Kevue Critique de med. et. Chir., No. 0.
" London Lancet, 1852.
15 Jour, des Sciences medic, de Lille, July, 1895.
I'Pres. Med., Jan., 1899.
" Phil. Med. Jour., Vol. iii, p. 687.
'« La Semaine M6d., 1902, No. 8. Ref. Merck's Archiv, 1902.
'■■> Deutsche med. Woch., Marz, 1899, p. 172.
2»Med. News, May 30, 1902. Deutsche Archiv f.klin. med.. Vol. Ix.xiiL
-■ La Semaiue M6d.
25 Mtineh. med. Woch., July, 1890.
23 Host. Med. and Surg. Jour., 1852, xxvi.
2* Am. Year Book or Surgery, Gould, 1902. Ref. La Semaine
Old 6 d i cii 1 6
25 Brit. Med. Jour., Vol. xxl, 1805, par. 183, from Sem. m6d., August 21.
2« Jour, de Med. et de Chlr. Pratique, 1891.
2' Med. News, Oct. 14.
28 Therapeutic Gaz., 1895.
2» Therapeutic Gaz., Jan., 1895.
*> Brault, Le Prognostic des Tumeurs fase sur glycogene, Paris, 1899.
AN ADDITIONAL CASE OF TYPHOID SPONDYLITIS.*
BY
ALBERT H. FREIBERG, M.D.,
of Cincinnati, Ohio.
Professor of Orthopedic Surgery, Medical College of Ohio ; Medical
Department of the University of Cincinnati.
It would seem at the present time that there is still
doubt as to the nature of the symptoms presented by
many patients after typhoid fever and which have been
grouped under the term "typhoid spine." By Osier'
the condition is really considered a neurosis, by others
perispondylitis, but since the paper of Lovett and With-
ington,^ presenting as it did a case with undoubted loss
of vertebral substance, a new aspect has been lent to the
question. On this account I make no apology for pre-
senting this report, more formal and complete, of a case
mentioned in discussion at the last year's meeting, since
I have in the meanwhile had the opportunity of further
observation.
Case.— An Italian boy, aged 15, was admitted to the medical
service of the Cincinnati Hospital February 18, 1901.
The patient's family history proved to be entirely negative,
especially as regards tuberculosis.
The present illness of the patient began a few days before
his admittance. He denied ever having been sick before. Upon
his admittance his temperature was 102° P., and his case was
considered a rather typical one of early typhoid. On the fifth
day after his admission rose spots developed in profusion.
On March 5 it was noted that his temperature had had a typ-
ical range reaching 10.3° to 104° F. daily. The case was unusual
in no particular except that the patient was ai)t to be noisy and
was somewhat hard to control. 'The Widal test made on March 9
was negative in its result. (I was mistaken about tliis in mak-
ing my former report.) ^
The patient was allowed to sit up in bed on March 20. Nine
days later he was allowed to be on his feet, but complained of
pain in the lumbar region, which continued after he resumed
recumbency. On April 3 he was put to bed again because the
pain in his back had grown much worse and more constant.
The pain was severest at night, the spine decidedly tender to
pressure, but there was no elevation of temperature. By
April () the pain in the back had grown so much worse that he
could scarcely use the bed-pan and evidently was most careful
to avoid any motion of the Ijody. The pain became so great on
April 7 that the patient required to bo given an enema and to
be catheterized on this account. Morphia in ordinary dose was
only slightly effectual in quieting the nocturnal pain. .\t this
time I was asked to see the patient by Dr. G. A. Fackler, in
whose service he was.
I found him lying upon his back, evidently in great pain
and very careful to avoid the least motion of the trunk. Pain
was greatest in the back over the spine and to either side of it.
It, however, radiated forward onto the lower part of the abdo-
men and downward toward the groins and upper parts of both
thighs. He objected vigorously at being moved to permit the
examination of the back.
Upon making such examination there was at once noted a
decided projection backward of spinous processes involving
the eleventh and twelfth dorsal and tlie first and second lumbar
vertebras and at the height of which the greatest tenderness of
the spine was found. In addition to this piojo<!tion there was,
however, a diffuse swelling extending both laterally and ver-
tically beyond its limit and all of which wa-s also sensitive to
pressure. Tliis tenderness was, however, not of superficial
character but required fairly deep pressure to make it evident.
The muscles of the back were rigidly contracted. The tendon
» Read before the Amencnu orthopedic Association, June, 1902.
586 American Medicinbj
IDIOPATHIC VAGINISMUS AND STERILITY
[OCTOBER 11, 1902
reflexes were somewhat exaggerated at the knees and there
was slight ankle clonus. It was impossible to detect any
impairment of sensation.
The patient was transferred to the orthopedic service on
April 11. A plaster bed was at once made for him with the
spine in a hyperextended position. Upon its application heat
once experienced great relief. This relief was, however, not
complete. The patient complained of more or less pain during
the next few days, although it was not severe and did not inter-
fere with sleep. On one occasion while unobserved he removed
the bandages and plaster bed, casting the latter upon the floor.
The pain immediately became so severe that he cried out and
begged to have the plaster replaced. On April 26 it was noted
that he had been free from pain for a week, his spine was exam-
ined and found very rigid and still quite tender. On May 8 a
plaster jacket was substituted for the plaster bed and the
patient was allowed to go about.
He was discharged from the hospital on May 23, upon his
request, and having been entirely free from pain. The exami-
nation which was made at this time still showed considerable
stiffness of the spine ; the bony deformity was unchanged but
the diffuse swelling of the soft parts had entirely disappeared.
I had the opportunity of examining this patient in ray office
in February, 1902. I found that the deformity at the lumbodor-
sal junction was about the same, although 1 had no exact
measure of it. The spine was freely mobile except in this
region, where there seemed still to be a manifest restriction of
motion. He has, however, had no symptoms of any kind since
his discharge from the hospital. He has been working at his
trade steadily, weighs more than he ever did, and is the picture
of health.
Since Lovett and Withington's paper several cases
have been reported in which the existence of posterior
deformity has made it seem in the highest degree prob-
able that destruction of bone tissue had occurred, though
of limited extent. Such a case is that of W. J. Taylor.'
Kuehn * reports one such case and Neisser ^ two, in
which it was believed that bone destruction had occurred.
In all of these cases, however, spontaneous cure resulted,
leaving the spine, as far as I can determine, in a perfectly
normal condition. Both of Neisser's cases continued for
over two months, and in both of them fever was present
until the disappearance of pain. Kuehn's case was char-
acterized by the presence of a distinct lumbar gibbus,
which disappeared in 1 J months, leaving no functional
disturbance whatever. All of these cases have certain
symptoms in common, such as the sharp and severe
pain, the diffuse swelling, the great tenderness upon
pressure. Lovett and Withington's case and the one
which I am reporting are the only ones, however, in
which bony deformity remained long after the subsidence
of subjective symptoms. In these cases, at least, it
would seem impossible to avoid the conclusion that an
inflammatory lesion with circumscribed loss of bone had
existed. In these, however, such is the similarity of
subjective symptoms, history, and physical evidence
with the many other cases reported that I believe we
are justified in attributing them to a local process of
inflammatory nature rather than in looking upon them
as of neurotic character. This would seem to be of some
importance, even though all of the cases hitherto
observed have resulted in cure without suppuration,
especially so in view of the great relief which has been
afforded by thorough immobilization of the spine in
those cases in which this was done.
The question might be raised as to the nature of the
destructive process in the spine, granting that such had
existed. I take it that there is no reasonable doubt as to
the nature of the preceding febrile disease, in most of the
cases at least. I think, however, that there is sufiicient
deviation in the spinal symptoms of these cases from the
usual types of caries, more particularly in the manner of
complete recovery, that they may be easily and certainly
considered not tuberculous. If this is true we have but
to consider them in the same class with the many sequels
of typhoid in periosteum and bone.
BIBLIOGRAPHY.
1 Osier, Johns Hopkins Hosp. Reps., Vols, i and v.
= Lovett and Withlngton, Boston Med. and Surg. Jour., March 29,
3 W. J. Taylor, Trans. Orthop. Assn . Vol. xiv.
< Kuehn, Miinch. med. Woph., 1901, No. 23.
6 Neisser, Centralb. f. inn. Med., 1901, s. 438.
IDIOPATHIC VAGINISMUS AND STERILITY.
BY
E. CASTELLI, B.A., B.S., M.D.; L.M., OP Dublin,
of Washington, D. C.
Idiopathic vaginismus seems to be a functional neu-
rosis of the vagina, i. e., one not connected with demon-
strable anatomopathologic lesions. On account of its
treatment it must be carefully dilferentiated from the
vaginismus due to anatomic lesions of the vagina. Vul-
vitis, ulcerations, gonorrhea, cartilaginous hymen, etc.,
are very often the cause of vaginismus, but if treated
properly all the symptoms disappear. However, we
must not forget that both the idiopathic and symptom-
atic vaginismus have always as common ground a
neuropathic tendenoy ; phlegmatic and quiet persons are
not so easily affected, while those who are nervous and
hysteric suffer whenever the exciting cause is present.
The symptomatology of idiopathic vaginismus is as pro-
teiform as that of hysteria, so it is incorrect to speak of
one form of vaginismus, but rather of many forms.
Being the dif|ase expression of a functional neurosis,
the vagina may be affected in different ways ; either the
sensitiveness, or the circulation, or the secretion, etc.,
can be aff'ected and give rise to diff'erent symptoms. I
should like to call attention to a case that came under
my care seven months ago, and that for its peculiarity I
think worthy of mention :
Case.— The patient is a woman of 27, who has been married
three years. Her father and mother are living and in good
health. When 18 years old she suffered with neurasthenia in
consequence of a sudden change in the financial circumstances
of her family. At that time she was taken to a sanatorium
where she slowly recovered, but since then she lias never felt
well. Any little worry, any unpleasant occurrence puts her in
a most depressed condition, compelling her to remain in bed
for several days. At 24 years of age she married and seemed to
be happy. She came to consult me in October, 1901. She
wanted to know why she could not have children. Her hus-
band was young and strong, she was a little nervous, but noth-
ing else was the matter with her, and sterility was a source of
great unhappiness to her. On the following day I made a thor-
ough examination. Everything seemed to be normal. I could
attest no displacement, but in removing my fingers from the
vagina I noticed a spasmodic contraction of the muscles of the
perineum accompanied by a rather abundant watery discharge
from the vagina. Inspection showed a tonic contraction of the
vaginal muscles. I asked the patient if she had ever noticed
any contraction of the perineum, and if she had ever had
watery discharge from the vagina. She told me that always
after coitus a painful, cramp-like sensation of the perineum
followed, accompanied by abundant watery discharges. These
facts seemed to me a sufficient cause for the sterility of which
she complained. For, if a watery secretion immediately fol-
lows coitus we have a mechanic fact that prevents fecundation.
The sperma diluted by the secretion produced all over the vag-
inal walls is discharged from the vagina during the contraction
of the constrictor vagin». There is also a cheraic action. The
secretion, either acid or exceedingly alkaline, as sometimes
occurs in very nervous people, diminishes the vitality of the
nemasperma. The watery discharge is evidently the demon-
stration of a va.somotor and secretory disturbance of the mu-
cosa3 vaginse. I will not discuss an anatomic divergency,
for instance, if, according to Husehke, the mucosa of the vagina
is abundantly provided with muciparous glands, or, if, accord-
ing to Robin, it is not. Of course, in the first case the secretion
would be of glandular origin, while in the second case it comes
directly from the tissues. The chemic composition of the
secretion might produce much discussion, but in this connec-
tion it is not necessary.
The physical examination of the patient showed (a) marked
evidence of anemia and emaciation, (6) irregular pupils, (c)
zones of anesthesia on the left shoulder and thigli, (d) hyper-
esthesia in the region of the left ovary, (e) diminution of the
pharyngeal reflex. She suffers quite often from gastralgia.
In the treatment I adopted the following views: First,
sterility is due to a mechanic fact, ('. e., to the expulsion of the
nemasperma from the vagina after coitus. Second, the vagin-
ismus manifested with vasomotor and secretory disturbances is
a symptom of hysteroneurosis. Third, anemia is probably the
cause and effect of the hysteroneurosis. The treatment must
be psychic and constitutional.
I prescribed injections of the following solution, to be taken
every morning :
Sodium phosphate 4 grams
Sodium sulfate 8 grams
Sodium ehlorid 2 grams
Carbolic add '. i gram
Water (boiled) 100 grams
OCTOBBR 11, 1902]
PROFESSOR NICOLADONI'S CLINIC, GRATZ
(AKKBICAN MKDICINJ
587
In this way I aimed to gradually repair the general nervous
debility and at the same time engage the patient's confidence so
far as possible.
Suggestion having a great effect on all patients, and espe-
cially on the nervous ones, I insisted tliat she would soon
become pregnant and that she was in no way different from
other women.
I also prescribed good nourishment, life in the open air,
distractions and no intellectual work ; cold douches every
morning for 20 seconds on all the body except the head, fol-
lowed by dry friction and a walk. In the afternoon, before
dinner, methodic massage, and at meal-times a tablespoonful of
the following :
Sodium bromid 80 grams
Potassium iodld 30 grams
Sodium arseniate 0.15 centigram
Water 1,000 grams
After a month's treatment the patient gained TJ pounds and
had a good color. Contractions of the perineum after coition
and the discharge from the vagina had ceased. The treatment
was followed with intervals of rest during three months.
On December 27 the patient had her last menstruation.
Since then many signs indicate a diagnosis of pregnancy. Its
course seems to be normal.
SPECIAL ARTICLES
PROFESSOR NICOLADONI'S CLINIC, GRATZ.
BV
NICHOLAS SENN, M.D.,
of Chicago.
Gratz is a charming university city, with a happy, contented,
peaceful, refined population of 120,000.
The little city is beautifully located in a green, fertile
valley, surrounded by forest-clad mountains and bisected
by a tumultuous stream of the purest, crystal-clear water.
Although the city is in the direct line of railway travel from
Trieste to Vienna, it is not much frequented by tourists, and
the advantages offered by its university have not been sufll-
ciently appreciated by those who seek postgraduate education
abroad. The University of Gratz recently celebrated its third
centennial. The medical department was organized 35 years
ago, and has now an attendance of 300 students. The laboratory
facilities are excellent, and the clinical material far beyond
requirements. The surgical clinic has 280 beds, and receives a
large amount of material from the outdoor department. The
operating amphitheater has all modern improvements, instru-
ments and appliances, is well lighted and can seat from 85 to 100
students.
Professor JTicoladoni, formerly of Innsbrtick, came here In
1893 to take the chair of surgery made vacant by the resignation
of Professor WOlfller, who accepted a call from Prague. Nico-
ladoui is a modest, hardworking, scientific surgeon, and an
impre.ssive teacher. His book on scoliosis, which was pub-
lished about the time ho loft Innsbruck, is a masterpiece of
careful investigation and sound teaching, and is now being
revised by its distinguislied author, and will soon make its
appearance mueli enlarged and more fully illustrated. His
coutributious to surgical literature have beeu many, and all of
them are noted for the originality of the material they contain.
His fame as a plastic surgeon has given him an international
reputation. He was the first surgeon to practise tendoplasty, a
branch of orthopedic surgery which has since been so rapidly
developed and practised on such a large scale by Hoffa and
others. His most recent innovation in plastic work is the use
of cartilage taken from the ribs out of which to make an unyield-
ing framework for the frontal flap in rhinoplasty. This opera-
tion will^)e fully described further on. In his clinic he is
assisted by four resident surgeons. The work begins each day
at 9.IW a.m., and it is seldom finished l>efore 2 p.m. During
this time two and some times three operate simultaneously.
His first a-ssistant. Dr. Payr, received an assistant professor-
ship a few days ago, and the event was appropriately cele-
brated. Professor Payr, although a young man, has reached
well merited distinction by liis original work on the use of
magnesium in surgery. In Nicoladoni's clinic, choloroform
and the A. C. E. mixture are used as anesthetics. Silk has
almost entirely taken the place of catgut. Gloves have been
abandoned. Hand disinfection consists of thorough scrubbing
with water and marble soap, followed by alcohol and subli-
mate solution. Recent wounds, when no drainage is required,
are covered with Bruns' airol paste. This paste consists of
Airol )
Bolus alb. \ of each 20
Glycerin J
Glycerin ss.
The yellow paste becomes firm in a short time and is easily
washed away with warm water. It is claimed that this paste is
one of the means to prevent stitch abscesses.
Magnesium in Surgery.— Br. Payr has made the effects of
magnesium on the tissues a special study for a long time.
Arrows of magnesium in cavernous venous angioma.
Pieces of this metal introduced into the living tissues produce
certain definite chemio changes which effect the absorption of
the metal. Under its action the watery constituents of the tis-
sues are reduced to the original elements, oxygen and hydro-
gen. The gases evolved accumulate around the metal, the
3.
A, B, C, application of magnesium ring. I), Payr's magnesium ring
for uniting severed bloodvessels.
oxygen combines with it and forms a soluble magnesium oxld.
The hydrogen is absorbed. Payr has found the magnesium
wire too brittle for suture and ligature material. He has used
nails made of this material for direct fixation of fractures and
in immobilizing the bone ends after resection. Nails ofthe
thickness of a small lead pencil are absorbed in the course of
three to four weeks. He has made many experiments with a
small grooved magnesium ring in unitingsovered bloodvessels.
In uniting asevered artery the ring is slipped over the proximal
end and after turning the coats ofthe artery back and over It a
ligature is applied over the groove of the ring. (See illustra-
tion.) With four fine silk sutures the distal end is drawn over
the proxinnal end, thus bringing intlma in contact with Intiina
588 Ameeioan Medicine]
PROFESSOR NICOLADONI'S CLINIC, GRATZ
[OCTOBEK 11, 1802
over a considerable surface, when a second ligature is applied
to maintain the invagination. The continuity of the artery is
restored in this manner by means of the extravasculav magne-
sium ring and two fine sillt ligatures. The ring is absorbed in
three weeks, and the vessel unites as a rule without the forma-
tion of a thrombus. In uniting a severed vein the ring is
applied to the distal end, as the invagination must be made in
the direction of the blood current. He has resorted to this pro-
cedure with success in the case of a wound of the common
femoral vein inflicted accidentally during an operation for the
removal of carcinomatous glands in Scarpa's triangle. Four
centimeters of the vein were resected, the ends united in the
manner described. The patient died three days later and the
postmortem established the fact that the union was firm and
the lumen of the vein free from thrombus formation. Nicola-
doni also suggested the use of magnesium in the case of a large
venous angioma of the face. At different times needlelike
fragments of the metal were inserted into the tumor through
punctures made with a tenotome. At the time of my visit about
22 magnesium arrows had been inserted and at different points
gaseous crepitation could be elicited around the foreign sub-
stances on pressure. The tumor had diminished under this
treatment more than one-half its size. This new therapeutic
agent is entitled to a fair trial in the management of cavernous
venous angioma not adapted for a more speedy treatment by
excision.
Clinical Oases. — The following are some of the more im-
portant operations that came under my observation during my
two visits to Nicoladoni's clinic :
Case I. — Rhinoplasty by Nicoladoni's method. The patient
was a man about 30 years of age. Nearly the entire nose had
been destroyed by
syphilitic ulcera-
tion. There were
numerous facial
scars from the
same cause. Two
months ago the
first operation was
performed. A
number of ribs
were exposed by
an incision over the
costal arch on the
right side. With a
resection knife a
piece of cartilage
about four inches
in length was ex-
cised from the bor-
der of one of the
ribs. This piece
was intended to
serve as a support
for the bridge of
the new nose and
the septum ; it was
implanted oblique-
ly underneath the
skin between it and
the occipitofron-
, ., , talis on the left side
of the median line of the forehead. A number of fragments of
cartilage were inserted at right angles on each side so that the
subcutaneous cartilaginous framework represented somewhat
in outline a Maltese cross. The crossbars were intended to
serve as supports for the alae of the new nose. The implanted
cartdages could be distinctly seen and felt underneath the skin,
and their position and prominence are well shown in the
accompanying photograph. A guttapercha model of the nose
was made, and over this the paper was cut with which to out-
line the frontal flap. Under strict aseptic precautions the
rhinoplasty was made. The flap included all of the tissues
down to the frontal bone. The free margins of the alae and the
septum were lined by turning the skin in the direction of the
nasal cavities and suturing it with fine silk. The immediate
cosmetic result was excellent. The frontal defect was reduced
in size by tension sutures, and will be paved with Thiersch's
skin grafts as soon as the surface is covered with granulations.
The nasal cavities were not packed with gauze. An external
absorbent dressing completed the operation.
This case will unquestionably prove a great success, and
will be reported in full by the operator so soon as the remote
cosmetic result can be determined.
Case II. — Strumectomy for parenchymatous struma.
Operation performed by Prof. Payr : The patient, a girl, aged
20, was the subject of a symmetric struma which recently had
Nicoladoni's case of rhinoplasty, showing the
subcutaneous Maltese cross of cartilage be-
fore second operation.
commenced to give rise to pressure symptoms. The swelling
is smooth, of uniform consistency, and descends somewhat
behind the jugulum of the sternum. Patient otherwise is in
excellent health. Chloroform was used as an anesthetic. The
operation was performed with the patient nearly in a sitting
position. Kocljer's anterior curved incision was made down to
the capsule of the swelling and hemorrhage carefully arrested
as the operation proceeded. Some of the larger veins were cut
between a double ligature. The left lobe was first removed.
The thyroid arteries and veins were ligated separately. The
isthmus of the gland was isolated and a vertical linear crush-
ing was made with a pair of crushing forceps, and ligated with
a silk and a strong catgut ligature when the left lobe was
removed. On the right side only the superior thyroid artery
and vein were ligated and only a portion of the lobe excised
after preliminary eii, masse ligations with catgut, as advised by
Mikulicz. The operation was completed in less than an hour
and with the loss of not more than a teaspoonful of blood. "The
clean anatomic dissection and the careful hemostasis exhibited
the work of a master.
Struma is very prevalent in the mountainous regions of
Austria. In the Graz surgical clinic about 75 strumectomies
are performed annually.
Case III. — Abdominal ttimor ; death from the anesthetic.
The patient, a multipara, about 35 years of age, was admitted
into the clinic a few days ago suffering from an abdominal
tumor. The patient's mental faculties were much impaired
and her statements concerning the early history of the growth
could not be depended upon. Emaciation was "marked as well
as the anemia. The tumor, the size of a child's head, occupied
the right iliac fossa. It was hard, nodulated and not freely
movable. For some time she had had symptoms of intestinal
obstruction without vomiting. Tlie abdomen was tympanitic,
tlie muscles, however, were relaxed. No temperature or any
other signs of peritonitis. Tuberculosis or malignant disease
of the cecum was suspected. From the general appearance of
the patient it was evident that the case was almost a hopeless
one. The A. C. E. was cautiously administered, the field of
operation prepared and the surgeon was in the act of making
the first incision when respiration and the heart's action ceased
almost simultaneously. Artificial respiration was performed,
camphoi -ether injected subcutaneously, but no response fol-
lowed. These fruitless efforts were continued for half an hour
when the corpse was sent to the morgue for a legal autopsy.
Case IV. — Carcinoma of the mamma ; excision. 'The patient
was a woman, somewhat advanced in years, who was at the
same time the subject of a large goiter, which, however, caused
no inconvenience. Under chloroform anesthesia the entire
breast with overlying skin and underlying pectoralis major
were removed first, when the axilla was cleared out. The lower
part of the wound could not be closed and was left open to heal
by granulation. Tubular drainage for the axillary space was
instituted and a large absorbent dressing applied.
Case V. — Right inguinal hernia ; radical operation by Bas-
sini's method. The hernia was a small one and a straight
incision was made over the inguinal canal. Sac and spermatic
cord and vessels were isolated and drawn forward with a strip
of iodoform gauze placed underneath them. Isolation of sac,
which was excised below the silk ligature applied to its neck.
Closure of canal by Bassini's method. The wound was sealed
with Bruns' pa^te, over which a compress of cotton was
applied and held in place by a spica bandage.
Hernia operations are performed in this clinic daily and
inguinal hernias always by Bassini's method. The patients are
permitted to leave bed in 10 to 14 days.
In 1,500 cases operated upon recurrence is said to have fol-
lowed only in 2%, certainly a result it would not be easy to
duplicate.
Case VI. — Relapsing appendicitis laparotomy; appendix
not found. The patient, a young man, had his first and severest
attack four years ago, followed by mild attacks nearly every
month since. No palpable swelling in the ileocecal region. In
making the abdominal incision in the customary place and
direction all of the layers were divided. A piece of the great
omentum adherent over the cecum was divided between two
silk ligatures. Search was now made for the appendix. The
posterior surface of the cecum was found firmly attached to the
iliac fossa. The adhesions were separated with the greatest care.
An enlarged mesenteric gland embedded in the adhesions and
first mistaken for the appendix was removed. The operator
witli the utmost patience and care continued the search for
nearly two hours, when the space made behind fhe cecum
caused by separating the adhesions was drained with a long
strip of iodoform gauze and the incision, at least six inches in
length, was closed with four rows of silk sutures.
This was evidently one of those trying cases in which dur-
ing the first attack a large retrocecal abscess ruptured into the
cecum after partial or complete slougliing of the appendix.
Case "Vll.— Scrotal hernia of large size ; radical operation
by Bassini's method. This was a good test case for Bassini's
operation. The hernia was the size of a cocoanut and the open-
OCTOBER U, 1902]
THE WORLD'S LATEST LITERATURE
[AHERICAN MBDICINS 589
ing in the abdominal wall large enough to admit three fingers.
The patient was a young man otherwise in perfect health. The
hernia was located on the right side and had existed for a num-
ber of years. No attempt had been made to retain it by truss
pressure. The incision was made over the center of the swell-
ing and in the direction of the shortened inguinal canal. The
sac contained the cecum and several loops of the small intes-
tines. The separation of the sac required much time and
patience. In the isolation of the sac the operator made frequent
use of short chopping strokes with a short-bladed scalpel. The
sac was ligated and excised in the usual manner. Six silk
sutures were necessary to close the inguinal canal underneath
the cord and its vessels. The deep fascia was sutured over the
cord with very fine silk sutures and the skin united in a sim-
ilar manner. The wound was sealed with Bruns' paste, over
which a cotton compress was applied.
Cask VIII. — Fciscia .sarcoma in right parotid region ; exci-
sion. The patient was a woman, aged 35. A swelling over the
lower segment of the right parotid gland was noticed first a
few months ago. The growth was rather rapid and compara-
tively painless. The tumor was the size of a walnut, movable,
and the skin over it was normal. Skin was incised vertically
and the tumor removed with a zone of apparently healthy tis-
sue. The cut surface of the tumor on section presented all of
the macroscopic appearances of a fascia sarcoma. The capsule
of the parotid gland was intact. Wound was sutured and
sealed with Bruns' paste.
Case IX. — Tuberculosis of lymphatic glands within the cap-
sule of the parotid ; removal of tuberculous product with sharp
spoon. The patient was a younganemic woman. Development
of the swelhng, which was the size of a pigeon's egg, was slow
and without much discomfort, tender chloroform anesthesia
the swelling was incised and cheesy material scraped out with
a sharp spoon. The wound was sutured and sealed with Bruns'
paste.
Case X. — Recurring tuberculosis of glands of right ,'dde of
neck ; excision of affected glands. The patient, a young anemic
woman, was operated upon a few months ago for the same
affection. A clean excision was made of all affected glands and
fistulous tracts. Partial suturing of wound was done and iodo-
form gauze drainage instituted.
Case XI. — Femoral hernia : radical operation. The patient,
a woman, a^ed 50, had a hernia, size of lien's egg, on her right
side. Swelling disappears in the recumbent position. Verti-
cal incision, four inches in length, was made over the crural
canal. Excision of sac was followed by suturing of Poupart's
ligament to the periosteum of the pubes with four silk sutures.
External wound was sutured and sealed with Bruns' paste.
Case XII. — Lipoma over upper part of right biceps muscle ;
operation under local anesthesia by Schleich's infiltration
method. The patient was an elderly woman who had a flat,
lobulated, movable, subcutaneous tumor the size of a woman's
fist, below the shoulder-joint. Schleich's solution was injected
into the skin in the line of the purposed incision. The incision
was made without causing much pain. The loose connective
tissue around the tumor was then infiltrated, but during the
enucleations the patient evinced pain. The wound was sutured
and sealed with Bruns' paste.
The above cases show what is being done daily in theOratz
surgical clinic. Professor Xicoladoni has a splendid staff of
assistants who lighten the arduous work of their chief as much
as is within their power. They perform nearly all of the minor
operations and do not shrink from the most diflicult task when
the profes.sor makes the request. Nicoladoni stimulates his
assistants by example and suggestion to original research, a
fact which accounts for the many valuable reports and scien-
tific papers which are credited to his clinic by his enthusiastic
and devoted assistants.
Gkatz, July 11.
Heroism of Hospital Corps In Manila. — Surgeon-General
Forwood has re<!eived the following from Captain O'Neill, U.
S. A., in the Philippines:
The death of Private Joseph G. M. Eiseman, Hospital Corps,
United States Army, is announced. Private El.seman was
detailed to face death as a cholera nurse for one of our comrades,
and died from the disoaso caught from his (charge — an example
of devotion to duty to be held up for all men to emulate.
Private Leonard B. Stevenson, Hospital Corps, I'nited States
iiy, was detailed to nurse both of oureomrades, well knowing
that his j)redof:essor was cut down while performing the same
duty. Without a murmur he responded and remained until
the sod covered his plague-stricken charges, and now he
returns to his routine duties. The men of this command who
have faced death amid the whistle of bullets can readily appre-
ciate the courage required to daily await his approach in the
form of one of the most dreaded diseases known to the world
today, and the commanding officer makes this an opportunity
to publicly acknowledge that " duty well done," the highest aim
of a soldier, is a goal Private Stevenson has reached. This
order was published at parade on Tuesday, the 27th ult.,
and at general inspection of the Hospital Corps on the 31st
ult.
THE WORLD'S LATEST LITERATURE
Journal of the American Medical Association.
October 4, 190t. [Vol. xxxix. No. 14.]
1. The Surgical Aspects of Pancreatitis. William J. Mayo.
2. Obstruction of the Bowels from Meckel's Diverticulum. Jahbs E.
Moore.
3. Anatomy for the Practitioner. Clarence M. Jackson.
4. Acquired Non-malignant Stricture of the Rectum: Causes, Symp-
toms and Treatment. W. Duff Bullard.
5. Pathology of Uveitis. William H. Wilder.
6. The Treatment of Certain Nonseptlc Lesions of the Uveal Tract
with Pilocarpln and Sweat Baths. Thomas A. Woodruff.
7. The Treatment of Uveitis. WiLBaR B. Marplk.
8. A New Scheme of the Zones and Centers of the Human Cerebrum,
with Remarks on Cerebral Localization, Especially with Refer-
ence to Osteoplastic Operations and Brain Tumors. Charles K.
Mills.
9. Etiology of Chronic Nephritis. Arthur R. Elliott.
10. The Classification of Chronic Nephritis James B. Herrick.
11. Open-air Treatment of Tuberculosis; Tent Life In Arizona. R. W.
Craig.
1.— See American Medicine, Vol. Ill, No. 25, p. 1039.
2.— See American Medicine, Vol. Ill, No. 25, p. 1040.
3.— See American Medicine, Vol. Ill, No. 25, p. 1041.
4. — See American Medicine, Vol. Ill, No. 25, p. 1042.
5, 6. — See American Medicine, Vol. Ill, No. 25, p. 1052.
7. — Treatment of Uveitis.— Success in treatment depends
largely on discovering the underlying cause. Specific plastic
iritis is an early secondary lesion indicating mercury, not
iodids. Marple prefers inunctions and calomel. For the
absorption of vitreous opacities following choroiditis the iodids
are recommended. Mercurials are often serviceable in non-
specific cases. Salicylates accomplish more here than the
iodids. Subconjunctival injections of sublimate or sodium
chloride may be tried. The treatment of chronic uveitis with
macular changes in elderly persons is unsatisfactory. In all
forms atropin is generally indicated, aided in many cases by
moist heat and diaphoresis, [h.m.]
8.— See American Medicine, Vol. Ill, No. 25, p. 1056.
O. — See American Medicine, Vol. Ill, No. 25, p. 1034.
lO.— Classification of Chronic Nephritis.— It is impor-
tant to have a working classification though the pathologic
anatomy is so incomplete. Kenal congestion and amyloid
kidney are excluded from the nephritides. Parenchymatous
and intestinal nephritis are misnomers, as the process is really
diffuse. The best classification is practically that of Senator :
Chronic diffuse nephritis (1) without induration; (2) with
induration. The latter may be subdivided into {a) primary
and (6) secondary chronic inter^itial nephritis and (c) arterio-
sclerotic kidney. The transformation of chronic parenchy-
matous into the interstitial form is denoted by Reisman's term
(6). [H.M.]
11. — Open-air Treatment of Tuberculosis. — Including
unrecognized cases revealed at autopsy &)% to 73% of patients
with pulmonary tuberculosis recover. The most important
problem in treatment is nutrition, and more damage than
benefit has resulted from drugs, such as creosote, ichthyol, etc.,
which disturb digestion. If a ease is recognized within the
first few weeks and placed in hygienic surroundings with
absolute outdoor life chances of recovery are good. If second,
ary infection has occurred the best conditions seldom afford
much improvement. The patient should always be acquainted
with his ailment for the protection of himself and others. His
mode of life demands unremitting attention. He may do him-
self more damage in a day than can be repaired in a mouth.
Exercise must be strictly regulated according to pulse, tem-
perature and symptoms of fatigue. In Arizona it is not uncom-
mon for relative humidity to road less than 10% as compared
with 60% to 80% in the Eastern and Pacific coast cities. The
temperature averages 15° to 20° higher in summer and 30°
to 40° in winter than in the North Central States, but rela-
tive humidity makes sensible temperature in summer seem 5°
to 10° lower. The tent, 18 x 20 feet, should have a tight floor
and be boarded up 3 feet from the ground, with detachable
sides, and a fly stretched over it for more thorough protection,
and should l>e near a ranch house whore good board may be
obtained, [h.m.]
590 Ambrioan Mbdioiskj
THE WORLD'S LATEST LITERATURE
[OCTOBEK 11, 1902
Boston Medical and SnrKleal Joamal.
October 2, 190t. [Vol. oxlvii, No. 14.]
1. Contagioiis Conjunctivitis. Myles Htandish.
2. The SImpUHcatlon of the Treatment of Lateral Curvature. E. H.
Bkadford.
3. Sensory Hallucination and Its Analogues. ROBEKT MacDouoall.
1.— Contagions Conjunctivitis.— Standish has found that
a large proportion o( the cases of acute catarrhal conjunctivitis
can be aborted by dusting iodoform into the sac tvfo or three
times at intervals of 12 hours. Ophthalmologists who deny
the contagiousness of trachoma must confuse it with follicular
conjunctivitis. The author describes the characteristics of each.
Trachoma formerly constituted 20% to 25% of the cases treated
as out-patients at the Massachusetts Eye and Ear Infirmary.
The number is now reduced to 3.5%. This is due to the exclu-
sion of trachomatous immigrants and also to improvement in
treatment. The latter consists in expression of the granules,
Prince's forceps being preferred, and subsequent antisepsis,
biehlorid 1-500 being vigorously rubbed into the surface. The
eflfect is prompt, the lids opening perceptibly wider in 24 hours.
Corneal complications are rare and in one or two years the dis-
ease is cured without visible cicatrices in either conjunctiva or
cornea. The average duration of the patient's stay in the hos-
pital has been reduced from 64.5 to 29 days and the danger of
infecting others much lessened. Ophthalmia neonatorum is
now treated only in the wards, the child being separated from
its mother. There were only four deaths in 82 admissions in
1901, a small percentage considering the weakly and otherwise
diseased condition of most of these patients. By flooding the
conjunctiva with protargol and thus avoiding the mechanical
injury to the cornea in applications of silver nitrate, the pro-
portion of unsuccessful cases and time required for treatment
have been distinctly reduced. The unaflTected eye is thickly
covered with iodoform, cotton and collodion. By using 20%
solutions of protargol all corneal complications have been
avoided in those having a clear cornea on admission. In 12
patients with infiltrated ulcers treated immediately by the
keratotomy of Saemisch 9 retained a clear cornea over the
pupil. In diphtheric conjunctivitis treatment with antitoxin
has given most gratifying results. Diagnosis must rest on the
clinical picture since laboratory processes are too slow. Blind-
ness and pauperism have been remarkably reduced by
improved treatment in these diseases, [h.m.]
2. — See American Medicine, Vol. Ill, No. 24, p. 1001.
Medical Record.
October 4, 190S. [Vol. 62, No. 14.]
1. The Postoperative History of Fifty Cases of Simple Chronic Glau-
coma. Charles Stedman Bci/L.
2. Medical Reciprocity, or Interstate Exchange of L/lcensures. B. D.
Harison.
3. Epidemic Poliomyelitis, with a Report of Ten Cases. D. H. Mac-
kenzie.
4. Discussion of the Heport on Yellow Fever on the United States Ship
" Plymouth " In 1878 and 1879. W. C. Gokgas.
5. Some Clinical and Operative Phases of Appendicitis. A. H. CoK-
dier.
6. Traumatic Injuries of the Liver. J. L. WiQGiNS.
1. — Postoperative History of Simple Glaucoma. — Bull
gives a review of the preoperative condition in the 50 patients.
After iridectomy there was temporary improvement in central
vision in 7 eyes, permanent in 3, immediate failure in 2, gradual
failure in 58, maintenance of vision existingat time of operation
in 24 from 2 to 18 years. Tension was demonstrated immedi-
ately in 89 eyes, permanently in 18, no effect in 5. The form
field was unchanged in both eyes in one case and in one eye in
two cases ; it was widened in one eye in one case, in 11 the
result was absolute glaucoma ; in the remainder the field was
narrowed in various ways. The best results as to ultimate
vision occurred in the cases in which central vision was the
best and the fields least encroached on at the time of operation,
those operated on as soon as the existence of the disease was
established. Simultaneous operation on both eyes gives the
best resvilts. The curative action of iridectomy stands in direct
proportion to the increase of tension. If performed while the
iris is still mobile, the field but little contracted and the cup-
ping slight, it often arrests the disease, at least for a long time,
and preserves what sight remains, [ii.m.]
a.— Medical Reciprocity.— Harison gives a list of the
States providing for interstate exchange of licensures. He dis-
cusses the weak points in the organization of the National
Confederation of Medical Examining and Licensing Boards
and the methods of the American Medical Association and
other bodies in reference to this matter. If reciprocity is to
become a fact it must be brought about by the cooperation of
the several State medical boards, not through individual mem-
bers. Members of the National Confederation could have done
more good by working for it within their several State boards
than as members of an association that represents no authority.
State boards represent authority to do things and their members
are generally the. authors of medical acts. lie gives a brief
history of the formation of the American Confederation of
Reciprocating Examining and Licensing Medical Boards and
the qualifications required of candidates, including (1) those
who have obtained their certificates througli a State board
examination, and (2) reputable physicians who have registeretl
under a reregistration clause or who have obtained their certifi-
cates on the basis of a listed college diploma or who have
obtained such licenses previous to the adoption of the dividing
line or date between 1 and 2. Any reciprocal legislation
that ignores the older practitioner is unju.st and unconstitu-
tional. This does not mean a letting down of the bars to the
incompetent, since it is at the discretion of the board whether
it shall accept an applicant or not. Three or four State boards
uniting means the raising of the standard of every college
affected, and a State is thus enabled to throw out its inferior
schools, as they would not be recognized by other States. It
may be necessary to begin with a modified reciprocity, owing
to unequal qualifications required in different States, but in due
course this will bring complete reciprocity. To illustrate the
modus operandi of the Confederation's plans the writer appends
the Michigan Board's resolutions relative to the same and the
blank forms of application adopted under qualifications 1
and 2. [h.m.]
3.— Epidemic Poliomyelitis.— In the epidemic reported
there occurred, presumably from the same cause, cases of poli-
omyelitis, neuritis and cerebrospinal meningitis, a circum-
stance lending color to the contention of Auerbach that these
several forms of nervous disease may result from the same
microbic infection. Two of the fatal cases were diagnosed as
Landry's paralysis, which is probably a special form of multi-
ple neuritis, [h.m.]
4.— Yellow Fever on the " Plymoutli."— This instance is
referred to more than any other as a case in which the disease
could not have been perpetuated and transmitted by the mos-
quito. In an analysis of the dates on which ca.ses occurred and
of the reported condition of the ship after disinfection, Gorgas
shows how the disease might have been so transmitted, but
personally he is inclined to question the diagnosis of the two
eases occurring after disinfection and a winter spent in the
north. He appends letters from Finlay and Uuiteras dealing
with the same questions, [h.m.]
5.— Some Clinical and Operative Phases of Appendi-
citis.— Cordier summarizes his paper with tlie atTirmation tliat
in appendicitis operative indications for immediate interference
are often present and well marked. The object of his article is
to call attention to the fact that to expect to find these typical
symptoms and be governed by tlieir presence or absence is a
mistake, and will cause delays and fatal errors in cases in wliich
patients should be saved by early operation. The presence or
absence of leukocytosis is not of sufficient diagnostic value to
be taken seriously as determining for or against operation. In
proper hands no uncomplicated case of appendicitis should end
fatally unless operation is too long deferred. Opening the
abdomen and removal of the diseased appendix is not going to
ward oft' a peritonitis under the liver and left kidney. All
timely operations are easy, free from adhesions, with no fistulas
and no hernia. Early operation with small incision, quick
surgery and closed wound gives the perspective of speedy and
complete convalescence. Delayed operation means a game of
chance in which a human life is at stake, and even if the game
is won it means a tardy recovery, a long incision and subse-
quent danger of hernia, etc. [a. B.C.]
OBER 11, 1902]
THE WORLD'S LATEST LITERATURE
[American Medicine 691
6. — Traumatic Injuries of the liiver. — Wiggins reports
a ease of traumatic injury of the liver, occurring in a workman
of 35, caused by his being accidentally struck in the region of the
liver with a bar of iron. Operation was not considered indi-
cated, so slight were the symptoms, until the fourth day. Fol-
lowing a median Incision the abdominal cavity was found to
contain eight liters of dark blood. The iipper surface of the
liver showed a stellate rupture, the wound being three inches
long. The gallbladder was'distended with four ounces of dark
greenish-brown fluid. The patient's condition was desperate.
On the twelfth day after operation symptoms of shock reap-
peared and there was much trouble with looseness of bowels.
The stools were waxy and contained blood-clots. On the
twenty-second day after operation it was evident that a hema-
toma was forming on the upper surface of the liver. Aspira-
tion withdrew three ounces of bile and blood. A day later
three inches of the seventh and eight ribs were resected, the
Vound cleansed and gauze drainage inserted. The secretion
and discharge of bile was profuse, being estimated at 14 gal-
lons in the 53 days during which the wound remained open.
The patient was discharged cured 132 days after the first opera-
tion, [a. B.C.]
New York Medical Joornal.
September 27, 190S. [Vol. lxxvi. No. 13.]
1. Perforating Ulcei's of the Duodenum. John B. Mukphy and J. M.
Neff.
2. Placenta Prievia ; Its Early Recognition and Treatment. Edwaeb
A. Ay REM.
3. Complications in the Passage of a Gallstone. Neil Macphattkr.
4. Pain as a Symptom in Gynecologic Disease. Samuel M. Bbickneb.
5. The Treatment of Yellow Fever. J. Hobart Egbert.
1. — Perforating Ulcers of the Duodenum. — The authors
review the salient points in the etiology, pathology and diag-
nosis of duodenal ulcers and consider especially the surgical
treatment of perforations. Nineteen cases, including one of
their own, are i-eported in which operations were performed
for this complication. The diagnosis of perforating duodenal
ulcer is difficult, or practically impossible without an explora-
tory laparotomy. In many cases there is no evidence of duo-
denal disease previous to the perforation. The most important
physical sign in addition to those of perforative peritonitis
from perforations in other portions of the intestinal tract is the
flatness of the superficial, piano, percussion note. Leukocy-
tosis in the author's case was pronounced. Collapse is absent
in duodenal perforations, except when associated with severe
hemorrhage. The importance of early operation is emphasized.
The longer the escaping material is in contact with the peri-
toneum, the greater the danger of destruction of its endothelial
covering, and thus the greater the danger of absorption. Of 13
oases in which operation was performed 30 hours after perfora-
tion, all terminated fatally; while in 12 cases in which less than
30 hours had elapsed, 663% terminated in recovery (Weir). The
operation must be complete ; that is, it must bo pursued to an
effective suture of the perforation. Drainage is insufficient, as
of 18 patients treated by drainage alone all died (Lasp6yres).
Suture of the opening can be esisily accomplished, as in 98% of
the perforating ulcers the opening was in the first portion of the
duodenum. When duodenal perforation is suspected the inci-
sion should be through ttte right rectus muscle. It can then be
carried upward to the costal arch or downward to the sym-
physis pubis without dividing any of the transverse muscles.
Drainage or no drainage is a matter of personal election, influ-
enced more or less by the pathologic condition present at the
time of operation. The after treatment is that commonly fol-
lowed after abdominal section, except that the patient is kept
elevated in bed at an angle of 35° for the first 48 hours after
operation in order that all fluids may gravitate into the pelvis.
The prognosis depends: First, on the virulence of the peri-
tonitis produced. Secjond, on the time the material has been
allowed to remain in the peritfjnoarn. Third, upon the pres-
ence or absence of blistering or abrasion of the peritoneum at
the time of operation. [c.A.o.]
2.— Placenta Pra^via.— Ayres discusses the methods used
in the diagnosis and treatment of this condition. The question
of the induction of lalmr requires careful judgment. In cen-
tral or marginal cases the ideal or elective period for delivery is
the eighth month. If the mother can be placed in a hospital
and have a skilful physician and nurse constantly at hand, and
the pregnancy is before the eighth month, and particularly
when a living child is especially desired, it is just and couserva^
tive to delay. Cases of partialis should seldom be put to
induced labor. The Barnes' rubber bag is used by the author
in dilating the cervix. It applies its full force directly In dila-
tion and puts the tissues upon such tension as to check all
bleeding. He believes that better results in regard to the infant
mortality are obtained by the commonly-practised method of
delivery than by applying cesarean section to cases of central
placenta praivia. [c.A.o.]
4. — Pain as a Symptom in Gynecologic Disease. —
Brickner outlines a few of the characteristic forms of pain as
they are narrated to the gynecologist. Pain is of real value to
the physician in those patients complaining of the secondary
symptoms of pelvic disease, such as discharges, a bearing-
down feeling, or of difficulty in urination or defecation. Pain
will be found to be spontaneous in all acute diseases, metritis,
salpingitis, perimetritis, etc., and in some chronic diseases,
especially in the presence of newgrowths. Evoked pain is of
much more value in diagnosis than spontaneous pain. In cases
of perimetritis or in pain due to dilation it will be continuous,
while in appendicular disease, with its curious radiations, it is
usually Intermittent. It may be lancinating, as iu the forma-
tion of a perimetric abscess or in parametritis ; or it may appear
in the form of a colic, as in tubal pregnancy, or in the presence
of a uterine polyp, or of tubal Inflammation. [c.A.o.]
5. — Yellow Fever. — Egbert believes that the chances of
recovery from this disease depend largely upon the early
institution of treatment and the attention and intelligent care
bestowed upon each given case. Even upon reasonable sus-
picion of the inception of yellow fever the peripheral capil-
laries should be relaxed, the portal circulation quickened, and
the emunctories stimulated. To this end the patient should be
wrapped in blankets and hot drinks freely administered.
Following this an active cathartic should be given and the
patient kept warm and moist, but not unduly weakened by long-
continued drenching. During the continuance of the primary
fever the following mixture may be used :
Tinct. aconite rad cc. 0.32 (m. v.)
Spir. setherls nltrost cc. 11.25 (3HJ>
Llquoris amraonil acetatls, q. s. ad cc. 90(3113)
M. Slg.— cc. 7.5 (3IJ ) In water every hour or two.
If within 24 hours the initial fever has not subsided, acetani-
lid and quinln should be given.- For maintaining action of the
emunctories and guarding the stomach, administering night
and morning, one or two pills, each containing salol, gm. .065
(gr. 1); resin of podophyllum, gm. .013 (gr. J); extract of
jaborandi, gm. .0325 (gr. J) ; compound extract of colooynth,
gm. .0f)5 (gr. 1) will be found of service. Every means for
guarding the action of the kidneys must be carefully con-
sidered. Only liquid food is allowed throughout. Nervous
manifestations are to be treated with bromids and cold. In
the severer forms of secondary fever strychnin, nitroglycerin,
digitalis, alcoholic stimulants, free sponging of the entire
surface of the body with cold water, or even wet packing and
douching and methods for stimulating the einiuictories, are of
service, [c.a.c]
Medical News.
October 4, 1902. [Vol. 81, No. 14.]
1. Wandering Kidney, and the Ilesults of Operation. Clarence A.
Mow ILL I a. MS.
2. The Nervous Manifestations of Movable Kidney. .\ 1,, IIbnedict.
8. The Modern Treatment of the More Common Tniunmtio Injuries of
the Eye. Charles . J. Kipp.
4. Suecess in Pracllcc. Charles E. Nammack.
5. Sterility In the Female and Its Curability. .S, L. Kistler.
C. A Caseof Chronic Lymphatic Leukemia. Accompanied by Lympho-
aarcoma, or Myeloma, of the Sternum and Ribs. Charles V.
Ckaiq.
2. — Nervous Manifestations of Movable Kidney.— Bene-
dict reports several series of observations on movable kidney
in both sexes. Of 82 cases seen In private practice all empba-
si7.ed their nervous condition. It is significant that 8.59!) in
men and 38.4% In women should be met in digestive practice.
The nervous manifestations are sometimes not of great
592 American Medicinb
THE WORLD'S LATEST LITERATURE
[October 11, 1902
severity, but include also suicide, insanity, nervous prostra-
tion, etc. [H.M.]
5.— Sterility in the Female and Its Curability.—
Kistler, in discussing sterility in the female, enumerates the
following causes for this condition : 1. Loss of sympathetic
nerve force, the effect of disease, or injury arising from sexual
demands. 2. Imperfect participation of the uterus in the sexual
orgasm, and the consequent lessened respiratory action of the
uterus. 3. Inactive ovaries. 4. Inactive condition of uterine
mucosa. 5. Congenital deficiencies, anomalies of tlie hymen
and malformation of the congenital tract. 6. Arrested develop-
ment of the ovaries and tubes. 7. Excessive acid reaction of
secretion of the vaginal mucous membrane and catarrhal
changes in the mucous membrane of the uterus and tubes.
8. "Vaginismus, neurasthenia, exhaustion, physical decadence,
nymphomania. 9. Amenorrhea, dysmenorrhea, narrow internal
and external os. 10. Flexions, versions. 11. Laceration of the
cervix. 12. Gonorrhea, especially with involvement of the
adnexa. 13. Constitutional diseases and conditions. 14. Neo-
plasms, myomas, malignant growths, hypertrophy. 15. In-
gestion of certain articles of diet and medicines. 16. Obesity.
17. Incompatibility. 18. Higher education. After discussing
various remedies he arrives at the following conclusions :
1. The great majority of cases of sterility are dependent upon
slight causes. 2. The greater number of cases are curable.
3. Many apparently hopeless cases are curable. 4. Length of
time a case has persisted is no bar to treatment, providing
organic change has not obtained which precludes possibility of
cure. 5. The treatment must depend upon the case in hand.
[W.K.]
Philadelphia Medical Journal.
October 4, 19m. [Vol. x, No. 14.]
1. Address in Obstetrics. J. M. Baldy.
2. A Modlfleation of the Barker Method for the Treatment of Fractures
of the Patella, with Illustrations. H. T. Wii^liams.
3. Notes on the Treatment of Colles' P'racture. James Porter Fiske.
4. Fractures of the Extremities : A Report of a Third Series of 500 Con-
secutive Cases, Verified by Radiographs. G. G. Ross and M. I.
Wilbebt.
1. — See American Medicine, Vol. IV, No. 14, p. 530.
2. — A Modification of the Barker Method for the
Treatment of Fractures of the Patella. — Williams
describes his modification as follows : A double ligature is
used ; the needle can be introduced either from above down-
ward under the patella if it is desired that the knot be tied
below, or from below upward if the knot is to be tied above.
The ligature should be threaded double into the eye of the
needle after the needle has appeared at the opposite incision
from which it is introduced. Holding the two ends of the liga-
ture outside of the skin the needle can be withdrawn sufficiently
to bring it with the loop just beyond tlie opposite side of the
fragments of the patella ; without withdrawin,g it from the wound
pass it above the fragments and bring it out through the incis-
ion at its first point of exit. The loop is then unthreaded from
the eye of the needle and the needle withdrawn ; in this manner
the ligature is doubled around the fragments and by not com-
pletely withdrawing the needle before it is passed above the
patella it prevents the skin or subcutaneous tissue from being
caught in the ligature, as is apt to be the case in the Barker
method. After the needle is withdrawn one end of the ligature
Is passed through the loop, and after pulling both ends tightly
they are firmly tied, thus making what is known as the Staf-
fordshire knot. A little manipulation over the seat of fracture
as the ligature is being drawn tight helps materially to arrange
the fragments in their proper position. The ends of the liga-
ture are cut off and the small incisions above and below the
patella are closed with one or two catgut sutures, the parts
antiseptically dressed and the limb placed in anterior and
posterior splints. The advantages of this method are : The
double ligature, the prevention of integument or subcutaneous
tissue being caught between ligature and fragments, and by
using the Staffordshire knot the ligature can be more tightly
drawn and the fragments held more closely together. Two
cases are detailed, [k.c.ii.]
3. — Treatment of Colles' Fracture. — Fiske first discusses
the various questions which arise in regard to the employment
of the x-ray In connection with fracture work. The common
errors in the treatment of Colles' fracture are failure to employ
an anesthetic, to place the hand in the ulnar flexion, to employ
massage, to employ the hot-air box, temperature 250° to 350°
F., especially in patients over 40 years of age, and also the early
attempts to break up adhesions about joint and tendons by
wrenching. Each of these is detailed. Stress is laid upon the
examination of a fracture by the x-ray after the fracture has
been reduced and the dressing applied, in order to ascertain if
perfect coaptation has been oljtaiued. [f.c.h.]
4, — Fractures of the Extremities. — Ross and Wilbert call
especial attention to the following : That the x-ray method of
diagnosis has revealed the comparative frequency of more or
less extensive bone injuries at or near their articulating sur-
faces. This latter class of injuries, while a most important one
from an economic point of view, has not received the attention
that its importance would appear to entitle it to, despite the fact
that the x-rays have been in use for upward of six years as an"
aid to the careful and scientific study of fractures and other
pathologic conditions of the osseous structure. The proper and
careful treatment of apparently slight injuries at or near a joint
is of as much importance as the treatment of more evident
injuries involving the diaphysis of one of the long bones; the
character and location of these joint fractures, the absence of
crepitation or any marked deformity, all tend to render these
injuries obscure and frequently make a positive clinical diag-
nosis impossible ; much valuable data is gained by the routine
examination of fractures with the x-ray; the possible use of
x-ray pictures as a basis of suits for damages for malpractice is
another factor that has deterred many practitioners from using
this means of verifying a diagnosis. This article includes the
report of a third series of 500 cases verified by radiographs.
[f.c.h.]
CLINICAL, MEDICINE
David Riesman A. O. J. Kelly
EDlrOBIAL COMMEIS'T
Germ-Carrylngr Pet Animals. — During the past
year some work done at the Pasteur Institute at Paris
seems to show the dog in the role of a disease distributor
of an eminently undesirable character among children.
In a series of investigations of the nasal discharges
of patients suffering from ozena a bacillus of a specific
type was constantly found to be present. This same
bacillus was found to occur very commonly in the nasal
discharges of dogs. A study of the habits of the
patients suffering from ozena showed that in their early
years, and it is at this time as is well known that
ozena is contracted, they had almost without exception
been overfamiliar in their relation with dogs. The
conclusion suggested is that association with dogs is
responsible for the disease and that the bacillus which
causes scarcely more than a simple catarrhal secretion in
the dog is, when transferred to the more delicate human
tissues, the cause of a very offensive discharge. A
recent report from Ohio is suggestive of disease distribu-
tion in another way, though also»through pet animals.
Despite the most careful enforcement of severe quaran-
tine regulations, scarlet fever has recently found its
way apparently from town to town in the interior of
the State. The health authorities after puzzling over
the problem of conveyance of the disease beyond the
quarantine have at last came to the conclusion that the
distribution is due to pigeons. All other ways apparently
have been excluded and special care has been taken to
give assurance that no other animals of any kind have
served as distributors of the disease. It is well known
that almost anything, a letter, a sheet of paper, may
serve as fomites for scarlet fever. Pigeons pick among
the sweepings of infected houses and so may easily carry
on their feathers the germs of the disease. Just how
the germs would find their way back to human beings is
not so easy to see, but association with other pigeons
whose owners were children iiiight be suggested. The
OCTOBEK 11, ISKK]
THE WOKLD'S LATEST LITEEATUEE
iAmebican Mkdicinb 593
original cases of scarlet fever in the district occurred in a
house having a large dove cote on the roof. These were
the only living things that were allowed to leave the
premises and under the circumstances suspicion naturally
points to them.
There seems every reason to think that nearly always
living things and not such physical agencies as air or
wind are the real carriers of disease. All our modern
discoveries with regard to disease distribution point this
way, and to be suspicious beyond even our present actual
knowledge is probably to take precautions for which
good reasons will be found before very long. Pet
animals certainly deserve to [)e objects of much more
suspicion in this matter than they have been so far.
Children as especially susceptible to contagion should
not be allowed to play as freely as is now often permitted
with animals, and during the existence of epidemics the
possibility of animals becoming the carriers of infectious
material because of iissociation with other animals should
always be borne in mind.
The Preveiitiou aud Treatment of Insanity. —
Increase of insanity is reported everywhere. In Massa-
chusetts there are nearly 11,000 cases, and there has been
an increa-se of 356 patients during the last year. One-
eighth of all patients in public institutions of this State
were sleeping in beds set up in halls, etc., each night and
removed each morning ; this, despite over-fllled dormi-
tories, rooms, etc. From many States comes the same
complaint. As to prevention it would be well if, as
physicians, we should look into our own responsibility
for not a little of the insanity of the world. We are
sometimes too prone to think only of the physical dis-
ease of our patients, and forget or ignore their mental
and moral habits, their drift toward insanity. Do we
not, both profession and public, too much indulge hys-
terical crankery ? There is a time in a large number of
cases when a tendency toward insanity is under the con-
trol of the will, and when by proper methods it may be
arrested and cured. These acute and incipient cases
should be studied and treated with the greatest care. To
this end there should be greater attention given in medi-
cal and postgraduate schools and hospitals toward
adequate clinical instruction. The managers of some
hospitals seem to try to shut practitioners out who
would like to study mental disease. The contrary plan
should be pursued so that practitioners may have oppor-
tunities for the study at least of acute cases, and before
the patient's condition has become hopelessly chronic.
In this fact there is ground for the criticism of the large
central hospitals, the huge "concentration camps"
where thousands of the insane are segregated, away
from friends, local influences, and especially local physi-
cians. If the standard of etticiency of the medical
work in our hospitals for the insane were elevated far
beyond where it is at present the medical profession
would be much more willing to recommend patients who
show the earliest symptoms of alienation to come to these
hospitals at a period when much good may be accom-
plished by treatment. As things now are the evil day
is postponed as far as possible and many patients are
incurable who would not have been in this class if they
had entered an institution at the beginning of their
trouble. There is also a great need of elevating the
standard of nursing in our hospitals for the insane.
What good could be done if cases of mental depression
in their earliest stages could receive the same skilled
nursing that a patient with typhoid fever or pneumonia
receives — massage, hydrotherapy, etc. Everything points
to the wisdom of the psychiatric clinic, and the loc»l
treatment of acute or borderland cases, as necessary for
the goJKl of the patient, the profession, and in the inter-
ests of State economy. This plan is earnestly advocated
by Dr. Peterson, the President of the New York Lunacy
Commission, and others in our country, and is to be
seriously and practically undertaken in Scotland, and
especially in Edinburgh. There is also now under the
consideration of the London County Council the establish-
ment of " reception houses " for patients with incipient
mental disease, where they may be studied, treated,
and a decision reached whether they must be sent to
an asylum or not.
KEVIEW OF LITERATURE
Hemorrhagic Cephalorachidlan Fluid.— G. Milian's
paper ^ opens with a summary of contributions to the knowl-
edge of cephalorachidlan fluid and of intraarachnoidal hemor-
rhages which have been made since Quincke in ISOO practised
puncture of the subarachnoidal space for the first time, and
Fiirbringer in 1895 called attentidu to the sanguineous discolorar
tion of the fluid obtained by lumbar puncture iu two cases of
cerebral hemorrhage. A bibliograpliy of the papers by subse-
quent observers is given, and the development of chromo
diagnosis (Sicard, 1901) and the value and significance of
xanthochromia (Tuffier and Milian, 1902) is traced. This is
followed by a description of the technlc of lumbar puncture and
a discussion of the coloration of normal serum by pigments or
" serochromes," such as hyochrome lutein, etc. It appears that
xanthochromia is not always present in cases of cerebral
hemorrhage, that it may exist normally or be due to cholemia
or to the retention of urinary products, or be due to faulty
technlc in making lumbar puncture. [o.s.D.]
The Production of Hemolytic Amboceptors by Means
of Serum Injection.— If an animal is injected with red cor-
puscles from another species thdre appear iu its blood-serum
new substances — socalled hemolytic amboceptors (immune-
bodies) — which have the power of fixing themselves to the
corpuscles of the species from which the blood used for injec-
tion was derived. Through this fixation they enable another
body (the complement) contained in normal fresh serum to
bring about solution of the red corpuscles (hemolysis). The
fixation of the amboceptors in the red corpuscles is rendered
possible by the presence in the latter of certain chemic groups
known as the receptors. The union between the receptor and
the amboceptor is specific, and is a strictly chemic process, in
which the morphology of the cell is of subordinate importance.
That the cell itself is not essential to the production of ambo-
ceptors is shown by Morgenroth,^ who succeeded in producing
them by injecting blood-serum entirely freed from cells into an
animal of another species. In the experiments rabbits were
injected with goat-serum. The results were analogous to those
produced by the injection of goats' blood, and showed that the
serum contains receptors identical with those found in the red
corpuscles. Such receptors are also present iu the urine.
Whether they are secretory or decomposition products is not
definitely known. Their presence in the urine, however,
would suggest that they belong to the latter group. While,
however, the receptors may be derived from the decomposition
of red corpuscles or other cells, it is also possible that they rep-
resent physiologic groups that have been thrown off in the
metabolism of these cells. Actual experiments with the ambo-
ceptors developed in rabbits by the injection of goat-serum and
blood— that of the ox being used— showed that hemolysis did
not take place, on account of the presence of anticomplements ;
that is, substances which counteract the solving action of the
complement. By proper methods, however, the anticomple-
ments could bo overcome, and hemolysis could be brought
about. [U.B.]
Supernumerary Venous Pulse.— Ascoli,' who has been
paying considerable attention to this subject, reports three
patients each of whom had a venous pulse. This, a purely
venous pulse, was accompanied by a complete cyclic activity of
the heart, and was due neither to cardiac shock, murmur nor
transmitted arterial pulse. This pulse varied but slightly in time
from the arterial pulse although occasionally it became much
more rapid. From his observations Ascoli concludes that each
part of the heart is capable of independent activity. He believes
possibly that the right may be disassociated from the left heart,
■ Gazette hebrtomartalre de M6declno et (leChlrurgle, August 7, 1902.
3 MUnchener iried. W(x;h., ,)uiit> il, lil02.
' Berliner kllnlsche Wochcnschrlft, April 21, 1902.
594 AHEBICAX MKDIOINXJ
THE WORLD'S LATEST LITERATURE
[OCTOBEB 11, 1802
and especially that there is a disassociation of the auricles from
the ventricles. The contractions of the auricles are more fre-
quent than those of the ventricles. Some of the atiricular con-
tractions stopping at the auriculoventricular boundary cause
the socalled " blocked heart." This is au argument which points
toward the auricles as the beginning of the cardiac contractions.
Ascoll considers the venous pulse to be of value iu diagnosing
a "blocked heart." [w.e.e.]
Plague as a Soil Infection.— Farrar ' brings forward some
evidence to support his view that outbreaks of plague are
dependent on infection with a specific microbe of soil contami-
nated with the excreta of rats or other animals that have suf-
fered with the disease, and that except in pneumonic cases infec-
tion is ordinarily the result of direct inoculation from the soil,
the element of personal communication being a factor of rela-
tively small importance. This view is said to be supported by
the " localizing tendency " of plague, by the efficacy of evacu-
ation in cheeking the spread of epidemics, by the fact that
sporadic eases of plague that occur in health camps after evacu-
ation of an infected district occur almost exclusively in persons
that have surreptitiously visited their homes against orders,
and by the inconclusive evidence that the disease is conveyed
by direct inoculation. The terrible susceptibility of the people
of India to plague is believed to lie ia the fact that generally
speaking they are a barefoot race, and being subject to fre-
quent abrasions of the feet, infection is easy, [a.o.j.k.]
Trichesthesia, a peculiar form of tactile sensibility, is de-
scribed under this name by N. Vaschide and P. Rousseau ^ in a
communication made at the mpeting of the Academic des Sci-
ences of Paris, July 28, 1902. It is independent of the general
sensibility of the skin, being confined to the regions possessing
hair, and is affected by physical factors, notably by the hygro-
metric state of the air and by the mental state of the individ-
ual. [C.S.D.]
Congenital Syphilis Simulating Banti's Disease.—
Hockes reports a case in which a female patient, 20 years old,
with no hereditary taint complained for three years of intermit-
tent pain in the splenic area. There was a feeling as if a foreign
body were under the ribs in the left hypochondriac region.
Occasional vomiting occurred, and at times the vomitus con-
tained blood. There was anemia and asthenia, with palpitation
of the heart and difficult breathing. A tumor was found to be
present on the left side, which appeared to be an enlarged
spleen. Over the tumor a distinct vascular murmur was
audible. -The first blood count showed red blood cells, .3,750 000 ■
white blood cells, .3,200, and hemoglobin 7 gm. Stained speci-
mens of blood showed polychromatic degeneration of the red
cells and moderate poikilocytosis. No nucleated red cells were
seen at this time, but they did appear before death. The leuko-
cytosis continued to increase until the count, half an hour
before death, was 58,000. The red cells decreased to 2,640,000, and
the hemoglobin fell from 7 gm. to 2.5 gm. The last specimen
showed the presence of myelocytes. Professor Jacksh con-
sidered the condition very much like Banti's disease, yet he
believes congenital syphilis to be the cause. Autopsy showed
an enlarged spleen, dilated esophageal veins, chronic intersti-
tial hepatitis, general anemia, an old tuberculous area in left lung
and genital hypoplasia. Hocke believed that on account of the
presence of lymphemiaand leukopenia which occur in congeni-
tal lues, that the diagnosis is syphilitic hepatitis with a pericir-
rhotic splenitis. Splenectomy was not considered because of
the rapid course of the condition, [w.k.r.]
A Case of Inoculation Tuberculosis in an Abattoir
Employe Through the Tuberculous Organs of Cattle.—
Krause,* who does not seem to know anything about the numer-
ous American publications upon this subject, reports the fol-
lowing case: The man was an abattoir laborer who had
handled the carcasses of diseased cattle. In the spring of 1899
he sustained an injury to the right thumb, and soon afterward
had pain in the arm and swelling of the glands, with the forma-
tion of small and large ulcers on the arm. A clinical diagnosis
of tuberculosis of the lymph-glands and lymph-vessels was
1 British Medical Journa!, August 16, 1902.
2 La Scmaine mfidleale, August 6, UXfl.
3 Berliner klinische Wochenschrlft. April 21, 1902.
< Muncbener ined. Woch., June 21, 1902.
made, and in an excised piece the presence of the bacilli was
demonstrated. There was no sign of tuberculosis anywhere
else. The case is reported to show the infectivity of bovine
tuberculous material for the human subject, [d.r.]
A. B. Craig
GENERAL SURGERY
Martin B. Tinker
C. A. Orb
EDITORIAL COMMENT
The Treatment of Chronic Ob.scure Diseases of
the Stomach hy Operation — Until quite recently
chronic diseases of the stomach have been treated almost
exclusively by medical means, and in the vast majority
of ca.ses no doubt this will continue for years. There
have always been numerous sufferers from more or less
obscure gastric symptoms, treated under the name of dys-
pepsia or chronic gastritis, or who are said to have motor
insufficiency, hyperacidity, neurasthenia and varioas
other indefinite ailments. Modern scientific methods
have cleared the diagnosis in many of thase cases, and
have somewhat advanced the curative treatment. The
majority of such patients, however, go from one physi-
cian to another for years, hoping to find some one who
will cure them, or at least relieve them. Many of them
become the victims of quacks or use patent medicines,
which, through the alcoholic stimulants and tonics con-
tained, sometimes give temporary relief by stimulating
the stomach. Such cases should, of course, first come to
practitioners who are sufficiently Interested in disea.ses of
the stomach to give test-meals, make careful examina-
tion of the stomach-contents, and try all indicated medi-
cal means. When these have been given a fair trial, if
no considerable improvement is noted, such patients
should be offered the chance of relief from surgical inter-
vention. In many cases it will be possible to determine
with a fair degree of accuracy the condition of the stom-
ach. It certainly should be possible to recognize any
very marked obstruction at the pylorus, dilation, or
active ulceration before operation, and thus suggesting
the appropriate operative treatment. In many other
cases it will be impossible to determine just what pro-
cedure is indicated until the abdomen is opened, yet the
results of many surgeons both in this country and abroad
have shown that such chronic gastric affections can be
dealt with successfully in very many cases, and hy opera-
tions which have a comparatively low mortality. Mayo '
reports 80 gastroenterostomies, among other operative
procedures, with benefit or relief in the cases of obstruc-
tion or ulceration thus treated. Dalziel,* of Glasgow,
has recently reported 30 gastroenterostomies for non-
malignant affections of the stomach with very successful
results. Barker^ also reports satisfactory results from
gastroenterostomy. All of his patients recovered from
the operation, and the change of health is said to
have been most remarkable. All increased rapidly
in weight and their symptoms disappeared entirely.
Similar satisfactory reports have come from the
clinics of Mikulicz, in Germany ; Hartmann, in
France ; Carle and Fantino, in Italy ; and numerous
other wellknown surgeons all over the world. If all
cases of oljscure gastric trouble were operated upon
promptly so soon as suitable medical treatment had been
proved unavailing, many cases of carcinoma of the
stomach would be discovered early enough so Ihat a
radical operation could be undertaken with fair hope of
success. But gastric ulcer and its sequels causes more of
these obscure troubles than any one condition. If the
ulcer can be located, excision may be indicated. If the
trouble arises from adhesions resulting from an ulcer, it
may be only necessary to free the adhesions. In many
other cases chronic inflammation and stenosis of the
pylorus result. If there is much thick;pning about the
1 Boston Medical and Surgical Journal, 1902, Vol. cxlvl, p. 4.51.
2 Liincet, 1902, Vol. ii, p. 50.S.
OCTOBER 11, 1902]
THE WORLD'S LATEST LITERATURE
(AKSRICAN MKDICISK 595
pylorus or very dense adhesions, gastroenterostomy
probably offers the best prospects for relief. If there is
stenosis without such thickening and adhesions, many
surgeons advise pyloroplasty by the Heineke-Mikulicz
operation. This has the advantage over gastroenteros-
tomy that the reflux of bile and intestinal fluids into the
stomach is much less likely to occur, while the normal
function of the pylorus is restored and the operation has
a lower mortality. In certain cases of motor insufHciency
with great dilation of the stomach, gastroplication or
gastrorrhaphy may be indicated ; provided there is no
obstruction at the pylorus. This operation has been per-
formed about 17 times, the reports being almost unani-
mous in its favor. Pylorectomy, or resection of the
stomach, may be indicated in some rare cases. Finney's
new method of pyloroplasty seems to combine the
advantages of pyloroplasty by the old method with
those of gastroenterostomy. It is practically a subpy-
lorlc gastroduodenostomy, the duodenum being folded
directly onto the stomach below the pylorus and lateral
anastomosis being made, but the incision is carried
through the wall of the stomach, through the pylorus,
and into the duodenum, so that the operation is properly
called a form of pyloroplasty. The various forms of
operative procedure would no doubt give better results
if applied in selected cases. The medical profession and
the public have been gradually educated up to a recog-
nition of the importance of surgical intervention in
appendicitis. Such education is needed in many other
directions and in the future many chronic, distressing
afliections of the stomach and dangerous complications
will be avoided by conservative and timely surgical
operations.
REVIEW OF LITERATURE
A New Method of Pyloroplasty.— The operation proposed
by Finney ' is practically a modification of the metliod of lateral
anastomosis suggested by Dr. Ilalsted. It is described as fol-
lows: Divide the adhesions binding the pylorus to the neigh-
boring strictures, also free as thoroughly as possible the pyloric
end of the stomach and first portion of the duodenum. The
success of the operation depends very largely upon the thor-
oughness with which the pylorus, tiie lower end of the stom-
ach, and the upper end of the duodenum are freed. A suture,
to be used as a retractor, is to be taken in the upper wall of the
pylorus, whicli is then retracted upward. A second suture is
then inserted into the anterior wall of the stomach, and a third
into the anterior wall of the duodenum, at equidistant points,
say about 12 em., from the suture just described in the pylorus.
These second sutures mark the lower ends of the gastric and
duodenal incisions respectively. They should be placed as low
as possible in order that the new pylorus may be amply large.
Traction is then made upward on the pyloric suture, and down-
ward in the same plane, on the gastric and duodenal sutures.
This keeps the stomach and duodenal walls ta\it, and allows the
placing of the sutures with greater facility than if the walls
remained lax. The peritoneal surfaces of the duodenum and
the stomach, along its greatest curvature, are then sutured
together, as far posteriorly as possible. For this row Finney
recommends the use of the continuous suture, as it is more
easily and quickly applied, and it can be reinforced after the
stomach and duodenum have been incised. After the posterior
line of sutures has been placed, an anterior row of mattress
sutures is taken, which are not tied but left long. These
.sutures, after they have been placed, are retracted verticjally in
either direction from the middle of the portion included in the
row of sutures. Then after all of the stitches have been placed
and retracted the incision is made in the shape of a horseshoe.
The sutures should be placed far enough apart to give ample
room for the incision. The gastric arm of the incision is made
through the stomach wall Just inside the lowest point of the
line of sutures, and is carried up to and through the pylorus
and around into the duodenum, down to the correspondingf
point on the duodenal side. Hemorrhage is then stopped. It
> Jobn8 Hopkins HoHpitnl Bulletlu, July, IW2.
is well to excise as much as possible of the scar tissue upon
either side of the incision in order to limit as far as possible the
subsequent contraction of the cicatrix. A continuous catgut
suture is now taken through and through all the coats of the
intestine on the posterior side of the incision. This reinforces
the posterior line of sutures, secures better approximation of
the cut edges of the mucous membrane, and prevents the
reunion of the divided intestinal walls. The anterior sutures
are then straightened out and tied, and the operation is com-
plete, unless one wishes to reinforce the mattress sutures with
a few Lembert stitches. This procedure, as is readily seen,
gives the minimum of exposure of infected surface. All the
stitches are placed and the posterior row tied before the bowel
is opened, and it remains open just long enough to control the
hemorrhage. The size of the newly-formed pyloric opening is
limited in this operation only by the mobility of the stomach
and duodenum and the judgment of the operator. Unless the
stomach is very much dilated or has descended to an unusual
extent, the lower limit of the new outlet is at or near the level
of its most dependent portion. When the stomach is much
dilated, there is no contraindication in this operation to the
performance, at the same time, of gastropexy or gastroplica-
tion, if one considers them indicated. [o.s.D.]
Surgery of the Central Nervous System. — Stiles' dis-
cusses those aflfections which occur specially in children — spina
bifida, congenital internal hydrocephalus, microcephalus,
tuberculosis meningitis, paraplegia in Pott's disease. Of his 18
cases of spina bifida 12 were excised (7 cures), 3 injected with
Morton's fluid fall fatal), one by incision and packing (fatal),
one tapped repeatedly (fatal), one patient died before operation.
The association of congenital hydrocephalus with spina bifida
is a contraindication to operation. The latest method of treat-
ing congenital internal hydrocephalus was the establishment of
a drain between the ventricles and the peritonejil cavity by
passing a few strands of horsehair from the subdural space of
the lumbar cord under the erector spina muscle into tlie peri-
toneal cavity just external to the descending colon. The patient
died a few days later of cerebral meningitis, the result of leak-
age and sepsis following a previous tapping of the ventricles.
Stiles is inclined to give this method a further trial, although
he does not hope for any permanent benefit from surgical inter-
ference in that condition. The operative treatment of micro-
cephalus is invariably disappointing. He would not recom-
mend operation in tuberculous meningitis, but would not
refuse to resort to it in exceptional circumstances. [A.a.E.l
The Reestablishnient of Movable Joints After Anky-
losis.— Pupovac^ discusses the various methods which have
been proposed for the reestablishnient of joint function in cases
of confirmed ankylosis. He reports a case of ankylosis of the
elbow-joint following gonorrheal arthritis, which he treated by
the method which has recently been tried experimentally by
Chlumsky, namely, the interposition of a metallic magnesium
plate between the surfaces of the bones after separating the
ankylosed parts. The operation was successful in so far as
bony union was prevented, but the functional result was not so
good as might have been hoped. Passive movements were
begun in the joint 22 days after the operation. At the same
time electricity and massage were applied to the muscles of the
arm and forearm. The passive motion was extremely painful.
While complete motion was not restored to the joint, the
patient was able to resume her occupation and was very well
satisfied Avith the result, [m.ii.t.]
The niagnostic and Therapentic Value of the Modern
Direct ICndoscopIc Method of Observation in Cases of
Foreign Bodies in the Trachea and Ksophajfus.— (iustav
Killian' makes a strong argument for the more extended use
of the endoscope In the detection of foreign bodies in the
trachea and esophagus. He calls attention to the lack of suc-
cess following other procedures and refers to the successful
outcome in a large number of cases handled by this method,
giving bibliographic references. [o.s.D.]
Excision of the Scapula.— Delaup* reports a case of total
1 British .Medical Journal, 8optcmber«, UHK.
■' Wlenor kllnlKclio Woclictis<'lirlfl. I'.Kh!, Vol. xv, p. «3(t.
X IViil-srlie incdiclnlsdic Woi^lu'iischrlft, Scploiiiber 4, 19W.
• I'l-oceedlngs of the Orl. aiis I'arl«h Medical Society, June 1, 1902.
596 4.MEBICAN MEDiCINE]
THE WOELD'S LATEST LITERATURE
I OCTOBER 11, 1902
excision of the scapula in a negro of 20. Conjoined caries and
necrosis were extensive, and long-continued suppuration iiad
caused considerable separation of the periosteum. To prevent
infection of the new joint with tuberculous material the upper
portion of the free margin of the capsular ligament was
anchored to the acromial end of the clavicle, and the remaining
portion of the free margin to the soft parts below the clavicle.
The wound finally healed perfectly ; he possessed all the
voluntary movements of the arm, and could elevate it from the
side about 30°. No trophic changes followed the operation.
[c.A.o.]
Three cases of actinomycosis, ending fatally, are reported
by Rowland.' [a.o.j.k.]
Rupture of the Diaphragm. — Erdt^ describes a case of
traumatic rupture of the diapliragm with incarcerated hernia
of the stomach and intestine into the thoracic cavity. Death
resulted on the fourth day after the accident, [c.s.d.]
Lieftsided Appendicitis. — Damianos' reports a case of
leftslded appendicitis occurring in a boy of 19. At the time of
entrance to the hospital the patient's abdomen was not dis-
tended, the muscles were somewhat rigid, the resistance being
more noticeable in the lower left quadrant. The patient had
■ been sick for five days with typical symptoms of appendicitis.
The tenderness was entirely situated on the left side, however,
and tentative diagnosis of strangulation was made. An incision
was made through the left rectus muscle ; distended reddened
intestiues were encountered on opening the abdominal cavity.
There was an inflammatory focus in the region of greatest ten-
derness, and the tip of the appendix was located in this region,
the appendix extending from here toward the right. After
isolating the appendix, it was ligated, excised, and the stump
buried in the cecum. Gauze drainage was inserted. The
patient did very well for the first six days, was entirely witli-
out fever; then suddenly symptoms of perforative peritonitis
developed and death followed on the second day after. At
autopsy it was found that there had been a small encapsulated
abscess which had ruptured into the general peritoneal cavity.
A second case is reported in which the symptoms of intraperi-
toneal trouble were localized in the left side. The symptoms
referred to the right side were insignificant. At the operation,
however, the appendix was found in its normal position, but
there was an abscess encapsulated between the loops of intes-
tines which had spread to tlie left side. Besides cases of leftr
sided appendicitis like these, others are mentioned in which
there is congenital anomaly in the position of the appendix, but
Damianos does not report any cases of this kind. The literature
of the subject is reviewed, [m.b.t.]
GYNECOLOGY AND OBSTETRICS
WiLMER Krusen Frank C. Hammond
EDITOKIAI. COMMENT
The Vaginal Douche. — There is no doubt that
vaginal douching has rendered immense service in the
treatment of all pelvic disorders, yet very often pliysi-
cians become careless in prescribing a routine method
and neglect to give the patient the explicit directions
necessary to secure the best results. This is particularly
true in regard to ordering the time, quantity and char-
acter of the douche. Perfunctory methods prove disap-
pointing to physician and patient. It is easy, but not
sufficient, to direct a patient to buy a fountain syringe
of certain size and use a specific quantity of some anti-
septic powder or solution. Scanzoni was the first to
teach the important lesson that vaginal injections should
be copious. Later, Emmet did much to systematize its
therapeusis, introducing his method, one of the princi-
ples of which was that no patient can use vaginal injec-
tions efficiently herself, but must have them adminis-
tered by another. This is often impossible, since many
patients cannot impose such a delicate task upon a friend
or servant, or bear the expense of a daily visit by a
' Lancet, September 6, 1902.
- Munchener mediclnlsche Woehenschrift, September 6, 1902.
s wiener bHnlsche Woehenschrift, Vol. xv, p. 862.
trained nurse. The two most important points in
Emmet's teaching were, first, that a copious flow of hot
water varying from 100° F. to 110° F. is most appro-
priate in cases in which congestion exists ; second, that
cold water thus employed is hurtful by causing first vas-
cular contraction and afterward dilation, while hot
water produces first expansion and then contraction.
According to Kellogg hot irrigation is indicated when
the effect desired is to relieve pain, to promote the
absorption of vascular exudate, and to stimulate vascular
activity in cases of salpingitis or socalled cellulitis, also
in chronic metritis, ovaritis and endometritis. Very hot
irrigation is of high value as a means of checking hem-
orrhage. For this purpose the applications must be
made at a.s high a temperature as can be borne, a tem-
perature of 125° F. to 130° F. being desirable. Runge
has demonstrated that the prolonged application of
water at a temperature above 104° F. gives rise to para-
lytic phenomena with venous congestion of the uterus, a
fact to be borne in mind. When merely a cleansing
douche is required, for instance when a pessary is being
worn, a small quantity of tepid water suffices ; but this
will have no effect upon the pelvic circulation. The
selection of the astringent or antiseptic to be employe<l
in the vaginal douche is largely a matter of individual
choice. Mercuric clilorid should be avoided except for
gonorrhea because of its poisonous properties, and creolin
or lysol, which are less toxic, may be substituted. Intra-
uterine injections are rarely required except in puerperal
infection, and are much more dangerous than vaginal,
and we believe should invariably be administered by the
physician himself. The application of concentrated
drugs to the interior of the uterus may produce alarming
collapse and has been discarded by gynecologists unless
the organ has been previously dilated and thorough
drainage assured. Careful vaginal douching may be
practised during pregnancy even at a temperature of
115° F. to 118° F. without the slightest danger of pro-
ducing uterine contractions or any tendency to abortion.
Finally, absolute cleanliness in regard to nozzles,
syringes, etc., is imperative, and with all the possibili-
ties of transferred infection they should never be lent.
REVIEW OF tlTEBATUKE
The Illumination of the Abdominal Cavity as a
Method in Vaginal Celiotomy.— D. v. Ott,' while he con-
siders vaginal celiotomy as a decided advance in surgery,
admits that one great disadvantage of this method is the inabil-
ity to see over the whole field of operation. For this reason this
method is often abandoned for the more dangerous laparotomy.
To obviate this difficulty he recommends the ventroscope, an
electric lamp about the size of a hazelnut, with a reflector and a
contrivance to protect the abdominal cavity from any higher
temperature. The lamp rests upon one side of the speculum
and being concealed from the eyes, illuminates the whole
interior so that the operator, when the patient has been placed
in proper position, can overlook the whole operative field ;
indeed, he can see in most cases the cecum, appendix, trans-
verse colon, stomach, part of the liver, gallbladder and
spleen. The inner surface of the abdominal wall, the round
ligaments and posterior bladder wall are also visible. By a
special arrangement he also illuminates the interior of the
bladder and the rectum. He has used this ventroscope for a
year in a series of varying cases and found it exceed his expec-
tations ; it materially widens tlie sphere of vaginal celiotomy.
[W.K.]
Internal Antepartum Hemorrhage.— Alberto S. de Bus-
tamente ^ reports a rare case of serious retroplacental hemor-
rhage in which by prompt dilation and delivery and the use of
tampons the patient's life, was saved. According to Braxton
Hicks and Goodell the maternal mortality in these cases is oO^fc,
and Goodell is quoted as having observed three instances of
this condition out of 22,498 parturitions, [c.s.d.]
1 Centralblatt fur Gynakologie, August 2, 1902.
s Revista Medlca Cnbana, July 15, 1902.
OCTOBEK 11, 19021
THE WORLD'S LATEST LITERATURE
(Ahbbican Hbdicini, 597
Symphysiotomy, with Drainage by the Vagina of the
Prevesical Space.— Zweifel ' cousiders the causes and pro-
phylaxis of the unfa\orable results which have led to the con-
demnation of symphysiotomy by many of his colleagues.
Every aseptic wound will heal unless some mistake has been
made. After symphysiotomy the reunited cartilage is known
to heal well; and the wound in the skin offers no difBculty in
treatment; therefore the trouble must be with the wound
behind the bones affecting the prevesical space. When the
pubic bones are united this last wound forms a pocket, open
above but closed below, in which blood and wound-secretion
from the vessels and from the corpora cavernosa clitoridis may
accumulate. Zweifel formerly drained this retropubic pocket
by means of a tube passed in from above, and the great amount
of the discharge proved the need of such drainage. The patients
thus treated recovered, but they continued to have some fever
which was unsatisfactory. Subsequently in several cases acci-
dental injuries opened a free communication between the pre-
ve.sical space and the vagina and then the recovery was without
fever and very satisfactory, which led to the conclusion that
drainage from above was not sufiloient. He, therefore, substi-
tuted drainage downward through the vagina in every symphys-
iotomy. To secure this he uses a trocar and cannula 9 mm. in
external diameter with a lumen of 8 mm., and therefore large
enough to receive a drainage tube of medium size. The trocar
is introduced to a spot near the urethra, but free from vessels,
and then pushed through the vaginal wall. He has employed
this method of draining the prevesical space in five cases, in all
of which healing was uninterrupted. He is convinced that
with this method of treating the retropubic wound the patient
is practically free from any risk to life; there is every proba-
bility of uninterrupted recovery, and a better prognosis than
after cesarean section. [w.K.]
Hot Air Therapy in GynecoloKy.— Oscar Polano' de-
scribes the apparatus used in hot air therapy and the method of
application, with the degree of heat. The contemporaneous in-
troduction of a vaginal speculum is advisable only when the
process is limited to the vaginal vault, or an immediate influ-
ence upon the uterus is desired. This hot-air treatment is espe-
cially adapted to hard exudates which have resisted other
therapy, or which are situated deep in the Douglas sac or in the
higher part of the hypogastrium. Kehror advises its use in
adhesive pelvic peritonitis and fresh gonorrheal processes ; he
has also found it especially valuable in cases of infantile geni-
tal organs, as it increased the flow of blood to those organs and
promoted their development. Fever is considered an absolute
contraindication to the use of hot air treatment. [w.K.]
Uterine Rupture In the Early Months of Pregnancy.—
Karl Kober^ states that the majority of cases of perforation of
the uterus in the early months of pregnancy result from a
criminal attempt to interrupt pregnancy by the use of unsuit-
able instruments in unskilful hands. In the case reported,
however, the pregnancy was interrupted because of alarming
heart trouble. The cervix was dilated and contents removed
with a small, sharp curet. Persistent hemorrhage followed,
which all packing failo<l to control, and the removal of the
uterus became necessary. Kober concludes that the cleansing
out of the uterus after abortion should never be attempted
until labor pains have begun. A forcible dilation of the
uterus should be avoided on account of the groat danger of
extensive laceration; and in the first three months dilation
should be by laminaria, later a metreurynter may be used. If
labor pains are present and there is suflicient enlargement of
the OS, any remaining portion of the fetus may bo removed by
a broad, blunt curet. The error in the case reported was the
use of a small, sharp instrument. [w.K.]
Pure Puerperal Staphylococcic Pyemia.— Magnus*
gives a detailed account of a case of puerperal pyemia, associ-
ated with metastatic suppuration in the shoulder-joint, in the
right mamma and in the lower lobe of the right lung. Cultures
made from these localized secretions, as well as from the lochial
discbarges, showed the existence of Staphylococcus aureus
< Brltlgb Oynec. Jour., August, 1902.
'Ccntralblalt f(lr Hyiiakoloifle, Heptemlwr 13, 1902.
» M«ncheniT inedlcliilsclic WoohenHclirlft, Septembers, 1902.
* Uentralblatt fUr Oyriftkologie, AugUHt iS, 1902.
pyogenes alone. The symptoms, however, were just the same
as in streptococcic pyemia. White mice infected with a 24-hour
bouillon culture of the uterine secretion died in 24 hours. Mag-
nus quotes similar cases from Hahn, Hoflf, Pawlowsky and
others. Pawlowsky claims that staphylococcic pyemia affected
the inner organs and soft tissues, while the streptococcic
pyemia was localized in the joints, but in the case reported by
Magnus the staphylococcus became localized in both the joints
and the soft tissues, and he believes that whatever organism is
found in the affected tissues the symptomatology of the sickness
is the same, and the prognosis of the pyemia depends upon the
virulence rather than on the kind of organism present. [w.K.]
Treatment of Placenta Prsevia.— DeLee ' presents a
brief exposition of 30 cases of placenta prsevia. No one method
of treatment was pursued but all measures were applied as
indicated by the conditions present. Only one mother died,
her death being due to sepsis contracted at the hands of mid-
wives and physicians. Ofthe 31 children 15 died. Four were
premature and not viable, five died before the arrival of the
writer. Of the remaining six, one died as the result of the pla-
centa becoming prolapsed before delivery, and in the other
cases death occurred before the writer deemed it safe to extract
as the cervix was not sufficiently dilated. He believes the use
of the colpeurynter in subsequent cases may save an increasing
number of infants and at the same time not increase the danger
to the mother. As the maternal mortality is reduced to zero by
the usual obstetric methods, it does not seem justifiable to do a
cesarean section simply to decrease the infant mortality, since
it is probable that if cesarean section for placenta prasvia were
tried generally in many cases and extirpation of the uterus
would become necessary because of hemorrhage. The experi-
ence gained in the 30 cases reported leads DeLee to conclude :
(1) Placenta prsevia should not cause death, except in rare
instances, when it is due to air embolism or the hemorrhagic
diathesis; (2) placenta prjcvia should not be treated in a half-
hearted manner. If the child is viable, labor should be induced.
When the hemorrhage is moderate one may wait, provided the
patient remains in bed and is in a well-appointed hospital ; (3)
no one method of treatment will meet all cases. The accouoher
should have all known measures at his command ; (4) the
young practitioner should follow Schroeder, who says : " The
ac(-ouclier will have the best results in placenta pnovia who has
the least regard for the child " ; (5) placenta previa is more for-
midable than most laparotomies, and the patient should be in a
well-equipped obstetric operating-room ; (fi) the best way to
induce labor is to puncture the bag of waters and to put a col-
peurynter in the uterus, resting on the placenta and pressing
this against the cervix, and then to put traction on the tube ;
(7) after labor is begun the treatment must be pursued with
vigor, and the doctor must not leave his patient until she is
delivered and all danger is past ; (8) treatment should be
directed to stopping the hemorrhage, emptying the uterus,
and ensuring complete hemosta.sis. The state of the cervix and
the degree of hemorrhage indicates the course to pursue. The
writer warns against loo great traction and too rapid or too
early delivery. The cervix in cases of placenta prsevia is
altered so that it seems more distensible than it really is. In
every case be well prepared for j)Ostpartum hemorrhage. If
the bleeding is more profuse than it should bo, tampon tightly
the whole uterovaginal tract. For this purpose the writer uses
gauze wrung out of .5^ lysol solution. [w.K.] '
Splenic Anemia in Infancy.— Melland '' reports eight cases
of splenic anemia of infants and states that there is a tendency to
hemorrhage in these cases. Much more notable, however, is
the great liability to bronchitis and bronchopneumonia, which
all the patients exhibited without exception. Of those who
died in the hospital it was observed the fatal termination was
either caused or hastened by pulmonary trouble. The progno-
sis, though serious, is not hopeless. Some 50% of the patients
tided over the tendency to bronchitis and bronchopneumonia,
improve greatly under treatment and may finally recover. The
treatment is mainly symptomatic, iron, arsenic and careful
feeding with codll ver-oll, or such a substitute as virol if rickety
symptoms are present. [w.K.]
. ■
> American Oynecotogy, August, 1902.
< British Medical Journal, September 6, 1902.
698 Ahkrican Medicinbi
THE WORLD'S LATEST LITERATOEE
[OCTOBKB 11, 1962
TREATMENT
Solomon Sows Cohkn
H. C. Wood, Jr. L. P. Applbman
EDITOKIAL COMMENT
The Treatment of Tuberculosis by Inhalations
of Antiseptics. — Ever since the discovery of tlie specific
cause of tuberculosis, constant efforts have been made to
treat the disease by attacks on the bacilli. The futility
of giving antiseptics by the mouth with the expectation
that they could reach the lungs through the blood,
becoming evident with advancing knowledge, attempts
have been made to reach the lungs directly through the
trachea. The methods which have been employed to
introduce drugs into the lungs are intratracheal injec-
tions, atomization of watery or oily solutions, and con-
verting the antiseptics into respirable gases. The last
of these has received, recently, considerable attention,
especially among German physicians.
One of the most recent contributions on this method
of treating tuberculosis is a long and interesting paper
by Kudolph,' in which it is claimed that the failure of
the treatment to achieve popularity is owing to defi-
ciencies in apparatus. He points out the faults of the
various appliances used for the purpose, including the
steam atomizer of Siegle, the simple but useful device
on the principle of the washbottle, and the complicated
arrangement of Jahr, ending with a description of a
new model which excels them all, at least in complexity.
Reference to the cut will save the necessity of a lengthy
description of this apparatus, but we would point out
that it is fundamentally a series of washbottles, con-
nected with long, spiral tubes, the advantage of which
is not apparent, nor is it mentioned in the text. The
only real difference in Rudolph's apparatus from the
common bottle-inhaler is that the air is forced through
by a rubber bulb instead of being drawn through by
inspiratory force, and as complex as it is, we cannot see
why the same results could not be procured by simply
attaching a double bulb to the bottle-inhaler.
Nevertheless the inventor has demonstrated that the
air that comes out through his apparatus has distinct
germicidal power if the bottles are filled with a volatile
antiseptic, as guaiacol or acetic acid. He has also shown,
chemically, that the vapors will pass into all portions of
the lung of an animal breathing this air. He offers,
however, no proof of the really essential question as to
whether the vapors are not so diluted by the residual
air of the lungs as to lose their germicidal properties.
In fact, his own statements tend to show that they do
lose these powers, for he afiirms that his patients con-
tinued to expectorate tubercle bacilli even after a pro-
longed course of treatment. It is our belief that none
of the present known disinfectants can be introduced
into the lungs in sufficient quantity to be active without
exercising a deleterious effect on the delicate pulmonary
structure or causing a general intoxication ; and we must
further confess to grave doubts that any such antiseptic
will ever be discovered, because all such bactericides are
of necessity protoplasmic poisons and bound to affect the
protoplasm of the patient as well as of the bacterium.
Any improvement which follows the inhalation treat-
ment of tuberculosis is more justly attributable to the
effect of the drug on the mucous membranes than on the
tubercle bacilli, [ii.c.w.]
REVIEW OF L,ITEKATUKB
The Dangers of Internal Antisepsis.— Robin ^ recalls that
in 1892 he published an observation on a syphilitic woman who,
after active treatment by mercury bichlorid for 36 days, was
attacked with infectious bronchopneumonia of extreme sever-
ity, and of which she died in less than four days. This case
1 Therapcutisohe Monatshefte, August, 1902, xvi, 396.
sBuUetln G6n6ral de Th6rapeutlque, Vol. cxlill, No. 16, 1902, p. 610.
demonstrated that the internal administration of one of the
most powerful antiseptics was unable to prevent microbic
infection, to checli the multiplication of microorganisms, or to
decrease their virulence. He cites another instance confirming
this conclusion. A woman attacked with secondary syphilis,
without any other pathologic history, was submitted to very
active mercurial treatment. In 15 days she took i grain of
mercuric benzoate, 6 grains of mercury bichlorid in pills and
44 grains of metallic mercury in pills, making nearly 11 grains
of mercury in various forms. While under this treatment she
developed typhoid fever. The continuance of the treatment
hindered neither the infection nor the multiplication of the
bacillus. On the contrary, the patient from the first had a
grave form of the disease. Cold baths produced no effect. On
the nineteenth day gangrenous phlyctena and phlegmasia alba
dolens appeared, and the patient died on the twenty first day
without any medication exerting the least influence on the
progress of the disease. Prom this case and the observation of
1892 the author draws the following conclusions : 1. Impregna-
tion of the organism with mercurial preparations does not
hinder infection by the bacillus of Eberth and does not diminish
its virulence. 2. Petit and Serres have endeavored to abort
typhoid fever by administering from 1.5 to 20 grains of mercuric
sulfid, together with inunctions of mercurial ointment. Salet
and Bourchard have recommended calomel. B. de Simone
declares that the latter preparation lowers the temperature after
the tenth day of the disease, that it acts on the intestinal ulcera-
tions, and that it protects against the pathogenic organisms of
the intestine. Kalb proposes mercurial inunctions and states
that in 80 cases out of 100 it shortens the duration of the febrile
period. Others have given corrosive sublimate in doses of i
grain daily. However, observation demonstrates that the
employment of mercurial preparations in the treatment of
typhoid fever is able to realize neither intestinal nor internal
antisepsis. Calomel may be employed occasionally and excep-
tionally as a purgative, as a stimulant to biliary secretion, or as
a diuretic when the indication for such action presents itself;
but the mercurial preparations, whatever they may be, should
not be made the basis of systemic treatment, since, Ijesides their
negative ihtraorganic antiseptic effects, they have the great
objection of preventing organic oxidation, when we seek in the
treatment of typhoid fever to stimulate the oxidizing powers of
the organism, which furnish one of the best means of defense
against autointoxication. 3. Consequently, outside of the re-
stricted and always transitory indications which appear, mer-
curial preparations are of no value in typhoid fever and may
rather be thought injurious, since the mercurial impregnation
of the organism appears to have been one of the causes of the
aggravation of the disease, [i^.k.a.]
Carbolic Acid as a Synergist to Rontgenism In the
Cure of Lupus.— Walker ' has found that in cases of lupus, pre-
viously painting the part with pure carbolic acid increases the
curative action of the x-ray. As the result of the combined
effect of the x-ray and carbolic acid there is widespread ulcer-
ation, leaving behind more healthy granulations, which usually
heal well under soothing treatment. In most cases a single
application is enough, [h.c.w.]
Actionof Continuous Currents on Sclerotic and Cica-
tricial Tissue.— Stephane Leduc ^ supplements previous con-
tributions (Action therapeutique des courants continus ;
Gazette m^dicale de Nantes, 1893, Traitement electrique d'une
arthrite Cberthienne ; Arch, d'electriciti?. medicale) with a
report of the success with which he has since employed the con-
tinuous electric current after traumatisms and inflammations
for preventing the formation of sclerous and cicatricial tissue
and the restoration of a normal condition, [c.s.d.]
Immunization Against the Pneumococcus by Stained
Cultures.— Sergent," in studying the action on animals of
microbes stained with various coloring materials, found that
pneumococci stained with crystal violet still retain their viru-
lence. When injected beneath the skin of the rabbit the animal
died very quickly, but wheu injected into the veins or into
the peritoneum no harm followed ; however, the animals thus
1 Scottish Med. and Surg. Journ., May, 1902, p. 416.
! tiazette M6dicale de Paris, August Hi, 191)2.
U^a Mfidecine Moderne, Vol. .\lii, No. i, m.2, p. 23.
OCTOBER 11, 19(K]
THE WORLD'S LATEST LITERATURE
iAkkkican medicine 599
treated acquired even a greater resistance to inoculations of
very virulent pneumococci tlian animals immunized by ordina-
rily prepared cultures, [l.f.a.]
Value of Ipecacuanha in Dysentery. — WoodhuU' con-
tends that ipecacuanha is a specific in dysentery as quinin is in
malaria. The reasons that it has not been more generally
employed are : First, on account of the vomiting produced ;
second, a great deal of what is sold as ipecacuanha is not the
true drug; third, improper methods of administration have
only increased the patient's distress without affecting the dis-
ease. The method advised by Woodhull is as follows: The
stomach must be emptied, the patient recumbent; about 20
minutes before giving the ipecacuanha the epigastrium is
painted with tincture of iodin, or a mild sinapism is applied.
Ten to 15 minims of laudanum are given, followed in 10 min-
utes by 15 to 30 grains of ipecacuanha in pill or paste. No food
nor fluid should be taken for at least four hours afterward, the
patient retaining rigidly the recumbent position. The dose of
ipecacuanha may be increased in severe cases, as in those con"
ditions there seems to be a tolerance for it. As much as 60
grains may be given to an adult. The results of this treatment
are, first, relief of pain; second, subsidence of the fever; third,
cessation of the bloody discharges. When brown copious
stools are produced the remedy should be withdrawn, or the
dose made smaller, [h.c.w.]
Cutaneous Treatment of Obesity. — Kisch ' has employed
inunctions of iodin and the iodids over the loins and the abdom-
inal walls in the hope of obtaining a more favorable action by
this direct application to the skin than by the digestive appa-
ratus and the circulation. For application over the loins he
uses the following:
lodid 4.5 grains
Potassium iodid 45 grains
Vaselin 1 ounce
This may be replaced by the following, which has a disa-
greeable odor :
Spirit of peppermint 2 drops
Iodoform 15 grains
Vaselin 2J drams
After several minutes' friction with a sutficient quantity of
ointment, and while the skin is still covered with the ointment,
a cloth saturated with the following solution is placed over the
part :
Alum 14 grains
Lead acetate 75 grains
Distilled water .'IJ ounces
This is covered by gutta-percha, which is held in place by a
bandage. When the abdomen is especially fat, Kisch recom-
mends frictions over the region with the following alcoholic
solution ;
Potassium iodid 2J drams
Vinegar of squill 65 ounces
[I..P.A.]
Treatment of Acute Rheumatism with Hot Air. —
Skinner' recommends in acute rheumatism the use of hot
air. If more than one Joint is affected simultaneous treat-
ment should be made, if possible, with different appara-
tus. The treatment should be applied twice a day at a
temperature of 400° F., 15 or 20 minutes. Rest, not massage,
is Indicateti. In the choice of salicylates he gives pref-
erence to aspirin, which he gives in doses of 4 to 5 grams
(about 1 dram) daily. Next to this he has found salicin of
value. Methyl-salicylate is often applied witli great advantage
l(X»lly4 gau/.e is soaked in 5 to 10 grams of the remedy,
wrappetl around the part and covered witli guttapercha dress
ing. It exercises a local influence and is absorbed through the
skin. Skinner asserts there is no logical indication for alkalies
and he has never seen any good results from them. Electricity
is sometimes of value to control the pain. Regarding diet, he
makes the astonishing assertion that if the patient has a good
digestion beefsteak and anything may be given to him without
fear. [The usoof hot air in acute inflammations of the joints is
capable of producing harmful or oven dangerous results.
I Thurapeutlc Gazvlte, I(t02, Viil. xxvl. p. '2U.
' lyA MCdeclnc Modcine, Vol. xlll, No. «, IIKW, p. IM.
» Journal of .Advamed TlierapeiitlcK, April, 19/2, Vol. xx, p. 288.
Apparently the increased circulation in the joint resulting from
the heat is capable of carrying the poison to other portions of
the body, and changing what may have been chiefly a local
affection into a generalized one. H.c.w.]
Calcium Eosolate.— The Bulletin Oiniral de Th6rapeu-
tique. Vol. cxliii. No. 9, 1902, p. 348, states that calcium eosolate
contains nearly 25% of creasote. It is described as a grayish-
white powder of acid taste, having a strong odor resembling
ether. It is soluble in 8 to 10 parts of cold water and in about 7
parts of hot water ; it is very soluble in alcohol, hydrochloric
acid, citric acid and other organic acids. It is employed exclu-
sively in the treatment of diabetes in the dose of from 4 to 9
grains 3 or 4 times a day. [l.f.a.]
Ulmarene.— Bardet and Chevalier • recently reported to the
Sociotij de ThOrapeutique of Paris the results of their investi-
gation of ulmarene, a salicylic ether discovered by Bourcet. It
is a mixture of definite quantities of salicylic ethers and ali-
phatic alcohols, and occurs as a rose-yellow refractive liquid
of a fever odor, and contains about 7b% of salicylic acid. It is
soluble in alcohol, ether and chloroform, but insoluble in water.
Its administration by the stomach is free from the irritating
effects of salicylic acid, and the salicylates may be taken in
doses of five grams without inconvenience. They predict its
extensive use in rheumatic affections, [c.s.d.]
Treatment of Ijeprosy.— L. Raynaud ^ gives the results of
the administration of sodium cacodylat© in six cases of leprosy.
The drug was given hypodermically, beginning with a dose of
one grain daily for one or two weeks, then increasing to two
grains daily. In four cases he obtained rapid cicatrization of
the open lesions, and even of the phagedenic ulcers. In all
cases the general condition improved and tlie weight increased.
Raynaud does not consider sodium cacodylate a specific for
leprosy, but believes it is of great value. The oils and opiates,
which have given excellent results, are not always tolerated by
the gastric or rectal mucous membrane ; under these circum-
stances he recommends sodium cacodylate. [l.f.a.]
Diphtheria Antitoxin.— Cook' draws some lessons regard-
ing the use of antitoxin from a series of 100 cases, in which he
was obliged to administer more than two doses in but three,
with only one death in the whole series. A serum of high con-
centration is preferable to one of low potency. In inquiring
into the means by which antitoxin does good, he states that
immunization in an animal by means of the serum from an ani-
mal of the same species lasts longer than when the antitoxin is
derived from another animal. The immunity artificially
acquired with the antitoxin is transmitted from the mother to
the offspring, although the antitoxin value of the offspring is
very much less than that of the mother. He believes that the
most probable theory of its mode of action is that it acts as a
stimulant to the protective cells rather than as an antidote. The
claim that the sequels of diphtheria are more frequent after the
antitoxin treatment he says Is due to the fact that the severe
oases in which paralysis would be likely to occur frequently
proved fatal, whereas now the antitoxin saves the life, but
does not prevent the oncoming of neuritis. If the antitoxin is
given early enough, he considers that it has a tendency to pre-
vent the occurrence of paralysis. The diphtheria neuritis, he
believes, is secondary to a central myelitis, involving the cells
of the anterior cornua. [h.c.w.]
The Value of an Intermittent Millc: Diet.— f'amescasse*
states that certain women at the menopause show symptoms of
alimentary toxemia— anorexia, vertigo, insomnia, headache,
palpitation, etc.— associated with arteriosclerosis. In these
cases he directs that the patient take her ordinary diet the first
five days of the week, but for the last two days she must sub-
sist on two quarts of milk, with some potatoes and a little
bread. Laxatives should be given if necessary. By this
means the normal equilibrium of the system is quickly reestab
lished. Excellent results have also followed the use of this diet
by patients of sedentary habits who eat to excess, by patients
subject to migraine, and in the exaggerated fatigue following
long journeys, etc. [i,.f.a.]
' La Mfidcclne Modernc, August 13, 19W.
5 iM Viols TlK^nipcutiquc, Vol. Ill, No. 5, 1902, p. 55.
» Pediatrics, Ma.v, lIKh!, 1,'i, :Mt4.
* Bulletin (KfiiOml de ThCrapcutlque, Vol. cxlUl, No. 5, 10C2, p. 181.
600 Amkbican MbdiciniS
THE PUBLIC SERVICE
[OCTOBEB 11, 1962
THE PUBLIC SERVICE
Health Reports.— The following cases of smallpox, yellow
ftver, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service durine
the week ended October 4, 1902: .^
8mai,i,pox— United Statks.
„ „ , „ 1 „ Cases Deaths
Sussex County Sept. 1-25 7
Freeport Sept. 20-27 a
Indianapolis Sept. 20-27 2
South Bend Sept. 20-k7, 2
Wichita Sept. 20-27 3
Chels-ea Sept. 20-27.. ' 1
Grand Ilaplds Sept 13-20 1
Butte Sept. 20-2S 1
Nashua Sept. 20-27 13 1
Newark Sept. 20-27 3
New York Sept. 20-27 6 1
Cleveland Sept. 20-27 79 17
Erie Sept. 20-2T ' 1
McKeesport Sept. 20-27 .... 14 2
Pittsburg Sept. 20-27 7 7
Charleston Sept. 20-27.... 1
Green Bay Sept. 20-28 1
Smallpox— FoBKiGN.
•;■■■••■ ■"• ^"8- 31-Sept. 15 . 226 11
Amherstburg Sept. 20-27*. 1
Dundee Sept. 13-20 1
Liverpool Sept. 13-20 3
London Sept. 6-13 7 2
Sunderland Sept. 6-13. 4
Naples Sept. 6-13 '." \
Palermo Sept. 6-13 10 1
Mexico Sept. 14-21 1
St. Petersburg Aug. 30-Sept. 13.. 18 9
Singapore Aug. 2-16 1 1
Ybllow Fbvkr.
Panama Sept. 15-22 3 1
Havana Sept. 19 1
removed from S. S. Havana, from Mexican ports.
Coatzacoalcos Sept. 13-20. ... i 1
Delaware :
Illinois:
Indiana:
Kansas :
MassachiJsettSjf
Michigan ;
Montana ;
New Hampshire:
New Jersey :
New York :
Ohio:
Pennsylvania :
South Carolina :
Wisconsin :
Barbados :
Canada :
Great Britain :
Italy:
Mexico:
Russia :
Straits Settlements
Colombia :
Cuba:
Mexico :
Mexico Sept. U-21.!
Tampico Sept. 26 ,
2
China :
India:
Japan :
Java :
Straits Settlements
California :
Cholera— Foreign.
Hongkong Aug. 9-16
Calcutta Aug. 2:^-30
Osaka and Hlogo....Aug. 30-Sept. 6...
Batjivia Aug. 16-2:5
Singapore Aug. 2-16
Plague— United States.
San Francisco Sept. 11-16 2
Plague— Foreign.
21
19
11
17
18
;«
;w
00
55
China:
India :
Hongkong Aug. 9-16 ...
Calcutta Aug. 2:5-30..
12
12
24
Changes In the Medical Corps of the U. 8. Armv for
the week ended October 4, 1902 : '
^""rom aboi^ Octob'erT"*""^'^ surgeon, Is granted leave forone month
■''''^»H^JiHH'*^"^''"i"l*' Colonel Henry S., deputy surgeon-general, is
Inrt wIm n?,.'?».'5,",'^' S" "K?^ .surgeon, department of tbe^Mis^uri,
and will proceed to New York City and assume charge of the raedi-
M Rr^£ J ^S"^","".""''' city during the ab.sence of Colonel Justus
Phtt ; rp« M = ,^l 1 '\"^ surgeon, on leave granted him September 16.
thPdivi^S,^/,'^"''J'-i''"'^K™°' "• relieved from further duty in
Pp! i^H ^y^ Phiiippmes, and will proceed to San Francisco,
for orders '''' t<^'<'g™P»i '« the adjutantgeneral of the Army
^"pvnf^^i'^S' "f;"e,nant Thomas L., assistant surgeon, will upon the
p^^l • " "^^ ^'^'^ '*'''''■'' granted bim September 11, proceed to San
fal?.^ ^"S' • •' ."""^ report for assignment to duty at the U. S
General Hospital at that place.
is^^'nfffr1:?H^:l■;.?°^P"^' ^f^?'^^' hospital corps. Fort McDowell,
IS transferred to the camp at Monterey, Cal., for duty.
1sSha.1e°d Se1Smber'l7"S"' '^"'""^ "^"'"""'^'' "'^ resignation,
'''' daysCm'alfom bcH™'2.'"'"^^"' '' ^^""^^^ "^^* '°'' '*«°ty-two
^'^If^^h.i^""'*' Lieutenant Frederick F., assistant surgeon. Is
TH.?:S^«h,5 ^^'\ '^°'' ^^"^^'^ months, to take effect about October 1.
tendS^one month'"''"""' '*"''S^'"^"' ^^^""^ granted August 16 is ex-
'^^^m^Vfil'^tS'^'i ^,'e'itenant Wilfred, assistant surgeon, is relieved
J^^»H t^ S*'''*^''"'^.'" *'"^ division of the Philippines, and will pro-
Senprn 1 ^.f"?), '■«°"'*""i' ^'al-. and report by telegraph to the adj utaut-
general ot the Army for orders.
fnrt h'i^''l;.?".S^ Alfred C, assistant surgeon-general, is relieved from
nrt^n^,.^,?'^''?", B Washington, D c, to take etrect upon the
?niTr,„li^ *i*''^.^?'' present session of the Army medical cxamin-
inm^^?"** '^"' proceed to San Francisco, Cal., and report to the
t.? M^„i I 'S^,^*'"'^,r'*'' department of California, for transportation
riirfriJ^i V,;.^-^.^.'!?''''hewill report to the commanding general,
T. ^,Xi^" °'^'^'''' ^'"'"PP'oes- fo>' assignment to duty.
it^vort fi^"^^"'.'"' Colonel Blair D., deputy surgeon-general, is re-
Arl „ H™ ""'y **' ^°''t knelling and will proceed tollot Springs,
vTi.ol' ?..'^'*?"'T'®<'°nimand of the Armyand Navy General Hos-
\i»?L -?;„ ' V\^^<i, relieving Major George H. Torney, surgeon,
i^^™ rorney will proceed to San Francisco, Cal., and report to the
..^ M? ,? ?,S^'""^,''al. department of California, for transportation
M>Manlla P I. wljerehe will report to the commanding general,
division of the Philippines, for assignment to duty
Marrow. First Lieutenant Charles E., assistant surgeon, will pro-
ceed to Fort Riley and report to Major-General John C Bates for
temporary duty in connection with the military maneuvers at that
post, and on the completion of this duty will return to his proper
station at Fort Sheridan.
Lipfitt, Captain William F., assistant surgeon, is relieved from duty
at Fort .McHenry and will proceed to Fort Monroe for duty, to relieve
Major Frank R. Keefer, surgeon. Major Keeler will proceed to
fort Meade for duty, to relieve Lieutenant Colonel Edward T.
Comegys, deputy surgeon-general, liieutenanl Colonel Comegys
will proceed to Fort Bayard and assume command of the U. s.
General Hospital at that place, to relieve Major Daniel M, Appel,
surgeon. Major Appel will proceed to San Francisco, Cal., and
report U) the commanding general, department of California, for
transportation to Manila, P. I., where he will report to the com-
manding general, division of the Pliillpplnes, for assignment to
duty. I
Ct-ARKE, Captain Joseph T., assistant surgeon. Is relieved from duty as
attending surgeon and examiner of recruits in Philadelphi.i, Pa., to
take etrect upon the completion of tlie duly assigned him in orders
of September 22, 1902, and will proceed to Fort Ethan Allen for duty,
to relieve Major Marlborough C. Wyeth, surgeon. Major Wyeth
will proceed to Fort Wadsworth for duty.
Smith, Captain Allen M., assistant surgeon. Is relieved from duty as
attending surgeon and examiner of recruits in Baltimore, Md.. to
take effect upon the completion of the duty a.ssigned him In orders
of September 22, 1!X)2, and will proceed to Fort Douglas for duty.
Ireland, Captain Mekritte W., assistant surgeon, is relieved from
duty as attending surgeon and examiner of recruits in St. Louis,
Mo., and will repair to Washington, D. C, and report to the sur-
geon-general of the Army for duty in his office.
Usher, First Lieutenant Francis M. C , assistant surgeon, now atSan
Francisco, Cal., is relieved from further duty In the division of the
Philippines and as transport surgeon on the U. .S. transport Law-
ton, and will report to the commanding general, department of
California, for assignment to duty in that department.
Bobbins, First Lieutenant Chandler P., assistant surgeon, now In
San Francisco, Cal., will proceed to Fort Terry for duty, to relieve
Contract Surgeon Ernest W. Fowler. Contract Surgeon Fowler
will proceed to Fort Mansfleld for duty.
Brewer, Major Isaac W., surgeon. Is honorably discharged, to take
effect -November 7, his services being no longer required. He will
proceed to his home.
Shimer, First Lieutenant Ira A , assistant surgeon, is relieved from
temporary duty at Fort Michie to take effect upon the departure of
the One Hundred Twenty-fifth Company, Coast Artillery, and will
return to his proper station. Fort Niagara.
Shepherd, John M., contract surgeon, is relieved from further duty
at Fort Myer and will return to his station. Fort Hamilton.
Gr. gory, William G., contract surgeon, will proceed to the Presidio
and report at the Army General Hospital, for duty at that hospital.
Smith, Harry C. contract surgeon, will proceed to his home, Deni-
son, Tex., for annulment of contract.
Long, S. M., contract surgeon, leave granted is extended fifteen days.
Changes In the Medical Corps of the U. 8. Navy for
the week ended October 4. 1902 :
McCuLLOUGH, F. E., pas.sed assistant surgeon, detached from the
naval hospital. Mare Island, Cal,, and ordered to the Alert— Sep-
tember 26.
Pbyor, J. C, passed assistant surgeon, detached from the Massachu-
setts and ordered to the Bancroft— September 26.
Leys .(. F., passed assistant surgeon, detached from the naval hos-
pital, Newport, R. I., and ordered to the Supply— .September 29.
Cook, F. C, passed assistant surgeon, detached from the Supply and
ordered to the naval hospital, Newport, R. I .—September 29.
Armstrong, E. V., passed assistant surgeon, placed on the retired list
September -27, 1902— September 29.
The following-named olHcers are detached from the Solace and ordered
home to wait orders: Passed Assistant Surgeon A. R. Alfred,
Passed Assistant Surgeon C. P. Bagg, Passed Assistant .Surgeon
M.K.Johnson and Assistant Surgeon H. E. (Jdeil-September k9.
Law, H. L., surgeon, retired, ordered to the naval recruiting rendez-
vous, Boston, Mass, — October 2.
Holloway', J. H., acting assistant surgeon, appointed assistant sur-
geon September 27, 1902, with rank of lieutenant (Junior grade)—
October 2.
Changes iu the Public Health and Marine-Hospital
Service for the week ended October 2, 1902:
Stoner, G. W., surgeon, granted leave of absence for 16 days from Sep-
tember 1.5— September 11, 1902. Bureau letter of September 11, 1902,
granting Surgeon Stoner leave of absence for 16 days, amended so
that said leave shall be for 14 days— October 2, 1902.
Brooks, S. D., surgeon, leave of aljsenee for 15 days from September
27, 1902, granted Surgeon Brooks by Bureau letter of Septeintier 20,
1902, amended so that It shall commence September 29, 1902— Sep-
tember 27, 1902.
Cobb, J. O., surgeon, granted leave of absence for 2 months from Octo-
ber 8, 1902, on account of sickness — .September 24, 1902.
Hastings, Hill, passed assistant surgeon, granted extension of leave
of absence for 2 months and 26 days from October 3— September 30,
1902.
Heiser, V. G., assistant surgeon, relieved from duty as Immigrant
inspector in Canada and directed to visit different ports between
the United States and Canada to Institute a system whereby uni-
formity in medical Inspection of alien immigrants bound for ports
in the United .States can be assured— September 27, 1902.
Warren, B. S., assistant surgeon, granted leave of absence for 11 days
from September 29— September Ti. 1902.
Duffy, Francis, acting assistant surgeon, leave of absence for 6 days
f ranted Acting Assistant Surgeon Duffy by Bureau letter of August
I revoked— September 27, 1902.
Scott, E. B , senior pharmacist, department letter granting Pliarma-
cist .Scott leave of absence for 19 days from September 6 amended
so that said leave shall date from September l(f-September 25, 1902.
ResUjnation.
Passed Assistant Surgeon Hill Hastings resigned to take eflbct
December 29, 1902.
American Medicine .
QEORQE M. GOULD, Editor
G. C. C. HOWARD, Managing Editor
CHARLES 8. DOLLEY
MARTIN B. TINKER, AiiitUmt Editort
Clinical Medicine
DAVID RiESMAN
A. O. J. Kelly
H. H. CnsHiNO
Helen Murphy
Oeneral Surgery
Maktin B. Tinker
A. B. Craig
Charles A. Okr
Orthopedic Surgery
H. Augustus Wilson
COLLABORATORS
Obstetrio and Gynecology
WiLMER Krusen
Frank C. Hakmond
Nervoxts and Mental Diseases
J. K. Mitchell
F. Savaby Pbarck
jyeatmeni
Solomon Solis Cohen
H. C. Wood, Jr.
L. F. Applbman '■
Dermatology
M. B. Hartzbll
Laryngology, Bte.
D. Bbaden Kyls
Ophthalmology
Walter L. Pylb
Pathology
R. M. Pkarce
PUBUBHSD WlXKLT AT 1331 WaLITUT STSIST, PhILADKLPBIA, BY THI AhBUCAM.MkdiCINI PuBLWHIIIA ComTAWT
Vol. IV, No. 16.
OCTOBER 18, 1902.
$5.00 Yeaely.
Infant Mortality. — According to our valued con-
iemporary, the Boston Medical and Surgical JoumcU, the
deaths of infants under one year of age per 1,000 births
were as follows :
Countries.
1874-1S83.
1881-1898.
Countries.
1874-1883.
1884-18ie
England and Wales
143.9
119.8
96.8
140.6
103.7
128.0
2«5.4
250.8
146.4
12^.3
96.4
186.1
96.3
107.1
268.6
217.8
Switzerland
186.4
215.7
298.3
201.3
153.1
165.4
191.7
207.9
159.3
•207.5
Bavaria
Holland
Belgium
279.0
Denmark „
174.5
162.9
168.3
Ru8.sla
Spain
Austria .
Italy
190.4
The significance of this table would have been more
striking if it had been arranged in the order of the
countries exhibiting the greatest care of the lives of
children in 1884-1893. Norway, Ireland, and Sweden
would thus precede all others, with Scotland, Denmark,
and England next. The greatest sinners would be
Prii.ssia, Austria, Ru.ssia, and Bavaria. It is rather odd
that the order seems to run parallel with that of the
progress of democracy. There is now appearing a series
of remarkable articles by H. G. Wells based upon the
text that the birth and care ^f the child is the great
object of civilization, and that personal and national
morality and success is to be measured in the future by
this standard. Is there any doubt of it in the mind of
the vital statistician and physician ?
Mendall's law is an illustration of the strange
neglect of a disttovery by the official scientists when it is
made by a layman and not published in the regular way.
In this instance the " layman " was a priest — a German
monk — who publishe<l his excellent scientific thesis in an
obscure German village in 1865. Within the last two
years the law has been rediscovere<l, practically independ-
ently and simultaneously, by four biologic investigators,
one of whom, Correns, of (jiermany, discovered Mendall's
thesis. Briefly stated, the law is that a first cross will
result in offspring resembling one or the other parent,
but possessing in an undevelope<l form, termed by Ger-
man .scientists "recessive," the attributes of the other.
The second cross will result in fixed types possessing,
respectively, the characteristics of one parent, of both
parents, and of iKith parents in varying degrees. If
true, the law, it will Ik! seen, will have a tremendous
effwt upon the hybridization of plants and the breeding
of animals, affecting or supplanting the older theories of
atavism and of cross-breeding. Professor Spillman, of
Washington, expounded the theory last November
before the Association of American Agricultural Colleges,
and at the recent conference in New York on hybridiza-
tion and plant-breeding the principle was extensively
discussed.
A Politician's Blunder. — Dr. S. D. Van Meter, in an
address published in the Colorado MedicalJourmd, July,
1902, thus tells of the miscalculation of " a certain politi-
cal aspirant : "
" It was because he unwisely catered to the newspapers and
their supposed following in their tight against our attempt to
improve medical registration, by giving vent to his inex-
haustible sarcasm in a pusillanimous tirade against legitimate
medicine, and not the simple vetoing of the bill, as the press
was wont to claim. In the performance of that act we all know
he had a perfect right, and furthermore, that if in so doing he
thought the law unjust he did his duty. However, the error of
going out of his way to scandalize the medical profession, as an
argument to justify the veto was a sad one— one that brought
fruit least expected. The very people that urged him on in the
act used the support thereby gained to defeat him in his sena-
torial aspirations, which, with the influence of the medical pro-
fession added, was successful. We are all human, hence liable
to err, and I do not recall the foregoing to make ex-Governor
Thomas enemies, but I cannot refrain from citing the incident
to remind the profession of their powerful though silent influ-
ence in public affairs, and as a caution to those who, in future,
might be foolish enough in their career to underestimate it and
fall into committing a similar mistake."
The Huxley Lecture on Ininiunity by Professor
Win. H. Welch.— We are indebtetl to Dr. Welch for
a manuscript copy of his masterly address ui)on " Recent
Studies of Immunity with Special Reference to Their
Bearing on Pathology." Profes-sor Welch has re(iuest€d
that the addreas should not be published until alter his
return from England. Therefore in honor we cannot lay
it before our readers in the present issue. In his epitome
Dr. Welch has wisely included those investigations
which have revealed si)eciftc properties of cells and fluids
in health and disease, i^nd which show the close inter-
dependency of the stJences. The great value of the con-
tributions of Metchnikoff are recognized whatever may
be the attitude taken as to his theory of phagocytosis in
immunity. Welch urgt^s that Metchnikoff has had "a
large measure of success" in tlefending his phagocytosis
602 AHERICAN MKDICtKEl
EDITORIAL COMMENT
[OCTOBBK 18, 1902
theory. Due recognition is next given Nuttall's system-
atic studies of the antibacterial properties of the body-
fluids, especially the blood-serum. Buchner and others
further extended our knowledge of this subject, and
Pfeiffer's work in 1894 led up to the great discovery of
Behring of the protective and curative value of antitoxin
serum. As a result of these and other studies we have
come to know of the capacity of the organism to produce
substances specifically antagonistic to foreign cells,
products, and derivatives. These antibodies are divided
into two groups, the antitoxins, single bodies, and the
cytolysins requiring the cooperation of two bodies. The
theory of Ehrlich concerning antitoxin is in the language
of Behring, as follows : " The same substance, which
when incorporated in the cells of the living body, is the
prerequisite and condition for an intoxication becomes
the means of cure when it exists in the circulating
blood. ' ' 0^ the twofold bactericidal and cytolytic agents,
therefore, the living body possesses substances which
may protect it by destruction of invaders, or may injure
it by destruction of its own cells according to the mates
with which these substances are joined. The mechanism
resulting in the production of the antitoxins, cytolysins,
etc., is the same as that of the physiologic function of
assimilation of food by the cells. Serum diagnosis has
become of the greatest practical value in clinical medi-
cine, the most familiar example being the agglutination
test for typhoid, and lately in paratyphoid fever, in the
diagnosis of BckUIus dysenteric Shiga, etc. The great
practical problem of bacteriology today is to make avail-
able to medical practice the bacteriolytic sera such as
antityphoid, antipneumococcus, antistreptococcus, anti-
plague, antidysentery, etc. To aid in the explanation
of the source, mode of production, and the nature of
bactericidal toxins, Welch advances a hypothesis
whereby the degenerated and dead bacteria, while rec-
ognized as a source of poisoning in infections are not
assigned an exclusive role, and the living bacteria pro-
duce and secrete receptors which may become the means
of intoxication. The investigations of Flexner and
Noguchi, as yet unpublished, show that the toxic
action of venom depends upon the combination of
intermediary bodies contained in the venom with
the animal cells for which these bodies have affin-
ities, and also with corresponding complements con-
tained in the cells and fluids of the animal. Kyes
has demonstrated the existence of a special class
of intracellular complements or endocomplements of
great pathologic interest, and Flexner explained the
action of venoms in producing hemorrhages as due to
an endotheliolysin, or a cytotoxin having the power of
dissolving endothelial cells. This may prove of signifi-
cance in explaining purpura and other hemorrhagic
afitections. It is certain, then, that bacteria may exert
their,' blood-destroying power within the living body,
and^the fact helps to explain the secondary anemias of
many infectious diseases. The l^acterial hsemaglutinins,
hsemolysinins, and leukolysinins help to explain throm-
bosis. Our understanding of the morbid anatomy of
typhoid would be advanced by the demonstration of the
production of a lymphotoxin by the typhoid bacillus.
In closing his address, Dr. Welch said :
"The researches on immunity, which to some of short
vision once seemed to threaten the foundations of cellular path-
ology, have served only to strengthen them. These researches,
which have already led to the saving of thousands of human
lives and will lead to the saving of untold thousands more,
have been carried on by the experimental method and can be
conducted in no other way. This method is as essential for the
advancement of medical science as for that of any of the natural
or physical sciences. To restrict unnecessarily and unjustifi-
ably its use is nothing short of a crime against humanity. It is
an evidence of the robust vitality of English physiology and
medicine that in spite of unwarrantable obstacles thrown in
their path their contributions to science in recent years have
been, so numerous and so important. The influence of English
thought and action is great with us in America. See to it, my
colleagues and men of science in England, that you retain for
yourselves and hand down to your successors, at least without
further impairment, the means of promoting medical knowl-
edge and thus of benefiting mankind."
Endowment and ludepeudeiit Journalism. —
Modern conditions make it so impossible for independ-
ent lay journalism to exist that there are in the world
extremely few examples, and these achieve succeas only
by the self-sacrificing lives of one or several noble-
minded men who, knowing the profound and far-reach-
ing efftects of a pure and intellectual journal, give their
lives to it instead of selling them for the meaas of self-
indulgence. There is no sinner so harmful as he with
power who refuses to aid such men, he who "passes by
on the other side," or who even aids the enemy. Inde-
pendence in journalism is so difficult on the Continent
that Vienna capitalists have been moved to endow a
journal. The editors say :
"We have accepted this money only on condition that in
the management of our paper we remain independent not only
of governments, parties, cliques, wire-pullers, banks and
advertisers, but also independent of our own financial organ-
izers. This condition has been incorporated according to law,
and every one is at liberty to convince himself of its existence
by examining the statutes of the Imperial Royal Court of Com-
merce in Vienna. It follows that the daily paper Die Zeit will
be an absolutely independent paper, which will exist exclu-
sively on the income derived from honest subscribers and
advertisers, and which will know no secret side-profits or
crooked financial resources. This independence will enable
Die Zeit to speak fearlessly where other papers must be silent,
apologetic, or hypocritical."
How is it with medical journalLsm in America?
What a spectacle ! Several hundred socalled " medical "
journals exist, the msyority of which are far from being
either owned and controlled by the profession, or guided
l>y professional considerations. When editors or pub-
lishers arise who would give their lives to bring honor
and decency into this filthy barbarism, how are they
treated ? They are left to fight it out to success or fail-
ure without the money or help which is their due, and
any corrupt and slimy blackmailing, nostrum-debauched
abortion of a journal can secure guarantees of respecta-
bility from "eminently respectable" medical men.
Only by endowment can our professional journalism be
made "independent, not only of governments, parties,
cliques, societies, wire-pullers, banks, and advertisers,
but also of the financial organizers, and knowing no
secret side-profits, or crooked financial resources." So
long as the fact is ignored so long will our professional
disorganization and degradation persist.
OCTOBER 18, 1902)
EDITORIAL COMMENT
AHEKICAH MBDICINK 603
The Eiiryg-enesis of Mau The almost insurmount-
able obstacles to the acceptance of the doctrines of the
monogenetic or polygenetic origin of human beings are
avoided by the theory that man originated a.s a distinct
zoologic species by the gradual amelioration of a race of
the animal precursors having a widespread or cosmo-
politan distribution. This theory finds an able exponent
in O. F. Cooke, of Washington, D. C, who {Science,
June 13, 1902) establishes the important distinction
between the zoologic raonogenesis of man's body and
the ethnologic polygenesis of nations, languages, and
arts. Attention is directed to the obvious fact that
man's origin and primary distribution are zoologic
rather than etymologic questions, since an indefinitely
great period of time must have elapsed between the
organic perfection of man and the development of the
races, languages, customs, and arts studied by anthro-
pologists. This view tends to the rehabilitation of
anthropologic methods which have of late years
suffered a marked desuetude. From the standpoint of
the zoologist and evolutionist the methods employed in
distinguishing man in the modern sense from the " old
time people," precursors of man, by means of morpho-
logic studies, craniometry, etc., are sufficiently satisfac-
tory, but as applied by recent writers on anthropology,
especially those of the French and Italian schools, to the
determination of the relationships of peoples and races,
they have proved unreliable and delusive. Man is
physically so plastic, so prone to modifications from
internal and external causes that in the brief periods
during which groups of men become isolated there arise
morphologic variations most misletuling when used a.s a
basis for the determination of genetic relationships, as
small variations are liable to occur not only in closely
related tribes, but also in peoples widely separated geo-
graphically and with no consanguinity this side of the
Urmensch. The records to be observed in organic nature
of human utilization of plants and animals furnish a far
more reliable ground for speculation as to man's early
history, and for the determination of the localities at
which he passed from the feral to the domestic state and
of his tribal relationships than do any schemes of cranio-
metric comparison, so liable to error from pathologic and
other variational causes, therefore, when it comes to the
study of anthropologic questions as distinguished from
zoologic, we are glad to note evidence of a return to the
historicolinguistic methods exemplified in the writings
of the school of which Victor Hehn was a representative.
The prognosis of death is the special expert work
of the life insurance examiner. He makes up his esti-
mate from many observations and considerations and
his success is a demonstration of the nearness of the
approach of medicine Uj being a science. There are cer-
tain diseases that are so slow in inception and progress
that if a policyholder dies within a certain time after he
has been accepted as a risk it shows that the medical
examin<!rs have been careless. This, of course, if too
often n^peatetl would naturally end the examiner's con-
nection with the company, so that s<!lf-interest alone
would prompt the greatest possible accuracy and rare.
From the report of Dr. Hanscom, the Medical Examiner-
in-Chief of the Royal Arcanum, we learn that in 1901
the organization lost 2,375 members by death, and of
this number 95 died within one year after admission.
How far is the company's loss due to lack of the best
possible prevision ? That is the question which interests
the examiner especially, but scientificly it interests
every physician. We find that the causes of death in
the 95 cases are as follows :
Casualties 19 Strangulation of bowels . . 2
Suicides 4 Inflammatory rheumatism . 1
Consumption 7 Anemia 1
Diseases of kidneys .... 2 Congestion of lungs .... 1
Heart disease 9 Acute indigestion 1
Pneumonia 11 Intestinal trouble 1
Typhoid fever 9 La grippe 1
Meningitis 4 Erysipelas 1
Appendicitis 5 Peritonitis 1
Gastritis 3 tiuiusy 1
Cerebral apoplexy 3 Ijeukeraia 1
Cancer 6 Enterocolitis 1
It is noteworthy that the largest single cause is acci-
dents, an indication of the extent to which machinery,
manufacturing, etc., dominate our life. However im-
possible may be prevision in these and other causes
cited, there can be little doubt that 25 out of 95 cases
due to "consumption," heart disease, cerebral apo-
plexy, and cancer, is to some extent a reproach to prac-
tical medicine.
The Minnesota School for Dependent and Neg-
lected Children serves indirectly as noble a medical
as sociologic function. Its work is described in a most
admirable way by the State agent of the school in the
Bulletin of Iowa Jmiitutions for April, 1902. The little
"victims of poverty, cruelty and neglect" come from
the Probate Courts, the State assuming their guardian-
ship during their minority. Miss Johnston shows that
it is shrewd economy and policy, as well as perfect benev-
olence, to care for the children in this way, as the
plan " cuts off at its source the material that goes to fill
up the public institutions." The finding of homes for
the pupils (no stigma is allowed to attach to their
"schooling") is the arduous but unique occupation of
the State agent. How busy she must be and how
delightful her work ! Last year the average number out
in homes and under supervision was 1 ,123. The average
cost of supervision, per capita, was $5.00. A merit and
demerit system in the school, called the Badge System,
makes it poasible for a boy or girl to be out on furlough
in about a year, though the average time is about two
years. The method of finding homes and of meeting
all difficulties demands much tat^t and knowledge of
human nature, as well as a devotion to the work that
would, we hope, be forthcoming in many State agents
were the plan generally pursuetl. " You may force but
the length of your arm ; you may beckon as far as one
can see," gives a charming glimi»se into Miss Johnston's
method. She declares the results of child rescue are
better in the State institution than with the private
societies. The boys, it is n^luctantly confessed, are more
reftwmable than the girls. The love of home is pathet-
icly shown in the joyful announcement of a boy that
he is "going home." Asked where his home is he can
only say, " I don't know yet." About 80/e of the fur-
604 Amebioak Medioins]
EDITOEIAL ECHOES
[OCTOBBB 18, 1902
loughed do well, and other trials bring the delinquent
20fo lower still.
Intemperance and self-indulg-ences vary with dif-
ferent nations, but none is so thoroughgoing and horrible
in results as that of the Chinese. A recent traveler
describes the opium villages of northern China in a way
that should make the living writhe who are directly
or indirectly profiting by the Chinese opium war. Mr.
Nichols says :
" Every year a number of the mountain settlements suc-
cumb to the blight on the land and sinlc into 'opium villages.'
The entire population becomes addicted to the habit simul-
taneously. The drug is introduced into a village. Some one
delighted with the sensations which follow his first smolce tells
his neighbors. They all experiment with it. They, too, are all
charmed with the happy oblivion it gives to cold and fatigue
and the dull monotony of their lives. Men, women and chil-
dren begin systematically to smoke opium. It is only a ques-
tion of time before they become its victims. Their fields are
neglected ; they cease to care for nourishing food ; the only
interest they have in life is the fatal fruit of the poppy ; they
cease to be recognized as human beings ; they are only dwellers
in an ' opium village.' From that time their doom is sealed.
Their village is shunned so far as possible by every one, and
they are referred to as a company of the lost, very much as
though they were already dead. By degrees all that they have
in the world is spent to satisfy their cravings for opium. Either
as a direct result of its use or because of the exposure and
neglect incident to it, they die, one by one, until what was for
centuries a dwelling-place of peaceful, contented husbandmen
becomes only a shapeless mass of crumbling walls and roofless
houses, deserted and untenanted, where no sound of human
voice breaks the mountain stillness, and where the bitter Mon-
golian winds of winter sweep unchecked through the wrecks
of homes."
Reform of Criminals. — At a meeting of the Na-
tional Prison Congress held recently in Philadelphia,
the chairman of the committee on discharged prisoners
said that the treatment of the criminal is by probation,
confinement, reformation, and readaptation. The first
of these is recognized as of the highest value in the case
of the first offender, esiiecially if he is a juvenile. Con-
finement is generally practised throughout all lands, and
its visible sign is our prisons. Reformation is recog-
nized as a theory by most of us, and its practice is
attempted in a number of prisons. Readaptation, or read-
justment to the conditions of the outside world, is one
of the most important parts of this worli. Yet few
States have recognized it, and in many individual effort
for helping the discharged prisoner is not even organ-
ized. It appears that those eflbrts at reformation
which have so far been made consist of separation of
young men from older criminals, separate prisons for
male and female offenders, and the indeterminate
sentence. A strong plea was made, and we thinlc cor-
rectly, for a more universal application of the indeter-
minate sentence. Particularly should this be applied to
the one who has committed his first offense. How dif-
ferent is the probability of complete and permanent
reformation in one who goes from prison repentant, and
whose reformation is, as it were, vouchsafed by the
authorities, and the one who has sullenly completed his
sentence, measured in months or years, and who goes
forth to do battle with the world with every man's hand
against him.
"Doctors of Optics" Made by Correspondence
at $7.50 Each.— Such is the offer l)eing made to the
physicians of the United States. The cost of three
circulars sent by mail to all of the physicians of the
country runs into thousands of dollars. It must pay or
it would not be continued. For this $7.50, " instead of
$25.00," one gets a vast deal, however. First, of course,
and most important, is the " diploma," 22 x 28 inches in
size, on parchment, with " the corporate seal on gold,"
etc. But the Isnowledge— ah, the knowledge one can
get, and the skill, for $7.50 ! " The use of the ophthal-
moscope and the retinoscope, a practical drill in hand-
ling and using them in everyday work ; a perfect compe-
tence to diagnose and correct all errors of refraction," all
by correspondence, and in cla.sses of 1,000— and this for
seven dollars and fifty cents, in advance ! And not for-
getting the parchment diploma with the corporate seal
on gold, 22 X 28 inches '. Well, what are you going to do
about it? The nation and the profession, because of
such things, become the butt of the world's ridicule.
The success and ideals of the McLean Hospital,
of Massachusetts, as set forth in the report for 1901 of
the superintendent. Dr. Edward Cowles, will prove of
exceptional interest to all students in the scientific
investigation of insanity. It describes a singularly con-
tinuous and patient working out, during 22 years, of an
early defined problem by the true scientific method.
Summed up in a word, Dr. Cowles says that the labora-
tory investigations constitute the working tools of the
therapeutist, and that the clinical-pathologic laboratory
bears the same relation to their clinical work that the
costly surgical equipments do to a modern hospital.
" This ' movement ' here," says Dr. Cowles, " has reached
a fulness of growth that demonstrates its just claims. In the
lines of great scientific and philanthropic endeavor, and in the
generous encouragement of it at the present time, there should
be no neglect of such a cause as lies in the prevention and cure
of insanity. It has come to be seen that medical research in
laboratories and clinics, in connection with teaching institu-
tions, is a proper object for endowment. But there is no
endowment in any hospital, in this country at least, for prac-
tical research in problems that can be most hopefully studied
in the living patient with the means of investigation immedi-
ately at hand, as in the work which this hospital is doing. The
McLean Hospital, as an institution under the control of the
corporation of the Massachusetts General Hospital, is compe-
tent to have charge of such a fund."
An appeal is made for a house for women patients,
and a special fund for promoting the scientific study of
the causes, prevention, and treatment of insanity.
EDITORIAL ECHOES
The White Slave Trade. — For obvious reasons, the
particulars of this traffic have not been generally made
public, yet enough has become known to justify the
strongest measures for its abolition. The Frankfurter
Zeitung says that tliis trade in women has become as
well recognized and as thoroughly organized as was the
trade in negroes a century ago. It has its agents, its
centers of distribution, and its exchanges. In fact, the
Commercial Advertiser adds, it has cast a network of sys-
tematized infamy over the civilized world, and appar-
ently there is nothing save concerted action on the part
of the different governments that can destroy it. — [iledi-
cal Record.']
OCTOBEK 18, 1902]
REVIEWS
I'AKEBioAN Medicine 605
BOOK REVIEWS
The Study of the Pulse, Arterial, Venous and Hepatic, and
of the Morements of the Heart. — By Jamks Mac-
kenzie, M.D. (Edin.). Published by the Macmillan
Company, New York. 1902. Price, J4.50.
No means of making or assisting to make a diagnosis is so
constantly drawn upon as the pulse, and yet probably no
diagnostic sign is understood less. The author has written a
book, replete with sphygmographs, and containing more than
309 pages on this interesting and highly instructive subject.
Much theorizing is done in the textbooks and in the lecture
room upon the pulse and its signiflciuee. But this author
bases his deductions upon the actual sphygmographic tracings,
which Illustrate the conditions with a clearness many times
more impressive than written or spoken words could supply.
Pulsation in the veins, particularly in the jugular veins, is
elucidated clearly by means of the tracings. Hepatic pulsation
of particular significance in certain forms of ruptured compen-
sation, as well as other conditions, has much light thrown upon
it, and upon the mechanism necessary to its production. Every
aspect of the heart's action, together with the mechanical rela-
tionship of its several cavities and the connected bloodvessels,
is fully set forth.
Atlas and Epitome of Abdominal Hernias.— By Privatdo-
cent Dr. Georo Sultan, of Gottingen. Edited, with
additions, by William B. Coley, M.D., Clinical Lecturer
on Surgery, Columbia University (College of Physicians
and Surgeons). With 119 illustrations, 3C of them in
colors, and 277 pages of text. Philadelphia and London:
W. B. Saunders & Co., 1902. Cloth, ?;5.00 net.
Outside the great surgical centers the subject of hernia is
altogether too poorly understood, and this especially with refer-
ence to the surgical treatment of this affection. Strangulated
hernia, for instance, must be recognized promptly and treated
scientifically and with despatch, and yet the space in surgical
literature devoted to this subject is comparatively small. The
present splendid publication takes up every phase of the vari-
ous forms of hernia and by short but lucid description, and
especially by a series of splendid illustrations, gives the eti-
oloBy, the anatomic condition and treatment to be applied. In
this respect it surpasses any work on this important subject
with which we are familiar.
Wharton's Minor Surgery and Bandaging.— New (fifth)
edition, thoroughly revised. A Manual of Minor Surgery
and Bandaging. By Henry R. Wharton, M.D., Profes-
sor of Clinical Surgery In the Woman's Medical College,
Surgeon to the Presbyterian Hospital, Pliiladelphia, etc.
In one 12mo volume of 612 pages, with .509 illustrations,
many of which are photographic. Cloth, $-'i.00 net. Lea
Brothers A Co., Publishers, Philadelphia and New York.
It appears that the title of this work is almost a misnomer,
from the fact that not only does it deal fully with minor sur-
gery and bandaging, but with general surgery as well. Special
articles are devote<l to surgical bacteriology, tracheotomy, intu-
bation of the larynx, ligation of arteries, and amputations. The
portion devoted to bandages and the various forms of mechani-
cal apparatus for treating fractures and operative cases Is full,
practical and lucid. Most of the operations in general surgery
arc tersely described and fully illustrated. The author has
compiled in this one volume a storehouse of information for
the student and the general practitioner, and the reviewer feels
that no one will regret having become its owner.
The Principles and Practice of Bandaging.— By Gwilym
G. Davis, M.D.. A.ssistant Professorol' A])plied Anatomy,
University of Pennsvlvania; Surgeon to the Episcopal,
St. Joseph's and Orthopedic Hospitals. Pp., 146. Illus-
trations, 16;i, from original drawings bv tlie author. Phil-
adelphia : P. niakiston's Son & Co., 1902. Price, $1.50.
This volume is based on a previous one Issued In 1891, but
the illustrations have been redrawn and the text so thoroughly
revised that it is practically a new book. It is divided Into
three parts : I. The Roller Bandages ; II. The Tailed Bandages
or Slings; III. The Handkerchief Bandages. Bandages and
turns embodying principles are described and illustrated in
detail, no attempt being made to describe peculiar bandages.
The illustrations are clear and explanatory, in many the turns
being numbered and their direction indicated by arrows.
Part III is especially valuable.
Short Talks with Young Mothers on the Management of
Infants and Young Children.— By Charles Gilmore
Kerley, M.D. G. P. Putnam's Sons, New York and
London, The Knickerbocker Press, 1901.
The aim of this book is to help the young mother to a clearer
acquaintance with, and a more intelligent appreciation of, the
nature and demands of the little life entrusted to her care. The
author has shown great wisdom in avoiding technicalities and
In not overestimating the knowledge of the lay reader. The
book Is not to usurp the place of the family medical adviser,
but to teach the young mother how to recognize symptoms of
Illness and appreciate their significance. It also gives lucid
advice as to the care of the healthy infant. Only on one point
do we disagree most emphatically with the writer, and that is
his advice that the baby be trained to the bottle at an early age
even tliough the mother is nursing him satisfactorily, his chief
argument being that bottle-feeding " will allow the mother to
go to the theater, to go shopping, or calling on her friends"
(sic). It seems the high mortality we find in artificially fed
babies ought to have as much weight as theater going. Women
who have the genuine maternal instinct and devotion are ready
and willing to make sacrifices of pleasure in order that the
primal maternal duty of nursing may be performed. It is hard
enough for the obstetrician to incite women to the performance
of this duty without book writers advising an early cessation of
natural nursing. It is more in sadness than in censure that we
note the position of this recent author. We are glad to read his
vigorous condemnation of the disgusting " pacifier," which is
so frequently seen in filthy use on our street cars or in places of
public resort. The little volume is well written, and is typo-
graphically elegant; and we have no hesitation in commend-
ing it as a valuable addition to the library of young parents.
The Roller Bandage.— By William Barton Hopkins, M.D.,
Surgeon to Pennsylvania Hospital and to the Orthopedic
Hospital and Infirmary for Nervous Diseases. Fifth
edition, revised. Pp. xvi, 162. Illustrated. Philadelpliia :
J. B. Lippincott Company, 1902. Price, $1.50.
The destruction by fire of all the plates and electrotypes of
the former edition of this book necessitated the preparation of
new illustrations for this edition, which has been completely
remodeled. The original plan of teaching by illustrations
rather than by descriptive text has been retained, 105 reproduc-
tions from photographs being inserted. Explanations are
brief and explicit. The chapter on fixed dressings is specially
instmctive, and exhibits some of the author's wellknown
practical ingenuity. The book can be heartily commended.
Saunders' Questlon-Compends, No. 25. — Essentials of His-
tology, by Louis Lbroy, B.S., M.D., Professor of His-
tology and Pathology in Vanderbilt IJniversity, Medical
and Dental Departments, etc. Second edition, revised and
enlarged. Pp. 2(i;i, with 92 illustrations. Philadelphia
and liOndon : W. B. Saunders it Company, 1902.
Preparing a second edition has given the author opportunity
to insert new illustrations which, like the old, are original.
Many of the photomicrographs lack clearness. The chapter on
technic has been enlarged and gives a very readable description
of histologic methods. The book can be commended as fulfill-
ing its purpose, a brief statement of the " essentials."
The Clinical Thermometer. — Currie, of Edinburgh,
employed a thermometer in the treatment of typhoid fever
patients witli the cold douche as early as 1797. He was ridi-
culed by his German contemporaries as an instance of medical
decay in English medicine. The first clinical application of
the thermometer was made by Santorius, of Padua. He
Invented a thermometer open at the end. After being held by
the patient it was plungwi into cold water. Boerhaave taught
the importance of the thermometer. DeUaen— 1704 to 1776 —
must bo given the honor of introducing the thermometer into
current use at the bedside. It was not until 1850 to 1870 that it
came into general use. — [Baltimoi-e Sun.']
606 AMweacAxt Mbdicihe)
AMERICAN NEWS AND NOTES
[OCTOBEE 18, 1902
AMERICAN NEWS AND NOTES.
OENBBAIi.
Appointment.— Dr. Rolando Kuehn has been appointed
port surgeon and coroner of Bluefields, Nicaragua.
Smallpox, as officially reported in the United States from
June 28 to October 10, shows 7,608 cases and 438 deaths, as
against 12,390 cases and 298 deaths for the correspondine period
in 1901.
Hospital Benefactions. — PniiiADELPHiA : Under the will
of the late Ann D. Wliittaker, the bulk of an estate valued at
$56,000 will revert to the Philadelphia Home for Incurables
upon the death of Clara S. Manny. Portsmouth, N. H. : The
late Hon. Prank Jones bequeathed $10,000 to the Portsmouth
Hospital.
The Huxley Ijecture. — A most flattering reception was
accorded to Prof. Welch, of Baltimore, upon his delivery of
the Huxley lecture in London on October 1. Lord Lister
moved the vote of thanks in the most appreciative terms and
was seconded by Sir William Church, president of the Royal
College of Physicians. The address was considered a unique
and masterly summary of the subject of Immunity and a
most valuable contribution to medical literature.
EASTERN STATES.
Sanitary Conference.— According to a recent report Dr.
John Guiteras will represent Cuba at a sanitary conference to
be held at New Haven, Conn.
NEW YORK.
Minister Pined for Violating Medical Law. — Rev. W.
N. Richie, of New York City, has been found guilty of practis-
ing medicine illegally and fined $75. The New York County
Medical Society was the complainant in the case. It seems that
for the last three years Dr. Richie has advertised a cure for the
drug habit. He also organized a committee for the purpose of
receiving donations for the curing of victims who could not
afford to buy the remedy.
Against Tuberculosis. — At the annual meeting of the
Committee on the Prevention of Tuberculosis in New York
City, preliminary arrangements were made for a vigorous cru-
sade against the disease. The plans include relief in special
eases and by exceptional means, research work, and the wide
dissemination of information by means of free lecture courses
and pamphlets. The campaign will be waged principally in
the tenement-house districts.
New Hospital for Deaf and Dumb Institution. — A new
3J-story and basement hospital building and dormitory for the
sick will be erected in connection with the New York Institu-
tion for the Instruction of the Deaf and Dumb. The building
will face One-hundred-and-sixty-fifth street and will be con-
nected in the rear by a bridge with the dormitory, which in
turn will be joined to the main building by a corridor. The
new structure will be built of brick, and it is estimated will cost
1100,000.
New York Infirmary for Women and Children.— The
new psychopathic ward which has been added to the infirmary
offers free treatment to patients suffering from mental diseases
in the initial stages. In connection with the ward, however, a
limited number of rooms have been opened for pay patients.
Especial attention is to be paid to the obscure nervous affections
which are in many instances allowed to go without treatment
until it is too late to benefit the patient. It is announced that
an endowment of $250,000 and a fund of |25,000 will be necessary
to provide for the permanent, maintenance of the work.
Bacteriology of Clean and Dirty Streets. — In a series
of experiments recently conducted by Dr. Woodbury, Com-
missioner of Street Cleaning in New York City, some interest-
ing facts respecting the influence of clean and dirty streets
upon public health were brought to light. Plates were exposed
simultaneously for half an hour at street level and six feet
above in various parts of the city, care being taken to eliminate
so far as possible conditions that might have effect upon the
number and classes of bacilli found. It was found that a plate
exposed in a cleanly uptown district showed but five isolated
pinhead colonies after an enlargement of 700 diameters, while a
similar plate exposed in the crowded tenement district showed
nearly 10,000 colonies. Both plates were exposed on asphalted
streets, the experiments proving that where there is little traffic
the air is comparatively pure, and where traffic is heavy the air
is laden with bacteria. Air taken at or near the street level
was found much more heavily laden with bacteria than that at
a level of six feet or more above the sidewalk. This is of
importance as accounting for the greater susceptibility of
infants than of adults to zymotic diseases. Street flushing was
found to be the most effective means of minimizing the various
organisms.
Matteawan State Hospital for Insane Criminals.— The
annual report just Issued for the year ended September 30, 1902,
shows that during the year there were 206 discharges or trans-
fers, reducing the number of inmates to 605. There were 18
deaths during the year and 19 patients recovered their reason.
Criminals adjudged insane and sent to this institution are com-
pelled to endure a longer term of confinement than the average
term in penal institutions. At the present time, according to
the provisions of the State law, the only male convicts who can
be admitted are those who have been declared insane while
undergoing sentences for petty offenses. Females from penal
institutions are received as heretofore regardless of the nature
of the crime, as the whole number of female prisoners in the
State is extremely small.
PHIIiADEIiPHIA. PENNSYIiVANIA, ETC.
Resignation of Hospital Superintendent. — The resigna-
tion of Dr. Carl Prese as medical superintendent of the German
Hospital is announced. Dr. Frese has held the position for 14
years and during his administration the hospital has become
one of the foremost institutions of its kind in America. Under
his direction a medical society for resident and ex-resident
physicians was formed and he enforced the rule that every week
a medical treatise prepared by one of the resident physicians
should be read for discussion by the society.
The annual report of the Pennsylvania State Board of
Health, which has just been issued, contains the first complete
list of township school boards of health which were authorized
by act of Legislature in April, 1899. There are 20 of these now
in operation. During the year 19 town and borough boards of
health have been established. Lists are given of the points in the
State in which smallpox has occurred. The assistance of the
board was required for the repression of diphtheria at 29 points
as against 38 during 1900. It is earnestly recommended that the
passage of a bill be procured to prevent unreasonable and
unnecessary contamination of the waters of the State.
Typhoid Outbreak in Twelfth Regiment Camp. —
Within the past two weeks 30 of the men in camp at Shenan-
doah have been stricken with the disease. A special investiga-
tion conducted by the local board of health developed that there
were no cases in the borough among civilians, and it was finally
concluded that the disease was introduced by one of the soldiers
and the infection spread before its presence became known. An
inspection of the camp showed that all sanitary regulations and
rules were being faithfully followed and every possible pre-
caution taken to prevent the spread of the disease. It was
decided to remove the camp so soon as a suitable location is
found.
Philadelphia Charity Hospital. — This institution, which
has been in working operation for more than 40 years, dispenses
its charity without regard to class, creed, or color. It receives
no aid from the State or municipality and has never sought
public contributions, although it does receive the remission of
tax on its real estate. It has never been a hospital for in-patients,
its work lying more in the direction of a dispensary and car-
ing for emergency surgical cases. During the past year its clinic
cared for 8,956 patients and the dispensary compounded free of
charge 9,824 prescriptions. The government of the institution
is vested in a board of 18 trustees, and the medical administra-
tion is in charge of a staff of 18 physicians.
State Board of Medical Examiners of New Jersey. —
At a meeting of the board held at Newark, N. J., October 1, 23
of the 28 physicians who took the State examination held at
Trenton, N. J., September 16-17, were duly licensed to prac-
tise medicine in New Jersey. Beginning with the examination
in June, 1903, each applicant for examination will be required
to file with his application a recent photograph of himself with
autograph signature, duly attested before and under the seal of
a notary. In the matter of interstate reciprocity of medical
license, the policy of the board in endorsing the licenses issued
by other States whose examining requirements are substan-
tially the same as those of New Jersey, provided that the appli-
cant fully meets the academic and medical requirements of the
State, is gaining favor both with the profession and other State
boards. This policy places the admission of an applicant upon
the basis of his personal fitness and the thoroughness of his
examination, which is believed to be the fairest and most
equitable method of endorsement so far devised.
SOUTHERN STATES.
The Georgia Pasteur Institute. — The second annual
meeting was held in Atlanta, October 3. The physician's report
showed that 65 cases had been treated without a death after
treatment had been completed. They represented the follow-
ing States : Georgia, 38 ; Louisiana, 9 ; Alabama, 7 ; South Caro-
lina, 6; Tennessee, 2; North Carolina, 1 ; Mississippi, 1 ; and
Texas, 1. The Board of Governors recently purchased a nice
permanent home for the institute. The following officers were
elected : President, Dr. Henry R. Slack LaGrange ; vice-presi-
dent. Dr. J. H. McDuffie, Columbus ; treasurer. Dr. C. D. Hurt ;
secretary and physician. Dr. Jas. N. Brawner ; and pathologist.
Dr. Claude A. Smith, all of Atlanta.
OOTOBKK 18, 1902|
FOEEIGN NEWS AND NOTES
■AXEBICAN MEDtCtlTB 607
Woman's Medical College of Baltimore. — The following
changes are announced in the faculty: Dr. Pearee Kintzing has
been transferred from the professorsliip of anatomy and clinical
surgery to the professorship of surgery ; Dr. James Bordley, .Tr.,
has been elected professor of diseases of the eye and ear ; Dr.
L. Gibbons Smart, of Roland Park, professor of therapeutics
and clinical medicine; Dr. S. Griffith Davis, professor of
anatomy, operative and clinical surgery ; Dr. Mary A. Waters,
adjunct professor of hygiene.
Maryland Tuberculosis Commission.— At a recent meet-
ing the commission decided to prepare a report setting forth as
clearly as possible the results of tlie most recent investigations
concerning the nature of the disease and the various ways in
whicli infection may occur. A special study will be made con-
cerning its prevalence in the State, and its economic and socio-
logic importance. The commission proposes to issue printed
ijlanks to physicians throughout the State requesting a report
on all cases. It is hoped by this plan to discoverto whatextent
the disease has secured a hold in the State.
Government Hospital for the Insane. — The annual report
of the Board of Visitors to the Secretary of the Interior has
been completed. The report states that the year has passed
without any untoward incidents and that the admissions for the
year were 086, the largest number in the history of the hospital.
Of these 297 were from the Army, Navy and Marine-Hospital
services and .389 from civil life. There were 248 recoveries and
177 deaths. The health of the inmates has been generally good
throughout the year, with the exception of a few cases of
typhoid fever during the fall of 1901, which all terminated in
recovery. In spite of a most thorough investigation all
attempts to trace the origin of the disease were futile. It is
recommended that the law regulating commitment to the hos-
pital and the discharge of patients therefrom be amended so
that the superintendent will have authority to grant trial visits
before discharge to such patients as are believed to be in a con-
dition to warrant it and also to discharge to the custody of
friends sucli as can be safely cared for outside of a hospital and
who cannot be benefited by hospital treatment.
Interment of Persons Dying of Contagious Diseases.—
At a recent meeting of the Maryland State Board of Health rules
to govern the interment of those dying of contagious diseases
■were formally adopted. Hereafter in every case of death from
cholera, bubonic plague or smallpox, the body will immedi-
ately be taken in charge by the lijcal health officer and buried
or cremated within 24 hours; the transportation of such bodies
is absolutely prohibited. Every possible precaution must be
taken in preparing such bodies for burial, and it must be done
with as little disturbance of its immediate surroundings as pos-
sible. The vehicle conveying the V)ody must be thoroughly
washed in a 1 to 1,000 solution of mercuric chlorid. When
death occurs from diphtheria, membranous croup or scarlet
fever, the body must be prepared at once for burial either by
arterial or cavity embalming, or by covering with a layer of
absorbent cotton at least one inch in thickness and then securely
ijandaged or rolled in a sheet, the entire covering to be satu-
rated in a 409c formalin solution or 1 to 500 solution mercuric
chlorid, and the Ijody immediately enclosed in a tight coffin.
If tlie scalp, face and (iavities of the mouth and nose have ijeen
thoroughly disinfected with an approved germicidal solution
they need not be covered, and the lid of the cofiin may have a
fixed glass jianel over the face to permit inspection. It is made
unlawful to open the coffin except upon written consent and in
the presence of a health officer. Interment must take place
within 24 hours after death, and only adults may act as pall-
bearers. The members of the immediate household and the
necessary attendants will be the only persons allowed admit-
tance to the house. Penalties are provided for violations.
WESTERN STATES.
Medical Practice Act Sustained.- By a recent ruling of
the Indiana Supreme Court, the act of legislature of 1901,
defining what constitutes the practice of medicine was held
constitutional, and the powers of the court to enforce it against
persons attempting to practise medicine without a license was
fully sustained.
Michigan Asylum for the Insane.- The State Board of
f lorrec^tions and ('harities made a thorough investigation of the
institution recently, and found it in the best possible condition.
Among the proposed improvements laid before the board for
their consideration was the erection of a new hospital for acute
cases among men, at a cost of $i'J,iiOO. There is already such a
building for women, and it is declared there is urgent need for
a similar institution for male patients.
Health of Chicago.— The total number of deaths for the
week ended September 27 was 446, an unusually low rate for
this period. The annual rate would be 12.73 per 1,000, while
for the corresponding week of last year it was 14.41 per 1,000.
A continued increase is noted in the scarlet fever and diph-
theria cases, tliere l)eing fully 40% more than for the preceding
week. The mortality from these diseases was nearly 88%
greater than for the corresponding period in 1901.
Instruction in Ijife Insurance.— The Wisconsin College
of Physicians and Surgeons has inaugurated a special course for
instruction as to the various phases of life insurance as con-
nected with medicine, the base of estimates, frauds on physi-
cians and other matters of interest.
FOREIGN NEWS AND NOTES
OONTINENTALi EUROPE.
Infectious Hospital at Nice. — It is reported that the muni-
cipality of Nice has purchased the old monastery of Saint Pons
for an infectious disease hospital. The building is ready for
immediate use, being provided with all the necessary appli-
ances of a modern hospital.
Boric Acid in the Preservation of Meats.— A resolution
has been adopted by the Society for the Protection of the Inter-
ests of the German "chemical Industry against the prohibition
of the use of boric acid in preserving meats. An appeal has
been made to the Bundesrath to reverse its decision.
ROntgen Rays in the Treatment of Animals. — After a
number of experiments, Professor Hoffman, director of the
Royal Veterinary Hospital in Stuttgart, Germany, reports the
x-ray as being of highly practical value in the treatment of
animals, enabling the detection of a variety of diseases.
Precautions Against Cholera. — According to a recent
report the Russian government has sent a large number of mil-
itary surgeons to its eastern departments for the purpose of
cooperating with other European nations in an attempt to pre-
vent the introduction of cholera from Egypt and other centers
of infection.
Malaria in the Italian Campagna. — The vigorous meas-
ures that have been enforced against the disease has resulted in
a remarkable diminishing of the number of cases. According
to the British Consul at Rome, since 1888, when the proportion
of population afflicted with malaria was 216, the rate has been
reduced to 3.73.
Analysis of Rare Air. — An analysis of the air at the top
of Mont Blanc, recently made by French scientists, showed the
air contained but few germs. In 100 analyses not a single
microbe was discovered, while two analyses of the air in the
observatory built on the summit of the mountain showed 540
and 260 germs respectively, showing that numerous microbes
are imported by temporary guests. Further tests showed a
regular ratio of increase as one descends the mountain.
Sanitary Houses.- According to a recent report the Coun-
cil of Nice has decided to distribute annual prizes for the best
constructed buildings, either public or private, erected during
the year. The points to be considered are the general appear-
ance, materials with which they are built, arrangement of
gardens facing the public streets, interior plans and the sanitary
system. As regards heating, ventilation and sanitation, this
movement should be productive of beneficial results, as at the
present time the building industry at Nice is in its infancy.
OBITUARIES.
Abel Mix Phelps, a brief notice of whose death appeared In our
columDS last week, had attained a national reputation as an ortho-
pedic surgeon. Among ills noteworthy operative achievements was a
new operation for harelip and also the operation for club-foot that is
known by his name. He was an occasional contributor to medical
literature. He first became Interested In orthopedics while surgeon of
the Vermont Central Hallway, and in order to perfect himself In this
branch he went abroad and spent some years In studying at the clinics
of some of the leading medical schools of Europe. Upon his return to
this country he originated and was appointed to the chairs of ortho-
pedic surgery In the Vermont and New York Universities. Later he
becamechlef orthopedic surgeon to the New York Postgraduate Hos-
pital, and was also visiting surgeon to the New York Hospital. He
was largely Instrumental In establishing the Dalsyfleld Hospital for
Crippled Children at Englewood. He was at one time president of the
New York Medical Society. He was a Founder of American Medicine.
Nieto y Serrano, one of the oldest and most Illustrious physicians
In Spain, died recently. He was secretary of the Royal Academy of
Medicine for more than forty years, and afterward became Its presi-
dent and Its representative In the .Senate. He was a wide contributor
to medical literature and In 1883, In recognltlouof his services to science
and literature, he was created Marquis of Ouadalerzas.
James W. May, In Kansas City, Kan., aged .'>2. He was graduated
from the Cincinnati College of Medicine and Surgery In 1875. At the
time of his death he was dean of the College of Physicians and Sui^
geons, Kansas City. He was one of the founders of the Institution and
was professor of ophthalmology and otology. He was president of the
Kansas Medical Society.
608 Ambbioan Meoioinbi
CORRESPONDENCE
lOCTOBIEB 18, 1902
Moses T. Babcock, of Hammondsport, N. Y., died recently. He
was graduated from the Geneva Medical College, New York, In 1852,
and afterward took a postgraduate course at the Buffalo Medical Col-
lege. He was a member of the New York State Medical Association
since 1884, and has served as president of the Steuben County Medical
Society.
Federlco Rublo y Galll, the acknowledged leader of the medical
profession In Spain, died recently In Madrid. He performed ovariotomy
for the flrst time in Spain in 1860 ; he was also the first surgeon in that
country to remove the uterus and the larynx. He published a number
of works on surgery which are of high authority in Spanish schools.
William R. Kennard, at Rockdale, Texas, aged 68. He was grad-
uated from the University of Pennsylvania, Philadelphia, in 1860 and
was a practitioner of Milam county, Texas, for many years. He was a
field and hospital surgeon in the Confederate service during the Civil
war.
Thomas Frederick Grimsdale, M.R.C.S., Eng.,.T.P.,a wellknown
gynecologist and obstetrician of England, died in Liverpool, August
26, aged 79. His best known operation was the enucleation of a uterine
fibroid in 1857, this being one of the earliest successful cases on record.
Elvira Kalnier, a prominent woman physician of New York, at
Oswego, N. Y., October 14, aged 55. She was graduated from the
University of Michigan in 1877. She was consulting physician of the
Oswego Hospital and secretary of the County Medical Society.
Daniel C. Malone, at South Bethlehem, Pa., September 24, aged 68.
He was graduated from the medical department of University of Penn-
sylvania in 1869. He was a member of the Lehigh Valley Medical
Association and of the Northampton Medical Society.
Jane K. Garver, at Graffenburg, Pa., October 9. She was gradu-
ated from the Woman's Medical College, Philadelphia, in 1872. For 22
years she had charge of the female department of the State Lunatic
Hospital in Harrlsburg.
Charles W. Bowen, at Westfleld, Mass., October 10, aged 58. He
was graduated from the Syracuse Medical College in 1874, and later took
a postgraduate course at the College of Physicians and Surgeons in
New York City.
J. Unterlugauer, who died recently in Gratz, Austria, created a
model sanitary system for Bosnia and Herzegovina, and as a result
smallpox has been exterminated and hospitals erected in every
province.
Bufus H. King, in Wolfeborough, N. H., September 17, aged 82. He
was graduated from the Medical School of Maine, Bowdoin College.
Brunswick, 1847, and was the oldest practitioner in Carroll county,
N. H.
Henry Horace Lynch, of Jersey City, October 12. He was gradu-
ated from the New York University in 1878. He was a member of the
Hudson County Medical Society.
E. George Walls, of Washington, D. C, in New York City, Octo-
ber 5. He was graduated from Washington University School of
Medicine in 1872.
Charles H. Boodey, at Cochituate, Mass., September 30, aged 64.
He was graduated from the Medical School of Maine, Bowdoin College,
Brunswick, 1871.
Edwin A. Harlow, a retired Boston physician, at Wollaston, Mass.,
October 12, aged 89. He was graduated from the Harvard Medical
School in 1846.
John Porter Gaston, in Gilbertsboro, Ala., September 20, aged 35.
He was graduated from the Vanderbilt University, Nashville, Tenn.,
in 1901.
Watson W. Archer, at Clifton Springs, N. Y., September 25, aged
67. He was graduated from the Geneva Medical College, New York,
in 1867.
Adelbert M. Corbett, in Marshfleld, Wis., September 22, aged 35.
He was a graduate of the Wisconsin College of Physicians and Sur-
geons.
Edwin E. Hunter, at Kansas City, Mo., September 24, aged 38. He
was graduated from the Ensworth Medical College, 8t. Joseph, Mo., in
1899.
E. O. AUhands, of Louisville, Ky., October 12. He was graduated
from the medical department of the University of Louisville in 1889.
George J. Peters, in Pittsburg, Pa., September 19. He graduated
from the Western Pennsylvania Medical College, Pittsburg, in 1887.
Seth C. lacey, in Aberdeen, S. D., September 18, aged 69. He was
graduated from the University of Michigan, Ann Arbor, in 1861.
Arthur E. Nichols, at Charlotte, N. Y., September 28, aged 48. He
was graduated from the Believue Hospital Medical College, 1879.
John J. Haptonstall, at Stone Cliff, W. Va., September 26. He was
graduated from the Medical School of Ohio, Cincinnati, in 1896.
John F. Eddelman, of Chicago. 111., September 19, aged 46. He was
graduated from the Rush Medical College, Chicago, in 1896.
Alfred L. Gaston, at Marbuts, Tenn., September 23. He was grad-
uated from the Vanderbilt University, Nashville, in 1891.
Aaron Baldwin, in Washington, D. C, October 10. He was a mem-
ber of the Washington Homeopathic Medical Society.
CLINICAL NOTES AND CORRESPONDENCE
[Communications are invited for this Department. The Editor is
not responsible for the views advanced by any contributor.]
CHRONIC ULCERATION OF THE LEG TREATED
WITH X-RAYS AND " BRUSH DISCHARGE."
W. L. HEEVE, M.D.,
of Brooklyn, N. Y.
Electrotherapy is gradually finding its way toward the
head of the list of specialties. The errors and vagaries attrib-
uted to this method of cure are probably the result of a lack of
knowledge on the part of the operator. Too few physicians
appreciate the importance of this method. My success in the
treatment of cancer with the x-rays has been an incentive to
me to experiment with this apparently new form of energy in
this most troublesome condition of ulceration.
Owing to the perverted surface nutrition which generally
accompanies these ulcers, e. g., in connection with varicose
veins of the leg, it is impossible by the old method of treatment,
in the majority of cases, to stimulate the process of repair, and
in the few cases in which we are able to produce healing the
new tissue has poor resisting powers.
Having noticed the active circulation and, therefore, the
good nutritional reaction which occurs in the new tissue
formed when superficial cancers are cured with the x-rays, I
was stimulated to try the same treatment for ulcers of the leg.
We can encourage our patients to accept the treatment, as it is
painless and it will immediately relieve the persistent itching
which generally accompanies ulceration. The sphere of useful-
ness of this wonderful form of electric energy is becoming
greater every day. The static machine being endowed with high
electromotive force and low amperage, capable of exciting a
Crooke's tube most admirably, has placed within our hands a
machine possessing powerful .therapeutic properties.
Generally patients suffering with ulcers of the leg have
run the gauntlet of quack medication, administered by un-
scrupulous pharmacists or some old friends who have cured
"hundreds" with their favorite recipe (consisting of tar, pitch,
dog-fat, horse-oil, or other rancid combinations).
When the patient presents himself to his physician for
treatment the ulcer is of the indolent variety, the edges indu-
rated, the surrounding parts edematous with perverted surface
nutrition and a localized, irritable, itching eczematous con-
dition.
Method of Treatment.— After thoroughly cleansing the
ulcer and surrounding parts with green soap and saline solu-
tion, getting rid of all loose shreds of broken-down tissue and
then thoroughly drying, the ulcer is in condition to be " rayed."
The healthy skin should be protected by covering of sheet lead
which has an opening directly over the ulcer, allowing Its
complete exposure, with a marginal area of about i inch.
The patient should assume a horizontal position upon an
examining chair. The tube should be placed at a distance of
about 8 inches, and in such a position that the platinum anode
plate is in the proper obliquity to reflect the rays upon the
ulcer. The tube should be of medium vacuum and actuated
strongly. The duration of the exposure should be of about 10
to 15 minutes. Between the first and second exposure at least
7 days should elapse, and between the second and third 5 days,
giving ample time to watch for the idiosyncrasies which some
patients have toward the x-rays. After the fourth exposure
— which should never be given before the fifteenth day — the
part should be " rayed " every third day until healthy granu-
lation tissue begins to form at the base. When this occurs I
begin treatment with the " brush discharge " from a static
machine."
The " brush discharge " must be applied over the ulcer and
the surrounding part. If varicose veins are the exciting cause,
then apply it along the entire leg and thigh, especially along
the course of the veins, and lastly over the ulcer. Each treat-
ment with the " brush discharge " must be 20 minutes in dura-
tion to obtain results, and the interval between each treatment
should not exceed 48 hours.
OCTOBER 18, 1902)
COREESPONDENCB
[AMBKICAN MbDICINK 609
During the last few months I have been using an electrode
made of soft wood and having a tastrtiibe covering the terminal ;
this will effect the same results as the patented vacunm
electrodes. The electrode should be about 28 inches in length,
and the terminal should fit tightly into the test-tube, expelling
all the air. The test-tube will act better if the inner surface is
"silvered." In using the "brush discharge" the indirect
method should be employed, the electrode being attached by a
chain to the gaspipe and held at the extreme end of the handle.
This will give a powerful discharge, but not painful. The
result w^ill be improved circulation, increased nutrition, reduc-
tion of the edema, and a rapidly healing ulcer.
With the above method a cure is established. In varicose
ulcers it produces rapid healing, overcomes the localized eczema
surrounding the ulcer, increases the circulation, thereby over-
coming the blood stagnation and producing an astringent effect
upon the smaller veins.
In some cases I have found that when the ulcer is healing
and the serous or lymph edema is disappearing, intense pain is
felt during the night; this, I believe, is due to pressure of the
deep-seated enlarged veins (comites), but it is immediately
relieved by the use of the positive large sponge electrode (gal-
vanic) over the painful area and the negative on the gluteal
region of the same side, giving about 15 ma. current of 5 to 10
minutes' duration.
With the treatment mentioned I have cured 24 cases of
chronic ulceration ; two due to traumatic causes were neglected
and passed into the chronic stage; three due to traumatic
causes, owing to the old age of the patients, resisted all medical
treatment, and 19 were due to varicose veins. Recurrence hap-
pened in one case of varicose ulceration, but it was immediately
controlled and repaired by seven treatments of the "brush
discharge." One case of varicose ulcer is worthy of reporting
in full :
Mr«. M., aged 45; weight, 192 pounds. After the birth of
her last child, two years ago, she complained of pains in the
left leg ; gradually the superficial veins became varicose and
lympli edema developed. Complete excision of the internal
saphena from the knee down was performed, giving relief for a
period of five years, with recurrence of the symptoms six
years after the operation. By wearing an elastic stocking and
with internal and external treatment she obtained temporary
relief. During Xoveniber of last year (1901), upon examina-
tion, the following condition was found : Large ulcer, measur-
ing 2J inches in diameter, indurated edges and a surrounding
area of edematous infiltration with purplish discoloration. All
the usual methods wore tried without success. .January 29,
1902, the part was " rayed " 10 minutes with a medium vacuum
tube, actuated by a static machine. After five exposures to
the x-rays granulations commenced, and then static brush
discharge treatment was given. She received 20 treatments-
one every other day — of the "brush discharge." Upon exami-
nation, April .■$, 1!X)2, the ulcer was entirely healed, very little
discoloration of the surrounding part remaining ; edema was
entirely overcome, and she was able to walk two miles without
difficulty. On further examination of this patient May 22, 1902,
the part presented a few small spots of bluish discoloration,
giving no symptom of discomfort, and from all appearances a
good result has been obtained, more than was ever expected.
CONCERNING DR. SCHELL'S ARTICLE ON PSEUDO-
CYESIS.
G. MAXWELL OHRISTINE, M.D.,
of Philadelphia.
Obstetrician, West Park Hospital for Women, Philadelphia.
I have read with considerable interest the article of Dr.
Schell in the issue of American Medicitie of .luly 5. In his open-
ing sentences the author refers to the etiology of pseudocyesis
in the following words : "After searching the literature on the
subject I could not find at that time (several years ago) any
suggestion that ovarian irritation had ever been considered as
a causal factor in this condition, and since then I have made a
more careful search with very little or no better results."
In order to verify the implied statement of the author, that
ovarian irritation or disease had not been considered as a cause
of false pregnancy, I picked up the first book at hand—" Quain's
Dictionary of Medicine " — and In it, under pregnancy, I found a
very satisfactory reference to ovarian disease as being one of the
numerous causes of this condition. The sentence will bear
repeating here to show how fully this matter was appreciated
back as far at least as 1871 : " The causes of pseudocyesis,
beside those referred to, namely, change of life, dyspepsia and
hysteria, are very numerous, including ovarian disease, uterine
tumors and physometra, abdominal plethora and obesity, molar
pregnancy and cystic disease of the ovum." In another
sentence on the treatment, the dictionary remarks as follows :
" Pseudocyesis is only an effect of certain morbid conditions,
the recognition of which we have endeavored to point out. The
treatment of these causes will be found fully described in
articles on these several subjects."
The article is quite satisfactory, and I would commend its
perusal to those who do not know that as early at least as 1871
the subject was fairly well understood.
Pajot says there is no such thing as false pregnancy— a
woman is pregnant or she is not pregnant. However, it is prob-
able that no better term can now be found to suit the ccmdition
than that of false pregnancy. It is a question of deception,
either intentional or otherwise. We have all seen examples of
both types. I recall one in which the woman engaged me for
her confinement at a certain date. On the evening of the day
fixed she sent for me ; I found her in bed, going through the
movements of labor pains. Examination revealed a normal
uterus, and I soon discovered the deception. Sending husband
and nurse from the room, I removed a large pad from the
patient's abdomen and accused her of wilfully deceiving me
and her family. She admitted the deception and pleaded fear
of losing the affection of her husband if she did not have a
child. She carried the deoeptiou so far she was afraid to admit
it until I discovered the fact. In another case a woman called
on me to determine whether she was or was not pregnant. I
spetitan hour or more in endeavoring to convince her she was
not, but she left me unconvinced. I afterward learned she was
mentally unbalanced and made it a practice to call on physi-
cians for examination and opinion. She was a proper subject
for an asylum.
The first case referred to by Dr. Schell was one attended by
a physician friend of mine, who had his doubts as to the exact
condition of the woman, and called me in consultation. I found
the condition present as described in the article of Dr. Schell,
and I informed the patient she was not pregnant. She was
apparently convinced, but unfortunately there was an aunt in
the room who declared my statement, that the woman was not
pregnant, was the most absurd thing she ever hoard. The
quarrel which ensued between the aunt and me continued down
to the doorway. My friend was discharged, which was unfor-
tunate, for the woman might have so profited by the statement
we had given her as to have made the subsequent examination
under ether and the curetment, which the author states did her
no good — unnecessary.
In this case there were ovarian and uterine distresses
responsible for carrying out tlio delusion as to pregnancy, fos-
tered by her own desire and helped along by her family, who
were convinced beyond all doubt that she was pregnant. In
her case it was clearly determined before the patient wa.s taken
to the Samaritan Hospital that there was no pregnancy. This
illustrates the advisability of a conference with the physician
who has gone before as to the condition of affairs as lie found
them. The error committed in this case was twofold— first, in
the woman being sent to the hospiUil for delivery when she had
already been informed she was not pregnant; second, in the
examination under ether and the curetment, when neither was
necessary in the presence of the fact that it was quite easy to
determine pregnancy did not exist.
Women are sometimes so impressionable they can be
made to believe almost anything, from cancer down to i)reg-
nancy. Especially is this true if they have the hysteric element
in them. Suggestion, auto or otherwise, is a large factor in tlie
operations of her functions. It can be well understood how in
some a suggestion added to existing pelvic distresses and
heigliteno<l by desire will contribute to this condition, which,
for the want of a better term, we call pseudocyesis. The cause,
as has been pointed out by the article in Quain's Dictionary,
may be anything likely to utuse sympathetic or direct irritation.
The subject is an interesting one and cannot be written on
610 Ajiebioan Medioike
OOERESPONDENCE
[OCTOBBR 18, 1902
too frequently. But cannot some one sive us a better term than
that of false pregnancy? one that will meet with the statement
of Pajot, that a woman is either pregnant or she is not?
SOME THEORIES AND FACTS ABOUT RHEUMATISM.
BY
G. VAN VRANKEN, A.B., M.D.,
of Passaic, N. J.
The word " rheumatism," from the Greek word /Vw, to
flow, evidently has reference to some morbid fluid that was sup-
posed to circulate from joint to joint in its unhappy possessor.
In 1642 Bellonius, a rheumatic physician, divided diseases
called arthritis into "gout and rheumatism."
Dr. Prout, over 65 years ago, in a book called " Stomach
and Urinary Diseases," said : " Lactic and lithic acids are
developed together, and their undue presence in the urine may
be viewed as indices of the existence of certain diseased actions
going on in the primary tissues of the body." This view has
been largely held ever since.
Dr. Elliston, professor of practice of medicine, London
University, wrote in 1843: "How malaria acts in producing
ague, rheumatism, and neuralgia we do not know." This is
not yet known. Of treatment, he remarks that venesection is
not always required. " Colchicum does good by purging ; and
mercury, when it makes the mouth sore, often relieves all
pain." (This last, perhaps, by taking the sufferer's mind off
a lesser trouble to consider a greater.) The same author, how-
ever, in an old cyclopedia of practice, recommends acupuncture
in chronic rheumatism, the sanae treatment advised for lum-
bago by Osier in his last edition of " Practice of Medicine."
So the old-time physicians administered opium and tonics,
and advised bleeding and purging for rheumatism. They
regarded it a disease or group of diseases caused by chemical
poisons, due to faulty metabolism.
One physician of recent years thinks he has produced
rheumatism in animals by the injection of lactic acid, but so far
as we know these experiments have not been verified, and so
are probably as reliable as the laparotomy figures of our " pro-
fessor doctor " who has 100% of recoveries.
If lithic or lactic acid is the cause of rheumatism, it should
be possible to demonstrate a lesser quantity of such acid
excreted by the body, or a greater quantity manufactured in
the body during a rheumatic attack. Neither has been satis-
factorily shown. Recently, in examining specimens of urine
from rheumatic patients about to start treatment, we found iu
some cases a diminished acidity of the urine, though generally
there was a marked increase of acid.
To support the theory of the acid origin of rheumatism, a
milk or buttermilk diet should be harmful, while the opposite
is true.
The theory that rheumatism is a disease of the sensory
nerves that supply the muscles or joints, does not explain what
causes the nerve disease, nor is there any definite pathology
known to uphold this idea.
That there is for rheumatism some specific though unknown
germ seems improbable, because lead-poisoning, syphilis, gon-
orrhea, pyemia and other conditions sometimes show the
same morbid changes in the nervous and circulatory systems,
and in the fibrous tissues about the joints and the synovial
sheaths of the tendons ; in other words, there is no distinctive
morbid anatomy for rheumatism.
Dogs and horses are known to be subject to rheumatism,
still we know of no case that has been produced by inoculation,
a, thing that must be possible if there is one specific germ for
the disease. Again, the treatment that succeeds (apparently)
so perfectly in one case, in the next is found as useless as
Passaic river water.
There is no apparent immunity acquired by an attack of
rheumatism, but rather one attack gives a predisposition to the
second of a subacute order, perhaps, and finally of a chronic
affliction. This, too, militates against a specific germ theory,
though not against a condition analogous to that in tuberculosis
when a mixed infection almost always occurs before any seri-
ous damage is done.
That rheumatism is a poisoning caused by the toxins of
several germs or that it may be caused by the toxins of any one
of several germs seems probable. Surgeon-General Sternberg,
U. S. A., long ago showed that the throat of a healthy person
may have a large number of staphylococci, sometimes strepto-
cocci, pneumococci, and other unknown germs. The congestion
that often occurs in the throat after chilling the surface of the
body or getting the feet wet, and caused, we suppose, by the
action of the sympathetic nerves, easily prepares the throat and
especially the tonsils for the growth oftho.se germs ; in fact, the
serum exudate is a first-class culture medium. Prom the
tonsils the road is short to the general circulation, particularly
to the lymphatic circulation. Since it has become generally
known that one or several of a number of germs may cause a
meningitis, an orchitis or a pneumonia, in fact an infiamma-
tion of almost any organ, it seems reasonable to say that differ-
ent infections may cause those symptoms we call rheumatism.
It would seem that the problem must be to find which one or
ones might be at the foundation of the trouble in a given case.
In the second number of the New York Medical Record, 1902,
is a detailed history of a case of acute articular rheumatism cured
by antistreptococcic serum. Should the staphylococci or some
other germ cause the symptoms in the next case, probably this
treatment would then fail, as the others fail in some cases.
In about one-third of the rheumatic cases there is a hered-
itary element, and in probably nine-tenths of the cases a history
of exposure to wet and cold, and an anemic condition, or indi-
gestion. Of course these things may simply reduce the power
of resistance and are likewise found in most cases of tubercu-
losis and in many other diseases.
A recent authority who devotes about 70 pages to the treat-
ment of rheumatism furnishes a list of remedies that rivals that
of the specifics for whooping-cough.
In a late number of American Medicine we are informed
that the rheumatism cures now amount to 1,437, and include such
useful discoveries as horse-chestnuts, electric rings, raw onions
carried in the pockets, and sulfur rubbed in the stockings.
For treatment Striimpell, in his last edition of " Practice of
Medicine," says : " For acute rheumatism give no iodids, and for
chronic give no salicylates." In acute attacks he recommends
cold sponging and in chronic cases hot packs, hot air, etc.
Most authors agree that large quantities of water are useful,
and so almost any spring may help in the treatment.
Electricity seems to be iu favor with the eclectics, while
many other physicians count it worthless.
Massage and passive movements are generally recom-
mended for chronic rheumatism. If toxins of bacteria are the
cause of rheumatism, then until the proper antitoxins can be
found and administered the eliminative treatment by cathar-
tics, diuretics, diaphoretics, etc., and the socalled antiseptic
treatment, are valuable.
The success in treating rheumatism with salicylates and
other antiseptics adds to our conviction that the cause of rheu-
matism is bacterial and the symptoms due to toxins.
GANGRENOUS APPENDICITIS WITH PERFORATION.
BY
JAMES D. LAWSON, M.D.,
of .St. Stephen, N. B , Canada.
To the Editor of American Medicine: — I recently had a case
of appendicitis which followed the usual course of rise of tem-
perature (from 100° to 103.5°) and rapid pulse (98 to 125). The
patient was a maiden lady, aged 49, residing with her brother's
family. I saw the patient about 18 hours alter the first symp-
toms of sickness, but permission to operate early was refused
and it was not given until the fourth day. On opening the
abdomen I found diff"used peritonitis with extensive and firm
adhesions. The appendix was about 3 inches long and curved
on itself. It had been perforated by the fecal concretions; one
of them 8 of an inch long, and two smaller. Two-thirds of the
appendix was gangrenous and at least one inch of the cecum
(apparently where the appendix had been adherent), was also
gangrenous. The patient lived seven hours after the operation.
In this case there was an entire absence of the sign sug-
gested by Dr. Howard, of Williamstown, Mass., in your issue
of August 2, 1902, viz., absence of fever and a low pulse, as an
indication of the presence of gangrene.
October Ig, 1902]
EUPTURED PUS-TUBES
[American Medicinb 611
ORIGINAL ARTICLES
RUPTURED PUS-TUBES.'
BY
CHARLES GREENE CUMSTON, M.D.,
of Boston, Mass.
Vice-president of ttie American Association of Obstetricians and tJy ne-
cologlsts, at*., Boston, Mass.
Of all the chronic diseases of the genital organs of
woman which are a decided impairment to the joys of
life are certainly inflammatory diseases of the tubes and
ovaries. These patients form that large cla&s, which it is
our lot to meet daily, of the socalled " sickly woman,"
because hardly has the pain and discomfort within the
pelvis abated by rest In bed when shortly after the
patient is up and about they again reappear. All this
readily explains why the.se affections of the ovaries and
tubes produce so much evil and distress in women occu-
pying all social ranks of life.
In this paper only the infectious diseases of the tubes
will be considered. They may arise from pyogenic
germs carried directly to the tubes by the blood or
lymph, or the process may be a direct extension from
the disease<l endometrium and Infected uterus. This,
briefly, is the manner in which pyosalpinx originates.
One of the most serious complications of pyosalpinx
is perforation into the surrounding hollow viscera such
as the bladder, rectum or vagina, or a direct perforation
through the abdominal walls. The symptoms of a per-
forated pus-tube are quite characteristic, the principal
one being a continuous secretion of pus from the fistula.
In these ca.ses there exists the danger that the patient
will be reduced to such a state of weakness by the con-
tinued loss of albumin and the ab.sorption of septic prod-
ucts that the important organs will suffer and undergo
amyloid degeneration.
If the opening of the perforation is quite small so that
by pressure on the tube the pus will only escape slowly,
it will eventually happen that if the patient should fall
or if much pressure is exerted over the suppurating
f(X!us, the pyosalpinx will burst and the purulent fluid
will escape into the general peritoneal cavity, and this
possible rupture of a .salpingitis is a constant menace to
the life of the patient.
It is really astonishing how even at the present time
certain surgeons and practitioners still treat these cases
with palliative measures, while all of them will be
decidedly in favor of operating if they are dealing with
a perforated pus-tube. In going over the literature for
the last few years I have been able to find the reports of
a immber of operations undertaken in cases of perforated
pyosalpinx, and a consideration of these will perhaps
give the best idea of the modern treatment of this unfor-
tunate condition.
In 1889 Veit published an excellent paper on perfora-
tion of pyosalpinx occurring into the vagina or through
the abdominal wall, and reports four cases. With re-
gard to these he makes the following observations : If
the tube can be successfully drained the increa.se of the
trouble is certainly prevented, but a permanent cure
never results. He does not believe that an absolute cure
is impossible by drainage, but he considers it as highly
improbable. He also attaches but little value to curet-
ment of the tubal mucosa, and the u.se of iodoform.
Veit considers that perforation of a pus-tube into the
vagina or through the alxlominal wall is a decided con-
traindication for a radical operation because the danger
of infecting the abdominal cavity is very great, for the
reason that before incising the abdominal walls the pur-
ulent pocket amnot be satisfactorily disinfectt^d. These
cases must \h^ treated by drainage, and according to this
authority a clo.sure of the fistula is pos.sible, so that a
' Kcad before the American AHHOclatlonof Obstetrlclnns and Gyne-
cologists, Washington, U. f;.', Heptember 1«, 17 and IH, 1!X)2.
gradual atrophy of the tubal mucosa will -occur. But
nevertheless the tumor must be watched closely and re-
moved by laparotomy should it increase in size.
Winter, in his paper, agreed in almost all points with
Veit, and considers that perforation of a pyosalpinx into
the vagina, rectum or bladder, as one of the most severe
complications on account of the continuous suppuration.
A spontaneous cure he considers improbab|le, and believes
that it is more than questionable whether by means of
curetment and other applications the pocket can be made
to heal. A new abscess can be formed at any time in
one of the diverticulums of the tube, which might be
overlooked during curetment, and the treatment by
incision and drainage according to his experience rarely
results in a cure.
He considers extirpation of a perforated pyosalpinx
as a rather risky proceeding because an infection of the
abdominal cavity from the septic contents of the tube is
practically unavoidable. He then reports three cases of
his own and makes the following observations : The
principal danger in the extirpation of a perforated pyo-
salpinx is the chance of Infecting the abdominal
cavity. The pus of a perforated pyosalpinx is
much more virulent than that of a common pyosal-
pinx, because the pus of the former has become
invaded by large numbers of saprophytes coming from
the opening in the neighboring organs, while in the pus
of a nonperforated pus-tube there are either no living
organisms or only gonococci, which are less dangerous
for the peritoneum.
He believes that it is advisable to draw off the pus
from the tube and then wash the sac out with carbolic
acid.
Another danger is opening the hollow vi.scus into
which the pyosalpinx has perforated. In four cases pub-
lished, the opening of the perforation into the organ
could not be found, and this is very often the case be-
cause on account of its minute size it is difficult to dis-
cover. Since, then, it cannot be found and clo.sed, the
opening will remain an entrance for bacteria until it
closes up. As a general rule a pyosalpinx is tightly
bound to the surrounding pelvic organs and the walls of
the latter are usually very friable from the extension of
the infectious process, and consequently the surgeou
must proceed with great caution in order to avoid en-
larging the opening of the perforation by tearing. Con-
trary to the opinion of Martin, Winter considers the
Trendelenburg position as most suitable when operating
on these patients.
N'^eit has recorded two cases of perforated pyosalpinx.
In the first another operator had closed the abdominal
cavity after removing one pus-tube, and then a pyosal-
pinx which afterward developed on the other side, had
openetl into the vagina. As no satisfactory results could
be brought about, Veit did a laparotomy and removed
the tube, with a successful result. In the .second ca.se
the tube had perforated into the rectum and laparotomy
followed by removal of the sac resulted in a cure, but
six months later the patient died of tuberculosis. Veit
agrees with Winter that the Trendelenburg posi-
tion is by far the best when operating for a perforated
pyosal{)inx. The danger, of course, in the elevated
position of the pelvis is that pus may be spread over the
peritoneal cavity, but he believes this is largely theoretic,
because if the field of operation is controlled by the eye
of the operator, infection from the pus can be avoided
since it is poasible to free the pyosalpinx as far down as
the point where it is perforated, and then immediately
remove it intact after cutting it off at the point of adhe-
sion with the organ.
Mackenrodt has reported the following case :
Tlie patient was 25 years old, and two years befort^ had a
postpartum hemorrhage acconipaiiiod by (over. Six months
later the temperature again wont up, with pains in the alxlo-
men and symptom.s of peritonitis, all of wlii(^h sutisidod for the
time being under a suitable treatment. A recurrence, however
612 American Mkdicinej
RUPTURED PUS-TUBES
[October 18, 1902
soon took place, and it was then found that a tumor could be
made out on the left-hand side, and on account of the urgent
symptoms it was opened through the vagina. A large amount
of pus was discharged, the pain subsided and the patient was
soon discharged from the hospital. The discharge of pus from
the vagina continued, however, and althougli the patient felt
fairly well she was unable to work and finally became weaker.
The discharge of pus from the vagina had stopped, and when
this took place the temperature went up and severe pains in the
abdomen and rectum were present. Local treatment was
unsuccessful, and on account of the septic conditions it was
decided to operate. Under ether the cicatricial remains of the
fistulous duct were found and this was again opened, giving rise
to a profuse discharge of pus, and after the abscess had im-
proved laparotomy was done. A slightly adherent pyosalpinx
on the right was removed, and then the left adnexa, which
plunged down deeply in the culdesac of Douglax, everywhere
closely adherent to the intestines, was freed and the tumor,
consisting of the tube and ovary, was removed. In order to
close the vaginal fistula the anterior and posterior wall of
Douglas' culdesac were brought together by suture. Recovery
was uneventful ; the patient gained in weight and is now per-
fectly well.
There are two methods of dealing with pus-tubes,
the first one of which is posterior colpotouiy, followed
by incision and drainage of the sac, while the second is
to remove the tube, and if the condition is bilateral to
do a total hysterectomy. Naturally, the easiest and
least dangerous method is drainage of the perforated
pyosalpinx through the vagina. The vagina is incised
and then the pyosalpinx and the walls of the pus-tube
may be united to the vaginal wall by means of forceps,
which are allowed to remain in place for one or two days
until union has been effected. In doing this operation
in two stages the vaginal walls are first incised and the
sac is united to the borders of the vaginal incision, and
after union has taken place the pus-tube is opened. In
both instances the cavity should be thoroughly irrigated
with a salt solution and large drainage tubes employed.
Landau says that by this method he has had very
good results in cases in which the tube formed only one
P')cket; but, in my opinion, a successful issue by the
vaginal route is most uncertain, even if proper drainage
can be secured. Curetment of the cavity rarely pro-
duces a complete destruction of the mucosa of the tube
and the cessation of pus formation, and besides, I believe
that there is great danger of perforating the walls of the
abscess and directly entering the general peritoneal
cavity.
While drainage is going on successfully and the
patient appears to be making a good recovery, she
may for all that be having a new abscess developing in
some other part of the tube, and in the end a radical
operation will become obligatory. In my opinion the
vaginal route — that is to say, posterior colpotomy — is
indicated only when we wish to empty a large abscess
preparatory to doing a radical operation, and under
these circumstances it is certainly of use, because by
the removal of the pus the septic condition of the patient
will be greatly ameliorated, and she can better withstand
the shock of a capital operation.
There is one thing relating to colpotomy that I would
particularly refer to, and that is the possibility of cutting
a large artery when incising the pus-tube. The result-
ing hemorrhage is very serious and most difficult to con-
trol, and can probably be stopped only by clamping or
packing tlie cavity tightly with gauze.
I think, however, the proper treatment for perforated
pus-tubes is by abdominal incision, whether perfor-
ation has taken place in the general peritoneal cavity
or into the intestine, bladder or vagina. After the
abdomen has been opened the tube or tubes should
be freed from the adhesions binding it to the bladder,
intestines or vagina, and should then be removed. This
dissection must be carried out with great care, because
the organs to which the pyosalpinx adheres are in a very
friable condition from the direct extension of the inflam-
matory process. When removing the pocket at the
point where it has perforated into a hollow viscus it is
better practice I believe to allow a piece of the wall of
the tube to remain where the supposed perforation open-
ing exists, because if an attempt is made to peel it off
completely there is great danger of tearing into the organ,
and to close a large rent is sometimes practically impos-
sible and at the best is very difficult.
If the perforation is very small, as it usually is,
whether it be in the bladder, rectum or vagina, it should
be closed, but in most cases when the opening leads into
the rectum it cannot be found, but it would appear that
this will usually take care of itself and rapidly close by
adhesions.
Until it has closed, however, it is an entrance for
new infection into the peritoneal cavity, although in one
case of my own in which a large pyosalpinx had been
discharging through the rectum for several months, and
at operation a rent in the wall of the rectum was made
to the extent of 3 or 4 cm., the patient pa.ssing all
feces through the drainage-tube in the abdominal wall
for over 10 days, the opening into the rectum took care
of itself so well that without any further surgical inter-
ference the fistula closed entirely at the end of two
months. It is now eight months since this operation
wa.s done, and the patient is perfectly well.
Many surgeons aspirate the sac after the abdomen is
opened in order to remove the pus and thus avoid the dan-
ger of contaminating the general peritoneal cavity, but it
has always appeared to me that this is a useless prelimi-
nary and that if care is taken in walling off the peritoneum
by gauze and removing all pus that has leaked out by
dry sponging, never by irrigation, that the ultimate out-
come of the case will be perfectly satisfactory. There is
no doubt but that the Trendelenburg position is the
best and renders the operation much easier, and there is
no contraindication to its use in the removal of pus-tubes
provided that the surgeon will take care to protect
thoroughly the general peritoneal cavity by carefully
packing with gauze sponges.
The extirpation of perforated pyosalpinx is particu-
larly urgent in those cases in which drainage by pos-
terior colpotomy has been unsuccessful, and also when
we are dealing with a tuberculous lesion of the tubes.
Also if from the inflammatory changes arising in the
pelvis from a perforated pyosalpinx, chronic pelvic
troubles such as ileus arises, laparotomy is immediately
indicated.
The prognosis, after a perforated pyosalpinx has been
removed bv laparotomy, is apt to be fairly good, and the
patients usually recover, but it must not be forgotten
that by abdominal inci^ion we cannot always be succe.ss-
ful, because in many instances the tubes and intestines
have l)ecomeso intimately united that the adnexa cannot
be removed entire ; and beside that, throughout this large
mass will be found multiple abscess pockets, and in such
cases I believe that drainage by posterior colpotomy or
combined abdominal and vaginal drainage is the proper
course to pursue until the condition can be somewhat
improved by this means.
I am not greatly in favor of vaginal hysterectomy in
cases of perforated pus-tubes, although I believe that
when the sac has burst into the bladder the vaginal route
might be indicated under certain circumstances. Vag-
inal hysterectomy I believe is indicated in those cases in
which the pus pocket cannot be reached on account of
the dense adhesions. It is especially indicated in those
cases in which after laparotomy an abdominal fistula
remains leading down to the stump formed by the re-
moved adnexa, which discharges continuously a large
amount of pus and weakens the patient.
Case I.— The patient, aged 35, was the mother of three
healthy children. She has complained of pain in the left iliac
fossa and rectum for the past two years. On several occasions
large quantities of pus have been passed per rectum and the
history of several attacks of localized pelvic peritonitis was
elicited. , , , , ,
Three weeks before seeing the patient she had had a miscar-
riage at about the third month for no known cause. For 10 days
after this all went well and then the temperature rose to about
October 18, 1902]
RUPTUEED PUS TUBES
[American Mesicini. 613
38.5° C. and the abdomen became distended. The bowels were
constipated, but the patient did not complain ol much pain in
the abdomen.
This condition remained the same for the next 11 days, wlien
I was asked to see the patient by Dr. Henry Hartung. Exam-
ination showed a large mass occupying the left iliac fossa,
which was not very painful by bimanual examination but by
pressure a certain amount ol pus was made to ooze into the
rectum. The abdomen was greatly distended and tympanism
existed everywhere.
The patient presented the typical picture of a septic perito-
nitis of a subacute form. The face was sunken and pinched,
the tongue dry and brown. The temperature, however, was
normal and the pulse 120.
The patient was removed to the hospital and I opened the
abdomen the next day. The intestinal coils were highly hyper-
emic and covered with flakes ol recent lymph. By long and
tedious dissection I was able to free the left tube, which was
about the size of a lemon, dipping down into Douglas' culdesac
and firmly adherent to the sigmoid flexure. As I was peeling
down I came to a small pus pocket outside of the tube and by
careful examination I found that the latter had ruptured and
had probably been the cause ol the generalized infection of the
peritoneal cavity.
I did not attempt to peel off the tube at the point where it
adhered to the sigmoid flexure, because I presumed that at this
point the opening into the gut had occurred, and I merely tied
oft the tip of the tube and cut it ott".
The course of events was most unsatisfactory. There was
not much discharge through the large tubes whicli f had in-
serted into Douglas' culdesac, but the bowels became more and
more distended and no means that we resorted to would produce
the escape of gas or cause a movement to be obtained.
Three days after the laparotomy I decided as a last resort to
do a right inguinal colotomy. This resulted in allowing the
escape of about three pints ol stinking liquid feces, but the
patient did not rally and died 16 hours later.
Here is a ca-se of an old pyosalpinx which a year or
two previously had perforated into the rectum and then
after the miscarriage it had again lighted up and had
burst into the general peritoneal cavity, giving rise to a
general peritonitis which wa.s beyond all reach of sur-
gical aid. 1 would also remark that had I appreciated
the real condition of affairs within the abdomen I would
not have operated in this case, for 1 believe that such
instances are far better left alone, but on account of the
history and the temperature I thought that interference
was justifiable.
Case II. — The patient, 30 years old, was a nullipara. She
gave a history ol pain in the left iliac lossa and an occasional
discharge of pus and blood per rectum. Also several attacks of
pelvic peritonitis during the last three years.
When seen in another attack tlie patient was found in a
septic condition with a dry tongue, a temperature of 10.'i°, and a
pulse of 11.5. The abdomen was not distended. A large mass,
which could be distinctly mapped out from tlie uterus, filled
the left iliac fossa, and fluctuation could be distinctly lelt.
Tlie next day I opened the abdomen and after a careful and
long dissection, Ireed the left tube, which was about the size ol
a large orange. It was intimately adherent to the sigmoid
flexure, which in turn was bound down by adhesions. Care-
fully proceeding at this point to free the tumor, I suddenly felt
the tissue slip under my finger and found a rent in the gut
about 3 cm. in length ; the tube and ovary were then tied off and
removed.
I next turned my attention to the opening in the sigmoid
flexure, but the organ was so bound down that it was evident I
would be obliged to stitch the rent with the gut down in the
pelvis. This 1 proceeded to do, but on account of the inflam-
matory softening ol its walls each Lembert suture which was
put in tore through when it was being tied, thus making mat-
ters still worse, and I finally concluded that I would drain.
Two large gLass tubes were inserted, and for a week the
patient passed all her feces through the abdomen. Her con-
dition, however, improved wonderfully after the operation.
Her temperature fell to normal and her pulse never went above
flo. The appetite was good, and in order to prevent the forma-
tion ol liquid feces, the patient was led on a full house diet.
The drainage tuljes were removed at the end ol a week, and
lor the next fortnight the patient passed feces through the
abdominal wound, but little by little, less and less were voided
by the abdominal opening, and more and more were expelled
by rectum. To make a long story short, without any particular
treatment the iibdoininal fistula finally closed in less tliaii throe
months, the patient made a perfect recovery and has remained
well ever since.
Va»b III.— The patient, aged 34, wa-s married. She had two
normal labors, the last five years ago. First menses occurred
at 14 years. She was always regular. While riding a bicycle
18 months ago she lell, the machine striking her in tlie abdomen.
The accident occurred during her menses which at once stopped,
and severe pains were complained ol in the pelvis for several
days. From this time on at each catameuia the pains were very
severe, so that the patient was obliged to remain in bed for 10
or 12 days.
About 10 months alter the accident the pain during the
menses was accompanied by tympanitis and a temperature ol
39° C, with a pulse ol 120. Since this severe attack any exer-
tion or exercise causes much pain in the pelvis, but at this
time, as nothing abnormal could be discovered by bimanual
palpation, medical treatment simplj' was instituted.
The patient was seen again six months alter the severe
attack already alluded to, and it was found that she had been
confined to her bed lor three weeks with pains in the abdomen,
which at first were chiefly marked on the left side, but later
had extended over into the right iliac fossa. The patient says
that she had noticed pus in the feces on several occasions.
There was also pain on micturition. Her general condition
was fairly good and the appetite and sleep were undisturbed.
By bimanual examination an enlarged, heavy uterus was
found, and a tumor the size of an orange, in the right iliac
lossa. It appeared to be pedunculated, as it was some-
what movable and seemed to adhere, more or less, to the
anterior aspect ol the uterus. It did not appear to have any
connection with the rectum. On the left a smaller, slightly
movable tumor could be felt, which had apparently prolapsed
into Douglas' culdesac.
Upon opening the abdomen several days later two cystic
growths, which were bound together on the posterior aspect of
the uterus, were discovered. The bladder was adherent, espe-
cially to the right growth, and this was freed by blunt dissec-
tion. The coils ol the small intestine were very adherent to
the tumors, and required great care in peeling them off.
Several nicks were made in the serous membrane ol the gut
dviring this dissection, requiring a lew Lembert sutures.
After the growths were finally freed they were ligated and
removed along with the tubes, which were highly vascular, but
appeared in no other way abnormal. The left cyst was ex-
tremely adherent to the sigmoid flexure, and had apparently
discharged its contents into the gut from time to time, but
when it was separated from the large intestine, no evidence of
an opening into the latter could be discovered. A drainage tulje
was inserted down into Douglas' culdesac and was left in place
24 hours, after which it was removed, as there was no evidence
of any leakage taking place from the gut.
The patient continued well until the tenth day, when the
temperature suddenly went to 40° C. By bi manual palpation a
large diffused mass was found in the pelvis, and I decided to
remove the uterus by vaginal hysterectomy. This was done
on the next day with some difficulty, on account of the dense
adhesions, and about 300 cc. of thick creamy pus was evacuated.
The cavity was packed with iodoform gauze, and from this
time on recovery was uneventful.
I now come to my fourth and last case of ruptured
suppurating salpingitis. In this instance the abscess
burst into the bladder, and after a short report of this
case, I desire to direct your attention to a few remarks
on the treatment of rupture of pus-tubes into the urinary
reservoir.
Case IV. — The patient was a young woman, aged 28, who
gave a distinct history ot a gonorrheal infection ol the uterus
and adnexa some two years before I saw her, since which time
she has had several attacks of localized pelvic peritonitis.
When I saw the young woman, in consultation with her
family phvsician, I found a large fluctuating mass on the right
side. I advised operation as urgently indicated, but this was
relused by the lamily.
One week later I was hurriedly sent for, and found the
patient in a wretched condition Irom pain in the bladder and
frequent micturition. The urine contained pus in large
amounts, and by palpation it seemed as if the tumor in the
right iliac lossa had decreased considerably in size.
On the next morning I opened the abdomen in the median
line and removed a pus-tube the size ol my closed fist which
intimately adhered to the bladder. In dissecting it off Irom
this viscus, it was found to have perforated througli the organ,
the opening being about the size of a 10-cent piece.
The opening into the bladder was freshened, and it was
closed according to the method that I have described in my
paper on "Injuries to the Bladder Daring Abdominal and
Vaginal Hysterectomy," which was iiublished in the Boston
Medical and Surgical Jotirnal for November 21, 1901.
The abdominal wound wa.s closed, excepting the lower angle
through which gauze wicking was inserted lor drainage, and
the bladder was drained by a permanent catheter. As im leak-
ing took place the gauzf drainage was removed on the third
day while the permanent catheter was removed on the fifth,
the patient making a slow but excellent recovery.
J believe tliat spontaneous perforation into the blatl-
der of a pelvic suppuration is far more frequent tlian ha.s
generally been admitted, and I also am of the conviction
that these collections of pus which open into the bladder
are not cases of abscess on the road to cure, but on the
contrary are those types of aggravated abscess which
614 AUEBICAX MeDICIMBj
KUPTUKED PUS-TUBES
(OCTOBEK 18, WOT
in most instances end in the death of the patient if
they are not treated in time by surgical measures.
To my way of thinking there are but two methods for
the treatment of pelvic collections which have opened
into the bladder. These methods are laparotomy fol-
lowed by either suture of the bladder or by drainage
without suture, or by anterior or posterior colpotomy
with drainage. Of vaginal hysterectomy for pus in the
pelvis complicated by a vesieal fistula, 1 can only say
that it appears to me an irrational procedure.
In simple cases, such as the one here reported, I
would say that laparotomy with suture of the bladder,
or simple drainage of the abdomen, will without any
doubt give perfect results. After the abdomen is opened
the purulent pocket is freed from its adhesions and re-
moved. An attempt may be made to close the opening
in the bladder, which if too diflftcult, may be left alone
and simple drainage through the abdominal incision
established.
But now if we consider those complicated cases in
which the bladder has been perforated, we are not deal-
ing with an easy problem, because under these circum-
stances the removal of the abscess is practically impos-
sible and should not be attempted, because should this
be done the opening into the bladder may be made much
larger and consequently its closure will be rendered ex-
tremely difficult.
It is well, then, in these cases in which everything in
the small pelvis is involved in the suppurative process,
simply to drain the abscess cavity freely. If the pocket
can be drawn up to the abdominal incision it may be
held there by several sutures, but if this cannot be done
when the general peritoneal cavity is not completely
walled off from the collection, I think that we should
resort to drainage both through the abdomen and through
the vagina.
The number of cases of pelvic abscess which have per-
forated into the bladder and in which recovery followed
simple abdominal drainage or combined abdomino-
vaginal drainage, provfi beyond a doubt that in many
instances this method is quite suflicient to bring about
closure of a tubovesical fistula. On the other hand we
all know that laparotomy is not always successful in
these cases, and in spite of both abdominal and vaginal
drainage the abscess has persisted and the tubovesical
fistula not closing allowed the entrance of pus into the
bladder and finally the unfortunate patients have died.
For that matter unless the fistula in the bladder can
be sutured it takes a very long time to obtain a cure of
this condition in most instances, and although the vesi-
cal perforation may close up quite rapidly after abdom-
inal drainage has been effected, the abdominal fistula in
most cases will close only after several months or even
longer. Sometimes it may happen that this small fistula
will persist indefinitely, and although out of danger to
the patient is nevertheless far from being agreeable.
There is one type of pelvic suppuration which very
frequently discharges into the bladder, and in which I
believe abdominal incision is always indicated, and that
is septic infection of dermoid cysts. By abdominal
incision it is usually an easy matter to free them from
their adhesions and remove the growth, and at the same
time close the perforation into the bladder. But under
these circumstances, before closing the viscus, the inte-
rior should be thoroughly ex[)lored, because it often con-
tains the debris which form the contents of these neo-
formations, which, if left in the bladder, would give rise
to the formation of calculi or other disturbances.
I believe that at the present time we are no longer
obliged to adopt a single method, and that the operative
procedure should vary according to the given case. It
is quite certain that a certain class of pelvic suppurations
which have perforated the bladder should be dealt with
by laparotomy, more particularly those that are situated
high up in the pelvis, or when a pus-tube exists on only
one side.
Anterior or posterior colpotomy certainly has its
indications in some forms of pelvic suppuration which
have opened into the bladder, and the experience of
many prominent operators have proved this beyond a
doubt. The same may be said of the vaginal route
when the collection has opened into the intestine and
the intestinal fistula has closed without any further
interference.
Vaginal incision followed by a free drainage certainly
represents the most perlect type of conservative gyne-
cologic surgery, and if after perfect drainage the tubo-
vesical fistula does not close, and if the pelvic abscess
has no tendency to subside, we have at least placed the
patient in such a condition that an abdominal incision
will usually reveal a condition of aflkirs that can be
easily attended to in a radical manner, thanks to the
preliminary drainage by the vHgina.
As to closing the bladder by way of the vagina, it
seems to me that perhaps in some few selected cases the
method might be applicable. But the operative difti-
culties will certainly be very great. The technic advised
by Condamin consists in doing an anterior colpotomy
and then searching for the posterior wall of tlie bladder.
After anterior colpotomy the posterior wall of the blad-
der is rendered very movable and without any severe
traction it can be drawn down almost to the vulva and
the opening repaired.
Baumgartner was successful with the following
technic : The uterus was drawn down and an incision
made around the cervix. Then a median incision
of the anterior vaginal wall was carried from this
incision to the orifice of the urethra. The vaginal flaps
thus formed were peeled back and then the bladder was
dissected ofl". The organ was then drawn down and its
adhesions with the surrounding tissues broken down.
The fistula was closed by two layers of sutures after the
borders of the opening had been freshened and the blad-
der replaced. The pelvic abscess was drained by the
vagina and a permanent catheter placed in the bladder.
The conditions under which the perforation of the
bladder from a pelvic abscess occurs, vary greatly. In
some instances the pelvic trouble is of long standing and
the patient is worn out by suffering and sepsis. In other
instances we will be dealing with a collection which has
rapidly formed and "bursts into the bladder before the
general health of the patient seems to have been
influenced.
Occasionally the evacuation of pus by the l)ladder is
preceded several days by certain symptoms. The patient
appears to be suffering more acutely, the abdominal pain
is more severe and is especially pronounced in the peri-
vesical region and is accompanied by a feeling of weight
in the pelvis. All the signs of an acute cystitis may be
present, and if the urine is examined it will be found
to have changed in character. It is usually high-
colored, sometimes tinted with blood and may even con-
tain a large amount of thick sediment, but it is usually
only after a few days that pyuria becomes manifest.
Usually these forerunning symptoms are wanting,
and in most cases after a short febrile attack the pus
suddenly becomes evacuated into the bladder, producing
immediate and very marked relief to the patient.
I would point out, however, that pyuria is not always
present, and it may last a few days, sometimes only a
few hours, and then it diminishes and finally disappears
completely. Oftentimes a long period of time elapses
before a new attack recurs which is followed again by
the evacuation of pus by the bladder.
This intermittent pyuria, which corresponds to alter-
nating evacuation and filling up of the abscess, is a fair
indication of a purulent collection in the tubes, and may
continue for a long time before it seriously acts on the
general health of the patient.
On the other hand it should be recalled to mind that
patients afflicted with tubovesical fistula do not always
escape so easily, because in many instances the rupture
October 18, 1902]
TERMINAL INFECTION OF BRIGHT' S DISEASE fAitEBicAN mbdicine 615
into the bladder takes on a very high grade of sepsis.
Pain is severe, cliills recur frequently and are violent,
vomiting is free, delirium may be present, and the face
soon shows those altered traits which denote a serious
infection. The temperature may reach or even go above
40° C. while the pulse is small, filiform, and may count
as much as 140 to the minute.
All this will lead the surgeon to suspect a serious con-
dition within the pelvis, but suddenly the pus is evacu-
ated by the bladder and all the serious symptoms
diminish in intensity. But in these cases the relief
obtained by the voiding of the pus is not so complete as
in the preceding instances, although the amount of
purulent matter voided may be considerable, but never-
theless the patient does not gain strength, and the
temi)erature chart will show that fever is still lurking
within her. Such a case when allowed to run on without
operation will ultimately terminate fatally.
There is still another clinical type in which the fistula,
whether of a permanent or intermittent kind, will not
provoke any reaction. There is no elevation of the
temperature, and the patient is free from pain, and it is
oftentimes only by chance when the patient's general
health has been suffering for some time that pus will be
detected in the urine.
But DO matter what may be the commencement of
tubovesical fistulas, no matter what may be their prog-
ress, whether the fistula is intermittent or permanent,
whether the symptoms which accompany this condition
indicate a severe grade of sepsis, or whether they
appear with an absolutely benign aspect, the end result is
nearly always the same, and these unfortunate patients
finally die.
Spontaneous cure of these fistulas is most exceptional.
They may close up and the patient appear in perfect
health, but this is only an illusion, because the improve-
ment is of short duration, and soon all the symptoms
reappear.
PERICARDITIS AS A TERMINAL INFECTION OF
CHRONIC BRIGHT'S DISEASE.
HERMAN B. ALLYN, M.D.,
of Philadelphia.
Instructor In Physical Diacnosls, University of Pennsylvania; Clinical
Professor of Medicine, Woman's Medical College;
Physician to Philadelphia Hospital.
The occurrence of pericarditis in the course of chronic
disease of the kidneys had teen noted by several early
observers. Bright' himself, in 1827, says: "Out of 17
dissections we have found three instances in which the
patients suffered decided attacks of infiammation in the
pericardium shortly before death ; and in two of these
cases we had proof of previous affection of the same
kind." And again, in 1836, he says that out of 100 cases
in which Bright's disease formed a prominent feature
during life, he found 8, or 1 in 12J, showing existing or
acute pericarditis, and 6, or 1 in 16 J, with remains of
previous pericarditis.
It was not until the remarkable paper of John Taylor^
apppared in 184.'j that the freriuency and importance of
Bright's disease as a cause of pericarditis began to be
ai)pre(;iated. His observations have been confirmed in
all important particulars by Chambers, Bellingham,
Sib.son, Dickinson and numerous later writers, although
lie was in error in thinking that Bright's disease was
nearly as frequent a cause of pericarditis a.s rheumatic
fever.
Taylor selected from the notes of his postmortem
inspections .50 cases in which the patients had either died
of liright's disease or were found after death to have had
that di.sease in a somewhat advanced stiige. Vive of the
cases showed pericarditis and 7 previous pericarditis.
On the other hand, in 142 postmortem examinations in
which the kidneys were either healthy or were not the
seat of any readily appreciable disease, pericarditis was
found only in 4, or 1 in ;55i, and previous pericarditis in
7, or 1 in 20.
Taylor carried his investigation still further and found
that other inflammations, notably of the bronchi, lungs,
pleura and peritoneum, were especially liable to occur in
persons affected with disease of the kidneys. Fifty cases
of renal disease yielded 48 examples of acute inflamma-
tions, that is, 96 inflammations in every 100 patients ;
and that 60^ of the cases were complicated with them,
and that there were 81 examples of previous inflamma-
tions, occurring in 90 fc of the cases. On the other hand,
the 142 cases without renal disease yielded 68 examples
of acute inflammation affecting 86^ of the cases and 179
examples of previous inflammations affecting 70..5^ of
the cases. Taylor concludes that the proportional num-
ber of acute internal inflammations in renal cases is
double that in the series of cases without renal disease.
As regards pericarditis, with which we are particularly
concerned, he finds, as already stated in figures, that it
occurs in lO/o of the cases.
Taylor's conclusions were confirmed by Sibspn's'
analysis of a much larger number of cases. In 285 cases
of Bright's disease examined postmortem at St. Mary's
Hospital, pericarditis was found in 8.8^c; and in 1,691
cases collected from various sources pericarditis existed
in 8.17%. He excludes partial or doubtful pericarditis,
of which there were 15 cases. In granular kidney, which
gives rise to the most typical form of chronic Bright's
disease, of which there were 162 cases, pericarditis was
found in 16, or 10 fc.
Dickinson * found recent pericarditis after death in 16
of 68 cases. He agrees that it is most frequent with the
granular kidney. As regards the relative frequency of
the various causes of pericarditis all are agreed that
rheumatic fever comes first, the percentage given by
most authors being from 30 ^ to 70 % . Sears,^ in a study
of 100 cases at the Boston City Hospital, assigns rheuma-
tism as a cause in 51 cases ; pneumonia or infection with
the pneumococcus in 18 ; while in 7 chronic nephritis,
and in 5 pleurisy were the primary diseases.
The cause of the pericarditis occurring in Bright's
disease has been the subject of considerable study. It
has been attributed to uremic intoxication, to adyscrasia
and to infection. For an interesting review of French
and German literature on the subject see liab6's * paper.
Lancereaux and his i)upil KCraval defended the uremic
theory. Lecorch6 and Talamon regarded it as an infec-
tion analogous to bronchopneumonia and pleurisy by
extension from neighboring organs. There were no
bacteriologic studies to support their theory. Banti, in
1888, reported a case of pericarditis occurring in Bright s
disease which he studied bacteriological ly without result.
Merklen, in 1892, also reported a ease in which he
obtained negative results from bacteriologic study. In
1 894 Banti reported two more cases with negative results.
He also experimented with rabbits, rendered them
uremic and produced pericarditis, but his results are in-
conclusive.
Beco (1894) obtained no result from cultures made
from the pericardium, but found li. colt communis in the
spleen and blood, and concluded that the pericarditis
was due to toxins secreted by this germ. He cites the
experiment of Charrin (1894), who produced inflamma-
tion of serous membranes by subcutaneous injection of
toxins of B. pyocjjaneus.
Banti,' a champion of the uremic theory, returns to the
subject again in 1895, and asserts that the bacteria found
in Beco's case were due to agonal invasion. Kab6 main-
tains that the pericarditis of Bright's disease can develop
without Inflammation of ac^acent tissues. Probably the
pericardium is a place of diminished resistance and then
infection occurs.
In 1896" Flexnerpublishefl "A Statistical and Experi-
mental Study of Terminal Infections," based upon the
records of 255 out of 793 autopsies in which occurred
616 AMERICAN MEDICINE, TERMINAL INFECTION OF BRIGHT'8 DISEASE
[(JCTOBEK 18, 1002
chronic heart or kidney disease and in which the
bacteriologic examination was sufficiently complete to
make them of use for study. Of the 255 cases 213 gave
positive and 42 negative results. In cases in which the
kidneys were the chief feature, of 32 cases unassociated
with heart or other chronic disease, 29 gave positive and
3 negative results. Similarly of 112 cases of combined
chronic kidney and other chronic diseases, tumors, etc.,
51 were positive and 3 negative. The infection may be
general or local. In acut« pericarditis the bacteria were
found in the following order of frequency :
Infection Atkium.
Pneumonia g
Bronchiiis 2
Erysipelas 1
Leg ulcer 1
Tonsils 1
Peritoneum 1
Cancer st«mach 1
Sloughing myoma.. 1
Doubtful 7
Bacteria,
M. lanceolatus 11
Streptococcus 4
Staphylococcus aureus 1
B. pyocyaneus 1
B. Influenzie 1
M. lanceolatus and B. coll com.. 1
Strep., stapbyl. aureus and B.
coli communis 1
Staphyl. and B. coli com 2
Unidentified 1
Probably an effect of the chronic disease is to lessen
the germicidal power of the blood-serum and so render
invasion by microorganisms easier of occurrence.
Since Plexner's paper appeared his results have been
verified as to pericarditis by two French writers, Bosc
and Baillet, although they do not seem to be aware of
Flexner's work ; Bosc" reports a case of pericarditis
occurring late in a chronic interstitial nephritis with
uremia. The patient was a man, aged 35 ; pneumococci
were found in the deep parts of the pseudomembranes.
Baillet " reports three cases of nephritis, two inter-
stitial and one subacute, in which pericarditis developed.
At autopsy, cultures showed bacteria to be present. In
two cases they were B. coli communis, the autopsies
having been made 36 and 35 hours after death ; in the
third case a streptococcus was found, the fluid being
serosanguinolent, and the autopsy 28 hours after death.
It is evident from this important study of Flexner's
that the numerous ailments that afftect old people and
those with chronic diseases are not simply the result of
exposure and the like, but are due to lessened internal
resistance, as a result of which pathogenic microorgan-
isms invade the lungs and serous membranes. It is pos-
sible also that in the case of the pericardium , the enlarged
left ventricle and increased energy of its contraction may
have a damaging effect upon the pericardium and so
make it a part of lessened resistance. Sibson states that
the heart was enlarged in more than half the cases of
Bright's disease with pericarditis in which the size of
the heart was defined (10 in 19) ; and although hyper-
trophy is absent in almost half the cases, he believes that
even in these the action of the left ventricle is unduly
strong, and this undue pressure on the walls of the peri-
cardium tends to induce pericarditis.
The pathologic anatomy of the pericarditis of Bright's
disease diffters in some particulars from that of rheumatic
fever. It may be dry, fibrinous, serous, serosangui-
nolent, bloody or purulent. The amount of fluid present
varies considerably. In Sibson's 25 cases the smallest
quantity was two drams and the largest about a pint, in
which case it was purulent. When fluid is present, it is
more frequently mixed with blood or pus than is the
fluid found in rheumatic pericarditis. In my own case,
to be reported presently, the fluid consisted of bloody
serum, and 44 ounces were withdrawn by aspiration
before death.
In the thesis of Debest de Laerousille," on hemor-
rhagic pericarditis, the author has collected 25 cases,
excluding old cases, cases due to cancer and to scurvy.*
Some of these cases evidently belong in the group
which we are studying. For example : In an autopsy
* For an account of an epidemic of scurvy in Russia accompanied
with hemorrhagic pericarditis see Seidlitz, Brit, and For. Med Rev.:
and Kyber, Edin. Month. Jour., March, 1840. In 60 sub.iects who died
of scurvy (Karawagen, Medicinische Zeltung, December, 1840, and
Brit, and For. Med. Rev., Vol. xii) 30 had hemorrhagic pericarditis.
The iluid was dark and amounted tx> four or five pints.
on a man who died of pericarditis, the pericardium was
enormously distended with IJ liters of bloody serum.
There was enormous dilation and hypertrophy of the
left ventricle and atrophy of the tubular structure of the
kidneys.
Here is another from the thesis of Marguerite (Paris,
1862) : A man aged 45 with hypertrophy of the heart,
old pericarditis, recent hemorrhagic pericarditis, right
hemorrhagic pleuritis, right pulmonary apoplexy, insuf-
ficiency of the mitral orifice, contracted kidneys.
And again another case, abstracted also from the thesis
of Marguerite : Old lead poisoning hypertrophy of the
heart without valve lesions ; hemorrhagic pericarditis ;
left hemorrhagic pleuritis; slight congestion of liver;
chronic nephritis.
There are other cases also in which the kidneys were
diseased, but the history does not make it clear that the
chronic nephritis was the primary disease.
Hemorrhagic pericarditis may also occur in rheuma-
tism. Sears" reports a case in which ten ounces of
bloody fluid were withdrawn from the pericardium, the
fluid containing pneumococci. He says he has found 11
cases of hemorrhagic pericarditis in literature", ending in
recovery. Six occurred in scurvy, five being reported
previous to 1854 ; three were rheumatic and one was
associated with exophthalmic goiter. One was appar-
ently iodiopathic, occurring in an alcoholic subject.
The following case is one of hemorrhagic pericarditis
occurring as a terminal infection in chronic interstitial
nephritis :
G. W., white, laborer, aged 26, was admitted to the Phila-
delphia Hospital June 6, 1902, complaining of pain beneath the
sternum and in the lumbar region ; there was edema of the feet
and legs, shortness of breath and weakness. The family
history is unimportant.
Previous History.— In 1897 he had a fall, breaking six ribs
and remaining unconscious about 12 hours. In the same year
he had another fall from a tree, alighting on a picket fence ; one
picket struck him above and to the left of the left nipple, and
left a soar about IJ inches in length. Also in the same year he
ran a pitchfork into the right foot, from which he says blood-
poisoning developed. In February, 1901, he contracted gonor-
rhea, which he says was treated and cured. About the same
time he began having severe headaches, occurring once a
week. They were accompanied by vomiting, and persisted up
to his entrance into the hospital. In November, 1901, his eye-
sight began to fail. On admission he could not see to read or
write. A physician who examined his eyes told him nothing
could be done until his kidneys were attended to. Last
December he noticed that he was short of breath on exertion,
and since then dyspnea has grown progressively worse. He
had a severe " cold " in March, lasting a week.
On admission there was marked dyspnea and general weak-
ness. He was almost too weak to stand alone. Vertigo was a
Erominent symptom and grew worse on the least exertion. He
ad shooting pains through his chest and a gnawing pain in
the epigastrium. There was severe pain in the lumbar region,
shooting in character. The feet and legs were much swollen
and edematous to the hips. There was some edema of the lumbar
region. He complains of an itchy feeling all over the body.
His general appearance is that of a fairly well-developed and
nourished man. The pupils respond to light and distance.
When attempting to see an object plainly he holds it within
six inches of his face. The tongue is covered with a dark fur
and is rather dry and cracked. The mucous membranes of
eyes and mouth show anemia. Teeth are in poor condition.
The pulse was slightly increased in frequency, regular, full,
not easily compressed. The veins of the arms and legs were
more distended than normal. The chest showed some promi-
nence of the precordium. The impulse of the heart was diffused.
The apex beat appeared to be li inches below the left nipple.
There was a systolic murmur faintly transmitted to the axilla
and to the angle of the scapula. There is a dull area extending
from the second rib to the sixth rib on the left side, and to two
inches to the right of the right border of the sternum. No
fremitus over dull area. A few fine crackling rales are heard
beneath the lower angle of left scapula. The abdomen shows
nothing except slight enlargement. The knee-jerks are les-
Jiinell, 1902: Lips and finger nails are bluish. There is
marked pulsation of the carotid, subclavian, and axillary
arteries. The superficial veins are full. The chest is well
formed, except that the left precordia is slightly prominent.
Respiration is frequent and labored. There is visible pulsation
all over the thorax, extending down to the right and left upper
quadrants of the abdomen. On percussion of the right side
dulness begins at the third rib, midclavicular line; at the
fourth in anterior axillary line, and at the fifth in midaxillary
OCTOBER 18, 19021
TERMINAL INFECTIOISr OF BRIGHT'S DISEASE iAmkmoan mkdicinb 617
line, and extends to the costal margin. On the left side dul-
ness begins at the second rib in the midclavicular line, fourth
rib in midaxillary line. At the seventh rib, midaxillary line,
the percussion note becomes tympanitic and continues so down
to the pelvis. Fremitus is slightly increased over the upper
portion of the right lung, diminished over the upper portion of
the left. There is distinct bronchophony over tne upper por-
tion of the right lung, where also respiratory murmur is some-
what roughened. Toward the steroum on the right side the
murmur is bronchovesicular. It has the same character in the
upper right axilla. On the left side the respiratory murmur is
very feeble, but the normal relation between inspiration and
expiration seems to be maintained. In the left axilla no respi-
ratory murmur can be heard. Vocal resonance is very distinct
down to the seventh rib, below that it is much diminished. In
the first interspace to the right dulness «xtends about a finger-
breadth 1 5 the right of the sternum, and about two finger-breadths
in the second interspace. There is a little resonance between
the margin of the sternum and the right parasternal line in the
fourth interspace. The dulness previously described in the
right midclavicular line is continuous to the sternal margin.
In the fifth right interspace dulness extends to the midclavic-
ular line. In the midsternal line dulness begins at the
level of the second rib. The dulness is accompanied with
much increase in resistance. There is no visible apex beat,
but it is felt most distinctly in the fifth interspace about one
inch external to the nipple line. At the aortic cartilage the
second sound is accentuated, impure, but without a distinct
murmur. To the left of the sternum there is a rumbling mur-
mur more distinct toward apex and heard at the fifth inter-
space an inch to the left of the nipple line ; here it has the char-
acter of a double mitral murmur, with a thumping first sound
and an accentuated second sound. It is slightly transmitted
to the axilla. The murmur is also well heard toward the ster-
num from the apex beat. A somewhat softer systolic murmur
is heard at the base of the xiphoid cartilage. This murmur
can also be traced up the sternum, but it is not heard in the
carotids. Posteriorly, percussion is clear on the right side, and
in the left in the midscapular line ; it becomes dull in the
posterior axillary line at the level of the scapular spine. In
the latter situation the breath sounds are feeble, almost absent.
There is a distinct systolic fremitus centering around the apex
and less intense in the axilla.
On .June 19 Dr. Pfahler made a fluoroscopic examination
which showed that the dull area was opaque and did not pul-
sate, but that the upper level moved on change of posture of
the patient. The patient became so wildly delirious that re-
straint was necessary.
On June 20, with the assistance of Dr. .lohnson, the resident
physician, an exploratory puncture was made in the fifth right
interspace and bloody seruui obtained. Aspiration was imme-
diately performed and 44 ounces of bloody serum withdrawn.
On June 21 it is noted that the previous dull area has con-
tracted so that on the right side dulness begins at the mid-
sternal line. On the left side the upper limit is the upper
border of the third rib. The apex beat is in the fifth interspace
li inches to the left of the nipple. The area of pulsation is
very diffuse, being practically the same as before. The first
sound is still strong and accompanied by a systolic murmur,
slightly rumbling in character. The second sound is accentu-
ated at the apex, pulmonary and aortic areas. Over the fourth
riband fourth interspace to the left of the sternum, a rather
high pitched, strong diastolic murmur can be heard. The lungs
are congested.
The urine was examined on two occasions, June 10 and
June 20. It contained albumin, but no casts. The specific
gravity was 1,010. The temperature was normal from his en-
trance to June 21, when it rose to 101°. The respirations ranged
from 24 to 28 until June 21, when they became ;W to 40. He had
a convulsion on June 21, and continued very delirious until
death at 4.10 p.m.
AutoDHy was performed by Dr. Gay at 10.30 a.m. June 22,
1902. Pathologic diagnosis : Chronic interstitial nephritis (small
granular kidney); hypertrophy of the loft ventricle of the
heart; acute serous pericarditis; acute fibrinous pleuritis;
congestion of the lungs; chronic interstitial splenitis.
The pericardium is seen to be euormously enlarged. The
left lung is closely adherent to the pericardial sac by fibrous
adhesions. Both lungs are bound very generally by fibrous
adhesions over the entire surface. The pericardial sac contains
about 2.50 ounces of bloody serous e.xudate. There are a few
strings of fibrin on the anterior surface of the heart, but not
adherent to the pericardium ; pericardium itself is injected, but
with the exception of two or three small areas is everywhere
smooth and glistening. The heart is enormously hypertrophied,
the hypertrophy beiug entirely confined to the lett ventricle.
The walls of the loft ventricle measure about .'tj cm. in thick-
ness. The heart valves are normal. Kndocardiuin is every-
where smooth and glistening. Heart muscle is normal in
appearance and presents no appearance of interstitial or fatty
change.
Both lungs are markedly congested, but otherwise normal.
Spleen is aliout normal in size and on section the connective
tissue trabeculic and inalplghian bcxlies are prominent. It
shows postmortem softening. The liver is smooth, normal in
size, and on section presents a uniform appearance. Oall-
l)ladder is normal, both ducts patent. Mesenteric lymph
glands are slightly enlarged and injected. Stomach, intestine
and pancreas are normal. Adrenals are normal but increased
in size.
Kidneys are similar; both are very much decreased in size,
grayish red in appearance, and markedly granular. Capsule
strips with some difficulty. On section the cortex is found to
be extremely reduced in thickness, measuring on an average
about 1 mm. There is a small retention CTst in tlie right kid-
ney. Bladder and prostate are normal. Testicles are normal.
Aorta shows a few healed atheromatous plaques, but in gen-
eral it is normal.
Dr. Gay tells me that cultures from the organs showed the
presence of B. coH communi.t.
The symptomatology of this form of pericarditis dif-
fers considerably from that of other forms. The reason
for this is easy to find. In the first place the pericarditis
develops almost always in the final stages of a disease
which of itself can account for all the symptoms that
may be present. It is, moreover, often latent and painless.
When effusion takes place the most constant symptom is
dyspnea. Owing to the hypertrophy of the heart there
may be no diminution in the intensity of the heart
sounds and no displacement of the apex beat. Its appear-
ance is so common at the end of Bright's disease and in
persons in uremia that it is spoken of by many French
and Gierman writers as uremic pericarditis. Its onset,
therefore, occurs without definite symptoms. In many
instances it is detected only at autopsy.
As to physical signs, Sibson noted that a thrill was
present in four out of ten ca.ses, and a new-leather sound
in six out of ten cases, and that these same signs are
much less frequent in rheumatic pericarditis. Moreover,
he thinks that the long duration of the friction sound
and its frequent suspension observed in several of the
cases distinguish them from those with rheumatic peri-
carditis.
When efl'usion takes place the most important sub-
jective symptom is dyspnea. It may or may not amount
to orthopnea and but rarely gives rise to the great pant-
ing for breath which is familiar in acute rheumatic peri-
carditis with eifusion, and the patient's face does not
betoken as much mental distress.
The physical signs of pericarditis with effusion are in
the main sufficiently familiar not to need repetition. I
would like, however, to dwell for a moment on three
which are important.
1 . Dulnejis in the Fifth Interspace to the Right of the Ster-
num.— This has been present in every case of pericardial
effusion that I have examined. In health thecardio-
hepatic angle in the fifth right interspace is acute, in
pericardial effusion it becomes a right angle or even an
obtuse angle.
2. Fluoroscopic Examination. — This is as helpful in
pericardial effusion as in pleural effusion, and is exceed-
ingly important. The opaque area does not pulsate as it
would in aneurysm or enlarged heart, afid the upper
level can be seen to move with change of posture of the
patient.
3. Pulsation of the Vessels of the Neck. — This may be
as marked as it is in aortic disease, and may be accom-
panietl with capillary pulse. Stokes mentionetl it, and
Huchard '" has recently called fresh attention to it. He
remarks also that a pericardial effusion can produce
nearly all the symptoms of a pleural effusion. IJulness,
diminution of fremitus, diminution and even absence of
respiratory murmur, and sometimes egophony. He also
declares that these phenomena of pressure upon the
lungs resembling those due to pleural effusion disappear
when the patient is placed in knee-chest posture,
whereas the pressure signs do not disappear when they
are due to pleural effusion. I have had no opportunity
to verify this assertion.
Exploratory Puncture with an Aspirating Needle. —
I believe this is harmless when civrriwl out with aseptic
precautions and with due care to avoid puncturing the
heart. It is the most certain method of discovering the
presence of fluid.
The duration of this form of pericarditis is short.
618 AMERICAN MBDrCINEj
ASTIGMATISM AND EYESTRAIN
[October 18, 1902
Rab6 says there are only two cases (thesis of K6raval) in
which the disease lasted more than eight or nine days ;
in one case it lasted a month, in another three months
after the appearance of a friction sound. In the case
here reported the duration may have been months.
The prognosis of the pericarditis of chronic Bright's
disease is practically always fatal. It merely hastens an
ending that would be inevitable at any rate. Sears says
that of his series every ca.se but two associated with hepatic
cirrhosis or kidney disease terminated fatally, and of
these exceptions one patient was discharged unrelieved,
while the other case was evidently not connected with
the nephritis but was rheumatic in origin. The recog-
nition of the pericarditis is therefore of greater impor-
tance in the prognosis of the renal affection than in the
treatment of the pericarditis itself.
BIBLIOGRAPHY.
1 Bright : Reports of medical cases, 1827, Vol. 1, p. 71 ; Guy's Hospital
Reports, Vol. i, 1836, p. 380.
2 Taylor, John : (Jn some of the causes of pericarditis, especially
acute rheumatism and Bright's disease of the kidneys ; with Incidental
observations on the frequency and on some of the causes of various
other internal inflammations; Medico-Chir. Trans., Vol. xxvlii, Lon-
don, 1845.
3Sibson, Krancis: Reynolds' System of Medicine, Vol. Iv; Mac-
mlllan & Co., London. 1877.
< Dickinson, W. Howship: Allbutt's System of Medicine; Vol. Iv,
Art. on diseases of the kidneys.
sSears, George G.: Boston City Hospital Rep., 1897, p. ■.30.
6Rab6: LaFfirioardite brightlque ; Gaz. des HOpitaux, August 21,
1897.
'Banti, G.: Ueber die Aetiologie des Pericarditis urajmica; Central-
blattfurallgem. Pathol., 1895, vi, 182.
*Flexner, Simon: Journal of Experimental Med., 1896, i, 559.
»Bosc, F. J.: De la pericardite des brightiques; La Presse MSd..
Paris, 1898, ii, 185.
■"Baillet, Emile : De la nature infectieuse des p^ricardites ure-
miques; Journal des Praticiens, Paris, 1899, xiii, 51
" Debest de Lacrousille, Armand : De la pgrlcardite hfimorrhagique ;
Thfese de Paris 1865.
1! Huchard ': Les symptomes pseudopleurltiques et pseudoaortiques
de la pgrlcardite ; Rev. g6n. de ciin. et de thgrapeut., 1898, xii. 227.
^3 Sears, George G.: A ca.se of hemorrhagic pericarditis due to pneu-
mococcus ; aspiration ; recovery ; Boston Med. and Surg. Jour., Sep-
tember 22, 1898 ; also December 6, 1900.
THE DISCOVERY
OF ASTIGMATISM AND
STRAIN.
EYE-
GEORGE M. GOULD, M.D.,
of Philadelphia.
Among the many minds fused in the personality of
Thomas Young there were those of the physician and
the physicist. Astigmatism was discovered by the mind
of the physicist, and great as was the discovery it is a
pity that it was so. Many others, and independently of
each other, soon rediscovered the fact, so that the world
would not long have been without the knowledge of it.
While we are proud that we owe the researches and the
memoir,* "On the Mechanism of the Eye,"' to a physi-
cian, the fact that it sprang from the intellect of the non-
medical scientist is of tremendous significance. The optical
and mechanical way of looking at astigmatism instituted
by Young was carried on by Airy, Bonders, Helmholtz
and their successors, and is today the certain and sole
cause that many millions of people are needlessly endur-
ing lives of intense suffering and wretchedness. To
Young and to the youngest ophthalmologist, excepting
a relatively small number of Americans, the sig-
nificance of astigmatism has been physiologic instead of
pathologic, has related solely to optics and the increase of
visual acuity instead of to disease, and the remote effects
of morbid physiology. This strange and fatal prepos-
session at once came out in Airy, who discovered
"abnormal astigmatism," that is, "astigmatism that
interfered with vision," by which term there was an
utter ignoring of the all-important truth that disease is
nothing more than morbid physiology. All over the
world socalled medical men practising ophthalmology
as a specialty have the same conception of the matter
* Read before the Royal Society, November 27, 1801.
and everywhere the ignorant and greedy optician is
criminally allowed to pursue his calling of using articles
of the materia medica (spectacle len.ses) which have as
powerful an influence in curing or causing disease as any
other, except the violent poisons.
Concerning Young's discovery his worthy successor,
Bonders,^ may be quoted :
The distinguished natural philosopher, whose brilliant
merits in the domain of physiologic optics were first duly esti-
mated by Helmholtz, was himself nearsighted. In relaxation
of the eye, consequently in determination of the farthest point,
he saw in his optometer, held in a horizontal position, the
double images of the thread intersect one another at seven
inches from the eye, on the contrary, at ten inclies when in a
vertical position. This indicates, on reducing the English to
Parisian inches, an astigmatism of 2*5; and it is, therefore,
strange that Young, as he himself remarlis, had experienced
no disturbance from it. The optician, Cary, to whom Young
communicated his discovery, stated to him that he had before
often found that nearsighted peopledi.'itinguished objects much
more acutely when the glasses suited to them were lield in a
particular oblique direction before the eye; now by this
maneuver, at least when strong glasses are necessary, a certain
degree of astigmatism may be corrected. Young, too, had
already studied and delineated the form of the diffusion spots.
'The source of astigmatism he sought in the crystalline lens,
because it continued when he plunged his cornea into water
and replaced its action by that of a convex lens. He now
assumed an oblique position of the crystalline lens as a cause,
and even thought tliat from the diffusion-images of a point of
light it might be deduced that the two surfaces of his lens
were not centered. In a double point of view, therefore.
Young's eyes presented an exception: the refraction was
stronger in the horizontal than in the vertical meridian, and
the cause lay principally in the lens.
NageP states that Gerson, 1810, described astigma-
tism, in the inaugural dissertation at Gottingen, in the
eyes of Professor E. G. Fischer, of Berlin.
We hear nothing more concerning the subject until
1815, when in Vol. xxviii, "Repertory of Arts," 1816,
Stedman Whitewell, an architect, describes square
shaped lenses for spectacles in which each side is ground
as a cylinder, with the axis of one at right angles with
that of the other. No mention is made of the device as
regards the correction of astigmatism.
In the Repertory of Patent Inventions for December,
1826, there is an article entitled, "On the means of
ascertaining the true state of the eyes, and of enabling
persons to supply themselves with spectacles the best
adapted to their sight," by John Isaac Hawkins, Chase
Cottage, Hamstead Road, and dated September 21, 1826.
From this I extract as follows :
I have, through life, noticed that I could not see so dis-
tinctly with my right eye as with my left, and recently by the
use of the optometer I have ascertained ttiat the indistinctness
is occasioned by the vertical focus of that eye being greater than
the horizontal focus, while in the left eye they are both at
nearly the same distance. By vertical focus is meant the
focus of those rays that enter the eye one above the other ; and
by horizontal, the focus of those rays that enter the eye side by
side, the difference no doubt arising from the vertical curvature
of the eye being different from the horizontal which may take
place either in the cornea or front part of the eye or in the crys-
talline lens situated within the eye. Having ascertained the
average measurements of each focus of my two eyes, I contem-
plate making glasses for my right eye that shall have greater
magnifying power vertically than horizontally; to accomplisli
which I shall avail myself of a plan patented in France by M.
Chamblant, optician, of Paris, and make the surfaces of my
glasses segments of cylinders, one side vertical and the other
horizontal as described in Dr. Rees' encyclopedia under the
article Spectacles.
In places where an optometer cannot be procured, a book
ruled for music will afford the means of ascertaining whether
there is any considerable difference between the horizontal and
vertical foci of the eyes, and of approximating toward an accu-
rate measurement of them.
To measure the horizontal focus of the left eye, hold the
music book with the lines vertical and shut or cover the
right eye, move the book nearer to and further from the eye
until the ruled lines appear most distinctly ; then measure
the distance from the book to the eye as before described.
Then hold the music book with the lines horizontal and
again move it until the lines appear most distinctly, the dis-
tance from the eye will be the vertical focus ; open the right eye
and shut or cover the left and proceed in the same way to ascer-
tain the two foci of the right eye, always recollecting that to
measure the horizontal focus the music lines must be held
OCTOBER 18, 1901i]
ASTIGMATISM AND EYESTRAIN
[American Medicine 619
vertically, and to measure the vertical focus the music lines
must be held horizontally.
Hawkins adds that these and other observations in
the same article are the results of 18 years of experience,
so that it is probable that he understood astigmatism
previous to 1826.
The foregoing reference to Chamblant may be sup-
plemented bj' the remark of Sulzer/ of Paris, who says
that lenses formed by two equal cylinders either convex
or concave, crossing one another at right angles, were
known before 1820. An article by Goode, published in
1847, states that Chamblant had also ground piano-
cylinders and unequal crossed cylinders that were
intended for the correction of astigmatism.
The next contribution upon the subject is that of
Airy, the Royal Astronomer of England, described in
the Transactions of the Cambridge Philosophical Society,
1827, Vol. ii, p. 267. We may again conveniently quote
the abstract of Bonders : *
Airy was the first to discover abnormal astigmatism ; that
is, astigmatism that interfered with vision, in fact, in his own
left eye. At the same time he conceived that a cylindrical glass
might correct the asymmetry, which he actually found to be
the case, the disturbance of vision being corrected by such a
glass. The form of his astigmatism was the compound myopic.
Airy conceived that if he had two concave cylindrical surfaces
ground, with axes directed perpendicularly to each other, each
corresponding to the degree of myopia to be corrected in the
principal meridians, the object should be attained.
As point of light a small opening in an opaque disk is
employed, turned toward the light of the sky, toward a dull
glass or the globe of a lamp, and this is moved along a gradu-
ated scale, for example, that of an optometer. We then find a
greatest distance at which the point of light appears as the
most slender line, and a shortest distance at which it again
becomes a thin line, perpendicular to the first. The distances
then give about the degrees of myopia in the principal merid-
ians. *
According to Lawrence' the lenses by which Airy
corrected his own astigmatism were ground by Fuller at
Ipswich {London Medical Gazette, Vol. i, p. 134).
The term astigmatism was first used by Rev. Dr.
Whewell to designate the defect described by Airy.
In the American Journal of the Medical Sciences for
April, 1872, n. s., Vol. Ixiii, pp. 355-359, there is a note
respecting the first recorded case of astigmatism in
America for which cylindric lenses were made, contrib-
uted by Dr. Henry D. Noyes, of New York. From this
the following extracts are made :
By the kindness of Dr. Gray, of the New York State
Lunatic Asylum, Utica, I have come in possession of a pair of
cylindrical glasses which I suppose were the first ever made in
this country. They belonged to Rev. Mr. Goodrich, who at the
time of his death was chaplain of the asylum. They were given
to me wrapped in a piece of writing paper on which, in the
owner's handwriting, was inscribed the following memoran-
dum: 'No. 7 French No. (number) cylinder, con. got of
McAllister May, 1828. I wore 14 months, i. e., till July, 1829.
Again put into use March 11th 1813; they were laid aside Dec.
10-18,50.'
The glasses are plano-concave cylinders of 7 inches focus
with axes horizontal and were mounted in a spectacle frame
witli oval eyes. The n\aker is the old and wellknown optician,
Mr. John McAllister, of Philadelphia.
The following is extracted from the account given by
Mr. Goodrich himself:
Prom my earliest years I have been sensible of a defi-
ciency in sight which 1 was induced to call nearsightedness
because I was obliged t<i approach nearer to objects to see them
than most persons, which is still the citse. This deficiency
until I was about Ki years of age was accompanied with weak-
ness of sight, but my eyes are now strong. I commenced my
studies regularly at the age of 19 and am now 24. Close study-
has had no other effect upon my sight than to strengthen its
endurance but not its precision or length. My right eye is and
always has been much better than my left, but the defect
in both is precisely of the same nature. At the age of 16 I pro-
cured a pair of plain green glasses, which were some little
assistance in moderating the intensity of the light. I tried to
• The theory of rcfnictlon by asymmetrical Hurfftce* was developed
by Sturm (Complcs reiidus dc rAi-adcinle des HeleiiceH de TarlH t xx
f^'l"*M"di '^H ""'A ''"^8£"''"''""'' Annalen, H. M, 116), (Compare with
get concave glasses, but could find none that were of any essen-
tial assistance. I afterward used a small convex lens of abuto
10 inches focal distance, as a microscope, to assist me in read-
ing, which was some assistance, but during the five years of
studying I have used no glasses whatever. In November last
(1825) I procured a pair of concave glasses in New York, about
5 or 6, which will accompany this letter. Until then I had
never discovered that a change of position had any influence
on my sight, but in looking through these glasses 1 found that
any object whose length is in a horizontal direction appears
much more distinct than a similar object whose length is per-
pendicular to the plane of the horizon. Thus the cross-rigging
of a ship appears mucli more distinct than the mast and per-
pendicular ropes. I have since been led to make experiments
first on the naked eye, then on it in connection with my glass,
which I send you, and the result at which I have arrived has
been universally the same. These facts [experiments and dia-
gram of Goodrich omitted] would lead me to conclude that
the crystalline lens of my eye is cylindrieally convex or, per-
haps, oblately convex, and that its greatest length is in a per-
pendicular direction (that is, in a Hue parallel with the length
of my body) ; consequently I would conclude that a glass
whose shape resembled the probable shape of the crystalline
lens of my eye, placed before my eye so that its greatest length
would be at right angles with the lens of my eye, would pro-
duce a perfect image. If it be true that my eye requires a glass
whose shape does not correspond to a portion of a true sphere,
but rather to a ])ortiou of a spheroid or, perhaps, a cylindric, I
cannot tell from any observations I have yet made on my eyes,
whether the glasses should be of the concave or Convex form.
The great difflculty is why should the appearance of objects be
entirely changed by the interposition of a concave glass?
When I purchased my glasses I was not aware of this curious
fact in regard to my eyes either with or without glasses. I only
knew that I got those through which, on the whole, I could see
best. If it be asked whether I considerthe glasses in question
are essential assistance to my sight, I answer that if my object
be to examine a horizontal object, they truly are assistance and
they are so in the examination of a perpendicular one, provided
I turn my head at a right angle.*
Leuff"' determined the radius of curvature of one
cornea in the vertical and horizontal meridian.
Wharton Jones " and Wilde' assume that the founda-
tion of astigmatism is really to be sought in the cornea
and that the cornea in its vertical meridian has a shorter
radius of curvature than in the horizontal and they
explain Airy's case by a peculiar development of that
difference.
Hamilton '" reports a case of abnormal astigmatism
in 1847.
Dr. Goode " described astigmatism in his own eyes
and those of other three gentlemen in the University of
Cambridge in 1848.
Stokes '* invented the astigmatic lens for determining
the degree of astigmatism in 1849. This consisted of two
cylindrical lenses, the one plano-convex of yVi the other
plano-concave of ^^. These are fastened in copper rings
which are fitted into one another and can turn past one
another around their axis. The lenses rotate past one
another, at the same time their flat surfaces being toward
each other. The degree of astigmatism is ascertained by
an index and scale on the rings.
Pastor Schnyder, according to Donders," of Meuz-
burg, discovered astigmatism in his own person."
In 1855 Helmholtz confirmed previous findings as to
the ellipsoidal nature of the cornea, and in 18(50 Donders
brought the matter to a full and complete scientific state-
ment.
An important factor of progress was now supplied by
an American, Dr. Ezra Dyer, who, after extensive
studies abroad, returned to Philadelphia in 1861 to prac-
tise ophthalmology. He was the first, I think, to per-
fect the inethods of accurate and scientific diagnosis of
astigmatism, and its relief by spectacles, as a daily clin-
ical practice. I cannot leiirn that Dyer had any intel-
lectual conception of the pathologic significance of his
work. That honor is reserved for Mitchell and for other
Philadelphia specialists in diseases of the eye. Dyer's
great service was that he first as routine practice did
honest and scientific work in refraction. The results
soon showed that patients were at once and unexiiectedly
• In I.iiwrence'B " DlBcaHOH of the Kye," 18.M, p. 669, two oilier eases
corrected for bim by McAUlgtor In PbflHdelphia In 1853 are described
by Hay.
620 AJIEBICAN MEDIOtlTBj
ASTIGMATISM AND EYESTRAIN
[OCTOBER 18, lii02
relieved of their previous iieadaches and other sufferings.*
The systemic effects of the neutralization of ametropia by
glasses were almost magical, and immediately a number
of keen-minded physicians caught the truth and began
their successful life-work as refractionists. These were
Doctors Thomson, Norris, Harlan, Hays, Morton, Risley,
and others.
The house of Queen & Co. began filling prescriptions
for cylinders in 1874, the order of the first ones being
signed by Norris, Thomson, Thomson, Norris, Norris,
Risley, etc., respectively.
Dyer first put into use the test types previously sug-
gested by Snellen, and which in the United States were
called " Dyer's Types," or " Dyer's Test Letters."
In 1863 Dr. Hasket Derby, of Boston, reported '" four
cases of astigmatism, the correcting cylinders being
ground by Paetz and Flohr, of Berlin. The first exam-
ination for astigmatism and prescription of cylindrical
lenses in Boston was one of these cases, and was made by
Derby on May 12, 1862. The patient was still living on
September 30, 1902.
Dr. G. Hay described a case of astigmatism in the
Boston Medical and Surgical Journal, 1867, Ixxv, pp.
513-515.
Dr. John Green,'" in 1867, wrote a paper on astig-
matism as an active cause of myopia.
Dr. O. M. Pray described his test type for the diag-
nosis of astigmatism in 1869."
Dr. Mills reported a case of compound myopic astig-
matism in the service of Dr. Harlan in Wills Hospital in
1871.'*
But up to this time there had been no word or hint
that astigmatism had any pathologic significance. With
all these investigators it had been solely a matter of
physiology, of optics, mechanic or physiologic, referring
at best only to visual acuteness. Now, however, arose a
man, an American, Dr. S. Weir Mitchell, who must be
recognized as one of the greatest medical discoverers and
benefactors of the race. So far as I can learn he first
taught the pathologic significance of astigmatism and
eyestrain, and that the prescription of cylindric lenses is
of vast importance in the cure and prevention of sys-
temic diseases.
Nothing that our distinguished colleague has ever
contributed to medical progress can equal the value
of that of the masterly articles which he wrote in 1874,
1875 and 1876 upon the subject of eyestrain. The first
was entitled "Headaches from Heat-strokes, from
Fevers, after Meningitis, from Overuse of the Brain,
from Eyestrain."" The second was called "Notes on
Headache," "^ and the third " Headaches from Eye-
strain." " The last article is a recapitulation and com-
pletion of the data and conclusions set forth in the first
two, and from it I make the following quotations :
My consultations have plainly enough taught me that
hardly any men in the general profession are fully alive to the
need of interrogating the eye for answers to some of the hard
questions which are put to us by certain head symptoms, since
many of the patients treated successfully by the correction of
optical defects never so much as suspected that their eyes were
imperfect. What I desire, therefore, to make clear to the pro-
fession at large is :
1. That there are many headaches which are due indirectly
to disorders of the refractive or accommodative apparatus of
the eye.
2. That in these instances the brain symptom is often the
most prominent and sometimes the sole prominent symptom
of the eye troubles, so that, while there may be no pain or sense
of fatigue in the eye, the strain with which it is used may be
interpreted solely by occipital or frontal headache.
3. That the long continuance of eye troubles may be the
unsuspected source of insomnia, vertigo, nausea, and general
failure of health.
4. That in many cases the eye trouble becomes suddenly
mischievous owing to some failure of the general health, or to
increased sensitiveness of brain from moral or mental causes.
* Dyer first sent his prescriptions for cylinders abroad to be filled,
but In 1862 or 1863 the Philadelphia optician, Zentmayer, was able to
fill them. According to Bumstead (Am. Med. Times, 1868, vli, pp. '203-
■Xo) cylinders were ground by Paetz and Flohr in Berlin, and by
Natchet, in Paris. In the same article Dyer's test types are described.
In seeking; to prove these propositions I shall use some of
the cases which I have already given in the lieporter, and
others which I have since seen, or which have been put at my
disposal by friends who are engaged in the practice of oph-
thalmic surgery.
I may here remark that the books on diseases of the eye
scar<!ely more than allude to the distressing cerebral symptoms
of which I have spoken, except when discussing the subject of
accommodative asthenopia from hypermetropia. Yet in prac-
tice almost all of the extreme refractive or accommodative eye
troubles give rise, in a certain proportion of people, to these
symptoms, while in those congenitally .sensitive, or who
become so in after-life, even slight optical defects, especially
when unequally developed in the two eyes, may also give ri'Se
to like annoyances.
I have certainly seen cases in which the form of headache
caused by eye troubles was a pure migraine or hemicrania, but
this I believe to be rare; while I am sure also that in many
persons who are already the victims of migraine it has been
made worse and more frequent by the over-use of defective
eyes, as, indeed, it may be from any cause of exhaustion, and
has again been le.ssened in severity and as to number of attacks
by proper correction of the eye disorder. Dr. Liveing, in his
interesting and thoughtful work on sick-headache (i. e., megrim)
states that M. Piorry long ago described megrim as capable of
being caused in those with weak eyes by straining at near or
minute objects, and this is doubtless the case; but the form of
head-pain, to which I am about to refer, is certainly not, as a
rule, of the nature of megrim, and as soon as it disappears
when the eyes are corrected, is lacking, happily, in the
obstinacy of that distressing malady.
The following cases fairly illustrate the first two of the
propositions I have stated above. First of these I put the fol-
lowing case, because it was the one whicli earliest opened my
eyes on this subject. My tardy knowledge certainly cost my
patient a long period of unrelieved distress :
Case I.— Mr. E., a prominent merchant, consulted me for
pain in the upper spine and occiput. It increased day by day
every winter, and left him during the summer, which was
spent in shooting and fishing— a tent life, in fact. Mr. B. was
even cauterized in. New York for these pains, and here at home
he had much able advice beside my own. When I first saw
him I was thoroughly misled. It was late in the winter, and,
as usual, while in the autumn only writing at first, and then
later reading, and then any near work, caused pain ; as time
went by there came a period when all mental laljor, when
excitement, emotion, or any thought caused pain. He was in
this over-sensitive state when I saw him, and was aided by
nothing I did. His holiday cured his head, and on his return
some friends, I believe, suggested to him that his eyes might
be weak, and with this idea he consulted Dr. William Thom-
son, who gave me the following additional particulars from his
notebook :
" Writing had become so distressing to this gentleman, that
for a year past all letters have been written by a secretary, at
his dictation. He states that a few moments spent in writing
give him a creeping sensation up the spine and through the
back part of the head, foliovf ed by giddiness and severe pain, so
urgent as to render him fearful of a ' fit of some kind.' . . ,
His compound hyperopic astigmatism was corrected, and on
using the glasses habitually, his distressing symptoms quickly
disappeared. He has long since forgotten his apprehensions of
an impending apoplexy or epilepsy; he can see as sharply as
any of his companions, and he can use his eyes continuously in
reading, writing, or any near work."
Relief in this case followed at once the use of glasses, which
proved competent without other means to conduct him to
perfect and useful health again.
The following case will answer to show how profoundly
the whole system may be perturbed by an ocular defect :
Case II.— Miss J., an accomplished and energetic single
lady, aged 30, from New Jersey, having the care of a sick
mother and of a household, began some five years ago to have
evening headaches, pain in the back of the head and neck, sense
of extreme fatigue and violent flushing if she persisted in
exerting her mind in writing or reading. Unfortunately, a
portion of her income and much of her pleasure in life depended
upon her ability to write, so that for a long time she continued
to do so, despite the increase of all her troubles. When at last
she came to me, a feeble, nervous, anemic woman, sleeping
little and cursed with headache almost constantly, I confess
that for nearly two years while I saw her at intervals, I looked
everywhere but to her eyes for the cause of the mischief. At
length, after a most unsatisfactory winter of rest from work,
freedom from care and many tonics, I made a more careful
study of her eyes, and having grown sure that they were
imperfect, asked her to consult an ophthalmic surgeon. At
tliis time the use of the eyes brought about pain in them and
sense of fatigue, whereas at first the headaches, which came
only after long use of the eyes were, as I have said, unaccom-
panied by any sense of trouble in the eyes. Her compound
hyperopic astigmatism was corrected (by Dr. Thomson) and
she was seen again May 26. Headache has disappeared, sleep-
lessness has vanished ; she can read and write without pain,
and she uses her glasses constantly. In October this lady was
seen again, and pronounced herself long since relieved and able
to use her eyes constantly, with the correction, in all near work.
October 18, 1902]
ASTIGMATISM AND EYESTRAIN"
lAHBBIOAir meoioisb 621
I myself saw this lady anew this autumn. The change in
her appearance was reuiarljable, and was, I think, solely due to
relief of the strain with which she used her eyes. The head-
ache left early, and with it the sleeplessness. Once able to
slumber and to get rest, the body swiftly repaired damages, and
the anemia also departing, a general gain in flesh, color and
strength were the results.
Another patient (corrected by Dr. Thomson) reports her-
self as perfectly comfortable, and only distressed at the loss of
16 years of useful life, and now able to read or sew as much as
she wishes.
The cases just told seem to me enough to prove that the eyes
may long rest unsuspected as the cause of headache, ancf of
other intracranial distresses and disorders. Case II is the more
remarkable of those which illustrate this fact, because when
attending this lady I was already on my guard as to this cause
of headache, and yet was for a long time altogether misled.
Who, indeed, could have supposed that a mere ocular defect
could have given rise to so serious a train of evils — beginning
with headache and ending with unconquerable anemia — and
who that had not seen it could believe that the correction by
glassesof the eye trouble could have given a relief so speedy
and so perfect that she herself described itas a miracle.
Case V was that of a woman of 27, who had nervous and
spinal troubles, frequent headaches, and prolonged hysterical
states. Dr. Wm. F; Norris, to whom she was sent, corrected
her astigmatism, compound myopic in one eye, and compound
hypermetropic in the other, and the relief given in the case was
almost immediate, but some time elapsed before the headaches
were entirely lost.
Dr. Wm. F. Norris sends me the following very striking
case of hypermetropic astigmatism in which there was no eye
pain, but violent headache, described as neuralgic, with nausea
and vomiting. The relief given by glasses was absolute and
abrupt.
The third proposition, to the effect that vertigo of most
alarming character, as well as other intracranial symptoms,
may be the chief expression of eye lesions, is illustrated by the
following cases :
Case VIII. — Miss B., aged 16, was well until her periods
began, and these being copious, she found that for several days
afterward she had headaches which came only upon use of the
eyes and were less grave as the month of interval passed by. I
suspected the cause, and, in fact, learned that she had unequally
myopic eyes. I advised that these should be corrected, but as
her lamily physician insisted that she must have had the eye
lesion always, and could, therefore, not be suffering suddenly
from what had always been present — she was easily persuaded
to yield to her own dislike of glasses, and so nothing was done
save only to strive to lessen the menstrual flow.
After a year more she came back to me with an addition to
her symptoms of occasional unsteadiness of gait, with a sudden
sense of terror and vertigo. The headaches were no better. In
a half-conscious self-defence she had given up sewing and
writing and read little, yet still the headaches continued because
she had now rea<-hed that advanced stage of sensitiveness in
which the ordinary every-day use of the eyes was hurtful. Of
late, too, her rest was broken and disturbed by dreams. Mean-
while, also, she had been reexamined, and by the aid of the
ophthalmoscope discovered to have cerebral anemia, because,
as I was told, the headaches went away in the night, when,
owing to her prone position, more blood went to the head.
The ophthalmoscope is just now where the stethoscope was
40 years ago, and is called upon to do things which I do not
think it can do, so that I am grown a little suspicious of state-
ments as to diagnosing by the eye-ground vessels the amount
of blood in the head. Save only in the case of gross lesions the
value of the ophthalmoscope has been overrated. I, at least,
am unable to diagnose slight degrees of cerebral anemia from
the state of the vessels of the disK.
My patient had been endlessly treated with tonics, but
somehow none did any good, and she was surely hastening
toward a course of uterine treatment, the usual goal in difficult
cases of obscure disease in women. At this time 1 urged her to
travel in Europe, and while there to have ber eyes corrected.
She took the agreeable part of my advice, but gaining little
from a few months of too rapid and wearying travel, again
wrote to complain of increasmg headaches and of more fre-
quent spells of ocular vertigo. I could only urge anew the
correction of the eyes, especially since she had improved in
color and as to gain of flesh, with no like bettering of the
cephalic troubles. This time she took my advice and was per-
suaded to wear her glasses steadily. At first the vertigo grew
worse, but soon it and the headaches and the insomnia passed
away, so that in a month she was able to sew, write or read for
hours at a time.
This briefly-told case is somewhat instructive, but I have
given it chiefly because of the vertigo, which is seen in some
instances, but which few physicians would suspect to be due to
troubles in the eye; nevertheless, I have learned to look to It
as one source of the symptom vertigo. There is an o<!ular ver-
tigo as well as an aural vertigo, and I believe that I have seen
it under three sets of conditions. Thus it is sometimes caused
by a sudden lessening of intraocular pressure, but is more often
seen in cases of disorder of the accommodative, or of the extra-
ocular nniscles ; being aft«r all neither so common nor so easily
caused as the analogue, aural vertigo. Usually, indeed, It
comes only after the eye trouble and some other cause of gen-
eral weakness have made the intracranial circulation unstable.
Occasionally, as I believe the oculists know, a dose of atropia
used in one eye will bring it suddenly ; and this is more notably
seen in persons whose balancing power is already affected by
posterior spinal sclerosis or by cerebellar growths. Perhaps
the most important, because the most misleading point in all of
tliis subject, is the fact that such as are in sturdy health are
often able for years to overcome, without sense of strain, mus-
cular difficulties in binocular accommodation, and to endure
unharmed astigmatism with accommodative troubles. But
with increase of years their powers fail, and they begin to feel
the added exertion now needed in some shape — either in eye or
head, or in both. Or else it chances that to one of these people
comes an attack of illness, a moral or emotional strain, or a
time of overwork with worry, when at once the eye trouble
leaps into mischievous prominence, and once felt is felt through
all the future more and more by a brain which, in the language
of the photographer, I might aptly describe as having become
oversensitized. I have seen in my practice or in that of others
examples of this sequence.
I must now, I think, have amply illustrated the fact that eye-
strain causes headache and worse disorders, and is often their
unsuspected cause. Simple deficiency of power in one internal
rectus muscle, if extreme, results in the patient being so utterly
unable to overcome it as to give up the effort and allow the eye
to roll out, contenting himself with clear monocular vision.
The effort needed to overcome lesser weakness is a competent
one, but ends in incessant exertion and fatigue. The accommo-
dative effort needed in hypermetropla, especially with astig-
matic trouble, is extreme, owing to the instinctive and never-
satisfied craving for distinct vision, and hence the source of
fatigue. I presume that the strain made on the eye by these
various forms of trouble in sight is due largely to the fatigue
which ever comes of the need to make volitional ettbrts to effect
movements which, in ordinary use, are sensually guided, and
are more or less in this view automatic. Besides which the use
of the eyes is so incessant that it is impossible for the victims
by any means save glasses to put the eyes at rest ; so that often
the strain is nearly incessant.
The profound and far-reaching importance of these
conclusions of Dr. Mitchell will not be adequately recog-
nized for generations. Since he established them many
an American oculist has personally seen thousands of
.such cases in which, as if by miracle, lives have been
changed from abject misery to happiness. As he looks
over the world, and especially the European world, he
knows that there are millions suffering in the same way
who could be immediately cured were it not for the false
conception of astigmatism and other forms of ametropia
entertained by medical men and ophthalmologists. For
the genius that first recognized the truth and for the
fearlessness that published it no honor is too great.
Several weighty improvements,, however, were still
needed to give the discovery that accuracy and practical
usefulness which should make it play in the world its
role of splendid beneficence. These were :
1. The extension of the method of estimating and cor-
recting astigmatism to the hyperopic, compound hyper-
opic, mixed, irregular, and unsymmetric varieties. This
was done largely by the Philadelphia specialists contem-
porary with Mitchell. The astigmatism observed before
Dyer was myopic, a very small portion of that existing,
and relatively speaking producing few reflexes.
2. The practical correction of anisometropia. All
textbooks up to 1892 taught, in the language of the
German master, Fuchs, that
" In anisometropia we grlve the same glasses for both eyes,
or correct only one eye and place a plain glass before the other."
This pernicious error was controverted, so far as I am
aware, for the first time in 1892." It was contt-nded that
it is unmedical, unprofessional, and unnecessary to leave
an amblyopic eye, injured from disuse, to its fate.
3. The bifocal spectacles. An American genius, Ben-
jamin Franklin, invented bifocal lenses for use in pres-
byopia, and an important improvement, the "cement
bifocal," was adopted in 1888 by Philadelphia physi-
cians. These devices have been of vast service in
lessening and extinguishing the evil effects of eyestrain
in presbyopes.
4. The perfecting and making i>ra*'tical of tlic art of
retinoscopy. This was also the work of Philadelphia
specialists. Only by this method can there be accuracy
622 AMERICAN Medicine)
THE TYPHOID-COLON GROUP OP BACILLI
[OCTOBEB 18, 1902
of diagnosis of ametropia in cliildren and in the
amblyopic.
5. Tlie recognition of tiie pernicious influence of eye-
strain upon the digestive and assimilative system, in the
production of functional gastric and intestinal diseases,
of chorea, of hysteria, of epilepsy, etc. This has been
brought about by the advocacy of other specialists of
Philadelphia or by their pupils located elsewhere.
t). The repression of unprofessional methods, e. g.,
the operative manias of the tenotomists ; the attempted
diagnosis of ametropia by machinery, the ophthalmo-
scope, ophthalmometer, etc.; the uselessness and inar-cu-
racy of diagnoses made with(jut cycloplegia ; the medi-
cal barbarism of the refracting opticians,* etc. These
things bring discredit upon the true science of ophthal-
mology.
7. The evil psychologic influence of eyestrain. This
was first pointed out by a Philadelphia oculist in 1 888.
Children suffering from ametropia have their intellects
and dispositions warped, injured, or wrecked. The
subtle malign influence of eyestrain upon character is of
enormous importance.
8. The economic and social significance, both public
and personal, of the correction of eyestrain. A life
may be handicapped in its usefulness or even wasted
without such correction. Eyestrain is one of the great
causes of weakening of vital resistance, so that other
diseases secure easier foothold. It causes inflammatory
and operative diseases of the eye. It creates many of
the defective and criminal classes. It is so large an
unrecognized expense item in our educational and school
systems that it would pay the State, cities, and institu-
tions of learning to have an official oculist whom every
pupil and student having no private oculist should
consult.
There is thus a genuine significance in the term The
Philadelphia School of Ophthalmology. It is that today
a hundred or more conscientious and skilled oculists in
this city are, before and above all, physicians, convinced
of the clinical value of refraction when estimated by
subjective tests under cycloplegia, in curing numerous
types of headache, neuralgia, vertigo, functional dis-
eases of digestion, assimilation, and of the nervous sys-
tem. They also know that such diagnoses and such cures
cannot be made by the methods in vogue in Europe, and
that the great clinical value of refraction consists pre-
cisely in preventing those inflammatory and operative
diseases of the eyes which make up the daily practice of
the vast majority of the oculists of the world. Learning
their art directly or indirectly from the socalled Phila-
delphia school, hundreds of oculists are finding a noble
lifework throughout the United States, and are giving a
million patients the indubitable proof of personal expe-
rience that eyestrain is the cause of terrible and varied
diseases, the cure of which, by spectacles, is one of the
greatest medical discoveries of the nineteenth century.
REFERENCES.
'Thomas Young: Philosophical Transactions, 1793, p. 169 ; 1794, p.
21 ; 1795, p. 1 ; see also a Course of Lecture^, etc., 1807, Vol. 2, p 575.
2 Refraction of the Eye, 1S&4, pp. 45tf-i.57.
SArchiv f. Ophth., Berlin, 1866, xli, 25-30, Historische hotz uber
Hyperopia und Astiffmatlsra.
•1 Annales d'Ocullstlque, 1902, abstracted in Annals of Ophthal-
mology, August, 1902.
5 Refraction of the Eye, 1861. pp 510 and 4a3.
"Di.seases of the Eye, Am. ed. by Hays, 1854, p. 669.
I Conf. Volkmann, Art. Behen, p. 271, In Wagner's Handworterbuch
der Physiologie, 1846.
8 Manual of Ophthalmic Medicine and Surgery, Second edition,
London, IK\t>, p. S52.
" Dublin Journal of Medical Science, First series. Vol xxviii, p. 105.
i» Monthly Journal of Medical Science, Edinburgh, 1847, p. 891.
" Monthly Journal of Medical .Science, Edinburgh, 1848, p. 711, and
Transactions of the Cambridge Philosophical Society, Vol. viii, p. 493.
'2 Report of the British Association for the Advancement of Science
for 1849, p. 10.
♦These are becoming more and more scarce in Philadelphia, and
consequently there is a growing class of honorable firms who take
pride in their true function and from whom patients can get such serv-
iceable and scientific work as the " eves-examlned-free " men never
dreamed of doing The optician must no more sell glasses than the
druggist poisons without a physician's prescription.
"Refraction of the Eye, 1864, p. 542.
"Ann d'Ocullstlque, t. xxi, p. 222, Bruxelles. 1849, taken from the
Vcrhandlungen der Schweizerischen Naturforschenden Gesellschaft.
"> \m. Med. Times, 1883, vil, pp. 277-278
■"Arch. Ophth. and Otol.. 1869, I, No. 1, pp 17-21.
" Am. Jour. Med. Scl., January, 1867.
'» Phila. Med. Times. 1871, ii, p. 70.
i» Medical and Surgical Reporter, July 25, 1874. and August 1, l'-?!.
2" Ibid, February «. 1875.
21 Am. .Jour. Med. Set., April 1876, pp. 363-373.
22Ambl,vopiatrics, by CJeorge M. Gould, M.D., Medical News,
December 31, 189i.
TYPES OF INFECTION PRODUCED IN MAN BY
INTERMEDIATE MEMBERS OF THE TYPHOID-
COLON GROUP OF BACILLI.
BY
WARREN COLEMAN, M.D.,
of New York City.
Professor of Clinical Medicine, Cornell University Medical College;
Assistant Physician to Belleviie Hospital.
^Concluded from page 579.]
III. THE RSITTACOSLS TYPE.
Psittaco.sis is defined as an infectious disease of .special
type transmitted to man by parrots (hence the name)
aff"ected with the same disease.
History. — Psittacosis was unknown in France until
1892. In December, 1891, 500 parrots were shipped
from Buenos Ayres. Of them 300 died on the voyage.
Following the arrival of the ' parrots in Paris two
epidemic centers of a new (?) disease of man were estab-
lished, the ramifications of which it was ea.sy to follow.
There was a total of 42 cases and 14 deaths. In 1893
another epidemic appeared but of less intensity. In the
following years only sporadic cases appeared. W. T.
Greene speaks as if the disease has occurred in England.
I have been unable to find any reference to the di-sease
in this country.
Psittacosis in Animals. — Parrots affected with psitta-
cosis assume the ordinary apearance of sick birds — head
drawn in, feathers erect, wings drooping. They become
somnolent and suff'er from continuous diarrhea. They
remain in this condition from eight to 10 to 15 days
(in France.)
Greene says that one firm in England imports 80,000
gray parrots a year, and that ' ' he has the best of reasons
for believing that many of the.se birds die within six
weeks from psittacosis."
In addition to parrots, poultry, pigeons, rabbits and
other domestic birds and animals are subject to the dis-
ease.
Dr. A. M. Farrington, of the Bureau of Animal
Industry, writes that they have had no reports of the
disease in this country.
Mr. Louis Ruhe, of New York City, who imports
30,000 parrots a year, tells me that bOfc of them die
within the first year of their arrival, and that 25^ die of
diarrhea which exceptionally is bloody. He insists
from the standpoint of the practical dealer in birds that
tliis diarrhea is not communicable from parrot to parrot,
and that disinfection of the cages is not necessary. He
further says that many parrots have diarrhea and
recover, while in canaries it is usually fatal. Moreover,
during his wide experience he has never known man to
contract any disease from parrots.
Of course, it is not proved that the diarrhea of which
Mr. Ruhe speaks is identical with the disease of parrots
described by the French writers. Yet it seems strange
if parrots sufiter from a disease which is communicable
to man that nothing lias been heard of it in other
countries than France. Durham doubts that parrots
were responsible for all the recorded cases.
PaoiUus psittacosis was discovered by Nocard in 1892
(the report of the discovery was made in 1893).
The bacillus is an intermediate of the typhoid-colon
group.
Durham considers Bacillus psittacosis a variety of
OCTOBER 18, 1902]
THE TYPHOID-COLON GROUP OF BACILLI iamkrican medicinb 623
Bacillus enteritklis, and apparently regards psittacosis in
man as a clinical form of meat-poisoning. Moreover, he
says that the parrots may have become infected with
Jiacillujf enteritkUs on shipboard.
Bacillus psittacosis is pathogenic for divers spe-
cies of animals (see foregoing) and for man, and retains
its virulence for a very long time. Greene claims that
the ordinary methods of disinfecting cages that have
been occupied by sick birds are utterly useless.
The bacilli have been recovered many times from
parrots dead of the disease, and Gilbert and Fournier
have found a bacillus which closely resembles it in the
intestinal contents of healthy parrots. They ask
whether these two bacilli have a common origin or
whether they are a single bacillus which may take
on pathogenic characters under certain conditions. The
same authors have sought for the bacillus six times in
man, but have found it only once in the blood of the
heart.
Transmission to Man. — No case is known in which
man contracted the disease from any other animal than
the parrot. Infection may occur in man in three dif-
ferent ways :
1. Directly from the affected bird. This is the most
frequent mode. Persons feeding sick birds from their
own mouths are especially likely to contract the disease.
'I. From inanimate objects, as cages which the birds
have used, etc.
3. From man to man. This mode of transmission is
rare, but nevertheless indisputable.
Women suffer from the disease more often than men,
because they are brought more into contact with the
sick birds.
Symptomatology. — Ordinary form. The period of in-
cubation varies from 8 to 12 days.
Sometimes the disease is ushered in by a local infec-
tion, consisting of fleeting edema of the lips and adjacent
parts, with painful elevations on the e<lges and tip of the
tongue and diphtheroid plaques on the buccal and
pharyngeal mucous membranes. There may also be
coincident swelling of the submaxillary regions. But
often this local involvement is absent and the beginning
of the disease is diflicult to fix.
The symptoms of invasion then approach insidiously
and comprise malaise, prostration, headache, vague
muscular pains in the trunk and limbs, more or less
intense lumbago, epistaxis, anorexia, nausea, and
vomiting, and either constipation or diarrhea.
Almost always there are pulmonary complications,
consisting either of mild bronchitis or bronchopneu-
monia, v/ith incessant cough and intense dyspnea. In
fact, so frequent is the pulmonary involvement that
many writers insist that the disease is essentially an
infectious bronchopneumonia with the development of
typhoidal syn>ptoms later. Others believe that the
pneumonia is merely a complication.
During the period of invasion there are more or less
intense rigors, accompanied by a slight febrile move-
ment. The period of invasion lasts from five to seven
days.
Slaiionar}/ Period. — A rapid rise of temperature to
103.5° to 104° F. marks the beginning of this period.
The temperature remains continuously high, with only
slight morning remissions and evening exacerbations.
Defervescence occupies only two or three days. The tem-
perature curve as a whole resembles that of typhoid,
differing, however, in the abrupt initial rise and in the
sudden defervescence.
Often (in the pulmonary form) instead of pursuing
this continuously high course the curve shows sharp
exacerbations and remissions with periods of apyrexia
for several days, the former indicating the establishment
of fresh centers of consolidation in the lung.
During the febrile period the pulse ranges from 110
to 120 or more, and possesses the usual febrile charac-
ters.
The tongue is coated and sometimes red at the tip
and edges. Anorexia is complete during this period.
The abdomen is tympanitic and may be tender. In
some eases there is diarrhea, in others constipation.
The spleen is enlarged, the degree of enlargement corre-
sponding to the intensity of the infection. The splenic
region may be tender.
The aspect of the patient is that of typhoid fever.
Stupor is the dominant note. Delirium is often present ;
generally tranquil, it may be violent, even with
suicidal tendencies. There is a febrile albuminuria in
the majority of cases.
The skin is hot and dry. A cutaneous eruption has
been observed in only one case (Rendu). At first it
resembled the typhoid rash, but became petechial and
disappeared in about four days.
In the cases complicated by bronchopneumonia, the
respiratory phenomena occupy a place of great impor-
tance. These will be dealt with under " Clinieal Forms."
Defervescence begins from the twenty-first to the
twenty-eighth day after the first symptom of invasion.
Convalescence is long and tedious. The patient is
anemic and suffers from vague pains in the limbs.
Walking is difficult and sometimes painful. The least
effort causes great fatigue, and it may be weeks before
the patient recovers his health.
Psittacosis is not always fatal. Death from uncom-
plicated psittacosis is rare. It is more often due to some
complication, and most of all to pneumonia. The mor-
tality is stated to be from 28 fo to 37 fc .
Clinical Forms. — The mild form affects persons who
have not been brought into direct contact with the
birds.
The symptoms are lassitude, headache, vague muscu-
lar pains, more or less marked anorexia and often a
variable rise of temperature. At other times the symp-
toms are more severe, with an added mild bronchitis, and
the patients take to their beds. The symptoms all dis-
appear rapidly and the patient is well again in a few
days.
The Ordinary Form. — There is a diversity of opinion
as to what constitutes the ordinary form of psittacosis.
The earlier writers contended that psittacosis was essen-
tially an epidemic bronchopneumonia, and we find this
belief reiterated by Nicolle as late as 1898. However,
greater experience with the disease seems to establish
that it most frequently runs the typhoidal course
described above.
Pulmonar}/ Form. — As already stated, psittacosis fre-
quently masks itself under the guise of a bronchopneu-
monia. This form does not seem to depend uiwn any
etiologic condition.
Rarely psittacosis pursues the course of frank pneu-
monia. Most often there is a marked chill, though this
may be replaced by repeated rigors.
At other times, with the symptoms and signs of
invasion one notes an incessant and obstinate cough,
intense dyspnea, increased by the least exertion, rapid
respiration and localized pain in the chest. Then during
the progress of the disease the pulmonary phenomena
occupy a prominent place, and examination of the chest
reveals disseminated foci of bronchoi)neumonia. The
sputum may be blood-tinged and contains pneumococci.
The temperature curve is strongly influenced by the
development of the pneumonia, and exhibits an eleva-
tion with each new foc\is involved. Moreover, the gen-
eral state of the patient is appreciably modified by the
pneumonia, and death frequently results from asphyxia
and cardiac failure.
The adynamic form is severe from the outset. Pros-
tration is extreme, the patient soon passes into deep
delirium and dies without return to coni^ciousness.
Serum lleaction. — Bensaude has tested the serum
reaction in three cases of psittacosis in man against
Bacillus psittacosis with negative results. The serum of
the first case, taken the forty-third day after the onset of
624 American Medicine,'
PUEPUBA. HvEMOREHAGICA
[OCTOBEB 18, 1902
the disease and of the second on the flfty-flrst day,
were both negative even in dilution of 1 : 5. The serum
of the third case was tested twice, on the thirtietii and
thirty-ninth days, and both times gave no reaction.
Gilbert and Fournier have also had negative results
with sera taken on the fourth and fifth days of the dis-
ease.
NicoUe obtained positive reactions with tlie sera of
two cases of psittacosis. The serum of the first, a fatal
case, reacted at 1 : 50 on the eighth day of the disease and
at 1 : 60 on the ninth day, the day of death. The same
serum was twice active against the typhoid bacillus at
1 : 80, but had no action on coli. The patient had not had
typhoid fever. The serum of the second case gave no
reaction on the sixth day of the disease against psittaco-
sis, typhoid or coli, but was positive at 1 : 10 on the elev-
enth day against psittacosis, while there was no reaction
against typhoid or coli. In the third case the serum was
inactive against all three organisms on the sixth day of
the disease, the first day of convalescence.
The net result of the reactions recorded is two of
eight cases positive.
This pronounced failure of the serum reaction in
psittacosis constitutes a source of error in the establish-
ment of the disease as a distinct entity.
The serum of animals immunized with Bacillus psit-
tacosis agglutinates this bacilli strongly. It also agglu-
tinates Bacillus tijphosus in low dilution (1 : 10).
Diagnosis. — Clinically psittacosis is most easily mis-
taken for typhoid fever. The points of difference made
by the French observers are the suddenness of the initial
rise of temperature and the abrupt defervescence, the
precocity and intensity of the respiratory troubles, and
the absence of eruption. Moreover, they say that when
diarrhea is present it does not possess the typhoid char-
acters.
La grippe, especially when complicated by pneumo-
nia, very closely resembles the pulmonary form of psit-
tacosis, and it is said that the only way of differentiating
the two diseases is to trace the source of infection.
BIBLIOGRAPHY.
Achard and Bensaude : Bull, et M6m. Soc. m6d. des H6p. de Paris
18%, 3s, xlii,,^80.
Ballard : Local Gov. Board Rep., Supplement Rep. Medical Officer,
looS— 89, xviii, 163.
Basenau : Arch. f. Hygiene, 1894, xx, 242, and 1898, xxxil, 21«.
Bensaude : Thgse de Paris, 1897, pub. by Oarrfi.
Bowes and Asbton : Brit. Med. Jour , 1898, ii, 14.56.
Brill : N. Y. Med. Jour., 1898, Ixvli, 48, 77.
Brion and Kayser: Munch, med. Woch.. 1 02. No. 15, p 611
Coleman and Buxton : Am. Jour. Med. Sci.. 1902, June.
Cushins: Johns Hopkins Hosp. Bull., 1900, xi, 156.
Deseazals : Gaz. des hOp., Paris, 1896, p. 1093.
Durham : Brit. Med. Jour., 1898, II, pp. 600, 1797; Lond. Lancet, 1898,
i, 1*4 ; Jour. Exp. Med.. 1901, v, 35:^.
Eckardt: Miinch. med. Woch., July 8, 1902
Fischer, B.: Zeit. f. Hygiene, 1902, xxxiv, 448.
Gaafky and Paak : Deutsche raed. Woch., 1892, xviil, 297.
Gaertner: Correspondenz-Blatier des Allgemeinen artzlichen
Vereins, von Thiiringen, 18«8, No. 9
J fi'lbertand Fournier; Bull, de I'Acad. de M6d., October 1896: Soc.
de B ol., December 12, 1896 ; Presse M6d., January 16. 1897.
Gilbert and Lion : Bull, de la Soc. de Biol., March 18, 1893.
Greene : Lond. Lancet, 18!)7, 1. 1387 ; Lond. Lancet, 1899, 1, 118.
Griinbaum : Quoted by Durham.
Gunther: Arcb. f. Hygiene, 1897, xxviti, 147.
Gwyn : Johns Hopkins Hosp. Bull., 1898, Ix, 54.
Hewlett : .\raer. Jour. Med. .Sci., August, 1902, p. 200.
Hume: Thompson- Yates Lab. Rep., vol. iv, part ii.
Johnston : Amer. Jour. Med. Sei., August, 1902, p. 187.
Kaensche: Zeit. f. H.vgiene, 1896, xxii, Si.
Karlinsky : Centralbl. f. Bact., 1889. vi, 289.
Klein : Local Gov. Board Rep., 1888-89. xviil.
Kurth : Deutsche med. Woch., 1901, xxvii, 501.
Libmau : Jour. Med. Research, June, 1902, p. 168.
Longcope : Amer. Jour. Med. Sci., August, 1902, p. 200.
Nlcolle : Comptes rendus Soc. de Biol., v, 1171.
Nocard: Report to Conseil d'hygifine publlque et de Salubritfi,
March 24, 1893.
Petruschky : Centralbl. f. Bact., xlx, 197.
" Psittacosis " : Resume Gaz. hebdom., 1897, ii, 361.
Rendu: Quoted from Psittacosis, loc. cit.
Schottmueller : Deutsche med. Woch., 1900, xxvl, 511: Zeit. f.
Hygiene, 1901, xxxvl, ;i63.
Smith, T., and Moore, V. A. : Bureau Animal Industry, Dept. Agri-
culture U. S., Bull. No. 6. 1894, 10. J< I R
Strong; Johns Hopkins Hosp. Bull.. 1902, xiii, 107.
^ r. ''" ^"n.lnghem ; T-ravaux du lab. d'Hygiene et de Bact. de 1' L^nlv.
de Gand., T. i. fasc. 3, 1892.
Wldal ; Semalne Mfidlcale, August 4, 1897, p. 285.
Wldal and Sicard: Soc mfid. des HOp. de Paris, 1896, xiii, 835.
Zupnik : MUnch med. Woch , August 5, 1902, p. 1305.
LARYNGEAL SYMPTOMS COMPLICATING A CASE OF
PURPURA HEMORRHAGICA.'
BY
JOSEPH S. GIBB, M.D.,
of Philadelphia.
Professor of Laryngology, Philadelphia Polyclinic.
Purpura liajmorrhagica, according to Osier and other
writers, is that form of purpura which is attended by
hemorrhages from the mucous surface, in contradistinc-
tion to the more common forms of purpura accompany-
ing rheumatism and other disea.ses.
No mucous surface seems to be free from such hemor-
rhages. The laryngenl mucous membrane is an unusual
site. So far as a careful search of the literature of the
subject has revealed, no case is reported .specifically of
hemorrhage from the mucous membrane of the larynx
in purpura.
The following case seemed worthy of report, not
because of its unusual nature alone, but also for the
rea.son that one or two points of interest are attached
to it:
The patient, J. B., aged 42, wa.s admitted to the Episcopal
Hospital, November 30, 1901, with the fallowing history : He
had never been very ill. in 1898 he had an attack of rheu-
matism lasting a few days and in childhood had scarlet
fever with dropsy. His father died of debility following apo-
glexy, and his mother died of typhoid fever. In other respects
is family history is unimportant.
The statement the patient gives of his present illness is as
follows: Three weeks before his admission he was vaccinated.
Ten days thereafter the legs became swollen and a hemorrhagic
rash appeared on them. He had no pain but there were burn-
ing and stinging sensations in the legs. While the condition
was not sufficient to incapacitate him he found himself becom-
ing progressively weaker. A few days before his admission
while quietly seated iu a chair he felt an unusually severe
stinging sensation in the limbs and upon rising found difficulty
in walking on account of stiffness. Upon investigation he
found an extra crop of hemorrhagic spots beside which there
was a copious wheal-like eruption. The next morning the
wheals had disappeared but the hemorrhagic spots remained
and have pei'sisted. The morning following the severe erup-
tion of hemorrhagic spots he had a free loose evacuation which
contained blood.
Upon his admission the following notes were made : The
arms, legs and sacral region are the seat of a marked purpuric
eruption. The tongue is coated. The bowels were moved
several times during the night and contained about four ounces
of blood. He remained in about the same condition, seemingly
very weak and much depressed, for five days, when he Avas
seized with severe persistent vomiting attacks, and a fresh crop
of hemorrhagic spots appeared. This was succeeded by persist-
ent uncontrollable hiccough which prostrated him severely.
These symptoms persisted for four or live days.
Two weeks after his admission, December 12, the urine for
the first time was found to contain albumin, and granular and
hyaline casts. A few days later the urine contained blood. On
December 18 the patient began to complain of difficulty in
breathing and his respiration became crowing.
My attention was called to the case for the first time the
afternoon of December 19, when the symptoms of oppression in
breathing had lasted for 86 hours. At this time he was seated
in a chair leaning slightly forward, and each respiratory effort
was attended with considerable labor. The extraordinary
muscles of respiration were called into play and there was some
recession of the suprasternal notch. Laryngeal examination
was quite easily accomplished. The fauces and epiglottis were
normal in appearance. The lumen of the larynx was much
diminished and the landmarks obliterated. The vocal cords
were recognized but much altered from the normal ; they
appeared as thickened, rounded protuberances of a pale red
color. The other parts of the larynx appeared as though the
submucous tissues were distended to a great extent, presenting
much the same appearance as is observed in cases of edema.
The color of the mucous membrane was pale red. Stenosis
was most marked at the level of the cords though the caliber of
the entire larynx was noticeably diminished. Auscultation
revealed numerous moist rales in the bronchi. The breath
sounds were weak, suggesting the presence of infiltration lower
down in the bronchi.
The following day (December 20) the symptoms of laryn-
geal obstruction became less marked and after an attack of
vomiting, during which was ejected a large quantity of choco-
late-colored mucus which evidently came from the bronchial
tubes, he was much relieved and the breathing became nearly
' Read before the eighth annual meeting of the American Laryn-
fological, Rhlnologlcal and Otological Society, Washington, June 3,
9U2.
October 18, 1902]
HEATSTROKE
[American Medicini 625
normal. The larynx at this time was seen to be less encroached
upon. The in filtration having diminished, apparently, upon
the left side. The surface of the mucous membrane was cov-
ered with fluid blood. At the first examination no application
was made to the larynx because his condition was so serious it
was not considered wise to risk the danger of spasm. At the
second examination an attempt was made to reduce the swelling.
An application of 10% cocain solution was first made, followed
l:)y a 1 to 1,000 adrenalin chlorid. These applications produced
an immediate coughing attack during which a large quantity
of chocolate-colored mucus was expectorated and the patient
felt much relieved. An examination of the larynx afterward
revealed a remarkable diminution of the swelling and an
increase of breathing space. This application was made about
5 p.m. and the patient was left in a more comfortable state than
he had been for several days. At 9 p.m. of the same day there
was a return of the symptoms of laryngeal stenosis, which
grew rapidly worse and he died exhausted at 1 a.m. the next
day.
The pathologic condition which existed in this case
was without a doubt a hemorrhagic edema of the sub-
mucosa of the larynx, similar to the subcutaneous pur-
puric spots which occur in the simple cases of purpura.
In all probability this infiltration extended into the
trachea and bronchi, though this was not verified by
postmortem examination.
There are one or two features in this case to which I
desire to direct attention and would be glad to have an
expression of opinion regarding the same.
The first point is : What influence may the vaccina-
tion have had in producing the hemorrhagic seizure?
The patient himself, who by the way was an intelli-
gent man, a veterinarian, was profoundly impressed
with the idea that the vaccination was responsible for
his trouble. That such an idea should occur to him was
natural, because at the time of the vaccination he was
in perfect health and we were hearing in Philadelphia,
especially through the public prints, much of tetanus,
septicemia and other conditions following vaccination.
Aside from the patient's view, which, of course,
amounts to little, it is a wellknown fact that purpura
occurs in many septic processes, e. g., smallpox, scarla-
tina, typhoid fever, etc. It is not unreasonable to sup-
pose that infection was introduced either at the time or
.subsequent to the vaccination. In the present state of
our knowledge it is impossible to prove a relationship
between these two morbid processes— the association of
the two seems of sufficient importance to be on record.
Another feature of the case comes in the form of a
query : What influence did the application of adrenalin
have in causing the unfavorable symptoms noted as
occurring four hours after its use ?
We are all familiar with the occurrence of secondary
hemorrhage in nasal operations after the use of adre-
nalin, the cause of which is paralysis of the vasomotors
subsequent to the initial stimulation of the vasocon-
strictors. Turbinates made ischemic by painting their
surfaces with adrenalin become hyperemic after the first
effect has passed. Is it not possible that such an effect
may have occurred in this case?
The adrenalin applied Ui the laryngeal mucous mem-
brane could have no effect in dissipating the transuded
blood in the submucous tissues.
The effect which it undoubtedly did produce was to
so act on the vasomotors as to drive the blood from the
vessels and thereby diminish the tissues encroaching
upon the lumen of the larynx. Now after this initial
effect had passed would not the subsequent effiE>ct be sim-
ilar to that seen in the turbinates, namely, hyperemia of
the parts, which, added to the already existing sub-
mucous hemorrhagic edema, would be sufficient to bring
about encroachment upon the lumen of the larynx ?
If this theory is true the les.son is plain to avoid the
use of adrenalin in this and similar conditions in the
larynx.
The probability that secondary hyperemia might
endanger the life of the patient was the thouglit when
laryngeal application was abstained from upon the flr.st
<'xamination — reference to which was made in the notes.
Upon the second examination (the next day), however,
so great diminution of the submucous edema had
occurred as to seem to render an application of this
nature safe.
The effect sought in the application was to constrict
the vessels and minimize the possibility of further sub-
mucous hemorrhages. It was not thought possible in
any way to affect the edema already existing by this
treatment.
HEATSTROKE, FOLLOWED BY NONFATAL LIGHT-
NING STROKE : REPORT OF A CASE, WITH
SEQUELS.
BY
GEORGE H. TORNEY,
Major and Surgeon, U. S. Army ;
AND
WILLIAM E. MUSGRAVE, M.D.,
Contract Surgeon, U. S. Army,
Hot Springs, Ark.
In this brief report no attempt will be made either to
review or to add anything to the already voluminous liter-
ature relating to heatstroke or its sequels. These manifest
themselves in a complex group of symptoms varying in
intensity from simple inability to endure heat in the
milder, to the more grave nervous, mental, and other
disturbances in the more severe cases. The pathology
consists principally of noncharacteristic inflammatory
changes in the nervous system, and of parenchymatous
changes in other organs.
There have been 713 deaths and 973 injuries reported
as occurring in the United States during the year 190(1
from lightning, but of the sequels of nonfatal lightning
stroke there is very little available literature. Quain
mentions as the remote effects paralysis — usually of the
lower extremities, derangement of the special senses, as
blindness ; a metallic taste in the mouth, noises in the
ears, and an odor in the nose; possible delirium, mania,
loss of memory, the falling out of the hair and of the
nails, and a general neuritis, which may develop and
finally prove fatal.
Crafts {Journal A. M. A., February 8, 1902) reports a
case of brachial neuritis, epilepsy, and angina pectoris
following a high voltage electric current ; his patient, a
street-car motorman, was in a 500-volt current for about
one minute. The effects began to manifest themselves
soon after, have continued somewhat intermittently, and
after one year the diagnosis is as given, with an unfavor-
able prognosis.
No mention can be found in the literature at hand of
heatstroke and nonfatal lightning stroke occurring in
the same patient. The following case is interesting, in
addition to its probable rarity :
Corporal R., aged 29, white, single, born in Pennsylvania.
He is of Scotch aescent, and his occupation previous to army
service was that of a student and traveling salesman. Ho has
used tobacco very moderately, alcohol not at all, and has
always been temperate in sexual habits. There is no history
of neurotic or other hereditary tendencies. His mother died of
puerperal fever, and one sister died in infancy. His father,
throe sisters and one brother are living and in good health.
His father is a physician in easy circumstances, a medicolegal
expert in mental and nervous diseases. The patient was reared
in comfort and liberally educated, holding university degrees
in arts and sciences. Ho is a linguist, and a thirty-second
degree Mason. He had sciarlet fever at 6 years of age, and no
other serious illness until the beginning of the present trouble.
There is no history of venei-eal disea.se.
On May 29, 1899, while drilling in the hot sun in Cuba, he
became dizzy, fell from his horse and was carrie<l to the hos-
pital in a semiconscious condition ; complete unconsciousness
and violent delirium quickly developed and (Continued inter-
mittently for 20 days. His temperature was 102"- 107° F. Treat-
ment consisted in the use of ice packs. A diagnosis was made
of "sunstroke." He had been convalescing from this attack
for about one week, and was able to walk out to his meals ;
when, during a thunderstorm, the hospital was struck by light-
ning and partially burned, one man being instantly killed and
the patient knocked down, unconscious. A third man who
626 Ambrican Medioinej
HEATSTROKE
[OCTOBEB 18, 1902
was sitting on one of the hospital cots, about four feet away
from the patientj was rendered unconscious, and reports that
he is now suffering from a condition very similar to that in
which our patient finds himself.
During the six days' unconsciousness that followed this
accident to our patient there was no fever, but frequent spells
of delirium in which (as he was Informed) only the broadest
lowland Scotch was spoken — mostly in the form of child ideas
and songs — a language which he had not heard nor spolien since
he was 6 years of age.
The hospital was a typical Cuban shack, consisting of posts,
rafters and palm leaf root, all fastened together by wire. The
mosquito nets were supported by wires fastened at one end to
nails in the wall and at the other to a long wire running full
length of the hospital, about six feet above the floor. The man
who was instantly killed was standing directly under the long
wire; and our patient was about one foot away, with a metallic
mess kit in his left hand and with his right resting upon the
other man's shoulder. It is stated that there was not a burn or
mark of any kind found upon either of these men.
After regaining consciousness from the electric shock the
patient complained of severe acute pains in the left side, back,
nip, and calf of the left leg. For more than a month he had
very little use of and could bear very little weight upon this
leg. It was colder than the other, felt all the time as if " asleep,"
and the knee was somewhat swollen, red, and very tender on
pressure. When he first began to walk, " the left hip would
slip out of joint when the weight was placed upon that leg,"
and the attending surgeons told him that there was dislocation
of the joint, due to relaxed ligaments. Notes in his possession,
which are stated to be copies of the hospital records, state that
the ligaments were so relaxed that the hip could be dislocated
and reduced at will, but with considerable pain to the patient;
and that sharp, stabbing pains were produced in the hip by
pressure upon the calf of the left leg. Symptoms of general
neuritis began to manifest themselves, the pains often requiring
morphia for relief. The condition did not improve in Cuba,
and he was granted two months' sick furlough, which was
spent in Buffalo, N. Y., hobbling around on crutches most of
the time. At the expiration of furlough, he was sent to a post
in New York City, where an exacerbation of the neuritis
occurred, confining him in bed from November 5 to December
25, 1899. The pains during this time were general, very severe
and constant, being worse in the head, back, left hip and leg,
and were aggravated by the slightest noise or excitement.
Fever was remittent in character, ranging from 100° to 101.5°.
Insomnia was constant, and there were frequent drastic ex-
hausting sweats. •
For some time after the lightning stroke there was alternat-
ing retention and incontinence of urine, the urethra having
become inflamed and very tender. This condition improved
during the furlough, but with the exacerbation of neuritis
which occurred in New York, retention returned and was con-
stant throughout the attack. The urethra again became so in-
flamed and painful that partial anesthesia was required for each
catheterization.
He was transferred to this hospital early in 1900, was trans-
ferred to the hospital corps as a private on March 7, 1900,
and was discharged the service February 2, 1902. For the first
three months under treatment here he suff"ered with symptoms
of a general neuritis, but after that time, though there was
never complete freedom from symptoms, he performed a cer-
tain amount of military duty as a liospital nurse. During the
last year the acute exacerbations have been growing more
frequent, more severe, and, for the four months previous to
discharge, he was practically incapacitated for any duty.
The acute attacks are brought on by a number of causes :
as by fatigue of any kind, stormy weather, wetting of the feet, a
slight cold, sudden excitement, emotional influences, and upon
one occasion he thinks the odor of ozone from a static machine
was the cause of an attack, and they have at times occurred
without any apparent exciting cause.
Hot weather does not appear to increase the number of
these attacks, though his general condition is much worse
during the hot season. The exacerbations come on rather sud-
denly, last from two to five days, and are usually preceded by
very severe headaches, which continue for days without inter-
mission. Just at these times the head feels as if it contained a
red-hot ball, which gradually grows larger and bursts, sending
red-hot streaks in every direction through the body; the pain
is excruciating, the patient lying fixed in bed, with every sense
at the highest tension, and the whole body bathed in perspira-
tion ; the slightest jar or noise will often cause him to cry out
with pain. While in this condition there is a marked dread of
being approached by any one, and a touch produces a spasmodic
muscular contraction with increased pain.
Between the acute attacks, when up and walking around, he
cannot bear to have anyone walk behind him, and any continu-
ous noise outside the field of vision produces a muscular tremor
which progressively increases, and if the cause of the noise
cannot be seen, in a very short time he is forced to sit down or
fall from exhaustion. Tapping lightly along the spinal column
with the finger or percussion hammer produces a similar condi-
tion. When in the erect position there is constant vertigo, and
when walking any disturbance of the equilibrium— as a slight
stumble — always causes a fall.
For the past 18 months there have been spells of cardiac pal-
pitation and precordial pains, which occur most often at night
when in the recumbent position. The heart is irritable, a little
irregular in rhythm, and averages from 75 to 82 beats. There are
no evidences of organic changes. During acute attacks there is
usually slight fever, but at other times the temperature is nor-
mal and occasionally as low as 97° F.
The hemoglobin estimates 78% (Fleischl), coagulation
delayed toOJ minutes; red cells number 3,800,000, and the leuko-
cytes 6,200. Differential count shows a few microcytes, megalo-
cytes, and moderate polychromasia; no nucleated red cells.
The leukocytes are normal in proportion, excepting a slight
increase in eosins (6.5%) and mastcells (2.4%).
Respiration is sighing in character at all times; physical
examination of the lungs is negative.
The appetite is very poor at all times, and the taking of food
is usually followe<J by a sense of oppression in the region of the
stomach ; no nausea nor vomiting. The bowels are regular,
with a tendency to constipation, and have always been under
complete control. The tongue is clear, and breath sweet; the
mucosa of the pharynx is constantly congested, and is painful
during the swallowing of food.
Neither retention nor incontinence of urine have been
E resent since he came under our observation, but the urethra
as been constantly inflamed and painful ; %vorse during the
acute outbreaks. The urine contains no albumin, nor casts; is
free from pus cells, and is sterile.
Since the lightning stroke there has been a metallic taste in
the mouth, which is worse immediately preceding and during
the acute attacks, and just preceding and during lightning
storms, and at night. The taste, in the patient's opinion, is
more like lead, and is more pronounced when taking food or
fluids. This condition has gradually grown worse, until now
it is oonstantly present, and very annoying. Speech is some-
what stammering, and words are frequently spoken which are
not intended. The senses of hearing and smell are exceedingly
acute.
Ptosis left, with blurred vision, was first noticed after the
lightning stroke. The ptosis has almost disappeared, but
blurred vision in both eyes is still present, and there are little
round, bluish bodies constantly floating before the left eye.
Distances are very inaccurately measured with either eye act-
ing singly. There is marked decrease in vision in twilight
or moderate darkness. Both pupils react to light and accom-
modation, and are of uniform size. Ophthalmoscopic exam-
ination was not made.
For the last year hair has been falling out from the head,
armpits, pubes, and other hairy areas. The skin is usually
clear, and apparently well nourished ; but sometimes just at
the beginning of an acute attack, a general erythema appears,
first along the back, and spreads quickly over most of the
body, disappearing again in from one to three days.
There is complete loss of sexual desire; no erection of the
penis having occurred for more than a year, and the patient has
a feeling that the act of copulation would kill him. The testi-
cles, especially the left, often feel as if supporting a weight of
many pounds.
His susceptibility to lightning is peculiar, but is hardly a
true astraphobia. Lightning and bright flashes of electric light
cause a sudden blindness, .staggering, shortness of breath and
tingling of the nerves for a few seconds, but after that the sen-
sations wear off somewhat, and while the tinglings continue,
he can usually watch the electric displays. He is completely
intolerant to the administration of electricity in any form.
He has grown irritable and unreasonable and at times mel-
ancholic; has marked loss of memory, with mental weakness,
and is troubled constantly with insomnia, and when sleep does
come it is unrefreshing and fitful and accompanied by horrible
dreams.
The reflexes are all markedly exaggerated and ankle clonus
is present on the left side. There is decided hyperesthesia over
the entire body, more marked along the spinal column and left
leg, with twitching of muscles, and when in the upright posi-
tion the whole body seems to be in a tremor. The thermic
sense is markedly exaggerated, and particularly along the back
and the trunk of the left sciatic, a temperature of 99° F. is com-
plained of as being scalding hot. The appreciation of cold, on
the other hand, is much decreased. The patient was discharged
from the hospital February 2, 1902, a physical and nervous
wreck and with decided weakening of the mental faculties
without alienation.
It is difiicult to say how much of his disaliiiity is due
to each of the two etiologic factors, but a careful analysis
of the symptoms leaves little doubt that both have con-
tributed to his present condition. The majority of the
symptoms might result from heatstroke alone, but a
few — as the metallic taste in the mouth, with its peculiar
variation, and the peculiar susceptibility to electric
displays — vvould appear to be a result of his lightning
stroke.
Physicians and Population.— For every 100,000 of popu-
lation Madrid has 246 doctors; Berlin has 141; Vienna, 130;
London, 128, and Paris 97.
October 18, 1902]
MULTIPLE GUNSHOT WOUND OF INTESTINES iamerican mbdicine 627
A CASE OF MULTIPLE GUNSHOT WOUND OF THE
INTESTINES ; LAPAROTOMY ; RECOVERY.'
BY
E. B. MARSH, M.D.,
of Greensburg, Pa.
Frank L., aged 16, on .Tanuary 27, 1902, while in company with
a boy friend, became a victim of the proverbial "unloaded" gun.
The gun, a 22-caliber rifle, in the liands of his companion some
five or six feet distant, was discliarged, the ball penetrating the
distal phalanx of the left little finger and the skin of the abdo-
men at a point two inches above the pubes and one and a half
inches to the left of the linea alba. The wounded boy walked
to his home, about 100 yards distant. He became faint and
vomited several times. The family physician was sent for, and
after an examination concluded there was a perforating wound
of the abdomen and most likely of some of its contents (he did
not use a probe). With all haste he had the injured boy prepared
to be taken to the Westmoreland Hospital, at which institution
he arrived at 12 o'clock noon, four hours after the accident. I
examined the patient and determined to open the abdomen.
His condition was good, pulse 90, respirations 20 and tempera-
ture 99° ; he had not vomited for two hours, the abdomen was
flat and but slightly tender. Peristalsis was almost, if not com-
pletely, arrested.
At 1 o'clock p.m. the patient was placed on the operating
table, anesthetized with ether and the operation begun after the
usual routine of aseptic surgery. The median line was chosen
for the incision. After opening the peritoneum a probe was
passed from the skin wound through the muscles and peri-
toneum, the direction being inward and to the left, the hole in
the peritoneum being almost at the edge of the incision on the
left side. This procedure gave us the direction of the course of
the ball, as well as positive evidence that the abdominal cavity
had been entered. After enlarging the incision the omentum
could be seen, drawn down and gathered together in a sus-
picious po-sition, in the right inguinal region ; upon carefully
withdrawing the omentum the wounded coil of intestine was
seen directly beneath. The soiled part of the omentum was
then tied <;» masse, and cut away, the stump and balance of
omental tissue being packed away from the field of operation
with gauze pads. The perforated small intestine was then
drawn up and each perforation closed when found, until in all
we had repaired eight. The mattress suture of chromicized
catgut was used. The intestine at two points was sutured in a
parallel direction, on account of the long lacerated tear of its
coats, the wound of entrance and exit being so close together.
At all other points the bowel was brought together in its trans-
verse direction.
The ball was found sticking in the last wound at the junc-
tion of the bowel and mesentery. The wounded intestine and
the parts that were in contact with it were then wiped of all
foreign matter, a small amount of saline solution poured in and
wiped out. We again cleansed our hands, as well as the field of
operation, and then made a systematic search for any further
damage, with negative result.
The abdomen was therefore flushed with normal salt solu-
tion (several gallons being usetl) and the abdominal incision
closed with silkwormgut sutures, an abundance of saline solu-
tion being allowed to remain in the abdominal cavity, and a
glass drainage-tube in the lower angle of the wound. The
dressings were then applied and the boy placed in bed, the head
of whicn was elevated. The time consumed in operation was
14 hours.
The boy's condition after the operation remained unchanged,
his pulse 1(X), respirations 20 and temperature 98°. His conva-
lescence was uninterrupted, the temperature never rising to
over 100° nor pulse above 98. The drainage-tube was removed
on the second day and replaced by one thin strip of iodoform
f;auze. He was denied water to drink for four days, liquid food
or one week and solid food for 2J weeks. Saline enemas were
given every four hours during the first fpur days and as often
in addition as thirst demanded, and seemed to relieve almost
■entirely that most distressing symptom. At the end of four
"weeks our patient was discharged cured.
Dr. John Marchand assi.sted with the operation and
Dr. C. E. Snyder anesthetized the patient.
Correction. — Dr. William H. Porter requests that the fol-
lowing correction be made in his article on " The Rational
Basis for the Dietetic Treatment of Tuberculosis," published in
Amerwan Mediciiie,, September 20: Conclusion 2, page 457,
should read : " That tuberculosis per se is never inherited, but
is always acquired in utero or after birth."
An Inspection of dyes sold in the open market will be
undertaken by the Sanitary Council of the Seine, Paris. Ex-
periments will be made both from the medical and chemic
])<)ints of view in order to ascertain their exact nature, with a
view to determining whether the wearing of dyed materials is
dangerous or harm fill to good health.
' Kead before the WeHtmoreland County (Pa.) Medical Society.
SPECIAL ARTICLES
THE TEACHING AND PRACTICE OF SURGERY IN
THE VIENNA ALLGEMEINE KRANKENHAUS.
BY
NICHOLAS SENN, M.D.,
of Chicago.
The Vienna Allgemeine Krankenhaus is a little city in itself
with a population of more than 3,000 inhabitants. Its present
capacity is 2,600 beds. The obstetric department, with 600 beds,
has been transferred to another locality, but is under the same
management. This hospital is to the sick poor of Vienna what
the Charlte is to Berlin, only it is much larger. The original hos-
pital was built in 1784. The buildings have been repeatedly
repaired and improved and new additions have been made as
the increasing demand for more space required. The old build-
ings are in good condition, and with their new mosaic floors
present a modern appearance. The wooden bedsteads and
feather beds have disappeared, and have been replaced by iron
cots with spring mattresses, snow white linen and comfortable
quilts and blankets. The wax candles are only seen in the
chapel, as all the wards, operating-rooms and living-rooms are
brilliantly illuminated by electricity. Many of the recent
improvements are the creation of the present Director Ober
sanitalsrath. Dr. Victor Mucha. The institution has been
under his management for eight years, and during that time
many useful changes have been made. Dr. Mucha is a man of
profound learning, unlimited enthusiasm, and an ideal dis-
ciplinarian. He works in harmony with the medical staff, and
is respected and loved by all the inmates of the institution.
He is ably supported in his arduous duties by his assistant.
Dr. Kn6dl. Dr. Mucha takes a just pride in the new steriliza-
tion plant for surgical dressings which has been in successful
operation for four years. This was the outeome of a careful
personal inspection and study of the different processes of
sterilization in all of the principal hospitals of Europe. It is
the finest and most complete sterilization plant in the world.
The room adjoins the dispensary, and is under the direction of
the chief druggist, Adjunct Gmeut. An automatic clockwork
connects the two rooms and gives the signals for the functions
of the Adjunct with an unfailing precision. Oversteam effects
the sterilization and dry heat dries the dressings. All of the
sterilized dressings are subjected to bacteriologic tests and a care-
ful record is kept of the results of the sterilization. The dressings
for each of the 13 surg^ical stations are placed in a metallic cylinder
and after sterilization the cylinder is locked and a stamp bear-
ing the date of sterilization is placed over the keyhole. The
only two persons who hold the keys, the chief druggist and the
nurse in the operating-room, are the only persons responsible
for the ascepticity of the dressings. The chief druggist is now
engaged in a series of experiments calculated to solve the prob-
lem of speedy and effective sterilization of silk. The work in
the Rontgen room is done by an expert. Dr. Oppenheim. Sev-
eral hours spent in this department will reveal all of the won-
derful results of the present status of the diagnostic and thera-
peutic value of the Rontgen ray. The Allgemeine Kranken-
haus has been the central figure of the progre.ss in medicine
and surgery during the last six decades. During all this time
it has been the great center for the diffusion of the knowledge of
modern pathology. It has been and is now the mecca for
students from all parts of the world who are in search of the
basis of rational medicine — a thorough knowledge of gross and
microscopic pathology. The great morgue of this hospital was
the workshop in which Rokitansky made his international
reputation. Here gross and microscopic morbid anatomy are
taught today more thoroughly than in any other institution in
the world. Here the student can see from 10 to 25 autopsies
every day, and here every pathologic lesion is subjected to a
most painstaking microscopic examination. The next thing
which attracts the attention of students from foreign lands in
this institution is clinical diagnosis. Bamberger made this
branch of scientiflc medicine famous and Nothnagel and
Kowacs are now the men whose teachings are eagerly sought.
628 Ambkican Mbdicinej
TEACHING AND PRACTICE OF SURGERY
(October 18, 1002
It was In this institution that the Immortal Billroth reached
the climax of his unparalleled reputation as a surgeon. It was
the material from the postmortem-room of this, the greatest
hospital in the world, that Kyrtl drew his inspiration and
became the greatest anatomist the world ever knew. This ven-
erable institution remains a source of incalculable benefit to
the profession at large and will continue to remain so for cen-
turies to come.
Billroth made it the great school for modern surgery.
Many of his pupils and assistants have become distinguished
authors and famous teachers. Two of them now occupy the
two chairs of surgery in the University. Vienna has not forgot-
ten the epoch-making teachings of her Billroth. One of the
great thoroughfares of the city is now known as the " Billroth
Arcade," and a handsome bust of the profound scholar, the
prolific author, and the original surgeon, ornaments one of the
University halls. The number of students attending the
University has greatly diminished since the demise of its
three greatest lights— Rokitansky, Kyrtl, and Billroth. At
present it does not exceed 1,500. The time limit for graduation
is five years and about 200 are graduated annually.
Nursing Force. — One of the apparent great defects of this
hospital is the lack of well-trained female nurses. Ninety
Catholic Sisters serve in the capacity of nurses, but none of them
have had the necessary theoretic and practical training. The
same can be said of the orderlies and male nurses. I was
informed that in the near future a training school under the
direction of Professor von Mosetig-Moorhof will be established,
and it is to be hoped that this project will soon be realized, as
it would meet one of the most urgent demands of this, the
greatest refuge for the sick.
Professor Freiherr von Fiselsberg's Clinic. — Professor
Eiselsberg succeeded Professor Albrecht as the chief of the
first surgical clinic. He was one of Billroth's most talented
and favorite students and taught surgery in a subordinate posi-
tion for several years in Vienna, when he was called to Holland
and later to Konigsberg, Germany, as professor of surgery. He
has not passed beyond the meridian of life and has already
attained an enviable reputation as an investigator and surgeon.
His present exalted position marks the climax of his academic
career. His ambition has been gratified and he has now an
opportunity to use his talents in one of the most cosmopolitan
clinics in the world. He is well prepared for the task before
him. He is a fluent speaker and an expert operator. He takes
great delight in performing difficult operations. He is an
enthusiast in his profession and has the faculty of imparting
this desirable quality of a surgeon to his hearers. In his clin-
ical lectures he devotes most of his time to the scientific part of
surgery, surgical anatomy, pathology and diagnosis. All of his
major operations are performed in a small room, to which stu-
dents and practitioners have access in small sections. Those
who attend his operations must appear in linen coats and
rubber shoes. The aseptic details are very exacting. The
operator and his assistants each wear cotton gloves, a white cap
and a gauze mask for the face. This mask is an ordinary
Esmarch inhaler, to which a spectacle fraraiework is attached.
To what extent such a mask can contribute to aseptic precau-
tions will be determined only in a very few clinics. The A. C.
E. mixture is the anesthetic used. Hand disinfection consists
in scrubbing with warm flowing water and potash soap for five
minutes, followed by alcohol and sublimate. The field of opera-
tion is disinfected in a similar manner after the patient is under
the influence of the anesthetic. Silk is the material used for
ligatures and sutures. During the clinic I attended the follow-
ing operations were performed :
Case I. — Large bronchocele ; strumectomy . The patient
was a country woman, aged 54. The thyroid gland commenced
to enlarge 20 years ago, and for several years the swelling has
produced pressure symptoms at irregular intervals. The entire
gland is involved, but the right lobe is much larger than the
left. The swelling is nodular and firm, and the right lobe with
a part of the isthmus is in part retrosternal. It is this part of
the swelling that is responsible for the teinporary attacks of
embarrassment of respiration. Although Eiselsberg prefers
to perform strumectomy under local anesthesia, an exception
was made in this case at the urgent request of the patient and
the A. C. E. mixture was administered. The anesthesia at no
time gave rise to any serious or even unpleasant symptoms.
The head and chest were placed in a slightly elevated position,
and the neck rested in extended position upon a circular pillow.
A curved incision with the curve extending outward was made
over the right loVje of the swelling. With quick strokes of the
knife the capsule of the tumor was reached and hemorrhage
arrested by the use of many hemostatic forceps. All of the
bleeding points were then tied with fine silk ligatures. A por-
tion of tlie tumor the size of a walnut at a point where the
superior thyroid artery enters the gland was tied off with cat-
gut ligatures and severed with the knife. The retrosternal part
of the tumor was next liberated by blunt dissection. The
inferior thyroid vessels were divided between two ligatures.
In separating the tumor from the trachea all of the visible
vessels were tied and cut in a similar manner. The isthmus of
the gland was subjected to vertical linear crushing before the
ligatures were applied, when the mass, as large as a man's list,
was amputated. The trachea was found considerably flattened.
The left lobe was not removed. A strip of nosophen gauze
was used to establish capillary drainage, and the balance
of the wound was closed with silk sutures and the usual aseptic
absorbent dressing applied. Cystic and calcareous degenera-
tion marked the location of the multiple adenomas imbedded in
the miasmatic struma.
Case II. — Struma complicated by echinococcus cyst; incision
and drainage. The patient, a woman, aged 45, had been the
subject of an enlargement of the thyroid gland since girlhood.
The swelling caused no inconvenience until a number of
months ago, when it suddenly Increased in size, became painful
and tender. Suppuration ensued, and when the large abscess
was incised a large quantity of fetid pus escaped. The acute
symptoms subsided but the abscess never healed. A fistulous
opening near the sternoclavicular joint leads into the large
goiter toward the right side where the swelling is most promi-
nent. This sudden attack was taken for an acute suppurative
strumitis and it was the intention of the operator to remove the
right lobe of the gland with the al^scess cavity. The operation
was performed under local anesthesia. The external incision
was made in the same manner as in Case I. After the swelling
was exposed by reflection of the semilunar skinflap, the fistula
was followed into a cavity the size of a small cocoanut which
contained a teacupful of the broken-down products of an echi-
nococcus cyst. The anterior wall of this cavity was excised, the
floor thoroughly scraped out with a sharp spoon and in several
places the surface was cauterized with the Paquelin cautery.
The cavity was then packed with a long strip of nosophen
gauze and the incision sutured down to the drainage opening.
This case is an extremely rare one. The echinococcus cyst
developed in the interior of a parenchymatous struma and the
suppuration which ensued in its interior simulated in every
respect a suppurative strumitis as described by Tavel anil
others. It was the echinococcus part of the swelling which
caused the distressing clinical symptoms and the elimination
of this unusual complication by operative interference will be
followed by permanent relief.
Case III. — Cicatricial stenosis of the esophagus; gastros-
tomy ; gastrorrhaphy. A girl, aged 16, had swallowed caustic
potash when a child. Symptoms of cicatricial stenosis soon
set in and two years ago it became necessary to resort to gas-
trostomy to prevent death from starvation. The patient was
nourished through the fistula until by the use of a gradually
tapering soft rubber bougie the stricture was sufficiently
dilated to render the artificial opening superfluous. The
patient is now able to insert the dilator without any difficulty
and can swallow solid food with ease and in sufficient quantity,
hence it was decided to close the fistulous opening. The opera-
tion was performed under local anesthesia by Schleich's infil-
tration method. It was evident from the patient's expression
that the operation was not without pain, but she endured the
ordeal with patience and fortitude. The fistulous opening was
circumscribed by two elliptical incisions, the peritoneal cavity
opened, the anterior wall of the stomach drawn forward into
the wound in the form of a cone to the base of which a pair of
compression forceps were applied. The fistulous opening was
closed by a smaller compression forceps and between the two
forceps the excision was made which left a small oval visceral
wound, this was sutured with two rows of fine silk sutures.
Three rows of silk sutures were employed in closing the
abdominal incision.
The outdoor department of Prof. Eiselsberg's clinic is con-
ducted in a new building, admirably adapted for the treatment
of polyclinic patients. The reception and examination-rooms
leave nothing to be desired and the small operating-room is
supplied with everything necessary (or aseptic work. Here
many minor operations are performed by his assistants.
Professor Oussenbauer' s Clinic. — Gussenbauer is Billroth's
successor. After the death of the great master discussion was
rife among the Austrian and German surgeons as to who would
in all probability be called upon to fill the vacancy. It was
generally conceded that the choice would naturally fall upon
one of his assistants who had won distinction by original
scientific work. The final decision ended in the appointment
of Gussenbauer, who for many years was professor of surgery
October 18, 1902]
THE WORLD'S LATEST LITERATURE
[AxsBiCAN Medicine 620
in the Prague University. Under Billroth he and WolfHer
made the experiments on animals which in their results proved
the feasibility of partial gastrectomy for carcinoma and circum-
scribed inflammatory diseases and which laid the foundation
for gastric surgery. Gussenbauer's experimental studies on
the repair of wounds made his name familiar in scientific surgi-
cal literature. His artificial larynx demonstrated his mechani-
cal genius. His successful career in Prague recommended him
as a worthy successor of his famous teacher.
The amphitheater in which he gives his clinics remains the
same as when Billroth left it. It is a clinic in which more dis-
tinguished surgeons have sought postgraduate instruction
than in any other. The plain wooden benches, the narrow
arena, the low ceiling, the simple instrumentarium remind one
of the time when the greatest surgical genius held here the most
distinguished clinical audiences spellbound by his matchless
work. Gussenbauer is not a Billroth, but he is a great surgeon
and a most excellent teacher. His language is short and pre-
cise, his diagnostic conclusions accurate, drawn as they always
are from the pathologic conditions presented by the case under
consideration. His operative technic is well planned and is
always carried out with care and deliberation. At the time of
my visit he was making preparations to leave the city for his
summer vacation and had turned over the operative work to his
first assistant. Dr. Salzer, but ho was kind enough to show me
some of the more important cases operated uponduring the last
semester. Among th&se was a case of sarcoma of the brain
operated upon by osteoplastic resection ofthe skull. The focal
symptoms left no doubt as to the exact location of the tumor.
A gradually appearing hemiplegia on the right side and aphasia
pointed to the left motor tract as the seat of the disease. The
wound healed by primary intention and the pressure symp-
toms were relieved by the operation. A case of obstinate neu-
ralgia of thetrigeminous was promptly relieved by removal of
the gasseriau ganglion. His experience with this operation has
been uniformly satisfactory. A number' of appendicitis cases
were shown, the patients having recently been operated upon;
all of them were on the way to a speedy recovery. Several other
cases were under observation and under conservative treat-
ment.
Three cases of ununited fracture of the shaft of the long
bones had been treated by exposing the seat of fracture and
immobilization by direct fixation with Gussenbauer's clamp,
and all of the patients were doing well. A case of recurring
carcinoma of the orbit made it necessary to resect the frontal
bone and the dura mater extensively, and the defect, as large
as the palm of the hand, was filled in with a celluloi 1 plate.
The large wound healed by primary intention. Gussenbauer
makes no display of aseptic precautions in his clinic. Turbans,
gloves and masks are not seen, but the hands, instruments and
field of operation are prepared with utmost care. Catgut is
used only in exceptional cases. Dr. Salzer made an exploratory
laparotomy in a case of far advanced carcinoma of the stomach.
Owing to the extent and location of the disease gastroenteros-
tomy was not indicated, and a radical operation was out of
question. The same forenoon he operated on a case of carci-
noma of the bladder.
The patient, a middle-aged man, hart suffered for several
months from irritation of the bladder, and recently hematuria.
He was anesthetize<l and placed in Trendelenburg's position.
The interior of the bladder was exposed by a median vertical
incision. The carcinoma involved the base of the bladder and
the vesical end of the left urethra. The entire thickness of the
wall of the bladder at a safe distance from the margins of the
tumor and half an inch of the vesical end of the urethra were
resected. The operation was an exceedingly difflcult one and
was executed with the utmost care and great skill. Buried
sutures of calgut were used in diminishing the size of the
cavity behind the resected part of the bladder and in implant-
ing tlie urethra and suturing of the vesical wound. The
anterior incision was only sutured in part, leaving a large
opening for drainage. The drainage opening in the bladder
was sutured to the fascia of the recti muscle with fine silk.
The patient was progressing favorably 24 hours after operation.
Vienna, July 1».
Appropriation to FlRht Cholera.— The insular govern-
ment of tlio I'hilippine Islands has appropriated $50,000 to fight
cholera in the province of Hollo, Panay.
THE WORLD'S LATEST LITERATURE
Jonmal of the American Medical Association.
October 11, 1902. [Vol. xxxix, Xo. 1.^.]
Diagnosis of Chronic Indurative or Interstitial Nephritis. A1.0Y-
StDSO. J. Kklly.
The Early Circulatory Indications of Chronic Bright's Disease.
Louis Fauheres Bishoh.
Uremic Aphasia. David Riesman.
Improved Technic of Amputation and Treatment of the Stump In
Appendectomy. Joseph Rilus Eastm.^n.
The Successful Treatment of Gonorrhea and all Inflammatory Dlg-
ea.ses of the Urethra by Packing It with an Antiseptic Oiled
Dressing. S. T. Rocker.
Exeislon of the Gasseriau Ganglion, with Reports of Ten Cases
Operated Upon by the Hartley-Krause Method. John B. Mor-
PHY and James M. Neff.
The Surgery of Rickets. Henry Ling Taylor.
Trephining for Brain Tumors; Report of Two Successful Cases-
One of Nine Years. Joseph Ransohoff.
Some Facts about Vaccination. Heman Spaldino.
Two Cases of Retinal Detachment Treated with Subconjunctival
Injections of Salt Solution. Robert L. Randolph.
The Evolution of the Treatment of Pelvic Inflammation. E. E.
Montgowery.
Drainage versus Radical Operation for Suppuration In the Female
Pelvis. Charles P. Noblb.
1, 2, 3.— See American Medicine, Vol. Ill, No. 25, p. 1035.
4.— Improved Technic In Appendectomy.— Whatever the
method employed, the operator seeks the prevention of con-
tamination of the surrounding tissues and injury to the intes-
tines. Removal by the cautery between light clamps is safer
than cutting. A ligature about the base prevents exploration
of the canal. If the canal is not pervious, the interior should
be dissected out or cauterized before suture or ligature is
applied to provide for drainage. Eastman has devised shields
attachable to the jaws'of the forceps which will catch all escap-
ing material, while at the same time protecting surrounding
tissues from the heat of the cautery. After operation of the
appendix these shields can be easily removed aud the sutures
introduced, the forceps remaining in place until they are ready
for tightening. On removal the canal may be explored and
the stump invaginated. The forceps should be slender and
beveled on the under side to prevent cutting the .serosa, [h.m.]
5.— Successful Treatment of Inflammatory Diseases of
the Urethra.- Rucker advises bodily rest only when conven-
ient for the patient. Diet must be nonstimulating and alcohol
and sexual indulgence prohibited and the bowels kept open.
After complete evacuation the bladder is irrigated with potas-
sium permanganate, 1-3,000. A packer is introduced carefully
and passed back as far as the seat of the inflammation. The
urethra is then lightly packed with one-inch gauze, or better, a
loosely-spun cotton cord saturated with one of the following:
(1) Iodoform gr. xcv (gm. 6), balsam of Peru 3iv (gm. 16), cas-
tor-oil to fsiv (cc. 120) ; or (2) ichthyol and resorcin of each gr.
xl (gm. 2.66), balsam of Peru siv (gm. 16), castor-oil to fsiv
(cc. 120). The patient is instructed to wait as long as possible
before urinating, when the cord is slowly removed. This is
done once daily till the discharge ceases and then every other
day for 10 or 14 days. Sometimes it must be done twice daily.
The patient injects a 2<fc solution of protargol in acute cases and
a Ifo solution of zinc sulfocarbolate in chronic cases once daily.
The packer is made like a urethral sound with the end curved
and tapered. The discharge cea.ses in 2 to 5 days and in 10 or 14
days more the patient is dismissed. [h.m.J
7, 8. — .See American Medicine, Vol. Ill, No. 25, p. 1042.
B. — See American Medicine, Vol. Ill, No. 2.5, p. 1047.
10.— See American Medicine, Vol. Ill, No. 25, p. 1053.
12.— See American Medicine, Vol. Ill, No. 25, p. 1045.
Boston Medical and Snridcal Joarnal.
Ocloher 9, 190t. [Vol. OXLVIX, No. 15.]
1. Ultimate Results of Operations for Appendlellls. Homer Oaok.
2. Chronic Laryngeal Obstruction Due to Enlargement of the False
Cords ; Tnicheotomy ; Later Partial Excision of False Cords
L. R. O. Crandon.
8. The Modern Operation for Radical Cure of Umbilical Hernia. W.
H. Con A NT.
4. Sensory Hallucination and Its Analogs. Roiiert MacDocoall
(Concluded.)
5. Ma«sago In Fracture Treatment. Edward A. Tracy.
1.— Ultimate Ilesnita of Operations for Appendicitis. —
Gage makes an interesting report concerning the 360 patients.
630 Ambbioan MEDionrK
THE WORLD'S LATEST LITERATURE
[OCTOBEB 18, 1902
operated upon by him for appendicitis previous to October 1,
1901. He prefaces his remarlcs by saying he has come to believe
there is really but one kind of appendicitis, and it demands
operation; but just when that interference should be advised
is a different thing. Of the 300 patients 240 were operated upon
in the course of an acute attack, and of tliese 35, or almost 159{),
died. It was some satisfaction to find that tlie mortality was
about 17% in the first 100, about 14% in the second and less than
13% in the third, showing a small but steady improvement.
There were 173 cases in which the appendix was removed at the
time of the operation, with a mortality of 13%, and 67 in which
it was not removed, with a mortality of 19%. He thinks the
mortality will always be a little larger in the latter class. In
operating on the most desperate neglected cases one often feels
obliged to be content with simply opening and draining an
abscess — in such the mortality is necessarily high, no matter
what course is followed. Another reason for the increased
mortality is, that very often secondary abscesses are disclosed
only by the removal of the appendix, and if both are left the
danger is correspondingly increased. There were 26 cases in
which the inflammation was not limited at the time of the
operation, and 8 of these were sound, most probably from the
thorough irrigation. Of the 60 patients operated on in the
interval there was one death, and the author thinks this could
have been avoided. In two of these interval cases the appendix
was not found. Of the 228 patients whose subsequent history
he was able to follow, 42 had complaints of some sort, fancied
or real, which they connected with the operation. Two cases
of fecal fistula failed to close — one has persisted seven years
and the other seven months. Out of 228 replies there were
reported 19 (about 9%) hernias, 17 of these appearing within
the first year after operation. In 9 instances there have been
attacks simulating appendicitis, occurring after operation. In
tliree of these the appendix was not removed, in two more it
was removed very imperfectly, [a. B.C.]
2. — Chronic laryngeal obstruction produced by
enlargement of the false cords is reported by Crandon.
The patient was an Italian of 30, who for the past three years
had suffered from increased hoarseness and stridor. Sudden
attacks of dyspnea lasting about five minutes appeared. On
admission to the hospital there was a marked odor of ozena, and
the nasal fossae showed an advanced condition of atrophic rhi-
nitis. The laryngeal mirror revealed a somewhat elongated,
thickened, red epiglottis, with dilated vessels on its under sur-
face. The vocal cords could not be seen. The chink of the
glottis was entirely bounded, even in deepest inspiration, by
the false cords. These were dull red, almost purple, in color,
covered by a glairy excretion, and approached each other so
closely in the middle line that, even during deep inspiration,
when they should have been most widely separated, the aper-
ture or breathing space was apparently only 1.5 to 2 mm. at its
widest. On phonation the edges of the false cords overlapped.
Soon after admission, during a violent attack of dyspnea,
tracheotomy was done. The cannula was removed on the
second day, and there was no further trouble for three months,
when the attacks reappeared. For several sittings a spray of
10% solution of cocain was used in the larynx and the laryngeal
punch introduced. The punch was then used to cut a small
semicircular piece of tissue once a week from the enlarged false
cords until two pieces had been removed from each false cord.
This with proper medication and spraying relieved the patient.
This condition develops secondary to atrophic or hypertrophic
rhinitis, or postnasal catarrh, or dry pharyngitis, and is due to
continued exposure of the larynx to dry air. [a.b.c]
3. — Radical Cure of Umbilical Hernia.— Conant describes
the operation used by himself in dealing with this condition.
The merits claimed for it are lessened liability to shock, less
tearing of the omentum and less hemorrhage, and brevity.
The essential features are described as follows: A straight
incision is made into the sac to determine the condition and
character of its contents. If bowel is present it is reduced, if
possible, without breaking up adhesions. Then an elliptical
Incision is made on each side of the umbilicus of about 4 inches
in length. This incision goes outside the sac, and a dissection
is made to the rings. The sac is opened on either side, as close
to the ring as possible, and the whole sac is then cut through at
this point. The omentum is tied oft", and if the intestine is
adherent it is tied off at the same time, and tiie tied-ofl' omen-
tum and intestines are pushed down through the enlarged ring.
The tying off of the omentum and adhesions at this point takes
but a very short time, and there is practically no bleeding.
The stump is then dropped back and the umbilical ring is thor-
oughly dissected out. The peritoneum is sewed with plain
catgut. This closes the peritoneal cavity, and the rest of the
operation becomes an external one. The fascia is dissected
back so as to show the recti muscles. If the muscles have
retracted they are pulled together and sutured, overlapping one
another in the median line. The fascia is closed either by
suturing longitudinally, or by the method of Mayo, i. e., by
overlapping and suturing horizontally, [a.b.c]
4.— Sensory Hallucination and Its Analogs.— MacDou-
gall discusses the systematically induced hallucinations of
hypnosis, " crystal gazing " and shell divination, and analyzes
the positive and negative hallucinations of hypnotism, and not
only sensory hallucinations, but those of memory and belief.
Hallucinations of belief form a more radical mental defect than
those of memory. The most important effect is the misdirection
of will in reaction upon the world, involving a fundamental
disturbance of sanity. Chronic forms are called paranoia, and
are grouped with delusions of persecution and delusions of
grandeur. Between sensory hallucination and these more
sinister anologs the chief distinctions are the different degrees
in which higher and lower mental processes are involved, the
chronic nature of the latter, and their relation to the subsequent
fortune of the individual, [h.m.]
5. — Massage in Fracture Treatment.— Tracy insists upon
the efficacy of massage in the treatment of fractures. Massage
may be employed from the very beginning of treatment. No
special method is requisite. Common sense and a knowledge
of the direction of venous and lymph currents is all that is
necessary. If there be swelling massage should be begun by
grasping tlie limb on the proximal side of the fracture, making
gentle but firm pressure and relaxing, then after a short interval
grasp similarly a half inch more distal, and so on till the whole
swollen area is traversed, then make long strokes from distal
part toward the center of circulation. When there is no swell-
ing this latter is all that is necessary. The author prefers the
wood-plastic splint to the plaster cast for fixation, because it
not only secures better fixation but can easily be removed to
permit massage, [a.b.c]
Medical Record.
October 11, 190$. [Vol. 62, No. 15.]
1. The Prominent Eye: Its Meaning and Clinical Associations. A.
Haig.
2. Resection of Nearly Eight Feet of Gangrenous Intestine; Becovery.
tiEORGE R. Harris.
3. Making and Closing the Median Celiotomy Wound. AUOCSTIN
H. GOELET.
4. Sensation and Volition. Herman Gasskr.
5. The Glycerophosphates ; Particularly the Glycerophosphate of So-
dium. P. W. Street.
6. Malarial Infection a Potent Factor In Asthenopie Conditions. J.
Lawton Hiers.
7. The Use of Argyrol in the Treatment of Acute Gonorrhea. G. K.
Swinburne.
8. A Case of Raynaud's Disease Occurring in a Patient SufTering from
Graves' Disease. S. W. Thompson.
1. — The Prominent Eye. — According to Haig, this is seen
in one or two out of every ten persons we meet. Blood-pressure
is the chief determining factor. Of the three cardinal symp-
toms of Graves' disease, the prominent eye is met frequently in
the high blood-pressure lieadache (migraine or uric acid head-
ache), the enlargement of the thyroid occurs during menstrua-
tion when blood-pressure is raised, and when those women who
suffer from migraine or epilepsy have their attacks. The
quick pulse is found in all high blood-pressure conditions, as
the heart begins to fail before this pressure. Wlien the heart
fails the headaches and prominence of the eyes and thyroid are
diminished. If a card is held vertically over the closed eyelid,
it should rest firmly on the supraorbital ridge and malar
and superior maxillary bones, touching the eyeball so lightly
as to cause no discomfort. When the eyes are prominent the
side of the face forms a cone with the eyeball as the apex. The
October 18, 1902]
THE WORLD'S LATEST LITERATURE
iAMERicAN Medicine 631
lids stretch over it obliterating the normal depression at the
margin of the orbit. The change being more gradual than in
Graves' disease, the lids have been able to follow the ball. Dis-
tension of the skin of the face is a concomitant sign. Later this,
while still puffy, falls into wrinkles, and as the heart fails loses
the color due to dilated vessels. Prominent eye is commonest at
about 45, and is increased in conditions obstructing the circula-
tion, as asthma, emphysema, coughing, straining, obesity, etc.
Not all who have high pressure from coUemia have headache ;
some suffer at anything over 130 mm. of mercury, and others
only at 100 mm. [h.m.]
3. — Resection of Nearly Eight Feet of Gangrenous
Intestine ; Recovery. — Harris, of Norwich, Conn., reports the
case. The patient was a muscular man of 33 years who, for
several years, had suffered from acute attacks of abdominal
pain, which were usually relieved by rest and massage. The
present attack refused to yield to the usual treatment, or, in
fact, to any form of local or internal medication. Operation
was deemed imperative, and the patient was conveyed 12 miles
in an ambulance and over a rough road. Laparotomy was per-
formed some 36 hours after the onset of the attack. A median
incision permitted the escape of much dark blood-stained fluid,
and revealed a very large mass of gangrenous intestine which
was bound down, for the most part, in the right iliac fossa.
The point of constriction was close to the posterior abdominal
wall and the cecum. The constricting band was the size of a
leadpencil, and appeared to be mesentery. Seven feet ten
inches of the gangrenous gut was resected, the distal end being
severed close to the cecum. Both severed ends of the remain-
ing gut were completely closed by Lembert sutures, one-half of
a Murphy button in each instance being previously inserted
and pressed against the intestinal wall, the connecting neck
being forced through a small slit. Lateral anastomosis of
intestine to cecum was accomplished, and recovery followed.
[a. B.C.]
3.— Making and Closing the Median Celiotomy Wound.
— Goelet, of New York, enumerates the various objections to
the straight-through median abdominal wound and the usual
method of closure by through-and-through sutures— such as
imperfect closure with weak wall, liability to stitch abscess in
the abdominal wall, etc. He then gives the method as practised
by himself as follows: The skin and fat are divided in the
median line down to the fascia covering the muscles of the
aMominal wall ; then one side of the wound is retracted, and
the fascia covering the rectus muscle, about a third of an inch
from the median line, is knicked with the knife and split up
and down with the scissors to the limit of the incision in the
skin above and below. The muscle is then separated with the
fingers in the direction of its fibers down to the subperitoneal
fat, which, with the peritoneum, is opened in the usual manner.
The advantage thus gained is that in closing the wound muscle
is approximated to muscle to one side of the incision in the
skin, and a firmer line of union is secured. In closing the
wound a continuous suture of No. 1 chromicized catgut is
applied throughout, and this is tied only at the start and at the
finish. The first layer includes the peritoneum, subperitoneal
fascia and the lower border of the muscle on each side, begin-
• nlng at the upper angle of the wound and continuing to the
lower angle. Continuing with the same suture from below
upward the fascia is united, and this layer of sutures is made to
include the upper part of the muscle with the fascia, [a.b.c]
4.— Sensation and Volition.— We cannot tell where the
sensory side of the nervous system ends and the motor side
begins, either centrally or peripherally, the continued circuit
of their function resembling the circulation of the blood. We
know our sensations only in our volitions. Gasser illustrates
his theory from the special senses. As the nerve cells of the
retina and visual centers are intimately united by plexuses it
is probalily not the cell body that reacts on the forces around,
but the plexuses themselves perform the true metabolism, the
cell being a storehouse and organizerof the plexelary function.
The cells with their dendrites are anatomically and physiolog-
ically connected liy the plexuses with a regular and continued
circuit of function, which the neuron theory denies. The optic
nerve is motor on one side of the plexuses and sensory on the
other. The specific function of the optic nerve and retina is to
react on light waves and to transmit them as nervous energy
to the brain, where they become vision. The stimulus of light,
like that of food in the stomach, causes increased amounts of
motor energy to be sent to stimulate all the locally related
physiologic functions, of which the blood supply is a part, and
so nourish the local functional life. It is not the light waves on
the retina that cause special sensation, but the physiochemic
reaction which is taken up by the plexuses and transmitted as
nervous energy and sent back as organized motor function.
[H.M.]
5.— The Glycerophosphates.- These are products of the
action of glycerophosphoric acid on various bases. The sodium
salt has received the most attention. They supply phosphorus
in easily assimilable form and are indicated in nervous impair-
ment due to overwork or excesses, in premature senility,
hysteria, neuralgia and convalescence from acute infections.
They are contraindicated in albuminuria and acute gout and
rheumatism. They should be given for three to six months or
longer. Street gives formulas for their administration, [h.m.]
6.— Malaria in Asthenopia.— In four years Hiers has
found 20 cases of hypertropic astigmatism associated with
malaria. In addition there have been 11 with no other assign-
able cause for the asthenopia. Parasites were observed in
abundance and antimalarial treatment verified the contention
that this is an etiologic factor. Two forms exist — acute and
chronic. The former is characterized by eyestrain, pain and
weakness of vision accompanying intermittent or remittent
febrile reactions. In the chronic form febrile reaction does not
necessarily accompany the history of the case and the cause
may thus be overlooked, [h.m.]
7.— The Use of Argyrol in Acute Gonorrhea.— Swin-
burne says the preparations of silver which are made by com-
bining argentum with some form of albuminous product
possess two great advantages, that they do not coagulate
albumin nor form silver chlorid when brought in contact with
solutions of sodium chlorid. Argonin, protargol and albargin
are the best known of these products. Argonin contains about
4% of silver and may be used in strength of 10%. It is abso-
lutely nonirritating, but deteriorates after standing a few days.
Protargol solution keeps better, contains about 8% of silver, but
cannot be used in the urethra in stronger solutions than i% or
2%. Even then it may be so painful as to require accompany-
ing injections of cocain. Albargin contains 15% of silver, and
may be used in strength of 5% to 2%, but is often very painful.
The author has lately tried with marked success not only in dis-
pensary work but in private practice the new silver preparation
manufactured by Barnes, of Philadelphia, and called argyrol.
It comes in dark-brown scales, is very hygroscopic, is soluble
to almost any degree in water, is nonirritating, contains about
30% silver, and solutions keep well without deteriorating. Con-
cerning his opinion of its value he says: This drug has decided
gonococcidal powers ; reduces and allays inflammation, and
can be used safely in almost any strength and at any stage of
the disease; the injection can be repeated almost as frequently
as the fancy of the physician dictates; I have not seen any
unpleasant symptoms due to the use of the drug, and I believe
it to be one of the most valuable remedies given to the profes-
sion in recent years, [a.b.c]
8. — Raynaud's Disease Superimposed Upon Graves'
Disease. — Thompson reports the case of a male of 29 who came
from a family of neurasthenics. He had always been weak and
nervous, occasionally suffering from convulsions, and for the
past nine years had suffered from Graves' disease. In December,
1901, he noticed that the middle and ring fingers of the left hand
became cold and pale when exposed to the air. The condition
gradually grew worse and pain appeared in the arm and hand.
Gradually the pain increa.sed in severity and his medical
attendant used codein, the galvanic current, tonics and hot
applications for its relief, but without avail. In May, 1902, the
nails were becoming flat and blebs filled witli serum appeared
on the ends of the fingers and at the base of the nails. The
pain was so great that i grain of morphia every hour failed to
give relief. The fingers in question became a dark bluish-
^reen color and the blebs began to ulcerate. Various remedies,
682 &HXRICAK MsmCINEj
THE WORLD'S LATEST LITERATUEE
[OCTOBER 18, 1902
such as nitroglycerin, etc., failed to arrest tiie process, and
amputation was effected at the junction of the middle and upper
third of the humerus. The patient came out of ether, but was
delirious and died two days after the operation, [a.b.o.]
New York Medical Journal.
October i, 190i. [Vol,, lxxvi. No. 14.]
1. Rotation In Lateral Curvature: A Reply to Dr. Judson. Robbbt
W. LOVKTT.
2. A Method of Circumcision. Walter C. Klotz.
3. A Case of Chelold. H. Taylor.
4. Complications In the Passage of a Gallstone. Neil MACpnATTEB.
5. Current Differentiation, Illustrated by a Case of Peripheral Neuritis,
Due to Parenchymatous Degeneration of the Cord. A. D. RocK-
. WELL.
B. P^irther Remarks on Insufflclentla Pylori as a Sequela of Chronic
Gastritis ; with Report of Fourteen More Cases, Treated Success-
fully Makk I. Knaph.
7. Bcatson's Cure of " Inoperable " Cases of Mammary Cancer. Jennie
G. Drennan.
8. Mastoid Disease in Infants, Two Cases ; in Adults, Two Cases ; the
Latter Complicated with Erysipelas. W. Peyke Porcher.
1.— Rotation in Lateral Curvature.— Lovett calls atten-
tion to the necessary association of rotation of the vertebras
with side bendings of the spine and gives cuts illustrating the
same, [c.a.c]
2. — A method of circumcision, which consists in remov-
ing a cuff-shaped flap of skin, leaving intact the areolar tissue,
with its bloodvessels and lymphatics, is described by Klotz. A
circular incision is made around the penis from 50 mm. (2 in.)
to 75 mm. (3 in.) behind the coronal sulcus, according to the
amount of skin it is desirable to remove. This incision should
divide only the skin so far as the areolar tissue. A second
incision is made around the penis about 12.5 mm. (J in.) behind
the coronal sulcus. This should be like the first, but in a
plane faced more obliquely, so as to be parallel with the
line of insertion of the glans. The two circular incisions are
then joined by a longitudinal one along the dorsum of the
penis, and beginning along the edges of the latter, the cuff-
shaped flap of skin outlined by the three incisions should now
be dissected off all around the penis. The two edges are then
brought together and united by interrupted horsehair sutures.
In this operation hemorrhage is slight and there is freedom
from edema and induration. There is prompt union and free-
dom from adhesions along the suture line. The operation is
not practicable on very young individuals, [c.a.c.]
3.— A case of keloid in a man of 21 is reported by Tay-
lor. The condition followed a blister involving the skin over
the lower ribs and the epigastric and hypogastric regions. The
tumor had been removed, but in 10 or 12 weeks was as large as
ever. The author says that removal by operation or treatment
by caustics is never successful in preventing a return, [c.a.c]
4.— Passage of a Gallstone.— Macphatter gives in detail
many of the various complications in the passage of a gallstone.
The greater number of impactions take place at the ostium
duodenale, next to this is the neck of the cystic duct. When
impaction is limited to the cystic duct the constitutional symp-
toms are usually very few, if it occurs in the common duct the
condition is much more serious. Whenever impaction occurs
a dilation of various degrees of extent takes place on the prox-
imal side of the stone ; while on the distal side it usually con-
tracts, and if long continued atrophy or entire obliteration of
the lumen may result. Cholangeitis is one of the most frequent
accompaniments of obstruction and stagnation from the pres-
ence of a calculus in the common duct. When pus is found in
the gallbladder it is usually associated with cholelithiasis,
although typhoid fever, tumors of the gallbladder, and pyo-
genic organisms may be an exciting cause, independent of the
presence of gallstones. Calculous hepatitis may be the result
of an inflammatory condition extending from the gallbladder
or tubes into the substance of the livei'. Ulcers in the walls of
the gallbladder and biliary ducts are commonly met in chole-
lithiasis. They are of chief importance because of the serious
consequences- such as stricture, hemorrhage, perforation, fis-
tula, local or general peritonitis, septicemia, pyemia and death.
Among the other complications are inflammatory adhesions of
the biliary passages to adjacent organs, affections of the portal
vein and intestinal obstruction. Biliary duodenal, urinary,
vaginal, thoracic, umbilical, pulmonary, pericardial, cutaneous
and pleural fistulas are discussed and cases mentioned, as are
also cases in which fistulous tracts were found between the
biliary passages and intestines or stomach. The article is
exceedingly interesting and should be read in the original.
[C.A.O.]
6.— InsufBcientia Pylori.- Knapp discusses this condition,
and for a cure outlines a plan of action that has proved success-
ful in 2<) cases treated by him. The immediate cause of the
condition is a chronic gastritis. His cases seem to bring out,
so far, three remote causes: (1) Mechanical; (2) organacidia
gastrica; and (3) alcoholism. The symptoms refer entirely to
the deranged functions of the intestine. They are diarrhea or
constipation, or both ; fulness in the abdomen, cramps, pain,
or a sensation of pressure or of emptiness, or a feeling of
weight in the abdomen. Headaclies, vertigo, anorexia, nausea,
singultus, are among the symptoms. Flashes of heat and cold,
especially late in the afternoon and evening, correspond with
the food's reaching the intestine. The dietetic treatment
resolves itself into the withholding from the m6nu of acid food-
stuffs and such as contain or generate gas. The food must
reach the stomach in a well macerated condition. Cellulose in
any shape should not be permitted. For some time after meals
the patient should lie on his left side to antagonize the tendency
of the food to gravitate toward the pylorus. To help intestinal
digestion the compounds of potassium, sodium and magnesium
are of excellent service if given at the right time. Pancreatin
and inspissated oxgall, in conjunction with the drugs just
mentioned, are valuable. For constipation, sodium sulfate in
hot water before meals acts well. For chronic diarrheas the
author has found strychnin, in rapidly increasing doses, to have
an excellent effect. Fourteen cases are reported in which the
treatment has been satisfactory. [c.A.o.]
8.— Mastoid Disease.— Two cases of mastoid disease in
infants, aged 6 and 8 months, respectively, are reported by
Porcher. The abscess was merely opened and drained in each
case, the curet not Ijeing used. Uneventful recovery followed.
Two cases of mastoid disease in adults, complicated by erysip-
elas, are also reported. The first case was that of a man who
had had diabetes for several years. The abscess pointed and
was opened above the zygomatic process. Erysipelas developed
but was controlled. He died one year later of diabetes. The
second case was one of mastoid disease from an old otitis media.
A Stache operation failed to give relief. Whiting's radical
operation was then performed and the tip of the mastoid
removed. Erysipelas developed on the third day. The condi-
tion soon cleared up and recovery followed. [c.A.o.]
Medical News.
October 11, 1902. [Vol. 81, No. 15.]
1. The Teaching of Surgery; with Especial Reference to Didactic
Method. Joseph D. Bryant.
2. Contribution to the Diagnosis of Renal Calculus. Fbedebic Bier-
HOFF.
3. The Criminal Equivalent of Insanity. William B. Noyes.
■1. Apocynum Cannablnum in Some Dropsical Conditions. M. L.
HiLURETH.
.5. The Etiology of Shock. H. H. Stoner.
6. How Much. Do We Positively Know About Tuberculosis? A Plea
for the Tuberculous. F. C. McGahey.
7. An Instance of Accidental Vaccination. George W. Kosmak.
1.— See American Medicine, Vol. Ill, No. 24, p. 994.
2. — Aid to the Diagnosis of Renal Calculus. — Bierhoff
proposes as an aid to the diagnosis of renal calculus that the
pelvis of tlie suspected kidney be repeatedly distended with
some bland, sterile fiuid with the hope of effecting a movement
of the calculus. This being effected (where a stone was
present) the procedure was followed within 24 hours by a dis-
tinct hematuria. The method employed was as follows : A
good-sized ureteral catheter was passed up into the renal
pelvis, and tepid, sterilized 1% boric acid solution was gently
injected until the patient complained of a sensation of pressure
in the renal region ; usually about 30 cc. is required. The fluid
was then allowed to flow off, and the maneuver was repeated
until 250 to 300 cc. had been employed. Altogether it was used
in five instances, upon four cases of pyelitis suspected to be due
to calculus. By this means a positive diagnosis of renal cal-
culus was made in two of the five cases, and a negative report
made in the three remaining cases. All were confirmed as
OCTOBKB 18, 19021
THE WORLD'S LATEST LITEBATUEE
(Amekican Mkdicine 633
correct by subsequent operation or the x-ray. In none of the
cases had the radiograph been used previous to the diagnosis
by irrigation. The author's explanation is that by distention of
the renal pelvis the stone is caused to shift its position, causing
a slight abrasion of the tissues and consequent hematuria.
[a.b.c.1
3.— Criminal Equivalent of Insanity.— According to
Noyes, moral insanity has no satisfactory place in the classifi-
cation of either ethics, psychiatry, or criminology, the com-
monest typo being merely au unusually marked case of " bad "
boy. There is not necessarily any direct proportion between
the moral limitation and general intellectual limitation.
Changes in moral nature may be associated with physical dis-
ease, as braiu tumor, epilepsy, meningitis, etc. Apart from
impairment of intellect and disease, defective moral control is
uncommon. In another type the moral and intellectual charac-
teristics seem normal in childhood, and .some accident or illness
at adolescence or later changes the disposition. The author
reviews English and American decisions as to legal responsi-
bility for crime. The law will hardly recognize the theory
that any uncontrollable impulse may so take possession of a
man as to compel him to do what he knows is wrong. At this
point medical and legal views diverge sharply. The will may
be impaired by defect of Impulse, by morbid fear or fixed ideas,
by uncontrollable impulse, or by the caprices of hysteria or
hypnotism, including autosuggestion. The last is one of the
most potent sources of crime. Lack of inhibition may give
free rein to any dominant trait of character which, under right
conditions, is normal, such as bad temper, selfishness vanity,
etc. The word degenerate is improperly restricted to those
who practise unnatural crimes. It should include men abnor-
mal from inheritance in both body and mind. Of these border-
land ca.ses, called by Lombroso " criminaloids," more than one
type can develop. Tramps and anarchists arc examples, [h.m.]
4. — Apocynnm Cannabinum in Some Dropsical Condi-
tions.— Hildreth thinks this has no equal in edema accompany-
ing the varicose condition and varicose ulcers in elderly per-
sons. He has used it with wonderful effect also in the general
aua.sarca following pregnancy, but never in the dropsies accom-
panying acute nephritis, as in scarlet fever, etc. It slows and
steadies the heart, increases blood-pressure, stimulates the
kidneys, probably by dilating their arterioles, and seems to
have a tonic effect on the general capillary system lessening
transudation of serum. He uses Lloyd's tincture in doses of
2 or -3 minims (cc. 0.12 or 0.18) every 3 or 4 hours. Tolerance
may necessitate increasing doses, [h.m.]
5.— The Etiology of Shock.— 8toner enumerates the well-
known symptoms of shock and asks if a more faithful picture
of sympathetic disturbance could be portrayed. Every symp-
tom is indicative of a profound impres-sion operating upon the
system of nerves which preside over the negative functions.
Tliese effects (the symptoms) are certainly produced through
the agency of the nervous system, and the same agent which
produces the blush of shame is responsible for the blush which
attends the state of shock ; both are due, no doubt, to an impres-
sion acting upon the vasomotor system which dilates the walls
of the capillary bloodvessels. The evidence is conclusive that
the pallor of shock and the pallor of fear have likewise a com-
mon cause, but here the impression made upon the vasomotor
nerves is such as to constrict the capillaries and drive the blood
from the surface. It is quite clear that the sweating of emotion
is manifested throvigh the agency of the sympathetic nervous
system, and if this be true, the inference is allowable that the
same phenomenon as it attends shock has a like origin, [a. B.C.]
6.— A Plea for the Tuberculous. — McfJahey illustrates
from Indian schools the comparatively slight danger from
infection in tuberculosis. Persons with syphilis and gonorrhea
are treated with so much consideration that we never think of
instructing those around them how dangerous they may be,
though these diseases are so much more contagious. We trust
to the patient that he will take necessary precautions. The
same consideration ought surely to be extended to the innocent
sufferer of tuberculosis, who is now becoming a social outcast.
Ordinances stgainst spitting are good, but a heavy fine should
lie exacted from women wearing skirts that are not at least two
inches from the pavement. Leather instead of plush should be
used for car seats and linoleum for the floor. Then the car
could be cleaned after each trip. Practical instruction in anti-
sepsis should be given in the schools, [h.m.]
Philadelphia Medical Journal.
October 11, 190i. [Vol. x. No. 15.]
1. Gastroptosls : A Method of Suspending the Stomach in a Hammock
Made of the Great Omentum. R. C. Coffey.
2. Uttoral California. William A. Edwards .,„„<, n m
3. Is Disease Transmitted to Man Through Meat and Milk? u. M.
4. Severe' BuVn of the Eye and Face by Nitrite of Arayl, with Loss of
the Eye. Edward A. Shumway. „„, „r
5. Extensive Destruction of the Nasal Septum, with Involvement or
the Accessory Sinuses, from Sepsis. Charlks I. Buvingkb.
1.— Gastroptosls. — Coffey reports two cases which he
treated by suspending the stomach in a hammock made of the
great omentum, a method which he believes has not been
touched upon in medical literature. The symptoms, pathology
and treatment of the cases are detailed, so that the reader may
judge of the merits of the operation with a clear understanding.
The operation suggested by suspending the stomach in a ham-
mock adds additional supports, namely, the posterior attach-
ment of the mesocolon and the anterior attachment of the great
omentum to the abdominal wall. Both of these attachments
are indirect and are capable of holding more than a direct
attachment, like the one from above. The dilation of the
stomach, which is generally concomitant with gastroptosls,
will in the majority of cases be relieved. The transverse colon,
being in the folds of the great omentum, cannot be displaced
downward, therefore this operation will greatly benefit if not
entirely relieve enteroptosis, by supporting the weight which
would otherwise be riding the small intestines into the pelvis.
In case of splanchnoptosis with a much relaxed abdominal wall
or separation of the recti muscles, the operation devised by
Webster should be done in closing the abdominal wound. In
this way no organ has its motion interfered with by the opera-
tion, and as has been demonstrated by the two cases, no pain or
inconvenience is produced by the attachment. The article is
profusely illustrated, [f.c.h.]
3.— Is Disease Transmitted to Man ThrouRh Meat
and Milk ?— McMasters thinks the great and important
questions of the day are: Is bovine tuberculosis trans-
mitted to other cattle ; is it transmitted to other ani-
mals ; is it transmitted to man ; what is the remedy and what
is our duty in the premises ? There is sufficient proof that bovine
tuberculosis can be transmitted to animals of different species.
Regarding the tubercle bacillus of man and that of cattle, might
they not be primarily the same, and if any difference exists,
might it not be due to environment? If tuberculosis exists
today in cattle, is it not a fact that the product of that animal
is disea.sed? If it be diseased, is it not likely that some
deleterious influences might be exerted upon man ? If it is not
tuberculous disease our duty, while apparently not so urgent in
the matter, is certainly plain. We should exclude all diseases
that are transmitted to man by inoculation and dwell upon dis-
eases transmitted to man through food. Laws should be
enacted compelling all dairies supplying milk to subscribe to
certain positive sanitary and hygienic regulations, aud compe-
tent men should be appointed to see that these laws are strictly
adhered to. [f.c.h.]
4._See American Medicine, Vol. IV, No. 12, p. 448.
CLINICAL MEDICINE
David Rissman A. O. J. Kelly
EDITORIAL COMMENT
The Nattire of Pernicious Anemia. — Despite the
many accurate antl painstaking clinical and pathologic
investigations of ca.se8 of pernicious anemia, especially
during recent years, the nature of the disea.se remains
one of the most elusive problems in medicine. While
some of the old and more or less ill-deflned views still
find a few adherents, the disease is now generally
regarded as a manifestation of intoxication of the system.
634 Aherioan Medicine I
THE WOELD'S LATEST LITER AT (IRE
[OCTOBEB 18, 1902
as a result in most cases of an autointoxication ; but the
source, tiie nature, and the mode of action of the toxin
remain the subject of much discussion. On the one
hand, it is held that the special action of the toxin is to
pervert hemogenesis— 1« cause the production of imper-
fect blood-corpuscles, while on the other hand, special
hemolytic activities are attributed to the toxin — activ-
ities whereby the blood-corpuscles are destroyed. In
addition, some writers are disposed to believe that the
disease comprises both defective or perverted hemo-
genesis as well as hemolysis. Thus Stengel looks upon
the disease not as a disease sui generis but as a condition
secondary to the action of hemolytic agents arising in
the gastrointestinal tract, and he believes also that in
some persons the hemogenetic function of the bone-
marrow is deficient or perverted. Hunter, who is well-
known as a supporter of the toxic nature of the affection,
attributes the toxin to carious teeth, assuming that these
lead to chronic catarrhal alterations of the stomach and to
toxemia, and that both the general symptoms and the
hemolysis are the result of the toxemia. To some extent
he illustrates his meaning by stating that the gastroin-
testinal lesions hold the same relation to pernicious
anemia that the throat-lesions do to diphtheria and that
the intestinal lesions do to typhoid fever. Without
citing the opinions of other writers, it suffices to point
out that the gradually accumulating mass of evidence
tends distintly to support the view of the toxic nature
of the disease ; indeed, in most respects the disease
seems insusceptible of explanation on other grounds.
Furthermore, the toxic theory finds support in the great
weakness that frequently is the first clinical manifesta-
tion of the disease, in the common want of relationship
between the general condition of the patient, which may
be very good, and the blood picture, which may be very
bad (and vice versa), and in the changes in the spinal
cord and the peripheral nerves, which are to be attributed
to the action of a toxin, rather than to the anemia per se.
Confirmatory evidence of the likelihood of the presence
of a gastrointestinal toxin is found in the presence, in
some cases of Botliriocephalus latus and other parasites,
of atrophy of the gastric mucous membrane, of ulcera-
tion and carcinoma of the stomach, etc. These views
with reference to the toxic nature of pernicious anemia
find a special application in the recent work of Warthin,
who details the results of his study of the pathology of
pernicious anemia, with special reference to the changes
occurring in the hemolymph nodes in eight autopsy
cases, and whose conclusions will be found elsewhere in
this issue. Pointing out that though much attention
has been paid in recent years to the changes occurring in
the spleen and the bone marrow, and that the lymphatic
structures have been practically disregarded as a possible
factor in the pathogenesis of this disease, he goes on to
describe the evidences of excessive phagocytosis and
destruction of the red blood-corpuscles in the spleen,
bone marrow, lymph glands, and hemolymph glands
that he found. These changes are not regarded as
specific of pernicious anemia, since they may occur in
other infections or intoxications characterized by great
hemolysis. This, then, the most recent contribution to
the literature of the subject, tends to confirm the view
of the toxic nature of pernicious anemia, and to prove
that it is essentially a hemolytic disease. But we have
not yet arrived at a knowledge of the ultimate nature of
the disease ; though we may be tolerably well informed
of the mode of action of the toxin, we know neither its
source nor its nature. Warthin, though he sees its
effects, which he compares with the action of toluyledia-
min on the blood and blood organs, still feels unable to
affirm whether the condition is a result of an infection
or a manifestation of autointoxication. Nevertheless
considerable progress is being made, and we may hope
that the toxin, which we may term a hemolysis, and
which is probably allied to some of the recently-studied
cellular toxins, will yet be isolated. When this shall have
occurred the most sanguine of us will look for the early
discovery of an antihemolysin.
REVIEW OF L1TEK.\TUKE
The PathoJojfjr of Pernicious Anemia, with Kspecial
Reference to Clianges Occurring in the Hemolymph
Nodes.— Warthin,' basing his opinion upon a careful study of
eight autopsy cases and a review of the literature, draws the
following conclusions : 1. Pernicious anemia is essentially a
hemolytic disease, the hemolysis being due to some as yet
unknown poison comparable in its effects upon the blood and
blood organs to the action of toluylediamin— whether autoin-
toxication or infection, remains yet to be determined. 2. The
poison of pernicious anemia stimulates the phagocytes of the
spleen, lymph, and hemolymph glands and bone marrow to
increased hemolysis (cellular hemolysis). Either the phago-
cytes are directly stimulated to increased destruction of red
cells or the latter are so changed by the poison that they them-
selves stimulate the phagocytes. The hemolysis of pernicious
anemia differs only in degree, not in kind, from normal hemo-
lysis or the pathologic increase occurring in sepsis, typhoid,
etc. 3. It is not improbable that from the destruction of hemo-
globin poisonous products (histon?) may be formed, which
have also a hemolytic action — a vicious circle of hemolysis may
thus be produced. No proof of this exists at present. The
hemolysis of pernicious anemia is not confined to the portal
area, as according to Hunter, but in some places at least takes
place also to a large extent in the prevertebral lymph and
hemolymph nodes and bone marrow. In the majority of cases
the spleen is the chief seat of the blood destruction. No evi-
dence of hemolysis in the liver, stomach, and intestinal capil-
laries were found in the eight cases. The hemosiderin of the
liver and kidneys is carried to these organs as some soluble
derivative of hemoglobin, is removed from the circulation as
hemosiderin by the endotheliu ja, and then transferred to the
liver or kidney cells. The deposit of iron in these organs is of the
nature of an excretion. 5. In the majority of cases only slight
reaction for iron is found at the sites of actual hemolysis
(spleen, lymph and hemolymph glands and bone marrow). The
greater part of the pigment in the phagocytes of the spleen,
lymph and hemolymph glands does not give an iron reaction
while in a dilfuse form. When changed to a granular pigment
the iron reaction may usually be obtained. The change to
hemosiderin is for the greater part accomplished by the endo-
thelium of the liver and kidneys. 6. The varying pathologic
conditions found in these different cases of pernicious anemia
can be explained only by a theory of cyclic or intermittent pro-
cess of hemolysis. This theory is also borne out by the exacer-
bations so frequently seen clinically. The autopsy findings, in
so far as evidences of hemolysis are concerned, will depend
upon the relation between the time of death and the stage of the
hemolysis. 7. The changes in the hemolymph glands found
constantly in these eight cases were dilation of the blood
sinuses and evidences of increased hemolysis, as shown by the
increased number of phagocytes containing disintegrating red
cells and blood pigment. In some of the cases these changes
were accompanied by great increase in size and apparent
increase in number of the hemolymph glands ; in other cases
there was no hyperplasia, the only evidences of the changes
present being that obtained by microscopic examination. The
changes found cannot be regarded as specific of pernicious
anemia, since it is probable that they may be produced by other
infectious or toxic processes characterized by great hemolysis.
8. The lymphoid and metabolic changes in the bone marrow do
not form an essential part of the pathology of pernicious
anemia and are to be regarded as of a compensatory nature— an
increased activity of red cell formation to supply the deficiency
caused by the excessive hemolysis, [a.o.j.k.]
Concerning Several Rare Cases of Migraine. — Pilssler ^
reports the following cases: The first was that of a healthy
young man whose mother was suffering from migraine. Im-
mediately after a fall from a bicycle he developed mild mi-
grainous attacks, which suddenly passed into attacks of great
1 American Journal of the Medical Sciences, cxxiv, 674, 1902.
sMunchener med. Woch., July 1, 1902.
OCTOBER 18, 1902]
THE WORLD'S LATEST LITERATURE
(AMBBXOAN MBDICtNE 635
severity. The aura, which was sensory and occasionally vis-
ual, was followed by aphasia, nausea, and the vomiting of
large quantities of fluid free from hydrochloric acid. The
headache was bilateral, but was more marked on the side oppo-
site that on which the aura had been noted. Vasomotor dis-
turbances, consisting in primary contraction of the vessels of
the head followed by dilation without sweating, were at times
present. In one attack the pupil on the side of the severer
headache was dilated. In the second case, a servant girl of 31,
the pupils during the attacks were abnormally dilated and did
not react to light. There were also vasomotor disturbances,
and when these were absent the pupillary phenomenon was not
ol)served. The third patient was a man of 38, formerly a lead-
worker. The attacks were left-sided, began in the occiput, and
were accompanied by phenomena suggesting cerebellar ataxia.
The vessels in the affected side of the head were dilated, and
during the attacks the knee-jerks were markedly exaggerated.
Under the useof quinin the patient improved greatly, the head-
ache, vertigo and titubating gait disappearing. The first case
is interesting in that the migraine followed trauma ; there was,
however, a family history of migraine. The papillary phenom-
ena in the first and second cases are uncommon and difficult
to'explain. In the first case, the relation of the localization of
the aura to the aphasic symptoms is interesting. Liveing
noted aphasia in 12 cases of sensory aura ; in 7 the aura was
right-sided ; in 4, bilateral. In the present case the aura was
right-sided. The third case is analogous to the one described
by Oppenheim as " cerebellar hemicrania." [d.r.]
liocalization of the Stomach by Transonance.— Blad '
favors a method for determining the position of the stomach
which though considered new in Europe has been in vogue in
America for some time. He outlines the stomach by means of
transonance, which consists in ausculting and percussing
simultaneously. By using a double stethoscope he performs
the operation without an assistant. He holds the stethoscope
with the left hand and with the right he begins percussing above
the normal outline of the stomach and gradually advances
toward the stethoscope. The change in the note will indicate
whether the stomach has been reached. This method is prefer-
able to insufflation of the stomach because of the discomfort the
latter occasions the patient, also insufflation is of little value in
fleshy people. Dilation of the stomach by soda and an acid is
always accompanied by some risk. Blad tries only to outline
the lesser curvature, for it alone is constant in fixation. He
uses this method not only for organs filled with air, like the
colon, stomach, etc., but also for diagnosing the position of the
solid organs, [w.e.r.]
The Hesistance of the Blood In Icterus.— According to
the observations of Vaquez and RibierrC,' communicated to the
«oci6t6 de Biologie of Paris, July 28, 1902, the blood-corpuscles
acquire a very marked resistance to the solvent action of dis-
tilled water during the course of an attack of icterus. [o.s.D.]
Concerning IsoafCKlutlnins in the Serum of Healthy
and Sick Persons.— It hsis been shown that the blood-serum
of certain persons possesses a su instance which has the power
of agglutinating the red corpuscles of other persons. This sub-
stance is called isoagglutinin. V. Decastello and Sturli ■> exam-
ined tlie blood of a variety of persons suflVjring from all manner
of ailments, to determine whether there is any relation between
any particular disea.se and agglutination. Their conclusions
are as follows : (1) In the majority of healthy and diseased per-
sons above six months of age the serum contains isoagglutinins ;
''-) tho typical phenomenon is observed regularly and in the
^ line manner in disease and in health; (3) the only exceptions
consisted in the total absence of isoagglutinins and in the .spe-
cific resistance of the erythrocytes ; this occurred in four out of
15.5 cases examined; (4) isoagglutinatiou possesses no diag-
nostic significance; (5) in the newl>orn and in infants under six
months of age apparent deviations from the typical behavior
are found; they are explained on tho assumption that the
agglutinins appear primarily in the serum and bring about
secondarily a change (immunization) of the red corpuscles;
(6) the development of isoagglutinins is not to be explained by
the physiologic or pathologic destruction of the blood; (7) rou-
leau formation has nothing to do with the action of agglutinins.
[D.R.]
A. B. Cbaio
GENERAL SURGERY
Martin B. Tinker
C. A. Orr
EDITOKIAL COMMENT
' Berliner kllnlRclie Wochensdiria, April 21, 1902.
» Qazette bebdomadalru de MC-decine et de Chlrurgie, August 7, 1902
' MOncbener med. Wooh., July 1, 1»02.
The importance of the puhiiouary complications
following operative intervention has long been recog-
nized and much has recently been written upon them.
Compardtively few definite conclusions have been,
reached, although the various views advanced as to their
cause, prevention and treatment are of much interest.
Those interested find inflammations of the lung after
operation much more frequent than seemed probable. In
many cases the complication delays recovery but little if
at all, and the few .symptoms might be readily over-
looked since to detect such inflammation always requires
careful examination. In other cases pneumonia, broncho-
pneumonia, or severe pleurisy may develop, not only
greatly delaying convalescence, but frequently resulting
fatally. It is generally conceded that such complica-
tions are most frequent after abdominal operations.
Some years ago Gussenbauer called attention to aflections
encountered after reduction of strangulated hernias,
whether by taxis or by herniotomy. Sonnenburg, in a
recent paper, states that pulmonary complications have
occurred in 5^ of 1,000 cases of appendicitis upon which
he has operated. Since Gussenbauer directed attention
to the possible embolic origin of pulmonary complica-
tions following abdominal operations frequent references
have been made to this etiologic factor. In incarcerated
hernias small capillary thrombi exist which may enter
the general circulation and may be carried to the lungs,
forming small infarcts which, if the thrombi are not
infected, give rise to very insignificant symptoms. If
infected, however, severe inflammations may result.
Such thrombi are nearly always present in all inflamma-
tory conditions within the abdomen, and give rise to
inflammations of the lungs in the same manner. Sur-
geons formerly greatly feared air embolus or fat embolus,
but it is probable that danger from these has been greatly
overestimated. Hare has proved that it is possible to
inject considerable quantities of air directly into the
veins without any serious results and many surgeons
have seen air sucked Into the large veins of the neck or
the axilla when dissecting along these vessels without
serious consequences to the patient. Still there are some
cases of inflammation of the lung undoubtedly due to
emboli. Ether anesthesia has been frequently consid-
ered a cau.se of pulmonary inflammations, and,
no doubt, so irritating a gas may predispose to such
conditions ; but it is interesting in this connection
to note that Mikulicz reported at least as many cases
of pneumonia following celiotomy under infiltration-
anesthesia as after the use of ether. Careful observa-
tion of these cases will show that the inflamma-
tion seldom appears until .several days after the adminis-
tration of the anesthetic, which should not be the case if
the inflammation resulted directly from the eff'ect of the
anesthetic. The exposure of the patient during opera-
tion has been thought to be of great etiologic impor-
tance, and it probably is. Suits of heavy woolen, which
fit the patient loosely and can be drawn over those parts
of the body not necessarily exposed, should be used
during the openition, and the patient should be wrapjied
carefully in warm blankets to prevent chilling, particu-
larly if there must be transportiition through long cor-
ridors, or exposun^ to the outer air, as sometimes hap-
pens in hospitals constructed on the pavilion plan.
These precautions, with proper heating of operating-
rooms, and, if necessary, the use of heated operating
636 AXIEBICAN MEDICIHE]
THE WORLD'S LATEST LITERATTTEE
tOC-TOBBR 18, 1902
tables, should practically eliminate this danger. The
tenderness and pain caused by respiration after certain
abdominal operations no doubt interfere with free respi-
ration and expectoration of mucus, favoring inflamma-
tory conditions of the lungs ; but if abdominal wounds
are properly made and closed they are seldom so painful
as to make this a very important factor. The accumu-
lation of secretions in the throat during operation is a
frequent cause of inspiration pneumonia, and its removal
is especially important. The custom of keeping patients
flat on the back for several days after operation in order to
lessen the danger of ventral hernia tends to develop
hypostatic pneumonia, and the fact that the affections
of the lung or pleura are much more common at the
back than in front would encourage belief that this
might be a factor of considerable importance. It is dif-
ficult to explain why an infection, without formation of
a thrombus or embolus, should cause inflammation at a
point so remote from the seat of infection, yet this is a
possible cause of pulmonary complications. P^orcible
taxis, needlessly rough handling of the intestines and
other intraabdominal organs during operation, improp-
erly applied retractors used with too much force, are no
doubt frequently responsible for the production of a
thrombus. The importance of careful handling of all
the tissues of the body ought to be one of the first
lessons learned. It would seem that all of these factors
may have important influence, and if kept in mind the
danger from these sources can be considerably lessenwl
and usually readily avoided. Careful observation of
large series of cases will do much to establish the
etiology of these important postoperative complications,
and thus aid in their prevention.
REVIEW OF MTEKATUBE
Restoring the Bridge of the Nose with Paraffin.—
Stephen Paget' reports two cases in which he restored the
depressed bridge of the nose with paraffin by the metliod of
Gersuny. The first patient was a young man who, when a
child of 7, sustained a fracture of tlie septum and a depressed
fracture of the bridge. Under general anesthesia the septum
was straightened and held in position by a Walshain's nasal
splint, and 2 cc. of paraffin with a melting point of 136° P. was
injected beneath the stem and the deformity corrected. The
second was a man of 30 with an old deformity, probably syph-
ilitic in origin. Four cc. of paraffin witli a melting point of
115° F. corrected the deformity. The author believes that a
melting point of 115° F. is sufficiently high, as in order to inject
properly the temperature of the paraffin should be about 10°
above the melting point and the temperature of the syringe
and needle about 15° higher still. Firm pressure around the
depressed area should be made by an assistant, and the paraffin
should be quickly molded into shape, [a.b.c]
Drainage of the Internal Iliac Fossa by the Ischiatlc
Notch. — O. Laureut has been able in two cases to replace iliac
trepanation for the purpose of effecting drainage in eases of
tuberculous suppuration of the anterior face of the sacrum by
use of the ischiatic notch. The method presents no great dif-
ficulties if the operator has very accurate knowledge of the
anatomy of the region. The drain is introduced into the pelvic
basin at the level of the iliac crest, it is insinuated into the deep
tunnel in close contact with the iliac bone, under cover of the
muscle, whereby the great vaaculo-nervous bundle of the pelvis
are shielded ; it passes out at the ischiatic notch outside of the
gluteal muscle and nerve. The technic of the operation is
described in detail, [c.s.d.]
Avulsion of the Brachial Plexus.— Bristow ' reports
three cases of this liind which have come under his observa-
tion, and in one of them operation was performed. The patient
was a colored man, who, in working as a sailor, got his forearm
entangled in a rope about a steam winch and was dragged under
it. At the time of entrance to the hospital there was complete
paralysis of the left upper extremity, with the exception of the
' British Medical Journal, September 13, 1902.
>Annal8 of Surgery, Vol. xxxvi, p. 411.
area of the Intercostohumeral and circumflex nerves. . There
was also a fracture of the ulna. The patient was suflering from
severe pain, which was referred to the arm and gave the sensa-
tion of extreme extension. Examination showed considerable
swelling in the inner region of the subclavian triangle. The
left pupil was contracted, making it probable that the nerve had
given way close to the intervertebral foramina. There was
considerable effusion at the base of the neck. An exploratory
incision was begun posterior to the sternomastoid muscle and
was carried down to the clavicle ; from thence along the bone
to the acromioclavicular joint. On turning the flap back, a
good exposure of the region of the brachial plexus was
obtained. Stumps of the plexus were protruding from the cel-
lular tissue between the anterior and middle scaleni muscles.
It seemed that the plexus had given way just at the point where
the four cervical nerves and the last dorsal unite to make up
the three trunics. The nerve trunks could not be seen in the
wound. A third incision was made beginning just internal to
the acromion process and was carried downward and inward
parallel to the incision in the neck. The clavicle and both pec-
toral muscles were divided. In this way the plexus was
exposed. The nerves were traced from below upward and ends
of the trunks were found under the clavicle. There was no dif-
ficulty in bringing up the ragged ends of the nerve trunks and
the stumps of the nerves in the neck, but it was impossible to
determine definitely their original relations. The nerve trunks
were sutured together as well as possible with chromicized cat-
gut. The arm was fastened to the chest in a Sayre's adhesive
plaster dressing. A month after the operation electrical reactions
were entirely lost in all the muscles supplied by the brachial
plexus. The left pupil was contracted more than the right, the
palpebral fissure was diminished, the eyeball appeared smaller
and less prominent, and its vision was less perfect. The left
ear was somewhat colder. There was an appearance of the skin
in the arm and forearm resembling senile atrophy. It is prob-
ably too early to determine the ultimate outcome in this case.
The date of operation is not given. The patient is reported to
have regained complete sensation over the entire upper arm at
last report, [m.b.t.]
The Motor Cortex as Exemplified by the Anthropoid
Apes.- Sherrington and Griiubaumi assert that the scheme
of localization in the motor area of the cerebral cortex which
they brought forward was the result of experiments on 16
anthropoid apes. The topography of the convolutions differed
considerably from individual to individual, and the sulci did
not form physiologic boundaries. The responsive area included
without break the whole length and breadth of the precentral
convolution, and extended into and down to the bottom of the
sulcus centralis. It did not extend onto the post-central convo-
lution. Compared with the total surface of the brain the motor
area of the anthropoid ape, like that of man, was relatively
small, [a.b.c]
GYNECOLOGY AND OBSTETRICS
WiLMBR Kbusen Frank C. Hammond
EDITORIAL COMMENT
A Plea for iDtranterine Exploration. — Volumes
have been written upon the etiology of carcinoma, and
pathologists have fought over various theories explain-
ing why certain cells in the human organism revert to a
lower type and produce symptoms and changes often
destructive to tfeat organism. The clinician in igno-
rance as to the cause of the pathologic conditions
he is combating can only urge with intense earnest^
ness the necessity for early diagnosis. Baldy, in
his recent address before the Pennsylvania Medi-
cal Society, says that "the duty of the hour is
for the specialist to teach the general profession on
all occasions, at all times and in all places, without
ceasing, the one sure thing about this miserable disease,
viz., that the hope of better results by our present
methods rests in an early diagnosis and in that alone."
' British Medical Journal, September 13, 1902.
OCTOBER 18, 10O2]
THE WORLD'S LATEST LITERATURE
(Americas Medioinf
637
Sinclair, in a recent address before the British Medical
Association, emphasized the same point, placing clinical
investigation and study ahead of the microscopic and
minute investigation without belittling the value of
pathologic work. Upon the general practitioner rests
the grave responsibility of the diagnosis of uterine carci-
noma ; to him the patient looks for a comprehension of
the significance of her symptoms ; of him she expects
that thorough investigation requisite to determine the
causes of her sj'mptoms. Cullen believes that cancer of
the uterus is so prevalent that nearly all practitioners
see at least two or three cases yearly, and that without
the assistance of the general practitioner the gynecologist
will invariably see the case only when the dis-
ease is too far advanced to permit of a complete
removal of the morbid growth. If careful biman-
ual examination is employed, the early diagnosis of
cervical cancer can readily be made ; but in that small
proportion of cases in which adenocarcinoma of the
body of the uterus is developing, nothing but uterine
dilation and intrauterine exploration will permit
of conclusive diagnosis. Frequently the uterus is found
to be freely movable, normal in size and contour, and
yet extensive malignant disease is present in the canal
without involvement of the portio vaginalis. Examinar
tion by touch or speculum affords no information, but
intrauterine investigation immediately solves the prob-
lem. The method of making this examination is by
uterine dilation, which is accomplished by using either
the graduated bougies or the parallel-bar dilators ; then
by the introduction of a curet, or if possible, a finger
into the uterine cavity and the examination of the tissues
removed or the determination of a diseased area by the
sense of touch. If it is inconvenient or undesirable to
administer an anesthetic, gradual dilation may be secured
by the use of a tent. Montgomery employs for this
purpose laminaria tents that have been rendered aseptic
by subjection to dry heat of 250° F. After the vagina
has been cleansed the sterilized tent is immersed in a
saturated solution of iodoform in ether and introduced
into the uterine canal. The tent should project from the
external os and should be held in place by a tampon of
iodoform gauze. It should be removed at the end of 12
hours and the interior of the uterus may then be
explored in ca.ses of suspected epithelioma or submucous
fibroid. By the employment of this method in all
obscure cases, especially those in which postmenopausal
hemorrhage occurs, a large |)ercentage of patients may
be given the advantage of earlier operation and a greater
number of women be permanently relieved by operation.
REVIEW or UTEBATURE
Defective Coordination in Utero as a Cause of Con-
Kenital Malformation.— According to Thompson ' there afe
three types of congenital malformation of hollow viscera In
which the main anatomic abnormality that is present consists
in very great muscular hypertrophy, for which no permanent
organic cause is discoverable. These arc hypertrophy of the
bladder, with dilation of the ureters, of the colon with no
organic stricture, and of the pylorus and stomach wall. In all
these the chief abnormality is enormous hypertrophy of the
muscular coat of a hollow organ, known to be active in utero ;
and the amount found in some cases soon after birth shows that
it must have been present during intrant -ine life, and in none
is there any evidence of such permanent organic obstruction as
would give rise to overgrowth of muscle. There are two chief
hypotheses as to the cause of this hypertrophy : (1 ) That it is a
primary developmental hyperplasia; and (2) that it results
from overexertion. Thompson accepts the second theory as the
true one, and since there is no obstruction to cause overexer-
tion he endeavors to show that it is the result of lack of coordina-
tion in the action of the organ during intrauterine life, and sug-
gests that this lack of coordination may be a kind of intrauter-
ine developmental neurosis. [W.K.]
1 BrltlHb Medical Journal, Heptember «, 1902.
Bossl's Dilator.— Ludwig Knapp' reports the case of a
multipara of 38, suffering with pulmonary tuberculosis asso-
ciated with conditions indicating the necessity for early
delivery in order to save her life. By using Bossl's dilator
the cervix was dilated in seven minutes and the child deliv-
ered by forceps in three minutes more. Immediately the cya-
nosis diminished, breathing became free and the patient at once
improved. He considers this instrument of great value in cases
in which rapid delivery is necessary or desirable, as it may be
in placenta prsevia, eclampsia, etc., and in which the required
distention of firm and thick tissues i^ impossible by the force
of the hand alone. It can be successfully used in many
instances in which cesarean section would not be possible
because of lack of time, of proper facilities, or because of the
condition of the patient, [w.k.]
Buttermilk as an Infant Food.— Baginsky = was at first
reluctant to test the value of buttermilk for infants as recom-
mended by Dutch physicians, and therefore began sparingly in
July, 1901, to use it in cases which failed to improve upon ster-
ilized or modified milk; as improvement followed, he then
commenced using it freely for other infants in the hospital.
From his experience up to the present time he concludes that
buttermilk, as prepared and recommended by the Dutch physi-
cians, is a good food for acutely and chronically sick infants.
It is well borne soon after attacks of acute dyspepsia and sum-
mer diarrhea. In chronic diarrhea and chronic enteritis cases
it may be looked upon as a life saving preparation. In the
cases which he has observed for a long time he has never seen
any disturbances of nutrition, such as rachitis or scorbutus,
develop. The buttermilk used was made from pure cream
which was soured by means of bacteria producing lactic acid
fermentation. The method of preparing the buttermilk pre-
vious to its use is fully described, [w.k.]
Sterile Yeast in Vaginal Operations.— W. Albert » con-
siders sterile yeast a valuable antiseptic because of its bac-
tericidal power. This has been verified by experimental tests
in virulent cultures of cholera and typhus bacteria and also
Staphylococcus pyogenes aureus, B. coli communis and B. aero-
genes. He has also successfully used the yeast in the treat-
ment of erosion of the portio ; for this condition alone, or
as preparatory to cervical and uterine treatment with
other remedies. The only disadvantage of this method is
that an ambulatory treatment is impossible ; for the patient
must remain in bed at least a few hours. Because of the anti-
septic qualities of yeast he also recommends its use in prepar-
ing patients for abdominal or vaginal operations, especially the
latter, it having proved satisfactory in more thau a hundred
cases. In preparing for a vaginal operation, the yea.st should
be introduced into the vagina the evening before and allowed
to remain 12 hours. Its great advantage is shown especially in
colporrhaphy, as it leaves the mucous membrane in a com-
pletely normal condition for the operation, [w.k.]
Splenic Anemia of Infancy.— Fowler '' says that the clin-
ical features of this disease are very characteristic. The patients
are usually between 10 and 18 months, and in one case an
enlarged spleen was noted at five months. It usually occurs in
that class of children among whom rickets are common and
equally in both sexes. A tabulated statement of 20 cases is
given, showing blood conditions and changes. The conclusions
are that enlarged spleen, often associated with anemia, is not
uncommon among young children ; the change in tlie blood dif-
fers from that in other disease, and is characterized by lymph-
ocytosis, due to the occurrence of numerous transitional and,
probably, immature mononuclear cells, and by the presence of
erythroblasts, often in number out of all proportion to the dim-
inution of the red corpuscles. Since the splenic enlargement
is more constant than any single change in the blood, and
since both arise independently of any other disea.se, it is not
justifiable to regard these as cases of secondary anemia; the
clinical features of the condition are snfflciently definite to war-
rant this being looked upon as a primary disease, to which the
name of splenic anemia of infancy may be given, [w.k.]
' Centmlhlatt fUr Qvnnkologle, August 30.
2 British .McMlical Journal, HeptcnibtT fl, IIKK.
•CentmlblHtt filr Gyiiakologle, .\ugU8t 16, ItKB.
638 AXZKIOAN MkDICISIEJ
THE WORLD'S LATEST LITERATUEE
[OcroBBB U, 1902
TREATMENT
Solomon Solis Cohkn
H. C. Wood, Jr. L. P. Applbman
BKVIBW OF LITERATURE
Acute Meningitis Cured by Antisyphilittc Treatment.
— Widal and Le Sourd ' report the case of a young man, aged 29
who suddenly developed symptoms of meningitis, h>eginning
with violent frontal and occipital headache and continuous
vomiting. Within 15 days all the other usual symptoms of
meningitis developed. ,The administration of mer.ciiry'
bichlorid and potassium iodid produced rapid amelioration,
and he was enabled to leave the hospital within six weeks of
his entrance. At the end of 10 months he was again seized with
headache, which yielded to the same specific treatment. The
cerebrospinal fluid was rich in lymphocytes, but without viru-
lence, which removed the suspicion of a tuberculous menin-
gitis. In spite of the absence of a chancre or other specific
lesions, Widal and Le Sourd believed the meningitis to be of
specific origin, [l.f.a.]
Citrophen.— Syers 2 has found citropheu useful as an
analgesic when given in doses of 10 grains, in various forms of
neuralgia, and even in lumbago and sciatica. He has, however,
not found it of use as an antipyretic; it does not even prevent
the evening rise in cases of tuberculosis, still less have any per-
manent effect in such fevers in acute rheumatism, [h.c.w.]
Hydrotherapentic Treatment of Pulmonary Tubercu-
losis.—The treatment of fully developed pulmonary tubercu-
losis must be a potentized hygiene. The most favorable con-
ditions for recovery will not be provided by any single curative
factor, but by an intelligent combination of all physical meth-
ods of treatment. Let emphasis be given by repetition : All
physical remedial measures and methods of treatment must be
drawn upon in the treatment of pulmonary tuberculosis.
Then, and not till then, will the physician have performed his
whole duty in the management of his tuberculous patients.
The question has been asked repeatedly, whether the indica-
tions from the bacterial standpoint will be fulfilled by hydriatio
measures. We can answer this question emphatically in the
affirmative. Numerous investigators have made the curative
process in the lungs dependent upon the active circulation of
this organ, on the assumption that the active circulation of
normal blood constitutes the best bactericidal agent. No form
of treatment is capable of inducing active hyperemia, an
increased flow of blood to and from the diseased parts, in such
a degree as is hydrotherapy. One of the essential effects of this
method is the strengthening of the circulation, the removal of
the circulatory weakness in the lungs, of the obstruction in the
lesser circulation, and the improvement in the flow of blood
through the lungs. The simplest, and at the same time the most
efficient measure for the attainment of this object is the use of
the crossbinder. By means of this the best circulatory conditions
in the lungs are established. The employment of the cross-
binder for months brings about conditions that are inhibitory
to the development of the bacilli, and induces reactive inflam-
mation, limitation, destruction, elimination, and also absorp-
tion of the diseased tissues. A second and highly important
measure for improving the circulation and for fulfilling all of
the requirements present is the cold precordial coil. A strength-
ening of the action of the heart, an increase in vascular tone, an
induction of active hyperemia in the diseased organs, will be
certainly brought about by means of this application. Finally,
general invigorating procedures involving the entire surface of
the body will, in addition to the eff'ects enumerated, render
possible the invigoration of the organism as a whole. Certain
individual symptoms may likewise be successfully attacked.
Anorexia, upon which depends essentially the unfavor-
able outcome of the disease, may be combated by means
of an abdominal binder, containing a rubber coil heated by
water at a temperature of 40° C. (104° F.). Cough and difficult
expectoration are best relieved by means of the crossbinder.
Pulmonary hemorrhage is most efficaciously treated by means
of small ice-bags placed in the supraclavicular fossa over the
si°,.^?*' ^f* Pniticiens, Vol. xvl, 1902. p. I69!
» ireatment, January, 1902, Vol, v, p. 8U.
thinnest portion of the crossbinder, and covered with the dry
portion of the latter. In this condition, also, the precordial
coil renders good service. If, however, the pulmonary hemor-
rhage is of a positive character, as occurs frequently in oa.ses of
tuberculosis, invigorating measures are indicated. Hydro-
therapy subserves an important function in the treatment of the
fever. The requirements of any form of therapy in this condi-
tion are quite clearly defined ; they are evident from the origin
of the fever. Relief from heat^reteution, prevention of exces-
sive temperature, checking of sweating, are the indications
under such circumstances, and these are best fulfilled by
means of partial ablutions or the cold rub. In this connec-
tion hydrotherapy is far superior to all other methods of treat-
ment.—Winternitz in " Cohen's System of Physiologic Thera-
peutics," Vol. ix. , .
Treatment of Hemoptysis In Children.-»-M^iy?, directs
that the patient should have absolute rest in bed, and that the
diet should be light. Ergotin or sulfuric acid lemonade are
among the older remedies employed for the control of the
hemoptysis ; opiates should not be given to children under the
age of 10 or 12. Among the newer remedies,'M6ry recommends
calcium chlorid and injections of gelatin solution. Calcium
chlorid may be given to children in doses of from 20 to 30
grains daily, preferably in solution with syrup of orange-
flowers and lime juice. It is administered in this dose for four or
five days, when the quantity is gradually decreased. Calcium
chlorid increases the coagulability of the blood. Milk is coagu-
lated by the drug, hence it should not be given with it.
Gelatin solution consists of a 5% solution of gelatin in normal
saline solution ; 10 to 12 drams of this may be injected subcu-
taneously in a child, or 3 to 6 ounces in an adult. M6ry does
not advise subcutaneous injections in children if they can be
avoided, [l.f.a.]
Purgatin ; a Synthetic Cathartic— Marshall » writes on
the effects of purgatin (also known as purgatol), which is the
diacetyl ester of anthrapurpurin and is therefore allied chemic-
ally to the anthraquinone group, which is found in nearly aU
the vegetable cathartics. It is a yellowish-brown powder, in-
soluble in cold water and dilute acid, sparingly soluble in hot
water, alcohol and ether. A perfect cathartic should, accord-
ing to Marshall, be inactive in the stomach, have a mild, stimu-
lating action upon the intestines, have a small dosage and
remain unabsorbed. The last two conditions are not fulfilled
by purgatin. As many authors have already noted, the urine is
reddened by purgatin, showing its absorption and elimination
through the kidneys. What effect it would have upon the kid-
neys has not yet been determined, but in several cases there have
been pains over the loins. Marshall himself produced a feeling
of heaviness and even severe pain in the lumbar region, asso-
ciated with increased action of urine without albumin, as the
result of 62 grains of purgatin. In doses of 30 grains the drug
had a mild laxative effect. He concludes that it is a slow, com-
paratively certain purgative, not causing much colic but giving
rise to irritation of the kidneys. The patient should always be
warned of the coloration of the urine, [h.c.w.]
Clinical Use of the Ipecacuanha Alkaloids.— Wild'
states that for seven years he has been using certain salts of
cephaelin and emetin for clinical purposes, and that he has
reason to be satisfied that in the hydrochlorid and hydrobromid
of emetin we have stable salts of reliable action which can be
given in small doses for expectorant, depressant, or emetic pur-
poses. Cephaelin hydrochlorid was found to be less suitable
for the ordinary uses of ipecacuanha in catarrhal conditions
and bronchitis than the emetin salts. The emetic action of
cephaelin is so powerful that it is very difficult to regulate the
dose so as to obtain any effect at all without causing nausea and
sickness after a few days' continued use. The salts of cephaelin
also are less stable than those of emetin. A solution of emetin
hydrobromid in 20% alcohol (one grain to each fluid ounce) has
been found satisfactory. The dose for adults is from 5 to 20
minims for expectorant and depressant purposes, and from one
to three drams for emetic purposes. A solution containing 1 in
100 of morphin hydrochlorid and 1 in 500 of emetin hydro-
1 Journal des Pratlclens, Vol. xvi, No. 17, 1902, p. 265.
2 Scottish Medical and Surgical Journal, May, 1902, p. 402.
' Lancet, September 6, 1902.
OCTOBBR 18, 1902]
THE PUBLIC SERyiCE
[American Medicine 639
chlorid has been used as a sedative and diaphoretic in place of
Dover's powder, but it has proved hardly as efficacious as the
powder, [a.o.j.k]
Arsenic lodid In the Treatment of Bronchitis of C5hil-
dren. — Saint-Philippe ^ calls attention to a form of bronchitis
infectious in origin which occurs in scrofulous children after
attacks of the grip, measles or whoopingcough. Treatment is
directed particularly to the improvement of the nutrition and
general health of the patient. He considers arsenic iodid the
best and most powerful remedy to employ for this purpose.
When mixed with the food it is easily digested, well borne by
the patient, and is almost tasteless. The following solution
may be used :
Arsenic iodid 5 grains
Distilled water .1 ounce,;),
To be dissOK'ed cold. Five drops of this solution should be
given in a glass of milk at each meal. This dose is increased
one drop morning and evening until 15 or 20 drops are taken at
each meal. The maximum dose is continued for about a
month, then reduced gradually to 5 drops at each meal, which
is maintained for a week, when the dose is again increased in
the same manner as before, [l.f.a.]
Glauber's Salts in Dysentery. — Dupaquier^ has employed
the saline treatment in dysentery with great success. The
formula recommended is 15 grams of Glauber's salts in 500 cc.
of water, to be given in four tablespoonful doses every two or
three hours, according to the severity of the colics. It should
be kept up for three or four hours after the appearance of fecal
stools. He has also obtained good results from the use of large
doses of ipecac before beginning the saline treatment. In every
case the following precautions are necessary: Absolute repose
in bed, feet and abdomen well wrapped in warm cloths,
bowels irrigated every four hours with normal salt solution ;
diet, a cup of lean broth every two hours, given until the tongue
clears, then a cup of diluted milk and light egg-water every two
hours. In chronic cases the treatment should consist of an
astringent instead of the saline evacuant. Dupaquler uses bis-
muth benz.oate in doses of 50 centigrams every two hours, and
calomel purges every week, [h.c.w.]
Substitutes for Potassium Bromid in the Treatment of
Epilepsy. — Huchard' has employed sodium borate in many
ca.ses of epilepsy with good results, but he states that in useful
doses it is liable to disorder the stomach. Mairet prescribes
from 7 to 15 grains of pure borax daily as a beginning dose in
the treatment of epilepsy, increasing the doso gradually until
1 or 2 drams are taken daily. If no result is obtained by the
latter dose it should be withdrawn. If the epileptic seizures
disappear, the dose is decreased to one dram daily, promptly
increasing it if the attacks return. Picrotoxin has also been
used in the form of the tincture of cocculus indicus, which is
prepared as follows :
Powdered cocculus indicus 6 ounces
Rectified alcohol 1 quart
This should be macerated for three weeks and filtered. Two
drops of this tincture are taken before meals, increasing a drop
daily until 20 or 30 drops are taken each day. Blocq has pre-
scribed amylene liydrate in nocturnal epilepsy, and also in
Jack.sonian epilepsy, with good results, in doses of 0.5 to 1.5
drams, according to the following formula :
Amylene hydrate 5 drataas
Distilled water 10 ounces
Huchard states that these drugs are inferior to potassium
bromid, but may be used a<lvantageously when the latter is
not well borne, [l.k.a.]
ConcerninK the Treatment of Tuberculosis with Oln-
namic Acid (Hetol). — Heusser'has use<l cinnamic acid dur-
ing a term of six years in 82 cases of tuberculosis. He has
employed gluteal and intravenous injections. With his expe-
rience as a basis he opposes Staub's conclusions, who has found
it of but little value in pulmonary tuberculosis, and on the
other hand agrees with Landerer, that within the lines drawn
by him, and in carefully selected cases, it may be used with per-
fect safety ; and that it is more likely to produce cicatrices and
healing in uncomplicated cases of tuberculosis than any other
remedy thus far recommended. It is no specific, but if associ-
ated with the proper climate, hygiene and diet, is the most
active drug against the disease. It is not so useful in very far
advanced cases, nor should it be employed in too large doses.
[E.L.]
The Neptune Girdle. — Wormley i speaks of good results
obtained in gastrointestinal catarrh by the use of cold com-
presses over the abdomen. These are applied in the form of a
girdle made of napkins or towels, wrung out of cold water and
wrapped around the abdomen ; they should be left on all night.
The relief from the flatulence and eructations, common in these
patients, brought about by this treatment is remarkable.
[H.C.W.] ..;.i vl
Toxic Effects of Heroin. — Campbell ' reports the case of a
woman who took two doses, 10 hours apart, of -^ grain of heroin
hydrochlorate. After the second dose the patient was remark-
ably dyspneic, with " vibrated pulse," contracted pupils and a
sense of impending death. Strong coffee was administered and
recovery was complete in a few hours, [h.c.w.]
THE PUBLIC SERVICE
' .Journal des Fnitlclens, Vol. xvl. No. 16, 1902, p. 253.
2 Tfierapciitic Gazette, April, 1902, p. 228.
8 Journal des Pratlclen8,..Vol. xlli, No. 12, 1902, p. 17.
< Corresp. filr Bchwetzer Amte, 1902.
Health Reports.— The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, during
the week ended October 11, 1902:
Colorado :
Illinois:
Kentucky :
Maryland :
Massachusetts :
Michigan :
Nebraska:
New Hampshire :
New Jersey :
New York :
Ohio:
Pennsylvania :
South Carolina:
Tennessee :
Wisconsin :
Austria;
Barbados:
Canada :
Ecuador :
Great Britain :
India:
Italy:
Kussia :
Upain:
Btralts Settlements
Switzerland :
Colombia :
Mexico:
Smallpox— United States.
Denver Sept. 20-27
Chicago Sept. 27-Oct. 4....
Covington Sept. 20-Oct. •»....
Baltimore Sept. 27-Oct. 4 ....
Boston Sept. 27-Oct. 4 ....
Fall River. Sept. 27-Oct. 4 ....
Detroit Sept. 27-Oct. 4 ....
Omaha Sept. 27-Oct. 1 ....
Manchester. Sept. 27-Oct. 4....
Nashua Sept. 27-Oet. 4 ....
Hudson County Sept. 28- Oct. 5....
Newark Sept. 27-Oct. 4 ....
New York Sept. 27-Oct. 4 ....
Ashtabula Sept. 27-Oct. 4....
Cleveland Sept, 27-Oct. 4 ....
Dayton Sept. 27-Oct. 4 ....
Hamilton Sept. 27-OcL 4....
Toledo Sept. 1:^-27
Altoona Sept. 27-Oct. 4 ....
Erie Sept. 27-Oct. 4 ....
Johnstown Sept. 20-Oct. 4...
McKeesport Sept. 27-Oct. 4 ....
Philadelphia Sept. 27-Oct. 4 ....
Pittsburg Sept. 27-Oct. 4....
Reading Sept. 22-/9
Charleston Sept. 27-Oct. 4 ....
Memphis Sept. 27-Oct. 4 ....
Green Bay Sept. 21-28
Milwaukee Sept. 27-Oct. 4..,.
Sma llpox— Foreion .
Prague Aug. 30-Sept. 20..
Sept. 1-15
Araherstburg Sept, 27-Oct. 4....
Guayaquil Sept. 6-13
London sept. 13-20
Newoastlc-on-Tyne..8cpt. lS-20
Sunderland Sept. 13-20
Bombay Sept. 2-9
Madras Aug. 30-.Sept. 5...
Palermo Sept. 13-20
Moscow Aug. 31-Sept. 6...
Odessa Sept. 0-20
Warsaw Sept. 6-.30
Barcelona Sept. 1-16
Singapore. Aug. 16-23
Geneva Sept. 6-13
Cases Deaths
3
3
11
10
18
1
2
21
I
7
1
1
50
1
3
16
2
1
33
5
3
24
2
2
2
1
8
1
19
India:'
Japan :
Caliromia :
Yellow Fever.
Panama Sept. '22-29 4 2
Coatzacoalcos Sept. 20-27 4
Veracruz Sept. 20-Oct. 4.... 25 14
Cholera— Foreign.
Alexandria Aug. 81-8ept. 20.. 012 469
Bombay Sept. 2-9 1
Calcutta „ Aug. 31-Sept. 6... 15
Madras Aug. 30-Sept. 5... 1
Nagasaki Aug. 31-Sept. 10.. 46 32
Plague— United States.
San Francisco Sept. 28-26 4 4
One case from Oakland.
> Medical Age, April 10, 1902.
'Liverpool Medlco-Chlrurglcal Journal, March, 1902, p. 67.
640 Ambbican Mbdioink;
THE PUBLIC SEEVICE
[OCTOBEB 18, IINB
PLAOCE— FOBEION.
Egypt: Alexandria Aug. 3l-8ept 20.. S 2
India: Bombay sjept. 2-9 41
Calcutta Aug. 31-8ept. 6... 16
Karachi Aug. 24-8ept. 10.. 10 8
Turkey : Smyrna Oct. 4 Present.
Changes In the Medical Corpg of the U. 8. Army for
the week ended October 11, 1902:
Shepherd, .John M., contract surgeon. Is relieved from duty at Fort
Hamilton and will proceed to Fort Rodman for duty.
Beai., First Lieutenant Howard W., assistant surgeon. Is relieved
from duty at Fort Columbus, and will report at Fort H. G. Wright
for duty.
Cooke, Robert P , contract surgeon, Is relieved from duty at Fort H.
G. Wright, and will proceed fo Fort Revere for duty.
TtJKNBDLi/, First Lieutenant Wilfrid, assistant surgeon. Is relieved
frtmi further duty In the division of the Philippines and will pro-
ceed to San F'ranclsco, Cal., and report by telegraph to the adj utant-
■general of the Army for orders.
Blanchard. First Lieutenant Robert .M.. assistant surgeon, recently
appointed, will proceed upon the expiration of his present leave
from Batavla, O., to Columbus Barracks, for temporaiy duty.
Wood, Halsey L., contract surgeon, now on duty on the U. S. trans-
port Warren, will report to the commanding officer of that trans-
port for duty as transport surgeon.
Walker, William H., contract surgeon. Is relieved from duty at
CampThoma.s, Ga., and will proceed to his home at Henderson,
Ky., for annulment of contract.
Thompson, Frank E., contract surgeon, Is relieved from duty at Fort
Niagara and will proceed to his home at Cleveland, O., for annul-
ment of contract.
Sears, C. Edward, contract surgeon. Is relieved from duty at Fort
Niobrara and will proceed to his home at Salem, Va., for annul-
ment of contract.
Amador, R. A., contract surgeon, leave granted June 27 Is extended
one month
Hartman, Henrv L., hospital steward, now at Lebanon, Pa., will
report on or before expiration of furlough to the commanding
general, department ol the East, Governor's Island, for assignment
to a station.
Rose, Frank O., hospital steward. Fort McDowell, Is transferred to
Fort Yellowstone, to relieve Hospital Steward Henry Roepke.
Steward Roepke will be sent to Manila for assignment to duty.
ToRNKY, Major Georoe H , surgeon, is granted leave for one month to
take effect upon his being relieved from dut.v at the Army and
Navy General Hospital, Hot Springs, Ark.
SO0THALL, Captain Edward A., assistant surgeon, is granted leave
for one month on surgeon's certificate, with permission to apply for
an extension of one month.
The following changes in siatlons and duties of officers are ordered :
Contract Surgeon Randell C. Stoney, now at Plnopolis, S. C, Is
relieved from further duty In the division of the Philippines, and
win proceed to Fort Screven for duty, to relieve Captain Charles F.
Kleffer, assistant surgeon. Captain Kiefl'er will proceed to Phila-
delphia, Pa., and assume the duties of attending surgeon and
examiner of recruits in that city.
Wells, Captain George M., assistant surgeon. Is granted leave for
three months to take effect upon the arrival of Major Marlborough
C. Wyeth, surgeon, at Fort Wadsworth.
Sinks, Captain Edward D., assistant surgeon, now In San Francisco,
Cal., will proceed to Fort Bayard and report at the U.S. General
Hospital at that place for treatment.
Skinner, Captain George A., assistant surgeon, leave granted Au-
gust 30 Is extended one month.
Changes in the Medical Corps of the V. S. Navy for
the week ended October 11. 1902:
Bagg, C. p.. passed assistant surgeon, ordered to Naval Hospital, Mare
Island, Cal.— October 3.
Brown, E. M., assistant surgeon, detached from the Naval Hospital,
Mare Island, and ordered to the Naval Museum of Hygiene and
Medical School, Washington, D. C. -October 3.
Blakeman, R. S., passed assistant surgeon, being Incapacitated for
active service on account of disability incident thereto Is placed on
the retired list of the Navy— October 7.
CORDEiRO, F. J. B.. surgeon, detached from the Constellation and
ordered to the Naval TralningStation, Newport, R. I.— October 9.
Crawford. M. H., surgeon, detached from the Chicago, and ordered
home, when his resignation, voluntarily tendered, will be accepted-
October 9.
BucHER, M. H., passed assistant surgeon, detached from the Panther
and ordered to the Machlas— October 9.
Bell. W. H., passed assistant surgeon, ordered to the Yankton—
October 9.
Carpenter, D. N., passed assistant surgeon, detached from the Illi-
nois, and ordered to the Chicago— October 9.
LiPPiTT, T. M., assistant surgeon, ordered to Naval Hospital, New
York— October 9.
Traynor, J. P., assistant surgeon, detached from Naval Hospital
New York, and ordered to the Naval Museum of Hygiene and
Medical School, Washington, D. C— October 9.
Stuart, A., assistant surgeon, detached from the Yankton, and
ordered home to wait orders— October 9.
BoGAN, F. M,, assistant surgeon, detached from the Machlas and
ordered to the Naval Hospital, Washington, D. C, on October 80
—October 9.
MtTNSON, P. M., assistant surgeon, detached from the Naval Hospital,
Washington, D. C, and ordered to the Naval Museum of Hygiene
and Medical School, Washington, D C— October 9
Baker, M. W., assistant surgeon, detached from the Naval Hospital.
Norfolk, Va., and ordered to the Naval Museum of Hygiene and
Medical School, Washington, D. C— October 9.
Strine, H. F., assistant surgeon, detached from the Naval Hospital,
Norfolk, Va., and ordered to the Naval Museum of Hygiene and
Medical School, Waahlngton, U. C— October 9.
Marcocr, R. O., assistant surgeon, ordered tothe Franklin— October9.
Odell, H. E., assistant surgeon, ordered to Naval Hospital, Norfolk,
Va.— October 9.
Ledbetter, R. E., assistant surgeon, detached from the Chicago and
ordered to the Illinois— October 9,
Doctors B F. Jenness, H. Shaw and R. H. Mlchels appointed acting
assistant surgeons, with the rank of lieutenant, (Jctober 4— October 9.
NEIL.SON, .John L., appointed an assistant surgeon, with the rank of
lieutenant, October 4 — October 9.
Changes in the Public Health and Marine-Hospital
Service for the week ended October 9, 1902 :
Irwin, Fairfax, surgeon, to proceed to Delaware Breakwater, Dela-
ware Breakwater quarantine and Reedy Island quarantine, as In-
spector of unserviceable property— October 7, 1902.
Carter, H. R , surgeon, detailed as a member of Revenue Cutter Serv-
ice Retiring Board convened to meet at Baltimore, Md., October l.'i,
1902— October 7, 1902.
Wertenbaker, C. p., passed assistant surgeon, granted two days'
leave of absence under paragraph 179 of the regulations.
Nydegger, J. A., passed assistant surgeon, detailed as a member of
Revenue Cutter .Service Retiring Board convened to meet at Bdltl-
more, Md., October 15, 1902— October 7, 1902. '
CoFER. L. E., passed assistant surgeon, detailed for special temporary
duty In the Bureau for two days, October 3, 1902; to proceed to
Washington, D. U., for special temporary duty— October 0, 1902.
Parker, H. B., assistant surgeon, rejoin station In Hygienic Labora-
tory, Washington, D. C.-Oct«ber 7, 1902.
Warren, B. S., assistant surgeon, granted six days' extension of leave
of absence from October 13— October 7, 1902.
Stimson, A. M., assistant surgeon, relieved from duty at Stapleton, N.
Y., and directed to proceed to Detroit, Mich., and report to medical
officer in command for duty and assignment to quarters— (October
7, 1902. Bureau order of October 7, 1902. relieving A.sslstant Surgeon
A. M Stimson from duty atStjvpleton, N. Y., and directing him to
proceed to Detroit, Mich., revoked, and directed to report to Sur-
geon G. W. Stoner, Immigration Depot, New York, N. Y., for tem-
porary duty— October 9, 190z.
Bailey, C. W., acting assistant surgeon, granted leave of absence for
fifteen days from September 28— October 1, 1902.
Foster, S. B., acting assistant surgeon, granted leave of absence for
seventeen days from October 20— October 4, 1902.
Goldsborough, B. W., acting assistant surgeon, granted leave of
absence for twenty-one days from October 8 — October 4, 1902.
Hallett, E. B.. acting assistant surgeon, granted leave of absence for
five days from October 10, 1902-October 6, 1902.
McCormac, J. T., acting assistant surgeon, granted leave of absence for
twenty-four days from September 23— October 4, 1902.
Rice, W. E., acting assistant surgeon, granted leave of absence for
seven days from October 7 — Oct her 3, 1902.
Rodman, J. C, acting assistant surgeon, granted leave of absence for
Ave days -October 8, 1902.
Goodman, F. S., senior pharmacist, upon being relieved by Junior
Pharmacist Frank Siedenberg, to proceed to Norfolk, Va., and
report to medical officer In command for duty— October 4, 1902.
LaGrange, J. v., senior pharmacist, upon being relieved by Senior
Pharmacist C. G. Carlton, to proceed to Boston, Mass., and report to
the medical officer In command for duty and assignment to quar-
ters, relieving Senior Pharmacist H. E. Davis- October 4, 1902.
Allen, G. C, senior pharmacist, relieved from duty at Norfolk, Va..
and directed to proceed to New Orleans, La., and report to medical
officer in command for duty and assignment to quarters, relieving
Junior Pharmacist Frank Siedenberg— October 4, 1902.
Carlton, C. G., senior pharmacist, relieved from duty at Chicago, 111.,
and directed to proceed to Cairo, III., and report to medical officer
In command for duty and assignment to quarters, relieving Senior
Pharmacist J. V. l>aOrange— October 4, 1902.
Davis, H. E., senior pharmacist, upon being relieved by .Senior Phar-
macist J . v. LaGrange, to proceed to Louisville, Ky., and report to
medical officer in command for duty and assignment to quarters,
relieving Junior Pharmacist C. W. Stephenson— October 4, 1902.
.STEPHEN.SON, C. W., Junior pharmacist, upon being relieved by Senior
Pharmacist H. E. Davis, to proceed to Chicago, 111., and report to
medical officer in command for duty and assignment to quarters-
October 4, 1902.
Siedenberg, Frank, Junior pharmacist, upon being relieved by
Senior Pharmacist G. C. Allen, to proceed to Key West, Fla., and
report to medical officer In command for duty and assignment to
quarters, relieving Senior Pharmacist F. S. Goodman— October 4,
1902.
Hoards Oonvened.
Board convened to meet at the Marine-Hospital office, San Fran-
cisco, Cal., October 6, 1902. for the physical examination of an engineer
of the Revenue Cutter Service. Detail for the board— Passed Assistant
Surgeon W. G. Stimpson, chairman ; Assistant Surgeon W. C. Hucker,
recorder.
Board convened to meet at Baltimore, Md., October 6, 1902, for the
physical examination of an officer of the Revenue Cutter Service. De-
tail for the board— Surgeon H. R. Carter, chairman ; Passed Assistant
Surgeon J. A. Nj'degger, recorder.
Board convened to meet at Washington, D. C, October 7, 1902, for
the physical examination of a candidate for appointment as second
assistant engineer, Revenue Cutter Service. Detail for the board —
Assistant Surgeon-General L. L. Williams, chairman ; Assistant Sur-
geon-General W. J. Pettus, recorder.
American Medicine ^
GEORGE M. GOULD, Editor
G. C. C. HOWARD, Ifanaging Editor
CHARLES 8. DOLLEY
MARTIN B. TINKER, AstUtarU Editor!
Clinical Medicine
David Riksman
A. O. J. Kelly
h. h. cushino
Hklbn Murphy
General Surgery
Martin B. Tinker
A. B. Craig
Charles A. Orb
Orthopedic Surgery
H. AuousTCTS Wilson
COLLABORATORS
Obsletrict and Oynecology
WiLMER Krusen
Frank C. Hammond
Nervous and Mental ZHseases
J. K. Mitchell
F. Savary Peabce
lyeatTnent
Solomon Solis Cohen
H. C. Wood, Jr.
L. F. Appleman
Dermatology
M. B. Hartzell
Laryngology, Eto.
D. Braden Kylb
OphthalTYwlogy
Walter L. Pylk
Fathology
R. M. Pearce
PCBLISHBD WXRKLY AT 1S3I WAtHCT StBBKT, PhILADKLPRIA, >T THB Au SBlCAH-MlDICIMS PuBUBHINO CoWPABT
Vol. IV, No. 17.
OCTOBEK 25, 1902.
$5.00 Yearly.
Progress in abating the subsidy evil is illustrated
in several parts of the United States. In New York City
the 1899 report of Controller Coler has aroused and fused
the opposing forces that were at work — ^the members of
the Charity Organizfttion Society, of the Medical League,
of the State Charities' Aid Association — and indeed of all
individuals not officially connected with some subsidized
institution. Governor Odell had not the courage to veto
certain appropriations, but he plainly stated his con-
demnation of giving State money without having State
management. In Maryland the sentiment against sub-
sidization is growing rapidly, and the establishment in
1900 of the Board of State Aid and Charities is the result
of a determination to abate the evil. In the District of
Columbia there was established a Board of Children's
Guardians in 1892, and for ten years there has been a
steady advance toward the abandonment of the whole
subsidy method. The greatest encouragement comes
from Indiana, where, a dozen years ago, political corrup-
tion of charitable institutions was as great as it now is In
I'ennsylvania. To-day Indiana is reported as "without
a vestige of the policy of charity subsidies." Professor
Futter points out that the subsidy evil and political cor-
ruption of charitable institutions is the atavistic relic of
;i medieval type of society, when public functions were
exercised by guilds, societies, and church organizations,
and that such methods are completely out of place in our
American life. It is in fact a historic relic and a socio-
logic blunder and will be done away with when we see
the utility of clean business methods and American
effectiveness in our political and benevolent life.
The ChiUl-rtependent and Subsidy. — There may
be some honest difference of opinion as to the effect
which sul)sidizing private charitable institutions may
have upon the dependent in the cases of adults, but upon
children of the State it is an almost unmixed evil. As in
all such cases the motive of the subsidy is not the good
of the object of charity, but the selfish benefit of the
officers of the institution. Hence, subsidy results in
detaining the child longer in the institution than neces-
sary, and discourages the placing out of the child in
private homes. At the extreme of the corruption the
officers will claim that the iastitution is better for the
child than home life. In one State it was impossible
for a i)enevolent and childless couple to get a child for
adoption from the monstrous overcrowded public
orphan asylums. This was at the same time as the
exposure of one subsidized institution in which the chil-
dren were found half-starved. Any method of caring
for dependents that does not look to stopping depend-
ency is, of course, wicked. Cure is the object of thera-
peutics, not an increase or prolongation of the disease,
and in the case of the dependent child home-life must
be sought for it soon and unremittingly. The rapidity
with which the subsidy evil grows is shown by the fact
pointed out by Professor Futter, that when California
entered upon the downward road the argument used in
the Senate was that the expenditure would never exceed
$30,000 a year. In 1880 it was $58,000, in 1890 $286,000,
in 1898 $410,000.
The Taxpayer and Private Charities. — In the
United States the total local and State aid to i>rivate
charities amounts at least to $11,000,000 a year. There
are only a few of the States in which the subsidizing
evil is not more or less entrenched. Pennsylvania is
the worst of all, nearly $6,000,000 of the public money,
more than for all the rest of the country combined,
having been used in 1901. New York is next with about
$3,600,000. But in New York it is the city and not the
State that subsidizes. In Pennsylvania it is the State,
and the resultant degradation is general and greatest.
Besides the wrong to the dependent, it is a wrong to the
taxpayer and to the general public. There can be no
reform so long as every influential citizen, Interested as
he is in some institution, dare not speak or act against
the boss and the dominant party. Democratic or Repub-
lican. State appropriations paralyze all independence
and prevent the possibility of betterment. The 1k)ss is
enthroned, so that criticism is unforgivable lese majcste.
The second most important harm done by this whole-
sale bribery is that private beneficence Ls dried up.
When the aid of the State treasury is so easily si^-ured,
there seems to bo no need of private charity. And with
the loss of this personal interest there is the loss of the
personal control which makes any institution of value
and of service to humanity. When the institution sub-
sidized is sectarian, the most fundamental principle of
our government, the separation of Church and State, is
outraged, and the grant in such cases could be, and
should be, declared unconstitutional. There is no abso-
642 amebicah Mesxcinbi
EDITORIAL COMMENT
[October 25, 1902
lute control by the State of the private subsidized
institutions, twist and misstate the facts as one will,
and without such control there is no guarantee of honest
management. Falsified statistics are often the means of
securing State aid. Charitable institutions should be
wholly and absolutely supported and managed by the
State or by private individuals.
Hospitals and Corrupt Politics. — The paper of
Dr. Lathrop, published in our columns of this week, is
suggestive in many ways. There was a general agree-
ment of the hospital directors in attendance at the meet-
ing that bad political influences are usually a source of
maladministration. Mr. Fahrenbatch, in speaking of
the abuses by members of the State legislatures, and
appropriation committees, said that these methods of
paying political debts is not only unfair to the taxpayers
of the State, an injury to the medical profession and an
injustice to the hospital, but it tends to paralyze the very
people the members of the legislature select as the
recipients of the State's bounty. Whenever politics has
entered the portals of a hospital, it has not been for the
benefit or welfare of that institution, nor for the benefit
of the political party that attempted to exercise control.
On the other hand, where politics does not attempt,
or is not permitted, to exercise control of institutions
organized for the sole purpose of succoring the sick and
the hurt, and where honesty, efficiency and merit alone
make the tenure of those employed secure, such institu-
tions are assured of the very best service and the patients
of the best care.
The degradation of hospital and professional life by
political influences is most efiectively done by means of
subsidies to private institutions. Concerning this aspect
of the question Professor Futter, of Cornell University,
in a recent number of the American Journal of Sociology,
says of the Pennsylvania subsidies :
"The last legislature allowed only a portion of the sum
which the State Board of Charities declared to be the minimum
requirement for the insane hospitals, while it granted millions
to private institutions. The Governor, however, still not satis-
fied, reduced the appropriations to State hospitals by several
hundred thousand dollars, while approving the subsidies sub-
stantially as voted. . . . That a State like Pennsylvania
should postpone for years the most urgent demands for the
feeble-minded and insane seems to be in part explained as a
result of the large use of subsidies."
The College Degree in Two Years. — President
Butler, of Columbia University, New York, in his annual
report suggests granting the degree of Bachelor of Arts
at the end of two years in order that undergraduates
may enter the professional schools at a less advanced age
than at present. Students who remain in the arts
course for four years are to receive the degree of
Master of Arts. The Dean of Columbia College
expresses his belief that the contemplated two-years'
course " could readily be made to include all the studies
now prescribed at Columbia for candidates for the
degree of Bachelor of Arts." Important as all will
concede it is that men should enter the profes-
sions younger than is now usually the case with men
who have taken the arts degree, we fail to see how any
one can reasonably claim anything like the educational
value for a course of two years that there is in the four-
years' course now generally in vogue in our higher insti-
tutions of learning. It is no doubt desirable in many
cases to shorten the undergraduate course to two years,
but we do not think it worthy of the dignity of a great
university to grant for such a brief course the degree of
A.B., which the traditions of centuries have taught us
to accept as evidence of a thorough, liberal education.
There is room for much diflference of opinion as to the
best course for the student to pursue as regards his pre-
liminary and professional education. The early years of
a man's life are certainly the most, valuable years,
whether in practice, in hospital experience, or in post-
graduate study. At that time men's minds are
plastic and best fitted to gain a thorough and
comprehensive grounding in professional work. So
far as merely professional success is concerned, quite
possibly more successful men would be turned out
if students were to enter their professional studies
after two years of collegiate work than if they
were to complete the full four-years' course which is
usually required for the A.B. degree. Harvard and
Johns Hopkins Universities have declared themselves in
favor of the more thorough liberal education, and
demand that their students shall hold a degree before
entrance upon the study of medicine. President Hadley,
of Yale, thinks that this ideal is impracticably high for
the average student of law or medicine. Presidents
Butler and Hadley would hope to see students enter the
professional schools at an early age and attempt to
accomplish this end by cutting short the collegiate
course, and we believe that the idea which has long been
advocated by President Eliot, of Harvard, is nearer the
correct one ; that the student at present enters college too
late as the fault of the preparatory school, and what is
needed most is to force the secondary schools to adopt
more efficient methods so that students may enter col-
lege two or three years younger than at present; and to
shorten the college course to three years by permitting
the able and ambitious student to take the course
required for the degree of Bachelor of Arts in three
years instead of two. President Butler's plan of grant-
ing the bachelor's degree after two years' study would
inevitably soon lead many of the high grade preparatory
schools to add a little to the efficiency of their work, so
that their courses would be on a par with those retiuiretl
at the university for a degree. This would give through-
out the country a large number of smaller educational
institutions which could be fairly compared with the
German gymnasium and the French lyc6e. This would
be contrary to long-cherished ideals of education in this
country. The present system of liberal education we
have inherited from our English forbears and its aim is
the development of men. A college education cannot
make a young man cultured, but it can help to give him
such tastes as will tend to develop him into a broad-
minded cultivated man. The French and German sys-
tem brings the student much more quickly into the pro-
fessional school and tends to develop the scientist rather
than the man. Anxious though we may be to promote
such methods as will give our country a body of practi-
tioners second to none in the world in their scientific
OCTOBBK 25, 1902)
EDITORIAL COMMENT
American Medioink 643
training, we hope that this will not be accomplished
through sacrifice of the old ideal, that the man is of more
value than the scientist. What the man studies is of less
importance than how thoroughly he studies it, and that
as thoroughly trainetl men cannot be produced by two
years' as by three or four years' college study is self-evi-
dent.
International Reciprocity. — We have received a
number of letters from correspondents relative to Pro-
fessor Lorenz having appeared before the Illinois Board
of Medical Examiners to pass its examination and be
regularly licensed in that State. We also see that the
newspapers are newspaperishly indignant over the
"insolent" and "unheard-of proceeding," charging
the medical profession with all kinds of vile motives
and methods. In reply it might be urged that it is a
question of executing the law or of changing the law if
the law is unjust, or discourteous. We are hearty
believers in the most liberal welcome to practitioners
from other States and from other nations who may be
visiting us, or who wish to settle among us. But there
must be a reciprocal liberklity on the part of these
others. Those who are indignant, or seemingly so,
against the Illinois Board should first learn what would
be the nature of the reception of an American practi-
tioner by Professor Lorenz's home colleagues. There
are several reasons why the action of the Illinois Board
was wise and proper. The chief interest in the operation
performed by Professor Lorenz is that he was the origi-
nator of the method. In these days of intercommunica-
tion there is no secret, nor any transcendent skill, pos-
sessed by any one member of the medical profession
which is denied to others. Those who talk about the
" atrocity " of the action of the Illinois Board should
know that hard as the law may be upon occasional indi-
viduals it has checked quackery and has been of tremen-
dous lialue in advancing the cause of honest medicine. It
is now our duty to remedy the defects of the law and not
to ignore it or abrogate it by nonexecution. True
courtesy lies iti reciprocity. State or national, but reci-
procity necessarily implies a mutual relation.
The pronunciation of Virchow's name has puz-
zled almost every one. There are at least three ways of
pronouncing the initial letter, either as the English ic,
V, or /. The stjcoiul letter may be pronounced as i in
Jir, or as e in me, and thus the total number of variations
is vastly increased. To the ch has been given the sounds
isch, sell, k, and the German ch as in Ich, and these four
multiply the possible methods almost beyond calcula-
tion. But the ow may be spoken as o, ow, or off, so that
the permutations at last become ludicrously large. A
correspondent in the London Times says that Virchow
himself was greatly pleased when Professor Harnack
addressed the guest at the eightieth anniversary giving
the sound of the initial letter as /, and of the ow as o.
The American, however, is relieved of but a small part
of his difficulty by this. He might guess that the i
should have the sound of long e, but if he knows not
(lerman he can never enunciate the ch. If he is able to
make this "goose-sound," then his troubles maybe at
an end with feer-cho, the ch being given as in the Ger-
man Ich, and this ipay be held as the proper pro-
nunciation. If this is for him out of the question, the
nearest he may come to it is to pronounce the eh as k —
feef-ko. Virchow said that he had been able to trace
his name to a small village and a lake in Pomerania,
both of which are named Virchow, which word the
natives pronounce exactly as Professor Harnack had
done. The Times^ correspondent says that a leading
German philologist devoted considerable time to the
subject of the origin of Virchow's name, and came to
the conclusion that it was Slavonic. The Slavs, he
thought, who bore it were settle<I in Pomerania about
the fifth century of the Christian era, and gave one of
their names to the village and the lake.
There are Ten Million of Them ! — Everybody
knows about them, the disease they spread, their hor-
rors, their worse than loathsomeness ! Every one en-
dures, submits in silence, feels himself powerless to
remedy. Boards of health cannot, or think they can-
not, attack the evil ; they do not there exist, or cannot
reach the disgrace, or they are too busy with things
they think, or affect to think, are more important. And
so the filthy country and village water-closet persists
from generation to generation. Occasionally a town
votes on the question of establishing a sewerage system,
but an increase of the tax rate makes the " best citizen "
shudder, and the project is voted down. Nothing more
accurately indicates the degree of uncivilization of a
family and of a country than the methods or non-
methods of its sewage disposal. The deodorizer that
seeks to conceal one smell under another is usually the
only stupid attempt at any remedy. The serious legis-
lator or the intellectual philanthropist is yet to come
who shall undertake one of the greatest reforms of the
world. There are millions of these indescribable atroci-
ties in America, of which we are ashamed and yet not
ashamed, which are constiintly scattering physical and
moral disease ; and yet indignation that shall ever come
to action and a resolve to put an end to the disgrace
seems quite as impossible as to the filthiest Hottentot.
The professional puft-writer is still at his nefari-
ous business. He jjiakes a poor income by writing
pseudoscientific articles extolling some nostrum for
manufacturing scamps who pay him for his lies. Pos-
sibly these are furnished to him in a crude form by his
employers, and all he has to do is to dress them up a bit
more respectably. But he is very cunning about his
business, and has fooled many an unsuspecting editor.
He is a graduate of reputable schools and has a varied
lot of titles dangling at the end of his name. Unlike
most of the qutuiks his English would not shock a ward
politician, and he has enough knowledge of medicsd
science to write therapeutics so intelligently as to deceive
any physician who does not know that every clinical
statement made is an absolute lie. Perhaps his sole error,
outside the domain of truth, is that he overloads his
articles with laboratory jargon and ultrascientific terms.
In some of the cases the ininu-ulous drug is not wholly
successful — there are degrees of perfection even in the
644 AMEBIOAN MESieiNB}
AMERICAN NEWS AND NOTES
[OCTOBKB 26, 1902
nostrum-miracle — but as a' rule there has never l)een
anything in this particular disease so wonderworking.
This is not said directly, but is modestly left to be
Inferred from the appended chart.
Slaughterhouse Products in Medicine. — The
special bulletins issued by the government in connection
with the publication of the Twelfth Census of the United
States afford in many instances information of interest to
physicians and pharmacists. That by Henry G. Kit-
tridge on the Utilization of Wastes and By-products in
Manufactures, may serve as a case in point. Under
Slaughterhouse Products the author refers to the use of
animal tissues in organotherapy. The gray brain-matter
of calves finds place in the treatment of derangements of
the nervous system, such as neurasthenia, agoraphobia,
chorea, psychosis. The stomach, thymus, thyroids, pan-
creas, parotids, suprarenal capsules, testes, etc., furnish
in their extracts powerful adjuvants to systems deficient
in particular glandular products through the congenital
absence or acquired defects of glands easential to normal
metabolism. The many ways in which gelatin, albu-
men, blood, and glycerin are made to serve the human
economy in medical practice are familiar to all ; but few
stop to think of the bearing of modern invention for
the recovery and utilization of the waste-products of
slaughterhouses and rendering-establishments upon the
practice of pharmacy, bacteriology, medicine and sur-
gery.
The lying testimonial writer is one of the dis-
graces of the medical or, rather, the quack advertiser.
Sir William Broadbent has lately had to protect his
name from being used by nostrum manufacturers in New
Zealand, and our esteemed contemporary, the Lancet, is
still unsuccessful in its efforts to prevent a company from
flagrant advertising of "Lancet Influenza Cures." In our
country the abuse is disgustingly prevalent in the news-
papers. Generally the wellknown names of dead men
are hit upon because the fraud is then much harder to
expose and break up. The editor of an American medi-
cal journal was included in Sir William Broadbent's
criticism, and in replying he said tliat although no editor
can be held responsible for the unauthorized use of
names in testimonials cited in advertisements his own
columns should be freed from blalne in the instance
mentioned, and that " every journalist will be only too
glad to correct any unauthorized use of a physician's
name in his journal." We wish this were true of the
lay journalist.
Knowledge, Feeling, and Action Illustrated
Appealing for help the head worker of the College Settle-
ment of Philadelphia writes :
"To say 'congested quarters, poor water-supply, surface
drainage and privy-wells, the street as playground, the mal-
odorous heat of our nights,' is one thing ; to feel the murder-
ous quality of these conditions is quite another thing. To aid
in changing for the better the condition and the people who
suffer and die from them— none the less because they are often
ignorant of and indifferent to, or sometimes even the cause of
their own loss and destruction— this is yet a third thing, but
the greatest, excelling knowledge and feeling, as charity sur-
psisses faith and hope."
AMERICAN NEWS AND NOTES.
OKNERAIi.
Reciprocity In Medical Liicensure.- According to a
recent report there are now 30 States contemplating laws to
regulate tne practice of medicine.
Cholera.— According to newspaper reports cholera is rap-
idly dying out in Manila. A great improvement is also noticed
in all the provinces with the exception of Iloilo, Leyte, and
Zambales. The cholera situation in Cebu is said to be under
complete control.
Inoculations In Yellow Fever.- It is reported that the
inoculation for experimental purposes of nonimmunes by
mosquitos which have IMtten a yellow fever patient, and whicfi
have been infected for over 10 days, has been prohiiiited by the
Cuban government.
Medical Colleges of United States. — Of the 155 medical
schools in the United States, in all but two a four years' course
is compulsory. Last spring there were 26,147 students enrolled
and 5,958 teachers in these colleges. During the year the degree
of M.D. was conferred on 5,444 students.
Hospital Benefactions. — Clinton, Mass.: The late George
W^. Weeks bequeathed §30,000 to the Clinton Hospital ; $15,000
of this is to be used generally, while the remaining ?15,000 is to
be kept intact and the interest to be used-for hospital purposes.
South Bethlehem, Pa.: Robert H. Sayre, of Mountain Hill,
Pa., has given a new ward worth $20,000 to the St. Luke's Hos-
pital. Lowell, Mass.: An anonymous benefactor has prom-
ised to give 8100,000 lor an endowment fund, provided the
Lowell General Hospital and the Corporation Hospital are
merged into one institution.
American Veterinary Medical Association. — The thirty-
ninth annual meeting of the association was held in Minne-
apolis, Minn., September 2 to 5, 1902, with Dr. J. F. Winchester,
of Lawrence, Mass., as president. A varied and interesting
program was rendered, and the following officers elected for
the ensuing year : President, Dr. S. Stewart, Kansas City, Mo. ;
vice-presidents, J. G. Rutherford, Ottawa, Can.; W. H. Dal-
rymple. Baton Rouge, La.; Dr. E. M. Rauck, Glenolden, Pa.;
Dr. M. E. Knowles, Helena, Mont.; Dr. M. H. Reynolds, Min-
neapolis, Minn.; secretary. Dr. John J. Repp, Ames, la.;
treasurer. Dr. William Herbert Lowe, Paterson, N. J. There
were 66 new meinbers elected, making the membership at the
present time over 500.
Navy and Marine Corps U. 8. Army. — The first annual
report of Surgeon-General Rixey shows that the percentage
of sick and the deathrate for the past year was lower than for
several years. An important feature of the report is the strong
recommendation that a woman's nurse corps be introduced
into the navy, and that Congress be asked to provide for the
establishment of such a corps, which should consist of a super-
intendent nurse, 8 head nurses, 16 first-class and 24 second-
class nurses, with the provision that these numbers are to be
increased at the discretion of the Secretary. A strong plea is
made for the appointment of dentists for the navy, as many
otherwise good recruits are lost through lack of dental care.
Attention is also called to the present entirely inadequate
medical corps, and it is recommended that 150 additional
medical officers be appointed, and that after each cruise surgeons
be given a period of duty either at home or abroad in one of
the great medical centers, where they can have an opportunity
to keep abreast with medical progress. Other measures advo-
cated in the report are the construction of two hospital ships,
one for the Atlantic and one for the Pacific ; the erection of a
sanatorium for the treatment of pulmonary tuberculosis ;
improvement of sick quarters aboard ship ; and the representa-
tion of the medical corps in the naval boards which design
ships, so that sanitary conditions may be improved.
EASTERN STATES.
Diphtheria of a somewhat malignant type is reported to be
raging in Milton, Mass. The disease first appeared among the
pupils of one of the public schools, and afterward spread to
such an extent that the school was ordered to be closed. At
this time there were 28 cases in the immediate neighborhood.
NEW YORK.
Resumption of Professional Work.— It is announced
that Dr. W. W. Van Valzah, of New York City, who has not
been practising for the past four years on account of ill-health,
has again resumed professional work in partnership with Drs.
Nisbet and Hayes.
Trachoma Ainons School Children. — Dr. Lederle, of the
New York City Health Department, reports 18fo of the pupils
attending the public schools as being atllicted with the disease,
and asks that an appropriation of ?21,800 be made for an addi-
tional staff of physicians to make regular examinations of the
children's eyes. It is believed that the appropriation will be
granted.'
OCTOBER 25, 1902]
AMERICAN NEWS AND NOTES
iAkbbican Meoicikb 646
Against Smallpox. — It is reported that President Lederle,
of the New York City Health Department, has issued a circular
letter to every physician in the city, asking cooperation in pre-
venting a return of smallpox during the comiug winter. The
city is declared practically free of the disease at present, but as
it is constantly e.xposed to reinfection from communities where
it still rages, an appeal is made for early and thorough vacci-
nation.
Sanitary Telepliones.— Commissioner Homer Folks has
issued an order that all telephones used by officials, physicians
and patients under the province of the department must be
cleansed and disinfected at least once each week. It is claimed
that in speaking into a telephone receiver held within an inch
or two of the mouth irregular sprays of saliva may be ejected
into the mouthpiece and the lips or mouth of a second person
coming into contact with this matter or the drying up and sub-
sequent blowing about of particles so ejected might cause infec-
tion.
Increased Appropriations Asked for Charitable Insti-
tutions.— Owing to the advanced prices of the necessaries of
life, many of tlie private charitable institutions in New York
City receiving public funds have exhausted tlieir resources and
the Board of Estimate has therefore been petitioned to make a
marked advance in the per capita allotment paid by tlie city for
dependent children in asylums and patients treated free in hos-
pitals. The city now pays 60 cents a day for medical cases and
80 cents for surgical cases, which is only a fraction of the actual
cost of caring for patients in first-class hospitals. It is urged
that the rates be increased to 80 cents and 90 cents respectively.
To Study Epilepsy.— On November 5 the National Associ-
ation for the study of epilepsy and the care and treatment of
epileptics will begin the meetings of its annual s&ssion at the
Academy of Medicine in New York City. The program con-
tains many papers of great practical value and interest, among
the contributors being the following: Drs. Abram Jacobi,
Frederick Petersen, Adolph Meyer, Roswell Park, William
Osier, H. N. Moyer, L. P. Clark, Thomas Prout, W. P. Sprat-
ling, and Wm. N. BuUard. Physicians and charity workers
generally are invited to attend the meetings. The association
was founded for these objects : To promote the general welfare
of sufferers from epilepsy ; to stimulate the study of the causes
and methods of cure of this disease ; to advocate the care of epi-
leptics in institutions where they may be educated, acquire
trades and be treated by the best medical skill for their malady,
and to assist the various States in making proper provisions for
this class. The association has no membership dues, and
applications to join it should be made to Dr. W. N. BuUard, chair-
man of the executive committee, 89 Marlboro street, Boston, or
to Dr. W. P. Spratling, the secretary, at Souyea, N. Y.
PHIIiADEIiPHIA, PENNSYLVANIA. ETC.
Bill for Emergency Hospital.— According to a recent
report, ihe Pennsylvania Legislature will be petitioned to pro-
vide for the establishment of an emergency hospital in Pitts-
burg. It is claimed that owing to the numerous accident cases
in that city and its vicinity the need of such an institution is
keenly felt.
Clinic at Jelferson Hospital by Dr. Ijorenz.— Professor
Adolph Lorenz, of Vienna, has- kindly consented to hold a
clinic at Jefferson Medical College Hospital upon his return
from San Francisco. In order that he may have a large number
of these rare ca.ses of congenital dislocation of the hip from
which to select, physicians having knowledge of such patients
who are poor and suitable are iisked to communicate with H.
Augustus Wilson, M.U., IGll Spruce street, Philadelphia. The
date of the clinic will be announced as soon as possible.
JefTerson Medical College.— Some time ago, acting on
information we believed to be authentic, we announced certain
appointments in clinical medicine at Jefferson College which
were incorrect. At a meeting of the Board of Trustees on
October lt> the following appointments were made: Dr. Solo-
mon Soils Cohen, senior assistant professor of clinical medi-
cine. Dr. Cohen was also appointed physician to Jeffer-
son Hospital, succeeding the late Dr. Wirgman. Dr. Addinell
Hewson was appointed assistant professor of anatomy:
Dr. John M. Fisher, assistant professor of gynecology ; and
Dr. E. (iuinn Thornton, assistant professor of materia modica.
Alvarenga Prize. — The College of Physicians of Philadel-
phia announces that the next award of the prize (about fl80)
will be made on .luly 14, 1903, provided that an essay deemed
by the Committee on Award to be worthy of the priztj shall have
been offered. Essays may be upon any subject in medicine
(unpublislied) and must be received by the secretary of the
college <m or before May 1, 1903. Each essay must be plainly
marked with a motto and be accompanied by a sealed envelope
having on its outside the motto of the paper and within the
name an<i a<ldros8 of the author. The Alvarenga prize for 1902
was not awarded, the committee having decided that no essay
of siilliciently high standard was submitted in competition.
The Pennsylvania Society for the Prevention of Tuber-
culosis, founded in 1892, and which was the pioneer society of
its kind in this country, printed during the past year over
30,000 copies of its tracts. This society has given efficient aid to
the Free Hospital for Poor Consumptives at White Haven, Pa.,
where 250 acres of land have been secured and a sanatorium
established ; it has been active in its efforts to secure legislation
requiring that pulmonary tuberculosis should be included
among diseases returnable to the Bureau of Health, also legis-
lation looking to the abatement of the spitting nuisance. The
society is doing a splendid work, and has by its example and
by means of its publications led to the establishment of similar
societies in other States. The organization is deserving of the
highest commendation and it should receive the active support
of all who are interested in pushing the war against the white
plague.
SOUTHERN STATES.
The " Doctors' Protective Iieague " is the name of a new
association inaugurated by Washington physicians to protect
themselves against non-paying patients. It is proposed to pro-
vide each member with a list of unwilling payers, and also to
formulate a fee-bill.
Overcrowded Insane Asylums.- In a report submitted to
the Governor, Superintendent Worsham, of the Texas State
Lunatic Asylum, deplores the overcrowded conditions existing
in the three asylums and says that the State is being imposed
upon by a large number of persons who are not suffering from
acute mental diseases but are drug victims or else decrepit
persons who have reached senility. He urges that in order to
relieve the congestion in these asylums that such patients be
taken care of by their relatives or by the counties and not by
the State.
W^ESTERN STATES.
Ijeprosy in Iowa.— Two cases of the disease have been
reported to the State Board of Health. One patient lives near
Humboldt, and the other in Gilmore City. The State has no
retreat for lepers and if the report is true the patients will have
to be takeu care of in their own homes.
Administration of Drugs in the Chicago Presbyterian
Hospital.— An investigation of the methods of administering
drugs to patients in the hospital has resulted in the announce-
ment that hereafter only a registered pharmacist will prepare '
medicines for the hospital and that no one but physicians in
charge will be allowed to prescribe medicines.
Dr. Lioreiiz Secures Medical liicense.- Dr. Loreuz, of Vi-
enna, recently appeared before the Illinois State Board of Health,
and after an examination by that body, obtained a li(;ense to
practise medicine in Illinois. This action was the outcome of
the fact that Dr. Lorenzhad been besieged by numerous appeals
to operate for congenital luxation of the hips, the oi)eration
which he came to Chicago to perform on a little girl, and as it
was understood that the doctor intended to continue in practice
for some time in the city, it was deemed necessary that he
should conform with the State laws and secure a license.
Physicians' Defense Company.— Israel W. Durham, Com-
missioner of the Pennsylvania Insurance Department, in a
recent communicatiou to Dr. A. P. Buchman, president of the
Physicians' Defense Company, of Fort Wayne, Ind., states that
since rendering the opinion of December 23, 1901, which declared
the business of the Physicians' Defense Company pertained to
insurance, he has made a careful and full reexamination of
their contract and has decided that there are no insurance
features whatever embodied in it, and that therefore when the
company is properly registered in the office of the Secretary of
the Commonwealth and his certificate obtained, the contracts
may be issued in Pennsylvania without being subject to insur-
ance laws or under supervision of the Insurance Department.
Health of Chicago.— With but one exception the number
of deaths (403) reported during the week ende<i October 11,
furnishes the lowest October mortality on record for that city,
the annual rate being 11.53 per 1,000 of the population ; the
exception mentioned occurring for the week ended October 19,
1901, when there were 376 deaths, making the annual rate 10.95
per 1,000 persons. The only reason that (Uiii bo assigned for the
remarkably low deatlirate is the (!ainj)aign against typhoid
fever which led to attention Iwing paid to the prevention of tho
disease, and also to an increased care of health generally. The
epidemic is reported to be practically ended. During the week
13 cases of smaUpox occurred. With the exception of one
patient of 2:1, all were children under 12. None had ever
been vaccinalod. Five other cases were found which had been
diagnosed and treated as chickenpox. Attention is called to
the appalling increase of self-destruction during the last det^ade.
Since .January 1 there have been 321 suicides, an annual rate of
22.() per 1(X),000 of population ; while in 1890 it was only 12. The
Health Department is confirmed by it« researches in the belief
that this increase of self-murder is due to inffuenza and again
urges upon physicians the great necessity for prompt diagnosis
of the disease and its radical treatment.
646 A.MEBIOAN MEDICINEI
FOREIGN NEWS AND NOTES
[OCTOBKK 25, 1902
Mortality of Michigan. — There were 2,548 deaths returned
to the Department of State for the month of September, cor-
responding to a deathrate of 12.6 per 1,000 population. This rate
is slightly higher than the rate for the preceding month, 11.8,
but is lower than the rate for September, 1901, which was 14.1.
By ages there were 607 deaths of infants under 1 year, 219 deaths
or children aged from 1 to 4 years, inclusive, and 662 deaths of
elderly persons over 65 years of age. Important causes of
death were as follows: Pulmonary tuberculosis, 102; other
forms of tuberculosis, 26 ; typhoid fever, 80 ; diphtheria and
croup, 48; scarlet fever, 17; measles, 4; whoopingcough, 24 ;
pneumonia, 119 ; diarrheal diseases, under 2 years, 329 ; cancer,
114; accidents and violence, 152. Typhoid fever nearly doubled
in mortality as compared with the preceding month, and diph-
theria and pneumonia showed considerable amounts of
increase. No deaths were reported from smallpox, tlie first
month in which this has been true since April, 1901.
CANADA.
Infant Registration.— At a recent meeting of the Montreal
Medical Society resolutions were adopted declaring the new
law, which renders physicians liable for the registration of
infants under penalty of fine and imprisonment, unnecessary
and a heavy burden upon the physicians of Montreal and
vicinity.
A new orthopedic hospital was recently opened in
Toronto, with Drs. B. E. McKenzie and H. P. H. Galloway in
charge. There are at present 30 patients in the institution. The
cost of the building and equipment is reported to aggregate
f40,000. The hospital has private wards and a large public ward
which will accommodate 22 patients. There is also a dispensary
for outdoor patients.
FOREIGN NEWS AND NOTES
GBNERAIi.
Yellow Fever. — It is reported that there are many cases of
the disease at Guayaquil, Ecuador, the greater proportion
occurring among the Germans.
Cholera is reported to be spreading rapidly in Palestine,
the chief center of infection being Goza, 48 miles from Jeru-
salem. It is stated there are 30 to 40 deaths daily in that city.
Plague in India.— During last July 4,229 antiplague inocu-
lations were performed in the Punjab. Further measures
against plague have been adopted by the Cannanore municipal
government, which has offered one cent for every large rat and
a half cent for every small one found in the municipal area.
GREAT BRITAIN.
Beri-beri on Shipboard.— It is reported that the Nor-
wegian vessel "Aurora," which recently arrived in Queens-
town, had eight cases of beri-beri on board. The captain and
a number of sailors were sent to the hospital.
Rules Regulating the Manufacture and Sale of Ice
Cream.— The health authorities of London announce through
the daily press that on and after November 1 ice cream and sim-
ilar commodities shall not be made, sold, or stored in any cel-
lar, shed, or room used for living or sleeping in, and having a
drain or outlet. All possible precautions must be taken against
contamination, and any outbreak of infectious disease in or
about the premises must be reported immediately to the health
department. Further, all itinerant venders must display on
their barrows the name and address of the manufacturer. The
foregoing measures were adopted after an extended investiga-
tion showed that ice cream of a poisonous nature was being
sold in the city. Out of 23 samples examined 12 were found
absolutely poisonous, while of 32 places where ice cream was
made 15 were found defective in sanitation.
CONTINENTAIi EUROPE.
Transmission of Plague by Bats.- Investigations con-
ducted by Dr. Gosio, of Naples, tend to show that a number of
cases of plague which recently occurred in that city were prob-
ably due to bats. This conclusion was reached after it was
found that bats are extremely susceptible to the disease, which
quickly reaches a fatal termination, and that the bacilli multi-
ply with great rapidity in their bodies.
Meat Inspection in Germany.— It is reported that the
new law regarding meat inspection will become operative on
April 1, 1903, at which time it is stated the Kingdom of Prussia
will have 56 inspection stations. The law provides that the
meat inspection be divided into three stages : The veterinary
surgeon's Inspection of all fresh and prepared meats ; micro-
scopic inspection of fresh and prepared pork; and chemic
examination of all prepared meats.
OBITUARIES.
Bertram Spencer, M.D., M.R.C.S. (Eng.), a prominent practi-
tioner of Toronto, September 28, aged 49. He was graduated from the
University of Toronto In 1879, receiving the degree M.B. I^ter he took
a postgraduate course In London, Eng., and became a member of the
Royal College of Surgeons. He held a position on the teaching staff of
Trinity Medical College for some years. In 1892 he was appointed Pro-
fessor of Medical Jurisprudence in the Toronto University, and In 1898,
Associate Professor of Clinical Surgery.
William A. Adams, A.M., M.D., LL.D., at Fort Worth, Texas,
October 15. He obtained his degree in medicine from the University
of Georgia in 1876. He was a wellknown railway surgeon and was also
connected with several prominent Insurance companies. He was
emeritus professor of the principles and practice of medicine and lec-
turer on clinical medicine in the Fort Worth University. He was also
a member of the Mew York Medicolegal Society.
E. G. Carpenter, at Columbus, Ohio, October 19, aged 44. He was
graduated from the College of Physicians and Surgeons, Baltimore,
Md., in 1884. He was a wellknown specialist in mental diseases and at
the time of his death was superintendent of the Columbus State Hos-
pital. He was formerly assistant superintendent of the Cleveland
State Hospital.
K. E. Hasse, at Hanover, Germany, September 19, aged 93. He
was at one time Professor of Internal Medicine at Zurich and also at
Gottlngen. He was popular both as an instructor and a writer, his
principal contributions to medical literature being his manuals of dis-
eases of the nerves, heart, and respiratory organs.
William K. Whitehead, of Denver, Colo., October 13, aged 70. He
was graduated from the medical department of the University of Penn-
sylvania in 18.53. He established the departments of medicme in the
University of Colorado and the University of Denver, and was the
author of many works on medicine and surgery.
Robert Drayton Earle, of Columbus, S. C, in Philadelphia, Sep-
tember 30, aged 28. He was graduated from the College of Physicians
and Surgeons In Baltimore, 1895. He was a member of the South
Carolina Medical Association and of the Medical Society of Columbia.
Abel M. Fhelpa At a meeting of the B'aculty of the New York
Postgraduate Medical School and Hospital, October 8, appropriate
resolutions were passed commemorating his work and deploring his
loss.
John S. Tennant, of Lucknow, Can., September 11, aged 60. He
was graduated from the University of Toronto in 1865. He was one of
the most popular physicians In Western Ontario.
John M. Brewster, of Pittsfleld, Mass., October 15, aged 85. He
was a graduate of the old Berkshire Medical Institute and later took a
finishing course in Providence, R. I.
J. H. Van Ueman, of Chattanooga, Tenn., October 18. He was
graduated from the medical department of the Western Reserve
University, Cleveland, Ohio, In lt52.
James D. Wade, a wellknown physician of Brooklyn, N. Y.,
October 19. He was graduated from the medical department of the
New York University in 1866.
William E. Doughty, of Hartsville, Pa., October 15, aged 66. He
was a member of the centennial class of the University of Pennsyl-
vania, 1888.
John Roberts, of Atlanta, Ga., October 12, aged 40. He was a
graduate of the medical department of the Tulane University of
Louisiana.
John J. Barry, in Valley Falls, R. I , September 26, aged 34. He
was graduated from the College of Pliyslcians and Surgeons, Balti-
more, 1899.
Clark H. Wright, of Carlsbad, N. M., at El Paso, Texas, Septem-
ber 23, aged 35. He was graduated from the State University of Iowa
in 1896.
temon R. Leach, in Hamburg, N. Y., September 27, aged 52. He
was graduated from the Berkshire Medical College, Pittsfleld, Mass.,
1848.
J. A. Chandler, at Guineys, Va., October 2, aged 74. He was
graduated from the South Carolina Medical College, Charleston, 1851.
Henry T. Sears, in Boston, Mass., September 26. He was gradu-
ated from the New Y'ork College of Physicians and Surgeons in 1862.
Charles E. McCallister died recently in Chicago, 111. He was
graduated from the National Medical University of Chicago in 1899.
Leander D. Tompkins, in Cassopolls, Mich., October 1, aged 85.
He was graduated from the Rush Medical College, Chicago, In 1852.
John A. Bufflngton, of New Windsor, Md., October 17. He was
graduated from the Jefferson Medical College, Philadelphia, 1884.
Frank B. McCall, of Nevada, Iowa, September 29. He was gradu-
ated from the Harvey Medical College, Chicago, in 1900.
Frank D. Toms, in Keyport, N. J., September 30. He was grad«-
ated from the Rush Medical College, Chicago, 1887.
Thomas G. Underwood, of Brooklyn, N. Y., October 19, aged 63.
Edward T. Noel, of Nashville, Tenn., September 26, aged 55.
OCTOBBK 25, 190!2]
SOCIETY EEPORTS
(Amekican Medicine
647
SOCIETY REPORTS
MISSISSIPPI VALLEY MEDICAL ASSOCIATION.
Twenty-eighth Annual Meeting, Held at Kansas City, Mo.,
October 15, 16 and 17, 1902.
[Specially reported for American ifedicine.]
The Association met at the Midland Hotel, under the presi-
dency of Dr. S. P. Collings, of Hot Springs, Arlj.
Officers Elected.— President, Edwin Wallier, Evansville,
Ind. ; vice-presidents, Hugh T. Patrick, Chicago, 111., and Wm.
Britt Burns, Memphis, Tenn. ; secretary, Henry E. Tuley,
Louisville, Ky. ; treasurer, Thomas Hunt Stucliy, Louisville,
Ky. Mempliis, Tenn., was selected as the place for liolding the
next meeting in iOOS. A resolution was adopted making the
Mississippi Valley Medical Association a district branch of the
American Medical Association. The constitution and by-laws
of the former will be revised to conform to this change.
After the reading of the reports of the Secretary, Treasurer,
Committee on Credentials, Committee on Publication, etc., the
President deliveretl his address.
The relationship syphilis bears to the body politic
was the title of the presidential address, delivered by S. P.
CoLLiNOS (Hot Springs, Ark.). He selected this subject, first,
because of the importance of calling attention constantly to a
disease so widespread as syphilis ; second, because it was a dis-
ease which proper education concerning its frequent occurrence
together with its various modes of transmission could be con-
trolled more efifectively than most diseases, and third, because
for the past 25 years he had been a daily observer of
its frightful ravages upon the body politic or society at large.
The prevention of tiie spread of syphilis by educating the pub-
lic more thoroughly as it is being educated concerning the com-
municabilityand modes of transmission of tuberculosis, should
be more vigorously advocated. The public, however, must
first be willing to learn before it can oe taught. Syphilis is
communicable not only by some infected person, but by
articles which have come in contact with the specific poison.
In our day the prohibition of prostitution was not practical.
Regulation of the vice has proved ineffectual in controlling its
spread. If it was legalized, the men frequenting the houses
should be subjected to the same rules in regard to examination
that the unfortunate inmates were subjected to. In New York
City there were in 1901 about 200,000 cases of syphilis and Gihon
a few years ago estimated that there were '2,(KX),000 cases in
the United States. Physicians can do more by educating their
patients a.s to the modes of infection and by advising with the
younger ones among those whom they treat than all the laws
that had been or will be enacted could do to prevent the spread'
of syphilis.
Medical Section.
FIRST SESSION.
Smallpox.— John M. Batten ( Downingtown, Pa.) detailed
the symptoms and then discussed the diagnosis, prognosis, and
empliasized the necessity of vaccination.
An Attempt to Obtain Uniformly Active, Sterile and
NonirritatinK Preparations of Digitalis for Subcutaneous
and Internal Administration.— E. M. Houghton (Detroit,
Mich.) referred to the unsatisfactory condition of our knowledge
of the chemistry of digitalis, and stated that a sterile, nonirri-
tating and uniformly active preparation was greatly needed.
He detailed his efforts to obtain such a preparation containing
the largest possible amount of active constituents and the
smallest amount of the inert constituents of the drug, based on
pharmacologic experiments on the lower animals. He gave
the clinical results and conclusions.
Some Developments In the Therapy of Iodoform. —
J. J. Gaines (Excelsior Springs, Mo.) regarded iodoform as
the best remedy for tuberculosis at the command of the physi-
cian. It is an ideal iodid, storing all <iuiintities of iodin, which
could be easily liberated. Ho mentioned its use in pulmonary
and gastrointestinal disea-ses, and reported a number of cases in
whicli he had used it with gratifying results.
Normal Sleep versus Dru^ Unconsciousness. — J. B.
Learned (Northampton, Mass.). Natural sleep was indispen-
saiile to long life and business success. Drug unconsciousness,
labeled sleep, was the reverse. The indoor Itrain worker failed
to lay the foundation of normal sleep by day, and sutlered by
night the result thereof. Brain and mus(de employed in the
open alone during the day would secure the normal conditions
of sleep at night. Automatic brain activity at theslceping hour
was the immediate cause of wakefulness. The ready remedy
was nniscular exertion under the direction of the will, either
mild, without change of parts, or the reverse. Control of the
respiratory and circulatory functions met the desire<l end by
withdrawing power from the brain centers. All automatic
brain work was suspended when coniientrated attention was
paid to alternate contraction and relaxation of certain groups of
muscles. Automatic brain work was pathologic. Brain and
muscle work, imder the direction of the will, was physiologic.
He detailed a method of inducing sleep.
The Treatment of Exophthalmic Goiter by Electricity.
— H. M. Beaver (Spring Hill, Kan.). The exciting cause
may be a previous illness, injury, or over-exertion, involving
a determination of the blood to the brain and medulla oblon-
gata, which acted as an irritant by pressing upon the nerve
centers, causing the incoordinate nerve action found in this
disease. The cardinal principles of treatment was to decrease
the flow of blood to the head. When this was accomplished
all the minor symptoms would subside. The author reported
three cases of the disease and described the mode of application
of electricity, also the battery used. He regarded exophthalmic
goiter as a vasomotor paralysis ; hence amenable to electrical
treatment.
Typhoid Fever ; Its Antiseptic Treatment.— James Bil-
linoslea (Baltimore, Md.) reported 150 cases. He said
Brand's method of cold bathing owed its merits largely to its
eliminative value. During the past year he had treated in
private and hospital practice 150 cases of typhoid fever with
acetozone without a death. He dissolves 15 to 20 grains of aceto-
zone powder— equal to 7J or 10 grains of the benzoilacetyl-
peroxid— in a quart of water and gives the patient this amount
to drink in the 24 hours, both in water and in milk, diluting the
milk one part of acetozone solution to three parts of milk. The
action of the drug would be materially aided by administering
a mild saline laxative, say sodium phosphate or magnesium
sulfate, every other day.
SYMPOSIUM ON TUBERCULOSIS.
What Class of Cases of Pulmonary Tuberculosis do
Well In Colorado?— W. A. Campbell (Colorado Springs,
Colo.) gave an analysis of 250 cases coming under his observ^a-
tion, in which his examinations were made soon after their
arrival in Colorado. He found in this series of cases that
the average age was 29f years. Those with tuberculous family
history did not do as well as the non-tuberculous. The percent-
age of benefited decreased as the duration of the disease
increased. The right lung was involved alone oftener than the
left. The percentage of benefited was slightly in favor of the
right lung. When both lungs were involved the mortality was
50%. In the first stage 92% were benefited ; in the second stage,
54% ; in the third stage, 13%. The diminished arterial tension
and dilation of external capillaries, due to lessened atmos-
pheric pressure, made it safe for hemorrhagic cases to seek a
higher altitude. He would not send cases of acute miliary
tuberculosis or phthisis florida to high altitudes. Neither
would he send those extremely nervous, with an irregular or
rapid heart and high temperature. Those having Bright's dis-
ease should not come. Advanced laryngeal or intestinal cases
did not do well.
Climatic and Electric Peculiarities of Colorado Favor-
ing Recovery in Pulmonary and Intestinal Diseases and
From Surgical Operations. — J. E. MacNeill (Denver,
Colo.) discussed the physical characteristics of Colorado affectr
ing its climate — the mineral springs of Colorado— and cited some
generally accepted facts regarding mountain climates applicable
to Colorado. He also discussed the value of high altitudes with
their rarefied air and direct sunlight in the treatment of abnor-
mal conditions, and finally the electric conditions.
Digestive Disorders In Pulmonary Tuberculosis, with
Notes on Mixed Infections. — Paul Paquin (Asheville,
N. C.) said the majority escaped this disease, not because they
were not attacked, but because they resisted the attack. The
most vital question was that of nourishment, whereupon one
might base such measures of treatment as might be deemed
best for restoration. A normal condition of the mucosa must
be restored before good digestion can take place. Among the
local measures to this end was stomach and high intestinal
lavage. As specific measures, serotherapy, the cacodylates and
iodin offered the greatest aid in preventing organic changes.
Immunizing antituljercle serum was effective, oecause it was
antagonistic to the tubercle toxins, which were, in a large
measure, responsible for such lesions. Mixed infections in
tuberculosis offered the greatest complexity in the dyspepsia
accompanying them.
Excellent Results In the Treatment of Disease, Espe-
cially Tuberculosis, by the Use of the Ultra- Violet Ray.—
Albert E. Steknb (Indianapolis, Ind.). The nude body
was exposed to intense light from powerful voltaic arcs, and in
addition free ozone was developed from a special ozonating
apparatus. In local applications only one pole was used, and
this was connected with vacuum tubes devised for different
portions of the body to be treated. His conclusions are: 1.
Actinic rays are chemic in their quality, but of small caloric
value. 2. They exist mainly in the ultra-violet zone of the
spectrum. 3. Actinic rays derived from high power electric
lights are similar or Identical to thoseof solar origin. 4. Their
use is as rational as sunlight itself. 5. Their value lies in their
decomposing, but at tlie same time reconstructive, molecular
action upon the body tissues, mainly the blood elements. 6.
Their activity is enhanced by the generation of ozone in free
and na.scent form. 7. Their ultimate effect is one of oxidation,
and consequently they increase the metabolic changes, thereby
augmenting the natural processes of regeneration within the
system. «. Their germicidal action is espe<!ially pronounced,
on account of the fact that germs can exist in tne presence of
free or nascent oxygen in either bianatoniic or trianatomio
form.
648 AUItUOAS Medioinx]
SOCIETY REPORTS
(OOTOBEB 25, 1802
Sanatorium Treatment of Pulmonary Tuberculosis
and How It May be Carried Out at Home.— Robert h'
Babcock (Chicago). The open air treatment was obtained by
the patient being exposed on a balcony or in properly con-
structed shutters where he was protected from cold winds and
elements, and kept in the open air sometimes even when the
temperature was as low as 13° below zero. Among the condi-
tions which indicated rest in the open air were progressive loss
of weight and cardiac asthenia. When patients had passed out
or the stage in which these conditions existed, were convalesc-
ing, then exercise was permitted, the exercise being carefully
determined by the medical attendant. The nourishment of the
patient was carefully selected, not only with reference to a
proper proportion of proteids which should be large, but also
include the proper amount of carbohydrates. Milk, raw eggs
meat, and its varieties, poultry and fish, etc., were the articles
on which reliance was chiefly placed. Hydrotherapy was
applied for the purpose of stimulating nutrition, toning up the
circulatory system, and overcoming the hypersensitlveness of
the skin which existed in so many tuberculous patients. Every
patient should be controlled from the time he got up in the
morning until he went to bed, and this was done by the super-
vision of a skilful medical attendant and nurses. The temper-
ature was carefully recorded, and even the recreations in which
they indulged were carefully selected by the medical attendants
with a view to the prevention of excitement, for even mental
emotion was deleterious to many of these patients.
Tent Life in the Treatment of Tuberculosis.— A. Mans-
field Holmes (Denver, Colo.) said tent life was the most
important means of securing the advantages of pure air and
sunshine. Those who had had no experience with tent life
invariably entertained an exaggerated idea of its dangers and
inconveniences. A short experience soon dispelled this fear,
and patients were with difficulty induced to return to an indoor
life. It increased the appetite, improved nutrition, diminished
cough, nightsweats ceased, sleep .was improved, weight in-
creased, fever decreased, and the tendency to take cold was
diminished.
Surgical Section.
.^PP*""***""^ *"•■ Cancer of the Mouth and Neck:
Address In Surgery.— Geo. W. Crile (Cleveland, Ohio) sum-
marized as follows : In the past three decades there has been a
continuous decrease in the operative mortality, and with a
single exception of the brachiogenic cancers, even a more note-
'^1°''^^ increase in the percentage of cures has been accom-
plished. Especially in the last decade there has been evidence
ot more confidence in operations as indicated by an increased
number ot cases submitted early. The supreme importance of
early diagnosis and early and radical operation is becoming
widely recognized. The same may be said of the socalled pre-
cancer stage, especially of the tongue. Except in cancer of the
upper jaw, the disease is now regarded as involving the regional
lymphatic system. The disease may be found in the lymphatic
"^Ifu® 1^5 lymphatic glands. It rarely extends to other parts
01 the body. Physiologic and clinical evidence show that sever-
ing the thoracic duct causes but little disturbance, owing to its
free anastomosis; that the effect of resection of the internal
jugular vein IS practically to7,- that unilateral resection of the
vagus does not alter the heart's action, the respiration, nor the
digestion, but produces a permanent hoarseness only. That
division of the superior laryngeal causes anesthesia of a part of
the larynx, but pneumonia is improbable ; that division of the
inferior laryngeal causes paralysis of the corresponding vocal
r? J- • • interference with respiration is not marked; that
the division of the spinal accessory has but slight effect
on account of the double nerve supply to the sterno-mastoid
and the synergistic action of other muscles; that the
division of the hypoglossal causes temporary interference
with speech and swallowing, but compensation occurs:
that the submaxillary and salivary glands may be removed
without symptoms; that the removal of the sternomas-
*J^ »u™"**''® '^ °°*^ followed by torticollis, etc., on account
ot the synergistic action of other muscles. The complete
removal of the lymphatic system of one side does not produce
pseudoelephantlasis of the face and head. Permanent closure
1 ^ external carotid has an operative mortality of 1% to 20%,
ttue to thrombosis and embolism. Permanent closure of the
common carotid or internal carotid is attended by an operative
P'iv5"'^ °' about 30%, but in the cancer period of life from 20
to 30% of cerebral complications follow, about .50% of which
prove fatal. Temporary closure of the carotid by means of a
special clamp, as shown in the writer's 43 cases, in which
neither death nor cerebral complications occurred, is both
eflicient and safe. These physiological and clinical data lead
to out two objective points in unilateral operations for cancer of
the mouth or neck, namely, complete removal of the disease
and preservation of the blood supply to the brain. If neces-
sary, sacrifice every other structure between the skin and the
place of the deep muscles of the neck. Loss of blood is the
greatest operative difficulty and danger. If hemorrhage is
likely to be considerable, the common carotid should be closed
auring the operation. In the mouth cases, an anesthetic may
be administered through rubber tubes passed through the
nostrils to the level of the epiglottis, with the tongue well
arawn forward. The pharynx may then be packed with gauze, so
^iSi f?','"l,'if''"'^'^*"'^""''°''ie lower larynx effectively, and
prevent blood from entering the pulmonary tract. The dissec-
tion should be made on the same plan and as thoroughly as in
the radical operation for cancer of the breast. The greater ease
and certainty with which diagnosis may be early made in this
region, the rarity of extension of the disease beyond the glands
of the neck, should enable the surgeon to obtain even better
results here than in cancer of the breast. The hope of the
patient lies in early diagnosis, early operation and a logical
technic.
Cancer of the Rectum. — Emerson M. Sutton (Peoria,
111.) reported cases of cancer of the posterior vaginal wall pene-
trating to the submucosa of the rectum, with ffiirous but non-
malignant infiltration around the rectum producing stricture.
He operated by the sacral route, resorting to the von Volk-
mann-Rose incision. He resected the vagina, rectum and one-
half of the cervix, anchoring the healthy end of the sigmoid to
the gluteal incision side of the wound.
Treatment of Extensive Rectal Strictures.— Emil Rice
(Chicago) pointed out the difficulties in treating these strio-
tures, referring to septic conditions, anatomic changes, and the
danger of recurrence. He discussed anastomosis after resec-
tion, end-to-end anastomosis, anastomosis without resection,
side-to-side anastomosis after exclusion, and end-to-side anasto-
mosis. He detailed his first case operated upon by the latter
method, saying that the patient was well over live years after
operation.
Ureteral Catheterism : Its Value in Male and Female.
— Bransford Lewis (St. Louis, Mo.) said ureteral catheterism
in connection with the cystoscope was for diagnosis and for
treatment. Cases reported showed that ureteral catheterism,
in both male and female, had been reduced to a practical pro-
cedure. With the author's cystoscope the operator was enabled
to look directly on the field. Air was used for inflating the
bladder. One or both ureters may be catheterized at the same
sitting. The operation was performed under local anesthesia.
Case I showed the falsity of an x-ray diagnosis of stone in the
ureter. Case II showed chronic unilateral pyelitis and cystitis.
Irrigations of the pelvis resulted in a cure. Case III was one
of tuberculous inflainmation of the bladder and kidneys, which
improved under irrigations. Case IV, hemorrhagic cystitis and
bilateral pyelonephritis ; under irrigations of renal pelvis was
much improved.
The Mechanics of Intubation. — B. F. Gillmor (Creston,
la.) exhibited drawings and x-ray plates. He emphasized the
importance of acquiring manual familiarity with instruments,
the means by which this may be acquired, and then alluded to
the problems of intubation and the difficulties of extubation.
Laminectomy for Fracture-dislocation of the Fourth
and Fifth Cervical Vertebras. — Joseph Rilus Eastman
(Indianapolis, Ind.) states that in the case reported laminec-
tomy was followed by improvement of motor and sensory con-
ditions, but was unsuccessful so far as saving the life of the
patient was concerned. Death occurred on the nineteenth day.
Laminectomy for fracture of dislocation should be made early,
the earlier the better. The longer pressure existed, the more
extensive the degeneration of the cord. Still hope need not be
entirely abandoned in old cases, for laminectomy had relieved
many such even after months had elapsed since the injury was
received. Laminectomy per ,<re was not dangerous. It repre-
sented the surest method of diagnosis of Iracture-dislocation,
and the most rational and efficient means of relief.
Extrinsic Traumatisms of the Spine ; their Diagnosis,
Pathology and Treatment.— Thomas H. Manley (New
York). In the present study of all lesions of a traumatic
character sustained by the rachidian structures or the medulla
spinalis not followed by clinical manifestations of central com-
plication will be included under the term extrinsic. These
were designated (1) contusions, (2) sprains, (3) hemorrhage,
(4) fractures, (5) diastasis and luxation, (6) structural and vis-
ceral complications. The most frequent injuries were external
to the spinal cord. They were rarely of such a character as to
seriously impair function, although deformity and impairment
of strength occasionally followed. No serious effort has yet
been made by an American author to classify the pathology to
elucidate the symptoms or to establish the ditt'erential diagnosis
in this important group of traumatisms.
Spinal Concussion. — Carl E. Black (Jacksonville, 111.)
called attention to the loose way in which the term was
used. The best dictionaries were quoted to show that the word
concussion is misused, and should only apply to the manner in
which the injury was received. A great deal of misunder-
standing had arisen from the attempt of various authors to use
the word to describe a distinct disorder. The various authors
on surgery were quoted to show that there was a misunder-
standing among writers as to the scope of the term concussion.
Wm. Thorburn, of Manchester, Eng., made the only rational
effort which had been made to classify these disorders. Minute
or capillary hemorrhage was the basis of most, if not all, of
these cases, and gave the following classification of injuries
produced by concussion of the spine: Primary effects: (1)
sprains; (2) contusion of the spinal cord; (3) minute hemor-
rhage into or around the cord. Secondary effects or complica-
tions: (1) shock or collapse; (2) acute hysteria; (3) nenrast
thenia; (4) chronic hysteria.
Spinal Cord Injury ; Socalled Spinal Concussion of the
Cord.— Frank Parsons Norbury (Jacksonville, 111.) stated
that a scientific interpretation of concussion of the cord socalled
had not yet been attained. The lesion was doubtless a disturb-
OCTOBKK 25, 19021
COKRESPONDENCE
iAMEKICAN MEDICIKa 649
ance of the circulation due to injury to the bloodvessels and
lymphatics. Intramedullary hemorrhage was thought by the
author to be the immediate lesion. Most nurologists were
inclined to the view that structural changes were probable, and
that the degenerative and vascular changes following injury to
the cord were indicated in the symptomatology of the disease.
Facts were accumulating which made this view both tenable
and reasonable. While many injuries to the cord showed no
external evidences, the symptoms which followed indicated
structural changes occurring within the substance of the cord,
and irritation of the cord roots by meningeal involvement.
The symptoms in pronounced cases of hemorrhage were com-
pared to the more obscure conditions called concussion, show-
ing that hemorrhage was common in traumatism of the cord ;
that similarity of sensory and vasomotor changes existed.
[To be concluded.]
THE NEW YORK STATE MEDICAL ASSOCIATION.
Nineteenth Annual Meeting, October 20, 21, 22 and 23, 1902.
[Specially reported for American Medicine.]
Alvin A. Hubbell, Buffalo, presided. A meeting of the
Council was held in the morning and the afternoon session was
devoted to the routine work of the Association, including the
election of new offlcers, as follows: President, Frederick
Holme Wiggin, New York; vice-president, W.H.Thornton,
Buffalo ; secretary, Guy D. Lombard, New York ; treasurer,
E. H. Squibb, Brooklyn; chairman of the committee of
arrangements, S. A. Brown, New York; chairman of the com-
mittee on legislation, E. Eliot Harris ; chairman of the com-
mittee on public health, .T. Scott Ward; chairman of the com-
mittee on publications, Emil Mayer, New York; chairman of
the committee on nominations, Charles E. Quimby ; chairman
of the library committee, John Shrady, New York ; delegates
to the American Medical Association, Jos. D. Bryant, New
York; Elias Lester, Seneca Falls; alternates, Parker Syms,
New York, and L. D. Farnham, Binghamton.
In the course of his Introductory remarks the presiding
officer referred to the approaches which had been made by the
Medical Society of New York looking towards recognition by
the Association. Committees had been appointed and confer-
ences held and there was the possibility of the two bodies be-
coming amalgamated in the near future.
The treasurer's report indicated that while the income for
the past year had been exceeded by the expenditures, the finances
of the Association were in a healthy condition.
SECOND DAY.
The morning session opened with an address of welcome
from the Chairman of the Committeeon Arrrangements, Irving
S. Haynes.
The Principles Involved in the Repair of liacerations
of the Pelvic Floor.— J. H. Btirtknshaw (New York) said
that while it was formerly taught that on the integrity of the
socalled perineal body depends the maintenance of the normal
positions of the organs of the pelvis, it is now generally con-
ceded that its function is solely to give needed support to the
curve of the rectum during the expression of intraabdominal
force. Rupture of this body may occur even through the anal
sphincter, yet pelvic equilibrium will not be disturbed if the
muscles composing the pelvic floor remain intact. He laid
particular stress on the important role of the levator ani
muscle and its fa.scia in imparting strength to the pelvic floor
and preventing prolapse. He questioned if the majority of mod-
ern operations of perineorrhaphy and colpoperineorrhaphy
actually restore the pelvic floor to its normal condition. As
the denudation extends only through the mucous membrane of
the vaginal wall, the muscles areonly backed up against them-
selves, in which position they serve to reduce the lumen of the
canal, partially close the orifice, and restore the curves of the
vagina and rectum. While an operation of this kind appar-
ently fulfils all indications here as elsewhere in the body, if a
muscular rent is to be closed the edges of the muscle must be
freshened and closely approximated by sutures. Many oper-
ators have appreciated this defect in posterior-wall plastic
surgery and have evolved special methods for the suture of
these superficially denuded areas, but in each case the object is
not attained because tlie underlying muscles are not directly
approximated. While Emmet is the pioneer in correctly attrib-
uting to the pelvic floor its proper function, the wellknown
operation known by his name does not accomplish all that its
author claims for it, because the levator and its fasciic are
bound to retract so soon as the retaining sutures are removed.
Conclusions: 1. The role of the pelvic floor in sustaining
the pelvic viscera being acknowledged, a laceration of the
muscles and fascia composing the most important section of
this floor should be repaired in order to restore the natural
equilibrium of the pelvis. 2. While a majority of the plastic
operations on the vaginal wall restore the natural curves of the
vagina and rectum and reduce the size of the vaginal outlet, to
restore the pelvic floor to a normal condition approximation
and suturing of the edges of the levator ani muscle and Its
fascia is imperative.
I To be concluded.]
CLINICAL NOTES AND CORRESPONDENCE
[Communications are Invited for this Department. The Editor 19
not responsible for the views advanced by any contributor.)
REAL TURKISH BATHS.
BY
JOHN S. PEREKHAN, M.D.,
of Chicago, 111.
Attending Gynecologist, Lakeside Hospital ; Lecturer on Anatomy
and Physiology, I,akeslde Hospital Training School.
To the Editor of American Medicine : — The Interesting note
by Dr. H. C. Wood, " On the Socalled Turkish Bath," published
in American Medicine of May 3, 1902, prompted me to send you
this note on the real Turkish baths as administered in Turkey.
The following description by a native Armenian is the best I
have seen and fully corresponds with my personal experience
in several cities in Turkey, including Constantinople. The so-
called Turkish baths as given in the United States, especially
in Chicago, with their excessively high temperature 170° F. to
200° F., are misnamed. To some people they are exceedingly
injurious. The'purpose of a bath is to warm, to relax, to induce
a gentle continuous and prolonged perspiration ; but the parch-
ing temperature of these baths in the oven-like room will
immediately dry up the tissue and rob the blood of its diluent
fluid by sudden' and excessive perspiration, and instead of soft-
ening the callous epidermis that it may be peeled off' by gentle
rubbing, hardens and dries it; then ignorantly you are con-
ducted to the "cooling" room and washed with soap and
water to complete the closure of the pores of the skin more
effectively.
The operations of the real Turkish bath consist in : (1) The
seasoning of the body ; (2) the manipulations of the muscles ;
(3) the peeling of the epidermis; (4) the washing or soaping ;
(5) the bed of repose.
A Turkish bath contains essentially three apartments:
Mustaby, open to the outer air ; inner hall with moderate heat,
and inner hall or the thermsB proper. On first entering a
Turkish bath you find yourself in a large hall covered with a
high dome. In the middle is a fountain about six feet high
with a basin around it. This basin is often surrounded with
flowers and plants, and by it stands the Indispensable coffee-pot
and the water pipes (Narkeely). You are taken to a couch to
undress. An attendant stands by to whom you hand your
clothes, which he folds, piles on a large napkin and ties care-
fully in a bundle. Two large soft Brussa towels are brought,
one tied around the body from the loins down to a little below
the knees. The second is thrown over the shoulders like a
lady's scarf, and sometimes a third one much smaller in size is
tied around the head like a turban.
Thus attired, you step down from the platform and put your
feet in wooden pattens— nalun— to keep your feet off the hot
floors and dirty water running in the passages. Attended by
two men, one on each side, you enter the region of steam. This
apartment is small and dark, the temperature is moderate and
the moisture slight.
Your mattress and cushion are placed against the marble wall
and you are served with coffee and pipes. The object sought in
this apartment is a natural and gentle flow of perspiration. In
fact, this is the social room of the bath ; here you calm your
senses, and shut iu from the external world you sit here, make
acquaintances, talk over town or village affairs, discuss politics,
etc. At certain intervals an attendant chafes your feet and taps
your neck, chest and shoulders to find out whether you are
ready for the second process.
At the proper time the bath man (tallack) of the Turks, the
tractator of the Romans, takes you by the arm, while, as before,
you wear your wooden pattens, and conducts you to the adytum,
a space such as the center dome of a cathedral, filled, not with
heavy steam, but with gauzy and mottled vapor through which
tinted rays of light from the stained glasses in the vault try to
reach the pavement. Here all the towels are taken away save a
small one around the loins. There is no distinction here
between bathers an<i attendants. The bathers are stretched on
marble slabs, and attendants work, manipulating the muscles.
Like the rest, you are stretched on a marble slab with a soft
650 /UCKBIOAIT MsStOISTK
OOERESPONDENCE
[OOTOBKB 25, 1902
towel as a mattress and another for a pillow. One, sometimes
two attendants commence manipulating your muscles.
The tractator or tallack kneels at your side and, bending
over, gently presses your chest, arms and legs, passing from
part to part, following the line of muscle " with anatomic
thumb." He turns you over in all kinds of attitudes in order
to correctly follow the line of muscle until your entire body is
operated upon. When he is satisfied that the state of your body
is ready for the peeling operation he puts on his right hand a
soft camel's-hair mitten. You are now seated ; he stands over
you and you bend down to him ; he commences from the nape
of your neck in long sweeps down your back until he has
started the skin ; he coaxes it into rolls, keeping them in and up
until within his hand they gather volume and length. He then
successively strikes and brushes them away ; you are turned
down, over and sidewise until the gloved hand has come in
contact with every inch of your body. When he gets through,
the marble slab upon which you are seated is covered with dead
epidermis.
Hitherto neither soap nor water has touched your body.
Strange as it may appear, yet it is a fact that if soap touches the
body the dead epidermis will not come off. The only explana-
tion that can be given is that the alkali of the soap combines
with the oily matter of the skin so that the epidermis loses the
consistency it must have to be detached by rolling.
Now you are conducted to a marble basin ; there are cocks
for hot and cold water, and water is obtained the temperature
desired. Your head is thoroughly shampooed ; if you desire
soap on your body, they bring a wooden bowl with castile soap
and a sort of soft powder puff, the " liff ;" by rubbing this with
the soap the lathering is done gently. The bowl is left by you
to complete the operation. A small but fancy wooden jar is
brought, which contains ot^Turkish, dewa-Arabic, the terra
media of the Romans. The preparation is composed of orpi-
ment and quicklime, and its use has been as old as the batli
itself. It is not corrosive unless left on the parts too long, and
its effect is certain and magical ; it is a depilatory.
Now ^ou throw away the wet clothes, and clothed with soft
towels as when you entered you are led as before to a cooler
room, where you are thoroughly dried, the towels are changed
and you are conducted to the " couch of repose."
As soon as you are comfortably seated the attendants appear
with coffee and pipes or cigarets, also sherbets, fruits and edi-
bles, as desired. The Turks have given up the cold immerson
of the Romans, but retain the practice of throwing cold water
upon the feet. The nails of the hands and feet are dextrously
pared with a peculiar oblique chisel by an attendant, and any
callosities that may be found on the feet are carefully rubbed
down. Your towels are changed twice and you are gently
patted as before.
Your body has come forth shining like alabaster, fragrant
as the cistus, slick as satin and soft as velvet.
The philosophy of the real Turkish bath is very simple.
Nature intends us to get rid of our waste matter through the
skin, and when we clog it up the natural and inevitable conse-
quence is congestion of the liver, intestines and kidneys. There
is no doubt that a real Turkish bath is the best specific for a
vitiated condition of the blood arising from a languid condition
of the skin and circulation, or any specfic poison lurking
within it,
TRUE CHOLERA MORBUS WITHOUT PAIN.
GRANT G. SPEER, M.D.,
of Manistee, Mich.
Attending Physician and Surgeon to Mercy Hospital.
Acute indigestion, ranging all the way from a mild distress
in the stomach or bowels, passing away in a few moments, to a
rapid, intense attack accompanied by vomiting and purging so
severe in its nature as to resemble true cholera, is one of the most
common complaints during the season of fresh fruits and hot
weather, and is apt to occur at any season of the year when con-
taminated food or water is ingested. But the symptom most
common in these cases and one we invariably expect to meet is
pain ranging in intensity with the severity of the attack. A
case in which this almost constant symptom is absent might
under certain conditions be misleading, valuable time might be
lost for necessary treatment and the patient's life jeopardized.
With this apology for so simple a subject, the following case is
presented :
Mrs. C. H., aged 48, the mother of a large family, pa.st the
menopause but experiencing periodic headaches that accompa-
nied menstruation, is a moderately fleshy woman, strong, hard-
working and usually in excellent health. On Thursday, July 24,
slie did a large washing, and afterward ate heartily of cherries in
the raw state. Friday she did a heavy day's work and felt
nothing unusual except that she was much bloated across the
abdomen. At 9 p.m., while visiting a friend She felt ill, and
excusing herself had a large watery stool. She stayed with this
friend an hour longer, and then walked a short distance. At 10
o'clock she was barely able to mount the stairs to her room and
had to be helped to bed. She vomited a single mouthful of
slime, and on being helped to the vessel for another movement
she fainted and became covered with cold sweat. Faint spells and
continual drowsiness followed this attack, until I was called at
about 12.45 a.m. The patient was exceedingly pale and haggard,
the cheeks flabby and the eyes dull ; the body surface was cold
and covered with moisture. The pulse was irritable, irregular
and intermittent, with a rate as high as 27 to the quarter minute,
but at times slow and measured, threatening to stop. The
drowsiness continued, leaving her at times only half-conscious,
and when the pulse was at its worst the paleness was extreme
and there was a great desire to throw the arms above the head
and yawn frequently. There was a feeling of intense illness
but not a particle of pain throughout this attack. The collapse
was very deep and for a time death threatened.
A hypodermic injection of nitroglycerin, gr. ^q, was
administered with no relief, and it was followed by a hypoder-
mic injection of strych. nitrate, gr. ^. Whisky and chloranodyne
was given by mouth, and heat applied to the chest, abdomen
and limbs. By accident her side was burned with a hot plate.
This did much to rouse her. Immediately following a dose of
castor oil in lemon juice and whisky she vomited a large
amount of chewed food, large hard pieces of boiled potato, and
cherry stones. At the same time there was a large, thin, watery
stool. Copious draughts of hot water were administered, and
as the stomach became settled the chloranodyne and castor oil
were repeated. She rested well the remainder of the night,- and
in the morning was resting comfortably with a pulse of 94 and
temperature normal. The bloating of the abdomen had nearly
disappeared.
AN ARGUMENT FOR TOTAL ABSTINENCE.
C. J. DOUGLAS, M.D.,
of Boston.
To the Editor of American Medicine .—Apropos of your
discussion of temperance instruction in your issue of Septem-
ber 13, 1 would suggest that the most effective instruction would
be a frank statement of the exact facts. All men who drink do
not become drunkards. Those who are thus unfortunate are
not so because they are weak in will or morals, for men of the
highest character have become inebriates. A man is a drunk-
ard because he has a nervous system that is peculiarly suscep-
tible to the poisonous qualities of alcohol. No young man,
when he begins the moderate use of alcoholic beverages, knows
whether or not he belongs to the class that can drink without
danger. But he will certainly become a drunkard, regardless
of his mental or moral character, if he has a nervous system
that is easily poisoned by alcohol. He can find this out only
by experiment, and after the experiment it is likely to be
too late to avoid the disastrous results. Hence the disease
theory of alcoholism furnishes a sound basis for a logical argu-
ment for total abstinence. It is the only theory, I believe, tliat
explains the apparently contradictory facts relating to inebriety.
The argument is this : While some men can drink moderately
without apparent injury, in others, with equal mental endow-
ments, the disease of alcoholism is produced— a form of drug
addiction which some of the strongest wills have striven in
vain to overcome. Hence strength of character and will are no
safeguards against the disastrous results of inebriety any more
than they would be against smallpox. Strict avoidance of alco-
holic beverages is the only logical conclusion, if grave dangers
are to be avoided. Whether alcohol is a food or a poison and
whether or not it is a useful therapeutic agent are questions
which seem to have but slight bearing on the issue of total
abstinence.
October 25, 1902]
REPOET OF TWO CASES OF GASTRECTOMY
lAKERIC&S MEOICINB 651
ORIGINAL ARTICLES
KEPORT OF TWO CASES OF GASTRECTOMY, WITH
REMARKS.^
ALBERT VANDER VEER,
of Albany, N. Y.
M.D.,
At one of the meetings of the Medical Society of the
County of Albany, I think during the winter of 1885, in
presenting a jiumber of pathologic specimens, I exhib-
ited a stomach that I had removed postmortem, a case
of carcinoma, and in my remarks I said to the gentle-
men present that this organ could have been removed
with probable success.
In all my abdominal work from that time on I did
not meet another case tliat offered any encouragement
in doing this operation until the following :
Case I.— Mrs. B. S., of Albany, N. Y., aged 42, a housewife
by occupation. She entered the Albany Hospital, February
12, 1900.
Present Illness. — More than one year ago she noticed that
when taking solid food she would vomit 5 or 10 minutes after-
ward. Liquids did not distress her, nor did she have any pain.
During the past year .she has not been able to take solid food
of any kind. Once in a great while she would vomit, even if
strictly on a liquid diet— never any great amount. She has
lived mostly on milk and has lost considerable in weight. For
about two months she has noticed a bunch in her left side, which
has gradually increased in size. On physical examination this
can easily be made out, just above the umbilicus and a little to
the left of the median line— a tumor, lobulated, the size of her
•fist, with .slight tenderness on palpation.
Past History.— yiarried at 21 years and has had six children,
four of whom are living; no miscarriages; menstruation
always regular.
Family History.— Patient has four brothers and four sisters
alive and well. No history of malignancy or tuberculosis. She
remained in the hospital until operation, vomiting more or less
continuously. A diagnosis was made of carcinoma of the
stomach, probably involving the omentum and transverse
colon. The condition was thoroughly explained to the husband
and patient and their consent readily obtained for an explora-
tory incision with the understanding that if the diseased mass
could be succe.ssfully removed we would go on with the opera-
tion. The patient, while in the hospital, had been given one
grain of calomel in divided doses, followed by two A. S. <fe B.
pills, apparently producing a good movement of the bowels.
The intestinal tract was thoroughly emptied by means of rectal
enemas. The pulse previous to the operation did not go above
100 at any time. Respiration was slightly increased and tem-
perature normal. She slept very well, although she was some-
what restless the night previous to the operation.
Operr(<«OM.— February 20, 1900; gastrectomy. A median
incision was made Vjetween the ensiform cartilage and umbili-
cus. Upon opening the abdomen a hard mass occupying the
greater curvature and cardiac end of the stomach was found.
There were a few adhesions, but the neighboring glands were
not infiltrated. The omentum was ligated in sections and the
stomach loosened from all of its attachments. The duodenum
and pyloric end of the stomach were grasped with forceps and
section made well below the tumor, the stomach being grad-
ually worked out of its bed up to the cardiac end. The cardiac
end of the esophagus was grasped, the stomach removed and the
duodenum joined to the end of the esophagus by means of a
medium-sized Murphy button. In the entire operation very
little blood was lost. There was considerable tension observed
at the time, the disease extending so eloile to the diaphragm,
and the esophagus was loosened by lateral incisions. The
abdominal wound was close<l by silkwormgut sutures and
standard dressings applied. The anesthetic was taken fairly
well, the operation lasting !{ hours.
The patient returned from the operating-room with a cold,
uncomfortable perspiration over the surface of the body, which
was relieved by brisk rubbing and wrapping up in flannel
blankets; pulse 126. She complained of a great deal of diffi-
culty in breathing ; could not take a full inspiration, at times
gasping for breath, and had a great desire to sit up. Mouth
very dry. Hot bottles applied to extremities.
At 3 p.m., pulse 114; 4 p.m., pulse 108; mouth occasionally
cleansed with hot water; patient apparently reacting very well,
much warmer and a better pulse of good volume ; 5 p.m., was
turne<l on her side and a pillow firmly applied to back ; com-
plained of pain through abdomen; 6 p.m., pulse 116; rectal
enema well retained: 6..'«) p.m., pul.se 126; A grain of morphia
given hypodermically; 7 p.m., pain much less severe; patient
said she felt better ; 8 p.m., pulse 124, temperatvire 98.8°, respi-
' K«ad at the meeting of the American Association of Obstetricians
and (iynecologlsta, Washington, D. C, September 16-18, 1902.
rations 30; 9 p.m., ^5 grain strychnia, continued every three
hours, rectal stimulating enemas every four hours, hypoder-
mically; has slept a few minutes and feels quite comfortable;
9.30 p.m., sleeping ; 10.10 p.m., rectal enema well retained ; pulse
128; 10.45 p.m., pulse 118, good volume; very quiet; not sleep-
ing; 11 p.m., voided 4 ounces of urine; position changed more
to side; 11.30 p.m., complained of sharp pain in right side of
abdomen ; position changed by great desire of patient and she
was made much more comfortable ; midnight, temperature 100°,
pulse 124, respirations 26; perspiring very freely; hot water
bottles continued to feet.
February 21 : 12.30 a.m., sleeping, pulse good ; 1 a.m., slept
15 minutes ; belching a little gas, no nourishment allowed, but
mouth rinsed frequently; 1.10 a.m., after sleeping 10 minutes,
awoke with a start, giving herself quite a severe movement of
the body, pulse soon after became weaker and rapid — about 140;
1.20 a.m., hypodermic injection of brandy, repeated in a few
minutes ; legs and arms rubbed with warm alcohol ; skin cold
and unpleasant to the touch ; 1.45 a.m., dressings changed and
wound found in good condition. From this time on the patient
grew more restless, pulse much weaker, respirations increased
to 36, very labored, gasping and sighing for breath, and she died
at 3.30 a.m.
Upon opening the site of the incision it was dis-
covered that the attachment between the duodenum and
esophagus liad given way, that the upper segment of
the Murphy button had loosened in its attachment to
the esophagus, allowing what little fluid contents were
present to escape into the peritoneal cavity.
I cannot conceive of a more embarrassing position
than in doing an operation of this kind, as it becomes
very difficult to make attachments to the under surface
of the diaphragm only.
Case II. — Transferred from the medical side by Drs. Ward
and Neuman. Mr. H. M., aged 55, native of Canada; black-
smith by occupation; r&sidence Turner's Falls, Mass. He
entered Albany Hospital January 1, 1902. Diagnosis, sarcoma
of the stomach. Operation, gastrectomy. Result, recovery.
Family History.— Mother died, aged 70, of heavy cold ; the
father, at 63, of pneumonia; one sister and two brothers are
living and well. One brother died at 28, of inflammation of the
bowels; one brother at 35 from disease contracted from a horse,
possibly actinomycosis.
Previous History.— The patient had the ordinary diseases of
childhood; pleurisy in 1873. Has had occasional attacks of
vomiting since 1877 ; hernia in 1883, for which patient has since
worn a truss. He has used tobacco for 40 years, chews it and
smokes a pipe. Has used alcohol for about 20 years, in the
form of beer and whisky. Is a hearty eater. No history of
specific trouble. Bowels always regular.
Present Illness. — Began in October, 1900, with pain in epi-
gastrium, independent of food, and especially marked between
4 and 5 o'clock p.m., with vomiting any time during the day,
which generally relieved pain. Quite diffuse burning sensation
after vomiting. Considerable eructation of gas occurred. Appe-
tite very poor since onset of disease. Vomitus had a sour,
bitter, disagreeable taste. Bowels constipated ; no bladder
symptoms. Chilly sensation occasionally at night. No cough,
shortness of breath, nor night-sweats. Has lost about 44 pounds
since beginning of the trouble and much strength. Has been
spitting some blood since having pleurisy, more especially
since present trouble came on. Vision and hearing impaired ;
general sensations normal.
Physical Examination.— J&nuary 1, 1900. The patient is 5
feet 10 inches, and weighs 148 pounds; is well developed ; lies on
right side ; expression cheerful ; skin and mucous membranes
rather pale; face slightly flushed; tongue slightly fissured;
pupils medium-sized, equal and react to light and accommoda-
tion; pulseSO, regular and full; arteries atheromatous.
Thorax. — Normal in shape, symmetric, clavicles somewhat
prominent, costal angle wide, expansion fairly good. Palpation
and percussion negative. Auscultation: Breathing harsh at
apices, with prolonged expiration.
Heart.— Dalness begins at upper border of fourth rib,
limited externally by nipple line and internally by left sternal
border. First sound at apex extremely loud, and second aortic
sound exaggerated.
Abdomen. — Oval, symmetric, respiratory movements trans-
mitted ; percussion note tympanitic; tenderness in epigas-
trium ; muscular resistance all over the upper half of the abdo-
men. Reflexes normal.
The case was explained to the patient, and the operation of
gastrointestinal anastomosis suggesteti, believing that this was
all that could be done. The patient consented readily, being
desirous of obtaining relief, oven temporary, if possible.
Operation. — .lanuary 4, 1902, at 11 o'clock a.m. Ether and
A. C. E. were administered and a median incision four inches
In length was made. The entire stomach (which was quite
movable), with the exception of about two inches at the cardiac
extremity, was found involved, as were also the surrounding
glands. It seemed possible to do a gastrectomy, which I pro-
ceeded with.
The mesentery was tied off with fine silk. Stomach clampa
1
652 AMEBIOAN MkOICINBj
ARTHRITIS DEFORMANS
[OCTOBER 25, 1802
were applied, and after thoroughly walling off the surrounding
parts with tampons, the stomach was excised at about two
Inches anteriorly, and three inches posteriorly, from the car-
diac end and just below the pylorus. The posterior and all
Involved glands were thoroughly removed, the excised ends
brought together and sutured with silk sutures, and all raw
edges invaginated by peritoneum. The abdominal wound was
closed with interrupted silkwormgut sutures, and one vaginal
iodoform gauze drain left in for drainage. Iodoform gauze and
standard dressing were applied. Operation lasted U hours.
The anesthetic was well taken.
After the operation the patient at times was restless and weak ;
the highest temperature was 102°, pulse 126, but he responded
well to stimulating enemas, and went on to uneventful, com-
plete recovery, the only complication being some delirium for
a short time, after the tenth day, and a stitch-hole abscess. The
after-treatment of this patient consisted in giving nothing by
the mouth for 48 hours, and several saline injections. He was
allowed to rinse out his mouth with hot water occasionally.
Stimulating rectal enemas were given every four hours, patient
retaining same very nicely. His thirst was quite distressing
for a time. At the end of 48 hours the dressings were removed
and found somewhat stained from drainage from the peritoneal
cavity. Part of the iodoform gauze drainage was removed, the
balance at the end of the fifth day. Aside from this no unusual
treatment was called for.
Pathologic report was as follows : Anatomic diagnosis, car-
cinoma of stomach, in region of pylorus.
Microscopic diagnosis, round-celled sarcoma of stomach,
with metastases to neighboring lymph glands.
The patient returned home on the twenty-fourth day,
and the following are from Dr. Houle, his attending
physician :
P'bbruary 3, 1902.
Mr. M. arrived home .lanuary 30, and although a little
fatigued, yet he bore the journey remarkably well. I dressed
the abdominal wound on the evening of his arrival and found
it in very good condition. His appetite is very good indeed,
and he would eat more if I dared let him. Have seen him every
day since, and his pulse and temperature have been normal at
each visit. He is in good spirits and feels confident that many
more will be sent " ad patres" before him. His mental condi-
tion was somewhat disturbed Thursday and Friday morning,
hut today it is much better. Will advise you from time to
time about his progress.
April 12, 1902.
I told you Mr. M. had a stitch-abscess. This healed, another
formed near it, and yesterday I located a buried suture, situ-
ated in the center of the abdominal incision, just to the right of
the median line. There has been more or less oozing of sero-
purulent matter from this location and it is annoying my
patient, otherwise he is the picture of health and weighs 165
pounds. I did not care to remove suture without getting your
opinion in the matter.
An answer was sent to remove the suture at once.
The patient was exhibited at the meeting of the
American Surgical Association, Albany, N. Y., June 4,
1902, and presented the following history : Appetite
excellent ; bowels in good condition ; wound thoroughly
healed ; is able to eat any kind of food, and in increased
quantity. Mr. M. has gained over 30 pounds in weight.
On September 13, 1902, a letter received from his
physician states that on August 1 Mr. M. purchased a
blacksmith shop, is able to work at the anvil, and is
apparently in full health.
REMARKS.
The rarity of this operation impresses itself upon one
who is doing much abdominal surgery. Very few ca.ses
present in which the operation of gastrectomy can be
performed. Partial resections are not infrequent, while
gastrointestinal anastomasis is by no means uncommon
and is a very satisfactory operation.
My first ca.se presented the most serious complications
in regard to the disease extending up to and implicating
the diaphragm, and were I to operate in another similar
case I would certainly close the duodenum, bring up a
fold of the jejunum and attach it to the under surface of
the diaphragm, including the esophagus, and not attempt
the use of the Murphy button, thus relieving the parts
from any strain. Undoubtedly it was this traction that
caused the severe pain in the back and the difficulty in
breathing, the parts dragging upon the diaphragm, ulti-
mately separating it from its attachment to the friable
portion of the esophagus.
It is a question whether the sudden start from her
sleep did not have some bearing upon the action of the
diaphragm, causing loosening before adhesions had taken
place.
The second case is very remarkable, regarding the
complete recovery the patient has made, and in the
great amount of comfort attained, not only in his ability
to attend to work again, but in his pleasure in the variety
of diet he is able to assimilate. His increased nutrition
illustrates the fact that the stomach can be removed and
the remaining portion of the intestinal tract perform the
necessary functions.
ARTHRITIS DEFORMANS.
BY
E. H. BRADFORD, M.D.,
of Boston, Mass.
The purpose of this paper is to call attention to the
need of more thorough study of this afltection, which is
more prevalent than cancer and at times less merciful,
as it is slower in its torture ; it is the curse of old age,
robbing it often of the contented philosophy which is its
right, as joyousness is of childhood ; and yet so little is
really known of the disease that the very name is a sub-
ject of dispute.
The term arthritis deformans is used here, avoiding
the other aliases of a disease so varied in its manifesta-
tions.
The morphology of this disease is so little understood
that a name without a pathologic basis seems in our,
present knowledge preferable.
Dissimilar processes may be, in our present ignorance,
grouped under one head, as great and smallpox once
were, or some of the varying manifestations of this
polyform disease, by some considered symptoms of dis-
tinct diseases, may, like the phases of syphilis, be the
results of the same process.
The group of symptoms classed under the term
arthritis deformans may be said to include alterations in
the structure or shapes of the ends of the bones forming
the joint, a loss of elasticity of the capsule and capsular
ligaments, with local swelling or atrophy, with or with-
out attacks of pain. These symptoms are often popu-
larly regarded as due to previous errors in diet or from
inherited dyscrasia, and are confused frequently with
gout ; an opinion, perhaps, based partly on the fact that
faulty metabolism may be the principal cause in both
affections.
The fact that the joints attacked are often painful has
given currency to the belief that the disease is a form of
rheumatism, and the term chronic rheumatism is the
one most commonly used, while the word rheumatoid
has been applied, suggesting a belief that the process
is not rheumatic but something like it. To add to the
confusion, the suggestion is made that the affection is of
bacterial origin.
While many writers believe that arthritis deformans
is a manifestation of a disease of the nervous system the
current literature of this subject gives evidence of the
lack of unanimity in the minds of the profession as to
the nature of the disease.
A list of articles published in medical journals in the
past year on arthritis deformans is sufficient to show the
direction of medical thought, and that a searching
investigation of the nature of this disease is needed and
will be welcome. (See references at end of article.)
The affection is observed in children and Tschernow •
finds that the affection in childhood begins with either
an acute or subacute onset. A marked distinction
is to be observed between this and real rheumatism
in children, which is not accompanied or followed by
deformity or the development of bone exostosis, although
heart complications were found in 9 of the 49 cases
observed by him.
OCTOBEK 25, 1902J
ARTHRITIS DEFORMANS
IAhbrican Medicine 653
Characteristic of the affection in children are hyper-
trophy of the epiphysis and atrophy of the diaphysis,
destruction or fibrous degeneration of the cartilages,
alteration of the synovial membrane and early muscular
contraction. In 400 cases the affection was found to
vary in age of onset from 1 year and 4 months to 25
years.
Although clinically the diseases are distinct patho-
logically the early changes in acute rheumatism are the
same as those in rheumatoid arthritis (Lebert Ranvier
Kusmaul, quoted by Parker^).
Certain disturbances of metabolism have been found
in a diminution of lime salts and earthy phosphates in
the urine, diminution in the excretion of uric acid and
urates without disturbance of the normal relationship
between the uric acid and the alloxan ba.ses (Kelley ').
Bain * reports a diminution in the uric acid secreted.
The phosphates were found to be markedly diminished
and the variation in their excretion closely follows that
of the uric acid.
Examination of the contents of the stomach have
been made by Murdock,^ but without determining any
causal relationship between the stomach contents and
the disease.
The neural theory in explanation of arthritis defor-
mans first brought forward by J. K. Mitchell had cer-
tain facts to support it. A nervous condition seems to
accompany the affection in many instances, but whether
as a cause or effect is not determined.
Irwin * reports a case in which the affection of the
joints was changed a few hours after menstruation. All
pains and swelling in and about the joints disappeared,
except Haygarth's nodosities and Heberden's nodes. The
joints became supple and the movements were not so
painful. The relief to the joints lasted from two to four
days, after which the swelling and pain returned. This,
however, is not the usual course of the affection and it is
a question whether the neural element may not act
simply as a disturbing cause in the chemistry of meta-
bolism.
Painter' is of the opinion that a marked distinction
exists between rheumatoid arthritis and osteoarthritis,
the latter being characterized by bone formation. This
opinion is not held by Garrod," although he regards the
rheumatoid and osteoid form of arthritis deformans as
different, as does Groldthwait in a valuable article pre-
sented to the American Orthopedic Association.
Pathologically the affection may begin sis a simple
synovitis with slight effusion, accompanied at first by
injection of the synovial membrane and later by devel-
opment of red soft villous growth or irregular folds or a
network of growths. This process is either dry or there
is an effusion of a small amount of synovial fluid, or the
development of a jelly-like exudation and a thin fluid.
Thickening of the capsule takes place with fibrous
degeneration and absorption of the cartilage. There is
a thickening and loss of elasticity of the periarticular
tissues which may lead to a loss of motion, fibrous and
lat«!r bony ankylosis, and a complete synostosis.
The synovial membrane is at first softened with the
villous growths originally reddish, but becoming more
thick, tougher and yellowish-retl in color, and these vil-
losities may cover the whole inside of the joint up to the
edge of the cartilage. Cartilaginous bone deposits are
formed in the fringes with more or less fibrous changes
and bone deposits, or the development of cartilaginous
or osseous loose bodies. There is an apparent erosion of
the bone tissue followed in places by fibrous and osseous
changes ; the periost*!um ligaments and muscles are
altered, exostoses are developed and the joint is altered
materially, either in the direction of stiffness or in the
direction of laxity.
The alterations found in bone are readily studied in
the joints in animals ; and considerable attention has
btK^n paid to the histology of these changes. Opinions
vary whether spavin (arthritis deformans of man) com-
mences peripherally as a periostitis or centrally as an
osteoarthritis of the hock bones.
Harper," after an examination of 40 specimens, found
that in seven there was no exostosis although there was
firm ossification and ankylosis of various bones. In all
cases accompanied by exostosis the internal lesions were
well advanced and in no case excepting one, and this
Spavin. (Warren Museum.)
was extremely doubtful, was there any peripheral deposit
with normal state of the articular surfaces.
"Spavin seems to develop excentrically, beginning
with the internal bony structure and the articular sur-
faces."
We cannot deny the prol)ability of si)avin commenc-
ing as a periostitis in cases of traumatism, but this is not
the general mode.
Ring bone may be articular or periarticular.
In the former the process is as follows : In the com-
pact bone tissue, a short distance under the articular car-
tilage, a rarefying osteitis takes place over an area
appearing in transverse section as large as a pea. The
bone tissue becomes absorbed, leaving a cavity filled up
with a more or less soft embryonic tissue and blood-
vessels. The priKjess extends gradually toward the
articular cartilage, which becomes ulcerated over irregu-
lar areas and desquamates, as is fre<iuently seen in cases
of osteoporosis, constituting an osteoarthritis. The
inflammatory zone of the bone now becomes the seat of
a condensing osteitis (osteosclerosis) ; the soft vascular,
embryonic material he<!omes organized, infiltrated with
calcareous matter, and converted into condensed and
compai't fM)ne ; the articular cartilage of the opposing
bon(! at the point opposite the articular ulceration of the
bone first affected likewise commences to ulcerate, and
leiuls to an osteoarthritis at that point. The two articu-
lar ulcerations being contiguous finally form adhesions
and become ossified.
In the periarticular form the exostosis develops upon
the periphery of the bone. It is an osteoperiostosis. It
commences as a rarefying and then paases into a con-
654 Ambbioan Medicine,
ARTHRITIS DEFORMANS
[UCTOBEK 25, 1902
densing osteitis of the superficial or subperiosteal layers
of the compact tissue of bone, which is cominunicatetl
to the periosteum and provokes a periostitis. The
result is a bone tumor of variable dimensions.
The exostosis of the ends of two contiguous bones
may become ossified, forming a peripheral or false
ankylosis, while the articular surfaces themselves may
retain their normal state.
The structure of an exostosis differs slightly from
normal bone. It is more porous. The Haversian canals
are larger and filled with embryonic tissue, the cells are
less numerous and its earthy salts are less abundant.
The ligaments and the synovial membrane also show
inflammatory ulcerations.
Bade '° examined a number of specimens of arthritis
deformans with the Rontgen rays and found that there
was a concentric atrophy in which the normal large
trabeculfe found in the neck and head are pressed nearer
together. There is also another form, a concentric
Wet specimen, fibrous synovitis, beginning arlbiitis defoinians.
{Warren Museum.)
hypertrophy in which the normal structure is preserved
but the trabecute seemed pressed apart. There is an
irregular atrophy and hypertrophy in which there is
unequal diminution and increase of the bone. The
diminution of the bone is found more in the periphery
of the hand. In the hollow of the net^k the increase
is found on the shaft between the trochanter major
and minor. A new system of radial support is formed.
The pathologic and anatomic characteristics observed
in arthritis deformans are so varied that they present a
long series of structural alterations. These are found
especially in the tissues of the cartilage, bone capsule
and periarticular tissue. This series is so interlaced that
it is difficult to find in some chronic cases a basis for
pathologic classification between villous arthritis on the
one hand and myositis ossificans on the other (Kitt " ).
The changes summed in the following terms indicate
the multiform character of the series : Arthro menin-
gitis catarrhalis sen serosa ; arthro meningitis sero haem-
orrhagica flbrinosa; synovitis flbrinc^a sicca; synovitis
serosa chronica proliferans ; synovitis chronica prolifer-
ans et ossificans ; arthritis erosiva pannosa; arthritis
erosiva pannosaet ossificans ; arthritis ossificans; arthri-
tis ossificans et ankylosans ; osteitis ossificans ; myosi-
tis ossificans.
The arrest, self-limitation or temporary check of the
disease is as characteristic as Its chronicity ; its fre-
quent tendency to remain stationary for a long period
as noticeable as the variety of its pathologic manifesta-
tions.
That arthritis deformans is very common in old age
is so well known that it needs no discussion, but its
prevalence is much greater than is supposed. Out of 66
men between 60 and 80 years old, in the Ijong Island
almshouse, 12 showed manifestations of arthritis defor-
mans interfering with activity. Although none of
these was bedridden, one of them was so thoroughly
crippled in many joints as to be almost helpless.
It was curious to note that all were unaffected in the
hands, none had Heberden's nodes. One had a knee and
a shoulder affected, one an ankle, one a hip and knee,
one a shoulder, two many joints, one a wrist.
In the women's department of the same almshouse,
however, out of the 96 patients but five had affections of
the larger joints, while 12 showed affections of the
hands.
Why the hands of men should be exempt from this
affliction and those of women affected has not as yet been
explained.
Looking at the affection as it is seen clinically, it is
as polyform as might be expected from the varied patho-
logic changes.
The disease may begin in childhood in such a way
that it is mistaken for tuberculous disease, as in the fol-
lowing cases :
Case I. — H., a child of three years, was healthy until she com-
plained of a slight pain in her left knee with slight consti-
tutional disturbance, with swelling and pain in the right knee
followed by pain in the other. There were constitutional dis-
turbances, and the right hand became involved. The pain
became very severe, but gradually subsided. A year later the
hips, knees, ankles, right elbow, right hand and cervical
spine and jaw were involved. There was muscular strain and
great sensitiveness. This condition has remained for two
years with subsidence. There was enlargement of the tissues
above these joints, but no new bone-formations were discovered
under x-ray examination. Distortions of the lower extremities
have been prevented by bandaging and traction. At present
there is slight motion of the lower jaw, and the respiratory
movements of the chest are normal. There is stiffness of the
hips, knees and ankles with muscular twitching. The knees
present hard globular swelling with slight increased surface
temperature ; slight subluxation. Back and toes are congested
and swollen as are also the fingers. The spine is entirely rigid.
In this case the onset was gradual, and the disease was con-
sidered to be tuberculous by the physician in charge.
Case II. — R., a child of 5, was noticed to limp slightly.
There was swelling in the left knee, a slight subluxation, and
little effusion. Later his right knee showed the same symp-
toms. This condition lasted six months, with improvement
under treatment of the right knee, which became entirely well.
The left knee after two years recovered, retaining normal
motion, but some swelling persisted. Child has remained well
for nearly two years.
Case III. — S., a child of 5, was attacked with gradual swell-
ing in the left knee, both elbows, wrist and neck. There was
little pain, but stiffness and distortion existed and enlargement
of the periarticular tissues. There was gradual increase in the
symptoms, and the patient was considered tuberculous. After
six months' treatment the patient recovered completely after a
persistence of the afiection for a year. The cure remained per-
manent a year after the recovery, since which time the patient
has not been heard from.
Case IV.— N., a child of 12, was attacked in the left knee
with symptoms resembling the ordinary tuberculous arthritis.
A few weeks later the other knee was attacked, and gradually
all the large joints and many of the smaller ones became in-
volved. There was extreme pain and sensitiveness, which per-
sisted for a year. The pain has diminished gradually but the
patient has remained crippled with distortion and stiffness of
all the important joints.
The treatment was equally thorough in the two cases
in which recovery did not take place as in the two case.s
in which it did. The symptoms in the two successful
October 25, 1902]
ARTHRITIS DEFORMANS
lAKSBICAN MEDICnU 655
cases were, however, less acute. The general condition
and surroundings of these patients were good in all cases.
:,The two cases following represent the disease begin-
ning in a similar way but with entirely different results :
Case V.— T., a young man of 17, of rapid growth, com-
plained of a puffy condition with slight pain in the knees and
■
Brii^i
mL^%H
HI
Bone of badly deformed hand, arthritis deformans. (Warren Museum.)
ankles. Symptoms wore not acute and improved slightly,
never disappearing entirely. A year later other joints became
involved, and ultimately permanent ankylosis of all the im-
portant joints followed.
Case VI. — W., a rapidly-growing boy of 16, presented him-
self with swelling, thickening and slight effusion of both knees
without pain. The condition remained stationary for two
years and gradually improved, but became worse after a fall,
di.sappearing almost entirely a year later. No stiffness or limi-
tation of motion followed.
The treatment in both these cases was similar, and
no apparent reason for the recovery of one patient and
the lack of it in the other could be determined.
Cask VII. — H., a lady of 2.5, became gradually stiffened in
the majority of the larger joints. No acute attack existed and
she remained in a crippled condition for several years without
change. There were occasional attacks of pain with swelling of
the joints, which subsided, and her condition remained un-
changed for eight years. She is able to go about her room with
<lifBculty, but suffers no pain.
Cask VIII. — A case similar to Case VII. in a lady of 45, of
apparent health. Progress of the affection was insidious and
accompanied by attacks of painful contraction of all the large
joints. There was great distortion of the hands and fingers and
contraction at the hips and knees. Patient became an habitual
morphia taker and her symptoms gradually increased. Cessa-
tion of the pain finally followed stopping of the morphia. The
patient died of exhaustion after an illness of ten years.
Case IX. — L., a woman of .'55, with symptoms similar to
those in the i)revious case but yielding to treatment by correc-
tion under an anesthetic and pla.ster-of-paris fixation until the
patient was able to walk about the room without a cane, and
with a cane could walk in the street. Gradual improvement was
noted for a year.
Case X.— P., a lady of .S5, with involvement of stiffness
which has persisted for ten years in the knees, hips, wrist,
arm, elbow and ankle, thumb and first finger of the left hand
and all the fingers of the right hand. In this instance the
patient, after forcibl(! (•orre<!tion and plaster fixation, was able
to walk about the house without cane or crutch and able to
walk a short distance in the street without a cane.
The following three cases in middle-aged ladies
resemble each other in general apjKiarance and condition,
but the symptoms vary as follows :
1. The first patient, after a period of slight pain and discom-
fort which was treated as rheumatism at several health resorts,
gradually developed a laxity of the lateral ligaments of the
right knee. There was no pain, but some swelling of the soft
parts existed with enlargement and puffy condition of both
knee-joints. This gradually increased until the patient was
unable to walk without a crutch and required the use of an
apparatus which enabled her to walk without crutches. No
improvement in the patient's condition has developed during
five years of observation.
2. In the second instance the conditions were seen in the
left foot under a skiagraphic examination. Exostoses were
found under the os calcis and at the lower end of the tibia.
3. In the third instance marked enlargement of the bone in
the knee was observed, with painful stages, but without the
development of laxity of ligaments. The patient walked with
difficulty with the help of a cane, becoming gradually worse,
needing a fixation apparatus, the use of which was accompanied
by occasional attacks of severe pain.
In a similar case presented by an older lady the bedridden
condition gradually improved and the patient is able to walk
about freely with the use of a cane, although there is no laxity
of the ligaments and but little enlargement of the bone.
In several of the above instances improvement appar-
ently followed treatment, but in many the affection
seemed to follow its course unaffected by treatment. It
is clear that in an affection in which arrest of symptoms
and a long-continued freedom from exacerbations are as
characteristic as the variety of parts attacked the exact
connection between the natural limitation of the disease
and the result of treatment is not easily determined.
In spite, however, of our ignorance as to the nature
of arthritis deformans, the records of treatment show
apparent benefit in many instances from measures which
meet the therapeutic indications which present them-
selves.
That which improves the patient's general condition
improves the patient's local symptoms in this as in
other general disorders. Motion of a joint, if protected
from strain, improves its condition, as it is a normal
function. Improvement will result if contracted joints
are straightened and placed in a condition in which
moderate motion is possible.
Measures to improve the circulation, viz., heat and
cold (dry and moist) and static electricity may be re-
Bone of badly deformed band, arthritis deformans. (Warren Museum.)
garded as measures checking the advance of the affection
or in establishing an arrest of the process.
The prognosis is by no meitns a prognosis of despair,
the arrest of the disease by the natural process should be
656 A.HKBICAN MBDICINBj
CONCENTRATION OF URINE CONSTITUENTS
tOCTOBKK 25, JW2
regarded as a stimulus to Investigation and tiie varied
manifestation of tiie disease a cliallenge for renewed
observation.
Artliritis deformans may be regarded as an affection
of the organs of locomotion, characterized by a fibrous
degeneration of synovial membrane, ligaments, bones,
cartilage, periosteum. This causes an impairmeitt of
elasticity, an alteration in shape, and stillness, and is
followed by osseous degeneration, bony ankylosis and
irregular bony deposit. The question suggests itself
whether tliese changes are similar in nature to those
which produce fibrous degeneration elsewhere, notably
arteriosclerosis ; and for improvement in our methods
of treatment we should look for investigation which
will throw light upon the causes of fibrous degeneration
and of osseous metamorphosis.
What is needed is more complete pathologic reports
of the condition of all organs and the whole body in
arthritis deformans, through investigations of the
changes of tissues in the milder stages of the disease ;
accurately recorded clinical facts in regard to the arrest
of the affection and the apparent self-limitation or long-
continued arrest of the disease ; careful chemic investi-
gation of the changes of tissues affected ; careful exami-
nation of the chemistry of the blood in early and late
cases of arthritis deformans ; careful examination of all
the excretions, including those of perspiration and
respiration, and thorough metabolism investigations.
All this is needed before the disease can be placed
upon a satisfactory scientific basis.
REPKKENCES.
Kelly, A. O. J. K. : Arthritis deformans, its clinical features, differ-
ential diagnosis and pathogenesis: Jour. Am. Med. Ass'n, Chicago, 1000,
x.\xv, 1618-1825.
Bam, William : Observations on the excretion of nitrogen in rheu-
matoid arthritis ; Trans. Clin. Hoc, London, 1900, 11, 124-m.
Bailey, G. L. : Etiology and treatment of rheumatoid arthritis and
allied affections ; Cincinnati Lancet Clinic, 1901, n. s. xlvii, 27-30.
Hawthorne, V, O. : Rheumatoid arthritis with mitral disease ;
Clin. Jour., Lond., 1900-1901, xvli, 18t-188.
Kerr, J. G. D. ; Rheumatoid arthritis; Jour. Bal. and Climat., Lon-
don, 1900, Iv, 279-289.
Parker, D.: Observations upon diseases under the heading rheu-
matoid arthritis; St. Barth. Hosp. Reps., IMOO, xxxvi, 178-194.
Hoke, Michael: Tue treatment of osteoarthritis and rheumatoid
arthritis of the feet, knees and spine; Atlanta Med. and Sur. Jour,
October, 1900.
Latham, P. W. ; The pathology and treatment of rheumatoid
arthritis; Lancet, Lond., 1901, 1, 998-1005.
Neuman, K. : The treatment of sciatica and arthritis deformans.
Report of the Tallerman treatment from the Grand Ducal " Landes-
bad " at Baden-Baden ; Med. Press and Clrc, London, 1901, n. s. Ixxl,
885-X88.
Tull, M. G. : Report of a case of arthritis deformans successfully
treated by the application of ice to the spinal column ; Proc. Phila. Co.
Med. Soc, Phila., 1901. xxli. 133-138.
Murdock, F. H. : The state of the gastric secretions in chronic rheu-
matism and rheumatoid arthritis; Med. News, N. Y., 1901, Ixxlx,
166-108.
Moncorro: Sur la polyarthrite deformante dans I'enfanee apropos
d'un nouveau cas observe chez un enfant de cinq mols; Rev. mens,
des mal. de I'enf.. Paris, 1901, xlx, 314-326 ; Interstate Med. Jour., St.
Liouis, February, 1901.
Neilson, W. H. : Rheumatoid arthritis ; Interstat* Jour, of Sur., N.
Y., ISXtl, xiv, 201-i03.
Whitman, R. : Spondylitis deformans ; Ref. Med. Times and Reg.f
Phila., I90O, xxxvlii, 234-235; Am. Pract. and News, Louisville, 1900,
xxlx, 427 ; Jour. Med. andscl., Portland, 1900, vl. 340.
West, 8. L. : Chronic and villous arthritis ; Phila. Med. Jour., 1900,
vi, 1143-1144.
BIBLIOGRAPHY.
1 Centralbl. f. Chir , p. 853, August 20, 1898.
2 St. Bartholomew Hospital Reports, 1900, xxxvl, 177.
3 Journal of the American Medical Association, Dec. 22, 1900, p. 1618.
< Transactions of the Pathologic Society of London, xxi, 124.
'Medical News, Vol. Ixxlx, No. 6, p ]6«.
"American Practitioner and News, Vol. xxxl. No. 9, p. 25.
' Boston Medical and Surgical Journal, November 28, 1901, p. 593.
e British Medical Journal, October 12, 1901.
0 Journal or Comparative Medicine, March, 1902, p. 133.
i»Zeltschrlft f. Orthopadlsche Chir., Bd. ix, H. 2, p. 207.
"Pathologic Anatomic des Hausthleres, Vol. I, pp. 325-328; also
Munchener Jahresberlcht, 1884-85, p. 72.
Health of Baltimore. — During September there were 812
deaths reported, an excess of 31 over September of 1901.
Typhoid is stated to be partly responsible for the increased
deathrate, there being 317 new cases with 43 deaths for the month
as against 180 cases with 18 deaths during the corresponding
period of last year. There were 78 cases of diphtheria and 49
cases of scarlet fever during the month. There were 828 births
recorded ; of these 344 were white males and 31.5 white females ;
81 colored males and 88 colored females.
THE CONCENTRATION OF THE URINE CONSTITU-
ENTS AS AN AID TO DIAGNOSIS.
BY
TORALD SOLLMANN, M.D.,
of Cleveland, Ohio.
From the Pharmacologic Laboratory of Western Reserve University^
Cleveland, Ohio.
CONTENTS.
I. Physical principles.
II. Methods.
III. Significance of the physical factors ; theirnormal varia-
tions.
IV. Effect of dietary changes :
1. Fasting.
2. Administration of water.
3. Milli diet.
4. Food free from all salts.
5. Salt administration.
6. Deficiency of water,
v. Effect of disease:
1. Fever with restricted diet.
2. Heart disease and slowed circulation.
3. Quiclcened circulation and increased diuresis.
4. Kenal disease. Table of the significance of the
changes of the physical factors.
5. Uremia.
6. Other conditions.
7. Cryoscopy as a means of surgical diagnosis.
VI. Bibliography.
Physical methods and various factors deduced from
them have recently been applied to the examination of
urine as a means of diagnosis. Many contributions to
this subject have appeared in German and French jour-
nals, but it has been rather neglected in American litera-
ture. In view of this it is hoped that an exposition of
the principles and applicability of these methods and a
brief survey of the principal literature relating to
them may not be inopportune.
I. PHYSICAL PRINCIPLES.
The quantity of the urinary ingredients, normal as
well as abnormal, furnishes important information about
the state of the kidneys, and of metabolism. The older
chemic methods of determining the composition of the
urine are, however, open to serious objections. This is
true, especially when we consider tlie "collective"
properties of the urine, L e., the properties which are
exerted by all its ingredients in common ; and also
when we wish to determine the ratio whicli the indi-
vidual constituents have to each other.
The work which the kidneys perform is measured by
the total amount of the substances excreted by them ;
and by the concentration in which the solids exist in
the fluid. The latter has usually been measured by the
specific gravity. The specific gravity depends not only
upon the quantity of dissolved substances, but is raised
to a definite but different degree by a given amount of
every dissolved substance. For this reason the insight
which the specific gravity gives into the concentration
of the urine is far from simple. It really furnishes only
a very rough, approximate view of the real concentra-
tion, and has been used mexely because no other known
method of determining the concentration was equally
convenient, simple, and rapid.
The gravimetric estimation of the total solids is more
lengthy and tedious, and in the end gives no more satis-
factory results ; for the work done by the kidney is not
determined by the weight of the solids which it excretes,
but by the number of the excreted molecules. To
excrete a certain quantity of a urine containing 5^ of
solids will require twice as much work if the average
molecular weight of the solids were 50 than if it were
100, since twice as many molecules must be excreted in
the first case.
The problem of obtaining a direct insight into the
molecular concentration of the urine has been solved by
the introduction of the freezing-point method. Baoult
has shown that the freezing point of a solution is lowered
October 25, 1902]
CONCENTRATION OF URINE CONSTITUENTS (Amkbican Mkdicike 657
in exact proportion to the number of molecules which
it contains. Each gram-molecule or "mof" (i. e., the
molecular weight of the substance expressed in grams)
dissolved in a liter of water lowers the freezing point
(denoted by the sign A) by 1.89° C. A solution depress-
ing the freezing point by 1° C. therefore contains 1 ^ 1.89
mols per liter. One lowering A by 2° C. contains twice
as many mols per liter, i. e., 2 ^ 1.89, etc.
This holds strictly true only for substances— such as
urea — whose molecules remain intact in the solution.
The molecules of salts, acids and alkalies break up or are
dissociated into their constituents (called ions) when
they are dissolved in water. These ions have the phys-
iciil properties of molecules, so that each free ion de-
presses A by the same quantity as any other molecule.
A molecule of NaCl, when completely dissociated into
its ions Na and CI, therefore depresses the freezing point
twice as nmch as an undissociated NaCl molecule ; NajSO,,
when dissociated into its ions Na, Na and SO^, three
times as much a.s the undissociated Na^SO^. In fluids such
as urine only a certain number of molecules undergo
dissociation, the number varying with the dilution. The
proportion of dissociated molecules is, in pure solutions,
perfectly definite for each degree of dilution, and may
be calculated with great exactness. When two or more
substances are present the conditions are much more
complicated. The addition of a second substance to a
solution lessens the dissociation of the substance origin-
ally in the solution, but the degree by which this is
lessened is too complex for calculation. Nor would such
a calculation be very important for clinical purposes. So
far as the work of the kidneys is concerned, the degree
in which the entire and dissociated molecules contribute
to the total concentration of the urine is quite imma-
terial.
II. METHODS.
The determinations which are most useful in the
physicochemic examination of urine are the daily quan-
tity, freezing point, NaCl, and nitrogen.
1. Method of Taking the Freezing Point.— This is done inva-
riably by tlie Beckraann's apparatus or one of its modifications.
A thermometer, capable of being read to 0.001° C, is supported
by a cork in a larsje tesl/tube (A) containing the urine. The
thermometer is arranged so that ita bulb is entirely covered by
the urine and does not come closer than 5 mm. to the walls of
the tube. Through this cork also passes a rather stiff wire for
stirring the urine. I have found a rolled-gold wire, wound in
the form of a spiral, the most useful. This test-tube fits
through a cork into a somewhat wider tube (B), which in turn
is supported by an appropriate device in a jar containing a
mixture of cracked ice and salt of a temperature of about
— 5° C. The Beckmann's thermometer is graduated into 0.01° C,
but the freezing point is arbitrary and must be controlled daily
by testing it on distilled water, or what I have found more con-
venient, on a l'/( solution of NaCl, which has been standardized
once for all. This test is carried out precisely as that to be
described for the urine itself.
To determine the freezing point of a liquid with the appa-
ratus the tube(A) is plunged directly into the freezing mixture,
stirring the urine steadily with the wire. The freezing mixture
is also stirred occasionally. The mercury will be seen to recede
from the reservoir and descend into the stem ; at a certain point
it will suddenly reverse its direction and ascend. The tube is
now removed from the freezing mixture and (B) is set into the
mixture. The stirring of (A) is meanwhile continued. The
urine is seen to he filled with small crystals of ice. It will be
noted that the mercury soon comes to a standstill, which
approximately corresponds to the freezing point of the liquid.
The stirring is continued until the ice is almost but not quite
<-onipIetelv melted. Care should be taken that the mercury
does not rise more than 0.2° C. al)Ove the freezing point. When
the ice has melted siifliciently the tube is plunged for a moment
into the freezing mixture, and is then set into the tube (B)
which in its turn rests in the freezing mixture, the stirring
being continued. The point at which the mercury remains
constant is the freezing point. The tube (A) is taken out, again
stirred until the greater part of the ice is melted, and the
freezing point is taken as before. The two determinations
should agree to 0.003°, although an agreement of 0.02° C. is suffi-
cient for most clinical examinations.
The method is simple, easy and quite rapid. The determi-
nation does not take more than 10 mmutes after the apparatus
has been set up and standardized. The necessity of standard-
izing the thermometer daily is rather annoying. More simple
thermometers with fixed freezing points have been suggested
for this purpose.! These are not quite as delicate, but are suf-
ficiently accurate for clinical work.
When the urine contains considerable urates these are
thrown out of solution by the cooling so that the observed con-
centration is lessened by the amount of the precipitated urates.
This quantity is, however, so small that it may be safely neg-
lected ; the more as it is not easily possible to make any correc-
tion. It would not do to dilute the urine, since this alters the
dissociation.
2. iVaCT.— This may be determined with sufficient accuracy
by any of the commonly used methods. I have always
employed Salkowski's modification of Mohr's method.^
3. Nitrogen. — For the present purposes the total quantity of
nitrogen is of greater importance than the form in which it is
excreted. The plain Kjeldahl process is therefore to be pre-
ferred.
4. Other Data.— The determination of the PjOs and the SO4
is not usually made, as their quantity is too small to modify the
physical conditions.
Hamburger' has suggested using blood-corpuscles as a
means of determining the concentration of urine by noting how
much the urine must be diluted to secure laking. This method
is not very useful, because urea penetrates the corpuscles.
Roth * has suggested the determination of the specific conduc-
tivity of the urine as a measure of its content of salts. While
this is a very quick means, its data are not simple, since the
conductivity varies not only with the num\)er of saline mole-
cules, but also with their nature, and is also modified by the
urea in a degree which it would be difficult to estimate.
III. THE SIGNIFICANCE OF THE PHYSICAL FACTORS ;
THEIR NORMAL, VARIATIONS.
1. A : The freezing point of the urine is a factor of
the dissolved molecules contained therein, and gives its
concentration ; just as do the specific gravity or the solid
residue. The latter two, however, are very complex
factors, being determined not only by the amount but
also by the nature of the dissolved substances. A > on
the other hand, measures the number of the molecules
f)f whatever kind. Lindemann * has first called attention
to the fact that it does not necessarily follow the specific
gravity closely.
A, which I use as denoting the depression of the
freezing point, will be diminished by diuresis, however
produced, but especially when due to the administration
of water ; by absence of urinary substances — especially
NaCl, and by decrease in the power of the kidney for
excreting of salts, or in the absorbing power for water.
Its normal variations lie usually between 0.9° and
2.1° C, especially if the quantity of the urine is between
900 and 1,700 cc. ; it may, however, range between 0.1°
and 8° C, even in healthy individuals (v. Koranyl");
but this only under very exceptional conditions.
Claude and Balthazard ' arbitrarily call A X 100 =
" molecule."
2. C : The real molecular concentration is found by dividing
the A l>y l'*^9- This factor is of course precisely parallel to A,
and varies in the same manner. Its calculation is usually
superfluous, and only necessary for the investigation of certain
special problems.
3. These numbers multiplied by the daily quantity
of urine in cc. give a measure of the grarn-molecules
excreJsdper day.
A X cc., requiring less calculation, has so far been
exclusively used. Lindemann' places its value \n nor-
mat individuals as between 770 and 3,.")60 ; mean, 1,700.
This factor gives a measure of the daily output of mole-
cules ; it varies with the activity of the kidneys ; with
the activity of the circulation ; and with the metabolism
or salt income.
Claude and Balthazjird ' believe that this factor should be
referred to the weight of the individual and replace it by a fac-
tor: ^^^p^°°'. (Normal range = 2,500-4,000.) Consider-
ing the rather variable value of the factor in different indi-
vid\ials. this appears to be rather a superreflnement.
4. To facilitate certain calculations relating to his theory
of exchange of urinary molecules, v. Koranyi* divides the
factor A X cc. by 61.3, and calls this factor "a." This corre-
sponds'to the weight of NaCl In grams which would be con-
tained in the same quantity of NaCl solution equimoleoular
• P ^^ weight of patient In kilograms.
658 Ambeican MedicuisJ
CONCENTRATION OF UEINE CONSTITUENTS
(OcroBBR 25, liXfci
with urine. It varies, of course, precisely as A X cc. ; its value
is given by Senator' as ranging between 22.6 to 61.5. Linde-
A X cc.
mann^ introduces a similar factor ' , ' '- (r. e., 1/10 that
of V. Koranyi) which he calls " x," and which corresponds to
the quantity (in cc.) of 1% NaCl solution, which contains the
same number of molecules as the urine.
The factors
AXcc.
and
AXcc.
no longer serve any useful
61.3 613
purpose and should be discarded, as pointed out by Wald-
vogel"" (page 44).
5. The individual urinary constituents may also be
expressed in physical values. In this connection it is
especially important to distinguish between the mole-
cules, which simply pass through the body without
change — i. e., mainly NaCl and partly P^Oj ; and those
which are elaborated in the body : N, 80^ and part of
the PjOj. Of these, NaCl and N are by far in greatest
abundance, and have the greatest significance ; so that
SO, and Vfi^ are either neglected altogether, or figured
with the N as "metabolic molecules." I repeat that
PjOj is only partly a metabolic substance ; yet its quan-
tity is too small to have the slightest significance for the
final conclusions.
6. V. Koranyi' deserves the credit of first intro-
ducing what is still the most useful of these factors, viz.:
rr-— — . It increases with small NaCl elimination (or
NaCl fo
assimilation), or with increased proteid metabolism. It
increases also when only a small amount of urine is
excreted, and serves under given conditions as a meas-
ure of the time during which the urine remains in the
kidney. "We will not at present seek for the cause of
this, but I shall merely state that one theory seeks to
explain the effect of slow diuresis on this factor by
greater absorption of NaCl, while another explains it by
A
greater secretion of urea. The normal value of rr— : —
NaCl^
lies between 0.9 and 2.3. But this factor is peculiarly
liable to be influenced by diet, i. e., its richness of NaCl.
Sick-diet is usually poor in NaCl, and hence the factor
rises. Lindemann^ (page 17) claims the normal mean
in seven urines to be 5.75, and the highest 9.74 ; on this
account he denies it practically all value. This does not,
however, dispose of the matter. The individuals were
evidently on an abnormal diet, at least so far as NaCl is
concerned. It is, however, precisely in this connection
that clinicians have erred in not considering the diet.
The factor has value only if the food contains a constant
amount of NaCl — or some 10 grams per day if different
individuals are to be compared. These observers, while
calling attention to the importance of this factor when
discussing diet, lose sight of it altogether when they dis-
cuss diseases.
The factor is lowered by the reverse conditions.
7. The converse of this factor is
A
This has been ad-
vocated especially by Waldvogel,'" who claims that it is sub-
ject to less variation. It gives no further information than
A ^
■KT„Qif ^nd while it may be useful for certain questions, it is
generally superfluous. Its normal values, according to Wald-
vogel, lie between 1.52 and 1.71. It varies, of course, inversely
an A
*^ NaCl-
8. Claude and Balthazard' introduce a new factor
" (!," which stands for the freezing point of metabolic
molecules. (The use of " (S " is unfortunate, since
Koranyi has already employed the same sign to desig-
nate the A of blood.) This factor '5 is obtained by sub-
tracting from the A actually determined in the urine
the A which would be due to the NaCl contained in the
urine, leaving the A of the nonchlorid molecules
(d= A —Ifc NaCl X 0.61]). This 6, multiplied by cc,
gives the number of elaborated molecules excreted per
day ; and this, divided by the weight of the patient in
kilograms, the number excreted per kilogram.
9. --- is a factor analogous to — , possessing over the
latter the advantage that it dispenses with the N esti-
mation, while it probably gives just as reliable results.
The main importance of this factor, however, lies in
this, that Claude and Balthazard try to establish empiric-
ally a certain correspondence between A X cc. and ^.
A table of the
A Xcc,
maximum values of - for a given
is given on page 774 of their paper.
On a ba.sis of a weight of 70 kg. these would corre-
spond to
A X CO. -^ not over
AXCC.
•V- not over
0
A Xcc.
^ not over
0
3S0
700
1,050
1,400
i
1. 1
1 1 ;
1.2
1.3
1,750
2 100
2,450
3,150
1.41
1..") [usual
7.6 1 values.
1.7 J
8,150
3.500
3.8.50
4,200
1.8
1.9
2..
2.1
Greater values than those given in the table are con-
sidered diagnostic of renal disea.se. This, of course, can
also hold good only for ordinary diet.
To sum up, I believe that the tables containing the
follomng factors will be found most ust-ful for clinical pur-
poses (the patient should be on a diet which contains
a normal and fairly constant quantity of NaCl) :
Quantity.
■ A
A X cc.
A
NaCl^
NaCljf
1.0 to
20
Per day.
NaCl
80to
15.0
N
Usual
variat'ns
800 to
1,500 cc.
0.92 to
2.14
900 to
2,000
0.9 to
2.3
0.4 to
1.2
10 to
20
IV. CHANGES OF THE PHY.SICAL FACTORS AND I'KIX-
ARY CONSTITUENTS FliOM DIETARY CHANGES.
The composition of the urine is influenced so greatly
by the diet, and particularly by its salts, that no conclu-
sions as to diagnosis can be formulated until the possible
influence of the diet is understood. This will serve as
an excuse of the rather prominent place which I have
given to this subject.
1. Fasting. — It is well known that the nitrogen
excretion falls in fasting, at first rapidly, and then more
slowly. Toward the death from starvation the nitrogen
excretion shows a considerable "premortal" increase.
The P2O5 and SO, may be expected to go parallel to the
N, since they must arise purely from proteid metabol-
ism, no food being taken. This is even seen when the
N excretion follows a rather irregular course, as in the
case of fasting during hypnotic sleep, observed by
Hoover and Sollmann."
The influence of fasting — in every case water was
given — on the physical factors has been studied by a
number of observers.
V. Koranyi » (page 36), making observations on the famous
Succi, finds that AX cc. is lessened, '' is greatly increased
(to 70.00 instead of the normal limit of 2.3). Lindemann^ (page
15) gives the data of five hunger-urines which do not differ
much from the ordinary in A and A X cc; since W4,-i is only
10, it is evident that the starvation in his patients was not very
prolonged. He gives no details. Waldvogel'" (page 48) finds
a high
„ p. (to 17) and correspondingly a low ^.
We may therefore say that fasting causes, as to phys-
and low
ical factors, most conspicuously a high
— or -^, due to the lessened excretion of NaCl. A does
NaCl
OCTOBER 25, 1902]
CONCENTRATION OF URINE CONSTITUENTS
iAmbrican Medicine 659
not depart much from the ordinary ; A Xcc, and, to a less
extent, (5 x cc., are diminished.
2. The Effects of Administering Large Quantities of
Water:
This may be conceived as acting primarily by increasing
the diuresis by diluting the urine; later by paucity of urinary
ingredients in the body.
In regard to nitrogen it has been found that its excre-
tion is temporarily increased by as much as 34^ , return-
ing to normal about the third or fourth day.'' As to
other ingredients very little definite is known; and I
could find no statement as to the effect upon the physical
factors.
The subject deserves investigation. A priori it would seem
that during the first period /\ should fall, as also the percent-
age of other ingredients, whereas the daily amount and A X cc.
would be increased.
A
would probably be diminished (as
the usual effect of the diuresis). As the experiment progressed
the NaCl would be the first to fall and that below normal:
jj p. would therefore become high. Later all ingredients
would fall
A would be very low,
A X cc. would return to normal or slightly below.
■ would follow
this course only if the salt income were kept constant. If
the salt could be taken ad libitum ~^^ would remain low.
NaCl
An instance of this is seen in diabetes insipidus. M. Senator
(0819) 9 finds in a case of this kind A = 0.38 to 0.68 ; =r=^^ =0.94
NaCl
to 1.62; NaCl = 0.2 to 0.59!,. Dreser" found A as low as 0.26.
In diabetes mellitus (Senator) A is about normal and ^ is
usually rather high (3 to 4.1) on account of the sugar.
3. The Injlttence of Milk IHet :
Milk is a food which supplies a rather small, yet suf-
ficient quantum of nitrogen ; a rich supply of P^O; ; but
a very scant allowance of NaCl. As a result we would
expect A X cc. rather low, <i X cc. low, but less so ; r~~~,
NaCl
very high, the latter especially if the milk regime
has continued for some time. — would be correspond-
ingly low.
Claude and Balthazard' (page 774) found results in agree-
ment with this : A X cc. was lowered, as also -=■ in milk diet
with bed rest. Nobf'court and Delamare" find in pregnant
women with a slight albuminuria (0.38%) a rather low AX cc.,
a"d ^s-77T rather high. The variations from normal are not
NaCl
very great ; but the NaCl figu res are also not very small ; in the
case of Claude and Baltliazard the milk diet was given for a
few days only; in the cases of Nob<;court and Delamare the
patient probably received some other food.
We shall see presently that most of the fever urines
agree entirely with the urines of plain milk diet.
4. Food Freed from all Scdt :
This object may be accomplished by giving meat which has
been boiled out several times; together with rice, fats, etc.
Experiments of this kind have not been made since the
physical methods wore introduced. Yet there is no reason to
suppose that the physical factors would differ in the least from
what is seen with milk diet. The only differences would bear
upon the individual salts, and in this respect the older
researches may bo considered sufficient. The most valuable for
our present purpose arc (rontjiined in the table on page .("S of a
paper by .7. Forster." It is seen here that the reduction in the
urine concerns practically solely the CI, while PsOr, varies as
the N excretion, i. e., is not materially reduced.
5. If now we turn to the opposite, viz., salt adminis-
tration, we find really very few data in the literature.
Perhaps the most thorough work has been done on the
effect of NaCl upon the N meiabolism.
A recent paper by W. Straub '» deals with this subject. He
finds that the ene<!t is somewhat different when the salt is given
alone, and when it is given with a free sjipply of liquid. In the
former case there is first a short diminution of N excretion, and
then a more than compensating increase. When the NaCl is
given with enough water to malce it practically isotonic, there
is a slight but distinct diminution in N excretion. Krum-
macher,'9 injecting subcutaneously 0.16 gm. NaCl in O.'ifc solu-
tion per kilo of dog, obtained a very insignificant increase in N
excretion.
I have recently caused this subject to be investigated
in my laboratory by Dr. R. A. Hatcher. The details of
these experiments will soon be published. Two patients
suffering from typhoid fever were given from 30 to 120
gm. of NaCl per day, 15 gms. being dissolved in each
liter of milk taken by the patients. The administration
was continued for from one to two days. The effect was
a large increase in the NaCl of the urine, which reached
16.9/(1 and 25.6 gms. per day. The quantity of urine
was increased, as also its A. AX cc. therefore showed a
large increase. The N is very slightly diminished in
A
percent, but the daily output is notably increased.
is much diminished, — is correspondingly increased to
(i
1.94. SO^ and P^Oj are increased in concentration, and
more especially per day. ,
Claude and Balthazard ' (page 775) obtained results
which agree with these as to — , although they were not
(J
nearly so great as those obtained by Hatcher, less salt
having evidently been given by them.
6. Water withdrawal may in some sense lj(B supposed to
act like salt administration. There are, however, complicating
factors, due, according to Spiegler "> to the interference of want of
liquid with the absorption of food. There is at first a diminution
of N, with a somewhat more than compensating increase as soon
as water is administered. This is due, according to Spiegler, to
the absorption of unassimilated N from the intestine. Iknow
of no researches into the other constituents and into the physi-
cal factors under such conditions.
CHANGES OF THE PHYSICAL, FACTORS AND URINARY
(X)N8TITUENTS FROM DISEASE.
1 . The Effect of Fever, Conjoined loith Restricted Diet.
— It may be considered as settled that in fever there is
an increased metabolism, which results in an increased
excretion of N, and with this P^Oj and NajSOi.'" The
quantity of urine is at the same time diminished. From
both causes its percentage content of the above sub-
stances increases. This would tend to produce a con-
siderable increase of the A and some increase of the
A Xcc. and of the factor ^^ . It may, however, be
considered doubtful whether the influence of fever, pure
and simple, has ever been studied. It is always joined
with some degree of fasting, and particularly with a
deficient CI income. The consequence of this is to keep
A and A X cc. near normal, whereas -77;; becomes very
high. The following literature bears on cases in all of
which the influence of the diet is directly discernible :
Gramatchikov" found that the excretion of SOs and PsOe
were doubled in cases of fever in which the patients were nour-
ished on bread, milk and water. 'I'hus the amount per day
during the fever (average of his five oasas) was SO.i, 4.1 ; PjOs,
2.8. About a month later, on much more liberal diet, the
average was 8O3, 2.0; PjOs, 1.4. The increase is to be attributed
partly to the higher proteid metabolism during fever.
Claude and Balthazard' (pa^os 96:j-966) have made a quite
extensive study of the urines in infections diseases by their
methods. They find that in pneumonia and broncliopnoumonia
A X cc. is slightly higher, and li X cc. is considerably increased ;
-= is very low. Three days after defervescence -j- suddenly
J *'
became quite high (2.1). In typhoid fever (pages 966-969)
A Xcc. is quite normal, whereas rixcc. is rather high, -j
during the fever is rather regular between 1.1 and 1.8; when
alimentation begins -7 becomes rather higher than is normal
for the existing A X cc. In diphtheria (page 969) -^ is usually
660 American Medicinb]
CONCENTRATION OF URINE CONSTITUENTS
[OCTOBKB 25, 1902
not so low as in other fevers, whereas A X cc. is a fairly accurate
Index of the heart.
These authors confess that in fever neither nephritis nor
vasomotor paralysis can be diagnosed according to their cryo-
scopic scheme, but that cardiac weakening can still l)e actm-
rately followed to a fair extent by A X cc. They seem at a loss
to account for the discrepancy; yet it is plain that the low
A X cc. and the low -r are due simply to the lessened salt
income, whereas the increased ,5 X cc. is an expression of the
increased metabolism of fever.
Waldvogel '» (page 59) found no constant changes of A X cc.
in typhoid fever ;
A
NaCl
was sometimes high, sometimes not.
The cause of this inconstant result is probably dietary.
The experiments of Hatcher, already alluded to, con-
tribute to this subject. The two patients had a fairly
high grade of fever (typhoid) which was kept in check
by cold sponging or cold baths. The milk regime was
rigorously adhered to in the first period. The changes
in the urine consist, in the first place, in a great diminu-
tion of the CI ; the total quantity of the urine is less
than in the period of convalescence and is also somewhat
lowered. The daily molecules are, therefore, somewhat
diminished. The daily quantity of N is diminished,
but its percent is increased; the factor rises
^ NaCl/o
greatly, even to 72. - is correspondingly low. SO.
(i
and PjOj are slightly lessened in concentration and par-
ticularly in daily quantity.
The height of the fever appears to have no influence
on the urine.
It will be seen that the effects correspond almost pre-
cisely to those of milk diet, without any fever.
2. Heart Disease: Slowed Circulation. — The pioneer
work in this field was done by v. Koranyi." He advanced
the theory that the urine in the glomerules is a dilute fil-
trate, containing the nonproteid substances of the blood
in the same relative ratio in which they exist in the
plasma. As the urine passes through the convoluted
tubules it loses water, and it exchanges certain of its
NaCl molecules for an equal number of urea molecules.
The theory in this form is open to serious objections. I
consider it more than doubtful that the glomerular fluid is
simply a filtered plasma ; I also consider it doubtful that a
molecule of NaCl is taken up for every molecule of urea
excreted. Whatever objections may be made to v. Koranyi's
theory do not, however, interfere with the usefulness of the
empirically ascertained facts for diagnostic purposes.
It has been observed by numerous clinical and experi-
mental investigators that the longer the urine remains
in the kidneys the more it becomes concentrated, and
the more it loses in NaCl, acquiring instead nonchlorid
molecules, mainly nitrogenous. In other words, a
lessened secretion of the urine tends to cause an increased
A, but a lesser A X cc. and an increased rr-— . The
NaCl
results will occur only if the diminished excretion
of urine is consequent to a slowed circulation through
the kidney, viz., in cardiac incompetence. When A X cc.
is less than 1,000, and — — more than 2.0, the indica-
NaCl '
tions point strongly to such a condition.
. The diagnosis should, however, only be made if the
salt-content of the diet is normal. A good illustration
of the importance of this caution is seen in one of
Hatcher's cases of milk diet. Thus A X cc. was 940 ;
A
^^^ was 72.3— the very extreme of the changes con-
sidered as characteristic of heart disease ; yet there is no
reason to suppose that such existed. Lindemann ^ (page
19) seems to be disposed to reject the factor ^- entirely
- ... NaCl
for this reason. This is going to an unwarrantable
extreme. With constant salt income valuable informa-
tion can be gleaned from this factor.
In this condition of slowed circulation — will be cor-
respondingly low — 1.1 to 1..5, instead of 1.4 to 1.7
(Claude and Balthazard ') ; -— is similarly diminished.
d X ec. will also be low.
The conditions described in this paragraph are found
according to Claude and Balthazard ' (page 777) in cardiac
weakening, or with increased general capillary resist-
ance, such as in emphysema, pneumonia, tumors,
ascites, etc.
3. If we take the contrary condition of quickened
circulation and increased diuresis, we should expect the
precisely opposite effects : low A , high A X cc. and
rfXcc. ; low r— - and high - and — . Such is
iN ai^i o jN
claimed by Claude and Balthazard ' (page 777) for early
cardiac hypertrophy, for arteriosclerosis, for heart dis-
ease under effective treatment, and for nervous poly-
uria.
4. Renal Disease. — The pathology of the nephrites is
so complicated — there are so many structures in the kid-
ney which may be separately or conjointly involved —
that the composition of the urine can hardly be expected
to make the conditions plain. Indeed, the changes in
the urine are about as obscure and as difficult to int«r-
pret as other clinical signs of renal disease.
Taking account of all the tenable theories of urinary
secretion and of the pathology of nephritis, one would
look to find :
(a) With diminished permeability of glomerules:
Diminished A Xcc.; increased r— -r;.
NaCl
(6) With increased permeability of the glomerules :
A
Diminished :r—- ; increased A X cc.
NaCl
(c) With diminished absorbing power of the convo-
luted tubules : Diminished A and -— -- ; increased
NaCl
A Xcc.
{d) With diminished secretion of urea : Diminished
A, A Xcc, and ^^j. ^
The urines of " renal disease " must therefore be far
from uniform ; the more so since none of these forms
ever exists pure. It is easy to see how difficult the inter-
pretation of the urine will become in such "mixed"
cases. If, for instance, (a) and (e) coexisted — which is
not at all inconceivable — the urine would appear nor-
mal, with very advanced renal changes. The matter is
still further complicated when cardiac disease coexists.
The statements of clinical observers support these
theoretic deductions. They agree that the urine is quite
variable and difficult to interpret.
V. Koranyi " ( page 15) states that A is low ; A X cc. variable ;
NiTri ** ^^^ *° °°® '■yps 8,nd high in another. As particu-
larly suggestive he« (page 782) regards the fact that a diseased
kidney cannot prepare a urine which varies much from AO-56.
This latter fact would be interesting if true, but so far as 1 can
judge he derived it purely from theory and does not seem to
have actually tried the effect of administering large quantities
of liquid to nephritic patients. Ijindemann^ disagrees with
this and claims that the A of the urine in interstitial nephritis
may be a half of that of the serum. He regards a low A— with
a normal water income— as the main pathogenic sign of neph-
ritis, and considers this as a means of differential diagnosis
between plain and nephritic albuminuria.
Claude and Balthazard' (pages 806 and 807) find the only
fairly constant phenomenon to be a very high '=j (corresponding
to low^^ ) ; A X cc. is variable.
October 25, 1902]
OPERATIVE TREATMENT OF HIP-JOINT DISEASE lamkhican mkdicinb 661
Waldvogel •» (pages 46 and 47) finds /\ usually low, ;^r=^
variable, but usually high. JNat^i
As regards salts in renal disease, Fleischer, 1881 (quoted by
Soetbeer, page 88), found that there was an actual retention of
P2O5. Soetbeer 21 (page 105) tinds acute nephritis and amyloid
degeneration of the kidneys characterized by irregularity in
the excretion of all urinary constituents, retention alternating
with compensatory hypersecretion, from day to day. In
chronic interstitial nephritis there is an abnormally great
excretion of acid by the urine.
If we combine these statements it will be .seen that
almost any cryosccpic combination ?««.!/ be found In
renal disease. Perhaps the most characteristic difFer-
ence from heart disease is that in renal disease
and A X cc. and A
in circulatory
NaCl
whereas
changes
to A X cc,
dated with a low A X cc. and a low
and A vary inversely
the evidence
all tend to be lowered
A
NaCl
When a low A exists, especially when asso-
A
NaCr
is fairly .strong in favor of renal disease. If such is not
the case, nephritis cannot be excluded. Indeed, the
normal limits are so large that cryoscopy cannot be con-
sidered a delicate method of diagnosing renal disease.
The value of the method is much greater if in.stead of
"nephritis " we use it to investigate the competence of
the kidney. Thus, a low A X cc, and especially a low
'5 X cc, indicates a deficient secreting power for urea ; a
high A X cc with low :j-r— an increased permeability
of the kidney, etc., according to the scheme given above.
The following tabulation may also prove helpful :
Higmflcance of Changes of Physical Factors.— how A :
Diuresis ; lessened absorbing power of the kidney ; lessened
metabolism (starvation).
High : Efficient absorbingmechanism; water withdrawal.
Low '^xcc. : Slowed renal circulation (cardiac disease);
impermeability of renal epithelium of glomerules ; low meta-
iiolism (starvation); salt withdrawal ; water withdrawal.
High A X cc. : Efficient function of the kidney ; abnormal
permeability of kidney; increased metabolism; salt adminis-
tration.
A
nitrogen metabolism;
I^ow j^^j : Diuresis ; salt administration ; deficient absorb-
ing power of the kidneys ; inefficient power of excreting urea;
deficient nitrogen metabolism.
High jj-r^pj: Salt withdrawal; starvation ; slowed renal cir-
culation (cardiac disease) ; increased
impermeability of glomerules.
I repeat, however, that the composition of the urine
is merely an aid to diagnosis. Considered as such, it
will well repay the investigator. But if any one
approaches the .subject of cryoscopy with the expectation
that it will solve on every patient the questions of phys-
iology and pathology which have so far withstood even
po.stmortem investigation and direct experiment, he is
doomed to disappointment.
.5. Uremia.— The cryoscopic changes in uremia do not
appear before the clinical .symptoms, are not quite con-
stant, and have, therefore, very small diagnostic value.
Much more can be judged from the A of the blood ; an
inerea.se of this almost invariably occurs, and is propor-
tional to the gravity. V. Koranyi" (page 782) found it
normal in a few of his fiital ca.ses, l)ut this is altogether
excei)tional, and can .scarcely be considere<l true uremia.
The urine was found by Claude and Balthaaard' (page
806) to show very low A X cc. and <' X cc. — ^ is
NaCl
usually low, but may be rather high when the circula-
tion hits become greatly slowefl.
6. FindinffK in OfJi^r Oonditiom.— There .still remain
a few miscellaneous observations to be mentioned. V.
Koranyi •' finds that severe mu.scular work lessens A and
A Xcc., but increases zrr:,-
NaCl
Nob6court and Delamare " investigated the urine of
pregnant women. They found A practically normal
in all X!ases. zttt, is also normal in the nonalbumin-
NaCl
uric urine and in certain of the albuminuric cases,
whereas in other cases of albuminuria it is rather high
(2.0 to 3.7). This may be due to interference with the
renal circulation by the pregnant uterus. But as no
special attention was paid to the diet, it may be due
simply to the latter.
7. Cryoscopy of Urine as a Means of Surgical Diag-
nosis.— According to Waldvogel '" (page 54, e. s.), one of
the most valuable features of cryoscopy is to determine
the efficiency of the kidneys when one of them is to be
excised, and in relieving the anxiety of the surgeon
when this excision has been performed.
He states (page 55) that if the urine possesses a A
superior to 1.0, excision of one kidney may be safely
done. After the excision the A and A X cc. are abnor-
mally low for a day in any case, but if the remaining
kidney functionates properly, they should recover their
normal value on the following day, and after that for
some days they are abnormally high. But if the A and
especially the A X cc. do not recover after this second
day, there must be grave fears that the remaining
kidney is also diseased.
BIBLIoaRAPHY.
> Waldvogel: Dcut. med. Woch., 1900, No. 46; 1901, No. 16.
2 Neubauer and Vogel : 'Analyse nes Harues," 10th ed., p. 709.
' Hamburger: Centralblatt f. Innere Medlcin, Vol. 21, s. 297, 1900.
* R6th : Centralblatt f. Physlologie, 1897, s. 271.
'L. l.indemftnn : 'Die Concentration des Harnes and Blutes bel
Nlcrenkrankhelten," Deutches Archlv. f. kiln. Medlcin, Vol. 65,8. ].
1899.
"Fr. V. Kornnyl, Berl. kiln. Wochenschr., Vol. .%, s 782. 1899.
' H. Claude and V. Balthazard ; " Cryo.scople des Urines," Journal
de Physlologie. Vol 2, s. 767, 804. 8:^1 and ii63, 1900.
» Fr. v. Koranyl : Zeltechr. f. kiln. Medlcin, Vol. 33, pp. 1 to .M, 1897 •
Ibid, Vol. 34, s. 1 to 52, 1898. •
»M. Senator: " Weitere Beltrage zur Lehre vom Osmotlschen
Druck thlerscher FlOsslgkelten," Deutch. med. Wochenschr., Vol. 26, s.
48, 1900.
"'Waldvogel: " KUnlsches und Experlmentelles zur NlerenDlag-
nostlk," Arch. f. Experira Pathol., Vol. 4B, s. 41, IWl.
lie. F. Hoover and T. SoUmann: "A Study of Metabolism during
Hypnotic Sleep," Jour, of Kxperlmenlal Medicine. Vol 2, p. 4 5. 1S97.
1= H. O. Neumann : Arch f. Hyg. and Infekt., Vol. 86, s. 248, 1899.
"Dieser: Arch. f. Exp. Pathol., Vol. 29, s. 303, 1892.
"Nobficourt and Delamare: "Cryoscople des Urines chez les
Femmes Enceintes," Journal de Physiologic, Vol. i, p. 993, 1902.
i«J. Forster: " Veryiche Qbcr die Bedeutung ilcr Aschebestand-
thelle In der Nahrung," Zeitschrlft f. Biologic, Vol. 9, s. 297 to 380 1873.
■■iSalkowskl : Vlrchow's Archlv. Vol. is. s. i'09 to 233 1871.
I'Gi-amatchlkov: Inaug. DIs.sert., St. Petersburg, 1890 (Kusslan).
Quoted In " Digest of Metabolism Experiments." Atwater and Lang-
worthy. Bull. 45, Office Expt. Stations, U. 8. Dept. Agriculture, 1898 8.
189 and 194.
i» W. Straub : Zeltschr. f Biologic, Vol. 37, p. 527, 1897.
I'D. Krummacher: "Ueber den EInfluss subcutan ln|lclerter
verdUnnterChlornatrlum-LOsungaufdIeElwclsszersetzung," Zeltschr
f. Biologic, Vol. 40. s. 17.3, IsOO.
»'A. Spiegler: ''Ueber den Stoff wechsel bel Wasserenlzlehung."
Zeltschr. f. Biologic, Vol. 41. s. 239, 1901.
«i F. Soetbeer : " Die .Sekretlonsarbelt der kranken Nlere," Zeltschr.
f. Physiol. Chemie., Vol. 85, 8. 85 to 110, 1902.
OPERATIVE TREATMENT OF HIP-JOINT DISEASE
BY
JAMES K. YOUNG, M.D.,
of Philadelphia.
Professor of Orthopedic Surgery, Philadelphia Polyclinic; Assistant
Orthopedic Surgeon, Hospital of the University of Pennsylvania.
A thorough consideration of the subject of the opera-
tive treatment of hip-joint diseases would occupy more
space than is allotted to this paper. It will therefore be
considered from the practical rather than from the scien-
tific standpoint.
The subject may be divided into the operative
measures eniploye<l for relief of deformity, and the
surgical operations required in the treatment'of arthritis.
An extended ex{)erienco in the management of cases of
arthritis of the hip-joint has convinced me that in many
instances operations may be avoided by early and
efficient conservative treatment. Hence conservative
treatment is far more important than operative. This
662 AMBBioAN mbdicinej OPERATIVE TREATMENT OF HIP JOINT DISEASE
[October 25, 1»02
fact is emphasized by the extreme rarity of the major
operations in private practice, clue to the better sur-
roundings and improved hygiene with personal care. I
have seen but one case in private practice that had been
continuously under the care of the same surgeon requir-
ing excision. When operative measures are required
Xo.i
'<^rton^
Fig. 1.— Diagram to illustrate different forms of osteotomy.
they should be thorough and definite, and should be
performed as quickly as is consistent with safety.
Under the operative measures for the relief of
deformity are included : (1) Multiple myotomy and
tenotomy ; (2) forcible straightening, and (3) osteotomy.
1. Multiple Myotomy. — When the ankylosis is of the
false variety, this method of treatment is frequently all
that is required, particularly when the second method of
forcible straightening is employed as an adjunct.
2. Forcible straightening by itself is not efficient for
the relief of deformity in hip-joint diseases, and great
iryury may result if tenotomies have not been performed
previously.
3. Osteotomy gives very satisfactory results in true or
osseous ankylosis, and the necessity for it can frequently
be determined by the skiagraph. Of the methods which
are employed the Adams operation (Fig. 1), through the
neck of the femur, is seldom required, on account of the
loss of the head and neck. The Barton or intertrochan-
teric operation does not give as satisfactory results as the
Gant or subtrochanteric osteotomy. In performing the
Gant operation it has been found more satisfactory to
use the chisel after the method of Maunder. In most
instances it will be found satisfactory to make a lateral
incision, particularly in children, but in adults it is
sometimes better to make an anterolateral incision. In
adults an oblique section of the bone is sometimes more
satisfactory than a transverse section. In some instances
the deformity is so great and the acetabulum has traveled
so high that the case is inoperable, no known opera-
tion giving satisfactory results.
After osteotomy for the correction of deformity
motion cannot be expected, as the limb is ankylosed in
the corrected position. On one occasion I made an
attempt, at the Home for Crippled Children, to make an
artificial joint by removing a large wedge-shaped section
from the surgical neck and trochanter. Motion was
kept up for three days, but the result was not satisfac-
tory, so far as motion was concerned, and the shock and
pain were so great that the operation did not compen-
sate for the risks that were taken. In cases of double
ankylosis fFig. 2) of the hip, after osteotomies have been
performed, it is best to set the limbs in an extended
position so that the patient may walk about on crutches,
although he cannot sit down very well, rather than to
set the limbs in a partially flexed or flexed position.
Under the operative measures for arthritis are
included, (1) aspiration ; (2) incision (simple) ; (3) eru-
sion (Willard) ; (4) excision ; (5) amputation.
1. Aspiration. — As an operative procedure this has
not been found satisfactory, on account of the thickness
of the pus and the presence of necrotic tissue. It is more
satisfactory in synovitis of the hip-joint, either for diag-
nostic or curative purposes, or as a prophylactic measure
against future tuberculous infection. The injection of
iodoform emulsion after aspiration of the hip-joint has
not been found satisfactory. In the small joints, as the
elbow and the ankle, it is valuable, but in the hip it
usually acts as a foreign body, and has to be subse-
quently removed.
2. Incision. — In performing the simple incision of the
hip-joint for the purpose of evacuating pus and examin-
ing the joint contents, the surgeon should always have
permission to proceed to a more radical operation if this
is found to be necessary. This will avoid delay. If,
upon making a simple incision, the disease is so wide-
spread that it cannot be entirely removed by curetage,
unless a formal operation is to be undertaken it is best to
manipulate the sac as little as possible but wash it out
with bichlorid solution after the method described in the
early part of the last century by Gross.
3. Evasion of the joint, after the method of Willard,
is favored in all instances when the disease is not exten-
sive, and particularly during childhood. The erasion of
the joint is accomplished by means of curetage of every
part of the joint surfaces, the debris being carried away
by the flow of sterile water through a canulated curet,
after which the iodoform emulsion may be thrown into
Fig. 2.— Double hip-Joint disease.
the cavity and drainage provided. All the sinuses
should be freely opened, as well as all abscess cavities,
and diseased tissues should be completely removed with
the knife and scissors. Erasion of the hip-joint is the
preferable operation in children even when the disease
is quite extensive, and the results more satisfactory, and
October 25, 1902]
BLASTOMYCOSIS OF THE SKIN
[Amkbican Medicine 663
it does away with the short leg which is frequently met
after excision.
4. Excision of the hip-joint, whether partial or for-
mal, is favored when the disease is extensive, particu-
larly in adults. In performing excision of the hip-joint
rapidity of operation, the use of an electrically heated
mattress and hypodermoelysis will diminish the shock
and reduce mortality. Rapidity of operation may he
facilitated by planning before beginning to operate, by
having a good corps of assistants, and by rapid aud sure
manipulation. Following the rule laid down by Ash-
hurst, excision was formerly considered equally fatal
with amputation at the same point. With the improved
technic in the socalled bloodless methods, the mortality
in the two diseases is equal only on account of the im-
provements in the technic of excision of the hip-joint by
rapidity of opera-
tion, conservation
of heat and hypo-
dermoelysis already
advocated.
Excision should
only be performed
in carefully selected
cases, and should
not be employed as
a routine measure.
The indications for
excision are long-
continued profuse
suppuration from
osseous disease and
albuminuria. One
very rare condition
may be mentioned
in this connection,
and that is the sepa-
ration of the carti-
lage by ulceration.
Only two such ca.ses
have been seen in
my experience.
This is indicated by
long continued
acute j)ain unre-
lieved by every
known method of
treatment.
The incision
which has been
found most satisfac-
tory is the curvili-
near one of Agnew
behind the great
trochanter. The
Fig. 3.— I'ott's disease, with hip-Joint disease -Rn-kp- nr nnterinr
reseinblliig sarcoma of the spine. uarKer, OF aiuerior
incision, has not
been found so valuable as was anticipated. If the disease
is extensive it does not give sufficient room, but in the
instances in which the disease is confined to the head
and neck it has proved satisfactory, but drainage must
always be provided posteriorly, in acute ulceration
producing separation the Barker incision and the
Adams osteotomy are very satisfactory.
5. Amputation. — I do not favor amputation for hip-
joint diseases, except in very rare instances. The fact
should always be borne in mind that excision was intro-
duced by the Fergusf^n school as a substitute for amputji-
tion which, at that time, was the j)referred operation.
The results of excision led to the disuse of amputation,
and I regret to see the present advo(«cy of amputation
by many writers of the present time. If the disease
has existed for a long time and a very extensive disease
of the ilium is present, amputation is contraindicated.
If the disease has extended down the shaft of the
femur beyond its upper third, and the disea.se of the
ilium is not extensive, amputation is indicated and may
be performed as a primary operation instead of excision,
or may be used as a last resort after excision has failed.
Illustrative cases of this kind have come under my
observation, in one of which, after extensive disease of
the femur following hip-joint disease, the hip became in-
fected and amputation was followed by a perfect result.
In another one of extensive disease of the iliac bones, I
declined the femur amputation, but it was performed by
another surgeon. The patient did not recover from the
shock of the operation, living but a week. I am there-
fore convinced that from these and other instances that
amputation should only be performed in very carefully
selected cases. Patients suffering from very extensive
disease should be treated by curetage, and should
be considered inoperable for more radical procedures
(Fig. 3).
The object of the present paper is to consider the
subject of operative treatment of hip-joint diseases from
the practical experience of 16 years of careful and pains-
taking observation in the special department devoted
to the treatment of these diseases.
REPORT OF A CASE OF BLASTOMYCOSIS OF THE
SKIN.
BY
ISADORE DYER, Ph.B., M.D.,
of New Orleans, La.
Professor of Diseases of the Skin In the New Orleans Polyclinic ;
Lecturer and Clinical Instructor on Diseases of the Skin,
;n Medical Department, Tulane University; President
Louisiana State Medical Society ; Editor New
Orleans Medical and Surgical Journal, etc.
This case of blastomycosis is interesting because of
its typical characteristics, its long duration in spite of
active treatment, its gradual but progressive spread, the
age of the patient and the general location on several
regions of the body.
Dr. E. Denfigre Martin, of New Orleans, first saw the
patient, who presented lesions on the right cheek, l)Oth sides of
the lower abdomen, both thighs, and on the loft leg on its outer
aspect. As Dr. Martin described these, they were much like
"indolent carbuncles," of slow development, all occurring
about the same time, somewhat elevatecl, and wlien the outer
covering broke there was a marked tendency to warty growth.
Acting upon the surgical indications. Dr. Martin freely
cureted the several areas affected, using subsequent antiseptic
dressings. All healed in due time, excepting the patch on the
leg. The areas on the face, abdomen and thighs scarred deeply.
In spite of varied and attentive care and treatment, the
growth on the leg continued to grow both in area and eleva-
tion, and assumed so formidable an appearance that I was
asked to see the patient to determine the malignant or carci-
nomatous nature of the disease.
Meanwhile a large lesion liad developed on the cheek, just
at the tjorder of the former scar, and a small lesion appeared on
the left thigh.
When first seen by me the leg presented a growth sugges-
tive of blastomycosis. There was a kidney-shaped patch, with
the concavity on the anterior side, of about four inches in the
vertical diameter and about two inches in width. The borders
were most elevated and weredistinctly fungating. In the con-
cavity of the growth there was marked scarring.
There was a foul, offensive discharge, ichorous, and of a
dirty brown color, which was here and there dried and crusted
on the growth. All over the diseased area were clots of papil-
lary V)lood vessels, looking black, and having the appearance of
small dots over the diseased surface.
Subjective symptoms were negative, beyond the pain inci-
dent to the dressing.
The patient was a Scotchman, aged 77, formerly a stevedore
and actively engaged in his occupation up to some four years
previous, when he retired. Flis surroundings are most comfort-
able, and he lives in an atmosphere of domestic cleanliness.
His general health had been always of the best, and when
seen his chief distress was the incapacitation incident to con-
finement in the house caused by his leg.
No history of antecedent syphilis could be a-scertained, nor
of any tendency to cutaneous disturbances. There was present,
and occurred from time to time, a rather acute manifestation of
seborrheic dermatitis, always limited, however, to the scalp
and to the hairy part of his face, which he wears constantly
clean shaven.
At the second visit, cultures were taken on bouillon and on
664 AHEBIOAN HBDlOtNE)
AUTOINTOXICATION
[OCTOBEB 25, 1902
acid agar from the areas of the (ace, leg and thigh, in all about
10 tubes. From these several successful cultures resulted and
were reported to me by Dr. .Toliu .J. Archinard, in whose labo-
Flg. 1.— Showing original lesion in upper third of left leg.
ratory the cultures from my previous case (see JoMr. Oen. XJrin.
and Out. Dis., January, 1901) were identified.
The lesion on tlie right cheek healed kindly in less than a
Fig. i.— Showing lesion In Fig. 1, as It ha,i developed between August,
1001, and August, 1902.
month,:'under dressiug.s of 10% resorcin solution in water,
yanea at times by an application of an ointment containing 3%
resorcm and 20% balsam of Peru.
The history of the thigh and leg has been quite different.
The patient was placed under active treatment January 20, 1901,
which has been constant until the present time.
Sodium iodid was instituted at the start and had been main-
tained throughout, increasing at times to the maximum of 120
grains a dose, three times a day. At time.s additional treatment
was given, consisting of strychnin, a preparation derived from
brewers' yeast, mercury biniodid, Donovan's solution of arsenic
and mercuric iodid, iron arseniate. Occasionally it became
necessary to omit the iodid, but it was always resumed and
carried to a large dosage.
Locally, mercurial plaster has been used for most of the
time; especially when the disease became aggressive and the
vegetations were most elevated it seemed to have the effect of
reducing these to the normal level of the skin better than other
remedies, and the lesion seemed to gi-ow worse under dry or
moist dressings. Ichthyol was used in watery solution and
lead iodid in ointment, also re.sorcin solution, mercurial
ointments, iodin, silver nitrate, wet dressings of bichlorid, wet
dressings of carbolic acid and of boric acid, sulfate of copper in
2fc watery solution, iodoform, etc.
During this whole period of treatment the leg all but healed
several times, while the thigh quite healed within the past two
months. Always, however, the leg would maintain one or two
spots of vegetating lesions, fulminating from time to time, and
covering within a few days the whole of the areas previously
affected in that region. This usually was accomplished by the
appearance of small bullas, quickly crusting and pustulating
and suddenly forming a papillary border, growing wider from
day to day.
The present condition, as shown in the second photograph,
has now been constant for over six weeks, and the most of the
area formerly affected is practically well, as a firm skin has now
formed. The lower border of the present area presents a band
of fungating lesion about a half inch in diameter, and measur-
ing an arc of about 4J inches long. The photograph shows the
advance of the disease from the upper third of the leg, moving
downward in a wide band until it now is in the lower third,
just above the ankle.
The treatment at present consists in daily irrigation with a
2% carbolized water solution, followed by a dressing w'ith a
powder composed of equal parts of nosophen, orthoform, calo-
mel, compound sterate of zinc and arrowroot, alternated with
the mercurial plaster when there is any crusting.
Internally the treatment at present con.sists of a dosage of 90
drops of sodium iodid per diem and ^ grain of strychnin sul-
fate three times a day.
If after a reasonable time the disease does not again spread,
we will euret and treat surgically.
AUTOINTOXICATION IN RELATION TO MENTAL AND
NERVOUS DISEASES.'
BY
JAY G. ROBERTS,
PH.fi., M.D.,
Chairman of the Section on Nervous and Mental Diseases, Nebraska
State Medical Society.
Although the principle of autointoxication has been
empirically recognized or assumed since a very distant
time, it has only been at a comparatively recent date
that anything like a definite or .scientific conception of
the subject has existed, and even now much of the
inf )rmation on the subject i.s in a very choatic state and
hard to classify.
That it was recognized and even greater stress laid
upon its correction than its importance demanded, is
evidenced by the universal practice of bleeding and
purging resorted to by our forefathers in medicine.
The time-honored custom among the laity of taking a
blood purifier, always composed of cathartics and elimi-
nants, is prompted doubtless by a vague and perhaps
unconscious conception of the principle of autointoxica-
tion, and it is a fact that many of these time-honored
customs have accomplished results which our scientific
scorn ha.s not yet been able to relegate to oblivion.
The influence of autointoxication upon nervous and
mental disorders ha.s been hinted at by the widespread
tendency toward eliminative treatment, but with the
exception of Brower, Butler, ^'^aug]ln, Pearce and a few
others, authors have laid little stress upon this factor in
the etiology of this class of disorders.
The toxic effects upon the central nervous system of
noxious gases and toxins absorbed from a .sluggish ali-
mentary canal are manifested by the attendant headache,
' Read before the Nebraska State Medical Society, May 6, 1902.
October 25, 1902]
AUTOINTOXICATION
Ambricak Medicink 666
vertigo, and general malaise ; while in children, fever,
rapid pulse, and convulsions are common.
Nor are these the most pernicious of its effects. By
its influence upon the general metabolism it contributes
largely to that more important form of autointoxication
long known under that ambiguous and much-abused
term, the uric acid diathesis. As has long been known
uric acid itself is not a toxic substance but a perfectly
harmless one, nor are the manifestations of the socalled
uric acid diathesis due to the retention of uric acid in
the system, but to the presence of certain products of
suboxidation known as the purin or alloxuric bases,
prominent among which are xanthin, hypoxanthin,
guanin, and adenin. These violently toxic substances
are the products of the suboxidation of worn out body
cells, leukocytes, etc., and certain articles of food which
by complete oxidation are converted into the harmless
and inert uric acid and thus eliminated.
It may readily be seen, therefore, how anything
which might interfere with the complete oxidation of
the purin bodies becomes at once a factor of supreme
importance in the welfare of the neurotic individual.
The effect upon the oxygen-carrying properties of
the red blood-corpuscles, of the absorption of toxic mat-
ter from the intestinal canal, is well known, but the
effect of this diminished oxidizing power through the
production of such highly toxic substances as the purin
bases has not been estimated properly.
It is evident, therefore, that the form of autointoxi-
cation usually considered, namely, that arising from
morbid alimentary action, is secondary in importance to
that graver form due to suboxidation, in the production
of which it may be and usually is a factor.
The beneficent effects of strychnin in the treatment of
nervous disorders, which it might naturally be expected
to aggravate, are to be explained upon the basis that by
stimulating respiration and metabolism it increases the
oxidizing processes of the body, thus completing the oxi-
dation of the alloxuric bases. Likewise the ill effects
often noted upon the sudden withdrawal of tea and coffee
from neurotic patients.
As stated previously, the purin bases are also derived
from certain articles of food, viz., those containing a
large amount of nucleins, as liver, kidney, sweetbreswis,
spleen, thymus, etc. Therefore, in arranging a diet for
neurotic patients these articles should be carefully
avoided.
In my article before this association last year I made
the statement that autointoxication was the fundamental
cause of the majority of cases of neunisthenia.
Now I wish to go further and say that in my opinion
it is the underlying cause of all cases. An unstable
nervous equilibrium, heredity, etc., may be predispos-
ing causes, but the underlying condition is a toxemia,
and the various sensory manifestations of the disorder
simply the effects of the toxic substances upon the sen-
sory nerves or nerve centers.
It is apparent that the influence of overexertion either
mental or physical is not alone confined to its consump-
tion of an already exhausted store of nerve energy, but
by increasing nuclear debris, always the product of
activity, mental or physical, it tends to increase the
alloxuric bases, which in turn exert their pernicious
effetits upon the nervous system.
A criticsil olwervation reveals in all but degree of
intensity a startling resemblance between the various
sensory manif<«tations of neurasthenia and those of many
infectious diseast«. Notably influenza, in which the ceph-
alalgia, backache, and other sensory symptoms are held
to be the effwts of the toxin of the causative germ. 8o in
neurasthenia the pains are undoubtedly due to the effects
upon the sensory nerves of these self-manufactured
tf)xins.
The influence of autointoxication in epilepsy is too
well known to need mention, though it maybe said that
while epilepsy is essentially a habit spasm, aut4^>intoxica-
tion, through its influence upon the inhibitory centers,
contributes to the formation of the habit. The prone-
ness of autointoxication to produce convulsions in chil-
dren is evidence of its importance in disorders of the
convulsive type.
In no condition perhaps is autointoxication a more
pronounced factor than in migraine, and to this fact is
due the success obtained recently in the treatment of this
affection by oxygen inhalations.
Nervous dysmenorrhea is always found to assail
women with sluggish and imperfect elimination, the
socalled bilious type, while from the fact that menstrua-
tion is to some extent an eliminative function, the auto-
toxic state may be increased by mechanic interferen:'e
with its performance.
To this cause also may be attributed the various
neuroses and other nervous psychic manifestations of the
menopause when the eliminative function of menstrua-
tion is suddenly thrown upon the other organs of elimi-
nation, and the subsidence of such manifestations when
these organs have fully assumed this extra responsibility.
So also the disturbance of pregnancy and the puer-
perium, when the organs of elimination must carry on
the work of two, which work constantly increases in
amount up to the time of delivery.
Many operation neuroses are doubtless dependent
upon autotoxemia due to sudden inhibition of elimina-
tion through fright or the action of anesthetics, the
inhibitory action of which upon the various vital pro-
cesses is well known. It is a factor of more or less
moment in surgical shock, a faet borne out by the
efficacy of transfusion or hypodermoclysis in its treat-
ment, which effect cannot be entirely the result of
stimulation of the heart or increasing blood-pressure.
That the various neuroses resulting from psychic shock
or insult are brought about, to some extent at least,
through the agency of autointoxication is not to be
doubted by those who have noted the pale, limpid urine
in these cases with its almost total absence of solid con-
stituents.
At present, how far this faetor of autotoxemia is
concerned in the production of tabes and paretic demen-
tia can only be surmised, but that progressive sclerotic
changes may be produced by the continued irritation of
the products of chronic autointoxication is no more
unlikely than that they may be due in syphilitics to the
toxins of syphilis, which is now generally conceded.
When we remember that some of the severer forms of
autoint(ixication resemble very closely in their mani-
festations these two grave disorders, we cannot but be
struck with the plausibility of the suggestion.
Many cases of temporary mental aberration, uncon-
scious automatism, and acute confusional insanity are
due to more or less acute conditions of autointoxication.
As evidence of which I will submit the report of a case
which recently came under my notice. The patient in
question had but recently made a considerable journey
by rail, the influence of which in aggravating conditions
of autointoxication is well known.
Cask.— Mr. P., aged 52, is a well-built, intelligent man ot
medium heiebt, weighing about 170 pounds. Ho had just come
a considerable distance to see a friend and had no other
acquaintance in the city. Toward evening on the day follow-
ing his arrival be began to act strangely, seemingly out of his
head, was very rootless, this constantly increasing in intensity
until I was called about 8 o'clock.
I found the patient in a state of great excitement, though
not violent until forcibly restrained. He seemed entirely obliv-
ious to his surroundings and kept moving constantly about
from place to place, reminding one of the active delirium of
typhoid. He had lost all sense of propriety and would urinat«
wherever ho happened to be, regardless of the presence of ladies
or others.
His pupils were moderately dilated and his tongue was
coated : his temperature 101° and pulse 99; urine was acid, sp.
gr. l,0"i'). There was no sugar, albumin, or casts, Init a large
amount of phosphates. Inquiry of his friend developed that
he was itadly constipated, his bowels not having moved for a
week.
No hospital being available he was taken to the county jail
666 AMERIOAK' Hxdioinej
RELATION OP POLITICS TO THE HOSPITAL
(OCTOBEa 25, 1902
and placed in a cell. A mercurial purge and an enema were
administered and a dose ofbromids given which, however, hsid
little or no effect, as his restlessness and excitement continued
until morning when he was almost exhausted. The cathartic
then operated thoroughly and was followed liy almost imme-
diate quiet and signs of returning reason. By noon he was
quite rational, though very weak and somewhat dull. A saline
was given and he was removed to the home of his friend, where
he made an uninterrupted recovery.
Subsequent inquiry developed that he had absolutely no
remembrance of anytniug that occurred during the night,
and of course he was greatly surprised at finding himself in jail
the next day. He had never had such an attack Ijefore and
there was no history of insanity in his family. He did not
drink, used tobacco but sparingly and denied absolutely any
venereal history.
Here, then, was a case of acute confusional insanity,
undoubtedly the result of autointoxication.
The element of periodicity in nervous and mental
manifestations, causing a tendency to recurrence upon
slightest provocation, makes it not unlikely that if the
patient ever again becomes the victim of any such pro-
found autointoxication that similar psychic manifesta-
tions will likewise follow.
It has not been my purpose to treat this subject
exhaustively ; indeed, such is not possible within the
scope of a paper of this character. I have endeavored,
however, to empljasize the importance of autointoxica-
tion in the consideration of nervous and mental dis-
orders and to draw attention away, in a degree at least,
from the factors surgical, psychic and gynecologic which
have so long held the attention of the profession to the
exclusion of all things else.
SPECIAL ARTICLES
THE RELATION OF POLITICS TO THE HOSPITAL.'
BY
WALTER LATHROP, M.D.,
of Hazleton, Pa.
Superintendent and Surgeon State Hospital, Hazleton, Pa.
The part played by politics in the management or work of a
hospital has been the subject of much thought, and a good deal
has been spoken and written upon it.
That many institutions are hampered by the influence of
politics and politicians cannot be denied. Whether this influ-
ence is from without, or within, it is always a serious question
to consider. The State hospitals of Pennsylvania are under
control of a board of trustees appointed by the Governor. The
superintendent is the chief executive of this board, and through
it has control of the institution and its workings. The authority
rests with a small number, while the subordinates and
employes may be numerous. The successful management of
such a hospital depends upon the cooperation of the managers,
or trustees, with the superintendent ; and it therefore follows that
the longer the managers are kept intact as a body the more will
the usefulness of the institution be increased. The best judges
of good res\ilts are those who have the most experience. This
experience in turn affords an opportunity to speak with author-
ity on matters pertaining to the workings of an institution. The
influence of politics, in the sense in which we xisually speak,
would be detrimental to the progress of any institution and
prevent a proper growth both in the scientific or professional,
as well as the executive or business department. The fear
or expectation of being removed by a change of political party,
regardless of ability shown, or services rendered, does not tend
to encourage any man, or set of men, to labor with the same
earnestness as would be the case where merit, and that alone,
counted in the scale of justice.
State hospitals as well as municipal institutions have a
board of managers, or trustees, who are responsible to the pub-
lic through the several powers that make appointments. In
some instances these boards, or a greater part of them, change
1 Read at the annual meeting of the Association of Hospital
Superintendents of the United States and Canada at Philadelphia,
October, 1902.
with each successive political party, without any regard for
ability or services rendered. Following such changes there
may be a general shake-up in the institution itself, and favors
distributed where they are thought to count most in political
strife or the control of votes for future use. In such instances
we may well believe that the relation of the hospital to politics
is a close one and a detrimental one. I do not agree with a cer-
tain distinguished surgeon and hospital director who said not
longagothat" the State, county and municipal hospitals require
their board to be responsible to the people through the several
superior appointing powers. Unfortunately, however, such
boards follow the complexion of the prevailing political party
and change not by civil service rules and very seldom by merit,
but by political favor. The result is that these boards may
be made up of politicians and the affairs of the institution
conducted on political lines, with all that that usually implies.
Unless something flagrant happens, what is everybody's con-
cern is not any one's special duty. These hospitals are con-
ducted by the boards of managers without question or control
therefore, and they may do anything with the appropriation,
and establish most outrageous rules and methods of manage-
ment, provided the visit of the official inspectors can be antici-
pated and accounts and reports arranged accordingly. Reports
and accounts are easily manufactured, and unless a thorough
examination be made of all the affairs of the management it is
impossible to cheek them. This thorough examination is
rarely ever made."
From what I know of the management of State hospitals,
and I speak only of Pennsylvania, lam sure that no such con-
ditions could exist, for no report could be doctored up or appro-
priations be used to suit the convenience of those in charge. I
know also that the audit of books both by members of the
board, and followed by paid accountants, who have no connec-
tion with the institution, would refute any such statements.
Further, the examination periodically by a State auditor would
tend to establish a system of economy and honest administra-
tion. I am speaking only of what I know, and from personal
experience. Abuses and mistakes there may be in some
instances, but flagrant misuse of an appropriation I do not
believe. An endowed institution is governed as a rvile by a
number of managers, or trustees, and they are not responsible
to the State, save in their report to the Board of Public Charities,
and if they have asked and received any aid from the State,
then an itemized report must be made out and sent in every
three months before any money is paid out from the State
Treasury. Inward strifes, petty jealousies and friction are often
the cause of more trouble, and interfere more with the proper
workings of an institution, than politics. This may also occur
among boards of managers, or the visiting staff, and make
things unpleasant for all. I know of one instance where the
entire staff of physicians resigned from an institution, appar-
ently from motives of jealousy, and where a few had more pull
than others. This same hospital was without a visiting staff
for several years, being attended by one physician who held
favor with the managers. Here also the superintendent was a
potent factor in breeding discord ; he was obliged to resign,
and his successor, a physician, after a rather trying tenure of
oflfice resigned also. Today the staff is again organized, and all
seems to be harmonious. There is a moral in this for a superin-
tendent, and that is not to think he is the whole thing, for there
are others.
The State of Indiana after a struggle of years with political
administration of State funds and charities, and during which
time many forms of corruption pervaded the institutions,
adopted the idea of a Board of Public Charities, appointed
without regard to their political affiliation and without salary.
The result has been a gradual and important uplifting of the
standard of the institutions and reduced expense. In six
years the expenses were reduced from ^630,168.79 to ?209,956.22,
or over 66%. This speaks for itself.
In Pennsylvania all appropriations for institutions must be
recommended and approved by the Board of Public Charities,
and while some may be favored more than others by means of
political pull, and, in fact, are thus favored, the tendency of the
board is to deal justly with all. Some hospitals ask for more
than is necessary, and expect to be out down to about what Is
October 2o, 1902]
MUNICIPAL WATER-SUPPLY
iAMBKICAN MeDICINB 667
needed. Others wishing to be honest in their request ask for
what is absolutely needed, and in many instances the honest
institution gets left behind. There is no doubt but what poli-
tics plays a strong part in the securing of funds, and in the
administration of many of our institutions, just as it controls
votes and swerves men to the side of wrong ; just as it exists
now so it will continue, unless the millennium is at hand. In
the work of hospitals politics should be eliminated absolutely,
but how to do it requires a wiser head than mine to say. It
injures not only the good name of the institution, but those
most dependent upon its care, the sick and injured ; it creates
suspicion, distrust of all its work, but sooner or later like a
boomerang, it returns to the starting point and the instigators
are exposed.
President Roosevelt once said in an address : " Cheap men
are always pushing to the front, demanding recognition, while
the able and responsible men are not in the cheap market.
When a State goes about in the person of her officials seeking
cheap men and cheap work, she is most certainly laying the
foundation of her own degradation. All business recognizes
the idea of good able men at good prices, and if the State does
not do so she must suffer, for cheap men and cheap things are
ever a menacing danger." The relation of politics to the hos-
pital is often the reverse of the above ; a political debt is paid
by a political job, without regard to the fitness of the man
appointed, and the resulting damage is great, but the man with
the pull has paid his political debt and it matters not who suf-
fers. Authority and service should meet on common grounds,
the one demanding and the other being able to meet the
demands ; and unless there is sincerity and honesty of purpose
the efficiency of any institution will be weakened. It has
been well said that " poor service is always a consequence
upon ignorance. Poor service not only engenders a loss to the
State, but also a loss to the individual. Poor service is a crime,
inasmuch as it obtains money under false pretenses. Poor
service is the bane of institution efficiency and the cause of
many hours of weariness and woe to the chief executive
officer." This would surely apply to an institution in which
politics played an important role. My personal experience
with politics in hospital work has been very small, and while
I am connected with a strictly State institution and in a State
supposed to be controlled by a few politicians, I am proud to
say that in ten years there has been no change in our board of
trustees, save by death or removal to another district. We
have a very influential board of trustees; their influence has
been used only for the highest and best interests of the institu-
tion, and each one has given honest effort and personal support
to all that furthered the advancement afld usefulness of the
hospital.
There are doubtless quite a number present who have had
more experience than I in this line, and can speak on the politi-
cal relations of the hospitals from their personal observations, so
I will not trespass further on your time. In conclusion, I would
say that no one is a better judge of the needs of an institution,
of the services rendered, or its faults, than the chief executive
or superintendent. He comes in daily contact with and is
hold responsible for the various workings of his hospital. By
observation, close application, and sincerity of purpose, he
should be the judge whose opinion and conclusion carry weight,
and I am sure that one who shows loyalty to his hospital'
fidelity to his work, and straightforward relations with his
board of managers will have no need to complain of the inter-
ferenceof politics either from without or within.
Governor Odell, of New York, in a recent address said:
" Politics should never be permitted to be a factor in the admin-
istration of institutions for the unfortunate. It has no place
there, and I have so much confidence in the wisdom of our
people that I do not believe they would tolerate such interfer-
ence and would be quick to condemn those who were instru-
mental in taking advantage of the deplorable physical
conditions which exist in our institutions for either party or
personal benefit."
Qiiaranline Balsed.-^Owing to the excellent wnditions
prevai ing at (Juban ports the Florida quarantine against Cu la
■was raised on October 15. fully two wee^s earlier thin usual
METHODS TO BE PURSUED AND SOURCES TO BE
CONSIDERED IN THE ADOPTION OF A MUNICI-
PAL WATER-SUPPLY."
BY
WILLIAM G. BISSELL,
of Buffalo, N. Y.
Bacteriologist, Department of Health.
In deciding upon and investigating a source for a public
water-supply, both practical and scientific measures should be
employed and carefully considered. By practical I mean the
question of economics, i. c, the cost to the consumer should be
considered. It may be argued that a municipality should have
a pure water-supply at any price, and this is true ; but it must
be remembered that pure water can be obtained under differ-
ing conditions, greatly affecting the price. For example,
Buffalo pumps its supply from Niagara river. It is practically
the water of Lake Erie that is supplied to the consumer, and it
is not unpolluted by any means. The city of Buffalo unques-
tionably obtains a considerable amount of its typhoid fever
from the use of the water supplied direct to the householders.
Such water can be made absolutely safe by means of individual
household purification, and if this measure was observed in
each household, the amount of typhoid fever occurring in the
city of Buffalo would be limited to that imported from other
localities. This method is, at the present time, the most practi-
cal means of purifying Buffalo's supply, because it is less
burdensome to the persons subjected to taxation.
As to scientific measures, engineering, chemic and bac-
teriologic examinations are essential. The competent sanitary
and hydraulic engineer can determine the means by which a
supply can be brought to and distributed through a munici-
pality. The water analyst can determine the exact quality of
the water distributed. In determining the quality of water
both chemic and bacteriologic investigations should be car-
ried on, the one supplementing the other. From the strictly
sanitary standpoint the bacteriologic examination will be of
the greatest value for, as regards the dissemination of disease,
the composition of waters makes little difference, providing the
elements of sewage are not contained therein. Such elements
are best detected by bacteriologic means.
The different sources from which a municipality may derive
a water-supply are as follows: (1) Rainfall direct; (2) ground
water; (3) surface water ; (4) subsurface water.
Direct Rainfall.— The rainfall as collected from roofs and
stored in cisterns is but little used in this part of the country even
as a private source of supply. Good water may be obtained by
this means, but in a municipality impure water is more often
met than that which is satisfactory. The purity of rain-water
depends upon several factors: (re) The condition of the atmos-
phere through which it falls; (6) the character of the roof over
which it flows; (c) the kind and condition of the cistern in
which it is stored. In the country districts, on account of the
freedom of the air from impurities, the quality of rain-water is
usually good, but in cities, water so collected is sure to contain
objectionable qualities. Clean metal or slate roofing does not
injure the quality of rain-water, but wooden shingles, foul with
dust and decaying vegetable matter, will cause the water to
become "musty " a short time after its collection.
Storage and around Supplies.— The condition of the storing
receptacle greatly affects the quality of a water. A cistern should
be constructed of masonry and should be well ventilated. It
should be frequently cleaned and should never bo located in a
dark and inaccessible corner under a building. The frequently
adopted filtering appliance, of building a brick wall partition
through which the water percolates, should be condemned, for
such appliances are filters in name only and are a greater
evil than benefit, since they cannot be cleansed.
Ground water is, in many respects, the best source of sup-
ply that can be obtained. Such water is more or less purified
as it filters through the soil and by the layers of soil lying
above, it is protected, to some extent, from surface pollution.
While this is the rule there are many exceptions. In the
1 Read before the ^Ksculaplan Medical Society of BuOblo, March 20,
668 American Medicinkj
MUNICIPAL WATER-SUPPLY
[October 25, 1902
country districts which are not thickly populated this source
of supply Is the most desirable, but in municipalities ground
water can seldom be relied upon for purity, unless it is taken
from a higher elevation and at a considerable distance from the
city it is to supply. Among the methods by which ground
water can be obtained are: (1) Springs; (2) dug wells; (3)
driven wells; (4) infiltration galleries; (5) large open wells.
Spring water is usually very desirable, provided the water-
shed is in an unpopulated district. When a spring is considered
for a public supply it should be submitted to careful scientific
investigation, and if the water is found to be adequate in quan-
tity and wholesome in quality the outlet and collecting basin
should be thoroughly cleaned and effectually protected by
masonry. Such procedure has been successfully carried out in
many small municipalities.
Dug Wells. — Of these, the one usually found in the individ-
ual farmer's yard is a good example. Such a means of obtain-
ing a water-supply has been in existence from time imme-
morial. The quality of the water secured by this method varies
greatly, depending largely on the formation of the soil in which
the water lies or through which it has passed. Water absorbs
more or less of the soluble matter found in the different kinds
of earth strata, and in regions containing limestone the water
will be very " hard," due to the presence of calcium carbonate,
while that passing through saline, sulfur, or iron formations,
■will contain differing amounts of the materials mentioned.
The chief difficulty that arises in the use of dug wells as a
source of ground water-supply is, that while the water may be
naturally a good quality it is liable to pollution in many ways.
In country districts a well, located apart from all buildings
and barnyards may retain its usual character, but a well
situated close to or under inhabited dwellings is very liable to
contamination, and the greater the number of inhabitants the
greater is the danger.
Danger in Private Supplies.— When a public water-supply,
of any known degree of purity, has been introduced into a city,
all wells should be abandoned. It is frequently very difficult
to convince the members of a household that their well is pol-
luted. The argument universally used is that the members of
the household have used the water for 20 years or more without
the slightest harm, which in their opinion must prove that the
water is safe at the present period. A short time ago the
authorities of Chautauqua Assembly passed through such an
experience, and in their efforts to close wells that were found
to be polluted they involved themselves in expensive litigation.
Driven wells are those bored to a considerable depth, and
usually extend through a strata of rock. They have the advan-
tage of economy and simplicity in construction and operation.
Such water-supply is, however, open to the same dangers as
dug wells and is rarely considered serviceable for city use.
Infiltration galleries are widely used in certain sections of
the country, and particularly in Vermont. This consists in
sinking a horizontal wall in a sandy or gravel soil formation
alongside or in the near vicinity of a stream. The water so
secured has the usual characteristics of ground water. It is
most prone to the growth of vegetable formations which invari-
ably impart a peculiar taste, and although it is in a degree filtered
water, such filtering appliances readily become foul and fail to
produce a safe supply. Too much reliance should not be placed
on the filtering qualities of infiltration galleries, as no form of
a filter can long continue to be effective that does not permit of
cleansing. In a personal investigation of the water-supply of
Bradford, Out., which has an Infiltration system, I found that
80% of the bacterial flora passed through the filtering gallery.
Artesian wells, occasionally used as a source of water-
supply, generally reach a very deep-seated water. There
seems to be a popular opinion that water so obtained is invari-
ably of good quality. Facts, however, do not support this
view, for water so obtained is apt to be charged with mineral
constituents that render it objectionable for domestic use,
although it may not contain organic impurities.
Large open loells are merely exaggerated forms of dug wells,
being perhaps 40 feet instead of 4 feet in diameter. They are
open to the same objections as are dug wells, but have the
advantage that two or three, suitably located, may be used as a
public supply to an entire municipality.
Surface-water Supplies. — The large cities of the country
most frequently depend on surface waters for their supply.
Such water is obtained either (1) from small streams, (2) rivers,
or (3) lakes. Water so obtained is usually soft and especially
well suited for general commercial and domestic use, but at the
present time it is more prone to pollution than any other source
of supply. The general introduction of water-flushing sewer
systems throughout the world has resulted in the universal
contamination of most natural waterways. Many surface
waters which were formerly adequate and pure supplies for
cities using them, have forced municipalities either to seek
means of purification by the expensive construction and main-
tenance of filter-beds and household methods, or use the pol-
luted water and reap its evil results. Illustrations might be
enumerated by the hundreds, but the fact is so well known that
it does not seem to require much comment. By the use of
streams and rivers into which sewage flows the results are
generally more serious than by the use of lake water. The
old idea that running water purifies itself to any extent is
erroneous, and personal observations along this line confirm
the results obtained by many other investigators, that mechanic
agitation and aeration play little or no part in the purifica-
tion of water. Water going over Niagara Falls is of the same
character as regards pollution as that in the river just above.
In the use of lake waters the factor that lessens the danger
is that the organic sewage pollution, if the lake is large enough,
is given an opportunity to settle and become deposited on the
bottom and there undergo slow oxidizing changes which ren-
der inert much of the contamination. The public water-
supply of Buffalo is a good example of this condition. When
the water of Lake Erie is not disturbed the sewage that is
emptied into it by the cities of Erie, Cleveland, etc., .settles to a
large degree before it reaches Buffalo. During high winds and
storms. Lake Erie, being comparatively shallow, has its bottom
disturbed, and the dirt so frequently found deposited in the
bathtub during certain seasons of the year, is due to this cause.
If the reports of the Health Department are consulted it will be
observed that the typhoid rate invariably increases 14 days
following such occurrences, which demonstrates that the water-
supply from Lake Erie is directly responsible for some of
Buffalo's typhoid.
Purification of Water-supply.— 'Whenexer it is necessary to
depend upon a polluted source of supply, resort should be had
to some means of purification. In no branch of sanitary science
has more progress been made than in that relating to the puri-
fication of water. While there is still much to be learned in
regard to this matter, our knowledge of the subject has reached
such a stage that no city need hesitate to introduce means of
purification for fear of failure to accomplish the desired result.
The means of water purification which are in more or less
common use are three: (1) Sterilization; (2) sedimentation;
(.3) filtration.
The common method of household sterilizing by boiling is
familiar to almost every one. This method furnishes an abso-
lutely safe water at a slight cost. It is a method necessarily
limited to private use, for the wholesale treating and distribu-
tion by municipalities would not be feasible.
In treating waters which carry a large amount of matter in
suspension, as is the case of several western rivers which do
not contain sewage, sedimentation is the best means of purify-
ing. Such water, although muddy in appearance from the sedi-
ment it contains, will clear and to a greater degree purify
itself by being brought to a state of rest, or by flowing at a low
velocity through suitably constructed reservoirs. If the objec-
tionable features consist of finely divided particles of the soil
through which the water has passed, sedimentation is all that is
required.
The process of filtration is in all respects the most impor-
tant, particularly as regards efficiency. The types of filters
used are of three kinds : (1) The domestic filter that is applied
to the household tap ; (2) mechanical filters— to filter water on a
large scale; (3) filter-beds for use in public supplies.
Of domestic filters there is but one type that is efficient.
Sand, charcoal and gravel, even in combination, will not, on a
small scale, retard the passage of bacteria. By the use of
unglazed porcelain the majority of bacteria can be retarded for
October 25, 1902]
THE WORLD'S LATEST LITEEATUEK
fAKXBICAlr MeDXCINE 669
a greater or less period of time. Mechanical filters are usually
made of some coarse-meshed material and a coagulant used,
like alum, to precipitate the organic matter. Filter-beds are
constructed on a large scale, witli the use of gravel and sand.
They are efficient if properly maintained, and many European
cities of today owe their low deathrate in typhoid fever to
this means of water purification.
It is most important, before water from any source is
used for a drinking-water supply, to know exactly its relative
degrees of purity. The methods of water analysis are too lengthy
and technical to be taken up here, but perhaps a short discus-
sion as to the methods of procedure and the interpretation of
results would be of interest.
There are three distinct methods of water examination : (1)
Chemic; (2) bacteriologic ; (3) biologic. The biologic exam-
ination is not of much value in determining the relative degree
of purity of a water, but it not infrequently explains why that
from a certain source possesses a peculiar odor or smell, as
tliere are a host of different vegetable growths and small ani-
mal organisms which will influence these conditions in water,
making them unpalatable for use, yet not unwholesome. In
older times chemic results were most relied upon to establish
the purity of a water. Most persons not familiar with the
work consider that it is only necessary to submit a sample of
water to a chemist and that he can tell if it is pure and whole-
some. Unfortunately thp problem is more complex and diffi-
cult, and although frequent analyses have been made and
judgment rendered upon this plan, experience and time have
taught their superficiality. No person is competent to give an
expert opinion on the purity of a water from a chemic standpoint,
unless he knows the surroundings of the well or other source of
supply, since conditions of surface drainage as well as under-
ground geologic structure may furnish clues for normal varia-
tions in the chemic character of the supply which might other-
wise be interpreted as impurities, and vice versa. In chemic
examination there is determined the amount of free and albu-
minoid ammonia, the oxidizable organic matter, chlorin,
nitrites and nitrates.
Every water, or at least water of a limited locality,
has its local standard of ingredients. The raw nitrogenous
material, no matter whether it is of animal or vegetable origin,
is represented by the amount of albuminoid ammonia found.
This material is the food of many water bacteria, and through
their agency is converted into free ammonia. No sooner is
the free ammonia produced than it is attacked by another class
of microbes which first convert it into nitrites and then nitrates.
Thus the successive production of free ammonia, nitrites and
nitrates represents three distinct stages in the conversion of
deleterious organic matter into harmless compounds, each less
capable of furnishing pabulum for disease-producing bacteria.
By knowing the relative amounts of albuminoid and free
ammonia, of nitrites and nitrates, one can gain some idea of
whether a contamination is of present or antecedent duration.
Thus an excess of albuminoid ammonia above the normal
standard, with a deficiency of nitrates, would point to a present
contamination ; an excess of each, to both present and antece-
dent ingress of organic matter ; while a deficiency of albuminoid
and free ammonia and an excess of nitrates would point only
to antecedent contamination.
Too much stress, however, cannot be laid upon the impor-
tance of knowing by repeated analysis what should be the
normal amounts of all these ingredients in the water under
oljservation.* The chemist can as yet throw no light upon the
character of the organic impurities found in water, his deter-
minations are quantitative not qualitative; and yet we desire
above all else to know something a-s to the source of these
impurities. In this regard the bacteriologist can render
greater service than the chemist.
It is known that certain bacteria are associated with special
kinds of organit; infusions, so that their presence in water
becomes a guide to the nature of theseorganic impurities. Thus
the colon bacillus is a constant inhabitant of Imman and animal
feces ; its continued presence in water Is therefore an index
of fecal contamination. Sacil/us vulgarin is a common asso-
ciate of decaying animal matter. Bacillun cloaca and Sacillus
enteritidis-sporogens are common inhabitants of sewage, and
Bacterium aerogenes of milk and household wastes. Anyone
of these germs are strangers to wholesome water, and their
discovery in the latter are probably sufficient grounds for
considering the water with suspicion.
Much importance was formerly laid upon the number of
bacteria per cubic centimeter. Lately we have learned that
this has only slight value. Here again it is important to have
local standards and to know the normal ranges of variation.
A slight admixture of earthy matter scarcely sufficient to
affect the appearance of a water may double or treble its bac-
terial count and have no significance from a hygienic stand-
point. For this reason river waters are subject to consider-
able variations in the number of bacteria. Well and spring
waters are more constant, so that a sudden increase in this case
above the normal may give grounds for suspicion.
Just so long as American cities pour their sewage into
waterways and drink the water unpurified, just so long will
epidemics occur of water-borne disease.
THE WORLD'S LATEST LITERATURE
Journal of the American Medical Association.
October 18, 190i. [Vol. xxxix. No. 16.]
Low Lateral Pharyngotomy, for Approach to the Lower Portion of
the Pharynx, Upper Portion of the Esophagus and Posterior Sur-
face of the Larynx, with an Illustrative l.'ase. Joseph D. Bryant.
The Symptomatology of Calculus Kenal and Ureteral Disease.
Chari.es Lester Leonard.
Infrapubie Section for Prostatectomy. E. Wyllys Andrews.
The Disappearance of Opacities of the Crystalline Lens. Waltkb
L. Pyi.e.
The Anatomy of the Ocular Muscles and Their Accessory Structures
and the Phorlas and Tropias. J. Elliott Colburn.
The Physiology of the Ocular Muscles. E. C. Ei.i.ett.
The Association of Graves' Disease with Glycosuria and Diabetes
McUitus. Heinrich Stekn.
8. Endocarditis as a Complication of Pneumonia. Edward F. WELLS.
9. Excision of the Gasserlan Ganglion, with Reports of Ten Cases
Operated on by the Hartley-Krause Method (Concluded.) John
B. Murphy and James M. Nefk.
1. — See American Medicine, Vol. Ill, No. 24, p. 988.
2, 3. — See American Medicine, Vol. Ill, No. 25, p. 1040.
4, 5, «».— See American Medicine, Vol. Ill, No. 25, p. 1053.
7. — See American Medicine, Vol. Ill, No. 24, p. 987.
8. — See American Medicine, Vol. Ill, No. 25, p. 1035.
O.— Excision of Gasserian Ganglion. — The authors take
up the principal points in the anatomy and patltology of the
ganglion, the etiology and symptomatology of tic douloureux,
the history of the development of the operation for excision and
the modern methods of performing it. They have used the
Hartley-Krause operation exclusively with the following devia-
tions: The De Vilbiss forceps is used for cutting tlie bone;
the base of tlie bone flap is extended to almost one-half inch
below the level of the zygoma. A blunt chisel is used and the
bone is fractured transversely with an elongated Kochor dis-
sector ; the flap is freed so it falls over the zygoma and is held
retracted by a suspender of gauze. In addition the rongeur is
used to retnove the bone down almost to the floor of the middle
fossa. The dura is elevated from the fossa until the second and
third divisions are exposed as they enter the foramens. The
middle meningeal can be ligated or crushed and the foramen
packed. The upper layer of dura is lifted with a blunt dis-
sector, exposing the ganglion and opened. The second and
third divisions are drawn strongly from the foramens by blunt
hooks, tho branches divided with scissors and botli detached
from tlie under layer of the dura. The forceps holding the
nerves are twisted and the sensory root evulsed from its attach-
ment to the pons. Hemorrhage from the cavernous sinus may
be controlled by the finger or gauze covered elevator. Tlie field
is packed with iodoform gauze, the end of which is drawn into
the posterior angle of the wound. There were no recurrences
in any of the operations reported, [h.m.]
Boston Medical and SurKical Journal.
October 16, 190t. [Vol. oiiiVii, No. 16.]
1. Pelvic Cellulitis as a Complication of Uterine Fibroids. A. T. Cabot.
1.— Pelvic Cellulitis as a Complication of Uterine
Fibroids.— Cabot reports two cases of hysterectomy for fibroids
670 AXEBIOAN MEDXCINE]
THE WOELD'S LATEST LITEEATUEE
[OCTOBER 25, 1902
in which death resulted from a cellulitis of the pelvic wall,
apparently awakened to activity by the operation. In Case I
the operation, which was not a difficult one, was followed
immediately by a rise of temperature and chills on the second
day. Careful examination showed no signs of peritonitis, but
as the patient grew worse drainage was introduced on the third
day, but without avail, as death followed a few hours later. The
autopsy showed the wound and uterine stump in good condi-
tion, but beneath the parietal peritoneum on the right side of
the pelvis was an abscess containing half an ounce of pus.
This abscess was separated from the wound about the uterus by
an inch of healthy tissue. The history of Case II was similar,
the patient dying on the fourth day after the operation, which
was also an easy one. The autopsy showed good condition of
wound and stump and a pus cavity outside the peritoneum and
separated from the wound by tissue free from inflammation.
In both cases the striking clinical feature was the sudden access
of fever immediately following the operation and leading to a
condition of profound septicemia. In both cases there existed
a degree of inflammation in the fibroid which might give rise
to secondary abscesses, and this inflammation had probably
extended through the lymphatic tissues. Hence Cabot con-
cludes that it is wise in any case of hysterectomy for fibroids
that are or have been recently inflamed to inspect the pelvic
wall with great care to see if any swelling or induration can be
discovered. The differential diagnosis between the condition
here described and a peritonitis may be difficult; the chief
clinical point seems to be that in peritonitis the onset is less
rapid, and the abdominal tenderness and rigidity are almost
pathognomonic. In Cabot's second case he suspected a patho-
logic condition similar to the first, but a careful examination
failed to give any indication of the situation of the pus, so that
there was no guide for surgical interference. [w.K.]
Medical Record.
October 18, 190S. [Vol. 62, No. 16.]
1. Statistical Report on Creosote In Pneumonia. I. L. Van Zandt.
•2. The Results of Treatment of laryngeal Cancer by Means of the X-
ray. D. Bkyson Uklavan.
3. Varicocele. Charles Chassaignac.
4. The Early Diagnosis of Pulmonary Tuberculosis. Beale Hakris.
5. Some Reflections on Cases of Acute Intestinal Obstruction. H.
Beeckman Delatour.
6. Dulness in Appendicitis. H. T. Miller.
7. The Doctor and the School Teacher: Can They yot Work More in
Harmony? Richard Cole Newton.
8. Foreign Bodies Accidentally Left Within the Abdominal Cavity;
How to Prevent the Occurence. Howard Lilienthal.
1.— Creosote in Pneumonia.— Van Zandt tabulates the
replies to the following questions from over 70 physicians who
have used the drug. 1. Do you believe creosote ever aborts
pneumonia ? 2. Do you believe the majority of cases are miti-
gated by it? 3. Have you ever found cases which, having
plenty of time, were entirely uninfluenced by it? They
report 1,130 oases treated. To the first question 37, reporting 762
oases, say " yes ;" 15, reporting 187, say " no ;" and 19, reporting
177, fail to answer. To the second question, 57, reporting 1,022
cases, answer " yes ; " 2, reporting 10 eases, say " no." To the
third, 23 say "yes;" 31, "no." The 5% of deaths is largely
accounted for by complications. The ordinary deathrate of
pneumonia is 259!,. The use of creosote or creosote carbonate in
the treatment of acute pulmonary inflammation is one of the
greatest life-saving discoveries of the nineteenth century.
[H.M.]
2.— See American Medicine, Vol. Ill, No. 23, p. 948. .
3. — Varicocele.— Chassaignac mentions constitutional or
even congenital lack of vascular tone as a predisposing and
probably all-sufficient cause in many instances for the presence
of varicocele. Among the exciting causes mentioned are
chronic constipation, producing prolonged pressure on the left
spermatic vein by the distended colon ; occupation demanding
continuous and prolonged standing ; sudden and violent efi'ort,
etc. In about 80% to 90% of cases, the varicocele is on the left
side, and in the remaining cases about two-thirds are afl'ected
on both sides. The great preponderance on the left side is
accounted for by natural anatomic conditions. Varicocele
occurs in from 10% to 15% of males about puberty, and in the
majority of instances it causes little or no trouble. Palliative
measures are sufficient when the symptoms are not severe, but
the only radical cure is by operation. Open scrotal ligation
and resection is the operation of choice, but suprapubic ligation
and resection may be used, and even subcutaneous ligation is
proper in selected cases. He would advise limiting the opera-
tion to the following conditions When the variocele is volumi-
nous enough to cause marked deformity, interference with
occupation, or skin irritation ; when it causes severe pain or
reflex neuralgia; when the testicle on the side affected is
becoming atrophied ; when the opposite testicle is lost or
seriously impaired from disease or injury ; when the disease is
increasing in spite of palliative measures ; when apparently it
alone causes marked mental depression and aberration of the
sexual function ; when a patient is desirous of entering a pub-
lic service and varicocele is the only obstacle.
5.— Intestinal Obstruction. — Delatour reports several
cases, and makes the following conclusions : The sudden onset
of obstruction of the bowels does not always mean the pres.
ence of a recent lesion, especially in those at or beyond 40
years. In many cases the symptoms may point to an attack of
appendicitis, as the appendix becomes distended by gas or fecal
matter. It is best in all cases when a newgrowth is suspected,
or when there is much distention, to first make an artificial
anus, using the cecum. At this time do not spend valuable
time, and produce some shock by making a thorough explora-
tion of the entire abdomen in order to satisfy yourself of the
exact condition. Always open the intestine immediately, as
you need to give relief as soon as possible, and there is no
danger of leakage of feces back into the abdomen, provided the
exit at the anus is not blocked by too tight dressings. Better
leave the wound exposed, the nurse being instructed to clean
away the fecal matter as it appears, [a.b.c]
6. — Dulness in Appendicitis. — Miller says in the symptom
" dnlness " he believes we have an infallible means of differ-
entiating between operative and nonoperative cases of appen-
dicitis. He further says in 41 cases coming under observation
dulness was found in 24. In the 24 pus was diagnosed by the
symptom of dulness in 17; verified in 14 by operation, in 2 by
postmortem examination, and in 1 by pus escaping through the
bowels. In one case, in which dulness covered an area the size
of a hand and gradually diminished to an area the size of a
silver dollar, all acute symptoms having subsided, an indu-
rated appendix was diagnosed and found. In two patients oper-
ated on, in whom pain but no dulness was present, an adherent
appendix was found. In one in which dulness was present but
disappearing under anesthesia, a normal appendix was found.
In one case with marked dulness, little pain, febrile symptoms,
tumor irregular in outline and movable, operation revealed
tuberculosis of the cecum and appendix. In one case with pro-
nounced dulness, no febrile symptoms, tumor regular in outr
line and freely movable, operation revealed a floating kidney.
In one case with no dulness, but intense pain upon pressure,
operation revealed adhesions between the ovary and appendix.
The remaining 17 patients had all the classic symptoms of
appendicitis, without the dulness, and all have seemingly
recovered, [a.b.c]
7. — Doctor and School Teacher. — Nine out of 10 family
doctors are content to wait until a child breaks down in school
before interfering. While teachers are too imbued with the
determination to get as much work as possible out of the
scholars, physicians are too inconsiderate in ordering all school
work stopped when often a partial intermission would be mor-
ally, mentally and physically better. Pupils often work beyond
their strength because the teacher is not a clinician and signs of
breakdown have been misinterpreted. Physicians should be
well enough versed in modern educational methods to direct a
child's studies and course of life so that his health shall not be
injured. The evils of overstudy and bad hygiene are due to
professional laxness. There is too much indifference also to
the claims of the " physical culturists," with whom an entente
cordiale should be established, [h.m.]
8. — Foreign Bodies Accidentally Ueft Within the Ab-
dominal Cavity.— Lilienthal says there is but one absolutely
certain way to prevent the accidental leaving of foreign bodies
within the abdominal cavity during the performance of surgi-
OCTOBEK 25, 1902]
THE WORLD'S LATEST LITERATURE
(American Medicine 671
oal operations, and that is to avoid placing any packing or other
object entirely within the cavity. He has never found it neces-
sary to insert a whole packing or sponge within the abdomen.
No enumeration before and after the operation can be so free
from possible error that the accident may not occur. If the
gauze is cut in lengths sufficient to permit at least two-thirds of
each piece to remain outside of the wound, and if no more than
one-third of each strip is used as a packing, it is obvious that
none can be lost. This has been thoroughly tested by the
author for more than four years and the fact practically proved.
[a.b.c]
New York Medical Jonrnal.
October 11, 1901. [Vol. lxxvi. No. 15.]
1. The Evolution of Urology. Ramon Guiteras.
2. The Indications and Limits for Operations by the Vaginal Route.
C. O. Thienhaus
3. The Silent Forms of Epilepsy. William P. Spbatlinq.
4. The Constitutional State versus Catarrhal Deafness. Sargent F.
Snow.
5. Septicemia and the Cnret. H. Plympton.
6. A Contribution to the Treatment of Spasmodic Wryneck. George
R Elliott.
3.— Operations by the Vaginal Route. — In operating by
this route there is less danger of infection and shock, drainage
in suitalile eases is established through the lowest possible part
of the body, there is no visible scar or possibility of ventral
hernia, and the convalescence after operation is usually
smoother, simpler and shorter. Thienhaus reviews the litera-
ture of the subject and mentions tlie conditions in which he
considers the vaginal route superior to the abdominal route in
operating. For cases of permanent abscesses lying in the pos-
terior culdesac, and for cases of perametritic and paravesical
abscesses, with and without pyosalpinx and py<)varium, easily
attainable by way of the vagina, the vaginal route is undoubt-
edly the best. In all cases in which both adnexa, with and
without the uterus, are affected to such an extent that conserva-
tive treatment and vaginal drainage seem inadvisable, he is in
favor of the socalled castration vaginale ginSrale. He cites a
case of tubal hematoma originating from an extrauterine preg-
nancy removed by him with excellent results by the vaginal
route. Good results are also obtained in cases of extrauterine
pregnancy, ruptured and unruptured, as shown by the statistics
of Diihrssen, Martin and Strassman. The author believes that
for cases of retroversion and retroflexion of the uterus the
vaginal route is preferable to all abdominal incisions, when the
intensity of adhesions or the seriousness of diseases of the
adnexa are not contraindications. In cases of prolapse of the
uterus, with and without cystocele, the author advocates the
vaginal route. He points out that in the same manner in which
we make use of the rectus muscle in cases of large umbilical
hernia, we can also make use of the muscular wall of the uterus
against the descensus of the bladder. Vaginal morcellation of
myomatous uteruses should be limited to tumors not extending
above the navel, and it must be possible in narcosis to displace
the tumor into the small pelvis, either from vagina by forceps
or from the abdomen by pressure, [c.a.c]
3.— Silent Forms of Epilepsy. — The silent forms of epi-
lepsy come from some disturbance in the frontal lobes. Two
forms are recognized — the psychic epileptic equivalent, better
designate*! as the psychomotor epileptic equivalent, because it
always embraces a motor element, and the psychic attack pure
and simple. So far as the location of the lesion is concerned,
they are probably at first identical, differing only in degree,
the former being more violent, more oommotional in cliaracter,
and having a general motor disturbance but no regular con-
vulsion ; the latter always quiet and unobtrusive and free from
motor disturbance of any kind, but just as destructive of the
faculties of the mind in the end. These mental seizures are apt
to occur in persons of a neurasthenic type, and it is because of
their disease they manifest neurotic tendencies. They have a
feeling that something is wrong, they are apprehensive, rest-
less, nervous, given to sudden impulses, solicitous, unable to
act or think logically, and above all they have a bad memory.
[c.a.c]
4.— Catarrhal Deaftiess. — Snow says that little can be
done in these cases if the skin is inactive, and that personal
hygiene must be considered of paramount importance. Cold
baths and frictions are exceedingly useful. A torpid liver fre-
quently thwarts the best efforts to get local treatments through
to the middle ear. Dyspeptic or intestinal disturbances, as
well as uric acid and uterine troubles, produce an irritability
of the mucous lining of the head quite sufficient to necessitate
their correction before the tubes will remain normally patent.
Vigorous exercise can be made a great aid in relieving the dis-
tended vessels. The author urges active arm exercise every
morning as a routine. With the correction of these conditions
a correction of morbid nasal conditions make the disease, as a
rule, nonaggressive and capable of much Improvement, [c.a.c]
5.— Septicemia and the Curet. — Plympton is not in favor
of cureting the uterus to remove fragments of afterbirth or
other debris. His method is to remove whatever fragments are
lying in the uterine cavity by means of forceps, care being
taken not to tear from the walls any adherent piece. He then
flushes out the cavity with an alkaline solution (110°), the reser-
voir containing the fluid being not more than .6 M (2 ft.) above
the level of the hips. This should be done every two hours
until there is a tendency to return to normal, when simple
vaginal douches every three hours, with an occasional uterine
flushing, will suffice. A tablet of extract of cannabis indica
.016 gm. a gr.) and ergotin .0325 gm. (J gr.) every hour until
the desired effect is produced will contract the uterus and
alleviate pain. The bowels should be moved freely, both by
enema and cathartics, [c.a.c]
6. — Spasmodic Wryneck. — The form of wryneck referred
to in this paper is purely of a nervous type, characterized by
spasm of the muscles supplied by the spinal accessory and
sometimes by the upper cervical nerves. The neuromeohanism
is irregular and the spasm intermittent. The author has devised
an apparatus based upon the principle of allowing necessary
support, without absolutely restricting any normal movement
of the head, for the treatment of these cases. A case is reported
and cuts illustrating the apparatus in position are given.
[c.a.c]
Medical News.
October 18, 190S. [Vol. 81, No. 16.]
1. The Huxley Lecture on Recent Studies of Immunity, with Special
Reference to Their Bearing on Pathology. William H. Welch.
2. Drug Habit: Review of Articles by Drs. Hare and Lott. Geo. E.
Pettey.
3. Polyhydramnios: Its Differential Diagnosis and Treatment, with
the Report of Cases. Edward P. Davis.
i. Recent Discoveries In the Domain of Etiology. D. H. Beroey.
1.— See American Medicine, Vol, IV, No. 16, p. 601.
2.— Drug Habit.— Petty challenges the statement that
patients with the morphin or alcohol habit can take massive
doses of hyoscin for days at a time with no evil effect. There
are as many persons who cannot take safely one hundredth of a
grain every hour as there are those who can. This statement is
based on the treatment of 350 patients. There are others who
have an unnatural tolerance. On a hyoscin habitui? the drug
may have no effect. The method of gradual withdrawal of the
hyoscin is a mistake. It should not be given for longer than
two to four days. The symptoms occurring on withdrawal of
morphin are due to effete material, which should be eliminated
by the help of purgatives. The office of hyoscin is to keep the
patient from suffering in the meantime. So treated tlie patient
usually craves solid food on the fourth or fifth day. Hyoscin
can be safely administered till its full physiologic effects are
manifested. Its toxic effects are extremely dangerous. The
physician himself should watch each dose. In some cases pro-
longed administration begets intolerance Instead of tolerance.
[H.M.]
S. — Polyhydramnios : Its Differential Diagnosis and
Treatment.— E. P. Davis reports five cases of polyliydramnios
and defines the term as meaning more than two pints of amni-
otic fluid at full term. As much as seven gallons have been
seen in the human species. Any fetal condition causing venous
engorgement tends to produce this condition. Irritating sub-
stances found in the lymphatics or excessive secretion from
the cerebrospinal canal of the fetus may be contributing causes.
As to differential diagnosis, in polyhydramnios we can usually
obtain evidence of faint uterine contraction, and can often
672 AMKBICAN MSDICINBi
THE WORLD'S LATEST LITERATOBE
[OCTOBEB 2b, 1902
insert the finger through the cervix and detect a presenting
part. In ovarian cyst the illness is longer, the swelling at first
unilateral. The intermittent hardening of the tumor is absent,
and the uterus can be found but little enlarged. In ascites the
dulness changes when the position of the patient is altered. In
hydatid mole the pear-shaped uterus has little fluctuation, and
there is repeated discharge of blood. In large or malformed
fetus the heart can usually be heard, and palpation reveals the
child. Attention is called to misleading phenomena— the
absence of such tension upon the membranes as would be
expected from the quantity of amniotic liquid, and also the
absence of early shortening of the cervix. Treatment by
drugs is without value. When polyhydramnios is slight and
not increasing and thegeneral health is good, pregnancy should
not be interrupted. When distention increases rapidly and the
general health is impaired the cervix should be dilated, the
membranes ruptured and the fluid allowed to escape gradually
until the presenting part descends firmly against the cervix.
The patient must be carefully watched, and labor should not
be hurried in the interests of the child, as the fetus is often
deformed, [w.k.]
4. — See American Medicine, Vol. IV, No. 13, p. 490.
Pblladelphta Medical Jonrnal.
October IS, 190$. [Vol. x, No. 16.]
1. Hodgkin's Disease, with the Report of a Case. Thomas C. Ely.
2. Infantile Scurvy : Report of a Case with Fracture of the Femur
and Multiple Epiphyseal Separations. Theodore J. Eltbrich
3. Acroparesthesia. Frank R. Fry.
4. Tent Life In Arizona In the Treatment of Tuberculosis. Henry H
Stone.
5. Littoral California (Concluded) William A. Edwards.
1-— Hodgkin's Disease.— Ely fully describes the disease,
and gives a detailed report of a case occurring in a German
child aged .3. He believes the disease is tuberculous in origin,
the process beginning as a purely local disease in a gland or
chain of glands, and extending by the spread of germs, just as
may be expected of tuberculous processes. Cases associated with
eczema of the scalp, or any abraded surface of the skin or
mucous membrane, may be explained by the fact that tubercle
bacilli pass through the skin, and not finding the skin a favor-
able soil, pass on to neighboring glands of the neck or axilla in
a predisposed individual, [f.o.h.]
2.— See American Medicine, Vol. IV, No. 13, p. 490.
4-— Tent Life in Arizona in the Treatment of Tuber-
culosis.—Stone ofi'ers nothing new in the treatment of tubercu-
losis. He calls attention to the superior advantages possessed
by Arizona over most climates in the outdoor treatment of
tuberculosis, [f.c.h.]
CLINICAL MEDICINE
David Riesman A. O. J. Kelly
EDITORIAL COMMENT
Bediiction in Infant Mortality in Larg-e Cities.—
The saving of infant life in the large cities is shown by
the .statistics of New York City, quoted by Dr. L. Emmett
Holt in the second edition of his textbook relative to the
diseases of infancy and childhood. There was a steady
and marked decrease in the deathrate for the ten years
1891 to 1900 inclusive. In the year 1891 in the city of
New York the population under five years of age was
188,703, and the number of deaths 18,224, or a deathrate
of 96.6 per thousand. In 1896 the corresponding popula-
tion numbered 216,728, and the deaths 16,807, or a
deathrate of 77.,5 per thousand. Similarly in 1900 the
population was 233,537, and the deaths 15,648, or a death-
rate of 67 per thousand. The actual numbep of deaths
during the ten years was thus decreased by 2,576, while
the population under five years of age was increased by
44,234, and the deathrate fell from 96.6 to 67 per thou-
sand. Holt attributes this splendid result to the " wider
diffusion of knowledge in the matter of infant feeding
and hygiene ; the fact that a larger number of infants
than ever before are now .sent into the country in sum-
mer ; that all infants are looked after with greater care
during the summer, many agencies being at work to
improve their condition. Not least important of these
is a bettering of the milk supply and the furnishing of
pure milk, gratis, from different centers, together with a
general adoption during hot weather of some form of
milk sterilization — a practice well-nigh universal in the
tenement districts. Antitoxin has reduced the death-
rate among older children." Can other large cities show
an improvement equally as great?
REVIEW OF LITERATURE
Movable Heart. — By movable heart, Leusser ' understands
a heart which simply possesses an abnormal degree of mova-
bility. Displacements by pericardial exudate, pneumothorax,
pleural effusion, ascites, etc., are not to be included under the
designation movable heart. The term is applicable when the
apex-beat moves more than 3 cm. when the patient lies on his
left side, and if certain nervous disturbances are present. The
author reports six cases, in all of which there were symptoms
of greater or lesser degree. The patients generally presented
the stigmas of neurasthenia and nearly always complained of
inability to lieon the left side. Palpitation, a feeling of anxiety
and oppression, some difficulty in breathing, vertigo, fainting
attacks, precordial pain, irregularity of pulse and rapid exhaus-
tion were usually present. In order to make the diagnosis the
patient must be examined in the erect posture, when lying on
his back and when lying on his left side. Sometimes it may
be wise to make an examination when the patient is lying on
his right side, though this does not give very satisfactory
results. It is important not to institute an active antifat treat-
ment should the patient be stout. If neurasthenic symptoms
are present these should be treated on general physicodietetic
principles. Overfilling of the stomach and bowel is to be
avoided. A sedentary occupation is harmful. Mild gymnastic
exercises and short walks are beneficial. Mineral waters, such
as Rokoczy, and carbonated baths are useful. Apparatus for
keeping the heart in position is entirely useless, [d.b.]
On the Value of the Inhalation of Oxygen.— Prom
experiments Koracs ^ found that the freezing point of the blood
was increased from insufficient breathing. This also occurs
when there is an excess of carbonic acid gas in the blood. He
found that inhalations of oxygen affect the osmotic pressure of
the blood in a favorable manner. Carbonic acid is thrown off
more readily when the blood is exposed to more oxygen than
is normally found in the air. Koracs observed that his cardiac
patients, after inhalations of oxygen, breathed more freely, the
cyanosis became less and the pulse became slower and regular.
[W.E.R.]
A case of acute mental disorder (acute confusional
insanity), probably toxic in origin and secondary to influenza,
is reported by Johnson and Goodall.' The results of the
necropsy were practically negative except that the diphtheria
bacillus was found in the blood, [a.o.j.k.]
A. B. Craig
GENERAL SURGERY
Martin B. Tinker
C. A. Orr
EDITORIAL COMMENT
Esophagoscopy. — Although the esophagoscope was
devised over 20 years ago it has not come into very
general use. We know of few in this country who have
used it, and no one who is specially expert in its use.
In 1880, von Mikulicz, who was at that time an assist-
ant of Billroth in Vienna, made the first experimental
studies which resulted in the esophagoscope in its present
form. His attention was turned in this direction by
observing sword swallowers who succeeded with appar-
ent ease in passing into their stomachs not only swords,
but almost any straight instrument of suitable dimen-
sions. By experiments on the cadaver, Mikulicz found
I iMiinchener med. Woch., July 1, 1902.
- Berliner klinlsche Wochenschrlft, April 21, 1902.
3 Lancet, August 1«, 1902.
OCTOBKB 25, 1902]
THE WORLD'S LATEST LITERATURE [akkrican medicink
673
that the anatomic conditions of the mouth, pharynx, and
esophagus were such that the normally crooked path to
the stomach could be made straight, permitting the
introduction of suitable straight instruments from the
mouth directly to the stomach. Before using the esopha-
goscope, the distance of any obstruction from the teeth
should be determined with an elastic esophageal sound.
In order to prevent gagging and discomfort, the mouth,
pharynx, larynx, and upper part of the esophagus should
be thoroughly cocainized by swabs saturated with lOfc
cocain solution. The patient is then placed on an oper-
ating table on his right side, and by bending the head
well backward, the entrance to the esophagus through
the mouth is made into an almost straight tube. The
patient is instructed to breathe quietly ; to raise his left
hand if the tube gives him special discomfort, as a sign
that he wishes to have the tube removed, for he cannot
speak after its introduction ; and to allow saliva to flow
out of his mouth quietly. Any clothing which might
in any way hinder the procedure (such as corsets) should
be removed. The tube is then introduced into the right
or left side of the mouth as far as the larynx and the
patient is directed to swallow. This permits the tube to
be pushed down into the esophagus without difficulty.
The mandrin which gives a rounded smooth end to the
tube is then removed and a panelectroscope is inserted
which throws light to the bottom of the tube. After
removing mucus or other obstructing material with
swabs on long carriers, the condition of the mucous
membrane of the esophagus can be inspected directly.
If cocain is used quite freely and the esophagoscope is
inserted skilfully, it is surprising how little difficulty is
experienced in most ca.ses in its introduction. Various
instruments have been devised for snipping out small
bits of tissue from tumors which may be present, forceps
for the removal of foreign bodies, etc. The diagnostic
value of such direct inspection of the esophagus in
doubtful cases can be readily seen. The mere use of an
esophageal sound maj' locate an obstruction, but it gives
no information as to whether the obstruction is within
or outside the esophagus pressing on its walls. It does
not tell whether the growth, if one is present, is malig-
nant or benign, or whether it is simply a spasmodic con-
traction of the muscles, such as has been found in a
number of cases. Probably Gottstein, an assistant in
Mikulicz's clinic at Breslau, has had more experience in
the use of the esophagoscope than any one else at pres-
ent, and his interesting monograph," Technik und Klinik
der Oef ophagoscopie " (Jena, Qustav Fisher), gives full
information as to the use of the esophagoscope, as well
as details of many interesting cases in his wide expe-
rience. Those who had the opportunity of seeing Dr.
Gottstein's demonstrations of the use of the esophago-
scope during his recent visit in this country could not
but have been impressed witii the ease with which one
skilled in its use can examine the entire length of the
esophagus. It is surprising how many practical applica-
tions may be made of the method. While many of the
conditions which may be diagnosed by this means are
inoperable, some cases of carcinoma of the esophagus
are tming treated with apparent success by the x-rays and
the ability even to make a positive diagnosis is a great
satisfaction. As is the ca.se with cystoscopy and cathe-
terization of the ureters, not many have the opportunity
of becoming skilled in the use of such special apparatus,
but we feel that every city or town which is a medical
center, and especially the metlical educational centers,
should have at least one or two men who are skilled in
their use. The expense of equipment with special appa-
ratus is considerable, and so large experience is necessary
that few may become experts. But this is the age of
specialists, and medical men should recognize the neces-
sity of supporting those of their number who have
developed special skill in the diagnosis and treatment of
conditions which it is beyond their own power to recog-
nize and handle successfully.
REVIEW OF LITERATURE
Thirty Gastroenterostomies for Nonmalignant Affec-
tions of the Stomach.— Dalziel ' reports his results in 30
operations undertaken for the cure of apparently incurable
dyspepsia. Many of the patients had symptoms of marked
pyloric obstruction, and had been under treatment for periods
varying from 2 to 17 years. In 16 cases there was a definite his-
tory of ulceration, and In 18 cases there was well-marked con-
traction of the pylorus. In 8 cases the obstruction was caused
by adhesions from peritonitis, originating in old tuberculous
glands behind the pylorus. In 3 cases previous operations had
been performed, freeing the adhesions, but only one was per-
manently benefited. Posterior gastroenterostomy was per-
formed in 6 cases. Death followed the operation in one case,
and at the necropsy a large malignant growth was found to
account for it. The results were considered very satisfactory.
Most of the patients have to be careful about their diet, and
occasionally suffer from attacks of flatulence. In some of the
cases the operation was performed too recently to determine the
ultimate results. Dalziel believes that the results of the work
of Kocher, Mikulicz, Robson and others have proved the safety
and efflciency of this operation in such cases, [m.b.t.]
Nephropexy.— In cases of prolapsed or floating kidney,
A. E. Benjamin ' advocates operation when, after a thorough
trial has been made of properly-fitting abdominal belts and
pads, and after regulation of the diet, habits, etc., we get no
relief of symptoms, and the kidney continues prolapsed. He
enumerates the various symptoms that may arise from this
condition and gives in detail his method of operating, together
with illustrative cases. The method consists irainly in dissect-
ing a strip of the fibrous capsule in a longitudinal direction,
making two flaps, one at either pole of the kidney. The flaps
thus made are long enough to bring up between the quadratus
lumborum muscle fibers on either side of the wound and to be
fastened in that position. The muscle fiber impinging upon
these Haps gives additional support and does not permit the
sutures to cut through the capsule. The technic of the rest of
the operation is about as described by other authors, [c.a.o.]
GYNECOLOGY AND OBSTETRICS
WiLMER Krusen Frank C. Hammond
EDITORIAI. COMMENT
The Thyroid Gland and the Genital Organs. —
That there is a peculiar relationship between the thyroid
gland and the female genital organs is a fact that has
been fully recognized. It is well known that any condi-
tion which will produce an enlargement of the uterus
will give a corresponding increase in the size of the
thyroid gland. During pregnancy the gland will become
large, soft and pulsating, and may so impinge upon the
trachea as to produce a certain amount of dyspnea.
After the termination of gestation it diminishes in size
to a certain extent, but seldom returns to its original
proportions. V^alentine has noted that in 25 pregnancies
in which the usual hypertrophy of the thyroid did not
occur, in 20 there was albuminuria. In cases in which
large doses of thyroidin were administered to pregnant
women, in whom the physiologic enlargement of the
gland was present, a marked diminution of the gland
resulted. Lange has also given thyroidin to a patient in
whom there was a pathologic enlargement of the thyroid
during pregnancy with a similar result. Another inter-
esting point in I^ange's paper is that when iodothyrin
was administered to patients suffering from the nephritis
of pregnancy it was found to produce a distinct diuretic
effect. Of other interesting communications upon this
subject two are worthy of special mention : the first by
Fisher,' in which he calls attention to the influence of
the genital apparatus upon the healthy thyroid gland, as
occurs at puberty, during menstruation, the puerperium,
lactation, sexual excitement, the menopause and genital
1 Lancet, 1902, Vol. 11, p. 508.
3 Northwestern Lancet, August 16, 1902.
s Wlcn med. Woch., No». « and 9, 1890.
674 AlUEBICAN MEDIOINBj
THE WORLD'S LATEST LITEEATUEE
[OCTOBBB 25, 1902
disease. He emphasizes the influence which a removal
of part of the thyroid gland has upon the physiologic
and pathologic condition of the genital apparatus, and
concludes: 1. That certain occurrences which influence
the genital apparatus, such as puberty, pregnancy, and
uterine fibroids, which produce a distinct change in the
metabolism of the entire organism, very frequently
cause an enlargement of the thyroid gland. 2. That the
deficiency of normal thyroid secretion is often associated
with atrophied changes in the genital apparatus. The
second report by Hestoghe' establishes the fact that
women deprived of the thyroid gland are subject to
excessive menstrual discharge ; as they grow older the
menses last longer, and finally become almost a constant
flow. He also noted that an hypertrophied thyroid is
always accompanied by an early and copious mammary
secretion, and that thyroid extract is useful in stimulat-
ing the secretion of lacteal fluid, and should be adminis-
tered when the secretion is diminishing. Hestoghe
further believes that thyroidin is indicated in cases of
frequent abortion, in which the menstrual flow is so
excessive that it sweeps away the impregnated ovum ;
he cites an instance of its advantage in sterility, and recom-
mends its use in myoma, prolapsus, and uterine conges-
tion. Cheron ^ also attests to the value of thyroid extract
in threatened abortion with hemorrhage and in prevent-
ing the arrest of uterine involution after childbirth. He
considers it a valuable galactagog, stimulating the mam-
mary secretion while it lessens the functional activity of
the uterus. Jouvin has referred to the remarkable shrink-
age of a fibroid while treating for obesity a patient who
had a uterine fibroid. Leith, Napier, Polk, and Schober
have also reported similar results along the same line.
Nicholson,' of Edinburgh, has been studying the re-
lationship of the thyroid gland to eclampsia, and is
firmly convinced that defective action of this gland may
and does produce symptoms of this disease. He has
suggested that in some women the supply of iodothyrin
in the ti&sues becomes gradually or suddenly insufticient
for the purpose of metabolism, so that certain toxins
enter the blood. These produce general vasoconstriction,
most marked in the kidneys, where the impediment to
blood-flow ultimately leads to suppression of urine and
convulsions. On the basis of this hypothesis two lines
of treatment are indicated : (1) Readjustment of the pro-
cess of metabolism to favor the complete metabolism of
the nitrogenous substances, and (2) reestablishment of
the secretion of urine. Thyroid extract fulfils both
these indications by its influence on proteid metabolism
on the one hand, and by its vasodilator faculty on the
other. He has himself frequently succeeded in reestab-
lishing the flow of urine in eclampsia by pushing the
drug to the verge of thyroidism. His observations have
also served to show that the blood-pressure in eclampsia
is at its highest when the secretion of urine is lowest.
Any theory which suggests a practical clinical remedy
for the relief of such a serious complication of preg-
nancy as eclampsia is worthy of earnest consideration,
and we hope that the profession, in addition to the dietetic
and eliminative treatment of preeclamptic symptoms,
will observe the action of thyroidin in these cases so that
more definite corroborative evidence may be secured.
KEVIEW OF I.ITERATUKE
A Case of Precocious Menstruation. — Stommer * reports
a case in which menstruation began regularly at the age of 6,
and eight years later ceased entirely without any climacteric
changes or disturbance of general health. He suggests as a
possible explanation that in the first years, in addition to an
intestinal catarrh due to Bacterium coli, there existed an unrec-
ognized affection of the inner genitalia, the resulting inflam-
1 Revue Med., January, 1899.
2 Rev. med. chl. des Mai des Femmes, November 25 and December
23, 1896.
» Therapeutic Gazette, October 15, 1902.
*MQncnener mediciulgche Wochenschrlft, September 16.
mation producing congestion and ovulation with the accom-
panying menstruation as in an ordinary catamenia, and when
tliis affection healed at the end of eight years the menstruation
ceased. It was also possible that rachitis (the child was rachitic
with crooked, badly developed legs) had given an impulse to
the early maturity of the genital organs as a compensation for
the deficient development of the bones ; and, thirdly, there may
have been some hereditary influence as the grandmother had 10
children and the mother at the age of 31 had already borne 5
children, [w.k.]
Can We by Modern Methods Anticipate Impending
Attacks of Puerperal Eclampsia.— .1. Ij. Rothrock' details
the various theories of the etiology of eclampsia, and believes
that it is less common among Russian .Jews in American
cities than Americans. If frequent examination were to be
made of the urine of all pregnant women, in only exceptional
instances would we fail to anticipate threatened eclampsia. A
weighty argument in favor of routine examination of the
urine in all oases is that with the early recognition of the first
sign of renal insufficiency the patient may be placed on pro-
phylactic treatment, and the attack if not absolutely averted
may be greatly modified. Furthermore, being in anticipation
of an attack, prompt and active treatment may be instituted
and the convulsions brought under control, [f.c.h.]
TREATMENT
Solomon Sons Cohen
H. C. Wood, Jr. L. F. Applbman
REVIEW OF LITERATURE
HlBtogenol.— Monneyrat^ calls attention to a new phos-
phorated arsenic compound, histogenol, which is a combination
of nucleinic acid with sodium methylarsenate, each teaspoon-
ful, the daily dose, containing i grain of methylarsenate and
3 grains of nucleinic acid. When employed in the treatment of
tuberculosis it causes an increase in the strength and weight of
the patient, and an improvement in appetite; cough dimin-
ishes, and the expectoration becomes nearly normal. These
results are observed after about a month of treatment, [l.f.a.]
Another Iodoform Substitute.— Israel ' has a preliminary
report on the result of trials with a new substitute for iodo-
form known as iodylin. This is a bismuth-iodo-salicylate. He
has used it principally in the form of gauze containing 7J% of
iodylin, but has also used it in a few cases as a dusting powder.
He concludes that for many of the purposes of iodoform it
seems very useful and deserving of further trial ; whether or
not it will possess the specific action in the surgical treatment
of tuberculosis he has not had sufficient experience with it to
determine, [h.c.w.]
Enteroclysis.- According to Harvey Gushing* rectal injec-
tions of saline solutions, when applicable, are to be preferred to
all other methods for ease of administration as well as for the
simplicity of preparation. In oases of acute secondary anemia
ordinary salt solution is rapidly taken up from the large bowel.
One or two liters (quarts) may thus be absorbed in 4i minutes,
according to Warmann. On one occasion in Cushing's experi-
ence, after an emergency operation in the country for ruptured
tubal pregnancy, other methods of infusion at the time being
precluded, two quarts of saline solution were slowly introduced
into the rectum and were apparently absorbed as though sucked
up by a sponge. After the high introduction of the rectal tube
or catheter— preferably one of sufficient caliber and thickness
to avoid kinking or turning backward— or, if nothing other is
at hand, of the rubber tubing attached to an ordinary douche
bag, the fluid, at or slightly above the body-temperature, should
be allowed to enter the bowel slowly. Reflex efforts at evacua-
tion, such as follow a low administration of the fluid, are thus
avoided. The patient, meanwhile, should be placed in the left
lateral Sims' position or else should have the pelvis raised on
pillows or the foot of the bed should be elevated. The Trendel-
enburg position is a favorable one. Many gynecologists intro-
iSt. Paul Medical Journal, October, 1902.
2 La Medicine Moderne, Vol. xlii. No. 12, 1902, p. 104.
8 Med. Wochensch., March 31, 1902, p. 139.
'Cohen's System of Physiologic Therapeutics, Vol. ix.
OCTOBEK 25, 1902]
THE WORLD'S LATEST LITEEATURE
jAkkbican Medicine 675
duce a saline enema aa a routine at the end of an operation and
before recovery from the anesthetic. Enemas of salt solution
containing a hyperisotonic percentage of sodium chlorid have
been recommended in ascites and anasarca for the purpose,
however, of abstracting fluid from the body rather than of
administering it. For purposes also of cleanliness, to remove
secretions and products of bacterial growth, saline solutions are
frequently employed as rectal irrigations. When there is pres-
ent ulceration of the bowel, the greatest care must be taken even
in this apparently simple form of treatment. In a case of
amebic dysentery, in which the customary quinin irrigation
had been administered, rupture of the bowel occurred.
Subcutaneous or Intramuscniar Injections of Yolk
of £gg. — Bayle ■ reports that the subcutaneous or intramuscu-
lar injection of yolk of egg, in addition to the usual treatment
of tuberculosis, has resulted in considerable improvement in
the general condition of the patient. Injections are usually
given subcutaneously into the back of the arm or into the del-
toid muscle. The syringe and the area of puncture must be
carefully sterilized. The contents of a perfectly fresh egg are
considered sufficiently sterile. The yolk is allowed to fall into
a sterilized bowl, care being taken that it touches no other
object. It may be mixed with an equal quantity of sterilized 0.7%
salt solution, which will enable it to pass more readily through
the needle, which must be of a large caliber. The needle should
be inserted into the tissues before attaching the syringe, in
order to b.e sure that a bloodvessel has not been punctured.
One dram of the mixture is then injected slowly into the tissues.
No abscess has resulted from these injections and they are not
painful as a rule, [l.f.a.]
A Peculiar Action of Aspirin.— In the course of chronic
pyelitis and gravel, both of which had been treated with indif-
ferent success for some time, a polyneuritis of the right arm
developed. Strohbinder' ordered aspirin, grains 45 daily, in
addition to the hot baths and local applications which had been
u.sed for some time. Within a few days the quantity of urine
was trebled, the gravel disappeared and the patient's general
condition improved. Within 10 days the neuritis, pyelitis and
gravel disappeared completely ; not one of them has returned
since, [e.l.]
LARYNGOLOGY, BHINOLOGY, and OTOLOGY
D. Bbaden Kylk George Fetterolf
EDITOKIAI, COMMENT
Some Points in Khinologic Temiinologry. — The
accuratjy of the terininology of a science usually advances
pari pcusm with development of that science and often
affords a safe index as to the point of development
attained. There are several innaccuracies and incon-
.sistencies now prevalent, the clearing up of which would
seem to be of material u.se to readers, writers, and teach-
ers in rhinology. One of these is the unscientific confusion
now existing with regard to tlie use of the words tonsil-
lotomy and tonsillectomy. From the derivation of these
two words and by analogy in the usage of theirendings as
to other parts of the body, but one meaning can be attached
toeach. Gastrotomy, literally a cuttingofthestomach, is
now generally accepted a.s indicating the operation of in-
cising the stomach ; gastrectomy, practically the same
wonl with the addition of the Greek f>», meaning from or
out of, can mean but one thing, removal of the stomach.
Numerous illustrations of this kind could be drawn in
order to make the point clear. Tonsillotomy has,
unfortunately, become accepted as meaning "ablation
of the tonsil." Another meaning, even perhaps less
justiflal'le, has become attached to it. In the Journal of
Ophthuhiiology, iMryngology and Otology, July, 1902, is
a symposium of the following question: "Is tonsillec-
tomy preferable to tonsillotomy? " On glancing at this
heading one exi)ect8 to find a philologic discussion,
instead of which the point discussed is whether complete
removal of the tonsil is preferable to partial. Here
'Lyon Medical, Vol. xcvlll, No. 8, 1902, p. 274.
«AIIg. Wtcn. med. Ztg., 1902, p. 124.
then Is a second meaning of the word tonsillotomy, viz.,
partial removal of the tonsil. This is a step in the
right direction in that it leaves to the word ton-
sillectomy the meaning of complete removal of the
tonsil. It would seem still more scientific if we go a
step farther and apply our terms as follows: Use
" tonsillotomy " to mean incision into the tonsil, its
termination in this way corresponding in meaning with
usage (toncerning other points of the body. When
removal of the tonsil is concerned, use the word "ton-
sillectomy," modified according to the operation per-
formed. If the whole tonsil is removed let the operation
be called "complete tonsillectomy;" if only a portion is
removed the operation is then a " partial tonsillectomy."
Considerable confusion attends the use of the words
turbinal, turbinate, turbinated (used as a noun), and tur-
binate or turbinated body. The confusion is due to the
fact that there are two distinct entities, one of which is
the turbinated bone and the other is the soft tissue cov-
ering the turbinated bone, and although it is usually
possible when reading rhinologic literature to grasp the
meaning of the writer, still there is no accurate termin-
ology which will enable one to differentiate between the
bone, the soft tissue overlying it, and the entire struc-
ture, including both bone and soft tissue. Various sug-
gestions have been made to improve the nomenclature
all more or less arbitrary and artificial. If the following
were adopted, the question could be definitely settled
and in a perfectly scientific way : Let the word "tur-
binate" apply only to the bone, since the bone is really
the only part that is scrolled ; for the soft tissue overly-
ing the bone, the word " epi turbinate " can be coined
and with the acceptance of the above limitation of
turbinal, the rationale of epiturbinal requires no
defense. For the entire structure, bone and soft
tissue together, the word panturbinate can be used.
The terminology of certain septal conditions can be
perhaps not clarified, but simplified. In the case of
deviations of the septum, one reads and hears of " de-
viations of the cartilaginous portion of the septum,"
"deviations of the bony portion of the septum," or
" deviations involving the entire septum." Here is an
unnecessary prolixity which is simply due to the fact
that no short terms are in existence to describe these
three different sites. The situation can be at once made
clear and the verbal hyperplasia dispensed with by the
use of the following terms : " Osteoseptum " as indicat-
ing the bony portion of the septum ; " chondroseptum "
the cartilaginous portion, and "panseptum" when the
entire septum is referred to. We have no desire to be
revolutionary, but simply feel as a result of reading
and writing that the above points are worth notice and
that if the suggestions offered are not accepted by our
co-workers they will at least arouse enough interest to
create discussion tending toward the clarifying of the
points at issue.
KEVIEW or LITEKATl'KK
NOSE
Nasal Deformity Correction by Injection of Paraffin.—
Broeckart ' reports four cases of deformity of the nose in which
the Eckstein modification of Gersuny's method was used.
(Jersuny's method was to inject hypodermically white vaselln
into the depressed areas, which was followed by absorption of
the vaselln and its replacement with connective tissue. Eck-
stein suggested that in order to avoid this ab8ori)ti<m and con-
sequent semirelapse to the original condition that paraffin be
used. Experiments on guineapigs showed that oven after six
mouths none of the injection mass had disappeared and that the
weight of the paraffin was exactly the same as when introduced.
There was soon formed around the mass a connective tissue
capsule which closely embraces the paraffin and prevents
absorption. He reports four cases with more or less satisfactory
results.
' 1 Rev. Hebdom. de LaryOKoI., d'Otol., et do Rhlnolog., Deo. 7, 1«1.
676 AXXBIOAN MEDtCIKK
THE WORLD'S LATEST LITERATUEE
[OcroBBB 25, 1902
Spicer > adds a case. His patient was a young woman with
a history of foul nasal discharge since childhood. There was
no history of trauma or of syphilis, either acquired or congen-
ital. The nose was deeply sunken at the bridge and the tip was
markedly tilted up. Profile photographs of the condition
before and after operation are given, as well as photographs of
casts taken before and two months after the operation. The
technic was as follows : A mixture of hard and soft paraflSa
with a melting point of 105° F., was sterilized and kept for use
in sealed bottles. The skin of the nose and the syringe were
carefully sterilized and the paraffin melted in a water-bath. A
15-minim German glass hypodermic syringe was used and 10
or 12 syringefuls Injected under the skin, some downward and
some upward from the sides of the nose into the depressed gap.
While the paraffin was being injected it was molded by an
assistant so as to have the part assume the proper shape before
the hardening of the paraffin. The syringe was removed from
its socket for refilling, the needle being allowed to remain in
place until sufficient had been injected to fill the gap in that
location. The operation was finished by cleansing the skin and
sealing the hypodermic punctures with collodion. There was
no pain, although the skin over the nose looked a little tense.
No paraffin passed into the eyelids, although a few days after
the operation the upper ones became somewhat edematous.
This edema has remained up to the present time (10 months after
the operation) and varies somewhat from day to day. In the
left upper eyelid is a nodule the size of a large shot, which has
been cut down on but is seemingly impossible to remove.
[Spicer apparently neglected the precaution of making pressure
at the base of the nose while the paraffin injection was being
made ; in fact, he states that in the future he will take care to
exert pressure at this spot at the time of injection, as has been
recommended by Eckstein, and will also see that the paraffin is
not any hotter than is necessary to allow it to pass easily
through the hypodermic needle.]
A Simplifled Method of Correcting Deflection of the
Septum.— Grants uses a combination of the methods of Moure
and Roberts. If the latter method, straightening and fixing the
septal cartilage by transfixion with a strong needle be used first,
Moure's cutting shears can be introduced with remarkable
ease. The steps of the operation are: (1) Cocainizing both
sides of the septum ; (2) straightening and transfixing with the
needle; (3) administering nitrous oxid gas; (4) cutting through
the cartilage by means of Moure's shears, horizontally below
the deflection, then obliquely in front of it and above it, par-
allel to the ridge of the nose, the incisions not meeting, below
and in front ; (5) manipulating the cartilage at the incisions to
encourage overriding, [a.g.e.]
Epilepsy Cured by Operation for Nasal Polyps and
Empyema of the Antrum of Highmore.— Grosskopff ' re-
ports a case of an epileptic youth of 20 who had been treated
by bromids and had undergone a sanatorium cure. His mind
was beginning to be greatly aff'ected and the convulsions
occurred about six to eight times daily. Examination of the
nose showed the right nasal cavity filled with polyps in the
Interstices of which was a quantity of yellow pus. The polyps
were removed and an opening for drainage of the antrum made
through the socket of the second premolar tooth. During the
removal of some of the polyps the patient was suddenly seized
with a severe epileptic convulsion, and since that time has been
absolutely free from epileptic seizures. The suppuration of
the antrum completely ceased at the end of three months' treat-
ment.
Rhinolith.— S. 8. Bishop * reports a case of a woman, aged
59, who came to him on account of intolerable itching in the
external auditory canal, associated with frequent attacks of
hyperemia and intense heat in the canal and auricle. Exami-
nation of the ear showed the presence of chronic nonsuppura-
tive inflammation of both sides. On inspection of the nose a
rhinolith was found in the posterior portion of the nasal cham-
ber. It weighed 71 grains, and on account of its size could not
» Clinical Journal, April 9, 1902.
' British Medical .lournal, August 30, 1902.
Archiv. fiir Laryngologie und Rhinologle, Band 13, Heft 1.
1 he Laryngoscope, January, 1902.
be extracted entire, but had to be crushed before its removal
became possible. By the aid of a small amount of treatment
of the nose and ears the ear-symptoms complained of rapidly
and entirely disappeared.
Bony Cysts of the Middle Turbinate.— Shambaugh ' re-
ports three cases, one of them being found postmortem.
Another anomaly in the last case was a large ethmoid cell
which communicated freely with the frontal sinus and opened
into the superior meatus, and through the cyst of tlie concha
media into the middle meatus. The literature of the subject is
reviewed. Shambaugh holds that the concha bullosa repre-
sents an enlarged ethmoid cell. This enlargement is not due to
inflammation, but is an anatomic variation, the result of a
developmental anomaly, [a.g.e.]
Bhinosclerotna. — The investigation of this disease by L.
Dor and Lgblanc,^ inspired by the observations of Maurice
Grenier, presented in his ThSxe de Lyon, 1901, according to
which rhinoscleroma is a malady of the nasal fauces due to a
specific bacillus (Bacillus rhinoscleromatis Cornil and Alvarez).
The malady is endemic and probably contagious, and up to the
present time, Grenier wrote, the disease had not lieen deter-
mined for France, except in the case of strangers. It has been
studied in Austria-Hungary, Russia, and Central America, and
is becoming more and more frequent. According to the re-
searches of L. Dor and Lfiblanc there is a relationsliip between
rliinoscleroma inman and the sniffing disease (maladie de reni-
flement) of swine. [c.s.D.]
A case of nasal vertigo simulating epilepsy is reported
by Noakes.' Cure followed ablation of the turbinate bones and
of some vegetations, [a.o.j.k,]
Suprarenal Extract in Khinolaryngology. — Rosenberg*
advises the use of adrenalin chlorid in place of or in combina-
tion with cocain for the treatment of rhinolaryngologic condi-
tions. Adrenalin decreases the sensibility and causes anemia
of the mucous membrane. It is preferable to cocain since it is
dangerless and causes no habit. It is of diagnostic use in nasal
conditions. Rosenberg uses it in combination with cocain in
operations. Used thus no liemorrhage results. It is of cura-
tive value in pharyngeal and laryngeal inflammations. It is
used internally in small doses for hay-fever or coryza. [w.e.r.]
Accessory Sinuses. — Maxillary antrum; observations on
35 cases of chronic suppuration. Herbert Tilley^ publishes
an article based upon only those cases seen in private practice,
and consequently their course could be carefully watched.
Tilley briefly reviews the anatomy of the antrum, speaking
particularly of normal variations and the relation the posterior
teeth bear to it. Dental caries is mentioned as being the most
frequent cause, others being the infectious fevers and any
condition that would tend to close the ostium maxillare. That
the dental condition is primary is proved by the history and by
the improvement that follows extraction ot, the offending
tooth. While the crown of the tooth may be healthy, pyorrhea
alveolaris or an abscess at the root may be present, and by
direct continuity infect the antrum. In all the 35 cases reported
there was disease of some of the posterior teeth. In four of the
cases the frontal, sphenoidal and ethmoidal sinuses were also
in a condition of chronic suppuration. Three eases presented
all the features of atrophic rhinitis. The local symptoms
include nasal discharge, which tends to enter the pharynx
during sleep ; headache over any part of the head, but especially
the forehead ; neuralgia and tenderness in the course of the
trifacial nerve. Sometimes the headache alternates with the
nasal discharge. Along with these are gastric, pharyngeal,
laryngeal and aural symptoms, most of which result from
direct extension or from the vitiating of the inspired air.
In one case there was bleeding into the nasopharynx
from a collection of granulations near the mouth of
the sinus. The prognosis, if the condition be limited to the
antrum, is good so far as relief of symptoms are concerned, but
not so good as regards the cure of the discharge. The following
points would influence the prognosis: (1) The source of the
1 Annals of Surgery. July, 1902.
'- Lyon Medical, April 6, 1902.
' Lancet, August 16, 1902.
••Berliner Itlinische Wochenschrift, June 30, 1902. ^
'■> British Medical Journal, April 19, 19<J2.
October 25, 1902]
THE WORLD'S LATEST LITERATURE
(Akkrican Mbdicinb 677
original infection ; (2) the lengtli o( time before tree tment was
instituted; (3) tiie patient's general liealth ; (4) the persistence
of the patient in following directions. The diagnosis is made
by repeated observations of pus in the middle meatus, opacity
under transillumination, and finally exploration with the tro-
car and cannula. The trocar should pierce the inner antral wall
about one inch behind the anterior end of the inferior turbinal.
The treatment recommended is either simple or radical. The
simple form comprises drainage and irrigation through an
opening in the alveolar sockets. A silver tube is introduced
for drainage, and is removed twice daily for the purpose of
irrigation with some antiseptic solution, such as boracic acid or
Condy's fluid. As the discharge diminishes in amount the irri-
gations are decreased in frequency. In three patients free bleed-
ing followed the alveolar puncture, in one of which the hemor-
rhage did not come on until eight hours afterward. In four
intense neuralgia followed the introduction of the tube, neces-
sitating the introduction of a smaller one. In 13 the tube was
removed within three months, in nine the discliarge has prac-
tically ceased, in eight the result is unknown, and in one there
has been no improvement. The more radical procedure
involves the removal of the anterior wall of the antrum and
part of the inner wall below the inferior turbinated bone. The
whole cavity Is then cureted and packed from the front, the
end of the packing being brought out through the nasal open-
ing. The anterior opening is then allowed to close, and the
packing removed and irrigation carried out through the nose.
In choosing the manner of entering the antrum the alveolar
method should be tried first, because (1) itis simple and affords
drainage from the lowest point ; (2) the operation can be per-
formed under " gas " anesthesia and the patient after a few
visits to the surgeon can carry out the after-treatment himself;
(3) in many cases it will be successful, and when it fails the
more radical operation can be performed. In the latter there Is
always the danger that in spite of the greatest care some portion
of pyogenic membrane will be left and that from this reinfec-
tion will occur. Should polypoid degeneration be present in
the antrum an open operation with free curettage would be
necessary.
PALATE
Teeth and Palate : Influence of Nasal and Nasopharyn-
Kcal Obstruction upon Development. — A. L. Whitehead'
reviews the various lesions which cause obstruction to the free
passage of air to and through the nasopharynx, the pharyngeal
tonsil of course taking precedence of all others, both in fre-
quency and importance. Among the sequels of neglected
adenoi 's are high-arched palate and irregular teeth. Korner
has called attention to two varieties of deformities, depending
upon whether the adenoids were present before or after the sec-
ond dentition. If before, the palate becomes higher and dis-
tinctly dome-shaped. The alveolar process forms an ellipse, the
lateral portions approach the median line, the whole growth of
the maxilla is retarded but the teeth are in normal position. If
after the second dentition the adenoids are still present the
alveolar approximation is still more marked, the palate more
elevated, approaching the Gothic type of arch, the anterior part
of the alveolus inclines forward and the jaw assumes the
V-shaped form so frequently seen. These changes result in cer-
tain alterations of the teeth. The central incisors are so rotated
that their lingual surfaces look toward each other. The lateral
incisors and frequently the premolars are pushed inward while
the molars turn outward. As the maxilla and mandible do not
develop at the same rate, normal dental articulation is interfered
with. That those conditions are due to nasal obstruction there
can be no doubt. Clinical observation has been confirmed by
the experiments of Ziem, who produced these same changes in
young animals by blocking their na.sal chambers with cotton
wool. When but one side was occluded the changes produced
were obvious. There was a general arrest of development of
the maxilla, the palate and frontal bones, the ear and the whole
side of the face. One explanation is that the normal descent of
the palate is interfered witli by the adenoids, which interfere
with the general development of the child. The sphenoid and
the septum fail to develop while the alveolar process and face In
' Brit. Med. Jour., April 19, 1902.
general grow at the usual rate. Another theory is based on the
fact that in mouth-breathers the tongue is not in contact with
the maxillas and there is no internal force to counteract the
inward pressure of the cheeks. As a result, the jaw is narrowed
and lengthened. During the change from the deciduous to the
permanent dentition the great vascularity of the maxilla causes
softening, which allows the marked changes which occur at this
time. Another explanation is that as the air passes through
the mouth there is negative pressure on the palate, and conse-
quently it is drawn upward. All these factors are probably at
work. [Perhaps pressure on the trophic nerves is a factor.]
PHARYNX
Adenoid Operation: Some of its Dangers.'— The
editorial is based on an article in the Australasian Medical
Gazette for December 20, 1901, and after pointing out the fact
that adenectomy is so frequently performed with no ill after-
effect relates the histories of three fatal cases. The first was in
a girl of 10, who had had for two years an intermittent purulent
discharge from the left ear. Adenoid vegetations were removed
under proper antisepsis. An acute inflammatory process at
once became engrafted on the chronic, resulting in mastoiditis,
sinus thrombosis, and a Bezold's abscess around the great vessels
of the neck. The right ear also suppurated. The suggestion is
made that the aural discharge in such a case should be cured or
at least that the parts concerned should be rendered as aseptic
as possible before the operation. The second case was one of
removal of adenoids and tonsils in a girl of 4. Necropsy
revealed diplococcal pyemia and malignant endocarditis.
Examination of the brain in the third case showed a left middle
ear and mastoid cells full of pus. Both cavernous sinuses con-
tained a turbid exudation and the lateral sinuses contained
dark clots ; the left contained a white antemorteni clot extend-
ing into the internal jugular vein. At the base of the brain was
a thick, yellow, purulent exudation, surrounding the optic
tract, medulla and pons, and extending into the great longi-
tudinal fissure. The ventricles and vertebral canal contained a
turbid exudate. The convolutions of the vertex were flattened.
A Cause of Bronchitis Adenoids.— Mfiry^ states that the
inflammation of the nasopharynx which exists in patients suf-
fering from adenoids may spread to the bronchi and give rise
to severe bronchitis, accompanied by signs of emphysema.
Sometimes asthmatic crises are produced. The curative treat-
ment consists in removal of the adenoid vegetations. M(5ry
recommends the following medication in addition : At first he
prescribes an expectorant consisting of
Syrup of ipecac 2.5 drams
Sodium benzoate 15 grains
Sodium bicarbonate 8 grains
Syrup of polygala 5 drams
Decoction of polygala 4 ounces
One teaspoonful every hour.
Mustard poultices should be applied to the chest and hot
drinks given. Morning and evening a small quantity of the
following pomade should be introduced into the narea by
means of an applicator :
Impalpable boric acid 1 dram
Resorcin 3 grains
Vaselin 1 ounce
The patient's mouth must be closed ; he will then draw in
the pomade through the nose. Instead of the pomade, a few
drops of mentholated oil, 1 to 100, may be used by means of a
syringe. Later, stimulating expectorants, such as terpin
hydrate in doses of from J to 1 grain will be of use. During
convalescence, 1 to 2 teaspoonfuls of the following may be
taken every morning :
Sublimed sulfur 2.5 drams
Honey 3 ounces
[I-.F.A.]
Granular and Ijateral Pharynifltls : Treatment.— Halle,»
of Berlin, in his article on the treatment of granular and
lateral pharyngitis, says that strong galvanocauterization
should always be avoided. If applications of trichloracetic
acid, chromic acid and nitrate of silver fall, one may resort to
1 Editorial, Pediatrics, April 1, 1902.
I Journal des Pratlclens, Vol. xvl, No. 24, 1902. p. S77.
> Berliner kllnlscbe Wochensohrifl, April 28, 1902.
678 A.MKKICAN MKDICINBI
THE WOELD'S LATEST LITEEATUEE
[October 25, 1902
the light use of the galvanooautery. If no results are obtained
by the use of the latter the granulations should be cut off with
a pair of scissors. For this method he has invented two special
instruments. One consists of a pair of long shears of which
the cutting portion branches just back of the lock at right
angles to the handles. The other one also consists of a long-
handled pair of scissors with three angle.s to it, the arms of
which are curved like a parabola. The ends of the handles are
bent downward at right angles for i inch, then there is another
bend at an angle of 45°. This part contains the lock. Back of
the lock are the cutting edges, which again are turned upward
at an angle of 45°. Halle advises the use of these instru-
ments whenever operation is indicated, as the operation is per-
formed quickly, without danger or pain, the edges of the wound
are smooth and unbruised, the reaction is but slight and the
patient takes liquid nourishment on the same day. The dura-
tion of convalescence is much shorter than if galvanooautery
had been used. The cicatrix which is formed is but slight and
disappears soon, [w.e.r.]
Direct Endoscopy of the Upper Air-Passages and
Ksopliagus. — Killian ' states that direct methods of examina-
tion, based on the recognition of the fact that we may penetrate
in a straight line into the air passages and esophagus without
damaging those organs, are a most valuable adjunct to the diag-
nosis and treatment of foreign bodies lodged therein. Direct
esophagoscopy is the only absolutely reliable method for
foreign bodies in the latter, as the oliveshaped probe and the
skiagraph may give wrong interpretations. When the foreign
body is revealed an attempt at extraction can be made under
strict supervision of the eyes. Indirect laryngoscopy often
fails in children. Then the direct method can be used, espe-
cially after an anesthetic is given. In the case of a foreign body
in a bronchus one point must be remembered, respiratory dif-
ficulties will occur if a tube be introduced into a principal
bronchus which is entirely occluded, as sufficient air cannot
pass by the side of the tube into the healthy lung. Under such
circumstances the tube should have a lateral opening some dis-
tance from its lower end. Killian gives notes of seven cases to
prove the value of the direct method, [a.g.e.]
LARYNX
Remarks on a Series of Cases of External Operations
on the Iiarynx.— A. Marmaduke Sheild ^ relates the history of
nine cases in which laryngotomy was performed. His method
and after-treatment are as follows : A long median incision is
made from above the thyroid to a point IJ inches below the
cricoid. The thyroid isthmus may be either drawn down or
divided between clamps. The trachea is then opened and a
tracheotomy tube covered with compressed sponge inserted.
The sponge is previously covered with iodoform powder.
Eight minutes are allowed to elapse to permit patient and anes-
thetizer to become accustomed to the new order. Chloroform
is used and the vapor is blown into the tube through a bent
cannula. The tube is secured by tapes and the thyroid carti-
lage divided, if calcified by a fine saw or scissors curved on the
edge. The upper part of the thyroid should, if possible, be
allowed to remain intact. The edges are grasped with artery
forceps and turned back, and a free view of the laryngeal inte-
rior is afforded. The growth to be removed is painted with a
20% solution of cocain, to which is added 10 grains of supra-
renal extract dissolved in a half dram of cold water. Oozing
is much diminished by the use of this solution. A small Tur-
key sponge with a piece of silk attached is passed into the
trachea at the lower angle of the wound and helps to prevent
the entrance of blood into the larynx. The growth is now
seized with mouth-toothed forceps and freely cut away. Pres-
sure is made on the raw surface by small sponges wrung out in
spirits of turpentine. A fine, sharp curet is then used and is
followed by the electrocautery at a cherry-red heat. A little
iodoform is dusted over the wound and the thyroid cartilage
united by strips of kangaroo tendon, following which the skin
incision is sutured with fishing gut and horsehair down to the
tracheotomy tube, which is removed as soon as the " coughing
reflex "is established. The lower part of the wound is not
1 British Medical Journal, August SO, 1902.
» Brit. Med. Jour., April 19, 1902.
sutured, but is covered with a pad of iodoform gauze. Treat-
ment After Operation. — The upper part of the wound is covered
with collodion and the lower with iodoform. On the fourth
day the edges of the latter are approximated with adhesive
straps. The patient maintains the sitting position in a steam
tent and at intervals inhales the vapor of creasote. A spray of
warm listerine in water is used three times a day, and the
patient is not allowed to use his voice for a month. Convales-
cence is established in from 14 to 20 days. The cases for
which the operation was done comprise the following : Fracture
of the larynx, papilloma, syphilitic stenosis, recurrent papil-
loma, fibroma, foreign body and laryngeal cancer.
L/aryngeal Tuberculosis : Treatment. — P. S. Donnellan i
observes that as laryngeal tuberculosis is, as a rule, second-
ary to an infection of some other organ, the first important
point in the treatment should be directed toward the general
condition. He lays especial stress upon outdoor life and upon
the avoidance as much as possible of speaking. In local appli-
cations the larynx should be first rendered anesthetie by a 10%
solution of cocain, and whatever topical application has been
decided upon may be applied afterward. When ulcerations are
present the use of lactic acid as recommended by Krause gives
very good results. The ulcers are first cleansed with Dobell's
solution, and afterward either with hydrogen dioxid or l-.3,000
mercuric chlorid, and then thoroughly rubbed every third or
fourth day with a solution of lactic acid 20% to 80%. Heryng's
recommendation to curet the ulcers before applying the acid is
of value to remove the necrotic tissue. Orthoform when applied
to these ulcers will, by its effect upon the ex posed nerve-endings,
give relief to the dysphagia, [h.c.w.]
TRACHEA
Calcareous Deposits Low Down in the Trachea. — The
patient exhibited by Law ^ was a woman of 36, who had had
ozena since childhood. During 18 years she has had a hacking
cough and makes frequent efforts to clear away something felt
low down in the trachea. Examination showed a number of
papillomatous excrescences arranged in an annular shape low in
the trachea. Various diagnoses were rendered by experts, the
majority being that they were ozenic incrustations. Later
examination with the bronchoscope and probe showed the
masses to be calcareous, [a.o.b.]
EAR
Deafness and Ear-Diseases in School Children.— This
editorial ^ article is based on a report by Arthur H. Cheatle on the
examination of the ears of 1,000 school children of the poorest
class in London and Southwark. The principal test used was a
quiet whisper at 18 feet with both ears unclosed, then with one
closed and finally with the other. Tuning-forks were used when
necessary, and in cases of middle ear disease, inflation, after
which the tests were repeated to note improvement. The ears,
nose and pharynx were then inspected, and of the whole num-
ber examined, the ears were normal in but 432 ; of the remain-
der the external ear was affected in 49; the middle in 518 and
the internal in 1. The hearing power was deficient in 520, and
in many of these had been unnoticed by the teachers. In 434 of
the 1,000 adenoids were found, of course a higher proportion
than would be found in a better class of patients. In Zurich the
ears of children were affected in 117 per 1,000. The Otologic
Society of the United Kingdom has appointed a committee to
further investigate the matter, with a view of submitting a plan
of furthering these investigations to the Board of Education.
Diseases of the Ear : Study, Teaching, and Prevention.
— Milligan^ states that the mass of otologic literature which
is now flooding medical journals, while an evidence of in-
creasing interest in the subject, is becoming a burden to those
who wish to keep abreast of the times. He would simplify the
problem by having the otologic societies of Great Britain,
France, Germany, Italy, Austria, America and Spain form an
international bureau for the advancement of otology. This
would issue a biennial epitome of the work done in these
countries, such epitome to be under the supervision of collabo-
1 Medicine, March, 1902, p. 197.
'British Medical Journal, August 30, 1902.
3 Lancet, April 19, 1902.
October 25, 1902]
THE WORLD'S LATEST LITEKATTJRE
(AUEBICAN MeDICINI, 679
rators elected by the respective societies. Milligan also empha-
sizes the necessity for Increased systematic instruction in
otology in medical schools. The prevalence of ear disease fol-
lowing the exanthems is an argument lor this contention. As
an aid in urging this upon authorities of schools he would make
obligatory the possession by candidates lor house physician or
surgeon of lever hospitals of certificates testifying to their
acquaintance with the principles and practice ol ear diseases.
[A.G.E.]
The Treatment of Chronic Purulent Otitis Media in
Children.— Melzi ^ has treated 43 cases of chronic suppurative
otitis media after the method ol Libby, with insufflation of
acetanilid, and in each case the purulent discharge ceased
within a month. Some ol the cases had existed lor years, and
had been treated after almost all the known methods. He
describes his procedure and concludes that it is a most excellent
conservative method in procuring the healing of long standing
eases of purulent otitis media, [e.i..]
Hemorrhage from the Ear in the Course of Typhoid
Fever. — During an attack of typhoid lever occurring in a 10-
year-old girl Uault and Specker^ observed hemorrhage Irom
the middle ear. It took place about the fourteenth day, and was
preceded by two hemorrhages from the intestines and accom-
panied by severe epistaxis. The latter ceased within 24 hours,
but the bleeding from the ear continued for lour days in spite ol
everything done to check it. The blood oozed through the
drum but no perforation could be discovered until after the
blood had ceased to flow, when pus was seen to come through
a tiny opening in the lower portion. Convalescence was pro-
tracted, but recovery was complete in the end. They have been
able to tind but one other case ol auditory hemorrhage during
typhoid lever recorded in literature, and then the blood could
be seen to ooze Irom the external auditory canal, [e.i,.]
Chronic Progressive Deafness. — Slowly progressing deal-
ness unassociated with ear disease, occurring insidiously and
without pain, is extremely common. A large percentage of
socalled cases ol sclerosis ol the middle ear result from simple
mechanic obstruction ol the eustachian tube accompanying
nasal catarrh. Under normal circumstances the contents ol
each cavity have free intercommunication. The tension of the
air in the tympanic cavity is the same as that in the nose and
surrounding atmosphere. When the tube is obstructed the air
contents of the cavity are partly absorbed, the drumhead is
driven in, the vessels of the lining membrane are dilated from
unbalanced intravascular pressure, causing thickening ol the
tissues. The lessened excursion ol the drumhead affects the
joints of the ossicles, and in time stillness and ankylosis super-
venes. The increased pressure on the stapes is communicated
to the labyrinth, and noises ol various kinds result. Early
recognition and treatment ol the condition olten results in per-
manent improvement. It is quite common in old cases to find
the nasal cavities healthy and the eustachian tube patent. The
catarrh has done the mischiol and subsided. The treatment
advised by Collier' is removal ol the catarrh and restoration
ol Iree intercommunication. The obstruction keeping up the
catarrh is olten due to turbinal atony, and may be episodal in
character, thus making detection difiBcult. The Politzer bag
and galvanocautery will relieve congestion and obstruction and
give tone to the vessels ol the postnasal space and tympanum.
[H.M.]
Deafness of Middle-ear Origin: Treatment. — Watson*
details the subsequent histoi-y ol some cases already recorded
as showing improvement under treatment by myelocene, a sub-
stance derived from bone-marrow. The favorable opinions
previously formed are confirmed. The summary ol his exper-
ience is that cases in which the pathologic process has appar-
ently been arrested give little or no results by this method of
treatment; the coexistence of internal ear disease does not
contraindicate the trial of treatment; any case that is not
improved by the local application ol myelocene alone is unsuit-
able for this method. The technic ol the treatment is given.
MyelcK-ene is supposed to act in one or both of the following
' Kev, (le Tlierap. med. chlr., 1902, 189.
= Kcv. heb(). do Laryng., 1902, 5.
' MtdUail I'renH and Clrculnr, February 5, 1802.
•British Medical Journal, August liO, 1002.
ways : By causing an increased vascular activity or specifically
in virtue of an enzyme or other active principle found in the
bone-marrow, [a.g.e.]
Cholesteatoma of the Middle Ear.— Grant ' describes at
length the course of formation of cholesteatomas. When the
growth is fully exposed to the air and kept dry, the patient's con-
dition may be one of comfort and safety. This is rarely the case,
and the surgeon should operate when the condition is discovered.
In the absence of pain, vertigo and bulging, dehydrating meas-
ures may be tried. In the presence of pressure symptoms, no
delay is permissible. If the cavity be small, granulation may be
encouraged. If the cavity be large it should be lined by means
of a Thiersch graft. Grant believes, however, that in those
oases in which the cicatricial process has extended over the
whole of the walls of the cavity, the lining is as good as can be
desired and should be preserved. The contents of the cavity
should be removed by gentle scraping and the wall thoroughly
swabbed with rectified spirit. Arlstol may then be insufflated
and a light tampon ol iodoform gauze inserted. After
a week, start the instillation of alcoholic drops. In several
cases this caused complete healing with a rapidity and ease not
equaled by other methods, [a.o.e.]
Otorrhagia in Typhoid Fever.— Raoult and Specker^
report the following case : A child of 10, suffering from typhoid
fever had, during one day, two intestinal hemorrhages. This
was followed on the succeeding day by bleeding from the nose
and from the right ear, which, in spite ol boraoic acid douches
and plugging with cotton wool, continued lor three days. The
character of the discharge then changed and became purulent.
Examination ol the ear showed a small anterior inferior
perforation, giving exit to the pus, which ceased flowing in
about two weeks under antiseptic douches. The reporters of
this case could find only three similar cases on record, their
own making the fourth. There is undoubtedly, during typhoid
fever, a disposition to hemorrhage, particularly from the nasal
mucous membrane. The effused blood may fill up the middle
ear and, by pressure on the tympanic mernbrane, produce
necrosis and perforation, or the contained blood may become
infected and the perloration lollow as a result ol the suppura-
tive condition. The writers believe that the blood came from
tjie tympanic mucous membrane, and not from the nose and
nasopharynx through the eustachian tube, for although it
occurred at the same time as the nasal hemorrhage, it also
occurred after the latter had ceased. •
Mastoiditis.— John Dunn" reports four cases illustrative
of the standpoint from which early operative intervention
should be viewed. In the first case there was extensive destruc-
tion ol the inner mastoid table with exposure of the lateral
sinus for nearly three-quarters ol an inch. The wound and
middle ear healed readily and hearing returned practically to
normal. In the second case the mastoid was filled with pus
and granulations and there was destruction ol the inner
table to the extent ol exposing the sigmoid sinus lor hall an
inch ; there was also perloration ol the outer table. Heal-
ing was uninterrupted and a good degree ol hearing was
obtained. Operation on the third patient, who had a
markedly brachycephalic head, revealed a large subperi-
osteal abscess over the mastoid lossa. The mastoid was
small and devoid ol air cells. While examining the antrum
with a bent probe the sinus was torn with the usual free hemor-
rhage. The case progressed well and healed readily with no
suppuration and good hearing. The fourth case had impalretl
hearing on account of suppurative otitis following an attack
of grip two years ago. A year later the same conditions arose
and resulted in right-sided mastoiditis, facial paralysis aud
great mastoid swelling. Paracentesis tympani was jierlormed,
the mastoid being allowed to remain untouched. The facial
paralysis disappeare<l, but the tympanic membrane was practi-
cally destroyed and replaced by perforated scar-tissue. Hear-
ing was very poor on that side, although bono conduction was
good. These cases teach certain lessons: (1) Extensive
destruction of the inner table occurs with mastoid inflammation
in acute cases; (2) early operation is therefore advisable; (3)
1 British Medical Journal, Augusts, IU02.
» Kev. Hebdom. de Uvryng., cfotol. et do Khinol., February 1, 1902.
» Virginia Medical Seml-.Monthly, April 11, ia02.
680 AHBBICAN MBDIOINEj
THE PUBLIC SERVICE
[OCTOBER 25, 1902
mastoiditis, even with facial paralysis, apparently can disap-
pear spontaneously ; (4) in tiie fourth case the ; disease was
allowed to run its course and hearing was lost ; (5) in highly
brachycephalic skulls the sinus lies nearer the posterior wall
of the external meatus and the development of the mastoid cells
is correspondingly poor.
THE PUBLIC SERVICE
Healtb Reports.— The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, during
the week ended October 18, 1902 :
8MALi<Pox— United States.
Cases Deaths
San Francisco Sept. 28-Oct. 5 11
California :
Colorado:
Illinois:
Indiana:
Michigan :
New Hampshire :
New Jersey ;
New York :
Ohio:
Pennsylvania :
South Carolina :
Utah:
Wisconsin :
Barbados :
Belgium :
Canada :
Ecuador:
France :
Qreat Britain :
Denver Sept. 27-Oct. 4..
Chicago Oct. 4-11
Freeport Oct. 4-11
South Bend Oct. 4-U
Detroit Oct. 4-11
Nashua Oct. 4-11
Elizabeth Aug. 31-Oct. 11...
Binghamton Oct. 4-11
New York Oct. 4-11
Cincinnati Oct. 3-10
Cleveland Oct. 8-10
Hamilton Oct. 4-11
Toledo Sept. 27-Oct. 4 ....
Youngstown Sept. 27-Oct. 4 ....
Altoona Oct. 4-11
.(ohnstown Oct. 4-11
McKeesport Oct. 4-11
Philadelphia Oct. 4-11
Charleston Oct. 4-11
Salt Lake City Oct. 4-11
Green Bay Oct. 5-12
Milwaukee Oct. 4-11
India:
Mexico :
Russia :
Spain :
Straits Settlatnents ;
Switzerland :
Colombia :
Ecuador :
Mexico :
Smallpox— Foreign.
July 13-Sept. 29..
Brussels Sept. 20-27
Ghent Sept. 20-27
Amherstburg Oct. 4-U
Guayaquil Sept. 13-27.
Paris Sept. iO-27
Dundee Sept. 20-27
Liverpool Sept. 20-Oct. 4 ....
London Sept. 20-27
Sunderland Sept. 20-27
Bombay Sept. 9-16
Calcutta Sept. 6-13
City of Mexico Sept. 20-28
Moscow Sept. 13-20
Odessa Sept. 20-27
St. Petersburg Sept. 13-27
Corunna Sept. 20-27
Singapore Aug. 23-30
Geneva Sept. 1.3-20
1
13
7
2
7
23
9
1
1
3
24
1
1
2
4
5
2
1
5
3
1
12
793
Yellow Fkvkr.
Panama Sept 29-Oct. 8..
Guayaquil Oct. 20-27
Coatzacoalcos Sept. 27-Oct. 4..
Merida Sept. 19-Oct. 3..
Vera Cruz Oct. 4-11
Cholera— Foreign.
Hongkong Aug. 16-30
New Uhwang Aug. 16-30
Alexandria Sept. 20-27
Suez Sept. 10-16
Calcutta Sept. 6-13
Osaka and Hiogo....Sept. 6-20.
Batavia Aug. 31-Sept. 6..
Chenampo Aug. 17
Syen Chun Aug. 17
Straits Settlements : .Singapore Aug. 23-30
China :
Egypt:
India:
Japan :
Java :
Korea :
13
3
1
1
1
15
1
1
2
U
6
5
2
25
21
90
H>
2(1H
177
2(1
16
10
2«
62
4K
40
92
,50
20
11
1
California :
China :
Egypt :
India :
Bussia :
Plague— United States.
San B'raucisco Oct. 7 1
Bacteriological confirmed.
Plaque— Foreign.
Hongkong Aug. 16-30
Alexandria Sept. 2u-27.
Bombay Sept. 9-16
Calcutta Sept. 6-13
Karachi Sept. 7-14
Madras Sept. 6-12
Odessa June-Sept. 29..
19
19
4
2
51
6
8
«
1
38
11
Changes in the Medical Corps of the U. 8. Army for
the week ended October 18, 1902:
HOFF, Lieutenant Colonel John Van H., deputy surgeon-general,
orders of September 23 are so amended as to direct upon the com-
pletion of his duty at Fort Bayard, to proceed to .fefferson Barracks
and make an Inspection of certain matters at that post pertaining
to the medical department of the Army, under such Instructions as
he may receive from the surgeon-general of the Army, and upon
the completion of this duty to return to his proper station in
Washington.
Metzger, Major John A., surgeon, U. S. Volunteers, is honorably dis-
charged, to take effect November 15, 1902, his services being no
longer required. He will proceed to his home.
Bowen, Major William, surgeon, U. S. Volunteers, Is honorably dis-
charged, to take effect November 20, 1902, his services being no
longer required. He will proceed to his home.
The following-named officers of volunteers, now at San Francisco, Cal.,
are honorably discharged, to take effect November 20, 1902, their
services being no longer required: Major Ira C. Brown, surgeon;
Captain Luther S. Harvey, assistant surgeon. The officers named
will proceed to their respective homes.
Reynolds, First Lieutenant Charles R.. assistant surgeon, is
relieved from further duty In the division of the Philippines and
will proceed to San Francisco, Cal., and report by telegraph to the
adjutant^general of the Army for orders.
Grissinger, First Lieutenant JAY W., assistant surgeon. Is relieved
from duty at Fort Totten and will repair to Washington, D. C,
and report at the Army Medical Museum Building to Colonel Cal-
vin DeWltt assistant surgeon-general, president of the faculty of
the Array Medical School, for course of instruction.
MaLLER, George W , hospital steward, now at Jefferson Barracks, is
assigned to duty at that post.
Ma us, Ijieutenant Colonel Louis M., deputy surgeon-general, is granted
leave for twenty days, from about October 15.
Kennedy, Major James M., surgeon. U. S. Volunteers (captain and
assistant surgeon, U. S. Army), is honorably discharged as major
and surgeon, U. S. Volunteers, only, to take eff'ect October 31, 1902.
The following-named officers of volunteers, now at San Francisco, Cal.,
are honorably discharged, to take effect November 20, 1902, their
services being no longer required : Majors Samuel O. L. Potter,
James C. Minor, Simon J. Fraser, surgeons : Captains lAurel B.
Sandall, George A. Zeller, George E. Means, Thomas W. Jackson,
Harry R. Leraen, assistant surgeons. The officers named will upon
the receipt by them of this order proceed to their respective homes.
The following-named officers of volunteers are honorably discharged,
to take effect November 20, 1902, their services being no longer
required : Captains Dwight B. Taylor, Paul T. Dessez, assistant
surgeons. The officers named will proceed to their respective homes.
Chapman, W. Earle contract surgeon, now at Governor's Island, is
relieved from further duty in the division of the Philippines and
will proceed to his home at Cheboygan, Mich., for annulment of
contract.
Scull, James A., hospital steward. Army General Hospital, Presidio,
is transferred to Madison Barracks to relieve Hospital Steward
Archibald Bobbins. Steward Bobbins will be sent to Manila, P. I.,
for duty.
Changes in the Medical Corps of the U. 8. Navy tor
the week ended October 18, 1902 :
Myers, T. D.. passed assistant surgeon, retired, ordered to the Naval
Hospital, Philadelphia, Pa.— October 10.
Neilson, J. L., appointed assistant surgeon with the rank of lieuten-
ant—October 10 ,,,,..,.,
Dunn, H. A., assistant surgeon, detached from Naval Hospital, Yoko-
hama, Japan, and ordered to Naval Station, Cavite, P. I.— October 10.
McLarty, C, pharmacist, appointed pharmacist from April 25, 1902—
October 11.
BuCHER, W. H., passed assistant surgeon, detached from Panther and
granted leave for one month— October 11.
Gordon, F. T., pharmacist, detached from Navy Y'ard, League Island,
Pa., and ordered to the Wabash— October 14.
Mtchels, R. H., appointed assistant surgeon from October 11, 1902—
October 14.
Changes in the Public Health and Marine-Hospital
Service for the week ended October 16, 1902 :
Godfrey, John, surgeon, to proceed to Cape Fear quarantine. South-
port N. C, as inspector of unsei-viceable property— October 13, 1902.
Eager, J. M., passed assistant surgeon, detailed to represent the serv-
ice at the International Conference on Tuberculosis, at Berlin,
Germany, October 22-26— October 13, 1902.
Gardner, C. H., passed assistant surgeon, to proceed to Port Town-
send quarantine, Washington, as inspector of unserviceable prop-
erty—October 13, 1902.
Gofer, L. E , passed assistant surgeon, to proceed to New Y'ork, N. Y.,
and report to Surgeon G. W. Stoner, Immigration Depot, for tem-
porary duty— October 13, 1902. Leave of absence granted Passed
Assistant Surgeon Cofer amended .so that it shall cover the period
from September 10 to November 18 -October 14, 1902.
Von Ezdokf, E H., assistant surgeon, granted leave of absence for
two months and twenty-four days from November,!- October 1,5, 1902.
Lord C. B. U., assistant surgeon, granted leave of absence for one
month from November 6— October 1 1 , 1902.
BURKHALTER, J. T., assistant surgeon, granted leave of ab.sence for
one month from November 3— October 11, 1902.
BoGGESS, J. S.. assistant surgeon, granted leave of absence for fifteen
days from November 1— October 13, 19 >2.
Ebersole, B. E., assistant surgeon, to proceed to Brunswick, Georgia,
quarantine station, aud assume temporary charge of the station
during the absence on leave of Assistant Surgeon J. T. Burkhalter
—October 13, 1902.
BULLARD, J. T., acting assistant surgeon, granted leave of absence for
thirty days from September 15— October 15. 1902.
Hunter, W. R , acting assistant surgeon, granted leave of absence for
fourteen days from October 13— October 15, 1902.
Stanton, J. G., acting assistant surgeon, granted leave of absence for
twenty-flve days from October 7— October 13, 1902.
Walklky^, W. S., acting assistant surgeon, granted leave of absence for
seven days from October 14— October 13, 19o2.
Macdowell, W. F.. senior pharmacist and special disbursing agent,
relieved from duty at Havana, Cuba, and directed to proceed to
New York, N. Y., and report arrival— October 10, 1902.
Ryder, L. W., senior pharmacist, granted leave of absence for fifteen
days from October 13— October 15, 1902.
Boards Convened.
Board convened to meet at Port Townsend, Washington, October
20, IDOi, for the physical examination of officers of the Revenue Cutter
Service. Detail for the board— Passed Assistant Surgeon C. H. Gard-
ner, chairman ; Assistant Surgeon M. H. Foster, recorder.
Board convened to meet at San Francisco, Cal., October 20, 1902, for
the physical examination of officers of the Revenue Cutter Service.
Detail for the board -Passed Assistant Surgeon W. G. Stlmpson, chair-
man ; Assistant Surgeon W. C. Rucker, recorder.
American Medicine
iS
GEORGE M. GOULiD, Editor
G. C. C. HOWARD, Uarutging Editor
Clinical Medicine
David Ribsman
A. O. J. Kelly
J. Edwin sweet
Helen Mukphy
CHARLES S. DOLLEY
MARTIN B. TINKER, Assistant Editors
General Surgery
Martin B. Tinker
A. B. Craiq
Charles A. Okr
Orthopedic Surgery
H. Augustus Wilson
COLLABORATORS
Obstetrics and Gynecology
WiLMER Krusen
Frank C. Hammond
^erv&its and Mental B-isenses
J. K. Mitchell
F. 8a VARY Peakck
Treatment
Solomon Solis Cohen
H. C. Wood, Jb.
L. F. Appleman
Dermatology
M. B. Hartzbll
Pdblmhkd Wkkklt at 1321 Walmot Strht, Philadslphia, by thk Amebican-Ukdicimb Publishino Company
Laryngology, Etc,
D. Bradkn Kyle
Ophthalmology
Walter L. Pyle
Pathology
R. M. Pearce
Vol. IV, No. 18.
NOVEMBER 3, 1902.
15.00 Yearly.
Raise the Standard of Fees. — A Western eon-
temporary, the Alkalo'ukd Clinic, advocates a general
agreement on the part of physicians to raise their fees in
accordance with the enhanced prices of the necessities of
life which have obtained of recent years. With some
conditions and limitations we heartily vote aye to this
resolution. The first condition would be that the fees of
the physician are those that should be raised — the
physician, we mean, as distinguished from the surgeon
and the specialist. The internists, the general or family
physicians, constitute the most important but the most
neglected class of the profession. We have conspired
with the thoughtless and melodrama-loving public to
give all the honor and all the profits also to the surgeons
and specialists. If the profession is to make any com-
mon stand for better wages, it must be for the sake of
the general physician. His work is worth just as much
as that of the operator, but he does not receive one-tenth,
and in many cases, not one-hundredth as much. We do
not say that the specialist and surgeon receive too much,
we urge only that it is the duty of the specialist and
surgeon to help raise the standard of fees of his col-
leagues to a level of that of their own. In the second
place the movement to increase the fee should at first
chiefly consider the country physician, as distinguished
from the city man. Either because the number of cases
is greater or other means of livelihood are obtainable
the city physician does not suffer from low and uncol-
lectible fees as does his country brother. The newly-
aroused professional consciousness must show conscien-
tiousness and the love of justice, or it will not endure.
The Ancient and the Modern Conception of Dis-
ease.— In his recent address at University College, Liver-
pool, Sir^'^rederick Treves discusses an interesting distinc-
tion between the ancient and the modern conceptions of
disease. The elder thought was of a malignant entity or
spirit entering into the body from without for purposes
of evil, and " to be stamped out by unconsidered vio-
lence." Hut the modern physician, says Treves, finds
that the symi)toms of disease prove that a beneficent
process is at work. In infectious disease the symptoms
are the evidences of the struggle of the organism to
eliminate or neutralize or isolate the noxious material.
In inflammation there is no malign purpose, but an
attempt to protect the body from parasitic invasion, and
to eliminate the septic matter already introduced. In
peritionitis and appendicitis the pain and collapse impose
rest in a recumbent posture, and the sensitiveness and
rigidity of the abdomen all work to emphasize this
necessity. Peritonitis is thus "a life-saving process."
With all proper deference to so excellent an authority,
we urge that this is hardly fair to the ancient and
medieval philosophers. Surely modern science has
demonstrated the extraneous origin of disease in a large
number of types. This is precisely the significance of
the germ theory of disease. The great fact that disease
comes from without and is a genuine invasion of the
body is even more true than the old pathologists could
dream. It is indeed remarkable that they so clearly
grasped the essential fact. What they did not do, and
could not be expected to do, was to distinguish between
the ab extra cause and the consequent subjective symp-
toms. It is indeed true that these are beneficent instead
of malignant, and that they give the modern physiciaa
most valuable hints and directions as to treatment,
which must always imitate the natural processes.
" A certain profession of dogmatism," says a
great surgeon in an address to medical students, " is
essential in the treatment of the sick. The sick man
will allow of no hesitancy in the recognition of disease.
He blindly demands that the appearance of knowledge
shall be absolute, however shadowy and unsubstantial
may be the bases of it." But is this good advice? It
is, so far as the patient is concerned, usually true at the
time of illness, but there are several other considerations
which we believe make the advice to the physician the
reverse of wise. In the first place there are the patient's
relatives and friends. Even in hospitjil practice and in
private practice among the poor it is not true that the
physician succeeds in humbugging the friends by an
assumed dogmatism without the reality of knowledge
and conviction. Among intelligent laymen, far more
fre(}uently than is supposed, one will find that any such
sham certainty is at once detected. Doctors make a
great mistake when they think their dcHieits really
deceive. Then there is the patient who recovers. When
he is well the false diagnoses, the changes of dogmatic
opinion tmd medicines, the blind alley of proved errors
— these are thought over, and the doctor is scornetl, not
loved. This is, in fact, the origin of the famous saw
682 American MbdicinkI
EDITOEIAL COMMENT
fNOVKMBER 1, 1902
concerning the wish of the devil to become a monlc
when he was sick, etc. Thirdly, comes the reaction on
the dogmatist's character. One cannot dishonestly
assume knowledge, and skill, and prophecy without at
last fooling himself, and he then enters upon a life of
continually descending tactlessness in which the fraud
becomes proportionately more evident to others as it
becomes more unconscious to self. The profession suffers
also, because to it is charged the sin of the tricky doctor.
Slyness, assumed virtues and knowledge, cunning —
these do, in fact, prevent true professional success. But
the foolish sly ones will never find it out.
The attitude to the patient is the same now as it
was of old. The centuries have made little difference
between the Religio Medici of Sir Thomas Browne and
that of Sir Frederick Treves. "It is possible that a
doctor may be acquainted with all that is to be known
of the diseases of man and yet know too little of the
man himself." Nothing surely is more profoundly
needed today than the advice that the physician must
have absolute fidelity, and never forget the solemn trust
imposed by the patient's faith ; and whether so invoked
or not, it is imposed by the spirit of the profession. No
matter how we may be maligned, regardless of ingrati-
tude and of the vindictive animus of antiscience and
ignorance, forgetful of the railing at " medical etiquet"
and "medical monoply," we must obey the command
of "the simplest justice, the simplest right doing, and
above all, the truest care for the interests of the patient. ' '
And, also, without fail, the simplest kindness and sym-
pathy. He who has not this genuine feeling toward his
patient is not a true physician. No " science " can take
its place, no skill, no operative technic, no learning, no
success. Nor can it be replaced by any "assumption of
manner, however elaborate or however precisely mim-
icked."
Another suggestion for shortening the college
course comes from President Hyde, of Bowdoin College,
who states that most of the distinguished alumni of that
institution graduated at about the present average age of
entrance, and were well launched on their professional
careers at about the age at which the average student
now graduates. He mentions a number of eminent men
who graduated at the agas of 17, 18, and 19, while at
present the average of graduation is 23. He finds that
the requirement for the bachelor's degree in most col-
leges, stated in hours of work, is about 54, that is,
eighteen courses each extending over an entire year for
three hours each week. The present system of ranking
as adopted in most colleges is as follows : a, excellent ; b,
good ; c, fair ; d, poor, and e, not passable. His plan is
to make quality count as well as quantity for the bache-
lor's degree. He proposes to let an hour in the course
for which the student receives d count 1 toward the
requisite 54 units, a e hour 1.1, a b hour 1.2, an a hour
1.25. No man shall be allowed to get his degree in three
years on d hours only, neither may he take it on a
majority of d's and a few c's. If, however, he can get
enough credit on his courses to retain the requisite 54
units in 51 hours or less (that is, 17 three-hour courses or
less), he may be allowed to graduate in three years. He
estimates that a man of average ability and somewhat
more than average application would take his degree in
three years on something like eight d hours, twenty c
hours and twenty b hours, forty-eight hours in all, or
sixteen three-hour courses ; six courses in one year and
five in the other two. This would not be an excessive
amount of work except possibly for one year. By this
plan students would do no more work each year than
they are now doing under the present four-years plan,
but they would get credit for doing it extremely well in
the form of a substantial reduction in the quantity of
work required. They would have just as much time for
athletics, society, and the management of college enter-
prises. A student could be a high scholar without being
forced to become a grind in consequence.
This plan has certainly much to commend it to the
attention of educators. A professional man cannot claim
to be thoroughly educated without preliminary college
course. But the four-years course with the present
requirements for entrance is an undue burden on parents,
delays self-support too long, postpones matrimony, and
brings men belated to their profession. The evil is espe-
cially great in the medical profession, in which post-
graduate hospital and laboratory work is so important.
The plans which have been suggested in the past, such
as allowing the fourth year in college to count as the
first year in a professional school, or allowing the student
to take summer sessions' work to count for one year, all
have their disadvantages. The plan of President Butler,
of Columbia, to give the arts degree after two years'
study cheapens the college course greatly and robs it of
value out of proportion to the shortening of time. This
plan of President Hyde's has other decided advantages
beside the shortening of the course. The stimulation of
the student by offering a premium for better quality of
work would have its decided moral as well as intel-
lectual influence. The interested discussion on the
shortened course of college study during the past year,
with many- valuable suggestions from prominent educa-
tors, indicates that the shorter course must soon become
an established fact, and we believe that some way will
be devised by which this can be accomplished without
cheapening the degree or unduly lessening its educa-
tional value.
The Punishment of the Hooligan. — The word
"hooligan" has not been acclimated in the United
States, but it will soon have to be adopted, that or some
other, because we are very fast growing the article. It
is the name given in England to the criminal loafing
boy of the cities. Our rowdy youths have not generally
developed the murderous tendencies of the London
examples, although they are fast catching up. When
brought before him two young ruffians were thus dis-
posed of by Magistrate Smith, of London :
" My powers are not so large as I could wish, for what Is the
use of a 40s. fine to stop this sort of ruffianism? You would
laugh at such a punishment. There is, however, another way
of dealing with such cases. I am going to exercise it now and
in future. You will each of you find two sureties in £25 each to
be of good behavior for six months, and in default you will be
kept in prison for that period."
November 1, 1902]
EDITORIAL COMMENT
American Mkdioine 683
I
The Lancet thinks they should have been well flogged.
In the Nineteenth Getitwy and After for July Mr. Robert
Anderson, who is well qualified to speak on such sub-
jects, would lean to this course if there were not a better
method in London of making these scamps ashamed or
of utilizing their lives. The trouble with the prison
plan is that our hooligans are proud of their sentences,
and " no punishment degrades a criminal so thoroughly
as one that allows him to make his crime a subject of
boasting." Anderson says that the prevention of hooli-
ganism is not only better but is vastly more easy, and he
advocates the enactment of a law against the making of
the streets their homes by able-bodied youths without
visible means of subsistence. The magistrates would
then send them, not to prison, but to the training-ships.
"Many of these youths would make excellent sailors if
they were thus rescued in time." Have we any possible
method whereby similar use might be made of this *' raw
material"? Lombrosos and the sticklers for the
"adamantine laws of heredity " may ponder Mr. Ander-
son's words :
" Then as to the future of those who would be thus rescued.
In the criminology of the Continent the ' type ' theory prevails.
But, so far as our own country is concerned, it is refuted by the
experience of practical philanthropists. It has been abundantly
proved by work done among destitute lads in London dur-
ing the last quarter of a century tliat the children even of vicious
and degraded parents, if taken in time, can be trained to live
clean and useful lives. Indeed, the failures are comparatively
so few that no special theory is needed to account for them.
True it is that the great majority of cases from which this expe-
rience is derived are removed from their evil environment
in early life. But if the 'type' theory were well founded, this
fact would be immaterial ; and I may add that in recent years
increased efforts have been made to deal with youths of the
' hobble-de-hoy ' class, and the results have been encouraging.
Indeed, the institutions which deal with such cases might well
be utilized under the new law."
Overpressure in the Public Schools. — At a joint
meeting of school superintendents and the State Board
of Health in Ohio, the question of overstudy was a
topic under discussion. The superintendents appeared
to take the position that there was no such overworking
of the pupils. The superintendent of the public schools
of Cincinnati said :
" It is not mental activity tliat hurts. It is the foul air, the
bad seat, the unequal heating of the room, the poor lighting.
Study doesn't hurt. A few days ago we had a case of a child not
yet ten years old who was suffering with headache and seemed
to be unable to give attention to the lessons. On investigation
it was found that that child had been up four nights until 11
o'clock ! We have thousands of such cases in Cincinnati in
which the bad eating, bad hours and irregular sleeping at home
produce these results. . . . But hard work is what the child
needs; not rest, not recreation, not relea.se from task, but infus-.
ing the task with a purpose so that in pursuing it the child
grows strong in mind as in body. Of course, mental exercise
as well as physical can be carried to excess. But the work of
the schoolroom which shows a stultifying process has to do
with the formal textbook side of the schooling."
But the physicians were of another opinion. Dr.
McCall, of Lima, said :
" From day to day I see the effects of overcrowding in our
public schools and so do my brother practitioners in Ohio and
other Htates. If the cliildren have their studies interspersed
with manual training, outdoor exercises and study of nature
there is no such thing as mental overwork. But that condition
does not exist in many schools. Of all the factors which we
find working on the nervous systems of the children the one
most detrimental is the giving a lot of dry facts to memorize
and recite, and the fact remains that such is done."
Dr. McCall gave a telling illustration of his truth
which, if it does not prove overpressure, decidedly does
prove the wicked stupidity of some all-too-prevalent
methods of teaching. He was called to see a little boy
of eight who was delirious and who was continually
repeating the inexplicable words, "Angy two times
meet me on pond." The next day the little fellow was
in a more normal condition of mind, but did not remem-
ber the doctor's visit nor what he was crying out the
previous evening. Asked what he was worrying about
he said he feared he should get a whipping this morn-
ing, that he was to learn something yesterday at school
and he could not. Questioning brought out the explana-
tion of the jargon which the poor little brain had so
feverishly wrestled with for 24 hours. The magnificent
truth his tortured mind refiected as "Angy two times
meet me on pond" was "An angle is two lines meeting
at a point!"
A suggestion of importance to advertisers and
readers is that in a recent number of the Lancet. The
editor says :
" Our experience proves that it is becoming almost impossi-
ble to admit articles in the columns of the Lancet from the pens of
general practitioners and others dealing with the results of their
therapeutical investigations into the value of new preparations
because all the favorable passages will at once be pounced upon
by the enterprising purveyor, perhaps garbled, almost certainly
dissociated from their context, and scattered broadcast over the
land. We are thus, perhaps, prevented, and by the very people
who would profit by the publicity, from putting before our
readers papers the practical value of which may be great. The
public, the medical profession, and the purveyors alike suffer.
The only way to remedy the position is not a satisfactory one,
but it is one to which we must have recourse."
It is true that there are many new pharmaceutic prepa-
rations of value to the profession that should be brought
to the notice of medical men by good practitioners in
reputable medical journals. But the abuse pointed out
by the Lancet is a veritable one. It is worse in our
country than in England, due to the absurdly large
number of medical journals and the professional puff'-
writer. It strikes us that the chief sufferer is the manu-
facturer of good products who will not push them by
dishonest methods. It is true that the honest manu-
facturer can trust to the profession righting him in time,
but some means should be devised to prevent the dis-
honest from reaping possible immediate benefits. Are
conditions reaching such a state that because of the abuses
by certain advertisers all mention of proprietary prepa-
rations must be interdicted l)y reputable medicjil jour-
nals? We have known many astute men who say that,
owing to the suspicion aroused in the mind of the readers,
such mention prevents sales rather than encourages them.
The " Cort-espondence school " applied to med-
icine, and especially to midwifery, is the latest. In
the yellow journal advertising columns interlarded with
the " Vitality restored" and "Willy communicate at
684 AKXBIOAN MKDIClinBj
EDITOEIAL ECHOES
(NOVEICBMIl 1, 1902
once" personals, appears the advertisement of a mid-
wifery course, as follows :
" Women taught by mail the paying profession of mid-
wifery in four weelcs ; handsome diploma on completing
course ; terms moderate, etc."
In its circulars and letters this school says the low
fee will only be maintained for a short time, and the
regular rate will soon be doubled. It is claimed that
nearly all confinements in the city are attended by
midwives, and that women taking this course are inval-
uable [without value, truly ! ] to the physician, and
that '' the medical profession is a unit in testimony of
the great value of our instruction." We are glad to
know that the medical profession is a unit about any-
thing, and we admit that the enterprising correspond-
ence school advertiser and teacher is nearly correct in
this instance as to our professional unity. The profes-
sion, doubtless, comes nearer being a unit upon this
question than upon any, but the union would first
emphatically deny the desire for any midwives at all,
and of those made by correspondence "during their
spare time" in four weeks (at the rate of $20.00 if paid
in advance) " beginning and ending their courses when
they please," — well, of these we are in truth very uni-
tary. They and their dupers should be speedily placed
in the hands of the law.
So Strang-e, So True !— From the S(.. Louis Olobe-
Dmiocraf, a newspaper, we cut the following advertise-
ment:
The Difference Between an Oculist and Optician. —
The optician tests youreyes Free and ruins them for you. The
oculist is a graduate of medicine who has to take a special course
and several postgraduate courses to become one. If you have
trouble with your eyes Oo to the Oculist and Pay for the Exam-
ination, then bring your prescription to me to be filled. I will
save you money. I am the best frame fitter in St. Louis.
Optician and Expent, Frame Fitter.
That optician deserves the encouragement of every
physician. Both poisons and spectacle lenses should
not be sold to the public except upon a physician's pre-
scription. Whatever article of the materia medica may
do physiologic good may also do as great or greater
harm.
" The Mature of the Case."— A friend of American
Medicine was recently traveling in the country in West
Virginia, and took from the door of a mill the following
posted notice :
Notice to all who wants prescriptions I will write them
for 5c to 10c each with directions for using same, if for a single
bottle or package 5c if more than that 10c
I will go all trips to visit the sick except midwifery at 10c
per mile and 50c per day extra
In Case of midwifery 82.00 for every case insured on quick
trips 50c per day for being detained over 1 day and 10c per
mile
Now Gentlem here is the nature of the case I would not
care to go some and write some for nothing but it is and every
day thing and I cannot do it all for nothing my Doctor Books
cost me over ten dollars I have spent over $50.00 worth of time
In reading them and besides my time is worth something to
me and I positively would rather not be bothered
Respectfully R. B. Lester.
EDITORIAL ECHOES
Concerning' Specialism.— It is irrational to treat
one organ without a knowledge of the interrelation of the
various organs and parts of the body. This is knowl-
edge which, of course, the specialist must have, and
which the properly equipped and conscientious worker
in a special field does have in far greater degree than is
usually placed to his credit. The deeper a man goes
into any branch of medicine, the more clearly he sees
these very interrelations which are so often the keynote
of successful treatment, and he sees them, we are inclined
to think, at times more clearly than the physician who
scans a broader field. That there are socalled specialists
who do not attain to this conception of their work is
self-evident, and the sooner such men are made to feel
their limitations the better it will be for the profession
at large. The ideal specialist is he who goes deeply into
a subject and then extends his knowledge into every
related field. Such a man is hardly to be looked upon
as narrow or bigoted, or even incapable of entering into
the finer appreciation of the idiosyncrasies and tempera-
ments of his patients. It might not be straining a
point for him even to act occasionally as " family ad-
viser."— ^Boston Med. and Surg. Journal.']
Why Require the Degree ? — The deans of various
schools of Columbia University are supporting the pro-
posal of the president of that institution that the bac-
calaureate degree shall practically be conferred at the end
of the sophomore year, at least in the case of those who
are going on to the professional schools. This means
that the professional schools of Columbia are about to
make the baccalaureate degree a prerequisite to matricu-
lation, and therefore that degree must be made more
easily or more quickly obtainable. It at once depreci-
ates the real value of the baccalaureate degree and
fictitiously inflates the standard of the professional
school. It seeks to give the professional school the
prestige of accepting none but bachelors as students, yet
at the same time it cheapens bachelorhood by making it
obtainable in two instead of four years ; and when that
fact is taken into account what becomes of the vaunted
high requirements of the professional school ? If it
were intended to restrict the numbers entering law and
medical schools, and thus save the professions from
overcrowding, there would be some reason in it, though
even that desirable end might be attained in a better
way. But such is not the case, for the declared object of
the proposed reduction of course to two years is to keep
it easy to get into the professional schools. It may be
desirable for all men to have college training. That
point is not now at issue; though it maybe remarked
in passing that if it is desirable, the thing that is desir-
able is the training and discipline of years of college
life, and not the hothouse cramming of immature brains
with undigested facts and figures from the books. The
fact is, however, that many of the best students in law
and medical schools, and many of the bast practitioners
in those professions are men who have never taken a
baccalaureate degree.
It may well be asked, then, why it would not be better
for the professional schools to stop " putting on airs " in
requiring baccalaureate degrees and to accept students
on the basis of fit and appropriate scholarship rather
than of engrossed sheepskin. For years a certain stand-
ard of scholarship has been required in these schools.
If it be desirable to raise that standard, well and
good. Raise it. But let it be an honest raising of
an honest standard, showing upon the face of it just
what it is, and not masquerading in the spurious
finery of a cheapened degree. — \_Neic York Daily
Tribune.']
NOVKMBKK 1, 1902J
AMEKICAN NEWS AND NOTES
iAkkbican Hedioins 686
AMERICAN NEWS AND NOTES.
OENERAIi.
Health of Havana. — For the month of September the
deathrate was 17.86 per 1,000 of populatiou. A noteworthy fact
Is that for the year ended September 30 not a case of yellow
fever originated in the city, an event unparalleled in the mem-
ory of any physician in the city.
Miscellaneous. — Philadelphia : With the advent of the
new year Dr. A. O. J. Kelly, of this city, will assume editorial
direction of the welllcnown quarterly. International Clinics. —
At a stated meeting of the Philadelphia Pathological Society
held October 9, the following officers were elected : President,
Dr. Charles W. Burr ; vice-presidents, Drs. Alfred Stengel,
Joseph McFarland, Simon Flexner, and Mazyck P. Ravenel ;
secretary. Dr. J. Dutton Steele; treasurer. Dr. Thompson S.
Westcott; recorder, Dr. David S. Riesman.— The following
appointments have been made at the University of Pennsyl-
vania: Dr. J. L. Gates lias been elected assistant demonstrator
of pathology ; Dr. Hidaya Noguchi, assistant in pathology ; Dr.
John T. Carpenter, instructor in ophthalmology ; and Dr. A. W.
.larman, demonstrator of prosthetic dentistry. Hartpobd,
Conn. : Dr. T. D. Crothers has been elected consulting neurolo-
gist by the Board of Trustees of the New Yorlc Metropolitan
Hospital and Dispensary. CAMBRiDaE, Mass.: Charles Sedg-
wick Minot, professor of histology and human embryology in
the Harvard University Medical School, has recently received
the honorary degree of Sc.D. from the Oxford University.
Hospital Benefactions. — Boston, Mass. : The late Joseph
B. Glover, of Boston, bequeathed ^,000 to the Ma-ssachusetts
Homeopathic Hospital. This institution will also receive a
proportionate interest in the income of a permanent trust fund
of SIOO.OOO of which the Massachusetts General Hospital, the
McLean Asylum, the Boston Lying-in Hospital and the Eye
and Ear Infirmary are co-sharers. Chicago, III. : Under the
will of the late Siegfried H. Kirchberger, of Chicago, ten
charitable institutions are given gl.OOO each. Among these are
the Alexian Brothers' Hospital, Xational Jewish Hospital for
Consumptives at Denver, Col., Chicagp Lying-in Hospital and
the Home for Destitute Crippled Children. For a memorial
room in the Michael Reese Hospital, 83,000 was provided. This
room will be known as theS. H. Kirchberger room. Winnipeg,
Manitoba : Through the generosity of real estate agents and
dealers the Winnipeg General Hospital has received a tract of
land valued at $2,000. Toronto, Ont. : A citizen, who wishes his
name withheld, lias given 825,000 for the erection in or near To-
ronto of a hospital for advanced cases of pulmonary tuberculosis.
The National Sanitarium Association is asked to find a suitable
site. Philadelphia, Pa. : The will of the late Philip Jagode,
of this city, deyises ?5,000 direct to the German Hospital for the
endowment ora free bed to perpetuate the memory of his wife.
It is reported that Henry Phipps, of New York City, has given
$600,000 for the establishment of a clinic in Philadelphia for
poor consumptives. He has also contributed ?.5,000 toward the
maintenance of the Free Hospital for Poor Consumptives at
White Haven, Pa., and has given 81,000 additional for the instal-
lation of a beating plant in that institution. Boston, Mass. :
The late Lamont G. Burnham bequeathed 8150,000 to the Boston
City Hospital for the erection of a new building to be known as
the Burnham ward. Portsmouth, N. H. : The late Frank
Jones left 810,000 to the Portsmouth Cottage Hospital and $5,000
to the Chase Home (or Children and Home for Indigent
Women.
NEW YORK.
Heart Surgery. — An operation performed on a woman of
32, recently admitted to Bellevuo Hospital with a stab wound
in the heart, is of interest as being one of the few of its kind
recorded in medical history in this country. Upon entrance
the patient's condition was considered hopeless but it was
decided that an operation might give her a chance for life. She
was therefore anesthetized and the original incision enlarged
until the heart was exposed. Six stitches of catgut were taken
in the left ventricle without disturbing the pulsations of the
organ. The operation, which took but 15 minutes, was per-
formed by Dr. George D. Stewart, professor of anatomy in
Bellevue Medical College. The patient rallied splendidly from
the operation and it was thought she would recover, but she
died suddenly 2} days later. On autopsy it was found that the
wound had united nicely ; and death was declared due to septic
poisoning caused by the knife used by her assailant. A suc-
cessful case of heart suture was recently reported by Dr. Luther
L. Hill, of Montgomery, Ala. In this patient the knife had
entered a little to the right of the left nipple and had penetrated
the left ventricle, making a wound one-half inch in length.
This was closed by a catgut suture, the patient making a
splendid recovery. Dr. Sherman, in the address on surgery,
delivered at the meeting of the American Medical Association
at Saratoga this year, summarized the whole subject of surgery
of the heart and reviewed 34 operations of this kind per-
formed since 1896, of which 13 cases terminated in recovery.
An extensive literature on the suture of heart wounds Is
given in Vol. vi. Second Series of the Index Catalogue of
the Library of the Surgeon-General's OflSce. In this connec-
tion it may also be of interest to note that according to statis-
tics recently published in France from 30 to 42 persons out of
every 100 persons who receive stab wounds of the heart recover,
although after a careful search of medical literature it is noted
there is no instance of recovery recorded after the heart has
been pierced by a bullet. However it is announced that such a
case, said to be the only one of its kind on record, was reported
before the last meeting of the French Academy of Medicine by
Dr. Peyrat, who stated that the patient was admitted to a hos-
pital in Paris suffering from a bullet wound in the heart. He
was operated on successfully by Dr. Saunay and was fully
restored to health.
The Strauss New York City Pasteurized Millc Depot.—
During the past season 976,040 bottles of Pasteurized milk and
milk foods were distributed, and over 1,000,000 glasses of milk
served on the premises. The greater portion of the milk was
distributed to the ailing children of the East and West Side
tenements. Dr. J. Corwin Maybe, of the Bacteriologic Labora-
tory of the Health Department, in an extended report stated
that he believed the low deathrate among children under five
years of age was directly attributable to the distribution of this
milk from the depots maintained by Nathan Strauss. In sup-
port of his view he says a careful investigation of the vital
statistics will show that a low deathrate is characteristic in the
sections of the city where the distributing stations of the Nathan
Strauss Laboratory are located. An examination of the statis-
tics for June, July and August of the deathrate of children
under five since 1891 shows that each year there has been a
steady decrease, the deathrate having been reduced from 126.0
in 1891 to 63.6 in the past season. Mr. Strauss has announced
that he will have a new and larger laboratory in operation
next year, as the demands on his unique charity has vastly
increased.
PHUiADEIiPHIA. FENNSYIiVANIA, ETC.
Philadelphia Hospital.— It is reported that the Councils'
Committee on Charities and Corrections will ask for nearly
$1,100,000 for the maintenance and improvement of the institu-
tion during the coming year. Of this sum $510,000 will be
devoted to making extensive hospital improvements, consisting
of a new operating-room for $150,000, a laboratory for clinical
medicine for $150,000, a bacteriologic and pathologic-room for
$80,000, a pavilion for consumptives for $80,000, and a pavilion
for nervous diseases for $50,000. The committee also recom-
mended the appointment of two women supervisors for the
female insane at a salary of $50 a month.
Physicians Contract Tuberculosis. — It is reported that
five physicians connected with the staff of the Philadelphia
Hospital are suffering from tuberculosis, which was contracted
in that institution. The death of Dr. Daniel E. Hughes, chief
resident physician of the almshouse, which occurred October 28,
is reported to be due to tuberculous peritonitis transmitted
through food prepared by a cook who is a victim of advanced
tuberculosis. It is also stated that one nurse died three months
ago from tuberculosis which she contracted in the hospital, and
at least two others c^n attribute their tuberculous condition to
the same cause. It is said that recently physicians and nurses
of the hospital are becoming alarmed, and as a consequence a
number have left the institution.
SOUTHERN STATES.
Ije^slation Regarding Health Boards. — At a recent
meeting of the Louisiana State Board of Health the following
summary of the recent legislation in the State was presented :
1 Vaccination shall not be made compulsory except in cases of
children attending the public schools of a parish where smallpox pre-
vails, and when the same shull have been recommended by a majority
of the local board of health.
2. Any violation of any provision or provisions, or regulation or
regulations of the sanitary code shall constttule a misdemeanor, and
the oireiider shall be punished by a flnoof $25 or 30 days' Imprison-
ment la the parish Jail for each and every offense, on conviction before
a court of competent jurisdiction.
8. The police Jury of each parish shall. Immediately after the pro-
mulgation of this act, and hereafter not later than the third regular
meellUK of the new police Jury terra, elect and appoint a parish board
of health to consist of three persons, said board to be composed of a
duly licensed and registered physician, a resident of said parish, who
shall be chalrinan of said board of health and health officer, and the
two (ilher members of said board shall be selected from the police Jury
of said parish.
4. The term of no parish board shall continue longer than that of
the body by which It was appointed.
.5. The chairman and health officer of a municipal board shall
receive such an annual salary as the city council or legislative body of
said municipality may fix and pay.
(i. The persons appointed to constitute the city board of health
shall .serve during the term of the body by which It was elected.
WESTERN STATES.
The Oriental Hospital and Dispensary, of San Francisco,
Is said to be the only institution in America for the treatment of
Chinese exclusively. It is a large two-story structure in charge
of (Chinese doctors and nurses. It is reported that Chinese
medicines are the only ones administered.
686 AMEBIOAIir MESIOtKBI
FOREIGN NEWS AND NOTES
TNOVEMBER 1, 1902
FOREIGN NEWS AND NOTES
OENSRAIj.
Miscellaneous. — Professor Hans Virchow, son of the late
Rudolf Virchow, recently celebrated his fiftieth birthday. He
has been for years a professor of anatomy at the University of
Berlin, and also at the Academic High School for Plastic Arts,
where his predecessors were Helmholtzand Du Bois-Reymond.
A Research Institute, which is open to all nationalities,
has been established by the government of the Federated
Malay States in the capital, Kuala Lumpur. The institution is
fully equipped for the study of special and general pathology,
clinical medicine, experimental physiology and bacteriology.
Such an institution will be specially welcome to students of
tropical medicine.
GREAT BRITAIN.
Health of liondon. — According to the Public Health and
Marine-Hospital reports, the following cases of infectious dis-
eases were reported to the London health authorities for the
week ended September 27, 1902 : Smallpox, 4 ; scarlet fever,
388 ; diphtheria, 125 ; enteric fever, 58. At the close of the week
there were 42 cases of smallpox, 2,703 of scarlet fever, 989 of
diphtheria and 360 of enteric fever under treatment. The 4
deaths from smallpox in England belonged to Liverpool, War-
rington, Sunderland and Swansea, respectively. In tne 76 great
towns of England and Wales, estimated population 14,862,084,
the deaths during the week corresponded to an annual rate of
17.5 per 1,000 — the three preceding weeks being 15.9, 16.4 and
17.7.
OONTINBNTAIj EUROPE.
Against Bubonic Plague. — At a session of the Federal
Council (Bundesrath) of the German Empire held July 13, 1902,
stringent measures were adopted for combating plague. The
directions are divided into four headings: (1) Preventive
measures; (2) obligation to report plague cases to the authori-
ties; (3) investigations regarding the disease; (4) measures to
be adopted to prevent the spread of plague. Preventive meas-
ures include the special inspection of dwellings when there is
danger of an outbreak of plague, and the prompt correction of
all insanitary conditions ; supervision by State officials Qf the
drinking water; the destruction of rats, mice, and other ver-
min ; creation of sanitary commissions ; introduction of steam
disinfecting apparatus in all disinfecting stations ; and the strict
surveillance of all persons arriving from plague infected dis-
tricts. Under the second heading is cited the persons who are
held responsible for reporting plague cases and deaths there-
from to the proper authorities and also directions to police
officials regarding the issuance of public notices calling atten-
tion to the duty of notifying authorities of plague cases. Under
the third heading is found the necessary steps whicli must be
taken by the health department when notified of the existence
of plague ; the ordering of postmortem examinations; and the
shipment of plague material. Under the fourth heading is
included proper quarantining disinfection, isolation of plague
patients, transportation, rules for the interment of those who
have succumbed to the disease and various other regulations
considered necessary to guard the public health.
The International Tuberculosis Congress held in Berlin,
October 22 to 26, was attended by many eminent authorities on
pathologic research. About one dozen countries were repre-
sented. Germany, of course, had the largest representation.
Prance ranking second with 20, Great Britain sent 4 delegates,
and the other European countries sent from 3 to 12, while the
United States had but 1 delegate. Dr. William Eager, of the
Marine-Hospital Service, who is stationed at Naples. Many
interesting papers were read discussing the progress made in
the various countries in the work of suppressing tuberculosis.
An exemplification of the work accomplisiied being furnished
by Germany, where, under Professor von Leyden's direction, a
system of sanatoriums has been established and associations
formed ; by Great Britain, where special hospitals have been
started with splendid success ; and by France, where there are
now 25 sanatoriums. This latter country has also a special
commission appointed by the Prime Minister, to inquire into
the best prophylactic measures against the disease ; it was also
announced that through public and private generosity special
establishments were to be erected in the near future. The
compulsory notification of tuberculosis cases was strongly
recommended, an example of the results of this system being
observed in New York, where the deathrate from this cause had
decreased 30% in a few years. It was announced that compul-
sory notification has existed in Norway since January 1, 1901,
while the adoption of such a measure was declared impossible in
England owing to public opinion, which is averse to interference
with sanitary measures in the homes. However, four meas-
ures were submitted on behalf of the Englisii association for
the prevention of the disease : First, the prohibition of expec-
toration under penalties ; second, systematic notification ; third ,
efficient ventilation and lighting in all factories and public and
private buildings, and fourth, the establishment of sanatoriums
for the treatment of tuberculosis in early and advanced stages.
The chief results of the gathering seem to have been the expo-
sition of the progress made in Germany in sanatoriums and
scientific appliances. There was a general feeling of regret that
the United States was not more largely represented and
especially that some one was not present to describe the results
of the experiments carried on in America during the last year
with regard to the communicability of animal tuberculosis to
human beings. The congress will meet next yeai in Paris.
OBITUARIES.
Daniel E.Hughes, of Philadelphia, October 28, aged 52. He was
graduated from the Jefferson Medical College, Philadelphia, In 1878.
After his graduation he became assistant clinical teacher under Drs.
Da Costa and Roberts Bartholow. In 1890 he accepted the post of chief
resident physician at the Philadelphia Hospital, and has held the
position ever since. He was widely known as an alienist, and made
insanity and amelioration of the condition of the criminal and pauper
Insane a lifelong study. He was also an expert therapeutist, and has
written many medical works, the most important being his " Clinical
Medicine," which is used as a textbook In a number of medical col-
leges. He was affiliated with many medical societies.
James J. Powers, of Denver, Colo., died at Santa Monica, Cal.,
October 3, aged 45. He was graduated from the College of Physicians
and Surgeons, Baltimore, 1882. He was a member of the Denver and
Arapahoe Medical Society, the Colorado State Medical Society and the
American Medical Association.
William Yonng, at Cold Spring on the Hudson, October 26, aged
82. He was the last surviving charter member of the Academy of Medl.
cine of New York. He was graduated from the University of Glasgow,
and later studied medicine in the Dublin University and in Vienna.
Joseph H. Sheppard, of Bridgeton, N. J., October 23, aged 74. He
was graduated from the University of Pennsylvania In 1849. He was at
one time a resident physician at the Philadelphia Hospital. During
the war he was a surgeon In the army.
Aaron Mercer Brown, in Cincinnati, October 3, aged 63. He was
graduated from the University of Pennsylvania in 1861. He was a
member of the Cincinnati Academy of Medicine and of the Ohio State
Medical Society.
Frederick K. Nordmann, of Baltimore, Md., October 22, aged 43.
He was graduated from the Baltimore College of Physicians and Sur-
geons in 1884. He was also a graduate of the Maryland College of
Pharmacy.
Isaac P. teete, at Branford, Conn., October 20, aged 82. He was
graduated from the Worcester Medical College in 1851. In his younger
days he was one of the leading physicians of Southern Connecticut.
E. P. Miller, in Sullivan, 111., October 7, aged 37. ^ He was gradu-
ated from the Kentucky School of Medicine, Xx)ulsvllle, in 1892, and
was a member of the Moultrie County Medical Society.
Lucian L,. Bedell, In Denver, Colo., October 5, aged 72. He was
graduated from the University of the State of Missouri, Columbia, 1855,
and was at one time a noted surgeon of Denver.
Henry C. Matthews, of Brooklyn, N. Y., October 22, aged 61. He
was graduated from the medical department of the University of Ver-
mont In 1870.
Dr. Edouard Meyer died recently in Paris. He was a wellknown
ophthalmologist of that city .and was co-editor of the Memte d'OpMhal-
mologie.
David M. McDonald, at Gatchellville, Pa., October 26. He was
graduated from the Eclectic Medical Institute, Cincinnati, Ohio, in
1871.
T. T. Orendorflf, at Rolling Fork, Miss., October 3, aged 55. He
was graduated from the Kentucky School of Medicine, Louisville, 1871.
Henry A. Cayley, of Butte, Mont., October 25. He was graduated
from the Eeole de Medicine et de Chirurgle, Montreal, Quebec, In 1890.
John W. Taylor, at Madison Courthouse, Va., October 4, aged 76-
He was graduated from the University of Pennsylvania In 1849.
Albert Potter, in Chepachet, R. I., October 2, aged 71. He was
graduated from the Harvard University Medical School, 1855.
Andrew J. Baxter, of Chicago, 111., October 25. He was graduated
from the Medical College of Ohio, Cincinnati, in 1861.
Hartwlg Range, of Stillwater, Minn., October 5, aged 89. He was
graduated from the University of Berlin in 1842.
Joseph L. Conway, in Chicago, October 6, aged 31. He was grad-
uated from the Rush Medical College in 1900.
Frank L. Martindale, at Port Richmond, October 26, aged 72. He
retired from active practice nine years ago.
J. Edwin Miller, of Pittsburg, Pa., October 6. He was graduated
from the Jefferson Medical College in 1870.
Andrew B. Bausman, in Chicago, October 21. He was graduated
from the Rush Medical College in 1882.
Professor A. Sigel died recently at Stuttgart. He was director of
the Olga Children's Hospital.
A. Blood, of Capron, 111., October 23.
NOVEMBBK 1, If 02]
SOCIETY EEP0ET8
(Ahxkican Mkdicink
687
SOCIETY REPORTS
MISSISSIPPI VALLEY MEDICAL ASSOCIATION.
Twenty-eighth Annual Meeting, Held at Kansas City, Mo.,
October 15, 16 and 17, 1902.
[Specially reported for American Medicine.]
{Oyncluded frovi page ffiP.J
Medical Section.
How Xot to Be Nervous : The Address in Medicine. —
Hugh T. Patrick (Chicago). The initiative of all thera-
peutics shouH be prophylaxis. Prevention was paramount to
cure. The first and most effective preventive of nervousness
was a reasonably long line of first-rate forbears. To be able to
present a specific illustration of the force of inheritance in the
genesis of luuctioual nervous affection he had tabulated from
his office records 100 consecutive cases which might be included
under the general term nervousness, and he found that in 10%
of them a nervous heredity had been in evidence. Next came
the never-ceasing formative power of environment. Reaction
to extraneous influences began at birth, and ceased only with
the extinction of life, but childhood and youth were the plastic
stages. For preventing nervousness in the child or removing
that already present, there is nothing so effective as the tough-
ening of the body and mind. But to produce this toughness a
certain exposure to bodily discomfort and mental hardship
was necessary. A deal of nervousness was caused or helped
along by misdirected energy, misplaced worry, longing for
baubles, the fighting of phantoms, etc. To recognize the
important things in life was one of the most difficult tasks of
Juagment that came to the individual.
Nenrastlienia. — George F. Butler (Alma, Mich.). Neu-
rasthenia was the expression of nerve tire of the central nerv-
ous system and its consequences. Nerve tire of the central
nervous system implies acceleration of the action of the excito-
motor ganglia of the organ, with first increased functionating of
these organs, and second, exhaustion with its consequences. In
this way central nerve tire, finding expression along the line of
least resistance, produced local organ expressions which were
claimed as the cause of the constitutional condition. From
these local expressions a vicious circle often resulted which
aggravated the original condition. As over-action of the organs
implied underelimination, autotoxemia of necessity followed
nerve tire of a very poisonous type, like all products of nerve
waste. From this renal and hepatic disturbance was added to
the clinical picture and intensified its blackness. Neurasthenia
might occur alone, or might be an expression and complication
of any constitutional disorder. In such cases both the nerve
tire and the constitutional disorder required treatment. The
neura-sthenia resultant on phthisis, nephritis, diabetes and
syphilis was a true neurasthenia, which if not treated intensi-
fied the disorder which gave it Ijirth.
The Criminal Kesponsibility of the Kplleptic. — John
PuNTON (Kansas City, Mo.) drew the following deductions:
1. That epilepsy is a symptom of some brain disease, 2. That
its continual presence tends toward mental deterioration. 3.
That the mental responsibility of the epileptic depends upon
the extent to which mind or self-control has been impaired by
the epilepsy. 4. That the legal test of in.sanity is not sufficient
as mental irresponsibility is not incomijatible with a knowl-
edge of right from wrong. 5. That epileptics are to some
degree at least responsible for criminal acts, more especially
when the epilepsy is produced by their own default.* 6. That
criminal acts of epileptics appeal to medicine rather than law
for their proper adjudication. 7. That in all cases of murder
where epilepsy is proved, the law should be amended to allow
of life commitment to an insane asylum rather that to a peni-
tentiary. 8. That the mental responsibility of the epileptic in
case of murder should be referred to a medical commission,
appointed bj' the court, which again may be referred to local or
county medical so<:ieties to name its members.
Sudden Atrophic Influence of Craniospinal Nerves. —
F. E. Coulter (Omaha, Neb.) summarized as follows concern-
ing the ca.se he reported : 1. All the hair was normal before the
attack, but within three days after the attack all disappeared
from the areas described. 2. The character of the new hair was
such as would be the natural product of a faulty nutrition ; if
due to the production of a toxin or the sudden diminution of
the normal elements, was difficult to decide. It was known,
however, that the abnormal hair was smaller in size, length
and diameter, and markedly deficient in pigment substance.
3. The fact that this was a bilateral lesion would naturally
indicate that one was dealing with a blood condition, possibly a
toxin, formed by the very sudden and severe convulsive state
and manifested itself on this particular nerve trunk because of
some histologic <;liaracter in its composition that we, as yet,
were unable to detect. 4. That in this particular case we did
not have an example of that strange, yet Interesting, condition
of change in color, a decolorization of the hair seen after a very
groat fright or severe mental anguish, which in a short time
changes the color of the hair completely, but instead a definite
nutritive alteration, acute in character.
Hebephrenia or Childhood Insanities.— W.B. Fletcher
(Indianapolis, Ind.) spoke of the causes, character, prevention
and treatment of the various forms of insanity incident to chil-
dren prior to and during the period of puberty. The writer
had observed 300 cases of hebephrenia in the city in which he
lived. He cited some interesting cases.
Sympathetic Eye Diseases.— James Moores Ball (St.
Louis, XIo.) made a clinical division into sympathetic irritation
and sympathetic ophthalmitis. He said sympathetic ophthal-
mitis was one of tne most formidable and obscure of ocular
affections. Only uveal inflammation which was caused by bac-
terial Infection could produce this disease. He mentioned the
date of appearance, frequency, symptoms, and divided the
affection into uveitis serosa and sympathetic fibrinous uveitis,
saying that the former was relatively mild, while the latter
was a malignant affection. Sympathetic papilloretinitis, which
rarely was the sole manifestation of sympathetic ophthalmitis,
was likewise discussed. Other sympathetic affections had been
described, without gaining recognition from ophthalmic
authorities.
Toxic Amblyopia.— J. W. Sherer (Kansas City, Mo.)
presented a clinical report of five cases of toxic amblyopia from
methyl alcohol that had been seen by him. In all a degree of
blindness rapidly followed drinking the poison. The eyes
appeared normal, externally, with pupils slightly dilated. The
media were clear. There were no hemorrhages. Early there
were no fundal signs, but later atrophy was visible. The fields
were contracted and showed absolute central scotomata. One
case was complicated by some involvement of the peripheral
nerves of the lower limbs. The pupillary reaction corre-
sponded to the description of Lauder-Brunton, who found It to
be the reverse of the Argyll-Robertson reaction. Patholog-
ically, the condition was tnat of peripheral neuritis affecting
the optic nerves or retrobulbar optic neuritis. Much work
has been done by different observers to demonstrate experi-
mentally the minute changes. Degeneration of the ganglion
cells and macular layers of the retina occurred. This was
partly due to vasoconstriction and diminished blood supply,
and partly to the action of the poison. Consecutively, the
nerve fibers degenerated. In the experiments with quinin
there was syncnronously with the onset of the amblyopia
chromolysis of the retinal cells, edema of the pericellular
spaces and wasting of the ganglion cells. Undoubtedly the
primary effect was on the fibers, but the cells were probably
simultaneously attacked.
Bilateral Glaucoma.— Flavel B. Tiffany (Kansas City,
Mo.) reported the case of a patient upon whom he performed
double iridectomy.
Diseases Preceding and Pollowine the Use of Alcohol
and Opium. — T. D. Crothers (Hartford, Conn.) regarded the
use of alcohol as one of the most subtle and serious causes of
disease. Clinical study pointed out many distinct lines of dis-
ease which preceded inebriety of which syphilis, trauma,
dementia, and toxic states were most common. Neurasthenic
conditions and tuberculous diatheses preceded the use of spirits.
Atrophic and hypertrophic sclerosis always followed the use of
spirits. An early recognition of the organic changes which
preceded and emerged into inebriety would enable one to prac-
tically prevent the disease.
Treatment of Typhoid Fever with Castor Oil. — C. C.
Bass ((Columbia, Miss.) reported 32 cases and except in a
very few of these cases, in which he gave some other medicine
to rneet some special symptom, he gave nothing else. Thirteen
cases were treated with one dose every 24 hours, and 19 cases
with a dose every 12 hours. The results following the treat-
ment were very gratifying. He commended this treatment as
worthy of further investigation.
Culture of Infusoria.- Henry G. Graham (Chicago,
111.) discussed the subject under the following heads: 1. Pre-
serving the identity of the individual organism while growing
it: (a) in running water; (b) in stagnant water. 2. Isolation
of the organism: (a) by means of the petri dish ; (6) by feed-
ing to laboratory animaLs. 3. Transfer of elementary form to
fluid culture media. 4. Second transfer of organism to fluid
culture media more accessible to the atmospheric air. 5. Fav-
oring growth of skeletal structure of protozoon at the expense
of the liquid protoplasm. His deductions were that culture of
infusoria will show that (1) MiiUer's dust-corpuscles are ele-
mentary infusoria; (2) the exceedingly minute and actively
motile forms are derived from the protozoa.
Croupous Pneumonia.— Wm. T. English (Pittsburg,
Pa.), lie nientloned the api)lication of remedies suitable to the
case and stage of the malady ; the advantage of grouping some
phenomena in securing a speedy diagnosis, and the necessity
for observing all signs and symptoms in differentiating diseases
with similar manifestations.
Pneumonia.— Wm. V. Barclay (Pittsburg, Pa.) consid-
ered the exciting causes of pneumonia and la grippe identical.
He bcliev«i a rational treatment was based on a study of the
immediate causes of death in pneumonia, as conciluded in a
large number of death reports in the city of Pittsburg. Heart
failure and exhaustion stood out as the immediate cause of
death in iW^ of all reported deaths in a circumscribed area of
almost I, (KIO.OOO people. Rest in bod in well ventilated rooms,
apart from atmosiiheric conditions, was of paramount impor-
tance. First, rest in bed with requisite protection from atmos-
pheric influences ; second, a thorough cathartic of calomel was
688 AjmaoAx MbdicikkI
SOCIETY KEPORTS
[NOVBMBEB 1, 1902
essential in bringiDg about a decisive derivative action of the
secretions of the body. Five to 10 grains of calomel, with 30 to
60 grains of milk sugar, was a formula that had never disap-
pointed him in its beneficial effect. Nux vomica, when prop-
erly administered, never failed in its power to alleviate the
symptoms and afford relief. The tincture should be given in
large and frequent doses, well diluted in water.
Treatment of Chronic Dysentery. — John L. Jelkh
(Mompbis, Tenn.) considered the disease of microbic origin
and this was the basis of all treatment. The sigmoidoscope and
long rubber tube had a field in the treatment of this affection.
The patients should be placed in sanitary surroundings free
from unnecessary heat and moisture. The diet should be care-
fully selected. The stomach should receive careful attention.
The portal engorgement should be relieved and the intestinal
tract thoroughly cleansed. Hemorrhage from the bowel when
profuse could be controlled by styptic enemas given through
the double tube. In using the sigmoidoscope he recommended
the knee-chest position. The bowel should be thoroughly
cleansed through this instrument with antiseptic washes
applied very hot. If there was much excoriation or ulceration,
nitrate of silver might be applietl to bleeding and eroded sur-
faces with a cotton probang, or in the form of a spray. Higher
treatment may be administered through one or two tubes of
soft rubber, which can be passed further into the colon and the
antiseptic solution administered by enema through these. If
necessary, boracic acid, iodoform or aristol may be insufflated
through the sigmoidoscope and the bowel thus thoroughly cov-
ered. In the chronic state he had found most benefit from
iodoform and ichthyol made into suppositories and passed
through the sigmoidoscope into the sigmoid. This was
especially indicated in tuberculous conditions but had its use in
any form of proctosigmoiditis or colitis. All toxic drugs must
be used with caution.
Snrgical Section.
The X-ray In the Treatment of Malignant Growths. —
Edwin Walker (Evansville, Ind.). The.x-ray had given
favorable results thus far. Its exact status must be determined
by clinical observation. He reported a case of alveolar mel-
anotic sarcoma of tl*«t face, which was removed. The growth
returned in two weeks and had extended to the neck. A
secondary operation was performed a month later. There was
rapid extension from that time, so that within a few days
almost the entire neck was involved. The wound had not
healed. There was immediate improvement after the use of
the x-ray. The wound had cicatrized in two weeks and all
indurations had disappeared at the end of three months. The
patient at this time seemed entirely cured. While the x-ray
was of undoubted value in malignant growths, it should not
be adopted to the exclusion of other known methods. Excision
should be done, if possible, before the x-ray treatment was
begun.
The Physiologic Action and Therapeutic Uses of the
X-ray.— C. M. MuTz (Douglass, Kan.) dissented from the
opinions of those who believed that the physiologic and thera-
peutic uses of the x-ray may be intelligently studied without
reference to its nature or genesis. It was not a " giant in
chains" which physicians needed to approach in fear when
they would unchain it, but no physician in his opinion should
be content to use a therapeutic agent without inquiry as to' its
exact nature and the elements of its entity.
The Relation of theSocalled X-ray Burn to the Treat-
ment of Malignant Growths. — J. Rudis-Jictnsky (Cedar
Rapids, Iowa). The action of the x-rays on the tissues was of
marked electrochemic character. Irritation followed, and a
regeneration of tissues was the result. Three factors deter-
mined the special effect on the cell : (1) Conditionof the body,
i. e., the amount of resistance the rays encounter ; (2) the
amount and intensity of the rays ; (3) the character of the rays.
When the irritation was moderate the cells might be stimu-
lated, but if prolonged or given in excess the change might be
progressive in the tissues, leading to the socalled burn, regen-
eration, absorption, reabsorption, or to a total destruction of the
cell.
The X-ray Treatment of Cancer, with Report of
Cases Cured.— Everett J. Brown (Decatur, 111.) discussed
the subject under the following heads: (1) Technie, comparison
of apparatus used, protection of the patient, protection of the
operator, the distance of the tube, the time of exposure, the
frequency of exposure, and the selection and management of
tubes; (2) description of x-ray dermititis as compared with
ordinary burns ; (3) the remarkable influence of the x-ray on
all low grade tissue was superficial in location ; (4) the uncer-
tainty of results in treatment of deep-seated malignant growths ;
(5) advantage of the x-ray treatment over surgery in many
cases: (a) painless; (6) nonuse of anesthetics ; (c) less destruc-
tion of tissue ; (d) astonishing results in many cases regarded
as incurable surgically ; (6) report of cases cured.
Renal Calculi or Hepatic Calculi ; Differential Diag-
nosis,— Charles E. Barnett (Port Wayne, Ind.). The x-ray
in differential diagnosis was not so valuable here as in other
regions. The author contended that it was impossible to make
a differential diagnosis, and suggested cutting down and expos-
ing the kidney, then being governed by the tindings.
Cyst of Mesentery.— Hekmak E. Pearse (Kansas City,
Mo.) reported a case of cyst of the mesentery, with recovery
after operation. He stated that cysts of the mesentery were
exceedingly rare.
Through-and-Through Intestinal Suture.— F. Greoory
Connell (Leadvillo. Colo.). This paper will appear in a future
issue of America)!, Medicine.
Gastrojejunostomy with the McGraw Elastic Liga-
ture for the Relief of Gastroptosls.— H. O. Walker
(Detroit, Mich.) .said that little had Deen done surgically for
the relief of this condition. He reported three cases operated
on successfully, and closed by saying that of all methods that
had been suggested for the performance of lateral intestinal
anastomosis none, to his mind, possessed the advantages of the
McGraw elastic ligature. 1. Its simplicity was far greater
than any other method yet presented. 2. The ease and rapidity
with which it could be done. 3. Less liability to sepsis than
by any other method. 4. There was no danger of a foreign
body. 5. A larger opening could be made without liability to
cicatricial contraction.
Section Following Vaginal Puncture.— John Youno
Brown (St. Louis, Mo.) spoke of the value of vaginal section
in selected cases of pus in the pelvis. He called attention to
vaginal section in contradistinction to socalled vaginal punc-
ture. He alluded to the postoperative complications following
vaginal section, as shown by a series of cases in which abdom-
inal section was subsequently done.
Cancer of the Uterus in the Mississippi Valley. —
Emory Lanphear (St. Louis, Mo.) said that eastern surgeons
did not operate on cancer of the uterus, while western surgeons
did. What was the re.sult? The census statistics of 190O
showed cancer of the breast, on which all operated, east and
west; cancer of the stomach, on which no one operated, and
cancer of the uterus, as follows : East, cancer of the breast, 613
cases; cancer of the stomach, 1,785 cases ; cancer of the uterus,
1,101 cases. Mississippi Valley, cancer of the breast, 874 cases;
cancer of the stomach, 3,776 cases ; and cancer of the uterus,
679. The difference showed larger proportions of carcino-
matous uteri operated upon in the west, with either a cure or
return of the disease in other organs ; hence death was not
included in the deaths from cancer of the uterus. Reports from
74 operators in the Mississippi Valley showed 274 cases which
had lived more than five years. The diagnosis was confirmed
by the microscope in most cases, a result encouraging for earlier
diagnosis and prompter hysterectomy.
A Plea for the Abandonment of the Abdominal Belt
After Celiotomy.— Maurice Kahn (Leadville, Colo.) said it
was his belief that it would be but a short time when the post-
operative abdominal belt would be obsolete. Attention was
called to the direction of the muscular fibers, which intersected
each other at angles varying from about 25° to 90°. By reason
of a common nerve supply the abdominal muscles acted syn-
chronously. The excellent cancellated arrangement of the
abdominal muscle fibers made the gridiron operation the one of
choice, for then the contraction of the muscles tended in itself
to safeguard against hernia. He believed the straight through
technie to be the most effective factor in subverting an ideal
result in most cases, not so much because the muscles were cut
transversely, but because of inaccurate suturing. The appli-
cation of an abdominal belt, which, if tight enough to exert
any influence, must relieve the muscles of their usual labor,
resulting in the atrophy of non-use, whereas it would be desir-
able to have the hypertrophy of over-use. If it were possible
to apply a belt internal to the abdominal wall, it might perhaps
be of service in giving the cut edges an opportunity to firmly
unite before any strain was imposed upon them. Such argu-
ments could not be advanced in favor of the external abdomi-
nal belt, which would not prevent the exertion of pressure on
structures internal to itself. It has been his practice for over
three yehrs, after removing the first dressing, which was
applied snugly for comfort and removed at the end of a fort-
night, to allow patients to go without any support.
Early Diagnosis and Conservative Treatment of Fibro-
myomatous Tumors of the Uterus.— L. G. Bowers (Rich-
mond, Ind.) called special attention to the importance of the
early diagnosis of fibroids, thus leading to conservative
methods of treatment. He enumerated some of the symptoms
of fibroids that were many times attributed to other trivial
causes by a superficial examination, and insisted that the
patient be examined under an anesthetic and cureted at the
same time if necessary. He pointed out that most of the
literature dealt exclusively with the operative views and noth-
ing was said about preventive measures. The early practice of
such treatment often obviated the necessity for hysterectomy
later on.
Treatment of Fractures of the Patella.— David C. Pey-
ton (Jeffersonville, Ind.) discussed the relative frequency of
these fractures ; the contractions of the quadriceps as an efficient
agent in the etiology ; the displacement of the fragments and
the associated injuries to the soft parts ; the diagnosis, and then
outlined the advantages of treatment by open arthrotomy a.s
compared with nonoperative procedures.
Truman W. Brophy (Chicago) gave a lantern demonstra-
tion of his method of operating on cases of cleft palate. He also
exhibited patients upon whom he had operated, showing excel-
lent results. The patients were able to articulate remarkably
well.
C. E. Ruth (Keokuk, Iowa) discussed the subject of anti-
streptococcic serum In septic conditions.
NOVBMBXB 1, 1902]
SOCIETY REPORTS
(AMERICAN MBDICINE 689
THE NEW YORK STATE MEDICAL ASSOCIATION.
Nineteenth Annual Meeting, October 20, 31, 22 and 23, 1902.
[Specially reported for American Medicine.]
lOontimted from page 649.)
The Pathogenesis of Eclampsia. — Frederick P. Ham-
mond (New York) referred to the formations of toxins in
eclampsia and quoted the views of various writers showing
that tiie urine of pregnant women was less poisonous than that
of those not pregnant. Some of the peculiarities of eclampsia
were pointed out and it was urged that whenever headache
occurred immediate attention was necessary. It should also be
established as a rule that the urine should always be examined.
The coal-tar products should be given with great caution. In
cases of failure of vision a cholagog cathartic should be adminis-
tered. Knowledge of the pathology of eclampsia is still very
incomplete. The presence of albumin in the urine was most
deceptive, and judging from statistics it might almost seem as if
it could be ignored. Proper treatment lay largely in diet. The
food should be simple, with fluids in abundance. There should
be wheat bread at every oieal and no meat should be allowed at
breakfast, red meat only at noon. The evening meal should be
light but of greater bulk than that of the morning. In vertigo
and similar attacks the diet should consist of fruits, but this
does not preclude fluid preparations from shellfish. A patient
suffering from heartburn required the salines more frequently
than others. Exercise in the open air and tepid bathing were
also recommended.
Bacterial Flora of the Vaginal and Cervical Canal in
Health, with Remarks Concerning Infections of the
Female Genital Tract.— W.m. K. Swan (Saratoga Springs).
DiJderlein had examined the vaginas of 195 pregnant women,
and divided the result into normal and abnormal. In the nor-
mal secretion no pathogenic germs were ever found by Doder-
lein, except a thrush fungus, capable to a very limited extent of
producingsuppuration and destruction of tissues when injected
into the skin or into the eye of an animal. In the abnormal
secretion, which was yellowish or greenish in color, a great
quantity of cocci and bacilli could be found. In only 8 of the
195 cases were streptococci found, and in only 5 was it possible
to detect that they were virulent. Swan recommended the use
of the vaginal douche, and said that all authors agreed in saying
that the female genital tract in health was divided into sterile
and infected, the line of demarkation lying between the exter-
nal and internal os uteri. Bacterial flora were found in various
abnormal conditions.
Treatment in Gynecology from a Medical Standpoint.
— Mary Gage-Day (Kingston-on-Hudson) said it was aston-
ishing how ignorant women who were well educated otherwise
remained on the subject of personal hygiene. Physicians
should be teachers as well as practitioners. She had found
iodin and icthyol of considerable service in cases of obscure
injury of pelvic organs. Two cases were referred to in which
there was a continued flow of blood, which she ultimately
stopped by the administration of adrenalin chlorid adminis-
tered as an internal styptic. In serious cases her own prefer-
ence was for curetage or operation. It had been her experience
that women past the menopause did not tolerate iodin as well
as those before.
What Advice Should be Given to a Woman Soffering
ftom Fibroid Tumor of the Uterus.— J. Kiddle (ioPFE
(New York) dealt with the many aspects of cases of fibroid
tumor, pointing out that they sometimes ceased to grow, some-
times remained stationary, even decreased, and had been
known to disappear. In treatment, curetage occasionally suc-
ceeded, but it re<iuired frequent repetition, and was often
dangerous. Much depended on the age of the patient. Refer-
ring to the advice given by some practitioners to unmarried
women with tumors to wait and not get married, the author said
this idea was most abhorrent to him. These tumors could be
removed by the vagina, or if too large, then laparotomy could
be performed. When the trouble was complicated by preg-
nancy, if necessary miscarriage could be brought on, or the
patient might be allowed to go to full term and cesarean section
done. Ho was convinced that removal by operation was indi-
cated in almost every case.
Etiology of Colds.- James J. Walsh (New York) con-
sidered that the old term " rheum " better expressed what was
generally meant by "a cold" than that now in use. Cold air
alone does not produce bad results, shown by tuberculous
patients kept night and day in the open and frequently damp
atmosphere, with the best results. The author thought that
bacteria might introduce catarrh which could be mistaken for
cold. Cold was only a predisposing factor, and cold in the head,
etc., were almost invariably due to batsteria. He then spoke of
the want of moisture in houses, and gave advice as to people
leaving crowded places, such as churches, theaters, etc., his
opinion being that it was always better to linger a little in the
hall or lobby before stepping into the outside air. Delicate
persons, he thought, should not frequent such crowded resorts,
as they were more susceptible to the attacks of the bacteria.
Symptomatology of Colds, with Inchlental Treatment.
— Georoe K. Cott ( Buffalo), speaking of the symptomatology,
expressed the opinion that there was a considerable difl'erencc
in the meaning of symptomatology to the patient and to the doc-
tor, and after illustrating this showed that a perfectly healthy
body, under certain conditions, would never contract a cold.
Treatment of Colds. — A. Alexander Smith (New York)
stated that he believed that cold in the head might be catching,
but he would not on that account isolate the sufferers. Cold
bathing would have a certain eflfect in preventing cold. He
thought that all with a temperature of 1(»° or over should go to
bed. Opium and quinin at night, with a cathartic in the morning,
were frequently productive of good. Giving a cathartic at tlie
beginning was commendable. Relief may be obtained by tak-
ing a few drops of spirits of camphor on a lump of sugar.
Coal-tar preparations had also been round useful, but they often
reduced the cold to a certain point and then it remained at that
stage. He had been disappointed in carbolic acid. Tincture of
aconite was good for children. Turkish baths were good in
the beginning of a cold. He had found no benefit from the
resinous preparations in tlie air-passages above the vocal
cords. Saline solutions often gave temporary relief, but they
were attended by danger. In recurrent catarrhal colds he
recommended the tincture of chlorid of iron in large doses, but
it should not be given beyond a few days. After all, the ten-
dency to recur could only be relieved by change of climate.
The Newer Relations of the Pancreas to General
Medicine. — Alfred Stengel (Philadelphia, Pa.). Experi-
ments had shown the connection between diabetes and the
pancreas. All that could be said at the present time on the
functions of the secretions of the pancreas was that the pan-
creas had a secretion which decreased the sugar-formation in
diabetes. The evidence from investigations pointed to a close
connection. In one case an autopsy showed the pancreas nor-
mal to the naked eye, but the microscope showed changes.
Only a beginning had been made in the study.
Study of the Metabolism in a Case of Myxedema
Before and After Administration of Thyroid Extract. —
C. N. B. Camac (New York) presented the case of a woman
who had lost 20 pounds in two months after the administration
of thyroid extract. The author gave the history of the case,
showing clearly that it was one of myxedema, and gave figures
and showed charts proving the correctness of the assertions.
Just what the loss consisted of or how it was brought about
they did not pretend to say. In discussion Stengel stated that
other experiments had shown that the thyroid extract had in
most cases caused a very rapid consumption of proteids.
The Present Position of Gallstone Surgery.- William
WoTKYNS Seymour (Troy) said that no field of surgery gave
better opportunity for the relief of pain than did this. He
would not advocate surgery in every case but he would say
that gallstones could not be dissolved by internal medicine.
There was but a small mortality from operations and they
could now promise an almost certain cure, although in nega-
tive cases the mortality might be high. Early operation should
be urged and the risk of refusal should then fall on the patient.
A Study of Indications for Nephropexy.— A uoustin
H. GoBLET (New York) was of the opinion that no belts or
corsets were of any use in the case of movable kidneys of the
third degree. He had given his views with regard to certain
points in a paper read at the last meeting of the American Med-
ical Association and ho contended that his views were right.
Operation was the only cure and it was perfectly safe. A.
Ernest Gallant (New York), in discussion, claimed that
there are men who operate and men who don't. The men who
operated in all cases were very few ; the men who waited and
only operated in the last extremity could be numbered by the
hundred. They might operate and still all other complications
would remain. He neld that any kidney that could be sewed
up could be supported by a corset if the corset was properly
put on. In that case the kidney could not be forced down try
as the woman would. Parker Syms (New York) thought it
diflicult to say what was the best thing to do. When he had
operated his results had been favorable. It was better, perhaps,
to try to build up in the first place. Einhorn had treated
many cases but had never found the movable kidney, as such,
diseased. It might be that he had met with a different class of
cases to those that Ooelet had. It was also undoubted that they
had to deal with other complications. Goelot, in closing, said
that out of 139 cases operate<i on he had not lost one. As to the
number that might remain cured a great deal depended on how
the kidney was fixed and how early the operation was per-
formed. What he was contending for was early operation. He
recalle<i only two cases in which complications had not been
removed by the operation.
The Surgical IJiseases of the Kidneys Fr<»m the Stand-
point of a General Country Physician.— (iEOROE A. Leit-
ner ( Piermont) gave the history of a man aged 47, who several
years ago had an excruciating pain in the region of the bladder,
with a strong desire to urinate. Eventually ho passed a largo
quantity of blood and urine. Four years afteranother attack of
a similar nature followed. He was sent to the baths at Baden-
Baden, but returned after some months showing but little
improvement. His urine still showed much albumin and
physical examination showed a large lump in the lumbar region.
Diagnosis, malignant growth on right kidney. An operation
was resolved on. The left kidney was normal. Two years ago
the operation was performed and the patient loft the hospital on
the thirty-fifth day. That was two years ago and the patient, who
is a farmer and hotel-keeper of strictly temperate habits, is now
in perfect health.
690 Amkbioah Medicine
SOCIETY REPORTS
[HOVEKBKB 1, 1902
Obesity as a Consequence of Asexualization. — Hein-
RICH Stern (New York). From time Immemorial animals
had been rendered improcreant with the intention of fattening:
them rapidly. Eunuchs were generally " Ijeefy," and sterile
women, if not affected witli systemic or malignant disease, at the
prime of life oftentimes tended to corpulency. The apparent
relation between improcreance and polysarcia had frequently
been noted. In the cases of 48 women whom he had treated for
polysarcia, 34 of whom were married, 1 had never menstruated,
12 had never been pregnant, single or double oophorectomy had
been performed in 8, 5 had scanty and irregular menstruation,
the catamenia had prematurely ceased in 2, 4 had congested or
Inflammatory conditions of the sexual organs, and only (i
seemed to be free from uterine and ovarian derangements. The
author quoted the cases of 100 women, taken by him at random,
at the menopause. Of these 8 were not certain whether they had
gained or lost in weight, 20 thought they had remained the
same, 29 had lost weight, and 43 had developed polysarcia. The
conclusions drawn were that the fattening process might be
facilitated by the nonperformance of sexual functions prevents
ing the expenditure of certain body material, and it was not
improbable that the reduction of protoplasmic catabolism miglit
constitute the basis of obesity in tlie improcreant.
A Case of Idiopathic Brain Abscess, with Focal Symp-
toms Diagnosed as Brain Tumor. — Hermon G. Gohdinier
(Troy) gave the history of this case, which had been treated
at the Samaritan Hospital during several months. Partial
autopsy showed an idopathic brain abscess, with a mass which
seemed to contain fluid. A description of the abscess cavity
was given, and the conclusion reached was the necessity of
exploratory incision in every apparently case of brain disease
without regard to the supposed pathologic lesion. He was
strengthened in the opinion expressed in a paper previously
published — that typical attacks of Jacksonian epilepsy might
be excited quite as well by lesion just below the cortex as by one
upon it. There were no external sensations except the attacks
in the left arm, and another interesting fact was that there was
an almost complete absence of fever until the day before death.
Melancholia Agitans. — Wm. E. DouanAS (Middletown)
gave the clinical history of the case, that of a young woman,
who was well developed and healthy except that she sufferea
occasionally during menstruation. She had fever some years
before and when the case was brought under his notice she had
been suffering from insomnia for eight weeks. She grew worse
gradually and several times attempted to commit suicide.
Later the case was diagnosed as hysteria. About the middle of
February her temperature rose suddenly and by the end of the
month she was worse with more insomnia. Prom March 16
until death the symptoms fluctuated greatly. On April 16 her
digestion, which had been impaired, improved, and she was
able to eat solid food, her mental state being quiescent. Death
took place on April 23.
Report and Presentation of a Case of Idiopathic
Atrophy of the Skin.— R. Abrahams (New York) said that
only about a dozen cases of this disease had been reported.
The progress was slow but certain, and there had been absolute
failure of all remedial agents. The patient is a man of 58, fam-
ily history negative. Personal history: small ulcers on heels,
followed by marked hyperemia of the toes and back ol left foot,
then right; these lesions by and by disappear. The skin of
the legs became pale, white, then brown, then shriveled. Tlie
organs are healthy and the man is healthy. The disease has
made unusual progress during the last year. Wm. S. Got-
THEiL (New York) gave microscopic details. The tissue was
one-half of its normal thickness, and all the various layers of
epidermis were thin. The entire skin presented the appear-
ance of having been the result of chronic inflammation.
Unrecognized Toxic Insanities. — T. D. Crothers (Hart-
ford, Conn.) was of the opinion that drug habits were increas-
ing. It was not the regular drunkards who appeared at the
bars of the police courts to whom he had reference to, but to
people in active life, men engaged in the active pursuit of daily
business, but who, through their addiction to drugs, made ulti-
mate failure. Close study of such cases showed a distinct
origin, jirogress and development of a psychosis, with progres-
sive degeneration ol the brain and nerve centers. People
addicted to the use of drugs were generally found to be unreli-
able, although they occasionally showed signs of genius. They
were often irritable, morose, unable to draw conclusions, and
their senses became impaired. All of this was distinctly trace-
able to the toxic form of drug used, and the changes could only
be explained as true psychoses.
Strangulated Hernia in Children Under One Year of
Age. — W. B. Reed (Rome) stated that he had only been able to
find nine other cases in addition to the one whose history he
was about to give. This was in a male child, 27 days old, on
whom he performed a herniotomy with recovery. This was a
robust babe which had been troubled with vomiting and whose
bowels had not been moved for 36 hours. A diagnosis was
hernia, which was confirmed after consultation. A tumor the
size of a hen's egg was situated in the right inguinal region.
The child was inverted and taxis tried but failed. At the opera-
tion the point of strangulation was found to be at the internal
ring, and was so tight that two incisions into the constricting
band were necessary to liberate the hernia. The day following
the operation the temperature was 102°, but gradually subsided
and remained normal. In his opinion the mortality need not
be more than S% in infants under one year of age if the opera-
tion was promptly done, even V)y a surgeon of limited experi-
ence. A. J. OcHSNER (Chicago) thought that strangulated
hernia in infants was not so uncommon as one would tliink,
because the literature was so meager. He had had as many
cases as those reported, but had never written or published
anything on the subject. He thought children bore herniotomy
very well. About Hflfo of the cases of nonstrangulated hernia
were cured spontaneously.
Local Anesthesia in Radical Cure for Inguinal Hernia.
—J. A. BoDiNE (New York) was of opinion that 5% of the men
of this country were ruptured, and urged operation as means of
{)ermanent cure. His paper related to 48 cases of inguinal
lernia operated on under cocain locally applied. The operator
located the three main nerve trunks and cocainized them, using
one-half to one grain of cocain muriate. It was easiest to find
the iliohypogastric nerve and if it was cocainized the anesthesia
would be satisfactory. The injection should be introduced and
not hypodermic. The method of introduction should be such
as to produce edematization of the skin as also acute anemia.
John A. Wyeth (New York) in discussion said that he had
been an advocate of cocainization from its earliest introduction.
Of those who refused operation 50% did so because of their
objection to general narcosis. It was necessary to inject the
cocain directly under the integument and with weak solutions
there can be no danger of cocain toxemia. Care should be taken
to have the cocain sterile. Dr. Lyi.e had performed 13 opera-
tions for hernia in the last three months, using nothing but
cocain. He was not afraid to use a much stronger solution than
that used by the author, knowing that in morphin they had a
perfect antidote. Dr. Gallant said that if one grain of boric
acid was added to four ounces of a solution of cocain it could be
kept fresh for months.
The regular program was at this point interrupted to allow
Dr. Wyeth to introduce a little girl who had had a congenital
cavernous angioma of the backhand who had been given up
as incurable. Dr. Wyeth presented this case as showing the
good results obtained by using his method of injecting boiling
water. He showed a number of the syringes which he had
used successfully in such cases.
Intestinal Obstruction.— John B. Harvie (Troy) pre-
sented this paper, and with it a number of pathologic speci-
mens. He thought it was astounding how easily hernia might
be overlooked. The symptoms were generally quite marked.
He gave the history of a number of cases, going to show that in
his opinion early operation would always produce good results.
The most common cause of obstruction of the bowels was some
malignant trouble, though sometimes it was only a partial
block or gas. The moment malignant trouble was suspected
would seem an opportune time for radical operation. He con-
sidered that the intestinal tract furnishes the greatest oppor-
tunity for brilliant surgery.
Radical Operations for the Cure of Cancer of the
Stomach. — Wm. J. Mayo (Rochester, Minn.). In his opinion
radical operation gives an increased life of 14 months, and cures
would be more frequent were the diagnosis earlier. The stom-
ach was a favorable organ for operation, as it had a large blood-
supj)ly from several sources. Given a person of middle age
steadily losing flesh without any other apparent cause, cancer
should at once be suspected and an exploration insisted on.
Much time was wasted in prolonged attempts to make a diag-
nosis by various tests of the stomach-contents. In making
diagnosis the author deprecated the use of the soda carbonate
test. It was better to distend the stomach with air, using a
Davidson syringe. Surgical operation presented no difficulty,
and every ulcer which can be located should be removed.
Operation is contraindicated by extension to neighboring
viscera and lymphatic involvement, unless localized to the
vicinity of the growtli, also presented great difficulty. Exten-
sion along the lesser curvature was less favorable than along
the greater curvature. Statistics were given showing the
result of 213 operations in St. Mary's Hosjaital during the last
10 years, 126 for nonmalignant disease with a mortality of a
little under 5%, and 92 for malignant disease with a mortality
of 10%. He had performed 20 pylorectomies with two deaths.
He could not say much about complete gastrectomy, as the
cases were too few.
Surgery of the Stomach for the Relief of Nonmalig-
nant Pathologic Conditions.— A. J. Oohsner (Chicago) had
a clinical experience of 27 patients operated upon for the relief
of nonmalignant disease of the stomach. The operation for
nonmalignant trouble he considered perfectly safe, unless it
occurred with a perforation into the free peritoneal cavity. In
this case, even with an early operation, tlie prognosis was bad.
It was therefore important to treat these cases surgically long
before perforation. Serious ulceration of the stomach occurred
only with faulty drainage. Proper drainage of a permanent
nature could only be applied by making an anastomosis between
the lowest point in the stomach and the duodenum, at a distance
of about 40 cm. from the point at which the duodenum issues
through the mesentery of the transverse colon. The great thing
was to select the lowest point in the stomach and the proper
length of small intestine. The ulcer need not be excised unless it
were located directly in the pylorus, or unless it was impossible
to make a positive differential diagnosis between ulcer and car-
cinoma.
[To be concluded.^
November 1, 1902]
COKRESPONDENCB
[AMBBICAN MEDICINB
691
CLINICAL NOTES AND CORRESPONDENCE
[Communications are Invited for this Department. The Editor Is
not responsible for the views advanced by any contributor.]
WHY DO THE STOMACH AND PANCREAS NOT DIGEST
THEMSELVES ?
BY
HOWARD B. BAKER, M.D.,
of Detroit, Mich.
This question, though as old as the physiology of the diges-
tive organs, has never been satisfactorily answered. There
have been -several theories on the subject: (1) That autodiges-
tion is prevented by the free flow of the alkaline blood through
the part ; (2) that the tissues are protected by a mysterious
"living principle." Neither of these is correct, as may be
learned from any of the principal works on the physiology of
the stomach. (3) Mucus has been mentioned as protecting the
tissues, but this, alone, is inadequate. What is the explana-
tion? The following theory, while not being at the present
time actually demonstrable, is at least reasonable and adequate
so far as the glands are concerned.
The " secretions " that are manufactured by cells are sub-
stances that they do not need, are in fact their excretions. It is
a wellknown fact that bacterial cells are poisoned and their
processes brought to a standstill, by accumulation of the prod-
ucts of their own activity. It is probable that this same autoin-
hibition is a more or less general law among living things. It
seems that every organism that lives and excretes must necessa-
rily be poisoned by the accumulation of the substances of which
it normally rids itself. I believe that this rule applies to the cells
of the complex animal body as well as to the bacteria, and my
explanation of the question under discussion is based on its
application to those cells of the body whose function it is to
excrete hydrochloric acid, pepsin, and the ferments of the pan-
creatic juice. Its application to other portions of the body is
very interesting, " but that is another story." Under normal
conditions the cells excrete their appropriate substances, which
pass out of the glands and are used in the process of digesting
food. Beaumont showed that the taking of food into the
stomach is the natural stimulus that induces the flow of gastric
juice, and that without food the stomach is normally empty.
This being the ease, undiluted gastric juice does not normally
lie on the lining membrane of the stomach ; when it is being
produced there is something in the stomach to take it up and
carry it away. So long as the excreted product is constantly
removed, the cells are in no danger of self-poisoning, but sup-
pose it accumulates? What limits the maximum activity of
the cell? With accumulation of the products, long before the
danger-point is reached the cell begins to be depressed by its
own products and to pour them out more slowly. If they still
accumulate, the cell is paralyzed altogether, its excretion stops,
and this before the product has become strong enough to do
any damage to the cells at the place of its formation. As to
other parts of the digestive tract than tiiose that furnish the
fluids of digestion, we may suppose a certain degree of resist-
ance to the action of these substances, but the coating of mucus
that normally covers the surface shares in their protection. All
these glandular membranes are well supplied with mucous cells
which pour out their product, and this must necessarily be a
great protection from the neighboring fluids. The normal using
of the fluids in the food and their removal in the chyme are also
important.
The bowel is in no danger from the gastric juice, owing to
the difference in reaction, and as to the pancreatic juice, it is
diluted with the bile, the succus entericus, and what is most
important of all, it mixes with and acts upon the chyme coming
from the stomach. All these factors, together with the mucus,
are enough to prevent its coming into contact with the
bowel wall in sufficient strength to do any damage. The
essential idea is that in the glands there is an inhibition
of cell activity when the normal excretions accumulate. The
relation of this theory, as of the others, to the pathologic
autodigestion of the stomach, duodenum and pancreas is of
the greatest interest. It is probable that a degree of accumu-
lation which would only slightly inhibit a vigorous living cell
might be enough to digest a portion of the stomach or bowel
wall that had lost its vitality by embolus or by death from any
other cause. Again, it is possible that under the stress of undue
nerve stimulation the cells of a part of a gland may be forced
to work even against the normal inhibition and may be sud-
denly overwhelmed, killed and digested by the greatly accumu-
lated products of their activity. This may be the explanation
of some of the cases of pancreatic autodigestion known as
"pancreatitis." With the process once started, of course the
fluid might find access to the surrounding tissues through the
breach thus created, and the damage would spread rapidly.
LICENSURE.
BY
L. D. SHEETS, M.D.,
of Bloomfleld, N. J.
To the Editor of American Medicine .—What is the object
of licensure ? It is presumed to be a means to prevent incompe-
tent persons and quacks entering the profession. But as the law
now stands it prevents good and able men from pursuing their
profession if they chance to remove from one State to another.
Among all your correspondents who have written upon this
subject no one has suggested a remedy in the case of veteran
practitioners who graduated before the present system of State
examinations existed. The law in force now is not in accord
with former methods of regulating the practice of medicine.
As it exists now it is retroactive, which, in my opinion, is un-
constitutional. If provision had been made for old graduates
the law now in force in this State would be unobjectionable, in
that it would apply to those only who have graduated since its
enactment.
Our State Board requires evidence of four years' study and
three courses of lectures to go before it for examination, or
a certificate from the applicant's State Board for reciprocity.
Now this procedure is simply imposible in the case of men,
like myself, who graduated over a half century ago. Then the
law of the colleges was three years' study and two courses of
lectures. All such graduates are thereby debarred from an
examination, unless they attend another course of lectures,
as was suggested to me by the president of our State Board.
But who, at my time of life, would do that !
A certificate of academic education from a college or high
school must also be presented to the board. In many cases this
cannot be complied with, as many capable practitioners never
enteretl a college or high school, but received their education
in common schools or select academies, neither of which issued
certificates.
If the four years' study and three courses of lectures were
out of the way, would it be fair to subject a veteran to the same
examination as one who is just out of college? I think it would
not. Many of us have forgotten things which are not really
essential to the practice of medicine; and many new subjects
have arisen since our student days — as bacteriology, the larger
development of histologic studies, microscopy, etc.— but of
which those of us who read have a fair understanding, although
we might be unable to stand a rigid examination.
Memory is sometimes at fault with us. During the past
few years I often forget words that are perfectly familiar, but
cannot recall at the moment; yet by and by they will come to
me.
A short time since I dreamed of being In consultation and
wished to ask my confrOre for a stethoscope, but could not
think of the word. When I awoke I remembered the dream,
but could not recall the word stethoscope ; after a short time it
came to me. This form of aphasia (amnesic aphasia, according
to Cowers) is common to many ad vanced in life. What a pre-
dicament for one undergoing an examination !
Between some States reciprocity exists. But this does not
relieve those who registered without an examination before
State boards of examination were formed.
It will be readily seen that we cannot avail ourselves o{
692 Akebioak Mkdioike
CORRESPONDENCE
[November 1, 1902
examination or reciprocity ; if we escape Scylla we fall Into
the hands of Charybdis ! We are thus completely ostracized and
prevented from earning our daily bread, and are deprived of
our standing in the profession.
To show the injustice of tlie law take my own case. I gfrad-
uated from the University of New York in 1849 ; I also hold a
diploma from a private school of medicine and surgery. In the
beginning of 1864 I was commissioned assistant surgeon,
U. S. v., by President Lincoln. To obtain this commission I
was examined four hours a day for six days ; and any one who
underwent a similar examination in Washington can testify it
was no child's play. I am also registered in Brooklyn, N. Y.,
with the Board of Health, and with the county clerk, and yet
all these credentials count for nothing.
In my present home I am not permitted to practise without
a license, and there is no avenue open by which I can obtain it.
The only remedy is to have the law amended.
1 would suggest that the law be changed so that those who
graduated a specified number of years before the law requiring
examination was enacted should be exempt from examination ;
or, at least, have a practical one only ; but that they should
present a diploma from a first class medical college, a certificate
from the board of health or county clerk where they had pre-
viously practised and a certificate of good moral and profes-
sional standing from reputable medical men before being
allowed to register.
I do not particularly desire to"resume practise in this State ;
but I do wish to have the status of a regular practitioner,
with the rights, privileges and Immunities pertaiuing thereto,
so that when I come to " shuflle oft this mortal coil " I may not
have to cross the fabled Styx "unwept, unhonored and
unsung."
DIABETES COMPLICATED WITH CARCINOMA OF
THE LIVER, THE DIABETES DISAPPEARING AS
THE NEOPLASM GREW.
D. N. KINSMAN, M.D.,
of Columbus, Ohio.
The patient became diabetic in 1900. For 18 months the
sugar varied from 2% to 5%, according to diet. In February,
1902, I found upon two occasions the sugar as low as 1%. The
quantity of urme during this period was 90 to 100 ounces daily.
On April 26, 1902, I made the following record :
D. W., a physician, aged 58, was always strong until he
became diabetic. Concerning cause of parents' death shows
nothing definite. He had a brother, over 40 years of age, who
died of liver disease. The only data obtainable were, " Liver
large and he was jaundiced for along time." An aunt also died
of socalled liver disease. Some time during the winter of 1901-
1902 the patient boarded a moving street car and was severely
wrenched on the right side. On the night of March 22, 1902,
he stood upon the street waiting for a street oar and was seized
with a severe pain in the region of the liver. He went home
and had a chill followed by a fever. He felt ill for some days,
but was not confined to bed. The liver became quite tender,
the quantity of urine fell, and the sugar at this time was dimin-
ished to Ifo. On examination I found a tumor projecting from
the left border of the left lobe of the liver, smooth and tender,
extending to the right and behind the cartilages of the seventh
and eighth ribs. HepatR dulness to fourth rib. The lower
border was concealed by the ribs. The whole liver was tender
on pressure, and there was tenderness on the right side of the
spinal column from the sixth dorsal downward.
The stomach was dilated and there was much belching. He
was often nauseated, but only vomited once. Lungs and heart
gave no indication of disease. The urine showed no albumin,
sugar, biliary pigment or acids. The quantity for 24 hours was
30 ounces. I gave him a test-meal. There was no HCl, nor did
the vomited matter tested upon three occasions ever give the
reaction. The blood count showed 4,500,000 red corpuscles,
8,500 white corpuscles, hemoglobin 70%. The skin appeared
fresh and rosy. There was no jaundice and no marked emacia-
tion. He was ordered to bed.
He suffered great pain, requiring morphin for its relief.
His bowels became constipated. A milk diet was ordered.
For constipation salines and castor oil were used. Some of the
oil was vomited 12 hours after its administration, which led us
to suspect stricture of the pylorus. Having found that food
did not distrass him he was allowed everything he wished, and
he had indulged in baked potatoes with the " skins on" before
we gave the oil. A piece of the potato skin was vomited, and
later the rest of the potato skin was found in the stool, showing
a pervious pylorus.
On May 8 he was seen in consultation by Dr. J. F. Baldwin,
and on May 10 by Dr. C. S. Hamilton. The question of diagno-
sis between cancer of the liver or stomach or cholecystitis was
raised, but not decided. Neither surgeon recommended an
operation at this meeting. May 17, both surgeons were present
with me. The same questions were raised as before.
In favor of cholecystitis was the sudden attack in March,
the cliango in the size of the tumor, which both the patient and
Dr. Baldwin believed had enlarged, Vjecome smaller and was
again enlarging since the former consultation.
On the other hand, the change in the size of the tumor was
not conceded by otlier consultants, and it wa« urged that the
rapid growtli of the tumor ; its position ; the absence of fever,
except at the first attack in the winter; the permanent disap-
pearance of sugar from the urine as the tumor grew, in spite of
a nonrestricted diet, pointed to a malignant growth. An ex-
ploratory incision was proposed and the subsequent course was
to be determined by its results. On this there was no agree-
ment. The whole question was laid before the patient with the
reasons pro and con. He elected the operation, which was
done by Dr. Baldwin, revealing a cancer of the liver. The
patient died four days later.
This case is reported because it is my only experience with
diabetes complicating a malignant growth.
Was the disappearance of sugar from the urine due in any
degree to the cancer of the liver? Brault says glycogen ap-
pears abundantly in the cells of all malignant tumors. Glyco-
gen in the tumor cells has both a diagnostic and prognostic
value.
ADMINISTRATION OF DRUGS IN TABLET FORM.
LAURENCE E. HOLMES, M.D.,
of Blltraore, Asheville, N. C.
That the modern method of administering drugs in tablet
form is a very convenient one, no one will deny ; that it is not
so reliable as it is convenient the following example will show,
at least with regard to phenacetin, which is one of the drugs
most commonly administered in this manner. Till very
recently I have never known any special reasons against this
method of its administration.
A short time ago, for the relief of a severe neuralgic head-
ache, I ordered phenacetin in gr. v tablets. During the after-
noon three tablets were taken, and the next morning two more.
As I have always found phenacetin a very reliable remedy in
this condition, I was surprised to find that the headache had not
been relieved in the slightest degree. This was explained the
following day, when one of the tablets was passed by the bowel,
undissolved. For three days the bowels did not move again,
though laxatives were freely taken. Finally, after taking
calomel in broken doses, followed by Epsom salts, the bowels
moved very freely indeed a number of times. In the tenth
movement two more of the phenacetin taljlets were passed,
somewhat reduced in size, but practically unaffected by their
four days' exposure to the action of the fluids of the alimentary
canal.
This proves what a length of time phenacetin may remain,
in tablet form, unaffected by the intestinal juices, and may
explain some of the cases in which it fails to have the desired
effect. It would thus seem always safer to administer it as a
powder, particularly in those cases, which we hope are becom-
ing more rare, when it is given (as a routine treatment) in
typhoid fever. In this condition the passage of an undissolved
tablet through the intestinal canal could not fail to increase the
irritation of an inflamed and ulcerating bowel, and thus cause
a rise in temperature, which we know can be brought about by
very slight causes ; and it is easy to understand how it might
be the final exciting cause of a perforation in a bowel wall made
thin and friable by typhoid ulceration.
Sulfonal is another drug which should never be adminis-
tered in the form of tablets. In the first and only case I ever,
used them, they were passed by the bowel unchanged.
Philadelphia Maternity Hospital.— The annual report of
the Board of Governors shows that during the year ended Sep-
tember 30, 135 patients were admitted, 65 of whom were under
21 years of age. The number of births was 125, 69 girls and 56
boys. Two deaths occurred among the mothers and 10 deaths
of infants.
NOVKMBER 1, 19021
LIGATION AND CLAMPING THE URETER
(AUEBICAS MSDICIKS 693
ORIGINAL ARTICLES
LIGATION AND CLAMPING THE URETER AS COM-
PLICATIONS OF SURGICAL OPERATIONS.
With a Report of Sixteen Cases Occurring in the Service of
Dr. H. A. Kelly at the Johns Hopkins Hospital.
BY
JOHN A. SAMPSON, M.D.,
of Baltimore, Md.
Assistant Resident Gynecologist, Johns Hopkins Hospital.
From the admission of the first patient to the gyne-
cologic department of this hospital on August 17, 1889,
until the present time, August 17, 1902, there have been
admitted to this department 9,850 patients. Of these
7,763 have undergone operation. Of this number there
have been 4,086 major operations, which term includes
all laparotomies, vaginal celiotomies, and kidney opera-
tions.
In the various gynecologic operations the ureter has
been tied or clamped as follows : Three times in 50
abdominal hysterectomies for carcinoma of the cervix,
once in 26 combined abdominal and vaginal hysterec-
tomies for carcinoma of the cervix, 3 times in 63 vaginal
hysterectomies for carcinoma of the cervix, 4 times in
516 hysteromyomectomies, twice in 276 hysterosalpingo-
oophorectomies for pelvic inflammatory disease, once in
63 repairs of vesicovaginal fistulas, once in 100 fixations
of the kidney, and once in a combined vaginal and
abdominal colpohysterectomy for carcinoma of the
vagina.
There have been 32 instancy of injuries to the ureter
occurring during an operation. The ureter has been
ligated or clamped 16 times. A portion of the ureter
has been intentionally excised with a growth primary
in another organ, but involving the ureter, 6 times. . A
ureter has been incised 3 times, and completely divided
3 times. The blood supply has been interfered with so
as to cause a ureterovaginal fistula 7 times. Nineteen of
these 32 injuries have occurred in hysterectomy for car-
cinoma of th6 cervix of the uterus, of which we have
had 139. Of the 19 instances occurring in hysterectomy
for carcinoma of the cervix in only 10 were there symp-
toms of the injury after operation, and 7 of these 10
were due to injuries of the blood supply or the ureter,
thus causing a slough of the ureter and an ureterovaginal
fistula.
The 16 eases of ligation or clamping the ureter have
been tabulated, being grouped acc;ording to the nature
of the operation.
The J^ects of Ligation or Clamping of tlie Ureter May
be C/assiJied cm follows: 1. The immediate effect on
ureter itself. 2. The remote effects arising from injuries
to the ureter, thus interfering with its function.
As one might suppose, a ligature, if removed at the
close of the operation, will cause less harm than a clamp.
In these 16 instances the ureter had been ligated and the
ligature removed tiefore the close of the operation in five
(.ases — Nos. IV, V, IX, X and XI — and in none of these
were there any jKwtoperative symptoms referable to the
injury.
On the other hand, the ureter was clamped and the
clamp remov<!d before the close of the operation in four
instances— Nos. II, III, XV and XVI. In No. II,
attempted vaginal hysterectomy for carcinoma of the
cervix, the silk catheter placed in the ureter in order
that the urefe-r might be the more readily palpated was
broken by the clamp. (Jn attempting to remove the
catheter, 17 cm. of it was left in the ureter, the patient
(lying on the seventh day. In Case No. XV, that of
vaginal and abdominal colpohy.sterectomy for carcinoma
of the vagina, the catheter was also broken, but fortu-
nately recovered through a slit made in the ureter, the
patient making, so far as the injury to the ureter was con-
cerned, an uneventful convalescence. In No. Ill, how-
ever, the silk catheter was removed intact, but nearly
broken in two by the clamp. In this instance a uretero-
vaginal fistula appeared on the third day, but healed
spontaneously in three weeks. In No. XVI, the ureter
was clamped in fixation of the kidney for nephroptosis,
but the injury was recognized and the clamp removed.
There were no postoperative symptoms referable to the
injury.
The ureter has been both clamped and ligated, and
the clamps and ligatures removed before the close of the
operation three times— Nos. VI, XII and XIII ; and in
only one of these instances— No. XII— were there any
postoperative symptoms referable to the injury, the
symptoms of obstruction being relieved by subsequent
catheterization of the ureter. A clamp or a ligature, if
permitted to remain, may directly occlude or cause a
stricture of the ureter at that point, either by compres-
sing the lumen or constricting the surrounding tissues
sufficiently to cause a ureteral kink.
In regard to the remote effecte : The clamp or liga-
ture may be removed later without injury to the ureter,
as in No. XIV, in which the ligatures were removed on
the fifth day. The ligature may be absorbed or loosened
so as to relieve partially or completely the existing con-
ditions. The ligature or clamp may so injure the ureter
as to give rise to a urinary fistula, as in Nos. I and III.
The injury may cause a stricture which may remain aa
such, or later become dilated ; or, on the other hand,
later lead to complete occlusion of the ureter. In No.
XII a stricture occurred which was subsequently dilated.
Clamping the ureter may so crush an ureteral catheter
that it will be broken and a portion left in situ on
attempting to remove it. This will necessitate a second-
ary operation for its removal, as in No. XV ; or the
condition of the patient may not warrant further opera-
tion, as in No. II. A ureter may be partially or com-
pletely occluded by a ligature or clamp without being
released at operation, as in the following six cases :
Case I.— Vaginal hysterectomy for carcinoma ol the cervix.
Two clamps were left on the right uterine vessels for 24 hours.
During that time the patient had frequent desire to urinate,
the only symptom that could be referred to an ureteral Injury.
Formation of a right ureterovaginal fistula which was dis-
covered on the seventh day.
Case II.— Also vaginal hysterectomy for carcinoma of the
cervix. Seventeen cm. of an ureteral catheter was broken off
and left in the ureter. Frequent desire to urinate and severe
abdominal pain, worse on the affected side, resulted, the patient
dying on the seventh day. In this case the symptoms could be
referred to a foreign body, probably not occluding the ureter.
Case VII.— Combined abdominal and vaginal liysterec-
tomy for carcinoma of the cervix. The patient failed gradually
after the operation and died on the fourth day. Autopsy
showed that the right ureter was occluded by a ligature. Noth-
ing was found to account for her death. Not a single symptom,
fofiowing the operation, could be referred to the injury.
Case VIII.— Attempted hysteromyoinectomy ; uterine and
ovarian vessels were tied. The patient died on the eighth day.
Autopsy disclosed double hydronephrosis, due to pressure of
the tumor on the ureters. The left ureter was occluded by
ligature. There were no (jostoperative symptoms which could
be referred to the injury. The patient passed a "fair amount
of urine" each day. The cause of death was probably renal
insufflciencv. . , ■ ■
Case XII.— Hysterosalpingooophorectomy for pelvic in-
flammatory disease. The right ureter was clamped and tied,
but released before the close of the operation. The ureter was
evidentlv kinked or injured in some way so as to give rise to
symptoiiiH of stricture. Postoperative symptoms were relieved
by catheterization. . , „ , , m i«»
Case XIV.— Repair of a vesicovaginal fistula. The lett
ureter was compressed by ligatures which gave rise to pain in
the region of the ureter, chills, and fever. These conditions
were relieved on the fourth day by releasing some of the
sutures. It is impossible to say whether the ureter was
occluded or simply comprassed, thus causing a stricture.
PATHOLOGIC CONDITIONH AKISIN(i FROM IMMEDIATE
AND COMPLETE OCCLUSION OF THE URETER.
The secretion of the urine Is dependent mainly on
two failures : 1. On filtration and diffusion, due to the
difference in pressure existing between the renal vas-
cular system and the extravascular renal tissue, and also
694 AMBBicAN MBDiciiraj LIGATION AND CLAMPING THE URETER
[November 1, 1902
Case.
No. I.
Mrs. B. Z.,
white,
aged 34.
Gyu. No. 2990.
No. If.
Mrs. J. D. S.,
white,
aged 57.
Gyn. No. 4088.
Diagnosis.
Operation.
Adenocarcinoma Aug. 22, 1894. — Hys.
cervlcls uteri. I terectomy, vaginal
Path. No. 427.
Ureters not catheU
erlzed.
Squamous cell Dec. 27, 1895. — At
carcinoma cer- tempted hysterec-
viels uteri.
Path. No. 1022.
tomy, vaginal
Ureters catheter.
Ized. Cervix thin
shell ; tissue so frt
able, and bleeding
so profuse that op-
eration was aban-
doned.
INo. III. ;Squamou8 c e 1 IjSept- 22, 1900.— Hys-
Mrs. M. M., j carcinoma cer-
white, ! vicis uteri. Pyo-
aged 22. I salpinx, chronic
Gyn. No. »139. salpingitis.
Path. No. 4351
No. IV.
Mrs. M. F. M.,
white,
aged 48.
Gyn. No. 2415.
•
No. V.
Mrs. N. G.,
white,
aged 76.
Gyn. No. 3693.
No. VI.
Mrs. I. T.,
white,
aged 34.
Gyn. No. 8539.
No. VII.
Mrs. K. K.,
white,
aged 53.
Gyn. No. 1134.
No. VIII.
Mrs. M. C,
black,
aged 45.
Gyn. No. «59.
terectomy, vaginal
Ureters catheter-
Ized.
I
Squamous cell
carcinoma cer-
vicls uteri.
Path. No. 895.
Nov. 2U 1893.— Hys-
terectomy, abdomi-
nal. Ureters not
catheterized.
Adenocarcinoma Aug. 3, 1895.— Uyster-
cervlcis u t e r I , ; ectoray, abdominal.
involving entire
uterine cavity.
Metastases t o
the left tube.
Path. No. 828.
Ureters not cathetr
erlzed.
Squamous cell March 6, 1901.— Hys-
carcinoma cer-: terectomy, abdonil.
vicIs uteri. Preg- nal. Ureters cathet-
nancy 4 months, erlzed.
Squamous c e 1 IJan. 30, 1892.— Hyster-
carclnoma cer- ectomy, abdominal
No. IX.
Mrs. J. H.,
white,
aged 41.
Gyn. No. 2899.
No. X.
Mrs. S. S.,
white,
aged 44.
Gyn. No. 6344.
No. XI.
Mrs. J. R.,
white,
aged 50.
Gyn. No. 8321.
vlcis uteri.
Path. No. 0178.
Myoma uteri, cys-
tic.
Myoma uteri, ad.
herent tubes
and ovaries.
Path. No. 376.
and vaginal. Uret^
ers notcatheterlzed.
Growth not all re-
moved.
April 6, 1891. — At-
tempted hystero-
myomectomy. Too
difficult; aban-
doned; bleeding
very profuse. Con-
dition of patient
very bad.
Injury.
Postoperative Condition.
Result.
Ureterovaglnal fistula, right.
Wide lateral extension of the
disease rendered the control of
the uterine vessels difflcuU.
Two clamps were left on the
right uterine vessels.
17 cm. of the ureteral catheter
was left in the left ureter.
Catheter crushed and broken
by clamping the ureter. Con-
dition of patient did not war-
rant further operation.
Right ureter was clamped In
controlling uterine vessel. The
artery spurted on cutting It,
due to a poorly placed liga-
ture. In attemptins; to con-
trol the vessels the ureter was
clamped. Uiamp was removed
as soon as the vessels were
secured On withdrawing the
ureteral catheter It was found
to have been nearly broken in
two by the clamp.
Left ureter was tied in control-
ling oozing about the cervix.
Recognized before the close of
the operation and released.
in controlling the uterine ves-
sels. Discovered by making!
traction on the catheter. Liga-
ture released, catheter found
to have been crushed where it
had been clamped
Successful uretero-
vesical anast4>mosis
2 months later. Liv-
ing and well Jan-
uary, 1902, 7% years
after operation.
Death, seventh day.
Cause not known.
Artery clamps removed at the end
of 24 hours. During the first 21
hours only symptom worthy of
note was a frequent desire to urin-,
ate. Convalescence uneventful:
until the seventh day, when on re-
moving the vaginal pack the pres-
ence of urine was discovered.
j
Frequent desire to urinate the firsti
24 hours. Severe abdominal pain,
especially on the left side, was
presentuntil death. Urinescanty,
2.50 cc. first day. 300 the second, rM
the third; incontinence the lasts
days. Patient gradually became
weaker and died on the seventhi
day. Highest temperature, 101.3°,
second day.
On the third day a ureterovaginaliDied 1% years after-
fistula appeared, which healedi ward, probable re-
spontaneously in 3 weeks. turn of carcinoma.
Convalescence uneventful. No Died 1% years after-
symptoms referable to the injury, ward. Return of
carcinoma.
Uneventful. No symptoms refer- Died lyearafterward,
able to the Injury. i anemia, malnutri-
tion and dropsy.
Return of carci-
noma (?).
Ri^ht ureter was tied in control
Img bJeeding at the vaginal
vault. Discovered at close oi
operation by noticing that the
ureter was drawn down Into
the vaginal vault. Kxact posi-
tion of the ligature determined
by making a slit In the ureter
and passing a bougie down to
theslteof the injury. Ligature
cut, bougie removed, and
ureter repaired.
Left ureter clamped and ligated Intestinal obstruction, due to a loop! Died i year afterward.
Right ureter tied.
at autopsy.
Discovered
Left ureter tied,
autopsy.
of the small intestine prolapsing: Return of
into the vagina, relieved by re-! noma,
placing loop No symptoms refer^i
able to the injury of ureter.
No symptoms that could be referred
to the injury. Some general ab-l
dominal pain, nausea and vomit-'
ing. Bowels well moved on third
day. Urine, 480 cc. first day, 8.30
cc. the second, 510 cc. the third.
Gradual failing since operation.
Died on the fourth day.
Death, fourth day,
cause not known.
Autopsy No. 278
showed remains of
caroinomaln pelvis,
right ureter oc-
cluded by a ligature
with flight dilation
of the ureter and
pelvis of the kid-
ney.
Discovered at No symptoms referable to the in- Death, eighth day,
Jury. Passed a "fair amount of cause renal InsufR-
urine each day." Died on the: ciency. Autopsy
eighth day. No 188. Ijirgeflbro-
I cystic tumor of the
uterus. Bilateral
I hydronephrosis
I with abscesses. Hy-
' dronephrosisdueio
' pressure of tumor
on the ureters. Oc-
clusion of left ureter
by ligatures.
July 9, 1894. — Hys-: Right ureter tied. Bilateral hy- Convalescence uneventful. No
teromyosalpingo-
oophorectomy.
droureter and displacement,
caused by the myoma. Ureter
tied in controlling uterine ves-
sels. Ligature removed before
the close of the operation.
symptoms referable to the Injury,
Recovery.
Myoma uteri. 'Sept. 9, 1898. — Hys- Left ureter tied In ligating uter-Convalescence uneventful. NojReeovery.
Graafian follicle! teromyosalpingo- Ine vessels. Discovered by: symptoms referable to the Injury.]
right
cyst of
ovary.
Path. No. 2592.
Myoma uteri.
Path. No. 4494.
oophorocystectomy [
systematically reviewing field
of operation. Ligature cut.
Nov. 19, 1900. — Hys- Right ureter tied in controlling Convalescence uneventful. No Recovery,
teromyosalpingo,' the uterine vessels. Recog-! symptoms referable to the injury.!
right oophorecio- nized at the time and released.;
my. '
November l, 1902]
LIGATION AND CLAMPING THE URETER iakkhican mkdicink 695
Cases.
No. XII.
Mrs. M. P.,
whit«,
aged 37.
Gyn. No. 7375.
No. XIII.
Mrs. K. S.,
white,
aged 37.
Gyn. No. 9195.
No. XIV.
Mrs. A. G.,
white,
aged K!.
Gyn. No. 2130,
No. XV.
Mrs. A. A.,
white,
aged -11.
Gyn. No. 4031.
No. XVI.
Diagnosis.
Adherent tubes
and ovaries.
Pelvic perito-
nitis.
Path. No. 3622.
Dermoid cyst left.
Adherent tube
and ovary right,
adherent appen-
dix.
Path. No. 5364.
Vesicovaginal fis-
tula (po.st puer-
peral).
Squamous cell
carcinoma, postr
vaginal wall.
Path. No. 1020.
Nephroptosis
right.
Operation,
Injury.
Postoperative Condition.
Result.
ectomy.
Dec. 18. 1899. — Hys-i Eight ureter clamped and tied,
terosalplugooophor-i Inflammatory tissue extended,
out to the ureter, and being
adherent was displaced when;
the pelvic organs were drawn!
up. The loss of control of)
the uterine vessels ob.scured
the fleld of operation so that:
the injury readily took place.
Recognized as soon as the ves-
sels were controlled. Released
Nov. a, 1901.— Hystcr- Right ureter clamped and tied
osalpingooophoro- in controlling the uterine ves-
cystoappendecto-j sels. Recognized at the time
my. I and released.
As soon as conscious Intense pain
in region of right kidney, partially I
relieved by morphia. This was
the only symptom aside from the
nausea and vomiting so frequent-
ly seen in recovering from anes-
thesia. No tenderness on palpa-
tion In kidney region. First 24
hours passed 430 cc. End of 24
hours right ureter was catheter-i
ized and patient was Instantly
relieved. Patient had two similar
attacks afterward, at Intervals ofl
6 hours. Duration of each about
% hour.
Convalescence uneventful . No
symptoms referable to the injury.
Aug. 4, 1893.— Repair
of fistula. Ureters
catheterlzed.
Left ureter llgated.
po-hysterectomy
Ureters catheter-i
ized
Dec. 23, 1895.— Vaginal Right ureter clamped, thus
and abdoniinalcol-i crushing the catheter so that
two-thirds of it was loft in the
ureter. Discovered before clos-'
ing the abdominal wound.
Removed through a slit made
In the ureter. .Slit closed with
fine silk.
Pain In course of ureter, sharp and Recovery.
Intermittent, continued for 4
days ; chilis and fever. Tempera-
ture reached 1(M.6° on the fourth
day. Fifth day attempted to
catheterlze left ureter; failed. Re-
moved some of the sutures, ureter
catheterlzed, sutures replaced.
Convalescence uneventful. No Patient died 1 year
symptoms referable to the injury. 1 later from return of
carcinoma.
Recovery. Difficult to
say what whs the
cause of the pain,
jxjssibl.v compres-
sion of the ureter by
the clamp cau.sed a
stricture at that
place which was re-
lieved by catheteri-
zation, to form
• again and finally to
disappear. The
stricture may have
been due to a local
swelling of the mu-
cosa or a kink In
the ureter.
Recovery.
— , 1901. — Nephror-
rhaphy.
Right ureter clamped In bring-
ing the kidney into the
wound. Discovered at the
time, clamp removed.
Convalescence uneventful. No
symptoms referable to the injury.
Recovery.
to the amount of blood flowing through the kidney in a
given time. 2. On the activity of the renal cells.
As one would suppose, the occlusion of the ureter leads
to a damming back of urine, which extends upward from
the renal pelvis into the tubules themselves. This dam-
ming back of urine diminishes the difference in pressure
between the circulatory system of the kidney and the
extravascular renal ti.ssue. The dilation of the pelvis
and tubules causes an increase in the size of the kidney,
which likewise interferes with the flow of blood through
it. As the difference between the intravascular blood-
pressure and extravascular urinary pressure diminishes,
.so will the flltrative and diffu.sive processes be inter-
fered with. Likewise, the interference with the blood
supply will mean less blood flowing through the kidney
and also less activity of the renal cells. Soon a stage
will be reached when the secretion of urine ceases.
According to Cohnheim ' the following conditions
ari.se after sudden and complete occlusion of a ureter :
At first the urine flows as usual from the papillas into
the pelvis of the kidney. The flow diminishes gradu-
ally as the pelvis and the portion of the ureter above the
ligature become filled, and ceases when the tension in
the pelvis reaches a certain level. The amount of tension
necessary to cause a ces.sation of flow varies for dif-
ferent species and for different individuals and also with
the energy of secretion, but in the dog averages about
50 mm. to 60 mm. of mercury. Following the ceasation
of the flow of urine, due to the pressure in the distended
pelvis, absorption takes place, as shown by the edema
present, not only evident in the kidney itself, thus
increasing its .size, but aLso in the perinephritic fat. After
six or eight hours hemorrhages appear in the fatty cap-
sule, in the walls of the i)elvis and in the ureter above
the occlusion. Cohnheim thinks this ecchymosis, which
dis}vpp«^irs after a few days, is due to compression of
the veins by the overfilled urinary passages. Ijikewise,
the presence of albumin and casts, seen after the
removal of a ligature, applied 24 hours previously, is
accounted for by this hyperemia. When the ligature is
left on the ureter permanently the pelvis and ureter
gradually distend, their contents become a thin watery
solution of urinary ingredients with a little albumin,
the kidney becomes anemic and no longer edematous,
but dry, showing that the mechanical hyperemia and
urinary secretion are at an end. According to Cohn-
heim's experience "the result will not be more than a
moderate degree of hydronephrosis."
Bradford '' ligated the ureter of dogs, near the bladder,
and after a period of from 11 to 40 days brought the free
end of the ureter out of a second incision and opened it.
In all cases the ligature caused a distention of the ureter
and kidney, for from 40 cc. to 70 cc. of altered urine escaped
at the second operation. After draining the kidney for
a period of from 7 to 51 days, the kidney was examined
and found to have regained its normal siiape and to be
about one-third to one-fourth of the size of its fellow
organ. The ureter, however, remained thickened and
dilated. The kidneys were examined microscopically
and the atrophy is accounted for by (1) diminution in
size of the renal cells, which have lost their granules
and become clear and glass-like ; (2) disappearance of
many tubules ; and (3) the crowding together of the
remaining tubules.
Lindemann,' experimenting on dogs and rabbits, used
both tight ligatures and tho.se simply causing stenosis.
The animals were killed at variable periods, tihe longest
period being nine months.
In cases of complete occlusion he showed that even
after U hours, when a solution of indocarmin was
inj'ecte<l into the circulation of the animal, it was
excreted in much smaller amount by the kidney whose
ureter was ligated than by the sound one, thus showing
a diminished activity on the part of that organ. The
pressure in the pelvis causes a venous stiwis, and the
increase iu size of the organ is due to edema and also to
the dilation of the tubules and glomerules which are over-
distended with urine. Following this stage of enlarge-
696 AMERICAN MEDIOtlTE]
LIGATION AND CLAMPING THE TJEETEK
[November 1, 1902
ment, the organ atrophies, owing to the degeneration
of the epithelial elements, the crowding together of the
tubules, and finally the replacing of these structures by
connective tissue.
Lindemann makes the following classification of the
results of his experiments :
Cause.
Primary changes.
Secondary
changes.
Tertiary
changes.
A. — Occlusion
from the onset.
B.— Progressive
stenosis, result-
ing in occlusion.
C— Periodic oc-
clusion (anomar
lies and neph-
roptosis).
D.— Stationary
stenosis.
1. Primary atro-
2. Primary hydro-
nephrosis.
5. Uronephrosis,
which soon as-
sumes a transi-
tional form.
7. Intermittent
uronephrosis.
9. Stationary uro-
nephrosis.
?. Secondary atro-
phy (seldom).
4. (Hydroneph-
ro tic atrophy).
6. Secondary hy-
dronephrosis
(closed cysts).
8. Secondary hy-
dronephrosis,
closed or open,
for a long time
maintaining a
transitional
form.
4. (Hydroneph-
rotic atrophy).
From experiments on the lower animals by Cohn-
heim, Lindemann, Bradford, Guyon,* and many others,
it would seem that following complete ligature of one
ureter, in the absence of infection, the final results are :
1. Atrophy of that kidney with more or less dilation of
the ureter and pelvis of the kidney. 2. A compensatory
hypertrophy of the other kidney. 3. General condition
of the animal not apparently greatly injured by the
operation.
Ligation or Occlusion of the Ureter in Man. — No case
of ligation or occlusion of both ureters has been recog-
nized in the gynecologic clinic of this hospital. The
following six cases, in which both ureters were occluded
and later released, are reviewed to show that it may be
diagnosticated :
1. Zwelfel.5— Operation : Hysterectomy. Injury : Both ure-
ters were occluded by ligatures. Diagnosis : Anuria 48 hours ;
presence of urine in the bladder on removing the ligatures in
the region of the ureter. Repair : At the end of 48 hours the
ligatures about the vessels in the region of the left ureter were
pulled away; no bleeding, urine appeared in the bladder.
On the sixth day the ligatures in the region of the right ureter
were removed.
Result: Recovery without the formation of uretero vaginal
fistulas.
2. Dorff."— Operation : Myomectomy. Injury: Both ureters
were occluded by ligatures which kinked them by drawing
together the surrounding tissue. Diagnosis : Anuria 48 hours.
Repair : Laparotomy ; release of the ureters.
Result : Died after three days in spite of the free excretion
of urine. Autopsy negative.
3. Purcell.'— Operation : Hysteromyomectomy. Injury ;
Both ureters were occluded by ligatures, which kinked the
ureters without surrounding them. Diagnosis : Anuria 58
hours, associated with symptoms of uremia. Repair : Laparot-
omy ; release of the ligatures which controlled the uterine ves-
sels, and at the same time occluded the ureters.
Result : Recovery.
4. Markoe and Wood.^ — Operation : Panhysteromyomec-
tomy. Injury : Left ureter was tied and a portion excised with
the myoma ; right ureter was occluded by being kinked in the
closure of the peritoneal flap. Diagnosis : Anuria 24 hours was
the only symptom ; piece of the ureter was found attached to
the tumor. Repair : Laparotomy ; right ureter was released ;
left ureter, ureteroureteral anastomosis.
Result: Recovery.
5. Neuman.'— Operation : Vaginal hysterectomy by the
clamp method. Injury : Both ureters were clamped. Diag-
nosis : Anuria three days, otherwise felt perfectly well ; clamps
were removed; urine appeared in the bladder.
Result : Ureterovaginal fistula appeared on the ninth day,
which was later closed by colpocleisis.
6. Martin. 10— Operation : Extirpation of a multinodular
myoma by Thumin clamps. Injury : Both ureters were tied.
Diagnosis: Anuria for 24 hours. Repair: Laparotomy ; ureters
were released.
Result : Death in 24 hours from peritonitis.
Death occurred in two of the six cases of ligation of
both ureters which were released. The longest time that
elapsed before the ureters were released was three days,
and during that time anuria was the only symptom
referable to the injury.. How long a patient may live
with occlusion of both ureters by ligatures or clamps one
cannot say, for the shock of the operation added to the
effect of the suppression of urine caused by the occlusion
of the ureters must be considered.
Postoperative anuria may be due to : 1 . Occlusion of
both ureters. 2. Nephritis (three in.stances occurred
in our department, with one death). .3. Shock (two
instances in our department, with one death). 4. One
has but to look up the subject of suppression of urine, or
anuria, and he will find a large number of cases of
anuria reported due to various causes, any one of which
could, of course, follow an operation.
LIGATION OF ONE URETER AS A SURGICAL PROCED-
URE IN INJURIES TO THE URETER.
Associated with the ligation of one ureter it is well
to consider the feasibility of such a procedure in cases of
injury to the ureter when ureteroureteral and uretero-
vesical anastomoses are impossible. Judging from the
experimental work on the lower animals, as well as the
finding at operation or autopsy of an atrophic kidney
due to the occlusion of the ureter by a stone or some
other pathologic condition, it would seem to be justifi-
able in man.
I have been able to find the following cases reported
in the literature :
1. Veit.i' — Operation : Removal of an intraligamentary
ovarian tumor. After operation there was found attached to
the tumor 6-8 cm. of the ureter (examined microscopically).
Result: Recovery. No symptoms pointing toward the
injury. Probably atrophy of the kidney.
2. Bastianelli.'^ — Operation : Removal of sarcomatous ovary
with adherent uterus. A portion of the right ureter was excised.
The central end was ligated and placed in the abdominal
incision.
Result: Recovery without pain. Atrophy of the kidney.
3. Ptith."— Operation : Removal of a myomatous uterus,
and ovarian cyst, right ; 10-12 cm. of the ureter were excised.
Central end of the ureter was tied.
Result : Slight discomfort and elevation of temperature
immediately following the operation. A mass (hydronephrotic)
formed in the kidney region, which did not give rise to any
symptoms.
4. Phaenemenow." — Operation : Removal of bilateral ovar-
ian cysts. Excision of a portion of the left ureter. Proximal
end of the ureter was tied.
Result: Convalescence uneventful. Atrophy of the kidney
probably occurred.
5. Weinreb. '5— Operation by Landau: Abdominal hyster-
ectomy for carcinoma of the uterus. A portion of the ureter
was excised and the central end was tied.
Result: Some dull pain in the region of the right kidney
and also nausea, with slight elevation of temperature. Never-
theless, the patient felt quite well. Urine was bloody the first
two days. Passed 700-800 cc. the first day; this gradually
increased to 1,000-1,200 cc. on the tenth day. Recovery. Atrophy
of the kidney.
6. Olhausen.'^— After tying the proximal end of an Injured
ureter the catgut suture was absorbed and led to a retroperi-
toneal infiltration of urine, which necessitated nephrectomy.
7. Ortmann."— Tied the ureter in a case of hydronephrosis
due to an anomalus of the ureter which emptied into the vagina.
Result: Recovery.
8. Bardenheuer.i8— Tied the ttreter after excising the lower
portion of it in hysterectomy for carcinoma of the cervix.
Result: Recovery, but death occurred in eight weeks, due
to renal infection.
9. Fraenkel.i' — After an ureteral injury occurring in the
removal of an intraligamentary cyst, tied the ureter. The liga-
ture cut through the ureter. This led to an infiltration of the
peritoneal cavity with urine.
Result : Patient died.
Praenkel suggests that the ligated ureter should be
placed in the skin incision. Should the ligature slip, be
absorbed, or cause a urinary fistula, it will be in a place
where it can be controlled. Likewise, a pyonephrosis
can be the more readily managed.
10. Blumenfeld.20— Operation : Removal of ovarian tumor,
partly intraligamentary. Ureter was tied unintentionally.
Result: Convalescence uneventful until the ninth day, when
suddenly symptoms of general peritonitis developed, and the
patient died on the fifteenth day. Autopsy showed that death
November 1, 1902]
LIGATION AND CLAMPING THE URETER
tAMEBiCAN Medicine 697
was due to rupture of the ureter just above the ligature, shut
permitting the escape of urine.
In t) of these 10 cases of ligation of the ureter recovery
took place without any marked constitutional disturb-
ances or symptoms referable to the injury. In one,
hydronephrosis developed, while in the other o renal
atrophy probably occurred. Failure in 2 of the unsuc-
cessful cases was due to the ligature cutting through or
so injuring the ureter as to cause a leakage of urine into
the retroperitoneal tissue in one case and abdominal
cavity in the other. Both patients died, but probably in
neither case was there drainage to the place of ligature,
otherwise a ureteral fistula would have formed, which
is the common indication of injuries to the ureter. In
another unsuccessful case a fistula developed, due to the
use of an absorbable ligature, namely, catgut. In this
case nephrectomy was resorted to. In the fourth case
death resulted from renal infection eight weeks after the
operation.
Ligation of a ureter as a remedy for a ureteral injury
should not be done : 1. When either a ureteroureteral or
ureterovesical anastomosis is possible. 2. When the
operator knows that renal insufficiency of the other
kidney exists. 3. When pyuria is present in that
kidney.
Ligation of the ureter is preferred to nephrectomy
for the following reasons : 1. It is a much simpler pro-
cedure and is done quickly. 2. Should at any time renal
insufficiency appear a lumbar incision into the pelvis of
the kidney whose ureter was ligated may te done, or,
better, if the ligated ureter has been sewed into the
abdominal incision, the ligature may be released and
thus probably the function of the kidney restored, as
suggested by Fraenkel.
Ligation of the ureter is preferable to anastomosis of
the injured ureter into the intestines, for Peterson^'
reports that in 33 cases of ureterointestinal anastomosis
in human beings there was a primary mortality of 33^,
and an ultimate mortality which was much higher.
Sewing the ureter into the skin incision in order to
form a urinary fistula, or the making of a fistula through
the lumbar region with the ureter or the pelvis of the
kidney, is preferable to ligature of the ureter when renal
insufficiency exists or pyuria of that side is present.
In ligation of the ureter care should be taken to use
heavy, nonabsorbable ligatures and to ligate twice. If
possible the end of the ligated ureter should be placed
in a skin incision, so that any further postoperative con-
dition which might arise may be better controlled.
Should placing of the ligated ureter in the skin not be
feasible, a gauze drain should extend to the place of
ligature so that if the ligature should injure the ureter
sufficiently to give rise to a fistula there might be an
avenue for the escape of urine.
The vesical end of the injured ureter should be tied.
Under normal conditions the reflux of urine from
the bladder into the ureters is impoasible. However
cases have been reported by Desnos," Modlinsky,^' and
others, in which this has taken place, undoubtedly
owmg to some abnormality or pathologic condition of
the vesiad end of the ureter, as a ureteritis, involve-
ment by cancer^ etc.
HOW TirE ACCIDKNTAI. MGATION OR CLAMPING OP
THK URETEK USUALLY (X"CUH.S.
1. In controlling the uterine vessels. This is espe-
cially true when the ureter is displaced by l)eing dragged
upward in abdominal, or downward in vaginal, hyster-
ectomy when either a newgrowth or inflammatory tiasue
extends out from the uterus and Involves the ureter
making it adherent— as in Nos. I, VI, VII and XIl'
On the other hand, thedifflculty in controlling the uterine
vessels arising from faulty ti<;s or poorly place<l clamps
IS responsible for many injuries. When the vessels are
cut the field of operation is filled with blood, the ves-
sels retract, and in the attempt to control them the ureter
may be injured. This possibility is, of course, increased
when a newgrowth extends well out toward the pelvic
wall-Nos. II, III, X, XI, XIII, XV.
2. Displacements and changes in the ureter ;brought
about by newgrowths either pressing on the ureters or
pushing them upward— Nos. VIII and IX. In both
cases a myoma caused double hydroureter and displace-
ment.
3. In controlling vaginal vessels after the uterine
vessels have been tied. The bleeding and oozing of the
vaginal vessels, especially the veins, is frequently very
troublesome in freeing a carcinomatous cervix from the
vagina. In two of the sixteen instances the ureter was
thus tied— Nos. IV and V.
HOW TO AVOID THE INJURY.
More care in controlling the uterine vessels. Make
sure that the tie includes only the uterine vessels. This
will exclude the possibility of the ureter being in the tie,
and when the vessel has been cut the absence of hemor-
rhage will greatly lessen the chance of harming the
ureter. Various plans have been adopted to avoid these
injuries in hysterectomy for carcinoma. Some operators
dissect out the ureters and hold them to one side by liga-
tures or blunt hooks.
Against the free dissection of the pelvic portion of
the ureter it may be said that the blood supply of that
organ is injured, thus there is a possibility of the forma-
tion of a postoperative ureterovaginal fistula, with its
accompanying disagreeable features.
Wertheim " reports (JO cases of hysterectomy for
carcinoma of the cervix, in which the ureters were
exposed over their pelvic portion, and in five uretero-
vaginal fistulas formed, two of which were double, on
account of interference with the blood supply of that
organ. Here in Johns Hopkins Hospital we have had
five similar instances in which ureterovaginal fistulas
have developed from the dissecting out of the ureter,
thus injuring the vascular supply of its pelvic portion.
At the instigation of Wertheim, Feitel ''^ studied the
blood supply of the ureter, especially as related to the
operation of hysterectomy for carcinoma of the cervix.
As the upper part of the pelvic portion of the ureter
receives its blood supply from the mesial side, /. e., from
the aorta, common and internal iliac vessels, and as the
lower portion receives its blood supply from vessels
lateral to the ureter, i. e., the uterine and superior vesi-
cal arteries, Feitel recommends a dissection which will
not injure these nutrient branches. When it is necessary
to expose the ureter, he advises that the upper part of
the pelvic portion should be exposed by opening the
peritoneum lateral to it, carrying the incision through
the peritoneum across the ureter at the middle of its
pelvic portion, and continuing down along the lower
portion mesial to the ureter. Thus the nutrient vessels
will not be injured. Our five cases differed from Wert-
heim's in this particular, that the bloodvessels supplying
the upper part of the pelvic portion of the ureter, /. e.,
those derived from the common internal, or external
iliac vessels, were probably not injured directly, for in
our operations that portion of the ureter has very
seldom been dissected free. Our injuries probably
occurred as follows: The main bloodvessels of the
ureter travel in its outer loose fibrous coat, the small
vessels arise from these and penetrate the ureteral wall.
By tying the uterine vessels well out toward the pelvic
wall, part of the blood supply to the vesical end of the
ureter was cut off", while the bloodvessels from above,
which descend in the outer loose fibrous coat, were
destroyed by the dissection of the ureter from the
adherent carcinomatous cervix ; thus the blood supply
of the lower end of the ureter was probably iryured suf-
ficiently to give rise to a slough, forming a uretero-
vaginal fistula. In Cases Nos. I and III, postoperative
ureterovaginal fistulas resultefl from clamping the ureters.
698 AKKRiOAN Medicine]
LIGATION AND CLAMPING THE URETER
LNOVEHBEK I, 1902
Here again the clamp injured the bloodvessels in the
outer fibrous coat. A part of the blood supply derived
from the uterine vessels had been destroyed in control-
ling these vessels. The result was probably sufficient
interference with the blood supply of that portion of the
ureter to give rise to a fistula.
From our experience it seems that when the ureter
is adherent and is dissected free, two things are apt to
occur: 1. The growth returns. 2. A ureteral fistula
forms, the very thing which it was intended to avoid.
Would it not be much better, when there is lateral
extension of the disease sufficient to cause the ureter or
ureters to become adherent, to remove that portion of
the ureter, together with the growth, and implant the
end of the ureter into the bladder? There are three
points in favor of this : 1. The growth is less likely to
return. 2. Ureterovaginal fistulas are less likely to
occur. 3. The time spent in cutting the ureter and
making a ureterovesical anastomosis would probably not
be any greater than that consumed in the careful dis-
section of the adherent ureter.
CATHETERIZATION OF THE URETERS PRELIMINARY
TO HYSTERECTOMY FOR CARCINOMA OF THE
CERVIX AS A MEANS OF AVOIDING
AND DETECTING INJURIES
TO THE URETER.
For 12 years Dr. Kelly has been catheterizing the
ureters with silk bougies in hysterectomy for carcinoma
of the cervix of the uterus. Thus the catheterized
ureter may be felt at any time during the operation,
which affords protection to the ureters in many ways
and makes this most dreaded operation in gynecology
safer, easier and quicker. Being able to feel the ureter
at any time renders the avoidance of injuries to that
organ easier. More of the work may be accomplished
by the sense of touch, for it is not necessary to look for
the ureter when it can at any time be readily palpated.
The catheter affords protection by making unnecessary
the free dissection of the ureter, in order to expose it so
that it may not be injured. Thus one source of injury
may be avoided, namely, the interference witli its blood
supply. The ureter, stiffened by the catheter, is less
likely to be kinked by a ligature so placed in the sur-
rounding tissue as to draw it together. Also displace-
ment of the ureter, caused by traction on the uterus
drawing to one side an adherent ureter, will take place
less in the catheterized ureter on account of the splinting
of the ureter by the catheter. The displacement of the
ureter is a very important factor in the causation of
injuries. A ligature about the ureter which will not
retain the catheter in the ureter, on attempting to with-
draw it, will probably not cause any trouble. Had the
catheter not been there the ligature would have occluded
the ureter. Being able to feel the ureter in any part of
its course, makes the review of the field of operation
much easier, the clamped and ligated ureter is more
readily discovered, and the incised or severed one more
easily seen. The catheter should be removed before
closing the abdominal wound. If the ureter is tightly
ligated or clamped the c«,theter will naturally be held
fast, and an opportunity is given to discover and remove
the cause before closure of the abdomen.
Of 32 cases of surgical injuries to the ureter 19 have
occurred in hysterectomy for carcinoma of the cervix of
the uterus. In 11 of these cases the ureters have been
catheterized. This seems a poor showing for catheter-
ization of the ureters, but it must be remembered that
the catheters not only made the operation itself easier
but also the detection of the injury, whether by ligature
or incision. In 2 of the 11 cases the catheter was clearly
seen in the incised ureter and saved the ureter from
being cut across ; also the apposition of the incised edges
was made easier by the catheter being in place. In 2
other cases excision of the lower portion of the ureter
was intentional. In Case No. VI the ligature was dis-
covered by the fact that the catheter was held firmly in
the ureter on attempting to withdraw it. The ureter
was released from the tie, without any postoperative
symptoms referable to the injury. In 5 cases postopera-
tive ureterovaginal fistulas arose from too careful dissec-
tion of the ureter from the carcinomatous cervix, thus
interfering with the blood supply of the ureter. It
would have been better to have amputated the ureters
and implanted them into the bladder, for in these cases
dissection of the ureter adherent to or involved by a
carcinomatous growth gives a bad prognosis, and besides
implantation of a ureter into the bladder is much easier
to manage at the time of operation than a postoperative
ureterovaginal fistula. In Case No. I a ureterovaginal
fistula forming on the third day and healing sponta-
neously in three weeks was probably due to clamping of
the ureter.
It may be said against catheterization of the ureters
preliminary to hysterectomy for carcinoma of the cervix
that:
1. It requires an operator who is skilled in cystoscopic
work, but the gynecologist who is not experienced in
bladder and ureteral surgery should not attempt to
remove a carcinomatous uterus.
2. It takes time and therefore prolongs the operation.
It may be done before the patient takes the anesthetic,
and even if done when the patient is anesthetized the
time spent in catheterization of the ureters is more than
compensated by the time saved by their use in the
operation.
There are, however, certain precautions to be taken :
a. Use only sound catheters, for it is not safe t<) have
friable ones in the ureter, which may be exposed to
rough handling, b. In abdominal hysterectomy for
carcinoma of the cervix, always remove the catheter
before closing the abdominal cavity. Thus an injury to
the ureter may be detected, and should the operator be
so unfortunate as to have broken the catheter in the
ureter, then it may be removed through a slit in the
ureter, as in Case No. XV (combined abdominal colpo-
hysterectomy for carcinoma of the vagina), in which on
withdrawing the catheter from the left ureter half of the
catheter remained in situ. The injury arose from clamp-
ing the catheterized ureter, thus breaking the catheter
inside its lumen, but the broken bougie was removed
through a slit in the ureter, which was then repaired.
There were no symptoms referable to the injury. In two
other cases — Nos. Ill and VII, both hysterectomy for
carcinoma of the cervix — the catheter was found to have
been nearly broken in two by clamping the catheterized
ureter, and one can see how the accident occurred in No.
XV. c. In vaginal hysterectomy for carcinoma of the
cervix, the catheterized ureter must be handled very
carefully, for should it be clamped there is the possi-
bility that the clamp may break the catheter so that a
portion of it will be left in the ureter. For its removal
an abdominal or retroperitoneal incision would probably
be necessary.
In Case No. II, attempted vaginal hysterectomy for
carcinoma of the cervix, on withdrawing the catheter
from the left ureter, 17 cm. of the catheter remained in
the ureter. The injury arose from clamping the cathe-
terized ureter. The patient was too weak to permit of
a further operation and never rallied, dying on the
seventh day. Therefore, when ureters have been cathe-
terized preliminary to vaginal hysterectomy for carci-
noma of the cervix, the utmost care must be taken not
to clamp them. But here the question arises. Is vaginal
hysterectomy for carcinoma of the cervix j ustifiable ? In
90 abdominal hysterectomies for carcinoma of the cervix,
reported by Wertheim," microscopic examination of
the lymphatic glands showed metastases in 30, and
there was no relation between the extent of the car-
cinoma and the presence or the extent of the gland
involvement. The vaginal operation does not permit
removal of these glands, and the percentage of cures
NOVK5IBKR 1, 1902)
LIGATION AND CLAMPING THE URETER
iAkerican Mkdicink 699
from hysterectomy for carcinoma of the cervix is too
small to have it still lowered by the vaginal operation.
Of cases in which the ureters have been catheterized
preliminary to hysterectomy for carcinoma, these two,
Nos. II and XV, are the only ones in which its use was
injurious and they suggest what precautionary measures
should be taken. In the catheterization of the ureters
for other purposes we have never seen any symptoms
which could be referred to the procedure
The ligated, noncatheterized ureter may be discov-
ered in various ways: 1. A ligature is seen in the
region of the ureter and on inspection the dilated ureter
may be seen above the ligature, indicating the site of the
injury. 2. If sufficient time has not elapsed to cause any
ureteral distention the ureter may be* seen included in a
ligature by systematically following the course of the
ureter through the field of operation. Itwasthus discov-
ered in five cases— Nos. IV, IX, X, XI and XIII. 3.
Displacement of the ureter caused by the ligature draw-
ing it to one side, may call attention to the injury, as in
No. V, hysterectomy for carcinoma of the cervix, in
which, on reviewing the field of operation, the right
ureter was seen apparently drawn down into the vagina.
As there was difficulty in determining whether or not
the ureter was ligated, an opening was made in the
ureter and a ureteral bougie was passed down to the
ligature. The ligature wa.s removed and the slit in the
ureter was closed. No postoperative symptoms refer-
aljle to the injury followed.
The ureter may be injured in congenital displace-
ments and abnormaliti&s, as in one instance in this hos-
pital, Gyn. No. 8,697. An abdominal tumor was found
in the pelvis and an attempted enucleation begun, when
it was discovered that we were dealing with an ectopic
left kidney somewhat atypical in form. In this instance
the ureter was not injured but the identity of the organ
was discovered just as the operator was about to tie off
the pedicle of the tumor, i. e., the ureter and the renal
vessels. Allen™ was not so fortunate. He mistook a
horseshoe kidney for a retroperitoneal lipoma. On
attempting to remove the tumor the ureter was first cut,
thus establishing the diagnosis. He repaired the ureter
by a successful end-to-end anastomosis.
DIAGNOSIS OF OCCLUSION OF THE URETER.
Undoubtedly many patients undergo gynecologic
operations in which a ureter is tied and the convales-
cence is uneventful, or the symptoms are such that they
are easily obscured by other postoperative symptoms.
An occasional autopsy, as in Nos. VII and VIII, reveals
the above, or a piece of the ureter may be found attached
to the tumor afterward, as in the case reported by Veit.
The report of cases in which ureteral fistulas follow the
removal of clamps on the seventh or tenth day after a
vaginal hysterectomy, as well as tying of the ureter as a
surgieal procedure in instances of injury, show that it
may give rise to no symptoms.
The question naturally arises. How are we to make a
diagnosis of occlusion of the ureter? If both ureters are
occluded, anuria will be present and may be the only
symptom. So the diagnosis is based on the presence of
anuria and the knowledge of a possibility of injury to
the ureters, and this can be confirmed only by catheter-
ization of the ureters or by an exploratory laparotomy.
When only one ureter is occluded, the diagnosis is
indeed very difficult, for in the majority of cases there
are no subjective symptoms. Pain in the region of the
ureter and kidney may be present. Such pain was pres-
ent in Case No. II, in which a portion of the catheter
was broken off and left in the ureter, but in this there
were symptoms arising from partial occlusion of the
ureter and also a foreign body in its lumen. Such pain
was present in No. XII, but in this again there was prob-
ably only partial occlusion, for the ureter was readily
catheterized, thus relieving the pain. In this case, when
the pain was very severe, local teudemees in the kidney
region Was absent. In Case XIV, repair of a vesicovag-
inal fistula, the end of the ureter was included in the
sutures, and here there was pain associated with chills
and fever. The patient was relieved by removing some
of the sutures, but it was not ascertained whether there
was stenosis or complete occlusion.
On the other hand, in Cases Nos. I, VII, VIII, as
well as in the others referred to in this article, in which
the ureter was completely occluded, there was no pain.
A stricture as we know, may be associated with pain.
It may be said that generally pain is not present when
the ureter is completely occluded. Oliguria, a dimin-
ished amount of urine, may mean so many things that
it is of very little value. The same is true of any other
subjective symptoms. We may say that the diagnosis
can be made only when there is pain which is localized,
and when the possibility of such an injury is known to
exist. Such a diagnosis was made in Cases XII and
XIV, and in both the cases stricture and not complete
occlusion was probably present.
Cystoscopic examination with catheterization of the
ureters will aid, but such a procedure will not be under-
taken unless there are sufficient, subjective symptoms to
warrant it, as in Case XII.
RESULTS OF OUR 16 CASES OF OCCLUSION OF THE
URETER.
All the patients recovered but three, Nos. II, VII
and VIII. In No. II, in which a portion of the
ureteral catheter was broken off and left in the ureter in
a vaginal hysterectomy for carcinoma of the cervix, the
patient died on the seventh day. While there were
subjective symptoms referable to the injury the ureter
was probably not occluded and the effect was that of a
foreign body in the lumen. The cause of death was not
known, but undoubtedly the ureteral injury helped.
In No. VII, combined abdominal and vaginal hyster-
ectomy for carcinoma of the cervix, the patient never
rallied from the operation, dying on the fourth day. At
autopsy the right ureter was found occluded, and there
was no apparent cause of death. Undoubtedly the
patient, with only one functionating kidney, was unable
to combat the condition of shock. Still she would proba-
bly have died had the ureter not been tied.
In No. VIII an attempt at hysteromyomectomy was
abandoned. The patient nearly died on the table, and
died on the eighth day. At autopsy bilateral hydrone-
phrosis with abscesses in the kidney was found. The
left ureter was occluded by ligatures. Hydronephrosis
was caused by pressure of the tumor. Undoubtedly the
occlusion of the ureter lessened the combative powers of
the patient, as she had renal insufficiency, due to the
bilateral hydronephrosis.
In only 2 of the 11 cases in which the ureter was
occluded during the operation and released before its
close, were there any postoperative symptoms referable
to the injury. In Case No. Ill a ureterovaginal fistula
appeared on the third day, probably as a result of clamp-
ing the ureter during the operation — this healed spon-
taneously In three weeks. In Case No. XII the post-
operative symptoms suggested stricture. These were
relieved by catheterization of the ureter. In Case No. I,
vaginal hysterectomy for carcinoma of the cervix,
clamps were left on the right uterine vessels for 24
hours. As a result, a right ureterovaginal fistula
appeared on the seventh day, which was successfully
rei)aired two months later. The 6 cases mentioned were
the only ones of the 16 in which there were any .symp-
toms or evidence of the injury after operation.
cx)N(;lu8Ions.
1. Occlusion of the ureter by a ligature or clamp is of
quite frequent occurrence during gynecologic operations.
Only a portion of these injuries are recognized, either
during the operation or afterward.
2. A ligature about a ureter, if removed before tlie
700 AHEBicAN MBDiciNEj LIGATION AND CLAMPING THE URETER
[November l, 1902
close of the operation, will probably not have Injured the
ureter. A clamp is more liable to give rise to postopera-
tive signs of injury than a ligature. Neither clamps nor
ligatures removed before the close of the operation do as
mucli harm as an operation which interferes with the
blood supply of the ureter sufficiently to give rise
to a urinary fistula, due to sloughing of the ureter at
that place.
3. Complete and permanent occlusion of the ureter
in the absence of infection leads to renal atrophy, with
more or less dilation of the ureter and pelvis of the
kidney. These conditions take place usually without
any symptoms or evidence of constitutional disturbance,
and probably without much shock.
4. Ligation of the ureter is probably less likely to
cause either a marked hydronephrosis or a pyonephrosis
than a ureteroureteral anastomosis.
5. Ligation of the ureter may be considered a justifi-
able surgical procedure, when necessary in cases in which
ureteroureteral or ureterovesical anastomosis is impos-
sible. (Successful ureteroureteral and ureterovesical
anastomoses, however, have been made under great ten-
sion, in cases in which 2 to 9 cm. of the ureter has been
removed.) In ligation of the ureter care should be
taken to doubly ligate it with nonabsorbable material,
and if possible to place the ligated end in a skin
incision.
6. Only a portion of the cases of ligation or clamping
of the ureter can be recognized after operation, as : a.
In cases in which both ureters have been occluded,
anuria will probably be the only evidence of the
trouble for the first 24 to 48 hours, b. Cases in which
urinary fistula develops as the result of the injury, fol-
lowing removal of clamps or absorption of ligature, or cut-
ting of the ureter by a ligature, c. Cases in which defi-
nite symptoms arise, as pain along the ureter and in the
kidney region, possibly associated with chills and fever,
or fever alone, and other evidences of constitutional dis-
turbances. These symptoms are the exception rather
than the rule, and probably indicate a stenosis rather
than occlusion, d. A mass may develop in the renal
region, due to the formation of a hydronephrotic kidney
and this mass may form without symptoms, e. The
injury may be discovered at autopsy.
7. Ligation of the ureter may terminate fatally (a)
when renal insufficiency exists, as in Case No. VIII ; (6)
in cases of profound shock. Ligation of the ureter may
increase the shock ; at least a person in such a condition
with only one working kidney has less chance than one
with two, as, possibly, in Case No. VII ; (e) the ligature
may slip, be absorbed, or in some way lead to the leak-
age of urine, which, if the abdomen be closed and there
be no avenue of escape, may cause death. This would
especially be true should infection be present.
8. Catheterization of the ureter preliminary to hys-
terectomy for carcinoma of the cervix is of great aid in
abdominal and combined abdominal and vaginal hys-
terectomies, but the catheter should be removed before
closing the abdominal cavity, (a) The ureter may easily
be palpated at any time, therefore there is less danger
of injuring it ; also on this account the operation may
be done more quickly and much of the work be accom-
plished by the sense of touch, for it is not necessary to
see the ureter in order to know its location. (6) Post-
operative ureterovaginal fistula, due to interfering with
the blood supply of the ureter, caused by exposure of
the ureter, so that it may not be injured in hysterectomy
for carcinoma of the cervix, is less likely to follow when
the ureter is catheterized, for the exposure of that portion
of the ureter above the broad ligament is unnecessary, as
it can readily be palpated. Also exposure of the lower
portion of the ureter is unnecessary unless the ureter is in-
volved by, or adherent to, the growth. Should the ureter
be adherent to the growth, the dissecting free of it would
probably mean a return of the carcinoma, and also possi-
bly a ureteral fistula due to interference with its blood
supply. Hence, it would be much better to make a wider
dissection, excising the lower end of the ureter with the
growth, and implant the free end of the ureter into the
l)ladder. Thus there would be less chance both for a
return of the disease and also for an ureteral fistula.
(e) The catheter itself protects the ureter in various
ways ; the increased stiff"ness renders its displacement a
little more difficult, as when a ureter adherent to an
inflamed parametrium or to a carcinomatous cervix is
drawn to one side when traction is made on the uterus.
Also, the stiffened ureter is less likely to be kinked by a
ligature in the surrounding tissue, which, while not
encircling the ureter, kinks it by puckering the tissue
about it. Should the ureter be ligated and the catheter
not held by the ligature, when the catheter is withdrawn
the ligature will probably not do harm, for the catheter
prevents the ligature from occluding the ureter. The
catheter offers resistance to a knife or scissors and pre-
vents cutting the ureter completely across, {d) Injuries
to the ureter are more readily discovered. The catheter
is seen in the incised ureter, or traction on the catheter
before closure of the abdominal incision makes evident
a ligature which holds the catheter in the ureter. Any
repair necessary to the ureter is more easily accom-
plished, as one has the catheter as a guide over which to
repair the injured ureter, (e) Clamping the catheterized
ureter may crush the catheter so that a portion of it will
be left in the ureter on withdrawing the catheter. This
portion can readily be removed through a small slit in
the ureter and the slit repaired ; hence, it is important
to withdraw the catheter before closing the abdominal
incision.
9. Should a catheterized ureter be clamped in a vag-
inal hysterectomy for carcinoma of the cervix, a portion
of the catheter may be broken off and left in the ureter,
which would probably necessitate an abdominal or retro-
peritoneal operation for its removal. While the cathe-
terized ureter is very easy to palpate in vaginal hyster-
ectomy and hence its exact location may at any time be
determined, the operator must always bear the foregoing
in mind and determine their position t)efore clamping.
Is not the vaginal hysterectomy for carcinoma of the
cervix counterindicated when, according to Wertheim,
in 90 cases of abdominal hysterectomy for carcinoma of
the cervix, metastases of the carcinoma to the pelvic
lymph glands were found in 30 of the cases, and
there was no relation between the local extent of the
disease and the presence or number of lymph glands
involved ?
REFERENCES.
1 Cohnhelm : Lectures on General Pathology, The New Sydenham
Society, London, 1890, ill, 1231-1234.
2 Bradford : Trans. Path. Soc, London, 1898, xllx, 169.
sLlndemann : Zeil, f. klin. Med., 1898, xxxlv, 299-321.
*Guyon ; Ann. des Mai. des Org. Genitourln., 1892, x, 161.
^Zweifel: Fest. zur Einweihung der neuen Universltttts Frauen-
kllnlk zu Leipzig, Berlin, 1892. Quoted by Hochsletter, Arch. f. Gyn.,
1894, xlv, 109.
«Dorff: Cent. f. Gyn., 189e, xx, 764.
' Purcell : Brit Gyn. Jour., 1898, liv, 174.
» Markoe and Wood : Ann. of Surgery, 1899, xxlx, 694.
'Neuman : Cent. f. Gyn., 1899, xxili. 1184.
'0 Martin : Cent. f. Gyn., 1899. xxiii, 1255.
11 Velt : Zeit. f. Geb. und Gyn., 1895, xxxl, H. 2, 454.
12 Bastlanelll : Ann. dl Ostet. e. Gin. Milano, 1896, xviii, 134.
i3Futh : Cent. f. G.yn., 1898, xxli, 731.
"Phaenemenow: Cent. f. Gyn., 1901, xxv, 22.
15 Weinreb : Arch. f. Gyn., 1901. Ixv, 161.
isQlhausen : Zelt. f. Geb. und Gyn., 1901, xlvl, H. 1, S. 118.
1' Ortmann : Quoted by Boari, Ann. des Mai. des Org. Genitourln.,
1899, xvii, 1075
18 Bardeuheuer : Quoted by Morris, Surgical Diseases of the Kid-
ney and Ureter, 1901. 11, 385.
i»Fraenkel : Arch. f. Gyn., 1901, Ixlv, H. 2, 438.
»■ Blumenfeld : MUnch. med. Wochenschrift, 1898, xlv, 992.
21 Peterson : Jour. Am. Med. Assoc. 1901, xxxvi, 573.
22 Desnos : Ann. des Mai. des Org. Genitourln., 1898, vli, 659.
23 Modlinsky : Cent. f. die Krank. der Harn-u. Sexual-Org., 1894, v,
252
"Wertheim : Arch. f. Gyn.. 1901, Ixv, H. 1, S. 1.
2«Feliel : Zelt f. Geb. und Gyn., 1901, xlvi, H. 2, S. 269.
2« Allen and Brlggs : Boston Med. and Surg. Jour., 1899, cxii, 344.
2' Wertheim : Cent. f. Gyn., 1902, xxvi, 249.
Endowment for Triennial Prize.— It is reported that
Professor Lannelongue, of Paris, has presented $7,500 to the
Paris Academie de M6decine for this purpose.
NOVKMBEK J, 19021
ARTHROPATHY OF VERTEBRAL COLUMN IN TABES aksbican medicinkj 701
ARTHROPATHY OF THE VERTEBRAL COLUMN IN
TABES.
BY
WILLIAM G. SPILLER, M.D.,
of Philadelphia, Pa.
Assistant Clinical Professor of Xervous Diseases and Assistant Profes-
sor of Neuropathology in the University of Pennsylvania.
Arthropathies of the vertebral column in tabes are of
such rare occurrence that the following case is worthy of
report. The patient has been under my observation
during the past two years in my service at the Philadel-
phia Hospital. When first admitted to the hospital she
was under the care of Dr. Charles K. Mills.
A. B., a woman, aged 59, a milliner by occupation, single,
was admitted to the Philadelphia Hospital September 13, 1900.
Fig. 1.— Arthropathy of spinal column. The spines of the vertebras
have been indicated by ink dots.
Her father died of typhoid fever; her mother of gastric and
uterine carcinoma. Her maternal grandmother and a maternal
cousin also died of carcinoma.
She was well until she had a chill in 1895 after exposure to
cold or dampness, and this wa.s followed by pains all over the
body so that she was obliged to remain in bea for a week. For
many years she had sharp pains in her lower limbs. She had
disturbance of gait ana staggered and was obliged to use
crutches. She had one or two severe falls with no serious con-
sequences. Her right shoulder became swollen and useless
about 1898, and would " come out of the socket " if used. Syph-
ilis is positively denied. Fn 1900 she had incontinence of feces
if she took medicine for her bowels, but had no bowel move-
ments without medicine or an enema. She had also inconti-
nence of urine.
In 1900 sensation was as follows: Temperature sense was
preserved except in the feet and legs, here sensation of cold
was not normal. Tactile sensation was also impaired in these
parts. After-sensations were present in the feet and legs. A
sensation of pricking and sticking was felt 5 to 10 minutes after
a needle thrust had been given, the pain being more severe at
this time than at the moment the needle was used.
The tendon reflexes of the upper limbs, the epigastric,
abdominal, patellar and Achilles tendon reflexes were absent.
The grip of the left hand was good, that of the right hand only
slightly impaired.
Notes made June 5, 1901, are as follows : The patient has an
arthropathy of the left ankle and probably also of the loft knee,
as crepitation of the knee-joint is obtained. The lower limbs,
especially the left, are edematous below the knee. She has very
little power of movement in the toes of the loft foot, and the
movement that is preserved is only flexion. The move-
ments of the right foot are normal. The left foot is exceed-
ingly edematous and is in extension. The upper and lower
limbs are not distinctly wasted, although the muscles are
flabby. The movements of the left lower limb at the knee and
hip are weak ; those of the right lower limb are fairly good.
The movements of the upper limbs are free except at the right
shoulder.
The report of Dr. H. P. Hansell is as follows ; " June 5,
1901. The patient has complete ophthalmoplegia externa and
interna ; no pupillary response to light ; media clear ; high
myopia ; complete atrophy of both optic nerves ; partial
atrophy of choroid and retina; right pupil is smaller than the
left; exophthalmos of both eyes, partly due to myopia."
An examination of the urine made September 19, 1901,
showed no important abnormal condition.
During the past year the disease has made little progress.
Her vision seems to be entirely lost.
There can be little doubt that this is a ease of tabes
dorsalis, and it is reported on account of the arthropathy
of the spinal column. Syringomyelia might be thought
of, but the symptoms are not those of this disea.se. The
patient first noticed aiwut four years ago that her spinal
column was becoming deformed. She has pronounced
scoliosis and lordosis in the thoracico-lumbar region,
and this deformity is said to have developed gradually.
The right hip is raised considerably higher than the left
when the patient is sitting, on account of the deformity
of the vertebral column. The spinal arthropathy is
associated with arthropathies of the left foot, left knee,
and right shoulder, and an arthropathy is probably
now developing in the left shoulder.
Oppenheim,' in the third edition of his textbook,
says that arthropathies of the vertebral column are rare
in tabes, and he refers to cases reportetl by Kronig and
by Abadie.
The deformities of the vertebral column in tabes did
not escape Charcot, and P. Marie * in speaking of frac-
ture of the vertebra.s as.sociated with arthropathies ^of
these bones gives a picture from Charcot's collection that
resembles very closely the one appearing in my paper.
As Marie says, it may be very difficult to determine
Fig. 2.— Arthropathy of the right shoulder. The head of the humerus
is dislocated and Is In Cront of the clavicle.
whether the condition is one of fracture or arthropathy
of the vertebras, and possibly the two conditions exist
together.
Kronig' believed that in his three cases of tabes with
deformity of the spinal column, the cause of the deform-
ity was fracture. In all three ca-ses the fracture and
dislocation occurred in the lumbar vertebras. In a case
with necropsy, describeil by Pitres and Vaillard,* the
arthropathy was also in the lumbar vertebras. They
702 Amebican Medicine}
SUBCUTANEOUS TENDON-SPLICING
[NOVEHBEB 1, 1902
refer to a doubtful case reported by Kronig '* and they
speak of a drawing in the museum of the Salpfitrifire in
which an arthropathy of the thoracico-lumbar vertebras
was represented.
It is possible that other cases of arthropathy of the
vertebral column in tabes may be found in the literature.
My object in reporting this ase has been to call attention
to a rare sign of tabes.
BIBLIOGRAPHY.
' Oppenheim, " Lc-hrbuch der Nervenkrankheiten," Berlin, 1902.
2 P. Marie. " Le?ons sur les maladies de la moelle."
»Kr6nig, Zeit.schrlftrarklin. Med., 1888, p. 51.
*Pltres and Valllard, Comptes rendus de la 8oc. de Blologle, 1885,
p. 679.
'Krouig, Zeltschrlft far kiln. Med., 1884, Supplement, p. 165.
SUBCUTANEOUS TENDON-SPLICING : A MODIFICA-
TION OF ANDERSON'S OPEN METHOD, ADAPTED
ESPECIALLY TO THE TENDO-ACHILLIS.
BY
J. T. RUGH, A.B., M.D.,
of Philadelphia.
Assistant Orthopedic Surgeon to the Jefferson Medical College Hospital;
Demonstrator of Orthopedic Surgery in the Jefferson
Medical College, etc.
In the treatment of deformities, associated with or
dependent upon a contracted tendon, the selection of the
method which will most successfully meet the indica-
tions is not only most important, but at times most diffi-
cult. The very nature of the desired results — preserved
function, tendon union, etc., and the necessity of careful
after-treatment — render necessary the exercise of the
utmost caution and the best judgment in dealing with
these cases.
Methods of operation being divided into subcuta-
neous and open, the choice is to be determined by the
peculiarities of each individual case, and these may be
included under the following queries :
(a) Has the tendon a distinct synovial sheath ?
(6) Is the function of the parts siich as will require
the continuity of the tendon to be preserved throughout
its entire extent ?
(e) Is the excursion of the tendon, or of the part con-
trolled by it, large or small ?
(d) Is the degree of the deformity great or slight ;
or, in other words, is the tendon much shortened or
lengthened ?
(e) What is the condition of the muscles from which
the tendon springs — that is, are they paralyzed or not ?
(/) If paralyzed, is the tendency toward contraction
or toward relaxation ?
(g) Has there been a previous operation upon the
same part ?
(h) How old is the patient ?
Before taking up these points separately it will be of
interest to indicate briefly the methods of repair in
tendons. After section of a tendon the same phenomena
of exudation, stasis, inflammation, absorption and
organization occur as after incision of any part, and
union takes place by one of two proces.ses, viz., organi-
zation of a blood-clot or proliferation of connective tis-
sue cells, which latter are replaced by plasma cells
springing from the connective tissue spaces in the nor-
mal tendon. A blood-clot between divided tendon ends
may organize, the resulting tissue becoming continuous
with the tendon, but always remaining fibrous tissue
and never possessing the same structure as the tendon.
On the other hand, there may be segmentation of the
connective tissue cells, and later (according to Tubby)
proliferation of plasma cells from the connective tissue
spaces of the normal tendon, which plasma cells feed
upon the exuded leukocytes and organize into tissue
simulating tendon, but possessing a different structure.
The same author claims that primary union of tendon
ends is an impossibility, but we fail to see why such
should not obtain in tendons as well as in other tis-
sues, for in no part does union of cut surfaces occur
without the interposition of granulation material, the
terms primary, secondary and tertiary union depending
wholly upon the amount of granulation material inter-
posed.
(a) Has the tendon a distinct synovial sheath ? Many
tendons, especially those of the hand, have a di.stinct
.synovial investment and will doubtless have a better
preservation of their function if the open operation is
done, and the edges of the opening in the sheath are
afterward accurately coapted. This better guards against
adhesions of raw surfaces and allows as free motion or
■^cr
u
A.— Splitting knife, actual size.
play of the tendon as obtained before the operation.
The necessity of this is evident when one observes the
results of the injury to such tendons and the frequent
failures following the attempts to restore their function.
(6) Is the function of the part such as will require the
continuity of the tendon to be preserved ? The answer to
this is in itself decisive of the method of operation.
Such necessity might arise either for the preservation
of the muscle function or for that of the joint or part
involved, as in a healthy tendo-Achillis or in a paralyzed
one. A pes equinus, due to primary or secondary con-
traction of this tendon, might be readily converted into
a pes calcaneus after severance Of the tendon, through
failure to obtain union of the ends, but if the tendon
were lengthened sufficiently to overcome the existing
deformity and kept at that point until union was com-
B. — Tendon exposed by a %-lnch incision.
plete, there would arise no risk of substituting the other
deformity or condition.
(c) Is the excursion of the tendon or the part con-
trolled by it large or small ? When freedom of motion
is of every importance there is almost always a distinct
sheath to the tendon and necessarily there should be as
little exposure of that .structure and disturbance of its
relations as possible. Adhesions mean limited motion
and are sure to occur when raw surfaces are left in con-
tact ; in such a case the open operation would present
fewer disadvantages than the subcutaneous, as the cut
surface of the tendon may be covered by the original
sheath tissue.
(d) Is the degree of the deformity great or small, or
in other words, is there much or little shortening of the
tendon ? The importance of the shortened tendon has
November 1, 1902]
SUBCUTA2TE0US TENDON-SPLICING
lAMBBICAIf MEDICINB
70S
.K
C— Ends sewed together In the wound.
much to do with the selection of the operation, no
matter what the degree of the deformity, as failure of
the tendon ends to unite may follow a subcutaneous
operation. It surely will if the tendon has a distinct
synovial sheath, and the action of the muscle necessary
to certain motions is lost ; yet with but a slight degree
of deformity, a tendon without a distinct sheath may
be cut subcutane-
ously at any age
and under almost
any conditions.
However, the ad-
vantages of splic-
ing the tendon
would, in any
patient past 7 or
8 years of age, far
outweigh the dis-
advantages and
should be consid-
ered the prefera-
ble procedure.
(e) What is
the condition of
the muscles from
which the ten-
don springs — that is, are they paralyzed or normal?
While the importance of this point deals partly with
the amount of function expected to be retained or
grained by operation, it bears more upon the nutrition of
the tendon after severance, the failure to obtain union
and the danger of sloughing. It is well known that
nonunion is much more likely to occur in a case in which
the muscles are already paralyzed than in one in which
they are healthy, because of the atrophic changes in the
entire part as well as in the affected tendon, not that the
blood supply is lessened but that the nerve control of the
nutritive functions is to a greater or less extent destroyed.
While this influence also increases the danger of slough-
ing, it is not of so much importance in determining this
condition as are (sareless methods of operating and, of
equal importance, too great tension upon the tendon
immediately following operation. These latter factors,
however, are of as great practical importance in the
unparalyzed as in the paralyzed muscles, as septic pro-
cesses progress as rapidl'y in the one case as in the other
and tension obliterates the small vessels which carry
nutrient supplies to the tendon as easily in the one as in
the other ; yet the presence of paralysis is always to be
considered in prognosticating results.
(./■) If paralysis is present, is there contraction or
relaxation of the
affected part?
This point, of
course, deter-
mines whether
the tendon is to
be lengthened or
shortened, and if
the latter, an
open operation
must necessarily
be performed.
In this condition,
too, the progno-
sis must be
guarded, as these
tendons and their
muscles or what remains of them will almost certainly
again relax after a varying period of two or more years,
and allow the deformity to re<'ur.
(.9) iras there bt«n a 'previous operation upon the
same jjart? The prest^nce of scar tissue not only renders
very difficult the performance of the operation, but also,
by it« lessened resistance from inferior vascular supply,
increases the dangers of sloughing and sepsis. By the
D.— Hbowlng length ofskln inoUion tn a patient
operated upon by Anderson's metbod.
former operation the original blood supply was neces-
sarily disturbed and in the new tissue formed about the
tendon the character of the vessels is entirely unlike
that of the former ones ; and when these new ones are
subjected to traumatism, nutrition is much less active
and reparative processes are delayed ; hence the le&sened
resistance to sepsis and the more rapid breaking down
from tension or other influences.
(h) How old is the patient? It is a wellknown fact
that the older the patient, regardless of the condition of
the muscles (normal or paralyzed), the greater the
liability to nonunion of the tendon ends after complete
severance, but it is impossible to set an age limit when
one or another form of tenotomy should or should not
be done. Yet for practical purposes it might be stated
that under 5 years of age tendon splicing will rarely be
found necessary or even expedient, and after 7 years of
age subcutaneous section of the more important tendons
will rarely be performed.
A careful comparison and analysis of the two methods
of operation show each one possessed of certain advan-
tages and eaeh also hampered by disadvantages which
are apparent to any one dealing extensively with such
conditions. Of subcutaneous tenotomy, the advantages
are:
1. The lessened danger of sepsis, not a single case of
such complication being on record.
E. — Showing length of Incision in a case in which there was about 2J4
inches lenKtbening secured
2. The lessened need of after-dressings and of close
attention to the wound.
3. The smaller skin wound and resultant scar, which,
in exposed parts, is a very important consideration.
4. The ease and rapidity with which it is ordinarily
done.
5. The more extensive division of structures possible
in a part like the foot. If an open section of the same
extent, as in Phelps' operation for varus, were done,
there would result a large granulating surface to be
healetl over and a scar which would almost certainly
contract, while in the subcutaneous method there is no
external evidence of injury, and the internal wound has
healed in two or three wwks.
Opposed to these are the following disadvantages :
1. The danger of cutting adjacent vessels, nerves, or
other important structures.
2. The almost certainty that in the use of the ordinary
tenotome much greater iryury will be done to the peri-
tendon tiasues than is neceassiry to correct the deformity,
which, therefore, creates a greater amount of scar tissue
and causes greater contractures than otherwise, tliereby
increasing the danger of a relapse of the deformity and
the difficulties in subse<iuent operations, should they be
necesstiry.
3. The liability to nonunion of the tendon ends
because of the extent of the st^paration.
4. The indefinite amount of lengthening stHJured and
the imperfect function resulting from the break in the
continuity of the tendon, even tliough the space between
704 AUXRIOAN MEDXCINKj
SUBCUTANEOUS TENDON- SPLICING
[NOVKMBEB 1, 190
the ends be filled with new tissues, as is the usual result.
There are also more or less extensive adhesions between
this new tissue and the skin.
The advantages for the open section or splicing, as
ordinarily performed, are :
1. The exact knowledge of the structures cut.
2. The definite amount of lengthening or shortening
obtained by splicing, and the greater certainty of pre-
serving the function by having the tendon continuous.
3. The lessened danger of nonunion.
The disadvantages are :
1. The greater risk of sepsis from a larger wound,
F.— Tendon exposed, with sutures In position.
and the extensive interference with the blood supply of
the tendon.
2. The greater scar in the skin, increasing the ten-
dency to secondary contraction.
3. The interference with the functions of the tendon
by the adhesions between it and the skin throughout the
length of the incision.
The following is a tabulation of these several points :
Subcutaneous.
Danger of sepsis lessened
Smaller skin wound and scar
Quickly done
Less after-care
Risk of cutting Important vessels or
nerves.
Greater Injury to peritendinous struc-
tures.
Liability of nonunion
Indefinite lengthening
Lessened function from severed ten-
don.
Open.
Increased.
Greater scar and adhesions.
Much more time required.
More.
None.
Less.
Practically none
Definite.
Function preserved.
While, therefore, the open operation overcame the
disadvantages of the subcutaneous, it presented some of
its own in the increased danger of sepsis and extensive
adhesions which interfered with the function of the
lengthened tendon. An operation, then, which was as
nearly subcutaneous as po.ssible, which gave accurate
amount of lengthening and ensured the continuity of
the tendon, and which prevented extensive adhesions
between the skin and tendon was evidently the one
desired, as it combined the best qualities of both the
others.
In 1889, Mr. Anderson, of London, first practised a
method of lengthening tendons by open incision, which
was far superior to any other plan in use at that time.
His method is described briefly as follows : The tendon
is exposed by a long incision directly over it, and is
separated from its sheath or bed; it is then split in
halves longitudinally, the one half severed at one end of
the wound and the other half at the other end. As
corrective pressure is made, the tendon ends slide past
one another, and when the deformity is overcome the two
overlapping ends are sutured in the position of correc-
tion. The skin wound is then closed and the parts held
in the corrected position by plaster-of-paris or other
fixed splint.
Its advantages over other methods in use at that
time were accuracy in lengthening, accurate knowledge
of parts cut, and absence of risk of nonunion, but it pre-
sented the disadvatages of the long skin incision and
subsequent adhesions, almost total shutting off of the
blood supply in lifting the tendon from its bed, and the
greater liability to sepsis. After having performed this
several times, it occurred to me that the same cuts could
be made in the tendon subcutaneously (or nearly so),
that suturing of the tendon ends could be done through a
very small skin incision, and that it was unnecessary to
lift the tendon from its bed. Accordingly, a small knife
was made (see cut A) with a long shank, and a blade
about one-half inch in length turned at a riglit angle to
the shank and having the cutting edge anteriorly so that
as the knife was pushed forward, the tendon would be
split. After thorough preparation of the skin, the opera-
tion is done as follows :
The tendon is put on the stretch, and an incision one-half to
three-quarters of an inch in length is made directly over it at
about its middle point (see cut B). After the tendon has been
exposed, the blade of the Itnife mentioned is passed through its
center, and being held on the same plane as the tendon, is
pushed to the one extremity of the tendon, or for a distance of
two or three inches, the tendon lieing outlined by the thumb
and finger held on either side of it. The knife is then with-
drawn in the same line, turned and pushed in the opposite
direction for the same distance, thus splitting the tendon for
four to six inches. The points at the upper and lower ends of
the tendon to which the knife reached are marked on the skin
with a sharp-pointed tenotome, and after withdrawal of the
splitting knife the tenotome is introduced on the right side of
the tendon at one end, and the right half of the tendon is
severed by carefully cutting little by little from above down-
ward until the dividing slit is reached. When this half is
severed it is seen to relax immediately, the tendon being held
tense the while. Then the left half is cut in the same way at the
opposite end and side, and as corrective pressure is made, the
two halves slide past one another in the wound. When com-
pletely corrected, the two ends are sewed together through the
small skin incision (see cut C) and the incision closed by one
or two sutures. A plaster-of-paris or other fixed dressing is
applied to maintain the correction secured, and this or another
one worn for about four weeks, by which time firm union will
have occurred.
It will be readily seen that the most important
objections to the Anderson method are overcome by this
one, viz., the long skin incision, the danger of sepsis and
that of sloughing from interference with the blood-
supply. Like everything else, however, it has its disad-
vantages, but these have been found to be easily over-
come. The first one is, the operation cannot be easily
G.— Showing the halves separated.
performed in those cases in which the tendon has a
partial twist, as the fibers do not run straight, and the
splitting knife may run out at one side or the other.
This condition, however, may be recognized so soon as the
tendon is exposed, and if present the incision can then be
extended and an Anderson operation done, without,
however, lifting the tendon or separating it from its bed.
If this is omitted, the circulation will be less disturbed,
and consequently there will be less danger of slough-
ing. The second disadvantage is, there may be some
uncertainty as to when the half of the tendon is severed,
as a few fibers still remaining above or below may pre-
vent relaxation of that half; but if the handle of a
bistoury or other flat instrument be introduced into the
NOVEMBKK 1, 1902]
POMPHOLIX IN NEW ORLEANS
(AnEBiOAK Medicine 705
slit, every filler on the one side of this may be cut with-
out danger to the integrity of the other half.
As before indicated, a very important point to be
observed in the after-treatment of the splicing operation
is that in making correction with a fixed dressing the
spliced tendon must not be subjected to great tension. If
tension exists sloughing and sepsis will almost certainly
occur. At the end of a week, when the wounds are
closed, corrective pressure may be increased without fear
of any ill effects.
The comparative length of the skin incision in the
two methods of performing the operation is shown in the
accompanying illustrations (see cuts D and E). The con-
dition of the tendon after the operation is shown in the
cuts F and G, in which the skin has been deflected from
the affected part.
I have done this operation in twelve cases with very
satisfactory results in each, there being no sepsis, a very
small skin scar, complete severance of the tendon being
easily accomplished, definite lengthening secured, and
l)ut a minimum of adhesions between the tendon and the
skin and, therefore, more complete restoration of func-
tion to the part. In one case, a girl 18 years of age, who
had a paralytic equinus, the wound healed by first inten-
tion, but owing to the very poor nutrition of the part
and the too early use of the foot, the wound opened and
remained so for several weeks. The tendon was firmly
united, however, and the wound finally closed. The
patient is now walking on the foot quite satisfactorily.
A PRELIMINARY NOTE ON POMPHOLIXfAS IT
OCCURS IN NEW ORLEANS.
ISADORE DYER, Ph.B., M.D.,
of New Orleans, La.
Professor on Diseases of the Skin in the New Orleans Polyclinic ; Lec-
turer and Clinical Instructor on Diseases of the Skin, Medical
Department, Tulane University; Visiting Dermatologist to
Charity Hospital; Member American Dermatologlcal
Association ; Kditor New Orleans Medical and
Surgical Journal ; President Ijouislana State
Medical Society, etc.
In the report sent by me to Dr. Hyde for statistics of
skin diseases as observed in public and private practice
in New Orleans for the year of 1901, there were noted a
total of 88 cases of pompholix.
In New Orleans during the summer months, and also
with the changing seasons in the spring and fall, both in
hospital and in private practice there have occurred a
miscellaneous lot of cases which I have classified under
the various titles from time to time adopted, discussed
and dropi>ed for some other term until pompholix has
survived as adaptable. Beside this, the doubt ari.sing
from misapprehension as to the exact distribution of the
types of eruption in a proper division of nomenclature
compelled some license in their location.
Thus in the past seven years since I have been a
member of the American Dermatological A8,soclation
and have annually supplietl a list of cases, there have
appeared in these lists a varied nomenclature of the same
affection.
It is the puriwse here to call attention to the various
types as they occur, with some general description, in
order to open the way to a subsequent presentsitlon of an
analysis of all the cases seen by me with an idea of deter-
niining the exact position of the affection as observed in
\(^w Orlean.-, and evidently differing in frequency and
in type from the disease called by the same name else-
where.
According to the nomenclature now current with the
American Dermatological Association, all of these erup-
tions will ])roperly fall under the head of pompholix,
but as these ciises are so evidently associated with the
function of the sweat gland apparatus and as [)ompholix
weems to be entirely dis.sociat<'d from any such connec-
tion, it must mean either a reconsideration of the term
or else a broader definition of pompholix.
When I first came to New Orleans my previous
observation of the disease, then called cheiropompholyx
or dysidrosis, had been quite limited, and the condition
was looked upon as a comparatively rare affection. Dr.
Stel wagon, in his recent text on skin diseases, defines
pompholix as a rare affection ; in other texts the
description of the clinical features is really meager. In
New Orleans the disease from April to November is
quite usual, presenting, as a matter of fact, much more
often for treatment than does miliaria.
Since 1892 these cases have gone down in our records
as hydroadenitis, dysidrosis, hydrocystoma, according
as the case presented.
The clinical appearances of these cases as they occur
in our observation show three distinct types, differing
sufficiently to require separate description :
1. The commonest variety finds its location on the
feet. It is usually bilateral, is almost invariably found
on the .solar aspect, the internal surface between the toes,
not infrequently extending to the ankles and to the
lower third of the legs. The eruption is made up of
pinhead-sized vesicles grouped in clusters, irregularly
compo.sed of from a half dozen to as many as fifty or
more deepseated lesions, uniform in size and with little
tendency to confluence. The contents of these vesicles
are fluid, clear and transparent, somewhat' sticky, but
not profuse. When the lesions occur between the toes
the friction of these parts causes them to break more
reatlily and they become raw quickly, the outline of the
denuded surface assuming the configuration of the
original cluster. Occurring on the soles, the groups con-
tain fewer lesions than elsewhere ; occurring on the sides
of the feet, the clusters are composed of smaller lesions,
not so deeply seated as those on the soles and instead of
discrete groups these clusters seem to follow the distri-
bution of the local peripheral nerves or bloodvessels.
The history of these cases is nearly always the same.
The patient will state either that there has been an
unusual dryness of the feet, with lack of perspiration, or
that at all times sweating is excessive. The feet burn
and sting, sometimes swell, and when the vesicles begin
to make their presence felt beneath the surface there is
intense itching, which persists until scratching or rub-
bing breaks the tops of these and lets the fluid contents
escape.
It is unusual to find any complicating history of bad
health, unusual (x;cupation, excitement or other factor
either producing or conducive to the disease. It is
selective of no particular set of individuals, but usually
occurs in adults, and in males oftener than in females.
2. The eruption occurring on the hands presents
much more the appearance of a true sudamina. The
eruption finds its location and distribution on both
the palmar and dorsal surfaces. Closely aggregated
small pinpoint to pinhead sized vesicles cover the backs
of the hands or the palms, running up to the wrists, or
else, as is most often the case, these lesions cover the
entire interdigital si)aces, extending over the backs of
the fingers as well. In milder types a few l&sions are
found disseminated over the palmar surfaces and between
the fingers, often breaking and drying without any
further concern to the patient. The subjective symp-
toms are slow in developing and the eruption may be
present for some days without producing any other .sen-
sation than that of ten.sene.ss. When the inflammation
starts there is considerable swelling, inflammatory red-
ness in the areas not covered by the vesicles, marked
itching, but at no time so severe as that of the feet. The
sensations most complained of by the patient are those
of burning and formication.
It is usually a noteworthy clinical fact that when the
hands are so involved the feet are seldom affec^ted,
whertws the reverse obtains when the feet are severely
afl'ected.
706 AMBBICAN MKDICINa)
PUERPERAL ECLAMPSIA
[NOVEMBBR 1, 1902
3. Besides the two foregoing types of tills condition
tliere is one otiier wliicii assumes a general location and
distribution. The eruption is found both on the hands
and feet, in the axillas, on the neck, sometimes on the
face, over the abdomen and in the folds of the crural,
popliteal, and elbow spaces. The eruption may or may
not be grouped. For the most part it is made up of
single lesions, rather uniform in size, about that of a split
pea. It is globular, not very deepseated, breaks ea.sily if
neglected, readily pustulates, and spreads somewhat
rapidly when the weather is especially hot. In the folds
of the skin these lesions are much more numerous, par-
ticularly in the axilla.s. As with the other types there
is more burning than itching, developing as the lesions
mature. This eruption is of rapid development, some-
times reaching its height in two or three days after it
has commenced. This type affects children quite often,
while it is less frequent in adults than others.
The treatment in each of these has been much the
same, namely, strychnin internally, diuretics, and
astringent lotions locally. While the eruption is exten-
sive on the feet or on the hands, poultices or the free
•use of salicylic acid in alcohol have prefaced the astrin-
gent treatment. Where there is much swelling, soaking
in hot starch water or keeping the region covered with a
2 fo solution of ichthyol in water on saturated cloths has
been adopted.
The close kinship of these eruptions, their occur-
rence in the summer, the evident relation to the sweat
apparatus and their frequency in a subtropic climate
make the whole subject full of questions for discussion
and, so far as I am concerned, for enlightenment.
THE CAUSES, PKEVENTION, AND CURE OF PUER-
PERAL ECLAMPSIA.
ROBERT REYBURN, A.M., M.D.,
of Washington, D. C.
Dean and Professor of Hygiene and Preventive Medicine, Medical
Department, Howard University, Washington, D. C.
In the study of this subject we are confronted at once
with the curious and interesting fact that there is no
definite and invariable relation between the different
forms of nephritis in the parturient female and the
occurrence of puerperal eclampsia. In other words, a
considerable proportion of apparently healthy females
who, previous to their pregnancy never suffered from
albuminuria or other symptoms of diseased kidneys, are
liable to attacks of this disease. Primipara are also
more subject to eclampsia than multipara. The statistics
of the Pennsylvania Hospital from 1874 to 1889 include
2,665 deliveries, with 9 cases of eclampsia, all of which
were in primipara. Other statistics make eclampsia
occur from 3 to 7 times more frequently in primiparous
than in multiparous women. It is more frequent between
the ages of 20 and 30 ; and during childbirth if the
child's head is unusually large, or the pelvis of the
mother narrow, it is more likely to occur. Many
women after their recovery from puerperal eclampsia
continue apparently in good health for an indefinite
time. Of course the existence of albuminuria during
pregnancy, especially if it coexists along with tube-
casts, is always a dangerous symptom, and demands the
immediate watchful care of the physician.
These dangers to pregnant women are rendered still
more grave if they are accompanied bj' a deficient excre-
tion of urea. In fact we are inclined to attach much
more importance to the deficiency of urea (as a symptom)
than we are to the presence of albumin in the urine of a
pregnant woman. What then can be the reason why so
' many apparently healthy women suffer from puerperal
eclampsia ?
We do not mean to a.ssert that the eclampsia is
caused by the mere accumulation of urea ih the blood,
but the deficiency in the excretion of urea is to a certain
extent the measure of the accumulation of wa.ste nitrog-
enous materials. The poisoning or autotoxemia which
occurs from the retention of these waste materials in the
system is probably a complex phenomenon resulting,
from the deficient elimination of all the waste products
of the tissues.
The indisputable facts that puerperal eclampsia occurs
most frequently in primapara and in young women in
the prime of life would seem to indicate clearly that it
must be caused by a toxemia resulting from deficient
metabolism and the retention of effete and waste products
in the body. What is ihe cause of this toxemia? How
can it be remedied? We are strongly convinced that the
cause is a very simple and obvious one, and that this
disease is due to the nonassimilation of the large amount
of meat and other nitrogenous foods consumed by the
majority of pregnant women. After the initial stage of
suffering from nausea and vomiting has passed to which
many women are subject during the early months of
pregnancy, the appetite is apt to become abnormally
keen. Patients are encouraged to gratify this abnormal
appetite by their friends, and even if the appetite should
fail they are urged to eat largely, it being a popular super-
stition that it is necessary for them to do so in order to
nourish properly themselves and their unborn offspring.
Another most reprehensible practice is the prescribing
by physicians of alcoholic drinks of various kinds at
mealtimes for the purpose of stimulating the flagging
appetites of pregnant women. Harm is done by this
practice in two ways, first, by stimulating the appetites
of these patients, inducing them to partake of more food
than they require, and secondly, alcoholic drinks (beer,
wine, etc.) diminish the metabolism and encourage the
retention of effete matters in the body.
Two other factors entering into the causation of this
disease are the neglect to take sufficient exercise in the
open air, and neglect to keep the skin in healthy condi-
tion by frequent bathing and brisk friction.
If the foregoing views are correct, and the chief
causes of puerperal eclampsia are improper diet and
hygiene, the question arises. How can this disease be pre-
vented ?
It is my firm conviction (based on 46 years of con-
tinuous practice) that many of these ca-ses can be pre-
vented, and of course, preventive treatment is far more
important and more successful than the remedial.
The following case is an illustration of preventive
treatment :
Mrs. M. R., aged 22, is of healthy physique, aud had always
had excellent health. She engaged me December 10, 1901, to
attend her in her first confinement. She was at this time
eight months pregnant. She was to go to the Columbia Hos-
pital for Women, which she entered December 31, 1901. She
complained of severe and continuous headaches, with sparks of
fire loelore her eyes and some vertigo. Her urine was examined
and showed the presence of albumin and tube-casts and a great
deficiency in the amount of urea, it averaged only three to four
grains per fluidounce. She was immediately placed on a rigor-
ous diet, and not allowed to take more than one-third her usual
allowance of food. Meat and stimulants were absolutely inter-
dicted, and she was given thin soups and a small amount of
milk and farinaceous food. For medication she was given
broken doses of calomel, followed by mild saline cathartics so
as to secure two or three loose movements of the bowels per
day. She was also given a mixture of citrate of potash with a
small proportion of potassium bromid. Under this treatment
she gradually improved and the amount of urea excreted grad-
ually increased, though it never came up to the normal amount.
She was watched carefully, and greatly to my relief symptoms
of labor set in January 10, 1902. Her confinement and her con-
valescence were normal and uneventful.
The above preventive treatment, however, has a
much wider field in the earlier months of uterogestation.
The urine of every pregnant woman should be system-
atically examined at least once a month until the end of
term.
If albumin is found in the urine (especially if accom-
panied by deficient excretion of urea) it shows that the
NOVEMBEK 1, 1902J
SARCOMA OF NARES AND ETHMOID CELLS
[American Medictne 707
elimination of waste material is abnormally lessened;
purgatives and diuretics should be given. Hydrotherapy
with diminution of or total abstinence from nitrogenous
food and alcohol are also powerful adjuncts in the treat-
ment of these patients.
But there may not be any opportunity for preventive
treatment, for the patient may be already in a state of
coma or in the throes of puerperal convulsions when we
first see her. This is an emergency that will tax to the
utmost the skill and self-reliance of the most accom-
plished physician. What shall we do? Shall we pro-
ceed to empty the uterus, bleed, give inhalations of
chloroform, or use morphia? In regard to the first
treatment mentioned all authorities practically agree
that if the convulsions develop during the labor, at full
term, delivery should be accomplished either by version,
the application of the forceps, or other means, as rapidly
as possible. This rapid delivery of the child will very
often entirely arrest the convulsions, or if it does not do
•so entirely, will so mitigate them as to render the case
comparatively easy of treatment.
This is not invariably the ca.se, however, for one of
the severest cases of puerperal eclampsia ever met in my
experience was one in which the convulsions began after
the labor had terminated satisfactorily. The labor had
not been unusually severe for a primipara, but there was
a smaller flow of blood from the uterus during and after
the labor than is usual. The patient was a vigorous
healthy young woman, plethoric and with full tense
pulse. ' The convulsions continued for 24 hours subse-
quent to the termination of labor, in spite of the free use
of inhalations of chloroform, and the administration of
chloral and morphia combined with bromids. The
attending physician and myself becoming almost des-
perate, we finally determined to bleed her. By the dim
light of a candle we bled her from the arm to the amount
of 20 ounces, and there was almost instantaneous relief.
The convulsions stopped at once and she made an
uneventful recovery. We felt satisfied from the full and
hard character of her pulse that the convulsions were
continued by the blood-pressure upon the cerebral cen-
ters and the result seemed to confirm this view of the
case.
No one at the present day would wish to revive the
old Sangrado .system of indiscriminate bleeding for
every disease, but it is the firm conviction of many
physicians, of which I am one, that we have been too
hasty in abandoning the use of blood-letting. The field
of usefulness of bleeding, however, is very limited, and
it is only in such cases as the one just described that we
would recommend it.
When puerperal eclampsia comes on during the
earlier periods of pregnancy before the fetus becomes
viable shall we bring on premature labor? It is a
fearful responsibility for us, as physicians, to destroy a
living being, immature though it be, and it is one that
we should never assume except for the most cogent
rea-sons. In reflecting ujyon my past experience in this
class of cases, lam firmly convmced that the beneficial
effects of this proceeding are outweighed by its dangers
to the mother. I would, therefore, most earnestly
recommend that all other methods of treatment be tried
before resorting to the induction of premature labor.
If we assume, for the sake of argument, that puer-
peral eclampsia is a toxemia resulting froin self-poison-
ing by waste products retained in the organism, it would
seem self-evident that the elimination of these products
is the key to the pro[jer treatment. How shall this be
<lone? Obviously by vigorous action of the excretory
organs — the skin, bowels and kidneys. When a patient
is first attacked, a favorite treatment is to place 10 grains
of calomel on the l)ack of the t<^)ngue; this is followed
by enemas of magnesium sulfate, glycerin and water.
Free watery evacuations are usually produce<l in this
way, greatly to the relief of the patient. Coincident
with this a hypodermoclysis of salt solution should l)e
given. If the skin fails to act, the hot vapor bath is
excellent when it can be had. If this is not available
the patient should be surrounded with bottles of hot
water, or hot bricks. Shall we give the patient chloral
by enema, or inhalations of chloroform, or give tinc-
ture of veratrum viride, or use morphia hypodermically ?
In my opinion these four methods of treatment,
while they have their uses, are psdliative and not cura-
tive. I do not think I have ever seen a case cured by
any one of them. We have, however, seen many cases
in which the symptoms were greatly mitigat>ed by
them, and in which life was prolonged by their use.
We believe, therefore, that by the use of chloral, chloro-
form, tinct. veratrum viride and morphia, we simply
gain the time which is necessary to excrete the toxins
from the body.
The really curative method in this disease, therefore,
is to increase the eiiminative powers of the system so
that the body can excrete these morbid products. An
ancient orator was asked what were the three great requi-
sites for effective oratory. He answered : action, action,
action. We would paraphrase the above statement in
regard to oratory by saying that the three requisites for
the successful treatment of puerperal eclampsia are elim-
ination, elimination, elimination.
SARCOMA OF THE NARES AND ETHMOID GELLS.>
BY
JOSEPH S. GIBB, M.D.,
of Philadelphia.
Professor of Laryngology and Rhinology, Philadelphia Polyclinic, etc.
Malignant disease of the accessory sinuses is so rare
and so little is known of its course, progre&s and results
that the publication of individual cases is warranted.
The case reported has been referred to in a previous
paper but has never been published in detail. The his-
tory is as follows :
E. A., aged 38, married, first came to my notice five or six
years ago while a patient in the Episcopal Hospital. She was
referred to the nose and throat department because of difficultjr
in nasal respiration. Both nostrils were blocked with polypi,
the right naris to a greater extent than the left. These growtns
did not differ from ordinary mucous polypi in appearance nor in
microscopic examination, but each attempt at removal was
attended with violent and profuse bleeding. The nasal
chambers were finally cleared, though it was noticed that nasal
respiration was not materially improved. Careful search
failed to reveal the presence of polypi either anteriorly or pos-
teriorly. The nasal chambers, however, were very narrow, and
this was especially the case in the region of the middle turbinate
bodies.
Several months, perhaps a year, elapsed after the first
removal of the polypi before there was recurrence, but after
this, recurrence would take place in a few weeks after removal.
These growths were removed at intervals, usually of from four
to eight weeks. Each operation was attended by copious and
at times serious l)leeding, often requiring thorough packing
with gauze. The growths were examined microscopically and
each time the diagnosis was mucous polypi.
About two years ago it was noticed that the narrowing, pre-
viously observed in the region of the middle turbinate, had
increased, the cause seeming to be a solid mass of tissue of a
deep red color; the polypi sprang from around this mass.
Repeated attempts were made to remove portions of this
mass ror microscopic examination without success, for the
reason that the hemorrhage was so alarming it always seemed
exi)edient to desist. Again, the situation of the mass was such
as to render its removalvery difficult if not impossible. About
this time spontaneous attacks of epistaxis began to occur.
These were always of an alarming character, and made serious
inroads on the general health of the patient. She became
anemic and weak, and had fre<juent attacks of cardiac palpita-
tion and disturbances of the alimentary tract. The mass con-
tinued to increase in size and gradually the nasal bones began
to separate.
T>io growth was now diagnosed as within the ethmoid cells
and the intranasal mass was simply the bulging of the tissues
over these cells. Gradually both orbital cavities were
encroache<l upon, much more upon the right than the left side.
The inner bony wall of the orViit bet^aine more and more attenu-
< Read before the Bectlon on Utoloey and Laryngology of the College
of Physicians, Philadelphia, May 21, 1902.
708
AMKBioAN MEDICINE SARCOMA OF N ARES AND ETHMOID CELLS
[NOVEUBEB 1, 1903
ated, and finally the growth burst through into the orbital
cavity on the right side, displacing the eyeball and giving to
the face a hideous, repulsive expression which is well por-
trayed in the accompanying photograph.
The pathologic diagnosis of this case was mucous
polypi. It is believed, however, that the true, underly-
ing morbid condition was of a malignant nature, prob-
ably sarcoma, and that the site of this malignant growth
was the ethmoid cells. «
Polypi of a mucoid type were undoubtedly present
and it was this form of growth alone that was submitted
to the microscope for diagnosis, but it is believed these
simply represented a form of degeneration of some other
growth or possibly an inflammatory process in the eth-
moid cells occasioned by the original growth. It was
not possible during life to remove any of the diseased
tissue in the locality of the middle turbinate body and
postmortem examination was denied, so that the true
nature can never be known.
The reasons offered for the opinion that the growth
was of malignant nature are: 1. The unusual vascularity. —
We occasionally meet polypi of a vascular nature, but it
has never been my experience \a meet a case approach-
ing the one here recorded in vascularity nor have
I ever seen true polypi attended by spontaneous
copious bleedings. 2. Rapid recurrence and extension of
the groioth.—lt is noted the growth seemed to progress
within the confines of the ethmoid cells until it finally
burst through into the orbit encroaching upon this
cavity and displacing the eyeball. No such experience
is met so far as I have been able to ascertain in simple
mucous polypi. If we are correct in our diagnosis of this
case it is another evidence of the fallacy into which we
may be led by a too rigid adherence to the microscope
for diagnosis. The fault, however, does not lie with the
microscope but rather with the surgeon who is unable to
furnish specimens from the entire morbid field for
examination.
A word as to the treatment of malignant growths in
the accessory cavities. In the case narrated the treat-
ment consisted in removing the masses as they appeared,
thus relieving the urgency of the symptoms. It was
felt that this was mere palliation and likely contributed
to the extension of the growth, as every incomplete
surgical operation in malignant cases is prone to do.
Many times more radical measures were urged, but the
patient always declined. The plan was to dissect up the
external nose, break into the ethmoid cells and curet
away every portion of the ma.ss accessible. It would be
interesting to know the result of so radical a measure in
a patient already exhausted by repeated hemorrhages.
The growth was undoubtedly very extensive and there
is much room for doubt if such a procedure could have
been successfully carried out.
In a paper on malignant disea-ses of the nose and
accessory cavities, read at the annual meeting of the
New York State Medical Association, in October, 1901,
the case herein reported was referred to and in a table
was classified under sarcoma of the nares. In the prep-
aration of this paper occasion was given to make a more
or less complete search of the literature of this interesting
subject. The result was a tabulation of 111 cases of sar-
coma airising primarily in the nasal chambers and only
3 cases of sarcoma taking their origin from the accessory
sinuses. Statistics, however, are at fault as to the fre-
quency of malignancy in the accessory sinuses. It is far
more frequent than the reported cases would lead us
to believe. Nevertheless sarcoma of the ethmoid cells
is very rare. No reference could be found of a case similar
to the one reported. A number of cases are reported in
which extension from sarcoma of the nares has occurred.
After a careful study of the cases collected and from
personal observation of cases that have come to my
notice the conclusions arrived at as to the surgical treat-
ment of malignant diseases in this locality is that intra-
nasal measures by means of snare, forceps, and curet,
rarely effect much permanent good and run a serious
risk of stimulating the process to increased activity, for
the reason that such operations, save in the very early
stages when the growth is small, must necessarily be
incomplete because of our inability to estimate properly
by any means of examination the whole field covered by
the newgrowth. The only truly rational treatment con-
sists in an attempt at thorough removal.
Dr. Dawbarn, of New York, proposes as a means of
treatment in all forms of inoperable malignant growths
in the nose and accessory sinuses the ligation of both
external carotids. In a monograph which received a
prize from this college Dr. Dawbarn reports a number of
cases. I have not had access to this paper and therefore
am not familiar with his technic.
In a case of sarcoma of the maxillary sinus to which
I have referred in a recent discussion, ligation of one
external cfirotid artery, together with complete excision
of the upper jaw, was done and no recurrence has taken
place in three months' time though previously in the
same case a partial resection of the upper jaw and pre-
sumably entire removal of the sarcomatous mass was
attended by recurrence in 17 days from the date of opera-
tion. Should there be recurrence in this case, which is
by no means unlikely, the respite from suffering, the
cessation of a disgusting malodorous discharge seriously
affecting the patient's appetite and general health, and
the removal of the repulsiveness of his personal appear-
ance would fully Justify the radical procedure.
What is true of the maxillary applies with equal
force to the ethmoid sinus. Should such a case as the
one reported again come to my notice I should have no
hesitation in advising ligation of one external carotid,
and after awaiting a reasonable period for the establish-
ment of collateral circulation, the ligation of the other
carotid. This latter to be followed by thorough curet-
ment of the mass within the ethmoid cells. The liga-
tion of the carotids, besides cutting off nutrition from the
growth, would immeasurably simplify the subsequent
curetment by diminishing the amount of hemorrhage.
Diphtheria.— An epidemic of diphtheria at present raging
in Morgantown, W. Va., has attained such a serious aspect that
the public schools have been ordered closed and a rigid quaran-
tine established in the infected districts.
NOVEMBER 1, 1902] SUEGICAL WORK OF PROF. VON MOSETIG-MOORHOF iamerican medicikk 709
SPECIAL ARTICLES
I
SURGICAL WORK OF PROFESSOR VON MOSETIG-
MOORHOF IN THE VIENNA ALLGEMEINE
KRANKENHAUS.
BY
NICHOLAS SENN, M.D.,
of Chicago.
The best surKical work is not always done in surgical clinics.
The clinical teacher has to contend with many things that
divert his attention. He is naturally anxious to build up or
maintain the reputation of his clinic and must use his material
for the instruction of a critical audience. The surgeon who can
give his undivided attention to the work before him can attend
to many little details which often escape the notice of the lec-
turer, or which, for want of time, must be referred to an assist-
ant. The most careful and painstaking operator I saw during
my whole trip through three continents was Professor von
Mosetig-Moorhof, of Vienna. He is in charge of one of the five
surgical services of the Allgemeine Krankenhaus. In the two
divisions under von Eiselsberg and Gussenbauer the medical
students of the university receive their clinical instruction.
The other three services are under the care of Professor von
Mosetig-Moorhof, Professor Lang and Professor Hochenegg.
Professor Lang's material is made up largely of venereal cases.
The curative power of the Finsen light in the treatment of
tuberculous affections of the skin is being tested. Experience
so far has shown that the treatment requires much time, on an
average daily sittings for a year, but if carried out persistently
yields good results. Each sitting lasts an hour and costs the
hospital ?1.20. The apparatus in use furnishes light for four
patients at one time. The expert in charge marks the particular
spot which is to be subjected to the light treatment, and nurses
and i)atients make the application. Under pressure the tissues
to be acted upon by the light are made bloodless so long as the
treatment lasts, otherwise the action of the light is useless. In
most instances the application results in the formation of a
blister. Counter irritation and tissue stimulation are evidently
the most important curative effects of the application. In all
recent cases a decided reaction in the diseased tissues is always
very noticeable. As the disease yields, the tissues become paler
and shrink. When ulcerations are present, the defects heal
by the formation of a pale, pliable, smooth scar. Reports from
other clinics seem to show that relapses after apparent cures are
by no means uncommon. I saw several patients with extensive
lupus of the face who were being treated by exposures to the
Rontgen ray on one side and the Finsen light on the other. The
effects of the Rontgen ray are more pronounced, quicker, and
the course of treatment much shorter than that of the Finsen
light. Professor Lang is a well-recognized expert in plastic
work with Thiersch's skin grafts in covering large skin defects.
His cosmetic results are marvelous. Hochenegg lias recently
been promoted to a professorship and placed in charge of one of
the surgi<al divisions. He is a young surgeon of great promise,
whose name has already found a permanent place in surgical
literature. His work in abdominal and pelvic surgery is well
known and thoroughly appreciated. I now come to the "Vienna
surgeon whose work I studied with so much inter6,st and profit
— I'rofessor von Mosetig-Moorhof. His personal appearance is
very striking. He is 64 years of age, tall, erect, with a full
flowing, well-trimmed beard. His eyes are blue and reflect the
nobleness of his soul. In a crowd of people his appearance
would always attract attention. He has been a diligent student
since the time of his graduation in 1863 and is familiar with the
teachings and practice of all surgical authorities in the world.
He is a patient worker, who takes few and but short vacations.
His greatest pleasure in life is to be among his patients and to
relieve tliem of their sufferings by his operative skill. His
division of 128 beds is always crowded. He is more than sur-
geon to his appreciative patients; he is likewise their friend,
who takes more than a scientific interest in their welfare. He
visits his wards regularly every morning at 8.30 o'clock, exam-
ines all new cases with the utmost care, visits every patient
recently operated upon and then begins his operative work,
seldom leaving the hospital before the clock in the tower strikes
12. He is assisted in his work by a number of faithful Sisters
and three resident surgeons. His contributions to surgical
literature have been many and of far-reaching importance. His
work on operative surgery is very popular and will soon appear
in its fifth edition. It is a book that reflects the ripe experience
of its author and on every page will be found good, sound
advice. The most careful aseptic precautions are observed in
the well-equipped and well-lighted operating-room. The few
visitors who attend the operations are each required to wear a
linen coat. The white aseptic cap is worn by the operator and
assistants only during abdominal work. Gloves and masks are
not in use. Hand disinfection is made by thorough scrubbing
with soap and hot water, followed by marbledust soap, alcohol
and sublimate. The field of operation is shaved and disinfected
in a similar manner after the patient is fully under the influ-
ence of the anesthetic, either chloroform or the A. C. E. mix-
ture. The operator wears knit sleeves. Fine silk boiled in 6%
solution of carbolic acid and kept in sublimate alcohol is the
favorite material for sutures and ligatures. Before each abdom-
lodoform plomb, four weeks after resection of the wrist Joint.
inal operation the silk is reboiled. Stitch abscesses are
unknown, the best possible proof of the care taken in preparing
the silk.
Directions for Catgut Sterilization.— The following are the
directions given for the sterilization of catgut:
1. Immerse the raw material for 24 to 48 hours in sulfuric
ether.
2. Immerse for 8 tolO days in 969t alcohol and change the
fluid frequently so long as it becomes turbid.
3. Place catgut in a I'/'o alcoholic solution of mercury bichlo-
rid for three days.
4. Keep for one day in 96^0 of alcohol.
5. Preserve in
Blchlorld of mercury 1.0
Glycerin 60.0
Alcohol 1,000.0
Professor Mosetig-Moorhof is never in a hurry when oper-
ating. He makes his plans beforehand deliberately and
executes them with the hand of a master. Every motion he
makes with knife, needle or sponge is for a distinct purpose.
He does not know confusion nor surprise, and when something
unexpected arises he is prepared for the emergency. His
knowledge of minute anatomy makes the finest dissections a
source of delight to him. In doubtful cases he exhausts all
modern diagnostic resources before he makes a final diagnosis.
710 AHERioAif MEDICINE} SURGICAL WORK OF PROF. VON MOSETIG-MOORHOF
[November 1, 1902
and if this cannot be done lie relies on the knife to clear up the
doubt. His patients, young and old, come to the operating-
room without doubt and without fear, with implicit confidence
in the man who is to hold their lives in his hands. It is a source
of genuine pleasure to accompany this surgeon on his daily
visits through the wards. He is greeted everywhere by pleas-
ant, smiling faces. There are no Indications of mistrust or
dissatisfaction, and he has for all a pleasant word or a friendly
nod.
Mosetig-Moorhof's Iodoform Plomb. — For a number of
years von Mosetig-Moorhof has made use of a preparation of
Iodoform in filling bone cavities after operations for tubercu-
losis or osteomyelitis. This antibacillary agent is used in the
following form :
lodoformi 40.0
Cetacei
01. sesaml aaSO.O
The menstruum is thoroughly sterilized by boiling. The
iodoform finely pulverized and sterilized is slowly added to the
mixture and agitated constantly until it cools oft" to ensure a
uniform dissemination of the iodoform throughout the mass,
Iodoform plomb, Ave weeks after operation.
which solidifies at an ordinary temperature. After the cavity
is prepared the mixture is heated and in a fluid state is poured
into it, when it again becomes firm and fills the cavity like
dentist's amalgam in a carious tooth. The Rontgen rays
show the exact location, size and form of the iodoform plomb
in the interior of the bone. The x-ray also shows the process of
healing by the gradual disappearance of the iodoform through
absorption and substitution of granulations for the absorbable
temporary packing. Cavities in the epiphyseal extremities
after resection for tuberculosis, treated in this manner heal in
the course of a few weeks, and the use of the Rontgen ray at
any time will demonstrate their gradual diminution in size and
the slow absorption of the iodoform plomb. In extensive oper-
ations for necrosis large cavities are filled with this material
and, as is often the case, if the cavity is not entirely aseptic the
foreign material is gradually discharged in small fragments as
the cavity diminishes in size. The greatest benefit from this
method of packing a bone cavity, however, is derived in cases
of tuberculous foci in the articular ends of the long bones. I
have used for many years with signal success decalcified iodo-
formized bone chips in the same class of oases, but from what I
saw in the practice of von Mosetig-Moorhof I am inclined to
give his method a faithful trial.
Tegmin. — Tegmin is a white, aseptic, adhesive substance
which is used as a substitute for collodion in sealing small
wounds that do not require drainage. It has the great advan-
tage over collodion in being absolutely aseptic and can be
readily washed away with warm water.
Stricture of the Esophagus. — I was a.stonished to find so
many strictures of the esophagus in the AUgemeine Kranken-
haus. I saw one case in Gussenbauer's clinic, and another in
von Kiselsberg's, and three cases in von Mosetig-Moorhof's
wards. In all of them the stricture followed the accidental
drinking of lye, and in all it became necessary to perform
gastrostomy to prevent death from starvation and to prepare
the way for successful treatment by gradual dilation. In the
last three cases mentioned the gastric fistula had closed or was
closed by operation, and the treatment by gradual dilation was
progressing satisfactorily. In one case the stricture, a very
obstinate one, was finally passed by a socalled gravitation
sound. A hollow, tapering, soft rubber esophageal tube was
filled with fine shot. It was inserted as far as the stricture, and
by its own weight
suddenly forced its
way through, an oc-
currence which was
immediately recog-
nized and announced
by the happy pa-
tient. Since then
gradual dilation
could be made with-
o u t encountering
any particular diffi-
culty. The experi-
ence here, like else-
where, has been to
the effect that the
strictures could be
passed after gastros-
tomy was performed
although they ap-
peared to be abso-
lutely impermeable
before operation. I
will make brief men-
tion of a few opera-
tions performed by
Professor Mosetig-
Moorhof during my
visits.
Resection of
Joints for Tubercu-
losis.— The number
of cases of tuberculosis of joints under the care of this surgeon is
unusually large. The brilliant results obtained by his thorough
methods are undoubtedly responsible for this. About 10 cases
of resection of the knee and elbow-joint were shown, the
patients having been operated upon from a few days to two
months ago. In all, the wound healed by primary intention
and the limbs were in a useful position. In elbow-joint resec-
tions the olecranon process is temporarily detached, and after the
resection is completed is united with the shaft of the ulna with
aluminum-bronze wire sutures. Several patients who had
this joint resected for extensivS tuberculous disease were shown
who had recovered with useful movable joints. The exter-
nal incision is made transversely over the base of the olecranon
process. In resection of the knee-joint, Langenbeck's trans-
verse incision is the one usually chosen in exposing the interior
of the joint. The epiphyseal cartilages are always saved and
the tuberculous foci in the articular ends are scraped out from
the sawed surface with a sharp spoon, and after thorough
cleansing are packed with the iodoform plomb. The greatest
stress is laid on complete extirpation of the tuberculous
synovial membrane, capsule, and thorough excision of para-
articular abscesses and fistulous tracts when they exist. In one
Iodoform plomb in the lower end of the radius,
eight weeks after operation for osteomyelitis.
I
NOVEMBEK 1, 1902]
SURGICAL WORK OF PROF. VON" MOSETIG MOORHOF [American medicine 711
case of tuberculosis of the knee-joint with moderate swelling,
but marked genu valgum, a tuberculous focus was found in
the internal condyle of the femur and one in each tuberosity
of the tibia. In excising the capsule the incisions were carried
deep enough to expose healthy muscles, tendons and fascia.
Particular care was taken in cleaning out the capsule over the
popliteal space. In this instance the patella was found exten-
sively diseased and was excised. The lower angle of the wound
on each side was drained by inserting a folded piece of gutta-
percha tissue, a favorite method of drainage with Mosetig-
Moorhof. The soft tissues around the resected bone ends, as
well as the external wound, were sutured with fine silk. Over
the dry, sterile hygroscopic dressing thin strips of beechwood,
socalled shoemaker's chips, were applied and held in place
with a moist organtine bandage. He never uses plaster-of-
paris in immobilizing a limb after resection. The first dressing
remains for two to three weeks. When the dressing is changed
the little drains and sutures are removed. The line of suturing
is kept moist, and the removal of the dressing and sutures
made easy by placing over the first part of the dressing, a few
layers of iodoform gauze, an impermeable cover of mackintosh
or guttapercha. This cover prevents evaporation and inspissa-
tion of the primary wound secretion in that part of the dressing.
The limb is immobilized in the same manner after the second
dressing, which then remains until, in cases of resection of the
knee-joint, firm, bony consolidation has taken place ; that is,
about three months. In an aggravated case of tuberculosis at the
base of the thumb in an adult the diseased joint surfaces were
exposed by a curved incision with the convexity directed
toward the radial side. The tendons and radial artery were
carefully held out of the way while the articular end of the
proximal phalanx of the thumb and the articular end of the
metacarpal bone of the index finger were resected and the
multangulum majus was extirpated. The fistulous tracts com-
municating with the primary seat of the disease were thoroughly
excised and the wound sutured, drained and dressed in the
manner described. The thoroughness with which all diseased
tissue is removed in all of Mosetig-Moorhofs operations for
tuberculosis, and the prolonged iodoformization of the original
foci of infection, account satisfactorily for his matchless results.
Amputations.— Two amputations I witnessed in this great
clinical school for postgraduate instruction demonstrated the
technical skill of the operator in this kind of surgical work.
The first patient was a man, aged 72, the subject of extensive
atheromatous arterial degeneration. Two toes adjacent to the
big toe were gangrenous. For good reasons it was deemed
necessary to make a high amputation. The Gritti supracondy-
loid amputation was made. The vivified surface of the pat-
ella was brought in accurate contact with the sawed surface of
the femur and fixed in position with buried sutures which
included the tendon of the patella and the periosteum and
paraperiosteal tissues of the posterior margin of the end of
the bone. Tlie long oval anterior flap was sutured in place
with silk, leaving the angles of the wound open for the small
guttapercha drains. After dressing the stump it was immo-
bilized with splints of wood shavings. The next day this
patient's condition was much improved and he stated that
lie had been relieved of all pain since tlio operation was per-
formed. Every step of the operation had been performed with
a manual dexterity that charmed the few visitors and yet
without any attempt whatever at display.
In the next case a Ohopart amputation was made for exten-
sive tuberculosis of tlie mediometatar.sal joint of the foot.
The plantar flap extended as far as the base of the toes and
when sutured in pla(« covered the amputation wound in an
ideal manner. With deep silk stitche-s tne extensor and rtexor
tendons were brouglit together in closing the external wound.
The heel was well supported with thin wooden splints applied
over the absorbent dressing and held In place with a moist
organtine bandage.
liadical Operation for //o-nm.— Professor von Mosetig-
Moorhof is partial to Bassini's method in operations for the
radical cure of inguinal hernia. The inguinal canal is closed
underneath the spermatic cord and its accompanying vessels
with not more than four aluminum-bronze wire sutures. This
material has given great satisfaction in performing this opera-
tion. The sutures can be tied with the same ease as silk
sutures and remain in the tissues indefinitely without giving
rise to irritation. His patients are confined to bed for three
weeks, when they are discharged without any mechanic
support. The remote results have been very satisfactory.
This operation was performed on a woman suffering from a
direct inguinal hernia. After resection of the hernial sac the
inguinal canal was closed with four aluminum-bronze wire
sutures and the skin incision with fine silk.
Gastroenterostmnp.— The patient, an aged emaciated woman,
had been suffering from pyloric obstruction for more than a
year. Physical examination revealed the presence of marked
dilation of the stomach. The incision was made through the
right rectus muscle. The disease was confined to the pylorus,
and although a number of lymphatic glands were found impli-
cated, it was deemed a proper case for a radical operation, which
would have been performed if it had not been for the critical
general condition of the patient. An anterior gastroenterostomy
was made. The position of the intestinal loop which corre-
sponded to the junction of the duodenum with the jejunum was
reversed and the mesentery of the small intestine was tunneled
with hemostatic forceps at two points about four inches apart.
Through each slit a heavy silk suture was drawn and tied so
as to exclude intestinal contents from the isolated portion
during the operation. After suturing the intestinal loop to
the stomach, the peritoneum, the length of the purposed
anastomosis over the bowel and stomach was incised and with
a continuous fine silk suture the parts were united. The
mucous membrane was next incised on both sides and
united with the same kind of a suture. The anterior
margins of the visceral wounds were united in a similar
manner. The whole operation was completed in 45 minutes.
At no time did the patient manifest the least sign of shock. In
this instance the operation was performed under general anes-
thesia, at the special request of the patient, although the routine
practice is to operate under local anesthesia. For the purpose
of preventing flexion of the bowel at the anastomotic opening
the proximal part of the loop was sewed to the anterior surface
of the stomach to a distance of at least three inches from the
anastomotic opening.
Fluid food is administered by the stomach a few hours after
operation, solid food is withheld for four or five days.
Acute Osteomyelitis. — Several cases of acute osteomyelitis
were operated upon.
In one case a girl, aged 5, had been ill only 11 days, and was
admitted into the hospital with all the signs and symptoms of
extensive involvement of the entire sliaft of the tibia. The leg
was enormously swollen, edematous and diffuse fluctuation
indicated the existence of a large phlegmonous abscess. Free
incisions were made and the greater part of the tibia was found
denuded of its periosteum. The immense abscess cavity was
washed out with a formalin solution, 5: 1,000, which is used in
preference to any other antiseptic solution in dealing with acute
suppurative affections. The cavity was packed loosely with
gauze and a dry absorbent aseptic dressing was applied.
Lapnrotomj/ for Volvulus of the Sigmoid Flexure. — The
gatient, a woman aged 30, the subject of a small umbilical
ernia, was suddenly taken ill two days ago. She complained
of pain in the umbilical region. Abdomen was tympanitic. The
sac of the umbilical liernia was empty. There was no vomiting
but complete obstipation. Diagnosis of intestinal obstruction
from some mechanical cause was made, l)ut it was impossible
to predict the location and nature of the obstruction. Abdomi-
nal incision was made through the left rectus muscles. Small
intestines were distended and very vascular. The incision was
enlarged and rapid eventration made. The prolapsed intesti-
nal loops were carefully protected by enveloping them in
warm, moist compresses. The large intestine presented the
same appearance. A volvulus of the sigmoid flexure was dis-
covered as the cause of the obstruction. The malposition was
quickly corrected, the intestines reduced and the large abdomi-
nal incision closed with three rows of fine silk sutures. The
next day this patient was found in excellent condition. An
early operation had been the means of preventing textural
changes in the twist of the sigmoid flexure which when once
developed render further operative interference almost hope-
less.
Vienna, July 20.
Mortality and In.luries fk-om Railroad Accidents.— A
bulletin recently issued by the Interstate Commerce Commis-
sion shows that during April, May and .lune la.st there were 140
persons killed in train accidents and 1,810 injured. Accidents
of other kinds, including those sustained by employes while at
work and by passengers getting on and off cars, etc., swell the
aggregate to (ilG killed and !),520 injured, or a total of 10,136
casualties. The total casualties during the fiscal year ended
June 30 last, including the al)ove figures, were 2,819 killed and
39,800 injured. An interesting comparison may be made between
the mortality resulting from accidents on American railways
and that occurring in the British Army during the South Afri-
can war. For the three years ended .June 30, 1900, there were
21,847 por.sons killed on Ameri(!an railways, while during the
Soutli African war, whicli it will bo romombered lasted nearly
three years, the mortality of the British forces, including deaths
from disease, was 22,000. It is also worthy of mention that dur-
ing 1901 not a single passenger was killed on British railways,
while there were 158 killed on the railways of the United States.
712 Amebican Mbdicine]
THE WORLD'S LATEST LITEKATUEE
[NOVEMBKB 1, 1902
THE WORLD'S LATEST LITERATURE
Jonmal of the American Medical Association.
October !S5, 1902. [Vol. xxxix, No. 17.]
1. Under What Circumstances is it Advisable to Remove tlie Vermi-
form Appendix when the Abdomen is Opened for Other Reasons?
HOWAKD A. Keli.v.
2. Drainage of Extravesical and Extraperitoneal Suppurations of the
Male Pelvis. Eugene Fuller.
8. External Urethrotomy from the Standpoint of the General Surgeon.
John C. Munro.
4. Traumatic Rupture of the Abdominal Viscera Without External
Signs of Injury. Daniel N Eisendrath.
5. Principles Controlling Operative Interference in Heterophoria. E. J.
Gardiner.
6. The Principles Controlling the Non-operative Interference In Hetero-
phoria. S. C. Aybes.
7. Appendicitis from a Physician's Standpoint. J AM ts Tyson.
8. The Surgical Relations of Traumatism of the Peripheral Nerves.
Harold N. Mover.
9. The Occurrence of Gout in the United States : With an Analysis of
36 Cases. Thomas B Kutcheb.
10. Trichophytosis. J. B. Kessler.
1.— Removal of the Appendix Daring Other Abdominal
Operations. — In a series of 115 cases in which the condition of
tlie appendix was noted, it was found adherent to the riglit tube
or ovary in 10, involved in adhesions in .'!7, congested in 3 and
obliterated at the cecal end in 1 case. In 200 abdominal sec-
tions, Kelly has had to remove it 25 times. In order to get the
views of prominent surgeons he sent the following questions :
When the abdomen is opened for other causes and the perfectly
normal appendix is easily accessible, is it your rule to remove
it? When the appendix is slightly adherent to neighboring
structures, as peritoneum, ovarian or fibroid tumors, do you
then remove it? He tabulates tlie replies of 74 operators,
giving their names. These show 44 to 26 against the removal of
the normal appendix, and 60 to 7 in favor of removal on the
slightest deviation from normal. Fecal concretions in a normal-
looking appendix is sufficiBnt reason for removal. After
removal of the right ovary, the stump should be covered with
peritoneum in order to prevent adhesions to the appendix, and
the latter, if long and free, should always be removed. The
appendix should be examined whenever the abdomen is
opened, provided no additional risk is involved. The risk and
the possibility that it may not be a funetionless organ contra-
indicate removal when it is normal, [h.m.]
2, 3. — See American Medicine, Vol. Ill, No. 25, p. 1041.
4. — See American Medicine, Vol. Ill, No. 25, p. 1042.
5, 6. — See American Medicine, Vol. Ill, No. 25, p. 1053.
7, 9. — See American Medicine, Vol. Ill, No. 25, p. 1036.
8.— Surgical Relations of Traumatism of the Per-
ipheral Nerves. — A traumatism of the nerve is frequently
overlooked, giving rise to faulty prognosis and sometimes
suits for malpractice. Simple contusion may have the same
effect as severing the continuity. If function is not shortly
restored there may be degenera;ion or inflammation resulting
in pressure paralysis. Immediately after injury the nerve
may seem unimpaired, there may be no loss of motility, but it
is always possible to determine the sensation of the skin, using,
preferably, a camel's hair brush. Lessened acuteness should
make the prognosis guarded. In fractures of the humerus
and in dislocations, especially of the shoulder, nerve injuries
are frequent, and it is well to delay favorable prognosis.
Injuries to the circumflex are frequent, often overlooked and
have serious consequences. A nerve regenerates about 1 mm.
daily. In order to assist the muscle to respond to feeble nerve
impulses, electricity and massage are valuable, [h.m.]
lO. — Trichophytosis. — The most frequent source of con-
tagion is from yearling calves. As they recover without treat-
ment, no attention is paid to the disease. In scratching them-
selves against various parts of the stall the disease is
transmitted to other animals. It is more virulent when con-
tracted from animals than from human beings. Every man
should have his own outfit at the barber'.s, for tlie disease is
brought here by farmers and stock raisers, [h.m.]
Boston Medical and Snrgical Journal.
October SS, 190i. [Vol. OXLVII, No. 17.]
1. The Teaching of Surgery. Herbkbt L. Boeeell.
2. Deciduoma Mallgnum ; Report of a Case. J. O. Hijbbard.
1. — See American Medicine, Vol. Ill, No. 24, p. 994.
2.— Deciduoma Malignum.— Hubbard gives the salient
points in the history of a case of deciduoma malignum occur-
ring in a woman of .34, tlie mother of five children. Her
mother had a malignant growth, her mother's sister a cancer of
the breast, and another sister uterine polyps. Her youngest
child was 2 years of age, and it was during this jiregnancy that
the symptom of hemorrhage was apparently first noted. Other
treatment failing to give any permanent relief, and the woman
gradually failing in strength, hysterectomy was finally per-
formed and the character of the growth determined by micro-
scopic examination. Six months after the operation she had
recovered her health and strength. The diagnosis of this dis-
ease is made from the excessive hemorrhages following soon
after some form of conception, and not yielding to the treatr
ment appropriate for retained portions of the pregnancy,
endometritis, metritis, or subinvolution ; the marked cachexia;
a uterus enlarged and boggy, containing a frialjle, soft, easily-
bleeding tumor; and from the microscopic examination of a
bit of the tissue. Its malignancy shows itself by its rapid
development, and the early formation of metastases soon fol-
lowed by death in the unoperated ca.ses. The treatment is most
necessarily radical ; and anything short of that, after the diag-
nosis is once made, is not justifiable. [w.K.]
Medical Record.
October S5, 190?. [Vol. 62, No. 17.]
1. The Urine from Each Kidney. Eebd. C. Valentine.
2. The Most Frequent Form of Vaginal Hernia; Its Etiology and
Treatment. Samuel Wyllis Bandleb.
3. On the Eradication of Yellow Fever in Havana. Edmond Souchon.
4. Some Early stages of the Disease of Inebriety. T. D. Crothees.
5. The X-ray. Milton Franklin.
6. Infectious Bronchopneumonia : a Report of Six Recent Cases. D.
W. Wynkoop.
1. — The Urine from Each Kidney. — Valentine objects to
the urine segregator of both Harris and Downes, because the
utility is practically limited to the female. Kelley's and Paw-
lik's methods appear easier and more effective for the purpose.
Preferable to any of the foregoing, however, is the method of
Cathelin, of Paris. Cathelin's divisor is based upon pushing
into the bladder a soft rubber membrane, whieli adapts itself
to the walls, and which is grasped by the bla Ider, thus dividing
the viscus into two halves. The instrument consists of a
cylindric tube (caliber 25 F.) shaped at one end like a short-
beaked catheter. Its distal extremity has a central orifice and
two lateral catheter-carriers, each of the three closing with a
screw-nut with washers, to prevent the escape of urine other-
wise than through the catheters when the instrument is in use.
The central orifice allows the easy propulsion of a shaft whose
handle is graduated to the varying vesical capacities from 10
grams to 300 grams. The two lateral catheter-carriers transmit
each a catheter. The other essential part of the instrument is a
very soft rubber membrane, set within a delicate steel spring.
The intravesical end of the divisor is guttered so that when the
membrane is projected within the bladder it maintains a verti-
cal position. It thus centrally divides the bladder and the end
of the posterior urethra into two parts. This fact enabled the
author to obtain the urine from each kidney separately even in
a case of cystocele. [a. B.C.]
2. — Vaginal Hernia. — Bandler, after a study of the rela-
tions of the vagina to adjacent structures, says it appears that
the vaginia, except at its outer end, is simply surrounded
by connective tissue. The only thing which prevents the
vagina from being pushed down by abdominal pressure
is the action of the levator ani muscle and the character of
its connection with the surrounding connective tissues.
Atrophy or degeneration of these tissues causes the mucous
membrane of the vagina to lie in folds, as is so frequently the
case at climacterium. After pregnancy there is a disturbance
in the anatomic condition of the various structures of the
pelvis. The levator ani and constrictor cunni are decidedly
stretched and often torn, and as a result, the narrow vagina is
widened and becomes a wide canal. There is a flabbiness and
edema of the connective tissues and ligaments which permits
the filled bladder, loosened from its fastenings, to descend and
produce a dilation of the weakened anterior vaginal wall and
thus gives rise to the various forms of vaginal hernia : prolapsus
NOVKMBBB ], 1902]
THE WORLD'S LATEST LITEEATURE
(Akebioan Mkdicink 713
vaginse anterioris or cystocele ; enterocele vaginae anteriorls ;
enterocele vaginae posterioris ; and rectocele. He recommends
two methods of treatment : First, the one used so successfully
by Thellhaber in 24 cases, anterior colporrhapy, making the
excision extend far, laterally into healthy tissue, resecting the
anterior up to the lateral wall so that the upper ends of the
levator ani muscle are brought closely together, and narrowing
the vagina. Second, vaginofixation as taught by Duhrssen.
When this is done mainly for the correction of a cystocele, the
fundus of the uterus is attached to a lower portion of the
anterior vaginal wall, and forms an artificial base on which the
bladder rests, and entirely separates the bladder from the
anterior vaginal wall. This operation, when correctly done,
avoids the possibility of future annoyance. [w.K.]
3.— Eradication of Yellow Fever. — While Souchon ad-
mits that the destruction of the mosquito may have prevented
the spread of yellow fever in Havana, he believes the real
cause of the present exemption is due to efficient quarantine.
This is corroborated by the absence of tlie fever at other ports
where no serious crusade against the mosquito was under-
taken. Fever in a locality exhausts itself in two to four years,
provided fresh eases, especially virulent ones, are not brought
in from outside. This is illustrated in the history of epidemics
in New Orleans. It would not be safe to do away with quaran-
tine restrictions and rely solely on the destruction of mosquitos
to prevent the port from becoming infected, [h.m.]
4.— Early Stages of Inebriety.— Inebriety is a well-
marked disease. The incipient stage before spirits are used is
marked by dietetic delusions and other symptoms of nerve and
brain irritability, all of which seem to depend on heredity or
some obscure injury to the nerve and brain centers. Recogni-
tion and study of this stage opens up a field of prevention and
cure. Crothers records illustrative cases, [h.m.]
6. — The X-ray. — Franklin gives a technical description of
the Geissler tube and Crookes' modification of the same, and
describes the phenomena observed in the tube when the
machine is in operation. He says the measure of a tube is
determined by its resistance as compared with air. There are
some important differences in the tubes now used as compared
with the original Crookes' tubes. The positive electrodes are
now made of platinum, sometimes combined with iridium, and
the cathode is arranged to propagate the rays at an angle to the
anode or other target. Some tubes have two cathodes, with a
view toward increasing the concentration of the rays in a given
direction. Tubes are called high or low, according as they
offer more or less resistance to the passage of the current ; this
is determined by the degree of exhaustion beyond the exhaus-
tion of least resistance. It has been found that the high tube
has the greater penetration, i. e., that it will penetrate sub-
stances of varying resistances with more uniformity, and there-
fore tends to level their densities. On the other hand, the low
tube has the opposite effect and tends to exaggerate the differ-
ence in intensity in the various substances traversed. Low
tubes produce more burn than high tubes. The degree of
attenuation of the medium within the tube determines the
resistance, which might be so great as to render the tube
impenetrable, [a. B.C.]
6.— Infectious Bronchopneumonia.— Wynkoop reports
a number of cases from a study of which he infers that a cer-
tain type of bronchopneumonia is highly infectious in young
children. The period of incubation is about 12 days. In these
<:ases there wa.s absence of coryza at the onset, and only in
adults was there severe pain in the back. The disease gener-
ally began in the larynx, resisting inhalations and quinin. It
is systemic. The prognosis is good with proper treatment. In
children afternoon temperature may continue for six weeks
after the lungs have cleared up. This does not affect the gen-
eral health as they pick up weight. There is no mental depres-
sion and one would not know they were ill unless he happened
to take the temperatures at the right time. The disease is prob-
ably often contracted at health resorts from convalescents, [h.m.]
New Tork Medical Journal.
October 18, 190t. [Vol. lxivi, No. 16.]
1. Shoe Deformities. E. H. Brai>fori>.
2. The Treatment of Prolapse of the Hectum. Josbpr M. Mathbwh.
3. The Evolution of Urology: an Opening Address Delivered at the
Annual Meeting of the American Urologlcal Association, neia ai
Saratoga, N. Y., June 13, 1»02. Ramon Guitekas.
4. Th<? Clinical Value and Treatment of Atonic Dilation of the btomacu.
5. Obse'rvatimis on Muscular Relaxation in Its ttelatlon to Women's
Diseases. D. Ernest Walker.
0. Studies la Stetbophonometry. Albert Abrams.
7. A Case of Acute Diabetes In a Child Three Years of Age. Frank B.
Swartzlandeb.
1.— Shoe Deformities.— Bradford discusses the deformities
of the human foot caused by footwear, such as an impairment
in the motion of the metatarsophalangeal joints ; loss or im-
pairment of motion in the first metatarsocuneiform articula-
tion, weakness of the muscles of the sole of the foot, mis-
placed position of the heads of the metatarsals, distorted posi-
tion of the toes, etc., and gives cuts illustrative. For active
exercise the front of the foot should not be compressed. Boots
and shoes should be straight on the inner edge, should be suffi-
ciently long, should not rock up at the top and should give
sufficient play to the toes. Boots should not bind the lower
instep, but should allow a certain amount of spread to the front
of the foot, as the weight falls upon it. [c.a.c]
3.— The treatment of prolapse of the rectum as found
in the adult is discussed by Mathews. The rectum is irrigated
with a hot solution of boric acid several times before the opera-
tion. After the patient is anesthetized the rectum is drawn out
to the full extent of the prolapse. It is then held firmly by
forceps, and an incision is made at the anal portion of the pro-
lapse, completely around the gut. A careful dissection is now
made of the raucous membrane and submucous tissue, extend-
ing to the terminal end of the prolapse, when with a stout pair
of scissors it is cut off, removing a cuff. The two edges are
then pulled together and sutured with catgut, [c.a.c]
3.— The Evolution of Urology.— Guiteras reviews the his-
tory of urology from its first steps to tlie more recent advances
that have served to develop this important branch of medicine
and surgery and to bring it to its present stage of evolution.
The earliest writing on the subject is the papyrus Ebers,
attributed to 1553-1550 B. C. This contains nothing of urinary
surgery, but gives a number of prescriptions for the treatment
of various disturbances of the urinary function. In the "Ayur-
veda," the ancient medical treatise of the Hindus, urologic sub-
jects, both medical and surgical, are given considerable atten-
tion. The writings of Hippocrates show numerous allusions to
urologic subjects, while the medical history of the Middle Ages
does not present any brilliant advances in the field of urology.
The factors in the evolution of modern urology have been
numerous and intimately correlated with the advance of pathol-
ogy and surgery in other fields. The chief of these factors were :
(1) the discovery of anesthesia; (2) the discovery of pathogenic
germs; (3) The perfection of urinary analysis; (4) the possi-
bility of illuminating the urethra and bladder; (5) the perfec-
tion of ureteral catheterism ; (6) the introduction of the Rontgen
rays; (7) asepsis and antisepsis; (8) advanced therapeutics and
improved operative technic. These factors are taken up seri-
atim and discussed, [c.a.c]
4.— Dilation of the Stomach.— Atonic dilation is usually
met as a sign or symptom of nervous exhaustion or nervous
dyspepsia, It may be or may not be attended with serious
disturbance of the gastric secretion, for in many cases prac-
tically normal secretion Is found, and in such cases the main
distress seems caused by the slow or imperfect emptying of the
viscus, with the nervous disturbances due to the general sag-
ging of internal organs. It is more frequent in women than
men and is often associated with prolapse of the uterus and
movable kidney. Loveland is of the opinion that excessive
mental o<;cupation including mental anxiety and worry, with
deficient physical exercise and the wearing of garments which
do not allow free play of the trunk muscles, are in a majority
of cases the fundamental errors which underlie the condition.
Rapid and injudicious eating and engorging the stomach and
imperfect recovery of tone after confinement are mentioned as
among the causes. The patient's habits of dress should bo cor-
rected and outdoor exercise insisted upon. Cold morning
sponge baths, and faradaic electricity over the stomach and
abdomen when the symptoms are principally local are valuable.
The diet includeBthe free use of water and milk at frequent
714 A.UEBIOAN Medicine]
THE WORLD'S LATEST LITERATUBB
[November 1, 1902
Intervals. The medicines useful are nux vomica or strychnin,
to which may be added rhubarb if there is a tendency to con-
stipation ; B naphtol and bismuth subgallate, if gas or intes-
tinal fermentation is a prominent symptom ; and, in lithemic
subjects, sodium salicylate given in a copious draught of water
between meals will often be of advantage, [c.a.o.]
5. — Observations in Muscular Relaxation. — Walker
believes that muscular relaxation enters largely as a causative
factor into those noninflammatory pelvic troubles of women
falling under the head of the granular erosions, congestions,
prolapses, menorrhagias, metrorrhagias, dysmenorrhea, and
also of subacute endometritis. He says that mechanical
uterine supports should be used as crutches — merely as tempo-
rary expedients to bolster up weakened tissues until they can
gain some strength. Active and passive exercise is of value in
prevention as well as cure, and the main object of treatment
should be rather to strengthen than to support, [c.a.o.]
7. — Acute Diabetes in a Child. — Swartzlander reports
such a case in a child aged 38 months. The negative family
history, the good health of the child previous to the last month
of its life, the apparent absence of cause, and the rapid course
of the disease, make this case one that is rather out of the ordi-
nary. Examination of the urine was as follows: Specific
gravity, 1,048. Reaction, acid ; color white, slightly opaque.
Albumin, negative. Sugar, 3.2%. Diacetic acid, a considerable
quantity. The urine voided in 24 hours amounted to 3 liters,
400 cc. (O7). The child died in coma, [c.a.o.]
Medical News.
October 25, 190$. [Vol. 81, No. 17.]
1. Note on the Newly Recognized Sugar-controlling Function of the
Suprarenal Glands. C. A. Herter.
2. Remarks on Intrathoracic Pressure, with the Illustration of the
Author's Method of Lung Immobilization. Charles Denison.
3. Strictures of the Male Urethra. Robert H. Greene.
4. Comparative Toxicity of Ammonium Compounds : a Study in Auto-
intoxication. B. K. Rachfobd and W. H. Crane.
5. Acute and Chronic Tuberculous Phthisis, with Cases. J.Cardeen
Cooper.
1. — The Sugar-controlling Function of the Suprarenal
Glands. — If large applications of adrenalin to the pancreas
cause temporary glycosuria slighter amounts may serve as a
continuous stimulus to the production of the sugar required
by cell metabolism, and one may assume the constant secretion
of this substance. Herter has tested this hypothesis experi-
mentally. Massage of one or both suprarenal glands was
followed in the case of three dogs by glycosuria, the sugar dis-
appearing from the urine within 24 hours afterward. Pressure
probably squeezes into the circulation an excess of the blood-
pressure-raising constituent, and this is probably responsible
for the glycosuria. Removal of the glands or ligature of their
vessels is followed by rapid decline in blood sugar. The secre-
tion is capable of stimulating the pancreas in svich a way as to
call forth an increased conversion of hepatic glycogen into
sugar, though the organism does not lose wholly its ability to
make sugar with removal of these glands. The early death
that follows extirpation may be due either to deprivation of
sugar or blood-pressure-raising stimulus. After extirpation of
both pancreas and suprarenals the urine invariably contained
a small quantity of a reducing substance (dextrose-glycuronic
acid?), but this instead of increasing after operation rapidly
lessened and left the urine entirely free from any reducing sub-
stance. The author suggests that codein diminishes sugar by
entering into chemical union with adrenalin, [h.m.]
2. — Intrathoracic Pressure and Lung Immobilization.
— Nature's method of cure in chronic pulmonary disease
involves not only the contraction and scarring over of diseased
areas, but compensatory distention of less affected portions.
Improvement bears a close relation to ability to breathe
properly. The chief consideration is for unilateral application
of immobilization so the other lung can do the supplementary
work. Opposition to the method of exhalation against pres-
sure is as groundless as opposition to altitude and exercise.
Denison describes and illustrates his method of strapping the
chest by which practically complete rest for the diseased lung
can be obtained, [h.m.]
3.— Strictures of the Male Urethra. — Green says we have
in the formation of true stricture two antecedent conditions :
(1) An acute exudative inflammation with infiltration; (2) the
formation of granuloma, at the base of which, in time, connec-
tive tissue forms, making true stricture. As the acute urethritis
subsides it leaves the urethra full of small excoriations, the
surface of which becoming granular gives rise to bunches
which can be recognized in the urethra. These have often been
incised under the name of soft stricture. It was their dis-
appearance without dilation which first caused the author to
study the pathology of the stricture. Nature herself, or any
treatment internal or local which assists her efforts by stimu-
lating circulation, tends to cause them to disappear. If they
continue long enough cicatricial tissue forms at their base and
true stricture results, but this is ordinarily a slow process, tak-
ing perhaps years for its accomplishment. His conclusions are
as follows : Careful treatment of chronic urethritis will prevent
the formation of stricture. True stricture is of slow growth and
can generally be best treated by a prolonged passage of sounds
and the proper treatment of any complication co-existent with
it. Cutting operations are almost never required in strictures
which have not been previously incised. Strictures once
incised, unless kept open, are liable to require further incision.
An incision being necessary, it is better to do an external
urethrotomy combined with an internal urethrotomy if
required, [a.b.o.1
4. — See American Medicine, Vol. Ill, No. 19, p. 763.
Philadelphia Medical Journal.
October S5, 1902. [Vol. X, No. 17.]
1. A Further Report Upon the Treatment of Tic Douloureux by Divis-
ion of the Sensory Root of the Gasserlan Ganglion. CHA8. H.
Frazier and Wm. G. Spillbr.
2. The Prevalence of Herpes Zoster. Max Joseph.
3. A Case E,xhibiting the Symptoms of Both Tabes and Multiple
Sclerosis. Wharton Sinklek.
4. The Value of Diphtheria Antitoxin. M. Howard Fussell.
5. A Case of Cretinism, Showing the Results of One Year's Treatment.
Alexander Heron Uavisson.
6. Anesthetics. Herbert O. Collins.
1. — The Treatment of Tic Douloureux by Division of the
Sensory Root of the Gasserian Ganglion. — Frazier and
Spiller give a further report upon this method of treatment for
tic douloureux. For an abstract of their first article, see
American Medicine, Vol. II, No. 25, p. 1010. It has now been a
year since the patient detailed in the first paper was operated
upon, and since that time there has been no recurrence of pain,
and the patient's mental state reveals marked improvement.
The operation depends for its immediate success upon the com-
plete division of the sensory root of the gasserian ganglion, and
for its permanent success upon what may be called the inability
of this root to undergo regeneration. Spiller urges that in
future operations the sensory root be divided close to the pons,
so as to leave no part of the root containing sheaths of Schwann
in connection with the pons, and that as much of the root
should be resected as possible, [p.c.h.]
2. — The Prevalence of Herpes Zoster.— Joseph discusses
this disease at length, with special reference to its frequency
and occurrence with relation to sex, age, locality, occupation
and season. His conclusions, based upon a study of 164
patients seen among 15,603 skin diseases in ten years, are as fol-
lows: Herpes zoster causes 1% of all skin diseases; there
appears to be no difference in the disease in men and women ;
it occurs most frequently from 15 to 30 years, before school age
and in old age ; it is very rare ; it occurs more frequently in
those parts of the body richly endowed with nerve supply, with
one exception — the trigeminal region ; both sides of the body
are apparently affected with equal frequency, bilateral herpes
zoster being rare ; epidemics occur in the spring and fall ; spo-
radic oases occur with almost equal regularity throughout the
entire year, [f.c.h.]
3. — A Case Exhibiting the Symptoms of Both Tabes and
Multiple Sclerosis. — Sinkler details the case of a male of 63.
The case is not absolutely typical of either disease but it shows
the most characteristic and salient features of both diseases.
The patient has lightning pain, absence of knee-jerks, inability
to stand with the eyes closed, loss of bladder control and loss of
sexual power. There is comparatively little incoordination of
the hands, and but little in the feet, and there is no Argyll-
Robertson phenomenon. In addition he has in a marked
November 1, 19021
THE WOELD'S LATEST LITEKATUEE
[Amkbican Medicine 715
degree exaggerated and intention tremor of the upper extremi-
ties and some tremor of the legs when standing; but there is
no nystagmus and the speech is not staccato or scanning.
[F.C.H.]
*.— The Value of Diphtheria Antitoxin.— Fussell is an
ardent advocate of this method of treating diphtheria, and
believes that if the following rules are observed the mortality
of diphtheria would be aboutm^, insteadof 30%,asit is in Phila-
delphia at the present time. Always make a culture in throat
ca.ses ; diphtheria cannot be certainly diagnosed without it ;
when called to see a case of sore throat which is doubtful in
character, give antitoxin at once and malie the diagnosis by
culture afterward ; when a case of undoubted diphtheria is seen,
administer 2,000 units immediately, and if there is no improve-
ment in 6 hours, administer another 2,000 units. Every 12
hours thereafter administer 2,000 units until improvement
begins. Always give a large dose, 2,000^,000 units has proved
sutficient, but in desperate cases much larger doses may be
used, as proved by the Boston experience, [f.c.h.]
5. — A Case of Cretinism Showing the Kesults of One
Year's Treatment. — Davisson details the case of a female
child of 3 years which has been markedly improved by the
administration of thyroid, 12 grains of the thyroid extract now
being taken daily, [f.c.h.]
6.— Anesthetics. — Collins does not consider that a fixed
choice can be made regarding an anesthetic, but rather that in
the hands of an efficient anesthetist either chloroform or ether
may be administered with a remarkable degree of safety. It is
questionable if any attempt should be made to adopt the one as
the routine choice in preference to the other, for each has a dis-
tinct field of its own, and the judgment of him who is responsi-
ble for its administration should be left free to select that
which best suits the individual case, [f.c.h.]
ClilNICAIi MEDICINE
David Riesman A. O. J. Kbllt
EDITOBIAI. COMMENT
The Supposed Parasite of Yellow Fever. —
Aristides Agramonte, professor of bacteriology and
experimental pathology in the University of Havana,
reports' the result of his recent visit to Vera Cruz,
Mexico, for the purpose of studying the hyaline bodies
discovered by the American Yellow Fever Commission
in the blood of yellow fever patients. While he was
able to verify the existence of these previously unde-
scribed bodias in the blood of certain yellow fever
patients they were not invariably present, and he was
able, upon his return to Havana, to demonstrate their
presence in the blood of a number of persons in normal
health. He concludes, therefore, that it is impossible as
yet to attribute to these bodies any definite relation to
the etiology of yellow fever. The bodies in question,
which may have been mistaken by previous investi-
gators for blood platelets, exist free in the blood plasma,
but are destitute of locomotor movement. They vary
in diameter from 2-4 microns, and appear at first
sight. to be transparent and hyalin, but upon closer
examination are seen to contain a few extremely minute
granules exhibiting rapid pedesis. Their discovery may
prove after all a step toward the elucidation of the
obscure etiology of yellow fever. Agramonte simply
takes the position that their role, if any, in connection
with the disease is yet to be explained. It does not fol-
low, from the fact that they were not found in all cases
and did occur in the blood of persons free from and,
perhaps, immune to the disea.se, that they are not
related to the causation of yellow fever. It is possible
that they may represent a developmental and transi-
tional stag(^ in the life history of the specific parasite,
whatever it may prove to be. In view of Bandi's recent
studies of Bacillm icieroides Sanarelli (referred to else-
where in our columns), we may await with interest
future researches for a demonstration of the existence
or nonexistence of some relation between microorgan-
isms and the hyaline bodies discovered by the Yellow
Fever Commission, both of which have a well-attested
connection with the disease.
' Revlsta Mcdica Cubana, October 15, 1902.
REVIEW OF LITERATURE
Contribution to the Bacteriologlc Study of Yellow
Fever. — Ivo Bandi, vice-director of the Bacteriologic Institute,
Sao Paulo, Brazil,^ describes a rapid method for the cultivation
and study of the Bacillus icteroides Sanarelli, and concludes from
his experiments that the bacillus represents a well characterized
bacterial species. It is to be found in the blood of yellow fever
patients not only after death and in mixed cultures, when it
may be accounted for as having migrated from the intestines,
but in pure cultures in the blood of patients with benign cases.
The differential diagnosis of Bacillus icteroides from other
germs, with which it may be confused, is based upon two
essential characters absolutely characteristic, viz., its specific
sensibility to the bacterioagglutinin contained in antiamarillic
serums and its steatogenic action on the protoplasm of the
hepatic cells, as seen in experimental inoculations of dogs.
No other bacteria possess this degenerative action on cellular
protoplasm, whereby is produced the characteristic lesions of
human yellow fever, [c.s.d.]
Posttyphoidal Paralysis of the Ulnar Nerve.— Liepelt ^
reports a case of posttyphoidal paralysis of the ulnar nerve,
and reviews 11 other reported cases. It usually occurs during
the convalescence, and rarely during the fever. It is infrequent,
as out of 22,405 typhoid patients only 5 presented this condi-
tion. Of the above cases 9 showed atrophy and anesthesia ;
5 showed reactions of degeneration. Pain was the first symp-
tom in 8 of the cases. The response to electricity was dimin-
ished in all of the cited oases. Paralysis is as likely to follow
light as severe types of typhoid fever. Liepelt believes the
prognosis is favorable except when the reactions of degenera-
tion are present, [w.e.r.]
Environment as a Cause of Ague.— O'Connell,' referring
to cases of chronic fever with enlarged spleen, cases clinically
malarial fever, but in which it is impossible to detect parasites
in the blood, states that under the term malarial fever as at
present understood are included two clinically identical yet
etiologically distinct fevers, which for convenience may be
referred to as parasitic malarial fever and nonparasitic
malarial fever. Referring only to the second class he
states that they are obviously and indisputably due to the
meteorologic environment under which they arise. By the
environment is meant the hot, moist stagnant atmosphere
under which they become most prevalent and which was
for many years considered a sufficient explanation of their
cause. It Is believed that the inevitable effect of this environ-
ment is to produce an intermittent excess of water in the blood,
and that this affords a clear explanation of the intermittent
fever, the anemia, the melanemia, the enlargement of the
spleen, and the other conditions characteristic of malaria. The
author summarizes: 1. Cases of fever clinically identical with
malaria occur in the blood of which parasites could not be
found after repeated search before quinin had been given.
2. The meteorologic environment found where such cases occur,
and indeed in all malarial climates, increases the amount of
water in the blood of those exposed to its influence by imped-
ing elimination through the skin and lungs (evaporation- heat
loss) and through the kidneys. 3. There is known to be
increase of water in the blood of those suffering with ague
(Liebermeister). 4. Increase of water in the blood increases
metabolism, that Is, heat production, and produces a rise of
body temperature (Payne). 5. As environment thus causes
diminished heat loss from the body and increased heat produc-
tion within the body it is plain that it causes pyrexia. 6. This
pyrexia must be of intermittent variety as the environment
which produces it is of intermittent intensity, that is, under-
goes diurnal variation. 7. Elimination of water from the blood
1 II PoUcUnlco, September, 1902.
« Berliner kllnlsche Wocliensehrlft, July 7, 1902.
' Lancet, Bepteraber 0, l»02.
716 Amebicam Mbdioinbi
THE WOKLD'S LATEST LITER AT ORE
[November 1, 1902
(sweat) in ague reduces the temperature to the normal. 8. In-
crease of water in the blood produces poikilooytosis, pseudo-
parasites, liberation of hemoglobin, extensive destruction of
the red blood-corpuscles, and melanemia. 9. An extreme degree
of these changes obviously leads to hemoglobinuria. 10. In-
crease of water in the blood produces enlargement of the spleen.
11. Removal from the environment that produces increase of
water in the blood usually cures ague. 12. All treatment of
ague which is efficacious reduces the amount of water in the
blood. 13. Prom these facts it is not unreasonable to conclude
that those cases of ague or intermittent fever in which no para-
sites can be found are demonstrably due to the environment
under which they arise, [a.o.j.k.]
Smallpox in Lioadon and the English Vaccination
l/aw. — Oppe ' discusses the recent smallpox epidemic in Lon-
don, and shows that the increase in the disease is attributable
to the laxity with which the vaccination laws are enforced. The
epidemic also illustrates the viciousness of the " conscience
clause." While the occurrence of the outbreak and the high
mortality are to be lamented, they serve a useful purpose in
emphasizing the indispensability of vaccination, [d.r.]
Enteric Fever and Se^vage Disposal in Tropical Coun-
tries.—Major A. R. Aldridge^ (NainiTal, N. W. P. India) dis-
cusses the occurrence of epidemics of enteric fever and the
question and the causes to which may be attributed its wide
prevalence in endemic form in India and elsewhere. His ob-
servations go to show that this is probably one of the dust-
borne diseases and that it is not sufficient to obtain a water pure
at its source, nor even to purify a doubtful water, but that the
chances of its contamination later by dust, flies, etc., are as
great — in many cases greater — than at its source. He recom-
mends so far as possible the use of water boiled and cooled,
without lengthened storage, as may be accomplished by the
Waterhouse-Forbes sterilizer. He also advises that special
provision should be made for the exclusion of dust and flies as
well as contamination from sewage, [c.s.d.]
A Case of Fatal Poisoning with Solanum nigrum.—
Tiirk 5 reports the case of a boy, 3i years old, who became ill
after eating the berries of the garden nightshade (SolaTiutn
nigrum). Symptoms of poisoning developed as follows :
Violent cramps and diarrhea, high fever, rapid and stertorous
breathing, semiconsciousness, very weak pulse felt with dif-
ficulty, reflexes disappeared ; later deep coma and death. There
was never any vomiting and mydriasis was very slight, [e.l.]
A. B.
GENERAL SUKGBBY
Martin B. Tinker
Craig • C. A. Ork
The Lorenz Operatioa and the Open Operation
in the Treatment of Cong'enital Dislocation of the
Hip, — The sensationalism of the lay press in regard to
the visit of Professor Lorenz is of a Icind extremely dis-
agreeable to the profession, but nevertheless is of value
in teaching the public that not only this deformity but
many other of the deformities of children can be success-
fully treated, thereby leading them to put their helpless
children under the care of competent men at an age
when satisfactory results can still be obtained. The
principle of the Lorenz method is very simple, consist-
ing in stretching the parts about the hip-joint sufficiently
so that the head of the femur can be brought into the
rudimentary acetabulum. When this is accomplished
it is held in position by plaster-of-paris until the weight
of the body in walking, constantly forcing the bone
against the cavity, gradually enlarges it until its normal
function is possible. The stretching of the muscles
must be sufficient to bring the trochanter down to the
level of Nelaton's line or lower. This may be accom-
plished by preliminary traction with heavy weights or
by manual force at the time of operation. The child is
anesthetized, a folded sheet passed between the legs and
held above the shoulder of the side to be operated
1 Munchener med. Woch., July 1, 1902.
2 The Journal of Hygiene, July 1, 1802.
» Allg. med. Central Zeitung, 1901, 88.
upon and the pelvis is firmly fixed by an assistant.
Then by a series of stretchings and relaxations, for
which Lorenz uses a powerful frame with a traction
apparatus, the resistance of the tissues is entirely over-
come. The thigh is then iiexed to about 90° to relax
the capsule, it is gradually and forcibly abducted under
traction to the limit of range and is rotated slightly
inward so that the head of the bone points toward the
opening in the capsule. In this position, while traction
on the thigh is continued, the head of the bone is lifted
and drawn over the rim of the acetabulum. It usually
goes in with a distinct snap and the leg remains in a
position of flexion and abduction. The thigh is again
forcibly rotated and extended to its full limit, so that
the anterior part of the capsule which is drawn tightly
across the depression may be distended and the capacity
of the new articulation increa-sed. When the manipu-
lation is completed the leg is put up in plaster-of-paris
in an attitude of extreme abduction, moderate flexion
and inward rotation. The bandage extends from the
axilla to the pelvis, and is continued as a spica down to
the knee. The patient is encouraged to walk as soon as
possible, the awkwardness being somewhat les.sened by
a thick cork sole on the shoe. The first bandage is left
for six weeks or longer, and is reapplied at intervals of
a month or more. With each successive change in the
bandage abduction may be somewhat lessened until at
the end of eight or ten months the normal attitude of
the leg is restored. The operation of reduction is only
a small part of the treatment, the maintenance of
the head of the bone in the over-corrected posi-
tion for a long time until a new acetabulum is
established being equally as important for the
success of the treatment. At the Thirteenth Inter-
national Congress in Paris Lorenz reported 260 opera-
tions of this kind with only four deaths, three of these
from accidents in the anesthesia. In properly selected
cases the operation is free from danger and the pain and
discomfort which follow are much less than one would
expect from the extreme force which is employed. Other
advantages are that, because of its freedom from danger,
it can be employed in young children so soon as the
diagnosis is made ; the consent of parents is much more
readily obtained than for the cutting operation and if
successful there is much less pain and limitation of
motion than is usual after a cutting operation. The name
of Hoffa of Wflrzburg is inseparably connected with the
cutting operation as at present practised. Hoffa reported
248 cases at the International Congress with 10 deaths, or
nearly three times the number of deaths in the larger
series of cases treated by the Lorenz method. If the
Lorenz method does not prove satisfactory the cutting
operation is rendered much simpler and is more easily
performed from the fact that the parts are drawn down
into nearly the normal position. Several other surgeons
have employed this or a very similar method of reduc-
tion of congenital dislocation of the hip before Lorenz
used it in 1895, though none of them hatl succeeded in
convincing the profession of the value of the method
until Lorenz by his persistent, painstaking work proved
its great value in these cases, illustrating that as much
depends upon the perseverance and thoroughness of the
man as upon the value of his method.
REVIEW OF tlTERATUKE
Foreign Body in the Rectum.— Scherenberg ' reports a
case in which he removed from the rectum of a 30-year-old man
an ordinary bicycle air-pump, which the patient claimed he
had attempted to use in giving himself an enema and which
had slipped from his grasp and had passed into the bowel,
where it was found to have lodged at the upper end of the sig-
moid flexure. Scherenberg doubts the motive of the patient,
and holds it possible that the use of the pump was connected
with some sexual perversion, [c.s.d.]
1 Munchener medlcinlsche Wochenschritt, September 16, 1902.
November l, 1902]
THE WORLD'S LATEST LITERATURE
[Amkbicak Medicine
717
Kifectnal Sterilization of Catgut. — Mayo Robson i states
that aft«r experimenting with a number of substances, the
boiling point of each being above 100° C, he found xylol the
best in which to sterilize catgut by boiling, better even than
methylated spirits, the catgut shrinking, gaining in strength
and "biting" better when tied. He prefers size "O" when
prepared in this way. Formerly he used chromic catgut, but
finding it persisted too long in the tissues, in some cases even
appearing unabsorbable, he discontinued Its use and employed
the unmedicated catgut, or what is better still, the formalin
catgut. He has ceased to wind the catgut on the glass reel and
now simply loosens the constricting band in the center of each
skein and reapplies it loosely. This permits the heated fluid to
reach every part of the catgut. The skein is then put in a
metal cylinder, of the author's own device, which is filled with
xylol, and the cap screwed firmly on. The cylinder is then put
into the sterilizer and boiled for at least 30 minutes. After
being sterilized the catgut is stored in 5% carbolic solution in
methylated spirits. During the sterilizing process it is fatal for
water to enter the cylinder or for the xylol to evaporate, [a. B.C.]
Varicose Aneurysm of a Branch of the Saphenous Vein
Falsely Diagnosed as a Femoral Hernia. — Plorian Hahn, of
Niirnberg,' reports a case in which he and his colleagues were
at fault In a diagnosis of a femoral tumor, mistaking the same
for an irreducible femoral hernia containing omentum, but
finding upon operation that it was in reality a tumor-like
varix of the saphenous vein. In a review of recorded cases,
Hahn finds that in only one case was a correct diagnosis of
aneurysm made at first. [c.s.D,]
Calculus in the Kidney and Ureter.— McOraw ' says it
is unpractical to divide caculi, etiologically, into primary and
secondary. It is better to study first the predisposing causes,
then the exciting causes. Among the former he thinks it not
impossible that small tubules may prove insufficient for the
discharge of urine and thus cause the formation of stone in the
substance of the kidney. Though nervous influences act upon
urinary secretion it is a problem why destruction of the tho-
racic cord is nearly always followed by the formation of stone
in the kidney. A point in the diagnosis is, that persistent irri-
tation of a stone in the pelvis of the kidney sometimes causes
a hardening and thickening of the fatty capsule, which stimu-
lates a tumor. The first attack of renal colic demands an
opiate. Mcfiraw has little fear of obscuring diagnostic aids by
the use of opiatas, and does not think that any experienced man
should mistake the quiet produced by an opiate for an improve-
ment in the disease, whether the disease is renal colic, gall-
stone colic, appendicitis, or intestinal ob.struction. Operative
measures are imperative in (1) suppurative kidney ; (2) severe
and repeated hemorrhages from one kidney; (3) suppression
of urine. Examination of the kidney by the x-ray after the
organ is exposed should be of assistance to the surgeon. When
suppression follows the presence of stone prompt operation is
the only relief, and should be performed on the diseased kid-
ney first. With extraction of the stone and splitting of the
internal capsule from end to end relief may follow. If there
be no secretion within 12 hours expose the other kidney and
split its capsule, [a.o.e.]
THE PUBLIC SERVICE
Health Reports.— The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, during
the week ended October 25, 1902:
California :
IlllnolH:
Indiana:
Kentucky:
Ma.sMicbuiiett8 :
Hi(Ai.i.pox— United States.
Sacramento Oct. 11-18
San Francisco Oct. 5-12
Chicago Oct. 11-18
F'rteport Oct. 11-18
South Bend Oct. 11-18
Covington Oct. 4-18
BoBton Oct. 11-18
Cambridge Sept. 18-Oct.4..
Everett Oct. 11-18
Maiden .Oct. 11-18
Cases Deaths
a
«
.. 8
.. 13
2
.. 21
8ep((
' MUncbener medlclnlsche Wocbenscbrlft, September 16, 1902.
"> Journal Michigan State Medical Society, October, 1902.
Michigan :
Missouri :
New Hampshire:
New Jersey :
New York :
Ohio:
Pennsylvania :
South Dakota:
Utah:
Washington:
Wisconsin:
Brazil :
Canada :
China:
Ecuador :
France :
Qreat Britain :
India:
Italy:
Huasla :
Brazil:
Colombia:
Costa Rica :
Ecuador:
Mexico :
Philippine Islands :
Detroit Oct. 11-18
St. Louis Oct. 1-2-19
Nashua Oct. 11-18
Newark Oct. 4-18
New York Oct. 11-18
Cincinnati Oct. 10-17
Cleveland Oct. 11-18
Dayton Oct. 11-18
Hamilton Oct. 11-18
Altoona Oct. 11-18
Erie Oct. 11-18
.lohnstown Oct. ll-lS
McKeesport Oct. 11-18
Philadelphia Oct. 11-18
Pittsburg Oct. 4-18
Reading Oct. 6-13
Sioux Palls... Oct. 11-18
Salt Lake City Sept. 27-Oct. 4 .
Tacoraa Oct. 5-12
Milwaukee Oct. 11-18
Arabia:
China:
Egypt:
India:
Japan :
Hawaii :
Africa:
Australia :
Brazil:
China :
India:
Russia :
13
5
25
3
2
2
34
1
2
1
2
13
1
2
37
2
1
2
1
22
SMALLPOX— FOKBIGN .
Pernambuco Aug. l.'j-Sl
Rlo de Janeiro Sept. 21-28
Araherstburg Oct. 11-18
Hongkong Sept. 6-13
Guayaquil Sept. 27-Oct. 4.. „
Marseilles Sept. 1-30
Leeds Oct. 4-11
London Sept. 27-Oct. 4...,
Bombay „ Sept. 16-23
Calcutta Sept. i:V20
Palermo Sept. 20-27
Moscow Sept. 20-27
Odessa Sept. 27-Oct. 4...,
Yellow Fevek.
Rio de Janeiro Sept. 21-28
Panama. Oct. 6-13
Port Limon Oct. 2-9
Guayaquil Sept. 27-Oct. 4...
Coatzacoalcos Oct. 4-11
Vera Cruz Oct. U-18
3
20
18
1
2
18
,974 2,994
17337,713
9
1 1
7,112
,235 6,651
82 208
Cholera— Insular.
Manila To Sept. 13 3
Provinces To Sept. 13 64,
Cholera— Foreign.
Hodeldah Sept. 10-12
Hongkong Sept. 6-13
Sept. 6-13
Sept. l:i-20 7,
Alexandria Sept. 13-20
Cairo Sept. 13-20
Damletta Sept. 13-20
Ismallla Sept. 13-20
Port Said Sept. 13-20
Suez Sept. 13-20
Calcutta Sept. 13-20
Madras Aug. 23-Sept. 12..
Fukuoka Ken To Sept. 22 1,
Hiroshima Ken To Sept. 22
Kagawa Ken To Sept. 22 2,
Nagasaki Sept. 11-20
Okayama Ken Sept. 11-20 2,
Osaka Sept. 20-27
Plague— Insular.
Honolulu Oct. 14 1
Plague — Foreign.
Cape Peninsula To Aug. 9 745 362
042
706
344
.52
102
182
8
S
41
12
1
616
34
140 1,455
4.5jn28
Port Elizabeth ... To Aug. 9..
Mossel Bay To Aug. »..
Other Places To Aug. 9..
New Castle Aug. 1-31...
Rlo de Janeiro Sept. 21-28..
Hongkong Sept. 6-13....
Bombay Sept. 16-28..
Calcutta Sept. 13-20..
Karachi Sept. 11-21..
1*5
13
14
1
22
Madras Aug. 2:i-Sept. 12..
Odessa June-Oct. 4 43
1
11
:i
14
1
14
Changes in the Medical Corps of the U. S. Army for
the week ended October 25, 1902:
CHIDE.STER, First Lieutenant Walter C, assistant surgeon, Is granted
leave for one month, with permission to visit the United States.
MuNSON, Captain Edward L., assistant surgeon, now in Manila, P. I.,
will proceed to VIgan, South Hocus, for ouly.
Kennedy, Major Ja.mes M., surgeon, U. S. Volunteers, now at San
Francisco, Cal., will report to the commanding general, depart-
ment of California, for assignment to temporary duty at the U. S.
General Hospital, at San Francisco.
WooDBUKV, First Lieutenant Frank T., assistant surgeon, now at
Sun Francisco, Cal., will proceed to Plattsburg Barracks for duly.
De Lokkbe, .Samuel .M., contract surgeon, now at San Franolsco, Cal.,
will repair to Washington, D. C, for annuitnent of contract.
PiNtiUARD, JosEi'Ji, contract surgeon, is granted leave for one month
and fourteen days, from about October '23.
Banta, William P., contract surgeon, Is relieved from duty at the
General Hospital, Presidio, and will ri'ixjrt to Major Ogden Itaf-
ferly, surgeon, medical superintendent of the Army transport
service at San Francisco, for duty as his assistant. r«t
Fauntlekoy, Captain P. C , assistant surgeon, is granted leave for one
month, from about November la.
Bkattv, Walter K., contract surgeon, now at Vancouver Barracks,
will proceed to Fort Lawton for duty.
Nicholson, John L, contract surgeon, now at Vancouver Barracks,
win proceed to Fort Stevens for duty.
Hewitt, John M., contract surgeon, is granted leave for thirty days
to take effect upon bis arrival at Fort Wood.
718 American UkdicinXj
THE PUBLIC SERVICE
[November 1, 1902
Hewitt, John M., contract sui-geon, now at Fort Walla Walla, will
report to Lieutenant Colonel P. H. Ray, Eighth Infantry, at Fort
Wright, to accompany the battalion of that regiment en route to
the department of the East, Fort Wood. Upon completion of this
duty dontract Surgeon Hewitt will return to his proper station.
WiCKiiiNE, W. A., contract surgeon, Is granted leave for thirty days,
from about October 10.
SiEVERS, Robert E., contract surgeon, will, upon the withdrawal of
the troops at Camp Merritt, Mont., proceed to F'ort I/incoln, for
temporary duty.
Wheeler, Lewis H., contract surgeon, Fort Lincoln, is granted leave
for one month, to take effect upon the arrival of Contract Surgeon
Robert E Slevera for temporary duty at that post.
GiRARD, Colonel Joseph B., assistant surgeon-general, upon his arrival
at San Francisco, Cal., will proceed to Omaha, Neb., and report to
the commanding general, department of the Missouri, for duty as
chief surgeon of that department.
Havard, LleutenantrColonel VAi,BRy, deputy surgeon-general, is
relieved from duty at Fort Monroe, and will proceed to West Point,
N. Y., and report to the superintendent of the U. S. Military
Academy for duty to relieve Major James D. Glennan, surgeon.
Major Glennan will proceed to Fort Myer for duty, to relieve Major
William B. Davis, surgeon. Major Davis will proceed to Honolulu,
H. I., and report at Carap McKlnley for duty, to relieve First Lieu-
tenant Edwin W. Rich, assistant surgeon. Lieutenant Rich will
proceed to San Francisco, Cal , and report by telegraph to the
adjutant-general of the Army for orders.
Johnson, Major Richard W., surgeon, is relieved from further duty
as sanitary In.spector, department of California, and fronr duty in
San Francisco, Cal., and will proceed to Fort Monroe for duty.
Wales, Captain Philip G., assistant surgeon, is relieved from further
duty as attending surgeon and examiner of recruits at Denver,
Colo., and will proceed to Fort Assiniboine for temporary duty.
Overton, David w., contract surgeon, is relieved from duty at Platts-
burg Barracks, and will proceed to Fort Schuyler for duty, to
relieve First Lieutenant Theodore C. Lyster, assistant surgeon.
Lieutenant Lyster will proceed to New York City for temporary
duty as attending surgeon and examiner of recruits in that city, to
relieve Captain James S. Wilson. Captain Wilson will proceed to
Fort Myer for duty.
Raymond, Major Thomas U., surgeon, is relieved from further duty as
attendtng surgeon and examiner of recruits at Chicago, 111., and
will proceed to Jefferson Barracks for duty, to relieve Captain
Francis A. Winter, assistant surgeon. Captain Winter will pro-
ceed to St. Louis, Mo., and assume the duties of attending surgeon
and examiner of recruits In that city.
Chidester, First Lieutenant Walter C, as.slstarrt surgeon, now at
San Francisco, Cal., Is relieved from further duty in the division of
the Philippines, and will report to the commanding general,
department of California, for assignment to temporary duty In that
department.
Sturtevant, Charles A., contract surgeon, is relieved from further
duty at Madison Barracks and will proceed to Fort Tottcn for duty,
to relieve First Lieutenant William N. Bispham, assistant surgeon.
Lieutenant Bispham will proceed to Fort McHenry for duty.
Ford, First Lieutenant Clyde S., assistant surgeon, is relieved from
further duty at J'ort Hancock, and will proceed to Fort Wadsworth
for duty.
Usher, First Lieutenant Francis M. C, assistant surgeon, is relieved
from further temporary duty at the U. S. Genera! Hospital, Pre-
sidio, and will proceed to Fort Yellowstone for duty to relieve
Major Edgar A. Mearns, surgeon. Major Mearns will proceed to
Fort Snelllng for duty.
Beatty, Walter K., contract surgeon, is relieved from further duty
at the U. S. General Hospital, Presidio, and will repair to Washing-
ton, D. C, for annulment of contract.
Wilcox, Major Charles, surgeon. Is relieved from further duty in
the division of the Philippines, and will proceed to San Francisco,
Cal , and report by telegraph to the adj utant>general of the Army
for orders.
Brooks, John D.. contract surgeon, now at Fort Meade, will report to
the commanding officer of that post for duty.
Fletcher, Richard M , Jr., contract surgeon, is relieved from
further duty at Fort Meade, and will proceed to Fort Niobrara for
duty.
The board of medical officers at Washington, D. C, for the examina-
tion of candidates for admission to the medical corps of the Army
is dissolved.
A board of medical officers, to consist of Major Louis Brechemin, sur-
geon ; Major Edward R. Morri.s, surgeon ; Major Alfred E. Bi-adley,
surgeon; Captain Henry R. Stiles, assistant surgeon; Captain
Harry M. Hallock, assistant surgeon, is appointed to meet In
Manila, P. 1., for the examination of candidates for admls.sion to
the medical corps of the Army. The board will be governed in its
proceedings by such instructions as it may receive from the sur-
geon-general of the Army.
GoRGAS, Major William C, surgeon, is detailed to represent the
medical department of the Army at the First Egyptian Medical
Congress to be convened at Cairo, Egypt, in December, 1902, and
will proceed at the proper time to that place via London, England.
Upon the adjournment of the congress Major Gorgas will return
via London to his station in Washington, D. C.
RoBBiNs, First Lieutenant Chandler P., assistant surgeon, Js granted
leave for one month.
The following-named assistant surgeons are relieved from duty at the
posts designated, to take effect at such time as will enable them to
repair to Washington, D. C , and report November 6, at the Army
Medical Museum Building, to Colonel Calvin DeWittj assistant sur-
geon-general, president of the faculty of the Army Medical School,
for the course of instritctlon prescribed by pa rag rap h.s 5l2and51.S,
A. R , 11*01 : First Lieutenants Harry L. Gilchrist, Vancouver Bar-
racks; George H. R. Gosman, Fort Wadsworth ; Reynold M. Kirby-
Smith, Fort Barrancas; William H. Moncrief, Fort Getty; George
L. Collins, Fort Warren; Nelson Gapen, Fort Myer; William T.
Davis, Fort McHenry ; Charles F. Morse, Fort Ethan Allen ; Sam-
uel E. Lambert, Washington Barracks ; Haywood S. Hansell, Port
McPherson; Junius C. Gregory, Fort Myer; Clarence H. Connor,
U. S. General Hosiptal, Washington Barracks; Will L. Pyles,
Plattsburg Barracks; Thomas Devereux, Fort Snelllng: William
M. Smart, Fort Monroe; Robert H. Pierson, Fort Columbus; Cary
A. Snoddy, Fort Thomas; Harry S. Purrrell, Columbus Barracks;
Robert M. Blanchard, Columbus Barracks; James Bourke, U. S.
General Hospital, San Francisco.
Orear, Captain William B., assistant surgeon, U. 8. Volunteers, is
honorably discharged to take effect November 18, 1902, his services
being no longer required. Captain Orear will proceed to his home.
Leave granted Captain Orear, September 18, is extended to include
November 18.
POEY, Captain Eddakdo C, assistant surgeon, U. 8. Volunteers, is
honorably discharged, to take effect November 2.5, 1902, his services
being no longer required. He will proceed to his home.
Hepburn, James H., contract surgeon, is granted leave for one month,
to take effect when his services can be spared b.v the post com-
mander.
Vass, George E., hospital steward, Jefferson Barracks, is transferred
to Fort Riley for duty.
Shaw, Captain Henry A., assistant surgeon, upon his arrival at San
Francisco, Cal., will repair to Washington, D. C, and report at the
U. S. General Hospital, Washington Barracks, for duty.
Stewart, Captain William J. S., assistant surgeon, U. S. Volunteers,
now at San Francisco, Cal., is honorably discharged, to take effect
October 22, 1902, his .services being no longer required.
Changes in the Medical Corps of the U. 8. Navy for
the week ended October 25, 1902 :
Marsteller, E. H., surgeon, ordered to Newark, N. J., October 27>
for duty in connection with recruiting— October 21.
Bell, W. L., passed assistant surgeon, commissioned passed assistant
surgeon with rank of lieutenant (Junior grade), from November 16,
1901— October 21.
Gabton, M. W., passed assistant surgeon, detached from the Columbia
and ordered to the Naval Hospital, Yokohama, Japan, sailing from
San Francisco, Cal., November 7, 1902— October 21.
JOHNSON, M. K., passed assistant surgeon, ordered to the Naval
Academy —October 21.
Taylor, J. S., assistant surgeon, detached from the Naval Hospital,
Yokohama, Japan, and ordered home and to wait orders-October21.
Bachmann, R. a., detached from the Naval Academy and ordered to
the Naval Museum of Hygiene and Medical School, Washington,
D. C, October 31— October 21.
HoLLOWAY, J. H , assistant surgeon, detached from the Naval Hos-
pital, Chelsea. Mass., and ordered to dtrty at the Museum of Hygiene
and Medical School, Washington, D. C— October 22.
Hoyt, R. E., assistant surgeon, detached from the Naval Academy and
ordered to the Museum of Hygiene and Medical School, Washing-
ton. D. C, on October 31— October 22.
MiCHELS, R. H., and Neilson, J. L.. assistant surgeons, ordered to
the Museum of Hygiene and Medical School, Washington, D. C.,
on October 31-October 22.
Shaw, H , and Jenness, B. F., acting assistant surgeons, ordered to
the Museum of Hygiene and Medical School, Washington, D. C,
October 31— October 22.
Orders Issued by Commander-in-Chief of Asiatic Station: Surgeon
J. E. Gardner detAched|from the Naval Hospital, Yokohama, Japan,
and ordered to the Kentucky ; Surgeon G. P. Lumsden ordered to
the New York ; Passed Assistant Surgeon M. S. Elliott detached
from the Kentucky and ordered to the New York; Assistant Sur-
geon F. A. Asserson detached from the New York and ordered to
the Kentucky; Assistant .Surgeon W. E. High detached from the
Glacier and ordered home ; Assistant Surgeon J. F. Murphy
detached from the Naval Station, Cavlte, P. I., and ordered home-
October 22.
Changes in the Public Health and Marine-Hospital
Service for the week ended October 23, 1902 :
Carter, H. R., surgeon, leave of absence for one day under paragraph
179 of the regttlations.
Banks, C. E., surgeon, granted one day's extension of leave of absence,
October 11— October 16, 1902.
Oakley, J. H., passed assistant surgeon, granted leave of absence for
one day— October 23. 1902.
Mathewson, H. S., passed assistant surgeon, upon being relieved by
Assistant Surgeon W. W. King, to proceed to Detroit, Mich., and
report to medical officer in command for duty and assignment to
quarters-October 22, 1902.
King, W. W., assistant surgpon, upon being relieved by Assistant
Surgeon Joseph Goldberger, to proceed to San Juan, Porto Rico,
relieving Passed Assistant Surgeon H. S. Mathewson and assume
the duties of chief quarantine officer of the island of Porto Rico-
October 22, 1902.
Goldberger, Joseph, assistant surgeon, relieved from duty at Tam-
plco, Mexico, and directed to proceed to Ponce, Porto Rico, relieving
Assistant Surgeon W. W. King, and assume command of the serv-
ice at that port- October 22, 1902.
Backus, S. H., acting assistant surgeon, relieved from duty in the
office of the U. S. Consul at Puerto Cortez, Honduras— October 20,
1902.
Carson, W. H.. acting assistant surgeon, relieved from duty In the
office of the IJ. S Consul at Port Limon, Costa Rica— October 20. 1902.
Fbick, John, acting assistant surgeon, to proceed to Matanzas, Cuba,
and assume temporary charge of the service at that port during the
absence, on leave, of Assistant Surgeon R. H. von Ezdorf— October
17, 1902.
Goodman, D. W., acting assistant surgeon, relieved from duty In the
office of the U. S. Consul at Blueflelds, Nicaragua— October 20, 1902.
OsTERHouT, Paul, acting assistant surgeon, relieved from duty in the
office of the U. S. Consul at Bocas del Toro, Colombia— October 20,
1902.
Peters, R. H., acting assistant surgeon, relieved from dirty in the office
of the U. S. Consul at Belize, British Honduras— October 20, 1902.
Robertson, W. B., acting assistant surgeon, relieved from dutv in the
office of the U. S. Consul at Ceiba. Honduras— October 20, 1902.
Macdowell, W. F., senior pharmacist and chemist, to report at
Bureau for temporary dirty— October 23.
Board Convened.
Board convened to meet at Washington, D. C, October 23, 1902, for
the physical examinatkm of cadets recently appointed In the Revenue
Cutter Service. Detail for the board— Assistant Surgeqir-General W. J.
Pettus, chairman ; Assistant Surgeon B. S. Warren, rei^rder.
Proviotion.
Stoner, .r. B., passed assistant surgeon, promoted to be surgeon and
to rank as such from September 16, 1902— October 16, 1902.
American Medicine
y\'
,c<
GEORGE M. GOULD, EdUor
G. C. C. HOWARD, Managing EdiUyr
CUnieal Medicine
David Ribshan
A. O. J. Kelly
J. Edwin Sweet
Helen Mukphy
CHARLES S. DOLLEY
MARTIN B. TINKER, AtHttant Bditort
General Surgery
Martin B. Tinker
A. B. Craio
Charles A. Orr
Orthopedic Surgery
H. AuousTiTS Wilson
COLLABORATORS
Obttetrict and Gynecology
WiLMER Krusen
Frank C. Hammond
Nervous and Mental Diseases
J. K. Mitchell
F. Savary Pearck
Treatment
Solomon Solis Cohen
H. C. Wood, Jr.
L. F. Appleman
Dermatology
M. B. Hartzell
Laryngology, Ble,
D. Braden Kyle
Ophthalmology
Walter L. Pyle
Pathology
R. M. Pearce
PuaLtaaiD Whklt at 1S21 WAtiorr STBtn, Philadilprli. by thi AMKBiCAN-MiDicm* PaBLtaHiMs Company
Vol. IV, No. 19.
NOVEMBEK 8, 1902.
^5.00 Yearly.
Governmental Sucoiiragemeiit of Intemper-
ance.— Such must be called the present method of pro-
tection by the national laws of the nostrum syndicates.
These nostrums are called patent medicines, possibly for
the same reason that the eddyites call themselves
Christians and scientists. Surely the patent medicines
are neither medicines, nor are they patent. If they
were patented this shameless American disgrace would
at once cease, because the ingredients would be known,
the exorbitant prices recognized, and every grocery store
and whisky shop in the land could mix the same con-
coctions for customers at one-tenth the price now asked.
One of the greatest agencies for directly producing dis-
ease, poverty, crime, and death are these government-
protected nostrums, which, in the name of medicine, are
destroying the health of their pitiable victims all over
the land. When we shall have an independent medical
press and an organized profession, we may hope to com-
mand enough power to secure the enaction of laws which
will extinguish this infamy. This can only be done by
requiring that every socalletl medicine that is sold to the
public, or has a copyrighted name, shall contain on the
label of each bottle or package an exact record of its con-
stituents. Besides this it must be made a crime for any
drug or other store to sell alcohol, cocain, inori)hin, etc.
etc., except upon the prescription of a legally qualified
practitioner. Dr. Bumgardner' says that in less than
three months there appeared in the Police Court of
Chicago forty victims of the cocain habit, induced
largely by the use of catarrh snuffs containing this drug.
What is more absurd than to create drunkards and mor-
phinomaniacs by government protection and sanction,
and then to build asylums and hospitals by the same
government wherein to lodge and care for them ?
The sale of poisons and narcotics has become
such a public scandal that many cities and States
have been enacting laws against it. We wish corre-
spondents would keep us notified of the jjrogress of
such reforms. The cwaiin habitues of Louisiana and
Mississippi are said to number thousands, and that so
widespread is the degra'flation becoming auiong the
negroes that something like an extermination of the
race is threatened. In Ohio a law has recently been
passed to stop the sale of cocain, morphin, etc., except
' Tranftactions Colorado State Medical Society, 1902.
upon a physician's prescription. The victims of the
habit in Cincinnati are said to be thousands. In Ken-
tucky the State Board of Pharmacy has determined to
stamp out the abuse. The number of habitues in Roa-
noke, Va., is estimated at 500. In Pennsylvania the
only condition imposed upon druggists is that the person
buying "poisons" shall sign his name in a book stating
by whom and for what purpose the drug is to be used ;
of course that is no restriction whatever. The profes-
sion, and especially the State Boards of Health, should
seriously concern themselves with some method of abol-
ishing this pernicious abuse. The "cough syrups " and
"soothing syrups" contain morphin or cocain, and
" cures " for the habitual use of cocain and morphin gener-
ally contain these drugs themselves. Their sale should be
interdicted by law, except upon prescription ; the ingre-
dients should at least be stated upon each package. Dr.
Bumgardner (Colorado State Medical Society, 1902) states
that a two-ounce bottle of " Mrs. Winslow's soothing
syrup" contains one-half grain of morphin sulfate, and
each ounce of "Dr. Bull's cough syrup" contains more
than one-fourth of a grain. He also says that certain
" consumption cures " are now put up in small bottles,
because not being a permanent mixture, the last dose
from the larger bottles sometimes killed the patient, but
that the last dose from the smaller bottle would contain
too little morphin and cannabis indica to prove fatal.
And this atrocious method of making money out of
inducing disease and death is permitted and protected
by a civilized government ! Worse than this, the gov-
ernment sanctions, and, by its copyright laws alone,
permits, the making of the diseased and defectives and
paupers which it then must support in hospitals and
asylums !
" Drug--habits " and Some of Their "Cures." —
One mail brings us two communications which explain
each other, and the fact revealed deserves the serious con-
sideration of the public. The first letter is addressed to
a physician and oflers to sell to one person only in a city
i^the secret of a cure "ervdoreed by all the physicians of
our oity " as the only certain Vomedy so far known for
" the morphin, opium, cocain, licjuor, or cigaret habit."
Of course it is " harmless," and every case in which it is
used "will yield you from one to three hundred dol-
lars." The second communication is from a reputable
720 American Medicine'
EDITOEIAL COMMENT
fNOVBHBER 8, 1902
physician who has found in one popular magazine 49
advertisements of such cures for drug-habits of all kinds
and for varicocele, etc. One morphin-cure especially is
chosen for investigation, as it was endorsed by physi-
cians, clergymen, et«., who offered testimonials galore,
free samples, etc., and had a name well calculated to
deceive the poor dupes upon whom the sharpers preyed.
Our correspondent was moved to look into this particu-
lar cure by the fact that a patient had taken it for a pare-
goric habit of eight years' standing. But the patient in
a year found he was more enslaved by the new habit
than he had been by the old paregoric habit, and he was
in great despair. A hard fight carried out under the
physician's guidance at a hospital finally brought about
a real cure of both habits. Two bottles in the original
packages were sent for analysis to the New York State
Board of Health. The director reported that the result
of the assay as prescribed in the V. S. Pharmacopeia for
tincture of opium, was that 100 cubic centimeters of the
liquid yielded 1.019 grams of morphin. It is said that
the wording of the advertisements is such that no legal
steps can be taken by the State Board of Health, but
there should certainly be some means of bringing the
scoundrels up standing. Why at least could they
not be compelled to publish the names of the "six
thousand physicians" who endorse this "wonderful
cure?"
Why Do Not the Temperance People Fight the
Patent Medicine Enemy? — That is a question we
would like to have any member of the W. C. T. U. or
other similar organization answer. If it is admitted that
the army-canteen made drunkards, surely the patent
medicine syndicates make a thousand times as many.
No one is ignorant of the fact that there are many mil-
lion dollars' worth of these alcoholic nostrums sold each
year, and that multitudes of people are thus secretly and
ignorantly turned into drunkards. Last year a great
temperance reformer's portrait and testimonials were
blazoned in every yellow journal in the country, extol-
ling the virtues of a nostrum largely made up of alcohol.
It was the alcohol in it that gave it its power and that
"cured" the temperance reformer. Dr. Bumgardner '
says that the following "patent" medicines contain the
percentages given of alcohol :
Greene's Nervura 17.2
Hood's Sarsaparilla 18.8
Schenck's Sea-weed Tonic 19.5
Brown's Iron Bitters 19.7
Kaufman's Sulfur Bitters 20.5
Paine's Celery Compound 21.0
Burdock's Blood Bitters 25.2
Ayer's Sarsaparilla 26.2
Warner's Safe Tonic Bitters 35.7
Parker's Tonic 41.6
Hostetter's Stomach Bitters 44.3
Think of a crusade against beer, which contains only
from 2% to 5^ of alcohol, while allowing the free sale of
" bitters " containing ten times as much. The " bitters "
are stronger than whisky, far stronger than sherry, port,
etc., and claret and champagne are far behind.
Is it beyond the truth to say that alcohol causes from
' Transactions Colorado State Medical Society, 19j2.
one-third to one-half of all the criminals, defectives,
insane and dependents which the State is compelled to
support? What proportion of these are the products of
the patent medicine syndicates no one can tell. It is
surely large. It is only by government protection that
the alcoholic nostrum traffic is carried on. This is a
profitable business for the syndicates so long as the State
will care for their pauperized victims. How long will
it continue to do so?
What is the Meaning of the Word "Consult-
ant?"— From the letter of a careful observer, an
English practitioner, we quote the following passage :
"Strictly speaking our profession is divided into two halves,
the consultants and the general practitioners, but I do not
think there exists anywhere a consultant, I mean one who con-
sults only with other practitioners. Tlie use of the word con-
sult has to do with this difficulty. When a patient sees a
medical man, if this is rightly called consulting, then every
medical man is a consultant. But what I think is the correct
meaning is, when a doctor is called in to confer with another
medical man this is a consultation, but it does not make the
doctor called in to confer a consultant, for in country places the
doctor called in is one who is generally regarded as the ablest
round about; but it is not always the case that the ablest is the
same man to all practitioners and consequently, even in coun-
try places, these would be consultants, but even those called in
would hardly arrogate to themselves this title. Consultants,
socalled, see patients the same as general practitioners, charge a
higher fee and are differentiated somewhat by limiting them-
selves to medicine or surgery as the case may be. The general
practitioner seldom consults say with an ophthalmologist (in
this country we have a very bad term, ophthalmic surgeon,
ignoring the physician's side ; ophthalmologist is a much
better term) because bad cases are generally sent straight
away to a hospital, and, I suppose, from an imperfect
knowledge, one could hardly call a conference with an oph-
thalmologist a consultation. It is the ease of a specialist
meeting with a general knowledger — this word is coined by
myself— but in the broader domain of surgery and medicine we
meet on better terms and therefore this is more of a consulta-
tion. Until a correct deflnition of " consultant " is obtained we
can hardly say who is and who is not a consultant, and the use
of the word, consulting, as applied to the meeting between
patient and general practitioner mast go by the lx)ard."
Although the conditions in the United States are
somewhat different from those in England there is a
similar indeflniteness in the use of the word which
should be done away with. For instance, should the
family physician, or even the specialist, who asks for a
consultation, be styled a consultant? Should the second
say, " I had a consultation with the family physician?"
A consultation is certainly a conference made up
of two or more physicians : can one of two be thrown
out as a nonconsultant and a true consultation remain ?
And yet by the word, consultant, is generally under-
stood the second or a third, etc., called in by the first,
who was originally in charge of the case. Being thus
usually understood it would seem as if we must accept
such as the definition, although it distinctly differs from
that implied in the term, a consultation. Although
participating in the consultation the first physician, the
one who calls in another in consultation, may not be
called a consultant. He is the practitioner originally in
charge of the case, and those subsequently called in are
consultants. The specialist thus called in is just as much
a consultant as the surgeon, or the "internist." And
November 8, 1902]
EDITORIAL COMMENT
AMBRICAN MEDIOtNB. 721
the question of ability, fame, expertness, etc., has no
pertinence. Consultations are often for other reasons
than t« secure "superior" advice.
International Standard for Potent Remedies. —
Among the basic principles discussed and subseiiuently
adopted by the International Convention for the Unifi-
cation of the Formulas for Heroic Medicines, which met
at Brussels, September 15, none perhaps is of more direct
interest to the American medical practitioner than that
establishing at 10 fc the strength of tinctures of active
or potent remedies. This is especially opportune with
the present revision of the U. S. Pharmacopeia. The
importance of the subject is emphasized in an article on
tincture of aconite read at the meeting of the American
Pharmaceutical Association held recently in this city by
M. I. Wilbert,' apothecary to the German Hospital.
He points out that the U. S. P. tincture of aconite is
seven times as strong as the British preparation, three
and a half times as strong as the German preparation,
and nearly double the strength of the French prepara-
tion. That it has been recognized that the strength of the
U. S. P. tincture is excessive, is shown by the repeated
reduction of the percentage. The tincture originally
represented 65 fc of the crude drug, and was reduced in
1860 to 50^, and in I860 to 40^, where it remained
until 1890 when it was reduced to 35^. We understand
that there is now a movement to return to 40 % , for no
reason other than that 40 fc is the official strength of the
tincture of veratrum viride. The tinctures of many
other potent drugs are from 50^ to 100^ stronger than
the proposetl international standard. These variations
in strength become of very serious moment when we
consider the potency of the preparations, their wide-
spread use, and the fact that foreign medical literature is
freely abstracted and liberally commented upon in med-
ical journals. Comparatively few physicians are in a
position to familiarize themselves with the differences in
the strength of galenic preparations in different countries
— whence the possibility of serious consequences from
the use of potent remedies in dosage advocated in foreign
publications. A uniform standard should be adopted,
and this standard should be international as well as
national. For instance, were tincture of aconite reduced
to the same strength as tincture of belladonna, it could
be administered in the same dose, and — a matter of
some importance — the difference between the average
medicinal dose and the lethal dose would be greater.
The facts cited should enlist the attention of the com-
mittee on the revision of the pharmacopeia, with a view
to the adoption of the strength-percentage recognized by
the Brussels convention.
Professional Bribe-givers, — In connection with
our recent statements c/jncerning the disgnice of sub-
sidies U) hospitals, colleges, etc., the Public Ijidger, of
Philadelphia, publishes on October 20, 1902, the letter of
an eminent lawyer whom the editor vouches for as a
man having the " unreserved respect of bench and bar."
In this letter it is stated that a medical man consulted a
wellknown lawyer, asking him for advice as to giving
' Druggist*' Circular, 1902, p. 20».
to a certain member of the legislature a percentage of the
appropriation voted by the legLslature to his institution.
If this " rake-off" were not given the institution would
not get the money, and would never get any share of the
appropriation in future. The lawyer advised that
although it would mean a calamity to the institution,
which is a most worthy one, bribery is a criminal offense,
and the money must not be paid. The advice was fol-
lowed, and the institution did not receive the appropria-
tion, and will not receive any in future. Of course this is
nothing new, and many such facts are said to be well
known. What would be new would be a rising in its
wrath by the profession, and a war against all the emi-
nently respectable scoundrels who are thus debauching
the profession and our institutional life. These men are
enemies to the suffering patients of worthy institutions,
enemies to their fellowmen, their country and to civiliza-
tion itself. Many of them are known to their colleagues
and fellow-citizens, and they are recognized as criminals
out of jail simply because of our American forbearance
and indifference. They are many of them LL.D.'s, M.D.'s
and other D.'s, and until as a body we learn to dishonor
and punish them they will continue to feed upon our
professional degradation. Let no lenient conscience
excuse indifference on the ground that these men are, as
it were, innocent and mistaken criminals, criminals for
the sake of the sick and for the good of the community.
Plunderers and thieves commit their crimes solely for
their own selfish advantage. The man who will give
one bribe will take two.
Plague in San Francisco. — Especial attention
should be given to the resolutions, etc., published else-
where of the national conference of the State and Pro-
vincial Boards of Health of North America, held recently
in New Haven, Conn. The authorities at San Francisco
deserve the severest rebuke for their negligence in the
matter of bubonic plague in that city. The various State
Boards of Health in the United States are asked to unite
in calling upon the Surgeon-General of the Marine-Hos-
pital and Public Health Service to arrange at the earliest
possible date a joint conference for the purpose of eradi-
cating plague from the United States. Since March 8,
1900, there have been 88 cases recorded in California, 15 of
this number occurring since September 9, 1902. It is
rumored that many other cases have occurred which were
not reported. The strange persistence in the policy of
concealment on the part of the political and commercial
authorities in San Francisco is thus having the result of
which we have repeatedly given warning. It is not
improbable that cases of plague are occurring in many
parts of ihe West and South. We hope the officers of
the Marine-Hospital Service will extend their investi-
gations into these sections, and that the policy of pub-
licity and absolute frankness may prevent the appalling
calamity that is i)ound to follow secrecy in these
matters.
The rtriijjrglst playing <loctor has lately received a
setbiu-k in the verdict of a jury against a druggist who
prescribed for a man. If there were a thousand such
verdicts in one year the abominable practice would stop.
722 AKBBIOAN MSDIOIinEJ
EDITORIAL COMMENT
[NOVEKBBK 8, 1902
There are plenty of these crimes and criminals, the only
thing that is wanting being the prosecutions. There are
in almost all States laws to prevent the prescribing
druggist from carrying on his sharp stupid tricks, but
they are so loosely drawn or so ignored that in 75 fo of
the drug stores of the country anything is sold that is
asked for. "Something good for it " is prescribed, with
no care for the law and in scorn of the alleged necessity
for a doctor's prescription. Worse than this, the cheap
druggist of the country village and often of the city
does not himself prescribe, but acis as the agent of the
nostrum manufacturer. "Send the coupons to, etc., and
you will get a prize." The druggist masquerading as
medical adviser is a scamp who injures not only the
ignorant patient who harbors the delusion that he can
" sponge " medical advice ; he is the enemy also of the
honest druggist who will not play the cheat. If a union
of the public-spirited physicians and honorable pharma-
cists could be effected and an attorney hired to prosecute
the fraudulent drug stores, there is no doubt that an
immediate reform could be brought about.
An Argument with the Politicians. — Through its
chairman, Dr. S. D. Van Meter, the Colorado State Med-
ical Society is sending a circular letter and literature to
the members of the profession of the State. A part of
the letter reads as follows :
This committee believes that the members of the medical
profession, irrespective of school or politics, are a unit in desir-
ing medical legislation which will protect the public and at the
same time improve the standard of the profession. To help us
to better existing conditions we ask you to consider yourself a
committee of one for the purpose of obtaining, without delay,
from the candidates of the respective parties in your com-
munity an expression of their views on this question. Request
of them a thorough reading of the reprint which has been sent
to them and then a statement of the position they take. For-
ward their opinions to this committee, that we may know who
are hostile and who are friendly to such legislation. Thus you
will have brought before the prospective legislators of both
parties forcible evidence of the immense influence of an organ-
ized medical profession and prepared them in a measure for
intelligent action when this question comes up for considera-
tion in the next legislature.
In view of the nearness of the election we hope you will
give this your prompt attention.
The number of votes cast and controlled by the med-
ical profession is often large enough the decide the fate
of a politician. Why not in all States, as well a-s in
Colorado i^ohere such union has proved effective in at least
one election), unite to make our power acknowledged ?
Private medical institutions are rapidly multi-
plying in all countries, but especially in the United
States. • The hydropathic establishments of England,
commonly called "hydros," which were once so popu-
lar, are changing character. Strict hydropathy does not
cure and does not pay, so that hydropathic hotels are
becoming popular in which the hydropathy is used or
neglected at the patient's will, and in which the hotel
business is the chief part. In our country a similar
change is taking place in a thousand institutions, in
which the medical aspect is subordinated or accessory to
others. In other words, many medical men are going
into the hotel business, directly or indirectly. So far a.s
we know this has not resulted in any considerable med-
ical abuses or scandals, but it can hardly be denied that
semi-quacks may and will demonstrate its dangers.
Indeed, there are already many institutions, falsely
called sanitariums, healing institutes, hospitals, etc.,
which are nothing but the devices of criminals to get
money under false medical pretenses. Honorable physi-
cians connected with private medical institutions owe
it to their profession to make it abundantly certain that
all their methods are above suspicion, and it is as surely
obligatory u])on them to stop the doings of the scamps.
Eddyites Indicted for Manslaughter. — The grand
jury which in New York last week brought in a verdict
of manslaughter in the second degree against three
eddyites because of the death under their hands of a
child suffering from diphtheria, will give encourage-
ment to sensible people everywhere. These pestiferous
fanatics must no longer be permitted to kill children
without punishment. Themselves they have a perfect
right to kill, if they are of age, and no one will unwisely
try to deprive them of this right. But in the case of
minors it is a very different affair. The community,
through the administrative and legal branchas of the
government, must protect children from wrong and man-
slaughter. From this time forward there should be no
pity and no parley with these criminals. It is not a
question of religion or of freedom of conscience or free-
dom of worship. No one would take these liberties
away even from the most foolish and most fanatic. But
when folly of opinion passes into acts of crime then there
is nothing that will meet the demands of the ca.se but
the iron hand of the law. Land such Quimbys and
Lathrops in the penitentiary and there will be a speedy
end of eddyite " manslaughter in the second degree."
A foolish ahuse of the word "scientist" is
creeping into use by the inattention of newspaper
reporters, and even some medical writers are so thought-
less as to continue it. The same issue of a daily paper
will, for instance, speak of " the prosecution of the
scientists" meaning the eddyites, and of "the session
of the Scientists," referring to some real science society.
In American Ifedioine the followers of Mrs. Eddy are
rightly called eddyites. They have no reason to object to
the term and should be made to accept it. Of all possible
names they should not be called by those they have
blasphemously tried to preempt. It is a common outrage
to Christianity and science to allow them to seize upon
the two best things in the world as names for their
irreligious lunacy. Let us eall them by no other term
than eddyites !
Milk Inspection in Chicago.— An increased proportion of
samples of milk below grade have been found by the milk
inspectors, but this is attributed to the fact that their labors
have been directed to the poorer districts. The health depart-
ment has resumed the publication of the names and addresses
of dealers who sell " skimmed milk " for " whole milk," so
that consumers may refuse to patronize them. It is announced
that the war against dealers whose families and depots indicate
that they cannot handle milk properly will be waged with even
greater severity than in the past. Several samples of milk
have been found adulterated with formalin. Suits were
promptly begun against the offenders, and will be pushed
vigorously.
November S, 1902]
AMERICAN NEWS AND NOTES
lAVEBICAN UKDlCVUa 723
AMERICAN NEWS AND NOTES.
OENERAI/.
Lepers in the Philippines. — It is reported that there are
3,063 lepers in the various provinces of the Philippine Islands.
Smallpox in Barbados.— Since July 13 there have been 1,090
cases of the disease reported. Of these 212 patients have been
discharged cured, and 41 have died. Vaccination is going on
rapidly, over 20,000 persons, or about one-tenth of the entire
population, have already been vaccinated.
Miscellaneons. — Baltimore, Md. : Dr. Frederick H. Balt-
jer, assistant resident physician of the Johns Hopkins Hospital,
has started to Europe to make a study of the x-ray treatment
of cancer. Philadelphia, Pa. : Dr. S. Weir Mitchell has
returned to this city and resumed practice.— A largely at-
tended dinner was tendered to Dr. William W. Keen and Dr.
Horatio C. Wood on November 6, to celebrate their safe return
to this country after a long absence. Ann Arbor, Mich. : Dr.
Eliza Mosher, professor of hygiene and dean of the women in
the Michigan University, has resigned her position and gone
into private practice in Brooklyn.
Lack of Army Surgeons. — The board in session at Wash-
ington has examined a large number of applicants for the 40
vacancies that exist in the grade of assistant surgeon, but only
five have been selected. The examinations are said to be so
severe that only a young physician far above the general aver-
age can pass successfully, and unfortunately there are few
inducements for this class to apply for the positions. For
instance, the pay of the new assistant surgeon, which is only
about 1^1,600 a year, and the slow advancement in position, may
be cited as reasons why many prefer thequiet routine of general
practice to the strenuous work of the army surgeon.
Prizes Awarded by the Maltine Company.- The two
prizes of 81,000 and ^iOO offered last January for the two best
essays on " Preventive Medicine" have been awarded by the
judges. Dr. I^wis, of New York; Dr. Reed, of Cincinnati, and
Dr. Rhodes, of Chicago, who met for a final consultation in
Buffalo. There were 209 essays submitted in competition, and
although nearly every State in the Union was represented in
the contest, both prizes were won by Philadelphia men. The
81,000 prize was awarded to Dr. W. Wayne Babcock. His essay
is entitled " The (ieneral Principles of Preventive Medicine,"
and Wiis submitted under the nom de plume "Alexine." The
8500 prize was awarded to Dr. Lewis S. Somers. His essay is
entitled "The Medical Inspection of Schools— a Problem in
Preventive Medicine," and was submitted under the nora de
fdume " Broad." The two successful essays will first be pub-
ished in representative medical journals, and then in perma-
nent form for gratuitous distribution to the profession at large.
Hospital Benefactions.- Baltimore, Md. : Dr. and Mrs.
C. A. Herter, of New York City, have given 825,000 for the
foundation of a memorial lectureship in the medical depart-
ment of the Johns Hopkins University, their object being to
promote a more intimate knowledge of the researches of foreign
investigators in the realm of medical science. Kach year some
eminent worker in physiology or pathology will be invited to
deliver one or more lectures at the Johns Hopkins University
upon a subject with which he has been identified. The lecturer
will receive as an honorarium the annual income of the endow-
ment. Boston, Mass.: Undertho willof thelate Mary Ijouise
Ruggles, of Boston, the Massachusetts General Hospital receives
810,000; the Massachusetts Homeopathic Hospital and the Mas-
sachusetts Charitable Eye and Ear Infirmary each receives
83,000. — The late Lament G. Burnbam bequeathed to the Boston
City Hospital the sumof $150,000, to be expended in erectinga
building to be known as the Lament G. Burnhain ward.
Sauatowa, N. Y. : The late 8. M. Rickard, of this city, left
8200,000 to be distributed among various charitable in.stitutions,
among which are the Saratoga Hospital and the Saratoga Home
for Children.
KASTERN STATES.
Compulsory V^accination for Somcrville. — It is reported
that the Health Board of Somerville, Mass., has ordered that
all the inhabitants of the city who have not been successfully
vaccinateti since .lanuary 1, 1898, shall be vaccinated at the
present time. All persons who violate the regulation will be
proseciite<l.
Htillman Infirmary at Harvard. — A circular recently
issued to advise studenu of the Infirmary's readiness to receive
patients brings to notice the fact that there are no wards for the
treatment of contagious disease.". In view of the fact that it is
chiefly those students who (contract contagious diseases that
require a college infirmary this omission is most unfortunate.
The institution has no enaowmont fund and, therefore, various
methods to meet the running expenses are under consideration.
The best suggestion odered thus far seems to be the establish-
ment of a system of voluntary sick insurance, but to do this it
is necessary that 2,000 students subscribe, and at present this
seems to be very unlikely. However, if it should prove a
success those who do not subscribe will be treated^^at a charge
of 82 a day, extra charges being made for private rooms and
special nurses except in the case of a needy student.
NEW YORK.
Alleged Victims of the X-rays.- Two suits to recover
damages for injuries caused by the use of the x-ray are now on
trial in the New York courts. One suit is against Prof. Samuel
Lloyd, of the Postgraduate Hospital. The plaintiff is a Mr.
Durst, who in the summer of 1900 suffered from an abdominal
disease. After a consultation with several physicians he went
to the Postgraduate Hospital wheie he had two radiographs
taken, from which his trouble was diagnosed as appendicitis.
His suit is to recover 850,000 damages for a "burn" which he
claimed resulted from the use of tlie x-ray. The other case is
that of a woman who claims that as a result of an attempt to
diagnose an affection of the left jaw bone by means of the x-ray
the left side of the face was severely burned and permanently
scarred and injured, she had lost all her hair, and that her nerv-
ous system was completely wrecked as a result of the opera-
tion. Her suit, which is also for 8^0,000, is against Michael
O'Connor, an x-ray specialist and Drs. Nelson Shields and
George F. Jernlgan, dentists, who advised the use of the x-ray.
This suit has been dismissed.
A United Profession in New York.— From a telegram
received from our New York correspondent just as we go to
Sress we are led to believe that the long-hoped-for union of the
ew York profession is soon to be realized. The matter came
before the annual meeting of the New York State Medical
Association. Our correspondent wires that the joint com-
mittee representing the New York State Medical Associa-
tion and the Medical Society of the State of New York agreed
to recommend the adoption of the name of the Medical Society
of the State of New York and the present organization of the
New York State Medical Association, and to apply to the legis-
lature at its next session for a new charter under this agree-
ment. The New York State Medical Association adopted a
resolution to the effect that the committee representing it be
continued for the purpose of cooperating with a committee
from the Medical Society of the State of New York to secure a
charter at the next session of the legislature in 1903 which shall
reconstitute the two State organizations into one State body. —
[Journal American Medical Association.']
PHIIjADEIiPHIA. PENNSYXiVANIA. ETC.
Abnormal Fear of Cats.— Dr. S. Weir Mitchell, 1524
Walnut street, Philadelphia, desires to hear of cases of fear of
cats and of persons presumed to be art'ected variously by cats
when the animal is not known to be in the room. On hearing
of such cases Dr. Mitchell will forward a set of questions to
which he will desire careful replies.
A Unique Coincidence.— A few days ago a Miss Death
was brought to the (merman Hospital to be operated upon
for appendicitis. She was a daughter, she said, of an under-
taker. The surgeon's name who was chosen to perform the
operation was Dye — Dr. Frank Hackett Dye. When the opera-
tion was over, Miss Death, by Dr. Dye's (firections, was placed
in a private ward in charge of two nurses. Miss Payne is the
day nurse; Miss Grone is the night nurse. The patient is
recovering rapidly, and in a week or so Miss Death will bid
good-bye to Dr. Dye, Miss Payne and Miss Grone. — [Public
Ledger.]
The Pharmacopeia of the German Hospital of Phila-
delphia has recently been issuetl by the trustees. It contains
a list not only of tlie drugs of the United States Pharmacopeia,
but also a number of the newer synthetic remedies, a large
number of formulas that have been designed to replace some of
the more popular proprietary preparations, and a number of
fornuilas of stock preparations that have been in use in the
hospital for upwar(l of ten years and the efficacy of which has
been sufficiently demonstrated to entitle them to continued
use. In addition, the book contains directions for treating
cases of poisoning, a table of the maximum doses of potent
remedies, giving the maximum single dose as well as the max-
imum dose that may be given in 24 hours, etc. A distinctive
feature of the pharmacopeia is that the quantities throughout
are in the metric system, a system used exclusively through-
out the hospital.
SOUTHERN STATES.
Blacklist Adopted.— The Macon Medical Society of Georgia
has adopUKl a Ijlacklist upon which appears the names of those
who are financially able to pay the (locUir's fee but who refuse
to do so. It is agreed that hereafter modi<^al attendance will be
refused such persons unless the fee is paitl in advance.
Episcopal Eye, Ear, and Throat Hospital of Wash-
ington.— A new building, with a frontage of .57 feet and a depth
of 112 feet, will be addo(r to the institution. The lot has been
bought and over $11, 0(X) has been subs(Tlbed and paid into the
treasury as a building fund. Building operations will liegin as
soon as the required additional funds are subscribed.
724 AHEBICAir Medioinbi
FOREIGN NEWS AND NOTES
fNOVKMBKR 8, 1902
"WESTERN STATES.
Indictment for Grave Robbery. — It appears that in
Indianapolis tiie robbing of graves has been carried on to a
large extent. Some of the ghouls have given information to
the legal authorities which has led to the indictment of a num-
ber of persons, including several physicians. It is asserted
that parties connected with medical colleges other than at
Indianapolis are implicated. A State without proper provision
for dissecting material is an anachronism, but there is much
just indignation over the acts of these vandals.
Common Drinking Cups to be Abolished from Chi-
cago Schools. — At a recent meeting of the Board of Education
resolutions were adopted looking to the abolishment of the
common drinking cup in the public schools of Chicago. It was
declared that the use of drinking cups at fountains and public
drinking places where persons afflicted with infectious di.seases,
such as tuberculosis, follicular tonsillitis, etc., drink in com-
mon with the general public, by placing the lips to the vessels.
Is a means of disseminating disease and a menace to the public
health. It was, therefore, resolved that the committee on
buildings be instructed to prepare and submit to the board a
plan for a drinking fountain to be used in all the public schools
that will provide a method of taking water without placing the
lips to any vessel.
Infections Diseases in Chicago. — According to the
weekly report issued by the Health Department, nearly all
infectious and contagious diseases show a decided increase. It
is stated that diphtheria especially threatens to be more
prevalent and fatal this fall than it has been at any time since
the antitoxin treatment was inaugurated in Chicago seven
years ago. For the week ended October ^ there were reported
20 deaths from the disease, which is eight more than for the
corresponding week of last year. This increase is made more
significant by the growing frequency with which diphtheria
bacillus is found in the laboratory examinations— an increase
amounting to more than 55% within the last two weeks. Pneu-
monia, influenza and scarlet fever are declared to be next in
order of frequency. The department recommends the inhala-
tion of forraaldehyd gas, which, it is declared will, in many
instances, cut short the'symptoms if used at the onset of cough-
ing, sneezing, running of the eyes and nose, or other premoni-
tory symptoms.
FOREIGN NEWS AND NOTES
OENERAL.
Against Bubonic Plague. — It is announced that the
government of the Punjab has issued an order directing that
the entire population should submit to inoculation against the
disease. It is said that no opposition has been offered, and the
work is progressing satisfactorily. Several native regiments
have presented themselves in bodies for the treatment.
Cholera in the Baat.— The fearful ravages made by the
disease are demonstrated by mail advices received by the
Marine- Hospital Service. It is estimated that the number of
cases occurring in the Philinpines since March 20 aggregate
75,000, with a mortality of 75%. Although, as before reported,
the disease has practically disappeared from the provinces first
infected, those recently infected are still suffering severely.
The situation in the Province of Iloilo and the adjacent island
of Negros is said to be especially alarming, some of the towns
being reported as having lost fully 10% of their population. In
Japan there have been 4,329 cases and 1,650 deaths. In China
there have been nearly 40,000 deaths in Nanking, and an
epidemic in nearly every city in the Province of Hunan and
Stansi. Egypt is reported to be infected at 1,557 places. For
the 11 days ended September 19 there were registered 13,515
cases and 12,0.39 deaths, while in Alexandria for the 12 days
ended September 20, 99 cases of cholera occurred among Euro-
peans, with 66 deaths.
Bubonic Plague in Yokohama.— The excellent results
attained by the stringent measures which have been enforced
against bubonic plague are evidenced by the fact that thus far
only five cases have occurred. The disease is believed to have
been introduced into the city by raw cotton from India. So
soon as the first case was authenticated a military cordon was
established around the district involved, and the whole area,
consisting of several blocks, was walled in by a board fence,
eight feet high, closely guarded. A price was set on rats, and
up to the present writing over 2,000 have been destroyed in the
quarantined district. Not content with cutting off the infected
district the authorities determined to remove its populace, and
for this purpose temporary buildings were erected at Kanagawa
Fort, an elevated point across the bay from Yokohama, and
the first instalment of 360 people have been taken there. The
government undertakes the support of the 1,240 persons in
quarantine, which it is estimated will cost $20,000 for the 20 days
considered necessary. The greatest precautions are taken to
prevent the spread of the disease to other towns. The popula-
tion is forbidden to walk barefooted, and passengers by local
trains are subjected to strict inspection by the liealth author-
ities.
GREAT BRITAIN.
Insurance Against Surgical Operations.— In order to
.secure the indej)endence of the working classes while phys-
ically incapacitated a movement lias been started in Great Britain
to provide insuran<'e against surgical operations. Attention is
called to the fact that the expense of an illness including an opera-
tion, medical attendance, nursing, etc., is so great that there
seems to be no possibility of effective provision for it, unless
some such scheme is adopted. It is proposed that for a certain
specified annual payment a subscriber be entitled to (1) a sum
down, or (2) free admittance to a nursing home and a free
operation.
OBITUARIES.
Frederick A. Packard, a prominent physician of Philadelphia,
November 1, aged 40. About a mouth ago Dr. Packard was taken ill
with typhoid fever, which, early in its course, became complicated
with appendicitis, necessitating surgical intervention. He bore the
operation well and was progressing satisfactorily, when Intestinal per-
foration developed. Although operated upon skilfully and without de-
lay, his life could not be saved. In 1885 he was graduated from the
medical department of the Univei'sity of Pennsylvania at the head of
Iiis class, taking three first prizes and one second prize. He then
became resident physician at the University and Pennsylvania Hos-
pitals successively and later was for three years assistant to the late
Dr. William Pepper in his private practice.
Dr. Packard was a remarkably correct diagnostician, and exhibited
a breadth of view and a soundness of clinical judgment by no means
common in this ultra-scientific age. As a therapeutist he had few
equals, and his lectures at the University of Pennsylvania upon this
subject excited great admiration. He was also consulting physician
to a number of Homes and hospitals. Comparatively early in his
career he became visiting physician to several hospitals— the Episco-
pal, Children's, Philadelphia and Pennsylvania— and filled these posi-
tions, not alone to the .satisfaction of their governing bodies, but also
to the eminent advantage of the young physicians who had the honor
of serving under him. His medical writings cover a wide field ; but
he was especially fond of pediatric subjects, and many of his contribu-
tions relate to diseases of children. For a man of his age. Dr. Packard
had held an unusual number of high and important offices. He had
the distinction of being a trustee of the University of Pennsylvania,
and had been president of the Pathological and Pediatric Societies. In
the College of Physicians he h'jd filled two important elective offices.
Dr. Packard's personality had a peculiar charm which endeared
him to all who knew him. He was sincere, unassuming and modest,
and possessed a dignity of character and deportment that made him
an exemplar to his juniors in the profession. He might, indeed, be
well termed an ideal physician ; for, besides these intangible qualities,
he possessed the attractions of a splendid physique and an extremely
melodious voice. The loss of a physician so generously endowed by
nature, and with a career so full of promise as that of Dr. Frederick A.
Packard, is a public calamity.
ISeiijamin I.. Bird, at his home near L.eeland, Prince George's
county, Md., October 31, aged 61. He was graduated from the Univer-
sity of Maryland in 18&1. For many years he was secretary of the
County Board of Health.
H, Marcus Schnetzler, a wellknown physician of Toledo, Ohio,
October 10, aged about 70. He was gi-aduated from the Starling Medi-
cal College, Columbus, Ohio, in 1862. He was a member of the Toledo
Medical Society.
Harvey W. Ralney, of Indianapolis, Ind., October 15, aged 48. He
was graduated from the L/ong Island College Hospital in 1882. He wa.s
resident physician in the Central Hospital for the Insane, Indianapolis,
for seven years.
Robert G. Kothrock, a prominent physician of Nashville, Tenn.,
October 9, aged 66. He was graduated from the University of Nash-
ville in 1861 and served as surgeon of the Fiftieth Tennessee during the
Civil war.
Walter B. Orlffln, assistant surgeon in the navy, died at the Cavit4
Naval Station, Philippine Islands, October 28. He had only been in
the service eight months, having been appointed from Michigan Feb-
ruary 20.
Chauncey Coston, a wellknown physician of ChilUcothe, Mo.,
October 19, aged 86. He was graduated from the Castleton (Vt.) Medical
College in 1848. He served as an assistant surgeon during the Civil
war.
John T. Field, assistant physician at State Hospital for the Insane,
No. 2, St. Joseph, Mo., died in that institution October 7, aged 34. He
was graduated from the Missouri Medical College, St Louis, in 1891.
NOVSMBBR 8,
SOCIETY REPORTS
lASERICAN MbDICINB 726
Ringwald J. Gregersen, an interne In St. Joseph's Hospital,
Denver, died suddenly in that institution, Octoljer 14, aged 41. He was
graduated from the Colorado School of Medicine, Boulder, 1901.
Oscar Cole Stout, at Syracuse, N. Y., October 29, aged 59. He was
graduated in 1875 from the American University of Pennsylvania,
Philadelphia, an eclectic school which became exUnct in 1880.
I. Newton Goir, of Cazenovia, N. Y., October 13, aged 6tf. He was
graduated from the College of Physicians and Surgeons, New York, in
1858 and was a member of the American Medical Association.
John H. Abbott, of Fall River, Mass., November 1, aged W. He
was tgraduated from the Jefferson Medical College, Philadelphia, in
1872. He was mayor of Fail Kiver in 1900 and 1901.
James J. Norton, of Monroe City, Mo., October 16. He was gradu-
ated from the Missouri Medical College, St. Louts, in 1852, and was a
member of the American Medical Association.
Joseph E. Brad way, of Oakland, Cal., October 11, aged 84. He was
graduated from the Rush Medical College, Chicago, in 1847. At one
time he was health officer of Oakland.
E. P. Smith, of Cleveland, Tenn., died at Chattanooga, Tenn.,
October 15, aged 42. He was graduated from the Hospital College of
Medicine, l^oulsvllle, in 1890.
Marcus E. Sanborn, of Eagle Kiver, Wis., died at M'auwatosa,
Wis., October 11, aged :U. He was graduated from the Medical College
of Ohio, Cincinnati, in 1891.
William H. Everson, of Pratt, Kan., at Kansas City, October ».
He was graduated from the College of Physicians and Burgeons,
Keokuk, Iowa, In 1881.
Charles E. Blallaui, at Washington, D. C, October 29. He was
graduated from the medical department of the Howard University,
Washington, in 1882.
Ernest «. Csrieton, suddenly at MorencI, Ariz., October 20, aged
,37. He was graduated from the College of Physicians and Surgeons,
New York, In 1892.
M. Walter Brooks, of New York City, died In Berne, N. Y., October
14, aged .39. He was graduated from the University of Vermont, Bur-
llngt )n. In 1879.
David M. UcDonsId, at Gatchellvllle, Pa., Octotrer 26, aged 50.
He was graduated from the Eclectic Medical Institute, Cincinnati,
Ohio, in 1878.
Alfred Letourneau, of Alpena, Mich., died at Artbabaskerville,
P. I., October 6. He was graduated from the Lival University, Quebec,
in 18s«.
William L. Mathers, of Bowling Green, Ohio, October 8, aged 41.
He was graduated from the Cincinnati College of Medicine and Surgery
in 1895.
Clarence M. Burnham, at Watseka, 111., October 18, aged 21. He
was graduated from the College of Physicians and Surgeons, Chicago,
In 1902.
Daniel A. Fogarty, of New York City, N. Y., October 5. He was
graduated from the Bellevue Hospital Medical College, New York, In
1896.
C. E. Leaphart, of Charleston, S. C , October 6, aged 57. He was
graduated from the Medical College of the State of .South Carolina In
1871.
George E. Mecuen, at Roxbury, Ma-ss., October 25!, aged 59. He
was graduated from the Harvard Medical School, Boston, in 1875.
Edwin F. De Graifenrird, at Wynnton, Oa., October 5, aged 79.
He was graduated from the University of Penn.sylvanla In 1816.
C. Edwin Poyntz, in Point Lick, Ky., October 21. He was gradu-
ated from the Hospitiil College of Medicine, Louisville, In 1891.
Thomas L. Terry, In Jennings, La., October 15, aged 40. He was
graduated from the Louisville (Ky.) Medical College in 1888.
AntoniuH A. Kowley, at Mlddleton, Wis., October 2. He was
graduated from the Rush Medical College, Chicago, In 1868.
Lorenzo P. Barrows, at Albany, N. Y., October 12, aged 83. He was
graduat<-(l frf)m the Albany Medical College, N. Y., In 1844.
Alfred P. Haynes, In Wahoo, Neb., October 1:!, aged 51. He was
graduated from the Omaha (Neb.) Medical College In 1809.
Charles M. Strlckler, of West Rockingham, Va., October 28. He
was graduated from the Virginia Medical College in 1892.
Lytton W. Pllley, at KIssimmee, Fla., October 4. He was gradu-
ated fn)m the Washington University, SU touls, in 1880.
K. W. Murphy, of San Francisco, Cal., October 21. He was a
graduate of the Cooper Medical College, San Francisco.
Fred. C. Sarver, in lilochcr, Ind., October 7, aged 30. He was
graduate<i from the Baltimore Medical College in i89.'>.
AI>hott M. Mason, in New Roehelle, N. Y., October SO, aged 65. He
practised for many years In Chatham, N. Y.
James E. Haines, of Rowlandsvllle, Md., November 1, aged
about iio.
Asa J. Childress, a retired physician, died at Terrell, Texas, Octo-
ber 15.
John 8. Cameron, at Evansport, Ohio, October 9, aged 88.
Horace Stlmple, at Concordia, Mo., October 16.
SOCIETY REPORTS
THE NEW YORK STATE MEDICAL ASSOCIATION.
Nineteenth Annual Meeting, October 20, 21, 22 and 23, 1902.
[Specially reported for American Medicine.)
[Continued from page G90.]
New Apparatus for the Treatment of Ksophageal
Stricture.— Theodore Dunham (New York) demonstrated
most successfully a new apparatus of his own devising by
means of which with the aid ol a little water a thread could be
carried down into the stomach.
President's Address.— A lvin A. Hubbell made medi-
cal ethics the subject of his discourse, and pointed out the part
the Association had played during the last 20 years in this
respect. He referred to Percival, of Manchester, Eng., whose
book, published many years ago, had been the guide in
Britain. Tliere were medical ethics in all countries, and the
code of ethics of the American Medical Association had exer-
cised a tremendous moral power in the United States. Some
looked on it as effete, but it was as vital as ever. It interfered
with nothing that was right, and State laws never could be a
substitute for it. Politics could be brought to bear upon State
laws so that osteopathy, christian science, and what not, might
be legalized. The " unwritten code " could not always be
depended upon, and it was better to have a written code. Con-
cluding, the president advocated the carrying out of the present
system of organization, and gave them lor a motto "All lor each
one, and each one lor all."
The Pathology and Bacteriology of Typhoid Fever
from the Standpoint of Recent IiiTCStigatious. — Georoe
Blumer (Albany). Tlie bacillus was found in the urine and in
the blood, and of late years 154 cases had been reported, in 98 ol
which typhoid bacilli had been isolated from the blood. The
blood of itsell exerted a germicidal action, and it was necessary
to obtain large quantities to offset this action. The presence of
the bacilli in the blood did not necessarily indicate severity
of the case. Sometimes the bacilli were found in the blood
before shown by the Widal reaction. Their presence in the
urine was ol diagnostic value. As a rule the bacilli did not
appear in the urine until the end of the second week, and some-
times as late as the forty-second day. Their number was
simply enormous, showing what might be excreted daily even
after the patient was convalescent. This showed the necessity
for disinfecting the urine as well as the stools of typhoid
patients. Bacilli in the bile had first been observed in 1888. It
had been estimated that 70% ol the cases ol death were due to
perforation ol the gallbladder. It was possible that gallstones
might precede the attack and predisj)Ose to typhoid.
Paratvphoid Fever.— Nathan E. Brill (New York)
had found many cases which presented the appearance of
typhoid lever in which the typhoid bacillus was not to be lound
and the Widal reaction was absent. His opinion then was
that it was a specific and distinct disease. Laboratory investi-
gation had led to the discovery of other bacilli which had not
yet been properly identified. There were two groups ol cases.
In the first, which very closely re.sembled typhoid in its symp-
toms, the prostration was acute, even more so than in typhoid.
The duration ol the fever in the first was not over five days,
and in the second a little over two weeks. These cases were
now known not to be so rare as at first supposed, many cases
having been reported during the past year.
Arteritis and Arterial Thrombosis in Typhoid Fever.
— W. S. Thayer (Baltimore) gave the history ol five cases.
In one ease the patient died on the twenty-second day and no
necropsy (!0uld be had. In another, that of a boy, 18 years of
age, the fluctuations were remarkable, and it was not until the
seventy-ninth day that the boy left the hospital cured. Among
the questions which the author wished to liave solved were,
How to account for the disappearance of pulsation, and what
was theexciting cause in thechangeofthearteries? Knowledge
on the subject was yet incomplete.
The Modern Treatment of Typhoid Fever.— W. Oilman
Thompson (New York) said antiseptic treatment might yet be
readied. He was against the administration of calomel in
daily doses, although the initial dose might be useful. When
milk diet was inadvisable the patient should be nourished with
broths, egg albumen mixture, etc. The mouth should be kept
clean with hydrogen dioxid, and the patient should be given as
much water as he can <irink. Bathing should act as a stimulus
as well as reducing the temperature. The patient should never
be left to shiver. In the case ol intestinal hemorrhage lood
shoitld be withheld from the stomach. He had lound the supra-
renal extract do good in such eases, but not always. In a num-
ber of cases hypoderino(rlysis or a saline solution had produced
remarkaiile results. All typhoid cases could not bo treated by
one rule, and it was hard to say that a change ol diet, under
proper regulation and supervision by the physician, would not
be a good thing.
Report of an Interesting Case of Typhoid Infection.-
Albert W. Preston (Middletown) related the history of the
case of a young woman, aged 27, who, in .laniiary, 1802, com-
plained of headache and loss of appetite. Tho po.ssibility ol
typhoid was not then considered, but on the third day a temper-
726 AXSKIOAIT MeDICIKB]
SOCIETY REPORTS
[NOVEMBEE «, 1902
ature ol 105° was reached and indications of typhoid fever were
found in the stools. The history ol the case up to the present
was given and showed that it was one of hemorrhagic pleurisy,
and that the patient had been aspirated on several occasions,
when typhoid bacilli were found in the fluid. The conclusions
drawn were that the hemorrhage might or might not have been
an accident ; that it might be limited to the lung and pleura
without appearing in the intestine ; that typhoid might begin
in the thorax and extend to the intestine, and that pleurisy
might appear later.
[To be concluded.]
BUBONIC PLAGUE IN CALIFORNIA.
History of the Outbreak and Resolutions Passed at the Con-
ference of State and Provincial Boards of Health of
North America, Held at New Haven, Conn., October 29,
1902.
[Specially reported for American Medicine.]
At the meeting of the State and Provincial Boards of Health
ol North America, held at New Haven, Conn., October 29,
1902, the following history of the outbreak of bubonic plague in
California was recited, and the appended resolutions were
passed. The preamble and resolutions were presented by the
delegates from Maine, and their adoption was moved by the
delegates representing the State of Maryland, seconded by the
delegates from Pennsylvania and Connecticut. Seventeen
States were represented and voting, and in addition the
United States Army, Navy and Marine-Hospital Service and
Canada were represented, their representatives, however, not
voting. The text of the preamble and resolutions is as fol-
lows:
Whereas, Bubonic plague has been present in California
since March, 1900, information as to the extent of the disease
being withheld by the local authorities, no effective measures
of restriction having been put into operation, and the history of
the outbreak, so far as we can ascertain from authoritative
sources, being as follows :
March 6, 1900, a case ol bubonic plague was discovered by
Dr. W. H. Kellogg, bacteriologist to the San Francisco Board of
Health, the diagnosis being confirmed by surgeon J. J. Kin-
youn, of the United States Marine-Hospital Service.
March 7, the City Board of Health of San Francisco quaran-
tined the whole of Chinatown, pending investigation, the quar-
antine being removed 60 hours later by order of the Mayor.
March 11, another death from plague occurred.
March 12, the City Board of Health, being without funds, at-
tempted an inspection of Chinatown by volunteer inspectors, the
Chinese being thereby incited to conceal all cases of sickness.
March 19, two more deaths from plague. The Mayor pro-
vided ?1,000 for inspection and disinfection. The deathrate for
Chinatown subsequently dropped so far below earlier experi-
ence as to suggest successful concealment or suppression of the
facts concerning death as well as sickness.
April 4, and May 2 and 13, other cases of plague discovered.
May 15, a case of plague discovered. Demands were made
of the City Board ol Health and the United States Marine-Hos-
pital Service to suppress the facts. The Surgeon-General of the
United States Marine-Hospital Service wired advice to make
house-to-house inspection in Chinatown, to disinfect China-
town, to establish a pesthouse and house of observation,
destruction of rats, and the employment of Hafkine's antipest
inoculation.
May 17, State border inspection begun by the United States
Marine-Hospital Service. Transportation companies ordered
not to furnish transportation to Chinese and Japanese except
upon certificate of Marine-Hospital ofiicer.
May 18, commercial associations urged the adoption of the
Surgeon-General's suggestion, particularly as to the use of Haf-
kine's inoculation. City Board of Health willing to undertake
this work. The City Board of Health officially announced the
presence of bubonic plague and called upon the State Board of
Health for aid.
May 19, house-to-house inspection begun. Chinese resist.
Chinese and Japanese begin to leave the city. No effective
restrictions. State Board of Health met in conference with
City Board ol Health and United States quarantine officer.
State Board of Health promises to cooperate.
May 20, public meeting ol the State Board of Health and the
City Board of Health and representatives ol railroads and mer-
cantile bodies. Railroads and mercantile bodies demand quar-
antine ol the whole ol Chinatown. State Board of Health
announces that unless this is done the remainder of the State
will quarantine against San Francisco. Chinatown accordingly
quarantined. House-to-house inspection continued.
May 21, Surgeon-General of the United States Marine-Hos-
pital Service took charge of quarantine measures in and around
Calllornia. Quarantine effective. Chinese and .Japanese popu-
lation rendered stationary within 12 hours. Gov. Henrv T.
Gage made a report on plague to U. S. Secretary of State llay.
May 22, the State Board of Health notified the State Boards
of Health of other States of the existence of bubonic plague in
San Francisco, and described the measures taken to restrict its
spread.
May 24, the Chinese companies applied for an injunction
against the City Board ol Health and United States quarantine
officer. Bribe of $40,000 offered by Chinese Six Companies to
the United States Marine-Hospital officer if the facts were sup-
pressed.
May 28, courts granted injunction prayed for by the Chi-
nese. Quarantine abandoned.
May 29, case of bubonic plague discovered. Inspection of
Chinatown suspended, but resumed by order of the Surgeon-
General of the United States Marine-Hospital Service.
June 2, case of bubonic plague discovered.
June 3, the State Board of Health of California passed a
resolution thanking United States quarantine officer for co-
operation and assistance, stating that for want of funds inspec-
tion could not be continued, and that the whole matter was
referred to the Governor, H. T. Gage.
June 9, case of bubonic plague discovered. The State Board
of Health, A. M. Henderson, acting secretary, reported to
other State Boards of Health the number of cases of bubonic
plague to that date. Dr. Henderson removed from the State
Board of Health. Dr. Haddon appointed to fill the vacancy.
Dr. Winslow Anderson appointed to fill the place of Dr. Bazet,
whose resignation had also been obtained. Merchants and citi-
zens raised §29,000 to aid the City Board of Health in cleaning
up Chinatown. United States Court enjoined local board from
molesting Chinese. Attorneys of the Chinese brought a suit of
habeas corpus upon the affidavit of a Chinaman that he had
not plague, had not been near plague, was prevented from
working and was hungry. Chinaman was released. Quaran-
tine dissolved.
June 16, contributions of Citizens' Relief Committee
stopped. Writ issued by Court ordering Surgeon J. J. Kin-
youn. United States Marine-Hospital Service, to appear belore
Judge Morrow on a charge ol contempt. Kinyoun cleared.
June 17, Gov. Gage, with the delegates to the National
Convention and the State Central Committee ol his political
party, appealed to the President of the United States to stop
the quarantine proceedings.
June 18, quarantine ordered suspended ; 3,000 Chinese and
Japanese left for various parts of the State.
June 25, proposition made by the United States Marine-
Hospital Surgeon Kinyoun to employ a special commission of
experts from outside of California to investigate the question
of the presence or absence of plague. Proposition not enter-
tained.
July 6 and August 11, cases of bubonic plague discovered.
August 15, ease of bubonic plague discovered. Dr. Ryf-
kogel, bacteriologist to the State Board of Health, dismissed.
He reported positive evidence ol bubonic plague. Dr. Ryfkogel
had received nosalary or pay. A bacteriologist appointed to
replace Dr. Ryfkogel declared that the cause of death in the
flrst case investigated by him was due to the bacillus of hem-
orrhagic septicemia, familiarly known as fowl cholera. In his
second case he identified the plague bacillus and so reported.
He was thereupon dischai"ged, and another bacteriologist was
appointed who maintained consistently the diagnosis of fowl
cholera in subsequent cases.
October 5 and 10, cases of bubonic plague discovered.
October 12, Secretary of the State Board of Health, Dr. W. P.
Mathews, wrote to Health Officer Blunt, Austin, Texas, advis-
ing him that no "suspected case" had been reported to him
within 60 days. The case of October 10 had been reported to
Dr. Mathews by Dr. Williamson.
October 14 and 31. and November 1, cases of bubonic plague
discovered.
November 3, case of bubonic plague discovered. United
States quarantine officer asked that an inspector be sent to San
Francisco.
December 7, case of bubonic plague discovered. Surgeon
J. H. White, of the United States Marine-Hospital Service, sent
to San Francisco. Reported to Surgeon-General presence of
plague.
January 6, ease of bubonic plague discovered.
January 7, Legislature of California meets. A great part ol
the Governor's message devoted to the plague question. The sec-
retary of the State Board of Health drafted a bill making it a
felony to print or publish or to make in writing a report of plague
or cholera before the public announcement had been made by the
State Board of Health. A joint resolution was introduced call-
ing upon the President of the United States to remove United
States quarantine officer Kinyoun from the Pacific Coast.
January 15, two cases of plague discovered. Surgeon
White, United States Marine-Hospital Service, recommended
the appointment of a Federal Commission of experts. Drs. L,
P. Barker, Simon Flexner, and F. G. Novy appointed.
January 24, the joint resolution asking for the removal of
Surgeon Kinyoun passed the State Senate, but failed in the
lower house.
January 28, the Federal Commission arrived in San Fran-
cisco. Rooms for the work of the Commission offered by the
Medical Department of the University of Calfornia. Before
the work was fairly started the president of the university
requested the Commission to vacate in 24 hours, as their pres-
November 8, 1602]
SOCIETY REPORTS
(Akkbican Medicins 727
I
eace in the university building endangered tiie State appro-
priations. Quarters for the Commission were furnished by
Mayor Piielan in the City Hall. Gov. H. T. Gage sent a telegram
to President McKinley complaining that an undesired commis-
sion had been sent to investigate the health affairs of California,
"ignoring the State authorities, and proceeding in the line
with reports heretofore made" by Surgeon Kinyoun. Gov.
(itage hoped that the discourtesy is not intentional. Gov. Gage
also suggested that the Federal Commission be advised to
cooperate with the State authorities and with home physicians
and bacteriologists.
January 30, Hon. Lyman J. Gage, Secretary of the
Treasury, replied to Gov. Gage, declaring the independence of
the Federal Commission, disclaiming the intent of the Treasury
Department to be discourteous.
January 31, Gov. Gage sent a message to the State Legisla-
ture, representing that the United States Treasury Department
had sent a " commission of experts to make an ex-parte investi-
gation " to be " conducted in secret," " the State being denied a
hearing," imperiling " the welfare of every citizen and inhabi-
tant of the State." He asked legislation by which the State
might assume " general and unrestrained control over the sub-
ject of public health within its borders."
February 5, 6, 7, 10, 12, 14, cases of bubonic plague discov-
ered.
February 17, Gov. Gage sent a telegram to President
McKinley complaining that the Federal Commission had not
fiven him an opportunity to meet them from January 28 until
'ebruary 16, at which time the work of the Commission was
done and the report about ready for transmission. A copy of a
letter to the Governor sent by the Commission on January 20
is found on page 25 of the Report of the Governor's Special
Committee. The Governor informed the Federal Commission
that this letter was never received. On page 26 of the same
pamphlet is a copy of the Governor's reply to the Federal Com-
mission. This reply, the Commission says, was not received.
Gov. Gage asked for a reinvestigation by a commission to
include three Federal appointees, three State appointees, and
one to be chosen by these six.
February 19, Secretary of the Treasury Gage declined to
join in a reinvestigation.
February 2.5-March 1, Gov. Gage promised to cooperate fully
and heartily with the Federal authorities and appointed iive
distinguished citizens to visit Washington for the purpose of
consultation.
March 1, report of the special commission handed to Gov.
Gage by order of the Surgeon-General.
March 10, the committee from the State of California in a
signed letter to the Secretary of the Treasury accepted the rec-
ommendations of the Surgeon-General, and "agree that the
same shall be promptly and efficiently carried out by the health
officers of the State of (Jalifornia and the City Board of Health
of San Francisco, and accept the advice and coop-
eration of Dr. J. H. White, United States Marine- Hospital Serv-
ice."
April 1, case of bubonic plague discovered.
April 4, Surgeon Kinyoun removed from San Francisco.
The special committee, with the State Board of Health, began
to arrange for the cleansing of Chinatown. In about three weeks
the cleansing was begun. Texas threatened quarantine. Sur-
geon White's advice and recommendations ignored. No cases
of plague discovered. The rates for sickness and death far
below normal. The Surgeon-General was informed by Surgeon
White that he believed that sickness and death were concealed
by the collusion of the State health authorities with the Chinese
Six Companies. The notification arrangement, according to the
Sacramento Bee, was as follows : Cases of sickness among the
Orientals to be reported first to the Six Companies, by the com-
panies to the State Inspector, and l)y the State official to the City
Board of Health and the United States Marine-Hospital Serv-
ice.
May 18, Surgeon White reports to Gov. Gage the evidence
of c<}ncealment of plague with the evidence of infection in other
parts of the State and suggests a "quiet " investigation of places
outside San Francisco.
May '28, (Jov. Gage wired Surgeon White notifying him that
no officer of the Federal Government had been requested to
"participate in an examination, etc., outside the city and
county of San Francisco. Your mere suspicion from the
improved health of the Chinese district that the sick are being
remove<l from San Francisco is not only unwarranted as a con-
clusion, but I know it to Ije unfounded in fact." Gov. Gage
offered to send "someone suitably qualified professionally to
look over the matter" with Ur. White, but did not send any
such person, nor was any investigation made outside San Fran-
cisco.
June 7, the State Board of Health of California suggeste<l to
Dr. J. H. White that the United States Marine-Hospital Service
would certify to the health authorities that there is no longer
any danger of plague. Surgeon White declined to do this, and
made a definite proposition to both the State Board of Health of
California and the Governor, providing for the completion of
the disinfection of Chinatown and tbe continued inspection of
sickness and investigation of deaths by the United States
Marine-Hospital officers.
June 8, diHinfo(^tion of Chinatown suspended by order of
State Board of Health.
June 10, Surgeon White recalled to Washington.
June 18-24, the Surgeon-General and Gov. Gage exchange
" congratulations that no cases have been found during the
progress of this work, and that the outlook is so encouraging."
July 2, a Chinese undertaker mistaking Dr. Blue, of the
United States Marine-Hospital Service, for a State health official
reported the case of a moribund Chinaman. Dr. Blue and
other investigatoi-s made a diagnosis of plague in this case. The
State officials disputed the diagnosis and ascribed the death to
syphilis. Next, 3 Japanese women were found ill with plague ;
2 died and 1 recovered. The 2 deaths were charged by the
State officials to sewer gas.
August 31, September 1, 11, 16, cases of bubonic plague dis-
covered.
September 16, Gov. Gage's special committee published its
report, which concludes : " San Francisco is and has been abso-
lutely free from the disease, and those who said it existed were
either mistaken or deliberately misrepresented the facts." To
this is appended a report of the State Board of Health, signed
by W. P. Mathews, secretary, which concludes: "We take
great pleasure in assuring you that plague does not exist in San
Francisco, and that it has never had lodgment there nor else-
where in California."
September 27, two cases, and Octoljer 10, 19, 22, 30, single
cases of plague discovered.
October 30, E. E. Schmitz, newly-elected Mayor of San
Francisco, addressed a letter to Drs. Williamson, Baum, Buck-
ley an I Leavitt, composing City Board of Health, removing
them from office, appointing in their stead Drs. J. Coplin-Stin-
son, A. S. Adler, T. A. Rottanzi and M. E. Van Meter. The
Mayor was enjoined by the City Board of Health, and the old
board still remains in office. Funds are not furnished. From
this time scanty information is obtainable, no published com-
munications between the United States Marine-Hospital Serv-
ice being available, and those who conspired to suppress the
facts being in complete command of the situation.
November 4 and December 12, 1901, and February 22, April
20, May 19, 28, 29, July 13, 18, 19, 20, 21, August 7, 17, 19, 20, 22, 23,
25, 26, 31, cases of bubonic plague discovered.
August 31, ?1,000 appropriated to disinfect premises and to
September 9, 11, 16 (2), 20, 23 (2), 26 (2), October 5 (3), 8,11,18,
17, cases of bubonic plague discovered.
Total cases reported to October 17, 88.
And Whereas, Thirty of these cases have occurred since
July 13, 1902, no information as to their origin or exact loca-
tion having been furnished, no effective steps having been
taken to restrict the spread of the disease, the City Board of
Health of San Francisco being helpless, and the malafldes of
the State Board of Health of California having been fully estab-
lished by the foregoing history, supported \>y documentary evi-
dence in the possession of this Conference ; therefore
Be it Resolved, That the Conference of .State and Provincial
Boards of Health of North America views with abhorrence the
irretrievable disgrace of the present State Board of Health of
California, and pronounces the plague situation in California a
matter of grave national concern ; and
Be it further Resolved, That the National Conference of
State and Provincial Boards of Health of North America does
hereby advise the various State Boards of Health of the United
States to consider the propriety of calling upon the Surgeon-
General of the United States Public Health and Marine^os-
pital Service to arrange at the earliest possible date a joint
conference for the purpose of eradicating plague from the
United States.
Trachoma In New York City. — Considerable interest has
apparently been caused over the prevalence of trachoma. Not a
few children have been excluded from the schools, and the
hospitals and dispensaries devoted to diseases of the eye have
noticed a marked increase in the number of patients suffering
from the disease. A conference of physicians has been held in
the city to secure correct data on the subject and to devise the
best means of combating the malady.
Mortality of Indiana.— The total number of deaths for
September was 2,312. This is a deathrate of 13.6, and is exactly
the same rate as appeared in the statistics for the corresponding
inontli last year. The number of deaths under one year was
536, or 20% ; between one and five years, 288, or 10.7% : 65 years
and over, 613, or 22.9%. The important causes of death were as
follows: Pulmonary tuberculosis, 282 : other forms of tuber-
culosis, 51; typhoid fever, 2;?2; diphtheria, 34 ; scarlet fever, 7;
whoopingcougn, 16 ; pneumonia, 112; diarrheal diseases under
five years, .322; cerebrospinal meningitis, 24 ; influenza, 6 ; puer-
peral septicemia, 17; cancer, 114; violence, 105. In comparing
those figures with those of the. same month last year we find there
is an increase in the rate for pulmonary tuljerculosis of 8.8, for
typhoid fever there is an increase of 21.6, and for pneumonia the
increase is 18.9. Smallpox for the twentieth consecutive month
was the most prevalent disease. There were 219 cases reported
with three deaths. In the corresponding month last year there
were 80 cases reported with no deaths. Typhoid foVBr was the
next most prevalent disease during the month, and the same
order prevailed in the preceding month. All diseases of the
respiratory tract increased in area of prevalence, while the dis-
eases of the intestinal tract showed a decrease.
728 AmtBIOAN MKDXOrNE
00REE8P0NDENCE
[November 8, 1»02
CLINICAL NOTES AND CORRESPONDENCE
[Communications are Invited for this Department. The Editor Is
not responsible for the views advanced by any contributor.)
AN UNUSUAL CASE OF MORTON'S DISEASE (META-
TARSALGIA) TREATED BY A NEW METHOD.
J. M. HEYDE, M.D.,
of Loudonvllle, Ohio.
Cask. — The patient was M. R. W., a minister, aged 5.S.
Previous aud i)reseut health good. In June, 1902, he sustained
an injury to the fourth and fifth toes of the left foot by having a
heavy piece of timber fall on the foot. The injury was of a
trivial nature and no attention was paid to it at the time, other
than the use of the common household remedies for a contusion.
In a few days after the injury he was about as usual. It gave
him no further trouble until one Sunday morning in June of
1902. He was seized with an agonizing pain in the fourth toe of
the left foot. The pain was so severe that he had to leave his
pulpit and try to relieve the pain with local anodynes. The
pain, however, continued unabated for several days. When I
first saw him, examination revealed an axial rotation outward
of the fourth toe, a relaxed metatarsophalangeal articulation of
the same toe and considerable tenderness between the third and
fourth toes. There was no evidence whatsoever of any inflam-
matory trouble in the toe, nor was there any evidence of there
ever having been a fracture or dislocation. The condition stub-
bornly resisted all attempts to relieve the pain, until the treat-
00^0
^tk ^^ 'JtJv ftiv
HxL 5^
Fig. 1.— Transverse section through fourth and fifth toes of the normal.
Fig. 2.— Transverse section through fourth aud fifth toes of this pa-
tient. Fig. 3.— Diagram showing the correct on of the rotation after
applying the plaster; also shows method of application.
ment to be described was used. Believing that the external
branch of the musculocutaneous nerve was subjected to unusual
pressure or tension by the outward rotation of the proximal
phalanx of the fourth toe, I used the following method of correc-
tion : A strip of surgeon's ordinary adhesive plaster (j in. wide
and 5 in. long) was started at the upper side and inner side of
the fourth toe, carried around under the toe, up the outer side,
across the top of the toe to the place of starting; this was
repeated again until the outer side of the toe was reached,
when it was drawn tense, carried up between the fourth and
fifth toe and given a turn around the fifth toe to anchor it. The
result was that it corrected the outward rotation of the toe and
relieved the pain almost immediately. The treatment was con-
tinued for a month, with complete relief to the patient. At the
end of this time the plaster was dispensed with, and there has
been no return of the trouble.
The method (so far as I am able to ascertain) is original with
me. I can find no mention of the treatment here used in the
literature at my disposal. The method is Illustrated by the outs.
THE PSYCHOLOGY OF THE ALCOHOL QUESTION.
BY
J. L. TRACY, M.D.,
of Toledo, Ohio.
To the Editor of American Medicine: — Your editorial crit-
icism upon the teachings of our public school textbooks as to
the physiologic effects of alcohol and tobacco, seems to me to
emphasize that curious trait of our psychologic makeup, that we
are always prone to condemn more intensely what we consider
to be an ill advised or devised attack upon wrong than we do
the wrong itself. In this present instance the alleged perni-
cious effects upon the scholars, of the fanatic teachings of these
school physiologies suggests the question, Are not the lager beer
brewers and the whisky distillers, and not the W. C. T. U.,
back of the misleading, un.scientific and "disgusting" teach-
ings of these books? It would throw some light upon the sub-
ject if it could be known definitely whether such ideas as
"liquor books" originated in the minds of the scholars or
whether the childish idea was first thought out by the teachers.
Possibly, also, the response which the Buffalo scholars gave to
the question may have been a teacher's reflex.
When one party to an argument finds out for a certainty
that his opponent is a " fanatic," the impression prevails at once
that the greatest possible depth of argument on his side has
lieen reached. But another strange psychologic fact is that a
person who does not use alcohol or tobacco is much more likely
to be fanatic, to have biased opinions and hence unreliable,
than one who does use them. Why this is so is inexplicable,
but that it is true is abundantly proved in that so many who
argue the alcohol side of the question discover the defect in
their opponents. In this city a man of brilliant intellect
remarked, as he swallowed four fingers of whisky, that he was
on his way to the Y. M. C. A., where he was to talk upon the
evil effects of alcohol upon the system, and he said that he did
not know that any one would be more likely to feel the evil
effects of alcohol than the one who had a few ounces of it in
him. The cigaret fiend, like this man, may have been from the
Innermost recesses of his better nature wailing out the loss of
physical, mental and moral boyhood. However, one loads
himself with responsibility when he in the least degree com-
mends either of these routes as roads leading to brilliancy.
Alcohol is doubtless a food, that is to say, certain things
grow under its use. It is not an absurdity to say that among
those who recover from smallpox, for instance, there are those
who are the better physically for having had the disease.
Neither is it absurd to say that the number of those thus bene-
fited in proportion to the sum total of suffering produced by
the disease is as large as is the number of those who are really
benefited by the use of alcohol to the sum total of the suffering
produced by the use of alcohol. Few physicians, however,
would advise allowing smallpox to become endemic as a health
measure for the community.
That part of our ego which teachers call the moral is
believed to be in some way connected with and influenced by
the physical. Just what that connection is and where located
may, like the connective causative link between the physical
and the phenomena of some diseases, be forever beyond our
ken, but since certain moral phenomena obtain coincidently
with the use of tobacco and alcohol, the suggestion seems a sen-
sible one that your teachers ought not to pay any less attention
to the moral but more to the physical.
DANGERS OF INCOMPLETE ANESTHESIA.
BY
WILLIAM HARMAR GOOD, M.D.,
of Philadelphia.
To the Editor of American Medicine : — In reply to Dr. Harry
Morell's criticism in your number of September 20, 1902, I
would state that I agree perfectly and did so in my article on
reflex inhibition, August 23, 1902, in the statement that " the
operation is comparatively free from danger when no anesthetic
has been given, or when the anesthesia is perfectly complete ;
the period of danger being that of imperfect anesthesia."
I do not think that irritation of the trifacial will ever cause
" a reflex depression of tone in the bloodvessels." Under light
anesthesia, ammonia applied to a cat's nose will cause a cardio-
inhibition and a rise of blood-pressure. In rabbits the effect is
the same.
In the case cited of massage of the epithelioma, in which
there was no anesthetic to cause a reflex depression of tone of
the bloodvessels, very alarming symptoms appeared. If the
irritation had been continued, death would probably have fol-
lowed.
In operations without an anesthetic the patient rapidly feels
the effect of the reflex, and causes the operator to stop until he
has recovered. Under incomplete anesthesia the irritation is
kept up until the operator notices the grave condition, and pos-
sibly it is then too late. Under complete anesthesia the reflexes
are abolished. ,
I think this is a more simple and a very reasonable explana-
tion of the danger of operating during partial or incomplete
anesthesia.
NOVKMBKR 8, 1902]
VASOMOTOR ATAXIA
iAHBBICAIi HKOICINS 729
ORIGINAL ARTICLES
A FURTHER CONTRIBUTION TO THE SUBJECT OF
VASOMOTOR ATAXIA.'
BY
SOLOMON SOLIS COHEN, M.D.,
of Philadelphia.
This communication is intended to supplement the
articles publishetl in the Philadelphia Polyclinic, June,
1892, and The American Journal of the Medical Seiences,
February, 1894. While in the description of his cases
no other writer has adopted the term " vasomotor
ataxia" proposed in the communications referred to, yet
a number of cases belonging to one or another sub-group
of this general class have within the last few years been
placed upon record under other names, new or old.
Reference may be made especially to the phenomenon of
vascular throbbing in certain neurasthenic patients
described by Dana in 1897, under the name of angio-
pathic neurasthenia, and to Savill's discussion of the neu-
rovascular disorders of the extremities.-'
In brief, the class of cases to which it is desired to
recall attention exhibit multiple and diverse phenomena
suggestive of instability of vasomotor control, central
and peripheral. To cite but a few examples : In one
subject a slight blow upon the skin will produce circum-
scrlpt edema, or even extravasation ; in another a slight
indiscretion in diet will be followed by swelling of one
side of the face and lips ; in another, without traceable
cause, "blood blisters" will appear in the pharynx ; one
will suffer today with urticaria and next week with
asthma; another will have paroxysms of migraine,
alternating with gastric crises, antl sometimes attended
with mucous enteritis; one will manifest acroasphyxia
with mild vertiginous phenomena; another may
have no marketl syndrome except hay-fever in ite
due season. In no person are all the phenomena
invariable ; in few is there but a single group of manifes-
tations ; in none are the exciting causes always definite
and the same ; but in all, certain stigmata of the condi-
tion are constantly present, and upon their recognition
depends the diagnosis — which consists in the assignment
of the individual to his class, rather than in the giving
of a name to the special symptoms presented at a par-
ticular moment.
I shall not detain the association with reports of cases
of which I have gathered very many. A sufficient number
is already on record to illustrate nearly all the points to
be touched upon ; while so gretit is the number and
so varied the character of the symptoms manifested in
individual patients at one time or another that their
recital would leave no time for the main purpose of the
present communication. I shall ask attention, rather,
to certain considerations pertjiining to the philosophy of
medicine, and especially to that portion thereof that an
eminent English obst^rver has denominated the study of
the "synthesis of disease."
In studying the aberrations of the human organism we
must take into account not only the forces of the environ-
ment that may excite disturbance, but also the forces
within the bixly through derangement or failure of which
the disturbance becomes manifest. In so doing, we must
consider not only chemie and physical action and resiction,
not merely cells, tissues, organs, systems and functions,
Individually, but also — to adapt Whewell's term — the
" w)nsilience" of the organism.
That there are difleren<;es in the r<!sponst« not only of
different species, but also of different individuals of the
same species, to environmental changes, is a matter of
everyday olwervatiou. The same order of facts obtains
' Head before the Auociatlon of American Pbyslclang, Washlnc-
lon, April :!0. 1902. '
■-"Uii iicroparcKlheKla, erythromelalgla, RClcrodactylla, and other
ani^lonciirotlc dIsturhanceH; with an alUsmptcd clanftillcatiun of angio-
neurotic dliiordergof lueexlreinilie8."— /<ancc<, June 1, 1901.
likewi.se in the pathologic laboratory, and may be mani-
fested even when the species is one so little resistant to
infection as the guineapig and the environmental change
one so decided as the inoculation of cultures of tubercle
bacilli. A certain child may swallow several grains of
a quinin salt and exhibit no obvious disturbance of
physiologhs equilibrium ; another takes but a fraction of
a grain and becomes febrile, flushed and delirious. Of
several men exposed to the same cold winds and snow,
one contracts pneumonia, one exhibits hemoglobinuria,
another suffers with frost-bite, another manifests Ray-
naud's phenomena in the extremities, and some escape
with slight discomfort.
In a case under my own observation, a boy of 7 years
was so markedly affected by 2 grains of cinchonidin
salicylate, administered by his mother, that until I had
learned of the drug-giving I suspected the existence of
scarlatina. A woman of 40 years exhibited general ana-
sarca following the administration of strychnin, of nux
vomica, or of picrotoxin, the two latter being given as tests
of the susceptibility. A woman of 20 years went into a
cataleptic state of nearly two days' duration following
the use of J grain of morphin sulfate by the mouth ;
after recovery she informed me that a similar condition
had occurred in sequence to the hypodermic use of mor-
phin some years previously. She did not know that
my prescription contained the drug. All these patients
exhibited in some degree the physical and psychic char-
acteristics to be described later.
It is (juite easy to speak of peculiar individual
responses to drug action, to bacterial attack, to meteoro-
logic conditions, to psychic influences, as "idiosyn-
crasy ; " but is this not merely another form of the
ostrichlike head-hiding habit that is too common in pro-
fessions having a technical terminology ? What shall it
profit us to translate our ignorance into Greek? Idio-
syncrasies must have a physiologic basis ; normal as to
the individual, they are abnormal as to the race. In
certain instances, undoubtedly, they are but manifesta-
tions of the tendency to variation of which evolution
sometimes takes advantage to improve the species ; in
others they are of a more general character. When such
an apparent abnormity is congenital, usually inherited,
often shared with others of the same family— and in
addition is manifested by members of many unrelated
families — it is evidently not so purely individual as the
term idiosyncrasy would imply ; but is representative of
a condition actually or potentially present at some time
in all men. It is abnormal, not quoad naturam but
quoad tempus. It may be a reversion to a condition for-
merly common to the race, or may be the beginning of a
new development of good or evil promise.
I am not unmindful that modern tendencies are
toward the discrimination and separation of syndrome
groups through specific etiologic, morphologic and meta-
bolic characteristics, rather than toward their inclusion
in general classes through broad functional relationships.
We seek for definite responses to definite Irritants as
criteria for the new nosology that shall substitute accu-
rate description for vague surmise. Even the rather
definite group of csises that we now include under the
term of typhoid fever will doubtless be divided into sev-
eral other groups, differentiated by data of gross or
minute pathologi(! anatomy and of bacteriology ; acute
polyarthritis no longer means rheumatism ; hema-
tology is rapidly accumulating the basic facts for a
reclassification of the anemias. It may thus at first
view apjicar retrogressive to erect a nosologic class based
upon the very indefiniteness of the exciting cs\u.ses and
the organic responses ; and including syndrome groups
apparently so opposite as those to which the names of
Graves and of Raynaud have respectively been given.
The endcAVor to determine the exact nature and location
of the metabolic and histologic alterations that are asso-
ciated with these syndromes would seem much better
worthy of attention. Of the great importance of minute
730 AMEBIOAN MEDIOimtJ
VASOMOTOR ATAXIA
lNOVEMBl<;B g, 1902
aad exact research there can be no question ; but upon
the interpretation of its results there may be division of
opinion. That opinion is not unanimous concerning the
etiology or pathology of Raynaud's disease, or of
Graves' disease may have other explanation than
incompleteness of research. The great biologic question
as to the relation of structure and function is here in-
volved. If function may precede and determine struc-
ture in normal evolution, a similar sequence may take
place in pathologic evolution. The morbid alterations
discovered after death in bodies that during life have
manifested the functional disturbances described by
Graves or by Raynaud may be, in greater degree than
we believe, sequential rather than precedent.
By the term vasomotor incoordination or ataxia it is
proposed to designate not a disease, but a fundamental
disorder, out of which through the incidence of varying
exciting causes varying syndrome groups may be
developed. If the eternal question, " What is the
explanation of that explanation?" may still be asked,
and must, for the present, remain unanswered, nothing
in medicine or other sciences is free from the same limi-
tations. The fundamental disorder to which reference is
made is a deficiency rather than a perversion of the nor-
mal order. It may be congenital or acquired ; in the
former instance manifesting incomplete development,
individual, familial, or racial ; in the latter instance
illustrating Hughling Jackson's law — which is but one
aspect of an universal law — that neural functions latest
developed are earliest overthrown. The function in ques-
tion is that of inhibition of cardiovascular motion. As
heart and vessels have been developed from one primi-
tive tube, and their nerve supply has arisen from one
primitive source, it is convenient to speak of vasomotor
— meaning cardiovasomotor — phenomena. The impor-
tance of inhibition in evolution, biologic and sociologic,
may briefly be alluded to. Life, development, progress,
depend upon it. The inhibition of chemic and physical
changes occurring under ordinary environmental condi-
tions, so that response to certain definite environmental
stimuli may become more and more specialized, even pur-
posive, is one of the principal distinctions between living
and nonliving matter, and in progressive degree,
between various kinds of living matter. The inhibi-
tion of psychic responses unfavorable to mental and
moral progress influences the development of indi-
viduals and races. The inhibition of individual desires
and tendencies by the forcps of organized society makes
civilization possible. This is one side of the shield, of
which the other is termed voluntary activity or will.
In other words, the evolution of inanimate matter into
bioplasm, of bioplasm into man, of men into civilized
communities, is characterized first by gradually increas-
ing control of the reactions of the organism to the forces
of the environment ; and, second, by progressive organ-
ization of this control, so that what was at first volitional
or, at least, the result of effort accompanied with
consciousness, becomes automatic. This automatic
control or inhibition is not annulment of the
function restrained, but regulation — preservation of nor-
mal balance — and thus involves also the excitation
of the function under appropriate conditions; the
pneumogastric inhibition of the heart being the clear-
est example. The normal balance of cardiac function
being represented by a rate of 72 beats to the min-
ute in the quiescent man, normal pneumogastric
control permits acceleration of the cardiac rate within
certain limits, to meet the demands of exercise, in resist-
ing the attacks of certain pathogenetic agents, in the
attempt to compensate for structural or functional per-
versions in the blood or in the heart itself, and under
other conditions. One of the lower animals being fright-
ened by the approach of an enemy seeks escape in flight.
The normal mechanism of his flight calls for relaxation
of pneumogastric inhibition, the heart beats rapidly, the
eyeballs protrude, possibly the thyroid gland may enlarge
with the increased supply of blood. I have observed in
human beings protrusion of the eyes sufHcient to show the
sclera above and below the cornea under certain condi-
tions of emotional excitement accompanied by increased
cardiac activity — notably in a nymphomaniac, but in
less degrees in others, both men and women, in condi-
tions of nonsexual excitation. It is, I think, not
uncommon in those who at the same time become red in
the fa'^e from rage. The relation between menstruation
and changes in the size of the thyroid gland — especially
when the latter is enlarged — is as well known as the
Roman matron's custom of measuring the neck of her
newly-wedded daughter. But the rapid heart, the pro-
truding eyes, the possibly enlarged thyroid, normal
under certain conditions and subsiding when the occasion
has passed, are abnormal under other conditions or when
persistent. The woman who, being alarmed, does not
try to run away, has no physiologic need for the increased
circulatory and nervous activity that helps the frightened
rabbit to escape. To preserve the balance of function
that we call health, her pneumogastric or other inhibi-
tory activity must be strengthened rather than relaxed
under the strain. If it can meet the emergency, there
is perhaps a transient excitation of the heart, with pallor
or flushing of countenance, and then equilibrium is
restored ; but if not. Graves' syndrome may be initiated
and persist. I have observed at least two instances in
women in which the development of persistent tachy-
cardia and goiter immediately following fright, with
subsequent development of exophthalmos, seemed to be
established beyond question. In other apparent in-
stances of the same kind, previous observation had not
been sufficiently accurate to exclude the probability of
error in date of origin of symptoms. But such is not
the history of every case of Graves' disease ; nor
is such the result of every severe fright to woman or
man. Evidently then two elements enter into con-
sideration ; the one fundamental, the other accidental.
The former must be present, the latter may or may not
be brought to act upon it. Without the fundamental
disorder the exciting cause does not produce the specific
result. Without an adequate exciting cause the funda-
mental disorder does not become manifest in the specific
manner. The fundamental condition is one, exciting
causes may be various. Various exciting causes having
certain features in common may be followed by identical
results, as the mechanism of a clock acts in the same
manner whether the pendulum is started by a push
with the hand or by the attraction of a magnet. Other
exciting causes lead to results resembling those of the
first class in some particulars, and differing in others.
Exciting causes differ in degree and in persistence, as
well as in kind. The degree of the fundamental dis-
order differs in different individuals. Thus the possi-
bilities of diverse combinations of factors being great,
the possibilities of results diverse in degree, in per-
sistence, and in individual particulars are equally great ;
but withal there must be a fundamental resemblance in
results, dependent upon the identity of the fundamental
disorder. Considering the continual demand of normal
function upon the vasomotor taxic mechanism for accu-
rate adjustment to the instant needs of organs, tissues,
cells, as well as to the constant demand of the organism as
a whole ; taking into account, further, the varying con-
ditions of the environment and the necessity for (|uick
response of the vascular mechanism to the necessities of
occasion— realizing even then verj' imperfectly how
mobile, yet how steady, mustbe the vasomotor control —
it is not difficult to understand either the importance of
this control or the numerous symptoms to which defect
therein may give origin.
Granting such fundamental defect, not only do the
diverse manifestations described as the basis of this com-
munication become understandable, but also we are able
to recognize the origin of many symptoms, otherwise con-
fusing, that may occur in certain individuals during the
NOVEMBEK 8, 1902]
VASOMOTOR ATAXIA
AMEBICAN MkDICIKH 731
course of various acute and chronic diseases, and which,
without this clue, might lead to serious error in diag-
nosis or in treatment.
As a matter of fact, it is not probable that any indi-
vidual has complete automatic vasomotor control. Yet
equally, as a matter of fact, the vast majority of human
beings have control practically adequate to all ordinary
occasions. The symptoms occasioned by defective con-
trol, or, as I wish to term it, vusomofor ataxia, are, on
the whole, phenomena perfectly normal under adequate
causation. Their abnormity lies in the fact of their
occurrence under stimuli normally inadequate, in their
undue persistence, or in their excessive degree. They
are also characterized by a certain associative character, as
in the definite syndromes of Graves and Raynaud ; the
number and character of the associated symptoms depend-
ing on factors and relationships that we need not now
inquire into. They differ very much in degree, and in
character may be either apparently spastic or appar-
ently paretic ; that is to say, may indicate either exces-
sive vascular relaxation or excessive vascular constriction.
Until the question of dilator and constrictor nerves of
the vessels is settled, it cannot be said that relaxation is
actually paretic ; in all probability it is at times active.
Rarely are all the phenomena in a given seizure dilative
or constrictive ; both sets of symptoms are often com-
mingled, though one or the other will usually predom-
inate. An individual will, as a rule, show the predom-
inance of the same class of symptoms in his various
paroxysms — for example, always becoming pallid or
always flushing with his migrainous or vertiginous
attacks ; though there are many exceptions even to this
rule. The flushings, chillineas, and other vasomotor dis-
turbances of the climacteric in women, are of the same
order of phenomena, and as frequent concomitants of
a physiologic process may be said to be normal. It is
to be noted, however, that the process in question is one
of devolution. Individuals of deficient vasomotor con-
trol always present certain phenomena indicative of
their condition. Some of these stigmata are to be dis-
covered only upon careful search, others may be seen at
once ; but they rarely attract the interested attention of
patient or physician until more marked manifestations
occur. The symptoms which lead to the discovery of the
condition are, as a rule, paroxysmal in character, and do
not recur regularly, or even in an invariable manner,
until some special association, as Raynaud's syndrome
or Graves' syndrome, becomes, as it were, organized.
Among the more or less constant characteristics of
those whom I am accustomed to term " vasomotor
ataxics " may be mentioned the following :
1. Dermographism can always be demonstrated ; and
in marked cases factitious urticaria is produced readily.
2. There is usually a tendency, especially during
conversation of an exciting character, to contraction of
the upper eyelid, exposing the sclera above the cornea.
Sometimes this can be developed by having the subject
fix his eyes upon a point at the normal level of the pupil,
and telling him to open his eyes as widely as possible.
I have looked upon it as a larval condition of the palpe-
bral contraction known as Stell wag's sign of exophthalmic
goiter.
3. There is in many cases an exaggerated tendency
to blushing. Sometimes what might almost be termed
a " permanent blush " occupies one cheek or a portion of
a cheek. Fretjuently there will be a tendency for one
cheek and one ear to become hot and flushed, without
.s[)e<;ial emotional or other excitation, while the other
cheek and ear remain normal.
4. Minute cutaneous angiomas are often to be found
upon various portions of the body.
•5. The nails (exhibit the most constant characteristica.
Apart from striations, which are not rare, they show
certivin stratji of more or less definite coloration. In
the most pronounced cases I have been in the habit of
terming them — in order to impress the condition ujwn
students — "patriotic nails;" the markings being red,
white and blue circular segments. At its base, for prob-
ably half its length, the nail is more or less cyanotic-
blue, purple or faintly violet ; beyond this there is a
broad, whitish area ; and then toward the fingertip the
nail becomes pink or red. In the midst of the pink area
there appears a semicircular or crescentic line of deep red.
Sometimes these crescentic markings of red, white and
blue alternate in greater number. Sometimes there is a
blue or white area beyond the deep red line. Sometimes
the nail is pink, purple, or leaden throughout, except
for red and white crescentic areas toward the fingertip.
Usually the nails are curved ; but they may be flattened.
At times the skin around the base of the nail is of a deep
brick-red color. Often there are certain permanent
characteristic but indefinite colorings of the fingers
and, at times, of the whole hand. These colorations
become accentuated temporarily under conditions of
temperature variation, natural or artificial. In certain
persons the hands are always more or less pinkish, and
the color extends in some instances a greater or less dis-
tance up the wrist. In others, the wrist and the palm
and dorsum of the hands may be cyanotic, and the
fingers pink, or pinkish purple. In others, the fingers
may be pink or purple, or of mixetl hues, and the palms
and dorsums of ordinary color. In some subjects there
is an irregular mottling. I have noticed this mottling
extending over the arms, or indeed over nearly the
whole cutaneous surface, as an hereditary phenomenon —
and in some cases as a paroxysmal one. In one marked
instance in my clinic, red, white and blue areas scattered
over the whole body, including the foreskin, developed
under observation after the patient — a boy just reaching
puberty — had been stripped for examination on a some-
what cold day. Weather changes cause considerable
difference in these appearances, cold having a tendency,
as a rule, to increase the depth of the cyanotic (venous)
hue, while heat tends to increase the proportion of the
pink or red (capillary) tint ; though this may vary in
different individuals. As a rule, if one hand is kept in
ice water for several minutes it will become red, while
the other becomes more deeply blue. Warm water or hot
water will redden the immersed hand without obviously
affecting the other. Pressure, or stroking, quickly
changes the color of the part manipulated to white,
but the original coloration returns after a brief interval.
Elevation of the hand will cause the color, whether
pink, blue, or purple, to disappear as the vessels become
emptied, leaving the hand abnormally white. If the
whitened hand then is allowed to fall, it first becomes
pink at the finger tips, the pink tint spreading over the
hand as the capillaries fill ; and then, as the dilated veins
begin to receive blood, the coloration will change through
various shades to that formerly manifested — the same
distribution of blue and pink as in the other hand
being observed after some two or three minutes. If,
however, the wrist is constricted by a broad ligature
when the hand is allowed to fall, the return of the
coloration is delayetl, or even prevented entirely while
the bandage is in place.
C>. In addition to the effect of weather upon the hands,
referred to in the preceding paragraph, persons of defi-
cient vasomotor coordination usually exhibit marked
general sensitiveness to changes of temperature. They
may be divided, according to the nature of this temper-
ature reaction, into several groui)s, of which three may
be taken as types. In the first group may be placed
those who suffer in summer but are comparatively com-
fortable in winter. These will complain of the heat of
an apartment whose temperature is pleasant to its other
inmates. They sweat exct^sively on slight exertion,
and usually exhibit Shakesi>eare's "moist palm of
youth " even when advance<l in years. In such subjects,
too, one is likely to find some degree of enlargement of
the thyroid gland, and they are always made worse by
the administration of thyroid extract. In the second
732 American Medicine)
VASOMOTOR ATAXIA
INOVKMKER 8, 1902
group are those who complain in winter and are usually
comfortable in summer. These persons ask for windows
to be closed when others in the room prefer to have the
windows open ; they wish fires to be lighted earlier in
the fall than is necessary for the comfort of other people ;
they usually burden themselves with excessive weight of
clothing; they have dry palms, and even when the
weather is but moderately cool, their hands may be cold
and cyanotic, perhaps swollen, while their noses become
red or white and cold. In some, perspiration is deficient
even in summer, and these suffer inordinate distress in
hot weather as well as in moderately cold weather.
Others perspire with undue readiness. The third group
includes those v/ho are comfortable only in moderate
temperatures, being distressed not only by extremes of
summer or winter weather, but even by slight degrees
of either heat or cold. In addition, there are numerous
individual variations even among those falling into one
or the other of these three classes. It is because of these
intermediate variant cases that we are enabled to gather
all these persons into one class. It will be observed that
those who suffer from heat approach to the type of
Graves' phenomena, while those who suffer from cold
approach to the type of Raynaud's phenomena ; yet the
vascular phenomena observed in the hands even among
those who show the cyanotic coloration are not those of
excessive constriction of vessels, but of dilation, as is
proved by the experiment of elevation and depression,
both with and without ligature, as detailed in the pre-
ceding paragraph. Constrictive phenomena of l)oth
cyanosis and pallor may occur paroxysmally without
obvious cause or under natural or artificial excitation of
sufficient degree.
7. In certain patients, especially those with more or
less constant red flushing of the face, if a silver probe is
drawn across the flushed cheek, a bluish-black mark will
be left which can afterward be wiped off. I assume that
this is due to the formation of silver sulfid, but I have
not as yet been able to have a chemic study made.
8. Refractive errors are almost invariably present;
in the great preponderance of cases there is hyperopic
astigmatism.
9. The majority of those who manifest these stigmata
are highly emotional and would unhesitatingly be classed
as "nervous" "neurotic" — sometimes even as "hys-
teric"— individuals; yet some whom I have studied
are persons of great intelligence and stability of char-
acter. These latter have usually possessed highly devel-
oped sympathy and imagination ; among them are
artists, actors, authors, bankers, jurists, and physicians,
of the first rank.
The phenomena just described are more or less con-
stant, and some of them at least will be found in every
individual of the class under discussion. Other charac-
teristic phenomena are found in certain individuals only,
but in many persons and in more or less intimate but
inconstant association. Among these, special mention
may be made of tingling and numbness — not only in the
extremities, but in the face, tongue and lips, and some-
times over one-half of the body — and of blood losses — as
epistaxis, hemoptysis, hematemesis, hematuria (which
may be so slight, however, as to be discoverable merely
by the presence of erythrocytes in unusual quantity upon
microscopic examination of the urine), hemoglobinuria,
retinal hemorrhage, petechise, etc. Slight, transient
albuminuria is not uncommon. Hives and attacks
resembling erythema nodosum are manifested with more
or less frequency, while recurrent circumscript edema
(angioneurotic edema)— sometimes affecting especially
one-half of the tongue— or giant urticaria, local or general,
may appear in apparent sequence to trauma, to emotion,
to indigestion, to food and drug intoxication, or to sudden
chill. In some persons the hands will swell to almost
twice their normal size when exposed to cold even in
slight degree. These subjects sometimes have attacks of
chromidrosis or hemidrosis. Many subjects have, at
different times, what maybe termed substitutive crisas —
as vertigo, migrain, asthma, nausea, and emesis ; — but to
extend the list of symptoms and syndromes would be to
begin the record of cases, and to pass beyond the purpose
of this paper. That the crises or paroxysms are often pre-
cipitated by toxic influences of endogenous or ectogenous
origin is probably true ; but whatever be the toxicopatho-
logie mechanism of individual symptoms or of special
groups of symptoms, underlying all is the fundamental
defect of inhibition, which Savill terms " vasomotor inco-
ordination," and for which I prefer my original term —
vasomotor ataxia.
Apart from the general relationships discussed, there
is a practical clinical value to these observations. It
lies in the recognition and assemblage of the cases
that as yet do not fall into accepted syndrome groups.
Doubtless more or less definite causation and more
or less definite toxicopathologic mechanisms will ere
long be established for Graves' and Raynaud's syn-
dromes, as for Mitchell's erythromelalgia ; and other
syndrome groups among those described, may — like
angioneurotic edema, hay-fever and migrain — receive
limiting descriptions and specific names. I shall in a
future paper attempt to point out some of the more or
less constant associations that may serve as the bases for
such diagnostic entities. But beyond all these will
remain many vague and inconstant manifestations,
recurring irregularly and in varied aasociation — differ-
ing from time to time in the same individual— to which
the general term— vasomotor ataxia — will still apply,
and which, without the clue afforded by a knowledge of
this disorder would be most puzzling. Yet upon correct
diagnosis depends their intelligent treatment. A patient
alarmed by hemorrhage — gastric, pulmonary, or nasal —
by sudden transient blindness, or by sudden general
anasarca, may be soothed by a truthful assurance that
there is no danger ; the physician made unnecessarily
anxious by the discovery of albumin or blood in a
patient's urine may be relieved by the recognition of its
origin ; the substitutive symptoms occurring in the
course of years in a given patient will be attributed to
the one true cause, and not treated as so many different
diseases. Though the spokes of the wheel are many,
and at the periphery widely separated, there is but one
hub, and that hub has but one center ; and to this, not
merely to spoke or to rim — to the central disorder, and
not merely to the peripheral symptoms — must the thera-
peutist direct his attention.
As to treatment, this must be largely individual, and
at first, tentative. The congenital defect cannot be
remedied, but its ill-consequences may measurably be
overcome. Chief to this end are hydrotherapeutic appli-
cations that will improve vascular tone and educate,
from periphery to center, the responses to thermic and
mechanical stimulation. Graduated douches and ablu-
tions of alternating temperature (hot and cold) and effer-
vescing thermal baths followed by cold water frictions,
are among the best of these. Electrotherapy, and mas-
sage are also useful, and I anticipate good results from
electric light baths. When edematous and erythematous
phenomena are most marked, ergot, barium chlorid, or
thymus gland internally, and adrenal preparations topi-
cally or systemically, are often of service. When con-
strictive symptoms predominate, thyroid preparations,
or relaxing medicaments as erythrol tetranitrate, sodium
nitrite and glonoin may palliate. Strychnin is a useful
vasomotor tonic in some cases ; but picrotoxin — which if
necessary may safely be given to adults in doses of 1/10
grain or even more — is perhaps the drug of greatest
benefit in the majority of cases.'
' Since reading this paper ttie girl. Sarah O'N., whose ease was the
first that I published (Philadelphia Polyclinic, June, 1892), lias reported
in good health ; her hands exhibit color changes in hotand cold water,
but she has no headache, no goiter, no tachycardia. The thyroid gland
can easily be demonstrated, hence there is slight enlargement. Picro-
toxin was tlie drug employed in her treatment, adrenal not having
come into use at that time.
NOVKMBKR 8, 1902]
TEACHING OF PSYCHIATRY
[AUEKIOAN MKDIOINJS 733
General and special dietetic and hygienic regulations
should not be neglected. Work and rest are to be super-
vised ; and to prevent autointoxication the patient
may be advised to drink water freely.
RECAPITULATION AND SUMMARY.
For description of cases the writer refers to his
previous communications and to the recent observa-
tions of Savill upon a subgroup manifesting acro-
paresthesia and acroasphyxia. Attention is called
to the condition of essential instability of the con-
trolling (or taxic) apparatus of the vasomotor nerv-
ous system as a large factor in the defective reaction of
the individual toward environmental changes, so that
persons of the type de^ribed exhibit upon slight excita-
tion (physical, chemic, or psychic) certain phenomena
which in other persons require causes of greater moment.
These phenomena depend upon irregular, and sometimes
widely-distributed contractions and dilations of the cap-
illaries and the smaller arteries and veins and may be
divided into three classes : (1) Those dependent upon
excessive relaxation (dilator-excitation or constrictor-
paresis) of the vessels, often with concomitant impairment
of cardiac inhibition ; (2) those dependent upon excessive
constriction of vessels, usually with disturbance of cardiac
inhibition also, but sometimes without definite cardiac
phenomena clinically demonstrable ; (3) those in which
phenomena of the two opposite groups are commingled.
The third group is the more common. Graves' disease
presents an extreme type of the phenomena of excessive
vascular dilation with paresis of cardiac inhibition. Its
exciting causes are various, and its toxicopathologic
mechanism undetermined. Raynaud's disease presents
an excessive type of vascular constriction, and of it the
same may be said concerning undetermined exciting
causes and toxicopathologic mechanism. Between these
two extremes are many varieties, differing much in
severity and locality of symptoms — simple urticaria,
angioneurotic edema ; migrain of the spastic type and
migrain of the paretic type; anomalous eruptions of
various kinds; drug idiosyncrasies; hay-fever; asthma;
intermittent albuminuria; polyuria; tendencies to hemor-
rhage from various organs, to petechial and purpuric
spots, and to small mucous or cutaneous varices and
hematomas ; minute cutaneous angiomas ; paroxysmal
tachycardia ; and other more or less closely related
phenomena. As definite exciting causes and definite
toxicopathologic mechanisms are determined, definite
nosologic groups may be separated and certain syndromes,
like those of Graves and of Raynaud, made into diag-
nostic entities. Over and above these, however — and'
for the present, this is the most practical issue of these
observations — will always remain many vague and ill-
deflned conditions arising in response to any one of if
number of different stimuli, among which temperature,
weather, endogenous and ectogenous noxae, and emotion
are most prominent. The symptoms may vary much in
the same individual at different times; they may be
manifestefl in the course of various acute and chronic
diseases, confusing the diagnosis ; with the clue afforded
by the knowledge of vasomotor ataxia, however, the
symptoms become clear, and intelligent treatment can
be instituted. Hysteria, neurasthenia and epilepsy bear
close but as yet undetermined relations to the condition,
which may be predominant or apparently insignificant
in their semeiology. The symptoms of the meno])ause
are essentially vasomotor ataxic in character, but are
a transient phase in the devolution of the female.
Essential vasomotor ataxia is usually congenital — often
affecting, in different ways, several members of one
family ; but at times the disorder seems to be acquired
in sequence to disease or mtcident. Treatment is to be
largely dietetic and hygienic, with such medication and
such measures of physiologic therapy aa seem to be
appropriate in the individual case.
THE ASYLUM, THE HOSPITAL FOR THE INSANE,
AND THE TEACHING OF PSYCHIATRY.'
BY
STEWART PATON, M.D.,
of Baltimore, Md.
Associate in Psychiatry, Johns Hopkins University ; Director of the
Laboratory, Sheppard and Kuoch Pratt Hospital.
The alienist is frequently asked if individuals who
are mentally deranged receive as good care in a hospital
for the insane as patients in the wards of a general hos-
pital.
Unfortunately, this question must be answered in the
negative. Nor is the main reason for this disparity far
to seek, if we consider for a moment the striking differ-
ences in the organization of the two classes of institu-
tions.
In our general hospitals the medical care of the
patients is entrusted to a staff, the individual members
of which are expected to devote themselves solely to the
discharge of their professional duties. In the hospital
for the insane the medical officers are fortunate if a large
part of their time and energy is not absorbed in the
performance of purely administrative work. Those of
you who are familiar with the present system of organi-
zation in these institutions will appreciate this fact.
Recently the medical superintendents of three of the best
known hospitals for the insane in the United States have
in my hearing expressed dissatisfaction with a condition
of affairs that gives them so little opportunity or leisure
in which to study the patients entrusted to their care.
The importance of such an expression of opinion can
hardly be overestimated, for it means that the men best
qualified by experience to judge such matters appreciate
the existence of a radical defect and would be among the
first to welcome a thorough reorganization of our hos-
pitals for the insane. When a physician-in-chief finds
that it is impossible for him to keep abreast of the times
in the practice and study of his profession, the work of
all his associates on the medical staff must inevitably
suffer from the lack of efficient and capable criticism,
while at the same time they are deprived of an enthusi-
astic and inspiring leadership. In the face of such a con-
dition of affairs the general medical public, seeing that
the resident physicians in our hospitals for the insane
are permitted to devote only a portion of their time to
their professional duties, may be pardonetl if they infer
that very little is known regarding the causes and treat-
ment of insanity, and consequently conclude that the
commitment of patients to hospitals for the insane is
indicated only when all other methods of treatment
have been tried and proved to be of no avail. As
a result of this unfortunate belief many cases of mental
disorder which might have been cured had they been
dealt with in a hospital at the onset of the attack are left
without proper treatment until they have become hope-
lessly chronic.
Physicians as a rule do not willingly admit that meta-
physics has influenced the practice of medicine. Never-
theless, the present defect in the organization of our
hospitals for the insane is a concrete example of the
potency of the belief once generally entertained to the
effect that the ills to whi<!h the materia cogitans non
externa was heir were too intangible to admit of any
successful therapy. A strict adherence to the letter of
the Cartesian philosophy would doubtless relieve the
alienist of responsibilty so far as many cases coming
under his observation are concerned. It is fortunate,
however, that there is to be found an increasing number
of those who believe that in all cases of insanity there is
an organic lesion situated sometimes above but quite as
often below the diaphragm. Eiven a slight degree of
familiarity with the psychologic reactions produced by
> Read by Invitation at the meeting of the Canadian Medical Asso-
ciation, Montreal, September 17, 1902.
734 Ajikbioan Mbdioink]
TEACHING OF PSYCHIATRY
[NOVEMBEB 8, 1902
" calomy and laudamy " or with brimstone and molasses
should be sufficient to demonstrate the impossibility of
always distinguishing clearly betweeen the materia cogi-
tans non extmsa and the materia extensa non cogitans.
Improvement in the medical care of the insane, as
well as hope of progress in the study of psychiatry,
depends primarily upon the adoption by the managers
of our hospitals for the insane of a system which shall
make it possible for the medical officers In these institu-
tions to devote themselves solely to their professional
duties. Let us consider briefly how these ends may be
attained. The most efficient and capable medical offi-
cers can be found only in those institutions in which the
methods of organization are similar to those employed
in the best general hospital. It must not be understood
that I am advocating the introduction at present of such
methods into all institutions devoted to the care of the
insane. Reference is made solely to those which have
assumed the name of hospital. The term asylum is
generally assigned to the institutions which are given
up solely to the care of the more chronic forms of aliena-
tion. The hospitals for the insane are of two classes :
First, there is the type of hospital best represented by
the German Psychiatric Clinic, and of which we, unfor-
tunately, have no counterpart on this side of the Atlan-
tic. Second, generally in or near a large city there is
an institution formerly called an asylum, but which,
having now assumed the name of hospital, is in a stage
of transformation.
With reference to the first class, it is difficult to
believe that the present century will pass without either
the State or private munificence giving to the insane in
all our large cities the benefits to be derived from the
erection of fully equipped modern hospitals similar in
construction and organization to the psychiatric
clinics at Berlin, Kiel, Giessen and other German
cities. These institutions are situated in the heart
of the city. They have accommodations for from 80
to 200 patients. The physiclan-in-chief, as a rule, is
professor of psychiatry in the university, and is also
engaged in active practice as an alienist. He, as well as
the other members of the medical staff, is entirely free
from administrative duties. Think of the amount of
enthusiastic interest in their profession that may develop
in the members of the medical staff in such institutions
where the ties binding this with the other departments
of the university are so numerous. Can there be a more
worthy object of philanthropy than the very liberal
endowment of such institutions in all our large cities so
that not only may the insane have the benefit of the
highest medical skill, but at the same time every oppor-
tunity is given to those who are endeavoring to discover
the laws upon the keeping of which mental vigor and
sanity depend. It is interesting to note that according
to German alienists the spirit which gave birth to the
movement resulting in Germany's great advance in the
care of the insane had its origin in the philosophy of
Hume and Locke. The *' philosophy of common sense "
was popularized in Prance by Voltaire, Diderot, Rous-
seau and others, and by these teachings the reformer
Plnel was profoundly Influenced. Nevertheless, as a
French alienist has recently pointed out, the great
reforms in the care of the insane instituted in France,
England and America at the beginning of the century
have not been carried forward in these countries, which
in this respect have lagged far behind Germany. More
than 50 years ago Compte' said: "There has been
plentiful study of monomania, but it has been of little
use for want of a due connection and comparison with
the normal state. The works that have appeared
on the subject have been more literary than scientific ;
those who have had the best opportunity for observa-
tion have been more engaged in governing their
patients than in analyzing their cases; and the suc-
iThe Positive PhUosophy of August Compte, Bohm's Philosophi-
cal Library, Vol. 11, p. 133.
cessors of Pinel have added nothing essential to the
ameliorations introduced by him half a century ago
in regard to the theory and treatment of mental aliena-
tion." Let me now ask your attention to a few consid-
erations in reference to the second class of In.stltutions —
those which within the last decade or two have assumed
the name of hospital. If one reads the annual reports
of these institutions it will be noted that frequent refer-
ence is made to the fact that a neurologist, a neuropath-
ologist, or a pathologist, has been added to the staff. In
some instances investigations in physiologic psychology
have been attempted. It is not my purpose to belittle
the services of those who have successfully advocated
the necessity of these changes. Little permanent good,
however, either in increased efficiency of the staff or in
the discovery of new facts relating to the causes of men-
tal disease can be expected until the organization of
these institutions is so changed that the .standards by
which the professional capabilities of the medical officers
are gauged are as high as tho.se now re([uired by the
managers of our best general hospitals. To aid in the
accomplishment of this end an advisory medical board,
the members of which have had practical training as
attending physicians to a general hospital, should be
appointed. This advisory board would act in conjunc-
tion with the physician-in-chief and the trustees of the
hospital and their services would be all-important in
demonstrating clearly to the lay members the absolute
necessity of distinguishing clearly in matters of organi-
zation between the institutions intendetl for the chronic
and those for the acute and con.sequently more hopeful
cases of alienation.
The effective organization of a hospital for the insane
in which the medical care of the patients is as good as
that afforded by our best general hospitals depends upon
the recognition by the managers of the importance of
the following fundamental principles :
1. The reorganization of the institution must rest on
a basis that should make it possible for the medical
officers to devote their time solely to the performance of
their professional duties.
2. The best results in the treatment of patients suf-
fering from acute mental disorders can be obtained in a
hospital so organized, even without many of the acces-
sions that are a necessary and integral part of the
asylum. The huge grounds, farm, outbuildings,
amusement pavilions, etc., all useful adjuncts in the
treatment of the chronic cases, are either unnecessary or
of secondary importance in connection with the work of
the hospital. When patients have reached the stage in
which the therapeutic measures made possible by the
existence of such accessories are indicated they are either
well along in convalescence or have reached the chronic
1 stage in their disease and are then better off in an
asylum. I think a fair and impartial observer who is
thoroughly familiar with the organization and conduct
of affairs in our best general hospitals must admit that
while these Institutions are admirably adapted to the
treatment of patients, the same cannot be said of our
hospitals for the insane. In this second class of institu-
tions admirable provision is often made for the care of
convalescent patients, but there is a marked deficiency
of the means as well as methods best adapted to the
treatment of patients in the earlier and more acute
stages of their disease.
3. The managers of these institutions as they become
more familiar with the conduct of affairs in our general
hospitals will doubtless realize that not only is the effi-
ciency of the medical staff greater in those hospitals in
which regular clinical teaching of students is practised,
but that under these conditions alone is it possible to
bestow upon the individual patient the benefits to be
derived from careful methodical study and observation
of his case.
Unfortunate as are the existing conditions in the
organization of our hospitals for the insane, physicians
November 8, 1902]
KERNIG'S SIGN
'Amkkican Medicink 736
must remember that the laymen who are trustees of our
institutions are not solely responsible for the present
attempt to make bricks without straw. In the United
States and, so far as I know, in Great Britain, there is no
opportunity presented for as careful bedside instruction
in the study of mental diseases as there is in other
departments of medicine. Where then can those who
purpose to become resident officers in our hospitals for
the insane receive their training? Whence can the
medical expert whose opinion is frequently couched in
terms of apodictic certitude gather the facts which
justify such an expression? Largely, I fear, only from
his inner consciousness. Where can the family physi-
cian who should have a practical knowledge of certain
forms of mental disorder get any clinical training in
psychiatry? At the present time, nowhere.
Some of the beneficial results that would be sure to
follow the reorganization of hospitals for the insane
along the lines indicated may be summarized as follows :
Physicians in general would naturally gain greater con-
fidence in the efficiency of the medical staffs of these
institutions, and as a result many patients would be
referred to these hospitals for treatment at a time
when satisfactory results might be expected. The com-
plete separation of the hospital from the asylum would
clearly indicate that mental disorders are of essentially
the same nature and are amenable to treatment similar
to that which is applicable to other bodily maladies.
Not only would the highest class of men in the medical
profession be attracted to become medical officers in
these institutions, they would also be given every
opportunity to devote their talents to advancing our
knowledge of the causes and best means of preventing
the increase of insanity. Doubtless a strictly modern
hospital for the insane would become in time the recipi-
ent of donations which would render it possible for
investigations along scientific lines to be prosecuted on a
scale that would be productive of the best results.
KERNIG'S SIGN : ITS FREQUENCY OF OCCURRENCE,
CAUSATION AND CLINICAL SIGNIFICANCE.
BY
ROBERT D. RUDOLF, M.D., Edin.; M.R.C.P., Lond.,
of Toronto, Can.
Lecturer on Medicine and Clinical Medicine in the University of
Toronto.
Kernig's sign has of late years attracted considerable
attention both in Europe and upon this continent.
Kernig was a Russian. In 1884 he published a paper '
describing the sign, stating that he had found it present in
15 cases of meningitis, of which 13 were of the cerebro-
spinal tyi)e, 1 tuberculous and 1 suppurative.
The sign a.s described by him consists in the inability to
extend the knee passively and fully while the patient is
sitting upright, i.e., while the thigh is flexed at a right
angle to the body.
A more convenient way of applying the same test is
that given by Osier.'' The patient is allowed to remain
horizontal (which is a great advantage, when we remem-
ber that he is probably seriously ill) and the thigh is
passively flexed at right angles to the trunk and then
the knee is extended as before.
According to some writers" Kernig considered his
sign as pathognomonic of meningitis, and while most
authors appear to endorse this view, some go even
farther and say that it is diagnostic of the cerebrospinal
form of this disease. Thus Dr. .James Barr, of Liver-
pool, wrote in 1900 that "Professor Osier, M^jor
Buchanan and others look upon Kernig's sign as diag-
nostic of cerebrosi)inal meningitis." * However, medi-
cal papers soon began to publish cases in which the sign
was present in such diseases as encephalitis,' cerebral hem-
orrhage,* spastic paralysis,' arthritis in the limb tested,*
typhoid fever," uremia,' sciatica ^ and others. In sciatica
this is an old observation, as I remember years ago being
taught this as a sign of that disease.
Herrick " examined for Kernig's sign in 19 cases of
meningitis ; 9 were cerebrospinal, 8 tuberculous, 2 pneu-
mococcic and 1 syphilitic. He found the sign present in
89.4 /c.
An examination of the records of the last 18 cases of
meningitis treated in the Victoria Hospital for Sick
Children, in Toronto, showed that in 13 the sign was
present. From this it cannot he concluded that it was
absent in the remaining five ; it may not have been
looked for, or may have been found and not not«d. Of
the 18 cases 6 were of the cerebrospinal type, 5 were tuber-
culous, 5 pneumococcic and in 2 the exact nature of the
meningitis remained uncertain.
In spite of the fact that occasional cases are put on
record in which Kernig's sign is present without menin-
gitis being present also, the general deduction may be
made from the literature of the subject that while the
sign is usually present in meningitis it is very seldom
found otherwise. If the sign consists (as Kernig and all
writers have described it) in inability to extend the
knee passively and fully while the thigh is at right
angles to the body, then I can most emphatically state
that such an inability exists in a very large proportion of
persons who have not meningitis. In other words,
Kernig's sign is present in a far greater proportion of
cases than has been hitherto recognized.
After having noted this general fact in a number of
cases, I made a simple instrument by means of which
one could measure the angle of the leg to the thigh and
thus make the results obtained more accurate. With
this instrument I examined for Kernig's sign in 162
cases and found that it was more or less present in 60^ .
The patients were of all ages, though chiefly children,
and the conditions from which they were suffering were
of divers kinds. Many of them were perfectly healthy.
Disease.
Chorea
Corneal ulcer.
Fracture of femur
Psoas abscess
Hip disease
Cerebral thrombosis
Pott's spinal disease
Meningitis C')
Gastritis
Klieumatism
Iritis
Lacrimal fistula
Epilepsy
Talipes equlnus
Injury to knee
Tuberculous disease and bed-sores.
Chronic nephritis
Alveolar abscess of Jaw
Enlarged tonsils
Tuberculous glands in neclc
Genu valgum
Chronic cystitis, patient aged 45
Malignant disease In mouth, pa-
tient aged 30.
Tuberculous abscess in baclc
Congenital hernia, patient aged 8
montlis.
Carcinoma In scar of burn on back.
Congenital dislocation of hip
Hyphills
Uremia (very ill)
Orbital neumlgia
Varicose veins of leg
Broljcn leg
.Vppcndiceal abscess,
lOnili.vi'ina
Pnciiitionia
Injury to eye
Osteomyelitis
Recambent.
IK to 6 months.
Not recumbent.
2 days to 1 month.
6 mos. U p d u ri ng last mo.
7 months to i years.
10 weeks.
Years.
10 days.
I week.
2 to 9 months.
Not recumbent.
No.
No.
No.
S weeks.
8 years.
1 year.
2 weeks.
2% years.
Months.
4 months.
4 months.
6 months.
No.
1 year.
13 weeks ofTand on.
7 weeks.
3 weeks.
2% weeks.
7 weeks.
3 weeks.
No.
Not for months.
Total -.... 10 4»
«2
MS.
as
736 Amebioan Mkdioike}
KERNIG'S SIGN
[NOVKMBKB 8, 1902
On the other hand, in a good many young children there
was slight hyperextension of the knee ; this only occurred
in one adult — a case of locomotor ataxia.
Full extension of the knee means of course an angle
of 180°, and, as stated, in 60 fc of the cases examined this
angle was less. In 36.4 fc it was 165° or less, and in C>fo
it was 135° and under ; that is, a very marked degree of
inability to extend the knee fully was present.
In the preceding table an analysis is given of 59 cases
(the 36.4^) in which the angle at the knee was 165° or
less.
While this sign thus occurs so frequently in numerous
diseases among a series of patients of all ages, it must
be emphasized that it does not occur at all, so far as I
have seen, among healthy children leading active lives.
In order to investigate this point I examined the in-
mates of the Toronto Cr6che, 17 children, varying in age
from a few months to 7 years, and the sign was com-
pletely absent in all, and, in fact, slight hyperextension
of the knee was present in 10. In some healthy adults,
however, a slight degree of the sign is present. The
most potent cause of the sign is recumbency, and this
factor explains its presence in nearly all of the cases in
the list given. Place an individual in bed for a few days
or a few weeks and he will almost with certainty develop
Kernig's sign, no matter from what disease he is suffering
(there are a few exceptions). He may be kept recum-
bent on account of a fracture and otherwise be healthy,
and yet he will develop Kernig's sign just the same.
There are some conditions in which mere recumbency
will not account for the development of the sign. In
meningitis it is usually present as already mentioned.
In spastic conditions it is, of course, found. In fact, in
any condition in which the hamstring muscles are in a
state of hypertonus the sign is present. Also in painful
conditions of the limb tested. An interesting point in
the list is that the sign was present in all three cases of
corneal ulcer examined. In one it was markedly pres-
ent, and yet none of these patients had been recumbent.
A muscular hypertonus, probably of a reflex nature, is
evidently present in such cases. In fact, Kernig's sign
was more or less present in 9 out of 11 cases of acute eye
trouble examined and yet none of the patients was con-
fined to bed.
Massage has a marked effect in preventing the occur-
rence of Kernig's sign in the recumbent, and of lessening
or removing it when developed.
During the investigation I found that there was a
simpler method of testing the rigidity of the hamstring
muscles than Kernig's. In his method it is necessary to
note two angles, viz., the one at the hip, which must
always be a right angle, and the one at the knee. If the
examiner commences by fully extending the knee, while
the thigh is also extended, and then flexes the thigh,
keeping the knee always straight, only the hip-angle need
be measured. This test is very simple, and I tried it in
200 cases in which accurate measurements of the hip-
angle were made. The angle measured was always the
external angle, i. e., with the thigh and leg in the same
line as the body the angle is zero ; with the thigh and
leg at right angles to the body the angle is 90°. This
latter angle equals the full development of extension at
the knee — 180°. The 200 cases examined included those
tried for Kernig's sign. The percentage of cases in
which an angle of less than 90° could only be reached
was 60^, which is the same as that in which Kernig's
sign was more or less present, and proves the accuracy
of this simpler test.
A further advantage of this method is that all degrees
of hypotonus can be measured and expressed by one
angle, while this is impossible with Kernig's method,
beyond that occasionally, in children, a slight degree of
hyperextension of the knee-joint is possible.
Of the 200 cases thus examined, 31 ^ were found to give
a greater angle than 90° at the hip, and in several infants
the head could be touched with the toe while the knee
was kept extended. All the normal children living
active lives showed this suppleness. No healthy adult
gave it, but it occurred in a case of locomotor ataxia,
and no doubt will be found to be present in all condi-
tions of limpness of the lower limbs.
I have great pleasure in acknowledging my indebted-
ness to Drs. Lowrie and Rutherford, Drs. Graham and
Waters, past and present house physicians of the Victoria
Hospital for Sick Children, for their able a.ssistanee in
carrying out these measurements.
There appears to be a general tendency among writers
to consider Kernig's sign as a special symptom apart
from rigidity of the muscles of the body elsewhere, and
this has led to very narrow views as to the causation of
the sign.
It has been noted ever since the disease was first
described that in meningitis there exists a proneness to
muscular rigidity, and it appears to me that Kernig's
sign is simply an evidence of this rigidity occurring in
the hamstring muscles, as it does in those of the neck,
back, abdomen and upper limbs. The reason why we
are not able to extend the knee fully with the hip at
right angles to the body so often in meningitis, while
only occasionally are we unable to extend the elbow
fully, is that in the former case we are applying a much
more severe test of rigidity than in the latter. As
already pointed out, in most individuals the position of
extended knee With the hip at right angles is the
extreme limit to which the hamstrings will admit of
being stretched, and frequently they will not admit it —
a position never naturally assumed. Hence when even a
slight degree of rigidity occurs in the hamstrings,
Kernig's sign is at once present. On the other hand,
the position of full extension of the elbow is one very
commonly assumed, and the muscles easily allow of it.
In 131 cases examined as to this point we found that full
extension occurred in all, and that hyperextension was
possible in 54.2^. Hence it takes a much greater degree
of nmscular hypertonus to interfere with full extension
of the elbow than it does to produce the same result at
the knee. If we had as delicate a test of rigidity of the
muscles of the upper extremity as we have of that in the
lower, then I believe that such hypertonus would be
detected just as soon in the arm, and probably to as
great a degree, as it is in the leg.
Some writers have actually used the term " Kernig's
sign" as applying to this rigidity of the upper limbs.
Thus Dr. W. J. Buchanan,'" writing of a case of cerebro-
spinal fever, says : " Kernig's sign was present very dis-
tinctly in both legs when the patient sat up ; but it was
also found that both forearms were held in a position of
extreme flexion across the chest, and on attempting to
straighten the arms it was found impossible to do so.
The tense state of the flexor muscles exactly resembled
that of the hamstrings in this symptom as usually de-
scribed. ... I have not been able to find any
allusion to this symptom appearing in the arms in any
of the numerous writers on this disease that I have been
able to come across."
And Dr. James Barr, in a subsequent number of the
same journal writes : " "I have seen it (Kernig's sign)
very marked in both the upper and lower extremities in
cases in which there was no reason to suspect any spinal
mischief." One might just as well speak of Kernig's
sign in the back of the neck, or in other words, use the
term as a synonym of "increased muscular tonus," as
these writers seem to have done. This would be mani-
festly incorrect, as Kernig was not the first to describe
muscular rigidity in meningitis, but merely the dis-
coverer of a convenient method of testing for that
rigidity.
The explanation of the sign which is usually accepted
is Netter's, which he gives as follows:^ "In conse-
quence of the inflammation of the meninges the roots of
the nerves become irritable and the flexion of the thighs
upon the pelvis when the patient is in a sitting posture
November 8, 1902J
KERNIG'S SIGN
(Amekicau MEBicriJll 737
elongates, and consequently stretches the lumbar and
sacral roots and thus increases their irritability. The
attempt to extend the knee is insufficient to provoke a
reflex contraction of the flexors while the patient lies on
his back with the thighs extended upon the pelvis, but
it does so when he assumes a sitting posture." There
are many objections to this view. In the first place, the
sign is often present in conditions like cerebral hemor-
rhage, cerebral thrombosis and purely intracranial men-
ingitis, but according to Netter it should not exist until
meningitis of the lower part of the spinal meninges has
set in. Again, although extension of the knee with the
thigh flexed probably puts tension on the nerves, it can-
not be that extension of the elbow does so, or slight
flexion of the head, and yet the same rigidity is often
found here. Increased intracranial and spinal pressure
has been advanced as a cause. Roglet " has shown ex-
perimentally that increase in cerebrospinal fluid in
rabbits does not produce Kernig's sign. All the same, I
have seen the sign much lessened in a ca.se of meningitis,
by lumbar puncture, which looks as if pressure had pos-
sibly something to do with it.
Joseph Sailer ' thinks that " the most reasonable ex-
planation of Kernig's sign that we possess at present is
to ascribe it to an irritative lesion of the pyramidal tract
that diminishes but does not destroy its functional
activity. It is obvious that it is not a lesion of the men-
inges but of the subjacent nervous substance that causes
the occurrence of Kernig's sign. Practically all cases of
leptomeningitis are associated with a more or less severe
degree of encephalitis. So far as the writer has observed,
however, the occurrence of the sign in the course of a
typical case of encephalitis has not been recorded."
It must be remembered that any condition which
will produce inability to move apart to the normal
extent the origins and insertions of the hamstring
muscles will produce Kernig's sign, and, as these condi-
tions are various, so must be the explanations of this
phenomenon. Thus postmortem rigidity brings it out
in the cadaver to perfection ; so also will the contrac-
tures due to long disuse of the limbs as we have seen in
cases of hip-joint disea.se, etc., such contractures being
either active or due to actual fibrous change in the
muscles. As has long been pointed out, painful condi-
tions of the sciatic nerve will give the sign. Recently
an Italian writer' has published a case of Kernig's sign
occurring in sciatica. If any one would publish a case in
which it did not occur in acute sciatica it would be
more interesting.
All muscles tend actively to resist passive stretching,
and if they be irritable from any c»use, i. e., their tonus
increased, then they will resist more strongly, and
when this occurs in the hamstrings then Kernig's sign is
produ(!ed. It may be mentioned in passing that if the
stret(!hing be done quickly an active contraction of the
muscrles is apt to ensue, probably of the same nature as
the knee-jerk. Hence in testing cases the extension
should be made slowly.
All muscles are normally in a state of what has been
termed by Foster " " skeletal tone." This is the quality
by virtue of which they are kept taut and ready for
active contraction. When any of the factors upon which
this skeletal tone depends are done away with, then the
muscles become limp and flaccid and actually longer than
before. These essential factors are several, and any dis-
cussion of them hero would be out of i)lace, but we
might agree with Foster that " clinical experience shows
that the central nervous system does exert on the skele-
tal muscles such an influence as to give rise to this
skeletal tone; changes in the nervous system leading in
some cases to a diminution, or loss of tone, in other
cas(*i to exaggeratif)n of tone manifested often as con-
spicuous rigiflity." "
One might theorize that some toxin of an irritating
strychnin-like character was produced during the
inflanmiatory process in meningitis, and that this, act-
ing on the nervous system, produced a heightened tonus
of the muscles and hence the rigidity and Kernig's sign.
It must be remembered in this connection that there is
also an increased sensory irritability in meningitis, as is
shown by the photophobia and the hyperesthesia of the
surface of the botly and the resentment of the patient to
being moved. Even when the patient is semicomatose,
this irriti\bility is manifest and constitutes to ray
mind one of the best distinctions from typhoid fever, in
which disease there may be as much hebetude but not
this mixture of dulness and irritability.
It has been repeatedly shown '* that irritation of
the cerebellum will produce increased tonus and even
spasm of the muscles of the body, the muscles being
affected on the same side as the lesion. Further, it
is interesting to note that Luciani " has shown that
the muscles most affected by lesions of the cerebellum
are those which fix the head and those of the hinder
extremities. These seem to be the most rigid in cases
of meningitis. Hence one may fairly state that either
the toxins set up by the meningitis, or an extension
of the inflammation to the cerebellar substance, so act
on the cerebellum as to cause the rigidity in this dis-
ease and the fact that this is most marked in basal men-
ingitis is in favor of this cerebellar theory. The rolling
movements and conjugate deviation of the eyes, the
nystagmus so often seen in meningitis, all point in the
same direction, as such symptoms constantly occur when
the cerebellum is experimentally irritated. This is the
view advanced by Drs. Lees and Barlow,'" and here I am
only applying it in the explanation of Kernig's sign. In
support of this explanation I may mention a recent case
under the care of Mr. I. H. Cameron, in which Kernig's
sign was well marked. The disease was diagnosed as
cerebellar tumor, and this was confirmed on postmortem
examination. In those cases of meningitis in which the
sign is absent then the site of the disease is probably away
from the region of the cerebellum. On the other hand,
in those in which, after a period of rigidity, flaccidity
sets in, jirobably the cerebellum, having been at first
irritated, is then paralyzed by the process and hence we
get the same result as when the cerebellum is experi-
mentally destroyed, L e., a loss of skeletal tone.
CONCIiUSIONS.
1. Inability to passively extend the knee fully while
the thigh is at right angles to the body, l. e., Kernig's
sign, was present in over C0% of all hospital patients
examined.
2. Kernig's method Is to place the patient in a sitting
posture and then extend the knee. A more convenient
way of applying the same test is that mentioned by
Osier, in which the patient is kept recumbent and the
thigh is placed at right angles to the body and then the
knee is extended.
3. A procedure having advantages over both of these
methods is first to extend the knee fully, then flex the
thigh on the pelvis and measure the angle at the hip.
Thus only one angle requires to be gauged instead of
two and hyperext«nsion of the hip (showing muscular
hypotonus) can be measured.
4. There is a great proneneas in meningitis to in-
creased muscular tonus, which is most apparent in the
muscles of the neck and in the hamstrings. This hyper-
tonus, occurring in meningitis, is probably due to cere-
bellar irritjition, and conversely cerebellar irritation is
probably the explanation of Kernig's sign in meningitis.
5. Inability to extend the knee fully with the hip at
right angles to the body, or to flex the hip to a right angle
while the knee is extended, occurs in many conditions
besides meningitis.
Among such conditions are cferebellar diseases and
disejises of the upper neurons of the motor tracts, acute
eye troubles, disuse of the lower limbs for some days, as
in recumbency, lowil conditions in these limbs as sci-
atica arthritis and contractures, old age, etc.
738 A.MEKIOAN MEDICINE)
OXYGEN BATH FOR THE PERITONEUM
[November 8, 1902
6. When Kernlg's sign is well developed in a re-
cently healthy individual who has fever and none of the
conditions mentioned then it is a valuable sign of men-
ingitis, and this is probably, at least partially, in the
cerebellar region.
7. For the purposes of greater clinical accuracy, it is
urged that writers upon this condition express the angle
at the knee or hip in degrees, rather than merely men-
tioning the presence or absence of the sign.
BIBLIOGRAPHY.
1 Berlin, kiln. Woch., December 29, 1884.
■ Cavendish Lecture, Ijancet, June 21, 1899, p. 1703.
3 Aldo Mngri, La Riforma Medica, April 9, 1902. Quoted In Medl
cal Record, May 10. 1902.
* British Med. Journal, March 24, 1900, p. 699.
s Joseph Haller, Amer. Jour, of the Med. Sciences, May, 1902.
« r.,ancet, January 6, 1900, p. 47.
' Rutter Williamson, British Med. Jour , April 26. 1902, p. 1025.
' Herrlck, American Jour, of the Med. Sciences, July, 1899.
» Shields, American Jour, of the Med. Sciences, 1902, p. 781.
i« British Med. Journal, February .S, 1900, p. 255.
" British Med. Journal, March 24. 1900, p. 699.
i2Roglet, Gaz.Heb.de M6d. et do Chirurg., July 15, 1900. Quoted In
Phlla. Med. Journal, September 22, litOO.
" Foster's "Physiology," seventh edition, parts, p. 996.
" Schafer's " Textbook of Physiology," Vol. 11, p. 893.
15 Ibid, p SI96
i« Clifford Allbutt's ".System of Medicine," Vol. vli., p. .528.
THE OXYGEN BATH FOR THE PERITONEUM AND
ITS POSSIBLE VALDE.-SECOND REPORT ON
THE CANCER CASE RELIEVED BY AN EX-
PLORATORY LAPAROTOMY.
BY
EUGENE R. CORSON, M.D.,
of Savannah, Ga.
What I have to oflfer in this paper is more in the
way of suggestion than demonstration. Suggestion may
prove of value if it leads to experimentation and re-
search, and one thought gives birth to other thoughts
which may ultimately come to something tangible and
of value. As practising physicians, much conies to our
minds which vanishes as quickly as it comes, and again,
we are possessed by certain thoughts which cling to us
and clamor for a certain recognition.
A ca-se of cancer, the preliminary report of which I
published in American Medicine, March 22 of this year,
started me along a certain line of reasoning and along a
limited line of experimentation, which seem to offer a
suggestion in the way of further experimentation, and I
shall outline briefly the subsequent course of the case and
the little I have so far done in an experimental way.
In this case the simple opening of the abdominal
cavity was follovved by results which were remarkable.
Great pain and dyspnea disappeared as by magic, and
infiltrated tissues were relieved almost as quickly. I
reproduce here that portion of the paper referring to the
clinical features of the case :
Nearly 10 years ago I removed the left breast of a negress
aged 45, doing but the partial operation. There wa.s no return
for nine years, wiien, immediately following a vaccination four
months ago, pain started in the neck on that side, spreading
over the old scar and extending to the right side, followed
rapidly by the appearance of hard nodular tumors in and under
the skin of the entire chest. W^hen she came to me the skin
over the chest was bound down in a firm mass. The right
breast was enormous, containing several hard tumors. The
nipple was not retracted. The skin had the typical pigskin
appearance .so much dwelt upon by Banks. Both axillas and
supraclavicular spaces were full of se<!ondary growths. It was
a typical picture of cancer en cuirasse.
The subjective symptoms were equally pronounced. There
was great dyspnea, especially at night, the patient spending
most of the time in a chair by the fire. There were burning,
lancinating pains through the affected area. The face showed
pain and air-hunger. The patient walked bent over.
Recognizing the case as inoperable, I decided to try the
Beatson operation, and sent the patient to our colored hospital,
the Georgia Infirmary. On opening the abdomen I found a fair-
sized uterine fibroid, with tubes and ovaries and bowels adher-
ent to the uterus. The liver was examined for secondary
growths, but none found. Just as I started to break up the
adhesions the patient stopped breathing, and only after much
effort was she resuscitated. Fearing to continue the anesthesia,
the atjdomen was closed without any further interference.
One of the skin tumors removed under cocain has l)een
examined by Professor V. A. Moore, of Cornell University, and
pronounced carcinoma.
At the end of 48 hours a very marked change was evident
in the right breast and in the skin over the old scar and over
the entire chest. This was admitted by the four physicians
who were present at the operation and who have seen the
patient since then. The right Ijreast had gone down one-half ;
the pigskin appearance was gone, and the breast lay wrinkled
and flabby on the chest. The subjective symptoms had disap-
peared with the objective ones ; the pains and the dyspnea were
gone, and the woman could sleep all night on her back. The
facial expression had changed to one of comfort and content-
ment. The patient declares that the relief to the subjective
symptoms came soon after she recovered from the anesthesia.
But three weeks have gone by since the operation, and each day
an improvement is visible in the skin, which is becoming
movable and soft. The supraclavicular and axillary growths
are movable and are somewhat smaller ; the former seemed to
feel first the retrograde movement.
This improvement only lasted a month, but short as
it was it could not do away with the hard fact that a
great change had been produced by a simple procedure.
What the real nature of this change was, what the real
causative factors were, is a problem still to be solved ;
and it is one, I think, which can be solved in the physio-
logic and pathologic laboratory, if not at the bedside.
The simple operation of opening the abdomen, the
simple exploratory laparotomy, is done daily many
times all over the world, but it is probably rarely done
for the conditions existing in my patient. That this
simple procedure would cure tuberculous peritonitis has
been known for some time. That apparently even more
serious conditions have been benefited or cured by this
operation was also known. I may state as a part of my
own experience that on one occasion I opened the abdo-
men of a woman to remove a tumor on the left side of
the pelvis, and found a hard mass filling up the iliac
fossa, growing from the bone apparently, and to all
appearances sarcomatous. The abdomen was simply
closed and the family acquainted with the probable
nature of the trouble and its incurability. I gave the
patient about three months to live. This tumor gradu-
ally disappeared, and the woman is alive today. I
imagine that a careful search of the literature will dis-
close more cases of this kind, pointing to the curative
action of the laparotomy per se.
I am not aware that any satisfactory explanation has
been given of tlie cure of tuberculous peritonitis by the
simple opening of the peritoneal cavity. The general
impression is that it is exposing the peritoneal surface
to the air, the opening of a cavity to the air which is as
much shut off from the outside world and the atmos-
pheric air as the ventricles of the brain. Even if this
were admitted as the primary factor in the case, we are
quite in the dark in what way, by what channels, nature
is enabled to pull herself together and to remove a dis-
ease which has attacked her very vitals. The percentage
of cases of tuberculous peritonitis cured by this means is
fairly large, and this is a very hard fact which demands
much more careful scrutiny and investigation than the
physician or physiologist has so far .seen fit to give it.
The solution of so vital a problem must unlock for us
many secrets, must open the doors to many avenues and
byways of research, and all honest research accomplishes
something, even in a negative way.
Wonderful as the peritoneum is from an anatomic
standpoint, and much has been done in recent years in
this direction, its actual life must be even more wonder-
ful. That nature has provided such an enormous peri-
toneal area means much. We know but too well how
great its power is toward death when affected by disease
beyond its control. This jiower must be equally great
toward life and health when properly aided. Occasion-
ally under the most adverse conditions apparently, and
from the most desperate provocations, we see it over-
coming all obstacles and bringing the patient back to
health. With the great triumphs of modern peritoneal
NOV'EHBEK S, 1902]
OXYGEN BATH FOE THE PERITONEUM
I Amebic AN Medicini 739
surgery we have not seemed to fully realize how much
we owe to the peritoneum itself. The bolder we become
the more we encourage its help and the more its wonder-
ful vitality is shown. There is no tissue of the body
which gives us such a helping hand.
Assuming that the primary factor in my own case
was the admission of air, it occurred to me that if ordi-
nary atmospheric air, which is, roughly speaking, a
mixture of oxygen and nitrogen, one to three, could so
stimulate the peritoneum and the great emunctories of
the abdomen, the introduction of pure oxygen would
have a still greater influence. It also occurred to me to
test the absorbability of the peritoneum to gases, and
laughing gas, N^O, suggested itself as the best suited
for the purpose, being bland and having anesthetic prop-
erties, which would be evident were the gas absorbed to
any rapid extent. I therefore determined to try it on
my patient when the opportunity oifered itself.
As I stated, the groat improvement following the initial
operation lasted one mouth, when the infiltration of the tissues
of the chest returned very rapidly, along with the great dyspnea
and pain, with a rapid and weak pulse. The pigskin appear-
ance of the breast returned, and the left arm and hani were
considerably swollen. When she came into the operating-room
the dyspnea was so great that she could not lie down, and the
abdomen was opened under oocain while sitting up. The
nitrous oxid was first passed through a warm wash bottle to
warm the gas before passing it into the abdominal cavity. The
patient could feel the gas streaming over the bowels, but the
pulse and respirations rapidly became worse, and fearing again
that my patient might die on the table the experiment after a
few minutes was stopped, the peritoneum stitched, and the rest
of the wound brought together with adhesive strips. Dr. Jabez
Jones, resident physician of the Savannah Hospital, who
attended to the NsO apparatus, and who is accustomed to give
the gas, thought that there was some evidence of its absorption,
but the distressing condition of the patient prevented any care-
ful observation in the matter, and I felt that the experiment
was a failure. However, the good effect of opening the abdomen
was soon apparent, for before the patient left tlie operating-
room she was able to lie down, and she expressed herself as
feeling better. The palliative effect was thus again shown.
A constant cough and the continued dyspnea led to an
examination of the chest, which a month before had been ex-
amined with negative result, and some fluid was found in the
left pleural cavity. This was drawn off by aspiration— three
pints of very bloody serum. This operation, however, relieved
neither the cough nor the dyspnea, but seemed rather to aggra-
vate the condition. The patient, thinking she was going to die,
begged to be allowed to return to her home. In a few days
improvement again became evident ; the swelling in the chest
went down, the breast returned quite to the improved condition
following the first operation, and the patient was again thor-
oughly comfortable. This second operation was done on Feb-
ruary 26.
On March 6 there was more dyspnea, and the breasts began
to enlarge again, and tlie patient consented to our trying the
oxygen. The skin was cocainized by Schleich's stronger Infil-
tration solution, and a small cannula and trocar, 24 mm. in
diameter, was passed into the peritoneal cavity. It is surpris-
ing how much force is necessary to pass even so small a trocar
when there is no resistance from fluid in the cavity. The pass-
ing of the trocar, however, gave her no pain. The oxygen was
passed in through a comfortalily warm wash bottle at a mode-
rate pressure. The patient felt the gas streaming over the
bowels. The pulse, which was 90 and of poor tension, soon
went up to 100, with good tension, almost bounding like an
ether pulse. .Slie expressed herself as feeling better, '"stronger
iu the legs," as she said, and tlie improvement in the dyspnea
was soon apparent to those present. Tlie gas was allowed to
<listend the abdomen until it became large and tense. This
OHUsed no pain, but the pressure on the diaphragm was evident
by the more difficult respiration, and the gas was allowed to
pass out, almost whistling through the tube. Throe times was
the abdomen filled in this way, and after allowing the distention
to go down somewhat, the cannula was withdrawn and the small
opening closed by an adhesive strip. Some gas escaped through
the hole after removing the cannula. The residual gas was
absorbed rather slowly, and was not all gone before the end of
two hours.
The general improvement from this oxygen bath was again
very evident; the pulse and respirations in two days coming
down quite to the normal. The swelling again went out of the
chest, the breast and the arm.
On March Hi the fluid in the left pleural cavity had reao-
cumulated, and although the patient was fairly comfortable,
this was withdrawn by aspiration— three pints of bloody serum.
The aspiration, as in the first instance, did not seem to help
much, the returning swelling in the breast and arm remaining
about the same.
On .March 18, 12 days after the first oxygen bath, the oxygen
was again used ; the same procedure was carried out and with
the same relief. The respirations, which were 48, went down
to 36 in a half hour, and down to 24 in two hours. The great
stimulation of the pulse was again evident. When I saw the
patient two hours later she was comfortably sleeping in bed, the
respirations 24, the pulse 90.
Again, on March 27, the oxygen was used. When the gas
was first passed througli the cannula there was evidently some
obstruction, and I found that the cannula was not in the peri-
toneal cavity and that some gas had passed subperltoueally into
the connective tissues. The breathing became very short and
distressing, and the patient's condition was much aggravated.
The gas was afterward passed into the cavity itself, but it had
to be given in small doses and the gas allowed to escape. When
seen in an hour's time I found the right side of the neck and
face eniphysematous, the gas crackling under the skin on pres-
sure. 'The respirations were still labored, though much im-
E roved, and the patient expressed herself as feeling generally
etter.
Next morning the patient was much easier, had slept
all night in bed lying down ; emphysema in right neck and
face still evident, though somewhat reduced from the evening
before. The rapidity with which the gas passed from a point
just below the umbilicus, a little to tlie right of the median
line, to the subcutaneous tissues of the neck, is a very curious
phenomenon. It would seem to point to the close connection
between the subperitoneal, the .subpleural, the submediastinal
and the cervical connective tissue spaces.
Oxygen was again introduced on March 31 ; no discomfort
has been caused by the emphysema, which is still evident.
The accident showed how slow the connective tissue spaces are
in absorbing the gas and how comparatively rapid is the ab-
sorption from the peritoneum. The patient has been steadily
losing ground. The swelling in the feet has gradually increased
and has extended up into the thighs and hips and lower abdom-
inal wall. The swelling in the left hand is marked. The fluid
in the left pleural cavity has suddenly become evident again
and will soon have to be withdrawn. The breast and chest
and cancerous growths show no increase. It seems to be the
heart and mediastinal complications which are the serious feat-
ures in the case. There was a slight sputtering of straw-
colored serum through the cannula on allowing the gas to es-
cape, but there is no noticeable fluid in the abdominal cavity.
The pulse showed the stimulation from the oxygen ; patient
expressed herself as fooling better.
April 1, drew off three pints of serum from the left pleural
cavity ; there was much less blood in it, and its withdrawal did
not distress the patient. She is, however, losing ground rap-
idly ; the legs are greatly swollen and the edema has extended
well up into the abdominal wall ; the pulse is of poor tension,
irregular, and occasionally intermittent.
April 5, used the oxygen again with some relief to the dysp-
nea, but not sufficient to allow the patient to lie down.
April 8, jiatient begged for the oxygen, which was given
her, but without relief ; she died during the night, three months
after the first opening of the abdomen.
I regret that I have not a complete pathologic record
of this case. An autopsy was not permitted. Treating
a poor negro in a cabin offers many difficulties in the
way of precise records. In a general way I can state
that the external carcinomatous process seemed of
secondary importance to the involvement of heart,
mediastinum and left pleural cavity. The urine showed
but a trace of albumin ; the kidneys otherwise were
working properly, judged by the quantity of urine
pas.sed and the good specific gravity, 1,020 and over.
The digestive organs were in good shape. The heart
action was bad ; there was a dilated heart, with a pulse
of poor tension, thin, irregular, and intermittent, and
the dyspnea was cardiac and mediastinal, for the removal
of the fluid from the left pleural cavity never gave much
relief. The symptoms pointed to the same infiltration
and engorgement in the mediastinum which existed
externally in the breast and chest. The swelling in the
chest impressed me as an angioneurotic edema, for there
was no suppuration or inflammation apparent in the
tissues. There was no evidence of arteriosclerosis, a
condition common in the negro ; certainly nothing
marked in this way. The gradually increasing edema
from the feet up, involving the lower abdominal wall,
pointed to the heart. The edema of the left arm seemed
to be more the ordinary venous obstruction. Even at
the end the breast and chest showed leas engorgement
than in the beginning, and skin and cancerous mas.ses
remained freely movable. The supraclavicular glands,
which had decreased in size after the first great improve-
ment, remained as they were. The axillary tumors were
740 A.MEBIOAN Medicine]
ACID FACTOBB OF GASTRIC FLUID
INOVEMBEB 8, 1902
also movable, though when first seen were adherent.
The skin over the old incision in the left breast, origin-
ally firmly adherent, was still soft and movable. Short
as the improvement was following the first laparotomy,
one could not but be impressed by its brilliancy, and by
the thought that the principle of relief must have a value
when the conditions are more favorable. Even a specific
has its limitations. There are instani-es when anti-
toxin is too late for diphtheria, and forms of syphilis too
hopeless for mercury and potash. It is the right remedy
at the right moment which avails. I feel that if this
treatment had been carried out three or four months
earlier the improvement would have been more lasting.
That the patient begged for the oxygen the day before
she died showed how much relief it had given her.
The thoughts suggested by this case are many. If
the stimulation from the oxygen is greater than that of
the ordinary atmosphere, perhaps the use of ozonized
oxygen may be greater still ; the experiment at least
seems worthy of trial. Oxygen through which the
electric sparli has been passed could easily be used.
The effect of the exposure of the peritoneum to the
atmospheric air in abdominal operations is well worthy
of more careful consideration. This great cavity has
become the wonderland of the body. There is no tissue
which heals so quickly and no serious lesion which it
does not seem able to overcome, provided we keep out
sepsis and give it the proper chance. No other cavity
in the body is the surgeon so willing to leave to its own
resources. At times under the most serious septic con-
ditions this cavity is able to work out its owu salvation.
Here the great process of phagocytosis seems at its best.
In the use of gauze drains after serious operations I
have always been impressed by the fact that the chief
drain was into. the blood-vessels and lymphatics rather
than out through the wound, and that when there was
much drain externally the peritoneum was not doing its
full duty. I have thought that the mere presence of the
drain was the stimulating factor, yet I cannot but believe
now that the stimulation of the air introduced must be
a potent factor. I have long felt that the bad cases of
peritonitis following operation were best treated by an
immediate opening of the cavity with a good washout.
Would not, in these cases, the oxygen bath prove an
additional help? After serious abdominal work, just
before the peritoneum is finally closed, would not the
oxygen bath be a benefit and help turn the scale toward
recovery ? And, again, during convalescence, if recovery
is delayed, or, perhaps, stops, and a retrograde move-
ment sets in, will not the oxygen bath help ? These
questions naturally come up, and they seem sufficiently
rational to demand experimental investigation.
In the very treatment of tuberculous peritonitis will
not the oxygen bath do more than the simple opening
of the peritoneal cavity ? The simplicity of the proce-
dure and the ease with which it can be repeated almost
indefinitely would suggest an answer in the affirmative.
And this suggested to me its use in tuberculous cattle.
Bovine tuberculosis, affecting so often the abdominal
viscera and the peritoneum, would suggest the opening
of the peritoneal cavity as a possible curative measure
from its good results in tuberculous peritonitis in man.
Possessed by the idea, I wrote to my friend. Professor
V. A. Moore, professor of comparative pathology and
bacteriology in the Veterinary College of the State of
New York, at Cornell University, and he has taken
steps to thoroughly test the matter. Should the tuber-
culosis of cattle yield to surgical methods, it would be a
greater step toward the eradication of the disease than
the present wholesale slaughter of affected animals.
In the operation of paracentesis for Ascites little or
perhaps no air is introduced into the abdominal cavity ;
would not the oxygen bath here be of some value ?
As the opening of the abdomen gave relief to the chest
symptoms in my patient, will not the same procedure
prove useful in other chest condition!? ? In this patient
the carcinomatous process was far advanced. It involved
the media.stinum and left pleural cavity, and the dyspnea
was evidently cardiac and mediastinal, and was beyond
any treatment. The fact that any relief was obtained
argues strongly in favor of the method. During the
patient's stay in the hospital I used the thyroid extract
for a few days, but it had no efffect and was discontinued.
Drugs were purposely avoided that we could see the full
effect of the treatment.
If the stomas of the peritoneum are direct openings
into lymph spaces and lymphatics, it is possible that the
oxygen introduced finds a direct point of entrance into
the lymphatics and the veins, and may stimulate greatly
the lymphatic flow and function. Oxygen so introduced
may have more effect than the same amount introduced
into the lungs, and thus the peritoneum acts as a
vicarious lung by oxygenating the lymph. My limited
experiment showed, I think, that there was a consider-
able absorption of the gas by the peritoneum, a rapid
absorption when compared with the absorption by the
connective tissue spaces. In conditions in which the
blood fails to get its proper quantity of oxygen (cases of
heart and lung troubles) oxygen so introduced may at
least give temporary relief, more relief than by the usual
channel. I believe that in cases of pulmonary edema
and congestion, due to whatever cause, this method
would give relief, and perhaps tide the patient over a
dangerous moment, un mauvuis quart (Vhenre, better
than the counter irritation and the heart stimulants at
our disposal.
The influence of the removal of the ovaries which
was Dr. Beatson's idea, never appealed to me as rational.
There were, to my mind, so many reasons for doubting
it. The removal of important organs as a curative
measure is so at variance with the whole theory of
organotherapy which is to supply to the organism those
organic extracts which are lacking. Then the removal
of ovaries at a time of life usually when they have
ceased to functionate, when they are atrophied or dis-
eased, seemed to be an operative measure of supereroga-
tion, and as cancer of the breast usually comes when
ovaries go, added to the difficulties of a rational view of
the matter. So that when, by an accident, I was pre-
vented from removing these organs, and I still obtained
a remarkable improvement in my patient, due evidently
to the laparotomy itself, my doubts were confirmed, and
I could only regard the Beatson operation as a lapar-
otomy pure and simple, the improvement coming in
spite of the removal of tlie ovaries.
Not a hundred years have gone by since McDowell
did his ovariotomies and we began to learn something
about the peritoneal cavity. Since then its secrets have
gradually been discovered, and today we know much
about this great vital center. The secrets yet to be dis-
covered are greater still. There is much research ahead
of us to be done. Embryology, physiology, and path-
ology will all give a helping hand, and the day is prob-
ably not very far off when our knowledge of this great
membrane will be at least sufficient for what is possible
in our efforts to cure disease and to^rolong life.
THE DETERMINATION OF THE ACID FACTORS OF
THE GASTRIC FLUID.
BY
CHARLES PLATT, M.D., Ph.D.,
of Philadelphia.
Probably no clinical test has suffered more from
incompetent and careless writing than has the determi-
nation of the acid factors of the gastric fluid. Methods
have been gravely recommended and highly praised by
men who have never practised the analysis described,
and the result is confusion and disappointment to the
physician who confidently makes the endeavor to apply
them. Dimethylamidoazobenzol, for instance, was long
NOVBMBKR 8, 1902J
ACID FACTORS OF GASTRIC FLUID
(AxEBiCAK Medicine 741
ago recommended by somebody as a test for free hydro-
chloric acid, and the recommendation was accepted
apparently without investigation, until now, having
gone through the usual journal life, the test has attained
to textbook dignity, where, once arrived, it may be
counted upon to persist for many years. Indeed, most of
the methods now advised for the differential determina-
tion of the various acid factors begin with an estimation
of the free hydrochloric acid, dimethylamidoazobenzol
being the indicator used. The two following will serve
as examples :
Afethod T.—(a) Titrate with dimethyl for free hydrochloric
acid ; (6) titrate a second sample with alizarin i'or the free
hydrochloric acid, the acid salts and the organic acids; (c)
titrate a third sample with phenolphthalein for the total acidity.
Finally subtracting (a) from (6) we get the acid salts and
organic acids, and subtracting (6) from (c) the proteid— com-
bined acid.
Method II.— (a) Titrate with dimethyl for free hydrochloric
acid and (&) in the same sample continue the titration with
Congo- red for organic acids ; (c) in the same sample again, using
now alizarin as the indicator, determine the acid salts; and (d)
finally complete the titration with phenolphthalein for the pro-
teid-combined acid. The sum total of decinormal alkali used
expresses the total acidity.
An indicator for any volumetric test must fulfil the
following requirements : The completion of the test, the
end-reaction, must be marked by an indisputable change
in color, and this change must not be gradual ; but little
of the indicator must be used, and the color change must
not be interfered with by extraneous substances present,
nor by the products of the reaction itself; its presence in
the solution must not modify the chemic reaction, nor
shall it enter into combination with the reagent used
before the main reaction be accomplished. In several of
these requirements dimethylamidoazobenzol fails, its
color change being effected, for instance, not by hydro-
chloric acid alone, but by lactic acid, by acetic acid, by
butyric acid, by succinic acid, and also, according to
Knapp, by formic acid, by malic acid, and by the acid
phosphates of calcium and magnesium.
That dimethyl is not always to be relied upon for the
free hydrochloric acid is now recognizetl by some, but its
retention as a routine indicator by others, and the knowl-
edge gaining ground that the color change may be
equally effected by lactic and other acids, has led to a
truly remarkable confusion of methods. For instance,
A recommends the estimation of the free hydrochloric
acid with dimethyl, and the estimation of the organic
acids with tropajolin, while B recommends the estima-
tion of the free hydrochloric acid with tropa'olin and
that of the organic acids with dimethyl. Is there any
wonder that the practitioner who is not a chemist fintfe
the results of hLs tests less satisfactory than he had been
letl to expect from the article read? Fortunately for the
patient, the elaborate method is not long persisted in ;
after a few failures it is abandoned and the necessary
deductions drawn, henceforth, from the qualitative
examination and from the estimation of the total acidity.
On the other hand, I do not wish by this criticism to
imply that dimethyl is never of value in ga.stric analyses,
for, as a matter of fact, we all know that in many sam-
ples, despite the theoretic objection to its use, it does
yield satisfactory results, apparently serving as an effi-
cient indicator for the free mineral acid. This successful
operation of an Indicator faulty in theoretic action is
probably to be explained by the fact that in the presence
of free hydrochloric acid we rarely find organic acids in
any considerable amount, and that small amounts of the
organic acids have, in presence of certain proteids, a
lessened influence upon the color change. In other
words, while dimethyl can not be used as an indimtor
for the differentiation of mineral and organic acids in
pure mjueous solution, it may often, but not always, be
so ased under the conditions presenting in the onifinary
clinical analysis of the gastric contents.
1 have mentione<l tropa-olin as an indicator for free
hydr<x;hloric acid, and this substance, I may add. Is
fairly satisfactory, Ewald, notwithstanding, provided
only that we know exactly the color change to expect
and that we use the tropseolin 00 in saturated alcoholic
solution. This indicator is not entirely indifferent to
organic acids, but the latter produce a true red and not
the magenta or purple-red due to the mineral acid. In
using it as an indicator in the titration of the free hydro-
chloric acid the change will then be from magenta or
purple-red to a true red in the presence of organic acids,
or from magenta or purple-red to yellow in the absence
of the same. In the first case the change is not suffi-
ciently marked to make the tropajolin an ideal indicator,
but with care it may be used with a fair degree of
accuracy.
It has been suggested, in a method referred to, that
we may estimate the free hydrochloric acid, the organic
acids and the general acidity in one sample, using suc-
cessively tropaeolin, dimethyl and phenolphthalein as
the respective indicators. The difiiculty here, however,
lies in the fact that the dimethyl end-reaction would be
obtained before all of the organic acids had been neutral-
ized, the sensitiveness of the indicator being lessened by
the nucleoalbumin present. In fact, in many cases the
organic acids by such a method would be overlooked
entirely, and this because of that peculiarity of the indi-
cator which makes it, as already noted, a practical pos-
sibility in hydrochloric determinations. For this rea.son
I would prefer to titrate, in one sample, with tropseolin
for the free hydrochloric, with congo-red for the organic
acids, and with phenolphthalein for the general acidity.
The congo-red paper used should be darkly pigmented,
and the titration should be continued until a drop of the
solution fails to produce even a grayish tint.
It is my opinion that with our present knowledge,
or lack of it, the ordinary clinical analysis of the gastric
fluid may well be limited to the following acid tests :
First, qualitatively., for free acids in general with congo-
red paper ; for free hydrochloric acid with Gunzberg's
or Boas' reagent ; for lactic acid and other organic acids
by the modified Uffelmann's test, using the ethereal
extract of the filtered gastric fluid.
Second, quantitatively, for the total acidity with
phenolphthalein, and for the free hydrochloric acid using
either the titration method with tropseolin or the more
exact though more tedious method by successive Gunz-
berg's reactions. The organic acids maybe estimated in
the same solution by continuing the titration with
congo-retl paper as the indicator. All of these quantita-
tive tests may, in case of need, be made with one sample
of the gastric fluid, determining the various factors in
the manner described, first the free hydrochloric acid,
then the organic acids, and, finally, the total acidity.
When an attempt is to be made to determine all of
the acid factors separately, the following plan, while
open to criticism, is still fairly satisfactory. In the first
place, the results of the qualitative examination should
be borne in mind and the steps of the analysis modified
to meet the requirements of the actual condition present.
It would be well, too, to include with the other qualita-
tive tests one for the acid salts, the acid phosphates, and
this may be conveniently done by Knap{)'s method.
His reagent is the red ferric thiocyanate, obtained by
adding to 5 cc. of waters drops of a 10^ solution of
ferric chlorid and 5 drops of a bfo solution of ammonium
thiocyanate. To test for the acid phosphates, 1 cc. of
the reagent is placetl in each of two test-tubes, and to one
the filtered gastric fluid is atlded while to the other is
added an e(|ual amount of water. In the presence of
acid phosphates the ferric thiocyanate is either entirely
or partially decolorized.
Prtsuming, then, that the (lualitative examination has
shown all of the atnd factors to be present, the plan of
analysis would be as follows, two samples being used :
To a mea.sured specimen of the filtered ga-stric fluid deci-
normal alkali is added until a drop of the fluid gives no
reaction with Gunzberg's reagent, or, less exactly but
742 AMEBIOAN MEDtCIKE]
CONGENITAL HEENIA OF LIVER
[NOVBMBEK 8, 1902
more conveniently, a few drops of a saturated alcohoJic
solution of tropteolin GO may be added to the fluid and
then the standard alkali until the magenta or purple-red
of the solution turns to a true red (or, in the absence of
organic acids, to a yellow). In either case the number
of cc. of alkali used serves for the calculation of the free
hydrochloric acid. The addition of the decinormal solu-
tion is now continued until the fluid under titration
fails to give a reaction with congo-red paper (the solu-
tion should now have a yellow color) and from the
number of cc. used the organic acids are estimated. A
few drops of a 1 ^ aqueous solution of alizarin are now
added and the titration continued until the yellow-
brown of the solution turns to violet ; from the amount
of alkali required to effect the change the acid salts are
estimated. Finally, the total acidity is determined in
the second sample, using phenolphthalein as the indicator,
and from this the free hydrochloric acid, the organic
acids and the acid salts are deducted to obtain, approxi-
mately, the amount of hydrochloric acid in proteid com-
bination.
As an alternative method we may determine the free
hydrochloric acid and the organic acids as above indi-
cated, and then, adding phenolphthalein, continue the
titration until the color change is effected. The amount
of alkali added after neutralization of the organic acids
gives together the acid salts and proteid-combined acid.
The total alkali used indicates the total acidity. A
second sample may now be titrated with alizarin as the
indicator, this giving all of the acid factors with the
single exception of the acid in proteid combination, the
latter may then be obtained by subtracting the results of
the alizarin titration from the total acidity.
CONGENITAL HERNIA OF THE LIVER INTO THE
UMBILICAL CORD, WITH REPORT OF A CASE.*
BY
J. W. BULLARD, M.D.,
of Pawnee City, Neb.
This developmental deformity is very rare, many
prominent surgeons never having seen a single case.
Jonathan Macready ' cites a table containing the records
of 47 cases of congenital hernia of the umbilical cord, in
28 of which the entire contents of the sac consisted of
intestine only, in 9 of the liver and intestine, and in 10 of
the liver only. In a very exhaustive paper by Dr.
Homer E. Safl'ord,^ read before the Detroit Medical
Society in 1900, are tabulated 126 cases of congenital
hernia of the cord. His first table, that of Lindfors,
contains 36 cases, supposed to be all the cases reported
cured up to 1882. He also gives Lindfors' second table,
comprising all reported cases of hernia of the cord from
1882 to 1891, 31 cases; Berger's table, completing the
record to 1893, 12 cases; and the remaining cases of
Hallet's table reported to 1900, 43 cases ; to which he adds
4 cases not hitherto reported, making the total 126. To
these I will add the case of Dr. George Kassel, reported
in the Medical Record,^ Dr. A. L. Muirhead's case,
reported to me by letter, which occurred in his private
practice at David City, Neb., and has not been reported,
and my own case, which will make a grand total of 129
cases.
In the 126 cases tabulated by Safford the liver was
included in the hernial sac in thirty-four instances, in 23
cases together with other viscera, and in the remaining
11 cases it was the only viscera in the sac. Dr. Muir-
head's case, previously cited, contained both liver and
other viscera ; Dr. Kassel's case, also previously cited,
contained only intestine ; while the case I wish to report
contained only the liver.
Of the 129 cases thus far reported the liver was the
a ,,1?'^*'^''®'°'"* ^^® Nebraska State Medical Society, lield May 6,7 and
8, 1902, at Omaha, Neb.
only vLscus in the sac in but 12 cases, and was included
together with other viscera in 26 other cases. In a
recent letter to me Dr. W. B. Coley ' says that during
his 12 years' service in the New York City Hospital for
the Ruptured and Crippled, he has seen only 2 cases of
hernia of the cord, one of which contained the liver
with other viscera. He further says that it has been
estimated that hernia of the liver occurs once in about
5,184 births.
Chadwick, cited by Warren,* describes several mu-
seum specimens in which not only the liver and intes-
tines were in the cord, but the heart as well.
Etiology. — The study of embryology teaches us that
physiologically the cord, next to the body of the embryo
till about the sixth to the twelfth week of intrauterine
life, contains portions of the intestinal tract. At this
time the umbilical vesicle should atrophy, the intestines
recede into the abdominal cavity, the umbilical ring
contract and the omphalomesenteric duct be closed.
Should this physiologic process be interfered with, hernia
of the cord is likely to result. Chadwick thinks that
at this period there may be a failure in the proper
development of the abdominal plates, thus forming a
partial cause for this deformity, the contents of the
undersized abdomen being of too great volume to be
embraced by the deficient walls. Warren here suggests
that " If the umbilical vesicle persists till a later period
than usual, that portion of the intestinal tul)e to which
it is attached is anchored outside of the umbilical ring."
Just why the liver should occupy this abnormal posi-
tion we are not told.
The prognosis of hernia of the abdominal viscera into
the umbilical cord is necessarily grave.
Of the 36 cases of all classes of hernia of the cord
reported cured prior to 1882, as tabulated by Lindfors,
eight contained the liver, two together with other
viscera, and six the liver only. The six containing the
liver only were treated as follows : Four by simple pro-
tective dressings, one by compressing bandage and one
by radical operation. In this latter case, which occurred
in 1846, it is said a protrusion the size of a fist remained.
The two containing other viscera were both treated by
reduction and ligature of the sac. One of these is said to
be the largest cord hernia ever reported, measuring
seven inches in diameter. This case was reported in
1820 by Bal, in Tiel, Holland.
In Lindfors' second table, comprising all reported
cases from 1882 to 1891, there are reported six cases of
hernia of the cord containing liver and other viscera, and
one case of liver only. The six cases containing liver,
together with other viscera, were treated as follows : Two
by simple incision of sac, reduction and suture; both
cured ; one by incision of sac, reduction, freshening of
wound-edges and deep and superficial sutures resulting
in cure ; two by radical operation, both cured ; and one
by simple protective bandage resulting in death. This
patient, however, was not seen till 10 days after birth,
and died next day from peritonitis. The case containing
liver only was subjected to radical operation, and the
patient died seven hours afterward. In this case the
liver was strangulated and adherent to the sac.
In Berger's table of 12 cases, all reported cases occur-
ring from 1891 to 1893, there are the reports of four cases
of hernia of the liver in which other viscera were con-
tained in the hernial sac, and none of liver only. Of
these four patients, one was subjected to radical operation
with resulting cure ; two were operated upon after the
method of Olshausen, and a cure was the result. The
remaining case was operated upon by the percutaneous
ligature with resulting death.
In the 43 cases in Hallet's table, occurring between
1893 and 1900, there were 15 cases in which there was
hernia of the liver into the cord ; 12 cases with other
viscera, and in three cases the liver only was involved.
The 12 cases containing other viscera besides the liver
were dealt with as follows : Eight were subjected to the
NOVBMBBR 8, 1902]
MEDICAL LONDON IN SUMMER
(.Ajueisican Mesicink 743
radical operation with five cures and three deaths ; one
patient was treated with simple moist dressings and died
on the fourth day from peritonitis ; one was subjected to
the radical operation, together with resection of the sus-
pending ligament of the liver and removal of Wharton's
jelly. Result unknown, but it does not seem that a
favorable result could have' followed. The remaining
patient was operated on by the radical method, the left
lobe of the liver resected from the sac, the cystic duct
ligated and the gallbliulder excised, with resulting death
after 36 hours. The three oases containing liver only
were treatetl as follows : In one an attempt was made
to suture the rese<;ted membrane over the reduced liver,
but the sutures would not hold ; the edges of the skin
were vivified and the abdominal walls sutured en bloc
and the child pronounced cured after six months. In
another, in which the entire liver was in the sac
and irreducible, the radical operation was done and death
followed in a short time. The other case, that of
Warren, of Boston, in which the entire liver was in the
sac, the radical operation was done and a cure effected.
Of the four cases reported by Safford as not having been
previously reported, one contained liver only, and one
liver and small intestine ; the latter patient was operated
upon by reduction, resection of sac and suture of abdomi-
nal walls and resulted in cure. The patient with hepa-
tocele was subjected to radical operation and died in
four days. In the case of Dr. Muirhead referred to,
the radical operation was attempted, but owing to the
feebleness of the child, and the liver being badly
adherent to the sac, had to be abandoned. The child
died. In this case the contents were half liver and half
intestine.
The case I have to report contained liver only and is as fol-
lows : The child, a boy, weighing 3i pounds, was born on the
morning o( February 22, 1902. The father is healthy. The
mother nas an old choroidal trouble and an interstitial keratitis
in the right eye, and has a history of having had one miscar-
riage. There are four living children, all healthy. Dr. H. L.
Akin, of Du Bois, Neb., who was in attendance at the birth,
asked nie to see the child the same evening. In the tissues of
the cord was a tumor as near the size and shape of a hen's egg as
could be well imagined, the small end being attached at the
umbilicus with a base one inch in diameter. The tumor was
in the tissues of the upper side of the cord, as the vessels passed
over the lower part of the tumor and up to the apex. The
tumor had a pinkish color, was partly solid, couW not be
reduced and the contents seemed adherent to the coverings.
The coverings of the cord were opaque so that the contents
could not be seen through them as is sometimes the case. There
was no impulse transmitted to the tumor when the cliild cried,
though it seemed slightly more tense. The baby was so small
and weak, and as its kidneys and bowels were performing their
proper functions, it was thought advisable to watch the case for
a few days till the patient grew stronger. The doctor gave the
case his personal attention and noted that in about one week
the cord proper, as it passed down over the lower part of the
tumor, was undergoing its usual changes and the amnion cover-
ing the tumor, was becoming desiccated. The child's functions
were still properly performed and it was taking nourishment
from the mother.
On the evening of March 6, when the baby was 12 days old,
Dr. Akin telephoned me that the mother had developed a pelvic
trouble, the t)aby was not doing well, and he wished me to see
them. On examination the child presented the following
appearance: The cuff-like elevation arising from the abdomen
around the base or pedicle of the tumor was red and its free
border was losing its epithelial covering. The diameter of the
pedicle was slightly increased, the amniotic covering of the
tumor was dry and discolored, and at the cuff-line there was a
well-marked line of deniarkation. The child had not gained in
flesh and had a pinched expression. It was quite evident that
operative interference offered the only hope, though that was a
forlorn one. Accordingly the next morning the child was
anesthetized with chloroform by Dr. Williamson, of Du Bois,
and, assisted by Dr. Akin, I proceeded to operate. The field
was cleaned and disinfe<!t«i,and as it was evident that reduction
without opening the abdominal cavity was impossible, the
radical operation was attempted. The abdominal cavity was
opened immediately bolow the tumor. It was impossible to
determine the exact condition of affairs through this incision,
so it was enlarged by carrying it up on either sideof the tumor,
when it was found that the content of the hernial sac was com-
posed entirely of liver, which appeared to lie about half in the
hernial sac, the anterior portion of both right and left lobes
being involved. A loop of small intestine was adherent to the
Ix)nler of the ring on either side of the tumor, but did not enter
the sac. At the lower border of the sac the liver was not firmly
adherent and I was able to separate it from the sac walls almost
to the fundus, but at all other points the adhesions were so
firm that they could not be broken up, consequently there was
but one thing left to do, close the abdominal wound and leave
the child to its fate.
This was done and the child died 20 hours later. Xo post-
mortem examination was made so I cannot give a dehnite
description of the pathologic condition. It is possible, though
I think hardly probable, that a favorable result might have
been secured had the operation been attempted soon after
birth.
In the above summary, cases are reported as cure<l
when it was necessary to wear some kind of retentive
bandage to retain the small hernia which protruded after
the operation unless the pad was worn.
It is my opinion that, with our present knowledge
and technic, it is advisable to do the radical operation on
these cases soon after birth, as delay, with its consequent
changes in the cord and the amniotic coverings of the
sac, is likely to lessen the chances for a favorable result.
BIBI.IOORAPHY.
' A Treatise on Ruptures, by Jonathan Macready, F.R.C.S.
■ Philadelphia Medical Journal, February 23, 1901.
' Medical Record, March 3, 1900.
* .Medical Record, Vol. 56, No. 19, 1899.
5 Lancet, Vol. 11, p. 1332, 1893.
SPECIAL ARTICLES
MEDICAL LONDON IN SUMMER.
BY
NICHOLAS SENN, M.D.,
of Chicago.
Summer is not a good time to see medical Iiondon at its best,
as the teachers and distinguished men in medicine and surgery
take their much-needed vacation about the middle of July. The
English doctor knows where and how to spend his days of rest.
Many of the ambitious, restless American doctors utilize their
vacation in making long journeys, visiting hospitals, labora-
tories and libraries, with a view of increasing their store of
knowledge, returning to their work in a worse mental and physi-
cal condition than when they left It. Not so with the average
English doctor. He knows the necessity of an entire change In
thought, surroundings and daily habits of life, and governs him-
self accordingly. He seldom crosses the channel, and very
rarely undertakes an ocean voyage. The island kingdom is his
favorite resting place. In a few hours he is at a safe distance
from a noisy city practice in full enjoyment of a comfortable
summer home, in a quiet environment that suits his tastes, or
at a well-conducted seashore or mountain retreat. Here he
remains until the long shadows of the September sun remind
him of his duties to his clients and the institutions he repre-
sents, when he hastens home with the body revived and the
mental activities renewed, and resumes his work with a vigor
and enthusiasm that he found flagging at the end of a busy year
weeks before his departure. During his absence the most
necessary hospital and private work is done by one or more
young assistants, but enough material has accumulated upon
his return to engage at once his whole time and attention. He
finds after his well-spent vacation that work has become a
source of pleasure instead of the unavoidable necessary task it
was when he left It. With what interest and care the surgeon
examines his patients, and how deliberately and skilfully he
wields his scalpel, and with what precision he grasps bleeding
vessels on his return from his long summer vacation ! His eye-
sight is keener, his hands more steady, his step more elastic,
his actions more deliberate and his sallow, careworn face is
covered with a living mask of ruddy, sunburned skin. It only
takes from eight to ten months to wear off what was gained by
the much-needed vacation, when in Justice to himself, to his
profe.ssion and his patients he again abandons his routine
work and seeks rest and recreation. Of all learned professions
the medical is the one in greatest nec<l and most deserving of a
long, free-of-care annual vacation. It is hard to make the public
understand this, but it is nevertheless true. During the sum-
744 Ambbioan MKDioimEj
MEDICAL LONDON IN SUMMER
[NOVBMBER 8, 1902
mer months the complicated machinery of the law comes to a
standstill, and the lawyers take their vacation without
crippling their bank account to any extent. The fashionable
churches close their doors when the members of the congregra-
tions go to their luxurious summer homes, and the rectors and
preachers, with purses well filled with gold by their grateful
parishioners for their vacation expenses, leave the great cities
and spend their allotted leisure weeks and months where they
are sure to find rest, comfort and recreation. It is the doctor
who is expected to work from one end of the year to the other.
It is the doctor who must pay full rate traveling and hotel
expenses when he tears himself away from his work for a short
vacation. It is the doctor whose annual income suffers when
he leaves his practice for a much-needed outing. It is the
doctor who carries away with him the weight of his responsi-
bilities to a greater extent than the members of any other pro-
fession when away from daily routine work.
The public must be made to understand that medical men
are entitled above any other profession or class of men to an
annual vacation, and that such vacation, properly spent, will
bring to patients better service, and will be one of the most
important factors in promoting the science of medicine, public
hygiene and sanitation. In London, like in all large cities in
Great Britain and on the Continent, most of the clinical work
during the months of July and August is done by the working
assistants, whose teachings and operations are usually credit-
able reflections of the practice of their chiefs. In many of the
surgical clinics, for instance, the first assistant operates as well
and in some instances better than his master. The visiting
doctor, however, is always desirous of witnessing the work of
men whose names have become famous in medical or surgical
literature, hence he is often disappointed in visiting clinics
during vacation months. For profitable laboratory study and
clinical instruction in small classes, under competent ajisist-
ants, the summer months offer many inducements to students
and physicians from foreign countries. The rich anatomic and
pathologic museums of the College of Physicians and Surgeons,
and of the numerous hospitals in London, alone would furnish
rare object studies for an entire summer to students desirous of
becoming thoroughly grounded in the two most important
fundamental branches of medicine and surgery— anatomy and
pathology. Anatomy is taught more thoroughly in England
than in any other country. Vienna leads in pathology and
Berlin in bacteriology and clinical instruction. There are too
many hospitals and medical colleges in London. The govern-
ment does little or nothing toward the support of medical edu-
cation, and the hospitals have to rely largely for their support
on private contributions. It is not unusual to find in any of the
great daily papers an appeal to the public from a number of
hospitals for support, showing their pressing need of financial
aid to meet current expenses. With the exception of St.
Thomas', most of the hospitals are small, and as nearly all of
them have their own college, it is easy to see that the clinical
material is inadequate, and that the necessary improvements
are not made as promptly as the increasing demands require.
If London had one large, general hospital under the control of,
and supported by the government, and in connection with a
great medical school, the cause of medical education and post-
graduate instruction in England would be materially advanced.
All of the existing medical schools do excellent work, and their
graduates compare favorably with those of the continental uni-
versities, but the practical training could be conducted in a
much more satisfactory and efficient manner in a school in con-
nection with a large, general hospital under government
control.
The British Medical Association is the largest organization
of medical men in the world. It has reached the mature age of
70 and embraces the majority of the practitioners of the island
kingdom and of its numerous colonies. It owns a central home
on the Strand in the very heart of London, which has been
acquired at an enormous expense. The official organ of the
association, The British Medical Journal, has the largest circu-
lation of any similar publication in the world. Through the
able business-like management of Mr. Ernest Hart, its late
editor, the journal has become a source of income instead of a
financial burden to the association. The income from legitimate
advertisements last year amounted to $97,675. Good manage-
ment of the business affairs of the association has placed it upon
a sound financial basis. Last year ?1,875 was voted for scientific
research and 83,250 for scientific research scholarships. Since 1874
the association has appropriated out of its funds for scientific
research $85,115. This is an example worthy of imitation by the
American Medical Association. So long as the governments and
the public in England and America take so 1 ittle interest in medi-
cal scientific research it becomes the duty of the profession not
only to do the work gratuitously but also to contri bute the neces-
sary means to advance the science of medicine. The present mem-
bership of the association is 18,758. Much of the scientific work
is done in the many branches of the association in the island
kingdom and its colonial possessions throughout the civilized
world. The annual meeting is devoted largely to social func-
tions and entertainments of all kinds. The working hours are
from 10 a.m. until 1 p.m. The Plnglish physicians enjoy such
diversions. These entertainments include many out-door amuse-
ments. What is expected of the visitors in a social way may be
learned by a glance at the following social program furnished
this year:
1. Official opening of the Annual Museum and Exhibition.
2. Garden Party by Mr. and Mrs. Edward Donner.
3. Soiree at the Owen College by the President and Local
Executive Committee.
4. Excursion to Blackpool.
5. Garden Party by Dr. and Mrs. Mould.
6. Garden Party by Mr. and Mrs. H. H. Smith-Carrington.
7. Reception and F6te in Whitworth Park by the President
and Local Executive Committee.
8. Garden Party by Mrs. Rylands.
9. Annual Dinner of the Association.
10. Ladies' Reception and a Variety Entertainment at the
Princess Theatre.
11. Garden Party by the Council of Owen College and the
President of the Manchester Medical Society.
12. Garden Party by the Mayor of Salford.
13. Lord Mayor of RIanchester's Conversazione In the Town
Hall.
14. Ball, given by the President and Local Executive Com-
mittee.
15. Visit to Crewe Works.
16. Excursion to Bury.
17. Excursion to Northwich.
18. Excursion to Southport.
19. Excursion to Windermere.
20. Excursion to Lancaster.
21. Excursion to Chester and North Wales.
22. Excursion to Colwyn Bay and Conway.
23. Excursion to Llambevis, Snowden, etc.
24. Excursion to Haddon Hall and Chatsworth.
25. Excursion to Lake District.
The effect of so many entertainments was made manifest in
the general and section meetings, many of which were scantily
attended. During the midst of a meeting of the Gynecologic
and Obstetric Section I counted 30 members in attendance and
in the Surgical Section there were seldom more than 100 present
at any one time. The Manchester meeting was presided over
by Mr. Walter Whitehead, P.R.C.S. (Edin.), F.R.S.E., a sur-
geon of great repute. It is one of the customs of the British
Medical Association to select its president, orators and chair-
men of the different sections from the local profession of the
city in which the meeting is held. This plan has much to
recommend it as it gives the local physicians a recognition
which they as well as the public appreciate and limits the
honors of the association to the men who have to do the hard
work to make the meeting a success. The president's address
as well as the addresses in medicine by Sir Thomas Barlow and
in obstetrics by Professor W. Japp Sinclair were well received.
The subjects for the work of the diflferent sections were selected
and arranged with care. The discussions were characterized
by harmony and brought out much valuable pathologic and
clinical information from the varied and extensive experiences
and observations of the different speakers. Tuberculosis of the
genitourinary organs, prostatectomy and the palliative treat-
ment of carcinoma were the principal subjects discussed in the
Surgical Section.
Drs. Alexander and Parker Syms, of New York, took a
leading part in the discussion of prostatectomy, and their
remarks made a deep and favorable impression.
Coronation Honors for Medical Men. — The King has no
more loyal subjects in his vast empire than the physicians.
NOVEUBEB », 1902]
MEDICAL LONDON IN SUMMER
[AHKRICAN MKWCIKB
745
When the South African war broke out the most distinguished
surgeons with princely incomes, moved by the purest patriotic
feelings, oflered their services to their country. Sir William
MacCormac, Sir William Stokes, Mr. Frederick Treves, Mr.
Thomas Jones, and many others took the field regardless of
many unavoidable privations and a hostile climate, and in a
most unselfish manner gave their services to the sick and
wounded. Their unselfish, patriotic deeds cannot be estimated
in money value. They risked their lives, and Sir William
Stokes, Mr. Thomas Jones, and many others found an honor-
able soldier's grave. His Majesty has recognized the patriotism
and valor of his medical subjects and has been liberal in the
distribution of honors. The council of the British Medical
Association has this to say on the subject in their report for this
year:
" The council has noted with much satisfaction the honors
conferred upon members of the association by the King in con-
nection with his coronation. More especially are congratula-
tions tendered to Sir Victor Horsley, whose work in connection
with the association the council is glad to acknowledge."
Of the knighthood recently bestowed upon Scotland's most
distinguished surgeon, William Macewen, the ^Edinburgh
Medical Journal says :
"Sir William Macewen, professor of surgery in the Univer-
sity of Gla-sgow, ha.s achieved by his contributions to surgical
science such a reputation that his clinic has become a Mecca to
which pilgrims are drawn from all parts of the world,"
The successful operation performed upon His Majesty by
Sir Frederick Treves for appendicitis has made for this eminent
surgeon a lasting reputation, and his grateful royal patient will
know best how to remunerate him for his skilful life-saving
service. The King has had a personal experience with what
modern surgery can do in averting death and alleviating pain,
and in view of his speedy and satisfactory recovery by opera-
tive intervention from a dangerous disease, we may expect in
the near future a perfect shower of honors upon deserving
medical men outside of those who are in immediate charge of
the nation's patient.
Two lyiteresting Surgical Operations by Sir Victor Horaley.
—Victor Horsley is continuing his scientific researches on brain
localization. He is a tireless and systematic investigator. As
an intracranial surgeon he has no superior. As a diagnostician
of brain lesions he has no equal. His knowledge of the minute
anatomy of the brain and the functions performed by its
various parts, and the disturbance of these functions by definite
pathologic processes, enable him to recognize and locate affec-
tions amenable to successful surgical operations. He is a
cautious, expert operator. Like most English surgeons, he
combines asepsis with antisepsis. As an irrigation fluid a
solution of bichlorid of mercury, 1 : 10,000, is employed. No
gloves are used. After thorough cleansing of the hands and
field of operation with warm water and soap, turpentine and
bichlorid solutions follow as chemical disinfectants. Chloro-
form is used as an anesthetic. He has never used spinal anes-
thesia, and is averse to this procedure, as he considers it more
dangerous than the administration of anesthetics by inhalation.
As a dressing moist cyanid of mercury gauze is given the
preference over dry antiseptic dressing material.
I had an opportunity to witness two of his operations at the
University College Hospital.
Cask I. — Wtrtlcy-Krause operation for neuralgia of the
trigeminus. The patient was a man advanced in years, who had
suffered for a long time from excruciating pain in thecour.se
of the first and second branches of the trifacial norve. Medical
treatment afforded no permanent relief. His general health
was not seriously impaired. The entire scalp was shaved and
thoroughly prepared by scrubbing with hot water and soap,
followed liy turpentine, and after removing the turpentine
with a similar scrul)hing the surface was washed and scrubbed
repeatedly with a 1 : 500 solution of bichlorid of mercury. After
the patient was fully under the influence of chloroform the
temporal region was freely exposed by making a horseshoe-
shaped incision, with the base directed downward, and by
reflecting two (laps, the first one including the skin and the
deep one all of the soft structures down to the bone. The skull
was opened by removing a disc of bone with a large trephine,
the opening was then enlarged in tlie direction of the base of
the skull with strong bone-catting forceps. The sharp-pointed
triangular liladas manipulated by the expert operator accom-
plished thetask quickly and well. With the operator's dural
reflector the envelopes of the brain were carefully separated
over the extent of the cranial resection. Tlie size of the skull
defect before the intracranial operation was commenced
amounted to at least 3 inches in the transverse and 2J inches in
the vertical diameter. It was in the exposure and excision of
the gasserian ganglion that the great skill of the operator
became most apparent. With a broad retractor of silver the
brain and its envelopes were lifted away from the base of the
skull, which was followed largely by the use of dull instru-
ments until the ganglion was reached. The isolation of the
ganglion proved to be the most difficult part of the operation.
This was finally accomplished by the cautious use of a very
small scalpel and the dural reflector. Capillary and venous
hemorrhage was quite free and was kept under control by
making compression with a small gauze sponge held in the
grasp of a forceps.
The ganglion was excised with as much of the proximal
side of the nerves as could be reached with safety. As some
hemorrhage continued, the space occupied by the excised gang-
lion was packed with a strip of gauze which was brought out
at one of the angles of the wound. The two flaps were sutured
separately with fine silkwormgut. This is at present Hors-
ley's favorite suture and ligature material. Catgut is seldom
employed in his practice. A large, moist compress of cyanid
of mercury gauze constituted the dressing. The next day the
patient stated that he was free from pain. The gauze tampon
was removed and a similar dressing applied.
Professor Horsley has performed this operation 65 times
with four deaths. In the patients that recovered the result was
satisfactory. As a precaution against ophthalmic complica-
tions, the eyelids are sutured together with three or four silk-
wormgut sutures, which are not removed for three or four
days.
Case 11.— Removal of a large sarcoma of the cerebellum. In
this ca.se the diagnostic acuity of Profes.sor Horsley was fully
confirmed by the findings revealed during the operation. A
little boy, about 6 years of age, had been suffering for several
months with symptoms which pointed to the cerebellum as
the probable seat of the disease. Among the prominent symp-
toms were hemiparesis in the right side, the characteristic
pupillary changes and pain in the occipital region with moder-
ate retraction and fixation of the head. From these and other
minor symptoms the conclusion was reached that the tumor
was located in the cerebellum on the right side. The same
E reparations were made as in the foregoing case. The patient's
ead and chest were slightly elevated and turned well toward
the left side. The occipital bone on the right side was exposed
by reflecting a slightly oval flap with the convexity upward.
Somewhat profuse hemorrhage from several large openings in
the bono occurred, and was promptly checked by rubbing into
the bleeding places aseptic wax. From the promptness with
which hemorrhage was arrested from this source it was evident
that this material is of great value in arresting hemorrhage
from bone. With cutting forceps, an oval opening was made in
the occipital bone, about two by three inches, with the long
diameter in the transverse direction. The pulseless dura at
once bulged into the opening. Between two delicate, grasping
forceps the dura was nicked, when a sm&ll amount of cerebro-
spinal fluid escaped. A small, grooved director was inserted
into the slit, and upon it the dura was incised in a vertical
direction to the extent of about two inches. The brain now pro-
truded into the dural opening. With a probe the operator tore
a small opening in the center of the protruding mass, when in
consequence of the intense intracranial pressure the rent greatly
increased in size, and a large tumor made its appearance in the
tear of the mantle of brain- tissue which covered it. The tumor
was firmer and more vascular than the surrounding brain-
tissue. The operat<jr remarked that he considered it dangerous
to complete the operation, as he had lost some cases from cerebral
edema which followed the immediate removal of large tumors
of the brain. The wound was drained with gauze and sutured.
The dressing consisted of a largo, moist oomjiress of cyanid of
mercury gauze. The child showed no untoward symptoms dur-
ing or after the operation. The next day the stitches were
removed, the skin-nap reflected and the tumor, nearly the size
of a hen's egg, was found on the surface of the corel>elluin, and
was removed without the slightest difficulty. The intracranial
pressure had effected almost complete spontaneous enucleation.
The idea of removing large tumors of the brain in two
stages is a most excellent one, and this method will undoubtedly
be the means of materially reducing the mortality of such
operations. Professor Horsley is a brilliant scientist and a
remarkable surgeon, and when the King knighted him he per-
formed an act which met a hearty approval of the profession
throughout England. •
Tivo Cases of Hysterectomy for Nonmatignant Disease of the
Uterus by Professor W. Japp <Smctorr.— During my attendance
on the meetings of the British Medical Association I had the
pleasure of witnessing the surgical technlc of Professor W.
Japp Sinclair, of Owen College, Manchester. As an eminent
746 Ahebjoan Mbdicine]
THE WORLD'S LATEST LITERATUEE
[November g, 1902
author and successful clinical teacher he is well known in the
medical world. He is a sturdy hardworking Scotchman, a
graduate of the University of Aberdeen, and has taught obstet-
rics and gynecology in Owen College for 12 years. By ability
and hard work he has come in possession of a large and
lucrative private practice. He is a firm believer in asepsis in
surgery, but his methods in accomplishing the desired object
are of the simplest kind. In his hospital work two assistants
and four trained female nurses render the necessary assistance.
He is a bold and yet a conservative operator. When he sees the
indications clear for an operation he proceeds without hesitation
and performs it on plans well mapped out. He has performed
cesarean section IS times and saved 16 mothers and their chil-
dren. In one of the two fatal cases death ensued from remote
causes. His address on obstetrics before the British Medical
Association was a scholarly product full of good sound teaching
and was highly appreciated by his large and attentive audience.
He is a deep thinker and a fluent speaker. He is a strong advo-
cate of Schuchardt's method of vaginal hysterectomy. The
operation is described as follows by Schuchardt, and quoted by
Sinclair :
While the perfected vaginal method of extirpation of
the uterus is characterized by careful protection of the vaginal
canal and of the external genital organs by means of specula in
order to keep the passage to the portio open, etc., the first object
of the paravaginal method is to obtain free access, consistently
with surgical principles, to the diseased organs. No attention
is paid to the conventional sparing of the external genitals; the
left labium is completely split, and with it the whole vaginal
tube, with the vaginal vault, the paravaginal and pararectal
tissues, the levator ani and coccygeal muscles, the cellular
tissue of the ischiorectal fossa, as well as the skin of the peri-
neum and of the lateral anal region down to the sacrum.
Incisions hitherto employed produced only a dilation of the
lower portion of the vagina, the paravaginal incision causes a
complete gaping of the vagina and vaginal vault. The para-
vaginal incision begins on the left labium, and divides the
vaginal wall on the left side, but in its deeper parts it is essen-
tially a median incision. Superficially the wound is situated to
the left only so far that the rectum and sphincter ani are not
injured. The skin incision is situated in the vicinity of the
anus, distant only about a finger's breadth from it; it then
turns round it in a circle behind the anus to the middle line. In
this essentially median position of the wound, which yet permits
it to be deepened as far as to the ligamentum sacro-spinosum
i' necessary, lies the peculiarity and the chief advantage
of the paravaginal incision. ... If the paravaginal incision
is effected in the manner described, then the parametrium on
both sides becomes equally accessible and a second incision on
the right side is unnecessary. . . . Only when there is
occasion to remove a portion of cancerous rectum with the
cancerous vaginal wall does an incision on the right side
become necessary. The two incisions then enclose between
them the diseased portion of the vagina and rectum, and meet
behind in the middle line.
Sinclair has performed the paravaginal operation 14 times
and is well pleased with the technic of the operation and its
results.
Case I.— The patient was a nullipara, aged 35, married, but
never pregnant. For three years she has suffered from monor-
rhagia and pelvic distress, has not been benefited by repeated
curetings and general treatment. Uterus was enlarged, para-
metrium free. The operation was performed in the manner
described. The slitting of the vulva and vaginal wall gave
rise to free hemorrhage, which was at once arrested by the
application of hemostatic forceps and ligation. The deep) gap-
ing wound rendered the access to the uterus and adnexa very
easy. The operation was completed in less than an hour, as
the uterus was movable and yielded readily to traction. The
operator's large curved needle was used in applying the deep
silk ligatures. The vaginal vault was sutured and the culde-
sac drained with a soft rubber tube, to which a strong silk liga-
ture was tied for its easy extraction. The vaginal cut and the
ischiorectal wound were sutured likewise with silk. The
vagina was lightly tamponed with iodoform gauze and iodo-
form was freely sprinkled between the layers of the gauze.
Ketractors were only used in lifting the anterior vaginal wall
forward. The extirpated uterus was enlarged, succulent, and
the mucosa granular.
Case II.— The patient was a married woman, aged 52, who
nad given birth to several children and had reached her meno-
pause at the age of 50. Recently she has suffered repeated uter-
ine hemorrhage and profuse leukorrheal discharge. Vaginal
examination revealed a fixed uterus with a hard mass on the
right side. The suspicion of malignancy was a strong one and
nysterectomy was recommended and eagerly accepted by the
patient. In this case the operation proved a very difficult one,
owing to the numerous firm parametric adhesions, and the
paravaginal incisions did not give any too much room for the
extirpation of the uterus. The right ovary was cystic and
embedded in a naass of adhesions. The operation required
much patience and perseverance, but was completed without
any mishap. The wound was closed in a similar manner as in
the first case.
The paravaginal operation is to be recommened, particu-
larly in cases In which the vagina is narrow and unyielding,
and when the uterus is fixed in a high position, and finally
when carcinoma has involved the tissues around the vaginal
portion of the uterus.
London, August 2.
THE WORLD'S LATEST LITERATURE
Journal of the American Medical Association.
November i, 1901. [Vol. xxxix. No. 18.]
1. Tuberculosis of the Myocardium. James M. Andees.
2. Case of Scurvy, with Unusual Poverty of the Blood. James Ely
Tallky.
3. Some Physiologic Factors Involved In the Origin of Scurvy (Scor-
butus). Roy Ravone Rogers.
4. Traumatic Rupture of the Abdominal Viscera Without External
.Signs of Injury. Daniel, N. Eisendrath.
5. The Relative Merits of the Various Methods of Intestinal Anasto-
mosis. K. C. Coffey.
6. Principles Controlling Operative Interference In Strabismus.
Edward Jackson.
7. The Xonoperative Treatment of Strabismus. George M. Gould.
1, 2.— See American Medicine, Vol. Ill, No. 25, p. 1036.
3. — Physiologic Factors in Scurvy.— Rogers endeavors to
correlate the theories as to the origin of scurvy and refer them
to ^simple terms. Scurvy does not depend on the activity of
microorganisms, although the latter may establish conditions
favorable to the onset or may aggravate a case already existing.
The direct cause lies in lack of oxygen in the tissues. Those
conditions which tend to prevent the formation of acid, i. e., of
hydrogen ions (and possibly other products also) in the tissues
and tend to increase the store of available alkalinity, i. e.,
hydroxyl ions, in the blood and lymph, are the conditions most
antagonistic to the development of scurvy or its continuance
and those most favorable for its cure, [h.m.]
■t. — See American Medicine, Vol. Ill, No. 25, p. 1042.
5. — See American Medicine, Vol. Ill, No. 25, p. 1043.
6, T.— See American Medicine, Vol. Ill, No. 25, p. 1053.
Boston Medical and Surgical Journal.
October SO, 190i. [Vol. CXLVII, No. 18.]
1. The Teaching of Surgery. Herbert L. Bcbrell.
2. A Report of the Blood Examination in Ten Cases of Severe Bums
of the Skin. Edwin A. Locke.
3. Septicemia and the Curet. U. Plympton.
4. Severe E.xtrinslc Traumatisms of the Spine. Tho3ias H. Manley.
1. — See American Medicine, Vol. Ill, No. 24, p. 994.
3.— Result of Blood Examination in Severe Burns.—
Locke reports the results of his observations in 10 cases treated
in the Massachusetts General Hospital. His conclusions are
as follows: The blood flows sluggishly, and is of a peculiar
dark, purple appearance. An immediate increase in the num-
ber of erythrocytes, in severe but not fatal cases, of from
1,000,0(X) to 2,000,000 per cm., takes place within a few hours ; in
fatal cases of from 2,000,000 to 4,000,000 per cm. A rapidly-
increasing leukocytosis constantly occurs ; in cases ending in
recovery often of 30,000 to 40,000 per cm. ; in fatal cases usually
above 50,000 per cm. Morphologic changes in the erythrocytes
are slight. The percentage of neutrophiles is somewhat above
the normal, but not so much as in the ordinary inflammatory
leukocytosis. A considerable destruction of the leukocytes
takes place, especially in the very severe burns. Myelocytes
may be present in small numbers in severe cases. There is,
as a rule, marked increase in the number of blood-plates.
[a.b.c]
3.— See American Medicine, Vol. IV, No. 17, p. 671.
4.— See American Medicine, Vol. IV, No. 17, p. 648.
November 8, 1902]
THE WOELD'S LATEST LITERATUEE
[Akbrican Medicine 747
Medical Record.
November 1, 190S. [Vol. 62, No. 18.]
1. The Use of Concentrated Actinic Sunlight in the Treatment of Tubeo
culosis. .1. W. K1.ME.
2. Some Experlment-s with Paraffin. A. E. COMSTOCK.
3. The Use of the Clinical Thermometer a.s an Aid in Quarantine
Inspection. A. H. Doty.
1. X-rays in the Treatment of Cancer and Other Malignant Diseases.
Emit. H. GRtiBBft
5. Hydremia and Malaria. K. Cadwalimder.
1.— Actinic Sunlight in Tuberculosis.— In Kime's exi)eri-
ence, laryngeal tuberculosis has yielded most readily to this
treatment. After a few applications pain disappears and
aphonia diminishes. Of 60 cases of pulmonary tuberculosis,
the disease was arrested in 12 patients, practically arrested
in 11 more. One did not improve, 5 were dismissed after
a few days' rest as incurable, and 31 are still under
treatment and show satisfactory improvement. The reflec-
tor used is .'i6 inches in diameter. The light is focused three
feet in front upon a spot eight inches in diameter. An
intense blue light, rich in actinic rays, is thus thrown upon the
bare chest of the patient two or three hours daily when the sun
shines. The light produces engorgement, the influx of blood
increasing nutrition. It also has an inhibiting effect on bacilli.
The appetite and other functions improve. Open air, good food
and general hygiene contribute to the cure. There is increased
dy.spnea for a few days. Sunlight is preferable to that from
any other source. He reports 29 cases in detail, [h.m.]
2.— E-vperiments with Paraffin. — Comstock used prepa-
rations which were a mixture of soft commercial paraffin,
melting at about 120° F., and white cosmolin, melting at about
100° F. Mi.xtures of these were made varying in their melting
point from 102° F. to 110° F. These were sterilized by boiling
for .'W minutes over a flame, the beaker being protected by
asbestos. The syringe used was the metallic aspirator, because
it was of sufficient size to hold the required amount and retain
the heat. The experiments were made upon rabbits, the injec-
tions Ijeing made in the ear or in the hip. Injections of paraffin
with a melting point slightly below the normal temperature of
the rabbit invariably caused death of the animal within two
weeks, due to thrombosis. Photomicrographic views are pre-
.sented in the article, showing the degrees of organization or
encapsulation. The author believes the paraffin with a melting
point of 110° F. is better and more quickly and completely
encapsulated or organized than the specimens with a lower
melting point. He disapproves of filling the space with a
liquid previous to the paraffin injection, [a. B.C.]
3.— The Clinical Thermometer in Quarantine Inspec-
tion.—Doty states that owing to the difficulty of securing
frank statements, the little attention sailors pay to mild attacks
of disease, and the danger of ambulant or convalescent ca.ses of
infectious disea.se being overlooked, it is better to take the tem-
perature of passengers and crew. Many cases have been discov-
ered in this way when visual examination indicated health. Care-
fully tested thermometers should be used. Persons should never
bo allowed to take their own temperature. The author describes
the method in use at the New York (Quarantine Station by
which a large number of persons are tested at once. He gives
atableof 16,l.i2 temperatures showing a range in health between
'.Mi" and 99.4° F., the average being 98..')°. Prolonged exposure
to heat as among stokers may cause an elevation. The large
number of temperatures above 9S.5° found among steerage pas-
^(•ngors was due to excitement. A temperature below 98° is
usually found very early in the morning. When the tempera-
ture is not over !>9..5° and there is no other reason for detention,
passengers should be allowed to proceed, [h.m.]
4.— X-rays In theTroatment of Mallfcnanl Diseases.—
<irubbC- summarizes the results of his work and observations
in connection with the x-rays as follows: The x-ray is the
most remarkal)le therapeutic agent of the last decade ; in prop-
erly selected ca.ses of socalled " incurable conditions" it has
brought about remarkable results; relief from pain is one of
the most prominent features of the treatment; retrogressive
changes are noticed in all primary cancers or tuberculous
growths; it lias a pronounced eflect upon internal cancers;
the greatest value of it is obtained in treating postoperative
ciiNOs to prevent recurrences ; the proportion of (clinical cures
by this treatment is greater than that obtainable by any other
method of treatment ; we are positively justified iu assuming
an idiosyncrasy to x-rays; the peculiarities of each case must
be studied in order to get the best results, i. e., no strict rules
for treatment can be laid down : dermatitis, if properly pro-
duced, is within certain limits a desirable feature: since the
vacuum of an ordinary x-ray tube changes constantly, such
tubes are useless for radiotherapeutic work, and only tubes
which allow of perfect control of vacuum should be used ; it
has a selective influence upon cells of the body; abnormal
cells being affected more readily than the normal ; hemor-
rhages and discharges are decidedly lessened and, ultimately,
cease in the majority of cases; even in the hopeless, inoperable
cases, the x-ray prolongs life, makes the patient comfortable,
and the last hours free from pain. [a. B.C.]
5. — Hydremia and Malaria.— Cadwallader, in the study of
an epidemic along a river front, notes that in 8 of 18 cases he
had previously advised drinking water in largequantities. The
greatest number of cases were also at a season when skin elimi-
nation was lessened. There is a Arm belief in the locality that
eating watermelons will cause "the chills." The deduction was
suggested that increase of water in the blood may play an
important part by creating susceptibility, increasing the effects
of infection, or favoring the flow of saliva from the mosquito to
the subject. Observations that fit in with the theory are the
lack of thirst in malaria, the increased number of cases in
summer when the rainfall is unusually heavy and during fall
rains and seasons of evaporation. In other words, the cases fol-
low inversely the water excretion of the people, which may be
taken as an index of their hydremia. Quinin and all its sub-
stitutes except arsenic are diuretics. Arsenic produces watery
movements. Dysentery is said to accompany frequently estivo-
autumnal malaria and in tertian and quartan fevers conva-
lescence is often marked by polyuria, both being efforts to get
rid of all the water possible, [h.m.]
New York Medical Journal.
October «5, 190i. [Vol,, lxxvi. No. 17.]
1. Diseases of the Gallbladder. John B. Deavkr.
2. Experimental Gastritis; Early Pathologic Changes. Fenton B.
ruK<'K.
3. The Treatment of the Insane In Private Practice. F. Savary
Pearck.
I. The Results of Examinations of the Blood for the Wldal Reaction,
Performed at the Diagnosis Laboratory of the Health Depart-
ment of New York City During 1901. JOHN 8. Billings.
.'). The Prevention of Smallpox. M. I-. Hughes.
1.— Diseases of the Gallbladder.- Deaver calls attention
to the marked analogy which these diseases bear to appendicitis
and draws comparisons one to the other throughout the article.
The diseases of the gallbladder are divided into (1) inflamma-
tory affections; (2) cholelithiasis, and (.3) specific infections,
such as carcinoma and tuberculosis. The inflammatory affec-
tions are further divided into catarrhal, suppurative, ulcerative,
phlegmonous, gangrenous and obliterating, including stricture.
Catarrhal cholelithiasis is usually relieved by the use of rest,
moist heat and aperients. When empyema results, with or
without the presence of stones, surgical intervention is as
necessary as it is in appendiceal abscess. If suppurative
cholaugeitis has not already occurred, operation is still more
urgently demanded. In discussing the prophylactic treatment
of cholelithiasis he calls attention to proper diet and clothing,
sufficient exorcise and fresh air, and a restriction of the amount
of alcohol used. When gallstones have once formed a surgical
operation is the only rational cure. Cystotomy, with removal
of the stones and closure with fine silk Lembert sutures, may
be done if one is absolutely sure there is but little infection
present. When suppuration exists, the gallbladder should be
opened and drained. Malignant disease of the gallbladder is
practically inoperable, [c.a.o.]
2.— Experimental Oajstrltlg.— Turck, in his experiments
on dogs, has selected mustard for producing acute gastritis
because of its relatively mild and prolonged irritating proper-
ties and the peculiar toxic eflect that causes a distinctive and a
specific reaction. The experiments here presented show the
earlier histologic changes of the walls of the stomach, as well as
the more prolonged effects. The specimens were taken from
748 A.HBRICAN MBDICIRE]
THE WORLD'S LATEST LITERATUIIE
[NOVBMBEB 8; 1902
animals under anesthesia during life and put in fixing fluid
before any other changes could occur. The following points
are of interest : 1. The early appearance of an exudate on the
surface of the mucosa, composed of cells, granular debris and
fibrillar masses, leukocytes and red cells, within one and two
hours after the introduction of the mustard emulsion. 2. Later
the debris of cells becomes more ill defined and forms a more
homogeneous mass. 3. The marked chemotactic efTect of the
mustard shown in the early specimens. 4. The surface epi-
thelium not destroyed in proportion to the marked changes
occurring deeper in the mucosa. 5. The early appearance of
necrosed acid or parietal cells, which become granular and lose
their nucleus. 6. Karyokinetic figures make their appearance
within six hours, and are very active even deep in the body and
fundus of the tubules. 7. Cyst of the glands in 24 hours' .speci-
men with accumulation of leukocytes and degenerated epithe-
lial cells. It is important to note that the exudate that forms
on the surface at first is not a good soil for the development of
microorganisms, but as the exudate becomes changed in char-
acter and appearance, bacteria early develop in the coating on
the surface, [c.a.c]
3. — See American Medicine, Vol. IV, No. 12, p. 448.
4. — The Wldal Reaction.— Billings gives the results of
the examinations of blood for the Widal reaction performed at
the Diagnosis Laboratory of the Health Department of New
York City during 1901. Of 1,908 specimens examined, 304
showed a positive reaction, and 111 cases were considered by
the attending physicians as being cases of typhoid, even though
the results of blood examination were doubtful or false. In 131
instances, where the result of examination was doubtful, and
in 1,362 where it was negative, the cases proved not to be
typhoid. In 88% of the cases showing a positive reaction the
blood was not taken until the end of the first week of the dis-
ease. Of those cases showing no reaction which proved clinic-
ally to be typhoid fever, in 63% the blood was taken previously
to the seventh day. In 47 cases in which the blood was negative
on the first examination and positive on later examinations, in
81% the first examination was made prior to the seventh day of
the disease. In one case the reaction did not appear until the
sixth week, and in another case the reaction was present from
one to two days only. Of 164 cases showing doubtful reaction,
39 proved not to be typhoid, .33 were typhoid, and in 92 no infor-
mation could be obtained. Thirteen specimens which failed to
show the Widal reaction were tested with different strains of
paratyphoid bacilli. The results were uniformly negative.
[c.a.c]
5.— The Prevention of Smallpox. — Hughes expresses a
firm belief in the efficacy of vaccination, but is not in favor of
using glycerinized lymph. He advocates isolation and disin-
fection with sulfur dioxid or formaldehyd and a rigid quaran-
tine for two weeks. During convalescence the hair should be
cut close ; carbolic soap baths in the morning and a mercuric
chlorid bath, 1 : 1,000, in the evening is his routine treatment
forthe home preparation. All garments worn from the hospital
are best prepared by a two hours' boiling in a 1 : 1,000 mer-
curic chlorid solution. Infected articles that cannot be boiled
or are not permeable to smoke or cannot be exposed to anti-
septic solutions should be burned, [c.a.c]
Medical News.
November 1, 1902. [Vol. 81, No. 18.]
1. Shortening of the Radius in CoUes' Fracture. Georgb Ryerson
FOWLKR.
2. Report of 90 Cases of Typhoid Fever In Infants and Children. Isaac
A. Abt.
3. Parasitic Amebas. Frederick Q. Canney.
4. Vertigo in Neurologic Diagnosis. Pbarce Bailey.
5. Ocular Vertigo. Wilbur B. Marple.
6. To What Extent, If at All, Should Physicians Dispense? H. C.
Masland.
1.— Shortening of the Radius in Colles' Fracture.— G.
R. Fowler says the upward displacement of the lower frag-
ment, whether from impaction or from displacement in one or
another of the usual directions, leads to shortening of the radius
and consequent elevation of the radial styloid, and thus the nor-
mal half-inch difference in the level of the two processes is
destroyed. The deformity relates more particularly to the
ulna at its lower end, and consists In a diastasis of the radio-
ulnar articulation with a relative downward and positive for-
ward displacement of that portion of the bone. If, in the treat-
ment of Colles' fracture, sufficient force can be brought to bear
to overcome the deformity at once, and pains be taken to main-
tain the normal position of the ulna by a sufficiently hard and
properly applied pad placed on the palmar side of the head of
the ulnar, and if in addition early massage and movements of
tlie fingers, both active and passive, be employed, the best
results can be obtained in the great majority of cases. For this
pad a tightly rolled portion of an ordinary muslin roller band-
age is used. The pad is retained in position with adhesive
plaster. In some refractory cases the author resects the head of
the ulna. [a. B.C.]
2.— Typhoid Fever in Infants and Children.- The
youngest child in Abt's series was 8 months old. In the smaller
children the onset was frequently abrupt and the pulse rapid,
while the older ones followed the adult type. Roseola was
found often on the third or fourth day. Desquamation was
observed in 10 ca.ses. Five cases out of 15 examined showed
typhoid bacilli in the urine from the end of the third to the
middle of the fourth week. Sometimes these may appear at the
end of the second week or as late as the forty-fifth day. When
in small numbers or accompanied by other species they may
escape notice. There may be so many as to render the urine
turbid. Albumin and pus were always present, although pus
microbes in many examinations were absent, lending support
to the theory that the typhoid bacillus is a pus producer. The
centrifugalization and baeteriologic examinution of all typhoid
urines is demanded. Disinfection is necessary or urotropin
should be administered to prevent the development of the
germs. The Widal reaction was positive in all but two cases
and was found on the second or third day. A large proportion
of the cases received no drugs. Children bore baths badly at
70° or 75° F., living in constant terror of the succeeding ones.
If put in 90° and allowed to remain five minutes with constant
rubbing the temperature was reduced 2° and they enjoyed the
bath. In lOor 12 minutes a greater reduction could be obtained.
A hammock was suspended in the tub in which the child
reclined comfortably, [h.m.]
3. — Parasitic Ainebas.— Canney presents cuts showing
amebas embedded in epithelial tissue. Their occurrence in
malignant tumors may be only an interesting coincidence,
though there are many reasons for suspecting infective agency
in certain cases. They are seen with more complicated pseudo-
podia in carcinoma than in sarcoma, and are almost always
situated in a vacuole. They show a nuclear structure, or at
least a darkly staining endosarc that is sometimes not sharply
differentiated from the ectosarc. Sporulation is evident in
many of the sections, [h.m.]
4. — Vertigo in Neurologic Diagnosis. — Bailey says it is
associated with neuroses and diseases of the brain, and with
toxic conditions affecting tlie nervous system. Potassium iodid
in large doses in suspected syphilis by its pronounced lowering
of blood-pressure may cause excessive vertigo. Dizziness is
often one of the symptoms of migraine, a nervous disease of
toxic origin. In neurasthenia vertigo is generally subjective.
Cases presenting objective symptoms invite closer attention.
This may be due to fermentation or to degeneration of the cere-
bral bloodvessels. In hysteria vertigo is less complained of,
but in some cases with paraplegia the mode of progression is
perplexingly similar to cerebellar disease. Vertigo from
organic disease is due to interference with the centers of equi-
librium in the medulla and cerebellum. These may have
representation in the cortex. The centers may be invaded by
sclerosis, tumor, hemorrhage, thrombosis, abscess and trauma,
or through changes in blood-pressure or general brain-pressure.
Under the last two are included epilepsy and general paresis.
Cerebral endarteritis is the most fertile cause of vertigo, espe-
cially in the aged. As a symptom of apoplexy it is extremely
prominent. If recognized as a herald of impending mischief
the stroke may in many cases be avoided. In tumors dizziness
is usually not extreme. In trauma of the head there is suscep-
tibility to it long after the accident, [h.m.]
5. — Ocular Vertigo. — Marple says the commonest cause is
diplopia following paralysis or paresis of the ocular muscles,
November 8, 1H0!2|
THE WORLD'S LATEST LITEEATTIRE
fAHERICAIT MSOtCINE 749
the patient being less and less disturbed as the weeks go on.
The less conspicuous the defect to the observer the more the
patient is apt to suffer. The vertigo may continue with one eye
closed, the patient projecting falsely in the direction of the
affected muscle, this resulting in a swimming of objects when
the patient moves or turns his head. An exclusion glass should
be worn. Xo operative treatment is indicated until other
measures have failed and at this stage the vertigo has disap-
peared. If there is no paralysis it is only barely possible the
eyes may be the cause of the vertigo. Correction of ametropia,
especially in neurasthenics, often gives surprising results.
6.— Should Physicians Dispense ?—Masl and say s tablets,
if from manufacturers of proved integrity, need not be consid-
ered to contain inferior drugs. Some drugs deteriorate if kept,
but the physician must exercise due discrimination. Tablets
allow of immediate administration in cases in which this is
important, and also of surer control of the patient, who must
return to the doctor or remain untreated. Dispensing drugs is
not commercialism. Extensive dispensing is a matter of policy
to be decided by the individual practitioner, [h.m.]
Philadelphia Medical Journal.
November 1, 1902. [Vol. x. No. 18.]
1. Report ofa Case of Penetrating Wound of the Heart: Unsuccessful
Attempt at Suturing. John H. Gibbon.
2. A Contrlbulion lotheSlurtyof Nephritis In Smallpox. Based Upon
Analyses of Urine in 128 Cases. WiLMAM M. Welch and Jay F.
SCHA.MBKKG.
S. The Autobiography of a Victim of Chronic Catarrhal Appendicitis.
Krkdekick a. Rupp.
4. Report of a Case of .ScpUcemia as I Felt it Myself. J. C. Newman.
5. Conclusions as Regards the Exsanguinated Uterine Zones. Byron
Robinson.
t. — See American MerUeine, Vol. IV, No. 14, p. 530.
2.— .\ Contribution to the Study of Nephritis in Small-
pox.—Welch and Schamberg base the following conclusions
upon analyses of urine in 128 cases : Albuminuria is more com-
mon in smallpox than is generally believed ; it was present in
65% of the oases examined. The fact that tube-casts were found
in ib'fc of the cases warrants the assertion that the albuminuria
in most cases is the expression of a structural change in the
kidneys ; cases of discrete variola and well-marked varioloid
are accompanied by nephritis almost as often as cases with
more profuse eruptions, suggesting the kidney involvement to
be the result of the influence of the smallpox poison. The
daily fluctuation in the presence of the abnormal urinary con-
stituents necessitates repeated examinations in order to avoid
misleading results. Microscopic examinations of the sediment
will frequently reveal the presence of tube-casts when albumin
is present in quantities demonstrable by the ordinary tests.
The clinical symptoms of variolous nephritis are, as a rule,
mild and by no means as obvious as those observed in scarla-
tinal nephritis. Arnaud's investigation demonstrates that albu-
min may persist in the urine in minute quantities after con-
valescence from smallpox. This occurred in 75% of his ca.ses.
The histologic examination of the kidney would indicate that
this minimal albuminuria represents interstitial changes in the
kidney. The practical lesson is that the urine of patients con-
valescent from infectious diseases should be carefully and
repeatedly examined and the diet and mode of life of the
patient regulated a<!Cordingly. [f.c.h.]
CLINICAL. MEDICINE
David Riesman A. O. J. Kellt
\
KDITOKIAL COMMENT
IiitcrtraiiNiiiiH.sibility of Bovine and Human
Tubert'ulosis. — It would be difticult to And more t-on-
(•lusivt! (jvidenco bearing on the contention of Koch and
Baunigiirten that bovine and human tuberculo-sis are
distinct and nontransiniasible affections tlian tliat sup-
plied by the case of accidental and experimental in(x;u-
lation just brought forward l)y Spronk and Iloeftuigel (see
abstract following). While there have \->cvn numerous
reporttd cases of accidental incKJUlation of abattoir em-
ployes with bovine tuberculosis, such as that cited by
Krau.se,' there ha.s been no iiieitance recorded in which the
■ Amtriean Medicine, October II, page SUI.
traumatic inoculation has been followed up by such a con-
tinuous chain of observations, covering the conveyance of
tuberculosis from cow to man, from man to the perfectly
healthy guineapig and calf, and from the calf back again
to other healthy guineapigs, the lesions all along the line
being characteristic and unmistakable. A few such expe-
riments as that of Spronk and Hoefnagel will do more to
settle the controversy regarding the unity of the tuber-
culosis of man and cattle than any number of polemic
dissertations.
REVIEW OF MTEBATBBE
Transmission of Bovine Tuberculosis to Man by Acci-
dental Inoculation and Experimental Keinoculation Into
a Calf.— C. H. H. Spronk and K. Hoefnagel,' of Utrecht, record
a case which is of particular interest at the present time, in
view of the extended discussion regarding the intertransmissi-
bility of human and bovine tuberculosis. In May, 1900, a
veterinarian, A. A. Overbeck, accidentally wounded with a
knife the finger of a butcher who was assisting him in the
inspection of the tuberculous organs of a cow. The wound
healed promptly, but was followed within a few days by tume-
faction and the formation of cracks In the skin. The skin of
the finger became thickened and blue in color and the cracks
covered with little scabs. The infection appeared to be local-
ized in the skin, although the flexion of the joint was some-
what limited. The patient e.xperienced no sensations of ill-
ness. In February Professor Nareth extirpated the affected
portion of the skin, together with the tumefied cubital ganglia.
The tuberculous nature of the cutaneous lesions, as well as that
of the hypertrophied ganglia, was easily recognized, both by
microscopic examination and by the inoculation of guineapigs.
The spleen from one of these guineapigs, which exhibited well-
defined tuberculous lesions, was triturated in a sterilized mor-
tar with 15 cm. of sterilized salt solution, and with this emul-
sion a calf was inoculated. The calf, which was of Holland
stock, was placed in a newly-constructed stable in which no
animal had been kept. The animal had been demonstrated to
be free from tuberculosis by preliminary injections of tuber-
culin. The feed was carefully regulated, milk being excluded.
Five days after the inoculation a swelling was noticed, and in a
few days the superficial cervical ganglia were visibly tumefied.
In the course of 11 days the swelling extended at the point of
entrance of the virus and had reached the size of a fist. Within
a few more days the animal began to exhibit constitutional
symptoms, remained lying down most of the time, and drank
excessively. The swelling increased rapidly, and the animal
was slaughtered 57 days after the inoculation. At the autopsy
there was found at the point of inoculation of the virus, on the
right side of the neck, a tuberculous granuloma of the size of
a fist, enclosing at its center a large cavity filled with a soft,
cheesy mass. The neighboring superficial ganglia were found
granulomatous, hypertrophied and hard. The pleura and the
visceral folds presented numerous tubercles, varying in diam-
eter from 1 to 6 mm. The tissue of the lungs was also the seat
of tubercles of similar size, each showing an inflammatory
areola. The bronchial and mediastinal ganglia were hyper-
trophied, and on section showed caseous, noncalcified contents.
Similar conditions were found in the organs generally through-
out the body. Microscopic examination demonstrated that the
tuberculous foci contained abundant giant cells and numerous
tubercle Ijacilli. Finally two guineapigs, wlii<!h had been inoc-
ulated with material from the hypertrophied cervical ganglia,
one in the peritoneum and the other beneath the skin, died of
tuberculosis. The observations leave no doubt as to the possi-
bility of the infection of mau with bovine tuberculosis, and
the authors hold that cases of contagion from the use of milk,
butter and meat provided by tuberculous cattle is not so rare as
Koch and Bauingarten maintain, [c.s.i).]
The OrlRin of Urine Alljumln.— Aschoff* undertook a
series of experiments to control and to add to Morten's recent
experiments that went to show that the albumin in the urine
in nephritis is derived from the blood. An emulsion of human
1 La Heuialne Medlcale, October 15, 1902.
> Lancet, September 6, 19i>2.
760 AUBBICAN MEDICINKI
THE WORLD'S LATEST LITERATOEE
[NOVBUBBK 8, 19C2
kidney, as well as a solution of kidney albumin, were injected
into rabbits, and after a number of injections the animals were
killed, their blood-serum collected and added in varying pro-
portions to human urine containing albumin and also to solu-
tions of blood albumin, and the tubes were kept under observa-
tion at blood heat. The tests were negative; that is, there
occurred no precipitate even after long observation. The
experiments, therefore, are held to confirm Merteu's previous
work, and to support the view that the albumin in the urine in
nephritis is derived from the blood and is different from the
specific kidney albumins, [a.o.j.k.]
Increase in the Frequency of Cancer, Its Predomi-
nance In Cities, It8 Predilection for the Feminine Sex ; is it
Real or Apparent?— R. de Bovls,' professor in the Medical
School of Rheims, presents under the above title a valuable
review of recent cancer statistics. The question of the unequal
value of statistics is discussed, and a full bibliography is given
of all authorities on the subject. Quoting Roswell Park's state-
ment that " if the same deathrate is maintained for the next 10
years, the State of New York will have more deaths from cancer
than from tuberculosis, smallpox and typhoid fever taken
together," the author points to statistics to show that this and
similar pessimistic predictions are amply justified, the mor-
tality from cancer having doubled or tripled, according to the
location, within 20 years. In proof of this the following table is
presented showing the mortality per 100,000 inhabitants of all
ages for the years 1880, 1888, 1900:
„ , , fKingdom 51.1
England {i^^nAon 58.7
Austria (clsleithan) 37.6
Bavaria 56 2
o .!„ ,1 fKlngdora 49.1
Scotland | j,,g]jf principal cities 46.5
Spain (Madrid)
' (Fans... t8.2
F'^"'=<'icities of over 5,000 inhabitants
Holland 50.1
Ireland »4'4
1888 1900
62.1 82.9
69.6 94.0
491 75.9
98.5
61.0 77.0
62.8 88.0
89.3
107.1 121.0
99.0
69.0 95.9
43.0 58.0
Ttalv 21.1 42.7 51.9
Norway" '.V » 43.0 54.0 85 0
Prussia; 26.1 40.9 57.3
Russia (St. Petersburg) 116.1 88.6
Sweden.. 80.1 100.2
Switzerland 114.4 132 4
fBaltimore 45.1 60S
Buffalo .32.0 52.0
,. ..., ^. ♦„„ J Washington 60.0 69.4 70.3
Inited S^tates.j gg.yg„,jjrgest cities In America 35.4 66.4
I State of Massachusetts .52.0 60.0 60.6
I. All States taken together 29.0
(Province of Tucuman 10.6
^•'S^'i""*' I City of Buenos Ay res 90.0
To complete the picture the following figures are quoted
from Behla : ^ In Queensland the deathrate from cancer was 26
for 1891, 36.7 for 1895. In New Zealand it was 26.9 for 1881, 47.5 for
1890 and 53..3 for 1895. Cancer is " very rare " in Central and
Western Africa, "rare" in Constantinople, in Egypt and in
India, "a little less rare" in China, "rather common" in
Japan, " unknown " in Greenland, the Faroe Islands, etc. In
order to show the advance of cancer during greater intervals he
refers to the statistics which show but 17.7 deaths for the year
1840 for every 100,000 inhabitants of England, but 19 in 1865 for
Norway as against 85 in 1897. Exblom presents the cancer
deathrate for the small Swedish town of Fellingsbro for 100
years, during which it passed from 2.1 to 118 per 100,000 inhabi-
tants, the figures representing the average for the first and last
decade of the century. After discussing the unreliability of
statistics in general, the author allows that the figures given
point to a rapid augmentation in the frequency of cancer, but he
is convinced that the real condition is not so bad as it looks ;
that analysis of available data shows that external cancers are
practically stationary and that the apparent increase is due to
visceral cancers. This throws doubt on the uniform correctness
of the diagnoses. He therefore concludes that there is no such
alarming increase as is supposed; that the disease is about
equally divided between the sexes, and that the greater rate of
increase in cities as compared to the country is more apparent
than real, [c.s.d.]
A New Method of Preventive Inoculation in Anthrax.
— Sobernheim ' gives a method of immunization in anthrax by
La Semalne Mfidicale, September 10, 1902.
Centralblatt fur Bakterlologle, 25, November, 1899.
8 Berliner klinische Wochenschrift, June 2, 1902.
the injection of anthrax serum and a weak culture of anthrax
bacilli. He experimented with a large number of animals
over a period of two years and obtaine<l excellent results. The
combined injection of anthrax serum and bacilli is free of
danger, not having killed a single animal. The animal may be
injected in one day and not repeated as in the Pasteur method.
A more powerful injection may be employed than in the latter,
which results in better and longer immunity. Sobernheim's
method also acts as a healing agent, which never results in the
Pasteur treatment, [w.e.r.]
Albumin and Sugar Reaction at the Bedside. — Stlch '
has devised a compact case for carrying reagents and apparatus
for making urinary tests at the bedside. It has been placed on
the market by Griibler & Co., of Leipsic. [u.r.]
Disinfection for Yellow Fever.— Gorgas ' gives the results
in Havana during the year 1901 of disinfection for yellow
fever under the hypothesis that Stegomyia is the only means
of transmitting the disease. For practical operations three
fields of work had to be considered: 1. To destroy all the
stegomyia so as to limit the number of insects capable of con-
veying the disease, since it seems obvious that if there were no
stegomyia there could be no yellow fever. 2. To prevent the
stegomyia from biting the yellow fever patient, since if one
could prevent the mosquito from becoming diseased he could
also prevent yellow fever. 3. To destroy all mosquitos that had
bitten yellow fever patients and thus become infected, because
if these were destroyed it is evident that the disease would be
stopped. The measures adopted consisted in requiring all
people to keep receptacles containing water mosquito proof,
pouring oil into all puddles, cesspools, etc., fining all persons
having larva on their premises and draining all pools and low
ground ; screening infected houses and hospitals and distribut-
ing throughovit all infected buildings and all adjacent buildings
pyrethrum powder. The practical results of these measures
were seen in the practical absence of yellow fever, [a.o.j.k.]
Antifermentative Properties of Blood-serum. — S. Sim-
nitzky,^ after referring to the discovery by Fermi, Hahn,
Roden and Morgenroth that the serum of healthy persons
has the power to weaken, more or less, the action of fer-
ments, and to corroborative investigations by Hildebrandt on
emulsion, by von Dungem on proteolytic action of bacteria,
and by Liandsteiner on trypsin, he describes his discovery of
the antifermentative action of blood-serum on papayotin. He
finds that the serum of an animal which has been immunized
against property of bacteria to liquefy gelatin not only acquires
an antifermentative power opposed to the proteolytic ferments
of the bacteria in question, but also to such ferments of other
bacteria. The antifermentative action of blood-serum is, there-
fore, not to be relied upon for the determination of the nature
of an infection, but simply whether the pathogenic microbes
in any given case have or have not the property of liquefying
gelatin, [c.s.d.]
The Treatment of Heart Disease by Kreuznach Baths.
— Boehr* reports a number of acute and chronic cases of heart
disease which were treated by Kreuznach baths. This water,
like that of Nauheim, contains 1% sodium chlorid, but it con-
tains less free carbonic acid. Boehr gives baths at least 10
minutes long with a temperature never lower than 31.5° C. He
believes the baths of long duration affect the cardiac and vas-
cular system more gradually than the shorter ones, and that,
therefore, the influence is more permanent. All of his reported
cases showed improvement. In two patients all cardiac symp-
toms disappeared, in another case, cardiac hypertrophy was
cured, and in two cases of murmurs none were audible after
treatment, [w.e.r.]
The Pathogenesis of Acute Articular Rheumatism. —
KoUmann' reports the following cases to illustrate that acute
articular rheumatism may be contagious : A man of 29 who had
had the disease several times developed a severe attack with
involvement of the mitral leaflets. Before he had entirely con-
valesced his mother, who had nursed him, was struck down
with articular rheumatism. She was 54 years of age and had
' Munchener med. Woch., July 1, 1902.
- liancet, September 6, 1902.
^ Prager medlclnische Wochenschrift, September 11, 1902.
'Berliner klinische Wochenschrift, May 26-June 2, 1902.
November 8, 1902]
THE WORLD'S LATEST LITERATURE
[Akebican Medicine 751
never had rheumatism before ; neither had she ever had chorea
or endocarditis. She had been in the habit of covering herself
at night with the woolen blankets with which her son had been
covered during the day while sweating, [d.r.]
The Diagnostic and Prognostic Value of the Lieuko-
cyte Variations in Asiatic Cholera.— Rogers,^ basing his
observations on 2^ cases of cholera and 6 cases of acute diar-
rhea other than cholera, says that leukocytosis was present in
every case of Asiatic cholera that was examined in the early
stages. In 9 cases it was present in comparatively slight degree,
less than 20,000 leukocytes per cubic millimeter, and 5 of these
patients recovered. On the other hand, out of 14 cases in which
this numl)er was exceeded 11 were fatal. A high degree of
leukocytosis, therefore, is a bad prognostic sign, and a slight
degree a good one, yet a very high degree is not incompatible
with recovery. The constancy of occurrence of leukocytosis in
cholera is of importance in distinguishing it from some forms
of acute diarrhea in which it is absent, as in most of the 6 cases
reported. In a number of the cases there was a dispropor-
tionate lymphocytosis. It is said that when the leukocytosis
is of less degree, with a correspondingly low polynuclear
count, the prognosis is comparatively good. In the case of the
leukocytes, however, there is in cholera a very low percentage
and a comparatively low total count as characteristic features.
On classifying the cases according to the percentage of lympho-
cytes there is found that out of 16 cases in which less than lOfo
were found no less than 12 ended fatally, while out of 7 cases in
which over 10% were present 4 patients recovered and only 3
died. On the other hand, tliere is no such relationship between
the total number of lymphocytes per cubic millimeter and the
mortality, which is what might have been expected, as the
tendency of the high degree of leukocytosis in fatal cases to
increase the number of lymphocytes is counteracted by the
opposite tendency of low percentage of lymphocytes in severe
cases. Out of 6 cases in which under 10% of large mononuclear
corpuscles were found there were 4 recoveries, while out of 15
cases in which over 10% of large mononuclear cells were
present only 3 patients recovered and 12 died. The total num-
ber of large mononuclear cells per cubic millimeter shows a
similar relationship, as in this case the favorable low degree of
leukocytosis coincides with the equally favorable low percent-
age in reducing the total number of these corpuscles and vice
versa. Thus recovery took place in no less than 4 out of 5
cases in which the total mononuclear cells were less than 2,000
per cubic millimeter, while out of 18 cases in which over 2,000
were present 14 patients died. It is concluded, therefore, that
there is a definite relationship between the decrease of the per-
centage and the total number of large mononuclear cells and
the severity of the disease — a relationship of the very peculiar
leukocyte changes described which it would be difficult to
explain on any other ground than that these changes are of a
specific nature, [a.o.j.k.]
Anesthesia by Means of Methyl Chlorld.— Richet and
Marcille* report successful experiments in the use of methyl
chlorid as an anesthetic. It acts entirely by arresting the res-
piration and produces anesthesia in quantities too small to
have any action upon the heart. [o.s.D.]
Acute Tuberculous Infections of the tiungs. — Fraenkel'
differentiates between circumscribed, disseminated and more
diffuse acute tuljerculous infections of the lungs. In the
first form hemoptysis occurs early and is associated with
or without fever. Fraenkel discussess the various theories
accounting for hemoptysis and believes in the " Birch-Hirsch-
feld" theory. According to the latter it is believed that a
rupture in the walls of the air spaces causes the hemorrhage.
The apices are early involve<l bccau.se of their comparatively
anemic condition. Induration occurs in that part of the lung
be<:ause of the lessened expansion. Tuberculosis begins often in
the bronchi, because of the irritation of the inhaled dust, yet in
most cases the initial point is the bronchial lymph glands. In
the disseminated type a nunilier of foci exist, a cavity develops
and the bacilli are found in the sputum. The third variety is
called "galloping consumption." In this form a large number
I I>ancet, September (1, IWi.
■ Gazette heDdomadalre de MC-dcclne ct de Chlrurgle, No. 39, 11)02
' Berliner klinllche Wocbengcbrin, May 26-Jane 2, 1802
of cavities may be found, and with it there is usually a mixed
infection or some intercurrent constitutional disease. Fraenkel
says that when a large number of tuberculous foci exist it
may be difficult to diagnose the condition from an ordinary
lobar-pneumonia. He gives a large number of complications
and says that a tuberculous Infection may result in a "sub-
acute fibrous phthisis." [w.e.r.]
A Case of Osteomalacia.— J enner > describes an interest-
ing case of osteomalacia in a girl of 19, the first symptoms
appearing during 1897 as rheumatic pains of the lower extremi-
ties and especially of the left ankle-joint. Later the bones above
the left external malleolus could be bent at will. An intercur-
rent infection made the patient's state much worse. In 1898 she
could still get about on crutches, but gradually her weakness
became so great as to drive her to a wheelchair. While still
using crutches she fell and broke the first phalanx of the middle
finger of her right hand. Last year she broke her left femur
while resting it against the arm of her nurse, who was carrying
her downstairs at the time. She is able to demonstrate the soft-
ness of her femurs with her own hands. The shape of all her
bones has changed materially ; she has a marked rachitic rosary.
During the last few months a mass has appeared on the right
side of her face, probably a tumor of the antrum; operative
treatment is excluded on account of the patient's condition.
Ovarian and thyroid extract, phosphorus and codliver-oil have
failed to do any good, [e.i,.]
A. B. Craio
GEXlBRAIi SURGERY
Martin B. Tinker
C. A. Orr
BDITOKIAI. COMMENT
Anesthesia by compression of the carotid
arteries, noticed by us editorially '' some months ago
lias recently been attracting a great deal of attention,
especially by lay journals. Steiner, a Dutch physician
in charge of a hospital for the care of native prisoners in
Java, observed a native healer using the method, and
in subsequent experiments found that only iive out of
thirty natives did not respond, and that the loss of sensi-
bility when stupor was produced was so great that in
one instance an inguinal abscess was lancecl without
pain. He attributes the anesthesia to cerebral anemia.
In view of its uncertainty and the possibilities of harm-
ful effects, the method seems unworthy of serious con-
sideration. It is a sample of the numerous " dis-
coveries " of old and practically worthless methods
which are constantly cropping up in medicine. This
particular procedure has been commented on a number
of times since the era of Galen.
REVIEW OF LITERATURE
Treatment of Fractures of the Shaft of the Humerus.
— In fractures of the shaft about the middle or higher, it is
impossible for an internal angular splint to have any hold on
the upper fragment, as it does not extend high enough. As it
is impossible to immobilize the forearm of a patient who is going
about, it is a mistake to fix the elbow, since all movement is
then conducted to the next movable point, the site of the frac-
ture. When the wrist is slung from the neck the forearm is
brought across the chest and the lower fragment is rotated
somewhat on the upper. The elbow is carried forward and
outward, and the upper arm no longer hangs perpendicularly.
Thus the extending force of the weight of the forearm is lost
when the patient is erect, and the fragments tend to sag back-
ward and form an angle when he is lying down. Wilkinson'
obtains fixation of the shoulder-joint by bandaging the upper
arm to the diest wall after padding in such a way as to make
the arm hang perpendicularly. He recommends that the wrist
be kept extended and the fingers flexed and that the hand shall
not be confined under the clothing, that there shall be no pres-
sure at the bend of the elbow, that the internal splint shall be
1 Deutsche med. 7Ag., 1901, 1208.
'American Medicine. April 19, 1902, page 628.
aciuarterly MtdlcalJoiirnal, August, 1902.
762 AlTBBIOAir MEDIOIHE
THE WORLD'S LATEST LITERATURE
[NOVEUBKB 8, 1902
prevented from pressing in the axilla, that the external splint
shall reach from the great tuberosity to just above the external
condyle, and that passive movements of the wrist and Angers
be made each day and the splints tightened up as the swelling
subsides. He describes in detail the technic in the accomplish-
ment of these ends, [h.m.]
Tetanus After Gelatin Injection. — Gradenwitz ' refers
to the frequent recommendation of gelatin as a hemostatic
agent and to its rapid action through local application to the
point of hemorrhage or through subcutaneous injection ; he
then speaks of the great danger of infection therefrom, adding
an eighth case to the seven already reported in which tetanus
followed the use of gelatin. He considers that the hemostatic
power of gelatin is conclusively shown in his case, since after
the ordinary methods of controlling hemorrhage had failed
and death seemed inevitable it was quickly arrested by the
subcutaneous injection of lOO cc. of a 2% solution of gelatin.
Unfortunately, six days later death followed from tetanus.
Because of the great efficiency of gelatin in controlling hem-
orrhage it seems most desirable that great efforts be made to
render iffree from tetanus germs ; but it should not be used
until its freedom from germs has been fully tested upon ani-
mals. [w.K.]
Surgery of Tuberculous Kidney.— Haughey^ mentions
the case reported by Kelly at the Atlantic City meeting of the
American Medical Association, and marvels at the temerity
of that operation, which consisted in removing the kidney and
entire ureter including a section of the bladder surrounding its
implantation. The patient died as a result of the bladder
sutures giving way and allowing escape of urine. Haughey
says that the epithelium of ureters, bladder and urethra is
arranged to prevent absorption, and asks what probability is
there of the tubercle bacillus passing through and gaining
access to the systemic circulation? Is that probability suf-
ficiently great to warrant the additional risk incurred by open-
ing the bladder to remove another inch or two of the ureter
when the bladder and entire urethra (whic J cannot be removed)
have been equally exposed to the action of the germs? Two
cases are reported. In neither of these was the lower end of
the ureter removed and both patients are now in good health
after the lapse of four years, [a.o.e.]
Accessory Thyroid Tumors at the Base of the Tongue.
—Smith' reports a case of this kind in which he operated suc-
cessfully by the transhyoid route, dividing the hyoid bone and
splitting the floor of the mouth just beneath the jaw. He has
collected from the literature 20 cases of this kind, which he
tabulates, and finds that the location of such tumors is always
closely back of the circumvallate papillae, almost exactly in the
median line, although occasionally toward one or the other
side. It frequently reaches down as low as the epiglottis,
which it covers, but is not intimately connected with it. Fre-
quently such tumors may even touch the posterior wall of the
pharynx. The size varies greatly, usually from that of a cherry
to that ofa walnut, although the tumor may reach the size of a
small egg. The surface is smooth, usually covered by mucous
membrane, which is paler than normal. The form is usually
pointed or oval and elevated somewhat above the level of the
surrounding mucous membrane. It has abroad base, and the
consistency is firm and elastic. The symptoms are relatively
few. When such tumors rea h a sufficient size they may cause
difficulty in breathing, swallowing, or interference with speech,
so that the patient talks as though he had a potato in his mouth.
Bleeding may be a symptom. It is reported in 5 out of 20
cases in this series, and led to a mistaken diagnosis of ulcer of
the stomach in some of the cases. The only satisfactory treat-
ment is extraction of the growth, which may be done by the
use of the electrocautery, extraction through the mouth (which
has been done most frequently), suprahyoid pharyngectomy
with division of the hyoid or even after division of the inferior
maxillary bone, or Kocher's incision for excision of the tongue
may be employed, [m.b.t.]
The Treatment of Appendicitis.— Sonnenburg * says that
'Centralblatt fiirGynakologle, September 13, 1902.
2 Journal Micbigan State Medical Society, October, 1902.
'Nordiskt Medicinskt Arkiv, 1902, Vol. xx.w, haft 2, No. 10, p. 1.
*La Mfideclne Moderne, October 1, 1902.
he was one of the first surgeons in Germany to advocate early
surgical interference in all acute cases of appendicitis. For
some time he followed that teaching, but of late his views have
changed, and he now rarely operates during acute attacks, pre-
ferring interval operations. This change in apinion has been
brought about not only by the observation that in a large num-
ber of acute cases the patients recover without surgical inter-
vention, but also by the resistance of the public and a great
number of physicians. He believes that it is possible to makea
diagnosis of the pathologic state of the peritoneum and of the
appendix itself. During the last two years he has done this
before each operation, announcing his diagnosis to students and
physicians. Operations have proved the correctness of his
diagnoses. He depends much on the degree of leukocytosis
present. This is a great aid in fixing the precise moment at
which to interfere during the course of the disease. In acute
simple appendicitis without peritonitis, there is no leukocytosis.
[A.fJ.E.]
Treatment of Abdominal Wounds in War.- Roberts '
says if we exclude those who die in the first 24 hours, we may
estimate that of the cases of penetrating abdominal wounds
amenable to surgical treatment about 60% of the patients will
recover. The recoveries are chiefly among those cases in
which the area of the small intestine is not crossed, and when
this area is involved the mortality is probably very great. Too
often, without exploration, we cannot be sure whether perfora-
tion exists or not, and while a routine laparotomy is not justi-
fiable in every case, it should be performed at the first evidence
that perforation exists. Such evidence may be found in the
persistence of shock, a steady increase in the rate of the pulse,
and in the abdomen becoming increasingly rigid and tender,
and especially is it probable if vomiting has persisted and the
passage of flatus is arrested. The operation is especially likely
to be successful when the injury is localizetl, the patient seen
within six hours of being wounded and transportation has not
been difficult. When the bullet is retained, or the track is a
complete transverse oue, the prognosis is far less favorable.
The results of laparotomy for gunshot wounds in war have
been most unfavorable. In the Spanish-American war, Senn
reported that all patients he knew of that were operated on
died. In the Tirah campaign, of eight cases of penetrating
wounds of the abdomen, five patients were operated on and all
died. In the Boer war I only knew of two successful opera-
tions performed for wounds of the small intestine. In the
American war in the Philippines, Dr. Robinson reported that
five patients were operated on and four died. The unfavorable
results are attributable to various causes. The severity of the
injuries, the delay in bringing in the wounded, difficult trans-
port and the unfavorable surroundings render abdominal
operations at tlie front in most cases unpermissible. [a.b.c]
Fractures of the Patella, with Special Reference to
Their Treatment by Suture.— Courtney ^ believes that cases
of simple fracture without displacement should be treated by
one of the nonoperative methods. Vertical fractures; fractures
comminuted by direct violence and with untorn fibro-periosteal
covering and capsule; oblique fractures without displacement,
and such transverse fractures as have little or no separation of
fragments, should be thus treated. Massage of the quadriceps
muscles should be made as frequently as po.ssible, and passive
motion of the joint begun as soon as it may be done with safety.
He details three of five cases in which he has operated, which
demonstrate the value of treating these fractures in selected
cases, by opening the joint, and using the proper sutures, a
method practically free from danger and affording perfect, or
almost perfect, restoration of the anatomy and functions of the
patella and of the joint, and enabling patient to resume his
occupation within 2i to 3 months, [f.c.h.]
Gunshot Wound of the Heart.— Hammond ' reports a
case of accidental gunshot wound of the thorax, which per-
forated two inches above the ensitorm cartilage and 11 inches to
the left of the sternum, fracturing a rib at that point. It passed
through the pericardium and through the apex of the heart,
making a wound i of an inch in depth. It then perforated the
' British Medical Journal, October 4, 1902.
SSU Paul Medical Journal, October, 1902.
3 Annals of Surgery, 1902, Vol. xxvl, p. 550.
NOVKMBER 8, 1902]
THE WORLD'S LATEST LITERATURE
[AUBBIOAN MKDICIN& 753
pleura and made its exit between the sixth and seventh ribs,
where it was found later in the subcutaneous tissue. The
patient was treated by absolute rest in bed and local autiseptic
dressing. He did very well until the fourteenth day after the
operation, remaining in bed unwillingly. He was then seized
with an attack of vomiting, which caused his death almost
instantly. Hammond believes that had this not occurred the
patient would almost certainly have recovered. He has col-
lected from the literature a number of such gunshot injuries
of the heart, in some of which complete recovery took place.
[M.B.T.]
Treatment of Tetanus. — Vallas ' speaks of tlie older medi-
cal and surgical treatment of this disease, and then considers
seriatim the modern methods. Serumtherapy is discussed as
to (1) its preventive value. This, Vallas says, is well estab-
lished in spite of five cases of apparent failure reporte<l by as
many observers. He has used it in 20 cases of wounds soiled
by earth or dust, and no case of tetanus developed. An injec-
tion of 10 cc. should be given on the first, third and tenth days.
If the wound does not heal promptly a fourth injection should
be given on the fifteenth day ; (2) the curative value of serum.
This is considered under four heads as regards methods of
ailministration : (a) Subcutaneous. Of 373 collected cases thus
treated there were 145 deaths, ^9%. In 141 of these eases the
incubation period was less than 10 days and the deaths were
57% ; incubation 10 days or over, 118 cases, deaths 20% ; incuba-
tion undetermined, 114 cases, deaths 36%. Some forms of
tetanus were especially resistant to the serum, as shown by 15
cases of tetanus neonatoram with 11 deaths, and 15 cases of
puerperal tetanus with 12 deaths. A point emphasized is that
no danger is incurred by the use of serum and enormous doses
may be used with impunity. In one case 1,800 cc. were
employed; (6) intravenous. Of 31 patients treated by this
method 18 died, a mortality of 42%. This is slightly higher than
by the subcutaneous method, but the method was probably
reserved for the most serious cases; (c) intracerebral. This
has been followed by serious results and is not to be recom-
mended; (d) subarachnoid. This is inferior to a and 6 in
results and has an element of danger. The carbolic acid treat-
ment of Baccelli is discussed at length, and the statement made
that animal experiments show tliat it is not a specific remedy
against tetanus. Clinically 80 cases have been observed with
Ijut 8 deaths. Mosl of these patients were from Italy, which
gives a low mortality by all methods. Other series of cases
show greater mortality. The treatment is regarded as a good
symptomatic one but not a specific. Vallas concludes that pre-
ventive serumtherapy possesses a sure action, and that if it
were used systematically in all suspicious wounds tetanus
would disappear the same as has variola under the use of vac-
cine. When tlie disease l)egins we are still at a disadvantage,
but serumtherapy is the best treatment. The use of chloral and
carbolic acid is of value in controlling spasms and should be
considered an auxiliary method. It is well to employ these at
the same time that the serum is given, and in view of the tox-
icity of the acid the preference should be given to chloral.
[A.a.E.l
Aid to the Sick and IVounded Daring War : Hospit«l
Orderlies. — Huttou^ empliasizes the work and importance of
the iiospital orderly in the field. Sir Frederick Treves is
quoted as saying : " The question of orderlies is a difficult one.
The present (South African) campaign showed that nurses,
keenly as tlieir services were appreciated, could not work in the
field hospitals, and they must fall back on the orderly." The
author says theque.stion of the supply of hospital orderlies is
intimately connected with one of the most important parts of
our army medical organization in war, ?'. c, the field hospitals.
From the writer's remarks it was apparently difficult to obtain
hospital orderlies in suffi<^ient number to satisfy the demand.
His idea appears to be that the government should make some
provision for the proper training of Iiospital orderlies, [a.b.o.]
Ueusner's Kxtension BandaKe.— Hans Wiilfing' after
referring to the ditliculties commonly experienced in the use of
adhesive plaster in securing extension bandages, calls attention
' Gazette Heb. dp MMhtlnc pt ilfi t^'lilriirgle, October 5, 1902.
' British Medical Journal, October -1, laOi!.
'MOncbenermedlclntacbe Wocbenacbrlfl, September 23, 11102.
to the many advantages afforded by the method devised by
Heusner and perfected by Bruns, in which a spray apparatus
is employed and a spray fluid consisting of castor oil, 3.0 grams
(46 grains); gum dammar, rosin, aa 10.0 grams (154 grains);
chian turpentine, 1.0 gram (15 grains) ; ether, alcohol, spts. tur-
pentine, ua .55.0 grams (850 grains). This must be prepared with
oare and thoroughly filtered. The limb is sprayed with this
varnish and the extension strips of flannel, felt or the socalled
buckskin or moleskin material, applied in rather broad pieces
so as to cover the limb and give wide traction surface. Bruns
employs a stockinette tube with the lower end slit up. This is
drawn over the well sprayed limb. The use of this varnish
spray can be made to replace adhesive plasters in many other
dressings as well. [c.s.D.]
Cyst of tlie Urachus.— Page • reports this case, the patient
being a man of 36. For 3i years he had had intermittent or con-
stant pain in the hypogastric region. Cramps and diarrhea
were other symptoms. A mass the size of an average orange
was situated midway between the symphysis and umbilicus.
From this four or five ounces of thick, flaky, yellowish-brown
fluid was evacuated. Discharge was free, recovery wasslow, and
a sinus that required several ouretments persisted for some time.
[A.G.E.]
Cholecystectomy.— Ries'-' speaks of three epochs in the
development of the surgery of gallstones : first, in which the
stones themselves were thought to be the entire cause of trouble,
and after their removal the closure of the gallbladder was con-
sidered the ideal operation. This standpoint is abandoned at
the present, for it is clear that the diseased mucous membrane
of the biliary tract is an important factor in cholecystitis.
Draining the gallbladder and the biliary passages was next
generally adopted as the usual treatment of these patients, but
the large number of biliary and mucous fistulas and occasional
re-formation of stones has led surgeons to favor removal of the
gallbladder. Ries reports a ca.se in which he did cholecjrstec-
toniy, successfully removing the entire gallbladder. Exami-
nation of the gallbladder microscopically showed that the
glands in the mucous membrane penetrated the muscular coat
and were often embedded in the tissue of the subserous coat.
This ho believes indicates that Mayo's operation of excising
the mucous membrane cannot be considered the ideal operation
in these cases, [m.b.t.]
Dislocations of the Metacarpal Bone.— Berdach and
Herzog' report an interesting case of isolated dislocation of the
index metacarpal bone occurring in a man of 22. The injury
was caused by a blow on the back of the hand by a lever with
which a man was trying to lift a heavy car. A brief review is
given of the cases of luxation of metacarpal bones which have
been reported in literature. Only 11 injuries of this kind are
mentioned, [m.b.t,]
GYNECOLOGY AND OBSTETRICS
WiLMER KRtJSRN FRANK C. HAMMOND
EDITORIAL. COMMENT
" Facultative Sterility " is tlio term used by Kock
of the University of Bonn to designate a new procedure
he has devised, and which he recommends for use when
it seems necessary to prevent possiliility of conception
for any length of time without permanently depriving
the subject of procreative power. He form.s two folds of
mucous membrane, one at tlie anterior and the other at
the posterior lip of the external orifice of the uterus.
The.se act as valves, permitting the outflow of the men-
strual fluid and preventing the entrance of the si)erma-
tozoa. He uses the word " facultative " becau.se, by the
removal of the folds, fertility may be restored. Since
the days of Sims and his artificial impregnation no pro-
cedure has been introduced to the profession which
seems (juite so original and ingenious as this. It remains
to be seen, however, how effective these arliflcially pro-
duced valves will be against the spermatozoa, possessing as
< The FoMtfraduate, October, 1902.
< Annals of Suivery, 1902, Vol xxvl, p. 008.
> WIen. kiln. Wocbenschr., 1902, Vol. xv., p. »40.
754 Ahsbioah MbdioineI
THE WORLD'S LATEST LITERATURE
[November 8, 1902
they do such remarkable motility. Should they prove
effective, the procedure will be of great value in the class
of cases in which tubal ligation or exsection has hitherto
been practised, and particularly in married women suf-
fering from diseases of the lungs, heart, or kidneys,
rendering pregnancy peculiarly perilous.
REVIEW OF LITERATURE
Poreijfn Bodies in the Uterus.— In the first case reported
by Toff 1 the patient had undergone tamponade treatment to
control hemorrhage after abortion with subsequent intrauterine
irrigation. After leaving the hospital she began to suffer
severe abdominal and pelvic pain with excessive vaginal dis-
charge which would not yield to ordinary treatment. An exam-
ination of the discharge showed the presence of cotton filaments
so that a diagnosis was made of a forgotten tampon in the
uterus. Subsequently there were removed from the uterus
strips of gauze tissue .SO cm. in length. In the second case
Tofif found in a four months' pregnant uterus small pieces of
wood of helleborus niger, which had probably been introduced
to produce abortion, a dangerous procedure, as there was a
great probability of uterine perforation by these slivers of
wood. [W.K.]
Hypogastric Experitoueal Liaparotoiny for Vag^ino-
uterine Cancer.— Makenrodt'' describes this operation briefly,
and maintains that the great advantage of hypogastric experi-
toueal laparotomy is that it brings into view all the vessels and
glands of the small pelvis and permits of their complete
removal with the minimum exposure and interference with
abdominal cavity and peritoneum. After operation for cancer
of the rectum, the frequency of recurrence in the paracolpium
added to the impossibility of separating theparaproctium from
the paracolpium in isolated extirpation of the rectum, has led
him in carcinoma of the rectum never to remove the rectum
without the vagina, together with the paracolpium and the
uterus and the entire Douglas sac with the anterior parametria.
Then what is left of the rectum with the adjacent connective
tissues is loosened and the end is sutured to the sphincter. In
case of uterine carcinoma, as in rectal cancer, it is of course
possible to remove radically all the inguinal glands and all
pelvic glands belonging to the rectum, an advantage not suffi-
ciently appreciated in operations for rectal or vaginal cancer.
[W.K.]
Tlie Oijstetric Aspects of Idiocy.— William Gillespie-*
concludes as follows : The more frequent use of forceps with
the object of preventing asphyxia will tend to decrease the per-
centage of idiots to the general population ; infantile cerebral
palsy and spastic rigidity or paralysis of spinal origin will
become less frequent in proportion to the success of our efforts
to prevent asphyxia ; although congenital deafness is some-
times due to malformation of the auditory mechanism, there
can be no doubt that some cases are due to injury during partu-
rition, and the percentage of such unfortunates in the commu-
nity may be lessened by the rational management of labor ; in
thoroughly developed children asphyxia occurs before birth,
in the premature it usually develops after birth ; a clinical dis-
tinctioti may be made between cases when cerebral injury
results from asphyxia ahd those in which asphyxia results from
cerebral injury, from the fact that in the former the circulation
is disturbed from the beginning, while in the latter disturbance
of the circulation follows respiratory failure. If cases are
found where cerebral injury is plain and yet there is coincident
disturbance of both functions it is probable that both trauma
and asphyxia are at work. This point is important in that it
enables us to judge with some degree of accuracy where we
have been unskilful, thus assisting in the formulation of a
proper operative technic ; in children who have inherited a
neurotic tendency idiocy may follow an injury which would
not have had such serious consequences in one that was
descended from more stable stock; while injury from forceps
is not a very prominent cause of mental defect or infantile cere-
bral palsy, and their judicious use constitutes our best pre-
1 Miinchener medicinisohe Wochenschrift, September 2.3, 1902,
2 Berliner kllnlsche Wochenschrift, September 22, U»02.
3 The Cincinnati Ijancet-Cllnlc, September 27, 1"J02.
ventive treatment, there can be no doubt that in exceptional
cases these conditions are to be ascribed to their use. It is
therefore imperative that those who work in this department
not only study carefully the conditions which call for their use,
but that they acquire the skill and judgment necessary for their
application, in order that we may have the maximum of benefit
with the minimum of injury. It is probable that in most cases
where instruments produce cerebral injury it is their abuse
and not their use ; finally, for every case of idiocy or infantile
palsy resulting from asphyxia we have many fetal deaths
which might have been prevented by more skilful obstetrics.
[P.C.H.]
Removal of Ovaries for Cancer of the Breast.— D'Arcy
Power' reports three cases in which the ovaries were removed
for inoperable cancer of the breast. Two of the patients were
past the menopause, and in these the operation gave no percep-
tible benefit, but in the other patient, a woman of 42, there was
an arrest and apparent retrocession of the cancerous process
and improvement in general health with an entire cessation of
menses, [w.k.]
Cesarean Section in Eclampsia.— Salin' reports this
case in a girl, 16 years old, gravid in the tenth month. During
the night preceding her admission to the hospital she had ten
eclamptic seizures, remaining all the time in astate of profound
coma. Soon after admission early in the following morning
she had another attack. In spite of large doses of morphin
subcutaneously she had several very severe attacks, and had in
all 17 seizures within nine hours. On examination gestation
was found to be at its termination, head presenting, and fixed,
as admitting one finger. Vagina very narrow. No pains.
Membranes intact. On catheterization were obtained about
200 gms. dark-brown urine, containing 6% of albumin. Patient
was very low and remained deeply unconscious between the
attacks. No signs of labor setting in. As nothing was likely
to be gained either by the expectant plan of treatment or by
an attempt at dilation of the cervical canal, it was decided to
empty the uterus as speedily as possible by operative measures.
The cesarean section was given the preference to Diihrssen's
method of splitting the cervix and incising the vaginia, fol-
lowed by forceps extraction. When on the table the patient
was immediately before the operation again seized with a most
violent attack which seemed likely to end it all. This subsided,
however, and the operation was performed in the customary
way. No complications or difficulties were encountered. The
full-termed fetus was asphyxiated, but respired after a few
minutes. It evidently also suffered from eclampsia, showing a
great tendency to cramps. Even after several hours a feeble
blowing on the cheek sufficed to throw the whole body in
cramplike contractions. The child has since been doing well.
The patient had no eclamptic attacks after the operation.
On the third day she developed pneumonia, and a feeble heart
murmur was discernible. The pneumonia resolved, the
incision wound healed normally, and the uterus involuted per-
fectly as an ordinary puerperal uterus, and in the third week
hopes were entertained that the patient would soon be able to
get up. But now the temperature again Ijegan to rise, the cardiac
murmur louder, and cardiac dulness considerably increased.
At first pericarditis was suspected, but gradually symptoms
of septic endocarditis became apparent with double pneumonia,
pains and swelling of joints, and death occurred in the tenth
week after the operation. At autopsy the diagnosis of endo-
carditis was verified. The abdomen showed no sign of perito-
nitis. The uterus was perfectly normal in size, [a.e.e.]
External Examination in Childbed. — Frickhinger'
emphasizes the danger of infection from internal examination
during labor with resulting puerperal fever. He quotes the
opinion given at the German Gynecologic Congress that there
is no disinfection of the hands. Hence the limitation of internal
examination even to its cessation is a postulate which might
almost be affirmed. He reviews the pros and cons, and while
admitting the necessity for vaginal or internal examination
under certain conditions, advises more thorough instruction of
obstetricians and their assistants in all methods of external
1 Lancet, October 4, li)02.
2Hygela, Stockholm, Oct.
3 MUnchener med. Woeh.,
1902.
September 30, 1902.
NOVEHBEB 8, 1902]
THE WOELD'S LATEST LITERATUEE
(AXBRICAN MSDICtNE 755
examination during pregnancy and labor, that the known per-
centage of deaths from infection may be reduced rather than
increased, [w.k.]
Dislocation of the Hip Durinf; Normal Labor.— I^. B.
Newton • details the case of a Vpara, 27 years of age. During
her last accouchement the physician in attendance, for " fear of
exhaustion and to save time," rendered an instrumental deliv-
ery. Although the patient complained of pain in the left hip,
after recovering from the anesthetic and for a day or two sub-
sequently, the physician did not make an examination. In
due course of time an abscess appeared IJ inches below
Poupart's ligament, in close proximity and to the left of the
femoral vessels. At the expiration of three weeks the first
physician was discharged, and a second called in who opened
the abscess. Newton was eventually called in, and ascertained
the above history. He found the woman emaciated and mark-
edly debilitated. The hip and thigh were swollen and painful,
the abscess discharging pus. The hip was so swollen and
tender that it was impossible to make an examination of it.
On palpation, fluctuation was felt from the crest of the ilium to
within four inches of the knee. The thigh was flexed at a
right angle with the body, and the leg at a right angle with the
thigh, the foot inverted. When the abscess had healed and the
swelling about the thigh had greatly diminished the disloca-
tion was reduced. By the manipulation of the leg in the
adjustment of the joint the cicatrix of the old abscess was torn
open and the fibers of the muscles and tendons were more or
less ruptured. She was put to bed with a weight and pulley
to the leg to retain the elongation if possible, and kept so about
four weeks. In a short time subsequent to the reduction pus
accumulated in the tissues of the thigh, which necessitated the
introduction of a rubber catheter drainage tube two-thirds of
the length of the thigh. Soon after the healing of the thigh
the knee-joint became swollen ; it was opened and two ounces
of pus evacuated. She was subsequently discharged with the
leg about 1 J inches .short. The dislocation in this in.stance is
attributed to meddlesome midwifery, [f.c.h.]
Paralysis of the Arm In Delivery.— Schuller' reports
three ea.ses of paralysis of the arm resulting from delivery. In
the first case there was a presentation of the pelvic extremity
and manual assistance in delivery with a paralysis of the plexus
of the right arm and a slight curvature of the neck. In the
other two cases there was head presentation, forceps delivery
with paralysis of the right arm in one case and extensive
paralysis of the left arm in the other. This paralysis with the
accompanying wry-neck was without doubt caused by the for-
ceps delivery. The electric sensibility in the arm gradually
diminished and the paralysis remained after 2} years, [w.k.]
Intraabdominal Hemorrhage and Pelvic Hematocele.
Hellier' reports 16 cases, including dift'uso intraperitoneal
hemorrhage, and intraperitoneal and extraperitoneal hemato-
cele. Until he had acquired boldness in opening the posterior
culdesac he did not realize that hematocele was so frequent.
He gives a tabular summary of the eases. The diagnosis of
cause may rest upon the finding of chorionic villi. A negative
result is almost valueless. Pain, metrostaxis and palpable
swelling are generally present, the first due to pre-ssure and
tension. Internal pelvic hemorrhage has irregular external
hemorrhage as a very constant accompaniment. In the
reported cases operation was resorted to much more frequently
than ordinary book-teaching prescribes. He advocates opening
the posterior culdesac in cases of obscure swelling and notes
the frequency with which old standing hematoceles undergo
septic changes. Another reason for early operation is the
importance of allowing the patient to return to work. In extra-
peritoneal hematocele expectant treatment is best. These may
require opening if long unabsorbed, if they increase in size or
become septic, [h.m.]
VaKlnal Fixation.— McCann • concludes that vaginal fixa-
tion, which it must lye clearly understood is not an operation
for prolapsus uteri, is indicated in cases of backward displace-
ment: (1) Caasing symptoms when little, if any, prolapse
' The Medical Age, Sfpt«mber 25, 1902. '
•Wiener Itliniwlio WiK-hcuschrlft, No. .'(7.
'The Quarterly Medical .lournal, August, 1902.
« British Medical Journal, October II, 1902.
exists ; (2) causing dyspareunia either from a tender uterus or
tender prolapsed ovaries ; (3) when nervous symptoms arise as
a result of prolonged instrumental treatment; (4) associated
with severe dysmenorrhea and sterility; (5) with adhesions,
but no definite inflammatory masses in the pelvis ; (6) in cer-
tain cases of cystocele. The advantages of this method are that
the position of the uterus thus obtained is more nearly normal
than that after any other fixation operation ; there is no abdomi-
nal scar ; there is no tendency to hernia ; the risk is only that of
the anesthetic when the operation is performed by one skilled
in vaginal surgery, [w.k.]
Spontaneous Rupture of Cord. — Brodhead' gives notes
of eight obstetric cases, one of which was spontaneous rupture
of the umbilical cord during labor. The rupture occurred dur-
ing the birth of the body, being situated about four inches from
the umbilicus. Bleeding was slight. The stump was tied at
once and the slight asphyxiation present soon disappeared. The
cord was but .32 cm. in length. Three cases of persistent occipito-
posterlor position of the vertex with rotation by forceps are
also reported. None of the children was injured and there
was slight laceration of the perineum in but one case, [a.o.e.]
The lodobromosallne Waters of Salsomaffglore In
Diseases of Women. — Curatulo^ bears testimony to the great
curative value of the muriated iodobromin waters of this little
village' among the foothills of the Appenines. What gives
these springs their supremacy is not only richness in mineral
principles but the great amount of bituminous substances they
contain. There are also traces of ichthyol. The mother liquor
remaining after the extraction of the sodium chlorid is very
rich in iodin, brominand lithium. It is used in the prepara-
tion of the mud for inhalation, irrigation and pulverization, and
is very often added to the baths of the natural mineral waters.
The treatment at Salsomaggiore consists of baths of natural
mineral water and mother liquor, local application of mud,
inhalation and irrigation, and vaginal steam-spray by means of
a specially contrived steam-spray speculum. Good results are
obtained in cases of pelvic inflammation, simple and parenchy-
matous metritis, subinvolution, catarrhal endometritis, salpin-
gitis and oophoritis ; and remarkable absorbent action has been
observed in cases of exudates caused by perimetritis and para-
metritis. Retrodisplacements, certain forms of dysmenorrhea
and inoperable flbromyomas have all been relieved, [w.k.]
Puerperal Septicemia. — Dimmook' reports a case of puer-
peral septicemia, interesting because of remarkable variations
in temperature. The patient, aged 20, was in the fifth month
delivered of a stillborn child, which had apparently been dead
a week, the placenta being macerated and brownish, but with-
out bad odor. The patient grew worse, the temperature rising
on the second day to 100° F., and despite curetment and intra-
uterine douching continued to rise. Two doses of antistrepto-
coccic serum of 10 cc. and 15 cc. were administered at an interval
of two days, but without any appreciable effect, the temperature
rising until it reached 106° F., nearly two weeks later. After
this with many fluctuations it gradually began to come down ;
she began to convalesce and is now better in health than for
years, [w.k.]
Abuse of Mercuric Chlorid Solutions in Obstetric
Practice. — Marshall'' afl[irms that many deaths have occurred
from the use of mercuric chlorid solutions as a douclie. Nearly
all the fatal cases have resulted from injections into the uterus,
but the toxic symptoms have also l)een produced l)y simple
irrigation of the vagina. This has been specially the case when
a perineal laceration existed. The symptoms are generally
abdominal pain and diarrhea, small, rapid pulse and subnor-
mal temperature. Headache, dulness, depression, delirium or
coma may be present. The collapse is usually gradual, and the
patient commonly dies in from 7 to 10 days, sometimes 20. In
conclusion Marshall lays stress upon the danger of this treat-
ment, and empliasi/.es the fact that it is not so much the strength
of the solution employed as the total amount of mercuric chlorid
passing through the uterine cavity which is the danger. Hence
the best plan in using such treatment is to employ brief irriga-
tion as least dangerous and probably as efilcAisious. [w.k.]
' Tlio PoRttfraduatc, October, 1902.
: BrltlKh Medical Journal, October 11, 1902.
"Lancet, October II, 1902.
766 Ajcebicajt Medioikej
THE WORLD'S LATEST LITERATURE
[November 8, 1902
TREATMENT
Solomon Solis Cohen
C. Wood, Jr. h. F. Applkman
EDITORIAL COMMENT
The Use of Chinic Acid in Gout. — Despite numer-
ous careful studies concerning the cause of gout, we are
still without definite knowledge of its true pathology
and are in almost as complete ignorance of any remedy
that exercises a curative effect, aside from temporary
palliation. One of the latest candidates for favor as a
cure for this intractable affection is chinic acid, a sub-
stance related chemically to benzoic and salicylic acids
and which is placed upon the market in different forms
under various trade names as sidonal, chinotropin, etc.
Huber and Lichtenstein ' have published (juite an elabo-
rate study of this drug based partly upon literature
and partly upon their own experiments, pronouncing in
favor of the medicament upon both scientific and practi-
cal evidence. Concerning the latter we have not much
to say because it seems still too small to warrant of itself
positive conclusions. We need but recall the long list of
synthetics introduced with high applause by the Ger-
man clinicians only to pass into speedy and complete
oblivion.
The scientific evidence brought forward to justify the
therapeutic use of this substance is founded on the asser-
tion originally enunciated by Weiss and confirmed by
other investigators, that chinic acid lessens the output of
uric acid. While it is generally believed that uric acid
has some connection with the gouty diathesis, we have
no very definite knowledge of the exact role that it plays
in this disease. If we accept the common idea of its
relation to gout, it is difficult to understand in what way
the lessening of the elimination of this poison is likely to
relieve the disease unless there is a lessening also in the
formation of uric acid. It is, however, an unsafe con-
clusion to assume without further proof that because the
quantity of uric acid in the urine is altered that there
has been a corresponding difference in its formation.
The most recent investigations tend to show that the
uric acid output varies almost uniformly with its intake,
exactly as we find the formation of urea influenced
chiefly by the nitrogenous absorption. According to
Loewi ^ the entire amount of uric acid ingested with the
food is eliminated, and it is improbable that any con-
siderable quantity of it is destroyed in the system.
From this point of view it is evident that the drug can
affect the formation of the uric acid only by altering the
absorption of the foods containing it or by affecting the
excretion of uric acid already in the system. In other
words, a decrease in the amount of uric acid eliminated
in the 24 hours means either a disturbance in the diges-
tive tract or a retention of the poison in the body. As
a matter of fat't, it has been shown that tannin, for
example, lessens the output of uric acid still more
markedly than has been asserted for chinic acid, this
effect probably being due to interference with the absorp-
tion by the precipitant action of tannin on albuminous
substances.
The experiments of Richter, who found that chinic
acid prevented the deposit of uric acid that usually fol-
lows the administration of potassium chromate to birds,
cannot be accepted as evidence, because the uric acid
metabolism in birds differs so essentially from that in
mammals.
Ulrici ^ has shown that except under special circum-
stances the uric acid elimination bears a constant rela-
tion to the output of urea, and therefore any experi-
ment concerning uric acid metabolism that fails to take
into consideration the general nitrogenous changes can-
not be regarded in the light of scientific evidence.
Apparently this point has been almost uniformly over-
1 Klinlsche Wochenschrift, 1902, xxlx, ^.
2 Arch. f. experim. Path. u. Pharm., 1900, xllv, p. 1
3 Arch. f. experim. Path. u. Pharm., 1901, xlvl, p, 321.
looked by those who have studied the effect of chinic
acid in gout, and Ulrici, in his own experiments, found
the reduction in the amount of uric acid eliminated so
small as to be within the figures of possible chemic
error. It seems from his experiments that there was
delay in the elimination of uric acid, since the quantity
eliminated was smaller on the first day the drug was
taken than on any succeeding day. He points out the
same fact in the experiments of Weiss, who argues that
the periods of his observations were too short to show
positively the effect of the drug on tissue change. These
results would indicate rather increased retention of uric
acid than decreased formation.
REVIEW OF tlTEKATURE
The Therapeutic Use of Sodium Cacodylate.— Mendel '
says that although Gautier has claimed that the cacodylates are
active only after hypodermic administration, the experience of
others has shown they are also absorbed from the stomach.
Mendel has usually employed the hypodermic method, com-
mencing with 0.2 gm. daily and increasing. In a large number
of cases he has given it also intravenously with much success.
In chlorosis he has obtained a cure in four to six weeks, more
quickly therefore than with the classical iron treatment. In
tuberculous conditions his results were not so brilliant as those
of some other investigators, but in the majority of cases he says
there was a distinct increase in the patient's weight and in his
subjective condition, although the physical signs and temper-
ature were not greatly affected. In diabetes there was no
diminution In the quantity of sugar secreted, although here
again there was improvement in the general condition. Of two
patients with exophthalmic goiter who were treated with the
cacodylate, one was not at all affected, but the condition of the
other was very much improved. In neuritis he advises the
injection directly into the inflamed nerve. He has used it
also in various skin diseases .with more or less benefit, [h.o.w.]
Treatment of Night-Sweats in Tuberculosis.— Cohen ^
uses a 10% solution of formalin soap. For children a 6% solu-
tion is used. The whole body is rubbed well with this soap for
one minute every evening and then dried with a towel. Irrita-
tion of the conjunctiva appeared only once. Out of 12 patients, 7
experienced absolute relief, 4 were improved and 1 failed to get
better, [w.e.r.]
Treatment of Fissures of the Hands.— Steflfen ^ recom-
mends the following ointment in the treatment of fissures of
the hands :
Menthol 22 grains
Salol 30 grains
Olive oil 30 drops
Lanolin 2 ounces
To be applied twice a day. The pain ceases rapidly, the
skin becomes soft, and the fissures disappear promptly, [l.f.a.]
Hydrotherapy in Phthisis.— B. Buxbaum* would sum-
marize the plan of treatment by hydriatric measures to be pur-
sued in an average case of pulmonary tuberculosis as follows:
In the morning immediately upon getting out of bed, a cold
rub— 10° to 12° C. (50° to 53.6° F.)— or a partial ablution with
water of the same temperature is practised. In the case of
febrile, bedridden patients, this should be followed by the
application of a crossbinder in which, in the course of the morn-
ing, the precordial coil is introduced for from half an hour to
an hour. A febrile patient should lie down for the necessary
period of time in the course of the morning, for the purpose of
applying the precordial coil. In the afternoon the application
of the precordial coil should be repeated, and on its removal, a
very cold shower-bath— 10° to 12° C. (50° to 53.6° F.)— of a quar-
ter of a minute's duration be taken. Before going to bed a
partial ablution or a cold rub should be given as in the morn-
ing, and this should be followed by the application of a cross-
binder. Individual symptoms should be treated in accordance
with general principles.
The Effect of Acid Mouth- washes on the Teeth.—
> Therap. Monats , April, 1902, Vol. xvl, p. 179.
■ Deutsche med. Woch., 1901, No. 43.
3 Bulletin G6n6ral de Thfirapeutlque, Vol.cxllll, No. 10, 1902, page 400.
< Cohen's System of Physiologic Therapeutics, Vol. Ix.
NOVEUBBB 8, 1902]
THE WORLD'S LATEST LITERATURE
(Ambbioan Medicinb 757
Ellison ' has recorded an interestinj; series of experiments on
the effect of certain antiseptic mouth-washes on the teeth
which contained as their bases either salicylic or benzoic acid.
Under the conditions of the experiments there was loss of
weight with these washes of from 10% to 30%, owing to the acid
rendering the lime salts of the teeth soluble. He recommends
as harmless a proprietary wash called odol, which has salol
for its active basis (and slowly liberates carbolic and salicylic
acids), [h.c.w.]
Incompatibilities of Antipyrin.^— The following incom-
patibilities of antipyrin should be borne in mind: (1) Sub-
stances which contain nitric acid, such as amyl nitrite, ethyl
nitrite, etc., produce a green color with antipyrin-iso-nitro-anti-
pyrin ; since this substance or its products of decomposition
are toxic, it is necessary to avoid mixtures of antipyrin and
substances containing nitric acid; (2) antipyrin with mercury
bichlorid gives rise to a very toxic substance; (3) solutions of
antipyrin are precipitated by carbolic acid ; (4) antipyrin and
sodium salicylate when powdered and mixed result in a sticky,
semiliquid mass; (5) afttipyrin and chloral when mixed form
an oily liquid, which has not the properties of its components ;
(6) the mixture of antipyrin and B-naphtol gives a product
which quickly liquefies; (7) solutions of antipyrin are precipi-
tated by tannin ; (8) antipyrin raises the coefficient of solubility
of caffein and the salts of quinin. [L.f.A.]
Concerninjc the Use of Digitalis In Heart Disease.—
Einhorn ' reviews the work of other clinicians regarding the
use of digitalis in heart disease and then, before pointing
out definitely the indications for its use, asks and answers two
questions: 1. What are the beginning signs of a disturbance of
compensation, or better still, of a commencing weakness of the
cardiac muscle? 2. Is digitalis to be given at the beginning of
cardiac weakness or only after it has existed some time? A
diagnosis of beginning cardiac weakness may be based upon
abnormal increase in the size of the chambers of the heart, as
noted by percussion, upon signs of blood stasis, upon changes
in the pulse (its number, rapidity, rhythm and volume), upon
lowering of blood-pressure and diminution of quantity of
urine. In regard to the second question he recommends the
use of digitalis at the very onset of failing compensation (the
first change in pulse or respiration is the signal for him). It
acts best in the healthy heart enlarged from overwork, worst
in the fatty heart, as this has no muscular strength left. Acute
valvular endotarditis he considers a contraindication, as the
heart requires rest in every way. He discusses the different
preparations of the drug, and regarding dosage he recommends
the study of each case concerning individuality toward different
preparations at different stages of the disease. It should be
given so long and in such doses as is necessary to produce the
desired result, which is when the pulse is full and regular and
the number normal over quite a long time. If small doses are
used, the system will accustom itself to the drug, no cumulative
action nor toxic symptoms will be seen ; it acts as a heart tonic
and as such it can be used over long periods in old age. [e.i,.]
Treatment of Dysentery.— H. A. Hare ' advises that the
diet in dysentery should consist of easily digestible and absorb-
able foods. Milk is not always useful because of the large
curds sometimes formed which, on account of the feebleness of
digestion, afford an excellent medium for the growth of micro-
organisms. If milk is employed it should be freely diluted or
even peptfmized, and given in small quantities. Semisolid foods
like milk-toast, especially when partially predigested by means
of pancreatin, are often valuable. There are three methods of
treatment: The ipecac plan, the purgative, and by the use of
intestinal antiseptics. Ipecac is used on purely empiric
grounds, the only explanation of its mode of action being based
on the increased flow of bile which it rau.ses. The method is to
give a full emetic dose, and after vomiting has occurred small
doses of 3 grains every hour until the tarry stool is passed,
vomiting being controlled by the use of opium. In the evacu-
ant treatment the bowels are first freely moved by magnesium
sulfate or other salts, and then aromatic sulfuric acid is given
1 Treatment, Aiijjiist, um. vl, 409.
■ Iji Kcvue MMlcjile dii Canada. July ?, 1902, p. II.
3 Volkraaiin'ii Hummlung kiln. Vortrftee, 19UI, 312.
< Tbeiapeutlc Gazette, April, 1902, Vol. xxvl, p. 229.
freely. The beneficial influence of the acid depends not only
upon its astringent influence but upon the fact that intestinal
bacteria do not flourish in the acid medium. The result of the
plan of treatment by intestinal antiseptics, such as bismuth,
salol, etc., has failed to justify the theoretic conclusions. One
of the most important measures in the treatment of dysentery
is the local treatment, which should be given in the form of
large clysters. In these there niay be dissolved either zinc
sulfocarbolate in the dose of 20 grains to the pint, or silver
nitrate in the same amount. The injection should, be given
with a fountain syringe, and very slowly, so as not to cause a
spasm of the bowel. Hare recommends the avoidance of luke-
warm solutions, which do not have the stimulant effect of very
hot or very cold applications. When the dysentery is due to
the Shiga bacillus the use of antitoxin promises excellent
results. In cases of amebic dysentery injections of quinin in
the strength of 1 to 5,000 have been highly recommended.
[H.C.W.]
Hydrogen Dioxld in the Treatment of Diphtheria.—
N. Novikov' states that the use of hydrogen dioxld, to the
exclusion of all other medication, in the treatment of diph-
theria, gives results equally as encouraging as serum therapy
in regard to the number of cures. The false membrane is
detached more slowly than by injections of antidiphtheric
serum, but the depressant action of the diphtheric toxin is neu-
tralized to a certain extent by the hydrogen dioxld, which
favors oxidation. The author directs that the patient gargle
the throat night and morning with 2 or 3 tablespoonfuls of a
Sfo solution of hydrogen dioxid to a glass of water. In very
young children who cannot gargle he prescribes hydrogen,
internally, as follows :
Solution hydrogen dioxid 1 to 2 drams
Simple syrup 4 drams
Distilled water 3 ounces
One teaspoonful or 1 dessertspoonful every 1 or 2 hours.
In order to hasten the detachment of the false membrane, the
throat may be painted with a 3% solution of hydrogen dioxid
2 or 3 times daily. These applications, although painless, must
not be repeated too often, as they may cause edema of the soft
palate. Hydrogen dioxid gargles also give excellent results
in nondiphtheric sore throat and in various forms of stomatitis,
especially when of mercurial origin, [l.f.a.] [At the present
day it is inexcusable' to omit antitoxin in the management of
diphtheria, s.s.c]
Treatment of Alopecia by liactic Acid.— Stejanovitch »
reports that Balzer employs an antiseptic solution in preference
to epilation to stop the progress of alopecia. The hair is out
close and the scalp lathered and washed every day with
Mercury bichlorid 3 grains
Acetic acid 15 drops
Alcohol, 90% 3 ounces
IpWt of lavender }''^^^^ ^ »'"»«««
To reestablish the functions of the hair follicles and the
atrophied papillas, the following stimulating lotions maybe
used:
Ammoniac 75 grains
Spirit of turpentine 6 drams
Camphorated alcohol 4 ounces
or,
Acetic acid 15 to 75 drops
ChloraL 75 grains
Ether 6 drams
Jacquet irritates the hairy scalp with a stiff brush. Finsen
concentrates the chemic light-rays on the diseased area with
good results. Ualzer employs a 50% aqueous solution of lactlo
acid, which is applied by means of a tampon of absorbent
cotton. Friction is employed until the skin is reddened. If
too mucli irritation is caused the application should be stopped.
The aqueous solution of lactic acid may be replaced by the fol-
lowing :
Lactic acid 2 drams
Alcohol, 90% 1 ounce
An antiseptic solution should be employed at the same time.
Excellent results have followed this treatment, [l.k.a.]
< I>a Hemutne Mfidlcale, Juno 2.5, 1902.
3 Bulletin Qdndral de Thempeutlque, Vol cxilll, No.lS, 1902, p. 689.
758 Ambkican MediciniC
THE PUBLIC SERVICE
[NOVKHBES 8, 1902
FORMUIiAS, ORIGINAL! AND SELiEOTED.
For Acne. —
Zinc sulfate ]
Potassium sulfate > of each 1 to 2 drams
Precipitated sulfur J
Bose water, enough to make 4 ounces
For external use. — Lusk, the Post-Oraduate. [h.c.w.]
THE PUBLIC SERVICE
Health Reports.— The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, during
the week ended November 1, 1902:
Smallpox— United States.
California ;
Illinois;
Indiana :
Maine :
Massachusetts :
New Hampshire :
New York :
Ohio:
Pennsylvania;
Utah;
Wisconsin :
Barbados :
Canada ;
Ecuador ;
France :
Gibraltar :
Great Britain :
San Francisco Oct. 12-19 .
Chicago Oct. 18-25 7
.South Bend Oct. 18-25 1
Biddeford Oct. 18-25 2
Cambridge Oct. 18-25 2
Maiden Oct. 18-25 1
Marlboro Oct. 18-25 1
Manchester Oct. 18-25 i
Nashua Oct. 18-25 18
New York Oct. 18-25 3
Cincinnati Oct. 18-21 4
Cleveland Oct. 18-25 21
Youngstown Oct. 18-25 4
Erie Oct. 18-25 7
.Johnstown Oct. 18-25 6
McKeesport Oct. 18-25 7
Pittsburg Oct. 18-2i 43
Salt Lake City Oct. 18-25 6
Milwaukee Oct. 18-25 22
Smallpox— FOREiON .
Cases Deaths
Quebec Oct. 11-18 .
Guayaquil Oct. 4-11 ..
Rheims Oct 5-12.,
Oct. 6-12..
Bristol Oct. 4-11 ..
..Sept.28-Oct. 13.... 290 It
India :
Italy:
Russia ;
Colombia :
Costa Rica ;
Ecuador :
Mexico ;
China :
Egypt:
India ;
California ;
Hawaii:
1
1
1
Edinburgh Sept. 27-Oct. 4 2
'■ ■ „ . - g
2
1
Liverpool Oct. 4-11 .
London Oct. 4-11
Manchester Sept. 27-Oct. 4...
Bombay Sept. 23-30
Madras Sept. 13-19
Naples Oct. 6-13
Palei-mo Sept. 27-Oct. 11 .
Moscow Sept. 27-Oct. 4..
4
9
1
St. Petersburg Sept.'27-Oct. 4 5
Yellow Fever.
Panama Oct. 13-20 7
Port Limon Oct. 16-23 1
Guayaquil Oct. 4-U
Mexico Oct. 12-19
Tuxpam Oct. 14-21
Vera Cruz Oct. 18-25 10
India ;
Cholera.
New Chwang Aug. 31-Sept. 13.. 68
Oct. 12-18 705
Alexandria Sept. 27-Oct. 4 129
Bombay Sept. 23-30
Calcutta Sept. 20-27
Madras Sept. 13-19
Plague— United States.
San Francisco Oct. 11-16 2
Pla e HE— Insular.
Honolulu Oct. 16
Plague— Foreign.
Bombay Sept. 23-30..
Calcutta Sept. 20-27..
Karachi Sept. 21-28..
120
1
11
1
21
76
15
18
Changes in the Medical Corps of the U. S. Army for
the week ended November 1, 1902:
Clayton, First Lieutenant Jere B., assistant surgeon, is assigned to
Vancouver Barracks for station.
Eraser, Major Simon J., surgeon, U. S. Volunteers, now at the Pre-
sidio, will proceed to Fort Bayard to report at the U. S. General
Hospital at that post for treatment as a patient.
Woodbury, First Lieutenant Frank T., assistant surgeon, is granted
leave for ten days. x m
De Loffre, First Lieutenant Samuel M., assistant surgeon, recently
appointed, now in Washington, D. C, will report November 6 at
the Army Medical Museum Building for the course of instruction
prescribed by paragraphs 542 and .543, A. R., 19C1.
Davis, Major William B., surgeon. Is granted leave for three months,
to take effect upon his being relieved from duty at Fort Myer.
CORBUSIEB, Harold D., contract surgeon, is relieved from duty in the
division of the Philippines, and upon the expiration of his present
leave will report at Fort Columbus for temporary duty.
Walter, Emil, hospital steward, Fort Myer, will be sent to Manila,
P. I., for assignment to duty.
Temple, Harry P., hospital steward. Fort McDowell, will be sent to
Vancouver Barracks to relieve Hospital Steward Joseph Meisel.
Steward Meisel will be sent to Manila, P. I., for assignment to duty.
BoBERL, John, hospital steward. Fort McDowell, will be sent to Fort
Grant to relieve Hospital Steward Lewis J. Schmidt. Steward
Schmidt will be .sent to Manila, P. I., for assignment to duty.
Kemp, Jambs F., contract surgeon, is granted leave for one month.
Usher, First Lieutenant Francis M. C, assistant surgeon, now on
temporary duty at the Army General Hospital, Presidio, Is assigned
to duty at that hospital
Parke, Joseph R., contract surgeon, will proceed to his home, Phila^
deiphia. Pa., forannulment of contract.
JuENEMANN, Gkorge F., coutract surgeon, Is granted leave for one
month, and will proceed to his home, Washington, D. C, for annul-
ment of contract.
Belt, Horatio P., and .Iames F. Kemp, contract surgeons, will pro-
ceed to their homes. New Orleans, La., and Washington, D. C,
respectively, for annulment of contract.
Mabry, W. C, contract surgeon, will proceed to the discharge camp,
Angel Island, Cal., for temporary duty.
Wilson, Roy A., contract surgeon, will proceed to the Presidio for
temporary duty.
Williams, First Lieutenant Allie W., assistant surgeon, leave
granted for seven days October 3 is extended twenty-three days.
Anderson, Robert H., contract surgeon, leave granted for twenty
days is extended seven days.
Gardner, Major Edwin F., surgeon, is granted leave for fifteen days
from about October 27.
SOUTHALL, Captain Edward A., assistant surgeon, V. S. Volunteers,
Is honorably discharged, to take elTect November 6, his services
being no longer required. He will proceed to his home.
Rhoads, First Lieutenant Thomas L., assistant surgeon, leave granted
September 11 is extended one month.
Gbmmill, Harry C, contract surgeon, will proceed to his home
Logansport, Ind , for annulment of contract.
Porter, L. B., contract surgeon, is granted leave for one month, with
permission to apply to the adjutant-general of the Army for an
extension of one month.
Usher, First Lieutenant K. M. C, assistant surgeon, is granted leave
for one month.
Stewart, W. J. S., contract surgeon, is assigned to duty as transport
surgeon of the Army transport Logan.
Graner, Carl, hospital steward, division of the Philippines, Is
relieved from further duly in that division and will be sent to San
Francisco, Cal.
Changes in the Public Health and Marine-Hospital
Service for the week ended October 30, 1902 :
Geddings, H. D., assistant surgeon-general, detailed to represent the
service at the meeting of the Association of State and Provincial
Health Officers at New Haven, Conn., October 28-29, 1SX)2— October
2.5, 1902.
McIntosh. W. p., surgeon, granted leave of absence for fifteen days
from November 1— October 27, 1902.
Anderson, J. F., assistant surgeon, detailed as assistant i^irector of the
Hygienic Laboratory— October 21, 1902.
Heiser, V. G., assistant surgeon, to proceed to Washington, D. C, for
duty— October 29, 1902.
Ramus, Carl, assistant surgeon, granted fifteen days' extension of
leave of absence from October 25— October 29, 1902.
McLaughlin, A. J., assistant surgeon, relieved from duty in the
Hygienic Laboratory and directed to proceed to New York, N. Y.
(Stapleton), and report to medical officer in command for duty and
assignment to quarters— October 26, 1902.
Alexander, E., acting assistant surgeon, granted leave of absence for
five days from November 1— October 3 J, 1902.
Ford, C. B., acting assistant surgeon, granted leave of absence for
fll'teen days from October 18, 190i, on account of sickness-October
i9, 1902.
Hargrave, E. T., acting assistant surgeon, granted leave of absence
for thirty days from October 12— October 29, 1902.
Changes in the Medical Corps of the U. S. Navy for
the week ended November 1, 1902 :
Grove, W. B., passed assistant surgeon, detached from the San
Francisco and ordered to the Prairie, for duty with the marine
battalion aboard that vessel— October 25,
Stuart, A., assistant surgeon, ordered to duty at the Naval Hospital,
Navy Yard, New Y'ork, N. Y'.— October 25.
Rodman, S. S., assistant surgeon, detached from the Alert, and when
discharged from treatment at the Naval Hospital, Mare Island,
Cal., ordered home and granted sick leave for two months-October
26.
Gordon, F. T., pharmacist, detached from the Wabash and ordered to
the Naval Hospital, Boston, Mass., for treatment— October 26.
Ames, H. E., surgeon, ordered to the Texas - October 30.
Page, J. E., passed assistant surgeon, detached from recruiting duty
and ordered to the Newark— October 30.
Balch, a. W., assistant surgeon, detached from the Monongahela and
ordered to the Machias— October 30
Dk Lancy, C. H., assistant surgeon detached from the Buffalo and
ordered to recruiting duty with Ensign D. C. Hanrahan, at Knox-
vllle, Tenn.— October 30.
American Medicine
GEORGE M. GOULD, Editor
G. C. C. HOWARD, Managing Editor
CHARLES S. DOLLEY
MARTIN B. TINKER, Assiatant Editors
dinical Medicine
David Riesman
A. O. J. KKLIiY
J. Edwin Sweet
Helen Mpkphy
Oeneral Surgery
Maktin B. Tinker
A. B. Craiq
Charles A. Orr
Orthopedic Surgery
H. Atjgitstus Wilson
COLLABORATORS
Obstetrics and Gynecology
WiLMER KRUSEN
Frank C. Hammond
Nervous and Mental Diseases
J. K. Mitchell
F. Savary Pearce
Treatment
Solomon Solis Cohen
H. C. Wood, Jr.
L. F. Appleman
Derynatology
M. B. Hartzell
Laryngology, Bte.
D. Braden Ktlk
Ophthalmology
Walter L. Pylb
Pathology
R. M. Pearce
Pdbluhbd Wbbrlv *t 1321 Walnttt Strbbt, Philadblphia, by thb Ambkican-Mbdictmb P[;blibhim« Compabv
Vol. IV, No. 20.
NOVEMBER 15, 1902.
^5.00 Yeakly.
" There is no law against credulity," said Coro-
ner Dugan, of Philadelphia, at an inquest recently held
in Philadelphia to determine the cause of death of a
patient of a lung-cure establishment. "It is not the
business of the coroner's office," he added, " to prevent
people making fools of themselves." One witness
of many testified thus: "'You don't skin us,' they
said. ' You come up with the money, and you'll get
advice.' So they got my money and my wife got
worse." " I managed to get the $46 they wanted in
advance," said another, "and they said the medicine
cost $9 an ounce in Germany." "Those in charge of
the institute could not be held, as the physicians were
duly authorized by law to practise." There is no law
against credulity, but there are methods whereby an
organized profession, if we had it, and an attorney of
an organized profession, could stop the obtaining of
money under false pretences. Organize!
What is " a Man of Science ? " — No one could be
more emphatic than we are as to worth of "pure
science" and the need of encouraging it, but there can
be extremes in all things. We notice with profound
regret a tendency in many places to aid what is called
this "pure science," and to limit the word "science"
to theoretic and experimental studies and to call all
practical applications of science by some other name.
This comes out in the notice of the editor of Soience, who
writes as follows :
"At the request of the executive committee of tixe Carnegie
Institution lam compiling a biographic index of the men of
science of the United States. It is intended in the first instance
for the use of the institution, but it will probably also be pub-
lished. The index should include all those who have carried
on research in science, the terra, however, being used in its nar-
rower sense so as not to include on the one hand philology, his-
tory, economics, etc., nor on the other hand medicine, engineer-
ing, education, etc., except in so far as these applied sciences
may contribute to pure science."
We are not in the least criticising the trustees of the
Carnegie Institution, who probably have just and special
reasons for compiling any sort of a list of names they
desire. But wo do protest against any bias of thought
or of opinion which would exclude from a national list
of .scientific men those whose subjects are philology,
economics, history, education, engineering and medi-
cine. If when published the volume bears a title that
clearly expresses the fact that such a list is a limited and
special one, that it is a list in its narrow sense, then no
objection can be raised. The trutli is that practical
America should not budge a jot from the true stand of
denial of the doctrine that science is science only when
it is " pure " or theoretic. Knowledge for its own sake
is a glorious pursuit, but there are other kinds of knowl-
edge as honorable and praiseworthy and as deserving the
name. The reduction of the deathrato that saves mul-
titudes of lives is as much " science " and absolutely as
noble an aim as the knowledge of the construction and
evolution of nebulas billions of billions miles away.
Alcoholism and the Post Exchange. — The report
of the Surgeon-General of the U. S. Army gives no
encouragement to those who have abolished the post
exchange ; 2,018 cases of alcoholism are reported. In
the department of the Columbia " the liabits of the men
are not up to the standard which existed prior to 1898,
nor to what they were under the old status of the post
exchange." "Intemperance generally is somewhat
more common than before the post exchange was
abolished." In the Philippines, the native drink,
"vino," causes little drunkenness among the natives,
but among the .soldiers, " those who drink ' vino ' at all
become slaves to the habit."
"Since American occupation, a numl)er of mixtures made
from this impure alcohol have been manufactured with the
various essences of brandy, whisky, rum, gin, etc., in numer-
ous establishments, many being made actually while you wait.
That these liquors are injurious, both from a physical and
mental standpoint, needs no further proof. Vino causes a
maniacal acute alcoholism, in which any crime may be com-
mitted, and after recovery from a debauch, depression is greater
than from ethylic alcohol. Repeated overindulgence may act
as an exciting cause of insanity in those with a proper predis-
position. Melancholia is more common than mania. Prac-
tically all habitues become perverted, entering into that state
so often seen in morphin fiends of loss of responsibility and
inability to distinguish between right and wrong."
The venereally-diseased is not worth his keep
— so says the Chief Surgeon of the IJ. S. Army of the
Division of the Philippines. These are his words in the
report of the Surgeon-General of the Army :
"The bimonthly physical examination has limited spread
of venereal affections and its continuance should be enforced.
Regulation of prostitution has beeu'takeii from tlio hands of the
760 Amekican Medicink
EDITORlAJj COMMENT
f November 15, 1902
army by the establishment ol civil government. While the
segregation of syphilis is more necessary than the segregation
of lepers, familiarity with the former disease has so much min-
imized the fear of It in the public mind and in America distaste
to recognize the existence of the prostitute is so great that little
will probably be effected. Any fine or decrease of pay in a
soldier suffering from venereal disease is to be deprecated as
leading to concealment of such disease, which is most undesir-
able. If a soldier contracts syphilis the question becomes much
more difflcult than if he suffers from other venereal disease.
The long period required for cure, danger to his companions
and their fear of him, and not infrequent difficulties in the way
of treatment necessitated by a soldier's duties, making it doubt-
ful if it is worth while to retain him in the service. In fact,
such a man seldom gives value received for the money the gov-
ernment spends on him, and it would be better after treatment
of the earlier lesions, but without return from the hospital to
his company, to discharge him for disability not in the line of
duty and give him transportation to his place of enlistment."
Then naturally arises the question that if the patient
with venereal disease does not pay expenses as a soldier
in the army, where he can be kept under discipline and
treatment, what is he worth as a business investment by
society generally ? This startling fact should arouse
reflection in the minds of those who are opposed to the
regulation of prostitution. Government is not senti-
mentalism ; it is at least a business that should pay
expenses. The syphilitic has to be charged up to profit
and loss.
The origin of syphilis, we judge, will no longer be
in dispute by those who read carefully the capital work of
Dr. I wan Bloch, entitled " Der Ursprung der Syphilis."
With the thoroughgoing scholarship and zeal of a Ger-
man Gelehrter the whole question is gone over, and not
from the standpoint of deduction and discussion, but
by the incontrovertible data of history. The proof
seems conclusive that the disease was derived from the
Indians of Hayti and by the men of the crews of
Columbus brought to Spain in 1493, where it was
at once taken to Italy by the army of Charles VIII in
1494-5, and in 1495 scattered over all Europe by the
soldiers. Bloch makes every point clear by establishing
the nonexistence of the true disease in Europe prior to
the return of the first Columbus expedition in 1493, by
demonstrating the existence of the disease among the
Haytien Indians, Aztecs, etc., even according to their
mythology, names, treatment, etc.; by the testimony of
trustworthy physicians and writers contemporary and
witnesses of the transplantation of the infection at the
time of the return of Columbus, and of the expedition
of Charles VIII, etc. , all necessary conditions were present
to carry the poison everywhere with incredible rapidity.
As to the ultimate origin of the disease among the
Indians, a note on page 197 is not to be overlooked, and
that the disease existed among them when Columbus
arrived is made evident. As to the virtue and character
of the sailors of Columbus little need be said. At his
return to San Domingo upon his third voyage there
were but 160 living of the men ' he had left, and they
were all sufliering from the disease. As to the army of
Charles and the "war" in Italy, there was scarcely a
decent man in the lot. Drunkenness and lechery vied
with lechery and crime at every stage and step of
the way. It was almost impossible under the conditions
existing in France and Italy that one of the 32,000
should escape syphilis if any one of them had it to start
with. The routes traveled by the vagabonds of the
scattered army are told by the names given the disease
in different countries. It was a French army, although
made up of renegades from all Europe, and hence in the
terms morbus guUicus, mal franzoso, etc., the French
were credited with having brought the disease with
them. Whoever was the original sinner mattered little,
except historicly ; vast hordes of abandoned women
traveled with the soldiers and met them everywhere.
The stay of the army in Naples was one frightful orgy
of lubricity, and here syphilis became epidemic. Hence
the name mal de Naples, morbus Neapolitanus, etc. The
Portuguese received the disease from Spain, and their
name for it was el mal de Jos Castellanos. The Poles got it
through Germany, and they called it the Oermxtn disease,
while the Russians, catching it from Poland, named it
the Polish disease. In the Orient, France was usually
the distributor, and hence the general term the French
disease, but as the Persians received it through Turkey,
they called it the Turkish disease. And so it went over
the whole world. In England it was first called the
Spanish Pocks {Pox or Pockes, Ger., Pocken; M. E.,
Pokke, a pustule, Tp\. pokkes), and at once, as in France,
it was differentiated from the smallpox {petite virole,
parva variola) by the term Great Pox {grosse vkrole,
magna variola).
Uncinariasis and Filth. — In illustration of what
we recently said of the connection of filthy habits and
disease, comes Dr. Ch. Wardell Stiles' report concerning
the prevalence in the South of hook-worm disease or
uncinariasis, published in Public Health Reports. The
disease is widely prevalent in Virginia, North Carolina,
and South Carolina. Dr. Stiles reports it to be the most
common disease in two counties. It is not so fatal as
the totally different European disease, which is caused
by Uncinaria duodenalis. Dr. Stiles says :
" In general, it may be said that the ' pale skin,' the ' heart
disease,' the ' diarrhea,' the ' bloat,' and the suppression of
menses, which I have thus far examined, all represented
various stages of heavy infections with Uncinaria americanai
and it is impossible to escape the conclusion that so far as the
farms and plantations are concerned, a radical change in the
general therapeutics practised in the localities in question is
urgently indicated. As for the economic side of the problem,
it should be recalled that the disease in question is resulting in
loss of wages, loss in productiveness of the farms, loss in the
school attendance of the children, extra expenses for drugs and
for physicians' services, etc. The heavy and frequent infections
found are amply explained by the almost total absence of
privies and closets on the farms visited. Defecation occurs at
almost any place within a radius of fifty meters from the house
or hut, and as a result the premises become heavily infested
with the embryos. The disease as thus far traced is primarily
a 'poor man's' malady. Indications are not entirely lacking
that much of the trouble popularly attributed to ' dlrteating,'
' resln-chewing,' and even some of the proverbial laziness of
the poorer classes ol the white population are in reality various
manifestations of uncinariasis."
We call attention in this connection to the note pub-
lished in our present issue by Dr. H. F. Harris, and
especially to his, valuable suggestion that much of what
has been held to be malarial anemia is in reality due to
ankylostoma infection.
XOVEMBER 15, 1902]
EDITORIAL (X)MMENT
Amkricak Mbdicinb 761
£ducatioii of the Public in Hygiene and Sani-
tation.— The statement which has recently appeared in
the iMTicet that preventive medicine has increased the
average lifetime of males in J^ngland from 39.91 years
in 1854 to 43.66 years in 1890, is sufficient evidence that
the continued agitation of questions of hygiene and
sanitation has not been without valuable fruits. Not
only is the average life of men four years longer than in
the middle of the last century, but these four years are
added to the most useful working part of a man's life.
By the same calculation it is stated that the average
prolongation of life in women is between five and six
years. There can be no question but that there is still a
great deal of ignorance among the people as a whole as
to the importance of sanitary measures and that we have
at present no efficient means of instructing them on
these important topics. In a recent introductory address
on the "Advance of Surgery During Thirty Years,"
delivered at the opening of the winter session at Yorlc-
shire College, Leeds, England, Mr. Mayo Robson goes
much further than to sketch the advances in surgery
during the past thirty years. In speaking of modern
operations for the cure of deformities he expresses the
belief that ' when Insanitary areas in large cities are
cleared away, when cellar dwellings are abolished and
parents are taught the correct principles of infant feed-
ing, most of these deformities will be a thing of the past
and the necessity for operation will be obviated. He
says : " In order to attain the ideal we must teach the
people that to live in a healthy neighborhood will not
keep them clear of disease unless they give up intemper-
ance, live healthier lives and pay more attention to
ventilation." It seems a curious fact that many cases
of surgical tuberculosis come from healthy resorts at the
seaside and from agricultural districts, but when we
inquire into the homas of the ftsher folk and of the
Iiea.santry and see their crowded bed rooms and living
rooms, their crude ideas with regard to the use of win-
dows and their absolute ignorance of sanitation, all
wonder ceases. Mr. Robson advises that the education
department seriously take up the subject of teaching
nurses and mothers in the future the principles of infant
feeding and management of children. Simple lessons
in domestic economy. Including plain cooking, could be
made compulsory for all girls after they have finished
their elementary school course. He believes that such
instruction would be one of the keys which would
unlock the difticult problems of intemperance and
domestic infelicity, as well as being a means of pre-
venting much disease. Such courses have been given at
several scthools in America for a number of years, and
t iiere seems to be some evidence that people are beginning
to ai)preciate the importance of such instruction. The
l)ranche8 taught in the elementary schools are already
sufficiently numerous, but it would seem that certain
subje<;ts might well be omitted and considerable pains be
taken to introduce in all public schools such courses as
Mr. Robson suggests, which would undoubtedly have a
;,'reat influence in i)romoting public health and happiness.
Institutional Ac-cuuntin;>:. V. — It is an acknowl-
edged fact that every Board of Managers and Trustees
must rely largely upon officers and employes for the
execution of their plans ; but there is a vast difference
between the results attained by a board that is run by
its employes and employes who are properly directed
and supervised by the board. The following are a few of
the general principl&s that should be observed in the
management of any institution :
1. The concentration of purchasing power in the
hands of one person who should be held strictly respon-
sible for the use made of this power, and who should be
given all necessary assistance. In a large institution it
is often necessary for the purchasing agent, who fre-
quently acts in other capacities, to delegate to others a
part of the actual work of purchasing certain supplies,
but the board should recognize no divided responsibility.
2. Goods received should be carefully compared with
a duplicate of the original order and any discrepancies
should be promptly reported. It should be insisted
upon ^hat all bills shall be rendered at least as often as
once a month, and as soon as received compai'ed with the
order, and if correct, approvetl by the purchasing agent,
from whom they should then pass to a finance or other
committee for final approval before being entered in the
books. The chairman of this committee should, if pos-
sible, be some one familiar with markets and the technic
of purchasing.
3. All payments should be made by checks signetl by
the treasurer, who should pay accounts only after they
have been approved by the chairman of the finance com-
mittee. That the treasurer should be the custodian of all
funds and the actual disbursing officer should apparently
need no discussion ; that would seem to be what a treas-
urer is for, but as the custom of turning over, in lump
sums, large amounts of money to the superintendent or
matron, to be by them paid over to creditors, is so
prevalent it would seem that quite often the treasurer is
only a dignified figurehead.
4. All money received should be promptly deposited
in bank to the credit of the corporation.
5. The bills for purchases should be charged in the
accounts under the month in which the goods were
received, without regard to the date of payment. The
same also applies to expenditures for any services
rendered. Unless this is done it is impossible to know the
cost of maintenance for any given period, as most insti-
tutions meet their indebtedneas according to the state of
their funds, rather than with any reference to the date
when the indebtedness itself was incurred ; and even
when prompt payments are the rule a considerable
portion of any given month's bills cannot be paid until
the following month.
What is known as the voucher system is practically
the only entirely satisfactory method of recording the
expenditures of an institution, this system having the
double merit of comprehensiveness, coupled with extreme
simplicity.
Herbert Spencer and Sanitary Science. — It
seems unfortunate that men who are deservedly honored
for great thinking on scientific subjects apart from mwli-
cine should sometimes without due warrant express
opinions with regard to hygiene and sanitation that are
762 AHEKICA^r Mediciotcj
EDITORIAL ECHOES
[November 15, 1902
decidedly reactionary and are calculated t» retard the
acceptance of important practical ideas in sanitary
science by even intelligent members of the community.
Mr. Alfred Russell Wallace, for instance, took occasion
to express with characteristic energy his personal
views on phrenology and vaccination in his book,
"The Wonderful Century," issued two years ago
as a tribute to scientific accomplishment in the nine-
teenth century. Mr. "Wallace considers that the two
greatest mistakes of present-day medicine, the errors for
which the present generation will be most blamed by its
successors, are the rejection of the scientific value of
phrenology and the attempt to enforce universal vaccin-
ation. It has been well said that the statements form
an excellent commentary on each other and that the
mere fact of bringing them into immediate juxtaposi-
tion is sufficient of itself to show how little attention
need be paid to the arguments advanced in support of
either of them and at the same time how little the
opinion of even a great scientist may amount to when
l>eyond his last.
At least one of the short essays in Mr. Herbert
Spencer's recent book, " Facts and Comments," exhibits
the same reactionary tendency to a marked degree.
Mr. Spencer has announced that this will be the last
book that may be expected from his pen. It seems
especially unfortunate, then, that it should contain critical
comments for which there is no excuse in the present
condition of sanitary science. In the essay on sanita-
tion in " Theory and Practice " the distinguished English
philosopher seems to assume that the main purpose of
sanitary regulations is to prevent the spread of diseases
that are necessarily connected with foul odors. He argues
at some length that people who live in the midst of
almost unbearable odors and noisome smells even from
excrementitious materials — as, for instance, those who
work in sewers — may enjoy excellent health for long
lives. He wonders why such an egregious error as the
connection of bad odor with disease could possibly have
gained general credence and suggests that the maintenance
of sanitary regulations has developed a bureaucracy
which has an interest in keeping up these delusions.
" Every organized body of men," he says, "tends to
grow and to magnify its importance." Hence, he would
have his readers assume, comes the present persuasion as
to the efficacy of sanitary regulations which are really
ineffective and serve only to make life harder and more
expensive for the poorer classes.
It is too bad to think of such drivel as this going out
under Herbert Spencer's name in the last book he is to
publish. Something should evidently be done to keep old
men from injuring their reputations in their dotage. If
there is anything that modern sanitarians are insisting on
it is that not dirt in general ; nor filth, however unpleas-
ant ; nor smells, however noisome ; are disease-producing,
l)ut specific kinds of dirt that may, to the ordinary senses,
not betray itself as dangerous at all. As to sewage
being dangerous because of its odor, it is a well-known
and oft-repeated observation that the workmen engaged
in the sewers of London and Paris and the laborers on
the sewage farms near Berlin suffer proportionally less
from contagious diseases than the rest of the city popu-
lation of the same class. The reason for this immunity
is that careful precautions are insisted on for these work-
men, the violation of which leads to dismissal. Sanitary
science thus shows that not only does it know just where
the danger lies, but also knows how to arrange prophy-
lactic measures that will minimize the risks that may
have to be encountered.
The "Purple Mother" and the Cuban Childreu.
^We have several times referred to Mrs. Tingley and
the " Universal Brotherhood." They have recently got
a little free advertising of a not very pleasant kind to
themselves by the exposure of their attempt to secure a
lot of Cuban children to "educate." The Society for
the Prevention of Cruelty to Children stopped the trans-
portation of the eleven children at New York and refused
to let the California peculiars have the little ones. The
testimony of the witnesses called is enlightening. Is
the world going crazy ? one feels inclined to ask when
overlooking this modern spawning of the wild-eyed
everywhere. What does the "Purple Mother," or as
she is familiarly called, "Purple," want to do with
Cuban children? To train them up in these follies, or
something worse? We read of " Mrs. Judge's spirit in
Purple's King Charles spaniel directing the grand
work;" of stocking-footed sunworshipers ; of members
standing in the cold barefooted, etc., and wonder what
it all means.
The Fish Doctor. — Differentiation and specializa-
tion of function, so frequently spoken of as characteristic
of civilization is illustrated in the existence of the fish
doctor. If the fish is an animal then the fish doctor
becomes a specialist of the specialty of veterinarian
medicine. At present he must combine the two offices
of surgeon and internist. He gives medicines — castor
oil, for instance— for swelling of the swimming bladder,
and nux vomica for debility and emaciation ; his surgery
is largely confined to trimming the tail when there are
fungus growths upon it, excising tumors, etc., and
"stripping " the fish to remove adherent eggs or milt.
EDITORIAL ECHOES
A Ministry of Public Health. — The developments
of recent years require, we think, that preventive medi-
cine should bulk more largely in the aggregate of the
board's work and that the president for the time being
of that board should feel that he alone is responsible to
Parliament and to the country for the health of the
people. And this brings us to a question which is now
frequently asked and which will soon be ripe for answer.
Is not a further expansion desirable ? Ought there not
to be a Ministry of Public Health ? It would seem rea-
sonable that the public health duties, which are at the
present time scattered over several government offices,
should be focussed in one department and that all mat-
ters affecting the health of the empire should, in so far
as the central health authority is concerned, be dealt
with in one department. Such an office should be the
public health and statistical bureau of tlie empire, where
uniformity in statistical methods and the nomenclature
of disease should be arranged and where the public
health material sliould be digested and turned to the
best account. — [^The Lancet.'\
NO*El[BEK 15, 1902]
AMERICAN NEWS AND NOTES
iaherican Heoioinb 763
AMERICAN NEWS AND NOTES.
OE!I>nSBAIi.
Cholera in the Philippines.— A recent report states that
the recorded total of cases aggregates 105,000 and of deaths
67,000. It is rumored that the actual number of cases exceeds
the recorded number by 20%. The disease continues to be inter-
mittent in different parts of the archipelago.
Position of Postofflce Physician to be Abolished.— Post-
master-General Payne has issued an order, to take effect Decem-
ber 1, abolishing the position of postofflce physician in all cities
of under 500,000 population. There are about one dozen cities
where such positions exist. This action is the outcome of the
fact that postinasters in many of the large cities have declared
these positions sinecures, there being no practical use for special
physicians.
Cancer Hospitals for the Destitute.— It is claimed that
there are only two institutions in all America that are devoted
exclusively to the treatment of destitute male and female
patients in the advanced stages of cancer. These institutions
were both established by a New York association known as the
Servants of Relief for Incurable Cancer. One establishment is
located in Xew York City and the other, a larger branch of the
same, is located at Sherman Park, in West Chester county,
N. Y. There are at present 30 patients under care in these
hospitals.
Serum Treatment of Scarlet Fever.— It is asserted that
Dr. fr. A. Charlton, Rockefeller fellow of pathology at the
McGill University, Quebec, has discovered a serum which will
combat the scarlet fever parasite. Dr. Charlton experimented
with the serum on patients in the Montreal Civic Hospital and
13 out of 15 patients made prompt recoveries without complica-
tions. The serum tends to the quick subsidence of the fever
and rapid convalescence. As announced in Americ<m ifedidne,
Vol. IV, >fo. U, p. 527, Dr. Moser, of Vienna, has also discovered
a serum which has repeatedly proved successful in the treatment
of scarlet fever.
Miscellaneous. — Philadelphia : The suggestion that a
tablet be erected in memory of the late Dr. Daniel E. Hughes,
for many years medical superintendent of the PhlladeTphia
Hospital, is meeting with approval in substantial form. Bal-
timore, Mn. : Dr. Harry Friedenwald has been elected to suc-
ceed his father, the late Dr. Aaron Friedenwald, as professor of
diseases of the eye and ear in the College of Physicians and
Surgeons. New York City, N. Y. : It is announced that Dr.
George Taylor Stewart, Superintendent of Bellevue and Allied
Hospitals, has resigned, to take effect January 1 or earlier, at
the convenience of the trustees. Trip to the International
Medical Conoress at Madrid in April, 1903: As a large
number of physicians throughout the country are planning to
attend the International Medical Congress to be held at
Madrid in April, 1903, special arrangements have been made as
regards terms, etc., for a party of physicians from the Eastern
States. Those desiring information should communicate with
Dr. Ramon Guit(5ras, 75 West Fifty-fifth street. New York City.
EASTERN STATES.
Smallpox Threatened.— The presence of a case of small-
pox in Hudson, Mass., has led the authorities to issue an order
that all persons employed in the mills and factories shall be
vaccinated.
Hospital for Deaconesses.- It is announced that ground
has been V)roken for the new Deaconess' Hospital which
is to be erected in Boston. The site selected for the insti-
tution is situated between Bellevue Park and Autumn streets,
in LoDgwood. The building when finished will cost about
^120,000 and will accommodate 100 patients.
Italian Hospital. — The Italians of Boston have started a
fund for the erection of a hospital, to be devoted to the care and
treatment of their people. The institution will be a memorial
to Christopher (Vjlumlnis and will be known as the f'olumbus
Hospital. It is estimated that there are over ;*),000 Italians in
Boston and over 3,0(X) Italian children born annually in Massa-
chusetts, and for these especially is the hospital needed.
NEW YORK.
The Belh Israel Hospital of New York. — The capacity
i>f this hospital has been so overtaxed that the managers have
deemed it wise to purchase adjoining property and extend the
children's department.
Medical Inspection of School Children, — According to a
report made to the Health Department, there have been l,o27,885
inspections made since the public schools opened, and as a
result 19,"15:i chihlren have been excluded attendance most of
them for short perifMls. of this number ll,3!Xi had diseases of
tlie head and t>,(it(7 hafl contagious eye diseases. The latter have
given the most trouble, hospitals and dispensaries reporting
tliat they have treated two, four and even eight times as many
children for eye trouble as in the same period last year.
Care of Epileptics.— The annual meeting of the National
Association for the Study of Epilepsy and Treatment and Care
of Kpileptics, held November 5 in New York City, was well
attended. The general interest which has been aroused in the
subject was evidenced by the large number of persons present
representing the laity. Dr. Frederick Peterson, president of
the association, presided. In his opening address Dr. Peterson
said that the number of cases of epilepsy in the United States
alone aggregated 140,000. At the present time there are 19
States which have made provisions for the care and treatment
of epileptics, and in many instances cures have been established.
In Europe also there are many homes and colonies established
for the care of these unfortunates, and the movement has even
extended into the countries of Asia and South America. In
closing Dr. Peterson made an appeal for funds by which to
enable the association to carry on its work, and also for a
greater increase in membership, notalonefrom the medical pro-
fession but from every walk in life. Dr. Edgar J. Spratling
read an interesting paper on " The Legal and Social Standing of
the Epileptic," and spoke of the work of the Craig Colony for
Epileptics. The papers read by Dr. Roswell Park, of Buffalo, and
Dr. Aoraham Jacobi, of New York City, will appear in future
issues of American Medicine. Other speakers were Dr. Adolph
Meyer, Dr. William Osier, Dr. Thomas Sprout, and Dr. Wil-
liam N. Bullard. The following officers were chosen for the
year : President, Dr. Wharton Sinkler, of Philadelphia ; vice-
president. Dr. William Osier, of Baltimore; treasurer. Dr.
William P. Spratling.
Reunion in the New York Profession. — The following is
the text of the resolutions adopted by the Council and Fellows
of the New York State Medical Association at the annual meet-
ing, October 20:
Resolved, That the report of the committee appolntol to confer
with a committee representing the Medical Society of the State of
New York for the purpose of devising a plan for the union of the New
York State Medical Association and the Medical Society of the State of
New York Is hereby approved.
Resolved, That the plan presented at the joint session of the two
committees by the committee representing this Association, whereby
the New York State Medical Association and the Medical Society of
the State of New York be reconstituted by an act of the I.,eglslature
into a State medical body to be known as the Medical Society of the
State of New York, of which all members In good standing in both
bodies shall l>e charter members, and the reconstituted Sttite medical
body shall be the representative in this State of the AmerU-an Medical
Association by virtue of Its accefitanee of the constitution and by-laws
of the American Medical Association, Is hereby accepted by the New
York State Mediciil Association as an expression of our sincere desire
for a union of the medical profession in this State.
Resolved, That the committee is hereby continued for the purpose
of cooperating with any committee from the Medical Society of^ the
State of New York to secure a charter from the IjCgislature at Its next
session in 1903, which charter shall reconstitute the two State organiza-
tions into one State body, as set forth In the preceding resolution, but
if the Medical Society of the State of New York shall rail to approve of
such plan of union by a charter to be secured at the approaching
session of the Ijeglslature In 1«03, then this committee shall be con-
sidered as discharged, and the proposition of this Association with-
drawn.
Resolved, In case this committee should find occasion to apply to
the Legislature at Its next session for the purpose of securing the said
charter, it shall cooperate with the standing Committee on Leglslar
tlon of this Association.
PHUiADEIiPHIA. PENNSYLiVANIA, ETC.
Typhoid Fever in Philadelphia. — It is reported that
there are more than 500 cases under treatment in this city at
the present time.
State Hospital for Epileptics. — At a meeting of the Penn-
sylvania State Convention of the Directors of the Poor, held
recently at Somerset, it was recommended that Highland Inn
and 100 acres of ground be purcha.sed for the purpose of estab-
lishing a .State Hospital for Epileptics.
Hospital Staff of Mercy -Hospital Resiens. — Because
they considered themselves unjustly treated by the officials of
the hospital the staff physicians employed at the Mercy Hos-
pital of Pittsburg have resigned in a body. The consulting
physicians were summoned and it is announced that a new
staff will be appointed.
Hainot Hospital, of Erie. — Extensive improvements and
additions liavo been made to the institution, which was for-
mally reopened October 16. A complete working clinical lab-
oratory, a home for nurses, and a complete suite of operating-
rooms are among the most Important additions. A complete
system of electric bells and house telephones have been Installed
throughout the hospital and nurses' home. The storilizing-
room has also been thoroughly equipped with a modern and
complete sterilizing plant.
The Franklin County (Pa.) Medical Societ/.- At the
seventy-seventh annual and quarterly meeting, held in Cbam-
bersburg. Pa., October 14, the following officers were elected for
the year 1903: President, Dr. A. Barr Snively, of Waynesboro;
vice-presidents, Drs. J. Burns Amberson, of Waynesboro, and
Oliver P. Stoey, of Roxbury ; recording secretary. Dr. .Tohn J.
Coffman, of Scotland; corresponding secretary. Dr. H. Clay
Devilbiss, of Chambersburg; treasurer. Dr. David Maclay, of
Chambersburg; censor. Dr. Theodore H. Weagley, of Marion.
764 AWKBIOAN MeDICINBJ
FOREIGN NEWS AND NOTES
fNOVEMBEK 15,*1902
SOUTHERN STATES.
Trl-State Medical Associatian. — The next regular meet-
ing will be held in Cuinberland, Md., December 4. The presi-
dent for this year is Dr. W. O. Skilling, of Lonaconing, Md.
Few Smallpox Cases In Maryland.— It is announced that
there are only four cases of the disease in the State at the present
time. Three of these are on KUiott's Island. Dor.^hester county,
and have broken out within the past week. The fourth is in
Cumberland.
Negro Cocain Fiends.— Curious as it may seem, the cocain
habit has fastened itself upon the plantation negroes of some
f)arts of the South. It appears that the habit was first estab-
ished among the roustabouts of New Orleans, who found that
it gave them temporarily increased strength to perform their
arduous labor. From them the habit has spread to the planta-
tion negroes and is leading to serious consequences, a number
of the victims becoming Insane.
Annnal Mortality of Washington.— According to the
annual report, which has just been issued, the total number of
deaths for the past year was 5,947, a rate of 20.75 for the entire
population. Of these 3,259 occurred among the white popula-
tion, and 2,688 among the colored. In only one year during the
past decade has the mortality f roui typhoid fever been exceeded,
the number of deaths (206) being not only '£i larger than for
the preceding year, but also considerably above the average
number. Malarial fever in a fatal form was less prevalent
during the year than for any other recent period. Inflamma-
tion of the kidneys and Bright's disease were responsible for
346 deaths, this being the largest recent mortality from these
causes. A large increase is shown in deaths from diabetes and
from malignant tumors. Diphtheria and scarlet fever aie
reported to have been less prevalent than for some years.
The Postgraduate School for the Instruction of Medi-
cal Officers was formally opened in Washington on November
4. The school is open for an advanced course for assistant sur-
geons on entering the navy as well as for other officers who may
have the opportunity of attending the lectures. It begins with
a class of 12 assistant surgeons recently appointed. The course
of instruction will cover a period of five months, and will con-
sist principally of clinics at the different hospitals of the city
and of practical laboratory work. One or two didactic lectures
will also be given daily upon such branches as preventive
medicine, military medicine and surgery, preventive inocula-
tions, serumtherapy, etc. General George M. Sternberg has
been elected president of the faculty, and the Surgeon-Gen-
erals of the Army, Navy, Public Health and Marine-Hospital
Service are members of the Executive Committee. The special
attention given to preventive medicine and to laboratory work
in bacteriology and sanitary chemistry will afford public health
officers unusual advantages for perfecting themselves in the
scientific studies which must serve as a foundation for their
practical work.
WESTERN STATES.
Proposed Clinical Hospital for the University of Cali-
fornia.— In a report submitted by a committee representing all
interested factors in the university administration it was pro-
posed to add to the university's equipment a clinical hospital
that will cost ?400,000.
Illinois Western Hospital for the Insane. — Trustees of
the institution will petition the next session of Legislature for
appropriations aggregating $450,000. Of this sum $250,000 will
be used to erect a new ward building. The balance is to be
used to meet the running expenses and for some needed altera-
tions.
Knifeblade Removed From Man's Brain. — It is reported
that a Chicago man has undergone a successful operation for the
removal of a knifeblade IJ inches long, which he had carried in
his brain for 22 years. The blade had broken off in the skull
and during those years the point had been inserted in the brain.
The patient had sutTered from frequent epileptic seizures from
which, it is believed, he will entirely recover.
Judgment Secured for Medical Services Rendered to
Charity Patient.— Dr. Sidney Kuh has secured a judgment
for 820 for medical services rendered to a charity patient of the
free clinic and hospital of the Postgraduate Medical School,
Chicago. The patient was admitted to the institution in March,
suffermg from a nervous disorder which made her blind. Dr.
Kuh discovered she had means, and therefore claimed that it
was only right that she should pay a reasonable fee.
Proposed Union of the Rush Medical College and
University of Chicago.— It has been announced that the trus-
tees of the University of Chicago have agreed to receive the
Rush Medical School as an organic part of the university, pro-
vided that the trustees of the medical college succeed in raising
$1,000,000 by July 1, 1903. It is believed the sum required can
be obtained in the time specified. It will be used for the erec-
tion of new buildings, the endowment of chairs of instruction
and the purchase of additional equipment. The Rush Medical
College was founded in 1837, and is one of the oldest institu-
tions of learning in the West.
FOREIGN NEWS AND NOTES
OENERAIi.
An epidemic of measles on the Kamchatka peninsula is
reported to have carried off nearly the whole population of
some of the country villages. It is said that nearly 10,000 per-
sons have succumbed to the disease.
Absinthe Consumption. — Statistics show a steadily con-
tinuing increase in the consumption of absinthe in France.
Between 1885 and 1892 there was an increase of 85,000 hectoliters.
From 1892 only four more j'ears were needed to add another
85,000 liters to the consumption. What this means in the physi-
cal deterioration of the people may be inferred from recent
experiments, in which it was ascertained that six drops of
essence of absinthe in three gills of water were as deadly to fish
life as six drops of prussic acid in the same quantity of water. —
[Revue Statisque.]
To Eradicate Plague.— Everything possible is being done
to stamp out the plague in Odessa. The Governor's efforts are
being supported financially by the corporation of the city, which
has agreed to furnish .500,000 rubles (about $257,000) for increased
hospital accommodations, etc., and by the central government,
which has assigned 25,000 rubles (about $13,000) monthly to
provide medical assistance. The deaths up to date number
only 15. The outbreak is attributed to infection carried by rats.
A big colony of these vermin has been destroyed by burning a
large bazaar in the center of the town which contained dozens
of old wooden buildings.
Fourteenth International Medical Congress. — The
American Committee of the Fourteenth International Medical
Congress to be held in ISIadrid, Spain, from April 23 to 30, 1903,
announces that the following list of sections has been author-
ized: (1) Anatomy (anthropology, comparative anatomy,
embryology, descriptive anatomy, normal histology, and tera-
tology) ; (2) Physiology, Physics and Physiological Chemistry ;
(3) General Pathology, Pathological Anatomy and Bacteri-
ology; (4) Therapeutics and Pharmacy; (5) Internal Path-
ology ; (6) Ne v us Diseases, Mental Diseases and Criminal
Anthropology; (7) Pediatrics; (8) Dermatology and Syphilis;
(9) General Surgery; (10) Ophthalmology ; (11) Otology, Rhin-
ology and Laryngology; (12) Odontology and Stomatology:
(13) Obstetrics and Gynecology ; (14) Military and Naval
Medicine and Hygiene; (15) Hygiene, Epidemiology and
Technical Sanitary Science; (16) Legal Medicine and Toxi-
cology.
GREAT BRITAIN.
Increase of Insanity in London. — According to the
annual report of the asylums committee of the London County
Cjuncil the increase of insanity in London during the past
year was greater than any year since 1896. On January 1 last
th^re were 22,155 lunatics under the surveillance of the com-
mittee. A new asylum was opened in March for the accommo-
dation of 2,000 patients, and already the committee has under
consideration the necessity of proceeding with the construction
of another building in order to provide for the estimated
increase of 500 cases a year. Among the causes of insanity in
the patients admitted, hereditary predisposition is held account-
able for '27% of the cases and alcoholic intemperance for 17%.
OBITUARIES.
James C. Merrill, at Washington, D. C, October 27, aged 49. He
was graduated from the University of Pennsylvania, Philadelphia, in
1875. He was major and surgeon In the U. S. Army, and at the time of
his death was librarian of the Army Medical Museum. He Is widely
known for his contributions to ornithology.
Robert C. Kedzle, of liansing, Mleh., November 7, aged "9. He
was graduated from the medical school of the Universltj- of Michigan
in 18.51. He practised surgery for ten years In Vermontville and served
one year as surgeon In the volunteer service of the United States Army.
For the past forty years he was professor of chemistry In the Michigan
Agricultural College.
John J. M. Angear, of Chicago, November 8, aged 73. He was
graduated from the Rush Medical College, Chicago, in 1860, and at the
time of his death was professor of nei-vous and mental diseases In the
Illinois Medical College. He was ex-president of the Chicago Patho-
logical Society and e.\-president of the Commission of Insanity, Lee
county, Iowa.
Pierce Butler Wilson, at Baltimore, Md., November 3, aged 66.
He obtained his degreee in medicine from the University of Pennsyl-
vania, Philadelphia. He was widely known as a Chemist, having
devoted many years to the study of that science. For thirty-flvc years
he was city chemist and gas Inspector for Baltimore.
L,. Laroyenne, professor of gynecology In Lyons, October 15
aged 72. His principal work was on pelvic suppurations and surgery
in children. His intraperitoneal method of hysteropexy is widely
known. He was president of the International Congress of Gyne-
cology in 1900, and of various local organizations.
NovaMBKK 15, 1902]
SOCIETY REPORTS
[Amebican Mkdiciits
765
Theodore F. C. Van Allen, of Albany, N. Y., October 28, aged 41.
He was graduated from the Albany Medical College In 188S and later
became ophthalmic and aural surgeon at St. Peter's Hospital, Albany.
He was at one time president and treasurer of the Albany County
Jledical Society.
Francis F. Davis, at Oil City, Pa., October 31. He was graduated
from the medical department of the University of Michigan, Ann
Arbor, in 1867. He was a member of the American Medical Associa-
tion, International Association of Railway Surgeons, and various medi-
cal societies.
H. Eulenberg, a prominent German authority on matters of
hygiene, died recently at Bonn, aged 88. He was the founder of the
Correspondenzhlall and of the Archiv filr Psychiatric, and was also
one of the editors of the Vierteljahrsschrifl filr gericht. Med. forl8 years.
Joseph S. Rlcliinond, in Windsor, Vt., October 22, aged 74. He
was graduated from the Vermont Medical College in l&M. He was for
many years secretary of the Vermont State Medical Society, and was
also a member of the Connecticut River Medical Association.
Robert N. Tooker, of Chicago, November 9, aged 61. He was
graduated from the Bellevue Hospital Medical College, New York City,
in 186.5. He was president of the Illinois Homeopathic Medical Asso-
ciation. He was a frequent contributor to medical literature.
Jacob F. HofiTa, in Washingtonvllie, Pa., October 27, aged 50. He
was graduated from the Jefferson Medical College, Philadelphia, In
1876, and was three times a member of the Pennsylvania Legislature.
He was president of the Montour County Medical Society.
Woodford M. Vertreeg, In ISast Nashville, Tenn., October 22, aged
76. He was one of the founders of the medical department of the Uni-
versity of Tennessee and for the past twenty-flve years had been profes-
sor of materia medica in that institution.
Josepii C. Rutlierford, In Newport, Vt., October 20, aged 84. He
was graduated from the Vermont Medical College, Woodstock, In 1849,
and during the Civil war served as surgeon of the Tenth and Seven-
teen'h Vermont Infantry, U.S. V.
Jolin H. Howard, In St. Louis, Mo., October 24, aged 75. He was
graduated from the Kentucky School of Medicine, Louisville, In 1875.
He was for several years resident physician at the State Hospital for
the Insane, No. 1, Fulton, Mo.
Wilmot Ayres, of Harrisburg, Pa., November 7, aged 54. He was
graduated from the Baltimore Medical College In 188;^. Buring the
Spanish-American war he was a surgeon at Camp Meade.
Asa B. Gardner, at BellviUe, Te.\as, October 22, aged .50. He was
graduated from the University of Louisville, Ky., in 1874. He was an
ex-presldent of the Texas State Medical Association.
Benjamin F. Hoicomb, in Fostorla, Ohio, October 21, aged 67. He
was graduated from the University of Wooster, Cleveland, In 1865, and
was for many years a practitioner of Jackson, Ohio.
Charles E. Jackson, in Massillon, Ohio, October 24, aged 40. He
was a graduate of the Jefferson Medical College, Philadelphia, and a
contract surgeon of the U. S. Army.
Joseph Senay, in Salem, Mass., October 20, aged 34. He was gradu-
ated from the Harvard Medical School In 1893, and was a member of
the Massachusetts Medical Society.
Charles M. Hollingsworth, of Harrisonburg, Va., November 9, aged
about 45 years. He was graduated from the University of Maryland
School of Medicine in 1882.
Hubert Sleeper, a retired physician of Meriden, N. H., October 22.
He was graduated from the Dartmouth Medical College, Hanover,
N. H., in 1860.
K. R. Crothers, at Colora, Md., November 8, aged 58. He was
graduated from the University of Maryland School of Medicine In 1873.
Keith Fonde, of Cltronelle, Ala., at Mobile, October 10, aged 34.
He was graduated from the Medical College of Alabama in 1894.
James W. Davis, In Fayettevllle, Tenn., October 24. He Was
graduated from the University of Tennessee, Nashville, in 1888.
Samuel C. Fechtig, at Wellersburg, Md., November2, aged 80. He
was graduated from the University of Pennsylvania In 1816.
John N. Green, at l«slie, Mlch.,Octot)er 23,aged 51. He was gradu-
ated from the University of Michigan, Ann Arbor, In 1889.
Afarlon B. Carter, in Richmond, Va., October 28, aged 66. He was'
graduated from the University of Pennsylvania In 1859.
James Johnston Bell, of Chicago, November 4, aged 41. He was
graduated from the Rush Medical College In 1886.
Krastus B. Bills, of IJurant, Iowa, October 16, aged 74. He was
graduated from Yale University In 1854.
J. ,F. Appell, In Lake City, Fla., October 20. He was graduated
from Harvard Medical School In 1866.
William J. W. Pnrnell, a wellknown practitioner of Mllford
Dei., October 19, aged 78.
A. M. Tally, of Chicago, at Los Zegas, Hot Springs, N. M., Novem-
ber 5, aged 48.
Dr. McLarty, a wellknown physician of Manitoba, November 7
aged 6:i.
.M. J. Belden, In Maquoketa, Iowa, October 27, aged 70.
SOCIETY REPORTS
THE NEW YORK STATE MEDICAL ASSOCIATION.
Nineteenth Annual Meeting, October 20, 21, 22 and 23, 1902.
[Specially reported for American Medicine.^
[^Concluded from page 726.\
The Serum Reaction in Typhoid Fever.— Thos. W.
Hastings (New York) stated that Widal's reaction iu dilutions
of 1 : 30 and 1 : 50 and higher shows positive reactions iu 95% of
the cases. Occasionally cases other than typhoid produce
serums giving complete reactions with Bacillus typhosus in
dilutions of 1 : 20, rarely in dilutions of 1 : 30. Eckardt reports
positive reactions in dilutions of 1 : 100 and 1 : 1,000 in two cases
of Weil's disease. He remarks that such cases occur where
typhoid is endemic, and that the absence of Intestinal ulcera-
tions does not exclude the typhoid infection. Some of the
typhoidal infections showing repeated negative reactions (49'o
to 6%) have been explained by obtaining one of the paratyphoid
or paracolon bacilli from blood cultures. Among the tests car-
ried on during the last year in the Cornell Laboratory of
Clinical Pathology 33 cases of typhoid gave positive reactions in
dilutions of 1 : 80. One case diagnosed as typhoid gave on two
occasions partial reactions at 1 : 20. Another case, reported
negative, a case of syphilitic fever, gave a complete reaction at
1 : 20, but was repeatedly negative at 1 : 80. A case of jaundice,
with no previous historir of typhoid fever, gave negative reac-
tion at 1:20 on two occasions. One of the repeatedly negative
cases proved to be aparatyphold infection. In conclusion the
author noted: (1) The importance of using dilutions of 1:50
and higher for obtaining reactions diagnostic of typhoid infec-
tion ; (2) the similarity of results from reaction with serums of
adults and children; (3) the importance of applying sera
repeatedly negative to Bacillus typhosus to the paratyphoid
group: (4) the possible value of the granular degeneration of
the red cell in suggesting malarial infection in cases clinically
typhoid with negative Widal reaction.
The Advantages of Nitrous 0.vi<l in General Surgery. —
H. W. Carter (New York), in presenting this paper, exhib-
ited a stopcock of ingenious construction by which the operator
could with facility regulate the exact amount of oxygen he
wanted. He gave a full description of the stopcock and pro-
duced many arguments in favor of using nitrous oxid.
SuKgestions Favoring a Standard Technic in Opera-
tive Surgery. — Edward Wallace Lee (New York) con-
tended tliat the constant change from one theory to another had
a demoralizing effect, not only on the profession but on the
laity. He advocated the establishment of a standard technic.
It was not a question of who is right and who is wrong, but
what is right and what is wrong. He deprecated the one pro-
fessor demolishing before his ola.ss the methods of another and
holding them up to ridicule. The student was too prone to
seek out some new method for himself. They should all be-
more content to follow masters and this could be done without
interfering with the spirit of progress. He suggested a congress
of authorities who should map out a standard technic, not for
the bright and shining lights of the profession, but for the
humbler brethren.
Points in the Control of Kmergency Hemorrhage,
Both Medical and Surgical.— Robert H. M. Dawbarn
(New York) said there was no use for drugs in pulmonary
hemorrhage, but referred to the use of aconite. He then gave a
description of his method of cording limbs to decrease hemor-
rhages in case of emergency. Three of the limbs should be
corded tight, as close to the trunk as possible. After half an
hour one of the limbs should be released and the fourth one
corded, and so on. Nose bleeding could be controlled very
often by the use of a hairpin, cleaning away the clotted blood
with the bend and using another hairpin to cauterize the
wound. In such cases he had often found adrenalin of great
service. In nasal tamponing he used a catheter, introducing a
double string through the nostrils, with cotton batting as the
tampon. Ordinary cotton batting was preferable to any other
substance.
Pneumonia From the Bacteriologic Standpoint.— A.
C. AiiBOTT (Philadelphia) cautioned against the u.se of pneu-
mococci serum, since there remained considerable doubt as to
its efficacy. Only a small number of experiments had been
successful.
LieukocytoBls in pneumonia, Albx. Lambert (New
York) said, appeared with the chill or shortly after, and varied
with the amount of tissue involved. Much depended on the
resistance. It was of no value for prognosis. With complica-
tions no increase in leukocytes might be sliown. To be of use
in diagnosis the record uiu.st be taken daily, not always possible
with the ordinary practitioner. He cited 87 cases of lobar
pneumonia to show variations. When the count wa.s below 7,000
usually meant a fatal prognosis, although cases as low as 5,600,
varying to a very much higher figure, had been known to
recover. It must bo noted, however, that the count did not
remain normal. In fatal cases wliere the count had been high
there had been variations.
Treatment of Pneumonia. — Joseph W. Grosvenob
(Buffalo) said that mild cases will recover without treatment;
766 AMKKIOAN MKDIOINlt)
CORKESPOXDENCE
(November 15, 1902
blood letting is inadmissible except in a very few cases. He
does not believe in aborting cases ; nature was the great thing.
The Pinsen Ray.— Francis P. Kinnicut (New York)
exhibited an instrument which he had obtained in Loudon,
where he had visited the hospitals in 1901 and 1902 and seen some
very remarkable results from the treatment with the Finseu
light. There has been some criticism of the lamp, but he con-
sidered it perfect for the treatment of lupus vulgaris. The
author Introduced a patient who had been ti"eated and received
great loenefit. He showed how the treatment was applied, the
crystal of the lamp being pressed close to the spot to be treated.
The Rontgen Ray: Its Mechanics, Physics, Physi-
ology, and Pathology.— Eden V. Dblphey (New York)
spoke of the advantages and disadvantages of different machines.
He could not say whether the x-rays produced results. Chemi-
cal changes in the tissue might be beneficial or they might be
otherwise. As for the pathologic effects opinions still differed.
The Operative Treatment of Fractures as Indicated
by the Rontgen Rays.— Carl Beck (New York) demon-
strated by a large number of skiagraphs the great field which
the Rontgen rays had opened up for surgery. He showed that
many deformities had not been properly understood up to the
present time, but now guided oy the rays they were able to
execute what formerly they would not have had the courage or
ability to carry through.
Results in Fifty Cases of Cancer Treated with the
Aid of the JRontgen Rays.- Charles Warrenne Allen
(New York) presented a tabulated statement showing 50 cases
treated during the year, the ages varying from 15 to 80 years.
His conclusions were that the x-raysjiossess therapeutic quali-
ties, that they may produce bad effects, that carcinoma may
follow the x-ray burn, it was not to be relied upon in all cases,
and that their reckless use was to be condemned.
The Rontgen Ray in Gynecology.— Eden V. Delphey
(New Y'ork) said that the ordinary practitioner who had
drifted into this special line should be thoroughly acquainted
with anatomy. Burns by too long exposure should be avoided.
One of its main uses in exploration was the discovery of tumors.
With care the x-rays should not cause pain, should not destroy
tissue. Operators should not lose faith even after 15 treat-
ments. As a rule 15 minutes' treatment was long enough.
The Rontgen Ray in Obstetrics.— Joseph B. Cook con-
cluded that there had so far been nothing achieved by the aid of
the x-rays, in obstetrics at least, which could not be carried out
by the skilful surgeon with ordinary care.
Measles and Other Diseases Among Natives of the Arc-
tic Coast.— Captain Newth, of the steamer "Jeannette," brings
the following news to San Francisco: "At least 25% of the
natives along the Arctic coast have died from measles and there
seems to be nothing to check the deathrate. The march of
civilization has increased the deathrate from Nome north. Two
years ago the devastation began, and it has continued since.
When the natives began to wear civilized man's clothing, and
drink white man's whisky, then liegan their decline. Pneu-
monia, rheumatism, influenza, and every conceivable malady
made their'appearance among them and spread along the coast
with appalling results."
Cancer in Italy. — Statistics covering the I'i years 1887 to
1899, collected by Dr. O. Kuata, show that while other diseases
tend to diminish, the prevalence of cancer is ever increasing in
Italy. During the period in question the deaths from cancer
showed an average increase of 1,681, so that the total mortality
from that cause, which in 1887 was 12,631, had in 1899 ripen to
16,680. Of these 16,680 deaths, the majority (4,613) were due to
cancer of the stomach and esophagus ; then followed next in
order the liver, spleen, pancreas, and intestine, with a total
mortality of 3,240. Cancer of the breast caused 916 deaths, the
patients in 19 of the cases being men ; cancer of the female
genitals was accountable for 2,578, of the male organs for only
213 deaths. Analysis of the figures is held to show that of all
organs the uterus is the one most liable to the disease; next
comes the stomach, then the liver. In regard to sex, of the
16,()80 persons who died, 6,980 were males, and 9,700 females. Up
to the age of 60 the mortality was, owing to tlie prevalence of
uterine and mammary cancer, greater in the female than in the
male sex. From 60 upward there was very little difference
between the two sexes. A remarkable fact brought out by
these statistics is that while the prevalence of all infectious dis-
eases is affected by the density of population, mountainous
character of the country, etc., in the case of cancer those
factors seemed to have no influence. The place which showed
the highest mortality was Ravenna with 120.4 deaths in every
100,000 of population; this is a province flat over almost the
whole of itstextenf, without large towns, and therefore without
agglomerations of people. The small province of Sondrio,
vvhioh is very mountainous and contains only small centers of
population, showed a fairly high cancer mortality (62 per 100,-
000) grea'er than that of Turin (59.7), Genoa (59), Rome (58),
and Naples (47.6), all of which comprise the largest centers
of population in Italy. On the other hand, Cheti, situated In
the heart of the Apennines, and having, like Sondrio, a moun-
tain population, has a low cancer mortality (26 per 100,000).—
[BHtish Medical Journal.}
CLINICAL NOTES AND CORRESPONDENCE
[Communications are invited for this Department. The Editor Is
not responsible for the views advanced by any contributor.)
I
A NEW PLATINUM NEEDLE-HOLDER.
BY
HANDLE C. R08ENBERGER, M.D.,
of Philadelphia.
Demonstrator of Bacteriology, Jefferson Medical
College.
Bacteriologists find many disadvantages in
the use of a glass rod, caused principally by
changes of temperature and coming in contact
with bouillon or any other medium. An
inferior grade of platinum, or the continued
use of a platinum needle, causes it to break,
and consequently much time is lost in replacing
it. While Ravenel's aluminum needle-holder
with its glass sheath is quite good it has one
serious objection, namely, the difficulty in
extricating the stump and securing the new
wire.
The holder devised by the writer is well
shown in the illustration. It consists of (a) an
aluminum rod in which there is a groove (6);
(c) a collar that slips over and secures the wire
in the groove, and (d) a hard rubber handle to
prevent burning of the fingers by the hot
aluminum rod.
The advantages are, the easy removal of
the needle, the quick introduction of a new one,
and that there is no danger of its being broken New platinum
when dropped. . f^^f Aluminum
For assistance in perfecting this instrument rod. (6) Groove.
I wish to express my thanks to Queen & Com- <^'j H^^d rubber
pany, Philadelphia, Pa. handle.
NEURASTHENIA.
BY
GEO. P. SPRAGUE, M.D.,
of Lexington, Ky.
Superintendent High Oaks Sanitarium, Lexington, Ky.
In 1869, when Beard, of New York, wrote so exhaustively of a
condition of nervous irritability to which he gave the name
" neurasthenia," so little was known of it that European physi-
cians called it the American, or " Beard's disease." It was
soon found, however, in examining medical literature that
such conditions had been noted by many others, and that even
Hippocrates had described a condition of irritable weakness ;
but it had remained for Beard to gather together from among
the multitude of symptoms the essential ones, and to recognize
in them a definite morbid state. Even yet, it is as Beard said in
the preface to his book " the most frequent, the most interest-
ing and most neglected nervous disease of modern times." We
still betray our ignorance of neurasthenia by calling it a func-
tional disease. At autopsy no pathognomonic lesions have
been found, and the present theory, based largely upon the
experiments of Hodge in producing fatigue in motor cells, is
that there is in neurasthenia a morbidly lessened recuperation
of motor cells after their use, coupled with absorption of the toxic
products which are found even after healthy function and to
which are probably added other toxins due entirely to the abnor-
mal nerve action. It is thought by some that the mechanism of
the vasomotor nerves is especially concerned— but that would not
account for the dominating mental symptoms, which depend
upon involvement of the cerebral cortex and the higher brain
centers. Berkeley says : " In the faulty organization of the
brain together with an incapacity on the part of the elements to
absorb a sufficient supply of pure pabulum, is to be sought the
origin of the train of symptoms of nervous hyperexcitability."
And Dana says : " This vasomotor disturbance is one character-
ized by a weakness of the inhibitory vasoconstrictor centers.
NOVEMBBK 15, 1902]
CORRESPONDENCE
(Amebican Medicine 4
67
As a consequence the vessels dilate and contract irregularly in
the different systems of the body. Furthermore, they do not
respond normally to the stimulus of functioning; when brain
or stomach acts it calls for a definite and well regulated supply
of blood ; in neurasthenia it does not get it, hence the mental
symptoms."
It has been shown by Foster that in mental exertion, even
without muscular work, the muscles are fatigued, and it may
yet be found that neurasthenia is primarily a disease of the
central nervous system acting upon the muscles through the
vasomotor nerves and by autointoxication.
Xeurasthenia occurs at all ages, and in both sexes, but the
largest number of cases in this country are found in women
between the ages of 20 and 50. Dana, however, in 100 consecu-
tive cases found 53 women and 47 men — 59 of these were natives
of the United States, 29 of Ireland, 12 of Germany, and 9 of all
other countries. The primary and most frequent cause of
neurasthenia is heredity : and yet, even in such cases, there is
some exciting cause, such as overwork, excessive worry, too
frequent child-bearing, unusual responsibility, sudden shock,
sexual excesses, reflex irritation, syphilis, poisoning, etc. As
remarked by Dana : " There are many persons with delicately
balanced organizations who only require some single depress-
ing or irritating agent to put them into a pathologic state." It
is generally difficult and often impossible to determine the
exact cause in a given case. There is probably no complaint
except hysteria that presents such a vast array of symptoms as
does neurastlienia, and this fact alone would suggest that it is a
symptom complex and not a disease entity. This multiplicity
of symptoms hfes resulted in many clinical forms, such as cere-
bral, spinal, genital, traumatic, acute, gastric, hysteric, etc., but
the only essential forms are the hereditary and the acquired.
The true neurasthenic may appear to be in perfect health ;
the color may be good and the weiglit well preserved, but the
hemoglobin will generally be found below normal, the red cells
not developed as well as usual, the breath stale, the appetite
fitful and the bowels constipated. There will be general mus-
cular weakness, usually somewhat worse in the legs ; a won-
derfully rapid failure in strength upon exertion, and a dull,
heavy headache, usually in the region of the occiput and
extending down into the neck. It is likened by the patient to
a heavy weight on the neck, or an Iron band or a lead cap on the
l>rain. Instead of occipital pain there may be frontal ache,
tender points along the spine, intercostal neuralgia or facial
neuralgia. There is usually severe backache upon exertion and
even without it, persistent insomnia, gastrointestinal dyspepsia,
and cardiac irritability. The special senses all seem unnatur-
ally acute, but this is probably as much due to the mental as to
the physical irritability. Hands and feet are cold most of the
time, though there may be flashes of heat similar to those
observed at the climacteric. Spots of numbness may occur on
the extremities, or an ear or finger or entire hand may suddenly
become red and swollen and tingle somewhat as experienced
by contact with an electric current. A sudden emotion or a
rapid walk may cause urticaria or a profuse localized sweating.
This completes the most common physical symptoms, although
there are various other more rare ones. The mental symptoms
are the more important, inasmuch as the physical ones depend
largely upon the mental state for their continuance, even if they
are not originally caused by it. The mind, like the muscles, is
in a constant state of irritable weakness ; the accustomed duties
become a he.ivy burden ; responsibilities are avoided, familiar
friends are shunned, letter-writing becomes almost impossible,
depression may l>e continuous, or it may be occasionally alter-
nated with a few hours of exhilaration ; violent prejudices and
preferences may be rapidly acquired upon slight foundation;
harsh noises are \inbearable, and even pleasant sounds soon be-
come distressing ; anticipation of the postman's ring, a friend's
call, or a neighbor's voice may produce agitation ; hearty
laughter may end in crying, a harsh word may cause an hys-
teric attack, as may also overexertion. The neurasthenic soon
becomes introspective, and c<)unts her pulse, takes her tempera-
ture, pays close attention to her appetite, waUihes her appear-
ance from day to day, and is persistent in relating her symptoms
to her physician, nurse or dearest friend, although the thought
of others asking about her health makes her nervous.
In the patient of normal weight and color there may be con-
stant fear that friends may consider her an impostor, or she may
wonder whether she is not simply lazy and childish to succumb
so quickly ; the memory soon becomes impaired, but beside
this, the lack of ability to concentrate the attention is mistaken
for loss of memory by the patient, who is sure she is becoming
demented, or that she will soon die, or at least will never be
able to resume her former place in life. Some persons become
constantly restless, and It is difficult to keep them from going
beyond the point of normal fatigue; they are hopeless of ever
being better, are afraid they will jump from some high plaec,
ocmmita theft, utter some profane word, or kill themselves ; or
they may have the feeling that they have touched filth, or left
the safe or private drawers unlocked, or failed to turn off the gas.
The diagnosis of neurasthenia is of the greatest importance, as
it is not a self-limited disease, and always needs early and
definite treatment; it must ever be borne in mind that neuras-
thenia is a disease of the nervous system, including the brain,
without being an insanity. If tlie symptoms are typical the
diagnosis is usually easy ; the emotional weakness, the ability
to do the usual duties well for a short time, suddenly followed
by extreme fatigue, are, in the absence of other symptoms, suf-
ficient upon which to base a diagnosis.
But no case should be considered one of neurasthenia until
every possible organic disease has been searched for and elimi-
nated. If the loss of emotional control be a prominent feature,
hysteria may be suspected ; but the previous history, the dis-
orders of motility and sensation, and the absence of fatigue in
hysteria, will enable us to decide between the two conditions.
If introspection be marked, the fears of disease, contamina-
tion, etc., may suggest hypochondriasis, but the latter is a true
insanity, and the fear of disease in the neurasthenic becomes a
positive belief in the hypochondriac, and is usually concerned
with the reproductive organs. In this same connection doubling
insanity may be considered, but here also the neurasthenic's
fear that he may say some bad word, or acquire syphilis, or
commit a crime, has, with the other, become a delusion that it
has been or may have been already done. Very early in paresis
the condition may seem a simple neurasthenia, but disorders
of reflex, tremor of the facial muscles, expansive ideas and
ambitious plans will point to the true condition. More easy off
differentiation, and yet to be considered are simple acute-
melancholia, tabes, cerebral syphilis, cerebral tumors, andi
the nerve exhaustion that sometimes ushers in tuber-
culosis. The prognosis is favorable, as the majority of
patients get well, or so nearly well that they can withstand
almost as much strain as formerly. However, this will take,
even with good treatment, from one to five years. In the treat-
ment, drugs are of but minor importance, but it is abso-
lutely essential to success that the physician have the patient's
confidence. Any physician who fails to recognize the promi-
nence of the mental J^mptoms, who ignores the trifling
ailments upon which the patient may lay stress, who laughs at
her doubts and fears, or who questions her sincerity, falls short
of his full usefulness in the case. Each patient should, if pos-
sible, have a trained nurse ; but no matter how perfectly trained
a nurse may be, if she is not acceptable to the patient she is apt to
be useless. The right surroundingsaro, perhaps, the most diffi-
cult part of the whole treatment to secure ; for the majority of
patients partial or complete isolation (preferably in the country)
is best, although the exceptional patient suffers when deprived
of society. Every minute of the time should be mapped out by
the physician— not necessarily to be rigidly adhered to in nones-
sentials—but so the patient may feel complete freedom from
responsibility, besides having the benefit of regulated treat-
ment. The friends must be shown that scolding and ridicule
are harmful ; that stimulating the patient's will to do, still fur-
ther increases the i\erve-poverty and that family cares and
worries must not be discussed with her. In severe cases among
women, when there is not much restlessness, the full rest treat-
ment is indicated. This will include over-feeding— preferably
with milk, massage at night or in the early morning, with sheet-
bath or tub-bath at temperature of 90° at night. With occa-
sional patients a prolonged bath of from 105° to 110° acts as a
soothing soporific. The skin should be dried after the bath by
brisk rubbing with a coarse towel. The liver, which in most
768 &UEBICAN MbDIOINE
CXJRRESPONDENCE
[XOTKMBBB 15, 1902
cases becomes torpid, must receive attention and the bowels
kept active, and of course any coincident symptom must
receive its appropriate treatment. In mild cases and in conva-
lescence rest in bed until after breakfast with return to bed
immediately after supper will suffice. Insomnia is usually
troublesome and may t)e combated witfi massage, baths, elec-
tricity (preferably the static current) and drugs, such as 15 to 25
grains of sulfonal, 15 grains of trioual, or one of the bromids.
When the appetite flags some form of iron is indicated — such
preparations as peptomangauate of iron, and malt with iron
being specially useful. Hypnotic suggestion has been much
advised by German writers, but experience shows that it
simply increases the loss of will-power. Bearing in mind that
the central thought in treatment must be to secure rest, final
success will depend on the physician's tact, watchfulness and
perseverance. He must make the patient believe in his sin-
cerity and in his knowledge of the case. He must give careful
consideration to her symptoms and statements, her desires and
inclinations and her surroundings, and then decide kindly,
firmly and wisely ; he must ever be on the alert to see when
she is not benefited by massage, or by rest, or is having too
much exercise, or is being agitated by an untactful or unkind
nurse or relative. When improvement becomes well estab-
lished it will, in many cases, take all his skill and force to pre-
vent the patient, delighted at the prospect of relief from
montlis of invalidism, from assuming cares and work that
speedily cause a relapse. If the neurasthenic were idle and
affluent, it would still be difficult to treat him successfully, but
most cases occur in busy men who cannot drop their responsi-
bilities, in women with large families or with small children
dependent upon them, and in persons without means. Then
the ability of the physician is taxed to its uttermost.
LENGTH OF THE UMBILICAL CORD.
BY
H. E. RANDALL, M.D.,
of Lapeer, Mich.
The report of a case of an umbilical cord 39 inches long is as
follows :
Mrs. W. G., aged 29, the mother of 4 children, gave birth
February 11, 1902, to an 8-pound boy. Labor was normal, L.O. A.
The cord was wound twice around the neck and measured 39
inches. Placenta was normal and there was no other abnor-
mality except the length of funis.
I was not aware until I read in Gould and Pyle's "Anomalies
and Curiosities of Medicine " that an umbilical cord of 39 inches
was unusual. It has seemed to me that many cords were as
long as this one, which measured just^9 inches. Gould refers
to Nolde's case of 38 inches and Werner's of 51 inches. Lusk's
"Art and ScienciB of Midwifery," quoting Chautreuil ("Des
fontiens du corden," Paris, 1875), says the cord averages 20
inches in length, though it has been observed as long as 70 inches
and as short as 2i inches.
THE SOUTHERN PHYSICIAN AND HIS COLORED
PATIENTS.
BY
K. H. BOLAND, M,D.,
of Atlanta, Ga.
To the Editor of American Medicine : — In the issue of your
journal for September 20, under the heading of "An Oppor-
tunity for the Negro Physician," you quote President Merrill,
of Fiske University, as saying in a recent number of the Chicago
Record- Herald that the competent colored doctor has an
"amazing opportunity" before him. inasmuch as the black
man turns to a physician of his own color as readily as the
white physician in the South turns away from colored patients
whenever he can honorably do so. This is a serious reflection
upon the white physicians of the South, and one that I feel
sure President Merrill would nf)t have made had he taken time
and opportunity to investigate the matter. Since 1874 I have
lived in the South, coming here from the North, and have had
ample opportunity to observe and judge of the relations exist-
ing between the Southern physician and his colored patient,
and I can testify to the interest he takes in these people, and
the patience and toleration shown, and the allowance made for
their ignorance and superstition. Especially in what is known
as the black belt, all physicians have a large percentage of
colored patients, and as a rule these are.the cause of consider-
able outlay to the doctor, who does not stop at visiting them
but furnishes the remedies needed, knowing that otherwise
they would not be secured. This is done by the doctor for a
large majority of his colored patients without any hope of
remuneration or reputation. If the history of the medical pro-
fession of the South in its relation to the colored race is ever
written, and it is to be hoped that it will be, it will manifest a
spirit of altruism that will be most gratifying to those inter-
ested in the progress of both races, and will certainly be a
surprise to those who, like President Merrill, believe that the
white physician of the South turns away from his colored
patient when he can honorably do so.
A SIMPLE METHOD FOR CLOSING THE BODY AFTER
AN AUTOPSY.
BY
JOHN J. GILBRIDE, M.D.,
of Philadelphia.
Assistant Demonstrator of Anatomy at the Medlco-Chirurgical College.
The most difficult and tedious part of an autopsy is closing
the body, the cause being the tough skin, the effort required to
push a needle through taking considerable time. I found this
could be avoided by taking a scalpel and puncturing the skin
from the suprasternal notch to the symphysis pubis on each
side of the incision, making the punctures about an inch from
each other and an inch or so from the edge of the incision. I
use a medium-size sailmaker's needle, threaded with twisted
silk or fine twine. The needle can be grasped in the hand and
introduced through the punctures in the skin with ease and
the opening closed with the baseball stitch, the needle being
introduced from the under-«ide all the time and crossed from side
to side in a continuous suture. This constitutes a rapid method,
taking only five to ten minutes, after which there is no oozing.
INFANT FEEDING.
BY
C. L. CASE, M.D.,
of Ramona, Cal.
I read with interest a few weeks ago in American Medicine
the opinions of quite a number of doctors on infant feeding. I
did not cease to liope until I read the last article that I would see
something about feeding the cow, which to my mind is the most
important part.
This is the plan I follow : A healthy cow is selected with a
calf as nearly as possible the age of the baby, older rather
than younger, if a choice is necessary. The cow is given dry
feed, plenty of hay and bran, and no green feed for the first two
months, and above all no bitter weeds.
To begin with I order 2 oz. of boiled milk, 2 oz. of boiled
water, 1 oz. of limewater, 5 grains of white sugar, and 1 grain
of salt every two hours, to be put into an eightrounce graduated
nursing bottle with no tubes. I gradually increase the milk
about i oz. each month for each feeding. I also increase the
sugar and salt in proportion with the milk, but the other ingre-
dients I leave the same in quantity for about nine months,
when the child usually passes from under my care and begins
to eat with the family.
The intervals between feedings are to be increased 15 min-
utes each month up to six months and night feedipg done away
with as much as the child will allow.
November 15, 1902]
INFECTIOUS FORM OF ECZEMATOID DERMATITIS fAHERicxN memcxnb 769
ORIGINAL ARTICLES
AN INFECTIOUS FORM OF AN ECZEMATOID DER-
MATITIS*
BT
MARTIN F. ENGMAN, M.D.,
of St. Louis, Mo.
Chief of the Clinic for Cutaneous Diseases, Polyclinic, Medical DeparU
ment, Washington University ; Member of the American
Dermatological Association.
There is a catarrhal inflammatory condition of the
skin which, to me, seems to be a distinct clinical type ;
distinctive through its etiologic factors, objective symp-
toms and clinical history. In all textbooks upon diseases
of the skin it is included in the eczema group ; one form
under the name of eczema impetiginoides, impetiginous
eczema and sometitnes scrofulous or tuberculous eczema.
Since the idea of the parasitlcity of eczema was
brought so prominently before the profession by Unna,
in 1890, the role of microorganisms in that group of
affections has been energetically investigated by many
observers, with the result that there is at present some
confusion as to just what is meant by the term eczema.
Tliis is the battleground, one might say, of modern
dermatology. Is "eczema" a purely vesicular dis-
ease, or should the term include various other forms of
inflammatory lesions and catarrhal conditions? The
brunt of the discussion hinges upon the fact that the
majority of investigators have found the initial and
earliest eczema- vesicle sterile, while all of them admit
the important pathologic role played by staphylococci
later on in the process. Through this confusion of
names and what is meant by them, and, since modern
investigations have not isolated the specific cause of the
eczema-vesicle and the common forms of this catarrh,
we are therefore compelled to take seriously the defini-
tion of Norman Walker : " Eczema is the term used to
designate all inflammations of the skin, whether moistor
dry, of which the observer does not know the cause or
nature."
From these few remarks you will admit our wisdom
in speaking of the condition which we will attempt to
describe as a "dermatitis;" an "eczematoid derma-
titis," because in its course we have papules, vesicles,
pustules, a retldened scaly surface from which oozes a
sticky liquid that stiffens linen and forms crusts.
The description of this condition cannot be introduced
in a clearer manner than by quoting from a few histories
of ca.ses seen in private practice and at Dr. Hardaway's
clinic for cutaneous diseases at the Polyclinic.
Case I.— Mrs. J., aged 29. Clinic case. Upon the index and
second fingers of the right hand and upon the web between
them was a sharply defined, red, inflammatory surface, which
was weeping and scaly ; the border was undermined ; that is,
at tlie peripheral or progressive border the epidertnis was
slightly lifted and split up. Over certain portions of this sur-
face were small vesicles which ruptured and oozed a sticky
serous fluid. The patient's son had a discharging sinus upon
Ills foot which she dressed daily. He also liad a similar eczema-
toid condition about the wound. The trouble upon the patient's
hand began as small vesicles. The clinical evicfence in this case
ot infection is too strong to be overlooked.
Cask II.— Miss C, aged 17. Private case. This young lady
while sewing stuck a needle obliquely through the skin on the
tip of the index finger, making a wound which " festered" and
became quite inflamed. From this infected wound thorespread
upward to the first joint an inflammatory condition similar to
the one for which she came for advice. Upon the scalp were
numerous patches of what would commonly be termed an
impetiginous eczema. The skin over the last phalanx of the
left index finger showed at the consultation signs of recent
inflammation ; the nail was raised from its bed, was discolored
and deformed. The patient stated that she had scratched or
rubbed her scalp with the "sore" finger and thought that
she had probably inoculated her scalp in this manner. Her
brother, a boy of 8 years, was brought for treatment at the next
• Read before the St. I,oul» City Hoflpital Alumni Association,
Thursday evening, September 18, 1902.
consultation. He had a patch of eczematoid dermatitis upon
the chin, left cheek and left side of neck, consisting of red-
dened, sharply defined, crusted areas, ranging from the size of a
silver quarter to that of a half-dollar. The brother and sister
had used the same towels and occupied the same bed, taking no
precautions as to pillows, linen, etc. The brother's affection
had appeared after that of the sister.*
Case III.— Mrs. R., aged 23. Private case. The patient's
infant, of nine months, has an eczematoid dermatitis upon the
upper lip, chin and both cheek s. The disease began in the child
by a discharge from the nose, which infected the upper lip and
spread from there to the other points. Upon both breasts of
Mrs. R., about the nipples and extending beyond the areola,
was an eczematoid surface of a dry, scaly type with sharply
defined undermined borders. The patient had noticed the erup-
tion upon her breasts some weeks after that of her baby, which
she had nursed only twice daily. Here the evidence of direct
Infection seems to be perfect from the location of the disease
upon mother and child.
Case IV. — Mr. S., medical student. Upon the dorsum of
the patient's left foot was a weeping surface, rather serpiginous
in outline, with sharply defined borders and undermined epi-
dermis. A dry, scaly patch of the same type, but not so inflam-
matory in character, was located upon the right buttock. Some
weeks previously Mr. S. had remained all night at a country
inn, where he was obliged to share his bed with a fellow-trav-
eler. Upon undressing this stranger complained of an itchy
eruption upon his foot, which Mr. S. examined and pronounced
eczema (?). The disease began in Mr. S.'s case upon the foot.
Case v.— J. H., aged22. Cliniccase. Upon the right side and
in front of the neck, just where the collar rubs, was an eczema-
toid eruption, which at times discharged. The man was not at
all cleanly, wearing his collar several days about a neck equally
as dirty. He states an unusually rough or frayed collar started
the trouble. On the back of the right hand, beginning at the
base of the first and second fingers and running upward toward
the wrist for three inches, was an eczematoid surface, probably
an inch or so broad. The patient voluntarily stated that he had
constantly applied that portion of his hand to the discharging
surface upon the neck.
Case VI. — H. K., aged 14. Clinic case. Two weeks ago
a few grains of emery powder flew Into the patient's left eye,
which was followed in two days by a severe conjunctivitis and
pustular discharge. The day following the appearance of the
discharge both lids became itchy and inflamed upon their exter-
nal surfaces. At the consultation the entire outer surfaces of
both lids were reddened, scaly, eczematous, while upon the
cheeks and forehead were several red, scaly spots the size of a
pea to that of a silver dime.
Case VII.— Izie L., aged 22. Clinic case. A month ago
patient had measles, during which the throat became very sore.
At the consultation her mouth and throat both seemed slightly
reddened. Upon the left corner of the lip, extending downward
over the chin and adjacent portion of that side or the cheek,
was an eczematoid dermatitis of the type already described,
thickened and crusted. The patient slept upon her left side,
and during her sleep a stream of infective saliva dribbled over
the skin of that side, thus, no doubt, exciting the dermatitis.
CaseVIII.— Myrtle Z. Aged 2. Cliniccase. The child's
nose began to discharge two or three weeks ago, which infected
the skin of the upper lip. After this the eyes became sore, fol-
lowed by the disease for which we were consulted, which was
located upon the scalp and face. The patient's nostrils were
filled with greenish, impetiginous crusts; the eyelids were
inflamed and crusted over half their surfaces. Scattered over
the face were a number of Inflammatory areas, which were at
first vesicles upon a reddened base ; these when isolated, crust
and heal (impetigo?), but when they occur in clusters or are
situated closely together an active process ensues by their coa-
lescing into a weeping progressive eczematoid patch. Upon the
occiput was such a patch, larger than a silver dollar.
Case IX.— Rozelle R. Aged 2. Clinic case. The disease
began five months previous to the consultation as a discharge
from the ear (due to middle ear disease), inducing an eczema-
toid condition of the external ear and the skin just behind it.
The nose began to discharge one month ago, succeeded by infec-
tion of the upper lip. Atthe consultation the eczematoid condi-
tion was located upon the left ear, just behind it, upon the scalp,
and about the nares and upper lip.
Case X.— Mr. C, aged 65. Private case. The summer of
ISiX) was quite warm. The patient suffered for some weeks
before the outbreak of his eczematoid dermatitis with severe
lichen tropicus, causing him to rub and scraUih his skin fre-
quently. The dermatitis began upon the legs, but when the
patient was first seen by me it was scattered over forehead,
arms, body, buttocks and thighs in various sized patches,
shiirply defined, of a scaly or weeping character. The lower
two-thirds of the skin of both logs was entirely covered with a
similar eruption— a weeping, crusted surface with split-up
epidermis at its periphery. Tiie disease was cured by proper
regimen, to keep down the lichen tropicus, and local treatment.
A curious Incident happene<l in this case: The following
summer the patient called with a spot in the center of
• At a later date the brother showed a granular condition upon the
marginal conjunctiva of the lids of both eyes. He scnitelied his der-
malllls and then rubbed his eyes, thus Infecting them.
770 AMBBioAN medicinbj INFECTIOUS FORM OF ECZEMATOID DERMATITIS
(November 15, 1902
his forehead, similar in location and character to one
he had had the previous summer. He was a very intelligent
man, and he remarked that a few days before the spot appeared
he had resurrected and worn a straw hat which he had used
during his former attack.
Only these few histories have been cited to illustrate
several methods of inoculation of the process, and types
of the affection. More clinical evidence of a similar
nature could be given were it necessary for the purpose.
In Dr. Hardaway's clinic, out of 1,200 new cases 35 have
been of this type (about Sfo), presenting various forms
of this dermatitis, with histories of inoculation or auto-
inoculation from a suppurating process or an eczematoid
surface.
II.
Fr«m the cases just cited you can discern that we
WASh to call your attention to a condition which is from
clinieal observation, apparently, infectious ; character-
ized at the height of the process by a crusted, weeping,
or scaly, inflammatory patch (or patches) which extends
at the periphery by the formation of vesicles or pustules,
but more commonly by the splitting up or undermining
of the peripheral epidermis. Insensible or sensible
weeping forms a scaly, crusted, or discharging surface
as it thus progresses, dependent probably upon the par-
ticular chemotactic power or character of the organism
and the reaction of the patient's tissues. There is never
any attempt here to central involution, as in many other
dermatites ; as, for instance, in impetigo circinata.
From a close study of this afl'ection a vesicle, pustule,
or an erythematous, scaly, crusted, or weeping spot,
seems to be the primary lesion. These points may coa-
lesce into a patch, if closely placed, or individually
spread from an initial point. When the dermatitis has
been too energetically treated, irritated, or if the infec-
tion is of great sero-tactic power, a condition indistin-
guishable from an eczema rubrura of the ordinary type
supervenes.
In these cases if the patient is carefully questioned, a
history of preceding trauma or infection can generally
be elicited. The trauma may be in the form of a blow,
surgical wound, bite of insects {Pediculus capitis or P. vesii-
menti),^ irritation of a simple pimple, chemical or thermal
irritation ; scratching, especially in complication with
certain symptomatic prurituses and lichen tropicus,
or any factor which may break or assist in rendering the
epidermis vulnerable. In this group may be included
varicose ulcers and vaccine ulcers, about which this
eczematoid dermatitis often occurs ; especially frequent
is it a complication of the former ; in fact, the majority
of the socalled varicose eczemas are of this type, the
organism readily gaining access and virulence through
the ulcer, invading the vulnerable, sodden and poorly
nourished epidermis.
The most aggravated form of this dermatitis often
occurs after a surgical or accidental wound or recent
irritation of an old ulcer as a rapidly spreading, discharg-
ing surface, extending with sharply defined, irregular
borders over great areas of skin ; undermining or rais-
ing the peripheral epidermis by the attraction of a sero-
purulent discharge for one-eighth of an inch to three
inches from the denuded surface border ; thus in a few
days to as many weeks stripping the whole hand or foot
of its epidermic covering. There is sometimes in these
virulent cases slight edema of the subjacent tissues.
The surface thus denuded is covered by a sticky, sero-
purulent discharge which oozes from points, and when
not too profuse dries into thin crusts. This fluid teems
with white or yellow staphylococci, or both, and can
be pressed out, when profuse, in drops from under the
loosened epidermis at the border ; but when it is not so
freely attracted, the disease progresses slowly with just
epough moisture to detach the peripheral 'epidermis,
which unites with it and with the debris to form crusts
upon the reddened surface thus left in its wake. The
older part may slowly undergo restitution by the cessa-
tion of the discharge and the formation of new epider-
mis ; this new covering may again be attacked and
destroyed in the same manner, a procedure I have seen
repeated several times. In this form of the eczematoid
dermatitis, vesicles or pustules never form, as the organ-
ism's chemotactic attraction is so powerful that the epi-
dermis becomes soaked, then lifted up en masse as it
were, and is in severe cases washed or broken away
before the flow of serum, which thus actively attracted
also prevents the formation of crusts to any marked
extent, but in the slower or less virulent forms these
features are of less degree ; we may have a slowly-pro-
gressive, spreading inflammation, taking weeks to
destroy the epidermis of the back of the hand, to a
rapid, virulent, profusely weeping type, taking only a
few hours to accomplish the same result, when, the
soaked and sodden epidermis is detached in slieets of a
dirty, creamy-white color, breaking upon slight traction
and readily detachable, flush with the apparently
healthy skin. The surface thus denuded is similar in
its appearance to an eczema rubrum with the exception
that here and there little islets of sodden, dirty-white
epidermis, for some reason still adherent, dots the sur-
face. It is from these that the new covering springs
when the discharge is checked.
The similarity between this particular spreading form
of eczematoid dermatitis just described and Crocker's
"dermatitis repens " is at once obvious; the clinical
picture is the same, according to his description ;* both
start from a wound, but two cases seen last spring illus-
trate the fact that it can follow the irritation of a patch
of eczematoid dermatitis of the type most commonly
seen and already described.
A lady consulted me on account of patches of eczematoid
dermatitis of the usual dry, scaly, chronic form upon the
fingers and back of the left hand. A sulfur and balsam of Peru
salve was ordered. The second day following she returned
with her hand almost denuded of epidermis by the extension of
the individual patches in the manner just described. The
appearance of the disease had entirely changed. Las«ar's paste
was then ordered. Upon her return in 24 hours the disease had
progressed to the wrist. The sodden epidermis was all
removed , a bath of hot water rendered pink with potassium per-
manganate was given and the hand finally dressed in a moist
surgical poultice of aluminvim acetate. This treatment was
continued with minor modifications for two weeks, when the
patient was dismissed cured. During the time, she came to the
office daily for a proper dressing, necessitating a daily manipu-
lation and cleansing of the surface. At this time there appeared
upon the end of the palmar surface of my index finger a large
very flat bulla or whitened area, which upon rolling under my
thumb seemed to contain fluid, but upon pricking and tearing
off' the easily detached epidermis was found to be merely moist.
For purposes of study this apparently infected patch was let
alone, but as it soon began to spread, further study was cut
short by an application of pure carbolic. Before puncturing
the macroscopically intact epidermis it was washed with
alcohol and cultures taken in the usual manner, from which a
pure culture of the white staphylococcus resulted. This coccus
was also found in pure culture from the patient's hand.
An old lady of 80 years came to the Polyclinic for an
eczematoid dermatitis of the fingers of both hands and dissemi-
nated small, circumscribed, sharply-defined patches over the
body, arms, legs and thighs, which had existed for some
weeks. The condition first appeared upon the finger tips (the
nails were split up, deformed, and partially raised from the
nail-bed). She had had a great deal of general pruritis pre-
vious to the eruption, and was constantly rubbing and scratch-
ing herself, thus disseminating over her person the disease,
which existed upon the fingers and nails, by autoinoculation.
A mild sulfur salve was prescribed, which irritated terribly,
starting an active uncontrollable spreading dermatitis which
soon involved the whole body by characteristic peripheral
extension of the old patches and the formation of new ones.
Rigors, sweats and temperature accompanied the process from
the absorption of toxins. A collapse was feared, and vigorous
supportive treatment administered. The picture presented in
this case at its height was strikingly suggestive of a moist
dermatitis exfoliativa (Devergie). After trials of various
external remedies without success, a 3% ointment of menthol,
gradually increased to 6%, effected a cure.
Sulfur in the form of a salve is dangerous in all cases
of eczematoid dermatitis, but when combined in a paste
is often wonderfully beneficial.
• Diseases of the Skin, 1893, p. 180.
November 15, 19021
INFECTIOUS FORM OF ECZEMATOID DERMATITIS (American Metdicike 771
III.
Cases similar to VI, VII, VIII and IX you have all
frequently seen. Many of them are referred to our
department from the eye, ear, nose or throat clinics. It
is a common occurrence, according to our observation,
for the discharge from an inflamed eye, ear, mouth or
nose to infect the adjacent skin surface, and from there
extend by autoinfection. It is true infection under
these circumstances does not always occur in the form of
an eczematoid inflammation ; not infrequently it occurs
as a form of impetigo. It is also not unusual to find
both impetigo and eczematoid dermatitis in the same
individual ; but the impetigo either heals after the
formation of the crust (Fox) or when of the circinate
type heals as it extends; whereas in the eczematoid
infection the disease is different in its manner of exten-
sion, its failure to attempt central involution with its
typical eczematous characteristics. A catarrhal condi-
tion of the skin can be caused by the infectious dis-
charge from a c"atarrhal mucous membrane, and vice
versa a mucous membrane can be infected by autoinocu-
lation from the skin. Both of these facts can be often
verified by careful clinical observation, and are of vast
importance in the pathology and treatment of these
affections. Dr. Hardaway in his textbook calls atten-
tion to the frequent occurrence of marginal blepharitis
and eczema of the scalp.*
During or after an attack of any of the acute exan-
thems, Infection of the skin often occurs from an
inflamed throat or mouth. The patient, while asleep,
places the head in such a position that drainage of
the infected saliva occurs through the opened mouth ;
thus it dribbles over and infects that portion of the
chin or cheek corresponding to the side upon which the
patient is in the habit of sleeping. The infectiousness
and the etiologic relationship of these pustular processes
were most conclusively demonstrated among the babies of
the Bethesda Foundling Home during the summer of
1900. Several of the little inmates of this institution
became infected with scabies, and through the irritation
of the itch mite and scratching, an epidemic of staphylo-
genetic infections was started, consisting of impetigo
bullosa, furunculosis and eczematoid dermatitis, which
was far more difficult to combat than the scabies ; in
fact, it continuetl for some months after the latter. Sev-
eral members of the medical staff beside myself were
careful and interested observers of the condition, all of
us agreeing as to its infectiousness and etiology.
About this time catarrhal aff ctions of the eye, ear
and nose bec-ame prevalent and many of the children
had dermatitis with these complications, which appeared
either before or after the skin infection. Of course, the
natural query would be: Did not all these children with
the dermatitis have scabies, and did not the latter induce
the former? The cases were carefully inspected almost
daily, therefore we can state as positively as clinical evi-
dence and our knowledge of the lesions of staibles will
allow that the majority of the cjises with staphylogenetic
infections did not have scabies. It was only by strict
isolation that the infection was checked. Children with
discharging eye, ear or nose, as well as those with skin
lesions, were isolat<^d.
It was of great interest and instruction to study the
various degrees and varieties of infection in this institu-
tion—boils, bullous impetigo, Boc-khart's impetigo,
circinate impetigo— and flifferent varieties of eczematoid
dermatitis, from all of which, with a few exceptions,
pure cultures of the yellow or white staphylococcus, or
both, were obtainwl. Streptococci were found in only
one c^tse of bullous impetigo t and three of eczematoid
dermatitis, but with sta|)hylococci. The cultures were
taken with the usual care and in cases of the dermatitis
from the earliest lesions (vesicles) or crusted spots; from
• CllnlcAl Manual ofi^kln Dlsenxea. Ig9«, p. 144.
+ Ji>ur. Ueiiito-Urlnnry and Cut. Dls., AprU, IWl.
the surface of the latter after the removal of the crusts ;
thus pure cultures were almost in every instance obtained.
To get the fluid from the vesicles or pustules sterilized
capillary tubes were generally used.
During this summer of 1900 the weather was very-
hot and sultry. Dispensary and private practice pre-
sented a greatly increased number of staphylococcic infec-
tions, therefore an exceptionally good opportunity for
the study of these conditions thus presented itself. The
pure impetigo group was far more infectious, and there-
fore more prevalent than the dermatitis; the two condi-
tions, though apparently due to the same specific cause,
stood out clinically as tsvo distinct types ; however, it
was noticed in several instances where impetigo cir-
cinata did not unjlergo its usual central involution that
such a patch became characteristic of eczematoid der-
matitis. When infection could be traced, as in institu-
tions and families, impetigo reproduced impetigo and
the eczematoid dermatitis its autotype. From this fact,
type seemed to be more a question of the chemotactic
character of the organism than the nature of the soil.
Another factor which probably has its influence is the
depth of the accidental inoculation, the eczematoid con-
dition being a deeper process than impetigo, which
seems to be further verified by the fact that lymphatic
glandular enlargements occur frequently in the former
and rarely, if ever, in the latter condition. In the der-
matitis the inter-epithelial lymph channels are all widely
dilated by a slowly progressive serotaxis, while the
parakeratotic horny layer gives only slow and partial
exit or drainage to the serum, which is ([uickly rendered
toxic or infected; thus more absorption of infectious
material takes place with the subsequent adenopathy in
the contiguous lymphatic glands.* In the impetigo type
serum attraction comes suddenly, lifts the comparatively
unchanged horny layer and a few cells under it into a
chamber of various sizes (vesicle or bulla) which when
filled breaks, or is accidentally broken, giving free
drainage, removal and cure. Therefore, the particu-
lar chemotactic virulence of the organism may by
the slower action or chemic character of its toxin
produce parakeratotic changes and thereby differ-
ence of clinical type, namely : (1) A toxin of very
powerful serotactic power may produce an impetigo
bullosa to an impetigo vesicle of Fox ; (2) a toxin of
less virulence and rapidity of action produces very slight
parakeratosis, as its serotactic properties act too rapidly
to allow time for much of this slowly-formed change ;:
thus, rather free drainage is allowed and central involu-
tion occurs while the process continues at the border,
producing the clinical type, impetigo circinata. In thi»
circinate variety just enough parakeratosis occurs U>
change the nature of the horny layer and offer more
resistance to the exit of serum. In the impetigo of Fox
the crust " soaks up serum like a sponge " (Unna), thus
assisting in a cure ; but in the circinate type it does not
act in this manner, on the contrary, resisting the flow by
its firmer partial parakeratotic formation and allow-
ing the disease to extend peripherally. But the cru^t
thus formed is not of such a high degree of resistance a»
is found in eczema'oid conditions; therefore, through
this lack of firmness it is soon thrown off and involution
occurs in the older or central part of the diseased surface ;
(3) in eczematoid dermatitis we have the organism pre-
senting serotactic characteristics of a true eczematoid
nature in its rapidity of attraction and histwhemic char-
acter ; producing in the epidermis a firm parakeratotic
horny layer, which allows the widening of the lymph
channels by its resistance to the exit of the fluid ; luiin-
thosis occurs, and if the vessels and tissues thus inflicted
are additionally irritated by too energetic treatment or
increased virulence of the organisin, eczema rubrum
ensues. Indistinguishable from the common type.
•The beneflclal action of a past* In this form of dtrniatlllH Ih prob-
ably iltie, In part, to the atlrarilon It has for liquids, thus aBttlstlnf la
relieving the tluues of the poisoned lymph.
772 AMKBioAS mkdicink; infectious FORM OF ECZEMATOID DEKMATITIS
[November 15, 1902
Charrin * has found from a study of the liacUlM pyo-
cyanem that a multiplicity of toxins are produced ; so it
seems that microorganisms may at times produce toxins
of different chemic characteristics. This seems to be
true of the staphylococcus ; anyway, bacteriologic and
clinical observation certainly suggests such a fact. Such
a slight change is necessary in the chemic character of a
toxin which produces an impetigo to cause an eczema-
told dermatitis that it is impossible to detect it in the
morphology and biology of the organism which produces
i'. Why we always get the same results in experiments
made by inoculation from cultures grown upon artificial
media can probably be explained in this manner ; that
is, the chemic character of the toxin is probably changed
or distorted by the artificial growth pf the organism.
That the chemic equation of the host and his various tis-
sues enter into this question must also be admitted, as
the location of the infection with the distinct and specific
local reaction of the part no doubt influences the forma-
tion of a toxin of certain characteristic properties and
the production of a certain type of disease. The differ-
ence in the clinical appearances of a group of diseases can
be thus more rationally explained than by straining
every point in the vain effort to find a specific organism
for every phase, symptom or type.
Btside the specific cause of disease and the variations
in its chemical products other factors contribute in the
production of clinical differences, so much so that they
often lead to an erroneous and improper diagnosis. This
fact was illustrated by two cases occurring at the Bethesda
Home during the staphylococcic epidemic referred to.
These were cases of a severe dermatitis of the diaptr
region, which had spread beyond the covered portion
(diagnostic of syphilis in many textbooks), involv-
ing the soles of the feet, inner and posterior surfaces
of the thighs and legs, buttocks, genitalia, extending
to more than half the distance between the pub( s
and umbilicus. The affection consisted of a reddened
skin, slightly infiltrated, with undermined or scaly bor-
ders, slowly extending peripherally, leaving this red-
dened inflammatory surface in its wake. There was
just enough edema to cause a mild parakeratosis and
the formation of a few small scales, which were con-
stantly removed by the urine, the diaper and frequent
washing. The influence of these various factors, together
with the mild edema in the derma and dee()er layers of
the epidermis were sufficient to give to the stretched
and freshly washed horny layer a shimmer, which is
said to be characteristic of a syphilitic erythema in this
region. In fact, these cases were diagnosticated as lues
and had received sufficient specific internal treatment to
improve the condition, if luetic, but without result.
Upwn the institution of a sulfur paste a cure of both
cases occurred with marvelous rapidity.
Given an infant with a discharge from the nostrils,
and a dermatitis having the characteristics and location
as in the cases cited, the improper diagnosis of lues
would probably be frequent, especially in these bottle-
fed little waifs, who are often delicate or marasmic. A
great source of error lies in the frequent coincident use
also of mercury ; giving it locally as a salve or paste and
internally, thus placing a proper and absolute diagnosis
beyond a possibility. How much this means! Withtlie
stigmata of syphilis wrongly placed in the history of a
"foundling;" interfering with its adoption, the only
hope of its class.
The association of pustular conditions of the eye,
nose and ears with "eczema" is spoken of in every
treatise upon that subject. The English place stress
upon a "scrofulous diathesis" in these cases, which, in
our experience, is wholly unfounded and a relic of the
old and erroneous ideas of the etiology of skin diseases.
Possibly the condition occurs more frequently among
till' crowded and poorly nourished, but infection is the
* Deutsche med. Wochenschrlft, No. 16, 1902.
prime and all-injportant factor. We have not over-
looked in our observations the influence of soil in its
bacteriologic meaning ; on the contrary, we place much
stress upon its importance ; however, soil does not mean
a scrofulous (tuberculous) diathesis. The complications
above enumerated occur, taking them as they come in
practice, as frequently In the well-nourished and robust
as in the anemic and illy -nourished. The habit of pick-
ing the nose, so common in children, is, no doubt, a
source of infection in many instances.
Unna's "tubercular eczema" probably belongs
here. It is certainly a fact that when there is an atro-
phic rhinitis and an eczematoid dermatitis of the
upper lip infected by the purulent discharge there is
more edema than is seen where the atrophic rhinitis
does not exist. It is also true that there is generally
more marked edema through the whole thickness of the
skin, not only in this form of dermatitis, but in all
inflammatory conditions, occurring in the " run down "
and poorly nourished, no matter what may be the source
of this depression.
Unna thought that he found improvement in his
"tubercular eczema" from injections of tuberculin, but
as Crocker says, "tuberculin may modify various forms
of unstable tissue." Unna differentiates this form of
dermatitis (tuberculous eczema) from his seborrheic type
by the latter skipping the orbits and spreading down
upon the face and body.
Crocker, in speaking of Unna's " tubercular eczema,"
says: " The tuberculous is the form seen chiefly on the
face or in association with conjunctivitis and rhinitis, or
otorrhea in the strumous children of the poor, and, in
my opinion, is nothing more than a dermatitis excited
by contagious pus — a form, indeed, of impetigo conta-
giosa." Upon the latter two words of his remarks
hinges the question of nomenclature. If by the term
impetigo is meant a disease, characterized by the forma-
tion of a pustule or vesicopustule, which dries into a crust
(Fox) or spreads peripherally and involutes in the
center (Unna), then the disease under discus-ion is not an
impetigo, because it occurs In patches and not as isolated
phlyctenules, which crust and heal. Furthermore, it
shows no inclination to undergo central involution ; on
the contrary, produces eczematoid surfaces often difficult
to heal.
IV.
Staphylogenetic (?) eczematoid dermatitis is character-
ized by the following points, many of them differentiat-
ing it from ecztma in the more limited acceptation of
the term :
1. The initial or earliest lesion may be a vesicle, pus-
tule, erythematous, scaly or crusted point or plaque.
2. The vesicles are not so closely placed and are larger
than those seen in an acute symmetrical vesicular
eczema.
3. There is no symmetry in the arrangement of the
lesions, except when thus accidentally inoculated.
4. It occurs in patches, usually not involving a large
area of surface in a single patch. When the disease
begins as vesicles they soon break to form a scaly patch
which extends in the usual manner. New foci may
begin as a cluster of vesicles.
5. The patches are circumscribed with sharply defined
borders. The epidermis at the periphery is usually
undermined, split up, detached or raised ; the two latter
events being caused by perceptible or imperceptible
serous or seropurulent fluid, which may, if it contains
much fibrinous material, instantly form a thin ridge-like
crust about the periphery, while if in larger amounts
and more fluid, drops of it can be pressed out from under
the raised epidermis.
6. The disease increases by peripheral extension of
the patches and the formation of new ones by autoin-
oculation.
7. The exposed parts are the most frequently affected.
NOVKMBER 15, 1902]
SURGICAL ANATOMY OF THE MIDDLE EAR
I Americas Mediotni 77 i
8. There is no attempt at central involution.
9. There is a minimum amount of itcliing.
10. The nearest lymphatic glands are often enlarged.
11. The initial and earliest vesicle, pustule, scaly or
crusted spot contains the yellow or white staphylococcus
in pure culture, as well as the surface and crusts of the
later patches.
12. Experimental autoinoculalion can usually be suc-
ceasfully performed, but the lesion thus produced begins
as an erythematous patch which soon weeps and crusts,
and not as vesicles.
13. The history of trauma, infection or association
with suppurative conditions is characteristic of the affec-
tion.
14. Local antiparasitic applications are sufficient to
effect a cure.
V.
The role of microorganisms, really staphylococci, in
eczema has been investigated by Gilchrist,' Scholtz and
Raab,' Kreibich,' Fr6d(5ric,' Broca,^ Veillon," Torok,'
Unna," Sabouraud,' Benda, Bockhart and v. Gerlach,'"
Galloway and Eyre," and others, all of whom have dis-
cussed the subject so thoroughly and many of them so
recently that it is not necessary here to dwell in detail
upon their findings. As has been mentioned, they all,
with the probable exception of Unna, admit that the
.staphylococci play an important role in eczema, espe-
cially in its later manifestations. Scholtz and Raab go
.so far as to state that the common type of eczema can-
not exist without the influence of these cocci. Sabou-
raud has coinetl the term " impetiginization " and Bes-
nier "eczeniatization," probably to express this produc-
tion of a common type of cutaneous catarrh, apparently
caused by *'the local invasion cf common microbes"
(.Jadassohn) upon a certain vesicular condition, which is
supposed to be the true eczema, in which the vesicles
have, so far, been found sterile by the majority of inves-
tigators.
Sabouraud says when eczema appears to be contagious
it is only apparently so, and is due to the impetiginous
condition superimposed on it; however, he wisely
qualifies his statement by adding that there does exist
several eczematiform conditions of the epidermis which
are due to microorganisms.*
Benda, Bockhart and v. Gerlach conform these con-
flicting views in regard to the sterile primary vesicle
and the appearance of slaphylococci later on in the
eczematous process, by stating that all the healthy skin
follicles contain staphylococci in an inactive form, which
are awakened into activity or pathogenicity by some
cause, acting from within or without. Thus from this
increased metabolism the cocci excrete a staphylotoxin,
which diffuses itself from the follicle into the epidermis,
where it displays its serotactic influence by the forma-
tion of vesicles and papules which contain serum and
almost no qckki ; therefore they remain for a certain
length of time sterile, but later on the cocci increase and
are readily found.
Unna's morococcus is no doubt a form of the white
staphylococcus, as has been so satisfactorily demonstratfxl
by the experiments of Galloway and Eyre f and others.
(Jedercreutz,:!: from his work in Sabouraud's laboratory,
believes that the morocoi-cus of Unna, Micrococciui citiix
communis of Sabouraud and Stuplii/l<x-wcm epidermidis
albm of Welch are one and the same organism, and that
cocci producing yellow cultures and those producing
white or greyish are probably arliflcUU, and do not
exist in actual fact. He wills this coccus with which he
has been working "a polymorphic coccus, the habitual
denizen and parasite of the human skin."
•Kounli Iiiterniiilonal CimgreHH of DermatolOKy, BrIUsb Jour.of
Iterin., Heptem l>«r, liKiO, p. S2«
+ BrltlBli Jour, of Derm., ."September, 1900.
; InvestigftllonH on a pol.vrat)rphlc cocriis, the hnbltunl denizen and
IMininile of the human skin. By Axel Cedercrcutz. Purls; O. Steln-
These isolated facts dovetail so nicely into one
another that it promises for future investigation into the
role of staphylococci and their various chemotactic
properties in relation to the etiology and varieties of the
eczema groups, a rich reward.
The result of our own investigations in the form of •
eczeinatoid dermatitis under discussion we will give
below. These studies have extended over a number of
years, not in one continuous series, but in several series
and epidemics at different periods.
Not to tire you with the details of these investiga-
tions, which we hope to give later in a complete report,
we will merely enumerate here the basic or principal
results, namely :
1. The contents of the initial vesicles, serous and
seropurulent discharge, under surface of crusts and scrap-
ings from freshly denuded surface of eczematoid skin,
produce, when inoculated into artificial culture media,
pure cultures of the staphylococcus, yellow or white or
both. These cocci sometimes vary slightly in the
peculiarity of their growth, but are certainly the staphyl-
ococcus of the ordinary types.
2. When the apparently healthy skin of a person
suffering from an eczematoid dermatitis is slightly irri-
tated, after being rendered sterile by the usual mesms,
and then inoculated with the discharge from the ecze-
matoid surface, there appears thereon a condition similar
in its flora and symptoms to the one from which the
discharge was taken. Inoculation experiments from
individual to individual have not been encouraging,
due most probably to thepatient's unwillingness to prop-
erly submit or the reaction of the foreign soil.
3. Inoculations upon individuals from artificial cul-
tures were also not encouraging. The organism must
undergo some change in its chemotactic character in
artificial media, as inoculations from it produce impetigo
or purely impetiginous lesions which quickly heal ; or
if the lesion takes on an eczematoid character it heals
too rapidly to be of much experimental value.
4. The suppurative conditions with which eczema-
toid dermatitis is often associated always contain staphyl-
ococci.
5. The association with suppurative conditions ; his-
tory of apparent infection and autoinfection ; the excit-
ing factor of traumatism and infection, with the bacte-
riologic findings enumeratetl, all indicate and confirm
our belief in the staphylogenetic origin of this dermatitis.
BIBLIOGRAPHY.
> Trans. Amer. Derm. Aaso., twenty-third meeting, 181*9.
■i Annates de Derm, ct de Syph., 1900, p. 409.
•' Annates de Derm, et de Syph., 1900, p. 509.
< Miinchener mod. Wochen-schrlft, 48 JahiK-. No. 38.
■' Annales de Derm, et de .Syph., January, February, March, 1900.
'• .Vnnalesde Derm, el de Syph., June, 1900
' Annales de Derm, et de Syph., December, 1898.
' IH'titsch. Medlzinal Keltung, AUKQst, 1900.
"lirltlsh Jour, of Derm., Seplcniber, 1901, and Fourth Intemat.
Coiiaress of Derm.
'" .vionalsha. f. Dermal., Bd. xxxlil. No. 4, August, 1901.
>i BrlUsh Jour, of Derm., September, 1900.
THE SURGICAL ANATOMY OF THE MIDDLE EAR :
A FACTOR IN FAVOR OF EARLY INTERFER-
ENCE IN SUPPURATIVE AFFECTIONS (WITH
DEMONSTRATIONS).*
BY
EMIL AMBERQ, M.D.,
of Detroit, Mich.
In order to consider to what extent the surgiral
anatomy of the middle ear furnishes a factor for timely
interference in suppurative affections of this region, we
may remember the following points :
1. The tympanum, epitympanum, aditua ad antrum,
antrum and mastoid cells form one cavity which is con-
nected with the pharynx through the eustachian tu'>e.
• Read before the Wayne Ck>anly (Detroit) Medical Hoolety, Hep-
tember 4, 1902.
774 A.HKBIOAN MKDiciNKi SURGICAL ANATOMY OF THE MIDDLE EAR
[November 13, 1902
This explains why in every acute suppuration of the
tympanum, according to Politzfr,' pus is found in the
Fig. 1.— Posterior part of left temporal bone. Cut tbr. ugh decalcified
specimen, photographed at an angle of about 90° from the front.
(Photographed by C. M. Hayes <t Co., Detn It.) A, antrum; B,
horizontal semicircular canal; (.', meatus; D, facial nerve; E,
part of stapes ; F, carotid.
cells of the mastoid process, and explains further that an
inflammation of the tympanum may easily affect the
cavities mentioned. We may, therefore, well make the
Fig. '2.— Anterior part of same temporal bone (see Fig. 1). Back view.
Photographed by C. M. Hayes & Co., Detroit, at an angle of about
46°, and somewhat from below. A, antrum; B, Facial nerve; C,
part of stapes.
practical deduction that it is wise to prevent, by a
timely incision of the drum membrane, an accumulation
of pus in the tympanic and adjacent cavities. This
i.s especially important when the ear is involved in
infectious diseases. Koerner,'^ of Rostock, says : " We
further see that a cure resulted the quicker, the earlier
the paracentesis was done. On the average the cure
wa.s completed as follows :
" When the paracentesis was done on the first day, cure effected
on the seventh.
" When the paracentesis was done on the second day, cure effected
on the ninth.
" When the paracentesis was done on the third day, cure effected
on the fourteenth.
'■ When the paracentesis was done on the fourth day, cure effected
on the fifteenth.
" When the paracentesis was done on the fifth day, caie effected
on the sixteenth.
" When the paracentesis was done on the sixth day, cure effected
on the twenty-fourth.
" When the paracentesis was done on the seventh day, and later,
cure effected on the twenty-sixth.
" If the drum membrane was allowed to break by itself on the
first, second, third, fourth day, or later, cure effected on the four-
teenth, seventeenth, twenty-first and twenty-sixth days respectively."
Koerner also shows that early paracentesis is the best
preventive of complicating mastoiditis.
Fig. 3.- Cut through decalcified specimen, showing proximity of epi-
tympanic cavity to cranium, etc. (Part of hammer-head lost, rest
of hammer-head peihaps somewhat outof position.) A, hammer;
B, anvil ; C and D, carotid.
2. The floor of the tympanic cavity and the floor of
the mastoid antrum witli the mastoid cells are not form-
ing one smooth plane, but are separated from each other
like two valleys are separated by a h.ll. This explains
why a middle ear suppuration which involves the ma.s-
toid antrum and the ma.stoid cells may come to a stand-
still .so far as the tympanic cavity is concerned, and yet
the process may go on in the antrum. It also explains
that the hearing may be good, and i evertheles.s, a
destructive process continue in the mastoid. We sh( uld
not regard the absence of discharge from the tympanic
cavity as a contraindication for opening the mastoid
when there are syiuptoms of mastoid involvement, and
interference .'^hould not be delayed.
On June 27, 1902, Dr. Learuiont, of Croswell, brought to my
office E. W., a male, aged 7. I was told that a year ago last
May the left ear discharged after a cold ; no pain previous to
the discharge. In November or December a swelling occurred
behind the ear. An incision was made behind the auricle by
another physician, while family was in L. The wound healed,
November 15. 1902]
SUKGICAL ANATOMY OF THE MIDDLE EAR [American mtoicink 775
leaving a fistula whiirh allows a probe to enter for about an inch
in depth. There is also a fistula in the canal in the posterior
lower position near the entrance. There is no discharge from the
inner part of the meatus. The boy hears " 25 " whispered a dis-
tance of about one foot, in left ear, and "85" in conversation voice
a distance of about 12 feet. There is no pain on pressure over
the mastoid except over the tip. The patient has rosy cheeks
and looks very healthy. The parents were told that the only
safe way was to follow the fistula in order to see where the
trouble was located.
The patient was admitted the same night to Harper Hospital
and operated on the next morning. After the incision a large
cavity was found filled with detritus. This was thoroughly
cureted. Separated from the first focus by a bridge of healthy
bone, upward and backward on the outside of the bone was a
second cavity about i inch in diameter. The patient remained
two weeks in the hospital, the wound being dressed almost
ddily with iodoform gauze dipped in weak creolin solution, on
account of the presence of Bacillus pyocyaneus in detritus,
which was reported as being present by the Detroit Clinical
Laboratory. Examination for Bacillus tuherctilosis not made.
The patient returned home, and according to the last report,
August 25, the wound has healed since August 1.
3. The mastoid cells lie in all directions from the
antrum. This explains that a mastoid affection is not
Fig. 4.— Cut tlirough decalclfled specimen. Same left, temporal bone as
Fig. 3 Stiows facial nerve, horizontal and upper semicircular
canals, etc. A, K, horizontal semicircular canal ; B. upper semicir-
cular canal ; C, horizontal semicircular canal; U, facial nerve; E,
upper semicircular canal ; F, facial nerve. Figs. 3 and 4 were pho-
tographed by E. H. Hayward, a medical student In Detroit.
an affection of a uniform character. The disease may be
found in one or more parts of the mastoid. The practi-
cal deduction, therefore, is not to wait to open the mas-
toid until an extensive destruction reciuires an extensive
operation, a-side from inviting the danger of neighboring
parts becoming affected.
The multiform character of the ma.stoid also explains
why it is necessary to investigate thoroughly under
proper illumination every diseased portion of the mas-
toid {)rocess. The anatomic fact that the mastoid cells
reach downward also explains neck abscesses through
infetttion after the tip has been perforated.
Sometimes pus may migrate between the cutaneous
layer of the external meatus and the mastoid and infect
the tissues of the neck.
4. In the middle ear we find the three ossicles, of
which especially the hammer and anvil serve to make
the epitympanic space and also the tympanic cavity
more uneven and complex. The practical deduction,
therefore, is to remove the diseased ossicles in case of
suppuration in order to remove a focus of infection and
attain a smoother cavity.
5. The roof of the epitympanic cavity is very thin,
sometimes as thin as paper.
6. The lateral sinus is practically imbedded in the
mastoid cells without having a firm protection, as, e. g.,
the semicircular canals.
7. The facial nerve, in part of its course, sometimes
suffers from the same disadvantage. A part in the hori-
zontal portion is not covered by bone in almost all cases.-*
8. The bulbus of the jugular vein is separated from
the floor of the tympanic cavity only by a thin layer of
bone. In very rare cases it even appears in the tym-
panic cavity.
9. The carotid artery is so located that caries of the
lower floor and of the inner wall of the tympanic cavity
can affect the same.
10. The relation of the inner ear to the middle ear
and to the cranial cavity is a close one.
11. The middle and posterior cranial fossas are direct
neighbors of the middle ear.
12. In early years a fissure, the petrosquamosal fis-
sure, runs the whole length of the tegmen tympani.*
13. In childhood the mastosquamosal fissure is open
and remains occasionally unossifled in after life.*
Aderman could see the mastosciuamosal fissure among
5, 108 mastoids in the collection of skulls in the
Museum of Natural History in Vienna 1,860 times; in
64 it was very plain, in 845 plain, and in 951 traceable.
The fissure could be missing in children and be present
in skulls of very old people."
14. Many veins form a connection with the dura
matral system of veins.'
15. Many of the before mentioned conditions are
made more formidable by the sclerosis of the outer wall
of the mastoid process which is frequently found in sup-
purations of long standing, obscuring the symptoms and
forcing the pus to work its way to the points of least
resistance.
The photographs illustrate fairly well the surgical
anatomy of the middle ear.
When we consider the multitude of ways by which
a suppuration of the middle ear may lead to serious
complications and death, we can well understand Wilde's
remark: " So long as otorrhea is present we never can
tell how, when or where it will end, or where it may
lead." And also that Macewen, of Glasgow, can say:
" Where the tympanic cavity has become the seat of
chronic suppuration with ulceration of the mucous
membrane extending into the antrum and mastoid cells,
it becomes a standing menace to the safety of the
patient. The disease progresses insidiously, and one
cannot be certain as to where and when it may end. A
person might as well have a charge of dynamite in the
mastoid, antrum and cells, etc."
Judging from the number of articles in various
medical journals, the interest of the profession seems at
present to be somewhat directed toward the justification
of an early mastoid operation, and I therefore repeat the
classic indications as enumerated by Schwartze,' which
are justified by the surgi(Sil and pathologic anatomy of
the middle ear and by the clinical experience of those
most able to judge :
"1. In acute primary and secondary inflammation of
the mastoid process, if under application of antiphlogis-
tic remedies (especially applimtion of ice), pain, edema
and fever do not cease after a few, not more than eight,
days. 2. In chronic inflammation of the mastoid por-
tion, with repeated attacks of swelling which disappear
for a time, or with already-formed abscess, fistulas of the
skin over the same, with descending abscesses on the
side of the neck and throat, in the meatus, or toward
the pharynx, even if for the time being there do not
exist symptoms endangering life. 3. In chronic suppu-
776 Ahebioan MeDICISBi
ANKYLOSTOMIASIS
[NovhMBER 15, 1902
ration of the middle ear, without other symptoms of in-
flammation of the mastoid, so sooni as symptoms appear
which malie it probable that there is a complication
endangering life, caused by retention of pus or the for-
mation of cholesteatoma. 4. In otherwise incurable
neuralgia of the mastoid process. 5. As prophylactic
operation against fatal sequels or incurable fetid suppu-
rations without signs of inflammation on the mastoid
process and without signs of retention of pus (pain,
fever) so soon as an exact otoscopic examination shows
that the suppuration is not confined to the tympanum."
When interference is not directly based on the vital
indications we may remember that a timely paracentesis
may frequently make a mastoid operation unnecessary,
that a timely mastoid operation may save the patient
from undergoing a radical operation or operations for
complications, which latter interferences, as we know,
are not by any means always crowned with success.
BIBLIOGRAPHY.
•Adam Politzer: Lehrbuch der Ohrenheilkunde, pp 415 and 516,
Fourth edition ; Stuttgart, Verlag von Ferdinand Enlce, 1901
2 Koerner: Arcliiv fur Ohrenheilkunde, Vol. 56, pp. 87 and 88, Au-
gust 5, 1902.
^Henle: Lehrbuch der Anatomle, 1855, Vol. i, p. 147 (quoted by
Trautman in (Jhirurgische Anatomle des Schlaefenbelnes, etc., p. 2.5;
Veriasr August Hirschwald, Berlin, 1898).
* William Macewen : Pyogenic Infective Diseases of the Brain and
Spinal Cord, etc., p. 5; James .Maclehose & Sous, publishers, Glas-
gow, I89».
sibid, p. 5
" Aderman : Zeltschrlft filr Ohrenheilkunde, xx.xvii 4, p. 358 (quoted
from Archiv fiir Ohrenheilkunde, .August, 1902.)
'See 4, pp. Band 7.
« Hermann Sehwartze: Handbuch der Ohrenheilkunde, ii, p. 791.
Verlag von F. C. W. Vogel, Leipzig, 1893.
ANKYLOSTOMIASIS, THE MOST COMMON OF THE
SERIOUS DISEASES OF THE SOUTHERN PART
OF THE UNITED STATES.
BY
H. F. HARRIS, M.D.,
of Atlanta, Ga.
In American Medicine for July, 1902, I reported a
case of ankylostomiasis. After my article had been sent
to the publishers the distinguished helminthologist of
the United States Bureau of Animal Industry, Dr.
Charles Wardell Stiles, announced the important dis-
covery that a species of Ankylostimum exists in this
country that is not found in the old world, and differing
in some important particulars from Uncinaria dtuxknalb.
This new parasite he has named Uncinaria americana.
It may as well be stated here that Dr. Stiles has kindly
examined the parasites from one of my cases and has
found that they belong to his new species ; in all other
instances where the worms were obtained the like was
found to be true. The discovery of a distinct American
species of the hook-worm is very important, as it leads
to the inference that the aborigines of this country were
infested with this parasite, and that the worm is prob-
ably present in all parts of the United States where the
conditions are suitable for its development.
My observations during the last six months bear out
this assumption in a most striking manner. A few-
weeks after my first case of the disease was seen a
second one was encountered that originated in middle
Georgia, but though I was constantly on the search for
it, no other case was found among the numerous
patients that come to the clinics of the Atlanta College of
Physicians. In June of the present year I made a trip
to north Georgia, a region that has long been noted as
one in which the inhabitants are very pale and anemic,
this condition being commonly reputed to be the result
of dirt-eating. Here I saw many instances of what was
in all probability ankylostomiasis, but as a result of the
ignorance of the people and their suspicion of all
strangers, a proper examination could be obtained in
only four cases, in all of which the parasite was demon-
strated. Subsequently a case of the disease was seen that
originated in middle Alabama. During September and
October I have been studying malaria in f-outh (ieorgia
and Florida, a region in which the people show profound
anemia even more often than in north Georgia. This
condition is commonly ascribed to malaria, but my
observations show that in almost all instances the sufferers
have no malarial parasites in their blood, but eggs of the
ankijlostoma are constantly found in the feces. During
my entire stay in this region I only saw one case of pro-
found anemia from malaria, and in this instance the
patient did not exhibit the extraordinary anemia so
commonly found in those infected with theankylostoma.
I feel no hesitation in saying that time will show that
by far the greater number of cases of anemia in Georgia,
Alabama, and Florida are due not to malaria but to the
ankylostoma, and that this is the most common of all the
.serious diseases in this region. There can be no reason-
able doubt that what is true as regards the States named
likewise holds good for the entire South. Since my first
case was reported thirteen other instances of the disease
have been seen — eleven originating in this State, and
one each in Florida and Alabama, and if all of tho.se
encountered who were suffiering from anemia could have
been examined there can be no doubt that the number
would be many fold greater.
This communication is written in the hope that
Southern physicians will take up this most important
matter at once, for in no other serious disease does the
victim suffer so long, in no other condition is he for such
a period a menace to those about him, and in no other
malady of such gravity is the treatment so rapidly and
surely successful.
I shall be very glad to report without charge on
specimens of feces sent me for examination. A very
small quantity of fecal matter is sufficient for this exami-
nation, but it should be sent in a bottle in order to keep
it moist.
THE ACCIDENTS OF ANESTHESIA : THEIR PREVEN-
TION AND TREATMENT.
D.VNIEL N. EISENDRATH, M.D.,
of Chicago, 111.
Professor of Clinical Anatomy. Medical Department University of
Illinois ; Surgeon to Cook County Hospital ; Professor of
Surgery, Postgraduate Medical School.
It would seem as though the subject of anesthetics,
especially ether and chloroform, had been discassed so
tlioroughly in the last 20 years, both in Europe and
America, as to leave but little to be .said. My only
reason for bringing it up at the present time is that our
more exact methods of clinical observation and of ex-
perimental investigation have given us far more accurate
knowledge of their action. Antisepsis, anesthesia and
hemostasis have been the foundation stones upon which
modern surgery has been erected. Many anestlietics or
methods of anesthesia have been proposed from time to
time, bit the two jnoneers, ether and chloroform, still
hold the first place. Ethyl bromid, ethyl ehlorid, and
Schleich's petroleum mixture as general anesthetics, and
the methods of spinal anesthesia and local anesthesia
(Schleich), have been brought forward by enthusiastic
advocates, but each in turn has been either set aside ot
its field of usefulness greatly limited. Of these later
methods the local anesthesia of Schleich with proper
limitations bids fair to become a i)ermanent aid. Its
sphere, however, seems to be chiefly for minor or moder-
ately severe operations, the former class including the re-
moval of .small tumors in the skin, and the latter removal
of goiters, etc. Its application must necessarily be some-
what limited, and neither it nor the use of spinal anes-
thesia can ever hope to supplant the use of general anes-
thetics. I have tabulated below that which clinical
observation and experimental study in animals has
November 15, 1902]
ACCIDENTS OF ANESTHESIA
American Medicinh 777
taught US in regard to our two most frequently used
anesthetics — ether and chloroform. It will not be neces-
sary to repeat in detail the names and results of the in-
vestigators, including work of my own, which have per-
mitted this tabulation. There is no question that
chloroform, according to every statistic, is far more
dangerous than ether. In 240,806 cases of chloroform
anesthesia collected by the German Surgical Society
there were 116 deaths, or one in 2,075 cases. In 56,333
cases of ether anesthesia there were 11 deaths, one in
5,112.
The physiologic action can be compared as follows :
Arterial ten-
sion and
blood-pres-
sure.
Heart.
Mouth, nose
and pharynx.
Stomach and
intestines.
I.iver.
Kidneys.
Ether.
Oreatly increases both.
Stimulates and large
doses paralyze. Zone
between these quite
large.
Has slightly direct ir-
ritating effect, caus-
ing some increased
traclieobronchial se-
cretion. Stimulates
respiratory center
and large doses pa ra-
lyze. Zone very
large.
Greatly increases all se-
cretions. Large doses
pariilyze muscks ol
tongue, epiglottis and
palate. Both above
favor aspiration.
Considerable nausea
and vomiting. Mod-
erate tympanites.
Chloroform.
Temperature.
Pupils and cor-
neal rotlex.
No effect.
In normal kidneys
transitory effect
(casts and traces of
albumin), decreased
amount of blood and
secretion. In diseased
kidneys bas a bad ef-
fect, may cause anu-
ria and uremia.
Lowers 11.
Pupils contracted some
and respond. Corneal
rellex of some value.
Gradually decreases bolh.
Depresses and large doses
paralyze; zone between
these two, small.
Slows respiration and
large doses paralyze.
Zone not large.
SC-vrcely .any effect on se-
cretions. Large doses
also paralyze tongue,
etc.
Less nausea than ether as
a rule; in large dosis
causes some fatty degen-
eration of muscles.
Prolonged administration
causes fatty degenera-
tion with decreased gly-
cogen, icterus, and in
fatty liver may cause
acute yellow atrophy.
In ordinary administra-
tion and normal kidneys
but slight transitory ef-
fect. In prolonged ad-
ministration causes con-
siderable fatty degenera-
tion.
Lowers it less than ether.
Pupils somewhat con-
tracted but respond. Sec-
ondary dilation of pupil,
bad sign. Corneal re-
flex of little value.
Whereas ether stimulates the heart, chloroform
directly depresses it. The heart mu.scle is very sensitive
to the poisonous effect of chloroform and death may be
caused by its toxic action on the heart ganglions alone.
l''.fnbley has lately shown that chloroform raises the
excitability of the vagus mwhanisni and stimulates the
central medullary va.soniotor system, causing great fall
in bloofl-pressure, and this directly producing a failure
of rosi)iration. Upon the lungs chloroform jirobahly
has no direct local effect a.s it has upon the iicnrt. It
produces a slowing of resiii ration and failure through the
fall in blood-pressure. Ether, on the other hand, stimu-
lates the respiratory center and has a slight local irritat-
ing effect, causing some increased secretion of tlie tracheal
and bronchia! mucous glands. On the mouth, nose and
pharynx, chloroform has no direct effect, while ether
greatly stimulates their .secretions, and especiidly the
secretionof the sail vary glands. Ether, as a rule, produces
more nausea and vomiting than chloroform, although at
times the opposite seems to be the case, due perhaps to the
toxic action of chloroform upon the kidney, and the
resultant uremic condition. Ether has no effect on the
liver while chloroform, when administered for a long
time, causes fatty degeneration and icterus. In cases of
fatty liver it may cau.se acute yellow atrophy, as has
been observed several times. Upon the healthy kidney
chloroform has about the same effect as ether ; that is, a
transitory (two to three days) appearance of casts, and
traces of albumin. This is somewhat more frequent
with chloroform, as I observed it in 110 cases, than with
ether. Prolonged administration of chloroform, how-
ever, has a bad effect upon the parenchyma of the kid-
ney in the same manner as it has upon that of the heart
muscle — it produces fatty degeneration and may cause
death a number of days after the anesthetic has been
given. Upon the diseased kidney some still contend
that ether has no effect, but my own clinical observatioil
of cases of uremia following ether administration and
the reports of Emmett and Weir would seem to be suffi-
cient grounds upon which to base the opinion that it has
a bad effect and may cause anuria and uremia. Both
chloroform and ether at first dilate the |>upil, this being
rapidly followed by contraction, during which latter
period they respond to light. In case of chloroform
this response to light is one of the Ijest guides as
to the depth of the narcosis, and as soon as the pupil
begins to dilate for the second time, that is after it has
been contracted, syncope is already present.
When should we give chloroform and when ether?
1. Ether should not be given when there is increa.sed
arterial tension and blood-pressure, for example in
atheromatous conditions. 2. It should not be given
when there is gnat tympanites or under conditions
which will interfere with the actions of the diaphragm.
3. It should not be given to nei)hritic patients for the
reasons before stated. 4. It should not be given when
the postoperative treatment requires a prolonged recum-
bent position, for as I will show later the hypos atic
congestion of the lungs plus the increased amount of
.salivary secretion, which latter ether causes, favor the
development of pneumonia. 5. Ether is contraindi-
cated in individuals who have from any cause a hypcr-
emic condition of the respiratory tnict. The increased
secretions which it causes are so frequently aspirated
into the lungs. Contraindication to the use of chloro-
form is any condition in which there is decreased
blood-pressure owing either to great lo.ss of blood or
some sy.stemic disea.se, for under these conditions the
tendency of chloroform to increase the already dimin-
ished lilood-pressure will cause a rapidly fatal syncope.
6. It is eontraindicated in affec^tions of the heart in
which there is lack of compensation, in myocarditis and
in pericardial adhesions. The opinion which is pretty
generally held at the present time is that there are no
contraindications to its use in ordinary valvular or
functional forms of heart conditions. I have bad occa-
sion to administer chloroform to a number of patients
witli compensated valvular affections and could not
observe any unpleasant symptoms. The cardiac disease
which perhaps requires the greatest care according to
.some is aortic disease. At a recent meeting of the Paris
Medical Society the general conclusion was that there
was no obje<-tion to administering chloroform to ptiticiits
with heart disease provided there was compensation and
no myocarditis. 7. Chloroform should not be adminis-
tered in the socalled status thymicus or the thyroid
state, Kundrat in 18!)5 first called attention to the reg-
ularity with which the administration of chloroform
was followed by death in this condition. Me reported
at that time 12 fatal cases, and recently Lacpicr reported
the same condition in a child, and Strausmann found this
condition fourtimes in tenautopsiessubsequenttocholoro-
form administration. It is fretjuently impossible to diag-
nose this state l)efore operation, but we should bear it in
mind. It consists in enlargement of the faucial and'
lingual tonsils, persistentand enlarged thymus gland and
enlarged spleen. 8. Chloroform slinnld not be given in
778 AUERICAN MEDIOIKE]
ACCIDENTS OF ANESTHESIA
[November 15, 1902
either acute or chronic septic conditions, the heart being
already greatly wealiened through the action of toxins.
9. Chloroform should never be given when it is neces-
sary to administer it for more than an hour, on account
of its degenerative effect upon the heart muscle and
parenchyma of the liver and kidney.
There are certain general diseases in which we
should hesitate greatly to administer either chloroform
or ether ; for example, diabetes, leukemia, and cachetic
conditions, etc. A number of eases have been reported
of diabetic coma following tlie administration of an
anesthetic.
Administration af Anesthetics. — Kionka has shown
that in order to produce narcosis with chloroform it is
only necessary to have from Afo to 1.3% chloroform in
the inspired air. In order to accomplish this, an ordi-
nary Esmarch mask, covered with gauze two layers
thick, must be used, and not a towel and handkerchief.
It should be given drop by drop. In order to over-
come a paralysis of the muscles of the tongue and liga-
ments of the epiglottis and the resulting closure of the
glottis, the patient should be kept on the side as much
as possible during the administration of the anesthetic,
especially of chloroform, and the anesthetizer should be
taught the best method of pulling the jaw forward.
In the use of ether one must remember that this
anesthetic greatly stimulates the secretions of the mouth,
nose and pharynx. Their aspiration has been beauti-
fully demonstrated by Lindemann and Holscher. There
is with every inspiratory effort a direct aspiration of
this mucus into the finest bronchi. These investigators
.stained the mouth secretions and found them in the
finest bronchi after one hour's anesthesia. This aspira-
tion of the mouth secretions with their myriads of
organisms has frequently caused the pneumonia follow-
ing operations. In case of ether we can avoid this
aspiration to a certain extent by giving it in a
diluted form on an Esmarch mask, as first shown by Dr.
Prince, and avoiding as much as possible the older
method of asphyxiation.
Kionka has also shown that it is not necessary to have
97 parts ether and three parts air as many have formerly
thought, but that it suffices to have a mixture of from
2/c to 8ff ether with the inspired air. With every
anesthetic a larger quantity is necessary to produce sleep
than to continue it. We can also aid in avoiding pneu-
monia after ether by adhering to the same rules as in
chloroform, keeping the head dependent below the level
of the trunk and turned on one side. There is little
danger in using ether other than the bronchial irritation
if these suggestions are strictly adhered to.
It was formerly thought that acute pulmonary com-
plications following operations were' more frequently
found with ether than with any other anesthetic.
Mikulicz has shown that the percentage is relatively
larger in local anesthetics (Schleich) than if a general
anesthetic is given. In the last few years 1,007 goiter
operations and laparotomies with general anesthesia
(chloroform) were followed in 7.5 /o of the cases by
pneumonia, and of these 3.4 /c terminated fatally. Of 273
similar operations under local anesthesia, 12.8 fc were fol-
lowed by pneumonia, of which 4.10 /«, terminated fatally.
This shows that we can no longer blame the general
anesthetic as being the chief cause of pulmonary compli-
cations following operations.
It is now generally believed that these complications
may be due to one or a combination of the following
factors : First, they may follow an anesthetic, especially
ether, when given in too concentrated a form, due to the
fact that the mouth secretions are aspirated into the
trachea and bronchi, and may give rise to a bronchitis,
lobular and lobar pneumonia. Second, they may be
hypostatic, and this may occur with ether as well as
with chloroform, due to the recumbent position,
diminished heart-a^-tion, close fitting dressings, and to
the tympany following operations, which is frequently
a result of the paralysis of the muscular fibers of the
intestines. Third, there may be aspiration of the
particles of food, and this may occur with ether as well
as with chloroform, giving rise to pulmonary abscesses
and gangrene. Fourth, embolism, and this is the fre-
quent explanation of the causes, including the cases in
which cocain has been used, of the pulmonary complica-
tions of which we have spoken. This is especially fre-
([uent after operations in the pelvis and strangulated
hernias, and when there has been any previous anemia,
or in cachetic individuals.
We can avoid these complications to some extent by
remembering that both ether and chloroform lower the
temperature of the body. Chilling, which is due to
unnecessary exposure of patients and the overheating of
the operating-rooms and the application of moist aseptic
towels, should be avoided as much as possible. The
glass top of the operating-table heated by hot water
bags would seem to be the ideal condition. In older
patients stimulants should be given before and after
anesthesia. Patients should never be kept in a
recumbent position for too long a time. They should
be encouraged to take deep breaths after the opera-
tion. Tympany may be somewhat relieved by the
use of turpentine enemas. Whenever it is permissible
we should try to operate under local anesthesia (Schleich)
as much as possible. As a preparation for any operation,
in order to avoid accidents, the urine should be carefully
examined in a 24-hour specimen for casts, albumin,
sugar and percentage of urea. It has been observed that
latent diabetes is brought into prominence and may
cause death by diabetic coma after anesthesia.
Examination of the urine after anesthetjia will fre-
quently show the cause of persistent headaches and
nausea to be due to uremia. Patients should be encour-
aged, if possible, to take fluids freely after operations,
and if this is not possible, be given enemas of salt solu-
tion at regular intervals. In case a large quantity of
blood has been lost and the blood-preasure lowered, an
intravenous salt transfusion may be given during or after
operation, for many a life has been saved in this manner.
A quarter to one-third grain of morphia given before the
anesthesia begins will greatly diminish the difficulty
of anesthetizing alcoholics. Among other preparations,
the emp'y condition of the stomach and intestines, and
removal of foreign bodies from the mouth, a bath given
not too soon before the operation and absolute mental
quiet, are requisite.
Having taken all these precautions to prevent an acci-
dent, how can we best treat them ? Plrst, in case of a
syncope following either the administration of chloro-
form or ether, especially the former, after which it is
more frequent, there should be in the minds of every
operator a certain sequence or routine of methods of
resuscitation. In every hospital or ambulatory clinic
the anesthetizer should be taught that in ordi r to be suc-
cessful in treating a syncope there must be no confusion.
Every method must be tried in a certain more or less
fixed succession. This will, of course, vary somewhat
with the experience of the individual operator.
The main points are to begin early and systematically.
Artificial respiration began one-half to one minute after
syncope has begun has been shown to be of no avail.
The moment, or rather second, that the cessation of pulse
or respiration is noticed, raise the foot of the table. Do
not lose valuable time trying to get hypodermics with
heart or respiratory stimulants ready ; they are of no
benefit when there is no circulation to carry them to the
heart. The plan of many operators is to begin first of
all with artificial respiration by the wellknown method
of raising the arms as far as possible above the head and
then bringing them down upon the thorax in a flexed
position, at the same time making firm pressure against
the side of the chest with the elbow of the flexed arm.
I have been in the habit of using the method of Konig-
Maas, massage of the heart, as the first method after
IV'OV EMBER Id, 1902]
PERNICIOUS ANEMIA AND ACHYLIA GASTKICA .ajuericar mkdicxsk 779
raising the foot of the table. This consists in making
pressure over the precordial region at the rate of about
1:20 times to the minute. It is practically a shaking up
of the heart and acts by mechanically stimulating the
heart muscle and thus preventing clotting of the blood
in the ventricles. I have never failed to obtain an
immediate response, so that the heart would begin to
contract again very promptly. During the past three
years I have had occasion to try the efficacy of this
method in 7 cases of syncope, all in the deep state of
iiarcosifi. The anesthetic was given in hospital or dis-
pensary work, by undergraduates in four and by gradu-
ates in the other three. There was unquestioned cessa-
tion of the heart, as was remarked at the time, before
that of respiration in 6 cases. This primary cardiac
paralysis is far more frequent than is generally believed.
Mikulicz found 34 primary cardiac and 6 primary respi-
ratory syncopes in 44 cases. In 4 there was simultaneous
cessation. Such a primary heart syncope is a very
serious condition and must be met promptly. In all
7 cases shortly after the massage of the heart was
begun the heart was felt to contract again, and then with
the aid of a second method, which I believe ought to be
tried either at the same time or immediatt-ly after, the
respirations soon returned.
This second method is that of Laborde's rhythmic
tractions of the tongue. This is done by taking hold of
the tip of the tongue with vulsella forceps and pulling it
out as far as possible at the rate of 16 to 18 times a
minute. It acts by stimulating the respiratory center
reflexly through the glossopharyngeal and superior
laryngeal nerves. I believe that ordinarily one of these
three methods— artificial respiration, massage of the
heart, and tongue traction — will suffice. But in case of
the continuance of the syncope there are a number of
other excellent methods which have restored some
patients in an apparently hopeless condition. They are
the methods of Prus— intravenous transfusion and the
intratracheal inflation of air.
The method of Prus was first proposed in 1900 as the
result of experiments on dogs. Out of 21 with cardiac
paralysis following chloroform 16 were, resuscitated by
this method. During IttOl a case of a human being
kept alive for eight hours after all other methods had
failed was reported by Maag. The heart did not begin
to beat until it was grasped by the hand placed inside
of the thorax, and then it continued to beat for eight
hours, although the respirations did not begin spontane-
ously until half an hour after the heart had begun to
beat. This method of Prus certainly ought to be tried
ill desperate cases. It consists in opening the peri-
cardial cavity and making the same movements while
the heart is held in the hand as one would in compress-
ing a rubber ball. Before reading of this I resuscitated
a dog by a similar method, with the hand introduced
into the left pleural cavity, two years ago. The object is
the same as that of Konig-Maas' method, viz. , to stimulate
the heart mechanically. The only difference is that in the
Prus method the heart is caused to beat by the direct
contact of the hand, while in the other it is done through
the chest wall.
Intravenous transfusion accomplishes remarkable
results when combined with one of the other methods.
Korte rescued a patient with a seemingly hopeless case 40
minutes after the heart had ceased to beat. He employed
the method of Konig and transfusion. This is espe-
cially recommended when the syncope is due partly
to the sudden lowering of blood-pressure due to chloro-
form and a considerable loss of bhxKl.
Another meth<Ml for use in desperate cases is to per-
form a tracheotomy and introduce a Trendelenburg bal-
loon cannula and then inflate with the aid of a pair of
bellows. The object of the special mnnula is to prevent
the entrance of the air into the stomach and intestines,
thus pushing up the diaphragm. The stimulus to the
lungs has been found to start up resj)iration after syncope.
Among other methods I might mention are the
electric stimulation of the phrenics, stretching of the
sphincter ani, irritating the fauces, the finger inserted
into the throat and acupuncture of the heart (McArthur).
In regar I to ether accidents, their prevention is the
more important. The pneumonias and other pulmonary
conditions should be treated as if they arose from other
causes.
SUMMARY.
1. Chloroform has a narrower zone of safety than ether.
Its toxic effects are as a rule manifest at the time of ad-
ministration. Ether is the cause of death in many cases
through renal or pulmonary complications from hours to
days after the anesthesia. The late deaths due to chloro-
form are so rare as to render this factor practically of no
importance. Chloroform is a more dangerous anesthetic
than ether and must be watchetl far more carefully.
2. Chloroform kills more frequently through pri-
mary cardiac than respiratory syncope, and the anesthe-
tizer must watch constantly the decrease in volume and
rapidity of the pulse, indicating the fall of blood-pres-
sure, and a slowing of the more shallow respiration.
Chloroform syncope can be avoided by keeping the head
low, if possible turned to one side, keeping the jaw for-
ward, watching the pulse, respiration and pupil, keeping
the patient's mind quiet, and keeping the chloroform
well diluted with air.
3. Ether rarely causes death through its immediate,
but more frequently through its after-effects, such as
pneumonia and uremia. These complications may be
avoided by keeping the head lower than the level of the
body, turned to one side, and not giving the ether in too
concentrated a form ; also by not keeping the patient on his
back too long, and by relieving postoperative tympanites
as soon as possible. The contraindications to the use of
chloroform are myocarditis, pericardial adhesions and
noncompensated valvular disease. In all other forms of
heart disease it may be given. It should not be given
when the blood-pressure is low or in status thymicus, or
when a prolonged anesthesia is necessary.
4. The pulmonary complications are relatively more
frequent with local anesthesia than if a general anes-
thetic is given. They may be due to aspiration of
mucus or food, or due to hypostasis and to embolism.
The latter is far more frequent than is ordinarily
thought. Avoid these by exposing patients as little as
possible. Use heated operating tables, avoiding recum-
bent position and tympany.
5. Avoid renal complications by careful examination
of the urine before anesthesia.
6. Begin process of resuscitation immediately and
systematically : Artificial respiration, the method of
Konig-Maas, or massage of the heart, rhythmic traction
of the tongue, method of Prus, or direct exposure of the
heart and intravenous salt transfusion. I prefer to begin
with massage of the heart and rhythmic tractions of the
tongue (16 to 18 times a minute).
THE RELATION BETWEEN PERNICIOUS ANEMIA
AND ACHYLIA GASTRIGA.'
BY
HARRY ADLER, M.l).,
of BalUmore, Md.
Associate Professor of Diseases of the Stoniach and Intestine!* In the
University of Maryland.
Patients with progressive pernicious anemia present
themselves, showing marked pallor of the skin, suffering
from loss of appetite, various symptoms of faulty diges-
tion, general weakness and difficulty in locomotion,
associated perhaps with an atiixic, or more rarely, a
spastic gait. Examination of the blood gives the
charatiteristic blood cell changes. Examination of the
I Head before the American Gastroenterological Society, Wash-
ington, May 1, 1902.
780 AMKKicAK MKDxciNE, PERNICIOUS ANEMIA AND ACHYLIA GASTRICA
INOVKMBER 15, 1902
stomach contents shows, certainly in the majority of
cases, the absence of hydrochloric and the ferments,
symptoms of atrophy of the gastric mucosa. Attention
to the nervous system furnishes evidence of spinal cord
trouble, indicating, usually, involvement of the posterior,
less frequently of the lateral columns. The question
immediately suggests itself: Is there a fundamental
trouble underlying these pathologic conditions of the
blood, stomach, and cord, or is one the cause of the
others ?
As early as 1860 Austin Flint, in a lecture on anemia, re-
ferring to this condition of intense anemia associated with
anorexia and an absence of postmortem change sufficient
to explain the cause of death, said : " I suspect there
exists degenerative disease of the glandular tubuli of
the stomach. ... I shall be ready to claim the
merit of this idea when the laborious researches of some
one have shown it to be correct." It was Fenwick who
carried out these researches and to whom the credit is
due of having placed upon the basis of pathologic inves-
tigation the proof of what was until then only a suspi-
cion. He was the first to demonstrate atroijhy of the
stomach in pernicious anemia, and looked upon the
anemia as the result of the action of abnormal sub-
stances formed in the atrophic stomach. After H. C.
Wood's and Conheim's discovery of the changes in bone-
marrow in this disease, consisting of a transformation of
yellow marrow into red lymphoid marrow, in which
nucleated red blood cells, both normoblasts and megalo-
blasts, are especially numerous, the fundamental cause
was thought to have been discovered. The marrow was
thought to contain the essential lesion and be the seat of
the disease to which the blood changes are secondary.
Observations by Eichhorst, LC'pine, Ferrand, Bramwell
and Neumann have effectually disproved this theory.
They found that in undoubted cases of pernicious anemia
these changes did not occur, and that on the other hand
they were present in cases of secondary anemia from
protracted hemorrhage, tuberculosis and carcinoma of
the stomach. Neumann published a case of continuous
uterine hemorrhage resulting in death, in which the
yellow bone-marrow showed the transformation into red
marrow with an enormous increase in the nucleated
reds, changes identical with those found in pernicious
anemia. The fact that after hemorrhages these changes
occur causes us to look upon them as secondary and
regenerative, rather than primary and degenerative.
Since we can no longer look upon the bone-marrow as
having causal relation, are we to regard the gastric and
intestinal atrophy as the primary condition ? Following
Fenwick's classic publication on the coincidence of
gastrointestinal atrophy and pernicious anemia, numer-
ous similar cases have been reported, notably by Quincke,
Nothnagel, Brabazon, Bartels, Scheperlen, Eisenlohr,
Stengel, Sasaki, Henry and Osier, Riegel and Kinnicut.
All look upon the gastric atrophy as a primary con-
dition.
Max Kock, who has recently reported five cases,
regards the anemia as primary. Ewald has expressed
the opinion that it is hardly possible to decide this ques-
tion from the histologic findings alone. Valuable data
are obtainable from the clinical study. In this connec-
tion I wish to report three cases coming under my
observation, two occurring in the University of Mary-
land Hospital and one in private practice.
Case I.— Minnie D.,aged 43, white, married, and the mother
of four children, two of whom died in infancy of diarrheal
trouble. She has been a hard-working woman, with good
habits of eating, drinking and sleeping. Sanitary surround-
ings are fairly good. There is no history of lues or alcoholism.
i<amily history is entirely negative. Father and mother lived
to the ages of 70 and 75, respectively.
Patient had the usual diseases of childhood and was in good
health until the second child was born, when she had puerperal
mania for 10 weeks. Last child was born 16 years ago. Her
present trouble began in August, 1899, with fever, jaundice and
vomiting. Jaundice cleared up in a few weeks, but she says
her skin never regained a healthy color. She became more
pallid until her skin became lemon colored. She was treated
lor Bright's disease, but says her urine wiis never examined.
She entered the hospital under the care of Dr. McElfresh, sutlV'r-
ing with extreme weakness, shortness of breath and cardiac
palpitation occurring after the slightest exertion, loss of appe-
tite, nausea and vomiting. Bleeding from the bowels was
present but no local cause was found on rectal examination.
On physical examination she appeared fairly well nourished,
weighing 145 pounds. Pallor of the skin was most marked, of
a lemon hue; conjunctivas were pearl-white and there was
piiftiness of the eyelids. Loud venous hum was present in the
neck ; systolic murmur over base of heart ; no cardiac enlarge-
ment,
Examination of other organs was negative. Patellar
reHexes were lost.
Urine. — Sp. gr. 1,020, high color, no albumin, sugar or ca'ts.
Stomach contents showed absence of free and combined HCl
and absence of ferments.
Stools, repeatedly examined for parasites and ova, were
negative.
Examination of Blood. — Ked cells, 520,000; hemoglobin, 12^;
color index, 1 + ; white cells, 3,000. Poikilocytosis marked,
normoblasts and megaloblasts present. One week later: Red
cells, 500,000; white cells, 3,000; hemoglobin, 11%. Patient
improved somewhat on arsenic and left the hospital three
months later; red cells, 750,000. She returned a few months
later with the cells reduced to 519,000. She was sufTering with
relative mitral insufficiency, marked edema of the extremities,
ascites and hydrothorax. Red blood count fell to 400,000; hemo-
globin, 9%, and sp. gr. of blood, 1,028. She died shortly after-
ward. No autopsy vvas obtainable.
Case II.— Cyrus L., aged 41, white, farmer, married. He had
been a moderate eater; frequently takes whisky before break-
fast; chews tobacco.
Family Histofi/.— Good ; mother and father living at ages
of 71 and 69, respectively. He had various diseases of child-
hood. At the age of 25 years he had dysentery that lasted three
months. Two years previous to his entrance into the hospital
he both vomited and passed lumbricoid worms per rectum.
No history or evidence of lues. Present trouble dates back
about U years. He began to feel languid and exhausted after
his day's work. He became gradually worse, until at the end
of four months he was compelled to give up his work and tak"
to bed. He entered the hospital under the care of Dr. C. W.
Mitchell. Blood counts made by Dr. William Messiok. The
slightest exertion, even the etfort to raise himself in bed, causes
shortness of breath and giddiness. Appetite is much impaired,
suffers from nausea but rarely vomits. He is somewhat con-
stipated. Hemorrhoids are present but they rarely bleed. He
complains of blurred vision, ringing in the ears, tingling and
numbness of the hands and feet.
Physical Examination. — Patient is of medium size, good
development, but muscles are flabby. Skin is dry, lemon-yel-
low colored, and its elasticity is diminished. Conjunctivas very
pale; tongue dry and slightly coated. Few crackling rales at
the base of both lungs. Arteries somewhat sclerotic. Soft
blowing systolic murmur over base of heart ; no cardiac
enlargement. Venous hum in the neck. Examination of abdo-
men entirely negative, except some tenderness in epigas-
trium. Both ankles somewhat edematous. Patellar reflexes
lost. Recent macular hemorrhages in both eyes. Distant
vision, T%V
Urine Analysis.— 'So albumin, sugar or casts. Deposit of
u rates.
Analysis of stomach contents made at various times gives a
total acidity varying from 10 to 15; no free or combined HCl.
Ferments absent ; trace of lactic acid. Few long bacilli.
Stools were repeatedly examined for ova and parasites, with
negative results.
Examination of Blood.— Red blood-cells, 546,690; hemo-
globin, 20% ; color index, 1 + ; white cells, 3,200.
Differential count: P. N., 40.9% ; S. M., 47.6% ; L. M., 9.1% ;
eosinophiles, 1.5%i ; myelocytes, .8%.
Poikilocytosis present. Of 40 nucleated red cells 23 were
normoblasts and 17 were megaloblasts.
One week later, February 19, 1901, R. B. C, 641,590 ; W. B. C,
3,800; hemoglobin, 26%. February 24, 1901, R. B. C, 961,500:
W. B. C, 4,000; hemoglobin, 30%. March 3, R. B. C, 1,241,500;
W. B. C, 3,800 ; hemoglobin, 35%,. March 20, R. B. C, 2,014,800 ;
W. B. C, 2,400; hemoglobin, 55%. March 25, R. B. C, 2,021,800;
W. B. C, 2,200; hemoglobin, 55%.
Arsenic in the form of Fowler's solution until 30 gtt., t.i.d.
He left the hospital much improved.
Case III. — Joseph S., aged 41, white, insurance agent,
married ; father of 5 healthy children. Family and previous
history unimportant. No history or evidence of lues or intem-
perance. Chews tobacco. Has always been robust until two
years ago, from which time he dates his present trouble. It
began with soreness of the tongue, for which he was given bin-
iodid of mercury for a number of months, his physician think-
ing the tongue luetic. He came to me suffering with weak-
ness in the legs, dyspnea on slight exertion, dizziness on
assuming the erect posture, loss of appetite, nausea and vomit-
ing. Bowels move once daily. He complains of ringing and
buzzing noises in the ears and tingling in the fingers.
Examination of the patient shows extreme pallor of a
lemon hue ; conjunctivas a yellowish white and lips extremely
NOVKMBEK 15, 1902
PERNICIOUS AXEMIA AND ACHYLIA GASTEICA iAmerican medicine 781
pale. He appeal's well nourished, has a considerable amount
of subcutaneous fat and weighs 150 pounds.
Lungs are normal. No cardiac enlargement. Soft systolic
hemic murmur heard at times over the base of the heart.
Arteries are soft, venous hum in the neck. Liver normal in
size. Stomach normal in size and position. Spleen not palpa-
ble. Slight edema of ankles. Reflexes exaggerated, especially
the patellar reflexes. Ankle clonus present. Fundus of the
eye is pale, but otherwise normal.
Urine.— High colored, large urate deposit, indiean increased,
no albumin, sugar or casts.
Stomach Contents. — Free and combined HCl absent. Total
acidity, 6. No pepsin, rennin or lactic acid.
Stools normal ; no parasites or ova.
Examination of Blood. — Red cells, 1,537,000; hemoglobin,
Mfo; color index, 1 |-: white cells, 8,000. Ditl'erential count:
P. N., m.l<fc; S. M., S2.i<fc; L. M., 3.2%; eosinophiles, 1.3%.
Poikiloeytosis marked. Four normoblasts and two megalo-
blasts were found while counting 1,500 leukocytes. One week
later, on .June 2, 1901, R. B. C, 1,500,000 ; hemoglobin, 38%. June
22, R. B. C, 1,750,000; hemoglobin, 44%. August 15, R. B. C,
4,0 0,000; hemoglobin, 8ti% ; but even here one normoblast was
found ; no poikiloeytosis.
With this marked improvement in the quality of the blood
I was interested to ascertain whether the gastric secretion had
improved, in other words, whether it was merely functional,
due to the impoverished condition of the blood. After the test-
breakfast the total acidity was 10, absence of free and combined
HCl ; no ferments. Lactic acid absent. No improvement had
taken place; there was evidently an atrophy of the mucosa.
The patient passed from observation until April 16, 1902. Two
days {jrevious he Jiad become feverish and jaundiced. When I
saw him his temperatvire was 101° F., skin yellow and scleras
jaundiced. Urine contained considerable albumin and both
hyaline and granular casts. Urobilin present. Examination
of the blood showed a complete relapse. R. B. C, 1,492,700;
hemoglobin, 36%. Poikiloeytosis again marked.
Death occurred six week later; no autopsy obtainable.
The above represent typical cases of pernicious
anemia. They all ran a mild fever chart, the tempera-
ture in one case rising as high as 10.3° F. In all there
existed the clinical evidences of atrophic gastritis. In
two ca.ses there was loss of the patellar reflexes ; in one
it was exaggerated with ankle clonus.
We have seen that the consensus of opinion is that
the anemia is secondary to the gastrointestinal atrophy.
Osier says that atrophy of the stomach may certainly
cause progressive pernicious anemia. That the atrophy
of the intestinal mucosa is not an essential factor is shown
not only by the fact that it is absent in a number of
cases, notably Nothnagel's and two reported by Max
Kock, but also by the strikingly well-nourished condi-
tion of many of the patients and the presence of consider-
able subcutaneous fat, as existed in two of the three
cases cited herein. Neither can we regard the gastric
atrophy as the direct or immediate cause. We should
have to assume a hematopoietic function of the gastric
muco.sa for which we have no warrant ; and further,
numerous cases of gastric atrophy occur without per-
nicious anemia resulting. What, then, is the exact rela-
tion letween these two conditions? The work of Wm.
Hunter is of the greatest value in throwing light in this
connection. According to the results of his investiga-
tions pernicious anemia is essentially hemolytic : there
is a rapid disintegration of the red blood cells which is
confined to the portal area, as evidenced by the enor-
mous amount of blood pigment found in the liver, while
but little is found in the other organs.
The anemia which he had found to be due to an
active blood destruction in the portal circulation suggests
the a<'tion of some toxic agent, and Hunter has found
that the features of-pernicious anemia as a whole can be
reproduced by poisons having a special hemolytic action
such its toluylendiamin.
Additional evidence of the toxic nature of this dis-
ease is furnished by the clinical features : (1) The fever ;
(2) the changes in the spinal cord, and (3) the occurrence
of ptomains in the urine.
1. Fexjer inthisdisea.se is usual, and is rarely entirely
absent. In many cases it occurs in a paroxysmal man-
ner. The marked ri.ses in temperature are associated
with a marked reduction in number of red blood-cells
and with an exacerbation in the symptoms pointing
unmistakably to a constitutional cause, such sis toxemia.
•1. The spinal cord changes are worthy of special note.
In 1887 Lichtenheim first called attention to the marked
coincidence of degenerative processes in the cord with
pernicious anemia. In not a single case of this disease
did he find the cord normal. In some cases there were
scattered miliary lesions resulting, probably, from pre-
vious hemorrhage. In others there existed extensive
and severe degenerative processes in all parts of the
cord. He considers these changes to be due to a toxic
process. Minnich believes also in the toxic origin
theory, since the intensity of the spinal symptoms do
not run parallel with the degree of anemia, and at times
occur early in the disease. Additional evidence is fur-
nished by the absence of these cord changes in the severe
secondary anemia of malignant growths. The close
association of pernicious anemia with cord degeneration,
and the fact that one is not the cause of the other, sug-
gests the existence of some common cause. It is now
the accepted belief of most neurologists that toxins circu-
lating in the blood reach the cord and exert their dele-
terious influence in the nervous matter neighboring the
bloodvessels.
3. The study of the urine furnishes valuable data.
Hunter has been able to isolate two ptomains from the
urine in pernicious anemia : pulrescin and cadaverin.
These ptomains are not found in the urine of healthy
individuals ; nor do they occur as the result of increased
putrefaction in the digestive tract. Their presence is
indicative of a special toxemia. The evidence as to the
toxic nature of this disease is, I think, incontestible ;
certainly there is no other theory by which the various
phenomena can be explained satisfactorily.
To sum up : We have to deal with a toxic process,
the stress of the action of the poison or poisons being
exerted upon the blood and cord. The resulting hemo-
lysis is confined chiefly to the portal area. The gastric
atrophy is regarded by alinost all authorities as the
primary condition. The gastric atrophy presents, then,
the conditions favorable for the elaboration and absorp-
tion of the toxins, the atrophy of the stomach acting, in
other words, as a predisposing cattle. We are, I think,
to look upon the anemia of pernicious anemia as but a
symptom, but from the marked alteration which the
blood undergoes, and the vital effects thereof, it is the
most important symptom of the disease to which our
therapy for the present must be directed.
BIBLIOGRAPHY.
Brabazon : Case of General Atrophy of the Stomach, with Absence
of Organic Disease, liiitlsh Med. .loiirual, 187», July 27.
Bartels: Kin Kail von pernlc. Antcin. mlt Icterus, Berlin, kiln.
Wochens., 1888, No. 8.
Biiunwell: Anemia.
Klchhorst: Die progressive pernlclose Anemia, Leipzig, 1878.
Elnhorn: Med. Itecord, .June II, 1892.
Elsenlohr: Ueber primilr Atrophic der Magen und Darmschleln-
haut und deren Bezlehung zu sehwerer Anremle und Rilckenmarks-
erkrankung, Deutsch. med. Wochonschrift, I8fl2, No. 49.
Ewald : Kllnlk der Verdauungskiankhelten, Berlin, 1898.
Henry and Osier: Atrophy of Siomach, wllh Clinical Features of
Pernlc. Anemia, Amer. Journal of Med. Sciences, 1886. p. 498.
Hunter: (a) An Investigation Inio the Pathology of I'ernie. Anemia,
Lancet, 1888; (fi) Observations im the llnne of Pernlc. Anemia, Practi-
tioner, Vol xlil, 1889; (c) Monograph on Pernicious Anemia.
Kock, Max : Ueber veranderungen am Magen u. Darm bei der per-
nicios Anaemic, Magdeburg.
Kinnlcut: Atrophy of the Gastric Tubules; Its Relations to Pernlc.
Anemia, Araer. Journ. of Med. Sciences, i8^7. /
Lf pine : Sur les anemies proKres.>i|v( s. Revue de MCd., 18T7.
LIchlhelm: Zur Kenntnlss der Pernlc. Ana;m., Vcrhandl. d. Con-
gress riir Inn. Med., 1887.
Martins: Ueber anaemlsche Zusliindc, Insbesonden ilber scbwere
Aniemla gastro-lntestlnalen ursprungs. Aerztl. .Monalsch] ill, 1. .labr-
gang. 1898.
Minnich: Zur Kenntnlss der Im Verlaufe der pern, .\ii.iinle beo-
bachteten .Splnalner krankungen, Zeltsehr. f. kliii. .Mid., Mil. 11, 22,
189.'-:).
Neutnan, E.: Ueber Blutregeneratlon und BUuhlldung, Zcitschr. fdr
kiln Med.. Ill, 1881.
N'othnagel: Clrrhotlsche Verkleinerung des Magens, etc., mit der
BIkl der jiern. anicmte, Deutsch Arch, fur kiln. Med., 1879, p. Sfi:!.
(Lxler: Practice of Medicine, Second idillon.
Pepper and Stengel The GasrroinUstinal Origin of Pern. An.,
Verb d. Congr. f. Inn. Med. WlesiiiKlen, 18911.
tiulncke; Ueber pern. Anierale, Volkinnn's Samml. kiln. Vort., No.
100, 187(>.
■Sasaki: Ueber Veranderung In den Nervosen Apparatus di r
D.irinwand, by Pern. Aniemie, etc., Vlrch. .\rchiv, I8sl, \\. ■i-<i.
Scheperlen : Nord. Med .\rk., 1879, Bd xl.
siewerat, D. D.: Amer Journ. Med. Sciences, Noveniiur, isiir,.
782 AUEHicAN Medicine]
PULMONARY TUBERCULOSIS
[NOVEMBEK J5, 1902
PRACTICAL DEDUCTIONS FROM EXPERIENCES IN
A HOSPITAL FOR PULMONARY TUBERCULOSIS.'
BY
B. F. LYLE, M.D.,
of Cincinnati, Ohio.
The profes-sion in already aware tliat males, as a rule,
have pulmonary tuberculosis later in life than females
and that in colored people it occurs earlier than in those
of the corresponding sex of the white race. We are
also aware of the pernicious influence of improper sani-
tary conditions and know that a stranger visiting an
unknown city can, by an intelligent survey, judge of the
locality where tuberculosis, crime and intemperance can
be found to the greatest degree.
But why couple tuberculosis with crime and intem-
perance ? Because tuberculosis is primarily a result of
physical degeneration, inherited or acquired, and this
same physical instability leads to that dwarfing or ob-
tunding of the mental and moral powers which results
in crime and intemperance. Some disciple of Malthus
may, therefore, because of these connections, regard
tuberculosis in the light of a public benefaction, and
"with Spartan-like indifference to the sensibilities of the
individual, look upon the elimination of the physically
weak as a means for the upbuilding of the welfare of the
State. But no benefit can be derived from this method
of elimination. Tuberculosis is a penalty for the disre-
gard of sanitary and hygienic laws, and its subjugation
rests not with the physician, neither does the remedy lie
with the lawmaker. It can be largely secured, however,
by an enlightened public sentiment which will regard
with horror our dark, decayed and musty tenements,
the curse of child labor, sweat-shops and insalubrious
workrooms with their usual accompaniment of low
wages.
Our statistics show that individuals of the colored
race and of foreign birth, the dwellers in our worst tene-
ments, are in evidence in a ratio far beyond that borne
to the rest of the community in the census returns.
Thus we come to the principal factor in the causation of
tuberculosis — ignorance; and, perhaps we should also add,
the cupidity of those whose philanthropy does not keep
pace with their knowledge. To our public schools we
must look for the general enlightenment which will
enable us to eliminate the predisposing factors of the
disease. The teaching of hygienic and domestic science
in the district schools, sanitary inspection of the schools
by competent physicians, popularization of public baths,
placing of school buildings in proper sanitary conditions
so that children can be brought up to appreciate the
advantages they offer, are some of the innovations that
are necessary. A lady interested in charitable work
visited a grocery store in the slums about the noon hour,
and found that articles were purchased not with refer-
ence to their nutritive value but their ease of prepara-
tion. These, supplemented by a bucket of beer, fur-
nished a meal insufficient to supply the needs of the
body. Is it any wonder the cravings of hunger lead the
toilers of the family to resort to alcoholic beverages in a
futile effort to sustain their physical powers?
The objects of a municipal hospital for the care of the
tuberculous are : First, to furnish an abiding place for
the incurable, where they can receive kind and skilful care
and where they will cease to be a menace to their fami-
lies ; second, to assist those who are able to overcome
the disease ; third, to instruct the patients and public in
methods of caring for the sick, and avoiding contagion,
and also show the necessity of proper hygienic and sani-
tary rules.
Tuberculosis with impartiality visits all ages and all
conditions of man. Necessarily, we have in a public
hospital persons of all degrees of culture and tempera-
• Read at the meeting of the Ohio State Medical Society at Toledo,
May ;w, lnosj.
ment. For practical purposes we may classify them as
the earnest, the restless and the indifferent.
The former are the ones who are ambitious to resume
their avocations and are willing to assist in every possi-
ble way the efforts made in their behalf. In this cate-
gory we find the sole breadwinner for parents, wife and
children, or the mother who has left her little ones in
the temporary care of another. This is the class for
which it is the special province of the hospital to care.
It is sad to see these patients frequently leave the hos-
pital after only a few weeks' stay, in which time they
have gained a little strength, because they can no longer
resist the pleadings for help of those depending upon
them. The care of these helpless ones must be looked
after if we wish this class to be benefited by the public
beneficence.
Many people are naturally restless and disease
increases this number. These are the patients who
derive but little benefit from any institution, as they
are unwilling to await results, or even assist in securing
them. If the Utopian plan of sending tuberculous
patients to some central point is ever realized, a large
fund for transportation must be provided for this class.
The indifferent patient brings wrinkles and gray
hairs to the attendants and are an imposition on the
public. The motives which animate their actions are
inscrutable and the results are frequently disastrous.
Let me illustrate to those of you who are not initiated a
few of the difficulties with which we have to contend :
A " stretcher case " is brought in. By careful attention
in the course of a month the patient is able to get about, in
two months more he has gained 20 pounds and is the pride
of the institution. He receives permission to go home
for a few hours to see his family, a message is received
later that he has been taken suddenly sick and is not able
to return. Several days after, the ambulance brings in
what remains of our patient after a prolonged debauch,
or the dyspnea, due to a dilated or flabby heart, is
increased by the surreptitious use of tobacco, the cough
due to an irritated throat, aggravated by smoking, or
the intractable diarrhea placated by means of a mince
pie.
Discouraged and faint-hearted, time gives you cour-
age and you take up the broken threads and renew your
efforts. In the presence of one class, however, exempt
because of the nature of their infirmity from the ordinary
60-day rule, our courage fails. These are the indiffer-
ent chronic patients, a peculiar and unique class. Their
only object in life is to be well fed and cared for. Their
digestive abilities are unequaled and they are enabled
to dispose of any and all kinds of contraband articles
with impunity. Asked to render a service the ever-pres-
ent pleuritic pain comes to their relief or a sudden attack
of dyspnea renders the slightest effort impossible. If I
may, I will take the liberty of giving a warning. Never
turn a hospital for tuberculous patients into an infirm-
ary. Intemperance and syphilis are predominant in the
personal histories of our patients. Pneumonia is notice-
able as a predisposing factor. Influenza has not seemed
to b of as serious import as is usually reported. Con-
finement in general hospitals for some time seems to be
important ; we are never without several patients who
have but recently occupied beds in the surgical or med-
ical wards.
One-third of the cases have a family history of tuber-
culosis. The disease has occurred in the mothers twice
as often as in the fathers. How far contagion acts as a
primary factor in the disease is a (luestion now occupy-
ing a large part of the attention of the profession. The
cases reported by Weber are significant in this connec-
tion, nine husbands, tuberculous before marriage, lost
18 wives ; one lost four in succession, one three, four lost
two each, and three one each. The wives were healthy
at date of marriage, and, with one exception, were free
from hereditary predisposition to the disease. When no
family history of the disease exists, we frequently obtain
November 15, 1902|
PULMONARY TUBERCULOSIS
'American Mediciite 783
a history of infection of husband or wife from the oppo-
site marital partner.
Owing to various reasons six tuberculous mothers in
our hospital have had their infants with them. In one
case the child was born at the hospital. These children
have invariably had tuberculosis. The one born at the
hospital died of 'general tuberculosis at the age of 78
days ; this was no doubt congenital. Another, aged 15
months, died after an apparent illness of !>() days. The
disease in all cases has been general, the lung trouble
far advanced. The method of infection is uncertain as
a rule, in one instance it was probably due to the mother
masticating the food previous to giving it to the child.
Her sputum showed about 50 bacilli to the field. The
fact that all of these children have had tuberculosis may
be unique. It serves, however, to illustrate the danger of
allowing infants to be cared for and caressed by tubercu-
lous mothers and nurses.
We are reminded constantly of the unreliability of
the statements of patients regarding the duration of the
disease. Cadaverous-looking individuals, with flat
chests, clubbefl fingers, edematous feet and all the symp-
toms and physical signs of a universal lung involvement
will frequently state they have been sick but several
weeks or possibly months. Their early demise fre-
quently leads to contentions between their friends and
the industrial insurance companies when a policy has
been in force but a few months. I have frequently
endeavored to have the patient modify his statements
after making a physical examination, but he will usu-
ally insist on the correctness of the history he has given.
This fact accounts for the variability seen in statistics
giving the average duration of the disease, our statistics
give 13 months as the average duration of the disease in
applicants. Of 1,000 cases, our averages are: White males,
39 years; colored, 38 years; white women, 35 years ;
colored, 27 years.
About i):)^^ of our cases have been of the flbrocaseous
variety; 9% of the fibroid form of the disease, while
acute miliary tuberculosis of the lungs and lobar caseous
pneumonia are rare. All patients have pleurisy, the
dry variety, seldom with effusion. The large majority
of persons under 20 years of age have a more or less
extensive involvement of the lymphatic glands, (ren-
eral tuberculosis is more likely to occur in the young.
Next to the lymphatics we find the frequency of tuber-
culous complications of other organs in the following
order: Larynx, intestines, pharynx, joints, kidneys,
peritoneum, bladder, meninges, testicles. Other com-
plications which are present so fretjuently as to require
almost constant attention are indigestion and faulty cir-
culation due to myocarditis or a dilated heart ; when the
patient is quiet dyspnea seldom occurs except from this
cause. While the majority of patients give a history of
hemoptysis at some time during the course of the disease
it is rarely an important complication. Death is not
causetl by it in more than one patient in 200, although
'i</c have at some time hemorrhages in which the? loss
exceeds four ounces. Chills and fever occur fre-
quently in some cases without any marked periodicily.
Night sweats are usually profuse and exhausting
only when the sanitary surroundings of the patient are
poor.
The temperature is rarely above 102° at its maximum
height. This is usually late in the afternoon. When
the maximum temperature is higher than this, a marked
remission fre<iuently occurs, the difference between the
maximum and minimum sometimes being 7°. The
fretjuency of the pulse seems to depend more on the car-
diac tone than the degree of temperature. The respira-
tory rate is influenced early in the disease by toxic
conditions, later the amount of lung involvement plays
the principal role. The influence of the rapidity with
which the flis<»ase progresses must also be considered
in this conn«H'tion.
The loss of weight which many patients undergo is
considerable, from } to i is the amount of diminution in
advanced cases.
We are told the ability of a physician can be gauged
by his prognostic powers. I therefore take the liberty
of advising all who pride themselves upon this to be
extremely oracular in their predictions when speaking
of pulmonary tuberculosis. In early cases wait for re-
sults, and in apparently moribund ones never fix the
date of death. Familiarity with tuberculosis leads one
to regard the prognosis of the disease in a much more
favorable light than that in which it is seen by the pro-
fession in general. That the dire consequences of the
disease are not always realized is evidenced by the
numerous sanatoriums making their appearance through-
out the country. These indicate the growing confidence
of the public in our ability the cure the disease. Cincin-
nati for five years has generously maintained an institu-
tion of this kind. How long will the remaining portions
of the great Ohio State withhold their assistance to those
who are suffering from pulmonary tuberculosis '?
I will not ask you to find your way through the laby-
rinth which poly therapeutists and polypharmacists indi-
cate as the road to success in the treatment of this disease.
Their efforts have been useful, as the relics of their labors
serve to keep us from treading the same paths. As we
turn from the contemplation of the bewildering array,
untrammeled by the hope of obtaining a specific remedy,
we can view our task in the proper light. The tendency
of the profession at present is not to exhaust all efforts
in futile attempts to destroy the tubercle bacillus. In
fact, the bacillus is being relegated to a far less promi-
nent position. Physical and mental depreciation due to
inheritance, faulty hygiene and ssmitation, insufficient
food and rest, pernicious habits, debilitating diseases or
prolonged and fatiguing mental strains are the factors
which predispose the individual to tuberculosis.
Since the recognition of these facts our results in the
treatment of the disease have been marked. Were it
necessary to promulgate a creed, mine would be: "I
believe in the inherent ability of the cells of the body to
maintain the tissues in a healthful condition, both by
destroying disease germs and neutralizing the products
of their activity. In order that this be done their
potency must be maintained at the highest standard."
This condition can only be effected by the air which
enters the lungs being free from the deleterious gases
due to combustion, decomposition or exhalations from
the lungs, absence of undue humidity and the freedom
from suspension in the air of various organic and inor-
ganic particles. Probably still more important is the
necessity of having the air exposed to the vivifying
influences of the sun. An intelligently selected dietary,
properly prepared, is also necessary.
The deleterious influenie of alcohol on cell function
and metabolism, and the pernicious influence exercised
by tobacco on the ui^per respiratory tracts, as well as on
the heart and general nervous system, are so well known
as only to require mention to secure a recognition of the
necessity for the discontinuance of their use.
No easy road has yet been discovered to the diagnosis
of pulmonary tuberculosis. A careful, methodic physi-
cal examination is still our chief assistance. In the
early stage of the diseiwe, when with slight dulness w©
have only a prolonged expiratory sound or slight crepi-
tation, due to a localizetl pleuritis, one hesiiates to make
a positive diagnosis. A sputum examination will then
be negative, as tubercle bacilli are rarely seen until after
the inflltratetl tissues begin to break down. Streptococci,
staphylococci and Micrococcus tetrageniis are much
more apt to be found. One ought never to exclude the
presence of tubercle bacilli from the sputum because of
their absence in one or two examinations, frequently the
fifth or sixth will give a field of a hundred germs. Of
even greater importance is the ust; of the thermometer.
The tuberculous have a rise of temperature during i-ome
portion of the day. A chart showing the temperature
78 I AMERICAN MBDIOINE!
ALTITUDE IN FACT AND FANCY
[NOVFMBER 15, 1902
taken every two hours is very significant if it covers a
period of 7 to 10 days.
Five years ago when studying the character of the
pulse of some of my patients at the hospital, with the
sphygmograph, I made a tracing of the pulses of several
of my friends; two of them resembled those of the
tuberculous patients. Both of these gentlemen have
been under treatment for tuberculosis for the past three
years. A rapid and weak pulse should always be given
consideration.
An examination of the blood is sometimes of interest,
although never of pronounced diagnostic value. A com-
parison of the blood of patients with chronic and acute
suppurative diseases, represented by tuberculosis and
smallpox, shows the following :
Tuberculosis.
Smallpox
Normal
,
V
!!■;
■6
i
■^1
it
5
,S
a
4-
H
0
a
>,
>>
0
o
J
►J
S.7*
4,218,000
11.765
1M
15<
73«
5,000.000
11,514
nM
3SS*
47*
6 4*
5,000,000
7,500
iyf,
'i^
66,-(
8* 1
Nucleated red corpuscles are frequently found in pul-
monary tuberculosis. Mast cells are found in the blood
of half of the tuberculous patients and 95^ of smallpox
patients. Polymorphonuclear neutrophiles are found
in the largest number in individuals with cavities in the
lungs. (I am indebted to the interne of the hospital,
Dr. Safer, for the examinations.)
The results of the examination of the urine are only
of general significance. If the patient has a high tem-
perature and a considerable area of lung involved, the
amount of urea excreted may be double, or even triple,
the normal amount. Albumin is also frequently present
under the same conditions. It is not of particular prog-
nostic significance and .seems to be due to the local
changes in the kidneys caused by the toxemia present.
When lack of time does not permit a delay in making
a positive diagnosis, tuberculin injections are permis-
sible. If the initiatory dose of 1 mm. does not cause a
rise in the temperature of two or more degrees, larger
doses of from 3 mm. to 10 mm. may be given. A period
of three days should elapse between the injections.
It is unneces.sary to dwell upon the treatment of pul-
monary-tuberculosis. The profession is rapidly coming
to the conclusion that we have no specifics. However,
I will venture to criticize a practice now quite prevalent.
I refer to the treatment of all patients by the same
means and methods — a practice not far superior to that
of prescribing patent medicines.
In no other disea.se do the conditions call for such a
variety of procedures. Of paramount importance is the
sustenance of the patients, which can be secured only by
watchful care to preserve the functional abilities of the
digestive tract.
The old adage, that health is wealth, is recalled to
mind as we watch the elusive efforts to acquire the
former by the methods of obtaining the latter. I refer to
what I think in mining parlance is called prospecting.
1 am told three dollars is spent for every dollar of gold
mined. The locating of mining claims is carried on
with a certain amount of judgment. But what can we
say of the thousands of consumptives who are .scattered
today broadcast over our land searching for health with-
out any knowledge of the way to obtain it. The futility
of combining with a diagnosis of tuberculosis orders to
leave home is forcibly brought to the notice of a physi-
cian of a tuberculosis hospital. Climates, like drugs,
should be prescribed with discriminating judgment and
likewise should not be ordered if the patient lacks the
financial ability to obtain them. A scientific knowledge
of tuberculosis will show us there is no El Dorado fur
the tuberculous, and that in the sunshine, fresh air, and
congenial surroundings of our own localities, when aaso-
ciated with proper hygienic and sanitary conditions, our
patients will find their most favorable opportunities for
recovery.
The laudatory accounts of the value of the x-raj' in
pulmonary tuberculosis led me to use it. For diagnostic
purposes it undoubtedly is very useful in supplementing
or modifying the findings of the physical diagnosis.
The normal excursion of the diaphragm is found to be
diminished on the affected side. The density of the
shadow is proportionate to the degree of involvement of
the lungs and pleura. It rendered invaluable services in
persons who have had a short time previously pneumo-
nia, pleurisy or bronchitis, or who have valvular lesions
of the heart, for many of these cases present symptoms
and physical signs that are very .suggestive of tubercu-
losis. I have not found it of value in locating cavities
in advanced cases ; as the contents of the cavities, the
consolidated infiltrated lung tissues surrounding them
and the thickened pleura were sufficient to compensate
for any loss of lung tissue. The u.se of the ray for thera-
peutic purposes was disappointing in 15 ca.ses in various
stages of the diseases in which I gave it a thorough test.
Its effect on relieving pleuritic pains was marked.
It is unnecessary to specify the various drugs used to
combat annoying symptoms. Remember, however,
that by temporarily relieving the patient of a symptom
we may use drugs that have a bad general effect. The
chief ones in this category are opium and alcohol.
SP£C1AL ARTICLES
ALTITUDE IN FACT AND FANCY.'
BY
HENRY 8EVPALL, Ph.D., M.D.,
of Denver, Colo.
The field of the medical cliinatologist, like tliat of the sani-
tarian, is one which continually broadens and deepens before
the view as the investigator reaches successively higher and
higher points of observation. It would not seem impertinent,
even before such an association as this, for each contributor
now and then to map out his bearings as an aid to future prog-
ress.
We must depend upon the meteorologist for data concern-
ing the physical factors which determine the differences of
climate. We must 1 )Ok to the physiologist for instruction as to
the vital reactions of the normal body to varied ineteorologic
conditions. But it is on the observations of the clinician,
which are fortunately unlimited as to number, but devoid for
the most part of the searching test of experiment, that we must
found our conclusions concerning the Influence of climate on
living man, sick or well.
Thus the clinician is forced to undertake the solution of
some of the most complex problems in physiology and path-
ology, while at the same time he is almost completely deprived
of the most valuable aid t) scientific investigation, that of
experimental verification. It is not surprising, therefore, that
in the field of medical climatology the worker is particularly
liable to be the victim of the errors to which all original investi-
gators are .subject, chief among which are, perhaps, (1) inexact-
ness of observation ; (2) the interpretation of facts by fancies
which lead to some preconceived hypothesis or which satisfy
some personal desire.
The physical data of meteorology become thus the orna-
ments of his generalizations rather than their foundation. Pos-
sibly there occur to each one here present illustrations of such
errors of observation or of logic in elimatologie writings.
A resident of the city of Denver, at an elevation of one
mile above sea-level, I have naturally come to estimate the
' Read at the meeting of the American Cltmatolojlcal Association,
held at Lo4 Angeles, June, 190i
November 15, 1902]
ALTITUDE IN FACT AND FANCY
[AHEitiCAN Medicine. 785
biologic influence of altitude as a factor in certain medical
cases. In the popular mind ot dwellers among or near moun-
tains every function of life is modified or determined by the
influence of " thin air." Yet when we attempt an analysis of
the physiologic relations of altitude, we find at once that we are
dealing with a combination of different and hardly separable
physical factors. For witli the low barometric pressure of
elevated regions go low humidity ; more sunliglit; less atmos-
pheric absorption of solar rays and corresponding increase in
their kinetic energy ; a magnified difference between the tem-
peratures in the sun and shade and of day and night; new con-
ditions for the evaporation of water and for the absorption
and radiation of heat; not to spealf of the little-known relations
of the storage and dissipation of electric energy. All these
physical factors and possibly others that we know not of are
changed when we proceed from one telluric level to another,
and the physiologic effect is the resultant of their combined
action. We are interested in these meteorologio phenomena
only in so far as they are retlecte<l in the reactions of the living
organism and so give rise to the science of climatology.
How insufficient mere physical data are for the deductions
of the climatologist has been pointed out by Captain Glassford
and others by showing the lack of parallelism between the
isotherms of ordinary instrumental and sensible or physiologic
temperature.
Owing chiefly to the progressive aridity of the air with the
elevation, the dweller in a high altitude may actually experi-
ence the same summer temperature as one who lives at sea-
level much nearer the pole and the same winter temperature as
one closer to the equator. Tliat is, the sensible temperature of
a locality, or the temperature it would seem to us to have, is
measured not so accurately by the dry bulb thermometer as by
the wet bulb. In other words, the physiologic effect of external
heat is a function of at least two physical variables, heat and
humidity. As to the further physiologic influence of the modi-
fication of glandular and nervous activity resulting from altered
surface evaporation we can now only conjecture. Then again,
merely physical or meteorologic data invilve nothing subjec-
tive. The modification of the psychic state, one of the most cer-
tain tiierapeutic concomitants of climatic changes, is a matter
that at present escapes all analysis. It may some day be shown
that the psychologic relations of climate are mathematically
detennined by the vast uuin'ier of physiologic variables that
make up our machine life. How momentous sujh considera-
tions must bo in the treatment of many diseases it is need-
less to urge. No thorough exposition of the climatology of
high altitudes can be expected until the physiologic constants
of life in such regions have been accurately a.scertained. It is
worth suggesting that the influence of this association may
properly be used in seeking to direct toward this subject part
of t le munificent endowments that hive recently been made
for the prosecution of original research. Only the best trained
worker is competent to resolve into their simplest parts the
problems that confront us, and tliere is no nhysiologic problem
so simple but reqiiires for its solution the application of the
finest techuic and severest scientific reasoning. For example,
every one admits the constant apparent increase of the re<l
blood-corpuscles attendant upon removal to high altitudes, but
this phenomenon attains an entirely different significance from
that at first attached to it when it is considered that even a
momentary impediment in a blood stream must cause a local
congestion and corresponding increase in the number of blood-
corpuscles at that point. If it but be granted that an effect of
high altitudes is to cause either vascular dilation of the skin or
more sluggish venous outflow therefrom, the curious results of
the bematologist are explained without presuming an inordi-
nate rapidity in cell multiplication, indeed, it is perhaps
more logical to suppose that the increa.se of blood-cells in the
peripheral circulation argues for a congested skin ; and, if such
be the fact, it is not a far-fetched presumption that some of the
peculiar physiologic attributes of high altitudes may be due to
such excessive surface distribution of the nutrient fluid of the
body. Such ideas are useful and even necessary as working
hypotheses, but it is the chief purpose of this paper to insist
that they be not used as argument until distinctly supported by
experimental evidence.
The distinguished Italian physiologist, Angelo Mosso, made
an exhaustive set of observations upon human respiration, gas
exchange, and circulation, in the Alps at an altitude about cor-
responding to the top of Pike's Peak. Mosso's conclusions as to
the modification of certain physiologic functions incident to
high altitudes are directly at variance with the conceptions gen-
erally held by clinical writers. According to Mosso, moreover,
the tension of carbon dioxid in the blood plays a hitherto
unsuspected role, and he holds that abnormal diminution of
that tension is the directcauseof socalled " mountain sickness."
The careful reader will insist upon confirmation of these obser-
vations before accepting them : and it may be suggested that
more purely physiologic results should be expected from
experiments carried on at a lower elevation and through longer
periods of time. Nothing is more obvious than the, at least tem-
porary, change in the activity of the kidneys incident U) change
in altitude, yet evidence is altogether lacking as to the cause of
this variation in secretion. It is important that we know what,
if any, is the relation of altitude to the elimination of meta-
bolites, both nitrogenous and nonnitrogenous. Dr. Webb, of
Colorado Springs, tells me that according to his observations
the quantity of urea excreted by a person living in that place
is very much less than the normal as estimated at sea-level.
No physiologic function rightly attracts more attention in
its modification by altitude than does the circulation. The
familiar attendance of cardiac dyspnea upon slight exertion in
high altitudes at once marks the heart as an organ whose func-
tion is directly affected by change in barometric pressure. The
purpose of the heart in the body is chiefly or solely to maintain
a certain arterial blood-pressure, yet we know nothing what-
ever of the effect of altitude upon this all-important driving
force of the blood. Fortunately the heart submits itself with
unusual completeness to clinical observation, and it seems to
me that in our physical examinations we have culpably
neglected estimates of the individuality and work power of the
normal heart.
At this point I am obliged to enter the dangerous ground of
clinical observation unsupported by the prop of experiment.
Provided their sources of error are held in view, the conclu-
sions deduced can do no harm, but may serve a useful purpose.
It has seemed to me that the characteristic efffct of high alti-
tude upon the circulation is an overloading, with a tendency to
strain of the right side of the heart. Some evidences of this
view have been i)resented in detail in another communication.
Admitting, tentatively, the validity of the conclusion, two
sequels must be considered : First, there would be entailed a
higher venous congestion of organs, with probable modification
of metabolism and tendency to the gouty or lithemic state;
second, the heart would either respond to the strain of height-
ened right-sided intracardiac pressure by increased vigor of
contraction, leading to physiologic hypertrophy and better
nutrition throughout the body, or the organ would fail to
answer the extra demands upon its powers; it would then
dilate to the right, more or less venous stasis would intervene,
and the nutrition of the body would proportionately suffer.
It has seemed to me usually possible to determine by phys-
ical examination the character.of heart that is not likely to bear
well the strain of high altitude life. The clinical features which
seem to me to indicate lack of reserve power on the part of the
structurally normal heart are: abnormal increase in the rate of
beat with exertion or on assuming the erect position ; the easy
production of dyspnea with exertion; an increase toward the
right of the area of cardiac dulness; undue prominence of the
jugular veins in the recumbent position of the patient; but
more significant than all, as it appears to me, is what may be
called a wavering character of the first sound of the heart, with
a more or less marked reduplication of that sound. Finally
may bo mentioned that well-established sign of weakness, the
shortening of the first sound with a change in its quality which
makes it resemble the second sound, accompanied by more or
less abbreviation of the lesser pause.
In my experience, persons suffering from pulmonary tuber-
culosis, however slight the affection, and manifesting these
signs of heart weakness, do not usually thrive well at even a
moderately high altitude; and I have repeatedly known such
patic its, while gradually failing, to improve immediately and
786 AMEBICAN MEDICINE;
PROFESSOR JOHN BERG'S SURGICAL CLINIC
[November 15, 1902
proceed steadily toward recovery when sent, under proper con-
ditions, to an elevation of less than 2,000 feet above the level of
the sea.
The study of cardiac physiology in relation to pulmonary
tuberculosis seems to me to be of supreme importance, partly
because in this disease there Is already thrown upon the right
side of the heart a more or less excessive burden, due to the
restriction of the vascular area of the lungs. It was once my
unfortunate experience to see a patient whose right ventricle
was just able to send its blood through lungs far advanced in
cirrhotic contraction, collapse after the administration of 15
grains of trional given to induce sleep.
The heart is at once the servant and master of every tissue,
and the condition and power of that organ are fair indices of
the state of the whole body. In the therapeutic relation I would
consider the indications of altitude in pulmonary tuberculosis
to depend chiefly upon the vitality of the heart. When this
organ can adjust itself to the extra demands incident to con-
siderable elevation above sea-level, such reaction probably
strengthens it throughout, and leads to improvement in the
nutrition of every tissue.
It has seemed to me that for every case of pulmonary tuber-
culosis there is an optimum altitude at which the patient has,
other things being favorable, the best chance of improvement.
This elevation may be any fraction of 10,000 feet above sea-level.
It is the altitude at which is secured the most thorough physio-
logic reaction ; let it be exceeded ever so little and the patient's
vital powers are overburdened instead of strengthened.
When the physiologic relations of climate are better under-
stood, the climatic treatment of disease will give way to the
climatic treatment of the patient, and our advice will be more
definitely founded on the effects on individual metabolism of
the various meteorologic conditions available to us. No climate
is a specific against any disease, but can only aid in its cure by
facilitating in one direction or another the sum of the nutri-
tional processes of the body. Every climate has its typical efl"eets
on the living organism, just as every nation has its pictured
type, but in judging a definite medical case the physician must
use a type only as a point of departure. For example, the
characteristic effect on the nervous system of a person recently
arrived in Denver from the East is one of exhilaration, but
some complain of depression and that the feet feel as heavy as
lead. Some sleep worse, some better than in lower altitudes.
One ill-founded fancy regarding the therapeutic relation of
high altitudes to pulmonary tuberculosis seems general both
among the laity and the medical profession ; it is that persons
cured of tuberculosis in high altitudes cannot so safely return
to lower levels as patients who have recovered health near their
homes. It would require a volume of statistics accumulated
through years of research to combat effectually this belief.
But, in brief, I think I voice the prevailing opinion of those
medical practitioners whose experience has included socalled
" cures " in high as well as in low altitudes, in maintaining that
a reinfection or relapse is no more likely to occur in the one than
in the other case when the patient has returned to the scene of
his former life.
Without dwelling on the difficulties of achieving or esti-
mating a "cure" in tuberculosis, it will be admitted that most
of our favorable cases still show physical evidence of the dis-
ease, though the activity of the morbid process has been
arrested. It is a matter of the highest importance to determine
why it is, that of the patients with arrested cases, whose lives
have been saved under appropriate climatic conditions, some
return with impunity to the scenes of their former activity and
take up again their chosen work, while others venturing the
same change of base, quickly lose ground and relapse fatally.
In conclusion, I venture to invite the attention of practi-
tioners in high altitudes to an inquiry as to the physical signs
by which we are accustomed to recognize the existence and
extent of pulmonary tuberculosis.
To illustrate, a patient newly arrived in Denver presents a
letter from his medical adviser in the East stating that the said
patient has but a slight infiltration of the right apex. Careful
examination, however, may reveal fine bronchial rales through-
out the right lung besides signs of moisture at the top of the
left. This experience has occurred so often with me that I have
suspected that one of the early incidents of removal to a higher
altitude is either the excitement of a bronchial catarrh, as
indirectly it may produce a rhinitis, or that the climatic change
has resulted in disclosing an extent of pulmonary involvement
not before apparent, or both. Of course it is easily possible that
the presumed effect of altitude upon the physical signs i»
imaginary and only an illustration of the common circumstance
that the same physical condition is variously described by dif-
ferent observers.
PROFESSOR JOHN BERG'S SURGICAL CLINIC.
BY
NICHOLAS SENN, M.D.,
of Chicago.
Sweden has three universities, located in the cities of Stock-
holm, Upsala and Lund ; each of these universities has a
medical department. The largest medical school is the Caroline
Medico-Chirurgical Institute, connected with the University of
Stockholm. This institution has an attendance of from 250 to
300 students, and graduates from 20 to 50 every year. The
medical course extends over seven to nine years, according to
the natural ability and application of the student. The long
course of study, the small classes, the abundance of clinical
material and the well-equipped laboratories afford the students
all necessary facilities to obtain a thorough theoretic and prac-
tical knowledge of medicine and surgery.
For the last 15 years women have been admitted to th&
medical school, and have made an enviable record as earnest,
diligent students. Professor Berg informed me that they rank
among the first in the different classes, more especially in the
theoretic courses. In the audience of about 30 in the surgical
clinic I attended there were three women, and I noticed how
intently they followed the remarks of the lecturer and every
step of the operative work, and they were the last to leave the
clinical theater. There are now 25 female physicians in Stock-
holm engaged in practising their profession and in honorable
contest with their more numerous male competitors. So long
as women insist on studying and practising medicine they
should be given the best opportunities to satisfy their desire
and ambition, and this can only be done by coordinate educa-
tion. Female physicians have secured a permanent foothold in
the medical profession, but it would be to their interest and
advantage if they would devote their time and talents to gyne-
cology, obstetrics, diseases of children, diseases of the eye, ear,
nose and throat, and dentistry. Nature has endowed them with
qualities well calculated to practise these specialties with suc-
cess and a good prospect of an independent, comfortable exist-
ence. The clinical teaching of the Caroline Medico-Chirurgical
Institute is conducted in the Serafrim
Hospital.
Serafrim, Hospital.— This institu-
tion is supported by the government,
and has a capacity of 400 beds. Tl e
members of the faculty compose the
medical staff. The surgical depart
ment has 140 beds and is located in the
old part of the building. The surgical
clinics are conducted by Professor
John Berg and Professor J. H. Aker-
man. Professor Berg is the head pro-
fessor. The surgical cases of the large
Poliklinik are in charge of the same
men. The clinical service alternates
between the two professors every
four months. The clinical amphithe-
ater can seat about 50 students. Most
of the major operations are per-
formed in an adjoining operating-room, to which only a few
students, wearing linen gowns, are admitted. Both operating-
rooms are supplied with all necessary instruments and facilities
for asepsis. In the operating-rooms there is no unnecessary
display in making preparations for an operation. No gloves and
no caps. The fact is fully recognized here that clean hands,
sterile instruments, ligature, suture and dressing material and
Professor John Berg.
November 15, 1902|
PROFESSOR JOHN BEKG'S SURGICAL CLINIC (American medicine 787
a carefully disinfected operative field are the essential pre-
requisites to procure asepsis. Hand and surface disinfection
are made by scrubbing for a sufficient lengtli of time with warm
water and potash soap, followed by 1:1,000 bichlorid of mer-
cury solution and a 291! solution of creolin. Chloroform by the
<lrop method is the favorite anesthetic, but ether is used in
cases in which it is deemel safer than chloroform. Two house
surgeons assist the operator. A trained female nurse handles
the instruments, ligatures and needles, and a second one takes
care of the gauze, sponges and dressing material. Catgut is pre-
pared according to von Bergmann's directions, and instruments
and silk are sterilized by boiling. In the abdominal cavity
silk is used almost exclusively, catgut for buried sutures. In
the clinical amphitheater much of the time is spent in diagnosis
instruction, the operative work being limited to emergency
cases, minor operations and infected oases.
Professor Berg, the successor to the late Professor Rosa-
ander, is the head professor of surgery and senior sur-
geon to the Serafrim Hospital. He is in the prime of life, above
average height, with a noble, dignified bearing that at once
betokens the gentleman and scholar. Modesty is one of the
most reliable indications of genuine greatness, and this is one of
the many virtues that characterize the life and work of Profes-
sor Berg. He is a great favorite among his students and a
friend to his patients. He is careful in the selection of his cases
for operation, and his clinical teaching is noted for the con-
servative spirit which predominates, something which cannot
be said of all of the clinics on the Continent. He recognizes the
limits of the art of surgery, and takes great pains in emphasizing
them in his teachings. He is a fiuent and forcible speaker who
has no difficulty in commanding the attention of his class and
of imparting his earnestness and enthusiasm to every one of
his listeners. A very important feature of his clinic is the
assigning of a case to one of the candidates for graduation.
The student must write a full history of the case, which is read
by the professor when the case is presented, and he must be
prepared to defend his diagnosis, witness the operation and
visit and report upon the progress of the case daily thereafter.
This kind of clinical instruction is a method of teaching best
calculated to make the student a good diagnostician and a
thinking, safe practitioner. Sweden has an excellent system of
preparing young physicians for hospital work. Throughout
the kingdom hospitals are being built in all of the larger
villages, but restrictions are placed on the candidates who
make application for the medical service. It is an inrtexible
J rule that such candidates must present a certificate showing
that they have served satisfactorily as an assistant in one of the
large clinics for a period of at least three years. This is a most
excellent plan, as it assures for the most remote parts of the
country excellent medical and surgical skill.
Limitation of hospital practice is surely needed in our
country, and it would be well for our profession, and still
better for serious cases remote from medical centers if the
same regulations could be enforced which have been in such
successful operation in Sweden for a number of years.
Operations. — Professor Berg is a very careful and skilful
operator. He makes no attempt at display of his manual dex-
terity. He operates upon his clinical cases with the same care
and consideration as upon his private patients. He never for-
gets that he is not only an operator but also a teacher. He is
keenly conscious of his responsibilities to his students, who,
as is generally the case, will imitate the example of their teacher.
He teaches his students not only how to operate but also where
and when not to operate. His clinical lectures are devoted
largely to diagnosis and a comprehensive study of the patho-
logic conditions presented by the case under consideration.
The faror operattvun has found no foothold in his clinic. He
is familiar with what is going on in the surgical world but is
slow in adopting new doubtful procedures. He regards spinal
anesthesia with mistrust and has never given it a trial. He is
not willing to abandon well-tried reliable methods for innova-
tions of doubtful value simply because they are something new.
On the day of my visit to his clinic two very rare and extremely
interesting cases furnished the text for his clinical lecture.
Cauk l.—ReleHtion cyst {/) of the frontal sinus ; operation.
The patient was a man, aged 25, the subject of an orbital swell-
ing. The swelling involved the right orbital cavity and was
first noticed seven years ago. There was no pain nor tender-
ness. There was slight exophthalmos and outward deviation of
the eye. Nasal cavities were normal. Distinct fluctuation
elicited on palpation led to the information that the swelling
was in part covered by a thin plate of bone. The swelling
occupied the inner upper quadrant of the orbital cavity.
Eyesight was unimpaired. The case was thoroughly dis-
cussed from a diagnostic point of view. The obscurity of
the nature of the swelling was emphasized. Osteoma of the
orbit, dermoid cyst, inflammatory diseases of the frontal sinus
and ethmoidal cells and malignant tumors were all mentioned,
but the final diagnosis was left for the operation to reveal. The
patient was prepared, anesthetized and the operation com-
menced by making an incision along the orbital arch down to
the frontal bone. With an elevator the periosteum was reflected
in the direction of the swelling. As soon as the orbital cavity
was reached a yellowish white gelatinous material escaped and
the opening led into a large cavity— the distended frontal sinus.
This cavity contained at least three ounces of the same kind of
material. The communicating opening between the frontal
sinus and the nasal cavity was found without any particular
difficulty with the probe. With a chisel and hammer part of
the orbital margin was removed to att'ord freer access to the
cavity which was then thoroughly cleansed of its contents and
the lining membrane excised with forceps and curved scissors.
The opening between the sinus and nasal cavity was enlarged
until the tip of the index finger could be inserted. The cavity-
was then packed with a Mikulicz drain and the external inci-
sion reduced in length by suturing witli silk. A small
absorbent dressing finished "the operation. The nature of the
cyst contents, the absence of all inflammatory indications, leave
but little doubt that the case was one of retention cyst or
myxoma of the frontal sinus.
Case \l.— Ulcer of duodenum; gastroenterostomy. The
patient was a woman of 40, who for 20 years had suffered from
symptoms indicative of a faulty digestion. Pain and distress
was not aggravated by the quantity and quality of the food.
There were repeated attacks of hematemesis and discharge of
altered blood through the intestinal canal. An enlargement
could be palpated in the region of the pylorus. Patient was
somewhat emaciated and anemic. Heart's action was weak,
circulation feeble. Probable diagnosis of ulcer of duodenum
was made by exclusion. Owing to the weak action of the
heart ether was used as an anestTietic. The skin in the line of
abdominal incision was infiltrated with Schleich's solution for
the purpose of reducing the amount of the anesthetic to a min-
imum and to shorten the time required for operation. The
operator decided to perform a gastroenterostomy with a view of
securing rest for the ulcerated part of the intestinal tract by
excluding it from the active process of digestion. A median
incision was made extending from the tip of the ensiform car-
tilage to the umbilicus. The stomach and duodenum presented
no visible or palpable evidences of disease. From this it was
evident that the ulcer of the duodenum, which wasumiuestion-
ably present, had not penetrated deep enough to involve the
peritoneal coat. The head of the pancreas was enlarged, but
retained its form and consistency. Professor Berg is in favor
of posterior gastroenterostomy, but in this case the anterior
operation had to be performed because the mesocolon was too
short for the posterior. The anastomosis was made near the
pylorus and the large curvature of the stomach. Doyen's long
clamps for the stomach and intestinal clamps for the jejunum
were used to exclude stomach and intestinal contents from the
seat of operation. A loop of the upper part of the jejunum
was sutured with silk to the anterior surface of the stomach in
its long axis at the point indicated to the extent of three inches.
Tlie peritoneal coat of the stomach and duodenum was incised
two lines from the row of Lembert stitches, over which another
row of serous stitches was applied. The visceral wound on
each side was next completed, the mucous membrane all
around united, and the anterior stitches buried under two rows
of Lembert stitches. The sewing was done exclusively by con-
tinuous silk sutures. A flap of the omentum whs now drawn
from the pyloric side and laid over the line of suturing
anteriorly and fixed in place with three serous sutures. The
abdominal Incision was closed with three rows of silk sutures.
The wound was covered with a small absorbent dressing. The
whole operation was completed in less than an hour and was
executed with a delicacy and skill as pleasing to the audience
as it must have been satisfactory to the operator.
Other Stockholm Hospitals.— HUKkhohn has made ample
provision for its sick poor. It is well supplied with well-man-
aged liospitals and charitable institutions for the Insane, the
aged, the poor, and the orphans,
Sophia Hospital. — This magnificent hospital, with its park-
like grounds, is the creation of the (^ueen of iSwedeu. It con-
tains 80 beds and is managed by the Sisters of Sophia. The
material for this order of Sisters is selected from the best families
in Sweden. The Sisters are in training In this, the mother house,
for 2i years, and after their graduation they are expected to
servo the rich and the poor without expectation of a financial
reward, as their earnings go Into the general ftind of the sister-
788 Americas Mbdicink
THE WORLD'S LATEST LITERATURE
[NOVEMBKR 15, 1902
hood. The nursing in this hospital is therefore of the highest
order. The wards and private rooms are elegantly furnished.
The two new operating-rooms are models of their kind and a
glance at them would inspire every surgeon with confidence so
far as the facilities for aseptic precautions are concerned. One
of the features of these rooms is the electric lighting. The
electric lamps over the operating table are covered with glass
and a convex glass between the lamps directs the rays of light
In such a manner that no shadows are cast upon the field of
operation. For the best private rooms a charge of seven Icronen
is made. The hospital expenses of the poor are often paid by
the congregations to which they belong. The Queen is a liberal
contributor to the annual expenses and is a frequent visitor at
the hospital.
Grown Princess Louisa Hospital. — This hospital is devoted
to the care of sick children and is under the patronage of Crown
Princess Louisa. The buildings are two and tliree stories high
and are surrounded by an attractive flower garden. It has a
capacity of 120 beds. The medical side is in charge of Prof.
Jonas Waern, the surgical department is presided over by
Docent Dr. Bjorn Floderus, and Dr. Oscar Gibson is chief of the
polyclinic. The operating-room is small, but is well supplied
with instruments and all facilities for aseptic work. The
expenses for indigent children are paid by the districts from
which they are sent. Last year a bazaar under the patronage
of Princess Louisa netted 86,068 kronen. Of this amount James
Carnegie contributed 20,000 kronen. The receipts from pay
patients during the same time amounted to 6,547.25 kronen,
while the total running expenses for the year reached the sum
of 110,434 kronen. Last year 244 operations were performed,
with 2.34 recoveries, five improvements, and only five deaths, a
good record considering that many of the operations were per-
formed for far advanced tuberculous affections of joints, bones,
lymphatic glands, and skin. In the polyclinic 435 minor opera-
tions were made with no mortality. •
Deaconess Hospital. — This hospital, with 80 beds and a
home for the aged, is beautifully located on a high embank-
ment facing the harbor of Stockholm. It is in charge of an
order of Sisters and has an excellent training school, where
Sisters are prepared for their life work. Dr. Hugo Toll, who
practised his profession for a number of years in Minneapolis,
Minn., Is the surgeon-ln-chief. His skill as an operator is
highly appreciated by the hospital authorities, the Sisters and
his patients. He keeps pace with the rapid progress of surgery,
and his results would compare favorably with those of any
other hospital. Space does not permit to describe the remaining
hospitals of Stockholm, but it can be said with credit to this
Venice of the North that it has made excellent and wise pro-
vision for patients of means as well as its deserving sick poor.
Stockholm, August 10.
Mortality ft-om Acute Infectious Diseases in Russia. —
According to a report made to the Public Health and Marine-
Hospital Service, the deaths resulting from acute infectious
diseases in Russia during 1901 were as follows : Smallpox,
40,274; scarlatina, 115.827; diphtheria, 58,984; measles, 109,667;
whoopingcough, 66,159; typhus, exanthematous, 4,256; enteric
fever, 18,369 ; typhus, recurrent 2,466; typhus fever, 52,217; dysen-
tery, 20,737; diarrhea, 231,460; anthrax, 2,250; hydrophobia. 286.
Disposal of City Waste.— At a recent meeting of the New
York Society of Medical Jurisprudence, Dr. Woodbury, com-
missioner of street cleaning, in speaking of the work now being
done by his department and the difliculties to be overcome,
gave some noteworthy facts regarding the disposal of the city'.s
waste. He stated tliat in the Eleventh ward, which extends
from Broadway to the East river between Houston and
Broome streets, and which is largely populated by the foreign
element, street cleaners pick up by hand every day in the year
18 tons of garbage that has been thrown on the pavements, this
being in excess of that collected in cans. Last year the city
spent #7.30,000 for the disposal of sewage, which is not now
carried out to sea and dumped as was formerly the practice.
Since February the department has added 25 acres of land to
Riker's Island, in the Kast river, from ashes, etc. ; each acre is
estimated to be worth $1,000. It is estimated that within a year
land will be deposited worth 8250,000. A plant in process of
erection at the foot of West Forty-seventh street is expected to
pay for itself and will furnish 250 horse-power of energy as a
result of burning the city's waste. Since January $100,000 has
been realized on the sale of municipal rubbish. i(See editorial,
American Medicine, April 12, 1902, page 583.)
THE WORLD'S LATEST LITERATURE
Journal of the American Medical Association.
November 8, 1901. [Vol. xxxix. No. 19.]
1. Memorial to the Late J. T. Eskridge, M.D., of Denver, Colo .Chair-
man of the Section on Neurology of the American Medical Asso-
ciation. Chari.es K. MiLiJi and Frank P. Norbuky.
2 Address on an Exhibit of Early ( Prior to I860) British and American
Ophthalmic Literature. CASEV A. Wood.
3. A Modified Form of TestKiard and Test-letter. Elmek G. Stabr.
4 .Metivstatic Sarcoma of the Choroid. Meyer Wiener.
.5 One Thousand Personally Conducted Cases of Ethyl Chlorld Nar-
cosis. Martin W. Ware.
6 The Subarachnoid Injection of Cocaln for Operations on the Upper
Part of the Body. A. W. Morton.
7. Syphilis of the Liver. Charles G. Stockton.
8. An Analysis of 70 Cases of Gastroptosls. J. Dutton Steele and
Albert P. Francine.
9. The Purse-string Suture in Gastrorrhaphy for Gunshot wounds :
An Experimental Conlributlon. N. SENN.
10. The Purposes of Ureter-catheterlsm : Presentation of Ureter-cysto-
scope for Male and Female. Bkansford Lewis.
11 The Bole of Syphilis as a Causative Factor In the Production of
Pyorrhea Alveolarls. A. H. Ohmann-Dumesnil.
3.— See Americati Medicine, Vol. Ill, No. 25, p. 1052.
3.— A Modified Porm of Test-card and Test-letter.—
Starr describes a card on which colored letters are placed on a
background of a complementary color, and another in whicli
the parts of the letter are composed of complementary colors on
a gray background. The general surface of the card is black.
The advantages are lessening of fatigue caused by a white
background ; absence of Irradiation as seen with white letters
on a black background and a more sensitive test object in the
particolored letters, lack of perfect focusing, causing the colors
to blend into gray and become indistinguishable from the back-
ground. [H.M.]
4.— Metastatic Sarcoma of the Choroid. — Wood says
this is extremely rare and has been authentically reported only
by Shiess-Gemusens, Pfliiger and de Schweinitz. It is not
mentioned in the textbooks. In Wiener's case the patches
were chiefly of the round-celled type with some spindle cells,
located chiefly in the tunica vasculosa, involving al.so the
chorio capuUaris. He attaches the postmortem record, [h.m.]
5. — See American Medirine, Vol. Ill, No. 25, p. 1043.
6.— Subarachnoid Injection of Cocain.— Morton has used
this method 673 times without failure of analgesia, and 60 of the
operations were above the diaphragm. Only one fatality could
be attributed to Its use. He reviews its advantages over gen-
eral anesthesia and describes the technic of administration.
Should analgesia be desired in the upper extremities the needle
must be introduced in the third lumbar space and the dose
should be 0.4 to 0.5 of a grain of cocain. The patient will occa-
sionally complain of cramps in the limbs, or a warm sensation
over the body, rapid pulse, perspiring, nausea, vomiting,
involuntary evacuation, and later, headache and chills. Some-
times there is some shock, seldom alarming. The headache
will seldom occur if the cocain is dissolved in the cerebrospinal
fluid and all of this is returned. He has oljserved nine chills,
but no serious result following. He reports 48 cases, [h.m.]
7.— See American Medicine, Vol. Ill, No. 25, p. 1036.
8.—Gastropto8is.— Dutton and Francine say this condi-
tion is more common than supposed. It is almost constantly
present in women showing symptoms of gastric atony. It is
less frequent in men. It is common to all ages. The causes
vary. The theory of congenital predisposition is hypothetic.
In all the authors' cases the position assumed was vertical.
Total descent is probably extremely rare. Some dilation of
the pyloric end was always present, presumably secondary.
In general dilation the displacement is probably secondary.
The transverse colon assumed the M or V shape, and when
inflated was in contact with the greater curvature. The hepatic
flexure may not be displaced or may sink to the level of the
umbilicus. The right kidney was movable in 60.9% of the
cases, the left was rarely so, the spleen in but one case. The
liver sagged in three of six cases operated on, suggesting that
ptosis of this organ may elude ordinary methods of examina-
tion. Absence or diminution of HCl is the rule. In a few
cases the amount was normal. Hyperacidity was rare and
associated with general dilation and a neurotic taint. The sub-
jective symptoms were those of motor insiifl[iciency, more
severe in general dilation. Pain was present in the upper
November 15, 1902]
THE WOKLD'S LATEST LITERATIJEE
iAmbeican Mbdicinb 789
abdominal region in about half, and in the lumbar region in a
quarter of the oases. The same causes that produce neuras-
thenia appear to favor ptosis of the abdominal viscera. These
conditions react on each other, but have no direct causative
relation, [h.m.]
9. — Purse-String Suture in Gastrorrhaphy. — According
to Senn, in gunshot wounds the principal object of suturing
is to guard agajnst extravasation and approximate a maximum
surface of intact peritoneum. This is accomplished by making
a cone of the injured part with the apex toward the lumen of
the organ. The cone acts as a valve. For wounds of the
posterior wall, the purse-string suture of heavy catgut should
be applied through the anterior wound and the latter be closed
with silk applied to the base of the cone on the serous side.
The posterior wound is found by inserting forceps through the
anterior wound. The greater part of the posterior wall is
accessible to sight and touch through an opening large enough
to admit the index finger. In doubtful cases inflation should
be practised for the detection of another perforation. Senn
describes experiments ou dogs demonstrating the safety of the
circular suture, which has great advantages over other methods
in ease of application and saving of time, [h.m.]
lO. — See Amei-ican Medicine, Vol. IV, No. 17, p. 648.
11.— Syphilis a Cause of Pyorrhea Alreolaris. — Ohmann-
Dumesnil says the latter is a bete noire to dentists mainly due to
the fact that they cannot cure it and are compelled to prosthetic
dentistry. In examining cases of syphilis he observed the
facility with which pus could be made to exude from the alveoli
by pressure on the gums. This he noticed also in gout and
other dyscrasias. A number of cases of pyorrhea alveolaris
were submitted by dentists on request and about two-thirds gave
a history of syphilis. A little care and study will enable us to
save many valuable teeth, [h.m.]
Boston Medical and Surgical Journal.
November 6, 190t. [Vol. CXLVII, No. 19.]
1. A Clinical Study of l;i5 Cases of Empyema, Based Upon the Bacterio-
logic Findings in the Exudate. K. Withington.
2. Round .Shoulders and Faulty Attitude : A Method of Observation
and Kecord, with Conclusions as to Treatment. Robert W.
LOVETT.
3. The Actinic Rays. Paper I ; Their Use In Minor Surgery. Edward
A. Tracy.
i. Segmented Ring for Intestinal Anastomosis. Francis B. Har-
rington.
1.— See American Medicine, Vol. Ill, No. 20, p. 807.
2.— See American Medicine, Vol. Ill, No. 24, p. 1001.
3. — The Actinic Rays. — Tracy quotes a statement to the
effect that Minin, of St. Petersburg, after devising a set of
lamps for utilizing the actinic rays, treated burns, hematuria,
acute myositis, acute articular rheumatism, and the pains
of pleurisy. He also claimed for it the power to produce
local anesthesia of the body surface. The author, acting on the
suggestion in the last instance, has used it successfully in three
ca.ses under the following caption : Removal of large sebaceous
cyst from the scalp without pain — actinic ray anesthesia ; sub-
cutaneous abscess tlie size of a marble opened under actinic
ray anesthesia ; removal of skin slough from the hand. The
method of producing the anesthesia is by illuminating the
wound by bringing near one of the lamps for a period of 10
minutes, [a. B.C.]
4.— SeRinented Kings for Intestinal Anastomosis.—
Harrington describes a segmented ring devised by himself,
which consists of a ring of aluminum made in four sections,
which are joined together firmly by a small bar of steel, with
a screw shoulder and screw thread, which serves a.s a handle.
It can be used for end-to-end anastomosis, for lateral anasto-
mosis, and for gastroanastomosis. [a.b.c]
Medical Record.
November 8, 1902. [Vol. 62, No. 19.]
1. The Diagnosis of Surgical Diseases of the Kidney Accompanied by
HyurTa. RA.MON OuiTftKAS.
2. The Treatment of Acute Dysentery. J. D1CK.SON HuNTKH.
:!. A Table of the Dlrt'erentlal Diagnosis of Coma, with Report of a Case
of Fracture of the Base of the Skull, Intracranial Hemorrhage,
and Compression of the Brain, Diagnosed by Symptoms Alone;
Trephining; Iteeovery. SINCLAIR TousKY.
4. Educational Limitation of Venereal Diseases. Ferd. C. Valen-
tine.
1.— Diagnosis of Surgical Diseases of the Kidney.—
Ramon Guiteras gives the following summary of the article:
Given a case of pyuria, the seat and the nature of the lesion
should be determined by all the methods at our command
before an exploratory incision or an operative procedure is
attempted. These methods include, in addition to the general
and physical examination : (1) Examination of the urine,
including cryosoopy and the phloridzin test ; (2) cystoscopy ;
(3) ureteral catheterization ; (4) segregation of the urine from
each kidney by appliances introduced into the bladder and
not into the ureters ; (5) radioscopy. It is possible, by a care-
ful study of the pus, blood, casts, and particularly by a study of
the epithelial elements of the urinary sediment, to determine
the nature of the lesions and the seat thereof in the urinary
tract. A renal lesion of suppurative character being found, it
becomes necessary to locate it in one or the other kidney, or to
determine whether the opposite kidney is present and healthy.
This may be done with the aid of cystoscopy, ureteral catheter-
ization combined with the phloridzin test and followed by the
examination of the urines from each kidney, the x-rays, and in
case of doubt, exploratory incision, [a.b.c]
2.— Treatment of Acute Dysentery.— According to Hunter
a case presenting the slightest sign of dysentery should never
be looked on as trivial. It is more prudent to overtreat from
the first. Hunter generally prescribes at first ipecacuanha, 3
grams (45 grs. ), preceded by 15 or 20 drops of tincture of opium or
a hypodermic of morphin a half hour before, and a sinapism to
the pit of the stomach, with abstention from food before and three
hours afterward. Even with these precautions there are
generally considerable nausea and vomiting. As the vomited
matter is acid, sodium bicarbonate is agreeable in a mouth-
wash. Peruvian practitioners generally prescribe infusions of
the contused root. The supernatant fluid is less provocative of
disgust. From 150 cc. to 180 cc. (5 oz. to 6 oz. ) of a 1 : 2,000 solution
of potassium permanganate is useful as an enema preceded by
a solution of sodium bicarbonate, or an injection of liquor
hydrargyrum perchloridi (P.B.) 1 cc. to 30 cc. (15 m. to 1 oz.)
of water. Starch and opium enemas, hot sitz baths, and hot
water or poultices to the anus are soothing ; also hot toasted
bran or salt in a bag on the abdomen. When ipecac does not
cure emulsion of castor and almond oils in small frequently
repeated doses may be tried, or the fat dissolved out of the
omentum of a fowl in doses of two to ten or more tablespoonfuls
in mallow tisane or chicken soup. Sublimed sulfur 1.33 gm.
(20 grs.) and Dover's powder 0.33 gm. (5 grs.) every four hours ;
also the sulfates of magnesium or sodium podophyllum and
turpentine are useful . Lactic acid may be given when the stools
are green, [h.m.]
3.— -Fracture of the Skull.— Tousey reports the case. A
boy of 9 years was suffering with a contusion of the right
cheek and a hematoma of the forehead, sustained by a fall.
There was epistaxis, vomiting of some blood, and the patient
was stupid. A careful examination failed to discover anything
suggesting fracture. The patient rapidly became more stupid,
passing into the stage of coma. The various symptoms sug-
gested cerebral compression. An incision was made over the
hematoma and a triangular fracture was found. Lifting the
fragment of bone hemorrhage was plentiful. This was con-
trolled, clots, were removed, and the patient made a good
recovery. A table giving the differential diagnosis of coma
accompanies the article, [a. 11.0.]
4.— Educational Limitation of Venereal Diseases. —
Valentine advocates the segregation of prostitutes in defined
districts. No minors should be permitted to enter the district,
nor others, until provided with a circular giving the necessary
information for such safety as is possiljle. Periodic examina-
tion of prostitutes should be rigidly enforced. And furtlier :
Sufliclent of the physiology and pathology of the genitourinary
apparatus should be taught, in institutions for higher educa-
tion, to convey to students the dangers of genitourinary dis-
eases to themselves and toothers. Similar instruction should
be given in schools attended by boys at the age of puberty.
No man who has ever had gonorrhea should be allowed to
marry until it is proved by a physician that he cannot infect
his wife. Regular physicians should be elected by their socie-
ties to deliver evening lectures to the public on genitourinary
790 A.MKKICAN MBWOINK)
THE WORLD'S LATEST LITERATURE
[November 15, 1902
diseases. Every lather should be taught to warn his sons of
the dangers of genitourinary diseases. When from incompe-
tence or delicacy the father cannot or does not wish to do this,
the family physician should discharge that duty. Every med-
ical society should elect its most competent member to write at
least one article on the subject, worded for laymen's compre-
hension, and to be published under the auspices of the society.
[a.b.c]
New York Medical Jonrnal.
November 1, 1903. [Vol. lxxvi. No. 18.]
1. A Case of Necrosis of the Mucosa of the Large and Small Intestine,
with Hemorrhage into the Tissues, Produced by Streptococci
(Enterococci). H. F. Harris.
2. Rotary Curvature of the Spine; a Reply to Dr. Lovett. A. B. Jud-
SON.
8. The Modern Basis of Dietetic Treatment in the Uric Acid Diathesis.
Ai-rRED C. Croftan.
4. The Medical Treatment and Management of Acute and Chronic
Cholelithiasis. Leonard Weber.
5. The Effect of Climate on Laryngeal Tuberculosis, with Special Refer-
ence to High Altitudes. Robert Levy.
6. The Burke Foundation, and a Plea for Proper Homes for the Conva-
lescent Poor of Large Cities. S. A. Knopf.
7. The Dependence of Skin AfTections Upon Nutritive Disturbances.
W. R. Inge Dalton.
8. On the Immediate Repair of Cervix Lacerations. Anna F. Dono-
GHU*.
1. — Necrosis of the IMncosa. — Harris reports a case of
necrosis of the mucosa of the large and small intestine
with hemorrhage into the tissues, produced by streptococci.
The patient was suflfering from Bright's disease, and the
author believes that the condition of lowered resistance was
in a large measure responsible for the pronounced char-
acter of the changes observed in the intestine. The mucous
membrane of the large intestine from the caput coli to
the transverse colon was found to be intensely ecchymotic.
Almost all of the ileum and the lower part of the jeju-
num were also involved. The part of the intestine affected
was much thickened, of a dark dun color, and very friable.
Where the pathologic condition was most intense the depres-
sion between the valvules conniventes was less marked than
in health, on account of swelling of the intervening mucosa.
The portion of the colon involved in this hemorrhagic condi-
tion was covered with what seemed to be numerous enlarged
lymph follicles; these were not apparent in the small intes-
tine. In cultures from the intestine colon bacilli, staphyl-
ococci, and streptococci were obtained. In sections stained by
Weigert's method enormous numbers of bacteria were found in
the necrotic areas. Some of these were long, rather thick
bacilli, bvit by far the greater number of vegetable forms con-
sisted of diplococci ; in some instances they formed short chains
of from 3 to 8 individuals. These bacteria corresponded in
every way with those described by Escherich as enterococci.
The observations of authors cited in this paper leave no reason-
able doubt of the frequency of infection of the intestinal walls
— with the production of profound alterations in the tissues— by
these vegetable forms, [c.a.c]
3.— Dietetic treatment in the uric acid diathesis is
discussed by Croftan. He believes that nondestruction is a
more prolific cause of uric acid accumulation than overproduc-
tion. The two chief indications for the dietetic treatment are:
(1) To prevent the increase of uric acid in the blood. This
accomplished, the precipitation of urates is rendered impos-
sible ; (2) to promote the solubility of uric acid either in the
blood or in the concretions that have already formed ; in this
way precipitation may be prevented. As uric acid is chiefly
formed from disintegrating cell nuclei, the restriction of articles
of food containing many cell nuclei, or nuclein or uric acid or
its chemical congeners, the alloxuric bases, must needs decrease
the formation of uric acid. Dietetic regulations aid in the
elimination of uric acid ; directly by exercising an effect on the
circulation and the renal excretion, indirectly by sparing the
heart and kidneys and enabling them to perform their function
in a normal manner. Foods that tend to increase the alkalinity
of the blood should be given. The meat of birds may be given,
and there is no difference between the dark and the white meat.
Boiled meat is better than fried meat, because the extractives
have been removed from the former. Eggs in moderation may
be permitted. Milk in addition to a mixed diet is good, if it
can be borne. As uric acid patients should be instructed to
take much physical exercise, the addition of some fat to the diet
is almost indispensable to maintain full nutrition. Carbohy-
drates should be restricted. Salads and all green vegetables
may be given freely. All fruits may be permitted. Water
should be the chief beverage. [c.A.o.]
4. — Acute and Chronic Cholelithiasis ; Medical Treat-
ment.— An acute attack of gallstone colic requires lor imme-
diate relief a hypodermic injection of morphin ; a hot linseed
poultice over the upper abdomen ; a large enema to relieve and
empty the rectum ; later on, when nausea and vomiting have
ceased, calomel or compound cathartic pills for thorough
cleansing of the intestinal tract. The author follows an acute
attack of gallstone colic lor a week or so by a daily enema of
Irom 120 cc. to 180 cc. (4 oz. to C oz.) of warm olive oil, carried
high up by a long rectal tube, to be retained over night and
followed by copious flushing of the colon with plain warm
water the next morning. Foods rich in lime and magnesia
salts should not be taken. The patient should be moderate in
the amount of food taken and in the use of alcoholic beverages.
The bowels must be kept regular and twice daily 240 cc. (8 oz.)
of hot Carlsbad water should be taken before eating. In all
chronic gallstone diseases the author advises the use of the
alkaline waters and the diet at least twice a year and for four
weeks at a time. To these are added suitable hydrothera-
peutic procedures. The same treatment is also advised in
cases after operation in which the gallbladder has not been
excised, [c.a.c]
5. — See American Medicine, Vol. Ill, No. 25, p. 1061.
6. — The Burke Foundation. — Knopf expresses his deep
appreciation of the gift of $4,000,000 worth ol real and personal
property to be used as an endowment for a hospital for the
New Yoi"k convalescent poor, and ventures some suggestions
as to the uses to which this fund might be put, with a view to
obtaining the greatest good to the largest number of people.
He suggests that instead of one institution there should be four
and that each should liave a million dollars. First, there
should be a home lor patients convalescing Irom nervous dis-
eases, and another lor patients discharged Irom the surgical
and obstetrical wards. The third institution needed is a home
for convalescent typhoid, pneumonia, grip, rheumatic 'indi-
viduals, etc., and a fourth should be consecrated to the conva-
lescent tuberculous patients. He also suggests that all four
institutions should be in different localities and that, if at all
practicable, each home should have a division for convalescent
children, [o.a.o.]
7. — Skin Affections. — Dalton believes that skin affections
are due to nutritive disturbances — a defective degenerative
metabolism, producing a lethargic condition of the skin, an
inefficient stimulation of the nerve twigs supplying the sudor-
iferous glands, that bacterial agencies cause septic and putre-
factive changes in the alimentary canal, and that inanimate
toxins maintain selective affinities for the tissues, exerting
their action upon the primordial protoplastic group ol cells.
He insists that the patients have their bowel emptied every
day ; that they abstain from alcoholic or malt beverages ; that
no sweets be taken, and no meat for six weeks, though
fish and eggs are permitted ; and that they drink copiously of
water, especially before breakfast. He also recommends the
use ol the following tablet :
Napthalin 3 .3 (gr. 50)
Ipecac 1 6 (gr. 25)
Charcoal (willow) 5 (gr. 75)
Calomel ]
Strychnin ^of each 03 (gr. ss)
Pilocarpln J
Make 50 tablets or capsules. Dose: One at each meal.
[c.A.o.]
8. — Immediate Repair of Cervix Lacerations. — Dono-
ghue insists on the immediate repair of the cervix, especially in
a practice among the middle and lower classes, if the tear is at
all extensive. The reasons given are that profuse and danger-
ous hemorrhage frequently follows a cervical tear, that spon-
taneous healing of the cervix is not common, and that among
all but the upper classes secondary operations, except where
the pelvic symptoms are very seveie, are rare. [c.A.o.]
K'OVEMBER 15, 1902]
THE WORLD'S LATEST LITERATURE
(Amebican Mkdicink 791
Medical News.
November S, 19m. [Vol. 81, No. 19.]
1. Treatment of Congenital Dislocation of the Hip. Royal Whitman.
2. The Etiology of Smallpox ; with a Special Keference to Its Micro-
biology and a Demonstration of Its Microbe. William Sba-
GROV.E Magill.
3. A Modified Method of Auscultatory Percussion. Albert Abrams.
4. Symptoms, Diagnosis and Complications of Gonorrhea. Abraham
li. WOLBARST.
5. The Use of Salicylate of Sodium in the Treatment of Pneumonia.
A. Fkaxk Taylor.
1.— See American Medicine, Vol. Ill, No. 24, p. 1001.
2.— Etiology of Smallpox. — Magill believes mail matter is
responsible for various epidemics. Disinfection by sulfur after
perforation is totally inefficient. Smallpox is contagious at
every stage from before eruption until the formation of new epi-
thelium, attaining its maximum during the formation of pus,
the period often extending over 40 days. All organic fluids and
residues contain the special bodies which are exceedingly
resistant, surviving air desiccation of crusts for at least two
years. Contagion is not diminished by the wind, but is limited
to direct or Indirect contact. No age is exempt. In the very
young it takes the form of a pure septicemia. In the fetus
incubation may be prolonged to one month. Natural immunity
is estimated at 1 in 1,000. Race immunity has not been con-
firmed by facts. Previous attack, inoculation and vaccination
are efficient in the order named. None confess absolute
immunity. The germ penetrates usually through the respira-
tory sy.stem. The blood is profoundly altered. Mononucleosis
is invariably found. If virulence is not too great, as it is in the
liemorrhagic form, expulsion of the invader takes place through
the skin. The pus is the work of the specific agent. Doubtful
diagnosis in abortive types can be fixed if mononucleosis is
present. The Carnegie Laboratory is endeavoring to determine
whether the variolic body is a protozoon, to study its life
history and its metabolic relations by grafting it upon the
simplest form of animal capable of developing the life-cycle.
The simplification of food intended for such organisms is also
a subject of investigation, [h.m.]
3.— A Modified Metliod of Auscultatory Percussion.—
According to Abrams this embodies the principle of trans-
sonance. The clavicles, sternum, ribs or vertebra are per-
cussed without the interposition of the finger as a pleximeter.
If the area of cardiac dulness is in be obtained the clavicle or
manubrium sterni is percussed directly, and the stethoscope is
gradually carried toward the organ in all directions from the
lung. It is possible to outline the right auricle and left ven-
tricle on the posterior chest surface, the patient being erect with
the body inclined slightly backward. The blow must be con-
tinuous and uniform as the stethoscope is carried toward the
organ. Corpulence is a drawback. Abrams has elicited incipi-
ent lung consolidation by this when conventional methods have
failed. He has outlined the lower border of the stomach by it.
It is of no value in determining the lower border of the liver.
For the latter the patient should incline the body backward as
far as possible, supporting it by resting the hands on the hips.
Light percussion will now easily elicit the border since it is
approximated to the abdominal walls, [h.m.]
4.— Symptoms and Diagnosis of Gonorrliea.— Wolbarst
says three cardinal symptoms are always present in acute gon-
orrhea. These are profuse discharge, angry-looking meatus,
and cloudy urine. Of course in all cases the finding of the
characteristic germ makes the diagnosis positive. Commonly
in anterior urethritis there is no frequency of micturition
though this is nearly always present in posterior urethritis;
this condition is differentiated from one of neurasthenia by
the fact that it is by night as well as by day. Several causes
may lead to a nonspecific urethritis and among them are:
Contact with leukorrheal or menstrual discharges, irritant con-
dition of the urine, instrumentation, and irritant injections.
Chancre or chancroid in the urethra may produce symptoms
strongly simulating simple urethritis. Spreads of pus for
microscopic examination should be made with platinum wire
' , and not by pressing the glass slide against the meatus. Exten-
sion of the disease process to the posterior urethra is very com-
mon and is usually accomplished by the third week or earlier.
The Thompson two-glass test condemned and the Jadassohn-
Goldenberg test recommended. It is doubtful if a gonorrheal
cystitis ever develops from a healthy bladder. That usually
assigned as such is a posterior with involvement of the vesical
neck. Extension from the posterior urethra to the seminal
vesicles and ejaculatory ducts is not uncommon and is usually
attended by a high fever. The sudden disappearance of pus
aud shreds from the urine in the midst of a severe attack is
often prodromic of epididymitis, [a.b.c]
5. — Sodium Salicylate in Pneumonia. — Taylor reports
the results in the treatment of 25 cases. The only death was in
an infant 22 days old. To adults he administered 15 grains (1
gram) every four hours, with veratrum viride and aconite
until the temperature fell, then lessening the salicylate and
using turpentine and lard on the chest with a covering of
flannel and rubber dam. Narcotics were not usually needed,
pain yielding to the salicylate, [h.m.]
Pliiladelphia Medical Journal.
November 8, 190i. [Vol. x, No. 19.]
1. A Year's Work at the Whlt« Haven Sanatorium of the Free Hos-
pital for Poor Consumptives. Lawrence F. Flick.
2. A Case of Stammering ; with Exhibition of Patient. G. Hudson
Makuen.
8. Report of Recent Advances in Gynecology. Matthew D. Mann.
4. The Treatment of Placenta Proevia ; Is Cesarean Section Justifiable?
Robert A. Murray.
5. Suppurative Tubal and Ovarian Disease. J. J. Gubnky Williams.
t>. Movable Kidney ; Its Diagnosis and Treatment. Robert J. Reei).
1.— A Year's Work at the White Haven Sanatorium.—
Flick details the results which have been obtained, and feels
that the following conclusions are justified: Tuberculosis
is curable under the most primitive conditions, provided the
patient is kept out of doors and given plenty of proper food ;
for successful sanatorium work patients should be carefully
classified and kept apart, according to the classes to which
they belong, and these are incipient cases aud chronic cases
with good resisting power and a strong tendency to recovery,
advanced cases in which there is fever and the prognosis
uncertain, and dying patients; tuberculosis is seldom recog-
nized in general practice until it is far advanced, many of the
patients having tubercle bacilli in the urine ; the incipient
cases recover in a very short time, and advanced cases require
a loug time for complete recovery, [f.c.h.]
2.— See American Medicine, Vol. Ill, No. 24, p. 1002.
3.— See American Medicine, Vol. Ill, No. 21, p. 856.
4.— See American Medicine, Vol. II, No. 23, p. 945.
5.— Suppurative Tubal and Ovarian Disease. — Williams
concludes as follows : Gonorrhea is by far the most frequent
cause of suppurative tubal and ovarian disease ; vaginal punct-
ure is dangerous and unsurgical; the mass should always be
removed through an abdominal incision ; plain sterile water
should be used in all abdominal operations ; the use of mer-
cury, pota.ssium permanganate, or any antiseptic, except
alcohol, is unnecessary in the preparation of the operator or
assistants. Cleanliness is the great point, and may be obtained
by soap, water and brush, using many changes of water and
taking many minutes to scrub ; silk should be used for all liga-
tures within the abdominal cavity; an absolute differential
diagnosis previous to operation is impossible in the majority of
cases; the cases in which drainage is used usually do better
than those not drained. The absolute avoidance of morphin,
or any form of opium, before or after operation, should be im-
perative, [f.c.h.]
O.— Movable Kidney. — Reed details the diagnosis and treat-
ment of movable kidney, and emphasizes the following points:
Do not wound the iliohypogastric nerve ; do not attempt to
anchor the kidney in too high a position, its major portion
should rest below the twelfth rib; aim, in fixing the kidney in
its new position, not to change its normal relation to the axis
of the body, that no kink or twist may be given the ureter; and
keep the patient in bed three or four weeks. In many cases
tonic and constitutional treatmeut should be begun and indefi-
nitely continued, [f.c.h.]
792 AVEBICAir Hedicii^e]
THE WORLD'S LATEST LITEEATURE
[NOVEKUER 15, 1902
CLINICAL MEDICINE
David Ribsman A. O. J. Kelly
EDITORIAL COMSIENT
The Effects of Castration. — There is widespread
belief that castration is followed by obesity caused by an
increased deposit of fat. This is also said to occur after
the normal climacteric. The explanation usually given
is that the sexual organs possess an internal secretion
that simulates oxidation, and that when this secretion
is absent, the oxidative processes are lessened and fat
accumulates. But there is another explanation, viz.,
that there is often, after castration, a greater degree of
quiet, with the development of phlegmatic habits, a con-
dition readily leading to obesity. Luetje ' has approached
this question experimentally.
He took pure-bred dogs of the same litter, and of each pair
castrated one and kept the other for control. The dogs were
placed under the same conditions of activity and upon the same
food, and their metabolism was carefully studied. Without
going into the endless details given by the author, suffice it to
say that in the male dogs the castration was without influence
upon the accumulation of fat, as there was practically no diflfer-
euce between the two animals. In the case of the females, the
castrated animal was a little heavier and contained a greater
percentage of fat than the noncastrated ; but as this difference
had existed prior to the castration, and as it was not altered
proportionately after this procedure, the latter could not have
had any influence. The author, therefore, concludes that the
sexual organs have not, in either sex, any specific influence
upon metabolism. If in the human subject an increased
amount of fat is deposited after castration or after the cessation
of the catamenial periods, it can, he thinks, be due only to indi-
rect causes— to change in the psychic sphere, greater quiet and
inactive habits. Pinzani made some experiments upon the
blood of castrated animals, and noticed an increase in the red
cells and a diminution in the white, together with an increase
in hemoglobin. Luetje had these experiments repeated by one
of his pupils, but was unable to confirm Pinzani's results.
It is not improbable that too much importance has
been attributed to the hypothetic internal secretion of the
sexual organs. The changes produced in the male are,
to a considerable extent, of psychic origin. This is also
true in a measure in the female. As regards the natural
menopause, it is a physiologic process, and in the
majority of women probably passes without any note-
worthy effect upon metabolism ; yet there are facts that
suggest the existence of an internal secretion. Gynecol-
ogists, recognizing this, are less prone to remove the
ovaries than formerly, and moreover, when at all pos-
sible, leave a little of the ovarian tissue behind. The
animal experiments, whatever they may teach, must be
supplemented by observations upon man.
REVIEW OF LITERATURE
Dental Inspection in Scliools.— Ensch and Polus^ call
attention to the importance of health boards giving attention to
such diseases of children in schools as are readily relieved, as
dental caries, adenoid vegetations, affections of the ears and eyes,
and refers to the very satisfactory results obtained by the
special dental service of Brussels organized in 1877, and the
work of various individuals in other European cities. The ten
commandments of dental hygiene proposed by Dr. Rose, of
Munich, are commended to the attention of hygienists and
parents : 1. Forget rather to wash the body than to wash the
mouth and clean the teeth. 2. Accustom children to the pleas-
ure to be derived from dental hygiene. That which is neglected
in youth is never retrieved later. The care of the milk teeth is
no less important than that of the permanent teeth. 3. Avoid
sweets and very soft foods. The best means of preventing
caries is the vigorous chewing of bread with thick crust. 4.
Never forget to clean the teeth at night. He who defers cleans-
ing the mouth till morning resembles one who shuts the stable
door after the horse is stolen. 5. Mechanical cleansing with the
aid of a brush constitutes the basis of all artificial hygiene.
6. Inofifensive antiseptic mouth- washes and a good tooth pow-
der are very efficacious for completing the buccal and dental
1 Arch. f. Exp. Path. u. Pharmak., Bd. xlvii, Hfte. 3 u. 4.
2 Journal Mfedlcal de Bruxelles, August 28, 1902.
hygiene. 7. Have the teeth examined twice a year by a dentist,
who will discover and check the spread of decay. 8. Have the
tartar removed from time to time. 9. Old roots which cannot be
saved by treatment should be removed, whether painful or not.
10. Mothers should give preference to foods rich in nutritive
salts (green vegetables, milk, eggs, etc.) before the birth of
their children and during lactation — and the child during earlier
years should take the same with a view to greatest possible
development of the teeth, [c.s.d.]
Diagrnostic and Therapeutic Remarks Concerning
Gastric Ulcer. — The principal points made by Ag6ron ' are
that the use of the stomach-tube is perfectly safe in competent
hands in gastric ulcer and that there is always a disturbance of
motility. The latter is of diagnostic value in cases in which
symptoms suggestive of ulcer are present, and helps to difi'er-
entiate between a nervous affection of the stomach and ulcera-
tion. In the treatment, a semiliquiddiet, in which sugar should
form an important constituent, and posture are of importance.
The patient should lie on the back or slightly tilted toward the
right, with the pelvis elevated, in order to remove the pressure
from the greater curvature. This causes the contents to lie
principally on the posterior wall and facilitates the administra-
tion of fluids, since the passage of these is favored by the posi-
tion. The author also recommends the introduction into the
stomach of large doses of bismuth subgallate, 10 grams at a
dose, suspended in 200 grams of linseed or poppy oil. [d.r.]
Congenital Pulmonary Stenosis. — Burke ' states that the
theory of Kussmaul appears the most probable as the etiologic
factor for the origin of the pulmonary stenosis, because it sees a
cause in the embryologic arrest in development, as well as in the
fetal inflam matory phenomena, for the development of a congen-
ital pulmonary stenosis. Pulmonary stenosis of moderate degree
can promote the remaining open of the foramen ovale, as well
as eventually the persistence of a septum defect. The ductus
Botalli remains uninfluenced or even hindered by the pure
physical narrowing of the pulmonary stenosis. In the extra-
fetal state the pulmonary stenosis affects the right ventricle,
a condition occurring in lack of development which corresponds
to a primary insufficiency, resulting in stasis in the veins,
cyanosis, epistaxis, dilated venous network, etc. When a com-
pensatory hypertrophy can occur, the pulmonary stenosis can
cause a mixed cyanosis, particularly in open foramen ovale.
He concludes that the assertion that in pulmonary conus steno-
sis an accentuation of the second pulmonary sound proves the
existence of a coexisting open ductus Botalli, although possi-
ble, yet appears unsupported. He believes that an open fora-
men ovale is sufficient reason to explain the accentuation of the
second pulmonary sound. He states that the statistics of the
cases of pulmonary stenosis show that we can demonstrate a
narrowness of the aorta also with the pulmonary stenosis in a
series of cases. This phenomenon appears to be a particular
cause for the frequent occurrence of the complicating pulmo-
nary stenosis, and would agree better with the postulated ane-
mia of the lungs — because such a condition could be caused by
a narrowing of the vessels — as well as with the frequency of the
congenital narrowness of the vessels in tuberculosis, [c.a.c]
Dilation of the Stomach. — Allbutt-' confines his remarks
to the atonic form. Acute dilation he attributes to compres-
sion of the distended viscus itself about the junction of the
duodenum and jejunum. The mean position is more vertical
than generally supposed and the pyloric end tends to become
dilated through gravitation of retained contents. Relaxation
may depend on toxins or mere atony. Distention advancing to
dilation not uncommonly retards convalescence from typhoid,
rheumatic fever, etc. When the condition follows slow diges-
tion with fermentation, anemia, or mere inanition, the muscular
failure is primary. Spasm of the pylorus, from ulcer, hyper-
chlorhydria, or lumpy contents, probably causes some cases.
Peristalsis is not visible in atonic cases. Continued mental
depression or shock, also excessive athletic exertion, may
cause dilation. It is not rare in children and infants, but
acute cases can be readily relieved by an emetic or the tube.
The symptoms are often indefinite or misleading. The bal-
' MQnchener med. Woch., July 29, 1902.
2 Buffalo Medical Journal, August, 1902.
'Medical Press and Circular, August B, 1902.
November 15, 1902]
THE WORLD'S LATEST LITERATURE
[American Mkdicini 793
looned stomach is apt to push up the diaphragm and encroach on
the thorax. Such a stomach may play a large part in the dis-
tress of heart disease. Physical examination must be made at
various periods of digestion and when the stomach ou§ht to be
empty. In health the stomach contracts on its contents, in
dilation an area of resonance will be found at the cardiac end.
In health no squelchy sounds, should be obtainable and resid-
uum should contain no particles recognizable as remnants ot
food. The diet should be regulated and fluid at meals restricted
In sleepless patients hydrotherapy should be recommended.
[H.M.]
A Case of Accessory Thyroid Gland at the Base of
the Tongue Treated by Transhyold Pharyngotomy. —
Smith,! of Copenhagen, reports a case of accessory thyroid gland
at the base of the tongue in a woman of 48. The tumor was
situated just back of the circumvallate papillae, and when the
patient protruded her tongue it nearly closed the faucial
isthmus. The tumor was smooth, firm, elastic, nousensitive,
and covered by highly vascularized mucous membrane. Under
chloroform anesthesia the tumor was extirpated by transhyold
pharyngotomy. The patient made a good recovery and did not
develop myxedema, neither was there any return of the
growth. Microscopic examination proved the tumor to be
composed of thyroid tissue. The author has collected 19 addi-
tional cases from the literature; in three of them myxedema
followed the removal of the growth. It is probable that in two
the supposed accessory thyroid gland was really a misplaced
thyroid. [d.k.J
The Existence of Bacterial Virulence fk-oiu Experi-
ments with Cholera Vibriones.— Pfeiffer and Fried berger'''
experimented on rabbits with cholera vibriones to determine
the presence of a bacterial virulence. They concluded that
virulent and avirulent cultures of cholera vibriones diff'er in
the number and the degree of affinity of their haptophore
groups, both of these elements being greater in the virulent
than in the avirulent cultures. The immunizing effect of inoc-
ulations with cholera vibriones is dependent upon the degree of
the virulence used. The existence of virulence depends upon
the bacterial species used and its relation to its amboceptors.
[W.E.K.]
Neurasthenic Neuralgias. — E. Jendrassik ' calls attention
to the need for greater care in the diagnoses of neuralgias, par-
ticularly in the differentiation of those cases of pseudoneu-
ralgias or neurasthenic neuralgias, frequently attributed to some
nonexistent cause of irritation, a supposed bone splinter or
imperfectly- filled tooth, forms of neuralgia referred to by Paul
Blocq under the name topoalgias, or by Galippe as dental
obsessions. These pseudoneuralgias described by Blocq as
monosymptomatic neura-sthenias are to be recognized not only
by the neurasthenic symptoms and heredity, but by the absence
of the wellknown symptoms of true neuralgia, such as period-
icity, flushing of the face, involuntary shedding of tears, etc. —
all of which fail in the neurasthenic variety, [c.s.d.]
Postoperative Nonseptic lieukocytosis and Other
Blood Conditions.— King,* from a study of the question,
concludes that an increase of from .5,000 to 10,000 leuko-
cytes per cubic millimeter following operation in from
6 to 36 or even 48 hours is a normal postoperative con-
dition provided it is not sustained. Probably the maxi-
mum leukocytosis in the majority of cases occurs within
the first 12 hours after operation, and it is transient. The
leukocytosis in the normal reparative process bears but
slight relation to the pulse and temperature. A postoperative
leukocytosis of 10,000 or more above the individual normal and
sustained for more than a few hours may be looked upon with
suspicion. The apparent increase of erythrocytes following
operation is not caused by an actual increase of red cells in the
circulating blood, but is due rather to the temporary aVjstrac-
tion of the fluid constituents from the blood or it is merely
a phenomenon of the peripheral blood and transient in charac-
ter, [a.o.j.k.]
' Nord. Med. Arklv {KIriirgI), Afd. 1, hftft. 2, 1902.
' Berliner kllnlKchc Woehcnsohrirt, .June 23, 1902.
'Deutgche medlclnisohe Wochcnschrlft, Hept<!mber4 and II, 1902.
* American Journal of the Medical Sciences, cxxlv, 450, 1902.
A. B. Craio
GENERAL. SURGERY
Martin B. Tinker
C. A. Orr
EDITOKIAI. COMMENT
Pulmonary Tuberculosis Inoperable. — The suc-
cess with which simple abscess of the lung and abscess
following; acute gangrene have been treated has perhaps
aroused the interest manifested in recent years in the
treatment of tuberculous foci and abscesses. Several
surgeons have reported successful results after excision
of tuberculous areas, drainage of tuberculous abscesses,
resection of ribs over a considerable area to allow col-
lapse of the chest- wall to aid in closing large cavities left
by tuberculous disease, and the injection of nitrogen gas.
Probably surgeons have been encouraged by these favor-
able reports to perform many operations which have not
resulted so brilliantly as in those cases which have come
into more general notice, for successes are always sooner
reported than failures. To determine the possibility of
operative intervention in pulmonary tuberculosis, Whit-
acre,' of Cincinnati, has studied carefully the autopsy
material in 978 cases of pulmonary tuberculosis treated
in the Cincinnati Branch Hospital during five years. He
finds that excision of tuberculous areas is excluded from
consideration because of involvement of at least four
lobes in nearly 75^ of the cases which he examined,
and that in 98% of the cases operation would be inadvis-
able because of extensive involvement. Even in the
remaining 20% of cases in which excision might be per-
formed, it is questionable whether that more patients
would not be cured by climatic, dietetic and general
hygienic measures. As to the drainage of tuberculous
abscesses, Whitacre finds that the vast majority are
located in the apex or upper lobes of the lungs, sites most
favorable for drainage through the bronchus, and in 978
cases he did not find a single cavity in which operation
would have promised sufficient relief to make operation
justifiable. Excision of a number of ribs is attended
with a good deal of shock, and when such an operation
would prove helpful the patients are usually too weak to
withstand a procedure involving such risk. The value of
thesestudies will be apparent to any one sufficiently inter-
ested to read Whitacre's article. As a rule surgeons are
not inclined to undertake tedious investigations which
discourage operative intervention and hence tend to de-
prive them of the means of livelihood. Such honest work
is greatly needed, however, for it is certainly as important
that the operating surgeon should know in what cases it
is advisable to withhold the knife as to know when
operation is indicated. The method of compression by
nitrogen gas Whitacre considers the only procetlure
which is safe and has been followed by favorable results,
but we doubt if this gives a larger percentage of cures
than climatic and hygienic treatment. From Whitacre's
studies, which will, we believe, be confirmed if others
will take pains to examine the lungs in cases of pulmo-
nary tuberculosis, postmortem operation seems definitely
contraindicated in most cases, and the favorable results
which have been reported must be considered more as
fortunate accidents than the result of good surgical judg-
ment.
REVIEW OF LITBKATURB
Postoperative Urinary Retention and Its Conse-
quences.—Taussig' states that urinary retention after abdomi-
nal operations in the female has not been sufliciently studied.
He has observed retention for more than three days in 00
patients, for more than six days in 43, out of a total of 282 dif-
ferent abdominal operations. The gravity of the retention
seemed to be in proportion to the gravity of the operation. The
disturbance of the blood supply is not the cause of this, but
rather an interference with the spinal nerve supply. The sym*
> Journal American Medical Association, 1902, xzxix, 748.
2 Mdnobener medlclnlscbe Wochcnschrlft, October 7, 1902.
794 AMERICAN MeDICIHKI
THE WOELD'S LATEST LITER AT OBE
[NOVBKBEB 15, 19C2
pathetic nerves will compensate after a time, but Immediately
after tiie operation they are paralyzed by the shock. Cystitis
results from nearly all cases of retention. Twelve ca.ses were
studied baoteriologically : in eight cases Streptococcus pyogeiiex
aureus was found to be the agent, in six the colon bacillus,
and in two cases mixed infection existed. To prevent retention
he advises intravesical faradization, or dilation of the urethra.
In two cases micturition resulted by waiting 30 hours after
operation. Urotropin and silver irrigations proved of the
greatest value in curing the disease, [e.i..]
Appendicitis Consecutive to Dysentery and Dysenteric
Perforation of the Cecum.— Vandenbossche> reports this
interesting case. The patient was a soldier of 34, a member of
the Chinese expedition in 1901. For three months he had had
diarrhea, at first simple, then dysenteric. For three days the
pain which had before been felt vaguely over the whole abdomen
had become localized in the right iliac fossa. The diagnosis of
appendicular abscess was made and the patient operated upon.
An encysted, retrocecal abscess containing fetid pus was found.
On the inner wall the appendix, in the form of a hard cord, was
felt. The cavity was cleansed with gauze tampons and drained.
The patient died the sixth day. Autopsy showed a retrocecal
abscess cavity the size of an orange, limited by thick adhesions
and communicating with the interior of the cecum by an open-
ing through which fecal matter was discharging. The cecum
presented no trace of attachment of the appendix. Dysenteric
ulcers, particularly numerous in the head of the cecum, were
found along the entire length of the colon. The sequence of
events is supposed to be as follows : Dysentery, with lesions
particularly severe in the c^cum ; infection of the appendix by
propagation; sloughing of appendix and abscess formation;
perforation of the cecum by dysenteric ulceration. The writer
concludes by saying that this case shows a new origin of appen-
dicitis (dysentery.) ; that it is an argument in favor of the theory
that appendicitis can be caused by a propagated lesion ; and
that in such eases the usual operation may be insufficient, the
cecum also demanding attention, [a.g.e.]
Kxcision of the Lumbar Lymphatic Gland In Caici-
noma of the Testicle.— Roberts ^ believes that if we are to
adopt the same thorough and radical measures in the treatment
of malignant disease of the testicle as in the case of malignant
disease elsewhere, it will be necessary to remove the lumbar
lymphatic glands together with the spermatic vein in such
cases. He reports a case of recurrent carcinoma of the testicle
in which he removed the glands but not the vein. Intestinal
obstruction necessitated a second operation later on, and fistula
developed which finally resulted in death from peritonitis.
Pathologic examination of the tissue showed carcinomatous
involvement of four of the lumbar lymph glands. In removing
these glands Roberts suggests a median incision extending
about two inches above and below the umbilicus. Care should
be taken to avoid injuring the inferior mesenteric artery, along
which the glands lie. The nodes lie upon and at the sides of
the aorta from its bifurcation to the level of the renal vein.
They vary in size, often being not larger than a grain of wheat.
As they are embedded in fatty tissue, the safest course would
be to remove all fat in front and on both sides of the aorta and
vena cava. As the lymphatics run to both sides, it would be
wise to excise the glands on both sides. The spermatic vein
should be excised on the side corresponding to the growth.
[M.B.T.]
The Surgical Treatment of Hourglass Stomach.—
Schmitt' refers briefly to the various surgical methods used in
thetreatmentof hourglass stomach. They are: digital or instru-
mental dilation of the stenosis through a gastric incision ; gas-
troplasty (making a longitudinal incision through the stenosis
and suturing it transversely) ; gastroanastomosis (connecting
one gastric sac directly with the other) ; gastroenterostomy ;
resection of the stricture; a combination of any of these
methods. He operated on three cases of the condition, perform-
ing posterior gastroenterostomy twice ; in the third case he did a
gastroplasty, but had to follow it with gastroenterostomy 10
1 Gazette Heb. de Medicine etChlrurgle, October 9, 1902.
' Annals of Surgery, 1902, Vol. xxvl, p. 539.
8 Manchener mediclnische Wochenschrlft, September 16, 1902.
months later. He discusses the advantages of each operation
and the conditions under which they should be performed.
[E.L.]
Wh^n Is It Necessary to Operate In Appendicitis?—
Galleti does not accept the dictum of those surgeons who
advise operation in all cases of appendicitis. He believes that
a minute analysis of the sympto^ms in a given case permits a
sufficiently accurate prognosis to prevent, when combined
with a careful watching of the patient, surprise by the sudden
onset of an incurable peritonitis. In appendiceal crises, when
the diagnosis is clear, operate immediately. In the most com-
mon form, appendicitis with localized peritonitis, there is
often a tendency to encystment. In these cases medical treat-
ment under active surveillance, a veritable armed expectation,
has given Gallet better results than immediate surgical inter-
ference. In general peritonitis several openings for drainage
should be made immediately. The necessity of operation in
recurrent appendicitis is very strongly urged by the writer,
who states that the difficulties from adhesions which may be
encountered during these operations have not been sufficiently
emphasized. In two cases he had to resect the cecum. [a.(i.e.]
The Diagnosis of Hourglass Stomach.— Hourglass
stomach may exist at birth, but is usually the result of either
carcinoma, perigastric adhesions or healed ulcers. Decker'
reports two cases following chronic ulcer, in both of which the
diagnosis was made prior to operation. The gastric ulcers had
existed respectively 12 and 6 years. The diagnosis was based
upon the following points: The violence of the pain simula-
ting a tension pain ; this pain did not stop with the vomiting
but lasted a full half-hour longer ; it returned as soon as the
patient was taken off the rest cure. But small portions of food
were vomited at one time on account of the stricture. Rem-
nants of food appeared in the lavage fluid after it had been
clear for some time. Water entering the stomach through a
stomach tube does not reappear until the pyloric compartment
flows over. The stomach is unequally distended when blown
up with air; this permits the stricture to be seen easily; the
cardiac sac distends before the pyloric sac. Electric illumina-
tion shows an unequal light, and at the point of the scar a
shadow. When distended, and one or the other part of the
stomach is pressed upon, a gurgling sound is heard. This is
not heard if pressure is exerted over the stenosis, [e.i,.]
Excision of the Scapula.— Delaup » credits the first oper-
ation of this kind to Langenbeck, in 1&56. In his own case a
negro, aged 20, entered the hospital with a suppurating sinus at
the junction of the spine and vertebral border of the scapula.
On making an incision along the spinal border of the scapula
such extensive disease of the bone was found that complete
excision seemed indicated. This was accomplished by keeping
the knife close to the bone, and with so little hemorrhage that
no large arteries needed tying, and only three or four ligatures
were used. The arm was not disturbed. The patient made a
very good recovery from the operation and was afterward able
to use his arm very well. With his clothes on the deformity
was scarcely noticeable, [m.d.t.]
Ambulance Stretcher.- Mansfield * describes an ambu-
lance stretcher which he devised. It is designed for conveying
wounded men on board ship. Its great recommendation is
the facility with which it can be constructed by the ship's car-
penter, sailmaker, and the armorer for the metal work. It con-
sists of an ordinary stretcher with the cross bars fitted, when
not required, to fall in line with the side poles but readily fixed
in position when desired. A combined canvas perineal support
and chest piece is attached to the middle of the canvas on which
the patient is extended ; this is fixed by eyelet holes in the
attached canvas straps to hook on the poles at the required
situation. The patient can also be supported by the broad
canvas foot piece the width of the stretcher attachable by side
eyelet holes to the poles where desired. It can be carried as a
stretcher, hoisted up or lowered from a top, down an ammuni-
tion hoist or narrow hatchway, or over ship's side. It can also
by the adjustment of the cross bars be folded up. [a.b.c]
1 Gazette Heb. de Mfideclne et de Chlrurgie, October 2, 1902.
- Munchener mediclnische Wochenschrlft, September 16, 1902.
3 Annals of Surgery, 1902, Vol. xxvl, p. 563.
* British Medical Journal, October 11.
November 15, 1805!]
THE WORLD'S LATEST LITERATURE
[American Medicine 795
GYNECOLOGY AND OBSTETRICS
WiLMBR Kbusen Prank C. Hammond
EDITORIAL COMMENT
Publotoiny in Obstetrics The results of 346
cesarean operations performed by 1 1 renowned operators
showed a mortality of only 23, or 6.6%, and a com-
petent man working under favorable circumstances on
suitable eases need fear no mortality from this pro-
cedure. In symphysiotomy injuries may occur which
cause a prolonged convalescence and even lead to the
death of the patient. Rubinroth, examining the world's
literature of three years, 1896-'98, found 136 cases of
symphysiotomy with a maternal mortality of 11 fo and
an infantile mortality ofl4fo. These statistics are not
encouraging to the advocates of this operation ; neither
will Americ-an obstetricians be likely to regard with
much favor the revival of the operation of pubiotomy
which has been selected by some obstetricians in prefer-
ence to symphysiotomy. The operation has been chosen
for cases in which the symphysis is a synostosis instead
of synchondrosis. It probably has its place in a Naegele
pelvis delivery in which the operation termed ischio-
pubiotomy ha.s been performed by some operators. The
distinctive fetiture of a Naegele pelvis is the atrophy of
one lateral mass of the sacrum, producing an obliquely
contracted pelvis. On the side, where the ankylosis of
the sacroiliac joint is found, the pelvis is cut with a
chain saw in two places, in the ascending branch of the
pubis 5 cm. from the median line, and where the descend-
ing ramus joins the a-scending ramus of the ischium.
After the bones are cut, according to Garrigues, it is
necessary bluntly to separate the obturator membrane
along the outer border of the isehiopubic branches in
order to obtain a separation of the ends. By the gaping
of these bones, combined with the mobility at the
symphysis and the other sacroiliac articulation, enough
space is gained for the passage of the head. Quite
recently H. van de Velde (see accompanying abstract)
has advocated in cases of obstructed delivery a similar
operation, terming it hebotomy, claiming that it has
little danger for the mother and is favorable to the child
f)eside8 presenting no difficulty for the obstetrician. In
-pite of such advf)cacy we still believe in the superiority
of cesarean section over either of these operations upon
the osseous structure of the pelvis, the comparative
mortality being sufficient ground for this preference.
KEVIEW OF UTERATUIIE
Hebotomy in Obstructed Delivery.— 11. van de Velde'
reports two ca-ses, describes the operation in detail and claims
the following advantages over symphysiotomy: Since the
sawed surface is not in the median line, the natural supports of
the bladder remain and preserve the urethra. Since the soft
parts on the side are thicker than in the middle, the tearing
through of the wound into the vagina is more difficult; and
while the clitoris is avoided, dangerous hemorrhage is less likely
to occur; the spanning of the abductor longus and gracilis
muscles prevents the wide separation of the pelvii; lialves;
the opportunity (or prompt healing is better in cutting
through the bono simply than in cutting through the joints,
and there is less danger of infection. As a disadvantage is the
fact that the incision lies among the large crural vessels and
may give rise to hematoma or infection. But this possible dis-
advantage falls in the scale before the great advantages of
the operation. Hebotomy is an operation favorable to the
ihild, has little danger for the mother, is not difHcult for the
Ml)stetrician, and is adapted to a contracted pelvis.
Total Abdominal Hysterectomy for Fibromyomu L'terl.
— H. Spencer ' says the chief objections urged against total
abdominal hysterectomy are the long duration of the operation,
the danger of injuring the ureters, and that the removal of the
' Centralblatt fur rij-nakologle, Heptember 13, 1902.
' British Medical .Journal, Octolicr II, 1902.
cervix takes away the keystone of the vaginal arch, shortens
the vagina and gives rise to hernia. Of these the only real one
is the slightly longer duration of the operation, and this draw-
back is more than compensated for by the folloviring advan-
tages: Complete hemostasis, for should any oozing occur it
appears externally, gives evidence of its presence at once, and
is easily dealt with through the vagina; small loss of blood
during the operation; good (vaginal) drainage; complete
closure of the peritoneum, thus avoiding raw surfaces and
extensive seams to which the intestines are prone to adhere;
avoidance of leukorrhea, septic discharges, infection of the cer-
vix and exudations around the cervix ; prevention of carci-
noma or sarcoma of the cervix. [w.K.]
Kxtrauterine Pregnancy Diagnosed as Appendicitis.—
I.egnen ' reports two cases In which he made this error. The
first was a woman of 48, who was seized with violent abdomi-
nal |)ain which became localized in the right iliac fossa, the
abdomen became distended and the temperature rose. There
were no abnormal uterine manifestations. Incision revealed a
normal appendix and a ruptured left tube, which was removed.
The second case was a woman of 20, who presented the same
symptoms with the addition of vomiting. The left tube in
this case was ruptured and a median laparotomy was necessary
for its removal. In neither case was there menstrual irregu-
larity, uterine hemorrhage or the usual general changes noted
in pregnancy, and the temperature was elevated. The only
point that was not in favor of appendicitis was the absence
of nmscular rigidity, [a.o.e.]
The Kxternal Examination During Labor. — Frick-
hinger' makes an ardent plea against vaginal examinations in
normal confinements, urging many arguments why in such
cases external examination should suffice. The most important
are the large number of Vjacteria within the vagina, the impos-
sibility of complete disinfection of the hands, the fact that many
cases of puerperal fever originate in these examinations. He
urges the traiuiug of midwivesand nurses in external examina-
tion and advises, if necessary, the prolongation of the teaching
term to thoroughly instruct them in it. [e.l.]
Phototherapeutlcs in Obstetrics and Gynecology. —
Curatulo^ believes that the dilation of the capillaries, the direct
stimulation of the cells, the reflex excitement produced in the
vasomotor nervRS by the application of light baths, will cer-
tainly benefit some forms of female diseases. To test the effi-
cacy of light baths in these diseases, he has devised a speculum
by which the incandescent electric light is divided into its con-
stituent parts ; the three kinds of rays, heat, light and chemic,
are isolated and applied separately or united as adapted to each
case. The instrument permits the simultaneous use of the
liquid douche and the light bath, or the latter may replace the
former and act as a hot air douche. By moderate application of
chemic rays we may obtain important modification of nutri-
tion in cases of metritis or hypertrophy of the cervix. This
increased nutrition has been found u.seful when the uterus and
the cervix are not well developed— a frequent cause of sterility.
It also tends to facilitate the absorption of the exudations in
cases of perimetritis and parametritis, a very frequent cause of
uterine displacements. The stimulating effect of the vaginal
light bath is also u.seful in cases of uterine inertia. The author
thinks the germicidal power of the chemic rays will he of value
in specific ulcerations of the cervLx, and ho is making some
clinical researches that will be given in extciuio in a future note.
Meanwhile he begs his colleags to experiment in the same line
on a larger scale than his work will permit. [w.K.]
Concerning the Connection Between Vesical Diseases
and Myoma Prognosis.— Congestion of the bladder predis-
poses to cystitis. Such a condition, according to Hahn,' is fur-
nished by pregnancy, retention of urine, menstruation, dis-
placement of the uterus, especially antilloxion, in particular,
however, by uterine fibroids. A myoma producing cystitis,
even though no other symptom exists, should be considered as
requiring removal, as the cystitis will certainly become chronic
if tumors are not removed. [e.l.]
■ Guzette heb. de Mfdeclne et de Chlrurffle, October 10, 1902.
sMilnchcnor medicliilsche Wochcn.schrlfl, September .tO, 1902.
» HrltlKh .Medical .lourniil. October 11, 1902
^.VlUnehencr inedleinisehe Woohenschrlft, October 7, 1902.
796 AMSKIOAN MBDieiNX]
THE WORLD'S LATEST LITERATUEE
[NOVEHBSK 15, 1902
Pritsch's Fundal Incision in Cesarean Section.— Munro
Kerr,' from his own experience, concludes that the only advan-
tage of Pritsch's fundal incision is that the child can be more
easily extracted. The only proved objection to the incision is
that the uterus becomes attached higher up to the abdominal
wall and remains larger, weighing one against the other. An
anterior longitudinal incision, if made high, is the best for
routine practice, but when the uterus has also to be removed
subsequently to the extraction of the child, Fritsch's fundal
incision is the better, as the child can be more readily extracted.
[W.K.]
T^ratopages Showing Life.— Baudouin ' reports four new
cases of viable xiphopages in addition to the 14 cases previously
collected by him. In one of these later cases the monster lived
7 months and 14 days. He also reports one case each of viable
cSphalopage and hypogastropage and a sternopage that perhaps
showed life, [a.g.e.]
Ectopic Gestation : Its Diagnosis and Treatment. —
Harrison ' confines his remarks to tubal gestation in its earlier
months. If, as rarely occurs, the physician is consulted in cases
of tubal pregnancy before the death of the ovum, the diagnosis
may be made with a near approach to accuracy if menstruation
has been absent once or twice; if the uterus is soft, enlarged,
and somewhat elongated ; if there are subjective and objective
signs of pregnancy; and if there is felt a soft tumor involving
one tube with strong arterial development. The soft, elasticity
of the tumor is almost pathognomonic. One symptom to which
Veit draws attention is a transitory hardening of the tube. The
death of the ovum is proved conclusively when a tumor
originates suddenly without fever and with the attendant signs
of acute anemia, then becomes hard, undergoes diminution, or
remains constant, and when in addition there is a discharge of
dark tarlike blood by the vagina. A very important symptom
is urinary tenesmus, a constant symptom due to the sudden
interference with the capacity of the bladder consequent on the
development of the hematocele. Most authorities are agreed
in the opinion that so soon as a pregnant tube is certainly recog-
nized it should be removed at once ; for the simple reason that
it is not in our power to ward off the dangers that menace
the life and health of the patient by any means short of radical
intervention. For the operation the author prefers the abdom-
inal route. In cases of rupture of the tube the same principles
that guide us in general surgery are applicable, [w.k.]
Gangrenous Lymphangitis of the Scrotum in the
Newborn.— Duvernay-' reports this case, the infant being but
13 days old. Repair began after the tissues were incised and
had sloughed, but erysipelas set in and soon extended from the
knee to the umbilicus. Picric acid arrested its spread the first
day, but it then continued and the child died. Duvernay has
been able to find six other cases of this type. Of the seven
patients three died. The prognosis is to be considered favorable
so long as the infant takes food regularly. If it refuses food, a
fatal termination may be expected, [a.g.e.]
Fifty Cases of Cesarean Section.— As regards the indica-
tion for operation in these 50 patients Cameron ' says that they
all had extremely deformed pelves, the true conjugate at the
brim in no case having exceeded 2i in., while many of Ihem had
frequently undergone craniotomy and induction of labor. It
can be well urged that embryotomy in a very contracted pelvis
is as dangerous to the mother as is cesarean section, and it
always compromises the life of the child, which may be saved
by the latter operation, and that no one has a right to sacrifice a
child when he can save it without exposing the mothel- to any
additional risk. Cameron thinks cesarean section might be
advisable in some cases of eclampsia, but a skilful obstetrician
would never think of such a procedure in a case of placenta
prsevia. There can be no doubt that cesarean section is a highly
dangerous operation ; but the danger depends for the most part
on delay, and death most frequently results, not so much from
the operation, as from previous operative abuse, which is the
just term for all injudicious attempts to extract the fetus
through a deformed natural passage, [w.k.]
' British Medical Journal, October 11, 1902.
'Gazette Mfidlcale de Paris, October 11, 1902.
» Gazette heb. de Medicine et de Chlrurgle, October 12, 1902.
TREATMENT
Solomon Sows Cohen
C. Wood, Jr. L. F. Appleman
EDITORIAL COMMENT
The Therapeutic Uses of Sodium Glycocholate. —
Some months ago we called attention to the fact that the
most active stimulant of the liver was bile or its salts,
and cautioning against the promiscuous use of the biliary
stimulants in conditions of obstructive jaundice.
Recently Keown ' has published a paper on the physi-
ologic effect and therapeutic uses of sodium glycocho-
late. He shows that when injected into the blood this
salt acts as a destroyer of the red corpuscles, that in
small doses it seems to have a slightly depressing effect
upon the circulation, but that its typical action is stimu-
lation of the liver. On account of this stimulating effect
he recommends it in icteroid conditions, dependent on
insufficient hepatic activity, such as socalled "liver
spots" and "biliousness." While recognizing the possi-
bility of a toxic action from sodium glycocholate when
there is obstruction of the bile duct, he recommends it in
gallstones on account of its solvent action upon the
stones. We must confess to some doubt concerning
the usefulness of the salts of bile in conditions of chole-
lithiasis. It is, of course, well known that these salts
render cholesterin, the most important constituent of
gallstones, more soluble. Dr. Keown has found in the
laboratory (hat some of these stones, after being kept in
a 1<^ solution of sodium glycocholate, " become friable
so they can be crushed to powder with the finger." We
must remember, however, that the conditions are very
different in the gallbladder from those in a test-tube ; if
the bile as originally secreted did not prevent the pre-
cipitation of cholesterin, it is hardly likely that mere
increase in amount of the same bile will dissolve these
stones. The amount of sodium glycocholate which is
given, it is hardly necessary to say, is far too small
quantity to have any solvent action of itself. Moreover,
if the gallstone is placed in such a position that it inter-
feres with the flow of the bile, anything which stimu-
lates the liver will, of course, increase the jaundice, and
augment the toxic symptoms accompanying icterus.
Dr. Keown, however, has found what seems to us a per-
manent therapeutic use for sodium glycocholate apart
from its action upon the liver. He takes advantage of
the well known fact that the bile-salts play an important
role in digestion, aiding in the emulsification and absorp-
tion of fats, to employ a forced fatty diet, in which the
digestive tract is enabled by the administration of
sodium glycocholate to fulfill the increased demands
on it in pulmonary tuberculosis, in convalescence from
typhoid fever, and in other wasting conditions. He has
found also that the glycocholate seems to have the power
of clearing the complexion in certain cachetic states as
neurasthenia or morphinism.
REVIEW OF LITERATURE
The Present Status of Light Therapy.— In a summary
of our knowledge concerning the action of light, Marcuse^
says that a clear distinction must be made between local and
the general effects of light. It was shown by Charcot, in 1859,
that sunburn is not dependent on the heat rays of sunlight, but
on the chemic rays. Widmarks has been able to produce
typical sunburn by electric light. The erythema of heat is an
essentially different type of inflammation from that brought
about through the action of the violet and ultra violet rays.
Finsen has shown that under the influence of light there is a
dilation of the bloodvessels which lasts an extraordinary
length of time after the exposure. His assistant. Bang, has
demonstrated a marked leukocytosis accompanying this vaso-
dilation. Beside this local effect, light seems to exercise an
influence on every form of organic life. In the higher animals
' Merck's Archives, .September, 1902, p. 355.
2Balneol. Central/.elt., 1902, No. 22.
NOVEMBEK 15, 1902]
THE WORLD'S LATEST LITERATURE
[American Medicink
797
there is an increase iu the COj given off; among the lower
forms of life, especially bacteria, strong light has a fatal action.
This bactericidal property of light belongs to the violet end of
the spectrum, and is shared to an extent by artificial light.
The ordinary arc lamp will kill bacteria in five to eight hours,
but Finsen has, by means of concentration of electric light,
killed them in as many minutes. The therapeutic effect of light
depends on the combination of these germicidal and vaso-
dilatory powers. Finsen's claim of its efficacy in lupus has
been abundantly confirmed by other observers, and it must be
regarded as a specific. It is also of value in other skin diseases
of a parasitic nature, as herpes tonsurans or favus. Marcuse
warns very emphatically against many sooalled " light cures,"
which are swindles and bring disrepute on a valuable thera-
peutic measure, [n.c.w.]
Hydrochloric Acid in Chronic Diarrhea. — Soupault'
states that certain persons suffer from attacks of idiopathic
diarrhea lasting from a few weeks to several months, some-
times appearing at intervals of several months. Between the
attacks the stools are normal or there is even constipation. In
these cases there is always a tendency to abundant diarrhea,
brought on by emotion, fatigue, exposure to cold, or by an
error in diet. The stools are liquid, very fetid, and variable as
to number. Ordinarily the patients do not complain of gastric
trouble, and examination of the abdomen reveals no important
sign. Analysis of the gastric juice in 30 patients one hour after
a test-meal showed that there was deficiency of the hydro-
chloric acid, especially in the serious cases. The general state
of the health is usually satisfactory. In the treatment of these
cases hydrochloric acid gives good results if it is used in doses
of from 15 to 30 drops daily. Ten to 20 drops of the pure acid
may be given in water before meals, or in the form of lemon-
ade, as
Pure hydrochloric acid 1.5 to 2 drams
Syrup of lemon 0 ounces
Water 26 ounces
Amelioration usually occurs in from two to eight days and com-
plete cure follows in a short time. This result may be obtained
witliout any special diet, although Soupault restricts the diet.
Of 38 patients thus treated, 6 did not return for treatment,
21 were cured ; in 6 others, the colic disappeared and the stools
were reduced to two or three daily, but they remained soft ; in
the other 5, the diarrhea disappeared so soon as the adminis-
tration of hydrochloric acid was stopped, [i^.f.a.]
Turkisli Bath.— Kellogg'^ believes that the Turkish bath
renders valuable service in the treatment of obesity, alone or
combined with diabetes ; in the autointoxication so commonly
present in chronic dyspeptics; in the uric acid diathesis; and
in many cases of neurasthenia, hypochondria and melancholia.
Most forms of chronic nervous disease, even cases of locomotor
ataxia, chronic myelitis, paresis, paralysis, neuritis and other
equally obstinate maladies, are materially helped, even though
a radical cure may be, in the majority of cases, impossible. In
anemia and chlorosis it promotes blood formation and relieves
visceral congestion. Care must be taken, however, to avoid
• xtreme temperatures and prolonged exposure in these cases,
i>n account of the degeneration of the bloodvessels which is
sometimes present. As a hygienic measure the Turkish bath
not only produces thorough cleansing of the skin, but also the
combined hot and cold applications which it involves in the
highe-st degree promote vital activity and the building up of the
powers of resistance to disease. The Turkish bath produces
pronounced effects upon the circulation of any internal viscus
that it may be desired to influence. For example, in cases of
chronic gastritis or chronic intestinal catarrh, chronic spinal
congestion, cerebral hyperemia, or renal congestion, the general-
effect of the batli in relieving visceral congestion may be inten-
sified by a suitably placed cold application, consisting of an icd^
l)ag, a (!old compress, or a cooling coil. In cerebral congestion
an ice-bag may be applied to the head, or an ice-collar may be
fitted about the neck. A towel wrung out of io^-water may be
applied to the face and ears. In renal congestion an ice-bag
may be applied over the lower third of the sternum. In uterine
' Le Mol8 Th<5rapeutl<iue. Vol. Ill, No. 3, 1902,
>8yst«m PhyxlulOKic Tberapoutlcx, Vol. Ix.
p. 2K.
and ovarian congestion, or the socalled chronic inflammation
of these organs, an ice-bag may be applied to the groins and the
hypogastrium. In chronic inflammation of the stomach or
intestines, or congestion of the spleen or liver, a cold applica-
tion should be made over the parts indicated. The application
of cold in the manner suggested, especially to the head, renders
a higher temperature tolerable, and may permit of a longer
duration of the bath. Due attention must be given to counter-
indications and precautions. The Turkishbath is counterindi-
cated in cases of cardiac dilation, tachycardia and arteriosclero-
sis ; in exophthalmic goiter ; in organic affections of the heart
in which there is evidence of deficit or failing compensation ;
in irritable skin affections and all febrile disorders ; and for
apoplectic subjects. The bath must be used with great care in
all forms of nephritis, and is counterindicated in advanced
stages of renal disorder. The pulse should be watched care-
fully, especially during the first stances and the first few-
moments after the patient enters the bath. Undue cardiac
excitation may generally be relieved by the application of cold
over the heart. If the effect desired is not readily induced the
patient should be removed from the bath, and the incandescent
electric light bath or some other unobjectionable heating pro-
cedure adopted.
Treatment of Scrofulotuberculosis. — Perier ' recom-
mends :
SsTu^a'^p^^o'fp^gate} "^ «-^ ^^ ^■•-- .
Syrup of gentian 3 ounces
Wine of quinin 16 ounces
To be taken in dessertspoonful or tablespoonful doses ;
or,
Calcium iodid 90 grains
Iji me water 2 ounces
Peppermint water 3 ounces
One teaspoonful in water.
Every two days the patient should be given a bath, lasting
15 minutes, containing
Salt 2 pounds
Sodium carbonate 3 ounces
Starch 8 ounces
Dry friction of the entire body with a flannel glove should
be practised every day. [l.i'.a.]
Salol as a Mouth-wash. — James' has made a series of
experiments with a proprietary emulsion of salol, known as
odol, to determine whether it is broken up into its active constitr
uents in the mouth. He has shown that it is decomposed by the
saliva, by the mucous membrane, and by various bacteria, thus
slowly liberating carbolic and salicylic acids. [H.c.w.]
Colyria with Sodium Cacodylate.—Galezowski' has fre-
quently employed sodium cacodylate internally in the treat-
ment of various ocular affections with good results, particu-
larly in rebellious herpetic keratitis. He has also employed it
locally in the eye in the form of an oily or aqueous colyrium
as follows :
Sodium cacodylate 2 grains
Cocain hydrochlorate 4 grains
fjiquid vaselin 4 drams
A few drops in the eye 2 or 3 times daily, [l.k.a.]
Concerning the Treatment of Tuberculous Lymph-
Klands.— To produce very small scars in removing cheesy
glands, Williams * uses a method which he names " puncture fol-
lowed by dry drainage." He makes a puncture from 3 to 4 mm.
long over the center of the enlarged gland, inserts and fastens a
drainage-tube, expresses the cheesy particles through this and
applies a- dry dressing of iodoform and cotton. The tube is
removed after four weeks, a very small, fine scar resulting.
This treatment is preceded by an application of 10% iodoform
collodion ; if no improvement follows after several days it is
discontinued and the operative method resorted to. The
advantages over the injection method are: a smaller scar, less
discomfort to patient, no further suppiiration, less chance of a
fistula, and if this does occur, it heals easier. He uses dry
drainage even when the gland has broken down and fistulas
formed, [e.l.]
1 BulleMu General deThempcutique, Vol cxilll, No. 15, 1902, pa«e5»2.
s The Therapist, August l.'j, 1902. 151.
■■■ lAi .M6<Je<-liie .Moderne, Vol. xlll, No. 28, 1902, page 226.
< XUg. Wlen. med. Ztg., 1902, xlvll, p. 188.
798 Amxbican Medicine,
THE PUBLIC SERVICE
INOVIMBER 15, 1902
THE PUBLIC SERVICE
Health Reporta.— The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, during
the week ended November 8, 1902:
California:
Colorado :
Illinois:
Indiana :
Iowa:
Kansas :
Kentucky :
Maine :
Massachusetts :
Michigan :
New Hampshire :
New York :
Ohio:
Pennsylvania :
South Carolina :
Wisconsin :
Austria :
Belgium:
Canada :
Ecuador :
France :
Great Britain :
India :
Russia :
Straits Settlements
Turkey :
Colombia :
Ecuador:
SMALLPOX— United States.
San Francisco .Oct. 18-26
Denver Oct. 18-25
Chicago Oct. 25-Nov. 1...
Indianapolis Oct. 25-Nov. 1...,
Ottumwa Sept. 27-Nov. 1.
Wichita Oct. 24-Nov. 1...
Covington Oct. 18-Nov. 1...
Lexington Oct. 2.5-Nov. 1...
Blddeford Oct. 25-Nov. 1...
Boston Oct. 25-Nov. 1...
Cambridge Oct. 25-Nov. 1...
Everett Oct. 2,5-Nov. 1...
Detroit Oct. 25-Nov. 1...
Grand Rapids Oct. 2.5- Nov. 1...
Nashua Oct. 2.5-Nov. 1...
Blnghamton Oct. 25-Nov 1...
New York Oct. 25-Nov. 1...
Cincinnati Oct. 24-31
Cleveland .
Dayton Oct. 2o-Nov. 1..
Youngstown Oct. 18-Nov. 1..
Altoona Oct. 25-Nov. 1..
Erie Oct. 25-Nov. 1..
.lohnstown Oct. 25-Nov. 1..
McKeesport Oct. 25-Nov. 1.,
Pittsburg Oct. 2b-Nov. 1.
..Oct. 25-Nov. 1 11
1
1
. "4
3
6
3
18
Cases Deaths
1
1
2
1
2
1
22
12
. ■ 1
. 18 4
I
1 ■
13
8
. 23
1
1 1
3
Charleston Oct. 18-25
Milwaukee Oct. 25-Nov.
Two Imported.
2
10 1
Smallpox— Foreign .
Prague Oct. 4-11
Antwerp Oct. 11-18
Ghent Oct. 11-18
Amherstburg Oct. 18-Nov. I..
Quebec Oct. 25-Vov. 1.
Guayaquil Oct. 12-19
Paris Oct. 11-18
Rheims Oct. 12-19
Liverpool Oct. 11-25
London Oct. 11-18
Bombay Sept. 30-Oet. 7 .
Moscow Oct. 4-11
Odessa Oct. 11-18
St. Petersburg Oct. 4-18.;
Singapore .Sept. ft-20
Constantinople Oct. 12-19
Yellow Fever.
Panama Oct. 13-27.
Guayaquil Oct. 12-19 .
21
4
3'
1
8
Cholera.
China: Hongkong Sept. 20-Oct. 4 5 4
Egypt: Alexandria Oct. 4-11 72 71
india: Bombay Sept. 30-Oct. 7 2
Madras Sept. 20-Oct. 3 3 3
Japan: To Sept. 30 11,228 6,302
Korea: Seoul Sept. 27 ..Between 50
o, ,^ „ , , and 2.50 deaths dally.
Straits Settlements : Singapore Sept. 6-20 15
India:
Japan :
Plague.
Bombay Sept. 30-Oct. 7..
Karachi Sept. 28-Oct. 5..
Yokohama...; Sept. 27-Oct. 4..
112
22
1
Changes in the Medical Corps of the U. S. Army for
the week ended November 8, 1902 :
Cooke, Robert P., contract surgeon, is granted leave for seven days
from November 2.
Carroll, First Lieutenant James, assistant surgeon, recently ap-
pointed, now in Washington, D. C, will report to the surgeon-gen-
eral of the Army for assignment to duty as assistant curator of the
A rmy Medical Museum.
De Witt, First Lieutenant Wallace, assistant surgeon, now at San
Francisco, Cal., will repair to Washington, D. C.\ and report
November 6 at the Army Medical Museum to Colonel Calvin De
Witt, assistant surgeon-general, president of the faculty of the
Army Medical School, for the course of Instruction prescribed by
paragraphs 452 and 453. A. R., 1901.
Harris, Samuel J., ho.spltal steward, now at Louisville, Ky., is
relieved from further duty at Fort McDowell, and will report on or
before expiration of furlough at Fort Revere for duty at that post.
SouTHALL, Captain Edward A., assistant surgeon, U. S. Volunteers,
1.S honorably discharged, to take effect November 25, 1902, his serv-
ices being no longer required.
McOallum, Captain Francis M., assistant surgeon, U. 8. Volunteers,
Is honorably discharged, to take effect November 5, 1902, his serv-
ices being no longer required.
Baird, William T., contract surgeon, leave granted September 16 Is
extended one month.
The following-named assistant surgeons, recently appointed, now at
the places indicated, will report November 6 at the Army Medical
Museum to Colonel Calvin De Witt, assistant surgeon-general,
president of the faculty of the Array Medical School, lor the course
of instruction prescribed in paragraphs .5t2 and 513, A. R., 1901 :
First Lieutenant Louis C. Duncan, Meridan, Kan.; Edward M.
Talbot, F'alls Church, Va.; John A. Clark, Washington. D. C; Sam-
uel J. Morris, Washington, D. C: Noel I. Barron, Washington,
D. C: J. Morgan Coffin, Phoenixville, Pa.; John W. Hanner, Frank-
lin, Tenn.; Levy M. Hathaway, Owensboro, Ky.; Alexander Mur-
ray, Alexandria. Va.; Philip W. Huntington, Washington, D. C;
James Carroll, Washington, D. C ; James D. Fife, Charlottesville.
Va : Wllllara A. Powell, Cairo, Ga : Leon T. LeWald, New York
City ; Jesse R. Harris, Kenmore, N. Y.; George H. Scott, Butler, Pa.;
Edwin D. Kllbourne, Chicago, 111.; Robert L. Carswell, Chatta-
nooga, Tenn.
Reed, Major Walter, surgeon, will proceed to Fort H. G. Wright for
the purpose of Investigating and reporting upon the epidemic of
typhoid fever among the troops quartered at that post during the
recent maneuvers in that vicinity, and upon the completion of this
duty will return to his proper station in Washington, D. C.
Edger, First Lieutenant Benjamin J., Jr., assistant surgeon, having
reported his arrival at San Francisco, Cal., will report to the com-
manding general, department of California, for temporary duty at
the U. S. General Hospital at that place.
Grobbs, First Lieutenant Robert B., assistant surgeon, having
reported his arrival at San Francisco, Cal., will report to the com-
manding general, department of California, for temporary duty at
the U. S. General Hospital at that place.
The following-named oiHcers. now at San Francisco, Cal., are honor-
ably discharged, to take effect December 9, 1902, their services being
no longer required: Majors Thomas B. Anderson, Robert P.
Robins, Charles H. Andrews, Frank H. Titus, surgeons, U. S. Vol-
unteers ; Captains George W. Daywalt, James K. Stockard, Clarence
H. Long, George K. Sims, William Alden, Willis J. Raynor, assist-
ant surgeons. U. S. Volunteers. The officers named will proceed to
their respective homes.
Price, Richard J., contract surgeon, now at the Presidio, will pro-
ceed to Fort Bayard and report at the U. S. General Hospital at
that place for treatment.
Porter, Major Ralph S., surgeon, U. 8. Volunteers, is honorably dis-
charged, to take effect November 12, 1902, his services being no
longer required. He will proceed to his home.
S.4.NDALL, Captain Laurel B., assistant surgeon, U. S. Volunteers, is
honorably discharged, to take elTect December 31, his services being
no longer required.
Webber, First Lieutenant Henry A., assistant surgeon, will report
to the commanding officer. Post of Manila, for duty.
Edwards, First Lieutenant J. F., assistant surgeon, is granted leave
for one month with permission to visit the United States. Lieuten-
ant Edwards is authorized to proceed by the transport McClellan
to New York, N. Y.
Morris, Major Edward R., surgeon, now on duty at the First Raserve
Hospital, Is assigned to command of that hospital, vice Major
William H. Arthur, surgeon, relieved.
Byars, Caspar R., contract surgeon, now at San Pedro de Tunasan,
Laguna, will proceed to Manila, P. I., and report at the First
Reserve Hospital for treatment.
Winn, First Lieutenant Robert N., assistant surgeon, is granted leave
for one month from about November 15.
Many, Harry C, contract surgeon. Is granted leave for one month
from al>out November 8.
Perley, Major Harry O., surgeon, is granted leave for ten days.
Minor, Captain John F., assistant surgeon, U. S. Volunteers, is honor-
ably discharged, to take effect December 10, 1902, his services l)elng
no longer required. He will proceed to his home.
Johnson, Major Richard W., surgeon, is granted leave for flfleen
days.
Usher, First Lieutenant F. M. C, assistant surgeon, is granted leave
for one month, with permission to apply for an e.xtension of one
month.
Morse, First Lieutenant Charles F., assistant surgeon. Is relieved
from duty at Fort Mansfield and will proceed to Washington, D. C.
Cobbusier, Harold D., contract surgeon, will proceed from Fort
Columbus to Fort Manstleld and report for temporary duty.
Changes in the Public Health and Marine-Hospital
Service for the week ended November 6, 1902 :
White, J. H., assistant surgeon-general, granted leave of absence for
fifteen days from November 8— November 6, 1902.
Maqruder, G. M , surgeon, granted leave of absence for twelve days
from November 17 — November 6, 1902.
COFER, L. E., passed assistant surgeon, relieved from temporary duty
at the Immigration Depot, New York, N. Y.— November 3, 1902.
KoRN, W. A., assistant surgeon, granted leave of absence for twenty-
one days from November 18— November 6, 1902.
BOGQESS, J. S., assistant surgeon, granted seven days' extension of
leave of absence from November 16— Novembers, 1902.
Alexander, E.. acting assistant surgeon, granted two days' extension
of leave of absence— November 5, 1902.
Walker, Agnes, medical inspector, granted leave of absence for
thirty days from November 1— October 31, 1902.
O'GORMAN, T. v., senior pharmacist, relieved from duty at Louisville,
Ky.. and directed to proceed to New Orleans, La., and report to the
medical officer in command for duty and assignment to quarters —
November 1, 1902.
Board Convened.
Board convened to meet at Port Townsend, Washington, Novem-
ber 4, 1902, for the physical examination of such officers of the Revenue
Cutter Service as may present themselves. Detail for the board-
Passed Assistant Surgeon C. H. Gardner, chairman ; Assistant Surgeon
M. H. Foster, recorder.
American Medicine
OEORQE M. GOULD, Editor
G. C. C. HOWARD, Afanaging Editor
CHARLES S. DOLLEY
MARTIN B. TINKER, Asnttant Editors
CXinical Medicine
David Riesman
A. O. J. Kelly
J. Edwin Sweet
Helen Mukphy
General Surgery
Martin B. Tinker
A. B. Craig
Charles A. Orr
Orthopedic Surgery
H. AuocsTCS Wilson
COLLABO^TORS
Obttetrici and Gynecology
WiLMER Krusen
Kbank C. Hammond
Nervous and Mental Diseases
J. K. Mitchell
F. Savary Pearcb
l^eatment
Solomon Solis Cohen
H. C. Wood, Jr.
L. F. Appleman
Dermatology
M. B. Hartzeli.
Laryngology, Etc.
D. Braden Kylb
Oph thalmology
Walter L. Pyle
Pathology
R. M. Pearcb
PtnLIIBBD WlBKLT AT 1321 WaLKCT STBKBT, PrILAOILPHU, BT TUB AMBBieAN-MBDtCIKB POBLIBHIHS CoHPAHT
Vol. IV, No. 21.
NOVEMBEE 22, 1902.
15.00 Yearly.
Disea.ses and Deaths in the Navy and Marine
Corps. — From the Report of the Surgeon-General of the
Navy we find that, with an average strength of 26,101
men, the following were the admissions to hospital, etc.,
during 1901 :
Epidemic catarrh liilS
Malarial diseases 1112
Rlicumatic affections 778
Wounds 717
Diarrheal affections 69.5
Gonorrhea 617
Contusions .581
Syphilis 516
Sprains 492
Dengue 427
Alcoholism 230
Chancroids 217
Pneumonia 18.5
Fractures ; 181
Measles 163
Mumps 153
It is startling to notice that the admissions from vene-
real diseases are greater than for any single cause, reach-
ing the terrible number of 1,380 in a total of 9,579 — a
I>ercentage of 14.4. This is of significance in view of
the fact that the venereally diseased is as a soldier con-
sidered not worth his keep. If we add the alcoholics
the figures and lessons grow rapidly. Then, too, how
many of the other diseases and deaths were indirectly
due to venereal disease and alcohol ? There were 1 6G
deaths in the Navy last year and their direct causes
were as follows :
Dysentery 119
Hernia 110
Burns 138
Pulmonary tuberculosis 125
Typhoid fever 105
Heart disease, organic 104
Heatstroke 95
Diphtheria !8
Rubella 88
Luxations 52
Nephritis.... 25
Drowning 23
SmaIlpo.\ 22
Cerebrospinal fever.. 8
Bubonic plague 3
Drowning.. 28
Pneumonia 22
Heart disease 17
Typlioid fever 14
Pulmonary tuberculosis 13
Xx>cal injuries (other) 10
Gunshot wounds 5
Asphyxia (gas) b
Poison 4
Dysent<.'ry 4
A Icohoiism 4
Nephritis 8
Peritonitis 8
Broncliopneumonia _ 3
.Meningitis 3
Aneurysm „ 8
Septicemia 8
Cerebrospinal fever S
Appendicitis 3
Apoplexy 2
Hepatic abscess 2
Syphilis 2
Diphtheria 'i
Heatstroke 1
Bimpyema 1
Smallpox 1
Intestinal catarrh 1
Remittent fever 1
Intestinal oiistructlon 1
Sarcoma 1
Carcinoma •. 1
Articular rheumatism 1
Diabetes 1
Edema of glottis 1
Gastric catarrh 1
Hemiplegia 1
The dearth of medical ofllcers in the Navy is
shown in a striking manner by Surgeon-Cieneral Rixey
in his report for 1901, just published. The relative
increa.se of medical corps and of surgical work between
1897 and 1901 is shown in tlie following table:
Percent.
Incrtiasein the medical corps 1.5
Increase in actual strength of .Navy and marine corps 70
Increase in number of admissions to sick list „ 76
Increase in total number of sick days "95
lncrca.se In nu mbcr of patients tretited In naval hospitals.. 137
lncr(?ase in number<if medical surveys held 174
Increase In number of persons examined for enlistment.. lU!
This tremendous increase of work leads to a service
overworked and undermanned. The promotions due
after the three years' service cannot be carried out, and
in tho next two years there can be under the present law
but 14 assistant surgeons to relieve 45 who should 'be
promoted. Distinction is despaired of under such
adverse conditions, so that capable and ambitious men
will not enter the service. A great increase, estimated
at 150, is therefore urged in the number of medical
officers in order to provide for proper medical attention
to the enlarged Navy now authorized. Without such
an increase in the corps, the present intolerable condi-
tion will become a positive disgrace. After a three-years'
cruise, in which the medical ofticer has found it impos-
sible to study or associate with other medical men, he is
now ordered to duties that absorb all his time and
energies, and that again separate him from colleges,
clinics, and laboratories. The bureau rightly urges that
this deadens progress and ambition. There should be a
term of service, opportunity, and leisure in or near the
great mcdieal centers of study, so that they may keep up
with medical progress.
The Pathology of Katabolisni. — In the forelying
pages appears an interesting contribution to the litera-
ture of the chemic origins of disease, embodying a new
theory of the etiology and pathology of carcinoma and
supposedly allied conditions. Though based largely on
hypothesis, Dr. Wakefield's views doubtless will com-
mand serious attention ; but it is not unlikely that the
speculative nature of much of his discussion, as well as
his departure from the accepted tenets of pathology and
the novelty of his opinions with reference to the common
origin of widely differing disorders, will excite conten-
tion and may obscure the truths underlying his very
thoughtful contribution. It is but natural that the
recent extraordinary developments in physiologic and
pathologic chemistry should beget considerable specula-
tion concerning ma^j* more or less obscure diseases.
Admitting the wide latitude for honest difference of
opinion, many readers doubtless will be slow to accept
the theory that cancer, a presumed aseptic process, and
tuberculosis, admittedly an infectious disease, have a
common origin ; that both arise primarily in an aseptic
degenerative process of subkatal)olism. In addition, It
is also a surprising contention that " all of the diseases
800 AMEBIOAil MeDICINKI
EDITORIAL COMMENT
[NOVHMBKB 22, 1902
of the socalled rheumatic series, pneumonia, lardaceous
disease, amyloid kidneys, and many similar affections,
are of common causation with cancer; and that syphilis,
malaria, and other affections have many manifestations
displaying a pathogenic process common to cancer, and
of diseases of katabolic stasis generally."
Katabolic stasis, as elucidated by Dr. Wakefield,
thus becomes an exceedingly interesting study. Point-
ing out that an expression of normal cellular activity
consists in the production of sarcolactic acid which
becomes almost immediately neutralized by the alkaline
intercellular juices, and that health is represented by a
balance between metabolic constructive and destructive
processes, he says that diverse pathologic states may result
from excessive formation of sarcolactic acid or from
defective neutralization or oxidation. The greatest
morbid influence is attributed to defective neutralization
(subkatabolism, or katabolic stasis), a condition mani-
fested by inactivity, devitalization, and premature
senility of the cell ; and due to suboxygenation, hyper-
acidity, absence of sun, light and heat, and excessive
strain and fatigue of the cerebral, nervous, muscular, and
fibrous tissues. This katabolic stasis is believed to
manifest itself locally in persistence of the cells in a
superannuated form in hypertrophies and hyperplasias
of the fibrous and cellular structures (local suppurations,
tumor formations, etc.), while the general or systemic
manifestations consist of different degrees of cachexia,
pigmentation of the glands and the skin, petechias and
angiomas, catarrhal conditions of the mucous mem-
branes, and a predisposition to general suppuration on
slight provocation. The detailed discussion of the pre-
sumed dependence of carcinomas and sarcomas on
katabolic stasis will well repay the reading, particularly
since many of Dr. Wakefield's statements with regard
to these newgrowths are not in accordance with the
prevailing opinions of pathologists. Not the least inter-
esting of a number of suggestive statements is that
"the arrest of dissolution of the maternal nuclei after
division and following an acid-produced retardation of
katabolism gives rise to changes, by virtue of which
they present appearances which have been mistaken by
some observers for protozoa, blastomycetes, and other
unicellular organisms." Although Dr. Wakefield be-
lieves that he has disposed of the theory of exaggerated
growth as a basis of tumor-formations, we suspect that as
a rule pathologists will be disposed to differ from him.
However, we bespeak for a paper so replete with im-
portant suggestions a consideration as thoughtful as the
attention given to its preparation.
Suicide in America. — In our issue of October 11 we
referred to certain statistics of suicide, the origin of the
figures not then being known. We now learn that they
were furnished to the insurance publication. The Specta-
tor, by Frederick Hoffman. They are therefore pre-
sumably correct, and if so they dispose of that old
and oft-repeated absurdity that the loneliness of the
farm produces the suicidal impulse. The average rate
for the whole country is found to be 11.8 to 100,000
population for the year 1900. But for the fifty largest
cites the rate in 1901 was 16.6. The next most impor-
tant fact demonstrated is that suicide is increasing. The
average rate (fifty largest cities) for 1890 was 12, while
in 1901 it was 16.6. This is also demonstrated by the
increase of suicides in the total number of deaths of
insurance companies. In the Mutual Life, e. g., the
proportion of suicides to all deaths has risen from
\.%fc to 2Afo in the last fifty years. The third
mystery revealed is the difference in the rate in
different cities. Taking the average for the whole
ten year period ending with 1900 Mr. Hoffman
finds that there were 25.7 suicides for every 100,-
000 people in St. Louis, while the rate in Trenton was
only 5.1, and in Fall River 2.9. The percentage in sev-
eral other cities was almost as high as that in St. Louis.
The figures for Chicago are 23.3, Hoboken 23, Oakland
(Cal.) 21.5, and that part of New York City included
in the boroughs of Manhattan and The Bronx, 20.9.
Even in Newark the rate is 16.2, while that for Brook-
lyn is only 15.7. Boston makes a better showing — 15.4
— while Jersey City's figures are still lower — 14.6.
Why one suburb of the metropolis on the west shore of
, the Hudson should have a higher rate than this city,
and another one very much lower, is at present inex-
plainable.
Uuvaccinated immigraiits, says Dr. Reynolds, the
Commissioner of Health of Chicago, are the causes of 14
out of the 19 epidemics of smallpox in Chicago since
1863. To the same cause is undoubtedly due the high
incidence of the disease in New York. Since January 1
and up to the end of October there have been 310 cases of
the disease discovered and removed to the Isolation
Hospital in Chicago. Not one of these, says Dr. Reynolds,
had ever been properly vaccinated. Out of the total num-
ber 4 died, 295 have been discharged recovered, and 11
remained in the hospital at the close of last week. The
weekly reports of the New York Health Department
— with three weeks missing — show a total of 1,489 cases
and 307 deaths in that city during the same period in a
population barely twice as large as that of Chicago. In
Evanston, immediately joining Chicago, with a popula-
tion of less than 20,000, there are now 33 cases of small-
pox. In Chicago, with a population of 1,700,000, there
are but 11 cases. In Evanston the 33 patients are in 12
houses ; in Chicago all are safely housed in the Isolation
Hospital. An uuvaccinated Greek was allowed to enter
the United States ; another uuvaccinated person brought
the disease from South Evanston. Both developed the
disease in Chicago immediately after their arrival there
last week. The only unvaccinated person in a large
hotel in Chicago contracted the disease two weeks ago
from a convalescent patient from Denver.
Eddyism aad lufectioiis Diseases The deaths
of patients suffering from diphtheria while under the
care of their " healers " have at last convinced the
eddyites that they must stop treating those afflicted
with infectious diseases. We should have said the law
has convinced them instead of the deaths. For the
deaths alone these fanatics have shown no regret or care,
but for the results of illegally produced deaths — well.
November 22, 19021
EDITORIAL ECHOES
AUERXGAN MKDICINK 801
that is a different thing. Mrs. Mary Mason Baker
Glover Patterson Mother Eddy has therefore ordered
her children not to treat patients suffering from infec-
tious diseases. This is the first limitation we have
known to be set to the infinite powers of these babies
and their mother, who at one word have extinguished
the material world, together with philosophic and medi-
cal science. Omnipotence they thus at last renounce —
but not omniscience ! Without having studied medi-
cine, while disbelieving in the very existence of disease,
these silly children claim the right to decide in every
case whether the disease is infectious or not. Thus there
are two kinds of disease, the nonexistent, noninfectious
disease, which the mother eddyite babes treat, and the
nonexistent infectious disease which they- must not
treat. How there can be two kinds of nonexisting
disease would puzzle any but a child of Mother M. M.
B. G. P. Eddy to explain. The next movement we
have to undertake is to compel the confession that the
1 children are as little omniscient as they are omnipotent.
They cannot distinguish diseases any better than they
can extinguish the material universe. The law must
stop their pretence as to the diagnosis of disease. The
physical world may be trusted to take care of its own
existence.
Do not neglect any cold is the advice suggested
by Dr. Reynolds, the Commissioner of Health of Chi-
cago. The tables of mortality of that city show that for
the week ending November 8, 1902, there were 67
deaths from pneumonia, while from "consumption"
there were but 49. This increase of pneumonia is a fact to
which we have previously called attention. To what
extent it obtains throughout the country and world we
have not the data at hand to say, but it is evident that
in several parts of the United States pneumonia is the
most widespread and fatel of all acute disea.ses, outstrip-
ping pulmonary tuberculosis as the chief item in the
tables of mortality. The advice is therefore timely and
needed : " Do not neglect a cold, however slight, at this
season of the year."
Antlvivisection Morality. — Stephen Paget, in the
November number of the Contemporary Review, again
exhibits the utter indifference to truth of the antivivi-
sectionists in general, and of Mr. Stephen Coleridge,
their secretary, in particular. The latter had said in a
I)revious issue that certain methods of treatment discov-
ered by the help of experiments on animals are worse
than useless, because certain diseases have of late shown
an increased deathrate. We suppose every zoophilic
indifferentist to animal suffering and hater of medical
science is repeating this fatuous and fanatic misrepre-
sentation, so that those who wish may be set right by a
reference to Mr. Paget's answer. The little battle is
chiefly over the diphtheria statistics. Paget quotes
veritable figures showing that in nonantitoxin years,
1889-1894, the percentage mortality ranged from 40.74
to 29.21, while in the antitoxin years, 189')-1900, it
dropped from 22.85 to 12.01. Coleridge's error in which
he persists after its frequent exposure consists in quoting
the deathrate, while entirely ignoring the proportion of
deaths to cases. There are of course more cases in some
years than in others, and in some the virulence is greater.
Mr. Paget thus disposes of Mr. Coleridge's logic :
According to this method of argument, umbrellas also are
worse than useless, because they do not diminish the annual
rainfall. Indeed, the more umbrellas are sold, the more wet
days there are. If umbrellas were so useful as the umbrella-
makers say, of course every increase in the umbrella business
would be followed by an improvement in the weather. The
same applies to mackintoshes. Blankets, again, ought to make
the thermometer go up, whereas they actually make it go down.
The police, also, are worse than useless : for wherever they are
most busy regulating the traflBe, there the streets are most
blocked. And vaccination is worse than useless, because the
rush for vaccine last winter in London positively coincided with
a very marked increase in the number of deaths from smallpox.
License Trained Nurses. — When we consider that
physicians endorse medical examining boards chiefly
because they prevent charlatans and quacks from enter-
ing the profession, one wonders why nurses who have
spent three years in hospital wards qualifying them-
selves to take proper care of the sick do not adopt a
similar plan of licensure. We believe the really
" trained " and graduate nurse will welcome the exam-
ination necessary to obtain a license, especially when it is
made clear that physicians will employ her with
increased confidence in her ability and, what is of still
more consequence, that it will give proper status to
those well-meaning but very unfit persons who have
"graduated" in a short theoretic course from some
office building or through the medium of some " cor-
respondence school." Progress toward proper recogni-
tion of the nursing profession, as well as toward the
realization of their professional ideals, can best be
obtained through such qualificatory standards and tests.
EDITORIAL ECHOES
Physicians' Investments.— Almost every mail
brings to our desk a communication inviting us to invest
our hard-earned money in various ventures, promising a
remuneration of any where from 20/c to 1,000^ per annum.
These circulars are skilfully worded to deceive the
unwary ami inexperienced. To those who have been
"caught" they are so transparent that they wonder
how any one could be so credulous as to be caught by
such schemes. The companies being promoted are
nearly always doing business at a distance — anywhere,
in fact, from " Greenland's icy mountains to India's
coral strand," or from Alaska to Patagonia. As a rule,
too, one finds among the list of those interested in the
scheme the name of some prominent man, ofttimes of a
physician. Why a physician should be regarded as a
good authority of the value of an investment we do not
know. To our mind, his testimony is about as valuable
as that of a clergyman to a patent-medicine advertise-
ment— and that is not saying much, we are sure!
" Let the shoemaker stick to his last," is an old and
wise saying. We would paraphrase it, " Let the doctor
stick to his medicine." Let him, when he has money
to invest, put it in something that is certainly good.
Let him beware of investments {)romising large returns.
Let him beware of concerns which make a si)ecialty of
bringing riches to physicians. We would say that in
the miijority of atses in which companies seek investors
among physicians, they cannot get the cooperation of
th6 business world. — \_Hahnemannian MonMj/.}
802 A.WBBIOAK MESIOINSI
AMERICAN NEWS AND NOTES
fNOVEMBER 22, 1902
AMERICAN NEWS AND NOTES.
OENERAJL.
Leprosy In the Philippines.— According to the vital statis-
tics for July, there are 3,0(>'i lepers living in various provinces
of the Philippine Islands.
The Sanitary Commission which has been studying yel-
low fever in Vera Cruz has come to the conclusion that the
prevalence of the disease is due to the Mexican custom of col-
lecting rainwater in barrels for drinking purposes. The barrels
of water serve as breeding places for the culex mosquito. A
new system of water-supply is to be instituted.
Cholera in the Army.— Although the strictest sanitary
measures have been enforced since the beginning of the epi-
demic last March, cholera has several times made its appear-
ance in the Army. Nearly every case, however, has been
traced to the drinking of unboiled water or the eating of native
food. Thus far, more than 100 deaths have occurred. It was
believed that the disease had entirely disappeared from Manila,
but a recent report states that it has again reappeared among
the men of a detachment of the Fifth Infantry. It is said seven
men have already died and others are seriously ill. The
detachment has been placed on guard along the Maraquina
river, whence Manila receives its water-supply, it being deemed
necessary to protect the stream from possible pollution. The
cholera developed while the men were on this duty. A late
report states that the disease is spreading rapidly in the city,
there being an average of 30 cases daily. The First Reserve
Hospital, the casual camp at Santa Mesa, and Bilibid prison
are now included among the places infected. The disease is
also spreading in the Maraquina Valley, where the danger of
infection of the water-supply is regarded as grave. Should the
wafer-supply become infected a general epidemic is considered
inevitable.
Miscellaneous.— Chicago, III. : The Northwestern Uni-
versity will confer the degree LL.D. on Professor Adolf
Lorenz, of Vienna. New York City: The New York Civil
Service Commission announces examinations on November 29
to fill the position of bacteriologist in the State hospitals at a
salary of $l(K) a month, and of physician, with a salary
beginning at $900 a year and increasing to ?l,000.— Dr. Pearce
Bailey has been appointed consulting neurologist to the Roose-
velt Hospital. — Dr. Herman Knapp, of the medical school of
the College of Physicians and Surgeons, has been appointed
emeritus professor in ophthalmology. Long Island City :
Dr. Peter Hughes has been elected consulting surgeon to
St. John's Hospital, to' succeed the late Dr. John Byrne.
Philadelphia : Drs. E. W. and Clarence H. Clark have given
8100,000 to the University of Pennsylvania for a chair in Assyri-
ology. Governor of Rhode Island : Dr. Lucius F. C. Gar-
win has been elected Governor of Rhode Island. Prof, von
Esmarch : The eightieth birthday of Professor Frederick
von Esmarch, of Kiel, which occurs January 9, 1903, will be
honored by the erection of a monument in his native town of
Tonuing. The unveiling of the monument will not take place
until the summer of 1903. As Professor von Esmarch is well
known to the profession, and especially to the surgeons of the
United States, it is thought that many would desire to con-
tribute to such a monument. In such an event contributions can
be sent direct to the Reichsbankhauptstelle in Kiel, or to the
Stadtische spar und Leihkasse in Tonuing, Germany, or else
to Dr. W. W. Keen, 1729 Chestnut street, Philadelphia, who
will transmit them. Such contributions should be sent within
the next week or 10 days, as the time is so very short.
Health of the Army. — The rates of admission to sick
report for disease and injury, the rate of discharge for disa-
bility, and the mortality rate for the calendar year of 1901 all
agree in being considerably less than the corresponding rates
of the year 1900. This shows the gradual improvement in the
condition of the troops, notwithstanding the fact that many of
them were subject to the exposures of the tropical service in
the division of the Philippines. That the rates continue to be
higher than the average rates of the previous decade, 1890-1899,
is to be expected, for during 8 of those 10 years the army was
on home service in time of profound peace, and, owing to the
great attention paid to sanitary conditions, had lower rates
than at any time in its previous history. A gradual approach
to the lessened rates of the decade may be seen in each of the
items of the record of morbidity. Thus, the admissions to
sick report in 1901 constituted 1,791.59 per thousand of the
strength as compared with 2,311.81 in 1!X)0 and with 1,502.47, the
mean annual rate of the previous 10 years. The rate of dis-
charge for disability was 19.95 in 1901, as compared with 22.60 in
1900 and with 10.69 for the decade, and the deathrate from all
causes was 13.94 per thousand men as compared with 22.74 and
11.91, respectively. Deaths from disease constituted 9.58 per
thousand of mean strength, as compared with 15.79 in 1900 and
with 8.49 during the years of the decade, and deaths from injury
4..36 as compared, respectively, with 6.95 and 3.42. During the
year the mean strength of the army consisted of 92,491 men, of
whom 81,885 were regulars and 10,606 volunteers. The admis-
sion rate for troops serving in Porto Rico was 1,367.74 per
thousand of strength, in the United States 1,550.25, in Cuba
1,557.49, and in the Pacific islands and China 1,928.14. The
deathrate from all causes was 5.29 per thousand of strength in
Cuba, 6.90 in the United States, 7.81 in Porto Rico, and 17.96 in
the Pacific islands and China. Deaths from disease constituted
only 3.21 per thousand in Cuba, 4.68 in the United States, and
12.40 in the Pacific islands and China. The mean strength of
the commands were: In Porto Rico 1,153, in Cuba 5,297, in the
United States 26,51.5, and in the Pacific islands and China
59,526. — [Ueportof the fixirgcon-GeneralJ]
NEW YORK.
Trance Due to Hysteria.- Detailsconcerningthenecropsy
performed on Nellie Corcoran, of New York City, a girl of 19,
who died suddenly after a trance of 20 days, are interpreted as
confirming the theory that her condition was due to hysteria.
No sign of disease in any organ could be found.
New York Eye and Ear Infirmary.- Physicians and
others connected with the nose and throat department of the
New York Eye and Ear Infirmary are protesting vigorously
against the resolution to discontinue this department to make
room for the increased number of ca.ses of trachoma.
PHIIiAJOEIiPHIA, PENNSYIiVANIA, ETC.
Hospitals Request State Help.— The State Board of
Public Charities has been in session for several days in Phila-
delphia hearing the requests from the various hospitals of that
city and Eastern Pennsylvania for financial assistance from the
State. The amounts asked for, though in most cases increased
over previous requests, will not be made known until the board
makes its recommendation to the Legislature next January.
At a meeting of the board soon to beheld in Harrisburg the
requests from the hospitals of Western Pennsylvania and Pitts-
burg will be considered.
Bubonic Plague Suspected on Shipboard.— The na-
tional quarantine authorities at Lewes, Del., refuse to permit the
Russian steamship Baron Drieson to leave the Delaware Break-
water until it is determined whether or not one of the crew
died of bubonic plague. The ship arrived at the Breakwater
nearly two weeks ago from Java. Within a few hours after
arrival one of the crew died, and the body was buried at the
quarantine grounds, but not until properly authorized experts
had removed tissue for the purpose of examination. The
report has not yet been sent in and hence the detention.
SOUTHERN STATES.
The Washington Postgraduate Medical School, which
will be opened January 12, 1903, is intended to afford post-
graduate Instruction for physicians and surgeons in civil prac-
tice and for public health officials. General George M. Stern-
berg is president of the faculty, and the Surgeon-Generals of the
Army, Navy, Public Health and Marine-Hospital Service are
members of the executive committee. This school is a distinct
organization from the Army Medical School and Navy Medical
School, and it is hoped that many desirable additions to the
different branches of the government medical service will be
made from among its pupils, who will have special advantages
for becoming familiar with the character of examinations and
other conditions relating to an appointment in the me Ileal
departments of the Army, the Navy and the Marine-Hospital
Service.
WESTERN STATES.
Certificates Required From Invalids.— It is announced
that after December 1 invalids desiring to board trains in
Colorado must present a physician's certificate stating that the
bearer has no contagious disease. This action was taken
because the railroads have had much trouble with persons
afflicted with contagious diseases. Pulmonary tuberculosis
is included in the list. In spite of the utmost vigilance on the
part of conductors it has been found impossible in many-
instances to detect such diseases. It is hoped that this will
be only a part of a general movement to have all roads
adopt the physician's certificate scheme as a means to protect
passengers.
Mortality of Michigan.— During October there were 2,.360
deaths reported to the Department of State, a decrease of 188
deaths from the preceding month. The deathrate was 11.4 per
1,000 population, as compared with 12.6 for September. There
were 470 deaths of infants under 1 year; 181 deaths of children
aged 1 to 4 years, inclusive, and 607 deaths of elderly persons
aged 65 years and over. Important causes of death were as fol-
lows : Pulmonary tuberculosis, 143 ; other forms of tubercu-
losis, 19; typhoid fever, 84; diphtheria and croup, 73; scarlet
fever, 19 ; measles, 2 ; whoopingcough, 13 ; pneumonia, 149 ;
diarrhea and enteritis, under 2 years, 130; cancer, 104; acci-
dents and violence, 188. A decrease was shown in the mortality
from tuberculosis, whoopingcough, and diarrheal diseases
from the preceding month, and an increase in deaths from
diphtheria and pneumonia. Two deaths from smallpox were
reported, one in the city of Mt. Clemens, and one in Detroit.
One death from hydrophobia was reported from Grand Rapids.
November 22, 1902]
FOKEIGN NEWS AND NOTES
I American Medicini 803
Smallpox— A Comparison : Evanston, 111., witha popula-
tion of 20,000, now has 54 cases of smallpox, quarantined in
various houses, whereas Chicago, with a population of 1,700,000,
has but 11 cases all safely confined in the isolation hospital.
The coniparatlve freedom of Chicago from this scourge is
ascribed to the relentless war waged by means of vaccination.
Evanston neglected this wholesome precaution and is now
reaping her harvest. The Health Department, however, has at
last realized the extreme gravity of the situation and is doing
everything in its power to check the progress of the disease.
Notices have been sent to all principals of public schools ;
superintendents of Sunday-schools and pastors that all places
of congregation would be closed if the people attending are not
vaccinated.
An honorable and logical eddyite thus writes :
"TOFEKA, Octobers, 1902.
" To the Hon. Pension Commissioner :
" Having become converted to the belief commonly known as
Christian Science, I herewith voluntarily surrender all claim to the
pension which 1 have been drawing for the past 12 years. My pension
was allowed on account of alleged rheumatism and alleged stomach
trouble contracted during my service in the Civil war, and the mortal
error which made me think I had them also made the doctors who
examined me think the same. But I am now convinced that there is
no such thing as rheumatism or stomach trouble ; that by the blessing
of God I am free of error, and that I have no right to take money from
the government on account of a cause which does not exist.
" Yours respectfully.
The official who sent the above letter to the K<msas City
Journal withheld the name of the old soldier who wrote it. If
Christian Science should spread among the pensioners ! — [N. Y.
Tribune,]
FOREIGN NEWS AND NOTES
GENERAL..
Mortality Prom Wild Beasts and Snakes in India. —
From published reports it is ascertained that during the year
1901 22,810 persons were killed by poisonous reptiles and 1,859
by wild beasts, mostly tigers, in the various provinces of India,
"rtiere is an increase in the number of deaths from these causes
over those of the preceding year.
Seram Treatment for Pertussis. — A Dr. Leureaux, of
Brussels, claims that he has discovered a serum which pro-
duces an early cessation of the coughing fits and a considerable
diminution of the normal period of illness. The serum is
injected under the skin in the abdominal region, the first effects
being apparent about 48 hours after inoculation. He states
that if the injection is made immediately on the manifestation
of the visual symptoms the disease can be cured in from eight
to ten days.
Miscellaneous. — According to ficience. Dr. Swale Vincent,
lecturer on histology at the University College, Cardiff, and for-
merly a.ssistant professor of physiology at University College,
London, who has already made numerous contributions to tne
literature of the ductless glands, has been appointed to the re-
search scholarship for the study of the thymus and other duct-
less glands recently established in England by Mr. .1. Francis
Mason. Mr. Mason has also made a donation of i;200 to the lab-
oratory of the Edinburgh Royal College of Physicians to enable
the medical superintendent. Dr. Noel Paton, to carry out a
combined research on ductless glands.— Professor Ribbert,
of Marburg, ha.s been appointed director of the Pathological
Institute at Gottlngen in succession to Professor Orth, who has
succeeded the late Professor Virchow as professor of pathology
in Qprlin.
CONTINENTAIi EUROPE.
Remarkable Fecundity. — Nearly 3,000 persons have
signed a petition to the Italian (liovernment for a pension in
favor of Signora Magdalena(irametta, near Naples, who during
20 years of married life has become the mother of tB children,
59 boys and 3 girls.
Nervous Breakdown of Military Men. — A French in-
vestiifator has recently come to the conclusion that the brains
of military men give out most quickly. He states that out of
every 100,000 military men 199 Decome hopeless lunatics. Of
the liberal professions, artists are the first to succumb to brain
strain, next lawyers, followed at some distanc'O by doctors,
clergymen, literary men and civil servants. Striking an aver-
age of this group, 177 out of each 100,000 become insane.
OBITUARIES.
Edssr Pomphrey Cook, in Mendota, III., October 81, 1902. He was
graduated from the medical department of the Western Keserve
University, Cleveland, Ohio, In 1854. During the Civil War he served
as surgeon of an Illinois regiment. From the beginning of his medical
career he Identified himself with the general interests of his profession.
He was a member of the Illinois State Medical Society, was Its presi-
dent in 1879, and at the time of his death was chairman of its judicial
council. He was one of the early presidents of the L.aSalle County
Medical Society, twice president of the North Central Illinois Medical
Association, and a member of the American Medical Association, the
Association of ttailway Surgeons, the American Public Health Associ-
ation and other organizations, and was an honorary member of the
Physicians' Club of Chicago. He was a delegate to the ninth and tenth
International Congresses. He performed th 3 first successful laryngot-
omy for tumor in the West, and was one of the first to operate for
ectopic gestation. For many years he was local surgeon to the Illinois
Central and Burlington railroads.
Lennox Brown, F. R. C. S. Edin., consulting surgeon to the Cen-
tral London Throat, Nose and Ear Hospital, died November 2, aged 62.
He founded this hospital in 1874, and was for many years its senior
surgeon. He was one of the original Fellows and at one time president
of the British Laryngologlcal and Rhlnological Association. He wa»
also a Fellow of the Medical and Pathological Societies, an honorary
member of the Philadelphia Medical Society, and a Corresponding
Fellow of the American Ijaryngological Association. He contributed
largely to the literature of his specialty, his chief work being atextr
book on " The Throat and Nose, and Their Diseases," a fifth edition of
which appeared In 1898. This work has been translated into French.
He was also an accomplished artist, and probably the best record of
his work and his most permanently valuable contributions to science
are to be found in his colored drawings of diseased conditions.
William Henry Haines, a specialist In nervous and mental dis-
eases, and president of the Bi-ookly n Society of Neurology, died in that
city, November 1.5, aged 47. He was graduated from the medical
department of the New York University in 1878. For some years he
was on the visiting staflS of the Brooklyn Eye and Elar Hospital and
the Bushwick Hospital.
Charles B. Spratt, of Jacksonville. Fla., November 13, aged 32.
He was graduated from the-Iefferson Medical College. Philadelphia, In
1897. At the time of his death he was assistant surgeon, with the rank
of captain, of the First Regiment, Florida State troops.
W. Clark Allen, of Chicago, III., November 4, aged 37. He wa«
graduated from the Northwestern University Medical School, Chicago,
in 18J4. At the time of his death he was surgeon at the Kedzie Hos-
pital, Chicago.
Alfred Booth, of Springfield, Mass., November 10, aged 78. He
was a graduate of the Harvard Medical School, but only practiced
medicine for a short time, giving up his practice to go into newspaper
work.
Charles M. Bethanser, of Columbus, Ohio, October 30, aged «»..
He was graduated from the Starling Medical College, Columbus, Ohio,,
in 1882, and was well known both as a physician and clergyman.
Mfvlor William H. Crlm, of Baltimore, Md., November 15, aged 57.
He was for 25 years surgeon of the Fifth Maryland Regiment. He wa*
graduated from the University of Maryland in 1870.
Koger T. Atkinson, assistant surgeon in the United States Navy,
died at the Naval Hospital, Norfolk, November 10, aged .SO. He was a
native of Wakefield, Mass.
W. H. KImberlln, a pioneer resident and prominent oculist of
Kansas City, Mo., aged 58, was shot and killed instantly by a former
patient November 11.
Andrew J. Manvllle, of Bowling Green, Ohio, Novembers, aged
68. He was graduated from the Bellevue Hospital Medical College,
New York, in 1866.
Henry M. Cox, in Washington, N. J., October 7, aged 65. He wa«
graduated from the medical department of the University of Michigan
In 1868.
Frank A. Holland, at Dubuque, Iowa, November 4, aged 41. He
was graduated from the University of Minnesota, Minneapolis, io
1886.
John C. Drake, in Oakley, Mich., November I, aged 60. He was
graduated from the Western Reserve University, Cleveland, Ohio, la
1868.
Obadiah Newcomb, of New York City, November 10, aged 81. He
was graduated from the Medical College of Ca«tleton, Vt., in 1850.
Andrew J. Schmidt, at Cedar Rapids, Iowa, November 3, aged .?»,
He was graduated from the McGiU University, Montreal, in 1886.
J. Aloore Hart, of Toronto, Can., November 12, aged .52. He wm
graduated from the Trinity Medical College, Toronto, in 1871.
Robert L. Wood, of Kansas City, Mo., October 31, aged 62. Ha
was graduated from the Kansas City Medical College in 1873.
Gerard M. Muller, at Grand Rapids, Mich., November 3, aged 70,
He was a graduate of the University of Utrecht, Holland.
Lee B. Windham, of Stone, Ala., November 14. Ho was graduated
from the Medical College of Alabama, Mobile, in 1900.
J. W. Sheets, at Northumberland, Pa., August 3. He wasgrada-
ated from the University of Pennsylvania in 1871.
Ira B. Ge«r, of Winter Parkj Fla., November 8, aged 81.
«;. \., Cook, In New York City, November 2, aged 78.
804 &XBBIOAN MbDIOIKSj
SOCIETY EEPOETS
[NOVKMBBK 22, 1902
SOCIETY REPORTS
THE SOUTHERN SURGICAL AND GYNECOLOGICAL
ASSOCIATION.
Fifteenth Annual Meeting, Held in Cincinnati, Ohio, Novem-
ber II, 12 and 13, 1902.
[Specially reported for American Medicine.]
Officers were elected as follows : President, J. Wesley
Bov6e, of Washington, D. C. ; first vice-president, Bacon
Saunders, of Fort Worth, Tex.; second vice-president, Chris-
topher Tompkins,' of Richmond. Va.; secretary, W. D. Haggard,
Jr., of Nashville, Tenn.; treasurer, Floyd W. McRae, of Atlanta,
Ga. Place of next meeting, Birmingham, Ala.; time, the
week preceding Christmas, 190;!. Chairman of Committee of
Arrangements, .John D. S. Davis, of Birmingham, Ala.
Hypertrophy of the Prostate.— N. P. Dandbidqe {Cin-
cinnati, Ohio) claimed that complete perineal prostatectomy
enabled the surgeon to deal with a class of most distressing
cases in a more satisfactory manner than ever before. The
author did not decry the merits of any of the newer operations
upon the prostate. He urged strongly the necessity of not being
carried away by operative furor. The experience of Murphy
was worthy of special notice, the ready manner in which stone
in the bladder could be dealt with after a perineal prostatec-
tomy. The necessary opening of the urethra afforded an oppor-
tunity for the extraction of stone.
Conservative Operations Upon the Ovary. — L. H. Dun-
ning (Indianapolis, Ind.) reported his experience in over
100 operations. He incised single cysts, removing the lining
membrane, trimming away the redundant portion of the outer
wall of the cyst, and joining the edges of the incision by a run-
ning stitch of line catgut. Single hematoma was treated in a
similar manner. In a few instances he used the thermocautery
to check hemorrhage, and in other instances he punctured
several small cysts and dropped the ovary. He reported grati-
fying results in 80% of cases. After a few trials he rejected con-
servative methods in pus cases, and in cases in which there
were numerous small cysts in all parts of the ovary. He found
conservative work unsatisfactory in sterile married women,
and in interval appendicitis operations in which there was a
markedly cystic riglit ovary.
The Surgical Treatment of Pancreatic Cysts, with
Report of Two Cases. — A. M. Cartledge (Louisville, Ky.)
said that cysts of the pancreas, while rarely encountered, were
still the most common pathologic condition of this deep-seated
organ that surgeons were called upon to treat. A comparison
of the results shown by statistics Indicated that incision and
drainage should be practised as a routine procedure in pancre-
atic cysts, and yet a closer stud^ of the clinical form which
the cyst might present, together with a careful study of the con-
valescense of the drained subject, might cause surgeons to
attempt extirpation of the sac more frequently, and with better
results. His experience was limited to two cases, one treated
by Incision and drainage and the other by enucleation of the
cyst. Both patients recovered.
The Curse of Uonorrhea. — Joseph Taber Johnson
(Washington, D. C.) said that the evidence was indisputable
and overwhelming that many women lost their lives annually
from the pelvic inflammation caused by this disease and its
complications, and that thousands probably lost their health,
or their power of conception from the same cause. The chief
danger of gonorrhea in the female was the infection of the
uterus and uterine appendages. Gonorrhea was the chief source
of salpingitis and pelvic peritonitis. Other complications were
mentioned. Gynecologists should make themselves more cer-
tain in the future than they had done in the past that patients of
both sexes were absolutely cured beyond the danger of a
relapse before they were dismissed from further observation,
control and treatment.
Chronic Appendicitis and Movable Right Kidney. —
Walter P. Manton (Detroit, Mich.) renewed attention to
movable right kidney as an etiologic factor in producing chronic
appendicitis. In his experience, movable kidney was tlie most
frequent cause of chronic appendiceal disease. In aOO consecu-
tive cases from his notebooks he found that the right kidney
showed an abnormal mobility in 36.5%, and in 65J% nearly of
these cases a diagnosis of chronic appendicitis was also made.
In 22.5% the diagnosis was confirmed by operation. Among
the other cases some were of too mild a type to demand imme-
diate surgical intervention ; the patient refused operation, or
was now waiting for this to be performed. In obscure abdom-
inal conditions a diagnosis should not be attempted until mov-
able kidney and chronic appendicitis can be excluded by care-
ful abdominal palpation. When nephroptosis and appendicitis
were present operations upon the uterus and adnexa would not
be followed by a cure unless one or both of these conditions was
also removed.
Operation for Complete Laceration of the Perineum.
—George H. Noble (Atlanta, Ga.) described a new operation
for the relief of this condition, which consisted in splitting the
rectovaginal septum, dissecting the lower end of the rectum
from the vagina and drawing the anterior rectal wall down
through and external to the anus, converting a complete tear of
the perineum into an Incomplete laceration. He detailed the
various steps of the operation.
Pregnancy and Labor Following Complete Nephro-
ureterectomy.— J. Wesley Bovee (Washington, D. C.)
reported a case of complete nephroureterectoniy, the operation
having been performed March 18, 1901, for pyonephrosis, renal
calculi, and miliary abscesses in the ureter. April 15, 1902, after
a normal labor of six hours the patient was delivered of a male
child weighing 10* pounds. On the third day after delivery she
complained of intense pain diffused over the abdomen, which
on the following day became localized along the course of the
left ureter. There was tenderness for several days after cessa-
tion of the pain in this region. The urine was carefully
watched for calculi, but none found. Since the birth of her
child she had breast-nursed it, and had remained in splendid
health. The condition of the remaining kidney did not seem to
be worse than before pregnancy. There was little doubt that
pregnancy and labor following nephrectomy seriously jeopar-
dized the life of the patient ; that the renal complications must
necessarily be greatly increased, and therefore induction of pre-
mature labor and other forms of treatment of these complica-
tions more frequently necessitated. In these cases the evidence
of permanent impairment of the remaining kidney, as a result
of pregnancy and labor, was by no means convincing, but the
writer's individual opinion was as records were made of such
cases such effects would be apparent.
Personal Experience with McGraw's Method of Gas-
troenterostomy.— Samuel Lloyd (New York) reported seven
cases, all but one for cancer. All recovered from the operation.
One of the patients was still alive. This was a case of stricture
of the stomach due to adhesions which drew the pyloric end
out into a long tube and caused it to bend on itself. Of the
others, all except two died from exhaustion from progress of
the growth after several months, and without signs of obstruc-
tion. One was lost sight of and the other died from an involve-
ment of the anastomotic opening in the cancerous growth and
consequent secondary closure of the new opening. His experi-
ence showed that the method was admirable ; that it was enica-
cious, and rapid in execution. He advocated in operating for
pyloric obstruction that from 8 to 10 ounces of peptonized milk
and 1 ounce of whisky be introduced through a needle into
the intestine below the point of the anastomosis during the
operation. Its possible regurgitation during the operative
manipulations could be prevented by pressing it well down
along the intestine or by the application of an intestinal clamp.
The President's Address.— W. E. B. Davis (Birming-
ham, Ala.) advised the members to establish a memorial to the
Association in Birmingham, the birthplace of the organization.
National special societies had wielded a wonderful influence in
the medical profession, and medical literature had been
enhanced in every way by them ; as Individual societies they
should be encouraged, but their union into a national congress
was not conducive to the best interests of the medical pro-
fession. There should be one class of membership for sections
of the A. M. A. that can be held by only those who are recog-
nized as teachers and leaders, to make membership very desir-
able and sought after. He would suggest that this class be
known as Fellows, and that they pay, in addition to the annual
dues of the Association, 85 annually for section dues, which
fund would be expended in the publication of the proceedings
of the section. The officers and authors of papers should come
from the Fellows. All members should have the opportunity
or privilege of taking part in the discussions.
Indications for Kxtlrpation of the Gallbladder.—
Maurice H. Richardson (Boston) drew the following conclu-
sions : 1. Certain lesions in themselves demand removal of the
gallbladder whenever possible. Such are newgrowths and gan--
grenes. 2. Certain other lesions of the gallbladder are better
treated by extirpation. These are the contracted and inflamed
gallbladders with thickened walls. All gallbladders which do
not permit of easy and efficient drainage should be extirpated,
for in such gallbladders the risks of drainage are quite as great
as the risks of extirpation ; and the one great advantage of raten-
tion is impossible— retention of the biliary reservoir to fulfill the
functions of that reservoir and to permit, if necessary, renewed
drainage for future years. 3. Drainage is preferable in the dilated
and infected gallbladder, which, however, is neither gangrenous
nor to any great extent changed — the slightly thickened gall-
bladder containing gallstones and infected bile. This gall-
bladder will, after drainage, become normal and therefore
capable of fulfilling the functions of the gallbladder. Through
it the biliary passages will become effectually drained, after
subsidence of the temporary swelling about the cystic duct.
4. As a rule drainage rather than extirpation is demanded in
acute cholecystitis with severe constitutional symptoms, when
the bladder is dilated or at least not contracted. 5. In chronie
infections of the gallbladder with dilation and thickening,
and especially when a stone is impacted in the cystic duct,
extirpation is the preferable operation, unless the stone can
be dislodged backward into the gallbladder, in which case
drainage is, if not preferable, quite as advantageous as extirpa-
tion. 0. In simple gallstones, without visible evidence of infec-
tion, or of chronic changes incompatible with complete restora-
tion of function, simple drainage of the gallbladder is indi-
cated. 7. In chronic pancreatitis, associated with gallstones or
not, drainage through the gallbladder is indicated.
ITo be concluded.]
NOVEMBEE 22, 1902]
CX)RRESPONDENCB
(AlTESICAIT MKDICIinC 806
CLINICAL NOTES AND CORRESPONDENCE
[Communications are invited for this Department. The Editor is
not responsible for the views advanced by any contributor.]
RECOVERY AFTER LIGHTNING STROKE.
BY
<- F. J. BARDWELL, M.D.,
of Tunkhannock, Pa.
The accompanying illustration is from a photograph of the
back of T. K. V., of South Eaton, Pa., who was struck by light-
ning .Inly 14, at 4.30 p.m. It was taken July 17, three days after
the accident, and
shows the length
and course of the
burn, but not the
width, which was
from two to three
inches, nor the col-
oring, which was
blood-red in the
center, shading off
to the edges of
white skin in a
manner very char-
acteristic of light-
ning. It is not un-
common for people
to be stunned by
lightning, but so
far as I know this
is the only person
ever struck and
marked by liglit-
ning who lived to
tell the ci rcu m-
stances. The pa-
tient and three
other men had
gone up on the
mountain after
huckleberries.
When the storm
csme up one man
went under a tree and was killed by the lightning. The patient
sat under the wagon 12 feet from the spot where his companion
was killed. The other two men stood at a distance of 4 rods and
40 rods away. The patient did not iiear the report, but remem-
bers a very vivid flash and having called " Help! " " Help! "
When he liecame conscious he found the two men rubbing him
According to one of these men, immediately after a terrific
flash, he heard the patient call for help and saw him writhing
on the ground. Both men rubbed him for ten minutes before
he recovered consciousness. For two hours after he was struck
the patient was troubled with a constant desire to urinate. For
several days he suffered from general muscular weakness.
THE PHYSIOLOGY AND THE TEMPERANCE OF THE
W. C. T. U.
To the Editor of American Medicine : — In an editorial on
" Had Physiology and Bad Temperance," in your issue of July
12, you quote from Mrs. Hunt, of the W. C. T. U., who insists
on one-fourth of the elementary books on physiology being
devoted to socalled temperance teaching. This has been the
State law in regard to high school textbooks on physiology in
many of the States for a numi)er of years. You advocate that
the tea<!hing of hygiene and physiology should be brought back
" to sound scientific and pedagogic principles." It is a fact that
many writers of school physiologies have been afraid to teach
the truth about alcohol and narcotics, for if they did their books
would be wiped out in many places Ijy the exertion of the
W. C T. U. It is also a fact that in many cities at least the
study of physiology and hygiene is being associated with and
absorbed by biology, partly because high schools are aping
university education, partly because teachers are becoming dis-
gusted with trying to teach temperance subjects, about " hob-
nail livers," etc., etc., and partly because sanitary science
(hygiene) demands today a clear and scientific treatment of
"foods," "exercise," etc., subjects about which the average
physiology teacher knows little and cares less.
Years ago I wrote a little school physiology for young
pupils. It was presented attractively and with illustrations
that were new, and with all the temperance teaching that a
young child should have. After it had been in circulation for
a time I was called to the publishers to see Mrs. Hunt, who was
making a tour to visit authors and publishers of school physi-
ologies. She told me that my book was one of the best, but the
temperance part was unsatisfactory ; that I ought to teach that
an apple with the skin on was all right, that with the skin off it
was all wrong, etc., etc. She wished me to alter the temperance
teaching, and as an inducement the shekels would flow to me
from the endorsement of the book by the members of the
W. C. T. U. throughout the United States. I objected. She
then offered to make corrections (?) herself. To this I did not
agree. Within a few months the publishers produced a book
modeled after mine and endorsed by the W. C. T. U., and my
book fell flat, so far as income from it for me was concerned. I
sold out to the publishers, who still produce it garbled. The
State Board of Health of Louisiana endorsed my book, I believe,
against the protests of the W. C. T. U.
I wrote a textbook on physiology and hygiene for high
schools. The publishers advised me to comply literally with
the State law of New York, and furnish one-fourth of the text
on temperance. It was padding, for all that ought to be said on
the subject could be given in one-tenth of the book ; but what
I did say was carefully and, I believe, scientifically written. It
did not please the convention of the W. C. T. U. Hardly any-
thing that I said was true. Alcohol is never a stimulant or a
food but is always a poison. So the convention moved against
the book. Letters passed to and fro on the subject; but my
publishers stood firm for the truth as they and I understand it.
That the W. C. T. U. has hurt the sale of the book I have no
doubt. But that the W. C. T. U. can in this socalled enlight-
ened age exert the tyranny that it does is a reproach to the
members of the medical profession, the natural custodians of
the health of the people. Author.
HERPES COMPLICATING PNEUMONIA.
BY
FRED CANDLER, M.D.,
of Bonner Springs, Kas.
Thehistoryof the following case may be somewhat out of
the ordinary :
Mrs. W., aged 57, had pneumonia three years ago. The
present illness is also pneumonia, and is following the usual
course of the disease. On the seventh day of her present illness
was noticed an eruption in the supraclavicular regions on both
sides, covering the whole of the triangular spaces. It had all
the appearances of a herpes. This eruption disappeared on
twelfth day, the temperature becoming normal. Death occurred
on the fourteenth day.
The eruption had the appearance and action of a herpes
labialis, drying up and disappearing after the temperature
assumed a normal curve.
REPORT OF CASE OF PROLAPSE OF THE RECTUM.'
BY
CHARLES E. McGIRK, M.D.,
of Phlllpsburg, Pa.
Burgeon to Drs. McGirk, Sanitarium.
This patient, whose case I desire to report, was referred to
me by Dr. H. A. Collins, to whom I am also Indebted for con-
siderable valuable data in regard to her history.
Case. — Mrs. P., aged 38, the wife of a farmer, was married
at the age of 16. She has always been a hard-working woman.
The family history is negative. Her menstrual life has been
entirely uneventful. She is the mother of seven children, all of
whom are living and well. The first four labors were normal
in every respect, and she has never had a miscarriage.
In 1893 she gave birth to her fifth child, which weighed 14
pounds. This labpr was prolonged for 48 hours and during this
> Read before the Clearfield County (Pa.) Medical Society, July ».
1902.
806 AXKBICAN MEDICINXj
COKRESPONDENCE
[NOVEMBEB 22, 1902
time a protrusion from the bowel was present, which she oon-
sidered piles. Labor was finally terminated by instruments, but
the protrusion from the bowel remained. She has since had two
chilaren, the youngest being 14 months of age. These two
labors were difficult, on account of the prolapsed rectum and
the absence of general muscular tone. She now complains of
frequent urination with extreme vesical tenesmus. She cannot
retain her urine longer than an hour. Urine is usually cloudy,
and often contains blood and bloodclots. Within the past two
weelis she has passed a number of gravel stones ; she says she
never passed any previous to this time. Bowels have always
been regular. The protrusion from the rectum follows each
movement of the bowels. For a long time it gave her no trouble
except during defecation, when it produced tenesmus to an
almost unbearable degree until replaced. During the last 14
months, since the birth of her last child, it comes down inde-
pendently of bowel movements, the simple act of arising from
a chair being sufficient to produce it. At times she has consid-
erable pain in the left lumbar region radiating around her side
to the groin. The pain comes on periodically since 1893, and
during these attacks she has always noticed that her urine was
retained for three hours. Heat relieved the pain, but it never
ceased until she was able to void her urine. Her appetite has
always been .good and she is not nervous. She would sleep
well were it not for being disturbed hourly on account of the
vesical trouble.
Physical Examination.— Rea,Tt and lungs are normal. Urine
is normally acid and contains no sugar, but there is a trace of
albumin even after filtration. Specific gravity is 1,014. Micro-
scopically are seen some blood and pus cells, some phosphatio
crystals and debris, but no oasts. Macroscopically the vulva is
seen to be lax, the anus dilated and the depressions or pits
showing the location of the torn ends of the sphincter ani
muscle are present and well marked. When asked to strain or
bear down in the dorsal position there is seen to exist a pro-
lapse of the rectum which protrudes about 3 inches and is about
75 inches in circumference.
Digital examination reveals almost an entire absence of the
perineal muscles as well as a complete rupture of the sphin<!ter
ani muscle; an extremely thin and lax vaginal floor ; the pres-
ence of a large rectocele and cystooele. A slight unilateral tear
is found in the cervix. The uterus is retroverted to the third
degree and the organ as a whole is prolapsed ; internal measure-
ment is 3i inches. Both tubes and ovaries are prolapsed, but
are not adherent. Both ovaries are slightly enlarged, but are
not tender.
On assuming a squatting position the rectum protruded
8 inches and was 14 inches in circumference, as shown in the
accompanying photograph. During the existence of this pro-
cidentia (9 years) she had no ulceration, hemorrhage or hemor-
rhoids. Ithas never been irreducible, butattimes ithas become
slightly inflamed from handling. All tunics of the bowel are
involved, as well as several loops of the small intestines. The
opening at the apex of the tumor is slit like. Although the
tumor protrudes 8 inches from the anus there is no invagination.
On careful investigation of the bladder I was unable to find
gravel or stone, but I discovered that the base of the bladder
was the seat of an extensive ulcerative process, with a large
granulating surface.
This condition had been treated by Dr. Collins for some time
without benefit ; he believed his failure to be due to the residual
urine, which was impossible to gt t rid of on account of the pres-
ence of the cystocele. In this opinion I heartily concurred.
After carefully reviewing her case with D.\ Collins I concluded
that a perineorrhaphy, a plastic operation on the cystocele and
rectocele, a ventral suspension, and an abdominal colopexia
would be the only means of restoring her to a life of compara-
tive comfort. I therefore advised her to undergo the operations.
She came to my sanitarium on .Tune 11 and was prepared for
operation, which was done June 13.
In the perineorrhaphy I did an Emmet's operation, except
that I dissected out the two ends of the sphincter ani muscle and
united them with two catgut sutures. This I did to get perfect
approximation ; I then introduced silkwormgut sutures in the
usual manner. I repaired the cystocele by making a circular
denudation, closing it by means of a purse-string suture.
All the sutures that passed through the raucous membrane
were of catgut, the buried perineal sutures were of silk, with
the exception of the subcutaneous sutures uniting the torn ends
of the spnincter ani muscle, which were of catgut. The abdo-
men was opened in the usual manner, but on account of the lax
condition of the abdominal wall I was careful to go through the
body of the rectus muscle to avoid the possibility of a ventral
hernia.
The sigmoid flexure was found and through the serous coat
of the first loop were passed two sutures which were united to
the peritoneum at what would correspond to the center of the
left inguinal region. I then suspended the uterus Vjy passing
two sutures through the posterior of the fundus in the usual
manner, the abdomen was closed in layers, using silk for the
perineum and muscular sheath. The skin was united by a
smgle intracutaneous silkwormgut suture, the ends being
secured by shot. In spite of great loss of blood and the two
hours' time required for the operation, the patient reacted well
and made a normal convalescence. She had incontinence of
urine for the first four days, her bowels moved 24 hours after
operation, but the wound healed in a remarkably short time
and without the infection of a single stitch. For the first two
weeks she gave a great deal of troubleon account of the irritated
condition of the bladder. This I felt I could not treat locally on
account of the presence of the perineal stitches, by which I
wished to obtain firm union of the sphincter muscle. I gave
her salol, benzoic acid, lithia, and lots of water. On June25 she
called the nurse and told her that she had passed some gravel,
which proved to be true. Not now fearing the stitches I felt
that I could safely use some local application to the bladder.
This I did and removed by flushing 18 or 20 small particles of
gravel, the largest being the size of buckshot. They were all
soft and easily crushed, and under the microscope proved to be
phosphatic. I continued to wash her bladder every day so long
as she remained in the sanitarium, noticing a daily improve-
ment. In washing I used a saturate solution of boracic acid.
She was dismissed on July 8. The prolapsus and the cystitis are
entirely cured.
DOUBLE POTT'S DISEASE.
D. T. BOWDEN, M.D.,
of Paterson, N. J.
Chief Surgeon Paterson Orthopedic Hospital and Dispensary. Assist-
ant Surgeon New York Orthopedic Hospital and Dispensary.
To the Editor of American Medicine : — In the issue of Amer-
ican Medicine for September 13, 1902,.R. Tunstall Taylor, M.D.,
Baltimore, reported a ease of double Pott's disease. The case,
as I understand it, was reported owing to its extreme rarity.
The absence of reference to such cases in medical literature
being commented on, I quite agree with him on the latter point,
as I cannot recall having read a report of such a case, but think
many, like myself, considered it not at all a rarity but compara-
tively infrequent.
I have a private patient whom I have been treating for the
past 18 months who has kyphosis involving the first, second and
third, and another the tenth, eleventh and twelfth dorsal verte-
bras, the former lesion appearing about nine months after the
latter. He also has tuberculous arthritis of the right ankle.
In my hospital and dispensary service I have two cases of
double Pott's disease and I have seen cases in the service of
other members of the staff far too frequently to class it as
rare, and to do so is misleading.
If you will pal-don a digression, I would like to make refer-
ence to another statement made by orthopedic writers, i. e., that
multiple tuberculous joint lesions are very uncommon. I
believe that in at least 5% of the cases of tuberculous arthritis
involvement of two or more joints will be found sooner or later.
I have a number of cases in my hospital and private practice,
e. g., hip, knee, and Pott's ; double hip and Pott's ; both ankles ;
hip and shoulder, both on the same side ; one case of tubercu-
lous synovitis of both knees almost equally active ; in fact,
almost any combination. A detailed history of each of these
individual cases could be furnished from private and hospital
records, but though they would prove interesting to the ortho-
pedist I fear there would be unwillingness to allow the amount
of space necessary. This being true, why should we consider as
rare, lesions in a series of contiguous joints, when from the
bony and muscular arrangement multiple infection would seem
to be most liable.
What I consider exceedingly rare is the development of
tuberculous disease with equal activity in more than one joint
at the same time.
Nov^BER 22, 19021
SURGICAL TREATMENT OF EPILEPSY
[Amxrican Mkdicthe 807
ORIGINAL ARTICLES
THE SURGICAL TREATMENT OF EPILEPSY.'
BY
ROSWELL PARK, M.D., LL.D.,
of Buffalo, N. Y.
Professor of Surgery, Medical Department, University of Buffalo.
Has modern surgery essentially advanced the treat-
ment of this most ancient disease, the morbus sacer or the
"falling sickness" of the old writers? In order to
determine this we must perforce contrast it with the non-
operative or medicinal and dietetic methods. Epilepsy
is a malady which seems to have no national, racial,
climatic or other limitations. Widespread, met alike in
tropics and frigid zones, affecting rich and poor, the
educated and the ignorant, it is one of the most cosmo-
politan of diseases. It is, of course, to be expected that,
occurring in all times and climes, it has been subjected
to every kind of treatment. Strangely enough, the
pathologic findings in this disease lead little to a dis-
covery of its causes, and still less to its rational therapy.
Trephining for epilepsy is one of the most ancient
operations, and has paased through all the repeated
phases of favor and disfavor which the changing opinions
of mankind could permit.
For 20 years I have been operating for the improve-
ment of this condition upon those patients whose cases
have seemed to justify it. My patients were not at first
80 well selected, nor perhaps so well treated as in later
years. Experience has taught us all lessons of the
greatest value, and not the least of them is that careful
discrimination and good judgment on the part of the
operator are here factors of the greatest importance.
Statistics are of but small value in a study of the
questions involved in this matter. I shall quote but
few, but these constitute almost the only ones which are
of real help. Neither shall I attempt here to reproduce
my own case histories or results, but regarding these
will only say that my personal experience has included
some brilliant results and some complete failures, but
hardly a death. At worst I have only failed to benefit
some patients, not made them worse. On the other
hand, I have had several cases so successful that I am
willing to compare them with the best results of other
operators. They furnish ample argument for surgical
treatment of selected cases. For instance, on the day of
writing this sentence a subject of traumatic epilepsy,
operated upon a year ago, presented himself. The man
was injured in the charge of San Juan hill, a bullet
ploughing its way over his skull and injuring the brain.
Three years later he came to my clinic with spastic
hemiplegia and epileptic seizures as often as once a
week, which were increasing in frequency. I did
craniectomy over the motor area and excised the hand
and arm centers, because the convulsive movements
began in the thumb. He told me today that he had had
but one " fit " in the last six months. He is in circum-
stances which permit none of that after-care which is,
in my estimation, so important for such patients. This
case, strictly speaking, is not to be reported as a cure,
yet it is practically such for him.
Those epileptic cases which present surgical phases
may be classified about as follows :
A. Those presenting reflext>s from peripheral irrita-
tation. Such, e. g., as those caused by phimosis, by
sensitive scars, by rectal or nasal polypi, and probably
those connected with eyestrain.
B. Cases of gross anatomic lesions within the cra-
nium, e. r/., pachymeningitis, tubercle, gumma, or brain
abscess, bone fragments, deep brain scars, cysts, adhe-
sions, results of old fractures, etc. A lesser group should
also be made to include external scars, depressions, etc.,
about the skull, results of traumatism.
' Read before the Katlonal Association for the Htudy of EnlleDsy
NoTember 5, 1902. f r j •
C. Cases of socalled essential epilepsy of nontraumatic
origin, presenting distinct localizing phenomena.
In a discussion of its surgical treatment we may well,
but somewhat diflferently, classify cases which justify it
under two headings :
A. Those which call for relief of some peripheral
irritation, e. g., circumcision, excision of scars, of irri-
table ulcers, etc.
B. Those in which operative intervention is directed
toward the nerve centers.
This class of cases again needs subdivision into
1. Those in which these centers are indirectly in-
fluenced, to be treated perhaps by ligature of the verte-
bral arteries, or by excision of the cervical sympathetic.
2. Those calling for direct attack upon the brain or
its membranes, including craniectomy (trephining) and
deeper work upon the parts thus exposed.
The generally accepted theories of today center them-
selves largely around the question of circulatory dis-
turbances in the brain. That the disturbing influence
radiates from the brain, perhaps after the reception of a
disturbing sensation from without, is abundantly demon-
strated by an experiment which I first saw Horsley
make, in London, years ago. Oil of absinthe injected
into dogs, for example, will promptly produce epilepti-
form convulsions. If after its injection the spinal cord
be divided, only so much of the body as is innervated by
the portion still connected with the brain will still be
convulsed.
Is it, therefore, a question of cerebral hyperemia or
anemia? There is much to make us l)elieve that the
latter is the condition of the brain during an attack.
The physiologists produce convulsions experimentally
by a sudden and simultaneous ligation of both caro-
tids, and by pressure upon both arteries in our own
necks sudden unconsciousness may be produced. Con-
vulsions are known to follow serious hemorrhages;
the death agony of most animals killed by bleed-
ing methods includes epileptiform tremors. The face
usually becomes blanched before a seizure. Doyen
claims to have witnessed the occurrence of a seizure dur-
ing the midst of a trephining operation, and to have
noted at the moment a pronounced anemia of the brain.
This is important if corroborated.
Accordingly it is physiologically correct, as will be
emphasized later, to excise the sympathetic in certain
patients, since tiie vasoconstrictor nerves are mainly
found in its structure, and its removal abolishes vascular
spasm. Moreover, and equally important, the sympa-
thetic trunk is in intimate relation with the viscera by
nerves of peculiar sensibility, by which reflexes are
easily conveyed.
It will be seen that the effect of this operation is
expected to be similar to the effect of amyl nitrite or the
other nitrites. When these drugs prove effica('ious in
checking or preventing seizures we shall therefore find
the plainest indication for this procedure. (Vidal.)
Exsection of the sympathetic was first practised,
though in an incomplete manner, ijy Alexander, in 1883 ;
he removed only the upper ganglion. During the same
year Baracz removed the upper and middle ganglia
while tying the vertebral artery. In 1892 Jaksch reported
two cases in which he removed the lower ganglion after
tying this artery, and Kiimmell one of removal of the
upper. The following year Bogdanik reported a removal
of the middle ganglion on both sides, and Pean and
Jaboulay one each of mere division of the nerve without
exsection. (Winter.)
But it was Jonnes(;o who gave real impulse to these
efforts, by reporting to the (Jerman Congress of Surgeons
three cases of complete ex.section of all three ganglia,
with their connecting nerve trunks. Since then he has
added immensely to our knowledge of the measure, and
in 1900 he reported to the Congress at Paris his statistics
of 97 cases.
Jonnesco wrote in 1899 as follows : " In epilepsy we
808 Ambbioan MBDICXinCJ
SURGICAL TREATMENT OF EPILEPSY
[NOVEHBBB 22, 1902
should produce an enduring alteration in the brain-cir-
culation, in that we convert cerebral anemia into a per-
manent congestion, by which perverted nutrition of
nerve cells is altered, or by which they are freed from
toxic products. In other cases of reflex epilepsy we
checlc the transmission of irritations from the viscera to
the brain." He, moreover, holds it to be essential that
all three ganglia be removed in order that the desired
eifect be completely attained. Mere division of the nerve
trunk he, with others, holds to be quite inadequate.
After a careful survey of the literature to date Winter
has collected 213 cases of sympathetic resection for relief
of epilepsy, of which 7 patients died from various
causes. These deaths were nearly all remotely or indi-
rectly connected with the operation. Of the 213 cases he
rejects 91 as having been too recently or too inexactly
reported. Utilizing thus 122 cases for serious study he
finds that Alexander and Jonnesco have each furnished
4 cases that have been under observation for at least
three years and the patients have remained free from
attacks. These he describes as cured, i. e., 6.6^.
Of cases observed for from one to two years he
accepts 17 patients as apparently cured (" vorlauflg
geheillt"), i. e., 13.9^. Twenty-three patients could only
be considered as improved (attacks less frequent and
severe), i.e., 18.9^. Seven patients died, t. e., 5.7/c ;
though not one death was directly attributable to the
operation. Sixty-seven patients, i. e., 54.9 fc, seemed but
little if at all influenced by the operation.
Nothing can better illustrate honest differences of
opinion between surgeons than the divergent views con-
cerning the blood supply of the brain during epileptic
attacks, entertained by different men. Surgical attack
upon tiie sympathetic is based largely upon the supposi-
tion of cerebral anemia. Yet Kocher sees the explana-
tion of the benefit known to have followed many trephin-
ing operations and craniectomies in the relief thereby
given to intracranial blood pressure and the equaliz-
ing effect thereby produced, and he seeks to prevent, even
by artificial means, bony closure of the opening thus made.
Of this view it must be said that the numb>er of cases
which may justify it is relatively small, though it has
the benefit of Kocher's profound knowledge and well
tempered judgment.
For my own part I see no reason to feel that
epilepsy is always one and the same disease, and I
believe that quite different conditions may prevail in
different cases. In certain socalled essential cases, when
no external sources of irritation are visible, and when it
does not assume the Jacksonian type, but when it is
more probably of visceral or toxic origin, I believe that
it may be produced by toxins which have a vasodilator
rather than vasoconstrictor effect. And in cases of Jack-
sonian type, or of traumatic or peripheral origin, again,
I believe that it is possible to have variations in vascular
pressure which are not produced through the mechanism
of the cervical sympathetic, and for whose suppression
various surgical procedures may be demanded. But I
would not go so far as to say, with Braun, Dejerine and
Bergmann, that no case of essential epilepsy justifies
surgical treatment. The very expression "essential
epilepsy " implies a confession that the source of the
irritation has not been discovered.
Before we draw too gloomy conclusions regarding the
prospects of surgical treatment of epilepsy let us scan
the statistics afforded by nonoperative methods. Win-
ter presents the results of the bromid treatment as
affbrded by the two great institutions at Bielefeld and
Bethel. Of 8,000 patients treated at Bielefeld the per-
centages stand: cured, 1.72%, improved, 3.35%. At
Bethel the results are better, i. e., cured, 7.7 % , improved,
22%. Even here, however, at Bethel, patients who
have gone but one year without a seizure are counted as
cured ; were the limit placed at three years one may
readily understand that the percentages would be far
less favorable. As Winter reminds us, the results of
operation on the sympathetic are much more brilliant
than these.
At Craig Colony, where patients certainly have the best
care and the most intelligent medical treatment that the
world at present affords, results may be summarized in
the following words of Dr. Spratling ' :
" Under proper treatment, that is, under conditions
that enable us to control absolutely all the habits of the
patient, from 8% to 10%, if taken in time and treated
long enough, may be matle to recover." Dr. Spratling
also writes me that " some 18 or 20 patients have left the
colony who have gone this length of time (two or three
years) without an attack, and who were unquestionably
confirmed epileptics when they entered the colony."
Nevertheless, this statement does not raise the percentage
of cures above that stated.
No one may question the honesty of the views
expressed in this quotation, nor, on the other hand, can
the most decided optimist derive very great encourage-
ment therefrom. It shows the hopelessness of the
malady, since even to attain this percentage of recoveries
constant vigilance is demanded. Surely those ca,ses
which call for surgical treatment are the most hopeless
from the medical point of view. If, now, these cases
can only be selected early and subjected to proper opera-
tive measures how much better the outlook for them.
Matthiolius has perhaps done more for the statistics
of craniectomies for epilepsy than any other student of
the subject. He collected 258 ca.ses of Jacksonian (i. e.,
cortical) epilepsy in which the patients were thus oper-
ated upon ; some 20% were reported as cured, though
only 10 of the entire number had been followed for over
three years, and only 18 of them for more than one year.
Of the others 15 % were reported improved, while in 56 %
no improvement was noted, and 13% died.
Keetly's figures are not essentially different. Braun
collected 30 cases of traumatic epilepsy in which Hors-
ley's plan of excision of the affected cortical area was
carried out ; of these, 13 patients were reported as recov-
ered (though only 3 of them were followed for three
years), 9 as improved, and 8 as unimproved. But few
cases of nontraumatic epilepsy in which complete
excision has been practised have been followed. Matthio-
lius found only 14, of which but one was considered
cured, while the result was negative in 10.
Rassumowsky has recently added 7 cases of his own
to this number, with 2 apparently brilliant results, 2
with more or less improvement, 2 with little or none,
and with 1 death so long after operation that it is hardly
fair to connect it with the same.
When the skull is opened much seems to depend on
whether the dura is also opened or not. Kocher has
insisted, and apparently with the best reason, that the
opening of the dura very much improves the prognosis.
Excision of electrically determined areas, as advised
by Horsley, has also much to commend it. Braun in
collecting 30 such cases found that 13 of the patients
had recovered and 9 were improved. Kocher regards
this measure, though sometimes symptomatically indi-
cated, as not always reaching the real seat of the disease.
Beresewsky has reported the results of 11 patients
operated upon by Kocher (trephined), which he was able
to follow for two to nine years afterward ; he found 6
of them really cured, while in the other 5 there had
been only improvement.
It is much regretted that so little help can be
gained from statistics. Truth is they are not exactly so
unreliable, perhaps, as misleading, for every case must
be a law unto itself. Bergmann has rather caustically
remarked that the greater part of these cases are reported
before the Wound is healed.
It is wise to set some limit, arbitrary thougli it may
be, to the time which should elapse without seizures
before we may flatter ourselves that a patient is cured by
surgical procedures. By general consent this has been
> Jour. Am. Hed. Assn., May 3, 1902.
NOVKMBBR22, 1902]
PATHOLOGY OF KATABOLISM
(Amkbican Medicinb 809
placed at three years. Judged by this canon cases of
actual cure must be rare. This canon is, however, too
severe if we are to judge by it as to benefits to be
obtained. A cure is an ideal result for which we may
always strive, while not forgetting the great benefits
accruing to the patient if the number and severity of
seizures are only notably reduced. Marked tempwrary
benefit often promptly follows any well considered
operation for the relief of epilepsy. Two factors enter
into this consideration, which seem to be of inestimable
importance, yet too often overlooked.
The first is the relatively late period at which opera-
tions of all kinds are performed. Usually years have
elapsed during which various drugs have been used by
different physicians. When these patients are finally
brought to the surgeon he finds not only that the disease
is well and long established, but that they have had
their elimination so poorly cared for, and have been so
neglected or so drugged that they make wretched surgi-
cal subjects. I have operated on many epileptics, but
never yet got hold of one as early as it should have been
operated ; they always come late. This is due mainly
to the inattention of the family physician and the preju-
dice of parents or friends. I find that the neurologists
generally are quite alert as to the surgical needs of these
cases ; the fault is usually with the family practitioner.
The second factor is the mistaken notion that when
surgery is applicable it is in and of ii self sufficient. This
will lead, if not corrected, to frequent, nay invariable
disappointment. I always insist with my cases that if
surgery is indicated, it must be regarded as only the
first step in a prolonged course of treatment, which shall
include most careful attention to the diet, habits and
elimination of the patient, along with whatever drugs
may be indicated.
Itegarding prognosis it is very difficult to speak. The
operation is not one of great hazard, save in exceptional
cases, or when operation has been too long delayed.
Beside the ordinary dangers of shock and infection, about
the only conditions we have to dread are postoperative
paralysis and prolapse of the brain. The former usually
quickly disappears when due to disturbed circulation.
When due to excision of a motor area it may never com-
pletely vanish, though it is astonishing how substitution
of function occurs and how it gradually improves.
Brain prolapse occurs commonly only after extensive
openings into both bone and dura have been matle.
This is an important reason why large openings should
be made by some osteoplastic method and why large
defects should be filled with some plate, as well as why
the dura should be carefully sewed.
CONCLUSIONS.
1. Epilepsy is the last disease to which surgical
measures should be indiscriminately applied. In ju-
diciously selected cases, radical operations of various
kinds, suited to the individual needs of each case, have
given far more satisfactory results than has nonoperative
or medicinal treatment.
2. Every case must be studied as a problem by itself.
The only general laws applying are those rt'garding the
removal of peripheral or local foci of irritation and the
destruction of paths of conduction which convey dis-
turbing impulses. In each case we must decide as to
the operative method by which we may best meet these
indications.
3. In order to attain the best results patients should
be seen early. It would be well to have every epileptic
carefully studied by an accomplished surgeon, who
should review the case with a view to the possibility of
surgical intervention.
4. Operation, when indicated and undertaken, should
be regarde<l as a first measure to be followed, and often
preceded, by others looking to a correction of all faults
of diet, of elimination, etc. Long continued attention
to these matters is the price of eventual success. I
5. In those cases characterized by blanching of the
face, when the seizures can be warded off or mitigated by
the prompt use of amyl nitrite, we may well consider
the propriety of an exsection of the cervical sympathetic.
BIBLIOGRAPHY.
MatthloliuB : Zeit. f. Chir.. Bd. 52.
Keetly : Mittheil. a. d. Grenzgeblet, Bd. 5.
Alexander: Treatment of Epilepsy, Edln., 1889.
KummeU: Deutsche med. Woeh., 18SW, No. 23, p. 526.
Baracz: Wiener med. Woch., 1889, No. 7.
Jaksch : Wiener med. Wocli., 1892, No. 16.
Bogdanilc : Wiener med. Presse, 1893, Nos. 15 and IS.
Jaboulay : Rev. de Mfidgcine, 1899. p. 1.
Rlcard : Gaz. des H6pitau.x. 1898, p. 286.
Braun : Archlv f. klin. Ctiir., 1901, p. 715.
Jonnesco: Centralblatt f. Chlr., 1897, No. 2; 1899, No. 6, and 1900,
No, 48.
Graf: Arehiv f. klin. Cliir., 1898, p. 591.
Kocher: Centralblatt f. Chir., 1899, p. 40.
Vidal : Centralblatt f. Chir.. 1900. p 341.
Winter: Archlv f. klin. Chir., Vol. 67, p. 816.
Braun : Zeit. f. Chir.. Bd. 48.
Rassumowsky : Arch. f. kiln. Chir., Vol. 67, p. 139.
THE PATHOLOGY OF KATABOLISM IN RELATION TO
THE ETIOLOGY AND PATHOLOGY OF CANCER
AND ALLIED STATES.
BY
HOMER WAKEFIELD, M.D.,
of New York City.
Attending Physician, Outpatient Department, Bellevue Hospital ;
Member New York Pathological Society, American
Medical Association, etc.
INTRODUCTION.
The present paper is submitted not as a finished or
complete investigation, nor as an exhaustive or con-
clusive exposition of the subject. It is presented simply
as a preliminary statement of deductions reached, but
which are intended to receive their mature elaboration
in a work on "The Chemical Origins of Disease," now
in preparation.
In tumor formation we encounter a pathogenic
increase of the cellular or fibrous tissues, or both
together, as the case may be, of a circumscribed area,
which must be accounted for either by an undue accel-
eration of anaAolism, implying proliferation, or, anabo-
lism being normal in rapidity in an equally, well marked
retardation of katabolism, producing hyperplasia by
accumulation. An extensive review of the literature of
malignant growths reveals the fact that most investi-
gators, to date, have sought the solution of this problem
in attempts at its interpretation by various theories
of pathogenically exaggerated anabolism. The most
accepted theory of this class has been that of Cohnheim,
who, by tracing tissues to their embryonic origins, has
evolved a theory of embryonic perversion, that .sets
forth a combination of an unrestrained and exaggerated
growth, together with a coincident arrest of develop-
ment, by which tissues are presumed to continue to the
point of degeneration in the embryonic stage. By this
the<jry gelatiniform tissues so commonly found in these
conditions, owing to their resemblance to rudimentary
tissues as seen in the umbilical cord, are supposed to be
tissues perpetuated in the embryonic state. The theories
advanced, setting forth infectious origins of the disease,
also generally allege resulting proliferations, which
implies an exaggeration of formation, development, or
growth.
There are many points of evidence against all of
these theories of exaggerated growth, as also of a perpet-
uated embryonic state. Against the former theory,
which implies a rapidity of growth, exceeding that of
the normal processes of disintegration, may be men-
tioned :
1. Neoplasm formation is most common in the post-
meridian of life, when anabolism in general is much
slower than in youth.
2. When tumor formation occurs in esu-ly life, the
involved tissues are those which are slowest in growth,
810 AUERICAN MSDIOtKB)
PATHOLOGY OF KATABOLISM
[November 22, 1902
and these tumors, with few exceptions (to be mentioned
presently), also are slower of growth than those occur-
ring in later life.
3. Those tissues of greatest metabolic activity (which
implies the most rapid anabolism), namely the muscles,
when metabolic equilibrium obtains, are, per se, under
circumstances common to neoplasms more disposed to
atrophy than to hypertrophy or to hyperplasia.
4. The fact that many of the most typical of cancer
cells are multinuclear, proves that the stage of cell
division had been normally attained when the patho-
genic change interfered with this reproductive function.
5. Cancer processes do not spread by proliferation ;
that is, by a prolific pathogenic multiplication of young
cells, or of elementary tissues, in abnormal amount.
Moreover, neoplasms do not spread by infiltration into
adjacent tissues, except as they traverse the lymph and
blood channels. Individual cells and small clusters of
cancer cells, observed in surrounding tissue, may be said
to have degenerated in situ.
6. While it must be admitted that no observer has
ever traced the cell through its various stages of separa-
tion from the maternal cell, its development and decline,
or its stages of degeneration, other evidence of the cell's
life history is conclusive ; and the same may be said of
the processes of degeneration. Against the theory of
perpetuated embryonic states may be argued that during
the period from birth to the outbreak of the malignant
growth (it must be admitted) the tissue-cells fully
develop and cell-division is normal ; hence it is evi-
dent that cellular maturity, up to that time, is fully
attained and that the gelatiniform condition later observed
is entirely consequent to the pathogenic process developed.
This fact alone is conclusive evidence that the alleged
embryonic tissues have not existed from the time that
the afflicted person was in the embryonic state, for it
must be admitted that no cell existing in the human
body at the time of the outbreak existed even a year
prior to the initial manifestations, and also that all
ancestral cells must have been normal, both in their
development and in their maternal functions.
It being established then that a region composed of
cells and fiber, which has become involved in a neo-
plastic process, was once normal, it must be admitted,
regardless of the embryonic classification of those
tissues, that they have encountered some kind of a mod-
ification of their extraneous influences which has been
responsible for the change from the normal to the indis-
putably morbid state.
Gelatiniform tissue-cells and fibers, characteristic of
cancer, have never been known to develop into adult
cells, and yet adolescent and adult cells exist in the
growing edges of cancer. The majority of such cells are
multmucleated, and still if embryonic cells they would
not have reached the age of nuclear division. Cancer
areas, composed solely of cancer-cells, are characterized
by but one course— necrosis. Hyperplasia is always
absent in the absence of an admixture of living, growing
cells, which are free from the characteristics of cancer-
cells. The marginal areas (the growing edges) of cancer,
to the contrary are hyperplastic approximately in direct
ratio to the proportion of adolescent cells, and the rate
and extent of hyperpla-sia is dependent upon a combina-
tion of the rate of growth of the adolescent and the
rapidity of necrotic disintegration of the retrograde
tissues.'
It is self-evident that, in order that tissues might
morbidly so long continue in such a fixed stage of unde-
velopment, katabolism more than anabolism must be
concerned in the process ; and this being the case, taken
together with the above established incompatibility (and
hence the untenability of the anabolic theory) it is neces-
sary to consider the etiologic laws and relations of katab-
«.|l»^n'^^*^;7^.^'"' »T'^°iP.?"* '^ meant fully and normally developed
dl^rtb^d. attained the meridian of their exlstencei, elsewhere
oligm, together with its compatibilities with neoplastic
processes in general. A consideration of the parasitic
theory will be found under the head of complications
and infections.
STATEMENT OF HYPOTHESIS.
In order to facilitate a clearer understanding of the hy-
pothesis of neoplastic formation intended to be set forth,
it may be briefly prefaced by the statement that my
theories are : That gelatiniform tissues, as observed in
neoplasms and elsewhere, invariably represent a stage
of degeneration of tiasues once healthy, the said degen-
eration bearing no relation whatever to the embryology
of the tissues.
The conditions responsible for the increase in the
involved tissue is a retardaticm of katxibolism, producing
a hyperplasia, by an accumulation, due to a retardation
of dlHintegration, coexisting with an uninterrupted for-
mation and growth of the contained tissues.
The gelatiniform celU of the initial tumefaction, and
of the growing edge," after the central suppurative
degeneration obtains, are superannuated cells that have
failed of normal katabolism. This in turn will be shown
to be a process of alkaline digestion, or dissolution, com-
bined' with the oxidation of its products. Tissues are
subject to tumor formation in inverse ratio to their katab-
olic digestibility; blood-cells, as well as tissue-cells, fail
of normal dissolution in the presence of the established
causes of katabolic retardation, and, like the latter,
increase in numbers. Both blood and tissue-cells are
victimized by subkatabolism, in inverse proportion to their
established innate faculties of counteraction of estab-
lished causes of katabolic retardations.
It will be shown that subkatabolized cells, or cells
which have encountered an arrest of normal alkaline diges-
tion in its various stages and which may show recognized
signs of acid effects upon their membranes or nuclei, are
disposed to water absorption, and a consequent sivelling and
transluoency, and they manifest the recognized function
of phagocytosis.
In accordance with the structure of the tissue or tis-
sues involved, the environmental conditions, as to
moisture, edema, dryness, exposure to air, bacterial
infection, irritation and the continuation of suboxidation
and subalkalinity, the gelatinous condition will con-
tinue unchanged or become more or less hydrated ; it
may become fatty, putrid, gangrenous, hyperemic, hard,
soft, or encapsulated ; the cells may show a predomi-
nance of an acid or an alkaline effect upon the nuclei, or
they may, while retaining a soft, gelatiniform resem-
blance to their former forms, englobe contiguous floating
melanotic particles or bits of integrated cells, thus pre-
senting peculiar appearances. However, these cells
always experience arrest and perversion from the normal
katabolism, and in the presence of a continuance of the
established causes they pursue but one course — that of
degeneration.
A general application of the physiologic and path-
ologic laws herein presented will be of widespread and
far-reaching value and importance, for they elucidate the
etiology of many diseases heretofore obscure.
In presenting this new theory of tumor formation it
will be necessary to set forth my ideas on the underlying
physiologic basis and from that standpoint build up the
hypothetic pathologic fabric. In so doing it will be
necessary to include not a little of what may appear a
useless recitation of accepted physiologic and pathologic
fact.
Most writers to date being very well agreed as to the
modus operandi of cellular formation by nuclear division
from the maternal cell, that phase of the subject will be
accepted as established, and the following discussion will
be devoted exclusively to the causative relations of cellu-
lar physiology and pathology in their present develop-
ment, as bearing upon neoplasms and their allied dis-
eases.
November 22, 1902]
PATHOLOGY OF KATABOLISM
(Amekican Medicinr 81 1
The mention of other diseases, some of which may
appear foreign to the theme, is made with a purpose of
elucidating a common causative relation, and, by that
method, proving the fundamental theories.
A COMMENT UPON NORMAL CEI.LUIjAK PHYSIOLOGY.
The individual cell, like the complex animal, from
the period of its separation from the maternal cell, under-
goes a career of chemical and physical development
(adolescence) and decline, a change in size and in func-
tion, as characterized by the balance in its own metab-
olism, in other words, by the absorption of nutriment
and the excretion of carbonic acid, urea and water (as
has long been agreed to by physiologists), and ending in
final digestion (dissolution).
During the period of active growth until the meridian
in the life of the cell is reached the cell-nucleus is well
clothed with protoplasm, which, during the decline in
the life of the cell, gradually diminishes, until in the
aged cell it is so thin as to be hardly distinguishable,
and in the superannuated cell (in cancerous tissue) it
often appears as a bare nucleus. Cellular activity,
metabolic and maternal, is greatest in direct ratio to the
thickness of this protoplastic investment. In seeking
the solution of this problem I have found in the phys-
iology of the vegetable cell an important analogy ; and
if the slightly varying physiology of the plant cell is
acceptable as applying to the animal to this degree, it
throws much light upon the subject.
The vegetable cellular sap contains in addition to
other ingredients several organic acids and their salts.
Moreover, it has been observed that the leaves of certain
plants, as the Senecis flcoides, Bryophyllum calycinum, and
others, which are tasteless at noon, have a slightly bitter
taste in the evening and a sharply acid taste in the early
morning. This is conclusive evidence that the metabo-
lism of the vegetable cell gives rise to an acid product
which is oxidated by the action of the sun's rays during
the light of the day, and that in the absence of light and
sun at night the acid product gradually accumulates until
morning on the surface of the leaf. We shall observe
later that we have very good evidence that the same
phenomenon occurs in animal metabolism as is seen in
man. Thus we know that, while the animal and
vegetable cells are opjiosites as regards their physiologic
utilization of oxygen and carbonic acid, they evidently
both generate an acid as a metabolic product, and in
both instances the chemic action of light and, sun is
depended upon to oxidize them.
The combined observations of several investigators
upon ciliated animal cells prove conclusively that the
physical effects upon them produced by oxygen, alkalies,
light and heat are identical, namely, the acceleration of
functional activity. This convinces me that these
agencies all serve, assist, augment and magnify the one
end — oxidation. Therefore, we are warranted in looking
for retardations and disturbances of oxidation in all
cases in which the mentioned environmental conditions
are reduced, counteracted or absent. And we do observe
the Siime result from all the mentioned factors, an unoxi-
dized excess of sarcolactic acid, in the event of excess
demands upon the cells, collectively, as is illustrated in
cases of undue and severe strain and fatigue.
We are unmistakably able to observe, both clinically
and by chemicophysiologic experiment, that identically
the .same results are attainable by theoi)positesof all the
above named conditions, by suboxygenation, hyper-
acidity, absence of sun, light and heat, and by excessive
strain and fatigue of cerebral,' nervous, muscular and
fibrous tissue. From each and all of these conditions
we observe retarding effects upon the katabolism of the
cell, hereinafter to be exploited, and which by delicate
hist»chemic analyses are proved to be due to sarcolactic
acid in animals, and a variety of other organic atiids and
their salts in the plant. Physiologically and in health
it is observe<l that the sarcolactic acid product of the
animal cell does not linger, but that its oxidation keeps
abreast with its formation ; and when this is observed
to be in effect, none of the pathogenic conditions herein-
after to be treated of is in evidence. During the period
of cell growth and of metabolic equilibrium we have no
apparent decomposition of tissue, so long as the balance
between the constructive and destructive processes is
maintained. The normal dissolution of cells is so
gradual and complete as to be unapparent, and the end-
products are simply carbonic acid, urea and water,
which are readily excreted as formed. Normally tis-
sues do not continue an existence unto death and necrotic
change, hence necrotic tissues are always indicative
of either conditions impossible to life or to subkatab-
olism.
We have seen that normally the individual cell does
not, as does the complex animal, maintain its invest-
ment of protoplasm up to the moment of an abrupt
death, but beginning with the very height of its growth
and the zenith of its existence, the cell begins a gradual
wasting of its protoplasm. From this we observe that
the cell nornmUy spends a part of its career in a gradual
decline in size, function and vitality. It might be said
also that this meridian, or climax in the cell-life, marks
a point of final development of the cell, the end of metab-
olic equilibrium, and the point of beginning of katab-
bolism. As we have seen illustrated by physiologic laws,
the elementary essentials of the life of the cell are pri-
marily an adequate supply of oxygen, and finally light
and a constant degree of alkalinity of the intercellular
substance as conditions necessary to oxidation.
THEORY OF NORMAL AND PATHOLOGIC KATABOLISM.
We have absolute evidence that the intercellular sub-
stance is normally maintained richly alkaline, and also
that the tissue-cells are more or less soluble in its pres-
ence. It has been observed that during the period of
growth and activity of the cells they normally generate
and exude sarcolactic acid, and during this period they
are observed to be richest in protoplasm. Yet after the
meridian, and as the vitality and functional activity of
the cells decline, they offer decreased resistance to the
solvent or digestive power of the alkaline mediums, as a
result of which they gradually lose their protoplasm
until the almost bare nuclei remain. I infer from this
that before the meridian is reached, the acidity produced
by normal cellular activity protects the cells by its
neutralizing effect upon the intercellular alkalies, and
thus preserves the investment of protoplasm.
If the intercellular substance, from any cause, becomes
seriously reduced from its normal alkalescence, or a
localized area is rendered acid, all of the contained cells
experience a stasis of katabolism ; those of antemeridian
states experience serious metabolic and functional dis-
turbances, owing to the resulting stasis of katabolism of
their metabolic products. Thus remarkable perversions
of function and maternity result. Their function of
growth seems to be the least interfered with, for they
continue until they attain their full, if not exaggerated
size; they continue the function (though seriously per-
verted) of new cell-division, but stagnate in activity,
become devitalized, and finally are possibly pretnatnrel)/
pas.sed intf) the postmeridian state, all owing to the loss
of the alkaline mediums necessary to their dissolution
and of the suboxidation of their ordinary metabolic
pro<lucts. The cells of the postmeridian state, already on
the decline, not unlike those of the antemeridian state,
encounter a stagnation and a more or less comjjlete stand-
still in their katabolic changes, which bears a relation to
the degree of digestibility of the tissues involved.
It is observed that tissue katabolism is analogous to
the digestion of flesh in the alimentary tube, in that
tissues also differ in digestibility, the connective tissue
being most difficult, the epithelium next, and lastly the
brain, nervous, and muscular tissues, of which, while in
themselves differing somewhat, they may perhaps be
812 AXEHICAX HeDICINX]
PATHOLOGY OF KATABOLISM
(NOVKMBER 22, 1902
considered the most digestible. Bone and cartilage
come under the classification of connective tissue, whicli
comprises their skeletal tissues. Thus we observe that
to a given degree of interference to katabolisni, indi-
vidual cells suffer hindrance to normal dissolution,
depending approximately upon the nature of their tissues.
Depending upon the degree of the stasis produced
and the nature of the tissue involved, the cells continue
in a stationary condition for a period of varying dura-
tion, when finally a gelatiniform change, a softening
begins, a water absorption and lastly fatty or suppura-
tive metamorphosis follows, passing gradually througli
all of the stages of fatty change, from the softened, gela-
tinous cell, into the pus-cell, and thence through one of a
homogeneous, fatty, purulent mass, into a fluid cream
or milk, as it becomes emulsified.
Those tissues most difficult of katabolic digestion, and
hence those which are most susceptible to katabolic
retardations, when oxidation and other vital processes
are most active, as in early life, in spite of the fact that
anabolism is also most active at that period, are the
slowest of growth. As a rule, the lower the proportion
of fiber in a tumor, and the greater the proportion of
cells, the more rapid the growth. Conversely, the malig-
nancy of tumors bears approximately an inverse ratio to
the digestibility of their involved tissues. In apparent
contradiction to this are the medullary and round-cell
sarcomas, but it must be considered that the connective
tissues in these instances do not become malignant until
they have attained the gelatiniform stage and become
impregnated with water, thus greatly softening them
and promoting their digestibility. Moreover, these
.sarcomas are highly cellular and they present great con-
trast to the dry forms of fibrous tumors, which are very
slow growing and inclined to be benign.
An analogy to the marked increase in digestibility of
animal tissues, wrought by water absorption, is observed
in vegetables which when fresh and succulent, are
digestible, but when dry, are woody and indigestible.
Moreover, fresh vegetables, like water-absorbed necrotic
tissues, are prone to putrefaction, and conversely, dried
vegetable fiber, like the dry hypertrophies and tumefac-
tions of fibrous tissues, are not so disposed. We have,
in the process of cookery, one of facilitation of digesti-
bility, and in the processes of stewing and steaming, of
partial hydration.
With the knowledge of the laws and relations of
katabolic stasis observed it does not require an extended
stretch of the imagination to compass the effect of any
serious interruption of normal retrograde metamorpho-
sis. On a consideration of the cells, collectively, instead
of singly, it appeals to reason that in the event of a
great number of cells of a localized area failing of disso-
lution, in the presence of a practically uninterrupted new
cell-formation, a tumefaction must result, and should the
stasis continue long enough for the pathogenic transition
of the involved tissue, a gelatiniform, suppurative
degeneration, or other necrosis, must be aii inevitable
result — either a fibrosis, a hypertrophy, an induration,
or a tumor, a pimple, a boil, a carbuncle, an ulcer, an
abscess, a felon, a benign or malignant growth. All of
these represent in some form the pathogenic manifesta-
tions of the superannuated cells of some tissues that
have failed of katabolism and are in some stage of path-
ogenic degeneration.
During the period of metabolic equilibrium and of
prime activity the cell is most active in nuclear divis-
ion, hence in new cell-formation. It is in this stage
that it encounters serious disturbances of function,
evinced by the delays in the processes of fragmenta-
tion, in which cells and nuclei linger in one stage or
another. In consequence of this the completion of the
process of cell division, after the nuclei have divided, is
prevented, and as a result the socalled giant cells, as
well as other characteristic cancer cells containing two or
more nuclei, are found.
The arrest of dissolution of the maternal nuclei, after
division, and following an acid-produced retardation of
katabolism, gives rise to changes, by virtue of which
they present appearances which have been mistaken by
some observers for protozoa, blastomycetes and other
unicellular organisms. The thickened, resisting envel-
ope, the gelatinized nuclear substance, and the peculiar
appearances presented by irregular and perverted mitosis
and phagocytosis, are noteworthy characteristics.
Returning now to the direct causes of the diverse
conditions found in neoplasms, it is observed that in
addition to the mentioned evidence of the effect of acids,
as responsible for katabolic stasis and its train of conse-
quences, the fact that so universally are the involved
nuclei laid nearly or entirely bare, and the remaining
nuclei are entirely intact, suggests strongly that the inter-
cellular media is in such cases changed from an alkaline
to an acid reaction. Highly illustrative of the proces.ses
described, namely, the relation of acids and alkalies to
cellular katabolism, may be mentioned the universally
used technical methods of histologists, known as Kolli-
ker's distinguishing feature between the nucleus and the
membrane of the cell. When it is desired to dissolve
away the cellular membrane and substance, exposing the
nuclei, more or less concentrated solutions of the organic
acids are used, and conversely, when the nuclei, or the
entire cell including the nuclei, are to be dissolved, dilute
alkaline solutions are used instead. The envelope of the
nuclei resists organic acids. A promising field for
research is opened in demonstrating the effects of various
acids on the elementary metabolism of the cell.
In the exposition of this subject I have aimed at a
direct application to cancer. It may promote the elucida-
tion of the theme to add that there are, in my observa-
tion, many intermediate manifestations of katabolic
stasis that are entirely general (systemic), not localized
and not characterized by tumor formation, or local sup-
puration ; thus are observed all degrees of cachexia,
from a muddy complexion to the classical type, pigmen-
tations of the glands and skin, the appearance of
petechiffi and angiomas, catarrhal conditions of mucous
membranes, and a predisposition to general suppuration
on slight provocation. The excess of subkatabolized
tissue debris, in all stages of gelatiniform, fatty and other
forms of perverted retrograde metamorphosis, may be
observed to Qccur in both blood and urine. The occur-
rence of an impregnation of the blood with these degen-
erate tissues highly predisposes the economy to all kinds
of infections, of which tubercle bacilli are prominent
among the most frequent.
If permitted to invent an appellation there is a form
of noninfecfed malaria which I see much of at my clinic
among the New York poor, in a class living in houses in
which the sun seldom or never peeps, where dampness,
filth and poverty reign, and especially in certain seasons
of the year when only moderately cold, but when damp
and wet weather prevails. Though it resembles the
infectious malaria of the swamps and the tropics, it is
not entirely identical in manifestation. That suboxida-
tion is caused, in these cases, by carbonic oxid and car-
bonic acid poisoning there can be no doubt. Proximity
to damp cellars, damp moldy walls, badly lighted and
ill-ventilated rooms are undeniable prolific causes of a
suboxygenation of the contained air, which becomes
Impregnated with the exhaled carbon dioxid, with the
carbonic oxid emanations from the damp walls, dark
airshafts and cellars of these poorer class of tenements
and old houses. Also, leaky gas-mains in the streets and
pipes in these superannuated buildings pour their toxic
monoxids into the already vitiated air of these living
quarters. In such cases the gas proves doubly toxic
when combined with the noxious vapors from unsanitary
water closets, open and unvented waste pipes connecting
with the sewers, sulfureted hydrogen, ammonium
sulfid, together with nitrogen. The symptoms of chills,
fever, headache, vertigo, nausea, weakness and rarely
KOVKMBKR 22, 1902]
PATHOLOGY OF KATABOLISM
[American HKDiom 8 13
loss of consciousness are among the observed results.
Another affection, on the order of the types mentioned
and often associated, is a form of " biliousness," a mani-
festation of an excess of tissue debris in the system which
may be cleared away largely by cathartics, diuretics and
oxidants. In this affection the tongue is loaded with a
dirty-looking coating of epithelium detritus, the muddy
appearance of the skin approaches nearer to a cachexia
than a jaundice (no yellow in the conjunctiva). This
condition is usually entirely independent of biliary
obstruction, and such an association may not be devel-
oped.
All of these conditions of katabolic stasis in which the
economy is impregnated with subkatabolized cells of all
stages and grades of degeneration render the system
extremely prone to bacterial infection, owing to the
varying degrees of reduction and absence of vitality, as
well as to the several stages of disintegration of the
superannuatetl cells, which generally becomes a putrid
process, a dissolution by suppuration, thus obscured by
its generality, and its almost universal relationships to
other morbid processes. There is no doubt that this
general condition constitutes the vaguely expressed
"predisposition " in nearly if not all infectious diseases.
It may be roughly stated that the "proliferation of
cells" in a repair process is due to a katabolic stasis,
which in turn is caused by the paralactic acid formed by
the irritation to the cells, incident to the exposed raw
surfaces. As the gap of the open wound is closed by the
cellular increase (granulation), the local irritation sub-
sides (provided that the wound does not become infected)
and if the general metabolism is normal, the repair pro-
cess ends with the ending of the local irritation. Thus
during the repair process, namely, during the stasis of
katabolism, anabolism proceeds normally, as before, and
after the ending of the process ; and the increase of tis-
sue necessary to the repair i» entirely due to temporary
stasis of katabolism, which automatically adjusts itself
to the needs of the situation. If, however, the repair
becomes unduly delayed, the oldest cells become degen-
erated, healing is interrupted and an indolent, chronic
sore results.
When infection complicates such a wound, the nature
of the bacillus is important, as also the type of its media.
If an acid-excreting microorganism, the katabolic stasis
is increased ; if considerable hyperemia is produced the
stasis is modified by better oxidation. (See section on
infections.) If the irritation of raw tis.sue is extreme, as
in a burn, the effects are more pronounced, and an
excess of connective tissue Is caused, often with con-
traction, as the socalled "cicatricial inflammation " con-
tinues.
It is observed in all cases of tissue repair from any
injury that the connective tissue, the least digestible,
accomplishes it before the stasis becomes great enough
t() int*!rfere with the normal katabolism of the more
tligestihle tissues, and thus the fibrous tissues precede
the cellular. The greater the inflammation present the
more the connective tissues predominate.
The most conclusive evidence that the cause of
neoplasm-formation is not an exacerbation of anabolism
is the already mentioned fact that the type of neoplasm
most prone to occur in early life, when anabolism is
most active (sarcoma), is one of slow growth, and, in fact,
slower than those characteristic of lat^r life (carcinoma),
hence it cannot be inferred that superactivity of cell-
formation is resiK)nsible for its pathogenic existence. We
have indisputable evidence that neoplasms are products
of katabolic stasis in the fact that the tissues of the
neoplasms of greatest malignancy' and those occurring
♦■arliest in life are the mostdiftlcult of katalwlic digesti-
bility. Moreover, the tissue most difllcult of digesti-
bility is the one characteristic of neoi)lasms of early life,
when the normally active katabolic processes are most
prone to preclude the probability of the katal)olic failure
of tissues of easy digestibility. The facts maybe aug-
mented by the observation that tumor growth is more
rapid in proportion as it is composed largely of cells, and
slower as it is composed mainly of fibrous tissue. (This
is true of the cells of both epithelium and of connective
tissues.)
COMMENTARIES UPON SUBKATABOLISMS OF BLOOD-
CELLS.
A study of the intimate relations and analogies exist-
ing between the fixed tissue-cells and the blood-cells is of
much interest and lends atlditional confirmation to the
theories above set forth. Many of the laws above
attributed to tissue-cells apply equally well to the blood-
cells, which are subjected to a very similar katabolism
and, therefore, to the same retardations.
An important additional proof of the role of alkalies
and oxygen in kataboli^ is the observed fact that in all
those conditions above mentioned, in which by hyper-
acidity, subalkalinity and suboxidation are produced
katabolic stasis in tissue-cells, occur the same effects upon
the white blood-cells, including the increase in numbers,
due to an accumulation of subkatabolized, superannuated
cells, in the presence of a continuous anabolism. The
increase in numbers of the leukocytes, which are not
oxygen carriers, in these conditions is as characteristic
as is its absence in the red blood-cells, which are oxygen
carriers and which suffer only premature, pathogenic
dissolution when the etiologic factors are sufllcient to
produce katabolic stasis of bone-marrow. Thus it is
seen that the red cells never suffer per se from suboxida-
tion however great the subalkalinity or acidity they may
encounter. To the contrary, the white cells may suffer
a stasis, oxidation having been made impossible by the
presence of an acidity or a subalkalinity. This again
indicates that a given etiologic factor possesses greater
counteracting effect upon the oxidase of the white cells
than upon the hemoglobin of the red cells. The
lymphocytes, which have been shown by Lillie to be
much more active in oxidase than the leukocytes, are
proportionately less represented in leukocytosis. As a
rule the tissue-cells are most often subkatabolized
directly by suboxidation, and conversely the blood-cells
suffer mostly from subalkalescence, the white cells only
meeting with katabolic stasis as a result. Cardiac debil-
ities, with dyspnea, are generally responsible for but
little leukocytosis, while tissue-cell katabolism may
suffer greatly.
Pathologically, the changes in the blood in heart dis-
eases are directly referred to broken compensation, and
to the dyspnea consefjuent to suboxygenation. It is
observed that suboxygenation due to direct loss of blood, .
as by hemorrhage, is not infrequently the cause of leuko-
cytosis, (lastric and other alimentary affections char-
acterized by hyperacidity are also intimately associated
with leukocytosis. .Jaundice is observed to bear an
etiologic relation to leukocytosis. (Note elsewhere its
relation to tissue-cell subkatabolism, mechanical in
nature.)
With the exception of diabetes, in which tissue-
oxidation though unbalanced is generally excessive, it
may be broadly stated that leukocytosis is most char-
acteristic of those diseases which have been chemically
demonstrated to be sissociated with a diminished alkales-
cence of the blood. More prominently may be men-
tioned leukemia, anemia, fevers, malignant neoplasms,
etc. It is affirmed that leukocytosis is well marked as a
rule, only after the onset of suppurative, degenerative
jjrocesses, but that does not point to a purulent etiology
any more than to a common causative factor.
An interesting relation between oxidation-processes
and the pathology of the blood, is the fact that the
lymphocytes in the bl(M)d, which have i)een shown by
liillie to be richest in oxidase are {as compared with
h'ukocytes) least affected by the divers causes of katab-
oJic stasis. Again, it has been shown that sarcoma, a
neoplasm of early life, is usually attended by lympho-
814 American Mediciniej
PATHOLOGY OF KATAB0LI8M
[November 22, 1902
cytosi8, while on the contrary, carcinoma is more com-
monly accompanied by a polynudear leukocytosis.
The significance of these relationships in the latter
instance, Ewing suggests, is due to the freedom of the
lymph paths in the former, and their occlusion in the
latter case. This conforms with the observations and
theories of Sir William Jenner, in his essay on " Rickets,"
namely that persons of clear complexion, thin skin,
superficially distinct veins, bright eyes and delicate
organization are, when victims of katabolic stasis, prone
to tuberculosis, while those of opaque, thick skin, dull
complexion and phlegmatic temperament are disposed to
scrofulosis and cancer. In the latter, katabolic stasis is
manifested by disturbances of pigmentation of the skin
by a pasty, muddy complexion, infiltration of the lym-
phatic glands with gelatiniform. or what Sir William
Jenner termed an albuminous, degenerated material, a
characteristic of cancer as well as of scrofula. It must be
recognized, however, that the rule is not invariable, and
these may co-exist. Negroes are disposed to tubercu-
losis and a commonly coexisting scleroderma, which is a
not uncommon accompaniment of cancer.
The changes in the blood-cells characteristic of katab-
olic stasis, as well as those of the tissue-cells in the
same condition, when in that intermediate stage of
delayed katabolic digestion, though differing somewhat
from the latter, owing to the diversities in the various
structures involved, present an appearance and con-
sistence suggestive of the soft, half-trembling gelatin
jellies of ordinary diet. Cells in this stage of metamor-
phosis have so forcibly impressed upon many observers
their striking resemblance to rudimentary tissue as to
cause them to support the socalled embryonic theory of
cancer etiology.
In connection with the foregoing it is of interest to note
the fact that leukemia has been observed to present a
partial resemblance to a neoplasm, as it affects the
lymph nodes, spleen, marrow and blood, and from it
such a theory of origin has been founded and maintained
by several observers. Gilbert has compared lymphemia
to a sarcoma affecting lymphocytes. It is evident that
a varied assortment of lymphocytes in all stages of
development and retrograde metamorphosis are often
combined in a lymph node. The promiscuous interspac-
ing of the living antemeridian cells by those of the post-
meridian stage undergoing gradual demise, and by the
necrotic cells, together with the enclosure of the whole
mass by a firm glandular structure, fulfills the require-
ments of a neoplastic formation. The continuous forma-
tion of new cells, the perversion of nuclear division of
the adult cells and the retarded katabolism of the dying
and dead cells, acting together, provide the essential
characteristics, namely, "cellular proliferation" and
multinucleated cells. The interspacing of the living
cells with the dying and dead cells in all stages of sup-
purative degeneration, causes the disruption of the nor-
mal continuity of the tissues, and the degeneration
which they attain, the continued unequal exercise of the
reproductive proclivities and the absence of the normal
adhesive properties, or what some authors call intercel-
lular afiinity, give rise to the dismemberment of meta-
static thrombi.
It is worthy of note that the now almost obsolete
term scrofula formerly stood for a condition similar to
the above, in which nuclei and white cells " prolifer-
ated " and finally underwent purulent disintegration.
These suppurating tumefactions of the lymphatics have
been long observed. In scrofula, leukemia and other
diseases of similar type, the acidity responsible for the
leukocytosis also produces a fibrosis, namely, an hyper-
trophy of the connective tissue of the glandular struc-
ture, characterized by both contractions (cicatricial
formation) and thickening. An ultimately fatal issue
may arise from this in two ways, namely, development
of lymphosarcoma, or in the event of a complete circular'
contraction (sclerosis) of the gland structure, the dehy-
drated purulent contents soon present the typical aspects
of a tuhercle (the reverse of the hydrated pus-cavities)
with its encapsulated cheesy contents, which is very
prone to a continued and prolonged existence and to
infection, thus favoring primarily a lymphatic tuber-
culosis, and secondarily pulmonary, hepatic, and other
localized tuberculoses, by metastasis.
Of further interest in the application of these katab-
olic theories to the pathology of the blood, is the
observation that whenever the marrow suffers a severe
or prolonged subalkalinity, acidity or suboxidation, the
typicaj change of retarded katabolism, which has
been characterized as "a reversion to the embryonic
type," presents, and the general manifestations of pro-
gressive pernicious anemia complete the clinical picture.
The marrow changes are characterized by the develop-
ment of the gelatiniform type of cellular degeneration,
herein identified with the suhkatabolic degeneration so
typical of neoplasms. A review of the effects of sub-
katabolism upon the other blood-cells must be omitted
here, yet the same principles apply.
The great majority of cancers are accompanied by a
corresponding oligocythemia leading to the changes of
pernicious anemia, after the onset of the cachexia.
Hemoglobin, however, begins to suffer much earlier
than the red blood-cells, and Ewing has never seen an
uncomplicated case of visceral carcinoma, positively
identified, which had failed to reduce the percentage of
Hb. He has found the Hb. index uniformly low, and in
some cases it has approached that of chlorosis, thus pre-
senting a closer resemblajice to chlorosis than any other
cause of secondary anemia. Ewing adds: "When
chronic cachexia has been long established in the blood,
it shows the characters of secondary pernicious anemia,
with variations in the size of the cells and an increasing
Hb. index, yet with rare exceptions the relatively great
loss of Hb. remains characteristic." From the foregoing
it is suggested that in the extreme stages of malignant
neoplasms, complicated by melanosis, the excess of pig-
ments present is derived from the blood, notwithstand-
ing their changed characteristics.
The alkalinity of the blood is commonly found dimin-
ished in cases of malignant tumor-formation, and the
diminution of the nucleated red cells, and leukocytosis,
are common accompaniments. Osteosarcoma has been
reported by many observers to have been recognized,
accompanied by progressive pernicious anemia, which
is further confirmatory of the observations delineated.
THE KOI.E OF OXYGEN AND ALKALESCENCE IN GEN-
ERAL KATABOLISM.
That an adequate supply of oxygen is essential to
normal katabolism is attested by the fact that katabolii*
stasis is observed to occur constantly as a result of patho-
genic and experimental suboxygenations of the entire
organism, as well as of local tissues. A Well-defined
picture of general katabolic stasis is observable in the
more or less prolonged spells of cardiac dyspnea, in
which a gradual cachexia develops, the tongue accumu-
lates a heavy dirty coating, a bitter taste occurs in the
mouth and a feeling of malaise and nausea, loss of appe-
tite, etc., present, suggesting the lay term "biliousness."
Odors of decay emanate from the mouth and skin, and
symptoms of autointoxication, especially manifested by
twitchings and clonic movements, are observed.
PetechiiB and angiomas develop quite often upon the
chest, and a characteristic muddy hue and occasionally
pigmentation and jaundice characterize the general
cutaneous appearance. In these cases it should be added
that the angiomas and pigmentations are of slow devel-
opment and are products of long continued and chronic
forms, while the muddy complexion may gradually
develop, according to conditions of oxygenation and its
opposing factors, in from a week to a month, the jaun-
dice appearing as a later complication and evidently as a
sequence of the same cause. An extended observation
November 22, 1902]
PATHOLOGY OF KATABOLISM
'American Medicine 815
and study of this phase of subox j-genation convinces me
that especially the portal circulation and spleen become
clogged with tissue detritus, and in the former the
biliary function is interfered with, and the characteristic
biliary disturbances are caused.
There are other disturbances, accredited to be of
biliary etiology, conditions associated with several affec-
tions characterized by various phases of hyperacidity,
vaguely described by writers under the term " cholemia,"
with which there is much evidence of relationship by
the before- mentioned conditions. Actual jaundice and
intestinal acholia often complictite the later stages. Haig
also describes under the name "collemia" a condition of
capillary obstruction, which he attributes to a clogging of
the capillaries by urates, yet he mentions a "colloid"
form as composing the real obstructing deposit.
My analysis of the existence of a variety of sub-
stances other than of suppuration products, which also
pervade and obstruct the vascular system, is that they
also are products of a deficient action of normal katab-
olic digestion, which are set free in a semi-dissolvetl
condition, and are taken up and carried along by the
blood current. Thus we observe as an incomplete meta-
morphosis of the basement membrane of some connec-
tive tissues a condition characterized as amyloid, waxy,
and lardaceous ; that of the protoplasm of cells and
intercellular substanc-e we have the socalled mucoid and
colloid ; and from muscular and other tissues, the hyaline
degeneration, that of the albumins as coagulation-
necrosis, etc., all of which are herein characterized col-
lectively as the gelatiniform stage. In the presence of
an excess of acid, and in the absence of the normal
alkaline digestive powers of katabolism, that action
known as coagulation-necrosis (of albumins) is not of
uncommon oa-urrence, and this condition obtains until
the gelatiniform or fatty change or a real necrosis (dry
decay) sets in. In some diseases the degeneration does
not progress beyond the gelatiniform stage.
If the tenets of the above hypothesis are accepted,
that deficient oxygenation is a common causae of katabolic
stasis, and at the same time of a perverted and even a
suppurative decomposition of tissue-cells, it may be
inferred that in the light of the natural inclination of
the tissue detritus to be carried to the liver, spleen and
lungs for oxidation, and in the existing conditions of
excess of such detritus, exceeding the powers of these
organic combustions to consume, the devitalizing influ-
ence of the presence of such decaying organic matter
would naturally contaminate and compromise the nor-
mal organic tissues, and as a result of the organic atonies
80 caused, a general clogging of the portal system would
be first produced, resulting in the classic biliary stasis
so characteristic of the later stages of these cases. We
may conclude then that the biliary condition present is
principally one of obstruction of the hepatic vessels
jtrimarily from suboxygenation, and is not one of com-
pensatory hyperemia of the liver, acting reflexly as a
direct result of cardiac insufficiency, as many writers
have heretofore analyzed it.'
The fact that these hepatic atonies develop gradually,
and that the biliary symptoms follow the production of
the muddy complexion, the uremic symptoms and the
obstructed circulation strongly suggest that the inability
of the l)lood to reach the liver cells, and a consequent
failure of [wrtal combustion, account for the cause of the
jaundice.
' In the glandular strtictiiren. as the blood paiises from the artertes
through the mlmit« ramifying capillaries, wllh their very thin walls,
the ganeoua exchange with the tissues Is consUmt, and the oxygen
being rendered active by the oxidase present, oxidation Is a Hpoiita-
neouH result. The spleen and liver present two distinct forms of oxi-
dative function, the spleen representing one of direct oxidation of the
detritus In Ihe blood, as It passes through the capillary network and
the liver presi'ntlng one In which the oxygen conveyed by the hepatic
artery acts .jointly with that of the portal vein to oxidate the tissue
detritus of the former and food contents of the latter. The spleen Is
essentially an organ entrusted with the offlce of clearing, by combus-
tion, the blood of Its contained detritus, while the liver Is essentially an
organ for the combustion of food.
In the consideration of the divers causes of the sub-
oxygenations and suboxidations of the tissues in general,
we must include the quality of the air and the processes
of inspiration, conduction, and of all of the physical,
chemic, and physiologic accelerating, retarding, vitiating
and neutralizing influences, that are brought to bear
upon the various processes involved.
We have seen that diminished alkalescence, and sub-
stitutions of acid for alkaline medias, in addition to
directly retarding or arresting the chemic part of katab-
olic digestion, also independently retard the oxidizing
action of the same. Then a variation in effect and prod-
uct is ob.served to result, according to the nature and
peculiarities of the defaulting factors, and depending
upon their general or localized influences. Oxygenation
may be primarily diminished by a deficiency of the
function of respiration, depending upon inactivity or
incapacity, or it may be due to an insufficiency of oxy-
gen, or an excess of carbonic acid in the inspired air.
Secondarily oxygenation may become inadequate as a
result of defective conduction, as observed in the circula-
tory deficiencies of cardiac debility, vascular obstruc-
tions, and in all conditions of poverty of the hemoglobin
in the blood. A third cause of interruption of oxygena-
tion, or rather a source of suboxygenation, which it
appears has been overlooked, is the hypercombustion of
the oxygen of the blood in the portal system (and often
in the left heart and large arteries), thus consuming an
exceas proportion of the general supply of the economy,
and depriving the tissues themselves of more or less of
their normal quantity and reducing it below the limits
of the demands of a normal katabolism.
The excessive oxidation of one localized part of the
body may exhaust an excess of the whole blood supply
of oxygen for a given time, and during that period other
parts of the body will be caused to suffer a proportionate
deficiency. If the period is unduly prolonged the
deprived tissues will suffer in direct ratio from suboxida-
tion. Oxygen is consumed in the system in the locality
of highest combustibility or conversely combustion
occurs in the diret'tion of least resistance. The higher
the combustibility of ingested foods the greater is the
exhaustion, by combustion, of the oxygen of the blood ;
accordingly, as many foods are more combu.stible than
the tissues, an excess ingestion of highly concentrated,
soluble and oxidizable foods and beverages, by an exces-
.sive combustion consuming the inspired oxygen, maybe
responsible for a suboxidation of the tissues. Moreover,
an excess ingestion of highly oxidizable and soluble
foods may by their excessive combustion in the same
manner deprive foods and beverages of lower combusti-
bility of an oxygen supply adequate to their complete
combustion.
In recent years several physiologists and medical men,
especially German observers, have published observa-
tions on the use of oxygen inhalation, indicating that no
acceleration of oxidation could be attributed to it. These
reports have served me as an impetus to determine, if
possible, the several influences bearing upon oxidation,
other than respiration. The line of studies and clinical
observations that I have devoted to intraportal and
arterial oxidation has, I am convinced, not only solved
that problem but other problems of equal or greater
importance. By the ingestion of foods and chemicals of
known highly oxidizjible properties, of great concentra-
tion and solubility, and known to be conducted to and
burnetl in the portal system, I have in spite of an accel-
eration of oxygenation by inhalation, been able to produce
the recognized as well as .some newly-determinetl .symp-
toms of suboxygenation, many of them not having been
heretofore recognized as so related.
If a slight rtiKres.slon may bo pardoned, it may be added
here that deductions based upon clinical observations and
studies of the ptibiished investi|irations of others boarinK upon
the subjjoot, talion togother, have led to the conviction tliat
many of the ob.sciireamsctlons itnown as cirrhosis, sclerosis and
816 AMKBIOAN HBDimXEl
PATHOLOGY OF KATABOLISM
[NOVEMBER 22, 1902
erosion, and characterized mostly by fibrosis, that Infest the
venous and arterial channel, stretching from the portal entry
directly forward to thecapillaries, are almost entirely the result
of excessive combustion (oxidation; of foodstuffs and chemi-
<mls in the blood; in other words, they are burns. In tracing
these processes it is observed that they occur in the liver, after
which the same blood with the same content of foodstuffs
or chemicals, passes on through the hepatic vein to the right
heart and thence to the lungs, and yet oxidation ceases soon
after it leaves the liver. From the lungs it is returned to the
left heart, by which it is pumped into the aorta and vascular
system. After pulmonary reoxygenation, however, oxidation is
resumed and extends forward through the left heart into the
arterial and capillary vessels until the process is completed.
My analysis of this process is, that combustion of food-
stuffs and chemicals absorbed from the alimentary tract occurs
in the portal system to a degree depending upon the oxygen
content of the hepatic blood, the quantity, solubility and the
oxidizing properties of the said foodstuffs and ingested chemi-
cals. Whenever the oxidizable foods and chemicals are not
excessive and the oxygen supply is ample, we may observe a
combustion in the liver of wide and perhaps excessive varia-
tion, but always confined to the liver. If, however, the assim-
ilated oxidants exceed the capacity of the hepatic oxygen sup-
ply to oxidize from the point of their egress from the portal
vessels, however excessive the hepatic combustion has been,
no further combustion occurs until a fresh supply of oxygen
is obtained in the lungs, when combustion is reestablished, to
be continued until the exhaustion either of the oxygen or of
the oxidant. Under the head of foodstuffs, alcohols, ethers,
acids, sugars and all highly organized and soluble carbohy-
drates, and among chemicals, arsenic, phosphorus and the
metals have been most studied. The greatest and most impor-
tant relation borne to katabolism is that of the production of
a suboxidation of tissues by this pre-combustion of the inspired
oxygen in the vascular system. The affections of the vascular
walls, the erosions, sclerotic and atheromatous conditions
observed in the liver, in the left heart, and the arterial system,
are all either primary or secondary effects of the excessive com-
bustion of oxidants of various degrees of intensity, diffusibility,
solubility, volatilability, etc., physically expressed as are the
characteristic external burns, by fibrosis and cicatricial
(sclerotic) formations, and sfecondarily through suboxidations
produced by thickenings and hypertrophies, and atheromatous
changes, as effects of the resulting subkatabolism.
We have loilg known of the socalled tissue-sparers
and proteid-gparers. All these foods and chemicals of
great concentration, solubility and high combustibility
have attained the reputation of acting relatively in this
way. And that they do perform such a mission is con-
firmed by the general application of the law that oxygen
seeks combustion in the direction of least resistance,
and the further fact that all foods and chemicals meeting
combustion in the portal system have an oxidative
advantage over those which are introduced through the
lymphatics and meet combustion in the general circu-
lation or the intercellular substance of the tissues. The
neutral fats, which always are cpnsumed in the capil-
laries or tissues, while in themselves highly combusti-
ble, experience a slow combustion for the above reasons.
It is worthy of note that there is one exception to the
above rule. Notwithstanding the fact that excessive
portal combustion lowers general systemic oxygenation,
it will be observed that a limited acceleration of portal
combustion, by the ingestion of active oxidants which
are burned in the liver, may be made to serve the pur-
pose of clearing the system of subkatabolized tissue
detritus, which is normally a hepatic function. This is
a common remedial measure for lost appetite, bilious-
ness, etc. It is possible that hyperoxidizable substances
may possess the property of attracting oxygen, or of
transforming it into active oxygen. That has not yet
been determined.
Not less important than oxygenation itself are the
oxidative functions or properties of the cell-nucleus,
their bearing upon both general and localized oxidation
and their close functional relation to the habits and the
socalled critical periods of life. Since the interesting
studies of Draper and of other early observers in the
chemistry of light and animal phosphorescence, in
which the functional relations of phosphorized or nucleo-
proteids were made known, and the similar composition
and functions of the cell-nucleus were brought to light
by other observers, the greatest interest in the further
development of studies of the functions of the cell-
nucleus has been aroused, and perhaps others, as well as
myself, have ardently hoped that proof Could be obtained
that the powers of this active principle of the cell are
responsible for tie long-known function of conversion of
ordinary oxygen into an active oxygen capable of spon-
taneous combustion of oxidants at the temperature of
the body.
Lillie, of Harvard, following ih the footsteps of
Schmiedeberg, Zaquet, Spitzer, Loeb, and others, has
brought the development of this subject to a surprising
state of perfection, and has recently succeeded in demon-
strating by delicate microchemic methods that the cell-
nucleus actually possesses the faculty of converting
ordinary oxygen into active oxygen, or in other words,
of setting free we^tre oxygen. The inherent substance of
the cell-nucleus possessing this power is called the oxi-
dase. Also the function is known by the same name.
He has determined that, of the tissues, connective
tissues are poorest in oxidase, the muscular tissues prob-
ably next. Cellular structures vary in activity in direct
relation to the governing influence of the contained
nucleus, thus columnar and mucous epithelium cells are
very active at the inner ends, which are the nuclear
regions, while the opposite ends are practically inert.
The disposition and arrangement of the nuclei, their
numbers and surface areas, all exert active influences.
Probably the most powerful exhibition of the oxidase
process is observed in the columnar epithelium, in
which the internal lining surfaces of the tubes are com-
posed of closely studded nuclei, directly adjoining one
another, which is indicative of the fact that identified
with the function of intestinal absorption is a process of
active oxidation, and it is therefore also of importance
in the general considerations of the relative oxidations
of ingested foods, beverages and chemicals. Oxidation
must be closely related to all glandular functions, for in
general, glandular structures are very rich in oxidase.
Of the blood-cells, the lymphocytes are most active,
leukocytes next, and erythrocytes are least energetic.
Lillie has observed that the nuclei were most active
when surrounded by the least protoplasm, therefore we
may conclude that normuUy cellular katabolism is much
accelerated by the gradual loss of protoplasm character-
istic of the postmeridian cells, antedating their final
digestion ; and we may hence appreciate the additional
retarding action on oxidation of an arrest of the normal
protoplasmic diminution as the cell begins its post-
meridian period. We observe that the course of sub-
katabolism is progressive, i. e., the initiatory processes
combine with the original cause to further the s-uboxida-
tion, and hence follows the process of progressive katab-
olic stasis to the extreme stages observed.
The relation of oxidation activity to organs is of great
importance and throws a flood of light upon the subject
of this paper. Lillie has found that the organs most
active in oxidase are the "liver, spleen, pancreas, lung,
kidney, ovary, testes, the various regions of the intes-
tinal tract, striated muscle, the various regions of the
brain and spinal cord, and certain lymphatic structures,
especially the thymus and the ventral gill vestiges." It
has been observed in general that the above oxidations
are most rapid in those regions of organs in which are
contained the most numerous and most densely aggre-
gated nuclei. The regions showing the greatest oxi-
dative activity were those in which the nuclei were
chiefly seated.
The relation of the oxidation properties of organs to
their functions is close, and especially in respect to that
which we will now consider. Practically all of the sub-
katabolic and autointoxication-products of the system,
so soon as they are freed from the sites of their forma-
tions, are at once transported by the circulating
body fluids to the liver, spleen, lungs and kidneys,
where they, with all forms of tissue detritus, are found
deposited in cases in which these organs fail in their
normally active oxidative functions. It is known that
November 22, 19021
PATHOLOGY OF KATABOLISM
(American Memcikb 817
dogs may be rendered susceptible to diseases to which
they have natural immunity by the removal of the
spleen, which we now know would be the removal of an
organ possessing very high power of clearing the blood of
cellular and other detritus by combustion, and also
undoubtedly in large degree of accomplishing the normal
katabolism of the blood-cells, and the absence of which
would naturally greatly increase susceptibility to infec-
tion, owing to the normal increase in the degenerate
tissue debris so accumulated.
That tissues may recover from the eflfects of a retarda-
tion of their oxidative functions is attested by the
observations of Loeb, who found that there resides in
the tissues a substance which presides over their solu-
bility accordingly as affected by the presence or absence
of oxygen. While in the ctenolabrus eggs studied, the
katabolism was observed to be the opposite of that of the
mamma, yet the interesting fact was observed that the
cell wall dissolved in the absence of oxygen and reap-
peared when the oxygen was restored. This observation
has its analogy in the animal tissue-cell, which has long
ago been observed. In studying the effects of acids and
alkalies upon ciliary motion, Virchow observed that
after the arrest of the movements by acidulation they
were promptly revived by alkalies. Both of the obser-
vations mentioned confirm the fact that the oxidase
properties of cells (which Lillie found were active o?ili/
when in the presence of alkaline mediums) when pre-
vented by acids may be restored to normal activity by
restoration of the alkaline environment. In the granu-
lation of a tissue repair by second intention, we have an
instance in which a gelatiniformed area of cells becomes
restored to normal by the normal resumption of alka-
lescence and oxidation. As the process is comparatively
rapid, there is better evidence of cellular restoration
than of excessive metabolic activity, namely, the destruc-
tion of the cells and filling the places with new ones.
Of greatest importance in the clinical history of malig-
nant neoplasms is the intimate relation to their etiology
borne by the synthesis and exhaustion of nudeins,
the significance of which will be appreciated, since the
foregoing reviews of their relations to oxidases and
oxidation.
From birth to adolescence sexual activity is normally
almost nil, and we learn from clinical observations that
the oxidation powers of the body are unequal to any
sexual activity, and even after puberty, until maturity
is attained, we observe that sexual development is evi-
dently in advance of physiologic nuclein synthejsis, as is
attested by the diseases characteristic of suboxidation,
developing as a penalty of sexual exercise and vices at
this critical age, and moreover, in some persons, even in
the absence of an exercise of the sexual function during
the period of adolescence, a stagnation of the oxidative
proc«.sses and the characteristic manifestations of katab-
olic stasis present, namely, in obesity, tuberculosis,
neoplasins, etc.
Marked incn-ase of adipose deposition, pustular
tumefaction and tumor formation in both sexes, and
chlorosis in the female are most observable. In the
female, adipose acciuisition is particularly noteworthy,
and often a condition may be observed characterized by
loss of appetite, bitter taste in the mouth, foul breath,
coated tongue, headache, malaise, and not rarely a craze
for acids (vinegar, pickles, lemons, etc.), which serve to
accelerate the portal combustion, temporarily clearing it
of subkatabolic detritus, thus improving the appetite,
but coincidently lowering still more the general oxida-
tion, and increasing the predisposition to tuberculosis.
During the period of a<lult sexual activity exhaus-
tion of the cellular nudeins is occasionally attained by
sexual excesses and vices, and the characteristic results
of subkatabolism may be thus attained to any degree,
modified, of course, by other extrinsic and intrinsic
influences. Other illustrations of the relation of the
sexual system to oxidation are observed in the breasts of
women which become very fat in amenorrheic subjects,
the loss of sexual appetite in the obese, the lean and
> elderly spinsters who grow plump after marriage ; in
men the accession of fat as the sexual powers decline, in
cases of impotence, in religious celibates, in castrated
persons and animals; women, as widows, who suffer
sexual inactivity, and tho.-e who prematurely or nor-
mally experience a cessa'ion of menstruation. Inter-
rupted pregnancies are often observed to result in sub-
oxidation, and occasionally in marked obesity.
The gradual decline of oxidation progresses in close
relation to the decline and obsolescence of sexual power,
and in both sexes is observed the increase of diseases-
of katabolic stasis as such modifying and exciting influ-
ences may be brought to bear. As the great mortality
among women from malignant growths has been largely
due to neoplasms of their two principal maternal organs,^
the uterus and breast, and their inception has borne
such a constant relation to the sexual functions, their
detailed consideration is worthy of our best thought.
The more prominent illustrations of the intimate rela-
tion of the associated decline of sexual powers and oxida-
tion to neoplasms are presented in the painful swellings
of the breasts of girls at puberty, which sometimes last
for months, but never develop into malignant tumors,
generally subsiding on the regular establishment of the
menstrual flow ; in the stimulation of the breasts in single
women during the menstrual period and in those of
married women from coitus ; in the innocent tumors
during the prime of life from the disturbances of self-
abuse, sexual excesses, pregnancy, lactation, and other
causes of suboxidation or suboxygenation. Lastly, we
observe the notorious and frequent relation of the obso-
lete breast and uterus, at or after the menopause, to that
condition — malignanci/ of neoplasms, which would logic-
ally be expected to bear a relation to the extreme condi-
tions of suboxidation.
Malignant neoplasms are observed to develop in
children at those ages when their oxidation is lowest, as
attested by their greater tendency to fat accumulation at
the same ages, and in women who have passed the meno-
pause, in those organs most affected by the ending of
the active sexual career, and in direct relation to the
degree of exhaustion or senility of these organs. The
more active the sexual life, the higher the fecundity and
the greater the lactation, the earlier will come the meno-
pause and the greater will be the postclimacteric obso-
lescence of the mamma and uterus. It is well knowri
that the universal anatomic product of senility is
fibrosis, and that this product is attained more con-
stantly by functional activity than by years. Such i»
the case in pregnancies and lactations which are often
attended with intense localized and general hyperaciditj%
which, during each pregnancy and lactation, add new
thickening to the connective-tissues, thus paving the
way to malignancy, which is attained when the
decreased oxidation reaches a stage, when to the connec-
tive-tissue subkatabolism is added that of the more
highly digestible (katabolizable) epithelial structures,
contained within the previously involved connective-
tissue, which adds to a tissue of slow metabolism one of
activity of growth and decomposition.
Most authorities on cancer, ancient and modern, have
regarded as prolific predisposing causes of cancer, mental
shock, strain, anxiety, worry, grief, distressful disjip-
pointments, neurasthenia, insufficient sleep, prolonged
and exhausting labor ; others have disputed the theory as
an impossibility, being unable to appreciate the causjil
relation. We, however, in the light of modern physio-
logic chemistry, can trace the connection through the
fact that they all are now known cjjuses of hypersarcolac-
tic acidity, which by causing suboxidation, produces
katabolic stasis ; and depending upon other influences
and the degree of the katabolic stasis, tuberculosis may
result if infection take place, otherwise ulcers, abscesses,
pustules, tumors, benign or malignant, may develop.
818 American Medicine]
PATHOLOGY OF KATABOLISM
[NOVEHBEK 22, 1902
Tubereulosis, cancer, arteriosclerosis and capillary fibro-
sis are tlie classical results of these causative factors, the
niodu.1 operandi probabfy being an arrest of the oxidase
function by the induced hyperacidity.
INTKKMIODIATE AND SEMIMALiIGNANT CONDITIOXS.
It is a logical certainty that all pathogenic conditions
must pass through intermediate stages before becoming
fully developed diseases ; also that diseases of slow or
gradual development must present antecedent, interme-
diate manifestations, and that such conditions may abort
at any stage, become modified by various environmental
influences, or may become actually so perverted from
their predestined courses as to lose their initial identities.
Such we find to be the case with neoplasms, as of many
other pathogenic processes. When tissues experience a
stasis of katabolism, they linger in intermediate stages
of the process, in a gelatiniform, possibly a semifluid
state, and undergo necrotic changes according t« the
structure of the tissues involved, and, it may be added,
depending upon the environmental conditions, for we
observe the fatty change is characteristic of situations
protected from the air, caseation to small, compressed
and encapsulated processes, and dry gangrene to exposed
placas. We observe slower oxidation processes among
the enclosed tumefactions, and more rapid ones in the
open or exposed ones ; even changes from purulent to gan-
grenous necrosis have been observed after the opening of
suppurating cancers— thua illustrating the marked eff"ects
of the absence and presence of ordinary air.
After considerable study and clinical observation I
have reached the conclusion that suboxidation manifes-
tations of divers degrees are much more common than
even the preceding arguments would suggest ; the most
common of these are the soealled catarrhal conditions,
affecting the mucous membranes of the various organs of
the body, and which represent perhaps the mildest as
well as some of the more aggravated forms in which a
low percent of mucoid gelatiniform detritus may be
exuded in a liquid form, or semisolid when intermixed
with pus. The form analogous to a noninfectious malaria
is commented on elsewhere. A low condition of general
systemic suboxidation often develops insidiously and is
manifested in various ways, according to environmental
accidents, remote influences, habits of life, etc., as indu-
rations, tumefactions, glandular swellings, fatty degene-
rations, pustules of various kinds and sizes, etc. Small
whitish patches may arise upon the mucous membrane
of the mouth, lips, etc., and eventually develop into
malignant growths (leukoplakia). It is observed that
narcotic and anesthetic habits are predisposing to suboxi-
dation by lowering either oxidation or oxygenation.
I am convinced that most of the soealled infectious
diseases are primarily subkatabolized conditions of the
tissues and blood-cells, which secondarily become in-
fected by microorganisms and later assume the charac-
teristic processes of the dominant microbe, which then
dominates the ultimate process. Especially is this the
case in tuberculosis and malaria.
That subkatabolism is the rule in senile diseases is
illustrated by the fact that the gelatiniform stages of
pathogenic tissue-disintegration are those selected for
calcareous deposits, as also of uric-acid salts in gout. In
general all diseases characterized by suboxygenation,
suboxidation, subalkalinity or hyperacidity, including
all of the soealled rheumatic series, and the acid diseases
of Bouchard, present subkatabolistic forms of necrotic
changes.
LOCAL CONDITIONS AND EXCITING CAUSES.
When a circumscribed area of tissue is subjected to
an intense and unusual development of sarcolactic acid,
as by chill, fatigue, strain, irritation, by traumatism, or
an erosion, and the general oxidation or alkalescence of
the system is too low to oxidate or neutralize it, it will
contuiue to exist in situ, and a stasis of katabolism of
the tissues involved will be the result. Those tissues
requiring the most active digestion for perfect and com-
plete katabolism will be the first affected, the other and
more digestible tissues following in order, as the general
and local causes of stasis increase.
If a sudoriparous gland or number of glands fail
normally to excrete the fatty acids, they accumulate in
the gland, producing a localized subkatabolic necrosis,
which is oxidized or continues in situ, according to the
existing capacity for final katabolism. A universal
result of the most common causes of katabolic stasis,
namely, irritations, strains, faiigue, traumas, transient
acidulations and abstractions of alkalies, is fibrosis, i. e.,
a hypertrophy of the fibrous connective tissues. A
sclerosis of these tissues is produced, and the greater the
formation of this scar-tissue, the greater will be the diffi-
culty of the contained cellular tissues to obtain adequate
oxidation. Moreover, with the fibrosis there is observed
an obliteration of the involved bloodvessels, which
proportionately interferes with both the oxygen and
nutritive interchange. Thus warts, moles, and all
cicatrices are predisposed to neoplastic development ; so
also are unprotected chronic sores, cracks, fissures and
leukomas, owing to their exposure to constant irritations,
which act to continue the katabolic stasis, and because of
the coexisting interspacing of growing cells, by the
necrotic cells in all stages of degeneration, repair processes
are prevented, and in the absence of adequate oxidation of
the necrotic cells, the condition, and hence also the pro-
cess continues. Chronic sores and other raw surfaces
manifest a perversion of their natural proclivities to
heal by repeatedly scabbing off and partially cicatrizing,
but fail in the repair owing to the discontinuity of
healthy cells, the general broken integrity of the
involved tissues, the consequent disruption of that
normal complicity and concordant collusion, and cooper-
ation of the individual cells, so necessary to the normal
conditions and functions, as well as to the cohesion of
tissues.
Malignant neoplastic processes must always be reck-
oned as perniciously progressive elaborations', operating
in pernicious circles. The initial exciting cause is
directly seconded by one or more of the general causes,
namely, subalkalinity, hyperacidity, suboxidation and
suboxygenation, as characterized by subkatabolism. In
the presence of subkatabolism the pernicious circle is
advanced by the katabolic stagnation of two or more
tissues of different degrees of susceptibility to katabolism ;
and by so slowing the necrotic disintegrations of the
tissues as to make possible the coexistence of tissues of
opposite extremes of growth, decline, and of necrotic
change as characterized in the metastatic stage by the
suppurating center, and of the surrounding indurated
areas of mixed living and necrotic cells, intervening the
outer areas of normal tissues.
The resulting fibrosis and scarification of the involved
slow-changing fibrous tissues, with their characteristic
obliteration of bloodvessels, the reduction of caliber and
occlusion of both bloodvessels and lymph vessels by
scleroses and by metastatic deposits of pus and tissue
detritus, acting coincidently with the general melanosis,
combine to arrest entirely any remaining tissue oxy-
genation or metabolic exchanges whatsoever ; and taken
together with the farther action of contiguous sarcolactic
acidity of the early (gelatiniform) stages of the process,
any oxidase properties surviving this stage are also
arrested.
Contusions of the soft tissues of the female breast
resulting in circumscribed glandular hypertrophies or
tumefactions, which in the functionally active breast of
sexually active women are readily dissipated by katab-
olic processes, may form the initial lesions of malignant
tumors, in those who have attained by age or an acquired
exhaustion a normal or premature obsolescence of the
glands, probably always characterized by a decline or
arrest of the nueleonic oxidation properties of the cells.
NOVKMBEK 22, 19021
PATHOLOGY OP KATABOLISM
(Akebi
ICAN MeDICIITH 819
A fact of great interest and importance, and substantiat-
ing the liypotiiesis of oxidase destruction in these cases
and its intimate relation to the sexual function may be
illustrated by adding that women presenting malignant
neoplasms, especially of the breast, appear to be other-
wise perfectly normal, and only the involved organs
seem to suffer from suboxidation, thus showing the
exclusiveness of these sexual influences. It also points
to the fact that it is due to faulty oxidase proi)erties of
the involved tissues, and them only.
Chronic uterine low inflammatory conditions which
have existed for years, with fibrosis and tumefaction,
but attended with a barely adequate oxidation of their
metabolic products, on the obsolescence of the oxidation,
often manifest those perverted conditions which we
term malignant.
A typical illustration of the local etiology of malignant
growths is presented in the not uncommon instances of
the development of epithelioma by continuous irritation
produced by constant piclcing of the part until the
decline in katabolic capacity is ample ; then the gradu-
ally producetl fibrosis finally attains, though slowly,
an advanced gelatiniform stage, and together with the
ft' more digestible cellular tissues it becomes involved with
the advancing stasis of katabolism, and thus true and
perhaps high malignancy is established, depending upon
the fluid content of the involved locality.
Analogously to progressive pernicious anemia, the
bones may experience a circumscribed stasis of katabo-
f lism, in neoplastic genesis, and as a result of the suboxi-
dation of katabolic acid formations we observe exostosis
and decalcification of the bone ; and following this period
the process continues as a sarcoma of the remaining con-
nective tissues which follow the necrotic changes char-
acteristic of this type of tissue. These sarcomas may
have their primary lesions produced by contusions from
blows, kicks, concussions of falls, a variety of injuries
and emboli occluding supplying vessels, etc. Thus local
causes may be intrinsic or extrinsic. It is observed that
sarcomas occur mostly in bony i)arts, subject either to
great functional activity or positions exposed to trauma,
yet always subject to modifications of oxidations inci-
dent to contiguous muscular activity.
Sarcoma bears a close etiologic relation to gout and
rheumatism, in that it displays a predilection for articu-
lations of great functional activity and strain, as the
shoulder, knee, ankle and great toe joint", which owing
to their disposition to the excessive paralactic acidity of
fatigue and strain, become doubly liable to attack.
Malignant neopla.sms occur in those situations in the
visceral organs where the tissues are subjected to the
greatest irritations, and where they are most exposed to
pathogenic acidity. Such are the pyloric and cardiac
orifices of the stomach, the duodenum, the cecum, the
appendix, the sigmoid flexure and the rectum ; the more
constantly acid large intestine being the more common
site when below the stomach. Illustrative of the long-
continued local and exciting causes of malignant growths,
may be mentioned the constant irritations to the tongue
by rough, projecting and calcareous teeth, badly fitting
dental plates, to the mouth and lips by the friction and
heat of pipes and cigars, tobacco smoke ; oft repeated
injuries in the same place, lacerations of parturitions.
In general, low inflammations, traumatic injuries,
mechanical pressures, chemic irritations, chills, undue
fatigue, strains, unusual frictions and undue sexual
excitations and exhaustions may l)e mentioned.
A typical illustration of mUHcular strain as an etiologic
factor is cited by Pitlield Mitcliell, as follows: In a case in
•whicii the riglit upper extremity was disabled from youth, the
left side was requtre<J vicariously to perform an undue
increased lalior. The nef)j)lasm was developed after lifting a
heavy weight, thus showing tlic predisposing and exciting
causes combined in one process. Osier and McCrae have found
In a number of examinations in cases of gastric cancer a quite
universal condition of deficiency or absence of HCl and an
associated excess of organic acids, the two together, I believe,
bearing an important and significant etiologic relation.
In all situations it is noteworthy that contiguous
suppurations contaminate healthy cells, and by produc-
ing a stasis and perversion of katabolism, those cells in
the retrograde stage pass rapidly into fatty or purulent
change, and thus the suppuration spreads. .
Those conditions of chronic sores, characterized by a
general interadmixture of adolescent and degenerated
cells, and popularly known as " proud flesh," owing to
their inability to heal, are examples of well-defined
katabolic stasis and are very liable to develop into malig-
nancy when permitted to continue long.
PATHOLOGY AND ANALYZED MORPHOLOGY.
Neoplasms, benign and malignant, are not definite
organismal structures possessing individuality and
special attributes of antagonism to the economy, as
Mitchell and other writers have taught, but, as pointed
out, are simply the products of a perversion from a rapid
and imperceptible digestive to a delayed, gradual and
perceptible degenerative metamorphosis, and coincident-
ally to a more or less serious disturbance of the normal
relations of anabolism and katabolism ; the multiplication
of cells being entirely due to their accumulation, owing
to the incidental delay of katabolism in the presence
of a continuous anabolism.
As before mentioned, tissues are delayed and per-
verted in their metamorphosis, inversely to the degree
of their digestibility. This corresponds to the related
attributes of the highly " specialized " and organized tis-
sues of other writers, the most highly specialized being
those of highest digestibility and last affected by katalxjlic
stasis. When tissues of low organization and digesti-
bility are subkatabolized the rapidity of their dissolu-
tion, as normally of their growth, is very slow, hence
they long remain apparently unchanging in their condi-
tions. After they have passed from the circumscribed
hypertrophic into the gelatiniform condition the appear-
ance of fibrosis disappears, and even at the borders no
remaining fibrous tissues justify the name of an encap-
sulation ; conversely, however, the rapidly growing,
highly digestible and specialized structures give rise to
neoplasms of cellular degenerations, surrounded by an
implicated connective tissue, which presents a marked
contrast to the neoplasm ; the tumor being perhaps in an
advanced stage of fatty change, while the slow-acting
marginal fibrosis forms veritable encapsulations, such as
are observed about the tubercle. The analysis of this
process in the carcinoma type is, that the connective tis-
sue at the margin of the neoplasm not being affected by
the exciting cause of the tumor proper, receives just
enough irritation from the contiguous cells of the neo-
plasm to produce the fibrosis.
Malignancy of tumors is generally conceded to depend
largely upon the rapidity of growth, which is also closely
identified with metastasis. Not that metastasis is due t«
the rapid growth, but both are due to the characteristics
of the tissue structures involved, namely, mixed degen-
erating cellular and fibrous tissues, the malignancy
increasing with the proportional increase of cellular
tissue and with the degree of attainment of water absorp-
tion by the cells while in the gelatiniform stage of
degeneration. This cancer type is perhaps best illus-
trated by the encephaloid. It should be emphasized
here, however, that cellular tissues attain their greatest
degrees of malignancy in proportion to their absorption
of water while in the gelatinized stage, after the attjiin-
ment of which their fatty or purulent evolution is
much more rapid. The conditions of water-absorption
may be the favorable situations, complicating soft watery
structures and especially glandular and edematous tis.sues.
There is also rea.son to believe that the absorption of
water plays a part in the formation of giant cells, other-
wise analyzed above.
The type of sarcoma characterized by high malig-
nancy, rapid growth, large size, and soft consistence, is
best represented by the medullary .sarcoma, so named
820 AUERlCAir MSDIOINlCj
PATHOLOGY OF KATABOLISM
LNOVEHBEK 22, 1902
owinp to its resemblance to medullary cerebral structure.
This tumor may be so soft as to appear semifluid and
may give the sensation of fluctuation. Tissues soft by
nature or by edema not only furnish the necessary fluid
for cellular' absorption, but their unresisting characters
also admit of the rapid expansion of both individual cells
and the tumor as a whole. A typical illustration of an
opposite condition is the slow progressing epithelial can-
cer, when the dry sclerosis of the connective tissues com-
plicate it with cicatrices, thiis at the same time prevent-
ing fluid absorption and producing a resisting fibrosis.
So it will be seen that the characteristics of involved
tissue, location of tumor, resistance, and complicating
conditions, as edema, all play Important parte in the
production of the malignant state; and with the absorp-
tion of water by the involved cells, it will be seen
that carcinomas and sarcoma.s assume a remarkably simi-
lar appearance and a relatively high degree of malig-
nancy, so much so that these varieties of neoplasms of
both epithelium and connective tissue are characterized
by writers by the same name, to wit, medullary, the
name eneephaloid being used interchangeably in carci-
nomas. Other attributes of malignancy will be discussed
presently, under the head of metastasis.
As a rule pain is greater in the resisted, hard tumors,
and least in the softest and most fluid. It is self-evident
that the fatty disintegration of water-absorbed neoplasms
would set free the surplus water, and that it would serve
to form an emulsion with the fatty detritus of the degen-
erated cells and pus and thus form the socalled cancer
milk, so characteristic of these varieties. Hardness and
softness of malignant growths are markedly influenced
by exposure to air, thus the superficial epitheliomas are
dry, slow growing, hard and not as prone to fatty change
as to ulcerous formations. On the contrary, neoplasms
occurring in glands in the lymphatics and other soft
tissues, which take on all the attributes of carcinoma
when covered, undergo a marked change when the cov-
ering is broken and the fatty changes then become imper-
fect, and if the mass remains aseptic (free from suppura-
tive infection) the pus becomes an ill-formed sanious
product, mingled with detritus, and the necrotic change
may evolve into a dry gangrenous one.
Cancers enlarge in the direction of least resistance ;
those of the gallbladder and common bile-duct are dis-
posed to grow into the liver while those of the rectum
spread upward into the pelvic cavity. The point of
initial stasis of katabolism is first to manifest the condi-
tion by the accumulation of. cells, or of circumscribed
hypertrophy, as the case may be ; and during the exist-
ence of this condition the tumor is said to spread by cen-
tral proliferation and to possess the characters of benig-
nancy. Conversely, if the same tumor experiences a
sulHciently prolonged stasis of katabolism, the central
cells first showing " proliferation " are first to undergo
necrotic change, and later the central focus becoming
broken down into a purulent mass, the indurated borders
only exhibit " proliferating " tendencies, and hence the
description of pathologists that such tumors spread by
marginal proliferation and thus possess the character-
istics of malignancy.
Many writers note the slight reparative power of
highly specialized tissues. This is explained by the diffi-
culty in producing a stasis of their katabolism, owing to
their easy digestibility. In some tumors such as the
myxomas, the gelatiniform condition appears to be perma-
nent. This is probably due to the peculiarities of a high
admixture of semicartilaginous structures such as of
the parotid region, or of decalcified cartilage. As a rule
those cells observed in the gelatiniform stage, or only
beginning fatty change, having preserved an irregular
resemblance to their original forms, are characterized as
the most typical cancer cells. There are, however, no
differential lines of demarcation and they are not much
more characteristic of malignancy than many other
forms of the necrotic change.
Observers have remarked on the abundance of young
cells in the margins of malignant growths. This is a
logical outcome of the fact that the older cells are first to
undergo the necrotic changes, leaving the younger cells-
in the majority. However, I fully appreciate that many
writers, julherente of Cohnheim's theory of embryonic
etiology, have characterized the cells in the gelatiniform
stage of degeneration as embryonic cells, basing their
conclusions largely upon their resemblance to the rudi-
mentary tissues of the umbilical cord.
Robin, of Paris, long ago observed a contrast between
the action of acetic acid upon the cancer-cell and
upon the normal epithelial cell ; in the former the
nucleus, together with the cell, is rendered paler, but.
neither is destroyed, and the nucleolus is perfectly
untouched by it. In the latter, especially those of the
skin, in which the nucleoli are generally wanting, the cell
is destroyed, leaving the nucleus unaltered. This illus-
trates the fact that in the case of the cancer-cell already
in a state of katabolic stasis and a victim of organic
acidity, the further addition of acid simply exaggerates
the stasis and accelerates the development of the gelatin-
iform stage, while in the latter case the results are
analogous to those described in the section on cellular
pathology.
The characteristic appearance of these cancer-cells,
that of enlarged granular nuclei largely divested of their
protoplasm, is simply the logical result of a superinduc-
tion of superannuated cells, as caused by katabolic
stasis. The granulation of the nucleonic content, how-
ever, like other features of the cells, presents typical
analogies to the acid treatment of cells for purposes of
identification, as described in the section on cellular
pathology. These are the small granulations, as
observed in the most typical cancer-cells (bare nuclei)
and must be distinguished from the granulation tissue,
so called, composed of well-defined cells. Cancers do not
spread by tissue-infiltration, as has been taught by the
older writers. This idea has arisen from the observa-
tion of the cancer-cells intermixed with the normal cells
in the surrounding tissues, but such cells did not migrate
there ; they are simply the oldest cells of these tissues,
and from pressure, irritation, etc., combined with the
general suboxidation, they have undergone degeneration
in situ. Lymphvessel and bloodvessel infiltration is
alluded to elsewhere. The marginal implicated tissues
(the growing edge) referred to correspond with the
described " no man's land " of Mitchell. The continued
degeneration of these tissues after the removal of the
tumor proper often gives rise to the socalled secondary
formations from " infiltrated virus."
Under most circumstances in which connective tis-
sues hypertrophy, muscular fibers atrophy, thus they
have been observed to occur simultaneously — contiguous
to each other — so often that some observers have deduced
that under such circumstances the muscular evolve into
the fibrous. This, however, is without foundation.
It must be borne in mind that whatever the site of
neoplasms the tissues of the involved area always com-
prise a variety of forms ; thus, connective tissue com-
poses the stroma of muscles, glands, epithelium blood-
vessels and lymphvessels, sheaths of nerves and tendons
and the skeletal tissue of bones, cartilage and the peri-
osteum. Also it should be borne in mind that connec-
tive tissue is composed of both fibers and cells ; yet,
perhaps, several of these elements being present at the
site of the neoplastic process, the etiologic factors are
more or less selective and discriminating in their attacks ;
thus a prolonged low inflammation or a slight continued
irritation often causes simply fibrosis ; a more marked
katabolic stasis, as obtains in obsolescent organs or in
later life, may affect other tissues on an ascending
scale, the cellular connective tissues, the epithelium, the
cerebral and nervous structures, and, last and least of
all, the muscles, which are comparatively seldom
affected. A profound stasis of katabolism aft'ecting the
XOVKMBER 22, IIXK]
PATHOLOGY OF KATABOLISM
[American Medicine 8-1
rapidly metabolized epithelium cells may, under favor-
able circumstances, run so rapid a course as to cause the
death of the patient without causing a mariced hyper-
trophy of the slow metabolized fibrous tissues ; j'et any
of the tiasues of an involved area may exhibit an increase
of structural elements and thus constitute itself an active
tumor element.
Among the first observed results of acid toxemias, as
affecting katabolism, is a coagulation-necrosis of the
albumins of the blood, lymph and cells, the metastasis
of which infiltrates and clogs the lymphatic glands,
spleen, liver, kidneys, brain, thymus, heart and capil-
laries, interfering with the circulation, nutrition and
oxidation, and hence with the functions of these organs
and vessels. Evidently the enlarged spleen character-
istic of these conditions is due to its engorgement with
these albuminoids ; and the general failure of nutrition
so common in these cases is undoubtedly due to the
same cause, especially when preceding katabolic perver-
sions which involve degenerations of tissues. Such
manifestations are observed in the rickets of childhood
and many diseases of hyperacidity and suboxidation of
adult life. Undoubtedly it plays an important part in
the low oxidative processes of cardiac debility, when
uncomplicated by cachexia, thus causing high blood-
pressure.
Neoplasms may experience periods of quiescence,
lasting even for years, due to improved conditions in
general oxidation, or relief from local irritation ; also
they may experience reductions and exacerbations from
unstable states of the same condition. Regeneration of
tissue in neoplasms may be said to be dependent upon
conditions parallel to that of the repair processes of
other tissues, that is, to the extent of the degeneration
present, the tissue involved, and the mode of action of
the excitant of the coexisting inflammation. Fatty and
myxomatous degenerations, pigmentations, necrobiotic
changes and hemorrhages are subject to the combined
effects of enhanced suboxidation and malnutrition, due
to plugging of bloodvessels and lymphvessels by infil-
trations of detritus of tissue and blood.
The ordinary conditions of amenability to carcinoma
and sarcoma of adult life, are somewhat different in child-
hood, when the normal metabolism is much more rapid
than in later life, and hence even fibrous tissues grow
somewhat faster; and thus at this time a diminished
period of subkatabolism may be necessary to produce a
neoplasm, and also the better nutrition and vital resist-
ance may make necessary a more powerful causative
agent. That younger subjects are less liable to malig-
nancy than the adult, is attested by the fact that in
childhood the strumous swellings and hypertrophies of
lymph-glands seldom become malignant, while in later
years such acting causes and irritated lesions as are pre-
sente<l would almost surely become so. There is little
justification in describing the gelatiniform stage of
katabolic stasis as "albuminous" in the encephaloid,
"gelatinous" in the scirrhus, etc. ; and as such t<»rmi-
nology is misleading, notwithstanding the variation of
consistence, etc., in various tissues, the retrograde change
is so similar that a general term as gelatiniform is prefer-
able for all jellylike conditions, as expressing a degenera-
tive stage.
A matter of importance in the predisposition of scar-
tissue to cancer-formation is the hypersensitiveness and
hyperirritability of these tissues, probably due to their
hardness and their unyielding contact with nerves.
Scar-tissue formed in normal tissue-repair presents the
same intrinsic morphologic conditions as in hypertrophy
from disturbances of katabolism. Notwithstanding that
fibrous tissues are most susceptible to subkatabolisms, it
must be borne in mind that owing to their slow growth
they are only amenable to long-continued causative
factors. Conversely, cellular tissues require more com-
plete katabolic stasis, though a less prolonged period of
the disturbance. A low grade inflammation or irrita-
tion of fibrous connective tissue results in a thickening
(a hypertrophy) which may be general or circum-
scribed (the latter forming an intermediate stage be-
tween general hypertrophy and tumor formation) or a
well-defined tumor may result. Should the etiologic
factor prove sufficient in strength and duration, a gelatin-
ous change occurs, resulting in the socalled amyloid
degeneration. In this stage bacterial infection may
occur ; or, if the original cause proves sufficient, the
necrotic process may continue into a fatty change.
Perhaps nothing has been more deceiving to patholo-
gists generally than the conditions of vascularity and
turgidity in positions of evident malnutrition and sub-
oxidation. Analogous instances are observed in several
diverse conditions ; for instance, the vicinity of malignant
neoplasms is often very vascular and injected, the sup-
plying vessels are largely occluded by metastatic emboli
and detritus. In gout and in those rosy, full habits of
drinkers of malt liquor, sweet wine and champagne, a
general cutaneous, capillary dilation and possibly a
paresis is presented. In cardiac insufficiencies a rosy,
flushed face is not an unusual feature ; and lastly, but
not of less importance, is observed the pink or rosy skin
of the subjects of well-defined carbon monoxid poison-
ing. That these conditions, collectively, are examples
of suboxidation and not of hypernutrition, is at once
apparent. Many instances of apparent new formations
of bloodvessels are undoubtedly simply dilations of the
more minute capillary vessels because of the occlusions
of anastomosing vessels.
A marked and quite constant manifestation observed in
connection with suboxygenation of the tissues generally, is
a general peripheral capillary dilation. This is most com-
mon among the gouty, the habitual drinker, and the libertine
on the one hand, and in the modified form, in the hectic flush
of the phthisical, on the other. The characteristic appearance
is most apparent upon the face where the skin is thinner and the
capillaries are naturally more prominent, owing to the viccissi-
tudes of constant exposure. A common manifestation of severe
protracted suboxidation is characterized by a marked capillary
dilation in the choroid, which we generally refer to as " blood-
shot eyes." That the latter manifestation is occasionally due to
asuboxidation of nuclein deficiencj', from an interference with
their synthesis, or to their exhaustion, is attested by its causa-
tion, namely, by all violently acting causes of hyperacidity, as
cold, fatigue, sexual excesses, and especially as a result of beer
and liquor sprees. Another cause ol peripheral capillary dila-
tion, is the local eflect of flesh bruises. Tliese traumatisms are
well known to represent a localized area of cellular acidity,
and as the acidity lias been shown to interfere with, or arrest
cellular oxidation, the resulting localized capillary dilations
are explained. Another form of localized capillary dilations
are those which come in the absence of traumatism, in constant
relation to certain dyspepsias, which I believe comes under the
same category. As some of the malignant neoplasms are sur-
roundetl by a marked dilation of the connecting vessels, some
have assumed it to be evidence of an accelerated anabolism.
This is not the case, however, and when increased blood-supply
is shown to be present, I am convinced that it is compensatory
to the suboxygenation, due, as suggested to a dehoiency of
nucleins, vascular obstructions, etc. The characteristic super-
ficial capillary dilation of gout, alcoholics (especially acid varie-
ties, as Irom wines and beer) which have been so long assumed
to be plethoras, we know now from blood examinations are
not ; such conditions never exist. Therefore, the socalled
plethoric condition of gout and of drinkers of wine and beer
I believe to be due entirely to the compensatory vascular dila-
tion, of a tissue suboxidation together with the coexisting
hyperarterial pressure, which may play some part.
It is observed that the direct effect of the ingestion of
any hyperoxidizable food or chemical, as alcohol, is a
prompt dilation of the peripheral capillaries which I
believe to be due to the suboxidation of the tissues so
caused. We have good evidence that cancer-formation
is an acid process, characterized by suboxidation, and
according to the above [)hysiologic law, we should
expect to observe a dilation of its supplying vessels ap-
proximately in relation to its degree of suboxygenation.
[To be concluded.]
First Olrl Baby in a Century.— It is claimed that a baby
jflrl which was born recently in the Becker lamily of St. Louis,
IS the first female birth that has occurred in tliat family in over
a century.
822 American Hkdicinb]
NASOPHARYNGEAL TUMOR
[NOVEMBEB 22, 1902
A NASOPHARYNGEAL TUMOR, WITH EXHIBITION
OF PATIENT.'
BY
G. HUDSON MAKUEN, M.D.,
of Philadelphia.
Profcsgorof DefecUof Speech In the Philadelphia Polyclinic; I-.aryn-
gologlst to St. Mary's Hospital and the Douglass
Memorial Hofepltal.
The patient, C. F. B., a pharmaceutical student, presented
himself at my clinic about a year ago with the following his-
tory : Difficult nasal respiration, beginning more than two
years previously and growing progressively worse; a right
unilateral catarrhal otitis media with slight deafness, also of
two years' standing, sore throat and headaches. Operations
had been performed, one of them under ether at the German Hos-
pital, in which several masses of tough fibrous tissue had been
removed by means of tliecold wire snare. Copious hemorrhages
accompanied each operation, and large wires were broken in
the ecraseur. For these details I am indebted to Dr. EUwood
Matlack, of Philadelphia, wlio performed the operations. An
examination of the patient (a year ago and two years after the
operations described above) revealed the following conditions:
The left nostril was entirely impervious to air, even after a free
local application of a 5% solution of cocain. A small probe
could be inserted, however, underneath and along the inner
aspect of a large tumor occupying the posterior third of the
nostril and appearing to extend into the vault of the pharynx.
The right nostril was also partially occluded, its lumen being
encroached upon by the convexity of the septum, which
appeared to be pushed over by the tumor in the opposite nos-
tril. There were also some adhesions between the septum and
the middle turbinal bone in the right nostril, such as we some-
times find after neglected intranasal operations. No history,
however, of any operative procedures in this nostril could be
elicited. There was practically no nasal respiration through
either nostril, but with great effort some air could be inspired
through the right nostril, and it was with difficulty that the
patient could blow his nose. The rhinoscopic mirror gave a
picture of a tumor filling the vault of the pharynx and appar-
ently accommodating itself to its shape, it being longer in its
lateral than in its anteropo.sterior diameter. Digital examina-
tion revealed the fact that the tumor was attached to the vault
of thepharnyx in the region of the pharyngeal tonsil.
A small section of the growth was secured through
the anterior nares and submitted to Dr. David Riesraan
for histologic examination. He pronounced it an ede-
matous fibroraatous growth crossed by stratified epi-
thelium. Soon after, it was my pleasure to show the
patient to several members of this society. Dr. J. A.
Stucky, of Lexington, Ky., saw him with me in my
oflice, and said he thought it was a fibroma, that he had
seen one or two like it and that I would have great
trouble in removing it. Dr. Walter J. Freeman also
examined the patient, and pronounced the tumor a
fibroma or a fibrous polyp springing from the ethmoid
region, and he thought it could be cut off with a cold
Wire snare and removed either through the anterior
nares or posteriorly by way of the pharynx. He men-
tioned also the possibility of its having undergone sar-
comatous changes and the strong probability of its
I becoming malignant. Dr. George C. Stout, my colleague
at St. Mary's Hospital, then saw the patient with me,
and we decided to try to remove the growth under gen-
eral anesthesia.
On July 7 of last year the patient was etherized and the left
nasal fossa cocainized, in order to give as much space as pos-
sible for the necessary manipulations. A No. 10 silver wire
was payed back along the tioor of the nostril, underneath the
tumor, until the loop appeared in the pharynx below the
border of the velum palati, and then with the index fingers an
attempt was made to engage it behind the tumor in the vault of
the pharynx.
So far down was its attachment, however, that only a com-
paratively slight portion could be grasped within the loop, but
having engaged as much as possible we succeeded, by means
of the Parwell snare, in cutting off a portion about the size of a
large almond.
Although the operation was done with great deliberation,
considerable hemorrhage supervened, but not so great as upon
the former occasion when a small section of the nasal aspect of
the tumor was secured by means of the knife.
The pharyngeal section was referred for examination
to Professor W. M. L. Coplin, of Jeff'erson Medical
College, and he gave the following diagnosis :
>Read before the American Laryngological, Rhlnologlcal and
Otological Society.
Cancerous processes can be excluded. The question of sar-
coma has been considered, but the extensive arterial change,
the marked inflammatory infiltration, the areas of necrosis,
while occasionally observed in sarcoma are here so conspicu-
ous that we have not been inclined to regard the growth aa
sarcomatous.
Although there is a superficial resemblance to tuberculosis
we think this process can beexcluded. The structure is histo-
logically granulomatous and might be of luetic origin. Aside
from the distinct inflammatory nature of the process the micro-
scope reveals nothing characteristic.
The patient has been subjected to two operations
under general anesthesia in addition to numerous lesser
ones under local anesthesia, and he has, therefore,
appeared to lose interest in his case, and to be loath to
submit to further operative procedures, and to be indif-
ferent to treatment of any sort. Nearly a year has
elapsed since the last operation, and not only has noth-
ing been done in the interim, but I have seen the patient
only a few times. Little if any change has taken place
in the general appearance of the growth, and aside from
difiicult nasal respiration with a sensation of fulness in
the orbital and frontal regions, and slight headaches, he
has been quite comfortable. During the year, however,
there has appeared some infiltration of the tissues of the
face, about the left side of the nase, extending down
into the buccinator muscle. So great has been this
tumefaction in the left cheek, and there being also some
signs of fluctuation, at the suggestion of Dr. Howard
Dehoney, who chanced to be in my office at the time,
acupuncture was made through the mucous membrane.
The needle passed with difliiculty as if into a tough
leathery substance. It should be added that this swell-
ing in the. cheek undergoes marked changes in size.
A few weeks ago Dr. D. Braden Kyle and I transll-
lumined his face with negative results so far as the
antral and frontal sinuses were concerned, but the
shadow of the tumor in the nasal fossse was fairly
well outlined. I may add that there is no specific his-
tory, and antisyphilitic remedies have been given with
no benefit whatever.
Dr. Louis F. Love reports that the ophthalmoscope
reveals no gross changes. This, in brief, is the report of
the case up to the present time, and it is made for the
purpose of eliciting discussion and especially opinions as
to its future treatment.
REMARKS ON VERBAL AMNESIA, APROPOS OF A
CASE OF SENSORY APHASIA.'
i BY
ALFRED GORDON, M.D.,
of Philadelphia.
Instructor in Neurology, Jefferson Medical College.
Mrs. M. B., aged 51, came to the neurologic clinic of the
Jefferson College Hospital, July 21, 1901, with the following
history: About two years ago, while going upstairs to call
somebody, she suddenly lost her speech. Although phonation
was present, her voice became thick, so that it was impossible
to understand her. When she was put to bed the family noticed
that she lost to some extent the power in her right hand,
although voluntary movements of the whole right upper limb
were preserved. At tiie same time the lower part of the face
was drawn to the right. The mentality of the patient became
so low that when at first spoken to she could not understand.
During two months the condition remained unchanged, and
only at the beginning of the third month did she tiegin to
improve. The patient's previous history is negative. No infec-
tion, no alcoholism, no miscarriages. Out of three children
one died from tuberculous meningitis.
Personal /fj'.storj/. —The patient appears to be poorly nour-
ished and of a quiet temperament. Her mental condition is
below normal ; she does not understand well when first
addressed. Her face is slightly drawn to the left.
Upper Extremities. — With the dynamometer the power of
the rignt hand shows 40, the left 45. Sensations: Touch and
T° are normal, but there is a distinct hypalgesia in the right
hand in comparison with the left. Stereognosis for size and
shape of objects, also for space, is normal. Lower extremities
are normal. Examination of the heart shows the first sound
' Read, and patient exhibited, before the Philadelphia Neurological
Society, December 23, 1901.
November 22, 1902]
VERBAL AMNESIA
lAMSBICAS MEDICINS 823
at the apex rough and prolonged. At the aortic orifice the
second sound is very much accentuated. The examination of
the peripheral arteries points to arteriosclerotic changes. The
main interest of the ca.se lies in the speech.
Examiniilion for Motor Aphasia. — If the main symptom of
motor aphasia consists of a complete loss or considerable reduc-
tion of the number of words that a patient is capable of pro-
nouncing, this is not the disease our jiatient is suffering
from. On a.sking the patient to recite familiar names or objects
she does it perfectly well so far as the pronunciation is con-
cerned, but she has some difficulty in naming special words.
Being asked to tell what she had for dinner, she says tirst,
"Meat;" but would not go on because she tried to remember
the name of the dish she had before the meat. After several
vain efforts on her part we reminded her of soup. She imme-
diately says, "Yes, soup; " and went on to mention the vege-
tables, but tried to recall the name of the dessert ; after a few
efforts she said, "Stewed fruit." When she is told to repeat
words spoken before her she does it very easily, even the long-
est and most complex words. The articulation of the words is
absolutely perfect. Although articulation is normal, the spon-
taneity of speech is somewhat interfered with, because she
cannot remember exactly the names of the words she wishes
to use. As the spontaneity of the speech was somewhat imper-
fect, but the repetition of words and their articulation correct,
we excluded the possibility of a cortical motor aphasia, but
began to consider whether a subcortical motor aphasia, a form
described by Dejerine, Lichtheim and others was present in this
case. According to these authors there is difficulty in pro-
nouncing words loud but there is no sensory disturbance of
speech. Further examination of the patient proved this was
not the case.
Examination for sensory aphasia was made.
In order to empha-size the differential diagnosis of
this case a few definitions are quoted, as follows :
Word-deafness. — In a lesion of this center a patient is
incapable of understanding words uttered before hiin.
In slight cases of auditory aphasia only some words may
not be understood.
Word-blindness. — This form of aphasia is to vision
what word-deafness is to hearing. The patient affected
with word-blindness will not be able to understand the
letters that he attempts to read ; he may recognize the
contour of the letters and be able to compare two hand-
writings, but he is incapable of understanding the mean-
ing, he cannot read (alexia). He sees the form of the
letters but does not understand the idea expressed in
them. Exactly as in word-deafness there are cases in
which only a few words will be read or only some
syllables. We must remember that in alexia the acuity
of vision is, as a rule, normal.
Agraphia. — In cases of motor aphasia there is usually
a right hemiplegia and the study of writing with the
right hand is therefore often difficult. In a slight hemi-
plegia or monoplegia it is important to study the motor
state of the hand and fingers ; otherwise the agraphia
may be attributed to a lesion of the writing center while
in reality it is caused by the paralysis of the hand. It
is only aftef we find out that the patient can accomplish
delicate acts with his hand, like buttoning, sewing, etc.,
that he can be considered agraphic, if his writing is
deficient. It is also important to investigate three
forms of writing : («) Spontaneous, (6) unJer dictation,
and {<•) copying. All this should be done in the exam-
iner's presence. Agraphia may be absolute, or only in
its spontaneous form or only in its copying form. Writ-
ing under dictation is very often preserved, because this
act is more or less mei'hanical.
Our patient's hearing is good and the interpretation of
words and phrases is normal ; when she is told to touch objects,
to perform a certain act, she <lots it correctly. She is, therefore,
not affected with word-deafness.
She can read, but with dirtieulty. She does not read as
fluently as she used to l)efore her pre.sent illness. Some words
she mistakes, l)Ut not all. The words she does read she under-
stands. When her mistakes in reading are corrected she
repeats the proper words and iiiiderstands them. The mistakes
are made not liecause she has any difficulty in articulating the
worils, but because she does not recognize them. Not only
some words are mistaken, but also some letters. She is, there-
fore, affecte<l with paralexia and not with true alexia.
(Jur patient, it is true, is sliglitly monoplegic, but she can
accomplish the most delicate and minute acts with her right
hand; the motility is, therefore, preserved, and still her writ-
ing has no resemblance to that previous to her illness. The act
appears difficult to her. When she is asked to write she will
say that she cannot, but when one insists she will do it. The
power in handling the pen is complete. She writes spontane-
ously, under dictation and can copy. The three tests give sim-
ilar results : she will substitute some letters, b\it some words
will be correct. Although the copying gives better results than
other forms of writing she will, nevertheless, sometimes omit
letters.and misinterpret them, other letters will be placed by
her in the middle of the word, so that the word will be with-
out meaning. She has more difficulty in writing unusual
words than familiar ones. She will, therefore, present par-
agraphia for some words, but she is not affected with a true
agraphia. (See illustrations.)
sPo>vtoL.T\.&ou.s WFnunq.
coPy'iTvig OF PRiuted Letters.
Dictabion/.
Naming. — Very often the patient makes mistakes in naming
objects or persona, although she has a perfect knowledge or
what she says and she knows that she is mistaken. She often
calls one daughter by the name of the other; she will call for a
fork instead of a knife. During our investigation in this direc-
tion we noticed that so soon as she pronounces the wrong word
she will immediately make an effort to correct herself, give
other names, again correct them, etc., until she gets the right
name, but very frequently she will fail to find it; if reminded
she will immediately recognize and repeat it, but if for the
.sake of experiment we give a wrong name, she will not accept
it until we give the proper word. She does the same in writ-
ing ; she wUl stop writing for want of the right word. There
is evidently some disturbance in naming. To sum up, the
patient presents a right monoplegia and facial palsy (neither
very pronounced) and particularly a sensory aphasia, which is
not complete. There is a paragraphia, a paralexia and diffi-
culty in naming, but absence of word-deafness. Two speech
centers are, therefore, partially involved — those for writing and
reading; the disturbance of these two sensory functions being
accompanied by a disturbance in naming. I would say that
there is present a verbal amnesia, to use the adopted term.
When we attempt to analyze the conception of mem-
ory we certainly meet the greatest difficulties. There Is
no doubt that the four known speech centers play a
great role in maintaining the normal condition of mem-
ory, but in reality this psychic function is more compli-
cate<l than it may appear. It is probable that a great
number of cells and neurons disseminated in various
regions of the brain take part in displaying various acts
of memory. Without entering into lengthy arguments
concerning various theories of memory, we must cer-
tainly admit that from a general standpoint there are
two factors of which memory is composed, one serves to
fix and preserve, the other to recall and name psychic
images. Speaking in a figurative sense we will say that
one is a static, the other a dynamic memory. That the
fixe<l memory is pr&sent in our patient we know from
the fact that she understands what we want her to say,
beciiuse she repeats immediately after us, but that the
recalling or naming memory is missing is evident. The
conception of the object is intact, but the couching of the
idea is lost. There is certainly a defect in the association
of the idea with its verbal sign which should express it.
Broadbent was the first observer who supposed that there
824 AHEBIOAN MESICINB]
ADENOCAECINOMA OF THE MALE BREAST
[November 22, 1902
Is such a thing as a naming center, although the terra
verbal amnesia, which is practically the same, was
known long before. Bouillaud, Ijordat, Fabret, SanderSj
Charcot, speak of it as of a symptom of some aphasias,
but Kussmaul was the first who considered it as a sepa-
rate form of aphasia. A number of ca.ses were reported
in which this symptom was sometimes present and
sometimes absent. Notwithstanding this fact, the
question of a special naming center is still undecided.
The opponents believe that the . trouble in naming
depends upon and can be explained by defects in other
speech centers. It is true that a greater number of cases
of sensory aphasias associated with verbal amnesia are
on record than cases of pure amnesic apha.sia. If it is
perhaps easy to explain the first, how can we explain
the cases of pure verbal amnesia? In some cases the
inability to name is so striking in comparison with the
other sensory disturbances of the speech that we are
at a loss to see how insignificant involvements of the
speech could produce marked mnemonic trouble unless
we suppose a special center for the verbal amnesia. Such
cases were reported by Bateman, Broadbent, Bergmann,
Bastian, Laplace, and James Ross. The cases of Ch.
Mills, G. M. Hammond, E. E. Jack, and Thomas are
certainly striking in regard to the point in question.
Mills' and Thomas' cases show a new lesion in the cor-
tex but no involvement of any of the four known
aphasic centers. My case to some extent resembles that
of Pitres. The partial loss of memory for words inter-
feres even with correct writing and correct reading. It
is not the idea but the verbal image that is wanting.
When she cannot find the word that she is trying to
remember it is sufficient to remind her of even one
syllable, when the whole word is immediately con-
structed in her mind, and then the sensory and motor
images appear perfect. Whatever its localization may
be the existence of verbal amnesia as a clinical entity is
very suggestive. As to the nature of the lesion in our
patient, it is probably due to a softening, as shown by
the condition of the patient's arteries and aorta.
ADENOCARCINOMA OF THE MALE BREAST.'
FRANK C. HAMMOND,
of Philadelphia.
M.D.,
Malignancy of the male breast, though not of frequent
occurrence, is sufficiently rare to render a report of cases
interesting. Warfield ' has made a careful and exhaust-
ive study of the subject and of its literature. He found
that up to 1890 Schuchardt had collected from every
source and tabulated 472 cases of carcinoma of the male
breast. Since 1890 Warfield has found but 32 cases in
literature, to which he adds 5, reported for the first
time.
The majority of the cases occurred between the age
of 40 and 70, the longest period the tumor was noted
was 35 years, and the shortest 2 weeks. The left breast,
according to some statistics, is more often the seat of
the tumor, while others give the right breast. Pain was
not a prominent symptom. Ulceration occurred in 13
of the 87 collected by Warfield, and in 70 of 219 of
Schuchardt's cases. Retraction of the nipple was noted
in 12 instances. Discharge from the nipple occurred in
a very small proportion. The axillary glands were
enlarged and palpable in 29 of the 37 cases.
Of the series of 37 cases, 34 patients were operated
upon, 2 refused operation, and in 1 the disease was too
extensive. One patient failed to recover from the imme-
diate effects of the operation, dying a few days after
removal of the tumor, from "hypostatic congestion of
the lungs."
1 Read by title, Philadelphia County Medical Society, May 28, 1902.
= Bulletin of the Johns Hopljlns Hospital, October, 1901.
In only one instance was a family history of carci-
noma obtainable. In many of the cases trauma was
frequently noted. Recurrence has taken place in the
incision, also in the viscera.
I desire to report two cases for the first time, one
occurring in my own practice, the other being under the
care of Dr. J. M. Fisher, to whom I am indebted for the
notes of the case :
Case I. — A. M., German, age 75, an inmate of the Odd Fel-
lows' Home of Pennsylvania. During August, 1!MX), he felt an
" uneasiness" in the left breast, but did uot seelc medical aid
until two months later, when the pain was quite severe and a
lump had formed, which had been present about 10 days
previous to the time 1 first saw him, whicli was October 24,
1900. He was at that time under the care Dr. F. S. Bower, one
of the attending physicians of the Home. A diagnosis of carci-
noma was made and operation advised, which was performed
two days later. There was no history of trauma, nor of family
malignancy. Neither was there a discharge from the nipple.
Pain was the prominent symptom.
Tlie operation consisted of an amputation of the left breast
by an elliptical incision. The fascia over the pectoral muscle
was removed. There was no enlargement of the axillary
glands.
Dr. Bower (who had the subsequent care of the patient)
tells me that about 48 hours after tne operation the patient
slipped his hand in between the dressings and the cliest, in
order to relieve, by scratching, the pruritus in the incision.
Through the violent efforts in so doing all the sutures were
pulled out. He washed the wound with a bichlorid solution
and approximated the edges with adhesive strips. The wound
promptly healed.
This patient died several months ago from apoplexy.
I am indebted to Dr. Jesse W. Hirst for the following
pathologic report :
Pathologic Report. — The specimen consists of an elliptical
portion of skin, with subjoined tissue, 11.5 cm. by 6.5 cm. by
4 cm. In the center of the area is located a conical elevation 4 cm.
in diameter and 2.5 cm. above the general surface level. On this
is a nipple, located somewhat exceutrically. The latter is
5 mm. in diameter and 3 mm. above the surrounding tissue. It
is also surrounded by a furrow 2 mm. in depth. There is a dis-
colored area surrounding the nipple, extending about 1.5 cm. in
all directions. A lew slight abrasions appear on one side of the
elevation (due to scrubbing prior to operating).
The portion of skin over the tumor Is somewhat " smoothed
out." A few hairs are present just without the discolored area.
The skin is fixed to the underlying tumor through about one-
half its extent. Under the skin, and surrounding the tumor
mass, is a collection of fat and subcutaneous connective tissue,
but immediately beneath the tumor there is little of this fatty
tissue, and it appears to be more intimately attached to the
tumor substance.
Histologic Examination. — Specimen was fixed in formalin.
The sections were cut entirely through the tumor mass. The
outer surface is covered with skin, the epidermal layer of
which is thickened, while the papillas of the corlum extend
far up into the former. The latter are also quite numerous.
Round cells are demonstrable in the epidermis, which become
more numerous in the derma and subdermal tissue near the
tumor substance, particularly about the bloodvessels. Beneath
the corium gland tubules begin to appear. They are at first
empty, enlarged and lined by only one layer of cuboidal epi-
thelium. Deeper in the tumor the arrangement in tubules
cannot be clearly made out. What appear to be gland lumina
is filled by masses of epltheliod cells. These cells are also seen
in finger-like processes, reaching out in all directions into the
surrounding tissue. The separating bands of connective tissue
are less evident toward the deeper parts of the growth. These
tumor processes consist of round or oval and irregularly shaped
columnar cells, with deeply staining oval nuclei. Some of the
nuclei are distinctly granular. They vary greatly in size.
Some mitotic figures are seen, but they are not numerous.
The cell bodies stain quite deeply with eosin. They stain uni-
formly, while the nuclei vary considerably in their staining
properties. Small, round cells are numerous and general in
their distribution. Polymorphonuclear leukocytes are occa-
sionally seen in the connective tissue and around the blood-
vessels. Portions of the newgrowth can be traced to the
extreme inner border of the specimen or line of excision.
Diagnosis. — Adenocarcinoma of the mammary gland.
Case II. — A professional man, over 50 years of age, oper-
ated upon by Dr. Fisher. There was a lump in the right breast,
accompanied by slight pain. No axillary glandular enlarge-
ment. The breast was excised, on a suspicion that malignancy
was present. This patient is still living and in perfect health.
Pathologic Report. — Specimen: Tumor of right mamma.
Specimen consists of a piece of tissue irregularly globular in
shape, and measuring 3 cm. by 2 cm. by 2 cm. The surface is
ragged. Approximately one-half of the specimen is composed
of what appears to be adipose tissue. This part is soft and
spongy. The remainder of the specimen is soft and firm and
NOVEMBER 22, 1«021
PARAFFIN INJECTIONS IN SADDLE-NOSE
AMERICAN MEDICINB 825
slightly resistant on incision. Specimen was received in 909i)
alcohol ; hardening and dehydration were continued in alcohol,
after which the mass was infiltrated with and embedded in
paraffin, sectioned and stained with hematoxylin, picric acid
and by van Gieson's method, also with borax carmin and piciro-
nigrosin.
HistologicaUy the sections consist of a scanty reticulum of
connective tissue, in which are groups of qells possessing the
morphologic tissue and tinctorial characters of epithelium. In
one part of the section the connective tissue is quite dense and
abundant and the cellular elements are scanty. In another part
•of the specimen there is a more delicate reticulum, in which
are numerous nests of polymorphous, rather large cells. The
arrangement of the connective tissue stroma is not uniform,
leaving the nests of irregular shape. One margin of the section
is composed of adipose tissue, otherwise no normal tissue is
apparent.
Diagnosis and Remarks.— The neoplasm is clearly a glands
ular carcinoma; though not rich in stroma it might be termed
a scirrhus. It is fairly circumscribed and with but little evi-
dence of peripheral infiltration.
A MODIFICATION OF GERSUNY'S METHOD OF PAR-
AFFIN INJECTIONS IN SOCALLED SADDLE-NOSE,
TO PREVENT DISTURBANCE OF MUSCULAR
ACTION OF THE NOSE.
BY
FRANCIS ALTER, M.D.,
of Toledo, Ohio.
Apropos of the now all-prevailing methods of cor-
recting nasal deformities, especially "saddle-nose," by
injections of paraffin, I wish to call attention to a disturb-
ing element in a case of mine which may militate against
complete success in these cases, introducing as it does a
complication which, so far as I know, has hitherto been
unmentioned. I have reference to a paralysis of the
muscular action of the wings of the nose resulting in
imi)eded nasal respiration.
The current of air rushing into and through the nose
carries with it an Inherent tendency to draw the ate
sei)talward ; this, however, in a normal condition is
counteracted by the action of the dilators of the ate nasi,
viz., the dilators nares posterior and anterior, pyra-
midalis na.sil, and a few fibers of the levator labli
.suiwrlorls aheque nasi.
The modus operandi of the suspension of action of
these muscles by this operation is by compression, the
presence of the paraffin interfering mechanically with
free muscular contraction and relaxation, resulting in a
collapse or inward drawing of the wings of the nose dur-
ing inspiration. This is a disturbing factor of no little
moment and this result must be reckoned with \^henever
injections of [)araffln are made.
My patient suffered greatly from this interference with
nasal respiration, changing him from a natural nasal-
breather to a mouth-breather with the distressing accom-
paniments. We succeetled in correcting the condition by
<xsecting the inner posterior lateral portions of the ate
of the nose.
It is our belief that this condition can be in a great
mea.sure prevented by firmly compressing the wings of
the nose by an assistant placing a thumb in each nostril,
making counter-pressure on the outside with the index
fingers, this j)ressure being maintained until the nose
has been molded into its proper shape.
SPECIAL ARTICLES
Child liabor In Alabama.— It is announced that every
effort will be made to secure the passage by the General
Assembly this winter of a measure restricting child labor
throughout tlie State. The proposed law excludes from mills
and factories all children under 12, unless a widowed mother
or invalid father is wholly dependent upon their labor. It
requires millmen to keep on file certificates as to the age of
children employed ; provides tliat no child under 10 shall be
employed for night duty; that no cJiild shall be emjiloyed
unless he ('an road and write his name and simple Knglish sen-
tences, and that no child between 12 and 14 years shall be
employed unless he attends school for at least 12 weeks during
the year. The penalty for violation is a fine not exceeding if.')00.
VENEREAL DISEASE AMONG THE FILIPINOS.
BY
E. F. ROBINSON, M.D.,
of Kansas City, Mo.
In general, it may be said, the native Filipino is freer from
venereal diseases than any of our tropical races. This statement
carries with it the presumption of morality— and judged from
an Eastern standard the Filipino leads a morally virtuous life.
We, with our advanced standard of Western morals, must not
judge him harshly, nor, indeed, for our own peace of mind must
we compare his condition in this respect with our own. For,
notwithstanding his open breach of the moral code, there is in
the Malay capital less venereal disease (as evidenced by the
record of our own army) than in any Christian city of a like
population and business activity.
The reason for this freedom from venereal disease can be
traced to many causes. In the first place, the race's isolated
island position. With the possible exception of its one great
city (Manila) the Philippines are off the route of national travel.
Protected by the policy of national isolation, this country when
under the blight of Spanish rule has avoided the crusades and
admixtures of foreign races, so prolific and causal a factor in
disseminating and producing venereal disease.
Again, the family tie is strong in the Filipino. Even cohab-
itation with the Spanish and slight foreign element in the
islands has not disturbed or shaken this influence. To his
partner " in the flesh" the native is most constant, with or
without the bond of ceremonious marriage, and the Spaniard
has adopted these native customs. At little cost he sets up his
" casa" or domicile, with the consent (although without the
formal sanction) of the Church. The system is so general and
so easy that the incentive to outside venereal excesses is
removed, and consequently an important factor in the produc-
tion of venereal disease does not exist. Although monogamous
cohabitation is the rule, marriage among the lower classes is
not common. This is chiefly due to the fact that the average
native cannot afford to get married. The process costs too
much, and beside to him seems a useless formality. As is
doubtless generally known, the country is dominated abso-
lutely by the Church. It is priest-ridden. The Church holds
all the arable lands in fief and leases out small holdings to the
natives. It is with difficulty that the peasant can meet the
demands of the clergy and furnish sufficient material returns to
support his family. He cannot afford to pay the exorbitant fee
for a formal marriage, so he goes without it. But he is constant,
and the same rules of family union are maintained, even with-
out the pale of the law and the Church.
The lack of alcoholic indulgence is another most important
factor in maintaining this comparative immunity from vene-
real disea.se.- Among the natives there is but little drunkenness.
They do not drink whisky and the stronger alcoholic liquors.
They do not care for beer ; the great amount shipped and the
little brewed in the country being consumed entirely by the *
foreign population. Claret and the heavier wines of the Spaniard •
are used only by the upper classes, and by them in great mod-
eration. " Bino" (a distilled product of the nipa palm) is the
native beverage. This resembles very nearly " anisette " cordial.
While used generally it is partaken of in great moderation. It
is only the American who takes enough of it to become intox-
icated. I have never seen a drunken Filipino during all my
residence in the islands.
The extreme cleanliness of the people is another important
factor in the immunity from venereal disease. Bathing, and wash-
ing clothing are their chief occupations. Fortunately they wear
but little, but this is scrupulously clean. White is worn uni-
versally. The poorest peon has his daily bath and dons his clean
clothing as regularly as the landed owner. However lax they
may be in regard to public hygiene they are personally cleanly.
It is not an infrequent sight to see men, women, and children,
practically naked, bathing together, yet with no more impro-
priety than a similar group at Atlantic City or Newport.
The people are modest, altliough clothing is scant and but
826 Amkbioan Mediolne?
VENEREAL DISEASE AMONG FILIPINOS
INOVKMBEB 22, 1902
little worn. While men and women may go about the streets
half naked, and think nothing of answering the calls of nature
by simply stepping to the side of the road, they are neither
lewd nor obscene in manner, and it is rare indeed that they
expose themselves in public. In fact, so very modest are they
and so reluctant to admit to the "medico Americano" their
venereal disea.se that information on this subject is often dif-
ficult to obtain. However, from several reputable Filipino and
Spanish physicians and from the " medico " in charge of San
Lazero Hospital, my own observations were verified, that the
natives are unusually free from this disease.
Manila has a population of between 300,000 and 400,000 {an
exact census report is impossible to obtain). Like all seaboard
cities venereal disease prevails, but to a less extent than in
other kindred cities. It is a sad but veritable fact, and one by
no means complimentary to our civilization, that prior to the
advent of the American army the disease was almost unknown
outside of the Malay capital.
The principal venereal disease is the chancroid, with its
attendant bubo. This, in a measure, may be explained by the
great tendency in a tropical country for any slight abrasion or
wound to suppurate. From the great amount of vegetable and
animal life in the dust of the streets and houses, infection may
be said to be veritably " in the air." In fact, to such an extent
is this presence of germ life manifest that even in the labora-
tories it was found difficult and often impossible to make " plate
cultures," so continually did contamination occur from the
atmosphere. The chancroid or infected abrasion is followed
almost invariably by the unilateral (and often bilateral) bubo.
Idiopathic abscesses are common (explained probably by this
widespread tendency to infection). Bubon d'embl6e frequently
results. The natives rarely open these bubos, but allow them
to rupture, a large poultice of macerated leaves (usually guava
leaves) is applied, and kept moist until the abscess breaks.
Then simply a few layers of wet leaves are applied so long as
the discharge continues. A method of treatment by no means
without its virtue, for the frequent application of these cooling
leaves, with their slightly astringent properties, is not only
most cleanly but greatly favors drainage.
Gonorrhea was decidedly uncommon among the native
population prior to the advent of the American soldier. But
even then its prevalence fell far below that of similar cities of
the Western continent.
Syphilis, while a well-recognized disease in the islands, is by
no means so common as in many of our own seaboard towns.
It is most carefully differentiated, however, by the native and
Spanish physicians. Leprosy is the disease with which it is
most likely to be confounded.
In the outskirts of the San Sebastian district, well isolated
and protected by a great crumbling wall, is located San Lazero,
the great leper hospital. One-half of the structure is given up
to the treatment of venereal disease, but only the worst sorts
are admitted— extensive suppurating bubos, phagedenic ulcers
and syphilitic cases. The individuals treated here are princi-
pally prostitutes— the " Margaretas " of the street, and a few
men suffering with tertiary syphilis. Upon my last visit to the
hospital, in May, 1900, there were only between 30 and 40
venereal cases.
As in all Oriental countries, the treatment of disease in
general, and syphilis in particular, has reached by no means
the degree of efficiency it has on the Western continent.
Although the Oriental is reasonably well advanced along the
lines of diagnosis, he is in a great measure helpless in checking
this disease. Fortunately it is not general. As an example of
this and also as a demonstration and lesson in contentment, the
remarks of an inmate in the leper hospital are remembered. He
was a little, misshapen dwarf, frightfully scarred by leprosy.
His fingers and toes were gone, his limbs atrophied and his
face so distorted that he could scarcely speak. As I was
examining a case of tertiary syphilis, with gummas of the
extremity and ulceration of the face and throat, he said in
Spanish with a ghoulish laugh as he pointed with the stump of
his right hand at his kindred unfortunate, " Lepra mucho beno-
syphilitica mucho malo, mucho malo " (leprosy very good; syph-
ilis very bad, very bad), and still laughing and evidently con-
gratulating himself upon his own good fortune, he walked away
No better Idea of the freedom from venereal disease among
the inhabitants of the Philippines can be had than a glance at
the report of the Surgeon-General of the Army for the year end-
ing June .10, 1900, for the army reflects the condition of the
community in this particular as does no other class of men;
and in no other way are statistics so correct or easily secured.
From this report it is seen at a glance that the percentage of
venereal disea.se of all kinds in the army in the Philippines is
much less than in either Cuba or Porto Rico, and considerably
under that of the troops in the United States itself.
Page 278, Bobgeon-General's Rkpoet, 1900.
Army.
Cuba.
Porto
KIco.
Philip-
pines.
Untted
States.
13.98
80.23
38.79
16..56
87.92
44.89
30.59
170.64
85 06
11.74
60.39
44.6.5
13.49
87.29
26..57
Total venereal
183.00
148.87
286.29
116.78
127.35
While the above report gives relatively the percentage of
venereal diseases, it is by no means absolute, as many cases
are concealed and only the more severe appear on hospital
reports. However, the conditions in this particular are uni-
versal in their application, and are not important in a compara-
tive study. A very correct idea of the relative prevalence of
the various forms of venereal disease present in the islands also
can be had by a glance at the reports of the First Reserve Hos-
pital in Manila. At this great Manila hospital in U years there
were treated 18,596 cases of disease. Of these cases 1,245 were of
venereal disease, making but 6.6% patients sick enough to be
admitted to the hospital for treatment. Of these 714 were cases of
chancroids, and of this number over 70% developed unilateral
or bilateral bubos.
Gonorrhea and its associated diseases (epididymitis and
orchitis) were very unusual, there being but 278 cases admitted
(22%); 109of these were complicated by gonorrheal bubos. This
very small number, it is true, can partially be explained by the
fact that gonorrhea per ae is not often considered a liospital dis-
ease, but the fact remains that there was a very small number
of such cases among the troops, and prior to the advent of
the army the disease was very rare indeed among the natives.
There were but 115 cases of syphilis treated— only 9% of the
venereal cases in hospital. Of these, 102 were secondary and
13 tertiary syphilis. The majority of these cases were con-
tracted in the United States or in the seaport towns in transit,
and not from the native population. As syphilis is the only
disease demanding discharge from the army on surgeon's
certificate of disability, it has never gained a foothold among
our troops,- and in our far off island possessions, at least, there
is little danger of its spread. Without doubt there is danger to
health in tropical residence, but this fact remains beyond cavil,
that to our army in the Philippines, at least there is less
danger from venereal disease than at home.
Rejections of Recruits XJ. 8. Army.— The total number
of men examined for enlistment during the vear 1901 was
58,782, of whom 56,894 were white and 1,.SS8 were'colored. The
number accepted was 36,721, or 624.70 out of every thousand
examined. The ratio of accepted men was 623.93 for the white
and 647.78 for the colored. White men to the number of 86 67
and colored men to that of 69..38 per thousand declined enlist-
ment. The rate of rejection on primary examination was
289.40 among the white and 282.84 among the colored candidates,
giving a mean of 289.19. Of every thousand examined 64.76
were rejected on account of imperfect physique, including
overheight, underheight, overweight and underweight ; 41.14
for diseases of the eye ; 38.74 for diseases of the circulatory
system ; 28.51 for diseases of the genitourinary system ; 20.74 for
venereal diseases ; 19.96 for diseases of the digestive system ;
13.00 for hernia, while 10.55 were rejected as generally unfit or
undesiralile ; 6.80 were rejected as minors ; 5.48 as unclassified ;
.5.12 for di.sea.ses of the integument and subcutaneous connective
tissue ; 4.27 for diseases of the muscles, bones and joints ; 3.10
<m account of bad or doubtful character, while only 2..35 were
rejected on account of illiteracy, imperfect knowledge of the
English language, or mental insufficiency. Of every thousand
of the accepted men 884.97 were natives of the United States,
33.44 were born in Germany, 24.78 in Ireland, 12 50 in England,
10.81 in Canada, 5.28 in Sweden, 4.49 in Russia, 3.70 in Austria,
the remainder in various other countries.— [ftepor^ of the
S'lirgeon-Oeneral.}
NOVKHBBB 22, 19021
THE WORLD'S LATEST LITERATURE
(AUKBICAN MEDIOIKB 827
THE WORLD'S LATEST LITERATURE
Journal of the American Medical Association.
November 15, 190t. [Vol. xxxix. No. 20.]
1. William Beaumont, a Pioneer American Physiologist. William
OSLER.
2. Pneumonia : Its Fatality and Increasing Prevalence, with Sugges-
tions for Individual Prophylaxis. Edward F. Wblls.
3. Pneumonia: Its Incidence, Mortality, Prophylaxis. James J.
Walsh.
4. Venesection. H. B. Favill.
5. Blood-letting and Blistering In the Treatment of Pneumonia. James
Tyson.
6. The Drug Treatment of Pneumonia. A. A. Stevens.
7. Experimental Research on the Heart of the Dog, with Keference to
Cardiotomy and Cardiorrhaphy. Merrill Ricketts.
8. Address on an Kxhibit of Early ( Prior to 1860) British and American
Ophthalmic Literature. Casey A Wood.
9. Renal Insufficiency In the Tropics. James Cabell Minor.
2.— See America7i Medicine, Vol. Ill, No. 25, p. 1047.
3. — Pneumonia. — Walsh says the mortality is distinctly
on the increase in large cities. Such precautions as are insti-
tuted ■with tuberculosis should be used to prevent its spread.
Dust is a prolific source of the disease, especially in absence of
sunshine. The question of clean streets is most important,
also the furnishing and disinfection of places of public assem-
blage. Gas leakage, reaching dwelling houses through drain
pipes, keeps the lungs in a low state of congestion favorable to
infection, [h.m.]
4. — .See American Medicine, Vol. Ill, No. 25, p. 1035.
6. — See American Medicine, Vol. Ill, No. 25, p. 1060.
6.— vSee American Medicine, Vol. Ill, No. 25, p. 1060.
7. — See American Medicine, Vol. Ill, No. 25, p. 1042.
8.— See American Medicine, Vol. Ill, No. 25, p. 1052.
9. — Renal Insufficiency in tlie Tropics.*— The majority
of busy people procrastinate when the instinctive call for water
comes between meals. The soldier is forbidden to indulge it.
If he cannot drink water in safety between meals, or at meals,
or on the march, what must he drink and when must he drink,
now that the canteens are closed ? Many of the disorders fol-
lowing exhausting practice can be traced to autoinfection from
renal insulHciency. Minor gives a long list of nervous, gastro-
intestinal, cardiovascular, genitourinary and cutaneous dis-
orders, due to excessive loss of fluids by the skin with the sup-
pression of the excretion of urinary solids. In his division
hospital the only remedy tried successfully in most cases was
the systematic use of drinking water. Water should be taken
as fast or faster than it is wasted by the skin, and should be
used externally, together with sun-baths, which have a tough-
ening and contractile influence on the skin, [h.m.]
Boston Medical and Surgical Journal.
November IS, 190t. [Vol. CXLVII, No. 20.]
1. Barber-surgeons. Frederic W. Taylob.
2. TheClinicaiHtudyof48.5Case8of Nail Disease. Charles J. White.
3. A Probable Myxoflbroma of the Nose. Skabuby W. Allen.
i. tiuDshot Fatality : Source of Shooting Proved by an Examination
of Ammunition. O. J.Bbown.
2.— Diseases of the Nails. — Of 485 examples of pathologic
nails reportetl by White, 404 were due to one of six diseases—
e<!zema, 107 cases ; trauma or felon, 72 cases ; paronychia, 68
cases ; psoriasis, 67 cases ; professional dermatitis with parony-
chia, 62 cases ; and syphilis, 28 cases. The author carefully
records the symptomatology and pathologic findings in the
various diseases, and furnishes a table of the cases discussed.
His conclusions are that at the present time nobody can claim
sufficient knowledge to make a positive diagnosis without the
aid of the microscope, when one is confronted by the presenta-
tion of diseased nails, unless the skin is also attacked, for all
can see bow the same lesions appear over and over again in
almost all of the disea.ses. [a. B.C.]
8.— Probable Myxofibroma of the Nose.— Allen reports the
following interesting case: The patient was a man of .34, about
four feet in height, of healthy parentage and unusual intelli-
gence. About 22 years ago he noticed a slight protrusion of the
lower left eyelid, aud a few months later a soft, friable, easily
bleeding tumor appeared at the left nostril. From that time
the growth has been slowly progressing and has lately emerged
from the mouth, having come through the hard palate and sep-
arated the upper teeth. Owing to the obstruction there is dif-
ficulty in articulation and in eating, and until recently there
has been a continuous discharge of saliva and muco-pus, the
latter coming from the center of the mass, which has sloughed
away, leaving a cavity as large as one's fist. The left eye has
lost its sight, but not its sensitiveness ; neither eye can be com-
pletely closed because of ectropion of the lower lids. The case
is not considered operable. Seven x-ray exposures greatly
diminished the odor and the amount of discharge. The patient
refuses to permit the removal of a specimen for microscopic
examination on account of severe bleeding from the slightest
erosion, [a.b.c]
4.— Source of a Fatal Shooting Pound by Examination
of Ammunition.- Brown reports the result of a necropsy
performed on the body of a man dead of a gunshot wound
through the upper abdomen. The man, with a companion, had
been hunting when the fatality occurred. The companion told
a plausible story of accidental self-infliction of the wound. At
the necropsy a number of the small shot were removed from
the tissues, and these, together with a cartridge from the belt of
each man was sent to a chemist for examination. It was found
that one dozen of the shot thus obtained corresponded very
nearly in weight with a like number chosen from the cartridge
of the companion, and differed materially from a similar num-
ber from the other. The companion confessed that he himself
had accidentally done the killing, and had lied for fear of his
life, [a.b.c]
Medical Record.
November 15, 1901. [Vol. 62, No. 20.]
1. The Primary Newgrowths of the Pleura. Francis Delafibld.
2. The Present Status of Radiotherapy In Cutaneous Diseases and
Cancer. Charles Warrenne Allen.
3. Biogenesis and Heredity. Raymond Wallace.
4. The Criminal Responsibility of the Epileptic. John Pcnton.
1.— Primary Newgrowths of the Pleura.— The number
of cases so far recorded is small. Delafield reports four. The
tumors are endothelial, originating in the lymphatics. In the
earlier stages there is only diffuse thickening of the pleura,
and embedded In this tubules lined or filled with epithelial
cells. Later, tumors project inward, composed of basement
substance, containing tubules or irregular cavities filled with
polygonal cells. The pleura is coated with films, and contains
large quantities of serum. The history is that of pleurisy with
effusion. At first only the bloody serum and the temperature
are suspicious. Later, loss of flesh and strength suggest malig-
nant disease, [h.m.]
2. — Radiotherapy. — Allen says in substance that radio-
therapy has accomplished more in the treatment of inoperable
malignant disease than any other agent. In addition to using
it in the treatment of malignant diseases of the breast, he has
used it in a variety of skin affections, including lupus, lupus
erythematosis, inveterate psoriasis, obstinate eczema, acne,
sycosis, leprosy, xeredoma pigmentosum, favus, ringworm,
lichen, planus, etc. On the whole he has found radiotherapy
of decided aid in controlling these affections, [a.b.c]
3. — Biogenesis and Heredity. — Wallace says so far as has
ever been demonstrated the molecular composition of a living
cell and of the same cell dead is the same, although the living
cell po8ses.ses numerous qualities of assimilation, secretion,
growth, and reproduction that the dead cell does not. There is,
then, manifestly something in the molecular mass, the idio-
plasm of the cell nucleus, which is peculiar to it and which dif-
ferentiates it from all nonliving matter. There may be a
change from a lability to a stability of the molecules In the
death process, there may be a delonization, or there may be a
disappearance of polarity, [a.b.c]
4. — See American Medicine, Vol. IV, No. 18, p. 687.
New York Medical Journal.
November 8, 190t. [Vol. lxxvi, No. 19.]
1. Pathology and Treatment of Epilepsy. William H. Thomson. (To
be concluded.)
2. Suggestions Favoring a Standard Technlo In Operative Surgery.
Edward Wallace Lee.
3. The Relationship Lues Bears to the Body Politic. S. P. Collinqs.
828 Amxbioak Mboicinxj
THE WORLD'S LATEST LITERATUEE
[NOVEHBEB 22, 1902
4. Climatic and Electric Peculiarities of Colorado Favoring Recovery
In Pulmonary and Other DlseaHes. J. E. Macneill.
5. Diseases Preceding and Following the Abuse of Alcohol. T. D.
Ckothebs.
0. Subcutaneous Injections of White of Egg. Holmes C. Jackson.
2. — Standard Technlc In Operative Surgery. — Lee
believes that surgery has made suflficient advances to warrant
calling a halt and a careful sifting of existing methods. He
says the frequent changes in technic and the great diflferences
of opinion on this subject not only cause confusion and tend to
consign certain methods to oblivion but have a demoralizing
effect on the laity. We must consent to have fewer masters
aad more followers. He is in favor of a surgical congress made
up of men who are considered authorities, to take up in detail
the various methods and operations ; discuss them freely ; sift
the wheat from the chaff; establish certain rules about which
there can be no question ; and arrive at a unanimity of thought
regarding details.
3, 4. — See American Medicine, Vol. IV, No. 17, p. 647.
5.— See American Medicine, Vol. IV, No. 18, p. 687.
6.— Subcutaneous Injections of White of Egg.— The
article is a reply to one by Leigh, in which he advocates the
hypodermic injection of the white of egg in oases in which it is
impossible to administer nourishment by the mouth or by the
rectum. Jackson maintains that it is practically impossible to
obtain sterile fluid egg albumen, and that this proteid intro-
duced as such directly into the circulation is not assimilated
and therefore can supply no energy, [c.a.o.]
Medical News.
November IB, 190t. [Vol. 81, No. 20.]
1. Climatology of California. Alexander MoAdie.
2. The Climate of the Eastern Foothills of Southern California. C. A.
Sanborn.
3. The Climate of Maine. Guy Hinsdale.
4. Lacerations of the Uterine Cervix and Their Sequels. Charles H.
BnSHONG.
5. The Influence and Value of Organization. George W. Miles.
6. Uric Acid In the Blood and Tissues as a Cause for Certain Stomach
and Intestinal Troubles. Free.man F. Ward.
7. Gunshot Wounds of the Chest and Abdomen from a Military Stand-
point. Louis A. La-Garde
8. Medical Treatment of Cholellthia.sis. B. Alexander Bate.
1-— Climatology of California.— McAdie says though the
climate of different parts is full of contrasts, the temperatures,
as a rule, are moderate and equable. The prevailing easterly
drift of the air brings a supply to most of the State, neither
too hot nor too cold. The general path of storm movements
lies further north. The effect of climate is shown in the flora.
[H.M.]
2.— Climate of the Kastern Foothills of Southern Cali-
fornia.—Sanborn says this is as nearly perfect as can be found
anywhere, and patients with pulmonary lesions not far
advanced do well, especially where orange-growing and conse-
quent dampness from irrigation do not prevail. The extensive
use of commercial fertilizers has caused irritation of the respira-
tory tract. An increasing tendency toward nervousness has
been attributed to north winds, altitude and continued eye-
strain from a succession of bright days without proper pro-
tection for the eyes. Nostalgia is probably the most important
factor. [H.M.]
3.— Climate of Maine. — Hinsdale says the mean summer
temperature is 62.19° F. The cold in winter is penetrating.
There has been noteworthy decresise in deaths from pulmonary
tuberculosis in the last ten years. The interior counties afford
wonderful opportunities for camping and hunting. The finest
bass and trout fishing is found there. Hinsdale briefly describes
the various resorts, including the mineral springs, [h.m.]
6.— Uric Acid as a Cause of Stomach and Intestinal
Troubles.— Many socalled gastric neuralgias are cases of rheu-
matism or gout of the stomach or intestines. Ward believes
that part of the uric acid, if not all, is due to lack of proper
changes in the foodstuff as it passes through the cells during
absorption. After extensive trial he recommends sidonal, a
synthetic compound of quinic acid and piperazin, in 15 grain
(1 gin.) doses in water one to two hours after meals. It is to
be given only in case there is an excess of uric acid in the
urine. He also lays stress on hydrotherapeutics, emphasizing
the importance of studying the therapeutic qualities of our
native springs and providing facilities for treatment, [h.m.]
7.— Gunshot Wounds Prom a Military Standpoint.—
La-Garde says the cases of unexpected recovery from gunshot
wounds of the thorax is explained on tlie ground that struc-
tures like the heart and great vessels and the esophagus are
held by loose cellular tissue which permits displacement at the
moment of impact. The change in position is more apt to occur
when the remaining velocity of the bullet is low. In the case
of the heart we may infer that its variability in bulk from
systole to diastole explains some of the phenomenal escapes
from death. The loss of life in battle from penetrating gun-
shot wounds of the chest, inflicted by bullets of the larger
calibers, varies from 62.5% in our Civil war to 91.6% among the
French troops in the Crimea. Of 198 cases of penetrating gun-
shot wounds of the chest reported by the Surgeon-General
which occurred during the years 1898 and 1899 in Cuba, Porto
Rico and the Philippines, 55, or 27%, ended fatally. In gunshot
wounds of the abdomen, the mortality, as shown by Grant's
statistics of operative cases, amounts to 52.5% in a series of 253
cases in civil practice. Morton reports a mortality of 58.9% in
234 cases collected from various sources. Coley's statistics
show a deathrate of 53.8% in a series of 39 cases operated upon
during the first 12 hours after injury ; and a mortality of 77.2%
in 22 cases operated upon at a later period. In military practice
the deathrate in the Crimea for the French and English troops
was respectively 91.7% and 92.6%. In our Civil war the fatality
reached 90%. Of 116 cases reported by the Surgeon-General of
the Army for 1900 — cases which occurred in the Spanish-Ameri-
can war and during the Philippine insurrection— there was a
mortality of 70%. It is fair to state that of the remaining 30%,
the large majority sustained no injury of the intestines.
[a.b.c]
8. — Medical Treatment of Cholelithiasis. — Bate says
the indications are the prevention of the formation of calculi,
the control of symptoms and expulsion of the calculi when
formed. The speediest relief from pain can be had by hypo-
dermics of heroin hydrochlorids, with atropin in small doses re-
peated. Prophylaxis includes prevention of an excess of organic
acids, care of menstruating and pregnant females, prevention
of stagnation of the bile and promotion of its fluidity, the use
of antiseptics, and of lecithin or other solvents of cholesterin.
Expulsive agents may act either on the tissues of the biliary
tract or on the concretion itself. Various drugs may be used.
An ideal prescription contains lecithin as solvent for the
cholesterin, pichi to dissolve the matrix of mucus, and diosco-
rea to assist expulsion, [h.m.]
Philadelphia Medical Journal.
November 15, 1902. [Vol. x. No. 20.]
1. Some Points In the Treatment of Postoperative Abdominal Cases
John B. DEAVERand George P. MCller.
2. Aneurysm of the Ascending Portion of the Arch of the Aorta,
Manifested Early by Intractable Intercostal Neuralgia; Also
Keporl of a Case of Aneurysm of the Abdominal Aorta ; Rupture
and Death. William C. Krauss.
3. The Diet In Typhoid Fever. William Egbert Robkrt.son.
4. Foreign Bodies in the Vermiform Appendix. James Bell.
5. The Microscopic and Chemical Factors in Determining the Func-
tional Condition of the Kidney. Louis Heitz.masn.
6. A Case of Severe Dermatitis, Following the Use of Mercurial Oint-
ment. Lawrence E. Holmes.
1. — Some Points in the Treatment of Postoperative
Abdominal Cases. — Deaver and Milller detail some of the
methods which have proved of value at the German Hospital,
Philadelphia. Shock is seldom seen, but wlien it occurs is
promptly combated by the employment of strychnin, atropin,
whisky and camphorated oil, hypodermically, with hot water
bags and ;the use of hot saline solution by the bowel. Hypo-
dermoclysis is never practised, as it is cumbersome, slow and
painful. In severe shock intravenous injection may be neces-
sary, and between 2,000 cc. and 2,500 cc. (2 quarts to2J quarts) of
salt solution is given. In clean appendiceal cases, without
drainage, asafetida suppositories are given every three hours.
The use of water by the rectum has never, in their experience,
lessened the thirst. Change of posture affords more relief lor
backache than anything else. In removing gauze drainage,
boric acid should be used for irrigation, as the adhesions may
November 22, 1902]
THE WORLD'S LATEST LITERATURE
[AMERICAN MeBICINK 829
not be perfectly formed, and a peritonitis could result from
flooding the abdomen by bichlorld or carbolic solutions. Gas-
tric lavage for nausea and vomiting is very valuable. Morphin
should not be given after abdominal operations, [f.c.h.]
2. — Aneurysm of the Aorta. — Krauss reports two cases
of aneurysm, one of the ascending arch of the aorta in amale of
34 was manifested early by persistent intercostal neuralgia,
the other involving the abdominal aorta. The latter ruptured
upon the operating table, resulting in instant death. In this
case a large sacculated aneurysm was found which had eroded
I the bodies of the eleventh and twelfth thoracic and first lumbar
vertebras, [p.c.h.]
3.— The Diet in Typhoid Fever.— Robertson is firmly
convinced that patients ill with typhoid may be given quite a
[ variety of foods, not only without harm but with decided
advantage, both as to their condition during the attack, and as
a means of effecting prompt restitution of their physical vigor.
[p.c.h.]
4. — See American Medicine, Vol. IV, No. 15, p. 567.
5. — The Microscopic and Chemical Factors in Deter-
mining the Functional Condition of the Kidney.— Heitz-
mann emphasizes the importance of combining the microscopic
I and chemical examination in all specimens of urine, and of the
' value of a careful study of the pus corpuscles, [f.c.h.]
fl.— Severe Dermatitis Following the Use of Mercurial
Ointment.- Holmes details the case of a negress of 27 suffer-
ing from tenderness of the cervical lymphatic glands. Equal
parts of belladonna and mercurial ointment were ordered. On
the day following the night the ointment was first used a severe
extensive dermatitis developed. In the absence of other causes,
it was attributed to a mercurial idiosyncrasy, [f.c.h.]
ClilNICAIi MEDICINE
David Riesman A. O. J. Kbllt
EDITORIAI- COMMKNT
The Origin of the Fat iu Fatty Degeneration
of the Heart. — Until a comparatively recent date,
pathologists were in the habit of differentiating very
sharply between fatty degeneration and fatty infiltration,
defining the former as a conversion of the cell-proto-
plasm into fat, and the latter as a deposition of fat from
without into the cell ; but the researches of Rosenfeld,
Taylor, Lindemann, and others have shown that there
is, in all probability, no fundamental difference between
the two, and that even fatty degeneration is an infiltra-
tive process. In the case of fatty degeneration of the
heart, so-called — which, by the way, is a much rarer
process than is generally believed and does not of neces-
sity impair the functional power of the myocardium^
the source of the fat has been quite a mystery. The
marked histologic difference between infiltration and
what is called degeneration would suggest a difference
in the origin of the fat. In infiltration the fat is usually
found between the muscle-fibers ; in degeneration it is
contained within the fibers in the form of minute
granules. Leick and Winckler,' however, in a recent
study have shown that even in fatty degeneration of
the heart the fat comes from fat-depots elsewhere in the
body.
They fed dogs on lean horseflesh, in order to reduce the
(luantity of fat in their bodies as much as possible. The dogs
then received large quantities of meat and sheep-tallow. After
a certain time it was found that the animals had in their fat-
depots a fat very similar to that of sheep-tallow. This point
being reached, the dogs were slowly^ poisoned with phosphorus,
so as to produf« fatty degeneration of the heart and other
organs. Then the fat in the myocardium was compared with
that in the pericardum, about the kidneys, and under the skin ;
and it was found that the fat in the Cattily degenerated heart
was of practically the same composition as the mutton-tallow
with which the (logs had been fed.
As to the reasons why fat-droplets are at times dis-
covered in the heart-muscle of the human subject, it
would seem that there must be a sort of degeneration of
I Arch. f. Exp. Path. u. Pharmak., xlvlll Bd., 3 a. 4 Hft.
the myocardium. Rosenfeld has designated the process as
"degeneration with fat-infiltration," implying that the
fat is deposited in a previously degenerated fiber. But
there is another possibility, viz., that the visible fat is
nothing else than the fat that normally enters the
heart for the purpose of yielding energy. It is not seen
in normal muscle-fiber, because it is used up as quickly
as it enters. The diseased cell, on the other hand, is not
capable of utilizing the incoming fat ; and it is, there-
fore, deposited. These studies are valuable, in that they
throw light upon an obscure subject that is interesting
both clinically and pathologically.
REVIEW OF LITERATURE
E}xperlmental and Clinical Observations Concerning
States of Increased Intracranial Tension.— Gushing • de-
tails the results of his very valuable study of intracranial ten-
sion and states that some of the especially prominent effects of
alterations in the cerebral circulation as they are influenced by
varying degrees of compression are as follows : In the first
place, the venous stasis which becomes apparent on but a mod-
erate increase of the tension, fortunately gives early evidence
of itself in the eye-grounds except in those oases of local com-
pression, in posterior basic meninges, for example, so remotely
situated that the compression-effects are not readily trans-
mitted as far as the cavernous sinus and ophthalmic veins.
Furthermore, local pathologic processes, such as are confined
to the hemispheres, may be responsible for local circulatory
disturbances sufficient to cause a cessation of function of a large
part of the forebrain without leading in any way to a corre-
sponding implication of the medulla. When, howe%'er, the local
process is in the near proximity of, or, if remote, when its
effects are so far-reaching that the vital centers in the bulb are
compromised, the one symptom which with regularity is called
forth, and which betokens a serious alteration iu the local cir-
culation, is a persisting rise in blood-pressure, which may or
may not be associated with a pronounced vagus pulse, with
rhythmic alterations in blood-pressure, and with a retardation or
periodicities of the respiration approaching a Cheyne-Stokes
type. The first and minor symptoms of compression are found
in association with varying degrees of intracranial venous
stasis, the major symptoms of compression of the brain, with
an approaching capillary anemia of the medulla, [a.o.j.k.]
Concerning Bone and Joint Affections In the Course of
Typhoid Fever In Children.- M6ry * describes the case of a
boy of 14, afflicted with typhoid, who suffered with a relapse
and during it complained of severe pain and tenderness in his
right leg, knee and hip. They persisted long after his recovery
and were so great as to force him to keep his limb in a state of
semiflexion. Three months after convalescence the hip-joint
was immobile, the great trochanter was enlarged and the struc-
tures around the joint were inflamed and doughy to the touch.
The lower femoral and the upper tibial epiphysis were in the
same state. Exploratory puncture excluded suppurative
arthritis. With gradual straightening, cauterization, compres-
sion, massage and passive motion the limb improved so much
that now there is but slight edema and tenderness. The hip-
joint still presents slight ankylosis. Although the Bacillus
typhi abdominalis was not isolated from any of the joints,
M^ry is firmly convinced that this is a case of typhoid^l osteitis
of femur, the joint disturbance being secondary to it. [e.i,.]
The Problem of Alimentary Glycosuria In Liver DIs-
ease.- Bruiningi gave glucose, levulose and saccharose to 21
patients afflicted with liver disease. Of these 19 had cirrhosis,
one had cancer of the liver, and the other catarrhal icterus.
Levulose appeared in the urine in each case. Glucose was but
rarely followed by glycosuria, while saccharose gave glyco-
suria is nearly every case. Bruining believes that the ingestion
of levulose is of diagnostic value in liver disease. He thinks
further study of the action of the liver upon the different
sugars will give new methods for diagnosing liver conditions.
[W.E.R.]
' American .lournal of the Medical Sciences, cxxlv, 875, 1902.
«I,a M«dcclne Modonie, KMK, 10.
"Berliner kllnlsche Wochenschrlft, June 23, 1902.
830 AJCXBIOAK MBDieiNl]
THE WORLD'S LATEST LITERATURE
[NOVEHBEB 22, ItXU
The EtioIoKjr of Return Cases of Scarlet Fever.—
Millard ' states that return cases of scarlet fever are caused by
the carrying home of Infection by patients returning from the
hospital. The latter may be conveniently referred to as the
infecting cases. Return cases are essentially a "hospital
phenomenon ; " analogous cases rarely arise after treatment of
scarlet fever at home. The " infective influence" persists for a
much greater length of time than was at first supposed. If a
limit must be set to the length of the " interval " which may
elapse between the return home of the patient and the occur-
rence of a return case it should be at least six weeks. The
clinical complications of patients leaving the hospital most fre-
quently associated with the carrying home of infection are
discharges from the nasal and aural passages and unhealthy
conditions of the nasal mucous membrane with or without
visible discharge. The fatality of return cases is above the
average. With regard to the influence of duration of stay in
the hospital upon the occurrence of return cases, it is pointed
out that the only effect of detaining patients a longtime in the
hospital is to exculpate medical officers from the charge of
sending the patients home too soon, but that it has not reduced
thenumber of return cases. It is suggested that the detention
of patients in a hospital in infective wards may be actually the
cause of return cases either (a) by interfering with the process
of elimination of infection, and so causing protracted infec-
tivity, and (6) causing patients to accumulate extraneous infec-
tion which they carry out of the hospital with them. It is
believed that the germ of scarlet fever, like the bacillus of
diphtheria, may under certain circumstances find a suitable
nidus in the nasal cavity, and probably in the oral cavity also,
in which it may persist for long periods ; that its activity may
vary, at times being almost dormant, at others comparatively
virulent, and that this activity is intimately related, whether
causally or consequentially is not yet certain, with the presence
of a discharge, [a.o.j.k.]
A Case of Direct Transference of a Carcinoma. —
Clemm' describes the case of an elderly gentleman having a
dog ill of cancer of the lower lip and jaw, which he attended
personally for some time. About six months after the removal
of the dog the old gentleman began to complain of loss of appe-
tite, abdominal pain and weakness. Loss of weight was pro-
gressive, jaundice appeared and paroxysmal pain developed in
the region of the gallbladder, while an irregular mass could be
felt in that region. At the autopsy Clemm found this to be a
carcinoma with numerous metastases in many of the organs.
[E.L.]
A Case of Carcinoma Cured by the Adamklewicz's
Serum.— Kugel ' reports a case of mammary carcinoma in a
woman 53 years old. During a period of six years she was
operated on four times, after which she again had recurrence in
the other breast and in the costal and subclavicular lymphatic
glands. She received 20 injections of cancroin, the serum of
Adamkiewicz. All the cancer nodules disappeared, the patient
increased in weight, and has been perfectly well since. Well-
known authorities excluded all doubt of cancer by microscopic
examinations, [w.e.r.]
Antityphoid Inoculation.— Wright • brings forward a
series of statistics to prove that, having regard for the degree of
exposure to infection and the proportion of inoculated to uniu-
oculated persons, there was at least a twofold reduction of
cases of ,typhoid fever in the inoculated. In certain cases a
greater reduction in the incidence of typhoid fever was
achieved— a reduction varying from a sixfold to a 28-fold
reduction. Superadded to the diminished incidence of the dis-
ease there was a striking diminution of case mortality— in the
aggregate the proportion of deaths to the cases among the inocu-
lated being approximately half that among the uninoculated.
The combined effect of the diminished incidence and dimin-
ished case mortality manifests itself in the diminished death-
rate from typhoid fever among the inoculated. The minimum
reduction in the deathrate is a twofold diminution, usually it
nas not been below a fourfold reduction. Emphasis is directed
' British Medical Journal, August 16, 1902.
« Medizinlsche Woche, li)01, 39
Berliner kllnische Wochenschrift, June 16, 1902.
» Lancet, September 6, 1902.
to the fact that in connection with all protective inoculation
there is a risk : (a) When the patient's resistance is naturally
low or has been reduced, as is often the case, by a previous
attack of typhoid fever ; (6) when the patient is inoculated with
a full dose of vaccine in actually infected surroundings ; and
(c) when the patient is inoculated with an excessive dose or is
reinoculated too soon, the system may be left more open to
infection at a period when it stands in need of protection. It
must be the task of the future to try to minimize the risk, on
the one hand, by working out an adequate method of standard-
izing the vaccine, and on the other, by combining with the
study of the changes produced in the blood by antityphoid
inoculation the study of the blood in typhoid convalescence
and also the study of the gradual success or failure of the pro-
cess of immunization in the actual typhoid attack, [a.o.j.k.]
Hepatic Abscess. — Hannaberg' reports four cases of
abscess of the liver, the diagnosis of which was verified by
operation. Many points must be considered as important in
attempting a diagnosis of liver abscess, but he lays especial
stress on enlargement of the liver upward, whether this be
localized or includes the entire upper surface. Enlargement of
the liver downward is not of nearly the same importance unless
signs of fluctuation are present. He also reports a case of
syphilis of the liver with paroxysms resembling malaria.
Large doses of potassium iodid produced a cure where quinin
had failed. Diarrhea and excessive tympanitis in the course of
pleurisy and pneumonia are caused, in his opinion by bacterial
toxins. He has seen five such cases. In one of them typhoid
fever was suspected, in another peritonitis ; a third patient was
operated on for obstruction of the intestines, with negative
findings. In the latter case the autopsy revealed a pleuro-
pneumonia. [E.Ii.]
A Case of Tuberculous Meningitis Followed by Recov-
ery.— Thomalla ^ reports a case of tuberculous meningitis in a
young man 20 years old. Both of the patient's parents died of
tuberculosis. He had had pharyngeal, cervical and rectal
tuberculosis. The patient presented all of the typical symp-
toms of tuberculous meningitis, including tubercles of the
retina. The treatment consisted of creasote in rapidly ascend-
ing doses and potassium iodid. In one month the tubercles of
the eye had disappeared, and in four months, after an opera-
tion, the fistula-ln-ano was healed. Since then the patient has
been perfectly well. Thomalla ascribes the recovery to the
early diagnosis of meningitis with the early administration of
large doses of creosote and potassium iodid. [w.e.r.]
A case of traumatic rupture of the choroid, with hem-
orrhage from the upper branch of the Inferior temporal vein,
is reported by Oliver.' [a.o.j.k.]
A Contribution to Our Knowledge of Hydrochloric
Acid Secretion. — Attempts have been made to determine to
what extent the secretion of hydrochloric acid is influenced by
the character of the food. It occurred to Cloetta * that it would
be of value, in addition to the chemical analysis, to make an
anatomic study of the mucous membrane, particularly in view
of Heidenhain's discovery that the parietal cells secrete the
hydrochloric acid. It might be presupposed that the stimula-
tion of these cells would cause an increase of the hydrochloric
acid and that a hypersecretion of this acid might be accompanied
by an anatomic change in these same cells. The problem could
be readily solved if it were possible, in patients suffering from
true hypersecretion, to examine intra vitam small pieces of the
gastric mucous membrane. The author, however, disapproves
of the method of Ilemmeter, that of chipping out little pieces
with a sharp tube. In ten healthy persons Hemmeter had
found normal conditions eight times. The patients with hyper-
chlorhydria showed, in two-thirds of the cases, hyperplasia of
the tubules and hypertrophy of the parietal cells. If the hyper-
plasia is primary, then the hyperacidity is a disease with a
characteristic anatomic basis ; if, however, it is secondary, the
etiology of hyperchlorhydria is as obscure as before. It has
been shown that dogs secrete more hydrochloric acid on a meat
diet than on a mixed diet. Cloetta made the following experi-
i Alle. Wlen. med. Ztg., 1902, 151.
2 Berliner kllnische Wochenschrift, June 16, 1902.
3 American Journal of the Medical Sciences, Vol. cxxlv, p. 432, 1902
*MOnchener ined. Woch., August 12, 1902.
November 22, 1902]
THE WORLD'S LATEST LITERATURE
[American Medicine 831
inent: He fed two dogs exclusively on fat milk with the addi-
ment of iron, to prevent anemia; and two on raw meat. The
milk-fed dogs did not secrete any hydrochloric acid, while the
meat>fed dogs did. The animals were put to death by shooting.
Their stomachs were immediately opened, and pieces from
various parts were excised. Strange to say, there was found to
be absolutely no difference between the acid-containing and the
acid-free stomachs. The observations show that milk diminishes
the formation of hydrochloric acid ; but, in view of the micro-
scopic findings, it seems unlikely that it was a curative action.
The experiment also indicates that the removal of small pieces
of mucous membrane in hypersecretion is of no diagnostic
value. It does not follow, however, that the observations on
dogs can, in their entirety, be applied to man. [d.r.1
Treatment of Repeated Pleural Effusion by Gas Injec-
tions.^To produce a cure in pleural effusions, which, in spite
of all treatment recurred, Vagues and Omiserne' provoked.
after the method of Potain, an artificial pneumothorax with the
intention of preventing the re-formation of the fluid. As their
method depends for ita success on purely mechanical pressure
they chose for their gases such as were absorbed with difflculty
in preference to antiseptic vapors. They describe the method
employed, especially in regard to amount of gas to be injected,
and relate two cases in which recovery resulted. One had been
tapped 13 times, the other 6. In each case I liter sterilized air
was injected. No bad after-efTects were produced. The pneu-
mothorax in the one case last«d three months, in the other two
weeks, and at no time was there any sign of the fluid return-
ing. They used atmospheric air, as it is absorbed much slower
than oxygen ; in some cases even it is absorbed too rapidly; in
such eases nitrogen should be used. The production of the
pneumothorax prevents the possibility of "galloping cx>nsump-
tion," which occurs at times in cases when lungs compressed for
a long time suddenly find themselves relieved of pressure.
[E.L.]
The "Blood-purifying" Function of the Kidney.—
Strauss,^ after removal of the albumin, determined the amount
of nitrogen retained in the transudates and blood-serum of 200
patients affected with nephritis. He also made a quantitative
test of the uric acid and ammonia. These elements were
greater in chronic interstitial nephritis than in normal condi-
tions, or in the chronic parenchymatous nephritis. Sodium
chlorid and ash varied but slightly. The serotoxicity was
greater in chronic interstitial than in chronic parenchy-
matous nephritis. In the latter there is a dilution of the nitro-
gen in the blood and tissue fluids, while in the former there is
increased cardiac action, polyuria, and an increase of tissue
fluids, Strauss strongly advises that the heart be carefully
examined, as the change from the chronic parenchymatous
nephritis to the chronic interstitial form is often dependent
upon the state of the heart muscle. He believes uremia is due
to the chemic action of some undiscovered substance that
contains nitrogen. To prevent uremia, the albumins should be
decreased and the carbohydrates and fats increased. In uremia
sweat baths should be ordered and the alimentary canal
thoroughly washed out. Strauss advises venesection both before
and after the development of uremia, [w.e.r.]
Fatal Hemorrhage Into the Bursa Omentalis Simu-
lating Acute Intestinal Obstruction.— Grassmann's^ patient,
a man of 54, was suddenly seized with symptoms of intestinal
obstruction. The bowels could not be moved, and there was
thirst and marked dyspnea. The abdomen was distended, the
liver dulness not obliterated, and there was dulness above the
symphysis. At the operation the intestines were not found
distended, but on lifting the great omentum a large volume of
blood gushed forth. The hemorrhage seemed to come from
above. Gauze tampons were introduced into the region of its
supposed source, the abdominal cavity was cleansed of blood
and coagula, the wound sewed up, and this followed by saline
infusion. Tlie patient, however, died shortly afterward, 35
hours after the onset of the symptoms. At the autopsy the
source of the hemorrhage was found to be an adenoma of the
liver in the st)igclian lobe, which had ruptured through the
1 Bull, el Mem. (Ic la Hoc. M6d. dcs Hflp. de Paris, May 29, 1902.
' Berliner kllntschc Wochenschrift, Junes, mn.
' MOnchener medlclnlsche Wochenwhrift, .\ugust 12, 1902.
capsule and had bled into the lesser cavity of the peritoneum.
The pressure of the blood had pushed the stomach forward and
compressed the transverse colon. The intense dyspnea was
probably due to pressure against the diaphragm. The liver
was found to be the seat of hypertrophic cirrhosis, with the
formation of minute adenomas. The one in the spigelian lobe
was, however, the only one that was large. The author empha-
sizes the rarity of hemorrhage as a cause of intestinal obstruc-
tion, and the difticultiesof diagnosis. In defense of his failure
to diagnosticate internal hemorrhage, he states that the symp-
toms were so predominantly those of intestinal obstruction that
all other signs were placed in the shade, [d.k.]
A Case of Goundon.— J. M. Espini ^ describes a case of this
affection which appears to be confined to the negro race, and is
rare outside of Africa. The etiology of this form of nasal tumor
has been attributed by Chalmers {Lancet, January, 1900) to
periostitis osteoplastica, consequent to frambesia, and by Strac-
hau {British Medical Journal, January 27, 1874) to atavism.
Espini regards the growth as a manifestation of hereditary
syphilis, an osteitis syphilitica hereditaria, [c.s.d.]
Tremor of the Muscles of the Face and Extremities
Due to Chloral, but Resembling General Paralysis.- Ballet
and Delherm ' report the case of a woman whose father died of
tuberculosis and most of whose brothers and sisters died of
meningitis. At the time of admission she was thought to be a
general paralytic on account of her mental dulness and general
tremor, but 24 hours afterward the diagnosis was revised to
chloral poisoning. The symptoms at the time of admi-sion
were: Very marked mental depression, questions being
answered wrongly or not at all ; tremor of the muscles of the
face and upper extremities, especially upon exertion. The
slightest exertion would make the muscles of the forehead, eye,
nose, cheek, mouth and tongue tremble violently. Speech was
markedly tremulous. Twenty-four hours later her mind had
cleared ; the tremor persisted to a less degree. Forty-four days
previous to admission she began to take chloral on account of
mental worry, physical fatigue, and inability to sleep. She
began with 15 grains (1 gr.), increasing this within 12 days to
180 grains (15 gr.) at a dose. She took this dose every night for
15 nights before admission. During this time she developed
difflculty in walking and climbing, confusion of speech, visual
and auditory hallucinations ; she spent most of her time in bed
asleep. The tremor gradually disappeared, recovery being com-
plete after some days, [b-l.]
A. B. Craig
GEKERAIi SURGERY
Martin B. Tinker
C. A. Orr
REVIEW OF LITERATURE
Operative Dislocation of the Head of the Femur iu
Tuberculosis of the Acetabulum. — Bradford.' In cases of
tuberculosis of the acetabulum when no dislocation occurs
spontaneously and the disease process is active, the difflculty of
drainage is very evident. The head of the femur crowds into
the carious acetabulum, preventing escape of the diseased tis-
sue. Drainage finally occurs by perforation of the acetabulum
and development of the pelvic abscesses, which burrows under
the tissues, usually finding an Imperfect outlet and resulting iu
sinuses and chronic septic changes. The condition is one in
which our first thought must be to save life at any cost rather
than to attempt to establish cure without deformity. Bradford
has operated upon three cases of this kind by opening the joint
through a posterior incision, as for excision of the hip. The
capsule is incised freely and the head dislocated by traction on
the hip. The limb is then fixed in the flexed and abducted
position with plaster. The acetabulum can then be swabbed
with pure carbolic acid and alcohol. A large drainage tube at
least an inch in diameter is then inserted through the wound
directly to the acetabulum. This permits of packing and thor-
ough treatment directly to the site of disease. Bradford has
> Bevlsta de la Asoclacl6n Medlco-farmac^utlca de la Isia de Cuba,
May, 1902.
» Bull, et Mem. de la 8oc. MM. des H6p. de Paris, May 16, 1902.
'Annals of HurKery, 1802, Vol. x.\vl, p. 579.
832 &IIEBICAN HEDIOtNE]
THE WORLD'S LATEST LITEEATUEE
[November 22, 1901!
followed three cases treated by this method for one a half years,
one year, and three months, respectively. The immediate
results were extremely satisfactory. There was improvement
in the patient's general condition and increase of weight.
Patients were soon able to go about on crutches, in the same
condition as those patients who were cured of hip disease with-
out deformity. The drainage tube is maintained in place for a
long time permitting thorough drainage and treatment until
the diseased area is covered with healthy granulations. Brad-
ford considers the procedure a life-saving one in these eases.
Later on, reduction or correction of the deformity may be
accomplished by subtrochanteric osteotomy, [m.b.t.]
A Case of Anterior Luxation of the Tibia.— Bruening '
reports a case of dislocation of the tibia forward, which Ront-
gen photographs showed to be complete. The diagnosis was
easily made. The posterior tibial artery did not pulsate until
the second day after reposition. A spot on the outer side of the
knee became gangrenous as the result of pressure ; the sole of
the foot sloughed because of a burn due to having placed
against it hot bricks on the night of the injury. The former
healed promptly, the latter required a Pirogoff amputation in
the end ; the patient has a very good, serviceable stump, [e.l.]
Autopsy Findings on the Appendix. — The condition of
the appendices in 60 persons coming to autopsy are recorded by
Marcland.2 In one-half the cases the appendix was diseased,
and 20% of these were surrounded by thick, solid adhesions and
occasionally accompanied by atrophy of the cecum. These
were thought to represent acute appendicitis cured. Others,
25%, presented lesions of an endoappendicitis. These lesions
were macroseopically evident, in some cases causing oblitera-
tion. Between these two classes the author places a third in
which there seems to have been only a periappendicitis. If, as
some writers assert, it is necessary to have an interior lesion,
these cases must have had a parietal inflammation insuflScient
to cause obliteration, but sufficient to cause a peritoneal reaction
that persisted, [a.g.e.]
Rupture of the Intestine Without Severe External
Injury. — Tornqvist ' reports three cases of this kind. A man
of 20 suffered a rupture of the jejunum from a kick on his
abdomen from a horse. Celiotomy was performed 11 hours
after the injury, and death resulted from general peritonitis
seven days after the operation. In the second case a man of 25
was operated upon for rupture of the jejunum from a horse's
kick six hours previously. Recovery followed. In the third
case a boy of 16 suffered a rupture of the lower part of the ileum
by being struck in the abdomen by a stone the size of the fist.
Celiotomy eight hours later was followed by recovery. In dis-
cussing these injuries TOrnqvist lays stress upon the following
symptoms, which he considers characteristic of rupture of the
intestine: 1. The rapid rise in pulserate occurring immediately
after the injury and steadily increasing. This is especially
important in the absence of other symptoms, indicating intra-
abdominal hemorrhage. 2. The rapidity with which the gen-
eral condition of the patient grows worse. 3. The increasing
zone of dulness in the region of the injury. 4. Rigidity of the
abdominal wall and the appearance of pain and tenderness. In
the treatment of these injuries he advocates immediate celiot-
omy with cleansing of the peritoneal cavity by sponging and
the use of free drainage, [m.b.t.]
The Undescended Testicle.— Eccles * asserts that nor-
mally the testis has a double function, the elaboration of an
internal secretion which is utilized in some way by the general
economy and the production of the spermatozoa. It is con-
ceded that an undescended testicle is useless in the latter par-
ticular, but that it may be useful in the former, and therefore
be highly important to the general growth and development.
An undescended testicle may be treated in three ways when
operating for inguinal hernia: It may, if the cord is sufficiently
long, be brought into the scrotum ; it may be returned to the
abdomen ; or it may be removed. There is want of evidence to
prove that abdominal testis is likely to become malignant. In
case there is unilateral arrest of a testis accompanied by a
' Mttnchener inediclnische Woohensohrlft, September 23 1002
' Gazette heb. de Mgdectne et de Chlrurgle, October 12, 1902
'Nordiskt Medlcinskt Arklv, 1902, Vol. xxxv, haft 1, ko. 2 n 1
' British MedlcalJournal, OcU/ber 25, 1902. > r- •
hernia on the same side a radical operation is indicated, and
the testis should be placed in the scrotum if this can be done
easily and with a strong probability that it will not recede ;
otherwise it should be returned within the abdomen. Suppos-
ing both testes are arrested, it is injudicious to remove either of
them, for the amount of internal secretion that together they
may produce may be sufficient to cause a proper development
of the body in general. In such instances it is well to replace the
testis within the abdomen on the side on which the hernia is,
if it cannot readily be brought down or there is no scrotum to
receive it ; for in this manner it is almost certain that its power
of providing an internal secretion for the body is maintained,
although there will be no attempt on its part to develop and
produce spermatozoa, the possessor becoming virile but remain-
ing sterile, [a.b.c]
Operative Treatment of Certain Diseases of the Lang.
—In a boy, 9 years old, who when four years of age was said to
have inhaled a grain of corn, Treupel ' made a diagnosis of
nontubereulous infiltration of the lower left lobe, with begin-
ning sclerosis and bronchiectasis. There was dulness over this
area posteriorly, with bronchial breathing and a few rales. He
had daily paroxysms of coughing with profuse fetid, purulent
expectoration. Treupel resected the seventh, eighth and ninth
ribs posteriorly, draining the cavity through this large open-
ing. Seven weeks later the fetid bronchitis was practically
cured, and the extensive resection had given the lung tissue a
chance to collapse completely, [e.l.]
Chronic Pancreatitis.- Owen » reported two cases. One
was that of a man of 62 who was supposed to be suffering from
malignant disease of the liver or the head of the pancreas,
jaundice being marked and characteristic of either of these
conditions. Laparotomy was performed and the liver found
normal while tUe pancreas was found uniformly enlarged and
hard. The abdomen was closed as it was confidently supposed
the man would soon die of malignant disease. He recovered
completely and resumed his work. The other case was that of
a woman of 30, who had suffered from a variety of symptoms
supposed to be of uterine origin. Two months before entering
the hospital she became jaundiced and began to waste rapidly.
There was a tumor and tenderness below the ninth rib a little
to the right. Laparotomy showed the cause of the jaundice to
be an enlarged pancreas. After operation the patient became
better and left the hospital but the jaundice has not subsided,
and she is not doing well. Owen says he knows of no way
to differentiate benign from malignant pancreatitis before
operation, [a.b.c]
A Case of Congenital Dilation of the Colon in a Child.
—A child, 3J years old, with congenital dilation of the colon, as
the result of which she never had a bowel movement since
birth without enema, had been vomiting after almost every
meal for some time past, and was rapidly going down hill.
BjSrksten ' performed an inguinal colostomy, finding the large
intestine to be five inches in diameter and its wall of consider-
able thickness. Improvement was at once noticeable, move-
ments occurring daily through the artificial anus. Unfortu-
nately she developed scarlet fever shortly after: the tissues
immediately around the wound became necrotic, and a few
days later a piece of large intestine 10 inches long came away.
In spite of all this the patient recovered sufficiently for a
second operation— a colorectal anastomosis, after which the
feces passed partly through the anal, partly through the
inguinal orifice. Two months later the unnecessary portion of
the colon above the artificial anus was resected, and a month
afterward the artificial anus closed. The operations seemed
fully successful, but they could not prevent the further decline
of the patient, death taking place 11 months after the first
intervention. The autopsy revealed the complete success of
the operations, no stenosis or dilation being noticeable in any
part of the intestinal tract, [e.l.]
Acute Occlusion of the Esophagus in a Five- Year-Old
Child.- Killian * reports the case of a boy five years old who,
after partaking greedily of meat two days before, suddenly
1 Munchener medicinische Wochenschrift, October 7, 1902.
2 British Medical Journal, October i.5, 1902.
sjahrbuch fQr Klnderhellkunde, 1902, Vol. Iv, No. 6.
4 Munchener medicinische Wochenschrift, September 23, 1902.
NOVEKBEB 22, 1902]
THE WORLD'S LATEST LITEEATUEE
i'Amebican Medicine 833
found himself unable to swallow ; not even liquids would pass
into the stomach. At 2i years he had swallowed some lye, but
had not experienced any trouble from this after the first few
days. As the child was getting weaker because of this enforced
fast an operation had been arranged for. By means of the esoph-
agoscope, Killian was able to locate the mass of flesh and
removed it with delicate forceps, controlling his efforts abso-
lutely by vision. The mass occluded completely the caliber of
the esophagus a short distance above the cardiac orifice, [e.l,.]
Tabercalosis of the Testis. — Myles^ believes in con-
servatism in the surgical treatment of tuberculosis of the testis.
When one or two small nodules of a chronic type occur he
would do a partial operation, later removing the whole testis if
necessary. In cases similar to the foregoing but with slight
enlargement of the prostate and vesicles he would place little
reliance on operation. When there is enlargement of the
organ and suppuration, with or without vesical or prostatic
involvement, he would extirpate the whole testis at once.
Cases with both testicles involved present a most serious prob-
lem, for usually men will face death before castration ; how-
ever, the welfare of others may demand this radical advice.
Patients having pulmonary tuberculosis or tuberculous
involvement other than in the genitals should not be subjected
to operation, [a. B.C.]
Two Cases of Perforative Peritonitis Cared Without
Operation. — Weber ^ reports two cases of perforative perito-
nitis, in both of which the patients refused operation, to recover
ultimately without one. The first case dealt with a perforation
of an inflamed gallbladder containing calculi, the second with
intestinal rupture after traumatism, [e.l.]
Fibromuscalar Interposition in Resection of the Elbow
for Ankylosis. — To prevent reankylosis in cases where resec-
tion of joints was performed on account of firm ankylosis,
luenu' advises the interposition of flbromuscular strips
between the resected surfaces after the method of Nfilaton. A
girl who, at 16, had broken her elbow and acquired a fibrous
ankylosis, had since been operated upon several times unsuc-
cessfully. After a longitudinal incision over the posterior
surface, he resected the lower end of the humerus and upper
part of forearm. He severed the anterior ligament at its lower
part, pleated it, and interposed it between the bony surfaces.
He covered this with the fibers of the brachialis anticus,
sewing them to the ligament. The arm was encased in plaster-
of-paris for two weeks, and upon discharge the patient was
able to flex and extend her arm completely with the greatest
ease, [e.i,.]
GYNECOLOGY AND OBSTETRICS
WiLMER Kbusen Fkank C. Hammond
EDITORIAL COMMENT
Treatmeut of Incomplete Abortion. — So many
of these ca.se8 occur without ever coming under the
ob.servation of a physician or without the patients hav-
ing any medical attendance that it is impossible to esti-
mate their fre<iuency. Yet constantly the physician
sees cases showing evidence of lesions due to incomplete
removal of the ovum or the fetus and the secundines.
Women do not realize fully the dangers which may
result from the lack of proper attention during abortion,
and many physicians are prone to treat these cases in a
perfunctory manner. In no condition affecting the
genital tract is the let-alone policy more likely to be
followed by serious consequences. Retention of any of
the products of conception within the uterus exposes the
patient to the danger of hemorrhage or septicemia, and
the uterus should be thoroughly emptied if there is the
slightest possibility of any fragment of the decidual
tissue remaining within the cavity. Not only does this
lessen the possibility of hemorrhage or infection, but it
favors complete involutionary changes in the organ, and
often saves the patient from chronic uterine inflamma-
I BrIUHh Medical Journal, October 25, 1902.
' .VlUnchener medlciniscbe Wocbennchrlft, September 30, 1902.
' Hull, el .M6m. de la 8oe. de Cblmrgle de Paris, July 1. 1902.
tion. The importance of rest in bed after a spontaneous
abortion cannot be too strongly insisted upon. It is
surprising how often patients, who will ordinarily rest
in bed for two or three weeks after delivery at term,
will resume their active duties in two or three days after
an abortion. Routine intrauterine exploration and evacu-
ation in all cases of abortion after the second month may
be a radical policy, but far better results will be
attained and fewer cases of septicemia and pelvic
inflammation or chronic parenchymatous metritis would
occur. Nothing is so good as a curet to clear out the
thickened decidua which almost invariably remains
behind in early abortion. Duhrssen has demonstrated
that the decidual tissue removed from the uterus in this
way is not rudely torn off, but is separated in a natural
manner in the cellular layer. If the gestation is
advanced far enough for placental formation, Hoennig's
method of expression may be tried ; for the removal of
an adherent placenta nothing is better than the finger,
which can be made to reach the fundus if the uterus is
pressed down from above by means of the hand exert-
ing pressure through the abdominal walls. After the
complete evacuation of the uterus, irrigation and drain-
age with iodoform gauze are advisable.
KEVIEW OF LITEBATUBE
Indications for Cesarean Section.— Galabin i remarks
that the progressively improved results of cesarean section
attained, the advance in antiseptic surgery, and the increased
experience of operators, are leading to a progressive increase
in its scope. He believes that in case of contracted pelvis
cesarean section should be advised in place of embryotomy,
provided the decision can be made before labor, that the patient
has not been exposed to sepsis, and that an operator skilled in
abdominal section is available. This is justified in the interest
of the mother alone, and the desire to save the child's life adds
greatly to the conclusion. Embryotomy should be performed
when it unexpectedly proves impracticable to deliver by for-
ceps and in houses in which it would be difficult to perform an
abdominal section with perfect asepsis. The author prefers
cesarean section to symphysiotomy in almost all cases. A rare
indication for cesarean section is pregnancy in an imperforate
horn of a double uterus. In conclusion he would urge that the
time is ripe for further extension of this method in cases of
pelvic obstruction ; but that extreme caution should be used in
its application to the treatment of antepartum hemorrhage or
eclampsia. [w.K.]
Sterilized Clothes for Narslings.— Weill and Agniel'
have tried the use of sterilized clothes for infants in institu-
tions where cutaneous infections as erythema, pustules, boils,
abscesses, etc., were practically epidemic. Antiseptics too often
only aggravated these conditions, but the sterilized clothes at
once produced a change, the lesions rapidly healing. The
infants exempt from infections remained so, so far as their
bodies were concerned, and the use of sterilized caps also pro-
tected the head. In specific infections, as chickenpox, second-
ary infections are prevented. In cases of ulceration, lymphan-
gitis and erysipelas are lessened, [a.u.e.]
A Case of Complete Spontaneous Uterine Rupture.—
F. Klelnertz' reports a case of spontaneous uterine rupture
occurring in the eleventh pregnancy of a woman aged 39. Soon
after the rupture of the membranes the patient suffered severe
pain in the abdomen, after which there was no further progress
toward delivery. When Kleinertz saw the patient it was evi-
dent that the fetus was no longer in the uterus. I^aparotomy
was performed, and after removing the normally developed
child, which lay in the abdomen, it was found that there was a
rupture of the uterus extending from about the middle of that
organ to the inner os uteri, and a second transverse tear extend-
ing across the anterior uterine wall. The injuries were
repaired and the patient made a good recovery. There appeared
to be no cause for the rupture, except that the uterine walls
1 British Medical Journal, October U, 1902.
• Gazette heb. de Mfideclne et de Cblrurgle, October 80, 1902.
aCentralblatt fUr Uynttkologle, October 4, 1902.
834 AKKBioAir HssicnrB
THE WORLD'S LATEST LITERATURE
[NoVEKBRR 22, ig02
were weakened by so many pregnancies in rapid succession in
a badly nourished and overworlied woman. fw.K.]
Intermenstrual Dysmenorrhea Cnrecl by Successive
ttophorectomles. — Whiteloclte ' gives the details of a case in
which the chief points of interest are: The complete relief of
all symptoms since the removal of both tubes and ovaries ; the
comparative rarity of recorded cases of intermenstrual pain with
such definite periodicity (10 days before in this case) ; the pres-
ence of a fibroid in so young a woman (aged 26) and which
showed such rapid shrinkage after oophorectomy; the cystic
degeneration of the right ovary coming on so soon after the
removal of its fellow ; the absolute failure of drugs and cervical
dilation to secure relief ; the suspicion that the presence of the
fibroid had more to do with the matter than the cystic degener-
ation of the ovaries ; hlstologicly the ovaries showed nothing
peculiar, [w.k.]
Tbe ligation of the hypogastric and ovarian arteries
on both sides is advocated by Kronig ' In palliative treatment
of uterine carcinoma. In inoperable cancer the cauterization
of the cancerous mass often fails to check the bloody or putrid
discharge, and the desired result is better secured by such liga-
tion, which can be best accomplished through a small trans-
peritoneal incision between the navel and symphysis. With
this method there is little loss of blood and a brief convales-
cence. It is best to ligate the hypogastric artery at Its point of
departure from the common Iliac artery, and the ovarian at its
entrance Into the broad ligament. In suitable cases this pro-
cedure may be combined with the cauterization of the cancer.
He thinks the ligation of these arteries Is indicated in all cases
in which, after opening the abdomen, it is found Inadvisable to
perform a radical operation. [w.K.]
Inflammation of Uterine Appendages.— Barbour' says
the inflammation of the uterine appendages has received atten-
tion only during the last 20 years, and was not recognized until
the days of abdominal section. Although the part played by
germs is well established in the gonorrheal, tuberculous and
acute septic forms of inflammation, their presence has not been
proved In all cases. The normal vaginal secretion has been
shown to have a distinctly germicidal action. Menge and
Kronig maintain that the distinction between physiologic and
pathologic vaginal secretions does not hold that all are equally
germicidal, but that different germs vary greatly in vitality.
Menge tested the efficiency and rapidity of the germicidal
action by introducing pyogenic organisms into the vagina in
80 cases, and found that the vagina cleansed Itself from these
in periods varying from 2J hours to 3 days. Barbour gives as
the four symptoms of Inflammation of the appendages : Dys-
menorrhea, menorrhagla, pelvic pain more or less contin-
uous, and sterility. Sterility and dysmenorrhea with scanty
menstruation Indicate Inflammation of the uterosacral liga-
ment ; but profuse bleeding means that most probably the
appendages are involved. He distinguishes between dysmen-
orrhea which is periodic and the continuous pelvic pain due to
active congestion of diseased structures. Sterility naturally
results from adhesions of the ovary and the fimbria, and from
destruction of the ciliated epithelium of the tube. The normal
tube cannot be felt in ordinary bimanual examination, and
if the ovary and tube are distinctly palpable it means they
are enlarged by chronic inflammation. Nonoperative treat-
ment consists of antiseptic douches, tonic aperients and other
internal remedies. Rest is of first importance. Tampons
favor rest by supporting the ovaries ; glycerin tampons Induce
removal of serum from Inflamed tissue and ichthyol causes
absorption. The minor operation of curetlng is of value in
those cases in which the inflammation of the appendages is
secondary to that of the endometrium and is relieved when the
diseased endometrium Is removed by the curet. Dilated tubes
which may rupture call for Immediate operation and removal.
A second indication for removal is profuse menstruation, which
is pulling down the patient's strength and will not yield to
ergot or to cureting. [w.k.]
liaceratton of the Uterine Cervix.— Bushong * thinks that
'British Medical Journal, Oct. 11, 1902
' Centralblatt far Gy nakoloKie, October 11, 1902.
8 Scottish Medical and Burglcal Journal, September. 1902
< Medical News, November 15, 1902. , ^<r^.
a large proportion of uterine lacerations can be cured without
operation, and continued experience has led him to advise
operation in a smaller percentage of cases each year. The
great advantage of cure by local treatment is that the cervix has
absolutely no cicatricial tissue left in it. In all but recent
lacerations an area of hard cicatricial tissue is found under and
around the torn surfaces, which acts as a foreign body and
causes distressing symptoms. The complete removal of this
tissue is the key to successful treatment. Several drugs possess
the power of promoting the absorption and removal of this
hard structure, but Bushong has found Mousel's solution the
best. After all discharges have been removed and the vagina
thoroughly cleansed, Monsel's solution is liberally applied to
the cervix and vault of the vagina, the part over the scars being
flooded with it and a tampon introduced to prevent the escape
of the medicine. The tampon should be withdrawn in the even-
ing after treatment. The application may be made about every
five days, and meanwhile there should be copious douches of
warm or hot water, and a free bowel movement daily. If there is
an erosion of the cervix, the best remedy is a combination of
pure tincture of iodin and beechwood creosote. Bathe the sur-
face in this before using Mousel's solution. When there is no
cicatricial tissue, the iron is omitted. Bushong reports the case
of a woman, aged 33, the mother of four children, who had been
suffering from cervical laceration for four years, and who was
cured by a regular local treatment during six or eight months.
The hard resistant mass of tissue all disappeared ; no evidence
was left of the right laceration, and the left had healed to half
its depth and was smooth and soft. He also reports the case of
a woman with a hard, ragged cervix, who was treated for two
months during her pregnancy, with the result that the cervix
became softer and less congested so that she was delivered at
term without Interference. [w.K.]
Varicose Dilation of the Brain Binnses in a Child
vrlth Congenital Defect of the Cardiac Interventricular
Septum. — Geissler ' reports the case of a child li years old, in
which a short time after birth was noticed a moderate hydro-
cephalus with very marked dilation and varicosity of the super-
ficial veins of the scalp, neck and chest. A heart lesion was
also diagnosed. Death resulted from bronchopneumonia. The
autopsy confirmed the above visible conditions; in addition
enormous varicosities of the sinuses of the cranial cavity were
found, especially of the transverse, straight and superior longi-
tudinal sinuses ; the lateral and third ventricles were also
dilated. The heart was very much enlarged, especially Its
right side. The Interventricular septum showed a perforation
near its upper extremity. The arteries were normal. He dis-
cusses the theories regarding the peculiar association of malfor-
mations, and comes to the conclusion that as the result of the
septal defect the right side of the heart dilated, the sinuses and
veins became varicosed and the left heart hypertrophied and
dilated ; but in addition there must have been present insuf-
ficient development of the elastic fibers inthe walls of the veins,
diminishing their resisting power to the slightly Increased
blood-pressure, as without such the enormous dilation of the
sinuses could not be explained at all. [e.l.]
Uterine Carcinoma. — E. Schroeder^ reports a case in
which a uterine carcinoma was removed in the sixth month of
pregnancy by a vaginal operation, resulting in the death of the
child. He believed that the ligature of the uterine artery pre-
vious to delivery of the child was the cause of its death, and
was convinced that when one has to do with a living child, it
should be delivered before placing any ligatures on the para-
metria. [w.K.]
Operative Treatment of Prolapsus Uteri.- Berry Hart,*
after a careful review of cases and operations, sums up as fol-
lows : Prolapsus uteri may be regarded as a hernia of a definite
part of the pelvic floor. After replacement the hernia is repro-
duced by the patient's straining. The most useful operations
are the combined cervical amputation, elytrorrhaphy and peri-
neorrhaphy in medium cases, and ventrofixation In selected
cases. In advanced cases in widows, vaginal resection and
hysterectomy have to be considered. [w.K.]
' Jahrbuch f. Klnderhellkunde, 1902, Vol. Iv, No. 6.
2 Centralblatt fOr Gynakologle, October 4, 1902.
3 British Medical Journal, October 11, 1902.
NOVKMBEK 22, 19a2J
THE WORLD'S LATEST LITERATURE
[American Medicine 835
TREATMENT
Solomon Solis Cohen
H. C. Wood, Jr. L. F. Apfleman
5 gram (7.5 grains)
005 gram ( ^^ grain)
grams (6 ounces)
REVIEW OF LITERATURE
Phosphorated Compouads. — Robin i states that in select-
ing a pliospliorated compound for internal administration
phospliorated oil and phosphoric acid should be avoided. He
considers phosphorated oil dangerous because of the toxic
effects which may follow its use, and because of its liability to
disorder the stomach. Phosphoric acid is but little better. In
atonic conditions of the nervous system Robin prefers the hypo-
phosphites, as follows :
Calcium hypophosphite . .
Strychnin hypophosphite .
Syrup of orange flowers . . 187
One dessertspoonful before meals.
The more complex formulas, containing the hypophosphites
of sodium, magnesium, iron and quinin, in doses of 2 or 3
grains, are considered too stimulating to the stomach ; in cases
of hypersecretion of hydrochloric acid there is danger of
increasing the disorder. In such cases Robin employs the
glycerophosphates, as follows :
Calcium glycerophosphate . 5
Extract of kola 4
Syrup of cherry 187
One dessertspoonful before meals.
If the hydrochloric acid does not diminish, the following
may be substituted :
grams (90 grains)
grams (75 grains)
grams ( 6 ounces)
Tribasic calcium phosphate . . 1
Calcined magnesia 0
Calcium carbonate 0
gram (15 grains)
2 gram ( 3 grains)
5 gram ( 7.5 grains)
For one cachet, to be taken during meals, [l.f.a.]
Treatment of Erysipelas. — Gersuny ^ paints the skin of
the affected area with a drier, which may be obtained from
any oil dealer. This remedy forms an air-tight film over the
skin. In more than one-half of his cases the pain ceased after
this treatment. The temperature fell to normal after a few
hours. After four days the infection disappeared. Collodion
may be used in the same manner, [w.e.r.]
Treatment of Typhoid Fever by Cold Enemas. — Le-
moine' employs rectal injections of cold water for the reduction
of fever in those cases of typhoid fever in which the cold bath
cannot be used. A tube is insertetl 6 of 8 inches into the rectum
and then attached to a fountain syringe, which should be held
not more than 20 inches above the patient. Two quarts of cold
boiled water, at a temperature of from 04.5° to 68° F. is allowecf
to pass slowly into the bowel and the flow interrupted occa-
sionally in order to allow the bowel to distend gradually.
Colder water than this should not be used, as it might produce
painful contractions of the intestine and increase the danger of
perforation. These injections act in two ways : by lowering the
temperature and Ijy disinfecting the intestine. The fall in tem-
perature occurs sooner than by the use of the bath, but it is less
lasting. The minimum temperature is obtained about 20 minutes
after the injection, then the temperature rises, and in half an
hour is as high as before the injection. In spite of this, the
patient is free from delirium and nervous phenomena; the
appetite remains good, the tongue is moist, and the mind clear.
This treatment has been used in 32 cases with only 1 death, a
mortality of 3%, or almost the same as by the use of the cold
liath. Lemoine considers the rectal injections of cold water
much more efficacious than cold sponging or the application of
cloths wrung out in cold water, [l.f.a.]
The Use of Suprarenal Gland in Diseases of the Nose
and Throat.— Kyle* noted that occasionally disastrous results
were obtained from a comparatively diluted solution of adren-
alin chlorid, possibly attributable to changes in the drug brought
about by acid secretions. Foroperativeprocedures he employs a
solution of ia% or jo'do. 'or the relief of local congestion johoo
solution. In the latter use of the drug a pledget of cotton soaked
in the solution is allowed to remain in the nostril ten minutes.
1 lounial des Pnvtlc-lctiH, Vol. .xvl, No. 8, 1902, p. 119. '
2 Wlcn. med. W., V.m. No. 1.
'Bulletin GCni'inil (leThf'raiieuUque, Vol. cxllll, No. 14, 1902, p. 650.
< Therapeutic Uazettc, 1(102, v'ol. xxvl, 438.
In a number of cases, contrary to what was at one time claimed
for the drug, there occurs a marked secondary congestion after
its use. He has even seen the congestion made worse by the
application of this drug. He thinks it a more powerful vaso-
constrictor than cocain, but does not recommend its use in
operative work, as it is likely to be followed by severe hem-
orrhage. This bleeding is not a true secondary hemorrhage,
but is simply a delayed primary hemorrhage through pressure
on the larger vessels. He has also seen sloughing follow its
use. His experience with it in hay-fever has been unfavorable.
[h.c.w.]
Treatment of Cerebrospinal Meningitis.— Blauat ' points
out that hot baths are very efficacious in the treatment of acute
nontuberculous meningitis, and especially in cerebrospinal-
meningitis. The baths are given at temperatures varying from
100.4° F. to 101° P., and are continued, on an average,
25 minutes. They are repeated every three or four hours,
day and night, throughout the disease. Woroschilsky and
Wolisch noticed that after the fli-st bath insomnia disappeared.
Later the pains in the head, the rigidity of the muscles of the
neck, and the other pathologic symptoms also disappeared.
Wolisch obtained five cures out of seven cases treated. Lumbar
puncture may also be practised. This method is ordinarily
harmless, provided the cerebrospinal fluid is not aspirated. It
may be repeated until the cerebrospinal fluid becomes normal,
which Is determined by microscopic examination and by cul-
tures. This method should be used only when hot baths fail.
[L.P.A.] [I can commend hot baths in meningitis, especially of
children, s.s.c]
Strychnin Cacodylate in the Treatment of Tuber-
culosis.— Eysseric^ has employed strychnin cacodylate in
tuberculosis with very satisfactory results. The therapeutic
activity of this preparation depends more upon the strych-
nin than upon the arsenic which it contains. It acts as a
stimulant to the appetite, and patients gain weight rapidly
as a result of its use. This increase in weight is soon lost
after withdrawal of the drug. Strychnin cacodylate is admin-
istered in the dose of .002 gram (^ grain) at the outset.
This is gradually increased until .02 gram (J grain) is taken
daily; the dose is then maintained at .02 to .03 gram (J to J
grain) daily, according to the effect obtained. One-half this
amount is sufficient in women. The following solution may
be used hypodermically :
Strychnin cacodylate .... 1
Glycerin 9
Distilled water 31
gram (15 grains)
7 grams ( 2J drams)
1 grams ( 3 ounces)
The salt should first be dissolved in the glycerin on a water
bath, and the water then added. Each 15 minims (.92 cc.) of
this solution contains .009 gram {} grain) of strychnin cacody-
late. [l.f.a.]
Arrhenal in the Treatment of Malarial Fever. — Gu6rin'
has found the arsenical preparation termed arrhenal an excel-
lent remedy against malarial fever in tropic climates. He
reports four cases in which its administration was followed by
rapid amelioration, [l.f.a.]
Sidonal in the Treatment of Gout. — Mylius* states that
sidonal, which i.s piperazin <iuinate, acts as a specific in gout.
In acute cases, the administration of from 1 to 2 drams of
sidonal daily, for four days, is sufficient to abort the attack, while
the usual treatment does not produce the same result in less
than three or four weeks. By the fifth day the patient begins
to walk, after which time the drug must be contirtued three or
four days longer in order to complete the cure, [l.f.a.] [Sido-
nal is by no means so useful as various reports state, s.s.c]
A New Antiseptic. — Septoforma is a condensation product
of formaldehyd,'* with the terpen-naphtalin-phenol group,
which by moans of an alcoholic potassium oleate forms a yel-
lowish noncaustic solution in water. While it softens the skin
it is not soapy and even the concentrated solution does not red-
den or irritate. According to Engels a S% solution destroys
staphylococcus pyogenes aureus in three minutes, the cholera
'Journal des Pratlclenfi, Vol. xvl. No. 15, 1902, p. 287.
« Le MolH ThCrapeutlqiie, Vol. Ill, No. 7, 1902, p. 7.5.
"Bulletin OCnC-ral dc Th«r«peutlqi|p, Vol. cxilv. No. 4, 1902, p. 128.
<Ija MC-dcrlne Moderne, Vol. xlll, No. 12, 1902, p. 97.
<■ Ule Med. Woc-h., October 8, 1902, 414.
836 AmCBIOAN Mkdioinxi
THE WORLD'S LATEST LITEEATUEE
[NOVEHBEB 22, 19C2
vibrio in one minute and the typhoid bacillus In ten minutes.
Instruments of various metals were exposed for three days to
SOfc solution of septoforma and none of them showed the
slightest change except those made of aluminum. It was first
Introduced through veterinary surgery, but has been used by
several observers in gynecologic work and in general surgery.
It seems to have advantages over other similar disinfectants,
owing to a much less penetrating odor, absence of local irrita-
tion or injury to metal instruments, and that It has a consider-
able degree of germicidal power. It Is recommended for the
disinfection of instruments in the strength of 5% to 10^ solu-
tion and as a wash for wounds in a S^'r solution. It Is also
useful In various skin affections and in suppurative ulcers in
the form of a 10^ ointment with lanolin, with which its deodor-
izing property makes it of special value, [h.c.w.]
Treatment of Malignant Tumors. — B. T. Bobone' reports
five cases of malignant tumors In which he used the local
application of arsenious acid in alcoholic solutions varying in
strength from 1 : 150 to 1 : 100, as recommended by Czerny-
Trunneoek. He draws the following conclusions from the treat-
ment of these cases: 1. Local applications of an alcoholic solu-
tion of arsenious acid have a decided influence upon epitheli-
omas. They can be cured, and much more easily if they are so
situated as to be exposed to the air. 2. The applications seem
to have no curative efl"ect upon other varieties of cancer ; at the
best they may be able, under favorable circumstances, to
decrease the progress of the disease and to relieve the patient.
3. Warty affections of the skin resist the action of arsenious
acid, which instead of curing, may irritate them. 4. The
method of Czerny-Trunnecek is a valuable therapeutic measure
which sometimes cures and very often relieves patients
attacked with Inoperable malignant tumors who fear opera-
tion. [L.P.A.]
Ethyl lodid in the Treatment of Whoopingoough. —
From the fact that whoopingoough presents a certain analogy
to asthma, Bardet^ directed that ethyl iodid be employed to
relieve the paroxysms of coughing. In two rebellious cases
the following procedure was adopted : At the onset of a parox-
ysm a large-mouthed bottle, containing a small quantity of
ethyl iodid, was placed under the patient's nose so that the
fumes of the drug were inhaled. The attacks diminished In
frequency and Intensity, the bronchial secretions at the same
time became more fluid. The effects of this treatment, although
very marked at first, diminished later, but the progress of the
disease was shortened nevertheless, and at the end of eight
days the number of paroxysms had been reduced from 40 to 6
in 24 hours, [l.p.a.]
Treatment of Dyspepsia.— A. Robin ' discusses the symp-
tomatology and treatment of dyspepsia, with secondary fermen-
tations due to deficiency of the gastric secretions. In order to
stimulate the gastric functions he directs that the patient shall
eat cooked meats, boiled or roasted, eggs and fish. Feculent
articles of food are not allowed ; bread may be taken In small
quantity. Green vegetables containing potassium, which is a
stimulant to gastric secretion, are the most useful. Of drugs,
Robin employs the bitters, strychnin, and ipecac. In order to
stimulate the secretion of gastric juice small doses of sodium
bicarbonate may be taken half an hour before meals. After
meals the muscular and secretory functions of the stomach
may be further stimulated by a preparation containing strych-
nin and ipecac, as follows :
Tincture of nux vomica 6
Tincture of ipecac 2
Tincture of badian 4
(IJ drams)
( J dram)
(1 dram)
This should be mixed and filtered ; eight drops in a little
Vichy or Vals water after each meal.
The direct antiseptic method of treating the fermentations
by means of naphtol, benzonaphtol, salol, bismuth salicylate,
etc., is not recommended. These substances, while being anti-
septic, at the same time decrease the gastric secretions. Robin
prefers to combat fermentation by (1) introducing Into the
stomach only such food as will not readily ferment and which
has been sterilized by thorough cooking; (2) the use of indi-
rect antiseptics, which may be employed in small doses that
will not retard digestion. In lactic acid fermentation he
employs :
Ammonium fluorld . . . .1 to .2 gram (IJ to 3 grains)
Distilled water 300 cc. (10 ounces)
Two dessertspoonfuls daily ; one at a meal.
(3) the removal of the fermenting materials and the digestive
residue by lavage, vomiting and purgation, [l.f.a.]
The Use of Hyoscln. — Bering ' reports a case of severe
alcoholism bordering on delirium tremens in which large
amounts of hyoscln were administered as recommended by Dr.
Lott. The drug was given in doses of from .0006 to .001 gram
(tJb to jJo grain) every hour. This was kept up for two days
with an occasional dose of strychnin to combat any depression,
and was followed by the use of pilocarpin. The patient left
the hospital after four days' treatment without any apparent
evidence of his debauch, but slightly weak. There were no
alarming symptoms of any kind during the treatment, [h.c.w.]
Sulfur in the Treatment of Typhoid Fever.— Y. S.
Vorochilsky,^ after noting the successful results obtained from
the use of sulfur In dysentery, employed the drug In typhoid
fever in the hope of modifying the ulcerative processes. He
administered sublimed or washed sulfur to adults in thedoseof
1.3 gr. (20 grains) every two hours, and to children in doses of
from .3 to .5 grams (5 to 8 grains). At the end of two or three
days considerable improvement was noted in all the pathologic
symptoms ; temperature diminished, the tongue became moist,
while at the same time the abdominal pains and diarrhea dis-
appeared, sleep became normal, and the appetite improved. In
grave cases amelioration was noticeable only after the fifth day
of the treatment. The administration of sulfur must be con-
tinued until the patient is cured. Slight constipation may be
caused by its prolonged use, but this can be overcome by an
occasional enema. This treatment must be associated with
the usual hygienic and dietetic precautions and with cold bath-
ing. Vorochilsky believes that sulfur forms a protective coat-
ing which reduces the danger of irritation to the inflamed and
ulcerated mucous membrane. It also acts as a vasoconstrictor,
thus reducing the hyperemia of the parts, and as an antiseptic.
[L.F.A.]
Treatment of Herpes Zoster by the Epidural Injection
of Normal Saline Solution. — Amba'rd' reports the case of a
woman, aged 57, who was attacked with a severe pain in the
* left submammary region, which persisted for several days.
When seen seven days after the onset of the pain a band of
herpes zoster presented on the left side, extending at right
angles across the ninth, tenth and eleventh ribs to the spinous
processes behind. She suffered from insomnia, owing to the
very severe pain. Antipyrin and pheuacetin gave no relief.
An epidural injection of 5 drams of normal saline solution was
followed by gradual diminution of the pain and the patient was
enabled to sleep comfortably during the night, the first time in
many weeks. The following day she was allowed to return
home. There was no return of the pain, either spontaneously
or on pressure, [l.f.a.]
Test for Albumin in the Urine.*— Pour some boiling
distilled water into a perfectly clean test-tube of convenient
size, and then allow a few drops of urine to fall into the water.
If albumin is present it will coagulate, forming a very charac-
teristic opalescence resembling tobacco-smoke. This test is
much more delicate than the boiling method, and is especially
valuable when there is only a small quantity of urine avail-
able, [l.f.a.]
Dangers of Picric Acid in the Treatment of Burns.—
Manseau ° reports the case of a child who was burned about
both legs, and who was treated by the application of absorbent
cotton dipped in a 1 : 100 solution of picric acid. At the end of
48 hours the patient became suddenly worse, the temperature
increased, the healthy skin became red and the urine was
lono'^'S-Jo'^*^ **" Mfidecine et de Chlrurgie Speclales, Vol, 11, No. 12,
■liAAfi, p. two.
•La Semalne MMlcale. June 25. 1902.
'Bulletin Gfenfiral de Thfirapeutique, Vol. cxliv, No. 4, 1902, p. 117.
1 Therapeutic Gazette, 1902, Vol. xxvi, 507.
2 1^ Seuiuine Mfedicale, No. 28, July 9, 1902, p. 2.32.
3 Journal des Pratlcieus, Vol. xvl. No. 40, 1902, p. 630.
<Lyon Mfidical, Vol. xclx. No. 40, 1902, p. 481.
'Journal des Pratlciens, Vol. xvl. No. .38, 1902, p. 600.
NOVBMBER 22, 19021
THE WORLD'S LATEST LITERATUEE
(AMBBICAN ilBDICINE 837
colored yellowish-red. Believing that the patient was poisoned
by the picric acid, the urine was examined. The cause of the
trouble was found in the form of picrocyanicacid. The picric
acid dressing was then replaced by an ointment of aristol.
The fever disappeared and the urine became normal in color.
[L.F.A.]
Masturbation and Its Treatment.— Hirschkron i believes
that the sequels of masturbation are commonly much exag-
gerated. The harmful effects of onanism depend chiefly on the
exhaustion of excessive venery— for he regards it equivalent
in this respect to natural coitus— but also largely on the nervous
strain of constant struggles to overcome the vice. The use of
mechanic measures, such as painful applications to the prepuce
or the wearing of apparatus, although sometimes of temporary
benefit, soon lose thei r effect. Neither can marriage be regarded
as a certain cure. The proper treatment consists, after the
removal of any reflex cause, among which he mentions espe-
cially anal eczema and nocturnal enuresis in girls, in prolonged
physical exercise before retiring. For some reason the same
amount of gymnastics practised in the morning proved of less
benefit than when taken at night, [h.c.w.]
Subcutaneous Injections of Camphorated Oil.— Alex-
ander' employs subcutaneous injections of camphorated oil, 1
part camphor to 9 parts of olive oil, as a stimulant in various
depressant diseases and in collapse. He has obtained excellent
results from its use in the following affections: (1) As an
abortive agentat the onset of quinsy, acute coryza and pharyn-
golaryngitis ; a single injection of 15 minims sufficing; (2) in
catarrhal bronchitis. After the fourth daily injection the
expectoration disappears even in severe cases ; (3) in fibrinous
pneumonia it lowers the temperature about 1° and perceptibly
improves the general condition of the patient. These injec-
tions are particularly indicated in old persons, in persons who
are debilitated and in those suffering from cardiac feebleness ;
(4) in the third stage of tuberculosis, the night-sweats and the
hectic fever often disappear after the first injection, and always
after the third ; the cough and expectoration diminish, the
patient becomes stronger, sleep is calmer and the appetite
improves. The intensity and duration of the hemoptysis
diminish. In tuberculosis of the larynx the pain in the
throat is lessened and the voice becomes stronger. This treat-
ment fails in the presence of profuse diarrhea; (5) in chlor-
anemia and in cardiac affections injections of camphorated oil
are very useful. By reason of the cumulative action of the
drug, headache and restless sleep are sometimes complained of
after the fifth daily injection of 15 minims of camphorated oil.
To avoid this it is advisable to stop the injections for about
eight days, [l.f.a.]
Contributions to Medical History.— The BiiUelin of the
Johns IIopkin-H Hoxpital for August-September, 19(J2, contains
four valuable contributions to the history of medicine in the
United States. The first article, by Kugene F. Cordell, on the
"Transactions of the Hartford Medical Society, 1707-S,"
is an abstract of an interesting MS. volume, the property of the
Medical and Chirurgical Faculty of Maryland. Cordell also
contributes the second article on "The Doctors Gustavus
Brown of Lower Maryland," in which he sketches briefly the
life histories of the three physicians, grandfather, father and
grandson, the latter two of whom were among the physicians
attending General Washington during his last illness. Walter
R. Steiner pictures the chaotic state of medicine in the seven-
teenth century in "A Contribution to the History of Medicine
In the Province of Maryland, 1630-1071." The paper by
Henry Barton .Jacobs on "Some Distinguished American
Students of Tuberculosis" is particularly interesting. The
sketches of Benjamin Rush, Samuel <ief)rge Morton, .James
.Jackson, William W. (iearhard, Henry Ingersoll IJowditch and
Austin Flint are accompanied by excellent portraits of these
brilliant physicians. Appreciative reference is also made to the
work of Jjawrence F. Flick, Edward D. Trudeau and Vincent
Bowditch. The contributions of America to the study of tuljer-
culosis is summarized as follows:
1. That Rush's influence directed men to study in every case
the natural history ofdi8ea.se rather than to follow blindly some
old world dictum ; in his trenlment of consumption he directed
men into the path which with slight deviations is followed still
today.
2. That Morton first brought back to America Laennec's
> Therapeutlgchc Monatsliefte, 1901 xv, 805.
2 Iji Medeclne M<)(U-rii<!, Vol. xlll. No. .W, lft02, p. 313.
methods of auscultation for the benefit of his fellow-country-
men, inculcating accurate observation and stimulating the
study of the morbid anatomy of the disease and spreading the
knowledge of it by clear description and accurate illustration.
Through his independent investigations he was led to Laennec s
andliouis' views, viz., that the tubercle, singly or in groups, is
the sole pathologic expression of tuberculosis.
3. That young Jackson discovered a new auscultatory feat-
ure in early pulmonary tuberculosis.
4. That William Gerhard disseminated widely the knowl-
edge of auscultation and percussion and Laennec's pathology of
consumption by his repeated publications.
5. That Bowditch demonstrated the pernicious influence of
unsanitary surroundings, particularly of soil moisture, on the
production of consumption and first illustrated the sate and
advantageous use of thoracentesis for pleuritic effusions which
so frequently are tuberculous in origin. Moreover, that he was
at least one of the first to revive the doctrine of the infectious-
ness of consumption and thereupon suggested a mode of treat-
ment which precluded the possibility of its direct transmission.
6. That Austin Pli nt introduced several auscultatory features
of value in determining the pulmonary condition, and by his
teachings ' was beneficial in controverting the retrogressive
teachings of Niemeyer. His careful analysis of an unexampled
series of cases widened the knowledge of the disease, and his
unbounded influence led to the early acceptance, in this country
at any rate, of the discoveries of Villemin and Koch.
7. That Flick has demonstrated that the danger lies in the
dry sputum collected in infected houses.
8. That Vincent Bowditch and others have proved that in
local sanatoria as well as in mountain resorts the consumptive
may recover.
9. That Trudeau has experimentally demonstrated the value
of pure air in resisting tuberculosis and has assisted in demon-
strating the almost complete valuelessness of socalled specific
drugs. Furthermore that he has controverted by his experi-
ments much that was false in regard to the value of tuberculin
and in other ways greatly added to the knowledge of the treat-
ment of pulmonary tuberculosis.
10. And finally that many others of our countrymen whose
names unfortunately cannot here be mentioned for lack of time,
have contributed, by their writings and by their experience, to
a fuller understanding of this disease.
Under the title, " America's Contributions to Surgery,"
Martin B. Tinker reviews the more important achievements of
American surgeons, which we may collect under an alphabeti-
cal arrangement: Bigelow, Henry Jacob : One of the first to
practise reduction of luxations of the hip- joint by manipula-
tion. Bobbs, John S. : First to perform cholecystotomy. Buck,
Gurdon : Introduced apparatus for the treatment of fractures of
the femur by extension. Carnochan, John Murray: First to
perform resection of the superior maxillary nerve beyond
Sleokel's ganglion. Crosby, Dixie; First to perform interscajm-
lothoracic amputation on removal of entire upper extremity.
Deaderick, William H.: First to perform excision of lower
jaw. Detmold, William: First to evacuate a brain abscess.
Dudley, Benjamin Winslow: First of modern surgeons to suc-
cessfully trephine for the relief of epilepsy. Dugas, L. A. ; Orig-
inated method of diagnosing dislocation of shoulder joint by
placing the hand of the dislocated side on the opposite shoulder
and trying to bring the arm to the side. Gibson, William :
First to ligate the common iliac artery ; devised a bandage for
fractures of the lower jaw still quite generally used. Hamilton,
Frank Hastings: First to suggest skin grafting. Hartley,
: Devised a method for the removal of the gasserian gang-
lion. Jackson, Charles P. : Established the value of ether anes-
thesia. Jameson, Horatio G. : First to perform excision of
upper jaw. Knight, Jonathan: Introduced treatment of aneu-
rysms by digital compression. Long, Crawford W. : First to
employ ether anesthesia. McClellan, George : Introduced excis-
ion of parotid gland into surgery; one of the first to amputate
the entire upper extremity. McDowell, Ephraim : First to
perform ovariotomy. Morton, Thomas G. : First to perform
appendectomy. Morton, William T. G. : One of the first to
introduce ether anesthesia. Mott, Valentino: First to tie tlie
innominate artery; first to perform excision of the clavicle.
Pancoast, Joseph; First to successfully perform extrophy of
the bladder. Physick, Phillip Syiig: First to advise the use of
animal ligatures" in tying arteries; invented the tonsillotome.
Heid, William 15. : Kstat)lislied in modern surgery the method
of reducing dislo'^ations by manipulation. Post, Wright ; First
to ligate the suliclavian artery on the scapular sideof thescalonl
muscles. Rogers, J. Kearny: First to ligate the subclavian
artery between the scaleni muscles. Smith, Nathan: Trephined
for osteomyelitis long before the operation was suggested by
Brodie; performed ovariotomy without knowledge of McDow-
ell's operation; taught reduction of dislocation by manipula-
tion. Swift, Joseph Iv.: First to use e.xtonsion apparatus in the
treatment of fractures. Twitchell, Amos: First to successfully
ligate the common carotid artery. Walcott, : First to per-
form nephrectomy. Warren, John : First to perform excision
of parotid gland. Warren, John Mason : First to do the plastic
operation on the hard palate, known as uranoplasty ; lirst to
puncture the pericardium for the relief of effusion. Warren,
Mason ; One of the first to treat inoperable aneurysms by com-
pression. Wells, Horace: Discovered nitrous oxid anesthesia.
[C.S.D.]
838 AMBBICAN MBDICISe;
THE PUBLIC SERVICE
[NoVXMBEB 22, 1902
THE PUBLIC SERVICE
Health Reports. — The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, during
the week ended November 1.5, 1902:
SMALLPOX— United States.
California:
San Franclpco
Oct. 26-Nov. 2..
...Oct 25-Nov. 1..
Cases
6
3
1
4
1
'.'. 3
4
2
.. 13
8
1
1
.s 20
4
.. 19
1
2
.. 20
4
4
.. 12
1
.. 14
1
1
8
5
3
.. 52
1
1
.. 20
8
1
4
6
'.'. 1
1
3
1
.. 1
.. 6
2
." 1
'.'. 7
49
3,853
38,083 3
. 225
. 58
. 49
1
.. 13
.. 45
Deaths
Florida:,
Illinois :
Indiana:
Kentucky :
Massachusetts :
Jacksonville .
Lamont
Mayport
Pensacola
Chicago
Freeport
Indianapolis...
Lexington
Boston
Cambridge
Medford
Detroit
Grand Rapids
St. Louis
Omaha
Manchester ...
Nashua
New Y'ork
Nov. 1-8
Oct. 18-Nov. 8..
Oct. 18-Nov. 8..
Oct 18-Nov. 8..
Nov. 1-8
Nov. 1-8
Nov. 1-8
Nov. 1-8
1
Nov. 1-8
1
Michigan :
Nov. 1-8
Nov. 1-8
Oct. 25-Nov. 8..
Nov. 1-8
Nov. 2-9
Nebraska :
New Hampshire;
Nov. 1-8
Nov. 1-8
Nov. 1-8
New York :
Ohio:
Nov. 1-8
Oct. 31-Nov. 7..
1
Cleveland
Hamilton
Toledo
Warren
Altoona
Erie
.rohnstown
Philadelphia...
Pittsburg
.Sioux Falls
Salt Lake City
Milwaukee
Smallpox-
Prague .'
Antwerp
Bahia
Pisaqua
Guayaquil
Bristol
London...
Manchester
Moscow
Odessa
Geneva
Yellow
Nov. 1-S
Nov. 1-8
5
Oct. 4-Nov 8....
Oct. 2o-Nov. 1..
Nov. 1-8
2
Nov. 1-8
Nov. 1-8
1
South Dakota:
Nov. 1-8
Oct. 2)-Nov. 8..
Nov. 1-8
8
Utah:
Nov. 1-8
Wisconsin :
Austria :
Nov. 1-8
-Foreign.
Oct. 18-25
Belgium :
Oct. 18-25
1
Brazil :
Chile:
Ecuador:
Great Britain :
Sept. 27-Oct. 18
Oct. 13
Oct. 18-25
Oct. 11-18
Oct. 18-25
3
1
1
Russia:
Switzerland :
Oct. 18-25
Oct. 11-18
Oct. 11-18
Oct. 11-18
Colombia:
Fevek.
Oct. 27 Nov. 3..
Costa Rica :
Ecuador:
Port Llmon....
Guayaquil
Progreso
Tamplco
Oct. 25-Nov. 1..
Oct. 18-25
2
Mexico :
Oct, 17-24
Oct.26-Mov.2.
.Oct. 25-Nov. 1..
1
5
5
Philippine Islands:
Cholkka—
Manila
Provinces
Cholera-
Insclak.
Sept. 14-20....
36
Egypt:
Sept. 13-20
Fokeign.
July 12
2,454
2 377
Japan :
Alexandria ....
Kobe
Plague— Uni
San Francisco
Plague—
Karachi
Odessa
Oct. 25-Nov. 1..
Oct. 11-18
Oct. 4-11
22
55
22
California:
TED States.
Oct. 28
India :
Russia :
Foreign.
Oct, 5-12
Oct. 18-25
8
IB
Changes in the Medical Corps of the U. 8. Army for
the week ended November 15, 1902:
BUSHNELL, Ma.jor GEORGE E., surgeon, is granted leave for one month
from about December 2.
Sinks, Captain Edward D., assistant surgeon, U. S. Volunteers is
honorably discharged, to take effect November 15, 1902, his services
being no longer required.
Austin, R. E., contract surgeon, is granted leave for two months from
November 20.
HoFF, Lieutenant^Colonel John Van R., deputy surgeon-general Is
relieved from duty in the office of the surgeon-general of the Army
to tjike effect December 1, and will then proceed to Fort Leaven-
worth for duty.
So much of orders of November 4 as relate to the discharge of Major
Ralph S. Porter, surgeon, U. S. Volunteers, is amended so as to
honorably discharge Major Porter, to take effect January 12, 1903.
his services being no longer required.
Heller, Major Joseph M, surgeon, U. S. Volunteers, Is honorably
discharged, to take effect November 30, 1902, his services belne no
longer required
Arendt, Max, hospital steward. Fort McDowell, will be sent to Fort
ttuachuca to relieve Hospital Steward Charles Gates. Steward
Gates will be sent to Fort Baker to relieve Ho.spital Steward Angus
McLcod. Steward McLeod will be sent to Fort Rodman for duty.
Butler, Will G., hospital steward. Fort McDowell, will be sent to
Fort Morgan to relieve Hospital Steward George GIbbens. Steward
Gibbens will be sent to .lefferson Barnuks to relieve Hospital .Sttw-
ard George W. Muller. steward Muilcr will be sent to Fort Leaven-
worth to relieve Hospital Steward William Bahr. .Stewaid Babr
will be sent to Manila. P. I , for assignment to duty.
Shaw, Captain Henry A., assistant surgeon, is granted leave for ten
days.
Garlington, Captain Joseph C, assistant surgeon, U. S Volunteers,
Is honorably discharged, to take effect November .30, 1902, his serv-
ices being no longer required. Captain Garlington will proceed to
his home.
The following changes In the stations and duties of contract surgeons
are ordered: William C. Mabiay, now at the discharge camp. Angel
Island, Cal., is relieved from temporary duty in the department of
California, and from further duty In the division of the Philippines,
and will proceed to Columbus Barracks for duty. Louis A. Thomp-
son is relieved from duty at Columbus Bariacks, to take effect
upon the arrival at that post of Contract Surgeon ilabray, and will
then proceed to Fort Thomas for duty.
Rhoades, Rex H.. contract dental surgeon, now at Lynden, "Wash.,
will proceed to Fort Leavenworth for duty.
Phillips, Major John L., surgeon, having reported his arrival at San
Francisco. Cal, in compliance with orders heretofore Issued, will
report to Major-Gc-nerai Adna R. Chaffee for special duty and to
accompany him to his station, and upon the completion of this
duty will report by letter to the adjutant-general of the Army for
further orders.
Merrick, John N , contract surgeon. Is granted leave for twenty days.
Belt, Harry D., contract surgeon, Fort Keogh, will proc(«d to Fort
Missoula for duty during the temporary absence of Contract Sur-
geon John N. Merrick. On completion of this duty Contract .Sur-
geon Belt will rejoin his proper station.
Changes In the Medical Corps of the U. S. Navy for
the week ended November 15. 1902 :
Waggener, J. R., medical inspector, detached from the Marine
Recruiting Station, Boston, Mass , and ordered to the Navy Yard,
Mare Island, Cal.— November 7.
Baker, J. W., surgeon, retired, ordered to the Naval and Marine
Recruiting Station. Boston. Mass.— November 7.
Drake, N. H., surgeon, detached from the Navy Y'ard, Mare Island,
Cal., and to continue dut.v on Solace — November 7.
Moore, P. A., surgeon, detached from the Indiana and ordered to the
Raleigh, when in commission— .Vovember 7.
Winslow, G. F., medical director, detached from the Naval Recruit-
ing Station, Boston, Mass., and directed to wait orders — Novem-
ber 8
Shaw, H., acting assistant surgeon, appointed assistant surgeon from
October 28, 1902— November 8
Dunbar, A. W., passed assistant surgeon, detached from the Navy
Yard, Puget Sound, Wash., and ordered to the Wyoming when
commissioned— November 10.
Alfred, A. R., passed assistant surgeon, ordered to the Navy Yard,
Puget Sound, Wash.— November 13.
Grow, E. J., passed assistant surgeon, detached from the Navy Y'ard,
New Y'ork, and ordered to the Marblehead — November 13.
Changes in the Public Health and Marine-Hospital
Service for the week ended November 13, 1902:
GEDDiNGS. H. D., assLstant surgeon-general, to proceed to Delaware
Breakwater quarantine for special temporary duty— November 3,
1902
Godfrey, John, surgeon, granted leave of absence for one month from
November 13 — November 12, 1902.
MclNTOSH. W. p., surgeon, granted leave of absence for three days
from November 27— November 10, 1902.
GuiTERAS. G. M , passed assistant surgeon, to proceed to Reedy Island
quarantine for temporary duty, relieving Assistant Surgeon T. F.
Richardson— November 10, 1902
Oakley, J. H., passed assistant surgeon, granted leave of absence for
one day— November 11, 190vi.
Wickes, H. W , passed assistant surgeon, to proceed to Cleveland,
Ohio, and assume temporary charge of the service ditring the
absence on leave of Passed Assistant Surgeon J. B. Greene— Novem-
ber 13, 1902.
Greene, J. B., passed assistant surgeon, granted leave of absence for
fifteen days Irom November •.?2— November 13, 1902.
Heiser, V. G.. asslstiint surgeon, to proceed to Philadelphia, Pa., and
report to medical officer lu command for special temporary duty—
N..vember JO. 1902.
Macdowell, W. F , senior pharmacist and chemist, relieved from
temporary duty in Waslilnglon, D. C, and directed to proceed to
New Y'ork, N. Y., and report to Surgeon G. W. .Stoner, Immigration
Depot, for duty, relieving .Senior Pharmacist and Acting Chemist
A. M. Roehrig— November 7, 1902.
Roehrig, a. M., senior pharmacist and acting chemist, upon being
relieved from duty at the Immigration Depot, New York, N. Y., to
proceed to New York (Btapletoni and report to medical officer in
command for dut.v and assignment to quarters, relieving Senior
Pharmacist Charles Miller— November 7, 1902.
Miller. Charles, senior pharmacist, upon being relieved from duty
at New York, N. Y'. (Stapleton), to proceed to Pensacola, Fla., and
report to the Acting Assistant Surgeon in charge of the .Santa Rosa
quarantine station for temporary duty— November 7, 190;;.
Boards Convened.
Board convened to meet at Washington, D. C, for the consideration
of the Act of Congress approved July 1, 1902, entitled "An act to regu-
late the sale of viruses, serums, toxins, and analogous products in the
District of Columbia, to regulate interstate traffic in said articles, and
for other purposes." Detail for the board— Assistant Surgeon-General
L. L. Williams, chairman; Assistant Surgeon-General H. D. Gcddings;
Passed Assistant .Surgeon M. J. Rosenau ; Assistant Surgeon B. S.
Warren, recorder.
Board convened to meet at the U. 8. Marine Hospital, Chelsea,
Mass., November 17, 190.'. for the physical examination of officers of
the Revenue Cutter Service. Detail for the board— Surgeon R. M.
Woodward, chairman ; Assistant Surgeon W. K. Ward, recorder.
American Medicine
i
GEORGE M. GOULD, Editor
O. C. C. HOWARD, Managing Editor
CHARLES S. DOLLEY
MARTIN B. TINKER, AiHatant Editor!
Clinical Medicine
DAVID RiKSMAN
A. O. J. Kkllt
J. Edwin Swekt
Helen Mukphy
Oeneral Surgery
Martin B. Tinker
A. B. Craio
Charles A. Obb
Orthopedic Surgery
H. Augustus Wilson
COLLABORATORS
Obstetrio and Gynecology
Wilmer Krusen
Frank C. Hammond
yervous and Mental Diseases
J. K. Mitchell
F. 8a VARY Peaboe
T^reatraent
Solomon Solis Cohen
H. C. Wood, Jb.
L. F. Appleman
Dermatology
M. B. Hartzell
Laryngology, Etc.
D. Bbaden Kyle
OphttuUmology
Walter L. Pyle
Pathology
R. M. Pearce
PUBLnHSD WiRKLT AT 1321 WaLITUT StBXIT, PhILADBLPHIA, BT THB AUBBICAN-MbDICINB PUBLUHINe CoUTAIfT
Vol. IV, No. 22.
NOVEMBER 29, 1902.
15.00 Yearly.
Political and Professional Ethics. — In a com-
munication, wiiich for the writer's sake we prefer not to
publisii, we receive a protest against tiie advice tliat
piiysicians should vote for those political candidates
who are in favor of professional and hygienic progress
rather than for other candidates who are opposed to
medicine and sanitary measures for the betterment of
the health of the community. Our critic thinks this is
inethical, a prostitution of one's suffrage, cites Virchow's
example as against such a course of action, etc. It is
said also that no body of men will stand together to
accomplish a common political end, and that medical
men especially will not do so. As to the ethics of the
subordination, by physicians, of political partisanship
to sanitary progress, we hold that this is axiomatic and
admits of no discussion. Virchow's example is a
demonstration of this view, not of that of our critic.
As to the organization of the profession, it has been
found feasible, and great reforms have been realized by
it in England ; it is fast coming in our country. Our
critic's contention is so manifestly absurd that we should
not have noticed it were it not that the last half of his
letter is filled with an attempted demonstration that
altruism and ethics are right and possible and advis-
able for the sucx-essful physician, but not for the young
man who is struggling for place. We quote the words
of this teacher of morals, as follows :
" Give me a reputation and I can well afford to be an honest
doctor— aye, my honesty will be my fortune. Start me
unknown and there is a premium on rascality."
This atrocious nonsense would apj)ear ludicrous and
ironical. It is most seriously meant. The more "suc-
cess" the writer has the less " honest " he will be.
Foolish Leniency to Professional Scamps. — In
nearly every community and in all cities there is at least
one medical rogue unjailed. He is at heart a thorough
quack, although the degree of M.D. was once conferred
upon him. He probably belongs to the local and State,
and perhaps even to the national, medical organizations,
but as the latter society would not help him to secure
victims he cares little for it. When a patient appears in
his office by the help of the many secret sources he
attends to so carefully, there is first made a thorough-
going calculation of how much can be got out of him by
all the tricks and devices of the confidence man, the
intimidator, and the alarmist. Expensive instruments
must be bought by him of the firms named, secret prepa-
rations of the druggists named, and long treatment is
required by the very great and learned (but very cun-
ning) doctor. When the patient's money and patience
are exhausted he is suddenly cured, discharged, or law-
suits are instituted or are threatened, etc., according to
the existing conditions. Every reputable physician in
the community knows of this scalawag and of his ways,
but none dares say a word against him. The censors of
the local medical society are not incensed or only so
mildly so that action is never undertaken. The scandal
is known to the community, but the result is to make its
anger more pronounced at the entire medical profession. It
is held that we are all more or less " tarred with the same
stick " or we would not allow these fellows to go on profit-
ing by our professional association. Thusisantimedicalism
and the race of healers encouraged. Is there no remedy ?
Patent Insldes and Duplicate Manuscripts. —
The fatuous organizers of the patent-insides scheme of
medical journaMsm have lapsed into silence under the
indignant protests of all professional journals. There is
a variant of this plan, however, which is still to receive
its quietus — the method of many journals synchronously
publishing the same article. It began a number of
years ago with the plan of sending two copies of an
article to two different journals, and it is ending in a
hundred or more copies of a paper, sometimes in praise
of some special remedy, to all the journals of the list.
Sometimes the plea is made that, like the addresses of
the presidents of national societies, " this contribution"
is so tremendously important that it "should not be
buried in one journal." Such pleaders forget that their
motive is selfish ; that the scheme is hardly consistent
with professional dignity ; and that it does not encour-
age professional journalism. If an article is "buried"
in one journal-grave, it certainly behooves the chief
mourners to prevent the existence of several hundred
unfilled and yawning graves, awaiting corpses. Occa-
sionally even the leaders of the profession will forget
to notify the editors that they have sent their articles to
others. Naturally it often happens that the least worthy
journal, hungry for papers, secures precedence by rush-
ing violently into print, occasionally even violating the
unwritten laws of editorial courtesy and honor in order
840 AMBRICAir Mbdioihb
EDITORIAL COMMENT
(November 29, 1902
to anticipate the publication by other journals. It is
true that in such cases the offending journal may possibly
be l)lacklisted by the profeasional leader, who sees his
" enterprise " negatived by too great avidity on the part
of one publisher. The syndicating author also is pun-
ished by missing his " wider audience" and by the sus-
picion that may possibly attend future receipt of MSS.
from him on the part of the more honest journals.
Besides, when the scheme succeeds, the silent majority
of physicians, the great body of working and earnest
, professional men, are sure to recognize that the medical
politician's undue desire for publicity is merely to inflate
his own reputation. While reputation may gain for a
time by such shallow cunning, the character of the
offender is sure to be discounted eventually by the
observer, in this case the reading physician to whom the
enterprising syndicating author appeals. But who is to
compensate the publisher who takes the syndicator in
good faith, has his article in type and illustrated, often at
great cost, and must lose prestige and money by the desire
of author and rival publisher for publicity and precedence ?
Those who seek selfish ends under the plea of
advancing scientific interests, aid to maintain the nonpro-
fessional and unprofessional journals through which so
many evils arise, evils that we can only be rid of by
independence and professional ownership and control.
They furnish the ideas for the patent-insides schemers,
and must be held ultimately responsible for such
attempts to debase the profession through its journals.
The W. C. T. U. and Real Temperance " The
Superintendent of the Department of Anti- Narcotics for
Philadelphia County," writes in defence of her organi-
zation (the W. C. T. U.) in reply to Dr. Howard 8.
Anders. American Medicine was quoted by Dr. Anders
in the Public Ledger as to the folly of a campaign against
beer, for instance, when the patent medicine syndicates
were allowed freely and uncriticised to sell "bitters"
containing ten times as much alcohol. The " defence "
is only in words of lofty and abstract glorification of the
W. C. T. U., which, says the "Superintendent, etc.," is
wide awake to this evil. But, dear "Superintendent of
the Department of Anti-Narcotics, etc.," do tell us when
and where and how you "have not been asleep, but
fully aware, etc." You say of yourselves that yours
" is the largest organization of women in the world,
numbering hundreds of thousands, banded together for
one common purpose, namely, the best good of humanity
against the worst evils, and always on the side of right,
for which we receive the anathemas of all those who
would profit by preying upon the mental, moral and
physical welfare of their fellow men,, but we are in the
right and hope to succeed." And yet in your banner
State, Vermont, the people are tired of prohibitioq,
which is a dreadful failure, and are going back, or rather
forward, to local option and high license. Almost all
educators and the entire medical profession agree that
your socalled " school physiology " crusade is neither
in the interests of true education nor of genuine temper-
ance. Every one who has carefully looked into the mat-
ter knows that your enforced temperance breeds intem-
perance, and your extreme antialcoholism begets worse
forms of drug intemperance. Army officers and Arch-
bishops are convinced that your abolition of the army
canteen was a blunder worse than a crime. When, and
where, and how have you attempted to limit patent
medicine alcoholism, while you were so active in the
ways set forth above ? In all of your crusades do you
even now show one sign of recognition of the wisdom of
adding knowledge to your zeal?
"The slaughter of the innocents," according to
an English statistician, is today as great in his country
as it was 50 years ago. In 1900 there were born in Great
Britain 927,062 children, and of these 142,912, or at the
rate of 163 per 1,000, died within one year. Died, or
were killed ?— one is inclined to ask when the conditions
are closely inspected. In the agricultural counties the
rate often falls below 100, in one as low as 79, while in
the manufacturing and mining regions it runs from 170
to 180. One writer (Mrs. Tennant, in Professor Oliver's
Dangerous Trades) describes the evil of employing young
women in factories who know nothing of the arts and
duties of home life, baking, washing, sewing, etc., and
who bring forth daughters who are as ignorant of these
things, and worse still, of the care of children, as were
their mothers. Thus a special class of women is devel-
oped who inherit the want of home-making and child-
raising ability. Secondarily there is begotten another
class, the substitute mothers and substitute housewives.
Another woman, an inspector, writes as follows of^both
classes of these unmothering mothers :
" They feed and clothe their children improperly, and neglect
the most elementary sanitary precautions, thereby making
their homes veritable hothouses for disease germs of all kinds.
Young babies are fed on bread and starchy foods, and in many
cases have in addition exactly the same diet as the rest of the
family, including bacon, potatoes, currant buns, stewed tea, and
even beer ! They drink cheap condensed milk and water out of
filthy long-tubed bottles, are frequently left unwashed until late
in the day, are exposed to the broiling sun in the summer and
to the cold winds of winter and spring, etc."
The Medical Press, from which we glean the forego-
ing facts, says that the advantages resulting from the
attempt to check this vicious tendency by the English
Infant Life Protection Act of 1897 are evident from the
fact that the movement has already proved successful.
Those who are working for such governmental oversight
in our country may he encouraged by this fact.
"Guilty Intention." — The eddyites, the demi-
eddyites, and the pseudoeddyites, through their organs,
the yellow journals, are making much of the contention
that the "healers" should not be punished for the
deaths of their victims any more than should physicians
when death follows their attendance upon the sick. As
immortal earthly life has not yet been discovered, the
logic seems somewhat faulty. It is, however, based
upon the statement that the healers do not wish the
death of their patients, and that there can be no guilt
without a guilty intention. All government is carried
on by means of laws to protect the ignorant and innocent
from the injurious effects of acts, whether intentionally
criminal or not. Civilized society could not last a day
if the law punished only those intentionally wicked.
If a smallpox patient ignorantly goes into a crowd, the
November 29, 1902]
EDITORIAJ. COMMENT
AMKRICAN MKDtOINB. 841
unvaccinated in that crowd will suffer just as much as if
he intended to scatter the germs of the disease. The
grand jury are therefore perfectly right in indicting the
eddyite Quimbys and Lathrops for manslaughter. The
allowance for intention is made by the law by the fa<?t
that the indictment is for manslaughter in the second
degree. That it should be in no degree whatever only
the race of the antis, the pseudos, and the demis would
think of suggesting. That principle in law would
instantly deprive the healers and the antis themselves
of the very governmental protection which enables
them to live with outraged and indignant neighbors.
"The Newer Dispensation." — There is needed a
word to describe and name the thousand kinds of occi-
dental representatives of the Oriental religions, mysti-
cisms, and occultisms. It is a new product in the world,
or almost a new one, for all the Eastern and ancient
exponents of these mystic beliefs were frankly crazy or,
at least, patently sincere. They believed, or believed they
believed, most absolutely in their own unbeliefs. One
cannot imagine a really Oriental " Purple Mother," or
a many-husbanded one. The occidental contribution to
the nonsense and nonscience of the Orient is cunning and
humbug. It is a strange mixture, and it must be a
mechanical rather than a chemical one. There is a wink in
the glance of the modern western hazyist. While ordering
the belief by her sillies of a thousand unbelievable nonsen-
sicalities, she " gathers in the dollars " by ail the arts of
a consummate commercial cunning. There is, of course,
a truly occidental differentiation of function in the evo-
lution : the haze, mysticism, ignorance, etc., are for the
disciple-dupe, the cunning and the dollars for the
mothers, purple, scarlet, or yellow, as the case may be.
That the editor of the Contemporary Review should have
been foolish enough to give up his columns to a hazyist
is a proof of the impertinence of ignorance and of the
deterioration of journalism. In the November number
there are 14 pages of eddyrotic nonsense entitled " The
Newer Dispensation." There is coming, it is said, a
great unity of Christianity, faith-cure, eddyism, theo-
sophy, occultism, spiritualism, and physical science.
This is called the newer dispensation — from which, as
from pride, vainglory and hypocrisy, good Lord
deliver us! The profession ha.s, it seems, been too
stupid to see the truths of the hazyist, and we are to be
improved and taught by the eddyite variety. This is
the way we are toploftily dismissed :
Physicians only claim to assist nature, and when we
remember the difflculties of diagnosis and the liability to get
on a wrong track and hinder ratlier than assist, we see the need
of more reliable treatment. This need is emphasized when we
see the tendency of physicians to despair of their own art, and
to hand their patients over to the terrible knife— to the more
progressive art of surgery. So Christian " Science," although so
bitterly opposed, may yet prove a benefactor in disguise to the
doctors by inducing them to improve their methods, and to re-
gard their patients as something more than mere physical bodies.
Whatever the medical value of the new cult, it may safely
be contended that in mind we have tlie best of all physicians,
and that in the exhauslless store of vital energy of the universe
we have an ever-present supply of the best of all medicines;
that faith, courage, cheery confidence, give the mental attitude
which enables us to avail ourselves of this medicine. In the
absence of personal faith the faith of the mental healer can
supply its place, and the mysterious action of mind on mind
aids recovery. The more the mind can withdraw itself from
the basement, and the lower stories of its habitation, the body,
and the more it can live In its upper stories the stronger will be
its command over the body, of the mind over matter.
In a case of diphtheria or lues the prescription should
therefore be :
Pr Of the exhaustless store of the 1
vital energy of the universe j
Misce ad aeternitatem.
Sig.— Pro re nata.
q.s.
The Holy Ghosters is another of the thousand
fanatic sects that are springing up. It has its head-
quarters in a little town in Maine where It has a temple,
ceaseless prayer, and where some 200 paupers, so fear the
citizens, will be thrown upon the town when the craze
explodes. The "Holy Ghost," not the parents, takes
care of children when they fall down stairs, and the
treatment of the sick of course falls upon the same
agency. So David Thompson preferred to die from
pneumonia with the help of the " healers" rather than
to call in a physician. All members must be baptized
by immersion three times face downward in the river
through holes cut in the ice. Mrs. Lombard died a few
days after her baptism. This is excellent treatment for
adults, but the State of Maine should protect children
from such cruelty. By the way, why are the antivivi-
sectionlsts and the societies for the prevention, etc., not
indignant, just a little indignant, at least, at the cruel-
ties practised upon minors by the insane?
The Pathology of Katabolisni.— In presenting the
concluding portion of Dr. Wakefield's able discussion of
the pathology of katabolism, particularly the etiologic
relationship of katabolic stasis to carcinoma and sup-
posedly allied conditions, we refer again to its impor-
tance and suggestiveness. The paper has already awak-
ened considerably interest, and will doubtless stimulate
research in a field as yet practically untilled. It repre-
sents a conscientious effort to advance knowledge of a
subject concerning which ignorance is great and must be
accepted or rejected on its merits. It must be read ia
full that its full import may be appreciated, and it must
not be rejected merely because in some respects it run*
counter to prevailing opinions — since in reality this
contradiction may be in advance of present day knowl-
edge. A consideration as thoughtful as the care
bestowed upon its preparation should be accorded.
The life of St. Luke, the physician, is the sub-
ject of an interesting monograph by Edward Clapton,
M.D., physician to St. Thomas' Hosi)ital (London, 1902 :
J. & A. Churchill). While the amount of definite
information about the apostle's life and medical career
seems to be very meager, even the few facts given wilJ
be of considerable interest to the profession which recog-
nizes St. Luke as an honored member. Clapton finds
that St. Luke was probably born at Antioch, then the
metropolis of Syria, at about the year 15 B. C. At
that time Josephus spoke of it as the third city of the
Iloman Empire, the "Crown of the East." And among
its magnificent public buildings was a university with a
medical school connected. Luke was a Greek gentile,
as he states, " not of the circumcision," and he acquired
942 AXKKIOAN MiSIOllriB,
REVIEWS
{NOVBMBEB 29, 1U02
ooiislderable literary culture as well as metlical educa-
tion at the University of Antioch. While there he
became a Jewish proselyte, and at that time the name
by which we know him was probably adopted. Possi-
bly his Jewish religion led him to settle in Jerusalem
when he was about 24 years of age. Here he was, no
doubt, more than welcome as a skilful physician with a
liberal education, having many good introductions. At
the time there were no regular qualified medical men,
and the practice of medicine among the Jews was almost
purely empirical. He was, no doubt, an eye-witness to
most of the events about which he writes in his gospel
and Acts of the Apostle, and he seems to have remained
in Jerusalem from the time of the Ascension of our Lord
to the conversion of St. Paul. With the first gather-
ing of the church at Antioch he was sent there to reside
and confirm its members. When there he arranged
most of his writings for publication. In the time dur-
ing which he was in Greece, before the arrival of St.
Paul, he evidently had to do with the management of
the churches, "going before and tarrying for Paul." His
ministrations in these churches had taken him on his
way through Pergamos, which at that time had the largest
library in the world next to Alexandria, and near which
on a conical hill had been erected the temple of ^scu-
. lapius. His wanderings also took him to Epidaurus,
where there was a famous temple of iEsculapius and a
school of medicine, and hospital for 128 in-patients.
Luke also mentions his visits to Cos, the Island on which
Hippocrates was born and where there was a celebrated
school of medicine as well as a museum and hospital.
Hence it would seem that while St. Luke is best
known to us as the apostle and minister, added to his
thorough medical education he must have had an unusu-
ally comprehensive idea of the state of medical science
at that time from a visit to the chief centers of medical
education of that day and association with men promi-
nent in his profession. As a physician his practice was
not ^sculapian or Jewish, but Greek, according to the
best principles of that day. The universal testimony is
that St. Luke was a most faithful, pious, and self-denying
Christian ; that he had a cultivated intellect and was
thoroughly honest and impartial in all of his descrip-
tions Of persons and events. He described nothing but
what he witnessed himself or received direct from those
immediately concerned in what he so faithfully recorded.
He met his death about the year 67 at the age.of 82.
It seems a great misfortune that more is not known
with regard to his medical career.
Revival of the " Index Medicus " Assured. — Just
as we are going to press we receive the information that
the trustees of the Carnegie Institute have decided to
revive the lnd£x Mediem, a measure first advocated in
American Medicine September 27. .Details are lacking,
but we hope this wise resolution will embrace the con-
tinuance of the Index from the time of its suspension,
since all the material is readily available. We con-
gratulate the profession upon this great addition to
the equipment of medicine, and the Carnegie Institute
upon the beneficent wisdom which has directed this
action.
BOOK REVIEWS
The Diseases of Infancy and Childhood. — For the use of Stu-
dents and Practitioners of Medicine. By L. Kmmett Hoi.t,
M.I)., LL.D. With 225 illustrations, including nine
colored plates. Second edition, revised and enlarged.
New York: D. Appleton & Company, 1902.
Probably no important department in the whole field of
medical science is so poorly understood andsolittleappreciated
by the average recent graduate in medicine as the subject of
pediatrics. In this branch of medicine Dr. Holt is authority,
and his excellent textbook needs no introduction to the profes-
sion. Students and practitioners, however, will be pleased to
learn that a second edition, thoroughly revised and up to date,
has recently appeared. Since the first edition of this valuable
book much progress has been made in the proper care of chil-
dren ; particularly is this true in infantile dietetics. The author
has, in the present edition, made many changes in this impor-
tant particular, making the work thoroughly abreast of the
times. A criticism which occurs, however, is that'in his tabula-
tion of infant foods no discrimination is made between the milk
foods and the milk-modifiers. These results therefore vary
from standards accepted by the profession. We ))espeak for the
volume the cordial reception which it will doubtless receive at
the hands of the profession.
Work Book In Surgery. — Comprising the Principles of Gen-
eral Surgery and Surgical Procedure. By Luzkrne
OoviLLE, Lecturer on .Surgery, formerly Lecturer on
Anatomy, Cornell University Medical College, at Ithaca;
sometime student at P. <fe S. in New York. 1902. Privately
printed. Ithaca, N. Y.
This little book of near 300 pages is not intended by the
author as an exhaustive treatise on surgery, but is rather a
brief, terse handbook on the principles of surgery. Operative
surgery in the fullest sense is left to the larger volumes. The
work is particularly adapted to the needs of students of surgery
In the second and third years of the medical course, and to such
it will prove a most convenient and valuable textbook. Its
brevity and clearness relieves the student of much that is
cumbersome and practically useless In the larger textbooks.
The paper used is of good quality, the printing satisfactory and
the author's English is lucid and forceful. We trust the volume
may have the wide circulation which it merits.
Progressive Medicine.— Edited by Hobart Amory Hare,
M.D., assisted by H. R. M. Landis, M.D. Volume -HI.
Lea Brothers & Co.
This, volume III for 1902 of the .wellknown quarterly.
Progressive Medicine, contains a critical digest of diseases of
the thorax and its viscera. Including the heart, lungs" and
bloodvessels, by Dr. William Ewart ; of dermatology and
syphilis, by Dr. William S. Gottheil ; of diseases of the nervous
system, by Dr. William G. Spiller ; and of obstetrics, by Dr.
Richard C. Norris. The several subjects are well and exhaus-
tively treated by the respective contributors, and on the whole
the volume, reflecting recent advances in the different depart-
ments of medicine to which it is devoted, forms a valuable
addition to contemporaneous medical literature.
Transactions of the Medical Association of the State of
Alabama.— Brown Printing Company, Montgomery, Ala.
This volume of 488 pages contains the full report of the
meeting of 1902, held at Birmingham, April 15-18. The scientific
program includes 46 papers, embracing a wide range of medical
and surgical topics. The appearance of the Transactions is
more prompt than is usual with such publications.
Atlas and Epitome of Traumatic Fractures and Dislo-
cations.— By Professor H. HBiiFERioH. Edited by
Joseph C. Bloodgood, M.D. W. B. Saunders & Co.
The original intent of the author in writing this epitome is
tersely expressed by himself "out of my desire to perfect the
explanations accompanying the plans." This has been well
executed. The 216 colored illustrations and 190 cuts (including
numerous reproductions from Rontgen-ray plates) are, in
themselves, explanatory of the auatomy and diagnostic features
of most of the important and many of the minor and less
frequent fractures and dislocations. The subject-matter is not
as full as one would expect in a volume devoted entirely to a
NOVEMBBB 29, 19021
REVIEWS
(Amkkican Medicink, 843
single department of surgical practice ; this is especially appli-
cable to the paragi-aphs devoted to treatment. Much has been
done, however, by the editor of the present translation to over-
come this deflciency of the original text. To the student the
volume will be particularly valuable as an aid to a comprehen-
sive knowledge of the anatomy and diagnosis of fractures and
dislocations, and as a ready reference book for the general prac-
titioner it is admirably adapted.
A Treatise on Diseases of the Skin.— By Henry W. Stel-
WAGON, M.D., Ph.D. W. B. Saunders & Co. : Philadel-
phia and London, 1902.
The keynote of this handsome volume of more than 1,000
pages, in which there is not a superfluous page, is practicality.
As stated in the preface, it was the author's aim to produce a
practical treatise which should be useful to the general practi-
tioner in the recognition and management of those diseases of
the skin with which he daily comes in contact, and a careful
examination of the book shows that he has been more than
ordinarily successful in the accomplishment of his purpose.
While the more strictly scientific aspects of dermatology, such
as pathology and pathologic histology, are given due considera-
tion, it is in the sections upon diagnosis and treatment that
the intensely practical character of the treatise is especially
manifest, these being elaborated with unusual care. In the
section upon General Symptomatology, the primary and
secondary lesions of the skin are minutely described, the
author believing that without an accurate knowledge of these
any correct comprehension of the various cutaneous maladies
is impossible. The section upon General Diagnosis seems to us
especially worthy of notice ; we have never seen the subject
better treated, and it is well worth careful reading. Special
attention is called to the fact that the distribution of the erup-
tive lesions often affords very valuable aid in diagnosis, a point
upon which sufficient stress is not laid by the majority of
writers. We quite agree with the author as to the frequently
misleading character of histories as obtained from the average
patient; to pay much attention to these is to fall into error fre-
quently. Owing to the difference of opinion concerning the
identity of lichen ruber and pityriasis rubra pilaris, Hebra's
own account of the former affection is reproduced. The latter
malady is regarded, properly as we believe, as a distinct aft'ec-
tion. The parasitic origin of psoriasis is regarded as probable, its
occurrence in several members of the same family arguing just
as strongly for infection as for hereditary transmission. We
believe that future research will demonstrate the correctness of
this view, ^]czema is held to be a catarrhal inflammation of the
skin, due to a great variety of causes, some of which arise within
the organism, others externally to it. While admitting the fre-
quent presence of microorganisms, the parasitic origin of the
diseases is not regarded with much favor. The management of
this very common and protean affection is treated at length
and with the careful detail its importance merits. Both local
and constitutional remedies are believed to be necessary for
permanent success. It is pointed out that there are no specifics
for eczema, but that the treatment, both local and internal,
must be carefully adapted to the needs of each case. Not only
are the remedies believed to be useful mentioned, but what is
quite a-s important, the manner of using them is minutely
described so that they may be intelligently employed. The re-
cently much discussed eczema selmrrhoicum is treated in a sepa-
rate section. The author limits the use of this term much more
than IJnna and his followers, applying it only to those ca.ses
which may be considered to be a combination of a mild eczema
with seborrhea. Tothe dermatologist one of the most valuable
features of the book is the al)undant references to the literature
of dermatology which appear on almost every page. These add
immensely to the value of the treatise as a work of reference,
and ought to insure it a place in the library of every working
dermatologist. The volume abounds in bea\itiful illustrations
which are for the most part reproductions of photographs, with
!i number of colored plates. The photfigraphic reproductions
iiri- unusually fine and worthily supplement the text. In con-
ilnsioii, wo regard this treatise as one of the best which has
tliiis far appeared from the pen of an American author, useful
:il ike to the student as a textbook, to the practitioner as a reli-
able guide in the treatment of cutaneous diseases, and to the
specialist as a thoroughly up-to-date work of reference.
BOOKS RECEIVED.
[Prompt acknowledgment of books received will be made in this
column, and from time to time critical reviews will be made of those
of Interest to our readers.]
Clinical Methods By RoBKRT Hdtchison, M.D., M B.C P.,
Assistant Physician to the London Hospital, and to the Hospital for
sick Children, Great Ormond Street; and Harry Kainy, M.A.,
F.R.C.P. (Ed.). F.K.8.E., University Tutor in Clinical Medicine, Boyal
Intlrmary, Edinburgh Fifth edition, with 150 Illustrations and 8
colored plates. W. T. Keener & Co., 1902.
The New York Aledtcal Directory of New York, New Jersey
and Connecticut : Vol IV. The New York State Medical Association,
1902-1903.
A Compend of Human Physiology : Especially adapted for the
use of medical students —By Ai.bekt P. Brubakek. A M., M.D.,
Adjunct Professor of Physiology and Hygiene in the Jefferson Medical
College, etc. Eleventh edition, revised and enlarged, with Illustrations
and a table of physiologic constants. Price, 80 cents net. P. Blakiston's
Son & Co., Philadelphia, 1902.
Tabetic Ataxia: An e.xposltlon of the principles and practice of
compensatory movement treatment.— By H. S. Frenkel, Medical
Superintendout of the Sanatorium *' Krelhof " In Helden, Switzerland.
Only authorized English edition, translated and edited by L. Frey-
BBRGEK. M.I) (Vienna), M.R.C.P. (Lond.), M.R.C.S. (Eng.), Hon.
Physician to the St. Pancreas and Northern Dispensary, etc. With 132
Illustrations. Price, 8:5.00 net. P. Blakiston's Son & Co., Philadelphia,
1902.
Practical Examination of [Jrlne: For the use of physicians and
students.— By Jamks Tyson. M.D., Professor of Medicine In the Univer-
sity of Pennsylvania, etc. Tenth edition, revised and corrected, with
a colored plate and wood engravings. Price, $1.50 net. P. Blakiston's
Son & Co., Philadelphia, 1902.
Elementary Hygiene for the Tropics.- By AZRL Ames, M.D.
(Harvard), 1871, late Major and Brigade Surgeon, U. 8. Vols., etc.
Price, 60 cents. D. C. Heath & Co., Boston, 1902.
A Nurse's Guide for the Operating-room.— By Nicholas Senn,
M.D.. Ph.D., LL.D., CM., Professor of Surgery, Rush Medical College,
in affiliation with the University of Chicago; Attending Surgeon to
the Presbyterian Hospital, etc. W. T. Keener & Lk)., Chicago, 111., 1902.
A Textbook of Anatomy.— By American authors Edited by
Frederick Henry Gurish, M.D., Profe.ssor of Anatomy in the
Medical School of Maine, Bowdoln (;ollege. Second edition, revised
and enlarged. Illustrated with 1,003 engravings in black and colors.
Lea Brothers & Co., Philadelphia and New York, 1902.
Mannal of Gynecology.— By Henry T. Byford, M.D., Professor of
Gynecology and Clinical Gynecology in the College of Physicians and
Surgeons of Chicago; Professor of Gynecology In the Postgraduate
Medical School of Chicago, etc. Third revLsed edition, containing 363
Illustrations. Price, 83.00 net. P. Blakiston's Son & Co., Philadelphia,
1902.
Diet and Food. — By Alexander Haig, M.A., M.D. Oxon.,
F.R.C P., Physician to the Metropolitan Hospital and the Royal Hos-
pital for Children and Women. Fourth edition, with 7 Illustrations.
Price. 8t 00 net. P. Blakiston's Son & Co., Philadelphia, 1902.
A Manual of Medical Treatment: Vols I and II. By I. Bcbnky
Yeo, M.D , F R.C.P , Emeritus Prolessorof Medicine In King's College,
London ; Consulting Physician to King's (;allege Hospital, etc. Tenth
edition. W. T. Keener & Co., Chicago, 1902.
Pathology and Pathological Anatomy.— By Hans Schmau.s,
E.xtraordlnary Professor and b'lrst Assistant In the Pathological Insti-
tute, Munich. Tanslated from the sl.\th German edition by A. E.
Thayer, M.D., Instructor in Pathology in the Cornell University
Medical College, New York. Edited, with additions, by James EwiNG,
.M.D , Professor of Pathology In the Cornell University Medical College,
New York Illustmted with liil engravings. Including 35 colored Inset
plates. Lea Brothers & Co., Philadelphia and New York, 1902
Genitourinary and Venerea] Diseases. — By LouiS K. SCHMIDT,
M.Sc, M.D., Associate Professor of (Jenltourlnary Diseases, Chicago
Polyclinic, etc. Series edited by V. C. Pkdehmen, AM., M.D., recently
Associate Demonstrator of Anatomy. College of Physicians and Sur-
geons, Columbia University, New York City; House Surgeon of New
York Hospital, etc. Illustrated with 21 engravings I^ea ijros. it Co.,
New York and Philadelphia, 1902.
Transactions TVIsconsIn Slale Medical Society, 190%, — State
Journal Printing Company, Madison, Wis.
The Public and the Doctor.- Published by Dr. B. E. Hadra,
Dallas, Tex.
Diseases of the Skin —By Joseph Orindon, Ph.B., M.D., Profes-
sor of Clinical Dermatology and Syphilis, Washington University ;
Dermatologist to the O'Fallon Dispensary, .St. Louis MuUanphy Hos-
pital, etc. Series edited by Bern. 11. (*ali.auI)ET .M.D., Demonstrator
of Anatomy and Instructor In .Surgery. College of Physicians and Sur-
geon.s, Columbia University, New York, etc. Illustrated with 39engrav-
Ings "Lea Brothers A- Co., Philadelphia and New York, 1902.
transactions oftlie Colorado State Medical Society.— Published
for the Btx;lely, August, 1902.
The Science and Art of Obstetrics By Henry J. Oarbioues,
A.M., M.D, Consulting Obstetric Surgeon to the New York Maternity
Hospital ; Gynecologist to St. Mark's Hospital, etc. With 504 Illustra-
tions. Price, cloth, ».').00; sheep, (Nl.OO. J. B. I-lppincott Co., Philadel-
phia, 1902.
International Clinics: A <iuarterly of Illustrated clinical lectures
and especially prepared articles on medicine, surgery, neurology,
therapeutics, obsletrUs, pediatrics, pathology, etc.— By leading mem-
bers of the medUail profession Miroui;lii>nt Ihe world. Edited by
IIknrv W. Cattrm,, A.m., M.D., I'liliiulcl|>lilH. Vol. Ill, Twelfth
series, 1902. J. B. LIpplncott Co., Phllailclpliiii, 1902.
A Treatise on Massage.— By DriuoLAS Graham, M.D., member
of the American Association for the Advancement of Science, etc.
Third edition, revised, enlarged and Illustrated. J. B. LIpplncott Com-
pany, Philadelphia, IMM. Price, tl 00.
814 AVBBIOAN MEOIOIKBI
AMERICAN NEWS AND NOTES
[NOVEMBBB 2», 1902
Trannsotlonit of the Medical Aonoolatlon of State of Alabama :
Organized 1847; meeting of 1902. Brown Printing Co., Montgomery,
Alabama, 1902.
Practice of Surgery.— By Hknry K. Wharton, M.D., Clinical
Professor of Surgery, Woman's Medical College of Pennsylvania and
the Children's Hospital, etc., and B. h'ARtiUHAB Curtis, M.U., Profes-
sor of Clinical Hurgerv and Adjunct Professor of the Principles of 8ur-
fery in the University and Bellevue Medical College of New York, etc.
'rofusely Illustrated. Third edition. J. B. Lippfncott Co., Philadel-
phia, 1902.
Human Anatomy: A complete systematic treatise by various
authors. Including a special section on surgical and topographical
anatomy.— Edited by Henry Morri.s, M.A. and M.B. Lond., F.R.i; fe.,
Eng. Member of the Council (late vice-president) of the Royal College
of Surgeons of Kngland, ete. Illustrated by !M(i wood cuts, the greater
part of which are original and made e.xpressly for this work by special
artists ; 2m are printed in colors. Third edition, revised and enlarged.
Price, 8(i.0O net. P. Blakiston's Son & Co., Philadelphia, 1902.
Tlie Diseasen of tlie Blood By Ai-feed C. Coles, M.D,, B. Sc.
of Public Health, Edinburgh. Formerly Senior House Surgton of the
County Hospital, York. Second edition, with si.x colored plates. J. &
A. Churchill, London, 1902. P. Blakiston's Son & Co., Philadelphia.
Tlie American Text-book of Obstetrics: In two volumes —
Edited by Richard C. Norkis, M.D.; Art Editor, Robert L. Dickin-
son, M.l5. Second edition, thoroughly revised and enlarged. Two
handsome Imperial octavo volumes of about BOO pages each ; nearly 600
textrillustrations, and 49 colored and half-tone plates. Per volume,
cloth, Si .'iO net; sheep or half morocco, $1.00 net. W. B. Saundere & Co ,
Philadelphia, 1902.
A Handbook of Materia Medlca, Pharmacy and Therapcn-
tlcs By Samuel O. L. Potter. A.M , M.D., M.R.C.P. Lond.. form-
erly Professor of the Principles and Practice of Medicine in the Cooper
Medical College of San Francisco, etc. Ninth edition, revised and
enlarged. Price, *5.00 net. P. Blakiston's Son & Co., Philadelphia, 1902.
Diseases of the Pancreas and their Surgical Treatment.- By
A. W. Mayo Robson, F.R.C.S., Senior Surgeon, Leeds General Inflrni-
ary ; Emeo-ltus Professor of Surgery, Yorkshire College, Victoria Uni-
versity, England; and B. G. A. Moynihan, M.S. (Ijond ) F.R.C.S.,
Assistant wurgeon, Leeds General Infirmary; Consulting Surgecm to
the Skipton and to the Mirfleld Memorial Hospitals, England. Hand-
some octavo volume of '293 pages, illusti-ated Cloth, $3.00 net. W, B.
Saunders & Co., Philadelphia. 1902.
A Text-book of Diseases of the £ar: For students and practi-
tioners.—By Dr. Adam Politzer, Imperial-Royal Professor of Aural
Therapeutics in the University of Vienna. Translated and edited by
Milton J. Ballin, Ph.B., M D., and Clarence L. Heller, M.D.
New fourth edition, revised and enlarged. In oneoctavo volume of 896
pages with 318 original illustrations. Cloth, $7.50 net Lea Brothers &
Co., Philadelphia and New York, 1902.
Diseases of the £ye, Nose, Throat and Ear: For students and
practitioners. By various authors.— Edited by William Ca.mpbkll
Posey, M.D., Professor of Ophthalmology In the Philadelphia Poly-
clinic, etc., and Jonathan Wright, M.D., Attending Laryngologlst to
Kings County Hospital, etc. Illustrated with 650 engravings and 35
plates in colors and monochrome. Lea Brothers & Co., Philadelphia,
1902.
American Kdition of Nothnagel's Practice: Diseases of the
Bronchi.— By Dr. F. A. Hoffmann, of Leipsic. Diseases of the
Pienra.- By Dr O. Rosenbach, of Berlin. Pneumonia.— By Dr. F.
Aufrecht. of Magdeburg. Edited, with editions, by ,Iohn H. MtJS-
SER, M.D., Professor of Clinical Medicine, University of Pennsylvania.
Handsome octavo volume of 1030 pages, illustrated, including 7 full-
page colored lithographic plates. Cloth, $5 00 net; half morocco, $6.00
net. W. B. Saunders & Co., Philadelphia and London, 1902.
The Work of the Digestive Glands. — Lectures by Professor .1. P.
Pawlow, Director of the Physiological Department of the Institute
for E.xperimental Medicine. Translated mto English by W. H.
Thompson, M.D., M.Ch., F.R.C.S. (Eng.), King's Professor of the Insti-
tutes of Medicine, Trinity ' ollege, Dublin, etc. Illustrated. Price,
$2.00. J. B. Llppincott Co, Philadelphia, 1902.
Bacteriological Technique: A laboratory guide for the medical,
dental, and technical student.- By .1. W. H. Eyre, M.D., F R.S. Edln.,
Bacteriologist to Guy's Hospital, and Lecturer on Bacteriology at the
Medical and Den till Schools, et<^ Octavo of 375 pages, with 170 illustra-
tions. Cloth, $2.50 net. W. B. Saunders & Co., Philadelphia and Lon-
don, 1902.
Spectacles and Kyeglasses : Their forms, mountirg and proper
adJustment.-By R. J. Phillips, M,D., Ophthalmologist, Presbyterian
Orphanage, Late Adjunct Professor of Diseases of the Eye, etc. Third
edition, revised, with 5i illustrations. Price, $1.00 net. P. Blakiston's
Son & Co., 1902.
Development of Human Body : A manual of human embryology.
—By J Playfair Mc.Murrich. A.M., Ph.D., Professor of Anatomy
in the University of Michigan. With 270 illustrations. Price, $j.00 net.
P. Blakiston's Son & Co., 1902.
Genitourinary and Venereal Diseases.— By Locis E. Schmidt,
M.Sc , M.D., Associate Professor of Genitourinary Diseases, Chicago
Polyclinic, etc. Scries edited by V. C. Pedersen. A.M., M.D., recently
Associate Demonstrator of Anatomy, College of Physicians and ."bur-
geons, Columbia University, New York City; House Surgeon o'f New
York Hospital, etc. Illustrated with 21 engravings. Lea Brothers &
Co., Philadelphia and New York, 1902.
Memoranda of Poisons — By Thomas Hawkes Tanner, M.D.,
F.L.S. Ninth revised edition. By Henry Leffmann, A.M., M.D.,
Professor of Chemistry in the Woman's Medical College of Pennsyl-
vania, etc. P Blakiston's Son & Co., Philadelphia, 1902.
Practical Gynecology, Obstetrics and the Menopause: Being
a revised and enlarged reissue of three serial articles appearing in the
Medical Council.— By A. H. P. Leuf, M.D. The Medical Council, Phila-
delphia, 1902.
Diseases of the Skin : A manual for students and practitioners.—
By Alfred Schalck, M.D.. Instructor of Dermatology, Genitourin-
ary and Venereal Diseases, Rush Medical College, Chicago, 111. Series
edited by V. C. Pedersen, A.M., M.D., Recently Assistant Demon-
strator of Anatomy, College of Physicians and Surgeons, Columbia
University, New York City, etc. Illustrated with 34 engravings. Lea
Bros & Co., Philadelphia and New York.
AMERICAN NEWS AND NOTES.
OENEBAIi.
Miscellaneous. — Havana, Cuba : Dr. .Juan Guitoras and
Dr. Carlos Pinley will represent Cuba at the sanitary coiigress
to be held in Washington in December. New York City:
James Stillman, president of the New York City National Bank,
has presented 8100,000 to the Howard University for the endow-
ment of a professorship in comparative anatomy.
Hospital Benefactions. — Milford, Mass. : The Milford
Hospital has received an endowment of $10,000. North Adams,
MAhs. : The late Mr. E. S. Wilkinson bequeathed $.5,000 to the
North Adams Hospital. Woonkocket, R. I. : Mrs. Chester B.
Smith has given sufficient funds to build a new wing to the
Woonsocket Hospital. Newport, R. I. : A recent report
states that in memory of her husband, Mrs. Cornelius Vander-
bilt will provide for building a #100,000 addition to the Newport
Hospital. Nevvburyport, Mass. : The Anne Jacques Hos-
pital has received a bequest of ?6,O0O. Framingham, Mass.:
Two donations of $1,000 each were recently received by the
Framingham Hospital. Philadelphia, Pa.: Under the will
of the late Eliza G. Landreth, of this city, it is provided that on
the death of certain persons named in the testament, $5,000 shall
revert to St. Luke's Hospital of New York City for the endow-
ment of a free bed ; $J,0fl0 to the We.st Philadelphia Hospital for
Women and $5,000 to the Episcopal Hospital to endow a free
bed. — The Children's Hospital has receivtfd a donation of $1,100
from friends of the institution.
Sanitation for the Panama Canal. — The problem of sani-
tation along the route of the Panama Canal is assuming serious
proportions. Medical Inspector Simons in a report to the
Surgeon-General of the Navy explains fully the dangers to life
under the conditions existing at present on the isthmus. He
urges that during the time of active building operations, when
thousands of men will be congregated in close quarters, and
when the newly turned, damp soil will invite malarial fevers in
every form, the United States should obtain actual police con-
trol of a strip of territory at least three miles wide on each side
of the canal, including the two cities of Colon and Panama at
the ends of the canal route. He thinks that in no other way
will it be possible to maintain the necessary quarantine and
enforce the strictest sanitary regulations. These two cities
should be put in good sanitary condition by cleaning, disinfects
ing, and asphalting the ground floors and pavements, and a sys-
tem of high license enforced for grogshops and brothels. He
believes the houses built by the French Canal Company are
scattered too widely, and for purposes of sanitary control
should be gathered into groups. The hospitals should be placed
in the interior of the canal zone, and as high as possible above
sea level, where the air is drier and more salubrious than at
either of the port cities. Plants for distilling water and making
ice should be installed, the water being furnished free to the
workmen and the ice at so low a price that all can afford to
buy it.
EASTEKN STATES."
Smallpox in Boston.— The Boston Health Department has
ordered that all inhabitants of the city who have not been suc-
cessfully vaccinated since January 1, 1900, be vaccinated or
revaccinated forthwith. This action was taken because small-
pox has reappeared there and in near-by places.
Smallpox in Maine. — Reports from the lumber camps of
northern Maine would indicate that a smallpox epidemic has
started. A camp at Holeb is under armed guard. The pas-
senger coaches on the mixed trains running oetween Brown-
ville and Megantic are fumigated twice daily and all immigrants
crossing the line aredetained under quarantine or else returned
to Canada.
Infectious Bovine Malady. — In Massachusetts and Rhode
Island a disease has appeared among cattle which is declared
by Dr. John R. Mohler, of the Bureau of Animal Industry, to
be the foot and mouth disease which was widely prevalent in
the former State •'SO years ago. The disease was traced to Rhode
Island, where it has prevailed for about two months, and a
quarantine was immediately established against all the cattle
of that State. Minute directions are given as to the precautions
necessary to prevent a further spread of the disease. It is said
the disease is readily conveyed to sheep and swine.
NEW YORK.
Unrecorded Births.— The New York City Health Depart-
ment has instituted an investigation in Queens borough relative
to unrecorded births. From the investigation so far it appears
that from 900 to 1,000 births go unrecorded annually. There is
a fine of $100 for each unrecorded birth. j
Unsanitary Churches. — An inspection of 196 churches in
the borough of Manhattan was recently undertaken by the
Health Department, with the result that in 25 unsanitary con-
ditions were found, these unsanitary churches being situated
either in the extreme east or west sides.
XOVEHBEH 29, 19021
FOREIGN NEWS AND NOTES
■American Medxcikb 846
PHILADEIiPHIA. PENNSYIjVANIA. ETC.
Typhoid Fever In Trenton, N. J. — According to news-
paper reports an epidemic of typhoid fever has apparently
broken out in Trenton. A goodly number of patients have
l>een sent to the hospitals and many others who are under
observation are suspected of having the disease. The source
of the disease Is not clear.
Dispute Over the Pauper Dead. — The State Anatomical
Board of Pennsylvania alleges that the pathologists to the
Philadelphia Hospital and Almshouse are using almost 509^ of
the dead bodies of that institution and that the medical colleges
of the State are thereby deprived of their full quota of cadavers.
The pathologists in rebuttal assert that they are using no more
than necessary.
White Slave Traffic. — According to late reports the city
detectives and police of Philadelphia, aided by various chari-
table and philanthropic organizations of the city, have uncov-
ered one of the foulest abominations of any age or time. It
appears agents, backed by a syndicate, have made it a business
to visit < 'ontinental Europe, particularly Germany, Austria and
Russia, and there by misrepresentation induce ignorant young
girls and women to go to the United States. The main induce-
ment was that they could readily secure lucrative employment.
The victims were brought to Philadelphia and there sold at
so much per head to the owners of brothels and held prac-
tically as slaves in a life of shame. Many of the victims, ignorant
of our laws and customs, believed themselves the chattels in
fee of those who held them. A raid by the city police secured
more than 100 of these unfortunates, and at lea.st some of the
men engaged in this nefarious traffic are under arrest. Plvery
etTort \yill be made to secure for these men and their abettors
long sentences in the penitentiary.
SOUTHERN STATES.
State Care vs. County Care for the Insane.— The Medi-
cal and Chirurgical Faculty of Maryland at a recent meeting
fully endorsed the plan for bringing all indigent insane which
are now in county almshouses under the general control of the
State.
Testing the Effects of Pood Preservatives. — Prof. Wiley,
Chief of the Bureau of Chemistry of tlie Agricultural Depart-
ment, has begun a series of experiments on twelve young men
in government employ at Washington for the purpose of deter-
mining the physiologic eifects of the eating of foods preserved
with borax and other chemicals. The work was outlined some
time ago, but is now to be carried out to decide what ground
there is for the objections of the German Government to Ameri-
can meat. The twelve young men selected are volunteers, and
all are young and vigorous. Each has pledged himself to
abstain from food and drink except as permitted by Prof.
Wiley. The men will be weighed before each meal and careful
notes will be taken of their appearance each day. For two
weeks continuously six of them will be fed on "pure" foods,
untreated meats and vegetables, while the other six will par-
take of the same fare after being submitted to chemical treat-
ment. At the end of this time the arrangement will be reversed.
WESTERN STATES.
Chlcajfo Pasteur Institute.— The report of the work
accomplished in the institution since its establishment in July,
1890. shows there have been 1,538 cases of tetanus treated with
but 7 deaths.
The Death-roll of 1002.— From the St. Paul Globe we
<luote the following:
" Few people realize how frightful have been the ravage* of 1902 by
dIscaHC anil disaster. Only a little more than 10 months of the 12 are
Kone and yet close to 1,000,000 persons have perished from epidemics,
floods and volcjinoes. l-^arly In May a series of eruptions In Martin-
ique and neighboring Islands In the Carrlbean Sea cost many thou-
sands of lives. Homewliat later the Yellow river of China overflowed
Us banks and tens of thousands of Chinese were drowned. Not in 40
years has there been such an epidemic of cholera as for the past 6
months has been raging in fclgypt, Japan, China and the Philippines.
Official it'portH show that the disease has been no respecter of persons,
but has raged with equal virulence In the slums of Canton anil Shang-
hai and among those of royal blood in Pekin. Neither did the pesii-
lence break out In one town and spread to another. It appears to have
broken out almost In the same hour in Manchuria, ShensI and half a
dozen other provinces and Is now frightfully fatal In almost every sec-
tion of China. The busiest men in .Japan have been the undertakers,
and how dreadful has been the mortality from the disease In the Phil-
ippine archipelago is shown by the reports made to this gos'ernmcnt
by American ottlcials stationed there. Though the statistics have
been kept imperfectly— in some sections not at all— the loss by the dis-
ease has easily been BOO.OuO people since the opening of the year. And
now comes the news that an epidemic of measles in sweeping over
western Eun)pe and lias already crossed Behring Sea Into Alaska.
Thousands have already died, particularly In Kamtchatka, and the
living are so worn out with caring for the sick that they are In most
cases themselves fit subjects for the hospltjil."
While this may be an exaggeration in several particulars,
still the fact remains that the year now closing has been marked
liy a large death-roll.
FOREIGN NEWS AND NOTES
OENERAIi.
Cholera.— There have been 494 deaths from cholera at Jeru-
salem and 78 at Ghuzzeh during the last week. Great distress
prevails at Lydda because of the inadequacy of medical aid
there to cope with the disease. Reports from Egypt to
the State Department show a marked diminution in the number
of cases. According to news received from the acting consul-
general at Cairo, there have been ^5 cases of the disease and 212
deaths in all Egypt since October 25.
Miscellaneous.— Friedrich Kraus, of Gratz, has been ap-
pointed to the chair of clinical medicine in the Berlin Univer-
sity, succeeding the late Professor Gerhard. It is said that this
is the first time in nearly a century that an Austrian has been
appointed an ordinary professor in the medical faculty of
Berlin. — It is said that Major Ronald Ross, the principal of the
Liverpool School of Tropical Medicine, will receive the award
of the Nobel Research Prize of ?15,000 for his investigations con-
cerning the propagation of malaria. Major Ross has conducted
several expeditions into the mosquito-breeding districts of
West Africa.
GREAT BRITAIN.
A Huxley Memorial. — An exchange states that a memorial
tablet to the late Professor Huxley, the great physiologist, was
unveiled recently in the public library of Ealing. The move-
ment to commemorate in some suitable way Professor Hux-
ley's connection with Ealing, his birthplace, was begun last
year by Mr. B. B. Woodward, of the British Museum, and sub-
scriptions to the amount of £96 odd were received. The tablet
is of marble, with a medallion portrait of Huxley in bronze
in the center. It bears the following inscription : " The Right
Hon. Thomas Henry Huxley. Born at Ealing, 4th May, 1825.
Died at Eastbourne, 25th June, 1895. Try to learn something
about everything, and everything about something."
CONTINENTAIi EUROPE.
State Homes for Convalescent Children. — It is pro-
posed to erect State convalescent homes in Austria for anemic
children and those whose weakened condition renders them
liable to tuberculosis.
Koch Admits His Error. — Prof. Brouardel, who repre-
sented France at the tuberculosis congress at Berlin is credited
with stating that Koch no longer denies the possibility of the
communication of bovine tuberculosis to human beings.
Trained Nurses In Germany. — The trained nurses of Ger-
many are considering a petition to the government to grant
them an official examination after a three years' course of train-
ing, and a certificate for successfully passing the examination.
This certificate can be withdrawn by the authorities in case of
unworthy conduct on the part of the graduate. They also
demand that the government should not appropriate futids for
the support of hospitals which exact more than eleven hours of
service from the nurses and which have not madeadequate pro-
vision for pensions in case of old age and sickness. The gov-
ernment is also petitioned to supply means for an official three
years' course of training. — \_Journal American Medical Asso-
ciationj]
OBITUARIES.
Major Walter Keed, one of the foremost bacteriologists and path-
ologists of the country, died at the Army General Hospital In Washing-
ton, D. C , November 23, aged 51. His death was due to appendicitis, for
which an operation was performed a few days previous. He was a
graduate of the medical department of the University of Virginia and
of the Bellevue Hospital Medical College of New York City. He
entered the Army as an assistant surgeon In June, 1875, and at the
time of his death was first on the list of majors and surgeons. During
the Spanish- American war he was a member of the commission which
Investigated the cause of the typhoid fever epidemics In the Army
corps of the United States. In 1900 he went to Cuba to make a study of
yellow fever, and as a result of exhaustive observances and experi-
ments he became convinced that the mosquito conveyed yellow fever
germs. His official report on the subject demonstrated clearly the
correctness of his theory. Sanitary measures tending to the destruc-
tion of the Insect and the screening of Infected per.*<ons were put Into
effect Immediately in Havana, with the result that for more than a year
no case of yellow fever has developed there, though the disease had
existed permanently In Havana for three centuries. Since his return
from Cuba he has been stationed at the Army Medlcjtl Museum as
curator, and has also been professor of bacteriology and pathology in
the Army Medical School and lecturer on those subjects In the Colum-
bian Medical College. The following resolutions regarding the loss of
this eminent scientist have been passed by the faculty of the Colum-
bian .Medical School ;
The sudden and unexpected demise of our esteemed friend and col-
league, M»Jor Walter lieed, U. ». A., professor of bacteriology and
846 AnBIOAIf MXDIOIKIE
SOCIETY REPORTS
INOVIMBKB 28, 1902
patbolosry In the Mtdical School of Columbian University, Is an event
that brings to us the most acute regret and overwhelming sorrow.
Taken from us In the prime of manhood, and In the zenith of his
professional usefulness, at a time when the medical profession and
humanity at large were prepared to do him homage for his great work
In demonstrating the method of exterminating yellow fever by protec-
tion from Inoculating mosqultos, and by whleh that fatal disease has
been abolished from someof Its most malignant haunts, at a time, too,
when his relations with the faculty and students of Columbian Uni-
versity had become securely united by bonds of mutual aft'ectlon and
esteem, under these circumstances It is with a most earnest and sin-
cere feeling that we the medical faculty of the Columbian University
liereby desire to express our unreserved admiration for the work, life,
and character of Professor Heed, both as a physician, a teacher, a
trusted friend, and a man of science. In testimony whereof It Is hereby
R/;«olve(i, That the foregoing note be recorded In the permanent
archlvesof the faculty, that a copy of the same be given to the press
for publication, and also forwarded to the family of Dr. Keed as an evi-
dence 01 our sympathy for them In their great sorrow.
Remlveti, That as a further mark of respect for our lamented ool-
leag, the exercises of the .Medical School be suspended, and that the
students and faculty attend In a body his funeral obsequies.
(Signed) A. F.A.King,
J. Ford Thompson,
.James Carroli,,
G. Wythk Cook,
George N. Ackkk,
Committee.
Thomas F. MeManus, In Pittsburg, Pa., November 5, aged 42. He
was graduated from the Western Pennsylvania .Medical College In 1890,
and at the time of his death was an active member of the Allegheny
County Medical Society.
Carl resold, in St. Louis, Mo , November 6, aged 44. He was grad-
uated from the St. Louis College of Physicians and Surgeons In 1892.
He was major and surgeon. First Infantry, Missouri National Guard.
E, A. Allen, of Randolph, Mass., November 19, aged 85. He was
graduated from the Worcester Medical College In 1847. He was a
member of the New England Eclectic .\ssoclatlon.
Frederick K. Potter, a former surgeon in the Navy, died in Ports-
mouth, N. H., November 18. He was graduated from the medical
department of the University of Vermont In 1860.
Andrew G. Clarke, of Parkersburg, W. Va., November 7, aged 93.
He was a graduate of the Transylvania University, Lexington, Ky.,
and had practised medicine for nearly 70 years.
John M. Cunningham, of Martintown, W. Va., November 20. He
was graduated from the medical department of the Unlveralty of
Louisville in 1891.
John E. Mealy, at Cleveland, Ohio. November 2, aged 30. He was
graduated from the College of Physicians and Surgeons, Columbus,
Ohio, in l(-96.
William T. Lavvorn, at Newell, Ala., November 1, aged 28. He
was graduated from the College of Physicians and Surgeons, Atlanta,
Ga., in 1901.
George A. Osborne, in South Bend, Ind., November 5, aged 80.
He was graduated from the Medical College of Indiana, Indianapolis,
In 1873.
Koy H. McCarl, of Wellman, Iowa, at Omaha, Neb., Novem-
ber 2, aged 29. He was graduated from the Omaha Medical College In
1896.
Itlcliard N. Hawl<ins, of Birmingham, -Ma., November 6, aged 56.
He was graduated from the Miami Medical College, Cincinnati, In
1888.
i. C. Beal, In Unlontown, Pa., October 29, aged 52. He was gradu-
ated from the Western Reserve University, Cleveland, Ohio, in 1884.
John A. Watsun, of AshevlUe, N. C, November 4, aged 53. He
was graduated from the Uqiversity of Maryland, Baltimore, in 1872.
John W. James, in Pittsburg, Pa., Novembers, aged 65. He was
graduated from the Jefferson Medical College, Philadelphia, In 1895.
Areliil>al<l B. Terry, In Longview, Texas, October 30. He was
graduated from the Tulane Uulverslty, New Orleans, La., In 1898.
John C. Lig:htfoot, near Drake. Ky., October .31, aged 35. He was
graduated from the University of Tennessee, Nashville, In 1891.
A. M. Powell, In ColUnsvllle. III.. November 3, aged 67. He was
graduated from the Washington University, St. Louis, In 1860.
Charles P. Leonard, of Philadelphia, November 2:5, aged 24. He
was a member of the staff of the Medlco-Chlrurgical Hospital.
John V. Everett, In Weatherford. Texas, October 28. He was
graduated from the Tulane University, New Orleans, In 1876.
Harry H. Young, in Columbus, Ohio, October 18, aged 34. He was
graduated from the Columbus Medical College in 1890.
Frank Livermore, in New York City, November 18, aged 62. He
was graduated from the University of Paris In 1868.
Edward Little, In Buffalo, N. Y., October 30, aged 75. He was
graduated from the University of Buffalo In 1862.
Professor Eugen Hahn, director of the surgical department of the
Berlin Municipal Hospital, November 1, aged 62.
Henry C. Summers, in Daievllle, Ind., November 4. He was grad-
uated from the University of Cincinnati in 1878.
William A. Guild, of Sanford, Fla., November 21, aged 75. He was
a graduate of the Harvard Medical School.
D. E. Seymour, of Calais, Me., November 23, aged 76.
SOCIETY REPORTS
THE SOUTHERN SURGICAL AND GYNECOLOGICAL
ASSOCIATION.
Fifteenth Annual Meeting, Held in Cincinnati, Ohio, Novem-
ber 11,12 and 13, 1902.
[Specially reported for American Medicine.\
[Concluded from page SOI,.]
Intramural Extraperitoneal Anchorage of the Kound
liigaments for Posterior Displacements of the Uterus. —
George H. Noble (Atlanta, Ga.) .said that since performing
his first operation for intramural extraperitoneal anchorage of
the roimd ligaments, his technic had been changed to simplify
it, and to fortify the abdominal vifound against the danger of
hernia. The feature of the operation was the intramural extra-
peritoneal implantation of the round ligraments. Combined
transverse ana vertical incisions were employed to open the
abdomen. The various steps of the operation were given in
detail.
Intraabdominal but Retroperitoneal Shortening and
Anterior Fixation of the Round Ijigaments for Posterior
Uterine Displacements.— F. P.Simpson (Pittsburg) described
a simple means of accomplishing this end. It consisted essen-
tially in changing the course of the round ligaments from
transverse to nearly an anteroposterior direction; in shorten-
ing the round ligaments, so that the weali part is left as slack,
the strong part being used to control the movements of the
uterus ; finally, and especially in effecting these changes
beueatli or by pucicering the parietal peritoneum, thus leaving
no bands of adhesions and no pocltets which may strangulate
an intestine.
Gas Bacillus Infection.— Robert T. Morris (New York)
reported three cases which occurred this spring in his practice.
The first patient from whom he removed a myoma of the uterus
was 46 years old. Hemorrhages furnished an indication for
the operation, which was done April .30, 1902. The following
day the patient complained of headache; pulse 116, tempera-
ture normal, respirations 20. There was a bloody discharge
from the vagina. The next day patient had a temperature of
99.6°, pulse 102, respirations 22 ; nauseated, and suffering from
continuous headache. The bloody discharge from the vagina
was increasing in amount. May 2 the patient complained of
intense pain in the abdomen; headache continuous; tempera-
ture 100°, pulse 120, respirations 24. He examined the abdom-
inal wound, and found it had healed by primary union. The
subcutaneous tissues on the right side of the abdomen were
distended with gas, which was quite abundant in amount, but
unassociated with tenderness. May 3 the gas within the
towels caused great distress; headache was continuous; tem-
perature 99°, pulse 120, and respirations 24. A bloody discharge
continued from the vagina. On May 4 the patient became very
restless, nauseated, had continuous headache, with a tempera-
ture of 100.6°, pulse 144, respirations 16. On the fifth and sixth
the symptoms were .somewhat similar, except that tliere was
gas beneath the skin of the abdomen. The patient died on the
seventh day. In the second and third cases specimens sub-
mitted for examination showed pure cultures of Bacillus
aerogene/i capsulatus. These patients recovered.
Prolapse of the Uterus. — Charles R. Robins (Rich-
mond, Va. ) said that successful treatment could not depend on
any one procedure, but it must meet all of the pathologic con-
ditions present. Proper preliminary treatment was of the
utmost importance. The operative treatment recommended
consisted of amputation of the cervix, operation for c.ystocele,
perineorrhaphy, and an operation for maintaining auteversion.
This treatment not only cured prolapse, but restored function.
If relapse occurred, Edebohls' panhysterocolpectomy seemeu
to be the only operation for effecting a cure.
Diseases of the Ribs Following Typhoid Fever. —
J. Shelton Horsley (El Paso, Tex.) reported the case of a
man of 40 in whom disease of the lett sixth and seventh costal
cartilages, the anterior end of the sixth rib, and part of the
sternum developed a few weeks after convalescence from
typhoid. The aiiscess had been opened, and later the resulting
sinus cureted before the patient came under his care. Then
two extensive resections, involving a portion of the sixtli rib,
the costal cartilage of the sixth and seventh ribs, and part of the
sternum had to be performed before a complete cure was
effected. He called attention to five peculiarities that dift'er-
entiate posttyphoid disease of the ribs from similar affections
of other bones: (1) The marrow of the ribs was a particularly
favorable seat for the typhoid bacilli ; (2) the superficial posi-
tion of the ribs and their continuous movement made a locus
minoris resistentia; more liable to occur here; (3) necrosis of
the ribs very rarely occurred, which was not the case with
other bones ; (4) posttyphoid disease of the ribs invariably
occurred in adults ; (5) thorough operative treatment was more
difficult in the case of the ribs than of most other bones. A
table containing 55 cases gathered from the literature on the
subject and personal communications was appended. Con-
servative measures were advised in mild cases. If these were
unsuccessful, incision and curetage were advocated, and if,
NOTEMBKR 29, 1(02]
COEEESPONDENCB
(Amkbicas -MEDicnat
847
after a few weeks, the wound had not healed, extensive resec-
tion should be practised.
Endometritis. — H. J. Boldt (NewYork). The local treat-
ment giving the promptest relief from bleeding in cases of
chronic endometritis was undoubtedly to be found in the judi-
cious use of the caret. Although the operation was comparatively
simple, it should not be resorted to indiscriminately; neither
should it be done by one who was not trained in the technic of
gynecologic surgery, because frequently serious results fol-
lowed its improper employment. Before the operation it was
imperative that a careful bimanual examination be made to
determine whether or not a tubal swelling was present. He
had known tubal pregnancy and pyosalpinx to be ruptured as
the result of the traumatism produced by the operation. In a
few instances he had desisted from cureting and opened the
abdomen subsequently through the disclosures revealed by
bimanual examination. If resorted to, the same precautions as
to cleanliness should be employed as in a major operation. In
his experience, about GOfc of the women were relieved from
hemorrhage for a variable period of time by cureting. After
cureting, it was his custom to make an application of pure
carbolic acid to the interior of the uterus. In patients who had
not obtained the desired relief by cureting, subsequent local
treatment became necessary. The general condition of the
patient in all instances required careful supervision. After the
endometritis has become chronic, it should be treated with
intrauterine applications of one of the usual remedies. He pre-
ferred a 10% solution of carbolic acid. Frequent intrauterine
irrigations with large quantities of a mild antiseptic solution
also gave good results.
The Use of the Klectric Cautery Clamp in the Treat-
ment of Cancer of the Uterus.— Charles P. Noble (Phila-
delphia) presented for consideration a new adaptation of an
old principle in the treatment of cancer of the uterus. Hyster-
ectomy performed by means of the electric cautery clamp pos-
sessed all thoadvantagesof anyof the methods heretofore in use,
and had in addition certain advantages peculiar to it alone.
These especial advantages were : (1) More tissue outside of the
uterus was removed or cooked than by the classical methods;
(2) all the connections of the uterus were severed either through
tissue which had been cooked in the bite of the cautery clamp
or those connections had been severed with the electric cautery
knife. In this way the lymphatic vessels were sealed either by
the burning or the roasting process. Whatever the risk of
implantation of cancer upon the field of operation may be by
this means it was greatly lessened or done away with. An
exception to the above statements must be noted, in that the
attachments of the bladder to the.viterus were severed in the
usual way ; (3) much less blood was lost than was usual with
the classical technic, and a dry, bloodless field was left after
operation. Noble had operated five times by this method, and
said that some years must elapse before the actual value of the
electric cautery clamp in the treatment of cancer of the uterus
could be determineti, but in view of the results secured by
Byrne and of the positive theoretic advantages it had over the
ligature method, it was reasonable to expect that it would give
a larger percentage of cures than the older methods, more espe-
cially in cancer of the cervix.
The Council presented the following resolution, which was
adopted :
Whkkea.s, Dr. W. K. B. Davis during 12 years of faithful service
as secretary of ttie Association deolined t^> dniw any salary for his serv-
ices, expecting in time to eslabllsh a suitable memorial of this Asso-
ciation with the fund created thereby, therefore be It
Retolved, That in eonsidcralion of this fact J2,(X)0, a sum far less
tlian the sa'ary offered would liave amounted to, he appropriated for
the establishing of a memorial In Birmingham, Alabama, the birth-
place of the Association; and that this memorial be placed In the
Charity Hospital of that city as a ward to bear the name of the Associ-
ation.
Venereal Diseases In the Army. —In the army as a whole,
with a mean strength of 02,491 men, there were reported during
the calendar vear liXIl, 13,itll cases of venereal disease, equiva-
lent to an admission rate of l.'J0.4I cases per 1,000 of strength.
These cases furnished IRl discharges for disability, equaling
1.70 per 1,000 men, and eight deaths, equaling 0.08 per 1,000.
These rates are exceedingly high when we compare them with
the mean annual rates of the decade 1888-1897: Admission 70.60,
discharge 1.71, death n.03. The rates in the Philippines and in
the tlMite<l States durhig the past year did not differ much, but
those in f'uba wore high and those in Porto Rico very high. —
[Report, of the Surgeon-General.']
Sanitary Precautions in Cuba.— A translation of instruc-
tions issued by the Cuban Government to all governors of
provinces has been supplied to the State Department by United
States Minister .Squiers at Havana. Among other things
greater vigilance is counseled in the observance of sanitary
laws, as it is obvious that the introduction or spread of disease
in this island would be a matter of international concern.
Special emphasis is laid upon securing vaccinations and revac-
(Mnations, as the risk of Importing smallpox is still very groat.
It is recommended that the greatest vigilance be exercised in
enforcing police ordinances, especially those relating to public
hygiene and to clean streets. In conclusion, the cooperation of
all the governors is asked in the work of definitely exterminat-
ing from Cuban soil all avoidable diseases.
CLINICAL NOTES AND CORRESPONDENCE
[Communications are Invited for this Department. The Editor is
not responsible for the views advanced by any contributor.)
INDEX MEDICUS COMPLETUM : A SUGGESTION AS
TO ITS REALIZATION.
BY
C. D. SPIVAK, M.D.,
of Denver, Colo.
Secretary Colorado Medical Library Association.
In his presidential address before the American Orthopedic
Association at the annual meeting held at Philadelphia, June
5-7, 1902, Dr. H. Augustus Wilson ' broached a subject which*
although dear and near to the hearts of all workers in the field
of medical literature, yet, paradoxic as it may appear,
receives hut .scant attention; namely, the subject of medical
literature. What Dr. Wilson has to say in reference to his
association may be appropriately applied to all other organiza-
tions. He says : " It is evident that the force of the association
lies In uniting the individual strength and power of its Fellows
as practitioners, as teachers, and as writers," and. because writ^
ing is " one leg of the tripod " he considered it appropriate to
allude briefly to the subject of orthopedic literature. He finds,
for instance, that the Transactions of the Association as pub+
lished at present is simply a burial ground for many papers^
and that to save some valuable contributions from uttei'
oblivion the authors are obliged to publish their w6rks also in
a periodical. Many of us vaguely believe that the Transac-
tions are never read and but seldom referred to ; we have felt
that it is a superfluous quantity and the cause of unnecessary
waste of time, money and energy. We thank Di". Wilson foi"
having given expression to these vague feelings.
But Dr. Wilson is not satisfied with the presentation of the
negative side of the question. He does not wish to destroy, but
to turn the Tran,sactions into something useful. In addition to
publishing in the Transactions all papers read by the members
of the association, he advocates that they should also containi
"all papers of decided merit, and especially comprehensive
abstracts of all orthopedic literature, no matter where pub-
lished or in what language." In short, his plan is to transform
the Transactions into a year-book of orthopedic surgery.
At a meeting of the American Gastroenterological Asso-
ciation, held May .5, 1902, I presented the following plan :
Physicians who delve into medical literature need no introduc-
tion to such works of reference as the " Index Medicus,"
" Bibliographia Medica," the " Catalog of the Surgeon-
General's Office," the Medical Review of Reviews, and the
abstracts of current literature to be found in the weekly and
monthly medical periodicals published here and abroad.
Useful and indispensable as they are to the student and investi-
gator, yet none of them individually, or even collectively, gives
a complete register of all the articles publLshed, in all period-
icals, in all languages. Out of the medical periodicals published
in the United States, France, England,Germany, Russia, Poland,
Italy, Portugal, etc., we will say agrand total of 1,000 periodicals,
not more than 400 publications are indexed. That the weeklies
and monthlies limit their space to a certain number of period-
icals is excusable on the plea that they limit themselves only
to the best. They havearightto be critical and discriminative.
But the publications that pretehd to index the literature of
the world and yet do not embrace every medical publication in
all languages and in all countries, either deceive themselves or
deceive others. Such publications should not discriminate
between good and bad, truth and falsehood, between " scien-
tific" and "practical," between regular and irregular. The
business of a medical Index is to index everything pertainiuf;
to medicine. This ideal has not been reached, nor even
approached, by any publication. From tlie nature of things, it
seems that such a comprehensive index is at present an impoS''
sibllity. The work is so arduous, the outlay counected with It
so enormous, and the demand so limited, that such an under-
taking would bankrupt a Cr<»sus.
' The Advance of Orthopedic Surgery, American Medicine, July 12,
1K02, Vol. Iv, No. i, p. B7.
848 AMSBIOAH MEDIOimii
CORRESPONDENCE
(NOVEHBES 29, 1902
However, there is a way to lay the foundation for such an
ideal index. I propose that our association should publish
every year an index of all articles pertaining to diseases of
digestion, metabolism, and dietetics appearing in the periodical
literature and transactions in the Knglish language during the
previous year, such index to begin with the first year of the
twentieth century.
I have no doubt that many other special organizations will
emulate our example and publish such complete indices. Let
the Germans take care of their language, the French of theirs
and the Russian of theirs. Let every specialty take care of its
own literature. Eventually these various societies may coop-
erate and work harmoniously together and produce the ideal,
Index Medicus Completum. I am sure should the association
see fit to adopt such a plan it will redound to its glory as the
pioneer of the ideal index of the literature of a great specialty
of one language in one year. I have worked out many of the
details connected with the collection of the literature, the classi-
fication, etc., and shall be happy to render my assistance to a
committee appointed for that purpose.
The similarity of the plans proposed by Dr. Wilson and
myself consists in the fact that we both wish to widen the
scope of the Transactions, and to make the time and money
spent on such publications yield some return.
The difference between our plans re3ts upon more than one
point, though they can all be deduced from the nature and
definition of the " Year Book " and " Index." A year-book is
helpful in emergencies, but not for deliberate study and
research. A year-book, however conscientiously prepared and
skilfully arranged, will still represent the bias of the editor or
editors, which will manifest itself in the choice of articles
abstracted, as well as in the wording of the sentences. But he
who wishes to make a thorough study of any subject will not
take on faith that only the articles mentioned in the year-book
are worthy of consideration. He wishes to use his own judg-
ment, be his own critic. All the investigator wishes is to know
the titles of all articles on the particular subject.
Dr. Wilson thinks that the printing of mere titles is value-
less, since " titles give no conception of the contents of papers,
and are frequently misleading." That is true so far as it goes.
However, I have followed closely, for the last few years, some
of the best periodicals and found that the species of writers who
report " Three Interesting Cases " are gradually disappearing
to the joy of all sound-minded readers, and to the elimination of
profanity among librarians and catalogers. Should, however,
such a barbarian, in spite of the law of survival of the fittest,
continue to inflict his imbecile titles upon a long-suffering com-
munity, it is then the cataloger's duty to look up each of the
" Three Interesting Cases " and enter them separately where
they belong. Any one who has examined carefully the Surgeon-
Oeneral's Catalog will be convinced that the catalogers have
done their duty well ; they read not only the titles of the articles
but also the articles themselves.
Of course the Year Book may attempt to include also an
index of all papers published on the subject of orthopedics in
all countries and in all languages. I doubt, however, whether
such an undertaking is possible or feasible. It would necessi-
tate the procurement of all medical periodicals published in
the world, something none of the libraries in the United States
or abroad can boast of, not even the Surgeon-General's office,
and it would sorely tax the linguistic capacities even of such a
thoroughly educated body of physicians as compose the mem-
bership of the Orthopedic Society, since, so far as I know, none
of them can read either Chinese, Japanese, Turkish, Hungarian
or BDhemian, in which languages medical periodicals are pub-
lished.
It is different with an index of articles in any one language,
say the English. We can be sure beyond any shadow of a
doubt that we can procure all the periodicals, and consequently,
the index of all articles on any one subject in any one year will
be absolutely complete.
In the outline of my plan I have referred to the possibilities
bi cooperation. At present, however, they are remote. Many
countries have not special societies, therefore cooperation is out
©f the question. I hope that Dr. Wilson's appeal to his associ-
ation will create at least discussion on the subject in other
national organizations, and the agitation will keep on until the
present routine publication of transactions will become a thing
of the past, and a new structure, be it a year-book or something
else will be reared in its place.
A CONDITION OF RECIPROCITY.
To the Edilor of American Medicine: — You will pardon
me for taking exception to your editorial on "A Condition of
Reciprocity," published in American Medicine, August 2. Did
it never occur to you that persecution is always detrimental to
the launching of any plan? When you aim to make two
classes in your reciprocity arrangements to license physicians
you lower one class in the estimation of the people and place
the members In antagonism to your views. The higher stand-
ard class of licentiates are looked upon in about the same light
that the snob or dude is by the common people, and it is reason-
able to expect them to resent any arrangement that does not
give them the same right in another State as the physician of
the other State demands of them. An investigation will show
that the death rate is less in the States that do not require an
examination than in those that do. In my State we simply
register diplomas and we never had a board of examiners, yet
I venture to assert that there are few States in the Union with a
lower deathrate or that have fewer quacks and nonethical men.
The quack, as a rule, is educated, and State laws or examina-
tions cut no figure with him. Why is it that less than one-
quarter of the physicians of the country are in our medical
societies? Ask some one who is not a member and he will
tell you that, as a rule, city physicians, specialists, professors
in colleges, etc., treat him as a kind of under dog and when he
trusts a patient to one of them he reciprocates by doing him all
the injury he can ; instead of insisting that the family physician
be in attendance, he rather tries to discourage such attendance. I
have attended over 1,500 confinements in my professional
career with but two deaths. I never lost a patient who had a
miscarriage or aborted and I have performed all the operations
incident to obstetric practice including one cesarean section,
still I probably could not answer 50% of the questions asked
by the majority of examiners on obstetrics. I have not lost a
case of typhoid fever or pneumonia in an adult in 10 years.
Last winter I piloted more than a dozen cases of smallpox
through a severe siege without a death. I am a registered
druggist and think I know something about pharmacy and
therapeutics — mediainal and nonmedicinal — yet I could not an-
swer enough of the questions put out in stereotype form to pass
these examining boards. Recently I met a physician who had
just passed a State board. His papers showed he had obtained a
high percentage, still he will not succeed as a practitioner,
because he lacks judgment and that great essential in all kinds
of business— good common sense. I am only one of many thou-
sand physicians who are in the same boat — lam in favor of a high
standard, find also of reciprocity, but not of reciprocity with a
tail to it. Say to every graduate of medicine from a reputable
school, you have earned the right to practice medicine the bal-
ance of your days anywhere in the United States. But say to
those about to enter practice who are not such graduates, you
must come up to our high standard or you cannot practice. This
kind of a spirit among the States five years ago would have done
much to prevent the legaliziugof osteopathy, etc., and even now
would do more to unite the medical profession than anything
else. Without a united profession no medical law will stand.
If I were a member of a medical board I would vigorously
resent any arrangement that would give a right to another State
that we did not receive from them. You may think, perhaps,
they can practice in such States anyhow. Let them try it ; per-
haps it is not so easy as it appears. T. H. L.
A New Eye Disease. — A new and peculiar disease, called
the " gas eye," is prevalent among the employes of the gas
pumping stations throughout the gas belt in Indiana. The pain
is severe and physicians are unable to determine the cause of
the disease. Men working around the big gas compressors are
in escaping gas all the time. Their eyes become inflamed,
tender, and it is almost impossible to expose them to the light.
Permanent injury to the eyesight has resulted in several cases.
November 29, 1902]
TREATMENT OF WOMEN AFTER CHILDBIRTH iambricas mbdicisk 849
ORIGINAL ARTICLES
THE IMPORTANCE OF A MORE CAREFUL EXAMI-
NATION AND TREATMENT OF WOMEN AFTER
CHILDBIRTH.'
BY
B. C. HIRST, M.D.,
of Philadelphia.
If any one physician in general practice calculates the
number of cases he sees in a limited time, of rectocele, of
cystocele, of uterine retroflexion originating in the puer-
perium ; of injured cervix and all its consequences,
including cancer ; of prolapsus uteri following childbirth,
of subinvolution and endometritis following abortion or
labor ; of the pelvic inflammations of puerperal infec-
tion, of splanchnoptosis following diastasis of the recti
muscles and of coccygodynia ; if he multiplies his expe-
rience by that of the thousands of his colleagues in
America, if he reflects that every one of these conditions
represents the fault of a physician, that every one of
them could have been prevented, or could have been
cured without delay, he must be appalled by the thought
that the medical profession itself is responsible for five-
sixths of the diseases of women as we see them today.
We are accustomed to think of the control of contagious
diseases, of the limitation of tuberculosis, of the preven-
tion of enteric fever, of the cause and cure of cancer, as
the great medical problems of the present time. These
questions sink into insignificance when compared with
the preservation of the health, the usefulness, the fer-
tility, and the happiness of our childbearing women.
Moreover, this question concerns us closely. We are not
directly responsible if a municipality compels its citizens
to drink diluted sewage. We cannot be reproached
because the self-sacrificing medical scientists of the world
have not yet discovered the cause of cancer. But we are
too often responsible for the vast numbers of invalid
women who owe their incapacity and suffering to child-
birth ; for the thousands of women who refuse or are
unable to bear more children because the birth of one
was 80 disastrous to them. This is our fault, or rather
the fault of the crude teaching and practice of obstetrics
that has prevailed in America.
There is not one of the consequences of childbirth
enumerated that cannot be prevented or cured before it
has afliected the individual's health.
Every woman should be subjected to three examina-
tions after labor. One immediately or within 48 hours
to detect the injuries of childbirth ; the second before
she leaves her room, to determine the position of the
uterus ; the third at the end of thepuerperium, six weeks
after labor, to observe the condition of all the pelvic
organs and structures, of the abdominal walls and coccyx
and the position of the kidneys. If this rule were
uniformly followed we might escape the responsibility
which undeniably rests upon us now for a great part of
the invalidism of American womanhood.
It behooves us to remove this reproach ourselves
before reform is forced upon us from the outside. Suits
for damages based on the injuries or other ill conse-
<iuences of childbirth are common enough already in all
conscience. They will, it is to be feared, be still com-
moner when it is more generally realized that a woman
should be left in as good a condition iifter childbirth as
she was before, and that it is the physician's duty to see
that she is.
How can we remedy the existent defects of medical
l)ra(!tice in this particular?
The problem is a difficult one. Our present methods
are certainly not satisfactory. In every large American
community experts in gynecic surgery are busily
engaged In correcting the faulty work of their brother
> Read before the Mercer County DiBtrlct Medical Society, at Tren-
ton, N. J., November 11, 1902.
practitioners. This is neither creditable to us nor satis-
factory to our patients. I see the greatest hope for the
future in our maternity hospitals, not as they were but
as they are at present equipped and conducted; in the
kind of experts that they are developing and in the
instruction they are giving to medical students.
For example, in the maternity department of the
hospital of the University of Pennsylvania there is a
perfect equipment for pelvic and abdominal surgery in
women, and an operating amphitheater of the most
modern construction. Not one of the women delivered
in that institution is allowed to leave, if she accepts our
advice, with any of the injuries of childbirth, subinvolu-
tion, uterine displacements, diastasis of the recti muscles,
injury of the coccyx, or the pelvic inflammations uncor-
rected. Two careful examinations are made while she is
in the hospital ; one within 48 hours of delivery ; another
when she is about to leave the hospital, and a third six
weeks after her delivery ia the obstetric dispensary of
the University Hospital. At the first examination, the^
cervix, the anterior vaginal wall, the posterior vaginal
wall, the pelvic floor, and perineum are carefully
inspected and palpated. Any injury in these localities is
repaired. All injuries of the cervix have been repaired
without exception in the University Maternity for several
years past. The results have been so satisfactory that the
practice will be continued. It must become general, not
only in hospital, but also in private practice. There is
no good reason why a woman should suffer the ultimate
consequences of injuries to the cervix in labor, including
possibly cancer, or should be obliged to undergo a
secondary operation. We find that 48 hours should
elapse after labor before closing, the lacerations of the-
cervix. We can then secure a successful result whatever
their extent or number, unilateral, bilateral, or multiple.
If there is some reason, such as infection, against an
operation at this time, the injured cervix should at least
be repaired before or at the completion of the puerperium.
There is no reason in any case for longer delay.
For the greater part of a year I have been restoring
the muscle of the urogenital' trigonum (Waldeyer) in the
anterior vaginal sulci, which is the chief support of the
anterior vaginal wall, and which is very frequently in-
jured in labor. If this injury is neglected a pathologie
progress begins which ends in a cystocele. The laceration
of the muscle is almost always submucous. After display-
ing the sulcus by three bullet forceps, one alongside the
urethra, the second opposite the first on the corresponding
labium, the third at the apex of the triangle which appears
on the vaginal mucosa, when the first two instruments
are separated, a suture of silkwormgut is passed under
the sulcus, catching the ends of the torn muscle. Instead
of clamping or tying this suture directly over the site of
the injury, which would crowd the mucosa between the
ends of the muscle and would thus prevent their union,
the end of the suture is returned superficially under the
mucous membrane and the two ends are shotted along-
side the tear instead of directly over it. Three or four
such sutures are usually required. The laceration is
almost always worse on the left side, and is often con-
fined to that side. Nothing need be said in favor of
restoring the pelvic floor and perineum, if these struc-
tures are injured in labor. Poorly as this work is often
done in general practice, its necessity is generally appre-
ciated.
At the final examination, uterine displacements, sub-
involution, pelvic inflammations, diastasis of the recti
muscles, nephroptosis, lacerationof a coccygeal joint, and
the injuries of former labors are carefully looked for, and
if found are corrected by the appropriate surgical or
other means. We can claim, therefore, tliat the patients
under our care secure an immunity from injured cervix
and its consequences, from rectocele, cystocele, retro-
flexio uteri of puerperal origin (vastly more common than
any other cause), from splanchnoptosis following dias-
tasis of the recti muscles, pelvic inflammations, pro-
850 AKKR.cAv MEDiciKEj TUBERCULOSIS BACILLUS OF HUMAN ORIGIN.
[NOVEMBKR 29, 1902
lajisiis uteri, subinvolution and endometritis followin}?
('hil(ll)irtli or abortion and from cowygodynia. In short,
tliey escape by far the greater number of the diseases
peculiar to women. It is an Important question how all
classes of society can secure the same good treatment
which the poorest classes are obtaining in the best of our
modern maternity hospitals. The majority of the
middle and upper cla.sses are attended in labor by
general practitioners. It cannot be expected that they
sliall have an expert's ability in diagnosis or in surgical
technic. It would be an inestimable blessing to child-
bearing women if every physician who laid no claim to
special skill in gynecic surgery would have his patients
inspected by a specialist shortly after labor and again at
the end of the puerperium. If some such system is
elaborated by which women are ensured a practical
immunity from all the ill consequences of childbearing
— which is perfectly possible — as great an advance will
be made in medicine as has yet been witnessed, ranking
with vaccination, anesthesia, and asepsis.
SOME FACTS WHICH SHOW THAT THE TUBERCU-
LOSIS BACILLUS OF HUMAN ORIGIN MAY
CAUSE TUBERCULOSIS IN CATTLE, AND THAT
THE MORPHOLOGY AND VIRULENCE OF THE
TUBERCLE BACILLI FROM VARIOUS SOURCES
ARE GREATLY INFLUENCED BY THEIR SUR-
ROUNDINGS.'
BY
E. A. DE SCHWEINITZ, Ph.D., M.D.,
AND
MARIOX DORSET, M.D.,
Biochemlc Laboratory, B. A. I.,
AND
E. C. SCHROEDER, M.D.V.,
Experimental SUitlon, B. A. I., Department of Agriculture, Wash-
ington, I). C.
Without discassing the excellent work that has been
done by many investigators, we propose to present to this
conference a brief statement of some of the important
results which we have recently obtained in connection
with our investigations in tuberculosis.
That the tubercle bacilli obtained from various ani-
mals are largely influenced in their morphologic appear-
ances, depending upon the animal in which they happen
to develop, and more especially upon the nature of the
media and length of time of development upon artiticial
media, is well known. We have recently made a study
of the tubercle bacilli derived from the bird, the horse, tlie
cow, the dog, the pig, carp, and three varieties, differing
in virulence, of the germ of human origin. In the tirst
instance I (de Schweinitz) had inoculated a number of
flasks of the ordinary liquid medium (glycerinized beef
broth) for the cultivation of tuberculosis bacilli with each
of the above named germs. These cultures were divided
into three lots, one set allowed to grow for three weeks,
another for about six, and another for about three
months. Preparations of the different germs were made
from each flask after these varying lengths of time. It
was found that there was uniformly change in the mor-
phology of the different germs, those that had been
grown for the longest time being very materially
different in appearance from those that had grown for
the shortest time. It was noted also that the most viru-
lent germs showed less change in the morphologic
appearance than those that were less virulent, but even
with these a change in the size of the germ that had
grown upon the artificial media for the longest time was
apparent.
The chemical composition of these same germs has
also been studied by de Schweinitz and Dorset, the com-
1 Read at Tuberculosis Congress, In Berlin, October 22-26, 1902
Advance sheets of a bulletin presented now through the courtesy of
l)r. D. E. Salmon.
plete results of which study have already been published
in Cmtralbl. /. Bakt., 1902, Vol. xxxii, p. 186, and
American Medicine.^ The results obtained all point to a
closer resemblance between the bacilli of bovine origin
and the virulent bacilli of human origin than that which
exists between virulent bacilli of human origin and
attenuated bacilli of human origin.
Again we have made tuberculins from cultures of
the attenuated human, virulent human, bovine and
horse bacilli, and tested their effects in causing reactions
in cattle as well as in tuberculous individuals, and have
found that the tuberculin prepared from a bovine cul-
ture produced the same characteristic reaction in man
and cattle as the tuberculin obtained from a human
culture, and also vice versa.
I have in my laboratory a culture of the human
tuberculosis germ which is exceedingly virulent for
small animals, and another which, originally very
virulent for small animals, through long years of care-
ful cultivation, has become very attenuated. The
immunizing property of this attenuated germ for small
animals was already noted and emphasized by myself
(de Schweinitz) in the Medical News, 1894, December 8,
where it was shown that an apparent positive immunity
to tuberculosis in guineapigs could be established by inoc-
ulating them with this attenuated germ. The animals
were tested by subsequently exposing them to a virulent
germ. These attenuated germs still yield valuable
tuberculin.
It is universally acknowledged that, in general,
tubercle bacilli obtained from cattle are more virulent
than the average tubercle bacilli obtained from man,
although a number of human bacilli have been found,
some of which we will refer to presently, that are just
as virulent for cattle as those which have been obtained
from cattle. It would be strange, indeed, if the bovine
germ, which is uniformly so virulent for all varieties of
animals upon which it has been tried, should suddenly
become less virulent when attacking man, another
species of animal. To test this we (de Schweinitz and
Schroeder) have made some preliminary experiments
upon monkeys, as the nearest relatives of man. Some
of the results obtained were published in American
Medicine, .lanuary 4, 1902. We have inoculated baboons
and the rhesus with bovine and human tubercle bacilli.
Both the baboons and the rhesus succumbed to these
inoculations, the autopsies showing very generalized
tuberculosis, the lesions produced by the bovine germ
being more marked, especially in the lungs, than those
produced by the human bacilli. The inoculations of
these animals were made subcutaneously, from .5 cc. to
1 cc. of the liquid culture of the bacilli being used. In
general, we may say that in the case of the lesions pro-
duced by the bovine germ, every organ and gland was
tuberculous.
The next step was for us (de Schweinitz and
Schroeder) to inoculate heifers of about eight months
of age, subcutaneously, with a piece of the tubercu-
losis material taken from the monkey that was dead
from human tuberculosis. The heifers had been, of
course, previously tested with tuberculin and carefully
observed and found to be free from tuberculosis. This
was always done with all of the animals that have been
used in our experiments, so that there is no possi-
bility of infection having come from any other source
than the direct inoculation with the germ. After eight
months these cattle were killed. The animal injected
with the tissue from the monkey that died of human
tuberculosis showed no lesions except a small pocket
filled with pus at the point of inoculation. The animal
inoculated with the tissue from the monkey dead
from the inoculation with the bovine culture showed
also a small pocket at the point at which the injec-
tion had been made, a slight abscess in the glands
of the shoulder on the same side aa that where the
■ American Medicine, Vol. Iv, No. 3, p. 93.
November 29, 1902)
PATHOLOGY OF K AT ABOLISH
(Ambbioan Mkdicike
851
inoculation had been made, and necrotic foci in tiie
mediastinal glands. No other evidence of tuberculosis
was present. Another animal inoculatetl on November
2, 1901, with 10 cc. of a virulent bovine culture (Bovine
III of Dr. Theobald Smith) grown upon liquid media,
showed, when killed on October 2, 1902 (this bovine
culture was the same one that had been used for the
purpose of inoculating the monkey above referred to),
the following : The general condition of the animal
was good. At the seat of inoculation was an indurated
patch about six inches in diameter in which were
imbedded numerous small abscesses containing a soft-
ened cheesy material. The shoulder glands on the side
of the injection, both deep and superficial were enlarged
and sprinkled with necrotic foci. The mediastinal
glands also contained numerous necrotic foci. No other
lesions were found and the animal appeared in excel-
lent condition. These experiments show that the
bovine bacillus may require a long time to produce evi-
dence of tuberculosis in cattle when injected subcu-
taneously, and they also suggest that the passage of the
bovine bacillus through the monkey has apparently
decreased its virulence.
We have experimented further with a number of
bacilli derived from ca.ses of generalized tuberculosis in
children and in adults, and with tuberculous sputum
from adults. The material used has been obtained from
the several hospitals in Washington, and the isolation of
the cultures has been made by Dr. Dorset. In this work
he has found the use of the egg medium, suggested by
himself, a description of which is published in American
Medicine, Vol. Ill, No. 14, p. 556, April, 1902, to be of
great value. We have succeeded in producing appar-
ently tuberculosis in a calf by intraperitoneal inoculation
of tuberculous sputum. A guineapig has since died
with tuberculosis from an inoculation of the tubercles
on the peritoneum of this calf.
Three cultures have been isolated from cases of
generalized tuberculosis in children, which cultures
have caused the death and generalized tuberculosis in
calves of about four months of age, after these calves
had received a single intravenous injection, an emulsion
in water of 5 cc. of the respective cultures.
The cultures were grown upon the egg media above
referred to. The animals died in from 18 days to 4
weeks. The two most virulent of these cultures were iso-
lated from generalized tuberculosis of a child. One,
which we will designate as No. 4, and which killed by
intravenous injection in 18 days, has also given us posi-
tive results in cattle at the present time after SMAcj^ianeows
injection. On April 12, 1902, a heifer, No. 250, was
inoculated subcutaneously back of the left shoulder with
a small piece of lung taken from this child. No. 4 ; and
back of the right shoulder a small piece of the intestine
taken from the same child was used. The autopsy on
October 2, 1902, showed at the seat of inoculation a group
of small absceases in the skin. The glands in front and
back of the shoulder and in the flank contained numer-
ous necrotic foci, in which, upon microscopic examina-
tion, the tubercle bacilli were found. On the pleura of
the lungs, numerous pale-red excrescences were found
very plentiful on the right side and the posterior border
of the principal lobe. Similiar growths were sprinkled
over the diaphragm. The growths on the diaphragm
produced tuberculosis in guineapigs, which died. (The
growths on the pleura of the lung were found to contain
numerous tubercle bacilli.) The subcutaneous injection
of this tuberculous matt^rial from a child caused, there-
fore, within six months as much evidence of tubercu-
losis in a calf as that which resulted from the subcu-
taneous iiyection of a virulent bovine culture after one
year.' The results in this case are positive, and as noted
'Blnce writing the above, another calf has succumbed within four
wefkf* to a HUbcutaneouH lno<'ulatlon of a culture obtained from tliU
Niiinc child, No. 4. The autopsy (.Schroeder) Hhowed very gencr-
all7.cd tuberculosis.
above, we have at least three different cultures of human
origin, which we feel warranted in believing will pro-
duce disease in calves upon subcutaneous inoculation.
The details of all this work, with illustrations, will be
published later as a Bulletin. We have presented the
above experiments without giving details here, as facts
are wanted at the present time. I (de Schweinitz) feel
warranted by our work in drawing the following con-
clusions :
The morphologic appearance of the tubercle bacilli
derived from various animals is influenced greatly by
the artificial media upon which the germs are allowed to
grow and the length of time that the germs have grown
upon such media. The virulence of the tubercle bacilli
derived from various sources is influenced by their
growth upon artificial media, as well as by their passage
through different animals. Bacilli can be and have been
isolated from children afltected with generalized tubercu-
losis, which have been, upon subcutaneous inoculation,
as and more virulent for calves as the bovine bacilli used.
Bacilli isolated from tuberculous children which are very
virulent for calves upon intravenous inoculation, appear
also to be virulent upon subcutaneous inoculation. Several
or even one positive case of the transmission of tuberculo-
sis to calves by subcutaneous inoculation where the
material has been obtained from a tuberculous human
prove positively the possibility of infecting cattle by the
germ obtained from man. There is a difference in the
virulence of germs isolated from different human sub-
jects, and also a difference in the virulence of the germs
secured from the different organs.
That tubercle bacilli obtained from cases of human
tuberculosis can produce disease in cattle is to my mind
(de Schweinitz) by our own work, not to mention that
of many investigators, like Nocard, Ravenel and
others, absolutely proved.
THE PATHOLOGY OF KATABOLISM IN RELATION TO
THE ETIOLOGY AND PATHOLOGY OF CANCER
AND ALLIED STATES.
BY
HOMER WAKEFIELD, M.T).,
of New York City.
AttendlDK Physician, Outpatient Department, Bellevue Hospital ;
Member New York Palliolofjical Society, American
Medical Association, et*:.
[Continued from page 821.\
DIFFERENTIAL MORPHOLOGY BETWEEN BENIGN AND
MALIGNANT NEOPLASMS.
Having already delineated the etiology of neoplasms
in general, and the various tissue characteristics in the
divers processes, it will be hardly necessary to point out
the differential features of the benign and malignant
forms. However, to avoid a possible stumbling-block to
some readers leas familiar with the subject, it may be
stated broadly that in the benign form the katabolic
stasis may be weaker or shorter in time length. It may
be entirely local and shortly overcome by the processes of
a normal, general condition. The tissue, or combination
of tissues involved, may be ill adapted to malignancy.
Any general or exciting cause may be of too short dura-
tion for the attainment of the conditions necessary to
malignancy. While it is admitted that certain tissues
and tissue-combinations are more prone to malignancy,
we have abundant evidence that boils, ulcers, tumors,
and many eruptions for long periods benign, may attain,
under favorable conditions, pronounced malignancy. It
is observed that all the divers tissue-elements possess
varying degrees of digestibility, so that any particular
grade of irritation will produce but a single effect upon a
single tissue. In such event, malignancy could never
result from any ordinary etiologic factor. Hence to pro-
duce malignancy the exciting cause must be sufficiently
852 A3IKBICAN MSDICIHBj
PATHOLOGY OF KATABOLISM
INOVEHBER 29, 1902
prolonged and continuous to ensure the coexistence of the
adolescent, the declining and the degenerated (superan-
nuated and disintegrated) cells thus presenting an unsta-
ble circumscribed area of mixed living and necrotic
cells ; or the katabolic stasis of one tissue must be con-
stant and continuous as it is gradually increased to a
point when other more digestible tissues become coinci-
dently subkatabolized.
The essential characteristics necessary to malignancy
in neoplasms consist of a prolonged and continuous effect
of katabolic stasis upon the involved tissues, both gen-
eral and local influences being favorable to the continual
production of a marked retardation of katabolism of the
cells as they severally pass their meridians, up to a point
when the oldest cells reach a stage of fatty necrosis.
When a condition is attained in which the tissue-cells
and fibers involved present a sufficient number of the
various degrees of perversion, decline and degeneration
of both the antemeridian and postmeridian cells to
compose a complete working combination, malignancy
may be said to be attained. Neoplasms differ in malig-
nancy according as they contain a combination of the
extremes of conditions of tissue metamorphosis, and
also as they involve tissues of opposite structural attrib-
utes ; thus a combination of slow-growing and slow-
disintegrating fibrous tissues, together with that of the
rapidly growing and disintegrating epithelium cellular
tissues, forms the most malignant tumors, after the first
mentioned process is established.
METASTASIS AND SECONDARY GROWTHS.
One of the chief attributes of malignancy is that of
metastasis, namely, the formation and emigration of
thrombi, together with their development into secondary
tumors in foreign tissues, either before or after the extir-
pation of the primary or maternal growth. The attrib-
utes and the stage of development of the maternal
growth essential to metastasis consists of a central zone
of suppurative or fatty degenerated tissue, surrounded
by an indurated margin (the growing edge) of mixed
adolescent, retrograde and degenerated tissues, gradually
merging from the normal outer tissues into the inner
degenerated zone. With these attributes and conditions
the constant extension of the zone of degeneration, or,
in other words, the continued degeneration of the
indurated margin by the unequal purulent disinte-
gration of its contained superannuated cells and fibers,
the normal continuity and stability of these tissues are
destroyed, and as a result the margins adjacent to the
inner zone break up into particles or clusters of various
sizes, which, when small enough and conveniently situ-
ated are taken up by the open ends of lymphvessels and
bloodvessels extending to the sloughing edge of the dis-
integrating tissue. The dilated vessels conduct these
thrombi to other situations, near or remote, where owing
to the occlusion of a vessel, or other cause, they reach a
standstill, and in situ they begin the secondary growth.
While as a rule the lymphatic glands are the seats of
metastatic growths, the location depends upon the nature
and situation of the tissues of the maternal growth ; for
example, the usual metastasis from a cancer of the
stomach is to the liver, the thrombus being conducted
into the portal vein. In cancer of the breast the axil-
lary glands are first and most involved, segregated
particles invade quite generally the venous and lymph-
vessels leading from the site of the tumor ; thus the
attributes of secondary growth occur, and either in situ,
or when set free by further metastasis, they may be
general.
The thrombus wherever lodged becomes the focus of
development, and from it the continuous reproduction
of the tissues of the maternal growth takes place, sur-
rounded by tissues, however foreign in nature to that
of the malignant growth. Metastatic cells, fibers, and
debris, in order to form a focus and become the causative
factors of a secondary tumor, must primarily consist of
a thrombus of several cells carrying with them the per-
verted intercellular juices. The contained cells must
consist of a variety of stages of development, as also of
degeneration, in order that some degree of new cell-
formation may be possible, and this must exist under
the perverting influence of a suppurating metamorphosis
of contiguous degenerating cells. The ti&sues of the
thrombus must be sufficiently difficult of digestion to
exceed the existing digestive powers of the location of
its final lodgment ; and the general conditions favorable
to metabolic stasis must continue for a sufficient length
of time and be of sufficient power to admit of develop-
ment of the thrombus to the point of the suppuration of
its oldest cells (its foci), in which event its malignancy
is certain and its individual career and its progeny are
assured, until such an overwhelming revival of the
normal katabolic processes is reestablished as to oxidate
all of the superannuated cells and tissues and thus
restore the normal balance of metabolism and the condi-
tions necessary to its continuance.
I have no doubt that many thrombi migrate from
cancers, ulcers, and other suppurative affections of
various kinds, which meet all varieties of successes and
fates, according to their tissues and the make-up of their
structures, the locations of their lodgment and the gen-
eral systemic conditions then existing and following the
migration. Even when metastasis is active, compli-
cating malignant growths ; I am convinced that of many
thrombi that are carried by the lymph and blood
currents to other locations, comparatively few find a
lodgment in tissues and locations favorable to
"secondary growth." The normal vascularity, the
conditions of the nucleonic oxygenating function and
other influences of adjacent tissues exert a direct effect
upon the katabolism, and mold the future, the growth
or oxidation (disintegration) of the thrombi. When they
meet with a sufficiently active katabolism, or are not
favorably constituted to continue the perverted meta-
morphosis, they dissolve and the morbid manifestation-j
are discontinued. If a thrombus is large enough it
makes little difference whether the tissues in which it is
deposited are the subject of inflammation or of katabolic
stasis. The mass acting as an irritating foreign body, is
often sufficient to produce local stasis in its surrounding
tissues and of the leukocytes attracted there, rendering
them inert as oxidants ; and thus the mass increases and
evolves into the malignant course, little disturbed by
oxidation, especially if its constituent cells comprise the
essential attributes of secondary cancers. The same may
also be said of grafts of cancers which are made with a
view of testing its supposed infectious nature. These
masses in many respects grow exactly as do transplanted
normal tissues, and in the same manner as does a graft
of the thyroid gland in myxedema, which, as is well
known, functionates in its transplanted position. A
cancer thrombus or graft, however, as distinguished
from normal tissue, requires protection from oxidation.
This protection, however, is furnished by the erosive
effect of the cancerous mass upon the surrounding tis-
sues, which is usually characterized by a fibrosis and
more or less encapsulation. The fact that degenerated
cancerous parenchyma is more highly oxidizable than
normal tissue is attested by the effect of arsenic and
other oxidants upon superficial cancers, which when in
proper strengths act upon the cancerous mass only, thus
sparing the adjacent normal tissues.
When growths recur repeatedly, each successive
return is characterized by a lower scale of degeneration
and the intervals between the recurrences gradually
diminish. The tumors of each recurrence are in turn
progressively softer, more succulent, and more and more
approach the consistence of soft masses of nearly liquid
gelatin, thus demonstrating the progressiveness of the
suboxidation and malnutrition, as oxidation and nutri-
tion is more and more interfered with and edema is
caused by the repeated metastatic infiltrations of each
November 29, 1902]
PATHOLOGY OF KATABOLISM
[American Medicinb 853
suci-essive tumor formation. There is evidence that those
advanced and malignant cases of cancer which are char-
acterized by melanosis, represent an extreme degree of
suboxidation and a subkatabolic involvement of the
adrenals, which undoubtedly possess a function of some
variety of metamorphosis (probably oxidative) of effete
hemoglobin or hematin into hemochromogen. The
retention of effete pigment, with its distribution to the
mucous membranes, skin, and urine, accounts for the
bronzed skin and other pigmentations of Addison's dis-
ease, carbonic-acid poisoning, and in the degenerated
tissues of cancer and other subkatabolic necrosis.
In very malignant and metastatic cancers, after the
bloodvessels and lymphvessels have become well infil-
trated and occluded, the return of carbonic acid to the
lungs is impeded, and thus a resulting carbonic acid
poisoning would produce melanosis. Again, metastatic
thrombi occluding vessels supplying or ramifying in the
' adrenals, may thus produce a suboxidation of one or both
of the glands, and a resulting subkatabolic degeneration.
Abundant illustration of the intimate relation borne by
oxygenation to melanosis, is noted in "arsenical melan-
osis," after the prolonged administration of arsenic, and
in the aggravation of Addison's disease, by the same
cause. In the most malignant and suboxidized forms
and stages of malaria, melanosis may be quite marked,
and it is associated with a corresponding corpuscular
destruction in the blood, which is loaded with an abun-
dance of free granular matter and pigment impregnated
leukocytes. I have observed a case of most pronounced
melanosis, with the typical bronze skin, in a man, for
many years an employe of a gas works, who did not
present the other classical manifestations of Addison's
disease. The initial institution of katabolic stasis is
characterizetl by a decrease in the excretion of carbonic
acid and urea, but after the inauguration of metastasis of
tissue and blood-cell detritus, and especially after active
gelatiniform or fatty degeneration is established, the
excretion of these end-products may exceed that of
health, thus demonstrating that the disintegration of a
perverted katabolism is often more rapid than that of
normal katabolism. The observed predisposition of can-
cer to recurrence in old scar-tissues is not a characteristic
of cancer only ; it is observed in all chronic sores. Often
healed sores originally due to hyperacidity are subject to
exacerbations with a recurrence of the hyperacidity and
without local injury or other cause for recurrence at the
.site of the original sore.
COMPLICATION'.S AND INFECTIONS.
Among modern writers on etiology it has become
quite a universal habit to refer vaguely to waste-products
in the system a-s predisposing factors to infection. They
describe sallow and " greeny yellow " complexions, etc.,
SIS characteristics, but do not attempt to inquire deeper into
their origins. I have herein attempted to set forth the
primary and all intermediate causes of these conditions,
and will henceforth treat such a hypothesis as estab-
lished. It must thus be accepted : that predisposition
to infection depends upon a surplus of necrotic tissue-
detritus in the vessels and organs of the economy, and
that such conditions precede the successful infection by
microorganisms. It must be, and it is quite generally
admitte<i, that most if not all of the above-described con-
ditions, attributed to katabolic stasis, may be and often
are a.septic. I will ((ualify the above by admitting that
they are very prone to infection and often become
infticted ; thus the iiuestion in acute articular rheuma-
tism has long swung in the balance as to its bacteriologic
or chemic etiology, ifor affected joints have respectively,
at various times been found sterile, and others infected,
by equally competent and reliable observers.
I feel justified in nuiking the following comments
upon infection laws: Infection never takes place in
normal tissues under normal conditions. Infection is
always swondary to some degree of katabolic stasis,
somehow produced, the most acute infective diseases
only excepted. The socalled nonpathogenic bacteria by
their gastrointestinal fermentations are as a rule more
active as primary etiologic factors, on otherwise healthy
subjects, than the socalled pathogenic organisms which
require nonreactive retrograde gelatiniform or suppurat-
ing tissues as a medium.
It is usually more important to oxidize (obliterate)
retrograde and suppurating tissues, after infection has
taken place, than to attempt direct destruction of the
microorganism itself. While this fact has not been duly
recognized our most successful practice is just as thor-
oughly along those lines as though it were instituted on
those principles. The emptying and treating of pus-
cavities has long been the universal treatment. No
surgeon would think of injecting one with germicidal
agents and leaving the pus there, and yet injections of
oxidants, as alcohol, is a successful practice.
In genitourinary practice our internal administra-
tions of terpenes, balsamic and aromatic extracts which
oxidize the urinary acids, relieving irritation, are at once
beneficial in all urethral suppuration, also the injections
of chemieals, acting as oxidants, such as hydrogen,
dioxid, etc.; caustics, as zinc sulfate; astringents, as
alum ; and styptics, as lead, fulfill all indications without
germicides. We destroy the disease by obliterating the
favorable culture-medium of the bacteria. Even in the
most virulent gonorrheas it has been practically demon-
strated that powerful oxidants are the most potent
agencies against the bacterial process ; yet the fact that
they are ultimately successful in human bacterial infec-
tion is the only evidence adduced to the effect that they
are directly bactericidal in their actions.
All authorities in medicine and bacteriology have
taught that predisposing conditions are observed prece-
dents to most infections. We have seen that extensive
and grave katabolic perversions, attended with wide-
spread degenerations, are not only possible but are of
general occurrence without the aid of any infection ; and
moreover, that pathologists generally have admitted
that catarrhal, ulcerative, suppurating and sloughing
conditions, the established results of general and local
katabolic stasis, are notorious as the most favorable of
known conditions, predisposing to all bacterial and fun-
goid growths.
It is not denied that infections occur from contagion
and often when the victims are apparently in good
health ; yet a clearer and more general insight into this
subject by the profession will demonstrate that some
degree of stasis of katabolism is alwai/s present in such
cases and that pathogenic bacteria are able to live, grow
and proliferate only in and among necrotic tissue and
blood-cells that have failed of normal katabolism. The
experiments made upon the lower animals determine
that the primary etiologic relations of bacteria are
extremely inconclusive to that result ; for example,
Watson Cheyne has determined that 250,000,000 cocci
must be injected into a part to produce an abscess, and
Bi^jwid holds that even 1,000,000,000 is insufficient.
Thus at all odds it is evident that such a number would
pr(Kluce the characteristic effects of foreign bodies, and
certainly with their associated effects of activity, their
metabolic excretions, often of an acid nature, and the
decay of their dead, they are much more irritating than
inert bodies, and it is not surprising that the contiguous
tissues should suffer katabolic stasis and thus become
prey to the bacteria thus acting as saprophytes. Bacteria
are not ordinarily introduced into the lx)dy in such
numbers and concentration, and such experiments pro-
duce no criterion for the pathogenesis of bacteria entering
the body by natural methods.
In my opinion the socalled nonpathogenic bacteria,
by their fermentations of food in the gastrointestinal
tract and in the production of excessive quantities of the
divers fatty and other organic acids are more prolific as
primary causes of disease in general, including the
854 AHBRICAN MBDICINE]
PATHOLOGY OF KATABOLISM
[NOVEUBEK 29, 1902
socalled infectious diseases, than are tlie patliogenic bac-
teria ; and indeed, it is yet an unsolved problem wliether
the nonpathogenic organisms may not become patho-
genic, after an acid produced stasis of katabolism of the
intestinal walls for example, and thus assume new char-
acteristics of form and virulence, in the new and more
favorable medium. It is well known that the colon bacil-
lus, in a sugar medium, excretes lactic acid, and that the
typhoid bacillus in a changed medium so closely
resembles the colon bacillus as to be almost indistinguish-
able. It is well known that all microorganisms change
their forms and other characteristics, with change of
medium, and often they change more than would be
necessary to the colon bacillus to assume the char-
acteristics of the typhoid bacillus.
I have elsewhere intimated my views on the com-
mon origin of cancer and pulmonary tuberculosis, and
attempted an analysis of the differential predispositions
of the two maladies. Pulmonary tuberculosis is indis-
putably an infectious disease, and to accord it a common
etiology with cancers, which are at the same time
declared aseptic, may appear paradoxic ; yet when it is
considered that pulmonary tuberculosis is primarily an
aseptic degenerative process of subkatabolism, and that
the infection is secondary, the identity of the primary
etiologic factors is not incompatible. It may be men-
tioned that all of the diseases of the socalled rheumatic
series, pneumonia, lardaceous disease, amyloid kidneys,
and many similar aflfectioos, are of common causation
with cancer ; and that syphilis, malaria and other affec-
tions have many manifestations displaying a pathogenic
process common to cancer and to diseases of katabolic
stasis generally. Thus a new field is opened in tracing
the parallels and differentiations of these in other
respects dissimilar maladies.
Additional evidence of the noninfectious nature of
cancer is furnished by the fact that most parasites pro-
duce a proliferation of connective tissue only, while in
malignant neoplasms other tissues are as frequently
involved. Again, in the metastasis of cancers, the tissue
of the primary tumor is reproduced, while conversely,
in the metastasis of microorganisms the tissues of the
site of the secondary lodgment are increased and form
the tumefaction. That cancers are usually aseptic is
demonstrated by the marked modifications noted in
cancerous tissues when bacteria are experimentally intro-
duced into cancerous masses. No proof has ever been
adduced to establish that neoplasms are due to parasites,
and to the contrary we have been able to show that all
of the conditions and manifestations of cancers are possi-
ble under generally accepted pathologic laws, and with-
out the aid or complication of any pathogenic organisms.
Infection of cancers having long ago been observed to
produce hyperemia and a beneficial efftect upon the
growth, it has led to the institution of much study and
research with a view of finding a means of cure of the
disease. Microorganisms capable of producing high
degrees of inflammation and hyperemia, have been
experimented with, and as a result the present treatment,
by the mixed toxins of the streptococcus of erysipelas
and Baeillm prodtgiosm has been found most efficient,
but far inferior to the artificial acceleration of oxidation
produced by the rays of Rontgen and actinic light, and
the direct chemical oxidations mentioned under the
head of therapeutics. We have also in the tubercle
infection by Koch's bacillus, much observed in several
organs where thrombi are deposited, an illustration of a
low inflammatory modification.
An extremely striking and significant illustration of
the predisposition of cancerous tissues to infection is the
fact that the suppurating zones, when not kept in a sani-
tary condition, not infrequently in warm weather become
infested by animalcule saprophytes, as worms and
maggots. Why not then put these factors down as
worthy of an etiologic relation? If inoculated into ani-
mals they probably would produce a subkatabolic degen-
eration, also induration and perhaps more or less tume-
faction, or a circumscribed tumor-formation.
THE DISTRIBUTION OF CANCEK.
As may l)e inferred from the deductions reached in
general etiology, cancer, like tuberculosis and all allied
diseases, finds its localities of prevalence in those places
where from the nature of the soil " malaria " is prone to
break out during the wet seasons. It is observed in
valleys, in those parts most shaded by high mountains.
It occurs in localities in which the inhabitants are over-
worked, illy clothed, and deprived of the comforts of life,
in houses which are damp, poorly heated and ventilated,
and deprived of sun.
More important, however, are the localities peopled
by classes and nationalities which, from vices of eating,
drinking and life habits, develop cancer directly from
these causes. The ingestion of excessive quantities of
sweets, acids, alcoholic liquors and beer, ales and porter,
may be a community, or a family, as well as an indi-
vidual habit ; thus a man and wife, or other persons,
unrelated by blood, but subject to the same life-condi-
tions, food, beverages, habits, eto., may be alike the
victims of the malady. The maple-sugar-eating New
Englander has suffered owing to this excess. The Ger-
mans in their native land appear to be afflicted approxi-
mately in direct ratio to their beer-consumption, while the
Germans in America suffer far more, owing to the com-
bining of the beer, acid wine, and sauerkraut diets with
those of the Yankee, which include many sweet dishes
unknown to this people in the land of their nativity.
Moreover, in the average American beer, which is con-
sumed while in an active stage of fermentation, not
near completion, the active yeast present not only con-
tinues the fermentation after it is ingested until the
contained maltose is consumed, but it continues upon
glucose and other sweets, ingested as candy, cake, and in
other combinations. It is not an uncommon sight to
observe mothers even, alternating beer and candy in
feeding young infants and children. I have also often
seen physicians so disregard this incompatibility as to
combine beer and sweet desserts in the same meal.
Acid fermentation is an inevitable result of such errors,
and the strongest stomach will give way to it in time.
A coingestion of sauerkraut and other pickled foods,
so popular with the Germans, simply adds to the organic
acid excess in the stomach, which must be burnt in the
liver, or in the event of an amount exceeding the oxygen
of the hepatic blood-supply to oxidate, it must be passed
on into the arterial blood where it will find combustion
after the blood is reoxygenated in the lungs, thus con-
suming an excess of oxygen and depriving the tissues.
The ingestion of large quantities of salted, dried
and smoked meats by the classes mentioned proves an
additional factor without doubt ; yet not owing to the
amount of salt coingested, but to the fact that such
meats are so hardened by these processes as to be indi-
gestible, and especially in the absence or greatly dimin-
ished secretion of hydrochloric acid, which is a common
accompaniment of organic acid excess in the stomach.
Being slow of digestion in these cases the chemically
hardened fibers, divested of their fluid constituents,
remain in the stomach for long periods and fall prey to the
acid fermentation microbes, and to their acid products I
attribute the observed results. Among the affluent
classes the addition of sedentary and indolent habits,
deficient exercise, financial anxiety, and acquired dys-
pepsias, and the habitual wine, spirits and malt-liquor
drinking, too common among all classes, furnish the
essential elements.
When a house attains the reputation of being a
cancer-house, through cancer fatalities of many succes-
sive wives of one continuous husband, I would be
inclined to suspect sexual excesses, as occasionally occurs
with unusually vigorous men. Other vices, however,
may be combined, as alcoholic intemperance, to which
November 29, 1902)
PATHOLOGY OF KATAB0LI8M
rAXERICAN Medicinb 855
women fall prey so much more readily than men, espe-
cially when coincidentally debilitated by sexual excess.
Sexual excesses must be accorded an important factor
among all classes.
Family habits, tastes and training are more impor-
tant than all other predisposing causes. Dispositions to
literary pursuits, sedentary habits, addiction to drink,
to rich cooking, eating between meals, etc., may be
mentioned among the more prominent characteristics.
Some families consider life not worth living without an
abundance of pies, cakes, puddings, tarts, rich fruit jel-
lies, sweetened breads, honey, sweet and sour pickles, vin-
egar-saturated lettuce and other salads, and meat and veg-
etables renderetl hard and impermeable in the frying-pan.
Recipes for rich and delectable culinary preparations are
handed down from one generation to another, and thus
serve as progenitors of the diseases that are " visited
upon the children unto the third and fourth genera-
tions." Occasionally when married to persons of stronger
wills, members of either sex may surrender their family
habits and food preferences for the habits, and therefore
the disease-consequences of another. However, it is
generally observed that the family traits of the married
representatives of the families excelling in cookery are
apt to prevail in this respect. The acquired habits of
early life while under the parental roof are very strong,
and are prone to be permanent. The vices of rapid eat-
ing, of bolting food, of drinking during meals, especially
an exceas of coffee, tea, wines or beer, and other perni-
cious habits must be accounted as factors in the propa-
gation of family diseases in later life.
I have observed three generations of one family in which
the maternal grandmother died of cancer, two daughters and
a son preceding her, dying of pulmonary tuberculosis in early
adulthood. A third daughter developed scleroderma at about
50, dying 10 years later of cancer. The last surviving child, a son,
died when past 60 of cancer. Two children of the scleroderma
patient, both under 23, have manifested a hemorrhagic diathesis.
Of the first two generations, the lean ones died of tuberculosis,
and the fat ones of cancer. Among the family characteristics
the most marked was subnormal animal heat, which is indica-
tive of suboxidation. This family very well illustrate the
hereditary traits above described. Here three deaths from
tuberculosis and two from cancer occurred in one house, the
other death from cancer occuring in another city.
Another consideration of importance in the etiology
of suboxidative cases is that after oxidation has been
unduly lowered by supercarbohydrate oxidation, not
only does tissue katabolism fail, but as has been inti-
mated, the oxidation of flesh foods becomes retarded or
arrested, and in consequence they clog the vascular and
lymphatic systems and thus further the existing oxida-
tive stasis, producing a progressive decline of oxidation
and its several resulting maladies. These conditions
have been long observed among those who combine
highly soluble concentrated and soluble carbohydrates as
well as those who drink wines and other alcoholic bever-
ages with a generous meat diet. It may be added here
that in my opinion animal flesh, when fresh and properly
cooked, preserving the natural moisture, is never injuri-
ous perse. When, however, ingested with an excess of
higher oxidants the oxygen needed for the meat is
diverted and the meat suffers from the privation in its
digestibility.
Fle.sh being the most highly organized and concen-
trated form of nutrition, it should be eaten solely when
a concentrated nutritious diet is indicated. Never
should highly soluble and oxidizable carbohydrates be
substituted. When meat is taken the best digestion and
oxidation are obtainetl by combining the more bulky
carbohydrates in the form of fresh green vegetables.
Thus it is observed that the average dessert and table
wines and liquors are incompatible with meat diets.
When ingesttKl flesh fails of systemic oxidation, inst<'ad
of prohibiting meat the medical man should prohibit
the concentrated carbohydrates, ethers and alcohols, and
otherwise restore oxygenation and oxidation, using the
oxidation of meat ingested as a criterion of the success
attained.
It is seen there are many explanations why cancer,
like tuberculosis and similar diseases, is observed to
occur among certain communities, houses and families,
and why though appearing to be both an infectious and
a hereditary disease, it is neither. Also it may be con-
ceived why no single causative factor has been hereto-
fore offered which was general enough to comprise all of
the elementary causes of subkatabolism. No one has-
heretofore compassed that all-important factor. In con-
sidering the many denials recorded of etiologlc factors
heretofore presented, we must bear in mind that counter-
acting agencies are always occurring in individual cases,
thus : Active labor and temperate habits may overcome
the ill-effects of an otherwise unhealthful locality or
house. Conversely, intemperate habits at the table, bar
or marriage-bed may overbalance the favorable effects of
the most healthfully situated and appointed house.
Another group bearing an etlologic relation to the
subject that has not been to my knowledge heretofore
presented for consideration, is the rancid butter, oils and
fats, and soured milk, largely consumed by the pauper
classes in great cities, owing to their greater cheapness.
It must be observed that while the neutral fats are taken
up by the lacteals and are slowly burnt in the superficial
circulation, particularly of the muscles, the fatty acids
are conducted directly to and are burnt in the portal
system, and when excessive in quantity any of the per-
nicious results of superportal combustion may be caused.
In selecting diets for invalids physicians must not only
give consideration to the caloric values or properties of
food, but they must anticipate the location of their com-
bustions, for example : the neutral fats possess very high
caloric values, and would give rise to much higher com-
bustion if burnt in the liver than they do in the capil-
lary circulation, notwithstanding that in the latter the
principal heat of the body is generated.
PROPHYLAXIS.
That cancer is preventable as well as curable is not
too great an anticipation. Knowing the etiology, the
pathology, the morphology, the antecedents, and the
clinical history of the disease, we are prepared intelli-
gently to prevent and counteract both the predis-
position' and the actual processes. When manifesta-
tions of the recognized predisposing factors arise, an
intelligent public will seek the physician of the future,
who will in the light of our present knowledge
make careful inquiry into all the possible and
probable causes of the subkatabolism. The physical,
chemic, and bacteriologlc causes of hyperacidity, the
pulmonary, cardiac, hematomatic and hyperoxidative
causes of suboxygenation, the nucleonic causes of sub-
oxidation, air, food, drink, exercise, and all the habits
and functions of life will be investigated and corrected.
Patients will be taught to meet the impulse constantly to
irritate a forming lesion, by protecting it from irritation
and briskly stimulating every other part of the body.
The profession must learn to recognize that it is not that
carbohydrates are hurtful by nature, but that they are
consumed, by both sick and well alike, in a too highly
concentrated, soluble, and combustible form. We take
too much of sugars, starches, and malted foods and bev-
erages, and often too little of the green vegetables and
other forms in which the starches and sugars are in their
natural combinations. We must learn that natural
forms seldom ferment or disagree, and that the socalled
predigestion by artificial diastatic digestions only con-
vert carbohydrates into a fermentable form, which is
extremely serious to digestion and in which they are too
rapidly assimilated and consumed, thus causing pro-
cesses described ; or if not otherwise com|)licated l)efore-
hand, the oxidating tissue (nucleonic oxidase) so changes,
that chronic glycosuria may be Instituted, together with
failure to consume the most meager quantities. Whea
856 Amkbioam MsDiciirx)
PATHOLOGY OP KATABOLISM
[November 29, 1902
highly concentrated and soluble foods of high nutritive
value are demanded, it is logical to administer nitrog-
enous foods. Whenever nitrogenous foods cannot he
assimilated and normally oxidated, it may with good
reason be suspected that katabolism of the tissues of the
body is imperfect as well, and it is important to know
that oxidation of nitrogenous foods is seriously retarded
by an excessive coingestion of highly soluble and oxidiz-
able carbohydrates, as contained in rich desserts, highly
sweetened coffee, and beer, wines and liquors, so com-
monly taken with meals by the same classes that are
large consumers of butchers' meat. The public must be
educated to recognize the early stages of stasis of katab-
olism by the symptoms detailed, and the importance of
seeking medical and prophylactic treatment, in a full
'•ealization of the penalty of negligence. In my estima-
tion the due recognition of these great initiatory condi-
tions will lower the mortality rate of tuberculosis as well
as cancer, more than a combination of all other methods.
THEKAPEUTICS.
As shown by clinical records and vital statistics, it is
distinctly evident that all diseases of hyperacidity, those
due to ingested acids, gastrointestinal acid fermentation,
acidity from oxidative incapacity in the portal system,
antl the divers hypersarcolactic acidities of the muscles
and other tissues from chills, strain and fatigue of mind
and muscle, mental distress, nervous tetany, and sub-
oxidation in general, are increasing and are least recog-
nized, least understood and suffer the most for want of
rational therapeutics. Pneumonia, arteriosclerosis and
its ultimatum, apoplexy, diabetes, cancer, rheumatism,
and gout, have all either increased or failed of decrease
with the general advance in medical development, and
not until the profession becomes satisfied that infection ig
a .jeeondary factor in the etiology of these diseases, and
will go back of it and combat the primary causative fac-
tors, will it achieve therapeutic success.
A review of the history of cancer therapy brings to
light a number of remedies highly praised by eminent
practitioners of the past, and if we give due considera-
tion to the physical and physiologic attributes of these
remedies, further confirmation is added to the etiologic
hypothesis presented. It is observed that practically
the same remedies that are of the greatest value in the
smaller and more common manifestations of katabolic
stasis, as boils, abscesses, carbuncles, and other suppu-
rative processes, in the past as at the present time, have
been of the greatest value in cancer. Of internal reme-
dies, probably codliver-oil has been most lauded by the
older clinicians, and when we consider its eminent
digestibility, the fact that it furnishes its own biliary
elements, thus counteracting its loss in the feces, and
considering the fact that otherwise it is conducted by
the lacteals to and is' burnt in the superficial circu-
lation, it is demonstrated a valuable aid to periph-
eral oxidation, the true source of animal heat. An-
other remedy which has proved of great value to the
older observers, is dilute hydrochloric acid, and in the
ligiit of our present knowledge of the quite universal
absence of this valuable digestive secretion in cancer
patients, we can appreciate its real medical value,
although it has heretofore been administered empiric-
ally. The alkalies that have possibly given the best
results but of which the action obtained has been least
understood, are now recognized as logical combatants to
the acid toxemia present.' It can be readily understood
1 When impired oxygenation is at fault, and In other Instances
■when It IS desirable to aogment oxygenation and oxidation, Inhalation
of oxygen gas may be IndTlcated. When it Is determined to make use
Ji}^ agent, it is important to make use of an absolutely nascent gas
as the older oxygen is the less active Is It. and the higher the oxidase
power required for Its recon%'erslon Into active oxygen. Demarquav
f t'^LI o'',7'"' ^^t' ^^^ process of compressing oxygen serves to render
Ji'tL^ V • ^ ''"^ii observed in cardiac cases the most perfect main-
tenance of oxygenation by the Inhalation of freshly made gas, and an
paTlents '' '^ '*"'' oxygen was Inhaled by the same
how the administration of iron may have contributed
toward enhancing the oxygenation in cases of deficient
hemoglobin. lodin, which has had a great popularity
as a cancer remedy, and which was supposed to possess
wonderful powers of accelerating absorption is in my
belief a powerful oxidant and has always produced its
scavenger functions in this way instead of by absorption.
On the "compound tincture of bark," which enjoyed
such popularity among British practitioners, as of some
other popular vegetable remedies, I am not prepared to
comment. The phosphates which have occupied such' a
prominent place in the therapeutics both of tuberculosis
and cancer, are in my opinion undoubtedly the most valu-
able internal remedies and approach most nearly to the
plane of specifics in the general conditions of suboxida-
tion of any known to this day. It is observed that
while phosphorus and the phosphates may in large
quantities act in the same way as arsenic, namely, by
being burnt excessively in the portal system, that small
doses, oft repeated, are utilized in the .synthesis of leci-
thin and nucleins, and thus serve as powerful accelera-
tors of the peripheral and general tissue-oxidation. It
is of interest that with medicinal doses of phosphorus
we observe, in addition to the acceleration of oxidation,
a restoration of sexual power in many cases in which it
has become unduly debilitated.
Arsenic when administered internally, always acts as
a retarder of peripheral oxidation, being always used
up in the portal system, where it consumes the portal
oxygen-supply to the exclusion of foods of less combusti-
bility, and especially of nitrogenous foods. As has been
mentioned, long-continued administration of arsenic
may so seriously retard general oxidation as to cause
general melanosis. Jonathan Hutchinson and other
writers have recently laid great stress on the importance
of a recognition of arsenic as a cause of cancer. Even a
continuous inhalation of arsenic from arsenical wall-
papers has been observed to produce the characteristic
manifestations of arsenic poisoning, characterized by the
several manifestations of suboxidation.
The internal administration of phosphorized food'* is,
I believe, one of the most valuable internal therapeutic
aids at command. The most valuable are the phosphor-
ized fats (preferably codliver-oil) and the glycerophos-
phates, and the ready-formed nucleoalbumins, the latter
represented by the flesh of young animals, notably veal,
and the testicular juice as introduced by Brown-S6quard.
Of local therapeutic measures, among the older remedies
may be mentioned the "saponification cure" of Roki-
tansky and the external applications of arsenic. In the
former, cures were occasionally obtained by the saponifi-
cation of the fatty degenerated mass by means of alka-
lies, thus at the same time accelerating the oxidation of
the diseased area. In the latter treatment arsenic is
applied directly to the diseased mass, and its remark-
able oxidative facilities are utilized to accelerate the
oxidation of the degenerated tissues, the very existence
of which is dependent upon a condition of suboxidation.
Knobner has reported sarcoma curable by arsenic
injected into the superficial circulation, where it increases
combustion of the tissues.'
Undoubtedly the most powerful stimulus to tissue
oxidation ever applied locally is that of the BSntgen
rays, and in them we without doubt have the most pow-
erful single curative agency for all neoplastic formations.
The great drawback thus far to their application, by
medical men, is the impracticability of applying them
more than a short period, once in 24 or 48 hours, when
logically the ideal application would be a much less
intense and a much more constant and continuous one.
1 It may be added here that when arsenic is injected directly Into
the tumor, where It Is deprived of the oxidation aid of the air. It is
Inert as an oxidizer, until the powerful oxidizing effects of the Kontgen
or actinic rays are added, when it Is observed that the effects are con-
siderably accelerated. Dr. C. W. Allen, of New York, has stated to me
that In his experience both the actions of the x-rays and those of arsen-
ical applications are considerably increased when used In combination,
and are greater than either, when separately applied.
NOVBMBER 29, 1902J
PATHOLOGY OF KATABOLISM
(Akkbican Medicikb 867
As metabolism is normally a continuous function, an
ideal stimulus is a continuous and a constant one. The
action of the Rontgen rays upon cancer was originally
interpreted as confirmatory of the parasitic origin of the
disease, it being contended that the rays acted as para-
siticides. It is now established, however, that bacteria
and other germ-cells are affected in exactly the same way
as tissue-cells, i. e., the rays producing stimulating or
quickening effects upon the tissue-cells, act the same
upon the different varieties of bacteria and cocci. Con-
versely, the superintense or long-continued exposures
which are observed to be at all destructive to bacteria
are similarly pathogenic to tissue-cells. In the case of
the former the destruction of bacteria has been observed
to be due to their exhaustion, due to excessive growth
and activity. No investigators have ever observed any-
thing that could be termed an inhibitory or bactericidal
action, and yet all are agreed upon the inherent powers
of converting cominon oxygen into active oxygen or
ozone. Brusii discharges, which have been observed to
be destructive to bacteria, are as much so to tissues.' It
may be seen that all points considered confirm the
hypothesis of subkatabolism. From every standpoint,
of etiology, physiology, pathology, symptomatology,
distribution, prophylaxis and all therapeutic agencies,
comes the analysis, consistent with the complications of
common origin, pointing to the one great etiologic factor :
katabolie stasis.
The greatest success in the systemic therapy of cancer
in the future will be attained in an intelligent combina-
tion of phosphorus, internally administered, in one or
more of its physiologic combinations, in the acceleration
of general as well as localized peripheral oxidation and
by intelligent combination of the topical measures
describefl. In addition to the general measures men-
tioned, the successful physician will diagnose and correct
all of the existing retarding conditions of oxygenation,
alkalinity, oxidation, and thus facilitate the general nor-
mal exercise of all the functions of the body.
It is observed that under therapeutic treatment which
accelerates the oxidation of malignant growths, those
tissues which are most digestible first succumb to the
oxidizing processes and the other tissues follow in the
order of their digestibility, the sarcomas being the least
amenable to treatment, and the fibrous tissues being the
last to yield. Additional confirmation of my general
hypothesis of cancer etiology is furnished by the fact
that the stages and conditions of the perverted meta-
morphosis, bear relation to oxidative therapy as well as
to the malignancy and other attributes, as mentioned ;
thus the liquefaction of tissues due to water-absorption
<lisposes both to rapid neoplastic growth and to oxidative
disintegration and combustion.
The acceleration of oxidation produced by exciting
active inflammation and a consequent hyperemia in and
about neoplasms by means of cultures of bacteria, or by
their toxins, is inferior to the direct chemic stimula-
tion of oxidation by Rontgen and actinic light rays ;
owing both to its comparative inefficiency as an oxidizer,
and to the fact that it produces its results by active irri-
tation, and coincidentally gives rise to fibrosis, by the
Hocalled cicatricial inflammation. It is, I believe,
the production of this scar-tissue that gradually lessens
and finally arrests the oxidation of neoplasms, which is
often observed to take place before the tumor has been
entirely consumed, and in which instance they again
grow and are unaffectetl by the continuance of the same
I
< I believe the recently reported methods of Massey, of PliMadel-
phia. which he terms "electric sterilization," might more properly
I>e termed '■ferfrir orittation or ozontrfion. The nomenclature of pnot(H
therapy might be Improved and Itsdescrlpllon facllltAted if the analogy
iMtHeen the rays of IIkIiI and electric units were recoKhlzed ; thus the
liful rays correspond to high voltage and the chemic rays to high
:iin|>emgeand a low voltiige. Both the sun and the Becqucrel rays arc
siilijuct to llils classlMcallon, the Kdntgen rays appear to be metaphor-
l<ally of higher amperage and yet are of low voltage, ond hence of
highest value In physiologic o.\l<latlon. They, however, differ In this
respect according to the hardness or softness of the tubes used, the
hign tubes being of highest potential.
treatment. "With the production of fibrosis, neoplasms
become less susceptible to the oxidation of the chemic
rays of light, yet it has been observed that the latter
will often accomplish the complete oxidation of the
tumor after it has failed to respond to a continuation of
the bacterial treatment. Recent research in the physics
and physiologic action of light proves it to possess the
power of converting ordinary oxygen into active oxygen
or ozone. This property being demonstrated outside of
the body confirms these theories on the oxidation reduc-
tion of degenerated tissue as accomplished by the normal
function of nucleins, and in its absence or retardation
by the direct chemic converting action of light which
acts independent of the oxidase action of cellular nuclei.
Contiguous fat has long been observed to exert a
marked modification upon pure fibrous hypertrophies
and cicatricial formations. This is attested by the almost
universal custom of applying fats in the form of oint-
ments, salves, toilet creams, etc., to wounds, irritations
and other conditions in which tissue repair is in prog-
ress. The dryness and solidity of fibrosis is certainly
lessened by these measures, probably owing to the
absorption of water from the more succulent fatty tis-
sue or applications. It is observed that fibrosis is gener-
ally absent in the soft cellular tumors, and especially
contiguous to the foci or central zone of fatty degenera-
tion. This seems to explain the fact that fibrous hyper-
plasia always occurs, when at all, at the outer border of
the growing edge of tumors and tubercles ; also that in
the latter, owing to bacterial irritation, fibrosis is a quite
constant accompaniment. The fluid absorption of the
fibrous tissues may have something to do with the dehy-
dration of the caseated contents of the tubercle. Such
tissues assume a whitish or grayish appearance when
deprived of oxygen, and when oxidation is prohibited
by acidity ; and it is only as water is absorbed that
tissue assumes the semitranslucent gelatiniform appear-
ance which characterizes its condition when at the
stage in which it so resembles rudimentary (embryonic)
tissue, and is so prone to suppuration, infection, and
calcification, when these complications are otherwise
made possible. That cells in the fatty stage of degen-
eration exert an influence upon the general cancer pro-
cess, there can be no doubt, and also an addition to the
eflfect of the ammonia present is evinced by character-
istic changes in the malignant process, coincidentally
with the fatty change of the foci.
Another animal process in which subkatabolism
appears to me to play a role is phagocytosis, the phago-
cytes being simply tissue and white blood-cells in the
several degrees and stages of subkatabolic degeneration
floating free in the circulating blood. These cells when
in the gelatiniform or fatty stage of degeneration, and
succulent from water absorption from the blood, are
extremely susceptible to bacterial infection, and when in
the jelly stage to impregnation by pigments and to pene-
tration by floating particles (englobation), generally,
on the principle of the jellyfish. The final digestion of
the englobed bacteria or other articles is due to the,
action of peptone common to all tissues in this stage of
degeneration. Phagocytes present many evidences of
their subkatabolic identities, such as multinucleated
cells, etc.
It may be said that in addition to all of the systemic
and local therapeuticall.y excited oxidations outlined,
when subalkalescence of the blood and local hyper-
acidities prevail as manifestations of primary etiologic
acidities, it becomes necessary to diagnose and treat the
primary causes of these factors. In addition to the pro-
phylaxis It may become necessary, as in diabetes, to
neutralize directly the acidity of the system by alkalies
administered internally, by the mouth, and by high
colon ii^ections. For both purposes sodium bicarbon-
ate is preferable, being administered in powder, tablet,
or solution, by the mouth, and by a saturated solution
by the rectum. Either the blood or urine may be taken
858 A.KEBIOAN MKDltnNE)
PATHOLOGY OF KATABOLISM
INOVEMBEB 29, 1902
as a guide to the results achieved ; in the latter, neu-
trality if maintained will be adequate. In all cases of
acid causation, therapeutic excitations of oxidation
should be combined with this treatment, and these to
meet indications.
SUMMARY OF DEDUCTIONS.
1. Every living cell, animal and vegetable, generates
and exudes one or more acids as a metabolic product.
This acid, during normal oxidation of the tissues is so
promptly and completely consumed that its existence is
not in evidence. The animal heat of all muscular activity
is largely due to the thus accelerated production and
combustion of this acidity. The phenomena of mental,
nervous and muscular fatigue, however caused, increase
this acid production. Any retardation of oxygenation
or oxidation, however caused, is responsible for an accu-
mulation of acid, and conversely, excessive a -idity from
any cause lowers oxidation, both in inverse ratio. The
lowering of oxidation and the accumulation of acid is
often mutual and progressive. Either a hyperacidity or
a suboxidation as primary agencies may be productive
one of the other, tlie interreaction being progressive.
2. Tissue katabolism consists of a combination of an
alkaline dissolution, an oxidation of the elements and of
the excretion of the end-products.
3. Tissue-cells and fibers and blood-cells are all
dependent upon a certain degree of alkalinity and of oxi-
dation for their normal katabolic dissolution and obliter-
ation. In the presence of a local retardation or arrest of
katabolism (anabolism being practically undelayed in its
rapidity), the tissues, in the inverse order of their katab-
olic digestibilities fail of katabolism ; and in passing
undissolved the limits of normal existence, continuing
as a superannuated, varying resemblance to their former
forms, hypertrophy of fibrous tissues and general hyper-
plasias of fibrous and cellular tissues become logical and
inevitable results.
4. Cellular acidity may be the accumulated result of
a failure to oxidate the normal acid-product, and con-
versely suboxidation may be due to the absence of the
alkaline medium necessary to oxidase activity. Thus
both acidity and suboxidation, however caused, may
progressively retard katabolism.
5. In cases of inadequacy or absence of one or both
of the factors necessary to katabolism, not only is tumor
formation a result of a continuance of cellular existence
beyond the normal limitations, but, as a result of such
superannuation of cells, we have to deal with the exist-
ence of more or less extensive general or circumscribed
conditions, in which these collections of cells, devoid of
the powers of sustenance, have no future except necrosis.
This alternative depends upon the modifying influences
of oxygenation, situation, environment, etc., together
with the nature of the involved tissues.
6. The inevitable degeneration of tissues that have
failed of katabolic dissolution must receive from medical
men the attention that its importance deserves as pre-
disposing causes of bacterial disease and as direct
causes of recognized pathogenic conditions, acting as
obstructions of the bloodvessels and lymphvessels,
mucous, gelatinous, fatty and necrobiotic in nature.
7. The acceptance of the above hypothesis of the
pathogenic degeneration of subkatabolized tissues in-
volves the recognition of new forms of both the death
and degenerations of tissues. In contrast to the normal
gradual demise and the coexistent alkaline dissolution
and oxidation of tissue elements, we meet a perversion
of functions, a death, independent of dissolution, and
finally a superannuated existence of dying and dead
tissues, the latter undergoing decay and necrotic disin-
tegration analogous to general postmortem changes.
We also observe individual cellular death and degenera-
tion, as diffbrentiated from the universal death of parts,
or or the whole organism, as now described by patholo-
gists.
8. It is assumed that the subkatabolic change of malig-
nant growths follows a course of degeneration, of which
the gelatiniform, fatty softening and purulent states
compose the chief stages.
9. In the absence of any local exciting cause of a cir-
cumscribed stasis general subkatabolism might proceed for
years, finally ending fatally by spinal or cerebral degen-
eration, by embolism, by amyloid, lardaceous, or other
degenerative disease of any organ or part as accidentally
victimized.
10. In general, katabolic stasis is the etiologic factor of
all repair processes, the modus operandi of which is typ-
ical. In healing by first intention the stasis is so slight
and short as to cause but a slight delay in the process.
In healing by second intention the granulations formed
are, however, degenerated to the gelatiniform stage and
represent both tissue-cells and blood-cells. Still more
prolonged processes present the types of degenerated
tissue seen in chronic sores generally.
11. We have in katabolic stasis the solution of the
etiology of tissue hyperplasias, of leukocytosis, lymphocy-
tosis, etc. , of mucous disease, amyloid and other degenera-
tions, of many forms of splenic, hepatic and other
glandular enlargements, of general vascular obstruction,
of fatty degenerations and infiltrations.
12. Suboxidation, subkatabolism and neoplastic pre-
disposition bear an inverse relation to sexual power, the
former rising on the decline and obsolescence of the latter.
13. There can be no doubt that the pigments of mel-
anosis and pigmentations of malignant disease are derived
from the blood ; and that tissues first blanched by sub-
katabolism, as in leukoderma and leukoplakia, are dis-
posed to shed their normal pigments. Conversely, after
the gelatiniform stage is reached and the phenomena of
phagocytosis are manifested, the englobation of pigments
is a common observation.
14. Great mental exertion, fatigue, strain, the tetany
of worry and anxiety and the depression of disappoint-
ment and grief, may be responsible, primarily, for cere-
bral subkatabolism, and secondarily, for general sub-
katabolism as characterized by phosphaturia and a sub-
alkalescence of the blood. It appears that the intense
systemic eff'ects of cerebral subkatabolism would indicate
a nerve-produced tetany of the muscular system.
15. Cancerous areas and thrombi, in order to be
capable of secondary growth, must possess a mixture of
adolescent and degenerating tissues. A segment com-
posed of all adolescent or all equally degenerated cells
never can, per se, become a focus of a secondary growth.
16. All causative relations — as age, traumas, irrita-
tions, fatigue, strain, acidities, suboxygenations, suboxi-
dations and infections, when they occur — are factors of
the one general cause, subkatabolism.
17. Cancers and allied states are not supernourished
processes, as the apparent vascularity would suggest, but
are really deficient in exchange of both blood and
lymph. The observed dilated vessels are probably due
to vicarious circulation more than to vasomotor paraly-
sis ; still in some cancers perhaps the latter condition
is present.
18. Malignant growths are not necessarily of bacterial
origin. When bacteria become causative factors they do
so acting either as irritants, causing sarcolactic acidity, or
by their acid excretions acting directly and in conjunc-
tion with sarcolactic aciditj'.
19. The sum total of all bacterial activity is the produc-
tion of subkatabolism, the direct causative factor of
cancers. When from other causes of subkatal)olism
aseptic cancers are caused, they are prone to infection
and may or may not become infected by one or more
microorganisms.
20. Primary degenerations of subkatabolism, when
they become infected, are more prone to other manifesta-
tions thaij that of malignant growths. Cancers, after
infection, are disposed to better oxidation and to some
improvement.
November 29, 1902]
STUDY OF MODERN AMPUTATIONS
[American MKDicjnre
859
21 . Cancers are not more prone to infection than other
forms of subkatabolism. Early infection of cancer foci
is disposed to change the succeeding process from the
classical course.
22. Cancer is a hereditary disease only in so far as
family tastes, habits and traits that predispose to the
causation of subkatabolism are hereditary. However,
congenital malformations, as defective hearts, narrowed
arteries, conditions restricting activity, etc., may predis-
pose to one or other of the elementary etiologic factors
of subkatabolism.
23. Cancer is both a local and a constitutional disease.
The local cause determines the site, while general and
systemic are the hyperacidities and suboxidations that
lower general katabolism sufficiently to inhibit the
katabolic dissolution and oxidation of locally produced
stases.
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Kd., Philadelphia, 1902.
Colcy, Wm. B. Sarcoma, Twentieth Cent. Practice of Medicine,
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Demarquay, J. M. Oxygen In Medicine, Philadelphia, 1889.
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Fenwick, W. S. The Dyspepsia of Phthisis, London, 1894.
Flnsen, N. R. Phototherapy, London, 1901.
Fothcrglll, J. Mllner. Diseases of Sedentary Habits and Advanced
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Frey. Heinrlch. The Histology and Histochemistry of Man, New
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Green, T. H. An Introduction to Pathology and Morbid Anatomy,
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Greenough. R. B. Report on the Presence of PUramer's Bodies In
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Hertlg, Oscar. The Cell (General Anatomy and Physiology), Lon-
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Hill. Leonard. The Mechanism of the Circulation, Shafer's i'hysl-
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Jennings, Chas. E. Cancer and Its Complications, New York, 1890
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A FURTHER CONTRIBUTION TO THE STUDY OF
MODERN AMPUTATIONS.
BY
W. L. ESTES, M.D.,
of South Bethlehem, Pa.
Director and Physician and Surgeon-ln-Chlcf of St. Luke's Hospital,
South Bethlehem, Pa.
In the Medical Record, November 3, 1894, I pub-
lished a paper, entitled "A Contribution to the Study of
Modern Amputations." This study was based upon 294
single miyor amputations, of which 38 were complicated
cases which required double synchronous operations, 7
triple operations and 1 quadruple synchronous operation,
making altogether 340 major amputations.
I wish in this paper to add 164 single major amputa-
tions, 27 double synchronous, and three triple .synchronous
List of Amputations fob the Last Eight Years— Single
Major Amputations.
Amputation of the arm
Amputation at the elbow-Joint
Amputation of the forearm
Amputation of the foot, Chopart's.
Amputation of the foot, Hay's
Amputation of the foot, Mikulicz's
Amputiitlon of the foot. Syme's
Amputation of the leg, lower third
Amputation of the leg, middle
third
Amputation of the leg, upper third
Amputation of the Ihign, lower
third
Amputation of the thigh, middle
third
Amputation of the thigh, upper
third
Amputation at the hlp-Jolnt
Amputation at the knee-joint.
Amputtltlon at the sboulder-Jolnt.
n
go
&a
!r.,2
S.2
?2
si
!^0
Si
Remarks.
l.S
2
...
17
4
S
2
One done for dis-
ft
ease.
82
...
14
One for disease.
1
36
8
1
12.5
5
2
40
4
•i
M
One had pyemia
when admitted
»
9
and was very
low. The other
died of acute
1(H
fl
3.04
anemia.
operations to my statistics (194 miyor amputations) asd
then briefly to comment on certain conclusions based
upon the study of the tabulated list of thcs(^ 534 m^or
amputations. But 5 of these latest amputations were
done for pathologic or diseastKl conditions, 189 were done
for ii\)urie8 ; of the whole list of 534 amputations, 24
S60 AJtBBIOAir MEDIOim]
STUDY OP MODERN AMPUTATIONS
[XOVKMBEB 29, 1902
were for diseased conditions, 510 were amputations for
injuries.
As in my former paper (in 1894) so in this I have in-
cluded in the list of double and triple synchronous oper-
ations not only multiple major amputations, but also and
in addition to the amputation such other operations as
Complicated Casks Rkuuieinq Multiple Operations— Double
Synchronous Operations During the Last Eight Years.
Amputation of arm, lower third,
and amputation of leg, middle
third
Amputation of the arm, upper
third, and amputation of the
thigh, upper third
Amputation of the forearm and
operation for extensive lacera-
tion of the scalp
Amputation of one foot, Syme's,
and amputation of the other leg,
lower third
Amputation of one foot, Syme's,
and amputation of the other leg,
middle third
Amputation of both legs, middle
third "..
Amputation of leg, lower third
and amputation of thigh, lower
third
Amputation of leg, lower third,
operation for severe crush of
other foot and fracture of both
bones of this leg
Amputation of one leg, middle
third, and of other thigh, lower
third
Amputation of one leg, middle
third, and amputation of one arm
through condyles of humerus
Amputation of oneleg, upper third,
and half of one hand through
the metacarpus
Amputation of one leg, middie
third, and operation for com-
pound comminuted fracture of
the humerus
Amputation of one leg" middle
third, and operation for very ex-
tensive laceration of muscles of
the other leg
Amputation through the "knee^
Joint, and of other leg, middle
third
Amputation through the icnee^
Joint and operation for com-
pound comminuted fracture of
the other femur
Amputation of the thighVlower
i'?"'.*i?.''5'' <"■ ^^^ otber leg, mid-
dle third
'*I?P".'*''^'°" of one'thighiiower
third, and operation for crushed
foot on other side
'^,'\!P"i""''°" of ""<-' t'high.'lower
third, and operation for crush of
mf other side"!"'"''" °' ""^-J"'"^
Amputation of one thighVlower
third and operation for com-
pound depressed fracture of the
cranium
■^J^Pr^H ''"™., °C^°^ tii'Sbriower
nmdietSfrd''^'^ "'''" "^'^'^'
^thfrd*^""" "'■''"''^ thighs,'middVe
'^fhFv"i''*'°'i °^ °°e ihVghrmVM
mw'. ''"? amputation of the
other leg, lower third.
IHP^i'*''"" of one thlgh.'upner
[^IJ^, and of other thlfh', iS^ll
nr^ 'i "^ amputation of one
arm, lower third...
JS,?i"^'i,V"^''r''''s'''"PPe'-'third;
other7c;it.!^.'::°°..?''..^:!«*.':°^.°f
Total number
©a
u o
S ft
«2
S£
100
100
Remarks.
This man had
valvular disease
of the heart and
died of embolus
of the brain two
weeks after the
amputa tlo n,
when the flaps
were practically
healed.
the case required, if the operation was of a major kind.
Many of these were more serious than another amputa-
tion would have been. I shall call these " complicated
cases requiring multiple operations."
The added experience of the last eight years has
strengthened my convictions as to the conditions requir-
ing amputation. I am more than ever of the belief that
whenever there is the lea-st possible chance of preserving
a useful limb, or a part of a limb which may prove of
service, careful antisepsis should be practised, hemostasis
should be most carefully assured, and the operation be
deferred for 30 or 40 hours, when all doubt will be re-
moved. Conservative attempts should not only include
waiting, careful hemostasis, and antisepsis (I say anti-
sepsis rather than asepsis advisedly, because such cases
as I have in mind cannot be made absolutely aseptic) but
also extend to the removal of crushed bone, suturing
muscles, tendons, etc., in cases which offer chances of
Synchronous Triple Operations During the Last 8 Years.
Number
of
Operations.
Deaths
after
Operations.
Mortality
Percentage.
Amputation of both forearms, and operations
for compound fracture of the leg, and multiple
1
1
1
1
1
Amputation of one thigh, lower third, and of the
other leg, lower third, and operation for com-
Amputation at the left shoulder-joint, amputa-
tion through the middle of the right thigh,
and Chopart's amputation of the left foot
Total number
3
ultimate recovery. In other words, conservative exsec-
tions and ligations should be practised rather than ampu-
tations whenever at all applicable. I have seen many
limbs which would be classed hopeless after the old
teaching preserved and recover almost complete useful-
ness.
As to the point of selection and technic of amputa-
tions, I have nothing special to add to my former paper,
except the further endorsement of my socalled gradual
dissection method for amputations at the hip-joint, which
my added experience has confirmed as a most valuable
method in cases in which the crush extends high up in
the thigh. I am more than ever convinced that the chief
points to regard in saving life after severe injuries which
Complete List of Single Major Amputations for 20 Years.
Amputation of arm
Amputation of elbow-Joint
Amputation of forearm
Amputation of foot (Chopart's)
Amputation of foot (Hay's)
Amputation of foot (Mikulicz's)
Amputation of foot (Plrogolt's)
Amputation of foot (Syme's)
Amputation of leg, lower third
Amputation of leg, middle third
Amputation of leg, upper third
Amputation of thigh, lower third....
Amputation of thigh, middle third
Amputation of thigh, upper third..
Amputation at hip-Joint
Amputation at knee-joint
Amputation at shoulder-Joint
Total number
- ^o
M 0)
O
40
2
51
11
5
2
1
14
79
42
2S
80
33
13
U
26
2J
458
2.5
1.26
i.M
6.25
8.48
23.07
27.27
8.84
4.54
4.12
require amputation are, first, saving of blood, and,
second, cleanliness and careful disinfection.
After-treatment is still conducted on general prin-
ciples.
The result with reference to usefulness of the stumps
has been, I think, uniformly good.
I wish to give special attention and deduction to the
mortality rate. The list of operations and their locations
has been carefully compiled by myself personally, and I
have tried to make it accurate. Reference to the list of
single major amputations will show that except for
amputations through the thigh above the lower third
NOVEMBKR 29, 1902)
STUDY OF MODERN AMPUTATIONS
American Medicinb 861
there has been no death following amputation. This is a
somewhat extraordinary showing for eight years' work,
Complicated Cases Requiring Mui,tipi.e Operations— Com-
plete Lists of Double Synchronous Operations
for 20 Years.
£ = «
o
Amputation at the shoulder-Joint, and of the
other arm, iower third
Amputation at the shoulder-Joint, and amputa-
tion middle third of other arm
Amputation at the shoulder-Joint, and of the
other forearm, middle third
Amputation at the shoulder-Joint, and a leg,
lower third
Amputation at the shoulder-Joint, and operation
for compound depressed fracture of the
cranium
Amputation of both arms, upper third
Ampu tallon of arm , iower ihi rd, and leg, middle
third
Amputation of arm, upper third, and the leg,
middle third.
Amputation of arm, upper third, and forearm,
middle third
Amputation of arm, upper third, and of the
thigh, upper third
Amputation of both forearms
Amputation of the forearm, and operation for
extensive laceration of the scalp
Amputation of both feet (Chopart's),
Amputation of both feet (Hay's)
Amputation of one foot (Choparts), and the
other leg, lower third
Amputation of one foot (Syme's), and the other
leg, lower third
.imputation of one foot (Syme's), and amputa-
tion of the other leg, lower third
AmputJition of both legs
Amputation of one leg, lower third, and the other
thigh, lower third
Amputation of one lee, lower third, and e.Ksec-
tion of tlie other ankle-joint
Amputation of one leg, middle third, and other
thigh, lower third
Amputation of one leg, middle third, and of one
arm through the condyles of the humerus
Amputation of leg, lower third, and operation
for crush of other foot and fracture both bones
of this leg
Amputjition of one leg, upper third, and half of
one hand through the metacarpus
Amputation of one leg, middle third, and operas
tlon for compound comminuted fracture of
the humerus
Amputation of one leg, middle third, and opera-
lion lor very extensive laceration of the mus-
cles of the other leg
Amputation at the knee-joint, and of the other
leg, lower third
Amputation at the knee-joint, and of the other
leg, middle third
Amputation at the knee-joint, and of the other
thigh, lower third
Amputation through the knee-joint, and opera-
tion for compound comminuted fracture of
the other femur
AmpuUition of one thigh, lower third, and of the
other leg, upper third
Amputation of one tliigh, lower third, and of the
other leg, middle third
Amputation of one thigh, lower third, and
ojjemtlon for crushed foot of the other side
Amputation of one tliigh, lower third, and
operation for crush of leg and dislocation of
the hIp-JoInt on the other side
Amputation of one thigh, lower third and
opcnitlon for compound depressed fracture of
the cninium
Amputation of one thigh, middle third, and of
llie other leg, lower third
Amputation of both thighs, lower third.
Amputation of one thigh, lower third, and the
other thigh, middle third
Amputation of one thigh, lower third, and of
one arm, lower tiiird
Amputation of both thighs, middly third
Amputation of one thigh, lower third, and
operation for removing fnigment.s, drainage,
and apposition for compound fracture of the
other leg
Amputation of one thigh, lower third, and of all
the ttjes of the other foot
Amputation of one thigh, upper third, and of
tlie other thigh, lower third
.-Vmputatlon of one thigh, upper third, and am'
potation of the great toe of the other foot
Total number..
|12
o
-He
X. o
100
100
37 .f
50
33.:«
lOO
85
11
SO
100
17
as compared with my earlier statistics. The very high
mortality rate of amputations of the upper third of the
thigh is also remarkable — 40 /c against 12.5 /c of my
earlier figures. True there were only five eases of upper
third thigh amputations, but they proved almost as fatal
as the hip-joint amputations. I wish to say more on this
point presently when I come to study the combined fig-
ures of the 20 years' work. The whole mortality rate
for single major amputations, 3.04 fc , and for complicated
injuries requiring multiple synchronous operations,
6.66 /c, I think has finally brought the results for opera-
tions after severe traumas to the status I predicted in
1«94. I said then: " If a thoroughly bloodless method
is pursued and the operation is not done during the non-
tolerant stage of acute anemia, statistics after mtyor
amputations should be as good as those of abdominal
sections, and I believe they will finally be so."
An examination of the combined tables of results
aft«r 534 amputations shows that the mortality in major
amputations runs up markedly for operations done above
the middle third of the thigh.
After a severe cru.sh of the lower extremity I find
Complicated Casks Requiring Multiple Operations— Triplh
Synchronous Operations During the La.st 20 Years,
u a
h
II
n
Reiiiaiks.
Amputation of both forearms and
operation forcompound fracture
of the leg and multiple lacera-
1
1
2
1
1
1
1
1
1 ■
Amputiition of one thigh, lower
third, left arm, lower third, aud
-imputation of thigh, lower third,
of the leg, middle third, and of
the arm, upper third
Amputation of thigh, lower third,
of the leg, iower third, and clos-
ing and draining extensive lace-
ration of the scalp
Amputation of one thigh, lower
thiid,of the otherleg.lower third,
and operation for compound de-
pressed fracture of the cranium..
Amputation of the thigh, middle
third, amputation of the left
shoulder-Joint and (Chopart's)
2 1 100
j
i
•
Amputation of the thigh, lower
third, of the arm, midfdle third,
and closing and draining exten-
sive laceration of tlie scalp
AiTipuUitlon of thigh, middle
third, Syme's amputation of the
right foot, and removal of frag-
ments, and apposition of com-
pound comminuted fracture of
1
103
This patient died
ofcerebrltlspro,
duced by the
head injury.
Amputation of both thighs, middle
third, and closing and draining
extensive laceration of the scalp.
1
100
10
i
40
that amputations of the upper third of the thigh are
almost as fatal as hip-joint amputations. It must be
remembered that the cases noted in my tables were
nearly all done for the worst sort of crushing injuries. In
all the patients there had been severe hemorrhage after
the accident, in several of them the bleeding had brought
them to a moribund .state before their arrival at the
hospital. In many instances I have postponed the
amputation for 30 or 40 hours, waiting for some recuper-
ation, in the meantime employing hypodermoclysis,
also strychnia, and atropin hypodermically, and large
quantities of water and liquid food by the mouth, to help
restore their strength. A very interesting fact is that the
only difl"erence in the condition and treatment of the
casts requiring amputations at the upper third of the
thigh and those amputated at the hip-joint was, the
use of an elastic tournitjuet and complete control of the
circulation of the upper third of the thigh cases, while
in the hip-joint amputations no tourniquet was u.sefl
and the amputation was done by gradual dissection,
with careful hemosta.sis during every step of the opera-
862 A.HKBICAN MEOIOIME}
USE AND ABUSE OF BR0MID8
[November 29, 1902
tion by means of hemostats, a method similar to that
employed in the removal of large tumors of the trunk
and elsewhere when constriction is not permissible — yet
the deathrate, so nearly the same, shows that the
element of time consumed in the operation is not of
80 much consequence as the saving of blood. I know
that the gradual dissection method results in the loss of
as little blood as the constriction method of controlling
the blood current. It takes longer, however, to do the
operation by this method. Hip-joint amputations are
considered much more fatal than any of the thigh
amputations, but it seems to me we must now revise our
former conclusions somewhat. The number of my cases
is too small to make a positive and conclusive argument,
it is true, but I think the relative results are very
suggestive. I am persuaded that the determining
QaADKUPLE OpEBATION
a 1
CO
o
^(2
Amputation of thigh, lower third, of the leg,
middle third, half of the palm of the hand, and
closing and draining extensive laceration of
1
i
features in the cases are the very extensive injuries
to all the tissues at a bulky part of the lower extremity,
making thus very large wounds, the almost inevitably
previous severe hemorrhage, and the very great
danger of serious infection. The hip-joint amputation
removes but a very little more of the extremity and
produces a wound which is only a little larger than that
made by amputating through the upper third of the
thigh of a muscular man. The traumatic features of
the operations are not very different. In upper thigh
amputations the circulation may be controlled by elastic
constriction, in hip-joint amputations for severe crushes
this cannot be done even by Wyeth's method without
serious added injury and subsequently very serious
oozing from the stump. The gradual dissection method
obviates the necessity of the constriction, and its results
compare more than favorably with all other methods.
THE USE AND ABUSE OF BROMIDS IN THE TREAT-
MENT OF MENTAL DISEASES.
BY
A. R. DEPENDORF, M.D.,
of Middletown, Conn.
The occurrence of six cases of bromism among patients
admitted to the Connecticut Hospital for the Insane
during the past three years offers a sufficient excuse for
calling the attention of general practitioners to the
common abuse of this drug in the treatment of mental
diseases, to its profound toxic effects when used in exces-
sive doses, and to some unusual symptoms of bromism
observed in these cases. From time to time since the
discovery of the physiologic effects of this important
drug by Graf 1 and Huette^ and its later adoption by
Brown-S6quard as the remedy par excellence in the
treatment of epilepsy, warnings of this sort have been
sounded, notably by Voisin,' "Weir Mitchell,* Hodges ^
and Alexander.^ Hare in the last edition of his Materia
Medica and Therapeutics says: "I know of no other
drug, with the exception of those that produce habits,
such as morphin, cocain, etc., that is so enormously out-
raged as the salts of bromin are. It is only necessary to
see the colossal mental and physical depravity that
sometimes results from the ignorant administration of
this drug in minor ailments, and sometimes even in
epilepsy, to fully appreciate this statement."
The chief purpose in presenting five of these six cases
is to record some unusual symptoms of bromism and to
offer additional safeguards to the practitioner in detect-
ing its symptoms when administering this drug.
Case I occurred in an unmarried man aged 31, with a
slightly defective constitutional basis. His lather and sin-
ter had convergent strabismus, mother was diabetic, one sister
suffered from excessive lieadache for 20 years, and one sister was
excessively obese. The patient's personal history was good
except for one attack of gonorrhea at the age of 30.
At 31 he began to suffer from what was diagnosed a.s petit
mal, and was immediately placed on the bromids, which were
gradually increased to 180 grains daily. Two months after
beginning this treatment he developed bromism, with thickened
speech, staggering gate and emaciation, but no somnolence.
The bromids were continued in slowly diminishing doses, but
symptoms increased and 24 months after the appearance of the
bromism he had hallucinations of hearing (people made
slurring remarks about him) and 3J months later hallucina-
tions of sight (people were seen dodging behind trees and
strange men were seen about the house). He then began to
show mental apathy, thought and mental application became
difficult, and lie was suspicious of his surroundings, but gave
no evidence of deftnite delusions. Meanwhile tne bromids
were continued in doses of about 150 grains daily to the end of
the sixth month, or the fourth month from the onset of brom-
ism. At this time somnolence appeared for the first time and
food began to taste salty. The bromids were then withdrawn.
After five days somnolence disappeared, but the hallucinations
of sight and hearing, and delusions of persecution increased in
intensity and deflniteness. In the course of six days insomnia
disappeared and there developed great fear as the result of con-
stant hallucinations, which impelled him to move restlessly
about in search of persecutors or to take refuge from them.
There were also hallucinations of smell and taste. At this
time he was committed to our care.
His consciousness was somewhat clouded, and he was
partially disoriented for time, place and persons. His memory
was only moderately impaired and that mostly for events oc-
curring during the recent weeks. Mental action was very
sluggish and it required considerable time for him to recall
wellknown facts. He had very little control over his emo-
tions, frequently weeping when angry. His movements
were slow and sluggish, and he rarely moved except
in reaction to his numerous hallucinations. The physical
symptoms of bromism had gradually increased during these
four months until his speech became very thick and indistinct
and his ataxia so pronounced that he could barely stand alone.
There was also great muscular weakness. The deep reflexes
were much exaggerated, the pupils were widely dilated and
reacted very sluggishly to light. There was a fine muscu-
lar tremor involving the extremities and the muscles of
the face and tongue. The skin was pale and anemic, the breath
typically bromic, and the secretion of saliva greatly increased.
Tlie heart's action was feeble, the pulse-rate increased and the
arteries compressible.
During the first week the patient became alarmingly weak
and once fell into a state of collapse from which he was re-
vived with great difHculty. From the third week his physical
condition improved gradually. In one month the speech had
become more distinct, and the pupils normal, but the great
muscular weakness and ataxia continued, necessitating his con-
finement in bed for three months. Mental improvement was
also very gradual. At the end of 2i months after withdrawal
of the bromids his consciousness became clear and most delu-
sions disappeared. Hallucinations were still present, mostly
at night. He would say that women came into his room and
prodded him in the buttocks to make him mad, and men filled
his stockings with feces, etc. He overheard men say that he
had murdered a colored boy and had better run to escape the
police. At the end of the tliird month the hallucinations and
fear had mostly disappeared, but he still remained languid and
had no energy for mental application or desire for social inter-
course. He retained only a partial memory for the events of
his psychosis. His reflexes were still much exaggerated at
this time, when he was removed from the hospital. The pa-
tient fully recovered in the course of five months from the
time the bromids were withdrawn.
Case II.— The next patient was a woman aged 39, who devel-
oped epilepsy at the age of 3, and from that time until 32 suffered
only from nocturnal petjJ mal. At 32 she had one severe seizure
of the grand mal type, which necessitated her confinement in
bed for five days. At 39 she had a series of 17 convulsions of
moderate severity, and following this an attack of infiuenza.
The patient at tliis time and for some months previously had
been taking "enormous doses of potassium bromid." Imme-
diately following the influenza the patient developed hallucina-
tions of sight and hearing with fear, at the same time showing
a profound disturbance of nutrition with great loss of weight,
and in the course of five weeks became stuporous. Meanwhile
there appeared a characteristic bromid eruption and such
marked ataxia and general muscular weakness that she was
confined to bed.
She was received at the hospital two weeks later, at which
time the condition of stupor was pronounced ; she was entirely
JJOVEMBEK 29, 19021
USE AND ABUSE OF BROMIDS
IAmkrican Medicine 863
unable to comprehend her surroundings, her responses to ques-
tions were mostly incoherent and irrelevant, and expressed
slowly and with difficulty. Her memory was also much
impaired. The hallucinations of sight and hearing (boys and
men calling to her, snakes in the bed, etc.) were accompanied
by fear and some restlessness. She would attempt to leave her
bed and go to her children, whom she heard calling to her, and
at other times would leave her room because it was afire.
Emotionally, she presented great instability, with frequent
crying. Physically, she was greatly emaciated, witli extreiue
ataxia, exaggerated deep reflexes, bromid breath, weak heart,
and a flabby rapid pulse (120). The extremities were cold and
clammy. Insomnia and gastritis were also present, and the
face and neck were covered with the characteristic bromid
■eruption.
For several days after her admission the patient was on the
verge of collapse, but following this, improvement was rapid,
and by the twentieth day her consciousness had become clear
and all hallucinations and fear had disappeared. The physical
symptoms liad also greatly improved. The ataxia did not
entirely disappear until about the thirty-fiftli day, at which
time the reflexes had also returned to their normal condition.
The date of the withdrawal of the bromids is not accurately
known, but probably occurred two weeks before her admission
to the hospital, at which time the family physician is said to
have become alarmed at her condition. In this event the whole
duration of the state of bromism was 50 days.
Case III. — The third patient was a man aged 3fi, without
hereditary taint, except thathisfatherwaseecentric. Thepatient
himself had always been regarded as peculiar and eccentric, but
a good, steady workman. At the age of 34 he developed grad-
ually a psychosis which presented the characteristic symp-
toms of dementia prfecox. Several months later he was placed
upon the bromid treatment, two drams of sodium bromid
three times daily. This was continued for eight weeks, at
which time he was brought to the institution, presenting
marked evidence of bromism. His articulation was difficult
and ataxia was extreme. Thepatientstoodaloneonly witli great
dilHculty. The deep reflexes were greatly exaggerated and
there was ankle clonus. He also presented the ciaaracteristic
acneiform eruption and bromid breath. The heart's action was
feeble, the pulse small and rapid, and the extremities cold.
Nutrition was profoundly impaired. Mentally there had ap-
Jiarently been no marked change, except a tendency to somno-
ence and some mental sluggishness. In accord with the clin-
ical picture of dementia prrecox his consciousness was
unclouded, he suffered from many auditory hallucinations,
expressed very many fantastic delusions of persecution, and
presented a mild degree of deterioration, as evidenced by his
faulty memory and judgment. During the first three weeks
af.er tlie withdrawal of the l)romids the improvement was
gradual. The ataxia and muscular weakness as well as the
somnolence and languor disappeared entirely. The nutrition
improved, and with it the heart's action became more regular
and the peripheral circulation healthy. The speech was clear
and tlie ankle clonus disappeared within two weeks. The re-
flexes, however, remained exaggerated until the time of his
di.scharge from our care, 12 weeks later. The mental symptoms
characteristic of the disease process remained unchanged
throughout his residence at the hospital.
Case IV.— The foirth patient was a well-developed female,
age<l 32, with good heredity, but who had always shown a faulty
constitutional basis, as evidenced by a very nervous and excit-
able lomperaraent. Shesufl'ered from an attack of manic-depres-
sive insanity at 18 years of age, of seven months' duration, from
whiiih she recovered entirely and was successfully employed as
a mill-hand until the onset of mental disturbance under con-
sideration. The amjearance of the disease, which was a typical
maniacal attack of manic-depressive insanity, was very sud-
den. At some time during tlie nine montlis which elapsed
between the onset of the disease and her admission to the hos-
pital she was submitted to bromid treatment, but just when,
cannot be ascertained. One week before her commitment to
our care she became bedridden and so ataxic that she could
liarely stand ; her speech was thick and slurring, and although
still loquacious, she could hardly be understood; the counte-
t nance was expressionless, and she seemed to be in a low mutter-
I Ing delirium. When admitted she presented the unmistakable
signs of bromism, a strong bromid breath, together with ex-
treme ataxia of the extremities, of the tongue, and of the face ;
thick slurring speech, marked general muscular tremor,
greatly exaggerated reflexes, widely dilated pupils and extreme
general del)iiity. There was no l)romid eruption.
Mentally, at first she lay in a stupor with her consciousness
profoundly clouded, and unable to comprehend any part of her
environment. There was no voluntary speech and she could
1)0 aroused to reply to questions only upon prodding, and then
her roi)lies were incoherent and irrelevant. All mental pro-
cesses se<!iiied to be in partial abeyance. Her voluntary move-
ments were slow and languid.
"Ten days after the withdrawal of the bromid the stupor
disappeared rapidly, leaving the patient in the maniacal state
rliaracteristic of her original mental disease; i.e., with marked
])ressiire of activity, dlstra<rtibllity, flight of ideaSj only slight
clouding of consciousness, and without hallucinations or defi-
nite delusions, but this condition also improved rapidly and
in the course of six days she was quite clear mentally, there
remaining but a slight pressure of activity and a tendency to
loquacity. Likewise, her physical condition improved rapidly,
the pupils became normal in size and reaction, the speech dis-
tinct and free, and the ataxia was so much improved that by the
seventeenth day she was helping about the ward and sewing.
The reflexes continued somewhat exaggerated at the date of
her discharge, 14 days later.
One year later this patient returned to us suffering from a
third attack of manic-depressive insanity, which was also of
the maniacal form, but failed to show any of the unusual and
untoward symptoms of her previous attack. Her disease this
time ran a typical course, with recovery in two months.
Case V.— The last patient was a woman, aged 30, with an excel-
lent family history. The psychosis, for the treatment of which
she received bromids, appeared rather suddenly following over-
work as a cashier during the heavy holiday trade in a large dry-
goods store. It was at first characterized by despondency with
delusions of reference (she thought that she was being suspected
of stealing money from her employers, etc.). Two weeks later
hallucinations of hearing, and finally of sight appeared. The
history of the psychosis following this and until committed to
our care is very incomplete. She is said to have been restless
and loquacious, and to have expressed expansive delusions.
Bromid treatment was begun about one month after the onset
and continued for at least six weeks, the patient receiving at
times as much as 10 grains of sodium bromid every three hours.
The date of the onset of bromism is unknown, but it probably
occurred about one week previous to her admission to the hos-
pital, which occurred in the third month of the disease. At this
time she began to develop a stuporous state. When first seen
by us she presented marked ataxia, some general muscular
weakness, faulty articulation, exaggerated deep reflexes and
ankle clonus, moderately dilated and irregular pupils, faulty
nutrition, acneiform eruption and a strong bromid breath. The
consciousness was profoundly clouded, the memory greatly
impaired, especially for recent events, and the content of speech
incoherent and disconnected ; mental action was very sluggish,
and there was marked difficulty of thought. She expressed
many incoherent and expansive delusions, such as that she was
married to a wealthy man, had 40 children, of whom the phy-
sician was one. Emotionally she was continuously exhilarated,
happy and often erotic. Her voluntary movements were
retarded and performed with difficulty, because of the ataxia
and muscular weakness. There was some restlessness seen in
her tendency to wander aimlessly about, but she was too com-
pletely dazed to take any part in her environment.
The usual symptoms of bromism as described by
most observers consist of great somnolence, depression
of spirits, sluggishness of mental processes, insensibility
of the skin and raucous membrane, abolition of sexual
functions and deep reflexes, fetid odor of breath, mus-
cular weakness, dilated and irresponsive pupils, ptosis
of eyelids, cachexia and yellowish skin. In more pro-
found intoxication there is paralysis of motion, of
sensation and of the mental processes, somnolence
becomes deep stupor, the circulation greatly impaired,
the respiration slow but easy, and sometimes death
ensues.
The unusual symptoms presented in these five cases
are worthy of note. Among the phy.sical symptoms the
most marked variation from those enumerated above is
the exaggeration of the deep reflexes which occurred in
all cases, and in two was accompanied by ankle clonus.
So far as ascertained, exaggeration of the reflexes either
with or without ankle clonus ha,s not been previously
recorded except by Seguin.' On the other hand, dimi-
nution and absence of reflexes are often mentioneid.
The absence of the bromid eruption is of importance
as it is often erroneously taken as a guide for dosage.
In the mental symptoms all of the cases presented
unusual features. The somnolence, regarded as so char-
acteristic of bromism, increasing to hebetude, lethargy
and stupor, and finally coma, occurred in only one case-
On the other hand, in two eases there was a marked
hallucinosis with affect of fear and concomitant agitation
and in one case even hallucinations of ta-stt; and smell.
The presence of hallucinations in bromism has been
notetl by Hammond, one case ; Clarke," one case ;
Hameau," one case ; Eigner,'" one case ; A. Voisin,"
one case ; Seguin," two cases ; Alexander," three cases ;
Ilolmden," one case ; Baker," one case.
In the remaining three cases, those of insanity, the
eflect of bromism seems to have simply overshtulowed
the symptoms characteristic of the original mental dis-
ease. During the manifestations of bromism all of the
864 A.XKRIOAN Medicine]
USE AND ABUSE OF BROMIDS
[November 29, 1902
mental faculties of the patients became sluggish ; appre-
hension was impaired, the memory defective, the content
of speech and association of ideas confused, the emotional
attitude unstable and the voluntary movements anergic.
In two cases this condition advanced to one of stupor,
with complete clouding of consciousness, and dazedness,
the memory entirely obliterated and speech so inco-
herent as to be unintelligible, the voluntary movements
absolutely languid and confined to tottering about
without evident purpose, or fumbling with the bedding.
Another notable feature is the rapid appearance of
bromism in one case following influenza, which misled
the diagnostician until the more characteristic stuporous
state made its appearance two weeks later.
A prominent characteristic of bromism mentioned by
most writers is the rapid disappearance of the symp-
toms, both physical and mental, upon the withdrawal
of the drugs. Of the eight cases collected from litera-
ture, in which the duration of the symptoms was noted,
the mental symptoms disappeared in one case in two
days, in two cases by the sixth day, in one case in a week,
while in the remaining four cases they were said to have
disappeared quickly. In the eases here reported the
duration in three was over one month (one over three
months), in two cases three weeks, and in one case ten
days. In all, the physical symptoms were the last to
disappear. There was no apparent difference in this
respect in the two epileptic and three insane patients, as
the duration in one epileptic was three months and in the
other one month.
The symptoms enumerated by no means exhaust the
evil effects of the excessive use of this drug. One does
not need an extended experience with epileptics to
appreciate the truth of the statements made by Ecchev-
eria, Bannister," Alexander, Mitchell, Hodges, and
Keniston," that the use of bromids may produce marked
irritability at times with outbursts of temper and suicidal
attempts. The last observer states that in his experi-
ence it has been found that the fewer the patients who
receive bromids and the smaller the dose, the less irri-
tability, noise, violence, and destructiveness there is in
the epileptic wards. Chapin makes a still stronger but
more general assertion, that the ignorant and excessive
use of this drug is without doubt responsible for a con-
siderable number of the hopeless epileptics that crowd
our asylums.
Alexander " in his series of seven cases, six of the
patients being epileptics, ascribes, among other symp-
toms, a pronounced aphrodisiac effect to the excessive
use of bromids. Kiernan '" and Monroe ''" report similar
cases.
It has also been observed that patients suff"ering from
gross cerebral lesions show a great susceptibility to the
bromids, which induce a variety of mental symptoms.
Mitchell™ reports one case in which the bromids
caused melancholic depression, especially at the men-
strual period.
A wellknown author, writing on the treatment of
nervous diseases, asserts that outside of the hypnotics,
which produce habits, there is no drug which is so out-
rageously misused in these disorders as the bromids.
The same statement, I believe, may be applied to its
abuse in the treatment of mental diseases. The pro-
longed administration of bromids In insanity is wide-
spread and should be vigorously denounced.
In reality the value of bromids in this field is very
limited. The physiologic effect of bromin salts, which
is to produce a lessened irritability of the motor centers,
especially the motor cerebral centers and the reflex cen-
ters in the cord, acting directly on the ganglion cells,
would seem to indicate their use in conditions character-
ized by motor excitement. On the other hand, the in-
vestigations of Lowald ^^ show that the bromids have the
most marked influence in allaying conditions of " nerv-
ous tension," but also affect memory profoundly while
they have no apparent influence upon the association of
ideas, release of volitional movements or muscular work.
The indications, then, for their use would seem to be men-
tal disturbances characterized by states of nervous ten-
sion and of excitability of the motor cerebral centers. In
practice we find this to be true. The drug finds its best
use in acquired neurasthenia, in relieving insomnia and
that peculiar state of inner nervous tension. In con-
ditions of mental excitement in which motor excitation
is the primary factor, the bromids receive almost univer-
sal recommendation. (Krafl't-Ebing, Ziehen, McPher-
son, Berkley, etc.) But one must make a careful dis-
tinction in the type of mental excitement, as there are
several distinct forms, and but very few of them present
motor excitement as the primary feature.
The form of excitement in which the bromids can be
used to advantage occurs in manic-depressive insanity.
There accompany it very few if any hallucinations or
delusions, and there is usually very little clouding of con-
sciousness. The essential feature is an irrepressible pres-
sure of activity ; the patients are extremely active, over-
energetic and talkative. The emotional attitude is one
of elation and happiness, with frequent evidence of irri-
tability.
Other forms of mental excitement which may be con-
founded with this condition, and in which the bromids
are useless, are those that occur in dementia prsecox,
general paresis and exhaustion psychoses. In all these
conditions the motor excitement is usually accompanied
by numerous hallucinations and delusions, and the con-
sciousness is more profoundly clouded.
The exhaustion psychoses, and particularly delirious
states accompanying febrile conditions or infectious disr
eases, in which motor excitement is apt to be very great,
are distinctly acute conditions arising from faulty meta-
bolism, poor nutrition and exhaustion. Here bromids
are clearly contraindicated because of their tendency to
interfere with and embarrass nutrition and disturb
digestion. One rather needs to employ supportive treat-
ment.
One further indication for the use of the bromin salts
emphasized by Kraff't-Ebing is in those forms of mental
disease which seem to bear a close relation to sexual
excitement, particularly if this is periodic.
For the relief of mental excitement occurring in
manic-depressive insanity, it is usually necessary to
combine the bromids with some more powerful hypnotic,
as chloral, sulfonal, trional, cannabis indica, hyoscin
hydrobromate, etc., for in order to obtain the desired
sedative effect one would have to employ the bromids in
such excessive doses as to produce bromism within a
very short time. It must be remembered that these
remedies are all merely palliati%'e and that the symp-
toms of motor excitement return as soon as they are
withdrawn. It is for this reason that in recent years it
has been regarded as far better practice to overcome these
symptoms by other than medicinal means, such as the
prolonged warm bath, bed treatment and the psychic
influence of a tactful and experienced nurse. In some
hospitals such measures are so successfully employed as
to render unnecessary the use of any hypnotic whatever.
If it seems necessary to employ the bromids, it is
essential that they be alternated with other hypnotics, a
rule which applies to all sedative or hypnotic drugs in
their use in mental disease. The dosage depends upon
the tolerance of the patient for the drug. One may
begin with 10 grains of sodium or potassium bromid or
a mixture of the sodium, potassium and ammonium
salts in combination with one of the more powerful
hypnotics, given three times daily. So soon as the toler-
ance for the drug is determined it can be rapidly increased
to 30 and even 40 grains, three times daily, but one
must be constantly on the lookout for evidences of
bromism, bearing in mind that the mental symptoms
play as prominent a role as the physical.
The inappropriate administration of the bromids is
evident in the cases of insanity here reported. In two of
MOVEMBEB 29, 19021
MYXEDEMA
'Ambkican Mbdicink 886
these cases they were prescribed for a form of insanity
in which there was no apparent motor excitement, but
the psychosis was one which is characterized primarily
by a process of deterioration, involving the memory and
judgment and accompanied by hallucinations ^nd delu-
sions. The moderate degree of motor restlessness in
either case was probably due to the hallucinations and
delusions. In the other case of insanity, in which there
was an indication for their use, they were given in excess
and probably without alternation or combination with
other drugs.
BIBLIOGRAPHY.
' Graf, Dekalil bromatlefflcaoltate Interna experlmentis lllustrata,
Upsiie, IMO.
2 Huette, RScherches sur les proprifitfis physloloftlques et thfira-
peutiquos de broinure de potassium. Mem. de la Soci6t6 de Blologie,
1850, Vol. li. p 50.
'A. ^■oisln, De I'eniplol de bromure de potassium dans les maladies
nerv-euses, Paris, lS7b.
* Mitchell, On the E.xceptional Eft'ects of Bromlds. Tr. Assoc. Am.
Phys.. Phlla , isae, xl, ll»5.
'Hodges, MarylandMed. Jour., xxxv, Si84, 1896.
' Alexander, Alienist and Neurologist, xvil. 279, 1896.
■ Keffiiin, New York Med. Jour., April 5, 1890.
- Clarke, Wood's Therapeutics, p 309.
■ Haineau, Wood's Thei-apeutics, p. ;J09.
"' Eiguer, Wiener med. Fresse, 1886.
" A. Voisln, loc. clt.
"Seguln, loc. clt.
13 Alexander, loc. clt.
" Holmden. London Lancet, 1890, li, p. 8 6.
" Baker, Med. Sentinel, 1897, v, .5:$
"Bannister, Jour, of Nei-v. and Ment. Diseases, 1881.
" Keniston, Clinical Psychiatry.
'■* Alexander, loc clt.
"Klernan, Medical Standard, 1887.
» Monroe, Medical Standard. 1891.
" Mitchell, loc. cit.
*LiOwald, Kriepelln's Physio oglsche Arbeltcn, Bd. 1.
MYXEDEMA.'
BY
B. C. LOVELAND, M.D.,
of Syi-acuse, N. Y.
I have chosen this subject hoping to make clear some
points in diagnosis that have troubled me in the past
and which have no doubt troubled others, and also to
report briefly two cases, which, while characteristic,
differ in some important particulars from those I have
seen described.
This disease, with its peculiar swelling of the skin
and subcutaneous ti.ssue, was described by Gull and Ord
as early as the seventies, but the recognition of it.s true
character and the brilliant re.sults attending the adminis-
tration of the dasiccated thyroid gland have resulted
from the observations and e.Kperiments of such men as
Ivocher and Reverdin, who noticed a .similar condition
following total extirpation of the thyroid gland, while
it failed to occur after its partial extirpation. Later
Schiff, by experiment, showed that the results of thyroid
extirpation could be averted by implanting in the abdo-
men of the animal operated on the thyroid of a similar
.s|)ecies, so it could continue to functionate. In the
evolution of our modern treatment api)ear the names of
Birclier, Ilorsley, Murray, Howitz, Mnckenzie, Kox and
others, who have added each his part, until it would
.seem that little more could be expected in that direction.
Birclier and Morsley followed closely the experiments of
8chiH', transplanting a portion of a gland from an animal
into man, with good results in some cases. Murray
prepared an extract from the thyroid gland which he
use<l hypodermically with better results, and later
llowitz and Mackenzie anrl Fox, each independently,
began the internal administration of thyroids, at first
raw or partly cooked, after that desiccated, which is the
method now employed, though there are preparations of
thyroidin, or a thyroid extract, on the market, which
are propo.sed in the place of the desiccated gland itself.
The cau^e of aojuired myxedema is the cessation of
function of the thyroid gland, which may i)e produced
ill several ways, viz., by traumatism, which includes
■ I: r.ii i,. i,,r ■ the Hyracuiie Academy of Medicine, June 8, 1902.
surgical removal of the gland ; by inflammation follow-
ing rheumatism or infectious fevers, and by cystic
degeneration. Profound shock to the nervous system is
also mentioned as a po&sible cause by one of the authori-
ties consulted ; this was the only assignable cause in one
of my cases. It should also be noted that the condition
occurs much more freciuently in females than in males
and rarely earlier than 30 or later than 50.
A detailed description of symptoms and diagnosis
will be omitted here and considered in connection with
the case reports.
Cask I.— Mrs. X., about 50 years of age, came under my
care in December, 1894. She had been an acquaintance of mine
for six or seven years, during which time she had been a
chronic invalid, often confined to her bed, a couch, or a wheel
chair. The pliysician wlio referred her to me said he did not
exactly understand her case, but believed her weakness and
swollen condition to be due to weak heart and kidney trouble.
The history taken at the time was as follows : Born of healthy
American parents, nothing of note occurred to interfere with
her health until a few years after she was married. She had
one child, who is now a healthy woman of perhaps 35 years of
age. Two or three years after this her husband met a sudden
and accidental death, which produced a profound shock to her
nervous system from which she said she had never fully recov-
ered. No accurate statement could be elicited as to the time
she began to suffer with the present symptoms, but they had
been insidiously progressive for several years. She had accu-
mulated a distressing amount of boggy flesh, while at the same
time she had become very weak. There was a progressive
impairment of hearing, so that she could not hear ordinary
conversation across the table: great vertigo which, with the
weakness, caused her to spend much of her time reclining or
being wheeled in a chair. She was heavy, sleepy or dull in the
daytime, but complained of having poor nights.
This condition led some to think she was addicted to the
use of morphin. She felt cold on the slightest change of tem-
perature, and was often the subject of a troublesome bronchial
cough with expectoration. In appearance she was light in
complexion, looked pale or anemic; her face was heavy and
lacking in expression, eyelids were swollen and overhanging,
the tongue thick and unwieldy, .so that her voice sounded as if
her mouth was partly filled with cotton, or that her tongue was
wrapped in flannel. There was a marked dryness of the skin
and its appendages, the hair lacking in luwter, and V)Oth hair
and nails were brittle. Her appetite and digestion were both
poor, and tiowels were constipated. She was dull and apathetic,
but i-lear enough mentally when aroused. Her urine showed a
trace of albumin.
It would seem that these symptoms should make the
diagnosis of acquired myxedema very plain, and so it
would today, but it should be remembered that all the
cases reported up to that time had been marked by pig-
mentation or darkening of the skin, especially of the
exposetl surfaces. This pigmentation of the skin had
been described as one of the symptoms in a paper read
shortly before this at a meeting of the A.ssociation of
American Physicians which I attended, and it was also
present in considerable degree in a patient shown me by
Dr. M. Allen Starr, about two weeks after this ca.se
came under my ob.servation. The other symptoms,
however, and especially the voice, the iieculiarity of
which it is impossible to describe accurately, were strik-
ingly like those just reported. The patient shown me
by Dr. Htarr was the one whose case was reported by Dr.
.John Woodbury (Medical Jiecord, October 31, 1896), the
pictures of which serve to Illustrate the subjwt of myx-
edema in Church's and Peterson's work on nervous
disease.
On my return from New York my patient had left the
institution where I then was, and no opportunity to try thyroid
feeding on her occurred for two years, when her daugliter came
to bring mo another member of the family for treatment, and
on inquiry she said her motlier was worse than she had ever
been ; that she had not been out of the house for tliree months,
much of the time was imable to sit up, and was suffering with a
terrible bronchitis which refuse*! to yield to any treatment she
had received.
At this time desiccated thyroids were prescribed, one 5 gr.
tablet morning and evening. Improvement was rapid and
remarkable, so that in three weeks she had lost almut '25 pounds
of her boggy flesh, had recovered her bearing so that she could
hear ordinary conversation across the table, and her voice had
bet'omo nearly free from its mullled character, while the bron-
chitis from which she had been suffering was relieved. Now,
however, began a set of symptoms which demanded a tempo-
rary suspen.sion of the thyroids, or a marke<l reduction in the
866 AMXBIOAir Hboicink
MYXEDEMA
[November 29. 1902
dose. Instead of thfl dull condition, mental and phyHical, she
became very nervous, hyperesthetic and sleepless. Her pulse
became rapid, breath labored on slight exertion, and whereas
she could stand any amount of massage bpfore the treatment
began, sh« begged to have it stopjjed on account of the pain it
caused. After a little experimenting it was found that one-half
of a tablet morning and evening was all the thyroid medi-
cation the patient could talte without causing distress, and this
has been continued, with short intermissions, until the present
time. The recovery in tliis case was practically complete and
the patient has had good health since the summer of 1895.
There is a tendency to a return of the old condition, however,
when the thyroids are entirely omitted for a considerable time.
Case II.— Mrs. Z., aged 84, was first seen on .July 28, 1901,
and was at that time suffering with vertigo, weak heart action,
short breatli and aswelling of the feet and limbs, which pitted
on pressure. Also great weakness, restless nights, and a
chronic mucus discharge from the bowels, with occasional
blood. She said at that time that all she wished was to get braced
up so she could ^et out of town, which she did in four days, and
no opportunity tor a thorough examination being offered no
positive diagnosis was made. She insisted that all the symp-
toms except the weakness and dizziness, which had recently
Increased, were of such long standing that there was no use
talking abouttliem or doing anything for them. She was next
seen on January 26, 1902, when she had become so weak-
ened that she was confined to the house. Her ver-
tigo had increased so that she had to support herself when
walking, by leaning on someone's arm or on a chair or table.
She was stupidly sleepy in the daytime, but slept little and
fitfully at night, her sleep being disturbed by dreams from
which she could with difficulty free herself when awake. Her
friends insisted that her mind was failing, but she seemed to
reason correctly enough when she was roused from her leth-
argic condition. Her tongue was so unwieldy that it was
almost impossible for her to pronounce some words, and her
voice was muffled and characteristic. Her skin was dry and
scaly. She complained of great dryness of the mouth, and
choked on attempting to swallow the smallest bit of solid food,
and would chew a pill rather than risk trying to swallow it.
She complained of drooling at night, or whenever she laid
dowri to sleep, and always provided for this by placing a towel
under her face when she slept. This towel would be saturated,
and when dried would be stiff with a limy deposit. She could
not wear her shoes on account of the swelling of her feet, which
swelling would pit on pressure. Her eyelids were heavy and
overhanging, making her eyes look not more than half their
size. She had a blind spot in one eye from a small retinal
hemorrhage, which occurred about a year previous to tliis
account, and both pupils, though regular, were very small.
Her pulse, not strong, was never over SO. Temperature was
normal, but she complained constantly of coldness. Bowels
were constipated, but mucus discharged from the rectum
almost constantly, with occasional blood. Urine was scanty,
high colored, 1,040 sp. gr., acid, no sugar nor albumin. She
looked very pale and anemic. All these symptoms had been
insidious and slow in their progress, and dated back several
years, just how long was impossible to ascertain. Physical
examination showed a weak heart action, great enlargement of
the liver and that peculiar doughy thickening of the subcutane-
ous tissue which has been described as belonging to myxedema.
A diagnosis of myxedema was made, and she was put on
thyroid tablets, one, morning and evening, with no remarks as
to what she might expect.
In four or five days there had been such an improvement
in her voice that it was remarked by her sister and nurse, as
well as by herself. Her pulse, which had scarcely been higher
than 50 and very weak, even with good doses of strychnin,
came up to 70 aud improved in quality. Before a week of thy-
roid treatment had expired the patient came down with a cold
of an influenza type, which for the time interfered with her
progress. Her temperature ran up as high as 102.5°, her bron-
chitis was increased, and for a week she was unable to resume
systematic medication. Then thyroids were resumed as before,
and a rapid loss of her boggy flesh was noted, besides steady
improvement in her pulse and speech. With the improvement
in heart action, the edema of the feet and legs disappeared.
Although improving as mentioned, she began to get excessively
nervous and restless. She had not for a long time slept well at
night, but felt she was making up for it in the day ; now her sleep
in the day was gone, and she became very anxious and worried,
and she, together with her friends, thought that she could not
survive any length of time. Her flesh became sensitive and
tender, and she complained of considerable pain in different
parts of the body, especially in the legs and in the region of the
liver. Along with this general change in her system she
noticed that she did not cough and choke almost to strang-
ling, as she had done frequently, daily it may be said.
With all the improvement in various ways, she felt that
improvement at the expense of such a nervous and hyper-
esthetic condition was dearly bought, and perhaps that would
have been true if the nervous state was to continue. The thy-
roids were temporarily suspended and sedatives employed, and
soon the nervousness began to subside. Then thyroid tablets
were administered, one in 24 hours, with a continued improve-
ment in her general condition and without increasing her
nervousness.
She gained slowly in strength, and left my care on April 19
last, her skin soft and moist, her voice dear, probably H5 pounds
lighter than in .January, and with little moie vertigo than her
weakened condition would acc>untfor.
That the diagnosis of nnyxedeina is not so easy and
plain a thing as might be supposed, Is amply proved by
the fact that these patients, and others whom I have
known, have lingered along as chronic Invalids under
the care of good physicians. As these cases present all
the classic signs of the disorder, it is unnecessary to
prolong this paper with a recital of .sym ptoms and means
of diagnosis. Both patients lacked that pigmentation of
the skin so often found — both had the characteristic
changes In the tegumentary system, and also in the
mental condition — and both showed a tendency to
hemorrhage. In the first case there was no history
other than a nervous shock which occurred several
years previous that could be regarded as a cau.se, while
in the second case there was a history of glandular
Inflammation in the throat, In which the thyroid was-
probably involved, causing a fibrous hardening or
atrophy of the gland, as a reason for its lack of function.
The age of the patient in Case II is a factor worthy
of note, as it is extremely uncommon for this disease to
develop after 50 years of age, also the true edema in this
case added to the difficulty of diagnosis.
The patient in Case I had slight albuminuria, while
albumin was absent in the second patient. Both albumin
and sugar have been noted at times in this class of cases.
The slow and weak pulse also deserves mention, as it
was especially marked in the patient of Case II, and did
not improve under strychnin, which she had taken for a
long time before coming under my care and which she.
continued till thyroid treatment was instituted. Many
of these patients die from weak heart finally if they do
not succumb to some intercurrent malady. The drool-
ing, so common in the cretin, I have not seen mentioned
in connection with acquired myxedema, but from the
relief in this direction which followed the use of thy-
roids, it seems probable that in this case it was depend-
ent on absence of thyroid function.
Of course a diagnosis cannot be made from a single
symptom, but must depend on the symptom complex,
or the general picture presented, but one symptom
which seems to me especially characteristic is the voice,
varlousl.v described as "husky," "hoarse," and "muf-
fled." My patient gave her own idea of it by saying " the
sound was as if her tongue was wrapped in cotton."
I do not think the voice can be accurately described,
but must be heard to be appreciated.
In regard to the untoward effects that thyroid medi-
cation may have on some persons, it has frequently been
noted that excessive thyroid feeding may produce many
of the symptoms of Graves' disease, and that no iron
rule can be laid down as to the dose for any particular
patient ; and these patients feel the nervous and hyper-
esthetic condition more keenly than the average patient
with Graves' disease, in whom the symptoms have
developed gradually.
These symptoms may require sdhie attention but will
subside with the temporary suspension of the thyroids
or the lessening of the daily dose.
The result of thyroid feeding in properly selected
cases prom'ses all that could be desired for the subject of
myxedema. Better results are obtained, however, in
the acquired than in the congenital form of this disease.
It should be borne in mind that myxedema cannot be
cured permanently, as the function of the thyroid once
gone can never be restored, but by the use of a .small
amount of desiccated thyroid continuously, or nearly so,
these patients otherwise hopeless, and almost helpless
when advanced, may be made and kept very comfort-
able in body and mind.
Unfortunately for the purposes of illustration neither
of these patients would allow her photograph to be
published.
NOTBMBER 29, 19021
THE WORLD'S LATEST LITERATURE
Ahicbican Mkdicine 867
THE WORLD'S LATEST LITERATURE
Joarnal of the American Medical Association.
November 22, 1902. [Vol. xxxix, No. 21.]
1. Concerning Some Vaccinal Eruptions. Henry W. Stklwaqon.
j. The Decentering of Lenses for Near Work. G. C. Savage.
». The Genesis and Treatment of the Myopic Eye. S. D. RiSLEY.
*. The Need of Correcting Ametropia After Middle Life. C. M. Culver.
0. The Prognosis and Treatment of Croupous Pneumonia; with an
Analysis of the Cases Treated in Cook County Hospital for 15
Months Preceding .\pril 1. 1902. E. Fletcher Ingals.
6. The Present Aspect of Ihe Tuberculosis Problem In the United States.
8. A. Knopf.
7. Essentials In the Construction of Hospitals for Large Cities. .\. J.
OCHSNER.
8. Death Due to x-ray? Madrice Kubel.
9. Binocular Magnifler for Use in Opeiating. Edward Jackson.
1. — Vaccinal Kraptions. — According to Stelwagon the
most frequent and usually more or less evanescent of the erup-
tions are localized or general erythema, urticaria, erythema
multiforme, a regional vaccinia, impetigo contagiosa and a
pseudoerysipelatous, or erysipelatous inflammation, or other
accidental regional dermatitis. In his experience impetigo
contagiosa is most common toward the end of the first week,
and it is probable that it has often been mistaken for general
vaccinia. Erythema multiforme and urticaria occur anytime
between the first day and the crusting period. The urticaria
often lasts longer than the ordinary type, and the tendency to
vesicobullous and bullous development is more marked. A
generalized pemphigoid eruption, relatively uncommon, is
usually not dangerous or fatal, but is sometimes alarming and
long continued. Since the disuse of human virus constitu-
tional maladies, like syphilis and tuberculosis, can scarcely
occur. That the serums used In certain diseases produce sim-
ilar rashes to the above points to a toxin or microbe derived
directly from the animal furnishing the virus, [h.m.]
2, 3, 4.— See Ame7-ican Medicine, Vol. Ill, No. 25, p. 1054.
5. — Croupous Pneumonia. — Both overfeeding and under-
feeding must be avoided. Ingals recommends a half pint of
milk or its equivalent every three hours. Vigorous catharsis is
harmful except in rare instances. There should be one move-
ment daily. Drafts should be avoided. Mortality statistics
show a reduction of from ;«% to 30% from the use of an oiled
silk and cotton jacket. Ingals believes it is possible to abort
the di.sease in some cases and hasten resolution in others by
counter- irritation. Ergot seems to diminish the intensity
of the initial symptoms. In dyspnea with congestion the
drawing of 6 or 8 ounces of blood appears beneficial. Pain
may be relieved by heat or cold or phenacetin. Opiates should
be given as a last resort. Ammonium bromid and hyos-
cyamus quiet cough and relieve insomnia. Full doses of
whisky produce sleep. Hydrotherapy, or guaiacol, rubbed
into the chest reduce temperature. Chloroform inhalation is
good as a respiratory stimulant. Nux vomica is the best heart
stimulant. When depression is great much benefit results
from hypodermoclysis or high rectal enemas of normal salt
solution with a calcium salt. In grave cases free alcoholic
stimulation is indicated. Oxygen is generally postponed till
too late and is given too infrequently, [h.m.]
O.— .Sec Ame7ncan Medicine, Vol. Ill, No. 25, p. 1046.
7. — .See American Medicine, Vol. Ill, No. 25, p. 1041.
8.— Death Due to X-ray ?— Riibel reports a death possibly
from this cause, and reviews the literature of thesuliject. Tliere
is no authentic i^ase of death directly traceable to the x-ray. [h.m.]
O.— Binocular Masnificr for Opera! Ing. — Jackson empha-
sizes the importance of keeping the two lenses of the magnifier
at the same height liefore the two eyes, otherwise binocular
vision is impossible. The gutta pcrcha headband may be
molded to the head after warming. A condensing mirror fur-
nishes the light, leaving both hands free for use in operating.
[H.M.]
Boston Medical and Suricical Joarnal.
November 20, 1902. [Vol. CXLVII, No. 21.]
1. Tetany In Gastric lilsorders. Lawrence W. Strong.
J. Notes on the Diagnosis and Treatment of Early Miscarriage. L. V.
Krikdman.
'2. — Early MIscarrlaKCs.— Friedman's notes on early mis-
carriageH, or pregnancies interrupted before the completion
of the first 18 weeks, are based upon 104 cases in the Boston
City and Lying-in Hospitals. The symptoms in diagnosis are
pelvic pain associated with uterine bleeding, absence of charac-
teristic menstrual odor, and a dilated os. There is usually an
absence of the symptoms peculiar to extrauterine pregnancy,
and the size of the uterus is frequently smaller than the history
would indicate. The question of threatened or inevitable mis-
carriage must remain one of personal judgment, and is often
very difficult. A firm uterus, closed os and slight ooze of
blood indicate, where the previous flowing has been slight, a
threatened miscarriage ; where the previous flowing has been
profuse and in clots— a complete miscarriage. If the os is so
patulous as to admit a finger easily, the ovum, intact or in part,
will be found almost invariably in the uterus. As to treat-
ment, when no part of the ovum is prolapsed through the os,
or when it is not sufliciently dilated to permit the finger to feel
the intact or ruptured ovum within the uterus, if the patient's
pulse is good in quality and less than 110, it should be expectant.
When, however, radical measures are necessary, the ovum
should be removed from the uterus by the finger rather than
by the curet, whenever possible, as this method leaves the uter-
ine mucosa in a more nearly normal condition. [w.K.]
Medical Record.
Novem,ber 22, 190S. [Vol. 62, No. 21.]
1. Repealed Ectopic Gestation. Brooks H. Wells.
2. Typhoid Fever, .Symptomatology, and Clinical Diagnosis. Charles
E. Nammack.
3. Monoplegia Disturbances of SeuslbiUty In Cortical Paralysis. Sol.
G. Kahn.
4. A Clinical Report on the Use of Argyrol (Silver VltelUn) in Diseases
of the No.se, Throat, and Ear. M'. D. Lederman.
a. RelationofConsclousness to theNervousSystem. Axel E Gib.son.
1. — Wells reports the case of a woman having two ectopic
gestations in the period of one year and three months. This led
him to study the etiology of ectopic gestation, and after an
extended review of literature on this subject, covering the
experiences of many noted obstetricians, he concludes it is
probable that the most frequent etiologic factor leading to the
abnormal implantation of the ovum is a mild infection of the
tube, which, causing a change in its epithelial lining, increases
the time occupied in the passage of the fertilized ovum through
the tube. [w.K.]
2. — Typhoid Fever. — Nammack classifies types as follows :
1. Ordinary typhoid with marked enteric lesions ; this includes
the immense majority of all cases. 2. Typhoid septicemia
without special local manifestations. 3. Typhoid with localiza-
tions other than enteric and masked by symptoms referable to
the lungs, kidneys, meninges,' or spleen. 4. Mixed infections
in which one organism favors the growth of the other. He pre-
sents in tabulated form the differential diagnosis between
typhoid, acute miliary tuberculosis, and cerebrospinal fever.
[H.M.]
3. — Monoplegia Disturbances of Sensibility in Cortical
Paralysis.— Kahn reports that a man of 'i.'} was struck by fall-
ing slag on tlie right side of the head, and sustained a depressed
fracture over the motor area. Examination showed the left
arm was not only completely paralyzed, but was devoid of
sensation from the finger tips to the shoulder, and the left side
of the body down to the lumbar region was likewise anesthetic.
The area involved was from the median line in front to the
spinal column posteriorly. The day following the injury
operation was performed, the woimd was cleansed and the
depressed bone elevated. The membranes and the brain sub-
stance were found somewhat lacerated. The wound healed
promptly and without infection. Disappointment was felt in
that the motor paralysis and the sensory disturbances did not
soon subside. Eight months have elapsed since the injury
and twitchings are still noticed in the paralyzed arm, but
are now less marked than formerly. One month after the
injury power commenced to return in the arm, though it
is yet deficient. There was at no time atrophy of muscles.
There is still impairment of sensibility in the regions before
mentionetl. The author asserts that the clinical oUservation of
this case shows cerebral paralyses (monoplegias) duo to lesions
of the motor area of the cortex, are also accompanied by loss of
sensibility, and that both motor and sensory areas mu.st be
''868 &MKBIOAN HbDICINR'
THE WORLD'S LATEST LITERATURE
(NOVBHBBB 29, 1902
.located in the same place. We may tiiid motor paralysis with-
out loss of seusatiou, or both paralysis and loss of sensation.
This is explained by the extent of the injury. Both areas
appear to be in one place, but on different planes. If the
Injury is slight and the contused or lacerated area of the cortex
is only superficial, we may have paralysis without anesthesia,
■but if the injury is more severe, and the deeper cortical cells
■are disturbed, we have both paralysis and loss of sensation.
[a. B.C.]
4.— Argyrol in the Treatment of Diseases of tlie Nose,
Throat, and Ear.— Lederman says his experience with this
new drug extends over a period of five months, and embraces
the treatment of acute and chronic catarrhal disturbances of the
nose, pharynx, and larynx, and chronic purulent otitis media.
It was used as a suljstitute for silver nitrate and employed in
strengths varying from 5% to a saturated solution. He con-
-cludes it is a worthy substitute for silver nitrate, for it pos-
sesses all the good qualities of the latter without any of its
unpleasant irritating features, especially in its application to
the nasal, pharyngeal, laryngeal, and aural mucous membranes.
Its superior therapeutic effect can be attributed largely to its
^solubility and its ready penetration of tissues which give it
superior constringing properties, as well as added germicidal
powers, [a. B.C.]
5. — Relation of Consciousness to the Nervous System.
— According to Gibson man depends on the sympathetic
system for his vegetative existence ; on the cerebrospinal for
his instinctive or psychic, while the unexplored regions of the
cerebral cortex may form the structural basis for his self-con-
scious existence. Man as thinker is a stranger to man as
animal or plant. The incentive to growth which the power of
self-analysis may impart overbalances every other factor in
-evolution. Man is advancing to a stage when he shall no longer
remain a stranger to his own life processes. The crowning
glory of evolution lies in attainment of self-mastery, [h.m.]
New Yorlr Medical Jonrnal.
November 15, 1902. [Vol.. LXXVI, No. 20.]
I. Pathology and Treatment of Epilepsy. William H. Thomson.
1. A Case of Ringworm of the Face, and Two of the Scalp, Contracted
from a Mlcrosporon of the Cat: with Some Observations on the
Identlflcation of the Source of Infection in Ringworm. Cases by
Means of Cultures. A. D. Mewbokn.
3. Depressed Fracture of the Malar Bone, with Report of Three Cases.
STEWART Le Roy McCckdy.
i. Experimental Investigations with ROntgen Rays upon Living Tissue.
J Rddis-Jicinsky.
-5. Studies on Heredity. Raymond Wallace.
1-— Pathology and Treatment of Epilepsy.— Thomson
says epilepsy is a disease characterized by a sudden derange-
ment of the normal regulative inhibition existing between
cortical nerve centers, induced in the first instance by an
abnormal afferent excitation. He says the afferent origin of
epilepsy is no theory is proved by the multitude of instances
in which it is admitted that the disease is caused solely by
some afferent irritation. The afferent origin of epilepsy is not
Id the least controverted by the development of the disease as
the result of focal cortical irritation, such as by trauma and
tumor. The afferent is as much in the brain as anywhere else,
and epilepsy may begin with an afferent excitation starting
within the cranium just as it may begin with a similar excita-
tion starting in the intestine. The treatment should begin by a
cartful examination of the whole patient, and a thorough
search for some abnormal afferent irritation. A venous throm-
bosis in the meninges following such diseases as typhoid and
scarlet fever is not an uncommon cause of epilepsy. The
greatest area of reflex excitability in the body is in the region
of the epiglottis. The author has seen two cases of epilepsy in
which the convulsive seizures had been diminished in severity
by two applications of silver nitrate to the larynx. For many
years he has made use of the red pepper pack to the whole
body of the epileptic on the theory that such repulsive measures
turn aside the abnormal afferent impression. The bromids are
often carelessly administered to epileptics; the fact that they
must be continued long makes it necessary to exercise care to
avoid bromism. This may be done by promoting the general
health by proper hygiene, and by the administration of the
bromids in conjunction with phosphorus and codliver-oil. The
bromids also act well in combination with thecoaltar remedies,
as, for example, .065 gm. (gr. 1) of antipyrin with every .1.3 gm.
(gr. 2) of bromid. Chloral is useful as an adjuvant, but should
not be prescribed in larger doses than .(J.5 gm. (gr. 10). These
patients are especially prone to toxemia, particularly from the
intestinal tract. The author always prescribes intestinal anti-
septics .sooner or later, and insists that the patient eat very
sparingly of meat. Epilepsy characterized by several seizures
occurring close together, and then a long interval of immunity,
are very apt to be dependent upon intestinal toxemia. The
open-air treatment is recommended as earnestly for the epilep-
tic as for persons afflicted with pulmonary tuberculosis, [c.a.o.]
2.— Infection in Ringworm Cases.— Me whom reports a
case of ringworm of the face, and two of the scalp, contracted
from a microsporon of the cat. He gives some observations on
the identification of the source of infection in ringworm, and
states that differences of soil modify the clinical picture of skin
ringworm as well as the microscopic appearance of the fungus,
and that in the fluid of an herpetic vesicle the mycelium of a
microsporon may produce external grape like spores. He also
states that the yellow and brownish bands and the tangential
fringe on beer-wort agar can be used to identify the source of
infection in ringworm of the cat. [c.a.o.]
3.— Fracture of the Malar Bone.— McCurdy reports three
cases of fracture of the malar bone. To elevate such fractures
he screws a coat hook into the outer surface of the bone; this
gives a hold on the bone firm enough to permit its being pulled
from its position of impaction. By this method the operator
can determine accurately how much force is being made and he
has perfect control of the fragment, [c.a.o.]
4.— RSntgen Rays Upon Living Tissue.- Rudis-Jicinsky
discusses the effect of x-rays upon the living tissues and gives
the results of his experiments and the changes produced, show-
ing that we have to deal with a special inflammatory process, or
electrochemical inflammation, as a process of repair, where
radiotherapy is possible. The author exposed 10 guineapigs
and 10 rabbits to intense radiation daily, first for 10 seconds
and later for 10 minutes. The guineapigs began to lose their
hair after 20 exposures and in two cases there was necrobiosis.
After 34 exposures two rabbits showed very bad necrobiosis.
A study of the direct anatomic changes in the tissues exposed
showed the longer the low vacuum tube backed by a strong cur-
rent was in action the lower the resistance of the animal sank.
The bodies of two guineapigs were dissected. Degeneration
was found in the entire gray matter in the posterior tracts, and
in the posterior horns of gray matter; the spinal canal was
dilated by hemorrhages. Microscopic examination of the
destructive process showed a special inflammatory process
with a development of fibrous tissues; the walls of the blood-
vessels, especially the iutima, were thickened and the lumen
contracted; a thin layer of necrotic tissue was destroyed, as
were also the nerves, [c.a.o.]
5.— Studies on Heredity. — Wallace discusses the subject
of heredity and concludes that the process of cell growth and
differentiation is a function of geometric and physiologic posi-
tion, and the permanency of the advanced differentiation is a
function of the time it has endured. He also believes that the
transmission of resemblances and the appearance of variations
is dependent upon sexual reproduction, with its phenomenon
of maturation and the reaction of the developing cells to vari-
ous environmental influences, [c.a.o.]
Medical News.
November 22, 1902. [Vol. 81, No. 21.]
1. Obsessions; Fl.xed Ideas; Indecisions; Imperative Conceptions;
Abulias ; Phobias. Theodore Dilleb.
2. The Significance of the Terms Acute and Chronic. Allen J.Skith.
3. Neurasthenia. .Ioseph M. Aikin.
4. A Study of Sex Production in Man. Louis Kolipinski.
5. General Remarks on Nasal Obstruction. John A. Donovan.
1. — Obsessions. — Diller divides these into five classes : Of
doubt, of fear, of impulse, of miscellaneous ideas, abulias.
While frequently seen in neurasthenic states, many are not so
associated. Some arise from melancholia, others from hysteria
NOVRMBBK 29, 1902]
THE WORLD'S LATEST LITERATURE
(Ajcbkicak Meuicinb 869"
or physiologic degeneration, while others are seen in those
apparently normal. He presents 17 cases seen outside of
asylums. No hard and fast rules can be given as to treatment.
Tlie physical tone must be maintained by hygiene, massage,
ftlectricity and simple tonics, but mental treatment adapted to
the individual should have first place, [h.m.]
2. — The Terms Acute and Chronic— Smith illustrates
the uncertainty of definition found among lexicographers, and
suggests the following : Acute as applied to a pathologic pro-
cess indicates of such a disease that it runs a fairly regular and
limited eourse; such a course being frequently, although not
necessarily, attended by severity of symptoms, and the limita-
tion being possibly in recovery. Chronic may be applied in
conditions presenting no definite duration, more or less irregu-
larity in the presentation of symptoms, a variable severity of
symptoms, and ordinarily limited only by the death of the
patient. He is unwilling to accept the general classification of
Bright's disease as presented by Osier and others, who
attempt to consider all acute ca.ses under one form, and all of
chronic duration which involve the parenchyma under another
single heading. They have forced an artificial separation of
the early and late cases of parenchymatous degeneration (with
or without inflammatory combinations), and have grouped the
early cases of this degenerative condition with the nondegen-
erative acute form of Bright's disease on the one hand, and on
the other the later cases with the more serious, fatty degen-
erated and contracted cases. This conduces to unfavorable
result in the management. Acute and chronic should be applied
as indicating in the one variety a relatively hopeful prognosis,
and in the other irremediability apart from any question of
durationofoour.se or severity of symptoms, [h.m.]
4. — Sex Production In Man. — Kolipinski, from his obser-
rations of 192 families with a total of 1,170 births, concludes that
the parent of stronger will reproduce his or her sex first.
Will he defines as synonymous with decision, resolution and
determination. From his study of the families and births
under consideration he adduces the following facts : There are
more males born than females, 594 boys to 576 girls. Twin births
occur once in 80 to 90 single births ; there are more twin boys
than twin girls, and mixed twins are more numerous than
either. In the 1,170 births there were twins 15 times, or 1 to 78 ;
boys 6 times; girls 5 times, and mixed 4 times. Older fathers
produce more boys, and wives older than their husbands pro-
duce more girls. Prostitutes give birth to more boys. Jews
produce more boys than the people of the race or nation with
whom they live, [a.b.c]
5.— Nasal Obstruction. — Donovan says many colds are the
result of the action of certain toxins on the central nervous sys-
tem. This would indicate early and thorough elimination by
bowels, kidneys and skin. A high power of resistance to sud-
den temperature changes may be cultivated by cold batlis, or
by warm ones followed by cold sponging. The restoration of
the nasal chambers to perfect anatomic condition is of the first
and great&st importance. Straighten the soptum, if it is
required. Myles instruments for this is preferred in most
cases, though the knife, saw, Kyle's saws, and Ashe's cutting
forceps, are useful. For spurs use the saw, knife, or cautery.
Those near the floor may be effectively reached with Pynchon's
concave blade saws. For polypus the snare is preferable.
Enlarged turbinates are best removed, the lower with saw,
scissors, knife and snare. For the middle turbinate, Holmes'
scissors and the snare are preferred. For hypertrophied tissue
puncture along the periosteum is indicated, thus saving the
normal surface, [a.b.c]
Philadelphia Medical Journal.
November 22, 190H. [Vol. x, No. 21.]
1. Amputation Through the Shouldcr-Joint as a Routine Trocedure In
Axillary Carcinoma, Secondary to Mammary Tumors, John B.
ROHEKTS.
2. Radical Cure of Hernia; with Report and Analysis of 116 Cases.
Fkank Martin.
3. Models for Demonstrating the Elementary Physiology of Vision.
B. Alex. Ranoall.
4. .\ (iiBc of K.xdphlluilmlc Oolter, I'resenting Home Unusual Features.
Chahles H. I'UTTS.
5. What Class of Pulmonary Patients Do Well In Colorado? W. A_
Campbell.
6. Mental Symptoms of Xeuraslhenia. W. K. Walker.
1. — Amputation of the Arm for Carcinoma of the Mam-
mary Gland and Axilla.— Roberts earnestly advocates ampu-
tation through the shoulder-joint as a routine procedure in
the treatment of axillary carcinoma, secondary to mammary
tumors. He details the case of a married woman of 58, who
died from shock two hours subsequent to the operation. The
subclavian artery and vein should be ligated above the clavicle
before the disarticulation is done, then the arm should be cut
off and the lymph nodes and other affected tissues removed. A
flap from the outer aspect of the arm may be retained to cover
the axilla and chest, if such integument be needed, [p.ch.]
2. — The Radical Cure of Hernia. — Martin firmly believes-
that every case of nonstrangulated hernia can be operated upon
without danger to the patient and with an almost certain pros-
pect of permanent cure. In competent hands the mortality is
less than 5%, or practically nil in uncomplicated cases. At the
present time with a mortality almost nil and the possibility of
a relapse exceedingly slight, and with an almost certain pros-
pect of permanent cure, patients are more willing to submit to-
operative treatment than formerly ; thus obviating the incon-
venience and irritation of mechanical devices and the danger of
strangulation which is ever present. He reports 116 cases of
hernia upon which he has operated by a procedure differing
from the Halsted operation, only in that the internal oblique
and transversalis muscles are not cut. There have been no-
recurrence in the cases so far as he has been able to ascertain.
In all but two cases nonabsorbable sutures were employed —
silk and silver wire. Ninety-five of the cases were inguinal in
type. Of these 73 were nonstrangulated and 22 strangulated ;
all of the former recovered and five of the latter terminated
fatally. Twelve of the ca.ses were of the femoral type. Of these
two were nonstrangulated and 10 strangulated ; all of the
former recovered and one of the latter died. Eight were um-
bilical. Of these five were nonstrangulated andthree strangu-
lated ; all of the former recovered and one of the latter died.
[p.o.H.]
3. — Models for Demonstrating the Elementary Physi-
ology of Vision. — Randall considers that the working model
has the great advantage over diagrams for demonstrating
optic lessons, inasmuch as it avoids the confusion of multiplied
lines indicating the primary and secondary directions of rays
of light, and shows with greater simplicity the fulness of
demonstration made with actual light beams and lenses, while
the size can be whatever is desired to make it readily discernible
in the largest class-room. The article is profu.sely illustrated.
[F.C.H.J
4. — A Case of Exophthalmic Goiter.— Potts details a case
of exophthalmic goiter in a male of 39, presenting the following
unusual features : A marked ankle clonus, which disappeared
as his condition improved, and attacks of either partial or com-
plete unconsciousness. Marked improvement followed the use
of sodium phosphate and the treatment of a chronic hyper-
trophic rhinitis, [f.c.h.]
5.— See American Medicine, Vol. IV, No. 17, p. 047.
6.— Mental Symptoms of Neurasthenia. — Walker empha-
sivies the following points: Every case of neurasthenia pre-
sents mental symptoms in some form ; the difference between
neurasthenia and certain forms of mental disease is largely one
of degree; in fundamental nature they are the same, i. e., a
pathologic lowering of the psychic function-s, having the same
etiology and, so far as we have been able to ascertain, the same
underlying pathology of nutritive change in nerve cells.
Viewed in this light the mental symptoms assume greater sig-
nificance, in many cases leading us to anticipate a greater degree
of defectiveness to follow, depending upon the duration and
virulence of the exciting causes, and the nature of causal
poisons and vulnerability of individual tissue. When they are
encountered in one of previous known mental weakness, insta-
bility or eccentricity, or In one of insane ancestry, they should
lead to energetic measures, not only remedial and recon-
structive, but to the ultimate regulation of the environment
and conduct of the patient in order that more serious develop-
ment may be prevented, [f.ch.]
870 AlUBIOiLN UXDTOIirSJ
THE WORLD'S LATEST LITERATURE
[NOVBMBBB 29, 1902
ClilNICAIi MEDICINE
David Biesman A. O. J. Kelly
KDITORIAI, COMMENT
Myelopathic Albiiinosiiria. — In a recent issue of
the journal we took occasion to discuss the nature of the
Bence-Jones albumin and myelopathic albumosuria with
especial reference to the investigation, of Simon ' concern-
ing the nature of the albuminous body that appears in
the urine. More recently the literature of the subject
has been enriched by several contributions — one by
Bradshaw ' being of some interest from a clinical point
of view. Bradshaw points out that as medicine pro-
gresses nosology advances along two different lines :
along the one we are led to recognize that morbid con-
ditions apparently diverse are essentially identical,
whereas along the other we come to separate morbid
processes that have been regarded as identical. This
finds its practical application in the separation of mul-
tiple myeloma from osteomalacia by Rostosky in 1873,
and by the more recent separation of cases of multiple
myeloma into two classes — the one associated with the
other without a peculiar albuminous substance in the
urine. It is to the former that the term myelopathic
albumosuria is applicable. The changes in the skeleton,
which consist of an invasion of certain bones by a soft
mass of newgrowth that replaces the proper bony struc-
ture, possess a special importance in some cases in that
for some time they may be confined to the interior of
the bones, being limited by the external compact tissue,
whence there occurs no obvious disorder of the bones to
suggest the cause of the patient's complaints. The
onset of the disease is insidious, the earliest manifes-
tations being connected with the condition of the
bones, or with the urine. The bones most likely
to become involved are the sternum, ribs, and ver-
tebral column— the pelvis, long bones, and skull
being much less frequently implicated. There can be
little question, however, that although commonly the
condition of the bones first attracts attention, the
peculiar reactions of the urine are present for some time
before external evidences of disorder of the bones. This
was the fact in several cases reported — by Bradshaw,
Kahler, etc. In some cases pains in the back and side,
suggesting rheumatism or neuralgia, progressive weak-
ness and anemia, are the earliest subjective symptoms.
The disorder runs a relatively acute course, death result-
ing usually within a year from the time of the onset of
symptoms. The manifestation of the disease, regarded
by Bradshaw as pathognomonic, consists of the occur-
rence in the urine of a proteid resembling albumin, but
differing from it in certain particulars, of which the fol-
lowing are the most obvious: (1) It coagulates at a
remarkably low temperature— 58° C. ; (2) the coagulum
is to a great extent dissolved at the boiling point and
reappears on cooling ; (3) the coagulum which forms on
treatment with cold nitric acid also dissolves on boiling
and returns on cooling ; and (4) it is readily coagulated
by hydrochloric acid. It is unnecessary to revert to the
discussion of the solution of the coagulum at the boiling
point— a solution regarded by Simon and others to be
dependent upon the presence in the urine of some other
substance or substances— probably the salts. Recently
Boston ' has suggested a new method for determining
the presence of this albumose— a method that depends
upon the presence in the substance of loosely combined
sulfur, and a method that merits further investigation.
Our knowledge of the disorder is being advanced, but
we are still ignorant of the exact nature of the peculiar
substance that occurs in the urine— whether it is, as
believed by Simon, a substance closely related to the
globulins, if it is not really a globulin itself, or whether
'American Journal of the Medical Sciences, cxxlil, 939, 1902.
^ Ijancet, il, 929, 19i>2.
' American Journal of the Medical Sciences, cxxlv, 567, 1902.
it is a substance sui generis, we do not know. Nor are we
certain of the source of the substance, although the evi-
dence at hand warrants the belief that it results from
abnormal metabolic activity related with the cells of the
newgrowths in the bones.
REVIEW OF tlTERATUKE
Carcinoma Cured by Injections of Cancroin. — Adam-
kiewicz' reports several cases of cancer of the tongue, larynx,
esophagus, stomach and breast. These patients were treated
with injections of his serum called cancroin. All recovered and
showed no recurrence after the treatment, [w.e.k.]
Kxperiences with tlie Use of Turpentine and Allied
Remedies in Perltyplilitis. — Mayer ^ believes that turpentine
and analogous remedies, given by the mouth and applied
locally, are useful in perityphlitis (appendicitis). He gives
three-drop doses, two to (our times a day, and finds that these,
combined with local applications of turpentine, promote the
absorption of inflammatory exudate. He believes that the
primary action of turpentine depends upon its leukotactic
properties, by reason of which it causes an afflux of leukocytes
to the endangered area, and that this leukocytic exudate acts
as a protective agent, [d.r.]
The Parasitic Nature of Certain Calcareous Degener-
escences, of Some Neoplasias and of Special Dystrophies
of the Skeleton. — Charrin and Delomarre, in a communication
to the Acad6mie des Sciences of Paris, announces' the dis-
covery that to the presence of the mold Oosporn guiguardi is
to be ascribed the deposition of carbonate of lime in the connec-
tive tissue of the walls of many cystic tumors and in skeletal
nodosities, [c.s.d.]
The Use of X-rays in Cancer, Iiupus, and Hodgkin's
Disease. — F. W. Hett * claims the following advantages : It is
painless ; it leaves small scars, thus doing away with disfigure-
ments ; it destroys diseased tissue, but not the normal ; it
relieves pain ; it removes odor ; the patient is saved the dread
of an operation, [f.c.h.]
Remarks on Barlow's Disease.— H. Neumann ' discusses
the relationship of this disease to the absence of fresh food,
with special reference to the use of sterilized milk, [c.s.d.]
Unrecognized Intestinal Obstruction. — Surmont* re-
ports the case of a woman, who was in the fourth month of
pregnancy and was suddenly seized with violent pain in
the right side; a diagnosis of gallstone colic was made.
Eighteen days later symptoms of obstruction manifested them-
selves associated with a large mass, the size of a man's fist,
on the left side of the abdomen. At this point was thought to
be the seat of obstruction. The obstacle disappeared at the
moment when the operation was about to be performed.
Bloody stools showed themselves and in due time a fragment
of intestine 94 cm. in length was expelled spontaneously. It
was at first thought to be mucosa, the result of a colitis. An
abscess of the abdominal wall pointed at the level of the sig-
moid flexure three weeks afterward, and necessitated an opera-
tion. Death occurred three days later as the result of pneu-
monia. The case is noteworthy on account of the length of the
eliminated piece of intestine ; on account of the absence of
symptoms of obstruction at the beginning of invagination,
and lastly on account of the existence of the symptoms on the
left side, although the ileum was invaginated into the cecum.
[E.L.]
The Influence of Alcohol on the Secretion of Gastric
Juice. — With the object of securing data to confirm or oppose
the general tradition that the ingestion of liquids more or less
alcoholized facilitates digestion C. A. Pekelharing' has under-
taken a series of experiments on animals, from which he con-
cludes that the lavage of the stomach with a bfo alcoholized
fluid stimulates the secretion of gastric juice; but that the
proportion of pepsin is diminished and the proportion of hydro-
chloric acid increased. The action of the alcohol is not due to
I Berliner klinische Woehenschrlft, June 16, 1902.
« Milnchener mediciniache Woehenschrlft, August 12, 1902. <
sija Semalne Mfidlcale, July 30, 19UA
* Dominion Medical Monthly, August, 1902.
' Deutsche med Woehenschrlft, August 2S, 1902.
« L'Echo Mfidlcale du Nord, July 20, 1902.
' Nederl. Tljdschr voor Ueneesk., April 19, 1902.
NOVEMBBB 29, 190i]
THE WORLD'S LATEST LITERATURE
JAMERicAN Medicine 871
the stimulus on the glands by direct contact but is indirect,
being the result of absorption and excitation of the nervous
system. Alcohol in moderate quantities may be said to have a
beneficial influence on digestion, though its advantages are offset
by the danger that the acid hypersecretion and the relative
diminution of pepsin will in the long run determine a chronic
inflammation of the mucous membrane of the stomach, if not
indeed an insufficiency in the digestive action of the gastric
juice. [C.8.D.]
DeRenerated Forms of Pneumococcl In Pleuritic
Exudates.— Michaelis ' reports four cases of pleurisy in which
the exudates showed degenerated forms of pneumococcl. He
observed 10 out of 24 other cases of pleurisy which presented
the same condition. These degenerated forms consisted of
irregularly outlined rods with pale centers and club-like ends.
Some of the microorganisms were so changed that it would
have been impossible to recognize them but for the presence of
the different stages in the transformation. They appeared in
isolated groups and grew on none of the ordinary culture
mediums. Injections of this organism in rabbits and mice pro-
duce no infection, except when the exudate used had become
purulent. Michaelis concluded that more pneumococcl are
found in the serous than in the other exudates, and that the
degenerated form may appear in the socalled sterile tuberculous
exudates, [w.e.r.]
The Skin Reflexes In Hysteria. — The general opinion is
that the skin reflexes in the anesthetic form of hysteria are
absent, while the tendon reflexes — e. g., the knee-jerk— are
present. Steiner^ reports one case, however, in which the cre-
masteric, which is a skin reflex, was preserved and the knee-
jerk absent. He concludes that, contrary to the prevailing
view, the disappearance of the knee-jerk does not exclude
hysteria when the cremasteric reflex is preserved, [d.b.]
Atony of the Stomach. — Atony of the stomach, a condition
in which the stomach's muscular tone is reduced, is, according
to Pick,' better named myasthenia or hypotonia. It is brought
on by repeated overloading of the stomacli, but symptoms arise
only when the stomach does not empty itself in the normal
length of time. The disease is usually acquired, though a ten-
dency to it may be inherited. Among the diseases and condi-
tions producing it are: Catarrhal gastritis, longstanding
exhausting diseases, peritonitis, mechanic distention, hernia,
emaciation, obesity, carcinoma of pylorus, etc. The symptoms
may be gastric, Intestinal, nervous, neurasthenic, circulatory,
etc., depending chiefly upon the gravity of the motor insuf-
ficiency. Depression of spirits and circulatory symptoms are
very frequent, leading the patient to suppose himself afflicted
with cerebral and cardiac disease. The diagnosis is best made
by auscultatory percussion, a Boas or Riegel test-meal. The
treatment consists in the removal of the cause, the wearing of
abdominal bands, massage, gymnastics, electricity, hydro-
therapy, the overcoming of autointoxication, the regulation of
the diet, the limitation of fluids, and ordering such drugs as
creosote, resorcin, sodium bicarbonate, etc. He recommends a
study of each individual ca.se on these lines, [e.l.]
Bovine and Human Tuberculosis.— Max Wolff* de-
scribed the successful outcome of a series of experiments
undertaken to demonstrate the possibility of transmitting
human tuberc\ilosis to cattle, [o.s.n.]
The Pathogenic Agent of Whoopingcough and Its
Serotherapy.— The microorganism of whoopiugcough is de-
scribed t)v Leuriaux ' as a little baton, short, somewhat thick,
perceptibly ovoid in form with rounded ends. It usually occurs
in groups in the secretions of the respiratory tract. The method
of isolation, manner of culture and the process of securing the
serum are all briefly given. Leuriaux has used this serum in
tifi cases of whoopiugcough with alossof only 5. It usually works
;i I'ure in from five to eight days, if administered at the inciplency
iltheattack. The serum should be injected so soon as the diag-
nosis is certain; the earlier, the more promptly the symptoms
will subside. The quantity used varies with the age; for infants
' Berliner kllulschc Wonhenschrlft. May 12, 1H02.
' Miliichcner medlclnlscbe Wochcnsehrlft, July 29, 1902.
'Allg. Wlcn. med. ZIk., liXK, p. 79.
* IX'UtHcho inert Woohcnsclirlrt, August 7, 1902.
' liU Hemulne Meilicnie, July 16, 1902.
from 6 months to 2 years, 5 cc. usually suffices ; at a greater age
10 cc. may be given as a dose. If administered in the early
stages of the disease one dose is generally sufficient, but a sec-
ond and third may be given if the symptoms abate very slowly.
It is not necessary to associate this treatment \yith any other
medication, though sometimes a slight emetic may precede it
with advantage. The child should have general hygienic care
and be protected from rapid changes of temperature. [w.K.]
Unclean Finger Nails a Cause of Tuberculous Infection
in Children.— Preisich andSohiitz' examined the finger nails
of 66 children and found the bacillus of tuberculosis in
14. The examinations were conducted during the winter
months when the children spend most of their time indoors.
The dirt removed from the finger nails was examined by stained
preparations and by injecting guineapigs. Most of the latter
died because of a mixed infection so that tuberculosis didn't
have time to develop. All but 5% of the patients gave a history
of tuberculosis in the family, and the casas in which the bacilli
were found had brothers or sisters suffering with tuberculous
lung, gland or bone disease. The authors believe that children
may carry the infection from their fingernails to their mouths
or noses and thus cause abdominal or pulmonary tuberculosis.
They also believe that decayed teeth are a source of tuberculous
infection in children, [w.e.r.]
A Case of Tuberculous Meningitis. — NothnageP dis-
cusses the various forms of meningitis, difTerentiating between
four groups of acute cerebrospinal meningitis, which, however,
do not differ much from each other in regard to symptoms.
1. The epidemic form, the cause of which is the Diplococcus
intracellularis meningitidis Weiehselbaum. 2. The tubercu-
lous type, which may be cerebral or spinal. 3. The type pro-
duced by the Diplococcus pneumonia;. 4. Rare cases in which it
occurs in the course of other infectious diseases. The latter
ditTer from the other three types in that the meningeal symp-
toms are always secondary to the other symptoms. Ho reports
a case of the tuberculous spinal variety, the history and initial
symptoms of which made it appear at first like acute gastritis.
A few days later the gastric symptoms disappeared in part ; the
patient complained of stiffness of neck and exquisite pain on
moving head. Pressure over spine beginning at lowest cer-
vical and extending to lumbar vertebras was very painful.
Hyperalgesia of skin was noted, especially over thorax.
The diagnosis of spinal meningitis based upon these symptoms
was confirmed by lumbar puncture. From the fluid tubercle
bacilli were isolated, [e.i,.]
Hemoglobinuria of Muscular Origin. — The researches
of .1. Camus and P. Pagniez' have demonstrated that muscular
tissue plays a role in the production of hemoglobinuria. The
intravenous injection of an isotonic solution of musclejuice pro-
duces this symptom, the dosage being much less than that re-
quired in the useof globular hemoglobin. The muscular lesion
produced by forced injections (1.50cc. in'lO seconds) of waterinto
the musclesof the thigh of a dog is followed by the appearance of
hemoglobin in the blood. This form of hemoglobinuria differs
from that produced by the destruction of the rod blood-cor-
puscles. In that it is not accompanied by hemoglobinemia,
whence it is concluded that the hemoglobin of muscle juice
traverses the kidney much more readily than that of the blood,
or that there exists in muscle juice substances which acting
on the kidney facilitate the passage of small quantities of hem-
oglobin. These substances resist a temperature of S0° C. and fil-
tration, [o.s.n.]
On the Function of Brunner's Glands. — Qlaessner,*
who has made a study of the peptic, trypsic, distaste and steap-
sic ferments of the duodenal mucous membrane, finds that the
glands of Brunner secrete a pepsin, while those of Lieber-
kOhn furnish a diastasic ferment, [c.n.d.]
Typhoid Without Intestinal Liesion.- Arthur Blumen-
thal' describes a case of typhoid infection without any specific
intestinal lesion. He refers to cases described by Ducazal, v.
Banti, Kuhmann, and Mennier. [c.s.u.]
> Berliner kllnlKche SVochenschrin, May 12, 190.'.
•Allg. Wicn. inert. Zt«., 1902, p. 1.
"1« Hemalne MMlcalc, August 20, 1902.
' Bettrftge zu. CliemlRlscben Pbyalologlc und PHtliologle 1. 1., f. M, p.
105,
> Deutsche med. Wochenscbrlft, August?, 1902.
872 AJIKRIOAir MBDIOIIfB
THE WORLD'S LATEST LITERATURE
[NOVEMBKB 2*, iy02
GENERAL. SURGERY
Martin B. Tinker
B. Craig
C. A. Orr
BDITOKIAL COMMKNT
Deformities Caused by Shoes.— The average per-
son would be extremely sensitive to sucii deformity as
congenital clubfoot, but it is surprising how many are
constantly wearing shoes which cripple and deform their
feet to an extent almost as great as that seen in the less
extreme congenital deformities. Moreover, the pain
which many persons suffer from flatfoot resulting from
wearing improper shoes frequently almost incapacitates
them from work. A number of articles liearing on this
subjec^t have appeared recently. Bradford' disc'usses
shoe deformities at some length and in a number of
illustrations shows the common deformities and the
forms of shoes which are usually responsible for them.
To correct such acquired deformities various misapplied
mechanical supports have been often suggested. But as
H. A. Wilson^ says: "The natural human foot best
performs its functions when free from restraint and it
can be quickly crippled into inefficiency by high coun-
ters, corset shoes, arch raisers, wedges and elastic
anklets. When burdened by misapplied mechanics the
foot is rendered weak and susceptible to injuries rather
than strengthened." The most thorough discussion of
this subject which has appeared recently is by Sampson,'
who shows the importance of footwear which is adapted
to the peculiarities of each individual foot and suggests
some ingenious devices for maintaining the foot in its
natural position after it has been weakened by wearing
improper shoes. The broad-toed, commonly called "com-
mon sense," shoe he shows may be as bad in its effect
upon the foot as many of the more pointed shoes. All of
these writers emphasize the importance of proper foot-
wear for young children which does not cramp or hamper
the movements of the foot nor hold it in a position to
produce hallux valgus, which is always an acquired not,
as commonly believed, a congenital deformity. Brad-
ford insists on the necessity of shoes suited to the occu-
pation of the wearer, but seems to believe that fashion
will always dominate in such matters. This need by no
means be true, for there have been very evident improve-
ments in the character of footwear within the past
decade and no one would be more susceptible to argu-
ment in favor of shoes which would permit a springy
elastic natural gait than the more intelligent class of the
fashionable set, many of whom now wear improper
shoes because not thoroughly appreciating the deformi-
ties and unnatural gait which may result therefrom.
REVIEW OF LITERATURE
The Liorenz Method of Redaction of Congenital Dis-
location of the Hip.— Ochsuer * describes the results obtained
in a case of congenital dislocation of thie hip by the method of
Lorenz. The procedure is divided into four stages, reduction,
reposition, formation of acetabulum and restitution of function.
These are not separate stages so far as time is concerned. In
accomplishing reduction the first condition is general anes-
thesia, the pelvis is held firmly and steady traction is applied
to the limb until the upper border of the great trochanter is on
a level with Nglaton's line. In younger children this miybe
accomplished by manual traction, bvit in adults unless a tackle
is used, several assistants are necessary. If reduction is very
difficult it is necessary to interrupt It at intervals of ten minutes.
So soon as the trochanter is down to Nglaton's line the head is
placed in the acetabulum. This Is the most difficult part of the
procedure, and can only be accomplished by steady manipu-
lations. Sudden jerks are apt to cause fracture. The hip should
be strongly abducted, so far as a right angle, the pelvis is then
steadied by an assistant, the thigh flexed to a right angle and
rotated slightly inward. With one hand the operator presses
' New York Medical Journal, 1902, Vol. Ixxvi, p. 661.
2 Annals of Surgery, 1902, Vol. xxxv, p. 868.
'Am-rican Medinue, 1902, Vol. Hi, p. 104.
■• Medicine, 19. 2, Vol. vl, p. 816.
on the trochanter and with the other makes steady traction
forward and at the same time attempts slow abduction. The
head of the femur gradually slips over the rim into the acetabu-
lum with a distinct thud. Other symptoms of accomplished
reposition are distinct lengthening of the leg, development of a
fulness in the groin, disappearance of the head from the dor-
sum of the ilium, and a tenseness of the hamstring tendons. To
make the reposition stable, the thigh is rotated outward with a
boring motion so that the anterior capsule is stretched and the
acetabulum deepened. The weight of the body in walking will
greatly aid the formation of a satisfactory joint, hence it is
necessary to place the limb in a plaster cast. When both hips
are dislocated there should be an interval of about one year in
the reduction. Ochsner presented a specimen of a pelvis
obtained from a girl of 7 years, who had had a double reduction
three years previous. The pelvis was of normal size and shape
and the head of the femur was in a normal position. The only
difference he was able to detect in comparison was that in the
normal pelvis the Y-cartilage seemed a little nearer the inferior
spines. The head of the femur was a little larger than normal,
not perfectly globular, and the whole surface was covered with
a smooth layer of cartilage. The evidence from this case proves
that there may be an almost perfect anatomic result, [h.c.w., jr.]
Cholelithiasis.— Irish 1 states that frequent postmortem
finding of gallstones which had produced no symptoms demon-
strates that they may remain in the gallbladder for an indefi-
nite time without causing harm. In general the diagnosis
from other affections is simple, but in acute inflammations the
diagnosis from appendicitis is often difficult. A case in illus-
tration is detailed. Acute infective cholecystitis is really the
only condition that is liable to be mistaken for appendicitis.
Operative technic is given. Suture of an opened cystic duct is
desirable, but the lack of closure probably makes but little
difference. Irish has not attempted suture in three cases, and
believes that recovery was not less rapid and satisfactory.
Suture of the common duct is of much more importance, but
not absolutely necessary. Immediate operation is advised in
(1) acute infective cholecystitis; (2) obstruction of cystic or
common duct; (3) in distention of the gallbladder, unless due
to cancer. Operation is also indicated when attacks of biliary
colic have been so frequent and severe as to impair the genera)
health and when several severe attacks of colic have occurred
at short intervals. These recommendations are made because
all the dangers, accidents and ditfleulties in gallstone disease,
with few exceptions, arise from delay, [a.g.e.]
Unusual Cases of Appendiceal Operations Occurring
in the Earlier Years of Surgical Intervention, with Brief
Clinical Histories.— Henry O. Marcy ' details seven cases, one
of which is the operation he performed in 1886 upon his former
assistant, the late Dr. Samuel L. Nelson. Although not aware
of it at that time, he is now led to believe that the case of Dr.
Nelson is the first on record of operation between the attacks.
The credit of it, however, he attributes as much to the inductive
reasoning on the part of Dr. Nelson as to himself. Although
one of the first to operate for appendicitis. Dr. Marcy claims
that at that time he was comparatively inexperienced, and the
whole subject in the minds of the general profession was still
subjndice. [f.c.h.]
Diagnosis and Frequency of Congenital Inguinal
Hernia.— Goldner' records the characteristics of congenital
inguinal hernia, but in particular has he studied the occurrence
and frequency in such cases of subserous lipomata, hyper-
trophy and intactness of the cremaster muscle and the presence
of the entire great omentum in the hernial sac. He reports 701
hernias operated on in men, of which 372, or 53%, were found to
be congenital; 71 in women, 40, or 56.3%, were congenital. In
45 cases were found subserous lipomata, in 26 hypertrophied
undivided cremasters, in 2 the entire great omentum was found
in the hernial sac. Some of these cases showed no other signs
of congenitality of the hernia, [e.l.]
A Report of Two Cases of Spinal Surgery.- The follow-
ing is one of two cases reported by Francis M. Harrington.' A
male, aged 11, was shot in the neck with a 38-caliber bullet-
1 Yale Medical Journal, November, 1902.
^American .Journal of Surgery and Gynecology, October, 1902.
3 Wiener klinlsche Wochenschrlft, Oetot>er 9, 1902.
November 29, 1902]
THE WORLD'S LATEST LITERATURE
(American Mkdicinh 873
The ball entered SJ cm. (IJ inches) to the left of the median
line, on a level with the pomum adami. When admitted to
the Pawtucket Hospital he was in shock, and almost exsan-
guinated. The arms and legs were paralyzed. The hemor-
rhage was due to injury of the internal jugular vein. The
.bullet was found embedded in the fourth cervical vertebra.
An incision was then made along the posterior border of the
sternomastoid muscle, and the bullet carefully dislodged. After
accomplishing this the respiration and pulse became so embar-
rassed that further procedure was postponed until the m xt
day. The latter incision was then enlarged and the injuad
vertebra explored. The superior articulating surface of the
fourth vertebra and its lamina were found pressing upon the
cord. There were numerous small pieces of bone found lying
in the wound. The latter were removed, the articulating poi-
tion of the bone carefully withdrawn and the lamina pried up
from the cord. With the exception of a partial paralysis of the
left arm the patient made a perfect recovery, [f.c.h.]
GastropIicatlon.^Banks ' reports the case of a man of 36
who had been a cavalryman and a heavy drinker. His
stomach was much dilated. Gastroplication after the method
of Weir, of New York, was done. Some 2} years after the
operation the man was well and had gained in weight. Of the
operation in general, he says : " The operation will clearly be a
failure if there is any obstruction at the pyloric sphii^ter, and
so the existence of this or its absence is the very first thing to be
ascertained so soon as the stomach is pulled out. Perhaps it is
wise not to make any incision in the stomach for this purpose,
owing to the danger of hemorrhage. The best way is to in vagi-
nate the distended stomach at a point within such a distance of
the pylorus as will permit the invaginating finger, covered by
stomach wall, to go through the sphincters. If it does so easily,
there cannot be pyloric narrowing. If this should clearly
exist, gastroplication must be useless, and either pyloroplasty
or gastroenterostomy should be done. There is one satisfactory
feature about gastroplication ; it is a very safe operation, being
little more serious than a mere exploration of the stomach, and
it is very easy to do. If it can be shown to be a permanent
cure, and not a mere temporary relief, it will prove to be a very
useful operation in appropriate cases." [a.b.c]
A Case of Habitual Gonorrheal Urticaria.— Orlipski '
reports the case of a man who had three distinct attacks of
gonorrhea within a short time, each one associated with violent
paroxysms of itching, and formation of hives all over his body.
No treatment was ordered for the eruption, but it disappeared
each time as the gonorrheal discharge diminished, [e.i,.]
The Peripheral Theory of Nerve Regeneration.— While
not discarding the central theory, Fleming' was converted to
the peripheral theory through success in getting paraffin sec-
tions of nerves to stain by Stroebe's method. Experimental
sections taken from the peripheral end of a divided sciatic in
rabbits showed marked regeneration. In the central end of
one divided nerve old neurilemma sheaths were seen greatly
distended by young axis cylinders, suggesting central neu-
rotization. Some specimens appeared to show actual division
of the preexisting axis cylinders. If we accept the neuro-
blastic theory of regeneration, may not that which occurs in
peripheral neuritis be simply an excessive degree of what is a
normal process ? Fleming is the first to describe this regene' a-
tion in neuritis according to the peripheral theory. We must
look for it in the region of the fine fibers. All these are medul-
lated, and therefore there is a gap between the axis-cylinder
and the nucleus. In the earliest stages the young axis-cylinders
are closely applied to the side of the nucleus of the neuroblast,
but later they become myelinated, and are with difficulty differ-
entiated from the fine fibers, except by two characteristics : the
young axis-cylinders are more wavy in outline, and there is
always associated with the possibility of regeneration the pro-
liferation of neurilemma nuclei, swollen and oval, rather than
long and slender in shape, [h.m.]
Accessory Pancreas. — Nicholls • reports the case. Ne-
cropsy was performed on the body of a youth dead from lum-
1 British Medical .roumal, November 1, 1902.
- MOnchener incrticlnlHche Wochenschrift,, October?, 1902.
'ScottlNli iMcdical mill Snrelcal Journal, September, 1802.
' .Montreal .Medical Journal, December, 1900.
bar caries. Just where the duodenum pierced the peritoneal
covering to become the jejunum there was a small flat nodule.
This was situated at the lateral border of the gut on the same
side as the pancreas. The nodule was roughly oval in shape
and measured 1.5 cm. by 1 cm. (J inch by J of an inch), and had
no connection with the normal pancreas. Microscopic exami-
nation showed it to consist of distinct pancreatic tissue. No
duct was discovered, but from the very healthy and normal
appearance of the cells, it was believed to be functionating,
and therefore provided with a duct. It was distinctly lobulated
and covered with normal peritoneum. The nodule was believed
by the author to have been originally one with the normal pan-
creas, but in the process of fetal development it became
separated, [a.b.c]
A Case of Bilateral Paranephritic Abscess.- A patient
of Piltz ' developed some time after an irregular influenza pain
in the region of the left kidney. A few weeks later an abscess
pointed externally and was opened. Within amontli a similar
condition was found to exist over the right kidney, requiring
operation. After this recovery was rapid and complete, [e.i,.]
GYNECOIX)GY AJfD OBSTETRICS
WlLMBB Kbuskn Frank C. Hammond
REVIEW OF LITERATURE
Potassium Chlorate as a Remedy for Fetal Death In
the Late Months of Pregnancy. — Upwards of half a century
ago Sir James Y. Simpson introduced the use of potassium
chlorate in the treatment of cases of habitual death of the fetus
in the later months of pregnancy in non-syphilitic cases. In
such instances the placenta is markedly degenerated and the
purification of the fetal blood is interfered with. Jardine^
reports five cases in which this drug was given continuously,
10 grains 3 times daily after meals, during the last three or four
months of pregnancy with very satisfactory results. In all
these cases there had been a previous histor.v of two or more
stillbirths, or premature death of the fetus; but under the
potassium chlorate treatment living children were delivered at
full term, [w.k.]
Intraperitoneal Hemorrhage Incident to Ectopic Ges-
tation,— CuUingworth' divides intraperitoneal hemorrhages
into two classes, diffuse and encysted ; he gives the diagnostic
symptoms of each and their etiology, the former and more
dangerous usually following tubal rupture while pelvic
hematocele ordinarily is the result of bleeding from the mouth
of the tube. It is during the earlier weeks when the abdominal
opening of the tube is still patulous that a hematocele is most
apt to be formed ; but under the pressure of recurrent hemor-
rhage, or any undue strain or from too strong pressure at the
time of examination, the sac may give way and the encysted
hemorrhage be suddenly converted into the more dangerous
diffuse form. CuUingworth especially emphasizes the impor-
tance of correct diagnosis. He adds that in scientific medicine
the first essential is accuracy of diagnosis without which all
treatment is haphazard and unscientific. Gynecology is
becoming more and more surgical and this is all the more rea-
son why medicine should keep a hold upon it, to exercise a
wholesome restraint upon its surgical enthusiasm, and to con-
tinue to inspire it with that reverence for accuracy of diagnosis
which otiierwise it might be apt to lose, [w.k.]
Neurasthenia, Hysteria and Abdominal Section.—
Stuart Nairne' thinks that there is almost invariably some
physical cause for neurasthenia or hysteria, though in many
cases it is so obscure that it escapes observation. One physical
condition which is usually present wherever neurosis presents
clinical symptoms is a rigid uterus, probably due to some
pathologic lesion of the cord in the lumbar region. This
accounts for the fact that patients are sometimes cured by
application of electricity or somecounter irritant applied to the
spine. In case of rigid uterus in which these methods fail he
advocates hysterectomy, and cites several cases whose history
confirms his view, [w.k.]
' MiliiehcniT inedlclnlKcho Wochcnschrlft, October?, i902.
"British .Mccliciil Journal. Oct. 11, IIKB.
ajjaneet, Novembers, 11)02.
874 AVBRIOAir HbdioineI
THE WORLD'S LATEST LITERATURE
[NOVBMBEB 29, 1902
TREATMENT
Solomon Solis Cohbn
H. C. Wood, Jr. L. F. Applbman
REVIEW OF LITEBATCRE
Solution for Stimalatlng Perspiration.— The Bulletin
General de Thfrapeutique, Vol. cxliii, No. 9, 1902, page 352, rec-
ommends 3 to 6 dessertspoonfuls of the followine solution dally
to promote cutaneous secretion in Bright's disease and in
threatened uremia :
Pilocarpin hydrochlorate . . I 01 gram ( h grain)
Mucilage of acacia 93 | 3 grams (3J ounces)
The quantity of pilocarpin thus administered, although
small, is sufficient to stimulate the activity of the skin without
causing the disagreeable eflfects sometimes produced by larger
doses of the drug, [l.p.a.]
Tetanus Following Gelatin Injections.— Margoniner and
Hirsch' utter a note of warning concerning the hypodermic
administration of gelatin as an antihemorrhagic. They have
collected seven cases of tetanus, including two of their own, fol-
lowing the injections. In several of these cases abscesses had
developed at the seat of injection. They conclude that the
methods ordinarily employed for the sterilization of gelatin solu-
tions are inefficient. Their method is to dissolve the gelatin in
warm water, and steam at 100° C. is forced through the solution
for an hour. Even after this process they had several abscesses
to occur at the point of injection. [I think that three repeated
boilings would be a far simpler and more effective means of
sterilizing gelatin solutions. — H.o.w.]
Treatment of Tuberculous Serofibrinous Peritonitis
and Pleurltis. — Mainof reviews the history of the treatment
of tuberculous peritonitis and pleurltis by lavage with very hot
sterilized water introduced by means of a paracentesis needle.
The following directions are given by Castaigne for performing
this operation: The solution and the area of operation must
be carefully sterilized. In case of pleural effusion it is neces-
sary to withdraw some of it, usually about a quart. Immedi-
ately afterward inject one quart of sterilized water at a tempera-
ture of from 114° to 120° F. If the patient bears the operation
well, the liquid is allowed to remain in the pleural cavity where
it will be gradually absorbed. If, on the contrary, the patient
is dyspneic, the liquid is allowed to remain for half an hour at
least, and then withdrawn slowly in order to avoid sufTocation.
In four cases of pleurisy with large effusions this method gave
excellent results, [l.p.a.]
The Action of Brewers' Yeast. — Hallion and Carrion,'
as the result of experiments on the lower animals, claim that
brewers' yeast shows an energetic antitoxic effect against the
diphtheria toxin, and that it ferments actively in the living
intestine after its ingestion by the mouth. It does good in
gastrointestinal fermentations and consequent diseases as acne
and furunculosis, by replacing the vicious fermentative pro-
cesses of disease organisms by a harmless one. [h.c.w.]
Rectal Feeding. — Stadelmann * states that patients requir-
ing rectal feeding should have absolute rest in bed. In the
morning he orders an injection of water to cleanse the rectum,
and an hour later the first nutrient injection is given, this fol-
lowed by two others in the course of the day. Rost employs
for each injection 8 ounces of milk, the white of 1 egg, a small
quantity of salt and flour, and a tablespoonful of red wine. In
all cases of gastric ulcer Ewald prescribes complete rest for the
stomach, and rectal alimentation for a period of six days.
After this time food may be given cautiously by the mouth,
beginning with a few spoonfuls of milk, and increasing the
amount gradually. Thirst should be relieved by gargling or by
washing the mouth out, although it is sometimes necessary to
give an enema or hypodermic injection of saline solution to calm
the thirst. When nutrient enemas cause violent pains, Ewald
employs a few drops of laudanum in each injection ; the num-
ber of injections may be decreased, or injections of saline solu-
tion may be used to avoid the pain, [l.f.a.]
The Use of Tropon in Children.— Krauss' has used tro-
> Therap. Monatsh., July, 1902, 334.
> Le Mois Thfirapeutique, Vol. xlli, No. 1, 1902, p. 8.
'Gaz hebd, April 27, 1902, p. 391.
5 BalletiQ GCn«ral de Therapeutlque, Vol. cxllil, No. 10, 1902, p. 398.
'AUgem. Wiener med. Woch., 1902, p. 91. . . f
pon in 24 patents, varying in age from 6 months to 15 years, and
considers it an excellent food. He employs it in daily quantities
of 1 to2gram8 (15 to 25 grains). His conclusions are : (1) Chil-
dren like it, its digestion iseasy andthedosemay be increased;
(2) no unpleasant side effects have been noted ; (3) it creates ap-
petite, which increases with further use; (4) it is absorbed by'
the intestine, as shown by early increase in weight ; (5) its food-
value is considerable in diseases associated with anorexia and
in convalescence after exhausting diseases ; (6) being cheap, it
can be used by the poorer classes ; (7) iron-tropon increases the
formation of blood ; the iron is in an easily soluble form, the
large amount of absorbable albuminous bodies assisting the
action of the iron; (8) tropon flour has been found useful as
food for children 3 months old ; also in older nurslings, during
the period of weaning. It agrees with them and they continue
to increase in weight, [e.l.]
Carbonic Acid Baths in Cardiac Diseases.- Battistini
and Rovfire ' have studied the action of artificial carbonic acid
baths on 13 patients. Two convalescing from typhoid fever
were benefited by them ; one patient with mitral disease bore
the baths well ; but in many cases of aortic disease and arterio-
sclerosis no benefit was derived from their use. In one man,
aged 40, who had exophthalmic goiter, the tachycardia dimin-
ished, the arterial tension decreased during the bath and rose
again some time after it, the amount of urine increased, but the
patient experienced no subjective relief. The baths usually
cause an increase in arterial tension, a slowing of the pulse, a
regulation of certain arhythraias and a quieting of the painful
sensations, oppression and palpitation. Diuresis is but little
influenced, [l.f.a.]
Adrenal Substance Curative in Addison's Disease.—
Hirtz^ reports two cases of Addison's disease in which cure
appeared to follow the administration of suprarenal gland. He
employed capsules containing 0.1 gram (li grains) of dried
suprarenal gland, of which 2 to 4 were given daily, [l.p.a.]
The Valnelessness of Salol in Smallpox.— Thomson and
Love ' made a thorough trial of salol in 77 cases of smallpox.
Despite the employment of such doses as 5 grams (80 grains)
daily, in only three cases could they observe any effects, and
these might justly be attributed to variations in the disease.
[H.C.W.]
Treatment of Hemoptysis. — Lemoine* directs that In the
hemoptysis occurring at the beginning of tuberculosis, the
patient should have absolute rest in bed in a well aired room,
and easily digested food ; revulsion is accomplished by the use
of hot footrbaths and purgative enemas. A mustard plaster
may be applied to the chest and thighs. Internally he employs :
Powdered ergot 0 I 5 gram (7.5 grains)
Quinin sulfate 0 | 3 gram (4.5 grains)
For one cachet. To be taken In the morning with a bowl of
milk.
In hemoptysis occurring in the course of tuberculosis,
Lemoine employs ergotin as follows, although its action on the
capillaries of the lung is problematic :
Ergotin } grain
Lactic acid 10 drops
Boiled distilled water 2J drams
Four drops of this solution may be injected hypodermically
as an initial. If the hemoptysis is persistent, tartar emetic or
ipecac must be used, [l.f.a.]
Action of liecithin on the Blood-corpuscles. — Stassano
and Billon' found that injections of lecithin into the veins of
animals produced an increase in the number and in the volume
of the blood-corpuscles, and increased their resistance to hyper-
and hypo-tonic solutions. At the same time the weight of the
animal increased. The leukocytes also increased in number
and dimension, especially the mononuclear variety. This
increase lasted 4 or 5 days after the injection, [l.f.a.]
TheUseof Schleich's Infiltration in Neuralgia.— Bloch*
lauds the percutaneous injections of anesthetics, especially
tropacocain, in the method suggested by Schleich for local
> Journal des Praticlens, Vol. xvi, No. 17, 1902, p. 270.
2 Bulletin General de Th^rapeutique, Vol. cxllv. No. 4, 1902, p. ISI.
3 Glasgow Med. Jour., .June. 1902.
4 Bulletin G6n6ral de Thfirapeutique, Vol. cxllil. No. 13, 1902, p. 510.
5 La M6decine Moderne, Vol. xlii. No. 7, 1902, p. 63.
» Therap. Monatsh., July, 1902, aiti.
NOVBMBER 29, 1902]
THE PUBLIC SERVICE
(American Medicine 875
anesthesia for surgical purposes, as a therapeutic measure
in neuralgia and similar rheumatic affections. At first
he employed the treatment merely as a palliative, but his
experience leads him to believe that it possesses distinct cura-
tive properties in certain cases. These are those painful con-
ditions occurring in groups of muscles or over the course of a
nerve as the result of exposure to cold. He has repeatedly seen
in lumbago or sciatica not only the pain disappear promptly
and permanently, but also the other symptoms of the disease.
So certain in its curative effects does he regard the infiltration
anesthesia that he employs it also for diagnostic purposes ; if
the injection fails to relieve the condition he takes it as an evi-
dence that the ca.se is not one of true rheumatism but is depend-
ent on some undiscovered cause, as gonorrhea or a toxemia.
[H.O.W.]
Iodoform Solutions.^— Iodoform may be given internally
in divided doses of .01 gram (J grain) each, and in an amount of
not over 0.6 gram (10 grains) daily. Usually 0.2 gram (3 grains)
is sufficient. In any case the susceptibility of the patient will
govern the dose, which should be small at first. Iodoform is
incompatible with alkalies and calomel. Internally the drug
may be used according to the following formulas:
1. Crystallized guaiacol 2.93 grams (45 grains)
Oil of sweet almonds 3 drops
Iodoform 1 gram ( 1 graiq)
For three capsules.
Creosote may be substituted for the guaiacol in this formula.
2. Iodoform 1 gram (15 grains)
Oil of sweet almonds 473 cc. (1 pint)
Spirit of cinnamon Ice. (15 drops)
3. Iodoform 1 gram (15 grains)
Codliver-oil 473 cc. (1 pint)
One tablespoonful of these preparations contains .03 gram (i
grain) of iodoform. They may be used in the treatment of tuber-
culo-sis. Externally iodoform is employed in the form of iodo-
form collodion or a solution of iodoform in ether, 1.3 to 4
grams (20 to 60 grains) to the ounce, in the treatment of all
forms of tuberculous suppurations, hydrocele, exophthalmic
goiter, and by injection or local application in erysipelas. Intra-
tracheal injections of 1 gram (15 grains) of iodoform to .30 cc.
(1 ounce) of sterilized olive oil may be used in the treatment of
laryngeal tuberculosis, or the same may be used hypodermic-
ally in the treatment of pulmonary tuberculosis, [l.f.a.]
Prophylaxis Against Nlcotin Poisoning. — Among the
processes to render tobacco inoffensive to the nervous and car-
diovascular systems, that of Gerold » has given the best results.
Gerold macerates tobacco leaves in a solution of tannic acid,
which neutralizes the nicotin and other injurious active prin-
ciples contained in the plant. In order then to restore the per-
fume of the tobacco, which is spoiled by the tannin, it is dipped
in a decoction of origanum vulgare. Experience is said to
prove that the toxic action of the tobacco has really been
decrea.sed by this means and that its use and even abuse is ren-
dered almost Innocuous, [l.f.a.]
Tetanus Treated with Snbcutaneons Injections of Car-
bolic Acid.'— Italian writers have reported excellent results
from the use of carbolic acid In tetanus, Ascoli especially, who
had .32 recoveries out of 33 cases. Baccelli's method consists in
injecting daily SO cgr. of pure carbolic acid either beneath the
skin or directly into the muscle. Courmont and Doyen, using
large amounts of tetanus toxin, have proved that these injections
do not prevent the disease in any way. Josias determined the
minimum fatal dose of toxin, using in it seven experiments,
which he describas very minutely. All of the animals sick-
ened and died promptly, thus showing that the injections are
in no way capable of preventing the outbreak of the symptoms.
He concludes that Baccelli's procedure does not influence the
symptoms and course of tetanus in the least, not even when the
injections are made immediately upon the appearance of the
first symptom, [e.i,.]
Herpetic Eruption Kollowing the Administration of
Disodium Methylarsenate.— />a Medecine Moderne, Vol. xiii.
No. 13, 1902, p. 108, publishes a case in which an herpetic erup-
tion resulted from the administration of arrhenal or disodium
>. Journal de8 I'ratlclens. Vol. xvl. No. 1, p. 11.
» Bulletin de TMrap., March 1.5, 1902.
' Iji Medecine Moderne, 1901, No. 4(t.
methylarsenate recently recommended by Gautier as a substitute
for sodium caeodylate. In the dose of not over .06 gram ( 1 grain )
daily for a period of 4 or 5 days, followed by a similar period of
rest, arrhenal was claimed to cause no digestive disturbance,
cutaneous eruption, nor other untoward effect. In the case re-
ported, the drug was prescribed in doses of .06 gram (1 grain)
daily for 5 days. At the end of 3 days a well-marked eruption
resembling herpes zoster had appeared at the base of the neck
extending forward in a semicircle toward the intraclavicular
notch. This was accompanied by considerable itching and red-
ness. The eruption was believed to be due to the drug, since
careful search showed no other cause, and, in 1864, Hutchinson
pointed out that herpes was one of the cutaneous manifesta-
tions of overdoses of arsenic. Arrhenal was stopped and the
irritated surface was covered with an antiseptic powder. The
burning ceased, the eruption grew paler and gradually faded ;
at the end of 5 or 6 days it had almost entirely disappeared.
[L.F.A.]
Treatment of Smallpox with Applications of Strong
Solutions of Carbolic Acid. — L. Petrarojai uses local applica-
tion of strong solutions of carbolic acid — 10 to 15 parts to 100 of
glycerin — in the treatment of smallpox in preference to the
usual 1% to 2fo solutions. These strong solutions exercise
a more favorable influence on the evolution of the eruption, in
moderating the suppuration, and in hastening the desiccation
of the eruptive elements. The applications hinder the con-
fluence of the pustules and the formation of cicatrices. Pet-
raroja has never observed the least sign of poisoning from the
drug, [l.f.a.]
FORMUIiAS, ORIGINAIj AND SEIiECTED.
For Diarrhea in Tuberculosis. —
Ichthoform 3 gram ( 5 grains)
Tannalbin 6 gram (10 grains)
Bismuth subgallate 6 gram (10 grains)
Codein sulfate 02 gram ( J grain)
Oil of peppermint 01 cc. ( i minim)
One such powder every 2 to 6 hours. — Pacific Medical Jour-
nal. fH.C.W.]
For Gastroenteric Infection in Infants. —
Resorcin 1 gram (20 grains)
Bismuth subnitrate 2 grams (40 grains)
Syrup of ginger 15 cc. (4 ounce)
Water, enough to make ... 60 cc. (2 ounces)
One teaspoonful every 2 or 3 hours.— Zaborsky, Medical
Standard, [h.c.w.]
THE PUBLIC SERVICE
Health Reports. — The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, during
the week ended November 22, 1902:
California :
Colorado :
Indiana:
SMALLPOX— UNITED STATES.
San Francisco Nov. 2-9
Stockton Oct. 1-Nov. 13,.
Denver Nov. 1-8
Indianapolis Nov. 8-15
Wichita Nov. 8-15
Cases Deaths
2
4
7
2
1
New Orleans
Blddeford
....Nov. 8-15
1
Maine:
Nov. 8-15
3
Massachusetts :
Portland
Boston
Cambridge
Marlboro
Taunton
Weymouth
Worcester
Detroit
Grand Rapids....
Nov 8-15
Nov. 8-15
1
..20 2
Nov. 8-15
Nov. 1-15
1 1
7
....Nov. 8-15
1
Michigan :
Nov. 8-15
Nov. 7-H
Nov. 8-15
1
1
SI
....Nov 8-15
0
New Hampshire :
Manchester
Nashua
...Nov. 8-15
Nov. 8-15
.. 2
16
New .Jersey :
New York :
Camden
Nov. 8-16
3
Newark
New York
Cincinnati
....Nov. 8-15
Nov. 8-15
1
2
Ohio:
....Nov. 7-14
3
Cleveland
Dayton
Youngs town
Altoona
Erie
-Johnstown
McKeesport
Philadel^jhla
PlttJiburg
Salt Lake City....
Milwaukee .........
Nov. 8-15
Nov. 8-15
Nov. 1-8
.. 21 4
8
1
Pennsylvania :
....Nov. 10-17
Nov. 8-15
....Nov. 8-15
3
4
5
trtab:
Wisconsin:
Nov. 8-15
Nov. 8-15
Nov. 8-15
Nov. 8-15
....Nov. 8-15
4
3
..25 7
1
.. 10
1 la, Semalne Mddlcale, No. 28, July 9, 1902, p. 232.
876 American Mbdicins
THE PUBLIC SERVICE
[November 20, 1902
Austria :
Barbados:
f'rance :
Great Britain :
India:
Italy:
Russia :
Straits Settlements
Turkey:
Colombia :
Mexico :
Philippine Islands :
China:
India:
Japan :
Java:
Straltfi Settlements
China :
India:
SMALLPOX— FoBEian.
Prague Oct. 25-Nov. 1 14
Oct. 13-25 H6
LaRochelle Oct. li)-26
KUelmb Oct. 19-Nov. 2. ... 1
Roubai-x Oct 1-Sl
Leeds Oct. '/S-Nov. 8 S
Liverpool Oct, 25-Nov. 1 3
Manchester Oct 25-Nov. 1 1
Bombay Oct. 7-21 6
Calcutta Sept. 27-Oct. 18... 1
Madras Oct. 4-10
Milan Sept 1-.S0.. 1
Palermo Oct. 18-Nov. 1 2
Moscow Oct. 18-25
Singapore Sept. 20-27
Constantinople Oct. 19-Nov. 2 2
Yellow Fever.
Panama Nov. 3-10 4
Coatzacoalcos Nov. 1-8 2
Tamplco <ov. 1-8
Veracruz Nov. 1-8
10
Cholera— Insular.
Manila Sept. 21-27 43 36
Provinces Sept. 21-27 5,583 3,560
Cholera— Foreign.
New Chwang Sept 13-20 25 25
Bombay Oct 7-21 2
Calcutta Sept. 27-Oct. 18... 47
Kobe Oct. 11-18 24 12
Nagasaki Oct. 11-20 61 41
Batavia Sept. 27-Oct. 4 42 38
Singapore Sept. 21-27 22
Plague— Foreign.
Hongkong Oct. 4-11
Bomhay Oct. 7-21
Calcutta Sept. 27-Oct. 18..
Karachi Oct. 12- 9
1
13
1
142
2'j
Changes In the Medical Corps of the U. 8. Army for
the week ended November 22, 1902 :
Holliday, Oliver M.,contractsurgeon, now at Cauayan, Isabela, will
proceed to Manila, P. I., and report at the first reserve hospital for
treatment.
MuRTAGH, First Lieutenant John A., assistant surgeon, now at San
Mateo, Rlzal, will report to the commanding officer, Post of Manila,
for duty.
Kellogg, W. v., contract surgeon, is granted leave for one month.
Lynch Major Charles, surgeon, U. S. Volunteers (captain, assistant
surgeon, U. S. Army), is honorably discharged as major and sur-
geon, U. S. Volunteers, only, to take effect December 15, 1902.
Line, First Lieutenant Arthur M., assistant surgeon, resignation has
been accepted, to take effect December 1, 1902.
Glennan, Major James D., surgeon. Is granted leave for one month,
to take effect upon his relief from duty at the U. S. Military
Academy.
Brewer, Isaac W., contract surgeon, now In Washington, D. C, will
proceed to Fort Huachuca, for duty.
Arthur, Major William H., surgeon, having reported his arrival at
San Francisco, Cal., In compliance with orders heretofore issued,
will repair to Washington, D. C, and report to the surgeon-general
of the army for Instructions.
Branch, Captain Frederick D., assistant surgeon, U. S. Volunteers.
Is honorably discharged, to take effect December 20, 1902, his serv-
ices being no longer required. Captain Branch will proceed to his
home.
Porter, L. B., contract surgeon, leave granted October 17 Is extended
one month.
Kemp, Jambs F., contract surgeon, upon the expiration of his present
leave will proceed to San Francisco, Cal., and report for transporta-
tion to the Philippine Islands, where he will report for assignment
to duty.
Tweedie, Hedley v., contract surgeon, is relieved from duty at the
general hospital, Presidio, and will proceed to Monterey, Cal , for
duty.
Nicholson, John L., contract surgeon, is relieved from duty at Mon-
terey, Cal., to take effect upon the arrival at that place of Contract
Surgeon Hedley V. Tweedie, and will then proceed to his home,
Dorchester, Mass., for annulment of contract.
Eber, Captain Albert H., assistant surgeon, V. S. Volunteers, is hon-
orably discharged, to take effect December 31, 1902, his services
being no longer required.
Dal", First Lieutenant Frederick A., assistant surgeon, now at San
Francisco, Cal., Is relieved from further duty in the division of the
Philippines and from duty as transport surgeon on the transport
Sumner, and will proceed to Washington, D. C, and report at the
U. 8. general hospital, Washington Barracks, for duty.
Sinks, Edward D., contract surgeon, now at the U. S. general hos-
gital. Fort Bayard, will report to the commanding officer of that
ospltal for duty.
McCaw, Major Walter D., surgeon, Is detailed to represent the medi-
cal department of the Army at the General Sanitary Convention of
American Bepublics, to meet in Washington, D. C, December 2.
Long, Stephen M., contract surgeon, Is relieved from further duty at
Alcatraz Island, Cal., and will proceed to Fort Du-Chesne for duty.
Henderson, First Lieutenant Albert B., assistant surgeon, is directed
to report to Brigadier-General Frederick P'unston, president of the
examining board at Denver, Colo., for examination by the board.
Tefft, William H., contract surgeon, will procee* to Manila. P. I ,
reporting to the commanding officer, flrst reserve hospital, Manila,
P. I., for observation and treatment.
McAndrew, First Lieutenant Patrick H., assistant surgeon, is
relieved from duty in the division of the Philippines, and will pro-
ceed to San Francisco, Cal., and report by telegraph to the adjutant
general of the Army for further orders.
Madara, Captain James W.. assistant surgeon, U.S. Volunteers, now
serving in the division of the Philippines, is honorably discharged,
to take effect November 21, 1902, his services being no longer re-
quired.
Lyon, Captain Palmer H., assistant surgeon, U. 8. Volunteers, now
serving in the division of the PhiUiDplnes, is honorably discharged,
to take effect December 31, 1902, his .services being no longer re-
quired.
Owens, George F., contract surgeon, now at Bongabong, Nueva Ecija,
will proceed to Manila, P. I., and report to the commanding officer,
flrst reserve hospital, for treatment.
Carpenter, Aldbn, contract dental surgeon, is granted leave for one
month and ten days, with permission to visit Japan.
Brechemin, First Lieutenant Louis, Jr., assistantsurgeon, Is detailed
as summary court officer at the hospital corps casual camp, Manila,
P.I.
A board of officers, to consist of Major Henry S. Klibourne, surgeon ;
Major Ogden Rafferty, surgeon; Captain .lohn S. Kulp. assistant
surgeon, is appointed to meet at the Army general hospital, Pre-
sidio, November 17, to examine Into and report upon the present
Shyslcal condition of Major A. H. Appei, surgeon, with reference to
Is application for sick leave.
Cable, George L., contract surgeon, leave granted September 25 Is
extended one month.
Changes In the Medical Corps of the U. 8. Na^y tor
the week ended Xovember 22, 1902 :
DuBosE, W. R., surgeon, ordered to the Navy Yard, League Island,
Pa., for duty in connection with fitting out the Maine, and ordered
to the Maine, when that vessel Is placed In commission— Novem-
ber 14.
Richards, T. W., passed assistant surgeon, detached from the bureau
of medicine and surgery, Navy Department, and ordered to the
Arkansas— November 17.
Huntington, E. O., passed assistant surgeon, unexpired jwrtion of
sick leave revoked, ordered to the Naval Hospital, New York,
N. Y., for treatment— November 18.
Bucher, W. H., passed assistant surgeon, sick leave extended one
month— November 20.
Shipp, E. M., passed assistant surgeon (orders received from Senior
Squadron Commander of Asiatic Station), detached from duty at
Port Isabela, P. I., and ordered to the Naval Station, Cavlte, P. I.—
Novernber 20.
Oman, C. M., assistant surgeon, detached from the Naval Station,
Cavlte, P. I., and ordered to duty at Port Isabela, P. I.
McLarty, C, pharmacist, reported at the Navy Yard, Norfolk, Va.>
October 7— November 15.
Changes In the Public Health and Marine-Hospital
Service for the week ended November 20, 1902 :
White, J. H., assistant surgeon-general, granted seven days extension
of leave of absence from November 21— November 20, 1902.
CoFER, L. E., passed assistant surgeon, department letter granting
leave of absence, so amended so that said leave shall be effective up
to and including December 10— November 10, 1902.
Gbubbs, S. B., passed assistant surgeon, granted leave of absence for
one month from December 8— November 20, 1902.
Fbicks, L. D., assistant surgeon, relieved from duty at Savannah, Ga.,
and directed to proceed to Cape Fear Ciuarantlne Station, and
assume temporary command, relieving Assistant Surgeon T. B.
McCUntic— November 17, 1902.
Heiser, V. G., assistant surgeon, to report to Assistant Surgeon-
General L. L. Williams, chairman of board of examiners, for
examination to determine his fitness for promotion to the grade of
passed assistant surgeon— November 15, 1902.
MoClintic, T. B., assistant surgeon, upon being relieved from duty at
Cape Fear (Quarantine Station, to proceed to Washington, D. C.
and report to the director of the Hygienic Laboratory for duty-
November 17, 1902.
KoRN, W. A., assistant surgeon, leave of absence granted for twenty-
one days by bureau letter of November 6, 1902, revoked— Novem-
her 15, 1902.
Berry, T. D., assistant surgeon, department letter granting leave of
absence on account of sickness, amended so that it shall oe for one
month and twenty-seven days— November 13, 1902.
Francis, Edward, assistant surgeon, to proceed to New Y'ork, N. Y.,
for special tempoi-ary duty— November 14, 1902.
Rucker, W. C, assistant surgeon, relieved from duty at San Francisco,
Cal., and directed to proceed to Reedy Island Quarantine Station,
and report to medical officer in command for duty and assignment
to quarters -November 19, 1902.
Barnesby, p. N , acting assistant surgeon, granted leave of absence
for twenty-one days from November 10— Novemb.r 10, 1902.
Gibson, L. P., acting assistant surgeon, granted leave of absence for
ten days from November 12, on account of sickness— November 15,
1902.
Boards Convened.
Board convened to meet at Washington, D. C, November 18, 1902,
for the examination 'of Assistiint Surgeon V. G. Heiser to determine
his fitness for promotion to the grade of passed assistant surgeon. Detail
for the board— Assistant Surgeon-General L. L. Williams, chairman;
Assistant Surgeon-General G. T. Vaughan ; .Assistant Surgeon-General
H. D. Geddings, recorder.
Board convened to meet at the Marine Hospital, San Francisco,
Cal., November 24, 1902, for the physical examination of a candidal*
for appointment as Second Assistant Engineer, Revenue Cutter Serv-
ice. Detail for the board -Passed .Vssistant Surgeon W. G. Stimpson,
chairman ; Passed Assistant Surgeon A. R. Thomas, recorder.
American Medicine
.-ii
GEORGE M. GOULD, Editor
a. C. C. HOWARD, Managing Editor
Clinical Medicine
David Ribshan
A. O. J. Kelly
J. Edwin Swekt
UiELKN Murphy
CHARLES 8. DOLLEY
MARTIN B. TINKER, AuitUmt Editor!
General Surgery
Martin B. Tinker
A. B. CRAia
Charles A. Orr
Orthopedic Surgery
H. Augustus Wilson
COLLABORATORS
Obstetrics and Gynecology
WiLMER KRUSEN
Frank C. Hammond
Nervous and Mental Diseases
J. K. Mitchell
F. 8a VARY Pearcb
Treatment
Solomon Solis Cohen
H. C. Wood, Jr.
L. F. Appleman
Dermatology
M. B. Uartzell
PDSLUHBD WbIKLT at 1S31 WaLHUT StKBXT, PhILADBLFHIA, BT THB AWBUCAM-MlDICntS PUBLUSIMa COHPAHT
Laryngology, Etc.
D. Braden Kyle
Ophttialmology
Walter L. Pyli
Pathology
R. M. Pearce
Vol. IV, No. 23.
DECEMBEK 6, 1902.
$5.00 Yeakly.
The Revival of the "Index Medicus." — The pro-
fession is to be congratulated tiiat two of its representa-
tive men are members of tlie Board of Trustees of tlie
Carnegie Institution. To this fact is due the revival of
the Index Medicus. We trust that we shall in the future
have other occasions to be grateful ! With our pleasure,
however, comes a disappointment, for, so far, there is no
expectation that the Index will be taken up at the date
of the last issue. Provision, as yet, has been made for
starting the work from the present time only. We
earnestly hope the trustees may yet find it possible to
order the collating and publication of the material filling
the gap. Ten thousand dollars a year has been voted
for the work, and the subscription price has been placed
at $.5.00. The Surgeon-General of the Army ha-s entered
heartily into the fulfillment of the plan, and it is under-
stood that Dr. Fletcher, of the Army Medical Museum
and Library, will have editorial charge of the publica-
tion.
The Proposed Permanent Foreigrn Medical
Corps of the U. S. Army. — We print elsewhere the
proposed bill to establish a foreign medical corps of the
U. S. Army, which deserves the serious consideration of
the profession and of legislators. The purpose of the bill
is to establish a permanent Medical Corps similar to the
British East Indian Medical Service, whose duty it will
be to serve the military and civil services of the United
States in those countries which, while under the United
States Government, are separated as to their people and
country from the United States proper. It is felt that
properly qualified me<lical men will* not conle In^ suf-
ficient numljers to the tropics to enable the officials and
other civil employes of the government t(i obtain that
expert medical attention which they would receive in
the United States unless incentive is offiered them. Men
WTib have not devoted time and study to tropical surgery
and medicine cannot attain to that proficiency which
will l>e given by those who are specially trained for this
work. Its provisions give an increiuse of 145 in person-
nel to the permanent Medical Corps of the Army, with-
out injustiwi to the present establishment. It will replace
the present corps of volunteer medical officers at a les-
sened expense, and in a large measure obviate the necessity
for the contract surgeon system. It oi)ens the door
whereby meritorious volunteer and contract surgeons
may be rewarded without injustice to any one. The corps
will be an integral part of the Army of the United States,
subject to the control and jurisdiction of the Surgeon-
General. Its further provisions give increased scope and
responsibility to medical officers, thereby increasing
their dignity, and promotes respect for the medical
department and the profession at large. There will be
a great advantage to the government to have at its dis-
posal a corps of this character in the medical service
necessary in the constructive work of the Panama canal.
The recent cholera epidemic in the Philippines demon-
strated the immense advantage and importance of such
an organization. There fortunately happened to be an
adequate number of medical oiiicers available. A highly
praiseworthy provision of the bill is that providing for
an eight months' leave of absence after four years of
service.
Due Rewards for Scientific Achievements. —
The recent death of Major Walter Reed directs attention
to the self-sacrifice of the medical investigator and the
inadequacy of the recognition which is attainable in
America by these heroes of science. His demise
deprives the country of a citizen whose public spirit,
devotion to duty, and splendid achievements justly
entitle him to an enduring testimonial. His scientifle
career, strictly speaking, began about 1890 when,
through the stimulating influence of his illustrious
teacher. Dr. Welch, of JoIibb Hopkins, his interest was
awakened in the intimate nature and underlying causes
of disea.se, and he took up the special study of pathology
and bacteriology. With ''rare ftWive intelligence, inde-
fatigable industry, high ideals, broad sympathies, and a
personality that attracted all who came in contact with
him, he soon distinguishetl himself as a trustworthy
independent investigator, and entered upon a work that
was to become a triumph for scientific medicine and ft
blessing to humanity. Notwithstanding his manifold
duties as curator of the Army Medical Museum, Reed
never lost his love for pure medical investigation, and was
a frequent contributor to medical literature. Yet while
his contributions in general to scientific medicine are
uniformly as good as the best, they are insignificant
when compared with the g^eat work upon yellow fever
with which his name will ever be inseparably associated.
His was the master mind and ho the guiding spirit in
878 AMBBICAW MkDIOINB)
EDITORlAIi COMMENT
IDECBHBEK 6, 1902
an irtvestigation whereby multitudes of lives have been
saved, a pestilential malady robbed of its mysteries and
terrors, and an annual expenditure of millions of money
shown to be in large part, if not entirely, needless. As
has been said, his work " means to the United States for
the future a saving in life and treasure that is cheaply
paid for by the whole cost of the Spanish-American war."
In other countries a man who had done such a work
as Reed would at once receive office, honors, and finan-
cial security. In ours we leave him unrewarded, to
work out his life, to die early, perhaps, and then we offer
his family a sum as a pension small beyond ridicule.
We appeal to Congress to demonstrate the nation's grati-
tude in this case. It should act promptly and in a
manner commensurate with the magnificent public serv-
ice rendered by our colleague. This, we are sure, is the
wish of every one conversant with what he has done.
The Sociologic Department of the Colorado
Fuel and Iron Company is something unique in the
history of the world and as interesting as it is excep-
tional. It is under the charge of a colleague. Dr. R. W.
Corwin, superintendent, of Pueblo, Colo. His report for
1901-1902 lies before us and every physician and philan-
thropist should read it. To the president of the company,
Mr. J. A. Kebler, is due the founding and success of the
" Sociologic Department." The people dealt with are of
32 nationalities, speaking at least 27 distinct languages.
There are 38 mining and coke camps, rolling mills, etc.,
owned by the company and scattered over Wyoming,
Colorado, and New Mexico, the extremes being 1,000
miles apart. We read of race jealousies, etc., culminat-
ing in battles on the hospital lawn by the convalescent
patients hurling canes, crutches, etc., at each other. To
improve the moral, educational, and physical conditions
of their people by all the systematic and organized
agencies in their power is the object of the company.
The difficulties seem enormous, the results wonderfully
encouraging. There is no foolish sentimentalism or
fanaticism in this noble work, and a proof is the estab-
lishment of "The Coalbasin Club," where it has been
found that the sale of pure liquors at one-half the usual
price for bad, with the rule that there is to be "no treat-
ing," etc., has almost eliminated drunkenness. Gambling
has also been almost extinguished by the rule limiting
the stakes in poker and other games to a merely nominal
sum. We read of the breaking up of a prize-fight by a
worker of "Harmony Hall," boys learning cooking,
night schools, gymnasiums, traveling libraries, reading-
rooms, lectures, circulating art collections, public schools,
free school books, summer social work, kindergartens
— no end of means caught up to benefit young and old !
Where biit' in America could such things be? And
medicine is everywhere ! There are lectures on health
and all sorts of medical and sanitary subjects fitted for
the audiences, a hospital department with its local
surgeon at every camp, emergency branch hospitals, etc.
Dr. Corwin should be " the happiest man in three
States."
Money-giving Alone is Not Beneficence. — A
woman of wealth who has devoted her life and power
to philanthropic work thus speaks of the uses and
obligations of wealth :
" There is one obligation upon all persons, rich or poor.
Spending money is only one way of meeting our obligations.
I have known many consecrated men and women, almost
penniless, who carried on a great work for the Master, and
they accomplished more real good than those whose labor
ended with the distribution of wealth.
" It is not enough that we should distribute alms. We
should be careful to see that our gifts reach the proper persons,
aod are not placed where they will accomplish more harm than
good. Many well meaning people expend their money where
it really isn't needed, while they ignore the urgent cases which
they might discover before their very eyes. They are not true
to their obligations. They are not commanded to distribute
money, but to do good to others, and their possession of wealth
should enable them to do good largely.
" It isn't right that we should give to unknown charities
without investigation, and yet to investigate will require many
hours, perhaps."
There is one truth that was forgotten by this noble
woman, one that all money-givers have not learned— the
truth that no one mind can decide as to what is the
proper method of using money in charity. Only science
can turn benevolence into beneficence. Most of the
money now given according to one's misguided feelings
is surely destined to become a source of evil. Much of
the rest, while not harmful, is not a benefit to humanity.
There is no way in which wealth could be used with
such advantage as in endowing a permanent commission
of independent and scientific-minded men whose sole
function it should be to advise the benevolent for what
purposes the gift of money would do the most good to
the world. Some of the great endowments of vast sums
were only saved from absolute failure and loss by the
wise and quiet influence of moneyless men.
Does Familiarity with Alcohol Breed Con-
tempt ? — A strange perversion of logic as well as of the
results of experience has been advanced in the claim
that drunkenness is diminished by familiarity with
alcohol. An English writer, Mr. Charles Smith, in a
report to the Society for the Study of Inebriety,
examines this contention and he finds that the average
individual consumption of alcohol a year in France,
Switzerland, Spain, Italy, and Hungary, taken together
as constituting the southern countries of Europe,
amounts to 2.53 gallons, while that in the northern group
— namely, Belgium, Denmark, Germany, the United
Kingdom, Norway, Sweden, and Russia, with the
United' States of America — amounts to 1.60 gallons.
Italy, a southern country, is far from beitig the home of
a sober population notwithstanding its almost primeval
familiarity with wine. Mr. Smith arrives at the conclu-
sion that the theory of an immunity derived from pro-
longed familiarity with the use of alcohol is unsupported
by the facts as observed in the test case of the European
nations. He adds also some instructive details from the
reports of the English exchequer to show that the sum per
capita spent in England and Wales during the last 39
years has varied in direct proportion with commercial
prosperity, rising steadily from £2 18s. OJd. in -1860 to
M 9s. in 1876, falling again during a period of compara-
tive depression between the latter date and 1888 to £3 6s.
8d., and 4^;ain gradually rising to £3 19s. lljd. in 1899.
DECKMBKB 6, 19021
EDITOEIAI. COMMENT
AXBRICULM MKDICINK 879
In oth^r words, the lack of purchasing power has acted
as a salutary check upon excess.
Statistics of marriage and divorce, according to
Federation, suggest some interesting comparisons. The
divorces in Cook county, 111., in 1901 were nearly 11^
of the recorded marriages of the same period, and in
San Francisco were 23%, while in New York they were
but 2.4 '/c. Marital relationships in the Eastern States
and cities are bad enough, but it appears that the laws
of New York State do not lend themselves so readily to
the dissolution of marriage contracts as do those of some
other communities. Such facts support the contention
of those who are urging the enactment of national laws
concerning marriage and divorce, or, if this is uncon-
stitutional, of some kind of uniformity of all the State
laws as shall do away with the present scandalous
license and injustice. The foundation of civilized society
is the family and stable marriage relations. In a multi-
tude of ways such stability touches medicine and none is
more concerned in the results than the physician.
Treatment of Disease, Case, or Patient. — The
opening paragraph of Sir Dyce Duckworth's clinical
lecture on Pneumonia, published in the British Medical
Journal of November 15, 1902, so aptly illustrates a
common misuse of terms that it should be quoted.
" I am going to speak to you," he says, " about the treat-
ment of pneumonia, or rather the treatment of cases suffering
from pneumonia. I have often called your attention to the fact
that we do not treat diseases, but sick people who suffer from
diseases."
"A case " is the fact and history of the illness of a
patient, and it is absolutely impossible to treat it. The
patient may sicken, be treated, recover, or die, but not
the case. Pneumonia also can not be treated. In the
words above, therefore, an error in language is committed
and corrected erroneously ; and finally both errors are
rightly corrected.
The Medical I>uty of Governments to Their
People.— In the report of the United States commercial
agent, H. T. Greener, from Russia, there is a paragraph
that shows how neglectful the Russian Government is
of the sanitary and medical needs of its subjects in
Siberia, Manchuria, etc. If the energy spent in
proselytism could be devoted to medical missions what
blessings could be brought to millions of sufferers. Mr.
Greener says:
" The villages have been long asleep ; dirt of years' accumu-
lation lay in the roads; in many cases, the midwife was the
only medical attendant for miles. True, there were district
doctors, mostly surgeons. Medical attention was, however, a
pure fiction. What could one district doctor do for personal
attention over many villages widely scattered ? What becomes
of a people left for months— in some eases years— without any
medical attention? The official doctor's time is taken up with
actual visits to his outlying places, and in compiling and for-
warding statistics. His duties are on inquests rather than for
remedial purposes, no matter how interested or earnest he may
be. Every such district doctor is a bureaucratic chief. In one dis-
trict where the doctor had no funds to buy paper to wrap medi-
cines in, he was forced to add a new item to his medical sup-
plies—wrapping paper. At several small hospitals in certain dis-
tricts a woman may not be received no matter how ill, because
the doctor has no authority to receive her. . . . Siberian
papers are full of complaints of harsh treatment and lack of
interest in their patients by the government doctors. Because
of this lack of interest and attention and the numerous disor-
ders attendant on this dispensatory system, the majority of
Siberian peasants depend on the women doctors and on Tartar
and aboriginal medical men, with their roots and incantations.
There is no medical school in all Siberia nearer than Tomsk.
The only wonder is the Russian peasant thrives so well on scant
food, meager amusements, lack of medical care, and monoto-
nous labor."
Practice in the Orient.— The report of the Presby-
terian Mission Hospital, Medical School and Leper
Asylum at Mlrfy, India, gives one interesting glimpses
into the conditions of medical life among Orientals.
Plague, famine, ignorance and superstition surround
these devoted colleagues. In a town of 12 miles from
Miraj 1,500 died of plague in three months. The fatalism
of the people is shown by such quotations as this :
" In many Instances, in fact it seemed to be the rule during
the height of an epidemic, the bodies were carried out and either
burned or buried with the matter-of-fact decorum that charac-
terizes an ordinary bazaar transaction. There is certainly not
the dread of the disease that formerly was so evident, though
the mortality Is scarcely less than It was three years ago.
Apathy and fatal hopelessness appear to have replaced the
terror of the past. Plague seems to have come to stay, and stay^
it will if we continue to ignore, and often with a most painful
stubbornness, the now pretty wellknown laws of its contagion.',
Not a member of any Christian community for
which the mission was responsible died of the disease.
The humors of practice are not absent even under these
unfavorable conditions. One has some difficulty in
understanding why men prefer death rather than the
loss of a leg or arm. A man cares nothing for the bad
effects of the loss of an eye, but for an artificial nose he
will sacrifice a great deal. The people cannot under-
stand why their cows, bullocks, and monkeys should not
be treated as well as themselves.
"A patient applied for treatment in a filthy state of disease,
the result of his own folly. ' Sahib,' said he, ' you are ray
father, cure me and make me a Christian.' It is unnecessary
to express the state of one's feelings under such circumstances.
Ordinarily one does not object to being addressed as ' mother
and father ' by persons in need, but to be thus spoken to by one
such as we have above referred to, is to produce a somewhat
' uncanny ' reflection. . . . ' Cut my stomach, cut my belly,'
was the cry with which he for several days harassed the Doctor
Sahib on his morning round. An operation was considered
quite inadvisable and he was dismissed, he having declined
medical treatment. It was after considerable difficulty and
moral suasion that he was persuaded to quit the compound,
which he finally did. We fancy we can still hear him saying,
as he was led to the gate, ' Oh ! if the Sahib would only cut my
stomach, oh ! if he would only cut my stomach I would either
die or get well.' "
Threadbare and Stilted Expressions. — Although
one's editorial colleagues usually seek to disagjree, we
are sure that our contemporaries will vote aye to the
suggestion that in their writings authors should avoid
hackneyed and verbose expressions. It is one of the
most exhausting of editorial duties to .screen out this chafif
from manuscripts and thus give to a paper greater con-
centration, freshness, and power. Worse than the work,
however, is the freriuent ingratitude of the contributor,
who too often thinks these maculas and wens are really
beauty spots. There is scarcely one article out of a dozen
in our medical journals that could not be made much
880 Akebican MEuiciintj
AMEKICAN NEWS AND NOTES
[December (I, 1902
9hort<!r, more attractive, and more cogent by such modi-
flcations. Throughout them one will find such good-for-
nothing flotsam and jetsam as these :
" I avail myself of this opportunity."
" I am at a loss to understand."
"It is to be hoped."
" It is only proper to add . ' '
" It has fallen to the share of the writer."
" It is curious to note."
" The sedentary existence he led."
One of the most exasperating of vulgarisms is the
term the writer or Uie author, implying one's self. In an
article, e. g., one reads :
" M. Verneuil thinks this is frequently responsible for the
primary infection. The writer never met with a case of this
kind."
One somehow suspects that the writer is not M. Ver-
neuil, but a mock-modest man whose vanity makes him
afraid to say / in print, though in speaking to you he
would never say the speaker tells you. "The writer"
also "meets with a case" and "arrives at" a conclu-
sion, instead of having the case and concludiiuf. If he
would think a moment he would simply seize the oppor-
tunity and say nothing about doing so ; he would say,
" I cannot understand," instead of " being at a loss," and
"I hope," instead of " It is to be hoped;" he would
" add " at once, and let the propriety of adding go hang ;
he would not talk about a man's " existence " when he
means his life or habit — and so on.
EDITORIAL ECHOES
Our Brothers Outside. — The importance and mag-
nitude of the need of union become apparent when it is
known that there are, as nearly as can be determined,
over 80,000 regularly licensed physicians in this country
who have never been members of any kind of an organ-
ization, county, district. State or National. . . .
Whether we will or not, it may as well be recognized,
too, that almost as much as of the members within our
organizations each of these outsiders is a factor for which
the profession is held responsible, and that in a very
broad sense the standing of the entire profession is
involved in his success or failure. That the public has
good reasons for this is readily understood when it is
remembered that he was graduated from a school whose
teachers were leaders in the ranks of our State and
National organizations; he was authorized to practise
under laws of our procurement ; he is met in consulta-
tion by members of established reputation, and in every
other respect, so far as the public is concerned, or can
see, he is a full-fledged member of the profession.
Probably a majority of those referred to are young
physicians whose lives are largely to be shaped or mis-
shaped by their professional environments. As mem-
bers of live local organizations, with frequent meetings,
and the broadening professional and social ambitions
incident thereto, the possibilities open to such men, and
through them to the profession, and the communities in
which they live, are beyond calculation. To cast them
©«■, or to leave them alone, which means practically the
same thing so far as they are concerned, is to continue
the old order of things, with the best energies of the
large majority of these really excellent men expended in
local or personal dissensions or strife, dwarfing and dis-
creditable alike to the individual and the profession as a
whole. — [Jour. Am. Med. ^Isso.J
AMERICAN NEWS AND NOTES.
OENERAJj.
The barmfnl effects of the aiiticanteen law are clearly
demonstrated by the reports of army officers upon the subject.
It is shown that out of 1,400 saloons near army posts from 250 to
300 were opened since the canteens were abolished. In addi-
tion the majority of posts report an increase in drunkenness
and desertions. The assertion is made that the abolishment of
the canteen has had an exceedingly bad effect upon the
morality, discipline, and health of the soldiers. Many post
commanders are unable, owing to frequent changes of garrison
and alisence of correct data, to report fully as to the degree of
detriment created by abolishing the canteen. It is a note-
worthy fact that in no instance has a post commander expressed
the opinion that the abolishment of the canteen has been fol-
lowed by improved conditions. The annual report of Briga-
dier-Qeneral Sanger, Inspector-General of the Philippines Divis-
ion, contains much of interest bearing on this suVjject. From a
careful census of the 342 companies in the Philippine Islands,
he shows that in 60 companies every enlisted man used vinous,
malt or spirituous liquors at date of enlistment; in 130 com-
panies, between 90% and 100% ; in 58 companies, between 80%
and 90% ; in 26 companies, between 70% and 80% ; in 20 com-
panies, between 60% and 70%. Unfortunately, quite a number
of men habitually drink to excess, and he believes this number
will increase if the men are obliged, as now, to resort to native
liquors in order to satisfy what to many of them is a perfectly
natural craving, and the result will be most deplorable.
The Proposed Foreign Service Medical Corps. — The
following is the wording of the act proposed by Major Surgeons
Thomason, Burns, Robins, Leepere, Pond, Heller, Zauner, and
Bell, for the establishment of a foreign medical corps in the
Medical Department of the Army of the United States :
Section I. Be it enacted by the Senate and the House of
Representatives of the United States of America in Congress
assembled, that the foreign service medical corps of the Medical
Department of the Army of the United States shall be consti-
tuted as follows :
One assistant surgeon-general, with the rank of colonel ; four
deputy surgeons-general, with the rank of lieutenant colonel ;
forty surgeons, with the rank of major ; one hundred assistant
surgeons, with the rank of captain and first lieutenant
mounted, as hereinafter provided. The pay and allowances of
these officers to be the same as for officers of like grades in the
United States Army serving in insular possessions.
After the original vacancies are filled as hereinafter pro-
vided, promotion by seniority shall apply in all grades.
Sec. II. That the one original vacancy in the grade of
colonel, two original vacancies in the grade of lieutenant colonel,
ten original vacancies in the grade of major, and thirty original
vacancies in the grade of captain, be filled by transfer by the
President of the United States, from the Medical Department of
the Army, of such medical officers as make application to the
Secretary of War, and who have had at least one year of actual
foreign service, as provided in Sec. II. Provided, that the new
rank to which the applicant is appointed shall be but one grade
higher than that held at the time of application ; except that of
the assistant surgeon-general, who, in order to fill this original
vacancy, shall be appointed by the President of the United
States, the selection to be made from officers ol' field grades, and
who are not under 45 years of age, and who have had one year's
actual foreign service.
Provided, that the transfers from the present medical corps
of the army to the foreign service medical corps shall be perma-
nent, and there shall be no exchange of officers from tne one
body to the other. That the promotions in each body shall be
by seniority and entirely distinct and separate.
Provided further, that if sufficient applications are not re-
ceived by the Secretary of War within six months after the date
this bill becomes a law, the remainder of the vacancies will be
filled as provided in Sec. III.
Sec. III. That all the original vacancies not filled as pro-
vided for in Sec. II shall be filled by appointment of regularly
graduated physicians who have served in the armies of the
United States, and not less than one year of actual service
shall have been, at some period, in the Philippine Islands,
Cuba, Porto Rico, Hawaiian Islands, or China, either singly or
collectively, and who have held commissions as medical officers
of volunteers, or who have acted as contract surgeons. United
States Army. Provided, that no person shall be appointed
until he shall have passed an examination by a board of five
medical officers, composed of two lieutenant colonels, appointed
under the provisions of Sec. II of this act, and three commis-
sioned medical officers holding the rank of field officers, who,
upon the advice of the surgeon-general of the United States
Army, have been selected by the Secretary of War for appoint-
ment into the service, for the purpose of taking part in this first
examination, from those referred to above in this Sec. III.
Provided, that such examination for appointment shall be
held in the same manner, and to be of the same scope, as now
pertains to the Medical Department of the Army lor promo-
tion, as provided for in the army medical manual. Provided,
that the previous record, character, and length of service on the
part of the candidate shall receive due credit in this exauiina-
December 6, 1902|
AMERICAN NEWS AND NOTES
iAmebicak Medicine SSI
tion. Provided, that no person shall be appointed to the grade
of a field officer, unless he shall have attained the age of 35
years, and does not exceed that of 45 years., Xo person shall be
appointed to the grade of captain unless he shall have attained
the age of 25 years, and does not exceed that of 35 years.
Provided, that the President may remove the upper age
limit, and appoint to the grade of field officer and captain, sub-
ject to the prescribed examination, such persons as have capably
served over two years as medical officers of volunteers or con-
tract surgeons, and are otherwise eligible under this section.
Sec. IV. That all original vacancies remaining twelve
months after this bill becomes a law (except those provided for
in Sees. II and III), and those thereafter occurring, shall be
filled by appointment of regularly graduated physicians,
between twenty-two and twenty-nine years of age, who have
passed an examination by a board composed of such officers of
the foreign service medical corps as the surgeon-general may
select. Such examination to be held in the same manner, and
to be of the same scope, as that held f( r candidates for appoint-
ment into the Medical Department of the United States Army
as provided for in the army medical manual. Provided, that
all persons appointed under the provisions of this section shall
have the rank, pay, and allowance of first lieutenants mounted,
until promoted in accordance with the provisions of Sec. V of
this act.
Sec. V. Promotions in all grades shall be, as now provided
for in law, for the officers of the Medical Department of the
Army, provided those persons appointed uuder provisions of
Sees. II and III of this act shall at once receive the grade of a
field officer or captain. Provided, that before final appointment
of such persons entering the service under the provisions of
Sec. IV of this act, each approved candidate shall pass a satis-
factory course of instruction in the Arrhy Medical School in
such subjects as the surgeon-general of the array may deter-
mine, and that the record of the candidate in this school, com-
bined with his entrance examination, shall determine his rela-
tive military rank.
Sec. VI. That on account of possible deterioration of
health from continuous service in the tropics, each officer of
this service may be allowed eight months (if ordinary leave of
absence, after every four years of service, on full pay, with
transportation to and from the United States, such leaves to
commence and end upon arrival in and departure from the
United States. These foreign service leaves may accumulate at
the rate of two months per year as long as the officer desires.
Officers of the foreign service medical corps shall also be
entitled to all leaves, except ordinary leaves, provided for by
existing law for officers of the United States Army.
Sec. VII. That after ten years of actual service in the tropi-
cal zone, as a commissioned officer in the military service of the
United States, officers of the foreign service medical corps shall
be entitled, upon their own request, to be placed on the retired
list of the United States Army on one-fourth pay, after fifteen
years' service three eighths pay, after twenty years' service
one-half pay, after twenty-five years' service five-eighths pay,
after thirty years' service three-fourths pay, after thirty-five
years' service seven-eighths pay, after forty years' service full
pay. Provided further, that all retirements from whatsoever
cause shall be made in the same manner as now provided for
by law for officers of the United States Army. The retired
list of the army, as estaljlished by law, shall be increased as
heroin provided.
Sec. VIII. The assistant surgeon-general of the foreign
service medical corps of the Medical Department of the United
States Army shall serve at the headquarters of the army, in the
office of the surgeon-general, United States Army, as well as
such other officers of this corps as necessity may demand.
For the purpose of retirement, this service shall count as
foreign service.
Sec. IX. Be it further enacted, that when, in the opinion of
the Secretary of War, necessity therefor exists, the medical
officers of the military services of the United States shall act
under the direction of the civil government in the controlling
of epidemic diseases, and such other public health functions as
the necessities of the case demand. |
When serving under direction of civil governments, the
duties of medical ofiicers shall be as follows: To render medi-
cal and surgical services to the civil officials and their families,
and such others as the civil authorities may determine are
entitled to this service, and to perform such public health
duties as may be require*!. When detailed to serve under the
direction of United States civil authorities, medical ofiicers
shall, for the period thus detailed, be removed from all military
jurisdiction, and subject only to the orders of the proper civil
authorities and the Secretary of War.
Sec. X. Be it further enacted, that the duties of the officers
of the me<lical department of the military services of the United
States not provided for in Sec. IX of this act shall be as fol-
lows:
1. The direction of measures for the prevention of disease
among the troops of the army,and of sanitary faults in location,
construction {and management) of posts and camps.
2. The medical and surgical care of diseased and injured
officers and soldiers of the army of the United States; the
physical examination of all officers and soldiers entering and
leaving the United States Army.
3. The care (of) and accountability for all transportation per-
taining to the movement of men and supplies of the medical
department and (of) sick and injured of the army.
4. The preparation and preservation of the records of trans-
actions takmg place under the three preceding paragraphs.
5. It shall be the duty of the senior officer of the (army)'
corps, division, brigade (territorial division or department)'
in which an actual outbreak of disease shall have arisen, to at
once take steps and investigate and determine the reasom
therefor.
Should this investigation show any carelessness or inatten-
tion to duty, either upon the part of the medical officer, or of
the officer in command at the infected point, he shall at once
make report (of the facts) to the officer in command of the
(army) corps, division, or brigade (territorial division or
department), whose duty it shall then be to bring the offend-
ing officer or officers before a court-martial for such punish-
ment, upon conviction, as the court may deem proper, and the
revising authorities concur in. Provided, that the member-
ship of the courts-martial for the trial of an officer of the staff
departments of the army shall consist of at least 20% of officers
taken from the staff department to which the accused ofiicer
belongs.
Sec. XI. The officers of the medical department of the
military services of the Army of the United States shall also
perform such other duties as the President or the Secretary of
War may deem for the best interests of the army.
The Secretary of War is hereby authorized and directed to
prepare suitable regulations for the enforcement of the pro-
visions of this act.
All acts and portions of acts in conflict with the above are
hereby repealed.
NEW YORK.
Birthrate In New York City. — According to the Evetiing
Post the birthrate in New York in 1901, 22.5;j, was higher than of
any American city of over 500,000 population, except Boston,
but it fell far below the birthrate of 33 smallerolties, 14 of which
are in Massachusetts, 6 in other parts of New England, 3 in
New Jersey, 1 (Yonkers) in New York State, 5 in Pennsyl-
vania, 2 in the South, 2 west of the Mississippi, and only 1,
viz., IJutte, Mont., west of the Rocky mountains.
Incarceration of Intoxicated Persons Forbidden in
Brooklyn. — Dr. Joseph H. Raymond, Assistant Sanitary Super-
intendent of the Health Department, has issued a general order
to all ambulance surgeons directing that hereafter all patients
to whom they are called, in whom there is partial or complete'
loss of consciousness, must be taken to the nearest hospital
whether they are apparently under the influence of alcohol or
not. This order was issued in order to break up the general
practice of locking up such persons in public cells, the claim
being made that the cold of the cell is frequently fatal in such
cases.
PHIIiADEIiPHIA. PENNSYIiVANIA. ETC.
Philadelphia County Medical Society. — A special meet-
ing of the society was held Decembers, to discuss resolutions
Erotesting against the purchase by the city of swamp lands for
ospital purposes.
Physicians Object to Hospital Plans.— From all accounts
it appears to be the intention of the municipal administration
of Philadelphia to locate the Municipal Hospital, the Alms-
house, and Hospital for the Insane, in the Fortieth ward. The
site which will probably be selected is the overflow swamp-
lands of the lower Schuylkill. This is being quietly but vigor-
ously opposed by many of the leading physicians of the city,
first on account of the unhygienic surroundings, and second or»
account of the tendency on the part of the municipal manage-
ment to group in one institution and practically under one
management institutions which are unrelated, arid which for
scientific and humanitarian considerations should remain sep-
arate and distinct. Some concerted action on the part of the
profession looking to the selection of a better site and the
segregation into institutions of the unrelated cases is expected.
SOUTHERN STATES.
Effects ofCljfaret Smoking.— A Galveston newspaper gives
an interesting account of experiments made on school children.
A public sdiool of 500 pupils was selected at random to make
a comparison between the youths who smoked cigarets and
those who did not. Twenty boys were selected from among the
smokers, and the same number from the abstainers. The
results show that the average efficiency of the average boy who
had not used tobacco was ab6ut 95%-- that is, of 100 such boys,
95 were efficient, while only about 6 in 100 of the cigaret
smokers measured up to the required standard of mental,
moral, and physical efficiency.
WESTERN STATES.
Eddyite Pined.— From Guthrie, Oklahoma, comes the
news that in Arapahoe an eddyite has been fined f 100 and costs
for refusing medical aid for his daughter who, after an extended
illness, diet! of typhoid fever. A strong fight was made by the-
defendant, but it was shown at the trial that none but elders ii>,
the eddyite church was permitted to administer to the affiicted
girl.
882 AUSBtOAII MBDICJNKI
FOREIGN NEWS AND NOTES
I December 6, 1902
CANADA.
Ohlldrea's Hospital for Montreal.— The Journal of the
Ameiican Medical Association says that in the near future a
hospital will be erected in Montreal for the reception of chil-
dren of eastern Canada suffering from such diseases as tuber-
culosis or deformities of the limbs or spine. The hospital may
be called "The Children's Memorial Hospital to Queen Vic-
toria," and will be built on Mount Koyal or in the country
immediately adjacent to the city.
FOREIGN NEWS AND NOTES
GENERAIj.
An International Exposition of Hygiene will be held at
Buenos Ayres in April, 1904, in connection with the second
Latin-American Congress.
Miscellaneous.— It is announced that three Nobel research
prizes have been awarded as follows: In natural science and
chemistry, to Dr. Emil Fischer, of the Berlin University ; in
physics to Dr. Arrhenius, of the Stockholm High School, and
in medicine to Dr. Finzen. Each prize is said to be worth
$10,000. We announced in a recent issue that Major Ronald
Ross, of the Liverpool School of Tropical Medicine, had also
received one of these prizes. McGill Medical Colleof;,
Montreal : Dr. T. R. Starkey, of London, has been appointed
professor of hygiene in the vacancy caused by the death of Dr.
Wyatt Johnston.
GREAT BRITAIN.
Abuse of Medical Charities. — The Western Daily Press
of recent issue contains a letter from a medical man calling
attention to the great evil of hospital abuse. He points to the
fact that in Bristol, a town of 130,000 people, in the west of
England, not fewer tlian 125,254 people were relieved during
the year 1901 by the medical charities of that town. The writer
holds firmly to the belief, now becoming common, that this
pauperizing abuse must cease, on the ground that it is not
charity and is harmful alike to the physician and the patient.
CONTINENTAL! EUROPE.
Monument for Rudolf Virchow.— The German commit-
tee in charge of the celebration in honor of Rudolf Virchow's
eightieth birthday — Professor Waldeyer, chairman, Professor
Posner, secretary— has begun collecting funds for tlie purpose
of erecting a monument in memory of that great and unique
man and physician. The undersigned are anxious and ready to
receive contributions, which will be duly acknowledged:
Frank Billings, president of the American Medical Associa-
tion, 100 State street, Chicago, 111.; Thomas D. Coleman, 505
Greene street, Augusta, Ga.; A. Jacobi, 19 East Forty-seventh
street. New York City ; W. W. Keen, president of the Congress
of American Physicians and Surgeons, 1729 Chestnut street,
Philadelphia, Pa.; Wm. H. Welch, 935 St. Paul street, Balti-
more, Md.
OBITUARIES.
Professor Engen Hahn, chief surgeon to the Friedrlchshaln Hos-
pital, Berlin, Germany, November I, aged 61. Dr. Uahn was widely
known for his work in practical surgery, and especially for his opera-
tion for fixation of the kidney and extirpation of the larynx for mallg.
nant growths. His contributions to medical literature were compara-
tively few and dealt principally with practical and technical questions.
In 1899 he was elected president of the German Surgical Association,
this being the first time the position was ever held by a hospital sur-
geon having no connection with a university.
J. Landls Seitz, of Harrisburg, Pa., November 28, aged 46. He was
graduated from the Jefl'erson Medical College In 1882. He was a mem-
ber of the American Medical Association, Pennsylvania State Medical
Society, and the Dauphin County Medical Society. He was formerly
secretary of the Harrisburg Academy of Medicine.
Thomas P. Weir, in Toronto, Can., October 27. He was graduated
from the University of Toronto In 1888, after which he became resident
physician in the Toronto General Hospital for one year. He was then
appointed a member of the medical staff of the asylum for the insane
at Toronto, serving four years.
James Bankart, consulting surgeon to the Royal Devon and
Exeter, and senior surgeon to the West of England Eye Infirmary, died
in Exeter, October 31, aged 68. He was a distinguished eye surgeon and
was an occasional contributor to medical literature.
Henry W. Ochsner, in Baltimore, Md., November 25, aged 25. He
was graduated from the medical department of the Johns Hopkins
University in 190-2, and at the time of his death was a member of the
medical staff of the Johns Hopkins Hospital.
Liendern M. FhiUips, In Penn Yan, N. Y., November 10, aged 44.
He was graduated from the University of Vermont in 1882, and at the
time of his death was a member of the Yates County Medical Society.
Edwin G. Granville, at Kansas City, Mo., November 24, aged 59.
He was graduated from the Kansas City Hospital College of Medicine
In 1885, and was a veteran of the Seventy-flrst Regiment of New York.
I-eroy J. Wisman, In Huntingdon, Ind., November 9. He was
graduated from the University of Michigan, Ann Arbor, In 1898. He
was a member of the Livingston County (Illinois) Medical Society.
John H. Carrey, of Nashville, Tenn., November 11, aged 71. He
was a graduate of the Shelby Medical College, Nashville, and was a
surgeon in the C(mfederate service during the Civil war.
Harrison Steele, at Peoria, 111., November 14, aged 66. He was
graduated from the Rush Medical College, Chicago, 1808. He was chief
surgeon of the Toledo, Peoria and Western Railroad.
Greg;ory J. Phelan, in San Francisco, Cal., November 15, aged 80.
He was graduated from the New York University In 1847, and was a
member of the American Medical Association.
Joseph A. Buhler, In Brookline, Mass., November 24, aged 63. He
was a graduate of the Harvard Medical School. He served as a sur-
geon in the navy throughout the Civil war.
H. M. Craton, of Jesup, Iowa, died at Downing, Wis., November
18, aged 76. He was graduated from the College of Physicians and Sur-
geons, Keokuk, Iowa, in 1867.
Ferdinand Fahr, professor of surgery in the University of Giessen,
died recently. His published works dealt chiefly with goiter aud
occlusion of the intestine.
Fred. C. Steele, in Bracebridge, Ontario, Can., October 31, aged 30.
He was graduated from the medical department of the Toronto
University in 1896.
Charles M. Hollingswortfa, in Harrisonburg, Va., November 9,
aged 45. He was graduated from the University of Maryland, Balti-
more, in 18S2.
Alex. H. Davidson, of Boerne, Texas, at Ban Antonio, November
2, aged 39. He was graduated from the Tulane University, New Or-
leans, in 1895.
Junius H. Wattles, at Kansas Chy, Mo., November 9, aged about
60. He was graduated from the University Medical College, Kansas
City, In 1897.
William H. Hosmer, at Penacook, N. H., November 15, aged 88.
He was graduated from Dartmouth Medical School, Hanover, N. H.,
in 1838.
George F. Mellfant, in Millville, Mass., November 4, aged SC. He
was graduated from the Dartmouth Medical College, Hanover, N. H.,
in 1888.
A. De V. lioggs. In Marquez, Tex., November 7, aged 58. He was
graduated from tbe Texas Medical College and Hospital, Galveston, in
1868.
Durham M. Creel, In Industry, Iowa, November 12, aged 83. He
was graduated from the College of Physicians and Surgeons, Iowa, in
1878.
H. S. Gilbert, at Brooklin, Ontario, Can., October 15. He was
graduated from the medical department of the Toronto University In
19U0.
Francis T. K. Wagner, in Wilkesbarre, Pa., November 1, aged 68.
He was graduated from the University of Gottingen, Germany, In 18.57.
Newell G. Tullls, in Thomasville, Ga., November 11, aged 50. He
was graduated from the Medical College of Georgia, Augusta, In 1872.
James W. McQultby, in Mldwf y, Mo., November .3, aged 30. He
was graduated from the Missouri Medical College, St. Louis, in 1891.
James A. Meek, in Bunker Hill, Ind., October .SO, aged 74. He was
graduated from the Jefferson Medical College, Philadelphia, In 1881.
WlIUs Sperry, in Tallmadge, Ohio, November 7, aged 79. He was
graduated from the Western Reserve University, Cleveland, in 1851.
J. S. Spangler, in Ute, Iowa, November 5, aged 43. He was a
graduate of the College of Physicians and Surgeons, Keokuk, Iowa.
Johannes A. L,. Bockendahl, formerly professor of forensic medi-
cine and hygiene In the University of Kiel, died recently, aged 77.
\ Charles R. Kiebsam, in Madison, Wis., November 12, aged 76. He
was a graduate of the University of Pennsylvania, Philadelphia.
George S. Dodge, at West Acton, Mass., November 2. He was
graduated from the Harvard University Medical School In 1881.
George W. Fringer, at Pana, 111., November 17, aged 67. He was
graduated from the .Mtssouri Medical College, St. Louis, in 1869.
William P. Kennedy, at Wnrsaw, N. C, November 9. He was
graduated from the University of Maryland, Baltimore, In 1885.
Thomias E. Powell, in Evansville, Ind., November 17, aged 55. He
was graduated from the University of Louisville, Ky., In 1874.
G. 0. McGregor, of Waco, Texas, November 23. He was gradu-
ated from the New York University Medical School in 1851.
Albert E. Burdlck, In Manistique, Mich., November 12, aged 56
He was graduated from the New York University in 1873.
James B. Clifton, In Loulsbui'g, N. C, November 2, aged 67. He
was graduated from the New York, University in 1857.
Thomas H. Price, of Philadelphia, November 22. He was gradu-
ated from the Jefferson Medical College In 1876.
Iiiglls Longh, of Toronto, Can., October 31. He came to Toronto
from Bermuda 26 years ago. ,
Decehbes 6, It021
CORRESPONDENClS
(American Msdiciite 883
CLINICAL NOTES AND CORRESPONDENCE
[Communications are Invited for this Department. The Editor is
not responsible for the views advanced by any contributor.]
LENDING PRESTIGE TO LOW JOURNALS.
BY
WILLIAM J. ROBINSON, M.D.,
of New York City.
To the Editor of American Medicine: — There is a certain
journal published in the West whose sole reason for existence
seems to be to advertise the products ol a certain manufac-
turing company, in vt^hich the editor is a large stockholder.
To my knovfledge it is the only journal which systematically
prostitutes its editorial pages for the purpose of booming a few
patent nostrums. The editorials, which are not taken up with
lauding the virtues of various patent medicines, are devoted to
fighting and ridiculing everything that is good and noble in
medicine. The journal fights all medical laws for the restric-
tion of quacks, it fights higher educational requirements, it
opposes vaccination, it ridicules and reviles such men as Vir-
chow, Koch, and Lester, etc. When one considers the attitude
of the medical profession as a whole toward such a publication
it is surprising that reputable men could be induced to con-
tribute to its columns ; and yetamong the original articles in a
recent issue of that journal I noticed two written by prominent
New York physicians— one a wellknown surgeon, the other a
wellknown gynecologist. The articles in themselves do not
amount to much, but it is not for intrinsic value that such a
journal cares ; all it wants is the prestige of the authors' names.
One wonders what unfortuitous circumstance ever induced these
physicians to lend their aid toward increasing the influence of
such a publication. It seems to me that we should be as care-
ful in the selection of our publication media as in the selection
of people with whom we associate. Although much less prom-
inent than either of the gentlemen referred to, I would no more
think of contributing one of my articles to the journal in ques-
tion than I would of bestowing my friendship on bunco-
steerers and dive-keepers.
CONCERNING THE ACTION OF THE ILLINOIS BOARD
OF MEDICAL EXAMINERS RELATIVE TO THE
VISIT OF PROFESSOR LORENZ, OF VIENNA.
BY
A. E. ENGZELIUS, M.D.,
of Denver, Colo.
To the Editor of American Medicine :— "Kindly allow me a
few words in answer to your editorial remarks in your issue of
October 25, relative to Professor Lorenz, of Vienna, having been
requested to appear before the Illinois Board of Medical
Examiners to pass its examination in order to be licensed to
perform in that State on a certain patient an operation whereof
he has the distinction of being the originator. Although the
defense for this ludicrous request on the part of the said Board
of Examiners is seemingly logical enough, it being urged that
it was simply a question of upholding and executing the law, it
might, I think, rightly be questioned whether it had not been
more creditable to the American medical profession in general
and to the Illinois Board of Examiners in particular if, instead
of enacting such a meaningless farce the board had in this par-
ticular case maintained an "eloquent silence." At the arrival
of the time when the American medical studentshall have, like
his European lirother of today, to spend eigiit or ten years over
his medical books preparing for graduation, and that only after
first having acquired a high school education of the highest type
— at that time, I say, such a request might be less mirth-pro-
voking. In connection herewith, and as a reply to the expressed
feeling of uncertainty as to the nature of the reception of an
American practitioner in Europe, let me recall the visit to
Sweden a number of years ago of our late Dr. Lewis A. Sayre,
who was called upon to operate or treat a member of the royal
family of that country for hip-joint disease. This groat Ameri-
can surgeon, enjoying an international reputation as the father of
orthopedic surgery, was received, as be well deserved and as a
matter of course, with the greatest courtesy by the medical pro-
fession of that country, and was subsequently decorated and cov-
ered with many tokens of high honors and distinction. Although
coming from a country where at that time the medical school
was yet in its infancy, and visiting for the purpose of practising
the art of his profession in a country possessing medical laws
and regulations of incomparable strictness, it is safe to say that
the idea of putting him through an ordeal similar to the one to
which Professor Lorenz, of Austria, was lately subjected in the
State of Illinois never entered the mind of any of his pi-ofes-
sional brethren whose honored guest he was.
ADMINISTRATION OF DRUGS IN TABLET FORM.
C. S. N. HALLBERG, Ph.G.,
• of Chicago.
To the Editor of American Medicine : — The note on the
"Administration of Drugs in Tablet Form," by Dr. Lawrence
E. Holmes, of Biltmore, N. C, which appeared in a recent
number of American Medicine, discloses a feature of internal
medicine which should receive serious consideration. The
experience of Dr. Holmes is not unusual ; on the contrary,
it is of frequent occurrence. As has been pointed out, it
is not safe to administer any water-insoluble chemicals in
compressed form, and the synthetic chemicals are water-
insoluble with one or two exceptions (resorcin and antipyrin).
They should be administered in the form of powder, or
encapsuled dosage forms only. While the tablet-triturate is
a safe and excellent form of administration owing to the lactose
diluent contained in it, the compressed pill, troche and tablet
are unpharmaceutical, and should be used only as dosage forms
for the extemporaneous preparation of solutions as in the
tablets for hypodermic solutions.
TREATMENT OF CONGENITAL HIP DISLOCATION.
BY
LEONARD W. ELY, M.D.,
of New York City.
To the Editor of American Medicine .—The enthusiasm of
the public over Professor Lorenz seems funny, but it has its
serious side and is not without its lesson for the profession. It
is another ease of waiting to be forced by the general public
into taking up a good thing. A few of us have been preaching
the treatment of congenital hip dislocation for some years, but
the seed fell on stony ground. I had an article on it in Ameri-
can Medicine, Vol. I, No. 13, but surgeons have continued to
refuse to treat these patients and have regarded them as hope-
less cripples until they learned from the daily papers that some-
thing could be done for them. Instead of teaching the general
public we have waited to be taught by them.
AU PIED DE LA LETTRE.
In Washington there is a Slab
Erected unto Hahnemann,
And on it there is chiseled large
A warning unto any man.
For underneath the statue stands
This motto in the center,
Similia similibus,
And under it, curentur.
And can it mean, " Who reads should run,"
In grammar homeopathic.
Remorse and good advice in words
Significantly graphic?
Or does curentur promise cures,
A jolly kind of banter?
Or was some conscientious soul
Afraid to write curanturf
Kansas City, November SO, 190S.
LlTKRATIM.
884 AHEitlCAK MkDIOINK)
COREESPONDENCE
[Decembeb 6, 1902
THE RELATION OF OXALURIA TO GLYCOSURIA.
BY
FRIEDA E. LIPPERT, M.D.,
of Philadelphia.
In a protracted series of urinalyses extending over the past
year, certain observations have directed my attention to the
relation, formerly more contested than at present, between
oxaluria and glycosuria.
The analyses were made in urines supposedly diabetic.
There were in almost all the cases the familiar clinical pictures
•of that disease, notably the nervous symptoms so ever present.
Careful, minute adherence to the exact following of tests, par-
ticularly that of Fehling, failed to elicit the proof of sugar. It
was through an over-persistent application of tests that the
•juery suggested in this article was provoked.
Universal authority directs that prolonged Mbiling be
avoided in the precise qualitative tests ; yet in the face of this, I
obstinately tried the effect of 15, 20, 25 minutes of boiling after
adding the urine to the test solution. Allowing the test-tube to
stand for 12 or 18 hours thereafter, I was surprised by the
appearance of a copper-colored sediment. Many authorities
apparently provide for this contingency by referring to the
reduction of cuprous oxid by uric acid, creatin, allantoin,
nucleoalbumin, milk sugar, and bile pigment. I have not
found, however, the statement of the wellknown chemic fact
that oxalic acid, and most oxygen acids, decompose copper salts
separating metallic copper therefrom.
Bearing in mind the clinical evidences presented in the
cases under investigation, associated with microscopic evi-
dences of abundant oxalates, I hold that the latter was the
probable explanation of the test and that the resultant yellow
precipitate was indicative of the presence of oxalates to an
abnormal degree. This conclusion, with the knowledge of the
pecviliar nervous and constitutional symptoms presented in
every case, led me to ask if the oxaluric state might be a pre-
cursor of the glycosurie that it so nearly resembled.
Simon, in his " Clinical Diagnosis," makes a similar sugges-
tion. He declares, at least, a subtle relation between the two
conditions, as denoted by " the vicarious elimination of oxalic
acid in diabetes." I believe that we may go a step further In
regarding the one as the forerunner of the other quite invari-
ably. Oxaluria itself has in other decades been the subject of
controversy. In 1845, Golding Bird advanced the theory of a
definite dyscrasia which he described as characterized by the
coexistence of abundant oxalate deposit in the urine, and the
clinical symptoms of gastric disturbance, irregular, intermit-
tent pulse, with mental and nervous irritability. To this he
gave the name of the " oxalic acid diathesis." His position was
contested by many skeptics. Among them was Owen Rees,
who declared that " the state of the system on which the secre-
tion of urine characterized by deposits of oxalate of lime,
depends, has not been thoroughly investigated. There appears
some degree of probability that it is connected with the forma-
tion of uric acid in excess." He called attention to the con-
version of uric acid into oxalic acid and urea, and positively
decided that " all the chemic relations of oxalic acid to urea,
lithic acid and the lithates, point to the derivation of the acid
and its salts, from uric acid."
In all of this the chemic more than the clinical facts appear
to have been the decisive data. Then as now, too often were
the reactions of the test-tube taken for the infallible reactions
in the living body. We forget that normal tissue metabolism,
in itself complex, is not identical when the pathologic condi-
tion supervenes. The chemic and the clinical reactions in
health cannot always be correlated in disease.
As a matter of fact, there are other sources of oxalic acid
than those stated above. It may have a carbohydrate as well as
a nitrogenous origin, it being readily formed by the oxidation
of sugar. Abundant sugar manufacture in the tissues may
therefore result in abundant oxalic production ; at the same
time that oxalic acid is produced by such oxidation, water is
liberated. This may account for the fluidity of the blood in
both oxaluria and glycosuria. Let oxidation fail, and the
oxaluric condition disappears, the glycosurie taking its place,
with the blood so inspissated that a balance cannot be readily
regained.
If this has been so far observed as to warrant the socalled
"vicarious elimination in diabetes," is it not a more probable
truth that it is the precursor of diabetes, and that the much-
disputed "oxalic acid diathesis" or "idiopathic oxaluria" of
Golding Bird's tenets was but a pathway blazed and not pur-
sued the full length of the trail? It is difficult to understand
why the clinical relation between the oxaluric and glycosurie
status has not been invariably and clearly taught. Simon says,
" Clinically, two forms of this disease (oxaluria) may be
described ; one characterized by progressive loss of flesh, occur-
ring in already emaciated subjects, general malaise, various
dyspeptic and neurasthenic symptoms with pain in the lumbar
region. In the other form the subjects are usually fat, and
furunculosis, lancinating pains, with neuralgic or neurasthenic
symptoms are present." Bartholow says of diabetes, " There
are two distinct types of subjects affected, the obese and phleg-
matic, the thin and nervous." To all of us the remainder of
their clinical history is familiar ; the (uruneular and carbuncu-
lar manifestations in the one type and the nervous hypochon-
driac symptoms in the alternate. Osier, speaking perhaps
prophetically, said of oxaluria, " Its local and general symp-
toms are probably dependent upon some disturbance of meta-
bjllsm, of which the oxaluria is but one of the many manifesta-
tions." Does not this likewise point to the fact of there being
this by-path along the road to the diabetic condition ? That
there is a very definite relation between the two no one can
deny. The line of research must be henceforth to establish the
measure thereof. If it be fundamental, we will have an added
means of clinical diagnosis within our grasp. If it be but coin-
cidental, we have at least a field wide in its resources for clin-
ical variation.
HYGIENE AND PUBLIC HEALTH.
BY
JEROME WALTER, M.D.,
of Brooklyn, N. Y.
To the Editor of American Medicine : — In your issue of May
10 you suggest that " hygiene and all matters pertaining to
personal and public health " should be taught by members of
the medical profession to the people in the free lecture move-
ment in New York City, and under different auspices in other
cities. Several physicians have lectured on these subjects for
several seasons in the free lecture course of New York, I among
the rest. The subjects selected by the supervisor for me have
been "Foods," "Skin," "Clothing," "Bathing" and "The
Nervous System," most of the time being given to the four first
topics. It has been a pleasure to talk to the people on these sub-
jects, for the audiences are attentive. They are also critical,
because they have been educated by listening to series of lectures
on various subjects, most of them illustrated by lantern slides.
Most lectures on hygiene do not admit of much lantern Illustra-
tions, and yet the people like " pictures," and many come to
lectures to see, not to hear. A lecture ou a hygienic subject
must be usually terse and interesting, and above all, truthful
in statement, otherwise it will be considered as " stupid " and
people will not come a second time to hear the lecturer.
It is a curious fact that while American Medicine advocates
popularizing the science of hygiene, and the State Board of
Health of Michigan suggests the use of the term in the schools
of " Sanitary Science " instead of physiology, the study of
hygiene is being discouraged in the public schools of some of
our cities. The fashion now is in such cities to combine physi-
ology with biology or zoology, giving less time to physiology
than heretofore. There is quite a prevalent idea among educators
that physiology is an easy subject to teach, and that any
teacher can grasp the subject. Whether it is or not need not be
discussed now, but hygiene is lost sight of. Yet the truths of
anatomy and physiology are only of value to the pupil as they
help to make clear the science and art of hygiene. Shall the
study of hygiene in the schools be extended or retired? is a
question that should invite discussion.
December 6, 1902|
APPENDICEAL DISEASE IN THE FEMALE
fAMEBICAN MKDICINE 8 ?5
ORIGINAL ARTICLES
PUS IN THE PELVIS DEPENDING UPON AND COM-
PLICATING APPENDICEAL DISEASE IN THE
FEMALE : METHODS OF TREATMENT.'
BY
JOHN B. DEAVER, M.D.,
of Philadelphia.
Surgeon-in-Chlef to the German Hospital, Philadelphia.
A localized purulent collection in the female pelvis
may be due to a pyosalpinx, tuhoovarian abscess, sup-
purating ovarian cyst, suppurating fibroid, hematocele
(such as a ruptured extrauterine pregnancy, which has
become infected), and lastly appendiceal disea.se.
Appendicitis may cause a pelvic abscess in one of
three ways: (1) By the extension of a purulent col-
lection from the right iliac fossa to the pelvis ; (2) by an
appendiceal abscess in the pelvis with the appendi.x
hanging over the ileo-pectineal line or entirely in the
true pelvis ; (3) and lastly, by infection of the tube and
ovary with involvement of both appendix and adnexa
in a purulent exudate.
Of course, in the rapid cases of appendicitis with
general peritoneal Infection the pelvis is as a rule filled
with sero-pus, but the majority of instances of pelvic
abscess with an appendix above the ileo-pectineal line
are due to a secondary involvement from the primary
focus. A woman develops a sudden attack of acute
appendicitis with pain, right sided rigidity, tenderness
and nausea, perhaps vomiting ; and, if the bacterial
infection is virulent enough, a localized purulent peri-
tonitis results with absceas formation. When insuf-
ficient adhesions are formed below, the pus will leak
into the pelvis and form a secondary abscess. The
patient may then suffer from bladder or rectal irrita-
bility and, from absorption of bacterial products, will
weaken and become septic. Physical examination may
reveal a ma.ss in the right iliac fo&sa, usually hard and
painful, and a vaginal or rectal examination disclo.se the
presence of a tender mass in the pelvis. A leukocy-
tosis of 18,000 or 20,000 is found as a rule.
With the appendix in the pelvis, somewhat the same
course is observed. The pain does not become localized
to the right side as a rule, but left-sided colic may be a
prominent symptom. The bladder irritability is more
marked and its the di8:'a.se progresses there seems to be
less septic absorption, with the pus confined to the pel-
vis. There may be no maas perceptible on abdominal
pall)ation, though a c-areful vaginal examination will
locate the lesion
The percentage of ca.ses in which acute appendicitis
exists in the female has been variously estimated by dif-
ferent observers and with wide variation. During 1901,
of 2.38 adult patients with acute appendicitis operated
upon by me, 34.8 fc were women.
Bland Sutton states that for some time appendicitis
was considered a disea.se peculiar to males, but that more
extended observation and more accurate diagnosis had
raised the percentage in the female. The error in diag-
nosis most often made is that between pyosalpinx and
apixindicitis, and this error is the more serious in that
ai)pendiceal disease is progressive in character and
demands o[ieration during the earliest stages, while a
salpingitis, which is usually due to gonorrhea, do<'s not
require an early operation tiecause of the limiting nature
of the disease. Those cases of salpingitis due to appendi-
ceal infection will be referred to later.
Pelvic al)scess due to infection ascending the tubes
will present symptoms distinguishing it from appendi-
ceal abscess in most instances. In the former class of
cases, and especially when the gouococcus is the infei-t-
> Read before the Philadelphlii OliHtetrlcal Hoclety, Noveml)er 7,
1902.
ing agent, the disease is very apt to be bilateral, and a
tender mass or resistance may be noted upon vaginal
examination. There is less sepsis, less abdominal
rigidity and tenderness, and a more prolonged course
before serious symptoms develop. In appendiceal
abscess the history of previous good health and the sud-
den attack of abdominal pain with nausea and rigidity
and the rapid progression of symptoms should help in
the diagnosis. A vaginal examination reveals a distinct
increase of resistance on the right side. Of course, the
history of a previous specific infection and the finding of
the gonococcus in the vaginal discharge would decide the
diagnosis, but such a history is difficult to obtain, and
the diplococcl cannot always be identified immediately.
A small ovarian cyst on the right side, twisted on
its pedicle, may simulate appendicitis in the pelvis,
with abscess. The more gradual onset and the less
colicky nature of the pain should be observed, and upon
vaginal examination the mass can be outlined more
easily, and has not the doughy feel of the appendiceal
absceas. There are fewer constitutional symptoms,
unless the cyst has become infected. It is interesting in
this connection to note that cases of infection of ovarian
cysts by a diseased appendix have been reported.
Extrauterine pregnancy gives the irregular menstrual
history, metrorrhagia, and sometimes the other subjec-
tive signs of pregnancy with the absence of the early
history of appendicitis. If rupture should o«!ur and the
resulting hematocele become infected, the diagnosis is
rendered very difficult, unless the patient can give a
clear description of the character of the pain and the col-
lapse at the time of rupture. In a robust individual the
anemia and weakness would be more marked than in
appendiceal disease.
Uterine fibroids are rarely confused with appendiceal
pelvic abscess. The following case, of interest in this
connection, came under my observation last summer :
A married woman of 38 years, without children and with
no previous menstrual irregularities or dysmenorrhea, was
seized with acute pain across the lower part of the abdomen,
localizing in a few hours to the right iliac fossa. Two weeks
later she noticed a mass about one inch below MoBurney's
point. Medical advice was sought, appendicitis with abscess
diagnosed, and operation advised. She then sought the opinion
of a gynecologist in this city, who confirmed the diagnosis. Eight
weeks after the onset of the acute attack she wa.s referred to me
at the Gorman Hospital. Examination of the abdomen revealed
a mass in the right iliac fossa about the size of an orange,
slightly tender and hard to the touch. There was no rigidity
and no vesical symptoms. Vaginal examination revealed a
mass in both culdesacs, more marked on the right side, and on
the same side a small nodule could be felt. Bimanual exami-
nation moved the mass in the abdomen and the nodule in
unison, and a diagnosis of fibroid uterus was made, with no
appendiceal abscess, but with inflammatory exudate around
the fibroid nodule which occupied the right iliac fossa.
Operation confirmed the diagnosis. Evidently the fibroid
was locked in the pelvis, and at the time of the " acute attack "
of circumscribed peritonitis the fibroid had slipped up over the
brim of the pelvis. The appendix was small and buried behind
the cecum and in no way related to the inflammatory trouble.
There now remains for us to consider a very interest-
ing phase of appendicitis, in which the right tube or
ovary may become infecte<l from a diseased appendix in
the pelvis. The number of cases reported of late years
would justify the assumption that appendicitis is a fre-
quent cause of salpingitis. Ten years ago Robb reported
a case in which acute appendicitis and pyosalpingitis
existetl on the right side, from both of which the strepto-
coccus was obtained. The tube on the left side, while
inflamed, was negative bacteriologically. Coe, Ijeunan-
der, Sutton, Crutcher, Davenport, Peterson, McCrae,
Downes, Somers, Ochsncr, and Kelly, among others,
have referred to apiM'ndicitis as a cause of salpingitis.
Ochsner in a tot^il of 248 patients found the appendix
and one or both fallopian tubes involved in 56 cases, of
which 41 hiwl primarily an apiwndicitis from which the
infection extended to the fallopian tube, while in 15
cases the pyosalpinx was the source of primary infection.
He further says that 30 fc of perforative or gangrenous
886 AxraicAw MiBicnntj VAGINAL SECTION OF PELVIC STRUCTURES
(December 6, 1902
appendicitis cases have a secondary involvement of the
right tube and ovary,
Peterson reports that in 9 cases of pyosalpinx, in 3
the appendix was adherent to the adnexa.
Keily states "that in a series of 115 abdominal sec-
tions in which the appendix was noted at the operation,
it was found adherent to the right tube or ovary in 10
cases, in 37 cases it was involved in adhesions, was con-
gested in 3 cases, and obliterated at the cecal end in 1
case. Only 64 appendices were perfectly normal."
Of the 83 female patients with acute appendicitis
operated upon at the German Hospital last year, in 5 dis-
ease of the adnexa was coincident. In 1 a cystic con-
dition of both tubes and ovaries was present ; in another
double pyosalpinx with an infected appendix. While in
3 cases an acutely congested and inflamed appendix
was undoubtedly the cause of a right-sided pyosalpinx
without any disease on the left side. In one case in
particular an abscess existed about the appendix, which
was perforated and necrotic, and to the wall of the abscess
the right tube was glued and dilated with pus. The left
tube was small and only slightly congested.
Clado has demonstrated the presence of a prolonga-
tion extending from the meso-appendix to the ovary and
styled the appendicular-ovarian ligament. It conveys
an additional bloodvessel to the appendix from the
ovarian artery and a chain of lymphatics as well, these
furnishing means of direct communication between the
two organs. Furthermore, the appendix when situated
in the pelvis lies in immediate proximity to the uterine
adnexa.
When the appendix is subjected to frequent attacks
of inflammation there results, as is well known, the for-
mation of more or less extensive adhesions to neighbor-
ing structures. With the appendix in close contact to
the right tube and ovary these organs are apt to become
adherent to it and a migration of pathogenic micro-
organisms through the walls of the appendix to the
adnexa can readily take place. This is especially true
when the appendix becomes acutely inflamed after
several previous attacks. The most frequent organism
found in the diseased appendix is the colon bacillus.
This is an uncommon cause of salpingitis, but such has
been recorded. For instance, Reigmond and Magill
reported 6 cases and trace each to intestinal infection.
The symptoms of pyosalpinx, due to appendicitis,
are those of appendicitis in the pelvis followed by
dysmenorrhea and irregular menstruation, sometimes
leukorrhea and the other symptoms of unilateral pyosal-
pinx without the indurated feeling of the vagina. There
is also no history indicating a gonorrheal infection.
The treatment of the appendiceal abscess will depend
upon the location of the pus and the condition of the
patient. In cases in which abscess is high enough in
the pelvis it may be reached by an incision in the loin
and reflecting the peritoneum from the iliac fossa, open-
ing and evacuating the abscess below its upper limits.
The cavity is then washed out and packed with gauze.
An extraperitoneal operation of this nature is advocated
only because of the size and situation of the abscess and
the infectious nature of the appendiceal pus, which may
render a complete operation more hazardous. The
number of times this method can be employed is neces-
sarily limited, and I have several times had to abandon
the procedure, failing to get below the upper limits of
the pus, and open the parietal peritoneum to the median
line side of the wall after all. This is especially the case
when the appendix, while pointing into the pelvis, is
well to the median line, and the great omentum endeav-
oring to aid in the formation of a protecting barrier
becomes infiltrated and simulates a mass.
If the condition of the patient is desperate, i. e., if
the anemia and sepsis are so marked that a prolonged
operation would cause the death of the patient, the
ab<cess may be evacuated by drawing the cervix well
forward or backward and incising the posterior vaginal
vault anteriorly or posteriorly freely, opening the
peritoneum and evacuating the pus; irrigation should
not be practised, and the cavity simply drained
with gauze. To repeat, this operation is indicated
only when the patient is in very poor condition.
While vaginal evacuation of a pelvic abscess, due to
tubal or uterine infection, is feasible and attended with
but little risk, that due to appendiceal disease is a more
serious undertaking. In the former the pus forms at
the lowest point in the pelvis and will push the intestine
upward, while in appendicitis the bowel is not only
involved in the abscess, but may tie first encountered on
opening the peritoneum.
Using the finger to evacuate the pus after incising the
posterior vaginal wall is very liable to spread the infec-
tion from the pelvis upward. The pus in appendicitis
is of a "vicious" nature and exceedingly virulent,
while it is well known that accidental rupture of a pyo-
salpinx while delivering the tube may spread the pus
over the bowel without caasing peritonitis. Whenever
poasible the abdomen should be opened and the intes-
tines well walled ofi" with gauze packing. The abscess
may then be opened and the pus wiped away with
gauze. The appendix and any infiltrated exudate or
omentum are ligated and excised and the tubes examined,
especially on the right side. In many instances they
will be diseased and may have to be removed, but if
possible should be left in situ, after walling off with
sterile gauze. The pelvis should be well drained with
gauze and a glass tube may be used for the first 24 or 48
hours.
The mortality from appendicitis with abscess in the
pelvis is considerably less than in those cases in which
the appendix lies tiehind the cecum, pointing upward or
to the median side of the cecum. I have seldom
observed necrosis of the bowel in the pelvic cases, and
consequently sepsis from absorption through the bowel
wall and fistula are of less frequent occurrence.
Death from sepsis is infrequent, perhaps because of
the lessened absorption in the pelvis, the pelvic perito-
neum being more tolerant than the bowel peritoneum.
BIBLIOaRAPHY.
Clado: Compt. Rend. Soc. de Blologle, 1S92.
Coe : The Physician and Surgeon, N. Y., November, 1894.
Crutcher : Appendicitis, Chicago. 1897.
Davenport: Providence Med. Jour., July, 1900, p. 100.
Downes : A merican Medicine, December 14, 1901.
Kelly: Operative Gynecology, 1898, Vol. 11, p. 213.
Kelly : Jour. Am. Med. Asso , Oct, 25. 1902.
Leunander: Appendicitis, Vienna, 1895.
MjcRae: New York Med. Jour., February 2, 1901.
Ochsner: Appendicitis, Chicago, 1902.
Peterson : American Gynecology, August, 1902.
Kelgmond and Magill : Annals of Surgery, Vol. xxlv, p. 459.
Robb: Johns Hoplsins Hosp. Bulletin, 1892, Vol, ill, p. '.3.
Soraers : Occidental Medical Times, December, 1901, p. 4;i3.
Sutton : Clinical Journal, March 14, 1900.
VAGINAL SECTION IN SUPPURATIVE DISEASE OF
THE PELVIC STRUCTURES : INDICATIONS AND
TECHNIC
BY
E. E. MONTGOMERY, M.D.,
of Philadelphia.
Professor of Gynecology, J eflTerson Medical College.
The possibility of successful treatment of the pelvic
organs through vaginal section has been demonstrated,
and is no longer to be questioned. The expediency of
this choice of route is still a subject of discussion and will
be decided very largely by the experience and predilec-
tion of the individual operator. While appreciating its
advantages for the relief of many conditions, I would not
assume that it should be the only route of attack. The
operator should decide the course of procedure only after
a careful investigation of the victim of the diseased
process. A procedure which will be applicable to one
• Read before the Philadelphia Obstetrical Society, November 7,
1902.
Decembeb 6, 1902]
PUS IN THE PELVIS
Amebicas Medicine 887
case will be wholly inadequate or undesirable in another.
If ooe were forced to choose a route of attack in pelvic
disease which should be applicable to all cases, he would
be compelled to decide in favor of the abdominal as
alfording the greater liberty of inspection and of action.
It is, however, a well recognized axiom in surgery that
the existence of pus demands its early evacuation
in that direction which affords the most complete drain-
age of the cavity with the least discomfort and incon-
venience to the patient. The abdominal route should no
more be selected for the routine evacuation of a large pus
accumulation in the lower pelvis than the same route to
reach a suppuration in the kidney or perirenal region,
or a median incision for a collection of pus about the
appendix. The existence of pus in an organ or cavity
must not be considered a positive indication for extirpa-
tion of the structure, even though it be lined by mucous
membrane. Doubtless many surgeons have seen cases of
evident tubal inflammation in which circumstantial
evidence would indicate gonorrheal salpingitis, and have
advised extirpation of the adnexa, when subsequently
the patients have recovered sufficiently to give birth to
children. In many instances I have broken up adhe-
sions, reopened closed tubes and in some cases milked
out and emptied them of a thin whitish discharge, then
returned them to the abdomen, closed the wound with-
out drainage, and had the patient pursue a normal con-
valescence. Such procedures can readily be accomplished
by an incision through either the posterior or anterior
vaginal fornix. I have been asked to give the indica-
tions for vaginal section, but before doing so I would
say, (1) incision is contraindicated through a virgin
vagina, (2) it should be discarded when the suppurative
collections are situated in the abdomen and do not dip
down into the pelvis, and (3) when the disease is sit-
uated at a high level upon one side of the pelvis, the
uterus remote from the vaginal orifice, and the operator
is desirous of saving one tube and ovary.
Vaginal incision should be the operation of election
when the pelvis, and especially the retrouterine pouch,
is the seat of a large collection of pus, whether secondary
to tubal disease or resulting from the degeneration and
infection of a pelvic hematoma. It should be the only
method contemplated when the condition of the patient
is so precarious that a severe operation cannot be con-
sidered. In such cases it is confined to incision and
drainage, leaving radical measures to a later period
when the patient has recovered her impaired vitality to
some degree. In suitable cases, the experienced operator
will prefer it when both ovaries and tubes are so evi-
dently destroyed as to render their retention a menace to
the life and future good health of the affected individual.
By suitable cases are meant those in which the organ is
readily accessible through the vagina and the disease is
confined within the limits of the pelvis or easily reached
through it. V^ery obese i>atients generally present more
ready access to the pelvic organs through the vagina.
As a preliminary to the operation, the lx)wels should be
thoroughly evacuated and the lower bowel cleansed by
frequent enemas. The vagina should be scrubbed by
gauze-wrapped fingers, using first a solution of creolin
7.") cc. (3ij), tr. sapon. virid. 60 ec. (.^ij) to a quart of hot
water, followed by the same process with sterile water,
and finally with alcohol. With a gauze sponge the
vagina and vulva are wijied dry, the cervix seized with
a double tenaculum and held forward, the perineum
retractefl and an incision with scissors or knife made
through the posterior vaginal fornix to eva<;uate retro-
uterine collections. The cavity is thoroughly irrigated
with a hot normal salt solution, and a careful examina-
tion made of the jK^lvic viscera. The tulx« and ovaries
are easily traced ; if either are sacculated they can be
readily incised and their contents emptied. The exposed
cavity should be thoroughly packed with iodoform
gauze. When the distended tubes are not i)rolapsed
they can often be more readily reached through an
anterior incision. Through such an opening the fundus
uteri can be turned down, the inspection of the ovaries
and tubes secured, and prop*»r treatment of diseased con-
ditions instituted.
While in abdominal operations I drain much less fre-
quently than formerly. Indeed rarely, yet I am confi-
dent that with gauze drainage through the vagina the
convalescence of the patient is more rapid, attended
with less distress and the subsequent health is quite as
good as after an abdominal section. In some cases the
drainage is l)est secure<l and the promise of good health
of the patient enhanced by the extirpation of the uterus.
After the incision, anterior and posterior, the fundus
is turned forward, and the ovaries and tubes reached
over the fundus. This position puts the broad ligament
upon a stretch and permits its course to be followed
readily so that adhesions of tube and ovary can be easily
recognized and torn off with greater ease than when
proceeding from above. The uterine arteries are easily
seen and can be secured by pressure forceps. The
upper part of the ligament should be ligated with
chromic catgut. The uterine arteries are likewise ligated
and the pelvic cavity packed with iodoform gauze.
The procedure can frequently be greatly ex peditetl by
employment of the method introduced by Landau and so
extensively practised by Pryor, which consists in the
bisection of the uterus and the removal of the separate
halves, which affords additional room for easy manipu-
lation. When the suppurative condition is complicated
by the presence of fibroid growths the latter can be
enucleated and the size of the ma.ss thus reduced.
The advantages of the vaginal section are : First, it
is r^arded as a less serious operation by the patient,
who will consequently consent to it at an earlier date,
when the chances for her recovery without a sacrificial
operation are much more probable. Second, the patient
experiences less pain and discomfort, her convalescence
is more rapid and she bears upon her body no marks of
the procedure.
PUS IN THE PELVIS AS A RESULT OF BONE OR
JOINT NECROSIS : DIAGNOSIS AND TREATMENT.'
BY
H. AUGUSTUS WILSON, M.D.,
of PWladelphla.
Clinical Professor of Orthopedic Surgery in the .lefferson Medical (Col-
lege ; Consulting Orthopedic Surgeon to the Philadelphia
Lj'ing-ln Charity and to the Kensington
Hospital for Women.
There are three principal sources of pus in the pelvis
having their origin in tuberculous bone— Pott's disease,
hip disease and tuberculous disea.se of the pelvic bones,
especially sacroiliac disease. It is to these three condi-
tions that this limited pa{>er will be confined, giving
emphasis to the last named as the condition most fre-
quently causing confusion with abscesses of the pelvic
organs. The real difficulties in diagnosis arise in cases
in which acute or chronic diseases of the pelvic organs
coexist with tuberculous bone diseases, or in cases in
which such diseases may have previously existed.
Abscess formation in Pott's disease not infrequently
exists for years after the original bone lesion has healed,
and not^infrequently when there is no spinal deformity
t<} direct attention to the site of its previous invasion.
A psoas or lumbar abscess has no well-definetl direction
of advance, but its vagaries cause it to be confused with
other conditions. Reliance must be placed upon the
evidences f)f the old bone disease. In the absence of
well-marked angular kyphosis or of a slight angular
curvature, faulty mechanical function of the spine will
be observed, due to bony ankylosis of two or more
vertebras. Often the most careful analysis will fail to
detect such ankyloses in those cases in which a perfect
recovery has taken place.
■ Read before the Pbl<adel|hla Olstetrloal Society, November 7,
1902.
S88 AnXBIOAir MEDICINE]
rU8 IN THE PELVIS
IDecehbeb 6, 1902
An abscess having its origin in tlie spine can always
be felt above the pelvis and by through-and-through
palpation ; its usually elongated shape lying close to and
upon one or both sides of the spine will indicate its
spinal origin. The history of the original Pott's disease
and the peculiar character of the temperature will aid in
the diagnosis. Pott's disease is peculiarly a disease of
childhood, and the adult woman is rarely affected pri-
marily by tuberculosis of the vertebra, although she
may be suffering with some of the results. Early recog-
nition has facilitated the early and prolonged procedures
which have made the recoveries so perfect as often to
leave no discernible trace of their former existence.
Sometimes less perfect recoveries are subjected to the
great strain of childbearing with the necessary altera-
tion of the postures of the spine as the child grows,
which produces a traumatism that the previously affected
joint is incapable of withstanding. In these cases a
relighting of the suppressed tuberculous process causes a
recurrence in adult life of the symptoms and conditions
of childhood. Such recurrences are usually unfavorable
in their progress, and abscess formation is more apt to
occur and become manifest in many ways peculiar to
tuberculous processes. The burden of pregnancy added
to the incapability of the spine, the desire of the mother
to nurse and care for the infant, make it extremely diffi-
cult to establish fixation of the spine and remove the
superincumbent weight. Such abscess formations are
usually viewed from the obstetric standpoint only, and
the natural recovery from pregnancy expected, and as a
result there is a failure to give the necessary attention
to the possible recurrence of spinal tuberculosis. After .
the usual period of convalescence from pregnancy has
occurred and the conditions of the patient indicating
serious disability, search for the real cause reveals the
presence of an abscess having its origin in the previously
existing tuberculous spine. Usually these abscesses
advance with greater rapidity than in childhood, and
unless evacuated by incision rupture spontaneously, for
which purpose they seem to select the worst possible
position for the subsequent sinus.
The more or less common backache of pregnant
women has often been in reality the cry for relief of
some overburdened spine that had recovered from tuber-
culosis in childhood. The triviality of backache and
growing pains are snares that have entrapped many con-
scientious and careful physicians into passing without
proper investigation the early symptoms of serious spinal
disease until they become too pronounced to be further
ignored. Too often the efficiency of appropriate meas-
ures in the incipiency have been destroyed by delays in
diagnosis not always easily avoided.
Abscess accumulations within the pelvis, due to hip
■disease are very rare, and occur only in those extreme
cases in which the acetabulum has been perforated, and
«ven then the tendency is more toward a downward
outlet than toward an upward course. It is a possible
source of pus within the pelvis, but the peculiar char-
acter of the destructive changes in the hip-joint would
prevent a mistake being made as to the origin. Again,
as in the spine, it is possible that pus from some other
condition may occur coincidently in a case of extreme
destruction of the acetabulum. In such cases the phe-
nomena of the hip-joint destruction would be clearly and
unmistakably marked.
Sacroiliac disease with abscess accumulation is per-
haps the most difficult of all to determine accurately its
source, and according to Senn it is quite frequent. The
absence of spinal limitation of motion, its occasional
cause being the traumatism of pregnancy, tends to make
a correct diagnosis very difficult. Because of the greater
exposure to exciting causes, men are more frequently
affected than women. It has been observed in cavalry
s)ldiers claused by the necessity of this joint sustaining a
.severe strain while in the saddle. It rarely occurs before
.the age of 15, and is most common in young adult life.
The symptoms in the early part are, difficulty of micturi-
tion or in bowel movements, general indisposition, slight
abdominal distreas. Patients often say that they feel as
though they were falling apart. Tilting of the pelvis is
characteristic. The limp is peculiar in the effort to
avoid pressure upon the affected joint which, however,
must occur with every step. The effort of the patient is
constantly to avoid using the affected side, and the leg
upon that side is allowed to hang. All jarring is
avoided by cautious movements, the patient preferring
to avoid heel-pressure in walking and standing. The
patient easily becomes fatigued. Motions of bending
forward and returning to the perpendicular are per-
formed with difficulty. Owing to the peculiar character
of the joint, there is no muscular spasm, such as occurs
in the incipiency in all movable joints affected with
tuberculous osteitis. The progress is insidious. The
pain at first is fugitive and intermittent, and soon
becomes constant and severe. Pain is nearly always
prt-sent, but is not always referable to the affected joint,
and varies as to its intensity and character. It is made
worse by standing or sitting, and is usually relieved by
recumbency. It is worse at night, and night cries are
often present. Patient prefers to lie upon the sound side
or upon the back. The pain often assumes the character
of sciatica, for which condition it has been frequently
mistaken. The pain is increased upon simultaneous
pressure upon the trochanters or upon the wings of the
ilia, and is referred to the site of the disease. Pressure
directly over the joint is painful. Anterior pressure over
the joint made by the fingers in the rectum elicits pain.
Pain is increased when the patient turns the body in
either the upright or recumbent position, by coughing,
sneezing or laughing. Abscess occurs in the majority of
cases, more commonly forming on the inner aspect of
the joint, but it may take place posteriorly. It may
appear in the groin like a psoas abscess, or at either
sacrosciatic notch or in the ischiorectal fossa.
The unfavorable prognosis of sacroiliac tuberculosis
is largely due to the more or less remote period at which
recognition occurs and appropriate treatment is applied.
In the incipiency recovery may almost invariably be
assured, and even after abscess formation a good recov-
ery may be obtained, even though slowly .secured. A
second and a third pregnancy has occurred after a tuber-
culous disease of this joint, illustrating the favorable
tendency under appropriate conditions.
Sacroiliac disease has been mistaken for sciatica, lum-
bago, psoitis, hip disease. Pott's disease, ovarian abscess
and diseases, and rectal abscess. The contiguous bones
and their synchondrosis are liable to have other affec-
tions than tuberculous disease ; among these may be men-
tioned osteomyelitis, acute and chronic articular or
gonorrheal rheumatism, arthritis deformans, and various
tumors may have their site in the locality of this joint ;
hydatids, enchondromas, sarcomas. Osteomyelitis is the
only one of the foregoing conditions likely to be accompa-
nied by pus. The rapidity of its onset and progress, and
the higher temperature, give evidence of an acute
process.
The other bones composing the pelvis are remotely
liable to become involved in a tuberculous or other
process either primarily or secondarily, but when so
affected it is almost invariably in childhood. It is only
likely that a knowledge of the symptoms of these con-
ditions would be required in the diagnosis of pelvic pus
in an adult woman. A walled-in or healed circumscribed
abscess accumulation, having its origin in the bones of
the pelvis, can persist from early childhood. The occur-
rence is rare, however.
I wish that I could remove the idea of the hopeless-
ness of tuberculous bone disease. This prevalent con-
ception has perhaps done more than anything else to
interfere with complete recovery by postponing the
application of proper and rational treatment until the
entire constitution has succumi^ed to the strain. It is
December 6, 1902J
DRAINAGE IN OPERATIONS
■American Medicinb 889
important that tuberculous bone and joint disease should
be considered as being such only when the condition is
in the incipiency, and that any conditions arising after
that period should be classed as results, and not neces-
sarily a part of the disease. The occurrence of these
results should be viewed as avoidable, to be avoided by
early diagnosis and appropriate immobilization pro-
longed beyond the possibility of recurrence, avoidance
of passive or active motions at all times ; increasing
the powers of recuperation and resistance by outdoor
life, careful attention to hygiene and building up the
general constitution. It is by such procedures that
abscess formation will be avoided, and then the diffi-
culties of diagnosis will not appear.
DRAINAGE IN OPERATIONS FOR SUPPURATIVE
DISEASE OF THE PELVIC ORGANS.'
BY
J. M. BALDY, M.D.,
of Philadelphia.
Drainage is a necessary evil in surgery, the necessity
for which is always to be deplored. Such is the case at
present and such it probably will be for all time. The
relations of drainage to pelvic surgery are exactly simi-
lar in principle as those to general surgery, being modi-
fled only by anatomic considerations. I am asked to
confine my remarks to drainage in operations for sup-
purative diseases of the pelvic organs and find it a par-
ticularly easy thing to do, as I know of no other condi-
tion in pelvic surgery, unless in exceptional instances, in
which drainage is a proper procedure. I exclude, of
course, such patients as are too weak to stand the neces-
sary time on the operating table. Drainage in non-
^ppurative diseases is an admission that the surgeon
has not yet learned the value and use of his needle and
catgut and this is true in exact ratio to the number of
his drainage cases.
In suppurative and infective ca.ses we are met by
another proposition ; but even here what I have said
holds good in great measure. The more experience, the
greater skill in the use of the needle and catgut, the less
the necessity for drainage. This is even more true when
the suppuration is confined to a sac which can be removed
with the results of the suppuration. Fortunately the
large majority of cases of pelvic suppuration are of this
type ; the minority only are true pelvic abscesses.
As a basis from which to distinguish the necessity for
or against drainage it may be stated that in cases of
ovarian absceas, pus-tubes, abscess of the uterine wall
(when it is justifiable to remove the uterus), in but rare
instances is drainage necessary. Two complicating con-
ditions in these casas must be considered as poasibly
modifying our decision : abscesses in the adhesions or
lymph surrounding the affected organ, and the acute-
ness of the infection. In the former condition it is rarely
necessary to decide for drainage ; these patients can and
should usually be treated without drainage. The one
thing which should most often decide the surgeon to
•Irain is the acuteness and virfilence of the infection. It
is a wellknown bacteriologic and clinical fact that a pus
which is today virulent and almost certain to infect the
o[)erative wounds may next week be handled with
impunity. An acute suppuration of the pelvic organs,
either gonorrheal or puerperal, should be allowed to
advance as far into the subacute stage as is consistent
with the safety of the patient before an operation is per-
foriruHl. I n the case of gonorrheal infection this advice
is saf<' for any physician to follow wlio knows sufficient
to be allowed to operate at all. To the other class I am
not addressing myself. 1 know full well this advice is
dangerous so far as it pertains to puerperal infection, but
I am talking now to a body of men who are specialists
1 Kcad before the Philadelphia Obstetrical Society, November 7,
1!I02.
and with whom it is not necessary to discuss expedi-
ency. I am giving you the rulas which govern my own
practice so far as it is governed by rules at all. I am
free to admit, however, that I am not much of a
respecter of rules but judge of the case on its own merits
when the patient is on the table. It might as well be
admitted also that when in doubt the decision is gener-
ally against drainage.
Suppurative diseases of the pelvis itself, such as puer-
peral abscesses free in the pelvic cavity (intraperitoneal),
suppurations in the pelvic connective tissue (broad liga-
rnents, etc.), pus in the pelvis as the result of bone or
joint necrosis, will always demand drainage and the
sooner it is established the better. In this class of cases
the more acute and virulent the infection the more the
necessity for drainage. In the first two conditions
vaginal drainage is the safest and best. Vaginal opera-
tions will always demand a much greater percentage of
drainage than will operations by the abdominal route
for the reason that it is practically impossible to cover
over raw and bleeding surfaces. As a matter of fact
surgeons who operate by the vaginal route establish
drainage in practically all of their cases, suppurative or
otherwise. It is one of the great objections to this route
for operating.
Taking my work as a whole, if it were asked what
was the percentage of cases in which drainage was estab-
lished, it would not be possible to say without looking
up scattered records of years of work. I should guess,
however, ^ot more than 5fc. If it should be asked do I
not at times close the wounds of patients when subse-
quent events prove that it would have been best to have
drained, I must in all candor answer that I do. It is
largely a question of judgment, and everything else
being equal, that man's judgment is the best who has
had the most experience, and yet the man with the
greatest amount of experience and the very best judg-
ment will err at times. Granting that the pus is no
longer virulent little more harm than a delayed conva-
lescence will result. There will be an accumulation of
drainage material in the pelvis, an accelerated pulse with
a moderate temperature of a septic character to indicate
the condition. Other causes being excluded, the knowl-
edge that the case was one for possible drainage, the
temperature and pulse, together with the vaginal exami-
nation, will render the nature of the trouble perfectly
apparent and will demand the opening of the vaginal
culdesac into the peritoneal cavity, irrigation and the
introduction of a drainage-tube ; a procedure which
occupies but five minutes and which is attended with no
danger. I have never seen a case which took any other
course than this. As to whether or not it results dis-
astrously to a patient depends largely on the judgment
of the surgeon conducting the after-treatment; if he
allow the condition to go beyond a certain stage unrecog-
nized the patient may succumb to sepsis. I was faced
with the necessity of opening the vaginal culdesac twice
under such circumstances during my last winter's work,
and so far as my recollection goes did not use a drainage-
tube of any kind in the pelvis. It is certainly unpleas-
ant to be forced to establish drainage subsequent to an
operation, but it is also unfortunate to care lor and run
the risks of the use of a large num'ier of drainage-tubes.
It is a choice of evils in the class of cases with which we
are dealing. With all the care possible, drainage-tubes
of any and all kinds through the abdominal incision pre-
dispose to fistulas, infected ligatures and hernias. Drain-
age-tubes through the vagina run as great risk of causing
infection as those through theabdominal wall. Surgeons
who dispense with drainage rarely or never see fistulas
and infected ligatures. In my judgment the risks of pel-
vic surgery are reduced to a minimum and the best inter-
ests of the patient subserved by dispensing with the
drainage-tube whenever possible, especially when it is
true that if an error of judgment has been cx)mmitted the
mistake is so readily and safely corrected.
890 AJiEBicAN Medicine.
RECENT ABDOMINAL CASES
[Decembek 6, 1902
CLINICAL NOTES ON SOME RECENT ABDOMINAL
CASES.'
BY
REUBEN PETERSON, A.B., M.D.,
of Ann Arbor, Mich.
Professor of Gynecology and Obstetrics, University of Michigan.
Cask \.— Splenectomy for a wandering spleen niluated in the
pelvis. This patient was referred to the gynecologic service of
the University of MichiKan Hospital through the kindne.ss of
one of the monibers of this society. Dr. J. C. Maxwell, ol Paw
Paw, Michigan, I showed the removed spleen before the
Chicago Gynecological Society in December last, and a brief
history of the case may be found in the transactions of that
society.* No report at that time was made of the blood changes
following the operation as shown by repeated examinations.
Hence I have thought it would not be out of place to make a
second report of the case, which should include a review of the
blood changes and a statement of the patient's present condiiion,
a year after the removal of the spleen.
Twenty years before entrance to the hospital the patient,
an exceedingly fleshy woman of .39, had been thrown to the
ground by a hard blow in the back. This accident was fol-
lowed by severe abdominal pain, which for the past three
years had been much worse. There was an indistinct feeling of
a mass in the pelvis. The laparotomy revealed a dislocated
spleen situated in the superior strait of the pelvis, its lower pole
adherent to the vesicoparietal peritoneum and its lower surface
resting upon the retroverted uterus. The immensely elongated
pedicle containing the splenic vessels was ligated by a chain
suture of catgut and dropped. On account of the enormous
amount of adipose tissue, the abdominal incision suppurated.
Otherwise the patient made an uninterrupted recovery.
Blood Chaitges.— Following the operation there was a de-
crease in the numberof red cells and hemoglobin, and a marked
increase in the number of leukocytes. The numbar of leuko-
cytes soon decreased, however, until they were only about one
and a half times the normal number, which condition remained
throughout her stay at the hospital. The red blood count and
hemoglobin soon regained their normal condition. A few days
after operation there appeared a few normoblasts which con-
tinued while the patient was under observation. On the fourth
day following vaccination there was a marked increase in the
large lymphocytes and a decrease in the small lymphocytes, but
this continued for only a few days. When she left the hospital
her blood was normal, save for a slight leukocytosis and an
occasional normoblast.
I am informed by her physician that she is at present in
excellent health. She has lost nearly 100 pounds and now
weighs only about 200 pounds. She has had no recurrence of
the severe attacks of abdominal pain so prominent before the
operation.
Wandering spleen is not a very common condition if
one may judge by the number of eases reported. J. C.
Warren' states that there have been 11 unoperated cases
during the past decade with 4 deaths, a mortality of
36.3fc. On the other hand, of 43 cases of wandering
spleen operated upon during the same decade, there was
a mortality of 6.9^, showing that as a prophylactic
measure extirpation of the wandering spleen is a justi-
fiable procedure and should be advised when the dis-
placement has produced marked abdominal symptoms.
Peters reports a case from the gynecologic service of
the Johns Hopkins Hospital. Attacks of renal colic
were produced by the pressure of the displaced spleen
upon the left ureter, and splenectomy was performed
with satisfactory results. Splenectomy has been per-
formed three times out of 9,261 admissions to the gyne-
cologic department of this hospital. In each case the
spleen was mistaken for another organ or neoplasm before
operation.
In the case reported I had not considered the possi-
bility of wandering spleen, but supposed the mass to be
a neoplasm until after the abdomen was opened.
The operation of splenopexy or the holding in place
of the displaced organ by sutures was considered, but
rejected because of the technical difficulties of such an
operation in such an obese patient ; and, second, because
of the great size of the spleen, as it was about four times
larger than normal.
From a study of this and other cases in literature I
1 Read by Invitation before the Kalamazoo Academy of Medicine.
October ai. 19(12.
'American Journal of Obstetrics, 1902, Vol. Iv, p. 420.
» Annals of Surgery, May, 1901.
am convinced that Warren's statement is correct: that
the blood changes resulting from a splenectomy are
not constant except for a nduction of the hemoglobin
and the red corpuscles and an increase of the white cor-
puscles. These conditions are of only temporary dura-
tion and in no way det)ar the patient from a complete
restoration to health after .splenectomy.
Case II. — Cesarean section for contracted pelvis ; recovery
of mother and child. The patient was a rachitic dwarf 4 feet
1 inch in height, aged 23. She was brought to the hospital May
23, 1902, by Dr. O. I>. Sigler, of Pinckney, Michigan. The
patient had been in labor over 24 hours, with the os fully
dilated and the head unengaged. Fortunately her physician
recognized the extreme contraction of the anteroposterior pel-
vic diameter, and made no attempts at delivery. At entrance
the pulse was 120 and of good strength. The diagonal conjugate
was only 5 cm., and it was evident that c-esarean section offered
the best chance for mother and child, and was in fact the only
operation indicated. The fetal heart was 148 and strong.
Operation. — Incision was made from the pubes to above the
umbilicus, followed by a longitudinal uterine incision. A child
was delivered weighing 6J pounds. An elastic ligature was
employed to control the bleeding. The uterine incision was
closed with two layers of interrupted catgut sutures. Mother
and child both recovered and were discharged from the hospital
five weeks later.
Forceps, symphysiotomy and even embryotomy were
contraindicated in the presence of such a high degree of
pelvic contraction. The absence of sepsis and the good
condition of the mother and fetus were also in favor of
the cesarean operation. The elastic ligature is unneces-
sary for the control of the bleeding from the uterine
incision, which is rarely troublesome. Any hemorrhage
can be controlled by the pressure of the assistant's hands
around the cervix and by stimulation of the uterus after
removal of the placenta.
Case III. — Large unilocular .suppurating ovarian cyst;
ovariotomy follotved by left ureteroabdominal fistula ; gradual
closure of latter ; recovery. The patient, a woman of 34, ha^
noticed a gradual eulargeinent of the abdomen for two years
prior to her being l)rought to the hospital by her physician.
Dr. James B. Wallace, of Saline, Mich., June 4, 19u2. About
two weeks before entrance she had been seized with intense
abdominal pains, accompanied by nausea, vomiting, and high
fever. Daring thesd two weeks there had been rapid enlarge-
ment of the abdomen and great prostration. The temperature
at entrance was 101°, pulse 124. The skin was dry and tongue
coated.
Examination showed an abdominal tumor, presenting all
the characteristics of an ovarian cyst, reaching as high as the
ensiform cartilage. The entire abdomen was exquisitely
tender, which sign, together with the history, led to a pro-
visional diagnosis of suppurating ovarian cyst.
The operation, four days later, established the correctness
of the diagnosis. There were 9,000 cc. of a foul-snielliug, dark-
colored pus evacuated from the cyst, and the latter removed.
The growth, which sprung from the right side, was densely
adherent to coils of the small and large intestine, fundus of the
uterus, and parietal peritoneum. During its enucleation the
adherent left ureter was recognized and stripped away from the
cyst wall. The enormous bleeding cavity lelt by tlie removal
of the cyst was packed with gauze, the ends of which were
brought out through the abdominal incision. This gauze was
removed some days later, and within a few days urine in large
amounts appeareil at the abdominal opening. The cavity
closed gradually, with concomitant healing of the fistula, and
was followed by the passage of urine by the natural channel.
Bacteriologic examination of the pus showed tlie presence of
Staphylococcus pyogenes aureus. The patient was discharged
cured, nine weeks after the operation.
The diagnosis lay between twist of the pedicle of an
ovarian cyst, with or without suppuration, and suppura-
tion without twist of the pedicle. The latter diagnosis
was favoi ed because of the absence of s^hock or trauma-
tism in connection with the onset of the acute symptoms.
A partial twist of the pedicle could not be excluded and
was considered. It is difficult to state the cau^e of the
infection. It may have arisen from the bowel, as the
adhesions of the intestines to the cyst wall appeared to
antedate the appearance of the acute symptoms. It is
surprising why a fatal peritonitis did not result from the
operation. Although every precaution was observed,
the peritoneal cavity no doubt was contaminated by the
purulent cyst contents. Possibly the gallons of hot salt
solution used in washing out the abdomen prior to the
closure of the wound may have aided in the prevention
December 6, 1902J
REPEATED ABORTION
iAKERICAN MEDICim 891
of the sepsis, but in other cases of suppurating cysts in
my practice, death has followed the use of the same
operative technic. A more lilcely explanation would be
the lack of virulence of the microorganisms in this par-
ticular case.
The ureteroabdominal fistula was an unavoidable
complication. The lesson to be learned from it is that
many ureteral fistulas will heal in time if they are so
situated that the surrounding parts can be packed care-
fully with gauze in such a way as to allow of a closure
of the wound from the bottom.
Case IV. — Puncture of an ovarian cyst follotvcd by leakage
into the abdominal cavity as shown by operation afexu days later.
I report this case In order to show the dangers of exploratory
puncture for the diagnosis of abdominal tumors. The patient,
a woman of 27, was referred to me by Dr. V. J. Rickard. of
Charlotte, Mich., ."Vugust 4, 1902. She presented unmistakalile
signs of a long pedicled ovarian cyst extending upward slightly
beyond the umbilicus. The growth was very movable and
nonsensitive. The case was considered with reference to diag-
nosis before the class of the summer school and a positive
opinion expressed as to the nature of the growth. As the course
was about to close and the members of the class could not be
present at the operation, I departed from my usual custom and
withdrew a small amount of fluid from the cyst, employing a
very fine aspirating needle. I explained that such a simple pro-
cedure, while not advisable when the abdomen is to be opened
later, was in reality free from danger if the precaution was
observed to avoid a bowel, and puncture was made through an
aseptic abdominal wall with an aseptic needle. The operation
a few days later showed the incorrectness of my statement, for
on exposure of the cyst its chocolate-brown contents could be
seen escaping through the needle puncture and there was nearly
a quart of fluid free in the abdominal cavity. Fortunately the
fluid was aseptic and the patient made an uninterrupted
recovery.
While exploratory puncture of a cyst may not be fol-
lowed in every instance by escape of fluid after the with-
drawal of the needle there is no way of knowing when
this will not take place. Hence from my experience
with the case just reported, I would never perform or
advise such puncture. It is impossible to state definitely
regarding the infectiousness of any cystic fluid and it is
the rule in abdominal surgery to act on the supposition
that every such fluid is septic and protect the peritoneal
cavity accordingly. The puncture of such a suppurating
ovarian cyst as existed in Case III would have been fol-
lowetl probably by a fatal peritonitis. My confidence in
using the small aspirating needle was ba.sed on the con-
viction that such a small puncture would close upon the
withdrawal of the needle and that no fluid would escape.
That this confidence was misplaced was shown clearly
by the subsequent operation.
Case V. — Myomectomij in a patient six months pregnant ;
recovery. The patient, a young married woman of 27, was
referred to me by Dr. C. VV. Palmer, of Chelsea, Mich., early in
the present month. Since her marriage nine months ago, her
periods have been irregular, her last regular menstruation
occurring in April, although she had a " show" in June. For
the past six weeks she has been growing larger, and has
noticed a lump in the right lower abdomen. The mass has
grown rapidly, and has given rise to considerable pain and
distress.
Examination showed a six months' pregnant uterus, in the
lower zone of which could be felt a fibroid mass the size of a
cocoanut. This was quite movable from side to side, but could
not be pushed upward. October 8, 1902, the patient was oper-
ated upon at my private hospital. The ai)domea was opened
by an incision from the pubes to the umbilicus, and the six
months' pregnant uterus with the tumor mass delivered
through the incision. The fibroid, the size of a fetal head, was
found to spring from the lower uterine segment, slightly to the
left of the median line. It was easily peeled from its capsule
through a five-inch incision. It was both interstitial and sub-
peritoneal, and the bottom of its bed was separated from the
fetal parts by only a very thin layer of soft tissue. The cavity
was closed by deep interrupted catgut sutures, reinforced by a
continuous T.embert suture. The uterus, which had been pro-
tected by warm towels, was returned within the abdo'.nen and
the incision closed by the separate suturing of the difl'erent
layers of the abdominal wall. The wound healed by first inten-
tion and the patient has shown no symptoms of aborting and
may be considered out of danger.
Here wsus a rapidly growing fibroid In a pregnant
ut<!rus giving rise to pressure symptoms. Was It safer
for mother and child to allow the pregnancy to continue
to full term, or to attempt the removal of the growth '!
Delayed operation meant possible miscarriage and loss
of child ; increased pressure symptoms with accompanj'-
ing loss of strength ; possibly obstructed and difficult
delivery with loss of child and great danger of sepsis.
Operation might mean loss of child from miscarriage or
necessity of sacrificing the entire uterus. It would seem
as if the operation offered better chances for the mother
and no worse for the child. I would have proposed
waiting until the child stood a better chance for life in
case of a premature delivery, had it not been for the
pressure symptoms.
THE GYNECOLOGIC AND OBSTETRIC ASPECT OF
REPEATED ABORTION.'
BY
S. MARX, M.D.,
of New York City.
The term abortion is used in the broader sense of the
vvord^- meaning the interruption of pregnancy at any
time during the period of uterogestation. This is done
solely for purposes of convenience and for clearness.
Under the strict obstetric classification the term abortion
would imply simply the evacuation of the uterine con-
tents up to the time of the first three months, the first
trimester ; the term miscarriage up to the time of pos-
sible viability, which would include and overstep the
period of the second trimester, and finally the term prem-
ature labor, from the period of viability to any time
up to the period of full term gestation which completes
the third period, or the last trimester. Consequently for
purposes of conciseness all the three periods are com-
bined into one and will be treated under the general
term abortion. We desire to emphasize two very
important factors which will be of the greatest practical
interest to us all as clinicians, namely, etiology and
treatment. My incentive for discussing a topic so com-
monplace as the one which the title of this pai)er bears
is the unsatisfactory results I have had in a period cover-
ing a large number of cases, and besides this, the appear-
ance of an article from the pen of the wellknown Lomer,
of Giessen, but a few months ago. In a critical review
of this very interesting paper which I presented to one
of the American medical monthlies, I said : " The ques-
tion of repeated abortion and the cause therefor has
ever been a dark chapter for clinicians to solve. Much
work has been done in this direction, some satisfactory,
some not. This question can only be solved when a
large number of abortion specimens with their secun-
dines have been examined and the pathologic conditions
at the bottom of the trouble systematically searched for."
For quite a number of .years it has been our custom to
carefully weigh all the evidence in a given ca.se of abor-
tion, in order, if possible, to solve the underlying pre-
disposing or exciting fa<;tor in a particular case. In the
main this has given us only partial results from a clinical
standpoint. From a macroscopic and microscopic stand-
point we have l)een more often than not sorely disap-
pointed since these evidences have nearly always been
most unsatisfactory. To mention all the causes that
might have a deleterious influence on the growing ovum
sufficient to destroy its vitality would cover the entire
field of indiscretion which wo poor mortals are heir to,
not to mention the remaining vices which are con-
sciously or unconsciously thrust upon us. Hut sufficient
unto the wise is to fwcasionally not mention all these
factors, but leave them to your own silent thoughts and
remorses. To this end we wish to cla,ssify the factors
into those that are due either to local or general causes.
After eliminating all possible trivial and fanciful causes
in the large numtiers of cases coming under our consider-
ation, excluding blood dyscrasia, we fully agree with
I Head before the Metropolitan Medical Sociely, May 27, 1(KI2.
892 A.KEBICAN HBDICINE]
REPEATED ABORTION
[December 6, 190li
Loiner in his excellent classification that the most fre-
quent etiologic causes provocative of abortion can be
presented under three heads: (1) Lues; (2) pregnancy
nephritis, including the true toxemia of pregnancy ;
(8) endometritis and the allied and complicating condi-
tions or predisposing lesions such as ectropion of the
cervix with or without lacerations in any part of the
canal, and displacements of the uterus. In the largest
majority of the cases presented one of these causes is a
predominant feature and a salient factor at the bottom
of the trouble. Before entering upon any of these sub-
jects we wish to call your attention t» certain blood
dyscrasias not luetic which we feel sure are powerful
elements in the destruction of the embryo. The
tact that it has often been our experience to note a rise
of temperature after a simple and normal abortion which
could not be explained away on the ground of sepsis,
induced us to look upon the cause of abortion and the
complicating febrile attack as due to one and the same
factor, and it has been our good fortune to discover on a
great many occasions the presence of plasmodia in the
blood, and this without any splenic enlargement, and an
absent history of an antecedent paludal infection. On
the other hand, we have come in contact with cases hav-
ing the cla.ssic history of a frank malaria in which the
obstinacy of the disease was shown by the failure of
quinln either to control the infection as the persistence
of the Plasmodia in the blood proved, and by the fact
the abortion became Inevitable in spite of the most
heroic antiperlodlc treatment. In our opinion this
failure to obtain the desirable result was due to the
failure of the quinin to act, as shown by the results : the
presence of the plasmodia in the blood and the resulting
abortion. It may be thought that the abortion might
possibly have been brought on by the liberal adminis-
tration of quinin. This we wish to deny as a result of
practical experience. We know well that this drug will
not, and does not influence the nonlaboring uterus ; in
other words, does not stimulate the pregnant uterus into
action unk ss actual pains have occurred, then it becomes
a most valuable oxytocic. On the other hand, in
malarial countries, especially in our own South, the
families are equal if not larger than our own, and yet
women take their quinin as regularly as we do our
morning coffee, and yet how seldom do they abort? It
is only in those cases in which quinin has given the
desirable results as shown by the disappearance of the
Plasmodia that an abortion following shows that we are
dealing with the resulting impoverished condition
of the blood which is sufficient to cause the abortion,
the depraved blood states extending from a simple
anemia to a pernicious blood dyscrasia. This also holds
good in impoverished blood, due to a wasting disease,
for example, a general tuberculosis, or that which fol-
lows a prolonged attack of fever — for instance, typhoid.
It is neither the tuberculosis nor the typhoid that pro-
vokes the abortion, but simply the depraved condition
of the blood. It is under these conditions that
a specific directed against the original malady will give
us no results, but treatment instituted in the right direc-
tion against the complicating anemia and Impoverished
blood will render us very valuable aid. It is just here
that the late Sir James Y. Simpson achieved his greatest
results when he exhibited his wellknown formula to his
patients. This combination was a mixture of the old
tinct. ferri. chlor., with large doses of potassium chlorate.
We have used this combination in just such vicious
blood states, and have been pleased with the results.
Fearing poisonous symptoms we give but small doses of
the potash, not more than five grains three times daily.
Whether or no the improvement is due to the iron alone
or due, as Simpson would have it, to a giving up of the
oxygen containetl in the salt, thus hyperoxygenating the
blood, we do not know, but empirically we do recognize
the fact that our patients improve under this mode of
treatment when other means fail. We will now discuss
in the order of their greatest importance the three causes
before mentioned which from our experience are most
frequently responsible for abortion.
(1.) Lue,s. — This without doubt is by far the most pro-
lific cause of repeated abortion. To discuss this subject
in its fullest details would bean enormous task, and even
though of the most supreme interest it is entirely beyond
the scope of this paper. Even as early as 1880 the dis-
tinguished syphilographer Fournier gave us a most com-
plete resume of this subject, and his work remains as
a classic to this day.
In the frank cases of a syphilitic Infection the interest
centers solely in the direction of both prophylaxis and
actual treatment. Should a recently infected man
marry, or if infected at that time is it safe to assume
that a cure has been attained ? On several occasions it
has been our experience to deliver women whose hus-
bands were recently infected without the slightest evi-
dence of either ^n infection in the mother or child. An
illustration of this is a ca.se clear in our minds of a young
man who was married three months after a specific
lesion was certified to by a wellknown dermatologist.
He continued specific treatment during this time, and
neither the wife nor the two babies born within two
years after this unclean marriage have ever shown the
slighest evidence of the antenuptial infection. Of course
this proves nothing but that all the parties concerned
were very fortunate. Until the patient has had a severe
course of treatment and after treatment has been stopped
for a long period, and no evidence of the disease has
returned, can he be assured that he is not in a position to
infect either wife or offspring. This is the best i)revent-
ive treatment we are aware of. It is as absurd to tell a
cured syphilitic that he may never marry as it is to tell
a cured gonorrheic the same tale. We cannot follow all
these patients through life, but if we could do so some
interesting problems in heredity and atavism might
come to light, but so far as the present generation and
our own experiences are concerned we believe the fore-
going statements are safe. In the atypical c ses In which
because of repeated abortions we are stumped as to the
real factors causing the conditions, we are in position to
fathom our evidence from four sources, either each
alone or in combination with the others : (1) It is safe to
assume that if the father and infant, or the product of
conception, show evidence of infection that the mother is
also luetic, even though she shows no lesions. This
statement applies to the mother and fetus as well, since
if they are victims of an infection it is also safe to assume
that the father is in the same condition. We may also
obtain evidence from (2) the father ; (3) the mother ; (4)
from the fetus and an examination of the secundines.
Subdivisions 1, 2 and 3 will not be entered upon, we
reserve our remarks to the last, the fetus and secundines.
Frequent interruption of the pregnancy at a later
period each time is highly suspicious of syphilis. This
interruption occurs at longer periods each time until tlie
mother eventually carries to term. This is to be ex-
plained in two ways. Either there is a natural attenu-
ation of the virus or else a lessened virulence due to
irregular treatment. We have the characteristic skin
lesions early in pregnancy, and what is very suspicious is
the birth of an immature living child which presents as
much exfoliation of the skin as if it had been dead a
number of days ; the socalled raw beef appearance. As
to the secundines, we have examined microscopically a
large number of these without being able to come to any
clear or positive evidence to prove the presence of
syphilis. We have seen presumptive evidence in the
form of a decidual endometritis or an occasional gumma(?)
present upon the placenta, and again on two occasions
a spontaneous rupture of the cord, due to a gumma situ-
ated at the point of rupture, has been observed. Of the
greatest importimce for purposes of diagnosis in obscure
cases is the presence of an adherent placenta, whether the
abortion takes place early or late. This being present in
Decembbs 6, 1902]
REPEATED ABORTION
'AXKBICAS MKDICIBK 893
successive labors in the absence of an aiiUcedent endo-
metritis we have a symptom of the utmost importance,
which gives the strongest presumptive evidence of a latent
syphilis. In the early abortion cases the placenta is the
seat of a fatty degeneration and in the latter there is a
decided calcareous degeneration present, due to the
reorganization of the antecedent process.
Presuming that the father is syphilitic, and the child
is the victim of the disease, it is more than likely that the
mother, either from direct infection from the father or
indirectly from the fetus, is also syphilitic. Treating
from these premises, we are decidedly in favor of subject-
ing both parents to a thorough antiluetic medication not
alone before impregnation, but during the earlier months
of pregnancy. If in spite of this treatment abortion still
occurs, we can rest assured that another complicating
factor is the cause of the trouble. Thus we limit our
specific treatment to those patients from whom we can
obtain specific histories, as well as to those from whom it
is absolutely impossible to elicit any cause for the
repeated abortion. This, on the ground that there may
still be a specific cause far removed, even "unto the
third generation."
(2.) Pregnancy, Nephrit'is and (he Allied Slate, the
Toxemia of Pregnancy. — The former condition is so well
known as a factor in the production of repeated abortion
that any lengthy discouree on this subject would be
superfluous. The nephritic state produces its results by
the occurrence of hemorrhages into the fetal sac, the pro-
duction of both embolic and thrombic formations in the
pliicenta, while the fetus suffers carbonic suffocation or its
vitality is cut off by toxins of unknown quality and
source. Practical experience has shown us that a most
prolific cause for repeated abortion is the very obscure
condition called the toxemia of pregnancy. This subject
has received scant attention, but from our investiga-
tions we feel sure that this condition is often responsible
for repeated abortion. We have studied thn subject
carefully from every point of view, theoretic and practi-
cal, and feel that we are in position to state our views
from these standpoints. We mean by the toxemia of
l)regnancy a total and progressive diminution of the
daily excretion of urea without the evidence of more than
a functional renal lesion, accompanied or not by symp-
toms of constitutional poisoning. On many occasions we
have called attention to these cases at term, and the
greater our experience the more confident we feel that
while urea may not and likely is not the sole cause of the
uremic condition, yet the progressive diminution of the
total amount of urea is the surest and most pronounced
signal we possess at present to herald an impending
danger. In fact, we have never seen a case that pre-
sented symptoms of toxemia in which the total amount
of urea was not diminished. On the other hand, we
have lately come in contact with cases in which the
t')tai amount of urea was alarmingly diminished without
even the occurrence of one symptom denoting a systemic
poisoning. How can this be explained?
First, that our theories are all wrong. This cannot
b3 true, since in the greater number of cases the diminu-
tion of the urea always goes hand in hand with an
increase of all symptoms, and an increased secretion of
urea is always followed by the subsidence of the uremic
signs. Second, that certain individuals excrete habitu-
ally and normally a very small amount of urea. Since we
do not know absolutely what the normal amount of urea
sf«retion is for each and every individual it is just pos-
sible that certain women excrete habitually a minimum
amount. This abnormality can only be proved by pro-
longed quantitiitiye tests extending over a long period
in the {)regnant as well as in the nonpregnant stat<'.
Third, setting aside the reliability of our chemic
reagents, which must always l>e considered a probable
sf)ur(!e of error, it has for a long time appeared to us
that decomposition of the urine is a very important fac-
tor in accounting for this apparent di-i n-pancy between
intoxication and urea excretion. The acidity of female
urine is much below that of the male, while the acidity
of the urine of the pregnant female is again much lower
than that of the nonpregnant, often so low that the reac-
tion is neutral or even alkaline. This favors early
decompo-ition (a correct estimate must be made from a
given 24-hour specimen) and this decomposition, by
which at least part of the urea is converted into ammo-
nia, is often very pronounced. As a result a urea esti-
mation from a decided decomposed ammoniacal urine
will be very much less than that from normal acid
urine. In order to overcome this feature we are in the
habit of instructing our patients to add sufficient forma-
lin to the total urine to make a bfo solution. By doing
this we feel that at least one disturbing factor is
removed.
When a patient presents herself with the history of
repeated abortion, in the absence of other disturbing
conditions we must estimate the urea from a 24-hour
specimen. Should this fall much below the average,
whether there be systemic symptoms present or not,
we must consider this as a causal factor in the pro-
duction of the abortions. The condition thus being
noted it becomes absolutely essential to keep these
patients in bed and to treat them accordingly, continu-
ing treatment until the urea estimation shows an
increase up to and above the normal. We have some-
times been compelled to kee|) these patients under con-
trol and in bed for the greater part of pregnancy.
(3.) Endometritis and the allied conditions and com-
plications are important causes in relation to this condi-
tion, and are often the reason of one child sterility and
repeated abortion. In this category we include infec-
tions of all kind, including gonorrhea, the lesions of the _
pelvic tract and displacements, whether phj'siologic or '
pathologic. A diagnosis is readily made on examina-
tion, and the therapy is evident— that is, the correction
of every evident lesion. As a rule, single complica-
tions are not present, but more often we find associate
conditions. For example, a marked anteflexion is not
the sole cause, and very often hardly the cause at all as
compared to the associate endometritis, and by a
thorough curetting we often overcome the difficulty
without the necessity of correcting the displacement.
We advocate the curettage, not during or immetiiately
after the abortion, but at some time remote from it when
the patient is not pregnant. When there are evident
lacerations of the tract they are repaired in the usual
fashion, always preceded by a thorough cureting.
Uterine displacements as causes of repeated abortion
are very important factors in relation to treatment. A
movable posterior displacement sufficient to cause abor-
tion requires orthopedic treatment ; that is, the introduc-
tion of a suitable pessary, with the correction of the associ-
ate lesions if any present. The most complicated are those
associated with pathologic or fixed retrodisplacements.
This is a subject so vast and has been written about so
extensively that the merest sketch of the lines of treat-
ment will be given. The time to attend to these cases
is not during pregnancy, except in rare cases in which
the correction of the condition ctin be safely undertaken
or is demanded, as witness the incarceration of a preg-
nant uterus when it might become necessjiry to open the
abdomen to liberate this organ. Excepting these rare
states we advise an operation during the nonpregnant
state in order to anticipate t' c compliciition. As a
pathologic adherent uterus always presupposes organic,
changes in the adnexa or surrounding structures, it
would seem that attacking these conditions by any other
method than that of opening the abdomen is a very
wrong and unscientific measure. We refer to the Alex-
ander operation. We recognize the indications for it**
performance, but we have always felt that it were better
to be in a jwsition to see and pal|)at<> the adnexa in order
to be able to exclude lesions of thes(^organs which might
account for the rcpeat<'d abortions when there are
894 iLXBtUOAS MEDtciirx)
MODERN TREATMENT OF ECLAMPSIA
IDbckmbCb 6, 1902
manifold corrections to be made, not alone for the treat-
ment of supposedly diseased adnexa, but for the
mechanic treatment of the displaced organ by suture ;
such suturing as is done should give the least mechanic
hindrance to the growing uterus if the patient would
later become pregnant. For this reason we do not con-
sider operations of the fixation type. We include in
this category all the various vaginal operations by which
the uterus is fixed firmly to one structure or the other.
We have simply to follow the reports of the trying diffi-
culties in the labors that have followed the various
vaginal fixation operations. In fact, so frequent have
they become that one German author has devised an
operation to overcome the dystocia from such operations.
In this category we also place the abdominal fixation
operations by which the fundus is fastened to the abdom-
inal fascia. This to us is a most reprehensible measure
during the period of possible impregnation, as proved
in our own experience by two cesarean sections which
had to be performed in order to overcome the enormous
difficulty of delivering the women, both of whom had had
previous normal labors. The true abdominal suspension
operation is the one that appeals fb us from all sides,
whether this be an operation on the round ligaments or
by any other means, so long as the uterus is suspended
freely and not fixed ; but we have always inclined to the
true peritoneal suspension, which answers every pur-
pose admirably. Whether or no the suspension liga-
tures be passed anteriorly or posteriorly to the fundus is
a matter of personal predilection and experience.
THE MODERN TREATMENT OF ECLAMPSIA.
HERBERT MARION STOWE, M.D.,
of Chicago.
Demonstrator of Operative Obstetrics, Northwestern University Med-
ical School; Assistant Obstetrician to Provident
Hospital, Chicago. *
The treatment of eclampsia, like that of many other
diseases, is being gradually weaned from its former state
of empiricism and established upon a more rational and
scientific basis. Although recent investigations liave
shed much light upon this terrible disease in emphasiz-
ing the importance of imperfect excretion and general
toxemia in the etiology, the essential causes remain
obscure. The value of a more intelligent line of treat-
ment, however, even though somewhat empirical, is
clearly shown in the reduced mortality. When we con-
sider the statistics of the earlier writers whose maternal
mortality ranged from Sofc to 55^ and compare them
with the report of Stroganoff of 58 cases with no mor-
tality from eclampsia and only 1.1 fc from complications,
and with the various reports of contemporary writers,
who keep their mortality under 20 fc , the improvement
is self-evident.
Generally speaking, our knowledge may be summed
up in the statement that eclampsia is caused by a toxe-
mia, a poisoning of the blood by certain unknown
toxins which are retained in the system by reason of
deficient action of the excretory organs, notably the
kidneys, alimentary tract and the skin ; these toxins, by
floating in the blood, augment the heightened instability
of the nervous system, raise the bodily tension, and by
irritating the motor centers in the brain, produce con-
vulsions, coma, and frequently death. This knowledge,
limited though it may be, furnishes the groundwork for
the most successful methods of treatment.
It is a noteworthy fact that the great majority of
cases can be prevented by a careful and constant super-
vision of the diet, provided we are able ta see the
patients early enough to place them under our care.
This supervision should be made a routine practice in
all obstetric cases, and we should teach our patients that
it is frequently as necessary to come under medical super-
vision in the early months of pregnancy as it is at term,
since it is in just that class of patients of which the
attending physician omits to make repeated examina-
tions, urinary as well as general, or in which he is not
called to the patient until labor begins, that untoward
results are so prone to occur.
The most reliable index we possess of the approach-
ing storm is the condition of the urine. A urinalysis
should be made bimonthly during the latter half of
pregnancy, and weekly during the last month, especially
if the former examinations have revealed anything
abnormal. The mere testing for albumin is, of course,
insufficient, as eclampsia without albuminuria occurs in
from 9fo to 16^ of cases, and is as fatal, if not more so,
than eclampsia with albuminuria. Serum albumin is
of importance only when associated with considerable
kidney debris and when in large amount. More im-
portant than the finding of albumin is the determination
of urinary solids. The healthy pregnant woman passes
from 50 to 60 ounces of urine a day, of a specific gravity
of 1,010 to 1,020. This gives a daily excretion of urinary
solids of from 45 to 70 grams. The urea should range
from 1.75 fo to 2.26 fc, or from 28 to 30 grams, taking
1,600 cubic centimeters as the normal daily quantity.
The daily excretion of the urinary chlorids is also of
importance as corroborating evidence, of the efficient or
deficient action of the kidneys. In health the excretion
of chlorids varies with the quality and quantity of food
ingested, the output representing very closely the
amount of sodium chlorid taken in. With a restricted
diet, however, the amount of chlorids excreted, other
disturbing factors as fever, etc., being absent, is a good
index of excretion. The amount normally ranges from
15^ to 20;?^, is increased in pregnancy, especially after
the fifth month, to SOfc, and as high as 70^ occurred in
one of my cases. A fall, therefore, to 10 fo or below
should, along with other signs, put the practitioner on
his guard. A fall in urea to 1^ or less is, in the
absence of marked activity of the skin or alimentary
canal, conclusive proof of deficient eliminative activity,
and measures should be undertaken at once to increase
the excretion and at the same time limit the introduction
of nitrogenous material into the system. The fact that
this morbid state may exist while the patient appears to
be in the best health is of great clinical interest.
Of much importance as corroborative evidence of
excretory insufficiency is the presence of general symp-
toms of the overloading of the blood with toxins, such
as high arterial tension, congestive headaches, an irri-
table nervous condition, nausea occurring through-
out the pregnant state, temporary, total or partial
amaurosis and inability of the organs to perform their
functions properly. By giving attention to the special
and general examinations of pregnant patients we will
be able to rescue many from the untoward results which
sometimes follow, and thus perform our whole duty to
them. The objections sometimes made against this
supervision, on account of the meagerness of the obstet-
ric fee in some localities, are certainly not jastiflable
unless the attendant labors only for the pecuniary com-
pensation instead of for the only true goal of the con-
scientious practitioner, namely, " the alleviation of
human suffering and the prolongation of human life."
Surely no physician would allow a patient to bleed to
death without trying his best to save her, because he
saw only a small fee in the case ; yet there are many
who will allow their patients to run serious andofttimes
fatal risks because of the extra amount of work neces-
sary to protect them from such risks. The physician who
works for money alone has surely missed his calling.
The treatment of toxemia in pregnancy may be
classed under three heads : First, the reduction so far as
possible of the urea-forming foods, that is, a nitrogenous
diet. Second, stimulation of the action of the kidneys,
liver, bowels, skin and lungs, thereby lessening the lia-
bility to toxic formation in the body. Third, if in spite
Ueckmbeb 6, 1902]
MODERN TREA.TMENT OF ECLAMPSIA
American Mkdicinb 896
of the hygienic, dietetic and medical treatment the con-
dition grows worse and threatens the life of the patient,
emptying the uterus by the method that will entail the
least amount of injury and irritation.
The ideal method, so far as is now known, of restrict-
ing the ingestion of nitrogenous food, is to place the
patient at rest upon a milk diet. This treatment was
popularized in France by Charpentier and Tarnier. In
Tarnier's clinic, from 1837 to 1887, the maternal mor-
tality wa-s 37 fc ; from 1889 to 1891, under the com-
bined treatment of chloroform, chloral and bleeding, he
kept this percentage at 38 J^ . From 1891 to 1896, with
the addition to this treatment of a rigid milk diet given
if necessary with a tube, he reduced his mortality to
9fo. Tarnier, at the present time, places upon a strict
milk diet his patients who have albuminuria, as well as
those who present symptoms of general intoxication,
whether albumin is present or not.
In cases in whicli the general symptoms of toxemia
appear threatening, it is well to place the patient in bed
at once upon a milk diet, and keep her there for a week
or two, or until improvement is evident. Chloral hydrate,
0.65 gram to 0.97 gram (10 to 15 grains), given per
rectum every four hours, followed if necessary by potas-
sium bromid if the muscles begin to twitch, is a valuable
means to control the nervous system until the emunc-
tories are stimulated. The advantage of bodily rest in
retiucing the formation of urea by nmscular activity is of
great importance. Massage or passive motions are
allowable and frequently beneticial. The patient should
be encouraged to drink large quantities of water, and
should she refuse to do so, her thirst can be increased by
taking sodium chlorid in capsules. The skin should be
kept active with hot packs, the limbs being wrapped
separately in hot moist towels. Special attention should
be paid to the kidneys and bowels ; the best diuretic as
well as the most harmless is pure water in abundance.
The carbonated waters or vichy, if taken cold, may be
freely employed. The effervescent salts of lithia, mag-
nesia and soda dissolved in plain water, form an admi-
rable substitute for the higher priced article. The potas-
sium salts are better avoided. When time is an object in
threatening eclampsia, one of the most elBcient methods
of stimulating diuresis and diaphoresis is the subcu-
taneous injection of normal salt solution. This may be
injected under the breasts, in the loins or abdominal
walls, and may be combined with hot packs over the
kidneys, or even cupping. Throwing two to four pints
of normal salt solution into the transverse colon has a
wellknown diuretic etfect. .
The intestines should be thoroughly emptied at once.
For the primary movement two or three compound
cathartic pills may be given at bedtime, followed by a
saline in the morning. Absorption is largely in abey-
ance during the convulsive seizures and the immediate
preconvulsive period, and hence the nearer the patient
is to the attack, the larger is the dose required for free
<'atharsis or the free action of any medicine. If there are
signs of fecal impaction, a high enema of turpentine and
ox-bile repeated in six hours is excellent. Hourly dram
doses of the saturated solution of magnesium sulfate are
useful in maintaining liquid catharsis. As the liver is
fre(iuently at fault, it is well to administer small doses
of blue mass or calomel in order to arouse the portal
circulation.
If under this treatment the condition of the patient
improves, other articles of diet may bo added as starches,
protcdd vegetables with the vegetable oils and butter,
then a full vegetable diet with fruits. The first meats
allowed should be the white meat of fishes and the white
meat of turkey and chicken as recommended by Profes-
sor De Lee. This method of dieting is far preferable to
that of allowing the patient a varied dietary and then
l)eing obliged to cut ott'all except the milk.
The great fact in the treatment of toxemia of preg-
nancy is that while both hygienic; and medicinal
measures are life-saving, success is mainly due to the
milk diet ; and a patient threatened with eclampsia if
placed upon a milk diet and in bed will run a fair chance
for her life if no other special treatment is given her.
Unfortunately, however, the symptoms may grow
rapidly worse under this treatment, and we are brought
face to face with the serious question of terminating
pregnancy at once. The accumulating toxins floating in
the blood at times so irritate the centers of parturition
by their virulence that nature steps in and spontaneous
labor results and the patient recovers without any treat-
ment other than that of watchful expectancy. When
this process occurs naturally, it is our duty to wait pro-
viding we can do so without jeopardizing the mother's
life. Generally the progress of labor is rapid, as the
nerves are hyperesthetic, and the muscular response to
nerve irritation is vigorous and intense. This is espe-
cially true if the patient is on the verge of a convulsion,
and she does not succumb to the Initial spasms.
The rule in those cases in which we are called upon to
interfere is that the labor should be completed with the
least amount of impression upon the patient's nervous
system and with the least amount of injury to her tissues.
The former condition may be obtained by having the
patient deeply chloroformed during any and all manip-
ulations in the pelvis. Rigid asepsis and antisepsis, both
subjective and objective, should be observed in the
eclamptic patient, as according to Zweifel, such are
much more susceptible to septic infection than the non-
eclamptic. We should, if possible, induce abortion, and
complete it all in one treatment and thus avoid repeated
nervous shocks to the patient.
Premature labor may be induced by the Barnes bags
or Braun's colpeurynter and then followed by manual
dilation of the cervix. The convulsions may, at times,
be prevented, or if they have occurred may be inhibited
in many cases by early rupture of the bag of waters thus
lessening the intrauterine tension and at the same time
affording a very efficient method of hastening labor. No
attempt should be made by the accoucheur in the later
months of pregnancy to empty the uterus unless the
condition of the cervix permits it. The time taken to
dilate the cervix depends upon the degree of cervical
eftacement, the duration of pregnancy, whetlier the
patient is a primipara or multipara, whether the cervix
lies high or low in the pelvis, and finally whether the
cervix is scarred or cicatrized by old lacerations or
inflammations. Grandin claims that half an hour is suf-
ficient time to dilate the os under deep anesthesia, but J.
C. Webster puts the average at one hour. The cervical
incisions of Diihrssen may be made when the cervix has
become effaced and the only remaining obstruction con-
sists of the OS externum. These incisions may he used
in conjunction with the bags and colpeurynter as is done
in Zweifel's clinic.
The occurrence of eclamptic convulsions commands
the continued presence of the physician at the bedside
until the patient is delivered and out of danger. This
rule should be followed strictly. The patient should, if
possible, occupy a large room with sufficient ventilation
but no direct drafts. This room should be darkened
and quiet enjoined upon the members of the household
and so far as possible upon the immediate neighborhood.
All sources of irritation of whatsoever nature should be
removed.
The principles of treatment for eclampsia at term
may be formulated as follows: 1. Control the convul-
sions. 2. Deep narcosis during all pelvic manipulations.
3. Rigid antisepsis in all pelvic manipulations. 4. Ad-
ministration of remedies that will control the toxic
effect. 5. Immediate stimulation of the various excre-
tory organs. 6. Empty the uterus by the most natural
method possible without undue regard for the life of the
child, especially if the condition of the child is poor.
7. Dilution of the toxins floating in th(> body fluids
8. Stimulation of the vital centers when necessary.
896 AXSaiOAir HBDlOINEl
MODEEN TREATMENT OF ECLAMPSIA
[Dkcember 6, 1802-
The eclamptic convulMons while not the Hole cause
of death have great influence in determining the final
result, and as frequently recurring spasms betoken a
serious condition it is our duty to limit so far as pos-
sible both their number and severity. The drug most
generally used for this purpose is chloroform by inhala-
tion. Unfortunately the drug has its disadvantages. If
it could be used continuously for many hours, as is rec-
ommended by Pamard, who has given it for 48 hours, it
would be of great service, but the effect of chloroform
in large quantities upon a heart already staggering
undering the twofold burden of pregnancy and tox-
emia is not always well borne. Reynolds for this reason
prefers ether for narcosis. The hitherto almost uni-
versal belief that chloroform could be given ad libitum
in labor without serious results has caused the profession
to deluge their patients with this vapor during the
eclamptic seizures, and doubtless some of the fatal
results could be traced to chloroform poisoning rather
than to the eclampsia. In the later editions of their
works both Olshausen and Veit admit the superiority
of ether while they strongly recommend morphin.
Fritsch, Ahlfeld, and Smyly of the Rotunda agree that
prolonged narcosis is dangerous and " increases the ten-
dency of death." Diihrssen has called attention to an
occasional death from chloroform in eclampsia with
much uterine distention. In cases of hydramnios,
therefore, it would be well to rupture the membranes
before giving the anesthetic. The inability of the med-
ical attendant to determine the probable onset of the suc-
ceeding spasm in time to give the patient enough chloro-
form to tide her over is the greatest obstacle to be over-
come. If he awaits until the convulsion begins, the chest
wall becomes fixed, respiration becomes arrested and the
amount of anesthetic inhaled is very small, in many
cases so small as to have no perceptible effect on the
convulsion. By reason of this temporary respiratory
subsidence, oxygen is imperatively demanded, the
chloroform inhaler preventing what little oxygen there
is present from entering the lungs; and it is for this
reason that some authorities, notably Stroganoff, prefer
oxygen during the spasm. Chloroform has the great
advantage, however, of acting promptly, holding the
convulsion in check until other measures have been
taken for their relief. Should the spasms occur in fre-
quent succession it is well to keep the patient narcotized
for a period of from one-half to four hours and then
gradually allow her to regain consciousness, watching the
while for signs of another spasm, upon the recur-
rence of which the chloroform is again administered.
The next most valuable agent is opium. Opium in
some form has been used since its recommendation by
Manning in 1771. As a matter of fact, in these early
days opiates were used for every kind of spasm or pain
and were combined later on with bleeding. The popu-
larity of this treatment is due to "Veit, of Bonn. He
begins as soon as the convulsion takes place with 0.03
gram (j\ gr.) of morphin hypodermically and adds .02
gram (} gr.) as often as necessary to keep the patient
quiet. He has given as much as 0.2 gram (3 gr.) in
four to seven hours and as a result lost but two patients
in sixty. Veit claims that failures under this treatment
are due to the insufficient amount of the drug used.
His statement that no one need lose a patient by this
method of treatment is open to criticism as the specific
for eclampsia is still to be obtained. Those opposed to
the Veit method, which is used almost universally by
the Germans, claim that this drug in large doses weakens
the respiratory center, suppresses the oxidation pro-
cesses in the organism, diminishes the vital capacity of
the cells and limits the activity of the kidneys. The
baneful influence upon the respiration may be lessened by
the administration of atropin and by requiring the
patient to lie in a lateral position. In favor of morphin
much may be said. Under its influence the convulsions
are certainly controlled and frequently prevented. Mor-
phin allays the irritability of the cerebrospinal system
and prevents the added accumulations of toxins from
being thrown into the blood. It does not weaken
mother or child to any great extent though it will pro-
long the comatose condition for hours, and yet under its
influence labor may come on and be completed without
causing more convulsions or increasing the danger to the
mother. Morphin should not be held responsible for
all cases of urinary deficiency. Before making this
charge the patient should be catheterized to exclude the
liability of vesical anesthesia which may be caused by
the action of the same drug. In a few cases the kidneys
will be found to be acting freely but the obstruction is
found lower down in the urinary Iract. The good effiects
of morphin outweigh the evil and morphin still remains
one of our cardinal supports in the treatment of
eclampsia.
Chloral hydrate is a valuable agent when used in
combination with morphin. It is preferred by the
French school, and was introduced into this country by
the late William Goodell, of Philadelphia. It may be
given in doses of- 1 .2 grams to 2.6 grams (30 grs. to 40
grs.) per rectum with or without sodium bromid, and if
necessary this may be repeated in two hours. Some
cases that cannot be controlled by morphin or chloral
separately in large amounts are very susceptible to
smaller doses of the two combined. Charpentier has
collecte<l statistics of 239 cases of eclampsia treated with
chloral with a mortality of 4^. In combination with
other remedies, he found a mortality of 8i /o . In his
own practice, Charpentier gives a dram of chloral in
three drams of mucilage per rectum, if the patient is
unable to swallow. If not retained, he gives another;
in five to six hours another. As much as a half-ounce
has been given to one patient. Winckel used chloral in
a similar manner, except that he gave chloroform until
the chloral had time to work. He reports 7 deaths in 92
cases.
Veratrum viride, if given hypodermically until the
pulse is below GO beats per minute, is claimed by Thayer,
Jewett, and others to prevent effectually the convulsions.
The action of veratrum viride is due to its two principal
alkaloids ; jervln reduces the heart beat and lowers
arterial tension by its direct influence upon the cardiac
muscle and by causing a general vasomotor paralysis ;
the other alkaloid, veratroidin, lowers the pulse-rate by
stimulating the inhibitory nerves. Both alkaloids
depress the motor centers in the spinal cord. Veratrum
also relaxes the cervix and the lower uterine segment,
and causes diaphoresis and diuresis as well. These
actions are of great benefit in the treatment of eclampsia,
and the reputation of the drug stands on a firm basis.
After the spasm has passed, 15 minims of a reliable tinc-
ture may be given hypodermically, or 5 to 8 minims of
Norwood's tincture may be used instead. Upon recur-
rence of the spasms 5 minims may be injected until the
action of the drug becomes manifest. Owing to its
depressing effect upon the heart, the patient must be
watched carefully and cardiac stimulants administered
when necessary. It requires considerable judgment
upon the part of the medical attendant to decide when
to depress the circulation for the sake of the eclampsia
and when to administer stimulants for the sake of the
heart.
One of the most important of the recent advances in
treatment is the use of normal saline solution. It is the
surest and quickest way to dilute the toxins in the blood.
Its beneficial action upon the skin and urinary secretion,
and the rapid amelioration of the threatening symptoms
are frequently remarkable. Normal salt solution with
or without sodium acetate or potassium bicarbonate, as
recommended by Jardine, may be injected preferably
under both breasts, in the lumbar region or in the
abdominal walls. The quantity may vary from a pint
to four to six quarts, according to its effects. The appa-
ratus necessary is so simple that it can be constructed
December 6, 1902|
MODERN TREATMENT OF ECLAMPSIA
[Akerican Medicine
897
and manipulated by any one, under the most unfavorable
surroundings.
The use of pilocarpin is condemned by the majority of
authors as favoring pulmonary edema, and should be ex-
cluded from the list of remetlies. In 56 cases in the Boston
Lying-in Hospital since 1885 in which pilocarpin was used,
5 patients, nearly 9fo, died from edema of the lungs.
Breus and Zweifel recommend treatment by baths.
Breus wraps the patient in a sheet and lowers her in a
bath as hot as can be borne for half an hour. She is then
allowed to perspire for two hours rolled up in hot
blankets. This treatment is especially useful when the
patient is api^arently dying from coma when the spasms
have ceased, the pulse failing and the temperature is
normal or subnormal. Jf the patient is hyperpyretic,
the cool or tepid baths may be substituted. Imminent
delivery combined with restlessness would interfere
somewhat with this treatment.
It is preferable to allow nature to terminate the
delivery if possible. The cutting operations should be
reserved for the more desperate cases. The great barrier
to the rapid delivery of the fetus is the cervical canal.
Cervical effacement is the one condition that should be
obtained before extraction is attempted. If the os uteri
is dilated incompletely and further delay is not permis-
sible, Diihrssen's crucial incisions may be made. These
incisions made before complete cervical effacement are
positively harmful. The bilateral operation is as bene-
ficial as the crucial incision and it obviates the danger of
injuries to the bladder or rectum frequentlj' occurring
with inexperienced operators. The preparation for the
fetal passage may be made with Barnes' bags, the
colpeurynter or by manual dilation ; all done under the
strictest antiseptic precautions. The difficulty of dilating
the cervix manually in primiparas with rigid tissues
will mitigate somewhat against its employment in these
cases. When the conditions for extraction are present,
the fetus should be delivered preferably by forceps
because of the increased amount of irritation caused by
the version, but if the child is dead or dying craniotomy
should be substituted. Should the cervix be closed the
patient must be placed under medical care for a time and
if the condition grows worse as noted by the recurrence
of the spasms and the more alarming general symptoms,
the pregnancy should be terminated at once, preferably
by cesarean section, as the shock is much less than would
follow a delivery through the natural passages. Other-
wise cesarean section should be reserved for cases in
which the mother is dead and the child still alive but
undelivered. The mortality of cesarean section varies
with the skill of the individual operator, but it is still
very high and except in these two conditions the mother
runs a better chance of recovery if the other methods of
accouchement force are employed.
When labor is completed we should enjoin quiet
upon the patient and aim to stimulate the excretions as
already described. The hemorrhage occurring in the
third stage and subsequent placental extraction is
nature's effort to throw off some of the poison, and mod-
erate hemorrhage may be allowed if the patient has a
high arterial tension. This loss of blood stimulates
osmosis and absorption to a considerable degree and to
this fact may be traced the reason why the prognosis is
so much better after fetal and placental delivery. In
cases of perineal laceration beyond the first degree it is
better to postpone the perineorrhaphy until later. The
irritation of the stitches, the necessity of fre<iuently soil-
ing the field of operation by purgation, the liabilty of
large scybala forcing the wound surfaces apart, and above
all the shock necessitated by the prolonged anesthesia all
militate against an immediate operation. The secondary
operation is as successful as the primary and the added
depression is deferred to a time when the i)atient is not
bringing all of her resources to her aid during a critical
period and to a time when the additional shock will not
be sufticient to cause untoward results.
The following hitherto unreported cases have come
under my observation :
Case I.— Mrs. W., aged 29, prlaiipara, began labor at 8
p.m., March 17, 1901. Her pregnancy had been uneventful and
apparently normal. Shortly after midnight her vision grew
dim, and in a short time complete amaurosis developed. (This
association of complete amaurosis with eclampsia is not fre-
quent.) After laboring through the night the first convulsion
occurred at 9 a.m. I now saw the patient for the first time.
The cervix was effaced, the os dilated and the head engaged in
the position of deep transverse arrest. After sterilizing the'
field I easily delivered a living child with forceps. The peri-
neum was torn to the third degree by a spasm which occurred
during the delivery, although the patient was well under the
influence of chloroform, and the head was forced out by the
violent vis (I tergo. The patient, when put back in bed, had a
pulse of 140, was cyanotic and comatose. Morphin sulfate,
.03 gram (J grain) was given at once hypodermically, and fol-
lowed every 15 minutes so long as the eyelids and angles of the
mouth twitched. During the first 24 hours 0.14 gram (2} grains)
of morphin was used. Chloral hydrate, 2 grams (30 grains)
was given per rectum. Saline solution amounting to nearly
five pints was infused under the breasts, and the patient rolled
up in hot packs. The urinalysis was as follows: Acid reac-
tion; specific gravity, 1,010; amount first day, 352 cc; total
solids, 8.20 grams ; urea, .4% ; total urea, 1.41 grams; chlorids,
8% ; phosphates, 6%; sulfates, i.ofc; no sugar; albumin, 26%
volumetric; traces of indican; broad and narrow granular
casts, cylindroids ; no blood ; few pus cells ; abundant pave-
ment and columnar epithelium and amorphous urates. At
10.30 p.m., March 18, the fourth and last spasm occurred, the
morphin having been omitted for six hours previous, I then
ordered 0.02 gram (i grain) every three hours for four doses,
and no more attacks occurred. Diuretin in 1 gram (15-grain)
doses was prescribed as a diuretic. The amount of urine
passed by half-days following the delivery was as follows:
352, 544, 768, 1,792, 1,280, 1,152, 1,792, and 1,(>00 cc. The patient
recovered consciousness on the fourth day. The liowels were
moved freely by Epsom salts, and the patient was, of course,
placed upon a milk diet. She gained rapidly, in spite of a pulse
varying from 102 to 118 for a week, and in three weeks was out
of bed. During this period diuresis, diaphoresis and cathars-is
were active, though the heavy coating on the tongue continued
for months afterward. On the twenty-fourth day following the
attack a secondary perineorrhaphy was performed and union
by first intention secured. The child suffered from a double
cephalhematoma which yielded to a purely expectant line of
treatment. The mother failed to supply milk for the child and
artificial feeding was necessary. Both mother and child recov-
ered perfectly. This patient immediately became pregnant
again and was delivered on March 21, 1902, with a normal
delivery. The breasts became active on the fifth day. During
the later months of the second pregnancy, the percentage of
urea had a tendency to go to 1% or less, but by regulation of
diet and diuretics this condition was relieved. There was no
albumin or casts.
Case II.— Mrs. B., aged 23, primipara, with a history of
mitral insufl^ciency started in labor October 28, 1899, at five
o'clock. Her pregnancy, except for the cardiac trouble, had
been normal. No albuminuria had been noticed at anytime.
After being in labor about two hours she was seized with a con-
vulsion and in two hours with anotherone. By court'sy of her
attending physician. Dr. (Jresens, I was called to the case and
came just as the third spasm occurred. The birth passages
being ready for delivery, after several trat^tions, the head was
disengaged from a right deep transverse arrest and a living
child extracted. The moderate laceration of the perineum was
operated upon eight days after delivery and healed by primary
union. Slight albuminuria presented four days after labor,
lasted three days and then disappeared. Kther was the anes-
thetic, and the usual eliminative measures were resorted to.
There were three attacks, all intrapartum. Both mother and
child recovered.
Case III.— Mrs. C, aged 29, multipara, American, living in
a good environment, consulted me in March, 1901, in the fourth
month of pregnancy on account of edema of the ankles and
shortness of breath. She dated her illness from the birth of her
first child some two years previous. Urinalysis showed the
daily quantity to be 600 cc; specific gravity 1,012; acid reac-
tion: total solids 16.78 grams, urea 1%, total urea 6.1 grams;
chlorids 18%: phosphates 6%; sulfates !'/» ; no sugar ; albumin
4%; no Indican. Microscopic examination showed numerous
hyaline and granular casts, no cylindroids, no pus, no blood,
pavement and granular epithelium in abundance, uric acid
crystals, considerable kidney debris, amorphous urates and the
usual microorganisms. The blood examination showed: red
cells, 4,200,000; white cells, 12,000; hemoglobin, 80%: specific
gravity, 1,056. The left ventricle was enlarged to the left, there
were no murmurs. , . ,
This patient was put upon a selected diet, was placed in
be<l and rest enjoined. All necessary hygienic precautions
were observed. Two compound cathartic pills were adminis-
tered daily and an abundance of water was ingested. After a
month of this treatment the edema and shortness of breath had
disappeared and the kidney findings had greatly improved.
Hot baths and potassium acetate served a useful purpose
898 AUBBICAN MEDtCIMIEJ
MODERN TREATMENT OF ECLAMPSIA
[Decembbr 6, 1902
In this case. The urinalysis at this time showed as fol-
lows: Amount. I,2ICcc.; specific gravity, 1,020; acid reaction ;
total solids, oti.fie grams ; urea, 1.8%; total urea, 21.8!J grams ;
chlorids, 28% i phosphates, O^ ; sulfates, 1%; no sugar; a trace
of albuuiin; no indlcau. Microscopic examination showed
hyaline and granular casts but less abundant, epithelium, no
uric acid crystals, less kidney debris. Blood examination
showed the red cells 4,460,000, white cells 10,240, hemoglobin
85%, specilic gravity 1,057.
The patient left her bed but continued the same treatment
excepting the cathartic pills, which proved too strong. Soon
After she left the city and so passed from my care ; she omitted
to send a weekly urinary specimen. When seven and a half
months pregnant I received a notice to visit her and learned
that her condition was aggravated and compelled her return to
the city. The edema had now extended to the hips, bands and
arms. She was very nervous, complained of severe headache,
some nausea, vertigo and tachycardia. Urinalysis showed only
256 cc. ; sp. gr., 1,022; total solids, 13.12 grams; urea, 1.1% ; total
urea, 2.82 grams; chlorids, 12%; phosphates, Sfc ; sulfates. 2% ;
albumin, 7.5% ; no sugar. The microscope showed the findings
of chronic nephritis. Blood examination showed the red cells
3,800,000, white cells 18,000, hemoglobin 70%, sp. gr. 1,052. The
Eatient was placed in bed upon a strictly milk diet, was given
ot baths, abundant water, and normal saltsolution was admin-
istered per rectum and suboutaneously. The next day vision
became blurred and slight muscular twitchings were noticed.
Chloral hydrate 1 gram and potassium bromid IJ grams were
administered per rectum every five hours. This gave some
relief, but the headache remained acute and the condition of the
urine failed to improve as before. The fetal heart tones num-
bered 140 per minute and were regular. While it is not desir-
able to induce labor in a patient on the verge of an eclamptic
convulsion except as a last resort, for the reason that the mor-
tality in such a condition is as great as by the expectant line of
treatment, still if the expectant treatment fails to relieve the
patient, an early termination of pregnancy is indicated as being
both prophylactic and curative. Under deep anesthesia the
cervical canal was dilated by the finger, Barnes' bag and the
Braun colpeurynter successively. The membranes were rup-
tured before tlie colpeurynter was introduced in order to avoid
any increase of intrauterine tension. When the birth passages
were prepared an easy version and extraction completed the
delivery. The placenta came away with difficulty and a slight
postpartum hemorrhage followed. The child was asphyxiated
but revived. The patient was given three pints of normal salt
solution under the breast, hourly dram doses of the saturated
solution of magnesium sulfate, and diuretin in gram doses
every four hours.
The general health ot the patient Improved greatly after
labor and in two months she had regained her usual health with
the excep*^^ion of the chronic nephritis, from which she still
suffers though in less degree. This patient had no milk and
was obliged to bring up the baby on the bottle. The child died
at eight months of gastroenteritis.
Case IV.— Mrs. R., primipara, aged 18, American. After
an uneventful pregnancy labor occurred January 12, 1900. Her
primary attack occurred in the first stage and I arrived a few
minutes later. There were no signs of increased tension, except
a pulse of 118 beats per minute. She complained of no unusual
symptoms, except the usual labor pains, talked rationally and
had no recollection of having passed through a convulsion.
XJpon examination I found the cervix nearly effaced, the os
admitting three fingers, the head in the median plane and not
engaged, pelvis normal and the child alive. During examina-
tion a second spasm came on and the child's head was forced
down nearly an inch toward the outlet. Dr. Baily adminis-
tered the chloroform and gave 0.03 gram (J grain) of morphin
hypodermically. After due antiseptic precautions I separated
the membranes partially from the uterine wall and introduced
a colpeurynter, which pulled out in half an hour. Delivery
was terminated by forceps. The perineum was intact. Both
mother and child recovered. The urinary findings on the first
puerperal day, the urine withdrawn by catheter, were as fol-
lows: Total quantity, 576 ce. ; acid reaction ; specific gravitv,
0,124; total solids, 32.21 grams; urea, 1.8%; total area, 10.37
grams ; chlorids, 19%; phosphates, 10%; sulfates, 1%; albumin,
6%; no sugar; numerous broad and narrow casts, pavement
and round cells, calcium oxalate crystals and abundant debris.
Blood examination gave the red cells 4,900,000, white cells 12,-
800, hemoglobin 75%, specific gravity 1,055. Of the white cells
there were polynuclear 82.4%, large mononuclear 4.8%, lympho-
cytes 10.9%, eosinophiles 1.4%, and mast cells .5%. The post-
partum treatment was limited to enemas of chloral hydrate
and potassium bromid, saline infusion and stimulation of the
emunctories.
Case V.— Mrs. W., aged 28, primipara, became pregnant
about December 1, 1901. Up to April 1 her pregnancy followed
the usual course. At this time she complained of an acrid
secretion from the cervix uteri that increased in amount and
acridity until the termination of her pregnancy. This secre-
tion, nonspecific in character, had its origin principally in a
hyperplastic, granular, cervical endometritis. This patient
also suffered from mitral insufficiency and had an intermittent
heart heat. Symptoms of threatening eclampsia appeared
about the seventh month of pregnancy. The urine showed a
aigh percentage of albumin, a low excretion of urea, and all
the evidences of Imperfect excretion. Dr. T. S. Middleton
when called recognized the approaching storm, but delayed
operative interference until the failing heart could i)e stimu-
lated and restored to a better condition. Two days later the
condition of the heart had greatly improved. The patient,
however, was rapidly growing worse and had passed through
several slight seizures. Dr. Middleton kindly asked me to see
the patient on June 29, 1902. The patient was at this time about
seven and a half months pregnant and had passed through
nine or ten spasms, some of them slight, others more severe.
She had not lost consciousness at any time. The urine showed
18% of albumin. The fetal heart tones were weak and num-
bered 100 beats to the minute. The vagina and vulva were
inflamed and thickened from the constant contact of the irri-
tating secretion. The patient was prepared rapidly, deeply
chloroformed, and manual dilation of the cervix made. The
external os was open and the cervical walls hard and thick.
The cervical mucous membrane was hypertrophied. After 45
minutes' effort with the fingers and Braun's colpeurynter the
cervix was sufHciently dilated to permit the passage of the
fetus. The membranes were then ruptured ajid the amniotic
fluid was very dark. The fetus presented by the breech. Ex-
traction was made up to the head. The cord pulsation was
slow and weak. The cervix at once pinholed the head and fur-
ther attempts at extraction were useless. Craniotomy on the
after-coming head was then performed and delivery accom-
plished. The placenta, which was fibrous and calcareous, came
away immediately, although there was no tension upon the
cord during extraction. The patient reacted well and made a
perfect recovery. The cervical secretion soon ceased and the
kidney findings improved immediately. There were no post-
partum convulsive seizures.
BIBLIOGRAPHY.
Monats. f. Geburts. u. Gynak., No. 12, 1900.
Ther peutic Gazette, December 15, 18»9.
Centralbl. f. Gyn., No. 39, 1896.
London Ijancet, March H, 18 8.
Obstetrics, .\ugust, ISM.
Annals of Gyn. and Fed , December, 1899.
Archlv f. Gyn., Bd. 63, H. 1 und 2.
Obstetrics, February, 1900,
Treatise on Female Diseases, 1771, p. 388.
Volkmann's Sammlung, No. 304
Boston Medical and Surgical Journal, March 18, 1897.
Obstetrics, April, 1900.
Traltfi pratique des Accouchements, Vol. 1.
Textbook of Midwifery, Winckel.
International Clinics, July, 18M7.
Charpcnlier: De I'lnfluence des divers Traitements sur les Acc^g
6claraptiquos, 1872.
London Lancet, June 15, 1901
Boston Medical and Surgical Journal, November 9, 1899.
Archlv f. Gyn., Bd 19.
London Lancet, July 13, 1901,
American Journal of Obstetrics, September, 1901.
London Lancet, .lune 25, 1901.
Medical Record. September i8. 1911.
Boston Medical and Surgical Journal, December 20, 1900.
New York Medical Journal, December 2, 1895.
Centralbl, f. Gyn., Nrs. 4, 6, 7, S, 1895.
Dublin Journal of the .Medical Sciences, March, 1896.
Therapeutic Gazette, July 15, 1895,
Jour, d' Accouchements, April 5, 1900.
Medical Record, March 4, 1899.
Medical Record, December 20, 1896
London Lancet, Vol. 11, 1889.
Archiv f. Gyn., Bd, 19.
British Medical Journal, Vol. ii, 1900; Vol. i, 1901,
Medical Inspection of Jurists.— It is asserted that the
Governor of Pennsylvania will enforce the act passed by the
last Legislatui'e authotizing the aupointment of Medical Com-
missioners to inquire into the mental and physical condition of
judges, with a view to having those who are incapacitated
retired for the balance of their terms. The entire judicial list
will be carefully gone over, and when a judge is found who has
not been able to perform his judicial functions for a year or
more because of ill health, a commission will be appointed to
examine him and the results of their investigation will be
reported to the Governor. In pursuance of this policy, several
commissions have already been appointed. The constitution-
ality of the act is questioned by a number of lawyers, and it is
claimed that even if a judge is declared incapacitated the act
does not make it compulsory for him to retire.
Babies' Hospital. —The new building of the Babies' Hos-
pital of New York City has been completed and furnished at a
cost of about $157,000. It is believed to be the finest building
of its kind in the world and probably the only hospital devoted
exclusively to babies under H years. The hospital contains 50
beds. Each bed is furnished with a simple contrivance by
which the spring and mattress can be readily raised or lowered
within the high sides. When down at its lowest point no
infant could clamber out over the tall sides. When placed at
an intermediate point the nurse can attend the ciiild with
greater convenience. If the doctor desires to examine the
patient the bottom of the bed can be raised to a level with the
tops of the sides, which are about as high as an operating table
is ordinarily set. It is said these beds were made specially for
this hospital and are the only ones of their kind in existence.
December 6, 19021
STATE MEDICAL BOARD EXAMINATIONS
(Amebican Mediciki 899
SPECIAL ARTICLES
REFLECTIONS ON STATE MEDICAL BOARD EXAMI-
NATIONS AND INTERSTATE RECIPROCITY.'
BY
ALOYSIUS O. J. KELLY, A.M., M.D.,
of Philadelphia.
Instructor In Clinical Medicine and Assistant Physician to the Hos-
pital, University of Pennsylvania, etc.
I have elected to depart somewhat from tradition, and
instead of reviewing briefly and cursorily the advances and
improvements in medicine during the past year, I direct atten-
tion to some reflections upon a question that recently has been
much debated, that has received the serious thought and consid-
eration of many physicians in all parts of the country, that con-
cerns all of us as a body, and that at any time may concern any
one of us as an individual. I refer to State Medical Board
examinations and interstate reciprocity.
It would be supererogatory to mention the elevation of the
standard of medical education that has been effected during
recent years— an elevation inaugurated and fostered by the
medical profession itself. C'oincidentally with this improve-
ment in medical education, with the lengthening of the course
of study and with the increase in the requirements for admis-
sion to college and for graduation, the diftereut States estab-
lished by legislative enactment — likewise inaugurated and
fostered by the memliers of the regular medical profession-
medical boards for the control of the practice of medicine. That
these medical boards indirectly exerted considerable influence
in shaping medical education, in elevating the standards, is not
to be gainsaid. If they did no more than help to rid the country
of the bogus medical college and the diploma-mill their estab-
lishment would have been amply justified. Happily, however,
they wielded a wider influence; but I take it that it is hardly
in accordance with the facts to attribute to their influence all the
recent improvement in medical education— which some at least
of their members suggest.
The motives that actuated the profession in calling for the
establishment of these medical boards were the highest in
morals and ethics ; that in many respects the results have been
directly the opposite of those contemplated, the many discus-
sions on the subject in recent medical literature bear ample tes-
timony. Undertaken with the twofold view to safeguard the
public health and to maintain the honor and reputation of the
profession— to prevent the charlatan and the mountebank from
humbugging those who desire to be (and really deserve to be)
huinl)Ugged, and to provide that only properly qualified physi-
cians should practise medicine, the medical practice laws as at
present administered are in large measure inoperative against
the quack, and they seriously inconvenience the reputable
physician. Indeed, in .some Slates, the charlatan, the quack,
the eddyite, the dowieite, the osteopath, the faith healer, the
clairvoyant, the midwife, etc.— to control whom the medicine
practice laws were especially planned— are by statute or other-
wise especially excepted from their provisions; whereas the
securing of the legal right to practise medicine by the reputable
practitioner of some years' standing is so hedged about with
obstacles that the laws in reality are sectionally prohibitive.
Practically it amounts to this: that a man may be a doctor in
one State and not in another— a condition absolutely anomalous
and without its counterpart in the practice of any other profes-
sion.
That these conditions must be remedied admits of no ques-
tion. But how? That the members of the profession in all
parts of the country are keenly alive to the importance of tlie
question is manifest from the many discussions that have
appeared in the medical journals, especially during the past
year— from the several plans of relief that have been proposed.
Interstate reciprocity is still a measure devoutly to be wished
for, although considerable progress in this direction has been
made quite refiently. I believe that when interstate reciprocity
' Address In .Medicine delivered at the flfly-Rerond annual meetlnic
of the Medical H<x-lety of the State ofPennsylvanla, hold In Allentown,
Scplembcr 18, 17 and 1», IWi.
shall have become an accomplished fact^as it inevitably will-
all the causes for just complaint will not be removed. Some
radical changes in the present methods and scope of examining
applicants for State license to practise medicine are imperative.
The State Medical Board examinations as generally con-
ducted are defective in several particulars, especially (1) in the
inanity and asininity of some of the questions asked ; (2) in the
fact that the exa'mination.s are wholly written, and thus of no
value whatever in determining the practical ability of the
examinee, although they are of service in furnishing evidence
of book-learning and of a good or bad memory ; and (3) in the
fact that precisely the same examination is required of the
reputable physician of many years' standing as of the recent
verdant graduate.
To those who think it must seem evident that an examina-
tion designed to test the knowledge of a person should be con-
ducted with evidences of active cerebral matter on the part of
the one examining, and with an appreciation of the true func-
tions of an examiner. De.spite this evident fact, however, many
of the questions asked at State Medical Board examinations
indicate a woeful lack of knowledge of present-day medicine
on the part of the examiners, a manifest disposition to be unfair,
and an absence of that judicious discrimination that one may
reasonably expect in a person qualified, by law at least, to
determine whether or not his professional brother or sister is
competent to practise medicine in a particular State. By the
State Medical Boards, medical students and medical colleges
are roundly (and deservedly) scored for the evident lack of
knowledge on the part of students of spelling, punctuation and
whatever of grammar there is in the English language —
unmindful, however, of the beam in the eye of the captious
member of the board who seems incapable of formulating a
question in correct English, or a question that is not ambiguous,
unfair, inane, or asinine. That some of the State Medical Board
examiners are absolutely heedless of the progress of medicine
during the pa.st 20 years is often but too apparent; and I ventuie
the assertion that were the facts known we should learn that in
some cases the honorable member of the State Medical Board
is more familiar with the practical politics of the day and with
the approved methods of applying the lubricant necessary to
secure the appointment to the board than he is with the present
state of medical science, and that in some cases the examination
questions are derived from the dust-laden books of the doctor's
library— which library consists in large part, if not exclusively,
of books that he was oblifted to procure when a student 20 or 30
years previously, and that have not been added to since the day
that he secured his diploma and the right to practise medicine
without the interposition of a State Medical Board.
What I have ventured to designate the inanity and asi-
ninity of many of the questions asked must be apimrent to any
one that has been examined or that has studied the questions
asked by the different State Medical Boards. It is true that
much of the the just complaint hedges about the questions
asked in anatomy, physiology, chemistry, and related branches,
but it is by no means confined to these. One may well leave to
the imagination the state of mind that suggests questions,
such as :
Differentiate between pneumonitisand croupous pneumonia.
What is the cause of the pea-soup appearance of the stools in
typhoid fever?
Explain in detail the pathology of shock.
What are the symptoms of acute interstitial nephritis?
Differentiate between chronic interstitial nephritis and
nephritis with exudation.
When a long list of erroneous answers, including bad spel-
ling, bad grammar, bad capitalization, bad punctuation, the
Incorrect use of words, etc., is published, I look upon it as a
reflection, it is true, upon the unfortunate student that was
obliged to appear for the examination and upon the college that
granted him his diploma, but as a reflection also upon the State
Medical Board that asked the questions. It is to be presumed
that the examiners themselves know the correct answers (or
that they may be found in the books that they may have con-
sulted when making up the questions), and it would have con-
tributed to the gaiety of the occasion had the correct answers
been published alongside the Incorrect answers printed for our
amusement and edification (?).
900 AMBBICAN MEDIOIltJCl
STATE MEDICAL BOARD EXAMINATIONS
[Decbmbek 6, 1902
I should not deem unfitted to practise medicine tiie man or
woiiiau unable to answer correctly the following questions, and
still it is correct answers to such questions that enable exami-
nees to make up an average sufficient for them to be considered
qyalified to practise medicine:
Enumerate the functions of a symbol.
Name 20 elements with their symbols.
What is the difference between an empirical, a rational, and
and a constitutional formula?
In what three ways may molecules differ?
What is valency and equivalence?
Mention two elements of each of the following groups:
univalent, bivalent, trivalent, and quadrivalent.
What is a binary compound ?
Write the graphic formula of sulfuric acid, representing S
as a dyad.
Why are (!) the chlorin group called halogens?
What is the boiling point, Fahrenheit, of water, alcohol, and
mercury ?
What is an aldehyde, chemically speaking?
What are alcohols, chemically? Name three of the most
important members of the alcoholic group.
What is the difference between fatty and aromatic com-
pounds and from what two hydrocarbons are they derived?
I pity the man whose qualification as a medical practitioner
is to be based in part upon his ibility to compute the weight of
the skeleton, of the muscles, and of the viscera, fat, blood, etc..
in a man weighing 150 pounds. I pity, also, the poor devil
called upon to mention the seven openings into the pharynx,
the seven digestive organs and the function of each, seven signs
of pregnancy, five causes of female sterility, five steps to be
followed in examining the contents of the stomach, the four
most common causes of acute intestinal obstruction, etc. And
of what practical value can it be to the average man to be able
to tell the size of an air-cell and how many constitute a lobule,
or to name the tumors that develop from the middle embryonal
layer, or to give the reactions of degeneration ? Wlio of us that
has been graduated 10 or even 5 years can tell the origin and
insertion of the pronator radii teres, or can name the nerves
forming the sacral plexus and its branches, or can tell with
what bones the malar articulates, or can mention the foramens
at the base of the skull and the structures that pass through
each? Who among us can name the varieties of muscle, and
give the size of the voluntary muscle fiber, and tell what is the
membrane of Krause and the median line of Hensen? What
Is the correct answer to the following question?
In a nerve muscle preparation, describe the intra and extra-
polar electrotonio condition, and explain why muscle contrac-
tion varies with the application of the electric current.
What shall we say of the Medical State Board that asks
such inane, ambiguous, and obscure questions as the following :
What is the difference between hypertrophy and enlarge-
ment?
DiflTerentiate coma and drunkenness.
What is crusta phloglstica, and how formed ?
Describe the incandescent electric light, and explain its uses
as an aid to diagnosis in medical and surgical practice.
Mention the nine pairs of cranial nerves.
Give the differential diagnosis between typhlitis and peri-
typhlitis.
DeS'Cribe what takes place in inflammation of the brain and
meninges, giving its symptoms and after effects upon the nerv-
ous system, also, treatment of an acute attack.
What bacteria are found in malaria ?
Describe a complete physiologic revolution of the heart.
In case of woman who, some days after childbirth, is sud-
denly taken with dyspnea and cardiac syncope and qulcltly
dies, define and explain the cause of death.
State the pathologic characteristics of epithelioma and car-
cinoma, and describe wherein they differ.
When one considers the character of some of the questions,
it is not surprising that at a recent examination a poor, harassed
student should have written that he could, but would not guess
at the answer to the question, nor that another student should
have frankly stated that he did not know the answer to a
certain question, and that it would not prove of auy value
to him if he did know. Nor can one wonder at the suggestion
made on several occasions—among others, at a recent meeting
of this society, that State Medical Board examiners themselves
should be examined. In reality many of the questions are not
less absurd than the following, said to constitute part of an
examination recently at the wellknown school for boys at
Harrow :
What are the Porte, a jeremiad, the Solar Spectrum, Our
Lady of the Snows, the proletariat, the Grail ?
To whom do the following initials belong: L. C. H. P.,
A. J. B., G. O. S.. R. U S., J. T. B., R. C. J. ?
Why is " Goat and Compasses " a public house sign ?
Why do we place knife and fork alongside after a meal ?
Why do dogs turn round before lying down?
Why have pewter mugs a glass bottom ?
I have probably said sufficient to indicate that I believe that
a change in the method and manner of conducting the State
Medical Board examinations is imperative. Aside from the
fact that all the questions should be selected with judicious dis-
crimination, and especially with a view to achieve the ends for
which the State Medical Boards were instituted, I believe that
the examinations in the fundamental branches, anatomy, phys-
iology, chemistry, and allied subjects, such as embryology,
histology, etc., should be confined strictly to the applied or
practical aspects of these subjects. I would not have you think
that I regard these subjects as other than extremely Important
branches of the medical curriculum ; of their importance there
can be no question— they are unquestionably the very founda-
tion of all medical knowledge, and in medicine, as in other
departments of knowledge and in difierent pursuits, the better,
the firmer, the more solid the foundation, the more stable the
superstructure. But in medicine, as in other departments of
knowledge and in different pursuits, it is the superstructure that
is the utilitarian part of the edifice, it is the superstructure
that is visible, that is inquired into, that is examined, that is
put to practical uses. I am sure that in days gone by many of
us here today passed creditable examinations in Latin, Greek,
geometry, trigonometry, calculus, etc., and while few, if any, of
us would be willing to submit to an examination in these sub-
jects now, none will deny that they were of incalculable advan-
tage to him ; they performed their function and were forgot-
ten. Let the State Medical Boards, therefore, limit their exam-
inations in the fundamentals to their practical aspects, to what
may be called medical anatomy, medical physiology, and medi-
cal chemistry. The ordinary medical man is not, does not
pretend to be, and should not be expected to be an anatomist, a
physiologist, or a chemist, and the examinations in these sub-
jects should be conducted with this fact ever in mind. Surely
the reputable medical college merits some consideration, it may
be trusted even by a critical State Medical Board ; and I believe
that should a graduate student furnish documentary evidence
of having performed a certain required minimum of practical
work in anatomy, physlologjy, and chemistry, the members of
the State Medical Board may with propriety confine their
examination in these subjects to their practical aspects. Of the
poor medical schools I shall say nothing ; their own students
tell the sorry tale. With a minimum, therefore, of the prac-
tical aspects of the fundamental branches of medicine, the
major part of the State Medical Board examinations should
consist of questions relating to the practise of medicine, includ-
ing pathology, surgery, obstetrics, therapeutics, and related
subjects (including what are commonly denominated the spe-
cialties).
There is another aspect of this question that merits consid-
eration. It is important to recognize the fact that the examina-
tions being entirely written by no means achieve the ends for
which they were instituted; they by no means furnish evi-
dence of the practical ability of the examinee. That written
examinations, to some extent at least, should be continued,
must be conceded; but they should be replaced in part by
practical tests. The candidate for a State license to practise
medicine should be obliged to examine a patient or patients, to
make a diagnosis, and to suggest the appropriate treatment ; he
should be called upon to perform certain simple laboratory
investigations of value in diagnosis and prognosis ; and, if the
necessary means could be secured, he should be asked to
furnish evidence of his knowledge of practical anatomy and
of operative technic on the cadaver. Similar examinations are
required of applicants for appointment to the U. S. Army, the
U. S. Navy, the U. S. Marine-Hospital Service, and even to
interneships at some hospitals. With the proper sort of exam-
inations, the certificates of the State Medical Boards might
become what they should be, but what they are not, a source of
pride to those that secure them, somewhat after the manner
Dkckmber 6, 1902]
MINERAL WATERS
[American MiajioiNB 801
of the Licentiate of the Royal College of Physicians of Lon-
don, etc.
This practical examination, desirable in all cases, is espe-
cially imperative in the case of the reputable practitioner of
some years' standing : whence I tal£e it that there should be two
sorts of examinations ; the one that I might call tlie recent
graduate's examination, the other the practitioner's examina-
tion— the latter for practitioners of Ave or more years' standing.
It is unjust to compel the reputable practitioner of some years
to undergo an examination in theoretic and technical subjects
that he has long since forgotten, that he may really never have
known well (since years ago even in the best schools certain
subjects, measured by present day standards, were inadequately
taught or not taught at all ) , and that even if he did know them
would prove of no practical value to him in his daily work.
The justice of this claim is emphasized by the action of at least
one State Medical Board in providing for an examination in
the fundamental branches of medicine in the middle of the
medical course— this enlightened board thus tacitly admitting
that it foresees that at the end of an additional two years the
students will probably have forgotten almost all they knew of
the subjects. How puerile and irrational, therefore, to continue
the present common method of examining in these subjects.
What I desire especially to insist upon is that the reputable
practitioner, the man who has practised in a given locality with
benefit to his patients, and with honor (if not with much pecu-
niary reward) to himself, and who desires or is obliged, on
account of ill-health or for other reasons to remove to another
State, as well as the practitioner that lives near the border of
several States, should not be subjected to the ordeal and the
indignity of a reexamination. He should be permitted, under
certain restrictions but without undue expense to himself,
f >rthwith to take up the practise of medicine in the State of his
electing. This brings up the question of interstate reciprocity,
concerning which, at the present time, I shall say but a few
words.
Relief from the onerous and embarrassing exactions of the
medical practice laws as at present administered may be sought
in one of two directions— either by a nationalization of the laws
or by interstate reciprocity. Without discussing the relative
merits of the alternatives I may say that in many ways nation-
alization of medical practice should prove ideal, but it is
futile to discuss the subject, inasmuch as the suggestion runs
counter to the sovereign and inalienaljle rights of each State to
regulate the practise of medicine (as well as other matters)
within its borders. The recent suggestion of Dr. Rodman's,
for the establishing of a Voluntary National Examining Board,
whose certificate should stand for the highest attainments and
should be acceptable to the several State Medical Boards, Is in
many ways admirable, though visionary. The objections to its
Ijeing carried out are so succinctly stated by the committee of
the National Confederation of State Medical Examining and
Licensing Boards as to require no reiteration by me.
Advocating, therefore, merely the principle of interstate
reciprocity, I leave to tliose whose special business it is, the
formulating of the (letails of a working plan. Manifestly the
scheme is beset with difficulties whlcli relate especially to the
standard of requirements for graduation from college and for
admission to the State licensing examination. Though these
differ materially in the difterent States, I should think it pos-
sible to remove much of the cause of contention by the dif-
ferent State Medical Boards agreeing among themselves upon
whatshall constitutea minimum of requirements. In doing this
those .State Medical Boards with the higher standards should be
able gradually to lead those with the lower standards. For-
tunately, considerable progress in this direction has already
been made, and one of the happiest signs of the times is the for-
mation recently of an orgauization known as "The Confedera-
ti(m of Members of Heciprocating State Medical Examining
and Licensing Boards," made up of members of the State Medi-
cal Boards of Illinois, Wisconsin, Indiana and Michigan. That
the praiseworthy aims of this organization are susceptible of a
wider application is evident from the statement of Dr. James A.
ICgan, secretary of the Illinois State Board of Health, who in a
summary of the laws and regulations concerning the practise of
medicine in the United States says that the following States arc
empowered to recognize certificates of other boards : California,
New Jersey, Delaware, New York, District of Columbia, Ohio,
Illinois, Pennsylvania, Indiana, Puerto Rico, Kansas, Texas,
Maine, Virginia, Michigan, Washington, New Hampshire and
Wisconsin. It would seem in order, therefore, for these
States to begin reciprocating— to follow the worthy example of
the four Western States previously mentioned and of New Jersey
for instance, in the East.
Without pursuing the subject any further at present, I con-
tend that the reputable physician of some years' standing, the
physician that possesses a good home record (of which the
State Medical Board may well be the judge) should, upon pre-
senting a certificate from the Medical Board of his State setting
forth this fact, be accorded registration and a license to practise
in the State of his election. Until such time as this shall have
become an accomplished fact, I beg leave to commend to the
attention of the other State Medical Boards the praiseworthy
practice of the Maryland board. The State Medical Board of
Maryland requires that a practitioner from another State desir-
ing to settle in Maryland shall furnish under oath information
regarding his place of residence, and the time and places where
he practised medicine. Should these statements upon investi-
gation be found to be true, and should the practitioner be found
to enjoy at home a good, moral and professional standing, he is
invited to meet the State Medical Board of Maryland, and he is
given a special examination in accordance with the merits of
the case. This is a practice that is reported to have operated to
the satisfaction of both the board and the applicants for license,
and being a sensible practice it appears worthy of adoption
by other boards until such time as interstate reciprocity shall
have become an established fact.
MINERAL WATERS : THEIR USE AND ABUSE.
BY
C. W. CHANCELLOR, M.D.,
of Washington, D. C.
Author of "A Treatise on Mineral Waters," " Medical Climatology,"
" Sewerage of Cities," etc., etc.
History of Mineral Springs. — From the earliest state of
society mineral waters have been employed as remedies whicli
were believed to operate powerfully on the human constitution ;
but it was not until the latter part of the seventeenth century
that any attempt was made to ascertain their character and
composition, or the source of their sanative power. They
attracted the attention of mankind at a very early period, even
before the Cliristian era, and were then as now employed both
externally and internally for the cure of diseases. The ancient
Romans for many centuries held them in high esteem, but
finally abandoned them after being convinced that they were
more a source of wealth to those places where they occurred
than an instrument of health to those who used them.
Seneca, when contrasting the splendor of the Roman
Empire with the simplicity of the Republic, tells of the won-
derful mineral springs and their gorgeous and expensive
embellishments, of which he says : " They are no longer foun-
tains of health, but a vortex of luxury and a harbor of vice,
where the wealthy dwell in luxury and disdain to tread on
anything but precious stones." Horace, in describing the
" fictitious fame" of those springs, speaks thus:
"Of Vclia and Hulernum tell me, pray,
The climate and the natives, and the way ;
For Bala< now Is lost on me, and I,
Once Its staunch friend, am now Its enemy."
Thus through succeeding ages mineral springs have been
in turn abandoned by the leaders of society, and the supposed
requirements of health have not been so poteutas the mandates
of fashion. The "resort" of one generation Is forsaken by
another.
In the early centuries of our era the Roman conquerors of
the Western world reared around the springs they discovered
■ Bala was a celebrated watering place, near Naples, during the
height of the Roman power; but It dually ceased to be vlslteif, and
became a stagnant pool. In modern times, however. It has been reno-
vated and Is again a fashionable watering place.
902 AJIEBIOAN MeDIOJNEI
MINERAL WATERS
[Decbkbeb 6, 1902
in Kngland, Germany and France splendid baths, the magnifi-
cence and extent of which are still the subject of fresh dis-
closures and the theme of increasing admiration ; but after the
Koman exodus these resorts fell into disuse, and from this
time, passing over a period of a thousand years, we have no
record of mineral springs, until Bracciolini, in 1420, described
Baden, in Switzerland, as " a place fit for Venus with her
troop." But knowledge concerning the medicinal value of such
fountains has not followed their ratio of development, and they
are, apparently, again passing into harmless disuse.
Dominant J'rinciples.— In nearly all mineral springs there
are some substances which, from their greater activity and
quantity, give a character to the waters, as acidulous, cha-
lybeate, sul/urous, etc.; hut we should not attribute to a single
principle, however dominant it may appear in the chemical
analysis, all the virtues of a mineral water. Iron and arsenic,
for example, are found in the waters of Vichy and Mount
Dore, respectively, and are justly esteemed valuable therapeutic
agents, but they have not given their name to the springs in
which they are found. On the contrary lithia, which, since its
discovery, has been found in small quantities in almost every
spring in Europe and America, has, in this country, suddenly
become dominant in the chemical analysis of most waters, and
the name is used as a make-weight to impress the public witli
the sanative value of various waters.
As the mineral substances held in solution in some of the
most efficient mineral waters do not amount to more than one
ten-thousandth part, we can readily incline to the belief that
their sanative properties most probably consist in the gases
they contain, with their peculiar proportion and combinations.
P''urthermore, if we reflect on the acknowledged fact that the
composition of mineral waters is, up to this time, imperfectly
known, and that ingenious men have indulged themselves in
vain conjectures on the nature of the substances to which sucli
waters owe their activity, we may not be accused of temerity
in asserting that nitrogen, oxygen, and carbonic acid gases
constitute the triple alliance from whence issues the mysterious
sanative power of most mineral waters, and they may, therefore,
be classed as their dominant principles. To these, also, should
be added sulfureted hydrogen gas in sulf urous waters.
Chemical Analysis. — The art of analysis is as yet apparently
in a state of so great imperfection that many impregnations of
waters may have totally escaped observation, and particularly
many gaseous impregnations, the effect of whicli on the body,
it is probable, are infinitely more powerful than those of the
substances which have been most attended to. The compara-
tively recent discovery of argon and helium blended with
nitrogen in the wellknown mineral waters of Wildbad and
Gastein in Germany, and the still more recent discovery of
other, perhaps less important, gases which accompany these,
all being much more soluble than nitrogen, and therefore
probably more readily absorbed through the skin and mucous
membrane of the bathers and drinkers of mineral waters,
appears to give additional explanation to the influence of these
waters upon the tissues of tlie body, and to facilitate their
curative effect upon the muscular and tendinous deposits from
arthritic and gouty diseases, for which they are so justly
celebrated.
It should be stated, moreover, that the waters of these
springs have a remarkably detersive and emollient effect on the
skin, which may be partly due to their alkaline character, but
in a much greater measure to glairin which is said to be present
in many mineral waters of similar composition and to com-
municate an emollient effect upon the skin. In our former state
of ignorance and uncertainty, it was not surprising that the
salubrity of many waters was attributed to their solid mineral
impregnations as set forth in analytic tables, compiled for the
use of the lay public and published in every spring's pamphlet,
but results clearly indicate that the proof is deficient, and the
effects quite inadequate to the solution of the problem. We
are, therefore, justified in discarding solid mineral impregna-
tions as the active therapeutic factor in mineral waters, and
may now be persuaded that physicians from the age of Hippo-
crates to our own day have been utterly deceived in attributing
cures resulting from the use of mineral waters to the solid
impregnations found in them by chemical analysis.
Medicinal Action.— It is now quite evident that the medic-
inal action of natural mineral waters is not in relation with
what we know of their constituent principles, that it is not a
few grains more or less of mineralizing salts which determine
the salutary effect of the water, but that this effect must be
ascribed to the fluid operating by its warmth, by its power of
dilution, and by the presence of certain gases, until recently
unknown or neglected, which impart a vital and animating
principle to the water. It may therefore be said that chemists
have hitherto analyzed only the corpse of mineral waters after
the vital principle had escaped. Chemistry has taught us to clas-
sify mineral waters by pointing out the predominating mineral-
izing substances, but it belongs to clinical observation, to the
authority of multiplied facts, to determine their therapeutic
action which is frequently not such as the chemic composition
would lead us a priori to suppose, seeing that eome waters but
slightly mineralized are productive of powerful and marked
effects. It is well known by those who have paid any attention
to the subject that in a chalybeate spring, for instance, the
tonic properties of which are extremely marked, and the pres-
ence of iron is evident to the taste and sight, the chemic analy-
sis does not exhibit in many instances more than i or i of a
grain of this metal to the pint, a quantity which if exhibited in
a pharmaceutic form would be productive of no effect.
The most skeptical on the subject of accomplishing great
results by simple means cannot retain their doubts after wit-
nessing or hearing recorded the numerous cures of various
maladies by the use of the Malvern and Cheltenham waters in
England, the Wildbad and Gastein waters in Germany, the
BarOges and Aix-les-Bains waters in France, the Clarendon
Spring in Vermont, the Capon Spring in West Virginia, the
Eureka Spring in Arkansas, and the Bethesda Spring in Wis-
consin, used as a drink and for bathing. It must seem an
incredible fact to many that waters like these should have
acquired such celebrity for the cure of diseases and ranked high
in the class of mineral waters when they contain no more tlian
two or three grains of mineral matter in the gallon, and some of
thein not more than one grain. In sensible properties, except
as to temperature, these waters cannot be distinguished from
common spring water, but no waters possess greater efficacy
in the cure of many diseases. Without pretending to offer any
very minute or refined theory of the mode in which they act, it
can only be accounted for by some new force — a gaseous
impregnation introduced into the tissues by absorption, and
thus in a very high degree stimulating every function of the
body.
Divesting ourselves of prejudice or prepossession derived
from the professional and scholastic refinements of one class,
and the love of the marvelous and spirit of exaggeration of
the other, we shall be compelled to grant that whatever good
effects have been evinced in using the waters of Buxton, Mat-
lock, Bristol, and Bath in England, Wildbad and Gastein in
Germany, Aix and Mount Dore in France, Lebanon in New-
York, the Old Sweet and Berkeley Springs in West Vir-
ginia, the Warm, Hot and Healing Springs in Virginia,
the Bedford Springs in Pennsylvania, the Warm Springs in
North Carolina, and the Hot Springs in Arkansas, they are
mainly explicable on the principle of dilution and temperature,
and in the presence of some of the newly-discovered gases-
argon, hilium, neon, crypton, and xenon— being blended with
nitrogen gas, which is abundant in all these waters, and which
being, as it were, liberated within the very pores of the skin
during bathing, may be more readily absorbed for the solution
of chalky depositions and other sanative purposes. Dr. Scuda-
more, a writer by no means ready to abandon art in favor of
nature, or to assign a virtue to asimple when itcan be contested
by a compound, said morethanhalfacentury ago that "the med-
icinal action of mineral waters generally is to be referred to their
purity, their temperature, and their gaseous impregnations with
azote."
These waters, as well as those mentioned above as contain-
ing a minimum of solid mineral impregnation, whether drank
or used as a bath, or made use of in both ways, are found to be
especially useful in cases of rheumatism, gout, neuralgia, spinal
irritation, and certain forms of derangement of the digestive,
urinary, and uterine functions. The fact that these, by reason
Decembek 6, 1902]
MINERAL WATERS
[Americas Medicisk 903
of the absorbed gases, are essentially and largely stimulating,
renders especial care necessary that they be not made use of
under improper circumstances, and that every means be taken
to render the cases to which they are adapted as fit as possible
for their beneficial operation.
In regard to the first of these particulars, oases of recent
organic or structural alteration in any of the great internal
organs, whether of the brain, heart, lungs, liver, stomach, or
kidneys, would indicate that no mineral water whatever should
be made use of. And, it should be added, that in cases in which
disease is of a congestive or inflammatory type, they should
either not be used at all, or used most cautiously, until the con-
gestion or inflammation has been subdued by appropriate
means.
Excess of Mineral Substances. — It appears certain that dis-
ease may be originated by an excess of mineral substances in
water. Of the metallic ingredients, the effects of iron and lead
have been the most fully ascertained. It would appear that
iron, if present in quantities large enough to impart a decided
chalybeate taste to the water, often produces headache and dys-
pepsia, while impregnation with lead lias frequently been fol-
lowed by symptoms of lead-poisoning. Arsenic and copper are
never found in sources of drinking water in this country in
Injurious quantities. The symptoms referable to an excess of
impregnation by earthy salts are mainly of a dyspeptic nature,
with general malaise. Many springs and wells, set aside for
purposes of health, contain double, treble, quadruple, and
even a hundred times the quantity of mineral matter designated
as a maximum for health. This is notably the case with min-
eral wells, all of which contain a great excess of niineral salts
and a remarkable absence of gjases, which serve, when present,
to modify the injurious effects of the mineral impregnations,
and to impart a sanative influence to the waters.
Dr. Wilson, of England, in his valuable work on hygiene,
says: " Itisdifllcultto fix the maximum amount of permissible
material matter in potable water ; but it certainly ought not
to exceed 30 grains per gallon." Dr. Parkes, the eminent sani-
tarian, maintains that the amount should not exceed 10 or 12
grains, while Mr. Simon and Dr. Lyon Playfair express them-
selves infavorof a still am&l\er (\\xa.ntity for pm-poses of health.
Dr. Sutherland, an eminent authority, asserts that water con-
taining an excess of mineral matter, i. e., over 10 or 12 grains
per gallon, will prove as injurious to many people as water
contaminated with organic matter. It produces constipation,
visceral obstructions and weakness of the contractile organs,
thus prostrating the vital energies and keeping the patient in a
state of semi-invalidism, especially persons of a weak and irri-
table constitution. This olijection, however, does not apply to
waters highly charged with gases, such as Vichy and Saratoga.
Thermal Waters. — Thermal waters possess various degrees
of heat, from the mean annual temperature of the place at
which they rise, up to and above the boiling point : and although
not as pure as the cold diluent waters they generally contain so
little foreign matter that their effect must be ascribed to the
fluid operating by its power of dilution, or through its natural
temperature and gaseous impregnations; hence the absolute
importance of such waters being used, whether internally or
externally, at the fountain head. Like most other mineral
waters they will not stand transportation, unless they hold in
solution a considerable proportion of natural gases. It may be
here stated, as a general rule, that highly mineralized waters
contain but little gas, and are not valuable as .sanative agents.
As a rule thermal waters belong to the alkaline saline min-
eral waters, among which they take first rank. Their action is
produced by the combined eff'ects of the water, the natural tem-
perature, and the contained gases. The natural temperature of
the water accelerates the action of the absorljing tissues, stimu-
lates^the circulation of the blood, and acts as a se<lative on the
nervous system. The gases not only act on the skin, but also
on the stomach, thus either augmenting the secretion of gastric
Juice, or calming the sensitive nerves of the stomach ; they also
act In an invigorating manner on the peristalsis of the stomach
and intestinal tract, facilitating digestion as well as resorption.
By acting on the lungs and lymphatic vessels they modify the
condition of the secretions, stimulating at the same time the
ganglionic system.
Sea- Water.— The practice of many who frequent sea-bathing
places in descending to the beach and there swallowing, period-
ically, a quantity of sea-water is extremely detrimental to the
health from the excessive and permanent irritation of the stom-
ach and bowels produced by the potion in its state of mechanical
mixture with selenite, floating particles of algse, and its integral
combination of sodium chlorid.
Sea-bathing is found beneficial in renovating the constitu-
tion when it is exhausted either by heat or the impure atmos-
phere and enervating modes of life prevalent in great cities.
Spring and autumn should be selected as the season most
proper for sea-bathing. About the first of July, and for six
or eight weeks thereafter, the sea-weeds disintegrate, and,
breaking up from the bottom of the ocean, are washed ashore
with innumerable mollusks undergoing decomposition and
producing malarial fevers.
The frequency of sea-bathing should be regulated by the
strength of the constitution ; to bathe on alternate days is sufli-
cient for the preservation of health. It is useful in removing
nervous complaints, and all other maladies originating in pure
debility ; it is contraindicated in all cases in which the applica-
tion of cold is injurious — as jaundice, indigestion, tuberculosis,
organic diseases of the heart and large bloodvessels, gout,
rheumatism, chlorosis and cutaneous diseases.
Collecting and Dispensing Mineral Waters. — In collecting
and dispensing mineral waters the utmost care should be taken
to preserve the gases and prevent decomposition of the chemie
constituents. This can only be accomplished by bottling
the water at the spring. A quart or half-gallon bottle will
answer the purpose. Care should be taken to have the vessel
thoroughly clean ; the cork should be new and clean, and fit
well. The bottle should be plunged into the water with the
mouth well under the surface. Fill to the neck, then insert the
stopper, previously well soaked in hot water, and cover with a
piece of clean muslin, wash-leather, or gutta-percha tissue,
tie securely and seal.
Barrels, carboys, demijohns and jugs are to be avoided ;
water should never be decanted from one vessel to another. In
filling bottles, unless at the spring, the gases unavoidably
escape, the chemie ingredients become decomposed and, what
is worse, the water is exposed to the influence of the surround-
ing atmosphere, often contaminated and filled with spores,
germs and other low forms of life, which find their way into
the water and cause disease among those who drink it. Under
no circumstances should bottles be refilled until they have
been thoroughly cleansed and sterilized by washing them with
strong sulfuric acid, followed by ordinary pure water, until
there is no longer any taste of acid, and finally rinsing them
with some of the water to be bottled. All this, however, should
be performed at the spring.
No one who has paid any attention to the subject could fail to
observe the incredible filthiness which is too often practised in
handling empty mineral water bottles. The uncorked, empty
bottle^for which a rebate is allowed, is sometimes disposed of to
junk dealers, or temporarily stored in some filthy cellar, out-
house, stable, bathroom, water-closet, or it may be in a room
infected with dangerous microorganisms. In this way the bot-
tle becomes filled with bacteria which are omnipresent in the
air of such places, and once having entered the bottle they can
not be displaced by ordinary rinsing. It has been observed,
moreover, that returned bottles sometimes bear unmistakable
evidences of having been used for very uncleanly purposes.
To ensure safety, no bottle should be refilled except at the
spring and after having been thoroughly .sterilized. A new
and fresh bottle is of course to be preferred. The bottling
should be done in the presence of a responsible ofllcer, who
should afllx his seal of office to each bottle. In some of the
European countries this is done under government super-
vision. Certainly a compulsory system of inspecting mineral
waters might be inaugurated after the fashion of milk inspec-
tion in many cities.
In 1893 the term " certified milk " originated in New Jersey.
A commission was organize<l with the view to ensure milk prop-
erly prepared and properly handled ; buildings were required
to be well constructed, drained and ventilated, and the milk
kept apart from all sources of contamination. Cows were
904 AMEBicAN Medicine]
THE WOEIiD'S LATEST LITERATURE
[Dbcexbkr 6, IWi
required to be handled by milkers with clean overalls and clean
hands: the milk packed in glass jars thoroughly cleansed and
sterilized, and hermetically sealed. These jars are then labeled
"Certified Milk," and no other milk is allowed to be sold.
Dealers, as was to be expected, resisted the innovation, but the
plan proved successful, and has been followed by other States
with manifest advantage to the public health. Why should we
not also have our mineral waters inspected and labeled " Certi-
fied Water?" The attention of health officers could not be
directed to a more important measure lor the protection of the
public health.
THE WORLD'S LATEST LITERATURE
Journal of the American Medical Association.
November 19, 190t. [Vol. xxxix, No. 22.]
Symmetrical (Jangrone (Kaynaud's) versus Endarteritis Obliterans.
James Diibley Mokgan.
A Simple Single-dls ^ Eye Mirror: the Working Ophthalmoscope
for the Eye Specialist and General Practitioner, and How to Use
It. Hek'man Ksapf.
Associated Movements of Head and Eyes. William Campbell
Posey.
The Present Aspect of the Tuherculosls Problem in the United
States. 8. A. Knopf.
The Army Hcspltal and Sanatorium for the Treatment of Pul-
monary Tuberculosis at Fort Bayard, New Mexico. D. M. Appbl.
Anatomic Treatment of Fraeturesof the Femoral Neck. C. E. Ruth.
Reportof Four Cases of Syphilis Mistaken for Smallpox, with Re-
marks on the DlfTerentlal Diagnosis of these Two Dlsea.<es. Jay
F. SCHAMBEKG.
Concerning Some Vaccinal Eruptions. Henry W. Stelwason.
The Place and Importance in the College Curriculum of Pharmacy.
J. Allen Patton.
The Outdoor Treatment of Tuberculosis. F. E. Waxham.
1.— See American Medicine, Vol. Ill, No. 24, p. 991.
3.— See American Medicine, Vol. Ill, No. 25, p. 1055.
4, 5.— See American Medicine, Vol. Ill, No. 25, p. 1046.
6.— See American Medicine, Vol. I, No. 12, p. 533.
7.— Syphilis Mistaken for Smallpox.— Schamberg states
It is particularly the pustular syphiloderm which is apt to be
confounded with smallpox. The variolaform syphilid may
develop after the disappearance of the earlier cutaneous out-
breaks. We do not note the sudden illness which precedes
unmodified smallpox. The appearance of the eruption in the
latter is usually sudden. In syphilis the lesions appear in
crops. Occasionally in modified smallpox the appearance of
ihe lesions may extend over three or four days. The distribu-
tion may be identical. The pustular syphilid, unlike smallpox,
may involve the trunk more than the face, and rarely affects
the palmar and plantar surfaces. The papular syphiloderm
commonly involves these surfaces. The vesicles and pustules
of syphilis never become full and globular, filling the entire
lesion, as do those of smallpox. The lesions of variola undergo
a striking change in a lew days ; those of syphilis are relatively
chronic. The lesions may simulate each other so closely that
even physicians of experience will be deceived, [h.m.]
9.— Importance of Pharmacy. — Patton holds that chem-
istry, botany and physics should be required as preliminary to
the medical course, their pliarmaceutic bearings as well as the
general principles of pharmacy being studied in the first year.
The next year should present the general application of the
principles and practise of pharmacy in the prescribing of drugs
and this should preferably be given by a teacher of both phar-
maceutic and medical experience. The clinical instruction
should give full directions from the pharmaceutic as well as the
pharmacologic side of the use of the drug. Adherence to the
preparations of the pharmacopeia is desirable, [h.m.]
lO.— Outdoor Treatment of Tuberculosis. — Waxham
says that tent life should not mean roughing it. A tuberculous
patient is in no condition to take care of himself. He should
be given rest and quiet. If the temperature is high rest should
be absolute. The best results are obtained from sleeping in a
tent the year round and this can be done by shifting patients
about allowing them to spend their summers in Colorado and
their winters in Arizona or New Mexico. They should be
under medical supervision, [h.m.]
Boston Medical and Surifical Journal.
November 27, 190t. [Vol. OXLVII, No. 22.]
1. The Normal Appendix: lU Length, Its Mesentery, and Its Position
or Direction, as Observed in im Autopsies. George H. Monks
and .1. Bapst Blake. , , „ „ , „ „
2. Six Cases of Rupture of the Intestines, with Four Recoveries. F B
Lund, E. H. Nichols and John T. Bottomlby.
3. Some Cases Which Were Not Pernicious Anemia. John LovEn
Morse. „ „
4. A Case of Poisoning by Thallium. William N. Bullard.
5. Tetany in Gastric Disorders. Lawrence W. Strong.
1.— The Normal Appendix: Its Length, Position, etc.-
Monks and Blake, after observing the appendix at 656 necrop
sies in the Boston City Hospital, make their report as follows
There were nine instances in which the cecum tapered into th(
appendix. In six instances the appendix was represented by i
white, glistening, fibrous cord, an obliterated appendix. On(
appendix was directed up behind cecum, passing over th<
anterior surface of right kidney t) within 1 cm. (J in.) of it!
upper margin; another was curled up behind cecum, jus
below the costal margin ; a third extended up and in, the tij
lying close to gallbladder. A fourth extended up externally t<
the right border of the liver; a fifth lay between the right lobi
of liver and right kidney ; a sixth lay behind the peritoneun
under the cecum, extending upward to the lower border o
right kidney; a seventh lay transversely across the abdomen
slightly upward, reaching beyond the middle line. The aver
age length of the appendix in men, women and children, India
criminately, is 7.9 cm. (3 in.) ; the extremes being 1 cm. (J in.
and 24 cm. (9J in.). There is apparently no relation betweei
the length of the body, the sex or age of the subject, and th
length of the appendix, except that children are apt to have ai
appendix proportionately longer than adults. Fully one-hal
of all appendices have a mesentery which reaches nearly to, o
quite to, the tip. Of the other half, by far the greatest proportioi
have mesenteries reaching as far as the middle point of th
appendix or beyond it. Occasionally an appendix has n^
mesentery at all. The commonest position or direction for th
appendix is "down and in," that is, toward the pelvis, th
appendix very frequently hanging over the brim. The secon(
commonest position is " behind the cecum." The third i
"down," and the fourth is "in." The appendix is in one o
these four positions in about three-quarters of all cases, [a.b.c.
2.— Rupture of the Intestine, with Report of Six Cases
—Lund, Nichols, and Bottomley insist upon the value of earl
exploratory operation in all cases of abdominal injury. The
report six cases under the following captions : Rupture c
intestine by fall from a bridge ; intestinal resection after 'i
hours— death. Rupture of the intestine, probably from kick c
a horse ; operation within 16 hours after the accident— recovery
Rupture of the intestine by kick of a horse ; operation nin
hours after the accident— recovery. Rupture of the intestine b
kick of a horse; operation three hours after the accident-
recovery. A boy of eight years was run over by a team, ther
was no loss of consciousness, but there was much pain in th
region of the umbilicus; operation within five hours after th
accident— recovery. A patient was knocked down on a smoot
wharf, and though there was no violence to the abdominal wa
from without, he sustained a rupture of the intestine. Th
authors conclude as follows : The one thing that means most t
patient and surgeon in all these cases is the length of tim
allowed to elapse between the hour of accident and the hour <
operation. Beyond the fourth or fifth hour every hour of dela
adds greatly to the danger of a fatal issue. We cannot wait fc
signs that indicate certain perforation. None of us would hes
tate to do an immediate operation upon a patient whom w
knew had a perforation; we would consider an operation hi
only chance for recovery. But in the great majority of cas<
we cannot know except by operation, and the best time t
know is to know early, when the knowledge will be of servic
to the patient, [a.b.c]
3.— Cases Not Pernicious Anemia.— Morse believes tl
diagnosis of pernicious anemia can not be made from the cond
tion of the blood alone. Severe secondary anemias are ofte
mistaken for it. He reports cases in which the discovery of th
estivoautumnal parasite, bleeding piles, and carcinoma wit
hematuria changed the diagnosis, [h.m.]
December 8, 1902|
THE WOELD'S LATEST LITERATURE
(Amksican Medicine 905
4— Poisoning by ThalHum.— Bullard briefly describes
the symptoms manifested in animal experimentation, and
reviews the instances of poisoning in man already recorded.
He reports the case of poisoning of a physician, due to self-
experimentation, causing numbness in the fingers and toes
which in the course of two or three days extended up the lower
extremities, involving the perineum and lower abdomen. The
nerves of the lower extremities were painful and there was con-
siderable weakness and partial paralysis, and total loss of hair.
The treatment consisted in rest in bed, dry heat and potassium
iodid. The condition was plainly a multiple neuritis. It fol-
lowed the usual course of this affeetion, and the patient event-
ually recovered completely, [h.m.]
5.— Tetany in Gastric Disorders.— Strong reports seven
cases and summarizes the descriptions of French and German
writers, reviewing also the American literature on the subject.
He concludes that the condition is a symptom-complex, indica-
tive of an increased nervous irritability, probably central in
location. The muscular spasm is a reflex phenomenon, caused
by some mechanic stimulation, as vomiting or lavage, with
possibly a direct action in the case of pressure and electrical
stimulation of peripheral nerve trunks. The spasm, however,
cannot be produced without antecedent nervous irritability.
The chief factor in diagnosis is the muscular spasm itself,
affecting the arms in a characteristic manner. The theory of
Intoxication is the only one adequate to explain the hyperirri-
tability. [h.m.]
Medical Record.
November 29, 190$. [Vol. 62, No. 22.]
1. Faratyphold Fever. N. E Brill.
2. A Report of a Case of Successful Suturing of the Heart, and Talile of
37 Other Cases of Suturing by Different Operators with Various
Terminations, and the Conclusions Drawn. L. L. Hill.
3. Hyoscln In the Treatment of Drug Habits. Howard C. Russell.
4. Inflammntion and Perforation of Meckel's Diverticulum as a Cause
of Septic Peritonitis, with a Report of Two Cases of Typhoid Per-
foration of Meckel's Diverticulum. A. E. Halstead.
1. — See American Medicine, Vol. IV, No. 19, p. 725.
2. — Successful Sature of the Heart.— Hill reports the
case. A negro youth of 13 was stabbed, the blade of the pen-
knife entering the fifth interspace 1 cm. (J inch) to the right of
the left nipple. At the operation, which was performed some
six or eight hours after the injury, the third, fourth and fifth rib
together with the pleura were cut through in the anterior axil-
lary line and the musculo-osseous flap was lifted, the cartilages
of these ribs acting as a hinge. The pericardium was much
distended with blood. The small wound in this was enlarged
and 10 ounces of blood evacuated. The cardiac wound was
closed with seven catgut sutures, shock was vigorously com-
bated and the patient made a good recovery. The author
reports in tabulated form the results in 37 other cases by vari-
ous authors. His conclusions are as follows : Any operation
which reduces the mortality from 909!, to about 63% is entitled
to a permanent place in surgery, and every wound of the heart
should be operated upon immediately. Whenever the location
of the external wound and the symptoms cause suspicion of a
heart wound it is the duty of the surgeon to do an exploratory
operation. Unless the patient is unconscious an anesthetic
should be given, preferably chloroform. Struggling is liable to
produce a detachment of a clot, and renew the hemorrhage.
Never probe the wound, as serious injury may he inflicted
upon the myoi'ardiuin. Kotter's operation renders access to the
heart extremely easy. Steady the heart before atteuipting to
suture it, either by carrying the hand under the organ and lift-
ing it up, or, if the hole is large enough, Introduce the little
finger, ('atgut sutures should be used, as wounds of the heart
heal in a remarkably short time. The sutures should be inter-
rupted, introduced, and tied during diastole, not involve the
endocardium, and as few as possible should be passed as they
cause a degeneration of the muscular tlher with its tendency to
dilation and rupture. In cleansing the pericardium it should
be sponged out and no fluid poured into the sac. The wound
in the pericardium should be closed and should symptoms of
compression arise, reopen the wound and drain, [a. B.C.]
4.— Inflammation and Perforation of Meckel's Diver-
ticiiluip.— The author enumerates the various pathologic condi-
tions which may arise from the presence of a Meckel's diver-
ticulum. He then reports two cases in which perforation of this
diverticulum occurred during typhoid fever. One was that of a
man of 26. During the fifth week of the disease symptoms of
intestinal perforation appeared ; laparotomy under spinal
anesthesia was performed and a diverticulum 5 cm. (2 inches)
long was found 2J feet from the ileocecal valve. At its extremity
was found a perforation which would admit the fiuger. No
other perforation was found. The patient was treated in the
usual way but died. A second case was that of a man of 45 who
developed symptoms of perforation in the second week of an
attack of enteric fever. Laparotomy showed a general septic
peritonitis from a perforation in the tip of a Meckel's diver-
ticulum which was situated 3J feet above the ileocecal valve.
The patient died. The author says : In reviewing the histories
of the reported cases of inflammation of Meckel's diverticulum,
we find that in none was the cause of the symptoms recognized
before laparotomy. In the cases operated upon the diagnosis
of appendicitis or of intestinal obstruction was made. No symp-
tom or group of symptoms are characteristic of diverticulitis.
In the majority of cases it closely simulates appendicitis. In
many the diverticulum occupies a position in the right iliac
region, close to the appendix. The onset is usually sudden,
with vomiting, muscular rigidity and pain, as in appendicitis.
In a few cases the symptoms have been those of recurring
appendicitis, with the interval between the attacks free from
any evidence of disease. In those cases in which the diver-
ticulum is attached to the umbilicus, periumbilical pain and
tenderness is some evidence of the disease, [a. B.C.]
tie^r York Medical Journal.
November SS, 190t. [Vol. lxxvi. No. 21.]
1. Ten Instructive Cases for the General Practitioner In Medicine, with
Remarks Upon the Detection and Relief of Eye-strain. Ambrose
L Ranney.
2. The Prevention of Intestinal Diseases In Infants During the Sum-
mer. Charles Gilmobk Kbblev and John Lawbencb
HCQHES.
:<. Rubber Gloves Robert T. Morris.
i. A Special Type of Crookes' Tube for Therapeutic Applications of
Rontgen Rays to the Cervix of the Uterus. E. W. Caldwell.
5. Three Cases of Shark Bite. J. A. Guthrie.
1.— The Detection and Belief of Eye-strain.— Ranney
reports 10 cases, each of which tends to illustrate some special
type of manifestation of eye-strain in consequence of reflex dis-
turbances upon the nerve centers. Kach case was selected to
prove that a scientific investigation and correction of eye-strain
can radically cure, in some instances, cases that are apparently
hopeless and incapable of permanent relief by medication. Of
the 10 cases reported several have apparently justified a diag-
nosis of organic di.sease of the brain or spinal cord. The first
case was one of absolute mental failure in which a diagnosis of
cerebral softening had been made. Perfect recovery followed
the relief of eye-strain. The record of another case shows that
chronic diabetes may be excited by eye-strain alone, and that
the relief of eye-strain may, In some instances, cause a total dis-
appearance of sugar in the urine. The existence of periodic
attacks of laryngeal spasm to a degree that seemed to imperil
life is illustrated in a third case. The relationship between eye-
strain and neuralgia is shown very forcibly in two cases ; in one
the neuralgia was in the orbit; in the other in the stomach.
The relationship lietween eye-strain and persistent reflex spasm
of a localized group of muscles is also illustrated. The three
epileptic cases reported as cured by eye treatment are particu-
larly interesting. One had no refractive error ; hence the
anomaly of the eye muscles could not be due to refraction. The
second has been relieved from convulsions for years by glasses
alone. The third is of interest now chiefly because, after the
seizures had persisted for 24 years, a total arrest by eye treat-
ment followed and has persisted (for over 16 years) since the
first graduated tenotomy was performed upon an eye muscle.
[C.A.O.]
2.— Intestinal Diseases in Infant«.— Kerley and Hughes
discuss the subject of summer diarrhea in infants and its treat-
ment, and give in detail their method of preventing an attack.
So soon as slight vomiting or a loose stool is reported, the breast
or cow's milk diet Is replaced by barley water— one tablespoon-
ful of barley to one pint of water, as many ounces being given
906 AXXBICAlf MSDieiNKl
THE WORLD'S LATEST LITERATURE
[December 6, 1902
as the child received of milk In health. From 2 cc. to 4 cc.
(30 gtts. to 60 gtts.) of castor oil is given. in purely intestinal
oases. If there is vomiting .0065 gm. (^ gr.) of calomel is
given every hour for six hours. In the vomiting cases the
stomach is washed, and if there is diarrhea the following
mixture is given :
Bismuth salicylate 065 gram ( 1 grain)
Bismuth subnltrate 65 gram (10 grains)
Aromatic syrup of rhubarb 18 cc. ( 3 minims)
Water, enough to make 8.7 cc. ( 1 dram)
This constitutes one dose and is given every two hours. When
the stools and temperature warrant it, the milk is gradually
resumed in from one-fourth to one-sixth its former strength.
Clean, suitably prepared, properly cared for, and properly
administered food is indispensable in the prevention of this
condition. [c.A.c]
3.— Rubber Gloves. — Morris says there are occasions on
which almost any one should use rubber gloves in surgical
work— for instance, in an operation upon a diabetic patient or
if the surgeon has just operated upon a septic case, but ordina-
rily he believes that the longer incisions and the greater length
of time required for an operation with rubber gloves allow
more bacteria to fall into the wound than would be carried into
it when the surgeon operates rapidly and neatly with bare
hands, prepared by some good method, depending upon the
germicidal action of blood serum for controlling any bacteria
which make their way from the deeper epithelium of the hands
before he has completed the operation. He also believes that
the normal resistance of the patient to infection can be better
conserved by the surgeon who trains himself to work quickly
and with smaller incisions. [c.A.c]
*•— A special type of Crookes' tube has been devised by
Caldwell, with modifications which adapt it especially for
uterine and vaginal work. In this tube, as in the old pear-
shaped tube of Crookes, the cathode stream impinges, not upon
a metal target, but upon the glass wall of the bulb, which there-
fore becomes the source of x-rays. A considerable amount of
heat is developed at the point of impact of the cathode stream,
which makes it necessary to cover the target end of the tube
with a water jacket in order to keep it cool. At the end there is
a depression for the os uteri, which is intended to assist in
keeping the tube in position. The rays emanate from the end
of the tube, [c.a.o.]
5.— Three cases of shark bite are reported by Guthrie.
In the first case there was entire loss of the left leg and a quan-
tity of muscular and other tissue of the thigh. In the second
case the muscles of the front of the right thigh were torn
through quite down to the bone, leaving a gap about ten inches
by six inches in area. In the third case the man was bitten in
the face. Recovery followed in each case, [c.a.o.]
Medical News.
November 29, 190t. [Vol. 81, No. 22.]
1. Preventive Medicine. William A. Howe.
2. Reminiscences of Nearly Half a Century In Medicine and Sureerv
Charles K. Briddon.
3. The Hyoseln Treatment of a Morphln Habitue. Handle C
EOSENBEKGER.
4. Some Phases of Infantile Feeding. Edward T. Abrams
5. Appendicitis. Lewis S. Blackwell.
6. Albargin or Gelatose Silver In the Treatment of Gonorrhea. Her-
mann (i. Klotz
7. The Influence of Alcoholic Heredity In Diseases ofChlldren. T D
Okothers.
8. The Early Diagnosis of Intussusception. F. Huber.
2.— Reminiscences.— Briddon remembers when the very
short course, which was purely theoretic, little or no laboratory
work, and no bedside instruction gave the recent graduate a
preparation wondrously inadequate to meet the demands of
intelligent practice. Comparatively few of the recent gradu-
ates could hope to obtain a hospital position, for vacancies were
few and candidates were many. The author at one time looked
with some disfavor upon the introduction of the trained nurse ;
now she is regarded by all as an absolute necessity for the best
interest of both patient and doctor. He regards the man who
leaves the great centers of learning and goes into remote
country districts to practise medicine and surgery as little less
than a hero; but men thus placed often become the most self-
reliant, resourceful and efficient practitioners. The increased
opportunities for acquiring medical education in the United
States has been most remarkable in recent years, and the time
will soon come, if not alrea<ly at hand, when study in foreign
lands will be wholly unnecessary, [a. B.C.]
4. — Infantile Peedinjf. — Abrams thinks that faulty feed-
ing is the chief cause of the large infant mortality. Percentage
feeding is and ought to be the only method of artificial feeding,
though this cannot take the place of mother's milk, and when
the latter seems to be faulty it is best not to give it up altogether
but combine artificial feeding with it. It will not do to make a
standard mixture and treat all cases alike. The physician
should be able to think in percentages and construct his own
formulas. Prolonged use of condensed milk or patent foods
will sooner or later show the lack of some essential element.
The formula that we begin with must be lower in proteids than
mother's milk, as the casein of cow's milk is difficult to digest.
A good percentage for an infant three weeks old would be fat
2, proteids 5 to 10, and sugar 5. If it agrees it must soon be
increased to fat 3 or 3.5, proteids .75 or 1, and sugar 6. The
percentages of human milk do not change as the child grows
older, simply the quantity is increased. Curdy stools indicate
excess of proteids, sour vomiting too much fat, watery stools
too much sugar or fat, vomiting of curdy mas.ses too much pro-
teids. If the child does not gain in weight the sugar may be
too low. Vomiting may indicate too large a quantity of food.
Sterilization is not desirable. Better results are obtained by
heating to 150° or 175° F. for 20 or 30 minutes, [h.m.]
5. — Appendicitis. — Blackwell says while Keen's aphorism
that " the first duty in case of appendicitis is to call in a sur-
geon," is certainly an indication of wisdom in the light of a
possibly fatal termination within 48 hours, yet its tendency is to
detract from the skill of the physician and the conservatism of
general medicine. Aside from the typical symptoms of appen-
dicitis, the diagnosis is materially aided by the fact that about
90% of all inflammatory affections in the right iliac region are
due to a catarrhal appendicitis. The gravity of the disease and
the great mortality caused by it, which is about 25% in all
cases, demand the greatest scrutiny in its inception, and the
application of the highest therapeutic skill on the part of the
medical attendant. The author reports the case of a young
man of 21, who suffered from appendicitis. He treated the case
expectantly, administering broken doses of calomel and mor-
phia in the early stages. He deems morphia justified on the
principle applied by Alonzo Clark in the treatment of perito-
nitis. He thinks surgery has usurped the function of the
internist to too great an extent in this affection, [a.b.c]
O. — Albargin or Gelatose Silver in the Treatment of
Gonorrhea.— Klotz states that albargin is a compound of silver
nitrate and gelatose. He reports the treatment of 26 cases of
gonorrhea with this dr«g. A previous careful microscopic
examination had in every case revealed the gonococcus. Of
the cases 21 were apparently new infections with gonorrhea in
patients who had previously been- infected with the disease.
Two of the cases were subacute, and 3 were chronic. Of
the 21 recent cases 15 came under observation within 24 to 36
hours after any symptoms appeared, and the remaining 6,
3 to 14 days after the outbreak of the disease. Of the 15
patients, 11 were discharged as cured within S days, no
further treatment being needed, though they were kept under
observation for some time. In some cases the discharge
stopped at once, but treatment was continued some days. The
average number of injections given these 11 patients was four.
The remaining 4 of the 15 cases failed to respond promptly
to albargin, and after several weeks other treatment was
resorted to for complete cure. In the 6 cases in which the
commencement of treatment had been delayed, although in
several of them astringent injections and internal remedies
had been used, a rapid diminution of the discharge and of the
inflammatory symptoms, as well as a great reduction in the
number of gonococci found in the specimens, was always
accomplished, but a perfect cure was not so quickly obtained
in but 3 cases. The 2 cases of subacute and the 3 cases
of chronic gonorrhea all responded to the albargin treats
ment. The drug is used in Jfc to 2% strength, and is not exces-
sively irritating, [a.b.c]
7.— Alcoholic Heredity in Diseases of Children.— Crothers
December 6, 1902]
THE WORLD'S LATEST LITEEATUEE
(AMERICAS MEDICINE 907
lias noted in the early history of inebriates a great variety
of the diseases of childhood which seem to have been more
intense than in other children. In the future the alcoholic or
insane predisposition will be changed or suppressed by treat-
ment begun in infancy. Alcoholic ancestors transmit defective
brain and nerve power. Low vitality with slow, irregular
growth is common. Another class from alcoholic parents is
precocious but early gives way to some form of nerve degenera-
tion. In some the craving for spirits is manifest very early.
Some show extremes of activity and a tendency to sudden libera-
tion of nerve energies, as in violent grief or joy, work or play,
which is followed by extreme prostration. In treatment no
form of alcohol is safe and narcotics should be used with great
care. Meats should be excluded as too stimulating. Hygiene
is of the greatest importance. Such cases should be guarded
against every extreme. Recent studies show that over 70% of
alcoholic cases are directly inherited, [h.m.]
8. — Early Diagnosis of Intassusception. — Huber says in
intussusception the pain, or rather the characteristic colic, is the
earliest signal ; then we notice changes in the facies of the child,
vomiting sets in followed by the escape from the rectum of
blood or bloody mucus. More or less collapse is observed. A
swelling, or rather fulness is noted in the right iliac fossa, par-
ticularly during the coliclsy attacks. This symptom-complex is
characteristic, and if the possible occurrence of intussusception
be kept in mind, an early diagnosis can be made without diffi-
culty. An English authority is quoted as follows: " In every
ca.se of acute colic in infants, the question of intussusception
should be considered, and the examination directed to its pos-
sible discovery. A recognition of its peculiar features leads to
an earlier diagnosis, and therefore early efficient treatment."
The author maintains that intussusception can no longer be
regarded as a borderland condition ; it is a surgical disease from
Its very onset. After the first few hours no time should be lost
in attempting reduction by inflation with air or a resort to
hydrostatic pressure. The case should be referred to a skilled
surgeon, one thoroughly familiar with abdominal work, and at
the same time a rapid operator. The author reports two cases.
In one instance the symptoms had lasted 6 hours, and in the
other 18 hours, when operation was done. In each instance the
operation, including the removal of the appendix, did not last
longer than 15 minutes. Both patients recovered, [a. B.C.]
Philadelphia Medical Journal.
November S9, 190t. [Vol. x, No. 22.]
1. TheSurgery of Brain Tumors from the Point of View of the Neurolo-
gist, with Notes of a Recent Case. Charles K. Mills.
2. Some Experiments Upon the Immunization of Cattle Against
Tuberculosis. Leonard Pearson and .S. H. Gilliland.
3. Methemoglobinemia Due to Aeetanilid, But without any Marked
Constitutional Symptoms. Richard C. Cabot.
4. The l/oca! Use of lodia in Corneal Ulcers. J. Lawton Hieks.
b. A Testrtul)e Filler. F. E. Montgomery.
1.— Surgery of Brain Tumors.— Mills discusses this sub-
ject at length, and tabulates from liis personal experience 22
cases in which operation was performed after the diagnosis of
tumor or cyst had been made. He believes in operations for
the removal of brain tumors in carefully chosen cases, notwitli-
standing the fact that the percentage of failures in such cases
has been large. Out of the 22 operations recorded, in only two
was the localization entirely wrong. He cites the causes of
failure in operations for brain tumor as being due to : Mistakes
In localization, lack of exactness in fixing the cranial areas for
operation, excessive hemorrhage, concussion and even contu-
sion of the brain in osteoplastic operations with chisel and
mallet, prolongation of operations, and the sudden disturbance
of the balance of pressure in the skull by the removal of largo
hard tumors. The Anderson-Maklns method of locating the
chief craniocerebral landmarks is to be preferred. The author's
method of procedure in a ca.se of operation for brain tumor is,
whenever possible, not only to locate the position of the tumor
but also to fix exactly the limits and direction of the osteo-
pla.stic flap wliich it seems most desiraljle to make. With the
advent of the Stellwagen trephine a now era in the making of
large osteoplastic flaps has been inaugurated, because it affords
the means of opening the skull without concussion and with
neatness and dispatch, and the l>one flap neatly and exactly fits
into the opening which has been made, thus adding to the proba-
bility of reunion and more perfect vitalization. Before begin-
ning an operation for brain tumor the surgeon should have at
hand the best appliances for temporary compression of the
carotids. Whenever possible a R6ntgen ray investigation
should be made when brain tumor is suspected. A case of
localized meningitis and gumma of the motor region, diagnosed
by clinical study and the Rontgen rays (by Dr. G. E. Pfahler),
with an osteoplastic operation with the Stellwagen trephine
(by Dr. W. J. Hearn), is detailed. An epicranial flap was
employed to replace the dura necessarily removed. The
operation and localization were a complete success, [f.c.h.]
2.— Some Kxperlments Upon the Immunization of
Cattle Against Tuberculosis. — Pearson and Gilliland detail
a series of experiments, from the results of which they conclude
as follows: After repeated intravenous injections of cultures of
tubercle bacilli from human sputum, the resistance of young
cattle to virulent tubercle bacilli of bovine origin may be
increased to such an extent that they are not injured by inocu-
lation with quantities of such cultures that are capable of
causing death or extensive infection of cattle not similarly pro-
tected, and that intravenous injections of much larger quan-
tities of cultures of human sputum tubercle bacilli than are
necessary to confer a high degree of resistance or immunity
upon the vaccinated animal may be administered without
danger to that animal, [f.c.h.]
3. — Methemoglobinemia Due to AcetanlUd. — Cabot
details the case of a male of 35, who six months ago began
taking on an average six 5-grain powders a day for pain. A
month ago marked blueness of the face and bands was noticed
which has persisted. Morphin is the only drug that relieves
the pain for which he was taking the acetanilid. The most
striking point in the case was the general good condition of the
patient. Despite the intense cyanosis and the easily demon-
strable methemoglobinemia, the patient felt and appeared to be
practically well during the intervals of freedom from pain.
His headache tortured him, but the methemoglobinemia gave
him no inconvenience whatsover. [f.c.h.]
4. — The liocal Use of lodln In Corneal Ulcers.— Hiers
claims priority for the successful employment of iodin in the
treatment of ulcers of a phlyctenular character and those of
traumatic origin. By this method the infecting organisms are
destroyed, and under its influence the products of inflammation
are absorbed, thereby instantly converting the diseased condi-
tion into a recent injury which rapidly heals under ordinary
antiseptic treatment. Since the inauguration of tliis plan of
treatment in 1895, he has treated over 200 cases with the best
results. It lessens rather than increases scar-tissue.
5.— A Test-tube Filler.— Montgomery describes an appa-
ratus especially devised for the purpose of facilitating the work
of filling culture tubes, small flasks, etc., with exact quantities
of liquid media. The apparatus is composed of two parts— a
double pinch cock and a glass buret with side tube, [f.c.h.]
ClilNICAIi MEDICINE
David Riesman A. O. J. Kellt
EDITORIAL COMMKNT
The Cytodlaguosis of Serous Effusions. — Until
a comparatively recent date very little attention wa.s
paid to the cellular elements of serous eflFusions, whether
in the pleura, pericardium, or elsewhere. Largely
through the efforts of Widal, who represents in a remark-
able manner the ingenious originality of the French,
the study of the cells in effusions has become an important
element in the diagnosis of the nature of .such effusions.
The method has received the name of cytodiagtiosU, and
has hitherto been of most value in the determination of
the nature of pleural effusions. For our present purpose
we may adopt the classification of Descos ' and divide
pleurisies into tuberculous, inflammatory and mechanical
and rare forms, such as cancerous pleuri.sy, hemothorax
and the form t<?rmed by the French pleural eosinophilia.
' Kevue de M6d., 8ept«m'jer and October, I90i.
90S AXKBIOAX MkOICIHK
THE WORLD'S LATEST LITERATURE
[Decembkk 6, 1902
(«) Tuberculous Pleurisy.— 0( this tliere is a primary
and a secondary form. The primary form is character-
ized by the almost exclusive presence of small lympho-
cytes with a tendency to confluence, and of a few red
corpuscles. Occasionally some larger elements are seen,
which may be endothelial cells. This cytologic formula,
as it is called, is characteristic of the pleurisies in the
fully developed stage ; in the earlier stages polynuclear
cells may be present in considerable numbers. In
secondary tuberculous pleurisy cytodiagnosis is of less
importance, as the character of the disease is readily
determined by other means. Observation has, however,
shown the presence of red corpuscles, polynuclear cells,
and lymphocytes. (6) Inflammatory Pleurisies. — These are
all characterized by the abundance of polynuclear cells —
polynucleosis. Under the head of inflammatory pleurisies,
Descos distinguishes pneumoeoccic, streptococcic and
typhoidal pleurisy, and a rheumatic form, or pleurisy
a frigore. The last mentioned shows a variation,
in that there are polynuclears and lymphocytes in
about the same amount, a considerable proportion of
eosinophiles, and a large number of endothelial cells.
(c) Mechanical Pleurisies. — Under this head the author
quoted classes hydrofeorax and pleurisy froni conges-
tion and infarction. The chief characteristic of these
is the presence of large sheets of endothelial cells.
(d) Speeixil Forms. — In cancerous pleurisy, the result
of carcinoma of neighboring organs, there may be
nothing peculiar. At times, however, cells of the malig-
nant tumor are found. Pleural eosinophilia is a rare
condition in which large numbers of eosinophile cells
(from Qfc to 54/c) are found in the effusion, without
there being any eosinophilia of the blood. Rabaut has
reported four cases: One in the course of secondary
syphilis, one in typhoid fever, one in pulmonary tuber-
culosis, and one in a case in which a clinical diagnosis
was not made. Barjon and Cade ' who have studied 43
cases of pleurisy, of which 25 were positively and 18
probably tuberculous, found the lymphocytic formula
almost constant, although they state the fact, to which
allusion has been made above, that in the earlier stages
there is a variable number of polynuclear cells. The
latter, however, diminish rapidly as the disease pro-
gresses. Endothelial cells are frequently present, but are
with difiBculty distinguished from large mononuclear
lymphocytes. In their opinion, cytodiagnosis is the
diagnostic method of choice, and is, indeed, infallible in
tuberculous pleurisy.
The Technic of Cytodiagnosis For ordinary pur-
poses, the simplest method of cytodiagnosis is to remove
a little of the fluid, centrifugate it immediately, and
spread cover-glasses or slides in a manner analogous to
that used in making blood preparations. Fixation mav
be accomplished by the use of equal parts of alcohol and
ether ; or, if Ehrlich's slain is to be employed, by means
of heat. Josu6^ recommends the vapor of chloroform.
The slide or film is either placed for a few moments in a
vessel containing chloroform, or a few drops of the latter
are placed upon the slide and allowed to evaporate. For
ordinary purposes, the hematoxylin-eosin stain suffices,
and is best employed with alcohol-ether preparations.
Diflerential counts are then made in the wellknown
manner. The method is applicable to pleural and other
serous effusions, to cerebrospinal fluid obtained by lumbar
puncture, to hydrocele fluid, etc.
REVIEW OF LITERATURE
Microbe of Acute Gaseous Gangrene.— G. Legros ' has
succeeded in isolating an aerobic bacillus, Bacillus septicn.s
aerohius, capable of producing gangrenous septicemica, an
affection hitherto attributable to various microorganisms of
anaerobic habit. This is the first aerobic species which has been
'Arch. g6n. de M6d., August, 1802.
aSS^P*?^ r*^**" '"^ ^^o''- Blologlque, June 15, 190).
3Th«8e de la Faculte de Paris, Ann«e, 1901-1902, No. 297, Naudln.
demonstrated as actively pathogenic in this affection. It
resembles in some respects the Vibrionic seplique of Pasteur.
[c.s.D.]
Tetanus Caused by Subcutaneous Injections of Gela-
tin.—Krause 1 reviews the literature on tetanus caused by injec-
tions of insufficiently sterilized gelatin. He gives a method for
the preparation of gelatin. Krause believes there is great
danger of tetanus infection whenever improperly prepared
gelatin is used subcutaneously. He advises daily sterilization
of the gelatin for five consecutive days. During this time it
should be exposed daily for one-half hour to a heat of 100° C.
[W.E.R.]
A New Laxative, Pur^atln. — V. Hosslin ' states that pur-
gatin is a mild and pleasant laxative, the average dose of which
is 1.5 grams {22J grains). It is best given at night and will then
bring about a movement in the morning. It produces a reddish
color of the feces and of the urine, of which fact it is well to
apprise patients in advance. It does not produce any harmful
collateral effects, [d.r.]
Contribution to the Etiology of Pellagra. — Melchiorre
Di Pietro ' finds that the cause of pellagra depen4s upon a
poisonous principle inherent in the spores of Penicillium glau-
cum and is not the result of decomposition nor due in any way
to the substratum upon which the mold grows. The poison in
question is stable, it resists putrefaction and prolonged boiling,
it is soluble in alcohol and in petroleum ether. The ethereal
and alcoholic extracts of the spores exercise the same action as
the spores themselves. Ingestion of the spores produces acute
intoxication, characterized by vomiting, diarrhea, prostration,
paretic phenomena, etc. [c.s.D.]
The Relation of Physlcochemlc Principles to Gastric
Pathology. — Bial * performed a long series of experiments on
the action of hydrochloric acid, sodium chlorid, and fermenta-
tion in the stomach. The results were explained according to
physlcochemlc laws. From these experiments he concluded
that the gastric juice, which contains hydrochloric acid, pre-
vents the action of the yeast fungus because of the presence of
sodium chlorid. The latter may destroy the antiseptic powers
of the hydrochloric acid. The property of disinfection that
dilute acids possess as regards yeast depend upon the number
of H-ions present. The quantity of H-ions present in the acid
is reduced according to phy&icochemic principles by the addi-
tion of salt. In this method the antiseptic properties of the
acid are also reduced. In special cases tlie antiseptic value
of the gastric-hydrochloric acid depends upon its H-ions.
[w.E.R.]
A. B. Craig
GENEBAIi SURGERY
Martin B. Tinker
C. A. Orb
REVIEW OF LITERATURE
Resection of the Stomach and the Patient Well
Kighteen Months Ijater. — Mayo Robson ' reports the case. The
patient was a man of 38 suffering from malignant disease of the
stomach. Operation showed a previously palpable tumor to be
a firm, nodular, malignant growth involving nearly the whole
of the stomach from the pylorus to the esophagus, the only
portion of the organ apparently free being a little dome at the
left of the esophageal opening. No enlarged glands could be
felt and no secondary growths could be found. The duodenum
was clamped and severed one inch from the pylorus, and all
save the uninvolved portion of the stomach was cut away with
scissors and the vessels ligated. An anastomosis between the
duodenum and small pouch of stomach at the cardiac end was
effected, a bone bobbin being used. The patient made a good
recovery and has gained much in weight. He has to limit the
quantity of food at each meal and must therefore eat more fre-
quently. The author says but 12 cases of complete gastrectomy
have been reported, with a mortality of 33% ; he is sure, how-
ever, the unreported fatal oases would bring the mortality up
to 50%. [a. B.C.]
1 Berliner kllnische Wochenschrift, July 21. 1902.
'■' Muncbener medlclnlsche Wochenschrift, August 12, 1902.
3 Annale d'Iglene sperimentale, fasc. I, 1902.
< Berliner klinische Wochenschrift, May 12, 1902.
5 British Medical Journal, Novembers, 1902.
DiiCKMBKB 6, 19(H]
THE WORLD'S LATEST LITEEATLTIE
[AHKRICAN MBBICINK 909
Frontal and Ethmoidal Sinnsitis and Its Orbital Com-
plications.—Axenleld ' believes orbital abscesses are usually of
ectogeuic origin, and are often traceable to periorbital sinusitis.
In many of these cases tiie nasal sinuses appear but little
affected, and occasionally not the smallest perforation can be
seen between orbital cavity and sinus ; especially is this so
when the infection spreads from the frontal sinus. In such
cases the infection travels along an emissary nerve or vein, or
as a thrombophlebitis through the diploe or the intact bone. If
such an imperforate state should be found in chronic sinusitis,
Axenfeld opens the frontal sinus directly through the operative
wound ; in acute sinusitis he prefers simply to drain the peri-
orbital abscess, leaving the frontal sinus to take care of itself, as
it often heals spontaneously. Should the symptoms continue a
trephine operation into the frontal sinus by way of the forehead
is indicated. He publishes the details of a case in which upon
opening the frontal sinus the mucous membrane was found to
be entirely normal. He considers this as an instance of spon-
taneous recovery. He next relates the details of a case in which
the frontal sinus was filled with thick pus, and while cleaning
this away he brought with it a portion of the bony septum
separating the one frontal sinus from the other. This was seen
to be absolutely free from infection, and it remained so in spite
of being separated from the infected sinus only by the thick-
ness of its mucous membrane. He believes that in order to
determine the condition of a suspected sinus it would be far
better to trephine through the forehead, then to remove the bony
septum. [E.L.]
Curetment of the Bladder in Clironic Cystitis.— Hock '
reviews the literature on the treatment of chronic cystitis
by curetment and reports the case of a woman of 23. The
cystitis was of gonorrheal origin and was not influenced by the
ordinary therapeutic methods. The bladder was cureted with
excellent results. In two weeks the cystitis was cured, and
there was no recurrence at the end of a year. Hock describes
the technic of this operation and advises its employment in all
cases of chronic suppurative cystitis which fail to respond to
the simpler treatments, [w.e.r.]
Subcutaneous Injection of Paraffin to Correct Deform-
ity._Downie' reports several cases in which he has corrected
a nasal deformity by injecting subcutaneously melted paraffin.
The wax used has a melting point varying from 104° F. to 108°
F. He prefers that the patient be narcotized with a general
anesthetic. To keep the wax in the syringe fluid he insulates
the barrel with a layer of cotton thread, then runs on a layer of
platinum wire each end of which is provided with a copper tip,
and a battery with a rheostat is attached. He has had no
instance in which the paraffin after setting spread toward the
eyes. Sufficient time has not elapsed to determine whether the
paraffin will become absorbed, but even if it should it may be
reinjected. Nine months have elapsed since his earliest opera-
tions, and the parts still retain their corrected shape. Only
enough of the paraffin to correct the deformity should be used,
as more is useless and may cause sloughing. Careful antiseptic
and aseptic precautions must be taken before and during the
operation, and firm digital pressure must be made around the
nose during the injection, [a. B.C.]
Extensive Cystic Dilation of the Ductus Choledochus.—
Kostowzew ' reports the ease of a girl of 13, who had had a
large abdomen for years, but had never been ill excepting for a
short time a year ago, when she was jaundiced. She had been
complaining for several mouths of abdominal pain, headache,
constipation, loss of appetite, jaundice, and increasing weak-
ness. The hepatic region was occupied by a fluctuating mass,
which was smaller some days than others. A diagnosis of
echinococcus cyst of the liver was made and an operation per-
formed, which, however, failed to reveal anything pointing to
echinococcus. Instead there was found an enormously enlarged
ductus choledochus, from which was removed at least four pints
of bile-like fluid. The patient died and on autopsy the liver
was found enlarged and yellowish green ; the bile capillaries
markedly dilated and surrounded by well-developed bands of
' Deutsche medlolnlscho Wochenschrlft, October 'Z, 1901!.
'FragermedU'lnlsche Wochciiscbrlfl, October 18, liKW.
3 British .Medical .lournal, November 8, KXW.
'Deutiiche mediclnlsehe Wochenschrlft, October 9 and 19, ItHB.
connective tissue. The gallbladder and cystic duct were normal
in size and structure and quite empty. The hepatic duct was
somewhat dilated ; both cystic and hepatic ducts emptied into
the cyst (ductus choledochus). At the point where they empty
into this was seen a reduplication of mncous membrane, form-
ing a valve ; this constantly and completely closed the cystic
duct, but opened in the case of the hepatic duct whenever the
cyst was very full. The ductus choledochus opened into the
duodenum at its normal point ; before doing so, however, it
described an acute angle, and at this point a similar valve was
seen, which opened only when the cyst was filled to distention,
preventing the flow of bile excepting at that time. The walls
of the cyst were very thick, and composed of fibrous connective
tissue. The condition evidently was a congenital one and
reached its present dimensions very gradually. But four sim-
ilar cases have been reported, [e.i..]
GYNECOL,OGY AND OBSTETRICS
WiLMKR Kbcskn Frank C. Hammond
EDITORIAL COMMENT
The Rontgen Ray in Gynecology.— The sueoess
attained by Finsen in the treatment of the various der-
matoses by concentrated chemical rays has impressed
the profession with the possibilities of the x-ray as a
therapeutic agent in the treatment of malignant disease.
The remarkable results attained at the Finsen Institute
at Copenhagen justify a favorable opinion of this method
of treatment. The action of the remedy is very slow in
most instances and its effect upon an internal growth
uncertain. We certainly feel that the field of experi-
ment with this procedure should be confined to recurrent
or inoperable cases, and that the physician is not justified
in delaying operation upon a favorable ca.se in order to
test this method. However, if the case is inoperable
when it comes under the surgeon's observation, or has
recurred after skilful surgical intervention, then experi-
mentation is undoubtedly warranted. Although the
x-ray may sometimes be of value to the gynecologist or
obstetrician in diagnosis, it is of far less use to either of
these than to the general surgeon who deals with the
osseous system. The x-ray picture of the pelvis, accord-
ing to Delphev, is often indistinct and unsatisfactory
and would rarely afford much a.ssistance to the gynecol-
ogist who had already become expert in the palpation
of this region. Better results were obtained above the
pelvic bones ; for example in the study of the ureters
and kidneys and for the localization of calculi in those
structures. It is possible that the presence of bone in
dermoid tumors or of calcareous plates in benign growths
might be demonstrated, but this is of minor importance
as the mere presence of such neoplasms is an indication
for their extirpation. Cook considers that although the
pelvis of the non-pregnant woman could be studied by
one skilled in the use of the x-ray yet many inaccuracie-s
arise from the distortion of the shadow ; and the results
cannot be compared with the usual pelvic examination
made by a skilled obstetrician. The maternal pelvis
could be clearly seen after a pregnancy of 4 J months, but
later than this the uterus and its contents formed a veil
on the negative. The position and presentation of the
child may be determined near the termination of gesta-
tion and the x-ray might prove of possible value in ca.ses
of multi[)le pregnancy. As to the value of the li^intgen
ray as a therapeutic agent in gynecology. Cleaves has
recently reported a ca«e in which the Ilontgen and ultra-
violet rays were employed in the treatment of uterine
cancer with marked improvement, and Coe has cited a
case occurring in the services of Jarman in which a
favorable result was obtained in recurrent carcinoma of
the cervix. The great difficulty in the treatment of
malignant diseate of the uttsrus is the application of the
ray to the internal part, and there is probably a legiti-
mate field for Invention in the construction of an instru-
910 AKBBIOAN MEOIOtRBj
THE WORLD'S LATEST LITEEATUEE
[Decbmbeb 6, 1902
ment suitetl to this purpose. Authorities differ as to the
necessity of the direct local application of the ray and
Cleaves believes that the tissues generally in the pelvis
should be brought under the influence of the x-ray. To
summarize the present situation, we believe that this
method should not supplant early surgery in malignant
disease, but should be used in recurrent cases ; and agree
with Coley that the greatest future of this treatment
seems to be as a prophylactic agent, to be used imme-
diately after every operation for primary carcinoma.
REVIEW OF LirERATURE
The History of the Fetal Theory Upon the Causes of
Eclampsia. — Mouton ' declares tliat the fetal theory of the
pathogenesis of eclampsia is a product of our own time, and
that two investigators have, Independently, reached virtually
the same conclusion. It has been learned from autopsies that
there are changes in the organs of both mother and child which
can only be explained through the presence of an abnormal
amount of toxins in the blood. The secretory organs of the
mother undergo anatomic and functional changes during preg-
nancy which Interfere with their powers of assimilation and
secretion. If in this impaired state they can do the increased
work required by the pregnant condition the woman continues
healthy. If not, a surplus of toxins remains in the system,
vitiates the circulation and may produce eclampsia. One sup-
port of this theory is the frequent occurrence of eclampsia in
twin pregnancy, which gives rise to a greater amount of toxins
than ordinary pregnancy ; another is the diminution of the
symptoms of threatened eclampsia when the fetus dies in utero ;
that is, when the increased production of toxins ceases. The
appearance of postpartum eclampsia is thought by some to
refute the fetal theory ; but it does not, since although after
delivery the increased production of toxins ceases, the changes
In the maternal organs causing the toxemia still remain. Fehl-
ing first published his fetal theory in 1899, but van der Hoeven
had formulated a similar theory in 1896. [w.k.]
Uterus Didelphys.— Brock' reports the case of a woman
with a uterus didelphys, twice pregnant and twice delivered of
full-term living children in normal labor and no complications.
Originally there were two vaginas, as well as two cervices and
two horns of the uterus independently movable. After the
first delivery the vaginal septum was removed, because of its
interference with marital relations. As in uterus didelphyd
the two horns are entirely separate, it is improbable that the
nonpregnant horn would ever be a serious impediment to labor,
and the formidable complication of attachment of the placenta
to a septum cannot arise, [w.k.]
A new apparatus for hypodermoclysis and intra-
venous injection is described by L. A. Oliva ' and by means
of an illustration the manner of using it is clearly shown. It is
simple in construction, and adapted for use in private practice,
as well as in hospitals, since it can be employed in any house in
which fire and water are found. By combining an ordinary
irrigator with this instrument in a few minutes either an intra-
venous injection or a hypodermoclysis may be given the patient,
^ thus furnishing the best means of avoiding death from hemor-
rhage, [w.k.]
TREATMENT
Solomon Solis Cohen
H. C. Wood, Jr. L. p. Applbman
EDITORIAL COMMENT
The Uncertainty and Undesirability of Com-
pressed Tablets — Anything that comes from the clear
thought and ripe experience of Pharmacist Hallberg of
Chicago, deserves careful attention, and his communica-
tion upon medication by means of compressed tablets is
extremely pertinent. We have long discarded their use
except in a few instances, as lozenges, i. e., when it is
> Centralblatt far Gynakologie, October is. 190J.
= Lancet. November 15. 1902. . lov.^.
' Centralblatt fttr Uynakologle, October 25, 1902.
desired that a medicament should remain for along time
in contact with the mucous membrane of the mouth and
pharynx. We have sometimes, in hospital and dispensary
practice, encountered slothful druggists or " economical "
lay superintendents who insisted upon dispensing tablets
when powders and capsules were prescribed. In such
cases we have directed the nurses or patients to search the
stools, and frequently the tablets have been discovered
there, practically unchanged, several days after their
administration. Especially in typhoid fever is the prac-
tice of administering salol tablets to be condemned.
Salol in powder or encapsulated dry may be of service.
In making up capsules some druggists use an excipient
which makes the medicament insoluble. More than
once we have had the content of such a capsule — the cover
having dissolved — brought to us by a nurse who has
found it in the stool and thought it to be a calculus. It
is well, therefore, to write in English and underline the
word dry in prescribing the capsule form for medica-
ments occurring as powders. Irritating substances such
as potassium iodid, sodium .salicylate or sodium ben-
zoate, should not, however, be prescribed in capsule, but
always in solution in a mucilaginous or "pepsin"
vehicle. Failures in medication are sometimes due not
to faulty diagnosis or mistaken therapeutics, but to the
fact that the prescription is faulty in form or not dis-
pensed as written. In this connection consideration may
be given to the following from Hallberg's excellent
monograph reprint from Western I>riiggist and MercVs
Report, August, 1901, referred to in his letter:
"The medical history of the Spanish-United States war
would no doubt have been different if soldiers stationed at
malaria-i nf ected camps had followed the precedent of the Civil
war and lined uj) at the bugler's call for ' come and get your
quinin '—and whisky— instead of having to rely upon the great
antiperiodic as furnished the hospital department in 1898 in the
form of 5,000,000 of gelatin-coated pills. The deathrate from
intestinal disorders would not have been so appalling if the
ubiquitous antiseptic calomel had been ' dished out from the
saddlebags' in heroic doses as when 'marching through
Georgia,' instead of being given in homeopathic doses at Chick-
amauga from the 40,000 tablets furnished by the medical
department of the Army."
After reciting the results of careful experiments,
Hallberg concludes :
" It will thus be observed that the most popular form of dry
medication, the compressed tablet, is the least desirable. The
tablet triturate is the only compressed form adapted for the
internal administration of medicinal agents, since, owing to the
relatively large proportion of milk-sugar and the method of
preparation, there is little danger of its forming a hard,
insoluble mass."
The conclusion is, in general, sound. The exceptions
are not sufficient in number to vitiate it.
REVIEW OF LITERATURE
The Effect of Grape-Juice on the System. — Moreigue ■
has been led by the growing popularity of the grape cure to
make a study of the manner in which it acts. The inorganic
constituents of the pulp, which is the active part of the fruit,
are very similar to the saline waters. He made four experi-
ments on the effect of the grape cure on the tissue change of
healthy subjects. As a result of the ingestion of 1 to 3 pounds
of grapes daily there was an increase in the quantity of urine,
a decrease in both urea and uric acid, with a lessened acidity
of the urine. There is also a relative (although not an abso-
lute) increase in the sulfur excreted, which he regards as
the result of increased hepatic activity, [h.c.w.]
Methyl Salicylate in the Treatment of Parotitis.^-
The local application of methyl salicylate in parotitis has
always been followed by good results. It may be used when the
inflammation is confined to one, or is on both sides. It is applied
usually by means of a cotton tampon, three or four times a day.
The inflammation disappears in three or four days at the most.
[L.F.A.]
1 Gaz. bebd., Alay 22, 1902, p 470.
« Journar Mgdlcal de Bruxelles, Vol. vli, No. 39, 1902, p. 623.
Dbcbhber 6, IH02]
THE WORLD'S LATEST LITERATURE
[Amebican Medicikx 911
Treatment of Myocarditis. — Syers ' is very strongly
opposed to active exercise by patients with disease of ttie iieart
muscle. Tlie popular treatment by means of graduated exer-
cise and liot batiis he believes is capable of harmful or even
fatal results. A nitrogenous diet is preferable to a carbohy-
drate one. When the cardiac musculature is decayed little
assistance may be expected from drugs, [h.c.w.]
Treatment of Cholera Infantum.— Luton,' in 1882, first
recommended the administration of large quantities of water in
the treatment of cholera infantum. Plain boiled water, a mild
mineral water or albumin water may be used interchangeably.
An infant of 5 or 6 months should receive about 1 quart in 24
hours. By this means intestinal fermentation is stopped and at
the same time the stomach and intestines placed at rest. At the
end of 24 hours, if vomiting has ceased and there is less diar-
rhea, the patient may receive 5 drams of sterilized milk with 2.5
ounces of boiled water every 4 hours, and in the interval boiled
water may be given alone. Fiessinger employs hot baths in
the treatment of this disease when associated with considerable
fever. The patient is placed in a bath at a temperature of 95° F.
for 10 minutes every 3 hours so long as the rectal temperature
reaches 102.2° F. Sometimes the temperature rises after the
first baths, but this is temporary and of little importance,
defervescence soon occurs. Aside from the antipyretic action
the diarrhea diminishes as a result of the baths alone. Rilliet
and Barthez add 2 ounces of mustard to a bath of 25 quarts of
hot water. After sufllcient reaction is obtained the patient is
wrapped in dry linen. The rectal injection of from 5 to 12
drams of 0.1% salt solution has given excellent results in infants
a few weeks old. Lavage of the intestine with the same solu-
tion may be practised with equally good results. A soft rubber
catheter attached to a fountain syringe should be introduced
into the bowel for a distance of about 8 inches, and the solution
allowed to flow from a height of 12 or 18 inches. From 2 to 3
pints may be used at each injection, morning and evening.
[r,.F.A.]
FORMULAS, ORIGINAL AND SELECTED.
Gargle for Acute Pharyngitis and Tonsillitis. —
Menthol 0 to 1 gram (10 to 20 grains)
Ammoniated tincture of guaiac . . 12 grains (3 drams)
Compound tincture of cinchona . 12 grams (3 drams)
Clarified honey )
Glycerin V of each . . 15 grams ( 4 drams)
Mucilage of acacia j
Mix and shake thoroughly. Add slowly
Potassium chlorate 4 grams (1 dram )
Rose water 90 cc. (3 ounces)
Use as a gargle every hour or two.
DERMATOLOGY
M. B. Hartzell.
KDITOHIAI, COMMKNT
Phototherapy and I{a(liothera]>y in Diseases of
the Skin. — Evidonco is daily accumulating, and has
already reached con.siderable proportions, tliat light and
the lt<jntgen ray have added irnmeasely to the resoHrces
of the dermatologist .'n the treatment of cutaneous mala-
dies. It is now generally admittt^d that the Finsen
light method of treating lupus vulgaris, while not by
'any means infallible, gives better results from every
point of view than any of those previously employed,
and it seems likely that the x-rays, when we have
properly developed our ttrhnic, will give equally good
results. Quite as certainly the latter reme<ly produces
almost miraculous results in many (rases of epithelioma
of the skin. Apart from the numerous j-eports of cures
which have been appearing in the periodicals during the
past year or two, we have ourselves seen, during the
■ past six months, results from radiotherapy incom-
parably suj>erior to those obtained by any otht^r method.
Indeed, this method of treatment may confidently be
< Treatment, June, 1901, Vol. vl, p. 2(8.
'.loumal des Pratlclenii, Vol. xvl. No. 12, 1902, p. 1K7.
said to have passed the experimental stage, and to have
transferred a disfiguring and often ultimately fatal dis-
ease to the list of readily curable disorders. In addition
to these graver maladies, a number of other disfiguring
and troublesome aflections of the skin, such as acne,
sycosis, both the ordinary and parasitic forms, favus,
keloid, are reported by trustworthy observers to have
been successfully treated by the Rwntgen ray. Even
that extremely obstinate affection, erythematous lupus,
has been reported to have yielded to the Finsen treat-
ment and to radiotherapy. Owing, however, to our
own unfavorable experience with the Rontgen ray treat-
ment in the last named disease, we are somewliat
inclined to be skeptical as to its good effects. Quite
recently the radiations given off' by radium have been
employed by Leredde with asserted good effect in lupus ;
and if these results should be confirmed by later observ-
ers, the treatment of this and other diseases amenable
to radiotherapy will be much simplified, since it will
enable us to dispense with the cumbersome and costly
apparatus now necessary. As to the manner in which
the therapeutic effects of light and the Rontgen ray are
produced, recent experimental investigations and histo-
logical study of tissues subjected to the action of these
agents seem to show that their bactericidal properties
play a very unimportant role ; their effects are most
probably due to an elective chemical action upon the
cells by which the diseased tissues are destroyed, the
partially diseased cells restored to their normal functions,
and the healthy cells incited to increased activity.
KKVIEW OF LITEHATCRB
The Treatment of Cutaneous Tuberculosis Since the
Introduction of the Finsen Method.— Leredde and Pau-
trier,' in a recent paper read at a meeting of the SocifitO Franipaise
de Dermatologie et de Syphiligraphie, compare the results
obtained by phototherapy in lupus vulgaris and lupus erythe-
matosus with those following other methods of treatment.
They conclude that of all the methods at present employed
phototherapy is the one which gives the best results in tuber-
culous lupus of the face, although radiotherapy may in the
future be found just as useful. While a cure cannot be prom-
ised in every case, the number of failures is small. In
erythematous lupus this method of treatment is infinitely
superior to all others, although the results are much less con-
stant than in tuberculous lupus. It is indispensably necessary
to produce complete sclerosis, and the phototherapy should be
continued until a cicatrix is formed. The indications and con-
traindications for the employment of this method of treatment
are as follows : It is indicated in every case of tuberculous
lupus which has resisted other methods of treatment. The
results are uncertain in cases with much thickening of the
tissues and in those in which a deep sclerosis has been pro-
duced by other treatment. In vegetating lupus the volume of
the tissues should first be reduced by scarification or caustics,
such as potassium permanganate; phototherapy may then be
able to exert its curative effects. In elephantiasic lupus this
method of treatment, as a rule, faijs. It is contraindicated in
recent lupus which can be curetl by ablation with union by first
intention; and in lupus of the trunk and extremities which can
be cured more rapidly by other methods. In tuberculosis of
the extremities it is likewise inapplicable because the hyper-
keratosis and acanthosis prevent the penetration of the chemic
rays. In lupus erythematosus it is contraindicated in the
superficial wandering forms curable by other methods, in par-
ticular by currents of high frequency. It can only be applied
in those cases in which the disease reappears in the same
places, and in which other methods have failed. In the fixed
forms, with or without a tendency to atrophic regression, it
may be employed after the failure of other remedies. Every
case ought to be treated energetically from the beginning since
the longer it lasts the deeper and more rebellious it becomes.
In those (^ses which have resisted phototherapy properly car-
ried out, radiotherapy or radiumtherapy may be tried. This
> Annales de Derraatologle et de HypblllKrapbie, No. 8, 1902.
912 Ay«TO«w MEDTOIMIj
THE WORLD'S LATEST LITERATURE
[Decbmbeb 6, 1902
method of treatment is contraindlcated in erytliematous lupus
of parts other than the (ace. In conclusion, phototherapy
should not be combined with other methods, but should be
used alone.
The Nature of the Regressive and Productive Tis-
sue Changes LeadinK to Hoalin^; which take Pla6e in
Lupus, Ulcus Kodens, and Vascular Naevus Under the
Influence of Finsen's Liight Treatment.— Sacli ' oflfers the
following conclusions concerning the character of the changes
produced by Finsen's light treatment in lupus, rodent ulcer
and vascular naevus ; The parts first affected are the bloodves-
sels, in the walls of which the first changes to be noticed are
swelling and proliferation of the endothelium. This is observed
in its simplest form in uncomplicated angioma of the slcin (endo-
vasculitis witbflnal obliteration of the vessels). It is also clearly
noticeable in the complicated structure of a lupus focus. The
entire process lias nothing wliatever to do with burning or
cauterization. The late appearance of the reaction, as well as
the clinical cour.se of the process negatives such a supposition.
But before all, the absence of the coagulation necrosis which
accompanies every burning and cauterization argues against
such an interpretation. The regressive changes are purely
elective in that they affect only certain elements, and these the
least resistant, of the diseased tissues, while the other elements
both within and without the diseased focus, are incited to in-
creased activity. Thechemic irritation of the light which affects
the diseased skin produces such conditions in the cells as to
make it possible (or those not wholly diseased to recover and
overcome the diseased one^. In this manner certain of the cell-
elements are absorbed, while others become connective-tissue
cells, thereby bringing about actual healing. Concerning the
important question whether the Pinsen treatment acts through
bactericidal or photochemic properties, it appears from the
results of histologic investigation that the latter play a far more
important role than the former.
Paget's Disease.— Matzenauer 2 discusses the question
whether Paget's disease consists of two clinically and patho-
logico-aaatomically distinct affections, viz.: Chronic eczema
and subsequent carcinoma ; and concludes, from a study of the
histo-pathology, that it is in no way related to eczema. He
believes it to be from the very beginning a primary cancer of
the skin.
Linpus Erythematosus.— Hollander' is of the opinion,
founded on direct clinical observation, that lupus erythema-
tosus has no etiologic relationship with tuberculosis. He
believes it to be a specific affection of the glandular apparatus of
the skin and mucous membranes, one affecting the sweat
glands as well as the sebaceous and mucous glands. He recom-
mends a neiv method of treatment with which he believes it
possible to produce improvement and cure in some of the
severest and most unfavorable cases. This method consists in
the internal administration of large doses of quinin and the
simultaneous application of tincture of iodin to the diseased
areas. Quinin is given in doses of 0.5 gram three times daily,
and morning and evening, immediately after the administra-
tion of the quinin, the patches are painted several times with
the iodin. This is continued for four or five days when the
treatment is interrupted for an equal period, until the crusts
formed have fallen off". it^'lliS' resiction is mild the dose is
increased. In no case has the author observed any lasting
injurious effects from these large doses of quinin. In recent
cases this treatment brings about the complete disappearance
of the patches; in older ones a peculiar scar-like atrophy of the
skin remains.
The X-riiy and Trikresol in Alopecia Areata.— Heid-
ingsfeld,* after recounting some of his unfavorable experiences
with many of the older remedies for the treatment of alopecia,
describes his experience with the above mentioned remedies.
One case of circumscribed patches, which had successfully
resisted various older forms of treatment for almost a year, was
used for a control experiment, so that some patches were
untreated. One large one was subjected to five x-ray sit-
1 MQnchener medicinlsche Wochenschrift, July 8, 1902
« Monatshefte fttr Praktlsche Dermatologle, Bd. 35, No. 5.
'Berliner kllnische Wochenschrift, July 28 190-i
♦Cincinnati Lancet and Clinic, September 20, 1902.
tings, after the method of Kienbock, and the rest treated once
weekly with 60% trikresol in alcohol. After an interval of two
months the trikresol patches were covered with a luxuriant
growth o( lanugo hair, and the others remained unchanged.
Trikresol was then applied to the remainder, with the result
that in six months all the patches were well covered with hair,
with the exception of the x-ray patch, which, in spite of trik-
resol applications, remained absolutely unchanged. Six other
cases 8howe<l the same marked improvement with trikresol
from two to six months. The author is so favorably impressed
with its efficacy, simplicity, and absence of objectionable stain-
ing, that he is using trikresol in alopecia areata to the exclusion
of all other remedies.
The "T. R." Tuberculin Treatment of Lupus Vul-
garis.— Crocker and Fernet,' in a short paper read in the Section
of Dermatology of the British Medical Association, report their
results with " T. R." tuberculin in lupus vulgaris. Their con-
clusions are as follows: Up to a certain point " T. R." tuber-
culin favorably influences lupus vulgaris in selected cases, the
greatest improvement being observed in the ulcerative forms
in the young. In the nodular forms with fibroid change its
efl'ects are trifiing or nil. Local injections appear to do better
than those made at a distance from the affected parts. In order
to produce permanent results the tuberculin treatment should
be followed by prolonged administration of thyroid extract.
The chief objections to the " T. R." tuberculin treatment are its
expense and tediousness. It has upon the whole only a
restricted use in selected cases as an adjuvant to other forms of
treatment.
Injection Treatment of Syphilis by Means of a New
Mercurial Formula. — Heidingsfeld ^ reviews briefly the
history of the injection treatment, together with the various
forms of mercurial treatment, and points out special objections.
The injection method, by meeting certain requirements, greater
efficacy, cleanliness, simplicity, control of patient, absence of
gastrointestinal disturbance, altering and eliminating influence
of the liver, dermatitis, publicity, etc., possesses decided advan-
tages over other forms of treatment, as evidenced by the
numerous attempts at substitution. That these requirements
have not as yet been fulfilled is evidence by innumerable fail-
ures of injection remedies, and the generous patronage given to
other forms. The success of any injection method will depend
largely on its tolerance, greater convenience and large dosage.
The author believes these requirements are mot in the follow-
ing modified formula of Lang :
Lanolin 2.0
Hydrarg. bidistill (dental) 6.060
Conteratur usque ad perfect extinct, hydrarg.
liq. albolin 2.0
M. S. — Inject .06 (one grain) every four days.
The injections are made into the buttocks with a 22 gauge
steel needle, 7 to 8 inches in length. By this method 240
cases, embracing over 2,000 injections, were successfully treated
without any marked intercurrent complications. Some of the
cases improved under this form of treatment which failed to be
favorably influenced by other forms.
Naftalan in the Treatment of Eczema.- Awerbach-
Charkow,' who has employed naftalan in about 180 cases of
variouaitorms of acute and chronic eczema and artificial inflam-
mations of the skin, concludes that when the diagnosis of acute
eczema or chronic eczema with acute exacerbations is once
established, treatment with naftalan should be begun immedi-
ately without regard to the localization, duration or distribu-
tion of the disease. The good effects of this remedy are chiefly
observable in the weeping forms of acute or chronic eczema
and in artificial dermatitis. In such cases it is well borne by
the skin, and might almost be designated a specific. For the
resorption of the infiltrate in chronic eczema, however, other
remedies, such as tar, are necessary. In the dry chronic forms
of eczema with scaling and infiltration, as well as in eczema
seborrhoicum, the effect of naftalan is, with few exceptions,
insignificant. The author agrees with-those who claim that the
remedy soothes the irritated skin, allays itching and pain and
1 British Medical Journal, October 25, 1902.
2 Journal of the American Medical Associalion, September 13, 1902.
3 Monatshefte fur Praktlsche Dermatologle, Bd. 35, No. 8.
Decembeb 6, 1U02I
THE WOKLD'S LATEST LITEKATUKE
iAmkkican Mkdicinb 913
dries up discharge. It is likewise an agreeable and cleanly
application. The author recommends the following formula :
Naftalani, 20; zinci oxidi, amyli, aii, 10; mentholi, 0.5-1.0.
Treatment of Ringworm.— Dr. Lusk (Posl-Graduate, xvi,
Xo. 11) recommends for ringworm of the scalp epilation or
shaving of the affected patches, arid the use of antiseptic washes
to pi-event further spreading. Night and morning the follow-
ing ointment may be applied :
Chrysarobin 2 grams (25 grains)
Ichthyol 1 cc. (15 minims)
Salicylic acid 0.6 gram (10 grains)
Petrolatum 30 co. (1 ounce)
An oil silk cap must be worn, so that the chrysarobin will
not be carried to the face and cause dermatitis or conjunctivitis.
In a few days a violent reaction sets in, which is treated by
soothing salves, such as boric acid ointment, [h.c.w.]
Treatment of Hebra's Prurigo.— De Beurmann i reports
a case of this affection which had resisted treatment in the
various clinics of Paris, but which recovered promptly and
completely as the result of applications of a pomade containing
camphor 12 parts, tar 15 parts, sulfur 8 parts, chaulmoogra oil 3
parts, and vaselin 62 parts. [c.s.D.]
A Case of Liclien Knber Acuminatus.- While Heller'
does not believe that pityriasis ruber and lichen ruber acumi-
natus are identical diseases, yet he thinks a differential diag-
nosis is very difficult. He reports a case of lichen ruber acum-
inatus which is of special interest, inasmuch as it occurred in a
child 3 years old. This patient had no hereditary taint and had,
up to the present time, been perfectly healthy. The child had
a fever, which was accompanied by slowly developing ver-
milion colored papules, which had a waxy, transparent appear-
ance. They appeared in colonies and were capped with a cal-
lous formation. There next were seen patches with a horny
layer similar to that lesion in psoriasis. The areas involved
were : the scalp, forehead, eyelids and ears, which were cov-
ered with scales. The body was covered in isolated areas, more
on the posterior than on the anterior aspect. The thighs were
but slightly involved. The knees and elbows were covered
with whitish scales, and surrounding the scaly area were the
typical papules. Heller mentions an important symptom,
namely, that the palms and soles were covered with scaly
patches which were separated from one another by fissures.
The disease is of long standing, and in the ease of a weak child
may cause death. Heller advises the use of arsenic in its treat-
ment. [W.E.R.]
Treatment of Acne.— Leredde (Journal Medical de Brux-
elles. Vol. xvii. No. 19, 1902, p. 292) points out that slight acne
of the face may be treated successfully by the free use of water,
morning and evening, as hot as can be borne. This facilitates
removal of the greasy material which accumulates on the skin
and stimulates the cutaneous circulation, which is often slug-
gish. Lotions of boric acid or sodium bicarbonate may be
used morning and evening, and 2% alcoholic solutions of
salicylic acid or resorcin may also be employed. After these
lotions, the skin should be greased lightly with the following:
Anhydrous lanolin 10 grams (2.5 drams)
Rose water 4 grams (1 dram)
Water 19 grams (5 drani»).j.
The diseased arwis may be painted with a 5% to 109!) aqlieousor
hydroalcoholic solution of ichthyol, after the greasy material
has been removed from the skin by means of alcohol. If the
skin becomes very dry it is necessary to grease it with fresh
lard or cold cream after these loti<m». The use of salicylic
rfOid, ichthynl or naphtol soaps is considered more dangerous ;
sometimes the skin Is irritated by their use. Careful attention
'should be given to diet and hygiene, [l.f.a.]
Treatment of Alopecia Areata and Mycotica.— Jessner
(Merck'x Archives, Juno, 1902, p. 225) says alopecia areata Is a
suddenly appearing type of baldness, probably of microbic
origin, unattended with any inflammation. In the treatment
all loose hairs should be removed and the scalp cleansed thor-
oughly with soap and water. The most useful remedy is an
< LaHemalne Mgdicalc, July 9, 1902.
» Ilerllner klinlgcbe Wochennchrlft, May 5, l«a.>.
ointment of chrysarobin in strengths of Ifo to lOfc ; care must
be exercised to prevent any getting into the eyes. The iaradic
brush and massage are useful adjuvants. Other irritant appli-
cations are sometimes of value, as:
Acetic acid, glacial .... 1 gram (16 grains)
Chloral hydrate 4 grams ( 1 dram)
Ether 22.5 cc. (6 fl. drams)
Internally pilocarpin or arsenic may be used. Mycotic bald-
ness is really a symptom of the growth of one of various para-
sites on the scalp, usually either the trichophyte of tinea
tonsurans or favus. The short hairs should be pulled out and
the scalp, after being thoroughly cleaned, painted with tincture
of iodin, alternating every 4 or 5 days with collodion. In alo-
pecia favosa the following combination gives good results :
Mercury bichlorid 5 gram ( 8 grains)
Tincture iodin 62 grams ( 2 ounces)
f^i*t'ifjJjfl*"^}ofeach. . . . 5 grams (75 grains)
PetrolaTu£.}°'«''«b 1^ grams ( 5 drams)
[H.C.W.]
Tixe Phototlierapy of Erysipelas.- H. Krukenberg
( Miinehener mediciniscke Wochenschrift, April 1, 1902) presents
the results obtained in the treatment of 13 cases of erysipelas in
the " red room," a ward lighted through red glass windows
and having the walls painted red. The favorable results
obtained are attributed not so much to the red rays as to the
exclusion of other directly ordinary rays. Thirty-three per
cent of the patients suffered a relapse after returning to ordi-
nary daylight. [c.s.D.]
Acne Kosacea and Oily Seborrhea of tlie Pace. —
Robin (Bulletin OinSralde Th^rapeutique, Vol. cxliii. No. 13,
1902, p. 504) has obtained satisfactory results in acne rosacea
with the following treatment: Black soap of the size of a millet
seed is lightly rubbed over a surface of the size of a 5-cent piece.
Two days later the friction is repeated over the same area, then
over an adjacent area of the same size. This treatment is con-
tinued until all the diseased area has been covered. In the inter-
vals the parts are bathed in a hot infusion of 7.5 grains of ipecac
in i ounce of water, and powdered with
Pulverized boric acid .... 47 grams (11 ounces)
Spirit of verbena 30 drops
Powdered talc 104 grams (3S ounces)
In treating oily seborrhea of the face it is first necessary to
express the core of each comedo. Then to prevent its return
and at the same time overcome the oily seborrhea, Robin pre-
scribes a 49!, solutionof boric acid, in addition to a toilet water
made as follows :
Thymol 0 13 gram (4.5 grains)
Menthol 0 2 gram (4 grains)
Spirit of verbena 15 drops
Cologne water 104 | grams (3J ounces)
Every evening the face is bathed with the infusion of ipecac
recommended in the treatment of acne rosacea, and powdered
with the borated talc before retiring. Twice a week, in place
of the simple borated water, the face should be lathered with an
infusion of Panama wood and quassia, then rinsed with borated
water, and powdered with borated talc, [l.f.a.]
Treatment of Brysipelaa. — R. J. N^;jiinogra (Proceedings of
the Orleans Pariah Medical Soci^fti/f >I''ebruary 22, 1902) recom-
mends in erysipelas the use of cold applications of moderately
astringent lotions. The cold application will inhibit develop-
ment of the bacilli and counteract their injurious effect. Iron
is not indicated, because during the thermic process it is not
assimilated and the tincture of iron should be avoided, espe-
cially as all acid preparations tend to irritate the mucous mem-
branes. (We know of no research justifying the conclusion
that iron is not absorbed in fever.) [h.c.w.]
X-ray Dermatitis. — Wiesner ' reports a severe case of
chronic x-ray dermatitis in a healthy blond young man who was
employed in a ROntgen-apparatus factory. He had a good deal
to do with the testing and demonstration of the instruments.
The disease affected the face and chest, and consisted in a swell-
ing and the formation of purulent vesicles. There was also
some pain, irritation of the conjunctiva and increased lacrima-
> Mdncbener mediclnlsche Wocbenaobrift, June 24, 1902.
914 AXIBICAN MBDICINBI
THE WORLD'S LATEST LITERATUEE
[December 6, 1902
tion. Crusts formed, under which suppuration continued. The
hair In tlie affected regions fell out; but after recovery it
returned everywhere, except on the lip and chin. The author
thinl(s that the sole cause of the dermatitis was the x-rays them-
selves. He considers the dermatitis to be a trophoneurosis.
[D.n.]
Treatment of Baldness. — Jersner (Merck's Archives,
June, 1902, iv, 222) declares that the most common type of
alopecia is the seborrheic. He states that if treatment is begun
early enough the prognosis is far from hopeless. Signs of
oncoming baldness are to be found in the rapidity with which
the hair comes out : if in a woman, the hairs under six inches
in length are more than one-quarter of the total number of
hairs pulled out in combing, then there is a pathologic condi-
tion of the scalp. In man, hairs which have not been cut
should not be found in any number in the combings. In the
prophylaxis of alopecia seborrhea it is essential to keep the
scalp clean ; the head should be washed once or twice a week
with tincture of green soap to which has been added a little
tincture of benzoin. Too vigorous washing may cause an
eczema, for the relief of which the following are recommended:
Ichthyol 0.5 cc. (8 minims)
ftoreh"^*^ } of each .... 2.6 grams (40 grains)
Petrolatum, to make .... 19 grams ( 5 drams)
Or,
Salicylic acid 0.5 gram ( 8 grains )
Ziucoxid 5 grams ( U drams)
Tincture benzoin 0.5 ec. (8 minims)
Petrolatum, to make ... 19 grams ( 5 drams)
If the hair is dry and brittle after the washing, it may be
lubricated witli a little oil, if no ointment is being used. To
check the inflammation and the excessive secretion of sebum,
be uses
Washed sulfur . . . 1 to 4 grams ( i to 1 dram)
Resorcin 5 to 3 grams (8 to 40 grains)
Vaselin. to make . . 62 grams (2 ounces)
This should Ije applied all over the head with a stiff brush,
preferably by an attendant. Less efficacious but more pleasant
are lotions, as
Resorcin 2 to 4 grams ( J to 1 dram)
Salicylic acid 2 to 4 grams ( i to 1 dram)
Tannic acid 6 to 10 grams (14 to 2i drams)
Spirit camphor . . .10 grams (5 drams)
Castor oil 2 to 8 grams (IJ to 2 drams)
Cologne water, to make . 207 cc. (7 ounces)
Or,
Resorcin 3 to 6 grams (45 to 90 grains)
Tann'^'ac^''™*^ [ *>' ^^^ ** *° l** grams ( IJ to 2J drams)
Tincture benzoin .... 1 to 2 cc. (16 to 32 minims)
Castor oil 5 to 10 grams ( li to 2i drams)
Alcohol, to make .... 207 cc. (7 ounces)
Very u.s9ful, but expensive, is the new remedy formed
from tannin and chloral, called captol. Medicated soaps are
of value when recovery is well advanced. If the baldness has
become marked, more actively stimulating remedies as chrys-
arobiu or cantharides are indicated, combined with massage
and the electric brush, [h.c.w.]
Treatment of Diseases of the Skin by the Exfoliative
Method.— Leredde (Journal des Praticiens, Vol. xvi. No. 17,
1902, p. 262) has obtained excellent results with the exfoliative
method in acne vulgaris, acne rosacea, lichen, and psorospermo-
sis. This method consists in producing temporary acute
inflammation of the skin, which is followed by decongestion,
temporary or permanent, according to the intensity of the reac-
tion and the particular case under treatment. The inflamma-
tion is characterized by redness and swelling ; at the end of 24
or 48 hours thick, moist scales appear, which dry and fall off in
a few days. The principal agents to produce this result are the
strongly alkaline soaps, resorcin, salicylic acid and betanaph-
tol. Leredde prefers resorcin, as follows :
Resorcin 39 grams (10 drams)
Terra fossile 2 grams (30 grains)
Zinc oxid 10 grams ( 2.5 drams)
Benzoinated lard 27 grams ( 7 drams)
This should be applied to the skin every eight days after a
slight washing, and left in place for 15, 20 or 25 minutes, accord-
ing to the case. The length of application may be increased
gradually at each application. Leredde has thus been able
to continue it for 40 minutes in one case. The inflammation
produced by these applications may be calmed by the use of
Vaselin l
Lanolin \ of each 10 grams (2.6 drams)
Water J
If the inflammation is very intense, the following should be
used:
Zinc oxid 16 grams (4 drams)
Vaaelin [ °' ^^'^^ ^^ grams (2.5 drams)
[L.F.A.]
Treatment of Skin Disease by Means of Cold.— Saalfeld '
reports having employed with success liquid air in the treat-
ment of lichen ruber, lichen planus, eczema, etc. The skin is
touched from 3 to 10 times with the liquid air, at intervals of
from 10 to 15 seconds, for a half minute to a minute and a half.
The effect resembles that of a burn, an exudate being caused
which gives rise to an ampulla at the point of contact. In some
cases, as in herpes tonsurans, rapid amelioration followed.
[C.S.D.]
The Kxtragenital Chancre From Its Clinical and
Hyg;ienic Standpoint.— During 21 years Neumann' has seen
4,634 individuals with primary sore; of these 207 (4.47%), of
whom 100 were men, 107 women, had the chancre at some extra-
genital point. Almost all parts of the body were affected,
oftenest, however, the lips, chin, tonsils, fingers and hand.
The patients were of all ages (from 5 months to 59 years) and
came from every walk of life; the methods of infection were
legion. He describes a number of cases, in many of wliich the
origin was claimed to be accidental, as in physicians, nurses,
washerwomen, etc. He warns against placing too much credence
in many of the alleged instances of infection. In districts where
syphilis is endemic and hygienic cautions are few (some por-
tions of Sweden, Norway, Russia, Bosnia) extragenital
chancres occur most frequently, and are constantly on the
increase. They differ from genital chancres in size and form,
but rarely ever are two, even if occurring at same point, alike.
They are often mistaken for epitheliomata or sarcomata; he
mentions a number of instances of such mistakes. If recog-
nized, the course of the disease does not diff'er from ordinary
syphilis, excepting in the graveness of its skin eruptions ; but
in so many cases the diagnosis is not made, a thing which
explains why so many of these patients reach the third stage
of the disease. The article is closed with a short consideration
of extragenital chancroids, of which he has seen 11 in ten years
out of a material of 2,864 cases, [e.l.]
The contagiosity of Alopecia areata (pelada) is dis-
cussed by Bazet,' who has had during the past year and a half
under observation 110 cases without any evidence of transmis-
sion. He cites the 547 cases of Ciarrocchi of Rome, in which
only 13 cases showed evidence of contagiosity. He concludes
that there exists an infectious form of pelade of great rarity,
and that the physician is not warranted in keeping children
out of school or workmen from factories for fear of transmission
of the disease. [c.s.D.]
Tuberculous Infections of the Skin and Their Relation
to the Internal Organs.— Under the above caption Petersen*
includes lupus vulgaris, tuberculosis verrucosa cutis, tubercu-
losis mifiaris acuta cutis, lichen scrofulosorum, scrofuloderma
or gumma, and probably acne cachecticorum and Bazin's indu-
rative edema. The tuberculosis congress in Berlin, 1900, gave a
new impetus to the study of dermal tuberculosis, to which may
be attributed the discovery of the Finsen treatment of lupus
vulgaris. Petersen believes lupus vulgaris is transmitted from
one part of the body to another by scratching. Not rarely is
this condition accompanied by fever, especially when the "
nodules begin to ulcerate. It is believed that 29% to 33% of
lupus patients are hereditarily predisposed to tuberculosis.
Tuberculous foci were found in the lungs in 70% of the lupus
patients. Petersen concludes that observations on the relation
of tuberculosis of the skin to that of the internal organs have
' La Mfideclne Modeme, June 18, 1902.
« Wiener kllnlsche Wochenschrlft, September 25, 1902.
'Journal medical de Bruxelles, August 21, 1902.
< Berliner klinUche WochenHchrift, April 21, 1902.
Decbmbbk 6, 1902]
THE PUBLIC SERVICE
(AKBBIOAir UsDioiirx 915
been much neglected ; that general tuberculosis may develop
from any local form of that disease. As skin tuberculosis is
considered a local condition, the treatment should be local.
[W.E.R.]
Treatment of Itching Kczema. — Albert Robin ' discusses
the pathology and treatment of itching eczema, with special
reference to acid fermentations in the stomach as a causative
factor. Before beginning treatment he always examines the
gastric juice. In nearly all there is found either complete
achlorhydria, or abundant lactic, or butyric acid fermenta-
tions. If butyric acid fermentation is present he employs the
double iodid of bismuth and cinchonidin, which has been
introduced into medicine under the name of erythrol. The
general treatment of these cases consists in confining the
patient to an absolute milk diet for a period varying from eight
days to one month. From 7 a.m. to 10 p.m. he is given a pint
of milk every three hours. This to be swallowed slowly,
allowing a half hour for its consumption. The quantity
may be increased gradually until U pints are taken at each
feeding. In order to avoid lactic acid formation, one dessert-
spoonful of the following solution is taken with each feeding of
milk:
Ammonium fluorid 02 gram (3 grains)
Distilled water 101 grams (3J ounces)
If the patient has distress in his stomach, as burning, cramps or
sourness, the excessive acid may be diminished by the admin-
istration of one of the following powders dissolved in a little
milk or water :
Lactose )
Calcined magnesia [-of each . 4 grams (1 dram)
Sodium bicarbonate)
Prepared chalk 6 grams (1.5 drams)
To be mixed and divided into 10 powders.
Local treatment consists in (1) powdering the diseased area
daily with
Powdered starch 59 cc. (2 ounces)
Pow^dered zinc oxid 16 grams ( 4 drams)
Finely powdered camphor . . 2 grams (30 grains)
(2) At night the diseased area is washed with a tampon of cot-
ton dipped in the following solution :
Sodium silicate 2 grams (30 grains)
Boiled water 296 cc. (10 ounces)
It is sometimes preferable to sprinkle the parts with this solu-
tion instead of washing them. In any ease, allow the solution
to dry on the skin, then paint the surface with a brush dipped
in compound tincture of benzoin. The compound tincture of
benzoin dries soon after its application and forms an antiseptic
coating, which protects the skin from contact with the air, and,
with the silicate solution, exercises a palliative and curative
effect on the cutaneous lesions, particularly on the itching.
These applications should be renewed daily, washing away the
previous coating of compound tincture of benzoin with the
silicate solution before applying a new one. [l.f.a.]
X-rays in the Treatment of Skin Cancers.— Rinehart,'
reviewing the literature, reports an additional case of cancer of
the face cured by the use of the x-rays, [a.o.j.k.]
Metastatic Conjunctivitis in Gonorrhea.— Just as the
gonococcus reaches the pleura, the meninges, the pericardium,
and other structures, by way of the blood and lymph circula-
tion, so it may reach the eye, setting up metastatic iritis, irido-
cyclitis and conjunctivitis; the latter condition is quite rare.
The 8ervi<!e represented by Kurka' treats 20,000 new cases
every year. He reports two cases from it, they being the first
ones which have been observed there; he was able to collect
but 20 other (Mises. Gonococci could not be found either in the
secretion nor in an excised piece of the conjunctiva. The con-
dition is characterized by an almost simultaneous involvement
of both eyes, the seat of the infection being chiefly in the bulbar
conjunctiva; it presents considerable swelling and episcleral
injection. The palpebral conjunctivas are very red, and but
slightly swollen ; the discharge is composed of stringy mucus.
Complications in other parts of the eye and other parts of the
1 Bulletin General de Thflrapeutlque, Vol. cxllll. No. 20, 1902, p. 757.
'American .Journal of the Medical Sciences, cxxlv, 114, 1902.
" Wiener kllnlscho Wochenschrlfl, October 2, 1902.
body are common, and relapses are frequent. If uncomplicated,
the disease lasts several weeks; if complicated, several months.
The prognosis is good, the treatment the same as in an acute
catarrhal conjunctivitis, [e.i,.]
The Use of Ferrichthol and Ichthyolcalcimn. — On
account of the disagreeable odor and taste of ichthyol, Unna'
prescribes ferrichthol and ichthyolcalcium. These drugs are
indicated in chronic infectious diseases of the skin, eczema
with varicose ulcers and in alopecia. When long continued
arsenic medication is necessary, the use of these drugs permit
of a greater increase in dosage and a better elimination of the
arsenic. Unna gives two tablets three times a day in milk.
[W.E.B.]
Mammary Syphilis in the Early Stage of the Disease.
— Syphilitic implication of the mammary gland in the early
stage of syphilis is comparatively rare. Matzenauer '' finds
only 11 cases reported in literature. He adds two cases to the
list. One occurred in a girl of 17 ; it manifested itseU at the
second month after inoculation, and affected both glands. The
right gland suppurated and had to be incised. In the second
patient, a man 43 years old, the infiltration showed itself about
about four months after the acquisition of the chancre. In
both patients the condition yielded to antisyphilitic treatment.
In nearly all the reported cases were the mammas involved
during the first year; only one of them belonged to the grave
type of the disease, [e.l.]
THE PUBLIC SERVICE
Health Reports.- The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Serrioo, during
the week ended November 29, 1902:
SHALLPOX— UNITBD STATES.
Sacramento Nov. 8-15 ...
San Francisco Nov. 9-16...
Denver Nov. 8-15 ..
Chicago Nov. 15-22..
Indianapolis Nov. 15-22..
Kokomo Nov. 15-22..
Lexington Nov. 15-22..
Blddetord Nov. 15-22..
Boston Nov. 15-22..
Clinton Nov. 15-22..
Weymouth Nov. 16-22..
Grand Riiplds Nov. 15-22..
Nashua Nov. 15-25 ..
Camden Nov. 15-22..
Jersey City Nov. 8-16...
New York Nov. 15-22..
Cincinnati Nov. 14-21 ..
Cleveland Nov. 15-22..
Dayton Nov. 15--,2..
Hamilton Nov. 15-22..
Toledo Nov. 8-22 ...
Altoona Nov. 15-22..
Eric.
California:
Colorado :
IlllnolB-
Indiana:
Kentucky :
Maine:
Massachusetts :
Michigan:
New Hampshire;
New Jersey:
New York :
Ohio:
Pennsylvania ;
Rhode Island :
South Carolina:
Austria :
Belgium.
Brazil:
Ecuador :
Ureal Britain :
India:
Italy:
Mexico:
Kussia :
St. Petersburg Oct 24-Nov. 1.,,..
Straits Settlements: Singapore .Sept. 27-Oct.'ll...
YklIiOW FsyxB.
Colombia: Panama. Oct. 10-17
Costa Rica: PortLlmon Nov. 1-8
ilouador: Guayaquil Oct. 26- Nov. 8. ...
Mexico: Mexico Nov. 2-16
Vera Crar, Nov. 8-15
Cases Deaths
2
3
3
8
S
I
1
lohn.slown Nov. 15-22..
McKeesport Nov. 15-22 ..
Pittsburg Nov. 15-22..
Providence Nov. 15-22..
Charleston Nov. 15-22..
6
12
2
1
1
«
12
1
4
15
2
.Nov. 15-22 28
5
4
46
1
2
SMALLPOX— FOBKION,
Prague Nov. 1-8
Ghent. Oct. 18-Nov. 8
Bahia Oct. 19-Nov. 1
Guayaquil ,_....„. Nov. 1-8
Dundee.... .;i.';.'.lik';:.'.?.;Nov. 1-8 2
London Oct. 25-Nov. 8 6
Bombay Oct. 21-28
Calcutta Oct. 18-25
Naples Nov. .VIO 4
Palermo Nov. 1-8 2
Mexico Nov. 2-16 1
Odessa Oct. 18-26
17
It!
2
16
Philippine Islands :
Cholbka— Insular.
Manila Sept. 28-Oct,. 5 ... 82 24
'• Oct. 6-12 JS 18
Provinces Sept. 28-Oct. 6... 9.288 5,276
Oct. 6-12 6,858 3.274
' MonaUheflo fdr PmkL Dcrmatolog., Bd. 82, No. 8.
'Wiener kllnlsche Wochenschrlft, October 2, 1902.
916 American Medioimb',
THE PUBLIC SEEVICE
[Dbcbmber 6, 1902
fSi&\'
California;
Australia :
India:
BusHia :
Choi,kba— Foreign.
Alexandria Oct. 26-Nov. 1..
Calcutta Oct. 18-25
PIjAOUe— United States.
San Francisco Nov. 15-18
29
Plague— Foreign.
Queensland, Brisbane. ...luly 1-31
Bombay Oct. 21-28
Calcutta Oct. 18-25
Karachi Oct. i9-26
Madras Oct. 11-17
Odessa June 1-Oct. '26..
4d
32
16
1
142
9
10
1
17
Changes in the Medical Corps of the U. 8. Army for
the week ended November 29, 1902:
The following changes In the stations and duties of officers are ordered:
Major .John L. Phillips, surgeon, having reported his arrival at
Governor's Island. N. Y., In compliance with orders heretofore
Issued, win report to the commanding officer, Fort Columbus, for
duty to relieve Major William H. Corbuiser, surgeon. Major Cor-
bulser will proceed to Fort D. A. Russell to relieve Captain William
F. Lewis, asslstivnt surgeon. Captain Lewis will proceed to San
Francisco, Cal., for transportation to the Philippine Islands, where
he will report to the commanding general, division of the Philip-
pines, for assignment to duty.
Boyd, Captain Robert, assistant surgeon. United Stat«s Volunteers, is
honorably discharged, to take effect December 18, his services being
no longer required.
Strong, First Lieutenant Richard P., assistant surgeon, is relieved
from further duty in the division of the Pliilippines, and will repair
to Washington, D. C, and report to the surgeon-general of the
army for duty in his office.
Clausics, Max F., contract surgeon, is relieved from duty at Fort
Huachuca and will proceed to his home, Harrington, 111., for annul-
ment of contract.
Fanning, G. J., contract surgeon, is relieved from duty at Fort
Huachuca and will proceed without delay to Whipple Barracks, to
relieve. Contract Surgeon V. E. Watkins, who will proceed to Fort
Hnachuca
The foilowlngnamed officers, now serving in the division of the Philip-
pines, are honorably discharged, to lake effijct November 24, 1902,
their services being no longer required: Majors John K.Hereford,
Samuel C. deKrafft, surgeons. United States Volunteers; Captains
Bruce Ffoulkea, Waller H. Dade, William H. Turkey, George H.
Jones, Ira Ayer, Wilson Murray, Julius A. Escober, Milton
Vaughan. William O. Cutlltre, Frank L. R. Tetamore, Edward N.
Bowen, assistant surgeons. United States Volunteers.
The following-named officers, now serving in the division of the Philip-
pines, are honorably discharged, to take effect November 25, 1902,
their services being no longer required : Major William H. Cook,
surgeon. United States Volunteers; Captains Oscar W. Woods,
Charles H. Stearns, Allen J. Black, Harold L. Coffin, Harry A.
Eberle, Ira A. Allen, assistant surgeons. United States Volunteers.
Ward, Captain Josiah M., assistant surgeon. United States Volun-
teers, now serving in the division of the Philippines, is honorably
discharged, to take effect October 25, 1902, his services being no
longer required.
Chaffee, First Lieutenant Jerome S., assistant surgeon, is relieved
from duty at the Army and Navy General Hospital, Hot Springs,
Ark., to take effect upon the arrival at the hospital of Contract
Surgeon James C. Minor, and will then proceed to Plattsburg Bar-
racks for duty.
Van Poolk, First Lieutenant Gideon McD., assistant surgeon, is
relieved from further temporary duty at the Army and Navy
General Hospital, Hot Springs, Ark., and will proceed to Fort Riley
for duty.
Minor, James C, contract surgeon, now at Hot Springs, Ark., will
report at the Army and Navy General Hospital at that place for
duty.
The following changes in the stations and duties of officers are ordered :
Major Henry P. Birmingham, surgeon, is relieved from duty at
Fort Leavenworth, to take effect upon the arrival at that post of
Lieutenant^Colonel John Van R. Hoff, deputy surgeon-general, and
will then proceed to Washington Barracks for duty, to relieve Cap-
tain John M. Stone, assistant surgeon. Captain Stone will proceed
to Fort Leavenworth for duty.
Stark, Captain Alexander N., assistant surgeon, is detailed to repre-
sent the medical department of the army at the annual meeting of
the American Public Health As.soelation, to be held in the city of
New Orleans, December 8«to 22, 1892. and will proceed via Washing-
ton, D. C., to New OrleahS-ih-pme! io reach the latter place on or
before December 8, reporting -Bh route to the surgeon-general of the
army for conference. Upon the adjournment of the Association
Captain Stark will return to his proper station at West Point, N. Y.
Keeler, Charles L., hospital steward, now at Exeter, N, J., is
relieved from further duty at Fort McDowell, and will report on or
before expiration of furlough at Fort Warren, to relieve Hospital
Steward Jason D. Byers. steward Byei-s will be sent to Manila,
-1.1. |,
Hogue, GUSTAV0S L., contract surgeon, is relieved from further tem-
porary duty at Fort Miiey and will proceed to Fort McDowell for
duty.
Repktti, Captain John J., assistant surgeon. United States Volun-
teers, 18 honorably discharged, to take effect December 31, 1902, his
services being no longer required. He will proceed to his liome.
Changes In the Medical Corps of the U. 8. Navv tor
the week ended November 29, 1902 :
•''"'No'^lm'berL! miNolIX™^^"*'"' '*PP°'"'«"» ^''''"^^^ «»^g«"".
''''ToX^ign*coc^"-L1i;5?i^l5l?ll'' """'^ "^"^ ^^^ ^'^'^'^^^ ordered
^='tIin^,■c^a^.?e?!.!<*I?f,lro?L^r"e^^S'?he'^^^itfn/L^ '*^* ^^^'^' ««-
Pearson, J. F., pharmacist, detached from the Naval Academy and
ordered to the Naval Training .Station, Newport, R. I.— Novem-
ber 21.
Changes In the Pabjic Health and Marine-Hospital
Service for the week ended November 27, 1902:
White. J. H., assistant surgeon-general, to proceed to Key West,
Florida, for special temporary duty— November 21, 190-'.
Murray, R. U., surgeon, granted leave of absence for seven days from
December 7 — November 22, 1902.
Godfrey, John, surgeon, granted extension of leave of absence for
three months from December 13— November 22, 1902.
Ramus, Carl, assistant surgeon, granted leave of absence for one
monlh from December 1— November 25, 1902.
Lord, C. E. D., assistant su rgeon, grantedextensionof leave of absence
for one month from December 6— November 25, 1902.
WiLLE, C. W., assistant surgeon, upon being relieved from duty at
Cape Charles tiuarantlne. to proceed to Washington, D. C, and
report to the director of the Hygienic Laboi-atory— November 21,
1902,
BoGGESS, J. S., assistant surgeon, relieved from duty at Reedy Island
(Quarantine, and directed to proceed to Cape Charles Quarantine
and assume command of the service, relieving Assistant Surgeon
C. W. Wille-November 21, 1902. To proceed to Norfolk, Virginia,
as recorder of board for physical examination of .Senior Pharma-
cists F. L. Brown and F. S. Goodman — November 21. 1902
Pierce, C. C, assistant surgeon, detailed to represent the service at
meeting of the American Public Health Association at New Or-
leans, La., December 8-18-November 22, 1902.
RucKER, W. C, assistant surgeon, bureau letter of November 19, 1902,
directing him to proceed to Reedy Island Quarantine, revoked,
and report to Surgeon G. W. Stoner, New York Immigration Depot,
for temporary duty— November 26, 1902.
Foster, a. D., assistant surgeon, to proceed to Wilmington, N. C, and
assume temporary command of the service during the absence, on
leave, of Surgeon John Godfrey — November 25, 1902.
Robertson, H. McG., assistant surgeon, to proceed to Chicago, III.,
and report to medical officer in command for duty and assignment
to quarters -November 25, 1902.
GOLDSBOBOUGii, B. W., acting assistant surgeon, leave of absence
granted for twenty-one days by department letter of October 4. 1902,
amended so that it shall be for one day— November 22, 1902. Granted
leave of absence for three weeks from November 20— November 22,
1902.
Hallett, E. B , acting assistant surgeon, granted leave of absence for
three days from November 26— November 25, 1902
Roehrig, a. M.. senior pharmacist, to report to chairman of board of
examiners at Stapleton, N. Y., for physical examination to deter-
mine his fitness for promotion to pharmacist of the first class-
November 24, 1902.
Achenbach, John, senior pharmacist, to report to chairman of
board of examiners at I'ort Townsend Quarantine, Washington, for
physical examination to determine his fitness for promotion to the
grade of pharmacist of the first class— November 24, 1902.
Brock, G. H., senior pharmacist, to report to chairman of board of
examiners at Detroit, Michigan, for physical examination to deter-
mine his fitness for promotion to the grade of pharmacist of the
first class— November 24, 1902.
Maguibe, K. S., senior pharmacist, to report to chairman of board of
examiners at Fort Stanton, N. M., for physical examination to
determine his fitness for promotion to the giade of pharmacist of
the first class— November 24, 1902,
Gibson, R. H., senior pharmacist, to report to chairman of board of
examiners at Gulf Quarantine Station, for physical examination to
determine his fitness for promotion to the grade of pharmacist of
the first class— November 24, 1902.
O'GoRMAN, T. v., senior pharmacist, to report to chairman of board of
examiners at New Orleans, La., for physical examination to deter-
mine his fitness for promotion to the grade of pharmacist of the
first class— November 24, 1902.
Brown, F. L., senior pharmacist, to proceed to Norfolk, Va., and
report to chairman of board of examiners for physical examination
to determine his fitness for promotion to the grade of pharmacist
of the first class— November 24, 1902.
Goodman, F. S., senior pharmacist, to report to chairman of board of
examiners at Norfolk, Va., for physical examination to determine
his fitness for promotion to the grade of pharmacist of the first
class— November 24, 1902.
Miller, Charles, senior pharmacist, to proceed to Mobile, Ala., and
rg^^tojchairman ef board of examiners for ptoeical examination
to a^N^ntlne his fitnefes for promotion to the gHpe of pharmacist
of the first class— November 24, 1902. -^ W"^
Woods, C. H., senior pharmacist, to report to chairman of board of
examiners at Chicago, 111., for physical examination to determine
his fitness for promotion to the grade of pharmacist of the first class
—November 24, 1902.
Hanrath, F. R., senior pharmacist, to report to chairman of board of
examiners at Cleveland. 0.,for physical examination to determine
his fitness for promotion to the grade of pharmacist of the first
class— November 24, 1902.
Richardson, S. W., senior pharmacist, to report to chairman of
board of examiners at St. Louis, Mo., for physical examination to
determine his fitness for promotion to the grade of pharmacist of
the first class— November 24, 1902.
LaGrange, J. v., senior pharmacist, to report to chairman of board
of examiners at Chelsea, Mass., for physical examination to deter-
mine his fitness for promotion to the grade of pharmacist of the
first class— November 24, 1902.
Appointments,
Holcombe McGavock Robertson, of Virginia, commissioned
(recess) as assistant surgeon— November 17, 1902.
Albert Douglas Foster, of Michigan, commissioned (recess) as
assistant surgeon— November 17, 1902.
American Medicine
v^
GEORGE M. GOULD, Editor
G. C. C. HOWARD, Managing Editor
CUnUxU Medicine
David Riesman
A. O. J. Kelly
J. Edwin Sweet
Helen Mubphy
CHARLES 8. DOLLEY
MARTIN B. TINKER, AsHstant Editort
General Bwrgery
Martin B. Tinker
A. B. Craiq
Charles A. Orb
Orthopedic Surgery
H. AUGUSTUS Wilson
COLLABORATORS
Obstetrics and Oynecology
WiLMEE Krusen
Fr5vnk C. Hammond
Nervous and Mental Diseases
J. K. Mitchell
F. Savary Pkabce
IVeatment
Solomon Solis Cohen
H. C. Wood, Jr.
L. P. Appleman
Dermatology
M. B. Habtzell
PUBLIBHXD WsKKLr AT 13'21 WalnITT StRBST, PHILADELPHIA, BY THB AMBRICAM-MbDICTNI PoBLIBHIBA CoHPAHY
Laryngology, Me,
D. Bbaden Kyle
Ophthalmology
Walter L. Pyle
Pathology
R. M. Pearce
Vol. IV, No. 24.
DECEMBEK 13, 1902.
$5.00 Yearly.
Lying: certificates of death, signed by weak or
criminal physicians, is a complaint of Dr. Reynolds, of
the Chicago Board of Health, who says the practice is
growing. The family often requests this, in deaths from
contagious diseases, in order to evade the law that
in such cases burials rnust be within thirty-six hours
after death, and the funeral services may not be public.
Hence deaths from diphtheria, signed by physicians as
due to bronchopneumonia or acute meningitis. Under-
takers can be controlled by the Board of Health, but not
physicians. But physicians through medical societies
can be controlled — if medical societies have any life and
health in them. Besides the principal danger to the
community by the spread of contagion, there is also
another that vitally concerns the profession and still
another that a.s closely concerns medical science and
statistics. For of what value are the statistics of
disease if they are vitiated by lies as to the cause of
death. But many medical societies have no life or
health in them. Hence they should be organized into,
or out of, life.
The W. C. T. U. and "Patent Medicines."— We
invite attention to the letter of Mrs. Allen published in
another column. It is good to know that the leaders of
the Union are moving in the fight against the real causes
of intemperance, even if it has not entered into the
minds and hearts of the majority of the members. We
earnestly hope " the multitude will follow in time."
Certainly we, and all true physicians, are against intem-
perance, but therefore are we against intemperate tem-
IKjranee?. We have read Mrs. Allen's pamphlet on
"The Danger and Harmfulness of Patent Medicines,"
and wish that it could be read by every citizen, and
especially legislator, of the United States. When the
W. C. T. U. as a body takes up such work a.s that and
stops its foolish struggles for impossible reforms, then it
will a«;omplish its aims. But it must learn that prohi-
bition does not prohibit ; indeed, that it increases
intemperance, and that it cannot make human nature
over. And it must try to teach fanatical ignorance and
guide its zeal to some useful ends. We notice, for
example, one silly W. C. T. U. tirade against the can-
teen, based upon the plea that the " navy boys" do not
have it, and therefore the "army boys" would not
need it if discipline, etc. This acute student of the
problem evidently does not know that the vessels of the
navy are surrounded by water, and that it would be
most expensive and difficult for the sailors to swim to
the hundreds of grog shops and immoral vessels that just
beyond gunshot constantly surround every armed cruiser
wherever she sails ! Another wiseacre writes columns
to prove that the army regulations re<iuire temperate
habits in all newly-enlisted recruits, and that we should
enlist no drinking men. He adds that our railroads
have effectual rules against the employment of drinking
men. Of course, any school-boy could tell these sociolo-
gists the difference between the material offering itself
to the recruiting officer and to the railway superintend-
ent, and could also see that the control and discharge
of men is an entirely different affair in the one case and
in the other.
Baby and Child Insurance. — The life insurance
companies — some of them at least — are said to be in dan-
ger of overmuch prosperity. They run a heatUong race
each year to see who shall make the greatest gain in
volume of business. America has beaten the world in the
ingenuity and fertility of schemes of insurance against
every risk conceivable. But in one we are only living
over the experience of Europe. Has human nature in
exceptional cases fallen so low that parents and care-
takers will permit or plot the deaths of the children they
have insured ? There can, we think, be no denial of
the fact. The crime of overlying, for instance (smoth-
ering children in bed by parents, etc.), has not always
been without intention. According to report there are as
many as seventy-five societies in one of our eastern cities
operating under a law which retjuires no report to
the Commiasioner of Insurance, no surplus, and in
which no age-limit is fixed. It is said that 240,000
children are insured in this city. Some companies issue
policies on infants one month old. There is the most
urgent neetl that Legislatures should at once enact laws
that will stop the abuses of child insurance. It is
already hard enough for the innocents to live without
putting a premium ui)on neglect and murder.
History of the Loreiiz Method. — In introducing
Professor Lorenz at the clinic held at Jefferson C/oUege,
Thursday, December 11, Professor H. Augustus Wilson
918 Ahbbioan MioioiNai
EDITORIAL COMMENT
[Decembbb 13, 1902
jjave a brief history of ttie Lorenz method of operation
for congenital dislocation of the hip, from which we
have gleaned the following facts : Dupuytren announce<l
in 1829 his conviction that congenital dislocation of the
hip was not only incurable, but that even palliation was
impossible. For nearly sixty years the medicail profes-
sion showed its conviction of the soundness of Dupuy-
treii's statements, and no attempt was made to do more
thaa overcome the shortening by the use of high-soled
shoes, or by applying some form of brace. In 1887
Buckminster Brown, 6f Boston, reported a case that has
become famous, in which he proved the curability of
this condition by the long continued use of extension in
recumbency. His patient was kept on his back for
thirteen months with extension constantly applied.
The result was restoration of function. In 1890 Hoffa,
of Wurzburg, first directed attention to his cutting
operation, and statistics rapidly accumulated showing
that the formerly hopeless deformity was curable.
Lorenz, of Vienna, became interested, and an advocate
of the cutting operation, which he continued to perform
until 1892, when he abandoned it for the bloodless
method of reposition, which has since been known as
the Lorenz method. Paci, of Pisa, previous to this
time, had tried unsuccessfully to reduce a congenital dis-
location of the hip in an adult, and by some is referred
to as having originated the procedure which Lorenz
perfected. Lorenz clearly proved its applicability to
suitable cases, and established its permanency and
freedom from the mortality which followed the Hoffa
cutting operation. To Lorenz belongs the credit of dis-
cerning that the method is applicable in early childhood
before gross changes to the acetabulum, head of the
femur and surrounding soft structures has taken place.
He has observed that his bloodless method was unsuit-
able in the case of a patient who had been allowed to
walk until the age of seven years, because the acetab-
ulum would by that time have undergone permanent
changes. These patients of seven years or over can be
permanently cured only by a cutting operation, but
much of the severity of that procedure is rendered
unnecessary if the bloodless method is first efficiently
practised. The method has often been applied in unsuit-
able cases, and yet the permanent cures by American
operators has been 25 /o . Lorenz himself has had about
()0^^ of cures, due to his skill and by not applying the
method in children over six years of age.
Cuba's Beturn to Medical Barbarism Many
causes unite to bring about a relapse to the old conditions
which obtained in Cuba before the war. Those who
think this country has not treated the Cubans justly and
generously will find the explanation in this political
wrong. Others will say that annexation would have
prevented the change for the worse. "No sooner had
the American occupation closed," says an informed cor-
respondent, "than discontent appeared in the hos-
pitals."
" The hostility against American innovations which existed
among a certain class spread rapidly, and it would be useless to
deny that the disaffection is now rather general throughout all
classes. In particular the lavish expenditure for sanitary pur-
poses amazed and horrified the Cubans. The earliest acts of the
native government were along the line of retrenchment in
public works. ' If the Americans want sewers,' one high
official is quoted as saying, ' let them build sewers. We got
along very well indeed without them.'
" The hospitals suffered from their short-sighted policy
almost at once. Nor did the trouble stop there. Many native
doctors advised the discharge of the American nurses. ' Why
should foreigners be paid so much money ? ' they argued. ' Our
own women are now perfectly well trained In scientific
nursing.' "
But the semi-oriental type of character of the Cuban
women and society prevents the Cuban nurse from being
efficient and energetic, and, as the beneficence of hospital
administration depends so largely upon the nurses, the
retrograde movement is, it is said, becoming alarming,
even to the native physicians.
Professor Atwater on Temperance Reform. — The
publication of Secretary Root's statement that the law
against the canteen has "increased drunkenness, vene-
real disease, insubordination, desertion, moral and
physical degeneration " will, we trust, make temperance
reformers temperate. We also hope it will make them
read and ponder well the articles on temperance reform
by Professor Atwater in recent issues of The Outlook.
He has set forth the relative merits of the three great
methods of combating the evil, the " Russian Mo-
nopoly," the "Dispensary," and the "Company" sys-
tems. The lesson of all is : First, that local option is
necessary ; second, that the social need supplied by the
saloon must be supplied in other ways ; third, the traffic
must be taken out of politics ; fourth, the profits must
be taken out of private hands ; fifth, the recognition of
the complex nature of the problem, that it is only one
part of social, economic, and ethical reform. The
primary requisite is that the prohibitionists and the
scientific meliorists shall unite in a common work.
This, in fact, means that the intemperate temperance
reformers shall join in effectual and progressive meas-
ures to lessen rather than to abrogate the evil. Concern-
ing the School Physiology question Professor Atwater
says :
" Many who earnestly desire reform have very incorrect
ideas as to the physiologic, economic, ethical, educational, and
legislative bearings of the problem. The unfortunate method of
using alcohol physiology as au instrument for promoting tem-
perance has done much to spread such incorrect ideas. A doc-
trine which, in wholly truthful form, is most effective, has long
been taught with a large admixture of error, and has been
brought with this admixture into the public schools by the aid
of the law, and into the Sunday-school and the pulpit with the
sanction of the church, so that the basing of the argument
against alcohol upon grounds which are untenable has become
very general. Add to those who have received such instruc-
tion the number who have had none, and the mistaught
and the untaught together make a large share of the popula-
tion."
A Possible Danger in Laboratory Research. — A
doubt has arisen as to the existence of a custom, due to
heedlessness, or perhaps exceptionally to greediness, and
consisting in the return to the open market of animals
that have already been once used for experimental pur-
poses. The laboratory danger arises in the fact that
Dbcembeb 18, 1902]
EDITORIAL COMMEKT
Akbrican Medioiite 919
these same animals may be used a second time by other
laboratory workers and their experiments thus rendered
misleading and erroneous. It has been rumored that
animals which have been used for toxin and antitoxin
tests by manufacturing companies have been sometimes
disposed of to public dealers. We do not think this is
true, except possilily in some exceptional case, as for
example, through a tricky or careless employe. The
mere suspicion of such a possibility is disheartening to
those engaged in experimental research and should lead
all concernetl to make it manifest that no such criminal
carelessness or greed exists. Scientific truth of the kind
gained by laboratory investigation is sufficiently difficult
to establish without the needless vitiation of results by
any such recklessness as that mentioned. And this
leaves out of consideration the fraternal courtesy and
honor which is a part of the unwritten code of all true
scientists.
The football wars for 1002 are ended and the
vital statisticians have counted the cost. There have
been a dozen or more killed, several more so baxlly
injured as to be called " very serious" or "fatal," and
nearly 100 less important injuries. There is a tendency
among many critics of the game to rest the case against
it with these accounts of physical injuries. Of course
this is a small and comparatively unimportant part of
the evil. Nor do the charges of " dirty football," with
" stabbed in the back " and " kicked in the head," affect
us so much. It is also true that this season's killings
and brutalities are greater than ever, greater than before
the " flying wedge '-' was outlawed. There are hundreds
of young men at our colleges who can be spared, if they
and their parents, and their professors, and the endowers
of educational institutions wish such "athletics," and
such "ethics," and such "educational" ideals. There
are three results of this sort of education which are far
worse than all these things : The degradation of educa-
tional institutions and ideals by concealed profession-
alism and the use of "teams" to attract students;
second, the harm to the character of the students by
the gambling and debauchery ; third, the aping of this
silliness and immorality by every boy, little and big, of
the country. We are training up a race of — not foot-
ballers— but of men with football ethics.
The value of systematic atliletics is perhaps more
generally recognized than it ever has been, though the
excesses which have resulted from the competitions
between large colleges and universities have caused many
people to overlook the good which may be ax-complished
if athletics are cultivated in moderation and with the
desire to develop sound bodies, rather than to make a
record. Now more than ever in history opportunities
I for exhibiting strength and skill have to be nianu-
' factured. In primitive days the young farmer, builder,
hunter or soldier found abundant opportunity to exhibit
his prowess without athletics. The development of
athletics in recent years is believed by Prof. Woodward,
of Washington University, 8t. Louis, to be dependent
not to change in the mental, moral and physical tastes
and appetites of young men, but to a social development
which renders necessary special provision for the gratifi-
cation of those normal tastes. A constantly diminishing
proportion of people are naturally employed in occupa-
tions requiring physical labor. The rest are walled up in
great cities, roofed in from sunlight and pure air and
then given a maximum of brain work with as little as
possible of physical exercise. Such a state of things
Woodward believes cannot long endure without serious
injury to our manhood unless something is done to pre-
vent this. It is unfortunate that the athletics of
schools, colleges and universities are at present so
arranged that only a few profit by them, for the possible
value of physical exercises in the open air can hardly be
underestimated. Prof. Woodward suggests a number of
rules with regard to the regulation of the college athletics
which we believe might be introduced with much
benefit. Close observers of the American people state
that nervous diseases and complaints arising from exces-
sive brain work combined with a lack of physical health
and vigor are steadily increasing. If we would avert
the threatened physical degeneracy we must introduce
physical culture and suitably regulated athletic games
which shall strengthen our bodies as well as invigorate
our minds.
" Failing Eyesight," Failing Intellect, and
"Advanced Civilization." — In our issues of March 8
and April 5, 1902, we noticed the newspaperish delusion
that failing eyesight is a result of civilization, and that
the proof of this is the increased use of spectacles. We
said that the saffron-colored medical journals would soon
be echoing this nonsense. This has come true, and we
read in our contemporaries that "failing eyesight is the
deplorable but unavoidable concomitant feature of
advanced civilization," that the habit of wearing glasses
is the proof of this, a habitgrowing not only in Germany
but all over the world, and that ga.s and the electric light
have much to do with this eyesight failure, possibly,
also, dust and fog, and traveling underground. The
cure advocated is that " an individual should avoid
poring over small print by artificial light, except when
absolutely neceasary." Poor newspaperdom ! To write
without thinking, without any knowledge of the facts,
and without seeking any knowledge, is so easy that, in
the stilted language quoted, it seems " a deplorable but
unavoidable concomitant feature of advanced civiliza-
tion." A little time ago this same writer explained that
the ill-health of Carlyle was due to "the insanitary and
sedentary existence he led." He did not care to learn
that Carlyle's "existence;" was not insanitary and
absolutely not sedentary, because he exercised in the
open air the greater part of the waking portion of
every day. In the same way our contemporary advises
the use of the rushlights and tiillowdips of our ancestors
instead of our superior gas and electric lights. Spec-
tacles, we may add, are not a proof of failing eyesight,
as there is no scientific proof whatswjver that the eye-
sight of civilizwl |)eople is failing, and there is every
reason to believe that it is improving. If there were
proof of failing eyesight the cure for it is not to
"avoid the poring," but to get proper spectacles for the
porer.
920 AmtBiCAN HuDioiirc'.
EEVIEWB
IDecrmbek 13, 1902
City Hospital for Children with ContagrioiiH Dis-
eases.—In the Health Department's bulletin of (Chicago
of November 29, Dr. lleynolds tells a little story which
should arouse every citizen's determination to remedy
the evil thus illustrated :
" While the Thanksgiviug dinner of turliey and trimmings
was being prepared (or the 70 fortunate inmates of the Chicago
' Home for Friendless Dogs and Cats ' last Thursday, an unfor-
tunate father, Charles F. Maloney, was trudging through the
streets of the South Division carrying his diphtheria-stricken
two-year-old daughter in his arms in search of some asylum,
home, or place where she could be taken in and cared for.
Refused admission at hospital and dispensary, one after
another, he finally reached a police station, whence he was
directed to the Health Department, but the child died before he
arrived at the Commissioner's office."
Dr. Reynolds need not hav,e emphasized his
sympathy with all means to alleviate the sufTerings of
friendless dogs and cats, and ask only for the sympathy
of others in providing hospital accommodations for
friendless children and infants stricken with contagious
disease. In Chicago the only provision is the county
hospital, 12, 16, or 18 miles from the city limits. Thus
is provided the most effectual means of spreading con-
tagion among rich and poor alike. How is it with other
cities?
Institutional Accounting-. VI — The busine.ss world
isjust awaking to the importance of an independent audit
of accounts, but charitable and benevolent institutions
have as yet done little in this direction. It is true that
in many instances an auditing committee is appointed
from among the members of the board of corporators ;
but the audit of such a committee, from lack of special
training required, is usually about as efficient as if the
matter had been left to a gravedigger. It is not a sim-
ple matter to audit the accounts of an institution if the
auditor has any true sense of the responsibilities resting
upon him. For instance, he should satisfy himself that
all receipts of the corporation are fully accounted for.
This side of the account is largely overlooked by an
amateur auditor, y«t it is much more difficult of verifi-
cation, and oflfers equal, if not greater, opportunities for
error and peculation than does the disbursement. It is
quite safe to say that if, during the past ten years, it hsCd
been the general custom on the part of institutions
to employ professional auditors, their accounts today
would not be in so deplorable a state, and in many
instances large savings would have been effected by the
stopping of leaks and improvement of business methods.
In all large centers of population there are to be found
professional accountants and auditors of standing and
repute, and in several States their practice is regulated
by legislative enactment. In all probability many of
these men would be willing to accept appointments as
auditors of institutions, giving their advice and services
without remuneration, in much the same way as mem-
bers of the legal profession act as counsel for charitable
enterprises.
In any event, the accounts of every institution sup-
ported by the public should, at fre(|uent intervals, be
subjected to a thorough audit.
BOOK REVIEWS
The New International Encycloptedla.— Editors, Daniel
CoiT Oilman, I.L.D., President of Johns Hcmkins Uni-
versity (187(5-1901), President of Carnegie Institution;
Harry Thurston Peck, Ph.D., L.H.D., Professor in
Columbia University; P^rank Moore Coi.by, M. A., late
Professor of Economics in New York University. In 17
volumes— Volumes I, II, III. New York: Dodd, Mead
* Company, 1902.
In their preface the editors first emphasize the fact that thiS
work is not a new edition or a revision of the International
Cpclopcedia, but is, for the most part, new and independent.
The change of name from CyclopwrJia to Enci/clopwdia is not
encouraging, as this latter word is an erroneous form based
upon a false reading, and of late Latin or pseudo-Greek origin.
Then the spelling with ce Is an affectation, as in so many such
old-fashioned things, of scholarship without the reality, or is a
commercially-motived flattery of English custom. In this
same work pedagogy is spelled ped-, although the classic form
is paid. We notice, however, that there is throughout the
work this al)surd and illogic mixture of the American or popu-
lar forms of words with incongruous briticisms. The word
gangrene, for instance, is spelled as we have spelled it, and
ether and equal and hundreds of words beginning pre-, and not
with ce. Honor and music are not spelled honour and musick,
although the American editors of an American cyclopedia for
Americans have ignored the advice of the American Associa-
tion for the Advancement of Science as to the proper forms of
a multitude of words in chemistry, etc. The spirit that made
these two mistakes in naming the work, and as to antiquated
spelling, we are assured will not be extended to the subject-
matter. Accuracy is rightly put by the editors before other
merits in a cyclopedia, and the plan of the unsigned article
wisely chosen as the best. The second point upon which stress
is laid is comprehensiveness; the third, lucidity and attractive-
ness of presentation ; the fourth is practical convenience. The
typography and paper are far above the average of such work.
The following are the contributors listed as in charge of the
medical articles: Frederick Randolph Bailey, M.D., Bacteriol-
ogy. Histology, Pathology ; tutor in the normal and pathological
histology of the nervous system, College of Physicians and
Surgeons, the medical department of Columbia University.
Prank Baker, Ph.D., Anatomy; professor of anatomy in the
University of Georgetown, superintendent National Zoological
Park. Percival R. Bolton, Ph.B., M.D., Surgery; instructor in
surgery at Cornell University. Russell Henry Chittenden,
Physiological Chemistry ; director Sheffield Scientific School,
New Haven. Archibald Church, M.D., Neurology ; professor
of nervous and mental diseases and of mental jurisprudence
in the Northwestern University Medical School. Albert War-
ren Ferris, M.D., Medicine; assistant in neurology at Columbia
University, and in medicine at the University an 1 Bellevue Hos-
pital Medical College. Assisted by: Dr. William A. Downes,
Anatomy and Surgery ; assistant surgeon to St. Mary's and the
General Memorial Hospitals. Dr. Hughes Dayton, Ophthalmol-
ogy and Materia Medica ; clinical assistant in medicine at
Columbia University. William Henry Howell, Ph.D., M.D.,
LL.D., Physiology ; professor of physiology and dean of the
medical school in the .Johns Hopkins University. Charles
Henry May, M.D., Vision; chief of clinic and instructor
in ophthalmology in the College of Physicians and Sur-
geons, Columbia University. Adolph Meyer, M.D., LL.D.,
Pathology; director of the Pathological Institute of the
New York State Hospitals. Three volumes have reached
our desk and we have conscientiously read through the
medical articles in all, comparing them with those in other
recent cyclopedias, medical and lay. As a result we can
honestly state that as regards fulness and scientific quality they
are up to our highest expectations. There are extremely few
instances of omission, of undue emphasis, or length, of articles
treating medical subjects. Amoeba coli Is not mentioned under
amoeba, and ainhiim and autoinfection are not in their places,
nor cross-referenced. There is possibly too extensive treat-
ment of physiologic phenomena, as for example the long account
of after-imagea and the relatively short one of anesthetics, the
December la, 1W2\
REVIEWS
AXKRICAN MKDICINK
921
first subject being curious and impractical, the latter being
of the highest practical importance. We are very glad to notice
the franlc, dignified accounts of subjects usually omitted from
cyclopedias by the stupid and false modesty of their editors.
We have here good articles on abortion, aphrodisiac, anaphro-
diaiac, amenorrhea, etc. We hope the articles on surgery will
be as tineas this on anatomy.
A Textbook of Materia Medica, Therapeutics and Phar-
macology.—By Gboroe Frank Butler, Ph.G., M.D.
Fourth edition, thoroughly revised. W. B. Saunders
& Co., Philadelphia and London, 1902.
When a work reaches its fourth edition it has passed
beyond the realm of ordinary criticism ; it has proved its right
to exist in competition with other treatises on the same sub-
ject, showing that it possesses features of merit not to be
found in exactly the same .shape in any other book. Among
the improvements in this edition of Dr. Butler's excellent work
we note especially that the chapters on Organotherapy, Serum-
therapy and cognate subjects have been enlarged and carefully
revised, and that a chapter has been added in which the newer
theories of electrolytic dissolution and its relation to the topic
of pharmacotherapy have been discussed in a simple and lucid
manner; while a very good exposition is given of the simpler
relations of chemical structure to drug action. Moreover,
there has been a thorough remodeling of the opening chapter,
bringing that into accord with recently discovered biologic
phenomena and the new views of the disease process as
reactive and selfpreservative. The print is clear and the book
can be read with pleasure.
A Textbook of Histology and Microscopic Anatomy of
the Human Body, Including Microscopic Technic.
—By Dr. I>ADisLAtrs Szvmonowicz, A.O., Professor of
Histology and Embryology in the University of Lem-
berg. Translated and Edited by John Bruce MacCal-
lum, M.D., .Tobns Hopkins University, Baltimore. Illus-
trated with 277 engravings, including 57 plates in color
and monochrome. Lea Brothers & Co., Philadelphia and
New York, 1902. Pp. 4.35. $3.00 net.
Dr. MacCallum states that his object in the translation and
preparation of this edition of Szymonowicz's work has been to
place at the command of English-speaking instructors and
students a textbook which includes the results of recent inves-
tigations. An effort has been made to trace, so far as possible,
the development of the organs and the steps in histogenesis, a
matter of the utmost importance, as every medical student
should secure a proper conception of the genetic relationships
existing between the tissues at times widely separated in the
body. The introductory cliapter considers the cell at rest, and by
the help of excellent diagrams renders clear the microscopic
structure, together with the rather formidable terminology
involved in the fibril-network theory of Heitzmann, Fromann,
and Loydig, and the granular theory of Altman, and that which
is essential to an understanding of the michrochemistry of the
cell and its nucleus. The living properties of the cell are
treate<] of at length, the various stages of indirect cell division
and the processes of fertilization are explained ; the remaining
pages of Part I being devoted to the consideration of the epithe-
lial, the supporting connecting or interstitial tissues, the mus-
cular and nervous tissues, the blood and lymph. The micro-
scopic anatomy of the organs follows, and together with a
presentation of modern microscopic technic constitutes Part II.
Tlie descriptions of tissues and organs are ample and lucid
throughout, and are rendered particularly plain by the excel-
lence of the typographic arrangements and the splendid
illustrations, among which are a number of innovations in the
nature of stereographic plates representing schematized models
of organs and their constituent tissues. These plates afford
iiiui^h the same lielp in the comprehension of the construction
of an organ as is furnished by a model made by the wax-plate
method, which lias proved so serviceable in comparative mor-
phology and embryology; Ijut being schematic they impress
the mind in somewhat the same way as do geologic sections
and topographic contours, and leave as little real idea of the
actual histologic complex as physiographic diagrams do of the
l)ea\itieH of a landsc ipe. It is a difficult problem that confroiitfl
I
the histologist, how to set before the student such a representar
tion as will create to some degree the understanding that comes
from the actual manipulation of the microscope. The photo-
graph with its blur and multiplicity of detail and its limitation
to a single focal plane is perhaps as misleading at times as is
the brilliant lithograph depicting the gorgeousness of selective
stains or a diagrammatic interpretation of a series of sections.
On the whole, the lithographic monochrome serves perhaps to
convey to the mind real values in the most satisfactory manner.
The author has made use of every available means for convey-
ing a true conception of histologic facts, and the illustrations of
this book come as near giving such conception of it as any sub-
stitutes for personal observation can do. One has only to recall
the textbooks of 25 years ago to appreciate the luxury enjoyed
by the modern student.
Klementary Hygiene for the Tropics.— By Azel Ames,
M.D. Heath & Co., Boston.
This book is a fair sample of the very numerous elementary,
inaccurate and unscientific publications that are being supplied
by textbook publishers to ignorant school boards and helpless
children. The publishers state that the author was assisted in
the preparation of the book by two educators of national repute
who have seen service in Porto Rico and Manila. The object
is to teach the young the principles of hygiene as they are
modified by tropical climates. Some good things are in the
book, but as a whole it cannot be recommended. We do not
understand why the fact that children are being taught should
demand questionable English, senseless repetitions and, above
all, misstatements of facts that must be unlearned later. A few
sentences from this book will illustrate: "When the blood
comes to the lungs through the little tubes or bloodvessels
(called arteries and veins) from all over the body," etc. Speak-
ing of the capillaries of the lung, the author says : " Through
these flows the dark, impure blood which has come to them
from all over the body, on its way to the heart." The child
will not know that these are anatomic untruths, but he will
later, if, having fortunately survived the perils of the element-
ary period of his existence, he is taught hygiene and physiology
correctly. Perhaps his survival will be due to the fact that,
cautioned by this book, he has avoided " the smells, fumes,
vapors, dust, and dirt given off from stables and from different
trades and manufactures," and has escaped malaria by heeding,
among many prophylactic measures, this one : " Take food and
drink coffee, especially in the morning." The book is amusing.
Read it— but do not give it to your children.
Electrotherapeutical Practice.- A Ready Reference Guide
for Pliysicians in the Use of Electricity. Seventh edition.
Revised, rewritten and greatly enlaced. By Charles
S. Neiswanoer, Ph.G., M.D. li H. Colgrove & Co.,
Chicago, 1902.
This is a rather clear and incomplete statement of the
physical principles of electricity, and an over-enthusiastic view
of the possibilities of electricity in therapeutics. It is illus-
trated with wornout cuts taken from an instrument maker's
catalog. One wlio desires a critical review of the subject will
have to look elsewhere; but one who wishes simple and prac-
tical directions for the use of electric apparatus that can lie
understood without much previous knowledge of physics and
without attaining any deep comprehension of scientific prin-
ciples, or of the actual status of electricity in medicine, will be
adundantly satisfied with the volume.
A Nurse's Guide for the Operating-room, by Nicholas
Se.nn, M.D., Ph.D., Lt,.D., CM. W. T. Keener & Co.,
Chicago, 1902.
This book is largely made up of abstracts of lectures
delivered by the author to the pupils of the training school of
St. .Joseph's Hospital, Chicago, and its usefulness must, espe-
cially as regards minute details, be to a great extent limited
to those nurses who work under him or under surgeons who
employ the same technic. Many parts, however, are of general
application. The contents include preparation of operating-
room and patient, hand disinfection, the administration of
anesthetics, sterilization of instruments and suture materials.
922 AjaXBIOAS MXDIOINEI
AMERICAN NEWS AND NOTES
IDrcember 13, 1902
antiseptic solutions, etc. Tlie latter half of the book is devoted
to lists of instruments for special operations. Numerous illus-
trations arc of value in familiarizing nurses with the names of
instruments. Some inaccuracies are noted, as on page 86,
bichlorid 1:400 for irrigation in vaginal hysterectomy. The
printer may be responsible for such an error, but that long-
suffering individual cannot be hold for the statements on page
46 that a 1% solution of carbolic acid is 8J dr. to the gallon, and
a 6% solution is 6} oz. to the gallon.
Applied Snreical Anatomy.— Regionally presented for the
use of students and practitioners of medicine by Gkorge
WooLSKY, A B., M.D., Professor of Anatomy and Clinical
Surgery in the Cornell University Medical College, Sur-
?eon to Bellevue Hospital, and Associate Surgeon to the
'resbyterian Hospital. Pages 521, with 12.5 Illustrations,
most of them colored. New York and Philadelphia: Lea
Brothers & Co., 1902. Cloth, 85.00 net ; leather, ?(i.00 net.
The author closes the preface to his volume with the follow-
ing statement: "An original work on such a subject can no
longer be written, nor would it have as much value as a volume
duly recognizing the vast fund of information accumulated by
tireless investigators. A single author can only hope to con-
tribute a fair proportion of original knowledge and to present a
chosen aspect of the science in a clear and practical manner."
We believe that the author's hope has been well realized and
that his endeavor to present the principles of surgical anatomy
in such a manner as to answer the needs of both students and
practitioners has been eminently successful.' The book is a
storeliouse of facts "for students and contains many working
rules for practising surgeons. It is divided into seven chapters :
1. The Head and Neck; II. The Upper Extremity; III. The
Thorax ; IV. The Abdomen ; V. The Pelvis and Perineum ;
VI. The Lower Extremity; VII. The Spine. The style of the
text is above criticism. Short, crisp sentences serve to eluci-
date ideas, and at the same time make easy reading. The
impression created by the book is that wherever possible
anatomic data have been enlivened by practical deductions.
The ilhistrations are in almost every instance those of other
textbooks, but have been well selected. The publishers have
executed acceptably the mechanical work of the book. We
take pleasure in commending this volume to prospective
purchasers.
BOOKS RECEIVED.
[Prompt acknowledgment of books received will be made In this
column, and from time to time critical reviews will be made of those
of interest to our readers.]
Transactions of the New Haiupsliire Medical Society at the
one hundred and eleventh anniversary, held at Concord. The Rum-
ford Pnss, 1902.
Pathology of Infectious Diseases of Animals. — By Verantjs A.
Moore. B.8 , M.D., Professor of Compiiratlve Pathology, Bacteriology,
and Meat Inspection, New York State Veterinary College, Cornell Uni-
versity, Ithaca. N. Y. With an introducUcm by D. E Salmon, D.V.M.,
Chief of the Bureivii of Animal Industry, United Stales Uepartmeni of
Agriculture. Illustrated. Taylor & Carpenter, Ithaca, N. Y., 1902.
Story of a Living Temple.— By FREDERICK M. RossiTEH, B.S..
M.D., and M. H. Rossiter, A.M. Fleming H. Revcll Company, Chi-
cago, 1H02.
Transactions of tlie Association of American Physicians ; Vol.
XVII. Uornan. printer, Philadelphia, 1902.
Abdominal Manipulation in Pregnancy. — By A. MacLennan,
M.B., CM. (Glasgow), Ij.M. (Rotunda, Dublin). Clinical Assistant to
the Professor of Obstetrics and Gynecology. University of Glasgow,
etc. With an introduction by Prof. MnKDOCH (.ameron. Rebman,
Limited. London. 1902. Price, J6.00 net.
A Manual of Dissection and Practical Anatomy Founded on
Gray and Gerrlsh.— By William T. Ecklev, M.D., Professor of
Anatomy, and Cokin.ne B. Eckley, Demonstrator of Anatomy in the
Medical and Dental llepartments of the University of Illinois. In one
octavo volume of 400 pages, illustrated with 220 engravings, 116 of
which are colored. Cloth. 83.50 net. Lea Brothers & Co., publishers,
Philadelphia and New York.
Regional Minor Surgery. -By GEORGE Gr*y Van SCHAICK, M.D..
Attending Surgeon to the French Hospital. New York. Jnternatlonal
Journal of Surgery Co., New York, N. Y. Price, Ji.oO.
Medical Microscopy — By T. E Oertel. M.D.. Professor of Histol-
ogy, Pathology, Bacierlology. and Clinical Microscopy, Medical De-
partment, University of Georgia. With 131 illustrations, some of which
are colored. P. Blaklston's Son & Co., Philadelphia, 1902. Price, $2.00
net.
Laboratory Exercises in Bacteriology. — By Allen J. Smith,
M.D., Pmfessor of Pathology In the Unlvtislty of Texas, Galveston
P. Blaklston's Son & Co., Philadelphia, 1902. Price, $1.50.
Heath's Practical Anatomy: Ninth edition.— Edited by J.Ernest
Lane, K.R.C.s.. Surgeon and Lecturer on Anatomy at St. Mark's Hos-
Eltal, etc. With 321 engravings on wood, of which 82 are colored. P.
laklston's Son & Co., Philadelphia, 1902.
AMERICAN NEWS AND NOTES.
GENERAL..
International Congress of Medicine. — The American
committee announces that blank (ormsof application addressed
to the Bureau des Logements in Madrid, forms of application
for those who desire to read papers at the congress, as well as
other literature bearing on the subje<;t, may be obtained upon
request from the secretary of the committee, John H. Hud-
dleston, M.D., 126 West Eighty-fifth street. New York City.
The InimiKratlon Evil Stopped. — It is announced that
hereafter undesirable immigrants who have been debarred at
Canadian ports, and who escape over the border into the United
States will, by permission of the Canadian Government, be sent
back across the frontier from this country in charge of the
United States immigration officials, and thence deported to
Europe on the vessels that brought them over. Formerly
immigrants of this class were sent liack at the expense of the
United States Government, but under the new agreement the
steamship lines bringing theminto British Provinces must bear
all expense of deporting them.
Miscellaneons.- Nkw York City: Dr. William Mabon,
who has been the medical superintendent of the St. Lawrence
Hospital for the Insane at Ogdensbur^ since 1896, has accepted
the superintendency of Bellevue Hospital. He will take charge
on January 1, and will also act as consulting physician to the
pavilion for the insane at Bellevue. Cambridge, Mass.: Dr. W.
B. Cannon has been appointed assistant professor of physiology
at the Harvard University Medical School. (Quebec : Dr. Fiset,
of CJuebec, has been appnnted staff adjutant of the Array Med-
ical Corps of Canada. He will be located at Ottawa. San Fran-
cisco, Cat..: Dr. .lacques Loeb, of Chicago, will take charge of
the department of physiology in the University of California,
January 1, 190.'i.
Hospital Benefactions. — St. Michael's Hospital, New-
ark, N. J.: Patrick Flanagan, of Perth Amboy, N. J., has
bequeathed?7,000tothishospital. Epwortii Hospital, Sodth
Bend, Ind. : The sum of g.50,000 was received from the Stude-
baker family on ihe anniversary of Clem Studebaker's death.
This makes a total contribution of $75,000 from this family.
German Hospital, Philadelphia: On the annual donation
day at the German Hospital $9,000 in cash was received and
about $2,000 worth of goods. Chicago, III.: Under the will
of the late Matthews Gottfried the Christian Brothers' Hospital
receives $2,000; the Mercy Hospital, $3,500, and the German
Hospital, $2,001). University Hospital, Ann Arbor, Mich.:
The late Mrs. L. M. Palmer bequeathed $20,000 for the establish-
ment of a children's ward to be called the " Palmer Ward; "
besides this sum $15,000 additional are given as an endowment
for the maintenance of the ward.
EASTERN STATES.
The American Association for the Cure of Inebriety
will hold its thirty-second annual meeting in Boston. Mass.,
December IH, 1902.
Smallpox in Boston.— For the week ended December 6
there were 7 deaths from from smallpox with 23 cases of the
disease in the city. One of the deaths was that of a woman
who had been recently vaccinated by her family physician,
who, it is said, advised her to wash otf the virus with al'-ohol,
as he did not believe the vaccination would do any good, and
that he only vaccinated her in order to conform to the regula-
tions of the Board of Health. It is reported that he also vacci-
nated tiiree other members of the family, two of whom washed
off the virus and have since contracted smallpox. The remain-
ing member did not follow his advice, and consequently did
not contract the disease.
Adulterations Increase. — The State Board of Health in
Massachusetts is exercising vigilance to detect adulterations in
articles of food and in commercial articles. It is asserted that
adulterations are increasing. Owing to the scarcity of apples a
great deal of adulterated vinegar has been put upon the market.
According to the report, the total number of articles examined
by the analyst during the year was 10,32.i, and the number of
prosecutions conducted was 95, of which 90 resulted in convic-
tion. Of these, 65 were for sales of adulterated milk and the
remainder were for sales of other kinds of food found to be
adulterated. The use of artificial dyestuffs in food products has
greatly increased, so that the time would seem to be at hand
when a spt-cial law should be framed, dealing more specifically
and stringently with the question of lolors than does the present
general food law. Artificial dyestuffs are added to foods in
most cases to conceal inferiority or to make them more attractive
in appearance, thus tending to deceive the purchaser as to tiie
quality of the goods. It would seem to be desirable to prohibit
tne use of coloring matter in food, unless so marked, with the
possible exception of confectionery, certain dessert mixtures
and perhaps a few other specified articles, wherein the presence
of color cannot possibly deceive.
Dkcbhbeb 13, 1902]
AMERICAN NEWS AND NOTES
:Aj(ebican MKDiouni 923
NEW YORK.
Mosquito Extermination. — The report of a committee of
Soiuh Oiaiige, X. J., states tliat by the use of oil and drainage
for two years fully 75% of the mosquitos of the region have
been exterminated. Next year they expect to exterminate 10%
more, but furtlier than that they cannot hope to go until the
surrounding communities take up the fight.
Colors in the Treatment of the Insane. — A series of
experiments as to the effects of various colors on the insane
now being tried on Ward's Island are said to have developed
some remarkable results. It is reported that a number of
patients have been cured. Although the treatment is new to
alientists it is believed that it is one that will prove very suc-
cessful.
New York University Will Appeal. — An appeal has
been made to the Court of Appeals from the decision of the
Appellate Division which awarded to the Medical College Labo-
ratory of the City of New York the premises which were
deeded over to the university in 1897 by the Medical College
Laboratory of the City of New York under a plan to combine
the university and the laboratory.
New French Hospital.— The corner-stone of the new hos-
pital to be erected by the French Benevolent Society in New
York City was laid recently by M. Jules Cambon, the depart-
ing French Ambassador. Of the ?260,000 required for its erec-
tion J2()0,000 has already been raised. Through the efforts of
M. Jules Cambon a contribution of 100,000 francs was received
for the hospital from the French Government.
Chinese Physician Seeks Medical liicense.— Dr. Bow
Chang, who says he was graduated in China from institutions
of learning bearing all kinds of odd-sounding names, in prov-
inces bearing equally as peculiar names, wants to be licensed
to practise meilicine in the State of New York. Healso desires
to establish a hospital in Chinatown tor the exclusive treatment
of the people of his race in New York and the East.
Free lectures on pulmonary tuberculosis have been
started in New York City by the Committee on the Prevention
of Tuberculosis, as one of the measures which they adopted in
planning a vigorous crusade against the disease. Several
lectures have already been delivered at some of the settlements
on the Kast Side, the object being to give instruction to mothers
and settlement-workers in the liest methods of preventing the
disea.se. A course of lectures covering various aspects of the
disease, such as social conditions, cause and prevention,
influence of climate, and sanatoriums, has been arranged and
will lie given oncb a month. Among those who will lecture
are Drs. lladdleston. Biggs, Janeway, Knopf, Trudeau, Jacob!,
and Joseph D. Bryant.
PHIIiADEIiPHIA, PENNSTIiVANIA. ETC.
St. John's Hospital, .Vllegheny, Pa.— A new addition to
the hospital was recently completed at a cost of about $3-3,000.
It contains 29 private rooms and 4 wards.
Philadelphia Patholojjical Society.— The annual exhibi-
tion meeting of the society will be held December 11, 1902, in
the Mutter Museum of the College of Physicians. Microscopic
displays of series of slides illustrative of special branches will
not be neglected, but small series of interesting gross specimens,
illustrative of surgical pathology, are especially desired, as the
meeting will be largely devoted to gross pathology.
Barbers Want Sanitary Laws Enforced. — The coming
session of the .Xew Jersey .State legislature will receive a bill
which has been drawn up by the Journeymen Barbers' Associa-
tion of the State. The legislature will be petitioned to pass the
bill, which asks foraState inspector to be appointed to visit all
barber shops and see that the laws regulating them are enforced.
They ask for stringent sanitary laws, one feature being the
compulsory sterilization daily of all instruments used.
Tuberculosis Pavilions. — Six pavilions, each accommodat-
ing -iO patients, will be erected on the Philadelphia Hospital
grounds out of an appropriation of $80,000, which Councils have
promised to make at an early date. The structures will be 48
reft long, ;i9 feet wide and 28 loot high, with a space 48 feet wide
between tliem and a piazza 80 feet in front. They will be con-
structed of steel and glass, with roof and sides arranged on
pivots, .so that they can be swung open on fair days.
Ijack of Funds to Fl^ht Smallpox.- The prospect of
stiiallpox epidemics in various parts of Peimsylvania has led to
efforts being made by the .State IJoard of Health to have the
$.")0,00<) emorgoncy fund for epidemics reestablished. The fimd
was reduced to $i"),000 by tJovernor Stone in I8!)9, and was abol-
ished altf)gethor by the last Legislature. Without the emer-
gency fund the State Board of Health is unable to respond to
the numerous calls for assistance it has received, and smallpox
Is reporte<l to be increasing, 87 cities, towns and villiiges having
more or less of the disea.se. It is to bo hoped in the interests of
IJiililic health that the efforts of the Board to have the fund
n.stablished will be successful.
SOUTHERN STATES.
Women Nurses for the Navy.— A bill now pending in Con-
gress provides for .50 women nurses for the navy. These nurses
are to be taken from the best training-schools and to be subjected
to a rigid mental, moral, and physical examination. They must
have sufficient knowledge of medicine to be able to prescribe
for emergency patients, and to diagnose cases if necessary.
The pay will be the same as army nurses receive, or about as
much as could be earned at private nursing. There are now
about 100 such nurses in the regular army corps under the
command of a woman chief nurse.
Scientlflc Experiments.— The Washington Star states that
a bill has been introduced in the Senate for the regulation of
scientific experimentation upon human beings and animals in
the District of Columbia and elsewhere upon men belonging to
the Army and Navy of the United States. The bill provides
that no experiment shall be made upon any human being
causing pain or distress ordanger to life without the intelligent
personal consent of such individual in writing, preceded by a
full written statement setting forth to the person affected the
consequences that are liable to result from these experiments.
No such experiments shall be made upon any newborn babe,
aged or feebleminded person. No experiment may be made
on any warm-blooded animal except to alleviate some ailment
from which it is suff'ering. Every laboratory where experi-
ments upon living animals may be legally performed must be
registered in the office of the Commissioners. Hules under
which experiments may be made by the Secretary of Agricul-
ture to test the communicability of diseases of animals are pre-
scribed. All experimenters are to report to the Commissioners
concerning their operations.
The Sanitary Conference of American Republics was
held in Washington, D. i^., December 2 to 4. Dr. Walter
Wyman. surgeon-general of the Marine-Hospital Service, pre-
sicfed. The governments of Mexico, Cuba, Chile, Costa Rica,
Salvador, Honduras, and the United States were represented.
Quarantine and sanitation matters affecting these countries
were discussed, and many interesting reports were submitted,
those of Dr. Juan Guiteras and Dr. Carlos J. Finlay, of Cuba, Dr.
Eduardo Moore, of Chile, Dr. Ulloa, of Costa Rica, Dr. Walter
Wyman, and Dr. Ch. Wardell Stiles, being especially worthy
of mention. A resolution was adopted which requires the
participating republics to transmit to the International Sani-
tary Bureau, whose permanent headquarters will be at Wash-
ington, all data relative to the sanitary condition of their ports
and territories, and to furnish every facility for investigation
of any outbreaks of pestilential disease which may occur. By
these means the bureau will be enabled to afford protection to
the public health of each of the republics and to facilitate com-
merce among them. The expenses of the bureau are to bo
paid out of a special fund created by annual appropriations by
the republics represented in the conventions. The next meet-
ing of the conference will be held in Santiago de Chile, March
15, 1904.
WESTERN STATES.
Western Surgical and Gynecolojcical Association. —
The twelfth annual meeting of the association will bo hold at
St. Joseph, Mo., December 2!l and ;!0, 1902. An extensive pro-
gram has been prepared. •
Akron City Hospital.- The Ohio Grand iiodge of Masons
recently laid the corner-stone of a new hospital to be built in
Akron. The new structure is to cost $100,000, and is the gift of
two of Akron's wealthy and philanthropic citizens.
Smallpox at Port Huron.— It is reported that a serious
outbreak of smallpox, numbering 60 cases, has occurred at Port
Huron, Mich. There have been few if any precautionary
measures fo prevent the further spread of the disease and the
city is without the proper facilities for combating the disease.
American Rftntgen Ray Society.— It is announced that
the third annual meeting will be held in Chicago, December
10 and U. Owing to the rapid evolution in Rontgen ray
therapy, as well as the technical improvements in apparatus
within the past year, this meeting should be of unusual interest
and importance.
ti'nnd to Fight Smallpox. — The increasing number of
smallpox cases in Evanston, 111., has led Mayor James A. Pat-
ten to make an appeal to the puV)lic for the purpose of o.stablish-
ing a fund to fight the disease. He states that ho wishes to raise
$5,000, which will he used to secure an isolation hospital and to
establish efficient quarantine.
A Hotel-hospllal.— .\ coml>ination hospital and hotel is to
be erected in Chicago at a cost of $400,000. Many physicians are
said to be Interested in the project. "The building of this struc-
ture comes from a want felt on the part of many physicians and
surgeons for some suitable place to take private patients,
especially those from out of the city, where friends and rela-
tives can reside under the same roof with them. The buildin|f
will be arranged In suites with private baths and all other
modern conveniences.
924 XUKBICAS MeoxOIBEI
FOREIGN NEWS AND NOTES
[December 13, 1902
Forinaldchyd Gas in AbortinK Catarrhal Conditions.
—The report of tlie Chicago Health I)e|)artrnent for the week
ended November 8 states that as so many requests have been
received for copies of BuUetion No. 44, October 25, which con-
tains the suggestion as to the value of forraaldehyd gas in
aborting catarrhal conditions favoring the development of
pneumonia, bronchitis, inHuenza, and other air-borne bacterial
diseases, a special edition of this part of the bulletin has been
reprinted from one of the daily papers. (Jopies may be had on
application to the secretary, in person, or by mail.
Diphtlieria in ChicaRo.— The reported deaths for the
week ended November 22 show an increase of 16% over those
of the previous week, and of 48% over those of the correspond-
ing week of la-'t year. Investigation has shown that many of
the deaths were due to a deceptive type of the disease, in which
the administration of antitoxin was delayed. The Health
Department, therefore, advises all persons having the care of
chililren to keep in mind that the disease may be in the back
part of the nose or in the windpipe, as well as in the throat
where the membrane can be seen. The true nature of the dis-
ease can only be learned by taking a culture, and when there
are so many of these cases present as now, tliis should never be
omitte<l. Antitoxin should be administered at once in every
suspicious throat case, it can do no possible harm in any event,
and it will certainly prevent death from diphtheria if used
within the first 48 hours. The laboratory examinations show
some decrease in the presence of the diphtheria bacillus; it was
found in less than 50% of the cultures examined. The week
before it was present in more than 60% of the cultures, but it
was found more frequently last week in cases not suspected to
be diphtheria.
FOREIGN NEWS AND NOTES
OENEBALi.
Miscellaneous. — According to an exchange the jubilee of
the eminent anatomist, Golgi, who is now in his eighty-sixth
year, was celebrated at Pavia on October 28. He was presented
with an edition of his works in three volumes.
GREAT BRITAIN.
Bnbonic Plague. — The medical department of the British
local government board recently issued an interesting report
by Dr. Bruce Law, with an introduction by W. H. Power,
P.R.S., medical officer of the board, of the progress and diffusion
of bubonic plague during the period from 1898 to 1901, giving
also an account of the measures adopted in various countries
for its control. An attempt has been made to record the time
and place of all outbreaks and to show the origin of the disease
and its extent and mortality. Mr. Power makes the observa-
tion that although certain lo('alities are In a condition to receive
the infection the disease has seldom become quickly and largely
epidemic, which would seem to indicate that the disease does
not readily adapt itself to localities where it has not previously
and recently prevailed. In speaking of the influence of rats in
the diffusion of plague. Dr. Law states that although rat and
man have sometimes ijeen affected simultaneously, in other
instances rats have been first infected and then man and vice
versa. Illustrations are given to show that rats may be
extensively affected and man remain free and that the reverse
may also occur. It is pointed out that at sea the disease is not
readily conveyed from rat to man or from man to rat. Mr.
Power points out that notwithstanding these observations it
would be exceedingly unwise to relax precautions against the
spread of plague by rats.
CONTINENTAJi EUROPE.
Tlie Brussels Congress of Hygiene will convene at Brus-
sels from September 3 to 8, 1903. The United States is invited
to send an official representative, and it is suggested that com-
mittees of propaganda, composed of persons eminent in med-
ical science and hygiene, be organized in the different States,
with whom the central committee at Brussels may correspond.
Effect of Balloon Ascension. — At a recent meeting of the
Acadgmie de M6decine Dr. Naugier, of Paris, made the asser-
tion that a two hours' voyage in the air causes a marked
Increase in the number of red corpuscles, and the condition per-
sists for 10 days after an ascent. Two such ascents in the
course of six or seven weeks, he said, are more beneficial to an
anemic than a sojourn of three months in the mountains.
Infant Mortality in Prance. — M. Bertillon has col-
lected and published statistics relative to infant mortality in
France. Concerning his publication the Medical Press says :
" From this article we learn that the mortality among infants
who are between the ages of ten days and one year, and who are
brought up at the public expense, was 203 per 1,000, while that
of infants generally throughout the country at the same age
was 128 per 1,000 ; consequently the mortality among the former
class exceeded that among the latter by nearly 60%. Asa result
of this state of affairs, while the birthrate in England for the
years 1874-1898 was 32.6 per 1,000, and the deathrate 19.4, the
birthrate in France during the same period only exceeded the
deathrate by 1.8 per 1,000, and on several occasions of late years
was actually lower than the deathrate. This is a serious state
of affairs, and M. Bertillon deserves credit for having called
attention to it. It is by checking such leakages of infant life—
if we may so term an avoidable mortality — that France will
best replenish her population. In this connection attention
may be drawn to a statement made at a recent meeting of the
Academy of Moral Sciences in Paris, that while the population
of the rest of Europe had increased 129% during the last 100
years, the population of France had only increased 44%."
OBITUARIES.
Timothy Field Allen, of New York City, December 5, aged 65. He
was graduated from the medical department of the New York Univer-
sity tu 1861, and was also a graduate of the Hahnemann Medical Col-
lege, Philadelphia. He was the author of an extensive encyclopedia
of materia medioa. He had been professor of materia medlca and
dean In the New York Homeopathic Medical College, president of the
board of trustees at the college, surgeon in and president of the New
York Ophthalmic Hospital and a fellow of the Academy of Sciences.
N. Y. Licet, ofScranton, Pa., December 6, aged 73. He was gradu-
ated from the medical department of the University of Pennsylvania
in 1852. He served during the Civil war as a surgeon. He was coroner
of Lackawanna county for a term, surgeon-in-chlef of the Moses Taylor
Hospital for many years, and also surgeon for the Delaware, Lacka-
wanna and Western Railroad Company.
Baniel Pearson I'ease, of New York City, in Paris, France, Decem-
ber?, aged 45. He was graduated from Bellevue Medical College in
188i. He served on the stafTof the Bellevue Hospital for some time and
was then placed in charge of a bureau in the contagious diseases
department of the Board of Health. At one time he also had charge of
North Brother Island.
M. N. Benjamin died recently at Dunkirk, N. Y., aged 59. He was
graduated from the Vermont University in 1864, and afterward prac-
tised In the Bellevue Hospital. New York. He served as surgeon in
the Civil war. He was known as a proficient linguist, having masti r
nine languages.
H. Melville Smith, of South Orange, N. .1., December 5, aged ai.
He was graduated from the New York College of Physicians and Sur-
geons in 1871. He had practised medicine in Jersey City for 17 years
and most of the time he was on the staff of physicians connected with
Christ Hospital.
J. A. Ferguson, of Ottawa, Out., November 19, aged 29. He had
recently received a medal from the Humane Society for the bravery he
displayed in the fire of the Laurentian Sanitarium at Ste. Agatbe des
Monts, Quebec, which occurred some months ago.
K. I>. Kobb, of Gainesville, F"la., In Jacksonville, December 6. He
was graduated from the Homeopathic Medical College of Missouri in
1874. He was physician-iu-charge of the Odd Fellows' Sanitarium of
Florida.
James Allen, of Richford, N. Y., November 25, aged 75. He was
graduated from the Berkshire Medical College In 1849. During the;
Civil war he was an a.ssistant surgeon in the Union Array.
George D. Blomer, Jr., of Philadelphia, December 1, aged 38.
He was graduated from the Jefferson Medical College in 1890. He was
a member of many fraternal and scientific organizations.
Charles H. Shaffer, in Elizabeth, Pa., November 21, aged 44. He
was graduated from the Western Reserve University, Cleveland, Ohio,
In 1882.
George A. Hillsman, at Ijivermore, Ky., November 19, aged 40.
He was graduated from the Jefferson Medical College, Philadelphia,
in 1888.
Pliilip P. Duval, in Richmond, Va., November 20, aged 75. He
was graduated from the University of Virginia, Charlottesville, in 1846.
<T. H. Booker, of Lottsburg, Va., December 3. He was graduated
from the College of Physicians and Surgeons, Baltimore, Md., in 1879.
Henry J. Cushing, In Meirlmac, Mass., November 18, aged 65. He
was graduated from the Harvard University Medical .School in 1868.
William T. Garwood, of San Francisco, Cal., November 21, agi d
65. He was graduated from the Cooper Medical College in 1861.
Charles C. Sprague, in Hull, HI., NovemberH), aged 67. He was
graduated from the Rush Medical College, Chicago, iu 1869.
A. C. Brasel, in Petro.s, Tenn., November 21. He was graduated
from the Tennessee Medical College, Kno.wiile, in 1901.
L,evi J. Hixson, of LaSalle, N. Y., December 5. He was graduated
from the Trinity Medical College, Toronto, Ont., in 1888.
Z. R. Millard, in Thackery, III , November 19. He was graduated
from the Medical College of EvansvlUe, Ind., in 1846.
J. Moore Hart, of Toronto, November 11, aged .52. He was gradu-
ated from the Trinity Medical College In 1871.
Charles S. Burton, of Hastings, .Mich., December 5, aged 80 ,
Dbckmbbb 13, lt021
COKEESPONDEN Cto
(Ahsbican Usdioins
925
CLINICAL NOTES AND CORRESPONDENCE
[Communications are invited for this Department. The Editor Is
not responsible for the views advanced by any contributor.]
A LARGE COMPLICATED ENCHONDROSARCOMA
REMOVED BY SIMPLE INCISION AND X-RAY.
BY
D. E. EVANS, M.D.,
AND
T. V. WILLIAMS, M.D.,
of New Castle, Pa.
Camk.— The patient, a woman, aged 55, presented over the
left wri-it-joint a large tumor which extended upward for about
three inches and downward over the entire back of the hand.
At times the growth caused considerable pain, she having
passed many sleepless nights on this account. Many surgeons
had been consulted and most of them made a diagnosis of sar-
coma, but the growth was not treated.
On March 7, 1902, an incision was made into the most prom-
inent portion above the wrist. A quantity of serum-like fluid,
and about a tablespoonful of hard gelatinous, round and oval
bodies (rice bodies presumably) of varying sizes, from the size
of common rice down, came away. The cavity was drained,
swabbed with tr. iodin and packed. In a few days another
incision was made on the back of the hand which did not
bleed but was hard and grisly.
The cavity was curetted and some rice bodies removed. The
inner walls were caseous in consistency and considerable curet-
ting was done before bleeding was provoked. Tr. iodin was
again syringed into the cavity and the wound dre.ssed anti-
suptically. The dressings were changed everyday, and every
other day for ten minutes the x-ray was placed over the
tumor at six inches distance from a soft tube energized from an
eight plate static machine. In about two months the whole
tumor had disappeared and for the first time in seven years the
patient could put on her glove. At the end of three months a
complete cure had been effected and at the present writing
there is no trace of the tumor. All that remains are the linear
scars of the incisions. In all about 12 x-ray treatments were
given.
WHAT THE WOMAN'S CHRISTIAN TEMPERANCE
UNION IS DOING TO FIGHT THE "PATENT
MEDICINE ENEMY."
Kilitor American Medicine:— \ friend has called my atten-
tion to your very pertinent question in the issue of November 12,
" Why do not the temperance people fight the patent medicine
enemy?" It gives me pleasure to let you and your readers
know what the Woman's Christian Temperance Union has
done and is doing in opposition to this evil. The National
Woman's Christian Temperance Union in 1895 adopted the
department of " Nonalcoholic Medication," and gave to me the
responsibility of superintending it. The object of the depart-
ment is to pass along to our own membership, and through
them to as many other people as possible, all that is written
against the medical use of alcoholic drinks by physicians of
acknowledged standing in the profession, and especially by
those who, having made special study of the elfects of alcoholic
drinks, have discarded them as remedies. In this work I have
been greatly helped by some of the leading physicians of this
country and of lOngland, and ro<^ently iielp lias come also from
Vienna, Austria, in the shape of two strong articles by Dr. Max
Kassowitz, a distinguislied specialist in children's diseases.
About six years ago a physician suggested that I study dis-
guised alcohol in the form of proprietary medicines and pass
along to the world the results. Aided by the reports of the
Mafwachusetts IJoard of Health and by several journals of the
pharmacy business, I prepared a leafiet called " The Danger and
IlarmfulneBS of Patent Medicines," the matter appearing first
in a religious paper which has a large circulation, the (Ihrintian
Advocate, of New York. A copy of tliis leaflet was .sent to
every lo<^al Woman's Christian Temperance Union in America
to be studied and thousands of copies have been put into liomos
by our workers. Later I studied fraudulent advertising in vxtn-
nection with proprietary medicines, and as I was ccmipiling a
book for physicians and for our workers entitled "Alcohol a
Dangerous Medicine," I devottxl a whole chapter to "Proprie-
tary Medicines." The book has been warmly commended.
especially this chapter, by many wellknown physicians. It is
being used in a considerable number of unions for study. Not
all members of the Woman's Christian Temperance Union are
in sympathy with the opposition to patent medicines, but the
leaders everywhere are, so the multitude will follow in time.
I shall be glad to furnish a copy of the leaflet to any one who
will send postage for it to 348 Delaware street, Syracuse, N. Y.
Yours respectfully,
(Mrs.) Martha M. Allen.
THE PHYSICIAN'S RESPONSIBILITY TO VENEREAL
PATIENTS.
BY
G. MORGAN MUREN, M.D.,
of Brooklyn, N. Y.
Instructor in Genitourinary Diseases, N. Y. Unlverslty-Belleyue Hos-
pital Mediml College; Uitely Attending Surgeon, Manhattan
Ho.spital, and Adjunct in Genitourinary Diseases,
Polhemus Memorial Clinic, Brooklyn.
So much is bsing written upon the various aspects of the
social evil, the prophylaxis of venereal diseases, etc., that it may
not be amiss to consider our responsibility to venereal patients
and how many of us live up to it.
That the great hospitals of New York City are not properly
caring for these patients is clearly shown in " The Report of
the Committee of Seven of the Medical Society of the County of
New York." ■ The following from this report is much to the
point as regards institutional work :
It would seem a strange perversion of the proper purposes
of charitable institutions that a patient is debarred entrance
into our general hospitals when the disease is acute and a
source of danger to others, but he is readily admitted when
suffering from the remote etfects of the disease which might
have been prevented by prompt treatment. Practically the
hospitals proclaim to this class of patients, " We cannot receive
you when your disease is acute and curable, but when your
gonorrhea has developed into stricture, salpingitis, peritonitis,
or when your syphilis has affected important central organs,
the brain, the spine, the organs of special sense, you may be
received, but your disea.se shall 1)6 baptized under another
name which does not offend the refined susceptibilities ot our
patrons." The com.mittee must censure the attitude of the
governing boards of our hospitals in excluding all mention of
venereal diseases from their reports, as if it were a shame and
a reproach. While it may be true that a respectable syphilis
does not exist, thev give the public the impression that it is
almost as disgraceful to treat syphilis as to contract it.
Are we doing much better for our private patients? It
cannot be expected that the general practitioner will give the
attention to venereal diseases that the specialist does, but it is
certainly fair to demand for this class of eases at least as much
consideration as he gives to others. From the careful question-
ing of a large number of patients (clinical and private) who
have been treated by other physicians I believe the following
to bea fair example of the average gonorrheal patient's first inter-
vie w with his physician. He is q uestioned as to his trouble, how
long he has been affected, period of incubation, pain on urination,
etc., and then he is asked to show his penis. The medical man
glances casually at it and makes no further examination. The
treatment consists usually of some of the balsams internally
and an injection, which frequently is not used " until the acute
inflammation has subsided," the entire time consumed by
the consultation being five or ten minutes. Some of the impor-
tant matters the physician, with a crowded waiting-room, has
forgotten, may be mentioned : Is the disease really gonorrhea,
i. e., are there gonococci present? Is the disease confined to the
anterior urethra? Oris the posterior portion also involved?
Is the prostate gland infetaod ? Is the trouble acute, or is it au
exacerbation of an old condition ?
One of the first <iuestions that all sick people ask, " Wheu
shall I be cured?" is a vital one to the venereal patient, par-
ticularly if he be on the eve of marriage. Shall the physician
tell the gonorrheic that his discharge will be "dried up in a
few weeks," and if it does disappear in that time, shall the
patient bo discharged as cured and allowotl to marry ? These are
' Medical NeWB, December 21, 1901.
926 Ambbioan MKOiotira)
CORKESPONDENCE
[December 13, 1902
very serious questions tliat affect too many innocent people to be
(fiven tlie scant consideration that is frequently accorded them.
Chronic gonorrheal conditions of the posterior urethra, prostate
gland and seminal vesicles may not in many cases be suf-
ficiently active to produce a discharge or any subjective symp-
toms, yet the young wife or unlucky prostitute is readily
infected by the patient. There are few curable diseases, if any,
that are more intractable than gonorrhea, and the man who will
tell a patient he can cure this disease in any specified time
must be either fool or knave. Like many lay fallacies traceable
to the profession, misconceptions regarding gonorrhea are too
common. When we tell the acute gonorrheic that he may be
well in a month or six weeks, but that perhaps he will be many
months under treatment, he usually remembers some friend
who "was cured in a few weeks." Here is a very Important
point: We must tell these patients the truth and the whole
truth regarding their disease. While this is not usually an
advantage to either patient or physician in other diseases, it is
important is this class of cases. The veneral patient' should
be made to understand that he is a center from which may be
spread a very dangerous infection, unless he uses every precau-
tion to protect others as directed l)y his physician.
Thesmall attention given to gonorrhea by some busy prac-
titioners is well illustrated by the following history of a chronic
case now being treated by me. The disease was contracted five
months ago, and the patient treated until six weeks ago by a
prominent man of this city with an unusually large office prac-
tice. The patient is a man of intelligence, and holds an important
commercial position. He has assured me that this physician
looked once at his penis and never again examined him in any
way. The treatment consisted of balsams and injections, and
when the discharge was reduced to a morning drop, the man
was told he could " marry and it would soon disappear."
Microscopic examination showed many gonococci in this drop.
The disease extended to the posterior urethra, and the prostatic
secretion expressed after irrigation also contained gonococci.
The date for this man's marriage had been set, and it was only
after many long discussions of the minutite of his condition
that he was persuaded to postpone the wedding indefinitely.
In syphilis the first question we should ask ourselves is,
" Is this case really syphilis ?" However great a man's expe-
rience, it is quite safe to say that no one can make a positive
diagnosis from the primary sore. The diagnosis can be posi-
tive only when we have some secondary lesions. Of course
many cases occur in which the second stage picture is by no
means complete, but in the great majority of cases the erup-
tion, adenitis, and throat and mouth symptoms will decide the
matter. The physician who tells a patient he has syphilis and
starts him on a two years' course of treatment merely because
he has an indurated sore upon the penis, is little short of crimi-
nal. A mild antiseptic wash or powder, some very positive
advice, and a few weeks waiting will settle the matter and do
no one any harm.
To treat venereal patients properly we must first secure
their complete confidence. In attempting to do this we must
expect to lose a few patients, who will drift to men of fairer, if
not as truthful promises.
INFANTILE DIABETES MELLITUS.
BY
MYRON E. FISHER, M.D.
of Delevan, N.Y.
On May 15, 1900, I was called to see G. K., a child aged 20
months. I found her in violent convulsions with an axillary
temperature of 105.5°. Her condition was such that it was
impossible to administer any medicine other than by the hypo-
dermic needle, and this I did not do. The convulsions were at
first controlled by the warm pack, but the high temperature
continuing, I wrapped her in sheets wrung out of cold water
This was kept up for several hours resulting in a very material
lowering of the temperature. After the convulsions ceased, the
child was m a nearly unconscious state for about 24 hours
when she gradually became conscious. Three or four days
trom the beginning of the attack we discovered that the mouth
AuKusl^fwl'*'"^ '" '^"'""''^^ Patients. Muren, American Physician,
was drawn to the left side and on further examination we dis-
covered that there was a right hemiplegia, the extremities on
that side being totally paralyzpd. In two weeks from the
beginning of the attack, the child had so far recovered as to be
able to sit up, but the paralysis remained. This condition
gradually improved, but very slowly. During the first year the
use of the leg was restored, but the arm improved very little.
On July 21, 1902, the parents brought the child to my office.
She was well nourished, very active, but she used the right arm
very little, although she could grip with fingers quite strongly,
and the mother said she could raise the hand to her mouth. At
this time (.Inly 21) they sought my advice because they had
noticed that for a week or two the child had been passing a
large amount of urine, was very thirsty, had a voracious appe-
tite and was peevish and irritable. They told me that she had
seemed to be quite well this summer, playing and running out-
of-doors, and that she had grown quite rapidly. She was as
large as a child of that age would be expected to be.
I asked for a sample of the urine, requesting that a 24 hour
sample be collected. This was done. The amount voided was
two quarts. The sample furnished me was very pale, almost
odorless, and upon examination I found a trace of albumin and
a very large quantity of sugar. The specific gravity I did not
take because I had broken my urine glass and was unable to
do so. I told the parents of the result of my inve.^'tigations,
giving an unfavorable prognosis. I however advised them to
diet the child, eliminating starches and sugars. A few days later
I examined another sampleof the urine, finding no diminution
in the amount of sugar. The child began to decline rapidly
from this time. She had attacks of dyspnea, which grew
gradually worse. She lost flesh. I was called to see her July
29, and found her suffering from a severe attack of dyspnea and
learned that she had lost considerable flesh since July 21. I did
not see her again until August 9, when I was called and found
her very much emaciated and suft'ering from severe dyspnea.
While I was with her she relapsed into a comatose state from
which she partially rallied in a few hours, only to become coma-
tose again ; from this condition she never rallied, but died about
eight hours later. I asked the privilege of making an autopsy,
but was refused.
During the two years which elapsed between the first attack
of convulsions and her death, she had several slight con-
vulsions. She was very nervous and often extremely irritable.
She was mentally bright and learned quickly.
I report this case because of the fact that diabetes mellitus
occurs rarely in one so young. As to its cause, I have no sug-
gestion to offer, unless it be that in this case it was a neurosis.
"THE SOUTHERN PHYSICIAN AND HIS COLORED
PATIENTS."
BY
FRANCIS B. HAYS,
of Atlanta, Ga.
Editor of The Southern Drug Journal.
To the Editor of American Medicine : — Dr. Boland's letter
in your issue of November 15 prompts me to report a specific
instance in support of his general assertion that the white physi-
cians of the South are kind and considerate in their dealings
with colored patients.
During our great grip epidemic of 1889 or 1890, my brother,
the late Dr. J. M. Hays, was practising medicine at Oxford,
N. C, in which town I had a drug store. Every member of a
colored family near town was down with the disease at once.
My brother, although much " rushed " at the time, nursed and
prescribed for them, and I supplied the medicines, which he
delivered on his rounds. Neither of us expected ever to receive
one cent for onr pains, and in this we were not disappointed.
When paterfamilias, who was a day laborer, got on his feet
again, I asked him to do some work for me, but while he was
fruitful in promises, after the manner of his kind, the promises
never materialized. No doubt every physician and druggist in
the various " black belts " of the South can relate hundreds of
similar experiences, and yet they keep right on doing the same
thing over and over again without feeling that they are being
badly treated or are deserving of any especial credit for their
actions. Those who do not know the negro judge him by the
same standard that they have set up to judge their neighbors
by, while we in the South have two separate and distinct
standards. The negro expects the white man to take care of
him " when it comes to the pinch," and consequently obliga-
tion rests lightly upon his shoulders.
December 13, 1902]
CAUSES OF EPII.EPSY IN THE YOUNG
'American Medicine 927
ORIGINAL ARTICLES
CAUSES OF EPILEPSY IN THE YOUNG.'
BY
A. JACOBI, M.D., LL.D..
of New York City.
The two series of the Index Catalog of the Surgeon-
General's library contain 125 columns filled inclose print
with the titles of books, pamphlets and magazine articles
on epilepsy. In the presence of such a mountain of
erudition, I felt I could do no bettfer than to refer the
anxious litterateur to those wonderful volumes, the
pride and honor of American medicine, and confine the
few minutes at my disposal to the elaboration, in as few
and as plain words as possible, of some personal expe-
riences, beliefs, and criticisms connected with the causes
of epilepsy in the young. I take it that meetings like
these should add to the learning collected in libraries
the inspiration of personal intercourse.
The predisposition to epilepsy may be inherited, or
acquired during intrauterine, or during extrauterine life.
Intoxications of the parents by morphin, lead, or alcohol,
their infttction with syphilis or tuberculosis, their constitu-
tional anemia, gout, or diabetes, or a local degeneration
of either testes or ovaries may not cause in the offspring
the identical disease or anomaly, but only a general debil-
ity of the tissues or their innervation. A variety of
causes may have the same result, and a variety of results
may follow an identical cause. Quite often the unexpected
is the rule, and a general neuropathy is more frequently
observed than a direct inheritance. Still, epilepsy
appears to be more directly inherited than any other
cerebral disorder. In Echeverria's 533 cases, 29.72^
showed a direct inheritance from an epileptic parent ;
Gowers has a percentage of 85 ; according to Spratling,
66^ of the epileptic children have epileptic parents.
Whether, and to what extent, ma'rimony between rela-
tives contributes to mental disea.se or degeneration is by
no means proved. From theoretical reasoning, from
personal experience, and from the incompetence of
statistics, which are amenable to a contradictory variety
of conclusions when handled by different reviewers
with different horizons and standpoints, I cannot atlmit
that two healthy persons, be they ever so closely related,
must, for the reason of consanguinity, have a diseased
child. Hut to what extent the state of the future will
interfere with the marriages of insane or epileptic
people, as also with those of carcinomatous or thor-
oughly tuberculous, remains to be seen. I can imagine
and believe that the offspring of the intellectually and
morally healthy couple will — other things being equal
and barring the accidents of pregnancy and birth-
serve the improvement of the race, while that of the
abnormal must impair it. From that point of view we
should look forward with hopeful exptfctations to a little
more paternalism in our government. There is no
country in the world in which a monarchy is less prob-
able, and the government of, for and by the people is more
certain t^) come than in ours ; for there is none in which
the organization of aipital and the organization of labor
are making such rapid strides toward a peaceful evolu-
tion of socialism as in ours. That is why the younger
men among us will live to see the time in which the
sanitation of the country and people, guide<l by the
legislative influence of the medical profession, will
render im[)ossible the perpetuation of deteriorating or
hmthsome diseases.
It is probably impoHsible ever to siscertain the exact
number of infant or young epileptics. Neither public
institutions nor specialists are in a iX)sition to gather
exact statistics. Very few are a« favorably situated as
Gowers, Binswanger, and others. Institutions are filled
' Kpad Iwfore the National AMOClatlon for the Study of KpllepRy,
November 5, 1902.
with patients in advanced years, specialists see them
mostly in the same way. Many an epileptic infant or
child dies before being observed or treated, or even diag-
nosticated ; for a great many cases of petit mal, vertigo,
dreamlike states and somnambulism, fainting, even
hysteric spells, are overlooked. They are neglected or
cared, for at home, and the seizure is taken to be an
eclamptic attack. An example of the kind is now in my
hospital ward ; a child with nephritis after scarlatina
which ran its course four months ago. While practically
in convalescence he was taken with an "eclamptic"
attack a few days ago. As there was a daily renal secre-
tion of from 500 cc. to 600 cc, a percentage of more than 2
of urea, and no indiscretion in his diet, the diagnosis of
a ursemic intoxication was out of the question. That
obliged us to inquire into his past, with the result of our
learning the history of several unprovoked convulsions
of epileptic character in the course of the last 18 months.
It is the general practitioner who sees the cases and is
able to j udge of them according to their merits. He does
not record them, but has more facilities to see them than
even a public dispensary. Many of these patients are
discovered in dispensaries and college clinics only after
a number of attacks have occurred and succeeded in
rousing the suspicions of the parents. With all these
drawbacks, however, I am certain that I have seen many
hundreds of such cases in the course of many years.
The actual or the proximate caxise of generalized epi-
lepsy is in the cerebral cortex ; its origin in anatomic
lesions of different localities. Thus, epilepsy may be
cerebral, it may be the result of persistently abnormal
circulation, or it may be of a reflex nature. All sorts of
cerebral tumors, solid or cystic ; the results of previous
encephalitis and meningitis, from insolation, otitis,
nasal infection, or otherwise ; disseminated sclerosis of
different territories ; " vasculitis " of the pia mater ; the
results of hsematomata or of thromboses ; arrests of cere-
bral development or heterotopy of gray substance ; pre-
mature ossification of one, some, or all of the cranial
sutures and fontanelles ; even the narrowness of the
occipital foramen ; cerebral exhaustion from masturba-
tion or premature venery, or local anaemia of known or
unknown origin ; diseases of the heart with secondary
venous obstruction ; congestion from other causes (in a
case of Gerhardt's, enlargement of the thyroid) ; the
influence of prolonged use of alcohol or ergot ; the
sluggish brain circulation attending constipation and the
general toxajmia of intestinal autoinfection ; external
irritations, such as peripheral tumors, cicatrices, foreign
bodies, and the reflex excitement produced by carious
teeth, Schneiderian hypertrophy, and nasal and naso-
pharyngeal growths ; vesical and renal calculi ; hel-
minthes, from ttenia to oxyuris ; in older children
delayed menstruation, are so many different causes of
epilepsy. It is, therefore, only the most painstaking
examination of all the organs and the whole surface of
the body which gives a promise of fintling the cause of
the disease as well as the indications for rational causal
treatment.
JacfcKonian epilepxy aft'ects a localized group of
muscles, and always the same ; the spasm is mostly
(clonic and painless, and when it becomes generalized the
attack begins in the same order. It is frequently, per-
haps mostly, the result of a coarse lesion, a detached
bone, a tumor, an abscess, a localiztid pat<!h of meningitis,
a hematoma, a cyst, a cicatrix, or a foreign body which
by irritation sets up a series of epileptic convulsions. A
(brachial) Jacksonian epilepsy was cured by the removal
of a foreign body from the ear by Monflier. But this
relation between a Jacksonian epilepsy and a local dis-
order cannot always be proven!. Exceptions are very
numerous; only lately Z. Bregman and N. Odefeld'
came to the conclusion that " a tumor occupying a large
part of the surface of the frontal lobe may look like a
lesion of the central convolution. A persistent paralysis
of monoplegic character and suggesting localization \n
928 AmtBIOAN Mboioihb}
CAUSES OF EPILEPSY IN THE YOUNG
IDECICMBEK 1», 1902
the cortex with syinptoirw of Jacksonlan epilepsy need
not prove a Iftsion of the motor zoue. Finally, there may
he an extensive lesion of the frontal lobe without corre-
sponding symptoms." I may add from my own experi-
ence that many a case of Jaeksonian epilepsy, when
examined postmortem, exhibited no tangible cause.
That is also why many an operation undertaken for
relief was futile.
Intrauterine influences, both inflammations and
intoxications, are certainly powerful as occasional causes
of epilepsy. Hereditary syphUis is considered a frequent
cause of epilepsy, botli Jaeksonian and universal. The
former results from the localization of an organic disease
of the brain, either meningitis, or encephalitis, or soften-
ing, or gummatous infiltration. In accordance with
their extent or localization there are symptoms of either
paralysis or irritation. When epilepsy is universal or
genuine, no such localization or local symptoms are met
with. These ca-ses show the fate of all those which per-
mit of nothing but the assumption of an unrecognized
cortical alteration. When children of five or seven years
are suddenly attacked with epilepsy, syphilis should be
suspected. These children are generally undersized and
puny, such as Fournier has pictured as parasyphilitic.
I have often seen and discussed them from that point of
view, but must confess that though in the majority no
serious nervous disorder seemed to mark their appearance,
in many, however, though no history of syphilis of the
parents could be elicited, visceral lasions were found in
autopsies. Nor are other nervous diseases of early
age exempt from .syphilis. In hydrocephalus it is
frequent, in polioencephalitis rare. In 20' • cases of this
form of paralysis, Sachs found only 2 that were
attributable to hereditary syphilis. From a similar
point of view mostly, the whole subject is thoroughly
treated in a classical book on " Syphilis and the Nervous
System," by Max Nonne, Berlin, 1902.
The conclusion should be that there are not many
cases of epilepsy that can be directly attributed to
.syphilis. But a great many epileptics exhibit symptoms
that make them very suspicious. Such are early
imbecility or idiocy, glandular swellings, chronic perios-
titis, and anomalous teeth. Not infrequently I found in
a family several cases, one case of epilepsy and others of
different cerebral disorders. It appears, therefore, that
the syphilitic virus, more or less modified, acts on the
germ from the beginning of embryonal life with differ-
ent results.
In this respect it resembles other influences which
control the predisposition to epilepsy, gout, diabetes,
hysteria, or insanity, which are prevalent in a family in
one of the two preceding generations.
Many intrauterine influences exhibit themselves
iuamediately or soon after birth. Among them I may
be permitted to speak of hypertrophy of the brain, pre-
mature ossification of the cranium, and spurious men-
ingocele.
Genuine hypertrophy of the brain is not frequent, but I
have seen it once with epilepsy that began when the
child was a year old and persisted until the autopsy was
made three years later. The cranium was of normal
tiiickness; 20 teeth had protruded. The dura mater
was tightly adherent to the cranium, pale and tense.
When it was inci.sed the solid cerebral substance bulged
through the incision. The brain surface was pale and
flattened and the cortex of fair diameter ; the white sub-
stance pale, hard, massive ; the ventricles small with no
.serum. As early as 1806* and 1828'Laennec reported
tliat in several cases diagnosticated by him as hydro-
cephalus he found no.serum, but the flattened convolutions
of a pale, compressed,, elastic brain. Hufeland (1824)
admitted to have made the same mistake. It was he
who first dascribed the bulging of the elastic brain
through the incision of the dura mater. His cases of
this real cerebral hypertrophy— that is, a large brain
within a normal skull — and those of other older writers
are referred to in E. Noeggerath and A. Jacobi's " Contri-
butions to Midwifery and Diseases of Women and Chil-
dren," New York, 1859, p. 84. Altogether, however,
these cases of abnormal hypertrophy of the tchite sub-
stance appear to be rare ; they should be carefully dis-
tinguishai from the large brains of Byron, Cuvier,
Turgenieff, and Cromwell , that were symmetrically large.
I think I am prepared to say that the epilepsy in my
case resulted from the hypertrophy of the white sub-
stance and the compression of the cortex. There was no
other tangible hypertrophy. Possibly it was the latter
alone that caused it, for hypoplasia of the cortex is
reported as the condition of a young man who died in an
epileptic attack, by Ziegler in the second volume of his
"Pathological Anatomy."
Hypertrophy of the brain, that is an abnormal and
abnormally large brain enclosed in a normal skull, must
be distinguished from premature ossification of the
fontanelles and sutures. In this interesting condition we
have to deal with an originally normal brain tightly
enclosed in an abnormal cranium. In the book I quoted
and in the Journal of Medicine of 18.57 I wrote " on the
etiological and prognostic importance of the premature
closure of the fontanelles and sutures of the infantile
cranium." The observations of this anomaly were at
that time only few. Extensive studies of the subject
had been made by Virchow, Huschke, and Lucae.
Hyrtl was the first to show that pathologic forms of
the skull might depend on the premature closure of single
sutures. Cruveilhier, Baillarger, and Schiitzenberger
reported cases. Gratiolet studied (1856) the direct
relation of cranial ossification in different races with their
intellectual development and found, for instance, that the
coronal suture closes earlier in the negro than in the
white, and that the receding forehead and bulging
occiput of the former depends on this precocity of bone
ossification. I approached the question from a noso-
logical point of view. A few Of the conclusions at which
I arrived, and which are still justified, are as follows:
A brain, in order to arrive at its normal development,
must have space. The normal closure, not genuine
ossification yet of the sutures and large fontanelle, takes
place about the fifteenth month of life. After that time
the growth of the brain, which, however, does not
entirely terminate before the sixtieth year, becomes very :
slow. When ossification is premature, the brain when ■■
normal cannot grow, is compressed in its entirety. When
synostosis is uniform the shape of the head is nearly
spherical, when it is local the corresponding part of the
skull and brain is rather flattened while the opposite is
bulging. In this way the asymmetry of the skulls of
many epileptics as described by Kiecken and by Miiller*
is easily explained. When the cranium is sunk in in
one or more places, for instance on and above the two
temporo-parietal regions, the case cannot be one of
premature ossification over an originally normal brain , but
is one of genuine microcephalus depending on an
arrest of development. The suggestion of craniotomy or
craniectomy in a case of real premature ossification may
still be justified, the fatality or uselessness of such ojiera-
tions notwithstanding. I have not changed my convic-
tion on that subject expressed in my Roman address
" non nocere " of 1894. Their performance by enterpris-
ing operators in cases of undiagnosticated or mistaken
microcephalia — no matter whether the fontanelle is large
or small, or the bone is thin or firm — is no longer a medi-
cal question. Where nature made a mistake the doctor
must not believe he can correct it by a crime.
The diagnosis is not difiBcult. When the case is one
of ossification at birth it is only the exaggeration of
what may be observed to develop slowly after birth. In
these cases the cranial bones harden, the fontanelle
decreases in size instead of its normal enlargement up to
the eighth month. They may close at the third, sixth,
tenth month. All the connective tissues of the cranium
develop at the same rate. Many such infants begin to'
^^
Dbcbmbkr 13, 1H02]
CAUSES OF EPILEPSY IN THE YOUNG
[AlCEKICAN MKDICINB 929
use their limbs early. The teeth appear early and not,
as in occasional cases of rhachitis, in long intervals, but
in rapid succession. The first teeth to appear are not,
as in the healthy, the lower incisors, but the upper.
These symptoms, together with the shape of the head
as described before, justify your diagnosis. After a
while the general development is disturbed by the
increasing pressure, or irritation, by the interference
with intracranial circulation, and by the additional
danger caused thereby to every occurrence of a slight or
serious ailment. During such a complication the first
convulsion may talce place. Often it occurs without
any premonitory symptom, and will return in irregular
intervals. Cases in which epilepsy of later years is due
extensively to the compression of an originally normal
brain in an abnormally compact and uniformly con-
tracted skull I have seen. But more are due to or con-
nected with a premature partial synostosis. There are
but few normal heads and brains in the well absolutely
symmetrical ; but it is the fate of a great many epilep-
tics to have a comparatively small cranial circumference
and an absolutely asymmetrical shape.
Savage nations * have made observations which show
their fear of such an occurrence. The Makalaka of South
Africa are always anxious to look for the location of the
first teeth, whether in the upper or lower jaw. In
Bohemia it is a popular belief that the child whose
upper incisors come first will soon die. David Living-
stone and Fritzsch report that some nations in Central
Africa kill the infants whose upper incisors protrude
ijefore the lower ones.
Meningocele spuria means a fissure of the cranium and
of the tightly adherent dura mater under an intact scalp.
It Ls the result of a forceps operation, of a fall or some
other trauma, of caries, or of syphilis. When the fissure
is superficial it need not interfere with the development
of the brain, for there is not even a permanent loss of
cerebrospinal liquor, but when it is injured down to a
lateral ventricle it results in porencephalia. Rhachitis of
the cranial bones, and the interposition of brain substance
between the fissured bones prevents spontaneous recov-
ery. A practical recovery without operation may take
place by the interposition of the membranes and of some
periosteum. This spontaneous process may proceed
kindly, but irritation of the compressed parts may cause
meningitis and epilepsy. I made the autopsy, 20 years
ago, of a child 5 years old.
I had seen her once when she was a few months old, with
-purious meningocele attributed to a forceps operation. When
she was about a year old she had a violent convulsion preceded
I ly numerous spells of petit mal. Before she died these were
numberless; severe epileptic seizures there were no more
than half a dozen all told. She had a moderate amount of liquor
in the lateral ventricles and some oedema and thickening ot the
I'horoid plexus. Round the fissure of the right parietal bone,
which wa.s closed by interposed cicatricial and hard tissue,
there was inside a pale, hard pachymeningitis, the alteration
extending over .3 cm. in every direction, and a thickened pia,
pale near the origin of the affection, bypereemic with large
veins to a distance of 10 cm. or 12 cm.
It appears that with the possibility of its resulting in
<l)ilepsy even a spurious meningocele should not be left
alone. A recent case demands the raising of the
(Ictpressed bone and either bone or periosteum suture.
< )lder cases, if pronounced inoperable, should be pro-
tracted by a pad ; iodine injections have proved successful ;
dropsical lateral ventricles may be drained.
In the foregoing remarks I have directed your atten-
tion to the unpromising results of intrauterine influences.
Ivet me turn U) another suiyect, in order to show that
there are other powerful influences for bad, the results of
which may be more frecjuently prevented than cured.
A frequ(!nt cause of epilepsy is asphyxia of the newly
born, frequently the first born — no matter from what
cause: moderate or st^rious compression of the fetal head,
compression or prolapse of the cord, intrauterine respira-
tion and aspiration of liquor amnii or meconium,
Iilrt'Kintiir detwiiment, morphine or chloral poisoning by
the maternal blood, malformations of intrathoracic or
intracranial organs, etc. The anatomical results in the
cranium are excessive hypersemia, tense veins, sanguine-
ous effusion, extravasation, and thrombosis. When the
baby lives at all, a meningitis or meningoencephalitis
may follow, and paralysis in many cases ; in many more,
idiocy or epilepsy or both are the final results. In one-
third part of the cases of idiocy there is a combination
with epilepsy. In a long life I could trace the cause of the
two latter to asphyxia in hundreds of cases. Without any
suggestions, my question, Did the baby cry when born, or
did the baby live when born ? is answered that it did not ;
that the doctor worked over the baby minutes or quarter
hours before it was resuscitated, and that the baby never
was like other infants, never smiled at the usual time,
took little or no notice, and had general convulsions, some-
times beginning on one side, quite often. Hundreds of
such cases I had opportunities to present at my clinics ;
never without the warning to my classes that the para-
mount duty of the practitioner is to shorten asphyxia,
and that there is nothing connected with the manage-
ment of a case of labor so vital as the prevention or
shortening of asphyxia, the attendance upon the mother,
though ever so urgently demanded, not excepted.
A single moment more or less of the asphyxied condition
may decide the future of the newly born, and the
presence or absence of a paralytic, idiotic, or epileptic
misfit in human society.
The same danger accompanies intracranial hemor-
rhages not connected with asphyxia of the newly born.
They are very frequent. The majority of babies who die
in their first week succumb from that cause. The
proximate cause may be found in disturbance of the
circulation or in a trauma, but the disposition results
from the incomplete embryonal structure of the blood-
vessel walls. This disposition to extravasation is as
great in the newly born as it is, for other reasons, in the
senile condition of the arteries, very rarely the veins, of
advanced age. The danger to life is increa.sed in the
former by the lack of coagulability of the fetal and infant
blood which causes the extravasation to be very copious
indeed. When it is not excessive, it may not destroy
life — the more is the pity — but the clot and the second-
ary inflammation and degeneration, and now and then
the final development of a cyst of the dura mater, will
cause hemiplegia, paralysis, idiocy, epilepsy. Many are
the instances in which I could find what pointed unmis-
takably to the connection of the hemorrhage with the
subsequent life-long disturbance.
The frequency of co«rM&»o»w in infancy and childhood
is another danger. Those of the first six weeks or two
months of life are of cerebral origin ; that is the period
in which clinical experience and Soltmann's experiments
teach us that reflexes are absent or feeble. After thai
time convulsions are either reflex or toxic. No matter,
however, how they are produced, every convulsion is a
danger to the brain by the possibility of bloodvessel
rupture. Small or large extravasations may occur in
every convulsion, no matter from what cause, and
endanger life, or mind, or health. The location or the
size of the hemorrhage and the dignity of the affected
part are of the greatest import. The danger is not so
great when the fontanelles and sutures are not yet closed,
and the expansible bloodvessels may be able to harbor a
larger amount of blood without being torn in their
weakest capillary terminations ; a fully or a prema-
turely ossified cranium furnishes a greater disposition to
hemorrhage. All this may happen, no matter what caused
the convulsion — intestinal irritation by undigested foo<l
or helminthes, acute intoximtion by alcohol, cocci or
bacilli or their toxins, in scarlatina, typhoid or influ-
enza, urajmia, inanition, whoopingcough or laryngismus.
Two cases of epilepsy I remember distinctly that were
caused by the convulsions of whoopingcough. Another
was due to an ajwplexy in an adult. The unfortunate
young man suffered from unmanaged constipation. 1
930 AxxBioAir Hbdicine]
CAUSES OF EPILEPSY IN THE YOUNG
[Decembek 18, 1902
was called 40 odd years ago to see him in a fit of wliat
wa« called a fainting spell. I found him on the water
closet with an apoplectic attack that soon terminated in
hemiplegia of the right side. A year afterward he had
his first attack of epilepsy, which was followed Ijy a
great many more until he died, long after from what,
according to the report of the case, appeared to be a
second attack of cerebral hemorrhage. Cases of cerebral
hemorrhage occasioned by a convulsion in a child can
be treated, but rarely cured; but many may be pre-
vented by the speediest possible interference with the
attack. No case of eclamptic convulsion should be left
alone. It requires chloroform, no matter what other
indications present themselves. Shortening of a con-
vulsion from any source, cerebral or reflected, by a single
half minute, may just be in time to prevent a hemor-
rhage and subsequent death, or what is worse, paralysis,
spastic encephalitis, idiocy, or epilepsy.
The causes of convulsions in infancy and early child-
hood are so numerous and their dangers so many that
it may be worth our while to spend a few minutes in
the consideration of at least a few of them, with the
object of facilitating an early diagnosis and the possi-
bility of immediate and correct treatment. They are so
many, some of them not generally appreciated, that it
will pay us to eliminate one at least that is credited with
more mischief than it is guilty of. I mean dentition.
William Philip Spratling* expresses himself as fol-
lows : " Next to heredity, it is my firm conviction that
dentition, when severe, and when acting on an organism
that bears the impress of transmitted weaknesses, plays the
most important role in causing epilepsy in early life.
Indeed, I fully believe that the importance of teething
in this respect has not been accorded the careful atten-
tion it deser%'es." Dr. Spratling fortifies his position by
quotations from Gowers and from replies received to a
circular inquiry. From among the latter he prints
quotations taken from letters written by me. Dr. G.
Elder Blumer, Graeme M. Hammond, Frederick Peter-
son, and T. S. Clouston, of Edinburgh. From Gowers
the following words are quoted: "Of all the cases that
commence in infancy, at lea-st three-quarters date from
infantile convulsions ascribed to teething." I wish you
to note that the words are "ascribed to teething," not
due to teething. I have no doubt he meant to say
" ascribed to teething by the men who sent me the cases
and their histories." Gowers' says, literally: "The
influence of the process of the eruption of the teeth is rele-
gated to its proper place, as merely a possible excitant
in a few cases." From my letter Dr. Spratling quotes
as follows: "Every convulsion, ever so slight or short,
may produce cerebral hemorrhage, with all the possible
results— epilepsy, idiocy, paralysis, and insanity. Such
cases are, unfortunately, frequent." You will notice
that teething is not mentioned by me. I certainly did
not believe, nor did I mean to infer, that the convulsions
spoken of were due to dentition. Dr. Blumer expresses
his belief that "there is no such thing as a convulsion
due to dentition pure and simple and uncomplicated."
Dr. Spratling himself emphasizes the requirement of the
" impress of transmitted weaknesses " that one must go
back of the dentition and regard the disturbance of this
process as the " mere existing cause of the explosion."
Dr. Hammond has " records of several cases in which
convulsions, due to dentition, were followed by true
epileptic convulsions." Dr. Peterson "can recall a
number of cases of epilepsy due to the convulsions of
dentition." Dr. Clouston is more positive than any of
the three mentioned correspondents. He asserts that
he has "seen the convulsions of dentition followed by
prolonged delirium ending in idiocy, or in true epilepsy,
or insanity of adolescents." I again state that the con-
vulsions giving rise to such cases of epilepsy are called
by the last named three authorities " convulsions due
to dentition." Neither Dr. Blumer nor myself go that
far. I speak of convulsions only, no matter from what
cause, and am, therefore, quite prepared to accept what
I think I always knew and proclaimed today, and what
Dr. Spratling expresses in a concluding remark, " that
the spasms and convulsions of infancy are serious mani-
festations, and if allowed to go unchecked, may lead to
explosions of genuine epilepsy, and later on to insanity."
Now what is dentition, and what its period?
It begins during uterogestation. The dental sacs of
the 20 milk teeth undergo ossification in the fifth month
of pregnancy. Behind them are the sacs for the perma-
nent teeth. Their separation from the former is not
completed until the fetus is born. Before and after
birth there is a constant growth, the cartilage of the wall
of the dental cavity and of the gums disappears grad-
ually. The two lower incisors make their appearance
between the seventh and eighth months, the upper
incisors between the eighth and tenth months, six more
teeth between the twelfth and fifteenth months, four
bicuspids between the eighteenth and twenty-fourth
months, the four second molars between the twentieth
and thirtieth months. The second visible dentition
begins about the fifth or sixth year. In the twelfth year
four molars make their appearance, the last of the
whole set, with the exception of the wisdom teeth,
which protrude between the sixteenth and twenty-fourth
year.
Thus the period of dentition begins about the middle
of intrauterine life, and ends visibly first with the thir-
tieth month, and secondly with the twelfth year. It is
principally the first which is charged with causing or
being attended by convulsions.
Convulsions occur almost universally between birth
and the thirtieth month ; this happens to be the period
of dentition. But it is also the period of defective inhibi-
tion, of nephritis, otitis, pneumonia, enteritis, and infectious
and cerebral diseases. All of these are fruitful causes of
convulsions ; dentition goes on during that period, like
the growth of bones and hair and nails, but it is not this
physiologic process, but those morbid, mostly acute
changes, that disturb the nerve equilibrium.
In regard to convulsions, infancy may be divided into
two periods. One comprises the first two months.
During that time reflex action is insufficiently devel-
oped. That is why convulsions at that time are almost
always, perhaps always, of cerebral origin, and caused
by hemorrhages, etc. The other begins with the third
or fourth month. About and long after that time
inhibition is insuflSciently developed ; that is why —
while convulsions of cerebral origin are not excluded,
the large Tnajority are of a reflex nature. The slightest
irritation of the digestive organs, of the integuments, or
the organs of circulation give rise to spasmodic muscular
action which meets with no control on account of the
absence of nerve inhibition. The difficulty of a correct
local diagnosis tempts the attention in the direction of
the known process of dentition. That is why the early
periods of popular and of professional medicine— identical
in so many centuries — and why the early period of a
practitioner's life, filled as it is with the lack of circum-
spect experience — are replete with the diagnoses of dif-
ficult dentition, or the legend of the dangers of normal
dentition, which, after all, is a physiologic process.
During the first year or two years of life — that means
during that period of physiologic dentition which is
most generally noticed by even the superficial observer,
remarkable changes take place. The heart of the newly
born and the young infant is comparatively muscular
and vigorous, the carotid (and also the vertebral) arteries
large, the blood supply to the head is ampler than at
any other part of its life. The rapid growth of the head
and brain connected therewith, or rather depending
thereon, is a wellknown fact. The salivary glands
develop rapidly, their and the mucous membrane's over-
secretion begins with the third month and is not the
result of, but coordinate with, the later appearance of
the teeth. The rapid growth of the cortex and of the
Dbcbmber 13, 1902]
CAUSES OF EPILEPSY IN THE YOUNG
•AKKSICAN HKDICINK 031
anterior lobes, greater in proportion than that of the rest,
explains the rapid increase of the infant intellect and the
motor function. Physiologic hyperfemia is very apt to
become pathologic on slight provocations, the more so
as the embryonal character of the brain tissue changes
only gradually in the course of a few years. These are
no new facts. Even in a book on " Dentition and Its
Derangements," New York, 1862, I could utilize a great
many anatomical data, conflrmed and added to since,
when trying to find for dentition its exact place in
etiology. My conclusions of 40 years ago I can still
repeat. There is a certain amount of itching, even
pruritus of the gums ; there is a vasomotor disturbance in
the shape of one or two flushed cheeks ; now and then a
slight muscular twitching ; now and then a rolling of the
eye caused by the incompetence of the muscles of accom-
modation met with in every infant to such an extent that
strabismus is common in healthy babies ; but when I said
in 1887 ' that I never in 10 years saw a convulsion due
to dentition alone I here repeat the statement as valid
for additional 1.5 years. Nor is diarrhoea a symptom
of dentition, for infants either at a healthy breast or on
well-selecte<l artificial food have no diarrhoea. Do you
wish another instance of the complete disappearance of
dentition from the etiological horizon ? When all of us
were 60 years younger did we not hear of "dental"
paralysis ? Nowadays we do not even permit the term
of " essential " or " infantile " paralysis. Poliomyelitis
does not fall back upon dentition as a cause. And what
is correct in the case of paralysis is so in convulsion.
When a convulsion, the first appearance of, or rather the
cause of consecutive epilepsy or idiocy, is attributed to
dentition, the history of the case as submitted to us is
incomplete, or our own diagnosis is at fault.
The high estimation in which dentition was held
formerly has assumed smaller proportions, even among
the maternal public. They do not insist any more as
they did when you and I were 40 or 50 years younger
upon having the baby's gums lanced over the conspiring
poor little teeth, just as little as they are clamorous any
more for worm medicines for their pets to the former
extent. The doctors who know how to make a diagnosis of
a bronchitis, pneumonia, nephritis, otitis, or a toxic infec-
tion are getting too numerous, and the diagnostic atmos-
phere is gradually becoming purified.
Still, it is claimed that it is difficult to arrive at a
diagnosis of the occult diseases of infancy. If the diffi-
culty is, or were, actual, there is a remedy. See to it
that the clinical advantages of our medical schools be so
numerous and so perfected that no young or old doctor
is in a position to accumulate more ignorance than
knowledge. Convulsions in the young are of frequent
occurrence in every practitioner's rounds. To treat it is
something ; to prevent it is better. This very day the
number of infectious diseases, with their high temper-
atures and their toxins ; the many intestinal disorders,
with their nerve reflexes, are still all-powerful. There
are still some meningeal atfections that are not always
fatal, but highly dangerous in their results. All this is
well understood. But there is a class of diseases which
lead as often to convulsions as any other ; that is
nephritis. I (jannot help emphasizing the fact that it is
common in the newly born and the very young infant;
that infarctions and jaundice are a frequent cause ;
enteritis, with its indican and its toxins engenders
legions of cases ; coal-tar medication is a fre(iuent source
of evil ; exposure causes some ; infectious disea.ses, from
mild varicella U) influenza or diphtheria or scarlatina, a
great many. As the diagnosis is easy to make, requir-
ing the examination of readily attainable urine only, I
admit that the failure to arrive at a diagnosis is a
constant source of surprise to me. Convulsions from
that source are very fre<iuent, and the vast majority of
them, with their poasible dreadful consequences, could be
avoided. Many a case attributed to dentition could
• •asily he rwognlzed as nephritic.
Among the important constitutional diseases that
have a great tendency to convulsions is rhachitis, not, as
Gowers says, on account of the late general development
caused by it, but for other reasons. His own words are
as follows : " It is impossible to doubt that the dentition
convulsions are a definite element in the causes of epi-
lepsy. So constant, moreover, is their association with
the defective development which we call rickets that it
is impossible to doubt that the prevention of rickets
would have a considerable influence in the prevention
of epilepsy." In the further course of his remarks he
defines as defective development mainly its retardation
of the growth of the bones, emphasizing much less its
influence on muscles, lymphatics and the large viscera.
The retardation of development hurts mostly ^ne
and tooth formation. But nobody ever claimed that
when a tooth is formed and protrudes late, it is for that
reason a source of irritation and convulsion. The minor
or major attacks of convulsions in rhachitis are always of
central origin. They always mean the hyperajmia or
oedema accompanying the rhachitical softening of the
cranial bones. When rhachitis is limited to the curva-
tures of the extremities, or the development of a rosary
or Harrison's groove, with ever so much deformity,
compression of lungs, annoyance of the heart, and dis-
lodgment of the liver and spleen, there is no convulsion.
It occurs in craniotabes which, after a period of restless,
cephalic perspiration and occipital baldness, begins with
the third or fifth month of life. It is attended by
hyperajmia and oedema of the galea, skull, dura and pia
mater and brain, not infrequently with efl"usion into the
ventricles. These central changes cause many cases of
tetany, almost every one of laryngismus stridulus and a
great many of the attacks of convulsions. Once started
they return at uncertain times, and generally disappear
with the recf)very from rhachitis, produced by projjer food
and hygiene, fresh air and phosphorus. As long as they
last they share the dangers of every attack of eclampsia,
viz., oedema, thrombosis, hemorrhage. Not infrequently
they last longer than the rhachitis that caused it. I do
not care to speak of a convulsive habit and to explain the
subsequent epilepsy by this habit ; that would be no
explanation but another word only for the fact. The
real explanation is afforded by the objective changes in
the structure of the intracranial contents caused by the
convulsive interference with the circulation of large and
small vessels.
The local irritation of phimosw, congenital or
acquired, complicated or not with balanitis, resulting
from the changes of smegma or retained urine, may
cause erection, sexual excitement and minslurbation
in the youngest infants. Headaches have often been
attributed to it, perhaps only on account of interrupted
sleep ; permanent nervous disturbances have been
ascribed to it 30, 20 or 10 years ago more often than
at present. Indeed, a London neurologist has gone so
far as to make the statement that in 25 casesof epilepsy he
found congenital phimosis 1 1 times. In the same way the
nosology of some colleagues of our own country at one
time explained spastic hemiplegia, polioencephalitis and
myelitis, chorea, catalepsy, epilepsy, contractures, also
idiocy by the presence of phimosis. Would it could have
been true ; for indeed if it had there would have l)een
less paralyses, less epilepsies, less idiocies. In 29 of 30
cases of phimosis condemned to be operated upon I find
gentle manipulation sufficient for a re<luction of the
usually slight ailment. I can say, however, that I
never in my life saw such a «vse that I could ascribe to
phimosis, anfl never a recovery from paralysis, idioey,
or epilepsy, due to circumcision.
I have mentioned |>himosis as one of the causes of mas-
turbation, which has frequently been connected with epi-
lepsy and other derangements of the nervous system.
Masturbation was always rettognized as a frequent occur-
rence in the periods of puberty and adolescence, but very
rarely before 1875 in infants and children. Like its pre-
932 Ahkkzcan MbdicineI
INTESTINAL OBSTKUCTION
IDkcember 13, IWr.'
cursor, the persistentsucking of fingers, itis oftenaseini-
conscious tuition, more frequent in girls in earliest infancy,
in boys later. Among its causes are manual irritation by
nurses, or misfit trousers, featiierbeds, excess of animal
foods and stimulating beverages, rancid smegma under
a long or narrow prepuce, eruptions on the penis, prepu-
tial adhesions, phimosis, vaginal and vesical catarrh, or
vesical or renal calculi, oxyuris, constipation, horseback
or bicycle riding. Unless it be continued too long, the
unconscious infant and child does not permanently suffer
from masturbation to the same extent as the adolescent.
la the latter I am certain that epilepsy resulted from
the habit in a good many cases. Such I have seen get-
ting well when it was stopped, and under proper treat-
ment— bromides a short time, cold water, lupulin, cam-
phor, and other roborants continued for years. Infants
and young children are not so punished, except appar-
ently in tiiose cases in which masturbation itself is the
result of a central disease. Goltz" places the erection
center in the cord about the fourth lumbar vertebra,
others in the pedunculi cerebri or the medulla oblon-
gata. It is quite po&sible that in such cases in which
epilepsy follows masturbation, both may be of the same
central origin. They are both probably incurable, and
neither a treatment directed to the center, nor irritating
vesicatories or brutal and vulgar clitoridectomy can pos-
sibly be expected to have an effect. Such cases of mas-
turbation iire as incurable as the vast majority of central
epilepsy. What I express as my opinion of clitoridec-
tomy is also valid in regard to worse methods. Baker
Brown is dead, Everett Flood, of Baldwinville, Mass.,
appears to be very much alive.' He eulogizes castration
and circumcision. The former was performed on 20
males and two females. The cases were reported at the
meeting of the American Medical Association at Atlanta.
He admits that castration has " bitter opponents " of the
same class that is " howling against vaccination." I do
not howl against vaccination. To me it is a wonder that
the criminal law of Massachusetts has not yet interfered
with these attempts at dealing with masturbation and
epilepsy, both of which render the consent to be muti-
lated an impossibility on the part of irresponsible,
unfortunate sufferers.
REFERENCES.
' Grenzgeb. Med. Chlr., 1002. p. 516.
2 loainal de M«d. Chlr. el Pharm., p. 669.
■'Revue .\1«d.
< Vlrchow's Handbuch, Vol. iv.
».V. Jacobl: The Intestinal Diseases of Infancy and Childhood,
Detroit, 18*7, p. 103
•Medical News, September 15, 18W.
'Clinical Journal, September 5, 1894.
« Intestinal Diseases of Infancy and Childhood, Detroit, 18W.
•Atlantic Med. Weekly, October 24, 1896.
INTESTINAL OBSTRUCTION : FECAL FISTULA, PER-
SISTENT PAIN, CURED BY SECONDARY OPERA-
TION AND END-TO-END ANASTOMOSIS.'
BY
HERMAN GRAD, M.D.,
of New York City.
The classification of bowel obstructions into acute
and chronic obstruction is of great practical importance.
In chronic obstruction the symptoms come on gradually,
the muscular hypertrophy of the intestinal wall above
the stenosis compensates the force recjuired to propel the
contents of the intestines through the narrowed lumen.
The higher up in the intestinal canal the stenosis is
located the less likely are symptoms of sudden obstruc-
tion to occur, owing to the fluid contents; but in a
gradually developing stenosis of the large intestine a
sudden obstruction may occur, for the fecal matter is
harder.
In acute intestinal obstruction much information may
be obtained by practising systematically auscultation,
M.,1, v?'}Ti,"^'lT''y Invitation before the Newark Medical Society,
May 13, 1902, at Newark, N. J. "
palpation, and percussion of the abflomen. Insi>ection
will show whether distention exists, and if so whether
it is uniform or localized ; also whether the pain is
localized or diffused. Attention should be given to pro-
trusions of the abdominal wall. In occlusion of the
duodenum protrusion will be confined to the epigastric
region. The distention may be confined to the right or
left of the median line according to the seat of the ob-
struction. The peristaltic motion of the intestines in a
patient with thin abdominal walls can also be noted.
Palpation indicates the sensibility of the various regions
of the abdomen. In some cases of intussusception im-
portant information will be obtained by this means.
Tumors of organs that may exert pressure on the intes-
tine occluding their lumen may be felt by practising
palpation, but this should be of the gentlest kind, as a
forcible hurried palpation will not give information.
Auscultation by gently placing a stethoscope on the
various regions of the abdomen will inform us as to the
vigor and presence of the noises incident to peristalsis,
and as to whether the muscularis is still capable of con-
traction ; absence of peristalsis noises shows that the
bowel is paralyzed. This is an important symptom in
determining whether the intestinal obstruction is due to
a mechanic cause or to paralysis of the bowel.
Percussion should not be omitted in these cases, but,
like palpation, it should be done gently. When the
abdomen is distended and the liver dulness has not dis-
appeared free gas is not present, but if the liver dulness
has disappeared it is probable that a perforation of the
inte.stine has occurred and gas is escaping into the peri-
toneal cavity. In some cases the splenic dulness also
disappears. When vibration of the abdominal wall by
means of percussion elicits pain it is almost certain that
the parietal peritoneum has become inflamed. Exuda-
tions near the surface of the abdomen can sometimes
be made out by percussion. After thorough examina-
tion of the abdomen careful digital examination of the
various hernial orifices is necessary, with a thorough
combined exploration of the rectum and vagina. If
necessary, the examination should be made under anes-
thesia. The urine and vomitus should also be examined.
The diagnosis of intestinal obstruction is, as a rule,
comparatively easy, the principal symptoms being com-
plete retention of stool and flatus. The disease, how-
ever, may be confused with peritonitis, appendicitis,
and early in the disease with biliary and nephritic colic.
In peritonitis there is a higher temperature, in occlusion
the temperature is apt to be subnormal at first. In peri-
tonitis the facial expression of the patient is different.
Pain in peritonitis is more constant, while in occlusion
it is paroxysmal. In occlusion, in a thin abdomen,
coincident with the pain, vigorous peristalsis can be
seen. This association of pain and peristalsis is absent
in peritonitis. In occlusion meteorism is at first circum-
scribed, in peritonitis it is general. Vomiting in peri-
tonitis is continuous, and not apt to be fecal, sterco-
raceous vomiting is characteristic of occlusion only ;
occurring in peritonitis it is the result of paralytic occlu-
sion. An exudate or serous effusion speaks for perito-
nitis, although the condition may be a later phase of
intestinal obstruction.
The differential diagnosis between peritonitis and
occlusion becomes easy, if one can demonstrate that
the symptoms of occlusion were preceded by pathologic
conditions that give rise to peritonitis, such as appendi-
citis, typhoid and other V)oweI ulcerations, diseases of
the female generative organs, ulcer of the stomach. In
the early stages appendicitis may eause confusion, but as
the disease develops the differential diagnosis will
become easy, as appendicitis rarely causes a train of
symptoms such as those found in occlusion.
In many cases of ob.struction it is not possible to
diagnose the type. Under such conditions the medical
attendant is .sometimes at a loss to know when to advise
operation for relief. The question may he asked, Is it
DECKHBBB 13, 1902]
INTESTINAL OBSTRUCTION
(AiiERiCASt Medicine 933
possible to formulate data that would guide the medical
attendant to decide whether the case in question is a
proper one for surgical intervention or not ? When we
consider how varied are the etiologic factors of intestinal
obstruction the above question can be answered in the
negative. It is impossible to formulate such data,
because we cannot always diagnose the type of the
occlusion in every case of intestinal obstruction. Not
alone is it at times impossible to know the type of
obstruction, but even cases of the same type will call for
different therapeutic measures. For instance, one case
of intussusception will be relieved by inflation, while the
next will require surgical intervention.
However, while no definite data can be formulated,
certain general statements may be made : A case with
symptoms of intestinal obstruction, which has been
under medical supervision for 48 hours and has resisted
therapeutic measures, will fare far better under surgical
treatment. The mortality rate of intestinal obstruction
treated without operation is 10 fc. The surgeon could
have saved 30 fo of these cases if operation had been
done early in the attack. In some instances, however,
48 hours will not be sufficient time to notice much im-
provement, and persistent treatment for coprostasis will
be rewarded finally by results. In these ca.ses, though
no bowel movement has been obtained in 48 hours, flatus
will occasionally escape, showing that the occlusion is
not complete.
With these preliminary remarks I will report the
following case, which is of interest, because it bafiled
diagnosis, prognosis, and treatment :
Mrs. W., aged 30, was first seen on the evening of January 5,
1!K)1. She has one child 8 years old. and had a miscarriage a
year previously necessitating a curettage.
The following history was obtained: Ten days ago the
patient was taken with symptoms of grip, and has since been
in bed. Menstruation has been regular ; she has missed no
periods, and has been menstruating for the last ten days. For
the last two days she has had abdominal pains at various
times, but during the past 24 hours these pains have greatly
increased ; some ai)domiual distention has also appeared.
Because of these symptoms a consultation was determined on.
The t)owels have moved every day ; t<jday, very slightly. The
tempt rature was 100° F. ; pulse, I'iO to 130; respirations, 23. The
disproportion between the pulse and rise of temperature was
noticed at the time, although little importance was attached to
it. Its significance, however, was shown at the time of opera-
tion. The patient has been vomiting at intervals for two days,
but during the past 12 hours vomiting has become very fre-
quent and exceedingly distressing, the intervals between the
spells being only from 10 to 15 minutes. The patient was not
able to lie down. Her head was raised with pillows, and she
was almost in a sitting posture. The vomitus was very bitter,
semisolid in consistency, alkaline in reaction and bad no fecal
odor.
Examination of the heart and chest was negative. Vaginal
examination sliowed a How of dark-colored bloo<i from the
uterus, while bimanual examination indicated that the whole
pelvis was filled with something which could not be defined.
The uterus could not be located, nor could the uterine append-
ages be mapped out. Attempts to raise the cervix or palpate
the contents of the culdesac caused considerable pain. The
pelvic c'ontents did not seem to be a solid mass, nor did it give
the impression that it was fiuid. The extent could not be
defined or outlined. A sound introduced into the cavity of the
uterus showe<l the organ to be of normal dimension. Exami-
nation of the abdomen showed that the distention was confined
to the left of the median line on a level with the umbilicus
extending downward toward the pelvis. The patient having
thin alxlominal parletifs the peristaltic action of the bowel
could bo plainly seen and felt. The pain in the al)domen was
centered at the umbilicus. In addition to this general abdomi-
nal pain the patient would at times have severe paroxysmal
pains coini^iding with vigorous peristaltic movements. Exami-
nation of the roctiiiii showed it distended to its utmost (■apacity
with hard fecal matter. The feral column could be felt extend-
ing into the sigmoid fiexnre of the colon. How much of this
fecal column was in the true pelvis, and how far it interfered
with a thorough pelvic examination was not known. It was
very clear that the pain and vomiting were due to the vigorous
peristalsis, this indicating an ol)struction in the bowel. That
there was not complete obstruction of the bowel was evi-
dent, l)e<-ause fiatus hud passed, small bowel movement had
occurred and ihe rectum contained considerable fecal matter. A
diagnosis was readily ventured that the case was one of fecal
impaction, and not intestinal obstruction. The stoma<!h-<:on-
tento was siphoned off and found to consist of about a
pint of bile-stained fluid mixed with a dark -colored semisolid
substance with no fecal odor. This procedure Wiis followed by
lavage with a copious quantity of hot salt solution, and before
removing the tutje a solution of half an ounce of magnesium
sulfate was introduced into the stomach tp save the patient the
annoyance of swallowing the saline. The rectum was then
emptied with an enema of soap suds, supplemented by an
oxgall enema to provoke bowel movements, and the patient was
ordered champagne and water in small quantities to allay
thirst.
The next morning it was found that after the lavage the
patient had four hours of relief when the vomiting returned and
had been continuous since. She had a restless night, abdomi-
nal pains at times being very sex ere, the bowels have not
moved, no flatus has passed, but a fair quantity of urine was
voided. The patient was in great distress, harassed continually
by vomiting and unable to lie down.
Examination of the abdomen showed distention had in-
creased, peristalsis very forcible, and causing excruciating
pain. The temperature was normal, pulse 120, respirations 22.
The rectum was found distended with feces, fully as much as on
the previous evening, with no inclination to defecate. Lavage
was- again practised, the rectum again emptied, and calomel
administered. The ill-defined mass in the pelvis was the same
as at the previous examination. In the evening it was found
that the patient had great relief from the vomiting since the
last lavage, but in spite of the calomel and salines the bowels
had not moved and no flatus passed. At intervals the pain
had been very severe, the distention had increased, and the
vaginal discharge had ceased. The temperature was 99.4°,
pulse 120, respirations 24.
The rectum was filled with feces, but not so much as in the
morning, a single small enemaclearingtheorgan. The stomach
having become less rebellious, it was possible for the patient to
retain some nourishment. The abdominal pain was increased
to such an extent that it was necessary to administer morphin
hypodermically. The next morning it was reported that the
patient liad passed a bad night, pain had greatly increased,
vomiting had decreased, bowels had not moved, and no flatus
had been passed. Abdominal distention is increased, petistaleis
is very vigorous, and the rectum is empty for the first time in
the 36 hours since the patient has lieen under observation.
Temperature normal, pulse 120, respirations 24. An anodyne
had been given frequently to relieve the pain. Repeated
enemas failed to provoke a bowel movement. It was now
evident that it was a case of gradually-developed intestinal
obstruction. It was evident that the ill-defined mass in the
true pelvis was closely associated with the obstruction. What
was the mass in the pelvis ? Was it blood, or a tumor, or the
uterus?
Another consultant called in agreed with the diagnosis of
a gradually-developed intestinal obstruction, but ventured the
opinion that the bowel was compressed by the retroverted
gravid uterus. Against this was trie fact that the uterus only
measured 2} inches in length, while its fundus could not be
mapped out on account of the abdominal distention: in intro-
du<-ing the sound into the uterus its direction would be forward
and not backward.
The therapeutic indications were to stop cathartics and con-
trol the stormy peristalsis by hypodermics of morphin, in order
to obtain for the patient a much desiretl rest, therefore 4 grain
of morphin was accordingly given.
The next morning, finding no improvement, surgical inter-
vention was decided on. The patient was anesthetized and the
pelvis thoroughly examined— it was found that the uterus
was of normal dimensions and in normal position, the
fundus being buried by the distended coils of intestines. The
mass in the true pelvis was semisolid. The uterus was cureted,
but nothing found in its cavity. The patient was then put into
position for abdominal section. On opening the abdomen a
quantity of dark fluid blood with some clots escaped. Passing
the hand into the pelvis a large blood-clot was brought into
view; in this clot was a loop of intestine so compressed and
bent on itself as to occlude the bowel lumen completely. The
walls of the gut were infiltrated and thickened. There were
oth^r clots also in the pelvis, but aside from this nothing else
was found. The uterus was small and in normal position. The
ap|>endages were also normal. What caused this large quantity
of blood in the abdomen I cannot tell, the patient's critical con-
dition precluding a systematic examination todis<!Overtlie pos-
sible source of the bleeding. Freeln(i| the abdomen of clots by
thorough irrigation with saline solution, and finding no active
bleeding, att<!ntion was now directed to the intestine. The
bowel above the constriction was enormously dilated, but so
soon as the clot of blood which caused the compression and
folding of the gut was removed the bowel contents of the dis-
tended portion rushed into the empty bowel. Seeing such a
favorable turn of <'ondition, I desisted from doing an cnleros-
tomv, though at first I was fully prepared to relieve the
oi)structlon by establishing an artificial amis. As her pulse was
becoming imperceptible and there was no fresh bleeding after
mopping the pelvic cavity with sponges, the abdomen was filled
with saline solution and closed without drainage by through-
and-through sutures of silkwormtut.
The patient was in a state of collapse, with an impert«pllble
pulse, sighing respiration, cold and clammy sweat, cold
extremities, to every appearance beyond the possibility of
934 A.KMtiCAti Medicine]
INTESTINAL OBSTRUCTION
(Decembbb 13, 1902
reactiuK. The prognosis wax very unfavorable. She was put
to bed, surrounded with hot water Ijags and the foot of the
bed elevated. The median basilic vein was then opened and a
gallon of salt solution infused. The reaction following the
transfusion was surprising. The color returned to the lipn, the
extremities became warm, the pulse returned and remained
steadily at about 140. Anodynes wore now administered to
relievo the pain of which the patient complained as soon as the
effects of the anesthetic wore off. There was a sharp rise of
temperature within six hours following the operation, and the
pulse ranged between 140 and 100 beats per minute. In this
extreme condition of debility and suffering the patient labored
from hour to hour. Twenty-four hours passed, but no bowel
movement occurred although mild cathartics and enemas were
administered. In the meantime the temperature rose gradu-
ally to 103° P. The abdominal pain had greatly increased, the
distention Instead of being localized had become general, the
liver dulness was gradually disappearing. Vaginal examination
showed a bulging in the culdesac. The rectum was empty. Peri-
stalsis was marked, but was not so stormy as before opera-
tion. The abdominal pain was more like that in peritonitis.
The stomach had remained quiet, which was very fortunate
indeed, as the patient was able to take a liberal quantity of
nutrition, consisting of bovinin, panopepton, somatose and
white of egg.
On the third day after operation, finding the abdominal dis-
tention greatly increased, I felt sure that free gas was present
in the peritoneum, and as the bowels had not moved, I re-
moved the two lowest sutures of the abdominal wound and
with a probe thfe recently united wound reopened. This was
done with great gentleness, and a.s the patient had just ra-
ceived J grain of morphia hypodermically she scarcely paid
attention to the procedure. So soon as the peritoneum was
punctured gas escaped, showing that bowel perforation had
occurred allowing gas to enter the peritoneal cavity. The
small opening thus made in the peritoneum was enlarged by
inserting a piece of wire bent into the shape of a hairpin, this
wire by springlike action established an opening in the peri-
toneum an inch long without causing the patient any inconve-
nience; a matter of supreme importance, Deeause her vitality
was at the lowest possible ebb. There was but a spark of life
in her, precluding manipulations of any kind. On removing
the wire it was found that a distended loop of intestine was
being forced into the peritoneal rent. After four hours the loop
of intestine, having become slightly adherent to the perito-
neum, was punctured, thus establishing an artificial anus.
Gas began to escape from the bowel immediately, and it con-
tinued to do so for many hours ; through the same opening the
Ijowels began to move within a few hours. This fortunate turn
of events raised our hopes, for with a quiet stomach and an
artificial opening in the bowel, much could be hoped for by
judicious feeding and stimulation, and to this end all energies
were bent.
A few days later symptoms of peritonitis appeared, the
temperature rising to 103°. In the culdesac of Douglas a fluc-
tuating mass appeared, which was punctured with a sharp pair
of scissors, and a large quantity of pus evacuated. A cystitis
also developed, which called for bladder irrigation. For about
10 days all the bowel contents came away through the abdom-
inal opening, but after this fecal matter would be found in the
rectum daily, requiring manual removal in conjunction with
enemas. No voluntary movements of the bowels occurred for
two months after operation. The rectum would sometimes
become filled with hard lumps of fecal matter and to relieve
the organ it was necessary to soften the contents with water,
and crush the lumps by pressing them against the coccyx and
sacrum, causing considerable pain and annoyance to the
patient.
Although the rectum was manually emptied daily and
sometimes twice a day the fecal matter found in the rectum
would always be hard and lumpy. In fact, these hard balls of
fecal matter could be felt through the abdominal wall and their
change of location noted from hour to hour. The bowel con-
tents escaping through the abdominal fistula were always
liquid or semisolid, never lumpy, as the fecal matter found in
the rectum. The explanation of these scybala was difficult and
the only explanation of the phenomenon I could find was that
the watery elements of the bowel contents finding a free outlet
througli the fistula, favored the unnatural hardening. Later, I
found that the scybala phenomenon had a more definite cause.
In about two weeks after the operation with the subsidence of
the inflammatory disturbance in the abdomen, the condition of
the patient began to improve, although it was nine weeks
before she left her bed, and two mpnths before she had a volun-
tary evacuation of the bowel.
In the fourth week of the illness the temperature and pulse
became normal, but the patient was greatly debilitated; the
emaciation was extreme. The patient was taking large quanti-
ties of nutritious food, all stimulants were stopped and every-
thing tended toward a favorable issue of the case. The abdom-
inal fistula showed a ready tendency to close up, but there was
one condition that gave rise to serious concern. This was the
fact that, in spite of the favorable condition of the patient in
every other way, she would complain of attacks of severe pain
in the abdomen, as many as six to eight spells in 24 hours. The
time of duration of these attacks would vary; some attacks
would last but a few minutes and others would last as many
hours. Some days the patient would be comparatively free
from pain, then again there would be days when she would be
compelled to remain in bed. The pain would frequently be so
severe that it was necessary to administer hypodermics of mor-
phia. An idea will be gained of how frequently an anodyne
was required when I state that during the nrst two months of
the illness, while a trained nurse was in attendance, the patient
received 220 hypodermics of morphia. During the first 28 days
she also received 92 hypodermics of strychnin.
At first the pains were attributed to the formation of scybala,
but during the third month when normal voluntary movement
occurred and no more scybala formed; the pains still persisted.
Although the patient would suffer numerous attacks of pain,
no systemic reaction would follow. The pulse and tenij erature
would remain normal. It was also thought the pain might be
due to intestinal adhesion or possibly to a gradually developing
stenosis in some part of the intestine. Cathartics neither
aggravated nor diminished the attacks. The patient would now
take short walks about the block, but she noticed that after such
exertion she would be apt to have an attack of pain. Massage
and electricity were also tried but gave no relief. During the
fourth month it was noticed that whenever the abdominal fis-
tula, which was now almost closed, became clogged with fecal
matter, the attacks of pain would be more severe than if the
fistula was discharging freely. One day, happening to be pres-
ent during one of her attacks, and finding the fistulous tract
clogged, I called for a fountain syringe full of water, and intro-
ducing a glass catheter into the fistula, the fecal matter clogging
the opening was washed away. This was followed by a copious
discharge of bile-stained fluid. I noticed that the fistulous
tract held about 8 ounces of water. A glass catheter would just
fill the abdominal opening of the fistula and I could thus fill
up a cavity which I thought existed between the coils of intes-
tine, shut off from the peritoneum by inflammatory adhesions.
This discovery seemed to offer an explanation of the cause of
the persistent pain. The explanation seemed to be that the
bowel fistula communicated with this cavity, and as the open-
ing in the bowel was on a higher level, the cavity would become
filled at times with bile-stained fluid. The fistula was high up
in the small intestine. This was shown by the fact that in 20
minutes after taking food some of it would appear at the fistula.
If a grain of carmin was taken in a capsule, the red stain would
appear at the fistula in 30 minutes. The chyme escaping from
the bowel and being retained in the cavity was reponsible for
the pain. It required quantities of water to cleanse the fistulous
tract, but finally the water returned clear. The immediate
effect of the irrigation was the cessation of pain. The next day
the patient reported that she had been free from pain for l;!
hours and bad taken no anodyne since seeing me. However,
she had pain for the past few hours but another irrigation
promptly controlled it. Prom this date on all anodynes were
stopped, irrigation being resorted to whenever it was found
Fig I.— Loop of intestine almost severed by sloughing, only mesenteric
border remainiug.
necessary, and the explanation given as the cause of the pain
was strengthened by the fact that irrigation always brought
relief. Under daily Irrigations the patient gained in health and
strength.
Eight months after the operation, finding that the bowel
fistula had no tendency to close, the patient was advised to sub-
mit to another section to enable us to see whether the bowel
opening could be found and sutured. The following prelimi-
nary steps were taken to endeavor to locate the fistula in the
intestine :
On September 9, 1901, the patient was given three grains of
carmin in a capsule, four hours before operation, to be repeated
in two hours. It was thought that the red fecal matter escaping
would assist in locating the opening in the intestine. Saturated
watery solution of methylene-blue was also prepared and steril-
ized by boiling, and this was injected into the fistulous tract,
the idea being that it would stain the tissues blue and thus
assist in the search for the fistula in the intestine. The patient
was anesthetized and an incision made on each side of the fist-
ula through the scar. On opening the peritoneum a cavity was
encountered which was stained blue. Inspection showed that
Dkcbmbkk 13, 1902]
EPITHELIOMA OF EYELIDS
AMKRicAN Medicine 936
it was lined by mucous membrane, hence it could be nothing
else than the interior of the intestine. The relations of the
cavity were such that its wall was everywhere adherent to the
abdominal parieties. Further search showed that the mass
was a coil of intestine, and after separating it from the abdomi-
nal wall, it was found that the bowel loop was almost severed
by sloughing, the two loops being held together by a piece of
the wall at its mesenteric border. (Fig. 1.)
The destruction of bowel tissue was doubtless due to slough-
ing, and during the inflammatory process the bowel became
adhered to the abdominal wall, the latter filling up the gap
between the severed ends of the intestines and also acting as a
jilane along which the contents of the intestine slid from the
fig. 2.— Anatomic relation of abdominal wall, fiBtiila and severed
Intestinal loop. A-B. Abdominal wall. C. Abdominal opening
of fistula. D. Oap in the Intestinal loop. K. Proximal end
of inte.stlne. F. Distal end of Intestine. G. Mesentery.
proximal into the distal end of the bowel lumen. The inter-
esting anatomic relations are shown in Fig. 2.
This peculiar anatomic arrangement accounted for the per-
si.stent pain as well as for the formation of scybalous feciil masses.
When semisolid feces arrived at the rent in the intestine there
was no propelling force, and therefore tlie fecal mass stagnated,
and only left this location when the cavity became filled up.
The vigorous peristalsis which was set up in the proximal end
of the tube was responsible for the frequent attacks of pain,
while the same anatomic arrangement served as a mold for
scybala.
The operation consisted in an end-to-end anastomosis of the
bowel, using throiigh-anil-lluoiigh sutures of catgut, followed
by a double layer of Leinbert sutures of fine catgut. On account
of the large sutured area, and fearing inflammatory reaction, it
was deemed best to malce provision for drainage. The lower
end of the incision was therefore left open and sterilized gauze
passed down to the sutured bowel. The abdomen was closed
with through-and-through sutures of silkwormgut. The
patient was put to bed. \ ery little reaction followed the opera-
tion. Temperature and pulse remaining normal, the gauze
was removed in 48 hours. The intestine became distended
with gas, but it caused little pain. On the fifth day the gas
began to pass by rectum, and two days later the bowel moved
normally. The abdomen closed in ten days and the patient
was out of bed in two weeks from the date of the operation. For
ten days the urine was 8taine<l by the methjlene-blue. Recov-
ery was complete, and since the operation, seven months ago,
the patient has had no trouble of any kind.
THE TREATMENT OF EPITHELIOMA OF THE EYE-
LIDS BY THE X-RAYS.'
BV
WILLIAM M. 8WKET, M.I).,
of Philadelphia.
The X-rays a.s a method of treatment in certain forms
of maliKnant growth.s may be considered to have paase<l
the experimental »ta^e, and to have apparently estab-
lished their superiority to operation in the relief of
superficial affei'tions like epithelioma. Apart from their
use in the primary treatment of newgrowths they have
a distinct value when employed after operation to
prevent recurrence of the disea.sed ti.ssue. What may
be done by the x-ray treatment of epithelioma of the
tissues surrounding the eyeball Is evidenced by tlie cases
here retarded.
' Head befon' Ami-iicmi (iphllialmolOKiral Hoclely, July, 1902.
Case I. — Mrs. G., aged 84, was referred to me on February
14, 1902, by Dr. W. P. Goff, of Clarksburg, W. Va. About 12
years ago a slight roughness of the skin appeared on the side of
the nose close to the inner canthus of the left eye. Four weeks
later a crust formed, which, upon becoming detached while
bathing the face, left a small ulcerated spot, from which a few
drops of blood flowed. For several years afterward the process
of temporary scabbing over continued without causing much
Kig. 1.— Kpllhelioina of orbit and face.
pain or inconvenience, althoug'h there was a gradual increase
in the ulcerated area. About four years ago the growth began
to spread more rapidly, passing upward on the nose and also
implicating the eyelids and the tissues of the orbit, the sight of
the eye being lost in about a year. With the spread of the
ulceration there was itching and considerable pain, the
paroxysms of the latter often lasting for many houra. Numer-
Klg. '.!.— Hesiilt of x niy Irintmcur,
0U8 ointments and lotions were employed without relief, bat
all operative treatment was refused.
The condition of the growth when I first saw it is showa
in Fig. 1. At this time there was an almost complete oblit-
eration of the conjunctival sac from inflammatory adhesions,
the eyeball was atrophic and there was an extension of the
growth into the structures of the orbit, but to what depth could
not 1)0 determined. The itching was Intense and the pain
would often continue throughout a whole day. F.xamination
936 AMaBICAM MboioiksJ
EPITHELIOMA OF EYELIDS
IDecembeb 13, i'JOJ
of the growth showed it to be a squamous cell epithelioma.
After a lead mask had been prepared to protect the face and
the sound eve from the action of the rays, treatment was com-
mence<l on February 15 and continued daily for periods rang-
ing from five to ten minutes for two weelss, when it was given
every second day for one month, and then every third or fourth
day for two weeks more. Within a week after the beginning
of the treatment there was a decided diminution in the severity
of the pain, the discharge was lessened and the area had a
Fig. 3.— Epithelioma of external canthus.
healthier appearance. At the end of the third week the size of
the growth had diminished slightly, healthy granulations
appearing at the edges. The improvement continued, and on
April 5 the nasal portion had entirely skinned over, and tlie
palpebral and orbital disease showed decided diminution in
size. The picture, Fig. 2, was taken at this time, after a total of
36 exposures.
On April 14 she returned to her home, and the treatment
has since been continued by Dr. GofT on an average of
three times a week, directed to the diseased tissue of the
orbit. The improvement has continued, but the refusal
of the patient to permit enucleation of the atrophic eye-
ball has rendered it difficult to reach all the diseased tis-
sue with the rays.
Case II. — Thomas M., aged 71, was sent to me Feb-
ruary 28 by Dr. C. A. Oliver, with the history of a growth
of the lower lid of the right side, close to the external
canthus. which started 11 years before as a small ulcer.
Under the use of ointments the ulcer healed and gave no
trouble for several years. In August, 1900, the disease
recurred and continued to spread, notwithstanding all
forms of local treatment. The growth was found to be
epithelioma. Its appearance at the first examination is
shown in Fig. 3. As the man lived some distance from
the city the x-ray exposures could only be given every
fifth or sixth day, and extended over a period of four
months, 22 treatments in all being given, with the result
as shown in Fig. 4.
Case III.— James M., aged S4, came to me from Dr.
C A. Oliver with a narrow ulceration on the edge of the
lower lid of the left eye, near the internal canthus, which
had existed for a number of years. No section of the
fTowth was secured, but it had tlie appearance of epithe-
ioma. After ten treatments, extending over a period of
five weeks, there was complete healing of the ulcerated
area.
The action of the x-rays in relieving malig-
nant growths has not as yet been satisfactorily
explained. All operators recognize a destructive
action of the rays upon embryonic cells, without,
however, affecting normal healthy tissue, except
under prolonged exposures; but the reason for
this selective action remains to be determined. The
sections made from a piece of the diseased tissue taken
from Case I, after a number of applications of the
rays, and examined in the laboratories of the .Jeffer-
son Medical College, showed intense infiltration of
leukocytes, although there was at that time subsidence
of the early inflammatory symptoms. f)ver 90% of the
cells were polymorphonuclear leukocytes, which were
conspicuous in the cancer areas, around the bloo<lvessels,
and in the bloodvessel walls, and as intravascular margi-
nal collections. The epithelial cells showed evident
degeneration ; the chromatin lieing fragmented at the
periphery of the nucleus, and appearing as line irregular
granules, with reduced intensity of stain reaction.
While leukocytosis may be a causative factor
in the cure, the prompt relief of the pain and the
fact that the ulceratecl area loses its sensitiveness
to touch indicates that some trophic change takes
place under the influence of the rays. This may
be secondary to changes of degeneration in the
finer nerve filaments, resulting iii decreased vitality
and ultimate destruction of the cells of the diseased
tissue. That the x-rays have a pronounced action
upon the nerve structures is seen in the loss of sen-
sation of healthy skin, following too long or too
frequent exposures, while as regards the cancerous
tissue, large portions may be excised without pain
after the part has been subject to the action of the
rays for several days.
In employing this method of treatment the
healthy tissues are protected from the action of the
rays by heavy sheets of tin foil, or by a sheet of
lead, about 0.3 mm. in thickness, having an open-
ing corresponding to the size of the diseased area.
A tube of low vacuum gives more rapid results
than one of high penetration, and should be placed
from 6 to 10 inches distant from the part. The ex-
posures var.y from 5 to 10 minutes. The closer the
tube is to the disease, the more powerful is the
effect. Care must be taken not to burn the tissues
seriously, a result that may reatlily follow expos-
ures that are prolonged, too frequent, or with the tube
too close. This burning does not usually appear until
a week or ten days after any given exposure to the
rays.
There is probably no portion of the body in which the
value of the rays will be greater than in the surgery of
Fig. 4.— Result of x-ray treatment.
the face, particularly of the eyelids. Their employment
will render unnecessary the extensive plastic operations,
with disfigurements of the face, which are now required
to cover the area after the disease is removed. Even the
new tissue that replaces the disease after the x-ray treat-
ment differs from ordinary sear tissue, having more
Dkcbmbek 13. IBOVi]
NEGLECTED POINTS IN PHYSIOLOGY OF VISION iaukwcas mkdicihb 937
nearly the appearance of normal skin, and being more
pliable and not so liable to contract.
The most uniform results have been secured in the
treatment of epithelioma and lupus, although the rays
are of value in other neoplasms. Sufiicient time, how-
ever, has not elapsed since the discovery of the method
of treatment to indicate the permanency of the results. I
believe that when the treatment is carried out properly
and continued for a short time after healing has occurred
the disease will not return. Even if there is recurrence,
exposure to the rays may be renewed, with results equal
if not superior to what may be secured by secondary
operations.
SOME NEGLECTED POINTS IN THE PHYSIOLOGY OF
VISION.
GEORGE M. GOULD, M.D.,
or Philadelphia.
With all the last-century study of the laws of optics
jind of the organ of vision, it is strange that the sig-
nificance of so many ocular structures and functions has
been misconceived or neglected. Most extensive investi-
gations with the keenest ingenuity have been made
upon the photochemistry of the dead retina,' and yet
the important organs and essential functions concerned,
in the living eye, in the avoidance of retinal exhaustion,
and the reinstitution of retinal sensibility, have been left
almost unnoticed. Theories of vision have been elabo-
rated with tireless ingenuity, and yet the fundamental
conditions of actual vision have not been recognized.
All the theories may be left out of the attention if we
wish to fix upon the fundamental fact and causes of
retinal fatigue, and the methods and devices for reestab-
lishing retinal sensibility. In truth the observation
underlying all theories is that the persistent action of
the light-stimulus or image upon one part of the retina
speedily lessens and extinguishes the sensation- response.
The more intense the light the greater the injury, and
the quicker it is produced. The reinstatement of sensi-
tiveness is by means of shadings, darkness, and varia-
tions of the stimulus. I have seen no systematic and
thoroughgoing statement of the devices and the methods
whereby this deterioration of function is prevented, and
the resensitizing process is brought about. The matter
is of so mucli practical significance that they deserve
enumeration :
1. The shadows Ciist by the retinal arteries, veins,
and crapillaries, according to the direction and intensity
of the entering light, are constantly shifted and modified,
so that the retina behind them and in their immediate
neighborhood is allowed variations of fatigue and recu-
peration. The most shaded portions serve perhaps as
centers whence extends the mysterious resensitizing
process.
2. Certain sensitive and trained eyes, when looking
toward the sky or a bank of cloud, can see a multitude
of little lights like pin-points flashing in and out of view
all over the field of vision. These may be resolved into
illuniiiiated paths or lines of light, zigzagging every-
where and api)earing and disappearing seemingly with-
out law or order. These have been called phosphenes,
corpuscular reflections, phoses, and aphoses.' They are
the reflections from the blood-corpuscles of the capil-
laries of the retina, which, as they turn and twist along
their routes, act as tiny mirrors to throw darting points
or traveling lines of light upon all parts of the retina.
These»multitudes of corpuscles also, of course, cast unob-
served shadows of themselves upon the retina. The
reflections may also have a function in producing needed
physiologic irritation in parts of the retina not habitually
' Epitomized In the ".System " of NorrlH and Oliver, Vol. I.
>8eean arilcle upon ihc subject in the Philadelphia .Medical Jour-
nal, July -n \>m.
stimulated by the incoming light, and in this way
keeping it in a state of preparedness or responsiveness.
3. The shatlows of muscje volitantes are probably of
greater service. Musca? should he recognized as of
physiologic, not pathologic, significance. They exist in
all eyes, although not usually recognized. Every part
of the fundus of all eyes during the waking life is pro-
tected by these floating and waving muscaj shadows.
4. The^ retinal pigment extends so far toward the
periphery'of the retina that functionally it joins that of
the iris in preventing all light, except that slight
amount possibly transmitted through it, from entering
the interior of the eye except through the pupil.'
5. The iris-pigmentation is essential for retinal shad-
ing. The tragedy of albinotic eyes is largely due to iris-
translucency.
6. The alternation of contraction and dilation of the
pupil under ever varying light-clianges and intensities
varies the size of the retinal image, and in this way adds
another to the agencies inducing changes of stimuli and
rest.
7. The natural pigmentation of the skin in the non-
albinotic gives added exclusion of useless and harmful
light which passes more freely through the eyelid of the
albino.
8. The function of the eyelashes has been supposed to
be the protection of the eyebidl from a striking body,
which, first touching the lashes, is followed by reflex
closure of the lids. I am convinced that the lashes are
of little or no service of this kind, and that their pre-
dominant use is to screen the light and shade the pupil,
while at the same time allowing the passage of sufficient
light to give a useful image of an object above or below
the eye. The existence of this function ain be observed
in others who are standing in sunlight, or in the photo-
graphs of sitters in open daylight, etc.
9. VV'inking has been explained as necessary for moist-
ening and cleaning the cornea and spreading the t«ar»
uniformly over the exposed surface of the eye. It
has this function, of course, but another, fully as
important if not more so, is that of completely shutting
out the entire retinal stimulus for an instant thousands
of times a day. That winking is not nec(;ssiiry for
spreading the tears, cleansing the cornea, etc., is shown
by the absence of winking in so many animals.
10. Binocular vision also serves more than would the
Cyclopean eye in breaking up the continuance of the
stimulus of the retina upon any one spot.
11. Of greater importance than any single one of the
preceding devices is that of the incessant movementn
of the eyes, those of the body and head aiding. In a
child it is almost impossible to secure anysteatly fixation
of the axis of vision, even for a few seconds, and theeye»
of adults, when healthy, are thus held with difficulty
for only 10 or lo seconds at most. Hut the motionless
stare of the blind or highly amblyopic eye is noticed
even by the layman. This ceaseless motion of normal
eyes pro<luces a similar rapid variation of images, shad-
ings, and rests of all parts of the retina in the region
of the macula. The nystagmus of albinotic eyes may
be defined as the ceaseless chase after a portion of the
retina which may have been a little less exhausted
than others by the terrible flooding of the entire retina
with light.
12. The eyebrow does, indeed, have the subordinate
function of leading wat<T and the sweat away from the
palpebral opening, but a more important use of it is to
shade the eye. A noteworthy confirmation of this is the
otherwise inexplicable growth of the eyebrow hairs in
old men. A striking example is shown in the photo-
graph of the lately-deceased scientist, Powell, shown
' The HtranRC tendency of xanlhrlasnia and other piKinent six>tB to
appear upon the llda and about the eyes, bears witness to the dlmculty
or attainment of normal ocular plKinentalion. 'I'hls is still more strik-
ing In the piitholoKic dark rln(tH or half-elriles that apiH;ar alxiut the
eyesotijlrlsand women sulTerlng rnim niiemlH, ehlorosis, and other
.ormsordenutrltlon.
988 AKKEicAK medicin.; NEGLECTED POINTS IN PHYSIOLOGY OF VISION
[Dkcbmbkk is, 1902
herewith, and reproduced from Science, October 10, 1!)02.
I have soinetimeH had to cut off' these long hairs la the
aged in order to lieep them from injuring the eye by
incurvation against the eyei)all.' In old age the resensi-
tizing process of the retina is more difficult owing to
failing nutrition, etc., and there is a need for a still
greater protection of the pupil from the incident light of
the sun and sky. This is effected by the visor of the
eyebrow, which at this time of life frequently takes on a
startlingly luxuriant growth. This naturally occurs in
men and not in women.
Some of these minor devices doubtless serve the pur-
pose suggested only incidentally, or accidentally, but
Photograph iUustiatlng the excessive growth of the eyebrow in old
men.
nevertheless actually, and one must be struck by the fact
that so many different methods combine and cooperate
toward a common end. One will scarcely find in the
entire organism such a startling number of diverse
mechanisms focussing to one final aim and result. If the
end were not of the supremest importance this would
hardly be permitted. If interruption of the stimulus
^ were undesirable, the ingenuity of nature would have
found a dozen ways to prevent it instead of as many to
encourage it.
These numerous devices are, in fact, but a very few of
the many proofs of the enormous difficulties met and
conquered by nature in the evolution of the eye. These
diffieulties are, apparently, a hundred times as numerous
and as complicated as those of any other organ of the
body. Hence the fineness of the adjustment, the ease
with which disease takes the place of health, the limits of
normality being almost infinitely delicate and narrow.
A glimpse into this amazing mystery is caught by the
observation that all this diverse mechanism from cornea
to macula must be highly transparent, and yet the
greater portion is not controlled by nerve-agencies, and
all is nourished by blood which is scarlet ! And millions
of transparent optic nerve fibers divested of their insu-
lating covering must perform independent and accurate
functions !
The most fundamental of the difficulties of the ocular
mechanic has undoubtedly been to create a mechanism
that shall respond to a stimulus lasting but 0.00144 of a
second, and that is hundreds of millions of millions of
times more slight than that of sound. This explains why
the receiving mechanism or photographic plate of the
retina can be kept sensitive for only a few seconds. In
order to resensitize it a change or cessation of the stimu-
lus must be ensured at least every few seconds. Hence
the elaboration of at least twelve methods of ensuring the
result.
There are many practical lassons to be derived from
the physiologic mechanisms mentioned. The almost
universal custom of wearing hats, bonnets, caps, etc.,
finds its raison d^etre in the need of shading and protect-
ing— not the head so much as the eyes. The chief sug-
gestion that arises is of course the avoidance of subjecting
the eye to a constant stimulus or to a harsh or intense
light. It is amazing what the eye will endure when its
ametrophia is perfectly corrected. It is equally aston-
ishing how easily a little ametropia morbidizes the
whole bodily and nervous organism. But it must be
noted that not even reading demands absolute uniformity
and continuance of the image. There is always a
gliding and changing of the shape and size of the image
by fluctuations. Interruptions, shadings, variations, etc.
If our reading was always by means of a consecutive
series of letters each appearing for a fraction of a second
at one and the same point, there would be very little
reading possible. But even with large print, and good
paper and ink, one should not demand fixation of the
eyes too long at a time. There should be little rests by
closing the eyes, looking away, etc., at least every few
minutes. In all continuous eye-work of any kind there
should be such interruptions. The light should also not
be in front, but should illuminate the book, paper,
sewing, etc., from behind or above. The book should
be held as nearly on the level of the eyes as possible. It
is a pity that printing with white ink on a dead black
surface is at present an impossibility.
When this important law of retinal fatigue and recu-
peration is recognized, there will take place a speedy
revolution in almost all our practical and esthetic arts.
The furniture, wall-papers, carpets, curtains, and win-
dows of our houses will then be very diffierent from
what they now are, — and more beautiful also ! Let us
more closely consider one or two of the many illustra-
tions.
It should dictate the fundamental tones, colors, shape,
and extent of our picture-frames. By the old-fashioned
gilt barbarisms the artist allowed the framer and gilder
almost to monopolize the mental, emotional, and physio-
logic attention of the spectator and to detract as much as
possible from interest in the picture itself. It is only for
a few seconds that any human eye can look at a picture
when the greater portion of the retina is outraged and
exhausted by the adjacent images of the atrocious frame.
In the ordinary gallery of pictures these ludicrous and
retina-paralyzing frames, close beside each other, become
positively torturing. It all seems designed to exhibit,
not art, not nature, not esthetic charm, and emotional
peace, but only the abject hideousness of the plebeian
framegilder's unart. Almost every traveler has noticed
the utter exhaustion and headache that is produced by a
short visit to a large picture-gallery. The crude harsh
gilt is the most wearying of all colors. Recently there
has arisen a reaction of which probably no one under-
stands the reason, consisting in the making of fram«s
with solemn and monotonous black. This extreme is
infinitely preferable to the other, but it is also mechanical
and stupid. Each picture should be framed by the
painter, or at least, and because he has shown himself so
blunderful about it, by another artist with this single
task in view. Each picture presents a special problem
to the artistic framer. It should be done so as to pro-
duce a peculiar, logical, and physiologic color-eft'ect, as
little wearying to the eye as possible, while dictated
primarily by the character, the colors used, the esthetic
aims, etc., of the painter. It should by all means be
hung sufficiently apart from all other pictures to allow
it the proper necessities of its own individuality and not
to destroy that of others hung in the neighborhood.
Pictures crowded together give evidence of esthetic sin
quite as decidedly as the physical crowding of human
beings demonstrates other sorts of immorality. In a
December 13, 1902J
ACCESSORY THYROID TUMOR
[AxERicAN Medicine 939
word, the present fashion of framing and hanging
pictures could not be more unesthetic and anesthetic,
more unphysiologic and pathologic, than it is.
Another corollary of the law of ocular tire and resensi-
tization may be noticed in parsing — a law that is out-
raged by the lighting of most of our churches, and of all
of our private houses, theaters, public halls, etc. The
millions of dollars spent each year in illumination are in
great part wasted and misspent, and by the methods
usetl all the harm is done to the eye that is possible, if^o
room should be lit in such a manner that the individual
lights are visible.' Illumination should be transmitted,
dissipatetl, and reflected light. There is nothing more
tiring to the eye than numerous separate lights whose
images upon various parts of the retina create there a
large number of useless and exhausting stimuli and
from which there is no escape by any device or turning.
American oculists have so many patients who, even
with the best spectacles, cannot escape suffering when-
ever they go to the theater, opera, etc., that the term
" theater-headache," or " panorama headache," has
come into general use. As much as to the character of
the sermon or of the worshiper, the famous sleepiness of
the church-goer was due to the somnolence caused by
ocular fatigue from harsh lights in front. One of the
most common symptoms of eye-strain, known of all
oculists, is sleepiness when reading by artificial light.
Part of this is certainly due to unphysiologic systems
and qualities of the light used.
ACCESSORY THYROID TUMOR SITUATED AT THE
BASE OF THE TONGUE.
BY
RANDOLPH WINSLOW, M.D.,
of Baltimore, Md.
Professor of Surgery, University of Maryland.
In January, 1901, Miss B. W., white, aged 17, came to the
throat clinic of the Presbyterian Eye, Ear and Throat Hospital
complaining of some ditficulty in swallowing. She was
examined by Dr. John K. Winslow, who discovered a growth
in front of the epiglottis, which he diagnosticated as an accessory
thyroid tumor. The patient was referred by him to lue, and
was admitted to the tJniversity Hospital on February 25. She
is a well-developed, rosy-cheeked, plump, healthy looking
girl, who works in a factory. There is notliing worthy of note
in regard to her family history, nor does her past history have
any bearing upon the present trouble. She began to menstruate
when 14 years of age, and that function ha-s been performed regu-
lar! v ever since, the flow lasting about three days and being unat-
len<ied with pain. She has always had some trouble with her
throat, which she thought was due to enlarged tonsils. She
said she suffered from sore throat most of the time. Her voice
wasmnlHed and indistinct, and she swallowed with difficulty.
Upon depressing the tongue an ovoid mass was seen extend-
ing well across the base of the tongue imme<liately in frcmt of
and completely hiding the epiglottis. With a laryngeal
mirror this mass was seen more distinctly and it was smooth
and covere<l with red mucous membrane. The opening of the
larynx could not be seen. Upon palpating the growth it was
found to be about one-half the size of a hen's egg and to give a
somewhat elastic sensation to the finger. The growth was not
painful nor did palpation cause any marked discomfort. The
lymphatic glands of tlie nock were not enlarged nor was anything
abnormal n()t(!d in regard to the thyroid gland. Tlie urinary
examination did not show any diseased condition of the kid-
neys or bladder; the specific gravity was high, 1,086, but no
sugar was present. All her organs appeared to be healthy, and
their functions to be properly performed. This growth was
located between the foramen cecum of the tongue and the epi-
glottis, in a region where thyroid tissue occurs in early life
and where growths of this character are occasionally found In
adults, hence the diagnosis of an abnormal or accessory thyroid
tumor made by my brother, was concurred in, and the patient
was advised t<> have the growth removed. As the neoplasm
could only be seen with the greatestdifliculty, it was manifestly
improper to attempt its removal through the mouth.
On February »i, 1901, the patient was placed under ether,
and her hea<l brought over the edge of the table and supported
in a depen<lent position V>y an assistant, in order that blood
might not trickle into the larynx during the operation. An
incision was made in the median line from the chin to the
'8«e an article entitled "Artlflclal Illumination." by Dr. L. A.
W. Alleman, In the Brooklyn .Medical Journal, December, 1900.
F^
hyoid bone, the mylohyoid muscle cut, and the geniohyoid and
feniohyoglossus muscles of each side, pushed apart by blunt
issection until the base of the tumor was reached. Thegrowth
was pushed down by the fingers of an assistant, placed in the
mouth, and enucleated until the mucous membrane was
reached, the mucous membrane covering the growth being
removed with scissors through the wound. A large ojiening
was left, communicating freely with the oral cavity. This was
closed with catgut, as were the separated muscles, and the skin
A -'
I'i-. 1.
incision was sutured with a subcutaneous silkwormgut strand.
There was some bleeding, but not enough to be alarming ;
no blood gained entrance into the larynx, but it collected in the
back of the pharynx, and was mopped out. There was con-
siderable pain, swelling, and difficulty in deglutition for a few
days, but this gradually subsided, and the whole wound healed
by" first intention. The operation was rather difficult, owing to
the contracted space in which to operate ; but with care, growths
of considerable size can be removed safely by this route. The
growth was examined by Dr. S. P. Latan^, who kindly made
the accompanying drawing of Its structure, which demonstrates
it to be thyroid in character ( Kig. 1 ). The gross relations of the
growth to the tongue and larynx are also shown In Fig. 2,
which was made by Mr. J. W. liurch, a medical student at the
University of Maryland.
It is well known that thyroid tissue may lie found in
abnormal iK)8ition.s, and that at times these glandular
collections may take on increafle<l growth and form
940 AMERICAN MaOtCIHEl
MANAGEMENT OF TUBERCULOUS LUNG
IDbcembeb lit, 1002
tumon* of eoDMiderable size. In early life the thyroid
jrland coiiiiiiunicates with the oral cavity by a tube
known ass the thyroghwsal duct, of which vestiges re-
main in the foramen cecum, at the base of the tongue.
This is one of the favorite locations of accessory thy-
roid tumors, of which a considerable number have been
observed and accurately studied. In 1885 Butlin, in
his monograph on diseases on the tongue, mentioned
four CiUH&s of adenoma of the tongue, but had not per-
sonally seen any ca-se. It is probable that some of these
cases were accessory thyroids, but they were not recog-
nized as such at the time.
In 1889, however, Butlin reported two cases and
determined their nature by a careful microscopic exami-
nation. About the same time Wolf, of Hamburg, re-
ported a case and demonstrated its character. Other cases
have been reported by Bernays, of St. Louis ; J. Collins
Warren, of Boston ; Mcllraith and Bond, of England ;
Schadle, of St. Paul; Theisen, of Albany; Watson, of
Philadelphia; (Jurtis and Gaudier, of Lille, France;
J. H. Reintjes, of Holland, and a number of other
European physicians, whose communications are not
accessible to me at this time, the whole number of cases
recorded, aggregating 28 to 30.
These tumors, situated at the back of the tongue and
immediately in front of the epiglottis, are ovoid in shape,
covered with smooth, normal or reddened mucous mem-
i)rane, and are somewhat elastic to the touch. They
rarely reach very large proi)ortions, and when first
observed may not be larger than a pigeon's egg, at
times attaining the size of a hen's egg. They are not
painful, but fre(|uently give rise to more or less discom-
fort. Deglutition is sometimes interfered with, but this
is by no means common. An alteration of the voice,
usually a muffled tone, has been observed in a number
of cases. The function of respiration has been materi-
ally affettted in only a few instancas. No glandular
involvement occurs. Usually the growth presses on the
epiglottis in such a manner as partially to cover the
opening into the larynx, so that it is either very difficult
or impossible to obtain a view of the interior of this
organ. In several cases it was noted that the vascularity
and size of the growth varied at different times. One
peculiar fact in connection with these cases is that the
subjects were all females, with one exception, whose
ages varied from 16 to 67 years. In some of these the
growth had been present many years, but in several it
was discovered accidentally and could not have been of
long duration.
A moderate-sized, rounded, elastic tumor, situated at
the base of the tongue and covered by smooth, normal
or congested mucous membrane, not painful, with no
metastases, growing slowly and occurring usually in
young women, is almost certainly a neoplasm consisting
of thyroid tissue. These growths do not usually present
any alarming symptoms, but should be removed when
they give rise to discomfort, or cause difficulty in deglu-
tition or respiration.
Various methods have been employed to remove
these tumors and apparently with success in each case.
In several the tongue has been forcibly extruded by
passing ligatures through its base in order to bring the
growth into sight and reach, and then the mucous
membrane incised and the tumor enucleated. Severe
bleeding occurred in some of these cases, but it was
easily arrested by pressure. Some were removed
through the mouth with a snare, but hemorrhage was
also severe by this method. Wolf first performed
tracheotomy and introduced a Trendelenburg cannula
tampon, and then made an incision through the cheek
and sawed through the inferior maxilla, and was thus
able to reach the base of the tongue laterally and to
excise the growth.
The method employed by me is the one recommended
by McBurney, and was found to offer a safe route ; while
.some operators have divided the body of the hyoid bone
in order to gain freer access to the base of the tongue.
Curtis and Gaudier draw the tongue out as far as possi-
ble, encircle the neoplasm with a suture, draw this tight,
incise and enucleate and then tie the suture. By this
means bleeding is almost entirely avoided.
It may not be amiss to call attention to the fact that
the thyroid gland proper, is usually not well developed
in patients with accessory thyroid growths, and that in
several instances symptoms of myxedema have super-
vened after removal of the lingual goiter, as the French
observers call them.
In conclusion, I wish to acknowledge my indebted-
ness to the excellent article in the Jiecue hebdomadaire
de Laryngologie, d' Otologic et de Rhinologie, of April 12,
1902, by Drs. Curtis and Gaudier, for much of the con-
tinental literature on this subject,which otherwise would
not have been available to me.
BIBLIOGRAPHY.
Butlin, Diseases of the Tongue, 1885.
Butlin, Trans. Clin. Society, Lond., Vol. xxlU. '
Wolf. Langenbeck's Archlv, Bd. xxxlx,22l.
Bernays, St. Louis Med. and Sure. .lour., Vol. Iv, p. 201.
J. C. warren. Am. Jour. Med. Sol., Vol. civ, p. 377.
J. Bland Sutton, Tumors, 1«»3.
Mcllraith and Bond, British Med. Jour., December 1, 18M.
Schadle, Journal American Medical Assoc, Vol. xxxill, p. 386.
Theisen, Albany Med. Aqnals, Vol. xxll. p. .537.
J. H. Reintjes, Soc. Laryng., Bhinol., and Otology, of the Nether-
lands, 1898.
A. W. Watson, N. Y. Med. Jour , 1899, Vol. Ixx. p. 579.
Armenia, Le Goitre lingual, Thesis of Lyon, 1900.
Benjamins, Nederl. TIJdsch. voor geneesk , 1899.
P. Meyjes, Soc. beige d'otolog . 1899.
Curtis and Gaudier, Revue hebdom de Laryngol , etc, No. 15, 1902.
DR. BRIDGE ON THE MANAGEMENT OF THE TUBER-
CULOUS LUNG.
BY
T. B. MOORE, M.D.,
of Canon City, Colo.
An obscure member of the profession may well pause
and consider his ground well before taking issue with
so high an authority as Dr. Norman Bridge, of Los
Angeles, Cal. ; yet, in the Journal of the American Med-
ical Association of January 4, 1902, he expresses some
views as to the management of the tuberculous lung which
are so at variance with all that experience has taught
me in over 22 years of active practice in Colorado that I
(;annot forbear expressing my dissent therefrom. To my
mind, and I think to that of all physicians of experience
in the mountain region of the West, it is apparent that
Dr. Bridge unwittingly bends facts to the theory, which
is equivalent to saying that he surely cannot have had
any extended experience in the treatment of tuberculo-
sis in the high altitudes of the Wast. The assertion that
" shallow breathing " is important and beneficial for a
tuberculous lung, and that " better than that no breath-
ing " are so diametrically opposite to the views born of ex-
perience in the treatment of tuberculosis in the high alti-
tudes that they are at once stamped as heterodox by all
physicians who have had such experience. This idea,
followed to its legitimate conclusion and accepted and
acted upon by the profession at large, would be most
disastrous in its results. Had the profession been domi-
nated by such an idea for the past generation Colorado
today would have probably one instead of two represen-
tatives in Congress, and would not occupy the proud
place she does in the sisterhood of States. Tens of
thousands of her citizens came to her borders with a
tuberculous lung and are today living, walking, work-
ing, and energetic object lessons in contradiction of this
statement as to shallow breathing.
The tuberculous patient finds it impossible to con-
fine himself to shallow breathing in the mountain region.
He must breathe deeply and he must breathe faster than
at a low altitude to get the necessary oxygen. He fills
and distends the air cells with the pure, dry, aseptic air,
thus favoring not only the expulsion of noxious material
Ubcbkbkr 13, 1902]
MANAGEMENT OF TUBERCn.OUS LUNG
iJuaaacjLK Hedicisx 941
but inaugurating a condition of improveti nutrition by a
freer circulation of an improved quality of blood.
Dr. Bridge ways: " Deep breathing does violence to
the new fibrous tissue and probably so stimulates the
growth of it, exactly as manipulation of an open sore
tends to an increase of scar tissue." As a statement of
a fact purely in the abstract no one can dispute this on
the<jretic grounds, and yet, as applied to tuberculous
patients in high altitudes, it is utterly fallacious, inas-
much as it presupposes a condition of conservative fibro-
sis, either incipient or fully inaugurated. Given a con-
dition of even incipient fibrosis, in a case not too far
advanced, and a removal to a high altitude will cause it
to progress rapidly to the formation of scar tissue and
the arrest of the disease. The trouble is that retrograde
metamorphoses and not reparative processes obtain in
n(>arly all cases coming to the mountain region.
A fibrosis is what we ardently hope for, in order to
protect the healthy portions of lung tissue from infec-
tion. This condition once set up and the cavity walis, if
a cavity exists, and, if not, the tuberculous area, ren-
tlered comparatively a.septic by the pure mountain air ;
with every air cell that can be inflated, distended to its
utmost capacity and the increased number of red
globules in the blood, carrying more and more oxygen
daily to aid the reparative process, and we have all the
(•onditions favorable for the arrest of the disease ; and
these together constitute the only " consumption cure"
known t« scientific medicine. After watching so many
patients through the various stages described and
noting their improvement and the final arrest of the
disease, deep breathing being a necessity all the time, I
find it hard to subscribe to the view that shallow breath-
ing or, if possible, no breathing, is important and bene-
ficial to a tuberculous lung.
The assertion that respiratory gymnastics do no good
and that the idea of increasing chest expansion by their
practice is entirely fallacious and " founded on poor
knowledge of anatomy" is really so directly antago-
nistic to wellknown and long-established anatomic and
physiologic facts as to require no answer. It must be
admitted that the boasted expansion running in some
cases as high as 8 or 10 inches is, in the great majority of
cases in which no actual deception is practised, made up
to a considerable extent by the contraction and swelling
out of well developed chest muscles ; but that, inde-
pendently of this, the actual, honest expansion maybe
largely increased by respiratory gymnastics is as well
established as any fact can be.
Since writing the foregoing part of this paper I have
read Dr. All)ert Abrams' article on " Respiratory (lym-
nastics" in American Medicine for March 29, 1902. I
deaire to quote two short sentences from his paper: 1.
" The good results achieved in tuberculosis by com-
|)ressed air are essentially due to inechanic action, viz :
dilation of the collapsed lung, readmittance of air, and
the expulsion of products due t<j retrograde metamor-
phoses." 2. "Among the many reasons adduced why
tuberculosis more freijuently attacks the apices than any
other part of the lungs, one above all others appeals to
reason, viz : the apici^ move less on respiration than any
other parts of the lungs."
I shall notice just one more position taken by Dr.
Bridge and then I am done with his paper. His fifth
and very dogmatic assertion is that, "altitudes do not
help the sick with lung tuberculosis by expanding to a
greater degree the air vesicles. The theory is fallacious,
unphysiologic and wrong." But is it unphysiologic?
Let us go back a little in the case and see. Possibly
with an inherittnl predisposition, which is in most cases
another name for a faulty nutrition, the patient has had
a bronchitis, la grippe, pneumonia or repeated "colds,"
as the result of whi(;h some portion of the lung is weak-
ened and its powers of resistance reduced. He has a
cough, loses flesh and strength and probably has some
fever. The part of the lung most oft<»n afl'ect*'*! is the
apex because of its comparative quiescence in the respira-
tory act. Its vitality is reduced and it is affected by cold
just as the whole body has its powers of resistance to
cold reduced when in a state of rest, for it is an unde-
niable fact that a "cold" is contracted far more easily
when the body is at rest than when in motion. The
" pre-bacillary period " as defined by Abrams, is now
well established in the case. All this has occurred in a
low altitude, probably in a damp climate also. This
stage continuing for a time pref)ares the soil for the
seed, which is always ready, and the tubercle bacilli find
a lodgment in the weakened apex. Perhaps the oppo-
site apex has the same amount of germs sown in it, but
the soil is not favorable ; the vitality is not sufficiently
reduced and the power of resistance as yet too great,
and they do no harm there.
At this point before a cavity has formed and before
digestion and assimilation are badly impaired, the
patient's physician perhaps advises a change of climate
and the patient goes to the mountain region, say in
Colorado. If no change is made, in the great majority
of cases the condition grows steadily worse and the
patient dies. If such a change is made, in the great
majority of cases his disease is arrested and he is again
a comparatively healthy man. Now why does death
occur in the one case and recovery in the other ? The
very first thing that happens in the high altitude is the dis-
tention of the air vesicles and consequently on this a better
pulmonary circulation, and following this there is soon
a larger number of red globules in the blood ; all three
steps together being strong factors in securing better
nutrition of the diseased lung, each following in regular
sequence ; distention of the vesicles being the first and
most important of the three, and without which the
other two are impossible or not operative to a markedly
beneficial degree. Surely distention of the air vesicles
cannot do harm, otherwise the first step in the repara-
tive process being wrong other factors would not be
operative in reestablishing nutritive processes. If not
harmful, and if first, as it surely is, in a sequence of
events that results in a cure of the disease in so many
cases, the theory that it is beneficial cannot be unphysio-
logic.
After what has already been said it can be clearly per-
ceived that I am fully committed to the theory that
tuberculosis is born of faulty nutrition, hence no apology
is necessary for the remaining portion of this paper
which might be consistently styled a digression.
In the hope that Eastern physicians who may read
this may be induced to so advise patients coming to the
mountain region of the West that they may receive the
most possible benefit from the change, I wish to call
attention to what I consider two mistakes too often made
in advising the change.
The first and preliminary mistake, genenUly fatal of
itself, is delay in advising the change to a high altitude.
The second, that patients are too often advised to
come to the larger cities instead of to small towns, or,
better still, to the country districts. They are advised
to come to Colorado for pure air and healthful surround-
ings, and either advised to .stop in one of the large towns,
or at most not advised against it, when there, above all
other platres in the State, they are sure of the worst air
and the most unsanitary surroundings to be found in the
mountain region. Not that Denver, Colorado Springs
and Pueblo are not infinitely preferable to any Eastern
city for such patients, and not that the sanitary condition
is bad, but that the crowding together of the tuberculous
where they seek each other out and compare symptoms
is bad, very bad, in its effects on the itwra/e of such
invalids, to say nothing of the contaminating influence
of the coughing and expectorating l)ees indulge<l in by
crowds of them in the hotel offices and sitting-rooms in
winter and on the sunny porches and verandas of hotels
and boarding-houses in all sea.sons.
This statement holds good whether under the theory
942 AMBBicAN MBDiciNK, SURGICAL METHODS IN THE HAMBURG-EPPENDORP'
[UeCEMBBK 13, 1902
that the air in contaminated chiefly by the dried sputum
or by the mist emitted in the act of coughing, or l)otli,
which is more probable.
To recur to the first mistake noted above, it may, I
thinl<, be safely laid down as a general rule that patients
with a cavity of any considerable size, whose pulse runs
jKirsistently to 1^0 or over, and whose digestion and
assimilation are badly impaired, should not be sent to a
high altitude — surely not to Colorado. Of course no hard
and fast rule can be laid down that will apply to all ca.ses.
Every case must be studied on its own merits, as it were,
yet it is undeniable that the vast majority of cases of the
class last described do not improve in high altitudes.
Consistent with the views entertained by me would be
the suggestion that in the early stages of the disease it
would almost be better if the physician could forget that
his patient has any lungs, and remember that his chief
danger is from faulty nutrition and consequent dimin-
ished resistance to infection. Then codliver-oil and
(sreasote would be relegated to deserved oblivion, and
fewer patients would have their appetite destroyed and
digestion ruined by their use. The obvious deduction
from the foregoing is to guard jealously the conservative
forces of the economy from the start, maintain digestion
and assimilation at the highest possible point and send
the patients to the high altitudes early in the course of
the disease.
I think too much stress is laid on the fact that " fever or
the poison that causes it, or both, are what, if they last long
enough, wear out the life of the patient," as Dr. Bridge
expresses it. While this is certainly true in the abstract,
it would seem better to go a step further back and con-
sider fever and toxins in their true character as symp-
toms of malnutrition, or plainly speaking, starvation
and consequently diminished resistance on the part of
the economy. A popular delusion that should also be
combated is the idea that a patient going to the moun-
tain region should at once enter upon an active life-
take long walks, climb high mountains and generally
produce a condition of fatigue every day of his life.
Nothing could be more wrong than this. Rest is very
important at first in a high altitude. Exercise may soon
be indulged in to the point of being tired, but never
until fatigue, without decided injury. Again, and finally,
the fact that invalids can spend so much time in the
open air and sunshine in Colorado even in winter is no
argument in favor of the suicidal practice indulged in by
so many of sitting for hours in a chilly atmosphere in
obedience to instructions to spend a certain number of
hours daily in the open air and sunshine. Patients
should be advised that the exercise of common sense in
the matter of avoiding taking cold is just as necessary in
Colorado as in New York or Massachusetts.
Pasting to Cure Disease— Prom a Minneapolis exchanee
conies news that a cult in that city has been formed, the mem-
bers of whicli hope to cure themselves of disease by fasting.
H.it * " ^ m the movement is a woman, who gives herself the
title of Doctor," though admitting she has no license to prac-
tise medicine. As evidence that they believe this practice
18 a panacea, it is reported that one member is fasting to cure
chronic bronchitis, another to cure "congested liver,'' another
for paralysis of the right side, another for general paralysis,
etc. One of their number recently died after having fasted
according to reports, for 40 days. iosi-Bu,
♦ .J^hJcago's Smallpox Record.— According to the bulletin
of the Health Department for the week ended November 22
the wonderful smallpox record still continues. With the dis-
?^^Tr"f'"^w^ *•"* '''i^ *° 1°«« proximity from Evanstonon
Infr^^.ti? *^ Hammond on the southeast, and with repeated
noTLtin.'"^^^}.*''®''*' '* n°. spread among the well vaccinated
&o^snitel Hn.w?!,'^*'''* SIX cases admitted to the Isolation
Hospital during the week-two from Evanston direct, three
S«L, *?.^*''*7K'°^*•P"?*'^'^1 ^^J^""' i° Evanston, but livhfg
Jlo„to*?fK°5':"'®™ "H """''S. and a traveling man who con-
tracted the disease probably in Milwaukee. None of them had
ever been vaccinated. At the close of the week there w?re 11
cases remaining in the Isolation Hospital, 7 having been dis
charged recovered and no deaths. naving oeen dis-
SPECIAL ARTICLES
PRESENT SURGICAL METHODS IN THE GENERAL
HOSPITAL HAMBURG-EPPENDORF.
BY
NICHOLAS SENN, M.D.,
of Chicago.
The new Allgemeine Krankenhaus Hamburg-Eppendorf
accommodates 2,000 patients. It is built on the barrack plan,
and is spread out over several acres of ground. The different
buildings are numbered and the streets and sidewalks inter-
secting them are laid out in the form of a miniature city. All
of the buildings are constructed upon modern plans, and are
lieated by steam and lighted by electricity. Tlie four operating-
rooms which are in use at the present time are furnished with
every possible convenience for aseptic work. Many of the
little aids to perfect aseptic precautions are the inventions of
Dr. Kiimmell, who has spent much time and thought in sim-
plifying and rendering more effective the aseptic precautions
now in general use. Among these are the ingenious applica-
tion of a rubber cork for bottles containing saline and antiseptic
solutions, a fountain alcohol dropper worked by compressing
a rubber bulb with the foot, and bottles in which catgut and
silk are preserved for immediate use. The instrument supply
in each of the operating-rooms is complete and in charge of a
well-trained orderly (Oberwarter), who is held responsible for
their perfect and sterile condition and proper arrangement on
the instrument table. Two house surgeons assist the operator
and a third administers the anesthetic, which at present consists
of a definite mixture of chloroform and oxygen gas. Two
trained female nurses attend to the gauze, sponges, and dress-
ings.
This hospital contains a larger number of surgical patients
than any other hospital in the world, the number ranging from
500 to 750. It is a great pity that this immense material cannot
be utilized for clinical instruction on a greater scale. Hamburg
should have a university, and the general hospital is the proper
place for the medical department. There are some indications
that this desire will be realized in the near future. An oper-
ating-theater with a seating capacity for 120 is now in process of
construction, and university instruction is now given by emi-
nent scientists in nearly all studies given in university courses.
These lectures are given gratuitously. Hamburg is the most
beautiful of all European cities, a great seaport in close touch
with all parts of the world, and all it needs to make it an ideal
city is a great university. The creation of alive, efficient med-
ical school would meet no difficulties, as the present clinical and
teaching force would constitute a strong faculty, and the
immense clinical and anatomic material, with the existing
laboratories and museums, would answer all the immediate
requirements as a teaching material. The surgical department
of the general hospital has won an enviable reputation
throughout the entire medical world. It is not uncommon to
find in the little audience of six to twelve which gathers around
the operating tables every day, eager to see the most recent
innovations in surgery and to witness the most difficult things
in operative skill, clinical teachers from as many medical
schools and countries. I know of no other place where a man
can see and learn more in the same space of time. The only
regret of the visitor is that he cannot witness all of the operations
going on at the same time. He is never idle. When an opera-
tion is completed all he has to do is to step into the next room,
where another operator is at work, and when he has finished
the visitor can retrace his steps and find another patient is on
the table ready for operation.
Surgical Service—Since Sehede left the hospital in 1893 to
accept the professorship at Bonn the surgical service i.s
divided equally between Dr. Hermann Kummell, first chief
surgeon, and Dr. Sick, second chief surgeon. From 10 to 14
new cases are received daily. The infected ones are assigned
at once to the wards where they belong ; all other patients enter
the receiving pavilion, where they are given a l^ath and are fur-
nished with the hospital garb. Dr. Kiimmell attends to the
Deckhbeb 13, 1902]
SURGICAL METHODS IN THE HAMBURG-EPPENDORF amebican mkdicib. 943
receiving ward four days in the week and Dr. Siclv tliree days,
but for the purpose of equalizing the material all children
under 12 years are assigned to Dr. Sick. In the receiving-room
the patients are examined and after the diagnosis is made are
sent to their appropriate wards. In this way the clinical
material is systematized and properly distributed.
Surgical Work of Dr. jfifi/mmei/.— "Pnesente segroto Tac-
eunt colloquia, Effogiat visus Decus omnia dominat morbus."
This is a warning printed in large type which stares the visitor
in the face from the wall he is
P» •^ ■?,
likely to face iu every operat-
ing-room. Every visitor is re-
quested to remove his coat and
wear a linen gown. Dr. Kiini-
mell was well prepared for the
» J. present position when he be-
Jj^^^^ came the successor to Schede.
ml^Si k. '^"^ scientific investigations
^^^^■^^^F^^h^^ which led to the introduction
^^^^^^H|A^^^^H|k|^ of bichlorid of mercury as an
^^^^^^^^BV^^^^^^^H antiseptic once
^^^^^^^^^^ ^^^^^^^Bl into prominence. His clinical
observations on intestinal ob-
Dr Hermann Kflmmell. struction and appendicitis are
closely interwoven witli the
progress of modern surgery. He is a diligent student and an
enthusiastic, deliberate and careful operator. He is not what
some are fond of being called, " a lightning operator," but his
vast experience, his thorough knowledge of anatomy, and his
familiarity with the changes wrought by pathologic processes
place him ina position to proceed with his work without hesi.
tation. He has reached the age of greatest usefulness and we
may look to him with confidence for many scientific and clinical
literary productions, the fruit of his labors in his present fertile
clinical field. When the opportunity presents itself he will
occupy the front rank as a clinical teacher, as he is in possession
(if all the desirable qualifications for such a position.
Dr. Kilmmeirs Methods in Abdominal Operations. — There
is no gynecologic department in the Hamburg General Hos-
pital. Gynecology is here a part of general surgery. From one
to four abdominal and pelvic operations are made here almost
every day. Dr. Kfimmell has contributed much by writing
and example to the perfection of abdominal surgery. He can
speak on this subject with authority. I will give a brief outline
of the methods now in use as practised by him and his colleague
Dr. Sick.
Preparation of Patient. — In very weak patients a roborant
and nutritive course of treatment is resorted to for a few days
before the operation. Subcutaneous injections of sterilized
olive oil (Ijeube), nutrient enemas and intravenous infusion of
physiologic solutions of salt have been found most useful in
increasing the resisting power of the patient sufficiently to war-
rant surgical interference. Two quarts of saline solution are
Infused twice or thrice a day for several days preceding opera-
tion. The bowels are moved thoroughly the day before the
operation. Prolonged or repeated catharsis is warned against
in most emphatic terms. If the stomach is not etnpty it is
evacuated by siphonage before the anesthetic is commenced. On
the evening before the operation the abdomen is thoroughly
cleansed with sulfuric ether, shaved and scrubbed with soap in
the cleansing bath. The abdomen is then covered with a com-
press wrung out of a bichlorid of mercury solution 1:2,000,
which is kept moist by applying over it some waterproof
material.
Anesthesia.— Vitteem minutes before the anesthetic is com-
menco<i, 0.01 gram morphia with atropin is injected subcutane-
ously. Male patients addicted to the use of spirits are given a
wineglassful of cognac.
In the narcosis-room absolute <iuietness is enforced ; no one
but the anesthetizer and a Sister are admitted. Oiloroform is
the anesthetic in use, ether in only exceptional cases when the
patient is very weak or the subject of heart disease, or finally In
(continuing the chloroform narcosis in operations of long dura-
tion.
The drop method was employed exclusively until the intro-
duction of the oxygen (Wohlgemuth) admixture. Theapparatus
now in use registers with accuracy the quantity of oxygen and
chloroform inhaled. A deep narcosis is essential in all opera-
tions in the Trendelenburg position, as the slightest muscular
contractions force the intestines forward into the wound, thus
obscuring the pelvic view. Local anesthesia by Schleich's
infiltration method is resorted to when the general condition of
the patient contraindicates the administration of a general anes-
thetic. Spinal anesthesia was tried in ten cases, but the results
were such that it has been permanently abandoned.
Disinfection of the Patient.— Xtler the patient is completely
under the influence of the anesthetic the disinfection is com-
pleted before he is transferred to the operating table. After
removal of the sublimate compress, one of the assistants, proj)-
erly prepared, scrubs the abdomen with marbledustsoap with a
bunch of sterilized wood fibers. The softened epithelial cells
are rubbed oft so far as this can be done. This, mechanic
cleansing is regarded as the most important part of the entire
process of surface disinfection. After removal of the soap with
a sterile towel the surface is scrubbed with alcohol, applied
with a gauze sponge, followed by rubbing with ether. The
use of the ether is continued until the white sponges
are no longer stained. When the white gauze is no longer
discolored the best proof is furnished that the mechanic
cleansing is as complete as it can be made. Alcohol is
then used again, and lastly rubbing olf with a bichlorid solu-
tion, 1 : 1,000, completes the disinfection of the field of operation.
The abdomen is then covered with a sterile cloth and tho
patient placed upon the operating table.
Preparation of the Surgeon and Assistants. — Contamination
of hands with septic material must be avoided for at least 24
hours before tho operation. If during that time it becomes
necessary to operate on septic cases, rubber gloves must be
worn. If visits to the postmortem-room are made, a change of
clothing and a bath are insisted upon. The operator and assist-
ants wear a white cap to avoid the entrance into the abdominal
cavity of hair and other infectious material, should, as some-
times happens, their heads come in contact during the opera-
tion. Linen gowns are worn by all in the operating-room.
Gloves, face and head masks are considered superfluous pre-
cautions.
Much stress is placed upon the importance of proper care of
the hands, as smooth skin can be more easily disinfected than
rough skin. Lanolin and glycerin are recommended. The
statement is made and emphasized that the hands with smooth,
healthy skin, alter a thorough mechanic cleansing are practi-
cally free from bacteria, with or without the subsequent use of
alcohol. The best remedy for the cleansing of the hands is the
prolonged and thorough cleansing with flowing warm water
and soap.
Kiimmell has used marbledust soap for 11 years, but
recommends Schleich's marble soap, which is prepared in the
pharmacy of the hospital, as the soap sold in the market is not
what it should be.
The hands are washed in running hot water for ten minutes,
during which time the finger nails receive careful attention, and
the a.septic brush is used with vigor. The hands are then
rubbed with gauze sponges saturated first with alcohol and
lastly with ether. Immediately before the operation is com-
menced the hands are once more rubbed with alcohol and
bichlorid of mercury solution.
Preparation of Dressing Material and fnstrutnenls.—'Tho
sterilization-room, separated from theopcrating-room by a glass
door, is supplied with all modern means of sterilization. Every-
thing that is to be brought in contact with the wound is ren-
dered aseptic by boiling or steam sterilization before It is
brought Into the operating-room. The orderly arranges needles
and lustrumentH and places them In pans filled with sterile
water on a table within easy reach of the operator. The Instru-
ments are wrapped In a linen cloth and are sterilized In a
Lautenschlager apparatus, and the wrapper is not removed
until they are to be used.
Silk is sterilized by boiling in bichlorid of mercury solu-
tion, 1 : 1,(K)0.
Catgut is boiled in a saturated solution of ammonium sul-
fate, according to the method of Kisberg.
Preparation of Ammonium Sulfate CVl/(/n^— Selection of
944 A.KKRICAN MBDiciNicj SURGICAL METHODS IN THE HAMBURG EPPENDORF
[Decembkk 13, 1W2
good raw material is important. The catgut is wound upon a
square kIors plate with projecting margins, in order to expose
the tiireads fully to the boiling solution, as they touch the plate
only at four points. The boiling is done in an enameled pot
and is continued for half an hour, when the plate is removed
with a pair of sterilized forceps and rinsed in sterilized water.
Fora short timethe catgut is immersed in alcohol to harden
it, when it is placed in sterilized oil of juniper ready for use.
Catgut and silk are kept in bottles with a wide neck securely
closed with a glass cork, which is removed when the material
is needed and a nickel cover sterilized by boiling substituted.
Through a central perforation in this cover the threads are
brought out. From the time the sterilization is completed no
one touches the silk or catgut except the operator, who threads
his own needles. The one who sterilizes the material and the
operator are the only two persons responsible for the asepticity
of the suturing material. The catgut prepared by this method
is firm, ties easily and securely, and remains in the tissues for
three to four weeks and more. Dr. Sick had recently an oppor-
tunity to examine a buried suture four weeks after the opera-
tion, and found the material softened but retaining its hold on
the tissues. Catgut is used almost exclusively for buried
sutures, and a large experience has shown the superiority of
the ammonium sulfate over catgut prepared by any other
method.
Elsberg's method of catgut sterilization is so simple and so
sure in its results that it soon will find its way Into all hospitals,
and it cannot he recommended in too strong terms for general
adoption in private practice.
Incision.— Dr. Kiiinmell is in favor of a small incision.
Bven in operations for intestinal obstruction he does not make
the incision as long as he advised a number of years ago. With
increasing experience the incisions are made smaller. A
median incision is made in all operations upon the stomach,
pancreas and in all gynecologic operations. In appendix opera-
tions all muscular layers are incised to the requisite extent.
If the uterine adnexa are involved the incision is made in pref-
erence along the outer border of the rectus muscle. In opera-
tions upon the gallbladder a vertical incision is made, begin-
ning at the costal arch. All abdominal incisions are made
quickly. With one stroke of the knife all tissues are divided
down to the peritoneum. The peritoneum is incised separately
and the incision enlarged with blunt-pointed scissors. With
small vulsellum forceps the peritoneum and skin are grasped
at bleeding points, rendering the use of hemostatic forceps
unnecessary. This manner of dealing with the abdominal
incision is noteworthy, and deserves imitation by all abdom-
inal surgeons. Drainage of the peritoneal cavity is seldom
resorted to. The abdominal cavity is never flushed. Blood and
other fluids are removed and the surfaces dried with gauze
sponges.
The incision is closed with four rows of sutures ; the first
embraces the peritoneum, the second the muscular layers, the
third the fascia and the fourth, of silk, the skin and deep fascia.
The wound is covered with a sterile compress, held in place by
strips of perforated adhesive plaster. The silk sutures are
removed on the seventh or eighth day.
After-treatment.— Aa a rule the fate of the abdominal cavity
is decided after suturing of the incision. In case of collapse an
intravenous infusion of a liter of saline solution is made at once
and if necessary is repeated in a few hours. This expedient is
resorted to in all cases when the pulse exceeds 120. Pain is
subdued by the administration of morphia. Vomiting should
be prevented by withholding all food and fluids by the stomach.
If no vomiting takes place coffee and tea are given in small
quantities 24 hours after the operation. Ice is never given.
The sense of thirst is relieved by rinsing the mouth with
acidulated fluids. If vomiting persists for more than 48 hours
peritonitis must be suspected. A diffuse pronounced perito-
nitis results in death and all efforts to prevent a fatal termina-
tion are useless. Laxatives after laparotomy for the pre-
vention of peritonitis have been abandoned. The rectal tube and
injection are relied upon in relieving tympanites and in securing
action of the intestines. If glycerin injections prove fruitless,
syrup and milk seldom fail. If rectal alimentation becomes
necessary three injections of sugar, salt, yolk of egg, and
cognac are given every 24 hours. Forced nutrition advised by
Leube consists in the subcutaneous injection of sterilized olive
oil underneath the fascia of the thigh in quantities varying
from 40 to 60 grams. If the patient requires energetic stimula-
tion camphor is added to the oil. It will be seen from the
foregoing that the after-treatment in many respects differs from
that in general use elsewhere. As the changes made are bascil
upon an enormous experience the advice given deserves tin-
serious consideration of all surgeons.
Dr. KilmmelV H Operations. — I was fortunate enough to find
Dr. Kiimmell at his post after his return from his summer
vacation and to witness a number of operations, which I will
describe briefly :
Case I. — Carcinoma of cardiac orifice of stomach; gastros-
tomy. The patient was an old man, emaciated almost to a
skeleton and very anemic. Cardiac obstruction was almost
complete. After the necessary preparatory treatment gastros-
tomy was performed under the influence of the chloroform-
oxygen mixture. An incision two fingers breadth below and
parallel with the left costal arch, which divided the rectus
muscle almost completely, was made. Stomach was very
small and atrophic and there was extensive malignant disease.
A small incision was made in the stomach as near as possible
to the cardiac orflce and a N61aton catheter the size of a large
lead pencil was inserted and fastened in its position with
two stitches of fine silk. Two inches of the catheter were then
sewed over according to Witzel's method. The anterior wall
of the stomach around the catheter was sutured to the parietal
peritoneum in the upper angle of the wound and the incision
closed with three rows of continuous catgut sutures and one of
silk for the skin and deep fascia. Two ounces of port win©
were at once poured into the stomach through the catheter.
Case II. — Betroversion of the uterus; shortening of the
round ligaments by the Alexander method. Dr. Kiimmell has per-
formed this operation 150 times, and is very much pleased with
the immediate and remote results. In a number of cases the
patients became subsequently pregnant, and experienced no
inconvenience before and after delivery. He follows the advice
of Dr. Goldspohn and opens the peritoneal cavity on both sides,
a modification of the typical extraperitoneal method of Alex-
ander, which he believes presents many advantages, as it per-
mits the insertion of the index finger, with which adhesions
can be separated, the exact position of the uterus ascertained,
and with which reposition of thedlslocated uterus can be made.
Incision was made over the entire length of the inguinal canal.
Bound ligament was found and isolated in the upper part of the
canal. The ligament was followed in a downward direction
and torn from its insertion. By making traction on the liga-
ment, the parietal peritoneum was drawn forward in the form
of a funnel and was incised with scissors above the ligament.
With the index finger introduced through the slit in the
peritoneum the necessary exploration was made, and by traction
on the ligament and pressure against the posterior surface of
the uterus complete reposition of the displaced organ eflected.
With two catgut sutures the pillars of the canal and ligament
were transfixed. The free end of the ligament was then used
as a living suture, using for this purpose a large, short, flat,
curved needle with which three stitches were made, including
the firm fascia of the external oblique. The ligament was
fastened to this fascia with two catgut sutures and the project-
ing part cut off even with the muscular layer. Suturing of small
superficial wound was done with silk. The same operation was
done on the opposite side.
Cask III. — Inoperable carcinoma of the rectum; left iliac
sigmoidoslomy. Under general anesthesia an incision was made
through all at>donilnal layers, three inches in length two fingers'
breadth above and parallel with Poupart's ligament. The dis-
tended sigmoid flexure was readily found and brought forward
into the wound. The surface of the bowel was sutured first to
the peritoneum, then the muscular layer, next fascia and finally
the skin with continuous catgut sutures. Visceral incision
will be made 24 hours later without an anesthetic.
Case IV. — Oenu valgum; tran.werse linear osteotomy.
The patient was a baker, aged 19. Right limb was affected,
deformity being far advanced. Under general anesthesia
an incision was made down to the bone an inch in length at a
point corresponding with the upper margin qnd internal
border of the patella. With an osteotome | inch in width
the bone was incised transversely until the fracture could be
completed by manual force. The bone was very dense and the
chisel had to be reinserted three times before it was possible to
fracture the remaining part of the bone. No sutures. The
wound was covered with a small sterile dressing. After correc-
tion of the malposition the limb was immobilized upon a well
padded posterior splint. In a few days a plaster-of-paris dress-
ing will be applied and will remain until bony consolidation is
complete.
Case V. — Relapsing appendicitis; appendicectomy. The
patient, a young man, had six attacks within as many months.
Last attack occurred 13 days ago. Acute symptoms subsided
a few days ago. There was no temperature, no swelling.
Oblique incision was made in line of McBurney's point, dividing
all of the layers of the abdominal wall. Appendix was imbedded
December 13, 1902]
SURGICAL METHODS IN THE HAMBUKG-EPPENDORF iamkricas Miroion™ 946
in a mass of adhesions behind the cecum. There was a small
abscess around the tip of the appendix in communication with
perforation. Mesenteriolum clamped in sections and tied after
removal of appendix. Appendix was ligated at the base with
fine silk. Mucous membraneof stump was excised with curved
scissors and raw surfaces sutured together separately. Stump
was buried by sewing over it the adjoining serous surfaces.
Pus was carefully wiped from abscess cavity, which was packed
with a strip of eophen gauze which was brought out at the
upper angle of the wound. Incision was closed with etagen
continuous catgut sutures. Skin was sutured separately with
silk. A small absorbent dressing was held in place with strips
of perforated adhesive plaster.
Case VI. — Tntestinnl obstruction; laparotomy. The pa-
tient was a woman, aged 30. For several months she had
repeated attacks, which from the syinptoms resembled in
many respects relapsing appendicitis. Tympanites was well
marked, especially in the upper segment of the abdomi-
nal cavity. No swelling could be detected in the ileo-
cecal region. Temperature 38° C. There was constipation
and occasional attacks of vomiting. Considering the uncer-
tainty of the diagnosis, the incision was made along the
outer border of the right rectus muscle. Patient in Tren-
delenburg position. Appendix was small and presented no
macroscopic lesions. Appendectomy. A cystic right ovary
was removed. Tube was removed separately. Upper part of
small intestine was distended and very vascular. Lower
part of ileum was pale and collapsed. Eventration and careful
examination failed to demonstrate the existence of a mechanic
obstruction. Cecum was also distended and vascular. Reduc-
tion of intestines was facilitated by lifting the margins of the
abdominal incision with short vulsellum forceps, and by cover-
ing the intestines with an artificial peritoneum of gauze over
which uniform, gentle, manual pressure was made. Suturing
of abdominal incision was done in the customary manner. The
operation relieved the symptoms of obstruction, and the patient
was progressing favorably four days later. (Was this a case of
adynamic obstruction caused by intestinal sepsis?) Toward
the completion of the operation the patient became somewhat
collapsed, and an assistant resorted promptly to intravenous
infusion of one liter of saline solution. The pulse and general
appearance improved visibly in a short time after the infusion.
Cask Vlf. — Renal tuberculosis; nephrotomy; freezing
point of the blood as a diagnostic and prognostic resource
in renal affections. This was a case of unusual interest,
as it gave an opportunity for the operator to give a compre-
hensive account of the diagnostic and prognostic value of the
freezing point of the blood in affections of the kidneys and renal
surgery. Dr. Kiimmell has made a very thorough study of
this subject, and he has found this test reliable in all cases in
which it was applied. The te.'it is a very simple one. All that
is required is a C. thermometer, a large test tube and a freezing
mixture of ice and salt in a glass bottle with a wide neck. Two
O'lnces of blood are drawn from the median basilic vein with a
cannula into the glass tube. Coagulation must be prevented by
constant aeitation. The glass tube is immersed in the freezing
mixture — also the thermometer. The column of mercury falls
until the freezing point is reached, when it rises. The observa-
tions are made at this time and the result recorded. As a con-
trol experiment, the freezing point of distilled water is subse-
quently ascertained for comparison. The freezing point of nor
mal bloo<l is 056° C. In renal insufficiency the freezing point
is lower, and falls with the accumulation of solid material in
the bIoo<i. These facets were first pointed out by Koranyi. Dr.
Kiimmell has applied this test in more than 2(>.'> cases, and has
always found it reliable. He has formulated from his experi-
ences the following rules:
1. A freezing point of 0.58° does not contraindicate an oper-
ation.
2. A freezing point of 0.39° demands caution.
3. A freezing point of 0.()0° and below is a positive contra-
indication to any operative interference on the kidney.
In Case VI I this test showed a low freezing point.of the blood,
butstill within the range of a justifiable operative attempt short
of nephrectomy.
The patient was a boy, aged 14. He had lupus of the face of
long standing. For several months there had been renal symp-
toms. Numerous bacilli were found in the urine. Rightkidney
was much enlarged. Chloroform-oxygen general anesthesia.
Right kidney was exposed by large transverse extraperitoneal
incision. The operator introduced his whole right hand
behind the kidney, liberated the upper pole and in a few min-
utes brought the organ forward into the wound. Kidney was
loi)ulated, pale, soft, and at least eight inches in length. From
the convex surface the kidney was incised from pole to pole,
laying open freely the distended riolvis and calices. Paren-
chyma was pale and edematous. There was very little hemor-
rliage. The immense visceral wound, pelvis, and cjilices were
tamponed willi eophen gauze and after the kidney was replaced
the external wound was tami)oned with the same material. If
after this operation tlie freezing point of the blood improves
nephrectomy will bo performed. A few days after the opera-
tion the patient was doing well.
Case VI If. — Cathefrrization of ureter in male. Dr. Ktlm-
mel is an expert in catheterization of the ureter In the male.
He says tFie operation is much easier in the male than in the
female. He makes use of the uretliral cystoscope manufac-
tured by Remigfr, Gebbel and Schalle, Berlin. The illumina-
tion of the bladder with this instrument is perfect. So soon as
the ureteral orifice is in sight the tip of the ureteral catheter is
bent in that direct ion by a spring, when the catheter is advanced
and finds its way into the ureter without any difficulty. The
case occurred in a man advanced in years who came into the
hospital to be treated for cystitis. Ureteral catheterization was
made as one of the important diagnostic resources. To obtain
the urine from each kidney separately it is only necessary to
insert the catheter a few lines beyond the ureteral orifice.
Catheterization of the left ureter was made in a few minutes
with very little discomfort to the patient.
Case IX. — Primary carcinoma of liver; exploratory lap-
arotomy. Progressive marasmus and repeated attacks of vom-
iting suggested the existence of malignant disease of the
pyloric end of the stomach. The patient was a man between 60
and 70 years. Incision was made a little to the left of the
median line. Liver was enlarged, bard, uneven, and under-
neath the capsule numerous carcinomatous nodules could be
seen and felt. The stomach was small and atrophied. The
abdominal incision was sutured in the usual manner.
Case X. — Radical operation for inguinal hernia by a modified
Bassini- Kucher operation. Dr. Kiimmell treats the sac accord-
ing to Kocher, and modifies the Bassini method of obliterating '
the inguinal canal by placi ng the cord over instead of u nderneath
the fascia of the external oblique muscle. He has performed
this operation in several hundred cases and is well satisfied
with the results. Relapse of the hernia is almost unknown,
and he has never observed atrophy of the testicle as a remote
complication. General anesthesia. Hernia right side. Incis-
ion was made over entire length of canal. Sao, cord and ves-
sels were isolated and lifted away from the inguinal canal with
a strip of iodoform gauze. The sac was opened and tip of left
index finger inserted and employed as a guide in separating
the sac from the cord and its accompanying vessels. Separa-
tion of .sac was done as far as the Internal Inguiual ring. A
Eair of closed hemostatic forceps passed into the canal from
elow, and with it the tissues were tunneled from within
outward over the neok of the sac. Through this tunnel forceps
were inserted from without inward and the sac grasped and
drawn tight. The neck of the sack was securely stitched to
the firm fibers of the external oblique muscle and the sac
amputated close to the sutures. The inguinal canal was closed
with a continuous catgut suture, which included also the
external oblique muscle. The subcutaneous fat and fascia were
sutured separately over the cord with catgut and skin with fine
silk. This operation appeared to be perfect in every detail and
was executed with the skill of a ma.ster.
Case XI. — Radical operation for inguinal liei-nia. Same
operation.
Case XII. — Congenital dislocation of hip-joint; bloodless
reduction. The patient was a girl of 4 J years. Three
months ago it was taken for granted that the bloodless reduc-
tion had succeeded, and the limb was immobilized in a plaster-
of-paris dressing. On removing the dressing a few days ago
the head of the lemur was found outside of the acetabulum.
According t<i the experience of Dr. Kiimmel such failures are
by no means of rare occurrence. In repeating the attempt
reduction was effected and tlie limb was at once immobilized m
a plaster-of-paris dressing at a right angle to the pelvis and
forcible rotation outward with Knee flexed. The fixation
dressing will remain undisturbed for three months.
Case XIII. — Myomatous uterus ; abdominal hysterectomy.
The patient was a multipara, aged .30. Trendelenburg position.
Subserous myofibroma the size of a billiard ball detached in
bringing the uterus forward into the wound. Fundus of uterus
was enlarged by an intramural tumor of the same size. One of
the ovaries was saved. Broad ligament and uterine arteries
were tied with silk. Vaginal opening was carefully closed
with a continuous suture. Abdominal incision was sutured in
the customary manner.
Case XIV. — Salpingilix ; salpingostomy; oophorectomy.
The patient was a multipara, aged 32. A few years ago a ventro-
fixation was made, Auterior uterine mitral adhesion drawn
out into a string at least four inches in length. The infiamed
right ovary was removed. Right tube was enlarged, tortuous
and fimbriated, extremity cl()se<l by adhesions. Almut an inch
of the distal end of the tube was exc'ised, and as the lumen of
the roinaining part was open the mucosa was stitched to the
peritoneal coat with fine silk sutures with the expe<;tation of
restoring the functional utility of the tube.
Dr. ifick's Surgical Work. — Dr. Sick is the second chief
surgeon to the hospital. He is a very quiet, modest man, who
finds his greatest satisfaction in the museum, laboratory,
morgue and operating-room. I doubt if he ever enjoys a vaca-
tion, as he is happiest wlien at work. He is a man of few words,
but knows how to interest his visitors in his operative work.
Ho Is a cxjol, deliberate and dextrous operator. Ho makes bis
plans cArofully and executes them without hesitation and with-
out unne<'os8ary haste. Kvery move he makes is for a definite
purpose, and accomplishes its object. Kvery one who witnesses
bis operations is Impressed with the idea that he is in the pres-
ence of a surgeon of unusual cx|K(rlcnce. Dr. Sick approaches
946 &.1(SBICAM MbOIOINB]
THE WORLD'S LATEST LITERATUBE
[December 13, 1S<W
the most dilDcult task with Ihe same ease of mind and body as
though he were called upon to perform the most insignificant
minor operation. He takes a justifiable pride in many of the
interesting specimens in his collection. He has made a special
study of acute osteomyelitis of the sternum, and his anatomic
and pathologic specimens illustrating this subject throw a fiood
of light on tliis somewhat rare affection. He is now investi-
gating the anatomic changes which take place in the neok
of the femur after amputation of the thigh. The angle of the
neck in the course of time is greatly diminished, undoubtedly
in consequence of traction made by the weight of the stump.
A skull is shown in which, years before death, a piece of bone
nearly the size of the palm of the hand of an adult was removed
and reimplanted. The outline of this enormous disc is well
shown in the specimen, proving conclusively that the bone
temporarily removed retained its vitality and took an active
part in the restoration of the continuity of the skull. The
inner surface of the skull is perfectly smooth, while the
external table of the implanted bone is slightly atrophied. A
number of skulls show what takes place after the Wagner-
Wolff temporary resection of the skull for the removal of
malignant tumors of the brain. The bone at the base of the
flap always united by bony union, while the upper part was
always lifted away from the margin of the cranial defect by the
gradually increasing intracranial pressure, leaving a gaping
cleft for the expansion of the intracranial mass. A large col-
lection of ivory braces and screws for direct fixation of com-
pound and ununited fractures show the different stages of
absorption.
A stomach is exhibited taken from a patient operated upon
lor ulcer of the stomach ten years before death from an acute
pulmonary affection. A gastroenterostomy was made. The
patient improved rapidly after the operation and digestion
remained unimpaired. The specimen tells an interesting story.
The communication between the stomach and upper part of the
jejunum is large enough to admit two fingers. Near the
pylorus and extending along the lesser curvatureof the stomach
is a large, smooth sear, corresponding with the location and
approximate size of the hourglass-shaped ulcer for which the
operation was made. Dr. Sick has had an unusually large
experience in gynecologic, abdominal and pelvic operations,
and I was greatly pleased to witness his skill in this depart-
ment of surgery. I will describe very briefly two of his
operations :
Case 1.— Myofibromas of the uterus ; abdominal hysterec-
tomy. The patient was a woman, aged 33, mother of two
children. Sue had uterine hemorrhages for more than a year.
Intrauterine myoma the size of a small cocoanut projects into
the vagina and was first removed. Laparotomy in Trendelen-
burg position. Quick median incisiou. Margins of incision
grasped with small vulsellum forceps at bleeding points. A
splendid view of pelvic cavity and contents was obtained. The
uterus, the si/.e of an adult's fist, was studded with subserous
tumors. Right ovary, tube and uterus were removed. Dr.
Sick makes exclusive use of catgut as ligature and suturing
material. Broad ligament was tied in sections. After tying
uterine arteries, the uterus was excised rapidly with blunts
pointed, curved scissors. Vaginal opening was hemmed with
continuous catgut suture, which checked all hemorrhage. The
opening was then accurately closed with peritoneal catgut
sutures. Abdominal incision sutured with lour tiers of con-
tinuous catgut sutures. Small absorbent dressing held in place
by strips of perforated adhesive plaster finished the opera-
tion.
Case W.— Appendicitis simulating salpingitis ; appendec-
tom,)/. Patient was a married woman, aged 30. Four years ago she
had a severe attack of what was considered at the time pelvic
peritonitis. Four weeks ago she was delivered of a child. She
has never been free from pain in the right iliac region since the
first attack. Probable diagnosis, pyosalpinx on right side.
Bimanual palpation under anesthesia detected a hard swelling
in the region of the right fallopian tube. Trendelenburg posi-
tion. Rapid median incision. A coil of small intestine was
found adherent to the parietal peritoneum in the right iliac
fossa. In separating the firm adhesions with finger and blunt
instruments, a fecal stone the size of a large bean escaped In
the small cavity in which the stone was lodged the open termi-
nal end of the appendix was discovered. Excision of walls of
abscess-cavity and perforated appendix. The raw surfaces on
the intestine and parietal peritoneum were carefully covered
with healthy peritoneum by suturing with catgut. Adhesions
extended to the fundus of the subinvolutod uterus. Abdominal
incision was closed with four rows of continuous catgut
sutures. No drainage.
A visit to the general hospital Hamburg-Eppendorf should
include inspection of the bath-house, gymnasium, massage-
room, orthopedic department, and morgue. The bath-house,
a model of its kind, is in charge of competent orderlies
and trained nurses. The gymnasium has a complete outfit
of Zander mechanical apparatus for passive and active exer-
cise of every muscle and joint of the body. This outfit was
purchased at an expense of 30,000 marks. Instruction in mas-
sage, theoretic and practical, is given free of expense. Alter
three months the candidates for this kind of hospital and pri-
vate work are examined and if found competent receive a cer-
tificate of proficiency from the orthopedic department. Corsets
and apparatus of all kinds are made by skilled workmen.
From five to twelve necropsies are made daily in the morgue
by men who are familiar with that kind of work and experts in
gross and microscopic anatomy. From what I have seen in
various places on this trip I have come to the conclusion that the
practitioner can see and learn more in one day in the general
hospital Hamburg-Eppendorf than in any other place on the
Continent or anywhere else.
Hambukq, AuKUSt 15.
THE WORLD'S LATEST LITERATURE
Joamal of the American Medical Association,
December 6, 190t. [Vol. xxzix. No. 23.]
1. The Treatment of Tuberculous Glands of the Neck. Leonard Free-
man.
2. Sanatorium Treatment of Tuberculosis: Analysis of 300 Cases
Treated at the United State.s Marine-Hospital Service Banatorlum.
P. M. Carkington.
3. The Sanatorium Treatment of Tuberculosis. S G. Bonney.
4. The Microscope in the Diagnosis of Scarlet Fever. W. N. Jaques.
5. The Treatment of Fractures of the Lower End of the Radius. Carl
Beck.
6. Sarcomatosls Cutis. David Liebekthai,.
1. — Tuberculous Glands of the Neck.— Freeman states
that the gravity of these swellings is underestimated, both in
regard to local deformity and remote secondary manifestations.
General treatment, especially hygiene, is of the utmost impor-
tance in cure of incipient trouble and prevention of relapses
after operation. A climate like that of Colorado is superior to
the seashore. In local treatment it is extremely important to
abolish .sources of infection in the teeth, tonsils, nose, ear, scalp,
etc. Pulmonary involvement does notcontraindicateoperation,
except in advanced cases. Curetment is applicable when com-
plete removal is attended with too much risk, otherwise
thorough operation should be done. The size and shape of the
incision must be adapted to the case, but should be free enough
lor thoroughness and safety. He discusses the possible injur-
ies to the jugular vein and various nerves. The subcuticular
suture should be used whenever practicable to avoid scars.
The chances of permanent cure after operation are better in
Colorado than elsewhere, [h.m.]
2, 3.— See Amei-ican Medicine, Vol. Ill, No. 25, p. 1046.
4.— .See American Medicine, Vol. Ill, No. 25, p. 989.
5. — Fractures of the Ijower End of the Radius. — The
x-rays have shown in CoUes' fracture that with the upward dis-
plai-ement is generally associated a lateral displacement, as a
rule in the outward direction. Beck has, with others, observed
a number of cases in which the lower fragment has turned
backward on the sagittal axis which itself has turned round.
The oblique type in which the joint surface is split was not
recognized before the Rontgen era. Beck reduces as follows :
The hand of the patient is grasped as in a firm handshaking by
the surgeon's left, while the thumb is held by the surgeon's
right hand so that the thumb of the latter presses the fragment
downward while his index finger presses it inward at the same
time. Counter e.xtens-ion must be made at the elbow. In
multiple fractures, even the Y-shaped variety, the articular
arch of the radius may sometimes be restored by repeated
efl"orts of reposition controlled and corrected by the x-rays. If
this proves impossible, speedy osteotomy must be resorted to.
He applies a plaster-of-paris dressing immediately after reduc-
tion. This embraces the thumb if the displacement is upward,
or upward and outward. The direction of the thumb influ-
Decembkr 13, 1902)
THE WORLD'S LATEST LITEEATUEE
(AMBKICAK Mkdicini: 947
ences that of the fragment. If pressure of the index finger does
not keep the fragment down, it must be pressed down with a
stick. When this is bandaged down, the fiuoroscope shows
■whether the fragment is in position. A dorsopalmar and lateral
examination must be made. In the T or Y-shaped variety the
outwardly displaced fragment is pressed inward by a pad of
adhesive plaster. The fragnient, toward the ulna, after being
shifted into place, is prevented from slipping back by rubber
tubing between it and the ulna on the dorsal aspect. The circu-
lar plaster dressing in abduction is indicated. We must not
depend on palpation to assure us of perfect reduction. The
x-rays are more reliable. Early massage for removal of extrav-
asation is indicated In intraarticular fractures and contraindi-
cated when there are chips, [h.m.]
6.— Sarcoinatosls Cutis.— Ijieberthal discusses the relation
to each other of the idiopathic multiple pigmentary or hemor-
rhagic sarcoma and the socalled sarcomatosis cutis, reporting
cases and reviewing the opinions of other writers. Lieberthal
believes both forms are the same process with some modifica-
tions. The character aijd arrangement of the cells are nearly
the same. The papillse and lymph spaces are in similar condi-
tion. There is much similarity in the clinical conditions. The
sarcomatosis cases yield readily to arsenic, while in tiie hemor-
rhagic variety only a few cases are recorded as cured. While
some of the cases do not change secondarily, and are therefore
more amenalile to cure, the majority are subject to secondary
changes, rendering the course unfavorable, [h.m.]
Boston Medical and Surgical Journal.
December 4, 190t. [Vol. cxr,vii. No. 23.]
1. Some Ob.ser\'!itloi).s Upon the Value of the Phloridzin Test for Esti-
raaliiig the Functional Capacity of the Kidneys: Keual Suffl-
ciency. Kkancis S. Watson and W. T. Bailey.
2. Cryoscopy. William T. Bailey.
S. A Note on Pleurisy in Typhoid Fever. Geokge G. Sears.
4. Infant Feeding. Ekne,st B. Kmekson.
1.— Renal Sufficiency and the Phloridzin Test.— Wat-
son and Bailoy employed the phloridzin test in 70 cases. This
test consists briefly in injecting sterilized phloridzin subcutane-
ously, the urinary bladder having been previously emptied, and
testing the urine for sugar one-half hour after the subcutaneous
injection; the test is again made at the end of the second half-
hour. The experiments were carried out with a view of deter-
mining whether it was of practical value in estimating renal suf-
ficiency, as, for instance, prior to a contemplated nephrectomy.
The authors' experiments showed that sugar was always elimi-
nated, but in greater quantity at the end of the first half-hour
than the second ; elimination was much greater in the normal
than in disease 1 kidneys. Experiments made with urine taken
from patients under ether showed the renal function stimulated
by the anesthetic if the kidneys were normal, but this was not
true if the kidneys were disea.sed. On the whole, they consider
the test a delicate and discriminating one, but in a few cases it
was the reverse of this. They are therefore not inclined to
urge its general adoption to the exclusion of the established
tests, [a. B.C.]
52.— Cryoscopy. — Bailey defines cryoscopy as a process
whereby the freezing point of certain liquids may be compared
with that of distilled water. Its application in determining
the renal function consists in a comparison of the freezing point
of the urine with that of tlie blood. Kiiinmel is cited as making
this comparison in 250 cases of diseased kidney and his find-
ings were as follows: The freezing point of the blood in
healthy persons without kidney lesions is .56° C, varying from
.56° to .,')7° below zero. That of the urine is more variable,
standing between 1.2° and 2..'i° below zero. A freezing point,
therefore, of the blood of .58° or lower, or of 1° or higher of the
urine, as compared with that of distilled water, indicates a
degree of renal insufllclency or impairment, making operative
interference on the kidney dangerousand unjustifiable. Bailey
concludes that the results of cryoscopy in renal disease appear
to be of the greatest value, and if by further work in this line
its value receives additional corroboration, the surgeon of the
future will have a means of diagnosis which will be invaluable
in all prospective operations upon the kidneys, [a.b.o.]
3. — Pleurisy in Typliotd.— Sears Ijelieves pleurisy froni
Eberth's bacillus is less rare than supposed. It may easily
be overlooked from the disinclination to examine carefully
patients in acritieal condition. It is rareduringthe first week,
most common after that date while the temperature is high, but
may be delayed until convalescence, or occur as the complica-
tion of a relapse. Its onset is generally insidious. In some
Oases with early onset the absence of abdominal symptoms
suggests that the bacilli may have confined their activities to
the pleura. In later cases emboli have been demonstrated. An
interesting point is the tendency of Eberth's bacilli to disap-
pear from the effusion, which later becomes sterile. In the
writer's cases the Widal reaction with serum from the pleural
cavity varied. In some it was negative, in others more intense
than when blood was used. None of his initial cases ended
fatally, while a considerable proportion of the later ones died.
Free incision and drainage was usually required, but some
recovered after repeated aspiration with or without antiseptics.
[H.M.]
4.— Infant Feeding.— According to Kmerson the child
must be fed so as to avoid not only acute gastroenteric disturlj-
ances but also chronic diseases as rickets, scurvy or marasmus.
The best substitute for human milk is that of the cow. He
gives the percentage constituents of Mellins', Nestles', and
Ridge's food, and malted milk, showing them to be deficient in
fats with an excess of carbohydrates, for the most part of forms
not found in milk, and for which an infant has no digestive
ferment. The fats and proteids moreover are of vegetable
origin. The child may increase in weight, but there is not a
corresponding increase in strength and power to resist disease.
He gives a method of obtaining cream of fairly uniform
strength and the proportions of other ingredients for a prop-
erly modified milk. [if.M.]
Medical Record. •
December 6, 190$. [Vol. 62, No. 2;j.]
1. Operations Upon the Uterine Appendages for Sterility. W. M. Polk.
2. spinal Cord Tumors; Tumors of the Central Nervous System:
Hemurkson Noteworthy Cases. Joseph (Collins.
8. Are Vessels Infected with Yellow Fever? A Keply to Dr. Cart«r.
Alvak H. Doty.
4. A New Stain for Diphtheria Bacilli William Gray Sohauffleb.
1. — Surgery for Sterility. — Polk considers that sterility is
mainly due to some obstruction in the channels of communica-
tion extending from the ostium vaginae to the ovary, and is
therefore very often the result of inflammation of the appendages
and may be removed by an operation upon the tu lies. He thinks
at present the operation upon the uterine appendages for the
purpose in question is no more dangerous than was the accepted
operation upon the uterus for that purpose 30 years ago, and is
therefore equally justifiable. Keference is made to a ease in
which he operated upon a patient for the avowed purpose of
correcting a condition of sterility. The left appendages were
(reed from adhesions and the right tube in part removed,
because it had become a hydrosalpinx and the ovary was
cystic. Two years later the patient gave birth to a child. He
cites similar instances from other operators, and concludes that
when patient investigation has shown conclusively that sterility
is due to some remediable wmdition of the appendagas surgical
interference is advisable. [w.K.]
2.— Spinal Tumors.— This article by Collins is in substance
a continuation of one previously published (Medical Itecord,
February 16, 1902) on " Tumors of the Brain." He says the two
most difilcult features in the diagnosis of tumors of the spinal
cord are to determine wliether the tumor is intradural or extra-
dural, and at what segment of the cord it is situated. The
author reports five cases of his own, and in addition reports the
history of 70 cases found in literature. Of the 70 cases, itO were
operated upon with tlie following results: Twelve wore suc-
cessful, eight partially successful, and ten wholly unsuccessful.
The nature of the tumor could not be ascertained in all the
cases, but so far as determined they were: Six fibroma,
twelve sarcoma, three endothelioma, and one myolipoma.
Most of the fatal cases were sarcomatous. The patients with
fibroma all recoverefi except one, which died of sepsis. A
singular feature is, that out of nine deaths in which the cause
was assigned, four were from sepsis or a septic meningitis.
948 Ajlbbioan Msoicinx]
THE WORLD'S LATEST LITEEATUEE
[Decembeb 13, 1U02
Autopsy showed that of the 40 cases not operated upon, 14 were
operable, thus making a total of 44 of the 70 oases operable.
Collins believes that 5()% of spinal tumors are operable, one-
half or one third being benefited by operation, and this he
says is twice as great as in brain tumors, and this result is
twice as good. H irgioal intervention is tlie only hope for a
patient with spinal tumor, and the earlier the operation the
greater the prospectof cure or marked relief, for long-continued
pressure destroys the elements of the cord beyond hope of
repair. Surgical treatment in tumors of the cord offers the
most hopeful field for surgical interference in all diseases of
the nervous system. One regret is that in the immediately
fatal cases sepsis occupies such a prominent place as a causal
factor. The author's paper gives much in symptomatology, is
exhaustive, and contains much valuable data. [a. B.C.]
8.— Are Vessels Infected with Yellow Fever?— Doty,
in replying to Carter, admits as before that secondary infection
Is not impossible, but holds that it is rare. The difference in
their conclusions may be accounted for by the fact that Carter
refers to a time when sailing vessels, which remained many
days in port, were employed, and when Laveran's Plasmodium
had not been discovered and differential diagnosis was more
difficult. In obscure cases careful ofiftcials give the public the
benefit of the doubt by a forced diagnosis of yellow fever, thus
swelling the numb'ir of secondary cases. In many reported
cases there is no record of autopsy, of the attendance of a sur-
geon, or of any intelligent medical aid. Of 113 cases reported,
but 11 were seen by Carter. Experiments have shown conclu-
sively tliat mosquitos confined in boxes or bags of clothing do
not live more than four days, [h.m.]
4.— New Stain for Diphtheria Bacilli. —Schauffler
describes the metliod of Piorkowski, which stains the bodies a
pale reddish color witli blue-black polar bodies. He has found
more decided results by substituting pyronin (Griibler) for
eosin, and has hit upon a combination of colors requiring the
use of but one solution for one minute and cold. Cultures on
plain agar-agar kept at 37° C. showed characteristic staining after
from 17 hours to 21 days, and spreads made from fresh diph-
theric membranes showed it also, though not so clearly. He
gives the exact formula. This stains the bodies blue and the
poles a ruby-red . [h.m.]
New York Medical Journal.
November 29, 190S. [Vol. lxxvi. No. 22.]
1. The Works of Edward Jenner and Their Value In the Modern .Study
ofSmallpox. Geokge Dock.
2. Typhoid Fever and Drinking Water. A. Seibkrt.
3. Tent Life In the Treatment of Tuberculosis. A. Mansfield
Holmes.
4. Orthoform in the Diagnosis of Gantric Ulcer. Frank H. Murdoch.
5. Uric Acid Bothers. William S. Stoakley.
2.— Typhoid Fever and Drinking Water. — Seibert has
arranged charts comparing the typhoid mortality of New York
City in 10 years with the typhoid morbidity in the Prussian
army. The charts show a striking similarity, proving that the
frequency of typhoid is distributed among the respective
months of the year in exactly the .same proportions among the
soldiers of the Prussian army as among the inhabitants of
New York. As these soldiers have but little in common with
New Yorkers, the author maintains that there must be a chief
carrier of typhoid infection, equally common to New York and
to Prussia, which is similarly influenced as to its efficiency by
the similar climate, and that this carrier is the drinking water.
Charts are also arranged showing the typhoid mortalities of a
number of American and German cities, and comparing the
different systems of water supply. The influence of central
sand filtration is most marked in Berlin, where the mortality
was reduced from 1 in 900 (1843-1853) to 1 in 50,000 (18!)2). [c.a.c]
3.— See American Medicine, Vol. IV, No. 17, p. 648.
4. — See American Medicine, Vol. Ill, No. 19, p. 705.
Itfedical News.
December 6, 1901. [Vol. 81, No. 23.]
1. Volvulus as a Cause of Intestinal Obstruction: With a Report of
Three Oases Operated I'pon Successfully John F. Ekdmann
2. Notes Upon Several Unusual Lnrval Insects Occurring as Parasites
In Man. Allen .1. Smith.
3. Cellulitis of the Orbit, Eyelids. Forehead, and Cheek, Following an
Infected Sore Upon the Finger : Treatment by Free Incisions and
Subcutaneous Injections of Sublimate. Charles Stkdman
Bull.
1. A Comparative Study of the Value of Methylene-blue and Quinln
In the Treatment of Malarial Fever. John T. Moore and W. L.
Allison.
5. Description of an Osteoplastic Metastatic Carcinoma of the Sternum
Following a Primary Carcinoma of the Uterus. A C. YODBB.
8. Laboratory Methods and the Country Practitioner. Edwin A.
MuKBACH and John U. Fauster.
1.— Volvulus.— Brdmann reports three cases of volvulus of
the intestine, causing inte.stinal obstruction. All were in adults
— one female and two males— and all were operated upon with
perfect success. The author quotes from Gibson {Annaig of
Surgery, Vol. xxxii), who studied 1,000 cases of acute intestinal
obstruction, as follows: "Volvulus occurred 121 times. The
frequency as to sex was found to be almost two to one for males
as compared to females. The average age was about 45 years.
Four cases reported were operated upon a second time for recur-
rence and one was operated upon three times. The mortality
when the small intestine was involved was 709^, as compared to
46% when the large intestine was involved." Only one case in
the entire list recorded was successful after resection of the
small intestine. One of Erdmann's reported cases had a resec-
tion of over 32 centimeters (12 inches) of small intestine on the
second day of the disea.se. [a. B.C.]
2. — Unusual Larval Parasites. — Smith describes two
examples. Tenebrio obscums is the American representa-
tive of the English " meal-worm," the larva of Tenebrio
monitor. This, in his case, was coughed up probably from the
esophagus or stomach, and was most likely swallowed, at
farthest, within a day or two of the time it was ejected, as the
intestinal contents of the larva showed a small amount of a
woody material. He gives a minute description of the worm,
as also of Hypoderma bovis obtained from a doughy swell-
ing in the skin. The specimen was somewhat macerated, but
seemed to be in next to the last larval stage. It had probably
existed in the ti.ssue several months before making its presence
known to the patient, [h.m.]
3.— Cellulitis of the Orbit and Face Following Infec-
tion from a Finger.— C. S. Bull reports the case. A woman
of 58 had what was diagnosed as paronychia; this was opened
and drained. She thinks she rubbed the left eye with this
finger. Pain, lacrimation and ocular inflammation super-
vened. Soon the conjunctiva, lids, cheek, face, forehead, and
all the glands of the region were violently inflamed and swol-
len. Repeated incision failed to detect pus. On tlie fourteenth
day subcutaneous injections of sublimate, ti^o, and cocain i%,
were begun. One week later some pus was detected and
evacuated. The patient made a slow and tedious recovery,
but although the eye appeared normal, it had lost the power of
vision, [a. B.C.]
4. — Methylene-blue and Quinin in 3falarla. — In treating
alternate ward cases full doses, 1 to 2.7 gras. (15 to40grs.)of
quinin, or 1.3 gms. (20 grs.) of methylene-blue in four doses,
were given daily according as each ease was assigned. It is
important to recognize the difference between methyl and
methylene-blue as toxic effects are reported from the former.
Powdered nutmeg lessens the tendent'.y to strangury; 60% of
the cases treated with methylene-blue were cured after 6.5 days.
After quinin the cures were 100% in 5.8 days. With the methyl-
ene-blue there was burning or pain on micturition, nausea,
vomiting and headache. His conclusions are that it Is less cer-
tain than quinin but useful when there is an idiosyncrasy to
the latter. It is probably valuable in hematuric and hemoglo-
binuric fevers on account of its diuretic action, [h.m.]
5.— Carcinoma of Sternum by Metastasis fk-om the
Uterus. — Yoder says that the first report of osteoplastic changes
associated with secondary carcinoma of the bone was made by
von Recklinghausen, who in 1891 reported five cases occurring
in males, but Dr. I>o Count, in 1900, reported a case of primary
carcinoma of the uterus with a secondary tumor of the sternum.
Yo'ler gives an abstract of the necropsy record and of the results
of the microscopic examination. The essential features of the
histologic structure of the metastatic carcinoma of the sternum
were: New bone and osteoid tissue exist, produced in part by
December 13, 19021
THE WORLD'S LATEST LITERATURE
tAMEBICAN MbDICINJ, 949
the periosteum, but mainly tlirougli the process of metaplasia,
fibrous connective tissue being changed into bone through the
intermediate production of osteoid tissue. Resorption of old
bone by lacunar absorption and by halisteresis. Ijacunar
absorption predominates when the bone is first invaded by the
carcinoma ; later, the bone being considerably involved, halis-
teresis predominates. The carcinoma is of infiltrating form
seemingly following previously formed vessels. This is espe-
cially well shown in the periosteal involvement and in the
tissue surrounding the periosteum ; but even in the solid bone
there appear small areas of carcinoma as if the epithelial cells
had grown into Haversian canals. Resorption of bone, invasion
by the carcinoma, and formation of new bone go on at the same
time. It is shown by this and other records that bone behaves
toward the epithelial cells as though they were foreign
felements ; here, as elsewhere, the stroma of the carcinoma par-
ticipates actively in the process of tumor growth. [w.K.j
6.— Laboratory Methods and the Country Practitioner.
— Every practitioner, according to Murbaeh and Pauster,
should have a small laboratory as an aid in diagnosis, equipped
for examinations of urine, gastric contents, blood, and sputum.
X-ray and Widal tests should also be provided for. The
writers describe the methods they have found most valuable.
[H.M.]
Philadelphia Medical Journal.
December 6, 1902. [Vol. X, No. 23.]
1. Tbe .Symptoms of Prostatic Hypertrophy: Their Cause and Their
Relief. Edward L. Keyes.
2. The Existence of Typhoid Fever in Atlantic City. Philip Marvei,.
3. Personality as a Factor in Medical Education. Edwakd A. Bai,-
LOCH.
4. iSorae Practical Deductions from 63 Successful Consecutive Opera-
tions for Inguinal Hernia R. C. Hill.
1.— Prostatic Hypertrophy.— Keyes details the etiology,
symptomatology and the treatment of prostatic hypertrophy.
He concludes as follows: Chronic obstruction to urination is
the underlying cause of almost all the symptoms attributable
to hypertrophy of the prostrate gland ; this obstruction may be
regarded as an elevation of the internal urethral orifice;
obstruction may exist without symptoms, and symptoms with-
out obstruction ; the immediate cause of all the symptoms is
congestion, hence to the patient the disease represents only a
congestion, while to the surgeon it represents, for the most part,
an obstruction and elevation of the urethral orifice ; the symp-
toms may often be relieved by depleting the congestion without
regard to the obstruction, yet such treatment is purely palli-
ative and is not the function of an operation ; radical treatment
consists in permanent relief of the obstruction in the floor of
the urethra with little regard to the congestion. This may be
accomplished by cauterization or extirpation of the offending
mass through a perineal or suprapubic incision ; the operation
to V)e preferred must attack the obstacle most directly and
remove it most rapidly, while preventing hemorrhage and pro-
viding drainage; of all the operative procedures so far
employed, perineal galvanoprostatotomy most often fulfils
these conditions, [f.o.h.]
2.— The Existence of Typhoid Fever in Atlantic City.—
Marvel endeavors to prove that the water and milk supply was
exempt from contributing in any way to the source of infection,
and that more than likely Atlantic City was the victim rather
than the source of the disease, [f.c.h.]
4.— Practical Deductions flrom Sixty-three Successful
Consecutive Operations for Inf;uinal Hernia.— In the cases
reported by Hill the Ilalsted operation was employed only
three times. In a few obese subjects an operation practically
identical with Halsted's was employed, but modified by omit-
ting the incision through the abdominal wall. The latter
i method has the following advantages: A portion of the sper-
[' matic circulation is removed in order to reduce the size of the
cord where it traverses the abdominU wall, and the cord is
- placed outside the external oblique muscle, hence being cov-
orod by the skin and subcutaneous fat only; and it does not
I itiirbthe muscles more than the Bassini operation. In all
lii>' other ca.ses the Bassini operation whs employed. Ik.c.ii.]
CLINICAL MEDICINE
David Riesman A. O. J. Kelly
KDITOBIAX COMMENT
The Nature of Beriberi — ^Araong the several
discussions iield at tlie recent meeting of tiie British
Medical Association, that on beriberi,' participated in
by a number of distinguished epidemiologists, was par-
ticularly opportune as well a.s extremely interesting.
The discussion revealed considerable divergence of
opinion with regard to the nature of the affection. Pat-
rick Manson, in an extremely valuable paper, pointed
out that the term beriberi has been variousfcr applied to
a number of different diseases— ankylostomiasis, epi-
demic dropsy, sleeping sickness, etc., and that even at
the present time experienced practitioners in the tropics
include several specifically distinct forms of neuritis
under the term beriberi. He urges the importance of
careful study of the disease, with a view to determine its
true nature. He states that undoubtedly in the tropics
there are cases of peripheral neuritis arising from alcohol,
from ptomains of different kinds, from minerals, such as
tin and arsenic, and from organic poisons developed in
the body in the course of specific infections— but all of
these must be diflferentiated from beriberi, which like the
diseases mentioned, is clinically a peripheral neuritis.
He suggests the following features as a basis on which to
found our recognition of beriberi as a distinct form of
multiple peripheral neuritis, and as more or less dis-
tinguishing it from other pathologic groups with neuritis
as their leading clinical phenomenon. Our ignorance of
its cause, its occurrence as an endemic and epidemic dis-
ea.se, its proneness to produce cardiac disability and
dropsy, the nonimplication of the cranial nerves, with
the exception of the pneumogastric ; the nonimplication
of the intellectual and emotional centers, the rarity
or complete absence of trophic skin lesions, and
the high rate of mortality under certain conditions.
He emphasizes the importance of loss of memory, on the
one hand, and ofproneness to cardiac complications on the
other hand, as differential diagnostic aids in distinguish-
ing malarial from beriberi neuritis. With regard to the
nature of beriberi he expresses the conviction that it is
due to a toxin, the product of a germ operating in some
culture-medium located outside the human body, and
he further believes that the toxin is introduced into the
body neither in food nor in drink, but that it is either
inhaled or introduced through the skin by c/)ntact or
by means of some insect or other animal which inserts
it under the skin, or by a combination of those ways.
The elaboration of these views forms one of the most
interesting contributions to recent medical literature-
more particularly the opinion that the disease is not an
infection by a bacterium or other germ proliferating in
the tissues of the body, an opinion believed to be suj)-
ported by the fact that most sufferers from beriberi begin
to improve shortly after they leave the endemic area.
Aside from the tx^xic theory of Manson, the rice theory
and the arsenic theory received considerable attention in
the discassion. Samlwn, supporting the rice theory,
stated that he did not think that ria> causes beriberi
bwause of its deficiency in mineral and nitrogenous
matters, but he was disposed to believe that rice may be
related to beriberi in the same way as we now believe
pellagra to be related to maize— that rice may become
the vehicle for beriberi inftx-tion. Itoss related some
atlditional instances of the presence of arsenic in the
hair early in cases of beriberi, and while he admits that
the finding of the arsenic may have been a curious ex)in-
cidence, he suggests that it may point to a real connw-
tion between the poison and the disease— a disease which
of itself Is very like chronic arsenical poisoning.
The general trend of opinion in the discussion, however,
was that the disease is an infection, though we are as
I Brilliili Medl al .lournal, 11, «tO, liKK!
960 AXKBIOAH MkDIOTKB
THE WORLD'S LATEST LITERATUEE
[Dbckmbrr 18, IMr.'
yet unable to lay our finder on the germ, its toxin, its
"nidus, or the mode of its entrance into the body. Man-
son well i)oints out that whatever tlie nidus of the toxin-
producinij Kf*'" i"*) both nidus and germ are inti-
mately associated with man, one or i)oth have a wide
general distribution, but a very limited particular dis-
tribution, and l)()th can exist on ships on the high seas
lus well as in men's houses on shore. He believes, also,
that whoever 8uccee<ls in reading this etiologic riddle
will confer an immense boon on multitudes of our fellow-
men, for it is reasonable to expect that when a cause
reiiuiring conditions so complicated as those demanded
by the toxin-jjenerating germ of beriberi is once known,
it can readily be controlled, if not abolished. In the
meantime, Sambon suggests that the following prophy-
lactic measures should be carried out :
1. Men who have recently suffered from beriberi
should not be allowed to join coolie gangs, because they
would most probably suffer from a relapse, and possibly
become a source of infection to others.
2. Patients suffering from beriberi should be isolated
in beriberi countries, because under certain as yet unde-
termined conditions they are undoubtedly a cause of
further infection.
8. Open wounds, ulcers, and abra.sions of any kind
should be most carefully cleansed and dressed in those
who are obliged to associate with beriberi patients.
4. The diet supplied to coolie gangs and to the
inmates of collective dwellings should be varied and rich
in nitrogenous ingredients. The rice should be of good
quality, recently decorticated, properly stored, carefully
washed, and thoroughly cooked.
KEVIEW OF UTERATUKE
Concerning Alcoholism in Children.— After referring
briefly to the great increase in drunkenness in Hungary and
the moral and physical depravity which goes hand in hand
with it, Gross' describes the symptoms of acute alcholism in
children. It acts on the central nervous system in them as an
active poison, producing clonic and tonic convulsions, etc. The
long-continued use of small doses of alcohol (whatever its
variety) produces even graver results, especially so, as it is
often by the advice of physicians that alcohol Is taken. Gastric
and intestinal dyspepsia are very frequent ; of cirrhosis of the
liver Gross has seen four cases in children within two years.
Its poisonous action on the central nervous system is shown by
the fact that epilepsy, chorea, moral depravity and neuras-
thenia can often be traced to its abuse ; he lias seen two cases of
epilepsy and one case of chorea in which spirituous liquors
were given almost from birth. Sometimes a tendency to alco-
holism is inherited, the parents of such children being drunk-
ards. He advises against the use of alcohol in any shape as a
beverage ; as a drug it should only be used in suc^h cases when
strength is rapidly ebbing away or in cases of sudden cardiac
weakness; even then the dose should be as small as possible
and with completion of convalescence it should be stopped.
[E.I,.]
Acate Kpizootic Lieukoencepbalitis of Horses.— W. G.
McCallam and S. S. Buckley « have investigated a disease of
horses which has been more or less prevalent for a number of
years in Maryland, and which has passed under a number of
names, such as staggers, horses' disease, and cerebrospinal
meningitis. The usual symptoms are drowsiness, imperfect
vision, partial paralysis of the throat, twitching of the muscles
of the shoulders and unsteady gait, with a temperature varying
from 9(5° to 103° P. The animals are stupid or delirious. The
disease is usually fatal in the course of a week, while such
horses as recover exhibit defective intelligence. Postmortem
examination reveals a softened area confined to the white sub-
stance of the frontal lobes of the brain. No specific organisms
were discovered, [c.s.d.]
The Topical Diagnosis of Gastric Tumor.- Glaessner '
'Archly fur Kinderhellkunde, 19(V2. Vol. xx.xlv p 15
' Maryland Agricultural suiilon Bulletin, No. so. ''
' Bellner kllnlscbe Wochentchrlft, July 21, 190-.!
reports 13 cases of carcinoma of the stomach, in all of which he
was able to diagnose the position of the tumor by his new
method. The fundus of the stomach secretes pepsin and renniii
while the pylorus produces only pepsin. Accordingly, if a
decrease of pepsin and rennin occurs, the tumor involves the
fundus. If only the pepsin is diminished in amount, the growth
lies at the pylorus. Glaessner advises that it palpation, auscul-
tation and iuHation fail to locate the tumor, his method
should be used, [w.k.b.]
Biologic Studies on Old Age.- On the whitening of the
hair Metchnikoff concludes from his observations that the first
symptoms of approaching old age, the turning gray of the hair
of men and animals, is due to a special phagocytosis. He finds at
the border of tlie medullary zone and the peripheral layer in
gray hairs a large number of pigmented cells of diverse forms,
and which he terms pigmentophages. These cells are of epi-
dermic origin. Arising from the medullary layer they despoil
the normal elements of the peripheral layer and migrate into
the root of the hair, whence they pass into the neighboring con-
nective tissue. [C.8.D.]
Concerning Gonorrheal Diseases and Their Treat-
ment.— Meyen '' discusses the late complications of gonorrhea,
the joint affections, neurites and gynecologic complications. He
considers " Moor baths" at a temperature to suit each indi-
vidual case as the ideal treatment and in most cases a specific,
not to be used only as a last resort but as soon as the condition
is definitely diagnosed, [e.i..]
Treatment of Obstinate Enterocolitis. — Weir' reports the
case of a young man who had suffered from diarrhea, with
blood in the stools, for three years. An exploratory laparotomy
revealed no malignant growth, but the colon was thickened
and congested. The vermiform appendix presented itself at
the incision and its free end was fixed, as it was found to be
permeable and offered a possibility of washing the intestine
through it. This was done after the third day, first with nor-
mal saline solution, tlien with a solution of silver nitrate in the
strength of 4 parts to the 1,000, and finally with a mixture of
bismuth subnitrate in starch water. Kapid recovery followed.
[L.F.A.]
Adiposis Dolorosa (Dercum's Disease). — Boehroch*
reports a case occurring in a woman of 56, who presented the
"four cardinal symptoms noted by Vitaut, viz., the enlarge-
ments, the pains, the neurasthenia, and the psychic symp-
toms" (impairment of memory and mental hebetude).
[A.O..T.K.]
Rtttheln.— Marsden ' gives a critical review of the literature
and his own experience. He agrees with those writers who eon-
siderthediseasefeebly contagious. Heplacestheminimum incvi-
bation period at 12 to 14 days. The most constant prodromata in
his cases have been headache and sore throat. In 60% of his
cases the rash was noted on the first day. At first the spots are
discrete. When fading the color becomes lighter and the rash
blurred so as to be indistinguishable from scarlatina. Thesize
of the spots is between those of measles and scarlet fever, not
so bright a red as the latter nor so purplish as the former.
Coalescence in patches occurs in certain regions, but in no case
has the writer seen it on the trunk. He specially emphasizes
the fact that maximum development does not occur in all
regions at once, thus differing from measles. Subsequent
brown mottling of the skin only occasionally takes place.
Various groups of glands may be affected, but it is generally
those in the posterior cervical triangle. A temperature of 100°
or 101° F., attaining normal about the third day as the rash
fades, is the general experience. The diagnosis is to be made
not on the condition of the skin but upon a mild infectious dis-
ease with an incubation period of 2 weeks or more without sud-
den onset, the rash being often the first indication of illness.
There is no risk of conveying contagion during the 12 days suc-
ceeding exposure. The disease is most infectious at the
beginning, but its infectiousness seems to disappear rapidly.
[H.M.]
> Annates del'lnstlfut Pasteur, No. 12. December 25, 1901, p. 865.
2 Allg. Wien. meri. Zeitg., 19(]2, xlvil, 230.
"Lyon Medical, Vol. xcix, No. 40, 1902, p. 482.
* American Journal of the Medical Sciences, Vol. cxxlv, p. 569, 1902-
5 Medical Chronicle, May, 1902.
Decembkb 13, 1802]
THE WOBLD'S LATEST LITERATUEE
(Amebicav Mbdicibi 961
A. B. Cbaio
GENERAL SURGERY
Martin B. Tinker
C. A. Orr
EDITORIAL COMMENT
Spinal Intramedullary Narcosis In 1884 when
J. Leonard Corning, of New York, made the remarkable
diJicovery that the whole abdominal and caudad portions
of the body could be easily and quickly narcotized tem-
porarily by injecting a weak sf>lution of cocain or eucain
at a proper point within the membranes of the spinal
cord, the fliscoverj- attracted but little attention, its
possibilities were not generally recognized, and it was
soon practically forgotten. Spinal narcosis was revived
within recent years and wide attention was called to the
subject some three years ago by the brilliant work of
Bier, Tuffler, and others. Following the publicity given
by these men, operations by this method of narcf>sis
l>ec-<ime general. In fact, there was very precipitate
action in the surgical branch of the profes-!ion in adopt-
ing the new method. Surgeons of eminence were vying
with each other to te the first in their respective
Icx-alities to employ spinal anesthesia. The discovery
was very important in its relations to surgery, and its
practical application was amply demonstrated. But
certain enthusiasts thought they saw in this means of
inducing narcosis almost a complete revolution in major
surgical prcx;edure ; chloroform and ether would fall
largely into "innocuous desuetude," and the dangers
and discomforts incident to the employment of a general
anesthetic would be obviateil. It is needleas to say
that subsequent events have proved these expectations to
have been poorly founded. On the other hand, the
popularity of this method of narcosis has distinctly
waned. No doubt even now a considerable numl>er of
rases are operated upon through this means of narcosis
which are not reported, but the fact remains that it has
largely fallen into disuse. There is not sufficient to
a<count for this disuse unless it lie that the method
ceased to be new and novel and that those who had
employed it once, or at most a few times, were willing
to return to the older methrxls. The ill effects following
this means of inducing anesthesia were not sufficiently
great to lead to such precipitate abandonment of it. It
is true that until very rec-ently the methofl was thought
to be limited in its application to the regions of the body
below the diaphragm, and practically below the umbili-
cus, and this has doubtless limited its employment.
Morton, of San Francisco, however, has recently shown'
that spinal intramedullary narcosis is applicable to all
parts of the bfxly. In contrast to the general nonuse of
this method by the profession, he reports its employment
in 073 cases, in 60 of which it was used for operations
alH)ve the diaphragm. Among the latter he mentions
amputation of the breast, amputation of the arm, excis-
ion of the suf)erior maxilla, excision of inferior maxilla,
thyroidect/^)my, excision of tuterculous glands, enuclea-
tion of eye, etc. Morton lost but one patient whfjse
death could be attributed in any way to the method of
anesthesia. This has extended the application of socalled
spinal anesthesia very much, but even without this
recent extension it has a field of usefulness in thfwe
jmrts of the body below the umbilicus, and it is particu-
larly Hdapte<l to operation in these regions in certain
conditions which contraindicate a general anesthetic,
such as dangerous pulmonic, cardiac, or renal lesions.
Of course, even in these castas spinal intramedullary nar-
cosis would not be resorte<l to in conditions suitable for
the Ifx-al infiltration method, but in operations upon the
deeper structures, particul&rly uiwn the lower abdomi-
nal viscera under the wjnditions named, is distinctly
indicated.
> Joiirml of the AmiTUan Mi-<ll<:il AKK/wlalion, Novembers, 19IIS.
BEVIEW OF LITERATURE
liang Complications with Appendicitis. — Sonnenburg ■
finds from examination of Iiis records in 1,000 operations for
appendicitis lung complications in 5% of tiie cases. Seven
hundred and forty cases were operated upon in the Moabit
Hospital of Berlin. Eml>olism and infarcts were observed in
3 patients, 2 of whom recovered ; in 5 cases of pneumonia 3 of
the patients recovered; in 7 cases of pleurisy and 1 of bron-
chitis all the patients recovered. In his private sanatorium 13
cases were reported ; out of 260 operations 3 cases of infarct and
9 out of 10 cases of embolism recovered. Twelve of these com-
plications occurred in operations undertalcen during the attack
of appendicitis, and only one in an operation in the interval.
In 20 cases of thrombosis, the right leg was affected 9 times, the
left leg 6 times, both legs in 2 patients, the portal vein in 2
patients, and the vena cava in 1 patient. As to the reason of
thrombosis and eml>olism in appendicitis Sonnenburg believes
that in the great majority of cases the cause is infection. The
operation, by disturbing the inflamed veins, loosens atbrombus
which is thrown into the circulation as an embolus. This may
(HXUT either at the time of the operation, or, quite as frequently,
several days later, [m.b.t.]
Gangrene of the Skin Followinf; HypodermocIysU.—
Baiscb's ^ statements that gangrene of the skin after hypoder-
moclysis with Tavel'g soda solution is due to the irritating
allcalinity of the soda, and that this never takes place with
physiologic salt solution, are combated by Wormser, who h»*.
however, no better explanation for it. He has seen one such
case after Tavel's solution was us«d, but has seen the same
when sodium chlorid solution was injected. He reports one
case of his own and refers to another of Ostermann's. He is
sure it was not due to impurity of the drug or sepsis. He sug-
gests the possibility of injury to a cutaneous nerve, with
secondary disturbance of the blood supply or trophic skin dis-
turbance, [e.i,.]
Operation for Chronic Nonmalixnant Disease of the
Stomach.— Barker ' reports ten cases of this kind in which he
has operated during the past year. All the patients were suf-
fering from pyloric obstruction with two exceptions, and these
were operated upon because of hemorrhage from chronic ulcers.
In one case there was an hour-glass contraction of the stomach
wliicb had been produced by chronic ulceration. He lays con-
siderable stress on the routine preparation of the patient for
some days before the operation by cleansing the stomach by
washing and the administration of only small quantities of
sterile food. Patients are given 10 grains of bismuth carijonate
three times daily as an intestinal antiseptic, and the lowel lx>wel
is cleansed with enemas. The patient is built up as much as
possible by the use of concentrated food and by enemas. In all
the cases gastroenterostomy was performed after von Hacker's
method. All of the patients recovered from the operation, and
the improvement in the health has been most remarkable.
They have all increased i n weight and have been entirely relieved
from their symptoms. Cm.b.t.]
Perineal Prostatectomy by a Special Method.— Hyms ♦
descrii^es his method as follows: The patient Is placed in the
lithotomy position, and thoroughly narcotized, usually with
chloroform. The urethra and bladder are repeatedly irrigated
with boric acid solution. Green soap is used as the only lubri-
cant A staff is introduced, and a median incision is made
through the perineum and the full length of the membranous
urethra is divided on the staff. The incision is deepened till
the apex of the prostate is reached, blunt dissection Iteing used
to give as free exposure as possible. The prostatic urethra is
dilated with a divulser, and the author's rubl>er retractor col-
lapsed is introduced into the bladder. Its stylet is withdrawn,
and the bulb of the retractor is distended with water ijy means
of a piston syringe. This l>ulb within the bladder presents a
Arm shoulder at the bladder neck, and when the stem is pulled
upon the prostate is brought well within reach. The operator
makes traction opon the retractor, turns the stem over the
pabes, and the assistant holds it firmly. It Is never in the way,
I
■ Arcblv r. ktlnlMbe Cblrurgie, 11102. Vol. |x vlll, p. 488.
* Dealaebe medlclnliicbe Wocbenwhrirt, October M. 1M2.
'Lancet, 1902 Vol U, p. rm
* British Medical Journal, .Noreniber 8, IMB.
952 AUBBIOAN MimCINBl
THE WORLD'S LATEST LITERATURE
[December 13, 19C2
It serves to keep the scrotam from the wound, and It answers
Its specific pur|)ose admirably. The operator incises the
filjrous sheath of the prostate with the uterine scissors; he
enters the sheath with his index finder, and, having found the
line of cleava);e, ho enucleates the prostate, removing first the
left lobe; next the middle lobe, socalled, and finally removes
the right lobe. Sometimes the prostate comes out intact within
Its own capsule. One great advantage of the rubber retractor is
its hemostatic power; as a lobe is removed the pressure of the
bulb closes the space and the bleeding is checked. Usually,
but not always, the floor of the prostatic urethra is divided
when the middle portion is being taken out ; but the author has
had all his specimens examined by the microscope, and it has
been shown that no mucous membrane has been taken away in
any case except one. After the enucleation has been completed,
the ordinary perineal drainage tube is introduced into the blad-
der. The wound and the space behind the bladder, from which
the prostate was removed, are packed with iodoform gauze and
dressings applied, [a.b.c]
GYNECOLOGY AND OBSTETRICS
WiLMKB Kruskn Frank C. Hammond
REVIEW OF LITERATURE
The Occurrence of Anaerobic Bacteria in Fetid Sup-
puration.—Wallgren ■ ascribes to Pasteur, in 1861, our first
knowledge of anaerobic bacteria as expressed in his principle,
" Fermentation is life without air." Two years later Pasteur
and others, in extended researches, found essentially anaerobic
bacteria in different animal excretions. The most important
and systematic recent experiments in this line are those of
Dr. Veillon, in Paris, in which he has demonstrated the exist-
ence of obligate anaerobia in appendicular peritonitis, liver
and lung abscesses, lung gangrene, and abscesses of the brain ;
also in infection of the urinary apparatus and female genitalia.
Wallgren reports the case of a woman with acute parametritis
following abortion. The malodorous pus obtained from the
abscess contained six different characteristic anaerobia, some
resembling cocci, others rod formed. After the patient died
there were found abscesses of the brain, the pus from
which furnished anaerobia of the same species. Wallgren con-
siders the combined methods of Liborius and Veillon as best
adapted to these investigations, and is convinced that they will
materially increase our knowledge of the processes of disease
[W.K.]
Necrosis and Spontaneous Elimtnation of a Large
Myoma.— Schmauch ^ reports a case of the spontaneous elim-
ination of a myoma occurring in a woman of 45, who had borne
two children. When he first saw the patient there had been
for four years at her periods a discharge of pieces of tissue
accompanied by much pain. Finally, on account of a persistent
watery discharge she sought medical advice. There was found
in the vagina a discolored secretion mixed with fibers. Exam-
ination showed in the much enlarged uterus a soft, smooth
mass, similar to a flaccid amniotic sac, which hung free in the
uterus, and because of the organ's enlargement, the exploratory
finger could not determine its pointof attachment to the uterine
wall. The diagnosis was simple ; it must be a decomposing
myoma, the necrosis so far advanced as to appear like an intra-
uterine maceration of a dead fetus. This mass was removed by
means of curved sarcoma forceps. In three days, by three
repeated applications of the forceps, 400 grams had been Uken
out without any hemorrhage ; and the microscopic examination
of the tissue confirmed the diagnosis of a decomposing fibroid
tumor. A solution of mercuric chlorid as an irrigant causing
uterine colic, ergotin treatment with Irrigation with lysol solu-
tion to cleanse the uterus, was employed and in a few weeks the
patient was discharged with the uterus moderately movable
and only slightly enlarged, a normal portio and no parametritic
exudate. A few similar cases are cited from literature.
Schmauch thinks the case which he reports was an instance of
anemic necrosis, [vv.k.]
> Centrajblatt far Gynakologie, October 18, 1902.
' Centralblatt fOr Gynttkologie, Novembers, 1902.
Removal of Bladder ftor Urinary Cancer.— A. Lapthorn
Smith ' ascribes to Simon the merit of first attempting to graft
the ureters into the intestines preparatory to the removal of the
bladder. Pawlik, of Prague, in 1888, first successfully removed
the bladder from a woman for urinary cancer, having trans-
planted the ureters into the vagina several weeks before. At
the same time he made a new bladder out of the vagina by clos-
ing up the vulva and turning the urethra into it. Ten years
later the woman was living in good condition. Peterson's
experiments on dogs show that the transplantation of the
ureters into the bowel was usually followed by death from
ascending infection, and according to Bovfie's statistics, out of
31 instances of this operation upon human subjects there were
1.3 deaths from the same cause. In order to avoid this infection
Mauclaire cut off the rectum at its junction with the sigmoid,
turned the edges in and sewed them up carefully so tliat it
would retain a half pint of urine, and this, when disinfected,
made a very good bladder, and did away with the danger of
ascending infection. This made necessary an artificial anus,
which Gersuny avoided by drawing down the sigmoid and
bringing it into the sphincter ani so as to have both the new-
bladder and the rectum under control. This procedure was
adapted to both sexes, but Pawlik's was for women only, and
of this there have been eight cases with two deaths. The
removal of the bladder for malignant disease is a serious
operation, since in 21 cases tabulated by Bov6e there were 11
deaths — over 50%. As this operation for exstrophy has a death-
rate of only 19%, Smith thinks that tlie earlier diagnosis and
operation for urinary cancer will bring much better results,
and he seems justified in thus believing by the fact that while
25 years ago the mortality for hysterectomy for cancer was '0%
at the present time it is less than 10%. [w.K.]
Chorionic Epithelioma Malignum. — Schmidt ^ gives the
history of a nullipara, of 2.3, whose symptoms about 4 months
after the cessation of the menses were such that the existence of
a mole was the probable diagnosis, and this was confirmed by
the delivery of this mole soon after. For a few days the patient's
condition was favorable, but on the eighth day there was
renewed hemorrhage, return of fever and a generally bad condi-
tion which persisted for several weeks. Then uterine scrapings
were made, which showed malignancy ; and two months after
the delivery of the mole the uterus was removed by the vaginal
route and found to contain a small tumor, which examination
proved to be a chorionic epithelioma. The blood was thin with
no inclination to clot and only 22% of hemoglobin. The patient
recovered and four months later her general condition was good
with no signs of recurrence. The growth of this malignant
neoplasm was favored by the lack of coagulability of the blood
and its low percentage of hemoglobin. The results of the exam-
ination of the uterine growth in this case add to the probability
of Kworostansky's theory that the chorionic epithelioma, not
finding sufl[iclent nourishment in the surface of the decidua, fol-
lows the course of the blood, penetrates deeper into the muscle
and destroys muscle fibers and cells. The ovaries in this
instance appeared completely normal with no signs of cystic
degeneration, and this fact weakens the claim of Baumgart and
others that the cause of the neoplasm is to be sought in the
cystic degeneration of the changed ovary. [w.K.]
TREATMENT
Solomon Solis Cohen
H. C. Wood, Jr. L. F. Appleman
EDITORIAI, COMMENT
On the Value of Codliver-oil. — Many experi-
menters have attempted to explain the advantages of cod-
liver-oil over other oils in the treatment of consumption
and similar wasting conditions. Their results, however,
have not thrown a great deal of light upon the subject,
and today there are even tho* who deny the possession
of any peculiar virtues to this remedy. *The amount of
evidence is nevertheless so overwhelming as to leave no
' American Gynecology, October, 1902.
2 Centralblatt fUr Gynakologie, October IS, 1902.
December 13, 1902|
THE WORLD'S LATEST LITERATURE
(Amebican Mebicinb 9fi3
room for doubt to the unprejudiced observer that this
substance either contains some principle which has a
peculiarly beneficial effect upon the nutritive process or
represents some combination of properties which make
it far more valuable than any other form of fat known. It
has been supposed that the virtues of codliver-oil depend
on the contained alterative substances, such as iodin, phos-
phorus and the other constituents not found in vege-
table oils, and an extract has been recommended which
shall contain these agents, and on account of its freedom
from the oHy substances be more pleasant to the taste
and less prone to disturb the digestion. On the other
hand some clinicians believe that codliver-oil is valuable
simply because it presents fat in an easily assimilable
form. These latter point to the experiments of Nau-
mann and Berthe, who have found that codliver-oil
passes more easily through an animal membrane than
the ordinary oils and appears in smaller quantities in the
feces than other fatty substances. This has resulted in
attempting to substitute for codliver-oil partially digested
forms of varioas other oils. We have, therefore, two
directly antagonistic theories concerning the virtues of
this substance, and as is usually the ease when we have
such complete opposition in the opinions of equally
trustworthy investigators, the probabilities are that
although each side may be partially right, both are cer-
tainly partially wrong. In other words codliver-oil
probably represents a combination of virtues which are
not to be substituted by any preparation save those
which contain the oil in its entirety.
Recently Wells presented a paper before the British
Medical Association {British Medical Journal, October
18, 1902, p. 1222), showing that codliver-oil holds a
unique place among fats. As the result of an elaborate
series of comparative experiments made with codliver-
oil and other fatty foods, he found that not only was the
entire amount of codliver-oil absorbed, but that a larger
propartion of the food fats were taken up during the
codliver-oil period, that is, that despite the increased
amount of fat (as represented by the oil) ingested, a
smaller quantity was found in the feces. Besides this
his experiments tend to show, although it was not defin-
itely proved, that the administration of codliver-oil not
only increases the fat absorption, but lessens the nitrog-
enous elimination, which would explain the well-
known clinical fact that there occurs not only a deposit
of fat tissue in persons taking this drug, but also an
increase in muscle. He believes that his experiments
show that it is possible for a patient to take on flesh
equal to seven times the weight of the oil taken. An
ordinary emulsion of codliver-oil in his experiments
increased the tissue-sparing effect, although the emul-
sion seems no more readily digesteid than the plain oil.
Incidentally Dr. Wells has showed the fallacy of
statements made concerning many highly-lauded sub-
stitutes for codliver-oil. He has found that a well-
known petroleum emulsion not only failed to influence
the absorption of other fats, but that 96 fc of the petro-
leum ingested could be recovered from the feces within
30 hours. Concerning an extract advertisetl as the
active principle of codliver-oil he remarks that it con-
tains practically all the nitrogen which occurs in the oil,
but that the oil Is better off" without the nitrogen than
with it. If his experiments are to be accepted it would
seem that these active jirinciples represent all the useless
part of the codliver-oil and that the valuable part of the
remedy is that which is thrown away. Nevertheless it
would seem from the experience of many practitioners
that morrhuol at least has developed a definite clinical
value, the explanation of which is still to be given.
KKVIKW OK LITEltATUKK
Thiocol. — The liullelin Oi'niral de Thfrapeutique, Vol.
cxiiii, No. l.'i, 19()2, page 512, states tliat thiocol, which is potas-
sium suKoKuaiacolate, is one of the best drugs in the treatment
of tuberculosis. It is very soluble in water, odorless, possesses
no toxic action, and may be administered in large doses by the
mouth or hypodermically. It may be prescribed In capsule, or
cachet, or in the following solution :
7 grams (2i drams)
3 grams (3j ounces)
5 grains (5 ounces)
Thiocol 9
Syrup of hitter-orange peel . 93
Boiled water 85
One dessertspoonful every four hours.
Under its influence weight increases, cough and expectora-
tion diminish, fever decreases, and the amount of urine is
increased while the quantity of uric acid eliminated is decreased.
[r,.F.A.]
Treatment of Postpartum Fever.— Lolt ' considers ergotin
a prophylactic and a specific against fever after childbirth.
Under the influence of ergotin the relaxed uterus contracts and
the lymph channels become smaller. In consequence there is
less absorption of putrefactive material. He uses the following
formula :
Ergotin 5 grams (IJ drams)
Distilled water 5 grams
Mixture bitter orange 15 grams (4 drams)
Mix. Dose, 10 to 20 drops. 3 times a day. [w.e.b.]
Treatment of Whooplngcough.— Gottschalk ^ has em-
ployed dionin in 52 cases of whoopingcough. In a large num-
ber the duration and Intensity of the attacks were much less,
but the duration of the disease was not shortened. The drug
was given every three hours in doses ranging from .0005 gram
(xio grain) to children 1 year old, to .004 gram (,^ grain) to
children between 5 and 8 years. Its administration must be
watched, [l.f.a.] [The treatment has nothing to commend it
and ought to be avoided, s.s.c]
Lieraon Juice for Rheumatism.— Desplats* recommends
the use of lemon juice in acute rheumatism. He begins with
two lemons, increasing it by two each day until good effects are
apparent. It is administered pure or diluted with water.
[H.C.W.]
Treatment of Conjunctivitis.— Slight catarrhal conjunc-
tivitis* may be treated by washing the lids with a hotSfc solu-
tion of boric acid four or five times daily. The instilla,tion of
three or four drops of the following solution, two or three times
daily, has produced good results :
2 gram (3 grains)
cc. (45 minims)
5 cc. (105 minims)
A feeble astringent solution may rarely be used, such as :
Cocain hydrochlorate 0
Adrenalin solution 1 : 1,000 • ■ -3
Distilled water 6
Or,
Zinc sulfate 0
Distilled water 18
(Jopper sulfate ... 0
Distilled water 18
05 gram {i grain)
5 cc. (5 drams)
05 gram (J grain)
5 cc. (5 drams)
Silver nitrate 0 1
Distilled water 30 |
A few drops of either of these solutions may be dropped
into the eye at night.
In catarrhal conjunctivitis of moderate intensity the lids
should be turned and their surfaces painted with the following
solution :
3 gram (4i grains)
cc. (1 ounce)
This should be repeated daily and must not be neutralized.
The smarting of the lids may be relieved by applying cold
compresses for a half hour several times a day. In rebellious
cases the eyes may be irrigated with a 1 : 4,000 solution of potas-
sium permanganate three times a day, but this is rarely neces-
sary.
Patients with intense catarrhal conjunctivitis, simulating
purulent ophthalmia, must frequently use a wash with a boric
acid solution and once or twice daily the turned lids must be
cauterized with the following solution :
Silver nitrate 2 or 3 grams (30 to 45 grains)
Distilled water 99 cc. (3.^ ounces)
This should be neutralized by saline solution. When the
eyes l)ecome better a i% solution of silver nitrate may be sub-
stituted. [L.F.A.]
> Therap. Monst8b., February, IV02.
' I-a MMcclne Moderne, Vol. xlll. No. IS, p. 106.
HJaz. hcbd. de .Med. el draCliir., April 'i?, liXW.
'Journal des Pratlclens, Vol. .\vl, No. 88, ItXXJ, p. 801.
964 AHBBICAK MbDIOIKK;
THE PUBLIC SEEVICE
[Decemueb 13, 1902 <
THE PUBLIC SERVICE
Health BeporU.— The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
General, Public Health and Marine-Hospital Service, during
tlie week ended December 5, 1902:
SMALIiPOI— UWITBD STATUS.
California:
Colorado :
Florida:
Georgia :
Illinois:
Indiana:
Kentucky :
lx)ulHlana:
Maine:
Maryland :
Ma.ssacbusetts
.Nov K-22
Cases
3
. 10
1
7
1
3
64
1
5
1
11
1
1
1
. 2
2
1
5
11
.. 57
9
3
17
1
1
1
1
2
5
3
. In
1
1
9
1
5
.. 35
ases Im
'.'. 2
2
9
1
'.'. 2
2
2
1
4
'.'. If.
•■s
.. 19
...3,793
]
Deaths
Nov. 15-22
Jacksonville....
.. . Nov. 22-29
Nov. 19-26
Chicago
Indianapolis....
Covington,
New Orleans....
BIddeford
Cumberland....
Boston
Cambridge
('helsea
Nov. 22-29
Nov. 22-29
Nov. 1-29
.N'ov. 24-29
Nov, 2J-29
Nov. l-m
Nov. 22-29
9
Nov. 22-29
Nov. 22-29
Ijiwrence
Marlboro
Newton
Nov. 22-29
Nov. 22-29
Nov. 22-i9
Nov. 22-29
Taunton
Grand Rapids .
Detroit
St. Louis
South Omaha,
e: Nashua
I Nov. 22 29
Michigan:
Nov. 2 -29
Nov. 22-29
1
Missouri :
Nebraska :
New Hampshli
New Jersey:
Nov. 2:^-30
Nov. 2:i-30
Nov. 22 29
1
Nov. 2-2-29
Newark
Hudson Co., Jersey
Hudson Co. Bayonn
Binghamton....
New York
Cincinnati
Cleveland
Hamilton
Altoona
Erie
McKeesport ....
Philadelphia...
Pittsburg
Providence
Nov. 22-29
New York :
Clty.Nov. 2:1-30
e Nov. 23-30
Nov. 22-29
Nov. 22-29
Ohio:
Nov. 21-2S
Nov. 22-29
Pennsylvania:
Nov. 2.'-29
Nov. -22-29
Nov. 22-29
Nov. 22 29
Nov. 22-29
]
Nov. 2'2--29
10
Rhode Island :
Four c
Nov. 22-29
ported
Nov. 22-29
South Dakota:
Sioux Falls
Milwaukee
smallpox-
Guayaqull
Quebec
Paris
Dundee
Nov. 22-29
Wisconsin :
Nov. 22-29
-Forrign.
Nov. 8-15
1
Canada :
Nov. 2-2--/9 . .
France :
Great Britain :
Nov. 8-15
Nov.S-15
Ni.v. 8-15
1
Italy:
Colombia :
Manchester....
Naples
Yellow
Panama
Guayaquil
Tampico
Vera Cruz
Cholera-
Cebu
Manila
Provinces
Cholkra-
Hongkong
Alexandria
Gaza
Lydda
Jaffa
Plague-
pe Colony, Port Eliza
Hongkong
Alexandria
Y'okohama
Nov. 8-15
Nov. 10-17
Fever.
Nov. 18-24
Ecuador :
Nov. 8-15
4
Mexico :
Nov. 15-22
Nov. 15-22
13
U
Philippines :
China:
-Insular.
Sept. 29-Oct. 14
Oct. 12-18
Oct. 12-18
-Foreign.
Oct. 21-28
2
18
2,563
1
Egypt:
Turkey:
Africa: Ca
China :
Egypt:
Japan :
Nov. 1-8
Oct. 25-Nov. 1..
Oct 25-Nov. 1 .
Oct. 25-Nov. 1..
Foreign.
beth.Sept, 2.5
Oct 21-28
Nov. 1-8
Oct. 19-Nov. 1.
1
... 449
... 75
5
1
1
"'. 2
1
1
1
1
Changes In the Medical Corps of the U. 8. Army for
the week ended December U, 1902 :
Allen, First Lieutenant John H., assistant surgeon, now at Camp
Vicars, win proceed to Zamboanga for duty as surgeon at that post
and health officer of the port of Zamboanga, relieving Malof
Thomas C. Chalmers, surgeon, U. 8. Volunteers.
Egan, Major Peter R., surgeon, now on duty as acting chief surgeon.
Sixth Separate Brigade, Tacloban, Leyte, is assigned to duty as
chief surgeon of that brigade.
Heard, First Lieutenant G. P., assistant surgeon, is relieved from duty
at Bacolod, Negros, P. I., and will proceed to Hollo. P. I., reporting
to the chief surgeon of the department for assignment to duty.
GIBSON, Major Robert J., surgeon, is relieved from duty in the
department of Luzon, and will proceed to Iligan, Island of Min-
danao, for as.slgnment to duty.
S.MITH, James W., contract surgeon, is relieved from duty at Hospital
No. 4, Manila, P. I., and will report to the commissioner of public
health, Manila, for duty.
Borden, Major William C, surgeon, is detailed to represent the
medical department of the Army at the third annual meeting of
the American Rontgen Ray Society, to be held at Chicago. 111..
December 10 to 11, 190-2.
Wood, Halsey, L., contract surgeon, will proceed to Fort Flagler for
temporary duty. "
Trcbv, First Lieutenant Albert E., assistant surgeon. Is relieved
from further duty at the U. 8. General Hospital, Washington Bar-
racks, and will proceed to West Point, N. Y., and report to the
superintendent of the U. S. Military Academy for duty, to relieve
First Lieutenant James R. Church, assistant sur)<eon, from tempo-
rary duly at that place. Lieutenant Church will return to nla
proper station at the IT. S. General Hospital. Washington Barracks.
PEhSONS, First Lieutenant Elbebt E., assistant surgeon. Is granted
leave for one month to take effect about December 15
The following-named officers, now at San F'ranclsco, Cal.. are honor-
ably dl.scharged, to take effect DecemberSl, 1902, their services being
no longer required. They will proceed to their homes: Majors
Joseph N. Henry, George B. Lawrason, Charles B. Nichols, sui^
feons, U. S. Volunteers; Captains Fred F. Sprague, Arthur D.
"rentlce, Arthur Jordan. Hyman M.Cohen, Henry W. Eliot, Wil-
liam W. Calhoun, Reuben M. Bonar, Percy L. .Jones, Fred W.
Palmer, Paul Mazzuri, Thurston Smith, assistant surgeons, U. 8.
Volunteers.
Boyd, Captain Robert, assistant surgeon, (J. S. Volunteers Is honor- .
ably discharged, to take effect December 31, 1902. his services being |
no longer required. He will proceed to his home.
AME.S, Captain Elwin W., assistant surgeon, V. S. Volunteers, now ■
serving lo the division of the Philippines, is honorably discharged
to take effect December 31, 1902, his services being no longer
required.
McHenby, Captain George A., assistant surgeon, V. S. Volunteers,
now at San Francisco, Cal., Is honorably discharged, to take effect
DecemberSl, 190-2, his services being no longer required. He will
proceed to ids home.
Bbatty, Walter K., contract surgeon. Is granted leave for twenty-
tlvedays.
SiMMEL. Martin, hospital steward, now at Wastedo, Minn., having
relinquished the unexpired portion of furlough granted him from
the division of the Pliilipplnes, is relieved from duty at Fort Mc-
Dowell and will report at Fort Lincoln to relieve Hospital Steward
August A. Bemtgen. Steward Bemtgen will be sent to Manila,
P. f., for a.ssignment to duty.
Smith, Harry T., hospital steward. Army General Hospital, Wash-
ington Barracks, is relieved from further duty at that hospital and
will report at the Army Medical School, Washington, D. C, forduty
in the pathological laboratory.
Changes in the Medical Corps of the U. 8. Navy tor
the week ended December 6, 1902 :
Dean, R. C. medical director, retired, ordered to Washington, D. C,
forduty as president of the Naval Examining Board— November 28.
Dickson, S. H., medical inspector, detached from the Marine Barracks,
Washington, D. C, and ordered to the Iowa, as fleet surgeon of the
South Atlantic Station— November 28.
Simons, M, H , medical inspector, detached from the lovva and ordered
home to wait orders— November 28.
Crawford, M H., surgeon, resignation accepted to take effect No-
vember-28, 1902— November 28.
Elliott, M. S., passed assistant surgeon, detached from the New York
and ordered to temporary duty with recruiting party at Pueblo,
Colo., and from thence t« the New York — November -29.
Rosenbleuth, J. C, passed assistant surgeon,- detached from the
Wilmington and ordei-ed home — December 4.
A.SSERSON, F. A., assistant surgeon, detached from the Kentucky and
ordered to the Wilmington— December 4.
Dunn, H. A., assistant surgeon, detached from Naval Station, Cavite,
and ordered to the Vlcksburg— December 4.
Changes in the Public Health and Marine-Hospital
Service for the week ended December 4, 1902:
Stoner, G. W., surgeon, granted seven days' leave of absence under
paragraph 179, Regulations.
C.iRTER, H. R , surgeon, detailed to represent the service at meeting of
American Public Health Association at New Orleans, La., Decem-
ber 8-13-December 3. 1902.
Wasdin, Eugene, surgeon, granted leave of absence for twenty-one
days from. December 15 — December 1, 1902.
Maqkuder, G. M., surgeon, leave of absence for twelve days from
November 17, 1902, granted by Bureau letter of November 6, 1902,
amended so that said leave shall be for eight days— November 29,
1902.
Cobb, J. O., surgeon, upon expiration of leave of absence relieved from
duty at Portland, Oregon, and directed to proceed to Los Angeles,
Cal,, and assume command of the service at that port— Novcmtjer
29, 1902.
Wbktenbakkr, C. P., pas.sed assistant surgeon, detailed to represent
the service at meeting ot American Public Health Association at
New Orleans, La., December 8-13 —December 3, 190-2.
Nydegger, J. \., passfd assstant surgeon, granted leave of absence
for six days from December 8 - Iiecember 1, 1902. »
WiCKES H. W., pas.sed assistant surgeon, detailed as inspector of
unserviceable property at Cleveland, Ohio- December 4, 1902.
Mathewson, H. S., passed assistant surgeon, granted leave of ab.sence
for seven days— December 1, 190.'.
Billings, W. C, assistant surgeon, assigned to duty in the office of
tlie United States Commissioner of Immigration at St. John, N. B.
— December 1, 1902,
WiLLE, C. W,, assistant surgeon, to proceed to Baltimore, Md., for
temporary duty — December 3, 1902.
Lloyd, B. J., assistant surgeon, granted leave of absence for three days
—December 4, 1902.
Bahrenburg, L, P. H,, assistant surgeon, granted leave of absence for
seven days from November 25— November 2i, 1902.
RUCKER, W. C, assistant surgeon. Bureau order of November 26, 1902,
directing Assistant Surgeon Rucker to proceed to the Immigration
Depot. New Y^ork, N. Y., for temporary duty, revoked ; and directed
to proceed to Boston, Mass., and report to medical officer in com-
mand for duty and assignment to quarters -November -29, 1902.
Ward, W. K., assistant surgeon, relieved from duty at Boston, .Mass.,
and directed to proceed to Reedy Island quarantine and report to
medical officer in command for duty and assignment to quarters —
November 28, 1902.
Bailky, C. W., acting assistant surgeon, granted leave of absence for
seven days from December 7 — December 4, 1902.
Hamilton, H, J,, acting assistant surgeon, granted leave of absence
for two days — December 3, 1902.
American Medicine
'x^'
QEOROE M. OOUL.D, Editor
Q. C. C. HOWARD, Managing Editor
Cfinical Medicine
David Biesman
A. O. J. Kblly
J. Edwin Swekt
Hklen Mukphy
CHARLES H. DOLLBY
MARTIN B. TINKER, Auittant BdUort
General Surgery
Martin B. Tinker
A. B. Craig
Charles A. Orr
Orthopedic Surgery
H. AuatJSTUs Wii^ON
COLLABORATORS
Obstetrics and Gynecology
WiLMKR Krusen
Frank C. Hammond
efervous and Mental Diseases
J. K. MlTCHBLL
F. Savary Pkabce
TreatmerU
SOI^MON 80I.IS COHKN
H. C. Wood, Jr.
L. F. Appleman
Dermatology
M. B. Uartzbu.
PCBLtHBBD WhkLY AT 1331 WALHDT StKSIT, PhILADILFHU, BY TUB AHKUCAM-UBDICUIB PoBUBHUW CoMTAHT
Laryngology, Ete.
D. Bbaden KYL.K
Ophthalmology
Walter L. Pylb
Pathology
R. M. Pbarce
Vol. IV, No. 25.
DECEMBER 20, 1902.
15.00 Yeably.
state Aid for Cripples. — One of the indirect
results of the visit of Dr. Lorenz to our country will per-
haps be the increased attention of the people and of our
State governments to the needs of cripples and so to the
somewhat neglected science of orthopedic surgery. We
have frequently asked for this added interest, because
there are no patients that so pathetically appeal to a true
human sympathy as the cripple, and especially the
crippled child. It is strange, however, that we have
been so long and so completely indiflTerent to their suffer-
ings. There are, for instance, thousands of patients, big
and little, going about on "peg-legs," and we have
never heard of a philanthropist endowing any fund for
the purchase for the poor of helpful and useful artificial
legs. We read that a movement is afoot to bring the aid
of the State of New York to her thousands of helpleas
cripples. We are only beginning to learn how much
can be done for these victims of disease and injury by
intelligent orthopedic surgeons, and how much can be
done by sympathy to make such patients self-supporting
and render their lives useful and happy. There is no
duty more incumbent upon the State than this of aiding,
edmating, and curing its cripples.
The Supreme Court and the Weltiner Case. —
Physicians will remember the decision of Postmaster-
General Smith in May, 1900, forbidding the use of the
mails to the "American School of Magnetic Healing "
because it was "engaged in conducting a scheme or
device for obtaining money through the mails by means
of false and fraudulent pretences in violation of the act
of Congress," etc. A demurrer was taken, but the
Supreme Court now overrules it and a temporary injunc-
tion is granted the complainants. All of this is based
upon the claim " that the mind of the human race is
responsible for its ills and is a perceptible factor in the
treating, curing, benefiting, and remedying thereof."
.Justice Peckham enters into a long, involved, and more
ingenious than ingenuous argument to show that this
claim of the "School of Magnetic Healing" <ainnot be
proved true or false, and therefore the law cannot
exclude from the' mails, etc. We Americans are learn-
ing disrespect for the law, it is said, much too fast and
furiously. Well, why? Because of such law and such
decisions. According to this decision how can anything
be called false or fraudulent! The counterfeit money I
scamp can substantiate his claim to the use of the mails
for his "fiat money" by exactly the same reasoning.
If his false notes will not pass when it comes to the
experts in money, neither will the claims of Weltmer
pass when they are brought to the test of the experts.
Has the mind of a man (not of the " human race ") any
power over the progress of typhoid fever, hemorrhage
from a severed artery, etc. ? What nonsense ! And
what encouragement to fraud ! When the receipts
averaged from $1,000 to $1,600 a day from persons in the
Unitetl States and foreign countries and the healer was
on vacation how could the "mind " of the healer have
its healing power upon thousands whose names he did
not know? Then what part did " magnetism " have in
the healing? If .Justice Peckham should ask Lord
Kelvin or any school-boy how magnetism works this
way he could get a scientific answer if the contempt of.
the physicist or the boy would allow him to give any
answer. We believe in honoring law and judicial deci-
sions, but we are so afraid of being disrespectful to
Justifje White and Justice McKenna, who could not agree
with Justice Peckham in his decision, that we think
Justice Peckham anfl his assenting associates are wrong,
and are damming the progress of civilization and turn-
ing law into a means of iiyustice and ridicule.
The National Antisaloon League, at its recent
annual session in Washington, so aptly illustrates the
charm-teristic of ignorant zealotry that we cannot for-
bear ((uoting these haters of temperance. The League
unanimously iulopted an addrt»« declaring that it " will
not cease this agitation until the public and those who
control the army understand that liquor selling in the
army canteen Is a ((uestion of national morality, and not
ahme one of military regulation, and that the issue is
whether a handful of ottlcers can safely defy the
expressed moral sentiment of the nation, or that they
can suwessfully convince the people that a saloon is a
ti^mperance society when conducte«l in the army." In
other words the L(«gue, knowing nothing of the facts of
military life at the posts, denies the statements made by
the army officers who do know the fa<!t8. It denies the
statement of SiuTetary lloot that the anti-cantwn law
has increase*! drunkt^nness, veni^eal disi'ase, insubordi-
nation, dt«ertion, moral and physical deterioration.
We do not care, says the League, what the facts may be.
056
EDITOEIAX. COMMENT
[Decehbeb 20, 1902
we do not care what the opinions of the experts may be,
we only care that our will in the matter shall over-
ride the wills of all others. Was there ever a more
unblushing exhibition of dogmatism, recklessness of
truth, and utter indifference to medical and sanitary
progress ? If this foolish fanaticism could in some way
be utilized for the cause of temperance !
What is the Cost of a Patient Per Bed-day in
a Hospital ? — At first glance this looks simple and an
easy question to answer. But is it so simple? An
inspection of the reports of any half dozen hospitals,
doing similar work under approximately the same cir-
cumstances, will reveal a wide range in the amounts
stated as the per diem cost in the several institutions.
In some cases this difference in "cost" is 50^ or more.
Does this mean that the administration of some is so
much more efficient than others? Does it mean that
some institutions are parsimonious in the care of patients,
serving rice perhaps where wholesome meats should be
provided? It does not necessarily mean any of these
things. It may and probably does indicate that the
conception of cost and of a bed-day varies materially in
the several institutions. Upon a uniform basis of calcu-
lation the variation in cost might be entirely normal.
The subject of cost is perhaps nowhere more carefully
studied than among manufacturers, and from them hos-
pital managers may learn some lessons of value. In a
manufacturing establishment the cost of the product is
usually reached in one of two ways. When the out-
put consists of large pieces, as, for instance, locomotives,
and particularly when few if any duplicates are made,
the plan followed is to compute the cost upon each unit
produced, and when the product is made up of many
small pieces, such as screws, each closely resembling its
fellows, it is necessary to ascertain the cost, not upon
units directly, but upon a larger block, say a dozen, a
gross, or even a thousapd. Evidently the first method
of computation is inapplicable to hospital patients, as
they must be grouped together and an average cost
is the most that can be secured. A second prin-
ciple recognized by the manufacturer is that
the charges entering into the cost of production must,
if his figures are to have any practical meaning,
be divided into two classes : (1) Items that are charge-
able directly against the cost of the product; and (2)
items that cannot be so allocated. In building a loco-
motive, for instance, the steel and other materials,
wages of mechanics, etc., belong to the first group, while
fuel consumed in generating power for the shops, repairs
to machinery, wages of foremen, etc., are treated under
the second heading. This principle applied to the com-
putation of the cost of maintaining patients in a hospital
would enable the direct cost, such as food, medical and
surgical supplies, and nursing, which to a considerable
degree must fluctuate according to the number of
patients under treatment, to be definitely ascertained.
The indirect cost, such as salaries of superintendent,
engineer, and clerks, fuel, light, repairs, insurance,
stationery, etc., would also be shown, but as a separate
sum. A plant and an organization must be maintained,
and the expenses incurred thereby are as much a part of
the cost of maintaining patients as is the food they eat
or the medicine administered to them ; but these indi-
rect costs are fixed, and do not in the aggregate fluctuate
to any marked extent in sympathy with the patient-
population, and for this reason they should not be indis-
criminately merged with items constituting the direct
cost, which does respond promptly to variations in the
number of patients. Then, too, conditions are not every-
where the same ; one hospital is located where the
expenses attending the operation of its plant are
necessarily higher than those of another hospital situated
in an entirely different neighborhood ; again, a small or
medium-sized hospital is likely to be under a relatively
heavier charge for fixed expenses than a large institu-
tion, and so in many ways conditions that must be met
produce an effect which if lost sight of may lead to
utterly wrong conclusions. In order to understand the
true meaning of the cost of maintaining a patient in any
hospital, it is necessary to know not only the total cost,
but the direct and indirect per diem cost as well.
State Registration and Leg-alization of Nurses.
— Not early enough, but better late than never, the
nurses are moving toward organization and registration.
At the recent meeting of the New York State Nurses'
Association, Dr. William S. Ely showed that the nurses
now stand where the State medical profession was in
1891, when the law went into effect taking the license to
practise medicine from the schools and putting it in the
hands of the regents. Since that time medical educa-
tion has been evolutionized so thoroughly that it is
equal to a revolution. The nurses are working for a
similar reform in appealing to the Legislature to be
placed under the control of the State Board of Regents.
It is not the aim to interfere with home-nursing, or the
gratuitous care of the sick, but it is plain that the work
of the quack nursing-schools must be ended. Significant
is the almost unanimous vote after much discussion that
the term registered nurse should replace that of trained
nurse in the proposed bill. The first section of this bill
is as follows :
"Any resident of New York State, being over the age of 23
years and of good moral character, holding a diploma from a
legally incorporated training-school for nurses connected with
a general hospital or a hospital for the insane giving a satis-
factory course of at least two years and registered by the
regents as maintaining in other respects proper standards, and
who shall have received from the regents of the university a
certificate of his or her qualitications to practise as a registered
nurse, as hereinafter provided, shall be styled and known as a
' registered nurse,' and no other person shall assume such
title, or use the abbreviation R. N., or any other words, letters,
or figures to indicate that the person using the same is such a
registered nurse."
In Illinois the State Association of Graduate Nurses
has prepared a bill more detailed in its provisions, but
which looks to the same end, and by much the same
methods, as that of the New York nurses. The term
registered nurse is also preferred, but it is made illegal
for those not legally qualified to use the term, trained, or
graduate nurse. As all such bills cannot be retroactive,
and as the quack schools are lavishly pouring out their
" graduates " with " handsome diplomas," the nurses in
all States should hurry to complete their organizations and
Decembeb 20, 1902]
EDITOEIAL COMMENT
[AuBBicAN Medicine 957
secure such legislation as is for the good of the nursing
and medical professions. It is as certainly for the benefit
of the community.
Fauaticisni vs. Evoliitiouary Therapeutics. —
Revolution is so much easier than evolution that all
weak and weak-minded reformers, those who would
reform by words rather than deeds, prefer shrieking
after impossibilities to attaining a measure of certain
betterment. Let us take three illustrations :
1. To enact laws is much easier than to keep up the
strain of educative effort, although every one knows in
his heart that men cannot be made moral by legislation.
Hence it is that so many people prefer prohibition, which
increases the evils of drink, which does not stop the
causes of it, to those small and possible measures which
certainly lessen it.
2. Next to the evils of alcoholism are those of the
unrestricted dissemination of syphilis and gonorrhea.
Probably as much human suffering today comes from
this source as from all other contagious diseases com-
bined. The community is willing to limit the spread of
other contagious diseases by restrictive and punitive
legislation. It elects to leave the curriers of the syphi-
litic and gonorrheal poisons unlimited opportunity to
scatter the virus freely among the innocent, and to curse
posterity for generations. There are fanatics who oppose
restrictive legislation in reference to these diseases in
British and American armies, and who would not allow
any limitation of the evils of prostitution by medical
and governmental control. The results are well-known.
The fiat Justitla rual cadum minds prefer to leave the
degradation utterly unchecked rather than to check it in
part.
3. There are a hundred sects with millions of adher-
ents who prefer to leave all diseases to run their courses
unchecked by that measurable degree of cure which
medical science offers, rather than give up their fanat-
icism for therapeutic imifossibilities.
There are no worse enemies of civilization than the
fanatics who kill all reforms by tlie raging fury of
ignorance for revolutionary impossibilities. Like life
itself, reform is made up of little things, and yet reform
is not a little thing. There is no progress except by
proceeding from where we stand by all the intermediate
stages to where we would be. Evolution is the progres-
sive advance from present conditions to the best through
the better, llevolution is never evolution.
Hospital Sued for Unskilful Treatment. — An
injured builder has brought suit for the sum of $50,000
against a Brooklyn hospital for alleged unskilful treat"
ment of a fractured leg. It appears the fracture united
improperly and a deformity ri'sulted, necessitating an
operation and the removal of bone. We know nothing
of the merits of the case in question, but the instances
within recent years In which surgeons and hospitals
have Ix^en suetl or threatened with suit for alleged mal-
practice have been far too numerous ; so much so indeed
that some surgeons make it a part of their yearly
expenses to be insured against suits for malpractice. It
seems the acme of injustice when an hontwt practitioner
is thus made to suffer pecuniary loas and loss of reputa-
tion, while at the same time " healers" and quacks and
professional abortionists go on unpunished in their
nefarious work. We trust in the foregoing case and in
all similar ones that judge and jury will weigh carefully
the evidence before reaching a decision. The fault
might easily be that of the patient in refusing or neglect-
ing to carry out the doctor's directions, and even though
the patient is blameless it does not follow that the sur-
geon or the hospital is at fault.
Punishing People for Being Sick. — All England
has been indignant at the crime and at the insufficient
punishment of a mother, who punished her daughter
brutally for "a bad habit." It is said that this " bad
habit" was incontinence of urine — which the punish-
ment probably and naturally increased. Almost every
one can remember such an illustration of punishing
children for being ill which occurred in his neighbor-
hood or family during his childhood. The fact arouses
the thought that the oldtime punishments of the insane,
of the aged, etc., are by no means past. To every
oculist's office are frequently brought the pitiable victims
of stupid school-teachers who are still often punishing
children for the astigmatism, myopia or hyperopia which
has prevented them from seeing figures on the black-
board, or from studying diligently, or from being as
bright-minded as the teacher wishes. We know of one
railway superintendent who punishes his men who are
growing presbyopic by discharging them if they wear
glasses. One wonders if the detestable superstition of
the evil eye, and the horrible punishment inflicted on its
supposed possessor, has not arisen because of strabismus.
" Stop prating about insusceptibility to vacci-
nation," says the Bulletin of the Health Department
of Chicago. In proof it cites the case of a little girl
vaccinated seven times without "taking," and her
physicians asked for a permit for her to enter school, on
the ground that she was " insusceptible." Another
trial, however, with another virus, did result in a bike,
and it is argued that if the last trial had not been made
the theory of insusceptibility would have been popularly
held as demonstratetl. Another illustration given is
that of a bank cashier in Hammond who had tried four
times and then trusted to the theory of insusceptibility.
He caught the disease and died on the seventh day after
the attack. What is the greatest number of nontaking
vaccinations known to any of our readers?
No Hospital I'rovision for Patients with Con-
tagious Diseases.— The Hulletin of the Department of
Health of Chicjigo says that there are 60 times as many
deaths from whoopingcough, 110 times as many from
scarlet fever, 28 times as many from measles as from
smallpox, and yet there is " absolutely no provision
whatever" for patients suffering from these diseases in
Chicago. Are there any other cities in which such con-
ditions exist? "When shall Chicago have suitable
hospital facilities for the isolation and care of patients
with contagious diseases?"
968 AMmtaoAa Uboioinbi
AMERICAN NEWS AND NOTES
(Dbcbhbbk 20, 19U2
AMERICAN NEWS AND NOTES.
OKNERAIi.
Scarcity of Doctors in the West Indies.— It is alleged
that there i« only one dootor available for a population of 13,000
in the West Indian island of Nevis.
Cholera In the Philippines is said to be rapidly dimin-
ishing. A late report states that the cases now average but 5
a day instead of 34 a day, as reported a week ago.
Vellow Fever at Panama.— A recent report states that
yellow fever has broken out among the United States marines
on the Isthmus of Panama. It is believed that the marine force
on the Isthmus will probably be concentrated immediately in
Colon, while active steps will be taken to prevent the spread of
the epidemic.
Miscellaneous.— Chicago : Dr. .lames B. Herrick has been
appointed to the Department of Internal Medicine and Dr. John
Ecfwin Rhodes to the Department of Laryngology in St. Mary's
of Nazareth, a new hospital of Chicago. New York City, N.
Y. : Dr. A. S. Chittenden has been appointed assistant in
pathology in the College of Physicians and Surgeons, Columbia
University.— Dr. William M. Leszynsky has been appointed
neurologist to the Lebanon Hospital. — Professor W. W. Keen,
of Philadelphia, and Professor W. Osier, of Baltimore, have
been elected honorary members of the Clinical Society of
London.
Mortality from Suicide.— According to the United States
census reports the total number of deaths reported as due to
suicide in the United States during the census year was 5,498, of
which 4,313 were males and 1,185 were females. The proportion
of deaths from this cause in 1,000 deaths from all known causes
was 5.5, while in 1890 it was but 4.5. Shooting was by far the
most popular method of ending life, with poison and drowning
in the order named. Suicide is on the increase, especially
among the married males. The deathrate of married males,
from 15 to 44, was greater than in unmarried males. After 45
the rate was much greater among the unmarried males. In
females, unmarried, between 45 and 64, the rate of deatli from
suicide was greater than of those married or widowed. Males
between 35 and 39 years were in the majority of those who com-
mitted suicide during the census year of 1900, while among
women the greatest number who killed themselves were
between 20 and 24. Summing up the results in 50 of the largest
cities of the United States, it appears that the average number
of suicides in 1890 was 12 per 100,000, while in 1901 it had grown
to 16.6. San Francisco has the largest ratio, 39.1 per 100,000 of
population. Next comes Los Angeles, with a ratio of 29.8.
Then follows Chicago, Milwaukee, New Orleans, Cincinnati,
New Haven, Rochester, Indianapolis, Philadelphia, Pittsburg,
then Baltimore, and Greater New York, which has only a ratio
of 13.6.
EASTERN STATES.
Must Destroy Infected Animals.— According to the daily
press the Secretary of Agriculture has sent instructions to Dr.
Salmon, of the Bureau of Animal Industry, who is personally
superintending the work of fighting the foot and mouth disease
epidemic in New England, to destroy all infected animals.
Congress has been asked to make an appropriation of $1,000,000
to fight the disease, but it is believed that $700,000 will be suf-
ficient for its eradication.
NEW YORK.
Smallpox in Rochester.— Rochester is reported to be
afflicted with smallpox. Some 40 cases of what is supposed to
be this malady have been reported by the health officer, and it
18 probable that the State Department of Health will send an
inspector to Rochester to investigate the conditions.
MustDisinfect Cars.— State Superintendent of Agriculture
Charles Wietinghas notified all the railroads doing business in
New York that contagious disease prevails among the domestic
animals of Massachusetts, Rhode Island, Connecticut, Vermont
and New Hampshire, and that all cars which have been used
since August 1 for transporting such animals must be thor-
oughly disinfected before they are again used.
Medical Pees.— A New York doctor, who was spending
the summer at an out-of-town resort, was called to attend a
patient with pneumonia. Later the physician returned to his
city practice, meanwhile visiting at stated times the patient in
question. The doctor rendered a bill charging an extra fee for
the visits from the city on the ground of longer distance. Liti-
?,2Vc>7'^^ resorted to and the physician was awarded $251.25 of
the $485.00 asked for.
Insanity in Syracuse.- It appears that Syracuse furnishes
more unfortunates for the insane asylum than any other place of
similar size in the United States. New detention wards are to
be erected in which patients may be placed while awaiting lecal
commitment to the asylum at Ogdensburg. About 75% of all
tne patients in the Ogdensburg insane hospital are from Syra-
cuse, which has occasionally sent 100 patients per year, the
average being about 75. i- j'oai,
PHIIiADEIiPHIA. PENNSYIjVANIA. ETC.
Board of Charities and Corrections.- It is stated that
Dr. Shoemaker, president of the Board of Charities and Correc-
tions, will recommend to the Mayor that the Board of Charities
and Corrections be discontinued, and that the charities be
placed under a commission and the House of Correction be
placed in the Department of PublicSafety. The plan is to place
a man at the head of each department, and pay him sufficient
salary to enable him to devote his entire time to his depart-
ment.
Analysis of Medical Samples.— The New Jersey State
Board of Health reports that 62% of the medical samples
analyzed by the chemists of the board were below the accepted
standard of purity. Examination of 126 food samples, other
than milk, showed there were 77 below the standard. The milk
samples made a better showing. Half of the olive oil samples
from drug stores were impure, but the samples obtained from
grocery stores were pure. The report shows, however, that the
adulteration is not so great as it was in other years. This fact
is due, doubtless, to the activity and vigilance of the Health
Boardj but still it can be seen that the adulteration of food and
medicine still exists to an extraordinary extent.
Hospital Association of Philadelphia.— It is announced
that 25 hospitals of this city have joined the association, which
has been formed for the mutual benefit and the advancement of
hospital work. Dr. .1. Vaughan Merrick has l)een elected its
president. The objects of the association as enumerated at a
recent meeting are as follows : To consider all questions that
may pertain to hospital management; to discuss matters and
methods that may increase the efficiency of the hospital service ;
to consider possible abuses and methods to protect hospitals
from imposition ; to confer, when necessary, with State and
municipal authorities; to devise methods for protection from
contagious and infectious diseases ; to secure such comity and
cooperation as may promote the best interest of all the hospitals
of Philadelphia and the public good. The association is advisory
only, and whatever it recommends is to be submitted for con-
sideration and action to the Boards of Managers of the hospitals
represented.
SOUTHERN STATES.
New Medical Agency Established. — The Supervisors of
City Charities of Baltimore have established in the Southern
dispensary district, where there is no general dispensary with
which the city contracts, a medical agency. The aim of the
agency is to supply the services of a good family physician, with
necessary drugs, to the poor who are not otherwise cared for.
Persons who cannot or should not leave their homes to go to a
dispensary and who are not hospital cases will be treated in
their homes.
Vaccination Certificates Necessary. — The Superintend-
ent of Public Instruction in Florida, acting under the advice
of the State Health Officer, has issued a circular to all school
boards, which directs them to instruct teachers and subordi-
nate officials controlling the schools in all cities, towns, and
villages to require that certificates of vaccination or of
exemption from vaccination be presented by every pupil,
and further, that these certificates Be accepted only when signed
by the city health officer, or an authorized agent of the State
Board of Health. The certificate of no other physician should
be accepted in lieu of that of an authorized health official.
Hospital Benefactions. — New Orleans, La.: Under the
will of the late A. C. Hutchinson three hospitals in this city
will receive $20,000 each. The bulk of the estate, which is
valued at $1,000,000, is bequeathed to the medical department of
Tulane University. Boston, Mass.: Under the will of the late
Mrs. Nancy E. Rust, of this city, the Addison Gilbert Hos-
pital, ot Gloucester, Mass., receives $10,000, to be put in trust
and the income used to maintain the " Chas. E. and Esther G.
Davidson room," which was furnished by Mrs. Rust upon her
husband's death ; $15,000 additional will be given to this hos-
pital, the income of which is to be used for general hospital
purposes. The Children's Hospital receives $5,000 as a memo-
rial to Frank Davidson Rust, a late sou of the testatrix.
Among others, each of the following institutions will receive
the sum of $2,000 upon the death of her husband : The Massa-
chusetts Eye and Ear Infirmary, the New England Hospital
for Women, the West' End Nursery and Infants' Hospital, and
the Home for Crippled Children.
WESTERN STATES.
Ohio Hospital for Epileptics.— The staff of the hospital
entertained the Gallia County Medical Society at its regular
meeting, November 6. A very interesting program was ren-
dered.
Plague in San Francisco. — It is reported that Surgeon-
General Wyman, of the Marine-Hospital Corps, will call a
meeting of the representatives of the California State Board of
Health to convene in Washington about January 1 to consider
conditions with reference to the biibonic plague in San Fran-
cisco. It is known that Chinatown is the nidus for the scourge
and an effort will be made to stamp out the malady.
Decbhbkb 20, 1902]
AMERICAN NEWS AND NOTES
■Akksican MKOioim 959
CANABA.
Smallpox in Ontario.— During November 105 cases were
reported from various parts of Ontario. This is a considerable
1 increase over the number of cases reported for the summer
months.
Commitment to Insane AsyTum. — The provincial secre-
tary of Ontario, whose department has charge of the asylums
of the province, charges that within the past few months
not fewer than five persons who were not insane have
been committed to various asylums in the province. On the
recommendation of the medical superintendents they have
been released. Dr. A. McKinnon, of Guelph, at one time presi-
dent of the Ontario Medical Association, has addressed letters
to the press asking proof that ten physicians have made false
statements relative to the sanity of these citizens. An investi-
gation will probably follow.
FOREIGN NEWS AND NOTES
OENSRAIj.
Jliscellaneons.— London, Eng. : Major Ronald Ross has
been elected to the newly-established chair of tropical medicine
at University College, London.
OiBcial AVoman Physician.— The Greek Government has
appointed a woman to act as prison physician. It is said that
she is the first woman to receive an official appointment at the
hands of the Greek Government.
Plague Inoculation and Tetanus.- The following reaches
us through a student at missionary college at Lahore, India:
"A terrible Ihina happened a few days ago in the Gujrat district
Just north of us. You know how badly the plague attacked the Punjab
last year, reaching Lahore, which had hitherto been immune. i)t
course the hot weather cbet^kcd It, but a great outbreak Is dreaded this
autumn. Though some doctors question its efflcacy, statistics up to
the present seem altogether favorable to ino<>ulation with a plague
serum manufactured In Bombay as a preventive. The great masses
of the people, however, are terribly afraid of it, saying: It Is a trick
of the English (iovernment tf) kill them and reduce the overplus
population ; it causes terrible disease and death; the pain of It is great
for a huge nc^edle is thrust right through the arm ; English folk, It is
true, are lnO(nilated. but the doctors have for them a special prepara-
tion which is harmless. Wild stories of all sorts are circulated and It
is forbidden to Mohammedans by many of their religious leaders. 8o
extreme care has been taken to remove prejudice and a great effort has
been made to Induce the whole population to be inoculated at the
beginning of this cold season. Twenty doctors came from England to
the Punjab alone for the work of Inoculation, and the work was going
on with moderate succe.ss In spite of opposition Now one of the terri-
fying accoinpanlments of the operation Is a haid bunch which appears
and remains for some time on the arm The maker of the serum after
experiment came to the conclusion that this could be avoided by
strengthening the serum and diminishing the dose. Forthwith he sent
out some of his new mixture without sulticlently testing It and a
supply came up to the i'unjab. In a village of Uujiat a docUjr, and If I
have the story correctly, the deputy commLssioner, were trying to
persuade the inhabitants to be inoculated. They demurred, but flnally,
when the deputy commissioner bared his arm, they assured him that
he need not be inoculated, that they were satistled with this exhibition
of his willingness, that they trusted his word More than twenty
were inoculated with the new serum and In a few days every man of
them died of lockjaw. Of course Inoculation for plague Is at an end in
India. Whether others have used the same serum we don't yet know.
The last man of the village In Gujrat died Sunday. There will be
a mighty stir when the natives learn the facts. At present the stop-
ping of Inoculation Is explained by the statement that there Is no
supply of serum to meet the demands of the numerous doctors The
people of the village declared their intention of killing ihe deputy
commissioner if they could lay their hands on him. The poor man
couldn't leave the wretched natives to die without some effort to help
thera, so !!<■ made his will, said goodbye to his wife, and went to assist
them as best he might. He got away alive, but the cursings he received
from the women of the village were terrible. The lieutenant governor,
who was striving his bast to protect the Punjab, and our own deputy
commissioner, who was pushing inoculation hard In l,ahore, are veiy
much cast down. We can't yet tell what will come of It."
CONTINENTALi EUROPE.
Increase in the Population of Krance.— According to an
e.tchange, olilcial statistics recently published show that there
was an increa.se in the population of I'Vance during the year
VMl of 72,:j!«. The statistics for the year I!«X) showed a decrease
of 25,988. The change in 1901 was due more to the increase in
the number of births than to the lowering of the deathrate.
OBITCARIES.
Luciua W. Baker, In Baldwinsvllle, .Mass., I>ecember 7, aged 60.
He was graduated from the medical department of Columbia Univer-
sity, New York, In IIWO. In 1881 ho wa« the medical founder of the
hospital cottages for children at Baldwinsvllle, of which he was one of
the charter corporators, and was the first superintendent, being In
charge for about six years. On June 17, of this year, the twentieth
annt versify of the Institution, he gave an address recounting its early
history. In 1885 he established the Rlvervlew Sanitarium, a private
hospital for adults afflicted with nerve troubles. He was a member of
the Massachusetts Medical Society, and an extensive writer on med-
ical and sanitary subjects.
Bartus Trew, professor of gynecology in the Maryland Homeo-
pathic College of Baltimore, Md., died in that city, December 12, aged
33. He was giaduated from the College of Physicians and Surgeons,
Baltimore, in 1890, and the following year was graduated from the
Hahnemann College, Philadelphia. He was resident physician for
two years at the Maryland Homeopathic Hospital, and last year was
chosen president of the Maryland Homeopathic Society.
Francis F. Forwood, of Chester, Pa., December 9, aged 35. He was
graduated from Johns Hopkins University, Baltimore, In 1888. He
went to Chester In li-92 and became resident physician of the Chester
Hospital, He was a member of the Delaware County Medical Society,
the Board of Pension Examiners, and various other organizations
Henry P. Fricker, In Ashtabula, Ohio, November 27, aged 66. He
was graduated from the Columbian University, Washington, D. C, In
1880. He served as surgeon during the Civil war and was at one time
Superintendent of the State School for the Blliid, at (Xjlumbus, Ohio.
Martin B. Billlngslea, a prominent physician of Northeast Balti-
more. December 8, aged M. He was graduated from -the University
of Maryland Medical School in 1878. He was a member of a number
of medical societies and at one time served as a school director.
Charles M. Lee, In Fulton, N. Y, November 28, aged 77. He was
graduated from the Geneva Medical College, New Y'ork, In 1850. He
was at one time president of the Oswego County Medical Society.
Allan P. Ebbert, In Atlanta, Ga., November 28, aged 3fl. He was
graduated from the Starling Medical College, Columbus, In 1889. He
served as surgeon during the Spanish-American war.
F. Dornhliith, a wellknown hyglenlst of FrankfortK>n-Maln, OeT-
maiiy, died recently at the age of 77. He was the author of works on
school sanitation and hygienic gymnastics.
Harry L,. Klehl, of Fayette City, i^a., died near Bentley vllle. Pa.,
November 29, aged 31. He was graduated from the Western Pennsyl-
vania Medical College, Pittsburg, In 1S96.
Benjamin C Toler, In Astoria, III , November, SO, aged 74. He was
graduated from the College of Physicians and Surgeons, Keokuk,
Iowa, In IteO.
John M. Welsh, In Deersvllle, Ohio, November 21, aged about 00.
He was graduated from the Cincinnati College of Medicine and Sur-
gery In IH«9.
Uorins I>, Oeppeii, In Bernvllle, Pa., December 8, aged 70. He was
graduated from the old Pennsylvania Medical College, Philadelphia,
In 185:5.
J. N. Rice, of Scranton, Pa., December 9, aged 57. He was a gradu-
ate of Ann Arbor Medical College and of the Bellevue College, New
York .
William H. Stayner, of Chicago, December 3, aged 42. He was
graduated from the College of Medicine of the University of Illinois In
1898.
Joseph Clark, of Baltimore, Md., November 27, aged 78. He was
graduated from the London University (Guy's Hospital), England, In
1847.
George F. .Hoiiahan, of Woonsocket, K. I., November 23, aged 27.
He was graduated from the Maryland Medical College, Baltimore, In
1900.
Curtis A. Wood, In Dublin, N. H , December 1, aged 56. He waf
graduated from the Dartmouth Medical College, Hanover, N. H., In
1878.
William H. Ingrain, In Kenedy, Tex., November 24. He was
graduated from the Memphis (Tenn.) Hospital Medical College In 18OT.
Norman G. Ross, In Detroit, Mich., November 27, aged 27. He was
graduated from the Michigan College of Medicine and Surgery In 1896.
James 1>. Abels, of Grant, I. T., died in Paris, Tex., November 20.
He was graduated fix>m the Louisville (Ky.) Medical College in 1894.
Francis .>!. Plillllps, of Lexington, Miss., November 23, aged Si. He
was gr-iUuated from the Tulanc University, New t)rlean8, In 1892.
j)avid H. Montgomery, In Mlflllnvllle, Pa., November 28, aged 68.
He was graduated from the Pennsylvania Medical College In 185'2.
AViUium 1'. Clower, In Cairo, Ga., November 17. He was graduated
from the Pennsylvania Medical College, Philadelphia, In 1855.
Samuel A. .StilolT, of Pattersfm. Pa., November 2:1, aged 45. He was
graduated from the Hush Medical College, Chicago, In 1882.
C. M. ItlcMurray, of Keddick, III., De<:eniber 11, aged .13. He was
graduated fmm the Kusii Medical College, Chicago, In 181W.
Adam E. ICobsnn, In Cincinnati, Ohio, November 27, aged 40. He
was graduated from the Medical College of Ohio In 1888.
Frank K. Agar, In West Toledo, Ohio, November 30. He was
graduated from the Toledo Medical College in 18U:).
I.uunard Laiululs, professor of physiology In the University of
Grelfswald, died recently, aged M.
Nathaniel Feuer, professor of ophthalmology In the UnlversUy of
Budapest, Is dead ut the age of 58.
960 AHBBIOAN MKDIOIJTB
SOCIETY REPORTS
tDEOKMBEB 20, 1902
SOCIETY REPORTS
AMERICAN PUBLIC HEALTH ASSOCIATION.
Thirtieth Annual Meeting, Held at New Orleans, La.,
December 8, 9, 10, 11, and 12, 1902.
[Specially reported for American Medicine.]
Officers for the Ensuing Year.— President, Dr. Walter
Wyinan, Washington, D. C. ; first vice-president. Dr. C. P.
Wilkinson, New Orleans, La. ; second vice-president. Dr. John
L. lieal, Paterson, N. J. ; secretary. Dr. Charles O. Probst,
Columbus, Ohio; treasurer, Dr. Frank W. Wright, New
Haven, Conn.
Officers of the Baoteriologic and Chemical Section.—
Chairman, Dr. H. L. Russell, Madison, Wisconsin ; vice-chair-
man. Dr. V. A. Moore, Ithaca, New York ; secretary, Mr. G.
C. Whipple, Brooklyn, New York ; recorder. Dr. Henry D.
Pease, Albany, New York.
Place of Meeting.— Washington, D. C, 1903.
Report of Committee on Disposal of Refuse Mate-
rlals.- W. C.-WooDWARD (Washington, D. C), a member of
the committee, stated that the present condition of the art of
disposal of city refuse had not advanced materially in the last
year. Many of the largest cities in America had reduction
plants for the extraction of the grease, with more or less suc-
cess. The latest, and in some parts of the country still the most
common method of disposal, namely, that of feeding kitchen
garbage to swine, was now earnestly advocated by a prominent
health officer, although most ardently opposed by most sani-
tarians for many years. It was advocated because under many
conditions it was not unhealthful, if properly conducted, and it
was more economical in smaller communities than any other
method. The Berlin proposition of converting kitchen garbage
into compost had not yet been sufficiently tried. The results
with this method in this country did not seem promising,
except where the soil was quite barren and the cost of labor
very low.
Report of the Committee on Animal Diseases and
Animal Food.— M. P. Ravenel (Philadelphia) made refer-
ence to researches with regard to the cornmunicability of
human tuberculosis to animals. The experimental work of
Ravenel, Mohler, DeJong, Delepine, Orth, Stenstrohm, Fibiger,
and Jansen, Max Wolff, Nocard, Arloing, Behring, and a num-
ber of other investigators was referred to at length, and these
investigations were sufficiently numerous and harmonious in
the results to establish the following conclusions: 1. Bacillus
tuberculosis found in human tuberculosis differed greatly in its
pathogenic powers as obtained from diflferent cases. 2. Two
types of tubercle bacilli might be obtained from man, namely,
one which was somewhat difficult to cultivate, which grew
slowly, and the bacilli of which are short, stubby, and free
from beading— the socalled bovine type ; and the second, which
was cjuite easily cultivated, grew rapidly, was longer, thinner,
and inclined to show beading and curved forms— the socalled
human type. 3. Virulent cultures might be obtained from
both of these types, which when inoculated, according to the
methods used by Koch, and upon the species of animals speci-
fied by him, produced progressive and fatal tuberculosis. 4.
The contention that human tuberculosis could not be trans-
mitted to asses, sheep, goats, and especially to cattle, had been
completely disproved. 5. Koch's failure to produce tuberculosis
in the animals named with bacilli from human sources was prob-
ably due to the use of bacilli of low pathogenic powers. The
report then discussed at length investigations as to the trans-
mission of bovine tuberculosis to man, mentioning the experi-
mental work recently done in this line. The results of these
investigations showed : 1. While the bacilli of human tubercu-
losis werfi found of feeble virulence for cattle, there was a con-
siderable proportion of cases in which these bacilli were viru-
lent for cattle as well as other animals. 2. Bacilli of both tlie
bovine and human type had been obtained from cases of human
tuberculosis. 3. Bovine bacilli introduced into the human
tissues by accidental inoculation, if left, multiplied and pro-
duced disease at the point of inoculation, and even recovered
after a considerable time with their vitality and virulence
unimpaired. 4. Various statistical studies indicated that a con-
siderable proportion of cases of human tuberculosis, and par-
ticularly with children, originated from the ingestion of the
bacilli with contaminated food. It appeared to the committee
therefore, that the conclusions of Koch, announced at the
British Congress of Tuberculosis, to the effect that bovine and
human tuberculosis were different; that human tuberculosis
could not be conveyed to cattle, and that man was insusceptible
to bovine tuberculosis were disproved, and should no longer
have weight with sanitarians. The evidence adduced indicated
that greater care should be exercised to prevent infection with
bovine tuberculosis, and particularly to guard children from
tuberculous milk.
Sanitary Measures Proposed to the Mexican Railway
Companies.— Eduardo Liceaga urged these measures- To
increase the number of cuspidors and furnish them with disin-
fecting solutions capable of destroying the tubercle bacilli
2. Place in conspicuous places placards containing the follow-
ing: Please spit exclusively in the spittoons, as otherwise the
germs of infectious diseases, especially those of tuberculosis,
will be carried into the air. 3. Until the paddings of the cars
was changed for other and more convenient drapery, a wise
plan would be to disinfect the car every time it was unoccupied
with a solution of formaldehyd, which would not alter the con-
dition of the cloth nor its color. 4. Disinfect all sheets and pil-
lowcases before sending them to the laundry. 5. Also disinfect
the tapestries and couches. 6. Keep the car as clean as possible,
and especially the closets and urinals. The railroad companies
in Mexico considered the above suggestions practical and prom-
ised to enforce them.
Cooperation Kssential to Progress in Vital Statistics.-
Cressy L. Wilbur (Michigan) said for the first time in the
history of the country there was an opportunity for continued
systematic cooperation between the permanently organized
departments of the National Government and the various State
and municipal systems of registration to the end that accurate
and uniform statistics of mortality might bo obtained for the
United States and made available for the use of all public health
offices.
Vital Statistics : A Plea for Actuarial Administration
and Control of the Great Resources of Preventive Medi-
cine.— To appear in a future issue of American Medicine.
IjOUIs E. Ruiz (Mexico) presented a paper in which he
spoke of the period in which every contagious disease could be
transmitted, and also of the period in which every sick person
was dangerous to healthy persons near him.
Jose P. Gayon (Mexico) read a paper in which he spoke of
the transmission of pathogenic fungi by flies and mosquitos.
Jesus E. Mon.taras (Mexico) discussed the principal
causes of infectious diseases and the chief means of guarding
against them.
Presidential Address. — Henry D. Holton (Vermont)
reviewed the status of sanitation in the United States, saying the
most wonderful progress had been made along all sanitary lines.
Much of it was the result of the work of members of the associ-
ation. In speaking of yellow fever, he said that we should
recognize the great courage of such devotees of science as Drs.
Walter Reed, James Carroll, and Jesse W. Lazear. The practi-
cal results of work done in regard to yellow fever had been
evidenced this past summer, in that not a case of this disease
had originated in the island of Cuba for the past 14 months, and
the quarantine period had been shorter by three months.
When education had advanced a step further, and the public
came to appreciate that sanatoria for the tuberculous opened to
such as had unfortunately become infected the most promising
avenue of escape from certain death, at the same time it was an
additional safeguard against the spread of the disease, then
would the vox populi demand that justice be done the impecu-
nious sufferers in the establishment by the State of institutions
where, in the earliest stage of the infection, they might be
placed and thus given all possible aid to recovery and the enjoy-
ment of social and productive citizenship. The modified viru-
lence and the reduced power of infection in smallpox had been
seized upon by antivaccinationists and the ignorant as an argu-
ment against vaccination. The association had been striving
for many years for the establishment of a public health service,
and the medical profession was to be congratulated that at last
their efforts had been crowned with success. While all that
was desired had not been granted, yet a substantial, and in
many ways a satisfactory organization had been effected. He
congratulated Dr. Wyman on the enlarged opportunities pre-
sented to him to develop upon a scientific basis a service of
varied functions which shall equal in original research and
demonstration any similar service in the world.
Report of Committee on Public Health Legislation
was presented by U. O. B. Wingate (Milwaukee, Wis.). Rep-
resentatives from various State boards of health and State quar-
antine officials met in Washington with the supervising Sur-
geon-General of the Marine-Hospital Service, and the matter
was carefully considered and finally a compromise ^as
effected, changing the name of the Marine- Hospital Servi^cBto
that of the Public Health and Marine-Hospital Service. A
copy of the law was submitted with the report. The law provides
for an annual conference of the health authorities of all the
States and Territories and the District of Columbia, and that it
shall be the duty of the surgeon-general of the service to call a
conference upon application of not less than five States or
territorial boards of health, quarantine authorities, or State
health officers. It was hoped that this measure provided a
foundation upon which might be built up a national health
service, such as the intelligence of the people and the age in
which we were living demanded.
Experiments in Disinfection with Formaldehyd Gas. —
M. P. Ravenel, (Philadelphia) detailed his experimental work
and drew the following conclusions: 1. Formaldehyd is justly
entitled to the high position which has been given to it as a dis-
infectant. 2. Special apparatus, while useful and convenient, is
not absolutely necessary for the successful application of the
gas. 3. The germicidal power of formaldehyd gas is dependent
on certain factors which, as yet, are imperfectly understood.
Other things being equal, moisture and temperature are the
most important of these factors. 4. In practice every operation
should be controlled by cultural experiment, and no room
which has been exposed to infection should be considered as
DacKHBER 20, 1902]
SOCIETY REPORTS
tAxKKioAK MKDtonnt 961
disinfected unless control cultures exposed in various parts of
said room are shown to have been destroyed.
Report of Committee on Disinfection and Disinfect-
ants.—Hibeet W. HiLi, (Boston). A careful examination of
articles published, both in America and in Europe, had failed to
reveal the discovery of any new disinfectant or process of dis-
infection of great practical value to public health officers
during the last year. As to gaseous room-disinfection, formal-
dehyd still held the first place in efficiency. There had been a
return, to a certain extent, to the ttse of sulfurous acid, owing
to its stronger action upon insect pests, but all the new experi-
ments showed clearly that it was a far weaker disinfectant
than formaldehyd, and could not be depended upon except in a
few limited cases. Gaseous disinfection, as the great panacea
for preventing the spread of contagion, has been considerably
discredited by recent experiments, but the committee were
strongly of the opinion that when properly carried out it was
an important and effective aid in public health work and would
continue to be, and that formaldehyd was by far the best
agent to use in carrying it out. In using formaldehyd two
things should be provided for: (1) A sufficiency of water in the
air of the space to be disinfected, and (2) a very rapid dis-
engagement of the gas. Most forms of apparatus failed in one
or the other of those points. The work of Robinson and Hill,
members of this committee, clearly showed that not only did
efficiency depend upon them, but by properly observing them
much time and material could be saved. The disinfection of
the future must be simple, short, and sharp.
Report of the Committee on National Leper Homes.—
Henry M. Bracken (St. Paul, Minn.) said, among other
things, that after carefully studying facts it would appear that
provision for the care of lepers in Canada was an inheritance
rather than a product of legislation, that the care of lepers in
Mexico began with the invasion of Cortes, and that the methods
of caring for them had been but little, if at all, improved upon
in that country since his time. That provision for the care of
lepers in Cuba was made at an early date by a Jesuit with phil-
anthropic tendencies. Of all the countries embraced in the
Association, the United States was the only one that had made
no provision for its lepers. The commission appointed by the
Marine- Hospital Service recommended one, or preferably two,
national leprosaria for the care of those unfortunates in the
United States. It recommended the selection of sites covering
broad areas in healthful localities where the lepers could have
unlimited out-of-door exercise and occupation. It recom-
mended that these homes should be made attractive and com-
fortable so that the unfortunate victims of this disease instead
of hiding their condition might make it known and request
admission to these public institutions. With present knowl-
edge of leprosy and the methods employed in care of lepers, the
committee advised that the resolution of last year be reaffirmed.
This resolution, in substance, favored the establisliment of
national leprosaria, which might serve not only as a refuge for
lepers, but also as a home and hospital, making their lives
tolerable so far as possible, furnishing employment to those
who were able to work, and giving skilled medical care to all
cases with the intent of possibly curing some, and making the
road to death less wearisome and painful than it now was to
others.
Dangers to the Public Health from Illuminating and
Fuel Gas.- Samuel H. Duroin ( Boston ) said : In pursuing
an inquiry into the danger to health by illuminating gas it had
been the purpose of the committee to consider not only the
question of its poisonous effect as observed from the ordinary
clinical standpoint and of the frequency with whieli the people
were exposed to the effects of this agent, but also to sliow from
carefully conducted experiments upon human subjects just
what physiological changes were produced by long and short
exposures to small amounts of tiie gas and to what extent the
observed changes were continued or permanent. It was shown
ijy investigations that tlie common condition of gas pipes and
fixtures was very poor, the mo<lerate small leaks very numerous,
and that a moderate increase of pressure in the llxtures above
the normal ^as pressure produced leakage in 89% of all the
houses exammed. It was also shown that the numl^er of fatali-
ties from illuminating gas was not only large but was increas-
ing from year to year. In order to a-scertain to what extent the
medical profession in Boston liad recognized cases of acute and
chronic poisoningby illuminating gas he sent out letters to 2,200
physicians, asking for tlioir personal experience in such cases.
He received replies from 4<iO pliysi(^ians; 240 of them reported
no experience; the oilier 214 reported 1,02.') cases of acute poison-
ing; .374 of these resulted fatally, 288 were found dead, and 86
lived from 1 hour to 12 months; 62.3 made complete recovery
iti periods varying from a few hours to 3 years: 28 made
partial recovery while under oljsorvation of from 3 weeks to
21 months. The symptoms reported in the chronic cases were
practically the same as those reported in the acute cases.
SVMPOSIITM ON YELLOW KEVER.
Annual Report on Yellow Fever In Mexico. — Kduar»o
IjICEaoa (Mexico) presented statistics of the spread of the dis-
ease along tlie Mexican coast. The recent epidemic in Vera
("ruz developed 877 cases, being the most fevere in the country.
His report sliowed that 873 cases were on tlie (Julf coast, while
only 27 cases had been reported on the Pacific (Jcoan coast. The
epidemic in the State of Vera Cruz liad been diminisiiing. Tlie
report mentioned the number of cases reported by States where
points of infection had been found. The deathrate was low,
and had been held down by the successful management of the
disease. The government of the State of Vera Cruz had adopted
up to date sanitary measures for the prevention of the spread of
yellow fever.
Yellow Fever Kpidemics in Orizaba, Mexico.- Nar-
cisco DEL Rio (Mexico) related with particularity the history
of the spread of the disease in his section. The inevitable con-
clusion was that the mosquito had been carrying his dangerous
freight from place to place in the Orizaba section, thus causing
the spread of the disease. The essayist found, in tracing the
disease closely, that a coachman who had hauled one sick per-
son had been bitten by a mosquito, and was soon taken down
with the fever. They at once took the necessary means to meet
this agency of transmission, and after that were successful in
cliecking the spread of the disease. '
Yellow Fever.— John W. Ross, U. S. A., gave at length
his reasons for believing that the only way in nature for
yellow fever to be contracted by man was from the mos-
quito. He recommended the following measures against the
propagation of yellow fever through mosquitos : 1. To prevent
those insects from stinging yellow fever patients. 2. To destroy
so far as possible the mosquitos which have been infected. 3.
To consider any place unsafe so long as the last mosquitos
which have stung yellow fever patients may be alive in it. He
stated that the clear-cut, scientific observations and classical
contributions of Surgeon H. R. Carter, of the United States
Marine-Hospital Service, showing the interval (about two
weeks) which occurred in houses between the first (infecting)
case and the first group of cases, secondarily infected, impos-
sible to explain by the theory of fomites, were now readily
understood in the light of present knowledge of the elaboration
of the yellow fever poison in the body of the mosquito, that
process requiring not less than 12 days.
Concerning the Method of Transmission of Yellow
Fever from Man to Man.— William C. Gorgas, U. S. A.,
enunciated practically the same views that have been pub-
lished in previous papers on this subject by him. As to
whether the disease might be transmitted through fomites from
man to man, or whether by the bite of fever-infected mosquitos,
the decision depended on what steps should be taken to confine
yellow fever when it made its appearance, whether a fight
should be made against the mosquitos, or whether cargoes and
vessels, and all things that were to be transferred from point to
point, in which fomites could be conveyed, should be thor-
oughly disinfected. If the germs of the disease could not be
transferred in fomites, then the disinfection of vessels and
cargoes was unnecessary. The only measures necessary would
be the destruction of infected mosquitos and the care of persons
who might transmit the germ to the mosquitos.
The Occurrence of Tubercle Bacilli of Exalted Viru-
lence in Man. — M. P. Ravenel (Philadelphia) stated tliat
the occurrence of tubercle bacilli in man which had a high
degree of virulence for experimental animals was rare, if one
judged by the published reports, and it was still more rare to
find cultures which were highly pathogenic for cattle. So
marked was the difference in pathogenic power of cultures
isolated from man on the one nand, and from cattle on the
other, that a division into races had been proposed depending
on this feature ; and Koch held that inoculation of a given cul-
ture into cattle would surely show whether it was of human or
bovine origin. Believing that bovine tuberculosis was a fertile
cause of the disease in milk-fed children, he had for some time
past taken every opportunity possible of selecting cultures of
tuijercle bacilli from the mesenteric glands of those who had
died of a tuberculosis which was not clearly of respiratory
origin. This had led to the discovery of two cultures, one of
which was as virulent for all animals on which it had been
tested as cultures obtained from cattle usually were; and the
other while not nearly so virulent, was still much in advance of
the usual human culture. The material from which these cul-
tures were isolated was furnished through the kindness of Dr.
Alfred Hand, of Philadelphia.
[ To be concluded ]
Increase In Population In Cities. — F'rom an exchange
we take the following: New York officials claim an increase
of the city's population from June 1, 1900, to January 1, 1902, of
140.728 persons. Chicago claims an increase in the same 19
months of 101,42.5 persons. Neither New York nor Chicago
claims to be retaininjf its percentage of growth from 1890 to 1900.
New York's growth in tliat decade was 37.19i). If New York
grow June 1, liKK), to January 1, 1902, at the rate of 37.1% per
decade, It should have addecf In that jieriod 201,763 persons to its
Sopulation, or 55,0.15 more than its officials claim. Similarly
hicago should have added ">0,822 more persons than are claimed
for it. Chicago claims an increase of 5.9% In 19 months; New
York claims 4.291j, and it is justifialile to say that New York's
otiicials liave probably figured so conservatively as to be below
the actual level of the city's increase. (Conceding, however,
that Now York grew June 1, 1900, to January 1, 1!)02, only 4.2%,
and that only the same growth lias Ijceii preserved to Octolier
31, 1902, the increase of the city since tlie federal census of 1900
must be at least 219,980 persons, making the present population
3,657,182 persons.
962 AxBBioAir MBSionnq
CORRESPONDENCE
[Df.cembek 20, 1903
CLINICAL NOTES AN'' CORRESPONDENCE
[Communications are lnvlt*d for thl8 ncparttnent The Editor le
not renpoDSlble for the views advanced by any contributor.J
BERIBERI AMONG THE CHINESE.
ALBERT 8. A8HMEAD, M.D.,
of New York City.
The Sei-I-Kwai Med. Jour., August .31, 1902, quotes from the
Slnfcapore FVee Presn as follows : " Beriberi causes more than
two-fifths of all deaths among Chinese ; the actual mortality due
to it is 97 for every 10,000 living— nearly l<fc annually, a heavy
toll to be taken by one single disorder from a population con-
sisting almost entirely of selected young male adults."
Will you allow me to inform you that this statement is con-
trary to what Dr. Baelz' said of the disease in 1882: "The
Chinese are seldom affected by the kakke ; Europeans never or
hardly ever." RCmy,* after speaking of the immunity of
Europeans, says : " But if there exists a pronounced difference
between Europeans and Japanese it does not exist between
Japanese and Chinese. Now the Chinese themselves, though
crowded and squalid, seem to be spared." Up to this time
all the European authors who wrote about kakke have
pointed out this immunity (Chinese). Dr. Baelz, in a summary
of their views, in 1882 says: " The Chinese are seldom affected
by the kakke, etc." And further on Dr. R6my says : " Orig-
inally from China, common in the first centuries of the Christian
era, the kakke seems to be infrequent in China at the present
time." The Chinese knew even the different forms of the
disease, wet and dry, etc. They tell of an emigration of
northerners to the south where kakke was rampant, when all
the newly-arrived fell sick. There is therefore no likelihood of
a mistake (in diagnosis). But, he goeson, as to the cause to
which the diminution of the disease ought to be referred, we
remain utterly in the dark. Inversely to China, Japan, which
was at first unscathed, seems to be in a period of increase of the
disease. Kempfer, who lived at Desima during the years 1690
and 1692, made no mention of the disease, and yet he was able
to recognize it if the " infection " was there. Scheube says that
the disease first appeared at the capitals Kioto and Tokio.
Yokohama then became " infected," later Hakodate, and thence
down the western littoral to Nagasaki (near Desima). A short
stay in any of these centers is sufficient to produce the disease.
Now will some one kindly tell us, if the Chinese disease
kakke in Japan was due to a germ, why it first attacked Kioto
and Tokio and not Desima or Nagasaki? And if it is due to
ricealimentation, or eating of " certain uncleansed sorts of
rice," as the State Surgeon of Negri Sembilan, as quoted in the
Singapore Free Press, says it is, why did it not appear first at
the ports of entry of such rice from China, or Ceylon, or India?
Rice culture came from China, and to the south of Japan sooner
than to Kioto and Tokio. Therefore it is reasonable to look for
the first appearance of this imported disease in southern Japan.
Yet just, the opposite occurred. The burning of charcoal in
stoves was more prevalent naturally in the cold north of the
Japanese Empire than in the hot south. Rice, however, is
never cooked in any part of Japan by charcoal fires but by
wood. The rice stove is different from the stove for heating
apartments and cooking tea. The rice stove fire is a well in
the floor ; the fire is started of course by transference of embers
of charcoal from the house stoves, but then wood is lighted over
them, and a hole in the kitchen ceiling allows the wood smoke
to escape. Thus rice importations as articles of diet did not
introduce the custom of burning charcoal in the house heaters.
Charcoal as fuel belongs to northern Japan. It was a habit there
and it spread from north to south as beriberi did. Here is one
connection between beriberi in Japan and charcoal. Besides,
there is another one, absence from Japan of beriberi in the win-
ter months. This might be said to operate against the theory of
carbon dioxid poisoning as the cause of beriberi. But we all
know that cold naturally dissipates carbon dioxid from the air.
08tiweln"\'s«^ Krankheit«n, MItthellungen, der Deut«ch Qesellschaft,
» Notes Mfedlcales sur le Japan, Paris, 1883.
So also does the sweeping north wind ; and moreover there is
necessarily more outdoor life in winter time.
Ogata, in the same number of the Sei-I-Kwai Medical Jour-
nal, has an article " On Ventilation of the Japanese Dwelling-
houses." He refers to his measurements of carbonic dioxid in
warm and cold air. As the air chilled the perceutage of the
gas rapidly diminished. But after setting braziers in the room
he found it to be increased. * He does not, however, refer to the
two important facts pertaining to Japanese house life which
have a bearing on this subject. These are, the habit of Japan-
ese sleeping on the floor, where the carbon dioxid, which is
heavier than air, is noticeably in excess (especially in the beri-
beri season, the wet summer months) ; and the chinks in the
wallsof all Japanese houses, which never keep out the fresh,
cold north winds of the winter months. All summer long
some one in every Japanese house every few minutes must rise
and open the paper doors (walls, really) to let into the room
some fresh air. But in the winter months it is not necessary to
do this. There is then even too much ventilation. In the
summer time the same number of hibatchis (charcoal stoves)
are found in Japanese houses as in winter time. They are
necessary for boiling the water to make the tea, which is drunk
every few minutes ; and to light the tiny pipe, holding only
tobacco enough for two or three whiffs, which must be con-
stantly relighted by placing it to a glowing ember of charcoal.
When Japan shall stop by edict the universal custom of
burning charcoal for fuel, then, and not till then, will beriberi
be eradicated there. Even Chinese pork-eaters have beriberi
whenever they burn charcoal in their houses in the wet season.
But whenever they burn wood instead of charcoal there is no
beriberi.
A CASE OF PHOSPHORUS BURN.
FREDERIC GRIFFITH, M.D.,
of New York City.
Surgeon, Bellevue Dispensary ; Fellow of the New York Academy of
Medicine
In the arts and trades in which escharotic acids and alkalies
are used, burns resulting from the handling of these substances
are notable for tenacious eschar formation. Bromin and phos-
phorus have likewise a peculiarly destructive action when
brought in contact with the body. The following is the history
of a case of accidental burning by the last-named substance
which fully bears out its reputation as a tissue destroyer :
R. K., aged 45, a shipping clerk, was awakened in the
middle of the night by an alarm of fire from one of the upper
floors of the tenement in which he resided. Reaching the
scene he found not only flames but a brilliantly burning
material flying about the room from a bottle upon the window
ledge. In his endeavors to beat out this sputtering fire with
his hands and bare feet he was burned over the left buttock,
thigh, hands and the extensor surface of his right foot. Home
treatment was attempted by means of vaseline spread on cloths,
but upon the tiiird day owing to the pain he was driven to the
clinic. The wounds were red and raw though there was but
little discharge. They varied from dime-sized splatters to the
large area covering the instep. Treatment consisted in remov-
ing the grease and washing with a 20% hydrogen dioxid solu-
tion, followed by the application of membranous rubber-tissue
strips. The strips were made of a size one-half of an inch by
two inches and were applied like shingles extending barely to
the edge of the sound skin. Demarcation was well defined.
The patient voiced the success of this form of application by his
report of disappearance of pain after the first dressing. Fluffed
gauze held on hy a light gauze bandage completed the dressings,
which were changed at intervals of three days. Sloughing
occurred at the site of each burn, was protracted, but was ac-
companied by but a slight watery discbarge. The cellular ele-
ments of the destroyed tissue appeared to undergo a slow fibrous
change. So tenacious and leathery did it become that it was
impo-ssible to remove it save by the process of slow disintegra-
tion which was washed and scraped off as the dressings pro-
gressed. There was no odor of putrefaction common to the
ordinary infecting slough. So pronounced was the effect of the
irritant to the skin and cellulaT tissue that healing of the ulcers
did not take place until the sloughs had entirely disappeared,
leaving cup-shaped craters which gradually healed by granula-
tion. Tliese burn wounds, which at first sight seemed to be
but a small matter for recovery, occupied 11 weeks in healing
and the smallest took nearly as much time as the largest to
repair.
DKCEMBBB 20, I902I
IRRIGATION TREATMENT OF GONORRHEA (American mkdicinb
963
ORIGINAL ARTICLES
FAILURES IN THE IRRIGATION TREATMENT OF
GONORRHEA.*
BY
FERD. C. VALENTINE, M.D.,
of New York City.
Corresponding Member, SocifitS Frangaise d'Urologle; Secretary
American Urologic Association; Secretary Qenitoorlnary
Section, New Yorlt Academy of Medicine; Honorary
Member Detroit Medicai Society, etc.
No advocate of the irrigation treatment ever averred
that it is an invariable panacea for gonnorhea. Its rights
to recognition are bksed upon the fact that it is the most
effective method known to combat this exceedingly
dangerous disease.
While there is no reason to retract any of the claims
made elsewhere' it cannot- be denied that in some
instances irrigations fail signally. It is the purpose of
this paper to present some observations on the causes of
the.se failures.
For convenience the subject may be divided into the
failures attributable to the physician and those in which
the patient is at fault.
Failures Attributable to the Physioiaii. — It would be
more than charitable to assert that any one method of
treatment of any disease can be equally successful in the
hands of all practitioners. With all physicians even so
simple a matter as effective irrigation of the anterior
urethra is predicated upon many conditions that are not
even similar. The most salient of these will be enu-
merated.
The Persmval Equation. — There are, in the profession,
men by nature entirely unfitted for genitourinary work.
Lest this remark convey anything disparging, I would
advance, against such an interpretation, my own con-
fessed abhorrence of obstetrics, my disgust for gyne-
cology an I dread of psychiatry. Unhesitatingly may be
added thereto such an excessive sympathy for children
as produces a state of utter unfitness for the proper,
calm consideration of the diseases of little ones. When
accused of incompetence in any of these branches I
feel no resentment at the perfectly veracious comment.
Genitourinary work, more than that of any other
specialty, involves an immense amount of detail. This
detail is, in the majority of cases, associated with dan-
gers and repugnance. These can be borne only by those
whose enthusiasm for the specialty causes them to dis-
regard everything but the end in view. Unless fired
with fervor for the special work, the dangers of infec-
tion are insuperable, the disgusting elements forbidding,
and painstaking attention to detail impossible. Men
who, for any reason, cannot meet all the elements
required cannot expect to obtain those results which
others secure.
I5y no means is it intended to convey that all cases of
gonorrhea should be treated by the genitourinary
specialist. From the very nature of things this is
impossible. That it is not necessary, is proved by the
very large number of excellent general practitioners
who have many successes to record in the irrigation
treatment of gonorrhea, the only subject at predent
under consideration.
Novelty of the Irrigation Method.— The continuous pro-
duction of new remedies for the treatment of gonorrhea
shows decided dissatisfaction with all drugs employed.
Although tending to indicate progress in therapeuti(w,
it creates suspicion of everything new. Irrigations
of the bladder without a catheter, however, are not
new. Hunter Maguire, over 30 years ago, showed that
the bladder can be washed through the metvtus urinarius.
Although this eminent surgeon did not present the fa<;t
• Ilcad before tlie Annuai Meeting of the American Urologic A»m>-
clation, Haratoga Hprlnga, N. Y., J une IS and M, IMC.
as such, it probably was the beginning of the irrigation
treatment of gonorrhea. Those who further developed
the matter for over 20 years are well known to medical
history. If novelty, therefore, is an objection to this
method of treatment, it can apply only to the siniplifi-
cation of the apparatus used and of the technic de-
veloped.
Sufficiency of the Old Methods.— It is also alleged in
confirmation of the objection to the novelty of the
method that the older ones sufficed in all cases. The
immense numl)er of sufferers from the complications
and sequels of gonorrhea furnish living and often dying
evideme of the inefflcsicy of those methods.
Unoleanliness. — Objection has been made to the irriga-
tion treatment on the score of its being uncleanly for the
patient and sloppy to the oflice. Even were this true,
the method should not be condemned for this reason, for
the results obtained are better and more prompt than
those which are accredited to the older methods. But
the fact is, that those who employ the correct technic do
not soil the patients, themselves, or their offices.
l^me Required. — It is perfectly true that more of the
physician's time is required for the irrigation treatment
of gonorrhea than in writing empiric prescriptions for
iiyections which are ineffective, and balsams whose
action is pra^tictilly limited to injuring digestion. It is
unnecessary to discuss here the dangers to the kidneys
which the balsams offer. However, in the light of
modern understanding of gonorrhea, no practitioner is
justified in treating this dangerous disease as if it were
a trivial matter. Therefore the time devoted to it is
fully warranted.
It must also be borne in mind that the urgent demands
upon the time of the general practitioner may often
make it impossible for him to keep appointments at his
oflice with patients who require irrigations. It was in
part to meet this oft recurring contingency that the auto-
irrlgator was presented to the profession. This will be
referred to in detail later on.
Irrigating Solutions. — To treat all cases of gonorrhea
by one kind of irrigation would be as unreasonable as to
expect salutary effects in any other disease by one drug.
It is true that in the majority of cases irrigations with
potassium permanganate accomplish the desired end.
But this drug is by no means a panacea. The others
recommended are, like the permanganate, still employed
empiriailly to a degree.
In a paper presented tefore the American Medical
Association' reference was made to the fact that we now
know of several forms of gonococci. We are not yet
able to distinguish them except by their varying con-
duct in different culture mediums. This knowledge is
due to Dr. A. V. Williams, assistant bacteriologist New
York Board of Health, whose excellent work is quoted
in the paper mentioned. It is evident that when all the
forms of gonococci are known we will be on the proper
path to determine what drugs act specifically in each
case. Our therapeusis will then become truly scientific.
The failures in the irrigation treatment attrilmtahk to
the patient are far more manifold than those laid at the
physician's door. Some of the former are owing to
Tlie rebellious patient who will not heed his physician's
orders.' It is not an open question whether such a
patient should Ix; left to the consequence of his obstinacy.
If the r<«ults (;oncerned the patient alone it might be
permissible to decline to treat him. But such an
unmanageable person is a menace also to his family and
to the community, in that he is an active focus for the
further dissemination of gonorrhea. Therefore if he
cannot be treated thoroughly, ho may at least be par-
tially so. in the hoiKJof obtaining control sufficient to con-
vincA! him of the need of aiding in his treatment and
reducing to some extent his chances of infecting others.
A case of this kind, however, has no place in forming
views on the value of irrigations in gonorrhea.
The patient who cannot visit his physician at the
954 AXEBICAN MBDIOIIOtJ
IRRIGATION TREATMENT OF GONORRHEA
Decehbeb 20, 1902
Fig 1.— Autoirrigator.
times necessary for irrigations at proper intervals is
oponsor for another cause of failure in this method of
treatment. These patients may be properly classed with
those who are obliged to travel, and those who cannot
pay the fees, whether large or small, that physicians are
compelled to charge for their services. For all these the
autoirrigator has been devised. This instrument was
never intended to place
the treatment of gonor-
rhea in the hands of the
laity, but merely to sup-
plement the efforts of the
physician, so far as possi-
ble, in those cases in
which, for any reason, the
patient cannot be regu-
larly irrigated in the prac-
titioner's office. The auto-
irrigator and its uses are
more fully described else-
where.*
Cmigenital defects can
not only interfere with
effective irrigations, but
may also prevent obtain-
ing the results as
promptly as is desirable.
Among the most frequent
of these defects are :
A Very Tight Preputial Orifice. — There can be no ques-
tion regarding the need of exposing the glans to remove
the risks of balanitis, condylomas, and inflammatory phi-
mosis. Therefore a free incision along the dorsum , slitting
the foreskin to within one-quarter inch of the coronary
sulcus is always advisable in such cases. This little opera-
tion can be rendered entirely painless by the Schleich
infiltration. When the patient has recovered from
gonorrhea, circumcision can be completed. The dorsal
incision just recommended does not apply, however,
when the phimotic prepuce has become thickened by
infiltration, as the cut will then expose but a small
triangle of the dorsum of the glans, hence accomplishing
no useful purpose. The treatment of such a case will be
outlined when presenting phimosis for consideration.
Stenotic Meatus. — However small the meatal orifice
may be, it can render irrigations only somewhat difficult,
but never impossible. Cases have been reported in
which this defect prevented the insertion of the finest
pozle. It is precisely the attempt to insert anything
into such a meatus which results in failure to irrigate.
The blunt nozle destined for that purpose is the only
one which will make irrigation through a small meatus
possible. For the
sake of emphasis
it will be pardon-
able to again
show the three
forms of nozles
provided for the
various cases.
Very Large
Me atxis . — Ure-
thral irrigations
(the patient's
meatus being
large) especially
when performed
by a novice, can-
„»„„*■• I -i, . not be done
effectively with any but the dome-shaped nozle (Fig. 3^
The pomted nozle (Fig. 4), which is most frequently used,
because of the vast preponderance of normal meatuses, if
emp oyed to irrigate a large anterior urethral opening,
would have to be deeply inserted to accomplish that bal-
looning of the mucous folds necessary for effective work.
Ihe insertion of this nozle, or of any instrument, into the
<:
^
Fig. 3A.
Fig. 3B.
Fig. 3C.
*"'& *4^-^2'°'«'i nozle. for a normal meatus,
rig.iiB.— Dome-shaped nozle, for a very large
meatus. Fig.
small meatus.
30. — Blunt nozle.
very large
for a very
inflamed canal is not only unneceasarily painful, but in-
evitably inflicts traumatisms to, at least, the macerated
epithelial covering. These traumatisms, however minute,
may invite local infiltration if not general infection.
Intraurethral Abnormalities. — Cases of congenital,
apparently double, urethras are not so rare a-s is generally
supposed. Most of these are an exaggerated depth of
the pouch formed by Guerin's fold. Of true double
urethra I have never seen a case, and have met but four
in literature. The cases in which a mucous septum
divides the channel into two usually reveal that the
adventitious canal has a culdesac and is situated above
the normal channel. During acute gonorrhea it is cer-
tainly not advisable to correct this defect. But it will
always be found that its presence will indefinitely per-
petuate a gonorrhea. It is therefore necessary, so soon
as the acute inflammation has subsided, to divide the
partition and thus reduce the urethra to one canal. This
is easily accomplished by pa.ssing a narrow, sharp-
pointed bistoury to the bottom of the adventitious chan-
nel and a grooved director into the normal urethra to
protect it from otherwise possible injury by the knife.
Coeain, or preferably eucain, injected into the urethra
before this little operation will render it painless.
Epispadias and hypospadias often interfere with ef-
fective irrigations because of the impossibility of occlud-
ing the abnormal meatus with a nozle. These deformi-
ties are frequently associated with paraurethral fistulas
opening about the meatus. Brilliant results from irriga-
tion can never be expected in these ca.ses. So soon as
feasible, the defect must be remedied by surgical inter-
vention. As regards hypospadias, preference for Beck's
operation ^ has been too well established to warrant dis-
cussion except in special papers on the subject.
Periurethral and paraurethral fistulas, whether asso-
ciated with a malformed meatus or existing independ-
ently, certainly interfere with the successful treatment
of gonorrhea. Their secretions will almost invariably
be found to contain gonococci, while they continually
feed to the urethra, thus incessantly reinfecting the
canal. When these fistulas are so near the meatus or
urethra that they can be safely opened into the canal,
this should be done. When distant from it, they may
be obliterated by means of the Kollmann electrolytic
needle.
Acquired Defects and Oomplications. — Those which
most frequently impede or frustrate the success of irriga-
tions in gonorrhea' are here briefly considered in
alphabetic order for convenience.
Balanitis and Balanoposthitis. — In practice one often
encounters cases in which, though the foreskin is very
capacious and easily retractible, the preputial sac is the
continuous site of a more or less intense inflammatory
process. This does not necessarily imply uncleanly
habits. Not infrequently the secretion is so persistent
that each time the patient holds his penis to urinate the
odor of decomposing smegma is transmitted to his fin-
gers. Many of these cases are amenable to no other
treatment than circumcision.
If such a patient acquires gonorrhea the reduced
resistance of the ever-macerated preputial lining makes
gonococcal infection thereof practically inevitable. With
this infection instituted, immense infiltration and edema
of the prepuce are often quickly established. The
meatus then is beyond reach and urethral irrigations
impossible. The infiltration of the prepuce often be-
comes almost cartilaginous in hardness, while the inflam-
matory process proceeds from the surface to deeper
tissues. Temporizing with hot or cold applications
avails but exceptionally. Even when it does, the gono-
cocci are thereby given more opportunity to proliferate,
to Invade the deeper tissues, to attack the adnexa and to
involve remote tissues. When such swelling occurs it
must be treated promptly by free incisions. It is an
error to incise the prepuce along its dorsum as thereby
but little of the glans is exposed. Splitting the prepuce
Uecbhbkr 20, 1902)
MILK FOR INFANT FEEDING
IAkekicah Mkdicikb 965
on each side, midway between the dorsal central line
and the frenal line, both almost to the coronary sulcus,
entirely exposes the glans and permits treatment of the
urethral condition with the least possible delay.
Chancre and chancroid on the gians or prepuce may
interfere with effective irrigations if the sore is in a very
irritable, inflamed condition. The difBeulty, however,
is entirely overcome by placing upon the ulcer a piece of
absorbent cotton, which will render the necessary manip-
ulations painless. If the practitioner be unfortunate
enough to have acquired any integumentary solution of
continuity, he will protect it from inoculation by sealing
the wound with rubber dissolved in chloroform.
Cicatrices at the meatus in consequence of chancroid
may render the orifice stenotic and sometimes diflicult
to traverse by the irrigating fluid. This may in some
instances tax the operator's ingenuity while the inflam-
mation is acute. Selection of the proper nozle will,
however, overcome the difticulty.
Conhjloiiias. — In. neglected cases, large, bleeding con-
dylomas may, if sessile about the meatus, positively for-
bid any effort at urethral irrigations. In severe cases
these growths will require prompt surgical relief before
any attempt is made at treating the gonorrhea.
FiHtulus, periurethral and paraurethral, may result
from abscesses produced bj- gonococcal invasion of the
crypts, glands, follicles or the stroma of the urethra
itself. They must be treated as outlined for the same
condition under congenital urethral defects {supra).
Ilei'pes progenitalis is the most frequent skin disease
that may interfere with irrigations. When a patient
suffers from this additional affection, irrigations can be
painlessly performed by covering the lesion with
absorbent cotton.
Infiltrations of the urethral crypts, glands and follicles,
and of the mucosa itself are the most frequent residue of
previous gonorrheas which causes by far the largest
number of failures in the irrigation treatment of a new
infection or the recurrence of an old one. While these
failures are not absolute, thej' are sufficiently marked to
warrant classing them with the nonsuccesses. It is true
that under judiciously conducted irrigations the acute dis-
charge Is reduced to a minimum or caused to disappear
entirely, but cure is never effected until the residue is
made to disappear. This has been more extensively
discussed elsewhere,' as have the methods employed to
that end.
Paraphimosis. — When the patient is seen early, it
usually can be reduced by taxis. Often, even within a
very short time after the prepuce has been slipped
behind the glans, the foreskin becomes immensely
edematous, preventing its reduction. Then it will be
well to make numerous punctures into the swelling to
allow as much escape of serum as possible. Frequently
this suffices to obtain reduction of the paraphimosis.
When, however, the paraphimosis has continued a
sufficient length of time to present a tight constricting
band which threatens to produce sloughing, this band
must be severed in the dorsal line before the prepuce
can be returned to its normal position. In some very
sc'vere («ses the incision just recommended does not
suffice ; then two more, eiujh midway between the
dorsum and the raphe, will be required.
Phimosis.— Thv futility of attempting urethral irri-
gations or of hoping for any result then^from while a
phimfwis exists needs no discussion. It must be relieved
at once by the method mentioned in outlining the treat-
ment of balanoposthltis.
ProsfaUtis and iSpermatocystitM. — Frank * holds that
when gonfx;occi jtcrsist for five days after a fresh gonor-
rhea comes under treatment the prostate is most likely
to be involved. Wossidio" insists that no patient with
apparently cured gonorrhea l)e dismissed without ex-
amination of the prostate. Fuller's work '" on the semi-
nul vesicles emphasizes and makes metho<lic the expe-
rience of every genitourinary specialist that gonorrheal
spermatocystitis may exist for years without any mani-
festation except frequently recurring gonorrheas.
In view of what has been sjiid, and the exceedingly
few examples cited from literature, it would be folly to
expect anything but failure from irrigations if tlie pros-
tate or seminal vesicles are involved. Systematic mas-
sage of the former and stripping of the latter are required
to obtain a successful result from irrigations in a new
attack or recurrence when either of these adnexa is
implicated.
Stricture. — Even wide caliber urethral coarctations
may be the cause of failures in the irrigation or other
treatment of gonorrhea. That retrostrictural maceration
of the urethral mucosa, which is seen when acute inflam-
mation has subsided, is a sempiternal nidus for the pro-
liferation of gonocoeci, and while the stricture persists
cure of acute gonorrhea is impeded. It is perfectly true
that some patients do recover, but the stricture remains
as a menace of possible future difficulties and dangers.
Urinary Abnormalities. — Most frequent among those
which can maintain urethral irritability, and conse-
quently delay the cure of gonorrhea, are phosphaturia
and oxaluria. These must be overcome before an effect
from irrigations may be expected.
No pretense at an exhaustive study is intended in
this very crude sketch. It is offered only as an outline
of the principal causes for the failures that occur in the
irrigation treatment of gonorrhea. Their mere mention
suffices to advise those who consult them for their
patients regarding the best manner of overcoming each
impediment to success.
Among those who will give time to reading these
lines there may be one who still hesitates to employ
irrigations in gonorrhea. If this presentation leads him
to test the matter, the result will be an all-sufficient
reward for my effort.
BIBLIOGRAPHY.
'The Irrigation Treatment of Gonorrhea: Its Local Complication
and Seqiielro, Wm. Wood & Co., New York.
*"The Examination of a Genitourinary Patient by tlie General
Practitioner," Journal of the American Medical Association, Match 1,
1902.
s "Advice to Gonorrheal Patients," Philadelphia Medical Journal,
Julys. Ih99
* 'Surgical Asepsis of the Urethra and Bladder," Journal of the
American Medical Association. January VI, lyOI.
6Carl Beclt (New Yorki: Ri'ports of the Deutsche medlclnische
Gesellschaft, meeting of October 4. 1897, New Y^orker medlclnische
Wochenschrlft,, November. 1897; New Y'ork Medical lournal, January
29, 1S98; same Journal, Augusts, 1899; Deut»chc medlclnische Wm'ben-
schrlft. No. 45, 1901. Valentine (New York' : •' Hypospadias Operated
on by Beck's Method." Medical Uecord. July 20, 190U. G. Marwedel ;
" Erfahrungeu iiber die Becksche Methode der Hypospadie-ojperatlon,"
Beltriiuo zur klinlschen Chirurgie, Band .xxix. Heft I. Parnham :
"Operation of Hyposi>adia8 and Epispadias." New Orleans Medical
•lournal, February, 1H()0. Fowler: Annals of Surgery, January, 1900.
Mayo: "On Ihe Operation of Hypospadias," Journal of the American
Medical Association, April a7, 1901.
•"Chronic Gonorrhea and Postgonorrbeal Urethritis," Medical
Record, June 29. IIWI.
'Vide op cit. I
'E. R. W. Frank (Berlin): "Gonorrhea of the Prostate," presented
by Terry M. Townsend, M.U., of New York, on behalf of the author,
before the Genitourinary Section of the New Y'ork Academy of Medi-
cine.—.Medical News, April 26, liX)2.
»H. R. Wossidio (Berlin): "Chronic Prostatitis and IlK Treat-
ment," Journal of the American Medical Ass<K^latlon, August 21, 1898.
'" Eugene Fuller: " Disorders of the Male Sexual Organs."
THE HOME MODIFICATION OF
FEEDING.'
MILK FOR INFANT
ALFRED HAND, Jr., M.D.,
of Philadelphia.
From the title of my |)aper I do riot wish it to be
understood as being of a controversial nature. It does
not deal with "Home Modification versus This or That
Methotl of Infant Feeding," but it is an attempt to show
what may be accomplished by a consistent following out
of a certain method. The artificial feeding of infants is
a difficult task if we attempt to feed all infants alike or
if we stagger blindly from one prcpare<l food to another.
' Read before the Pennsylvania SUile Medical 8oclety, AUentown
September 18, 1902.
966 Amekican Meoicimei
MILK FOR INFANT FEEDING
[December 20, 1902
The task may be rendered simpler by careful
attention to a few points. The first thing is to
consider each case by it«elf and to get a careful
personal history from birth. The family history need
not l)e gone into further than to investigate the possible
exist<'nce of active tuberculosis in other members of the
household and rarely the question of hereditary syphilis.
The routine points to be investigated in every case are :
C/isel
according to the percentages of fat, proteid and sugar in
the different ingredients, or in other words, to think in
percentages. While this involves a little calculation, it
is not enough to terrify any one. There are several
ways of working out the amounts of milk, cream, sugar
and diluents necessary to produce desired percentages;
thus Baner and Westcott have suggested formulas for
this purpose which are useful in one of three ways :
/t ir If ^ ju> 2l an, 13 j^
Age, weight at birth, at the present time, and all inter-
vening weighings ; different foods employed, their chro-
nologic order and why changes were made ; character of
the fecal evacuations ; intervals of feeding, and how the
child sleeps. With these data and the results of a
systematic physical examination we are in a position to
form some idea of the food-needs of the infant, and of its
digestive powers.
A second essential point in simplifying the problem
of infant feeding, after the recognition of the fact that
cow's milk in the long run is the best available substi-
tute for human milk, is to obtain a good, clean milk.
This is now possible in the large cities, such milk, owing
to the time and care necessary to produce it, costing 12
cents a quart at retail. It is not diflicult to persuade
people, especially parents, to use this milk nor to con-
vince them that the best is always the cheapest ulti-
mately. A few of the necessary points in the production
of such milk are that the stables must be of recent con-
struction and in accordance with the principles of modern
veterinary hygiene ; cleanliness of the cows, stables,
utensils and milkers should be enforced and the latter
should be intelligent enough to comprehend the neces-
sary points when explained and to realize their impor-
they may be committed to memory, and memory may
serve us a trick at an important moment ; or they may be
carried on paper in the pocket," and the paper may be
missing when wanted ; or they may serve as guides for
a few moments' thinking on the principles involved and
then, like ladders with which the heights have been
taken, they may be discarded as being no longer neces-
sary. There are other plans, also. Coit, of Newark,
the father of certified milk, suggests a decimal system,
Townsend, of Boston, having a somewhat similar plan.
Whatever scheme we follow it will only be of use to us
in so far as we understand it and make it part of our own
mental processes. The somewhat roundabout way in
which I arrived at what I know of percentage feeding
was the following : When I began work in infant feeding
it was before the introduction of the percentage method,
and I used, as a starting-point, what was known to me
as Meigs' mixture, equal parte of milk, cream, barley-
water and limewater. In using this I had a number of
very satisfactory results, but when it did not agree with
a patient it was often difficult to decide what change to
make. On estimating the percentages of that mixture
it is found to contain approximately, fat, ofo; proteid,
1.85^; sugar, 2.5^; the fat being too high for most
CascW
caseIs:
^ i 1 r
CastY
' ' t <l n It It,
tance. It would be out of place before this assemblage
to speak of the prompt cooling of the milk and further
details, but I must emphasize my belief that when such
milk cannot be had, then pasteurization or sterilization
(my own preference being for the latter) must be prac-
tised during the warm months of the year.
A third point which will help in making infant
feeding easy is to direct the preparation of the food
children and the sugar being too low. These percent-
ages are obtained in the following way : Cream usually
has 16 fo of fat, and as one-fourth of the mixture is cream
this brings 4^ of fat to the mixture; the milk, having
4^ of fat and also being one-fourth of the mixture,
brings, therefore, one-fourth of 4 ^ , or 1 ;X , making a
total oi^'/o fat in the mixture. Cutting down the cream
to one-eighth of the mixture and raising the milk to
L) ECEMBER 20, 1902]
RING-SHAPED BODIES
(American Mkdxcink 967
three-eighths gives a fat percentage of 3.o/c, which is a
good average percentage. Considering the proteid of
milk and cream as beifig practically the same (3.7 <fc), the
mixture, half of which is made up of combined milk
and cream, will have a proteid percentage of l.S.ifc.
This may be raised or lowered, as desired, by increasing
or lessening the amount of combined milk and cream.
The low sugar percentage is easily raised by adding to
each bottle sugar of milk or cane-sugar, my own prefer-
ence being for cane-sugar, in the proportion of J of a
teaspoonful to every 8 ounces of food.
We come now to the fourth point in the simplifleation
of the matter. If a child does not show a weekly gain
in weight after being put on a mixture directed by our
liest skill, before making any change let us try to find if
the child is getting what we think he is. This is the
great objection made by Rotch, the father of laboratory
feeding, to home modification, that we do not know
whether the child is getting what we prescribe or not.
The ingredient in milk notoriously subject to the greatest
fluctuations is the fat, and a priori^ this is the one most
apt to vary from the desired percentage. An estimation
of this is easily made nowadays with the aid of the cen-
trifuge and a set of milk tubes, and if we have not those
implements, it is not hard to find a colleague who has
and who will make the examination for a moderate fee.
1 do not think it necessary to go to the greater expense
of having the proteid estimated, for the work of our
Milk Commission in Philadelphia has shown such slight
variations in this ingredient that thej' may be disre-
t,^arded as being without clinical influence, if the fat is
found to show much variation from the supposed per-
centage, then it would be well to modify the mixture so
that the desired percentage would be obtained. As an
illustration of this, I once saw a boy 16 months old who
had been on practically whole milk from one cow for
several- months ; he had not gained in weight for two
months, and was getting flabby in spite of the addition
of a small amount of cream to each bottle, when an
<'xamination of the mixture as prepared for him showed
it to contain only a little over 2^ of fat. The correction
l)eing made, a gain of one pound was registered in the
next three weeks.
I do not wish from my experience to lay down any
dogmas on the subject of infant feeding, but I would
advise the use of barley water as a diluent, except when
constipation exists, and then oatmeal water is to be
preferred ; cane-sugar, a pinch of salt and a tablespoon ful
of Iwne water should be added to each feeding. With
patients of three months old and upward, I aim to have
the proteid at least 1.75%, and to increase it as rapidly
as the child can digest it. Infants under three months
need careful handling with regard both to {)roteids and
to fat, and in these cases I formerly used rather exten-
sively either peptogenic milk powder or pancreatin and
-oda with each feeding. For several years I have found
it unnecessary to do this, preferring when the digestion
is feeble to tone up the digestive organs to do their own
work, and for this purpose I use a mixture of sodium
bicarbonate in compound infusion of gentian l)efore each
I'l'eding. I have occasionally found useful essence of
[•'psin and nux vomica, separately or together.
The following weight charts illustrate some of my
vxperiences, and if the criticism is made that they are
too uniformly favorable, I can only reply that it is difti-
iilt tf) keep track of our failures which are met almost
vclusively in hospital practice, and to a less extent in
1 lie dispensary. In the accompanying charts the normal
curve is shown by a broken line, the ht^avy i)art of the
■ ontinuous curve showing the weight-progress when
iiiider immediate observation, the other records being
-liown by the lighter line. Appended are brief notes of
I he cases in explanation of the charts.
:::;Cank I.— M. H. v. had been fed from birth on cow'.s milk,
lie porceutaces at 7 mouths being: Fat, \A%\ proteid, 1.2%;
iijar, 4%. A chanjfe was at once made to: fat, 49fc ; proteid,
1.85% ; sugar, 6%. At the weelily weighing three days later the
increase for the Aveek was J pound. The next week a gain of 1
pound was registered and then for six weeks there was a steady
gain of J pound each week. At that time the fat was reduced
by 0.35% and tlie proteid increased by 0.2%, the next weekly
gain being li pounds. Medicine was not used in tliis case at all
(except for one or two little colds), the "sour stomach" and
constipation being corrected entirely by diet.
Case II. — M. A. was bottle-fed from birth, receiving at the
age of 3 months, milk and water, equal parts, with a teaspoonful
of uncooked arrowroot in each bottle. She was emaciated and
intensely anemic but improved rapidly on a diet of fat, 4% ;
proteid, 1.75% ; sugar, 6%. After being under observation for
five weeks, with a gain of 3 pounds, she was not seen again,
owing to her parents residing in another city, subsequent
changes in the diet being directed by correspondence.
Cask III. — B. H.J. was born six weeks prematurely and
was fed by the breast and bottle alternately for two months and
then solely by the bottle. Peptogenic milk powder was used
for the flrst three months with every bottle and then rapidly
discontinued. The percentages were frequently subject to
minor variations. A start was made with fat, 2% ; proteid, 0.5%;
sugar, 6%; with a gradual increase of strength to: fat, 3.5% ;
proteid, 2.25% ; sugar, 6%, by the sixth month.
Case IV. — S. A., sister of the patient of Case II, ilhistrates
the difficulties and perhaps the dangers of attempting to regu-
late the feeding without seeing the child. When seen at the
fifth month the general condition was fair but there was con-
siderable regurgitation of clear, sour fluid, which required
medication to overcome. In the seventh month the loss of
weight was due to a cold, probably influenzal, epidemic in tlie
houseliold, and that in the eleventh month to a summer diar-
rhea.
Case V.— -M. K., bottle-fed from birth, with various mix-
tures, condensed milk and different proprietary foods. The
child was emaciated, crying constantly and had enlarged cer-
vical glands on both sides at tiie angles of the jaw. This
enlargement subsided so very slowly that the suspicion of tuber-
culosis was entertained, but in four months the glands could
not be felt. When first seen the child was put on a mixture of
fat, 2%; proteid, 1.8%; sugar, (>%; the fat being increased
steadily until 4% was reached in a montli.
Case VI.— L. L. was bottle-fed from birth. She was the
third child, theolderchildren being undersized. When firstseen
at 6 months .she was lialf way through whoopingcougli, which
disease interfered considerably with nutrition. Aside from the
diet, the care which the child received left much to be desired,
but nevertheless there was a gain, so that by the eighteenth
month whole milk was lieing digested. At the start it seemed
necessary to use powders of pancreatin and soda for a time, as
a mixture containing f At, 2% ; and proteid, 1.5%, was not well
digested.
PRELIMINARY NOTE ON RING-SHAPED BODIES
(NUCLEAR REMAINS?) OCCURRING IN THE
RED CELLS IN CASES OF ANEMIA.
RICHARD C. CABOT, M.D.,
of Boston.
The accompanying cutis from microphotographs of
the blood of a case of lead poisoning stained with
Wright's modittcation ' of Leishmann's stain (eosinate
of methylene-blue dissolved in methylic alcohol). The
ring-shaped bodies stain bright red against the pale yellow
background of the corpuscle. In other parts of the
specimen there are many cells containing the dark blue-
>.I. H. Wright, Jounml ii( M. .lir il Research, Vol. vll, No. 1, 1»02.
968 AKER.OAK MKD.CI1.K) ' RELATION OF OBESITY TO IMPROCREANCE
[December 20, 1902
Htalned xranulations commonly oteerved in lead poison-
inff, pernicious anemia and other diseases. I have found
rlngrt like those in the cut in three cases of pernicious
Small Illustration on the lea shows ring-shaped arrangement of red-
stalnlng dots In erythrocytes from a case of lead poisoning
anemia, three of lead poisoning, and one of lymphatic
leukemia. A fuller description and study of these ring
bodies will appear in the Journal of Medical Research for
January, 1903.
ON THE RELATION OF OBESITY TO IMPROCREANCE.
BV
HEINRICH STERN, Ph.D., M.D.,
of New York City.
The apparent relation of improcreance as foundation
or predisposing element, and polysarcia has been fre-
quently observed. From times immemorial to the
present day, nomads, peasants, and stockbreeders have
rendered young cattle, sheep, hogs, chickens, etc.,
improcreant with the intention of fattening them rapidly.
Eunuchs are generally described and pictorially repre-
sented as "beefy" individuals, and sterile women, if
not affected with systemic or malignant disease at the
prime of life, oftentimes tend to corpulency. The male
subject in his declining age, the period of diminished
libido sexualis and physiologic improcreance, occasion-
ally acquires a voluminous fat bolster.
Much in the same manner, though more frequently,
obesity appears iir women, especially in the presence of
disorders of the internal organs of generation, after
oophorectomy, at the climacteric age — in short, after
serious disturbance or cessation of the catamenia.
Glaevecke ' states that of the women on whom oopho-
rectomy was performed by Prof. Werth at the clinic in
Kiel, 42% became more or less obese after the operation.
Among 38 women between the ages of 21 and 45 whom
I have treated for polysarcia, and of whom 34 were mar-
ried, one had never menstruated ; twelve had never been
pregnant ; in eight single or double oophorectomy was
performed, and of these eiglit two had undergone hyster-
ectomy ; five had always had scanty and irregular
menstruation ; in two the catamenia had prematurely
ceased (without operative interference); four had various
congestive or inflammatory conditions of the sexual
organs, and but six seemed to have been entirely free
from ovarian and uterine derangements.
Old statistics of Tilt (quoted by Ebstein^ after
Krieger) record that among 282 women in the climac-
teric age who had not menstruated for five years, 121 had
grown stouter, 90 became tliinner, while 71 had retained
their former circumference.
Of 100 women in the menopause chosen by me at
random, 8 were not certain whether they gained or
lost, 20 thought they had retained their previous volume,
29 had declined in body-weight and circumference, and
43 had developed polysarcia to a greater or lesser degree.
True, but insufficient absolute proof has been fur-
nished that an eventual obese condition is the im-
mediate consequence of the removal of the sexual
glands, or of their physiologic decline. Stock-farmers,
for instance, do not only castrate the animals, but often
emi)loy supplementary means to hasten the fattening
process. Breeders, especially those of poultry, frequently
resort to gavage. In addition to this the animals are
often kept within narrow limits— restricting freedom of
motion — and in places which are not penetrated by sun-
light. Stall-fed cattle are not forcibly fed, but the other
conditions which obtain during their fattening i)roce88
do not materially differ from those utilized in fattening
smaller animals— confinement and complete or relative
darkness. Thus we see that the experienced breeder in
order to procure profitable live stock does not always
depend upon castration alone but has recourse to three
valuable expedients, over-alimentation, compulsory rest,
and lack of sunlight. Overfeeding and deficient exercise
are wellknown factors in the production of polysarcia.
Lack of sunlight as a material aid in the causation of
corpulency is only known among the interested circle.
The small size of windows of stables in which cattle are
kept for fattening usually admit sunlight but sparingly.
The body-weight of many hibernating animals declines
relatively little ; they retire to places of seclusion and
concealment, as caves, holes, the brushwood, etc., loca-
tions which are dark or almost so. Darkening of sick-
rooms appears to interfere more or less with the oxida-
tion processes in the organi-ms ; a dark room, therefore,
seems to contribute toward the obese state which arises
not infrequently during and after acute diseases of some
duration. In castrated persons and in those in declining
age, overfeeding, lack of adequate exercise, and other
factors may also be incidental in causing corpulency, but
there is no doubt that such persons are as peculiarly pre-
disposed to fat deposition as are animals rendered
improcreant.
The tendency to adiposis may be observed in cas-
trated animals that are neither overfed nor confined, and
the number of women developing polysarcia after
oophorectomy, or in the climacteric, in spite of small
consumption of food and of sufficient bodily exercise, is
legion. In view of the numerous observations pertain-
ing to the propensity of improcreant individuals for
polysarcia we are forced to conclude that, regardless of
the eventual presence of other factors favoring adiposis,
there must exist a more or less direct interrelation of
improcreance and obesity. Entering more closely into
the study of the etiologic connection between improcre-
ance and subsequent polysarcia we may find as eventual
causative factors :
1 . Decline of systemic vivacity and vigor after castra-
tion and change of life.
2. Preservation of bodily resources otherwise utilized
in discharging sexual functions.
3. Participation of surplus blood in fat synthesis in
the female organism.
4. Diminution of oxygen-carrying factors in the cas-
trated or declining organism.
.5. Reduction of intensity of the general catabolic
processes in the improcreant.
The first of the possible etiologic factors seems to be
nothing else but a phase, an enunciation of the eventu-
ality mentioned last. Von Noorden,'' however, regards
it as a factor per se, although he does not give it any
further consideration. Its modus operandi may be as
follows : The general apathy of the improcreant organ-
ism calls forth abnormal conditions in the system. If
not interfered with improcreants sleep, as a rule, longer,
and at shorter intervals than younger and normal
organisms of their kind. This mode of living results
in diminished supply, but also in diminished demand of
oxygen. Diminished tissue combustion and acquisition
of more or less body rotundity are the not infrequent
consequences.
2. Nonperformance of sexual functions by prevent-
ing expenditure of certain body material, according to
Dbcbmber 20, 1902]
RELATION OF OBESITY TO IMPROCREANCE
LAmkrican Medicine
969
von Noorden's surmise (loc. cit.), may facilitate the fat-
tening process. So far as it pertains to females, or as
suppression of sexual activity is congruous to dimin-
ished bodily exertion, is this assumption plausible.
3. The conception of the participation of the retained
blood in the formation of fat in nonmenstruants is
in some ways related to the one of von Noorden just
mentioned. However, it is still an open question
whether and to what extent albuminous substances con-
tribute toward production of fat in the organism. It
appears more likely that the retention of the proto-
plasmic constituents of the blood prevent in a measure
disintegration of body albumin, and that they may al>o
assist in augmenting the latter. On the other hand,
increase in body-weight and circumference is also
noticed in such castrated female animals in which no
periodic sanguineous discharge exhibits itself. This is
sufficiently demonstrated by Pinzani's experiment,* who
found that a bitch after extirpation of both ovaries
excreted less nitrogen by the urine and feces than she
did before the operation, although she (ontinued to
ingest exactly the same amount of foodstuffs (bread,
milk, water) after this procedure.
4. In seeming contradiction to the two preceding
eventualities stands the contention that the production
of obesity on the basis of improcreance is due to dimi-
nution of blood, or better, of erythrocytes, and the con-
sequential decrease of tissue oxidation. The discrep-
ancy, however, is only an apparent one, as the retained
blood could not be converts! so readily into solid tissue
if it exhibited the same amount of oxygen-carrying
factors as in the normal state. In women, after oopho-
rectomy, the amount of red blood corpuscles is often
materially decreased.* This is especially the case in the
first 10 or 12 months after the operation, that period
in which an eventually arising polysarcia makes rapid
advance. After this time, when the circulatory condi-
tions.and those in the blood may have resumed a some-
what more normal degree, the process of adiposis does
not, as a general rule, progress in so rapid a ratio, or it
comes to a standstill, or, as Is often the case, the woman
begins to decline gradually in body-weight. The
anemic condition of such women, as well as of those in
the menopause, so long as it is not called forth by j)ro-
fuse hetnorrhages or by protracted illness, is jjrobably
due to a lack of a specific factor formerly furnished by
the ovary.
5. The general condition and behavior of the cas-
trated and of those in the beginning menopausal period
not infrequently point to a lessened degree of intensity
of the vital processes. The first scientific confirmation
of this clinical observation was furnished by Loewy and
Richter * in 1899. By determining theamountof oxygen
consumed they ascertained the intensity of the metabolic
processes in Intches before and after castration. The
first obtained the value of the normal interchange of
respiratory gases. After removal of the ovaries tlie
respiratory gas interchange experiments were continuetl
for a long time; at first nothing was administered to
alter the systemic condition ; later the animals were
brought under the influence of ovarian substance or other
organic prt^parations. The consumption of oxygen
wiiich before castration amounted to 6. 103 cmm. i)er
kilogram and minute after four months became re<luced
tf) ').0.')1 cmm. per kilogram and minute. Ingestion of
oophorin two and a half or three months after castration
averted not only further reduction of the oxygen demand
but produced a considerable augmentation of the res-
piratory interchange of ga«es. This increased to 8.47;t
• Plncanl (loc. cIt ), on the other hand, found an augmentation
of rod blood r,r)rpu«(:U« and dt-crease of leuk^icyt^H (n hla doj? after
cafttnitton We iiiuHt not for»5<'t. howcvt r. iliat the exixTlnirntu are
madf on healthy oiyantsinK, while BubJeetiuK a woman to oophorec*
tomy Ik prima faelc cvldcnee of an exIxthiK »y»temle anomaly. The
condition foMowlnK extirpation of th" ovarl<!« In a normal hlleh and
that arlHlnK after Imperative oophoreetomy In a woman are, therefore,
not exactly analogous.
cmm. per kilogram and minute, that is to 2.310 cmm.
more than in the normal. The experiments also fur-
nishetl proof that the administration of oophorin remains
without influence upon the respiratory gas interchange
in normal animals that are not castrated. Administra-
tion of preparations of the sexual organs of the male
(spermin) to castmted female animals did not affect the gas
interchange at all. Experiments conducted in castrated
male dogs evidenced a similar although less pronounced
reduction in oxygen consumption than in the female
animal. The decrease amounted from an average of
7.028 cmm. per kilogram and minute before to an aver-
age of 6.070 cmm. after «»stration, that is a dec-line of
13.63 fc per kilogram of body- weight. Oophorin did not
exert any influence Upon the metabolism of healthy uncas-
trated male dogs. In castrated dogs testicular substance
or spermin caused but a slight elevation of respiratory
gits interchange ; administration of oophorin on the
other hand affected increased metabolism also in the cas-
trated dog.
The stimulating influence of the ovary is again dem-
onstrated by ovarian grafting and the administration of
ovarian substance in women after oophorectomy. It is
beyond doubt that, in such women, in the majority of
instances the metabolic processes become markedly
enhanced after the ingestion of ovarian preparations. I
may here mention one of my numerous clinical observa-
tions.
Uterus and ovaries were removei from a woman of 29. She
experienced the circulatory disturbances often following this
surgical intervention in aii unusually pronounced degree. A
few months after the operation she began to grow stouter. She
became more apathetic from day to day. The circulatory disturb-
ances, although somewhat modified in the course of time, per-
sisted for the next three and a half or four years. One day it
occurred to me to give her some tablets of desiccated ovaries
which were standing on my desk. An improvement of her
general condition followed speedily. The continued use of tab-
lets of ovarian substance caused some diminution of body-
weight. (When starting this medication the body circumfer-
ence had already declined materially.) The woman has felt at
ease ever since.
Reviewing the possible factors underlying the associ-
ation of improcreance and obesity, we find that they all
depend upon diminished intraorganic oxidation. In
fact, if we abstract from the presence or intervenience of
certain minor factors the three eventualities first dwelt
upon are nothing else but phases or consequences of the
last two, which in turn are again interdepending.
There is little doubt that the sexual glands, particu-
larly the ovaries, are enabled to perform other functions
besides those known to us. Ovulation per se does not call
forth acceleration of j)ulse-rate and augmentation of
arterial tension or body temperature, neither does it
intensify the systemic processes in general or increase
the excretion of carbamid — phenomena which are inci-
dental with the precursor.v stage of each menstrual
period. The intc^rnal secretions of some oth(>r organs
possibly influence the menstrual i)rocess. There seems
to exist an indefinite functional interdependence or
vicariousness between certain glands. The internal
.secretion of various glands, as that of the thyroids, for
instance, may substitute that of the ovary, at least in
certain respects, and vice verm, the ovary under certain
conditions may exhibit qualities which normally belong
to the thyroid or some other gland. Nonappenratue of
l)oIys!ircia in all instances after castration or in the
beginning period of bodily decline is explainable only
on the basis of the eventual vicarious character of the
internal secretion of the ovar.v. Thus, removal or
atrophy of the sexual glands is followed by untoward
results in such instances onl.y in which they have
assumed the functions of another organ.
C.'oncerning nature and nunle of action of the lost
function nothing definite, of course, is known at this
<lay. This much, however, may be said with certainty
that its omi.ssion may occasion various more or less
970 AXKRIOAIf HKDIOINB,
ELECTROTHERMIC HEM08TASIS
[Deckmbek 20, 1902
chronic disturbances and anomalic conditions, among
whicl) obesity is one of the more important.
BIBMOORAPHY.
'Oluovccke: Koerporllcho unci GelstlKC Veraenderungen Im welb-
llclieii Kocrper nach kiieiistlk^lii'm VerluRte iler Ovarlcn elneisellK
mid dcs lIU-riiH undererseltx. Archlv f. Gyiittkologle, xxxv, 1, 188D.
"KbHU'ln, Willielm: U\e Keltlelblgkelt uiid Ihre Bcbandlung,
WIcHbaddi, iss:^.
» V. Noiirden, Carl : Die Fett»ucht. Vol. vll of Nothnagel'sSpccltUe
Patbologle und Tlicraple. Wlen. liXX).
■•riiizanl: Kxperimoiitolle Unlcr»iichungen ilber den Elnnuss der
Castration auf den Ktotlwecbsel und die Blutbeschaffenbelt. Central-
blattr. (Jynftkologle, xxlil, 1311.
» l^oewy, A., und Ulehtcr. P. Fr. : Sexuallunkllon und Stoffwechsel.
Arehlv f. Anatomie und Pbyslologle, 1899. «upplementband, 171.
(KoitschrlttederThler-Cheiule, 1900, m7.)
THE PRACTICAL SIDE OF ELECTROTHERMIC
HEMOSTASIS.
BY
ANDREW J. DOWNES, A.M., M.D.,
of Philadelpbia, Pa.
Gynecologist to St. Mary's Hospital.
The various steps in the development of a perfect
method of hemostasis, with the exception of the method
here advocated, have followed each other as similar pro-
cedures and required little extra material or instrumen-
tation. Most of the steps have had to do with ligatures
and methods of sterilization ; the various steps being the
septic ligature, the aseptic nonabsorbable and finally the
a,septic absorbable. The essential step, a ligature beyond
a temporary hemostatic forceps, was common. What-
c
more practical than is underst^jod. In fact, it is quite
practical. The instrumentarium consists of three prac-
tically indestructible forceps or angiotribes, a small
artery forceps electrotherm, a cautery knife requiring the
same amperage as the platinum in the angiotribes, a
cable made of two parts, one of which is sterilizable, a
transformer for the alternating current, and the same
with a motor in connection for the continuous current.
I have already published considerable on this method
of hemostitsis and will enter into, it but briefly in this
pai)er, and that chiefly to indicate its practicability and
to elicit, if po.ssible, more careful consideration and trial.
That the current method of hemostasis is faulty is
proved by the too frequent occurrence of secondary
hemorrhage from the slipping of the ligature. The
occurrence of death from sepsis traceable to infection
from the ligature material in a sterile field is much more
common than the occasional honest acknowledgment
would indicate. In an infected area the ligature is a cul-
ture medium. Many surgeons still use chemically pre-
pared catgut in the center of which only too often
virulent germs lurk. The elimination of the material of
the ligature and the handling of it in its preparation and
during the operation will add to the chances of the
patient. The introduction of ligature carriers deep in
the pelvis, the irritation of the nerves in the ligature
stump and the adhesions which always result all indicate
the need of a better method.
By the electrothermic method of hemostasis there is
elimination of all the handling required in the prepara-
tion of the ligature, of its handling during the operation,
thus dispensing with one assistant, of its
presence after operation, of all exuding
stumps, of all .sources of infection from its
use. In place of it we use the physical agents,
pressure and heat alone, with much less hand-
ling and instrumentation in general. The
hemostascd stumps are left as thin, sterile,
nonexuding, nonadhering ribbons with ob-
tunded nerves. In special .surgery, as in the
Fig. l.—Anglotrlbe with narrow blade.s, useful in hemostasis The mesoappendix deep nelvis thpre are other imnnrtsint noints of
in the pelvis and has a heinonboidal forceps. The blades are released by ptivis, mere are ouier imporiani poiui.-^ oi
.„•.,==„, -o „„ i,..„Hio„ •' superiority over the ligature. The broad
ligament can be severed bloodle.ssly and
pressure on handles.
ever change in the material or its preparation there was
equal practicability in its use. Hence surgeons accord-
ing to the logical indications had no hesitation or disin-
clination to try a new method. Even angiotripsy,
requiring cold pressure instruments, was only a shorter
step in an older process. Torsion of the vessels was also
simple with instruments always at hand. It made little
difference where the method originated, if logical and
requiring only common instruments it was hardly pub-
lished before surgeons all over the world gave it a fair
*''^' H'~?l^*'''°"'®'"'"'" ^"Biotribe with blades 5<Jor J.^lncL ....... i!...salever atendof
handles to maintain maximum pressure. Blades released on removal of lever.
trial and very .soon its proper status was established. So
wonderfully superior to older methods is current hemo-
stasis, so almost absolutely perfect the use of the aseptic
absorbable ligature, when used with proper technic, that
one advocating a newer method, e.specially if the surgeon
must depend on an increased or unusual instrumenta-
rium and unaccustomed physical agents, is liable to be
considered hypercritical, if not visionary. This means
that only the commonly admitted practical is generallv
tried.
It is the object of the present paper to indicate that
electrothermic hemostasis while quite novel is much
much closer to the pelvis wall, a valuable point in can-
cer. Adding to this the fact that the method leaves
closed lymphatic vessels, it is indisputably the method
to be used in hysterectomy for cancer.
In over 100 operations, including 15 hysterectomies, 50
appendectomies, 22 salpingooophorectomies, many ova-
rian cysts, hemorrhoidal and other operations, there has
been absolutely no secondary hemorrhage. While devel-
oping the proper instruments and technic there were
times when from too little pressure, too little heat or too
short an application, bleeding occurred after
.section on removal of the blades of the instru-
ment requiring reapplication. Whenever
after removal of the blades there was no bleed-
fe ; ing from the severed track it never occurred
v|/ I subsequently. Lately the hemostased track
• ''^ that does not bleed immediately on section
gives me no concern. A practical technic is
soon acquired. My latest model of instrument
simplifies the problem. This instrument is
made with three different blades, the differ-
ence being, however, only in width. The length is 2|
inches, the width }, | and j inch. The | blade is generally
useful. The J-inch wide blade gives a track wide enougli
to make section within it. The }-inch blade is an^ ideal
hemorrhoidal clamp ; it is excellent forhemostasiugthe
mesoappendix or any isolated artery. A special feature
about the last model instrument is the self-releasing
handle. There is in addition a lever attached at the end
of the handle. The poles for conducting the current to
the heat chamber in the blade are attached near the
blade yet far enough away for use even in vaginal hys-
terectomies. The cable is made in two parts — one non-
December 20, 1902]
ELECTROTHERMIC HEMOSTASIS
(AMERICAN Medicine 971
sterilizable, which brings the current to the edge of the
operating table ; the second part, rubber covered and with
lava tips, can be boiled indefinitely. It is perfectly
sterilizable and also quite flexible. There are a number
of transformers and motors now on the market made
especially for use with these instruments. The " Victor,"
made in Chicago, the " Ritzer " in Scotia, N. Y., and
the "Keystone" in Philadelphia, I have had practical
experience with and can recommend. The Keystone is
handled by Charles Lentz & Sons, the makers of my
instrument, and is made with a meter in connection
or without it. I have always advocated a meter in cir-
cuit. It is more scientific and as each instrument has a
maximum ampere capacity the current is thus always
used within proper limits. However, the practical lim-
itations of the instruments are easily learned and a meter
can be dispensed with. The practical way I have dis-
covered to know when the proper current and heat is
obtained in the active blade is to place water upon it and
when this boils throughout the blade the current is
proper. The rheostat can be set at this point, with the
knowledge that in so many seconds we will have the
Fig. 3.— Shield surrounding large blades In appendix or In
appendectomy.
proper temperature in the heating blade. Practice has
even allowed me to dispense with time keeping.
Another practical way to judge without a meter the
proper amount of current necessary to heat the heating
blade is to have my cautery knife, which requires the
same amperage as my electroforceps. The current that
heats the platinum of the cautery knife a bright red is
the proper current. This is quite practical and as this
cautery knife is a surgical requisite there should be no
mistakes. It is worthy of mention that my cautery knife
is made of platinum, copper and lava, all mineral, there-
fore sterilizable, and not affected by boiling.
In a hospital having the electric current electrother-
mic hemostasis is now simple and practical. Given the
current and transformer the armamentarium is less and
simpler than in ligature operations. As to technic, the
following brief reference must sufBce : For hysterectomy
the broad ligament is isolatefl and the blaides applied
down as near to the cervix as possible with a view of
including the uterine artery. This is not always possible
and a second ap|)lication may be necessary to each side.
Dry gauze is placed around the blades to protect adjacent
tissues and intestines. The cable is connected and the
current turned on. Heat and pressure should be from
twenty seconds to about one minute for thick surfaces.
With narrow blades temjjorary clamps are applied to
the uterine side of the electroforceps and section made
along the uterine side of the hemosttising blades. If the
half-inch blade is used section can be made on the uterine
side of the hemostased track of the blades. In salpingo-
oophorectomies in most cases the tube and ovary can be
twisted so that a narrow pedicle is made and one apj)li-
aition of the blade suffices. StK-tion is made along the
upper surfaces of the blades. In other cases two applica-
tions may be necessary, one down from the uterine
cornua, the other from outside the ovary to meet it. The
thus sterile occluded stump of the fallopian tube is a
great advance over the ligature closed stump. Keith
long ago controlled hemorrhage in the pedicle of ovarian
cysts by applying the actual mutery to the sides of the
blades of the pedicle forceps. The electrothermic method
which has replaced Keith's crude process is ideal in this
class of work.
In appendectomy the chief claim is that by this
method the infectious canal is compressed and sterilized
60 that section through it may be free from danger.
The addition of a fine catgut suture around the cecal
stump to cover it is a safeguard which I strongly advo-
cate against defective technic. The mesoapppendix can
be easily hemostased in 10 seconds by the narrow blades.
By the same forceps an isolated bloodvessel— uterine,
ovarian, or other — can be hemostased more quickly than
by the ligature. My work has l>een largely intraabdom-
inal, yet what little general surgery I have done indi-
cates the method as far superior to the ligature.
For small arteries, as in incisions, the removal of the
breast, in the neck and other places I have devised a
heater called the artery forceps electrotherm for heating
the tips of straight forceps. The electrotherm is applied to
any number of artery forceps near the tip of the blades,
10 seconds to each being ample time with the electro-
therm at the proper heat. This little heater replaces a
large number of perishable and expensive electrothermic
artery forceps. During the last five months I have not
used a ligature in the pelvic cavity, and find myself
turning to these electrothermic instruments as practi-
cally as formerly to the ligature carrier, the artery
forceps and the ligature.
In hemorrhoidal operations there is a special field for
electrothermic hemostasis. The application of the nar-
row blades is the same as for the ordinary pile clamp,
the current is turned on, section made of the redundant
tissue on the distal side of the blades, the instrument
then removed, leaving a white, thin, hemostased, non-
absorbing area. The operation is the quickest of all, and
is bloodless. Recently I have devised a shield for pile
operations. It is a forceps, all metal, with thin, narrow
blades from which five pointed, short projections extend
to prevent contact of the blades of the shield with the
hot blades of the electroforceps. The heat in the latter
travels through the small projections in such small
quantity that the blades of the shield remain cool.
Fig. 4.— Shield for hemorrhoidal operations. Shields have contact
with heated plates at a few points only and remain cool
through the operation.
This simple shield, though made for protecting the uiial
regioti from the heat of the hemorrhoidal electro-damp,
is Hi useful in shielding the cecum in appendectomy. It
may be used in salpingooophorectomy, and to .some
extent in hysterectomy, although I prefer gauze in the
pelvis.
As evidence of the practicability of this method I
may cite two hysterectomies for cancer performed this
month. In one the entire uterus and vagina with a por-
tion of the vaginorectal wall was removetl. In the
other, per abdomen alone, the entire uterus and proxi-
mal inch and a half of vagina was removed. In neither
case was ii ligature used. This makes five cjises of can-
cer during the la.st yetir in which I removed the uterus
by electrothermic hemostasis. The patients rtn-overed,
and as in all intraabdomintd operations by this method
there was little or no postoperative sho<'k or subseciuent
peritoneal pain. The following points should be borne
in mind by those not accustomed to this method :
The prt!.ssing surfsK-e of the blades must be 8meare<l
with sterile oil l)efore each application.
The field should be dried and freed from blood and
972 AMEBioAN MKDicw.j TUBERCULIN AS A MEANS OF DIAGNOSIS
[Dkcbmbeb 20, 1902
the surrounding tissues protected from the outer surface
of the blades.
AfU^r each removal of the blades from a hemostased
track all charred adhering blood must be removed from
their surfaces.
Too short an application should be avoided. No error
is committed if the time is half a minute longer than
required.
It should be distinctly understood that the term cau-
terized does not apply to the method of hemostasis by
electrically heated pressure instruments. To cauterize
is to burn. In this process we cook the compressed rib-
bon of tissue, a vastly different thing from burning it.
I have intended this as a short communication and
have attempted not to repeat from former papers, to
which I would refer those interested in this method. In
these articles many of the evolutionary stages of my final
instruments are depicted.'
A REPORT ON TUBERCULIN AS A MEANS OF DIAG-
NOSIS.
BY
J. D. MADISON, M.D.,
of Hathorne, Mass.
Assistant Physician, Danvers Insane Hospital.
The use of Koch's original tuberculin as a diagnostic
measure is, today, a very important question in medi-
cine, and this is largely because we have come to realize
the great importance of an early diagnosis in tuberculosis ;
and no other method seems to possess the possibilities
for that purpose that tuberculin does. It has been with
the hope of contributing something to our knowledge of
this most important means of diagnosis that the injec-
tions of tuberculin have been carried out on rather a
large scale at Danvers Insane Hospital, and an attempt
made to observe the patients as carefully as possible.
For U years all those admitted to the female wards of the
hospital have been given injections, unless the condition
of the patient rendered it impossible or undesirable.
There was no selection on account of suspected tuber-
culosis, but all suitable patients received the injections.
This series of consecutive cases numbered 400. A good
many other patients also received injections, the total
number being 525. The following is a brief statement
of the method used in giving the injections : The tem-
perature was taken every four hours for two to five days
before the first injection was given. The injections were
given about 8 p.m., and for the next 24 hours the tempera-
ture was taken every two hours. If there was no reaction
from the first injection, a second one was given three
days later. After this the temperature was taken for
three days, or longer, if for any reason it was found
desirable. In a short time the routine was adopted of
giving a first dose of 4 mg., followed if necessary by
7 mg. as the maximum dose. Some smaller and some
larger doses were given. Koch's original tuberculin
imported from Germany was used. A .6% carbolic acid
solution was usually made up so that each cc. contained
2 mg. of tuberculin. This solution was made up every
three to five days, and kept in a cool, dark place. Injec-
tions were not usually given if the previous temperature
for two days reached above 99.5° F. A rise of 2° F.
during the following 24 hours was considered a temper-
ature reaction, and in many aises the presence of a
reaction was determined wholly by the temperature
chart, on account of the character of the patients. I
would like now to record briefly several cases that came
to autopsy, and which seemed to be of special interest.
r„„™ Electrotliermlc Hemostasis in Abdominal and Pelvic SurKerv "
Journal of the American Medical Association. August 17 1901 " Eiei>
trolhermc Hemostasis in Vaginal Hysterectomies for Cancer " jintj^-
\iVf i''^VT;^^i''' 2'. 1902 •• Electrothermlc Hemostasis in AbdSm-
Uon J uty^l, 1802 ^'^''''^ """^ "' """ ^'"«'"'<=»" Medl<4° Assoc^
Case 1.— H. S., female, aged 40. Diagnosis of mental con-
dition was" brain tumor." The examination of the chest was
unsatisfactory, but there appeared to be slight signs at the right
apex. Acid staining bacilli were found in the feces, but these
could not have been tubercle bacilli. Patient's temperature
frequently ran up to 100° F. During the last two weeks the
afternoon temperature ranged between 100° and 102° F. She
was given 4, 7 and 10 mg. The liighest previous temperature
for two days was 100° F., tiie temperature having been taken
everv four hours. After 4 mg. the highest temperature was
100.2° F., and after 7 mg. it reached 100.3° F. Following the
injection of 10 tug. the temperature rose rapidly and 12 hours
after the injection had reached 102.3° F., and was accompanied
by general malaise and headache. The reaction was a typical
one, and the temperature returned to normal in about .36 hours.
The patient died 28 days later.
Autopsy. — A tumor, which proved to be a glioma was found
occupying mainly the middle lobe of the cerebellum. A com-
plete and careful autopsy was performed, including an exami-
nation of the brain, spinal cord, and viscera, special attention
being paid to the cervical, axillary, bronchial, inguinal and
mesenteric glands, but no evidence of tuberculosis could be
discovered, either macroscopically or microscopically. The
osseous system showed no evidence of disease. The lungs
were quite normal, with the exception of a moderate amount of
hypostatic congestion. The pleuras were entirely free from
adhesions, and there were no scars at the apices.
Case II.— A. S., female, aged SJ. Diagnosis of mental con-
dition was " cerebral thrombosis with dementia." Examina-
tion of the chest revealed nothing of importance. The patient
was given one injection of 4 mg. The highest previous tem-
perature for three days, taken every four hours, was 98.8° F.
The injection was followed by a typical reaction, the tempera-
ture reaching 103° F. at the end of 20 hours, accompanied by
some headache and pain in the right side. Following the reac-
tion there was a small rise of temperature each day for 18 days,
the highest temperature each day ranging between 99° and
101° F. It reached 101° F. only tlireo times, and at other times
did not go above 100°. Patient died eight weeks later.
Autopsy. — Examination of the brain was not allowed. Both
pleuras were free with the exception of slight adhesions at the
middle of the left upper lobe. There were no scars at either
apex. A portion of both lower lobes was consolidated. A care-
ful search was made for tuberculosis, special attention being
paid to the lymph glands. None was found macroscopically
or microscopically.
Case III. — L. B., female, aged 39. Diagnosis of mental con-
dition, "general paralysis." Examination of the chest revealed
nothing of importance. Patient was given 4 and 7 mg. The
highest previous temperature for three days was 99.8° F., the
temperature being taken every four hours. After 4 mg. the
highest temperature was 100.8° F. Three days later 7 mg. were
given, when the temperature rose to 102.8° F., 16 hours after the
injection. The temperature returned to normal the same day.
Patient was much demented, and did not complain of any gen-
eral symptoms. Death occurred about eight months later.
Autopsy. — The brain showed the changes usually found in
general paralysis. The pleuras were free from adhesions, with
the exception of the left apex, where slight adhesions and a
slight scar were present. The bases of both lungs were almost
consolidated. Careful search was made for tuberculosis In all
the organs, including the lymph glands, and the osseous system
was carefully inspected, but no evidence of tuberculosis beyond
the adhesions at the left apex could be found. Microscopic
examination of specimens from the organs and glands revealed
no tuberculosis.
Case IV.— .-v. S., female, aged 86. Diagnosis of mental con-
dition, "senile dementia." Examination of the lungs revealed
nothing of importance. Pour and 7 mg. were given. The
highest previous temperature for three days was 99.6° F. After
4 mg. the temperature rose to 101° F. Eight days later 7 mg.
were given, and the temperature reached 102° P., 20 hours after
the injection. She was restless, appeared sick, appetite poor.
Death occurred eight months later.
Autopsy. — A careful search for tuberculosis was made as in
the other cases, but nothing was found but some adhesions and
a small scar at left apex. No active tuberculosis was found in
the microscopic examinations of the specimens.
Case V.— D. E., female, aged 51. Mental diagnosis, " cere-
bral thrombosis with dementia." Examination of the chest
revealed nothing of importance. Patient was given 4, 6 and 8
mg. The highest previous temperature for three days was 100°
F., temperature being taken every tour hours. After 4 mg.
temperature reached 101° F. on the day of reaction. Four days
later, 6 mg. were given, temperature reaching 100° F. During
the two days preceding the last injection of 8 mg. the tempera-
ture was not above 99° P. Following this injection temperature
reached 101.6° P., 20 hours after the injection. The patient was
aphasic, but her general condition was not noticeably affected.
She died Ave weeks later.
Autopsy.— A complete autopsy was performed and a careful
search was made for tuberculous lesions, but none was
found, with the exception of adhesions over the middle lobe of
right lung and at the apex, where there were adhesions and an
old puckered scar, IJ x 3 x 4 cm., which contained several small
cavities 2 to 3 mm. in diameter. There was a small calcareous
nodule in the visceral pleura. The condition at the right apex
December 20, 1902]
TUBERCULIN AS A MEANS OF DIAGNOSIS
lAMKRtCAJS! MSOICTKE 973
seemed to be entirely a healed lesion, and a microscopic exam-
ination showed nothing but pigmented, fibrous tissue. No
other evidence of tuberculosis was found.
Case VI. — E. M., female, aged 70. Diagnosis of mental
condition, " cerebral thrombosis with dementia." Phys-
ical examination of the lungs revealed nothing of im-
portance. Patient was given 4, 7 and 10 mg. The highest pre-
vious temperature for three days was 98.6° F. After 4 mg. the
temperature rose to 99° F., and after 7 mg. to 100.5° P. Patient
complained of some headache and dizziness. Following 10 mg.
the temperature reached 101.2° F., 18 hours after the injection.
Headache and dizziness were again complained of. Patient
died 10 months later.
^4 atopvj/.— Complete autopsy was performed. The organs
and lymph glands wore carefully examined with special refer-
ence to tuberculosis, but nothing was found except the follow-
ing: The right pleura was adherent at the apex and over the
posterior portion of the upper lobe. The left pleura was firmly
adherent throughout. There were distinct, thougii small,
puckerings and scars at both apices. In the upper part of the
left lower lobe was a hard, irregular nodule, 10 x 3J mm., which
contained a white pasty material. At this point the adhesions
were especially firm. Microscopically no active tuberculosis
was found.
Case VII. — L. M., female, aged 30. Mental diagnosis,
"epilepsy." Examination of lungs revealed nothing of im-
portance. One, 2 and 3 mg. were given. Highest previous
temperature for three days was 98.5° F. After 3 mg. tempera-
ture reached 100.4° F. at the end of 20 hours, which was a rise of
1.9° F. Patient died eight weeks later.
Autopsy. — A complete autopsy was performed and a dili-
gent search for tuberculosis was made as in the other cases, but
nothing was found except slight adhesions of the left pleura,
the right pleura being firmly adherent throughout. Alicro-
scopically, no active tuberculosis was found.
Case VIII. — M. .J., female, aged 66. Diagnosis of mental
condition, "involution psychosis." Lupus was first noticed
on the left wrist September, 1897. By January, 1899, the lesion
was completely healed. Patient received a single injection of
6 ing. The highest previous temperature for two days was
98.6° F. Temperature reache<i 102'' F. at the end of 20 hours.
No general symptoms were complained of. On the day of
reaction the scar of the old lupus was much reddened and a
litj;le swollen. It continued to be slightly red during the fol-
lowing day. Patient died three months later.
Autopxy.— On the left wrist was a thin white scar, 4x6 cm.,
which showed no evidence of active tuberculosis. The left
pleura was adherent at the apex. At this point there was a
tuberculous area about 5 cm. in diameter, containing a small
cavity. Several other small tuberculous areas were found in
different parts of the same lung. All these nodules were firm
and composed mostly of fibrous tissue. Only a small amount
of active tuberculosis was present.
In the first case there \va.s a well-marked reaction to
10 mg. A careful search at autopsy revealed neither
active nor any evidence of old tuberculosis. One would
hardly be justified, however, in concluding that abso-
lutely no tuberculosis was pre.sent, as a very small lesion
might have escaped notice or been situated in a part of
the body not examined, such as the nasal passages.
The following six cases showed no active tuberculosis,
but each showed more or less evidence of old tubercu-
losis, though in three this evidence was very slight, and
may fairly be considered cases of healed tuberculosis.
The eighth case was one of fibroid tuberculosis. It was
included on account of the distinct local reaction of the
old lupus scar on the wrLst, and it seems to lend sup-
port tf) the idta that healed tuberculosis is capable of
reacting. Not all cases of healed tuberculosis react, as
several at autopsy showed old lesions, such as pleural
adhesions and s(!ars at the apex, but did not react to the
routine doses of tuberculin. It will be noticed that four of
tlie casts reporte<l were in old women. Of 80 women over
60 years of age who received injections, reactions occurred
in 40^. My experience would lead me to think that a
large percentage of these patients would show healetl or
fibroid lesions much as were found in the cases pre-
sented. Frazier and IJiggs ' liav(! reported 14 eases of
healed bone tuberculosis, 1 1 of which reacted. In these
patients there could be no assurance that there was not
active tuberculosis in some other part of the body. In
connection with the question of healed lesions njacting,
it is of interest to note that Stockman '■' obtained a moder-
ate reaction in a dog, and a well-marked reaction in a
pony, which had some time previously been ir\jet!ted
with a large (juantity of dead tubercle bacilli. The ani-
mals had previously failed to react to tuberculin. Two
of my patients who did not react to 4 mg. and 7 mg.
showed at autopsy active tuberculosis. One of these
patients died two years after the injections were given,
and the condition found at autopsy may have developed
in the meantime from a quiescent lesion which did not
readily react. The second patient was injected from
tuberculin which later was proved to have deteriorated.
One other patient who failed to react to the regular
doses later developed undoubted tuberculosis. It is
well established that cttses of proved tuberculosis have
not reacted to doses varying from 3 mg. to 10 mg.
Head,' Anders,* Cornet,* Heron,'* Neff,' Martin and
Robins," Berthenson," Ruedj,'" Braun," Po.st,'^ Bobrick,''
Otis," Elder,"* Wood,'" Grasset and Vedel," Frazier and
Biggs,' have all seen one or more cases of proved tubf-r-
Culosis, which did not react to doses varying usually
from 3 mg. to 10 mg. Head gave 24 mg. to a patient
with tubercle bacilli in the sputum, with no reaction. He
speaks also of a tuberculous patient not reacting to 30
mg. These patients who have failed to react have
almost invariably been those in which the disease was
far advanced. They represent only a small percent of
the total number of patients. The demonstration that
patients react when no tuberculosis is present is much
more difficult. Autopsies are not often obtained among
these patients, and I have seen mention of but one case
— that of Mason's " — in which there had been a reaction,
but no tuberculosis found at autopsy. Several writers,
however, have claimed to get reactions in the nontuber-
culous, but these statements are based on the absence of
physical signs, which are notoriously uncertain. At
autopsy tuberculosis is s) often unexpectedly found.
Trudeau '" refers to the fact that SO ft, to 40 fc of people
who die of other diseases at autopsy show unexpected
tuberculous foci. Maragliano" believes he obtained a
reaetion in 9^ of healthy persons, using as high as 25
mg. Guttsdat,™ from collected statistics, claims that Sfo
of healthy persons react. Mosler " claimed to have got a
reaction in 17 out of 21 nontuberculous patients. White"
collected 30 socalled nontuberculous cases, which
reacted to doses varying from 1 mg. to 5 mg. Again, it
is claimed that reactions are obtained in a great variety
of diseases other than tuberculosis. Netter -^ obtained
reactions in 27 out of 100 patients suffering from dis-
eases other than tuberculosis. Head ' collected 64 cases,
including a great variety of diseases, which showed \Sfc
of reactions.
Beck" reports a high percentage of reactions in a
variety of diseases; such as influenza, 106 cases, 63^
reacted; croupous pneumonia, 76 cases, Sbfc reacted;
facial erysipelas, 96 cases, .54 % reacted ; chlorosis, 86
cases, 60 fc reacted ; articular rheumatism, 82 cases, 56 /o
reacted. From the fact that tuberculous lesions are so
frequently associated with other diseases, and also from
the fact that the percentage of reactions reported in these
cases is usually small, it seems probable and most
writers believe that we have merely asswiation of tuber-
culosis with other diseases, and that these diseases alone
would not react. Statenients in regard to the percentage
of nontuberculous or healthy patients which react with-
out postmortem examinations are unreliable. There
seems to be more reason for believing that syphilis and
leprosy may be capable of reacting, and this claim is
made quite jjersistently by a number of ob.servers.
Straus and Teissier '» obtainwl a reaction in four patients
having syphilis ; they thought one patient with rupial
syphilid showed a local reaction.
Beck" injt^cted 143 syphilitic i)atienls, uilii 41^ of
reactions. Otis '* has more recentl.v injected 3;") carefully
selectfKl patients having syphilis, presumably without
evidence of tuberculosis, of which 17^ reacted. He con-
cluded that syphilis in any stage may react. To me this
seems an unwarranted conclusion. White" had 18.5^
of reactions among 70 patients showing no clininil evi-
dent of tuberculosis. Other diseases show as high as
nfo of reactions. In my list of 400 patients, whore-
974 Amxbioan MbdiojkbJ
TUBERCULIN AS A MEANS OF DIAGNOSIS
[Decehreb 20, 1902
oelved li^ections as they were admitted, no 85 consecu-
tive cases could be found which showed as low as 17% of
reat'tions. Hence it would seem to te not very difficult
to And 35 persons showing 17 ^c of reactions. Beck"
obtuincd a rather high percentage of reactions, but no
higher tlian tiie average percentage of other diseases in
his list. It is well known that syphilis and tuberculosis
are frequently associated. Heron *° has not seen a case
of syphilis reacting which did not show signs of tuber-
culosis. The three patients which 1 have injected all
reacted, but all showed fairly definite signs of tubercu-
losis. Mason '" found at autopsy in a case of syphilis
which had reacted, no evidence of tuberculosis. No other
reacting case which at autopsy showed tuberculosis has
come to my notice.
Kaposi," Arning," Babes and Kalendro,*" Gold-
schmidt" and Beck " have reported in all 18 cases of
leprosy in which the patients were injected with tuber-
culin, of these 15 reacted and 3 did not.
It is claimed that a local reaction is obtained with the
tuberculous form of the disease, and that the character
of the reaction in leprosy, both local and general, varies
somewhat from that seen in tuberculosis. We have here
again a disease frequently associated with tuberculosis.
No autopsies after positive reactions showing no tuber-
culosis have been met. Abraham ^'' states that tubercu-
losis is extremely common among lepers. In 109
autopsies he found tuberculosfs present in 33 cases. One
must admit, however, that with tuberculin there is a
distinct margin of error, and that this is considerable is
made evident when we consider that the standard of
reaction is only relative. Many Germans require a rise
of only .5° C. to constitute a reaction, while most
observers in this country and England require a rise of
2° F. Certainly a rise of less than 2° F. is often duo to the
presence of tuberculosis. In looking over my charts I
find that a rise of 1 ° F. after the final dose was present in a
sufficient number of cases to increase the reactions fully
10 fc , and it is only fair to assume that at least some of
these patients harbored tuberculous lesions. I believe,
however, that a rise of 1° F. is unreliable. It would
seem that there was at least 10 fc difference between the
two requirements.
Advanced cases are known not to react at times, and
it seems likely that at least a few patients react when no
tuberculosis is present, as in Case I of those reported,
while the following six cases illustrate the fact that healed
tuberculosis may also react. It is to be regretted that
more autopsies have not been obtained of patients who
have received injections. France '^ has reported 34
autopsies in patients who had been injected, 29 showing
tuberculosis and 5 no tuberculosis, which was in accord
with the tuberculin test. This was scarcely a fair test,
as only 1 mg. was used. Keactions obtained from so
small a dose would undoubtedly be more accurate than
those from higher doses, but it would just as surely over-
look many patients having a tuberculous lesion. Gutts-
dat,™ from collected statistics, finds that 95 fc of the cases
of known tuberculosis react. Head' has collected 83
cases of tuberculosis, nearly 6fo of which did not react.
One may, with some justice, appeal t« the results of
autopsies in cattle in attempting to estimate the margin
of error. Friinkel " refers to 8,000 postmortem observa-
tions in which the error in diagnosis was not more than
10%. Voges,'5 in 7,000 examinations, finds the error
in diagnosis by tuberculin is scarcely 3%. Ca-sselbery ■•«
refers to a series of 3,655 cattle which were tested. Of
these 560 were condemned, because of reactions, and in
only 8 could no tuberculosis be found. Only 8 nonreact-
ing cows were examined. I have examined postmortem
145 cows, injected by a competent veterinarian, following
the method recommended by the Massachusetts Board of
Cattle Commissioners. Among these 51 had not reacted.
Of these nonreacting cows 20, or 13.8 /<, of the whole,
showed definite tuberculous lesions. Also, in 13 react-
ing cows, no tuberculosis was found ; but I do not lay
stress on these, as In some, at least, a thorough examina-
tion was not made.
While in human subjects it is not yet possible to fix
more than approximattdy the margin of error, it seems
to me probable that it must be at least 10%. That is
scarcely more than the error with other of our best clin-
ical methods, and we surely have in tuberculin a very
valuable means of diagnosis. About 60 % of the react-
ing patients among the 400 injected at time of admis-
sion showed signs more or less positive, but in many of
these a certain diagnosis, or even a probable diagnosis,
could not have been made without a positive tuberculin
reaction. Beck " states that in his series 1,154 cases of
tuberculosis were first detected by tuberculin. Undoubt-
edly it is often difficult to draw proper conclusions from
the results of a test, as it often is with other methods of
clinical diagnosis. One must be enough but not too
much alarmed by a positive reaction. It must te kept
in mind that some tuberculous patients may not react
while others without perceptible lesions, or with a healed
lesion, may react, and that in considering a local condi-
tion, such a.s a joint or a tumor, an unsuspected tubercu-
lous lesion elsewhere may cause a reaction. The ques-
tion of dosage is one of importance, but one about which
there is little agreement as to the exact quantity. Nearly
every one who has used tuberculin extensively has fol-
lowed a routine of his own. Some begin with a small
dose, as J or 1 mg. and gradually work up to their max-
imum dose, giving several injections in all, if necessary.
Others again give but one dose, and that a fairly large
one, as 10 mg. Still others give a moderately large
initial dose of 2 to 5 mg. and this followed, if necessary,
by the maximum dose, usually not larger than 10 mg.
It became my routine to give 4 and 7 mg. and it has
proved satisfactory. It seems to me to be better than
the plan of giving several small, increasing doses, and is
perhaps somewhat better than just one large dose. The
first plan is more difficult to carry out, and is more try-
ing to the patient. It is believed by White,^^ Head,'
Heron," Whittaker,'* and others, that these small in-
creasing doses tend to produce a tolerance and that the
reaction is often not so distinct and decisive. There is
no question about this tolerance being produced in time,
and Heron" speaks of giving as high as 400, or even
1,000 mg. of old tuberculin without a reaction. An
initial dose of 1 mg. is advisable with feeble patients. In
looking over the charts of 200 reactions I find that in 45
of these the temperature reached 103° F. or more. Of
these 23 were after 4 mg. and 22 after 7 mg. after hav-
ing received a previous injection of 4 mg. Thus, failure
to react to a previous dose did not assure a rnoderate re-
action when a larger dose was used. Severe reactions
may follow small doses. Martin and Robins'* obtained
their highest temperature (105° F.) from an injection of
Jmg.
I shall not attempt to state just what the maximum
dose should be, but certainly such small doses as 1 to 4
mg. are not reliable, and would leave a large margin of
tuberculous patients which did not react. Among 200
reactions, 112 followed an injection of 4 mg., while 88
responded to 7 mg. after having failed to react to 4 mg.,
which gives some idea how unreliable the before-men-
tioned small doses are. I have found 7 mg. a satisfac-
tory maximum dose, but know of no serious objection
to using 10 mg. Higher doses are not advisable and are
unnecessary. It is desirable that the temperature for
several days before giving an injection be quite normal.
Atemperature of 99.5° F. is allowable, and most patients
in which the temperature reaches 100° F. will react
promptly. Distinct reactions occur with a temperature
of 101° F., or above, but there is considerable uncer-
tainty with these patients, and failure to react is of no
value. A few patients having undoubted tuberculosis
and running an afternoon temperature of from 102° F.
to 104° F. received several injections without the slight-
est reaction. On the day of reaction the temperature
December 20, 1902]
TUBERCULIN AS A MEANS OF DIAGNOSIS
"■American Medzcinx 97&
should be taken every two hours. Two hundred tem-
perature charts of reactions were examined with refer-
ence to the amount of error there would be in taking
the temperature every four hours or three times a day.
The margin of error, with the temperature taken every
four hours was about 4 <fc , while with the temperature
taken three times a day, Sfo to 10^ of the reactions
would be overlooked. In considering the doses that
shall be used a very important factor is the strength
and quality of tuberculin used. So many factors influ-
ence the strength of tuberculin that it has as yet been
impossible to produce a tuberculin of standard strength.
Together with this variation in strength, I believe there
is another factor of great importance which is usually
not considered. It is that the glycerin preparation itself
tends to deteriorate, and especially so if not kept in a
cool, dark place. The tirm from which the tuberculin
used was obtained stated that it was not known to deteri-
orate if kept in a cool, dark place, and I have seen no
statement to the contrary in the literature of the subject,
though most writers recommend that the diluted prepa-
ration be made up fresh or frequently. My attention
was called to the matter by the failure to react of certain
patients who were believed to be almost certainly tuber-
culous. The injections had been made from a freshly
prepared carbolic acid solution, but from a bottle of
tuberculin which had been opened several months, it
having been kept in a fairly cool, dark pla(«. From a
newly-opened bottle all the suspected patients promptly
reacted. After this experience, when a patient showing
suspicious signs did not react, injections from a freshly-
opened bottle were given. In this way evidence of
deterioration was found in several different bottles, after
they had been opened from four to eight weeks, and in
all, 22 patients with positive or suspicious signs, failing
to react with fresh carbolic acid preparation from bottles
opened from four to eight weeks, reacted promptly to a
preparation from a freshly-opened bottle. It should be
consideretl that the bottles may have originally varied
in strength, and this tends to obscure the question of
deterioration. Two bottles of tuberculin, which at the
time of being opened caused prompt refictions in 11
patients, were kept in a fairly cool, dark place for sev-
eral months, at the end of which time these patients
were again injected with the same doses. Six did not
react, four showed a reaction but less marked, and only
one reacted as strongly as at time of first injection.
With these two bottles there could be no question about
the deterioration. The same fact was noted with these
as with the other bottles, that some, or most of the
patients, depending upon the extent of the deterioration,
still promptly reacted. Whether there wa.s any deteri-
oration before the bottles were opened could not be
determined. The deterioration of the .iifk carbolic iicid
solution is beyond question, and it is generally conceded
that this deteriorates more or less rapidly. It became
my cust<^)m to open a fresh bottle every month, and this,
with being more careful to have the .5^ carbolic
acid solution fresh, has had a very important effect
upon the percentage of reactions among the newly
atlmitted patients. The last 200 patients showed about
10^ more reactions than the first 200; also distinctly
more patients have reacted to the first injection. Since
using freshly-opened bottliw of tuberculin, no patient
who has shown fairly definite physical signs has failed
to react. It seems likely tliat a large number of the
failures to react reccjrded in the literature would have
reacted had they been reinjected with fresh tuberculin.
I believe that delayed reactions are usually associated
with deterioration of the tuberculin, but this may not
be the only factor. A good many peculiarities in the
reactions occur for which there is not a good explanation.
Nearly all who have had considerable (experience with
tul)erculin have met these socalled delaye<l reactions.
In some ca.ses the entire reaction occurs on the second
day; more frequently there is a gradual riste, the maxi-
mum being reached on the second day. I have had a
number of such cases, and they were especially notice-
able and annoying during the summer months ; and
the suggestion is that the summer heat may have pro-
duced more than ordinary deterioration of the tubercu-
lin, although care wa-s always taken to keep it in as
cool a place as possible. Ten of the patients in whom
a marked reaction occurred on the second day, and whom
I was later able to reinject, after being impressed with the
idea that the delayed reactions might be caused by
changes in the tuberculin, promptly reacted to injec-
tions from fresh tuberculin. Well-marked reactions
seem less likely to be delayed, yet one of my pa-
tients had no reaction on the first day, but on the
second day there was a typical reaction, the temperature
reaching 103° F. Wood" believes that delayed reac-
tions are especially likely to occur in fibroid tuberculosis,
but that has not been my experience, and it cannot be
that it appears in these cases with any degree of con-
stancy. It will be noted in the cases reported, in which
there were only sc"drs or adherent pleuras, or as in
Case VIII, fibroid tuberculosis, the reactions were all
well within the first 24 hours. A few other patients at
autopsy showed a fibroid condition, but all had given a
prompt reaction ; also, nearly all of the patients in
which the lesion clinically seemed to be fibroid in char-
acter showed like prompt reactions. It has been sug-
gested that the delayed reactions appear in patients
who have received repeated increasing doses ; but, in
my experience, it occurs as frequently after the first
injection as after the second. The fear of bad effects
from tuberculin hsis deterred many from using it, and
this is, undoubtedly, a very important consideration.
The great majority of those who have written on this
subject profess to find no serious effects at all. Knopf,-'*
Ambler*" and V. Y. Bowditch" are among those who
believe it is too dangerous to use, or are not entirely
convinced of its innocuousness. The regular injections
have been given freely among seniles and other feeble
patients, and the harmful effects, although apparent in
some patients, have not been of great importance. In
no patient was there evidence of permanent injury. In
four seniles a temperature reaching 100° to l*)!" F. daily
wa-s present after the reaction for from 5 to 15 days ;
after that all returned to their previous condition. In
one of these. Case il, the autopsy showed no active
tuberculosis. Perhaps a temperature is more easily
excited in seniles than in others. One patient had an
irregular j)ulse for two or three days. In a very few
patients tender and swollen glands liave been present
for several days. A number of the patients felt the
effects of the reatttion for two or three days, while a few
did not recover entirely for about a week. These reac-
tions were usually severe and among the more feeble
patients. However, the great majority of the reacting
patients had symptoms only on the day of resiction.
The temperature does not always indicate the severity
of the reaction, but it is a fairly good index. Among
200 reactions, in 45 ca-ses the temperature reached 108° F.
or more, and in only 10, 104° F. or above. Klebs"
states that collapse, jaimilice, diarrhea, delirium and
coma have l)een known to follow injcjctions, but usually
after large doses. Head " reports a ca.se of Addison's
disease in which the patient died 36 hours after the
iiyection of 24 mg. Heron " reports a case in which the*
patient died 27 hours after the injection of J mg., but
concludes that death could not have l)een due to the
tuberculin. During the early days of the use of tuber-
culin Kwald '■' reported two deaths followinc injections
of tuberculin, in which he thought the causal relation-
shij) of tuberculin wa-s at lea.st very probable. The first
case was complicated with amyloid nephritis. Death
result<Hl on the day of reaction from liemoi)tysis, an
injection of 1 mg. having been given.
In the second case death also resultwl ftom hemop-
tysis, following a series of injections up to l(t mg. No
976 AMXBIOAM UICDIOINIEI
BUSINESS PHASE OF OUR DAILY WORK
IDeoehbbb ao, 1902
such cases have? since been reported. In considering the
danger of tuberculin, it is well to remernlier that we
continue to use chloroform and ether for diagnostic pur-
poses, notwitlistanding the fact that many deaths are
known to have been caused by them ; and surely there
are few diseases in which an early diagnosis is more
important than in tuberculosis. Tuberculin should gen-
erally be used only in early, incipient cases in which the
sputum exatriinations and physical signs are not decisive
—cases in which it would furnish profitable informa-
tion. Feeble patients should be excluded when possi-
ble, though they often pa.ss through a reaction without
being seriously affected. When used in strictly suitable
cases the danger from tuberculin seems to me to be
slight. The series of 400 patients injected at the time
of admiasion to the hospital is of considerable interest
as an indication of the frequency of tuberculosis. Of
these 40 fc reacted. Beck's '" series of 2, 137 cases showed
1,154 reactions, or h\<fo. The difference in the two per-
centages is nearly accounted for by the difference in the
requirements for a reaction. Beck required a rise of but
J° C, and a like requirement would have increased my
reactions 10^. In both series the patients were drawn
largely from the working classes. Zahn " has recently
published the results of 6,320 autopsies in which he
found tuberculosis present in 32.5% of the cases.
CONCLUSIONS.
1. Patients may react fo tuberculin and no evidence
of tuberculosis be found at autopsy, as shown by Case I.
2. The six cases following seem to demonstrate that
completely healed tuberculosis may react.
3. Cases of proved tuberculosis may not react to the
maximum doses.
4. The evidence is not conclusive that other diseases
than tuberculosis may rpact to tuberculin.
5. The margin of error of the tuberculin test is con-
siderable and probably not less than 10 /c.
6. The maximum dose should be higher than 4 mg.,
and not more than 10 mg. Small increasing doses are
not advisable, as the reiiction is not so likely to be dis-
tinct on account of the tolerance which may be pro-
ducefl. An initial dose of 3 to 5 mg. followed by the
maximum dose is better.
_ 7. The temperature should usually be normal before
injections are given. When the temperature is dis-
tinctly above normal a negative result is of no value, as
these patients will frequently not respond at all, even to
large doses.
8. It seems quite certain that the glycerin extraet of
tuberculin deteriorates, and a fresh bottle should fre-
quently be opened, care being taken to keep it in
a coo, dark place. The .5% carbolic acid solution
should be made up on the day it is used if possible. I
believe that deterioration of tuberculin is the principal
factor in producing delayed reactions.
9. It cannot be said that tuberculin injections are
entirely without ill effects, but their use among suitable
patients is no more dangerous than the use of chloro-
torm and ether for diagnostic purposes and is quite as
justihable as an early diagnosis of tuberculosis is of the
greatest importance.
10. About 40 f„ of all female patients admitted to the
hospital react to tuberculin.
BIBLIOGRAPHY.
»Stockm^n''H.H^l.^^"'r- Of Pfnn- Med. Bui., March, 1901.
« H/r: w\rLo"„i',^S^v"SftrU''' Tub^erculose. Weln, 1899.
2 5'S!'"^,?™!?''^'*' '"'■''• ^™"-'>™schr.,r8'91,' Vol. xvll D 412
i« Wood. Jour. Am. Med. Assoc, Apr. 19, 100.', Vol xxxvlil, p. 99«.
"Grassetand Vedel, La Semalne M«d., Keb. 26, 1»>90.
I'Trudeau, Med. News, N. Y , May 29, 1897, Vol. Ixx, p. 687.
'"Miiragliano, Borl. klin. Wochenschr., Nos. 19-20, 1896.
■•»'<)iitt.sdal, quoted by Trudeau, loc. cit.
8' Mosler, quoted by Martin and Robins, loc. clt.
2s White, Boston Med. and .Sur. Jour., 1897, Vol. cxxxvli, p. 123.
-'Nelter, quoted by Litbain, Lancet, I.«nd., 1901, Vol. 11. p. 1781.
=< Heck, Deutsche med. Wochenschr.. No. 9, 1899, p. rj7.
2'' Strauss and Tessler, \ja, .Semalne M6d., 1893, p. 381.
« Heron. Brit. Med Jour.. 1901, Vol. II, p. 213.
-' Mason, quoted bv Head. loc. clt.
-* Kaposi, Internat. klin. Rundschau, 1890, No. .50.
2» Arnlng, quoted by Head. loc. clt.
■w Babes and Kalendro. Deutsche med. Wochenschr., 1891, p. US.
»' Goldschmidt. Berl. klin Wochen.schr., 1891, p. 28.
'- Abraham, .\llbutt's System of .Hediclne, Vol. ill. p. 59.
»3 France. Jour. Ment. 8cl.. Lend., Jan.. j900. Vol. 46.
^'Frttnkel, Berl. klin. Wochenschr., 1903. No. 2. Vol. xxxvll, p. 255.
^ Voges. quoted by Strauss. Berl. kiln. Wochenschr., 1900, p. .M4.
38Cassell)ery, Med. News, N. Y., Oct. 12. 1901, Vol. Ixxlx, p. 575.
s' Heron, Phlla. Med. Jour., Sept. 21, 1901, Vol. vlli, p. 494.
» Whlttaker, Clnclnn. Lancet-Clinic, Sep. 11, 1897, Vol. xxxlx, N.
S., p. 245.
™ Knopf, Jour. Am. Med. As.soe., Dec. 9, 1899, Vol. xxxlll. p. 1445.
^Ambler, N. Y. Med Jour , Feb. 12, 1898, Vol. ixvii, p. 205
♦' Bowdltch, Boston Med. and Surg. Jour., p'eb. 8, 1900, Vol. cxUl,
p. 146.
« Klebs. Boston Med. and Surg. Jour., Feb. 10, 17, 1R98, Vol. i:}8. p 121
"Ewald. Berl. klin. Woctienschr., 1891, No. 4, p. 109.
"Zahn, Manchen. med. Wochenschr., 1902, No. 2, p. 49.
SPECIAL ARTICLES
THE BUSINESS PHASE OF OUR DAILY WORK.
I. N. PICKETT, M.D.,
of Odell, Neb.
In an experience of 20 year.s in society work I liave not once
heard the business phase of our daily work discus.sed. This is
not to be wondered at when we remember that the object and
design a.s set forth in the preamble of our societies is "the cul-
tivation and advancement of medical knowledge, for exciting
and encouraging emulation and concert of action in the medi-
cal profession," etc., and that we are taught our work is largely
one of charity and philanthropy ; that we are to go in storm as
well as in sunshine, and that darkness or light must not be
considered when the call of suffering humanity comes. This is
all right from a philanthropic point of view, but philanthropy
does not pay our bills nor charity fill our stomachs. When we
consider the value of our services to mankind it is most unfortu-
nate that so many senior practitioners should not be in a better
financial condition. Why should not the physician who spends
his life in relieving suffering humanity be as able to support
his family and educate his children as is the farmer, merchant,
or mechanic ? Why is he left all but destitute when from bod-
ily infirmities, incident to old age, he is compelled to relinquish
practice?
I know a doctor whose head is white with the frost of 79
winters ; whose step was once, when on errands of duty, quick
Had elastic, now, even with the aid of a staff, slow and uncer-
tain; whose figure, once erect and vigorous, is now bent and
feeble; whose intellect, once brilliant, is now in the twilight of
life clouded. People once called him "doctor," they now say,
" old doc." Were it not for the little rent he receives and the
assistance of a son and daughter this man would be an indigent.
Yet his courage in times of danger and his fortitude in the face
of adversity merit an opulence befitting the service he has ren-
dered humanity. It is not dissipation that has brought him to
this, for he has lived a temperate life, and in matters of econ-
omy and frugality he is beyond criticism. Where, then, lies
the cause that this servant of humanity should be denied the
comforts and ease that so justly belong to him at the close of a
long and useful career? I leave it to an ungrateful clientage to
answer. This is not an uncommon picture; there are hundreds
of practitioners who find themselves at the end of an active
life in this unfortunate condition. Therefore, for the good of
the profession, I think it our duty as a body to look occasion-
ally at the pecuniary side, in order to correct some wrongs that
undoubtedly exist.
1902
^» Read before the Nebraska State Medical Society at Omaha, May 7
December 20, 1902]
BUSINESS PHASE OF OUR DAILY WORK
• AKKBIO&K MEOIOtSH 977
Chief among these is the matter oi compensation. Thought-
ful consideration leads to the belief that in proportion to the
actual value of the services rendered the general practitioner
of medicine receives less compensation than any man In the
world. For instance, baseball players have been known to
receive ?.5,000 for a few months' work ; a wellknown merchant
has given §100,000 for a .single picture; while it is an every-day
occurrence for a lawyer's fee to run up into the thousands. If
a man commits a capital crime he will gladly pay the lawyer's
fee even if it requires the sacrifice of all his earthly po.sses-
sions; if instead of committing a crime he is the victim of a
suppurative appendicitis a remarkable difference is noted in
his method of reasoning. The doctor removes the offending
appendage, recovery ensues, and the graod final occurs when
his benefactor a.sks him for a slight compensation, say §100 or
$200. The pain is no longer located in the right lower abdom-
inal quadrant but has become a metastatic pang of financial
stringency, and in a paroxysm of anguish he exclaims, " Great
Caesar, what extortion ! " Some years ago I advised a client to
send his wife to a hospital for the purpose of having an ovari-
otomy performed. The probable cost was placed at ?250 to ?;3.50.
I thought this a conservative estimate, but my client seemed
greatly astonished and asked if that was not too aiuch. I
answered that it depended upon the money value he placed
upon his wife. This " wizard of finance" contributed ?800 to
the printers'-ink-practitioner before taking my advice, as the
surgeon's fee seemed to him exorbitant. General practitioners
are largely to blame for this ignorance on the part of the laity
as to the value of their services. Where is the justice in the
surgeon receiving the ordinary fee for removing an inflamed
appendix, when a physician curing the inflammation (and he
does do it sometimes) charges so much per mile for his services
amounting possibly to one tenth the fee received by the sur-
geon? Why should we not charge as much for administering
an antidote as for ligating an artery, or for giving a subcu-
taneous injection of diphtheria antitoxin as for performing
a tracheotomy? Why should the physician receive less for
curing an iritis than does the oculist? The general practitioaer
seems a dual personage: as surgeon he treats fractures and
receives from §10 to §7.5 ; as a physician he may jugulate a case
of pneumonia, which is more dangerous than the fracture, and
receive possibly §j. I allude to the foregoing, each example
of which is familiar to all, in order to call attention to the difter-
ence in the customary compensation for the service which has
for its object the saving of life. In the parlance of the specu-
lator, I do not wish to "bear" the fee of the surgeon, but
simply to " bull " that of the general practitioner. I would sug-
gest that charges should be made in proportion to the actual
value of the services rendered ; that we stiffen up all along the
line and not look to a second or third party for remuneration.
The acceptance of a dividend from a specialist is on a par
with the commission sometimes offered by the druggist and too
often accepted by the physician. Both are similar to a bribe,
and he who accepts either degrades himself. If we expect our
clientage to be honest with us, we must first be honest, and not
surreptitiously compel them to pay two fees instead of one.
It has been maintained Ijy some specialists that when a gen-
eral practitioner refers a case to a specialist that the physician
should share in the fee as an assistant, in the same manner that
one lawyer assists another. When we send our patients to a
specialist, it is because we have exhausted our resources; diag-
nosis may be uncertain, or there is inaljility or lack of courage
to perform some operation that requires adroitness which the
specialist is supposed to possess. Any knowledge of the case
that we posse.ss that is of service to the specialist should not be
used as a speculative commodity and delivered to the highest
bidder. An ideal specialist, and one to whom we, as con-
scientious general prac^titioners send our cases, is supposed to
have liis corps of trained assistants, with whom he is accus-
tomed to work ; and for us to take the place of such assistants
is to jeopardize the elHoiency of the end sought. There is
anotlier objection, viz., the dividend specialist is liable to
specialize on tlie dividend.
I hold that so soon as wo turn our cases over to the specialist
our responsil)ilities cease, and therefore we are not entitle<l to
any part of tlie fee. Iftliere has been an overcharge, give tlie
patient the benefit of the rebate, as we are supposed to have
been paid for our services.
If the acceptance of a commission from a specialist is wrong,
it is equally wrong to accept one from the druggist to whom we
send our prescriptions. While this custom is not general, it is
far more prevalent than the division of fees with the specialist.
The pharmacist, like the specialist in other lines of practice, is
a product engendered and fostered by the general practitioner
of medicine, and as such should be considered our colaborer,
and not we as his mercenaries. The law recognizes the impor-
tance of competency in the druggist ; he must prove by an
examination that he has a certain amount of knowledge of
the nature of drugs, their chemi9 and pharmaceutic combi-
nations, or he is barred from entering this branch of trade.
That the druggist should add a certain per cent to the retail
price of drugs used in compounding prescriptions, as compen-
sation for the extra knowledge and skill required by law, is
freely admitted. If, however, the physician demands a com-
mission, this otherwise justly added per cent too frequently
becomes extortionate, and our clients are forced to seek relief
in patent medicines or other hybrid methods of cure. We are
thus aiding some of the wrongs we are endeavoring to over-
come. It is clearly our duty to select a druggist whose honor,
integrity, competency and straight business methods are
beyond question. When a druggist proposes to share his
usual commission of from 20% to 33%, one of two things is
certain, either that his profit is becoming a burden to his con-
science, or that our clients will pay the revenue.
After our examination of the patient has been made and our
knowledgeof the clinical manifestations of disease and the ther-
apeutic indications of remedial agents focused into a prescrip-
tion, the patient pays or should pay us for that much of our
stock in trade which has a value that is universally recognized.
It is as legitimate a transaction as is the sale of the drug, and
ends with the payment of a fee. The patient has a valid reason
to believe and the physician admits that the debt is canceled.
But when the month rolls around the " tip doctor " calls on the
druggist, who, according to the terms of the conspiracy, tips
him 20% or 33J% of the amount that this patient paid for — what?
Not the prescription, nor for the doctor's knowledge or skill in
curing disease, for he paid for that once, but simply for the
drugs and pharmaceutical skill of the druggist plus the stipu-
latetl amount. I ask in all candor if the porter, bellboy or
waiter is more guilty of the pernicious custom of receiving
tips? If the prinoiple is not the same will some one kindly
differentiate?
It has been maintained that often the druggist's profit is
greater than the physician's in a given case. In such an event,
either the druggist is charging too much or the doctor too little.
If the druggist has made extortionate charges, he has proved
himself unworthy of confidence, and it becomes our duty
either to compound our own prescriptions or send them to a
druggist who will be satisfied with the legitimate profit that
properly belongs to him. If the doctor charges too little he is
at fault. If the case is a chronic one there should be an under-
standing from the first that, as the physician's knowledge, judg-
ment and time are his stock in trade, consultation, advice and
treatment will bo given at a stipulated amount for a specified
period of time. This is a legitimate business transaction and
will stand in the courts of justice.
The "tip doctor," or whatever you wish to designate this
class of practitioners, writes prescriptions galore, with ad
valorem as his beacon guide. If he accepts the customary fee
for his services he is guilty of receiving two fees when he is
entitled to but one. If he declines the proffered compensation
with a word or gesture that such service is of no value or is
free as a special favor, he is guilty of duplicity. If the prescrip-
tion is valueless he has imposed upon the confidence of the
sufferer by giving worthless remedies, and he is also taking
unfair advantage of his client, in order to secure what should
belong to the druggist. The annual amount of business done
by the general pra(;titioner probably averages about fU.OOO, Of
this he will probably collect §1,200 or ILSOO, and after deducting
the expenses of the year, he will bo very fortunate if he has
§2.50 or $500 surplus for a year's work. How many physicians
who have practieed 20 years are worth §10,000 as a result of their
978 Akbbican Msoioiirxl
TETTENHAMER ON E0SIN0PHILE8
[Ukcehbeb 20, 1902
practice? There are a few, but they have made business
inethorls as niucli a study as the cure of disease.
I am inclined to attribute the general practitioner's financial
condition to three factors, viz., leniency, laxity and laziness.
Leniency is the dominant factor and is largely the result of a
false idea that the practice of medicine is or should be a work
of charity and philanthropy. The sooner the practice of medi-
cine is divorced from charity the better it will be for humanity
in general, and the physician in particular. I would not for a
moment have the worthy poor neglected. A certain amount of
charity work is to be expected, but between this and the busi-
ness proposition a sharp line should be drawn. " Let not thy
left hand know what thy right hand doeth " is applicable to
charity work, which should never appear on the pages of our
ledger. Rural practitioners see little of the pauper class and
are therefore required to do very little gratuitous work, but in
large towns and cities it is different. Even here the Slate or
county has provided a fund, to which most of us contribute,
for their care and medical service which for political or other
reasons is too freely offered. The physician who pays his share
of the tax from which this fund is derived is unjust to himself
and the profession if he does the work at a loss. The usual cus-
tom of bidding for county practice is degrading to the profes-
sion, unfortunate for the successful applicant, dangerous for
the recipients of public charity, and should be abandoned.
When an account is opened in our ledger the credit column
should not remain blank very long. The accounts of those
unable to pay should be endorsed by the county supervisor of
the district in which the patient resides and the bill charged to
the county. It is for those who are able to pay that leniency is
apt to interpose and thwart proper business methods. Our
clientage will be prompt or negligent in the payment of bills in
proportion to the manner in which we educate them. It is
important to impress upon them that the practice of medicine
is a business proposition ; that in return for our services we
must be compensated ; that bills are due when the services are
rendered. We should adopt a system of book-keeping that will
always show the amount due. This method serves to impress
the patient with the fact that the account is due, and the ten-
dency is to beget promptitude in settling.
There is one class, which is fortunately in the minority,
that never mention the subject of payment. These should be
brought up promptly ; let them not impose upon yon. Assert
your dignity and collect your bills.
Then there is the " promising class," those who promise to
pay, and at the time do not intend to do so. It is a good plan to
keep in the column for remarks a record of promises made to
settle and to keep relentlessly after them. The column will
grow black sometimes, but it serves two purposes : First, in
case of litigation it is a record of repeated acknowledgments of
the account; second, it is an interesting page to show to the
debtor at intervals.
The lax habit of permitting accounts to run six months or a
year without an understanding, should be avoided, as the longer
payment is deferred the greater is the reluctance to compensate
for benefits long since received. The most opportune time to
settle an account is at the high tide of gratitude, when the
patient most appreciates our services and is not only willing to
pay but anxious to demonstrate in a material way his appreci-
ation of the greatest of all blessings— restoration of health. But
let the physician with loose business methods say to this grate-
ful patient, " Oh, never mind, wait until some other time. I do
not need the money now," and the patient becomes at first
indifferent, then obstinate, and finally if a settlement is ever
made it is at the expense of friendship and confidence in the
doctor, both of which would have been fostered by adhering to
business methods.
Edward N. Gibbs Memorial Prize.— The New York
Academy of Medicine announces that the sum of |1,000 will be
awarded to the author of the best essay on " The Etiology
Pathology, and Treatment of the Diseases of the Kidney." Com-
petition is open to all members of the regular medical pro-
fession of the United States. Each essay must be typewritten
in English, and must be presented to the Committee of the
Trustees of the New York Academy of Medicine on the
Edward N, Gibbs Memorial Prize before October 1, 1904.
TETTENHAMER ON EOSINOPHILES.
BY
EDWARD T. WILLIAMS, M.D. (Harv.),
of Boston, Mass.
In exploring the archives of hematologic literature, I
recently unearthed an article new to me, known, undoubtedly,
if scantly appreciated abroad, on the formation of acidophile
granules in leukocytes out of degenerating nuclein. This
article was written nine years ago by Dr. Eugen Tettenhamer,
formerly assistant in the Anatomical Institute at Munich, and
may be found in the eighth volume of von Bardeleben's
"Anatomischer Anzeiger," published by Fischer of Jena.' I
have not succeeded in findingany mention of it in the systematic
treatises on the blood. I only chanced to discover the title some
two months ago in the reference list of the American transla-
tion of Bohm and von DavidofTs Histology, but beyond the
title, without the least clue to its contents, I immediately sent
to the Boston Medical Library to inquire for the needed
volume. They did not own it, but through the kindness of the
assistant librarian. Dr. E. H. Brigham, I secured a loan of the
book from a distant city and copied out the article for my own
use. It proved a genuine find for me, as it confirmed
in a really marvel jus way the results of my own studies
on eosinophiles, embraced in a series of four papers on
the white blood-corpuscles, published in the four Septem-
ber numbers of the Boston Medical and Surgical Jour-
nal for 1901. The conclusions reached by Dr. Tettenhamer
were almost identical with my own, though arrived at by
totally different methods of investigation. The two studies are
mutually complementary and mutually confirmatory, each to
each. I have thought, therefore, that I could hardly do better
for the cause of science than to offer tlie readers of American
Medicine a, brief abstract of Tettenhamer's paper.
An added reason is that the author was soon after com-
pelled to give up his position at Munich on account of ill
health, or, maybe, for still graver reasons. At any rate I can-
nol learn of any farther communications of his on the subject,
though specifically promised in the present paper.
The original observations were made in a course of study
on nuclear degeneration as displayed in the spermatogenesis i)f
the spotted salamander, following tlie line marked out by
Flemming^ and afterward by Hermann.^ The special object
was to find out the ultimate destiny of the decomposing chro-
matin of the nuclei of the degenerating spermatocytes.
Tettenhamer extracted tlie testes of the animals named dur-
ing the breeding season, hardened them in corrosive sublimate,
and stained the sections with Mayer's hemalum and a watery
solution of eosin, to which headdedacertainquantity of sodium
sulfate after a formula of Bannwarth.* This addition, as he
claims, gives a much sharper differentiation than a simple
watery solution of eosin. His method was to stain the nuclei
first with hemalum, then eounterstain for a quarter of an liour
with the eosin, wash in water, and rinse in absolute alcohol.
The first change in the nuclei of the spermatocytes affected
witli destructive degeneration was the secretion of a substance
inside the cliromatin framework of tlie nucleus which stained
intensely with eosin, and in fact with all the acid dyes.
This substance, to which he gives the name of acidophile
substance, gives in all respects the impression of a liquid, since
it appears everywhere in the form of globular drops, which,
whether colored or uncolored, especially when examined in
water, present a highly refractive and glistening appearance.
The fact that this substance appears sometimes in many little
drops and sometimes in fewer and larger drops creates a certain
diversity in the pictures.
The cell bodies of the spermatocytes in this first phase of
degeneration show little change. In the later stage they con-
tract by degrees and eventually form sharply contoured globu-
lar masses scarcely larger than the normal nuclei of the sur-
rounding spermatocytes. Still later, in consequence of a dif-
fuse inhibition of acidophile substance (probably by a conflu-
ence of the previously separate drops), they change into glisten-
ing balls, which in colored preparations even under low powers
are conspicuous by their brilliant red color. Under stronger
magnification one sees shining indistinctly through the red the
dark blue chromatin (colored witii hemalum) of the equally
shrunken nucleus. The latter is simply changed into a
homogeneous intensely colored mass wliicli is always crowded
back toward the circumference of the cell.
As the process continues the cell loses the acidophile sub-
stance altogether, so that the chromatin of the nucleus again
becomes plainly visible, while the protoplasm assumes a faint
violet grey color.
Later still, the same cells show a secondary production of
Decbhbbb 20, 1902]
THE WOELD'S LATEST LITEEATUKE
[American Medicine 979
«o.sinophile substance with a continued diminution of the chro-
matin and an increased shrinkage of the cell body; but it is
now secreted, not as formerly, inside the nucleus but near it,
on the side turned toward the center of the cell. It often
spreads out as a red border on the same side of the chromatin-
clump, finally separating itself entirely in the form of discrete
drops. After the formation of a larger quantity it again
becomes diffusely spread through the whole cell.
Lastly, as the chromatic substance melts gradually away,
the shrinkage of the cell continues, so that finally only a small,
almost colorless mass remains in its place as the last relic of the
body of the cell.
It is worthy of note that the process of degeneration affects
pretty evenly all the cells belonging to a single spermatocyst ;
frequently almost all the cells of one cyst are destroyed.
The regular sequence of the phenomena above described is
to be attributed first to the progressive contraction of the
cells; second, to the parallel diminution of the amount of
chromatin.
The combi nation of these briefly sketched observations estab-
lishes the certain conclusion that, with the degeneration of the
nuclei of spermatocytes, an acidophile substance forms at the
expense of the chromatin, whose production continues until
the chromatin is used up.
It has already been noticed that the acidophile substance
repeatedly escapes from the degenerating cells. In some cases
greater and smaller drops are found lying free in the surround-
ing tissues. In others it entirely disappears. One of the
author's speidmens contained a large number of disintegrating
nuclei with a great abundance of eosinophile leukocytes. A
closer examination showed that the latter, though lying scat-
tered everywhere in the interstitial connective tissue between
the caualiculi, had collected in far greater numbers in the parts
surrounding the degenerating spermatocysts. Such collections
of eosinophile cells were observed particularly around those
sper£natocysts whose cells were strongly loaded with acido-
phile substance. Hence it is plainer than ever that it is chiefly
the spermatocytes lying nearest the eosinphile cells which
have already lost more or less of this substance. These sper-
matocytes often contain acidophile granules li ke those of the con-
tiguous eosinophile cells. Moreover, the eosinophiles which
lie between the cells of the degenerating cysts, in contrast to
those detected in the act of migration, show a marked expan-
sion of their cell bodies and a granulation which appears to be
very loose. Here we And among the granules a few much
larger drops. Besides those some scattering small drops are
found lying free in the tissue as the last trace of the here com-
pleted process.
From all this it becomes evident that the acidophile sub-
stance formed in the degenerating cells by alteration of the
chromatin passes into the cell-bodies of the leukocytes and
here displays the peculiar segmentation (Kornung) known as
the acidophile or Alpha granulation.
Thus occurs the breaking up of the acidophile substance
into the droplets, which correspond to the -Vlpha granules,
accompanied by an overflow of the same substance from the
degenerating cells into the leukocytes.
So far as concerns the similar behavior of the acidophile
substance and the Alpha granules toward dyes, it is well
known since Ehrlich's experiments that the diagnosis of acid-
ophiliain any substance cannot be satisfactorily made with a
single acid dye like eosin, but must show the same reaction
toward all. The author used not only eosin, but orange, nigrosin,
fuchsin S, and indulin, with invariable success.
The demonstration ofthe formation of the acidophile gran-
ules in leukocytes from decomposing nuclein being thus com-
pleted, the author goes on to infer that he has discovered a
gener?.i law. All that we have thus far learned, he says, about
i.iie appearance of eosinophile cells is wholly favorable to a gen-
eralization of this sort. The eosinophiles, as is well known, are
regularly and abundantly found in the lymphoid organs of ver-
tebrate animals. Au abundant destruction of cells in blood
and lymph must be admitted on apriori grounds. The cellular
elements are now retained in great numbers in the organs
named, so that here also both the growing, ageing, and dying
cells must collect together. In mammals the fading nuclei of
the orythroblasts here come into peculiar consideration.
K.xperimeiits on the lymph glands and bone-marrow of the
fnineapig readily showed decaying nuclei in great abundance,
lere, also, in these karyolytic cells Tettenhamer found acido-
phile substan(re near the chromatin. The pictures, however,
were inimeisurably inferior to those seen in the salamander.
The common concurrence in pathology of an increased i)ro-
duetion of eosinophile cells and an increased destruction of
normal cells must be explained in the same way.
The coincidence of the appearance of the cells in question
with the Charcot-Leyden crystals is equally striking. The
facts mentioned seem to afford some ground for an explanation
of this connection.
It is well known that the components of the cell nucleus—
nuclelns and nuclein-acids— contain phosphoric acid, which in
necrobiotic proi'esses may be set free in the organism.' Now
these crystals have already been proved to contain phosphoric
acid combined with an organic base, and for that reason may
possibly be extracted from the decaying nuclei like the acido-
phile substance.
It may be mentioned in conclusion that the fornaatlon of
acidophile substance out of chromatin may be observed in
still another way. Investigation makes it probable that the
same substance is also produced out of keratohyalin, which as
Mertsching* maintains and the author can confirm, is formed
directly out ofthe chromatin of the dissolving nuclei of cornify-
ing cells. The acidophile substance is here found partly in the
form of scattered drops in the stratum Malpighii and stratum
granulosmn, partly, as is shown by its reaction to dyes, in dif-
fuse distribution in the stratum hicidum. The latter indeed
owes its characteristic appearance to the strong refractibility of
the substance in question.
Prom this point of view the contradictory doctrines of
previous authors on keratohyalin and eleidin must needs be
explained.
The author closes by expressing his warmest thanks to his
honored teacher. Professor von Kuppfer, for the support given
him in his investigations.
The paper is really a remarkable one, and in my opinion is
worthy of a fuller consideration than it has yet received.
BIBLIOGRAPHY.
>Eugen Tettenhamer: lleber die Entstehung dcr acidophtlen
Leukoeytcn-granula iius degeaerirender Kenisubstanz. Auatom-
ischer Anzeiger, 8 Jalirgang, 8. 2«-2J8. Fischer, Jena, 1893.
2 Arch. f. mikr. Anat., Bd. x.xlx. S. 446 ff.
3 Arch. I. mlkr. AnaU, Bd. xxxiv, S. 99 a.
<Arih. f. inlkr. Auat., xxxvlii, 8.432 tf.
' Sclilefferdecker u. Kossel, GewebeleUre, 1891. I Ab., p. 53.
« Vlrchow's Archlv, 116 Bd., 1889, 8. 501.
THE WORLD'S LATEST LITERATURE
Joarnal of tbe American Medical Association.
December IS, 190t. [Vol. xxxix. No. 24.]
1. A Review of Current Pediatric Literature. H. M. SiIcClanahan.
2. A Critical Review of 416 Cases of Appendicitis Operated on In the
German Hospital, Philadelphia, In 1901. John B. Deaver and
G. G. Ross.
3. Appendicitis: A Brief Report of the Author's Nine Fatal Cases,
with Comments. Parker JSyms.
4. Anomalies of .Appendicitis. Ernest Laplace.
5. Alcoholic Epilep.sy. T. D. Crother.s.
6. The Pathology of Chromldrosls. M. L. Hedingsfbld.
7. The Blood in Fllarlasis. W. J. Calvert.
1. — See American Medicine, Vol. Ill, No. 24, p. 990.
2, 3.— See American Medicine, Vol. Ill, No. 25, p. 1040.
4.— Anomalies of the Appendix.— Laplace notes first tbe
anomalies of location lound in his own cases. Twice the
appendix was found adherent to the liver, once to the gall-
bladder, and twice to the urinary bladder. In enteroptosis it
may be found in any part of the abdomen, the location of pain
becoming obscure. The peritoneum may not refer the pain to
the right location. The infection often departs from the typical.
All bacteria in the diseased appendix are also found in the
healthy appendix and colon. If drainage is not possible, the
retained germs rise in virulence, producing a toxin as destruc-
tive as nitric acid, causing gangrene. The streptococcus is
chiefly responsible for this type. When the bacillus coli infects,
the case begins more quietly. This type results in the obliter-
ating form. Kxtraappendiceal absces.ses may occur. Mixed
infection gives to the chronic type an acute exacerbation. With
adhesions a favorable soil is formed for the chronic abscess of
tuberculosi.s. Mixed infections cause a great variety of clinical
.symptoms. Early and clean extirpation is the only safe treat-
ment. [H.M.]
5.— See, American Medicine, Vol. Ill, No. 24, p. 991.
6. — Ohromidrosis.- Heidingsfeld reports a case of yel-
lowish-brown chromldrosls. This disease is not an anomaly of
sudoriferous secretion. The yellow and brown, and probably
the black, blue, and green forms are exceedingly rare. Ked
chromidrosis is a different affection, due to a parasite. The
pigmented elimination in the yellowish-brown form is
insoluble in water, alcohol, ether, etc., is readily soluble In
chloroform, stains linen indelibly, shows no reaction when
treated with ordinary reagents, and is amorphous, homogene-
ous, and resinous. The sudoriferous glands are normal,
sebaceous glands absent, a hyperkeratosis is seen around the
hair follicles, and pigment accumulations near the latter, in
the stratum corneuni, lower layers of the rete, and the adjacent
cutis. The pigment is in eell-liko masses, is not finely granular,
and does not bleach with hydrogen dioxid like chromophoros.
Spectroscopic examination reveals no absorption bands, hence
it is not a derivative of oxyhemoglobin. It is an anomaly of
pigmentation, not of glandular secretion, [h.m.]
980 AMJEBICAN MBDIOIItEJ
THE WORLD'S LATEST LITEEATURE
[December 20, 1)X)2
7.— Blood III FllarlasU.— Calvert reports in detail the
blood-findinK« in liis cases. An accompanyinB cliart shows a
poriodicity of eosinophilia depending on periodicity of the
orabryoH in the peripheral circulation. When the latter are
crowded in the capillaries, a positive chemotaxis for eosino-
pbiles grwlually attracts the cells from the general circulation.
As the embryos reenter the circulation this local chemotaxis is
removed. As the disease progresses the leukocytosis and
eosinophilia gradually decrease to normal, [h.m.]
Boston Medioal and SurKical Journal.
December 11, 190t. [Vol. cxi,vii, No. 24.]
1 Infantile Paralysis: An Epidemic of iW Cases CHARLES K. Painter.
2 Congenital Anomalies of Phalanges, with Report of Cases Studied
by.skl8gnipliy. K. B. Lund.
3. l,eukop aklii Frederic C. Cohb. •
4. A (;ase of Suture of Divided Ureter : Recovery without Leakage.
Hugh Cabot.
l._See American Medicine, Vol. Ill, No. 24, p. 1000.
4.— Suture of a Divided Ureter.— Hugh Cabot reports
that on doing a hysterectomy for malignant disease the right
ureter was divided and 1 cm. (..3 inch) was removed with the
tumor. End-in-end anastomosis was effected as follows : The
lower portion of the ureter "was dilated with a pair of hemostatic
forceps. A traction stitch of fine silk was passed into the lumen
of the lower portion from without inward, carried out through
the open end up into the lumen of the upper portion from with-
out inward, and then back into the lower portion and out at the
same hole through which it was originally introduced. The
upper portion was then pinched together, and traction on this
suture invaginated the upper portion into the lower. The ends
were held in position by three sutures of fine silk placed at the
junction of the overlapping ends, but not entering the lumen of
the ureter. The traction suture was removed. The patient
made a complete but slow recovery. A subsequent laparotomy
for a recurrence of the disease showed the anastomosis to be
complete. Four methods of effecting ureteral anastomosis have
been employed. The transverse end-to-end method has been
done 12 times with 2 deaths; the end-in-end method has been
done 10 times with 1 death; the end-in-side method, and the
oblique end-to-side method each has its advocates, [a.b.c]
Medical Record.
December IS, 1902. [Vol. 62, No. 24.]
1. The R6ntgen Ray and Ultraviolet Light in the Trentment of Malig-
nant Diseases of the Uterus, with Report of an Inoperable Case.
Margaret A. Ci.eavI'S
2. Pulmonary Syphilis Simulating Pulmonary Tuberculosis. Henry
W. Bekg.
3. Three Phases of Pancreatic DLsease, with Report of Cases. John H
Bl.ODGETT.
4. The Neuron Theory ; Its Relation to Physical and Psychical Meth-
ods of Treatment. A. 1) ROCKWELI,.
5. Syphilis In the Barber Shop: A Case ol Infection Through an
Accidental Razor Wound. Antonio Fanoni.
1.— -Rontgeii Ray and Ultraviolet Light in the Treat-
ment of Malignant Diseases of the Uterus.— Cleaves gives
the history of a case of inoperable cancer treated with liltia-
violet light and the x-i"ay. The patient, a married woman of 42,
was suffering from cancer of the cervix with infiltration of
anterior and posterior vaginal walls and tlie broad ligaments,
an inoperable cervical cancer. Treatment was begun May 15
by means of a vaginal hydroelectric douche, 100° F., four quarts
medicated with loOgrams (10 grains) bichlorid of mercury, and
used not only for the purpose of cleansing the entire vaginal
tract, but to sterilize the tissues more deeply than was possible
by simple irrigation. This was repeated on the sixteenth, and
on twentieth and twenty-first vagina and cervix were exposed
to the ultraviolet rays for 10 minutes, causing a diminution of
discharge, lessening of odor, and improvement of circulation.
Then the x-ray treatment was instituted, and after four x-ray
and four violet light applications the following record was
made: Temporary arrest of hemorrhage, diminution and
changed character of discharge, disappearance of odor, relief
from pain and pelvic discomfort, gain in strength and vigor,
lossof cachexia with return of pink color to face and hands,
improved appetite, and appearance of healthy granulations
where before a ragged and fungoid condition of the cervix pre-
vailed. The treatment was continued during five months
and one week, 110 treatments being given ; for the first 2i
months daily, Sundays excepted, and then three times a week ;
of these, .50 were with the x-ray. These were not made at regu-
lar intervals, but according to the condition of reaction— thrice,
twice and once a week. At present appetite and digestion are
both good, bowels regular and sleep absolutely normal. There
has been a steady gain in strength and weight, and today she
feels strong and well. Tissues of the genitalia have become soft
and nonresistant, but the healing is not complete. The case is
not reported as one of cure, but to demonstrate what has been
done in a desperate condition and to call attention to the value
of the x-ray and ultraviolet light in combination for this class
of cases. The question may be pertinently asked. What
becomes of the malignant tissue and its toxic products? Sterne
tries to throw some light on this by reporting the case of a
patient afflicted with a tumor formation of the glandular struc-
tures, especially of the neck region, of enormous size, extend-
ing into the chest cavity and interfering both with respiration
and heart action. After daily treatment with the x-ray for some
weeks the tumors greatly diminished in size, but during the
latter part of the time mental dulness was noted, also irregular
heart action, persistent bronchitis, diarrhea, and enlargement
of the spleen. The x-ray treatment was discontiuued, but its
effects continued, the tumors steadily diminished, the spleen
enlarged ; and, in spite of every effort to counteract the poison-
ing, the patient finally died. Sterne points out that a slower
more intermittent treatment would have had less disastrous
results, forthesystem might have been enabled to throw off the
septic material more gradually, [w.k.]
2.— Pulmonary Syphilis SimuIatingTuberculosis.— Berg
reports a case in detail which recovered under antisyphilitic
treatment. The condition is not as rare as supposed and may
be present with true tuberculosis, for which it provides a favor-
able soil. It may be a manifestation of congenital as well as
acquired syphilis. In acquired pulmonary syphilis catarrhal
bronchitis is the most frequent finding in the early secondary
stage. Stenosis of the bronchi occurs later from infiltrating
gummas followed by atelectasis and bronchiectasis. A pul-
monary gumma causes an area of pneumonia with filirous
changes, breaking down finally into a caseous condition. Some-
times fibrosis involves almost the whole lung. While occlusion
of vessels may be too gradual to produce infarcts, it is logical to
believe it may produce a bronchopneumonia upon which
tuberculosis is planted. The symptoms are not sufficiently
characteristic to make diagnosis positive. Cough, hemorrhages,
and fever are more infrequent. Anemia and loss in weight are
less ; the breath is rarely fetid ; progress is slower. The treat-
ment consists in mercury and iodids. In 10 days improvement
will appear if the case is syphilitic, otherwise the cough and
other symptoms will increase, except possibly in the case of
simple fibroid pulmonary tuberculosis. When syphilis and
tuberculosis exist togetlier specific treatment aids cure of the
latter by removing the deteriorating influence of the former.
[H.M.]
3.— Pancreatic Disease. — Blodgett describes the functions
of the pancreatic juice, and reports cases of disease, per se, by
extension, ami as part of a general process, only autopsy
revealing the true cause of death. One usual explanation of
faulty motabolistn is congestion of the liver, yet we have no
jaundice or constipation, aud the stools are normal. May not
the trouble be functional deficiency in pancreatic secretion, and
should not stimulation ba directed toward the pancreas, rather
than the liver? [h.m.]
4. — Physical and Psychical Treatment. — Rockwell
reminds us that in the theory of structural isolation of the
nerve cell, together with amebic movements, the explanation
of mental phenomena resolves itself into a question of con-
nections. The difference between momentary forgetfulness
and permanent amnesia, between transient and incurable
paralysis, is simply one of degree. Hereditary want of stabil-
ity of the neuron is, in the majority of cases, the fundamental
cause of abnormal mental phenomena. The exciting causes
are fatigue or autotoxis. The symptoms differ. In the toxic
form of neurasthenia there is more confusion and irritability.
December 20, 1902|
THE WORLD'S LATEST LITERATURE
i.Ambbican Mbdicink 981
Some of the good derived from electricity is psycliic, wliich
adds to its value, but most of its influence on the neuron is
mechanic or electrotonic. The natural molecular vibrations of
the nerve elements, thus reinforced, opsn up new paths of
conduction, [h.m.]
5-— Syphilis From a Razor Wound.— Fanoni reports that
while an Italian of 40 was being shaved by his son, an amateur
barber who had obtained a second-hand razor from the shop, a
small cut was made just below the chin. The wound refused
to heal, suppurated, the adjacent glands became swollen and in
due time there was a well-marked syphilitic rash. That the
infection came from the razor wound is certain, though that the
razor carried the infection is not conclusive but most likely.
There was of course a mixed infection else the wound had not
suppurated. The author calls attention to the imminent danger
of contracting syphilis in barber shops and asserts that legisla-
tion for the proper regulation and inspection of the shops is
urgently demanded, [a. B.C.]
New York Medical Jonrnal.
December 6, 1903. [Vol. lxxvi. No. 2.3.]
1. The Treatment of Vascular Neoplasms by the Injection of Water at
a HiKh Temperature. John A Wyeth.
J. The Functional Weight-bearing Method of Treating Congenital
Dislocation of the Hip, as Originated and Practised by Professor
Adolf r^renz. Dkxtek li. Ashley.
:i. The Diagnosis and Operative Treatment of Femoral Hernia, In-
cluding a Description of the Fabricius Operation. Russell S.
Fowler.
I. The Works of Kdward Jenner and Their Value in the Modern Study
ofiSmallpox. George Dock.
.5. A Case of Cancer of the Larynx Cured by the X-rays. W. Scheppe-
GUELL.
1.— Angiomas. — Wyeth has treated a number of cases of
angiomas by the direct injection into their substance of water
at 190° F. to 212° F. and over, and reports excellent results. In
the arterial and venous tumors of large size the needle is
thrust deeply into the mass, and from 2 to 4 cc. (30 to 60 m.) of
water are forced out. It is then partly withdrawn and the
operation repeated until the entire tumor is solidified. The
water should be hot enough to coagulate the blood and the
albuminoids of the tissues at once, but not so hot as to produce
necrosis. In treating capillary angiomas, situated upon impor-
tant .structures, a small instrument with a delicate needle
should be employed, and water at 190° F. is preferable. Not
over .12 cc. to ..36 cc. (2 to 6 m.) should be injected in a single
puncture, and the treatment should start from various points at
the periphery, the operator watching closely the effect of the
first injections, and after a week or ten days repeating them as
may be indicated, [c.a.o.]
2.— Congenital Dislocation of the Hip.— The functional
weight-bearing method of treating congenital dislocation of the
hip, as originated and practised by Lorenz, is discus.sed by
Ashley, and the method given in detail. It consists in a series
of manipulations by which the head of the dislocated femur
is reduced into the acetabulum, the dislocating muscles
and ligainents stretched, and the acetabulum deepened. The
limb is then encased in plaster-of-paris, standing in the posi-
tion of abduction 00° and flexion 90°, to so remain for six to nine
nionths, until nature has deepened the acetabulum and con-
tracted the capsule around the neck, securing the stability of
the head in the old acetabulum. This is followed, usually after
the removal of the plaster-of-paris, by such exercises and
massage as will .stimulate the muscles giving stability, and
prevent those muscles from contracting which would tend to
produce reluxation. The age most appropriate for this opera-
tion is from three to five years, and Lorenz tliinks he can get
90% to 9.')% of anatomic repositions. Operations have been per-
formed upon patients from 1 to .35 years of age, with anatomic
repositions in !>()% of his practice, and functional improvement
in nearly all. [c.a.o.]
JJ.— Treatment of Femoral Hernia. — Fowler discusses
the diagnosis of femoral hernia and the conditions clo.sely
simulating it, and gives in detail the F'abriclus operation as
modifie<l l)y (ieorge R. Fowler. The incision is made so as to
expose Poupart's ligament at the spine of the pubes and the
line where that structure blends with the fascial structures of
ttie thigh, as well as tlie sheath of the vessels at the crural open-
ing. The sac of the hernia, after being exposed and cleared, is
opened and emptied and ligated at its neck. The latter in suit-
able cases is inverted toward the abdominal cavity. The edge
of the aponeurosis of the external oblique is then forced back-
ward to the level of the upper margin of the horizontal ramus
of the pubes, and there sutured to the periosteum and the origin
of the pectineus muscle. This suturing is very important, and
upon the care with which it is done depends the success of the
operation, [c.a.o.]
4.— The works of Edward Jenner and their value in
the modern study of smallpox is discussed by Dock. The
article is exceedingly interesting, showing that an extensive
review of the literature of .lennerand those associated with him
in his work has been made. The article does not lend itself
well to abstract, and should be read in the original, [c.a.o.
5. — Carcinoma of the Larynx Cured by the X -rays.-
Such a case is reported by Scheppegrell in a man of 57. A
medium vacuum tube was used and the exposure made for 10
minutes each day for 20 days. At the end of the third week the
congestion appeared more marked and the tumor showed no
signs of diminution, but the pain had disappeared after the
second exposure, and did not recur. Ten days later the treat-
ment was recommenced and continued for 10 days longer, at
which time the ulceration in the larynx had completely healed.
Two months later no recurrence was noted, [c.a.o.]
Medical New^s.
December IS, 1901. [Vol. 81, No. 24.]
1. Malignant Disease Involving the Gallbladder. William J Mayo.
2. Surgical versus Medical Treatment of Cholelithiasis. John B.
Deaveb.
3. Keiwrt on the Care of the Sick Pi^or of the State of New York ; with
Suggestions for the Establishment of Convalescent Homes, etc. '
8. A. Knopf.
4. Crede's Intravenous Injections of Silver (Collargol) In Ulcerative
Endocarditis. MoKuis Manges.
5. Remarks on One of the Complications of Anesthesia (Asphyxia).
Thos. L. Bknnet.
6. A New Compact Portable Operating Table. HowARn Lilienthal.
1. — Malignant Disease Involving the Gallbladder. — W.
J. Mayo reports that out of 405 operations upon the gallbladder
and biliary passages, there were found 20 cases of malignant
disease — being about 5?!)- and in every case of malignant dis-
ease of the gallbladder gallstones were present. He considers
the question whether there is an etiologic relationship between
cholelithiasis and malignant disease of the gallbladder. Conr-
voi.sier found that 74 out of 84 cases of malignant disea.se of the
gallbladder had gallstones. Siegert is quoted as stating that in
9a fc of all cases of primary cancer of the gallbladder gallstones
are present, while calculi are found in only 15% of .secondary
malignant disease of this organ. Beadles found that in four
cases of primary cancer of the gallbladder calculi were present
in all, while in 36 cases of secondary malignant disease of the
liver, gallstones were detected in no instance. Attention is
called to the fact that cancer of gallbladder is at least three
times as frequent in women as in men, and this proportion is
likewise true of gallstones; and further, cancer of the gall-
bladder is commonest between the ages of 50 and 60, which is
likewise the period of greatest frequency of gallstones. From
these facts the author concludes that cholelithiasis bears an
important causal relationship t« primary cancer of the gall-
bladder. vSo far as the author has observed, all of the cases in
which the liver was iuvolvetl, secondary to primary cancer of
the gallbladder have had early recurrence. This ia also true of
the cases in which the lymphatic glands in the fissure of the
liver were infected, .laundice occurs in about one-half of the
cases, and as it is a late symptom, operation is contraindicated.
[A.n.v.]
2.— Surgical versus Medical Treatment of Cholelirlii-
asis.- Deaver says the treatment of gallstones at the present
time is being discussed by both internists and surgeons with
much the same argument as was advanced a few years ago in
appendiceal disease. As no intelligent internist would now
procrastinate a moment in calling a surgeon in suspected appen-
dicitis, the same should hold true in lith lasts of the gallbladder.
Operation performed while the calculi are still In the gallblad-
der produces a mortality which Is almost nil, but if gangrene of
982 AM»°'""' MEOICIKBJ
THE WORLD'S LATEST LITERATURE
[Deckmbkb 20, 1902
the gallbladder takes place or if stones become impacted in the
common duct the mortality is (jreat. Delayed operation is very
apt to sot up an inflammatory process which causes adhesions,
or what is more disastrous, an ulcerative communication
between the gallbladder and a neighboring viscus, 'particularly
the stomach, may take place. If the patient survives the attack
extensive adhesions to the duodenum, stomach, colon or omen-
tum may makelife miserable. The contraction of the adhesions
may cause destruction of the bowel at any time and the constant
irritation of the stones may give rise to a carcinoma of the gall-
bladder. Since no drug has ever been found which will dissolve
and remove gallstones it is apparent that the only means of cer-
tain removal is by operation. As to whether cholecystostomy,
cholecystotomy and closure of the gallbladder, or cholecys-
tectomy shall be done depends entirely upon the conditions
found at the time of operation. The first is certainly indicated
in acute empyema of the gallbladder ; the second in the very
few cases in which infection is absent; the third is not indi-
cated if extensive adhesions are present, [a. B.C.]
3.— Care of the Sick Poor.— Knopf names the appropria-
tions for this pjirpose in several of the principal cities of New
York State. These are adequate for all but the tuberculous
poor. The State Hospital for the latter will meet the want in a
measure. The care of the insane and epileptic has materially
improved. The best facilities should be provided. There
should be small psychopathic hospitals for incipient cases in
all the larger cities. The tuberculous insane and epileptic
should be placed in specially constructed pavilions to prevent
contagion and on account of the improvement in the mental
state from treatment directed to the tuberculosis. The writer
notes the improvement in the condition of the Almshouse Hos-
pital and the establishment of a hospital for consumptives on
Blackwell's Island, and reviews the work of the Committee on
the Prevention of Tuberculosis. He emphasizes the need of a
dispensary for tuberculosis and of hospitals for advanced cases
and for convalescents from this and other diseases, [h.m.]
4.— Crede's Intravenous Injection of Collargol for
Ulcerative Kiidocarclitis. — Manges has employed this method
of treatment in two cases. The first was that of a youth of 18,
and in spite of 26 injections the disease pursued its course
unchanged. Streptococci grew vigorously in all the cul-
tures, the white cells remained high in number, the percentage
of hemoglobin gradually fell, and the intensity of the sepsis
may be inferred from the occurrence of mycotic aneurysms and
the other vascular phenomena. The patient was discharged at
his own request, after being in the hospital five months, his
condition being unimproved. The second patient was a girl of
18, who had all the symptoms of an ulcerative endocarditis.
After six weeks treatment in the hospital, six injections being
given, she was discharged unimproved. The author is of
opinion that notwithstanding his failure the method of treat-
ment is worthy of further trial, especially in view of the better
results obtained by Wenckebach, Klotz, and Herrick, and in
view of the serious nature of the malady, [a. B.C.]
5.— Asphyxia Complicating Anesthesia.— Bennet be-
lieves this is the most dangerous and troublesome complication
during the administration of an anesthetic. He does not
employ the term in its literal sense alone, but rather the con-
dition, well known to anesthetists, of deficient oxygen or
increased carbon dioxid, or both, in the blood. This condition
is usually produced as a result of one or more conditions, as by
the exclusion of oxygen, as in the inhalation of pure nitrous
oxid or highly concentrated ether vapor. By paralysis of the
respiratory center from over-narcosis, producing failure of the
respiration. By the production of a condition in which cyano-
sis is marked notwithstanding free respiration and no exclu-
sion of oxygen. This most frequently complicates the admin-
istration of chloroform and is usually associated with some
circulatory depression. The author believes it is due either to
a paralyzing eff"ect of the anesthetic upon the blood-corpuscles,
or to failure of the pulmonic circulation, this in turn being due
to depression of the cardiac and vasomotor mechanism or to
paralysis of the walls of the pulmonic vessels. Asphyxia
complicating anesthesia is most frequently produced by
mechanic obstruction to respiration. The general principles
to be observed in carrying out preventive treatment are:
Unobstructed respiration shojild be obtained by maintaining
an open air-way, by avoidance of conditions preventing free
respiratory movements, by the selection of the proper anes-
thetic, and by its administration in such a way as not to limit
the supply of oxygen or increase the percentage of carbon
dioxid to the extent of producing signs of asphyxia, [a.b.c]
6.— A Compact Portable OperatinR Table.— Lilienthal
describes the table. It is so constructed that it may be folded
up and placed in a carrying case, and is particularly suitable
for operation in private houses. It weighs but 28i pounds, and
when in the case 36 pounds. It is provided with various Joints
and hinges so any of the positions ordinarily used in surgery
may be obtained, [a.b.c]
Philadelphia Medical Journal.
December IS, 1902. [Vol. x. No. 24.]
1. Cholellthtasis. JOHN B. Deaveb. „ , ^
2 Surgical Kemarks on Typhoid Perforation. Robert G. Le Conte.
3. A Case of Typhoirt Fever with Perforation, Operation, and Recov-
ery. William Petry. . _ ..^ , ^
4. The Treatment of Pulmonary Tuberculosis with Kormlc Aldehyd.
W. G. Shallcross.
5. X-ray Therapy. G. E. Pfahler. , ,,, „ .
6 X-ray Tube-sshlelds and Specula for Treating Cancer of the Rectum
and Other Cavities .1. Rawsos Pennington.
7. Acule General Infections Originating In the Lymphoid Tissue of the
Upper Respiratory Tract. Henry L. Swain
8. The Historv of a Case of Intrajibdomlnal Extrauterine Pregnancy
Delivered at Term of a Living Child. W. L. Estes.
9. Adrenalin Chlorid In Urethral Work S. Leon Gans.
10. A Plea for the General Employment of Credfe's Method. W. J.
Weill.
1.— See Medical News, present issue, second abstract.
2.— Surgical Remarks on Typhoid Perforation.—
Le Conte discusses the subject with the premise that so soon as
the diagnosis of perforation is made operative intervention is
called for, unless the patient is obviously in a moribund condi-
tion. If this premise is true the surgical corollary will follow,
viz., that the sooner operation is undertaken after perforation
has occurred, the greater are the chances of recovery. When
perforation occurs in typhoid fever there is usually little or
nothing to oppose the escape of the bowel contents, and a rap-
idly spreading peritonitis is the ordinary sequel. A fatal result
may then be directly attributed to two causes, both of which
should, theoretically at least, be preventable : delay in opera-
tion, and surgical errors of judgment and technic. Delay may
result from the inability to make an early diagnosis ; the failure
to secure permission to operate from a parent or relative in
hospital cases until several hours subsequent to the perforation,
and the surroundings of the patient may necessitate removal to
a hospital, another source of delay. The time for a successful
operation is the moment the diagnosis is probable, and not
when it is made certain by the signs of peritonitis. The sur-
gical errors of judgment and technic are detailed under the fol-
lowing: Shock, incision, treatment of the lesion found, and
peritoneal toilet and drainage, [f.c.h.]
3.— A Case of Typhoid Fever With Perforation.— Petry
details the case of a man of 30, who had perforation on the
thirty-eighth day. Operation was performed seven hours sub-
sequently, resulting in complete recovery. The fortunate out-
come of this case was probably due to the promptness with
which the perforation was recognized and operated upon. The
character of the serum in the peritoneal cavity, which was
frothy but unstained, the limitation of the fecal leakage to a
comparatively small area, and the absence of adhesions,
denoted the very recent occurrence of the perforation, [f.c.h.]
4.— The Treatment of Pulmonary Tuberculosis with
Formic Aldehyd.— Shallcross details the method of treat-
ment and describes an inhaler for the practical administration
of the formic aldehyd. He concludes as follows: As a thera-
peutic adjunct in the treatment of pulmonary tuberculosis
formic aldehyd possesses certain distinct advantages; it is a
gaseous substance, having about the same specific gravity as air,
with which it readily diffuses and is soluble in water ; it is the
most powerful chemical disinfectant known and the nearest
approach we have to a pulmonary antiseptic; it is a stimulant
nontoxic and does not irritate the respiratory tract when
administered in the proper manner; it lessens the absorption
of toxins, reduces pyrexia, relieves nervous symptoms and
night-sweats, and sharpens the appetite ; cough is lessened by
Decbmbeb 20, 1902]
THE WOELD'S LATEST LITEEATUKE
[Amekican Medicink 983
its property to liquefy and render more mucous the secretions,
and by relieving the irritation of the pharynx and larynx.
[f.c.h.]
5.— X-ray Therapy.— Pfahler reports cases of epithelioma,
recurrent carcinoma of the breast, carcinoma of the uterus, car-
cinoma of the esophagus, tuberculosis of the skin and psoriasis,
which teach a new point or impress a fact that is old regarding
the treatment of such cases with the x-ray. He thinks we are
in danger of going to the extreme in the employment of x-ray
therapy, and thus bring this valuable therapeutic agent into
disrepute. The article is illustrated. [f.c.h.J
6.— X-ray Tube-shields and Speonla for Treating
Cancer of the Kectum and Other Cavities.— Owing to the
difficulties encountered in treating cancer of the rectum with
the x-ray, Pennington descrilies the procedures which he
employs in overcoming them. The article is illustrated.
[f.c.h.]
7. — See American Medicine, Vol. Ill, No. 23, p. 949.
8.— See American Medicine, "Vol. IV, No. 14, p. 530.
O. — Adrenalin Chlorid in Urethral Work. — Gans gives
the following indications for the employment of adrenalin
chlorid in urethral work: In cases of mucous or mucopuru-
lent discharge, in urine showing mucus, or flat, scaly shreds ;
when endoscopic examination shows granular patches or super-
ficial scleroses, and when the microscope shows pus cells, epi-
thelial colls or mucus without gonococci, with or without other
microorganisms, [f.c.h.]
lO.— A Plea for the General Employment of Credo's
Method. — Weill believes that the more general use of a 29ij
solution of silver nitrate will afford absolute protection from
primary infection of the eyes during delivery, and that its
more general employment should be encouraged, as no harm
can result from the use of this solntion when properly instilled.
[f.c.h.]
CLINICAL MEDICINE
David Riesman A. O. J. Kklly
EDITORIAI. COMMENT
The Adanis-Stokes Symptoiii-Coiiiplex. — Reports
of this intere.sting syndrome have recently become quite
numerous in medical literature. The first clear account
of it was given by Adams, in 1827. The value of
Adams' description was thoroughly appreciated by his
fellow-countryman, Stokes, who quoted Adams' case
verbatim in his monumental work, "The Diseases of
the Heart and Aorta," page i!21. The summary of the
case is as follows : Repeated apoplectic attacks during a
long series of years ; absence of paralj'sis ; remarkable
slowness of the pulse; fatty degeneration of both ven-
tricles, especially of the right. The patient was a
revenue officer, 68 years of age, of full habit of body,
who had for a long time been incapable of any ex-
ertion, as he was subject to oppression of breathing
and continued cough. When first seen by Adams,
in consultation, he was in a stupor, was drowsy, and
had a troublesome cough. His pulse was about 30
in the minute. He had ha<l no less than 20 of these
attacks. Tliey were always preceded for a day or two
by lethargy and loss of memory. He died in an attack,
and at autopsy the condition of the heart described was
found. The observations of Adams and Stokes had set^m-
ingly been forgotten until they were brought to light by
liuchardin 1893. The classical features of the condition
are bradycardia, respiratory difficulties, and loss of con-
sciousness. In some cases there is only bradycardia with
syncoiH^; in others, bradycjirdia with Cheyne-Stokes
breath i tig and irregularity of breathing; in still others,
bradycardia with vertigo or headache; and again,
bradycjirdia with angina pectoris or cardiac asthma, and
bradycardia with apoplectic seizures and transietnt hemi-
) plegia, for which the autopsy shows no tausative lesion.
Sometimes there is bradycardia with epileptiform
attacks, dilation of the pupils and respiratory disturb-
ances. As formes fruntes, Huchard described cases in
which, in patients with bradycardia, there are attacks of
sudden weakness or of precordial anxiety, with cardiac
irregularity ; or attacks of sudden pallor, with vertigo
and profound prostration. The disease is most common
in aged individuals ; but Luce ' cites two cases in young
persons — that of Hofmann, in a young woman of 23;
and that of Schuster, in a girl of 4. The pulse sinks
during the attack, and may be as low as 20, 15, or even 8.
There is commonly atheroma and calcification of the
aorta and of the coronary arteries, with aortic- valve dis-
ease and adiposis of the heart-muscle. In addition to a
cardiogenic Adams-Stokes syndrome. Luce recognizes a
neurogenic. In cases of the latter kind there are lesions in
the central nervous sj'stem or in the vagi. An interesting
paper on this unusual condition by an American, Robert
T. Edes, was published in American Medicine, Vol. I, p.
299. In a case reported by Neubiirger and Edinger
the nervous system showed marked alterations. The
patient's attacks had come on during defecation, and
were characterized by syncop.e, mydriasis, pupillary
paralysis, conjugate deviation of the head, and a pulse-
rate of 18. Upon autopsy, they found almost complete
absence of the right cerebellar hemisphere and, in addi-
tion, striking changes about the central canal in the cer-
vical region of the cord. These changes consisted in a
varicose condition of the veins with intense engorge-
ment. One of these varices was so situated that it must
have compressed the upper root-bundle of the spinal
accessory nerve, and it wiis clear how straining at stool
had been capable of bringing on the attacks. The case
affords a proof of the origin of the inhibitory fibers
of the pneumogastric in the sj)inal accessory nucleus.
In Luce's case the autopsy revealed a primary sar-
coma in the ventricular septum ; and, in addition, an
aneurysm of the sinus of Valsalva that had grown into
the conus arteriosus of the right ventricle, and also into
the left ventricle, causing a bilateral obturating stenosis.
There was also marked degeneration of the trunk of the
vagi, which was evidmtly of retrograde origin and
caused by the sarcoma of the heart. The case showetl
that the majority of the fibers of the pneumogastric run
in the cardiac septum. Luce draws other interesting
conclusions from the study of his case, viz. : that the
terminals of the vagus connect directly with the muscu-
lature of the heart, without the metliation of ganglia ;
and that the heart, in its trophic behavior, is, to a very
large extent, independent of the vagus. Myogenic or
neurogenic bradycardia is to be interpreted as an expres-
sion of a changed functional condition of the heart muscle.
The Adams-Stokes symptom-complex may wcur at any
time of life and with every variety of functional or
organic cardiac disease. The course is acute, subacute,
or chronically recurrent. Recovery is possible. Arterio-
sclerosis is not a condition sine qua non. The nervous
symptoms are the result of a reaction of the central nerv-
ous system, particularly of the oblongata, to the circula-
tory disturbance produced by the slowness of the pulse.
KEVIEW OF LITERATURE
The Elaboration of VenoKeno and Vcnin in the Parotid
Gland of the Asp. — L. Launan ■' lias delormincd the presence
in the cells of the parotid glands of the I<;uropean asp, Nipera
(tapis Merrem, of certain afranopbilo granules originating in
the nucleus, but which emigrate into the cytoplasm and which
at the moment of glandular ac'tivity are tfansformod by cyto-
chemic reactions into veuin. The granules in question are
composed of a chromatin, to which he gives the name venogene^
[C.S.D.]
Hysteria Following Trauma Combined with an Or-
ganic NervouB Disease.— Meyer' reports a case of a man 4!)
years old, who, following a slight injury totheellmw, presented
the following symptoms : Weakness, paresthesia, tremor, uius-
iDeut. Arch. f. kiln. Med.. B<1. Ixxlv, Hfie. »and4.
'Comptv rcn<liiK bebdnnindalre dcH neancoa de rAoademle del.
Hclenceti, I»arl8, October «, IWW. p. H&t.
< Berliner kllnl»'he Wiwbenscbrirt, AuKuat4, 1902.
984 AMEBIOAH HKDIOINE
THE WORLD'S LATEST LITERATURE
[Dkcehbkr 20, 190
cular Hpa!*in, and halting speech. The tremor was absent when
the patient l)elieved himself unobserved. This, with the (act
that the above symptoms were irregular in nature, varying in
Intensity and atypical in character, leads Meyer to suspect
hysteria. There were also various mental disturbances.
Immobile pupils and loss of knee-jerks. These proved the
presence of organic disease, the real nature of which Meyer
was unable to establish, [w.e.k.]
Autolytic Processes in Exudates.— Umber,' in an analysis
of serous exudates, found that the albuminous constituents
undergo, within the serous cavities, a disintegration to a greater
or less degree. He isolated a hitherto undescribed substance, a
phosphorus-free proteid containing considerable sulfur. The
is body related to the mucins, but yields only a minimal quan-
tity of reducing substance, and is designated " serosamucin."
In fresh exudates Umber regularly found primary and certain
secondary albumoses, but no peptones. Leucin and tyrosin
could be found, and traces of purin bases. The observations
prove that even in the body albumins pass through the same
changes as they do in artificial digestive processes. The break-
Ing-up processes continue In the sterile exudates outside of the
body, and are brought about by the presence of soluble fer-
ments. [D.R.]
Nourishment of Cliildren witli Goat's Milk. — To
find a milk more suitable to the nourishment of children
than sterilized cow's milk Barbellion* examined the milk
secretion of different domestic animals, with the result of
finding cow's milk richer in casein, less rich in butter than
woman's milk ; goat's milk with more casein, less butter and
sugar. Thus it would seem that goat's milk is even less
digestible than cow's milk. Upon examining the milk of dif-
ferent varieties of goats, he found the milk of some of them
better than that of others ; therefore, if the milk is carefully
selected and mixed we will have a liquid midway between
human and cow's milk, from the standpoint of digestibility.
Boiled or unboiled goat's milk is more easily digested than
boiled or sterilized cow's milk. He publishes his observations
on 10 children raised upon goat's milk ; they were altogether
very favorable. [E.ii.]
Gastric Achylia.— Kuttner,' discussing the general subject
of gastric achylia, reviews briefly the literature and gives the
results of a number of personal examinations of gastric juice
with reference to the total acidity, free HCl, and pepsin. The
amount of pepsin varied considerably in different cases and
without constant relation to HCl, but it was entirely absent only
in cases of complete absence of HCl. The conclusion is reached,
however, that the secretion of HCl and of pepsin are expres-
sions of two entirely different activities of the gastric mucous
membrane. The defect of gastric secretion, due to the usually
accepted causes of abnormal blood conditions, organic disease
of the stomach, or central or peripheral disturbances of inner-
vation, and associated usually with chronic catarrh of the
stomach, atrophy of the mucous membrane of the stomach, or
gastric neuroses, are discussed in detail. Reference is made to
the reputed diagnostic value of examining microscopically
portions of the gastric mucosa, and Kuttner states that with
increasing experience in this procedure he has come to regard
it without value. Concluding, he states that he believes it is
impossible to distinguish the clinical picture of simple gastric
achylia from that of defective gastric secretion, due to catarrhal
or atrophic alterations in the gastric mucous membrane. In
opposition to the views of some other writers he believes that
the individual symptoms are not pathognomonic; that clin-
ically and anatomically the functional disease may gradually
pass into the organic; and that it is impossible to determine
whether the defect or absence of secretion is due to organic
changes or merely nervous influences, [a.o.j.k.]
Concerning Myeloid Ciiange in Spleen and liym-
phatic Glands.— Hirschfeld* reviews the literature and gives
his experiments on this subject. He concludes that the mono-
nuclear, nongranular cells in the bone marrow may be changed
into granular cells. This theory, he claims, strengthens the
' MUnch. med. Woch., July 15, 1902.
2 Bulletin de I'AcadiJmle de Medecine, April 8, 1902
3 Zeltschrlft fur kllnlsche Medicin, xlv, 8, 1»02.
< Berliner klinische Wochenschrift, July 28 1002
possibility of a myeloid metamorphosis of the spleen and
lymph glands. The mononuclear cells of the spleen and lymph
glands are identical with the same element in the bone marrow.
This myeloid change is not always present in the different
infections. It depends upon the degree of the infection and
upon the resistance of the body. Hirschfeld believes the spleen
and lymph glands produce granular leukocytes and that in
infections these organs support the same function of the bone
marrow, [w.e.r.]
8na]<:e Venom. — In a note to the AeadSmie des Sciences C.
Delezenne ' calls attention to the fact that the venom of serpents
contains a diastase, having the same behavior with pancreatic
juice as enterokinase, or the leukocytic and microbic kinases.
[C.S.D.]
A Bare Complication with Carbuncle. — Numerous con-
ditions have been found associated with carbuncles; in some
cases carbuncles are the cause, in others only complications.
Berg ' reports the case of a 44 year old man, who several years
ago had 22 boils ; later a large carbuncle formed in the left lum-
bar region, requiring operation. A short time after a prostatic
abscess developed; it ruptured into urethra, setting up cys-
titis, ascending pyelitis, nephritis, and urethritis. The infec-
tion spread along the vas deferens and within a week an
abscess of the right epididymis had to be incised. Recovery
resulted after this. Eighteen months later the patient devel-
oped a severe attack of appendicitis, which was followed after
another month by a carbuncle in the right lumbar region and
a sciatica. Berg believes that the prostatic abscess was caused
by metastasis from the carbuncle ; and also considers the possi-
bility of close relationship between the carbuncle and the
intestinal condition, [e.l.]
The Influence of Antipyresis on the Agglutinating
Power of the Blood in Typhoid Fever.— Beniasch' gives
the results of his study of the relationship of temperature to the
agglutinating power of the blood of typhoid fever patients— a
study undertaken with a view to ascertain what influence, if
any, antipyresis (that induced by antipyretic drugs as well as
that occurring naturally in the course of the disease) had upon
such agglutinating power. It was found that the artificial
reduction of the fever in most of the cases exerted but little
influence on the agglutinating power of the blood, and that a
diminution rather than an increase occurred. The agglutinating
power of the blood is believed to constitute some indication of
the resistance of the patient. There follows a discussion of the
fever in infections, and the opinion is expressed that the com-
mon teaching of the beneficial influence of the fever is without
experimental proof. He believes that the theory of fever will
only have a firm basis after the clinical investigation of different
antipyretics in infectious diseases, after animal experiments in
which all of the factors of significance in the natural history of
the infectious diseases are reproduced, and after a study of the
influence of antipyresis on those substances known to protect
the organism against infection — antitoxins, bactericidal and
agglutinating substances, etc. [a.o.j.k.]
Concerning Gout and Its Treatment with Quinic Acid.
— Huber and Lichtenstein* believe quinic acid decreases the
amount of uric acid in the urine, and therefore is of use in the
treatment of gout. The action of this drug is explained in the
synthetic formation of uric acid. A series of cases are given in
which it was found that the amount of uric acid was decreased
one-half by the above treatment. Tophi are believed to be
caused by the irritation of the uric acid which forms inflamed :
and necrotic areas. The cause of the appearance of uric acid in
the blood is not understood. The authors advise the adminis-
tration of the acid of cinchona in the form of the anhydrid.
[W.B.R.]
Canine Babies.- J. Ehrhardt has recently published a
book entitled " Die Hundswut Ihre Verbreitung und Bekiimp-
fung; " Aarau : Emil Wirz, 1900, in which he gives a statistical
account of the presence of rabies in the several countries of
Europe, with special observations on the methods adopted for
checking the progress of this disease. [c.s.D.]
1 La Semaine Mfidlcale, August 20, 1902.
2 Monatshefte fUr prakllsche Dermatoiogie. Vol. xxxill, p. 510.
sZeltschrift filr kllnlsche Medicin. xlv, 51, 1902.
* Berliner kllnlsche VVoobenschrift, July 14, 1902.
■:
December 20, 19021
THE WOELD'S LATEST LITERATTJKE
[AUBKICAN MeDICINS. 9S5
Arthritis Dnring Scarlet Fever.— The histories of 15
scarlet fever patients, observed during one epidemic, all of
which presented kidney and joint complications, are reported
by Szontagh.i The cases were uniformly grave and the renal
complications severe ; the latter preceded the joint disturbance
in all but two cases. In each instance the arthritis was ushered
in by irregularly high fever ; it always arose late in the dis-
ease, usually about the fourth, sometimes as late as the seventh
week. Not one went on to suppuration ; in some but one joint
was affected, in others many. The ankle, wrist, and knee-joint
suffered oftenest. No case went on to uremia, although the
nephritis in all of them was severe. Some of the cases run a
subacute, others a chronic course, but in the end all recovered
completely. The author believes the arthritis was the result of
the poison, which produced the infection, or its toxin and not.
as has been supposed, a metastatic infection, [e.l.]
Leukemiclike Diseases.— Michaelis' reports the case of a
woman of .50, who 10 weeks prior to observation was taken ill
with weakness, cough, expectoration, and pain in the left hypo-
chondrium. The abdomen was distended and the spleen and
liver were enlarged. The hemoglobin was 40%, the erythro-
cytes 3,450,000, and the leukocytes 16,000. The differential count
was: Lymphocytes, 76% ; neutrophilic myelocytes, 7.29!! ; poly-
nuclear neutrophiles, 16% ; eosinophiles, 0.4%, and mast-cells,
0.4%. There were a few punctated erythrocytes and a few nor-
moblasts. The patient died within three months of the onset of
the symptoms. At the necropsy the liver was enlarged, the
spleen much enlarged and soft, the bone marrow red, and the
lymph glands were not enlarged. Discussing the relationship
that this case bears to leukemia and leukemiclike diseases,
Michaelis is disposed to include it among the cases of pseudo-
leukemia in the sense of Pinkus, who includes not only cases
without blood changes, but also those with only relative
increase in the lymphocytes (that is, lymphatic leukemia).
Proceeding to a discussion of the nature of the lymphocytes, it
is pointed out that the common description of a cell with a
round nucleus with a narrow rim of basophilic protoplasm is
insufficient, that in addition one must be able to describe them
as adult cells, to distinguish them from other cells, the undiffer-
entiated connective tissue cell which Michaelis and Frank in a
previous communication had described as the indifferent lym-
phocyte. Many of thesocalled lymphocytes in the case reported
are believed to be of this nature, an opinion donflrmed by the
appearance of many of the neutrophilic myelocytes. He
believes that the leukemiclike diseases, such as the one
reported, may be classified in a' group if one will designate
lymphocytes, the large cells without granulations and will
allow that they are indifferent lymphoid cells that in the course
of differentiation (whether the cells themselves or the daughter
cells) may become converted into granulated cells, [a.o.j.k.]
Acute Ascending Paralysis in Exophthalmic Goiter.—
Ro.senfekP reviews the literature on the subject of Basedow's
disea.se in relation to the different forms of paralysis and reports
a case accompanied by acute ascending paralysis. He posi-
tively excludes hysteria. Rosenfeld believes the paralysis is
caused by an intoxication, the nature of which is not yet
knoWn. [w.K.R.]
Wn (he Physiolojfy of Lienkocytes.- H. Stassano and F.
Billon,* in a communication to the Acad(5inie des Sciences of
Paris, state that they have ascertained that the action of the
enteric mucus in aiding trypsic digestion, which is increased
during digestion activity in the normal animal, is also increased
by injections of salts of mercury and iron, which may be
attributed to an increase in the diapedesis of leukocytes into
the intestine, affording a physiologic mechanism of elimination
and at the same time an aid to digestion. [c.s.D.]
Concerning Pernicious Anemia. -jReckzeh" reports five
cases of pernicious anemia. He gives full details as to the
methods and results of the blood examination. Pernicious
anemia occurs usually at the ago of 40, and more often in
women than in men. He discusses the causes of this disease
'.lahrbuch filr Kinderhcllkutide, 1002, Vol. Iv. No. 6.
= /A'llHchrlft Kir klinlsihc Mi'dlclii, xlv, W, li)02.
' Berliner klliilsche Wochcnseliilft, June », 1002.
< 1 Ji .Seriialne M€dl<;alc August 20, l'M^.
' Berliner kllnlsehe Wochcnsohrlft, July 28, 1902.
and dwells especially on the effects of the tapeworm. Symp-
toms that were of special interest in the above reported cases
were the appearance of hemorrhages from the mucous mem-
branes, stomatitis and paranoia. Reckzeh believes a patient
who once had pernicious anemia may only be considered cured
if there has been no relapse within five years' time. His treat-
ment consi.sts of arsenic and iron, [w.e.r.]
Dangerous Mosquitos in Kentucky. — H. Garman ' has
made a careful study of the species of mosquitos in Kentucky,
and reports A. punctipennis, A. maculipennis, Otilex pungevn,
C. itnpiger, Psorophora ciliata and Stegomyia fasciata. He
finds the last named species to be the most common mosquito
in Kentucky. It was found breeding in barrels, buckets and
other utensils in which water was allowed to stand during the
summer, [c.s.c]
A peculiar case of pnenmotborax is reported by Joch-
mann.' The patient was a man, aged 22 years, in whom the
onset of the disease was without symptoms. For several days
he had had a slight cough, a little dyspnea, and palpitation of
the heart. There was no history of tuberculosis nor of trauma,
and still examination of the chest revealed a high degree of
pneumothorax— a diagnosis that was confirmed by the x-ray.
The patient improved, but suffered a recurrence of the condi-
tion at the end of six weeks. At the end of about three months
the patient was well, and the physical signs of his chest were
normal. The interesting features of the case are the practical
absence of subjective symptoms despite a large pneumothorax,
the value of the x-ray in the diagnosis, and the absence of
etiologic factors. The case is presumed to be one of those few
cases due to the spontaneous development of a pleuropulmo-
nary fistula, [a.ci.k.]
On the Treatment of Cancer with Cancroin.— L. Kugel,
of Bucharest, and A. Adamkiewicz' contribute reports of the
satisfactory results obtained in the treatment of inoperable
cancers by means of injections of cancroin, otherwise known as
Adamkiewicz's serum. The cases, whicli included cancer of
the tongue, larynx, esophagus, stomach and mammary gland,
are cited as illustrations of the curability of cancer and of the
effectiveness of the Adamkiewicz method, [c.s.d.]
A. B. Cbaio
GENERAL SURGERY
Martin B. Tinker
C. A. Orr
EDITORIAL COMMENT
Wandering Kidney and Its Treatment. — The
term "wandering kidney" is intended to include tiie
movable kidney, i. e., one wliicli merely plays up and
down in the region posterior to the peritoneum, and the
floating kidney, or one with a mesonephron. Keen
states that it is practieaily impossible to distinguish
between the two. The above term, which includi«
Ijoth, therefore seems approi)riate. Various causes for
wandering Icidney have been assigned, such its preg-
nancy, tight lacing, excessive emaciation, enteroptosis,
etc. Harris, of Chicago, .says : "The essential cause lies
in a peculiar and a particular body-form, chara'ctcrized
by a marked contraction of the lower end of the middle
zone of the body, with a diminution in the capacity of
this part of the body cavity. This middle zone is
bounded above by a transverse plane passing through
the body at the lower end of the sternum proper, not
through the xiphoid appendix, while the lower bound-
ary is formed by a similar plane which cuts through the
lowermost points of the tenth rii)s. This diminution
depresses the kidney so that the constrictetl outlet of
the zone comes above the center of the organ, and all
acts, such !is coughing, straining, lifting, flexions of the
body, ete"., which te-ntl to adduct the lower ribs, press on
the upper pole of the kidney and crowd it still further
downward ; and it is the long-continued repetition, in a
suitable body form, of these influen«M, which collectively
' Kentucky Agricultural MtAllon Bulletin, SW.
» Zcltsehrlft fUr kllul»clie Medlcln. .\lv, 97, 1902.
" Berliner kllnlHehe WoclienHcbilfl, June 16, 1902.
986 A.MERZOAN MeDIOINB]
THE WORLD'S LATEST LITERATUBE
[Decembek 20, 1902
may be called internal trauma, that gradually produces a
movable kidney." Edebohls advances a somewhat
different theory, laying the blame for the most part
on lacing. During normal respiration the anterior
part of the liver descends, the organ rolling, as it
were, on a transverse axis, or perhaps more correctly
speaking, it has a hinge-like action from its attach-
ment to the posterior abdominal wall. Edebohls asserts
that the constricting corset prevents the normal increase
in the antero-posterior diameter of the lower chest
and upper abdomen and hence prevents the rolling
or gliding motion of the liver. Instead, the whole
organ is driven downward in a manner analogous to
the piston of a pump at each inspiration. It there-
fore impinges upon the right kidney and instead of
gliding on that organ, it gradually tends to loosen it
and drive it downward. The symptoms and complica-
tions of wandering kidney are manifold, and a condi-
tion of semi-invalidism often supervenes. Mc Williams,
of New York, has recently reported a series of 61
cases operated upon in one of the hospitals in that
city since 1888. Of this number all but two occurred
in women, and of these 64^ were married, but only
HTfc of the whole number had ever borne children.
In about 87 fo of cases the wandering kidney was on the
right side, while the remaining 13% were equally
divided between the left side and both sides. It is sig-
nificant that the author classifies about 82% of these
cases as of unknown etiology, and he wisely asserts that in
most cases renal mobility is probably due to a number of
causes which, as yet, we do not fully comprehend. He
is of opinion that not sufficient attention is given to the
gastrointestinal symptoms produced, they being present
in 25 of his reported cases, and attention is called to the
fact that pressure on the superior mesenteric vein may
cause congestion in the cecum and appendix, pro-
ducing symptoms resembling appendicitis. This was
the condition in 9 (15%) of his reported cases.
On the subject of treatment, McWlUiams believes
that the profession has been too optimistic concerning
the results of operation, and he agrees with Isreal in
the belief that "the only absolute operative indications
occurs in those cases having colicky attacks which are
the result of pulling or kinking of the pedicle, particu-
larly if these attacks are accompanied by temporary or
lasting retention. In the remaining cases nonoperative
methods first are to be employed, and these will, in
most cases, relieve very considerably, if not cure. In
event of their failure, operation is to be advised." Of
the 61 cases reported the author was able to communicate
with but 42 up to the time of his report. "Of these
42 cases, 22, or 52 % , have said that they were cured of
the symptoms dependent on the movable kidney, while
15, or about 36%, reported that they were benefited, and
5, or about 11%, were not improved at all by the
operation." It appears that other surgeons have se-
cured results not materially different from the above,
as Keen has reported 47% as cured, Frank 53%, Sulzer
and Reinboth 56%, AlOarrans 64%, Neuman 65%,
Wagner 51 % , and Kuster 58% . Natural conclusions to
be drawn from all the information at hand are that a
comparatively small percentage of those with wandering
kidney should be operated on; and even in selected
cases we are not to be too optimistic as to fiivorable
results, as it may be seen from the figures quoted above
that but few more than half are cured by opera-
tion.
REVIEW OF LITERATUBE
Purse-String Suture tn Gastrorrhaphy for Gunshot
Wounds.— Senu ' believes the best method of closing the wound
in the posterior wall of the stomach is by grasping its edge,
bringing it througli the anterior wound, enlarged if necessary,
> British Medical Journal, November 8, 1002.
and applying a purse-string suture. His successful experi-
ments on a number of dogs are convincing and, as he states,
demonstrate the safety of the circular suture in the treatment of
gunshot and other penetrating wounds of the stomach. All of
the animals operated on recovered, and the repair of the Injuries
as shown by the specimens was ideal. The absence of adhesions
over the posterior wound and their constant presence over the
anterior wound indicate that the silic ligature and the needle
punctures were the causes of the circumscribed plastic peri-
tonitis which produced them. In none of the specimens could
any indications be found of necrosis of the inverted tissues.
After tliree weeks the continuity of the mucosa at the seat of
injury was completely restored. The result of these experi-
ments shows that the circular suture compares favorably with
the methods of suturing in general use, and has great advantage
over them in ease of application and the saving of valuable
time. Suturing of tlie posterior wound by partial eversion of
the stomach through the anterior obviates unnecessary hand-
ling of the organ and interfering with the vascular supply inci-
dent to exposure of the posterior wound. If extravasation into
the retrogastric space has taken place, flushing through the
posterior wound and a vertical slit in the gastrocolic ligament
and gauze drainage through the latter are invariably indicated.
[a.b.c]
A Case of Tetanus Treated by Spinal Injections off
Serum. — Detotand Greuet' report a case of tetanus occurring
in a man of 35 treated by spinal injections of antitetanic serum.
Subcutaneous injections were also used. In all, 100 ce. of serur
were given subcutaneously and 30 cc. intraspinously. Th<
patient died eight days after the appearance of the first symptom*
The cerebrospinal fluid was sterile at both punctures and onlj
once contained a few lymphocytes. The authors are not incline
to agree with Vallas that the spinal route should be abandons
and regard it as offering tlie most hope in severe cases, [a.g.e.]
Plastic Operations for Closing Bone Cavities Follon
ing Operations for Osteomyelitis. — Busalla^ reports a cas
of sequestrectomy for osteomyelitis of the cuboid bone. In th«
cavity left by the removal of this important bone from the arcl
of the foot he placed a flap consisting of skin, periosteum anc
bone from the side of the os calcis. By turning this flap on i
skin pedicle it pressed the bone into the cavity. Before per
forming this secondary plastic operation the cavity had been
treated for some weeks until it was in a healthy condition
The skin and bone flap took well in the new position, and tin
foot was restored to nearly perfect function. This suggests th«
use of this form of flap in cloMng in these cavities, which ofteil
last for months unless some such means is adopted, [m.b.t.]
Operation for Gallstones. — Rutherford Morison' re-
ports a series of 43 cases operated on for gallstones. He pre-
fers the transverse incision which begins one inch below th<
tip of the twelfth rib and ends in front in the middle line at th<
upper part of the middle one-third of aline drawn from the
tip of the ensiform to the umbilicus. All the layers of the
abdominal wall, including the rectus muscle, are divided and
the cut edges of the peritoneum are caught up with forceps.
The wound is closed either with four tiers of catgut or with
two of catgut and two of silkwormgut. Tlie first suture brings
together the peritoneum, fascia transversalis, and internal
oblique muscles; the second the external oblique muscle; the
third secures the fat and skin subcutaneously to the external
oblique, and the fourth is subcuticular for the skin edges. Of
the 43 patients operated upon 7 complained subsequent to the
operation. A return of the symptoms means a return of gall-
stone trouble. In some instances gallstones will be left behind
after the most painstaking care at operation. Four of the 43
cases developed a hernia at the seat of operation; one was
due to suturing the cut edges of the gallbladder to the skin-
wound, and the others were due to imperfect suturing, [a.b.c]
Synchronous Ligation of Both Internal Jugular Veins.
— Baldwin' reports a case in which ho operated for the complete
excision of tuberculous glands in both sides of the neck. The
' Gazette heb. de Medicine et de Chirurgle, November 9, 1902.
2 Archiv f. klinische Chirurgle, 1902, Vol. Ixvlil, p. 444.
'■> British Medical Journal, November 8, 1902,
* Annals ofSurgery, 1902, Vol. xxxvi, p. 394.
Ueceuber 20, 1902]
THE WORLD'S LATEST LITERATURE
American Mbwoinb
987
patient had undergone three more or less extensive operations
at the hands of other surgeons, and as a consequence the
structures in the neck were very closely adherent to the cervical
vessels. In spite of great care in dissection of the vessels, the
jugular vein was opened on both sides of the neck, the injury
being of sufficient gravity to render ligation necessary. The
patient kept in very good condition, however, and complete
enucleation of the glands was carried out. When coming out of
ether .she had a violent convulsion. Aside from this no abnor-
mal symptoms were noticed, and she left the hospital two
weeks after the operation. The only evidence of interference
with circulation liad been a little puffine.ss in the face. Baldwin
believes that possibly long-continued pressure of the enlarged
glands had interferred with the return of blood through the
jugular veins, so that collateral circulation had been very well
established before the operation, [m.b.t.]
Cancer of the Ampulla of Vater. — Maury • presented to
the Society Medical des Hopitaux specimens illustrating a case
in which death followed a prolonged illness with chronic
icterus, extreme adynamia, a voluminous liver, and an enor-
mously distended gallbladder, with abdominal pains and abso-
lute decoloration of the feces. The autopsy demonstrated a
cancer of the ampulla of Vater, which proved to be a cylindrical
epithelioma. [c.s.D.]
Surgical Treatment of Non-neoplastlc Diseases of the
Stomach.— Hartmann ' gives conclusions based on 60 operative
cases. The immediate results were 10 deaths. Of these .36 were
received from physicians well acquainted with the treatment of
diseases of the stomach and but 1 patient died. Among the 24
patients sent by other physicians there were 9 deaths. From this
Hartmann concludes that the mortality in these cases depends
almost entirely on the physician who sends them. The 60 cases
include 29 that were operated more than one year ago — 1 pylo-
rectomy, 1 combined gastropexy and gastrorrhaphy for dilation
and ptosis, 18 gastroenterostomies for stenosis, 7 gastroenter-
ostomies for the various forms of hyperchlorhydria, and 2 gastro-
enterostomies for small repeated hemorrhages. All are prac-
tically well at the end of from 1 to 4 years except 2 cases of
stenosis, and they are greatly benefited. As to the indications
for operation, Hartmann says that simple dilation very rarely
calls for surgical treatment. Pyloric stenosis calls for interven-
tion so soon as the diagnosis is made. Recent ulcers should be
treated medically. Chronic ulcers situated near the pylorus
and causing the pyloric syndrome should be operated. Copious
hemorrhage does not indicate operation, but small, repeated
hemorrhages do. As to the variety of the operation, resection is
performed only when the exact nature of the lesion is not
understood and malignant transformation is feared. Pyloro-
plasty is rejected, gastroenterostomy being the operation of
choice, [a.o.e.]
Gastroenterostomy for Benign Affections of the Stom-
ach.—Dalziel ■■• reports 30 cases with the death of 1 patient. In
all except four instances the anastomosis was done on the pos-
terior wall of the stomach. Suture anastomosis was employed
in all cases, three rows of sutures being used. In one instance
a double ana.stomosis, after the method of Mikulicz, was done
without encouraging results. The patients had been under
treatment before operation for periods varying from 2 to 17
years, 16 of them with definite history of ulceration. Operation
showed 18 instances of well-marked contraction at the pyloric
orifice, two of these amounting practically to occlusion. The
ultimate results of operation have been very satisfactory on the
whole, all except two patients, with marked adhesions about
the stomach and one in which no organic lesion could be found,
being mnch improved. Kigliteon of the patients are a-s well as
they ever were. The author believes in this method of treat-
ment we have a means of relieving a vast amount of gastric
trouble with comparatively little risk. [a. B.C.]
Direct Anastomosis of the Portal Vein with the Vena
Cava.— Tansini.'of the Italian University of Palermo, describes
a new operation for turning the blood from the portal vein
directly into the vena cava. He believes that the advisability
1 Gazette hebdoinadlare de MCdeclne et de Chirurgle, No. S», 11)02.
JOazettc Midlcale de Paris. November m. 1002.
'BrltlKli Midlrnl .lonrnal, Novembers, IIMK.
< (Jentnilblalt f. Uhlrurgle, l»02. Vol. xxlx, p. 937.
of this procedure is becoming generally recognized, and that a
rapid and sure method of operation is needed. The operation
devised by Morrison, and generally known as Talma's opera-
tion, has proved of uncertain value for this purpose. Tansini
has practised his operation on cadavers in several cases, and it
has been carried out experimentally on 10 dogs in the surgical
laboratory by his students and by his first assistant, d'Angelo,
with perfect success in seven cases. He makes an end-to-side
anastomosis between the portal vein and the vena cava. The por-
tal vein is exposed and isolated, as is also a small section of the
vena cava. Bleeding is temporarily arrested by applying
clamps covered with rubber. One clamp is applied to the por-
tal vein and two to the vena cava. The portal vein is then tied
at the hilum of the liver and cut off. An incision is made
between the two clamps applied to the vena cava, or better, a
spindle-shaped excision may be made from the wall of the vena
cava, into which the portal vein fits better than into a simple
slit. The end of the portal vein is inserted in this opening in
the vena cava and sutured into the edges of the wound with
continuous silk sutures. It is not necessary to avoid perfora-
tion of the bloodvessel walls in the suture. The clamps are
now removed and the blood from the portal vein is carried
directly into the vena cava. During the time that the veins are
compressed by the clamps they are much distended, and the
intestines have a bluish discoloration. On removing the
clamps the circulation is immediately reestablished, and the
discoloration disappears. The failures in oases which Tansini
reports resulted, he believes, from the application of other
methods to some details of the operation rather than carrying
out the operation as suggested by him. The animals which
recovered were freely fed, though not with meats. They
remained well for several months, and gained in flesh until
they were killed. On examination after death dogs operated
upon two months previously were found in the best of health
and a complete union between the veins had taken place.
[m.b.t.]
Chronic Enlargement of the Prostate.— Freyer ' per-
forms suprapubic cystotomy, opens the mucous membrane
overlying the enlarged prostate with the finger-nail only. Then
with a finger in the rectum which steadies the prostate he care-
fully enucleates the organ in its capsule, leaving in most cases
the urethra intact. It is best to insert no instrument into the
bladder through the suprapubic opening, all enucleation being
accomplished with the finger. Freyer has performed this
operation on 21 patients, varying in age from 58 to 79 years, the
prostates removed weighing from IJ to lOJ oz. All had entered
on catheter life, varying from a few months to 14 years. All
were in broken health, some of them being almost moribund
before operation. Many suffered from cystitis, pyelitis, kidney
or heart disease, or some other complication. In 19 of these
affections a complete care has ensued. In one instance the
patient had recovered from the operation, and was passing his
urine naturally, when acute mania set in, from which he died
on the twenty-fourth day. Another case, after progressing sat-
isfactorily in all respects, suddenly, on the ninth day, died
from heatstroke. This operation, says the author, is comparable
to none other in surgery owing to the advanced age to wliich it
is nece.ssarily confined; and in judging of the mortality we
must not lose sight of the fact that patients of this age are
peculiarly prone to sudden death apart altogether from this
operation. Freyer is of opinion that the above operation is
superior to the perineal route of Alexander, which achieves
only a partial prostatectomy at best. [a. B.C.]
Venous Stasis In the Belief of Pain.— Hitter,' in a paper
entitled " Nature's Means of Uelief of Pain," reports some
experiences in Bier's clinic at (Trlefswald in the use of venous
stasis in the relief of pain. Bier's method of treating joint
tuberculosis by producing hyperemia is generally known.
RItter compares the hyperemia and edema which occurs in
inflammatory conditions to the infiltration of the tissues with
Schleich's solution. He calls attention to the fact that when the
tissues are thoroughly infiltrated by Inflammatory exudate the
pain usually disappears. This is nature's method of producing;
' BrIllHb Medical .Tournal, Novembers, 1902.
• Arcblv f. kllnlsohe Cblrurslc, 1902, Vol. Ixvlll, p. 12fl.
988 Akbrican Mkoioiks)
THE WORLD'S LATEST LITERATURE
[Decembek 20, 1W2
inflltration anesthesia. He suggests the use of venous stasis
for the relief of the severe pain caused by burns of the extremi-
ties and other painful aftections, and reports successful results
in cases in which he has applied this method. [M.n.T.]
Rodent, Ulcer.— J. I). McFeely ' points out certain differ-
ences between rodent ulcer and epithelioma. The former does
not show metastases. Kven when untreated it tends to take on
a reparative process in one part, while progressing in another.
It avoids hair follicles. Butonecase is on record in which it
attacked the scalp. The deeper layers of the cuticle are attacked
prior to the superficial. The serous exudate, so common as to
seem pathognomonic, seems to produce autoinfection. He
hopes to prove this by inoculation. The presence of exudate
proves diseased tissue is still present. It seems intermediate
between malignant disease and simple or spooiflc ulcer. It is
amenable to treatment without probability of recurrence.
McFeely applies pure formalin under general or local anes-
thesia, as the pain is intense. If a second or third application
is necessary formalin glycerin, 30% to 50%, with or without
tannin, can be used. When there is extensi ve destruction of tis-
sue he prefers the knife or curet, followed by tannin or supra-
renal gland, and then formalin. The slough should separate
spontaneously, assisted by bland ointments. The rate of
growth of healthy margins is marvelous. The formalin prob-
ably destroys the cell nucleus and stops mitosis, at the same
time assisting in the formation of scar tissue. This soon
resembles normal tissue. The time required for treatment is
one to two months. He has treated malignant growths also
with formalin, and most satisfactorily, [h.m.]
Subparietal Rupture of the Kidney.— Davis' reports a
case of this kind which he treated successfully by celiotomy
and iodoform gauze packing to prevent further hemorrhage
and for drainage. He collected from the literature 33 cases of
his kind, which he summarizes briefly. From his own experi-
ence and study of these cases he believes that the plan of treat-
ment is permissible in cases in which simple hematuria is the
only symptom. Prompt operation is indicated if there is tume-
faction, much blood in the urine, severe pain, or a history of
great violence. Nephrotomy with gauze packing is indicated
when the patient has not lost a great deal of blood ; nephrec-
tomy, when the kidney is irreparably injured, and in less
extended injuries attended by sepsis or hemorrhage which is
likely to prove fatal. In cases seen late it is often difflcult to
know what should be done, but in doubtful cases operation
should be performed. In many cases it is better to operate
when the history of the case indicates it rather than to wait for
symptoms. The reduction in mortality in six years since Keen
collected the cases of this kind has been due to Improved
technic and fewer deaths from sepsis. Several deaths from
hemorrhage could have been avoided by more prompt and
efficient operation. Davis believes that the mortality can be
reduced to 15%. [m.b.t.]
Renal Decapsulation versus Nephrotomy, Resection,
and Nephrectomy.- Edebohls ■< maintains that decapsulation
is preferable to nephrotomy, in that it causes no subsequent
renal infarct, and there is lessened danger from hemorrhage.
It is preferable again to nephrotomy, nephrectomy or resection
by reason of the fact that the wound can usually be closed
immediately and without drainage after decapsulation, while in
any one of the other operations drainage, with its after-danger of
fistula, etc., is often necessary. Of course in case of renal
calculus, renal tumor or collections of pus in the renal pelvis,
nephrotomy is indicated. When renal decapsulation is per-
formed for chronic Bright's disease, both kidneys should be
operated on at one sitting. The grave danger in this condition
is the anesthetic, and the patient should not be twice exposed
to this hazard. The author has operated upon the kidneys of
40 patients suffering from chronic Bright's disease— 23 women,
1 child, and 16 men. In 16 of the 40 more or less extensive
decapsulation, followed by nephropexy, was the operation. In
4 of the 16 the right kidney alone was anchored ; in 12 both
kidneys were operated upon. The results in these 16 cases he
has reported previously. On the remaining 24 patients a com-
1 Medical Press and Circular, Septembers 1902.
I Annals of Hurgery, 1902, Vol. xxxvi, p. 384.
3 Bntish Medical Journal, November 8, 1902.
plete bilateral decapsulation was performed for the sole pur-
po.se of curing chronic Bright's disease. The results in these
oases will not be published for a year or more. Lately, however,
he has operated by decapsulation upon 6 patients for conditions
other than chronic Bright's disease. His report is under the
following captions : Acute pyelonephritis and miliary abscesses,
complicated by chronic Bright's disease; right nephrectomy
and left renal decapsulation— patient much improved. Acute
right pyelonephritis with miliary abscesses — decapsulation of
right kidney— patient much improved. Acue hemorrhagic
nephritis — decapsulation of both kidneys atone sitting — patient
cured, but died a month later of pneumonia, and a pathologic
examination of both kidneys showed them almost normal.
Intermittent hydronephrosis of right kidney a.ssociated with
chronic Bright's disease — decapsulation and fixation of right
kidney — the patient is doing well. Intermittent right pyone-
phrosis and chronic interstitial nephritis — decapsulation and
fixation of right kidney— the recovery from operation was
uneventful, but the patient's condition remains unchanged.
Further operation will doubtless be necessary. Polycystic
degeneration of the kidney and chronic diffuse nephritis-
decapsulation of both kidneys — the patient is much improved.
The cases are too few in number and the periods of observation
are too brief to warrant deductions laying claim to conclusive-
ness in the matter, [a.b.c]
GYNECOLOGY AND OBSTETRICS
WiLMER Krusen Frank C. Hammond
REVIEW OF LITEKATUKE
The Justification and Importance of Interrnptins
Pregnancy in Tuberculous AVorking-Women. — Ham-
burger ' discusses this subject at length, and concludes that the
warfare against tuberculosis of the lungs as a common disea.se
remains defective so long as the question is undetermined what
shall be done with tuberculous working women in a pregnant
condition. The terrible significance of this question is clearly
shown by the fact that 75% of such women live under pecuniary
conditions in which effective treatment for this disease is out
of the question. Since it is a misfortune for a tuberculous
woman to become pregnant; since there is no possibility of any
improvement at this time, for the time for treatment has passed ;
since the expectation of life in the children of such women is
small, and according to all evidence each tuberculous person is
a menace to those around, a consideration for the diseased
woman, for her children and for all, demands that pregnancy
should be interrupted, the sooner the better, otherwise the few
chances present will be lost during gestation. This interruption
of pregnancy is justifiable when tubercle bacilli are found in the
sputum. He thinks great advancement has been made, since
the above view with reference to treatment now finds expression
in textbooks of obstetrics, [w.k.]
The Temperature of Nurslings. — Weill ^ gives the results
of investigations regarding the temperature of breast and arti-
ficially fed infants. In the former the temperature line was
practically horizontal at 37°, the morning and evening variations
being only about .1°. In the latter cases, when fed on cow's
milk, the variations were from .3° to .4°, the evening being the
higher. When fed on ass's milk the temperature line was of a
type intermediary between the other two, tending to approach
the horizontal but not being perfectly level. A change in tem-
perature, corresponding to the above, was also noted on the
same day in which artiflcially fed infants were transferred to
wetnurses. The fundamental difference, then, is that breast-
fed infants show a characteristic, practically constant tempera-
ture. When fed artiflcially, the daily temperature variations
are those of a normal adult. From observations on prema-
turely born infants the following as regards prognosis is
deduced : If the temperature line shows few oscillations and
tends to approach to 37°, survival is probable ; if it is unstable
or tends to descend, death is almost certain, [a.o.b.]
Contemporaneous Pregnancy in Both Tubes. — Kris-
tin us ' reports a case of double tubal pregnancy in a multipara,
' Berliner kllnische Wochenschrlft, November 24, 1902.
- Lyon Medical, Novemher 9, 1902.
s Vv iener kllnische Wochenschrlft, November 20, 1902
Decehber 20, 1S02]
CORRESPONDENCE
(Akkhican Mkdicinb 989
aged 30. The peculiar features of the ease were : The certain
evidence from microscopic examination of a bilateral contem-
poraneous tubal pregnancy; in the righttube there was a hema-
tosalpinx containing fetal elements, a tubal pregnancy in a
state of abortion; in the left tube there was a fresh rupture after
a few weeks earlier complete tubal abortion with the formation
of a liematoeele ; the rupture and fresh hemorrhage fi)llowing
were not in the liematoeele but in the fi-ee abdominal cavity ;
failure of any fresh corpus luteum in both ovaries; and no
appearance of the menopause in the patient's genital organs
and the recurrence of menstruation after the removal of both
ovaries, [w.k.]
Use and Abuse of Forceps In General Practice.— M.
Dewar' thinks the large majority of injuries attributed to
forceps is due to their use by the inexperienced. Every obstet-
rician ought to be an expert. City women demand help much
more frequently than country women, who endure all kinds of
pain more heroically. Inertia is common in city practice and if
unduly prolonged requires help. He has never had post-
partum hemorrhage after forceps delivery, not even in inertia.
He almost never applies instruments unless conditions indicate
their use, never unless the os is fully dilated, or dilatable,
except at the onset of convulsions or other dangerous complica-
tions. He records the mortality statistics collected from other
practitioners together with those of 1,000 deliveries of his own.
Of 300 city cases with a forceps percentage of .35 the maternal
mortality was 0.39{i; infantile, 1.6% ; much better than that of
the 700 country cases with a forceps percentage of 11 and a
maternal mortality of O.aTfo ; infantile, 2.89^. This compares
favorably with records of hospitals where strict antisepsis can
be employed, [h.m.]
TREATMENT
H,
Solomon Solis Cohen
C. Wood, Jr. L. F. Appleman
REVIEW OF LITERATURE
To the Editor of American Medicine : — Can you inform me if Pohl's
cerebrin Is of any value In epilepsy? If so, what forms? I believe
this cerebrin is the isolated proximate principle of the brain.
CHA.S. F. .\. Francis.
Cerebrin is the phosphorus-holding constituent of the
nervous system, and is chemically an unstable combination of
protagon and lecithin, the latter of which products has been
favorably commented upon a.s a therapeutic agent in a number
of conditions of malnutrition. Concerning the therapeutic
uses of Pohl's cerebrin we have no definite knowledge; it is
largely advertised as a valuable remedy in various brain
conditions.
The Uses of Hydrastis Canadensis. — French ' has found
hydrastis extremely useful in all forms of catarrh. In rhinitis
it is useful either applied locally or given internally. It is
valuable in ga.stritis, cystitis and other forms of mucous com-
plaints, especially when accompanied by oversecretion and
relaxation. Its value depends upon two alkaloids— berberin
and hydrastin. There is disagreement as to which the drug
owes its virtue in catarrh. Berberin has been found of value as
a bitter tonic, and in certain malarial conditions it seems to
have the effect of contracting the spleen, and may be frequently
combined with quinin very advantageously ; the dose is from
j to 3 grains, or in malaria as high as lo to 20 grains in a day.
French believes hydrastin of value in capillary hemorrhage on
account of its stimulant action on bloodvessels. Hydrastin
is an oxidation product of hydrastine, and is a very excellent
vtWiOconstrictf)r and uterine stimulant. It is chieHy useful In
hemorrhages from the womb, [h.c.w.]
I'ambotano, a Mexican Remedy for Malarial Kevers.
— E. L. Abogado-' calls attention to the efllcacy, in the treatment
of intermittent fevers, o{ Calliaiidra grandiflora Benth.,a legu-
minous plant indigenous to Mexico and commonly known as
Pambotano, Cabellos de Angel, Yerba del Angel, Xiloxoohitl.
[<'.H.D.]
' KdinburKb Medical ./ournsl, 8eptember, 1902.
» Merck's Archives. 1902, Iv, 846.
> CroDli» Medlca Mexicana, October 1, 1902.
Powdered Boric Acid in Thrush.— Escherich > uses for
the treatment of this disease in small children a small tampon
of aseptic cotton impregnated with powdered boric acid and a
small quantity of saccharin enclosed in a sac of sterilized silk.
The child sucks this and slowly mixes the acid with the saliva,
which acts directly and continuously upon the organism
present, [a. (i.e.]
The Uses ol" Aspirin.— Gorges' recommends aspirin, which
is acetyl salicylic acid, as a substitute for the older salicylates.
He has used it in hundreds of cases and only once has he seen
vomiting, and twice tinnitus aurium caused by its use. It has the
great advantage therefore that it does not disturb the stomach,
and further has not the unpleasant taste of the other salicylates.
He obtained excellent results in acute and chronic rheumatism
and in rheumatic endocarditis. He has also used it with suc-
cess in chorea minor. In this latter affection treatment with
aspirin in doses of 1 gm. three times a day has in 10-year-old
children a remarkable effect, bringing about entire recovery in
three to four weeks, while under the old treatment almost as
many months would have been required, [h.c.w.]
Treatment of Heart Disease.— Hare' believes that we
would often obtain more useful knowledge of the condition of
the heart from a therapeutic standpoint if the condition of the
valves was overlooked and attention paid solely to the mus-
cular tone. After the condition of the muscles, a most impor-
tant point is the presence or nonexistence of arteriocapillary
fibrosis; the condition of the kidneys is frequently an impor-
tant indicator of the condition of the arterial system. In grave
heart disease digitalis has proved itself so valuable that physi-
cians are wont to abuse it. A drug which is powerful enough
to do as much good as digitalis is also capable of great harm.
He believes it is given usually in too large doses and over too
long periods of time. He has frequently obtained excellent
results from 1 or 2 minims of an active tincture given 3 or 4
times a day. In cases in which we have reason to believe the
coronary arteries are obstructed, the drug is likely to do more
harm than good. In a large number of valvular cases aconite,
by virtue of the steadying effect it has upon the heart through
its inhibitory influence combined with its sedative action on
the mu.scles, will accomplish great good. Especially is this true
in overcompensation, or in irritable hypertrophied heart
which is sometimes found associated with rupture of compen-
sation, [h.c.w.]
A New Method for the ControIofEpistaxls.— Matthews*
has found the following plan very useful for controlling nose
bleed : By means of a semittexible catheter, a well-oiled con-
dom is inserted in the nostril so fir as required; the catheter
is then partially withdrawn and the condom inflated by blow-
ing through the catheter. The condom is then tied below the
catheter, making in this way a rubber bag, which presses
equally on all parts of the nostril. To remove it it is only neces-
sary to deflate, when it can be easily withdrawn without injury
to the newly-formed adhesions and clots, which is so often the
cause of starting fresh hemorrhage on withdrawing the ordi-
nary gauze packing. Care must be taken not to inflate the
tampon uncomfortably tight. Matthews has also employed it
as a splint in broken nose, [h.c.w.]
On the Value of Urinary Antiseptics.— Sachs » in an elabo-
rate study of the effect of various substances when given by the
mouth on the development of bacteria in the urine has found
that many have a distinct restraining influence on microbic
growth. The most powerful influence was exerted by urotro-
pin, which, contrary to common belief, exercises its antiseptic
properties in alkaline as well as acid urines.. The next most
valuable drug for this purpose was salicylic acid, which must
bo given in large doses, from 4 to 6 grams (00 grains)
daily. Other substances which seemed to have some effect,
although less powerful, were oil of sandalwood, menthylene-
blue, balsam of copaiba, and camphoric acid. On the other
hand, potassium chlorate, lx>ric acid, and uva ursl were without
effect, [h.c.w.]
> lot. M«declne Moderne. October 29, 19U2.
« l»crlliii-r kllnlHchi- WiM-hcnHchria, 19Ca, xllx, 758.
"Thcnipnutlc (iazi'tte. \Wi, W, 51)5.
« Therapeutic (ja/.i'ltc, law, -Jti, .57B.
>Tbe Therapist, 1902, zll, 121.
990 AKKJueAM HnDioiirV.
THE WORLD'S LATEST LITERATURE
[DSCKMBER 20, IWi
On the Treatment of Neuralgia by Subcutaneous Injec-
tion of Gases.— Rommo' and Vigne' have obtained excellent
results in various affections of the nerves, especially sciatica, by
nial<lnK pressure upon the nerve through injections into the
Burrounding tissues quantities of gas. Vigne experimented
with carbonic acid gas, hydrogen, and air. The best results fol-
lowed the use of air, which is preferred by Romine also. The
latter has found by experiments both on himself and on the
lower animals that these injections are quite harmless, save for
the possible Introduction of infectious microorganisms. Romme
employs for the injection an aspiratingpumpand rubber bag of
known capacity, which is used to measure the quantity of air
employed. Vigne used a hypodermic needle attached to the
bulb of a Paquelin cautery. For the purpose of sterilization,
the air is passed through a glass tube filled with cotton, although
unfiltered air has been injected without harmful result. The
needle is introduced near the neighborhood of the painful spot
and about, a pint of air is injected with careful caution as to
asepsis. The injection does not cause pain but some itching
and numbness follows. The skin near the injection is at first
pale but becomes red and remains so several hours. On with-
drawal of the needle the distended parts should be massaged
vigorously in order that the gaseous matter may be distributed
to the painful nerve filaments. The method has been found of
especial value in cases of sciatica, which are completely cured
by four or five injections at intervals of five or six days. It is
also of value in femoral neuralgia, in lumbago, and In neuritis
from contusions or dislocations. In traumatic neuritis, espe-
cially of the ascending type, it has proved uniformly successful.
The most plausible explanation of the effect of this injection is
that the distention causes stretching of the affected nerve fila-
ments. [H.C.W.]
The Treatment of Typhoid Fever.— Koenig ' says that
in the treatment of typhoid fever the physician's object should
be to prevent a fatal issue rather than to relieve Immediate
symptoms. In order to accomplish this he must endeavor to
prevent intestinal fermentation so far as possible, to eliminate
the toxin as rapidly as it is formed, support the vital functions of
the patient, and restrain the fever. To prevent fermentation
Koenig advises strict regulation of the diet, even to withdrawal
of all foodsduringthetimeof pyrexia, and the administration of
small doses of calomel every two hours. Concerning the
administration of food he is largely guided by the desires of the
patient. The best intestinal antiseptic in this case Isguaiacol,
which he gives routinely in doses of 2 to 3 drops, gradually
increasing the amount to 5 or 6 drops. It may be given in
whisky, which stimulant he believes very useful in typhoid
fever. To increase the elimination of the toxin he encourages
the patient to drink as much water as possible, and at least two
or three quarts of fluid should be introduced in the body every
24 hours. For the reduction of temperature he says the Brand
method is efficacious, but In private practice is inexpedient. A
properly administered sponge bath will usually give good
results. He warns against the too early return to solid food,
and says that the tongue and not the temperature must be taken
as the indicator of the condition of the intestines, [h.c. w.]
Brewers' Yeast in the Treatment of Diabetes. — Van-
damme ' has recently published in the Brussels Poiyclinic the
results of experiments to determine ti\e effect of yeast on
the production of sugar in the human economy. Experi-
ments with natural and artificial gastric juices in the pres-
ence of yeast to determine the effect of gastric juice on
alcoholic fermentation showed that this process was retarded
by the hydrocyoric acid present, but that the saccharomyces
was not destroyed, as its action reappeared after neutralization
of the media. Alcoholic fermentation of sugar is then possible
in the intestine. The action of yeast on the glycosuria of
diabetics was then tested in 10 cases, the sugar of the urine
being estimated under the following conditions: (1) Without
any intervention ; (2) restricted diet ; (3) restricted diet and
yeast ; (4) ordinary diet and yeast. The results showed that
in the majority of cases the yeast had a manifest action on the
> Pr«8se Medicale, May 28, p. 511.
» Journ. de Med. et de Chlrurg. Pratlq., March 25, p. 224.
•Pennsylvania Medical Journal, 529, 1902.
<Lia Mfideclne Moderne, Octobers, 1902.
alimentary glycosuria, in five the diminution being marked.
The yeast has no bad effect on the patients, some of whom have
taken it for a year. In some the thirst has been diminished.
Yeast will not cure diabetes but will destroy a part of the sugar
in the intestine. Its exhibition will obviate the necessity of
depriving the diabetic of some desiretl foods, especially bread.
[A.G.B.]
On the Danger of Spinal Anesthesia.- Mohr,' in an
elaborate study of general anesthesia by subarachnoid injection
of cocain, finds that not only is the anesthesia limited to the
lower extremities but that it frequently fails to appear
altogether, and according to some authors in as high as 3095, of
cases is imperfect. Sometimes the anesthesia will disappear
suddenly in the course of an operation. More than this, it is
very frequently interrupted by undesirable and even dangerous
symptoms, and in quite a number of cases has resulted in the
death of the patient. He places the mortality from spinal anes-
thesia at the astounding figure of 1 in every 200. The most
common toxic symptoms are nausea, vomiting (occurring in
2095, of cases), headache, collapse, various conditions of spinal
weakness, as shown by ataxia, incontinence of urine, etc.
According to Polubogatow and Crile, the most serious danger
lies in a too rapid extension of the fluid along the spine and
consequent involvement of the medullary center. Many
authors have attributed these untoward effects to the disturb-
ance of the equilibrium of the cerebrospinal fluid. Tropacocain
seems somewhat less dangerous than cocain. In comparison
with inhalation anesthesia the method has the following disad-
vantages : Danger from the lumbar puncture through infection
of the cord, uncertainty of anesthesia, insufficient duration and
greater mortality. The method, therefore, is certainly not
advisable save in cases in which there is reason to believe that
ordinary narcosis is dangerous or local anesthesia insufficient.
Unfortunately our knowledge of the comparative harmfulness
of the subarachnoid injection of cocain and of the ordinary
anesthesia in cases where either is dangerous is insufficient,
and it is therefore almost impossible for the practitioner to
make a rational choice of the case in which spinal anesthesia is
to be given the preference, [h.c.w.]
Bismutose.- Lissauer* has obtained good results with a
new bismutose preparation in the treatment of diarrhea of
children. This remedy is a combination of bismutose with
albumen, insoluble in water or in acids or alkalis, of a grayish-
yellow color and of bitter taste. When mixed with a small
quantity of hot water it forms a sort of thick broth, if a larger
amount of hot water is added it forms an emulsion. Its insolu-
bility interferes somewhat with its administration to children.
The recommendation which has been made of giving it with the
milk Lissauer thinks unwise, as an indefinite quantity may
adhere to the sides of the bottle. It is much better given with
a spoon. The usual dose which he uses is 1 gram (15 grains)
four times a day. He has given as high as 2 grams every two
hours, and has never seen any bad effects. He found it very
useful especially in cases of intestinal dyspepsia. [H.c.w.]
Hydrogen Peroxid in the Treatment of Diphtheria.—
Novikov' obtains lully as good results from the use of hydro-
gen peroxid as from serumtherapy in the treatment of diph-
theria. The false membrane, it is true, detaches itself less
rapidly than when serum is given, but the depressive action of
the toxin of the disease is to a certain extent prevented by the
peroxid, which favors oxidation. A gargle of two or three
tablespoonfuls of peroxid to a glass of water is to be used night
and day. For infants who cannot use a gargle the peroxid is
given internally by the following formula: Hydrogen dioxid,
5 or 7 cc. ; distilled water, 85 cc. ; syr. simplicis, 15 cc. [a.o.e.]
The Diagnostic and Therapeutic Use of Tuberculin.
— Moeller* reports the results of the use of tuberculin in the
sanitarium at Belzig. From the standpoint of the institutional
treatment of pulmonary tuberculosis, the diagnostic use of this
substance is of extreme importance, for in doubtful cases the
nontuberculous are saved the exposure to infection. He has
' Medicinlsche Wochenschrift, 1902, Nos. 34-36.
2 Deutsche medicinlsche Wochenschrift, August 14, 1902.
»La M6decine Moderne, Octobers, 1902.
* Zeltschrift for Tuberkulose und Heilk., 1902, lit, 279.
Decbmbbr 20, 1U02)
THE PUBLIC SERVICE
i'Akesican Medioidb 991
employed both the old tuberculin and the new, and in some
3,000 injections in all sorts of doses has never observed any dis-
advantageous results. For diagnostic purposes exclusively the
old tuberculin was used. This should be given in a 1:1,000
solution, the beginning dose being usually about 0.2 nig. Given
hypodermically and preferably in the evening. The temperature
should be taken every two hours for at least three days before
the injection. An elevation to 38° C. is taken as a positive reac-
tion. The counterindications to the test are fever, hemorrhage,
heart disease, hysteria, and epilepsy. Concerning the thera-
peutic value of tuberculin, although the number of patients
treated is not very large, they are inclined to a favorable view.
In several cases in which the ordinary dietetic treatment had
absolutely no effect upon the disease the combination of dietetics
and tuberculin frequently accomplished great good. In the
choice of cases for this treatment attention must be paid to the
condition of the lungs, although a generally poor constitution
and great loss of weight are counterindications to its use. In
diseases of the heart the remedy must be used cautiously on
account of the danger of possible hemorrhage. They begin with
0.1 mg. every three or four days and gradually increase the dose
as the patient becomes accustomed to the treatment. If the
drug causes a febrile reaction it is a sign that too large doses are
being employed. With care the dose may be increased to 50 or
60 mg. The most favorable cases are those in which the disease
has not progressed too far and in which the process is limited to
one lobe of the lung, [h.c.w.]
Formalin in Diphtheria.— Zdekauer > treats diphtheria
by painting the mucous membrane of the pharynx and tonsils
with a cotton swab saturated with formalin (40% forraaldehyd).
He reports six cases tliat responded immediately to this treat-
ment. Temperature fell to normal and the false membrane
disappeared rapidly. To prevent unnecessary irritation the
diet should consi.stof milk and water. At no time did symi>-
toms of formalin poisoning present, [w.e.b.] [In early cases
of doubtful diagnosis, after taking a swab for culture, I have
frequently used this application. It is very painful — the patient
feels suffocated— but the distress passes off shortly. In one or
two cases in which the cultures were positive clinical manifes-
tations were cut short, but in the great majority of instance^ of
true diphtheria the application was devoid of permanent bene-
fit. Tonsillitis was usually cut short. Since antitoxin has
been at our service I have not resorted to strong applications
of formalin, except in very incipient cases in which diphtheria
has been excluded on clinical grounds, s.s.c]
The PurKative Action of Phenolphtbalein. — It has long
been known * that many of the purgative substances contain
as their active principles chemicals lielouging to the anthra-
quinon grovip, and various attempts have been made to manu-
facture a synthetic derivative liased on this knowledge. One
of these has been placed on the market under the name of
purgatin, being chemically anthrapurpurin. It has recently
been discovered accidentally that phenolphtbalein possesses
valuable purgative properties. It is related chemically to the
anthroquinon derivatives, the phthaleins being easily converti-
ble into these substances. Upon the lower animals doses of
.06 gram (1 grain) to the kilo produced absolutely no symptom.
Tunniclifte has had the substance tested clinically in both
children and adults. In the former its pleasant taste makes it
very useful on account of the ease of administration. In both
cases the action was mild and unaccompanied by colic. It Is
marketed under the name of purgen, and may be given in
tablet form in doses for children from .05 to 0.1 gram (J to 2
grains), and adults from 0.1 to 0.3 gram (11 to 5 grains). In
obstinate cases of constipation it must be given in large quanti-
ties up to 1 gram (15 grains). It has no irritant effect upon the
kidneys ard seems to be without deleterious action of any
kind, [ii.c.w.]
Pharmacologic Action of Sodium an<l Potaaiiiam
lodlds.— Although the potassium salt contains only 77% of
iodin, as against 84% in the other drug, yet clinically it has
proved the more valuable. Wild" reports a series of experi-
ments showing the action of alkaline iodids on peripheral
' I'nwf r nicilrlnlHche Worhcndchrlft, Koliraary 27, 1902.
5 Hrftish Medical .loiinml, Drloher IH, 11)02, p. 1224.
» Medical (Jhronlcle, August, llKW.
bloodvessels uncomplicated by the eflfect of the vasomotor
centers or the heart. Comparison of the tracings made shows
that the presence of both potassium and iodid ions in the same
solution has a much greater dilating effect than either the base
or the acid alone. Both of these ions are foreign to the circu-
lation, and comparison with the action of potassium cUorid
indicates that the potassium is the more active agent. The
potassium salts dilate the vessels, while the sodium salts cause
slight contraction. Potassium iodid is preferable to other iodin
compounds on account of its extreme solubility and rapid diffu-
sive power, giving it a marked salt action of great importance for
diuretic and expectorant purposes, and enabling it to penetrate
to all parts of the body. Its power of dilating the bloodvessels
enables it to bring more blood to the tissues, thereby stimu-
lating nutrition and bringing more of the drug in contact with
the cells. The symptoms of iodism are rarely severe enough
to cause trouble, and the depressing efifects have been much
exaggerated. The latter may be modified by substituting
animal for vegetable foods containing potassium, [h.m.]
The Intratracheal Method of Producing Anesthesia.-
Floren • has found the introduction of anesthetic vapors
directly into the trachea useful to produce anesthesia in cases
which are usually difficult, such as those Involving operations
around the nose or throat, or in which there are obstructions of
the upper respiratory tract. For this purpose he employs a
flexible metal tube in the following manner: After production
of a slight degree of anesthesia by the ordinary method, the
tongue is drawn forward, and with the left forefinger the epi-
glottis is elevated, when tlie tube can.be easily introduced into
the larynx ; the pharynx is then tamponed with sterile com-
presses to prevent, on one hand, the inspiration of blood, and
on the other hand, soiling the field of operation from vomiting.
The end of the tube is provided with a funnel, over which is
stretched several layers of gauze, which serve as an anesthetiz-
ing cone. By this means it is possible to keep the patient
anesthetized, even during long operations, without any conflict
between the operator and the anesthetizer. Furthermore, the
field can be easily kept clean, and there is no fear of aspiration
pneumonia. In ca.ses in which the respiratory pa-ssages are
obstructed, the unpleasant or even dangerous cyanosis may be
absolutely avoided. He has also found the method useful in
general surgery in ca.ses in which the patient takes the narcotic
badly with a marked tendency to become cyanotic. In opera-
tions on the jaw, when it is desirable to have the mouth free,
the tube can be introduced through the nose, [h.c.w.]
THE PUBLIC SERVICE
Health Report*.— The following cases of smallpox, yellow
fever, cholera and plague have been reported to the Surgeon-
Qeneral, Public Health and Marine-Hospital Service, during
the week ended December 12, 1902:
Rmallpox— United States.
Cases Deaths
California :
Fresno
Nov. 1-30
2
Colorado :
Florida:
Nov. 22-29
1
Jacksonville
Nov. ■22-Dec. 6...
. 8
Fensacola
Nov. Z2-IJec. 8...
5
Georgia:
Atlanta
Nov. 27-Dec. 3...
1
Illinois:
Chicago
Nov. 29- Dec. 6...
1
Oct. l-«l
. 25
Nov. 1-30
. 40
Indiana;
Evansvllle
Nov 2»-Dec. 6...
1
Hammond
Nov. 2S-80
. 84
. Indianapolis
Nov. 20-Ucc. «...
8 1
Muncio
Nov. J-.tO
2
Nov. 1-22
. 22
Wiclilla
Nov. 15-29
2
Maine:
Blddeford
Nov. 2»-l)ee.. «...
11
MasBacbusetU :
Boston
Nov. 2I»-I)tr. «..
. 2S 7
C'hicopoe
Nov. 29-I)ee. «...
Everett
Nov. 29-I)ec. «..
I^wrence
Nov. 2»-I>ec.«...
Taunton
Nov.afl-IX-c. «..
Michigan:
Orand Itaplds ...
Nov. 29-IJec. «...
Missouri :
SI. Joseph
Nov. 2H-I)ee. «...
Nebraska :
Omaha
8ept 1-Dec. «...
New Hampshire:
New Jersey:
Nashua
Nov. 2»-l>ec,. «...
21
Jersey City
..™Nov. »0-I>i!C. 7_.
New York :
Klnghaniton
Nov. 2»-lK'<A«....
Hniralo
Nov 2!I-I)ee. «...
New York
Nov. 2»-l)ec.6...
North Carolina:
Charlotte
Nov. l-W
. 89 IS
> TberapeatlMbe Monatsbefte, 1902, zvl, 607.
992 AjfBBIOAN MBOIOINX^
THE PUBLIC SEEVICE
[Decbhbek 20, 1902
Ohio:
Cincinnati
(vleveland
Nov. 28-Dec. 5,...
Nov. 2»-Dec. 6 ..
8
11
9
1
2
8
2
1
6
36
2
1
3
Ini
1
4
38
4
1
3
6
3
17
58
8
1
4
3
15
3
4
10
2
Doner
.14
83
1
1
31
1
Toledo
Nov. 22-Dec 6
Warren
Zancsviile
Altoona
Kric
McKeesport ....
Philadelphia...
Nov.29-Dec.«....
Nov. 1-30
PenDsylvanla:
Nov. 2»-Dec. 6....
Nov. 29- Dec. a...
Nov. 2y-Dec. 6....
Nov. 29-l)ec. 6...
1
1
South;carollna :
Tennessee:
Texas :
Utah:
Pittsburg
Charleston
Chattanooga....
San Antonio...
Salt Lake City.
Nov. 2iKDec. «...
Nov. 29- Dec. 6....
Nov. 1-.S0
Nov. 1-30
Nov. 22- Dec. 6....
«
1
ported
Milwaukee
Nov. 29-Dec. 8
Austria :
Belgium :
SMALLPOX—
Prague
Antwerp
Marseilles
Paris
Rhelms
Bradford
Dundee
Leeds
FOBEION.
Nov. 8-22
Nov. 8-22
1
France :
Oct. 1-31
Nov. 15-22
Nov. 17-23
25
1
[1
Gibraltar:
Nov. 2-18
Great Britain :
Nov. 1-16
Nov. 15-i2
Nov. 15-1'2
1
Liverpool
London
Athens
Bombay
Palermo
Nogales
Moscow
Odessa
Riga
St. Petersburg..
Nov. 15-29
1
Greece:
India:
Italy:
Nov. 8-22
Nov. l.'S-22
Nov. 4-11
Nov. 8-15
4
Me.\lco:
Russia :
Nov. 8-29
Nov. 1-8
Nov. 8-15
Sept. 1-30
16
Nov. 1-15... .
2
Costa Rica :
Warsaw
Yellow
Port Llmon
Buen Ayre
Guayaquil
Tamplco
Vei-a Cruz
Chole
Batavia
Bombay
Calcutta
Nagasaki
Plague— Unit
San Francisco..
—.Plagcb— F
Bombay
Calcutta
Karachi
Yokohama
Oct. 2&-NOV. 1
Fevbb.
Nov. 22-29 ...
2
1
Dutch West Indies
Ecuador :
Nov. 15
On Dutch sch
Nov. 15-22
1
trader.
Mexico :
Nov. 22-29 ....
22
Nov. 22-29
2
Dutch Indies, Java
ra.
Oct. 4-25
India:
Japan :
California :
India:
Japan :
Oct. 2!>-Nov. 4
Oct. 25-Nov. 8
Nov. 1-10
ED States.
Nov. 27
OKEIGN.
Oct. 29-Nov. U...
Oct. 2o-Nov. 8
Oct. 2«-Nov. 9
Nov. 1-8
1
54
1
238
18
24
1
Changes in the Medical Corps of the U. S. Army for
the week ended December 13, 1902 :
Barry, Edmund, contract surgeon, is granted leave for 10 days.
Webber First Lieutenant Henry A., assistant surgeon, is relieved
?,"o'?jH';"'tf duty at Nueva Caceres, South Camarines and will
rfSiJ"^,,^" Man.la, P. I., reporting to the commanding ofhcer. Post
of Manila, for assignment to station.
OVERTON, David W., contract surgeon, is relieved from duty in the
department of the East, to taki effect upon the arrival at Fort
and i f^Stn'^J' Lieutenant Theodore C. tyster, a.ssistant surgeon!
oFcontrac^f proceed to his home. New York City, for annulment
^'^Charies^P JtTa^H I' "-elating to Hospital Stewards Max Arendt,
cnaries Gates and Angus McLeod, are revoked.
'^■''^nfJilifti^' I'o^Plta' steward, now at St. Louis, Mo., having relln-
3.„n^""* J-,""^ unexpired portion of furlough granted l^im from Fo"t
McDowell, IS relieved from further duty It that post and will report
mem St fZi"/ v^ officer, general depot, quarlermaste?^^ dep*?^"
raeiit, St. Loms, \vho will send him to Fort Huachuca to relieve
Hospita! Steward Charles Gates. Steward Gates will procSd To
Fort Baker to relieve Hospital Steward Angus McL«,d Steward
McLeod will proceed to Fort Rodman for duty. steward
Andrews, Major Charlis H., surgeon, U S. Volunteers orders of
e'ffe^t FebruaVv f mfh",*! ^S.^^ to^onombiy dischaJfe'himyto UakI
eneci r eoruary 1, 1903, his services being no longer required
So much of orders of November 25 as direct that Hosnltal Steward
MeviH ?• ^^'"^■•. K"J^ Warren, be sent to Fort mXwHI when r^
lieved by Hospital Steward Charles L. Keeler, are revoked
Byers, Jason D., hospital steward. Fort Warren upon exniratton nf
a"s&\Sn^dX '''"''"'"'*■ '' "" *" --' to'?"an^1a:n°fo°r'
De Sbon, Major George D., surgeon, U. S. Volunteers rcantntn
his services being no longer required. eoruary 1, 1903,
The following-named officers now serving in the division of the Phiii..-
pines are honorably discharged, to take effect December 8 1^'^
e?s"8r'"Edward T«r?h'°°«" '•^^"'^'^'1 ■■ CapSins Robert M.' End-
ers, sr., i,dward T. Gibson, assistant surgeons, V. a. Volunteers
''^\"£^^ek't^^^p^^§??o°L^,-?^e^tVe^^^^^^
J?.tV" c^SmpX''o?ScSoTk"oS%ri!l«rf ™^^^^ '<> "^""
The following-named officers are honorably discharged, to take effect
February 1, 1903, their services being no longer required : Majors
Arlington Pond, Henry D. Thomason, Robert H. Zauner, Walter
Whitney Thomas C. Chalmers. Seaton Norman, Mhadworth O.
Beasley, Frederick Hadra, Frederic A. Washburn, Jr., George P.
Peed, William D. Bell, Lawrence C. Carr, Abram L. Haines, Simon
J. Fraser, Howard A. Orube, Robert Burns, Joseph C. Reifsiiyder,
I,ewiH T. Griffith, Roger P. Ames, William D. Shelby, surgeons, U.
S. Volunteers; Captains Clark I. Wertenbaker, James S. Kennedy,
Guy G. Balle.v, Edward F. Horr, Elmer 8. Tenney, Samuel i).
Huntington, James K. Presnell, Frederick H Sparrenbergcr, Har-
old W.Cowper, Harry A. Littlefleid, Gerry S. Driver, Justus M.
Wheate, Piinest H. Wheeler, George R. Plummer, William R. Van
Tuyl, William F. James, Frank W. Dudley, George S. Wallace,
Timothy F. Goulding, Charles F. de Mey, Rene Vandam, Fred M.
Barney, William G. Miller, Edwin C. Shattuck, Albert L. Miller.
Charles G. Kicher, Giitiert I. Cullen, Raymond E. Whelan, Cyrus
D. Lloyd. William K. McPhersou, Thomas H. Landor, Charles A.
Cattermole, John S. Hill, Perceval S. Rossiter, Frank DuBols
Samuel K. Carson, Najeeb M. Saleeby, Herman J. Schlagetcr, Alva
8. Pinto, William R. Davis, Thomas C. Ijonglno, Charles W. Hack
Charles R. Gill, Francis J. Pursell. William T. Tanner, James G.
McKay, William B. Suramerall, Thomas K. Mulllns, Frederick A.
W. Conn, Luther P. Howell, Leonard K.Graves. Samuel T. Welrick,
Michael E. Hughes, H. Brookman Wilkinson, Abraham D. Wil-
liams, John Gilbert. Robert E Caldwell, George H. Calkins, W.
Turner Wooton, Michael A. Rebert, Henry Du R. Phclan. Edwin
M. Trook, William P. Baker, Luke B. Peck. Thomas R. Marsliall,
William C. Le Compte, Herbert Gunn, Waldemar A. Chrislensen,
Edward A Romig, .lames E. Mead, Herbert M. McConathy, James
B. Pascoe, Joseph L.Sanford. Thomas S. Lowe. William A. McVean,
Francis J. Bailey, John P. Kelly, ahsistant surgeons, U. S. Volun-
teers.
Mabsden, Robert, hospital steward, transport McClellan. New York
City, when his services are no longer needed aboard that ve.ssel,
will proceed to Boise Barracks, to relieve Hospital Steward Daniel
Mlllen. Steward MUlen will proceed to Manila, P. I., for assign-
ment to duty.
Adaik, George F., contract surgeon, is granted leave for one month,
to take effect December 1.
RHOAD.S, First Lieutenant Thomas L., assistant surgeon, is relieved
from further temporary duty at the Presidio, and is assigned to
duty at the Army general hospital, Presidio.
Appel, Major Aaron H., surgeon, now in general hospital, Presidio,
is granted leave for one month on surgeon's certificate.
Van Dusen, First Lieutenant James W., assistant surgeon, is granted
leave for one month, from about December 20, with permi.ssion to
apply for an extension of one month. ■■■■^~
McCallum, Francis M., contract surgeon, is relieved from duty at
Fort Sheridan and will proceed to Indianapolis Arsenal, Ind.. for
duty, relieving First Lieutenant Edward F. Geddings, assistant
surgeon. Lieutenant Geddings will proceed to Fort Brady for duty,
relieving First Lieutenant Charles E. Marrow, assistant surgeon,
who will then return to his proper station. Fort Sheridan.
Powell, Dwight C, contract surgeon, will proceed to his home,
Logansport, Ind , forannulment of contract.
O'Neill, J. A., contract surgeon, will proceed to New York City for
annulment of contract.
Tefft. William H., contract surgeon, will proceed to his home,
Belmont, N. Y., for annulment of contract.
Mabray-, William C, contract surgeon, Is granted leave for one
month.
CORBCsiER, Major William H., is granted leave for one month.
ASHBURN, First Lieutenant Percy M., assistant surgeon, is granted
leave for two months, to take effect about January 20.
Robins, Robert P , contract surgeon, now at Philadelphia, will pro-
ceed to Fort Niagara for duty.
Changes in the Medical Corps of the U. 8. Navy Jor
the week ended December 13, 1902 :
G0NNELL, F. M., medical director, retired, ordered to the Bureau of
Medicine and Surgery, Navy Department— December 5.
Huntington, E. J., passed assistant surgeon, detached from treatment
at the Naval Hospital, New Y'ork, and ordered to duty at the Navy
Yard, New Y'ork— December 5.
BucHER, W H., assistant surgeon, ordered to duty at the Naval Hos-
pital, Norfolk, Va.— December 9.
Changes in the Pnbllc Health and Marine-Hospital
Service for the week ended December 11, 1902:
White, M J assistant surgeon, relieved from duty at San Francisco,
Cal., and directed to proceed to Portland. Oregon, and assume com
mand of the service at that port-December 10, 1902.
CcBRiE, D. H., assistant surgeon, to report to Surgeon A. H. Glennan,
San t rancisco, Cal., tor assignment to duty— December 10, 1902.
Bailey, C. W., acting assistant surgeon, granted leave of absence for
seven days— December 6, 1902.
Barnksby, p. N., acting assistant surgeon, granted nine days exten-
sion of leave of absence from December 1-December9, 1902.
Gregory, G. A., acting assistant surgeon, granted leave of absence for
ten days from November 26— December 9, ]90.>.
Rodman, J. C, acting assistant surgeon, granted leave of absence for
four days from December 15— December 1], 1902.
Ross, M. H., acting as.sistant surgeon, granted leave of absence for four-
teen days from December 21— December 9, 1902.
Walker, Agnes, medical inspector, granted leave of absence on
l^count of sickness, for fifteen days from December 1— December
^^°,ZS' *• ^- pharmacist, to proceed to Philadelphia, Pa., for special
temporary duty-December 9, 1902. i- > , t^
BchlaarW. F., pharmacist, to report to Assistant Surgeon-General
rijAjJ^^J^an for temporary duty in office for the port of Wash-
ington, D. C- December 11, 1902.
American Medicine
cv"^'
OEOROE M. GIOULD, Editor
G. C. C. HOWARD, Marutging Editor
CHARLES 8. DOLLEY
MARTIN B. TINKER, AaUtarU Editor!
Clinical Medicine
David Riesman
A. O. J. Kelly
J. Edwin Sweet
HH.KN MURPBY
General Surgery
Martin B. Tinker
A. B. Craig
Charles A. Orr
Orthopedic Surgery
H. Augustus Wilson
COLLABORATORS
Ob»tetrici and Oyneeology
WiLMER Krusen
Frank C. Hammond
Nervous and Mental Diteaaet
J. K. Mitchell
P. 8a VARY Pearce
Treatment
Solomon Solis Cohen
H. C. Wood, Jr.
L. F. Appleman
Dermatology
M. B. Hartzell
Laryngology, Etc.
D. Braden Kyle
Ophthalmology
Walter L. Pyli
Pathology
R. M. Pearce
Pdblmhbo Wbiklt at 1321 Walhvt Stbbst, P^iladklpria, bt tbb Awbbicam-Ukpicinb FDBLnHllla COHPAMT
Vol. IV, No. 26.
DECEMBEK 27, 1902.
$5.00 Yearly.
" Mankind in the Making " is the title of a series
of articles upon Infant mortality and health, by H. G.
Wells, now appearing in the Fortnightly Review. With
exceptional clearness and sharpness he pierces the con-
ventionalities and stupidities usually met in the treat-
ment or nontreatment of the subject, and shows that this
is in fact the problem of civilization which underlies and
conditions all others. The bringing to healthy adult
life of the greatest number and of the best quality of
children is the source of national wealth and even of
national existence, and yet of 1,000 children born from
100 to 300 die within a year in our civilized nations. In
previous papers Wells has considered the question of
improving the breed and of raising the average heredity,
but concludes, somewhat hastily and hopelessly we
think, that nothing can be done in these respects.
Surely preventive medicine has already vastly lessened
the inheritance of disease, one of the factors excluded as
beyond conscious or legislative control.
But it is undoubtedly the improvement of the arti-
ficial or acquired elements of men's characters and
capacities that will bring the quickest and most certain
progress. In these things the argument is too vehe-
mently emphasized that Nature (with a capital N) is
not to be trusted, not even to be imitated in the nurture
of children. There was and* there will ever remain a
great truth in the cry, "Back to Nature," when it is
squarely and rightly determined what " nature " is and
how far it may obtain in the complex and unnatural
conditions of modern cities and their uncivilized life.
Nature and education in fact do not exclude but supple-
ment each other, as e. g., in the nursing of infantr^.
There is no more striking example of beneficent science
than artificial infant foods, and yet the mother's milk is
never to be supplanted by the artificial food whenever
the breast itself can be had. And science and art must
both unite to supply the health and life-giving mamma.
Love and Infant Mortality. — The child, says
Wells, requires such unremittent attention as only love
can give. Only the mother or a loving woman can sup-
ply this attention. It cannot be hired for money nor
got in any wholesale way. " Behind the mother must
be the highly-skilled medical man." " The absence of
this, or the attentions of overworked and under quali-
fie<l practitioners, may convert a transitory crisis or a
passing ailment into permanent iryury or fatal disorder."
Not more than 25 percent of children born have such
good fortune. In Lancashire, England, the mortality of
children under five is 274 per 1,000 births, three times as
great as it need be. If the community frees parents from
responsibility, births are stimulated in the least desir-
able classes. Philanthropic institutions generally fail in
their purposes, and lying-in hospitals and foundling asy-
lums are usually striking examples of this truth. In Eng-
land $70,000,000 is spent each year in charities, but Wells
says that if rightly spent one-thousandth of this sum
would result in more improvement. In the foundling
hospitals of the world the deathrate has usually been
over 75 per cent. Infant mortality has not been pre-
vented but organized by these institutions. The condi-
tions in France have been shown with appalling frank-
ness by Emile Zola, in his novel FicoivliU. There will
be no civilization worthy of the name until every child
has a home and is rightly " mothered."
Portable Iio-spitals are recommended by the Health
Department of Chicago. They are no longer experi-
mental, but have been thoroughly tested by the United
States Army Medical Service and adopted for emergency
use in the field and as a contagious disease acljunct to its
permanent hospitals. The Imperial Board of Health of
Germany has established depots of these hospitals, whence
they can be shipped to any {wint in the Empire where
an epidemic of diphtheria, scarlet fever, smallpox, etc.,
may appear. After the epidemic has been suppressed
the pavilion is taken down, disinfected, and returned to
the depot for storage until agiiin required. As Chicago
is 28 miles long the suggestion sei;ms decidedly com-
mendable, as a single isolation hospital would l)e
exi)en8lve and would not answer in epidemics. The
Bulletin says that since the beginning of the year there
have lH>en 55(') deaths In Chicago from diphtheria, and
only 4 from smallpox, and that, since the introduction of
the antitoxin, diphtheria may ha as ".successfully
handled " as smallpox. The hospital pavilions are i)ro-
curable of any desired capacity, but the size re<'oni-
mended as most economical of administration will
accommodate fourteen patients, with nurses' room, bath-
room, kit«'hen and all other requisites of a complete
hospital in Itself. It isdi-sired to s«h'u re several of these,
to be stored when not in use. " When epidemics of
994
EDlTORlAIi COMMENT
IDecembbb 27, 190!
diphtheria and other contagious diseases appear in a
lo{;ality one or more of these pavilions, as needed, could
be set up in the infected district within two or three
hours and the work of 'stamping out' the infection be
effectively begun."
The Nliarpcr disgruised as scientist is a too
frequent phenomenon, as the metaphysicians would say,
of our profe&sional life. The subtlety of the disguise,
the perfect way in which the face of innocence is assumed,
is indeed a marvel. By a most reputable and trust-
worthy colleague we are asked to warn the profession
against Dr. , of — -, , who in a very
plausible way is shrewdly exploiting the profession for
his own money-making ends. Coming to a city or town
he modestly distributes reprints of learned articles from
supposed professional medical journals which at once
establish the conviction In the minds of the local physi-
cians that this is a very expert and scientific and learned
brother on his chosen mission of good. He is a surgeon
introducing a new treatment for this terrible disease.
He wishes to demonstrate at the local clinic of the lead-
ing hospital his method and leave the subsequent care,
observation of results, etc., to the physicians who furnish
the patients. He is not just now prepared, of course, to
make his formula public, but will do so when the results
of enough cases have been gathered, etc. The conse-
quences of a premature announcement, as in the case of
Koch and others, are well known. Secretly, the man is
selling State rights for the use of the remedy to any one
who will buy, medical man or bucket-shop broker. A
number of dull-minded nimble-wits among the doctors
are slowly teased or bribed into the scheme, one such
saying, " Well, I'll first attend to the money side, and
look after the ethics by and by." Against the quack in
the scientist's garb, our correspondent evidently thinks
we need forewarning.
The Respectables Who Endorse Quack Institu-
tions.— Physicians often marvel at the ease with which
respectable and even philanthropic citizens are duped by
quacks and sharper,s. We recently saw the name of the
president of a great university, who is at least ex officio
the head of its medical school, among those supporting
an antivivisection crusade. There lies before us a cir-
cular of a scheme which guarantees to cure in every case,
which is capitalized in millions, which is a medical
matter if there ever was one, whose socalled "cure " is
secret, and yet which has the names of wellknown
D.D.'s, LL.D.'s, Ph. D.'s, Reverends, Honorables, Presi-
dents of this, that and the other; senators, lawyers,
editors, governors, etc., as endorsers and officers. It is
plain that such endorsing is proof either of an ignorance
or of a carelessness which is alike criminal. If they
support such evils their support of other causes may be
iis foolish and harmful to science and to the community.
Not one of these men but would go to a regular physi-
cian when sick. Why, then, not ask the physician's
advice before bolstering up poorly concealed commercial
and unconcealed quack enterprises? How much of the
"stock," watered to the thirtieth dilution, has been
given them for the use of their names ? If any, then are
they scamps despite their D.D. and other degrees ; and
if they have not the stock they are the more pitiable
dupes of the stock-broking manipulators. In either case
what laughable self-advertising of their mental, moral
and financial condition !
The Law as to Self-destruction, Sane or Insane —
It is gratifying to know the United States Court of
Appeals has made an end of the wrangles and quibbles
and doubts as to the liability of insurance companies as
regards suiciding policy-holders. In the case decided, the
policy stated that " self-destruction, sane or insane, within
one year from the date of the issuance of the policy is a risk
not assumed by the society in this contract." The lower
court had ruled that this was a proviso not limited to
wilful or intentional suicide, but included any self-
destruction, sane or insane. This ruling is confirmed by
the higher court, which says that "If the assured caused
his own death while sane or insane, that is the end ol
any right to recover, and there can be no looking intc
the condition of the mind of the deceased when he com-
mitted the fatal act. The case might be different if the
replication had stated that his death was due to an acci'
dental cause, if for example, he had taken a poisonous
draught, mistaking it for water ; or walked through 2
window, mistaking it for a door. Then it would fall
within the rule established by a number of cases, which
hold that accidental or unintentional self-destruction is
not within a condition forfeiting a policy for suicide."
The Mortality Rate in the German and th<
French Armies. — The sanitary condition of the Frencl
army was recently brought before the French Senate bj
M. Gotteron, who stated that while since 1870 Germanj
had lost only 13,000 soldiers from disease, France had los
99,000. General Andr6e, in reply to this startlin|
declaration, acknowledged that in France the military
mortality was 4.17 per 10,000, whereas in Germany i
was onlj' 1.41. Tuberculosis and typhoid fever, he said
were the principal factors. There was an attempt U
throw the blame for this upon local municipalitie
which did not supply good water, upon the recruiting
rules, handling of the conscripts, etc., explanation!
which explain nothing. Social and military an(
political philosophers will find many suggestions anc
subjects for study in this item of the vital statisticians
One such that will not perhaps come uppermost at firs
will be an explanation of the wisdom from a worldl;
point of view of the desire of the German nations fo
peace. We do not say it is disingenuous, only that i
coincides with an old rule to let j^our enemy destro;
himself. Another hint is derived from the statistics a
to the true grounds of national power and wealth. A]
national greatness and riches are at least dependent upoi
the number of able-bodied and healthy citizens. Th
Germans have been earnest in preventing disease, hav
recognized the value of thoroughgoing vaccination, hav
estimated the weakening power of disease to armies an
nations, and as a result their military mortality i
almost one-third of that of the French, who have ignore
this condition of national strength. The shrewd natio
which produces the most men and the most healthy me
December 27, 19021
EDITORIAL COMMENT
[American Medicinb 995
will by doing so win in the wars of the future, whether
they are wars of war or wars of peace.
Leonardo da Vinci and Andreas Vesalius. — In
154;3, when less than 30 years of age, Vesalius published
two volumes — a large work, entitled "De humani cor-
poris fabrica libri septem," and a smaller work that was
an epitome of the former. These created an incredible
excitement, and their author was maligned and perse-
cuted on the one hand and ardently defended on the
other. His enemies endeavored to have the work con-
demned by the theologic faculty of Salamanca on the
ground that it was unbecoming in a Christian to dissect
the human body. The Council, however, decided that
such a procedure was useful and permissible. The first
edition of the " Fabrica " is a folio of 700 pages, containing
more than 300 excellent steel engravings, the majority
of which were made by Johann Stephan von Kalkar, a
pupil of Titian. This work is considered as marking the
beginning of modern anatomy. And now we come to the
subject that gave the impetus to the present article.
This is the claim of Jackschath that both the text and
the illustrations of the "Fabrica" are not the work of
\''esalius, but of that colossal genius, Leonardo da Vinci,
.lackschath contends that, in the first place, a man of 28
would have been entirely too young to have been the
author of the "Fabrica," which could have been pro-
duced only by a man that had devoted many years to
the subject. He says, among other things, that the accu-
rate knowledge of the theory of proportions shown in
the illustrations of the human body presupposes that the
author of the work must have made measurements of
liundreds of bodies. Leonardo da Vinci and della Torre
are known to have made many dissections of human
beings and of horses. Then there are certain marks in
the illustrations of the work that are peculiar and unique,
and that are found only in the works of Leonardo, who,
it is well known, invented his own orthography. Then
there is also a striking similarity between several of the
passages of the " Fabrica" and certain dicta of Leonardo's
that have recently come to light. Some of the illustra-
tions are incorrectly shaded, and the iconoclastic Jacks-
chath claims that this was done by Vesalius in an effort
to conceal his plagiarism. Jackschath points out several
such illustrations that, to his mind, indicate a wilful
deception on the part of Vesalius. In 1598 a work on
the anatomy of the horse was published by Ruini, a rich
Councillor of Bologna. As early as 1855 doubt was
expressed that Ruini could have been the author of this
anatomy, which contains internal evidence of familiarity
with the human organism and with Galenic anatomy.
Jackschath alleges that the author of this book was also
the hajjless I^eonardo. There can be no doubt of the
ability of Leonardo da Vinci to have written the work*
attributed to Vesalius and Ruini, for he was certainly
one of the greatest minds that ever lived ; but it seems
highly improbable that Vesalius could have deceived
his contemporaries such a short time after lieonardo da
Vinci's death (1519). The great anatomists that were
the disciples and followers of Vesalius would hardly
have been so easily duped. We only need mention
Eustachius, Ingnissias, (Jolombo — who was almost on
the brink of making the discovery of the circulation of
the blood— Arantius, Varolius, Botallus, Fallopius,
Fabricius, Aquapendente, and others, many of whose
names are forever enshrined in anatomic nomenclature.
Why is Reciprocity Refused?— A physician, a
graduate of a reputable college recognized by the Penn-
sylvania Board, and licensed by the Illinois State Board
of Health after examination, made application to the
Medical Council recently for a license in Pennsylvania,
based upon the Illinois certificate. In reply the appli-
cant was informed that the Council recognized no licenses
except those issued by New York, this leaflet accom-
panying the letter :
"All applicants (or license to practise medicine in Pennsyl-
vania, with the exception of those holding certificates from the
State of New York, are required to pass examination before
one of the State medical examining boards."
In the interest of a needed and just reciprocity we
would like to know why the Pennsylvania Board refuses
reciprocity with Illinois ? The Illinois State Board of
Health stands ready to recognize, at any time, licenses
issued by the Medical Council of Pennsylvania, after
examination, to graduates of medical colleges in good
standing with the Illinois State Board of Health, pro-
viding, of course, that the Medical Council of Pennsyl-
vania will recognize licenses issued by this board, after
examination, to graduates of aecredited colleges. Does
the Pennsylvania Board contend that the requirements
in Illinois and in several other States are not as high,
are not even higher than in Pennsylvania? The entire
profession has been clamoring for practical reciprocity ;
why do its agents and representatives deny it when it is
possible, and every demand of justice is satisfied ?
" The American Institute of Social Service," if
wisely managed, should do a vastly beneficent work. It
is, too, an example of American ideals and methods of
which we have just cause to be proud. It was recently
organized at the home of that noble woman, Miss Helen
Gould. Its three chief functions are the gathering from
all possible sources of facts which have any bearing on
social and industrial betterment ; the interpretation of
these facts by ascertaining their causes and effects, and
the dissemination of the resulting knowledge for the
education of public opinion. The institute is the out-
■growth of the League for Social Service, which was
organized by Dr. Strong and Dr. William H. Tolman in
1898. Our object in calling the attention of physicians
to this movement is that the profession may bring its
influence to bear upon it by making plain the great
truth that so many social ills are really medical in
nature. The expense and suffering, for instance, endured
by the community, because of needless disease, should
be tirelessly explaintnl to those who have social better-
ment at heart. The deathrate in our country is far
higher than it need be. Some cities have reduced it by
almost one-half by thoroughgoing carrying out of the
known laws of preventive me<licine. And for every
death there are two years of sickness ! It is such facts
as these that should be brought to the attention of the
996 AKXBtOAA MssieiNK)
AMERICAN NEWS AND NOTES
[December 27, 1902
American Institute of Social Service by noembers of tlie
medical profession. Let us not fail to contribute to this
"clearing-house of social facts" the health -and-disease
fact upon which so many others depend.
liet Us Make an End of Popular Hypnotism.—
We never had much faith in it even in the hands of
experts. Even Charcot, it would seem, could have been
better occupied than with this neurotic nonsense. When
all the reports of physicians are gathered and analyzed,
if the analyzer is a cool and scientific man he will prefer
to drop the whole affair with a smile of disdain. If he
observes the vogue of the ignorant " Professor" and the
popular lecturer upon the subject he surely will conclude
that public exhibitions and money-making by means of
hypnotic practices should be absolutely forbidden by
law. Few know the extent to which the abuse has
grown, and the flood of literature advertised in the cheap
magazines and the crazy journals. It all has a sham
philanthropic ring, there is much gibbering of "self-
development," "power," etc., but closely observed one
finds that it is all erotic, neurotic, or tommyrotic. If
there is any truth or power in it, it is dangerous to put
such power in the hands of the ignorant and designing.
The newspapers have reported a number of cases of
criminal abuses by country charlatans.
A reductio ad absiirdnm of Mrs. Eddy is suggested
by a recent British essayist, who quotes this authority
" uncontaminated with human hypothesis " in her claim
that belief does cause the death of a person taking poison
by accident, although both the physician and patient
believe in the recovery. This, says the mother, is
because the vast majority of mankind, though they know
nothing of this particular case, believe that arsenic or
strychnin is poisonous, for it has been set down as a
poison by mortal mind. " The consequence," says Mrs.
Eddy, " is that the result is controlled by the majority of
opinions outside, not by the infinitesimal majority of
opinions in the sick chamber." Wherefore, says the
critic, Mrs. Eddy differs from Christ, who said "Thy
faith hath made thee whole," regardless of the unfaith of
the rest of the world. But what, then, becomes of the
claim to cure in the presence of an unbelieving world ?
There is, therefore, no cure by "mortal mind " or any
other kind of mind, except the majority of outsiders, to
the ends of the world, have voted aye upon the proposi-
tion. As the great mass of the earth's inhabitants do
not believe in the cures nor the possibility of cures of
Mrs. Eddy and her children, it follows, by her own
logic, that not one of those cures have been or could
have been real or true.
AMERICAN NEWS AND NOTES.
Diphtheria from Pencils. — Investigations conducted by
tlie Health Department of Passaic, New Jersey, liave led to the
discovery that many oases of diphtheria in the city have been
caused by the common practice among school children of put-
ting pencils into their mouths after other children have ck)ne
the same thing. It is a custom throughout the public schools
to distribute pencils at the beginning of the day and to collect
them at night. As this is considered a direct means of con-
tagion, the City Department has issued an order stating that
each pupil must keep one pencil continuously. His or her
name must be marked on it, and any other pupil found using
it will be punished. Thus far 80 cases of the disease have been
reported in the city.
OBNEBAli.
Smallpox.— According to the Public Health reports small-
pox occurred in 44 States and Territories during the past year.
The number of cases reported for the year ended June 30, 1902,
was 55,857. The deaths were 1,852, a mortality of ,3.31 % as com-
pared with 38,(506 cases and 689 deaths during the year ended
June 30, 1901.
Yellow Fever.— No yellow fever was reported in the
United States during the past year. Reports have been received
of the existence of this disease in Brazil, United States of
Colombia, Costa Rica, Cuba, Dutch West Indies, Haiti, Mexico,
and Salvador. Mexico has furnished a large proportion of
cases during the past year, and Cuba, which has heretofore
reported annually a large number, had only 61 cases and 14
deaths from yellow fever during the six months ended Decem-
ber 31, 1901, and 1 case and no death for the six months ended
June 30, 1902, and this one was represented as imported.— [Pub-
lic Heo'lth Reports.']
Increase of Medical Men in the Army.— The increase in
the standing army of the United States will necessitate an
increase in the number of medical officers. Surgeon-General
Rixey estimates that an increase of 150 medical ollicers should
be made, and the pt^psent Congress will have the matter urgently
brought before it. There are no vacancies at the present time,
since the places are tilled temporarily by men serving on the
addition list. These will have the preference in filling the new
places if Congress makes the necessary provision. It is reported
that provision will be made by the present Congress for 7.5
medical officers, leaving to the next Congress the duty of pro-
viding for the remaining 75.
Hospital Benefactions. — Cambridgk, Mass.: The late
Mary Longfellow Greenleaf bequeathed $5,000 to the Cambridge
Hospital for a "St. James' Free Bed," to be at the disposal of
the rector of St. James' Church, Cambridge. She also gave
$5,000 to the Maine General Hospital for a " Rev. Samuel Long-
fellow Free Bed." Bbooki.yn, N. Y.: William Hall, Jr., has
given $125,000 to complete the new buildings for the Seney
Hospital. Mr. Hall's gift, however, is conditional on raising
before June 1 next $50,000 to cover the rest of the building debt.
MiDDLKTOWN, CoNN.: Wesleyan University has received
$5,000 from the Andrew Carnegie Institute, Washington, of the
$200,000, which has been set aside for promoting medical
research in leading medical universities. This sum will be
used for promoting experiments into respiration by means of
the colorimeter. The special object to be promoted is the rela-
tion of oxygen to the animal economy. Philadelphia, Pa.:
Caroline J. Freddenberger, of Tainaqua, has bequeathed $2,500
to the German Hospital of Philadelphia and $1,000 to the Potts-
ville Hospital.
EASTERN STATES.
Bubonic Plague in New York.— The "Saxon Prince"
arrived in New York with three of her crew ill with what
appears to be bubonic plague. The three victims are now
under treatment at Swinburne Island Hospital at Quarantine,
while cultures have been sent to Washington for official inves-
tigation to set aside or confirm the diagnosis of bubonic plague.
The steamer will be sent to sea to discharge her water and sand
ballast, and the remainder of her crew and her few passengers
will be held at quarantine pending the investigation.
Open Air for Consumptives.— It is stated that the State
Forestry Commission will establish a number of cottages at the
edge of the forest near Mont Alto Park, Pennsylvania, for the
free treatment of consumptives. The cottages will be small,
containing two bunks and a table, the idea being to furnish a
comfortable sleeping place but to encourage the patients to
remain in the open air as much as possible during the day. A
tract of 40 acres is covered with a pine forest, the altitude is 2,000
feet, and the outlook is considered encouraging for the treat-
ment.
NEW^ YORK.
Japanese Physician Applies for Medical L/icense.— Dr.
M. Fujimori, of Japan, a graduate of the Sai-sei-gaku-sha,
Hongo, Tokyo, and of its postgraduate medical school, has
applied to the New York Board of Regents for license to
practise his profession in New York City exclusively among
his countrymen. S. Fujimori was licensed to practise medi-
cine by the" Interior Department of the Government of Japan.
He is especially endorsed by the Japanese weekly, Japan and
America, published in New York City.
Manhattan Board of Coroners.— The Manhattan Board
of Coroners addressed a letter to Dr. Albert Weston, calling on
him to show cause why he should not be removed from office.
The board met to prefer charges, but Dr. Weston's lawyer,
DeForest Baldwin, had procured a writ of prohibition, restrain-
ing the Manhattan Board from acting, on the ground that the
members were exceeding their authority, and only the Board
of Coroners of Greater New York had authority in such
matters. The charges were not preferred.
Dbcembeb 27, 1902]
FOREIGN NEWS AND NOTES
lAXKBICAN MKDZCINK
^97
Reduced Deathratc In Prisons.— C. V. Collins, Superin-
tendent of Prisons, in his report to be presented to the New
» orkLegisIature, gives some remarkable results of the system
which he introduced five years ago for tuberculous patients.
During these five years there has been a general decrease of
65% in thB annual deathrate in the prisons, and a 71% reduction
in the deaths due to tuberculosis. This has been brought about
by the transfer, when possible, of all prisoners suffering from
tuberculosis to Dannemora, where they were subject^ to a
special course of treatment.
SOUTHERN STATES.
Army General Hospital.— It is reported that the House of
Representatives has been asked for an appropriation of $:W5,000
for the construction of an " army general hospital " iu Wash-
ington. The hospital is to be used for the treatment of special
cases, for instruction in connection with the Army Medical
School, and to serve as a base hospital in time of war. The esti-
mate includes |140,000 for the purchase of a site for the hospital.
Verdict Secured Against Bacteriologist- The first ver-
dict in any of the tetanus damage cases of St. Louis, Mo., has
been secured against Dr. A. Ravold, former City Bacteriologist,
for fl.nOO for the loss of a child, who died September 2, 1901,
from tetanus induced by antitoxin serum administered for
diphtheria. The serum was furnished by the city. The Board
of Health and the city of St. Louis were named as defendants
when the case was filed. Thecity was dismissed about a month
ago, and later the Board of Health was dismissed, leaving Dr.
Ravold the only defendant.
Cave Sanatorium.— It is reported that a sanatorium for
the treatment of pulmonary tuberculosis, located at Luray,
Va., has the system of ventilation so arranged that all the air
for the institution is supplied from the underground caverns.
It is claimed that the air of limestone caverns has all the
characteristics of the pure, rarefied air of high altitudes, and
that an investigation of the air in the caverns supplying the
sanatorium showed it to be of uniform temperature, remarkably
pure and frae from all germs and dust particles and especially
•adapted for the treatment of pulmonary complaints.
WESTERN STATES.
California State Journal of Medicine.— The first issue of
this journal, which will be published monthly by the Medical
Society of the State of California, was issued November, 1902.
Rush Medical College.— Senu Hall, the building recently
added to the Rush Medical College, largely through the gener-
osity of Dr. Nicholas Senn, has been formally opened. It was
erected at a cost of 8130,000, of which Dr. Senn contributed
$.%,000. Other members of the faculty gave ^30,000 more, and
the remainder was furnished by the college.
Examinations in Ventilation Appliances Urged for
Architects. — It is reported that the State Factory Inspe<;tor of
Indiana is urging that a new law be enacted requiring architects
to undergo an examination in ventilation appliances. It is
claimed that most of the schoolhouses throughout the State
have no ventilation except through windows and this has been
found to be wholly unsatLsfactory.
The " Knockout " Cigaret.- It is asserted that crooks in
Chicago are in possession of a cigaret which has the appearance
of being perfectly innocent but when smoked by the intended
victim causes a period of unconsciousness lasting about 10 min-
utes, during which time the victim can be easily robbed. The
nefarious article is manufactured and sold by a chemist, who,
of course, does not make known the hypnotic used.
To Combat Tuberculosis.- It is asserted that the State Board
of Health of Wisconsin, in its annual report to be made to Gov-
ernor La FoUette early in January, will recommend that an ap-
propriation be made for the establishment of aState hospital for
the treatment of tuberculosis. It will also urge the Legislature
to appropriate a sufficient fund to carry on the work of stamp-
ing out this disease, which, it is believed, can be done if the
outdoor treatment now in vogue in the East Is introduced.
No Bubonic Plague in San Francisco.- The San Fran-
cisco Call states that Dr. A. H. Glennon, the accredited repre-
sentative of the United States Government, is propariniar a
report to Surgeon-General Wyman of the Marine-Hospital
Service at Washington, to the effect that there has never been
bubonic plague In California. Dr. (Hennon's report will go
further and declare positively that after a thorough and exten-
sive investigation, the bacillus supposed to be of the plague is
that of chicken cholera.
Vaccination Order Rescinded.- It appears that the
■.lutliorities of Gas City, Indiana, issued an order that vaccina-
tion should be necessary before a child could attend the schools.
A bitter war has been waged liy the antivaccinHtionists against
the measure, and suits were entered against the city. Tlie
order has now been revoked, and children vaccinated and
unvacclnated are attending the schools. The revocation it is
said was due to the fact that the mayor's sou died from the
effects of vaccination.
Chicltenpox vs. Smallpox Again. — The death from
smallpox appearing in the statement of mortality for Chicago
during the week ended November 8 was returned by the certi-
fying physician as from " chickenpox." The registrar of
vital statistics, before issuing a burial permit, referred the
certificate to the chief medical inspector, who immediately
viewed the body and identified the disease as smallpox. The
premises were taken charge of, all "contacts" in the vicinity
were vaccinated and the members of the family, including two
children who were found " scaling" from the socalled chicken-
pox, were treated to a disinfectant bath. The house was thor-
oughly disinfected with formaldehyd gas and corrosive subli-
mate solution.
Mortality of Michigan.— During November there were
2,357 deaths reported to the State Department, a decrease of 3
from the preceding month. The rate was 11.7 per 1,000 popula-
tion, as compared with 11.4 for October. There were 409 deaths
of infants under 1 year; 159 deaths of children aged 1 to 4
years, inclusive, and 703 deaths of elderly persons over 65 years
of age. Important causes of death were as follows : Pulmon-
ary tuberculosis, 129; other forms of tuberculosis, 34 ; typhoid
fever, 65; diphtheria and croup, 51; scarlet fever, 25; measles,
7; whoopingcough, 23; pneumonia, 201 ; diarrhea and enter-
itis, under 2 years, 57 ; cancer, 127 ; accidents and violence, 155.
A decrease was shown in mortality from tuberculosis, typhoid
fever, diphtheria and croup, and diarrheal diseases from the
preceding month, and an increase in the deaths from scarlet
fever, measles, pneumonia and cancer. One death was reported
from smallpox in the city of Detroit.
Colorado State Board Requirements.— The Colorado
State Board of Medical Kxaminers has adopted a schedule of
minimum educational requirements of medical colleges, to go
into effect January 1, 1903. Space permits only a condensed
abstract. Conditions of admission to lecture courses require that
a voucher as to moral character must be furnished by the can-
didate, signed by two physicians, and that a preliminary
education less than the equivalent of a four year's course at
high school will not be accepted. Advanced standing will be
granted to those having the degree of A.B. or B.S., or an equiv-
alent, but only for such work as is equivalent in time and
extent to the same in the freshman year in a medical college of
good standing. Advanced standing will likewise be given
those who are graduated from a recognized college of dentistry,
or college of veterinary medicine. Students of medical colleges
recognized by the board may be admitted to the next higher
class provided documentary evidence is furnished that the
previous year's work was complete and examinations passed.
Regulations as to length, number, and character of courses,
attendance, dissection, clinics and hospital attendance, instruc-
tion, graduation, etc., are detailed at length. A complete copy
of the requirements will doubtless be furnished by Dr. S. D.
Van Meter, secretary of the Colorado State Board of Medical
Examiners.
CANADA.
Vaccination In Montreal.— Stringent measures relative to
vaccination have been adopted by the City Council of Montreal.
It is enacted that vaccination shall be performed by no one
except a &n\j qualified physician. The site of operation, hands
of the physician, instruments, etc., must be rendered aseptic
previous to the operation. A fine of $40 or imprisonment for
not more than two months shall be the penalty for any viola-
tion of the law. Montreal is determined if possible to prevent
a recurrence of last winter's outbreak of smallpox.
FOREIGN NEWS AND NOTES
OENERAIi.
Plague Germs in Foods. — It is stated that investigations
have shown the foodstuffs shipped to Honolulu from Japan and
China via San Francisco to be responsible for the recent outr
break of plague there. Since these foodstuffs were imports at
San Francisco, and reshipped to Honolulu, it is fair to assume
that the former city is in some danger from this source of infec-
tion.
OBITUARIES.
Malcolm K. r»iTi>tt, of Brooklyn, N. Y., December 1«, aucd 56. He
was gradUittt'd from the JctTerson Medical Collef(c, Pblladilphla, In
1883. He wax renldent pby»lclun and HurKCon of the Jctfcnion iloHpltal
for a sliort lime, and for a year was Rurgeon of the Red Htar Line
Hteamablp Company. He wan a menil>er of the Medical Society of
the County of KIngH, the Associated PhynlclanH of I»ng Uland, the
Bnxiklyn Medical Hoclety, the Mutual Aid AHHoclution of New York,
and wan on the HtafTof the BuKhwIck Central Hoapltal.
Mary WIllitH, of Norrlstown Pa., December 16, aged 40. 8be was
998 : AmtBiOAN MKDicrfvit
SOCIETY REPORTS
[Dkcembeb 27, 1962
nrst asBlstant pbyHlcian of the female department of the State Hospital
for the Insane, and had been connecU^d with the Institution for over
ten years, Hho was a gradual* of the Woman's Medical College, Phila-
delphia. She was distinguished as being the first woman admitted to
the Philadelphia Medical Hodety ; this occurred June 20, 1888.
Henry C. Pearce, In Urbana, Ohio, December 2, aged 69. He was
graduated from the Starling Medical College, Columbus, InlSftS, and
was for five years lecturer on physiology and histology In that instltu.
tlon. He was a founder and for twenty-seven years an honored mem-
ber of the faculty of the Columbus Medical College. He wa« also for
more than thirty-flve years surgeon of the Pennsylvania lines.
John S. Lewis, of Weston, W. Va., December 15, aged 43. He was
graduated from the College of Physicians and Surgeons, Baltimore,
Md., In 1879. He was for several years superintendent of the West
Virginia Hospital for the Insane.
Henry N. Jones, In Kingston, Mass., December 18, aged 87. He
was graduated from the Dartmouth Medical College In 1840. He was a
member of the Massachusetts Medical Society and of the Plymouth
District Medical Society.
Joseph C. Stone, In Burlington, Iowa, December 3, aged 73. He
was graduated from the St. Louis and Missouri Medical College In 1854.
He was a veteran of the Crimean and Civil wars and a member of
Congress in 1878.
Tallio Verdi, at one time a celebrated physician of Washington,
D. C, died recently at Milan, Italy. During President Grant's admin-
istration he was commissioned to study the hygienic laws of Europe.
Stanley S. Cornell, in Athens, Ont., December 2, aged 37. He was
graduated from the faculty of medicine of Queen's Universitj' and
Royal College of Physicians and Surgeons, Kingston. Ont., in 1866
Lncien McDowell, in Flemlngsburg, Ky., December 4, aged 78. He
was graduated from the University of Louisville In 1849 and was a
prominent member of the Kentucky State Medical Society.
Wilbur C. Wright, in Unionville, Mich.. November 29, aged 41.
He was graduated from the University of Michigan, Ann Arbor, in 1887.
He was a member of the American Medical Association.
Joseph Charles, acting assistant surgeon U. S. Navy, died at New-
port News, Va., December 11. He was graduated from the College of
Physicians and Surgeons, Baltimore, Md., iu 1881.
Edward C. Evans, In Sedalla, Mo., December 4. aged 74. He was
graduated from the St. Louis and Missouri Medical College In 1854 and
from the Jefferson Medical College In 1858
John M. Krim, of Louisville, Ky., December 10, aged 60. He was
graduated from the University of Louisville in 1870. He was president
of the Louisville Clinical Society.
Linnaeus B. Anderson, formerly of Norfolk, Va.. died December
5, in Noel, Va., aged 78. He was graduated from the Medical College
of Virginia, Richmond, in 1884.
Ferdinand Venn, of Chicago, 111., December 17, aged 32. He was
graduated from the medical department of the University of Pennsyl-
vania, Philadelphia, in 1892.
Jolm Vansant, surgeon In charge of the Marine Hospital, died at
Charleston. S. C., December 12. He was graduated from the Jefferson
Medical College in 1855.
Alonzo W. Daum, in ConnersvlUe, Ind., December 3, aged 34. He
was graduated from the Medical College of Indiana, Indianapolis, in
1894.
Harlow J. Plielps, In Phoenix, Ariz., November 25, aged 28. He was
graduated from the Marion-Sims College of Medicine, St. Louis, in 1899.
Beivjaniin M. Ludden, in Brooklyn, N. Y, November 21, aged 87.
He was graduated from the Ohio Medical College, Cincinnati, In 1852.
Robert Terrill, of Darksville, Mo., December 2. He was graduated
from the College of Physicians and Surgeons, Keokuk, Iowa, in 1875.
A. F. Cope, of Oil City, Pa., December 15. aged 58. He was gradu-
ated from the Michigan School of Homeopathy and Surgery In 1870
Samuel K. Crawford, of Chicago, 111., December I, aged 67 He was
graduated from the University of Michigan, Ann Arbor, In 1861.
Homer C. Valentine, of Stoutsvllle. Ohio, December 8. He was
graduated from the Starling Medical College, Columbus, in 1898.
Robert E. L. Kincaid, in Bonham, Tex., December 7. He was
graduated from the University of Tennessee, Nashville, in 1888.
Alexander Demby, of Brooklyn, N. Y., December 18, aged 24. He
was graduated from the Long Island College Hospital in 1899.
Oscar T. Seeley, of Climax, Mich., December 19, aged 72. He was
graduated from the Rush Medical College, Chicago, in 1868.
Louis E. Krombein, in Buffalo, N. Y., December 7, aged 76. He was
graduated from the University of Buffalo, N. Y., In 1860.
T. O. Brewer, of Monroe, La., December 15, aged 51. He was
graduated from Louisville (Ky.) Medical College in 1881.
John Ring, of Chicago, 111., December 14, aged 70. He was gradu-
ated from the Rush Medical College, Chicago, in 1888.
James W. Eraser, of Philadelphia, November 27. He was gradu-
ated from the University of Pennsylvania, in 1884.
Samuel Doggy, of Philadelphia, December 15, aged 79. He served
as surgeon during the Civil war.
Lucy Edwards, of Newark, December 15, aged 60.
SOCIETY REPORTS
AMERICAN PUBLIC HEALTH ASSOCIATION,
Thirtieth Annual Meeting, Held at New Orleans, La.,
December 8, 9, 10, 11, and 12, 1902.
[Specially reported for American Medicine.]
[Ccmcltided from page 961,]
Observations on the Morphology of Bacillus Diph-
theriae, Bacillus Pseudo-Diphtherlae, and Bacillus Xero-
sis.— F. P. Denny (Brookline, Mass.). This paper was based
on the study of serial preparations made at intervals from the
same cultures. Bacillus diphtheriae. — In young cultures up to
eight or twelve hours the development was characteristic of all
bacilli and consisted in elongation of the rods and fission. The
bacilli would stain evenly. After this time fl.ssion eea.sed in
mcst of the bacilli and changes tooli place in the individual
organisms. Granules developed ; the rods became elongated,
and might become filamentous ; the protoplasm might break
up into segments; true branching might occur, though very
rarely, all of which were changes characteristic of the higlier
bacteria, and especially of the streptothrix. Certain variation
in the conditions of growth might hasten or retard these changes.
Thus variations in temperature and in the reaction of the media,
also symbiosis might prolong the solid staining stage and make
the diagnosis of 15hour cultures difficult, liacillus pseitdo-
diphtheriae.— This was like the young forms of bacillus diph-
theriae. It had no stage of development when it grew into long
forms like the higher bacteria. On the contrary, the bacilli
were even shorter in old than in young cultures. Bacillus
xerosis. — Young forms were solid staining like young bacillus
diphtheriae. In older cultures the bacilli became elongated
and the protoplasm, would break up into segments ; only rarely
did granules appear in pure culture. In symbiosis ^ith other
bacteria granular forms might appear which resembled bacillus
diphtheriae.
The Use of Immune Serum iu the Separation of
Typhoid and Colon Bacilli.— Adolph Gehrmann (Chicago)
said the difficulty in the separation of these species was
due to the constant tendency of Bacillus coli to overgrow
Bacillus typhosxis. The search for the specific retaining agents
had not resulted in entire success. If an immune serum active
for one or the other species could be used to restrain the growth
of one without disturbing the growth of the other, it would be
an ideal method of procedure. He related previous experi-
ments along this line. The serum of rabbits immunized
against Bacillus coli could be used for this purpose, and gave
results that were positive by artificial mixtures of the two
species. The method Could be improved by using the blood of
immune animals direct and by rapid cultivation in the
incubator. For practical purposes this metliod was not as yet
certain, and the establishment of a control was difficult. On
material containing other species the restraining effect of car-
bolic acid did not disturb the purpose of the Vjlood that was
used. Some indefinite results on the isolation of typhoid from
water had been reported.
An Examination of the Value of Certain Antiseptics
Used for the Preservation of Antitoxin and Other
Immune Serums.— Joseph McFarland (Philadelphia) said
this investigation had for its object the determination of the
antiseptic and bactericidal values of chloretoue, formaldehyd,
chloroform, trikresol and carbolic acid. It had long been
believed that the addition of 0.5% of carbolic acid and 0.4% of
trikresol and 0.1% of formaldehyd would satisfactorily prevent
the growth of microorganisms in the serums so prepared. As
some of these reagents threw down a precipitate, the question
arose whether the reagent itself was destroyed and too little
remained to properly preserve the serum. The research was
conducted by preparing the serums with the jiroper propor-
tions of the germicides, then adding known numbers of bac-
teria and determining their diminution or increase. Thie results
showed that, other things being equal, formaldehyd was prefer-
able to phenol, but objectionable because it did not kill molds.
Phenol was better than trikresol, and the recommendation was
made that hereafter trikresol be given up as a preservative of
the serum.
Formaldehyd.— H. W. Hill (Boston) concluded that
humidity was an important faetor in formaldehyd disinfection.
An amount of gas which failed to kill in six hours at 42%
humidity killed in 20 to 40 minutes at 100% humidity. Con-
sidering the unavoidable leaks and absorption of gas iiy walls,
etc., found in practice, practical disinfection required a rapid
discharge of gas and high humidity. The best of the generators
tested ran not more than 15 cc. per minute, and the condensed
effluent yielded in the first 10 minutes only about a 30% solution,
hence generation by boilingf in the ordinary way was too slow.
Spraying was somewhat objectionable from the wetting down
of the contents of the room. Atomization by steam current
under 15 pounds pressure yielded from six to eight times as
rapid a flow of full strength, with no polymerizing, and pro-
duct d a high humidity.
December 27. Ifc021
CORRESPONDENCE
(American Mesicikk 999^
The Diminishing Importance of Public Water Sup-
plies, and the Consequent Significance of Other Factors
in the Causation of Typhoid Fever. — Professor W. T. Sedo-
wiCK aud Mr. C. E. A. Winslow {Bostx>n) undertook to show-
that: 1. In the State of Massachusetts and in many of the
larger cities of the United States the public water supplies
were now unimportant as vehicles of typhoid fever. 2. In
cities having pure water supplies the annual curve of typhoid
fever mortality closely followed that of annual temperature.
3. In urban communities supplied with pure wat«r there still
remained a typhoid fever tax of from 15 to 25 deaths per 100,000
population. 4. This tax was due, not to any peculiar conditions
of soil, locality or climate (endemic factors), but to incomplete
disinfection of typhoid excreta with subsequent infection of
various articles of food and drink. These factors, when acting
upon a few or many persons at one time, might cause obvious
epidemics, sometimes large, though generally small ; but more
often the infection in moving from one point to another fol-
lowed different and obscure routes for different victims, and
hence might be described as prosodemic. 5. The only remedies
for such prosodemic typhoid were absolutely thorough ami
universal cleanliness and disinfection of excreta.
CLINICAL NOTES AND CORRESPONDENCE
[Communications are Invited for this Department. The Editor Is*
aot responsible for the views advanced by any contributor.]
Scarlet Fever In Montreal.— Scarlet fever in Montreal
threatens to become a serious matter. It appears that the city
has accommodations for but 25 cases of contagious disease, and
18 are already on hand. For years there has been an effort on
the part of many citizens in the city to secure the erection
of a hospital for contagious diseases. The great hindrance has
been the fact that the Catholics desired a hospital separate from
the Protestants. A hospital ("or contagious diseases is a munici-
pal and not a sectarian matter. According to present indica-
tious, Montreal may have to pay heavily for her neglect.
Diagnosis of Urethral Diseases. — Valentine {British
MeiHcal Journal, November 8, 1902) in presenting the subject
insisted that no effort was made to present anything new, but
rather he would merely recapitulate under proper headings a
general plan to be pursued in making a diagnosis of uretliral
disease. Discussion was given under the fallowing headings:
Family history — as to hemophilia, tuberculosis, and rheu-
matism ; personal history —as Ui previous good health and vigor;
urethral history — as to previous attacks; preparation of the
patient : position of the patient at the beginning of examination ;
urethral discharge— the great inipirtance of the microscopic
findings; preparation of specimens for examination; the urine
— how obtained, the significance of " floaters," how comparisons
are made, and the proper examination of tiie urine ; exploration
of the urethra; position of the patient; preparation of the
urethra for examination; exploration of the urethra— not with
the sound but, in the anterior urethra, with the bougie-fiboule ;
urethroscopy— anterior and posterior ; and the examination of
the seminal vesicles, prostate, etc.
Physician Honored. — The State of Georgia has decided to
place a statue of Dr. Williamson Long, the discoverer of general
anesthesia, in the Hall of Fame in the Capitol at Washington,
D. C. This decision was reached some time since by the State,
but the necessary fund was not voted until proof was adduced
that he was the original discoverer. A fund of $7,000 has now been
voted for the purpose. The Medical fress and CTi-cit/ar is author-
ity for the following statement concerning those who assisted in
establishing the proof: Of those who took an active interest in
examining the evidence adduced in favor of the many candi-
dates for the honor were Dr. Luther B. Orandy, who died recently
in the Philippines while in charge of the United States Army
troops ; Dr. Landon B. P^clwards, who obtained from Georgia
evidence from authoritative legal documents of the Supreme
Court of the Commonwealtli, and from living, trustworthy wit-
nesses ; Dr. Marion Sims, whose paper appeared in the Virginia
Medical Monthly ; a.nA Dr. George Foy, who exhibited the
proof of Dr. Long's original paper to the Society of Anesthetists
in lj<mdon, by favor of Dr. Luther B. Grandy, of Atlanta, Ga.
Quarantine Kegulattons.-The Governor of Texas, in a
recent proclamation, raised the general quarantine which was
instituted April 12, 1902, against ports south of 25° north lati-
tude. However all vessels infected with contagious diseases,
snch as yellow fever, cholera, typhus fever, smallpox, or
bubonic plague, or having had either of said diseases on ship-
board within a period of 20 days prior to the arrival of such
vessel at a Texas port, and vessels from ports infected with
bubonic plague and cholera, are prohibited from landing per-
sons or things at any place along the Texas coast until permis-
sion to do so is obtained trom the proper authorities. (Juaran-
tine is declared against any person or persons infected or
liable to Vjo infected with smallpox, yellow fever, cholera,
typhus fever, or bubonic plague either within or without the
State, and health oHicers of counties and towns are directed
and authorized to establish local (luarantines and to maintain
the most rigid isolation of all such inlocted persons. The citi-
zens and all health authorities of the Slate are requested to
notify the State health officer of any outbreak of epidemic dis-
eases, and to give to said olllcer any information that will pro-
mote the public health.
ERGOT IN HEMORRHAGE OF OTHER THAN UTER-
INE ORIGIN.
BY
WM. B. PENN, M.D.
[The following was found among Dr. Feon's papers after bis death,
and embodies his conclusions drawn from a thorough study of his
own ca«e of general tuberculosis and many other similar ones. Only
such insignificant corrections have been made as were necessitjited by
the incompleteness of a manuscript that was never llnally prepared
for publication, owing to the hurried ending of his struggle against the
•' white plague."— U. N. \V.)
There are few drugs so universally used for any one indica-
tion as ergot in internal hemorrhage, and this to such an
extent that flowing blood and ergot are as nearly inseparaljle in
our minds as syphilis and mercury, and malaria and quinin.
In my student days I was taught to give ergot for any and
every form of bleeding, regardless of its cause or character,
when a direct application could not be made to the bleeding
point. At the present day, in general practice, ergot is still the
first resort, whether the bleeding be from a congested mucous
membrane, from eroded arterioles, or a ruptured aneurysmal
sac. It occurred to me one day when studying the physiologic
action of ergot that a paradox existed between the known action
of the drug and Its reputed eflftcacy in practice. I could not u nder-
stand how a drug which increased the pressure in the pulmo-
nary vessels could diminish the bleeding of a ruptured pul-
monary artery. I remember suggesting this query to a fel-
low student and being unceremoniously snubbed for criticising
the authority of our Instructors. I subsided, but the idea
remained dormant in my mind, and when I began to practise,
although using ergot, I watched carefully for its supposed
effects, and rather to my surprise in vain. I could see no effect
that could not be much more easily and plausibly ascribed to
time and nature than to the drug. Especially was my attention
drawn to its action in pulmonary hemorrhage. In some cases
it is true the bleeding ceased after using ergot, but in others it
did not; in others it ceased without any ergot. My thoughts
finally crystallized into two beliefs :
1. The absolute impossibility of determining the local effect
of any drug in pulmonary hemorrhage.
2. The uselessness and probable harmfulness of ergot in
such cases.
When I ventured to hint at these ideas to others I was again
scorned as a crank. In the last two years my interest in the
subject has been renewed by finding here and there a practi-
tioner who has agreed with me ; aud I finally decided to study
the medical and therapeutic authorities on the subject and
determine if possible whether I was right, or wrong. My
researches were at first decidedly discouraging to my theories.
Such authorities as Wood, Hare, Flint, and Bartholow, in this
country, Ringer, of England, Striimpell and Eichhorst, of
Germany, unite m recommending the use of ergot in pulmo-
nary hemorrhage in the highest terms.
Wood says: "In all forms of hemorrhage in which no
direct local application can be made ergot is today, probably,
the most generally used remedy; and even when local applica-
tions can be made ergot may often be exhibited as an adjuvant
to the local styptic. It Is thus employed in menorrhagia,
hemoptysis, epistaxia, etc. Ergot acts with especial rapidity
and efficiency in these cases if given hypodermically ; used in
this way the suddenness of the result In hemoptysis is some-
times surprising." Such language would seem final when used
by a man of great experience and sound judgment.
Hare says: " In hemorrhage from the luugit . . . ergot is
very useful. ..."
Shoemaker says: "In hemoptysis, epistaxls, hematuria,
melena, and in uterine hemorrhage, ergot in 5drani doses
every hour or two will generally promptly cause cessation of
1000 Ambkioah Medioikx)
CORRESPONDENCE
[DrCEMBEB 27, ia02
the lileeding." If this be true, all my patiente must have been
exceptions to the rule.
Bartholow says: " The most effective remedy is the hypo-
dermic injection of ergotin. Often the most severe bleeding
will be at once arrested when other means of treatment have
been employed in vain." Clearly it was time for me to back
oat.
Flint also comes to their support: "Ergot is a valuable
liemostatic. The autlior has seen recurring profuse hemoptysis
repeatedly arrested by this remedy." Waring, of London, says :
"Among constitutional hemostatics ergot ranks first."
Striinipoll and Eichhorst speak as positively. Surely the delib-
erate statements of such men must be well founded. But is
there no authority on the opposite side?
My first comfort came from an Englishman. Fagge says:
"Of styptics it is difficult to say which is best. Ergot, gallic
acid, lead acetate, opium, each has its advocates, and it some-
times seems necessary to try one after another." Evidently
ergot in his hands was not a sure ally.
In the " Traitt? de Medecine," edited by Charcot, Bouchard,
and Bressaud, published in Paris, 1893, we find still stronger
doubt expressed: "Nearly all physicians are accustomed in
the beginning of a serious hemoptysis to give a subcutaneous
injection of ergotin. The preparations of ergot do not seem to
us to have as energetic an action on the pulmonary vessels as on
those of the uterus; they have almost never given good
results."
Bristowe writes in 1890: "... for medicinal remedies, such
as quiet the circulation or contract the smaller arteries. Among
these lead, gallic acid, digitalis, ergot, and turpentine." Then
he adds significantly : " The treatment of internal hemorrhage
is eminently unsatisfactory."
Trousseau writes : " We have ourselves tried ergot to
arrest other hemorrhages than those of the womb; we have
sometimes failed and where we have succeeded have not been
able to ascribe the success to the remedy."
Headland does not mention ergot in his treatment of pul-
monary hemorrhage. Pareira, writing as early as 1854, says :
" Having found it (ergot) unsuccessful in my own practice, see-
ing that in the hands of others it has also failed, and knowing
how difficult it is to ascertain the Influence of remedies on
hemorrhage, I think further evidence is required to prove the
antihemorrhagic powers of ergot."
Stills, one of our acutest observers, says : " To a great extent
hemorrhage will cease under the combined effects of rest and
slight compression when the arterial trunks are wounded, so
that there is no longer any doubt that so far as hemorrhage of
this sort is concerned ergot is useless."
In the "American Textbook of Medicine," J. C. Wil-
son, of Philadelphia, writes : " During the first 24 or 48Jhours
of pulmonary hemorrhage astringents are probably^of no use,
while ergot is positively harmful from the fact that itjiucreases
the pulmonary blood pressure."
Turning then to Osier I find that he condemns ergot as use-
less and perhaps harmful.
Finally, Francis Delafield ;writes the following assuring
sentences, after giving the ordinary treatment by astringents
and ergot : " It is also customary to keep the patients very
quiet. I doubt if it be wise to be too anxious and energetic in
the treatment of bleeding from the mucous membrane of the
bronchi. The bleeding, as a rule, will stop, no matter what is
done. The frequent use of astringents disorders the stomach ;
the insistence of absolute quiet demoralizes the patients ; keep-
ing the patients on a low diet unnecessarily reduces their
strength."
What conclusions can we draw from such conflicting
authority? Because doctors of equal experience and acuteness
disagree, must we conclude that all are therapeutic humbugs or
the victims of a biased imagination? Not necessarily. The
discrepancy is no greater than has existed in regard to several
other drugs whose action is well known and is susceptible of
determination in the laboratory. When such differences of
opinion exist, several forces are, as a rule, to be found at work,
and among them the following:
1. The strength of preconceived expectations.
2. The varied degree of development of the critical and
judicial elements in different men.
3. The wellknown difficulty of determining the action of
any drug and of separating its effect from that of the vis medi-
eatrix nrUurce in certain internal difficulties.
4. The confusion of two or more conditions under the same
name.
5. The failure to study carefully the proved physiologic
action of the drug in question.
All of these elements are of more or less influence in deter-
mining the current valuation of ergot as a pulmonary styptic.
Again, because the drug has been found to be of undoubted
value in uterine hemorrhage, the idea has been formulated that
it must be equally valuable in other forms, without considering
the essential difference in conditions or its mode of action.
This idea once promulgated, it has naturally followed that a
certain class of practitioners in whom the critical faculty is
slightly developed has accepted the dictum "administer the
drug and consider the results consequential as a matter of
course." Examples of just such faulty clinical observation
and conclusion could be given by the hundred.
I know of no condition in which it is more difficult to dis-
tinguish the post hoc from the propter hoc than in the treatment
of internal hemorrhage. Some hemorrhages take the form of
an oozing, scarcely staining the sputum. They may continue a
day or a week ; they may stop at any time, regardless of the
potions poured into the long-suffering stomach. Others may
come in profuse outbursts of fresh blood, and these also may
continue or cease when nature wills. The last drug employed
usually gets the credit due to the processes of nature. More-
over, hemorrhage may be venous, capillary, or arterial, and it
may come from a simple congestion or from the rupture of a
large artery. Is it reasonable to expect the same drug to act In
the same way in all cases? Might not a remedy which would
check capillary oozing increase the jets from a ruptured artery ?
It is at least p )ssible. Yet Osier is the only one of the writers
quoted who emphasizes this distinction, and he does not apply
the point definitely in speaking of drug treatment.
The physiologic action of ergot is. In its essentials, agreed
upon by all modern writers. The two points which concern
us are that it stimulates the vasomotors and contracts involun-
tary muscle fibers everywhere in the body, as a result con-
tracting the capillaries and arterioles and raising the blood
pressure in both the general and pulmonary circulations. It
stops hemorrhage from the uterus by powerfully contracting
this great mass of involuntary muscle and closing, by pressure,
the blood outlets in spite of the increased pressure in the ves-
sels. Can we expect the same result elsewhere? Possibly, if
the bleeding is from veins or capillaries ; certainly not, if from
a broken artery. F. .1. Smith, of the London Hospital, in a
recent article, strikes at the root of the whole matter when he
comes to the conclusion that the ordinary indiscriminate use of
ergot is quite as capable of harm as of good. He considers
ergot of value in venous and capillary hemorrhage, and harm-
ful in arterial hemorrhage, on the theoretic grounds mentioned
above.
My conclusions are as follows :
1. In profuse hemorrhage from the lungs, appearing in
mouthfuls, the likelihood exists that an artery of considerable
size is ruptured or eroded, and our object should be to quiet
the circulation and lower the blood pressure. We should use
rest and such drugs as aconite. Under such circumstances
ergot should never be given.
2. In slow oozing the source of the bleeding is usually the
congested capillaries in the mucous membrane. Ergot may
stop the bleeding by constricting these capillaries ; but as such
hemorrhage is usually decidedly beneficial and stops when the
congestion is relieved, and as ergot is not well borne by the
stomach and is decidedly disagreeable to take, the use is also
here rather contraindicated than otherwise. Digitalis, which
also contracts the capillaries, would be quite as useful, and I
am told that Trudeau, at Saranac Lake, uses the drug for this
purpose.
3. Uterine hemorrhage seems to furnish the preeminent,
and perhaps the only, indication of ergot as an internal styptic.
Decembek 27, um]
DIAGNOSIS OF CANCEE OF THE STOMACH
; American Medici nb
1001
ORIGINAL ARTICLES
THE DIAGNOSIS OF CANCER OF THE STOMACH.'
BY
WILLIAM FITCH CHENEY, M.D.,
of San Francisco, Cal.
I'rofessor of Principles and Practice of Medicine, Cooper Medical Col-
lege ; Physician to Lane Hospital.
Cancer of the stomach i.s not an uncommon disea.se,
and most of the authorities agree that it is l)ecoming
more common in recent years. Furthermore, it is now
generally admitted that all medical treatment so far
suggested is absolutely hopeless for cure. Whatever aid
can be rendered must come from surgery ; and even
here the prospect for permanent relief is very slender
unless the condition is discovered early. Thus it comes
about that everything depends upon a prompt diagnosis,
and there are today no more urgent questions before us iri
practice than these : How are we to decide that a patient
has cancer of the stomat^h, and when are we justified in
advising its removal by the surgeon?
To discover the presence of this disease we follow
three paths of investigation : (1) The clinical history ;
(2) physical examination of the abdomen ; and (3) exam-
ination of stomach contents after a test-meal. The clin-
ical history includes, first, the family history. Heredity
has a slight but undeniable influence in this disease, and
cancer does undoubtedly sometimes " run in families; "
yet t^io much stre.ss must not be placed upon this point,
either for or against the diagnosis. In the personal his-
tory the most important matter is the age. Three-fourths
of all cases occur between 40 and 70 years, and of these
the largest number between 50 and 60 ; nevertheless the
number between 30 and 40 is considerable, and even
between 20 and 30 the disease is not rare. Sex is prac-
tically of no importance in determining the incidence of
the disease, and occupation likewise has little or no
influence. The past history of the patient is commonly
enough, one of good health and of good digestion ; chronic
indigestion is by no means an essential predisposing
factor.
When we come to (he history of the present illness,
we And it a characteristic one, so that the patient's story
often makes us rea.sonably certain of the diagnosis even
before any other investigation is undertaken. The
trouble usually begins with persistent tZ.//«ppp«w— pres-
sure and fulness in the stomach after food, loss of appe-
tite, eructations, nausea, water-brash— constantly remind-
ing the sufferer of his stomach and giving him no peace.
This dyspepsia may persist for weeks before the cardinal
and diagnostic symptoms of cancer appear. The first of
these in pain ; a dull, aching, dragging pain, burning or
gnawing, rarely lancinating and piercing as in ulcer ;
diffused and widespread over the epigastrium, not
localized to one spot ; not dependent on the taking of
food, though often aggravated by it; more or lass con-
tinuous, with exacerbations but never with the severe
gastralgic paroxysms of ulwr ; not relieved by vomiting
nor by the completion of digestion. The second diag-
nostic symptom is vomiting, but this may not appesir
until aft<-r the initial dyspepsia has persisted for
weeks. At first it is infrequent and produced only by
some special food, such iis meat; gradually it grows
more constant and may ultimately occur several times
daily. Its freciuency depends upon the site of the growth
—it may not (Kicur at all if the cancer is on the wall, but
is never absent if the cancer is at the pylorus. At first
the vomited material consists only of the food t*iken at
the previous meal ; later, as obstruction octrurs at the
pylorus, the vomitus contains food that has been retained
for hours or days, the ((uantity is often much larger than
what has been taken at nny one iiiciil, the odor is
' Ilead Iwfore the Hnnl« Clara County .Mcili<iil Soclely, at Han Jow,
(111., AUIfUHt'il', VMIl.
extremely offensive and the color dark brown or like
chocolate'. The third diagnostic symptom is hemateme-
sis. The blood vomited in cancer is rarely profuse ;
rather there is a slight oozing, not enough to lead to
immediate vomiting, and hence the material remains
until digested, and then at last comes away as the well-
known "coffee grounds." This is apt to be repeated
many times and is quite characteristic of cancer. The
fourth diagnostic symptom is tumor, the "lump in the
stomach " which only too often the patient has already
discovered before advice is sought. It occurs, sooner or
later, in about iwo-thirds of all the ca.ses ; but as in one-
third the growth is so situated as not to show through
the abdominal wall, as it commonly does not appear
until late in the clini(!al history, and as many patients
do not discover it for themselves even when it is present,
the absence of this point from the patient's story is of
little importance. The fifth item in the clinical history,
however, is vital to the diagnosis, namely, loss of weight
and strength. It commonly begins early and its progress
is markeil and rapid. Stomach trouble that has been of
long duration and yet has never led to emaciation and
asthenia is probably not cancer.
If all the .symptoms described were always present,
the diagnosis would be comparatively easy from the
history alone ; but we do not usually find it so, and from
the history as given we can only strongly suspect the
nature of the trouble, and must depend upon other
evidence for confirmation of our suspicion. Physicsd
examination of the abdomen is the second road to a
diagnosis. We look for two things here ; first for a tumor,
second for a dilated stomach. The tumor can often be
plainly seen on inspection, by a good light, in the epi-
gastrium or hypochondrium usually, though it may be
as low as the umbilicus, or anywhere in the abdomen ;
commonly it moves downward and upward with respi-
ration, especially noticeable when the patient takes a
deep breath. If no tumor is visible, yet it may be
plainly palpable. If not felt under ordinary conditions,
it may come within reach when the patient takes a deep
breath. Its size is very variable ; its contour is usually
either rounded or elongatetl like a sausage ; it may be
freely movable, or fixed by adhesions ; usually it is
tender to the touch ; finally, it may be discoverable at
one examination and missing at the next, because its
relations to surrounding parts have changed. The fail-
ure to discover a tumor is never to be taken as proof that
cancer of the stomach does not exist. In the first place,
certain parts of the stomach are never normally
capable of palpation— the cardia, the fundus, the les.ser
curvature, and a considerable part of the anterior wall
are covered over by liver and ribs, and only exception-
ally, when the stomach is distorted by inflation or by
disease, do these parts come within reach ; while the
posterior wall is so (le€!psi>ated that a tumor situated
there can Ije felt only with great uncertainty until it has
attained considerable size. Furthermore, in the early
history, when we are most anxious to establish the diag-
nosis, the tumor is still small, and the abdominal wall
has not yet emaciated so that palpation through it is
satisfactory. A vague sense of resistance and thicken-
ing is frequently that all we are able to deteit, even when
the symptoms are characteristic and definite.
The second thing for which we look is a dilated
stomach. On investigation the signs of this condition
are an abnormal bulging in the upix^r abdomen and the
presence of peristaltic waves in the hypertrophied
stomach wall, passing visibly across the abdomen from
left to right. Sometimes these waves, if not already
visible, can be brought out by slapping the alnlomen
with a wet towel. On (lalpation, the sign of a dilated
stfjmach is the succussion splash ; but to mean dilation,
this j)henomenon must be present several hours after
food has been taken, and must be persistently present at
examination on different days. The presence of a dilated
stoma«-h is not so imicli a proof of lln' i\i-ti'nce of
1002 AMKEicAN M«Dio.». DIAGNOSIS OF CANCEE OF THE STOMACH
(DECkMBER 27, mrz
(•aiK*r us of tho location of the growth ; for it occurs
iw a (;on.sc<iuence of obstruction at tlie pyloru.s. As the
great majority of ga.stric cancers are at the pyloric end,
and *K)ner or later do obstruct the orifice, the discovery
of dilation afford.s an important bit of evidence in the
cjuse ; but the absence of dilation in no way negatives
the diagnosis, for many times the growth occurs in a
situation that does not lead to pyloric obstruction, while,
on the other hand, the presence of dilation does not
always mean cancer, because the pyloric obstruction may
be due to other causes.
Inflation of the j-tomach is an importantaid to exami-
nation in a case of suspectetl cancer. The plan usually
employed is the development of carbon dioxid by the
administration of one dram each of sodium bicarbonate
and tartaric acid in separate solutions. By such infla-
tion we may, by pushing the stomach downward, bring
out below the costal margin a tumor that was not pre-
viously palpable, if the tumor wa.s already discovered,
inflation defines its relation to the stomach. It also
shows the contour of the stomach if the abdominal wall
is thin, brings out waves of peristalsis not previously
visible, and permits auscultatory percussion to be made so
that the line of the greater curvature can be accurately
defined. The prcK'cdure is contraindicated only by pre-
vious profuse hemorrhage or by extensive growth. I
have never seen bad effects from it, though I have
employed it many times.
The third method of investigation as to the presence
of eancer is the examination of the stomach contents.
The test-meal usually employed is Ewald's — toast and
water — withdrawn after one hour. The general appear-
ance of the contents obtained affords much information ;
the amount, if dilation exists, is often much larger than
the test-meal given, and the material contains food par-
ticles eaten many hours or even days before — the most
positive proof of all that dilation and stagnation exist.
The contents withdrawn may be so foul and decomposed
as to offer no true evidence of the stomach's secretory
power ; and in such case it is better to wash out the
organ thoroughly the night before and then give the
test-meal in the empty stomach the next morning.
The test-meal once obtained there are three diagnos-
tic signs characteristic of the filtrate. The flrist is the
absence or great reduction of free hydrochloric acid.
This is due to the direct invasion of the secreting glands
by the newgrowth, and to the accompanying chronic
gastritis that occurs as a complication. As to the diag-
nostic value of this sign, hydrochloric acid is absent in
the large majority of cases of cancer of the stomach, and
persistently absent ; but it may also be entirely absent
in chronic gastritis without cancer. On the other hand,
hydrochloric acid may still be present in cancer of the
stomach if the growth is localized to a portion where no
hydrochloric acid is normally secreted, or if the accom-
panying giustritis is limited, or if the cancer ha.s arisen
from an old ulcer where hyperchlorhydria was a previous
characteristic. The S(cond sign furnished by stomach
analysis is the absence of the ferments, pepsin and ren-
nin, showing extensive destruction of the glands. The
f/drd is the presence of lactic acid. Lactic acid is formed
in thestomachby the fermentation of carbohydrates, and
its presence indicates fermentation due to stagnation. As
Hemmeter explains it, three conditions of the stomach
are essential to lactic acid formation : (1) Impaired
motility ; (2) absence or great decrease in the HCl ; and
(3) great decrease in the ferments— that is, impaired
albumin digestion. In the progress of cancer the secre-
tion of HCl suffers fjrst, from the destruction of acid-
secreting cells ; then the formation of the ferments is
impaired and the digestion of albumin is defective ; and
then as a third step lactic acid fermentation occurs,
provided there is stagnation of contents. The presence
of lactic acid in the filtrate Is not pathognomonic of
cancer, for it may occur when pyloric stenosis from some
other cause has led to dilation and stagnation. On the
other hand, it is rarely absent in ga.stric cancer, but may
be lat^king when motility is unimpaired by the growth,
and stagnation does not occur.
By microscopic examination of the stomach-contents,
another link has lately been added to the chain of evi-
dence. This is the presence of the socalled Oppler-Boas
bacillus. This can be seen either in the unstained sedi-
ment or after staining with methylenc-blue. It is an
unusually long, nonmotile organism, resembling a base-
ball bat. It is present in nearly all cases of ga.stric
cancer in enormous numbers, and so far has never been
found present in any other disease. Its discovery in the
stomach-contents has thus come to be considered very
important to the diagnosis, if not absolutely pathogno-
monic.
Such are the facts we seek to elicit by our routine
methods of investigation. But still something more is
needed in order to make a diagnosis — namely, reasoning
power to interpret the meaning of the evidence and to
weigh the relative importance of the facts as discovered ;
for several other diseases resemble cancer of the stomach,
or are rasembled by it, and they must be taken into con-
sideration before a conclusion is reached. This process
of differential diagnosis, as we call it, is best approached
in the case of cancer of the stomach by considering the
possibilities (a) when tumor is found, and (f)) when no
tumor is found. When a tumor has been discovered we
have always two questions to answer : First, is it in the
stomach ; and second, if in the stomach, is it a malignant
growth? For an answer to the first question we rely
upon the symptoms as obtained in the clinical history,
upon the discovery of dilation of the stomach, upon
analysis of the test-meal, upon the presence of the
Oppler-Boas bacillus and upon the relation of the tumo)-
to the stomach as shown by inflation. But we must also
look to the other organs that might be the site of the
tumor for the evidence they would present. These
other adjacent organs that must be borne in mind are the
liver, the colon, the pancreas and the kidney. A tumor
of the liver is usually manifestly a part of the liver and
can not be separated from it; the remaining surface of
the liver is often nodular and its size increased ; the
patient presents more or less jaundice; and the stomach
analysis is negative, unless a primary growth is present
there, to which the liver tumor is secondary. A tumoi-
of the co/on usually sinks lower in the abdomen than a
tumor of the stomach, unless it is bound by adhesions ;
inflation of the stomach shows that the tumor is not
within its outline, while inflation of the colon through
the rectum shows that the tumor does belong to the
bowel ; the symptoms are those of obstruction of the
bowel, and waves of peristalsis, if they are found, run
from right to left, opposite to those in the stoniach :
finally, stomach analysis is negative unless that organ is
simultaneously involved. A tumor of the pancreas it-
immovable with respiration and deep-seated, while
involvement of this organ produces three diagnostic
signs — glycosuria, fatty feces and icterus, none of which
is present with uncomplicated cancer of the stomach.
A turner of the kidney, finally, gives rise to alteration in
the urine and produces no symptoms or signs of disturli-
ance of the stomach.
Having concluded then that the tumor is situated in
the stomach, we have next to ask ourselves. Is ita malig-
nant growth ? Unfortunately this is always by far the
most likely explanation. It is possible that the tumor
detected may be due to an ulcer that has thickened and
cicatrized the tissues in healing; or to a hypertrophic
stenosis of the pylorus from chronic gastritis ; or to some
foreign body swallowed, such as a mass of hair. But
such possibilities are always remote ; and the constitu-
tional manifestations of malignancy— emaciation, asthe-
nia, cachexia — with the characteristic analysis of stomach-
contents, usually make it easy to decide as to the nature
of the growth.
When no tumor is found the case [iresent.^ even grcati r
Decehbbb 27, ]U02|
LUMBAR PUNCTURE
lAMERiCAN Medicine 1003
diftii'ulties in diagnosis. In this state of affairs the
symptoms may be mainly constitutional or mainly gas-
tric. If they are mainly constitutional— emaciation, loss
of strength, cachexia — the first question that always pre-
sents itself is whether pernicious anemia may not be the
cause. This question must be answered by blood exam-
ination. In cancer the blood shows the characteristics of
a secondary anemia ; the red corpuscles are reduced in
number, their color is pale, their shape is distorted, they
stain irregularly and the hemoglobin is usually reduced
below 60%. But in pernicious anemia the red cor-
puscles are still further reduced so that they are seldom
over 1,000,000 in number, and nucleated corpuscles of
different sizes are found. The test-meal shows the char-
acteristic analysis in cancer, but not in pernicious
anemia. Finally, although asthenia and cachexia may
be marked in pernicious anemia, and the patient may be
bedridden from weakness, usually the loss of flesh is
slight even though the symptoms have been of long dura-
tion— a point that is always against cancer of the
stomach. Besides pernicious anemia, the only other
condition that has to be eliminated as a possible cause of
the constitutional symptoms is Bright's disease, which
sometimes produces a similar state of marasmus.
Analysis of the urine and the discovery of albumin and
casts settles this question ; for in cancer of the stomach,
while the urine is often high in color and in specific
gravity, and contains a heavy sediment of urates, it does
not contain albumin or casts unless the case is compli-
cated by a nephritis.
When the symptoms are mainly gastric and no tumor
is found, we come at last to the problem that presents
itself most commonly of all. Is the case one of the
organic diseases of the stomach that do not give rise to
tumor — e. g., ulcer or chronic gastritis? Or is it one of
the purely functional neuroses ? Or is it cancer in an
early stage? The points upon which we must depend
for a decision are, a careful clinical history, repeated
analysis of the test-meal, and search for the Oppler-Boas
bacillus ; taken in connection with the age of the patient,
the family history and the effects of rational treatment.
The character of the pain, of the vomiting and of the
hemorrhage in cancer, as already described, are dift'erent
from those in other diseases of the stomach ; emaciation
is sooner or later almost inevitable ; the gastric analysis
is diagnostic when the characteristic conditions are per-
sistently found ; and the Oppler-Boas bacillus is coming
to be considered of great value in the evidence. In cer-
tain cases, however, when no tumor is found, and we
can not l)e positive in spite of all probabilities, the ques-
tion arises as to the employment of one other method of
diagnosis not yet mentioned — namely, the exploratory
incision. The early stage of cancer of the stomach is the
one for successful removal of the growth, and early diag-
nosis alone affords any hope for cure. With this in
mind it is our duty, in suspicious cases, to advise the
exploratory incision without waiting too long for the
development of positive proof. As Hemmeter puts it :
" Witli symptoms of chronic gastritis and absence of
riCl, rapidly developing emaciation and cachexia, do
not delay over one month with treatment, but urge
exploratory operation."
This brings us to the final question— a question that
must follow immetliately upon the diagnosis and that
haunts us even during the making of a diagnosis, When
shall we advise operation for cancer of the stomach ?
•I^et us lfK)k separately at the different possibilities of the
case ami ask ourselves what justification we have for
urging the patient to submit to surgery. ]. When a
large tumor is found, operation is practiciilly useless and
should not be recommended. In such a case total gas-
trectomy is required, and the successes following this are
as yet too few to warrant us in advising it. Most of the
subjfH'ts die on the tal)le or within a few days following
the operation. fHi.stro<>nterostomy may be advised in
^iich cases when (he |iiiti('iit i- dyin^ friiiii -(ar\ ation on
account of pyloric obstruction, but radical removal is
very rarely justifiable, and no conscientious physician
will urge it. 2. When a small pyloric tumor is found,
it is right to advise pylorectomy. But even here one
must remember what the statistics show — that about 50 ^
die from the operation, and of those that recover, the
great majority die from recurrence within two years. 3.
When no tumor is found, the case is most favorable for
surgery, and cure is still possible. On this point Hem-
meter, in his work on " Diseases of the Stomach,"
speaks as follows : " It will be possible in many cases
to fix the diagnosis with a great degree of probability,
even before a tumor is palpable, when elderly persons
previously sound grow rapidly worse in spite of suitable
treatment, and when cachectic .symptoms appear quickly,
when the absence of free HCl continues, or when there
is vomiting of coffee-ground material. Since ordinarily
the tumor can be felt only when the cancer has reached
a certain size and lies in an especially favorable position,
the diagnosis by recognition of a tumor is generally no
longer an early diagnosis." Speaking of the indications
for early operation in cancer of the stomach, Keen
enumerates the following combination as sufficient : (1)
Dilation as shown by the presence of food in the stomach
in the early morning before breakfast ; (2) cachexia ; (3)
persistent absence of HCl ; (4) excess of lactic acid ; (5)
the Oppler-Boas bacillus present; (6) the patient past
40 ; (7) hematemesis. Fenwick, of the London Hospital,
puts the matter in this way: "The occurrence of
chronic gastritis without definite cause in a person over
40 should always be regarded with suspicion ; if at the
end of a month the complaint has not yielded to careful
treatment, or if the patient has continued to lose flesh
and suffer from pain or vomiting after the use of milk,
while the stomach contains food in the early morning,
without free HCl, the presence of malignant disease may
be regarded as a certainty, even in the absence of
tumor."
It thus becomes evident what a heavy task the physi-
cian has laid upon him ; for to him is left the decision
as to the presence or absence of cancer of the stomach,
and as to when operation shall be undertaken. We can
not be too familiar, therefore, with the signs that the dis-
ease gives of its existence, or too alert in the recognition
of what these signs mean. The family physician in
general pnictice is the one to whom the patient first
comes, and on whom early diagnosis depends. I^et us
all, as such, be alive to our responsibilities in this matter
and awake to the importance of the part we are given to
play.
LUMBAR PUNCTURE AS A CURATIVE AGENT IN
MENINGITIS, WITH REPORT OF A CASE.'
BY
S. ORMOND <}OM)AN\ M.I).,
of New Yorii Cily.
Fellow New York Academy of Medicine ; Mimij. i American Mpillcal
AsHoclaUOD.eti-.
Whether a given case of meningitis is tuberculous or
not cannot be definitely determined from clinical symp-
toms. While lumbar puncture is the best and simplest
means at our dispo.sal for cstjiblishing tuberculous origin
in a given case, frequently no such evidences are mani-
fested after most careful investigation ; still, some of
these cases may for all that be tuberculous — that is, a
diagnosis cannot always be made even by this means ;
while from a progno.stic, as well as scientific standpoint,
an exact diagnosis is desirable, still our treatment is not
influenced at least in the acute stage of the disea.se, and
it may be said most patients rarely live beyond the
acute stage.
My reasons (or luinging to your notice the cii>c hiic
reported is t<} show a specific means of cure at least in
1 Read before the Pediatric Section of the New York Academy of
.Vlcdlclni', November i:t, 1<X«.
1004 AUBKICAK MEDICINK.
AUTOPSY FOUR HOUfiS POSTPARTUM
IDkcehbek Ti, 1902
some cases and to describe a phenomenon which may be
found valuable as a means of diagnosis, at least in the
exudative form of tlie disease.
I wish it to be fully understood that the puncture
made in this case was not done primarily for the means
of (establishing the tuberculous origin — though this was
investigated — but as a means of cure. My reasons for so
doing 1 will mention further on in the history of the case.
H. L., aged 11 months, was a healtliy child from birth.
There is no liistory of tuberculosis or trauma ; both parents and
the other two children are healthy. I was called to see the
child on account of persistent vomiting which had continued
about a day, and was followed by a convulsion. Nothing could
be elicited except that the child, who was considered unusu-
ally bright, had been in an apathetic condition the day before
the voinitiug commenced, apparently not taking notice of
anytlilng. In addition to a warm bath and enema, an appro-
priate purgative was prescribed without any appreciable bene-
ficial effect. Temperature was 102°, pulse 120 and rather full.
The following day when vomiting was less frequent con-
vulsions occurred frequently. Later the convulsions were
followed by complete paralysis of ihe right side of the body,
with left ptosis. There was rigidity of the muscles of the neck
and with clonic spasms of the left forearm. The left pupil was
markedly dilated and uninfluenced by light. With the excep-
tion of an occasional moan the child was practically comatose.
The temperature rose steadily after the second
day registering as high as 105°.
Regular symptomatic treatment was em-
ployed with fluid diet in sujall quantities fre-
quency repeated ; this was at first vomited, then
retained— later to be rejected owing to an ina-
bility to swallow. Nourishment per rectum w as
then substituted. The third and lourth day con-
vulsions were less frequent in number, which
I attributed to the rather large doses of sodium
bromid employed. The fifth day the child had
a particularly severe convulsion, after which
they ceased, but there was an occasional mus-
cular spasm. The temperature continued high
and each day seemed to find the child losing
ground.
The particular feature of interest in the case,
was the swelling which appeared at the fontan-
elle on the second day increased considerably up
to the filth day and then remained about the
same up to the time of the spinal puncture on
the eighth day.
The lumbar puncture was made in the usual
site, that is between the fourth and fifth lumbar
vertebrae and 14 cc. of fluid was removed. After
six hours there was a gradual but constant im-
provement in the child's condition with apparently com-
plete recovery after two weeks. Examination of the cere-
brospinal fluid showed no of tubercle bacilli.
Whether the increased quantity of fluid in many
cases of meningitis is due to an increased secretion
or diminished absorption, probably the latter, it is
difficult to say ; the explanation of the beneficial
eflfect resulting from the puncture is probably due
to a reduction of the fluid tension by means of
which absorption again talses place and equilibrium
is established analogous to what occurs in many
instances in pleurisy and a.scites.
What the cause is primarily of the abnormal
collection of fluid is also obscure. Probably trauma
is a frequent etiologic factor. That meningitis is
far more frequent in children can be explained,
partly, at least, in the nontuberculous cases, as
being due to the unstable condition of the nervous
system and the patent fontanelles by which even
slight injuries often unnoticed may be the prime
cause, whereas in the adult the brain being enclosed
m a bony, unyielding case, even considerable vio-
lence often produces no deleterious effect.
In my opinion lumbar puncture performed
with aseptic precaution is devoid of any risk, is
simple and of much value in establishing a correct
diagnosis, and may be, and undoubtedly is, cura-
tive in some cases, even when the quantity of fluid
abstracted is apparently small.
While I have performed lumbar puncture in 40
cases (the one reported being the first in menin
AN AUTOPSY FOUR HOURS POSTPARTUM ON A SUB-
JECT ON WHOM VENTRAL HYSTEROPEXY HAD
BEEN DONE FOUR YEARS PREVIOUSLY.
BY
BYRON ROBINSON, B.S., M.D.,
of Chicago, III.
In June, 1902, I was called with Drs. Wm. E. Holland
and Orville W. MacKellar to do an autopsy on a woman
who had died four hours after labor. Four years previously a
ventral hysteropexy had been done. The child was alive and
well. Arriving shortly after death, I made a bimanual vaginal
examination. A large, soft mass was palpable per vagi nam,
but the parts were so soft that nothing could lie determined
definitely. The abdomen was opened in the median line from
xiphoid appendix to symphysis pubis, and dense omental
adhesions were encountered. Inspection revealed a completely
invaginated, inverted uterus. A peritoneal baud about the
width of two fingers and about six inches in length, mainly
composed of omentum, passed distally penetrating the lumen
of the inverted uterus. The invagination was so complete that
the ovaries rested on the proximal rim of the uterus. The ovi-
ducal pavilion also projected proximal to the lumen of the
invagination. The index finger alone could penetrate the neck
of the invaginated uterus. The organ was easily dislnvagi-
nated by drawing on the omental band, which was fixed to the
fig. 1.— An illustration to demonstrate the method of progressive invagination of the
uterus: 1, original line of fundus; 2, the fundus progressively moving distally ; 3,
vagina.
gltis), in no ilistance was any difiiculty experienced Fig- 2.-An illustration of the invaginated uterus found at tl
in securing the cerebrospinal fluid ^I oviduct; », Ugamentum rotundum; 4, fundus of u
the vagina with diamond-shaped section removed ; 5. v
the autopsy : 1, ovary ;
terus iDvafinated In
igina, explains Itself.
Uecembee 27, 1902]
HYDROPS TAB^ PROFLUENS
Ahbrican Medicinw 1005
proximal fundus with one hand while the other hand in the
vagina forced the uterine fundus in a proximal direction.
Examination of the disinvagi nation showed that a fundal space
about three inches square had become extremely atrophied
from the dragging of the omental band which was fixed to the
fundus.
The uterine wall adjacent to the atrophic fundus was six to
eight times as thick. In fact, the fundal wall was so atrophic
and thin that the finger could press it distally and proxiinally
nervous shock was reorganized and carried directly to
the heart over the three cervical cardiac nerves. The
force passed also over the second, third and fourth sacral
nerves by way of the spinal cord to the brain, where
it was recognized and emitted directly to the heart
over the pneumogastric.
4. This patient experienced suffering during gestation
from dragging of the peritoneal
band flxed to the uterine fundus.
I have known of a number of
Crtses of severe pain during ges-
tation which had followed a ven-
tral hysteropexy. Reports are
constantly increasing in which
cesarean or other section is re-
quired at parturition subsequent
to the performance of ventral
hysteropexy.
5. It is rational to conclude,
therefore, that ventral hystero-
pexy should not be performed on
a reproductive person.
6. The large majority of
women with retrodeviations are
not suffering from the uterine
displacement, but from the ac-
companying myometritis, which
is the chief pathologic factor, and
which is not cured by produc-
ing another fixation— and dislo-
cation of the uterus.
KIg. 3.-Arterlal cireiilallon of llu' uiicipej-al uterus, four hours postpartum. Illustrating the utero-ovar-
ian vascular circle (the circle of Byron Robinson): 1, 2, S, 4. !>, 6, 7, a, 6, 8, i>, 10, II, 12, 13, 14. l.j shows
the spiral segment (utero-ovarian arlery); Ifi, straight segment abdominal aorta; 17. common lilac;
18, internal Iliac. Divisions of the spiral segment: (1) I'elvic floor segment, 1, 2, :i, 4 ; {2i uterine
segment, 4, 5, (i; (8) oviducal segment. 6, 7, !), ti, 8, «; (4) ovarian segment, 9, 10, 11, 12: (5) round liga-
ment segment, 13. 14, 15; ureter, 20, 19 : vaginal arteries, 26. Important locations In tbe spiral seg-
ment; Arterio-ureleralloop. 2; cervical loop. 2, 3, 4 ; distal arterlo-ureteral crossing, 2; rami cer-
vlcls, 22; rami corporis, 21; rami fundi. 21 ; rami ovlductus. 31, 32, ;«. Exsanguinated uterine
zones: {a) Central longlludlnal a.tls; (fc) lateral cervical border; (c) fundus; (d) cervlcocorporeal ;
{r. and p) is the atrophic bUmdless fundus. At the postmortem tbe uterus was Injected in •Uii : also
the ureters with red lead and starch. The specimen was x-rayed In Dr. Harry Pratt's X-rny and
Klectrotherapeutic Laboratory, doubly magnified by Dr. Wm. K. Holland, and followed as a model
by Mr. Zan D Klopper, the artist. Byron Robinson, Chicago, 1902.
like a movable diaphragm. The remaining pelvic organs
appeared normal. A drawing was made of the conditions
found and the uterus injected )'h .«<ie with red lead and starch.
The specimen was x-rayed, then prepared, and followed accu-
iHtely as a drawing model. Both cuts accompany this article.
I'he injected uterus is one-half life size.
CONflA'SIO.NS.
1. Death was caused by invagination of the post-
partum uterus, due to a ventral hy.steropexy performed
four years i)reviously.
2. The direct cause of the invagination was the
atrophy of the fundus, (hie to the dragging of the perito-
neal band or the fundus.
;i. The direct cau.se of death was heart shock. The
trauma was carried to the heart over tlie hypogastric
and ovarian plexu.ses by way of the abdominal, brain
and sphinchincs tf) the cervical ganglia. Here the
HYDROPS TUB^ PROFLUENS,
WITH REPORT OF CASES.
BY
F. HURST MAIER, M.D.,
of Philadelphia.
Assistant Gynecologist to St, Joseph's
Hospital ; Instructor of Gynecology
at Jefferson Medical College.
From the time that Froriep '
recognized the open and closed
varieties of hydro.salpinx until
the present day the possibility
of a tubal collection emptying
it.self through the uterus has, to
some, remained a mooted ques-
tion.
Rol>erts '' states : "At present
there is no trustworthy proof that
the fluid necessarily comes from
the tube." Granted it is not a
common occurrence, still a suffl-
cient number of cases have been
reported by careful observers to
contradict this statement. The
study of the two cases, in which
I was afforded opportunities to make repeated examina-
tions, satisfied me thoroughly as to the changes of the
conditions present.
Case I.— Mrs. M., aged ,30; was never pregnant. Her menses
were regular, lasting seven da.vs and were painful. She was
treated for the past ten years for a mucopurulent dischargo.
During this time she suffered with pain in the back and both
sides of the pelvis, aggravated during menstruation. For the
past five years she has been much annoyed by the periodic fiow
of a large"quautity of tea-colored fluid from the vagina, coining
witli a profuse gush two weeks after the beginning of menstrua-
tion, and continuing as a constant dribbh^ for several more days.
Kxamination in tlie interval between ^nenstniati.'u and the dis-
charge of the fluid referred to, disclosed a tense, elastic cyst, the
size of a large adult fist, and situated to the left and posterior to
the uterus. 'I'he mass was not flxed. l)Ut had a limited range of
mobility. To th« right of the uterus there was another enlarge-
ment, elastic, soinewliat irregular in shape, and tlio size of a
goose egg. It was always noticed iliat subsequent to the profuse
IntermenstruKl diseliHrge the mass on the leftside diminished to
1003 AlCaBICAK MBDtCINBJ
CORROSIVE SUBLIMATE POISONING
[Uecembbb Z!, 1902
the size of a small egg, while the tumor on the right side
remained apparoiilly uiichaiiKed. Considering the symptoms
and the physical signs, the existence of a produent hydrosalpinx
was a logical conclusion. Operation demonstrated the presence
of clmra(5teristic retort-sliapod hydrosalpinges on iiotii sides.
Tlie ieU one was consideraliiy larger than the riglit. IJoth
ovaries were cystic and enlarge<) to the size of walnuts and
adherent to the under surface of the wall.
Case II.— Mrs. S., aged 27, was married four years and was
never pregnant; she menstruated regularly every 28 days, the
flow continuing three days. With the exception of .slight ten-
derness on the right side on bimanual palpation, the patient
suffers very little from pain. For the past ten years she has
been annoyed at irregular intervals by a profuse watery dis-
cliarge from tlie vagina. Slie was under my personal observa-
tion for about six months, and during that time I repeatedly
had the opportunity of outlining an elastic tumor the size of a
tangerine orange in the right lialf of the pelvis, and of noticing
its disappearance subsequent to the evacuation of the fluid,
which no doubt represented its contents.
In connection with my own cases, it may prove of
value to mention briefly a few cases reported by other
authors.
Schramm ' cites the case of a woman with a previous
history of gonorrheal perimetritis, who developed a pear-
■ shaped tuboovarian cyst that disappeared after a profuse
vaginal discharge of serosanguinolent fluid during men-
struation. He also observed the alternate appearance
and disappearance of the tumor for several years, and
finally verified his diagnosis of hydrops tubse et ovarii
by an operation.
Heitzman * in treating a woman for uterine catarrh
ob.served that the left tube which for .some days previous
to menstruation was slightly enlarged, rapidly grew to
a tense elastic cyst the size of a child's head. For some
days following menstruation there was a constant dis-
charge of a serosanguinolent fluid, with a corresponding
disappearance of the tumor.
Thorn ^ reports a similar case of a medium sized
right-sided hydro.salpinx that increased in size during
menstruation, with a subsequent decrease following a
discharge of the tea-colored fluid. He states that by mas-
saging the tubal wall he could bring about an evacuation
of the fluid at will.
Mitchell* likewise reports a case in which symptoms
were relieved by the passage of a large quantity of fluid
per vaginam.
Terillon ' describes a profluent tuboovarian cyst in a
woman who had already passed the menopause.
Schramm, Heitzman, and Thorn, like myself, based
their diagnoses upon the result of repeated examinations,
at intervals sufticient to leave no room for doubt as to
the condition present. In Thorn's case he was even
able to make the diagnostic test of Frankenhauser and
Hausaman by emptying the tube by massage.
Intermittent serous discharges from the uterus, as a
result of a diseased endometrium, may at times cause
confusion in diagnosis, as illustrated by a case of Skene
Keith's described in Bland Sutton's work. This patient
suffered for years with intermittent discharges of such a
profuse type that her bed had to be made as for a con-
finement. Operation showed nothing to account for the
condition, either in the ovaries or tubes.
The pathology of this condition is nearly the same as
that of the ordinary hydrosalpinx, the difference lying
mainly in the form of occlusion that exists. In the'one,
inflammatory changes have destroyed the patency of the
canal, while in the other the obstruction is only tem-
porary, the procedure being entirely mechanical! This
may occur in a number of ways. In some cases the
resistance of the musculature, with a slight swelling of the
mucous membrane of the isthmus is sufticient to prevent
the escape of the contents. In other ca-ses there may be
a kinking of the tube, analogous to that of the ureter in
hydronephrosis, the outcome of flexion and torsion. The
cysts grow rapidly during menstruation, although refill-
ing begins immediately after evacuation, the result
of the congestion incident to the relaxation of the
walls. With the increase of its contents, pressure is
directed against the uterine ends ; there is a subsidence
of the mucosa tumidity; a change in the position is
effectetl with obliteration of the kinks, and the fluid is
free once more to flow into the uterus.
The influence of intraabdominal pressure in empty-
ing the cyst was first mentioned by Winckel. Watkins '
reports a case of pyosalpinx that discharged into the
uterus from the force of the manipulations u.sed in its
removal. Fritsche's theory of tubal contraction must be
rejected, as the muscle and elastic elements in the walls
of the hydrosalpinx are so separated and atrophied as to
preclude any contractile power.
Doran' describes a case of papilloma of the tube,
which gave rise to a hydrops tubaj profluens.
In conclusion, it may not be amiss to say a few words
concerning the bacterial origin of this disease. From
their investigation Menge and Doderlein have reached
the conclusion that the infection is usually of a mild
streptococcic character, and of puerperal origin. Klein-
hans, in a series of 15 cases, found tliis mild streptococcic
infection responsible in 11 instances. That gonor-
rhea cannot be altogether eliminated is suggested by
the cases of Heitzman and Schramm, both of whose
patients suffered from a gonorrheal perimetritis. As the
gonococcus almost invariably produces a purulent sal-
pingitis, the development must be an indirect one. The
inflammation runs its course, leaves the tube with one
or both ends sealed, and the subsequent congestive influ-
ences bring about a secretion.
That hydrosalpinx may be the result of an old pyo.sal-
pinx, as claimed by Bland Sutton and Landau, has been
vigorously denied by Clark, Menge, and others.
BIBLIOGRAPHY.
" Froriep; Berliner med. Zeitschrlft, Vol xxxlx, li>34, S. 617.
' Roberts : Gynecological Pathology.
sSchramm : Archives fiir Gyniikologie, Vol. xxxix, S. 17.
< Heitzman: AUgemelne Wiener med. Zeitung, 1S8.5
6 Thorn : Centralblatt fiir Gyniikologie, 1896, No. 43, S. 10O3.
•* Mitchell : American Journal of Obstetrics, Vol. xxix., p. 519.
' Terillon : Progrs. M6di04il6, 1888, No. 49.
* Winckel- Watkins: Correspondence to the American Journal of
Obstetrics, Vol. v, p. 28.
9 Doiun : Quoted from Albutt and Playfalr's System of Medicine.
A CASE OF CORROSIVE SUBLIMATE POISONING
FROM A VAGINAL DOUCHE.'
BY
HORATIO C. WOOD, Jk., M.D.,
of Philadelphia.
Demonstrator of Pharmacodynamics, University of Pennsylvania;
Instructor in Medicine, Philadelphia College for Postgraduates.
The earliest record of harmful effects following a
douche of the bichlorid of mercury, and curiously almost
the only one to be classed with the case I desire to
report, is that of Butcher which was reported in 1856.
The introduction of the antiseptic method in obstetrics
leading to the use of postpartum vaginal douches of cor-
rosive sublimate gave rise to a large number of poison-
ings, and we find the gynecologic magazines of the later
eighties teeming with reports of cases and discussions as
to the advisability of these injections. In 1891 Sebillotte
collected records of 148 such poisonings. The symptoms
varied from a mild stomatitis, such as is frequently pro-
duced in a mercurial course, to the most violent type of
corrosive sublimate intoxication with bloody vomit,
purging, hemorrhagic nephritis and collapse. That the
danger in these cases was not imaginary is shown bv the
fact that of Sebillotte's collection 30 cases (20 /c) ended
fatally.
His study of these cases led Sebillotte to the belief
that the poison was not absorbed through the mucous
membrane but was taken up by the raw surfaces conse-
quent on the lacerations associated with every case of
labor ; ill other words, that the absorption was a direct
one by the bloodvessels. He attempted to prove that
• Read befoi-e the Northern Mcrticai Asso<'iation, September Iti, 1902.
Hecember 27, 1902J
HERPES ZOSTER OPHTHALMICUS
I AMERICAN MEDICINI 1007
the vaginal mucous membrane was incapable of absorb-
ing drugs by injecting potassium iodic! into the vagina
of a nonparturient woman. Failing to iind any iodin in
the urine after such injection he concludetl that the
unbroken mucous lining of the vagina offered a sufficient
barrier to tiie entrance of poisons in the circulation. To
show that the bichlorid was not sufficiently corrosive to
destroy the mucous membrane and thus to make its own
raw surface for absorption, he made a douche of a 1 to
1,000 solution into a healthy vagina, with no symp-
toms of mfTcurialism.
This latter experiment, which was limited to two
trials, is, of course, absolutely worthless as scientific evi-
dence. No one has ever claimed that corrosive subli-
mate douches poison every woman to whom they are
given ; if they did, the list would reach into — no one can
say how many — thousands, instead of a couple of hun-
dred. Such a method of experimentation would have to
be repeated at least several hundred times to be of any
evidential value, negatively.
The experiments with potassium iodid with which he
endeavored to discover if the vaginal mucous membrane
could absorb, are conceived in much more scientific
spirit and deserve consideration. But even these, seem-
ingly applied in only two or three instances, should
have been repeated in a much greater series before the
results could be accepted as proof of his conclusions.
Moreover, these results of Sebillotte are directly contra-
dicted by the experiments of Hamburger. This investi-
gator placed tampons of cotton saturated with solutions
of various drugs in vaginas with intact mucous mem-
branes, allowing them to remain for 24 hours, examining
the urine, drawn by catheter, from time to time. He
found that potassium iodid appeared in the urine within
two hours after the injection ; potassium ferrocyanid in
three hours ; salicylic acid in three hours. I may also
quote as showing the absorbent power of the vaginal
mucous membrane a case of Dewar's, in which a vaginal
suppository containing two grains of belladonna extract
caused marked symptoms of belladonna poisoning.
Despite the fact, however, that it must be granted as
proved that the vagina is capable of taking up intro-
duced drugs, it is probable that there is a modicum of
truth in Sebillotte's contention that obstetric bichlorid
poisoning is in large part dependent on the lacera-
tions. In recent years, fortunately for parturient
women, the routine use of bichlorid douches has largely
gone out of vogue, and there has been a consequent
reduction in the number of cases of corrosive sublimate
poisoning. Indeed, I have been able to' find but two
recorded cases of intoxication by this poison from
vaginal injections not used for obstetric purp()s<^s.
Tlu!se cases reported by Butc'her and by (jore are
very similar in all their important details. They do not
throw muc'li light on the question of absor|)tions, how-
ever, for in both of them through a mistake of the
liliysician the women used inje<;tions of mercury
bir'lilorid in the strength of 1 to 2^>, and solutions of this
concentration are irritant enough to do almost any-
thing.
A case wliich 1 have recently seen shows very clearly
to my mind that the vaginal mucous membrane, even in
a comparatively healthy condition, /. e., without any
gross lacerations, such as are found after labor, is capa-
ble of absorbing sufficient corrosive sublimate to cause
toxic symptoms, and that the use of su<;h douches, espe-
cially when carried out at home, is not free from danger.
E. B , BingiG, a doiiii-siic, m^cI :;ii, wIhuu I h;u\ |iri'\ion.sIy
iroHted for jfaHtritis, and tlie roiainoexHiniimliiiii of u iiose iiriii«
h 1(1 /ill led to show any ahnormalily, came tome AiiifiiKt 27 with
I lie following history : Twelve days before she had applied at
one of the I'ity dispoiiHarlcs for relief from lenkorrhoa. .She
was orden^'l a douche of corrosive Hiibliiiiiilo of tlic Mtrengtli, as
1 iiltorward detormiiied, of 1 to 2/100, to bo used daily. Thii*
'"iiised 80 much pain that fearing a mistake she returned the
nixt day to the aispensary and was told that the pain wbm due
I" an improper syringe. She bought a ni'vv one and again
essayed an injection with like result. On again consulting the
dispensary she was told to use the douche of half the concentra-
tioii. At this visit she called the attention of the doctor to her
urine, which she said had become the color of blood after the
first injection She was informed, very truthfully, that she
had severe kidney disease, although the doctor seemed totally
blind as to its cause.
After the third trial she was so weak and suffered so much
pain that she was forced logo to bed, but was able the next day
to come to my office. When I saw her she complained of a
severe heavy pain in the loins, frequent painful micturition,
and loss of appetite with disgust for food, but no nausea nor
vomiting. Her urine was a smoky red color, acid reaction, and
on examination was found to contain 0.%% albumin by
Esbach's apparatus ; niieroscopieally, numerous red corpuscles,
squamous and columnar epithelial cells, crystals of calcium
oxalate, and tul)e-casts (though not so many as might have
been expectpd) chiefly of the hyaline variety with an occasional
blood-cast. Her temperature was 99.4°, pulse 108; the face puffy
with the peculiar waxy pallor of renal inflammation.
The next day, under the free use of diluents and moderate
doses of uva ursi, the albumin had fallen to O.lSi/o and she re-
ported feeling much better. By September 2 her urine was free
from albumin, her backache had disappeared, the puflBness
was gone fi-om her face. She still complanied of weakness and
loss of appetite. She was ordered a tonic mixture. When seen
again, September 9, her urine was free from albumin and tube-
casts, specific gravity 1,014, and she felt quite recovered.
I present this case primarily as a warning against the
indiscriminate use of corrosive sublimate as an internal
antiseptic, a purpose for which it is in no wise fitted.
Especially to be deprecated is the practice of giving it to
the patient for home employment. Aside from the
danger to the patient a virulent poison like mercury
bichlorid in the hands of the uneducated laity imperils
the lives of the whole household. I have seen a case of
such poisoning ending fata.ll,y in the husl)and of a woman
who had been given these dangerous antiseptic tablets.
The case is, however, not without scientific interest
as showing the possibility of absorption through the
vaginal mucous membrane.
KKKKRKNCKS.
Sebillotte Thesis, Paris, ISill.
Butcher: Dublin Quarterly ). Mid. Sciences, 1858, xxl, 242.
Hamburger: Vlert«ljahrs. f. I'rakt. Hellkunde, 1876, 129, p. 144.
Dewar: Umcet. 187S, 1. p. 181.
Gore-. Lancet, 1878, i, p. Ilti.
A CASE OF HERPES ZOSTER OPHTHALMICUS COM-
PLICATED BY OCULOMOTOR PALSY.'
nv
WILLIAM ZKNTMAVKK, M.D.,
of Philadelphia.
Attending Surgeon to wills' Hospital; OphllinhnologlKl to St. Mary's
Hospital.
The following ca.se of herpes zoster ophthalmicus com-
plicated by paralysis of the oculomotor nerve occurred in
the practice; of the late Dr. William F. Norris, and
through the kindness of Dr. (Jeorge W. Norris, I am per--
mittetl to place it upon record. Dr. Norris' notes of this
patient cover a period of 10 years, and there is in them
nollilng of interest relating to the present trouble :
I 'ash;, a. /.., aged 7G years, an American, was attacked on
March 2, I'JOl, with herpes zoster opiithalmicus of the left side.
There were large patciios of vesicles on the scalp and other
patches extending down the i-orrespouding side of the nose to
the tip. There was a large group just below the brow and a
second smaller one on the eyelid near the \ipper edge of the
tarsus. The lids were immensely swollen. The onliro cornea
was hazy, and there was a large, deep ulcer near the limbus ou
the nasal side. There was a low grade inflammation of the iris
which yielded to treatment, leaving considerable pigment on
the anterior c^psulw of the lens. At the height of the disease
there was marked swelling of the upper lid of the right eye.
On April 1, (luring the absence of Dr. Norris from tlie city,
I took charge of the case, and upon the fifth day of April
ilete<:te<l absolute paralysis of the internal rectus and of the
levator with partial paralysis of the inferior and superior rectus
musclea of the affected eye. The age of the patient and the use
of a mydriatic in the treatment of the inflammatory con<iition
made it impossible to determine whether or not the internal
muscles were also involved. The course of the disease was
' Head tjcfore the necllon on Ophthalmology, College of Physicians
of Pliilaili-plila.
1008 AMBRinAir Medicink
THE WORLD'S LATEST LITERATURE
(DECBMBER 27, 1902
tflilioiiH, the insensibility of tlie skin persisting for more than a
yimr nml »iK)iit«no()us dipiopiti oonlinuinB lor many inontJis.
WI>on l»st exaininetl, in Septonii>or of tliis year, tliere was still
weakness of tlie internal rectus and of tlie levator. The result-
ing corneal scar was transparent and excavated.
I'aralysiH of tlio ocular museles as a complication of
herims zoster ophtluilinicus is a rare condition. Tiie
third nerve is most frctiuently affected. The palsy may
be tottil or partial, internal, external, or mixed. The
external muscles are most frequently involved, and
almost without exception the levator is included. The
sixth nerve is but occasionally affected, and the fourth
almost never. There may be isolated palsy of the iris
or ciliary muscle.
The motor disturbance usually comes on some days
after the appearance of the efflorescence.
Several theorle« have btsen advanced to explain the
association of herpes zoster ophthalmicus with oculomotor
paralysis. In this connection it should be recalled that
the third nerve is in direct relation with the trigeminus
through the ciliary ganglion, and that the sixth and the
fourth lie close to the first branch of the fifth within the
cavernous sinus. Ginsberg, accepting the view that in
most cases of herpes zoster ophthalmicus the lesion lies
in the Gasserian ganglion and is of an inflammatory
nature, concludes that the inflammation is propagated
along the first branch of the trigeminus, sympatheti-
cally involving the oculomotor nerve with which,
through the ophthalmic branch, it comes into intimate
relation at their entrance into the orbit. Vernon con-
siders that the two conditions are related only in that
they both are expressions of a comtnon eause, namely,
rheumatism. Wyss, who in a case of thrombophlebitis
found foci of pus in the muscles, considers the paralysis
to be the result of the inflammation of the muscle tissue.
The eliologij of herpes zoster is varied. The present
tendency is to view it as an acute infectious disease,
points favoring this view being the immunity resulting
from an attack, and the occurrence of the disease at
tinu's in an epidemic form. Of course, other causes are
admitted, such as rheumatism, cold from exposure,
arsenic, carbonic oxid poisoning, autointoxication and
trauma.
The most thorough pathologic sluch/ of the disease
that has thus far been made is that of Head and Camp-
bell. They found in the intervertebral ganglia acute
inflammation with the exudation of small round cells,
extravasations of blood, destruction of the ganglion
cells and nerve fibers, and inflammation of the con-
nective tissue of the ganglia. The posterior roots showed
acute inflammation, with more or less sclerosis. The
anterior roots were normal. The peripheral nerves
showed, according to the degree of intensity of the
ganglionic lesion, a degeneration of the fibers. They
• consider the disease to be similar in nature to acute
poliomyelitis. The nature of the agent producing these
profound changes they believe to be unknown. Wyss
considers the disease to be due to an inflammation of the
ganglia and of the aasociated nerves. Eisenlohr holds
that herpes zoster ma*' be due to a pure neuritis
without disease of the ganglia.
Skin Eruption. — Friedreich explains the skin erup-
tion by propagation of the inflammation along the nerve
to its terminal filaments in the skin, where the mflam-
mation extends to the tissues. Ebstein and Reckling-
hausen both consider it due to vasomotor disturbance.
The former believes the condition to be one of irritation
of the vasodilators. Brissaud claims that the distribution
of the eruption does not correspond to an area of distribu-
tion of the terminals of a sensory nerve, as formerly held,
but rather to an area innervated by an embryonic segment
of the spinal cord, to which the term metamere is given,
and that the lesion is an inflammation of such a meta-
mere. The theory advanced by Abadie to account for
the eruption is that it is due to disease of the capillaries
and of their vasodilator nerves supplving the affected
skin area. He elaims that the aftected region is that
supplied by the terminal arteries, and not the terminal
branches of the sensory nerves, with which the distribu-
tion of the efflorescence by no means always agrees. In
herpes zoster ophthalmicus the eruption should, accord-
ing to this view, and Abadie claims that it does, cor-
respond to the region supplied by the supraorbital,
frontal and, at times, nasal arteries, as the sympathetic
filaments distributed to the wallsof the terminal arteries
of the ophthalmic artery have their origin in tlie
superior cervical ganglion, course and commingle with
the fibers of the first branch of the trigeminus.
The sympathetic filaments are affected along with
the sensory fibers by an inflammation having its seat
either in the trigeminus itself or in the Gasserian gang-
lion. The inflammation of the sensory fibers induws
hyperesthesia and anesthesia, while the inflammation
of the vasodilator fibers leads to overdistention and
finally to rupture of the walls of the capillaries. Not
only is the skin eruption and its trophic nature accounted
for by this view, but likewise the fact that the skin
eruption sometimes takes on an erysipelatous api>ear-
ance. It also explains why apparently (with rare excep-
tions) onlv the area supplied by the first branch of the
trigeminus is affected and not the area supplied by the
two other branches of the fifth nerve. It is due to the
fact that the vasodilator nerves supplying the arteries
distributed to this territory do not have their origin in
the superior cervical ganglion, do not traverse the
cranial cavity and are consequently not involved by
inflammatory processes affecting the trigeminus within
the skull cavity. He mentions as further evidence of the
sympathetic nerve origin of the affection the beneficial
effect of enormous doses of (juinin, the physiologic effect
of which is contraction of the capillaries.
An excellent article upon herpes zoster ophthalmicus
is to be found in Wilbrand and Saenger on " Die Neuro-
logic des Auges," from which I have freely translated.
THE WORLD'S LATEST LITERATURE
Journal of the American Medical Association.
December SO, 190g. [Vol. xxxix. No. 25.]
1. Typhoid Fever and Water-supply In Chicago. Edwin Oakes Jor-
dan.
2. The Surgical Treatment of Gallstones J. F. W. Ross.
3. Recent Investigations Concerning the Relation of Human and Bo-
vine Tubercnlosis. D. E. Salmon.
4. The IntertransraisKlblllty of Human and Bovine Tuberculosis: A
Review of the Experimental Evidence. R. R. DiNWiDDiE.
5. Dermatitis Repens. M. B. Hartzei.l.
6. Dermatitis Hiemalls: A Recurrent Inflammation of the Skin Asso-
ciated with Cold Weather. Wim-iam Thomas Corlett.
7. Concerning Morphln Addiction and Its Treatment. C. B. Burr.
8 Cholera Aboard the U. S. Army Transport Sherman. Experiences
of the Army Surgeons in Charge of the Cholera Cases. Suspects
and Contacts Debarked in lapan for Quarantme: Description of
the New Japanese Antitoxin and Cholera Vaccine. William C.
Mabry and Harry C. Gemmill.
1.— Typhoid Fever in Chicago.— Jordan speaks of tlie
more than local interest of the subject, since visitors have been
known to carry the rnfection to other places, while disease may
be scattered broadcast by the tanks of drinking water sent out
everywhere on trains. The epidemic of 1(K)2 he attributes to
pollution of the lake water by drainage from a large area not
yet connected with the drainage canal, the pollution being
greater tlian usual owing to excessive rains in June and July.
Completion of the intercepting sewers will not, however, pre-
vent incidental pollution from vessels, bathers, etc., or (i-ftm in-
dependent towns and villages near l>y. The experience of other
cities points to sand filtration as the surest and cheapest safe-
guard. Dust, tties, milk or food contamination cannot acoount
for so widespread an epidemic, though they may have con-
tributed to the high deathrate in August and September. [n.M.]
a.— Surgical Treatment of Gallstones.— By using Mori-
son's pouch for drainage when leakage is probable, the rubber
tube entering through the wound in front and emerging at the
December 27. IHOli]
THE WORLD S LATEST LITERATURE
{AHBRICAN UEUICINB 1C09
deepest part of the pouch, with iodoform paclcing about the
leaking points, operations for gallstones Ross asserts can be car-
ried safely through. He reports two case.s of gangrene in which
cholecystotomy and drainage resulted in recovery. In empyema
with inflamed and thickened walls the organ alter draining for
a time becomes normal. Intermittent irrigation is advisable in
this condition. In chronic infiauimation with calculi but no
pus Ross passes a tube into the bladder, stitching the opening
firmly around the outer wall of the tube and packing gauze
around it. Another drain is put in the bottom of Morison's
pouch. The first is removed about the fifth day and the latter
in two weeks. When the stone is impacted in the cystic duct
and the gallbladder has been so distended that gangrene is
imminent cholecystectomy should be done, the ligature being
placed beyond the stone. It is well to place a small strip of
iodoform gauze down from the abdominal wound to the end of
the duct. In obstructive jaundice cholecystectomy is not advis-
able. The stone may be removed, relying on future patency of
the duct, or cholecystenterostomy may be done with or without
removing the stone. Ross uses Murphy's button, allowing
long threads to float in the lumen of the gut, these making
traction on the button during the passage of feces, [h.m.]
3.— See American Medicine, Vol. Ill, No. 25, p. 1(W6.
4.— See American Medicine, Vol. Ill, No. 25, p. 1046.
5.— Dermatitis Repens. — Hartzell reviews the literature
of the subject and reports a case of his own, which he believes
was due to an infection. Some of the others were probably
neuritic, atrophic disturbances following injury and conse-
quent inflammation of the nerves supplying the affected area.
[H.M.]
6.— Dermatitis Hiemalis.— Corlett first described this
affection in 1894 and reports further cases. It is a disease of
winter disappearing with warm weather. It does not differ
histologically from eczema. Clinically it is more allied to the
erythema? than he at first supposed. It most frequently
attacks distal extremities, parts farthest removed from the
center of circulation, theM having a dark bluish tint. The skin
changes .seem wlioUy dependent on circulatory disturbances
and cold is the causative factor. Change to a warm climate
effects acure. Ichthyol benefited one case. Slightly astHngent
soothing applications are indicated when there is excoriation
and in hypertrophy salicylic acid grs. xx with diachylon oint-
ment .^ilj. Leather gloves should be worn, [h.m.]
7.— Morphin Addiction.— Burr notes the large percentage
of ca.ses among physicians, and emphasizes the need of in.stilling
a wholesome fear in the minds of medical students. He has
found cases of short duration the most difficult to treat. When
phy-iical strength will permit, and the patient cooperates fully,
it is frequently expedient to discontinue the drug absolutely
and at once, watching for untoward .symptoms, keeping the
patient under control long enough to build up the nervous
sysicrn by tonics and hygiene, [h.m.]
8.— Cholera.— Mabry and Gommill give an account of the
treatment of cases from the army transport while in quaran-
tine by the .Japanese antitoxin obtained by immunizing a
horse with the coma bacillus. The dose is from 10 to 72
grains in 24 hours. The .lapanese have also a prophylactic
toxin not so severe In its reactions as that of haffkine. Immu-
nity is <!onforred after the second day by 1 gram, lasting
4 to « weeks. Injections of 2 grams after 7 days and .3 grams
after 21 days give immunity for from 15 to 24 months. The
results from the use of both serums have been most encourag-
ing. Tlie writers report in detail the cases which came under
their own oi)sorvation. [h.m.]
Boston Medical and SnrKical Joarnal.
December 18, 190t. [Vol. rXLVii, No. 2.5.]
1. A .VI«UiodofSI«lnln({Spufuni for Bacterlologic Exaralnatlon. Wil-
liam H. HMITll. , _ .
• Kli'Vcn .\<-uteanrt Klgliloon Chronic Caxe^ of tnHiirnzn, Proved by
Bactwrl'iloiiilc KxmnlnHtlon. Krki>k«ick T. 1.i>ki>.
; i;.iiigeiilliil .Vnoiiiullcs of Thalangcs, Willi Keport of CniieH HtiidkKl
hvMltlacriipliv. K. B. l,l'!«D.
I. Kpi'ii'lyniiil I-Ipltlicllnin as n C'nnttltiipnt nf a Teratoma. Hkniiv .\.
I'lIl'rlHTl »N.
5. Observations on Three Cases of Hydatidlform Mole. Frank A.
HlOGINS.
1.— Staining Sputum.— Smith gives a list of the stains
needed. They should be fresh, and the specimens should be
examined .soon after they are raised. No carbolic or bichlorid
should be added to the solution. He describes the routine
methodof examination, the microscopic appearances in infec-
tion by the pneumococcus inllnenza bacilli, .streptococci,
staphylococci, bacillus mucosus capsulatus, and pseudopneu-
niococcus, also methods of cultivation from sputum. He
reports cases showing the diagnostic value of these examina-
tions, [h.m.]
2.— Acute and Chronic Influenza.— Lord notes the preva-
lence of influenza bacilli apart from epidemics. He found them
in the sputa of 60 out of 100 unselected cases with cough. In 29
of these they were in practically pure culture. There is nothing
distinctive in the clinical manifestations apart from epidemics,
and the diagnosis can with certainty be made only by exami-
nation of the sputum. Cough and expectoration generally last
only six weeks, but may linger for months or years. Many
cases (ormerly classed as chronic bronchitis are chronic influ-
enza. The latter with paroxysmal dyspnea may closely
recmble asthma. It is frequently mistaken for pulmonary
tuberculosis, [h.m.]
3.— CouRenital Anomalies of the Phalanges.- Lund
reports eight cases of these anomalies, and gives several illus-
trations by photograph and skiagraph. The paper is interest-
ing, but of such nature as not to lend itself to valuable abstract.
[A.B.C.]
4.— Kpendyinal Kpithellum as a Constituent of Tera-
toma.—Christian reports the case. The patient was a female of
17. She was well nourished, but had never been strong. For
more than a year she had noticed a gradual enlargement of the
abdomen, more marked on the left side. On examination the
outlines of an irregular mass, extending atwut three finger-
breadths above the umbilicus, could be made out. It was firm,
smooth, tense, and movable. Vaginal examination showed in
anterior ciilde.sac a large, hard mass, apparently part of and
growing from the cervix. Operation by a median incision
showed a large cyst of the left ovary, with a long pedicle. The
cyst lay on the right side, and the uterus was pushe<l toward
the left. There were many large varicose veins in the broad
ligament, and the tube was stretched to twice its normal length.
The flat, broad pedicle of tumor, including broad ligament,
tube, and round ligament, were tieti off with interlocking
chromic gut ligatures. The raw edgfts were sutured over with
catgut, and the abdominal wound closed. The patient made an
uneventful recovery. Examination of the tumor showed it to
be a teratoma, consisting of c.vsts, bone spicules, cartilage, dark
pigment, hair, etc. [a.r.(;.]
5.- Hydatidiform Moles.- Higgins reports three cases
observed re<-ently. Of these growths he says : The appearance
of the hydatidlform growth in all these cases was essentially the
same: a large number of vesicles of various size and shape, the
largest seen being al>out2 cm. (.7 of an inch) in diameter. Most
of the cysts were of a light, opalescent tint, and containeda thin,
light-colored fluid. Many, however, cont«ined blood, and con-
sequently were dark. The cysts wore all attacheit to an irregu-
lar membranous structure, the chorion, either directly or by
narrow pedicles, the membrane itself being attached to the
uterine surface at the placental site, and this attachment was no
larger than that of a normal placenta of the same period. There
was no evidence of fetus or of placenta in either case. The
blood supply of the growths seemed particularly small and the
hemorrhage during delivery was slight In all the cases. The
author does not believe it possible to make a diagnosis at three
or four months unless some of the cysts are thrown off and are
seen. Even If discharged from the uterus they may readily
become occluded In dotted blood. The most prominent symp-
tom is hemorrhage, and with continued hemorrhages in the
early part of pregiiam^y the possibility of the presence of
hydatidlform mole should be kept in mind. In the later montliM
of pregnanc.v the absence of fetal parts on careful palpation and
the iiiinsual size of the uterus, said lo be present, would tend to
make the diagnosis much more certain. [a.ii.<\]
1010 \MBKICA.V MBDICINKI
THE WORLD'S LATEST LITERATURE
IUbcembbr 27, 1902
Illus-
MAN
Medical Record.
December 10, 190t. [Vol. 82, No. 25.]
1 Thi; HVHieiiiii' or ConstltntlouBl Character of Gonorrhea: I
tnit<-(1 by Five Cases of IridochoroldltlK. Charles Sted
•i A ('B8(''of MiBlriu I'ectorls, with .Xutonsy. Bbveri.ky Robinson.
8. A Case of Typhoid Spine. Leonakd W. Ei.v.
4 A Study of the Indlcalloii for Nephropexy. AiJGUSTIN H. Uoelet.
,■> Observations on (lerman Therapentlcs Simon Baruch.
8. Instruotlons to Patients Affected with Syphilis and Gonorrhea.
K01.1.BN Cahot. ,^ „
7 (Congenital Absence of Pectoral Muscles. Chablks v. Burke.
t.— Gonorrheal Irldochorolditls.— C. S. Bull reports five
cases, and says of the affection : It is not an uncommon compli-
cation of Konorrhea. The Inflammation of the uveal tract
never follows the urethritis immediately, but is invariably
precededby an arthritis, usually of the knee-joint. The iritis
or choroiditis is distinct from the usual type of rheumatic
inflammation. It is sudden in its onset, rapid in its develop-
ment, the pain is severe, and the loss of vision is rapid and com-
plete. The inflammatory process, though obstiuateand subject
to frequent relapses, eventually rapidly subsides, leaving little
or no trace behind. Posterior synechias form, but they are
readily broken and usually leave no trace on the anterior cap-
sule of the lens. Such an iritis, or iridochoroiditis, is liable to
relapse whenever the patient has another attack of gonorrhea.
A noglocted gonorrheal iritis, in which multiple adhesions
have been formed, may readily relapse, and, in consequence of
relapses, the symptoms of the disease gradually lose their
peculiar character. The disappearance of the iritis under
appropriate treatment, without leaving posterior synechias,
proves the absence of the plastic character. Its prompt disap-
pearance distinguishes it from the usual form of serous iritis.
[a. B.C.]
2.— Angina Pectoris.— Kobinsou reports a severe case, with
the autopsy findings. The heart-muscle was remarkably good,
the coronary arteries patent, and their openings large. The
important thing was the general arteriosclerosis, uniform
throughout the entire arterial wall. The cause of the attacks
.seemed to lie in the nervous. mechanism of the vasomotor sys-
tem, and not in the circulatory system itself. Although the
kidneys showed only passive congestion, the angina was prob-
ably of uremic origin, the uremia being increased by the lock-
ing up of the secretions from repeated doses of morphin given
for the pain, [h.m.]
3.— Typhoid Spine.— Ely reports that a physician of 3:?
suffered from a severe attack of typhoid fever, complicated
by pneumonia and pleurisy. During early convalescence
the patient complained of a weak back, and a little
later there was stiffness, lumbar pain, and lateral curva-
ture. There was great difficulty in standing erect. Some
ten weeks after the beginning of the typhoid attack and
during convalescence he again contracted pneumonia; and
from a pleural effusion 62 ounces of fluid were withdrawn, but
no tubercle bacilli were found. On recovery from the pneu-
monia the patient went to Los Angeles, where he was prac-
tically bedridden for a number of weeks from the lumbar affec-
tion. Frequently the mere effort to change his position in bed
would bring on violent clonic pains, in so ranch that chloro-
form had to be administered for their relief. Usually the tem-
perature was about normal, but on one occasion It rose to 104.
Morphia was frequently given for the relief of pain. Strapping
the loin, the cautery, internal medication, etc., were all tried
without relief. Seven months from the initial typhoid attack
he began to recover from the "spondylitis typhosa." The
recovery is not yet complete, but has progressed to the extent
that the patient can attend to the lighter duties of medical prac-
tice. The author states that including the cases previously
reported by Gibney, Lord, and others this one makes the
thirtieth. All have recovered, but complete recovery has, in
some cases, been long delayed. Nine have been accompanied
by a kyphosis, and three by lateral curvature. The pathology
of the affection is unknown, as no case has come to autopsy, but
it is evidently an osteitis, destructive in some cases, and prob-
ably accompanied by a periostitis. Some cases present the
stigmata of hysteria. Treatment is rest and tonii-s. A unique
circumstance in connection with the article is th<t Ely washim-
.self the patient, [a.h.c]
4.— Indications for Nephropexy.- Goelet, of New York,
says there are three principal indications for fixing the kidney:
The symptoms of inconvenience it produces; the influence
which the prolap.sed kidney may exert in producing or main-
taining disea.se of the female pelvic organs, and its influence in
causing disoa.se of the kidney itself. He states that in the first
and second degrees of movable kidney, i. e., ca-ses in which the
lower pole and the lower one-half respectivelyof the kidney can
be palpated below the costal border, operation is not indicated
so far as danger to the kidney itself is concerned, and these are
the cases which are benefited by belts, corsets, etc. Biit in pro-
lapse of the third degree, i. e., those ca.ses in which the whole
organ can be palpated below the costal border, nephropexy is
indicated even though the symptoms produced are not marked ;
for a kidney so abnormally placed not only usually leads to
serious symptoms, but is in imminent danger of becoming dis-
eased. In fact, when the prolapse reaches this stage a careful
urinary examination nearly always shows a diseased kidney.
The author insists that not enough care is usually given to the
urinary examination in these cases. This work is very impor-
tant and noiiebutaspecialist should beeutrusted with it. Pads,
belts, and corsets are not only useless in these cases but are
often distinctly harmful. He quotes the views of eminent
surgeons on this subject, [a. B.C.]
5.— German Therapeutics.— Baruch deplores the alarm-
ing absence of bedside workers, too much thought, propor-
tionately, being concentrated on laboratory research. He favor-
ably contrasts the sanitary vigilance of the Germans with our
own. He notes the treatment of infectious fevers in the open
air, the simple hygienic treatment of acute diseases, and the
pronounced activity in the care of chronic eases. He describes
particularly the development of physiologic therapeutics,
including hydrotherapy and massage, [h.m.]
6.— Instructions to Patients Affected With Syphilis and
Gonorrhea. — Pollen Cabot insists that patients suffering from
venereal disease should bo given definite instructions concern-
ing it; this is particularly true in dispensary practice. In his
dispensary work he provides each patient having either syphilis
or gonorrhea with the appropriate card of instructions such as :
Instructions to those suffering from syphilis.— Syphilis is a
constitutional disease. It is " in the blood." Local remedies
and taking medicine for a few mouths will not cure you. You
must be treated for three years. The effects of this disease are
far-reaching, and if treatment is neglected, much trouble and
suffering may be caused, not only to yourself, but to others.
The following rules must be observed during the first year:
Sexual intercourse should not be indulged in. Alcohol in all
forms should be avoided, as it always aggravates the disease.
Do not smoke or chew tobacco. Sleep alone. Under no cir-
cumstances should any one be allowed to use your toilet
articles, as towels, brushes, combs, razors, shaving brushes,
etc. No article that has been in your moutli should be used by
others, as tooth-brushes, tooth-picks, pencils, pipes, cigars,
cigarets, forks, spoons, drinking-cups, etc. Y'ou must not
kiss any one, especially children. Brush your teeth night and
morning and keep your mouth clean. If you have bad teeth,
have them attended to by a dentist, and be sure to tell him that
you have syphilis, so that he can take necessary precautions
and avoid the possibility of infecting others. Acids in food
and drink should be limited. A similar and appropriate card
is given to those suffering from gonorrhea, [a. B.C.]
7.— Congenital Absence of Pectoral Muscles.— Burke
reports the case of a young man of 19, who was an athlete, a
ball-pitcher and wrestler, and who showed an entire absence of
the anterior axillary border of the left side. Examination
showed the absence of the lesser pectoral and the sternal
portion of the great pectoral. The man apparently had perfect
use of the arm, the movements being deficient in no respect.
The condition, according to the history, existed at birth.
[a. B.C.]
Deckmbbk 27, 19021
THE WOELD'S LATEST LITEKATUEE
(AMBKICAN mkuicini
1011
New York Medical Journal.
December IS, 1902. [Vol. lxxvi. No. 24.]
1. Laryngectomy for Malignant Disease. Frank Hartlbv.
2. TliePresentStatusof Genitourinary Therapeutics. EogkseFollkr.
8. The Treatment of E.'ctensive Rectal Strictures. E.MII. RiES.
1. — See American Medicine, Vol. Ill, No. 21, p. 856.
2. — See Americnn. yfedicine. Vol. Ill, No. 21, p. 856.
3.— Extensive Rectal Strictures.— A case of extensive
rectal stricture in a woman of 25 is reported by Ries. The
patient bad acquired syphilis seven years previously. She also
had a rectovaginal fistula, a stricture of the urethra, and a
lacerated perineum. The first rectal stricture was about 2 cm.
(.8 in.) within the rectum, the caliber of the bowel at that place
l>eing about the size of a match. A second stricture was found
in the sigmoid, which was bound down by exudate. An
incision was made through the rectovaginal septum, but it was
found necessary to open the abdomen to get above the second
stricture. The bowel was cut in two above the stricture, the
sti'ictured end closed, and the healthy colon brought down to the
aaus through the opening in the culdesae and fastened to the
rectum below the lower end of the first stricture. The conval-
escence was comparatively uneventful. In two months she
was able to worlc and had gained 35 pounds. Five years later
tha patient had daily natural passages, no incontinence, and
was apparently in good health, [c.a.o.]
Medical News.
December W, 19M. [Vol. 81, No. 25.]
1. Acute Pancraatitis: With the Report of Three Cases. George
WOOLSEY.
2. Rubella Scarlatinosa. Frederick C Curtis and Henry L. K.
Shaw.
8. Some Observations in the Children's Hospitals of London and Paris.
Llss.BUS La Fetka.
4. Impressliins of the Nonheredity of Acquired Characters. Lewis S.
Blackwell.
1.— Acute Pancreatitis.— This as a condition amenable to
operation is infrequent and rather obscure. Woolsey divides
it into varieties, according to the presence or absence of hemor-
rhage, necrosis, abscess, or general peritonitis. In sudden
death hemorrhage is frequent. Fat necrosis is rarely met in
other ailments, and is not present in all acute pancreatic dis-
eases. It is due to interference with the normal discharge of
the secretion and its escape into the tissues. Peritonitis is not
usually pre.sent with fat necrosis. The former is due to bacte-
rial infectiou, which may reach the pancreas through its ducts.
In one variety of pancreatitis there is necrosis of the organ in
whole or in part. Most operations are performed for the puru-
lent form. Alcoholism is frequent as a cause. The onset is
sudden, with collapse, eramplike epigastric pain, not relieved
by vomiting ; irregular temperature and abdominal distention.
When there is glycosuria or excess of fat in the stools the diag-
nosis is still more probable. Operation must be avoided
during collapse. Vigorous stimulation with or without saline
infusion is requiredduringand after operation. The prognosis
Is grave. Recovery without operation is almost out of the
question. Woolsey reports three cases recovering after opera-
tion. [H.M.]
2 —Rubella Scarlalinosa.— Curtis and Shaw report an
epidemic in which the infection was carried by milk and was
at first mistaken for scarlet fever ; 147 cases were treated by one
physician. Incubation averaged 19 days. The onset was
su<lden, attended by malaise, headache, sore throat, slight
fever, enlargement of the lymph nodes in neck, groin and
axilla, and an exudate appeared on both tonsils in many
instances. In hundreds of urinalyses no albumin wasdetected.
The writers de.scribe the varying appearances of the eruption.
I n some oases the peeling was copious. The strawberry tongue
was absent. Unlike scarlet fever, rubella frequently attacks
adults, life of the cases treated being over 'M years of age.
[H.M.]
4.— Impressions of the Nonlieredlty of Acquired Cliar-
acters.— Black well, in reply to Irwell's recent article, gives the
consensus of opinion in Europe and here as to the heredity of
the ali-ohol habit. [n..M.]
Pbiladelphia Medical Journal.
December 20, 1901! . [Vol. x. No. 25.]
1. A Case of Adiposis Doloro.sa, with In volvemenl of the Joints. F. X.
Deroum. . t 1.
2. Bronchitis and Bronchopneumonia fi'om Inhalation ol irritanu.
J. N. Hall. , . „
3. Polypi In the Nasal Accessory Cavities, with Specimens. A. K.
Solesbekoeb. .. , „ „,
4. Rare Forms of Ixicalized Posterior Staphylomata In .Myopic E-jes.
Burton K. Chance.
5. A Method of Treatment for the Proper Drainage of Tears in Derange-
ments of the Ijichrimal Apparatus. J. Winter Wamsley.
6. A Note on the Employment of the Hanging-drop Method in ine
Study of Hemopreclpllm.s. A. Robin.
1.— .A Case of Adiposis Dolorosa, with Involvement of
theJoints.— Dercumde-scribes a case of adiposis dolorosa occur-
ring in a white woman of 61, who ten years previously noticed a
weakness of the legs, followed by difficulty on ascending and
descending a stairway, and an inability to arise from a sitting
posture without a.ssistance. Eight months later a painful lump
of fat appeared at the back of the neck, immediately between
and above the shoulder-blades. Subsequently another painful
mass of fat appeared on the left collar-bone, and at various
times thereafter numerous lumps, more or less diflfuse in char-
acter, appeared on the left arm, right arm, and finally over and
above both knees. Coincident with the appearance of the pain-
ful masses of fat about the knees the patient began to suffer
from swelling in the joints. Joint complications in adiposis
dolorosa appear to be exceedingly rare. The examinations of
the joints in the author's cases justifies the conclusion that there
was present a marked thickening of the synovial membranes
and possibly of other structures in the neighborhood of the
joints ; there was a marked tendency to the formation of fringes
and rice bodies; that this thickening is due, in part at least, to
fatty infiltration and that this I'at is painful, just as is the fat in
the lipomas on the surface of the body, affords the most reason-
able explanation of the condition observed, [k.c.h.]
2.— Bronchitis and Bronchopneumonia ft-om Inhalation
of Irritants.— Hall reports a series of cases in which bron-
chitis and bronchopneumonia followed the inhalation of six
varieties of irritants, viz., chlorin gas, sulfurous acid gas, form-
aldehyd, kerosene, smoke, and smoke containing unknown
acid fumes. In a considerable experience of poisoning by
illuminating gas and water-gas, he has not met with much evi-
dence of subsequent bronchial or pulmonary irritation. In all
cases in which there is a possibility of relief of laryngeal symp-
toms, intubation should be borne in mind. In many of these
cases the mechanic impediment in the bron<rhi from swelling is
the insuperable obstacle to recovery, [k.c.h.]
3.— Polypi in the Nasal Accessory Cavities.— Solenberger
answers the question, Why do nasal polyps recur? (1) The
rhinologisl does not always trace them to their deeper path-
ology ; (2) he too often fails to find the scat of their first origin,
nor does he differentiate the various stages in their evolution or
the accessory causes of their continuance ; (3) all the necrotic
tissue is therefore not recognized and removed, and nature'-^
drainage avenues are not reestablished ; (4) many ca.ses recur
after all surgical measures have been exhausted, because too
many of the scavenger trains are keeping up the pernicious
habit of carrying the wastes ol the body to the old dumping-
ground. He presented 10 or 12 specimens, and cited one par-
ticularly interesting case in which the polyp was removed from
the sphenoid cavity, [f.c.h.]
4.— Rare Korms of Ijocallxcd Posterior Staphylomas In
Myopic Kyes.— Chance details seven cases which ho believes tti
be true posterior staphylomas of congenital origin and not as
expressions of the changes taking place during the progress of
increasing myopia, [k.c.h.]
5.— A Method of Treatment for OralnlnK the Lachri-
mal Apparatus.- Wamsley has devised a system of probes
and tubes, which in his experience is the nearest approach to a
permanent drainage of tears by any artificial means after the
natural apparatus has been destroyed, [f.o.h.]
0.—Uomopreclpitiu8.— Robin firmly lielioves in tlic liauj^-
Ing-drop method in the study of henioprecipitlns, especially for
medicolegal purposes. The time of observation is considerably
shortened ; the reaction can be observed with far greater accu-
racy under the microscope; and minute quanlitioi of blomi
can be employed, [i .<-.ii.]
1012 AjIEBIOAJf MBPIOIITB
THE WORLD'S LATEST LITERATURE
(Decshbkr 27, 1»C2
CLINICAL MEOICINE
David Riesman A. O. J. Keli-t
EDirOKIAL COMMKNT
On the Use of Alcohol.— The November issue of
tlie IMwtitioner is an extremely viiluahle number devoted
to iin exposition from (lifl'erent points of view of the use
and abuse of alcoliol. The ditferent contributors are men
of wide experience and ripe judgment, men whose
opinions are entitled to that serious consideration that
we accord all honest convictions. Not tlie least valuable
of the communications are the editorial comments by
the distinguished editor of the Practitioner. Sir Samuel
Wilks, Sir Henry Thompson, Professor Woodhead, and
Dr. James Edmunds discuss alcohol as a beverage, detail-
ing many of their own practical experiences, which
probably are not unlike those of many of their fellow
mortals. Dr. Edmunds, who may be taken as the rep-
resentative of the teetotallers, ably states his side of the
question, and expresses the belief that after 40 years of
the disuse of alcohol as regards the recovery of the sick
under his care, and as regards the endurance of his own
health, working power, and enjoyment of health, he and
his patients have gained everything and lost nothing.
Sir Henry Thompson, after a total abstinence from alcohol
for six months, found that he had got rid of severe hemi-
crania and rheumatism, to which he had previously been
subject. For many years he banished alcohol from his
dietary, though providing the best wines for his guests,
and when he began to decline into the vale of years,
remembering that "wine is the milk of old age," he
recx>mmenced its use, but soon became convinced of the
fallacy of the aphorism. Sir Samuel Wilks believes that
alcohol is a most valuable medicine, and that being so,
it must necessarily do harm when given injudiciously.
With regard to its value as a diet, he says the question is
interesting from a physiologic point of view, butof no
practical importance since the masses of people in all
countries never consult the doctor on the subject.
He refers to the proposition laid down by the
late Sir William Roberts, that the instincts of
civilized nations have not become extinct, and asks
why, inasmuch as we never discuss the propriety of
animals eating certain foods, nor question the reasons
for different people, as Esquimaux or Hindoos, taking
very opposite kinds of diet, should the natural propen-
sity toward alcohol be excluded in the case of the Eng-
lishman, Frenchman, or German ? Alcohol as a medi-
cine is ably discussed by the men already mentioned,
and by Sir William Broadbent, who, in an exceedingly
sane and judicious article, lays down extremely useful
rules for our guidance. The sociologic aspect of the
question is ably discussed by Dr. J. .J. Ridge and Dr.
Francis Vacher. Dr. Ridge points out the disastrous
effect of alcoholism, attributing to it three-fourths of
pauperism and three-fourths or more of all crime ; he
estimates that deaths caused by drink in the United
Kingdom amount to between 40,000 and 00,000 yearly,
and he points out that the alcoholic not only undermines
his own constitution but also that of his "children, and
that were it not for drink slums would speedily become
a thing of the pa.st. The pathology of alcoholism is
discussed by Professor Woodhead, who ascribes to it a
large factor in the etiology of different diseased pro-
cesses. Mr. Gould writes of alcohol in surgical practice,
and finds that the only condition in which it is of any
value is in shock. Finally Mr. Milne Bramwell write'^s
of the treatment of dispomania by suggestion. Collect-
ively the papers constitute an extremely valuable con-
tribution to medical literature. The questions at issue are
by no means decided and probably never will be. That
for a large proportion of mankind alcohol is the rankest
poison is generally conceded— pauperism, crime, degen-
eracy, venereal diseases, slums, etc., tell the sorry tale.
On the other hand, that in many cases the question is
individual cannot be gainsaid. If Professor Woodhead
and Dr. Edmunds were able to exert their best effort
without the aid of alcohol. Sir .lames Paget and Mr.
Gladstone fretiuently were not abashed to resort to a
little wine when about to engage in some unusual task.
The editor of the Prwtitioner well says :
Surely, too, there is something to be said for what De Quincey
would have called the "hedonist" aspect of the alcoholic qiies-
tioii. If wine gladdens the heart of man without disordering
his brain or dulling his moral sense, that in itself, in our opinion,
is a good reason for using it. If a man finds.thatitchases away
the cares of business when he is at home, and makes him more
cheerful in the midst of his family and friends, we go so far as
to think that it is his duty to take the small quantity required
to produce these effects. If, on the other hand, a man finds
that he cannot take even a small quantity of alcohol without
detriment to his health or his temper, it is equally his duty to
abstain.
The large body of men and women able to exercise
self-control in the moderate use of alcohol will probably
decide the question for themselves. As also pointed out
by the editor of the Practitioner, according to the first
sentence of Bacon's essay on the " Regimen of Health" :
" There is a wisdom in this beyond the rules of physic : a
man's own observation what he finds good of, and what
he finds hurt of, is the best physic to preserve health."
KEVIEW OF LITERATURE
The Identity of the Ozena Bacillus, the Rhinoscleronia
Bacillus, and Friedlander's Bacillus.— Klemperer and
Scheier' after considerable discussion, review of the literature,
and the detail of the results of their own investigations reach
the conclusion that nothing proves and that many things dis-
prove that the bacillus occurring in ozena and in rhinoscleroma
produces the disease. These bacilli resemble in all particulars
Priedliinder's bacillus, which Is commonly found in healthy
upper respiratory passages as well as in other diseases. The
ozena bacillus and the rhinoscleroma bacillus, therefore, are
Friedlander's bacillus which multiplies considerably in ozena
and in rhinoscleroma, and perhaps (though not positively) pro-
duces changes in the ozenous secretion and in the scleromatous
tissue; thus though not the cause, they may participate in pro-
ducing the clinical symptoms of these diseases. Inasmuch then
as the name ozena bacillus and rhinoscleroma bacillus is based
upon a misconception they should no longer be used, and one
should speak of Friedlander's bacillus in ozena and in rhino-
scleroma. [a.o.j.k.]
The Bacteriology of Epidemic Diarrhea.— (iordon^
mentions the bacteria that have been found in the diarrhea of
infants and in that of adults — B. lactis aerogenes, B. coli com-
rrmnis, B. streptococci, Proteus vulgaris, B. enteritidis sporogenes
of Klein, B. enteritidis ot Giirtner, etc.— the bacilli of dysentery,
ptomain poisoning, etc. He refers to the difficulty of distin-
guishing the one form of disease from the other, and suggests
that agglutination tests may prove of some value. He believes
that while great progress has been made of recent years, much
remains to be settled with regard to the bacteriology of
epidemic diarrhea, and that a more precise knowledge of the
relative abundance and the attributes of bacteria occurring in
the normal Intestine would be of great service in enabling us to
attach their due relative significance to many of the observa-
tions that have been made in cases of diarrhea. Again, the
relative abundance of the pathogenic organisms that have been
found to occur in the dejecta in diarrhea is a subject about
which too little is known. Yet such knowledge might prove
of the greatest service. For instance, did we know exactly the
nature of the microorganisms that occur in, say 1/10,000,000 of a
gram of normal feces, and their attributes, we should then on
analyzing a similar quantity of fecal material from the intestine
in a diseased state be in a position to see at once what altera-
tion had occurred. By means of the dilution method it is a
comparatively simple matter to make accurate observations of
this kind, and their value promises to be great, especially if a
large number of cases are examined. A further subject about
which accurate information would be welcome is with regard to
1 Zfiltschrifl fiir kllnlsche Medlcln, xlv, 133, 19 2.
5 Practitioner, Ixlx, ISO, V»m.
Dkcembeb 27, 19021
THE WORLD'S LATEST LITERATURE
lAMKBICAN MEDlCINli 1013
the exact relationship of various pathogenic members of the
great colityphoid family. Hitherto most attention has been paid
to B. coli communis and B. typhosus, but as our knowledge
increases, the pathogenic imporUnce of other members of this
large family of bacteria becomes more plain. Enteritis as a
whole seems to be often intimately associated with various
members of it, and further knowledge of their relations and
characters may result in more accurate perceptions both of
their effects and of the ways to counteract them, [a.o.j.k.]
GENERAL SURGERY
Martin B. Tinker
A. B. Craig
C. A. Orr
REVIEW OF LITERATURE
Hour-glass Contraction of the Stomach Treated by
Operation.— Gilford ' reports three cases, all occurring in
women who were aged respectively 32,37 and 38 years. In each
case there was an almost lifelong history of dyspepsia. The
true condition was only surmised in two cases, and wholly
unrecognized in the third before operation. He says perhaps the
nearest approach to the ideal in operation is the simple and eftec-
tual method of Heinecke and Mikulicz. This was the operation
carried out in these three cases. Properly performed it should
be as effectual as the complete restoration of the stomach to its
normal shape. The transverse incision must be of such length
as when turned vertical will leave ample room not only for the
passage of the stomach contents, V)ut for future contraction. It
is of equal importance that gastric ulcer and stenosis of the
pylorus, frequent complications of hour-glass contraction,
should also be dealt with. In one reported case though the con-
traction was of extreme degree, no ulcer could be found, and in
none of the three was there any stenosis of the pylorus. The
operation done is decidedly preferable to any operation which
has for its object the short circuiting of the upper pouch of the
stomach into the intestine. The latter leaves the stomach more
deformed than it was before. While no evil appears to result
from this distortion, it cannot be said that we have complete
knowledge on this subject. In regard to the mortality of the
operation, Mr. Mayo Robson has collected 13 cases, of which U
recovered, [a.h.c]
Retroperitoneal Sarcoma.— Naumann^ reports a case of
retroperitoneal sarcoma in a man of 20wliose symptoms were
principally gastric, consisting in vomiting and severe pain in
the epigastrium. Below and to the right of the umbilicus a
slightly sensitive, rounded, firm, scarcely movable tumor, the
size of an egg, was found. At the laparotomy this tumor was
discovered to be behind the peritoneum, at the root of the
mesentery, to the right of the spinal column. The patient
made a good recovery. A microscopic examination made by
Sundborg proved the tumor to be a polymorphic-cell sarcoma.
The principal interest of the article consists in the fact that
Naumann advances the hypothesis that his tumor grew from
the organs of Zuckerkandl. These are two small bodies that
are constantly found in embryos and the newborn, but are only
rudimentary in adults. They are situated symmetrically on
each side of the inferior me.senteric artery, and bear a close
relation to the sympathetic in this region. Therefore, Zucker-
kandl considers them to be " Nebenkiirper " to the sympa-
thetic. They have been generally considered lymph glands,
butthey differ from the latter in color and in structure. They
are abundantly supplied with bloodvessels, being provided
with an artery springing from the aorta directly below the
inferior mesenteric artery. In 14.8% of the cases examined by
Zuckerkandl the two bodies were connected by an isthmus
crossing the aorta. While the tumor presented no histologic
features suggesting these organs, it also had nothing that
recalled lymphoid tissue; and Sundberg, while not positive, is
inclined to agree with the view of Naumann as to the proba-
bility of its origin from Zuckerkandl's organs, [d.h.]
Vulllefs Nepliropexy Slmplincd.-Thomas' describes
VuUiet's method as the fixation of the kidney by means of
detached strips of tendon of the erector splnae mass passed
iBMUBirMedlcftl Journal, November A, ISOi
2 .NordUkt mcsdlclnlxkt Arklv, Bd. xxv, 1902, Hrt. 8.
through the parenchyma of the kidney, returned and fixed
In a small separate incision made by the side of the first
lumbar spine. The author has performed the operation 10
times, but has modified Vulliet's method to some extent. The
tendon is best divided by means of a small swivel fixed on a
delicate handle. The split tendon is passed under a strap of I he
kidney capsule, which has been lifted up between two incisions,
rather than through the parenchyma of the kidney. A few
sutures are then passed through the capsule and the fascia lum-
borum. This method of lifting up a strap of the kidney cap-
sule serves in a measure the purpose of decortication of the
kidney, [a.b.c]
Urethrectomy for Traumatic Stricture.— Thomas i
reports two cases in which he performed this operation with
entire success. The operation is described as follows: The
corpus spongiosum is severed on each side of the stricture;
the exsected stricture and its mucous membrane are removed.
The edges of the dorsal stirface of the corpus spongiosum are
brought together by means of interrupted catgut sutures pa>sed
down to the mucous membraue-carefully avoiding penetration
of it— in such manner that the knots are on the periphery of the
corpus spongiosum. This maneuver is of importent-e in
diminishing the risk of extravasation of and the infection of the
suture holes by urine. After completing anastomosis of the
corpus spongiosum the fascial layers are laid over It by buried
sutures, the skin is approximated by its own sutures, and a
collodion dressing applied. No drainage and no instrumenta-
tion of the bladder is performed afterward, the patients empty-
ing the bladder voluntarily. [a.b.c.J
GYNECOLOGY AND OBSTETRICS
WiLMER KRUSEN
Frank C. Hammond
EDITORIAL COMMENT
The Pathology of Skene's Glauds — In 1880 Skene
contributed a paper on the anatomy and pathology of
two important glands of the female urethra. It will be
remembered that the mucous membrane of the female
urethra, when not distended, forms longitudinal folds.
It has many depressions and blind canals and near its
floor lust inside the meatus, are found tlie two urethral
ducts "described by Skene. They admit a No. 1 probe of
the French scale and extend upward, parallel to the long
a.xis of the urethra, for J to } of an inch in the muscular
tissue beneath the mucous membrane. The mouths of
these tubules are found alK)ut J inch from the meatus
and if the mucous membrane is everted, these openings
are exposetl to view on either side of the entnince to the
urethra. Kelly, in an address before the Philadelphia
Obstetrical Society, IHxember 4, 1902, discussed tlie
functions and pathology of these glands. 1 le believes
that tiieir function is to moisten the urethral labia par-
ticularly during coitus, during the violent displaeement
of the labia up into the vagina when the labia urethrae
nee<l constant lubrication to obviate the injurious effwts
of attrition; in this way they occupy a position relative
to the urethral orifice corresponding to Bartholin's
glan<ls in their relation to the vaginal orifice. Their
atfections are aitarrhal or gonorrheal. The speaker cited
one case which was possibly a cyst of the left gland due
to a closed duct. They may be treateti by injection,
incision or excision. In order to inject them Dr. Kelly
showed a little syringe, which fully intH'ts all the
requirements, consisting of a delicate, blunt-pointed
cannula about o cm. long and 1 mm. in diameter, a piece of
simple rublxT tubing drawn over the end of the larger
cannula after closing the open end then miule an excellent
syringe, serving by i\w elasticity of the walls of the tub-
ing to draw a few drops of fluid up the cannula. With a
simple syringe of this sort the amount of fluid injected
was also fully under control. After citing a number of .
cases treatiHl by iixjectlon and by excision Dr. Kelly
referred to an Interesting case in the hands of Dr. Hun-
rBriUih Medirat .lournnl, November K, \Wi.
1014 AJIBKICAN MKOICIMKI
THE WORLD'S LATEST LITERATUEE
[Decembek 27, 1902
ner, his a.s«ociate, in winch smegma bafilli were found
in the abundant secretion from one of these glands,
showing how readily a tul)orcuIosis of the urinary tract
might have been inferred even though the vulva had
i)een cleansed before the patient passed her water. We
have no doubt that if more careful attention was paid to
these tiny structures many cases of persistent urethritis
or dysuria, which have resisted treatment, could be
relieved.
KEVIEW OF LITERATUKK
Treatment of Uterine Betroverston. — Villard ' obtains
very satisfactory results from a modilied Alexander operation.
He exposes both round ligaments by a curved incision made in
tlie hairy region of the pubis, in order to avoid an apparent
scar. The ligaments are then pulled strongly from the inguinal
canals and sewed together in front of the recti muscles. They
are also anchored to the fibrous tissue of the symphysis. To
show the after effects of this operation six cases are reported.
The first of these was operated upon in March, 1899, the last in
December, 1901. In each the abdominal symptoms disappeared,
the general condition improved, and the uterus has remained
in the normal position as replaced. Villard also emphasizes
the fact that patients who have undergone this operation go
through pregnancy and labor without the slightest inconve-
nience. Three of the six cases reported have most satisfactorily
withstood this test. This operation is most typically indicated
in cases of mobile retroversion with no disease of the adnexa.
It is also indicated when the employment of a pessary has been
unsuccessful and when patients prefer an operation to the
wearing of a pessary for some months, [a.o.e.]
Complication of Pregnancy and Labor with Rectal
Cancer.— Dr. Rossa ^ adds another to the 16 previously reported
cases of delivery complicated by rectal cancer. The peculiarity
of the case being that since the cancer was small a living child
was spontaneously delivered, with a subsequent operation for
the removal of the cancer. Whenever during pregnancy there
are pains localized in the back and sacral region, and painful
stools, Rossa advises an examination of the rectum without
delay, the same as in case of like pains in the nonpregnant.
[W.K.]
Uterine Rupture Treated by Operation.— Wiener '
reports two more cases of rupture of the uterus occurring dur-
ing labor. In both cases the labor had been long and painful,
due to a disproportion existing between head and pelvis. One
of the patients had a very small pelvis, the child's head being
of normal size; the other woman had a large pelvis, but the
head of the fetus was hydrocephalic. The first had a smooth
tear of but a few minutes' standing, and the loss of blood was
slight; he therefore closed this tear with sutures, bring-
ing about a speedy recovery. In the second woman, the tear
was ragged, three hours old, and the patient in a state of col-
lapse, and almost bloodless; he amputated the uterus; recovery
was delayed by numerous and grave complications. He con-
siders the operative treatment, preferable to tamponing the
uterus, and believes that in experts' hands the results will
grow more favorable, [e.l.]
TREATMENT
Solomon Sons Cohen
H. C. Wood, Jr. L. F. Appleman
REVIEW OF LITERATURE
Faradic Electricity in the Treatment of Itching Der-
niatoses.-Bouveyron * has obtained excellent results with the
faradic current in the treatment of various itching dermatoses •
among them circumscribed lichen, itching eczema, anal and
vulvar pruritus and itching seborrheic eczema. He believes
tliat the positive pole exercises a more sedative Influence on the
I Lyon .M«dieal, November 30, 1902
3 Vfn,^''?^'"''" fUf, pynakologle, November 15, 1902.
Jouma?rt''p', P™,'fM"'''"'\''^T''<'''.<^" October 21, 1902.
Journal rtos l^ratlciens. Vol. x vi, No. 39, 1902, p. (il8.
pruritic area than the negative pole. The current should be
employed as strong as possible without causing pain ; this will
depend upon the sensibility of the patient. The applications
should be made daily and continued half an hour, [l.p.a.]
Veratrum Viride in the Treatment of Kclampsia — E. A.
Ren6 de Cotret' has obtained excellent results from veratrum
viride in the treatment of eclampsia. In administering the
drug he takes the pulse as a guide : if it beats 120 times or more
in a minute 20 drops of the fluid extract of veratrum viride are
given hypodermically. If the pulse is below 120, from 10 to 20
drops are given hypodermically according to the pulse- rate. If
no decrease in the pulse-rate is noticed at the end of half an
hour, these doses may be repeated. In one desperate case, 400
drops were given hypodermically during the first six hours of
treatment, and the patient was cured. De Cotret recommends
that it be given in doses sufficient to lower the pulse-rate to not
more than 60 a minute. He concludes that: (1) Veratrum
viride is a safe and extremely powerful remedy; (2) it is easily
controlled, the pulse being a prompt and precise guide to
dosage; (.S) it is prompt in action, and is easily administered.
[L.F.A.]
Ichthyol in Rheumatism. — Post ^ recommends the use of
ichthyol in rheumatism, both of the acute and chronic type.
In the acute he paints the joints with a solution of pure
ichthyol and covers them with cotton and oiled silk. In
chronic rheumatism he employs oO% ichthyol, which should be
rubbed in vigorously, [h.cw.]
Tliiosinamin. — Suker' has found this drug useful in
various ophthalmologic conditions on account of its property of
dissolving scar tissue. It is especially useful in corneal opaci-
ties, in ectropion dependent upon cicatricial contraction, and
in unsightly corneal scars. It may be given in capsules, 3-grain
doses once or twice daily. He has also employed the subcon-
junctival injection of a 10% solution, but has not had sufficient
experience with it to say positively whether it has any advan-
tage over the internal administration, [h.cw.]
Cuprol in the Treatment of Conjunctivitis.— Sicherer*
has employed cuprol with excellent results in the treatment of
acute and chronic catarrhal conjunctivitis. This substance is an
organic combination of copper and nucleinic acid, and contains
about Off of copper. It is readily soluble in water, especially
in hot water ; it is not precipitated by alkalies. A 10% solution
of cuprol combined with 0.5% of ohloretone is the best prepara-
tion to employ. Its use is not accompanied by the least irrita-
tion, and it causes almost no pain. For this reason it may be
used without first employing an anesthetic. Sicherer recom-
mends cuprol in all eases of catarrhal conjunctivitis. In rebel-
lious cases he introduces the finely powdered drug into the
conjunctival culdesac. [l.p.a.]
The Urea Treatment of Tuberculosis.— Harper = pub-
lishes the result in 40 cases of his urea treatment of pulmonary
tuberculosis. In all there was either a pronounced improve-
ment or complete cure. As we have recently reviewed this
subject editorially, it is not neces.sary to take up again the
theoretic consideration of the modus operandi of this drug.
It should be given in 1.3 gram (20 grain) doses dissolved in pep-
permint water, Increased gradually if well borne by the
stomach. In cases of mixed affection he recommends the
administration of calcium sulfate along with the urea, the
former being used to control the growth of the septicus. He
asserts that the addition of urea to the culture medium is not
only inhibitory to the growth of, but actually kills them.
[h.o.w.]
For Epilepsy.— Spratling.«
Bromipin 4 ounces
Simple syrup 4 ounces
Spts. peppermint 4 drams
Mucilage acacia enough to make 16 ounces
One to two or throe tablespoonfuls three times a day, an
liour after meals.
' Itevue Medicale dii Canada. Vol. vl. No Ifi, 1902, p iSO.
^Iherapeutic Gazette. 1902, Vol. xxvl, p. 604
s Merck's Archives, September. 1902. 857.
* La M«decine Moderne. Vol. xiii. No. 37, 1902, p. 298
• British .Medical Journal. October 18, 1902.
"Journal American Medical Association
I
INDEX
I
A bbott, George E.: Finger tips totally lost : Their
-^*- reconstruction by sponge eduction, 139.
Abdominal — belt after celiotomy, 688; cases, clinical
notes on. 828,890; cavity, foreign bodies acci-
dentally left in, 670 ; cavity, illumination of, in vag-
inal celiotomy, 596 ; pregnancy, operation in,
530; hysterectomy for carcinoma, 356; hyster-
ectomy for fibromyoma,79o ; lesions, diagnosis in,
:i50; _route, in excision of the rectum, 897 ; section,
489, 568, 873 ; surgery, drainage and angiotribe in,
489; tumors, ascites with, 271 ; wall, callous si-
nuses of, 117 ; wounds in war, treatment of, 752.
Abdomen— inflamed, telephonic properties of, 488;
malignant growths, operation, 195.
Ablation of spleen, effect in animals without stomachs.
32.
Abortion, climatic treatment in, 437 ; incomplete, treat-
ment of, 8:J3 ; in working women, 988 : repeated
gynecologic and obstetric aspect, S9I.
Abscess— bilateral paranephritic, 873; brain, 89, 111,
690 ; bronchiectatic, 473 ; hepatic, 354, 473, 830 ;
mistaken for appendicitis, 79, 276; of appendix,
intraperitoneal, 233; ovarian, 461; pelvic, 489;
rectal. 9 ; sphenoid, chronic, 448.
Abstinence, total. 650.
Accessory— sinuses, 676 ; pancreas, 873 ; thyroid tu-
mors. 392, 752, 7a3, 939.
Accidents—and disease, 564 ; in Alps, 286; of anes-
thesia, 776; railway, and injuries, 564, 711.
Accouchement force in puerperal toxemia, 357.
Accounting, institutional, 8:^, 163, 204, 761, 920.
Acetanilid, methemoglobinemia due to, 907.
Acetonemia, vomiting with, 197.
Acetozone in typhoid, 119.
Achylia gastrica, 981; and pernicious anemia, 779.
Acid-resisting bacteria, relation to B. tuberculosis,
152.
Acid— biliary and surface tension, 470; boric, as food
preservative, 71, 395, 566,607; boric, increasing
solubility of, 278 ; carbolic, fixation of kidney by,
193 ; carbolic, in granular conjunctivitis, 439 ; car-
bolic, in smallpox, 875; carbolic, in tetanus, 875;
carbonic, in cardiac disease, 874 ; chinic. in gout,
756; cinnamic, in tuberculosis, 639; factors of
gastric fluid, 740 ; hydrochloric, in gastric carci-
noma, 230; hydrochloric, in chronic diarrhea, T97 ;
hydrochloric, secretion of, 830; lactic, in alopecia,
7.^7; mouth-washes on teeth, 756; oxalic, toxic
action, 192; phosphomanitic, and phosphomani-
tates, 313 ; picric, in burns, 836 ; sulfocarbolic,
5-59 ; uric, cause of digestional troubles, 828 ; uric
diathesis, dietetic treatment in. 790.
Acidity, gastric, lOl, 389.
\cne— nasal, 159; treatment. iiV.t. '.'!:;.
\coin, 519.
\croasphyxia, symmetric, 27:1.
Act, medical license— for Can:ui. I. Ii'. ; -.iistuliu-.l, t'lDT.
\ctinic rays, 744,789.
Vctinomycosia, 191, 476, 59*i.
Xcute and chr(mic terms, 869.
Adamkit^wicz's serum in carcinoma. s:tO.
Adams-Stokes symptom complex, 983.
Vddison's disease, treatment, 871.
\denocarcinoma — primary, thyroid. 331 ; removal of
cecum and ascending colon for, 309.
Adenoids, 392, 677 ; fatal secondary hemorrhage, 488.
Adenoma- nasal, 179 ; prostatic, removal, 34.
Adenomyoma of uterus, 36.
Adiposis dolorosa, 9.50, 101 1.
Adler, Harry: The relation I I'-i-Av^cn pernicious anemia
and achylia gastrica, 77''.
.Adler, Lewis H., Jr.: '1 h-: ancer of the
rectum, 400.
Adrenal — ectopia of, 395 ; sultstam c in Addison's dis-
ease, 874.
.\drenalin— active principle of suprarenal gland ?. 273 ;
chlorirt in eye surgery, 350. 3-'!*. 43S,
Adulteration of food, 71, 325, lI'.Ci. tW. -VUi. Hi)7.
\duIierations increase, 922.
Vdvf-rtisers and readers, suggest! '■
A.,'r-. average, of population, 448 ;
\m.
Vgiie, environment as cause, 715.
\id, first, to injured. 565.
\ir-paMages, upper, endoscopy of, 678.
.\ir— carbonic oxid in, 485; hot. therapy, 597, 509:
liqtiid, in cancer, 570; opfrn. in tuberculosis, 58ft ;
analysis «f, TrflT.
Alabama, child labor in, 825.
Albargin or gelatose silver in gonorrhea, 906.
Albumin — Bence-Jones and myelopathic albumosuria,
314 ; tests for, 750, 836 ; origin of, 749.
Albuminous expectoration following thoracocentesis,
287.
Albuminuria— after 50, 152 ; in Bright's disease, 359 ;
of pregnancy, 116.
Albumosuria, myelopathic, 314, 871.
Alcohol— as beverage, 108 ; does familiarity breed
contempt ?, 878; diseases relating to use, 687;
effect on gastric secretion, 870; in acute infectious
diseases, 60, 62; in therapeutics. 108; question,
psychology of, 728; seroantitoxicity of, in tuber-
culosis, 318; use of, 1012.
Alcoholic — cirrhosis of liver, 32 ; heredity in children's
diseases, 906.
.Alcoholism — and post exchange, 759; and tubercu-
losis, 206 ;* in children, 950
Algiers and Riviera, climates, 236.
Alimentary glycosuria in liver disease, 829.
Alkalescence in general katabolism, 814.
Alkaline medication, 118.
Allen, Martha M.: What the W. C. T. U. is doing to
fight the " patent medicine enemy," 925.
Allyn, Herman B.: Pericarditis as a terminal infection
of chronic Bright's disease, 615.
Alopecia areata, 757, 912, 913, 914.
Alter, Francis : A modification of Gersuny's method of
paraffin injections in socalled saddle-nose, to pre-
vent disturbance of muscular action of nose, 825.
Altitude— effect on blood, 367 ; on heart, 129 ; in fact
and fancy, 784.
Aivarenga prize, 646.
"A man of science," what is?, 759.
Amaurotic family idiocy, 151.
Amberg, Emil : The surgical anatomy of the middle
ear; A factor in favor of early interference in
suppurative affections (with demonstrations), 773.
Amblyopia, toxic, 687.
Amboceptors, hemolytic, production of, by serum in-
jection, 593.
Ambulance, 127, 287, 484, 565, 566, 794.
Amebas, parasitic, 748.
America, suicide in, 564, 800.
American Medical Association— fellows of. 804 ; surgi-
cal section of, 34.
American medical bibliography, 424, 482,
American Medicine, subscription price, 561.
American — mineral waters. 30; Steel and Wire Com-
pany, emergency hospitals of, 285.
Ames, Azel ; Vaccination vs. disinfection, 531.
Ametropia in kindergarten children, 402; eye-stiain
cause of epilepsy, 21 .
"Ammons, his, dropped," 2.
Amnesia, 432, 822.
Ampuiaiions, 193, 488, 859, 869.
.Amy! nitrite, bum of eye and face, 448.
Anaerobic bacteria in fetid suppuration, 952.
Analgesia, local, by heroin, 569; of teeth, by elec-
tricity, 352.
Analogs and sensory hallucination, 630.
Anastomosis— intestinal, 90, 110, 652,789,932; of por-
tal vein and vena cava, 987.
Anatomic changes, permanent, produced by sugges-
tion ?. 368.
Anderson's method, modification of, 702.
Anemia— edema of, 273; hysterc«:tomic5 during, 356;
pernicious, 16. 430, 633, 634, 779, 985; pernicious,
cases not, 904; red cells in, ring-shaped bodies
(nuclear remains?), 967; repeated small hemor-
rhages cause, 662; secondary, pernicious type
with jaundice, 221 ; spinal cord in, 228; splenic,
4H7, 597, 6:17 ; Uncinaria duodenalis cause of. lOl.
Anesthesia— accidents of, 776; asphyxia in, 982; by
compression of carotid artery, 751 : by methyl
chlorid, 751 ; chloroform. 72, 313, 519; incomplete,
dangers, 4.50, 728; intratracheal method. 991;
local, 6&if>,690; nitrous oxid, prolongation by, 'MVi ;
-spinal, 196, 473, 990; with eihv! brninifl. is. 279 ,
rthyl chlorid, 233.
Anesthetic leprosy, 5'28.
Anesthetics, 23.3, -279, 715.
Aneurysms, K5, lH, .350. 4.'i9. 17'.. 7 1 7 -^ '
Angina pectoris, 295, lOlO.
Angiomas, :?59, 690, 981 .
Angiotribe in surgery, 476, 489.
Animal — parasites, 11 ; vaccine, 349.
Animals— diseases and foods, 960 ; pet, germ -carrying,
592; Ronigen rays in treatment of, 607 ; various.
tubercle bacilli from, 93.
Ankles — arthrodesis for infantile paralysis, 256 ; weak,
children, misapplied mechanical support, 79.
Ankylosis, reestablishing mobility after, 595, 8^^.
Ankylostomiasis, government report on, 204; in Flor-
ida and Cuba, 100; most common of serious dis-
eases of southern U. S , 776; with symptoms ot
pellagra, 99.
Anomalies of appendix, 979.
Anonymous communications, 124.
Anopheles, new, 349.
Anthrax, 46, v86, 358, 750.
Anthropoid apes, motor cortex exemplified by, 636.
Anthropometry and new stiipes, 1^.
Anticanteen law, harmful e^cts, 880.
Antipyrin, incompatibilities of, 757.
Antisaloon league, national, 955.
Antisepsis— and asepsis, 70 ; internal, dangers, 598,
Antiseptic— new. septoform,835; treatment oftyphoid.
647 ; treatment of wounds, 48-1.
Antiseptics, inhalations of in tuberculosis, 598.
Antiserum method of differentiating blood, 374.
Antispitting crusade, 286, b&^.
Aniitoxin--<liphtheria. Ill, 699,715; for hog cholera
365; for tetanus, 286.
Antityphoid inoculation, 830.
Antivivisection, 92, 801.
Antrum of Highmore — operation in epilepsy, 676 ■
empyema of, 30, 309.
Anuria, 229.
Anus, artificial and enterectomy, 311.
Aorta affections (Musset's sign) of, 353 ; aneurysm of
350, 829.
Aortic regurgitation, 308.
Aphasia— and mutism, 152; motor, from injury t-i
head, 276; sensory and verbal amnesia of. 822.
Aphorisms, medical. 122.
Apocynum cannabinum in dropsical conditions, f 3;j.
Apoplectiform septicemia in chickens, 192.
Apparatus— for hypodermoclysis and intravenous in-
jections, 910 ; phototherapeutic, 515
Appendages, uterine, inflammation of, 834.
Appendicitis,72, lO^, \^\ 185, 2:il ,276, 389, 430, 471 .529
690, 629, 794, 804, 906; danger point in, 530; diaj:
nosis, 529, 670 ; extrauterine pregnancy diagnosed
as, 795; gangrenous, with perforation, 170, 610:
incision in, 5:i0: infections in region of liver fol-
lowing, 193; left- sided, 596; leukocytosis in, 396 :
lung complicalinns with, 951 ; operation for, ulti-
mate results of, 629; pathology of, 48,105; peri
tonitis complicating, 73; treatment, 27.5, s -
872 ; when necessary to operate in, 794 .
Prof Sonnenburg, 185.
Appendiceal disease in female, ant!
trcatment,885.
Appendix — abscess of, intraperitonr;i . . ;!i,
lies of, 979; autopsy findings on, 832; carcinom:i.
primary, 360 ; diseased and normal, anatomy of,
557; foreign bodies in, 667; hyperplastic tubercu-
losis of, 39.3; normal length, position, etc., 90'!;
perforation within hernial sac, 311 ; removal dur-
ing other abdominal operations, 712 ; why s-houUl
we not treat gallbladder as?, 54.
Applicant's right to examine papers, 7.
Arctic coast, measles and other diseases among, 766.
Argemone mexicana, ;i5H.
Argument with politicians, 722.
Argyrol— in acute gonorrhea, 6iJl ; in di.seases <-t
nose, throat, ana ear, 868.
Arm — amputation of, 869; paralysis of, in drlivciy.
755; sore, during recent vaccinations, cause, 88.
Army— cholera in, 802; health of, 526, 802; foreign
medical corps, 877, 880 ; medical department, 404 :
medical school, 46; navy anti marine corj's. 041
nurse corj»s, 89 ; Fhilippine, health in, 4-1 >
tion of recruits in, 826; surgeons, la* U
venereal diseases in, 847.
Airhcnal.235, 835.
.\ivfnic- dermatoses, 157 . i"iii<l in hronchitis of chil
dren, 6.39; poisoning, loy.il < ..nimission on, 88.
.Arsenical— necrosis, 532; poisoning due to lontimn
natcd Iwrtr, 516.
Arterial thrombosis in typhoid, 725.
Arteries— carotid, compression of, anesthesia by, 75]
femoral thrombosis of. 195 ; hyr>ogastric and ovar-
ian, ligation of, 831.
10l«
INDEX
Arteriosclerosis, 112, 238, 862, -178.
Arteriovenous aneurysm, surgical treatment of, 35.
Arteritis in typhoid, 726.
Artery— carotid coin pression for anesthesia, 751 ;
femoral, thrombosis of, 195; external iliac, ligation
of, lU : internal iliac, ligation of, 476 ; left inferior
thyroid, absence, 170; Ungual, ligation, through
mouth, 191 ; mesenteric, embolism of, 433.
Arthritis -chronic nonsyphilitic, calomel in, 399; de-
formans, 4(J6, 652 ; during scarlet fever, 985 ; ex-
perimental rheumatoid, 319 ; pneumococcic, 274 ;
septic, open method treating, 194.
Arthrodesis of ankle for infantile paralysis, 256.
Articular rheumatism— and immunity, 328; antistrep-
tococcic serum in, 31; pathogenesis of, 75l> ; so-
dium salicylate in, reverse action, 312.
Artificial -anus and enterectomy, 311; fistula adjuvant
to stomach operations, 533.
Ascaris lumbricoides, reflex convulsions due to, 112.
Ascites in fetus, dystocia due to, 75 ; with abdominal
tumors, 271.
Asepsis and antisepsis, 70.
Asexualization, obesity as consequence, 690.
Ashmead, Albert S.: Beriberi among the Chinese, 962 ;
origin of pre-columbian tuberculosis, 25*) ; trans-
mission of leprosy by fish and spore life of the
lepra bacilli, 90-
Asia, medical and surgical notes from, 467.
Asiatic cholera, leukocyte variations in, 7ol.
Asphyxia during anesthesia, 982.
Asphyxiated newborn, artificial respiration, 309.
Aspirin, 158, 236, 675, 989.
Asthenopia, malaria in, 631.
Asthma, bronchial, 554.
Astigmatism and eyestrain, discovery of, 618.
Asylum— insane, Nijchigan, t)07 ; insane, overcrowded,
645.
Ataxia — locomotor, crises of, 398 ; locomotor, educa-
tional movements, 78 ; locomotor, exercise in, 313 ;
locomotor, febrile crisis in, 395 : locomotor and
syphilis. 111; vasomotor, further contribution to
subject, 729.
Athletics, systematic, value, 919.
Atmokausis, castration by, 116.
Atmospheric pressure, variations in, and human or-
ganism, 112.
Atony of stomach, 871.
Atoxyl, toxic power of, 155.
Atresia of vagina, 382.
Atrophic — influence of craniospinal nerves, 687 ; rhi-
nitis and injections of paraffin, 394.
Atropin — in colic of lead poisoning, 111 ; effect on
pancreatic secretions, 353 ; intestinal obstruction,
130; of optic nerve, strychnia in, 437; of skin,
idiopathic, 690.
Atwater, Professor, on temperance reform, 918,
Au pied de la lettre, 883.
Auriculoventricular orifice, systole interrupted at, 153.
Auscultatory percussion, 791.
Australia, food adulteration in, 325.
Autointoxication and mental and nervous diseases, 664.
Autopsy — closing body after, 768; findings on appendix,
832 ; four hours postpartum on subject with ventral
hysteropexy, 1004.
Autolysis in exudates, 984
Automobiles — and medical journal, 164 ; physicians
may not speed, 166.
Avulsion of brachial plexus, 636.
Axilla, carcinoma of, amputation of arm for, 869 ;
glands of, temporary hypertrophy after labor, 271.
TJaby insurance, 917.
-'-' Bacilli * diphtheria, 998 ; in exposed persons, 391 ;
diphtheria, in well p-^rsons, frequency of occur-
rence, :^9^^; diphtheiia, isolation of well persons,
391 : diphtheria, virulence of, in well persons, 391 ;
diphtheria, new stain for, 948 ; lepra, spore life of,
90 ; tubercle, from various animals, composition,
9 J ; tubercle, influenced by surroundings, 860 ;
typhoid-colon group of, intermediate members,
infection produced in man by, 498, 578, 622 ;
typhoid, in sputum, 393; typhoid, in urine, 316;
xerosis, 998.
Bacillus— cholera, study of, 526; coli communis in
drinking water, 435 ; diphtheria, persistence after
serumtherapy, 353; gas, infection by, 846 ; Klebs-
Loffler diphtheria, 391 ; of gangrenous septi-
cemia, 318; pest, hemolytic power of, 318; pro-
teus vulgaris in surgery, 354 ; tuberculosis and
acid-resisting group of bacteria, 152 ; tuberculosis,
of human origin, may cause tuberculosis in cattle,
850 ; typhoid, 204 ; typhosus, brain abscess due
to, 111.
Bacteria— acid-resisting group, botanic relation to
tuberculosis, 15i ; anaerobic, in fetid suppuration,
952; metachromatic corpuscles in, 818; in fetus
of mother with typhus fever, 74.
Bacterial — cultures, 273 ; flora of intestinal mucosa of
normal rabbit, 546 ; flora of vaginal and cervical
canal in health, 689; virulence from cholera vibri-
ones. 793.
Bacteriologic— fluids, certain, lipase in, 393 ; study of
yellow fever, 715.
Bacteriology of clean and dirty steets,606; of gar-
ments and bedding. 287 ; progress in, 48.
Baker, Howard B ; Why do the stomach and pancreas
not digest themselves?, 691.
Baldness, treatment, 914.
Baldwin, J. F.: Should the tampon be used in postpar-
tum hemorrhage?, 16'.*.
Baldy, J. M : Drainage in operations for suppurative
diseases of the pelvic organs, 889.
Balfour, Vlr. Arthur, career of, 323.
Balloch, Edward A.: Intestinal obstruction, 182.
Balsam of Peru in bronchitis, 279.
Bandage, Heusner's extension, 753.
Banti's disease, congenitial syphilis simulating, 591.
Barlow's disease, 395, 870.
Bardwell, F. j.: Recovery after lightning stroke, 805.
Barker. Lewellys F.: Medicine and the universities.
143.
Barker's method in fractures of patella, 59^.
Barker, Prof.: Medicine and the universities, 121, 201.
Barnett, Charles E.; Atresia of the v.gina (colpa-
tresia), unilateral ovary and tube, with no uterus,
382.
Barnett, George C: High birthrate, 449.
Bartholow, Prof. Roberts: lodipin-phosphor, 142.
Bassett, V. H.: The etiology of the summer diarrheas
of infants : A preliminary report, 417.
Baths— bed, 38; carbonic acid, in cardiac disease,
874; continuous, in surgery, 191; electric light,
406, 478 ; ichthyol, in typhoid, 117 ; Kreuznach, in
heart disease, 750 ; mustard, tor suspended ani-
mation of newborn, 119; oxygen, for peritoneum,
738; pastil. 359; public, 87, 127, 325. 326 : Turkish
649, 797.
Batteries, galvanic, portable, 406.
Becquerel rays— ** burns " from, 113; in ocular diag-
nosis, 124.
Beer — consumption in Berlin, 366; contaminated,
arsenical poisoning due to, 516.
Belladonna ointment, poisoning from, 559.
Belt, abdominal after celiotomy, 688.
Bence-Jones albumin, 314,
Benedict, A. L.: Filtration of the stomach contents :
Changes in chyme due to delay in examination,
261. Notes on gastric acidity : Free HCl, 101.
Beneficence— not alone money-giving, 878.
Benevolence, maleficent, 124.
Benign neoplasms, 851.
Bennett, Arthur G.: Eyestrain and epilepsy ; A pre-
liminary report, 416
Bennett, William C: The new antiserum method of
differentiating human from other blood, and its
medicolegal aspect : Preliminary report of experi-
ments, 374.
Benzin poisoning, 352.
Berg, Prof. John, surgical clinic of, 786.
Bergey, D. H.: Immunity in the light of recent
investigations, 579.
Beriberi — among Chinese, 962; nature of, 949; on
shipboard. 616.
Berlin — cold drinks in, 168; surgical observations in,
66, 103, 185.
Bible, kissing, 364.
Bibliographic reference, unnecessary, 481.
Bibliography, American medical, 424.
Bichat, centenary of, 446.
Bicycle in dysoepsia, 276.
Bier's method in nontuberculous joint disease, 230.
Bierhoflf, Frederic : Further notes on vesical hyper-
esthesia in the female, 22.
Biliary — acids and surface tension, 470; ducts, extra-
hepatic normal microbism of, 153; obstruction,
cirrhosis of liver due to, 314 : system, affections
of, 151.
Bile-ducts, diseases of. 528.
Binocular magnifier for operating, 867.
Biogenesis and heredity, 827.
Biologic —properties of milk and nutrition, 417 ; studies
of old age, 950.
Biology — consciousness in, 241; new school of, at
Sharon, 86.
Birthrate— English, decrease in, 446; high, 449; in
New York, 881.
Births, unrecorded, 844.
Bismutose 990.
Bissell, William G. : Methods to be pursued and
sources to be considered in the adoption of a munic-
ipal water-supply, 667,
Bite, tick, strange disease from, 365.
" Blackwater " fever, 515.
Blacklist adopted, 723,
Blacks, southern, and northern cities, 243.
Bladder— curetment of, in chronic cystitis, 909 ; female,
tuberculosis of, 196; neuralgia of, 349; stone in,
114 ; suprapubic cystotomy withoutdistention,514;
ulcer of, 149 ; urinary, total extirpation for cancer,
568, 952.
Blastomycosis of skin, 663.
Blind, accomplishments of, 402; of New York, assist-
ance for, 404; shorthand system for, 247; teaching
to see, 323.
Blindness, congenital, operations for, 439; decrease
in. 365.
Blisters produced by suggestion, 368.
Blood— change, significance in diagnosis, 195; changes
due to altitude, 367; conditions postoperative, and
leukocytosis, 793; corpuscles, lecethin in, 874;
corpuscles, white, pathologic relation, 533; cultures
in pneumonia, 193 ; eflfect of Rontgen rays on, 11 ;
examination in severe burns, 746; examining,
273; films, rapid fixation of, 12; human, and
other, new method of differentiating. 374, 515; in
filariasis. 980 ; in icterus, 635 ; in typhoid, aggluti-
nating power, 984; in tuberculo is, 189; of par-
turient, leukocytes in, 357; pressure in diseased
conditions, 488 ; pressure in tumor of mediastinum,
393; purifying function of kidney, 831; serum,
antifermentative properties, 750; sewer rats,
trypanosoma in, 3l8 ; on paramecia, 3W4.
Biumenthal, Oliver A. : A foreign body impacted in
the larynx, report of a case, 327.
Blunder, politician's, 601.
Boards, examining, arrangement of topics by, 307,
Body, closing after autopsy, 768; human, dipterous,
larvas in, 394 ; tobacco's effect on, 403.
Boer war, statistics of, 5.
Boland, K. H. : The southern physician and his col-
ored patients, 768
Bone— affection in typhoid in children, 829; cysis of
middle turbinate, 676; cysts, x-ray and micro-
scopic findings, 79; fracture of fifth metatarsal,
113; grafting, new method, 55; malar, fracture of,
868; metacarpal, dislocations, 753; necrosis, pus
in pelvis as result. 887; temporal, venous system
and mastoid disease, 3.^0-
Boody, George : Postmortem observations on the ap-
pendix, 262.
Boric acid— as food preservative, 71, 566, 607 ; solu-
bility of, increasing, 278 ; toxicity of, 395.
Bossi's dilator, 117, 356, 637
Botanic relation acid-resisting bacteria and tubercu-
losis, 15!.
Bottini — incisor, new, 114; operation, 30, 191.
Bougies, elastic metal, labor induced by, 436.
Bovine malady, infectious, 844.
Bowden, D. T.: Double Pott's disease, 806.
Bowel — obstruction of, 232; paralysis of in peritonitis,
48«.
Brachial plexus, avulsion, 636.
Bradford, E. H.: Arthritis deformans, 652.
Brain — abscess, idiopathic, 690; abscess in typhoid,
111: abscess of optic origin, 89; adhesions in,
traumatic epilepsy, 115; disease and arterio-
sclerosis, 2:^8 ; function and cerebral localization,
70; knifeblade removed from, 764; sinuses, dila-
tion of, 834; slate pencil in, 20; tumor of, 554,
907.
Breast -cancer of, 35, 180; cancer of, removal of
ovaries, 754 ; male, adenocarcinoma of, 824.
Breath, offensive, treatment of, 437.
Breech presentation, fetal hydrocephalus in, 356.
Brewers' yeast -action, 582, 874; in diabetes, 990.
Bribe-givers, professional, 721.
Bridge, Dr., on management of tuberculous lung, 940.
Briggs, W. A.: Rectal approach in obstetrics, 545.
Bright's disease — chronic, pericarditis as terminal
infection, 615; surgical treatment, 471; rational
treatment, 553 ; with edema and albuminuria, 359.
Brinton's disease, 319
British Medical Association, reorganization of, 48.
Brock, G. Sandison : Salsomaggiore, 225
Brodel, Max : A more rational method of passing the
suture in fixati n of the kidney, 176.
Bromids in mental diseases, 862.
Bronchial -asthma, 554 ; glands, chronic swelling, 192.
Bronchiectatic abscess of lung, surgery of, 473.
Bronchitis— acute, treatment, 437; ad^moids caused
by. 677; balsam of Peru in, 279; caused by irri-
tant inhalants, 1011; chronic, 400; intratracheal
route in. 77 ; of children, arsenic iodid in, 639.
Bronchopneumonia — in children, 236; infectious, 713;
inhalation of irritants, 1011.
Bronchopulmonitis, pathogenesis, 317.
Brooklyn, incarceration of intoxicated persons forbid-
den, 881.
Brothers, our outside, 880.
Brown, Drs Gustavus, the, 246-
Browning-Magee case 126.
Brunner's glands, function, 871.
** Brush discharge" in chronic ulceration of leg. 608-
Bubo, syphilitic, 156, 190.
Bubonic plague. 565, 686,724, 924 ; in California, 726 ;
in New York, 996; in Yokohama, 724 ; suspected
on shipboard, 802.
Buccal -endodiascopy, 194; leukoplasia, treatment,
38; mucous membrane, fat-secreting glands in,
157.
Bulbar paralysis, degenerative, 33.
Bullard, J. W.: Congenital hernia of the liver into
the umbilical cord, with report of a case, 742.
Bullard, Marguerite J. : A study of the bacterial flora
of the intestinal mucosa of the normal rabbit, 546.
Bullet wounds of intraperitoneal viscera, drainage in.
138.
Bumgardner, Dr., remarks concerning poisons and
narcotics, 719.
Burke benefaction, 41, 142, 285, 790.
Burns, 190: by amyl nitrite, 44S; from Becquerel'srays.
113 : phosphorus, 962 ; picric acid in, 836 : severe,
blood examination in, 746 ; x-ray and malignant
growths, 688.
Bursa omentalis, fatal hemorrhage into, 831.
Business phase of our daily work, 976.
Butter preservatives in, 484
Buttermilk as infant food, 6;^7.
Cabot, Richard C; Preliminary note on ring-shaped
bodies (nuclear remains?) occurring in the red
cells in cases of anemia, 967.
Cacodylate, iodomercuric, 478 ; strychnin, in tubercu-
losis, 8:i5.
Cade, oil of, in seborrhea, 158.
Cairo, medical practice in, 550.
Calamities, stifferers from, relief fund for, 527.
Calcareous — degenerescences of some neoplasias, 870 :
deposits in trachea, 678.
INDEX
1017
Calcium eosolate, 599.
Calculi, hepatic, 6»8; intestinal, 559; renal, 632,688,
717 ; ureteral in male, 209
California, climatology of, 828 ; plague in, 282.
Callous sinuses of abdominal wall. 117.
Calomel— in chronic nonsyphilitic arthriti*, 399; in
tabes, 3l3.
Camphorated oil, subcutaneous injections, 837.
Camphormania, 46.
Canada, medical license act for, 46.
Candler, Fred.: Herpes complicating pneumonia. 805.
Cancer (see carcinoma), 3>, 570; after hysterectomy,
recurrence, 558 ; and allied states, a new theory,
809, 851 ; and tuberculosis, 392 : cataphoric treat-
ment of, 406 ; cause, 228, 809, 851 ; distribution of,
854 ; frequency, predominance in cities, 750; germ
of, 485;" hospitals for destitute, 763 ; in Germany,
168; in Holland, 168; in Italy, 766; liquid air i..,
570 ; metastasis of, 8oi ; new treatment of. 199 ; of
ampulla of Vater. 987; of breast, 3'>, 180; of
breast, removal of ovaries, 754 ; of mouth and
neck, operations, 648; of rectum, 460, 648; of
stomach, 690. 1001 ; of urinary bladder, extirpa-
tion of, 568, 9")2; of uterus, 89, 188, ZH, 356, 688.
847; predilection for feminine sex, 750; relieved
by exploratory laparotomy. 738; research, 168;
serumtherapy of, 519 ; tissue, transplantation of,
474 ; vaginouterine, laparotomy for, 754 ; x-ray in
88, 246, 406. 530, 568, 688; 766, 870, 915, 9}'3.
Cancroin, injections of, in carcinoma, 870, 9t5.
Canine rabies, 317, 984.
Cannon Ball Farm bill, 167.
Carbolic acid— in fixation of kidney, 194 ; in lupus.
59S: in smallpox, 875; subconjunctival injections,
in conjunctivitis, 439 ; subcutaneous injections in
tetanus, &75
Carbon monoxid poisoning, chronic, 338.
Carbonic— acid baths in cardiac disease, 874 ; oxid
air, 485.
Carbonyl hemoglobinuria, 338.
Carbuncles, 128, 40O, 984.
Carcinoma (see canceri, 217, 3S7 ; and intestinal poly-
posis. 276; cured by .-Vtlamkiewicz's serum. ►30;
direct transference, 830 ; electric sterilization, 421 ;
incipient, of endometrium, 228; injections of can-
croin in, 870 ; in women, clinical aspects, 31] ; of
appendix, primary, 350; of cervix, 357, 569;
obstruction to delivery, 398; of extremities, pri-
mary, 517; of hepatic flexure, 32; of large intes-
tine, 392; of larynx, IKI; of liver, and diabetes,
692; of mammary gland, 5:i0, 869 ; of penis, 354,
553 ; of scalp, 158 ; of sternum by metastasis from
uterus, 948; stomach, hydrocloric acid in, 230;
operation for, late results of. 396; of testicle, ex-
cision of lumbar lymphatic gland in, 794 ; opera-
tion for, late recurrence after, li&S, 35i; uterine
189, 8:i4: x-ray in, 217. 387, 406,981.
Carcinomatous uterus, abdominal extirpation, 356.
Cardiac— binder, Deschamp's, 118; death from diph-
theria toxin, 2:il ; disease, carbonic acid baths in,
874 ; disease, chloroform in. 278 ; inadequacy, 554 ;
interventricular septum, congenital defect, 834.
Cardiff, anatomic museum at, 89.
Care of sick poor, 982.
Caries, dental, treatment, 198.
Carnegie Institute, 561 ; Index Medicus should be
revived by, 481 ; to control Marine laboratory,
285; trust money, allotment of, 513.
Carotid arteries, compression of, anesthesia by, 751.
Carpal scaphoid, fracture, 114.
Cars, open, spitting from, 44.
Cartilage, nasal, disease of, 308.
Case, C. L.: Infant feeding, 768,
Case, nature of, 684.
Castelli, E.; Idiopathic vaginismus and sterility, 586.
Castor-oil — administering, 3V8 ; in typhoid, 687.
Castration - by uterine atmokausis in hemophilia, 116 ;
effects of, 792.
Casualties-by cable, 364 ; deaths from, 281.
Cataphoresis, mercuric, in epithelioma, 406.
Cataphoric treatment of cancer, 4(*6.
Cataract — 4,000 operations for, 88 ; beginning, iodin
solution in, 479.
Catarrh, chronic nasopharyngeal, 270.
Catarrhal -conditions, formaldehyd gas in, 924 ; deaf-
ness, 671.
Caies, Benjamin Brabson : Some surgical cases met in
private practice. 366.
Catgut — effectual sterilization, 717; sutures in rectal
fistulas, 9
Cathartic, synthetic, purgalin, a, 638.
Catheter, double, for prevention of cystitis in women,
116.
Catheterization, ureteral, 515, 648.
Cats, abnormal fear of, 723.
Cattle, human tuberculosis bacillus may cause tubercu-
losis, b50: immunization o', against tuberculosis,
907.
<'auda e<)uina, syphilitic lesions of, 192.
< auterizaiion, transvesical, in prostatic hypertrophy,
195
t !autery clamp, electric, in uterine cancer, 847.
'rustics, in lupus, 235,
< avities, pulmonary, treatment, 155.
V ecum — and ileocecal junction, resection of, 311 ; dys-
enteric perforation of, 794 ; excision of, 309, 568.
( eliotomy — abdominal belt after, ti88 ; biinguinal, for
uterine retroversion, 489 : vaginal, illumination of
abdominal cavity in, 596 ; wound, median, 6;il.
' ellulitis — ocular, following Bowman's operation, 448 ;
of orbit following infection from finger, 948 ; pfl-
vic, and uterine nbrold^, 64 9
Cells— ethmoid, sarcoma of, 707 ; red, in anemia, nng-
shaped bodies occiuring in, 967 ; with eosinophile
granulations, 393.
Census bulletin, 247.
Centenary of Bichat, 446.
Cephalorachidian fluid, hemorrhagic. 593.
Centralization and pure-food legislation, 441.
Cerebral-hemorrhage, epiphenomena of, 219; locali-
zation, 70, 528; paralysis, infantile, 433 ; tumor
151. '
Cerebrospinal fever, UO, 153,835: fluid, composition
of. 111.
Certificates— false, in cholera, 325 ; lying, of death
917; required from invalids, 802 '
Cervical— canal in health, bacterial flora of, 689; ver-
tebras, fracture- dislocation of, 648.
Cervix, carcinoma of, ;^7, 569; carcinoma of, obstruc-
tion to delivery, 398; expansion, with Bossi*s
dilator, 356; lacerations, 7y0, 834.
Cesarean section -50 cases, 796 ; Friich's fundal incis-
ion, 795; in eclampsia, 754 ; indications for, 8.^.
Chairs, clinical, in real university medical school, 202.
Chalodermia, 158.
Chancellor, C. W.: Mineral waters : Their use and
abuse. 901.
Chancre, extragenital, 914.
(Chancroid, rectal and genital, 308
Characters, acquired, nonheredity of, 151.
Charitable institutions, increased appropriations asked
for, 645.
Charities — medical abuse of, 882; private, and tax-
payer, 641.
Chase, William S.: Medical licensure reciprocity, 10.
Chauvinism in medicine, 528.
Chemic— pathology of saliva in diagnosis, 57 ; study of
fluid in pancreatic fistula, 133.
Chemistry, use of, by Knglish and Germans, 521.
Cheney, William Fitch : Lobar pneumonia in infants,
13 . .
The diagnosis of cancer of the stomach, 1001.
Chicago— diphtheria in, 924; health department, bul-
letin of, 206, 405, 569, 645; human life in, duration,
increasing, 87; infectious diseases in, 724; milk
inspection in, 722; schools, drinking cups to be
abolished, 724; sewage and drainage canal, 247 ;
smallpox record, 942; typhoid in, 326; what is
the matter with ?, 562.
Chickenpox, exaiithem abnormally developed, 231.
Chickens, apoplectiform septicemia in, 192.
Chilblains, treatment of, 559.
Child — dependent and subsidy, 641 ; acute diabetes in,
714; acute occlusion of esophagus in, 832; and
baby insurance. 917 ; congenital dilation of colon,
832; gangrenous intussusception in, 194; labor,
243, 247, 485, 825 ; paralysis of limbs, 92 ; unborn,
heir, 326
Childbed, external examination in, 754; fever, avoid-
ance of, 36.
Childbirth, examination and treatment of women after,
819.
Children — alcoholism in, 950; bronchitis of, arsenic
iodid in, 639 ; bronchopneumonia in, 236; chronic
joint disease, 309; chronic purulent otitis media,
679; cigaret smoking among, 366; convalescent,
state homes for, 845 ; Cuban, and " purple
mother," 762; deafness and ear-diseases in, 678;
dependent and neglected, Minnesota school for,
60-i ; empyema in, 149, 472; epilepsy in, causes,
927 ; gastric contents, examination, 70 ; goat
milk for, 984 ; hemoptysis in, 63? ; Illinois school,
examination of, 365; in Brooklyn, mortality
among, 86; kindergarten, ametropia in, 402;
mental disorders of, 191; neurotic, 432; school,
medical inspection of, 484, 76:< ; school, trachoma
among, 644 ; summer disorders in, dietetic manage-
ment, 228 ; tracheobronchitic adenopathy, 38 ;
tropon in, 874; tuberculous infection, unclean
finger nails a cause, 871; typhoid in, 198, 748;
typhoid bone-and-joini affections, 829; under one
year, strangulated hernia in, 690 ; weak ankles,
misapplied mechanical support to, 79; with con-
tagious diseases, city hospital for, 920 ; young,
clubfoot in, 78.
Children's diseases, alcoholic heredity in, 906.
Chile, liquor law in, 666.
China— hospitals in, 54 ; new medical college in, 7.
Chinese physician seeks medical license, 923.
Chinic acid in gout, 756
Chloral tremor of muscles resembling general paraly-
sis 831.
Chloralic medication in eclampsia, 618.
Chloroform — administ ation of, by gaslight, 154 ; and
ether, 113, 432, 519; aneithesia, 72, 313,519; in
cardiac diseases, 278.
Chloroma, 394.
Chlorosis — ocular affections (n, 489; treatment, 197,
•287.
Cholecystectomy, 311. 753.
Cholecystoiomy in movable liver, 354.
Cholelithiasis, 872 ; treatment, 79U, 828, 981 , 986.
Cholera, l25, Hw, 246, 285,286, 3-27. 446, 54«, 566, 566,
644, 646, 724. 76:1, Hl5; api ropriation 629; Asi-
atic, leukocyte variations in, 751 ; bacillus, to
study, 526; false certification in, 325; hog, 826,
:{65; infantum, trratmeni, 911 ; in army, 802; In-
oculations in India, 247; morbus, true, without
pain, 650; precautions against 607; saline injec-
tions in, 288; treatment, 1009; vibriones, bac-
terial virulence from, 793.
Cholesteatoma of middle ear, 679.
Chordee. treatment, '.ihV.
Chorioepithelioma matignum, 116.
Choroid— metastatic sarcoma of, 788; traumatic rup-
ture of, 830.
Choroidal affections, treatment, 313.
Chorionic epithelioma malignum, 952.
Christian science, 442.
Christ ne, G. Maxwell : Concerning Dr. Schell's
article on pseudocyesis, 609.
Chromatic reactions of blood corpuscles of diabetics,
319.
Chromidrosis, 979.
Chronic and acute, terms, 869. .
Church, modem, for profits or the law and the lady, 442.
Churchill, Frajik Spooner: Correction, 12.
Churches, unsanitary, 814.
Chyme, changes in, delay in examination, 261.
Cicatrices, electricity in, 437.
Cicatricial tissues, continuous currents on. .^98.
Cigaret smoking— among juveniles, 366; effects, 881 :
fine for. 445: in India, 126.
Cigars, molds on, 126.
Circulation, exercise on, 614.
Circumcision, method of, 632.
Cirrhosis hepatic, 32, 314. 470 ; pulmonary, 229.
Cities — American, and suicides, 54v4 ; great, sanitation
in, 483 : increase of population in, 961 large, in-
fant mortality in, 672 ; northern, and southern
blacks, 243.
Citrophen,39, 638.
City waste, disposal of, 87, 7h8.
Civilization, advanced, and failing eyesight, 919.
Clamp, electric cautery, in cancer of uterus, 847.
Clamping ureter in surgical operations, 693.
Cleveland and smallpox, 36.^.
Climate — and pulmonary invalids, 108 ; for dysmenor-
rhea, 235 ; of California, 828 ; of Maine, 828.
Climatic treatment— of abortion and sieriUty, 437 ; of
chlorosis. 197.
Climatotherapy of Graves' disease, 278.
Clinic— dermatologic, 6 years in, 349; Nicoladoni's,
Gratz, 5^7; Olshausen's gynecologic, 103; surgi-
cal. Prof. John Berg's, 786 : the ward, 548.
Clinical— chairs in real university medical school, 202 ;
abdominal cases, notes on, 890 : thermometer, 605,
747.
Clothes -old, source of infection, 84; sterilized, for
nurslings, 833.
Club-foot in young children, new principle of curing, 78.
Cobra venom as remedy, '^6.
Cocain-as thermogenic, 229 ; fiends, negro, 764 ; for
gastric pain, 118 ; intradural injections, 117 ; suba-
rachnoid injection, 788.
Cocainization, spinal, 151.
Cocci and rheumatism, 435.
Codein and elixir terpin hydrate, 400.
Codliver-oil, value, 9t'2.
Coffee, of fig, 7.
Coffey. R. C. : The importance of proper temperature
in the administration of salt solution : An accurate
method of determining temperature, 301.
Cohen, Solomon Solis : A further contribution to the
subject of vasomotor ataxia, 729.
Coincidence, a unique, 723.
Cold— applications in typhoid, stimulating, 357 : in
skin diseases, 914 ; in venereal ulcers, 113.
Colds — do not neglect, 801 : etiology, 689 ; symptom-
atology. 689 ; treatment, 689.
Coleman, N. R.: Medical licensure reciprocity, 170.
Coleman, Warren : 1^'pes of infection produced in
man by intermedi <te members of the typhoid-colon
group of bacilli, 498, 678, 622.
Coley, William B.; The influence of the Rontgen ray
upon the different varieties of sarcoma, 251.
Colic -hepatic, floating kidney a cause, 273 ; hepatic,
treatment, 197 : in lead poisoning, atropin in, lU.
Colitis — artificial fistula in, 553; mucomembranous,
72; mucous, etiology of, 223.
Colleger ourse, shortening, another suggestion, 682 :
degree in 2 years, 642 ; settlement writer, appeal
of. 644.
Colics' fracture — shortening of radius in, 748 ; treat-
ment of, 592.
Colloid struma, intratracheal, 895.
Colon— ascending, excision, 309 ; carcinoma of hepatic
flexure, 32.
Color of feces, 889.
Colorado— and recovery from certain diseases, 647 ;
fuel and iron company, sociologic department,
878 : what class of cases of pulmonary tuoerculosis
dowtllin.547.
Colored patients, and southern physician, 768, 928
Colors in treatment of insan'*, 9'28.
Colostomy, 9.
Colpatresia, 382.
Columbia fellowships for postgraduate study in France,
826.
Collyria with sodium cacodylate, 797.
Coma, rcmarkab c ca'c, 31.
Communicati' ns, anonymous, 124.
Compressed tablets— stamping of, by Roman oculists,
44; uncertainly and undesirabilily, 910.
Concussion, spinal, 648.
Confessions of a physician, 164.
Congenital — blindness, operations for, 439 ; cavernous
angioma, 690; defect of cardiac interventricular
septum, 834 : dilation of colon in child, 832: dislo-
cation of hip, 34, 567, 716, 872, 888, 981 ; heart
Icsiims, etiology and symptoms, 230 ; hernia of
liver into umDilicat cord, 742; Inguinal hernia,
diagnosis and frequency, 872 ; pulmonary stenosis.
792; malformation, caused by defective coordina-
tion in utero, 637 : syphilis simulating Banti's dis-
ease, 694.
I
1018
Conjugal diseases of nervous system, postluctic,
111.
Conjiinctiviiis— contagious, 590; metastatic, in gonor-
rhea, 915 ; treatment. 318, 439, 963, lOU,
Consanguineous marriages, 247, 492.
ConsciousncsR- and nervous system, fC8; in biology,
241 ; in pathology, 241.
Consent, age of. 472.
Constantinople as medical center, 427.
Constipation— electricity in, 472; valvoiomy in, 48.
*' Consultant," meaning of word, TliiO.
Consultation practice, discourtesy in, 1.
Consumptive poor, 471.
Consumptives— cuspidors for, 127; state sanatoriums
for,8t.
Contagion, milk as source, 47.
Contagiosity— of alopecia areata, 914 ; of feces of tuber-
culouB, 72 ; of leprosy, 474
Contagious— conjunctivitis, 590; diseases, handling,
9; hospitals for, 167, 920; diseases, interment
persons dying of, 607; diseases, no hospital pro-
vision for, 957 ; eye diseases in New York schools,
206.
Contract practice, 81.
Contraction, of prostatic fibers, encircling the vesical
neck, 462.
Convalescent— children, state homes for, 846 ; indigent,
home for, 286 ; outings for, 405.
Convulsions — of unknown origin, treatment, 399;
reflex, due toascaris lumbricoides, 112
Cooke, A. B.: Some sociologic aspects of preventive
medicine, 34.
Cord spinal— injury of, 648; in severe anemias, 228;
spinal tumor, operation in, 517.
Cord umbilical -congenital hernia of liver into, 742;
length of, 768; spontaneous rupture of, 755.
Cords, enlargement, false, 63(i.
Cornea— affections of, eserin in, 278 ; serpiginous ulcer
of, 439 ; tattooing, 448; ulcers, iodin in, 907.
Coronation honors for medical men, 2, 125,
Coroners' physicians, 285.
Corpuscles, metachromatic, in bacteria, 318.
'* Correspondence school " applied to medicine, 683.
Corrosive sublimate (see mercuric chlorid) — action on
hydatid cysts, ;^2 ; endovenous injections of, 310 ;
poisoning from vaginal douche, 1006.
Corsica, paludism in, 107.
Corson, Eugene R.: The oxygen bath for the peri-
toneum and its possible value— second report on
the cancer case relieved by an exploratory laparot-
omy, 738.
Cost of patient per bed-day in hospital, 956.
Cough— and hypertrophy of lymphoid tissue, 310;
whooping. Ml, 519, 963 ; pathogenic agent, 317,
881 ; to be placarded, 526 ; treatment, 199, 317,
399.836,871.
Craig, Charles F.: The pathology of chronic specific
dysentery of tropical origin, 571.
Craig colony, 246.
Craniospinal nerves, atrophic influence, 687.
Craniotomy, is it justifiable?, 477.
Cranium, gunshot wounds of, 228.
Creasote in pneumonia, 670.
Crede's method in endocarditis, 982.
Credulity, no law against, 759.
Cremation— progress in, 68, 163; statistics of, 126.
Cretinism, 193, 318, 715. •
Criminal— equivalent of insanity. 633 ; responsibility of
the epileptic, 687.
Criminality, habitual, as morbid condition, 91.
Criminals, reform of, 604.
Cripples, state aid for, 966.
Crookes' tube, special type, 906.
Croup, treatment of, 559.
Croupous pneumonia. 389, 687, 867.
Crural thrombosis, postoperative, 472.
Cryoscopy, 947.
Cuba— ankylostomiasis in, 100 ; return to medical bar-
barism, 918; sanitary precautions in, 847.
Cuban children, and " purple mother," 762.
Cultures bacterial, 273 ; stained, immunization against
pneumococcus by, 69«.
Cummings, Wm. M.: Reciprocity in medical licen-
sure, 10.
Cumston, Charles Green : Ruptured pus-tubes, 611.
Cups, common drinking, to be abolished, 724.
Curet and septicemia, 671.
Curetment of bladder in chronic cystitis. 909.
Currents -continuous, on sclerotic and cicatricial tis-
sue, 598; electric, diffusion of iodin by, 406; gal-
vanic, apparatus for sinusoidal alternation of,
406: high frequency, in pruritus, 159.
Curry, Joseph J.: On the nature of blood changes due
to altitude, 36".
"Surra" or Nagana. 96.
Curvature, lateral, rotation in, 632.
Cutaneous— medicine, ether as vehicle for, 479 ; treat-
ment of obesity. 599; tuberculosis, treatment since
Finsen method, 911.
Cyst— bone, 79, 676: hydatid, 352, 355: multilocular
ovarian, 351 ; of broad ligament, 278: of mesen-
tery, 688 ; of urachus, 763 ; pancreatic, 804 ;
sacrococcygeal, 72.
Cystic— degeneration of kidneys, 13 ; dilation of
ductus choledochus, 909 ; tumors of peritoneum.
191.
Cystitis— curetment of bladder, 909; etiology and
treatment, 5.V2 ; in women, prevention, 116 :
taberculous, diagnosis and treatment, 4:j3.
Cystocele, repair of, 171.
Cystoscopy -fallacies of, 72; in diseases of urinary
tract, 530.
INDEX
Cystotomy— in stone in bladder, 114 ; without dis-
tending bladder, 514.
Cytodiagnosis- of serous effusions, 907; technic of,
908.
Da(?osta, John C: An oven for the rapid fixation of
blood films, 12.
Da Vinci, Leonardo, and Andreas Vesalius, 995.
Daily work, business phase, 976.
Dane, John ; Remarks on arthrodesis of the ankle for
infantile paralysis, 266.
Danforth, I. N.: Case of cystic degeneration of both
kidneys, 13.
Darwin and Spencer, 202.
Datmg of canned foods, 44.
Davidson, Sarah K.; Bequest of, 326.
Davis, A. M.: Remarks on the hematology of rheu-
matism, 26"!.
Dead, pauper, dispute over, 846.
Deafness- catarrhal, 671; chronic progressive, 679;
in school children, 678; of middle-ear origin, 679.
Death— causes, as on certificates, 408; due to x-ray,
867; in epilepsy, 31 ; intrauterine, of fetus, 74;
lying certificates of, 917 ; prognosis of, 6u3.
Deathrate in 1901, 204; New Orleans, 205; Seattle's
low, ive.
Death-roll of 1902, 845.
Deaths— from reflex inhibition of respiration and of
heart, 293; from casualties, 281; in navy and
marine corps, 799 ; in New York, 1j5.
Deaver, John B.: Pus in the pelvis depending upon
and complicating appendiceal disease in ths
female : Methods of treatment, kHo.
Deciduoma malignum, 277. 477^ .Sfc8, 712.
Decortication of lung, for chronic empyema, 31 ] .
Defectives, mental, 272.
Defendorf, A. R. : The use and abuse of bromids in
the treatment of mental diseases, 862.
Deflection of septum, 676.
Deformities — caused by shoes, 713, 872 ; of foot, toes,
apparatus for, 49 ; of nose, subcutaneous injec-
tions of paraffin in, 488, 675, i'09 ; pelvic, in New
York, 307 : spinal, forcible traction in 228.
Degenerated forms of pneumococci in pleuritic exu-
dates, 871.
Degeneration — cystic, of kidneys, 13 ; fatty, of heart,
829 ; mucoid, in bilateral intraligamentous fibro-
myoma, 518.
Degenerative bulbar paralysis, 33.
Degenerescences of neoplasias, 870.
Deglutated frog, 82.
Degree, college, 81 ; in 2 years, 642 ; why require ?,
684.
Delirium tremens, strychnin in, 198
Delivery, carcinoma of cervix obstructing, 398 : frac-
tures during, 170; obstructed, hebotomy in, 795;
paral) sis of arm in, 755,
Dementia prsecox, diagnosis of, 336.
Dental— caries, treatment, lv8; colleges, "reputable,"
470 ; inspection in schools, 792 ; pulp, evolution of,
227; pulp, histology, 108.
Deportation and local responsibility for insane, 481.
Dercum's disease, 950, 1011.
Dermatitis — eczematoid, infectious form, 769 ; follow-
ing use of mercurial ointment, 829 ; hiemalis, 1009 ;
repens, 1009; x-ray, 913
Dermatologic clinic, 6 years in, 349.
Dermatosis, arsenic, 157; hepatic insufl^ciency in,
192; pruriginous, faradization in, 158,1014; x-ray,
272.
De Schweinitz, E. A.: Some facts which show that
the tuberculosis bacillus of human origin may
cause tuberculosis in cattle, and that the morphol-
ogy and virulence of the tubercle bacilli from
various sources are greatly influenced by their sur-
roundings, 850.
The composition of the tubercle bacilli derived from
various animals, 93.
Detroit medical societies, consolidation of, 206, 283.
Dextrocardia, 229.
Diagnosis — leukocytes in, 190; by exclusion, 285 ; in
intussusception, 907 ; neurologic, 748 ; of stomach
cancer, 1001 ; sialo scmeiology in, 57 ; significance
in changed character of blood, 195; tuberculin in,
972 ; urine constituents, aid to, 656.
Diabetes — acute, in child, 714 ; chro'^atic reaction
blood cells, 319; insipidus, 31u; mellitus, 926;
treatment, 235, 990 ; potatoes in, 198 ; with hepatic
carcinoma, 692.
Diabetogenic leukomains, 318.
Diaphragm— influence on liver, 231 ; rupture of, 596
Diarrhea — infantile, of summer, 190, 40l, 417 ; parasite
of, 343, 1012 ; treatment, 76, 190, 199, 479, 7y7,
875.
Didelphys uterus, 910.
Diet — in rectal disease, 8; in summer complaint, 228;
intermittent milk, 599; in tuberculosis, 141. 4->l,
559; in typhoid, 228. 829; in uric acid diathesis,
790 ; valvular heart disease, .569.
Digestion — disorders in tuberculosis, 647 ; pancreatic,
32.
Digitalis, administration of, 478, 647,7.n6.
Dilation—of brain sinuses. 834; of colon, congenital,
832; of ductus choledochus, 909 ; of heart, hyper-
trophic, 118 ; of stomach, 713, 792.
Dilator, Bossi's, 117, .356, 637.
Dillingham, Frederick H : Some observations in re-
gard to smallpox, 493.
Dimples, sacrococcygeal, 72.
Dionin, 519.
Dipterous larvas in ihe human body, 394.
Diphtheria,644,708, 996; analysis 55 cases, 644 : batilii
in well persons, 1^90, 391 ; isolation of those ex-
posed, 391; bacilli, new stain for, 948; persist-
enc*, after serumtherapy, 353; bacteriology of,
391 ; committee on prophylaxis, 390, 391 ; in Chi-
cago, 924 ; infection, danger of from healthy per-
sons, 391; notice of fee for, 47; postscarlatinal,
434 ; treatment, .599. 715, 757, 990, 991 ; toxin,
cardiac death from, 231
Disease — alcohol in, 60; among Arctic natives, 766;
and accidents, 564 ; and insects. 21 ; ancient and
modem conception, 681 ; blood-pressure in, 4^8;
contagious, hospitals for, 967 : case, or patient,
treatment of. 879 ; fasting to cure, 942 ; history of,
161, 284; in navy and marine corps, 799: in
wf-men, 271 : of nails, 827 ; pancreatic, 980; pre-
vailing in Egypt, .56(i ; propagation by fly, 392;
strange, from tick bite, 365; transmission in meat
and milk, 633 ; ultra-violet ray in, 647 ; water in,
271.
Disinfectant — and disinfection, 961 ; new mercurial,
313.
Disinfection — and disinfectants 961 ; tor yellow fever,
760 ; of floors for plague, 3,3 ; of paper currency,
446; school-books, 481; versus vaccination, 287,
6:^1.
Disinfector, emergency, 148.
Dislocation, congenital, of hip, 34. .567. 716_, 872, 883 :
from sneeze, 666; in fracture of scaphoid, 114 ; of
elbow, resection, 639; of hip during normal labor,
755; of hip in rheumatism. 351: of metacarpal.
753; operative, of femur, 81^1; subacromial, from
muscular spasm, 275.
Dispensation, newer, 841.
Displacements of uterus, 846.
Dissecting room, to save paupers from, 29.
Dissection, sale of bodies for. 46.
District of Columbia — medical work in. S7 ; serums
and viruses in, regulate sale, 104 ; typhoid in, 286.
Diverticulum, inflammation and perforation, 905 ;
intussusception of, 355.
Divorce and marriage statistics, 879.
Dock, George: Pernicious anemias : Their diagnosis
and treatment, 15
Doctor — ambulance 484; and school teacher, 670;
country, and eminent professor. 82 : country, and
gynecology, 432 ; druggist p'aying, 721 ; ** of
achievement," 81; of optics, 604; protective
league, 645.
Dogmatism, " certain profession of," 681 ; in science, 6.
Dominion health bureau, 667.
Dorset, Marion: -ome facts which show that the
tuberculosis bacillus of human origin may cause
tuberculosis in cattle, and that the morphology
and virulence of the tubercle bacilli from various
sources are greatly influenced by their surround-
ings, 850.
The composition of the tubercle bacilli derived from
various animals, 93.
Dosage in radiotherapy. 554.
Douche — in aborting mastoiditis, 89; vaginal, 696;
vaginal, poisoning from, 006
Douglas, C. J.: An argument for total abstinence.
650.
Downes. Andrew J : The practical side of electrother-
mic hemostasis. 97('
Drainage by vagina of prevesical space, 597 : for pel-
vic disease, 5.57, 889 ; in abdominal and pelvic sur-
gery, 489; in empyema. 530; in intraperitoneal
bullet wounds, lo8 ; of internal iiiac fossa by
ischiatic notch, 636; permanent suprapubic,
517.
Dressing to prevent eschars, 278.
Drink, nutritive refrigerant 198.
Drop, morning, treatment, 1'>1.
Dropsical conditions, treatment, 633
Drug- habits, 486, 671, 719: plants, cultivation of, 86;
tablets, dangers of, 692, 8S3 ; trust, 126; uncon-
sciousness versus normal sleep, 647 ; unusual
effect on nervous system, 238.
Druggist playing doctor. 721
Drunkards, habitual, in insane asylums. 41^^.
Duct— biliary, cystic dilation, 909; biliary, normal
microbism of, 163; thoracic, abnormal position,
557.
Dudley, Benjamin Winslow, fee of, 405.
Dulness in aprendicitis, 670
Dunton, William Rush, Jr.; On the diagnosis ot
dementia praecox, 336.
Duodenocholedochotomy for retained gallstones, 276.
Duodenum — perforating ulcer of, 568, 591 : removal of
portion. 354 : stenosis of, 235.
Duval, C. W.: The etiology of the summer diarrheas
of infants : A preliminary report. 417.
Dyer, Isadore : A preliminary note on pompholi.x as
it occurs in New Orleans, 706.
Report of a case of blastomycosis of the skin
663.
Dyes, inspection of, 627.
Dysenteric perforation of cecum, 794.
Dysentery — appendicitis consecutive to. 794 ; at St.
Vincent, 526; epidemic, 326, 414; pathology of,
317, 571; treatment, 237, 599, 639, 688, 757,
789.
Dysmenorrhea, 36, 118, 236, 278, 834.
Dyspepsia — 836 ; bicycle in, 279 ; cachets, 199 ; phos-
phaturia in, 119.
Dystocia due to ascites in fetus, 75.
Dystrophies of skeleton, 870.
INDEX
1019
E^r, -18, 678; anatomy of, 778 ; and diseases of, 48,
ti78, 679 ; treatment, 88, 679, 867.
Echinococcus of liver, 114.
Eclampsia, 117,312,328; causes of, 706,910; patho-
genesis of, 689; prevemion, 313, 674, 706; treat-
ment, 117. 313, 356, 518, 706, 754, 894, 10j4.
Economy, expensive, 561.
Ectopia of adrenal, 39^.
Ectopic gestation, 867; diagnosis and treatment, 796 ;
intraperitoneal hemorrhage, 873.
Eczema, treatment of, 39, 912, 915.
Eczematoid dermatitis, infectious form, 769.
Eddy, Mrs., a reductio ad absurdum of, 996.
Eddyism aad infectious diseases, 800.
Eddyites, 364, 802, 840, 881; indicted for man-
slaughter, 722.
Edema — in Bright s d.sease, 359; of anemia, 273.
Education and insanity, 327 ; from standpoint of
physician, 48 ; higher, and women, 563 ; medical,
242, 491 , 512 ; of public in hygiene, 761.
Educational limitation of venereal diseases, 789.
Ertu :tion in reconstruction of finger tips, 139.
Effusions, pleuritic, 309, 831 ; serous, cytodiagnosis of,
907.
Eggs, nutritive value, 119. 676, 828.
Egypt, prevailing diseases in, 550.
Eisendrath, Daniel N.: The accidents of anesthesia:
Tneir prevention and treatment, 776.
Elbow, resection of, 538, 833.
Electric— analgesia of teeth, 352 ; currents, diffusion oi
iodin by, 406 ; light bath, 478 ; light conjunctivitis,
439; phenomena during earthquakes, 112; steriliza-
tion in carcinoma and sarcoma, 421 ; ozonation in
tuberculosis. 471.
Electric cautery clamp in uterine cancer, 847.
Electricity — and gastrointestinal muscuUture, 189; in
angiomas, 359 ; in cicatrices, 437 ; in constipation,
472; in gynecology. 109,269.435; in eczema, 39;
in rectalstricturc,38; influence onelectricians, 278.
Electro thermic hemosiasis, 530, 970.
Eephantiasis, prevention of, 445.
Ely, Leonard W.: Treatment of congetital hip dislo-
cation, 883.
Embalmcrs to be licensed, 247.
Embolism — of mesenteric artery, 433; pulmonary 173.
Embryo, Wolffian body in, 394.
Emergency hysterectomy, 397.
Eminent professor and country doctor, 82.
Emphysema, and wind instruments, 193.
Empyema— frontal, 472; m children, 149, 472; of
antrum of Highmore. 30, 309, 676; pathology of,
473 ; treatment of, 311, 472, 530, 556, 676.
Encephalomyelitis, acute, 112.
Encbondrosarcoma removtd by incision and x-ray, 925.
End-to-«Dd anastomosis, 932.
Endocarditis — and pericarditis, 433; Crcde's method
in. 982; malignant, 34.
Endodiascopy, buccal, 194.
Endometritis, 847; treatment, 277, 400; for. 400.
Endometrium, diagnosis of carcinoma of, 22*'.
Endoscopy ot upper air-passages and esophagus, 595,
678.
Endovenous injections, 310, 352.
Endowed institution, medical school of future, 283.
Endowment and indtpendent journalism, 602.
Enemas in typhoid, 835.
England, vivisection in, 8.
Eogli'ih — birthrate, 446; gynecology, pioneers in, 276;
physicians, 167.
Engman, Martin F.: An infectious form of an eczema-
toid dermatitis. 769.
Engzclius, A. E.: Concerning the action of ihe Illinois
board of medical examiners relative to the visit of
Prof. Lorenz, of Vienna, 883.
Enterectomy versus artificial anus, 311.
Enteric fever— and sewage disposal in tropical coun-
tries, 716 ; during Boer war, 167.
Enteroclysis. 674.
Enterocolitis, obstinate, treatment, 960.
Enteropiosis, 31, 557.
Environment a.s cause of agur, 716.
Enteroenteral anastomosis, 90.
Eosinophilc granulations in tissues, 393.
Eosinophilcs, Tettenhamer on, 978
Eosinophilia — and hydatid disease of liver, 393; in
filariasis, 163; of helminlhia^is, 352
Epidemic— cerebrospinal meniDgiiis, 1 10 ; disease,
fatal, of horses, 95; dysentery, 326, 414; measles,
764; poliomyelitis, 590; scarlatina, due to milk,
362; smallpox, 248,327; typhoid due to mik in-
fection. 362.
Epidural injeciion in herpes zoster, 836.
Epilepsy — and eyestrain, 21,416; and nasal venigo,
239; and ocular muscles, 448; cured by operation,
676; death in. 31; fatalism of. 361; in young,
causes, 927: nasal vertigo simulating, 676; pa-
thology,868; silent forms of, 671 ; substitutes for
potassium bromid in, 639; tostudy,646; traumatic,
115; treatment. («9. 807, 868
Epileptics— care of, 76;J; Craig colony for. 246; crim-
inal responsibility, 687; dormiol in, 111; status,
2S9.
Epiphenomena of cerebral hemorrhage, 219.
Epistaxis, 989.
Epithelioma — chorionic, 952; of auricle and auditory
canal, 229; treatment. 350, 406, 9:i5.
Epizootic leukoencephalitis of horses^ acute, 950.
Eruptions -herpetic, f -llowind di-odmm methylarsen-
ate, 875; and malarial affections, 159; vaccinal,
430, 867.
Erysipelas, treatment, 431, 436. 835. 913.
Erythrma. hemorrhagic rxud.tlve, 435.
Eschars, to prevent, 278.
Esophageal— complications of typhoid, 316 ; stricture,
725.
Esophagoscopy, 595, 672,678.
Esophagus, acute occlusion, 832.
Estcs, W. L.: A further contribution to the study of
modern amputations, 859.
Estivoautumnal fever. 431.
Ether and chloroform, 113; administration, 432; as
vehicle for cutaneous medicine, 479; ethyl bromid
as primary anesthesia to, 48 ; vs. chloroform, 519.
Etherobacilline, globucidal action of, 118.
Ethics and organization, 464 ; < odes of, new element in,
521 ; medical, 725; political and professional, 839.
Ethmoid cells and Lares, sarcoma of, 707.
EthinO'dal and fron>al sinusitis and its orbital compli-
cation-, 9t)9.
Ethyl bromid, anesthesia with, 279; as primary anes-
thesia to ether, 48; chlorid as obstetric anesthetic,
233 ; in cancer, 199; iodid in whoopingcough, 836.
Etiology, recent discoveries in, 490.
Eunuchs, natural, 227.
Eurygenesis of man, 603.
Evans, D. E.: A large complicated encbondrosarcoma
removed by simple incision and x-ray, 926.
Evil and ill, 163; subsidy, progress in abating. 641.
Evolutionary therapeutics vs. fanaticism, 957.
Examinatioi , exttrial, in childbed, 754.
Exam nations, state board, 50; medical, 205.
Examining boards— arrangement of topics by. 307;
tor medical examiners, 1] ; state, reciprocity in, 10.
Exanthems — abnormal, in chickenpox, 231; in gen-
eral, ocular complications, 479.
Excision of cecum. 668; gasserian ganglion, 669; gas-
tric ulcer, 232; knee, 228 ; lumbar lymphatic gland,
794; rectum, 397, 460; sca^ u'a, 595, 794.
Exercise — in paralysis. 156; of locomotor ataxia, 313 ;
influence o" heart and circulation, 514.
Exfoliative method in skin disease;:, 914.
Expectoration, albuminous, following thoracocentesis,
287.
Experimental gastritis, 747.
Experiments, scientific, 923.
Exophthalmic goiter, 647, 869.
Experitoneal laparotomy for cancer, 754.
Expensive economy. 561.
Expressions, threadbare and stilted, 879.
External examination in childbed, 754, 795.
Extirpation — of caicinomatous uterus, 356; of gall-
bladder, 538, 804; hypophysis. 474; multilocular
ovarian cyst, 3fil ; urinary bladdtr, 5C8,
Extraction of metallic fragments from vitreous chsm-
ber, 414.
Extragenital chancre from clinical and hygienic stand-
point, 914.
Extrahepaiic biliary ducts, microbism of. 153.
Extrauterine pregnancy, 208,356,530; diagnosed as
appendicitis, 795 ; treatment, 398, 5150.
Extremities — amputation, 488; fractures of, 592;
primary carcinoma of, 517; tremcr of muscles of,
from chloial, ^31.
Extrinsic traumatisms of spine, 648.
Exudates— autolysis in, 984; pleuritic pneumococci
in, 871.
Exudative erythema, hemorrhagic, 435.
Eye— burn by amyl nitrite, 448; diseases of, 48, 205,
687, 848; disturbance in empyema, 30; general
symptoms from, 109; injury of. 109, 189, 448;
operations on. new inhaler for, 65; optic nerve,
atrophy of, 437; prominent, 630; surgery, 3r>9,
414.
EyeUd, epithelioma, treatment, 350,935.
Eyesight — failing and advanced civilization, 919 ;
specialists, 47.
Eye-strain — ametropic, epilepsy due to, 21 ; and as-
tigmatism, discovery, 618; detection and relief,
903 ; epilepsy, 416.
Face, acne and seboirhea, 913; amyl nitrate burn,
448; cellulitis of, 948; tremor of muscles from
chloral, 831.
" Facultative sterility," 763.
" Failing eyesight," "failingintellect,'" and "advanced
civilization,'' 919
Fallopian tubes — oiseases of, 48, 898; hernia of, 109,
196
Fanaticism vs. evolutionary therapeutics. 957.
Faradization in pruriginous dermatoses, 168.
Fasting to cure disease. 9)2.
Fat-secreting glands in buccal membrane, 157.
Eatty— degeneration of heart, origin, 829; tumors and
obesity, 156.
Febrile crisis in locomotor ataxia, 395; diseases, diffi-
culties in diagnosis, 30.
Fecal fistula, 932
Feces— color, 889; of tuberculous contagiosity, 72.
Fecundity— hereditary . 368 ; remarkable, 297, 803.
Feeblemindedness. 448.
Feeding— infant, 92,629, 768. H06, 917; home modifi
cation of milk, 965; milk analysis in. 69; rectal,
Fees— lawyers' and physicians*, 129; lithotomy, 406;
' medical, 958 ; question of, 241 ; raise standard, 681;
Female— appendiceal disease in, 886 bladder, luber.
; culosis of 196; genital tract, infections of. 689-
i pelvic, inflammation, 270; sex, predilection of
j cancer, 760 ; sterility in, 592 ; vesical hyperesthesia
In. 22.
Femoral — arteries, tbrombosi*, 195; hernia, treatment
of, 9bl ; varicose aneurysm faiselj diagnostd as,
717.
Femur — fracture in infantile scurvy, 490; head of,
operative dislocation, 831.
Fenger, Dr. Christian, eulogy of, 384.
Fenn, W. B.: Ergot in hemorrhage cf other than
uterine origin, 999.
Ferments, inorganic, and certain poisons. 33.
Fetal— ascites, causing dystocia 75; death, 74, 873;
hydroctpha us in breech presentation, 356; mal-
formation, 196; theory upon causes of eclitnipsia,
910; variola, 318.
Fetid suppuration, anaeiobic bacteria in, 952.
Fever — aphthous, transmission by milk, 317 ; "black-
water," 515 ; childbed, avoidance of, 36 ; hay, 199,
274 308 ; malarial, 30, 75. 272. 309. 351 . 835 ; para-
typhoid. 112, 516, 725; postpartum, 953; scariei,
126, 313, 527, 762. 830 ; spotted, 149, 486 ; swamp,
among horses, 126 ; typhoid, 77, 167, 286, 326, 352,
4(W, 405, 490, 716, 763, 845, 867 ; and drinking
waier, 189,948; arteritis in, 726; bacteriology, 326,
725 ; brain abscess in. 111 ; diseases of ribs follow-
ing, 846; esophage&l complications of,315 ; hemor-
ibage from ear in, 679; infants aid cbildrtn, 748,
8-.;9; infection, 362, 725; inoru'aiions against, 446,
565 ; nasaldisturbances,5l4 ; otonhi gia,679 ; pei-
fotaticn, 379; placental transmission, 394, 476;
pleurisy, 947; serum reaction, 765; surgical feat-
ures, :?69, 419 ; treatment, 39, 62, 117, 119,198,228.
357, 446,647,687, 725,829,835,836 ;C>/A«J-, 74, 247;
yellow, 71, 246, 285, 351, 364, 626. 591, 646, 713 ;
and mosquitos, 46, t08 ; are vessels infected with ?,
948; bactcriologic study, 526, 715; cause, 2C4 ;
disinfection for, 750; in early limes. Boston and
New Orleans contrasted, 7l ; inoculatiorsin, 644 :
on " Plymouth, ' 590 ; quarantine, 42; supposed
second attack, 285 ; treatmei.t, 149.
Fibroids— advice t ■ patients. 689: ci-use of, 388 ; com-
plicating preenancy, 529; marked anemia, 356;
multiple, 269; pelvic cellulitis, 669.
Fibroid tumor— marked anemia, S:56.
Fibroma of vulva, 312.
Fibroniyoma—iniraligamentous, 116, 518; ef uteius,
688. 795.
Filaria-is— blood in, 153, 9t0; in man, operation in,
528.
Filth and uncinariasis, 769.
Filtration of stomach contents. 261.
Finger-lips reconstrucitd by eduction. 139.
Finsen treatment in lupus, 157, 19:^, 766, 911. 912.
Fish — doctor, 762; hypothesis of leprosy, 33,90 ; salted,
poisoning bv. 127.
Fisher, Myron E : Case of diabetes mellitus, 926.
Fisher, William R.: School vaccination, £08.
Fissures of bands, 756,
Fistula— between gall-bladder and stomach, 630 ; fecal,
932; in colitis, 653; pancreatic, 133; rectal, 9;
vcsicov2ginal, 74.
Fixation— kidney, 176, 194 ; vaginal, 755.
Flat-foot, pathogenesis of, 79
Fleas and plague, 317.
Flora, bacterial, of rabbit's intestinal mucosa, 546.
Florida— ankylostomiasis in, lOO; new institutions for,
326.
Fluids— eliminated in pancreatic fistula, 133 ; gastnc
acid factors of, 740; hemorrhagic rephalora-
chidian, 593; lipase in bacterictogic, 893,
Fluorescence of quiuin, esculin and fraxin. In malaria,
272.
Fly, disease propagation. 98. 392.
Food— adulteration, 71,33 \ 395.490,526, 666, (^07 ; and
scurvy, 473 ; boric acid to preserve, 71 , 566 ; canned,
dating of, 44 ; digestive values, 7 ; infant, but-
termilk as, 637; intoxication, unique origin, 394 ;
legislation, 441, 484; milk as, 47; preservaiive,
teniigeffects, 441, 845; put e, 205.
Foolish leniency to professional scamps, 839.
Foot— and month disease, 958; club, in children, new
cure, 78; flat, 49. 59.
Football wars for 1902, 919.
Forceps, use and abuse, 989.
Foreign bodies— in abdominal cavity, 67 : in brain, 207
764; in esophagus and trachea, 596; in larynx,
827; in lungs. 153: in rectum, 716; in stomach. 178
in urethra. 270; in uterus, 76, 764; in veimilorm
appendix. 567.
Foreign medicalservice coip?, 877. F80.
Formaldchyd— disinfection. 960, 998; abortlrg catarih.
924; in pulmonary tuberculosis, 982; in whooping-
cough, 199. ^ ^ , ,
Formalin — in diphtheria, 991; m ophthalmology.
Formo—in tinea, 158; paraiitic action on hydatid
cysts, 862.
Foshay. P. Maxwell : Organization and ethics, or
ways and mr-ans, 464.
Foshay, L>r., noble words of, 441-
Fovea, opbthilmoscopic appearance of. 218.
Fractures— Colics', 692. 748; during delivery. 170; in
newborn, 861; massage in, 630; of carpal
scaphoid, 114; of extremities. fi9'J ; of femur In
•curvy, 4iO; of humerus, 248. 751 ; ofmalsr, 868:
of metatarsal. 118: of patella, 692. 688,752; of
radius. 615, 946; of skull, 789; of spine, laminec-
tomy for, 276, 648; operative treatment, 766; rare,
92
France— infant motlality. 446, 924; post-graduate
study, 326; public baths in. 127.
Fraternal orders, increased mortality In, 364.
Francis, Charles : Saline injections in cholera patients ,
288.
1020
INDEX
Fraser, M. Ethel V.: Complete procidentia uteri in
oulliparous women, 45U.
Freiberg, Albert H.: An additional case of typhoid
spondylitis, 585.
On fashioning apparatus for flat-foot and deformities
of the 1068,49.
French, Cecil; A simple methoi of performing enttro-
enteral anastomosis, 90.
French— infant mortality, 446; liquors, 343; medical
excursion, 47 ; medicine and ethics, 442.
Friedcnwald, Harry : Tuberculosis of the iris, 19.
Friedenwa'd, Julius : The report of two interesting
cases of foreign body in the stomach, with remarks
upon an unusual accidsnt with the stomach tube,
178.
Friend, Samuel H.: The effect of Rontgen rays on the
blood, 11.
Fritsch's incision in cesarean section, 796.
Frog,deglutated,82.
Frontal — empyema, 470 ; sinusitis, 909.
Fuel famine and public health, 521.
Fuller's pill5, 116.
Fumigation, faulty methods, 310.
Gallaudet. Thomas, 363.
G.llbladder— diseases, 354,528, 567, ft32, 747,
981 ; extirpation of, 538, 804 ; malignant disease
of, 981 ; surgery of, 195, 276, 567, 686, 986, 1008 ;
surgical diagnosis, 567 ; why not treat as we do
appendix?, 54.
Galvanic batteries, 406.
Galvanism in Meniere's disease, 435.
Game, " playing the," 241.
Ganglia— gasserian, surgery of, 669, 714 ; lymphatic,
and tuberculosis, 274.
Gangrene — gaseous. 908; intestinal, 631 ; of appendix,
610; of skin, 951.
Gangrenous — appendicitis, 610 : intestine, 631 ; intus-
susception, 191; lymphangitis of scrotum, 796;
septicemia, 318; stomatitis, 192.
Garbage disposal, 166.
Gardens, school, 322.
Gargle for pharyngitis and tonsillitis, 911.
Garlic cure for tuberculosis, 156.
GarnauU's experiments, 403, 442.
Gas — bacillus-infection, 846; dangers to health, 388,
961 ; escaped, tests for, 46 ; injections in pleural
effusion, 831 ; nuisance in street cars, 125 ; poison-
ing, 388,961.
Gasserian ganglion, surgery of, 669, 714 ; excision,
669.
Gastrectomy, report of 2 cases, 651.
Gastric — achylia acidity, 101, 389. 984; contents in
children, 70; disorders, tetany in, 905; fluid, acid
factors of, 740; juice and alcohol, 890 ; juice and
physicochemic principles, 908; pain, cocain for,
118 ; troubles, surgery in, 153 ; tumor, topical
diaposis, 950 ; ulcer. 35, 194, 232, 275, 569, 792.
Gastritis, experimental, 747.
Gastroenteric infection of infants, 875.
Gastroenterostomy — for nonmalignant stomach dis-
ease, 673, 987 ; McGraw's method, 804.
Gastrointestinal — disease, hydrotherapy, 471 ; muscu-
lature and electricity, 189.
Gastrojejunostomy in gastroptosis, 688.
Gastroplication, 873.
Gastroptosia and nephroptosia, 30.
Gastroptosis, 3it, 89, 490, 6:i3, 688, 778.
Gastrorrhagia, 309.
Gastrorrhapy, purse-string suture, 789, 986.
Gastrostomy, 194, 355.
Geist, James W.: Compound fracture of humerus
from gunshot wound, 248.
Gelatin — hypodermic injections, 235 ; injection, tetanus
after, 752,874, 908.
Gelatose silver or albargin in gonorrhea, 906.
Genital — chancroid, 308; organs, and thyroid gland,
673 ; tract, female, infections of, 689.
Genitalia, absence of, 558.
Genu valgum, 79.
Germ-carrying pet animals. 592.
Germany — cancer, 168; meat inspection, 125, 646;
railroad ambulance cars, 287 ; trained nurses, 845.
Gersuny's paraffin injections, modification of, 825.
Gestation, ectopic, 796, 867, 873.
Gibb, Joseph S.: Laryngeal symptoms complicating
a case of purpura hemorrhagica, 624.
Sarcoma of nares and ethmoid cells, 707.
Gibson, T. Catlett : The tampon in postpartum hem-
orrhage, 368.
Gies, William J.: A case of pancreatic fistula of 3
years' duration, with a chemic study of the fluid
eliminated, 133-
Gilbert, J. Allen : Ix)ss of sleep, 418.
Gilbride, John J.: A simple method for closing the
body after an autopsy, 768.
Girdle of Neptune, 63y.
Glands— accessory thyroid, 793; bronchial, 192; Brun-
ner's, 871 ; fat-secreting, 157; hemolymph, 315;
lumbar lymphatic, excision, 794 ; mammary, car-
cinoma of, 530, 869 ; suprarenal, 273, 714, 835 ;
thyroid, and genital organs, 673 ; tuberculous, ',97,
916.
Glaucoma, 590, 687.
Globucidal action of etherobacilHn, 118.
Gloves, rubber, 906.
Glycosuria — alimentary, in liver disease, 829 ; and
oxaluria, 884 ; phloridzin and pancreatic, 33.
Goat — hemolymph glands of, 315; milk for children,
981.
Godfrey, Henry G.: An analysis of 65 cases of diph-
theria, 544.
Goelet, Augustin H.: A new suture for securing fixa-
tion of kidney, r>;il.
Goiter, exophthalmic, 567, 647, 869, 985.
Gold chlorid in local tuberculosis, 77.
Goldan, S. Ormond : Lumbar puncture as a curative
agent in meningitis, with report of a case, imi3.
Gonorrhea— curse of, 804 ; diagnosis, 791 ; instruc-
tions to patients, lOlO ; metastatic conjunctivitis,
915; peritonitis, 74 ; treatment, 310,553,631,906,
950. 963 ; urticaria, 873.
Good, William H^rmar : Are not some deaths during
operation in the region supplied by trifacial nerve
due to reflex inhibition of respiration and of the
heart?, 293
Dangers of incomplete anesthesia, 728.
Gordon, Alfred : Remarks on verbal amnesia, apropos
of a case of sensory aphasia, 822.
Gould, George M.: Eyestrain and epilepsy: A pre-
liminary report, 410.
Six cases of epilepsy due to ametropic eyestrain, 21.
Some neglected points in the physiology of vision,
937.
The discovery of astigmatism and eyestrain, 618.
Gout— hepatic, 151 ; treatment, 756, 835. 984.
Governments— encouragement of intemperance, 719;
medical duty, to people, 897.
Grad, Herman : Intestinal obstruction : Fecal fistula,
persistent pain, cured by secondary operation and
end-to-end anastomosis, 932.
Grafting— bone, 55; skin, 303
Granular— conjunctivitis, iodin in, 313; pharyngitis,
treatment, 677.
Grape-Juice, effect on system, 910.
Grave robbery, indictments for, 724.
Graves' disease — climatotherapy. 278; paralysis in,
985; Raynaud's disease in, 631-
Griffith, Frederick : A carbuncle in the hand, 128.
A case of phosphorus burn, 962
Grip, pulmonary forms. 359.
Growths, malignant— in abdomen, operation, 195;
x-ray in, 432, 6>8.
"Guilty intention." 810.
Guiteras, John : Ankylostomiasis in Florida and Cuba :
The new species, Uncinaria americana. iCO.
Gunshot wounds — from military standpoint, 828 ; of
head, 228; of heart, 752; of humerus. 248; of
intestines, 432, 530, 627 ; of liver, lung, and
stomach, 530.
Gynecologic — aspect of repeated abortion, 891 ; clinic,
Olshausen's, 103 ; disease, pain a symptom, 591 ;
methods, recent, analysis of, 37.
Gynecology and country doctor, 432 ; Fnglish. pioneers
in, 276 ; operative, apprenticeship in, 489 ; therapy
in. 269, 435, 597, 689, 795, 909.
TTabit — drug, 671; morphin, 1009; psychology, in
^-^ surgical technic, 43U.
Habitual gonorrheal urticaria, 873.
Hair follicles, permanent destruction, 159.
Hallberg, C. S. N.: Administration of drugs in tablet
form, 883.
Hallucination, sensory, and analogs, 630
Hammond, Frank C.: Adenocarcinoma of male
breast, 824.
Hand, Alfred, Jr.: The home modification of milk for
infant feeding, 965.
Hands, carbuncle in, '28 ; fissures of, 756.
Handwriting tics, 123.
Hansell, Howard F.: A note on the ophthalmoscopic
appearances of the normal fovea, 218.
Harelip incision, 432.
Harris, H. F.: Ankylostomiasis in an individual pre-
senting all the typica' symptoms of pellagra, 99.
The most common fif the serious diseases of the south-
ern part of the United States, 776.
Hassall, Albert : Strongyloides stercoralis, the correct
name of the parasite of Cochin China diarrhea,
343.
Hatch, J. Leffingwell : Heroin as a local analgesic in
tuberculous laryngitis, 569.
Hauser, Charles D.: Unusual injury of the scrotum,
130.
Hay-fever, 199,274,308.
Hays, Francis B.: "The Southern physician and his
colortd patients, 9".^6.
Hays, George L : Perforation in typhoid fever, with
report of 7 operative cases, 379.
Head, injury of, 227, 228,276, 530; rhythmic oscilla-
tion, 353.
Hebra's prurigo, 913.
Health — and occupation, 323; resorts, treatment of
syphilis at, 398.
Heart — action during illness, 273 ; altitude, 129 ;
disease, treatment, 118, 433, ul4, 5iS9, 750, 757,
98v»; failure in pneumonia, 198; fatty dejfeneration
of, 829; lesions, congenital, 230; movable. 672;
reflex inhibition, 293; rupture 377; surgery, 73,
6>'5, 905 ; tobacco, 190 ; two aneurysms in, 459 ;
wounds of, 530, 752.
Heatstroke followed by lightning stroke, 625.
Hebephrenia, 687.
Hebotomy in obstructed delivery, 795.
Hecht, D'Orsay: A eulogy of Dr. Christian Fenger,
384.
Heeve, W. L.: Chronic ulceration of the leg treated
with x-rays and " brush discharge," 608.
Helminthiasis, eosinophilia of, 3i2.
Hemangiosarcoma of thyroid, 331.
Hematocele, pelvic, 461, 755.
Hematology of rheumatism, 264.
Hematuria, idiopathic, 473, 490.
Hemianesthesia, over 8 years' Juration, 111.
Hemianopia, bitemporal, 448.
Hemiplegia, 198,474.
Hemihypertonia postapoplectica, 72.
Hemoglobinuria, 116, ;i:i8, 87j.
Hemolymph glands, changes in, SI-*!, 634.
Hemolytic — amboceptors, after serum injection, 598;
power of pest bacillus, 318.
Hemophilia, uterine atmokausis in, 116.
Hemoptysis, treatment, 638, 874
Hemorrhage — cerebral, 219 ; emergency, 76; from
ear in typhoid, 679; in infectious disease, 236;
internal antepartum, 596 ; into bursa omentalis,
831 ; intraabdominal, 1^5; intraperitoneal, ectopic
gestation, 873 ; postp»tum tampon in, 169, 368 ;
puerperal, 195 ; secondary after adenoidectomy,
488 ; repeated small, cause of anemia, 5o2 ; treat-
ment, 999.
Hemorrhagic — cephalorachidian fluid, 593; exudative
erythema, 435 ; infarction of kidney, 152 ; pancre-
atitis, 271 ; polymyositis, acute, 514.
Hemorrhoids, 389 ; treatment of, 9, 233, 279.
Hemostasis, electrothermic, 530,970.
Henoch's purpura, 435.
Hepatic— abscess, 473, 830; calculi, 688; colic, 197,
273 ; disturbance and movable kidney, 32 ; flex-
ure, carcinoma of, 32 ; gout, 151 ; insufficiency in
dermatoses, 192 ; lesions in infant-y, 33 ; massage,
231.
Hereditary — fecundity and sterility, 363 ; syphilis,
229, 555.
Heredity — alcoholic, in pediatry, 906 ; and bi3genesis,
827 ; studies in. 868.
Hernia — congenital hepatic, 742 ; congenital inguinal,
872 ; femoral, varicose aneurysm falsely diag-
nosed as, 717 ; femoral, treatment of, 981 ; in chil-
dren, strangulated, 690; inguinal, 196, 949; of
ovary and fallopian tubes, 109 ; radical cure, 475,
630, 690, 869 ; reduction of, taxis in, 314 ; toxic
effects, 639; umbilical, 630 ; vaginal, 712.
Hernial sac, perforation of appendix within, 311.
Heroinomania, 199.
Herpes, 162, 158, 714, 805, 836, 875, 1007.
Herrick, A. B.: A case of severe anemia caused by the
uncinaria duodenalis, 101.
Herrick, James B.: The ward clinic, 548.
Herring, A P.: An atypical case of tuberculous men-
ingitis, 207.
Hessert, William : Uterus bicornis unicollis, with
ovarian abscess and pelvic hematocele, 461.
" Heterogenesis," 521^.
Heterophorias and tenotomies, 30".
Heyde, J. M.: An unusual case of Morton's disease
(metatarsalgia) treated by a new method, 728.
Hip dislocation — congenital, 34, 567, 981; treatment,
716, 872, 883. 981 ; during normal labor, 755 ; dur-
ing rheumatism, 354.
Hip-joint — amputation, 193 ; disease, operative treat-
ment, 661.
Hippocrates, lecture theater of, 48,
Hirst, Barton Cooke : Suspension of ovary, 50.
The importance of a more careful examination and
treatment of women after childbirth, 849.
Histologic specimens, preparing new method, 319.
History— medical contributions to, 837 ; of diseases,
161.
Histrionic element in mental disease, 190.
Hodgkin's disease, 108, 53:i, 672, 870.
Hoffa's orthopedic work, 185.
Hog cholera, 326.
Holland, cancer in, 168.
Holmes, Bayard : The trend of medical education in
the United States, 491.
Holmes, Laurence E.: Administrations of drugs in
tablet form, 692.
Tetanus in the light of modern treatment, with re-
port of 3 cases, 332.
Holton, Henry D.: Tuberculosis: Its transmission
and prevention, 298.
Holy ghosters. 841.
Home modification of milk for infant feeding, 965.
Homeopathy and "dominant" "school," union of,
522; "legitimate sphere and limitations," 522;
pharmacies, 246 ; surgery of, 247.
Hooligan, punishment of, 682.
Hookworm disease, government report on, 204.
Hopkins, George; Liquid air in the treatment of can-
cer, 570.
Horses — epizootic encephalitis, 950 ; swamp fever
among, 126; surra, 95.
Hospitals — and politics, 666; association, 958 ; admin-
istration of drugs in, 645; cancer, for destitute,
763; city, for children with contagious diseases,
920; corps in Manila, heroism of, .'S89 ; cost of
patient per bed-day in, 956; consumptives, state,
205; diseased immigrants, 526; pulmonary tuber-
culosis, deductions from, 782; government, for
insane, 607 ; improved diet in,4G; management,
medical representation in, 616; portable, 993;
provision for patients with contagious diseases,
957: request state help, 802; service, marine and
public health, new division in, 364; smallpox,
restrictions on. 327; state, for epileptics, 763;
suit against, 6, 957.
Hot — air, in gynecology, 597; pack in eclampsia, 313.
INDEX
1021
Hotel-hospita!, 923.
Hourglass stomach, 794, U 13.
House of Correction, decrease in population, 87.
Houses, sanitary, 607.
Housing problem in London, 566.
Howard, Charles F.: Habitual criminality as a mor-
bid condition, 91.
Howard, F. H.: Grangrenous appendicitis with per-
foration, 170.
Hull, Marion McH.: Causes of death as set forth on
death certificates, 408.
Human — actinomycosis. 191 ; blood, identification of,
516 : body, dipterous larvas in, 394 ; life, duration
increasing, 87 ; organism, and variations, in at-
mospheric pressure, 112; para si e *' Sarcocystis
tenella," 319 ; vivisection, and rage for fame, 403.
Humerus, fracture of, 248, 751 ; involved in bone cvsts,
79.
Hustle, physiology and gospel of, .524.
Huxley lecture on immunity by Wm. H. Welch, 601,
606.
Hyaline casts in urine in artificially produced icterus.
395.
Hydatid cysts, 3.52 ; of kidney, 355 ; of liver, 393.
Hydatidiform moles, 1009.
Hyde, President of Bowdoin College, suggestion of,
682.
Hydrastis canadensis, 989.
Hydremia and malaria. 747
Hydrocele, vaginal, zinc chlorid in, 116.
Hydrocephalus, 356, 395.
Hydrochloric acid — in carcinoma of stomach, 230; in
chronic diarrhea, 797; se retion, 830.
Hydrogen — chlorid, free in gastric acidity, 101 ; dioxid
in diphtheria, 757.
Hydronephrosis, intermittent, 389.
Hydrops lubse profluens, 1U05.
Hydrotherapy— details in, 477 ; in gastrointestinal dis-
ease, 471 ; pulmonary tuberculosis. 76, 638, 756.
Hygiene. 490, 884 ; education of public, 761 ; home,
shou'd be taught in schools, 524; oral, 387; prog
ress in, 47 ; visual, in public schools, !01.
Hyperemesis, saline injections in, 154.
Hyperesthesia, vesical, in female, 22.
Hyperkeratosis lacunaris pharyngis, 317.
Hypernephroma of kidney, 316.
Hyperplasia of pharyngeal lymphoid tissue, 392.
Hvperpyrexia, rheumatic, 516
Hypertrophy — in dilation of heart, 118; lymphoid tis-
sue at base of tongue, 310; prostate, 35, 195, 804,
949 ; rhinitis, 307 ; to skin glands after labor, 271.
Hypnotism, popular, let us make end of, 996.
Hypodermoclysis, 910,951.
Hypogastri::— arteries, ligation, 831; experitoneal
laparotomy, 7."4.
Hypophysis, extirpation of, 474.
Hypothesis, working in science, 5.
Hysterectomy— emergency, 397 ; for fibroid, 356 ; re-
currence of cancer after, 558 ; subperitoneal, 36 ;
total for fibromyoma, 795; vaginal, in cancer of
uterus, 356.
Hysteria— and organic disease, 51J ; definition, 111 ;
local manifestation, 151 ; neurasthenia, 873; skin
reflexes in, 871 ; trance due to, 802.
Hysterokataphraxis, 355.
Tchthyol baths in typhoid. 117.
-*■ Icterus— artificially produced. 395 ; blood in, 635.
Idiocy— amaurotic family. 151 ; obstetric aspects, 754.
Idiopathic - atrophy of skin. 690; brain abscess, 690;
hematuria. 473 : vaginismus and sterility, 586.
Ileocolic intussusception, secondary. 35-5.
Iliac— artery, ligation <»f. 114. 476; region, abscess
mistaken for appendicitis. 79, 276.
Iliopsoas birsa, surgical importance of, 553.
Ill and evil, 1*^3.
Illinois— leader in practical reciprocity, 282 ; medical
examiners, and Professor Lorenz, 883; medical
requirements raised, 126.
Illness insuring against 204.
Immigrants- diseased, hospital for, 526; trachoma
among, 365; undesirable, exclusion^ 485; unvac-
cinated. 800.
Immigraiinn evil stopped, 922 ; increased, 125.
Immobilization of lung 714.
Immime scrum in separating typhoid and colon bacilli,
998
Immunity and articular rheumatism, 328 ; in light of
recent investigations, 579.
Immunization against pneumococcus, 698; of cattle
against tuberculosis, 9u7.
Improcrcance — and improcreant, suggested words,
12J ; and obesity 968.
Incision— Fritsch'sfundai, 796; in extirpation of gall-
bladder, 538; in laparotomy, 30; in removal of
cnchondrosarcoma. Vt25.
Incisor, new Bottini, 114.
Incompatibilities, 398.
■' Index medicus," revival ol, 481, 842. 847, 877.
Inebriety— early stages, 713 ; in women, 206 ; narcotic,
449.
Infantile— cerebral paralysis, 433; paralysis, 33,256;
scurvy, 490; splenic anemia, a97, 637; syph-lis,
359, 555
Infants - bronchopneumonia, 3f3; dianhea, 401, 417 ;
empyema, 472; feeding. 69, 92, 529, 637, 768,906,
947, 966; gastroenteric infections, 875; hepatic
lesions, 33; mortality, 167. 284,446,484,566,601,
672,924,993; paralysis, 33, 256,433: pneumonia,
32, 131 ; registration, 646 ; scurvy, 49u ; summer
diarrhea, 190, 401, 417, MOb: syphilis, 369, 655;
typhoid, 748.
Infarction of kidney, 152.
Infections — 853; bronchopneumonia, 713; diphtheria,
391; female, genital, 689; finger, cellulitis,
&48; gastroenteric, 875; general peritoneal, 569;
hepatic, after appendicitis, 193 ; influenced by
alcohol, 60 ; in ringworm, 868 ; mixed, in tubercu-
losis, 359, 647 ; of ligatures, 489 ; of milk, 362 ; old
clothing a source, 84; para-typhoid, 318; septic,
329; soil in plague, 594; terminal, pericarditis,
615; tuberculous, 622,751,871,914 ; typhoid, 564,
726; typhocolon, 49^, 678,622.
Infectious diseases — 527, 724. 788; acute, alcohol in,
60; and eddyism, 800 ; bovine, 844 ; eczematoid
dermatitis, 769; hemorrhages in, 236; origin of
purpura haemorrhagica, 309 ; treatment of, 490.
Infiltration, Schleich's, in neuralgia, 874.
Inflammation — acute mastoid, 229 ; in female pelvis,
270; of appendix, 231 ; of fallopian tubes, 398 ; of
Meckel's diverticulum, 905; of nipples, 199; of
urethra, 629 ; of uterine appendages, 835.
Influenza, acute and chronic, 1C09.
Infusions — nutritive, 432 ; therapy, 118, 164.
Infusoria, culture of, 687.
Inguinal hernia — congenital, 872 ; consecutive opera-
tions, 949 ; of fallopian tubes, 196 ; radical cure of,
local anesthesia, 690.
Inhalation — in pulmonary tuberculosis, 359, 698 ; of
oxygen, 672.
Inhaler for operations on eye or face, 65.
Injections — conjunctival, 439; endovenous, 310, 352;
epidural, 83b; in arthritis, 399 ; in atrophic rhinitis,
394 ; atrophy of optic nerve, 437 ; in carcinoma,
870 ; in cholera, 2»8 ; in herpes zoster, 836 ; in
hyperemesis, 154 ; in hemorrhage, puerperal, 195 ;
in nasal deformity, 488, 675, 826, 909 ; in pleural
effusion, 831 ; in syphilis, 76, 437, 470, 912 ; in
tabes, 313; in tetanus, 874; intradural for pain,
117; intramuscular, 4'A7, 675; intravenous, 195,
910; of albumen. 828; of antidiphtheric serum,
111 ; of calomel, 313, 399; of camphorated oil, 837 ;
of cancroin, 870 ; of digitalin, 478; of gelatin, 235,
752, 908; of hermophenyl, 76; of iodomercuric
cacodylate, 478; of oxygen, 352; of paraffin, 3i*4,
488, 675,825,909; of saline solution, 154. 2X8, 195 ;
serum, produce hemolytic amboceptors, 593 ; sub-
arachnoid of cocain, 788.
Injured, first aid to, 566.
Injuries — from pessary, 278; of eye, 109, 189,448; of
head, 227, 228, 276 ; of intestine, 35, 832 ; ot large
joints, 110; of Uver,691 ; of scrotum, 130 ; of spinal
cord, 648: railway, 471, 564; thoracic, 116.
Innocents, slaughter of, 840.
Inoculation— antityphoid. 446, 556,830; in yellow fever,
644; preventive, in anthrax, 750; tuberculosis, in
abattoir employe, 594.
Inorganic ferments and certain poisons, 33.
Insane — asylums, 6, 286, 528, tK)7, 645, 733 ; asylums
and habitual drunkards, 408 ; asylums, unjust com-
mitment to, ii59: colors in treatment, 923 ; crimi-
nals, 606; deportation and local responsibility for,
481 ; grooves la nails of, 393 ; in private practice,
448; paralysis of, 2:^8; state care, 303,845.
Insanity — among negroes, 286; and education, 327,
554; childhood, 687 ; criminal equivalent 633; in-
crease in,2H5; sympathetic. 2;i9 ; prevention and
treatment, 633; toxic unrecognized, 690; unsus-
pected, 2.
Insects and disease, 21.
Inspection — in schools, dental, 792; quarantine, clinical
thermometer in, 747,
Institutional accounting, 83, 163,204, 761,920.
Institutions, charitable, increased appropriations, 645 ;
new municipal, 326.
Instrumental perforation of uterus, 357.
Insufficientia pylori, 632.
Insurance — .ngainst illness, 204 : against surgical oper-
ations, 724 ; b by and child, 917 ; physicians', 46.
Intemperance — and self-indulgence, 604 ; governmental
encouragement, 719.
Intemperate temperance teaching, 403.
Intention, gmlty, 840.
Interment of persons dying of contagious diseases, 607.
Intermittent hydronephrosis, 389.
International reciprocity, 64:1 — Red Cross, seventh
conference of, 268 ; standard for potent remedies,
721 ; unification of pharmacopeias, 361.
Interstate reciprocity and state medical board exami-
nations, 8yy.
Interstitial pancreatitis, 318.
Intertransmissibility of bovine and human tubercu-
losis, 749.
Intesti'tal— anastomosis, 110, 552, 789; calculi, 558;
carcinoma, 392 ; contents, influence on strychnin,
293: disease, 647, 905; invagination. 188; lesion,
typhoid without, H71 ; mucosa of rabbit, bacterial
flora, 546; mucous disease, 36; obstruction, 130,
182, -2.32, 670. 690, 831, 870, 932 ; perforation, 369;
409,514; polyposis and carcinoma, 276 ; putrefac-
tion, 37 ; rupture, 804, 832 ; surgery, 3.5, 194, 229,
4^*2, 6;}1 ; troubles caused by uric acid, 828 ;
wounds, 36, 432, 627.
Intoxicated, incarceration forbidden, 881.
Intoxication, food, by infected oatmeal. 891.
Intraligamentous degeneration. 6l8; fibromyoma, 116.
Intramedullary narcosis, spinal, 951.
Intraperitoneal— abscess of appendix, 233; viscera,
bullet wounds of, 139.
Intrathoracic pressure and lung immobilization, 714.
Intratracheal — colloid struma, 395 ; route in bronchitis,
77; medication, 235.
Intrauterine — pregnancy, 356 ; death of fetus, 74
exploration, plea for, 636 ; fibroids complicating
pregnancy, 629.
IntUDation— mechanics of, 648 ; peroral, 19:1.
Intussusception, 69 ; early diagnosis, 907 ; gangrenous,
in child, 194 ; of diverticulum, 355.
Invagination, intestinal, 1X8.
Invalids, certificates required from, 802,
Inversion of uterus, 37, 130.
Investigations, recent, immunity in light of, 579-
lodid, starch, therapeutic agent, 118.
lodids, sodium and potassium, 991.
lodin, diffusion by electricity, 4l'tt; in corneal ulcers,
907 ; in granular conjunctivitis, 313 ; in tuberculo-
sis, 276 ; reaction in leukocytes, 470; solutionis
beginning cataract, 479.
Iodoform — in pulmonary tuberculosis, 117 ; solutions,
876; substitute (iodylin), 674 ; therapy of, 647.
Iodomercuric cacodylate, injections of, 478.
Iodylin, substitute for iodoform, 673.
Ipecacuanha — alkaloids, 63r ; in dysentery, 599.
Iridochoroiditis, gonorrheal, 1010.
Irrigation treatment of gonorrhea, 963.
Iris, tuberculosis of, 19.
Irwell, Lawrence: Consanguineous marriages. 492.
Ischiatic notch, drainage by, 636.
Islands of I angerhans of lion, 193.
Isoagglutinins in serum of healthy and sick persons,
63^.
Israel, Prof., and renal surgery, 118.
Itching, 437, 915,
Jackets, spinal, skilful use of, 77.
Jacobi, A.: Causes of epilepsy in tie young, 927.
Jaundice — obstructive, 273; with secondary anemia,
221.
Jaws, nervous manifestations in relation to, 387.
Jenner — institute, Chelsea, 47 ; value of work, 981,
Jerusalem, hospitals of, 609.
Johnson, Wallace : X-ray treatment of carcinoma, 217
Joints— disease in children, 309, 829 ; treatment %{, 34,
230: distended, leakage in, 78; necrosis and pus
in pelvis, 887 ; reestablishing mobility, 596 ;
fchoulder, sarcoma of, 488; treatment of crushing
injuries, 110.
Jones, Eleanor C; A case of secondary anemia cf the
pernicious type associated with marked jaundice
Rapid recovery, 221.
Jourral, medical, and automobilists, 164.
Journalism, independent, and endowment, 602 ; medi-
ca', "patent insides" and piitent newsp^-percom
in, 402.
Journals — disreputable medical, why do reputable men
contribute to, 441 ; low, lending prestige to, 883 ;
medical, and physician.*, 82.
Judgment for medical services lo charity pat'ent, 764.
Jugular veins, sinultaneous ligation of both, 986.
Jurists, medical inspection of, 898.
T/'atabolic stasis, 800.
-'»■ Kalabolism, gtne^^l, oxygen and alkalescence
in, 814 :pathG|rgy(f. 799, 809, 841,851.
Kelly, Atoysius O. J : Reflrctions on state medical
board examinations and interstate reciprocity,
899.
Keloid, ca^e of. C32.
Kelsey. J. Edson : Complete inversion of uterus with
prolapse. 130.
Keratitis, phlyctenular, following smallpox, 448,
Kernig's sign, occui rence, causation and t ignjficance.
Kidney — " bloodpurifying" function, 881; calculus
in. 717 ; cystic degeneration, 13 ; decapsu'ation of,
988; each, urine Irom, 712; fixation of. 176, 194,
.531 ; floating, cause of jaundice and hepatic colic,
278: floating surgical interference in, 73; func-
tional condition, ractor«, 829; hemonhasic infarc-
tion, 152: hydatid cyst, 855 ; hypernephroma tf,
816; movable, 32. 234, 399, 591, 791, 804, 986;
operations OP. 354 ; rupture of, 988; surgical dis-
eases, 689, 789; luberculous, ttu-gery of, 762;
wandering. 985.
Kidneys, surgical diseases, standpoint of general
country phjsician, 689.
Kindergarten children, ametropf* in, 402.
King Edward— and physician*, 41 ; hospital fund, 405;
progress toward recovery, 1,
Kinsman, D, N.: Dialetes complicated with can i-
noma of liver, the diabetes disappearing as the
neoplasm Brew. 692,
KlebsLofller bacillus and dipbiberis. 391.
Knee-chest posture in operations upon vesical end of
ureters, 269
Knee, excision of, 228.
Knowledge, feeling, and action illustrated, 644.
Koch admits error, 845.
Krcuznach baths tn heart disease, 750.
Krt-kenberg's ovarian tumors, histogenesis of, 75.
Kus^mau) Adolf. 82.
Kyle, O. Hraden : The cbemic pathology of the saliva
and the pharyngeal secretions (sUIo-seirelology)
as means of diagnosis, 67.
1022
INDEX
Labor— and pregnancj*. following nephrourcterec-
tomy, »U4 ; dimciiit, suspended position for,
155; examination during, external, 795; induced
by bougies, 4'A& ; normal, dislocation of hip during,
765; relaxation of symphysis pubis, 607; tempo-
rary hypertrophy of axilta glands, 271 ; third
stage, rational conduct of, 312 ; when and why it
begins, 34».
Laboratory — marine, Carnegie institute to control,
285 ; methods and country practitioner, W49 ; posi-
tions in Manila, 864 ; research, possible danger in,
VlH
Laceration— of cervix, 790. 834; ofliver,73; of mesen-
tery, 514; of pelvic floor, 649; of perineum, opera-
tion, 269, SOL
Lachnanthes tinctoria, properties, 435.
Lactic acid in alopecia, 767.
Laminectomy in fracture of spine, 276, 648.
l.angerhans, islands of, of lion, 193.
Laparotomy— cancer relieved by, 738 ; exploratory,
489; for vaginouterine cancer, 764; incision in,
30 ; in multiple gunshot wound of intestine, 627 ;
preparation of patients, 34.
Lamed, Charles W.: Re urrent vomiting, 258.
Larval parasites, unusual, 948.
Larvas. dipterous, in human body, 394.
Laryngeal — obstruction, chronic, t>30 ; symptoms com-
plicating purpura haemorrhagica, 624 : tuberculosis,
treatment, 569, 678.
Larynx— 678; external operations on, 078; foreign
body in, 327 ; papilloma of, 3lO.
" Latah " among South Africans, 192.
Laihrop, Walter: The relations of politics to the hos-
pital, 666.
Law and practice of medicine, 243 ; anticanteen, harni-
ful eifects, 880 ; concerning rabid dogs, 286 ; medi-
cal, enforcing, 326; Mendall's. 6U1 ; oleo, 167;
sanitary, 923 ; sweatshop, 365.
Lawson, James D.: Gangrenous appendicitis with per-
foration, 610.
Lawyers' and physicians' fee, 129.
Laxative, new, purgatin, 908.
Lead poisoning. 111, 317.
Lead-workers, leukocytosis in, 554.
Leak, R. L.: Rupture of heart, 377.
Leake vs Lucas, case of, 469.
Lecithin, 279, 874.
Lecture — movement, free, 12, 532 ; on tuberculosis,
923.
Leech, D. Olin : Dietetic treatment of pulmonary
tuberculosis, 141.
LeFever, C. W.: A new inhaler especially intended for
operations on eye or face, t)5.
Leg, ulcer, x-rays and " brush discharge " in, 608.
Legalization and state registration of nurses, 956.
Legislation — pure food, -441, 484 ; regarding health
boards, 685 : vaccination and smallpox, 430.
Leidy, C. Koniaine Maury: Formalin in ophthalmol-
ogy, 408.
Leidy, Joseph, Jr.: The late Professor Leidy's let-
ters, 50.
Leidy, late Professor, letters of, 50.
Lemon juice in rheumatism, 993.
Leonardo da Vinci and Andreas Vesalius, 995.
Lepers, 246. 285, 404, 566. 723, 961
Lepra bacilli, spore life of, 90.
Leprosy, 127, 566, 645, 802 ; and fish hypothesis, 33,
90 ; anesthetic, 528 ; contagiosity of, 474 ; curing,
484 ; history of, 88 ; treatment of. 6, 599.
Lesions — abdominal, 350,871; congenital heart, 230;
hepatic,